Short Course Report Nutrition and Food Security ... Nutrition... · Short Course Report ... Nutrition for infants and young children module pilot 4 Introduction This report documents

Short Course Report

Nutrition and Food Security - approaches to

improving the health of women and children

Nutrition for infants and young children

module pilot

‘Nutrition and Food Security –Approaches to improving the health of women and children’ Course Report: Nutrition for infants and young children module pilot

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Participants

Albertina Maria Domingas Belo Ermera District Hospital, Timor Leste

Amelia Huddlestone Sunrise Health Service, Ngukkurr Community

Crispin da Costa Araujo World Health Organisation, Timor Leste

Dirce Maria Soares Ministry of Health, Timor Leste

Emily Mooka Northern Territory Department of Health, Darwin

Filomeno Joao da Silva Baucau Referral Hospital,Timor Leste

Gloria Dalywater The Fred Hollows Foundation, Katherine

Joao Bosco da Costa Ministry of Health, Timor Leste

Maria Bower Sunrise Health Service, Katherine

Patricia O'Donoghue Anyinginyi Congress, Tennant Creek

Priscilla Martin Anyinginyi Congress, Tennant Creek Facilitators and presenters

Translators Expedito Belo Norman Piressva Monitoring and evaluation

Jenne Roberts Menzies School of Health Research Technical advisory group Jennifer Busch-Hallen Independent nutrition consultant Danielle Aquino The Fred Hollows Foundation Tracy Leon Boab Health Services, Western Australia Dympna Leonard Queensland Department of Health Heather Grieve Menzies School of Health Research

Developed by Menzies School of Health Research (Menzies), representing Compass: Women's and Children's Knowledge Hub for Health and funded by the Australian Agency for International Development (AusAID; the Australian Government’s international aid agency) and The Fred Hollows Foundation (TFHF).

Heather Grieve Menzies School of Health Research

Danielle Aquino The Fred Hollows Foundation

Cecily Dignan Independent nutrition consultant

Kate Mellor Menzies School of Health Research

Anna Roesler Menzies School of Health Research

Jodi Phillips Menzies School of Health Research

Gill Farlow The Fred Hollows Foundation (nutrition student)

Judith Myers Menzies School of Health Research

Tina McKinnon Northern Territory Department Health

Anne Neubauer Northern Territory Department of Health

Joshua Heath Northern Territory Department of Health


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Executive Summary

The pilot of the Nutrition for infants and young children module of the Nutrition and Food Security - Approaches to

improving the health of women and children short course was delivered over five days in October 2011 to six

Indigenous health workers from the Northern Territory and five nutritionists from Timor Leste.

The module was delivered in a participatory, activity-based manner, with learnings reinforced through activities and

games. Data and case studies from Timor Leste and the Northern Territory were used throughout the module, and

participants were encouraged to consider and discuss how the learnings could be applied in their contexts and

roles.

Participants were introduced to the definitions, causes and consequences of the different types of malnutrition,

and the importance of addressing these conditions. The role of macro and micro nutrients was presented, as were

the causes and consequences of common micronutrient deficiencies. Key messages for appropriate nutrition

practices, including breastfeeding, complementary feeding, the management of malnutrition and food safety and

hygiene were discussed; and the evidence to support these messages and examples of appropriate approaches to

improving nutrition for infants and young children were presented and analysed.

Field trips provided opportunities for participants to observe the learnings of the course in practice. With ongoing

support from the facilitators, the individual action plans developed during the course will assist the participants to

apply the learnings of the course in their work roles.

Participants reported that the activity-based, participatory approach optimised their understanding of the

learnings, and that the case studies were ‘’well mixed, interesting, not too much from any one context, just a good

mix’’. As with the Nutrition planning and programming module, participants reported that bringing the two

country groups together had been beneficial, stating that they “found it interesting to learn from each other and

learn examples from different places”.

The positive feedback was reflected by a substantial increase in the number of correct responses submitted to a

quiz undertaken at baseline and again at endline, and an increase in the number of correct responses for six of the

seven learning areas in the quiz.


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Introduction

This report documents the process and results of the pilot of the Nutrition for infants and young children module of

the Nutrition and Food Security - Approaches to improving the health of women and children short course, which

was delivered over five days from the 10th to the 14th of October 2011 at Menzies School of Health Research,

Darwin, Australia.

This module followed the Nutrition planning and programming module, which was delivered in May/June 2011;

and is the first of three elective modules to be piloted. The two remaining elective modules, Nutrition for

adolescent girls and women throughout the lifecycle and Food security and livelihoods, will be piloted in 2012.

Nutrition for infants and young children builds on the learnings of the Nutrition planning and programming module,

and is designed to provide participants with an understanding of the importance of appropriate nutrition for infants

and young children. Content includes the key messages regarding appropriate nutrition practices, the evidence to

support these messages and examples of evidence based, comprehensive and multi-stakeholder approaches to

improving the nutrition of infants and young children. Participants were encouraged to consider how the theory

presented related to their context, and how the learnings could be applied in their own work roles.

As with the Nutrition planning and programming module, this module was delivered in a participatory, activity-

based manner. Where possible, data and case studies from Timor Leste and the Northern Territory were used to

support the theory, and presentations were given by nutrition experts from these areas. Learnings were reinforced

through role-plays and games†.

Participants included six Indigenous health workers and community workers from the Northern Territory and five

nutritionists from Timor Leste‡.

† Refer to Appendix 1 for the course timetable ‡ Course materials, including presentations and factsheets were translated into Tetun for the participants from Timor Leste


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178 9

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Definition of the 1,000 Days

Definition of "Infants and young

children"

Number of participants who correctly answered "general"

questions (n=11)

Baseline Endline

Gloria from The Fred Hollows Foundation with her doll, Freddie

Day 1: Introduction and macro and micro nutrients

Learning objectives

The role of macro and micro nutrients in promoting normal growth and development in infants and young

children

The role and food sources of micronutrients most at risk of deficiency (such as iron, iodine and vitamin A),

international cut offs that define a public health problem, and the causes and consequences of common

micronutrient deficiencies

Essential skills and knowledge

List the macronutrients required for normal growth and development. Outline their function and common

food sources

List the common micronutrients required for normal growth and development. Outline their function and

common food sources

Identify the role and one food source of the micronutrient most at risk of deficiency in their local context

(such as iron, iodine or vitamin A)

Recognise the causes and consequences of the most common micronutrient deficiencies (such as iron, iodine

or vitamin A) in their local context

Theory presentations, activities and evaluation results

Following a welcome and an acknowledgment of the Larrakia

(Gulumbringin) people as the traditional custodians of the land;

participants were invited to reflect on the Nutrition planning and

programming module, and asked how they had integrated components

of the theory into their work roles. This session was noted to be

particularly valuable to the three participants who did not attend the

Nutrition planning and programming

module, and revealed that the concept of

the “upstream causes and downstream consequences of malnutrition” and the

planning cycle had been particularly valuable in participants’ work roles.

Participants made individual life size baby dolls. This activity served as an ice-breaker,

and the dolls were used to demonstrate theory throughout the course.

