Teresa H. Stuart1
1 UNICEF Programme Officer for Information and Communication, UNICEF, Manila, Philippines.
2 Director, Penn State Nutrition Center and Associate Professor, The Pennsylvania State University, USA.
Strategies for community out-reach
Mass media and social communication
National food and nutrition policy in developed and developing countries emphasises the improvement of the quality of life of its citizens by striving to:
· stimulate and sustain the production and consumption of more nutritious foods,
· promote proper food habits and healthy lifestyles,
· reduce the prevalence of protein-energy malnutrition,
· reduce the prevalence of micronutrient deficiency, particularly vitamin A, iron, and iodine, among vulnerable groups, and
· reduce over-consumption of certain nutrients, particularly fat, saturated fat, sodium, and alcohol.
With the above objectives, nutrition education and communication are now recognised as a primary form of intervention in national food and nutrition programmes. Some argue that nutrition communication is part of nutrition education. Others maintain that nutrition education is part of nutrition communication. Either way, both are viewed as integral components of other nutrition intervention approaches, such as food production, food assistance, food formulation and fortification, supplementary feeding, promotion of breast-feeding, nutrition-related health services, and the provision of a potable water supply (Stuart, 1991).
The ultimate goal of nutrition education is to produce nutritionally literate decision makers who are motivated, knowledgeable, skilled, and willing to choose proper nutrition alternatives (Lewis, 1976). To be effective, nutrition education must communicate clear messages with a specific behaviour-change goal for target groups (Guthrie, 1978 in Valdecanas, 1985).
Nutrition education and communication programmes have evolved from a one-way flow of communication, that is, a mere dissemination of information to persuade target groups to change food beliefs, attitudes, and habits. A two-way process of sharing is preferred, where participants in a nutrition programme can freely exchange knowledge, values, and practices on nutrition, food, and related areas. This view of nutrition education as a mechanism for interaction, ensures the active involvement of those who could and should take part in decision making, and in motivating and providing users with easy access to nutrition-related information, resources, and services.
Much of the present work in nutrition education and communication is now viewed from a broader framework as a process, that is, a mechanism for interaction among participants, and as a resource, applying a co-ordinated, multi-sectoral and interdisciplinary effort, toward improving and sustaining the nutritional status of the most vulnerable groups, children and women. Several approaches to nutrition education have been developed and effectively applied over the years. These include: social marketing, social mobilisation, and development-support communication. These approaches have basic commonalties: (i) the ultimate goal is to improve the quality of life of people through a participatory process of communication, (ii) there is a demand to establish a dynamic relationship among the participants of the programme: the subjects of the nutrition education intervention, the policy makers, the planners, and the implementors, as well as the evaluators, (iii) information, education and communication (IEC) strategies are built into the process, and (iv) the core elements of the process are: formative research, assessment and analysis; capacity building; development of a multi-channel communication strategy; community organising; networking, alliance-building, and co-ordination with linkage and support systems; design, pre-testing, and development of messages and materials; and monitoring and evaluation.
Social marketing reflects the view that merely providing information is not enough to change behaviour. A host of psychological, socio-cultural, political, environmental, and practical factors impinge on the decision making process toward behaviour change. New strategies are needed to motivate people to adopt change and take an active part in their development. Social marketing uses business marketing principles to advance a social cause or idea (Kotler & Zaltman, 1971). It is described as "a social change management technology that involves the design, implementation and control of programmes aimed at increasing the acceptability of a social idea or practice in one or more groups of target adopters" (Kotler & Roberto, 1989). The strategy adopts the four Ps of marketing, namely product, price, place, and promotion. In the last 20 years, social marketers have been involved in promoting better health and nutrition in the developing countries of Asia, Africa, and Latin America. A great deal of experience has been documented in the social marketing of breast-feeding, weaning foods, oral rehydration salts, and immunisation (McKee, 1992).
Social mobilisation is described by UNICEF as:
"a process of generating and sustaining the active and co-ordinated participation of all sectors at various levels to facilitate and accelerate the improvement of the situation of children, women, and other vulnerable groups. The need for social mobilisation is based on the following concerns: (a) children, and often women, are powerless; (b) programme resources for solving problems are limited; and (c) concerns for children and women go beyond a project basis. The aims of social mobilisation are to hasten the delivery of basic services and to promote convergence and generate resources for children and women's programmes" (UNICEF, 1995).
To generate commitment and action among those who can contribute to the solution of social problems, certain strategies are employed that put prime importance on interpersonal communication. The six strategies include the following:
Advocacy among policy-makers, key personalities, groups and organisations. Advocacy is a planned communication effort to persuade decision makers at policy, planning, and management levels to adopt necessary policies and allocate resources for a cause.
Information, education, and communication (IEC)
IEC approaches are used to reach target groups. Social mobilisation uses all available and potential communication approaches, resources, techniques, channels, methods, and tools. It is not a mere information campaign or communication project, but a long-term programme built into the sectoral programmes of a community. Some examples of IEC activities are:
· the development, production and distribution of appropriate printed materials such as brochures, pamphlets, posters, leaflets, and flyers;
· radio spots, plugs, jingles, documentaries, and schools on-the-air;
· video and other audio-visual materials like slide-tape presentations and film showings; and
· messages integrated into communication programmes, services, and products of allied agencies.
Training of programme implementors
Training enables personnel to acquire the necessary skills for the delivery of services. The implementor also uses training to improve people's knowledge, appreciation, and mobilisation, of community resources to achieve the desired outcome, usually for local and individual empowerment.
Community organising to empower parents, families, groups, and the whole community, is used to build their capacity for problem solving, decision making, and collective action, thus developing and strengthening their networks. Community organising allows community members to recognise their problems and needs, decide on what they can do and how they can act collectively, that is, pool ideas as well as human and physical resources, and together benefit from all available resources and services.
Networking, establishing linkages, and building alliances
This includes networking, establishing linkages, and building alliances with those who can actually and potentially act on the problem. The implementor of social mobilisation builds alliances and linkages not only with families in the community, but also with institutions, agencies, and organisations. Among potential allies of the community are the non-governmental organisations (NGOs), people's organisations, self-help groups, and local government executives. These networks allow communities to maximise limited resources and services to a level where their inputs have a much greater impact.
Monitoring and evaluation
Monitoring and evaluation determines the efficiency of programme implementation and the effectiveness of the strategies used in achieving defined goals. The results are used to adjust the programme as needed to improve impact and maximise resources.
Development support communication (DSC)
DSC is described as "the systematic utilisation of appropriate communication channels and techniques to increase people's participation in development and to inform, motivate, and train rural populations mainly at the grassroots level" (FAO, 1987). The DSC approach is seen as a system with three sub-systems that provide the framework for planning, implementation, and evaluation. The sub-systems include: (i) DSC action plan or process model; (ii) DSC training plan; and, (iii) DSC management plan (Stuart, 1994), and are briefly described below:
The DSC action plan or DSC process model
The DSC action plan, or DSC process model, provides a systematic approach to changing and exchanging knowledge, attitudes and practices. It is adaptable to diverse development contexts and situations and thus allows room for adjustments according to local realities. It has four major stages: pre-planning, planning, implementation, and post-implementation with corresponding steps and activities.
The DSC training plan
As a sub-system, the DSC training plan recognises the importance of capability building in DSC and relevant technologies for all participants in a development programme where a DSC component is in place. The training promotes the sustainability of the programmes. There are eight steps in the training planning process: training needs assessment, setting training objectives, selection of training format, preparation of curriculum content, development of training support materials and media, training proper, evaluation, and planning for echo-trainings.
The DSC management plan
The DSC management plan is an essential part of the DSC system because orchestrating people, resources, and time requires a systematic management programme. Sound programme or project planning, implementation, and evaluation depend on good management. This involves planning, staffing, budgeting, controlling resources, guiding and co-ordinating people's activities, setting policies, guidelines and standards, and monitoring and evaluation.
Currently, there are evaluations of nutrition education programmes available that support the benefits of a healthy diet. The challenge for nutrition educators is to find ways of reproducing positive results routinely and on a large scale. Given the limited resources available in most developing countries, nutrition education and communication strategies must be able to reach large sections of the population in a cost-effective manner.
Mass-reach programmes are needed, not only to address existing nutrition problems, but also to promote the general nutritional literacy and health of the population, particularly because in many countries the food supply is in transition and persuasive food advertising is increasing.
