INTEGRATING NUTRITON INTO HEALTH AND DEVELOPMENT PROGRAMMES
Item
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- INTEGRATING NUTRITON INTO HEALTH AND DEVELOPMENT PROGRAMMES
- extracted text
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SHI
INTEGRATING Nl
HEALTH AND Di
w-
Hlllll A training guide
Volume 1
'■
•• ■
Participatory Methods
for Assessing and Analysiimg
the Nutrition Situation
, at the District Level
■
INTEGRATING NUTRITION INTO
HEALTH AND DEVELOPMENT
PROGRAMMES
A Training Guide
Volume 1:
Participatory Methods for Assessing and Analysing
the Nutrition Situation
ISBN: 1-86808-515-5
Second Edition
January 2002
Developed by:
School of Public Health and Department of Dietetics
(University of Western Cape)
Sustainable Approaches to Nutrition in Africa
(Academy for Educational Development)
Initiative for Sub-District Support
(Health Systems Trust)
Eastern Cape Department of Health
USAID
Copies of this Training Guide can be purchased from the School of Public Health,
University of the Western Cape, Private Bag 1 7, Bellville 7535, South Africa.
Enquiries should be directed to Marlene Petersen
Tel: (021) 959 2121 Fax: (021) 959 2890 Email: mpetersen@uwc.ac.za
Designed and printed by The Press Gang, Durban • 031 566 1024 • pressg@iafnca.com
The Nutrition Situation - Training Manual
Written by :
(in alphabetical order):
N\i<cke.'y Cbopr'a.
D&bbie. Gr cue. but bi
Slier. PivVoZ
Tbcundi Puuocune.
Dcuvid Sanders
R.ir>a_ Sv7c_r+
Acknowledgements
We would like to thank the Mt Frere district nutrition team especially Modesta Ngumbela, Zandile
and Boniwe and Ms. Kama and Ms. Ndabula from the Eastern Cape Provincial Nutrition Office for
their support. Benni Sikakhane & Dianne Kloka at National Department of Health: Nutrition and Joan
Matji UNICEF South Africa allowed us to test this manual within the Capacity Development Project.
Dave McCoy, Susan Strasser, Jon Rohde, and Wendy Hall have all assisted through discussions and
debates. Thanks to Lynda at The Press Gang for doing such a professional job.
This manual is the result of a partnership between the University of the Western Cape, Health Systems
Trust, the Eastern Cape Department of Health and AED. These organisations have been supported
by the Africa Bureau, Office of Sustainable Development, (US Agency for International Development),
the Kaiser Family Foundation and the European Union.
i
NUT' 100
11055
The Nutrition Situation - Training Manual
It is with great pleasure that I welcome the publication of this training manual. As a Provincial Nutrition
Programme manager, I have been very aware of the huge challenges that face health workers and
their partners in tackling the problem of malnutrition.
The many causes and widespread nature of the problem make it difficult for all of us to plan rationally
and see the results. This manual, and its companion publications, will help to provide health workers
with the vision, skills and techniques to initiate and sustain a multi-sectoral and comprehensive approach
to addressing the problem of malnutrition. Amongst the key objectives highlighted in this manual are
the development of local multi-sectoral and multi-disciplinary teams as well as the performance of a
rapid but thorough nutrition situation assessment.
While there are many training guides for nutrition field workers, this one has the advantage of having
grown out of real experiences in one of the poorest rural districts in South Africa. A variety of practical
and realistic tasks and activities based on our local realities therefore help to illuminate this manual.
While this manual does not mark the end of the scourge of malnutrition, nor diminish the huge challenges
that face us in ensuring that nobody goes hungry in this country, I am proud of the contribution made
by various members of the provincial Department of Health from Mount Frere, as well as their
counterparts in the Departments of Water Affairs, Education, Agriculture and Welfare.
I am sure you that this manual together with its set of companion documents can go a long way in
assisting district teams to make a start in developing effective Integrated Nutrition Programmes. 1
hope you will enjoy using this manual and wish you the best in your endeavours.
Nobcuhle. Nba.bix.lo_
Deputy Director: Nutrition
Eastern Cape Department of Health
ii
Kk
pr-.
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The Nutrition Situation - Training Manual_______________ ______________
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Table of Contents
Acknowledgements
i
Foreword
ii
P1
IB
S-
Introduction
1
Topic I
6
Topic 2
Topic 3
Topic 4
Course Orientation
Session 1:
Word of Welcome
7
Session 2:
Workshop Expectations and Concerns & Objectives
8
Session 3:
Workshop Methodology
9
iB:
The Nutrition Situation in South Africa
18
gL-
19
30
Session 1:
What is Malnutrition?
Session 2:
The Nutrition Situation in South Africa
Session 3:
The UNICEF Conceptual Framework
Session 4:
Integrated Nutrition Programme
Causes of Undernutrition
iii
it
s
53
Disease Control
54
Session 2:
Dietary Intake
Session 3:
Care Practices
8B 1
Session 4:
Household Food Security
57
64
67
Session 5:
Nutrition Situation Assessment
71
Techniques for Assessment of Nutrition Services and Programmes
Session 2:
Topic 6
31
33
Session 1:
Session 1:
Topic 5
pi.
a.
90
Assessment Techniques
91
Structured Observations
93
Session 3:
Key Informant Interviews
95
Session 4:
Focus Group Discussions
Session 5:
Preparation for Collection of Data
99
101
Working with Communities and Community Participation Techniques
113
Session 1:
Understanding Community Participation
114
Session 2:
Tools for Sensitising and Mobilising Communities
117
Session 3:
Planning for Work in the Community
123
Basic Data Analysis and Interpretation
127
BT-
JL
*
Session 1:
Reporting Back from Field Work Experiences
128
Session 2:
Preparing Data for Data Analysis
129
Session 3:
Analysing Qualitative and Quantitative Data
130
Session 4:
Interpretation of the Results
132
S—
Session 5:
Writing of a Research Report
'33
f
a
The Nutrition Situation - Training Manual
List of Handouts
Topic 1
Course Orientation
Session 3:
Topic 2
Workshop Methodology
9
H1.1
Workshop Methodology
15
The Nutrition Situation in South Africa
18
Session I:
What is Malnutrition?
H2.1
Topic 3
Disease Control
H3.1
H3.2
Session 2:
Session 3:
Case Study on the Importance of Care
Recommended Caring Practices
Sample Checklist for Assessing Individual Children's
Feeding Practices
Household Food Security
H3.9
Session 5:
Nutrition Values of Local Foods
Control of Vitamin A and Iron deficiency
Estimated Energy, Protein and Other Nutrient Requirements by Age
Care Practices
H3.6
H3.7
H3.8
Session 4:
Case Management of Diarrhoea
Nutrition and HIV/AIDS
Dietary Intake
H3.3
H3.4
H3.5
Questions for Assessing Household Food Security
Nutrition Situation Assessment
H3.10
Uses of Nutrition Situation Assessment
Techniques for Assessment of Nutrition Services and Programmes
Session I:
Assessment Techniques
H4.1
H4.2
H4.3
Session 2:
Session 3:
Session 4:
Steps in Preparing a Structured Observation
Guidelines for Growth Monitoring
Sample Checklist on Post Natal Care
54
74
75
57
77
78
79
64
80
81
83
67
85
71
86
90
91
103
104
105
93
106
107
109
Role Play Card for Key Informant Interview
How to Conduct Key Informant Interviews and Observations
Task Box for Key Informant Interviews and Observations
Key Informant Interviews
Tasks for Organising and Conducting Focus Group Discussions
Types of questions in Focus Group Discussions
Focus Group Discussions
Plan of Action for Data Collection
Working with Communities and Community Participation Techniques
Session 2:
53
H4.4
H4.5
H4.6
H4.9
Session 1:
19
36
Structured Observations
H4.7
H4.8
Topic 5
Definition of Key Terms in Nutrition
Causes of Undernutrition
Session I:
Topic 4
6
95
110
111
99
11 2
113
Understanding Community Participation
114
H5.1
125
The Participatory Continuum
Tools for Sensitising and Mobilising Communities
H5.2
Methods for Sensitising and Mobilising Communities
117
126
The Nutrition Situation - Training Manual
Topic 6
Basic Data Analysis and Interpretation
Session 3:
Analysing Qualitative and Quantitative Data
H6.1
H6.2
H6.3
H6.4
H6.5
Session 5:
Analysing Qualitative Data
Summary of Qualitative Data
Summary Matrix on Responses on Knowledge, Attitudes,
Beliefs and Practices on Breast-Feeding
Example of a Master Sheet
Examples of Tallies, Ranges, Percentages, Ratios, Rates,
Frequencies, Tables, and Central Tendency
127
130
134
135
136
137
138
Writing of a Research Report
133
H6.6
143
General Points on Writing a Report
List of Transparencies
Topic 1
Course Orientation
Session 2:
Workshop Expectations and Concerns & Objectives
8
Workshop Goal
4 Stages of the Training Process
16
17
T1.1
T1.2
Topic 2
The Nutrition Situation in South Africa
Session I:
What is Malnutrition?
T2.1a
T2.1b
T2.2a
T2.2b
T2.3
T2.4
T2.5
Session 2:
The Nutrition Situation in South Africa
T2.6
T2.7
T2.8
T2.9
Session 3:
Disease Control
T3.1
Session 5:
Infection - Undemutrition Cycle
Nutrition Situation Assessment
T3.2
T3.3
30
45
46
47
48
31
49
50
33
51
52
Steps for Conducting a Nutrition Situation Assessment
Information Framework
54
87
71
88
89
Basic Data Analysis and Interpretation
Session 5:
Writing of a Research Report
T6.1
T6.2
V
The South African Integrated Nutrition Programme
INP Focus Areas
19
38
39
40
41
42
43
44
Causes of Undemutrition
Session I:
Topic 6
UNICEF Conceptual Framework
Triple A Cycle
Integrated Nutrition Programme
T2.12
T2.13
Topic 3
Prevalence of Underweight by Province
Stunting Rates by Province (Height for age)
Vitamin A Status by Province
Iron Status by Province
The UNICEF Conceptual Framework
T2.10
T2.11
Session 4:
A Marasmic Child
A Marasmic Child
A Kwashiorkor Child
A Kwashiorkor Child
An Undernourished Child
Growth Chart
Growth Chart
Rules of Report Writing
Main Components of a Research Report
133
146
147
Introduction
Introduction
Who is this manual for?
This manual is targeted at personnel who are working at a district level and could play a role in
combating malnutrition. This includes people working in the:
health department: (including those working in nutrition, maternal and child health, health promotion,
environmental health, paediatrics, and nursing) and also other sectors such as:
Education
Public Works
Agriculture
Water Affairs
Social Development
Participants do not need to have any previous academic qualifications, or any knowledge of nutrition
science.
Purpose of manual
The purpose of this manual is to enable a district inter-sectoral nutrition team to be able to:
>
Come to a common understanding of nutrition concepts.
>
Gain an appreciation of the size and impact of the nutrition problem.
>
Identify the different causes of the nutrition problem.
>
Conduct a nutrition situation assessment using different data collection techniques to
collect the information.
>
Analyse and write a report.
How to use this manual
Preparing for Training
To ensure a successful training course, preparation must be done properly and efficiently long before
the first day of the course. Firstly you must develop a programme and objectives for the course.
Secondly, the administrative arrangements must be made such as booking a suitable venue, and
letters of invitation to participants should be sent out in good time. Travel arrangements to and from
the venue should also be properly arranged. As a course organiser and facilitator, it is a good idea to
arrive at the training venue ahead of the participants. This will enable you to welcome the participants
and give them any information they may need.
1
The Nutrition Situation - Training Manual
Checklist
Here is a checklist with the things you need to do to prepare for the training course.
Before The Training
Before the training there are a number of activities that you need to organise. The timing of each of
these depends on the nature of the activity.
□
Identify training needs
□
Identify number of participants
□
Select dates for training course
□
Make a list of all necessary materials
□
Establish a budget
□
Get quotations for the venue
□
Secure the necessary funding
□
Organise and purchase the stationery and other materials
□
Book the venue
□
Identify and select facilitators, resource persons and special guests
□
Send invitations to speakers, resource persons, and special guests
□
Send invitation letters to participants with programme summary and travel arrangements
□
Reconfirm the venue, training facilities, food and accommodation
□
Arrange transportation to and from the venue
□
Arrange for equipment
□
Prepare teaching notes and handouts
□
Plan and organise an opening
□
Arrange for press coverage, if necessary
During The Training
During the training, the facilitator has several administrative tasks to perform. Some of these tasks
can be delegated during steering committee meetings. These will help to ensure the smooth running
of the course. Here is a checklist of some of these tasks.
2
□
Make sure that all equipment and materials are available and in good working condition
□
Manage and monitor registration, reception, opening and sessions
□
Manage and monitor meals, breaks, special events and closing of the training course
□
File all training course documentation (flipcharts and notes)
□
Prepare participants’ address list and distribute
□
Monitor expenses in relation to established budget
□
Reconfirm participants' departure arrangements
□
Optional: Arrange for group photo and press coverage
□
Arrange for daily room clean-up
Introduction
After the Training
□
Prepare a brief report on the training session. This report should highlight all follow-up
activities agreed upon during the training session
□
Prepare a detailed financial report
□
Send a copy of the training report and the financial report to supervisors, funders and
other persons concerned
□
Send letters to all speakers, facilitators and special guests to thank them for their
contribution
□
Contact participants of the training session to provide support and assist with activities
agreed upon during the training session
□
If your training session included an Advocacy Day, maintain contact with these
representatives and provide them with the findings of situation analyses
□
Optional: Send feedback on this manual (shortcomings and positive aspects) to the authors
Team Facilitation
Training is often more fun and less stressful when more than one person conducts the training sessions.
If you are training more than 15 participants at one time, you need to have two or three facilitators.
However, if co-facilitators and outside resource people are not properly prepared, they can make
more work for you. Before the training begins, it is important for co-facilitators to discuss the following
issues:
>
Who is responsible for what part of the training or session plan?
>
Is there a lead facilitator?
>
What assumptions does each make about the training?
>
If there is a lead facilitator, what assistance does he/she need from the other facilitators)
during the session?
Ideally, you should use a team-teaching approach to present the contents of this training manual. This
can be done with co-facilitators and/or resource people. In order to team-teach well, it is important
for each member of the team to prepare thoroughly and present the session plans clearly. As a team,
facilitators should be supportive of their colleagues and work together to build a strong team spirit. If
possible, involve some of the participants who you feel can assist in the facilitation of some of the
training course sessions.
Whoever you choose, we have found it very useful to sit down and go through the session outlined
in this manual beforehand.
For team facilitation, you need to plan and prepare the sessions as a group by studying the steps in
each procedure and the additional notes for facilitators. The facilitators should agree on which parts
of the session each one is teaching. They also need to prepare the flipcharts and handouts for the
session.
3
The Nutrition Situation - Training Manual
Resource People
Resource people are technical experts you can call on to facilitate a session or a specific session
within a unit. Unlike facilitators they are often not expected to be present for the duration of the
training course. If you decide to use resource people or outside experts at the training course, you
should select people who are qualified, competent and knowledgeable in the areas they will be
presenting. You will need to contact resource people at least one month before the course and do
the following:
>
explain to them about your programme, training course and its objectives;
>
give them the programme including the unit objectives, timetable, knowledge level and
number of participants, and details about the venue;
>
review the session with them, listening to them describe what they are going to do and
making sure they understand the importance of keeping with the agenda and its objectives;
>
arrange transport, if necessary;
>
after the training, be sure to send a thank you letter, noting any relevant information from
the participants' evaluation.
Overview of the Training Manual
Each unit in the manual contains experiential activities that address the unit’s objectives in a variety of
interesting ways. Each activity specifies the purpose of the session, the materials needed, the
approximate time required, and the steps to follow. Some activities include preparation that must be
done prior to the session, for example accompanying handouts for participants, and/or transparencies.
To design and conduct a programme tailored to the needs of the participants, you need to do the
following:
•
Familiarize yourself with the entire Training Manual. In particular, consider the suggestions
for conducting experiential learning activities and small group discussions. Note the use
of additional information for facilitators and the text typed in boldface.
•
Determine your time frame. The time allocated in the manual for each activity is only a
guide.
•
Prepare any handouts or other materials that may be needed before the session begins.
If guest speakers are required, make sure they are invited well ahead of time and have
been properly briefed as to what you expect.
•
Introduce each unit of the package by going over the objectives for that particular unit
with the participants.
Many of the activities contained in the Training Manual require no more than pens. Some require
handouts for participants, and board and chalk, or newsprint and markers, for facilitators.
Have a ‘Question Box’ available throughout the duration of the training. Decorate an old cardboard
box or other container and cut a slot in the top to insert index or manila cards. Encourage the participants
to write any questions they have and assure them that there is no such thing as a ‘dumb question’.
Giving the participants an opportunity to ask questions anonymously helps ensure that you can address
their concerns promptly and appropriately. Make sure you read the questions in the question box
daily and reply to them the following day.
4
Introduction
Organising the timetable
We have tried to specify how much time each topic and session will take. This is to help you plan a
timetable. The timetable that you adopt will obviously depend upon the availability of participants and
venues. However we recommend a timetable as outlined below which has been used with district
teams:
Week 1+2
Day 1
Advocacy Day (Invitation to participants and a wide range of managers from different
sectors, and representatives from the community.) Topic 2 is used for this day.
Days 2-10 Topics 1 -4 (The participants remain behind and go through the first 4 topics and are
left with a task involving collecting data using techniques outlined in topic 4.) It is a
good idea to have a field visit during topic 4 for the participants to field test their
tools.
Week 3
(about 1-2 months after Week 1)
Day 1
Feedback from data collected
Day 2-3
Topic 5
Week 4
(about 1 -2 months after Week 2)
Day 1
Feedback from data collected
Days 2-5
Topic 6 and writing of situational analysis
5
The Nutrition Situation - Training Manual
TOPIC 1
COURSE ORIENTATION
Objectives
By the end of this topic, trainees should be able to:
✓ name their fellow participants;
✓ discuss their expectations and concerns;
✓ explain the objectives and purpose of the workshop;
understand the methodology to be used in the training.
Time
Topic overview
2 hours
Session 1:
Word of Welcome (40 minutes)
Session 2:
Workshop Expectations and Concerns &
Objectives (40 minutes)
Session 3:
Workshop Methodology (40 minutes)
Materials
writing pads, pens, VIPP cards, flipchart, masking tape, markers, pins,
brown paper, glue, overhead projector, overhead transparencies,
transparency pens
Handouts
H 1.1 Workshop Methodology
Transparencies
T 1.1 Workshop Goal
T 1.2 4 Stages of the Training Process
PURPOSE OF THE TOPIC
The purpose of this topic is to get the workshop off to a good start by having
participants introduce themselves and to explain the objectives of the workshop.
The workshop methodology will be explained and participants will have the chance
to express their expectations and fears. Any administrative matters will be handled
at this time.
6
1
Session 1:
Word of Welcome
Step 1:
Course Orientation
40 minutes
Activity: Welcoming Participants
a)
Begin this session by officially welcoming trainees to the course/
workshop. If there is an outside guest, invite him/her to speak.
b)
Step 2:
Give a brief overview of the course/workshop and the programme.
Activity: Introducing Each Other
a)
Explain to participants that since they will be together for the next
week, it is important to get to know each other and their interests,
likes and dislikes.
b)
Divide the group into pairs of people who do not know each other
well. Tell the pairs to find a place in the room where they can
interview each other. The interview should take about 5-10 minutes.
Each person should find out the following about their partner:
r>a_rr>G.'
be./sbs v^ovcld liks. +o be.
keowr. b'y in The. workshop;
I ikes/dislikesexperience in condu-c+in^ cssessmen+s;
experience in nuc+ri+ion^
a_n a_djec+ive
c)
describes +he perSon.
When participants have finished interviewing each other, ask for a
volunteer to introduce his/her partner. Do this until everyone has
been introduced. The facilitator has the opportunity when the
introductions are going on to ask for more information and to
encourage participants to find out more about each other. Each
presentation should not last longer than 3 minutes per person.
d)
At the end of the introductions, remind participants to find out
more about each other during nutrition breaks, over meals and
during their free time.
7
The Nutrition Situation - Training Manual
Session 2:
Workshop Expectations and
Concerns & Objectives
Step 1:
40 minutes
Activity: Listing Participant's Expectations and Concerns
a)
Hang up two cards:
E X pS. c.+cu+ i o ns
Give participants two sets of cards and ask them to write their
expectations and fears about the workshop on the different
coloured cards and then to hang them under the correct heading.
Tell participants to write one idea per card, but to write as many
cards as they need.
Step 2:
b)
Ask for one or two volunteers to read the cards under
"Expectations". When all the cards under that heading have been
read, ask for a volunteer to synthesize what the cards are saying and
pull out any cards that repeat what has already been said. Do the
same for "Concerns".
c)
Encourage trainees to explain why they have such concerns and
what they think should be done to allay these concerns.
Activity: Workshop Objectives
a)
Explain to participants that as the organisers of the course/
workshop, you tried to anticipate what professional expectations
participants might have, and on that basis you developed the
workshop objectives.
b)
Display the Transparency l.l (p. 16) with the workshop objectives
on it. As you present the objectives of the workshop, compare them
with their expectations and point out the close links between the
two. Also point out that the workshop may not be able to meet all
personal expectations.
c)
Ask participants if there are any objectives that are not clear and if
there are any objectives they would like to add or delete, based on
their expectations. Mention that the objectives will guide the
deliberations of the workshop and that participants should monitor
how well they are being achieved during the course/workshop.
d)
Show Transparency 1.2 (p. 17), which goes through the different
stages of the training. Explain to participants that the training will
take place over a period of time and according to a specific
timeframe (see "Organising the time table"on p. 5).
8
1
Session 3:
Workshop Methodology
Step 1:
Course Orientation
40 minutes
Activity: Learning About Participatory Learning
Distribute Handout 1.1. (p. 15) Explain to participants that the
methods that will be used in this training are participatory learning
methods. Ask them to read the handout which explains why such an
approach has been adopted.
b) Ask
"Are there any questions about the handout?"
Step 2:
Activity: Organising Times and Committees
a)
Explain to the trainees that in view of the amount of work arising
from the workshop objectives and their expectations, it is important
to agree on the procedures of the workshop. To do this, ask trainees
to negotiate the following times:
Also ask participants about times for working in the evenings and
on weekends. Once this has been agreed upon, point out that the
time must be respected and can only be changed after
renegotiation.
b) As part of setting the tone or climate of the workshop, mention to
the trainees that this is a participatory workshop. This means the
trainees must play an active role in the planning, organization,
management and evaluation of the workshop. Tell the trainees that
the success of the workshop depends of how well they do this. To
enable trainees to participate actively there are two committees that
must be established, namely the Steering Committee and the Social
Committee. Ask for volunteers for these two committees.
