1 Director, Health Development Foundation, Women's and Children's Hospital, North Adelaide, South Australia.
2 Head, Division of Communication and Behavioral Science, Institute of Nutrition, Mahidol University, Salaya, Thailand.
Part one: A framework for planning nutrition education programmes (Barbara Smith)
Part two: A framework for the implementation of nutrition education programmes (Suttilak Smitasiri)
The framework for planning and implementing nutrition education programmes presented in this paper is based on a number of assumptions arising from past experiences of nutrition education and on the changing context for nutrition education in many countries. It should be clear that this framework is intended to promote discussion about the appropriate concerns, parameters, approaches, and processes of nutrition education programmes, not to provide a prescriptive model.
Part one, based on work undertaken by the Victorian Health Promotion Foundation, Australia (Galbally, 1992), describes four components fundamental to planning nutrition education programmes. These four interactive components are underpinned by the nature of the food supply. The framework attempts to broaden the traditional focus of nutrition education in two ways. First, by addressing social health and epidemiological indicators for population subgroups, the framework should lead to the development of health enhancement programmes, as well as disease prevention interventions and ensure that the principles of equity become intrinsic to the process.
Second, analysing the environmental and social factors that contribute to the low health status of population sub-groups should lead to more appropriate settings and methods in programme planning. While it is true that nutrition promotion and education programmes cannot contribute directly to changing structural factors, such as poverty, income level, employment, and educational status, or the social impacts of race, gender, age, disability or ethnicity, they must take these impacts into account in the design, development, and implementation of the programme. This requires programme planners to move away from individual behaviour change and information transmission as the only approach, and to consider in their planning environmental supports, organisational change, advocacy and policy development, and, particularly working collaboratively across sectors and with social networks.
Part two of this paper draws on the knowledge that ineffective nutrition education programmes are more likely to be the result of ineffective implementation processes, rather than a lack of technical knowledge about what works in nutrition education to bring about behaviour change. Several major reviews have also indicated that adequate support from leaders and planners is essential for effective nutrition education programmes. Part two, therefore, looks closely at the phases in the process of implementing programmes, and highlights the need to establish a broad base of support throughout.
The scope of nutrition education
A central assumption of this framework is the question of whether nutrition education should be mainly concerned with those population sub-groups at risk or already suffering from malnutrition, or whether planners can and should be working more actively to prevent malnutrition and promote the knowledge, skills, and supports which will enhance and sustain good nutritional health.
It also raises the question of whether nutrition education must only be concerned with communication activities. For example, one school of thought says that the nature of the food supply is not a proper concern for nutrition education and this has led to definitions of nutrition education such as "any system of communication that teaches people to make better use of available food resources". The difficulty with such a definition is that it does not tell the nutrition educator what to do if available food resources are inadequate, confusing or have an insecure future.
Gussow and Eide (1985) propose that the role for a nutrition educator should be "one who helps people of whatever social, economic or political circumstances to meet their need for nutritious food". This definition implies strategies which go beyond communication activities and encourages planners to consider whenever possible a, variety of strategies to address the factors which are determinants of eating patterns.
This framework therefore aims to broaden the role of nutrition education programmes to include those which not only address existing problems, but also those aimed at promoting and enhancing nutritional health. It also proposes a role for nutrition education which incorporates a range of programme strategies, as well as communication and education activities.
The reason for proposing a broader approach arises primarily from the changing context for nutrition education in many parts of the developing world. For example, Theme Paper No. 5 from the International Conference on Nutrition (ICN) (FAO, 1992) discusses the radical and rapid social transformations which are occurring as the result of mass urbanisation. It is predicted that by the year 2000, about 45% of the populations of developing countries will be living in urban areas, up from 17% in 1950. In absolute terms this means an increase from about 285 million to over 2,250 million people. A significant proportion of urban dwellers are poor and their numbers are growing as urban economies are unable to provide employment for the large numbers of migrants.
The food choices of the growing numbers of urban poor are limited by economic constraints. They often live in poor housing and unhealthy environments, and they may be exposed to occupational hazards and become more sedentary. Urban poverty is associated with increases in infant and child undernutrition, poor diet generally in some societies, and an increased risk of cardiovascular and chronic diseases. There is an almost universal increase in fat and sugar consumption, compared with rural communities where diets are based on such crops as cereals, tubers, vegetables, and fruits.
While nutrition education, no matter how broadly defined, cannot resolve these complex social and economic problems, it can have a role to play in providing support for migrating populations, or those newly arrived in urban settings who are often confronted with a largely unfamiliar, industrialised food supply and limited -purchasing power. It has been said that urbanisation often turns knowledgeable food producers into naive food consumers. Programmes within this framework could be designed to promote the knowledge, skills, and supports needed to be adequately nourished, and to avoid as far as possible the social and economic costs of malnutrition and disease. Depending on the situational analysis, such programmes might include a wide range of education and other methodologies, for example, to increase urban dwellers' access to more affordable traditional foods (growers' markets in the city) and revalue these foods (media, community leaders); to help people understand what is good nutritional value for money in the market-place and to be critical of the vigorous advertising of the least nutritious foods; to provide nutrition education for school children; and to implement or advocate feeding programmes and nutrition education for parents in schools and day-care settings or to provide or advocate affordable, nutritious food at worksites. Strategies commonly used in rural community programmes, such as social mobilisation and community development, may also have value and relevance in urban environments to increase local community control over nutrition issues and provide social support for improved nutrition.
Links with health promotion
During the 1980s there was a growing recognition that the health of individuals was the product of the continuous interaction of the individual with his or her environment. The Ottawa Charter for Health Promotion, sponsored by WHO and developed by 38 countries in 1986 has had a major impact on 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
· reorient health services.
In this way educational strategies to increase the knowledge and skills of individuals are given structural and environmental support. "Make healthy choices, easy choices" (WHO, 1986). This has led to definitions of health promotion which still have education as a central activity, as for example, "Any combination of health (nutrition) education and related organisational, economic and environmental supports for the behaviour of individuals, groups or communities conducive to (nutritional) health" (Green & Anderson, 1986). This framework proposes an approach to promoting good nutrition for the public, which operationalises the Ottawa Charter and should enhance the reach and effectiveness of nutrition education programmes.
Finally, a framework which proposes that nutrition education addresses health promotion and enhancement, as well as risk factor reduction may raise the question of resources. For example, where resources are limited, is it better to preferentially allocate resources to school programmes in an attempt to create a more nutritionally literate future generation, or should resources be allocated to interventions in local communities at immediate risk from vitamin A deficiency? This framework assumes that we must find a way to do both.
Working inter-sectorally and collaboratively is fundamental to increasing the available resources. For example, teachers are already trained educators who, with some support, represent a huge workforce with the potential to have an impact on the health and development goals of a country. Agriculture extension workers may well have production targets or increased exports as their main agenda. Inter-sectoral collaboration can increase their capacity to advise communities on household food production for good nutritional health, without compromising other policy goals. Collaborating with social organisations, for example women's organisations, to support maternal and child nutrition may be an affordable approach. The food industry has an interest in their products being viewed as health promoting and may provide resources for, or participate in, education initiatives. Strengthening the capacity of local communities to solve their own local food and nutrition problems is viable in many situations.
Fundamental to the Ottawa Charter and central to ICN recommendations is healthy public policy. The ICN urged governments to "develop comprehensive policies for improved food supplies and nutrition, adapted to local conditions in each country, and support and encourage home gardens, traditional food production and consumption patterns that support nutritional well-being" (ICN, 1992). Government policy can directly or indirectly support public nutrition education programmes. Misleading food advertising can be regulated, and some countries limit the amount of food advertising directed at children or for products such as breast milk substitutes.
