D. Shrestha and M.A. Hussain
Dhruba Shrestha is Project Director for Multisectoral Training in Nutrition Prevention of Vitamin A Deficiency at the National Planning Commission, Kathmandu, Nepal. M. Anwar Hussain is a Senior Officer, Nutrition Programmes Service, Food Policy and Nutrition Division, FAO.
Sensibilisation des Népalais aux problèmes de nutrition grâce à la formation multisectorielle
Sensibilización en las cuestiones nutricionales a través de la capacitación multisectorial en Nepal
Vitamin A deficiency, particularly xerophthalmia, is a major public health problem in Nepal affecting primarily young children and their mothers, A national survey on xerophthalmia has reported an incidence of 1.3 percent for Bitot's spots and 0,6 percent for night blindness, both manifestations of clinical vitamin A deficiency, In certain endemic areas an incidence of Bitot's spots as high as 2.1 percent has been reported (UNICEF, 1993), These figures show only the tip of the iceberg, as there are many more cases of subclinical vitamin A deficiency.
The main reason for the high prevalence of vitamin A deficiency is the inadequate dietary intake of vitamin A-rich foods which is a result of the abject poverty found among the Nepalese people. Lack of knowledge about the potential for local vegetables to provide vitamin A and poor weaning practices also contribute substantially to the low dietary intake of this micronutrient. Thus, increasing awareness among the population and alleviating poverty will be two important elements for any programme to control vitamin A deficiency in Nepal.
Since 1987, the Government of Nepal has pursued a policy of national development to provide for the basic heeds of its population including food, health, education and shelter, More recently poverty alleviation has become the cornerstone of national development, and nutritional indicators will be one type of criterion for measuring the government's success, Nepal has signed the Declaration of the World Summit for Children and concurred with the World Declaration on Nutrition and Plan of Action for Nutrition adopted by the International Conference on Nutrition (ICN) in 1992.
NEPAL: BACKGROUND STATISTICS
|
Geography |
Landlocked; rugged topography; diverse agro-ecology |
|
Area |
56136 square miles |
|
Population |
18,4 million |
|
Population growth rate |
2.7 percent |
|
Life expectancy |
53 years |
|
Per caput gross domestic product |
US$170 |
|
Adult literacy rate |
26 percent |
|
Female literacy |
3 percent |
|
Staple diet |
Rice |
|
Crude death rate |
14 per 1000 population |
|
Crude birth rate |
39 per 1000 population |
|
Infant mortality rate |
102 per 1000 live births |
|
Under-five mortality |
147 per 1000 live births |
|
Access to safe water |
37 percent |
|
Access to adequate sanitation |
2 percent |
|
Immunization |
71 to 63 percent |
|
Food production (energy) |
95 percent of requirement |
Source: UNICEF, 1993.
In its determination to reduce this serious nutritional problem, the government has set the goal that by the year 2000 vitamin A deficiency will be controlled and/or prevented to the extent that it will no longer be a significant public health concern.
Le principal problème de santé publique que connaît le Népal est la carence en vitamine A, qui touche plus particulièrement les jeunes enfants et leurs mères. Les résultats d'une enquête nationale sur la xérophtalmie donnent une incidence de 1,3 pour cent pour les taches de Bitot et de 0,6 pour cent pour la cécité crépusculaire, deux manifestations de la carence clinique en vitamine A. La pauvreté extrême qui règne au Népal fait que la population a difficilement accès à des aliments riches en vitamine A, Le manque d'information sur les possibilités de culture locale de légumes riches en vitamine A et de mauvaises pratiques de sevrage expliquent, dans une large mesure, la faible teneur en vitamine A du régime alimentaire.
Pour lutter contre ce problème nutritionnel, le gouvernement a adopté une stratégie multisectorielle impliquant la coordination et l'association de différentes mesures prises par tous les ministères, et plus particulièrement ceux de l'agriculture, de l'éducation, de la santé et de l'administration locale, ainsi que par l'Université Tribhuvan. Par le biais de leurs programmes respectifs, des projets sont mis en oeuvre qui touchent toute la population. Les fonctionnaires de chaque ministère reçoivent une formation à la mise en oeuvre de mesures alimentaires à long terme visant à lutter contre les carences en vitamine A. Du matériel pédagogique et des programmes d'enseignement de la nutrition dans tous les secteurs de l'enseignement et de la formation, officiels ou non, ont été mis au point, Ces activités ont été suivies d'un projet multisectoriel de trois ans visant à renforcer les compétences des formateurs des agents de vulgarisation de terrain des ministères de l'agriculture, de l'éducation, de la santé et du développement local, ainsi que des instituteurs et professeurs des écoles primaires et secondaires relevant du ministère de l'éducation. L'accent est mis sur l'éducation des enfants fréquentant les écoles primaires et secondaires, puisque ce sont eux les futurs parents.