9
The Nutrition Situation - Training Manual
ADDITIONAL INFORMATION FOR FACILITATORS
To a large extent, the success of a training workshop depends on how well it gets off to a good
beginning. There are several things you can do to ensure that this happens.
introductions
To get the first workshop session started, welcome the trainees in a warm and friendly manner.
There are a number of games which are specifically geared to increasing the participants’
knowledge of each other. This is particularly important in the introductory part of a workshop
composed of people from different countries and backgrounds orthose who come from different
organizations. However, certain exercises are useful for situations when learners know each
other at one level and wish to probe deeper to find unknown aspects. The following are short
descriptions of some useful introductions.
Cobweb
Ask the participants to form a circle. One is given a ball of string, yarn or cord and is asked to
say his/her name, place of work, type of work, workshop expectations and one like and/or
dislike (for example, ‘I like soccer, I dislike people who shout’). When the person finishes, she/
he holds the end of the string and throws or passes the ball to another learner. Then the
receiver presents himself/herself as well and passes the ball to another learner. This procedure
goes on until all participants and facilitators) are interwoven in a cobweb. The facilitator
has the chance to say something about the important role that each person
plays in the workshop and that the success of the event depends on the
positive contributions from each person. There is a variation of this exercise.
It consists of disentangling the cobweb in the reverse order in which it was
built. Each one, before returning the ball of string to the one who passed it,
tries to repeat the information that was presented by that person.
Mutual Interview
Divide the group into pairs of people who do not know each other well. Each person takes a
sheet of newsprint and a marker. They interview each other for about 5-10 minutes each,
asking spontaneous questions and writing down information. At the end of the interview they
are asked to draw a symbol for their partner. When each person has been interviewed, a
presentation in plenary takes place. Participants stand in pairs in front of the entire group and
present each other, describing what they have learned about their partner and why they chose
that particular symbol. The presentation should not last longer than 3 minutes per person. If
you have room, hang the drawings for display for the remainder of the workshop. If the
students know each other well, you can ask them to find out about such
aspects as hobbies, secrets, visions of the future or experiences in childhood.
The Name Game
Some time during the first day of the workshop, ask participants to stand in a circle and clap
their hands. As they clap, call out the name of one person and say that person's name as you
continue to clap. When the person hears his/her name, the person has then to call out another
person s name. Continue saying the name until the person calls on yet another in the circle.
Continue to clap throughout. Do this until everyone has had a chance to have his/her name
called out. This is a good game for the afternoon of Day 1 or the morning of Day
2 of the workshop, when the trainees have heard several new names, but
may still be unsure of who is who.
10
1
Course Orientation
Who Am /?
Ask participants to write their name on masking tape and stick it their shirt or dress. Tell them
to stand in a circle, with everyone wearing his/her name tag. Give trainees 2 minutes to look
around the circle and try to get everyone’s name. Then tell them to cover their name and ask
for a volunteer to try and name everyone in the circle. Give three or four volunteers the chance
to do this.
Introductions are important because they are a good way of getting trainees to know each
other and feel free with each other. It is a good way to bring about group cohesion and a good
working relationship. Through introductions you also learn about the expertise and experiences
of one another so that this can be used during the course of the workshop.
Workshop Expectations and Objectives
Once the introductions have been completed, this is a good time to find out from the trainees
what their expectations of the workshop are. You should do this by asking them to share with
the group what they expect to learn, what new skills and attitudes they expect to acquire and
how they may personally benefit from this experience.
It is important to do this because it provides the trainees with the opportunity to see that their
views will be taken into consideration. It also enables you and the trainees to appreciate the
diversity of expectations, views and interests amongst the group. In general, if the workshop
objectives have been well conceived and formulated, they should match the trainees'
professional expectations. Their personal expectations should be taken care of during the
course of the workshop through the steering committee.
The objectives of the workshop provide a focus and a sense of direction to the learning
experiences that trainees will have. They also let the trainees know what they should expect to
accomplish or achieve by the end of the workshop.
Workshop Methodologies
Workshop methodologies help to establish a participatory approach to the organization and
management of the workshop. There are three procedures which need to be considered.
These are:
Negotiating the Timetable
Setting up the Steering Committee
Setting up the Social Committee
Negotiating the Timetable
Negotiating the timetable involves determining the working hours, when to start in the morning
and when to end in evening, and the duration of the breaks. This should be done so that the
workshop objectives can be realized in the time that is available and to enable trainees to
organise their personal activities during free time. Negotiating the timetable helps to ensure
that participants make a commitment to keep to the time that they all agree to.
11
The Nutrition Situation - Training Manual
Setting up the Steering Committee
The Steering Committee is a small group comprised of facilitators and trainees. Their task is to
sit together to plan and evaluate the workshop, on a daily basis. The purpose of the Steering
Committee is to provide feedback on how well the workshop objectives and expectations are
being realized and to plan for the next day’s activities. The workshop facilitators and any other
resource persons are permanent members of the Steering Committee. There are two different
trainees who join the Committee each day. The best way to get the trainees to serve on the
Committee is to put up a list of workshops days and ask for two volunteers for each day. Such
a list would look like this:
STEERING COMMITTEE MEMBERS
Date
Names
Monday 14/2
John, Anne
Tuesday 15/2
Ellen, Jessica
Wednesday 16/2
Jane, Louise
The course/workshop organiser is the permanent chairperson of the Steering Committee. In
order to give the trainees a chance to participate more fully, there is a new chairperson and
secretary for the workshop each day. They are appointed by the Steering Committee. The
chairperson of the day is responsible for keeping time and chairing all of the sessions according
to the day's timetable. The secretary prepares a short summary report of the day's proceedings.
This report should be given to the facilitator who will use it to compile the workshop report. A
report from the Steering Committee Meeting is shared with the trainees during the first 15
minutes of the next day under the session knows as Administrative Matters. This report is
given by the Chairperson of the day. During this time, the Chairperson should find out from the
trainees if they have any questions from the deliberations of the workshop.
The Social Committee
The Social Committee takes care of the well being of the trainees during the workshop. It
usually has five trainees. The committee is responsible for organizing entertainment and
recreational activities. The committee appoints one of its members to serve as the chairperson.
They may ask anyone else to join them as the need arises. They should consult the workshop
facilitator on any financial matters. The chairperson of the Social Committee should present
his/her requests to the Steering Committee for approval. Members of the Social Committee
should be nominated by the trainees in the workshop. The Social Committee does not meet
on a daily basis, but only when the need arises.
Administrative and Housekeeping Matters
There are certain details concerning the trainees, such as travel, accommodation and personal
expenses that need to be taken care of on the first day of the workshop. This helps them to
settle in at the workshop and puts their minds at ease. During this session, give information
regarding:
the procedures for making claims;
the facilities available at the venue;
the expenses trainees are expected to meet;
the resources available.
If all these tasks are well taken care of, the workshop should get off to a good start.
12
1
Course Orientation
FACILITATION TECHNIQUES
VIPP
VIPP stands for Visualization in Participatory Programmes. VIPP involves the use of different
shapes of coloured cards so that everything that is done individually and collectively can be
visualized, processed, synthesized and shared. VIPP encourages everyone to participate and
that it is based on well founded theories of adult learning.
Lecture
A lecture is a structured and orderly presentation of information delivered by an individual
(facilitator). A lecture can be used to impart knowledge or introduce skills. A lecture which
allows for an exchange between the facilitator and the participants is usually more effective.
Discussions
Discussions are a verbal exchange led by the facilitator or participants about a specific issue
or topic in the workshop. Through this process learners have a chance to share facts and
ideas and can listen to and consider different points of view. Discussions are useful in both
large and small groups. Small groups may offer shy or less verbal learners more of an opportunity
to speak. Discussions in the larger group give the facilitator the ability to control the flow of
conversation.
Pole-plays
Role plays are short dramas in which learners can experience how someone might feel in a
situation, try out new skills, and learn from each other. Role playing in small groups or pairs is
usually less threatening for participants and allows more people a chance to do it. Ask for
volunteers, as many people are embarrassed or uncomfortable to act in front of a large group.
After the role play, be sure to declare the role play over and ask questions about it.
Case studies/Scenarios
Case studies are stories, either fictional or true, often describing a problem by discussing
what a character’s options are or how these dilemmas might be resolved. Feel free to adapt
any scenarios in the manual so that the exercise better fits the group. Asking the participants
to come up with case studies or scenarios, sometimes as an assignment, is a good way to
ensure realistic situations and language.
Brainstorming
Brainstorming is a free flowing exchange of ideas on a given issue or topic in the workshop.
You ask a question, pose a problem or raise an issue and participants suggest answers or
ideas. Write down all the suggestions for the group to see. No editorial comment or criticism
is allowed. When the brainstorming is finished, the group evaluates the ideas together, perhaps
to identify those they consider most useful or to categorize them in some helpful way.
Guest Speakers/Resource People
Guest speakers or resource people can bring a topic or issue in the workshop alive by discussing
personal experiences and sharing their feelings. You need to identify such people and invite
them in good time to the workshop. Make sure they are dynamic, knowledgeable about the
workshop and comfortable speaking in front of an audience. Prepare the participants for the
speaker's presentation so that they know what to expect, are ready with questions and act
respectfully. Prepare the speaker with information about the group and a clear understanding
of your expectations.
13
The Nutrition Situation - Training Manual
Games And Exercises
Games and exercises are very much a part of the Training Manual. They include such things as
introductions, energizers, and warm ups. These games and exercises speed up and enhance
the amount and the quality of interaction in the group. Energizers and warm ups can be done
just before the start of a session, immediately before or after a tea break or lunch and or just
before the end of the day’s sessions.
Questioning Techniques
During the presentation of the training sessions, there will be many opportunities for asking
and answering questions. Questions can be used to introduce new ideas, to stimulate discussion
and to enable participants to pause and think about what they have been learning. The best
questions start with the following words: who, what, when, why and how. Encourage
the participants to use these words when they are asking each other questions. If for any
reason you do not have the answer to a question that the participants ask, you should say so
and note that you will look for the answer in order to be able to refer back to it and give it at a
later stage. You may find participants asking questions that are outside the workshop. Keep
these in mind by writing them down on the flipchart and answer them at a later time.
1
Course Orientation
Handout 1.1
WORKSHOP METHODOLOGY
There are a number of principles which underlie the approach that has been taken in this
training course. These are:
Enjoyment:
Experience-Based:
People learn best when they are enjoying the learning process.
There is a recognition that all the participants have been involved in tackling
malnutrition and therefore have substantial experience to draw upon. By
sharing and comparing approaches participants acknowledge each other as
invaluable sources of information.
Participatory:
For nutrition programmes to be a success there is a need for participation from
those effected. This course encourages learners to develop communication
skills to facilitate participation. Learning activities encourage co-operative group
work and listening skills.
Analytical:
The process aims to develop learners' critical thinking and planning skills.
Participants will learn basic nutrition and programme knowledge so that they
can effectively assess, plan and implement comprehensive nutrition programes.
African:
All of the data and examples are based upon experiences in Southern Africa.
There is also an emphasis on oral communication and sharing of stories as a
means of learning.
Adapted from "Reducing Risk: Participatory activities for disaster mitigation in Southern
Africa", A Kotze and A Holloway, Red Cross Publications 1996.
15
The Nutrition Situation - Training Manual
Transparency
1.1
a -
Wfi-
Workshop Goal
M«-
To acquire the skills to be able to conduct nutrition situation
assessments at the district and community levels using
participatory research methods.
H-
Workshop Objectives
BP
&By the end of the workshop, you should be able to:
>
Describe the nutrition situation in South Africa and in
your district;
>
Explain the immediate, underlying and basic causes
of nutrition problems and the interrelationships between
them;
>
>
Demonstrate an understanding and respect of local
knowledge and skills;
Ip
i-'
*
Utilize skills to facilitate local knowledge and
participation in nutrition activities;
* >
Perform a nutrition situational analysis for your district;
r-
■U
t16
1
Transparency
Course Orientation
1.2
4 Stages of the Training Process
>
Basic nutrition concepts; conceptual framework and the
INP; framework for nutrition situational assessment
>
Nutrition research methods and preparation of data
collection tools
>
Field work and data collection on assessment of nutrition
services and community programmes
>
Analysis, reporting and dissemination of situational
assessment
- J
eg
J-J
ea
Ba
Ba
-•3
17
The Nutrition Situation - Training Manual
TOPIC 2
THE NUTRITION SITUATION IN
SOUTH AFRICA
Objectives
By the end of this topic, participants should be able to:
✓ define malnutrition;
✓ explain how malnutrition affects different groups in the population;
✓ describe the nutrition situation in South Africa;
✓ explain the UNICEF conceptual framework and its use;
✓ explain the importance of a multi-sectoral approach in dealing with
nutrition;
✓ outline the Integrated Nutrition Programme.
Time
Topic overview
5 hours 30 minutes
Session 1:
What is Malnutrition? (120 minutes)
Session 2:
The Nutrition Situation in SA (30 minutes)
Session 3;
The UNICEF Conceptual Framework (90 minutes)
Session 4:
Integrated Nutrition Programme (90 minutes)
Materials
flip chart, pens, slides, VIPP cards
Handouts
H 2.1
List of definitions
Transparencies
T 2.1
Marasmic Child (a and b)
T 2.2
Kwashiorkor Child (a and b)
T 2.3
Undernourished Child
T 2.4
Growth Chart
T 2.5
Growth Chart
T 2.6
Prevalence of Underweight by Province (Weight for Age)
T 2.7
Stunting Rates by Province (Height for Age)
T 2.8
Vitamin A Status by Province
T 2.9
Iron Status by Province
T 2.10 UNICEF Conceptual Framework
T 2.11 Triple A Cycle
T 2.12 The SA Integrated Nutrition Programme
T 2.13 INP Focus Areas
PURPOSE OF THE TOPIC
The purpose of this topic is to provide participants with information in order to
clarify the concept of malnutrition.
18
.i
■3
2
The Nutrition Situation in South Africa
- ~d
Session 1:
What is Malnutrition?
120 minutes
’ J
Step 1:
J
Activity: Clarify the Session Topic and Outcomes
a)
Write the session topic on the flipchart.
“Looking at the topic, what do you think you will learn
about in this session?"
•3
Jot down a few ideas in a mindmap.
Who_+ is N\a_lnu.+Y~i+ion?
■4
b)
Summarise the main purpose, and key content covered in this
session:
- 3
"The main purpose of this session is to clarify the concept
of malnutrition and some key related terms. This
provides a foundation for the rest of the unit"
c)
.J
Write up the outcomes for this session.
youc shoucld be. a_ble +o:
in nu.+ri+ior>
0
De-Fine key
2)
Ouc+line key -Peo_+ix.nes o-C ucndevnuc+r'i+ion
-3
'.t3
J
3
Ask if they are clear. Explain that you come back to these at the end
of the session.
19
The Nutrition Situation - Training Manual
Step 2:
Activity: Define Terms
Define Nutrition
a)
Write 'Nutrition' on the flipchart.
"What words or phrases come to mind when you think
? y fl
of the word'nutrition'?"
Get 3 or 4 participants to come and write up their ideas.
---------------------------------------------------
—,
Food people eo_+
Pro+ein>
Nuc+ri+iors ___ +he b°aV
minero-ls, -Ca.+ ,
c.a-rboliydra-+e e+c.
needs +o live
Noi<r'ishmen+ -for good gr-ovv+h
b)
"Now, use these words and phrases to come up with a short
definition of nutrition."
Write up and discuss various suggestions. Rewrite these until you
have a good working definition that everyone is happy with. Make
sure that the definition refers not just to the food people eat, but
also to how food is used to produce energy to maintain life and
growth. An example of a definition: 'Nutrition is the outcome of the
food eaten (the diet) and it manifests as good growth and energy to
conduct activities and fight infection'.
Clarify malnutrition terms
a)
Add 'mal' to the beginning of the word 'nutrition' on the board.
Ask what 'mal' means. Then ask "What does 'malnutrition' means"
Make sure that participants understand that malnutrition is 'bad'
nutrition, which includes over- and undernutrition.
20
The Nutrition Situation in South Africa
2
b)
Ask
"What terms are used to describe the different forms
[or manifestations] of malnutrition?"
Write these on coloured pieces of paper and stick them up.
kxA/a-Sh iorkoY'
1
..................i-
c)
'
Organise groups of 3 or 4 persons per group.
Write up and explain the task.
i'l
v*/ha_+ +Jn2.se. nuc+r'i+ionoJ
2) Wfi+e. you.r ds.4-ir>i+ior> or e.xpla-rsa-+ior> o-$
e.o_c.h +e.Y~rr> on <□_ vs/Jni+e. pie.c.6. o-P pa_pe.Y7
"You have 10 minutes"
21
I
The Nutrition Situation - Training Manual
d)
Collect the pieces of coloured and white paper to use for the next
task.
Check understanding of nutritional terms
a)
Fold up and randomly distribute all the pieces of coloured and
white paper to the participants.
Ask someone with a coloured piece of paper to read
aloud what it says.
Ask the person who has the correct definition of this term on
a white piece of paper, to stand up and read it aloud.
Ask the group if this is the correct definition.
Repeat this until all the coloured pieces of paper are finished.
Ask if these terms are now clear to everyone.
Tell groups to check their definitions with those in Handout 2.1 (p. 36)
for a few minutes.
Step 3:
Activity: Identify and Describe Different
Types of Undernutrition
a)
Show Transparency 2.1a (p. 38).
Ask
"What is this child suffering from?"
"What are the main features of this disease?"
Explain that this child suffers from marasmus.
Marasmus
Marasmus is the result of a child having a very low intake of energy
and nutrients. It often follows severe illness or a period of frequent
infections or inadequate feeding early in life and is especially seen
in poor, urban communities where breastfeeding has been replaced
by inadequate formula feeding. Marasmus usually occurs in the first
two years of life, but it can occur at any age, particularly during
famine.
22
2
The Nutrition Situation in South Africa
Show Transparency 2.1 b (p. 39). Point out that the signs of marasmus
in children are:
> extremely low weight
> extreme wasting with loss of subcutaneous tissue and muscle
bulk: the skin often looks loose
> an "old persons" face
> irritability and fretfulness
Summarise that marasmus has 2 main manifestations
> severe undernutrition
> wasting (thinness, loss of muscle, visible bones)
Point out that dehydration and diarrhoea (the commonest cause of
death in children today) are common complications of marasmus.
b)
Show Transparency 2.2a (p. 40)
Ask: "What is this child suffering from?"
"What are the main features of this disease?"
Explain that this child suffers from kwashiorkor.
Kwashiorkor
Kwashiorkor is more complicated than marasmus. It is most
common in children aged 1-3 years, but it can occur in older or
younger children. Kwashiorkor is mainly due to a lack of energy and
nutrients in combination with some other insult - most commonly
an infection like diarrhoea and/or sudden removal from the breast.
Show Transparency 2.2 b (p. 41). Point out that the signs of
kwashiorkor are:
> misery and irritability
> oedema (swelling) of the legs and arms (especially feet and
hands) and, less commonly of the face
> 'moon' face
> moderately low weight
> wasted muscles
> weak muscles
> poor appetite
> pale, thin and peeling skin
23
The Nutrition Situation - Training Manual
> pale, sparse, straight hair which pulls out easily
> enlarged liver
> pot belly
Point out that not all of the signs are always present, especially in
more 'acute' kwashiorkor where oedema and misery exist but skin or
hair changes might not be present.
c)
Explain the dangers and complications of marasmus and
kwashiorkor
Dangers and complications of marasmus and kwashiorkor
> risk of death
> problem of sickness
> complications eg diarrhoea, dehydration, infections,
hypoglycaemia (low blood sugar),hypothermia (low body
temperature), anorexia (loss of appetite), anaemia, other
nutritional deficiencies.
Point out that in any community where malnutrition exists the severe
forms, such as marasmus and kwashiorkor, comprise only a small
proportion (about 10%) of all cases of undernutrition. The majority
of undernourished children are underweight because they are
stunted (too short for their age) and do not show obvious signs of
malnutrition. They can only be identified by being measured having their heights and weights recorded and compared to the
heights and weights of normally grown children of the same age.
Kwashiorkor and marasmus are markers of much more widespread
moderate undernutrition. If you compare undernutrition to a
hippopotamus: the top of the head and back which stick out of the
water are like kwashiorkor and marasmus. The dangerous 90% is
hidden, and it is the same with undernutrition in the community.
Some of these children may develop severe undernutrition marasmus or kwashiorkor - if not detected in time.
d)
Write
..
I
<Vi+ccmir' A de.-Cic.ie.nc.'y*
on the board and ask
"What are the results of this and what causes it?"
24
2
The Nutrition Situation in South Africa
Vitamin A deficiency (VAD) is one of the most important
nutritional diseases amongst young children because it:
> damages the eyes and can cause blindness
> increases the risk of infection and death
VAD occurs when a person is not eating enough vitamin A to cover
her needs and/or when the body stores are depleted through
repeated infection, especially diarrhoea and measles. Xerophthalmia
(which literally means dry eye) is the mildest of a range of disorders
that affect the eye and that can lead to blindness. The eye signs of
vitamin A deficiency occur approximately in this order night
blindness, xerophthalmia, Bitot's spots (small areas of dryness on the
eye) followed by corneal lesions and finally corneal scars, eventually
leading to blindness.
There is now a great deal of evidence to show that even children
who are Vitamin A deficient but do not have the above signs are at
a greatly increased risk of dying from infections.
e)
Write
on the board and ask
"What are the causes and results of this"
Iron deficiency anaemia
The most common form of anaemia is iron deficiency anaemia. This
means that the body cannot make enough haemoglobin and healthy
red blood cells because it lacks iron. Anaemia affects people's ability
to work, increases their tiredness and slows learning in children. In
pregnant women anaemia leads to greater illness and increased
chances of still-births and low birthweight babies. The signs and
symptoms of anaemia include paleness of the tongue and inside of
the lips, tiredness and breathlessness; but often children may show
no obvious signs.
Causes of low iron are poor diet, extra blood loss (e.g. women who
are menstruating, worms), poor absorption (e.g. due to infection of
the gut, or worms) and increased need for iron (e.g. women who are
pregnant).
25
The Nutrition Situation - Training Manual
f)
&
uj
Write
r;
ii-
on the board and ask
"What are the causes and results of this?
Iodine deficiency disorders develop when there is not enough
g_
iodine being delivered to the thyroid gland which requires iodine to
make thyroid hormone. The thyroid gland enlarges to collect more
iodine from the blood (this enlargement is called goitre). Sometimes
E-
the thyroid functions normally but sometimes it fails to produce
enough thyroid hormone. This causes hypothyroidism or cretinism.
E
Explain that cretinism is congenital hypothyroidism (i.e. being born
E
with insufficient thyroid hormone). The most common cause of
hypothyroidism is iodine deficiency and, in the case of cretinism,
hypothyroidism in the mother. This condition is not uncommon,
E
particularly in remote rural areas where the soil and all the foods
.jr
grown in it are iodine deficient and where people survive almost
wholly on foods they grow.
