Education nutritionnelle: Examen d'une approche fondée sur les éléments nutritifs
Educación nutricional: Examen del planteamiento basado en los nutrientes
1 This is the first of two articles on nutrition education. It reviews the consequences of nutrient-based, sender-oriented nutrition education practices while an alternative approach is presented in the second article, to be published in the next issue of Food, Nutrition and Agriculture.
M.T. Cerqueira
A health and nutrition educator, Maria Teresa Cerqueira has worked as a consultant for the Pan American Health Organization, the World Bank and FAO. She is currently a doctoral candidate in the Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
Disappointing reports that many nutrition education efforts have brought few changes in nutrition-related behaviour or nutritional status have sparked debate among nutrition educators.2 The first issue of controversy involves the effectiveness of current methods of information dissemination as a strategy for nutrition education. The usefulness of nutrition education with "sender versus receiver oriented" messages is a second topic of discussion. A third aspect being examined by nutrition educators is the effect of content that is determined by nutritional science and thus nutrient based rather than community based. These interrelated issues and their influence on the content and methods of nutrition education are examined below.
2 Many nutrition education efforts occur in the context of other programmes and were not evaluated; thus, it is difficult to draw empirical conclusions about all programmes.
Information dissemination
While dissemination of information through newspapers, pamphlets, posters, radio and television broadcasts has increased knowledge among target audiences and moderately influenced attitudes, this strategy has had little effect on changing eating patterns (Zeitlin and Formacion, 1981; Hornik, 1985; Johnson and Johnson, 1985). A review of nutrition education projects concluded that changing behaviour, rather than disseminating information, must be the clear intention of a programme if nutrition education is to be effective (Whitehead, 1973). In information dissemination the objective is to send a message, usually formulated for the general public. There is rarely any interaction or dialogue between the sender and receiver or concern with the analysis of problems or with the process of building people's capacity for making decisions and taking action to solve problems (Rogers, 1983; Stevenson, 1988; Cerqueira and Olson, 1991).
Nutrient-based messages out of context
Nutrient requirements influence the goals, objectives and content of nutrition education activities. Nutrition education messages generally address a nutritional problem (deficiency or excess) which has been identified in the population. The messages aim to change an eating practice that is considered to be the cause of the nutritional problem.
The term "nutrient-based approach" refers to activities or services that are determined by scientific knowledge rather than by the perceived needs of the persons receiving the service. While nutrition education is usually community-oriented, i.e. designed with consideration of the social and cultural context, it is structured in form and content according to the dictates of medical and nutritional science (Gussow and Contento, 1984). Materials are produced to reinforce or divulge the messages in a textual format, illustrated by drawings or pictures, in audiovisual form or in broadcast formats for radio and television.
Information designed (in form and content) by the person sending the message, usually a nutritionist, has been called "sender-oriented" (Dervin, 1981). The information is based on technical and scientific rules and modelled by the social and cultural context of the sender. In contrast, "receiver-oriented" messages are designed (in content and form) to stimulate critical thinking in the receivers and to respond to their information needs.
This issue implies that the concept of audience needs to be critically analysed. Receiver-oriented messages require meticulous audience research in order to have the text, language, graphic style, images, colours, dress, personal appearance, etc. resemble those of the receivers more than those of the senders.
The recognition that food habits and eating patterns are complex multi-dimensional behaviour, not simply biological functions, was an important breakthrough in nutrition education research. Nutrition educators studied the attitudes and beliefs of the audience and the social, economic, cultural and psychological factors that influenced the food habits and nutritional status of the population. Yet the focus of nutrition education on changing individual eating habits remained as they were still seen as the cause of the diet-related disease. In spite of the efforts of public health professionals to understand the economic and cultural conditions and to tailor information to individual situations, the basic message conveyed was still that derived from the biomedical model.3
3 Biomedical model: a system that determines the type of medical or nutritional care that is provided, the structure of the service and the content and method of delivery. In the dominant biomedical model, activities are organized around different disease states and the service is standardized for the group of patients that have a given disease, irrespective of their social and cultural context. The influence of the traditional biomedical model on nutrition education is discussed in Cerqueira (1990).
