1 Director, Health Development Foundation, Women's and Children's Hospital, North Adelaide, South Australia.
Summary of case studies
Discussion and conclusions
The nutrition education case studies from nine countries discussed in this paper were commissioned by FAO in order to provide an indication of trends in nutrition education, as the basis for discussion during the Expert Consultation on Nutrition Education for the Public, 18 -22 September 1995. The case studies are representative of a number of different regions and approaches. Most are recent and have not been reported before. In summarising these studies, this author has adopted a standardised format to highlight key aspects of the studies and provide some basis for comparison, where this may be appropriate. The format adopted is to highlight the nutrition issues being addressed and the general context for the intervention in a background section, followed by objectives, target groups, sectors and/or settings involved, strategies used, duration of the project, any results from evaluation, and finally the conclusions of the case study authors themselves. Where case studies have not reported on all these aspects of their programme, this is indicated. No case study authors identified the funding resources available other than to indicate in some instances whether support was received from the United Nations or other agencies. It was therefore not possible to discuss the possible effect of resource constraints. Each country case study summary is followed by brief comments by this author. The discussion below provides this author's conclusions regarding the trends which emerge overall, how these compare with past reviews and what examples of best practice are provided by these studies to better inform similar projects in the future.
The case studies demonstrate the diverse socio-economic and cultural conditions from which nutrition problems arise, and in which public nutrition education interventions have to operate. While poverty underpins many of the problems being addressed, it is also clear, as in the case of Oman, that rapid social change, even when it increases the resources available to a household, brings changes to the food supply and to lifestyles, that can produce serious nutritional consequences for a population. Most public nutrition education is aimed at enabling populations to make better use of available resources, or to know how to adapt to environmental changes. The case histories describe a wide range of information, education, and communication (IEC) strategies to achieve these aims, and many programmes include strategies designed to provide structural and environmental supports for nutritional improvement.
The nature of nutrition education
Nutrition education has been defined by Andrien (1994) as "that group of communication activities aimed at achieving a voluntary change in nutrition related behaviour to improve the nutritional status of the population". A distinction is often made between the terms "nutrition education, nutrition communication, nutrition promotion and information, education and communication (IEC)" (Graeff, Elder & Booth, 1994). There is a great deal of overlap in actual practice. Education activities can include information processes which are generally designed to inform unilaterally, e.g. through print and broadcast (radio and TV) channels or the more traditional communication processes which use interpersonal, face-to-face channels, e.g. group discussions, home visits, training and counselling. Each channel has its own strengths and weaknesses and it would seem that strategies which combine multiple channels have the most impact on changing behaviour. The question is no longer which channel is best but rather, how to use a combination of channels to teach and support nutrition behaviours.
While the focus of education activities is on changing individual behaviour, there has been a growing recognition that the health of individuals and their health-related behaviour is the product of that individual's continuous interaction with his or her environment. This includes the family, community, culture, social structure, and physical environment.
The Ottawa Charter for Health Promotion (WHO, 1986) developed by 38 countries has had a major impact on the ways of promoting the health (including the diet related health) of individuals, groups and populations. The Charter identifies five interdependent domains for action:
· Build healthy public policy.
· Create supportive environments.
· Strengthen community action.
· Develop personal skills (education).
· Reorient health services (to promote health as well as treating illness).
In this way, educational strategies to bring about behaviour change in individuals are given structural and environmental support. "Make healthy choices, easy choices". This has lead to definitions of health (nutrition) promotion which still have education as a central activity. For example, "Any combination of health (nutrition) education and related organisational, economic and environmental supports for the behaviour of individuals to promote (nutritional) health" (Green & Anderson, 1986). The parentheses are added to show the applicability to nutrition.
This broader concept of health promotion asks planners to consider building both education and supporting strategies into programmes. Frequently this will require inter-sectoral collaboration, e.g. developing a vitamin A communication strategy in the health sector and working inter-sectorally with agriculture to promote the home production of foods rich in vitamin A.
Trends in nutrition education
Nutrition education has been heavily influenced in recent years by theories and models of health behaviour change derived primarily from three disciplinary streams: psychology and other behavioural sciences, communication models, and social marketing (Achterberg, 1993). This has lead to a series of widely used public health communication models that include "how to do it" steps (Achterberg, 1993). These include the Triple A model of assess, analyse, and action. Green's Precede model emphasises the importance of identifying the predisposing factors (knowledge, beliefs, values, attitudes, confidence) that provide the rationale or motivation for the behaviour; the enabling factors (skills and resources) and the reinforcing factors (family, peers, teachers, etc.) which reward or contribute to the persistence of behaviour. The five-step model includes assessment, planning, development, implementation, and evaluation. More recently, Andrien has developed a planning model based on four phases: Conceptualisation, Formulation, Implementation, and Evaluation (Andrien, 1994).
In general these influences have lead to a more scientific and rigorous approach to planning, in which the importance of analysing the determinants of the nutrition problem, and clearly defining objectives and methods of communication are recognised. The principle of community participation in programme planning and evaluation, as well as implementation is also gaining acceptance.
Evaluation should underpin all nutrition education programmes. The importance of planning at the outset for evaluation and monitoring is recognised, as is the value of continuous evaluation, as the basis for reorienting actions during the course of a project.
There is a growing interest in adopting a settings approach to nutrition education. Selecting key settings (perhaps not traditionally seen as the domain of nutrition education programmes), enables population sub-groups to be reached where they work and live. The use of a wide range of settings and organisations provides for positive links to occur across disciplines and can encourage a wider community involvement in nutrition issues. A settings approach can also emphasise changes in organisations which support individual change ("healthy hospitals", "healthy worksites", "healthy schools", "healthy communities", etc.). Settings for reaching the whole population can include, apart from primary health-care services, schools, day-care centres, worksites, recreation settings, social, religious, cultural or sporting groups, retail and commercial settings - street vendors, and cafeterias.
Current issues for nutrition education
A number of reviews of nutrition education programmes in developing countries have been undertaken in recent years. These have been valuable both to highlight difficulties which can occur and also to provide examples of good practice which can be shared.
Issues for behavioural change
There are now a number of evaluations which provide credible evidence for the positive effects of education on health and nutrition behaviour. The factors which these evaluations have identified as contributing to successful behaviour change are summarised in Table 1. It should be noted that much of the scientifically developed knowledge base for nutrition education rests largely on evaluations of programmes conducted in developed countries. Strategies selected to bring about behaviour change should be mediated by local knowledge and contexts.
Actually bringing about behaviour change depends on many factors - probably the most critical being having behaviour change as the clear aim of a programme. The availability of trained personnel who understand and can implement behaviour change strategies appropriately, and who can involve learners in solving their own nutrition problems is essential.