E
IDD delays social and mental development. Iodine deficient children
E-
are difficult to educate.
&
E
Step 4: Activity: Determine the Importance of Malnutrition
ti
6k
Ask
"Why are we so worried about malnutrition,
particularly in children?"
lf participants struggle to answer, prompt by asking:
EeE
B
"What effect does malnutrition have on children?"
Summarise that malnutrition has direct and indirect effects on a
K
child:
Ss-s.
K...
E26
2
The Nutrition Situation in South Africa
Direct
> During the first two years of life malnutrition can prevent and
slow a child's brain from growing. By age 5, the brain has
normally reached its maximum size. A prolonged and severe
episode of undernutrition in early life can result in reduced
brain growth. This could affect a child's ability to learn.
> Undernourished children are more likely to suffer illnesses and
these illnesses become more severe than in well-nourished
children. This is especially true for diarrhoea, measles and
tuberculosis.
> Undernourished children are more likely to die.
Indirect
> An undernourished child has low energy levels, which makes her
less active, which, in turn, means she does not learn new things
through exploring and discovering for herself.
> An undernourished child has reduced powers of concentration,
which restricts his/her learning.
Step 5:
Activity: Examine How We Measure Undernutrition
a)
Show Transparency 2.3 (p.42) and ask the following questions
"Are any of these children undernourished?"
"Can you tell just by looking at them?"
"How could you find out for sure if one of them is underweight?"
Make sure that participants understand that we cannot tell if a child
is underweight just by looking at the child. The child's weights need
to be plotted onto a growth card.
Summarise:
> Most cases of malnutrition are not obvious - kwashiorkor and
marasmus are extreme forms and are only the 'tip of a large iceberg'
or the top of an almost submerged hippopotamus!
> To recognise most cases of undemutrition, growth monitoring must
be performed.
27
The Nutrition Situation - Training Manual
b)
Show Transparency 2.4 (p.43)
Ask
"Is this child undernourished?"
Show Transparency 2.5 (p.44)
Ask
"Now can you tell if this child is undernourished?
How do you know this?"
"What do we learn from this about measuring malnutrition?"
Summarise:
> It is difficult to judge whether a child is undernourished from just
one measurement. The direction of growth is much more important.
> It is important that the mother is encouraged to come for regular
weighing and that the weights are accurately plotted on every visit to
a health facility.
> Since undernutrition affects up to 30% of children in South Africa, it
is important that children are weighed at every contact with the
health service. This is especially important since most cases of
growth faltering occur after the primary course of immunisation has
been completed and children are then seen at a health facility only
if they have an illness or injury. Unless children are weighed and
plotted every time they visit a health facility with an illness, even if it
is minor, most cases of undernutrition - and, the opportunity to
prevent greater illness - will be missed.
Step 6:
Activity: Recognition of Different Measures of
Nutritional Status
a)
Ask participants:
"What are the different ways in which we measure nutrition?"
28
2
b)
The Nutrition Situation in South Africa
Summarize the responses by writing the following indicators and
measurements on the flipchart:
id tapper cur-m <cir'c.o.rv>-fe.r-e.r><se.)
c.linic.a.1
Inform the participants that the most commonly used indicators are
weight for age and height for age because they are usually the
easiest to measure.
c)
Explain that when a child suddenly becomes undernourished she
loses her body fat first and becomes thin. Thinness is measured by
the mid-upper arm circumference or her weight for height. Thinness
is also called wasting. If undernutrition occurs over a long period of
time then the child will stop gaining height. This can be measured
by height for age. A child who is of low height for age is called
stunted.
d)
Ask the participants:
"What makes a child have a low weight for age?"
e)
Explain that weight for age is made up of the degree of fatness and
the height of the child. So a child who is of low weight for age is
underweight and could either be suffering from acute undernutrition
(and therefore thinness or wasting) or chronic undernutrition (low
height for age which is stunting). The advantage of weight for age is
that it can pick up changes in the nutritional status very quickly and
is relatively easy to measure. Once again emphasise that this is why
it is important to regularly measure and plot the weight for age and
to detect any failure to gain weight.
29
The Nutrition Situation - Training Manual
Session 2:
The Nutrition Situation in
South Africa
Step 1:
30 minutes
Size of the Nutrition Problem in South Africa
Activity - Introduction to session
a)
Give a brief overview of the types of information that could be used
to measure nutritional status, including:
Biochemical analyses
Clinical signs
Dietary intake
Anthropometric measurements
b)
Point out that we can use anthropometric measurements of children
as a proxy measure/indicator for the nutritional status of the
population. Anthropometric measurements are also cheaper and
easier to perform than any of the other measures of nutritional
status.
Activity - Identifying the Size of the Problem
a)
Show Transparency 2.6 Underweight by Province (Weight for
Age) (p. 45) and
Transparency 2.7 Stunting Rates by Province (Height for Age)
(P- 46)
b)
Ask
"What do these graphs tell us about the distribution of
undernutrition in South Africa?"
c)
Explain to participants that less than '-2SD' is roughly the same as
the third centile. In other words we would expect 3% of children (in
a normal population) to fall under this level.
d)
Point out that Northwest Province, Northern Province and Eastern
Cape have high rates of underweight and also high rates of stunting.
Remind participants that stunting is related to long term
undernutrition when children fail to grow taller due to chronic (or
long term) undernutrition as a result of the poor quality of their diet
and/or frequent or chronic illness. This is reflected in the fact that
the poorest people and provinces have the highest rates of stunting.
30
2
I
\
e)
The Nutrition Situation in South Africa
Show participants Transparency 2.8 Vitamin A Status by Province
(p. 47) and
Transparency 2.9 Iron Status by Province (p. 48).
Ask
“What do you notice about the distribution of
micronutrient deficiency?"
f)
Point out that the distribution is similar to underweight and stunting
and shows that micronutrient deficiency is mostly linked to poverty
and poor diet.
g)
Discuss the situation of malnutrition in South Africa in general (and
in the provinces/regions in particular where the training and/or
programme is being conducted /implemented).
t
i
!
Session 3:
The UNICEF Conceptual Framework
Step 1:
90 minutes
Activity: Understanding the Multi-factorial Nature of
Undernutrition
a)
Divide participants into 4 groups and give each group one of the
following written on cards:
> undernourished child in rural setting
> undernourished child in urban setting
> undernourished pregnant woman
> undernourished breastfeeding mother
b)
Write the following instructions for the groups:
> Using cards and flip chart paper, write down all the possible
reasons why these people are undernourished.
> When you have done this arrange the cards showing the causes
to illustrate the relationships between the different causes.
> You have 25 minutes for this activity.
31
The Nutrition Situation - Training Manual
c)
Ask each group to share their presentation in plenary. Emphasise
that there are many causes of undernutrition - not simply disease or
lack of food, but also poor health services, poor water and
sanitation and lack of care to name just a few.
d)
Arrange the cards into different levels of causation from the most
immediate to the most basic. Point out that there is also a lot of
interaction between causes. Therefore undernutrition is the result of
the failure of many different sectors and not just a problem for
health workers alone.
Show Transparency 2.10 UNICEF Conceptual Framework (p. 49)
and go through the different levels. Remind the participants that it
was developed by UNICEF as a result of their experiences in Africa.
The next few sessions will be spent going through these different
causes in more detail.
f)
Ask participants to think about the different causes of
undernutrition in the settings where they work. Point out that in
different settings these causes assume different priority. In some
settings household food security may need to be addressed before
addressing caring practices. The conceptual framework can be used
to aid facilitators to guide the community in assessing, analysing
and acting on their information (performing a Triple A cycle).
g)
Show Transparency 2.11 (p. 50) with the Triple A Cycle and
explain that the conceptual framework is useful for guiding the team
in the first A - assessment - by directing the team to what are the
important causal factors in undernutrition. It is also useful in helping
the second and third As - analysis and action - since the
interventions should not only tackle the immediate causes but also,
if possible, the underlying and basic causes. Finally point out that it
is the local community members who are best placed to judge the
relative importance of the various causes of undernutrition. They are
also best placed to prioritise interventions or actions that are
appropriate for the community.
32
2
Session 4:
Step 1:
The Nutrition Situation in South Africa
Integrated Nutrition Programme
90 minutes
Activity: Identifying the Shortcomings of Nutrition
Programmes
a)
Inform the participants that in this session they will explore the
nutrition policy of the South African government. Point out that past
and present governments have spent millions of Rand on nutrition
programmes (mostly food handouts) but there has been little
change in the nutrition status of most children in South Africa.
Ask
"Why did these programmes have so little impact?"
b)
Ask participants to think about the relationship between different
programmes (e.g. PEN scheme. Soup Kitchens, NNSDP) and the
conceptual framework. Ask participants to write down answers to
the following questions:
"Which causes do these programmes address?"
"Are these causes basic, underlying or immediate causes?"
"Which causes do these programmes ignore?"
c)
Show the conceptual framework and point out that most food-based
interventions only tackle one of the immediate causes of
undernutrition: dietary inadequacy. Give the example of how the
PEM scheme can in fact undermine household food security and
caring practices by encouraging families to purchase expensive milk
powder as a way of feeding their children, instead of relying upon
foods and resources which are locally available. Handing out milk
powder from a clinic could be interpreted by the community
members that the health services favour cow's milk or formula
feeding which can undermine the promotion of breastfeeding.
d)
Explain that the government has now realised the need for an
integrated approach to address the immediate, underlying and basic
causes of malnutrition and has come up with the integrated
nutrition programme.
33
The Nutrition Situation - Training Manual
Step 2:
Activity: Outlining the Integrated Nutrition Programme
a)
Show Transparency 2.12 (p. 51) on the vision, mission and
principles of the INP and go through it.
b)
Explain that the INP is based upon trying to tackle the different
causes of undernutrition as outlined by the UNICEF Conceptual
Framework and through using the Triple A approach.
c)
Show Transparency 2.13 (p. 52) and explain that this transparency
shows the many different areas of activity which are included within
an INP. The challenge is to ensure that these activities are done in a
co-ordinated and integrated fashion. It may not be possible or
necessary to implement all of these activities. Generally it is best to
start with the most important ones.
Step 3:
Activity: Sharing Experiences of Nutrition Activities in
the Area
a)
Divide the participants into groups and give them the following task:
a. rr>cup o-G +bs
in v^hioh yoiA.
On This mcup mcur'k. ou_+ v\/he.r'S ThSr'S Cur'S
pr'ojSc.+s/cuc+iv'i+iS.S wkiic.b mi^h+ bs cu pcur~
N\cuk.S SucrS +hcu+ you. u/r'i+S. down cu briS-C
description o-C +hs cuc.+ ivi+y or prpjSct
cund who Cur'S +hs n^cuin rols-plcuySrS
Wbicb onSS o-F tbSSS projects /cuct ivit ies
Cur'S 5ix.ccess-fizP
Whcut mcuk.es them Su.ccesS-hu.1?
You have 30 minutes
b)
Share their maps in plenary and list the success factors for the
projects/activities.
From the responses try to ensure that the following questions are
addressed:
34
2
The Nutrition Situation in South Africa
What were the steps in implementing the INP?
What are the most important factors for success for the INP?
What skills/resources are required?
Who should be a part of an INP team?
c)
Explain to participants that the INP is an ambitious policy which
requires the nutrition team to:
advocate for nutrition
collaborate and organise with all sectors,
understand and be able to explain the basic causes of
undernutrition,
perform a nutrition assessment and analysis in their districts
and
plan, implement and manage integrated nutrition
programmes.
All of this must be done in a participatory way. Explain that this
workshop aims to provide participants with the skills to enable them
to be able to implement an integrated nutrition programme in their
district.
Step 4:
Activity: Bringing a Team Together
a)
Ask
"How can we encourage other members of the district
team, whom we have identified as having an important
contribution, to participate in the district INP team?'
b) Write up their responses. Stress that one way which has been found
to be successful is to invite them to a meeting where the whole team
then goes through some of the exercises that they have been doing
during the day. It could end with a commitment from all the
participants that they will form an INP team. One of the first tasks of
this team should be to perform a nutrition situation assessment.
c)
Explain to participants that the rest of the training workshops will
now concentrate upon giving participants the knowledge and skills
to conduct a participatory nutrition situation assessment.
35
The Nutrition Situation - Training Manual
Handout 2.1
DEFINITION OF KEY TERMS IN NUTRITION
Diet
is the overall pattern of food intake in an individual including the choice
of foodstuffs, and the size and time of meals in one day.
Epidemiology
is the study of the distribution and determinants of health related events
in a population.
Foodstuffs
are the edible parts from plants and/or animal origin appropriate and fit
for human consumption.
Health
is a complete state of physical, psychological, and social well-being and
not merely the absence of disease.
Incidence
is the number of new cases arising in a given period in a specified
population.
Indicator
is the expression of one measurement as a component of another
measurement. For example in weight for age, one measurement i.e.
weight is compared to another measurement which is age.
Kwashiorkor
usually occurs when there is a sudden change in the dietary quality of
the child such as during the weaning period. It is characterised by
extreme underweight with oedema, weakness, skin lesions and changed
colour of the hair.
Macronutrients
are carbon-containing compounds (energy providing) of which the body
requires large amounts and includes proteins, carbohydrates and fats.
Malnutrition
Marasmus
36
is the impairment of health resulting from a deficiency, excess, or
imbalance of nutrients.
is a form of severe undernutrition that occurred over a long period of
time and is charactised by extreme underweight, wasting (loss of muscle,
visible bones), irritability and fretfulness.
Micronutrients
are substances of which the body requires only small amounts and
includes vitamins and minerals.
Micronutrient
malnutrition
is the impairment of the health of the individual as a result of an
insufficient intake of micro-nutrients (vitamins and minerals).
2
Nutrients
Nutrition
The Nutrition Situation in South Africa
are the smallest particles in food that must be provided
to the body in adequate amounts. They include protein,
/\
/ u
fats and fatty acids, carbohydrates, vitamins, minerals,
water and fibre.
x
is the study of the foods, the nutrients and other
**
\2.1 /
\/
substances therein; their functions, actions, interactions and balance in
relation to health and disease; the process of ingestion, digestion,
absorption, transportation, and utilisation of nutrients and the excretion
of end-products. Nutrition refers also to the social, economic, cultural
and psychological meaning of food.
Nutritional care
is the application of the science of human nutrition to assist individuals
in the choice of food and the acquisition of food to nourish their bodies
in health and disease and throughout the lifecycle.
Nutritional status
is the health status of the individual as influenced by the utilisation of
nutrients. Nutritional status is assessed using anthropometric
assessments, biochemical analysis, clinical observations, and dietary
information.
Overnutrition
is the nutritional status of an individual resulting from an excessive
intake of energy and/or other nutrients.
Prevalence
is the total number of cases at a specific point in time in a specified
population.
RDA
Stunting
Undernutrition
Underweight
Wasting
refers to recommended dietary allowances of nutrients.
refers to a person's height being too low for his/her age (very short).
is the nutritional status of an individual resulting from insufficent intake
of energy and/or other nutrients.
refers to a person's weight being too low for his/her age.
refers to a person's weight being too low for his/her height (very thin).
37
The Nutrition Situation - Training Manual
Transparency
38
2
Transparency
The Nutrition Situation in South Africa
2.1b
A Marasmic Child
• Irritability and
fretfulness
• Extreme wasting
• Hunger
• Extremely low
weight
• ‘Pot belly’
39
The Nutrition Situation - Training Manual
Transparency
2.2a
A Kwashiorkor Child
40
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... ..
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Pale, sparse hair with weak roots
Misery and apathy
Poor appetite
Wasted, weak muscles
Oedema of legs,
arms and face
Enlarged liver
Moderately low weight
The Nutrition Situation in South Africa
Pale, thin, peeling skin
The Nutrition Situation - Training Manual
Transparency
2.3
An Undernourished Child
One in four children
suffers from malnutrition.
You can’t always see it
You need to weigh your child regularly.
2
The Nutrition Situation in South Africa
43
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Transparency
The Nutrition Situation in South Africa
2.10
UNICEF Conceptual Framework
Causes of Malnutrition <unicef 199O)
Manifestations
Immediate
causes
Underlying
causes
Basic
causes
49
The Nutrition Situation - Training Manual
Transparency
2.11
Triple A Cycle
ASSESSMENT
of the situation
ACTION
Based on the Analysis
and Available
Resources
ANALYSIS
of the Causes
of the Problem
2
Transparency
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(Department of Health, 2002)
Vision
Optimum nutrition for all South Africans
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2.12
The South African Integrated Nutrition Programme
Mission
Improvement of the nutritional status of all South Africans
through the implementation of integrated nutrition strategies
I.L1
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•
Good nutrition for all South Africans should be promoted as a basic
human right and as an integral component and outcome measure of
social and economic development.
•
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sound, people and community driven
•
There should be a clear strategy for promotion of nutritional well being.
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Cooperation between countries and international agencies should be
encouraged.
•
Adequate financial, human, and institutional resources should be
provided to ensure effective and efficient nutrition policies, programmes
and services.
•
High priority should be given to the rights of children, their survival,
protection and development.
•
The use of existing structures and programmes to address nutrition
concerns should be encouraged.
•
An integrated primary health care approach should be adopted.
•
Intersectoral collaboration of relevant structures such as line departments
should be mobilized at all levels to ensure joint action to address
nutritional problems.
•
The active participation of households, community leaders and structures,
NGOs, CBOs and other community role players should be mobilized at
project level to ensure that projects are people and community driven.
•
Communities should be empowered with the necessary skills and
knowledge to become self-reliant with regard to their food and nutrition
needs and to be in control of factors affecting their nutritional well-being.
•
Coping strategies already in place should be supported.
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The Nutrition Situation in South Africa
The Nutrition Situation - Training Manual
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- Nutrition Information System
- Human Resource Plan
- Financial and Administrative System
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Transparency
52
3
TOPIC 3
Causes of Undernutrition
CAUSES OF UNDERNUTRITION
Objectives
By the end of this topic, participants should be able to:
✓ Explain the relationship between dietary intake, disease and the
nutritional status of children;
✓ explain the role of food, health and care in determining the nutritional
status of children;
✓ develop a list of questions to measure feeding, health and caring
practices in a community;
*4 plan a nutrition situation assessment.
Time
Topic overview
7 hours 15 minutes
Session 1: Disease Control (60 minutes)
Session 2: Dietary Intake (90 minutes)
Session 3: Care Practices (120 minutes)
Session 4: Household Food Security (90 minutes)
Session 5: Nutritional Situation Assessment (75 minutes)
Materials
flip chart, pens, slides, cards
Handouts
H 3.1
Case Management of Diarrhoea
H 3.2
Nutrition and HIV/AIDS
H 3.3
Nutritional Values of Local Foods
H 3.4
Control of Vitamin A and Iron Deficiency
H 3.5
Estimated (rounded) Energy, Protein and Other Nutrient
Requirements by Age
H 3.6
Case Study on the Importance of Care
H 3.7
Recommended Caring Practices
H 3.8
Checklist for Assessing Individual Children's Feeding Practices
H 3.9
Questions for Assessing Household Food Security
H 3.10 Uses of Nutrition Situation Assessment
Transparencies
T 3.1
Infection - Undernutrition Cycle
T 3.2
Steps for Conducting a Nutrition Situation Assessment
T 3.3
Information Framework
PURPOSE OF THE TOPIC
The purpose of this topic is to clarify the multiple causes of undemutrition in children.
This should enable participants to plan a nutrition situation assessment in their own
community.
53
The Nutrition Situation - Training Manual
Session 1:
Disease Control
Step*!:
60 minutes
Activity: Clarify the Session Topic and Identify
Important Diseases
a)
Explain that the purpose of this activity is to:
> Identify the major diseases which contribute to, and are caused
by, malnutrition. Outline the important curative/rehabiiitative,
preventive and promotive actions to break the cycle of diseases/
undernutrition.
> Remind participants that we are dealing with the immediate
causes of malnutrition in the conceptual framework.
b)
Ask
"What diseases or illnesses in your community affect a
child's growth?"
The following diseases should come out:
Step 2:
diarrhoea
HIV/AIDS
pneumonia
hookworms/parasite infections
measles
TB
Activity: Understanding How Disease and Malnutrition
Interact
Show Transparency 3.1 (p. 87) and highlight the interaction
between infection and malnutrition: malnutrition leads to infection
which in turn leads to more malnutrition until the child either has
serious life-long handicaps or dies. Mention that 98% of children who
die, do so in developing countries and over 80% of these children die
because of this cycle between undernutrition and infection.
b)
Ask
"How does malnutrition lead to increased infection?"
The following points should be written down:
De<sreo_se<l immucni+y
De<sreo_sed a-bili+y +o u.nder+a.k.e
preventive beha.viou.rS
54
3
Causes of Undemutrition
Ask
c)
"In what ways does malnutrition decrease immunity?"
Start with the skin and then mention gut, respiratory lining and
finally white and red cells. Discuss how vitamin A, iron, protein etc.
deficiency reduces the effectiveness of each of these protective
factors.
d)
Ask
"How do infectious diseases result in malnutrition?"
The following causes should be written on the flipchart.
Infection leads to:
X- Iricr~e.a_se.cl need -For" rux.+r'ie.io+s beca_u.se
+he body’s rr>e+a_bolic. v~a_+e Cr'a_+e o-F
•Ciu_r>c+ior>ir>^p is ir>c.v~ea_sed.
X Decrea-Sed in+aJse. o-F nuc+r-ien+s bea.a_ix.se
o-F suppressed a_ppe+i+e, irri+a-bili+y a_r>d
vomi+in^'
X- Inarea-Sed loss o-F r>ix_+rier>+s in +he a.a_se
o-F diccrrboea. a_nd/or x/omi+ing
Step 3;
Activity: Management and Prevention of Diarrhoea
a)
Ask
"In your setting, which illness in your opinion has the
most serious impact on nutrition?"
For most participants in Southern Africa this should be diarrhoea.
On average a child has 3 episodes of diarrhoea a year in South
Africa; in poorer communities children have more than 3 episodes a
year. Point out that the proper management of diarrhoea is critical.
Distribute and read Handout 3.1 Case Management of Diarrhoea
(p. 74). Make sure the following points are emphasised:
> In the short-term rehydration is important and the hydrating
fluid can be either be made from packets from the clinic or
given as home prepared recipes e.g. Sugar-salt solution, soups
etc.
55
The Nutrition Situation - Training Manual
> Mothers should continue breastfeeding on demand and feeding
even when the child has diarrhoea.
> The child should be given extra high energy feeds after he/she
has recovered from the illness
b)
Ask the participants in pairs to answer the question:
"How can we prevent a child from getting diarrhoea?"
c)
Allow about 10 minutes for this activity and share their responses in
plenary. The following actions should be included:
> Immunization helps to prevent conditions such as measles that
leads to diarrhoea
> Proper growth monitoring to identify and prevent worsening of
undernutrition
> Provision of vitamin A to young children and lactating mothers
> Promotion of breastfeeding
> Provision of high energy complementary foods after 4-6 months
> Education on water, sanitation and hygiene (handwashing, safe
storage of food, preparation of fresh food etc.)