The key programmes that can reach a large number of people include:
· community out-reach programmes
· mass media campaigns
· pre-school and school programmes
· work-site programmes
Identifying key nutrition issues and analysing determinants of eating behaviour
The task of planning nutrition education interventions integrated into nutrition improvement programmes, requires that the various causes and effects of nutrition issues and problems be addressed in a concerted manner. Only through a systematic analysis of the nutrition and health-related needs of a community, can an effective nutrition education programme be developed.
Any nutrition education intervention should consider the socio-cultural, economic, political, and technological environments which include food and nutrition issues. Thus, the first step is a situational analysis examining the factors that would draw out pertinent issues to be addressed through nutrition education.
The step of identifying and analysing key nutrition issues and behaviour determinants is part of baseline or background research that involves three components (FAO/WHO, 1992): (i) an epidemiological analysis of the specific nutrition issues; (ii) a policy analysis of national nutrition priorities and resources; and (iii) a behavioural analysis to identify the barriers for adopting the desired behaviours, as well as factors that favour change.
The next step applies the first two A's in UNICEF's "Triple A" Approach, consisting of Assessment, Analysis and Action (UNICEF, 1992). An assessment determines the priority issues, problems, local power structures, supporting institutions, communication resources, as well as relevant policies, and the degree to which these affect the state of nutrition and health of the community. An analysis studies the underlying factors that impinge on the issues, problems, structures, resources and policies. Action, in terms of community out-reach strategies, includes: consultations with decision makers at different levels to find out their needs for information; planning and preparation of easily understood messages and materials; and social mobilisation of the community as a way of motivating people to cooperate and share limited resources and of empowering community decision makers, be they the local leaders, teachers, mothers, or school children.
In designing appropriate community out-reach strategies, nutrition education planners need two major types of information. These are: (i) information about people, and (ii) information about local resources (Stuart, 1991).
Information about people
Information about people is sometimes referred to as audience predisposition in communication models (Gillespie, 1987). The information about people will help identify the nutritional needs of the community. It includes:
· Nutritional status:
Four basic methods are employed to describe the nutritional status of "at risk" groups in the community: anthropometric studies, clinical studies, biochemical studies, and dietary intake studies.
· Food consumption patterns:
This describes what and how much people usually eat. It determines whether the amount and variety of food intake is adequate for the individual and the household. It also tells if there is food scarcity at certain times of the year.
· Medical information:
Morbidity and mortality rates and their causes are indicators of the interrelationships between nutrition and prevalent disease patterns, including infections and infestations.
Literacy and educational levels are guides in designing appropriate messages adjusted according to the audience's level of comprehension and language facility. It also guides planners in choosing interpersonal and mediated approaches.
· Media access and exposure:
This indicates the extent to which the community has access and is exposed to certain mass media channels, while it determines the community's media habits, ownership, and preferences.
· Economic status and education:
Types of occupations, incomes and educational attainment of family members, and whether women work outside the home, indicate if money is regularly available to buy food. Food expenditures also provide an index of the percentage of family income spent on food and non-food items. Child care providers should also receive nutrition education.
· Cultural information:
Food habits, practices, superstitions, attitudes, social and religious customs, and breast-feeding and weaning practices are useful in determining and designing appropriate nutritional messages and activities.
· Food and nutrition information networks:
The structure and flow of nutritional information or misinformation among women and men in the community help to identify specific target participants for nutrition education interventions, e.g. sources of erroneous beliefs about breast-feeding and weaning, superstitions, etc.
· Studies on functional classification:
These studies relate nutrient deficient patterns to spatial, ecological, socio-economic, and demographic characteristics of a population. For example, a study of upland dwellers can yield useful information for designing intervention programmes based on an "area level", integrating a development planning approach rather than a sectoral approach.
Information about local resources
Information about local resources that will help identify problems related to food and nutrition in the community include:
· Water supply:
This helps to identify possible sources of infection and whether enough water is used to maintain hygiene standards. It also indicates if it is possible to increase agricultural production.
· Local food production:
This identifies the kinds of foods that are locally available for consumption, including their seasonal availability.
· Markets and foods:
This gives an idea of what crops are sold locally, the process by which a quantity and quality of foods becomes available on the market, and the presence of street-food vendors, snack stands, and other outlets for prepared food.
· Food storage:
It should be determined whether food storage facilities are available, whether enough food can be stored properly for future needs, and whether lack of storage facilities causes specific losses and a shortage of supplies.
This indicates the adequacy of kitchen, toilet and other sanitation facilities. It is also used to measure space adequacy or crowding among family members.
· Local institutions, policy, and support services:
This shows whether the local government officials recognise the importance of nutrition in the overall development plans and programmes in their area of jurisdiction. It also determines if there are existing policies that guide local officials, organisations, extension agents, and non-government organisations so that they can participate and provide support services for nutrition interventions.
· Transportation facilities:
The availability of farm-to-market roads and public utility vehicles affects the flow of farm products to the market, the availability of food in the local market, and the mobility of individuals to visit health and educational facilities.
· Educational and communication resources:
The availability of these resources indicates the extent to which the members of the community have access to instrumental information and to formal, non-formal and informal education.
A community diagnosis is carried out by collecting the information listed above, either from primary or secondary data. Whichever information-collection method is used, the people from the community are the focal participants in this initial planning step. Some techniques that have been used for drawing out needed primary information are the participatory rapid appraisal or PRA technique, focus group discussion or FGD, problem tree analysis, village assembly, dialogue and consultation, communication network analysis, and community survey.
Selecting target groups
The members of a community can be divided into specific groups, or segments of participants, for a community out-reach programme based on information made available. Audience segmentation is the term used for planning a nutrition education and communication intervention when a population is divided into fairly homogenous groups. Each group may then be selected for distinct nutrition education messages. The basic premise is that everyone in the population does not have the same need for a particular piece of information, resource or service. Hence the need to segment target groups.
Target groups can be segmented according to the following characteristics:
Social demographic characteristics
These include age, sex, educational level, economic class, marital status, family size or number of children, race, religion, language/dialect, occupation, membership of organisations, media habits, geographic location (urban-rural; tropical-temperate), etc.
Food habits, breast-feeding and weaning practices, methods of food preparation, backyard gardening, cropping patterns, etc.
These include common lifestyles, social role, the manner in which a person thinks, feels and responds towards a specific nutrition and health-related behavioural issue. They include customs, traditions, indigenous belief systems, values, and other social-psychological traits. Current marketing practices place a heavier emphasis on psychographics than they do on demographics.
Examples of target groups for nutrition education are: the women in the community, school children, community health workers, teachers, political and religious leaders, and other field-workers, to name a few. These target groups may be further subdivided into more specific groups whose unique traits demand a particular message and strategy. For example, the women may be further segmented into groups of pregnant women, lactating mothers, and mothers of children from six months to six years of age. Other segments of women could be teenage daughters and mothers-in-law. Another important issue in audience segmentation is whether the central nutritional concern is under- or over-nutrition. Accordingly, the appropriate messages are designed and packaged.
The target group, based on the priority issue to be addressed, may be classified according to primary, secondary, and tertiary target groups. For example, when promoting vitamin A-rich foods in the community, the primary participants are the child-care practitioners, such as mothers, grandmothers or mothers-in-law, teenage daughters, and other siblings. The secondary participants are the community nutrition/health workers, teachers, and local political and religious leaders who could teach, support, and reinforce desirable practices, values and beliefs in the primary target group. The tertiary participants are those whose expertise and official positions, even if they are not from the community, could serve as valuable sources of information and support. This group could include provincial and district level development personnel in health, education, and agriculture, as well as university researchers, and marketing and communication/media specialists.
Establishing existing levels of nutrition knowledge, attitudes, and practices (KAP)
The primary target groups of nutrition education in most cases are women, because they tend to make the decisions when it comes to food, nutrition, and health concerns of the family. Specifically, these women are the pregnant and nursing mothers, mothers of infants and preschoolers (up to six years of age), and mothers of elementary school children. In some cultures the men control the allocation of food resources within the household, determine the mode of infant feeding, food preparation, and use of medical services, etc. Therefore, they may need to be targeted as a primary audience for nutrition education as well. In all cases, formative research is necessary to find out existing levels of KAP in the target groups. This activity will identify the gaps or needs in KAP that could be addressed through nutrition education.
