Caitlin Hosmer1
Johanna T Dwyer2
Armando Villarroel3
1 Tufts University, School of Nutrition, Boston, MA, USA.2 Director, Frances Stem Nutrition Center, New England Medical Center, and Professor of Medicine and Community Health, Tufts University School of Medicine, Boston, MA, USA.
3 Executive Director, The Inter-American Distance Education Consortium (CREAD), The Pennsylvania State University, University Park, PA, USA.
Introduction
Background
Training trainers and nutrition educators
Training programmes for nutrition educators
Other considerations
Conclusions
Recommendations
References
Definitions
Effective and affordable delivery of nutrition education depends on sound training so that knowledge and skills for behaviour change can be communicated to a target audience.
This contribution provides suggestions to guide the instructor who trains nutrition educators on planning and implementing in-service training that does this. Nutrition education is based on the sound application of knowledge derived from the food and nutrition sciences about the relationships between diet and health (Anderson, 1994). The use of educators with training in nutrition allows efficient use of human resources. Such individuals have a science base that encompasses both food and nutritional science upon which they can draw in crafting educational messages.
First we discuss some general issues that must be considered when embarking on nutrition education projects, including: who should be trainers and who should be nutrition educators? We discuss requirements for instruction of the instructors who provide in-service efforts to nutrition educators. We also review what communication skills nutrition educators need to encourage healthful diet-related behaviour changes. We address some other considerations, such as which causes of malnutrition can be remedied by nutrition education interventions. Finally, the institutional arrangements and resources for nutrition education are examined.
Recommendations especially relevant for nutrition education in developing countries follow the Conclusions section. A glossary gives definitions of terms referred to in the paper.
Information delivery must include application of findings from studies of behaviour change. It is evident that "facts about nutrition do not change behaviour unless they have some meaning for the individual and relate to his needs" (Ullrich, 1972). Many factors influence the success of effective in-service training. It is essential to assess the setting of each nutrition education effort, and to incorporate local considerations in planning and after the early stages of implementation. Instruction coupled to opportunities for practical demonstration and observation help to reach trainees regardless of their learning styles. Incorporating outcome-based evaluation at all stages helps ensure efforts to produce competent and effective nutrition educators.
Before launching a nutrition education effort, it is important to consider what such in-service training is expected to achieve, and what kinds of people will be the most effective trainers and nutrition educators to reach goals in the particular setting. We use the term "trainer" to refer to those who train "nutrition educators" (trainees). "Nutrition educators" are those who conduct nutrition education programmes for target audiences, in communities.
Nutrition educators vs. nutrition trainers, and nutrition education vs. nutrition "training" sessions
Effective nutrition education of the public starts with core, or pre-service, education and training to establish basic competence in both nutrition and education. However, core training may take a long time to establish and implement. Another means of promoting effective nutrition education is to provide appropriate in-service training for nutrition educators who are already trained, but whose education lacks some needed background or skills. Even those who are superbly trained need refreshers, and competency must be periodically renewed since nutrition science and communication are constantly evolving.
Nutrition educators are expected to be able to respond to situations or challenges with a body of knowledge and experience, and not to simply perform rote teaching tasks. Therefore it is inappropriate to refer to them as nutrition "trainers"; the terms nutrition educator or instructor are preferable. Nutrition educators must provide both skills and up to date scientific knowledge to foster meaningful engagement and training. But they also must include efforts on the part of the trainer to ensure that those trained are personally involved and interested in learning. Lewis et al. (1988) found that teachers' experience and commitment to nutrition education influenced whether or not teenagers made positive changes in food consumption patterns. Attention to motivation, interactive learning activities and encouragement assisted in this process.
Goals of in-service training
The goal of in-service training is to equip the learners (nutrition educators) with the knowledge and skills they need to teach methods for changing diet-related habits that will ultimately improve the nutritional status of the target group. Learners may include nutrition education professionals, paraprofessionals, volunteers, teachers, community members or agricultural workers.
In-service training must provide trainees, who will be educators in the future, with the skills they need to perform needs assessments, to collect and consider information germane to the problem being addressed, and to plan and implement their efforts accordingly. In-service training is best accomplished when specific learning objectives are identified on the basis of findings of a needs assessment, a specific population is targeted, and appropriate expertise is available to teach the teachers. Geographic, population, economic, and agricultural differences both among and between countries influence both the specific goals and objectives of these efforts, and the methods employed.
The types of nutrition education in-service training include public health efforts involving entire communities or specific sub-groups, research studies, and continuing education with no specific end in mind.
Who should instruct the trainers and nutrition educators themselves?
Among the many areas of overlap in the content of training for trainers and nutrition educators are communication skills, behaviourally-oriented techniques, and principles of adult learning. Needs assessment is essential to discover what learners need, rather than relying solely on what instructors are predisposed to teach. Traditionally training has been done by health care professionals who vary greatly in both their knowledge of the educational process and in their understanding of food and nutrition knowledge, even though they may be knowledgeable about human health. When educators are the trainers, content in food and nutrition sciences may be slighted and there may be an over-emphasis on communication skills. Training efforts which focus solely on teaching nutrition science or food science to nutrition educators fall short if they fail to include communication skills, and leave the trainee ill-equipped to fulfil the mission of teaching nutrition both for knowledge acquisition and behaviour change. Trainers should have a strong background in nutrition science as well as skills in communication and education.
To ensure that communication is adequate, those who instruct trainers and nutrition educators must have the skills necessary to communicate and to teach appropriate subject matter, in addition to being competent in their fields. They must be able to establish clearly the purpose, goals, and objectives of the training session, and have the skills to design and implement effective in-service programmes. Instruction of trainers must explicitly address the competencies that are expected to be developed at the end of the training programme. Instructors' subject matter expertise varies, depending on the specifics of application. Instructors must also have expertise in teaching skills, and their preparation should include attention to this. Appropriately prepared individuals may not exist in some countries. Under such circumstances it may be a necessary first step to develop the skills of a group of trainers who can in turn provide training for nutrition educators.
In developing countries, where pre-service training in nutrition is scarce or limited to a clinical rather than either a communication or a public health orientation, instructors may need expertise in prevention, education and communication as it relates to nutrition so that training sessions can provide skills in these areas. In addition to food or nutrition science expertise and substantive knowledge, professionals who can teach skills in areas such as information technology, use of mass media, communications, conflict resolution, and behaviour, may be useful as contributing faculty for planning and implementing training sessions for nutrition educators.
Who should the nutrition educators be?
The nutrition educator is the individual who interacts directly with the target group. Diverse aspects of character and role model attributes influence the nutrition education's effectiveness and so they must be carefully selected. The audience must be willing to listen to and be influenced by the instructor.
Some general traits to consider when choosing nutrition educators include the ability to share or to understand cultural and religious beliefs of the target population that influence food habits, and to shape communication messages to accommodate these. The educator must have credibility with the audience. Familiarity often seems to be an advantage. Needs assessments reveal a partiality to local and familiar persons rather than experts for imparting nutrition education. For example, Doyle and Feldman (1994) found that 322 Brazilian high school teachers were perceived by their students as more effective than outside nutrition experts. Sometimes role models are needed. For example, mothers who have raised children successfully are more acceptable for teaching young mothers about child feeding than are single women, who may be perceived as lacking such experience.
The Pawtucket Heart Health Study is a large community intervention in the United States which made extensive and successful use of volunteers from the target audience, even in complex roles (Lasater et al., 1988). The volunteers established access and credibility within organisations, groups and social networks made them valuable both as messengers to members of the target population, and as role models who were in the target population themselves. Communities may also be able to take advantage of the influence of people already in positions to influence people's food choices. Built-in familiarity and pre-existing dynamics possessed by community leaders, members of social organisations, food service providers, day care workers, medical journalists, village volunteers and religious leaders, make them good candidates for being trained to participate in nutrition education efforts both as volunteers or for pay.
The social value of drawing role models from the community is that much can be taught by them that would not be accepted when using non-community members. Such individuals may also provide instructors with insights on how teaching processes and content can best be adapted to local circumstances. Some recent efforts that capitalise on existing relationships and local human resources, include training adult peer educators (Lynde, 1992; Golden, 1991), village health volunteers in countries such as Thailand, community volunteers (Linnan et al., 1990) and use of community workers in Co-operative Extension nutrition programmes in the United States (Randell et al., 1989).