Table 1: Factors determining successful behaviour change
· Active Involvement. Active involvement of learners in identifying their own needs. (2,5,6)
· Appropriateness and convenience of settings. The ease and convenience of taking action. (1)
· Stages of behaviour change. Behaviour change must be seen as a process, e.g. raising awareness of motivation does not automatically result in behaviour change. (1,7)
· Setting Realistic Goals. Promotion of small discrete changes is more likely to be effective. (1,5)
· Specificity. Providing people with specific information about the desirable behaviour and how to make changes. (1,2,5)
· Variety. Specific interventions are more effective than general exhortations. A range of specific interventions is likely to be effective (1)
· Multiplicity. More than one channel of influence should be used to provide consistent messages from several sources. (1,3,4,8)
· Use of social networks. Community organisation and community leaders can support change. (1,5)
· Choice. Information which allows for reasoned choice is preferable to didactic methods. Opportunities must be given to discuss the issues. (1,3,5,6)
· Intrinsic Value. People are more likely to persist with actions if they find them enjoyable or rewarding. Present the desired behaviour in an enjoyable manner. (1)
· Sound Information and Instruction. Accurate information and instruction on how to make changes and channels for social action are critical. (1,3,5)
· Discussion. Decision and problem solving methods are more effective than didactic methods. (5)
· Independence. Dependence on any particular place or person reduces the individual's capacity to act independently. Developing problem solving skills is important for independent action. (1)
(1) Lee and Own (1985)
Issues for nutrition education programmes
There is less evidence available about the feasibility of reproducing positive results routinely and on a large scale. Given the limited resources available to most countries, nutrition education must have the capacity to have an impact on large sections of the population in a cost-effective way. The following issues have been identified as important for affordability, effectiveness, and reach, particularly for large-scale programmes.
· Programme design
Programmes need a clear institutional framework and government commitment (Berg, 1987, Achterberg, 1991, Cerqueira & Olsen, 1995). Programmes need to plan for building commitment at all levels. Planning for monitoring and evaluation at the outset is also crucial. Experience suggests that evaluation design should be as simple as possible for large scale programmes.
Clear and achievable goals, objectives, and strategies should be established based on an analysis of the factors affecting dietary practices and consultation with target groups. Limiting the number of components makes the goals more achievable. Training and capacity building should be planned for.
Appropriate targeting can substantially reduce costs (Berg, 1987).
If demonstrated improvements in the nutritional status of large population groups are being aimed for, new programmes may need to run for at least six years (Berg, 1987). New programmes must have sufficient lead in time to allow for detailed planning, consultation and field testing of education resources (Parlato, Green & Fishman, 1992).
· Community participation
Successful programmes work with the community and community leaders to promote solutions to nutrition problems (Parlato, Green & Fishman, 1992; Cerqueira, 1990; Whitehead, 1993; Gussow & Contento, 1984).
There has been a move away from medical models of educating, to the use of a range of strategies and communication channels, and the use of approaches such as social marketing (Achterberg, 1991.) There is a trend towards the increased use of locally available mass media, the adoption of more participatory approaches, and the inclusion of learners in all aspects of programmes (Gussow & Contento, 1984; Israel & Nestor-Tighe, 1984; Hornik, 1985; Zeitlin & Formacion, 1981; Cerqueira, 1990; Cerqueira & Olsen, 1995; Achterberg, 1995). There is a growing recognition of the need to include strategies designed to create supportive environments for behaviour change, and to sustain the effects of programmes through strategies designed to strengthen local ownership and to develop structural and institutional support.
Case study 1: Evaluation of a nutrition education programme in Oman
Case study 2: Public education campaign in the English-speaking Caribbean on food safety and control
Case study 3: Nutrition information and food labels as an aid in nutrition education of society in Poland
Case study 4: The Pacific
Case study 5: Federal Republic of Germany. Nutrition education, information and advice in the new states since 1990
Case study 6: Republic of Niger. Public nutrition and nutrition education experience and requirements
Case study 7: India. The Tamil Nadu Nutrition Project. A case study of the communication component
Case study 8: Ecuador. School vegetable gardens in the rural Andes. A school nutrition education experiment as part of a global community project
Case study 9: Philippines. The LAKASS programme in the Philippines
General characteristics of case studies
The case studies provide a valuable insight into a range of approaches. Four case histories examine specific public education strategies, operating mainly through print and broadcast channels. The Pacific paper evaluates the development of print resources for the region. The Polish paper evaluates the use of food labels as an educational tool, and from the Caribbean, there is an evaluation of a mass media campaign to address the issue of food safety. From Oman a study is described which used print and broadcast channels to promote improved infant and maternal nutrition.
Case studies from Niger and the Federal Republic of Germany include education activities which employ interpersonal channels as well as print and broadcast channels. The Federal Republic of Germany reports on a comprehensive information, education and advice strategy involving training of trainers programmes for a wide range of health and non-health professionals, combined with the establishment of mobile nutrition services and of local nutrition centres aimed at creating an accessible and reliable nutrition IEC environment. Niger addresses vitamin A deficiency using 'animation' teams who use games and role play to facilitate discussion and interaction with villagers. This interactive technique was linked with the development of broadcast and print resources.
The third group of case studies used IEC strategies in combination with environmental supports. The LAKASS programme from the Philippines combined a range of IEC strategies within a social mobilisation and advocacy framework linked to income-generating and food- production projects. From the rural Andes comes a case history using schools as the entry point to increase the knowledge and skills of the children and the local community, particularly in the area of vegetable growing and small animal production. This strategy was integrated with a broader community development project. Finally the Indian, Tamil Nadu Integrated Nutrition Project combines nutrition delivery services, rural health services and social mobilisation with a communications component in order to improve the nutrition of young children. Table 2 summarises the general characteristics of the Country Case Studies, grouped to show the relative complexity of the programmes, as defined by the range of strategies employed.
Table 2: General characteristics of Country Case Studies
Group 1: One way communication
Group 2: Two way communication
Group 3: IEC and Environment Supports
· Print and broadcasts channels
· Interpersonal channels.
Individual Knowledge Attitude Behaviour
7. India (Tamil Nadu)
6. Federal States of Germany
8. Philippines (LAKASS)
Target groups (TG)
2 A.O. Musaiger.
Oman is the second largest Gulf Cooperation Council (GCC) country with an area of 300,000 km2. The country is situated in the south-eastern comer of the Arabian Peninsula, sharing borders with Saudi Arabia, the United Arab Emirates, and Yemen. Most of Oman is semi-arid plains, desert, and mountains. The population of Oman is two million (1993) with nearly half a million people being Indian immigrants.
Both undernutrition and overnutrition exist in Oman. Undernutrition of children is a problem, with 13%-30% of children aged one to six years being underweight. The prevalence of stunting ranges from 9%-29%. Iron deficiency is a major problem with 60% of pre-school children suffering from anemia, which increases to 78% among children aged 6-14 years of age and decreases to 55% among adults.
Several factors contribute to undernutrition among children, including the decline of breast-feeding, early introduction of weaning foods, unsound food habits, infectious diseases, and unhygienic preparation of foods for children. Rapid socio-economic changes during the 1980s has resulted in the emergence of obesity and other diseases of affluence. In 1980, 17.4% of female adults were obese. By 1991, the prevalence had increased to 54%.
· Mothers to breast-feed their children as long as possible.