Nutrition messages addressed to the target groups are concerned with eliciting specific behaviour changes in what they know (knowledge of nutrition and health, food beliefs and superstitions, taboos and misconceptions); what they feel (attitudes, values, and preferences for certain foods and food preparation and child-feeding practices); and what they do (food habits, food preparation practices, customs and traditions, child-feeding practices, cropping system, etc.).
Food beliefs, preferences, and habits of the whole family are passed on from generation to generation, and become customs and traditions. They dictate the homemaker's decisions on food selection and preparation. However, many food beliefs and preferences unknowingly lead to poor nutrition and health problems. Hence, a community out-reach programme on nutrition should also address the need to: (i) change the KAP of the homemakers and their families that lead to, or aggravate nutritional problems; and (ii) reinforce behaviours that promote family nutrition and health.
Setting communication objectives
Setting communication objectives is an important step in planning nutrition education and communication programmes. The foremost consideration is that the participants, the planners, and the message and media developers, define together the specific outcomes expected over a given period. There must be agreement among the participants on the problem to be addressed, the need for change, the need to take action to prevent or reduce the problem, the strategy by which the change can take place, and the indicators by which such change could be recognised (Valdecanas, 1991).
Communication and educational objectives are stated in terms of the participants' desired behavioural outcomes, that is, in terms of the desired degree of change in what they know, feel, or can do. The results of the KAP study among the primary, secondary, or tertiary target group, as the case may be, provide the basis for setting the objectives.
Clear and well-defined communication objectives guide message designers and media/materials developers in selecting content, developing appropriate communication strategies and media mixes, and planning monitoring and evaluation schemes. Some useful memory guides in formulating communication objectives are:
A-B-C-D: Audience, Behaviour, Condition, and Degree
Example: "At the end of six months, 75 percent of the mothers with infants and preschool children in Barangay San Pedro will have adopted and prepared on a regular basis vitamin-A rich recipes learned from the Mothers Class."
S-M-A-R-T: Specific, Measurable, Attainable, Realistic, and Time-bound
Example: "After one year, 95 percent of mothers with nought to six month-old infants in Los Baños will be breast-feeding their babies and for longer periods than observed a year before."
Developing and pre-testing messages and materials
With adequate background information about the target groups and properly defined objectives, the next step is to develop a socially and culturally appropriate communication strategy, consisting of approaches, messages, and methods. Approaches chosen are those appropriate for each group. These could be a combination of any of the following: individual, group, or mass approaches using information, education/training, motivation, entertainment or advocacy. Messages vary according to the kinds of behaviour-change specified in the objectives, the available resources and services, technologies, other relevant information, participant needs, and method of delivery. In order that each approach be used, activities must be defined according to the programme objectives. Appropriate messages, media, and methods should be designed and pre-tested according to the audience's abilities, resources, and preferences.
Media and materials should ensure that target groups receive the message and act on it positively. Materials need not be expensive, for low-cost materials can be as effective. For example, a streamer can be made from used feed or flour bags, or a poster made from the back of old glossy calendars. Involving the community in making the materials is an effective way of getting the message across. For example, the feedbag streamer could announce the coming of health workers on immunisation day. A poster may carry a motivational message, such as "Mother's milk is best" or "Use iodised salt".
Pre-testing prototype materials, or formative research, is a very important step in message and media development. At the pre-testing stage, the message designer aims to discover any misunderstandings, misconceptions, or shortcomings in either the message or the medium that must be corrected and improved before the material is finalised, reproduced, and distributed. Pre-testing measures the reaction of a small but representative sample of the target audience to a set of communication materials. Materials may include posters, pamphlets, radio or video material, audio-visual materials for training support, and others. The developer designs two or three alternatives of a given material and tests them with representatives from the target audience. The materials should be found to be: attractive, easily understandable, credible, persuasive, culturally appropriate, memorable, and important to the audience (Bertrand, 1978).
Mobilising social support and community participation
Social mobilisation serves as the strategy for motivating mothers, children, families, groups, and communities to become active participants in meeting their food, nutrition, and health needs. It provides the framework for action that links up various sectors at all levels in making available all possible means and resources toward improving the nutritional and health status of women and children (UNICEF, 1995).
Five factors influence the nutrition and health situation of vulnerable groups in a community which may affect participation. These include:
· socio-economic and political environment - e.g. the lack of political will among local government executives to improve the situation and the poverty and social problems besetting the community;
· local culture - e.g. the traditions, customs, and superstitions which inhibit acceptance of correct practices;
· access to programme services - e.g. when there are few doctors, nurses, health workers, and community volunteers;
· technologies and resources - e.g. lack of qualified personnel and unavailability of facilities for service delivery; and
· home environment - e.g. when the parents' level of knowledge and attitudes are constraints.
The five components of social mobilisation can, in turn, enhance the positive contribution of the above five factors. These five components are: (i) advocacy; (ii) Information, Education, Communication (IEC); (iii) community organising; (iv) training; and (v) monitoring and evaluation. Through advocacy, the social mobiliser seeks the support and commitment of these sectors to facilitate and accelerate the improvement of the situation of women, children and other vulnerable groups. The decision is in the hands of national and local officials, opinion leaders, the media, and civic, political and religious organisations, in other words, those who have the authority to enact laws or allocate much needed financial, physical, and manpower resources. Through IEC, all concerned sectors, including the target groups, are informed of the problems and motivated to participate in community activities. Community organising allows the community to unify and collectively act to seek solutions to their problems. Training maintains the commitment of field-workers and implementors as it integrates new techniques to their work. Monitoring and evaluation provide feedback on how to improve strategies and measure goal attainment (UNICEF, 1995).
Strengthening community action and participation
A DSC project in the Philippines has several factors which involve community action and participation, and which have empowered the people and assured the sustainability of project interventions. The DSC approach is not just a media effort. It is a multi-directional process which can cause a synergism among the target groups, field-workers, implementors, and local leaders, toward participation, empowerment, and sustainable development interventions. Participation happens when people concerned are committed to organise themselves so that they can collectively get involved in making decisions about various economic, social, spiritual, environmental, and political spheres of community life. Participation helps them realise a true sense of empowerment when they are in control of their talents, time, resources, and achievements, that in turn ensures the sustainability of their initiatives (Stuart, 1994).
Factors that can strengthen community action and participation for empowerment and sustainable programme interventions:
Activities classified as social preparation start at the research, assessment, and analysis stage, when local people are conscious from the start that their ideas, problems, needs, preoccupations, and aspirations contribute to the planning and implementation of the intervention strategy. The interactions among the local people, their leaders, and the programme implementors in orientation meetings, site visits, focus group discussions, construction of a community profile, spot map, or problem tree, allow all involved to discover each other, draw out potentials, and establish or deepen friendships. More significantly, they are introduced to new contacts from outside the community that could be instrumental in meeting their needs. For implementors and field-workers, the training is a form of social preparation too.
Sense of ownership of the programme
A sense of ownership of a programme or project in the community by the target groups, the local government executives, and the community, is a key to active and productive participation. Ownership refers to the highest level of commitment to a programme. For the local people, it is like formulating the programme plan themselves, because they have been intensively and extensively involved in the planning process. Thus, if they feel that they are stakeholders, there is minimal need for other motivators, because ownership is itself the motivator. However, this sense of ownership must be coupled with a sense of responsibility and accountability.
Regular interpersonal communication
The target groups, their local leaders, and the implementors must agree to interact regularly through meetings, seminar-demonstrations, and the like. There is no mass media substitute for face-to-face contact, especially where timely advice, resources, and services are needed. Whether these interactions are weekly or monthly, all participants should develop the "habit" of anticipating and attending them.
Co-operation and respect among different programme participants
A spirit of co-operation and respect among the people involved in the programme is the basis for opening the lines of communication and thus encourages caring and sharing, collective decision-making, and team-work. Programme failure is often attributed to the fact that these basic affective states are taken for granted and not consciously nurtured.
Active involvement and commitment of development workers in all stages of programme development
The participation and manifestation of commitment by health/nutrition workers, whether as government service providers or volunteers, is essential. These persons have the important roles of linkage builder, facilitator and catalyser. As providers of front-line services and information, they have direct access to the target groups and are often regarded as credible sources of information. As such, they can persuade target groups to adopt correct practices and participate in programme activities.
