Éducation nutritionnelle: proposition d'une approche à assise communautaire
Educación nutricional: propuesta de enfoque basado en la comunidad
1 This is the second of two articles on approaches to nutrition education. The first article appeared in Food, Nutrition and Agriculture, Vol. 1, No. 2/3,1991. In the first article, the effectiveness of traditional nutrition education approaches was questioned. This article presents an alternative approach, the active participatory framework in nutrition education.
Maria Teresa Cerqueira is a health and nutrition educator who has worked as a consultant for the Pan American Health Organization, the World Bank and FAO. She is a Ph.D. candidate in the Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
Strategies to change nutritional knowledge and behaviour could be more effective if community members' ability to make decisions and solve problems were enhanced. To mobilize social energy in grassroots community development, several health and nutrition education programmes have applied an "active-participatory, democratic, empowering and problem-posing" approach based on the concepts of the Brazilian pedagogue Paulo Freire (Freire, 1970, 1973a-c).
This critical reflexive method involves an approach to teaching and learning that focuses on analysing issues of interest to the learner, reflecting on the causes of the situations and dealing with them in a problem-posing mode to find solutions. Information and knowledge are used as elements for action, to transform food habits or social conditions.
Health and nutrition educators who advocate this critical reflexive method contend that active participation of learners leads to more comprehensive and effective development of problem-posing and decision-making skills to deal with health, food and nutrition issues and needs (Drummond, 1975, 1977; Minkler and Cox, 1980; Praun, 1982; Uphoff, 1987a,b; Werner and Bower, 1982).
THE EMPOWERMENT EDUCATION METHOD
Empowerment education generates collective knowledge by promoting peoples' critical assessment of their experiences and uncovering of the personal and socio-political dimensions of their problems. Community members envision a better, healthier, more equitable society and develop strategies to overcome obstacles to achieve their goals.
A group discussion is facilitated by poster materials developed by a group of physicians for participants to elaborate (Bartolomé Maso, Cuba, 1987) - Un groupe de médecins a conçu ces posters qui faciliteront les discussions de groupe (Bartolomé Maso, Cuba, 1987) - Debate de grupo en el que se usan carteles preparados por médicos para facilitar la discusión (Bartolomé Maso, Cuba, 1987)
Freire's central premise is that education takes place in the context of people's lives; more than acquiring technical information, learning requires doing. In an intensive learning process of action and reflection, all participants are equal partners. The group has authority to identify issues, determine priorities and design its own curriculum and actions to address the problems in the lives and communities of its members. Nutritional science is one kind of knowledge shared with the group to analyse and solve problems.
The group examines the issues, creates objects for discussion and conducts a problem-posing dialogue around these issues. Role-play, stories, slides, photographs, songs and other communication methods and materials can be used. A problematic situation that is multifaceted, familiar to participants, open-ended and without solutions should be presented to stimulate critical thinking.
Facilitators lead the group with questions progressing from the personal to the social level of analysis and action. For example, the group members are asked to describe what they see and feel, to define different aspects of the problem and to share similar experiences from their lives. They ask themselves why the problem exists. In developing plans to address the problem, value judgements must be made; to do so requires critical and creative thinking and a reflexive practice.
From the problem-posing discussion, ideas for action emerge and are tested in the real world. The group begins a deeper cycle of reflection which encompasses the participants' new experiences. Participants monitor the progress in achieving their goals and objectives, identify problems and implement modifications. This process enables participants to learn from their attempts to change and to become more involved in overcoming cultural, social and historical barriers. This level of analysis is essential in identifying barriers and taking actions necessary for long-term change. Many of the problems posed in this process have no immediate solutions. Changes in lifestyle, health and nutrition, as well as culture and policy, require concerted efforts and perhaps long periods.
This framework has been used with different audiences and in very diverse contexts, for example in addressing malnutrition in northeastern Brazil and Guatemala (Drummond 1975, 1977; Praun, 1982); in dealing with obesity in the United States and in the Pacific Islands (Kent, 1988; Rody, 1988); and in preventing alcohol abuse among adolescents (Wallerstein and Bernstein, 1988).