· Sound weaning habits by introducing the right foods at the right time.
· Sound food habits during pregnancy and lactation.
· Hygienic preparation of foods for infants and young children.
· Primary: Women, mothers of reproductive age 15-45 years.
· Secondary: Health workers.
Sectors and settings
The Ministry of Health: work was carried out with an inter-sectoral committee, 'The National Women and Child Plan', supported by UNICEF.
Educational materials were distributed to clinics, hospitals, and health centres. Television and radio spots on commercial stations were used to reach women in their homes.
· Posters: weaning habits, healthy eating in pregnancy, promoting breast-feeding.
· Booklets: Health workers - proper management of breast-feeding, weaning and healthy eating in pregnancy and lactation.
· Leaflets: given to mothers.
· Television: several spots were prepared.
· Radio: information through family and health programmes.
The programme commenced in 1989. It has been continuous in health centres and periodic on radio and television.
A representative sample was selected (1024 mothers). They were interviewed by women students. Evaluated in 1991.
Most potential for nutrition education seems to lie with television, as there are high television ownership and low literacy rates. However, nutrition messages compete with food advertising, and the widespread use of satellite television with many channels makes positioning messages difficult. Mothers favour late evening as the best time for viewing television, and mornings for radio. However, most messages had been targeted to afternoon television. The effectiveness of printed materials was limited by high rates of illiteracy (50% men, 80% women). Eighty eight percent of women had seen the posters (80% in hospitals), but it was evident that the messages of two of the three posters were not clear to mothers.
The major lessons learnt from this case history are the need to involve target groups in the planning of the project, the need to pre-test printed materials, and for market research to segment the audience and decide on the appropriate placement of television and radio messages. It also raises the question of whether television, in spite of its popularity and high ownership rates, can be an effective stand-alone educational medium where there are so many commercial channels available, carrying competing advertising messages. The number of channels also made message placement difficult. These difficulties, and the high rates of illiteracy among Omani women, perhaps suggest that greater attention should have been given to face-to-face strategies in hospitals, particularly as 80% of women reported seeing the posters in a hospital situation. It is not clear whether health workers conducted classes for mothers or were given training. It seems that they just received the educational materials. The evaluation focused on programme and message delivery. It would have been valuable to have measured changes in knowledge and behaviour.
Although the Ministry of Health worked with an inter-sectoral committee, the settings used were exclusively health, apart from the mass media messages directed to households. The case history author concludes that there is a need for training both in methods of communication and in the management of nutrition education programmes.
3 C. Forrester
Although the countries of the region have a relatively small land surface, they are separated by vast expanses of water. The majority of English-speaking people who were targeted in this project are poorly literate. In 1983 FAO, the Pan American Health Organisation (PAHO) and the Caribbean Community (CARICOM) convened in Antigua to develop a Strategy and Plan of Action for Food Safety and Control in the Caribbean. This comprehensive strategy dealt largely with surveillance and control services and included an education and community participation strategy.
A preliminary study indicated that food-borne illness, especially diarrhoeal diseases, often initiates and aggravates malnutrition. The research also indicated the need to educate the population on the importance of proper handwashing; the protection of infected wounds/boils; the holding temperature of food (particularly with fast food and street vending); the dangers of the inadequate cooking of foods and the importance of maintaining a hygienic environment where food is prepared, sold, and consumed.
The reduction and prevention of the incidence of food-borne illness, through the adoption of safe food habits in the home and community.
Restaurateurs, street vendors, cooks in child care institutions, school children aged 12-15 years, housewives.
Sectors and settings
Co-ordinated by the Caribbean Food and Nutrition Institute (CFNI) in collaboration with the Council of Voluntary Social Services Organisation (CVSS), an umbrella body consisting of 60 member organisations, which included large numbers of people of various disciplines, social status and political persuasions. The third partner was the Department of Sociology, UWI, Jamaica. UNESCO provided seed money. Subsequently the project worked closely with the Caribbean Institute of Mass Communications (CARIMAC).
A mass media campaign using radio and television was the central strategy. Radio was assessed as accessible to a large cross section of audiences with lower production costs than television. Television was accessible to fewer people and very expensive.
A media consultant employed by the project facilitated a three-day workshop for 23 experienced media practitioners, 32 mass communication students, and CFNI members as resource persons. The workshop went through a process which led to the adoption of three television and 15 radio spots, and a catchy jingle which became the theme of the campaign -'covered, clean and cold'. The mass media students were from CARIMAC, UWI. The students, who were in their final year, were linked to media houses in the region. Their involvement secured their commitment to subsequent mass media activities on the subject and was a factor in media houses extending the campaign messages free of cost as a public service.
Messages were designed specifically for the three major target groups - adolescent school children, householders, and food handlers. The messages were pre-tested and minor modifications made. The audio and video tapes were acquired by the organisations within CVSS and used in public forums and in produce markets.
One year, 1986.
Monitoring and evaluation
All radio and television stations were monitored monthly to determine the frequency of broadcasting. The messages were found to be frequently broadcast in most cases. Resources limited the evaluation to a sample of 332 restaurateurs, food vendors, housewives,- household helpers, and students. In the selection of samples from St Christopher/Nevis and St Lucia, effort was made to have respondents covering demographic categories of age, occupation, sex, residence, and place of work. The sample group was tested before and after the campaign. In the case of St Christopher/Nevis, only students were sampled on the post-test which did not allow for much comparison within the population. A control group, which had not been exposed to the messages, was created to be compared with the experimental group. The evaluation established that there was a statistically significant increase in knowledge (17.6% increase in Guyana; 48.4% increase in St Lucia, and a 69.7% increase among students in St Christopher/Nevis). The theme and the jingle were easily remembered and very popular. External variables were not controlled. The author comments that the influence of other variables in the post-test scores could have been anticipated by including appropriate questions in the post-test questionnaire, and that individual interviews and focus groups could have been used to help validate the evaluation findings.
The author concluded that the project had strengthened the capacity of CFNI to make more aggressive use of mass communication channels. Previously they had relied almost exclusively on the print media. Partly due to the improved media relations facilitated by this campaign and the network of media practitioners developed, CFNI has worked with the media on a number of subsequent public education initiatives.
The inter-sectoral collaboration with CVSS and others established in the project, has strengthened CFNI's outreach capabilities at the community level. The significant feedback from the campaign in the form of requests for information, emphasises the need for continuity and follow-up.
This case history provides an example of the benefits of collaboration with both the media and social organisations. This was the first major mass media campaign in the Caribbean, and the process of audience segmentation and pre-testing of messages undoubtedly contributed to its success. It also served as a training process for the CFNI in the use of mass media.
4 W. Roszkowski and A. Kollajitis-Dolowy.
The level of nutrition knowledge in Poland is low. Nutrition education activities are not co-ordinated and much overlap and fragmentation occurs. Nutrition education in schools is limited by a lack of qualified teachers, an insufficient focus on health and the lack of a discrete curriculum component. Mass media (magazines) are frequently the source of false information about nutrition. Food advertising has had a negative influence.