Participants were then reminded of the concept of the 1,000 Days and introduced to

the definition of the terms “infant” and “young child”. A baseline and endline quiz§

indicated that the number of participants who could correctly answer questions on

these two concepts rose from one to eight and from seven to nine respectively.

§ Refer to Appendix 2 for the baseline and endline quiz


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The group brainstormed the role of macro and micro nutrients before the theory on this subject was presented. An

activity allowed participants to discuss local food sources of macro and micro nutrients in their context, and to

write or draw the “average” diet of a child aged 12 months in their context. Based on local food guides,

participants made recommendations to improve this diet. Participants from Timor Leste added fish, koto beans and

eggs to the diet of rice in order to increase the protein content, and noted that children in Timor Leste often

consume too much “unhealthy sugar”. The Indigenous Australian group added fruit and yoghurt to wheat biscuit

cereal, substituted the standard pie for spaghetti with meat and vegetables for dinner, and identified the need to

remove tea, soft drinks and undiluted cordial from the diet of a 12 month old child.

The role and food sources of micronutrients at risk of deficiency, including

iron, iodine and vitamin A, as well as the causes and consequences of

these deficiencies and the international cut offs that define a public

health problem, were presented. Mixed-country groups completed a

table of details related to each nutrient prior to the theory presentation,

and amended these tables following the presentation.

In a recap game conducted in two mixed-country groups the following

day, both groups correctly answered 12 of 14 questions on the content

covered on day one. Questions on the reasons for recommending the use of a small amount of [iodised] salt in a

child’s diet, vitamin A rich foods, and treating xeropthalmia generated particular interest and discussion.

These results are consistent with the results of the baseline and endline quiz, which demonstrated that at least

seven participants were able to correctly answer each of the five questions related to macro and micro nutrients at

endline.

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27 8 8 8 7

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Role of protein Sources of micronutrients Treatment of iron deficiency anaemia (IDA)

Consequences of micronutrient deficiencies

Cut off to define an IDA public health problem

Number of participants who correctly answered questions on macro and micro nutrients (n=11)

Baseline Endline

Recap quizzes were conducted through games at the start of each day


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Day 2: Defining malnutrition; breastfeeding, complementary feeding and the management of acute and severe

malnutrition

Learning objectives

Definitions of malnutrition, including overnutrition and undernutrition

The causes and consequences of undernutrition, including the intergenerational cycle of stunting, mortality,

morbidity and the risk of adult chronic disease

Appropriate breastfeeding practices, and the evidence to support these practices

The causes and consequences of inappropriate breastfeeding practices

Evidence based approaches and strategies to protect, promote and support appropriate breastfeeding

practices

Appropriate complementary feeding practices, and the evidence to support these practices

The causes and consequences of inappropriate complementary practices

Evidence based approaches and strategies to promote and support appropriate complementary feeding

practices

The key components of an integrated approach to the management of acute malnutrition


Define and describe malnutrition

Define and describ the types of undernutrition (acute and chronic)

Describe the causes and consequences of undernutrition (acute and chronic), mortality, morbidity, the risk of

adult chronic disease and the intergenerational cycle of stunting; and identify these in their local context

Describe methods of identifying acute and chronic undernutrition

Describe appropriate breastfeeding practices and the evidence to support these practices

Identify inappropriate breastfeeding practices and the causes of these practices in their local context

Identify one evidence based approach to protect, promote and support appropriate breastfeeding practices

Describe appropriate complementary feeding practices and the evidence to support these practices

Identify inappropriate complementary feeding practices and the causes of these practices in their local

context

Identify one evidence based approach to promote and support appropriate complementary feeding

practices

Identify the key components of an integrated approach to the management of acute malnutrition


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5 2 29 10

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Type of malnutrition

identifiable by HAZ

Most common type of

malnutrition

% of child deaths in developing

countries attributable to undernutrition

Number of participants who correctly answered questions on malnutrition (n = 11)

Baseline Endline


Following an introduction to the definitions and

description of the types of malnutrition, including

acute and chronic undernutrition, overnutrition and

micronutrient deficiencies, and the causes and

consequences of these conditions, participants were

invited to undertake weight, height and mid upper

arm circumference (MUAC) measurements of their

dolls to demonstrate the identification of acute and

chronic undernutrition.

The baseline and endline quiz demonstrated that participants understood the content of this session well, with

substantial increases in the number of participants who correctly answered that stunting is the type of malnutrition

that can be identified by height-for-age (HAZ), that iron deficiency anaemia is the most common form of

malnutrition globally, and that over half of the deaths in children under five years in developing countries are

attributable to undernutrition.

In country groups, participants were asked to consider the causes and consequences of undernutrition in their

context, and to represent these on a “problem tree”, in which the roots represented the causes of undernutrition

and the leaves and fruits represented the consequences. The Indigenous Australian group identified poverty,

overcrowding, limited knowledge of nutrition and limited education as underlying causes of undernutrition in their

context; and a lack of knowledge of how to cook a variety of foods, limited

infrastructure for cooking, and eating take away food as immediate causes. The

consequences of undernutrition identified by this group included an increased risk

of chronic disease, including diabetes, coronary heart disease and obesity, in

adulthood. The group from Timor Leste identified poverty and re-building the

country following many years of war taking priority over nutrition initiatives as

underlying causes; and limited food supply, a dependence on staple foods and

children being fed a lot of sugar, as immediate causes. Poor growth and

development, including cognitive development, was emphasised as a consequence

of undernutrtion by this group, who noted that malnourished children may have

delayed motor and cognitive development, which can result in parents postponing

school entry and keeping children at home.

Filemeno and Joao Bosco from the Ministry of Health, Timor Leste working on a problem tree, indentifying the causes and consequences of undernutrition in Timor Leste


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Participants were introduced to the key messages for

appropriate breastfeeding and complementary feeding

practices, and the evidence to support these messages. Prior

to the theory presentations, country groups were invited to

construct a table indicating the current breastfeeding and

complementary feeding practices in their respective contexts.

Following the theory, participants were asked to consider

which of the practices they had identified were consistent

with the key messages and those which required improving.

The Indigenous Australian group reported that many young

mothers exclusively breastfeed only while in hospital and provide other foods such as formula, cows’ milk, ice-

cream, fruit juice, custard or cereal thereafter; while other young mothers exclusively breastfeed for more than six

months, delaying the introduction of complementary foods.

These inappropriate practices were attributed by the group to a lack of available breastfeeding education and

inappropriate food labeling. The group from Timor Leste noted that many children in Timor Leste receive diets with

inadequate nutrients during the complementary feeding phase, and attributed this to acute poverty, noting that

many families can often only afford to feed their children rice.

Feedback indicated that the sessions on breastfeeding and complementary feeding were particularly useful, with

one participant from Timor Leste reporting that “we [now] know about the kind of food that can be consumed by

the baby ... In Timor Leste porridge is only made from rice, but ... we learnt about mixing other foods with the rice

for children over six months, so they get the right macro and micro nutrients. We think about more things now, not

just if the baby is hungry, but also about the quality of what they eat, if it is appropriate for their age”.