APPLICATION TO NUTRITION EDUCATION
In the traditional approach to nutrition education, the practitioner's role is to plan and implement surveys of infant feeding practices, to take anthropometric measures of infants and children and to give talks and demonstrations to teach mothers about the nutritional needs of infants and nutritious weaning foods. Often, standard information is given, which may not be clearly relevant to the specific situation.
With the participatory approach, the nutrition educator becomes a partner with the community in identifying and examining the factors that influence malnutrition and cause infant mortality. She or he is a facilitator committed to social change rather than an outside expert providing technical information. The educator is not an authority figure who informs people about programme services but a co-participant in the decision-making process.
Traditionally, knowledge comes from nutritional and medical science, and the content of messages focuses on individual behavioural change. In critical reflexive nutrition education the content is not a mere simplification or translation of science. Nutrition concepts are elaborated in terms that are useful to the community members and the nutritionist. Indigenous knowledge about local foods, health and illness is integrated into nutrition education activities, discussions, demonstrations and other events.
With the participatory approach, educational materials are not only illustrations of messages about food preparation; instead they help the groups to identify needs and problems, to envisage nutritional well-being for infants and children and to discuss appropriate decisions and actions. Materials are working documents that facilitate the critical creative process. Mass communication, especially using local radio and indigenous media, is also an important strategy. Rather than disseminating do and don't messages and broadcasting standard technical information, the main purpose of media and educational materials is to contribute to the analysis-reflection-action process.
STAGES IN A PARTICIPATORY NUTRITION EDUCATION PROGRAMME
Identifying and assessing issues of greatest interest to the community is the first stage of a participatory programme. The nutrition educator visits all the households with children under five years of age and meets with parents and others to develop a programme to improve infant and child nutrition. Group discussions are organized with community members and the participatory approach is explained. The nutrition educator listens to the community members and lists the major issues, needs and problems related to infant and child malnutrition, infection and mortality. Included in the list of topics for discussion are food and nutrition issues such as breast-feeding, weaning practices, access to health care, mother's employment and household income.
During the second stage, the nutrition educator facilitates a dialogue about the social, economic and cultural conditions underlying the nutrition problems. To present critical issues, photographs, role-play, songs or puppets can be used. Community: members describe the problems they see in health and nutrition of infants and children and discuss how they feel about them. They are asked to describe income, job and resource problems as well as the political situation and to relate these conditions to the health of children. Talk about food habits and beliefs is encouraged. They share personal experiences of household food insecurity (e.g. hunger, not enough money to buy food or little land and water to grow food), child malnutrition, infectious diseases (e.g. diarrhoea) and death. Community members are encouraged to ask themselves if hunger and malnutrition exist in their community and why. They are asked which people are most affected. The group develops an action plan to help people resolve this situation and to prevent infant malnutrition.
GOALS AND OUTCOMES OF A COMMUNITY-BASED PROGRAMME
· Improvement in the health and nutritional status of pregnant and lactating women, as well as children under five years of age; to assure adequate growth by strengthening services and increasing community involvement in health and nutrition education activities.
· Increase by 100 percent the number of children of low-income families in the community with adequate growth by a specific date.
· Increase by 100 percent the number of infants from low-Income families in the community that are breast-fed at least three months and the number of children under one year of age that receive liquids and calorie-dense foods during periods of illness by a specific date.
· Decrease by 60 percent the number of infant deaths in the community from gastrointestinal diseases preventable with clean water and adequate hygiene and nutrition by a specific date.
· Eighty percent of mothers in the community will be able to explain the growth chart, plot their child's weight correctly and interpret the growth pattern by a specific date.
· Fifty percent of community members, especially those from lower-income households, will be involved in discussions about the results of the growth monitoring by a specific date.
· The number of community workers trained and competent in nutrition will increase to at least one per 150 families by a certain date.
Through the method of critical reflexive thinking and analysis community members understand the specific context of infant and child malnutrition. Working with indigenous knowledge helps nutrition educators to broaden their understanding of the multiple dimensions of infant and child malnutrition in the community. Community members analyse the nutritional status of infants and children, the nature of the food supply and access in the community with health and nutrition workers. Professionals and lay people become partners in a learning process and in the search for feasible solutions. Together, community members and nutrition educators set nutritional health goals and objectives. Small groups of community members organize nutrition-related activities and there is increased decision-making by community members. The box on the left shows an example of goals, intended outcomes and objectives set by the community and nutrition educator.
