Improving Household Food Security and Nutrition in The

Improving Household Food Security and Nutrition

in the Luapula Valley, Zambia

- Project GCP/ZAM/052/BEL -

A Nutrition Education/Communication Strategy

for the LuapulaValley

- End of Mission Report -

(Mission period: 18.02. – 28.04.2001)

By

Gabriele Goetz

Nutrition Consultant (ESNP/FAO)

May 2001

IF I ONLY HEAR IT, I FORGET IT.

IF I HEAR AND SEE IT, I REMEMBER IT.

IF I HEAR, SEE AND DO IT, I KNOW IT.

ACKNOWLEDGMENTS

I would like to thank all those who have contributed to the development of the nutrition education/communication strategy for the LuapulaValley and the production of the respective education/communication material.

First of all, my thanks go to Ellen Muehlhoff from FAO/ESNP and Elizabeth Phiri, the National Project Manager of Project GCP/ZAM/052/BEL – Improving Household Food Security and Nutrition in the Luapula Valley, Zambia (IHFSAN), for commissioning the consultancy as well as for their valuable support.

Secondly, I wish to thank Don Kayembe, the Senior Nutritionist of Luapula Province, Chephas Mulenga, the District Nutritionist of Nchelenge, Patricia Chitalo, the District Nutritionist of Mwense andSofie Van Waeyenberge, the APO at IHFSAN, for their assistance and proficient contributions throughout the mission.

Special thanks are due to Davis Zulu for drawing the pictures that were needed for the production of posters, booklets, charts, T-Shirts etc. He did an excellent job in the time given.

I highly appreciate the valuable input of all the other people who participated in the development of the nutrition education/communication strategy (i.e. representatives from various ministries in the province and representatives from communities). Their readiness in involving themselves in the implementation of the strategy is worth mentioning.

I am grateful to all staff at the IHFSAN office for assisting in administrative, organisational and logistical matters.

Finally, my thanks go to those people who acted as volunteers for testing the developed nutrition education/communication material. I hope that their enthusiasm and interest in the information displayed will be shared by all the people in Luapula Province, Zambia.

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

SUMMARY

LIST OF ABBREVIATIONS AND ACRONYMS

1Introduction

1.1Background

1.2Objective

2Activities

3The Nutritional Framework in the LuapulaValley

3.1Perceptions on malnutrition and related diseases in children under five years

3.2Reported nutrition behaviours and care practices of children under five years

3.3Maternal nutrition and care

3.4Cross-cutting issues

3.5Service Providers and other influential institution

3.6Conclusion

4The Nutrition Education/Communication Strategy for the LuapulaValley

4.1Objective

4.2Approach

4.3Change and support agents

4.4Channels of communication

4.5Interventions

4.6Nutrition resource centre

4.7Co-ordination, monitoring and evaluation

4.8Training of the change and support agents

4.9Material needed for implementation

4.10Timeframe for external support

4.11Supportive measures

5Plan of Work 2001 for the IHFSAN Project

6Related Interventions of Other Institutions

7Recommendations

ANNEXES

ITerms of Reference

IIItinerary

IIIList of persons met

IVDocuments consulted

VWorkshop programme and participants

VINutrition education/communication material available at IHFSAN

VIIGuidelines for implementation on the topics selected

VIIIGuidelines for message and material development and testing

IIXMaterial developed:

-Complementary feeding (booklet, hand out)

-Vitamin A Deficiency (leaflet, chart)

-Promotion of palm oil (booklet, hand out)

-Promotion of mangoes (booklet, hand out)

LIST OF TABLES

Table 1Communities` perception on malnutrition in children

Table 2Schedule of interventions according to topic

Table 3Interventions of involved sectors

Table 4Nutrition focal points

Table 5Proposed timeframe for external support

Table 6Plan of work 2001 for the IHFSAN project

LIST OF FIGURES

Figure 1Explanatory model based on communities´ perception – Ukondoloka -

Figure 2Explanatory model based on communities´ perception – Chifimba -

Figure 3Topics to be addressed during nutrition education/communication based on their

causality in relation to the nutritional status of the child

SUMMARY

Rates of malnutrition in the LuapulaValley, especially in children, are unacceptably high. A study on knowledge, attitudes, perceptions and practices (KAPP) that was carried out by FAO in July/August 2000 provided the following information:

From birth onwards throughout the lifecycle, local behavioural patterns in relation to food, health and care have been identified that negatively influence nutritional outcomes. It appears that a large percentage of children in the LuapulaValley suffer from malnutrition immediately after birth. The consequences are severe and include poor physical and mental development, and finally death.