> Improved access to environmental services, especially water and
sanitation
Remind participants that many of these preventive actions are also
effective against other diseases such as measles, pneumonia and
worms. If the nutrition team is serious about preventing malnutrition
and illnesses then it must ensure that the above management and
preventive actions are performed optimally.
Step 4:
Activity: Role of Malnutrition in HIV/AIDS
Ask participants what role nutrition plays in HIV/AIDS. Distribute
and read together Handout 3.2 Nutrition and HIV/AIDS (p. 75).
56
3
Session 2:
Causes of Undernutrition
Dietary Intake
Step 1:
90 minutes
Activity: Clarify the Session Topic and Identify
Importance of Diet
a)
Introduce this session by telling participants that the objectives of
this session are:
To de.S<cr~iba
-fucr>c+ior>S o-C
nnic.r'o o_r>d noa.c.r'o-nuc+r'iSr>+s
die.+ccr'y
To de.-fir>e.
ind iviJ(x.a.I<, wi+h o_ -focu.5 on
o-C
youcng
ehild ducning +he vs/Ccuning pQ-niod,
>■ To descsnibe +he. compo5i+ion o-C oonomon
lo<sa.l -foods , vs/i+h o_n emphcuSiS on fhe.'ir'
SnSn^y o_nd pno+ein content.
X- To de.Semide. -the pr*inc.iples o-f a. na/Konod
die+a.ry cupproa-oh +o xx/Co-ning.
c)
Ask participants, in buzz groups, to give reasons why we need food.
The following points should come out:
Energy and metabolism (the body's normal functions)
Growth and repair (new cells and tissues being formed and
growing)
Activity and development
c)
Ask
"What are some of the early signs of a child
who is undernourished?"
> Listlessness or inactivity in a young child
> Falling off their growth curve
> More infections
> Poor concentration
Explain that food is converted in the body into various substances
that provide energy or "fuel" for the body. This energy is required for
the body to work, and it is also necessary to lay down the building
blocks of protein, which are necessary for cells to divide and grow.
57
The Nutrition Situation - Training Manual
Explain that energy is required for metabolism (body functions such
as breathing or staying warm), growth and activity. Mention that this
order is important. If we do not consume enough energy, then the
first thing to happen is that activity ceases. Next, growth processes
stop, and then finally, body metabolism slows and eventually ceases,
leading to death.
Also mention that a child who is already undernourished has
suffered from a reduction in normal activity and has progressed to
growth faltering. That is, he/she fails to gain weight or grow taller. In
children who have been exclusively breastfed on demand this
growth faltering will probably occur at around 6 months unless high
energy complementary foods are added to the diet.
Step 2:
Activity: Determine the Importance of Energy in a Diet
a)
Remind participants that two units are usually used to measure
energy:
Kilocalorie: This is the energy required to raise the temperature of
one millilitre of water by one degree centigrade at sea level.
I kcal (kilocalorie) = 4.2 kJ. (kilojoules)
b)
Explain to participants that foods are made up of nutrients, water
and fiber. Mention that there are macronutrients (including
carbohydrates, protein and fat) and micronutrients (such as vitamins
and minerals). Explain that micronutrients are required by the body
in very small amounts.
Mention that energy intake is important because the body's primary
requirement is for energy. When energy intake is not adequate, the
body uses protein foods for energy needs, rather than for body
building and growth, which only occurs if the body's energy
requirements are being satisfied. Inadequate energy intake may result
in protein deficiency because protein is being used to provide
energy. Explain that if you look after the energy, the protein will
usually look after itself. In other words, if a diet provides adequate
energy, it will usually also provide adequate protein.
Using Handout 3.3 Nutritional Values of Local Foods (p. 77),
give examples of different foods that are commonly eaten in the
district. For example, make the point that dry maize meal has little
water content and a high amount of energy (370 kcal/100 g). When
water is added to dry maize meal to make mieliepap, the energy
content (density) of the same weight or volume of food is lowered
58
3
Causes of Undernutrition
very significantly. It is now mainly water and the energy value is now
only 51 kcal/100 g. On the other hand, foods such as vegetable oil,
margarine, and peanut butter have very high energy content; if these
foods are added to the mieliepap, the energy content will be
increased. For example, a teaspoon of vegetable oil (5 g) will add
about 45 kcal and a teaspoon of peanut butter will add about 30
kcal to any recipe, as well as some protein.
Conclude this discussion by saying that the energy content of fats
such as margarine or vegetable oil is a lot higher (9 kcal/gram) than
the energy content of carbohydrates and protein (4 kcal/gram). That
is why oily foods are often recommended to improve the energy
content of foods for young children.
Step 3:
Activity: Identifying Micronutrients in the Diet
a)
Ask
"Can you give examples of different micronutrients?’
Make sure that participants mention vitamins such as A, B, C and D,
and minerals such as sodium, potassium, iron, iodine and zinc.
b)
Remind participants of the importance of micronutrients to the body
from Topic 2. Stress that we are now realising that even those with
deficiency but no clinical signs suffer from more severe episodes of
illness and have a greater chance of dying than those who have no
deficiency. Tell participants that in this session we will concentrate
upon iron and vitamin A.
Divide the participants into groups of 5. Assign each group either
c)
iron or vitamin A and ask them to complete the following task:
(allow them 20 minutes)
I,
Who_+ -Poods cuv-S rich ir> The.
m icronix.+r'ie. r>+?
2.
Which -Poods increase cdoSorpTior o-P +hs.
micr'onuc+r'ie.n+?
3.
Who_+ ir>+e.r">/e.io+ior>S cccr> improve +he.
rv>icroruc+r-iG.r,+ s+cu+ucS o-P indiv'idix.culs?
59
The Nutrition Situation - Training Manual
d)
Share the groupwork in plenary. Summarise by giving out Handout
3.4 (p. 78) and asking participants to read through it.
Step 4:
Activity: Assessing a Common Diet
a)
Ask
"What are the factors which affect the dietary needs of a child?"
Explain to participants that a child's dietary needs depend on several
factors: his/her age, size, whether he/she is healthy or sick, and his/
her levels of activity.
b)
Distribute Handout 3.5 Estimated Energy, Protein and Other
Nutrient Requirements by Age (p. 79). Explain that this handout
shows the energy, protein and micronutrient requirements for
children of different ages. Ask them if they have any questions about
the handout.
c)
Ask participants to consider a poor 1 year old child. As shown in
Handout 3.3 (p. 77), this child requires about 1000 kcal/day.
Ask
'What do you think this child usually eats each day?"
Be sure that participants mention breastfeeding. Tell participants that
breastmilk is an excellent source of energy, protein, and many
micronutrients. Tell them that it contains about 70 kcals/100 ml. In
addition it is a sterile and affordable source of food for babies and
young children.
Then ask
"How much energy is provided by breastmilk in a day?"
Make sure they mention that it depends on how often a child is
breastfed and the amount of breastmilk he/she consume. Explain to
participants that studies in developing countries reveal that a one
year old child consumes between 500-800 ml of breastmilk each
day, if he/she is nursing on demand throughout the day.
Ask participants to calculate how much energy is provided in
500 ml of breastmilk.
60
3
Causes of Undernutrition
Make sure that participants are able to make the following
calculation:
70 kcal/100 ml x 500 ml = 350 kcal
d)
Ask the participants to do the following calculation:
"If a one-year old requires 1000 kcal/day and breastmilk
provides about 350 kcal/day, how much energy is
required from other (solid) foods?"
Make sure that participants are able to make the following
calculation:
1000 kcal - 350 kcal = 650 kcal
e)
Point out that, apart from breastfeeding, maize porridge is most
often given at this age. Remind participants that maize-meal has
about 370 kcal/100 g in dry weight. Point out that nobody eats dry
maize meal. Mention that maize-meal swells when cooked with
water. This swelling results in a very bulky, high- volume, low energy
density porridge. Soft porridge mainly consists of water.
f)
Ask the participants
"What is the volume of a I year old child's stomach?"
Explain that children have small stomachs which can only
accommodate small amounts of food at any feed. Show the
participants a typical 250 ml teacup. Explain that a young child's
stomach can only hold the quantity of food that will fit in the
teacup.
Step 5:
Activity: Calculating Energy Intakes
a)
Instruct the participants in pairs to do the following calculation:
"If a child is going to be fed on maize porridge diluted with
water, how much is he going to need to fulfil his energy
requirements if he is also breastfeeding on demand?"
61
The Nutrition Situation — Training Manual
Referring to Handout 3.3 (p. 77) show participants that 100 g of
porridge contains less than 100 kcal. In order to eat 650 kcal, a
one-year old child will need to eat at least 700 g/per day. Remind
participants that children of this age have small stomachs and stress
that this means that if children are off the breast they must be fed at
least five times a day with the maize meal porridge in order to
consume his/her energy requirements. If the child is being breastfed
he/she will need to have porridge at least 3 and probably 4 times a
day.
b)
Ask
"How can we overcome this problem of a high-bulk,
low energy density diet described above?"
Make sure that the following suggestions are brought up:
> Fortify the porridge with high energy foods such as oil,
margarine, or peanut butter.
> The child should be encouraged to eat as much enriched
porridge as possible three or four times a day.
> At each feeding breastfeed the child first.
c)
Refer participants back to the Handout 3.5 (p. 79) on the energy,
protein, and other nutrient requirements for young children. Point
out that a one year old child would need about 10-11 g of protein
each day, which is relatively little. A teaspoon holds 5 ml or about 5
grams of egg white. Thus a child needs only about two teaspoonfuls
of egg protein or breastmilk protein a day and only about 3
teaspoons of other kinds of protein.
d)
Point out that the typical diet of a one year old child contains
adequate protein, and that energy deficiency is a more common
problem than protein deficiency. This is because young children
from poor communities eat bulky, low energy diets: their small
stomachs mean that, unless they are fed frequently, they receive little
dietary energy. Remind participants that it is the energy content of a
diet which is important - if you look after the energy the protein
will look after itself.
62
3
Step 6:
Causes of Undernutrition
Activity: Formulating Adequate Diets for Different
People
Ask participants if they have any questions about the information
a)
presented. Explain that practices for improving dietary intake of
young children will be discussed in the session on caring practices.
Divide participants into four groups.
b)
Assign each group one of the following:
a_r> ei^h+e.e.n month old child who is
I.
r'S.cove.r-in^ -from a_r> CpiSode. o-€
dia.rr'hoSa.
2.
a. seven rr>on+h old child who is beir^
exclusively br-ecusf-^ed
c)
Write up and explain the task:
Allow 20 minutes for this activity and share each
group's response in plenary.
d)
Inform participants that an important part of a nutrition assessment
is to find out the normal complementary foods given to children in
the community and the normal diet of breastfeeding mothers. The
information that has been presented to them in this session can help
them to analyse whether the diets of young children are adequate in
energy content and in micronutrients.
63
The Nutrition Situation - Training Manual
Session 3:
Care Practices
Step 1:
120 minutes
Activity: Clarify the Session Topic and Objectives
Explain to the participants that the purpose of this session is to:
a)
Identify irr>por'+cun+ c.a-r'C. pr-ex.c.+ic.e.s
wkii<ski <scur> plcuy o_ r'ole. in radix-cing
mo.lnuc+r'i+ion even in +he presence o-C
poverty o_nd poor environmen+cil
cond i+ionS.
X Learn hou? +o assess Sucoh pra_c.+ ic.es in
oizr c.omnnucni+ies So +ha_+ we ca_n design
in+ey-ven+ions.
b)
Refer participants back to the conceptual framework for nutrition
and remind them that care practices are those behaviours carried
out on a day-to-day basis which affect the nutrition, health, and
growth of women and children.
Step 2:
Activity: Identifying Important Care Activities
Divide participants into groups of 6. Distribute Handout 3.6 Case
Study on the Importance of Care (p. 80) and ask participants
"Write down all the reasons you think have made Sipho
undernourished. Write down each reason on a separate card/
(Allow 25 minutes for this activity)
b)
In plenary, ask the first group of participants to place their cards on
the wall. Then ask the other groups to place any cards listing
reasons that were not given by the first group.
64
3
c)
Causes of Undernutrition
After all the reasons have been put on the wall ask the groups to put
the reasons into different categories. Allow 10 minutes for this
activity.
d)
In plenary ask the groups what categories they came up with. At the
end of this exercise, the facilitator will summarize the major caring
practices that affect the nutrition and health of women and children,
organising them according to the 6 types of caring practices listed:
> feeding infants < 6 months ;
> feeding infants 6-24 months;
> psycho-social care;
> caring practices for women;
> hygiene;
> home health care.
Step 3:
Activity: Assessing Important Caring Practices
a)
Write the six categories on the flipchart and ask the participants to
choose a category they would like to further explore. Try to
encourage an even spread of participants to each of the categories.
b)
Give the following tasks to each of the groups
1.
Use Handout 3.7 Recommended Caring Practices (p. 81), to
prepare a 5-10 minute presentation to the rest of the group to
inform them more about your particular care practice.
2.
Also give a few examples of relevant behaviours and explain why
they are important.
3.
You have twenty minutes for this task.
Instruct the group to formulate a checklist in order to assess current
c)
practices in the community. Give them the following task:
-------------------------------------------------------------------------------------------- j
I. WHcl+ WoiaM you. lilcCl +o kcoovs/
The.
c.ccr'in^ p>~a_c.Tic.e. in yoix.r' commix-ni+y?
2.
How VA/ill '•joix. <colls<s+
3.
Rx.+ you.r
cIcl+cl?
in
cl
Tccble. Iik.2.
iS:
(Allow 45 minutes for this activity)
65
The Nutrition Situation - Training Manual
Care Practice
What would you like to know?
How will you collect it?
Exclusive
What proportion of women
exclusively breastfeed at three
Interview mothers who bring
their children for third DTP
months?
immunisation at 12 weeks
breastfeeding
What proportion of women
exclusively breastfeed at 6
months?
d)
Ask each group to present their checklist to the plenary and discuss.
Encourage participants to question the other groups about their
ideas. Ensure that the methods for collecting the data are within the
capacity of the team to use and appropriate for the information
required.
Distribute Handout 3.8 Checklist for Assessing Individual
Children's Feeding Practices (p. 83) to participants. Explain that
these are checklists that have been developed by others for
collecting information in order to assess caring practices. Ask
participants to go back into their groups and review these handouts
and compare them to the lists they developed. Discuss the
similarities and differences between these lists and ask them to
revise their checklists if the handouts have useful ideas.
Step 4:
Activity: Conclusion of Session
a)
Conclude this session by reminding participants that caring practices
are important, and that during this session good caring practices
have been identified as well as barriers and resources for carrying
them out in the communities where they work. Explain that when
they go to the field to collect information, they can use these
checklists to identify practices, barriers to them, and resources for
improving them.
b)
Tell participants that methods for collecting this information will be
discussed in Topic 4. After Topic 4, participants may want to revise
their checklists to utilise different data collection methods.
66
3
Session 4:
Causes of Undernutrition
Household Food Security
Step 1:
90 minutes
Activity: Introducing the Session
Introduce the session by outlining the objectives:
a)
X- To de.-Fine. +he. farm houcse.hold ^-Food
secu.ri+'y °
X To ouc+lir>e +he oonSE<^x.encSS o-F poor
household -food sec.u.r'i+y
X To ide-n+i-Fy +he di-F-Fere.n+ oompone.n+s
v\/lnic.h mcuke ucp household -Food se.cucri+'y
X To produces, a. ehSekliS+ +o ccSSSSS
JnoucSehold -Food SSeucri+y
Step 2:
Activity: Defining Household Food Security (HHFS)
a)
Split the participants into groups of four. Ask the groups to
brainstorm:
"How would you describe a household which
has household food security?"
b)
Share their responses in plenary and summarise with the following
definition:
A household is food secure when it has both physical and economic
access to adequate food of adequate quality for all its members and
when it is not at undue risk of losing such access.
c)
Ask
"Is South Africa, as a country, food secure?"
The answer is: "Yes since it produces enough food to feed everybody
and in fact can even afford to export food."
d)
Ask
"Is every household in South Africa food secure?"
"Why not?"
67
The Nutrition Situation - Training Manual
e)
Point out that HHFS depends not only on the adequate availability
of food but also on access to food. For example, South Africa as a
country is food secure since it is an exporter of food, yet many
households do not have enough food. Similarly a household can
have enough resources to buy food but not all members of the
household will be food secure since not all of them will have access
to the resources or the food, e.g. women or girls are the last to eat.
The definition includes the different reasons for not having HHFS:
lack of resources (land, agricultural inputs etc.) to produce sufficient
food, and/or lack of purchasing power to buy food, and/or lack of
control over food allocation.
f)
This definition also highlights the importance of continuous security
- some families can have HHFS during and immediately after the
harvest season but then lose their HHFS in the long winter season.
These families are said to be vulnerable. Explain that some
communities do not have adequate access to food all year round
due to seasonal factors, varying climatic and weather conditions,
variations over time or changes in economic conditions.
Step 3:
Activity: Consequences of Poor Household Food
Security
a)
In the same groups of 4 ask
“What are the consequences of poor household food
security for the family and individual?'
The following consequences should come out:
Human suffering (i.e. malnutrition, hunger)
Increased infections and treatment costs
Reduced productivity
Lowered school attendance
Lowered school performance
Poorer care practices
Increased erosion of land
Make the point that these things can themselves lead to reduced
food security (i.e. reduced productivity leads to lower wages) so a
vicious cycle is set in process.
68
3
Step 4:
Causes of Undernutrition
Activity: Improving Household Food Security
a)
Now set each of the groups the following tasks:
Whcu+ cur-e +he
n
in vx/hich Fcurrdlies
a.c.hieve hou.sehold -Good sec.u.r’i+y?
(You have 25 minutes)
Assign each group one of the following families in order to generate
a wide range of coping strategies:
female headed household
grandmother living with grandchildren
family with an alcoholic
traditional male headed household
If the groups are unclear, here are some examples of ways in which
families achieve household food security:
Grow crops
Exchange produce
Purchase cheaper foods
b)
Share their responses in plenary. Here are 4 categories in which the
examples could be divided:
X" Pr'odu.<s+ior> o-C crops Sot hou.sehold
c.onSu_mp+ion
X Food pu.r'c.hccSing
X Food s+or'a.^S. cund prepccrcu+ion
Food hcubi+s a.nd r'elcc+ed belie-Gs
c)
Point out that it is useful to establish the importance of each of
these ways of obtaining HHFS for each community. For example do
most people grow or buy most of their food? Does this change
during the year? This is useful for planning interventions to improve
HHFS and to monitor HHFS.
69
The Nutrition Situation — Training Manual
Step 5:
Activity: Assessing Household Food Security
Keep participants in the same 4 groups and assign them one of the
a)
following 4 categories
Production of crops for household consumption
Food purchasing
Food storage and preparation
Food habits and related beliefs
b)
Give the groups the following task:
Wlncc+ in-Cononcu+ion wokIcI youc likfi. +o
I.
hccve. in or'de.r' +o make cun a_S5esSmervf
o-C +he. v>/cuys in wlnic.ln -€cumilie.s er.Su.re
JnoucSShold -Cood SG.c.u.r'i+y?
2.
WJna_+ inTorma+ion v>/ou.M you. ne.e.d +o
C-S+a-bli.SIn Inow -Cood S&C-uune. JnouLSS-lnolds
cunC. MFS in a_ aommizni+y?1
(You have 30 minutes for this task)
c)
Use Handout 3.9 (p. 85) to check that they are thinking of the
right type of questions. Share their responses in plenary and
distribute Handout 3.9 (p. 85).
d)
Inform participants that they should add any of their questions that
are not in the handout and this can form the basis of an assessment
of HHFS in their district.
70
Fl
,-**
*
I 3
Step 6:
Causes of Undemutrition
Activity: Ways of Improving Household Food Security
a)
In buzz groups ask what measures they think can be taken to
improve household food security at the community and household
levels.
b) Write them on the flipchart. Here are some examples:
Ir>c.r'e.a_sir>2 -food prod u.c.+ion -for HoucS&hold
c.onSu.mp+ion
T/THj
I] U
promo+ion o-f loco-lly c.ucl+iva_+a_ble., SnCrgy
dense. -foods
pucrc-hcuSing o-f cup pr opria_+e., c.os+
e.-f-fe.<s+ive. -foods
bu-lk. pu.r<sha_Sir>2
be.++e.r Ioou.se.ho Id Storage, o-f -food
cuddre.SS -food Joadoi+s cund be.lie.-fs +hcu+ cudds
+o Vudnercubil i+y o-f womCn cund c.hildre.n
c)
Tell the participants to bear this example in mind for later when they
will be using some of these assessment techniques to answer some
of the questions from Handout 3.9 (p. 85).
Session 5:
Nutrition Situation Assessment
Stepl:
75 minutes
Activity: Introduction
a)
Remind participants of the Triple A cycle and that the first A stands
for assessment. So far they have been learning about the most
important causes of malnutrition and ways of measuring them. This
session will now bring all this together so that the participants will
be ready to perform a nutritional situational assessment.
■ -3
71
The Nutrition Situation — Training Manual
Step 2:
Activity: Uses and Steps in Conducting a Nutrition
Situation Assessment
a)
Ask
"Why is it important to do a nutrition situation
assessment before we start our interventions?"
|
HrT
b) Write all the responses on the board
and then distribute Handout 3.10 (p. 86) and see which uses have
been stated and which are missing.
\ /
Divide the participants into groups of 4. If possible, participants
c)
from the same area should be in the same group. Ask them to
complete the following task:
1.
Write down the steps which are needed to conduct a nutrition
situation assessment
2.
Start with the need to form a district nutrition team
(You have 10 minutes to do this task)
\
\
Share their responses in plenary and show Transparency 3.2 Steps
for Conducting a Nutrition Situation Assessment (p. 88) and
d)
******
Step 3:
summarise the steps.
Activity: Producing an Assessment Framework
In the same groups of 4 ask them to complete the following task:
a)
I.
You. ho.ve been inviTed by a. ne ighbou-r ing
disTr-iaT To ccdvise Them on whcuT
nu.Tr~iTion inTervenTionS a.r-e needed in
Their- disTriaT, Wr-iTe down wha_T
in-Cormcution obou.T The disTr-iaT you.
wou_ld like To hcuve be-fore you. <sccn give
ccny o.dvi<se a_bou.+ interventions.
2.
For- exa.mple, you. mighT like To know
how mu.c.h u.nder- or over nu.tr it ion
There is a_nd wheTher- The popu.la.Tion is
living in u.rbc_n or ru.ra.1 a.rea.5,
(You have 20 minutes for this task)
72
3
.