A successful model for appropriate use of volunteer counsellors to alleviate the demand for more extensively trained mental health professionals is described by Golden and may provide assistance for dealing with these issues (1991). Supervision, evaluation and ongoing training help ensure that helpers are working appropriately with the population as determined by the programme.
In developing countries, health providers may have relatively little formal training, but they can still be effective in outreach efforts to convey simple nutrition and health messages in an acceptable manner (Zeichner, 1988; Harvey, 1988; Engle, 1991).
This section provides a guide to in-service instruction of both trainers and the nutrition educators that they train. There are commonalties in the knowledge, skills, and behaviours required of these two groups of professionals, and therefore instruction is considered for both groups together. The section on Other Considerations below includes specific requirements for the training of nutrition educators which are not addressed in this section.
Assess what trainers and nutrition educators need to know
Both trainers and nutrition educators must master certain basic knowledge and skills. The basics vary depending on the trainees' background and their proposed role. The person who is responsible for training them must find out what they know and fill the gaps with instruction that will make them effective trainers and effective nutrition educators.
Plan on the basis of a needs assessment and actualise goals and objectives
The planning stage must include all aspects of the training cycle: the needs assessment of the audience and the endeavour, developing clear, measurable goals and objectives consistent with the desired approach, strategies for implementation and development of the training curriculum and teaching methodologies, and delivering and evaluating the training (Pont, 1991). Making a complete list of tasks with information about what the worker will do, how the worker does it, to whom or to what, and why, will help determine what needs to be done in terms of specific skills, knowledge and attitudes required to perform the job (Goldstein, 1986). Assessment also makes it possible to specify the objectives of the training, which in turn drive the design of the programme and establish measurement points for evaluation. Initially determining the purpose of the education effort "tells where to begin, and specification of objectives tells the completion point of the programme" (Goldstein, 1986).
In addition to clearly defined tasks, objective points for evaluation at the beginning of an education effort, and consultation with members of the groups to be reached during this stage, will help to ensure a realistic plan. Focus groups or qualitative assessment efforts which involve meeting with target group members may be in order, or selected members of the population can be officially involved in the planning stage on a programme committee.
For nutrition educators, understanding of the primary audience is key for identification of those who influence the primary audience, such as health and nutrition care providers, families and friends, popular public figures, and for what "gatekeepers" - who are still further removed from them, such as decision makers, health organisations, financial supports and other influential people - can do to help (Parlato, Green, Fishman, 1992; Ngo, 1993). All these different groups must be considered, and plans made to reach them will help to ensure reinforcement of messages to the primary audience from sources other than the nutrition educator. Trainers must keep in mind the importance of cultural identification and how best to incorporate cultural beliefs and traditions in planning and teaching while preparing nutrition educators.
Establish clear, measurable goals and objectives
Goals
A goal expresses a value in terms of an ideal future reality. Formulating goals forces one to think about desired ends and to anticipate the future over the long- rather than short-term. Goals are broad, general statements and as such they can neither be measured nor be fully expressed by any one statement. Goals are intentions to act that have meaning, specifically within the context of the effort at hand. The goals of a training programme for trainers of nutrition educators may be narrowly focused on the outcome behaviours or qualifications of the trainees. However, goals should be constructed keeping in mind how the ultimate outcomes affect institutions, organisations, or the larger community. An example of a nutrition education goal might be to increase the abilities and improve behaviours of pregnant women to select high protein foods during their pregnancies, which would decrease low birth weight, especially among teenage mothers.
Objectives
Goals must be concretely expressed through a statement of objectives. As measurable expressions of desired results, objectives provide the basis for evaluation. An example of how goals and very specific objectives may be integrated is in the Year 2000 goals of the USDHHS of the United States (USDHHS, 1990). The formulation of objectives should incorporate four characteristics: a measurable condition, a finite population, the amount of change desired (expressed as an absolute number or as a percentage), and a time period over which the plan will operate, at the end of which the results will be measured. Objectives should ideally reflect the "end" of the planning efforts, rather than the "means", that is, they should refer back to the larger goal. One example of an objective derived from the sample goal given above might be: after one complete 2.5 year cycle of training nutrition educators and the dissemination of education materials and interactions throughout the communities of interest, the protein consumption of pregnant women between the ages of 18 and 38 should have increased by 10%, to meet between 80-100% of the dietary standard for pregnant women.
Behavioural objectives
Behavioural objectives for the outcomes of in-service training must be realistic and obtainable. Nutrition educators must include as many as possible, of the many factors that influence nutritional status and dietary habits in the planning of goals and objectives. Also, objectives must be limited to those that can be addressed within the framework of the nutrition education effort. Pilot studies to determine if goals and timetables are realistic may be helpful. Time is usually limited for various reasons including funding, availability of trainers and trainees, and changing environment. However, trainees must understand that producing the desired results - sustained behaviour change - takes a considerable effort over a long time to learn, to implement and to measure. If nutrition education campaigns are institutionalised and fit into larger objectives they may receive more support.
It is important to spend the most resources in terms of time and money on the most important things. For example, spending a disproportionate amount of money on evaluation may produce an excellent evaluation tool but a sub-standard education effort as a result of the limited resources allotted.
Competency-based objectives
"Competency-based" refers to objectives that are geared to trainees attaining competence; this is accomplished by including tasks that can be carried out and evaluated during the process of training, that demonstrate the required knowledge and skills. Competency-based objectives should be established on each specific component of trainees' future tasks and stated explicitly m planning training and during its implementation. They should be evaluated to ensure that trainees are adequately prepared. For the above example, a competency-based objective would be: "educators are able to estimate the protein needs of a sample young pregnant Spanish-speaking woman who is poor (representative of the population of interest), and formulate a culturally, financially and otherwise appropriate dietary plan to meet these needs".
Manage for continuous feedback
Managing a nutrition education effort requires continuous feedback so that corrections can be made quickly. Responsibilities of all participants, trainers and nutrition educators alike, must be clearly stated initially, accountability stressed, and adherence to plans monitored. Records should be kept by all participants for quality assurance and feedback as well as for assessing ultimate effectiveness. Programme information and communication systems should be decided upon early in the project. They are especially critical if management is not centralised and in programmes covering large geographic areas.
Centralised vs. local
Both centralised and local management in large scale efforts have advantages. Central management should assure consistent messages, training procedures, materials, etc. Community management inputs are valuable for making sure that "messages are culturally appropriate, actionable and that they reach their intended audience" (Parlato, Green & Fishman, 1992).
Resource allocations
Resources are allocated in the planning stages of the project. However, good management of implementation includes monitoring of expenditures and reallocations, as there will inevitably be additional demands for resources. Occasionally adjustments may be needed. These allocations must be considered carefully in relation to pre-planned components, the benefits to goals and objectives, and other anticipated needs.
Develop training manuals and teaching resources
The educational and cultural background of the target audience must be considered when developing teaching materials and resources. Reading levels, quantitative and numerical ability, and preferred styles of presentation of learning materials should be considered. All trainees will benefit from clearly stated directions. Active rather than passive learning techniques include demonstrations, supervised practice, and use of a variety of media including slides and videotapes, which help trainees observe, absorb, process, and demonstrate the knowledge and skills being taught.
Build flexibility into development of complete training manuals and resources
Training manuals should include specific materials needed for the future training sessions of nutrition educators. They might include outlines of the training sessions with appropriate and specific objectives, basic information to be taught to participants, learning activities (role plays, case studies and field work), supplementary articles or information, a bibliography of reference materials, and handouts and worksheets which can be reproduced (Armstrong, 1992). It is wise to allow for flexibility in the organization of manuals and teaching materials, so that feedback from the trainees can be incorporated into beneficial changes. Teaching resources should enrich and expand upon materials in the training manuals.
Implement training programmes for the adult learner
Consider the special characteristics of adult learners to motivate and encourage them
Trainee characteristics that are important in planning in-service training includes trainees' readiness to learn, their learning potential, interests and past experiences, as well as their information and knowledge base, and their competence levels with respect to required skills. Their degree of independence (e.g. their willingness and freedom to apply what they have learned) must also be established (Rinke, 1986). Like all adult learners, trainees benefit when they see how their past experiences and capabilities can be employed in learning. In-service instruction of trainers should include a discussion of adult learning principles and examples of their application in the training sessions themselves. Table 1 presents Grabowski's (1976) list of competencies of adult educators that are relevant for training of both the trainer and nutrition educators.