Comprehensive surveys of consumers have indicated poor knowledge in the area of nutrients supplying energy: the energy value of food products and the food sources of key nutrients. There is better knowledge of the benefits of fibre and the harmful effects of an excess of fat and cholesterol in the diet, although not of the role of unsaturated fatty acids and salt. There are differences in knowledge levels according to age, sex, and level of education. Women, the well educated, and middle aged people have a higher knowledge level than men, the poorly educated or the very young or very old. Surveys also show a very low ability to read, interpret and recalculate data on food labels. Young people and the well educated have a better understanding.
The Department of Human Nutrition at the Warsaw Agricultural University conducted a series of four studies from 1990 to 1994 to examine various aspects of using food labels to disseminate nutrition information. Nutrition labelling has become especially important in Poland and other post-communist countries, because of the introduction of a free market economy in which the consumer faces the complexity of choosing from a wide range of highly modified and processed foods. These studies also have policy implications as there is a need to harmonise Polish food regulations with the EC Food Laws.
· To evaluate the interest of consumers in nutrition information of food labels (1990-1993, study 1).
· To evaluate different forms of nutrition information with regard to readability, presentation range, and perception of content (1990-1992, study 2).
· To determine the effectiveness of different forms of information (leaflet, talk, video) distributed to teach consumers how to read, understand, and use data contained on food labels (1993-1994, study 3).
· To develop an education strategy for schools to educate students on how to use food label information (in progress).
Consumers, school children.
Sectors and settings
A research project conducted by the Department of Human Nutrition of Warsaw Agricultural University.
Strategies (methodology) and results
In study 1 (consumer interest) a representative sample of the adult population was surveyed by questionnaire. More than 80% of respondents reported paying attention to nutrition information while shopping. However, 45% only paid attention occasionally, 25% frequently, and only 13% almost always. Women, the better educated, professionals, older people, and urban dwellers were more interested than men, the poorer educated, blue collar workers, the very young, and rural dwellers.
Only 7% of respondents placed nutrition information as the first factor influencing purchase decisions. Freshness, appearance, price, and attractive packaging were more likely to influence buying.
Study 2 (forms of nutrition information) was conducted on a group of 470 consumers at randomly chosen grocery shops in two big towns and one village. The form of presentation of nutrient information which gained the highest approval (40%) was numerical form, with a full range of content, particularly when the nutrients were indicated with bold type face or when there was a nutrition claim. The study stressed that one third of the least educated people were not able to choose any form of nutrition information as the appropriate one.
Study 3 (the effectiveness of education materials to support food labelling) was conducted through a questionnaire given to 1977 randomly sampled secondary school students (general, technical, and vocational schools). The survey compared differences in the level of knowledge by testing before and after applying one of three methods of communication (leaflet, talk, video film). Subjects were tested straight after use and then after three months. The results depended on the nature of the questions.
The most effective method was achieved by video film regarding the facts least known before the studies. Both video and talk methods were the most effective in dealing with questions requiring data from the nutrition information to be calculated. The leaflet method was more effective than video, only in the case of theoretical aspects dealing with the role and function of nutrients in the body.
Nutrition labelling can be one of the strategies used for educating the public. Although consumers declare an interest in nutrition information on food labels, interest is still relatively low which limits its educational effect. Young people show relatively less interest in nutrition information on food labels compared with the middle-aged.
Nutrition information in numerical and numerical-graphic form is preferred by consumers, but to meet various needs, the video film method of explaining the nutrition information on food labels is overall the most effective.
The author also recommends that nutrition education in schools in Poland should be updated to make it more effective, that better co-ordination of nutrition education efforts is needed, and that more use should be made of the mass media.
The findings of studies 1 and 2 tend to confirm prior studies which show that consumers are generally interested in nutrition information on food labels, but find it difficult to use and make sense of (Gussow & Contento, 1984). Study 3 demonstrates that consumers can be fairly easily educated to better understand food-labelling information through one-off sessions. The question remains about the relative merits of food-labelling information in an overall nutrition education strategy. Labels are found on packaged food and nutrition labelling may suggest to naive consumers that packaged food is nutritionally superior to unlabelled, fresh foods, particularly if the food is fortified. Nutrition labelling also gives information on the food per se rather than its role in a healthy diet.
5 T. Matenga-Smith.
The Pacific region is spread over 30 million square kilometres and contains 22 island countries and territories including some 7,500 islands. Of these only about 500 are populated.
The different races of people and the areas they settled in the Pacific are generally divided into three groups: Micronesian, Melanesian, and Polynesian.
Micronesia: The people settled in the Marianas, Marshall Islands, Federated States of Micronesia, Palau, Guam, Nauru, and Kiribati.
Melanesia: This covers the islands of Papua New Guinea, Solomon Islands, Vanuatu, New Caledonia, and reaches as far as Fiji.
Polynesia. The islands stretch from Hawaii to New Zealand, and from Tuvalu to the Easter Islands.
In mid-1994 the region's total population was 6.7 million. In terms of size the region is dominated by the five Melanesian countries, which account for 98% of the land area and 84% of the population. However, smaller island states carry the higher population densities. Compared with ten people/km2 in Melanesia, Polynesia has a density of 70 people/km2 and some Micronesian islands reach 146 people/km2.
Food and nutrition problems in the Pacific are substantial, with high levels of malnutrition in young children in Melanesia and Micronesia. This is linked to increased risks of respiratory tract infections and to increased severity of diarrhoea. In some islands vitamin A deficiency is prevalent in children aged one to five years. Iron deficiency anaemia is another common nutrition problem. High rates of infant mortality pertain in many of the Micronesian countries. Changing lifestyles (less physical activity) and a shift away from traditional local nutritious foods to imported foods are contributing to serious problems of heart disease, diabetes, cancer, and other non-communicable diseases.
A major strategy in combating these problems is community nutrition education with support training. The South Pacific Commission (SPC), founded in 1947 and based in Noumea, serves the 22 countries of the region with technical assistance including an integrated programme covering diverse activities in health, nutrition, agriculture, women's programmes, statistics and demography, oral health, AIDS, etc. The University of the South Pacific (USP) in Fiji is a regional institution serving 11 Pacific Island countries with both award courses as well as in-service training courses and workshops.
· To provide the region with a database on the composition of regional foods. (Food Composition Tables, SPC).
· To promote local foods through the development of information leaflets. (Food Leaflet Series, SPC).
· To provide regionally and culturally appropriate materials for use in training and community education programmes (Training Materials, USP).
Community and health workers, teachers, agriculture workers.
Sectors and settings
The SPC in collaboration with the USP.
Development of nutrition education resources for the region:
· Pacific Islands Food Composition Tables: Analytical work commenced in 1952. It involved co-operation with analytical programmes in New Zealand and Australia. By 1953, 65 foods were analysed. No further work was done until 1987, when a full-time co-ordinator was appointed. Priorities for analyses were established by user questionnaires in the region. With the assistance of New Zealand from 1989, the Food Tables have been completed. They contain over 800 foods analysed for 21 nutrients. A computerised database has been established. A further 200 local foods still need analysis.