Organisational maturity of the community
Experience has shown that communities with a good level of organisational development are the ones that take off faster when programme interventions are introduced. This is because they already have a system for dealing with decisions and problem-solving. It also takes less time and effort for them to organise new groups as needed, and to maintain a system for regular interpersonal communication and interaction.
Linkages and alliances with government and NGO support systems, media and those who can contribute to problem solution
Policy-makers and those who make decisions on fund and resource allocation must be made to recognise and become responsive to the problems affecting vulnerable members of the community: the infants, children, and women. The first step is to initiate discussion to generate political will, commitment, and action. Examples of these potential allies and support systems are government agencies, political parties, religious organisations, trade unions, social welfare organisations, professional associations (e.g. of doctors, nutritionists and dieticians, communicators, lawyers, etc.), multinational companies, business clubs, advertising agencies, media organisations, etc. These linkages and alliances should widen the perspective of community leaders, and the residents in general, on the opportunities open to them in generating resources and various forms of assistance, as well as livelihood activities.
Establishing evaluation methods, programme communication strategies, and management skills at the local level
Evaluation is integral to each stage of a programme intervention, from pre-planning, planning, and implementation, to post-implementation. The traditional view of evaluation as a purely ex post facto activity has shifted to its current use which also includes ex ante and ongoing activities during programme implementation. Evaluation is defined as "the process of delineating, obtaining, and providing useful information for judging decision alternatives" (Stufflebeam, 1981). In other words, evaluation provides useful information that will help in decision-making, and ascertaining the value of the intervention strategy in each phase of the programme. Evaluation information on the audience's level of KAP is needed to design an appropriate communication strategy, i.e. on whether to alter or make improvements on the strategy, whether resources are being used as planned, whether the programme has accomplished its objectives, and whether observed changes can be reasonably attributed to the intervention.
Evaluation is a special form of applied research designed to produce quantitative and qualitative data for decision-making. Before the intervention, the evaluation activity is classified as baseline or background. Evaluation of materials, protocols, or activities is called formative evaluation. Evaluation during the programme implementation is called process evaluation. Finally, the evaluation activity after the intervention is completed, is classified as summative or outcome. Evaluation methods for each stage of a programme can include the following:
Context evaluation during pre-planning
The purpose of this type of evaluation is to identify behavioural change objectives and system goals, by exposing problems, unmet needs, and unused opportunities. Some evaluation methods for this stage are situational analysis, problem identification and needs assessment, focus group discussion, key informant panel interview, KAP study, and community survey.
Input evaluation during planning
The purpose of this evaluation activity is to develop and analyse one or more alternative designs or operational strategies. Examples of evaluation methods for this stage are pre-testing of communication materials, piloting of a communication strategy or media mix, and feasibility study.
Process evaluation during implementation
The purpose of this evaluation activity is to detect or predict defects in the procedure or strategy, including management, for possible modification, adjustment, refinement, improvement or deletion. Process evaluation is a function of the adequacy of context and input evaluations. It provides feedback to implementors, identifies potential sources of failure, maintains a record of methods used in the programme, and monitors, controls, and documents intervention procedures. Process documentation techniques, monitoring procedures, and feedback gathering are some methods used in this type of evaluation.
The purpose of this type of evaluation activity is to measure and interpret attainments based on objectives and provide information for policy and any decisions about future programme recycling. Examples of evaluation methods for this stage are post-test, effects (behavioural) evaluation, and impact assessment.
Programme communication strategies are made up of a mix of interpersonal communication channels, community media, and mass media. These are planned on the basis of the community members' resources (radio and TV ownership, availability of electricity, free time), abilities (literacy rate, education), and predispositions (preference, motivation, willingness to participate).
Management skills are not the monopoly of programme implementors. Community-based implementors such as local leaders and health and nutrition personnel should also be trained in management skills. This is why management training should be part of the training plan of any programme. As discussed above, management skills include planning, staffing, budgeting, controlling resources, guiding and co-ordinating people's activities, setting policies, guidelines and standards, and monitoring and evaluation.
A programme management plan lists management related activities for each stage of the intervention in an action plan. This is usually presented in a Gantt Chart that specifies what activities will take place, the dates and duration, expected output, and individual or team responsibilities. A co-ordination scheme is also established, which includes schedules for regular management meetings, home visits, workshops, and reviews. The plan includes a programme for staff training. The manager analyses where the existing skills are inadequate to perform specific jobs. She or he also identifies trainers, sets training dates and prepares evaluation tools to determine impact on job performance, and potential multiplier effects on others. The manager is also responsible for costing major activities according to the approved budget. A nutrition education intervention must project budget requirements for: (i) research and evaluation activities - costs for focus group discussions, consultations, meetings, field surveys, etc., including materials and snacks; (ii) media development - costs for designing and revising prototype materials, mass production and distribution; and (iii) staff training - costs for trainer's fees, travel, daily allowances of participants, training materials, food, and accommodation. Another important management responsibility is setting policies, guidelines, and output standards. Smooth implementation is assured when management specifies and adheres to operational guidelines and policies on reporting, job performance, use of equipment and vehicles, and standards for outputs such as progress reports, minutes of meetings, trip reports, and financial reports.
Developing policy initiatives - at the local level
Any nutrition education intervention should be educational to all sectors at all levels. Through advocacy efforts, programme implementors can generate commitment and action from decision makers to provide the necessary resources to improve the nutritional and health status of vulnerable groups and the entire community. Such commitment and action must begin from the national and local political leaders who have the power to enact policies and legislation that would commit resources to solve specific problems.
For example, the Department of Health in the Philippines has effectively adopted a national policy to implement the Expanded Programme on Immunisation (EPI). It is a successful example of a partnership between the government and a local community for development. At the national level, a high sense of political commitment was manifested in order to provide all the resources needed to accelerate programme implementation at the community level. In 1986, former President Corazon C. Aquino signed Proclamation No. 6 implementing the EPI. The aim was to immunise infants against six deadly diseases, namely: childhood tuberculosis, diphtheria, pertussis, tetanus, polio, and measles, and to immunise mothers of child-bearing age against tetanus. After five years, the Philippines was cited as one of a few countries that had achieved the Universal Child Immunisation target. Upon assuming office in June 1992, President Fidel V. Ramos ensured its sustainability and reaffirmed the government's commitment to the Universal Child and Mother Immunisation Goal by issuing Proclamation No. 46. At the same time, he launched the National Immunisation Day (NID), scheduled every third Wednesday of April and May from 1993 to 1995. The NID aims to provide a higher coverage of immunisation for Filipino children under five years of age and to eradicate polio in the Philippines by 1995. Other countries, notably Vietnam, Cambodia, China, and some Latin American countries, have expressed interest in adopting the Philippine experience.
Developing curriculum support
It has been long recognised that undernourished children do not learn as well, are more susceptible to illness, and miss more days from school than well nourished children. Schools provide the logical place to intervene with children in order to improve their health and nutritional status. Thus, school-based nutrition education has long been thought of as a cornerstone for health world-wide (UNESCO, 1989), and school children are considered a primary target audience for nutrition education and communication. Nutrition education in schools relies primarily on classroom curricula, school feeding programmes, or a combination of both approaches.
Classroom instruction in nutrition can be offered as a separate, stand-alone subject, or it can be integrated into other subject areas. Traditionally, nutrition is taught as a stand-alone subject or as a unit in the health or home economics curricula. This teaching method has emphasised certain topical issues within nutrition, including the three (or four) basic food groups or food guides, the concept of a balanced diet, and food sources for specific nutrients (such as protein, iron or vitamin A). Teaching techniques are generally lecture-based, but may also include role-playing activities and games. These curricula tend to be designed for knowledge change rather than behaviour change. The booklet produced by Helen Keller International (1993) is a typical example of this approach. Several "how-to" resources are available for designing school curricula based on this model (Oshaug, Benbouzid & Guilbert, 1988).