Use instructional methods that are suitable in content and cater to adult learners' preferences
A person who has command of information does not necessarily have a grasp of effective methods of communication and information delivery. Teaching is a skill that is essential for implementing adult learning. This not only considers the learning styles of the audience, but the way information is packaged to teach the learner. Certain material lends itself better to some communication methods than others. For example, it is very difficult to teach cooking methods by instruction alone - demonstrations are critical. The most effective methods also vary depending on the characteristics of individual learners, and their favourite or most comfortable learning styles. Some adults respond best to facts, others to "hands-on" experimentation, and still others find ways of manipulating the information to fit their understanding of how it may be most helpful (Holli & Calabrese, 1991). Since no one style is favoured by everyone, it is best to present the material using a variety of methods to accommodate individual variation in learning styles, as well as in the type of material to be taught. Integration of didactic learning and "hands-on" practical experiences for skill development usually enhances learning best, regardless of prior training.
According to an extensive literature review of nutrition education efforts in the United States, behaviourally oriented methods of nutrition education are more likely to be effective in bringing about changes than didactic approaches. Including methods of behavioural modification in training sessions, however, requires competent educators and more time for reinforcement of the necessary skills, both of which make inputs for these approaches more costly.
Table 1: Characteristics of a competent adult educator
|
...understands and takes into account the motivation and participation patterns of adult learners |
Base training on sound theory
The theoretical basis for planning interventions for changing health behaviours rests on models of behaviour. The most common theories mentioned in the nutrition education literature are summarised in Table 2. Glanz and Rudd (1993) surveyed nutrition education and consumer behaviour professionals (both in fields providing information to influence food choice) for their opinions on which theories and models were most familiar and useful. Those in both fields selected a few familiar and current theories, but respondents concurred that theories were not all-important as there are frequently gaps between research and practice.
The practical application of these theories is difficult since no single model of behaviour change available today fits all situations. While theories attempt to identify all factors which may influence the outcome behaviour, they are simplifications of reality. Also, different theories are more successfully applied at one stage of learning than at another. Therefore, it is difficult to use a single paradigm for the whole intervention process. Nevertheless, theory-based nutrition education efforts and the use of theoretical models to help construct training efforts are useful since they permit the educator to methodically incorporate the influence of motivators, barriers, and other influential factors in the planning and implementation of nutrition education efforts. Eclectic models may be most appropriate.
Table 2: Frequently used theoretical approaches in nutrition education
|
THEORY |
COMMENTS |
|
Social Learning Theory | |
|
Behaviour change is mediated through cognitive processes (i.e. thinking, perceiving, believing) Cognitions (attitudes and beliefs) about a behaviour are altered most easily through actual performance or observed performance of the behaviour. Influences (components) include the environment, providing incentives and disincentives; situations which provide consequences, or "expectancies"; and skills (behavioural capacity), and self-efficacy, (the ability to do what needs to be done). Positive reinforcement is important for this component) (Bandura, 1986). |
Represents interaction and influence of factors in the social environment as they reflect and modify behaviour. |
|
Stages of Change/Translocation Theory | |
|
Emphasises construction of different messages to people who are at different stages of readiness to change a certain behaviour. The stages of readiness include pre-contemplation through contemplation and eventual action. For more complex applications, the transtheoretical (across several theories) model posits relationships among the stages and processes of change (Prochaska, 1990). |
Attitudes and attitudinal assessment of target audience are emphasised. |
|
Health Belief Model | |
|
Weights various factors influencing health behaviour change. People more likely to change are thought to be the ones who believe they are susceptible to a stated risk which has potentially serious consequences, when the solution offered is likely to decrease the susceptibility or severity of outcome, and the anticipated costs or barriers to participation are outweighed by this benefit. Further, those with high self-efficacy, such that they feel they can do what needs to be done to improve the situation, are most likely to change (Rosenstock 1988). |
Does not reach those who are at risk but do not see themselves as such, due to denial or lack of information. Does not include non-health-related reasons for behaviour (i.e. weight loss for aesthetic reasons). The focus on individual determinants can lead to victim-blaming. |
|
Social Action Theory | |
|
Based on the information processing theory, people are assumed to choose the alternatives which provide them with the most "good" outcomes and the fewest "undesirable" outcomes. Examines people's intentions to behave a certain way and assigns a probability of certain actions based on intentions, influence of others, etc. (Azjen and Fishbein 1987). |
Useful for explaining food-related behaviours over which people have control. Acknowledges the real world in that it considers social influences on certain behaviours. The more options that are identified along the continuum from intention to desired outcome, the better the predictive value of the model. |
Follow a four step approach: model; guide practice; provide feedback arid support
The four basic steps for optimal training of nutrition educators are based on sound theoretical considerations and empirical research (McAlister et al., 1976). First the instructor models or demonstrates new responses and action patterns. Second, guided, and increasingly independent practice in those thoughts and behaviours is provided. Feedback on the appropriateness and accuracy of responses is provided. Finally, trainee behaviours are reinforced by support and encouragement. Gradually the new habit or skill may have naturally reinforcing consequences which provide further rewards.
Develop motivational techniques to market messages
Without motivation to act on a specific message, information is useless. The educator must find out what factors motivate people to change their health behaviours, provide information that will motivate them, and deliver it in a context which promotes change. Training that motivates and reinforces the confidence of the nutrition educator, as well as training that includes techniques which improve these skills in counselling is helpful (Parlato, Green, Fishman, 1992).
Some questions answered through qualitative investigative techniques which contribute to developing motivational approaches and messages are listed in Table 3. Qualitative methods such as focus groups and surveys help to provide data needed to develop motivational techniques to personalise the audience assessment. Lopez (1993) used focus groups with low-income women to determine, develop and instrument measuring the effects of certain psychosocial influences on eating in this population.
Table 3: Questions potentially answered through focus groups and surveys of target groups
|
What motivates and reinforces the health behaviour in question? |
|
What are the barriers (negative motivators) to improved health behaviour? |
|
Who considers themselves at risk? |
|
How aware of the consequences of the behaviour are members of the population? |
|
How deterred by consequences are they? |
Select appropriate methods of education and communication for target groups
Effective education and communication techniques that are derived from marketing and the behavioural sciences are often appropriate and effective for changing nutrition-related behaviours at the community level (Parlato, Green, Fishman, 1992; Cabanero-Verzosa, 1991; UNICEF, 1990). This is called social marketing. Nutrition communication has been most effective when several steps are taken (Parlato, Green, Fishman, 1992). First, a limited number of specific behaviours significantly affecting the target group's nutritional status are selected. Second, small behaviour changes that provide a viable choice within the time and cost constraints of the household and community are targeted. Third, messages tailored for each of the groups of people that influence the intended beneficiary are employed using communicators and language that are meaningful to each group. These messages must be conveyed with enough salience and for a long enough time that the ideas enter into "normal" conversations in the target group and are eventually adopted as behaviours. Finally community involvement in message development and pretesting is also helpful.
Social marketing seems to be an effective communication technique, regardless of the information one is conveying, since it emphasises getting the message to the consumer rather than to the communicator. Social marketing emphasises that members of the target audience are consumers, or clients rather than inferior beings to be enlightened (Parlato, Green & Fishman, 1992). In this case, the consumers are both the nutrition educators (as trainees), and the target population. When applied to nutrition education, using the social marketing perspective requires that trainers prepare nutrition educators who are particularly knowledgeable about their audience and involve them in finding solutions to problems of inadequate nutritional practices. Nutrition educators should be able to: understand the client's circumstances and why current opinions and feeding practices are prevalent; seek practical solutions to nutritional problems in collaboration with the consumer, based on the resources available to the family; and, systematically follow-up and sensitise the community to the problem. Supervised practice in the use of these techniques is also helpful.
Familiarise nutrition educators with the use of social marketing techniques in crafting programmes
Social marketing refers to a process of delivering highly appealing audience-specific messages. It draws on insights from marketing and advertising. It requires finding out what people need and want, and then developing a programme based on those appeals (Novelli, 1990; Ngo, 1993).
The objectives of social marketing include disseminating new data and information on healthy eating practices to individuals, offsetting the negative effects of a practice or promotional effort by another organization or group, and motivating people to move from intention to action in implementing sound dietary practices. Social marketing incorporates the influence of the audience's motivators and reinforcers into planning nutrition education campaigns. Not all steps involved in planning a social marketing programme involve nutrition education. However each step helps define the appropriate nutrition information and best choices of communication to use to reach goals (Young, 1988).
