PARTICIPATORY CAPACITY AND NEEDS ASSESSMENT FOR KEY LOCAL ... · PDF filePARTICIPATORY CAPACITY AND NEEDS ASSESSMENT FOR KEY ... Main topics proposed to be covered by ... The study

Ministry of Health

Draft Report

Prepared by

PARTICIPATORY CAPACITY AND NEEDS

ASSESSMENT FOR KEY LOCAL PARTNERS

AND TARGETED COMMUNITIES (To Design, Implement and Monitor Nutrition and Food Security

Interventions; To Define Community Based Interventions)

January 2012

Participatory Capacity and Needs Assessment

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ACRONYMS

ADHS Albania Demographic and Health Survey

CSO Civil Society Organization

FAO Food and Agriculture Organization

FNS Food and nutrition security

IDA Iron Deficiency Anemia

IDD Iodine Deficiency Disorders

INSTAT Albanian National Institute of Statistics

JPN Joint Programme on Nutrition

LGU Local Government Unit

MADA Mountain Area Development Agency

MDGF Millennium Development Goals Achievement Fund

NGO Non-governmental Organization

PfD Foundation Partnership for development

PLA Participatory Learning and Action

PPS Participatory Priority Setting

PRA Participatory Rural Appraisal

RPA Rapid Participatory Appraisal

RRA Rapid Rural Appraisal

UNICEF United Nations Children's Fund

WHO World Health Organization


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TABLE OF CONTENTS ACRONYMS 2

TABLE OF CONTENTS 3

LIST OF FIGURES AND TABLES 4

EXECUTIVE SUMMARY 5

1. INTRODUCTION 8

1.1. Brief background 8

1.2. Definition and concepts of food and nutrition security 9

1.3. Purpose of the study 12

1.4. Methodology and approach of the study 12

1.4.1. Overview of the approach 12

1.4.2. A step-wise implementation approach 13

2. MAIN FINDINGS OF THE STUDY 17

2.1. Overview of the study area 17

2.2. Awareness and knowledge on food and nutrition security concepts 19

2.2.1. Level of knowledge of FNS concepts at local authority level 19

2.2.2. Level of community knowledge on nutrition concepts 23

2.3. Main factors of malnutrition and food insecurity 26

2.4. Local government capacities in dealing with FNS and coordination issues 30

2.5. Opportunities to increase food availability 33

2.5.1. Perceptions of local authorities on food availability opportunities 33

2.5.2. Perceptions of communities on food availability opportunities 34

2.6. Community opinions on food security and nutrition interventions 37

2.7. Improving local capacities 39

3. CONCLUSIONS AND RECOMMENDATIONS 41

4. ANNEXES 43

Annex 1. Details of proposed interventions 43

Annex 2. Aditional tables 48


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LIST OF FIGURES AND TABLES

Figure 1. Conceptual framework of malnutrition (UNICEF, 1991) .................................................................. 10 Figure 2. Conceptual framework of the nutritional status at household and individual level ............... 11 Figure 3. Determinants of Food and Nutrition Security ..................................................................................... 11

Figure 4. Aggregated scoring of key actors’ knowledge and understanding of key actors on malnutrition ....................................................................................................................................................... 19

Figure 5. Level of overall community awareness on nutrition issues ............................................................ 23 Figure 6. Main causes of malnutrition as perceived by the local authority representatives ................. 27 Figure 7. Main causes of malnutrition according to three main groups factors, as perceives by local

authorities .......................................................................................................................................................... 28

Figure 8. Main causes of malnutrition and food insecurity as perceives by community representatives according to the four main food security components ..................................... 30

Figure 9. Weighted level of LG capacities to deal with FNS issues at their territory ............................... 31

Figure 10. Importance of main groups of opportunities to increase food production ............................. 34

Figure 11. Main mission/limited food components in the usual diet ............................................................ 35 Figure 12. Possibilities for more fruits, vegetables, forest fruits and hers (by regions) ........................ 36 Figure 13. Opportunities to increase food production ......................................................................................... 36

Figure 14. Possibilities for more fruits, vegetables, forest fruits and herbs ................................................ 36

Figure 15. Main categories of interventions to improve food security proposed by communities (by region) ................................................................................................................................................................ 38

Figure 16. Main categories of interventions to improve food security proposed by community ...... 38 Figure 17. Main categories of interventions proposal by civil society members ........................................ 38

Figure 18. What should change to improve the local nutrition situation? .................................................... 39

Figure 19. Most effective interventions proposed to improve capacities and nutrition situation ........ 39 Figure 20. Potential categories off actors to be involved in public information about nutrition .......... 40

Table 1. Number and distribution of focus groups held with key stakeholders ............................ 15

Table 2. Main characteristics of the targeted study area ......................................................... 17

Table 3. The level of local authorities’ knowledge about concepts and components of food security

and malnutrition .................................................................................................. 20

Table 4. Main topics proposed to be covered by potential capacity building interventions at local

authority level for improving knowledge on food security and nutrition concepts .......... 22

Table 5. The level of community knowledge about concept and types of malnutrition ................. 24

Table 6. Main topics proposed for interpersonal communication interventions at community level

for improving knowledge on nutrition concepts ........................................................ 25

Table 7. Main factors impacting food security and nutrition in the study area ............................ 26

Table 8. The assessment of the current experience and capacities of LG (according to main

identified capacity issues) ..................................................................................... 32


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EXECUTIVE SUMMARY

The nutritional status of children has improved over the last 5 years. However, children face

multiple nutrition problems including high rates of stunting and overweight, disparities in

health and nutrition status and micronutrient deficiencies. Anemia (as one of the major

effects malnutrition, especially in young children) is considerable higher in rural areas than

in urban areas, for children of women with no education and for lowest wealth quintile.

Designing and implementation of cross sectorial interventions addressing malnutrition and

household food insecurity is an important component of the current nutrition programme.

The involvement of the community and key local stakeholders will help ensure endorsement

and validation of planned interventions, effectively mobilize the community and contribute

to sustainability of interventions. In this context, UNICEF, WHO, FAO, in cooperation with

Albanian Government are implementing a Joint Programme on Nutrition aiming to help

improve the nutrition situation in Albania.

The main purposes of this study was to: (i) identify needs/existing gaps of community based

partners and CSOs working with communities in the target areas to design, implement and

monitor nutrition and food security interventions; (ii) conduct a participatory needs

assessment at community level to define community based interventions in target areas;

and (iii) synthetize the results of both assessments in the form of a final report including the

recommendations for trainings and the proposed package of community based

interventions.

The study area included 15 local government units (LGUs) in three regions (7 in Kukes, 6 in

Shkoder and 2 in Tirana). The targeted areas cover a total area of 1.430 Km2 and have about

37.600 hectares of arable land. The 15 targeted LGUs have a population of about 153

thousand inhabitants and about 35,200 households. The approach selected for the

implementation of this assignment is based mainly on the Participatory Learning and Action

(PLA) approach, involving in itself a wide range of tools. The selection of the target area was

done by the JPN and included 15 local government units in three regions (7 in Kukes, 6 in

Shkodra and 2 in Tirana). In addition to a large number of individual meetings held with

representatives of various institutions, organizations and individual experts, 63 focus groups

consisting of about 10-15 members each (or about 760 persons attending these focus

groups) were held with the key regional and local stakeholders.

The assessment has been implemented during the period of October-December 2011 and

main findings of the assessment are as follows:


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• The overall level of awareness, knowledge and information of key regional and local

actors about nutrition issues (nutrition in general and especially related to children and

women) remain generally low, both at the regional and local level. The highest level of

awareness and knowledge on the subject was shows within the health sector specialists,

most of which could make a dissent description of nutrition and its causes and effects on

the population.

• The main identified causes of food insecurity and malnutrition are linked with: (i) the

overall level of local community development (mainly related to overall poverty level,

low local production capacities, limited market access and organization, limited non-

agriculture income generating activities, low incomes and purchasing power,

vulnerability to price fluctuations; traditional practices and lifestyle; (ii) the level of

community education and information, mainly related to improved production and

processing technologies and practices; limited market information, limited knowledge on

risk mitigation practices, limited knowledge on good nutrition practices; and (iii)

objective reasons mainly linked to overall economic context of the country and the

region, unfavour agro-ecological conditions for food production, limited job

opportunities, low efficiency of local support institutions, etc.

• Within the local authority actors, the health sector seems to be more involved and more

efficient in dealing with nutrition issues at community level. The agriculture sector

provides some support towards food security mainly through their advice to producers.

However, despite their potently important role, most communities perceive the

agriculture, social and education sectors as having low efficiency in improving nutrition

situation at local level. The current role of the local government administration in

dealing with the nutrition and food security issues remains very limited throughout the

study area. Only few of the local government representatives declared to have some

capacities and little previous experience in monitoring and reporting, while major

capacity gaps, mainly as regards assessment of food security and nutrition situation,

planning interventions and coordination of actors and actions.

• The majority of the targeted areas have significant opportunities to increase the

production and availability of food products within their territory, which are still unused

and/or unexploited due to the lack of capacities of the local actors and of the population

to transform them into goods for the betterment of the living conditions.

• The exploitation of these existing opportunities for improving food and nutrition security

may be reached through well targeted interventions focusing mainly on: (i) improving

post harvesting, handling and processing tools, technologies and practices; (ii)

introducing new types of productions and food products, and; (iii) increasing the

quantity of production of the current crops and livestock. In addition, these

interventions should be accompanied by information, trainings, advice and technical

assistance to the producers (on food security strategies and practices) and consumers

(on nutrition issues).