Face-to-face nutrition education strategies, especially health centre or hospital based, have reached very few people. In addition, health personnel have been inadequately trained and too burdened with curative and administrative duties to implement nutrition education activities. Mass communication greatly increased the audience of nutrition messages, yet the messages continued to focus on individual behaviour change.
Nutrition education based in the community
People's concepts and beliefs about feeding, health and growth are rooted in their traditions, and the language and conceptual framework for nutrition education needs to have meaning in each cultural context. Development communication studies involving health and nutrition programmes suggest that receiver-oriented messages are more appropriate than sender-oriented messages. Activities should be planned and implemented by a group of community members rather than by technical experts who are not members of the community.
Another breakthrough in nutrition education was the recognition that active involvement of community members is necessary to improve nutritional status because eating patterns are complex phenomena influenced by multiple social, economic and cultural factors. The transformation of social conditions such as improvements in community sanitation, water supply and food availability requires collective awareness,4 commitment and participation.
4 Collective awareness refers to the process of critical thinking generated by the Freire method (Freire, 1970; 1971; 1973) which assists people to think in their own terms and speak in their own active voices. Consciousness raising is a process in which a group discovers the historical roots and socio-economic and political relationships that affect their lives.
Involving the active participation of the learner is a more comprehensive and effective approach to developing food and nutrition skills. because a critical/ reflexive process trains people to make decisions, to set goals and to initiate action (Drummond, 1975; Praun, 1982). For instance, it is important that mothers know the basic mechanisms of human milk lactation and understand when it is appropriate to introduce other foods to their infants in order to avoid confusion by conflicting opinions. Other nutrition skills, such as washing hands before preparing foods, imply awareness that germs rather than the food itself cause diarrhoea. When children do get diarrhoea it is important that parents know that the body needs fluids and extra nourishing foods. Confidence, self esteem and perseverance are required to act upon this knowledge. The availability of water and sanitary conditions is also implicit.
Women need social support and empowerment to practice nutrition skills. Strength of conviction is needed to resist peer pressures, and it takes exceptional character to adopt new practices. This empowerment can best be achieved by connected teaching rather than by technical and procedural imposition of information that would aggressively challenge the women's notions and isolate them from their community. The importance of a participatory, community-based approach is that it trusts the participant's experience and thinking and encourages participants to expand them. How to engage members of the community in an active learning process is a critical question.
Content in nutrition education
The issue of selecting the basis for making choices about foods in various regions remains unresolved. Do we take a nutritional science approach, as in nutrient-based information, or a community-based approach, and work with indigenous knowledge? The content of nutrient-based nutrition education is determined by the nutritive value of foods. Foods are grouped by categories according to the nutrients they provide (especially the essential protein, vitamins and minerals), their presence in food and their functioning in the body. Surveys using anthropometric measures of preschool children and a 24-hour recall of the foods consumed by the family are usually the basis for assessing nutritional status and for identifying the nutrient deficiency problems in a community. If the children are low in weight then energy is the deficient nutrient; if the dietary data show low levels of retinol, then vitamin A becomes the basis of the nutrition education programme; etc.
Diverse food group categories and other teaching tools have been developed to provide consumers with information about food composition, human nutrient requirements and the relationships between nutrients and disease. The definition of "good" nutrition or adequate diet was based on the nutrient content of foods.