Cette stratégie vise à intégrer pleinement l'alimentation et la nutrition dans les programmes en cours, Ainsi, loin d'être un simple programme de formation supplémentaire, le projet fait partie intégrante des activités de formation sectorielle, Le projet a permis de renforcer les capacités des instituts de formation en matière de nutrition et a contribué à la constitution d'un cadre d'agents de vulgarisation et de formateurs prêts à faire le nécessaire pour améliorer le statut nutritionnel des Népalais. Il a permis en outre d'intégrer la nutrition dans l'enseignement tant officiel qu'informel, de sorte que la nutrition fait désormais l'objet d'un enseignement continu.
La carencia de vitamina A es uno de los principales problemas de salud pública en Nepal que afecta fundamentalmente a los niños pequeños y a las madres. Un estudio nacional sobre la xeroftalmía ha registrado una incidencia de 1,3 por ciento de manchas de Bitot y de 0,6 por ciento de ceguera nocturna, siendo ambas manifestaciones de una carencia clínica de vitamina A. La pobreza extrema de Nepal hace que sea difícil tener acceso a alimentos ricos en esta vitamina; el desconocimiento de las posibilidades de las hortalizas locales como fuentes de vitamina A y las prácticas de destete inadecuadas contribuyen considerablemente a la baja ingestión dietética de este micronutriente.
Para luchar contra este problema nutricional, el Gobierno de Nepal ha adoptado una estrategia multisectorial en la que se coordinan y combinan las actuaciones de todos los ministerios, en particular, los de agricultura, educación, salud y administraciones locales, y las de la Universidad Tribhuvan. Mediante las actividades de los diversos organismos, se ejecutan programas de extensión de alcance nacional. El personal de los distintos ministerios recibe capacitación sobre la aplicación de medidas alimentarias a largo plazo para controlar la carencia de vitamina A. Asimismo, se han preparado programas y material de capacitación destinados a incorporar la nutrición a todos los sectores de la enseñanza y capacitación académica y no académica. A todo ello ha seguido un proyecto multisectorial, de tres años de duración, cuyo objetivo es mejorar la capacidad pedagógica de los instructores de los agentes de extensión locales de los ministerios de agricultura, educación, salud y desarrollo local, así como de los profesores de enseñanza primaria y secundaria del ministerio de educación, Se está haciendo especial hincapié en la educación de los alumnos de las escuelas primarias y secundarias, ya que ellos serán los futuros padres.
Esta estrategia está diseñada para incorporar plenamente el tema de la alimentación y la nutrición en los programas en curso. Por tanto, este proyecto no es un programa de capacitación complementario, sino un elemento integrante de las actividades de capacitación sectoriales. El proyecto ha conseguido que los centros de capacitación estén mejor preparados para ofrecer una capacitación integrada centrada en la nutrición, al tiempo que ha contribuido a formar un grupo de instructores y agentes de extensión encargado de llevar a cabo actividades destinadas a mejorar el estado de nutrición de la población. Además, el proyecto ha incorporado la nutrición en todos los niveles de enseñanza, garantizando de este modo una educación permanente sobre nutrición.
Coordinated multisectoral action
In order to achieve this goal, the government has decided on a policy of coordinating and combining the actions of all sectors and utilizing and/or strengthening the existing services and infrastructures, Two broad strategies are employed, First, both short- and long-term measures to prevent and control vitamin A deficiency are implemented, Second, the actions of all ministries (particularly those of agriculture, education and health), local government and Tribhuvan University are coordinated and combined, These sectors' respective nationwide outreach programmes can cover both urban and rural communities.