A recap activity the following day in which participants worked together to develop a timeline of appropriate

breastfeeding and complementary feeding practices demonstrated that the group was able to recall the

recommendation that infants should be exclusively breastfed until six months of age, key messages about what

proportion of the daily nutritional requirements that can be met by breastmilk for infants and young children of

different ages and the importance of adding more energy to the diet as the child grows. Participants reported that

working as a single group was enjoyable: “it was fun and we could work together… we were all on the same page

on the nutrition issues”.

The number of participants who correctly answered questions on breastfeeding and complementary feeding rose

between baseline and endline for all but one question, for which there was no change (however, the high number

of correct responses at baseline for this question left little room for improvement), indicating that these sessions

were well understood.

Participants enjoyed working together to create a timeline for breastfeeding and complementary feeding


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5 86 70

4

8

12

Outpatient management of SAM

Management of SAM with complications

Number of participants who correctly answered questions on the managament

of acute malnutrition (n=11)

Baseline Endline

A presentation on evidence based approaches to the integrated management of acute malnutrition (IMAM)

recapped the importance of addressing malnutrition and introduced participants to the five key components of

IMAM. The recommendation that acute malnutrition without medical complications can be managed in the

community using ready to use therapeutic foods was presented, and the advantages of this approach were

discussed. A participant from Timor Leste then presented on IMAM practices in Timor Leste, which closely

reflected the key messages highlighted in the theory presentation.

Baseline and endline quiz results demonstrated a slight

increase in the number of participants who could correctly

answer one of the two questions pertaining to the

integrated management of severe acute malnutrition

(SAM), and a slight decrease in the number of participants

who could correctly answer the second.

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7 7 710

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10 10 9 10 9

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Appropriate duration of breastfeeding

Appropriate complementary

feeding practices

Appropriate feeding practices for infant under six months

Evidence for early initiation of

breastfeeding

Evidence for exclusive

breastfeeding

Introduction of milks other than breastmilk

Number of participants who correctly answered questions on breastfeeding and complementary feeding (n = 11)

Baseline Endline


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Day 3: Best practice in nutrition programming, the Healthy Under 5 Kids program and a field visit

Learning objectives

The importance of taking multi-stakeholder and comprehensive approaches to improving nutrition for

infants and young children


Describe the importance of taking multi-stakeholder and comprehensive approaches to improving nutrition

for infants and young children

Using case studies, identify the multi-stakeholder and comprehensive components of programs to improve

nutrition for infants and young children


A facilitator and a participant from Timor Leste co-presented theory on best-practice programmatic approaches,

and provided examples of how a variety of stakeholders had been engaged and a variety of evidence based

strategies incorporated into a program addressing malnutrition in Timor Leste.

A case study on anaemia prevention in Burma was presented, and participants were encouraged to critique this

case study against the recommended programmatic approaches presented earlier in the day. When asked to

consider the strengths of the program, participants noted that the program was based on “good data” and “looked

at the underlying causes”; the “target group was fully considered and well defined”; the program “addressed the

multiple causes of anaemia”; the “community and other stakeholders worked together”; the program was adapted

to the local context and the education component “made the women feel more empowered”. Participants

suggested that the program’s weaknesses included a failure to address “poor hygiene in the home” and “the high

rate of goiter”; and “not thinking enough about ongoing funding”.

A guest presenter from the Northern Territory Department of Health introduced the Healthy Under 5 Kids (HU5K)

program, a comprehensive monitoring and surveillance program which incorporates a variety of strategies to

prevent undernutrition in children under five years.

To reinforce the learnings of this session, participants visited Danila

Dilba Family Clinic, where they observed the components of the HU5K

program and spoke with staff about how the program operates in the

clinic and as an outreach service. When asked to reflect on the field

visit, participants identified good client follow up, good systems for

recording information, linkages with other programs, a good referral

system and the involvement of nutritionists as strengths of the

program; and the extensive use of computers as issue that may prevent

the model being adopted in resource-poor settings.

A field visit to the Danila Dilba Family Clinic


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Albertina from the Ministry of Health, Timor Leste, washing her hands as a part of the food safety and hygiene session

Day 4: Food safety and hygiene, an introduction to action planning and a field trip

Learning objectives

The importance of taking multi-stakeholder and comprehensive approaches to improving nutrition for

infants and young children (continued)

The importance of the Five Keys to Safer Food, and personal and environmental hygiene measures for

promoting appropriate nutrition

The causes and consequences of inappropriate Five Keys to Safer Food, and personal and environmental

hygiene practices


Using case studies, identify the multi-stakeholder and comprehensive components of programs to improve

nutrition for infants and young children (continued)

Name the Five Keys to Safer Food, and identify personal and environmental hygiene measures for supporting

good nutrition

Theory presentations, activities, and evaluation results

A case study of the Early Childhood Nutrition and Anaemia Prevention Project in

remote Indigenous Australian communities in the Northern Territory, northern

Queensland and the East Kimberly region of north-western Australia was presented,

and participants were encouraged to critique this case study against recommended

programmatic approaches. Participants noted that the strengths of the program

included undertaking formative research in the planning phase to identify the causes

of the problem, using reliable data, involving the community, the health sector and

non government organisations, educating key family members and using a variety of

integrated strategies to prevent anaemia. The group suggested that a remaining

challenge is to “get the belief of the community” in the program.

Participants were invited to re-visit a pre-course “Action Planning

Part 1” work sheet**, which required participants to identify nutrition

or food safety issues affecting infants and young children in their

contexts, the causes of these issues, and which of these causes they

can contribute to addressing in their work role. With the assistance

of facilitators, participants were invited to further consider the

nutrition or food safety issue they selected in the pre-course

worksheet (or another issue), the causes of this issue; and to identify

which cause or causes they are able to address in their work roles.

** Refer to appendix 3 for the Action planning part 1 - pre-course worksheet

Facilitator Danielle from the Fred Hollows Foundation discusses the “Action Planning Part 1” worksheet with Priscilla and Patricia from Anyinginyi Congress


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7910 11

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Ensuring food safety WHO Five Keys to Safer Food

Number of participants who correctly answered questions on food safety

(n=11)

Baseline Endline

Environmental health officers from the Northern Territory Department of Health presented key messages on food

safety and hygiene (based on the World Health Organisation Five Keys to Safer Food) and the evidence to support

these messages.

The learnings were reinforced with a field trip to the Mindil Beach Markets, where participants were given the

opportunity to view the food preparation areas of two food stalls, and invited to observe how the stall holders

implement food safety guidelines and how these are monitored. Participants were encouraged to identify practices

that were and were not consistent with the Five Keys to Safer Food, and investigated whether raw and cooked

foods were stored separately, separate utensils were used for handling raw foods, foods were thoroughly cooked,

and foods were stored and served at the correct temperatures.

During a verbal quiz, participants demonstrated a sound understanding of food safety, and listed storing food at the

wrong temperature, cross-contamination (transferring “bugs” from one food surface to another), and poor

personal hygiene as inappropriate food handling practices. In

a recap session the following day, participants could recall

four of the Five Keys to Safer Food, but were unable to recall

“use clean water and safe materials”. Consistent with these

results, the number of correct responses to the two baseline

and endline quiz questions on food safety rose between

baseline and endline, and all participants were able to identify

“keep food at safe temperatures” as one of the Five Keys to

Safer Food.