· Food leaflets: Arising from the food composition work, each leaflet pictures the food, highlights its nutritional value, comparing it with other local foods, and gives storage, preservation, and preparation information. These are widely used in community programmes. Over 40,000 of these leaflets have been used in the 22 countries. Some countries have translated them into the vernacular.
· Training materials: Regional meetings have frequently emphasised the need for culturally appropriate nutrition training for health and community workers. A series of 13 nutrition education books have been developed. The process of development included over 70 Pacific Islanders (mostly women) from 19 countries. The materials focus on the promotion of local foods, basic nutrition knowledge, and preventing and treating diet-related problems. They were extensively field tested and involved co-operation among many sectors and countries.
· Training programme: USP and SPC have completed 14 training modules for a Community Nutrition Certificate which commenced in 1994 with 100 students from 12 countries.
The participatory approach used has helped mobilise the community. It has lead to a strong sense of "ownership" of the resources and programmes. Pacific Island Governments need to build on these initiatives by taking a more "proactive" role in nutrition education, particularly in relation to school programmes.
The success of the project can only be measured in small ways, as lifestyle changes continue and no significant reduction in NCDs has occurred. These initiatives are seen as capacity building and support for the development of further health promotion activities.
This case history is primarily a description of capacity building for nutrition education in the Pacific region through the development of education and training resources and a community nutrition training programme. The development process for resources is characterised by the high degree of participation by both community representatives and community workers of the region to ensure cultural appropriateness and local ownership. This collaboration has resulted in countries of the region having resources available to them which individually they would not have been able to produce.
Field-testing and reviewing is referred to in the case history but not reported on. It would have been valuable to have the actual uses of the resources, and their usability by nutrition educators in each country, documented. There seems to be little institutional support for this process from country governments, with the resources not being linked to education and training programmes.
6 I. Leonhauser and I. Ruck.
The former German Democratic Republic (GDR) had a complex and cumbersome infrastructure for nutrition research and nutrition education. The stagnation of life expectancy and the prevalence of the diseases of malnutrition were attributed to the social and economic environment and lifestyle factors. People tended to resist the information made available, (partly because of food shortages) and held to traditional consumption patterns that were not always consistent with good nutrition. The challenge for the new system was to find a way to develop nutrition education intervention measures which would become part of the social structures influencing nutrition behaviour and which would reach large numbers of people. There was a need to provide information about the new products now available and to combat media misinformation.
To provide the population with information on new food products and the general principles of eating for good health, in a way which was accessible, credible and relevant to people's lives.
· Key change agents - health professionals, teachers, community leaders.
· General public, in particular pre-school and school children, parents, women.
Sectors and settings
Ministry of Food, Agriculture and Forestry, Central Office of Health Information, in collaboration with state governments, the German Nutrition Foundation and Consumer Advice Centres. Delivery of information was to local communities, schools, and a range of community-based clubs, agencies, and organisations.
A comprehensive range of strategies was implemented to make reliable nutrition information readily accessible to the population, particularly at the local level.
· Training: A training strategy underpinned the programme and enabled trained people to initiate nutrition education projects. Training was provided for teachers, doctors, librarians, and pharmacists through a mobile unit. Caterers were trained in nutrition through the Institutional Feeding Advice Service supported by the German Nutrition Foundation. Food law and food hygiene training were provided to such people as veterinarians and food chemists.
· Mobile Units: Six buses were furnished with technical equipment (personal computer, video and monitor, projectors) and materials (brochures, information sheets). They were staffed by a multi-disciplinary team of four. The Units provided: (i) direct advice to the public, (ii) developed nutrition education in co-operation with schools, health and consumer advice centres (iii) provided training courses. The mass media was used to promote the work of the Units.
· Consumer Advice Centres: These centres initiated a wide range of nutrition education activities and promotion, e.g. they established local nutrition centres, supported the Mobile Units, worked with the media.
· Nutrition Foundation: The Foundation also initiated many public nutrition education activities, e.g. healthy school breakfasts and snacks, iodine campaign, developed programmes with schools and nursery schools, ran letter and telephone services.
Continuously since 1990.
Evaluation is now being gradually undertaken. The Mobile Unit was widely used and accepted. Training programmes were well attended and there is a steady demand for advice and information from Advice Centres.
There is a need for further co-ordination of activities and for evaluation and assessment of cost effectiveness. This strategy of working within local communities and in a client-centred way, seems to be working, but there is a need to understand more about the psychological and social aspects of target groups. National standards for training are needed.
This case history reports on a wide range of strategies directed at increasing nutrition knowledge for most of the population. Evaluation is referred to, but not reported on, other than to report on high attendance rates in training programmes and an increase in consumer demand for nutrition information. The author comments on the need for "an exact definition of the target group", and it would seem highly desirable to research the specific needs of population sub-groups in order to focus the strategies to where they are most needed and may have the greatest impact. Evaluation of existing activities should be a high priority.
There also appears to be a need for greater co-ordination of nutrition education at all levels of government.
7 A. Mamadoultaibou.
Many surveys have identified major nutrition problems in the population. Protein-energy-malnutrition, vitamin A and iron deficiency are widespread, with pregnant and nursing mothers and children under five being the most vulnerable groups. The government has been focusing on increasing food production and the development of a new health service infrastructure, including community-based mother and child care services.
The prevalence of vitamin A deficiency in the Sahel region is partly due to the lack of availability of foods rich in vitamin A, particularly in the lean season, but partly due to lack of knowledge. This paper reports on a social communication and nutrition education project directed at reducing vitamin A deficiency and a communications training project.
· To develop a methodological approach to communication in nutrition to reduce vitamin A deficiency, through the increased consumption of locally grown food rich in vitamin A (community project).
· To provide support in training and methodology of audio-visual communication tools and their use (training project).
· Rural villagers (community project).
· Health and agricultural extension workers (training project).
Sectors and settings
Health, with support from USAID (vitamin A project), health, agriculture, media -support from FAO. The community project was delivered to rural villages. The training programme was directed to health and agriculture workers.
· Community project: The project was a pilot targeted at three villages without a health clinic or gardens. Initial research looked at local knowledge, attitudes, and practices; identified affordable, available vitamin A rich foods and surveyed the media. Night blindness was well known but not related to food. Wild green leaves were readily available and acceptable. Reception on local radio was very poor. Television was not available.
Five people per district trained in communication techniques using a 'Learning through fun' approach. They were called the 'village animation teams' and presented games and role play to village audiences in a way which involved participation. The project was evaluated and found to be very effective. Subsequently the project expanded to 80 villages.
· Training and capacity building: The 'Communication Support for Sahelian Programmes against Malnutrition and Vitamin A Deficiency' was given institutional support at every level - national, regional, district, and village, with inter-sectoral involvement at each level. This structure allowed for the initiation, co-ordination, and monitoring of communication strategies. The pilot lasted 21 months. Training workshops were held on the use of rural radio, audio visual aids, and video, which lead to a multi-sectoral team developing radio messages and scripts, posters and a number of video programmes.