Governments are also major employers. In this capacity they have a responsibility to implement government food and nutrition policies in their own worksites and facilities. Where government facilities provide food services, these should provide a model to the whole community for hygiene standards, the availability of nutritious foods, and nutrition information.
There is a considerable potential for the use of mass media in the nutrition education of the public, but purchasing media time and space can be prohibitively expensive. Where governments are the owners of media, allocating free time for public education can provide valuable support for programmes. Similarly the granting of licences to private companies could require the allocation of a percentage of free public service time.
Government policy initiatives may be able to provide additional funding for health promotion and nutrition education. Some countries have imposed a tax on tobacco products, which is used exclusively for health promotion. A similar strategy could be the imposition of a tax consisting of a percentage of the total advertising budgets of food and beverage companies to be used exclusively in support of nutrition education initiatives. In Australia alone, food advertising expenditure is $A400 million per year. Some 80% of the advertisements are for foods which could be classified as nutritionally undesirable (soft drinks, confectionery, etc.) (Sindall, 1993).
Components of the framework
The food supply is placed at the centre of this framework (see Figure 1) because it must remain the focus of all nutrition education and promotion programmes. It is access to, and the availability of, food which largely determine the kinds of nutrition issues which arise for population sub-groups and these are major factors in the selection of target groups. The selection of settings, sectors, and methods will partly be determined by the extent to which these components have the capacity to influence and mediate people's relationship to food.
As stated above, the framework is based on four interactive components. The starting point is the identification of the nutrition issues for population sub-groups. This will lead to the selection of target groups and determine whether the programme falls into one of two broad categories: health enhancement or risk factor reduction. Selecting the target groups (or population sub-groups) leads to the identification of those settings and sectors which provide the greatest access to the group, and which have the potential for organisational change to encompass nutrition issues in the long term. Finally, the methods appropriate to the target group and the setting can be selected to achieve both individual and organisational change and to provide a supportive environment for change.
Programme planning is not always a logical and linear process. If planners choose to start with another component (e.g. a request from the agriculture sector to incorporate a nutrition education programme into their work), the four components of the programme planning should still be seen as working together and interdependent.
It is assumed that the framework is based on a continuous research and evaluation process. Research and evaluation methods are important aspects of the methods component, as is the need to decide the training and management methods for a programme.
Finally, the framework is generic in that it allows for the incorporation of a variety of different theories and approaches, or combinations of these in programmes. It aims above all to foster an integrative approach that avoids the dichotomies which have traditionally existed between, for example, community development and social marketing, or risk factor versus social determinants of health, or individual versus organisational change.
Figure 1: Framework for planning nutrition promotion and education programmes for the public. (Adapted from Galbally, 1992).
The food supply
The nature of the food supply and people's access to it are obviously fundamental to nutritional well-being. Cultural practices and traditions influence the actual choices that people make. Nutrition education programmes, therefore, need to take account of the availability of food, people's access to food and the factors determining choice. A traditional role of nutrition education has been to increase the capacity of the household to use existing food resources to maximum advantage, particularly in relation to breast-feeding, weaning, and supplementary feeding of children, dietary practices during infectious disease, nutrition during pregnancy and lactation and food hygiene. Education on the ways to produce food at the household level and on ways to store, process, and prepare these foods has also been incorporated into many programmes.
However, nutrition education also needs to accommodate social and technological change. The food supply of many developing countries is changing rapidly as a result of economic growth. Value-added, processed foods become available, bringing both benefits and negative consequences. Frequently, many of these foods provide poor nutritional value for money and may displace affordable and more nutritious foods. Traditional nutritional wisdom does not exist for the use of these products and people may depend on advertising to "know" about these foods. As these value-added foods are usually the most profitable, they are likely to be vigorously and persuasively promoted. Patterns of health and disease will change as food consumption changes.
The starting point in this model is the identification of the nutrition issues affecting population sub-groups. These should be based on data obtained by regular national monitoring and surveillance of the dietary intake and nutritional status of the population. Together with nationally developed Recommended Dietary Intakes for nutrients, these data can underpin the development of dietary goals or guidelines. Although the terms "goals" and "guidelines" are often used interchangeably, goals are more likely to be quantified, with expected times for achievement (targets). Dietary goals are usually changes in the national diet which will improve diet-related morbidity and mortality. They are designed for the use of health professionals and for monitoring policy. For nutrition education, goals are more likely to be described as guidelines and provide desirable directions for dietary change. Guidelines can be developed specifically for population sub-groups, such as children.
The issue of ecological sustainability of the food supply and the need for countries to maximise food self-sufficiency are rarely addressed in guidelines. However, it has been argued that these issues intersect with health and should be reflected in guidelines through the promotion of fresh, local, and seasonal foods. This will help reduce the vulnerability of food supplies due to imports, and reduce the energy costs of processing and transporting foods.
A second consideration in addressing the nutritional needs of population sub-groups is the development of environmental, social, and intrinsic indicators that contribute to nutritional status.
The environmental indicators include structural factors such as poverty and income level, employment status and educational status. While nutrition education cannot contribute directly to changing such structural factors, knowledge about these factors and, in particular, how they relate to the nutritional status of the population sub-group, will influence the settings and methods of a programme.
The social impacts of race, gender, age, and disability are significant factors which can create disadvantage in gaining access to adequate nourishment. Again, while nutrition education programmes can do little to mitigate against these impacts, they must take them into account in the design, development, and implementation of programmes.
Physical infrastructure, such as housing and transport, must also be considered in planning. All of these factors can in turn, relate to the factors that have an impact on the individual and his or her vulnerability to nutritional risk. Along with inter-generational and familial factors, they can influence nutritional status, self-esteem, and motivation.
Finally, the perception of a particular population sub-group of its own nutrition priorities will contribute significantly to the effective design of programmes. Programmes are much more likely to be effective if the issues of greatest significance to the group are addressed and they are involved in the planning, management, and ownership of the programme.
Assessing the nutrition issues of population sub-groups using both nutritional status and social health indicators, should lead not only to risk reduction programmes based on malnutrition reduction, but also to programmes designed to promote and enhance the health of the population.
· Primary target groups:
(i) Population sub-groups - life cycle approach (see figure 2)
Assessing the nutritional issues of population sub-groups will lead to the identification of appropriate target populations. Taking a life cycle approach can be one way of ensuring that the needs of a whole population are assessed and of taking into account the developmental needs.
It has been suggested that the first stage would start at pre-birth and birth, the maternal and infant stage of life. The second stage could be seen as childhood, with adolescents having different developmental (and social) needs. The adult and family stages require different approaches again from the older stage of life.
(ii) Population sub-groups - special needs
In order to address inequalities in nutrition outcomes, groups with special needs should be identified and targeted. These groups will vary from country to country but could include ethnic communities, newly arrived migrants or newly arrived urban dwellers, unemployed and low socio-economic groups, people with disabilities, disadvantaged men or women at particular risk for gender specific issues.
Figure 2: Life cycle population sub-groups (Galbally, 1992)
· Secondary target groups:
Secondary target groups can be defined as the people who will be used to reach the primary target groups. These can include health workers, teachers, agriculturists, media journalists, food producers and retailers, child care workers, village volunteers, and so on. Training will usually be required for this group.
· Tertiary target groups:
These are people who are able to facilitate or support nutrition education initiatives. They may include decision makers at all levels - politicians and administrators, but can also include such people as influential community or religious leaders.