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Racing to the finish line in an activity to recap previous days' learnings

Day 5: Action planning

Learning objectives

Evidence-based, multi- stakeholder and comprehensive approaches to addressing nutrition priorities in their

local context


Using available data and resources, develop an action plan that incorporates evidence based, multi-stakeholder

and comprehensive approaches to protecting, promoting and supporting appropriate breastfeeding practices in

their local context; OR


and comprehensive approaches to protecting, promoting and supporting appropriate complementary feeding

practices in their local context; OR


and comprehensive approaches to improving the intake of the micronutrient most at risk of deficiency in their

local context; OR


and comprehensive approaches to improving the management of malnutrition in their local context


The final day of the module was dedicated to action plan development.

In country groups, participants were asked to brainstorm context

specific examples of key stakeholders and organisations to involve in

programs to improve nutrition for infants and young children, other

programs to link with, programs that have used multiple strategies to

address multiple causes, and data that can be used in planning and

targeting programs.

With support from the facilitators, the group worked together to develop an action

plan to address malnutrition prior to developing individual or small group action

plans.

Using the theory presented throughout the module, the individual or small group

action plans detailed the activities participants planned to undertake or change to

contribute to addressing one or more causes of malnutrition in their context. All five

participants from Timor Leste and three of the Indigenous Australian participants

developed action plans to address anaemia or low iron in children aged under two

years, utilising a combination of strategies including “educating mothers”, “cooking

classes”, “nutrition counseling”, “advertising on the community radio”,

“strengthening… IYCF at the hospital and community level through the health

Crispin from the World Health Organisation, Timor Leste and Gloria from the Fred Hollows Foundation during an activity to recap the previous day’s learnings


15

promotion program” and “giving out ‘Sprinkles’”. The remaining participants developed action plans to address

wasting through strategies such as “education on hygiene *and+ cooking classes”; and to improve low

breastfeeding rates by holding workshops at biannual women’s camps††.

Participants presented their action plans to the group, and received feedback from fellow participants and the

facilitators.

The action plans will be used for monitoring and evaluation purposes and participants will be supported to

implement their action plans in the months following the module.

†† Refer to Appendix 4 for participants’ action plans


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3

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Resources were clear and easy to understand

Presenters encouraged you to have your say and ask questions

Presenters made you want to learn

Presenters made topics interesting and engaging

Presenters were well organised

Presenters presented the material clearly

Presenters demonstrated a good knowledge/ understanding of

the content

Content coverved materials relevant to the learning

objectives

Content was useful for my work

Content was challenging enough

Content was informative

Content was interesting

Participant feedback (n=11)

Strongly agree Agree Disagree Stongly disagree

Discussion

Participant feedback

Participant feedback was generally positive.

Participants reported that the activity-based,

participatory approach consolidated their

understanding of the learnings, and that the

case studies were ‘’well mixed, interesting,

not too much from any one context, just a

good mix’’. As in the Nutrition planning and

programming module, participants reported

that bringing the two country groups together

had been beneficial, reporting that they

“found it interesting to learn from each other

and learn examples from different places”. It

was observed that both groups of participants

“are working to improve things for their own

people”; and that “there were people from

different places, departments and jobs, but

we all worked together”.

Working in groups, particularly for the daily

recap games, was reported to be beneficial,

as the groups could share information and

come to a consensus together.

Field trips were reported to be enjoyable and

a good opportunity to consolidate learnings.

Participants from Timor Leste found the field

visit to the Mindil Beach Markets particularly

useful, as there are plans to establish a similar

market in Timor Leste.


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Expectations

Lear

nin

g

General

“Learn new things” “Learn more skills”

“Increase my knowledge about practices and how to improve practices”

“Learn new things and new information”

Nutrition “Hear more [about] nutrition and food safety” “Learn new things about young children so I can take it back to my community to get better view on good nutrition”

“Learn … how to develop the nutrition/ nutrition treatment at the hospital”

Food safety

“How to implement better food safety”

Food security

“Learn more on food security”

Ob

serv

atio

n

“Visit other areas around Darwin” “Visit to the hospital and clinics to closely observe the preparation process and treatment”

“Do more field trips out of the office to local communities”

“Go to other community to share good experiences”

“Visit to health care center in rural areas”

“Field trip to make a comparison of the situation between Timor and rural Australia”

Ne

two

rkin

g

and

sh

arin

g

“Share experience about nutrition intervention program”

“Sharing good ideas regarding food safety”

“Experience sharing between Timorese and Australian Aboriginals people”

“Sharing ideas with each other”

While all participants agreed or strongly agreed that the content was interesting, informative, and challenging

enough, two of the 11 participants (18%) disagreed with the statement that “the content is useful for my work”. All

participants agreed or strongly agreed that the

module covered material relevant to the learning

objectives, and that it was well planned and

organised. When asked about presenters, all

participants agreed or strongly agreed that the

presenters demonstrated a good knowledge and

understanding of the content, presented clearly, were

well organised, made topics interesting and engaging,

and encouraged participants to ask questions.

While seven participants (64%) agreed or strongly

agreed that the resources were clear and easy to

understand, four participants disagreed (36%), and it

was reported that participants would have found it

useful to receive a manual of the course notes,

factsheets, and the case studies on the first day of the

module.

Participants’ expectations

Participant expectations of this module were gathered on the first day of the course, and were generally aligned

with the content of the course. In summary, participants expected to gain knowledge and skills in nutrition, food

safety and food security; to observe nutrition programs in practices; and to share their experiences with other

participants.


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Baseline and endline quiz results

Participants completed a 20 question quiz at the beginning

(baseline) and at the end (endline) of the module. At baseline,

a facilitator read each question aloud, and participants

recorded their response to each question on a square of paper

and handed it in before the next question was read out.

Participants noted that they preferred this method to a

written test because they felt less pressure and there was

plenty of opportunity to think through each option and seek

clarification. At endline, the quiz was conducted as a written

test, and participants were asked to circle the correct answer.

Comparison of the baseline and endline quiz results

demonstrates that while at baseline, participants answered an

average of 10 out of 20 questions correctly, by endline, this

had improved to 15 of the 20 questions.

Participants’ knowledge improved in 17 of the 20 questions.

For two questions - those relating to sources of micronutrients

and the evidence for exclusive breastfeeding - the number of

correct answers did not change from baseline to endline

(however, it is worth noting that the baseline correct response

rate was high for both of these questions, at eight out of 11

(73%)) and 10 out of 11 (91%) correct answers respectively,

leaving little room for improvement). For the question relating

to the management of severe acute malnutrition (SAM) with

complications, the number of correct answers fell slightly,

from eight out of 11 (72%) to seven out of 11 (64%).

At baseline, only one participant correctly answered a

question on the definition of the 1,000 days; and only two

participants correctly answered questions on the percentage of child deaths in developing countries attributable to

undernutrition, the most common type of malnutrition globally, the cut off to define an iron deficiency anaemia

public health problem, the appropriate duration of breastfeeding, and the appropriate time to introduce milks

other than breastmilk. These questions saw the greatest improvement between baseline and endline, with over

half of participants correctly answering each of these questions at endline.