The pilot project lasted 21 months with subsequent expansion (it may be still ongoing).
The pilot was evaluated and considered effective. (No details of the evaluation are reported).
The capacity for nutrition communication has been strengthened. The projects enabled successful inter-sectoral and multi-sectoral approaches to be developed. The clear institutional framework has fostered good working relationships. However, lack of equipment and funds for communication (e.g. document copying and delivery) led to communication problems within the project.
Traditionally, nutrition education methods have been didactic and based on a superficial analysis of the causes of malnutrition, and delivered by health workers poorly trained in communication. It is now recognised that strategy planning within a multi-sectoral, multi-media context is more effective. A range of communications methods are now used and the importance of community participation in all aspects of communication activities is recognised.
The training component of this project has given health care providers a theoretical base for their nutrition education work and expanded their skills in situational analysis and communication methods. It has shifted the emphasis from didactic talks to mothers, towards using participatory methods and a range of communication channels. The project linked health workers and made them part of a multi-sectoral strategy, thus reducing the 'isolation' many of them experienced. The case history demonstrates the need for, and value of training health workers in the area of nutrition education.
There is reference to training of workers from other sectors including agriculture and education. It would have been valuable to know how many workers from which sectors have been trained and to follow up on the ways they have been able to use their training.
8 K. Vijayaraghavan.
Many strategies are employed in India to alleviate poverty and malnutrition. Although the primary determinant of undernutrition is an inadequate dietary intake, lack of knowledge is a contributory factor. Nutrition education therefore has the potential to improve nutritional well-being. The Tamil Nadu Integrated Nutrition Programme (TINP) is a large-scale programme, implemented in the South Indian State of Tamil Nadu since the 1980s. TINP is funded by the World Bank and integrates health and nutrition interventions with a major communication component. TINP - 1, which is discussed in this paper, operated in six less developed districts, covering an estimated 1.1 million children and 0.28 million expectant and nursing mothers.
· To reduce malnutrition and the consequent high mortality in children under three years of age.
· To improve the health and nutritional status of children under three years and that of expectant and nursing mothers.
Children under three years. Pregnant and nursing mothers.
Sectors and strategies
Health, with the support of the World Bank. The programme was delivered in health centres and households in rural villages.
· Nutrition delivery services: Weighing of all children of six to 36 months at Community Nutrition Centres. Malnourished children were enrolled for short feeding programmes. Pregnant women were also selectively fed.
· Health services: Ante- and post-natal care, focusing on a reduction of infant and child morbidity and mortality.
· Communication: Designed to: (i) make mothers fully aware of the nutritional needs of children, (ii) address better intra-family distribution of food, (iii) enable the community to handle its health and nutrition needs more effectively. Targeting, both for nutrition intervention and communication, was critical. The communication strategy segmented the audience into primary and secondary targets and strategies were carefully planned for both. Two-way communication was used for the primary target group and one-way communication for the secondary audience. The primary target group was mothers, mothers-in-law, and fathers. Counselling was used, linked to weighing and supported by flip charts and flash cards. The secondary target group was the rest of the population. The methods used were films - incorporating popular film tunes, film strips, and slides. Pamphlets were available for the literate. An innovative strategy was the use of popular folk media "villupattu". Professional troupes incorporated nutrition messages into "villupattu" and audio cassettes were produced.
· Social mobilisation: Women's Working Groups (WWGs) were formed. They were trained in communication. Each group "adopted" a number of families, assisted with counselling mothers and later ran income generation projects, e.g. 200 WWGs produced weaning foods. Children's Working Groups (CWGs) relayed messages via songs, poems and jingles.
· Training: There was a three-month training for primary health care workers (PHWs), plus a two-week refresher after two years. Community Nutrition Workers (CNWs) - local mothers, were locally trained for three months. Joint training was conducted for the last ten days for PHWs and CNWs to build rapport and understanding. Annual refresher courses were provided. CNWs were supervised and supported. There was strong bureaucratic and political commitment to the project. The communication component was separately managed by a co-ordinator who was assisted by a team including a communication research officer, a librarian and an artist. Management was planned at all levels.
The project began in 1980 and ended in 1987.
Comprehensive but manageable evaluation was integral to the programme. Independent evaluations were conducted of the experimental and control type. Base-line, mid-term, and terminal surveys were conducted. No separate evaluation of the communication strategy was conducted, but it would seem that its main value probably lay in achieving better utilisation of project services.
The programme achieved a 55% decline in malnutrition over 72 months. In areas where the programme was evaluated over four years, the reduction was about 35%. Overall a 40% decline was achieved, with spectacular decreases in clinical deficiency signs. No statistical analyses were applied.
A major contribution of the communication strategy was to increase the community's use of services. IEC activities should be supported by other services/strategies which make it possible to act on the messages. Target groups were not involved in planning, and it is difficult to assess whether involvement would have improved the programme. It would have been valuable to have had direct monitoring of the communication component and to have had key indicators developed in this area.
A major factor in the success of the programme was the strong bureaucratic and political support. The project was carefully planned, but had flexibility and made modifications as needed. Technical expertise was available from national and international experts. The CNWs were local and credible to the community. Training and community participation through WWGs were other critical factors in success.
As the evaluation was not systematic and supported by statistical analyses, all conclusions should be interpreted carefully. Furthermore, no specific evaluation of the communication component was undertaken, making it impossible to assess its role in achieving nutritional improvements, which could have been mainly due to the feeding component of the programme. Formative evaluation was conducted to determine the most appropriate methods for the target groups, and audience segmentation methods were used. There was no pre-testing of messages or materials, although some modifications occurred during the programme as the result of feedback.
This case history again highlights the importance of training, which was given a high priority, although there is no report of an evaluation of this training. Overall this project is generally regarded as cost effective but the high cost of developing and distributing films, slides, posters, audio cassettes, and posters could be prohibitive for projects without outside funding. A range of communication channels was used, including folk media. In general TINP-1 suggests that interpersonal communication, supported by media, is appropriate for illiterate communities.
9 M. Chauliac
Evaluations of past attempts to improve nutritional status in Ecuador, particularly of women and children, indicated limited success. A combined Ecuadorian and French study concluded that the health sector or the agriculture sector alone could not resolve these problems. They also concluded that what was needed was a multi-disciplinary team working on the different causes of malnutrition, whether they were insufficient food supplies, economic difficulties, socio-educational and behavioural maladjustment, or health problems. This study led to the development of ANDES - an analysis-action-training programme. The programme is multi-disciplinary and multi-sectoral. It employs a community development approach which calls on people to participate in a meaningful way and in accordance with their social norms. The ANDES programme includes strategies for food production, food security, health services, improved sanitation and water, and education and training in the formal and informal sectors. The project described in this paper is a component of the ANDES programme.
The programme recognised three fundamental values: (i) the close relationship between the people and the land, with the earth viewed as a mother figure; (ii) that the community is central and prevails over the individual; and (iii) the relationship with God. Rites and festivities are bound to the triptych of God-community-earth.
