There has been a complete revision of the concepts, strategies and methods of nutrition education in the 1 980's.
Typically, nutrition education consisted of little more than "talks" given at health centers. Today, this approach is considered largely ineffective unless it is fully integrated into a broader program of nutrition education with well-defined strategies for communication.
The reasons for failure of "conventional" nutrition education have been the subject of numerous in-depth analyses. The "conventional" approach is limited because it excludes analysis of the causes of malnutrition, it makes use of only one isolated channel of communication (an interpersonal channel between the health worker and the population) and ineffective educational methods. It is based on weak unsupported theories of "behavioural psychology".
During the last two decades, interdisciplinary teams in collaboration with persons involved in nutrition education field activities have developed new approaches to nutrition education. The approach presented in this manual is based on work carried out by RENA, a network for nutrition education in Africa. The approach makes use of certain elements of a theoretical framework from the literature.
First, it is necessary to clarify the frame of reference for the approach to be presented.
In nutrition education, there are two distinct situations, namely, patient education and public education.
Patient education occurs during personal contact between the health worker and his patient. This is person-to-person communication during which the health worker communicates with an individual in order to improve the parents' or their child's nutritional status. This approach fails outside the domain of this guide.
Public education consists of interventions for improving the health of the general public. Nutrition education is concerned with modifying social communication to bring about middle or long-term changes in the common behaviour of the population. When interpersonal communication forms part of the proposed strategy, it has a complementary role, reinforcing other activities aimed at changing the behaviour of an entire social group.
A global approach to nutrition education
What is social communication?
It is defined here as that set of norms which determines how individuals of the same culture interact.
The modification of these norms is the ultimate aim of nutrition education directed at the general public. Nutrition education consists of interventions into the realm of social communication with the aim of changing undesirable nutrition-related habits.
Family practices at mealtime are determined by tacit rules which vary from culture to culture. In one culture, we will find that children normally eat at the same table with their parents; in another, they do not. In one culture, the best portion of meat is given instinctively to the child, while in others it is given to the grown men. These are examples of implicit norms for behaviour. The sum of these norms constitutes "social communication".
To achieve this goal, a project must be based on a thorough study of behaviour, attitudes and the practices of the social groups concerned. A considerable effort must also be made in the field of communication. Only multimedia strategies, utilizing several chapels of communication, can meet such a formidable challenge. Nutrition education can, thus, be defined as follows: it is that group of communication activities aimed at achieving a voluntary change in nutrition-related behaviour to improve the nutritional status of the population.
The participation of the population in the effort to resolve problems concerning them, is today recognized as a necessity by most development specialists. This is particularly important in nutrition education, because it aims at modification of behaviours which are deeply entrenched in the fabric of socio-cultural life.
Participation can be obtained by involving representatives of the target population in the planning committees, by their systematic involvement at all stages of planning and in surveys as well as programme evaluation before all interventions.
A programme to prevent Vit A deficiency in Thailand was recently inaugurated. The program organizers decided to promote the production and consumption of squash which is particularly rich in Vitamin A. This decision was made only after discussions with the representatives of the communities concerned. In-depth interviews were held with mothers, leaders of the community and health officers. The implementation of these communication activities was left to well-recognized groups and institutions in the community. For evaluation of this programme, volunteers working on this project as well as members of the local communities were called upon (1).
Nutrition education interventions should not be developed in a vacuum, but should form part of a wider program aimed at improving health and 10,5 nutritional status, within the context of socioeconomic development. Nutrition education should be part of a strategy for development and not an end in itself.
In the Iringa project in Tanzania, communication was the needed catalyst in projects developed by community members. The nutrition promoters made important contributions not only because of their work in nutrition but also very crucial was the social communication on nutritional themes which resulted in a tremendously successful project. This aspect of nutrition communication lead to successful realization of the local projects - an improvement in health conditions, access to potable water, agricultural production, etc - all of which contributed to a sharp decrease in the prevalence of malnutrition in the Province of Iringa (2).
Nutrition education is an activity which requires the involvement of specialists from different areas: Education, Communication, Agriculture, Horticulture, Public Health and Nutrition. The analysis of the causes of malnutrition reveals that a multiplicity of factors conditions malnutrition. Even at the levels of the village community, an interdisciplinary effort is needed (for example, collaboration between the teacher, agricultural and the health worker).