Settings and sectors
This model is intrinsically multi-sectoral because it relies on key settings which, apart from the primary health sector, are all external to health. The use of key settings, not traditionally seen as the domain of nutrition education programmes, enables population subgroups to be reached where they work, live, and play. The use of a wide range of settings and organisations provides for positive links to occur across disciplines and encourages a much wider community involvement in nutrition issues. It also enables precise targeting of the population to occur and the development of methods suitable to the measurable and perceived needs of these locations.
Furthermore, a settings approach can emphasise changes in organisations which support individual changes (Galbally, 1992). Such an example is policy development at the organisational level that commits the organization to practices which support healthy eating, such as healthy food services or nutrition information services.
Settings for reaching the whole population can include primary health care services, general practitioners, community health services, families, villages and local communities, schools, day care services, work places, recreation settings - social organisations, arts, cultural and sporting groups, retail and commercial settings - street vendors, cafeterias, and food shops.
Working in a variety of settings and with a variety of organisations, requires collaboration and negotiation and the cultivation of long-term relationships across sectors (Glanz & Mullis, 1988). In each case, a strategic assessment of possible areas of mutual benefit and the strategic use of influence measures become the mechanisms for attempting to bring about change (Sindall, 1993). Despite the extensive rhetoric about inter-sectoral co-operation, little theory or documentation exists to guide nutrition practitioners.
· Education and communication methods:
Selection of educational methods should be based on what is appropriate for the target groups and the setting. An analysis of the determinants of the nutrition behaviour of the target group, including the factors likely to influence behaviour, is the usual starting point (Andrian, 1994). In the widely used Precede model this takes the form of identifying the predisposing factors (knowledge, beliefs, values, attitudes, confidence) that provide the rationale or motivation for the behaviour; the enabling factors (skills, resources) and the reinforcing factors (family, peers, teachers, etc.) which reward or contribute to the persistence of behaviour (Green, Kreuter, 1991). This is the kind of information that provides the basis for planning the education and communication methods to be used.
(i) Selection of channels
Face-to-face education, either in groups or on a one-to-one basis, has been the traditional approach to nutrition education. In recent years this approach has been seriously questioned, usually in the context of the relative merits of face-to-face versus mass media approaches.
Nutrition education presents some unique challenges in the health education area. While the origin of all human behaviours is complex, nutrition education has the additional problem that good nutrition involves the capacity to discriminate among many different foods. It may be easier to identify a single substance (e.g. tobacco) as injurious to health, or to promote the benefits of a capsule or injection, than to provide the information required to make choices about a range of foods. This is further complicated by the fact that no one food can singly be labelled "bad" or "unhealthy", as it is amount and frequency of consumption which will affect health. In addition, nutrition is an area in which information alone is unlikely to be helpful. Advice to add nutritious foods to rice gruel weaning food, requires not only information about what foods, in what amounts and with what frequency, but may also require the development of skills to grow and prepare these foods.
On this basis, it can be seen that face-to-face methods are likely to be the most effective for nutrition education. Evaluations of nutrition education confirm that programmes which have an impact on behaviour (not just on knowledge and attitude) depend on social context and interpersonal interaction to provide participants with the opportunity to practise the new behaviours and learn to solve their own nutrition problems over time.
Mass media strategies, on the other hand, are based on marketing and communication models which tend to deal with simple messages or a discrete food or behaviour. Nutrition education is rarely dealing with a single behaviour or single food. Nonetheless, mass media has been used effectively where this is the case, for example, encouraging the use of iodised salt. Using mass media has also been effective in raising community awareness of a nutrition problem, or most commonly as part of a multi-channel approach in which mass media supports other actions or face-to-face activities.
In general, it is agreed that face-to-face strategies are more likely to be effective in changing behaviour than mass media programmes. Using the strategies synergistically seems to be best option in most situations. Table 1 summarises the complementary nature of the two approaches.
Table 1: Some relative advantages and disadvantages of face-to-face and mass media approaches
· Cheap per contact
· Weak engagement of users
Adapted from the Australian National Health and Medical Research Council's Nutrition Education Report (1989)
(ii) Food guidance systems
A significant issue is whether or not a country should develop a food guide as an educational tool for public education programmes. These usually take the form of a practical daily plan for food selection. Traditionally, recommending minimum daily servings which made up a daily "foundation" diet was the basis of food guides. The foundation diet was prescribed to provide approximately 70% - 100% of the Recommended Daily Intakes (RDI) for nutrients with additional foods (contributing insignificant amounts of nutrients) being discretionary. It has been argued that when there is a concern regarding the nutrient-energy balance of diets, the total diet should form the basis of food guidance. Another issue frequently raised is whether a country should have one guide or several. Those who argue for one guide maintain that a single guide gives consistency through public education programmes, in schools, the media, and advertising. A single guide can nonetheless be adapted for special needs, for example, low literacy, ethnic minorities or cultural differences. Others argue that a number of different guides needs to be developed for special nutritional needs, for example, different age groups.
Food guides can be developed in a variety of graphic forms (food wheel, pyramid, target, plate, standard blocks, etc.) to communicate the nutrition information. The effectiveness of the graphics and general communication strategy is evaluated less often than the nutrition aims.
Many other complex issues can arise in developing a food guide. These may include the extent to which a guide should reflect the current food supply and food practices, or whether it should represent an "ideal"; the extent to which guides should sacrifice accuracy or completeness for simplicity; the extent to which a guide should reflect a concern for sustainability of the food supply; to what extent a guide can "stand alone" or be part of a more extensive education strategy.
· Support strategies:
These are strategies designed to support the education process. For example:
Advocacy to influence decision makers to support nutrition promotion and to mobilise social support.
Policy (blueprints for action), can be developed at all levels of society. Apart from national policies impacting on the national food supply, local communities may make a commitment to allocating land for vegetable gardening; a day care centre can have a policy to only serve nutritious foods; a school can develop a policy to allocate specific time to nutrition education.
Community action. Community-based programmes can increase community control over information (relating to food and nutrition); relationships (mobilising social support, facilitating self-help), resources (resource sharing, increasing purchasing power for food) and decision making. Community action can be critical for the sustainability of nutrition improvement.
Regulation. While regulation may be outside the direct sphere of nutrition education, nutrition educators and community members can advocate for certain kinds of regulation. Regulation of the food supply can be a major strategy to support nutrition promotion. Providing enforcement strategies are in place, regulation can ensure the safety of food from many contaminants and agricultural residues. Compositional standards can protect the nutritional integrity of basic food stuffs. Where there is a clearly demonstrated need (not just for marketing purposes), fortification with a vitamin or mineral can address a specific nutritional deficiency. Food labelling laws can provide valuable information to consumers and controls can be exerted over inappropriate or misleading advertising and marketing.
Food production and processing. Many successful nutrition education programmes have been supported by developing participants' skills in growing, processing, and preparing foods.
Raising awareness. Social marketing methods such as media, advertising, and sponsorships, raise awareness of nutrition issues in the community, influence public opinion, and give nutrition education a higher profile. The process of creating broad social support, will often be the first stage in effecting positive changes.
Organisational change. Collaborating with organisations and sectors, such as local government, social organisations, worksites, educational organisations, health centres, and cultural groups, can lead to changes within these organisations which support nutritional improvements. The "healthy hospital", "healthy school", "healthy worksite" and "healthy community" movements are such examples. Achieving organisational commitment to support improved nutrition can be a major factor in the sustainability of programmes.