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• Improving the capacities of the local actors (especially local government) to plan,

monitor, report and implement food and nutrition security interventions, improvement

of coordination of actions between these actors and the improvement of community

information and knowledge are three very important challenges for the improvement of

the nutrition situation in all targeted areas.


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1. INTRODUCTION

1.1. Brief background 1

Children in Albania face many challenges that affect their chances for a better start in life

and reduce their potential to lead productive lives as adults. In spite of relatively low U5

mortality rates (22 per 1,000 - still high compared to other countries in the region) and good

exclusive breastfeeding rates in the first months of life, Albanian children face multiple

nutrition problems including high rates of stunting and overweight, disparities in health and

nutrition status and micronutrient deficiencies (IDD and IDA). According to ADHS 2008-209,

about 39% of children 0-6 months are exclusively breastfeed. While more than half of

children 6-8 months (about 55%) received complementary food in addition to breast milk.

Overall, about 25% of breastfeed children 6-23 months are feed will all recommended IYCF

practices compared to about 11% of non-breastfed children.

The nutritional status of children has improved over the last 5 years. However, about 19% of

children under age five were stunted. Stunting was present even among children under six

months of age. Stunting indicates chronic malnutrition and is more common in mountain

region (about 28%) than in Urban Tirana and Central region; Children in lowest wealth

quintile are two times more likely to be stunted (about 13%) than those in highest quintiles

(about 27%). Wasting (too thin for height) which is a sign of acute malnutrition is about 9%.

About 5% of children under age five were underweight for their age. Twenty –two percent

of children under five were overweight.

Micronutrients are essential vitamins and minerals required for good health. About 17% of

children 6-59 months in Albania have some level of anemia. Anemia is considerable higher in

rural areas than in urban areas, for children of women with no education and for lowest

wealth quintile. Nineteen percent of women whose hemoglobin level was tested were found

to be anemic.

Taking into consideration current nutrition situation of women and children in Albania, a

new Joint Programme on Nutrition (JPN), funded by the MDGF-Spanish Government, was

developed jointly with UNICEF, WHO, FAO and the Albanian Government and will help place

nutrition and food security higher in government agenda and design interventions focusing

directly to most marginalized population groups.

1 Based on UNICEF background information. 2011


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Designing and implementation of cross sectorial interventions addressing malnutrition and

household food insecurity is an important component of the current nutrition programme.

The involvement of the community and key local stakeholders will help ensure endorsement

and validation of planned interventions, effectively mobilize the community and contribute

to sustainability of interventions.

In this context, a step wise approach was selected by the JPN’s responsible institutions,

leading to community based nutrition interventions, including:

• Identifying the key partners involved in the planning and implementation of

community nutrition program;

• Understanding the priority nutrition problems (assess nutrition situation,

understanding the priority nutrition problems and analyzing causes of malnutrition);

• Selecting the most appropriate program approach (define goals and objectives, key

program targets, choose the most appropriate intervention strategy);

• Developing the institutional framework for implementation (defining management

and programmatic roles of different partners, eliciting commitments of partners to

their roles);

• Designing and appropriate programme action plan (programme activities and time

frame for implementation, determine resources needed).

1.2. Definition and concepts of food and nutrition

security

According to the accepted definition, food security is “adequate access to food for all people

at all times for an active, healthy life”. Food is here defined as any substance that people eat

and drink to maintain life and growth, where safe and clean water is also considered as an

essential part of food commodities. As such, food security is achieved, if adequate food (in

terms of quantity, quality, safety, socio-cultural acceptability) is available and accessible for

and satisfactorily utilized by all individuals at all times to live a healthy and happy life.

This definition of food security emphasizes “availability”, “accessibility”, and “utilization” of

food. The inclusion of “utilization” underlines that “nutrition security” is more than “food

security”. Figure below shows the conceptual framework of malnutrition, developed by

UNICEF and widely accepted internationally.


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Figure 1. Conceptual framework of malnutrition (UNICEF, 1991)

People are malnourished if their diet does not provide adequate calories and protein for

growth and maintenance or they are unable to fully utilize the food they eat due to illness

(under-nutrition) or they consume too many calories (over-nutrition). Thus, there are three

basic types of malnutrition:

• The first and most important is protein-energy malnutrition - the lack of enough

protein (from meat and other sources) and food that provides energy (measured in

calories) which all of the basic food groups provide. This is the type of malnutrition

that is most often referred to when hunger is discussed.

• The second type of malnutrition, also very important, is micronutrient (vitamin and

mineral) deficiency. This is not the type of malnutrition that is referred to most often

when hunger is discussed, though it is certainly very important.

• In recent years there has also been a move to include obesity as a third form of

malnutrition. Although obesity is certainly a health problem, considering it as

malnutrition expands the previous usual meaning of the term which referred to poor

nutrition due to lack of food inputs. It is poor nutrition, but it is certainly not typically

due to a lack of calories, but rather too many (although poor food choices, often due

to poverty, are part of the problem).


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The two most commonly used conceptual frameworks (food security and malnutrition) show

significant differences. The food security framework emphasizes an economic approach in

which food as a commodity is a central focus. The malnutrition framework adopts a

biological approach in which the human being is the starting point.

Figure 2. Conceptual framework of the nutritional status at household and individual level

However, both frameworks promote an

interdisciplinary approach to ensuring “Food and

Nutrition Security” (FNS) in common. Both

acknowledge that food alone is not sufficient to

secure a sustainable satisfactory nutritional status

and, therefore, aspects of health must be

considered. As a result, nutrition at the households

and individuals level is the function of food intake

and health status, as illustrated in figure below. The

conceptual framework of “Food and Nutrition

Security” integrates the food security and the

malnutrition frameworks.

Analyzed in this framework, the overall level of knowledge and understanding of the key

regional and local authorities (health, education, agriculture and social sectors) and

communities about nutrition issues, its current situation, causes and effects is considered to

be a very important element for the improvement of the situation. However, the results of

the assessment show that the overall level of awareness, knowledge and information

available about nutrition issues (nutrition in general and especially related to children and

women) remain generally low, both at the regional, local and community level.

Figure 3. Determinants of Food and Nutrition Security


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1.3. Purpose of the study

Based on the JPN’s main development goal and approach and working in close cooperation

with the technical staff of main strategic partners in nutrition and food security

interventions, local authorities in target districts and technical officers of UN participating

agencies (UNICEF, WHO, FAO), the main purposes of this study will be to:

• Identify needs/existing gaps of community based partners (community leaders, local

service providers (health, education, agriculture, social services) and CSOs working

with communities in the target areas to design, implement and monitor nutrition and

food security interventions;

• Conduct a participatory needs assessment at community level to define community

based interventions in target areas.

• Synthetize the results of both assessments in the form of a final report including the

recommendations for trainings and the proposed package of community based

interventions.

1.4. Methodology and approach of the study

1.4.1. Overview of the approach

The approach selected for the implementation of this assignment is based mainly on the

Participatory Learning and Action (PLA) approach. The PLA helped the study team to identify

and analyze the situation and problems and identify interventions and actions for

improvement of nutrition with the involvement of community. This approach involved in

itself the use of a wide range of visual and verbal methods and tools (involving participatory

rural appraisals (PRA), rapid rural appraisals (RRA), rapid participatory appraisals (RPA),

participatory priority setting (PPS), responsibility mapping, scoring, role-plays, diagrams,

brainstorming, planning charts, etc.) to identify and analyze situation, identify priorities and

potential interventions and actions.

The implementation of the PLA approach in this assignment was based on the following

principles:

• Sequencing: It started with a wide-open process to identify key issues: starting from

the national and regional level and go down to the selected local community level;

probe issues and priorities by using appropriate RRA and PRA tools. Eventually

appropriate measures were taken to adapt the tools to the extent of the particular

phenomena at each level.


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• Adaptation and creativity: The PRA tools were adapted according to the purpose

and particular phenomena at each level (avoiding the danger of “methods fixation”)

and considering first what issues the community has identified, and/or subjects the

assessment team needed information on or probing certain issues in more depth.

• Reversal of learning: Learn directly from the local community, gaining from their

local physical, technical and social knowledge.

• Triangulating information and results: The team used learning and triangulation

from several methods, disciplines, individuals or groups, locations and/or types of

information, cross-checking, comparing and verifying the information and results.

• Seeking diversity: This was an important element ensuring that the diverse

information, judgments, views and concerns of all the different groups within the

community have been heard and analyzed and that the diversity within any

community, economic or well-being categories, gender, age, were duly taken into

consideration.

• Sharing: Ideas and information are shared between the local people, between the

local people and the facilitators and of experiences between different communities,

institutions and organizations involved in the implementation this assessment.

1.4.2. A step-wise implementation approach

Phase I: Identification and selection of targeted area

This phase was supported by the UNICEF/WHO/FAO during the first half of 2011 and

included discussions with key community actors and technical staff at the ministries of

Health and Agriculture on selection of the target communes for these interventions. Several

regional workshops were organized by the JPN team respectively on May 2011 in the three

selected regions. As a result of these identification and planning workshops, it was agreed

on the selection of 15 communes for nutrition interventions, as follows:

• Kukes region - communes Shishtavec, Zapod, Topojan and Bicaj in Kukes district, the

commune of Golaj in Has district and communes of Tropoje e Vjeter and Bujan in

Tropoja district;

• Shkodra region - communes of Bushat, Rrethina in Shkoder district, communes of

Kastrat and Gruemire in Malesi e Madhe district and the Puka municipality and the

commune of Iballe in Puka district;

• Tirana region - municipality of Kamez and the commune of Paskuqan.