\
Causes of Undernutrition
b) Walk around to the groups and ensure that they are on the right
track by referring to the Transparency 3.3 The Information
Framework (p. 89).
Ask each group to write down one part of the framework on VIPP
c)
cards and stick it on the wall for everybody to see.
Rearrange the cards according to Transparency 3.3 (p. 89).
d)
Step 4:
Activity: Organising a Nutrition Situation Assessment
In the same groups of 4 ask each group to take responsibility for a
a)
part of the framework. Give each group the following task:
For- your po_r'+ oF +be.
writs
dowr>: wbcuF ir>-For'ma_+ior> is a.lr'e.a.dy
I.
a_va_ila_ble., a_r>d wha_+ ir>-Cor'rria.+ ior> r>C.e.ds
+o be. collected.
2.
For' +bc ir»For'rria_+ior> +ba_+ needs +o be
oolleo+ed, wher£ will youc
+bis
in+ormc.+ ior a_r>d bow?
(You have 25 minutes)
b) Ask each group to present their findings.
c)
Now ask the groups to fill in the following table:
Information
Who will collect
When will they collect
to be collected
the information
the information
d)
Explain to participants that the next few sessions will concentrate on
techniques which will help them in collecting, analysing and
reporting the information required to complete a situational
assessment. At the end of these sessions the team should have
completed a NSA which can then guide them in planning for
nutrition interventions.
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The Nutrition Situation - Training Manual
Handout
3.1
CASE MANAGEMENT OF DIARRHOEA
A child suffering from diarrhoea and vomiting becomes malnourished because it loses water and
nutrients which are essential for proper growth and functioning of the body. Lost body water must be
replaced at once. Replacing the lost water and salt is called rehydration.
There are two types of oral rehydration drink that caretakers can use. One comes in a packet
which you can get from the nearest clinic or hospital. It is called oral rehydration salts. This salt is dry
like powder and it must be mixed with clean water.
The other type can be prepared at home using ordinary salt and sugar. The child can also be given
other home made fluids such as thin porridges, fruit juice and soups. Continued feeding, especially
breastfeeding, is very important in managing diarrhoea. The mother should use a clean cup and spoon to
feed the child or give the rehydration drink.
In the past, we used to withhold food to rest the gut but we now know that this is harmful. The
gut needs to be nourished during episodes of diarrhoea. Milk can also be given safely to a child - most
diarrhoea is not due to lactose intolerance (in fact breastmilk has a lot of lactose).
From the onset of the first episode of diarrhoea or as the mother is bringing the child to the
health centre, she should continue to give liquids and food. After the child has stopped having the
diarrhoea the family should be informed that the child needs greater amounts of energy-rich food in
order for her to catch up her growth. It is also important that they bring the child to be weighed again to
check that she has regained her normal growth.
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3
Causes of Undernutrition
Handout 3.2
NUTRITION AND HIV/AIDS
Background
People with HIV/AIDS often suffer from malnutrition, either because of the symptoms of their
infection or because their diets are deficient in energy, protein, vitamins and other nutrients.
The symptoms of HIV/AIDS infection that affect nutrition include fever, diarrhoea, mouth sores
and infection, nausea, vomiting, weakness, and general loss of appetite. These conditions affect the
consumption and absorption of food and nutrients as well as their retention. Severe weight loss and
body wasting (loss of muscle) are commonly recognized symptoms of full-blown AIDS.
Malnutrition can also affect the progression of HIV to AIDS, and it may even affect transmission.
Good nutrition enhances the ability of our immune systems to fight infection and to recover from bouts
of illness. Vitamins A, B, C, D, and E as well as several minerals (e.g. zinc, selenium) are all needed for our
immune systems to work properly. Deficiencies in any of these may affect the progression of disease.
Vitamin A deficiency, in particular, has been associated with increased risk of HIV infection
(transmission) because of its impact on the mucosal linings of the body (e.g. gut, genital tract, mouth,
etc.). When mucosal linings are broken, or not intact, there is a greater chance that the HIV will enter
into the body. Vitamin A deficiency is also associated with other conditions such as prematurity, low
birth weight, and the concentration of virus in breast milk, which are also risk factors for the transmission
of HIV from infected mothers to their babies.
The benefits of nutritional supplementation for people with HIV/AIDS have not been proven
conclusively. Adequate intake of food (energy, protein, micronutrients) is important to maintain the
body's health. Multivitamins (Amegavitamins) should not be taken therapuetically (in high doses) to
prevent disease progression since some vitamins are beneficial whereas others can cause additional
problems.
Practical advice on nutrition for people with HIV/AIDS
Health providers should assess the nutritional status of all clients suspected to have HIV/AIDS and
related illnesses. This assessment should ascertain:
> body weight and if there have been changes recently (e.g. weight loss)
> dietary intake and if it is sufficient in energy, protein and micronutrients
> appetite and difficulty eating
> opportunistic infections, particularly those that will affect nutrition (diarrhoea, fever, oral/
mouth sores, etc.)
> current medications that may affect appetite; nausea, vomiting, etc.
75
The Nutrition Situation - Training Manual
Handout 3.2
> food and personal hygiene, water safety, basic sanitation
> other practices that will affect healthy living (e.g. alcohol, drug, or tobacco use)
This nutritional advice may be given to people who are HIV+ but do not have symptoms of
AIDS:
> encourage healthy living (avoid alcohol, smoking, unsafe sex);
> promote good dietary practices:
-
regular meals
-
hygienic food preparation to avoid contamination and diarrhoea
-
varied diets to include energy, protein, micronutrient-rich foods
-
continued feeding during periods of illness-related appetite loss
-
nutritional supplements (e.g. vitamins, food supplements) can be given to
correct specific deficiencies (but megavitamins should not be given otherwise)
> ensure immediate treatment for all opportunistic infections, particularly those that
affect appetite and oral health (e.g. oral thrush).
For people with AIDS the same advice holds, but for patients who are experiencing
wasting, extreme loss of appetite, nausea, vomiting, or other side-effects from treatment of
opportunistic infections:
> give him/her food that he/she prefers and can eat easily;
> increase the frequency of meals, provide small portions of food several times a
day;
> give plenty of water to prevent dehydration;
> provide a varied diet which includes energy, protein, and micronutrient-rich foods;
> avoid soft-drinks, alcohol, spicy foods, very sweet foods, and tobacco.
Adapted from: Piwoz EG, Preble EA. HIV/A1DS and Nutrition:
A review of the literature and recommendations for nutritional care and support in Africa.
Washington DC: Academy for Educational Development, 2000.
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3
Causes of Undernutrition
Handout 3.3
NUTRITIONAL VALUES OF LOCAL FOODS
(per 100 g of edible food) (MRC Food Composition Table, 1991)
Food
Water (g)
Kcal
Protein (g)
Fat (g)
Carbo
hydrate (g)
Maize Meal (dry)
13
374
9.0
3.5
80
- porridge
79
88
2
0.6
19.5
- soft porridge
88
51
1.2
0.3
11.5
- sweet potato
73
105
1.7
0.3
21
- irish potato
77.5
86
1.7
0.1
18.5
- peanut butter
1.4
588
24.6
50
15
- sugar beans
63
131
7
0.5
19.5
69.5
116
8.5
0.2
14
- pumpkin
94
20
1
0.3
3
- spinach
91
23
3
0.3
1.6
74
92
1
0.5
22
- hard margarine
15
730
0.3
82
1
- sunflower oil
0
884
0
100
0
52.5
286
27
19
0
- eggs
75
152
12.5
10
1.2
- milk
88
62.5
3.2
3.4
5
Breastmilk
87.5
71
1
4.4
7
Starches
Pulses/seeds
- lentils
Vegetables
Fruits
- banana
Fats and Oils
Animal
- beef mince
77
The Nutrition Situation - Training Manual
Handout 3.4
CONTROL OF VITAMIN A AND IRON DEFICIENCY
Foods with High Iron
Content
Promoters of Iron Absorption
Vitamin C
Meats
Egg yolk
Milk
Fish
Dark green vegetables
Micronutrient Interventions
to Address Iron Deficiency
Supplementation
Vitamin A
Acid sauces (tomato sauce etc.)
Food fortification
Dietary diversification
Heam-iron
Increased cooking of phytate
rich foods
Legumes (lentils, beans etc.)
Inhibitors of Iron Absorption
Breastmilk
Phytate
Improved dietary preparation
Improved hygiene,
environmental sanitation
Early detection and treatment
of infectious diseases
Increase breastfeeding
Tannin
Fibre
Foods with High Vitamin A Content
Egg yolk
Yellow/coloured vegetables/fruits
Dark green leafy vegetables
Legumes (lentils, beans, etc.)
Meat products
Breastmilk
Micronutrient Interventions to Address Vitamin A
Deficiency
Improved dietary intake
Supplementation
Food Fortification
Immunisation
Early detection and treatment of infectious diseases
Increase breastfeeding
78
3
Causes of Undemutrition
Handout 3.5
ESTIMATED ENERGY, PROTEIN AND
OTHER NUTRIENT REQUIREMENTS BY AGE
Nutrient
Age in months
0 up to 6
6 up to 9
9 up to 12
12 to 24
energy (kcal/day)
400-550
680
830
1100
protein (g/day)
9.1
9.1
9.6
10.9
vitamin A
375
375
375
400
iron (mg/day)
- low bioavailability
(i.e. non-animal sources)
21
21
21
12
- high bioavailability
(i.e. animal sources)
7
7
7
4
79
The Nutrition Situation - Training Manual
Handout 3.6
CASE STUDY ON THE IMPORTANCE OF CARE
In one village we visited a rich family with a severely malnourished child called Sipho. He was 28
months old, but looked much smaller for his age. He was very weak and had thin legs, a big head and a
big tummy. He had just begun to walk and did not yet talk.
When we entered the house, Sipho was sitting on the ground. The house was dirty and untidy with
unclean, stinking beds. It was apparent that Sipho was not bathed regularly.
Sipho's mother, Thuli, was a beautiful woman but with a tired look in her eyes. She was rather
lethargic and looked pale. Thuli virtually had no time for Sipho since she had been very busy with post
harvest sorting of crops. Peanut plants had been brought in from the field on the previous day and it was
Thuli's job to clean the plants and separate the nuts from the plants. She was also responsible for all the
domestic chores. We watched Thuli serve breakfast, wash dishes, cook for family members and guests.
Whenever she sat down to catch her breath, she was sharply rebuked by her mother-in-law, who lived in
the household. While she was busy, the younger child cried until he was completely worn out and fell
asleep. When we asked why nobody was brought in to help Thuli, the mother-in-law just laughed out
loud.
Sipho sat down to eat a meal with his father who said that Sipho normally had a good appetite.
They ate mealie-meal with a chicken stew and then mashed banana. Thuli, however, only had some
mealie-meal with gravy. When asked, she said that she was on a special diet as her breast fed child was
ill. She had been on such a restricted diet since becoming a mother. By asking her questions, we found
out that she did not believe in benefits of such a diet. Yet she did not feel that she could go against the
social norms and beliefs.
When Sipho finished his meal, he sat in the courtyard and started to eat peanuts that he had
picked up off the dirt with his dirty hands. Nobody bothered to wash the peanuts for him or to stop him
from eating them.
From the open-ended interviews and discussions with the parents we discovered that Sipho was
born with low birth weight. After two months it was felt that Thuli did not have enough breastmilk for
him and so Sipho was bottle fed with some Nestum as well. At eleven months Thuli gave birth to
another son and Sipho was weaned completely, in spite of his poor health. There was no special diet for
Sipho and he was left alone to eat what ever he liked from the family pot.
80
3
Causes of Undernutrition
Handout 3.7
RECOMMENDED CARING PRACTICES
FEEDING INFANTS < 6 MONTHS
>
Initiate breastfeeding within about one hour of birth.
>
Establish good breastfeeding skills (proper positioning, attachment, and effective feeding).
>
Breastfeed exclusively for about the first six months.
>
Practice frequent, on-demand breastfeeding, including night feeds.
>
Continue on-demand breastfeeding and introduce complementary foods beginning around six
months of age.
>
In areas where vitamin A deficiency occurs, provide lactating women with a high-dose Vitamin A
supplement (200,000111) as soon as possible after delivery, but no later than eight weeks post
partum to ensure adequate vitamin A content in breastmilk.
FEEDING INFANTS 6-24 MONTHS
>
Continue frequent, on-demand breastfeeding, to 24 months and beyond.
>
Introduce complementary foods by six months of age.
>
Increase food quantity as the child ages, while maintaining frequent breastfeeding.
>
Increase complementaiy feeding frequency as the child ages, using a combination of meals and
snacks.
>
Gradually increase food thickness and add variety as the child ages, adapting the diet to the
child's requirements and developmental abilities.
>
Diversify the diet of both the breastfeeding mother and the child by including fruits, vegetables,
fortified staple foods, and/or animal products to improve quality.
>
Practice active feeding, especially during and after illness, to regain lost weight.
>
Practice good hygiene and proper food handling.
>
Offer breastmilk before complementary feeds.
PSYCHO-SOCIAL CARE
>
Respond to young children's behavioral cues and developmental milestones with appropriate
actions.
>
Touch, hold, and talk to young children regularly.
>
Encourage children to explore their environment while protecting them from harm.
>
Prevent and protect children from violence and physical and emotional abuse.
81
The Nutrition Situation - Training Manual
/\_
CARING PRACTICES FOR WOMEN
>
Provide women and girls with equal access to food, health care, information,
.
education, and other household resources as men and boys.
>
H
X. 3 -j
Encourage and support efforts to delay the age of first pregnancy and practice
birth spacing (2-3 years between pregnancies).
>
Facilitate antenatal care and safe birthing practices.
>
Encourage pregnant and lactating women to eat extra food each day, and to be allowed a period
of postpartum rest, and support them in efforts to reduce physical activity and other strenuous
work before and after child birth.
Prevent and protect women from physical and emotional abuse, and support efforts to enhance
women's self-confidence and esteem.
>
Provide women with information and other resources that will increase their decision-making role
and power over food, health, and other care issues in the family.
>
Establish women support groups.
u, iJ,
>
y
Ui
>
Store foods safely (raw grains and cooked food) to reduce food losses.
U,
>
Cook foods thoroughly and feed them as soon as they are cool enough to eat.
III.
>
Use safe water sources and cover all stored water.
Ui
>
Wash dishes and all cooking utensils before using them.
>
Wash hands with soap after defecating and handling children's waste, and before cooking and
feeding young children.
>
Keep children clean by bathing them regularly, clipping their nails, and washing their hands.
>
Use sanitary facilities to dispose of children's and adults' faeces.
>
Keep children's play areas clean and free of human and animal faeces and other contaminants.
HOME HEALTH CARE
>
Prevent illness with good hygiene, environmental safety, and feeding practices.
>
Continue breastfeeding and practice active feeding during and following illnesses.
>
Seek care for children with persistent symptoms that do not improve.
>
Seek care without delay for children with high fever, rapid breathing, frequent vomiting
listlessness, and bloody stools.
>
Weigh young children monthly, plot their weights on growth cards, and complete their
immunisations by 1 year of age.
82
1.1:
HYGIENE
3
Causes of Undernutrition
Handout 3.8
SAMPLE CHECKLIST FOR ASSESSING
INDIVIDUAL CHILDREN'S FEEDING PRACTICES
Child Age:
months
Practice
Yes
No
How will data be collected?
Comments
1. Breastfeeding
a. Still breastfed
b. On demand
(8-12 times/day minimum)
c. Night feedings (if <12 mo)
2. Complementary Feeding
Frequency (meals + snacks)
0-5 mo - breastmilk only
(exclusive breastfeeding)
6-8 mo - 2-3 times/day
9-H mo - 3-4 times/day
12-24 mo - 4-5 times/day
3. Complementary Foods
Texture and Consistency
6-8 mo - mashed, semi-solid
9-11 mo - finger foods + snacks
12-24 mo - eating family diet
4. Complementary Food Energy
Density (from recall
estimations)
oil, margarine, peanut butter
added to maize meal porridge
5. Diet Quality
Vitamin-A rich foods daily
Meat, poultry, or fish daily
Fortified foods consumed
83
The Nutrition Situation - Training Manual
Handout 3.8
Care giver varies recipes to
child's tastes/likes
Care giver feeds slowly
and patiently
Care giver does NOT force feed
7. Hygiene
Care giver washes
own/child's hands
Foods served immediately
(not stored)
Clean utensils used
Feeding bottles NOT used
8. Feeding During Illness
Breastfeeding increased
Care giver offers favourite foods
patiently, encourages
child to eat
9. Feeding After Illness
Breastfeeding continued
Complementary feeding
frequency increased
Complementary foods
quantity increased
84
‘FI
'FT
Care giver encourages child to
eat more
IT
Adult assists feeding
(if 12 mo or older)
IT
Adult care giver feeds directly
(if <12 mo)
IT
6. Active Feeding
3
Handout
Causes of Undernutrition
3.9
QUESTIONS FOR ASSESSING
HOUSEHOLD FOOD SECURITY
Food availability and access
How do households obtain their food?
What do they purchase?
What do they produce?
Other sources?
Has this situation changed in the last years?
How?
Why?
Production for Household Consumption
What foods are produced by the household?
How many months do staples last?
During which months do they eat the other foods?
What are the problems encountered?
What are the periods of food scarcity? For which foods?
What efforts do people make to overcome these?
Food Purchasing
How much of the household income is spent on food?
What are the foods purchased? Which are considered as essential?
Which as luxury?
Why?
How have purchasing habits changed in recent years?
Why?
Food Use
How many meals do the different households members eat a day?
In which season?
What do they eat?
Any snacks in between?
Do children eat differently?
How often do they prepare meals for young children?
How do eating patterns change in times of scarcity?
How is food obtained in such cases?
If the household had more resources what foods would they like to eat more or more often?
What foods are considered especially good or to be avoided in certain circumstances?
What was the normal diet for children 20 years ago?
What are the main differences today?
The Nutrition Situation - Training Manual
Handout
3.10
USES OF NUTRITION SITUATION ASSESSMENT
The South African National Integrated Nutrition Programme (INP) has outlined a comprehensive
strategy to address the underlying socio-economic, environmental, educational and health related causes
of undernutrition. The major aim of the INP is to make a shift from a near-total reliance on feeding
programmes to providing more comprehensive community based nutrition programmes.
The causes of malnutrition are multiple, as can be seen from the UNICEF conceptual framework. It
is obvious that if we are to respond to the challenge of malnutrition effectively an intersectoral response
is necessary, initiating a programme around fighting malnutrition can serve as a model of intersectoral
collaboration.
Performing a nutrition situational assessment (NSA) is an important first step in implementing the
INP and can serve to:
> Pull together the different members of the district health management team (e.g. nutrition
programme manager, MCH programme manager, clinic supervisors, school health co-ordinator
eta).
> Bring together the intersectoral team and increase its appreciation of the important role that all
sectors play in fighting malnutrition.
> Be the first step in the triple A cycle (Assessment, Analysis and Action).
> Be an advocacy tool to persuade policy makers and funders of the importance of the problem
and the validity of your implementation plans.
> Assist in the future monitoring and evaluation of the INP.
> Assist in the development of a district health system. The NSA should fit into the broader
district situational assessment and could even be a model for the rest of the district to follow.
Furthermore, by ensuring that participatory approaches are used the NSA can:
> Serve as an educational process for both the district nutrition team and community as they
come to realise the causes of malnutrition and set about combating them.
> Promote the participation of different community groups (in particular, women, poor people,
young people).
> Contribute to community empowerment.
86
3
Causes of Undemutrition
Transparency 3.1
Infection - Undernutrition Cycle
More
infections
Underweight
Slower
recovery
More
underweight
More severe
illness
Marasmus
kwashiorkor
Death
87
1;-
ip
Bring together a multi-sectoral nutrition team
2.
Come to a common understanding of the problem of
undernutrition and the importance of performing a
participatory NSA
3.
Formulate the aims and objectives for the NSA
4.
Determine the framework
5.
Identify what information is already available and what is
required
6.
Determine the methodology that will be used and collect
the missing information
7.
Compile, write and disseminate the report
zl:
l£l
ip ip rp ip
rri
ip
ip
ip
m
Ip
1.
rri
ip
in
Steps for Conducting
a Nutrition Situation Assessment
ip
Ip
[p
Transparency 3.2
Ip !p
The Nutrition Situation - Training Manual
u
88
3
Causes of Undernutrition
Transparency 3.3
Information Framework
89
The Nutrition Situation - Training Manual.
TOPIC 4
TECHNIQUES FOR
ASSESSMENT OF NUTRITION
SERVICES AND PROGRAMMES
Objectives
By the end of this topic, participants should be able to:
✓ do a structured observation;
✓ do a key informant interview;
✓ conduct a focus group discussion;
✓ collect data for assessment.
Time
Topic overview
7 hours
Session 1;
Assessment Techniques (30 minutes)
Session 2:
Structured Observations (60 minutes)
Session 3:
Key Informant Interviews (90 minutes)
Session 4:
Focus Group Discussions (60 minutes)
Session 5:
Preparation for Collection of Data (180 minutes)
Materials
flipchart, pens, masking tape, cards, markers, overhead projector,
transparencies, transparency pens
Handouts
H 4.1 Steps in Preparing a Structured Observation
H 4.2 Guidelines for Growth Monitoring
H 4.3 Sample Checklist on Post Natal Care
H 4.4 Role Play Card for Key Informant Interview
H 4.5 How to Conduct Key informant Interviews and Observations
H 4.6 Task Box for Key Informant Interviews and Observations
H 4.7 Organising and Conducting Focus Group Discussion (FGD's)
H 4.8 Types of Questions in FGDs
H 4.9 Plan of action for Data Collection
Advance Preparation
Prepare and photocopy all handouts. Prepare role play for Session 1,
Step 3
PURPOSE OF THE TOPIC
The purpose of this topic is to explore techniques that could be used to assess
nutrition services and programmes in communities.
90
4
Session 1:
Techniques for Assessment of Nutrition Services and Programmes
Assessment Techniques
Step 1:
30 minutes
Activity: Introduction
a)
Ask
"Why do you think it is important to assess
nutrition services/programmes? ”
b)
Remind participants that the Integrated Nutrition Programme started
from an assessment and analysis of the previous nutrition
interventions and suggested the formulation of a more integrated
approach. The UNICEF triple A approach is crucial for the local
initiation of the INP. Explain that we need to describe and analyze a
problem or situation before designing an intervention.
c)
In the previous topics we have identified key questions, based upon
the UNICEF Conceptual Framework, answers to which are important
to plan district nutrition interventions. In the next three topics we
will concentrate on techniques to collect information to answer
these questions.
Step 2: Activity: Identifying Assessment Techniques
a)
Ask
"What nutrition services are offered as part
of the Integrated Nutrition Programme?’
Write their responses on the flipchart.