Focus and scope of the content in recent nutrition training materials
Orientation et portée de matériel récent de formation nutritionnelle
Orientación y campo de aplicación del contenido de materiales recientes para capacitación en materia de nutrición
|
Key activities |
Save the Children (1982) |
WHO (1986) |
FAO (1983) |
|
Needs assessment |
Helping communities uncover health and nutrition problems |
Getting to know the community and its needs |
Situational assessment |
|
Planning |
Setting goals and objectives |
Management of common nutritional deficiencies |
Setting objectives |
|
Training |
Workshop for community workers |
Teaching for better nutrition |
Exercises, games and group dynamics |
|
Implementation |
Developing learning materials |
Basic facts about food |
Programme implementation Information system |
|
Monitoring and evaluation |
Evaluation framework involving community workers and the community as set the during the planning stage |
|
Why evaluation is needed, how to do it, how to present the information and who can use it to improve nutrition |
Assessment of widely used training materials
A review of the contents of recent nutrition education training materials from three sources (see Table) reflects the concern with the identification of nutritional deficiencies, followed by technical information about high nutritional value foods and adequate eating practices, especially for women during pregnancy and children under two years of age. Another concern that is evident is that of planning nutrition education activities, especially for mothers with young children. The content of both the WHO (1986) and FAO (1983) documents is directed primarily at training community workers to implement activities to improve the nutritional status of these vulnerable groups. Traditional activities such as growth monitoring, preparation of weaning foods, infant feeding and avoiding infection are important topics.
The FAO (1983) training package has a thorough treatment of the collection, processing and use of nutrition information, especially for evaluation purposes. In both the WHO (1986) and the FAO (1983) training materials the content is nutrient based. Nutrition education activities rely mainly on dissemination of sender-oriented messages. The documents include a complete analysis of the social, economic and cultural factors that influence nutritional status, and stress that community workers consider local conditions. However, the topics focus on the change of individual behaviour associated with diet-related diseases.
The Save the Children (Keehn, 1982) monograph emphasizes the planning of training workshops for community workers and incorporating participatory learning approaches. With the group dynamics and participatory approach advocated in this monograph, technical nutritional science information can be integrated with indigenous knowledge. However, it is not clear that community workers will be able to mobilize the resources to plan and implement a nutrition education programme. The series of didactic techniques advocated in this type of training may not be sufficient to develop the skills that community workers need to assist community members in thinking in their own terms and speaking with their own active voices. It is doubtful that this brief exposure to group dynamics will enable the community nutrition workers to develop a participatory, empowerment-based approach in working with community members to improve the health and nutritional status of the population significantly. The question remains whether the community worker will acquire the information, knowledge and skills and have the support (level of discretion) both from the community and from the organization (e.g. health system) to be an effective change agent.
Both WHO (1986) and Save the Children (Keehn, 1982) could be more rigorous in training the community workers to record and use information in a practical but effective way to monitor progress toward community goals and to procure resources both internally and externally that would help to sustain the health and nutrition education programme. The quality of the performance of community health workers is crucial to building credibility with community members and involving them in the development of health and nutrition education activities. If the worker is not adequately prepared, community members may lose interest in participating in the activities that have been planned.
Messages for diverse audiences
Nutrition education in developing countries must address both nutritional deficiencies and chronic diseases. The concern with chronic diseases has yet to be incorporated into the nutrition education materials produced by international organizations for use in developing countries. Community workers need to be prepared to develop many diverse activities and need the tools to work with community members in identifying and determining solutions to both types of problem in order to contribute to the improvement of the health of all community members. With the increase in cardiovascular disease, messages may conflict since foods which have been considered "good" because they contain essential nutrients, such as protein, calcium and iron (meat, dairy and eggs) also present risks for cardiovascular disease because of their high content of saturated fat and cholesterol.
Conclusion
The controversy about the content of nutrition education and its focus on individual behaviour change has spurred a critical/reflexive analysis about the practice of nutrition education. The facts derived from nutritional sciences are not an inappropriate basis for nutrition education, but they are insufficient. It is important for nutrition educators to address dietary habits that are associated with the risk of disease, but nutrient-based information alone is inadequate, and a focus on individual behaviour change is probably insufficient and ineffective.
The issue is not whether sound medical or nutritional knowledge is important in nutrition education or even how much or what part of that knowledge is useful to those doing the eating. The issue is how to work with members of the population in a critical/reflexive and more systematic manner that would stimulate their active participation and commitment in their own learning process.5 Nutrition education needs to develop an approach that will empower community members to make the appropriate choices, using both scientific and cultural knowledge.