The selection of these local government units (communes/municipalities) was based on

socioeconomic status, malnutrition rates, geographical access, remoteness, level of

engagement of local authorities and receptiveness for intervention.


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Phase II: Implementation of the assessment

This phase was implemented by the PfD, with the information, data collection and meetings

held period October-November 2011 and the data processing, analyzing and the report

writing during December 2011. As relevantly proposed by the Joint Programme on Nutrition,

a step wise approach was selected for the implementation of this assessment, starting with

the analyses and understating of the national -> regional -> local -> community nutrition

situation, problems and priorities, leading then to identification of appropriate community

based nutrition interventions.

More specifically, the approach included the following main steps:

1. Reviewing of existing data: The team started with the review of the existing background

information and data on nutritional status of women and children in Albania and better

understand and become familiar with current situation and main objectives of

Government of Albania and partners agencies on nutrition and food security issues.

2. Identification of key partners: This step built on the results and findings of the previous

step and involved meetings and interviews with several representatives of key national

and regional institutions/organizations, aiming to identify more in details their roles and

responsibilities, their involvement in planning and implementation of nutrition and food

security programs, identify the key potential partners at each of the levels that would be

necessary to be involved in further steps of the assessment and potentially later in the

field implementation of the programme.

3. Data/information collection: (i) to assess the overall nutrition situation and needs of the

target communities; (ii) to assess the capacities of key partners involved in the planning

and implementation of community nutrition programs. In order to have a

comprehensive information and a clear picture on the current nutrition situation in the

target areas, and in order to be able design and undertake effective interventions in the

future for the improvement of nutrition in these regions, the assessment team used a

set of various instruments, including individual interviews and testimonials and focus

group discussions using open-ended questionnaires. Focus groups have been held with

three main target groups of stakeholders, as follows:

o Local authority actors, with stakeholders at regional level (Qark) and at local

government level (communes/municipalities);

o Local community, with community groups (families and family groups) and;

o Civil society actors, including NGOs, associations, independent experts, etc.

A specific open-ended questionnaire per each stakeholder category was developed and

used for collection of information and data during the focus group discussions and


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meetings held during this period. Besides the numerous individual meetings with

representatives of various institutions, organizations and individual experts, 63 focus

groups consisting of about 10-15 members each (or about 760 persons attending these

focus groups) were held with the abovementioned stakeholders. The table below

presents the distribution of focus groups according to the targeted regions.

Table 1. Number and distribution of focus groups held with key stakeholders

Kukes

region

Shkoder

region

Tirana

region

Total

Regional and local government level 8 7 3 18

Community level 14 12 4 30

Civil society actors 7 6 2 15

Total 29 25 9 63

The number of questionnaires per region was determined mainly based on number of

communes/municipalities preselected for the assessment and on the importance of the

nutrition and food security issues (resulting from the bibliographic review made during

the first step of the assessment). These questionnaires focused mainly on the following:

o At the local authority level (regions & communes): (i) how do the local

authorities perceive the nutrition situation in their territory; (ii) does local

government have any plans and capacities to promote and implement

interventions for the improvement of nutrition situation in their territory; (iii)

what is the level of coordination between various actors/sectors at local level to

analyze, orient, plan and implement interventions targeting nutrition issues in

their territory; (iv) what are the major constraints in the current food security

situation (food production and procurement), resources and opportunities for

increase in quality and variety of food products and improve food security in their

territory; etc.

o At the local community level (families and family groups): (i) how much do

community members know about nutrition concept, causes and effects (in

particular related to children nutrition); (ii) what are the main potential,

opportunities and necessary actions to increase the quality and variety of

production at local level in order to improve their households’ nutrition and food

security situation; (iii) which are the possibilities to introduce new and improved

products and production approaches, technologies and system (in crop and

livestock production, use of forest fruits and herbs, improved post-harvest and

processing practices, etc.); (iv) which could be the most effective ways, tools and

instruments to improve the level of information, knowledge and increase

awareness on the nutrition and food security issues; etc.


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o At civil society level and independent experts: (i) what are the most important

elements, tools, instruments that would need to changed, introduced or

improved in order to improve the situation; (ii) which could be the most effective

types instruments or interventions that would need to in the future; (iii) which

could be the most active and efficient actors to be involved in the

implementation of future interventions; (iv) which could be the most effective

instruments to be used for improving the community information and awareness

level on nutrition and food security issues; (v) which categories of products are

most limited in the usual/traditional diet; (vi) what are the resources and

opportunities available for improvement of the nutrition and food security

situation within their territories; etc.

4. Data processing and analysis: The data collected through the interviews and focus

groups consisted of mainly qualitative data. It’s processing and analysis was made mainly

by use of standardized Excel data analyzing tools (formulas, PivotTables and

PivotCharts). The use such tools for the qualitative data processing and analysis has

passed through the five main steps, as follows: (i) data consolidation; (ii) identification of

themes and patterns (ideas, concepts, behaviors, interactions, incidents, terminology or

phrases used); (iii) identify linkages and organize of the data in various categories; (iv)

assess the relative importance to each of the categories, scoring and identify

relationships and dependences; and (v) synthetize and bring meaning to the text through

the production and use of tables and figures. The data analysis and reporting is made by

presenting the results according to the main assessment topics/issues and according to

the three main categories of stakeholders. In addition, within each of the topic/issue, the

analysis tends to show as clear as possible the differences between various regions and

local communities.

In order to be able to analyze and present the data on comparative basis we have use a

scoring system (3=high; 2=moderate; 1=low; 0=none) for the main issues which was then

used for presentations of these issues on radar charts. The scoring was done based on

following approaches: (i) first during the discussions, participants in the meetings from

local authorities, civil society actors and community were asked to assess the main issues

raised based on their own judgment on the above scale from 3 to 0; (ii) the most

important issues were scored independently by the various categories of actors (local

authorities, civil society actors and community); (iii) during the processing of the

information collected through the questionnaires, our experts assessed the frequency of

repetition of a certain issue and allocated the respective score. This process in three

independent steps allowed a triangulation approach and improved of the final results.


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2. MAIN FINDINGS OF THE STUDY

2.1. Overview of the study area

The study area included 15 local government units (LGUs) in three regions (7 in Kukes, 6 in

Shkoder and 2 in Tirana). The targeted areas cover a total area of 1.430 Km2 and have about

37.600 hectares of arable land. The 15 targeted LGUs have a population of about 153

thousand inhabitants and about 35,200 households. An important characteristic of these

areas, especially in Kukes (Kukes, Has and Tropoja districts) and some of the areas in

Shkodra regions (in the district Puka and Malesi e Madhe), is that the majority of their

territory is highly mountainous, located in more than 600m of altitude and having a slope of

more than 15%, which creates significant difficulties for the development of many

agriculture production activities (especially crop production). The table below presents the

main characteristics of targeted local government units.

Table 2. Main characteristics of the targeted study area Total

Area

(in Km2)

Arable

land

(in Ha)

Population

(according to

2001 Census)

Households

(according to

2001 Census)

% of Area

at >600m

altitude

% of Area

with >15%

slope

Kukes 826.17 12,478.60 29,738 6,387

Bicaj 79.28 1,179.10 7,022 1,516 37.89 61.92

Bujan 167.53 1,677.50 3,297 713 17.32 61.88

Golaj 167.13 3,396.50 1,649 269 25.36 44.87

Shishtavec 65.97 942.00 5,871 1,343 99.97 83.32

Topojan 80.21 960.60 3,561 578 99.86 91.55

Tropoje 228.95 3,834.20 5,381 1,300 34.87 65.94

Zapod 37.11 488.70 2,957 668 89.79 98.33

Shkoder 565.45 22,152.30 58,046 14,250

Bushat 81.68 5,689.50 17,185 4,232 - 3.11

Gruemire 106.52 5,410.20 9,796 2,454 0.09 13.92

Iballe 145.15 1,332.80 2,689 659 72.31 69.61

Kastrat 150.88 5,410.10 8,460 2,023 17.11 17.48

Puke 25.60 353.30 4,579 1,097 77.27 61.86

Rrethine 55.63 3,956.40 15,337 3,785 - 1.72

Tirana 37.69 3,005.80 65,498 14,555

Kamez 23.48 2,119.70 44,443 10,010 - 0.01

Paskuqan 14.21 886.10 21,055 4,545 - 9.01

Grand total 1,429.32 37,636.70 153,282 35,192

Source: INSTAT (for area and population); MADA 2011 (for altitude and slope)


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The Kukes region has a total area of about 2,374 km2 organized in three districts (Kukes, Has

and Tropoja), 3 municipalities and 24 communes. With its terrain going from 257m-2175m

of altitude, it is considered as highly mountainous. The majority of the area is covered with

forests and pastures (occupying about 156,140ha) while only about and 25,295ha are arable

land (or only about 10% of total area of the region). The waterfront areas (lakes and

reservoirs) occupy 8200 ha. The region has a population of about 111,393 in about 23,050

families, with a population density of about 47 inhabitants per square kilometer. About 80%

of this population lives in rural areas and is directly linked to agriculture and livestock

activities. The targeted area in this region includes 7 communes, with a total population of

about 29,738 inhabitants and 6,387 households. Almost all these communes are highly

mountainous with their majority of land located above 600m of altitude (especially

Shishtavec, Zapod and Topojan have more than 90% of their territory above 600m), and with

located in more than 15% slope.