Steps for planning a social marketing campaign are listed in Table 4 (Ngo, 1993). Trainers of nutrition educators should introduce these steps in training sessions. Social marketing has been used for planning and implementing a variety of community nutrition initiatives in the United States including Project LEAN, Pawtucket Heart Health Programme (Lefebvre, 1988), Stanford Five-City Project (Farquhar, 1991), Giant Foods' campaigns to promote heart health and decrease cancer risks, and a campaign to increase breast-feeding by limited income mothers (Bryant et al, 1992).
Table 4: Steps involved in planning a social marketing campaign
|
1. |
Identify the problem |
|
2. |
Segment the audience |
|
3. |
Target the audience |
|
4. |
Position the "product" |
|
5. |
Design the "product" |
|
6. |
Implement and assess effectiveness |
When individual instruction and interaction is less feasible and messages are directed to the general public, such as in social marketing, nutrition education message conveyed via mass media must adhere closely to sound principles of communication in order to be effective. Some characteristics of successful messages for bringing about health behaviour change in populations are summarised in Table 5 (McAlister et al., 1982; Lefebvre, Harden, Zompa, 1988; Parlato, Green, Fishman, 1992; National Cancer Institute, 1992).
Use appealing and appropriate instructional methods in training
Personal contact is an effective way to influence dietary behaviour, so face-to-face presentations, demonstrations, and counselling are helpful in nutrition communication. Educators are able to do more effective nutrition counselling on the individual or group level if they have been exposed to these techniques and see them during training.
Instructional methods that are appropriate for the audience of trainers must be selected. Frequently a combination of methods is appropriate. Matching method with specific training needs will help to maximise both method and training effectiveness. Table 6, adapted from Pont (1991), describes a variety of common instructional methods and some of their distinguishing characteristics. Pont (1991) points out that research indicates that "learners retain about: 10% of what they read; 20% of what they hear; 30% of what they see; 50% of what they both hear and use; 70% of what they say; and 90% of what they say and do".
Table 5: Characteristics of effective messages
|
· Clearly presented and worded · Simple and repeated frequently · Consistent across all methods of delivery · Maximised credibility of the source and spokesperson · Anticipates and suppresses/answers counter arguments, suggests actionable next step (especially if using fear as a motivator) · Gets attention and stands apart from other messages · Persuasive · Provides situation and character-identification opportunities · Distinctive, and with a low fatigue index (to ward off disinterest and boredom after repeated exposures) · Appropriately appealing (i.e. not too much fear, humour, testimonial) · Culturally relevant |
Table 6: Pros and Cons of Widely Used Learning Methods
|
Method/Description |
Pros |
Cons | |
|
Lectures | |||
|
Widely used; importance has decreased with an increased emphasis on participative methods |
Appropriate for developing background for course, presenting material to introduce a topic, or presenting material supplementary to assignments |
Proceed at a pace determined only by the lecturer | |
|
Demonstration | |||
|
For hands-on reinforcement or follow-up to lecture, discussion, reading etc. |
Attracts and holds attention |
Although practice and preparation can help avoid mishaps, they can happen anyway | |
|
Discussion | |||
|
An excellent way to cover essential points and allow interaction with individuals in a group; incorporating discussion into lecture allows for an increase in maximum length of time recommended to maintain effectiveness and listening |
Can draw out conflicting opinions for constructive discussion; provides a memorable context for information |
Lengthens the time needed to get a point across | |
|
Active, participatory methods | |||
|
Such as case studies, role plays, simulation and games |
Allow for participation |
Higher degree of risk than non-participatory methods (unpredictable) | |
|
Open Learning | |||
|
(Sometimes called distance learning) |
Self-directed, allows for flexibility in administration and participation |
Expensive to produce and buy | |
Guidelines for establishing effective communication with groups and individuals include those listed in Table 7 (Parlato, Green, Fishman, 1992; Holli & Calabrese, 1991). Individual and group skills that are important include active-listening, asking questions, and using appropriate language and gestures.
Knowledge of skills for one-to-one and group instruction/facilitation
Working with groups requires unique skills, different from the skills needed to work with individuals. Communication and teaching methods important for working with individuals and groups are listed in Table 7. Working with individuals is more time consuming, but in that extra time the trainer or nutrition educator can potentially provide instruction based on a more thorough understanding of that member of the target population. Groups can be an efficient way of reaching several people with similar learning needs and interests that capitalise upon social supports and reinforcement by peers. Techniques for managing group dynamics are useful tools. Those who work with groups have the challenge of drawing out the potential strengths of groups, while minimising detractions such as dominant and/or disruptive group members. Often a combination of group and individual instructional methods are most effective for nutrition educators (Parlato, Green, Fishman, 1992). Trainers should use these techniques in training and include them as part of the curricula devised for nutrition educators.
Table 7: Guidelines for working with individuals and with groups
|
Audience |
Guidelines |
|
Individuals |
Treat clients as equals rather than as persons of lower rank |
|
Groups |
Acknowledge group members and their individual experiences |
Emphasise critical thinking skills
Strong critical thinking skills in trainers and nutrition educators will, among other things, enhance their ability to plan and teach subject matter most relevant to the intervention and audience of interest. Passing these skills on to the public successfully will result in an audience more capable of critically evaluating information and suggestions set before them, and appropriately applying recommendations in a variety of conditions. Both trainers and nutrition educators need to develop their own critical thinking skills if they are to be effective at teaching these to nutrition educators and the public, respectively. Several references are now available for teaching such skills, and these should be incorporated into training sessions (Plavacan et al., 1992; Brookfield, 1991).
Know and use the "tools" of nutrition education
Knowledge of the country's available "tools" for nutrition education is also essential in helping to keep messages consistent and to provide broad guidelines with which to work. "Tools" consist of various dietary/food guidance systems, including the United States' Food Guide Pyramid and Dietary Guidelines. Different subject matter areas within food and nutrition (such as food preparation, purchasing, budgeting, medical therapies, prevention of deficiencies, improving nutritional status) are usually so interrelated that it is possible to teach beginning with a point of individual interest, and eventually convey the message specifically targeted to the population at risk (Brink, 1995). Having standard tools for reinforcement of these messages allows basic information to be conveyed, while also responding to interests in other areas of interest to the population.
Use up-to-date instructional technologies
The potential for new computer-based technologies to increase and improve access to information by parts of the population in industrialised and developing countries, where much of the population is far away from a city or information centre, is tremendous. (Licklider, 1987). Other technologies can also enhance teaching world-wide. Table 8 shows some up-to-date instructional technologies. They include distance learning by radio and TV, and computer-assisted technologies, among others. The most appropriate technology depends on the learning situation, including the subject matter being dealt with, the reading level of trainees, the complexity of the technology required, time, money and availability (Holli & Calabrese, 1991). The training of instructors in the use of new technologies needs to be thorough enough for them to use them in their own teaching. Provision of backup resources, such as clearly written instructional manuals that include directions for troubleshooting, are useful.
Table 8: Summary of Instructional Technologies to use in training nutrition educators
|
Technology |
Pros |
Cons |
Nutrition education example |
|
Radio |
Widely available |
Not interactive |
Targeted messages to hard-to-reach audiences in developing countries; public service announcements |
|
Television (TV) |
Widely available |
Need broadcasting capabilities; not easily portable; not interactive |
Public TV programmes, public service messages |
|
Videotape |
Entertaining if short, can be specific to training needs |
Need television; expensive to make; tape sizes must match VCR to show in different places; not interactive |
Videos made by organisations with specific, targeted message (i.e. Eat more vegetables, breast feed, exercise) |
|
Audiotape |
Inexpensive; portable |
Must have recorder to use; hard to concentrate; not interactive |
Educational and training tapes |
|
Computer |
Can be available for fieldwork (laptops); potential for graphic display; interactive; assessment feedback available for audience with most programs |
Requires equipment; requires some expertise and/or training; delicate for fieldwork |
Text-based dietary assessment programs; visual-based dietary assessment programmes1 nutrient analysis capabilities; data collection |
|
Laser disc (CD-ROM and Interactive Video Disk) |
High resolution visuals; interactive; multi-media capability |
Expensive to produce; requires computer with CD-ROM drive or laser disk player; needs expertise and/or training |
Visual-based assessment and intervention programmes2 |
|
Portable laboratory measurement instruments |
Immediate feedback for audience or individual |
Needs expertise and/or training; portable instruments may be less accurate |
Cholesterol screening kits; body fat measurement machines; rapid assessment techniques to measure serum iron levels |
|
Distance learning |
Makes educational opportunities available when they might otherwise be impossible |
Needs infrastructure set up; needs a large audience to be cost effective |
Satellite conferences around the world; World Wide Web servers in the Internet |
1 Self-Reported Dietary Assessment (SRDA) program. Hernandez T. JWK International Corporation, Annandale, VA.2 Hispanic Multi-Media Assessment (HMMA) program. Hernandez T. JWK International Corporation, Annandale, VA.