5 Active learning process refers to a method of education which involves the learner in different activities that contribute to the acquisition of skills and knowledge. Active learning involves three aspects: the cognitive, the emotional and the psycho-motor. In this process, the learners are not passive listeners; instead they ask questions, discuss, practice, read and do other activities. This implies that the learner is involved in making decisions regarding the learning process. For more information, refer to the works of Freire (1970, 1971, 1973).
A second article in an upcoming issue of Food, Nutrition and Agriculture will address several questions such as: How could nutrition education be different if nutritional sciences were the basis of knowledge needed to analyse the problems rather than the recipe for the solutions? How would nutrition education change if we focus on the needs of the learner and the community? What is the role of nutrition educators in this emergent practice? Finally, how will the goals, content and methods of nutrition education change for the practitioner?
REFERENCES
Cerqueira, M.T. 1990. Recent approaches to nutrition education in developing countries. Paper presented at the Nutrition Education Workshop, 3-5 Dec. 1990, Food Policy and Nutrition Division, FAO, Rome.
Cerqueira, M.T. & Olson, C.M. 1991. Nutrition education in developing countries: an examination of recent successful projects. In P. Pinstrup-Anderson, D, Pelletier & H. Alderman, eds. Beyond child survival. Ithaca, NY, Cornell University Press (in press).
Dervin, B. 1981. Mass communicating: changing conceptions of the audience. In R.E. Rice & W.J. Paisley, eds, Public communication campaigns. Beverly Hills, CA, Sage Publications.
Drummond, T. 1975. Using the method of Paulo Freire in nutrition education: an experimental plan for community action in northeast Brazil. Cornell University International Nutrition Monograph No, 3. Ithaca, NY, Cornell University.
FAO. 1983. Capacitación y gestión de programas de campo en alimentación y nutrición. Course Manual and Materials. Rome, FAO.
Freire, P. 1970. Pedagogía del oprimido. Mexico, DF, Siglo XXI Editores.
Freire, P. 1971 La educación como práctica de la libertad. Mexico, DF, Siglo XXI Editores.
Freire, P. 1973, Education for critical consciousness. New York, Seabury Press.
Gussow, J.D. & Contento, I. 1984. Nutrition education in a changing world, A conceptualization and selective review, World Rev. Nutr. Diet, 44: 1-56.
Hornik, R.C. 1985, Nutrition education: a state of the art review, ASS/SCN Nutrition Policy Discussion Paper No. 1. Rome, FAO.
Johnson, D.W. & Johnson, R.T. 1985. Nutrition education: a model for effectiveness, a synthesis of research. J. Nutr. Educ., 17 (Suppl): 1-24.
Keehn, M., ed. 1982. Bridging the gap: a participatory approach to health and nutrition education. Westport, CT, USA, Save the Children Federation.
Praun, A. 1982. Nutrition education: development or alienation? Hum. Nutr. Appl. Nutr, 36A: 28-34.
Rogers, E. 1983. Communication of innovations. New York, Longman.
Stevenson, R. 1988, Communication, development and the Third World. New York, Longman.
Whitehead, F. 1973. Nutrition education research, World Rev.Nutr. Diet, 17: 91-149.
WHO. 1986. Guidelines for training community health workers in nutrition, 2nd ed. Geneva, WHO.
Zeitlin, M.F. & Formacion, C.S. 1981. Nutrition intervention in developing countries. Study It: Nutrition education. Cambridge, Mass., USA, Oelgeschlager, Gunn and Hain Pub.
Trois grandes questions d'un intérêt fondamental pour l'éducation nutritionnelle sont examinées: le recours à la diffusion d'informations comme stratégie d'éducation nutritionnelle, directement ou par l'intermédiaire des médias; la persistance de messages et de conseils fondés sur les sciences nutritionnelles et biomédicales de l'Occident; et l'accent mis sur les messages orientés par ceux dont ils émanent, qui souvent ne tiennent pas compte de la culture et de la langue de ceux à qui ils sont destinés.