In the third stage, decisions are made about actions to solve the needs and problems in both the personal and the social arenas. The community groups continue their learning interactions by organizing activities to meet goals and to overcome obstacles to achieving the health and nutrition situation envisioned. The groups make decisions about actions, set time frames and designate individuals to be responsible for coordinating the activities and making progress reports. A communication strategy should be developed to increase awareness of how personal and collective actions contribute to structural changes needed to improve child health and nutrition. A mass communication programme to build awareness of community needs and problems and to maintain public interest in the activities being implemented is developed. A group should be elected to negotiate with the local media and inform them of activities. Radio spots, billboards, theatre group announcements, etc. can be used to give recognition of extraordinary participation and results of activities.
A COMMUNICATION STRATEGY
The community members and nutrition workers determine the goals and objectives of a communication campaign. The questions presented in the box below may guide the development of a participatory communication programme.
A COMMUNICATION STRATEGY TO SUPPORT COMMUNITY PARTICIPATION
Questions to guide the design of a communication programme:
· What kinds of information do people use?
Examples for the use of local media (radio, printed press, indigenous and folk media):
· A local radio programme to recognize outstanding community effort; interviews with community members to talk about programme activities.
· A contest to recognize outstanding materials, stories, posters and other accomplishments.
· Newsletter or bulletin to inform of activities, discuss results and problems and invite other community members to participate.
In a participatory approach most of the communication strategies are face-to-face group interactions between the nutrition educators and community members. Mass media, if used, should be integrated with all the other activities. In a traditional media campaign, media activity is often isolated and the information disseminated may be unknown to community workers. A participatory approach is finely orchestrated with mass media functioning as a tool that assists in attaining the overall goals of the community. Local media can make the results of participation visible and, by recognizing the achievements of an involved community, can further motivate participation in nutrition education activities. Such media efforts require major coordination among the nutrition educator, the community members and the media workers.
In a participatory approach to nutrition education, learning takes place in the context of many activities. The involvement of community members with nutrition educators in planning and carrying out these activities is an important part of the learning process.
Some examples of activities to address infant and child malnutrition illustrate this approach. For instance, a growth monitoring project for children under three years of age can be organized and coordinated by a group of mothers on a rotating basis, with basic and ongoing training provided by the nutrition educator. Each month a group of mothers from a different area can meet to weigh and measure the children from their area and discuss their growth patterns. A weaning foods demonstration can be given as well. The groups of mothers who receive training and perform these activities would rotate until as many as possible have participated from all the neighbourhoods or areas. Another example would be a child care cooperative administered by a group of mothers whose responsibilities are rotated to facilitate the learning-by-doing process. A feeding programme to care for children while their mothers engage in income-generating activities is another example of this approach. The group could organize to produce vegetables or other foods to sell or consume. Vegetable gardens organized by a youth group to provide food for a child care centre, to sell to raise funds for school projects or for their own consumption is another type of programme. Finally, community development and primary health care programmes need to integrate nutrition education in literacy and adult education activities, reading circles, training for work, water sanitation and immunization programmes and especially the education of community workers.
Activities developed with participatory methods contribute to an ongoing process of analysis-reflection-action concerning issues and needs related to infant health and nutrition. A similar approach was used in the Iringa Nutrition Programme in the United Republic of Tanzania. Community members were involved in the assessment and analysis of problems and decisions about appropriate actions. Focusing on growth monitoring, the programme used a triple A (assessment, analysis and action) process as a key element in achieving the brood social mobilization that contributed to its success. Recent evaluations indicate that this process has contributed to significant decreases in infant malnutrition and mortality (Ljungqvist, 1988; WHO-UNICEF, 1989).
Training community health workers with participatory approaches and in learning-by-doing situations with community members was observed to increase their skills in facilitating participation of community members in nutrition education activities. In a modular training workshop, the use of participatory approaches increased the involvement of community members in the nutrition education activities developed with the community health workers (Cerqueira Aleixo, Cordini De Rosa and Alencar Werner, 1987).