The purpose of food guides is to present a practical daily plan for food selection for use by the general public. Most have been developed by a "top down" approach in a variety of graphic forms (food wheel, pyramid, target, plate, standard blocks, etc.). Few of these graphics or guides have been evaluated for effectiveness. There are also a number of other issues raised about food guides. These 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 the sake of simplicity, the extent to which guides should reflect a concern for sustainability of the food supply, and the extent to which a food guide should "stand alone" or be part of a more extensive education strategy. Other issues frequently raised are, whether the food guides should address only the daily "foundation" diet or total intake, and whether a country should have several food guides (for different ages and needs) or only one to improve consistency.
Overall, the intent of food guides is appropriate and desirable. Their functionality and impact, however, will depend on their developmental process and fit with the target audiences' perceived needs and desires. Most food guides probably need revision in order to meet these considerations. However, a food guide that makes sense to the target audience is a valuable addition to the curriculum.
One of the drawbacks of a "stand-alone" curricular approach is that nutrition will often not be taught if it is not required of teachers to do so. In addition, when nutrition is taught in this fashion, it may become disconnected from everyday life and the other subject matter in the school curriculum. Students may then have difficulty in integrating the nutrition information into their own life practices and/or relating the information to other subjects that they are taught in school.
In the 1980s, an integrated curricular approach was begun as an alternative, and is becoming more commonplace on a world-wide basis. For example, Malaysia integrated nutrition instruction in the primary schools (first six years of schooling) into subjects such as Man and His Environment, Islamic Studies, Moral Education and Music Education, where food and its basic functions are taught as well as the concept of a balanced diet. In Malaysia's secondary school curriculum, nutrition is incorporated into Physical and Health Education, where the relationship between nutrition, health, exercise, and concepts pertaining to overnutrition are taught (Karim, 1991). The Philippines has integrated nutrition into Health and Science as well as the core subjects in the "three R's," Arithmetic, Reading, and Writing (NNC, 1992). India evaluated the integration of nutrition education in health education and environmental sanitation during the third-fifth year of primary schooling. Results at the local school level indicated a significant change in height and weight indicators among children, and a marked decrease in observable deficiency symptoms, e.g. bleeding gums, after children received school instruction (Devadas, 1986).
One of the drawbacks of an integrated approach is that nutrition may be taught in a fragmented, uncoordinated, and uncomprehensive fashion. The net result may be less meaningful learning, comprehension and behaviour change than might be accomplished if nutrition were taught as a separate subject. Fragmentation can be avoided, however, if care is taken in curricula development to ensure that nutrition concepts are taught in a systematic, comprehensive approach where new knowledge is added to prior knowledge in a pre-planned sequence of steps and learning objectives. This approach requires a co-ordinated effort across subjects, often involving teams of teachers and administrators.
Studies to evaluate the impact of nutrition education in schools are relatively rare. However, there is a general sense of disappointment with the results of classroom-based education. Less than optimal results may be due to a number of different factors, including too little time given to nutrition instruction, use of a non-participatory classroom approach, lack of family involvement especially at the primary level, or lack of self-assessment of eating patterns at a secondary level. School programmes that are not behaviourally-based and theory-driven are also less likely to be successful. Most important, however, are environmental supports (Lytle & Achterberg, 1995). Regardless of the quality of instruction, the learning will not be put into practice and behaviour change will not be accomplished unless the immediate environment supports such practices or changes.
Creating supportive environments
Offering food to school children is the most important immediate environmental support. School feeding programmes may be offered to school children as a stand-alone programme or they may be integrated with classroom instruction on nutrition. Supplementary feeding programmes are probably the most commonplace; the provision of meals, most often lunch and more rarely breakfast, is widespread in some countries. The purpose of supplementary feeding programmes is to supply school children with needed extra nutrients and/or calories, to improve their nutritional status, to improve school attendance, especially in poor rural areas, and to improve children's cognitive development and school performance. The purpose of meal programmes is to accomplish the above three objectives as well as develop the eating habits and skills needed for life-long, positive, healthful eating practices.
There are two principal problems with feeding supplements, such as "Incaparina" to children: (i) it is difficult for the schools or health sector to sustain financially unless there is continuous government support and the necessary infrastructure to manage the programme, especially in urban areas (Kachondham, Winichagoon & Tontisirin, 1992); and (ii) it is difficult to obtain at the individual level if children do not attend schools or health clinics. Moreover, even if the supplement is available on the market-place, it will not become a part of the regular diet because it is "foreign" to the everyday food habits of the local people.
Experience in Thailand indicates that supplementary feeding programmes work better if the food supplement is processed at the village level, rather than developed and processed centrally and/or distributed through the health infrastructure (Kachondham, Winichagoon & Tontisirin, 1992).
Meal-feeding programmes (as opposed to single food supplements) may be partially or completely subsidised by the government or local community. Meals are preferable from a learning perspective, because the children are eating foods they can recognise and obtain in their own homes and communities. The feeding situation can then be an extension of the classroom, in essence, a learning laboratory, where proper eating habits can be demonstrated and reinforced in practice. This combined approach of classroom instruction and feeding has been encouraged since the 1970s (UNESCO, 1989).
Another important way to build a supportive environment for the school curriculum in nutrition is to involve the parents. Children can take their learning home and share it with other household members, but it is important to engage these other family members in the learning experience as much as possible. Dialogue between the parents and the teachers, as well as their children, should be encouraged. Parents can also become involved in food production, especially in school gardens, as well as in the planning for, and preparation of school meals for children. This Teacher-Child-Parent approach has been well exemplified in the Philippines (Salvosa-Loyola, 1993) and Thailand (Smitasiri, et al., 1993).
Creating links between the school and the community
School programmes will have greater impact and be sustained longer if they are tied to community activities, programmes, and other private and non-governmental organisations. School gardens provide an excellent opportunity for community involvement, as access to water, land, material input (plants, seeds, tools, etc.), gardening experience, available labour and extension information are needed to start and sustain them.
Thailand exemplified how such community linkages can be developed with a school-based nutrition education programme. To encourage the use of the ivy gourd plant (a rich source of vitamin A) and school market gardens (which raised food for the children to eat as well as for school income), they solicited help from the extension service and experienced home gardeners to start local projects. They involved key officials including school administrators, agricultural officers and the district committee to judge ivy growing and garden competitions between schools and districts. Mobile dramas also travelled to schools in all participating districts and provided entertainment with education to reinforce the communication message. They also involved Buddhist monks who played a promotional and educational role in the project. Finally, the message was also incorporated into local festivals and holidays, including New Year's cards with an ivy gourd greeting (Smitasiri, et al., 1993). Together, these various activities involved a large number of community members and opinion leaders, strengthening both the school programme and the community in the process.
Another logical linkage can be made between schools and health monitoring programmes. Children's growth and immunisation can be readily monitored in schools. Partnerships between health workers and agencies can provide access to children and needed support to all participants. Other potentials include involvement in teacher training and medical doctor training programmes, where the schools invite students into their classrooms to learn as well as teach. Libraries can also provide important links between the school and the larger community. Many countries use Village Health Volunteers or Village Health Communicators to work in rural areas. Volunteers can be trained in, and work with schools to broadcast programmes, motivate audiences, and coordinate nutrition and other health-related messages to children and the broader community.
Implementing special or system wide promotions
Linkages that occur at the local level can be extended to district, regional or system-wide programmes as well, especially in the area of nutrition surveillance and child growth monitoring programmes, other Ministry of Health programmes, child care centres, women's development programmes, home economics training for women's groups, or any programme that promotes home food production or home consumption. In fact, linkages should be systematically promoted at all levels, from local community administrators and extension workers to district committees, provincial government officials, and high level government officials. Such linkages should be used to frame and institute policy changes at each of these levels to assure that nutrition education and communication programmes, especially highly successful efforts, are sustained over time.
Facilitating policy development
There are many areas where government policy has an impact on nutritional status, food security, and nutrition education at national, regional, and local levels. Some of these areas include agriculture, including animal husbandry, crop production, fisheries, and forestry; health; environmental policy; women's development; population; urbanisation; international economics; and trade agreements policy. Education, advertising and consumer policies are discussed less often in terms of their interaction with nutrition, but are probably as important. Policy is inalienably a matter of politics. At the same time, the school system is charged with a custodial responsibility for children. It therefore seems that schools should also be involved in policy development to protect and sustain children's development. Food and nutrition policies are integral to that interest.