Le matériel didactique de la FAO, de l'OMS et de la Save the Children Federation concernant la nutrition est analysé. Dans les trois organisations, les messages relatifs à la santé et à la nutrition sont fondés sur les éléments nutritifs. Certes, le matériel comporte des exercices et la dynamique de groupe pour former des agents communautaires a l'identification des croyances culturelles et des habitudes alimentaires; mais ce matériel semble transmettre les informations fondées sur les nutriments comme si elles devaient, à elles seules, résoudre les problèmes nutritionnels des communautés. On s'attend à ce que les gens prennent ces informations pour argent comptant, les mémorisent et agissent en conséquence pour remédier aux carences nutritionnelles.
On peut se demander si cet enseignement est efficace et suffit à renforcer la capacité des populations à analyser elles-mêmes les problèmes de la communauté. Cette méthode d'éducation nutritionnelle ne donne pas aux membres de la communauté les moyens de s'exprimer activement, car elle impose des informations fondées sur les éléments nutritifs et propose des changements du comportement individuel. Ce type d'éducation ne permet pas aux populations d'analyser les problèmes et de discuter publiquement des solutions possibles. Les messages sont présentés comme la solution aux problèmes nutritionnels et n'aident donc pas les populations à prendre des décisions pour résoudre les difficultés socio-économiques qui engendrent ces problèmes.
Contrairement à l'approche fondée sur les nutriments, l'approche communautaire décrite par l'auteur renforce l'aptitude des membres de la communauté à analyser les problèmes et à prendre des décisions et des mesures appropriées, fusionne les connaissances scientifiques en matière de nutrition avec l'acquis indigène et culturel, élabore des messages mieux orientés vers les destinataires, et donc plus utiles aux populations. Cette approche sera examinée de façon plus détaillée dans un autre article, à paraître en 1992 dans la présente revue.
Se examinan tres importantes cuestiones que revisten sumo interés para la educación nutricional: el recurso a la divulgación de información, tanto mediante el contacto directo como a través de los medios de comunicación; la continua difusión de mensajes y consejos para divulgar información basada en las ciencias nutricionales y biomédicas de Occidente, y la insistencia en difundir mensajes realizados desde el punto de vista del que los transmite, que con frecuencia no tienen en cuenta la cultura y el idioma del que los recibe.
Se analizan los materiales de la FAO, la OMS y Save the Children Federation relativos a la educación nutricional. Los mensajes sobre salud y nutrición de todos ellos se basan en los nutrientes. Aunque se incluyen ejercicios y dinámica colectiva para capacitar a los trabajadores comunitarios a fin de que puedan identificar creencias culturales y prácticas alimentarias, los materiales parecen transmitir información basada en los nutrientes como si fuera por sí sola una solución a los problemas nutricionales de las comunidades. Se confía en que la población aceptará esta información al pie de la letra, y podrá corregir las carencias nutricionales.
Este sistema de enseñanza nutricional no parece eficaz y suficiente para aumentar la capacidad de la población de analizar los problemas de la comunidad desde su propio punto de vista. No ofrece medios para que los miembros de la comunidad puedan hablar con voz propia, y en su lugar impone una información basada en los nutrientes y propone cambios en el comportamiento individual. La educación basada en los nutrientes no permite que las personas analicen sus problemas y mantengan un diálogo público sobre las soluciones posibles. Los mensajes se presentan como la solución a los problemas de nutrición y por tanto no ayudan a las personas a adoptar decisiones para superar las condiciones socioeconómicas que generan dichos problemas.
En contraste con el planteamiento basado en los nutrientes, el autor describe un planteamiento basado en la comunidad que permite fomentar la capacidad de sus miembros para analizar los problemas, adoptar decisiones y tomar las medidas oportunas, integra el conocimiento científico en materia de nutrición con el conocimiento local cultural y elabora mensajes orientados hacia el receptor, que pueden resultar más útiles para la población. Este planteamiento se examinará más detenidamente en un segundo artículo que se publicará en 1992 en Alimentación, nutrición y agricultura.
