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Behaviour change and nutrition education
Socio-cultural beliefs, customs and attitudes towards food have a significant influence on consumption and therefore the dietary status of families. Customs and beliefs can also relate to certain foods that are considered an essential part of the meal or, on contrary, unacceptable for consumption. It may also influence systems of food sharing and distribution within the family, for example the manner of serving the meal and the distribution markedly affects the dietary intake of different family members.
The WHO indicates consumer preferences and intra-household decision-making as one of the factors related to vegetable consumption in sub-Sahara Africa. Attitude also plays a role and in general, and vegetable consumption, for example, is sometimes not highly regarded. Furthermore, more traditional foods and indigenous vegetables are often associated with the poor and backwardness.
Inclusion of nutritious foods like fruits and vegetables in dietary habits will only increase significantly when there is no severe negative consumer perception of those commodities. In order to do this, awareness on the benefits of eating healthier could contribute to higher nutrient intake. When this knowledge is increasingly present in markets, consumers will be able to make their choices when purchasing their food based on a wider knowledge of the contents of food available to them. Behavior change is thus the goal, whereas nutrition education is a key means to achieve this goal.
One of the main channels for the nutrition education, particularly to reach children, are of course schools. School-based health and nutrition interventions in developing countries aim at improving children’s nutrition and learning ability. In addition to the food and health inputs, children need access to education that is relevant to their lives, of good quality, and effective in its approach. A similar approach can be applied through communities, which opens up the opportunity to reach other target groups as well (e.g. pregnant and lactating women).
How to achieve dietary behaviour change?
Data from a large programmatic intervention in Haiti suggested that a preventive strategy of behaviour-change communication
and food supplements for children aged 6–23 months reduced numbers of children that were underweight or stunted.
However, it is important to note that interventions aimed at behaviour change only work when in conjunction with additional interventions that secure sufficient access to the nutritious foods that are promoted through nutrition education, such as preschool and school-age supplementary feeding programmes.
Based on evidence Zambia suggest that gains in awareness, knowledge and behavior can be achieved among children and their families with an actively implemented classroom program backed by teacher training and parent involvement, even in the absence of school-based nutrition and health services. Homework and specific messages taken home seem to be successful mechanisms for involving parents and families, but parents’ values and motivations also need to be explored. The role of good materials, backed by training, is
One model of interventions aimed at behaviour change to stimulate increased nutrient intake is Community-Based Growth Promotion Programs, which have been implemented all over the world for a number of decades running. These programs’ main interventions are nutrition education or counseling and links to essential health services. By targeting pregnant women and children under two years of age, successful large-scale child growth promotion programs have proven that it is possible to trigger a sharp decline in severe malnutrition in the first one to two years of children. The rate of decline in moderate and mild malnutrition thereafter is in general also present, but slower.
Key lessons about designing growth promotion programs presented by the World Bank in 2006 include the following:
- Female community workers are the best people to deliver services because they are less expensive than skilled health workers, on the spot and able to communicate with mothers better than men. Low levels of formal education are not an impediment to workers’ effectiveness so long as they are well trained.
- Because moderate and mild malnutrition are not readily apparent, regular monitoring of children’s weights on a growth chart is important, so mothers know whether their children are growing properly and can see the benefits of changes in practices; however, growth monitoring and promotion only work where programs can provide good training and effective supervision in weighing, recording, and counseling mothers, as well as other options for establishing regular contact with mothers.
- Well-designed and consistent nutrition education, aimed at changing specific practices, is key. There are two ways to ensure that recommended child feeding and care practices make sense for poor people in their cultural and economic context (box 3.3).
In order to ensure that new behavioral practices work for poor people, learning from successful exceptions can be a useful approach. In this case, successful exceptions are poor women with well-nourished children in areas with high under-nutrition prevalence. One example of learning from successful examples is the application of 'trials of improved practices' (TIPs). This is a consultative process that aims to develop locally appropriate, culturally acceptable counseling messages that address resistance points and play to motivating factors. Mothers are visited by researchers to discuss child-feeding problems and possible solutions. Part of these discussions are negotiated changes in practice. The researchers revisit when mothers have tried out the new practices and make modifications depending on what is found to be feasible. TIPs has been applied in more than 15 countries in Africa, Asia, and Latin America and shows that trials with merely 50 families, at a relatively low cost can generate valid, programwide findings.