Local communities decided on the following priorities:
· To improve the productivity of maize, the staple food.
· To diversify household food consumption by promoting fruit and vegetable growing and small animal husbandry.
· To provide safe water from stand pipes placed at locally designated spots, and by installing showers, wash basins, and toilets in schools.
It was decided that all community members of all ages were to be included. This case history focuses on the strategies directed at children.
Sectors and settings
A multi-disciplinary team, French and Ecuadorian, of doctors, agriculturists, educators, and sociologists. The setting for this project was five village schools in the rural Andes and the local communities.
School based education: It had been decided that school children were to be involved in the development activities. The decision to use schools as an entry point was not easy, as the rural communities saw schools as urban-oriented and out of touch with village life. The divide between school and community was even greater in the region of San Jose de Minas where this programme was conducted. Villagers used any excuse not to send their children to school. School and community integration was therefore a major focus of the project.
· Food and nutrition component: Children were introduced to the concept of nutrition and the role of agriculture in the human diet. They were asked to think about their own consumption, food availability and dietary patterns, and they examined popular perceptions of local foods.
Locally produced aids were developed, such as blocks of wood (like dominoes) with foods drawn on them, to use for educational games. A school shop was set up with children bringing food to school to play "shop" - to learn nutritional value for money, etc. Cooking lessons were organised, based on the foods and conditions at home, but adhering to hygiene standards and principles of nutritious food combination. Mothers prepared iron-enriched bread for consumption at school.
· School vegetable garden: Food growing skills were developed in three stages relating to the three cycles of education over the six years of primary school. This component developed children's knowledge of vegetable growing suited to the local culture and conditions. Active learning was fostered. Teachers were trained and a school garden established.
· Guinea pig breeding: Guinea pigs are a local food source. They are usually kept in unhygienic conditions. A permanent facility was built at the school to teach children the proper care of these animals to increase productivity and to provide a model for the community.
Children's knowledge, attitudes, and gardening skills were evaluated using experimental and control classes. Tests were validated and results statistically analysed.
Other indicators were direct observation of children's food consumption and such factors as children asking for seeds to take home.
There were significant knowledge gains for all children. The children's skill levels increased markedly between the beginning and end of the school year. The results for increased self-esteem, self-confidence and application were extremely positive.
The formative years of childhood are particularly important for nutrition education. Given that a child mainly depends on the family for food, schools must cooperate with families in guiding food habits, rather than confronting them. Nutrition education in schools must build developmentally and include skills as well as "theory". There is a great potential for integrating a school food and nutrition programme within a broader community programme and involving children in community development processes. In this project, the local community participated in all stages and the children became change agents for their families.
Training of health, agriculture and education professionals should sensitise them to all the determinants of food habits and facilitate their ability to work in a multi-disciplinary team.
This case history provided details of an extensive and rigorous evaluation of the school programme, which included measures of change in children's knowledge, attitude, skills, and food consumption. The resources available to the project from the French and Ecuadorian multi-disciplinary team no doubt made such extensive evaluation possible. The overall principle of community participation was also applied to this component of the project, with parents and teachers involved in developing the school programme and parents participating in school activities. An important aspect of this project, which no doubt contributed to bridging the traditional gap between the school and community, was the inclusion of learning activities (food production, etc.) of direct relevance to the community, and the development of resources adapted to local conditions.
10 T. Stuart
LAKASS is an intensive nutrition action programme formulated and co-ordinated by the National Nutrition Council (NNC) of the Philippines. LAKASS is an acronym standing for a Philippine statement meaning, "The body will become robust and healthy with adequate nutrition".
LAKASS addresses the twin problems of poverty and malnutrition. It combines livelihood opportunities with direct and indirect nutrition services, and includes a component on social mobilisation and IEC. The programme draws on the co-ordinated strength of the community in addressing its own nutrition problems.
The programme was initially implemented in 1989-1991 in 136 of the most nutritionally depressed municipalities (NDMs) of the country. In 1992-94 it was expanded to a further 31 NDMs, covering a total 167 NDMs out of 1,316 depressed municipalities and cities nation-wide. The community was involved in identifying the specific problems affecting the adequacy of food intake and the nutritional status of individuals and families. These included child-feeding practices, family food supply and demand, health and sanitation, intra-family food distribution and the economic condition of the household.
· To improve the nutrition situation in the identified NDMs and Barangays (villages).
· To provide effective and sustainable services for, and by the community to improve their nutritional status.
The family, particularly children under six years of age and women of reproductive age (15-45).
Sectors and settings
LAKASS was a national initiative, funded and supported by NNC and implemented by Local Government Units. Universities were commissioned to conduct monitoring and evaluation.
The expansion programme utilised the existing structures of the Philippines Plan of Action for Nutrition (PPAN), which consisted of regional nutrition committees and provincial, city, municipal or Barangay nutrition committees.
The programme was delivered in nutritionally depressed villages and municipalities.
· Social mobilisation: Community participation in all aspects of the project.
· IEC support materials: At the national level, locally researched and designed materials were mass produced. These consisted of LAKASS brochures, LAKASS implementing guidelines, nutritional guidelines, training kits, programme management information, leaflets, and posters.
A major way of reaching mothers was through Mothers' Classes. These weekly classes provided for active participation in discussion, and demonstrations on issues relevant to child health and nutrition. These classes also provided an opportunity to discuss traditional practices.
· Advocacy: Regular meetings were held with the 31 mayors of the NDMs, initially to seek counterpart funds and commitment to institutionalise LAKASS in local development plans. Subsequently, meetings provided a venue for experience and problem sharing.
· Training: Training was provided for municipal and Barangay officials, teachers, beneficiaries, government and NGO representatives. Local trainees learnt to assess their own nutritional problems and respond appropriately. This led to projects involving schools, livelihood projects, and home and school gardens.
1989 - 1994.
Monitoring and evaluation were built into programme design. Three programme stages were externally evaluated by universities: pre-implementation, mid-year implementation and a year-after implementation to assess impact. (Details not reported).
LAKASS has a commitment from Local Government through the institutionalisation of the programme into local government development activities with a budgetary allocation. Community training and participation developed strong local support. Credit assistance for income-generation projects have successfully augmented family income and ensure a steady food supply for low income families. All these aspects of the programme will contribute to its sustainability.
The LAKASS programme has proved to be effective in improving the economic and nutritional status of children, mothers, and other household members. For example, there was a 16% decrease in the prevalence of wasting among pre-school children and a reduction of stunting among pre-school children by 21 %.
Although social mobilisation and IEC are regarded as integral components, they have not been given adequate staffing, resources or specific attention in research, planning, implementation, monitoring, documentation, and evaluation.
Recommendations include the need to strengthen these components by designating a specific group at the NNC, with counterparts from State colleges and universities, to systematically plan, implement, and evaluate social mobilisation and IEC. Further training in these areas also needs to be developed, particularly directed at potential multipliers of the programme. Advocacy campaigns around the role of social mobilisation and IEC should continue.