Baseline and endline quiz results

Subject area/ question Baseline Endline

General

Definition of the 1000 Days 1 8

Definition of "Infants and young children" 7 9

Macro and micro nutrients

Role of protein 6 7

Sources of micronutrients 8 8

Treatment of IDA 4 8

Consequences of micronutrient deficiencies 6 8

Cut off to define an IDA public health

problem 2 7

Malnutrition

Type of malnutrition identifiable by HAZ 5 9

Most common type of malnutrition 2 10

% of child deaths in developing countries

attributable to undernutrition 2 7

Breastfeeding and complementary feeding

Appropriate duration of breastfeeding 2 6

Appropriate complementary feeding

practices 7 10

Appropriate feeding practices for infants

under six months 7 10

Evidence for early initiation of breastfeeding 7 9

Evidence for exclusive breastfeeding 10 10

Introduction of milks other than breastmilk 2 9

Management of acute malnutrition

Outpatient management of SAM 5 6

Management of SAM with complications 8 7

Food safety

Ensuring food safety 7 10

WHO Five Keys to Safer Food 9 11

TOTAL 107 169


19

77%

95%

59%

82%

79%

69%

77%

48%

73%

59%

53%

35%

64%

30%

0% 50% 100%

All questions

Food safety

Management of malnutrition

Breastfeeding and complementary

feeding

Malnutrition

Macro and micronutrients

General

Baseline and endline results by subject area

Baseline Endline

Analysis of baseline and endline results by subject area

demonstrates improvements in all subject areas, with the

exception of the management of acute malnutrition, for which the

number of correct answers did not change. The greatest

increases in the percentage of participants who correctly

answered questions in each subject area were observed in the

“general” (30% to 77%); malnutrition (35% to 79%); and

breastfeeding and complementary feeding (53% to 82%) subject

areas.

Monitoring and Evaluation Coordinator feedback

A Monitoring and Evaluation (M&E) Coordinator was engaged to

develop and implement an M&E framework for this module, and

to collect feedback from participants.

The M&E Coordinator reported that “overall the Short Course was

very successful” and that “by the end of the week, all participants

[could] articulate the relevance of the course and the content of

this module to their work and to the development of their

country”. She further reported that “most participants were

consistently engaged in the presentations, discussions and case

studies [and] the pitch of the course was appropriate for most

participants”.

The M&E Coordinator recommended a greater emphasis on linking learning outcomes to the “policy priorities,

programs and nutrition problems experienced in the settings in which participants work” and noted that where this

was achieved during this module, the response was very positive. She further recommended that the elective

modules should more closely follow the planning cycle presented in the Nutrition planning and programming

module.

While acknowledging that the delivery of this module was a pilot, and “not necessarily representative of how the

course will be delivered during roll out”, the M&E Coordinator observed that there were planning difficulties and

“last minute … rewrites and preparation of material”. She recommended that the development of a trainers’

manual and a participant manual would prevent some of the confusion caused to facilitators and participants by

these schedule and content revisions.

These recommendations will be considered in the development and delivery of future modules.


20

Thank you to all the participants for your active participation and your willingness to share

your knowledge, experiences and ideas.

Thanks also to the facilitators, presenters, translators, consultants, members of the

reference group and technical advisory group and Menzies support team; and to the

funders of this pilot, AusAID and The Fred Hollows Foundation.

“This is a war on malnutrition and this knowledge is our weapon”

[Participant quote during the course]


21

Appendix 1: Course timetable Day 1 0800 – 0830 House keeping and pre-course survey (expectations) 0830 – 0840 Welcome and acknowledgement of the traditional landowners 0840 – 0920 Reflection on Core module 0920 – 1000 Baseline quiz 1000 – 1015 Morning tea 1015 – 1130 Course purpose, expectations management and ice breaker 1130 – 1245 The role of macro and micro nutrients 1245 – 1330 Lunch 1330 – 1430 Micronutrients at risk 1430 – 1445 Afternoon tea 1445 – 1600 Micronutrients at risk continued 1600 – 1630 Summary of the day/monitoring & evaluation Day 2 0815 – 0900 Recap quiz 0825 – 0830 Monitoring and evaluation 0900 – 1000 Malnutrition: definitions, measuring, causes and consequences 1000 – 1015 Morning tea 1015 – 1040 Malnutrition causes and consequences; problem tree exercise 1040 – 1200 Appropriate breastfeeding practices and evidence; causes of inappropriate practices and evidence based approaches and strategies to protecting, promoting and supporting appropriate breastfeeding practices 1200 – 1230 Lunch 1230 – 1430 Appropriate complementary feeding practices and evidence; causes of inappropriate practices and evidence based approaches and

strategies to promoting and supporting appropriate complementary feeding practices 1430 – 1500 The key components of an integrated approach to the management of acute malnutrition 1500 – 1515 Afternoon tea 1515 – 1545 The key components of an integrated approach to the management of acute malnutrition continued 1615 – 1630 Summary of the day/monitoring & evaluation Day 3 0800 – 0805 Monitoring and evaluation 0805 – 0845 Making a timeline: Appropriate breastfeeding and complementary feeding practices 0845 – 0900 Team photo 0900 – 1000 IMAM case Study: Healthy Under 5 Kids program NT 1000 – 1015 Morning tea 1015 – 1100 Multi-stakeholder comprehensive approaches to improving nutrition 1100 – 1200 Case study: Anaemia project in Burma 1200 – 1245 Lunch 1245 – 1400 Case Study: Anaemia project in Burma continued 1400 – 1630 Field visit to Danila Dilba Family Clinic Day 4 0800 – 0815 Feedback from field visit to Danila Dilba 0815 – 0820 Monitoring and evaluation 0820 – 0845 Recap quiz 0845 – 1000 Case study: Anaemia Prevention in Indigenous Australian Communities 1000 – 1015 Morning tea 1015 – 1100 Case study: Anaemia Prevention in Indigenous Australian Communities continued 1100 – 1200 Pre-course worksheet reflections 1200 – 1300 Lunch 1300 – 1330 Pre-course worksheet reflections continued 1330 – 1445 WHO Food Safety 5 key messages theory presentation 1445 –1600 Field visit to Mindil Beach markets 1600 – 1630 Recap quiz Day 5 0830 – 0825 Recap of WHO 5 keys to food safety and hygiene 0825 – 0930 Food safety and hygiene in Timor Leste case study 0930 – 1000 Action planning 1015 – 1030 Morning tea 1030 – 1115 Action planning continued 1200 – 1230 Daily recap activity quiz 1230 – 1315 Lunch 1315 – 1430 Action planning reporting back to the group 1430 – 1445 Afternoon tea 1445 – 1515 Post course/end line survey conducted 1515 – 1600 Post-course monitoring and evlaluation 1600 – 1645 Presentations of certificates, photos and thanks you to participants and facilitators 1645 – 1700 Presentation of the group monitoring and evaluation results