The Shkodra region includes 3 districts (Shkodra, Puka and Malesia e Madhe), 5

municipalities and 29 communes. The region has a total area of 3,372 km2 (of which about

68,560 ha are arable land) and a population of about 256,000 inhabitants and about 62,720

households (with a population density of about 76 inhabitants per km²). The highest density

of the region is at the district of Shkodra with 94 inhabitants per km². The population living

in rural areas varies from about 53.7% of the population in Shkodra district, to respectively

89% and 82% in Puke and Malesi e Madhe. About half of the territory of the region is

situated in hilly and mountain areas with significant limitation in production of several

agriculture products. The study area in this region consists of 5 communes and 1

municipality with a total area of about population of 565 km2 and a total population of

about 56,046 inhabitants (about 14,250 households). Within the targeted area, communes

of Iballe (Puke), municipality of Puke and to some extent the commune of Kastrat (Malesi e

Madhe) are the most mountainous areas, while the rest of the targeted area is flatter and

has better agriculture production conditions.

The Region of Tirana includes Tirana and Kavaja districts and has a total area of about 1,586

km² and a total arable land area of about 55,497 ha. The population of this region reaches a

number of 966,000 inhabitants (with a density of about 364 inhabitants per km²), living in

about 233,230 households. About 75% of its population lives in urban and sub-urban areas

while only about 25% in rural one. The study area in this region includes the Kamza

municipality and the Paskuqan commune, representing about total area about 38 km2, (of

which about 3,000 ha are arable land) and a total population of about 65,498 inhabitants

living in about 14,556 households. Both of these local government units are considered as

mainly urban and sub-urban area.


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2.2. Awareness and knowledge on food and nutrition

security concepts

2.2.1. Level of knowledge of FNS concepts at local authority level

The highest level of knowledge and understanding on the subject was shows within the

health sector specialists, most of which could make (during the interviews and focus group

discussions) a dissent description of malnutrition and its causes and effects on the

population. Scored in a level from 3 (high level of knowledge/understanding) to 0 (none),

the health sector seems to reach an aggregated score of almost 2 (moderate level), with a

higher knowledge and understanding of the subject at the regional level, possibly due to

participation in recent training activities supported by the JPN, as compared to the local one.

While the majority of participants from the three other sectors seem to have significantly

lower level of knowledge and awareness on the subject, with social sector having an

aggregated scoring of 1 out 3, education sector 0.93 and the lowest on being the agriculture

sector with an aggregated score of 0.87 out of 3. The figures below present the aggregated

scores for each key sector according to the targeted regions.

Figure 4. Aggregated scoring of key actors’ knowledge and understanding of key actors on malnutrition

Note: 3 (high level of knowledge/understanding); 2 (moderate); 1 (low); 0 (none)


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Within the three regions, participants from the four key actors from Tirana seem to be more

aware of and have a relatively higher level of knowledge and understanding of nutrition

than their respective counterparts in the other regions. However, in the three regions,

almost the same picture was identified, with the health sector being the most informed.

Table 3. The level of local authorities’ knowledge about concepts and components of food security and malnutrition

Kukes Shkoder Tirana He Ag So Ed He Ag So Ed He Ag So Ed

1)Overall food security concept h m m m h m m m h m m m

2) Components of food security:

2.a) Food availability m m L m m m L m h m L m

2.b) Food accessibility L L m L L L m L L L m L

2.c) Food utilization m L L L h L L L h L L L

2.d) Stability L L L L L - L L L L L L

3) Overall concept of malnutrition h L L L h L L m h L L m

4) Types of malnutrition:

4.a) lack of proteins and energy h L L L h L L L h L L L

4.b) lack of vitamins and

micronutrients - - - - - - - - L - - -

4.c) other issues (such as

unbalanced feeding, obesity, etc) L - L - L - L - L L L -

5) Differences-Food security/Nutrition L - - - L - - - L - - -

Legend: “He”-health sector; “Ag”-agriculture sector; “So”-social sector; “Ed”-education sector;

“h”-high; “m”-medium; “L”-low; “-“ none or very low (insignificant)

The table above presents a summary of the major characteristics of the knowledge and

understanding that regional and local authorities have about various components/aspects

related to food security and malnutrition. As it may be seen from this table, the majority of

sectors in the three regions have generally a much better knowledge and understanding

about the overall concept of food security than of the malnutrition concept. Within the food

security, most of the actors know better the food availability aspects, while almost all show

a very limited understanding on issues related to the stability (of access and availability). In

addition, often many of them have difficulties making the difference between the food

availability and food accessibility.

The majority of the health specialists have a good overall understanding about both food

security and malnutrition. Within the food security components they seem to know better

issues related to food availability and food utilization than food accessibility and stability

issues. When asked about the types of malnutrition, , they seem to have a high level of

understanding of the overall malnutrition concept, and especially the type of malnutrition

related to the lack of proteins, vitamins and energy. They define malnutrition with

expression such as “not taking the main elements - carbohydrates, vitamins, fat and proteins

{Gruemire, Shkoder}”, “taking too much of these elements {Bushat, Shkoder}” and “having


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and unbalanced intake of these elements”, “lack necessary food items for a health body

{Bicaj, Kukes}”, “eating but not feeding the body {Iballe, Shkoder}”, etc. Most of key food

elements were mentioned (however, none them mentioned the “microelements” as part of

the necessary food intake. In certain cases, especially in Kukes and Shkoder, some of the

health specialist (mostly from local level) linked the women and child malnutrition with their

limited dressing and accommodation conditions and with the household assets. A nurse in

Shkoder declared “a good nutrition for a future mother means not only a good feeding but

also appropriate accommodation conditions, dessing, good health advice by the local nurses

and doctors, etc”..

The three other sectors (agriculture, social and education) seem to have almost the same

level (moderate) of knowledge and understanding about the overall food security concept.

However they seem to differ about the understanding of components of the food security.

While agriculture and education seem to know at moderate level the food availability issues

(“to have or produce enough food for the year {Shishtavec, Kukes}”, “secure the bread for the

family {Zapod, Kukes}”, etc.) the social sector seems to reach that level on the food

accessibility issues (“ensure money to buy additional food supply in the market {Kukes}”,

“have the possibility to go to the market {Kukes}”, “a steady supply of food through the local

shops {Shkoder}”, “have less food than is needed to feed the family members” {Iballe,

Shkoder}”, etc.), most probably because their work is more linked with accessibility. As

regards food utilization and stability aspects the three sectors show only a low level of

knowledge (with Shkodra agriculture sector showing a very low/insignificant level).

As regards the malnutrition, the three sectors show a moderate to low level of knowledge.

Most of them link malnutrition almost only to protein-energy deficiencies and a few cases to

obesity, especially from the social sector (with no reference to micronutrient deficiencies).

In addition, malnutrition is often broadly described as “diseases” {Bicaj, Kukes}, “anemia”

{Bujan, Kukes}, “lack of fat, proteins, calories” {Tropoje, Kukes}, “a poor food diet lacking

main elements” {Kastrate, Shkoder}, etc. In Shkodra and Tirana, the level of awareness on

obesity issues seems to be introduced. In this respect, a teacher in Shkodra declared that

“even in the better-off families there problems with malnutrition of children, due to the lack

of awareness and information of good nutrition practices they give children too much fast-

foods and potato-chips (patatina), which are bad for their health”.

When speaking about conceptual differences between nutrition and food security, with the

exception of some of the participants from the health sector, the majority of the other

participants seemed to have difficulties in stating the differences and tend to confuse and

often equal the two concepts.

When asked about the knowledge on the effects of the malnutrition, a large number of

participants from the local authorities seemed to have a general good understanding.

However they presented a general concern about the community awareness on the effects


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malnutrition. The main concerns in this regard seem to be represented by the following

expressions: “most parents are not ware about how malnutrition affects the psycho-motor

development of their children”, “the population does not have sufficient information about

malnutrition effects”, “access to information and medical services is difficult due to the

remoteness and long geographical distances between families” “we need more information

given in a simple way (reference is made to small brochure and leaflets)”, “most appropriate

persons to inform population on malnutrition effects to children are health workers

(particularly village nurses that meet more often mothers) and school teachers”, etc. In

addition, several representatives of the local authorities in Shkoder insisted that it is very

important to distribute brief/simple documentary materials on child nutrition through

schools, kindergartens, health centers and meetings with targeted parents presenting more

food security and nutrition risks. The table below presents the key topics identified as

important (according to authorities and regions) to be covered by any potential capacity

building intervention to improve the awareness, knowledge and understanding on food

security and nutrition issues at the level of local authorities.

Table 4. Main topics proposed to be covered by potential capacity building interventions at local authority level for improving knowledge on food security and nutrition concepts

Topics Kukes Shkoder Tirana

He Ag So Ed He Ag So Ed He Ag So Ed

Knowledge on overall food security

concept * ** ** ** * ** ** ** * ** ** **

Improving food availability (new types

of local productions) ** *** *** ** ** ** *** ** ** ** *** **

Improving food accessibility *** *** ** *** *** *** ** *** *** *** ** ***

Improving food utilization (better use

of local products, improve diet

composition, new types of dishes, etc.)