· Research and evaluation:
Selection of appropriate research and evaluation methods should be made at the planning stage. Pre-intervention data is needed for selecting the target groups, settings, and methods and to try to determine the cost-effectiveness of the proposed programme. Continuous evaluation of the programme for adjustment and change is needed as well as assessment of the final process and outcome results.
· Training and management:
The need and the methods for training need to be decided. As well as me implementors of the programme, secondary and tertiary target groups may need training programmes. Management training is often needed and the methods for managing the programme need to be established.
This framework is located within a health promotion model and broadens the scope of nutrition education to include health enhancement as well as risk factor reduction programmes. By recommending that the social health indicators of population sub-groups, as well as the epidemiological factors are considered, it moves nutrition education towards a focus on people and health rather than disease.
This change in emphasis requires programme planners to consider going beyond communication activities and including strategies designed to provide for environmental and organisational supports for individual behaviour change. The key settings and sectors approach also shifts the emphasis towards creating supportive environments for behaviour change. Achieving changes in organisations to make them more supportive of nutritional improvements will also lead to increased ownership of nutrition issues and make the sustainability of positive changes more likely.
Many countries of the world are faced with rapid social and economic changes, many of which are having a negative nutritional impact on sectors of the populations. Nutrition education can no longer afford to be only "picking up the pieces" after malnutrition has occurred, but must also find a way to promote and enhance good nutritional health in the face of these changes.
(i) Nutrition education programmes should be based on an assessment of the nutritional status and social health indicators of population sub-groups.
(ii) The development of Dietary Goals and/or Guidelines can be a valuable tool for the direction of dietary change desirable in a specific country. Guidelines developed for vulnerable population sub-groups, such as children, should be considered.
(iii) There is a need to develop both risk reduction and health enhancement programmes particularly in situations of rapid social and economic change.
(iv) Planning for nutrition education, and promotion programmes planning, should be based on an analysis of four major interacting components: the nutrition issues of population sub-groups and special needs groups; which in turn influence the choice of target groups; settings and sectors; and methodological approaches. The prevailing nature of the food supply and issues of access and availability will underpin these decisions.
(v) Key settings and sectors for the implementation of programmes should be those which provide greatest access to the targeted population group and which have potential for organisational change to provide long-term support for nutrition improvement.
(vi) Methods selected for nutrition education and promotion programmes must be appropriate for the target group and the setting and preferably include a range of approaches to bring about organisational as well as individual change.
(vii) Methods for both process and outcome evaluation must be included in the planning decision.
(viii) The training and management needs and approaches must be decided at the planning stage.
(ix) Governments should consider policies which support nutrition promotion and education for the population, e.g.· Regulating food advertising.
· Regulating the promotion of breast-milk substitutes.
· Making provision for health promotion and nutrition education through a tax levy on cigarettes and/or food advertising.
· Implementation of nutrition policy in government worksites to provide a model for other sectors.
· Making nutrition education in schools mandatory.
· Incorporating nutrition and nutrition education goals into agriculture policy.
Andrian, M. 1994. Social communication in nutrition: A methodology for intervention. Rome, FAO.
FAO. 1993. Report of the Inter-country Workshop on Nutrition Education for South and East Asian countries 22-26 February. Thailand, Institute of Nutrition at Mahidol University, FAO.
Galbally, R. 1992. Planning health promotion: The nexus between epidemiology and equity. Draft paper. Melbourne, Victorian Health Promotion Foundation.
Glanz, K. & Mullis, R.M. 1988. Environmental interventions to promote healthy eating: a review of models, programmes and evidence. Health Educ Q, 15: 395.
Green, W.W. & Andersen, S.C. 1986. Community health. St. Louis Times Mirror/Mosby College Publishing.
Green, L. & Kreuter, M. 1991. Health promotion planning: An educational and environmental approach. (2nd ed.) Mountain View, CA, Mayfield.
Gussow, J.D. & Eide, W.B. 1985. The challenge to the profession: how do we train for what we want to teach? In Taylor, T.G. & Jenkins, N.K. (eds) Proceedings of the XIII International Congress on Nutrition. London, John Libbey.
Hornik, R.C. 1985. Nutrition education: A state of the art review. ACC/SCN Nutrition Policy Paper No. 1. Rome, FAO.
Lee, C. & Owen, N. 1985. Behaviourally based principles as guidelines for health promotion. Community Health Studies, 10(2): 131-137.
ICN. 1992. Major Issues for Nutrition Strategies. Theme Paper No. 5. Promoting appropriate diets and healthy lifestyles. Rome, FAO/WHO.
National Health and Medical Research Committee. 1989. Implementing the dietary guidelines for Australians: Report, of the Subcommittee on nutrition education. Canberra, Australian Government Publishing Service..
Rose, G. 1985. Sick individuals and sick populations. International J Epidemiol, 14(1): 32-38.
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It is understood that science-based knowledge is available to promote better nutrition and to prevent those who know how to use such knowledge from suffering from most nutrition-related diseases and illnesses. Basically, what causes malnutrition, either over or under, and which essential elements are important to improve such conditions, are now known. Moreover, the necessity to establish appropriate national mechanisms to prioritise, develop, implement, and monitor policies, including laws to improve nutrition within specified time frames, based on both national and local needs, and provide appropriate funds for their functioning, has already been recognised by many leaders around the world (FAO\WHO, 1992). Therefore, it is time to focus more attention on the issue of knowledge implementation.
This paper aims to provide guidance for programme administrators on the implementation of nutrition education programmes. It emphasises, in particular, the processes of maximising the use of available nutritional knowledge to promote better nutrition for the public, especially for those in the less developed countries where nutritional conditions are commonly critical. However, the issues raised could be helpful for developed countries as well.
Nutrition education, in the last two decades, has gone through its own development process. Presently, it is recognised that generalised nutrition education (providing information that a problem exists and describing its parameters) is rarely effective (Worte, 1978; Ward, 1984; Hornik, 1985). Successful approaches, in general, accept that nutritional behaviour is very complex, and that changing this behaviour definitely requires not only cognitive change, but also attitudinal change. Moreover, motivation appropriate to the required action must often be created (Smitasiri, 1994). Nutrition education is thus no longer just imparting information, or bombarding people with nutrition messages, but getting people - everyone from target villagers to national policy makers - to do something differently in order to improve nutrition (Berg, 1993).
Based on the lessons learned in this field, at least two issues should be addressed before attempting any effective national or large-scale nutrition education programme: (i) what really is the major obstacle? Is it a technical or operational issue which inhibits nutrition education's contribution at the present time? And (ii) what should be considered before launching such a nutrition education programme? First, it is argued that the main obstacle in most cases should not be a technical one, since both extensive reviews of nutrition education work by UNESCO and the World Bank in the 1980s (Israel & Tighe, 1984) suggested that the problem with nutrition education was more how the techniques could be implemented effectively. For instance, Israel and Tighe concluded that good techniques were in fact available, but that nutrition practitioners lacked support in utilising the techniques effectively in their nutrition interventions.
Second, both reviews implied that adequate support from leaders and planners is essential to start an effective nutrition education programme. They need to really consider whether nutrition education can be a means to achieve significant goals of nutritional behaviour change. Their decisions and commitment to providing appropriate support for the work are fundamental. As Hornik (1985) put it, "if it is politically unrealistic to expect adequate support for nutrition education, then it is going to be unrealistic to expect worthwhile consequences". If leaders and planners believe that people need to know how to provide themselves with adequate intake, that they actually want to do it, and that they are able to take appropriate action, they must consider focusing their attention on how to apply appropriate techniques effectively in their contexts. Moreover, they must be realistic about their inputs and the consequences of the process. These particular issues, therefore, need to be considered seriously before launching a national nutrition education programme.