22

Appendix 2: Baseline and endline quiz

1. In developing countries what percentage of deaths of children under 5 years can be attributed to undernutrition:

a. more than a half

b. less than 2 %

c. almost a quarter

d. about 20 percent

e. I don’t know

2. Globally the most common type of malnutrition is:

a. stunting

b. wasting

c. iron deficiency anaemia

d. overweight

e. I don’t know

3. The term “infants and young children” refers to:

a. only children under 5 years

b. only children under 10 years

c. only children under 1 year only

d. only children under 18 months

e. I don’t know

4. Measuring height for age (HAZ) can be used to identify a child with:

a. severe acute malnutrition

b. moderately acute malnutrition

c. stunting

d. overweight

e. I don’t know

5. Breastfeeding should:

a. stop as soon as the child turns 2

b. stop as soon as the child is able to feed itself

c. continue until the child is at least 2 years

d. continue exclusively until the child is at least 2 years

e. I don’t know


23

6. The period between conception and 2 years of age is known as:

a. 1000 days

b. the critical window of opportunity to promote optimal growth and development through good nutrition

c. both a and b

d. neither a nor b

e. I don’t know

7. Protein is:

a. a micronutrient that protects against blindness

b. a macronutrient that is important for body building and growth

c. a macronutrient that is the body’s preferred source of energy

d. none of the above

e. I don’t know

8. In addition to breast milk, babies under the age of six months require:

a. no other food or drink

b. only additional fluid, such as water, in warm climates

c. a good source of iron, such as red meat

d. a source of carbohydrate, such as rice or potato

e. I don’t know

9. Which of the following statements is true:

a. orange fruits and vegetables, such as papaya and carrots, are good sources of vitamin A

b. liver is a good source of iron

c. seaweed is a good source of iodine

d. all of the above

e. I don’t know

10. A child with severe acute malnutrition (SAM) (“krekas maran”) should only be treated as an outpatient and at home if he or she:

a. lives too far from the nearest hospital and cannot afford medical treatment

b. has a medically trained family member and access to foods at home

c. has no medical complications, has a good appetite and is already receiving care from a traditional healer

d. has no medical complications, has a good appetite, has access to ready to eat therapeutic foods, and will

receive regular follow up according to national/local protocols

e. I don’t know

11. A child with severe acute malnutrition (SAM) and medical complications should be:

a. admitted to the nearest health centre/post for outpatient care

b. treated in hospital for stablisation of medical complications and nutrition rehabilitation


24

c. be treated in the home with ready to eat therapeutic foods at home

d. offered more breastmilk to increase appetite

e. I don’t know

12. Early initiation of breastfeeding has been shown to:

a. reduce neonatal mortality

b. cause breast engorgement

c. increase the risk of respiratory illness

d. delay wound healing after a caesarian section

e. I don’t know

13. Exclusive breastfeeding for six months reduces the risk of:

a. pneumonia and diarrhoea

b. allergies

c. infant mortality

d. all of the above

e. I don’t know

14. In order to ensure food safety:

a. cooked food should be kept at a temperature between 5 and 60 degrees Celsius

b. food should never be boiled

c. cooked and raw food should be stored separately

d. once cooked, food should never be re-heated

e. I don’t know

15. Intermittent iron supplementation is recommended in populations where

a. the soil is low in iron

b. red meat is not eaten

c. the prevalence of iron deficiency anaemia (IDA) is more than 20% in children under 5 or school age children

d. all of the above

e. I don’t know

16. Which of the following statements is true?

a. Children require other milks, in addition to breastmilk, at the age of six months as an additional source of

iron

b. Children require other milks, in addition to breastmilk, at the age of nine months to ensure good bone

development

c. It is recommended that milks other than breastmilk should not be given to a child before the age of five years

d. It is recommended that milks other than breastmilk should not given to a child before the age of 12 months

e. I don’t know


25

17. Which of the following statements is true?

a. iron deficiency can cause night blindness

b. vitamin A deficiency can cause goitre

c. iodine deficiency can cause anaemia

d. none of the above

e. I don’t know

18. An appropriate complementary feeding practice is to:

a. give thick mashed foods from the age of six months of age

b. give thin runny foods from the age of six months

c. replace breast milk with complementary foods when the child is weaned at the age of six months

d. stop complementary feeding when the child has a common illness

e. I don’t know

19. If a child has iron deficiency anaemia (IDA), he or she should?

a. seek treatment and drink tea with meals as tea helps with iron absorption

b. seek treatment and eat foods that are rich in vitamin C such as tomatoes and oranges with meals, as vitamin

C assists with iron absorption

c. seek treatment and stop breastfeeding until the iron deficiency is cured

d. all of the above

e. I don’t know

20. Which of the following is one of the WHO five keys to safer food?

a. freeze all left over food

b. keep food at safe temperatures

c. wear a hairnet when preparing food

d. shower every day

e. I don’t know


26

Appendix 3: Action planning part 1 – pre-course worksheet

During the next module of the short course, you will be asked to work more on your Action Plan, which will identify the ways you can improve the nutrition or

food safety of children aged under five years in the context in which you work. This worksheet will be referred to throughout the short course and will form

the basis of an action planning session. Please complete this worksheet and send it back to us prior to the course, and feel free to contact Kate at

[email protected] if you need any help. If you are unable to send it back prior to the course, please bring a hard copy with you to the course.

Thank you!

Details of the nutrition or food safety issue How do you know this?

What is a nutrition or food safety issue

affecting children aged under five years in the

context in which you work?

What are the causes of this issue in your

context?

Which of these causes can you contribute to

addressing in your job?

mailto:[email protected]


27

Appendix 4: Action Plans

Nutrition issue you will contribute to addressing with this action plan:

Iron deficiency anaemia in the NT Indigenous communities (anaemia prevention project) in Ngukurr

Causes of this issue: Iron deficiency, uneducated mothers, no food and overcrowding

Which of these causes can you address in your job? Mothers are not educated about iron deficiency anaemia and how it affects their children

What are you going to do to

address these causes?

How are you going to do it? Who will be involved? When will it happen? How will you check?

Educate mothers with children

aged 6 months -24 months

about foods high in iron with a

mix of group education and 1

on 1.

Give out Sprinkles

Continue to work on

existing activities including

Cooking with mothers

Taking them out to do

some education

Increase feeding practice

education

House to house visits

Every week focus on

different key messages

Do new posters with

pictures of participants

Do more posters in

traditional language

Health care staff

Family of the kids

Sprinkles program

The Fred Hollows Foundation

Support workers

Family as First Carers

Play group

Youth centre

Community leaders

Next week

Start of November

Then twice a month

MSC

Food intake

Monitoring form

Key message check in the

community

Questions


28

Nutrition issue you will contribute to addressing with this action plan: Wasting or skinny children in the Bagot community

Causes of this issue: Poor handling of food, healthy food prices too high, no fridges in houses, too many people in one house

Which of these causes can you address in your job? Poor handling of food and healthy food prices too high

What are you going to do to address these causes?