The short-term measures are primarily health oriented and curative: high-potency vitamin A capsules are distributed, children are vaccinated against measles and other infectious diseases, and oral rehydration salts are provided during children's diarrhoeal episodes. The long-term measures are mainly based on increasing production of vitamin A-rich foods and providing nutrition education to improve the consumption of vitamin A-rich foods and to inform people about the risk and consequences of vitamin A deficiency.
To implement these activities successfully, the creation of nutrition awareness among the public as well as government extension workers is a prerequisite, Training and nutrition education for different line ministries is an integral, essential element for implementing the government policy.
In consonance with the above policy, the Government of Nepal invited a joint FAO/WHO mission to recommend measures for strengthening government efforts to control vitamin A deficiency. A national workshop supported by FAO was held in 1986 to determine the responsibilities of different sectors in the effort and to ensure that activities would be coordinated for a complementary and synergistic impact on the problem. This led in 1988 to the development of a Technical Cooperation Programme (TCP) project to provide a basis for education and training for the implementation of long-term measures for controlling vitamin A deficiency.
The TCP project involved the review of training curricula and development of training materials for the introduction of nutrition in all sectors of formal and non-formal teaching and training. Special emphasis was given to education of primary and secondary schoolchildren, as they are the future parents of Nepal.
As teaching curricula and materials became available, the need for training of teachers and trainers was keenly felt by the government. To meet this need a multisectoral three-year training project, entitled Multisectoral Training in Nutrition for the Control of Vitamin A Deficiency, was conceived and became operational in January 1991.
The multisectoral training project
Goals and objectives
The main goals of the training project are to contribute to the improvement of nutrition; to prevent vitamin A deficiency and nutritional blindness; and to reduce child morbidity and mortality in Nepal through teaching and training. Specific objectives include the following:
· to strengthen the capability of trainers of field extension agents of the Ministries of Agriculture, Education, Health and Local Development as well as primary and secondary schoolteachers of the Ministry of Education in the teaching of nutrition and the prevention of vitamin A deficiency and to strengthen the knowledge of schoolchildren in nutrition;· to help field extension agents from the four ministries acquire the knowledge and skills to contribute to improved nutrition and the prevention of vitamin A deficiency in the respective communities where they work;
· to support the development and production of teaching materials as required from each sector for training trainers and field extension agents;
· to upgrade the teaching facilities of training centres from each of the four sectors to improve the quality of training.
The project is expected to have the following tangible results:
· stronger institutional capabilities in each sector for training with better audiovisual facilities, teaching materials and equipment;· a substantial number of trained teachers and extension agents able to integrate nutrition concepts into their work and to make special contributions to the activities for controlling vitamin A deficiency;
· a number of improved teaching materials developed and produced to meet training needs;
· improved quality of training and trained persons in all sectors.
Project strategy
The National Nutrition Policy Coordination Committee places high priority on the implementation of new curricula. Through the existing government training and education activities a large proportion of the Nepalese population will be informed about how they can prevent malnutrition and vitamin A deficiency. Furthermore, the teaching of nutrition at primary, secondary and tertiary levels will lay the basis for change in health practices, food habits and nutrition for future generations. To reach non-literate adults, appropriate food and nutrition topics and messages are integrated into adult education programmes to foster better dietary practices and complement the new knowledge of nutrition that children are obtaining in primary schools.
This strategy is designed to integrate the topic of food and nutrition fully into ongoing programmes, In view of this, new food and nutrition teaching materials have been developed and existing materials revised by technical training subgroups in each ministry.
The training programme is not complementary to sectoral training activities but is an integral element within them, For example, food and nutrition training using the project's materials is incorporated into the training of ophthalmic assistants for the national prevention of blindness programmes in the Ministry of Health, Similarly, women development workers of the community development programme in the Ministry of Local Development learn nutrition as an integral part of their existing training programme.
Training approaches
Initially, curricula were developed for the four ministries and Tribhuvan University (Faculty of Humanities and Social Sciences and Faculty of Education) by studying all the existing curricula from the different sectors and identifying the topics related to nutrition and vitamin A concepts as well as additional topics that should be incorporated. The new curricula were formalized in a workshop with the participation of nutrition experts from all the sectors involved in the project. Prototype teaching-reading materials and visual aids were developed on the basis of the developed curricula, These curricula and teaching materials were field tested by the trainers in each sector who would use the materials in the future, The materials were finalized in a workshop in which modifications were incorporated according to the feedback received from the field testing. In addition, texts, teachers' guides and audiovisual aids were developed by the different sectors (see Table 1).
