|Guidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)|
After studying this chapter, taking part in the discussions, and doing the exercises, a community health worker should be able to:
· Understand the need to impart simple messages to the community to help the people to adopt better health and nutrition practices
· Identify people in the community, either individuals or groups, who need special help to improve their nutrition
· Identify specially motivated people in the community who might assist her in conveying suitable messages to those who are in need of special help
· Select suitable messages according to the problem, and convey these in a simple and convincing manner.
Need for nutrition education
In the previous modules, mention was made of the need to teach mothers how to feed infants and children properly, how to care for a child with diarrhoea, and how to feed a child with diarrhoea or an infectious disease. In other words, community health workers are expected to convey suitable messages to the people in the community in an appropriate manner so that the people adopt correct practices regarding feeding, immunization, cleanliness, etc. This is called nutrition education. It is an important task of community health workers.
It should be remembered that mothers are always keen to improve the health and nutrition of their children. Unfortunately, many of them do not know how to do this. Moreover, in poor communities there are other problems such as an unhygienic (dirty) environment, lack of clean water, and shortages of food at some periods of the year. Community health workers should understand these problems and should be able to teach mothers ways of overcoming them.
In all cultures there are some beliefs and superstitions about foods and food habits, especially with regard to the feeding of young children and foods during pregnancy and lactation. The community health worker should know what beliefs and superstitions are common in her community. It is her responsibility to convince people to give up wrong beliefs. At the same time, she should teach people good health and nutrition practices.
In all communities there will be individuals and groups who will require special nutrition and health care (see Module 6). It is the duty of the community health worker to find out who these people are (see Module 1). She should then make an extra effort to convey appropriate nutrition messages to such persons.
Motivated people in the community who can help in nutrition education
A community health worker cannot improve the nutrition of a community by herself. She needs all the help she can get. In every community there are persons and groups who are helpful. In Module 1, mention was made of the need to know such persons or groups. These persons may be either officials of a particular branch of the government or informal leaders, e.g., the village head man, a teacher in the village primary school, a religious leader, or a traditional birth attendant or healer respected in the community. Voluntary agencies and women's groups are often active and eager to help. The community health worker should identify all the helpful individuals and groups (resource persons) in the community and establish good relationships with them before starting her work. This is not only important for her nutritional tasks but also for all her activities in health care.
When a community health worker makes an effort to change the dietary habits of the people through suitable messages, her task will be much easier if her messages are supported by the community resource persons. If the village leader is convinced that a certain message is good for the community and he gives his approval and support, this will make the members of the community more receptive to that message. Similarly, if the school teacher starts telling people about the benefits of good nutrition practices, the efforts of the community health worker will produce better results. Before trying to convey nutrition messages, it would be wise for the community health worker to discuss these with some of the community resource persons.
Conveying health and nutrition messages
Nutrition education is not so easy as many people think. This is because it is not easy to change people's eating habits. If a community health worker tells a mother to feed her child in a certain way and the mother listens to her advice, it does not mean that the mother will actually start doing what the community health worker has told her. To convince mothers to adopt better nutritional practices, the community health worker must first understand why people follow particular feeding practices. Often, the reasons for the feeding habits of the families will be linked to factors such as: poverty, cost of foods, availability of foods, beliefs and superstitions about foods, and time available to the mother for preparing food.
Before starting nutrition education understand why people follow particular feeding practices.
Once the community health worker has understood the reasons for people's feeding habits, she can start nutrition education. The following simple rules will help in getting good results.
Person - to - person discussions
· Talking with one mother at a time (person-to-person approach) is an effective way of conveying a message.
· Talking to a mother, when her child is not well and she needs help, is a good time to convey messages.
· Not more than one or two messages at a time should be discussed.
· The messages being conveyed should not go against the mother's culture or religion.
· While conveying a new message, it is always useful to mention some common beliefs and practices prevailing in the community that should be encouraged. For example, in many cultures, a religiouscum-social function is held to introduce solid foods to a six-month-old baby to initiate the adult-type of diet.
· Do not give any message that mothers cannot follow for other reasons, (poverty, religion, illiteracy, lack of knowledge, etc.).
Community health workers will get many opportunities to talk to a number of mothers together. On such occasions they should try to convey nutrition and health messages to them. In doing so, they can use teaching aids such as posters, flip-charts, and photographs. Sometimes, slides and even films may prove useful.
A child who has recovered from malnutrition as a result of a good diet composed of cheap locally available foods can be a very convincing example to use in such group discussions, especially if the mother of the child also explains how the diet was changed and why and what improvements she noticed. "Before and after" pictures of local children will also be useful in starting discussions. Similarly, growth charts can also be used.