Education on hygiene

Talk to community members to organise the

training

Speak with different departments so that

programs can be linked

Collect resources on hand washing, toilet

flushing and the importance of nose blowing

and hand out to participants

Organize guest speakers; including on cooking

hygiene

Conduct the training

NT government

Health promotion officers

Environmental health

officers

Bagot community leaders

Community groups

Women’s groups

Council members

Clinic

Nutritionists

30th October 2011

Resource collection

Training to commence

at the end of November

and then weekly

Community feedback

Cooking lessons Source funding possibly through Darwin city

council

Collect mothers to attend

In the community hall

Collect cook books to source recipes

Red Cross

Mothers groups

End of the Month Asking women’s groups

Feedback

Attendance numbers

Budget training for mums Hold a community meeting to ask if they want

to learn about budgeting

If there is community interest then hold a

community training session with external

experts

Red Cross and Amity

Community health workers

Community members

Council members

January 2012 Community feedback

Attendance numbers


29


Anaemia

Causes of this issue: Mothers are not educated about iron deficiency anaemia

Which of these causes can you address in your job? Mothers are not educated about iron deficiency anaemia and how it affects their children




Educate mothers with

children aged 6 months -24

months about foods high in

iron with a mix of group

education and 1 on 1

Give out Sprinkles

Support the community based

workers – by phone, and

through the clinic workers

Continue to provide cooking

activities and increase the

number of participants at the

cooking activities. Arrange child

care for the mothers to allow

them to attend

Educate the mothers about the

high rate of anaemia through

the community leaders. Have

the CBW’s approach the Elders

Work closely with the physical

activity officer from Sunrise to

visit the community

Provide support to CBW’s with

training – by notifying CBW’s of

trainings and organising them

Community support workers

Nutritionists

Community based workers

The Fred Hollows Foundation

Health centre staff

Family as First teachers

Ask elders to attend the cooking

activities

Other Sunrise staff

Next week

Start of November

Then twice a month

Food Intake

Monitoring form

Most significant change


30


Children 0-2 years of age low iron

Causes of this issue: Low intake of iron

Which of these causes can you address in your job? Low intake of iron




Continue to see current

Sprinkles mums Through the program Community based workers

SWBSC

Mums and nannas

Once every 4 weeks

Pre-testing

Monitoring forms

Increase the numbers of new

mums by having a community

BBQ for new and potential

mums on the Sprinkles

program

Engage community

Call the community every

two weeks

Call the health centre

Get photos from mums and

children already on Sprinkles

Make posters

Mail posters out to the CBW

to put up in the community

See if any other groups are

doing similar things e.g.

Recross , NT Government,

Talk to local community

radio with CBW’s & SWSBSC

Promote using local radio

station (BRACKS)

Community based workers

SWBSC

Mums and nannas

Community elders

Community leaders

Every fortnight have a BBQ

2 weeks starting October

28th

Every 2 week change the

photos

Pre-testing

Monitoring forms


31


High incidence in iron deficiency anaemia in East Timorese infants and young children

Causes of this issue: Bad environment, no clean water, education is low, parents have too many children , mother dies and no breast feeding for children

Which of these causes can you address in your job? Promote local food with good nutrition , demonstrate how to cook local food properly, PSH distribution, inpatient transfer for children with severe malnutrition and outpatient, weight measurement for children 0-5 and promote the importance of nutrition in one’s life to the community through local authorities and information sharing to link the relevant parties




Education, Nutrition

counselling and Promotion

Will be conducted together

with the secondary

programme together with

the Breastfeeding for

children 0 to 24 months

program to the families and

patients in general

Midwifes, nurses, nutritionist, NGOs It is an ongoing

programme and we

will try to make it

better

Post test using the

flip charts

Door to door visits


32


Low breast feeding rates in Tennant Creek

Causes of this issue: No education programs for mums and babies and children under 5

Which of these causes can you address in your job? No education programs for mums and babies and children under 5




Develop a program for

mothers with disabled children

and include information on

breast feeding and

complementary feeding

Obtain support from

manager

Research -

visit other services in our

community including Sunrise

and TFHF

Discuss possibilities with

FACS, clinic and hospital

Meet with the child health

nurse

Meet with the community

women (including the 10

women currently seeing)

Grant/funding

Gain support from the board

Develop and write a program

Community women

NT health child health nurse

Anyinginyi clinic

Anyinginyi Stronger Family

Women’s refuge

Julikani

Hospital

Julikkari elders

High school Stronger Sisters

Anyinginyi sports and rec child care

and gym

Family and children services

Child counsellors

Women’s health nurse

Develop the

program design in

2011, early 2012,

Feb 2012 visit other

organisations in the

area, and end of Feb

2012 start program

Report

Review

Assess that the right women

are coming for the right

reason

Community feedback

NT child health nurse

feedback

Julikkarli feedback

High school Stronger Sister

feedback

Funding received

Feedback from FACS

The board

Attendance sheets

Results from program


33


Low breast feeding rates (and possibly low iron levels)

Causes of this issue: Lack of education Community pressures

Which of these causes can you address in your job? Lack of education




Discuss nutrition and the

nutrition needs of women at

women’s camp held twice a

year

Discuss nutrition education

needs in our women’s

camp

Work with support worker

from the hospital to find

out about young mums

Source education material

Source and set up venue

Find out from PHU (public

health unit) and the other

Anyinginyi health centre

programs occurring

Discuss with other

Anyinginyi workers what to

discuss at the camp in May

Mothers with babies

Hospital support worker

Community family workers

Social worker

Develop a program Nov

/Dec 2011

Run the course mid 2012

(April)

Attendance sheet

Evaluation


34


Anaemia prevention for children 6 to 24 months

Causes of this issue: Pregnant women not had taken iron tables and not eating iron rich diet Lack of breastfeeding needs to be advocated and nutrition programme focus on breastfeeding from the national down to village level Lack of foods containing iron (for example: bean, red meat)

Which of these causes can you address in your job? As above




Nutrition awareness advocacy

campaign

Strengthen nutrition

education on Anaemia

IYCF at the hospital and

community level through the

health promotion program on

anaemia prevention and

treatment

Develop and implement IEC

materials, including a

pamphlet , and brochure on

the anaemia program

Health workers

Communities workers, MSG

PSF

January 2012 Check list monitoring

Assessment

Distribution of sprinkles Develop guidelines, and

conduct trainings on sprinkles

Health workers, communities

workers, MSG, PSF

DPHO nutritionist and DPHO

maternal and child health workers

January 2012 Check list monitoring

Assessment through the

monitoring and supervision

program


35

Appendix 5: Fact sheets Fact sheet: Breastfeeding

Key messages and the evidence

Breastfeeding is the natural and normal way of feeding babies from birth. Breastmilk provides an unequalled source

of nutrition and protection against infection. In addition, breastfeeding benefits the physical and mental health of

both mother and baby.

Initiation of breastfeeding within one hour of birth

Early initiation of breastfeeding reduces the risk of neonatal death by 19-22%

Colostrum, the first, yellowish milk, protects infants from illness

Breastfeed exclusively for the first six months – no teas, no water, no honey – nothing but breastmilk

Breastmilk contains all the energy, other nutrients and water infants need for the first six months of life

Exclusive breastfeeding reduces infant mortality and protects the infant from acute respiratory illness, diarrhoea

and other infections; and reduces the risk of chronic disease later in life

Continue to breastfeed until two years and beyond

Breastmilk continues to provide a significant proportion of energy and other nutrients into the second year of life

Breastfeed frequently, on demand, day and night

Baby-led feeding ensures baby’s cues are responded to

Frequent feeding helps stimulate and maintain milk production

Continue to breastfeed when the child or mother has a common illness

The nutrients and protective factors in breastmilk are important when the mother or infant is ill

Frequent breastfeeding meets additional fluid and energy requirements during illness and helps with recovery

Avoid artificial nipples – if the mother can not be with the baby, she should express milk and the baby should drink

from a cup

Artificial nipples increase the risk of illness, especially diarrhoea

Cup-feeding provides physical stimulation and closeness and does not interfere with the infant’s natural feeding

reflexes

Infants can be cup fed from any age

What works?