In the following, a generic framework is proposed to guide the implementation of national or large-scale nutrition education programmes. This framework suggests a conceptual process involving three major components: Decision, Development, and Dissemination, which are considered crucial for programme effectiveness. Each component, together with its elements are discussed. Also, specific recommendations are submitted for international agencies and countries, in order to support more effective nutrition education programmes aiming to improve nutrition situations over the next ten years.
The Decision-Development-Dissemination Approach as a generic framework for effective national nutrition education for the public
The Decision-Development-Dissemination Approach is defined as a holistic and systematic framework for implementing an action-oriented programme, with the emphasis on: the decision process necessary to lead the work in the right direction(s), the arts of programme development, and the significance of the dissemination process, in order to maximise nutritional change, as well as increase the programme's sustainability. This framework, as shown in Figure 1, is intended to stimulate the right foresight necessary before the actual implementation of a national nutrition education programme.
Phase. 1: The Decision process
Firstly, this framework suggests that an effective national nutrition education programme should start with a sound Decision process. Key policy and decision makers need to consider carefully whether nutrition education is a good strategy to improve nutrition situations in the country. In so doing, the process involves at least two essential elements:
· cause (s) Why is it necessary to invest in a national nutrition education programme? How much should a country invest in such activities?
· changer (s) If necessary resources are provided, will there be capable individuals in the country to manage the expected changes?
Though there were some examples of successful nutrition education programmes in the past, unfortunately, nutrition education approaches were not well perceived by many. Due to lack of confidence that nutrition education works, most countries devote only a pittance of their nutrition budgets to education activities. As a consequence, some experts believe that the potential of effective nutrition education programmes has been impeded (Hornik, 1985; Berg, 1993). Therefore, if Israel and Tighe (1984) are right that good techniques are already available for implementing effective nutrition education programmes, it is now up to national policy and decision makers to decide on the goals and objectives of their nutrition education programmes and to commit themselves to the implementation of such programmes. Their decision and commitment should be shown in the budgets and the level of involvement in the programmes.
In so doing, they should examine whether the root of nutritional problems in the country is determined by nutritional behaviours. If these behaviours were appropriate, would the result be better nutrition for the public? Nutrition education is a viable policy option when currently available resources at the household level are not producing optimal benefit. Nutrition education can also help people to adapt to current or anticipated changes in the environment (including non-educational nutrition interventions) to improve their nutritional status. Only when national policy and decision makers perceive that changing nutritional behaviours of the population will indeed be more beneficial for their nutrition development in the long run, is it the right time to discuss investing in nutrition education, and a time when nutrition education becomes a reasonable investment for the programme. National policy and decision makers need to perceive that the cause (s) of implementing a national nutrition education programme is (are) relevant to their country so that they really find it critical to support such a programme (see Figure 1).
It would be too idealistic, however, to expect policy and decision makers to automatically understand the importance of nutrition education. Therefore, programme administrators and individuals who see the benefits of such intervention for the country - they may be important nutrition scientists, key administrators at the ministry of public health or other related ministries, etc. (in the following these individuals will be called "change initiators") - often need to assist policy and decision makers in this particular process. This is one of the most crucial steps to be taken at the very beginning of any effective national nutrition education programme. Nevertheless, records show that this step has seldom been competently implemented.
Thus, it is important that change initiators be "proactive". They must consider policy and decision makers as their target audiences. Knowledge of the process of behavioural change, together with concrete evidence of how beneficial effective nutrition education programmes could be, should be used convincingly so that policy and decision makers perceive nutrition education as a relevant strategy for national nutrition development, and are willing to commit themselves, as well as reasonable resources, to nutrition education activities. They must understand that adequate investment in the right strategy at the right time will definitely result in the effectiveness of their nutrition interventions. Change initiators, therefore, have a major role to play at this initial stage. Their influence, if efficient, will give a national nutrition education programme a good beginning.
The next issue involves another type of changers. These changers usually interact directly with the target audience. They are called change agents. Change agents can be individuals at any level from the national to the community level. In general, they adopt the idea of the proposed change and are willing to influence others to change as well. Though change agents can be experts in related fields, government or non-government workers, or community members, etc., those involved more directly with planning and implementing nutrition education programmes, will be the focus here.
Figure 1: The Decision-Development-Dissemination approach as a generic framework for nutrition education for the public
One important reason why many nutrition education programmes fail, is the fact that governments often assign inappropriate people to manage the programmes. Nutrition education, on the surface, looks so simple that anyone can do it and people often say they can. This work, in fact, needs quality change agents with adequate capacity to engage in the behaviour change process (Berg, 1993). Therefore, it is crucial for national policy and decision makers to make a good decision about who should be key change agents for their national nutrition education programmes.
To assist national policy and decision makers in the selection process, some notable characteristics of change agents, which seem to be beneficial to nutrition education work, are suggested below. These characteristics will not be found in an individual change agent. They are suggested as characteristics necessary for a group of change agents who will be actively involved in the implementation of a nutrition education programme. The suggested characteristics are as follows:
· change agents should have the capability to think strategically;
· their ability to understand the target population is crucial;
· they should have talent and creativity to guide the design, development and dissemination of innovative and useful messages;
· they must be willing to use technology (especially communication technology which includes both mass media, small media, folk media and person-to-person) appropriately and creatively;
· an interactive orientation and an ability to work with others as partners in the behaviour change process are indeed essential;
· they must give priority to listening to all involved;
· their aim is to make a difference through education/communication and collaboration; and
· they should have knowledge of related theoretical and conceptual frameworks, in particular, about what it takes to bring about behaviour change.
If change agents at all levels have appropriate attitudes towards their responsibilities, it is more likely that the work will be successful. For example, effective change agents are those who usually believe in: comprehensive implementation, co-operative effort, and long-term sustainable change. Also, they often have realistic expectations about the outcomes of education/communication approaches. Therefore, to increase their chances of successful national nutrition education programmes, governments should be encouraged to make careful decisions in this selection process. If the aim is to use nutrition education as a strategy to improve national nutrition, it is important that people are not only aware about nutrition; they must also be willing to practise what they know to be right in their everyday lives.
Phase 2: The Development process
Secondly, this generic framework emphasises the importance of a national nutrition education programme's Development process (see Figure 1). Once the right decisions have been made to implement the programmes, developing them to the appropriate level of commitment and support is necessary. Issues that are important for the formulation of a national nutrition education programme are described below. In addition to the general procedures guiding effective implementation, this process highlights, in particular, three essential elements.
· Assessment. The need for contextual knowledge and information development in order to plan and implement a programme well.
· Analysis. It is suggested that critical analysis of the food supply, nutrition issues, target groups, and key settings, as related to nutrition education are crucial to a successful programme.
· Creative action. Actions leading to nutritional behaviour change in the population need to be creative. These actions should direct the audiences to move forward in the change process.
Since changing behaviour requires an understanding of people's perceptions and then a responsiveness to those perceptions, it usually requires an assessment of contextual situations. This can be done through what is normally called formative research, which is useful as a solid foundation to a problem-solving process necessary for an effective national nutrition education programme (Berg, 1993, Smitasiri, 1994). In terms of methodology, it can be said that any data collection techniques used in social sciences can be applied to collect formative research data for nutrition education work.