Many external, practical factors limit the application of technologies in training of nutrition educators, including unwillingness on the part of instructors to use them, lack of money, skills or facilities, or lack of back-up technical support. Small, mundane details must be attended to and can be quite disruptive if ignored: availability of power outlets, running water, air conditioning or ventilation for computers in hot climates, lighting, access, etc. With the advent of more recent distance learning technologies, the geographical location of trainees and means of access to them are also considerations.
Make objectives fit with the duration and location of training
A balance must be struck between the time needed to complete the necessary teaching/training and the length of time adults can remain alert in a learning environment. Table 9 provides some ideal conditions and brief comments regarding different training lengths. Training sessions often need to be compressed into several days of intense instruction. It is easy to become bored if the teaching styles are monotonous. Incorporating discussions and hands-on exercises can help to break up long blocks of time and lessen fatigue. Table 10 contrasts the pros and cons of centralised, on site, and distance learning locations.
Plan field experiences to bring training to life
After some initial instruction, it is helpful to provide field experiences that offer the opportunity for relevant interactive and hands-on experiences for trainees. They also provide the instructor with a chance to observe and evaluate trainees in a setting outside of the "classroom". Planned experiences may relate to any of the topics already covered or those coming in the future. Such experiences will help build a high level of competency and comfort with all material and techniques in trainees. Examples of such field experiences include trainer-observed instruction by nutrition educators in groups (local clinic) or with individuals (home visit).
Table 9: Options and pros and cons of different training lengths
|
Training Frequency |
Ideal Conditions |
Comments |
|
Consecutive days |
Full but not long days (i.e. 9-3) with breathing breaks and a lunch break to decrease fatigue |
Shorter rather than longer days help maximise absorption of material and minimise negative effects of fatigue. If travel is required, consecutive days may be the only option |
|
Once a week |
Several hours weekly over consecutive weeks |
Provides opportunities for practice in between sessions and reinforcement of material through follow up in subsequent sessions |
|
Initial training with follow up sessions |
Short initial training with regular, on-going supervision and evaluation |
Allows for ongoing guidance and learning after main, initial training. Provides opportunities for practice between training sessions |
Table 10: Options and pros and cons of different training locations
|
Training Location |
Ideal Conditions |
Pros |
Cons |
|
Centralised |
Closest large city to rural area targeted |
Variety of facilities and resources available; more likely to be an information centre; easier to plan for distance learning opportunities |
Transportation difficulties possible for those coming from far away; location may be very different from location of target population, limiting relevance of field practice |
|
"On site" |
Close to targeted communities |
Fewer transportation problems for local trainees; opportunities for highly relevant practice in the field |
Rural areas may have fewer options for meeting place, technology, and professionals |
|
Distance learning |
Easily accessible location |
Everything happens in one place; usually a centralised location |
Need transportation if centralised location is far from participants; practice in the field not included |
Address professional perspectives and personal values
Training sessions should address and discuss some of the more personal aspects of the individual being trained as a nutrition educator. Obvious inappropriate behaviours, such as cultural biases, prejudice, poor communication, judgmental and condescending attitudes, need to be discussed if individuals possessing these characteristics were not screened out while selecting potential nutrition educators.
Pre-existing value judgements by nutrition educators may have an impact on client interrelationships and can affect the way they communicate nutrition messages to individuals. The absence of respect for, and a caring attitude towards, all audiences while delivering messages/teaching diminishes the receptivity of the target audience and may jeopardise the entire nutrition education endeavour. This applies to issues involving some of the more obvious and sensitive possibilities for discrepancies between nutrition educator and audience, including class, race, and gender.
The inculcation of self-direction in learning and practice is a requirement of a good adult educator, and also a reflection of good in-service training and education. A nutrition educator who can separately assess each teaching situation and adjust the experience accordingly, as well as critically evaluate the success of each contact and revise future efforts accordingly, is one who will be well-equipped to take on the task of facilitating nutrition behaviour change in a target population.
Evaluate training efforts
Classify the type of outcomes desired
Outcomes can be regarded as cognitive (knowledge), behavioural (response to information), health (anthropometric, biochemical and clinical measurements, morbidity and mortality statistics) and system (institutionalisation, in that a message is incorporated in the content of other development messages and projects). These need to be explicitly stated. The specific parameters for success, or the size of effects may change in magnitude or specification over time.
Edwards, Mullis and Clarke (1986) describe several issues in evaluation research as important to consider for a thorough and comprehensive evaluation of nutrition education programmes. First, evaluation efforts should be flexible and interactive, and be used throughout the development of a new programme so that findings can be used to change future programme and subsequent evaluation procedures. Second, assessing qualitative data as well as quantitative data provides useful information, for example instructor and participant perceptions of course materials and instructional strategies. Integrating measures of process and performance reveals clues to explaining performance data. A closer look at process includes evaluation measures of a programme at each level of the organisational structure (i.e. client, instructor, and agency) and helps understand the overall functioning of the programme and all aspects which, directly or indirectly, affect outcome.
Measure short-term effects
Trainee competence with respect to knowledge processes and skills must be assessed both during and after training, to evaluate the overall effectiveness of the training and the achievement of the individual. Evaluation of the trainee should be based on the objectives of the training session - what the trainee must know to function effectively in the field. Paper and pencil evaluations by pre- and post-tests, quizzes and practicals, as well as evaluation by observation, such as requiring presentation or hands-on demonstrations, are both usually needed to assess the abilities of each trainee. Mid-course evaluations can provide immediate feedback and it is often helpful to build-in some test at the end of each training session. Also, participant feedback following training sessions provides valuable information for the planning of future sessions, and it should be solicited.
Measure long-term effects
Evaluation of trainees immediately following the programme is both necessary and useful. Long-term evaluation measures the "true" effectiveness (long-term outcome) of the training effort against the long-term goals and objectives of the larger intervention. These may be changes in knowledge, attitudes, or behaviour. Evaluation methods must be appropriate for the goals and objectives of the programme.
Regardless of the type of outcome desired or the time frame for its accomplishment, long-term evaluation must include baseline measurements on the same population, or some acceptable proxy for it. In interpreting results, secular trends and other possible factors contributing to behaviour change measured during the time of the intervention must be considered. Humans change their behaviour for many reasons. Therefore, all possible explanations must be considered (Rice & Foote, 1989). For example, measures may indicate that nutrition educators were successfully trained and performed their tasks well, but behaviours in the population did not change as expected in the given amount of time. Many uncontrolled variables, such as a sudden recession, might prevent learners from putting principles into practice because of lack of money. Attributing changes in behaviour to specific interventions has become difficult in the United States where secular trends and many community/public health campaigns, in addition to media attention, have focused on decreasing fat in the diet. Today it is nearly impossible to credit any one message or circumstance for doing this. In less industrialised settings with a dearth of public health efforts, a single intervention's effects may be much easier to quantify.
Reformulate and improve training based on results
Short- and long-term evaluation results are useless if they are not used to improve training programmes in the future. Analysis of both process and outcome evaluation together provides the most information with which to locate and revise contributors to less than desirable outcomes.
After the nutrition educators have been successfully trained and have demonstrated that they are knowledgeable, competent and skilled, more specific areas of expertise must be acquired before they are ready to go into communities to teach. This section addresses these more specific issues.
Base programming on knowledge of food, nutritional needs, and problems of the population and sub-groups by employing needs assessments and other techniques
At the outset, the population most in need of nutrition education needs to be identified, and nutrition educators need to know how to do this. Such needy groups often include infants and young children, pregnant and lactating women, and the elderly. Populations may also be targeted by risk factors for disease (i.e. breast cancer in the family, chronic hypertension, high cholesterol levels, etc.).
Conduct qualitative and quantitative baseline assessments of target group
Baseline assessments of the target population with respect to their food and nutrition problems, needs, and attitudes, are crucial to developing a nutrition education campaign which will change behaviour and improve health. Knowledge of the audience is critical for health messages. Such information is used widely today in social marketing as well as in product-focused messages by marketers.