* *** *** *** ** *** *** *** ** *** *** ***

Improving food stability (post-harvest

practices, conservation, etc.) ** *** ** *** ** *** ** *** ** *** ** ***

Understanding types of malnutrition * *** *** *** * *** *** *** * *** *** **

Understanding differences-food

security/nutrition ** *** *** *** ** *** *** *** ** *** *** ***

Principles and practices of good

nutrition ** *** *** *** ** *** *** *** ** *** *** ***

Diet composition and food nutrients ** *** *** *** ** *** *** *** ** *** *** *** High nutritious food products *** *** *** *** *** *** *** *** *** *** *** *** Rapid assessment/identification of

food security issues * *** ** *** ** *** ** *** ** *** ** **

Rapid assessment/identification of

nutrition issues ** ** ** *** ** ** ** *** * ** ** **

Legend: “He”-health sector; “Ag”-agriculture sector; “So”-social sector; “Ed”-education sector;

“***” identified as very important, “**” somewhat important, “*” less important,


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2.2.2. Level of community knowledge on nutrition concepts

As shown in the figures below, the same general tendency seems to be valid also at the

community level. Almost all community representatives in the three regions declared that

nutrition is a very important element for the development and a healthy growth of their

children. However, through the various discussions about nutrition issues, we come to the

conclusion that most of the community participants (household representatives) in the focus

groups know only moderately to low about the concept of the nutrition. However, many of

them seem to confuse the composition of the diet composition with the quantity of food

intake, while the majority of the community participants could not really distinguish

differences between the nutrition and food security concepts.

Figure 5. Level of overall community awareness on nutrition issues

The table below presents a summary of the major characteristics of the knowledge and

understanding that community seems to have about concepts and types of malnutrition.

The majority of communities seem to have a relatively moderate understanding about the

overall malnutrition concept, with four communities (Topojan, Kastrat, Gruemire and Iballe)

presenting a low level and one (Zapod, Kukes) very low level of knowledge and

understanding on the subject. However, almost all of them understand malnutrition only

linked with the protein-energy deficiencies, while other types of malnutrition seem

difficultly perceived from the respondents.


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Table 5. The level of community knowledge about concept and types of malnutrition

Kukes Shkoder Tirana

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1) Overall concept of

malnutrition m L vL m m m m L L m m L m mH mH


2.a) limited use of food

products rich in energy

and proteins

mL vL - m mL m mL L L m m vL m m m

2.b) limited use of food

products rich in vitamins

and micronutrient

- - - - - - - - - - - - - - -

2.c) use of unbalanced

food (i.e. too much fat,

carboihidrates, etc.,)

vL - - L vL L vL - - L L - L L L

3) Differences-Food

security/Nutrition - - - - - - - - - - - - - - -

Legend: “mH”-moderate to high; “m”-moderate; “mL”-moderate to low; “L”-low;

“vL”-very low; “-“ none

Few of the community participants from Kukes often referred to the nutrition with the food

security-like expressions, such as “I have secured the bread (or the food) for the winter”

{Zapod, Kukes}, “being able to eating at your will” {Shishtavec, Kukes}, “lack of common

(meaning basic) food item” {Zapod, Kukes}, “lack of the necessary quantity and quality of

food for the family” {Bicaj, Kukes}, etc. In addition, a large majority of community

participants seemed to confuse during the discussion the concepts of food content (in terms

of nutrients) and overall food quality. The level of awareness, understanding and knowledge

seems to be linked also with the remoteness of the area. Thus the lowest level was noticed

in the communes of Zapod (Kukes) Iballe (Puke) followed by Shishtavec (Kukes), while the

highest level was noticed in the commune of Bushat (Shkoder).

A better level of community understanding about nutrition was notices in urban and sub-

urban areas of Kamez (Tirana) and in some of the Shkodra region (such as Bushat, Rrethina

and Puka). Few of the community members from these areas that attended the focus groups

mentioned the case of “children eating too much fast-food” {Kamez, Tirane}, “eating

unbalanced food (meaning unbalanced in content of nutrients)” {Bushat, Shkoder}, “eating

mainly cereals, potato, bean and chees, especially during the winter” {Rrethina, Shkoder}

“eating very limited quantities of fruits and vegetables” {Puke, Shkoder} as malnutrition

cases.


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When community participants were asked about “how important they think that

malnutrition is for the children and women in their community”, the majority of them tend

to agree that it remains a very important issue. The most representative expressions in this

regard are “it is an important problem for our community” {Tropoje, Kukes}, “it is important,

our children are our future and need to be better cared” {Bicaj, Kukes}, “the problem

concerns about 70% of our community” {Kastrate, Shkoder}, “several families do not take

enough care about child and women nutrition, but it is very important as it has to do with

their heath” {Bushat, Shkoder}, etc. When asked about the effects of malnutrition most

community representatives have only a broad understanding. The following are some of the

most representative expressions in this regard: “various diseases, loss of child weight,”

{Zapod, Kukes}, “anemia, reduction of ability to work” {Shishtavec, Kukes}, “weak health

situation, more family costs for health and thus more impoverishment” {Kastrat, Shkoder},

“increase death prevalence, more health problems for the new generation” {Iballe,

Shkoder}, etc.

The table below presents the key topics identified as important (according to communities)

to be covered by any potential capacity building intervention to improve the awareness,

knowledge and understanding on nutrition issues at the community level.

Table 6. Main topics proposed for interpersonal communication interventions at community level for improving knowledge on nutrition concepts


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Improving the

overall concept and

types of

malnutrition

** *** *** ** ** ** ** *** *** ** ** *** ** ** **

Understanding

differences-food

security/nutrition

** *** *** ** ** ** ** *** *** ** ** *** ** ** **

Importance of

micronutrient in

food intake

*** *** *** *** *** *** *** *** *** *** *** *** *** *** ***

Principles and

practices of good

nutrition

*** *** *** *** *** *** *** *** *** *** *** *** *** *** ***

Diet composition

and food nutrients *** *** *** *** *** *** *** *** *** *** *** *** *** *** ***

Improving food

utilization (better

use of local

products, improve

diet composition,

new types of dishes,

ect.)

*** *** *** *** *** *** *** *** *** *** *** *** *** *** ***

Legend: “***” identified as very important, “**” somewhat important, “*” less important,


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2.3. Main factors of malnutrition and food insecurity

Local authorities: The key regional and local authority actors seem perceive and describe

the main causes of food security and malnutrition within three main groups (ranked in order

of importance as presented by the participants):

• factors related to overall community development level;

• factors related to the level of community education and information; and

• other objective reasons not directly linked with the community but more with the

overall social, economic and political environment.

The table below summarizes the main factors grouped according to the three main

categories above and the main food security components.

Table 7. Main factors impacting food security and nutrition in the study area

Community development

factors Community education

and information Other objective

reasons

Food Availability

Local production

Production of traditional products, tradition and inefficient production

systems, limited productivity, aging agriculture labor {Kukes and Shkoder}

Lack of knowledge and inefficient use of local

products; lack knowledge and information on new

potential products {especially in Kukes}

Difficult agroecological conditions, limited farm and poor quality land,

high input prices, limited access to credit for investments {Kukes

and Shkoder}

Importing capacity Limited market actors in

remote rural areas {especially Kukes}

Food stock

Traditional and inefficient storage and stocking practices {Kukes and

Shkoder}

Lack of knowledge on improved storing/stocking

practices (resulting on high seasonality of

available local products)

Limited access to finance/credit for

investments {all areas}

Food aid

Very limited and ineffective food aid

distribution {especially in remote communities

of Kukes} Accessibility

Purchasing power Limited cash available to

procure additional food when needed {all areas}

Limited bargaining power compared to

food traders {all areas}

Incomes

Limited professional skills, lack of cooperation to

improve access to markets for their products {especially in Kukes but also few areas

of Shkoder}

Limited knowledge and information on potential

markets for specific local products to increase incomes from sales

{especially in Kukes}

Limited job opportunities,

especially in rural areas {Kukes Shkoder}

Market and transport infrastructure

Limited market infrastructure and poor quality of rural

roads {especially in remote areas of Kukes}

Poor quality of rural infrastructure

{especially in remote areas of Kukes}


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Stability

Climate change

Limited knowledge and capacity to adapt their production system to

climate changes {especially in Shkoder}

Lack of advice and support to adapt to climate changes

{Kukes and Shkoder}

Price changes

Limited capacity to reduce risk and benefit from

seasonal price changes (fluctuations) {Kukes and

Shkoder}

Limited knowledge on how to reduce risk and increase benefits from

climate fluctuations {Kukes and Shkoder}

Political factors

Effectiveness of policies, support

measures, economic aid and other public interventions {Kukes

and Shkoder}

Economic factors

Limited non-agriculture income generating activities, poverty level {especially in

Kukes and Shkoder}

Weak overall economic environment and

business development, especially in rural areas

limiting economic opportunities {all areas}

Stability

Food safety

Use of traditional practices, not always safe

{all areas}

Food processing & handling practices and hygiene

High losses due to traditional and inefficient post

harvesting practices {Kukes and Shkoder}

Limited knowledge on improved post harvesting,

handling and food processing practices {Kukes and Shkoder}

Limited access to information on

improved technologies and credit for

investments {all areas}

Quality and variety of diet

Poor quality of nutrition due to use of traditional diets and cooking practices {all areas}

Limited knowledge on improved food diet

composition, seasonality of diet types {all areas}

Figure 6. Main causes of malnutrition as perceived by the local authority representatives

As we may see from the figure below, there may be identified various groups based on what

representatives of local authority representatives see as main factors causing of

malnutrition issues in their areas:

1. The most remote communes (Topojan, Zapod, Shishtavec and Iballe) where the three

groups of factors are considered as very important. In most of these households there

seem to be: very limited food production due to difficult soil and agro-ecological


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conditions; limited farm size and poor quality of soil; limited knowledge on new and

improved agriculture and food production techniques and technologies; limited types

and varieties of food products used, and as a result; generally a very poor diet (especially

during the winter);

2. The group of communes (Rrethina

Tropoje e Vjeter, Paskuqan, Bujan

and Gruemire) declaring the

community development factors as

highly important causes followed

with moderate to low importance

for other factors (especially the

lifestyle and the traditional way of

composing the usual dies);

3. The group of communes (Bushat,

Kastrat, Kamez, Puke and Golaj),

reasonably considering that (as

they have relatively good

agriculture and food production

conditions) the objective reasons

are only of low importance as

causes of malnutrition in the areas

while considering the community

development and education and

information factors as moderately

important.