Nonetheless, market research and qualitative research have been used more often in this area. In-depth interviewing and focus group techniques are believed to be very useful in obtaining information about the target population. These data are valuable for developing a programme's strategies and designing education/communication messages. Currently, most effective nutrition education programmes report the use of formative research as a necessary assessment before developing intervention strategies for their programmes. Sensible investment in this type of research for a national nutrition education programme is highly recommended.
Moreover, an understanding of the target population, and the ability to analyse this understanding, as it is related to the food supply, nutrition issues, target groups, and key settings are particularly critical for planning and implementing a national nutrition education programme. This process of analysis is essential because it allows programme administrators to select the appropriate target groups, the appropriate settings and sectors for programme delivery, and a range of educational and support strategies appropriate to the target groups and settings, in order to have maximum impact on the nutrition issues being addressed.
It is now known that availability of food, people's access to food and the factors determining choice are fundamental to nutritional well-being. A national nutrition education programme, therefore, needs to take account of the food supply (safety and sustainability, access and availability). In general, a national nutrition education programme should play an important role in increasing the capacity of the household to use existing food resources, and sometimes it is necessary to encourage people to produce better food for the family (store, process, and prepare) as well. In the long run, however, such a programme must also be able to develop a nutritionally literate population so that they can make better choices among the new valued-added, processed foods which are now commonly available in the market place. Such choices should be on the basis of nutrition, cost, and household food security. In some circumstances, nutrition education needs to be actively involved in promoting or revaluing traditional foods and practices. Nutrition education planners and implementors should analyse the country's food supply carefully and find the most feasible way(s) to use nutrition education strategies to adjust it in order to facilitate better nutrition for the public.
Identification of the nutrition issues, which is often the starting point of a nutrition education programme, should be based on data obtained by regular national monitoring and surveillance of the dietary intakes and nutritional status of the population. Usually, it is recommended that a national nutrition education programme should promote an understanding of the basic principles of healthy eating. Since food choice and eating behaviour are intimately linked to culture, a people-oriented approach which seeks to modify the social norms of eating behaviour is likely to be effective (Sindall, 1993). Nevertheless, groups with special needs who are at nutritional risk should also be identified and targeted. People who can be influential in the primary target groups should be considered as target groups as well. In addition, tertiary target groups (people who are able to facilitate or support nutrition education initiatives) may include other influential people at all levels (politicians and administrators), as well as people like community or religious leaders. Also, key settings (school canteens, health centres, etc.) can be used to enable population sub-groups to be reached where they are.
Through the processes of adequate assessment and good analysis, nutrition education programme administrators should be able to develop a sound strategic plan for their national programme. This plan, if it is well developed, can contribute greatly to a programme's success. These elements will benefit the development of a national nutrition education programme most if the steps suggested earlier are used by a planning team that recognises the importance of interdisciplinary planning. Before the actual planning sessions, programme administrators should agree to adopt an interdisciplinary framework. They should understand the difference between being a specialist and a generalist, and they should know their roles in the planning team. Thus, the characteristics of administrators and planners themselves are also important to good planning and implementation, since collective efforts are required for nutrition education planning and implementation.
Next, the Decision-Development-Dissemination Approach reveals the significance of creative action (see Figure 1). This element, in general, involves creativity in planning and implementing an action programme. The word "creativity", which means the power to bring into existence or the ability to create, is often seen as an alien factor in nutrition work, where the most influential actors are usually trained as scientists. Though scientific training is most important in obtaining more nutritional knowledge, nutrition scientists need to work with others in implementing nutritional sciences in order to improve nutrition in the population. Social scientists, anthropologists, epidemiologists, communication specialists, marketing strategists, etc., must be involved in changing the nutrition behaviour of the public. This interdisciplinary team should work together to create actions which are able to secure the target audience's attention. The audience should also be able to comprehend the purpose of the recommended actions. Such actions should also guide them to maintain the. changes.
A major action for a national nutrition education programme is usually the communication/education process itself In general, it is recommended that an effective programme should plan to manage at least two communication/education actions: (i) communication/education actions for changers (change initiators and agents) themselves, and (ii) communication/education actions for target audiences at different levels. Communication/education actions for changers are necessary, for instance, to maintain the level of knowledge, skills, and motivation needed to implement a programme, to facilitate team-work and indirectly to make changers themselves recognise their importance to a programme. These actions are often achieved through group communication such as meetings (formal and informal), seminars or workshops, person-to-person communication, and mass media (i.e. newspapers, radio, and television). These communication/education actions are frequently neglected in a national nutrition education programme.
Communication/education actions for the target audiences of a national nutrition education programme should be seen as a comprehensive intervention. Target segmentation is indispensable in order to maximise the effectiveness of the communication/education process. Usually, a comprehensive intervention will involve the use of multi-channel and multi-approach communication/education which is designed to maximise reach and effectiveness through an appropriate combination of community outreach, mass media and folk media, school programmes, and interpersonal communication. These communication/education actions for a national nutrition education programme should have at least three major objectives:
· to create an environment that supports the change,
· to focus on creating well-selected changes which are realistic in the light of the time and resources available, and
· to encourage community participation in the change process.
To create an environment that supports nutritional behaviour change, in other words, to create a nutritionally literate society. The appropriate mass media (i.e. radio, television, printed materials) is normally used to inform the public about important nutritional issues. Several nutrition messages should be strategically communicated through the selected mass media with emphasis on the attractiveness, clarity, and completeness of messages and their frequency. If this intervention is carried out well, outcomes should be expected as follows:
· the public is aware of important nutrition issues,
· the public understands those issues, and
· the level of nutritional information in the community is supportive of the change.
Nonetheless, generalised nutrition education is unlikely to be successful in improving nutrition in the population, no matter how sophisticated education/communication methods are used (Worte, 1978). So, it is recommended that a national nutrition education programme should have its focus on creating well-selected changes. Based on solid nutritional data and population assessments, decisions can be made as to what changes should be initiated in a society in a particular time frame. The social marketing approach is found to be particularly useful for this type of intervention (Smitasiri, 1994).
Once the public is aware and informed, many of them will go through a process in which they want to utilise their new knowledge but they often delay making decisions. At this stage, it is helpful to encourage more community participation in the change process. For instance, creating nutrition action activities in local communities and positive competition campaigns to allow people to try the proposed changes can be helpful in assisting them to experience such changes directly. If the experiences are positive, people will be likely to adopt the changes. Thus, community action programmes should always accompany intangible nutritional information. There are some enabling factors which can be conducive to creative action in a national nutrition education programme i.e. strategic implementation, "self efficacy", effective decision-making process, suitable managerial skills, and appropriate personality of the taskforce are especially noted (Smitasiri, 1994). An effective nutrition education programme requires implementation that secures the desired end. Therefore, carefully developed strategies of a programme action plan are essential to provide clear direction for creative action. Without this direction, it is unlikely that the work will be carried out effectively through co-operative efforts.
When implementing nutrition interventions, especially in less developed countries, it should not be a surprise to find that many lack confidence in doing the work. This is particularly common among those at the grass-roots level where interpersonal communication is most crucial. It is necessary to improve the situation. Initiatives should be taken to develop self-efficacy by helping individuals to strengthen confidence in their capacity to create the desired positive change. The setting of realistic objectives, the acceptability of the programme, and confidence expressed by the programme team are significant in developing self-efficacy. This should take place through informal and formal efforts at an early stage of the programme. Programme administrators and their teams will need to spend a great deal of time in establishing informal and formal contacts with several individuals in order to get to know them as people, to understand them in their working conditions, to give them full details about the programme's objectives, and to work with them in setting realistic achievable goals.