The following should be listed:
I
G'T'oVkz+h mor>i+or'ir>2 o_r>d promo+ioc
Immu.ciSa.fior> S&r'^ioe.S
o-C S&v'&re.l'y rr>a-lr>ou.r'ishe.<i
rj
c.hildr'Sn
An+e.
pos+ ncc+ccl
............. " ■■■■••?...........
91
The Nutrition Situation - Training Manual
Primo-ny School Nuctr'ition Pr'ogr'cumme.
Sche.m>e.
■
Community ba_se.d nu.+ri+ion pnoj2.cts
Writer o_nd Sc.nitc.tion -Fcucilitie.S end hygiene.
cduccetion
b)
Ask
"In what ways can we gather information in order
to assess nutrition services?’
The following methods should be noted:
Observations
Interviews
Records review
Focus group discussions
c)
Divide participants into 4 groups. Give one method to each group.
Give each group the following task:
Whet Sort o-F in-Fonmetion, u.se.-Fu.l -For*
doing c. nuctnition CLSSeS-Sment, cen you.
collect u.Sing the m&thod you. hcve been
given?
(You have 10 minutes for this activity)
The following points should come out:
Observations
Possible uses
> To follow a client through an activity at the
clinic;
> To observe provider/client interaction;
> To observe the health worker providing
services;
> To observe specific procedures, for example,
growth monitoring;
> To check on the availability/adequacy/
utilisation of supplies, equipment and
materials;
> To check on routine activities such as
maintaining the cold chain.
92
4
Techniques for Assessment of Nutrition Services and Programmes
Interviews
Possible uses
> To obtain specific information about services
from clients, health workers, community
members, and from the health management
team members such as provincial and
regional personnel
> To obtain information about household food
security
Record review
Possible uses
> Clients' files and charts for number of cases
treated with a certain condition such as
diarrhoea or malnutrition, type of treatment,
and patient management
> Attendance records for number of cases seen
during each month, and number of cases put
on Protein Energy Malnutrition Scheme
Focus group
discussion
Possible uses
> To obtain views and opinions of community
members and health service providers about
service provision
> To obtain information on community cultural
beliefs about feeding of young children
Session 2:
Structured Observations
Step 1:
60 minutes
Activity: Performing Observations
a)
Ask three participants to prepare and perform the following role
play which takes place at the clinic.
A mother has come to the clinic to have her baby weighed. The
health worker does not greet the mother, she weighs the baby fully
dressed. The health worker does not plot the child's weight correctly
on the chart but just writes it down and then does not give any
feedback to the mother. Improvise other bad behaviours on the part
of the health worker.
93
The Nutrition Situation - Training Manual
b)
After the role play, ask participants the following questions:
“What was this role play about?"
"What did the health worker do?"
"What should the health worker have done?"
c)
Ask what technique they used to evaluate this role play?
- The answer should be observation. Ask
"What techniques did you use to evaluate this role play?"
d)
Point out that they first imagined what a good consultation
consisted of and then checked it against what was happening.
Explain to participants that to do an assessment they need to use a
standard or guideline which identifies the procedures that should be
followed, and then to write a checklist against which they can check
whether or not these activities occur.
Step 2:
Activity: Preparing Observation Checklist
a)
Explain that a structured observation is used to learn about actual
conditions and practices in the field. Structured observations are
different from ordinary observations because the evaluator is
systematically looking at specific behaviours, activities and
procedures. The most frequently used instrument for collecting data
during a structured observation is a checklist. Where the description
is factual and accurate, structured observations enable the evaluator
to describe a programme thoroughly and carefully.
b)
Distribute Handout 4.1 (p. 103) on the Steps in Preparing a
Structured Observation. Take participants through it and clarify any
issues.
c)
Explain that the first step in developing an observational checklist is
to establish what should be the ideal situation. Distribute Handout
4.2 (p. 104) on the Guidelines for Growth Monitoring and
Promotion (GMP) and take participants through it. Explain to the
participants that this is a sample guideline for assessing GMP
programs, and that they will have to develop similar guidelines for
other types of nutrition-related services during the training. Point out
that where there are no guidelines or procedures manuals, the
district health team should develop its own.
94
U
Techniques for Assessment of Nutrition Services and Programmes
4
.M _
ll-
•J
d)
J
Divide the participants into groups of 5. Give each group the
following instruction:
- '2
Using Handout 4.2 (p. 104) and Handout 4.3 (p. 105) (which is
— '2
an example of a checklist) draw up an observation checklist that
could be used to assess the quality of growth monitoring.
2
(You have 20 minutes to do this)
- -A
e)
--3
Get each of the groups to visit the other groups and examine their
checklists to see what differences there are.
—rJ
f)
Finish this session by pointing out the need to blend in with the
environment when doing an observation. Ask the participants in
2
what ways they may introduce themselves to those whom they are
J
going to observe in order to minimise the problems of changing
behaviour as a result of observation.
;. 2
2
Session 3:
Key Informant Interviews
Step 1:
90 minutes
Activity: Introduction
a)
Ask
"What are key informant interviews?”
b)
Summarise the responses by stating that key informant interviews are
interviews with people who have been especially selected because
they might have special in-depth experience or knowledge.
c)
Then ask
“What are the reasons for doing key informant interviews?’
Write their responses on the flipchart.
The following points should come out:
> to reveal knowledge, attitudes and practices regarding the
provision of health services;
> to gather information on current practices and problems;
> to identify the resources available to solve these problems;
> to gather people's perceptions concerning the provision of
health services.
95
The Nutrition Situation - Training Manual
w
Step 2:
Activity: Identifying Key Informants
a)
Explain to participants that key informant interviews involve direct
u
s?-
questioning, using structured and open-ended questions with one
subject at a time. Ask
"Who in the community and the health services might be able
to provide important information about the nutrition
-
situation in the community?"
£
The following should come out:
> People who work within the community and have a professional
understanding of the issues: for example, school teachers, clinic
nurses, social workers etc.
> People who are recognised as community leaders and seen to
represent a section of the community: for example, councillors,
traditional leaders, church leaders.
5-
Divide the participants into 4 groups. Give each group Handout 4.4
(p. 106). Give each group the following task:
1.
Ask two members of your group to read out the interviews in
Handout 4.4 (p. 106).
2.
Ask the partipants to write down all the differences between the
two interviews.
3.
Now ask
"What are the qualities which are needed to conduct a good
interview".
(You have 30 minutes for this task)
96
Fl
fl If
'Fl 'H Fl Fl
Step 3: Activity: Identifying Skills Needed for Conducting
Interviews
!! fl H fl
play a central role in local communications: for example shop
owners, old women in the community, income generation
project leaders.
F!
> People who are important within informal networks and often
4
Techniques for Assessment of Nutrition Services and Programmes
Share the qualities of a good interviewer in plenary. The following
points should come out:
> articulate
> humble
> honest
> modest
> aware of the needs of other people
b)
> patient
> flexible
> clear on the purpose of research
> considerate
Distribute Handout 4.5 How to Conduct Key Informant
Interviews and Observations (p. 107). Ask each of the participants
to read out one paragraph at a time. Clarify any issues that
participants may have.
c)
Explain to the participants that the interviewer's attitude is very
important, not only because it must actually be an invitation for the
interviewee to talk, but because the interviewee (unconsciously
perhaps most of the time) imitates the interviewer's attitude. Ask
participants to brainstorm how an interviewer would demonstrate
the key qualities of a good interviewer. Write responses on the flip
chart.
Summarize the discussions by highlighting the following actions that
will improve an interview:
Giving attention and showing interest.
Maintaining eye contact with the interviewee.
Using appropriate voice.
Displaying an open inviting posture.
97
The Nutrition Situation - Training Manual
Step 4:
Activity: Developing Interview Schedules
a)
Point out that there are several types of questions that should be
included in an interview.
De.Sc.Y~iptive or open-ended ^estions.
These cure u.sed to obtcuin in-Formcution
on -FcuctS, opinions cund sensitive iSSix.es.
cun event throucgh probing.
Str<x.<stu.re.d
ot
close-ended ^u.es+ions
These cure u.sed when the rcunge o-F
possible, responses iS known.
Contrast ^w.estionS. These cusk the
d i-F-Ference between two or more
‘Why’ questions. These. ask respondents
b)
Using the same four groups of participants as before give each one
of the following four topics: The quality of growth promotion and
monitoring; The PEM scheme; Breastfeeding practices and related
attitudes in the community; and The functioning of the PSNP in
schools.
Then give them the following task:
Develop cun interview guuide -For key
in-Formcunt interviews in order to
gcuther in-Formcut ion to cussess youcr
2, Voix. will be. expected to shcure
interview guuide with the rest o-F the.
cIcuSS by conducting interviews in role
(You have 30 minutes for this activity)
98
4
c)
Techniques for Assessment of Nutrition Sen/ices and Programmes
Get each group to present their interview schedule in the plenary
through a role play.
d)
After each of the role plays has been presented, ask participants to
comment on the strengths and weaknesses of the role play.
Finish this session by distributing and read out Handout 4.6 The
Task Box for Key Informant Interviews (p. 109) and ask
participants if they have any questions about the handout.
Session 4:
Focus Group Discussions
Step 1:
60 minutes
Activity: Introduction
a)
In groups of three, ask participants to come up with a definition of
what focus group discussions (FGDs) are and to state when they
should be used.
Write their responses on flipcharts and ensure the following points
come out:
> FGDs are a qualitative method of assessment.
> They use group dynamics and the flow of discussion to probe
deeply into beliefs and concepts people have about a particular
subject.
> They are held with small groups of people who have similar
characteristics.
> FGDs are led by a moderator who uses a question guide to
introduce the topics of interest.
> The discussion may either be taped or written down by a
recorder.
b)
Distribute Handout 4.7 (p. I IO) on how to organise and conduct
focus group discussions and read through it with the participants,
noting the preparation tasks, the implementation tasks and the
analysis tasks. Clarify any questions they may have.
Distribute Handout 4.8 (p. Ill) on the different types of questions
that are asked in FGDs. Go over each one, giving examples.
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The Nutrition Situation - Training Manual
Ask participants if they have experience doing FGDs, and how they
were used. Ask them if they can think of other ways to encourage
group participants to speak freely and informatively about nutrition
and related issues. Ask them if they can think of times that FGDs
should not be used.
Step 2:
Activity: Skills Needed for Conducting Focus Group
Discussions
a)
Ask participants to brainstorm about the skills needed to facilitate a
group discussion. List their responses on the flipchart. The following
points should come out.
The facilitator should:
> encourage all members of the group to contribute to the
discussion;
> be a good timekeeper;
> be alert to people's reactions in the group;
i i i i I t U.
> be a good listener; not dominate the discussion;
ill Ul U l t.i.- Hi til ill Ul L i t i
d)
t
> be able to probe for further information;
Ask participants to brainstorm about the role and skills of a good
note-taker (recorder). The following should come out.
Ui
b)
til
> be able to keep the discussion to the topic.
The recorder should:
Li,
> be attentive;
Ml
> know what points are key and relevant to write down;
I
J
> be a quick and able writer;
> be able to summarise and interpret the discussion.
Step 3:
Activity: Performing a Focus Group Discussion
a)
Divide participants into 2 groups. Give each of them one of the
following subjects:
Beliefs about child feeding practices in the community
Issues regarding the PEM scheme
100
4
—3
Techniques for Assessment of Nutrition Sen/ices and Programmes
Give them the following task:
2. De.<side. who will be. +he. -Fa_<z.ili+a_+or' cur>3
3
The v-S-c.order?
~-3
3. CoMixr+ The.
groucp 3iS<su.SSior> wi+h
Six. +o ei^ln+ mSmberS o-F +he o+he.r 2>"otx-p-
3
b)
--3
Ask the participants what went well, what didn't go well and how it
could be improved.
3
c)
Complete this session by explaining to participants that once the
3
FGD has been conducted, they need to analyze the results. Remind
3
them that it is important to capture the opinions expressed during
the discussion and not try to quantify how many people gave
3
opinions.
■ 3
d) Also point out that FGDs may be used to develop and test nutrition
■ 3
messages. When this is done, it is useful to record the exact phrases
and words that were used by community members or health workers.
3
Clarify any questions the participants may have about FGDs.
3
3
-3
Session 5:
Preparation for Collection of Data
180 minutes
3
3
. 3
.
Step 1:
Activity: Organising a Field Visit
a)
3
During this topic they have learnt about and practiced a few ways of
collecting this information. They have also prepared a few interview
3
and observation guides. It is now important to develop further
3
. 3
3
... 3
Explain to participants that during the last topic they identified key
areas of the information pyramid which needed to be completed.
guides and to test these first before going around the district.
b)
Part of your preparation for the workshop should have included
organising a field site for the students to go out and test some tools.
The field site should include a couple of primary health care clinics
.. 3
.. 3
■ 3
wur too
11055
101
workers and mothers. You should now give some background to the
f]
where the participants will have the chance to interview health
(»',
IS
The Nutrition Situation - Training Manual
Tell the participants that they will now prepare to test their tools by
c)
(B|
(?|
etc).
11
participants about the field sites (e.g. how large the clinics are, what
services they offer, information about the communities they service,
V|
going out to the field sites.
R.e.'/ise. whiczh pcurts o-F the ir-Formcut ior
I,
f|ti
following instructions:
|®|
Divide the participants into district teams and give them the
d)
collect the dcutcu.
4.
Prepcure the cuppropricute dcutcu collectior
Decide who will be the Sucb^eotS; when
m
the dcutcu will be collected curd by whom.
(F,
5.
M
tool to cLolleczt the cuppropricute dcutcu.
in W
As a. groucp choose three pieces o-F
ir-Formcut ior curd pl cur how -youc will
3.
M
uuSirg one o-F the methods ~ obs&rvcutior >
irterviews or -FoczucS groucp diSouuSSiorS.
fm
For- ecu<ch missirg piec.e o-F ir-Formcutior
decide whether it ocur be czolleoted
2.
ip-1
czollectirg.
<n
<n
pyrcumid hcuve ir-Formcut ior whic.h reeds
e)
Visit each group and make sure that they have finalised the data
collection tool and have planned who they will interview/observe,
and that they have assigned tasks. (Use Handout 4.9 (p. 112) as a
guide)
102
■i
.i
i
fg!
m
(You have I hour for this task)
4
Techniques for Assessment of Nutrition Services and Programmes
Handout 4.1
STEPS IN PREPARING A
STRUCTURED OBSERVATION
1.
Decide if structured observations are needed and can be done, considering available resources.
2.
Generate a list of potential key behaviours which can be observed.
3.
Choose an observation method: either a checklist, coded behaviour records or delayed reports
which are filled in after the observation is made.
4.
Decide how long each observation must be in order to yield good data.
5.
Determine how many observations are needed.
6.
Prepare a plan for conducting observations by determining who/what to observe, where and when.
7.
Prepare the observers' recording sheets, if needed.
8.
Choose/train observers.
9.
Inform staff about planned observations.
10.
Conduct observations that you have planned.
11.
Code, clean and process data.
12.
Formulate conclusions and recommendations.
13.
Share the results with the community.
14.
Use the results for planning, implementation or further assessment.
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The Nutrition Situation - Training Manual
Handout 4.2
GUIDELINES FOR GROWTH MONITORING
1.
Greet the mother or caregiver.
2.
In a polite way, find out what service(s) the mother has come for and direct her there.
3.
Discuss the general welfare of the child and other family members since the last visit.
Ask:
has the child been well?
has the child been growing well?
have any developmental milestones occurred, such as starting to crawl, the appearance of
new teeth, starting to sit up alone?
4.
Set the scale to zero or check that it is at zero as you ask the mother to remove the child's clothes.
5.
Help the mother to correctly place the child on the scale (all parts of the child's body should be on
the scale).
6.
Read the weight correctly when the numbers on the scale stop fluctuating.
7.
As you record the weight and plot the weight for age on the child's health card by connecting the
dot at the previous point, tell the mother to take the child off the scale.
8.
Ask the mother to dress the child.
9.
Show the mother the card and see if she can interpret it correctly. For example, if the child has
gained or lost weight since the last visit. Praise her for doing so.
10.
If the child has gained weight, commend the mother and reinforce this behavior. If the child has
lost weight, find out from the mother if she knows the reasons why, for example, if the child has
been ill or any other problem.
II.
Ask the mother about current feeding practices, for example, exclusive breastfeeding or weaning
practices. Enquire about the availability/affordability of staples and specifically oily foods and cheap
sources of protein (e.g. beans, sour milk etc.). And then give proper advice (praise her for good
practices).
12.
Advise the mother how she may improve her feeding practices (e.g. active feeding).
13.
Check if vitamin A supplement has been given and ask about access to Vitamin A rich foods (e.g.
pumpkin, pawpaw, carrots etc.).
14.
Check if the immunisation record is accurate and up to date. Advise her accordingly
15.
Ask the mother if she has any questions or concerns regarding her child.
16.
Ask the mother if she has any questions or concerns about family planning. Advise her accordingly.
17.
Advise the mother when the child is due for the next visit.
104
4
Techniques for Assessment of Nutrition Services and Programmes
Handout 4.3
SAMPLE CHECKLIST ON POST NATAL CARE
Name of Observer
.............
Date
.............................................
Location/Clinic
_____
1. Post natal care for the mother
Did the service provider
Yes
No
Greet the mother?
Ask about general health of mother and child?
ask mother about her diet?
ask mother about baby's eating patterns?
encourage exclusive breastfeeding up to 6 months?
encourage mother to breastfeed when she/baby are unwell?
Provide appropriate counseling on mother's diet during lactation?
encourage the use of locally available foods (energy rich foods)?
encourage cultural practices that promote consumption of important
foods for lactating mothers?
discourage dietary taboos that restrict important foods for lactating mothers?
provide iron and/or folic acid tablets?
provide nutrition supplements?
examine for engorged breasts, cracked nipples or abscesses?
provide warning signs that indicate that the mother should seek help?
2. Post natal care for the baby
Did the service provider:
weigh the baby?
encourage the mother to take the child for growth monitoring?
check if baby is immunised?
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The Nutrition Situation - Training Manual
Handout 4.4
/ \
/
Mama Dlamini
I'll try to help you but as you can see I'm rather
busy. 1 have to go to the market in a few minutes.
Mama Ngumbela
Well I am afraid 1 must have this information
today and I can't come back later.
Mama Dlamini
What can I tell you, 1 am only a humble person?
Mama Ngumbela
That's right, you really know what's going on, but
the government has to check on it from time to
time.
Now 1 suppose you feed your children mainly on
maize without anything added?
Mama Dlamini
Well, I do my best, but at this time of the year
there is hardly any food to be found around here.
Mama Ngumbela
I'm sure there are some things to be had
somewhere, but wait a minute while I write that
down.
I haven't got much time. Perhaps you could tell
me what foods you eat which have a high protein
content
Mama Dlamini
I'm sorry, 1 don't understand what you mean
Mama Ngumbela
Well, never mind. How much money does your
husband earn every month?
Mama Dlamini
I'll try to help you but as you can see I'm rather
busy. 1 have to go to the market in a few minutes.
Mama Ngumbela
I appreciate that you're busy Mama Dlamini with
so many fine children to care for. I'd gladly come
back at a more convenient time, but unfortunately
I've got to get the information today. The
questions won't take a minute.
Mama Dlamini
What can I tell you, I'm only a humble person?
Mama Ngumbela
Of course, but your opinion is important. Well,
can 1 start by asking what's the main food you
feed your children?
Mama Dlamini
Maize porridge.
Mama Ngumbela
Thank you. And do you ever add anything to it?
Mama Dlamini
Well I do my best, but at this time of the year
there is hardly any food around here.
Mama Ngumbela
Thank you very much indeed. That information
was most useful. I'm very grateful. Oh one final
question. Could you please tell me what job your
husband does?
Mama Dlamini
He is a bus driver
Mama Ngumbela
Excellent Thank you again Mama Dlamini. I'm
leaving now, thank you very much for your
time. Goodbye.
106
im
,ei
Mama Ngumbela
Good morning. Mama Dlamini. My name is Mama
Ngumbela. 1 am from the Ministry of Agriculture,
Home Economics Division. I wonder if you could
help me. I am asking all the mothers in the village
about foods they use for feeding your children.
Might I ask you too?
ip ip in
Mama Ngumbela
Good morning. Mama Dlamini. The government
needs information about how you people feed
your children, so I would like to ask you some
questions.
A "good interview’
P?
A "bad interview'
m
ROLE PLAY CARD FOR KEY INFORMANT INTERVIEW \ 4 4
4
Techniques for Assessment of Nutrition Services and Programmes
Handout 4.5
HOW TO CONDUCT KEY INFORMANT
INTERVIEWS AND OBSERVATIONS
Key informant interviews and observations are techniques for identifying problems and potential
solutions. Interviews may be carried out in the clinics or at the hospital, in the school or in the
community during several visits. Observations and assessment of nutritional status and diet can be
conducted during the same visits. The length of time and number of visits depends on what is being
observed or discussed and on the participants' reaction. If a visit is too short, participants may not have
the time to relax and provide in-depth information. If a visit is too long, or too many visits are made,
participants may become frustrated by the inconvenience.
Prior to initiating an interview, it is important to establish credibility and a level of acceptance with
the person being interviewed. Visit the formal or informal community leader to ask for his or her
permission to carry out research in the community and explain why the information is being collected.
Some programmes may want to hold a community meeting to introduce the interviewers before
fieldwork begins. In other places the interviewers may make brief introductory household visits. It is not
always advisable to identify the interviewers by profession, especially if they are doctors or nurses,
because this can bias people's responses.
Establishing a friendly relationship with participants is generally not difficult if interviewers are
sympathetic and speak the local language. Once rapport is established, the interviewee will not feel he/
she must treat the interviewer like a guest, but will go about his/her usual chores, leaving the interviewer
to complete notes or to help.
The in-depth interviews are usually held in the home or around the hospital, clinic or housing
compound. Specific interview topics, such as food preparation, are discussed in the kitchen area so that
the actual utensils used to prepare and serve the food can be observed. This facilitates conversation and
permits the interviewer to compare reported practices and beliefs with actual behaviours.
Dietary recalls require greater concentration by participants. These are conducted in the most
comfortable environment possible, at a time when participants are not distracted by other tasks.
An interviewer who is in the house repeatedly or for an extended period can introduce discussion
about the neighbours or local problems to divert the conversation but still reveal the participants' views.
Remember, it is fine just to relax. If the mother sits in the shade for a minute to shell peas, sit with her.
Let her begin the conversation.
Similarly it is important to interview health workers in privacy and this may require negotiation
with the health facility management and arrangement of a time when the health worker can be spared
from normal duties. Every effort should be made to conduct the interview in a quiet, private area.
Start the interview with the basic questions listed earlier: name, address, and family composition.
Then guide the conversation by asking different types of questions, probing, and requesting clarifications.
Be careful to keep these questions free of suggestions of correct or desired responses.
Continued ...