This case history provides a model for sustainability through successfully institutionalising the programme into local government development plans with a budgetary allocation. It is another example of a project which integrates a number of strategies designed to support and enable communities to act on nutrition education. It would have been valuable in this, as in other integrated programmes, to have had an evaluation of the impact of the education component, as it is difficult to assess the role played by these activities in relation to the other strategies.
A feature of these case histories is the expansion of the scope of nutrition education. It is generally agreed that interpersonal methods conducted in local communities are appropriate to address the common problems of maternal and infant malnutrition, and this has been, and no doubt will continue to be, a major focus for nutrition education programmes. However, these case histories demonstrate an increasing concern to provide environmental and structural supports for these efforts, as in the LAKASS and Tamil Nadu programmes. There is also evidence of using multi-channel approaches more often in these situations and a trend towards more participatory methods. However, there is also evidence in these case histories of the need to address a range of nutrition issues arising from rapid social and technological change which is occurring in many countries. The Polish, German, Oman, and Caribbean case histories are examples of these, addressing variously the availability of more packaged and processed foods, changing food habits and the changing information environment in Poland, Germany, and Oman, and addressing food safety issues in the Caribbean. There is a definite trend towards more inter-sectoral collaboration, as in the case of collaboration with the media and social organisations in the Caribbean, with education in Ecuador, and local government in the Philippines. The settings for nutrition education in these case histories include schools (Ecuador, Germany), point-of-sale retail (Poland), local clubs and organisations (Germany), although the local community and health services continues to be the most common settings.
The evaluation of programmes varies considerably, with the Ecuador project providing for a rigorous process and outcome evaluation, while in others evaluation has yet to be addressed, as with the German programme. In some instances of integrated programmes, the education component is under-resourced and under-evaluated, making it difficult to determine its effects in relation to other components. The effectiveness of some programmes was seriously affected by lack of formative evaluation and pre-testing of materials, as in the case of the Oman programme.
Training issues also are variably addressed, although in almost all case histories, some training is provided for. It would have been very valuable to have had an evaluation of the training aspects included in the case histories. A need for training in the use of the mass media was frequently identified.
As mentioned, a major trend to emerge from the country case histories is that of using a combination of strategies and communication channels. Interpersonal methods emerge as an appropriate and effective way for reaching low literacy groups (especially where there is no broadcast media), for addressing complex skills and issues, or for discussing issues which may be regarded as sensitive for the target groups. Interpersonal channels were used in the Niger project where there was low literacy and poor reception of local radio. They were the basis of the Ecuador project, which taught school children skills over time and engaged the community in problem solving. In the LAKASS project, informal discussion allowed mothers to discuss the extent to which new knowledge could be integrated with traditional beliefs. In Poland, video and talk methods were the most effective in explaining how to apply nutrition information from labels. Given the difficulties of positioning messages over the many available television channels and the high illiteracy rates of women in Oman, it may have been valuable to strengthen the interpersonal methods used in this programme.
A feature of most projects is the increasing importance given to developing strategies only after extensive analysis of the influences on behaviour. This leads to a better understanding of what is likely to be effective. An interesting dimension of the interpersonal communication reported is how innovative many methods were, for example, the use of games and role play through village animation groups in Niger; the use of folk media in the Tamil Nadu project; the use of mobile units in Germany; and innovative local nutrition games in Ecuador.
The growing use of the mass media is also a trend, particularly as television becomes more accessible to greater numbers of people and as educators gain skills in its use. The Caribbean case study is particularly useful to identify a capacity-building process in the use of mass media. Through collaboration with media practitioners, a most successful mass media campaign was developed and nutrition educators gained skills and confidence. An interesting feature of this process was the additional use of 32 final-year media students, who were already attached to media agencies for training purposes. These students helped produce the messages of the campaign and developed a commitment to the project. Subsequently, as employees of media agencies they supported public service extension of the campaign, free of cost.
In Niger, the capacity to use a range of media was strengthened by training in the use of rural radio, the development and use of audio visual aids, and the use of video: Several studies highlight the critical importance of adequate 'market research' for mass media use, particularly in relation to audience segmentation, careful selection of channels which reflect the patterns of use of the target audience, the importance of pre-testing messages, and the importance of monitoring.
The Polish studies on the use of food labels as a source of nutrition information is pertinent for any country where there is a high or increasing use of packaged and processed food. The complexity of successfully using such a strategy can begin to be understood if we consider which of the 50 or so nutrients should be included, and in what forms, on which of many hundreds, or in some countries, many thousands of foods. How does this help consumers understand the relative nutritional merits of different packaged foods or the role of packaged foods in relation to unpackaged and unlabelled foods? It is becoming increasingly clear from the Polish and other studies that food label information has to be supported by education in how to use the label information.
Both the Pacific and the German case studies highlight the importance of using methods appropriate to the social and cultural context. The Pacific paper reports on the co-operative development of culturally relevant education and training materials for a vast region in which such development would be beyond the resources of individual countries. The Federal Republic of Germany addressed the urgent need to increase the credibility, the reliability, and the accessibility of IEC services at the local level. The strategies included extensive training of key community figures as change agents and positioning mobile units and advice centres locally.
Another major trend is the use of social mobilisation and community participation methods. The Philippines LAKASS project involved the community in a five-step process covering all aspects of the programme from planning to evaluation. The Ecuador project used a community development approach in which the community identified its own problems and prioritised their needs. The Tamil Nadu project used women's and children's groups to mobilise the community. The use of children as change agents is an interesting feature of both the Tamil Nadu and the Ecuador projects. Generally, it would seem that programmes using strategies which foster community ownership and control of projects are much more likely to be sustainable. Nonetheless, depressed communities must be extensively supported if their capacity to deal with malnutrition is to be strengthened. It would also have been valuable to have more detail on who in the community participates, and in what ways.
The need for strong institutional and political commitment has previously been well documented and is again highlighted in these papers.
(i) Recognise the central importance of nutrition education as a strategy for nutritional improvement when malnutrition arises from an inadequate use of available food resources and where there are rapid changes occurring in the food supply and lifestyle habits.
(ii) Make specific budget allocations for nutrition education in countries where malnutrition is a major barrier to the achievement of development goals and include nutrition education as a specific component of development plans.
(iii) Encourage all large-scale projects to allow sufficient lead-in time to achieve the best possible design. Programme design should include:· Clear, achievable goals and measurable objectives, based on an appropriate situational analysis.
· Appropriate primary, secondary, and tertiary target groups.
· A plan for facilitating the participation of target groups in all aspects of the programme.
· Selection of settings most likely to reach the target groups and which can support behaviour change.
· Selection of methods and strategies both educational and supportive, which are likely to achieve the objectives.
· A clear evaluation plan which includes both formative (including pre-testing of materials) and summative elements.
· Plans for training (educators, managers).
· A programme implementation plan.
· A clear institutional framework and clearly defined roles and responsibilities.
· An indication of the ways in which sustainability is being planned for.
· A communication strategy for the programme itself.
· A realistic estimate of inputs - time, materials, people.
(iv) Make the development of mass media communication skills a priority.
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