Local Community: At this level, analyzed according to the main food security component we

distinguish the following tendencies:

• Food Availability: The three regions seem to correlate to the issues related to the

local production issues and rank them as most important. Here they stress mainly

“limited available farm land”, “limited productivity”, “limited access and use of inputs

and improved technologies”, “use of traditional and inefficient production systems”

etc. Limited food production opportunities seems to be of a higher importance as

cause of malnutrition household food insecurity risks in Kukes region and especially

in remote areas. Despite the limited agriculture production conditions, even in

remote areas (such as Shishtavec, Topojan, Zapod and Iballe) the majority of the

community participants seem to put forward more issues linked to limited

knowledge about nutrition. Food stock seems to more of a problem in Tirana as

compared to the two other regions. Food aid issues seem important especially for

Figure 7. Main causes of malnutrition according to three main groups factors, as perceives by local authorities


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the remote areas of Kukes (Shishtavec, Zapod and Topojan) and the plain area of

Shkodra (Bushat and Rrethina, which may be linked with the food situation that

happened during the last years), while importing capacity (bringing food products to

local area from abroad or other areas within the country) seem to be more important

in the rural remote areas of Kukes (mainly due to the lack of traders going to these

areas). While availability seems steadier in Tirana, seasonal availability is a major

characteristic in almost all Kukes and Shkodra regions. “We have difficulties to ensure

sufficient food for the whole year” {Iballe, Shkoder}, “we have enough food products

in harvesting season and often lack major food items in the winter” {Gruemire,

Shkoder}.

• Food Accessibility in the three areas seems to be linked mainly with the low incomes

available and the limited purchasing power. The market and infrastructure factor

seem to be more important for the remote rural areas of Kukes. This is especially

important in Shishtavec, Zapod and Topojan. Few of them declare: “even when we

have some money, out local shop has limited food items that we may buy, and they

are very expensive due to the distance and the bad road”. {Shishtavec, Kukes}, “our

trader is also poor like us so he has not the financial capacity to bring here a lot of

food items, and they are usually of low quality” {Iballe, Shkoder}.

• Food Stability: In the three regions, issues seem to be more linked with the economic

factors (mainly due to the poverty, low local economic and business development

situation, especially in Kukes) and price changes (mainly due to the limited,

knowledge, information and capacity of the community to reduce risk and benefit

from the price fluctuations. “We are poor and for sure we eat poor, even when we

have we don’t know how to use it” {Zapod, Kukes}, “we may produce only during a

short production season and this is not enough to feed the family during the whole

year” {Topojan, Kukes}, “our incomes are not enough to buy additional food in the

market, besides few things such as oil, sugar, salt, etc.”, {Gruemire, Shkoder}.

• Food utilization issues seem to be linked mainly with the limited capacities of the

local community and use of traditional practices in processing and handling of food

products and with the poor quality and limited variety of food diets used. The

following expressions represent a sample of such concerns: “during the summer we

have a lot of fruits which are spoiled of feed to animals and in the winter we don’t

eat any of them” {Iballe, Shkoder}, “even during the summer when we have more

products we don’t know what is better for the children” {Topojan, Kukes}, “many

mothers don’t know to prepare healthy food for their children even when they have

enough food item at home” (Gruemire, Shkoder}, “often women are too engaged

farm labor or caring for animals and don’t care enough for the quality of food in

terms of nutrition” {Tropoje, Kukes}.


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Figure 8. Main causes of malnutrition and food insecurity as perceives by community representatives according to the four main food security components

2.4. Local government capacities in dealing with FNS and

coordination issues

The current role of the local government administration in dealing with the nutrition and

food security issues remains very limited throughout the study area. As declared by the local

governments represented met of those attending the focus group meeting, none of the local

governments have nutrition or local food security management plans and none of them

seems to have undertaken significant analysis of the on these issues (with the exception of

the management and distribution of the social assistance payments).

When asked about their capacity to deal with issues like monitoring and reporting the food

and nutrition security (FNS) situation in their territory and plan and management of FNS

interventions, almost all local government representatives accord that their capacities are

generally very low or not existent. The table below presents the results of the participatory

weighting level of their declared capacities, by communes/municipalities and aggregated

average at the study areas.


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Figure 9. Weighted level of LG capacities to deal with FNS issues at their territory

Some experience and capacities in monitoring and reporting and management of FNS

interventions seem to exist in the better off communes and municipalities (such as Kamez,

Paskuqan, Puke, Bushat, Rrethina, Bujan, Tropoje e Vjeter and Bicaj) mainly due to the

cooperation with any donor funded initiatives in their areas and the any demand for

information from central institutions (mainly from Ministry of Health). However, only local

government representatives from Bushat, Rrethina and Bicaj declared to have some

capacities and little previous experience in planning food security interventions in this field

(due to interventions in the context of few donor funded projects).

The coordination of efforts between various local authority actors seems to be a major issue

in the three regions. The heath sector is almost the only local actor some better quality

collecting data on nutrition (but still at operative level and not statistics) and reports them

to the Ministry of Health. The agriculture sector collects operational data on production and

sometimes about the imported food products and reports them to the Ministry of

Agriculture. The social and education sectors seem not to be involved at all in any data

collection of reporting related to food security and nutrition issues at local level. As various

sectors (health and agriculture that collect some data) report directly to their respective

ministries and the very low level of local coordination between the sectors, the information

available to the local government remains very scarce.

The table below presents more in details issues identified regarding the actual capacities of

local government to deal food and nutrition security.


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Table 8. The assessment of the current experience and capacities of LG (according to main identified capacity issues)


Shi

shta

vec

Top

ojan

Zap

od

Bic

aj

Tro

poje

Vj.

Buj

an

Gol

aj

Kas

trat

Gru

emira

Rre

thin

a

Bus

hat

Ibal

la

Puk

e

Kam

ez

Pas

kuqa

n

Knowledge and experience in planning • assessment of FS

situation - - - vL - - - - - vL m - - - -

• assessment of nutrition situation

- - - - - - - - - - L - - - -

• preparation of intervention plans

- - - vL - - - - - vL m - - m vL

Knowledge and experience in management • Implementation of

intervention plans - - - vL vL vL - - - vL vL - vL vL vL

• coordination of multidisciplinary teams

- - - L vL vL - vL L L H - L m L

• implementation of community based actions

- - - vL - - - vL vL - m - vL vL -

• implementation of FS actions

- - - vL - vL - - vL - m - L L -

• Implementation of nutrition actions

- - - - - - - - - - vL - - - -

Knowledge and experience in monitoring & reporting

• collection of FS data - - - - - - - vL vL L m - m L vL • collection of nutrition

data - - - - - - - - - - vL - vL vL -

• processing of FNS data - - - - - - - - vL - m - m m vL

• preparation of reports vL - - vL vL vL vL - - H H - m m vL

Legend: “H”- high; “m”-moderate; “L”-low; “vL”-very low; “-“none

When asked about what could be done to improve coordination and capacities to deal with

food security and nutrition, the following recommendations seem to be the most often:

• Improve cross-sectorial coordination between local actors in collection and exchange

of information and development of joint action plans for improvement of the

situation;

• Determination of a local reference point (institution or person) to arrange for an

effective coordination between actors (local and central ones). This experience exists

in the areas that has emergencies (like flooding in Shkoder) and may be used to build

more permanent and stable coordination mechanisms even in no-emergent

situations;

• Establishment of an office/structure within the local government administration to

deal with food security and nutrition issues at local and community level;

• The economic aid may be distributed in “food packages” for families that have

difficulties of access to food, which may use also to condition an improved nutrition

for children and pregnant women;


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• Implementation of pilot projects with schools and poor families in order to

demonstrate to the local actors the best practices to improve food security and

nutrition at targeted community level;

• Organize seminars and training workshops for improvement of capacities of local

government specialists on food security and nutrition concepts, approaches and

mechanisms to deal with it. The main subject of such training, as proposed by

participants, include:

o Improving technical knowledge and information on: principles of good

nutrition; types of products with higher content of nutrients; ratios between

carbohydrates, proteins, vitamins, micronutrients, etc.; alternative foods that

could be used, etc.;

o Improving planning of interventions: preparation annual plans for ensuring

community food security; improving local food production; proportion of

non-agriculture income generating activities; establishment and management

of local and community food stocks; assessment, monitoring and reporting of

food security and nutrition situation; etc.

2.5. Opportunities to increase food availability

2.5.1. Perceptions of local authorities on food availability opportunities

The majority of participants in the meetings declared that most of the areas have

opportunities to increase the production and availability of food products within their

territory. The existing opportunities (as declared by the participants) to increase food

availability may be grouped as follows:

• Improving post harvesting, handling and processing technologies and practices has

been identified as the most important opportunity in short-medium term to improve the

nutrition. Reducing the losses of significant quantities of production (as a result of

mismanagement and lack of post harvesting technologies) and introduction of small-

scale processing technologies and practices will significantly contribute to increased

food availability at the household level;

• Improving local production: Most households are producing mainly a limited number of

traditional types of food products in their farms. Despite the current difficult soil and

agro-ecological condition in some of the highly mountainous areas, there are possibilities

to: introduce new types of production (especially new fruits and vegetables); improve

yield and productivity; improve technical knowledge; improve farm specialization and

efficiency by improving production technologies, seeds, inputs’ use and cultivation


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practices. In addition there are possibilities to better exploit the forest fruits (i.e.

blueberries, blackberries and herbs) for home consumption.