TABLE 1
Curricula and teaching materials developed and printed, 1991-1993
Programmes d'études mis au point et matériel didactique publié, 1991-1993
Programas de estudio elaborados y material didáctico publicado, 1991-1993
|
Sectora |
1991 |
1992 |
1993 b |
|
Ministry of Agriculture |
In-service training for Agriculture Officers, JTs, JTAs, AAs, leader farmers, farmers' groups, rural women workers, female household members |
Trainers' guide for JTs/JTAs |
Flip chart (250 copies) |
|
Ministry of Education and Culture-Schools c |
|
Translation of existing curriculum |
Textbook on nutrition-vitamin A for grades 1-5 (1 000 copies) |
|
Ministry of Education and Culture - Non-formal education |
Naya Goreto (New Way) Steps 1-5 |
Translation of existing curriculum into Devanagari |
|
|
Ministry of Health |
Training of community nutrition workers, community health workers/leaders, middle-level health workers, district-level health workers |
|
Two kinds of booklets for all sectors (1 000 copies each) |
|
Ministry of Local Development |
One-year training of women workers |
Translation of FAO materials |
|
|
Tribhuvan University |
PCL Home Science (FHSS) |
Textbook for PCL |
15 posters (1 000 copies each) |
a Five coloured posters were printed for all sectors.
b Includes materials in preparation.
c School materials were not printed during 1991 because the sector wanted some modifications.Abbreviations: JT, Junior Technician; JTA, Assistant Junior Technician; AA, Agriculture Assistant; PCL, proficiency certificate level; FHSS, Faculty of Humanities and Social Sciences; FOE, Faculty of Education.
Sectoral training activities
Within the Nutrition Unit of the Ministry of Health, the project has trained groups of master trainers and on-the-spot trainers at the central level (see Table 2), At the community level, village health workers, community health volunteers and paramedics working at the health post are trained, Ultimately, the target beneficiaries should be rural people, including women and children.
TABLE 2
Training programmes, 1991-1993
Programmes de formation, 1991 - 1993
Programas de capacitación, 1991-1993
|
Sector |
Project target |
Category of trainees |
1991 and 1992 |
1993 |
||
|
Participants |
Duration (days) |
Participants |
Duration (days) |
|||
|
Ministry of Agriculture |
30 Trainers |
AGOs |
158 |
5 |
90 |
5 |
|
220 AAs, JTAs |
JTs/JTAs |
|
|
75 |
5 |
|
|
|
Leader farmers |
|
|
75 |
5 |
|
|
Ministry of Education and Culture - Schools |
20 Primary schoolteachers |
Primary schoolteachers |
80 |
11 |
40 |
6 |
|
|
|
40 |
11 |
50 |
2 |
|
|
20 Secondary schoolteachers |
Secondary schoolteachers |
40 |
11 |
50 |
6 |
|
|
Ministry of Education and Culture - Non-formal education |
60 Trainers |
Master trainers |
20 |
7 |
|
|
|
1000 Facilitators |
Trainers |
60 |
7 |
|
|
|
|
|
Facilitators |
1000 |
3 |
|
|
|
|
Ministry of Health |
20 Trainers |
Master trainers |
10 |
7 |
|
|
|
|
Trainers |
20 |
7 |
|
|
|
|
|
Paramedics |
|
|
50 |
7 |
|
|
|
Village health workers/community health volunteers |
|
|
82 |
5 |
|
|
Ministry of Local Development |
40 Trainers |
WDOs |
50 |
1 |
30 |
7 |
|
|
Women workers |
14 |
6 |
30 |
7 |
|
|
|
|
30 |
5 |
|
|
|
|
|
Supervisors |
|
|
30 |
7 |
|
|
|
Regional instructors |
|
|
30 |
10 |
|
|
|
Beneficiary group |
|
|
30 |
7 |
|
|
Tribhuvan University |
24 Teachers, FHSS |
Teachers, FHSS |
62 |
5 |
|
|
|
21 Teachers, FOE |
Teachers, FOE |
34 |
12 |
|
|
|
|
|
Teachers, FHSS/FOE |
|
|
40 |
45 |
|
Abbreviations: AA, Agriculture Assistant; AGO, Agriculture Officer; JT, Junior Technician; JTA, Assistant Junior Technician; FHSS, Faculty of Humanities and Social Sciences; FOE, Faculty of Education; WDO, Women Development Officer.