• Multiple factors have been identified that determine the harmful nutritional behaviours Traditional knowledge and notions mainly influence the identified behaviour in areas such as: (1) prevention and treatment of malnutrition, and related diseases; (2) nutrition and care of babies; (3) nutrition and care during pregnancy; (4) family planning. Regarding areas such as exclusive breastfeeding and complementary feeding, many of the community members that participated during the KAPP study, have modern knowledge and notions. However, their knowledge frequently does not go beyond being able to recite the messages that are disseminated by health service providers. Their understanding of the issue and why it is important for their own children is very weak or non-existent as most community members are not aware of the reasons why such behaviours are promoted. Additional factors determining the harmful nutritional behaviours are chronic and seasonal food insecurity due to inadequate production and incomes, women’s busy work schedule due to their multiple responsibilities and a strict gender division of labour, as well as men’s attitudes towards nutrition and care.

• The local communication patterns identified vary depending on the subject matter and comprise formal and informal institutions or people in the community. Modern knowledge is mainly obtained during the Under Five clinic (U5). Information on issues that are not addressed during service provision as well as information on the traditional notions of nutrition and care are obtained from friends, elderly community members (mainly females) and traditional healers.

Access to rural health facilities is generally inadequate due to poor coverage and the quality of health care (prevention and curative) provided is insufficient. Health centres are not only poorly staffed, but also ill-equipped in terms of medical supplies and their capacity to reach surrounding communities due to lack of transport. They are inadequately trained to meet local community members’ needs, they suffer time constraints and receive little guidance and supervision.

The nutrition situation in the LuapulaValley shows that standard nutrition/health interventions, including the dissemination of isolated educational messages, are ineffective in tackling the prevailing nutritional problems. To achieve positive behaviour changes and impact in terms of improved nutritional status of children, a broader approach is necessary. Hence, a comprehensive nutrition education/communication strategy was developed for the LuapulaValley. This is based on the information obtained during the KAPP appraisal and applies the following approach:

• Dissemination of culturally appropriate messages that cover all relevant topics and emphasise on locally appropriate solutions (e.g. food-based approach rather than supplementation and fortification measures).

• Involvement of a wide range of change and support agents for message dissemination in order to reach the target group. The selection of the agents was based on the identified communication patterns in the community so as to ensure that the agents have the potential to achieve behavioural change and are accepted by the communities (e.g. elderly females, traditional healers, etc.).

• A multi-media mix will be applied to disseminate the messages and allow inter-change of knoweldge, information and skills. The selected media will be based on locally available channels, which includes face-to-face communication supported by the mass media. The main channel will be face-to-face communication through focus group discussions to ensure dissemination of detailed information on the messages and to receive feedback from communities.

• Interventions will be community-based and carried out in a participatory manner, whichhelp ensure that communities identify their own solutions to the nutritional problems (e.g. discussions on traditional notions, mobilisation of nutrition promotion groups, etc.).

• Multi-sectoral integration of nutritional matters atall levels (i.e. provincial, district, community) to address the multiple causes of malnutrition and to ensure allocation of resources as well as feedback to policy level.

This approach allows: (1) maximum exposure to the messages; (2) detailed understanding on the nutritional status of a child; (3) long-term sustainability of the nutrition education/communication interventions. It is therefore anticipated that the proposed strategy will contribute to the improvement of the nutritional status of children in the LuapulaValley.

At present, only vertical nutrition education/communication interventions exist in Zambia. These focus on a limited number of problems and solutions only (e.g. educational measures with regard to breastfeeding as well as supplementation and fortification measures with regard to Vitamin A Deficiency, Anaemia and Protein-Energy Malnutrition), which fail to address prevailing nutrition problems and their causes in a comprehensive manner. There is growing recognition that this approach has not been effective in reducing child malnutrition (in particular stunting) and a broader and more sustainable approach may be needed to achieve positive and lasting behavioural changes. The proposed nutrition education/communication strategy for the LuapulaValley, if fully implemented, has the potential of pilot-testing a more comprehensive nutrition education/communication approach and intervention programme. This can produce important lessons on how childhood malnutrition can be effectively reduced for future integration into broad-based national policies and programmes.