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The Nutrition Situation - Training Manual
Handout
4.5
Unlike formal surveys, where responses are brief, in-depth interviews encourage clarification of
what each person says. Ask the respondent to explain the full meaning by repeating or rephrasing a
question. Questioning does not have to stick to the guides. In-depth interviewing involves probing for
information on new themes and issues as they emerge. If people are reluctant to talk because they do
not think they have any information to offer, offer assurance that their views are of great interest and
importance.
Decide whether the in-depth interviews are to be taped. Extensive note-taking helps to get the
most out of the interviews but it is difficult to take extensive notes and listen attentively at the same
time. If the field team lacks prior experience with note-taking, it is worthwhile to tape the in-depth
interviews. In this case, field workers listen to the tapes after an interview and add details to their field
notes as required. Transcribing the tapes is not necessary.
Interviews are summarised immediately so that decisions about modifying guides and exploring
new lines of inquiry are made and acted on.
Structured observation is a method for obtaining information about specific practices (food
distribution at meal time, where the baby is in relation to the mother throughout the day, or food
preparation by the mother, for example). Open observation is when interviewers notice something
casually (the presence of a food or other products in the home, for example). Observations conducted
during the interview capture the context in which behaviours occur and identify new behaviours or new
issues not discussed in the question guide. Observations may confirm or contradict what the respondent
reports during the interview and are an extremely important part of the home interview.
Here are some additional points to remember about how to conduct structured observations and
key informant interviews:
> Make sure you introduce yourself and the members of the team to the person(s) you are
interviewing and/or observing.
> Explain the purpose of your visit and note that it will not interfere with routine or on-going
activities.
> Point out that you want to learn more about their activities with a view to improving the
nutritional status of the district.
> After the interview or observation, quickly check to ensure that you have all the information
you need.
> Thank the person for giving you the time to be with them.
Adapted from Designing by Dialogue - K-Dickin, M. Griffiths, E. Piwoz. Support for Analysis and Research
in Africa 1997.
108
4
Techniques for Assessment of Nutrition Services and Programmes
Handout 4.6
TASK BOX FOR KEY INFORMANT
INTERVIEWS AND OBSERVATIONS
Preparation Tasks
Prepare the protocol and guides.
□
question and observation guides
Revise the research plan.
□
ensure that sample is suitable for question guides
Train the field team.
□
□
□
developing rapport
questioning and probing
recording and forms
□
□
□
unbiased observation
what to look for
structured forms
Test and revise the protocols
and guides.
□
□
to refine and correct and to familiarise trainees
to estimate amount of time needed for each interview
Draft a field plan based on the
research plan and results of
testing the protocol.
□
specify number of respondents per group (age,
respondent category, etc.) in each site
plan now to recruit respondents and divide the
interviews among the field team members
□
Implementation Tasks
Recruit the households.
□
□
select households
obtain informed consent
Conduct household interviews and
observations.
□
□
interview and record findings
observe household, feeding episodes, etc.
Conduct interviews with other
respondents.
□
□
select participants in research plan categories
conduct interviews, but usually not observations
Analysis Tasks
Analyse the interviews and
observations.
□
□
□
□
initial analysis
sort groups, summarise by themes, interpret
compare with interview findings
examine new issues raised
Develop recommendations.
□
list possible recommendations, constraints, motivations
Draft a brief report.
□
summarise findings and priorities for next steps
Adapted from Designing by Dialogue - KDickin, M. Griffiths, E. Piwoz. Support for Analysis and Research
in Africa 1997.
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The Nutrition Situation - Training Manual
Handout 4.7
TASKS FOR ORGANISING AND CONDUCTING
FOCUS GROUP DISCUSSIONS
Preparation Tasks
□
determine questions
□
choose type of participant
□
choose sites
Decide who will conduct the FGDs.
□
identify moderators and note-takers
Develop the question guides.
□
specify the key issues and questions
Train the moderators and note-takers.
□
discuss the roles of the moderator and the
note-taker
□
teach discussion techniques
Design the FGD protocol and develop the plan.
Implementation Tasks
Recruit the participants.
□
choose participants with similar
characteristics
Conduct the FGDs.
□
provide an introduction
□
guide and record the discussion
□
debrief
Analysis Tasks
Do initial analysis in the field.
Sort and summarise the results.
Write a brief summary of the results.
□
transcribe the tapes or prepare notes
□
summarise each FGD
□
identify themes and trends
□
compare and contrast groups
□
highlight how the results reinforce, conflict,
or add to earlier findings
Adapted from Designing by Dialogue - KDickin, M. Griffiths, E. Piwoz. Support for Analysis and Research
in Africa 1997.
110
4
Techniques for Assessment of Nutrition Services and Programmes
Handout 4.8
TYPES OF QUESTIONS IN FOCUS GROUP DISCUSSIONS
Asking why
The focus group discussion is not just another way to do a survey. The
moderator's job is to generate a discussion that will probe deeper into
common child feeding practices and the perceptions and reasons behind them.
For example, "Why do women generally believe they must...?"
Clarifying
an answer
If more information is needed after an explanation has been given by a
participant, ask others for clarification. For example, "Please tell me what Tola
means when she says..."
Substitution
Use the words of one of the participants to help clarify the original issue.
However, take care not to change what is at the heart of the topic.
Polling
This technique will help enliven a discussion or turn the group's attention away
from someone who may be dominating the discussion. Go around the group,
asking each participant to express an opinion. But remember that the objective
is to have a discussion among participants, not an in-depth interview with each
participant. Use this to spark debate on divergent opinions.
Contrasting
During the conversation, different opinions or practices may be mentioned for
the same problem or situation. Try to draw out the differences without making
anyone feel uncomfortable, and ask the group's opinion about these
contrasting views.
Projection
Use pictures or a story to present a particular situation that participants can
discuss without having to use themselves as examples. For example, show
photos of children and ask participants to imagine what these children's lives
are like and what makes them healthy or unhealthy, or ask the group to
complete a story that reflects decision-making on a relevant issue. You could
describe a family situation that participants can identify with, explain a problem
that the family is facing, and then ask the group to make up an ending to the
story that solves the problem.
Concluding
remarks
At the end of the session, ask participants what they think about what was
discussed and whether they have additional comments. Often, when
participants see that the formal session is over, they begin to speak more
frankly than they did during the session.
Adapted from Designing by Dialogue - KDickin, M. Griffiths, E. Piwoz. Support for Analysis and Research
in Africa 1997.
Ill
The Nutrition Situation - Training Manual
Handout 4.9
Date
Activity
Who
When
Where
Data to be Collected
How
PLAN OF ACTION FOR DATA COLLECTION
112
5
TOPIC 5
Working with Communities and Community Participation Techniques
WORKING WITH COMMUNITIES
AND COMMUNITY
PARTICIPATION TECHNIQUES
Objectives
By the end of this topic, participants should be able to:
✓ Describe the different types of, and the qualities required to
facilitate, community participation;
use tools to sensitise and mobilise communities around the
integrated nutrition programme;
»/ plan a community visit.
Time
Topic overview
12 hours
Session 1:
Understanding Community Participation (120 minutes)
Session 2:
Tools for Sensitising and Mobilising Communities
(8 hours)
Session 3:
Planning for Work in the Community (120 minutes)
Materials
flipchart, pens, masking tape, VIPP cards, markers, overhead projector,
transparencies, transparency pens, finger paints
Handouts
H 5.1 The Participatory Continuum
H 5.2 Methods for Sensitising and Mobilising Communities
Advance preparation
Prepare and photocopy all handouts, prepare transparencies. Inform
participants about role play to be prepared (Session 3, Step 1)
PURPOSE OF THE TOPIC
The purpose of this topic is to explore participatory methods useful for sensitising
and mobilising communities on nutritional problems, nutrition services and
programmes
113
The Nutrition Situation - Training Manual
Session 1:
Understanding Community
Participation
Step 1:
120 minutes
Activity: Outcome of Session
a)
Outline the main objectives of this session:
i X- To I is+ The. a.dv'a.io+a.gG.S o-C a. o m m uc i+y
po_r-+ic. ipo_+ion
To <x.r>de.v-s+a_nd +JnS
+ype.s o-G
communi+y pcun+i<s ipo_+ion
X- To ider>+i-fy a_r>d improve slcills r'S.^u.ir'e.d
•Tor- -Tcuc.i!i+a_+ir>2 commu.ni+y pa_r'+ic.ip<x.+ ior>
Step 2:
Activity: Types of Community Participation
a)
In buzz groups, ask
"What are the advantages of community participation
in an integrated nutrition programme (INP)?"
b)
c)
List the advantages on the board.
Explain that whilst there are many advantages of ensuring
community participation it is important to be clear about what we
mean when we say community participation. The next exercise is
about exploring the different meanings and levels of community
participation.
d)
Divide into groups of 5. Distribute to each group flipchart paper,
markers and crayons. Give them the following task:
I.
Discuss your experiences of community participation in nutrition
programmes.
2.
Create a poster which captures your experience and
understanding of good community participation.
(You have 30 minutes)
e)
Share the posters in plenary.
f)
Using Handout 5.1 (p. 125), go through the community
participation continuum and ask each group to say where on the
continuum of participation their picture lies.
114
5
g)
Working with Communities and Community Participation Techniques
Point out that whilst the ideal is to have a community driven process
this is not always possible to achieve. We quite often have to start
near the top of the continuum because years of neglect and poverty
mean that communities quite often need to start with the
partnership and assistance of outsiders such as ourselves. The use of
this table is for us to be aware of what level of participation is
currently occurring in our programmes and how we can move it
down the continuum towards greater community participation.
Step 3:
Activity: Skills Required for Community Work
a)
Explain to participants that this session is about sensitising and
mobilising the community to take responsibility for improving its
nutritional status.
b) Write the following definitions on the board:
SenSi+iScu+ion is +he. proc.e.SS
or
c)
cr£a.+ing
hcuve. ide.r>+i-€ie.d.
In buzz groups, ask participants
List the attitudes and behaviours that are important in order
to sensitise and mobilise communities and why these
attitudes and behaviours are important.
Make sure the following attitudes and behaviours are mentioned:
> be curious
> be humble
> be observant
> facilitate (do not direct)
> have respect
> be prepared but stay flexible, relaxed, and creative
> communicate clearly
> listen to others
115
The Nutrition Situation - Training Manual
d)
Explain to participants that listening is one of the most important
skills required for sensitisation and mobilisation. Tell them that in
order to appreciate the importance of good listening skills we will
practice listening to each other.
Break participants into pairs. Write up the following instructions:
One perSon
be +he listener curd the
other vx/ill be the speo-ker Ask the
Speaker to tculk -for 3 minutes a-boutt
Something Qoo'i thcut hcuppened to them
r-eoently. The listener shoucld remain
Silent, but shovs? thcut he is listening.
Then sv>/itc.h roles cund repecut the
ex.erc.ise.
e)
Bring participants back together and ask them what their partner
said, and to list the different ways that they knew their partner was
listening to them.
f)
Summarise by reminding participants that active listening is more
than just hearing what others say. It involves listening in a way that
communicates respect, interest, and empathy. These three things can
be conveyed through both verbal and non-verbal communication.
Examples of verbal cues are “Mmm, hmmm", "Yes, I see", or
repeating what the person has just said. Examples of non-verbal cues
are not interrupting the speaker, nodding your head and smiling,
leaning forward, maintaining eye contact (if appropriate), and
avoiding distractions.
116
5
Session 2:
Working with Communities and Community Participation Techniques
Tools for Sensitising and Mobilising
Communities
Step 1:
8 hours
Activity: Introduction
a)
Outline the main objectives of this session:
X To ir>+rodix.c.e. Somfi Tools \A>hi<ch ccm
a-SSisT ir> mobilising a_nd SS-nSiTising The.
community
X To pr-a-cTice ucSing These Tools
To idenTi-Cy Types o-F irTormaTion vs/hich
cc_n be gcuThened ucSing These. Tools
Step 2:
Activity: Exploring Some Participatory Tools
a)
Explain to participants that there are several useful tools for
sensitising and mobilising communities. In this session we will learn
about the following tools:
> Community mapping
> Seasonal calendars
> Venn Diagrams
> Three pile sorting
> Matrix scoring
> Story with a gap
> Community Action Plan
Distribute Handout 5.2 (p. 126) on different methods for sensitising
and mobilising communities. Explain that different tools can be used
to collect different types of information. The types of information to
be collected in the community are outlined in the nutrition situation
assessment framework. Before going to the field, the team should
review the framework, determine the information gaps, and then
choose the methods (tools) they will use to collect the needed
information. Explain that time will be set aside later, during this
session, to do this.
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The Nutrition Situation - Training Manual
c)
Divide the participants into 3 groups, and write up these
instructions:
vVi 11 do a. aorrx^cx-C'iT'y ooO-p,
the. second will develop a. se<L5ona.l
aa.ler.da_r,
a_rd +he third will develop a. Venn Dia-gra.™,
The instructions for each group are given below.
(You have I hour to complete this excercise)
Community mapping:
Ask the team to go outside to a location where they can draw on
the ground. Locate appropriate tools such as sticks, rocks, and chalk
to draw the map. Ask the team to draw a map of the nearby location
(training center). One person should be responsible for recording
the map on a piece of paper. If the team is large enough, it should
divide into smaller groups and several maps of the same location
should be prepared. During the plenary, each group can present its
map and discuss how/why they are different.
Seasonal Calendars
Ask the team to draw a straight horizontal line and divide it into 12
parts to represent each month of the year. On one side they should
list all the things that can influence the household food security of a
poor household in their area (e.g. it can include workload, income,
rainfall, food prices, etc). They should then decide how these things
vary during the year. After completing the exercise encourage them
to define different time periods for their calendars (e.g. weeks,
months, seasons) and to use different methods (bar graphs or sticks,
horizontal lines, beans, etc.) to portray the issues being recorded.
Venn Diagram
Ask the group to list all the organisations present in their
community. Then ask them to cut out circles of different sizes. Team
members should write the name of the biggest organisation on the
largest circle, the second largest on the next sized circle, etc.
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Working with Communities and Community Participation Techniques
On a large piece of paper the team should draw a square in the
center to represent the community, and then request the other
participants to place the circles at different distances from the center
of the square to represent the importance of the organisations to the
community. Important organisations should be placed near the
center. Organisations that are inter-related should be overlapping.
The team members who make the drawing should explain it to the
others to make sure that all agree on the placement of organisations
(circles) and understand the exercise.
d)
Ask all teams to present their exercises (maps, calendars, diagrams)
to the entire group in plenary. Discuss the findings, lessons learnt,
and what other information can be collected using these tools.
e)
Remind participants that Venn diagrams show the key institutions
and individuals in a community, and their relationships and
importance. Larger circles represent larger, or more important
components and the smaller circles represent smaller, or less
important organisations. Also the distance between the community
and the circle denotes the nature of the relationship.
Step 3:
Activity: Exploring Some More Participatory Tools
a)
Continue with the participatory exercises by dividing the participants
into 3 groups and giving them the following instructions:
Three Pile Sorting
Ask the team to draw or write the names of different foods, drinks,
and locally prepared recipes on different pieces of paper. Be sure
that they include fruits, vegetables, and at least 10 different drinks
and preparations. Ask the team to separate the papers into three
piles: foods/preparations that are good for a young child, those that
are harmful, and those that are neither healthy nor harmful. Team
members should give the reasons for each categorisation, and
discuss ways that the harmful foods might be made acceptable. At
least one team member should play the role of notetaker to record
the discussion and present it back in plenary (to the community). If
time allows, repeat the exercise for a pregnant woman.
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The Nutrition Situation - Training Manual
Pocket Chart Voting and Matrices
Ask the group to draw on different pieces of card the different
causes of undernutrition that were highlighted from the earlier
exercise on the causes of undernutrition in Topic 2. Make sure that
everybody recognises what the different drawings/symbols represent.
Place an envelope under each picture.
Give the men and women different coloured cards and ask each
person to vote for up to 3 causes that they think are most important
in the community where they work. At the end of the voting,
tabulate the results by card-colour (representing the opinions of
men and women).
Ask the group to write down the three most important causes of
undernutrition that were recognised from the voting exercise. Get
the group to think of three possible solutions to these problems
(causes). Next, ask participants to come up with a list of 3-5 criteria
that they would use to evaluate the pros and cons of these
solutions.
Write the 3 solutions on a vertical axis of a matrix and the criteria
on the horizontal axis. Give each participant 30 seeds/beans and
ask them to score each solution by placing more or fewer beans
under each criterion. Three seeds are placed if the solution scores
highly according to the criterion, 2 seeds if it scores medium and 1
seed if it scores low. Ask one member of each group to tally the
results and prepare to present them to the group.
Story with a Gap
Ask participants to draw a picture (or use an existing one) that
represents a bad feeding or hygiene related practice (e.g. child
defecating in the courtyard, mother handling animals and preparing
food) and one which they thought reflected good practice (e.g. child
defecating in a toilet, mother washing her hands before preparing
food).
Ask participants to fill in the gap by creating a story about the
process that the community might use to solve the problem -
moving from the bad to the good practice. This exercise is designed
to make participants think through the different steps involved in
implementing a community action plan. There are many examples of
before and after scenes. For instance:
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5
Working with Communities and Community Participation Techniques
Before Scenes
bo_by
b)
7
Ask all teams to present their exercises to the entire
group in plenary. Discuss the findings, lessons learnt, and
what other information can be collected using these
tools.
c)
Remind participants that Pocket Chart Voting is a
method which moves away from group consensus to
collating individual opinion. Pockets are envelopes or
containers of some sort which are attached below each
option which has been put forward. Participants are
given voting chips - slips of paper or any item will do -
which they place under the option they prefer. When
everyone has voted, the results are tabulated for all to
see. By giving different groups different colour slips or
types of voting chip one can see if patterns emerge
along certain lines - e.g. giving men and women different
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The Nutrition Situation - Training Manual
colours. The advantage is that people are not subject to group
pressure especially if you place the chart so that people are private
when they vote.
d)
Remind participants that when using Matrices and Ranking they
should keep it simple, if you try to do too much at once on one
matrix the results are not easy to read.
Step 4:
Activity: Learning About the Community Action Plan
a)
Explain to participants that in order for a community to mobilise
itself to act on the information uncovered through these tools, it
needs to have a well-defined strategy and a concrete
implementation plan. This is called a Community Action Plan (CAP).
b)
Mention that the CAP is a summary of the priority problems, the
proposed solutions, the strategies for implementing solutions. The
CAP also includes a monitoring and evaluation plan for the
community to track its own activities. The CAP is created by
community members themselves after they have gone through a
process of identifying priorities, constraints, and possible solutions
(using the tools described above).
Mention that there is no set process for how the community goes
about developing their plan. One approach is for the community to
select or elect a committee that will take responsibility for
developing the plan and monitoring its implementation. If a
committee is selected, it is important to ensure that all segments of
the community are represented on the committee.
c)
Explain to participants that, like other action plans, the CAP includes
the following components:
> name of the project
> who is in charge/responsible
> project objectives
> project outputs
> activities to be undertaken to produce the outputs
> resources required (in the community, external)
> a time line
> a monitoring and evaluation plan (including indicators to be
used to check progress and how often they will be tracked).
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Working with Communities and Community Participation Techniques
5
Session 3:
Planning for Work in the Community
Step 1:
2 hours
Activity: Introduction
Ask participants to divide into groups of 4. Give them the following
a)
task.
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(You have 30 minutes for this activity)
b)
In plenary, ask the groups to share their results.
c)
Ensure that in the discussion the importance of planning ahead,
punctuality and being clear about what the visit is about are
mentioned.
d)
Explain to participants that each will be working in a team. This
team will include:
> a team leader
> a note taker(s)
> team facilitators
Explain the roles and responsibilities for each team member.
e)
Explain that at the end of each visit, different groups should be able
to present and discuss their findings with other members of the
community. Discuss any problems that the teams might anticipate
during the community visit.
f)
Divide the participants into 4 groups. Assign one or two of the
scenarios to each group. Ask them to develop role plays that
address the challenges posed in each scenario:
I.
In a small group interview, the informants are very silent,
unresponsive, and reluctant to answer your questions.
2.
A team member is over-enthusiastic and keeps interrupting the
community members when they are speaking.
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The Nutrition Situation - Training Manual
3.
In the review meeting with the community, the local leader tries
to control the choice of project priorities.
4.
The majority of people in the community identify income
generation as a priority and not nutrition.
5.
The information collected from the women contradicts the
information collected from the men (on any aspect of health,
family dynamics, nutrition).
6.
The information collected during your secondary data review
contradicts what you learn from community members.
7.
You have asked a group of men in the community to create a
community map but they don't know where to start.
8.
One team member is taking a patronising attitude towards
women in the community and tends to lecture rather than listen.
Allow each team 5 minutes for each role play. At the end of each,
discuss the following questions:
> what was the role play about?
> what was learnt from it?
g)
Ask participants to work in groups of 6 to develop a plan for
approaching the community and for setting up an initial community
meeting. Each group should develop a matrix that states the list of
tasks, who will be responsible and when it will be completed.
124
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IX-
THE PARTICIPATORY CONTINUUM
Involvement of Local People
Relationship of Research/Action to Local People
Cooption
token, representatives are chosen but no real input or power
ON local people
Compliance
tasks are assigned with incentives; outsiders decide the
agenda and direct the process.
FOR local people
Consultation
locals opinions are asked; outsiders analyzesand decide on
a course of action
FOR/WITH local people
Cooperation
local people work together with outsiders to determine local
priorities; responsibility remains with outsiders for directing
the process
WITH local people
Co-learning
local people and outsiders share their knowledge to create
new understanding and work together to form action plans,
with outsider facilitation
WITH/BY local people
Collective action
local people set their own agenda and mobilize to carry it out
in the absence of outsider initiators and facilitators
BY local people
Source:
Adapted from Pretty (1995) in Cornwall (1996). Towards Participatory Practice: Participatory Rural Appraisal and the
Participatory Process In Korrie de Konig and Mation Martin (Eds). Participatory Research in Health: Issues and
Experiences. London: Zed Books.
125
Appearing in de Negri B, Thomas E, Ilinigumugabo A, Muvandi I. Empowering Communities: Participatory Techniques
for Community-Based Programme Development. Volume I: Trainer's Manual, June, 1998.