Several approaches have been found to improve breastfeeding practices, including: antenatal and postnatal

counselling by trained peers and health workers; targeted mass media promotion; and baby friendly hospital and

community initiatives. Successful programs use multiple strategies to address the multiple causes of inappropriate

breastfeeding practices, utilise relevant data, involve key stakeholders and build into other programs, plans and

policies.

Further information

Further information about breastfeeding can be found at: http://www.who.int/topics/breastfeeding/en/

http://www.who.int/topics/breastfeeding/en/


36

Fact sheet: Complementary Feeding

Key messages

Breastmilk alone provides enough energy and other nutrients for the first six

months of life. After six months of age, extra nutrients are required for healthy

growth and development. Complementary foods should be introduced, and

breastfeeding should be continued until two years and beyond.

Start to give foods when the baby is six months old and continue to

breastfeed until the child is two years or older

Feed baby responsively- allow baby to lead feeding and respond to cues

Practice good hygiene and proper handling of food

Increase the amount of foods as the child gets older, and continue to breastfeed

Change the texture and consistency to match the growing child’s needs and abilities

In addition to breastmilk, as babies get older feed frequently, and increasing the number of times a day the baby

is fed

Feed babies a variety of foods, in addition to breastmilk

Give babies fortified foods or micronutrient supplements when needed

Continue to breastfeed during illness and give extra food, more often after illness

What works?

Several approaches have been found to improve complementary feeding practices, including: behaviour change

counselling by trained peers and health workers; and increasing the energy and micronutrient density of

complementary foods at home and through simple technologies. In food insecure populations, provision of food

supplements should also be considered. Successful programs use multiple strategies to address the multiple causes of

inappropriate complementary feeding practices, utilise relevant data, involve key stakeholders and build into other

programs, plans and policies.

Further information

Further information on complementary feeding can be found at:

http://www.who.int/nutrition/publications/infantfeeding/9789241594745/en/index.html

http://www.who.int/nutrition/publications/infantfeeding/a85622/en/index.html

http://www.who.int/nutrition/publications/infantfeeding/9789241594745/en/index.html

http://www.who.int/nutrition/publications/infantfeeding/a85622/en/index.htm


37

Fact sheet: Management of acute malnutrition

Key messages

Community based management is a new way of managing acute malnutrition. Previously all children with acute

malnutrition were referred to hospital. However, many children do not access inpatient care, and a community

based approach is more feasible and appropriate. The use of ready to use therpeutic foods (RUTF), has enabled

supplementary feeding in the community. Integrating community, outpatient and inpatient care, ensures more

children receive timely, targeted care.

An integrated approach to management of malnutrition includes five key stages in the continuum of care:

1. Community mobilisation and actively finding cases

2. Outpatient management of severe acute malnutrition (SAM) without medical complications

3. Inpatient management of acute malnutrition with medical complications

4. Management of moderate acute malnutrition (MAM) without complications

5. Services and/or programs to prevent undernutrition

What works?

Summary of management of acute malnutrition

Further information

Further information on the management of acute malnutrition can be found at:WHO:

http://www.who.int/nutrition/topics/malnutrition/en/index.html

http://www.who.int/nutrition/topics/malnutrition/en/index.html


38

Factsheet: Program approaches

Key Messages

When developing a nutrition or food security program, there are four

important programmatic approaches to consider:

1. Use data to plan and target

For example, review existing health data or collect new data to identify the

nutrition and food security issues for 0-5 year old, and identify the immediate

and underlying causes of these issues

Helps identify the issue

Helps identify the best way to address the issue

Ensures that the right people are targeted, with the right approaches

2. Link programs into existing systems, programs, plans or policies (Integrated)

For example, distribution of ready to use food supplements by an existing network of community health

volunteers/workers

Enables resource and information sharing

Prevents duplication

Improves reach

Ensures that all stakeholders are working towards a common goal

3. Involve a range of relevant key stakeholders (Multi-stakeholder)

For example, involving the community, the government, non-government organisations (NGOs), women’s groups

and health centres at all stages of planning, implementing and evaluating and reviewing the program

Ensures that the problem is well-understood and there is a shared understanding by everyone involved

Ensures that potential linkages are identified

Ensures that the right people are involved and the community has ownership of the program

Enables cooperation and resource sharing

4. Include multiple strategies, known to work, to address multiple causes (Comprehensive and Evidence Based)

For example, provide nutrition education along with vitamin

supplementation, to encourage dietary change whilst ensuring babies are

receiving the nutrients they need in the short term

Broader range of causes are addressed, in more a holistic way

Ensures that the results of the program are sustaina


39

Fact sheet: Micronutrients at risk of deficiency – Vitamin A, Iron, Iodine

Nutrient at risk

Role Food sources Cause of deficiency Consequence of deficiency Global prevalence in children under 5

International cut offs for public health significance

Iron Red blood cell production, normal growth and development

High bio-available: breastmilk, liver, red meat, other meat Low bio-available: dark green leafy vegetables, eggs, legumes

Inadequate intake of iron; malaria; worm infections causing blood loss

Increased risk of mortality and morbidity; impaired mental and physical growth and development

47%

Intermittent iron supplementation recommended where more than 20% of children under five or school-age children are iron deficient

Vitamin A Maintains good immune function, protects against illness such as measles and diarrhoea, required for eye function

High bio-available: Liver, fish, dairy and eggs Low bio-available: plant sources, such as orange-coloured fruits and vegetables

Inadequate intake of vitamin A

Increased risk of mortality and morbidity, night blindness, xerophthalmia, and permanent blindness

33%

A severe public health issue when more than 20% of the population have are vitamin A deficient

Iodine Required for thyroid function and to maintain metabolism for normal growth and development

Fish, bread; baked with iodised salt, eggs, dairy and breast milk; plant and animal sources from iodine-rich soil

Inadequate intake of iodine; inadequate iodine in the soil leading to inadequate iodine in food sources; not using iodised salt

Goitre; impaired thyroid function; cretinism; impaired growth and mental and physical development; increased risk of morbidity and mortality

285 million school aged children have insufficient iodine

More than 5 % of population have an enlarged thyroid gland or more than 20% of the population have urinary iodine concentration less than 50 μg/L

Further information Further information on micronutrients at risk of deficiency can be found at WHO: e-Library of Evidence for Nutrition Actions (eLENA) http://www.who.int/elena/nutrient/en

http://www.who.int/elena/nutrient/en

Documents

Short Course Report Nutrition and Food Security ... Nutrition... · Short Course Report ... Nutrition for infants and young children module pilot 4 Introduction This report documents