In countries that have nutrition rehabilitation centres, the mothers of malnourished children are sometimes asked to help in preparing food for children at the centre; they may also be asked to help in feeding the children. This is a good practice because such mothers become convinced about good nutrition practices once they see their own children healthy again. Community health workers can ask these mothers to help in group discussions.
Some other useful hints about nutrition education
Catch the attention and interest of the mothers. If a woman has asked a question about her child, you have a good opportunity because she will be interested in your reply. Look for something about which you can compliment her. For instance, is her home tidy, is her child washed and clean, and is she breast-feeding her child? It may also be worth while to see if the growth chart of her child shows regular weighing and completed immunizations. The mother gets the feeling that personal interest is being taken in her child and family and she will listen carefully to what you have to say.
The message should apply to the mother's situation and to her hopes and desires. If her child has fever, the first message should be about how to reduce the temperature. Only afterwards will she listen to what you say about feeding children who are ill. Motivation and acceptability of a message depend on the immediate needs and desires of a mother.
The message should be simple. Try to put across only one or two ideas at a time. The ideas should be closely connected to something the mother already knows.
The message should be heard, seen, and understood. Speak clearly and use simple words. Whenever possible, use pictures etc., to show what you are talking about. This is important with different types of foods. Mothers will understand the messages more easily if simple examples are given.
Participation. It is easy to forget what has been said or seen, but doing something helps to remember it. What is even better is to show someone else how to do something. If a child is not growing well and a mother is told to give him extra food each day, she may not remember it. If the community health worker encourages her and helps her to get started, the mother may give the child the extra meals regularly. As the child's growth improves the mother will feel proud and happy at what she has achieved. She will remember the importance of more meals for small children. If the child was simply sent off somewhere for an extra meal twice a day promoted by a feeding programme, the mother will never really know about the importance of extra meals.
A local proverb or a joke can make it easy to remember a message. "A small seed, if properly nourished, grows into a mighty tree". It is obviously necessary to use a proverb correctly. It is important not to offend people. Understanding and judgement are necessary when making jokes in another language or in a culture different from one's own.
Repetition reinforces a message. After telling a mother something, it is useful to ask her to repeat the message and explain it in her own words. This will help her to remember it. The test of her understanding will be to see if she carries out the instructions in her own home.
A friendly and respectful relationship is a great help when teaching or learning. A welcoming smile and a helpful deed are a good beginning for exchanging information. An arrogant attitude will create barriers to learning.
Organizing and taking part in meetings to consider nutrition matters
Every culture has some form of gathering where people discuss matters of common interest. Sometimes all important decisions are made at such meetings. There may be different meetings for different groups, for example, young farmers, mothers, community leaders, and so on. Various aspects of nutrition could be discussed at these meetings. If there is no suitable group or meeting to discuss nutrition and health, the community health worker may have to start one.
Discuss nutrition problems in community gatherings.
Every meeting should have a definite objective, and for each objective a list of topics should be prepared. Both the objective and topics should be known to the people attending the meeting. The community health worker should prepare teaching methods and aids suited to the topics that will be discussed at the meeting, because it provides an important learning opportunity. She should collect together materials which can illustrate the topics being considered: for instance local foods, weighing scales, and growth charts.
She should make sure that the leaders of the community are invited. This means not only the official leaders, but also those who are looked upon for guidance by others in the area. If possible, she should have the meeting led by someone who will understand the social, economic, and health issues associated with nutrition problems, someone who is respected by others and not afraid of change.
The meetings should follow the local pattern, but an effort should be made to keep them informal. The community health worker should be prepared to take an active part. She can ask questions and make comments that will keep the meeting going in the right direction. The purpose of such a meeting is to keep nutrition and health issues in people's minds. It is an opportunity to inform them about other factors that affect health. The most important purpose, however, is to stimulate the people in the community to be active and to do something about their nutritional problems. Here you may use the approaches suggested on page 00. What is needed is personal and community commitment to make changes that will improve the nutrition and health of the high-risk groups. This is not an easy task, and very quick results should not be expected. Patience and persistence will be necessary.
1. Lecture: Training content.
2. Croup discussion: Organize an education session in the community for trainees to practice their communication skills.
3. Demonstration: Use of various teaching aids.
Exercise 1. Preparation of messages
The trainees should prepare some basic messages relevant to each of the previous seven modules and suitable for the community in which they are expected to work. They should also prepare some points regarding how they are going to convey each message.
Each trainee should present her messages and points to the class, and the other trainees should comment.
Exercise 2. Role-playing
Characters: A mother with a 9-month-old baby whose weight is not increasing. A community health worker.
The community health worker should convince the mother that the child needs solid foods, but the mother insists that she has sufficient breast milk and the child is quite healthy.