Furthermore, an effective decision-making process during implementation is also critical because collaborative decisions are necessary. Concrete information, such as that provided by the formative research, is especially helpful in this process. In addition, facilitating creative action in nutrition education work requires the following of a managerial unit:
· practices grounded in the real situation in which the programme operates;
· attention to the consequences of forcefully applying programme procedures to other related operational units (awareness of goals and objectives of all related inter-sectoral offices is necessary in order to decide how programme procedures should be applied);
· an understanding of existing conflicts among related organisations (its sensitivity to these conflicts is a safeguard for working effectively with each office);
· willingness to cope with existing limitations within the system;
· the ability to make the best of what is available and be willing to assist others to achieve the shared objectives; and
· maximisation of its interactive process by having team members who have personalities suitable for collaborative work (i.e. "nice in nature", "sincere", "respectful" and "hard working").
To summarise, the success of a national nutrition education programme will often be a result of well-organised Assessment and Analysis processes. However, it is necessary to mention a theory which should be used as a foundation of these processes: the Exchange Theory (see Figure 1). This theory states that exchange of any kind does not occur unless there are two or more parties, each with something to exchange and both able to carry out communication and distribution (Kotler & Zaltman, 1971). It also reveals that individuals engage in exchange activities only to the extent that perceived benefits outweigh perceived costs (Fine, 1990). Such costs can be psychological, or be seen be in terms of time, social status, opportunity, or money. Generally, designing a national nutrition education programme needs the support of:
· good communication for assessing, analysing, and taking action,
· good collaboration in order to increase social mobilisation and community participation, and
· sufficient concentration so as to make the programme relevant to a community's felt needs and wider social development requirements.
Phase 3: The Dissemination Process
Thirdly, this generic framework reveals the significance of a Dissemination process (see Figure 1). This process is significant for promoting and securing sustainable change. It consists of two major interactive elements: (i) management/control and (ii) monitoring/evaluation.
These elements are essential for nutrition education because the task is action-oriented in nature. In the following, some issues related to these elements are emphasised.
An effective national nutrition education programme not only needs good planning or excellent design, but also a system that will ensure that everything is implemented successfully as planned. One focal point of this system is, thus, management/control. Usually, the management/control of a national nutrition education programme is likely to be successful if it has, at least, three characteristics (Smitasiri, 1994):
· supportive staff,
· good collaborators, and
· the flexibility of the management/control itself.
Given that programme staff is well selected, it is still important to maximise its ability to work towards the programme objectives. Leadership style and an interactive working environment are most important to gain the support of programme staff. Leaders who are perceived by the staff to be strong, who are willing to allow time and effort to help the staff when needed, who have good listening skills, and who recognise the need for both technical and psychological support, are to be considered. This type of leader will be able to create the interactive working environment (i.e. involve the staff in decision-making processes, provide active participation, encourage group responsibility, create a sense of experiential learning) necessary for an effective national nutrition education programme which requires creative action.
As in any comprehensive intervention, there will be a need to work with others who are not directly involved with the programme. The generic framework specifies that the ability to recruit good collaborators is important for successful implementation. Four criteria for selection are suggested:
· individuals who themselves are interested in contributing to societal change;
· they have previous success(es) in similar activities;
· they are interested in social recognition; and
· they have already established themselves in their work.
Interested individuals who fall into all or most of these categories would be likely to be good collaborators in a national nutrition education programme.
In addition, the intervention's complexity requires that management/control be flexible, especially in the face of difficult and unexpected circumstances. Besides, the need for inter-sectoral collaboration usually demands a high level of flexibility. Therefore, a programme team should aim at controlling a total picture of the implementation; attempts to apply tight control over everything can damage the work. Thus, it is always helpful to have more than one option. Furthermore, to maximise the potential of management/control of a national nutrition education programme, it should be noted that nutrition education interventions in general, do not always reach the less advantaged sector which usually has more nutritional problems. This group needs special assistance because of the nature of the problems it faces, i.e., severe economic hardships, health problems, etc. The less advantaged are often on the fringes of the community which makes it difficult for them to participate in community activities. For these reasons, a special intensive programme for them is necessary in implementing a national nutrition education programme properly.
Effective management/control relies on a good monitoring/evaluation process. The implementation team should always have a clear and accurate picture of what is going on in the target population. Direct observations and regular discussions with the target audiences themselves are helpful. Systematic monitoring/evaluation must be considered whenever it is feasible. Direct involvement of local change agents can provide another channel for monitoring the programme, and formal discussions with these individuals can make self-monitoring a more feasible and collaborative endeavour. A good nutrition education programme also needs a comprehensive evaluation strategy, one which combines both appropriate quantitative and qualitative evaluation methods. An "outsider evaluation" is highly recommended, yet realistic expectations of what can be changed through the approach used are also necessary. Equally important is how to work with interdisciplinary evaluators and how the issue of professionalism is dealt with in order to ensure fruitful evaluation results. Moreover, techniques should be used to guarantee that the evaluation results of a national nutrition education programme are effectively communicated to all involved, including the public.
Lastly, the Decision-Development-Dissemination Approach as a generic framework needs the support of, at least, two other important elements: (i) the promotion of the changes achieved, and (ii) training needs for future implementation. For instance, when the Decision-Development-Dissemination Approach has been applied to a national programme for about three years and the results reveal the achievement of some expected outcomes, this is in fact the first cycle of changes. Thus, to activate the next cycle of change, it is crucial for changers to promote the changes they have achieved. This can be done by launching a forceful public relations campaign directed at multi-level audiences, i.e. national leaders, policy and decision makers, government and non-government workers, local leaders, and the public. The campaign, if well arranged, should result in:
· more support of the activities from important people in the country,
· more understanding about the changes and the benefits of such changes at both immediate and long-term levels, and
· more motivation for individuals, within their own capacities, to participate in the future change process.
This generic framework is aimed at assisting programme administrators in implementing an effective national or large-scale nutrition education programme. It is only written words - useless, if no one is interested in understanding, thinking further, and actually taking action. The effectiveness of the framework itself relies considerably on the quality of the individuals who utilise it. Since an interdisciplinary approach is necessary for a nutrition education intervention aiming to change nutritional behaviour in the population, a taste for interdisciplinary work and for assembling and managing a team will be a prerequisite for leadership of future preventive efforts, including nutrition education (Remington, 1990). Thus, in addition to basic training in education/communication strategies and techniques necessary for nutritional behaviour change, perhaps what is also needed is training which is broadly based in the various areas of understanding essential for implementation. Such training should be interdisciplinary, should go beyond the behavioural and social sciences as necessary, and should offer a basic understanding of human relationships and behaviours and of the solutions to persistent nutritional problems (Lazarsfeld & Reitz, 1975). This type of training is, in most cases, not presently available.
The Decision-Development-Dissemination Approach is proposed as a generic framework to promote good nutrition for the public. This approach is suggested, based on the assumption that science-based knowledge and good techniques are, in fact, available for nutrition education interventions and more attention should be focused on the implementation process. Therefore, it suggests that the processes of Decision, Development and Dissemination be considered with great care when initiating a national or large-scale nutrition education programme.
Firstly, the Decision process mainly involves policy and decision makers, as well as change initiators, as key actors. Policy and decision makers must decide whether nutrition education as an intervention strategy is significant to their country's nutritional development. In so doing, they need to understand the Cause(s) of nutrition problems and to consider how nutrition education could be helpful in improving the situation. If nutrition education is considered valuable, an investment in such a programme should be directly related to outcome expectations. Though policy and decision makers determine what should be done in this process, change initiators play an important role in convincing them to make the right decision. For this reason, change initiators need to be "proactive" and take responsibility for the results of this decision process. Moreover, whoever is responsible for a national nutrition education programme will be critical for its success. Policy and decision makers need to understand that quality change agents are indeed necessary for this type of intervention. They must choose the right ones.