LIST OF ABBREVIATIONS AND ACRNONYMS

CboH / Central Board of Health
CHW / Community Health Worker
DHMT / District Health Management Team
ESNP / Nutrition Programmes Service, FAO
FAO / Food and Agriculture Organisation of the United Nations
FHANIS / Food Security, Health and Nutrition Information System, Zambia
CbGMP / Community based Growth Monitoring and Promotion
GTZ / German Technical Co-operation
HEPS / High Energy Protein Supplement
HIV/AIDS / Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
IHFSAN / Improving Household Food Security and Nutrition in the Luapula Valley, Zambia (FAO)
IDA / Iron Deficiency Anaemia
IRNP / Integrated Rural Nutrition Programme, Kawambwa District/Zambia (GTZ)
KAPP / Knowledge, Attitudes, Perceptions and Practices
MAFF / Ministry of Agriculture, Food and Fisheries
MCH / Maternal and Child Health
MoCDSS / Ministry of Community Development and Social Services
MoE / Ministry of Education
MoH / Ministry of Health
NFNC / National Food and Nutrition Commission, Zambia
NHC / Neighbourhood Health Committee
ORS / Oral Rehydration Solution
PEM / Protein Energy Malnutrition
PCI / Project Concern International
TBA / Traditional Birth Attendant
TCP / Technical Co-operation Project
U5 / Under Five Clinic
UNAIDS / Joint United Nations Programme on HIV/AIDS
UNICEF / United Nations Children’s Fund
UNFPA / United Nations Population Fund
USAID / U.S. Agency for International Development
VAD / Vitamin A Deficiency
V-WASHE / Village Water, Sanitation and Health Education Committee
WFP / World Food Programme
WHO / World Health Organisation of the United Nations
ZAMSIF
ZIHP / Zambian Integrated Health Programme (USAID)

1INTRODUCTION

1.1Background

The LuapulaValley is located in one of the poorest and most neglected provinces in Zambia. Rates of malnutrition, especially in children, are unacceptably high. A nation-wide survey carried out in 1993 by the Central Statistical Office (CSO) and the Food Security, Health and Nutrition Information System (FHANIS) revealed that 64.3 % of children below five years of age in Kawambwa district, 49.0 % in Mwense district and 46.3 % in Nchelenge district were stunted (< -2 Z-scores height-for-age). In the same districts 7.1 %, 9.4 % and 5.0 % respectively were wasted (<-2 Z-scores weight-for-age). Micronutrient deficiency diseases, especially vitamin A deficiency(VAD) and iron deficiency anaemia (IDA), are also widespread. In 1989 the Luapula Valley Eye Disease Survey found that 16.5 % of children had critically low serum retinol levels and 2.0 % suffered from xerophtalmia. Very little quantitative information is available on iron deficiency anaemia. The IDA prevalence in Zambia is estimated at 25 %.[1] In addition, the incidence of diseases such as malaria, diarrhoea and HIV/AIDS[2] is high and contributing to malnutrition.

A participatory rural appraisal carried out by FAO in co-operation with the local authorities in 1996 identified four major underlying causes of malnutrition in the valley: (1) chronic household food insecurity; (2) poor access to adequate health, water and sanitation; (3) inadequate provision of care for the most vulnerable; (4) poor knowledge base due to lack of education and communication opportunities.

To improve the nutritional status of the most vulnerable groups (i.e. infants, children, women of child bearing age), FAO in collaboration with the Zambian Government initiated the project “Improving Household Food Security and Nutrition in the LuapulaValley” (IHFSAN). The project aims to improve year-round access to a balanced diet that is adequate in energy, vitamin A, iron and other macro- and micronutrients through an integrated and participatory approach. To date, the project’s main focus has been on improving household food security through agriculture-based interventions that aim at increasing and diversifying food production (e.g. palm oil, cassava, legumes, fruits) and, more recently, at improving year-round food availability to reduce seasonal shortfalls (i.e. food storage, food preservation).