Some of the issues that schools might address in terms of setting local policy and/or affecting regional or national policy include food subsidies, dietary guidelines, food labelling, consumer access to information about processed food products and practices, regulation of food advertising and marketing practices, limitation of foods adverse to public health, particularly in public feeding programmes (such as school lunch), guidelines for public catering, quality requirements for food, household food security, promoting healthy diets and life-styles, preventing and managing infectious diseases, caring for the socio-economically deprived and nutritionally vulnerable, and assessing, analysing and monitoring nutrition-dependent situations.
It should be recognised that the strategies for poverty alleviation have changed significantly in the past decade or so. It is now accepted by experts in behaviour change and nutrition communication that people's participation is fundamental for any sustainable improvement in the welfare of the poor. Participation means local people organising to shape the terms of the social, political, and economic processes that affect them. In other words, the people create organised demands upon governments and agencies as well as private and commercial bodies to meet their needs using indigenous expertise and technologies. Participation also implies capacity building and the strengthening of local institutions (Haralambous, 1993). Naturally, agenda-setting and policy formation play an important role in this effort. Food and nutrition policy may be among the most important and most obvious to people at the local level and local schools may be a natural focal point for such organization and participation. However, in some countries, the style of government does not permit the type of citizen participation discussed here.
Using mass media to increase awareness
The mass media were not used widely in nutrition communication until the 1970s. Before then, nutrition communication relied almost entirely on face-to-face instruction in health clinics (Lediard, 1991). Many early efforts using mass media in nutrition communication yielded disappointing results. This was often because the quality of many past programmes was inferior due to a lack of training or preparation, inadequate resources, or because it was used for inappropriate purposes. Media cannot, for example, cure poverty (Lediard, 1991). But, neither can media be relied upon to change behavioural patterns by itself.
Media-based nutrition education projects are now legion. Some have produced changes in behavioural practices, such as campaigns for oral rehydration salts in Egypt, the Honduras, Gambia, and Swaziland, but changes in nutritional status are rare (Hornik, 1985). It is now known that the best use of media, particularly for stand-alone media campaigns, is to build public awareness about a new issue, problem, or resolution.
One of the most powerful aspects of the media is its ability to set the public's agenda. That is, media shapes what people view as important in the world, and it identifies and defines concerns, issues and problems. This is another form of building awareness. The public, however, may not agree with the conclusions reached by the media about how to resolve these concerns (Severin & Tankard, 1988). Other forms of two-way communication may be needed to persuade the public to adopt a different behavioural approach, for example, to infant feeding.
Developing single message strategies
Today, the strategies used to develop mass media communications in nutrition are taken from social marketing literature. Several sources provide good descriptions of how to plan persuasive messages such as Andrian (1994), Rasmuson et al. (1988), and the US Department of Health and Human Services (1992). Generally, four questions are posed at the beginning stages. Who is the target audience or consumer for the communication? What is the product? What is the message? What are the channels of communication? Market research is used to answer these questions and the media messages and campaign are designed accordingly.
There are four elements involved in designing an effective single message (Hornik, 1992):
· good content - the message supports changes, beliefs or activities already present in the community;
· good message - the message is characterised by high technical quality;
· good channel use - the selected media has a broad reach and is accessible to the audience; and
· good audience knowledge - the message is relevant to, and well accepted by, the audience.
Some of the key points include creating messages that are clear, concise, credible, and easy to remember, all from the target audience's perspective. Above all, the messages need to appeal to the target audience's perceived need for information. The most effective messages include a precise behaviour change recommendation, use a memorable slogan or theme, and are presented by a credible source in a positive, uplifting style that is not offensive to any member of the target audience (US Department of Health and Human Services, 1992). Finally, a focus on motivation, not just information, is needed. Of course, all media should be thoroughly pre-tested with members of the target audience, as described earlier in this chapter.
A variety of media may be used to communicate a single message, including bulletin boards, booklets, pamphlets, posters, radio and television messages, newspapers, community bill boards, and promotional give-aways to name just a few. Promotional give-aways are products that carry slogans or short messages including calendars, T-shirts, caps, vests, ball point pens and pencils, notepads, pins, and bags. Effective promotionals are items that are regularly used by the recipients, routinely reminding them and those with them, of the message.
Print messages should specifically avoid jargon and technical terms, abbreviations and acronyms, small type, and long words, sentences, and paragraphs. Text should be written in an active voice and use organising headers, bold print and "boxes" to highlight important points. Graphics should be immediately identifiable to the target audience, relevant to the subject matter, and kept as simple, but up-to-date, as possible.
Short (10-60 second) public service announcements, spots, or plugs on radio or television should also recommend a specific action, make a positive (not a negative or fearful) appeal to the audience in simple language with a memorable theme, music, visual, or character to deliver the message.
Even the best designed message needs to be repeated many times if it is to build general public awareness or accomplish any other outcomes. Any form of mass media has a limited effect when it is delivered only once or for a short period of time. The audience needs frequent exposure to the message, even if it is familiar, but especially when it is new or novel to them. The greater the reach, frequency, and duration of a mass media message, the greater the number of people who will be reached and the greater the likelihood that change will occur.
Using mass media as the centre piece for a multi-channel campaign
A fundamental dilemma in nutrition communication is that interpersonal communication may be more effective at promoting behaviour change, but its reach, and ultimate impact, is limited by the size of the audience (Gillespie, 1987). The mass media reach far more people in far less time. However, single messages are unlikely to change strongly held attitudes or behaviours. Therefore, the best approach to a nutrition communication/behaviour change programme is to employ several different forms of media in a co-ordinated multi-channel approach (See Table 1).
Mass media campaigns are defined as planned, large scale, multimedia efforts to communicate a single concept idea to a target population(s) in a prescribed amount of time (Wallack, 1981). Generally, mass media campaigns:
· Use all available channels of media
· Address a single problem or behaviour
· Communicate a single well-focused message
· Are specific and relevant to the target audience
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)
The mass media do not ordinarily serve as a necessary or sufficient cause of behaviour change. Mass media campaigns may speed the rate of behaviour change, but rarely initiate it. They can also play a role in facilitating one or more steps in the behaviour change process. They work best, however, in synchrony with other intervention components. Strongly held attitudes and behaviours are probably best changed with a combination of interpersonal and media messages (Severin & Tankard, 1988). Several family members should be targeted by messages in order to facilitate a supportive home environment for the desired behavioural changes.
Different media have different effects on different people. Heavy users of the media react differently to media messages than light users. Heavy users (those who listen to or watch media for four or more hours a day) tend to rely on the media for information about their community and the larger society. Therefore, they believe the media more readily than people who do not rely on the media for news (Severin & Tankard, 1988). Some people are interested in certain topics (e.g. sports) and pay attention to any media that addresses their interests, but dismiss any messages that do not address their favourite subject. A multi-channel nutrition communication campaign that introduces new messages with star personalities drawn from these interest areas can take advantage of this. For example, in Brazil, the captain of Brazil's World Cup football team, a well-known male musical entertainer, and three well-known television actresses were used in 30-second television commercials to support breast-feeding (ad Kahn, 1991). Alternatively, nutrition messages can be incorporated into pre-existing heavily watched media (e.g. "soap operas" or "novellas"). Other communication channels can then be used to reinforce these messages and stimulate behaviour change, especially at the local level. In Thailand, for example, Buddhist monks were very influential within communities, but mass media was useful for initiating community campaigns for change (Smitasiri et al., 1993).
Facilitating pro-active use of mass media
Several factors contribute to the potency of any media campaign. Media effects are limited when interpersonal relations and prior beliefs conflict with the message. Media effects can be powerful when they coincide with interpersonal relations. When the public hears a message that makes them uncomfortable, they may selectively pay no attention to it, misinterpret it, fall back on their own rationalisations, disbelieve it, or attack the source's credibility to reduce their discomfort with the message. However, discomfort with the message can be overcome if it offers sufficient rewards, including utility, novelty or entertainment values (Severin & Tankard, 1988). People will be less resistant to a new message if it is introduced by opinion leaders in the local community or general society. Only sound market research prior to message development can anticipate and accommodate the conflicts the target audience might have with the messages.