• In addition, as yields for most of cultivated crops are still relatively low, there

possibilities to significantly increase the quantity of production of the current crops and

livestock through introduction of improved techniques, practices and technologies.

Figure 10. Importance of main groups of opportunities to increase food production

While all regions have stressed the opportunities to improve post harvesting practices

(especially processing and conservation of products), the level of perceived opportunities to

increase the quantity and types of products varies is also high especially Bushat, Gruemire,

Golaj, followed by a moderate level in comes of Kastrat, Bujan, Bicaj and Tropoje e Vjeter.

More limited opportunities to increase production seem to be perceived in Shishtavec,

Topojan, Zapod and Iballe, due to the highly mountainous terrain and more difficult agro-

ecological conditions, and in the urban and sub-urban areas of Kamez, Bushat and Puka,

these opportunities are limited mainly due to the limited availability of arable land.

2.5.2. Perceptions of communities on food availability opportunities

When asked about the most common types of food they usually consume, the majority of

community representatives seem to account about staple food (mainly cereals, beans and


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potatoes) and dairy products (“we don’t have the luxury to select food items, we eat what

we have” {Shishtavec, Kukes}).

In general there is little differentiation in

feeding within the family members between

adults, children and women (with the

exception of pregnant women in some

cases): “even if we want to differentiate, our

conditions don’t allow us to do as we may

not produce everything needed ourselves”

{Rrethina, Shkoder}, “we don’t have money

to buy the other things needed for a good

nutrition” {Bicaj, Kukes}, “we don’t have

tradition in differentiating family

members and we don’t know how to do it

without being seen as discriminating the

others” {Gruemire, Shkoder}, “the only time

when I heard about the need of

differentiating pregnant women and

children was at the local doctor, seems good

but is difficult to do in practice” {Dobrac,

Shkoder}.

When asked about what types of food

products a family should normally consume,

most of them mention the full range of

products (cereals, beans, meat, vegetables,

fruits, dairy and fish). As regards the

possibility of improving the availability of

these products, the majority of them declare

that the current economic conditions don’t

allow them, or they link it with the agro-

ecological conditions. When discussing more

in details about the local possibilities of production and processing of some additional

products, results that most women have a general good knowledge, especially in small-scale

home processing (pickles, dried meat, dried fruits, etc. The figures below present the

community perceptions about the possibilities of producing and consuming more products

at local level.

Figure 11. Main mission/limited food components in the usual diet


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Figure 12. Possibilities for more fruits, vegetables, forest fruits and hers (by regions)

Figure 13. Opportunities to increase food production

Figure 14. Possibilities for more fruits, vegetables, forest fruits and herbs

A woman in Kukes (from Shishtavec Commune) declared “It’s true that we have very little

arable land area in our farms and our production is really limited, but we also spoil and

misuse a lot of products. At harvesting season, a lot of fruits are rotten or feed to animals as

we do not manage to them and they are very little to send them to the market. I guess

something can be done with them but besides jam. I don’t know how else I may use them for

improving my children’s nutrition”. “We have a good tradition in dried meat and fruits but

produce these products in very small quantities as we don’t have appropriate equipment and

tools” {Bicaj, Kukes}, “we do some vegetable processing based on traditional knowledge and

in primitive technologies” {Bushat, Shkoder}.


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However, if developed, these products may contribute towards improving availability to

food during the off-season consumption (especially during the winter).

Other community participants in the focus group meetings described the issue with

sentences such as “we eat almost the same things during all year along, mostly things that

we produce in our little farms such as bread, beans, potatoes and dairy products”, “we see

fruits and vegetables in out diet only during the harvesting season (late summer and early

autumn)”, “the winter diet is almost only base on main staple food item”, etc.

2.6. Community opinions on food security and nutrition

interventions

The main categories of intervention proposed by the community participants for improving

food security at household and community level include (in order of importance):

• introduction of improved production, processing and conservation tools, instruments

and inputs at farm level;

• introduction of production and processing technology packages, including introduction

where possible of the year-round production system;

• provision of training, advice and technology assistance to the producers; and

• preparation and distribution of brochures, leaflets on new and improved ways and

methods of production, processing and conservation of local products;

The table below presents the weighted importance of the above-mentioned categories of

interventions as perceived by the local community representatives.


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Figure 15. Main categories of interventions to improve food security proposed by communities (by region)

Figure 16. Main categories of interventions to improve food security proposed by community

The civil society representatives that attended the focus group discussions seem to accord

with the proposals that come from the community members.

Figure 17. Main categories of interventions proposal by civil society members

They also favor at a large extend the support for the development of the small-scale agro-

processing and introduction of year-round cultivation system. However, many of the civil


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society members insist also in the promotion and support for the development efficient of

business models and the overall households economic activities.

In this context, the development of the non-agriculture rural economic activities is

considered as an important source of income, thus improving food security especially for

households which have limited food production opportunities such as the urban and sun-

urban areas (Kamez and Paskuqan). For the later, the promotion of urban agriculture

practices may be an important source of households’ food security improvement.

2.7. Improving local capacities

Almost equally in the three study regions, the majority of the civil society members and

individual experts represented in the meetings, tend to accord that in order to improve the

situation of the nutrition, one of the first thing that should change is the way how the local

government deals with the nutrition issues. This is followed by introduction of more

effective ways/methods to inform the community in nutrition issues and the introduce

improvements in the traditional nutrition practices and habits.

Figure 18. What should change to improve the local nutrition situation?

Figure 19. Most effective interventions proposed to improve capacities and nutrition situation

Organization of direct meetings with the targeted community members is declared to be the

most preferred and considered by the civil society and community members as one of the

most effective instruments in informing the community about nutrition issues.

These meetings should be continues and not only based in quick campaigns. In order to this,

the responsibility should not be left only to the health sector, but a large number of actors is

proposed to be involved, including, local government administration, agriculture specialists,

local NGOs, etc.


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Figure 20. Potential categories off actors to be involved in public information about nutrition


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3. CONCLUSIONS AND RECOMMENDATIONS

Key conclusions: Based on the findings and results of this assessment we would like

conclude by stressing few important points that we this are important in the preparation

and implementation of future interventions for improving food security and nutrition in the

targeted area:

• The overall level of awareness, knowledge and information of key regional and local

authority actors about nutrition issues (nutrition in general and especially related to

children and women) remain generally low, both at the regional and local level.

• Although the local government administration should be a very important actor for the

promotion of the local development, its current role in dealing with the nutrition and

food security issues remains very limited throughout the study area.

• The main identified causes of malnutrition are linked with: (i) Community development

factors, mainly linked to the lifestyle and tradition; (ii) the level of community education

and information; and (iii) objective reasons mainly linked to limited agriculture

production and productivity, limited incomes, etc.

• The majority of the targeted areas have significant opportunities to increase the

production and availability of food products within their territory, which are still unused

and/or unexploited due to the lack of capacities of the local actors and of the population

to transform them into goods for the betterment of the living conditions.

• The exploitation of these existing opportunities for improving food security and nutrition

may be reached through well targeted interventions focusing mainly on: (i) improving

post harvesting, handling and processing tools, technologies and practices; (ii)

introducing new types of productions and food products, and; (iii) increasing the

quantity of production of the current crops and livestock. In addition, these

interventions be accompanied by information, trainings, advice and technical assistance

to the producers (on food security strategies and practices) and consumers (on nutrition

issues).

• Improving the capacities of the local actors (especially local government) to plan,

monitor, report and implement nutrition and food security interventions, improvement

of coordination of actions between these actors and the improvement of community

information and knowledge are three very important challenges for the improvement of

the nutrition situation in all targeted areas.


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Key recommendations: On the basis we recommend that the potential future interventions

for the improvement of the food security and nutrition in this area should be along the

following lines:

• Rising the awareness and improving the capacities of regional and local actors on roles

and responsibilities of each of the sector related to food security and nutrition issues,

causes and effects of malnutrition to the population, planning, implementation and

monitoring of food security nutrition interventions;

• Support the local governments in preparation and implementation, on participatory

basis, of food security and nutrition management plans for the 15 targeted commune

and municipality;

• Raise awareness within with teachers, students and parents at all schools and introduce

of food security and nutrition as well as knowledge about the local resources as a subject

at school education for children;

• Facilitate the process of better valorization of local resources by the local community in

favor of improvement of nutrition and local economic development in the area (working

with different community groups and local stakeholders;

• Promote and facilitate an active participation of the community (and especially the most

marginalized of families) in economic activities, fostering food production and

processing, economic diversification and thus improving chances for improved food

security and nutrition;

• Test and demonstrate new and improved agriculture and food production technologies,

tools and practices, including introduction of new types of crops (especially fruits and

vegetables) improved input use practices, etc., in order to improve household food diet;

• Provide technical assistance, advice and accompany the new initiatives enough long in

time so to ensure their sustainability and, take-up and replication of best business

models;

• Promote and facilitate cooperation and coordination between different local actors and

community members in tackling and resolving various issues that may arise during the

implementation of the food security and nutrition interventions.