Working with Communities and Community Participation Techniques
Mode of Participation
The Nutrition Situation - Training Manual
Handout 5.2
METHODS FOR SENSITISING AND MOBILISING COMMUNITIES
Description
Potential Uses in Nutrition
Situation Assessment
Community mapping Community members draw a map of
the their community, including
geographic features, other resources
ice breaker
identify community resources
defining the community
boundaries, fields, gardens
Method
Seasonal Calendars
Identifies activities, problems, and
opportunities taking place throughout
the year; shows how things change
throughout the year
household food security
food prices
work patterns
water availability
disease patterns
Venn Diagrams
A social (organisational) data gathering
tool that shows how institutions in the
community are linked using circles
and a map
identifying potential
organisations and structures
that can be involved in
solutions to priority problems
Three Pile Sorting
Pictures are sorted into categories such
as good (beneficial), neutral, and bad
(harmful) practices; facilitated discussion
of reasons why, and how to move from
harmful to positive categories/practices
categorising foods
categorising practices
identifying ways to move from
bad to neutral to positive
practices or situations
identifying locally feasible
solutions to problems
Pocket voting
simple method for collecting opinions
on problems, causes, solutions
causes of malnutrition, poverty,
health problems
priorities in the community
Matrix Scoring
method for ranking alternatives
according to community-determined
criteria; useful in process of building
consensus to move forward
prioritising actions and
solutions
Story with a Gap
before and after scenes are giving
and community members are asked
how to move from the before to the
after; a preplanning tool
hygiene conditions/behaviours
sanitation conditions/behaviours
feeding behaviors
Community Action
Plan
a plan developed with/by community
members
defines the way forward
126
6
TOPIC 6
Basic Data Analysis and Interpretation
BASIC DATA ANALYSIS AND
INTERPRETATION
Objectives
By the end of this topic, participants should be able to:
>/ describe their field work experiences;
✓ explain how to prepare data for data analysis;
✓ analyse quantitative and qualitative data;
✓ interpret qualitative and quantitative data;
*4 write a report.
Time
Topic overview
7 hours
Session 1:
Reporting Back from Field Work Experiences (90 minutes)
Session 2:
Preparing Data for Data Analysis (60 minutes)
Session 3:
Analysing Qualitative and Quantitative Data (60 minutes)
Session 4:
Interpretation of the Results (30 minutes)
Session 5:
Writing of a Research Report (3 hours).
Materials
cards, flipchart, masking tape, pens, markers, transparencies, overhead
projector, transparency pens
Handouts
H 6.1 Analysiing Qualitative Data
H 6.2 Summary of Qualitative Data
H 6.3 Matrix Responses on Knowledge, Attitudes, Beliefs,
and Practices on Breastfeeding
H 6.4 Example of a Master Sheet
H 6.5 Example of Tallies, Ranges, Percentages, Proportions, Ratios,
Rates, Frequencies, and Central Tendency.
H 6.6 General points on Writing a Report
Transparencies
T 6.1 Rules of Report Writing
T 6.2 Main Components of a Research Report
Advance preparation
Photocopy handouts and prepare overhead transparencies. Assign
participants specific data collection techniques the night before so they
can prepare for the information market. Plan and organise a role play
involving a focus group discussion on a topic of participants' choice to
be performed during one evening.
PURPOSE OF THE TOPIC
The purpose of this topic is to introduce participants to basic data analysis skills to
enable them to complete a nutrition situation assessment.
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6
Session 2:
Basic Data Analysis and Interpretation
Preparing Data for Data Analysis
Step 1:
60 minutes
Activity: Differences between Quantitative and
Qualitative Data
a)
Start this session by explaining what the difference is between
qualitative and quantitative data:
Quantitative research is mostly interested in measurement and
quantification of data. The data is in the forms of numbers.
Qualitative research differs in that it is usually more interested in the
experiences of people and their actions in the context of the lives
they lead. The data is in the forms of words and stories.
b)
Point out that qualitative data is usually obtained through :
Open-ended questions
Loosely structured interviews
Focus group discussions
Observations
c)
Explain that for both qualitative and quantitative data the data first
needs to be sorted into categories, then summarised and then
interpreted. The next few activities will take the participants through
a process of ordering, summarising and interpreting both
quantitative and qualitative data.
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The Nutrition Situation - Training Manual
Session 3:
Analysing Qualitative and
Quantitative Data
Step 1:
60 minutes
Activity: Analysing Qualitative Data
Explain that qualitative data is recorded in narrative form and is
a)
often used to describe:
> certain procedures in greater depth;
> beliefs and knowledge related to health issues among the
population.
This data is also well suited to exploring the reasons for certain
b)
behaviour or the opinions of respondents on certain sensitive issues.
Remind participants that the first step in analysing data is the review
c)
of objectives for data collection. For qualitative data this is followed
by classifying data based on the objectives of the study.
Distribute Handout 6.1 (p. 134). (Example of data collected from
mothers, fathers, and grandmothers on breastfeeding practices,
beliefs, behaviour and knowledge.) Explain to the participants that in
this handout, data has been classified according to the objectives of
the assessment i.e. to identify knowledge, attitudes, beliefs, and
practices of different respondents on breastfeeding.
Distribute Handout 6.2 (p. 135). Go through the steps involved in
summarizing the data. Explain that the responses of different groups
are then summarized and displayed on a matrix sheet.
Draw the matrix on Handout 6.3 (p. 136) with only the top
heading written in and ask the participants, in buzz groups, to
complete the matrix. They have 15 minutes.
Distribute Handout 6.3 (p. 136) and go through the matrix.
Step 2:
Activity: Analysis of Quantitative Data
a)
Explain to participants that when analysing quantitative data the first
step is to order the data according to the objectives of the
assesment. Examples of objectives are to:
> describe variables, for example the distribution of malnourished
children in a certain population;
130
6
Basic Data Analysis and Interpretation
> look at the differences between groups, for example differences
between mothers who breastfeed and those who do not;
> determine associations between variables, for example mother's
level of education and length of breastfeeding.
b)
Explain that these categories are then put on a master sheet.
Distribute Handout 6.4 Example of a Master Sheet (p. 137). Go
through the handout with the participants.
c)
Break the group into groups of 5 and ask participants to display
their data on a master sheet.
(Allow 30 minutes for this activity)
Allow each group to give feedback.
Step 3:
Activity: Summarising Quantitative Data
a)
Remind participants that after ordering the data the next step is to
summarise the data.
b)
Explain to the participants it is easy to count from the master sheet
the numbers of different answers obtained.
c)
Point out that there are several numerical measures that can be used
to analyse data. These include;
tallies,
percentages,
ratios,
frequencies,
ranges, and
measures of central tendency (including the mean, median, and
the mode).
d)
Break participants into groups of 4.
e)
Distribute Handout 6.5 (p. 138). Using responses on Handout 6.4
ask the group to compile the following:
Tallies
Percentages
Frequencies
Measures of central tendency
f)
Share their results in plenary and ensure that everybody is clear
about the different terms.
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The Nutrition Situation - Training Manual
Session 4:
Interpretation of the Results
Step 1:
30 minutes
Activity: Interpreting Results
a)
Point out that once the data is presented it has to be interpreted
and used to draw conclusions. Explain that interpretation of data
depends on the objectives of the project. Normally, the following
are important:
> the level/status of the indicator of interest, e.g. what is the
nutritional status at the time of the data collection? what is the
level of exclusive breastfeeding? etc.
> seek to find the change in that status over time, e.g. has the level
(%) of exclusive breastfeeding changed between the base-line/
previous data and the period of recent data?
> is the size of change (the difference between the base-line/
previous and the recent data) what was expected?
> if the changes are not what you expected or had planned, find
the reasons.
Look at the results from the data on Handout 6.3 (p. 136) and
write down possible interpretations of the results.
Example of interpretation could be:
> Out of the children interviewed the youngest was 2 months old,
the eldest was 14 months
> 40% of the children interviewed were males
> 40% of children were breastfed
> 30% of the children had solids introduced immediately after
birth
132
6
Session 5:
Basic Data Analysis and Interpretation
Writing of a Research Report
3 hours
Activity: Thinking About the Reader of the Report
Step 1:
a)
Explain to the participants that one important aspect of research is
disseminating the results, and that results can be disseminated
through a written report. Explain that before a report is written it is
important to know the following:
> Who will read it?
> Why does she or he want to read the research report?
b)
Ask participants to brainstorm in buzz groups what questions should
be answered by a written research report? The following points
should be raised:
> Why did you start doing the research?
> What did you do?
> What did you find out?
> What does it mean?
c)
Explain that the participants should bear in mind that the reader:
> Is short of time
> Has many other things to attend to
> Is probably less familiar with the research topic than the writer.
d)
A
Step 2:
Put up Transparency 6.1 Rules of Report Writing (p. I46) and go
through the rules with the participants.
Activity: A Closer Look at the Different Components of
a Report
a)
Ask participants to think about what the components of a research
report should be.
b) Write their responses on a flip chart. Put up Transparency 6.2 (p. 147),
and go through the components of a research report.
c)
Break the participants into their data collection groups and ask them to
analyse, interpret and write a short report on the data they have
collected during their field work. (Use Handout 6.6 (p. 143) as a guide)
(Allow participants 120 minutes for the activity)
d)
Share some of their presentations in plenary.
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The Nutrition Situation - Training Manual
Handout 6.1
ANALYSING QUALITATIVE DATA
Responses from mothers on knowledge, attitudes, beliefs, and practices on breastfeeding
>
In our village every new born is breastfed.
>
When mothers go to work, they leave their babies with other relatives, who then feed them with a
thin cereal-based gruel.
>
Working mothers have to go back to work as soon as they are feeling better, because they do not
get paid for maternity leave.
>
The age of introduction of new foods varies, it ranges from birth to about seven months, because
there are different reasons why babies are given other food besides breast-milk.
Responses from fathers on knowledge, attitudes, beliefs and practices on breastfeeding
>
Traditionally children are given breast-milk immediately after birth.
>
Due to several reasons some children have to be bottle-fed.
>
The most common reason for bottle-feeding is that girls have children while they are still young,
and they have to leave the babies with their parents to go back to school.
>
We do not think it would be appropriate for another mother from the community to breastfeed
other parents' babies, it is just not done, and it is against our culture.
>
We can afford to buy infant-formula, so we do not understand why children should not be bottle
fed.
Responses from grandmothers on knowledge, attitudes, beliefs and practices on
breastfeeding
>
We would like to see all infants being breast-fed, but the modern way of doing things does not
allow this.
>
We do look after the babies, and feed them when their mothers are not around.
>
The mothers sometimes have their own engagements to attend to, so they have to leave the babies
under our care. Their engagements include:
- leaving to seek work in the cities
- returning to school
- visiting their own parents
- visiting their husbands at work, in the cities
134
6
Basic Data Analysis and Interpretation
Handout 6.2
SUMMARY OF QUALITATIVE DATA
With qualitative information it is not possible to perform complex statistical analysis, because the
data is descriptive (words not numbers).
However statistical frequencies can be used to itemize some of the characteristics of the groups
studied, and the beliefs, knowledge, attitudes and behaviours. Tabulations can also be used; an example
is given below on examining behaviour and knowledge on breastfeeding by different groups within the
community.
Handout 6.3 gives the information collected from fathers, mothers and grandmothers on
knowledge, attitudes, perceptions and behavior on breastfeeding.
The information in Handout 6.3 can be categorized and summarised in a table as follows;
Steps
1. Classify the three groups.
2. Categorize their responses as follows:
3.
-
age of introduction of fluids (other than breastmilk)
-
reason for not breastfeeding
Analyse for behaviour on breastfeeding by categorizing the responses.
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The Nutrition Situation - Training Manual
Handout 6.3
SUMMARY MATRIX ON RESPONSES ON KNOWLEDGE,
ATTITUDES, BELIEFS AND PRACTICES ON BREAST-FEEDING
Caregivers interviewed
Age of introduction of fluids
(other than breastmilk).
Reasons for not breastfeeding
Mothers (6)
As soon as the mother feels ready
to work.
Mothers either to go back to school
or to seek employment.
Fathers (4)
Immediately after birth.
We can afford to buy infant-formula,
so we do not understand why
children should not be bottle-fed.
Grandmothers (30)
Soon after birth.
- mother leaving to seek work in
the cities
- returning to school
- visiting their own parents
- visiting their husbands at work,
in the cities
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The Nutrition Situation - Training Manual
Handout 6.3
SUMMARY MATRIX ON RESPONSES ON KNOWLEDGE,
ATTITUDES, BELIEFS AND PRACTICES ON BREAST-FEEDING
Caregivers interviewed
Age of introduction of fluids
(other than breastmilk).
Reasons for not breastfeeding
Mothers (6)
As soon as the mother feels ready
to work.
Mothers either to go back to school
or to seek employment.
Fathers (4)
Immediately after birth.
We can afford to buy infant-formula,
so we do not understand why
children should not be bottle-fed.
Grandmothers (30)
Soon after birth.
- mother leaving to seek work in
the cities
- returning to school
- visiting their own parents
- visiting their husbands at work,
in the cities
136
Basic Data Analysis and Interpretation
6
Handout 6.4
EXAMPLE OF A MASTER SHEET
Respondent
number
QI:
Age in months
Q2: Sex
M
F
Q3: Breastfed
Yes
No
Don't
know
Age in months
when solid
introduced
1
7
2
3
X
3
6
X
X
4
4
3
X
X
4
5
10
X
6
2
7
4
8
3
9
7
10
9
11
4
X
12
3
X
13
1
14
9
15
14
16
6
17
8
18
7
19
12
20
3
Total
3
X
X
X
X
X
X
X
0
X
0
X
0
X
X
X
0
X
6
X
0
X
X
X
0
X
X
4
X
X
X
X
X
X
X
X
X
6
X
3
X
4
X
X
8
6
6
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The Nutrition Situation - Training Manual
Handout 6.5
EXAMPLES OF TALLIES, RANGES, PERCENTAGES,
RATIOS, RATES, FREQUENCIES, TABLES,
AND CENTRAL TENDENCY
Example of tallies:
Question:
Did the mother breastfeed her youngest child?
Responses:
Yes
No
Don't know
Tally:
Responses to breastfeeding practices by caregivers (Handout 6.1)
Breastfeed
HTf
(8)
Don't know
No
Yes
111
+rrT
i
(6)
HlT
Total
1
(20)
(6)
Percentages - %:
A percentage means part of something in relation to its total, which is normally taken to be 100.
Calculating a percentage
Divide the number of people or things in a group by the total number in that group and multiply by
100. An example is given below.
Percent of mothers who breastfed
Total number of responses from caregivers
=
20
Total number of mothers who breastfed their children
=
8
Therefore percentage of mothers who are breastfeeding their children
=
138
8/20 x 100 = 40 percent
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Basic Data Analysis and Interpretation
Ratio:
A ratio is a numerical expression which indicates the relationship in quantity, amount
or size between two or more parts. Ask the participants to look at Handout 6.1, and
determine the ratio of males to females.
The answer is 8 males to 12 females
Ratio = 2:3
Frequencies:
Preparing frequencies
Frequency tables are usually arranged from a large quantity of numbers.
The frequency tables can be arranged by undertaking the following steps:
1.
Organise your numbers into groups (include the whole range of numbers
from the smallest to the largest).
Example
The age of children (in months) included in the survey
Age in months
Frequency
Percent
0-4
9
45
5-9
8
40
10-14
3
15
Total
20
100
2.
All the groups should be of the same width (the groups should be equally
wide, to allow for comparison).
3.
Avoid overlaps (each number should belong to one group).
4.
Record numbers using selected groups (record and count the number of
children in each group).
5.
Add and check the results obtained (the total number should be similar to
the number of observations or interviews done).
6.
Display the results in a frequency table or distribution, with a title
describing the contents.
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Tables:
Preparing tables
Both words and numbers can be presented in tables. For example, number of clients
who attended maternal and child health services in the five years can be presented as
follows:
TABLE 1: Clients using maternal and child health services during 1993-1997 at clinic.
SERVICES
1993
1994
1995
1996
1997
TOTAL
Growth monitoring
120
156
200
198
220
894
Immunizations
320
450
580
600
720
2670
Antenatal care
140
330
320
500
536
1826
TOTAL
590
936
1100
1298
1476
5390
Points to remember when presenting tables
1.
Each table should have a full title, that explains the contents (who; what; when; where). Use capital
letters for the word TABLE, then give it a number.
2.
Give clear, full labeling. Use capital letters for headings, in boxes and at the beginning of important
words.
3.
Titles and labels should be outside the frame or box which surrounds the information.
4.
Provide a key to explain symbols.
5.
List the information source, such as where, when, how, and by whom the information was obtained,
so that reference can be made in case further information is required.
6.
Provide footnotes where necessary, for additional comments.
7.
Accompanying text must describe and discuss the key results.
8.
Using asterisks can help to highlight important results.
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Basic Data Analysis and Interpretation
Measures of Central Tendency:
Explain to the participants that the measures of central tendency include the mean,
median, and the mode. Explain that the mean is widely used, and that it contains
more information because the value of each observation is considered in its
calculation.
The mean, median and mode are the measures of central tendency, used for analysing quantitative data.
Mean
The mean is usually referred to as an average. It is the sum of a group measurements divided by the total
number of these measurements. It is usually near the middle of all the measurements or numbers being
studied, and can be calculated as follows:
Example of calculating the mean
For ten children attending a growth monitoring clinic in one session, their ages in months were, 5,7, 5, 3,
6,8, 6, 4, 4, 2. The mean age of these children is:
Number of children
=
10
Sum of their ages
=
50
Therefore, the mean age is
=
50 = 5 months
10
Median
The median is the value that divides a distribution into two equal halves. The median is useful when
some measurements are much bigger or much smaller than the rest.
To obtain a median do the following:
List all the observations (from the lowest to the biggest)
Count the number of observations (n)
-
a)
The median value is the value belonging to observation number (n+1 )/2 for an
uneven number of observations and (n/2) for an even number of observations
For example the median for the following numbers
5, 7, 5, 3, 6, 8, 6,
Re-order the numbers
3, 5, 5, 6, 6, 7, 8
The median value belonging to observation number
(7 + 1)/ 2 = the fourth one, which is 6
b)
For example:
5, 7, 5, 3, 6, 8, 6, 4
Re-order the numbers
3, 4, 5, 5, 6, 6, 7, 8
The median value belonging to observation number
(8/2) = the average between observation 4 and 5
The median is 5/2
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The Nutrition Situation - Training Manual
Mode:
The mode is the most frequently occurring value in a set of observations
For exampie
If the ages of mothers attending antenatal care are:
21, 32, 20, 21, 34, 23, 21, 19, 23, 22, 21
The mode is 21
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Basic Data Analysis and Interpretation
Handout 6.6
General Points on Writing a Report
There are some general points which you will find useful whatever the type of report
you are writing and whatever the audience. These are listed below.
/\
Z H
X. 6.6 /
Keep it Short
Very long reports tend to be used less than short ones. Who has time to read a long report?
i
Keep it Clear
The report is supposed to be read and understood. Avoid very technical words and jargon. Use simple,
clear and precise words wherever possible.
Use Short Sentences
Try to use not more than 20 words (and if possible less then 16) in each sentence. Use positive
sentences. Do not put a lot of ideas in one sentence.
Plan Spacing and Layout
For a clearer layout, break up the text into short paragraphs to help the reader. Present only one idea in
each paragraph.
Use Subheadings
These help people to remember what they read and make the report more interesting.
Emphasise Key Points
Use larger letters, underline changes in type style, and use stars (asterisks), dots, boxes, etc; to emphasise
key points in the report.
Use a Running Commentary
In a wide margin besides the main text of the report present the key points from the text in the form of a
running commentary.
Use Listing and Checklists
Information can be presented more concisely and absorbed more easily if it is presented in a list form. It
also saves space, and the reader's time.
Avoid Long Footnotes
Present additional information or references very briefly. Try not to use footnotes.
Edit Your Report Carefully
If possible leave a day between completion of the report and its final editing. This will be very helpful as
it will allow you to take a fresh look at it.
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The Nutrition Situation - Training Manual
What the Report Needs to Contain
Front cover
Title, name and location of programme.
Names of those who carried out the evaluation.
Names of those with whom programme is linked, such as ministries, agencies, etc.
Period covered by the report.
Date report completed.
Summary
A brief one- or two-page overview of the report is useful for busy readers and those who wish to study it
in more detail.
Explain the purpose of the evaluation; for whom it was carried out; how; where; when; major results:
conclusions; and recommendations.
Write the summary list last.
A question-and-answer style, or a specially designed diagram or table of the information, may be useful.
List of contents
A list of contents in clear, logical order will help the readers to find sections of special interest to them.
Background information
This puts the programme into perspective and shows its origin, objectives and evolution.
Explain briefly when, why, and how a programme began, who was involved by type/age/group/training/
number, etc.
Which were the priority objectives?
Which were the main activities and resources involved?
The length of this section will depend on the objectives of the report and the space available.
Programme proposals, plans, reports, minutes of meetings, memos, etc can be used to provide
information.
Ensure this section does not overlap with other sections (for example, manpower and resources).
Different opinions may have to be ironed out or presented as they are.
Purpose of data collection methods chosen
Explain the purpose of the data collection and state the intended audiences.
Be clear about what it is not intended to do.
Explain briefly the reasons for the particular evaluation plan and the methods used to obtain the
information.
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Basic Data Analysis and Interpretation
Include samples of methods used where necessary (for instance, questionnaires and
an appendix).
Mention problems of manpower, finance, physical resources and political context
(where appropriate). This can be drafted at the planning stage.
Outcome of using the methods
Where and how were the evaluation methods developed and tested before use?
How was the information collected and by whom, and which methods were used?
How reliable and valid did they prove to be?
Include any timetable or evaluation schedule in an appendix.
Also mention unintended results, if appropriate.
Results of data collection and analysis
After the analysis of the facts, figures and information collected, tables, graphs, test results, etc. can be
prepared and included.
You may also want to include typed examples from tape recordings, illustrations or photographs. These
can often convey a particular point which cannot be expressed in any other form, for example
numerically.
Briefly describe the methods you used to analyse the information, either with the results or at the
beginning of the section.
Conclusions
These may include the following:
W if
if if if if if
To what extent have the programme objectives been achieved?
Which aspects of the programme (such as planning, management, monitoring training, field activities,
etc) are strong, and which need to be strengthened?
Have human and material programme resources been used efficiently?
How has the programme changed with time?
What are the financial costs and benefits?
What predictions can be made for the short/long term future of the programme?
Most important of ail, what effect or impact is the programme having?
Recommendations
On the basis of your conclusions what course(s) of action are proposed?
U
How are these to be implemented, by whom and when? List your recommendations.
This may be the part of the report which some people read first. It may be the only part which they read.
Identify the priority recommendations.
&
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The Nutrition Situation - Training Manual
Transparency
6.1
Rules of Report Writing
> Simple.
Keep it short
> Justify.
Make no statement that is not based on facts
>
Avoid “Large”, “Small”,
Quantify.
instead, say
“almost 75%”,
“one in three”, etc.
>
Be precise and specific
>
Inform, not impress. Avoid exaggeration
>
Use short sentences
> Aim to be clear, logical, and systematic in your
presentation
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6
Transparency
Basic Data Analysis and Interpretation
6.2
Main Components of a Research Report
Title or cover page
Executive summary
> Acknowledgements (optional)
> Table of contents
> List of tables, figures (optional)
1. Introduction
2.
3.
4.
5.
Objectives
Methods
Findings
Discussion and Conclusion
6.
7.
8.
Recommendations
References
Annexes
(e.g. data collection tools, such as
questionnaires; additional tables)
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