Qualitative methods of needs assessment include using focus groups and surveys, or compilation of information on knowledge, attitudes, and practices of the target group. Quantitative assessment tools include anthropometric measurements, such as height and weight (plotted on growth charts), morbidity and mortality statistics, information on dietary intake, and information on biochemical and clinical measures of nutritional status from screening tests or surveys.
Identify factors to be changed in the target population
Identify barriers to better dietary habits and better health
Once the population needing help is identified and characterised through the use of qualitative and quantitative methods, the next step the nutrition educator takes is to identify major factors affecting food habits that can be changed. This information will help to identify barriers to better dietary/food habits and better health that can be overcome. In addition to lack of knowledge, other factors influencing nutritional status and dietary habits usually include economic, cultural, and social factors, individual preferences, lifestyles, and time constraints. Nutrition education cannot address all of these problems or overcome all of the barriers they create (Parlato, Green, Fishman, 1992). Therefore realistic objectives that stand a chance of success must be chosen.
Be aware of factors affecting local food supply as well as individual dietary behaviours
For solving some problems, the nutrition educator's knowledge of diet-related factors affecting health should also include knowledge of the local food supply and of the health and education sectors. Nutrition educators must be aware of all the aspects of food-getting that may be affecting health: acquisition, selection, preparation, storage, and consumption. Their knowledge must also include a broad range of factors affecting the food supply, in addition to individual dietary behaviours. Specific information describing the food and food habits of the target population should also be available to nutrition educators. This information is summarised in Table 11.
Table 11: Knowledge of local food and foodways useful to nutrition educators
|
What |
Includes... |
|
Nutritional value of foods |
Food tables (as relevant to country), charts, computer programmes, etc. With a proper introduction on how to use them, and opportunities for practice, evaluation and feedback, much valuable information is available |
|
Effects of processing (preservation and cooking) on nutrient values |
Knowledge of the effects of food preservation and cooking on nutrient values, to include local methods of keeping food and popular/traditional cooking methods. Relevant questions may involve issues about whether any of these compromise the nutritional value of the food such that they should be changed |
|
Food safety and hygiene |
General information on foodborne illness and pathogens most likely to affect target audience |
|
Selecting foods for sustainability and good nutritional and economic value |
Need knowledge of indigenous food supply (what is available and at what cost); seasonal trends affecting cost; how to best store foods to make them last longer and keep nutritional value |
|
Knowledge of production and marketing of foods ("Foodways") |
Knowledge of how the food is produced, processed, distributed, regulated, marketed, etc.; and how these factors affect eating/nutrition behaviours targeted for change and health improvement |
|
Consumer issues |
Factors affecting access to food and food choices available to your target population as consumers |
|
Practical skills as needed |
How to: cook, preserve foods, practice safe food handling techniques, etc., especially skills which need to be taught or modified to improve nutritional status |
Consider other influential factors that induce acceptance
A thoughtfully delivered, clear message is effective only if it addresses some factor that influences the behaviour of interest in the learner. Other factors that influence food and nutrition-related behaviours include values, attitudes, social and cultural norms, perceived social pressure, a sense of personal competency and control, and perceived rewards and other motivators that may result from following the recommended behaviour. Barriers to consumer education include, among others: language used, illiteracy, and the existence of conflicting messages (Macfarlane, 1993). Individuals with experience and insights about the target population's views on these issues, levels of understanding, and conflicting cultural beliefs or messages, may be helpful in identifying these factors and useful in training.
Use the media effectively
Rules of thumb for appropriate use of the media to communicate the message are included in Table 5. Local media channels used most frequently by the target population should be considered (within budgetary constraints). The use of "mini-media", such as church bulletins, worksite publications, and bulletin boards at various organisations, can also be very useful in reaching individuals where they work and play, although they are often underused in public health programmes (Lasater, 1988).
In-service education of nutrition educators should be accompanied by back-up assistance for communicating, disseminating and marketing their messages. One way to help them is to identify local channels of communication, such as local media (radio, TV, newspaper), some basic community action skills including locally appropriate methods of contacting key leaders in the field and political figures with whom it may be helpful to network.
Develop support strategies
Look within the community to develop support for interventions
Apply interventions with, rather than to, a community or group. This implies developing supportive structures in the community. Sophisticated health education efforts involving many aspects of the community have been well reported in the literature (Pirie et al., 1986; Linnan, 1990; Flora, Maccoby, Farquhar, 1990). Looking to the community for involvement is advantageous because communities can provide both valuable human resources and sources of support among the target audience that cannot be simulated or equalled by external efforts. The nutrition educator needs to know how to select and implement appropriate support strategies for education and communication efforts. These include skills in mobilising social support, using home gardening, school meals, and otherwise involving the community through organisations and community leaders.
Reach audiences beyond health systems in places that are familiar
Adult learning theories emphasise the advantage of working in a relaxed, trusting, mutually respectful, informal, warm, and collaborative climate, which supports efforts to reach people in their day-to-day comfortable, relevant settings. This is what is meant by a "supportive environment". Educating people where they work, live and play rather than just within health systems must be considered. Such settings include households, local communities, schools, worksites, markets and shops, and recreational and cultural settings which are closer to the point at which food choices are actually made. The United States' "5-A-Day" Campaign for increasing the consumption of fruits and vegetables targeted people in a work setting and has made use of the particular attributes of this environment for a nutrition education campaign (Sorenson, 1990).
Know and choose appropriate networks and contacts for nutrition education
Develop skills for long term collaboration and institutionalisation of programmes into community life
Community interventions seek to change organisations and environments as well as individuals. The nutrition educator must keep in mind that his or her work is in a long time frame since the aim is for permanence in community life. The goal is community improvement over the long run (Parlato, Green, Fishman, 1992). Therefore the nutrition educator needs to develop skills that permit collaboration with a range of different organisations and disciplines over a long time.
Influence and seek co-operation with community leaders and pro-established networks
Community leaders and networks are often effective channels for promoting solutions to nutrition problems. Community involvement and commitment should therefore be sought at various levels. The accomplished nutrition educator uses the influence of community members, such as officials, elders, group leaders, and community health volunteers, as well as contacts with "higher ups" in the community who can make efforts work more smoothly, and without whose co-operation the efforts may be difficult or impossible. For example, the Pawtucket Heart Health Programme in the United States turned to the community for volunteers and was able to staff many programmes with these resources. It also formed alliances with organisations including the local Department of Parks and Recreation, which provided facilities for unique opportunities in the campaign (Lasater, 1988). The Thailand vitamin A project integrated many influential people from all parts of the community and used them as channels in their efforts to reach village residents with their messages. Some of these channels included: district agriculture and primary school offices; district education offices; school and village communities; village volunteers; health centres; Buddhist monks; mobile drama groups; folk singers; and public address systems, radio spots and programmes, audio-visual materials and billboards.
Collaborate with other organisations/or more efficient and effective use of resources
The nutrition educator needs to know where and how to obtain an appropriate audience. Other agencies may share concern about the target population and may be ripe for collaboration. Sharing outreach efforts, facilities, channels of communication, and even education campaigns, are opportunities for using resources more efficiently and perhaps increasing effectiveness.
Ensure that specific knowledge needs for the task at hand have been imparted
Content as well as process are important in nutrition education. After assessment and targeting of those in need of nutrition education, some information and skills need to be transmitted. The subject matter detail that is necessary depends on the prior skills and knowledge of the nutrition educators who are trainees, and also the task at hand. While providing more facts in training does not increase effectiveness as educators, more knowledgeable educators may have more credibility with their audience and should be included in the training as appropriate.
Before launching in-service training programmes for nutrition educators, careful consideration needs to be given to the circumstances for which nutrition education is an appropriate intervention.
What causes of malnutrition can be remedied by nutrition education?
Clarify goals of intervention
Before embarking on nutrition education or training endeavours, the context and rationale for efforts need to be established. The following questions must be asked and answered: What factors contribute to the inappropriate or inadequate nutrition knowledge and food practices? Is the goal of the programme to increase nutritional knowledge, or to provide skills for making healthy dietary decisions to maximise nutritional status, or both of these?
Nutrition education can rarely remedy malnutrition alone
Nutrition education is an appropriate intervention only when a lack of food and nutrition knowledge, attitudes, or skills, harm the health or well-being of the individual or those she or he is responsible for. When factors other than lack of nutrition knowledge cause poor nutritional status, these also need to be addressed. Informational or educational efforts to combat undernutrition are ineffective unless they are culturally relevant and geared to the target group's interests.