Secondly, change agents play a crucial role in the Development process. They must be qualified to master the communication (assessing, analysing and taking action), collaboration (increasing social mobilisation and communication participation) and concentration (making the programme relevant to a community's felt needs and wider social development requirements, rather than only to nutrition) necessary for the task. Formative research is notably useful. It should be done well by using appropriate research methods. An analysis of the food supply, nutrition issues, target groups and key settings is essential for developing good strategies which are essential to effective intervention. Furthermore, creative action is required. Programme activities must be implemented not only for the target audiences but for changers as well.
Thirdly, the Dissemination process needs the contribution of change agents, change initiators, including policy and decision makers, in the management/control as well as the monitoring/evaluation of the programme. Management/control is an essential element which determines whether the programme will be implemented as planned. Supportive staff, good collaborators, flexible management and leadership style and intensive intervention for the less advantaged sector are helpful in managing/controlling a national nutrition education programme. Also, direct observations/regular discussions, systematic monitoring/evaluation, comprehensive evaluation strategies, realistic expectations, and techniques to communicate monitoring/evaluation results are important to the programme.
Nonetheless, the Decision-Development-Dissemination Approach reveals that nutrition planners and implementors should not aim only at an effective national nutrition education programme, but proceed to achieve national nutrition improvement by creating cultural and sustainable change through nutrition education. This can be done by maintaining and expanding the changes achieved through the programme. Promotion of the changes achieved is very important to gain:
· further support from important individuals in the country;
· further understanding of nutrition issues; and
· further motivation for better nutritional improvement.
Human resource development is crucial for any long-term interventions. Training for nutrition change agents should be organised so that they can understand the issues significant to nutritional implementation (i.e. the complexity of human relationships and behaviour), enabling them to come up with better solutions to the problems.
In order to encourage more effective national or large-scale nutrition education programmes, especially in less developed countries (LDCs) for the next ten years, the roles of international agencies and country governments are particularly important. Below, some recommendations are posed for further consideration. In principle, these recommendations support five domains for action (Green & Anderson, 1986):
· build healthy public policy,
· create supportive environments,
· strengthen community action,
· develop personal skills,
· reorient health services; and, any combination of health (nutrition) education and related organisational, economic and environmental supports for the behaviour of individuals, groups or communities conducive to nutrition and health.
(i) It is necessary to create more understanding among policy and decision makers about the significance of nutrition education in less developed countries.
International agencies and country governments should conduct a review of new research findings about diseases and ill health which are caused by inappropriate nutritional behaviours in developed and less developed countries, to highlight the importance of nutrition education. Investments in changing nutritional behaviour are, in fact, for better use of the food supply and for reducing the costs to countries of diseases and ill health. Nutrition education approaches are already available to attempt the changes. In doing so, efforts should be organised first through academic proposals (internationally and nationally) and then through debates on popular media at the country level.
International agencies should also convince national policy and decision makers about the importance of good nutrition and its impact on national development. They should demonstrate to them dramatically what would happen if most of the national resources are spent providing short-term solutions; show them how long-term investments in life style and behaviour change can result in sustainable nutritional development; and indicate through various means of communication the nutrition education solutions which are ready to be used. The messages used should be agreed among the lobbying parties. They should be based on substantial trustworthy arguments and they should be presented in a way that policy and decision makers can understand and be willing to take further actions to support the movement.
(ii) Induct nutrition change initiators and change agents to look at nutrition education as an intervention providing comprehensive nutrition solutions for the public.
International agencies should strategically communicate with active change initiators and change agents in selected countries to point out why nutrition education needs a new perspective (one example is the Decision-Development-Dissemination approach) in order to effectively influence changes in nutritional behaviours in the population. This communication should be made through orchestrated efforts during the initial period.
International agencies and country governments should create accurate understanding about a generic framework for nutrition education, and how it can be helpful if it is applied appropriately. This needs to be done carefully since most nutrition change initiators and agents are often influenced by a biomedical science orientation. Their backgrounds may make it difficult for them to accept the comprehensive and dynamic approach necessary for effective nutrition education.
International agencies and country governments should demonstrate the fact that target populations only need solutions to their perceived problems. With the focus on nutritional behaviours, implementation will be most effective if people perceive that relevant solutions are provided to them and for them. This will not be easy in nutrition education work, because the nature of science-based knowledge available in nutrition is sometimes inconclusive. Nutrition experts need to work on how to utilise their available knowledge to allow others to gain the benefits. Moreover, what target populations need might not only be nutrition information but also other elements, such as encouragement and necessary resources, in order to solve their problems once they recognise them.
(iii) It is important to initiate more interest among change initiators and agents in the interaction of knowledge and action.
International agencies and country governments need to uncover more evidence in nutrition education work to show that there is a need for more interaction between knowledge and action in this field. They need to encourage more operational research, and to disseminate widely to change initiators and change agents the results of such research, in particular, how this type of research can be helpful in improving work performance.
(iv) It is crucial to selectively implement national nutrition education programme in LDCs, which could provide good examples for this type of intervention later on.
International agencies should provide technical evidence that changing nutritional behaviours is a lifestyle/cultural issue. The nutrition intervention strategy alone may not be appropriate to the reduction of nutritional problems where they are most severe. Nonetheless, a nutrition education intervention can be the best way to create good examples. Since there are certain requirements for this work to be implemented effectively, international agencies should consider providing funding and technical assistance for nutrition education to countries where conditions are more ready for long-term nutrition interventions. The agencies should aim at creating good examples instead of trying to use this strategy to eliminate nutrition problems in a short period of time.
Country governments should assess whether it is possible to organise an efficient unit of operation for effective nutrition education work. An example of what is required has already been discussed in this paper. They should consider carefully how effective change in nutritional behaviours will benefit the nutrition development of the country. If it is really going to be beneficial to the country in the long run, and where and what problem(s) should be taken into consideration so that certain internationally accepted goals for nutritional well-being will be achieved. For instance, the ICN urged governments to "develop comprehensive policies for improved food supplies and nutrition, adapted to local conditions in each country, and support and encourage home gardens, traditional food production and consumption patterns that support nutritional well-being" (ICN, 1992). Decisions need to be made as to what actions are to be taken. Country governments should also commit themselves to national nutrition education programmes, as they are a means to create good examples to enable existing infrastructures to carry on the work afterwards.
(v) It is indispensable to find ways and means to strengthen the responsible units of operation.
International agencies should allocate funding to assist selected LDCs in formal and informal training for qualified change agents.
Country governments should create a mechanism that allows efficient collaborative efforts among government, non-government, and business organisations, in a national nutrition education programme, develop self-efficacy among local responsible units of operation, and provide assistance to improve work performance through operational research.
These recommendations are offered as a guideline to improve nutrition education at a national level, especially in less developed countries. The approach taken is intended to counteract the idea that ineffective nutrition education interventions are the result of a lack of good techniques, the cause being a lack of the support necessary to implement the techniques effectively. Thus, the recommendations focus on how to provide a better environment for national nutrition education programmes, at least, to the extent that more programmes could be expected to be more effective and be good examples for further interventions. Nutrition education is what everyone says definitely needs to be done, but not many really believe in its potential, so, successful examples are sorely needed. If it is true that nutrition education can help protect human beings from some diseases and ill health, a way must be found to demonstrate this.
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