Greater involvement of the participants in developing their own learning experiences resulted in increased goal setting for modification of personal behaviour in a project to prevent alcohol abuse among adolescents and in another project with adults for successful weight loss and maintenance and also enhanced mobilization of community members for community action (Wallerstein and Bernstein, 1988; Kent, 1988; Rody, 1988; Mackie, 1981; Moriarty, 1984).
LIMITATIONS OF A PARTICIPATORY THEORY FOR NUTRITION EDUCATION
Community participation changes the structure and relations of power in decision-making about the use and control of resources. The participation of community members in decisions about activities and resource use can be very threatening to existing groups as well as to the health system or other organizations. Changes from an authoritarian to a consultant style of leadership require basic and continued training. If community members have little authority over the decisions made about the allocation of resources they may lose interest and not participate in the activities planned (Paul and Demarest, 1984).
A fine balance is needed between extrinsic technical knowledge and indigenous knowledge to ensure that the nutrition education activities respond to the community's interests. A goal of participation is to build community members' capacity to solve their own problems; nevertheless, the participatory approach needs an initial stimulus and the continued support of technical expertise and funding from outside sources. The usefulness of external funding and technical assistance must be carefully weighed against the risk of dependency. Community members and the nutrition educator should discuss this issue, and the role and responsibilities of each set of participants should be defined.
Learning-by-doing: physicians and community members plant a vegetable garden while discussing nutrition problems and needs (Bartolomé Maso, Cuba, 1987) - Apprendre par l'action: un groupe de médecins cultive un jardin potager avec des membres de la communauté tout en examinant des problèmes et des besoins nutritionnels (Bartolomé Maso, Cuba,1987) - Aprendizaje a través de la práctica: un grupo de médicos discute problemas y necesidades nulricionales con la población mientras trabajan juntos en un huerto (Bartolomé Maso, Cuba, 1987)
As with traditional nutrition education, there is criticism that participatory approaches are not sustainable after technical assistance and outside funding are gone. In theory, the empowerment education approach will generate community commitment to continue the activities. Infrastructure and organization are central to sustainability and depend on the building of capabilities among community members. Extended periods are required to build up this infrastructure, community organization and managerial ability. The need for flexible time frames and funding terms is a major problem.
Whether the learning process will continue after the initial enthusiasm has worn off is unclear, especially when structural change is required. If the structural change does not materialize, frustration and anger among participants can occur. Poor participation by community members could then be misinterpreted as a lack of interest in improving the health and nutrition conditions of infants and children.
The theory of empowerment education addresses the critical elements of nutrition education interventions and provides a dynamic approach to developing cognitive processes and behavioural skills in an environment of group work. It facilitates a process of exchange of information and skills to improve nutritional well-being and is a planned development intervention. The approach may not be relevant in some situations or settings. While it may be less useful during the initial stages of emergencies, it is very appropriate during the reconstruction phase.
The focus of a participatory approach to nutrition education is to involve community members in a critical, creative, reflexive and interactive process to assess, analyse and act upon issues of interest. In theory, commitment and more sustained improvements in the quality of life in the community should be generated. In practice, there is very little empirical evidence available about the impact of this approach. Active research is needed to develop further the methods and instruments for evaluating participatory nutrition education projects and to improve their intervention design and strategy. Finally, nutrition educators wishing to develop programmes with this approach need to initiate a frank dialogue with national and international organizations to develop more flexible terms of funding and appropriate time frames.
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L'approche participative de l'éducation nutritionnelle proposée ici repose sur la théorie de Paulo Freire, selon laquelle le savoir naît de la prise de conscience. L'éducation est un processus d'action sociale, dans lequel les gens participent à des activités de groupe visant à identifier et à évaluer de manière critique leurs problèmes, à définir en commun leurs objectifs à long et moyen terme et à formuler des stratégies pour parvenir aux résultats souhaités. L'éducation nutritionnelle participative fait de l'élève un sujet et repose sur l'expérience collective. Elle fait appel principalement à l'acquisition du savoir par l'action et au développement de compétences en matière de prise de décision.