What are some other causes of malnutrition and how can they be addressed?
· Multifactorial economic and social inequalities contribute to malnutrition:
Many of the problems related to the ill effects of improper nutrition are due to economic and social inequalities. For example, among the poor in developing countries, undernutrition is a problem that is often due to inadequate food supply, limited purchasing power, poor health conditions, and incomplete nutrition knowledge (Berg, 1987). Problems of poorly nourished populations in developing countries are multifactorial and include disease, lack of education, poor education, other circumstances associated with poverty, and unequal distribution of food resources, not only within society but within families, as well as lack of nutrition knowledge. Abundant research shows that in situations of poverty, where food inadequacy exists, food-assistance programmes must precede educational interventions. Thus, it is especially important in developing countries to integrate nutrition education into broader programmes that encompass agricultural and food availability issues. Nutrition education must also be appropriate for the biological, cultural, economic, social, and cognitive contexts in which the programmes operate.
· Psychopathology:
When undernutrition is present, the causes may sometimes include not only insufficient economic resources to purchase adequate diets, or inappropriate food distribution in the family, but also psychopathology. This is particularly likely in affluent countries. Infants who fail to thrive and adolescents with eating disorders often come from disturbed families. Programmes to address prevention of failure to thrive (Pollitt, 1994) and eating disorders (Nagel & Jones, 1993) must also include both nutrition education and attention to these psychosocial issues.
Status of women
The status of women also has an impact on the effectiveness of nutrition education, especially in developing countries. In developing countries women have multiple social and economic roles, long working hours, and less access to education and nutrition than males (Brown, 1990). Yet it is they who are responsible for the alimentation of their families. The international human rights movement has neither considered nor remedied the low status of women, although it has called for respecting the political rights of people in general (Bunch & Carrillo, 1991). Gender discrimination and violation of women's rights deny many women education, health care, and good nutrition.
Economic and political instability
Developing countries must currently make "structural adjustments" in the economy, and austerity measures, which have a great social impact on food availability, may be implemented to cope with economic instability (Bradshaw et al., 1993). The latest international statistics on the effect of different social indicators, including level of nutrition, present a bleak picture, especially in poorer countries experiencing economic crisis, such as Mexico, certain other Latin countries, and Eastern Europe. Political conflict and wars increase already existing inequalities. During the Gulf War, there was a dramatic increase in malnutrition that threatened the lives of over 250,000 children under the age of 12 (UNESCO, 1991; Field & Russell, 1992). Violence in Croatia and Bosnia, in several countries in Africa, and in the countries making up the Former Soviet Union have also increased malnutrition. Political strife in Haiti, Somalia, Iraq, Cuba, and Chechnya may have led to food shortages, and under- and malnutrition in vulnerable groups. Education to improve food choices and handling under conditions of war may alleviate some of the impact on nutritional status as limited knowledge may contribute to the undernutrition seen in these circumstances, but undernutrition rarely yields to nutrition education efforts alone.
Developing countries
Environmental influences on nutritional status differ in degree between industrialised and developing countries, but are evident in both (Scrimshaw, 1993). For example, the effects of poverty on child development, links between anaemia and decreased levels of mental and motor development, the positive effects of supplemental nutrition programmes on child development, and the ill effects of poor nutrition and concurrent illness on school performance, are present in both poor and rich countries (Pollitt, 4994).
Ill-effects of malnutrition are well substantiated
Poor early childhood development, low productivity, violations of human rights and women's rights, and abject poverty all combine with lack of nutrition education to cause malnutrition in populations. Evidence for the deleterious effects of inadequate food is substantial. Foster and Rosenzweig (1993) reported that intakes of food energy had adverse effects on productivity in the Philippines, India and Pakistan. Khurana (1992) reported an association between malnutrition and lack of basic literacy skills among children in India. But in many developing countries, in addition to dietary inadequacy, nutrition-related feeding problems exist in early childhood development. The ill effects of improper nutrition early in life are many, and may sometimes be irreversible. Myers (1992), analysing the situation in Latin America, concluded that intellectual development, personality, and social behaviour were all severely impaired by lack of good nutrition. Glewwe and Jacoby (1993) indicated that nutritional deficiencies in early childhood in Ghana were associated with delayed primary school enrolment.
Nutrition education must be included as part of the solution
Prognoses of the nutritional status of populations around the world are not so negative that we should surrender to a future of malnutrition. The late, former-UNICEF Director John Grant (1993), analysed the State of the World's Children and found hope in the post-cold-war world. He indicated that now the means were at hand to end mass undernutrition, preventable disease and widespread illiteracy among the world's children. The estimated cost was only US $25 billion per year in additional aid to developing nations. Experts agree that if we are to address these problems, nutrition education must be included as part of overall development efforts. Risks of malnutrition cannot be addressed by nutrition education alone, but nutrition education is appropriate, and can be effective, in situations where food is available but food practices are inappropriate or uninformed from a nutritional standpoint. Frequently, such lack of knowledge is only part of the problem, and therefore for nutrition education to be most efficient and effective, it should be delivered along with programmes that provide the other components that are lacking.
The 1990 UNESCO "Education for All" conference (Fordham, 1992) called for enhancing the learning environment through early childhood care and education about health and nutrition. In 1991 in Lisbon, Portugal, education specialists from 51 countries concluded that systematic and continuous social and familial action, beginning in early childhood and continuing until maturity were necessary to tie together pre-school education, health, nutrition, and social service programmes in to effective intentions. Others have also emphasised the need to sustain nutrition education in the context of overall promotion of maternal and child health (Dwyer, 1990; Wallace, 1988).
Industrialised countries
In highly industrialised countries such as the United States and Western Europe amongst others, efforts to provide information to consumers so that they can make informed choices have been popular. In these countries, chronic degenerative diseases that have been linked to diet are more prevalent than undernutrition as causes of malnutrition (USDHHS, 1990).
Individual choice contributes to malnutrition through chronic disease
In these countries the choices of individuals, rather than insufficient incomes for purchasing adequate diets, make up most of the malnutrition problem. Many long-standing lifestyle factors, in addition to dietary patterns of excess, contribute to ill health and me development of chronic degenerative diseases that are common in those countries. These diseases include coronary artery disease, hypertension, non-insulin dependent diabetes mellitus, obesity and alcoholic liver disease (National Research Council, 1989).
Successful Programmes Focus Both on Lifestyle Factors and Diet
Programmes to decrease risks of these disorders are most effective when they include attention to lifestyle factors in addition to diet, as do programmes such as the National Cholesterol Education Programme (NCEP, 1987) and the National High Blood Pressure Education Programme (NHBPEP, 1988). Innovative, experience-based teaching techniques are also needed. For example, Fletcher and Braner (1994) report that an effective way of teaching children about nutrition is for them to prepare their own foods and to instil awareness of ethnic and cultural influences on food choice.
Institutional arrangements and resources for nutrition education
The institutional arrangements for nutrition education and training already in place within a country vary. Usually it is necessary to build programmes on these bases. Lead responsibility for each aspect of nutrition education should be clear whatever the institutional arrangement.
Both efforts sponsored by international and bilateral organisations (country to country) may be involved, and these may include not only governmental but non-governmental organisations as well. When the government is involved, in some countries, one institution or sector is designated as responsible for training. In other countries, responsibility is shared by several sectors (e.g. health, agriculture and education). The degree of centralisation of control over programmes also varies. Responsibility may lie with a centrally located group or less highly centralised structures may exist. Finally institutional structures may include only a single discipline or multiple disciplines.
Know organisational resources
Those who wish to develop in-service training in nutrition education must be familiar with the organisational resources and channels for communicating within these structures for developing training programmes. Imposition of in-service training in nutrition education by international organisations with little or no involvement by groups within the country is unlikely to succeed. Co-operation at the government level will make some aspects of training easier than efforts relying unilaterally on voluntary groups. Countries where interdisciplinary teams have already been formed with a mutual interest in nutrition (i.e. Thailand, with Ministries of Health, Agriculture and Education working together) may have systems in place for training and delivery of education which can be used. Large government organisations typically have specified procedures for training staff, which may be necessary and useful to incorporate into training plans if funding is to be obtained from the government agency. For example, in the United States, the Nutrition Education and Training (NET) Programme was established to support the training of nutrition educators of school age children (Ullrich, 1992), and training is built into the mission of the Co-operative Extension service organisations at the Federal and State level. These organisations exist to translate research information into practical terms, and to bring it to people in target groups who would otherwise not have access to it. In planning and training, nutrition interventions can be linked to other health and socio-economic development programmes.