Interdisciplinary work requires intersectoral collaboration because it is rare to find specialists in all the disciplines needed in any one ministry. The multimedia approach in itself requires intersectoral action as the use of several channels of communication generally implies the participation of several ministerial departments.
Intersectoral and interdisciplinary considerations
Many interventions in the fields of agriculture, health or nutrition aimed at changing habits, have failed because of inappropriate planning. More development agents now insist on planning by objectives for their projects. Nutrition education is effective only when it is based on an in-depth analysis of nutritional problems and a clear concise definition of objectives and the methods of communication. Continuous evaluation is necessary and beneficial as a basis for redefining strategies and actions during the course of the project.
The scheme for planning nutrition education is based on a theoretical framework (3), and consists of four phases: conceptualization, formulation, implementation and evaluation.
The logic of planning
The first phase of the process of planning is analysis. The problem to be addressed must be analyzed in order to identify the determining factors to be dealt with during the intervention. Indeed, this is a commonly-held view among promoters of nutrition, and health education projects. It is based on a method called causal analysis which has proven useful in nutritional diagnosis (4). It involves drawing up a network of factors affecting nutritional status in a given context. This is a hypothetical model on which the team responsible for the implementation of the project will rely, in selecting the objectives for the intervention.
In this model invariably, there are human behaviours, on which nutrition interventions can be focused. The intervention is thus considered educational. It will therefore be necessary to study carefully the factors which influence these behaviours and the habits one wishes to modify. This is the stage identified by Green et al. (5) as the educational diagnosis. It reveals clearly the factors on which actions must be taken, in order to modify the behaviours in question.
Finally, at the end of this phase of conceptualization, it will be necessary to identify the channels and media for communication, the reference and support groups and the social networks through which the messages for nutrition education will be disseminated.
To plan a strategy, it is necessary first and foremost to define clear objectives: general, specific and operational objectives. This is a fundamental step.
These objectives must be defined for each target group and even for the target segments within the target group.
The conceptualization phase and the determination of the factors affecting the behaviours to be modified, greatly facilitates the design of messages and materials. The messages and the materials have to be field tested using methods that require community participation.
Support materials cannot be designed until the various media have been selected. Selection of the media is another crucial step in the planning process. It is based on the results of the analysis of potential channels for communication carried out during the conceptualization phase in order to develop optimum synergy between the channels.
A multimedia plan is then carefully formulated. In such a plan, all communication activities are integrated with each other.
The support materials designed during the formulation phase are now commercially produced. Difficulties lie in obtaining the optimum balance between quality and price. It is always necessary to use support materials, whatever the scope of the project, as they serve to reinforce person-to-person communication.
Training the "change agents" is yet another vital stage. To ensure that all persons involved in the various communication activities carry out adequately their roles in their respective sectors, training and retraining is necessary. These agents, whether they are health workers, teachers, agriculture promoters or other persons from a diversity of sectors, must be very familiar with the message content as well as the techniques to effectively communicate these messages. They must also be well informed of their individual roles in the entire strategy.
Communication with the population can then begin, strictly adhering to the modalities defined in the preceding stages.
Evaluation must be considered as a necessary support activity, an instrument for refining or restructuring communication activities.
To this end evaluation must be participatory. It will bring together the principal players in the intervention: the promoters of the intervention (meeting through a planning committee), the communicators, the sponsors and the population itself (through community representatives).
The evaluation must respond to two fundamental questions:
Have the objectives been met?
Has the implementation process satisfied the various persons involved in the intervention and, above all, the population concerned?
2.2 Scheme for planning
The first activity would be concerned with establishing a planning committee to bring together the representatives of all the parties concerned.
· To attend to all the stages of planning of the program.
· To ensure the translation into action of all operations from the conceptualization to the evaluation of the intervention.
· To recruit technicians to carry out the operations.
· To ensure that the communication intervention is well integrated into development programs in the country, the region, and the district.
Who should be on this planning committee?
The composition of the committee will vary with professional level of members depending on whether the intervention is being implemented at the national, regional or local level. Whatever the level, however, the sectoral composition remains the same.
An intervention can take place at several levels at the same time. It will, therefore, be advantageous to have the planning committees functioning at these different levels, thus ensuring coordination between them.