Because multi-channel media campaigns are by definition complex, partnerships are highly recommended to facilitate their development, implementation, and evaluation. Nutritionists need to form partnerships with social scientists and communication or media specialists. In addition, multi-sectoral partnerships are also routinely required. They may involve private industry, non-governmental agencies, government agencies, religious leaders, and grassroots participation at the local level. Policy-makers should, in particular, be thought of as a target audience and be included in communication design. Desired changes are most likely to occur within a supportive environment for change. Only broadly based partnerships can create that context. Authoritarian-type governments may provide a better context for a co-ordinated, multi-sectoral communication programme than more democratic-type governments where communication industries are independent, commercially oriented, and owned by many different people.
In recent years, innovative mass communication approaches have been effectively integrated into mass media campaigns to create widespread attention, interest, motivation, and recall for particular nutrition, health and population messages. One approach has been called "enter-educate." It combines entertainment and education through songs and entertainment programmes featuring popular movie and television personalities. The enter-educate productions are aired over radio and television, featured in magazines and newspapers, and even through live shows in shopping malls. A similar approach, "info-tainment", combines the objectives of informing while entertaining the public via comedy and drama programmes over radio, television, and comics. Info-tainment has also been used by community development workers to reinforce their interpersonal approaches. Using mobile audio-visual vans, they present certain video documentaries on agricultural technology, alternating with a full length movie of the audience's choice. The advertising industry has also introduced "values advertising" and "development plugs" to inject messages with developmental value in their advertisements. Enter-educate, info-tainment and developmental plugs are unlikely to work effectively unless they are created by a team of nutrition educators and mass media specialists.
Inter-sectoral partnerships can accomplish two objectives. They may increase the broadcast of more positive nutrition messages, and thereby change the communication mix. They may also decrease the broadcast of negative messages as partners recognise the number and kind of negative messages already broadcast in the mass media. They may then voluntarily withdraw certain negative messages or work to change some of those messages.
Training media journalists
There is a shortage of media specialists in developing countries, especially those associated with ministries of health or education. In some cases, a ministry of agriculture may have access to communication expertise. Health ministries and education ministries should be encouraged to create positions for media specialists and include them in the earliest stages of programme development. They should also try to work inter-sectorally to support training for media specialists and create an infrastructure to support their activity.
Media journalists tend to be trained as generalists. Few have the expertise to correctly communicate health and nutrition information to the public. Therefore, multiple training programmes are necessary to promote effective nutrition communication campaigns:
· More media journalists need to be trained, with emphasis on the co-ordinated use of a wide variety of media for the purpose of mass media campaigns. This will require training on how to incorporate innovative technologies into programme planning as well as the use of traditional communication modalities.
· Continuing in-service training will always be needed to update media journalists on innovative technologies as well as nutrition and health information, because information and methodologies in both fields are changing rapidly.
· Health and nutrition professionals also need to be trained how to collaborate effectively with media journalists. This will require additional training in the behavioural and social sciences.
Training of media journalists and communication experts can be costly in itself, but the Union of National Radio and Television Organisations of Africa (URTNA) has developed an effective model that may be appropriate in many parts of the world. URTNA has 48 member countries that team together to sponsor training sessions and an exchange of programmes and teachers across international boundaries. In a three year period, they have graduated 120 technicians from their training programmes and have exchanged over 2,000 radio and 900 television programmes for broadcast. Regular meetings held every two weeks between communicators from national broadcast organisations and experts in family planning and maternal and child health are considered a key element in this programme's success. The meetings foster open communication between these two fields and stimulate teams in different countries to produce higher quality programmes (Demena, 1991).
Effective training programmes are needed, but are not sufficient, for the creation of successful communication programmes. Successful programmes require not only the incorporation of communication technologies, but also institutional infrastructure and a supportive policy and philosophy to sustain such communication efforts across a region or country.
Establishing the benefits to employers and employees
Healthy work-site programmes became popular in the 1980s and nutrition education is a common component of these interventions. They have been reported in telephone companies, police departments, Fortune 500 companies, and small local businesses. Healthy work-site programmes emphasise disease prevention or health promotion. They are based on the assumption that certain chronic diseases affect job performance and/or company profitability. For example, it is less costly to prevent hypertension via education than it is to treat it via medication. Some of these chronic diseases are related to food habits and choices. Since these food-related behaviours are not fixed, communication and other interventions designed to modify these behaviours may decrease the risk associated with these diseases, and presumably increase worker productivity, decrease company costs and improve the company's public image.
Work-site nutrition education programmes are appealing for many reasons. From the employer's perspective, they may increase workers' productivity, decrease absenteeism and turnover, improve recruitment of personnel, and generally improve company morale. From the health-care provider's perspective, work-site nutrition education programmes provide access to workers who may not otherwise be served by the health-care community, enable cost-effective and efficient screening opportunities, provide a forum where nutrition information can be efficiently disseminated, and an environment where behaviour can be monitored and social or peer influences can be used to reinforce behaviours. From the employees' perspective, work-site nutrition education programmes may be attractive because they are convenient, meaningful, credible, and ongoing. If successful, they can decrease health-care costs and improve the happiness, health, and quality of life for individual workers and their families (Johnson, et al., 1988; Ostby, 1989).
Screening and needs assessment
Groups of participants can be screened, counselled, and followed in a time-efficient and cost-efficient way (Johnson, et al., 1988). These screening data should be used to design appropriate interventions and communication campaigns for the company as a whole and possibly, for individuals within the company. Baseline data should be collected about the individual workers, their home and community environment, and their employers and work environment before a work-site programme is designed and implemented.
Screening and needs assessment of individuals may assess anthropometric variables (such as height and weight), demographic variables (such as age, sex, and marital status), biochemical indices (such as hematocrit or serum cholesterol), clinical variables (such as blood pressure), dietary variables (using a shortened dietary history, 24 hour food recall, or food frequency questionnaire), physical activity (including type of work performed), lifestyle characteristics (such as smoking, alcohol consumption, time spent at or away from home), nutrition knowledge, attitudes, and beliefs, interest in nutrition programmes, use of medical and social services, and a brief medical history (Alford, 1986; Kris-Etherton & Engelland, 1986).
Assessment of the work-site should include management style (e.g. autocratic vs. participatory or production-oriented vs. people-oriented), nutrition-related policy at the work-site (e.g. time allowed to eat), eating facilities, food storage facilities (including places where women can breast-feed and store breast milk if necessary), hygienic facilities (e.g. washrooms), hours of work and individual control over work time, seasonally of employment, job satisfaction of employees, relations between workers, shift work and company management, the company's long term objectives and goals, turn-over rate in employment, opportunities for social interaction on the job, and the norms, values, beliefs, and patterns of behaviour that guide daily functioning and interaction at the work-site (Johnson, et al., 1988). Some of these variables are important in order to determine how to introduce and sustain a work-site programme in the most acceptable manner to both workers and management.
Catering programmes, nutritional improvements of food services, and point of sale promotions
Many family members, including school children, spend a major part of their day in the workplace or in school. This means that they must eat at least one meal and about two snacks outside the home. This has led to the growth of the food service industry, particularly street-food vending in developing countries. The street-food trade is a source of livelihood for many people among the low income group, and is a source of cheap food for low to middle income people. Recognising the need to protect consumers against unhygienic and low quality street-foods, FAO supported pilot projects on the improvement of street-food safety and quality in several developing countries in Asia and Latin America. An education and communication component was built into the projects, addressing consumers on one hand, and educating street-food vendors on the other, on topics like basic nutrition, food preparation, hygiene, and sanitation. Seminars and training in the workplace had been successfully carried out for both groups, reinforced by well researched and properly designed print and audio-visual media such as posters, flyers, brochures, flipcharts, and training modules.
Work-site-based cafeteria interventions, in particular, have been one of the most popular work-site nutrition intervention strategies used (Glanz & Rogers, 1994). In these programmes, employers offer their workers choices of nutrient-dense foods (e.g. low calorie, low fat, high vitamin C, high vitamin A, or high calcium foods). These foods may or may not be offered along with other less desirable choices. Often nutrient information in the form of labels or posters accompanies the foods in the cafeteria environment. In companies that do not have cafeterias, employers may negotiate with vendors to ensure that point-of-purchase nutrition information and/or suitable choices are made available (American Dietetic Association, 1994). Entrepreneurial lunch wagons can offer nourishing food to field work-sites that are remote from feeding facilities. Facilities for washing before eating are also important. Some companies subsidise in-plant food services partially or totally, making them nutritious, attractive and convenient to employees. Some employers have also added nutrition awareness games and incentive raffles (e.g. free lunch) to employees to encourage their participation in these programmes (Mayer et al., 1987). Research studies have generally produced positive trends in dietary intake but often only outcomes over a short period of time are evaluated. Most of the catering programmes reported in the literature have concentrated on heart health issues, but other issues that could be considered include use of fluoridated water, iodised salt, adequate protein, clean water, and iron.