Investigate other organisations with and interest in nutrition education
It is also useful to investigate the willingness of other government, industry and volunteer organisations to cooperate in developing in-service training. They may have aims which overlap with or involve nutrition education. Monetary or in-kind assistance may also be available for nutrition education training programmes from these sources if their goals and objectives are consistent with those of these funding organisations.
Plan carefully
Thorough and thoughtful planning for training of nutrition educators improves the likelihood that desirable outcomes will result. In the best of all worlds there would be time, money, facilities, willing and capable volunteers, good channels of transportation and communication, co-operative government, and well-established organisational structures in which the trainer could operate. In the real world, this is often not the case and many barriers exist that cannot be overcome even by the most careful planning. Nevertheless, careful planning, coupled with the flexibility to modify plans to overcome barriers, is likely to achieve more than unplanned efforts.
Tailor context to learners' experiences
The content of training sessions should be partially determined by the experience of the selected nutrition educators. While subject matter must be provided to prepare credible educators, educators must also be prepared to communicate their messages effectively.
Special considerations applicable to developing countries
The guidelines for in-service training of trainers and nutrition educators apply both to industrialised and developing countries. However, there are some practices which are especially important for furthering nutrition education efforts in developing countries. First, it must be recognised that in developing countries, economic resources for health are limited. However, it is also true that existing resources are not used to their full potential (World Bank, 1980). More attention to planning and management may be helpful in this regard.
Planning can provide better utilisation of a programme, and effective management assures that the programme is efficiently administered and prevents a crisis management approach. In-service training of nutrition educators must adequately address questions of planning and management, including the manner in which the training is to be conducted, and the larger societal effects. General guidelines, especially appropriate for in-service training of trainers and nutrition educators in developing countries include the following.
(i) Assess the developing society's relevant characteristicsNutrition education programmes rarely exist by themselves; they must be examined in a broader context rather than considered in a vacuum. Political attitudes and social traditions affect the way people nourish themselves, as does the way a society conceptualises nutrition-related issues.
Trainers and nutrition educators, as planners and administrators, must use information provided by local respondents. Often health professionals and government administrators are unaware of, or unable to, provide information about the local situation.
(ii) Determine availability of human resources
Censuses of trained personnel and their locations, frequently carded out by direct site-by-site observation may provide more up-to-date and accurate data. Generally, most highly educated professionals, including physicians and health workers, are concentrated in the urban areas (Phillips and Verhasselt, 1994). The in-service training of rural nutrition educators presents special challenges since so few trained personnel are available. An effective way to increase the probability of a programme's success is to invite and encourage the participation of community leaders and teachers.
(iii) Set priorities
When faced with seemingly insurmountable social and economic problems, administrators and planners in developing countries often find it difficult to make decisions. Determining the most important issues to be addressed may assist in finding a proper balance between what is urgent and what is important, and in mobilising efforts.
(iv) Assure low cost programmes
The most important health programmes are those that have maximum impact at the lowest possible cost (WHO, 1978). Maximum impact is determined by attending to highest priority issues and lowest cost by using all available resources effectively. Berggren et al. (1981) and Gwatkin et al. (1980), have effectively lowered infant mortality rates through the operation of moderately priced, effective programmes.
(v) Take into account effective communication techniques in nutrition programmes
Effective communication techniques, derived from marketing and the behavioural sciences, and based on studies in the target group, are frequently lauded as most appropriate and successful for understanding and changing nutrition-related behaviours in various social contexts.
(vi) Overcome barriers to effectiveness of training
Some consumer education barriers include language, illiteracy, and the existence of conflicting messages (Macfarlane, 1993). Many developing countries are multilingual, and much scientific and technical information is not available in the indigenous language. Ideally, the training of trainers should be provided in the language in which recipients are most likely to learn. Trainers should know those languages and adapt the level of language used to match the characteristics of the learners. Illiteracy, or lack of understanding of language used in teaching, may also be a problem of the target group. Audio-visual technology and aural messages can be used to present or reinforce the message.
Training of nutrition educators should recognise the heterogeneity of messages and the existence of varying opinions and find a way to resolve these incongruities without providing false or misleading information.
(vii) Incorporate distance education techniques when feasible
Recent advances in distance education make it possible to implement multiple on-site training for a large or small number of nutrition educators who are providing face-to-face instruction. Pre-recorded relevant information can be projected or sent to the trainees. Distance education is also useful for reinforcing face-to-face training, using radio, television, and pamphlets mailed to recipients. Distance education is also useful for updating nutrition educators.
(viii) Emphasise the development of a back-up system of supervision and support for nutrition educators working in the field
The trained nutrition educator needs to have a good support system to count on, especially if she or he is geographically isolated. This support system ensures that the programmes can be sustained. (Wray in Perry, 1988):
"No matter how well-intentioned the programme, no matter how adequate or inadequate the training, unless auxiliaries (including village health workers) are part of a system that is capable of providing them with satisfactory guidance when needed, the necessary supplies and equipment to carry out the tasks assigned to them, and a referral system to which they can send problems with which they cannot deal, they are not likely to be able to function effectively."
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Education involves empowering the learner to take interest in the subject, and apply knowledge gained to make decisions that involve situations other than those specifically presented in training, and to integrate this knowledge with experience.
Nutrition education is a process by which people are assisted in making decisions about eating. Its ultimate goals are to improve the recipients' nutritional status or other aspects of their nutrition well-being through both knowledge acquisition and behaviour change skills (Devine 1988, The American Dietetic Association, 1986). Generally, the goal of nutrition education is to change specific dietary behaviours which contribute to the poor health of the public. However, other considerations such as taste and enjoyment must not be forgotten if efforts are to succeed.
Nutrition educators design, implement and evaluate programmes to help people understand healthful food consumption practices and gain skills to develop and maintain positive food and nutrition behaviours and nutritional status (Anderson, 1994). A crucial aspect of this work is to transform technical, scientific information into simple skills and practices that lay persons can put into action (Devine, 1988). An all-encompassing definition put forth by the Society for Nutrition Education regarding the Academic Preparation of the Nutrition Education Specialist states that a nutrition education specialist is "a professional who is trained in the fundamental principles of human nutrition, learning theory, and educational methods including behavioural change strategies. This professional nutrition educator designs, implements, and evaluates nutrition education programmes which focus on developing and maintaining positive food and nutrition behaviours" (Ullrich, 1992).
Distance education is education in which the learner is not in the same location as the trainer, and communication is via technology.
Training is the time during which instructors, with knowledge, resources and expertise, teach the learner new skills. It is also referred to as a training session or in-service training. Training also implies efforts to achieve competence in a certain specific skill. The result of training in nutrition education should be competence to teach in a certain area of food or nutrition. Formal adult education is often referred to as "training". The emphasis is on formal instruction addressed to enhancing immediate job-related skills or remedying problems on the job (Yerka, 1981).
Trainers are those who instruct nutrition educators by organising and implementing nutrition education training programmes. Trainers may be individuals with backgrounds in fields other than nutrition.
In-service implies that training is required, paid for, or at least strongly encouraged by employers and that it is related to a job. Those who are trained are usually adults who continue to work while they are being instructed.
In-service training sessions can be designed for adults not previously familiar with the field (these are known as initial, or core, in-service training sessions) or as part of ongoing efforts to maintain competence among those who are already experienced in a field (often referred to as continuing education or booster training.)
The content of in-service training instruction should vary depending on the needs of the trainees. This can be discovered by conducting a needs assessment. In actuality in-service training is all too often based on the existing subject matter strengths or presuppositions of the instructors. For example, if those whose disciplinary background is nutritional science do the training, there is a tendency to focus on detailed descriptions of intake and physiological aspects of nutrition problems rather than developing trainees' communication and education skills (Yerka, 1981).
Acknowledgements
We would like to acknowledge Audrey Maretzki PhD, Kathy Kolasa PhD, Carole Palmer EdD RD, and Teresita Hernandez PhD, with thanks for making insightful suggestions. Their comments were appreciated.
This project has been funded in part with Federal funds from the U.S. Department of Agriculture, Agricultural Research Service under contract number 53-3K06-01. The contents of this publication do not necessarily reflect the views or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organisations imply endorsement by the U.S. Government.