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4. ANNEXES

Annex 1. Details of proposed interventions

MAIN COMPONENTS

Based on the findings of this assessment we propose the below scheme of possible

interventions for the improvement of the situation, which lies in three main components:

1. Capacity Building with Local Actors and LGUs

2. Community awareness raising and formation

3. Community based interventions through investments of formative character.

In this context, the components include:

Component 1: CAPACITY BUILDING with local actors and lGUs

1. LOCAL ACTORS AT REGIONAL LEVEL

(i) Joint Capacity Building Session (all sectors)

Joint training sessions and on-the-job session trainings with the personnel of the health,

social assistance and agriculture sectors, focusing on the drafting of the “Nutrition

Management Action Plan at Regional Level”, in full coordination between sectors Health,

Social Assistance, Agriculture.

(ii) Health personnel at Regional Level (ToT with the personnel operating at communes

level)

Being that the health personnel is dependent of the Regional Directories, the

updating/training sessions are proposed for the health personnel operating at commune

level: family doctors, nurses, midwifes, with the aim to prepare them as Community

Trainers (ToT) and to train/update them with the most recent working methodology to

deal with the problems of:

• Malnutrition and its effects;

• Basic elements for a healthy nutrition at family bases.

(iii) Social Assistance personnel at Regional Level (involving also the social assistance

personnel operating at communes level)


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According to the study carried out, the Sector of Social Protection (Assistance), results to

be very indifferent, not well informed and not actively involved in the management of

malnutrition problems in the target areas, although it should be the primary sector to get

involved in the solution/alleviation of the poverty problems and consequently also of the

malnutrition ones.

Aiming to the improvement of practices in the future, building of capacities of the

personnel of this sector and in order to engage them seriously in the management of

nutrition at communes’ level, we consider that the involvement of the personnel of the

social protection (assistance) sector in mirrored training sessions is of crucial importance.

The subjects to be dealt during the training sessions with the social protection personnel

could focus on:

• How to have a clear picture on the current nutrition situation in their territory for

those categories suffering malnutrition, and how can they plan the opportune

interventions for the situation improvement.

• Which are the possible alternatives of social protection (social assistance)

including nutrition elements, that could be offered to the extreme poverty

category.

• Kindergartens and schools, as practical models of services to offer in favor of the

children’s healthy nutrition, and to serve also as focal points for the training

(formation) of the parents and community.

In this context, every Commune, under the assistance of the social worker, will

have to try and aim to create (activate) such practical model (pilot

kindergarten/schools), where the social assistance sector will be actively engaged

and involved for the successful management of these pilots and at the same time

will work with the community and with the parents for the dissemination of the

healthy nutrition practices and notions.

The trainings delivered, will help the social protection personnel, both at regional

and communes level, to be actively involved and professional in dealing with the

poverty and malnutrition issues and problems.

2. AT COMMUNES’ ADMINISTRATION LEVEL (sectors’ specialists)

The capacity building process with the personnel (sector’s specialists and officials) could

be organized like on-the-job trainings, focusing on the “Drafting and definition of the

Nutrition Management Local Action Plan in the 15 Communes involved in the project”.

The drafting and definition of the Communes Nutrition Management Action Plan will be

the result of training and capacity building process with the communes’ administration

(officials/specialists), during which will be dealt issues like:


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• Approaches to implement food security and nutrition assessments at community

level;

• Local participatory planning of food and nutrition security for

communities/families within their territory;

• Improving food supply opportunities within the territory (through improving local

food production supply chain) and through the market outlets;

• Better exploitation of local food production and procuring resources and

opportunities;

• Ensuring food stock (storage) for the winter period and in emergency cases;

• Monitoring and reporting the nutrition situation, with the respective sector’s

responsibilities, including periodical reviews and analyses at the Commune

Council level about the food and nutrition security situation in their territory;

• The coordination among local authority actors intervening within a certain local

government unit on various aspects of food and nutrition management in their

territory;

• Basic elements of the ‘Nutrition Management Action Plan’ at local level.

The result of the training/capacity building process with the communes’

administrations will be the drafting and development of the Local Action Plan for the

management of nutrition situation at every commune involved in the project.

Component 2: COMMUNITY AWARENESS RAISING AND TRAINING

Target of this component will be the below groups:

• Teachers and Parents: In all the 9-grade schools in the target communes, should

implement at least once per year an informative training (workshop) session,

dealing with the subject “What are the malnutrition effects (consequences), the

basic standard for a healthy nutrition in the family and family members nutrition

practices”.

These seminars could be organized and implemented in cooperation with the

health personnel trained/updated at regional level, playing the role of community

trainers.

• Teachers and students/pupils: In all 9-grade schools, working with the teachers of

the subject “Vendlindja” or “Geography”, where in the education program or in

specific teaching hours, to integrate (include) topics like: “Introducing the students

with the local products and practical work to make them familiar with the local


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resources and alternatives of their exploitation (forest fruits, tea, medicinal herbs,

blackberries, raspberry, strawberries, etc.) for a healthy nutrition”.

These workshops and seminars would need to be accompaigned with leaflets or

broshures of practical use and their distribution also in community.

• Health Centers and Community:

o Organization of informative and training sessions by the health centers

(the territorial health personnel) with the women in the villages, dealing

with subjects like: (i) the standard of family nutrition (feeding) and the

malnutrition consequences; (ii) feeding culture in the family and the

care/attention towards nutrition of children and pregnant women.

o Formation activities of practical character with the groups of women in

villages at every commune, where to implement practical cooking

demonstrations containing diversity of products and out of the traditional

way of methods.

o Production and dissemination of didactic materials on nutrition and

diversity of family nutrition.

Component 3: COMMUNITY BASED PILOT DEMONSTRATIONS

This component aims to introduce, test and demonstrate practical and feasible models

that have a direct impact on improving food and nutrition security situation for the

population in the target areas. The creation of these pilot demonstrations would aims to:

• Activate the local resources and opportunities of the targeted areas having an

impact in the improvement of the nutrition situation;

• Improve the local food supply chains (from production to processing and

marketing) having an impact on food availability and accessibility;

• Introduce practical models of efficient exploitation of local opportunities to

increase the range/diversity of food products available and assessable for a

healthy nutrition;

• Improve families’ food preparation and cooking skills and knowledge to ensure

food and nutrition secirty using locally available products.

• Promote establishment of efficient farming models and non-agriculture income

generating activities in rural families, as opportunities to insure increased

incomes, increased purchasing power and thus improved food accessibility.

Indicative pilot demonstration topics could be:


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1. Transformation of local resources (forest fruits, various teas and herbs, strawberries,

blackberries, raspberries, etc) into feeding and curative products for the population.

• Establish nr.X pilot demonstration models. Main types of investments proposed:

processing technology; working tools; experience sharing/exchange; promotion

dissemination materials; technical assistance / accompaniment.

2. Agriculture and livestock products processing methodology, as an opportunity of

nutrition diversification.


processing technology; working tools; experience sharing/exchange;

promotion/dissemination materials; technical assistance/accompaniment.

3. Build-up the family garden food products supply chain (conveyor) for the family feeding

needs and market supply.


working tools (greenhouses, seeds, inputs, etc); experience sharing/exchange;

promotion/dissemination materials; technical assistance/accompaniment.

4. Promoting / incentivizing the income generating activities, to assure/improve the supply

with supplementary products


assistance for the business plan preparation; support through financial

schemes (grant combined with credit) for small scale business activities;

accompaigning and monitoring the businesses start-up and consolidation;

experience sharing/exchange.


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Annex 2. Aditional tables

1. The level of local authorities’ knowledge in Kukes about concepts and components of food security and malnutrition

Health

sector

Agriculture

sector

Social

sector

Education

sector

1)Overall food security concept


2.a) Food availability

2.b) Food accessibility

2.c) Food utilization

2.d) Stability

3) Overall concept of malnutrition


4.a) lack of proteins and energy

4.b) lack of vitamins and micronutrients

4.c) other issues (such as unbalanced

feeding, obesity, etc)

5) Differences-Food security/Nutrition

Legend: - high or medium; - low; - none or very low (insignificant)

2. The level of local authorities’ knowledge in Shkoder about concepts and components of food security and malnutrition

Health

sector

Agriculture

sector

Social

sector

Education

sector






2.d) Stability










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3. The level of local authorities’ knowledge in Tirana about concepts and components of food security and malnutrition

Health

sector

Agriculture

sector

Social

sector

Education

sector






2.d) Stability









4. The level of community knowledge about concept and types of malnutrition in Kukes region

Shis

hta

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c

To

po

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Za

po

d

Bic

aj

Tro

po

je V

j.

Bu

jan

Go

laj

Ka

stra

t



2.a) limited use of food products rich in energy and

proteins

2.b) limited use of food products rich in vitamins and

micronutrient

2.c) use of unbalanced food (i.e. too much fat,

carboihidrates, etc.,)


Legend: -moderate to high; -moderate to low; -low; -very low; -none


Ch

ap

ter:

4.

An

ne

xe

s

50

5. The level of community knowledge about concept and types of malnutrition in Shkoder region

Gru

em

ira

Rre

thin

a

Bu

sha

t

Iba

lla

Pu

ke



2.a) limited use of food products rich in energy and proteins

2.b) limited use of food products rich in vitamins and micronutrient

2.c) use of unbalanced food (i.e. too much fat, carboihidrates, etc.,)



6. The level of community knowledge about concept and types of malnutrition in Tirana region

Ka

me

z

Pa

sku

qa

n



2.a) limited use of food products rich in energy and proteins

2.b) limited use of food products rich in vitamins and micronutrient

2.c) use of unbalanced food (i.e. too much fat, carboihidrates, etc.,)



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PARTICIPATORY CAPACITY AND NEEDS ASSESSMENT FOR KEY LOCAL ... · PDF filePARTICIPATORY CAPACITY AND NEEDS ASSESSMENT FOR KEY ... Main topics proposed to be covered by ... The study