L'éducateur nutritionnel aide les membres de la communauté à identifier leurs problèmes et leurs besoins et cherche à percevoir les questions importantes. Il dialogue ensuite avec le groupe par le biais d'une discussion problématique et détermine avec les membres de la communauté les questions, besoins et problèmes principaux. Les membres de la communauté, aidés par l'éducateur nutritionnel, analysent les conditions sociales, économiques et culturelles qui sous-tendent les problèmes nutritionnels et définissent les objectifs à long et moyen terme de leur projet. Les membres de la communauté acquièrent des connaissances en matière de nutrition en menant des activités visant à améliorer leur situation nutritionnelle. Les éducateurs collaborent avec les membres de la communauté pour planifier et exécuter les activités et atteindre les objectifs à long et moyen terme; ils soutiennent les mesures visant à obtenir les changements positifs souhaités par la population, et contribuent à la surveillance et à l'évaluation des résultats.
Dans les approches participatives, les membres de la communauté s'engagent dans un processus d'action et de réflexion. Il existe de nombreux exemples empiriques du recours à cette approche dans les projets de développement rural et de santé communautaire, mais peu en matière d'éducation nutritionnelle. Des expériences réalisées récemment et visant à faire participer la communauté aux activités sanitaires et nutritionnelles ont eu des effets positifs sur la croissance des enfants et ont permis de faire reculer la malnutrition et la mortalité infantiles. Les problèmes identifiés dans le cadre de cette approche concernent la nécessité d'établir des calendriers plus souples, de prendre des dispositions financières et de définir le contrôle des ressources. La part de responsabilité des membres de la communauté dans le processus décisionnel et l'équilibre entre les connaissances techniques de l'expert et le savoir autochtone sont des problèmes qui exigent une formation de base et continue.
El enfoque que se propone para la educación nutricional, basado en la participación, procede de la teoría de Paulo Freire de la educación como práctica de la libertad, es decir, la educación como proceso de acción social que requiere la participación de las personas en esfuerzos colectivos para detectar y valorar críticamente sus problemas, fijar metas y objetivos, y planificar estrategias para conseguirlos. La educación nutricional participativa se centra en el educando y se consolida con las experiencias de grupo. El proceso hace hincapié en el aprendizaje a través de la práctica y en la capacitación para la toma de decisiones.
El educador nutricional apoya a los miembros de la comunidad para que detecten sus problemas y necesidades prioritarios y presta atención a los temas más importantes. A continuación organiza debates de grupo sobre éstos utilizando un método consistente en plantear problemas y, junto con los miembros de la comunidad, hace una lista de los temas, necesidades y problemas más importantes. Los miembros de la comunidad, con ayuda del educador nutricional, analizan las condiciones sociales, económicas y culturales relacionadas con los problemas de nutrición, y fijan las metas y objetivos para su proyecto; de esta manera aprenden acerca de la nutrición aplicando medidas para mejorar la situación nutricional. Los educadores nutricionales colaboran con los miembros de la comunidad para planificar y realizar las actividades necesarias para alcanzar sus metas y objetivos; apoyan las medidas para efectuar los cambios positivos a los que aspiran las personas, y contribuyen a controlar y evaluar los resultados.
Los enfoques participativos involucran a los miembros de la comunidad en un proceso de acción y reflexión. Se dispone de pruebas empíricas considerables sobre este enfoque en los proyectos de desarrollo rural y de salud comunitaria, pero muy pocas en educación nutricional. Las experiencias recientes demuestran que la participación comunitaria en acciones de salud y nutrición produce mejoras significativas en el crecimiento infantil y una disminución de la malnutrición y mortalidad infantiles. Entre los problemas que se han detectado con este enfoque, se incluyen la necesidad de plazos más flexibles, de mecanismos de financiación adecuados y de control de recursos. El grado de autoridad que los miembros de la comunidad tienen en el proceso de toma de decisiones, y el equilibrio entre los conocimientos técnicos y los autóctonos, constituyen temas de reflexión que requieren una formación básica y continuada.