Nutrition education as a stand-alone work-site programme
Nutrition education that is not connected to any other form of health education at the work-site can be described as a stand-alone programme. Stand-alone programmes may include formal classes and programmes, newsletters, memos, payroll stuffers, posters, bulletin boards and electronic mail (e-mail) (Kris-Etherton & Farquhar, 1994), as well as informal discussion groups, buddy systems, and other support groups. Carefully targeted materials and classes can have a significant impact on nutritional status, not only for employees, but for their family members as well.
The success of stand-alone programmes depends on how supportive the company environment is of the recommendations. Stand-alone programmes are unlikely to work if they include only information dissemination. Generally, work-site nutrition education programmes require supportive environments (such as cafeteria or food catering programmes as described above). It is essential that employees have access to appropriate food choices. Release time from work and employer commitment to the programme are also viewed as important to success. Employees respond best to healthy work-site programmes that are simple, practical, and relevant and that allow them to participate actively in the learning activity during work time. Eating pattern messages which include specific foods or brand names and behaviourally oriented programmes are better accepted than messages containing medical jargon and lengthy background explanations (McCarthy et al., 1992).
Nutrition education as part of an integrated health programme
Nutrition education can also be integrated into a more comprehensive health programme at the work-site that might include, for example, smoking cessation programmes, drug and alcohol education, stress management, child-care education, and breast-feeding support. It may be combined with an exercise or fitness programme or more often, a weight control programme. Nutrition education may also be integrated into the health benefits and/or health insurance offered by the employer to workers, especially in companies with Health Maintenance Organisations.
Work-site nutrition education programmes can also be integrated into the broader community. Community-based wellness councils, for example, team non-profit health organisations with small businesses and vendors within and across communities. The councils do not compete. Rather, they bring together local providers with common interests to share ideas and resources to offer healthy work-site programmes that they cannot afford themselves. Often they share newsletters and strategies with one another. Wellness councils may publish "how to" guides, hold delegate meetings and annual meetings, or share the cost of bringing in an outside consultant or nationally known speaker (Kizer, 1987). Ideally, community-based wellness councils match local expertise to local needs and help small businesses lever their limited resources for maximal impact. Together, they may also affect an entire community to create a more healthful and supportive environment for its citizens.
Number of work-site programmes
Given the advantages of, and opportunities for work-site nutrition education programmes, it is interesting to note their small number, especially in developing countries. This may, in part, be due to the lack of an infrastructure for these programmes, but there are several other considerations as well. Work-site programmes have been criticised because many tend to serve only healthy workers or well-paid, professional employees, neglecting those in greatest need. They may increase personnel costs to the company, at least initially, and they may subject a company to liability concerns (Ostby, 1987). The most common criticism, however, is the lack of data indicating the relationship between quality and quantity of work performed by workers and their nutritional status (Kris-Etherton & Farquhar, 1994), and/or the economic savings realised by the company with such programmes (Ostby, 1987). It should be noted, however, that many of the evaluations are short-term and flawed by their research designs and/or analysis (Conrad, Conrad & Walcott-McQuigg, 1991). Relatively little attention has been given to developing methods for institutional commitment, and this seems critical to programme success.
This review has led us to draw four broad conclusions: (i) nutrition education and communication should be thought of as an integral part of a country's development plan; (ii) changing food and nutrition behaviours to improve nutritional status at a country level is a long process comprising many steps, in many sectors, at many levels; (iii) nutrition education and communication programmes need to be comprehensive and co-ordinated for effectiveness; and (iv) nutrition education and communication problems need to be participatory in nature for effectiveness. These conclusions are further developed below.
Nutrition education and communication should be thought of as an integral part of a country's development plan.
The nutritional status of a country's population is an important indicator of national development. The causes of poor food habits are complex. The simple provision of food or supplements does little to resolve long-term nutritional problems. Nutrition education and communication can have a significant impact on a population when there is political stability, social coherence, and a favourable economic climate. Nutrition education and communication provide people with the knowledge, know-how, motivation, and reinforcement to empower them to effectively address their own long-term food and nutrition problems.
Changing food and nutrition behaviours to improve nutritional status at a country level is a long process comprising many steps in many sectors at many levels.
Recognition of this fact may call for a reorientation in thinking about nutrition programmes. A long-term, holistic view of nutrition education and communication is needed, with nutrition education seen as a central component, not merely as a tool to use on occasion. This holistic view may also require a re-examination of the philosophy, processes, strategies, messages, and methodologies used in nutrition interventions. It involves many actors including policy makers, planners at community and national levels, educators and communicators, NGOs and other providers of resources, field support staff and service delivery personnel, community leaders, and finally, mothers, children, and other family members.
Nutrition education and communication programmes need to be comprehensive and coordinated for effectiveness.
Mass media messages, although cosmetically perfect, will be ineffective as stand-alone interventions. Rather, several communication channels should be used. At least some of these channels should involve two-way communication. These activities require an administrative infrastructure, including organisational structure and managerial mechanisms to support a coordinated effort. Usually these efforts will have to be multi-sectoral in nature. Commitment to the programme effort at all levels is needed for sustained programmes.
Nutrition education and communication programmes need to be participatory in order to effective.
Interventions should be problem-solving, decision-making and action-oriented. Ideally, the target audience should feel a sense of ownership of the programmes. Therefore regular interpersonal communication is needed with at least some representatives in all development, implementation, and evaluation procedures.
The conclusions lead to four specific recommendations:
(i) The commitment of political leaders, policy makers, and resource providers should be sought as an initial step to programme planning and launching of the implementation strategy.
(ii) A "two-way" flow of information and resources should be emphasised in all nutrition and communication programmes.
(iii) More and better quality training programmes are recommended.
(iv) Nutrition communication and education efforts should effectively combine the processes and approaches of social marketing, social mobilisation, and development support communication.
These recommendations are described in further detail below.
The commitment of political leaders, policy makers and resource providers should be sought as an initial step to programme planning and launching of the implementation strategy.
Communication programmes often lack the budget, the staff, and the resources needed for an effective and sustained public education programme (FAO/WHO, 1992). Advocacy efforts can help to enlighten policy-makers and resource-providers about the importance and effectiveness of nutrition communication in influencing behaviour changes to improve nutritional well-being. Continuous support and commitment is essential to success.
A two-way flow of information and resources should be emphasised in all nutrition and communication programmes.
A two-way flow implies the effective use of both top-down and bottom-up (as well as lateral) communication. It assumes that programme or project formulation begins with the target groups and it uses consultation, co-ordination, collaboration, and co-operation m feedback, information-sharing and decision-making. As a result of the public's participation in the process, they should be able to decentralise the provision of services and institutionalise policy for communication and behaviour change in their own community development strategy.
More and better quality training programmes are recommended.
Training should not be a mere one-off effort. Rather, continuous in-service training is needed in order to respond to changing priorities and problems, to share relevant experiences or lessons learned, and to develop educational and communication technology. Training in programme management should also be included in education and communication technology. A train-the-trainer approach could be used within country or across national boundaries. The first level of training, then, would be the training of more trainers. The second level should be training of field support staff, community workers, teachers, and curriculum developers. The third level should be the training of specific target groups such as women or school children.
Nutrition communication and education efforts should effectively combine the processes and approaches of social marketing, social mobilisation, and development support communication.
No single approach will be continuously effective or suitable to the resolution of all problems, but each of these approaches has proven effective for certain problems at certain stages of behaviour change and development. Programme planners should be adept at all these strategies and employ each wherever it is suitable, again in a comprehensive and co-ordinated manner. Other theories and approaches to behaviour change should also be explored.
In conclusion, development should concern everyone. Nutrition improvement is a basic requisite to development. Concerted efforts in nutrition education and communication may facilitate its realisation, providing sufficient resources are available. Yet, co-ordinated action on all the causes and effects of under-nutrition must be taken as well. Issues involving over-nutrition may not yield as readily to mass communication campaigns.
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