In the Department of Agriculture, the operating unit is the Nutrition Programme. The training programmes have covered all people concerned with the agriculture programmes from the regional level to the community level throughout the country, In the first tier three training programmes for District Agriculture Development Officers (DADOs) at the three regional training centres outside Kathmandu have covered all DADOs from 75 districts (whole country) plus key personnel working at the regional offices, In the second and third tiers, officers and assistant trainers are being trained, In the fourth tier, leader farmers and farmers in the community will participate in skill-oriented training.
Through the Ministry of Local Development all the Women Development Officers working in the 49 districts participated in a training course. Women workers are among the most effectively able to reach the rural women's groups in the community, and they have been trained as well, Eventually, women in the villages will be trained.
At Tribhuvan University, nutrition teachers working at proficiency certificate level have received training at the Central Department of Home Science and Women's Development as well as the Department of Health and Physical Education. Both departments have proposed intensive training programmes for the future which will enable the teachers to develop their competence in teaching the integrated concepts of nutrition and vitamin A.
In the Ministry of Education and Culture, the Adult Education Section has trained a group of master trainers who have in turn trained the trainers from three districts in the literacy campaign area, The trainers have then trained all the facilitators at the district level. While conducting adult literacy classes these facilitators integrate concepts of nutrition and vitamin A, thus disseminating the message to a huge number of village people.
In 1993 the Government of Nepal launched an adult education programme on the basis of literacy by payment, One district, Saptari, has been selected to test whether the integrated curriculum on nutrition and vitamin A can be taught without training the facilitators, Thus, the project will be able to assess the differences between the facilitators who have been trained and those who have not, The Adult Education Programme creates an opportunity to educate most of the adults including women and girls who have left school, More than 700 women and girls have been educated and instilled with the message about nutrition and vitamin A.
In the Terai region and the far western region where vitamin A deficiency is most prevalent the project activities will be integrated into the Basic Primary Education Programme (BPEP) project, a growth monitoring project of the United Nations Children's Fund (UNICEF) and the food supplementation programme of the World Food Programme. Primary and secondary level teachers from five districts of the Terai region's Narayani zone were trained by the Curriculum, Textbook and Supervision Development Centre.
The nutrition and vitamin A concepts will be taught to all schoolchildren from grade 1 to grade 10. The project has provided technical assistance in developing curriculum and in preparing teaching materials. Once the concepts are integrated into all the grades, it will become part of the school system.
Monitoring and evaluation
An important element of the project strategy is regular monitoring and evaluation of the programmes, The trainees are assessed with pre- and post-training questionnaires on knowledge, attitudes and practices (KAP). The training programmes are monitored from the initial stage to the end. Person-to-person contact with the trainers during the training sessions is another method of assessment.
The project's impact for the intended beneficiaries, for instance, improvement in their nutritional status, improved hygienic conditions and reductions in the incidence of vitamin A deficiency, has not yet been measured, In two sectors, the Women's Development Division under the Ministry of Local Development and the Adult Education Section under the Ministry of Education, Culture and Social Welfare, the training programmes have reached the community level. In the future, the impact of the training programmes on the rural population's nutritional status, especially vitamin A deficiency status, will be assessed.
Conclusion
The project on multisectoral training in nutrition to control vitamin A deficiency has effectively oriented important institutes towards the mobilization of national experts and administrators in the design, development and implementation of programmes on food and nutrition at various levels, It has also created support and political commitment for activities to improve the nutritional status of the population of Nepal, especially to control vitamin A deficiency.
The project has strengthened the training institutes' capacities to provide integrated training with concentration on nutrition and has helped to produce a cadre of extension workers and trainers to perform activities to improve the nutritional status of the Nepalese people, In fact, it has far exceeded the targets set for achievement at the beginning of the project. Further, it has integrated nutrition into both formal and informal teaching in Nepal, thus ensuring continuous nutrition teaching for the present and the future.
References
Institute of Medicine, Tribhuvan University. 1981. Nepal xerophthalmia study. Kathmandu.
UNICEF. 1993, The state of the world's children. New York.