In view of the multiple causes of malnutrition, interventions that focus on household food security alone are not sufficient to improve the nutritional status of the target groups. It was therefore decided to place more emphasis on nutrition education/communication to address the lack of knowledge that was identified as one of the contributing factors to malnutrition in the project area. In order to obtain more detailed information on the nutritional behaviour amenable to change and its determining factors, anappraisal on the knowledge, attitudes, perceptions and practices (KAPP) was carried out in the LuapulaValley in July/August 2000. The appraisal generated a wealth of in-depth information on the local situation that has enabled us to gain rare insights into local people’s food and nutrition behaviours, attitudes, and beliefs. It will serve as a unique basis for directing future nutrition education/communication strategies and actions.

1.2Objective

Since the present phase of the project ends in December 2001, Project Management decided to assist in developing a nutrition education/communication strategy for LuapulaValley and to support selected activities during the remaining period of the current project. Activities will be expanded if the project continues. If it does not continue, the existence of a nutrition education/communication strategy will help the Zambian counterparts identify and mobilise other sources of support. However, due to FAO´s mandate as well as the limited project resources vis-à-vis the expected support needed, additional assistance will be necessary in any case.[3]

A consultant was contracted in February 2001 to facilitate the following tasks (for details see the consultant’s terms of reference in Annex I):

• Development of a nutrition education/communication strategy for the LuapulaValley.
• Identification of pilot-interventions that can be supported by the IHFSAN project during the project’s present phase and in relation to ongoing priority project activities.
• Preparation of a plan of work for 2001.
• Development of the respective nutrition education/communication materials.

Due to the limited time available, one topic only was to be addressed. The set of materials developed for the topic would then serve as a guide for all other topics, which were to be addressed after the consultant had left.

The nutrition education/communication strategy was to focus on the improvement of the nutritional status of children under five years as the group that is most vulnerable to malnutrition. Since poor maternal nutrition is one of the contributing factors to early childhood malnutrition (viz. intra-uterine nutrition and low birth weight), nutrition and care during pregnancy and lactation were to be included.

2ACTIVITIES

The mission took place from 18 February to 28 April 2001 and included briefing and de-briefing at FAO headquarters in Rome (for details see the consultant’s itinerary in annex II). The work was to be undertaken together with the provincial and district nutritionists as well as with the Associate Professional Officer (APO) for nutrition and post-harvest technology at IHFSAN. Unfortunately, the group could not work in this composition throughout the mission since these staff were partially committed to other tasks and/or on leave during this period.

Prior to and following the consultant’s stay in Luapula, time was spent in Lusaka to visit several local and international organisations to: (1) gather nutrition education/ communication materials that are already available in Zambia; (2) obtain information on interventions related to the consultant’s scope of work; (3) explore possibilities for co-operation.

The work carried out was divided into several parts:

1. All available information on nutrition in the LuapulaValley was reviewed to identify problems that are amenable to behavioural change and related to knowledge, attitudes, perceptions or skills. The documents consulted are listed in annex IV. Based on the findings, a nutrition situation framework was developed to describe the local situation.

The issues to be addressed during the implementation of a nutrition education/communication programme were identified and grouped according to topics. They form part of the “guidelines for implementation” that can be found in annex VII.

1. As a next step, a nutrition education/communication strategy for LuapulaProvince was drafted. Prior to this exercise, proposed and existing education/communication strategies were reviewed to build on experiences and to obtain further direction. The documents consulted are listed in annex IV.

1. Thereafter, a workshop was conducted with representatives from various line ministries and project beneficiary communities. The aim of the workshop was to: (1) provide an overview of the local nutrition situation; (2) review, discuss, revise and finalise the draft nutrition education/ communication strategy; (3) identify the material needed for implementation; (4) to identify interventions that can be supported by the IHFSAN project during the current project; (5) draw up a work plan for implementation. Since the majority of participants was not familiar with the subject matter of nutrition and the technicalities of education/communication, the workshop started by introducing basic concepts of nutrition and education/communication. The workshop programme and a list of participants can be found in annex V.

1. Based on the identified needs, available nutrition education/communication materials were reviewed with regard to their relevance and adequacy. Some of the materials were considered useful and are therefore included in annex VII (“guidelines for implementation”). In addition, existing materials, which were considered useful but not available in Zambia, have been ordered. A list of all materials now available at the IHFSAN project, are attached to the report as annex VI.

Training material already exists but needs to be revised. In order to obtain more detailed information on what to improve and how, it was decided to first test the material during the initial stage.