iii. cv training guide complete

8/3/2019 III. CV Training Guide Complete

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EssEntial nutrition actions FramEwork

2011

iii. training guidE

For community

voluntEErs


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The 1,000 Days Eort to

Reduce Child Undernutrion

What is 1,000 Days?1,000 Days is a global eort to jumpstart the implementaon of the Scaling Up Nutrion (SUN)

Framework and Roadmap for addressing undernutrion during pregnancy and early childhood. On

September 21, 2010, on the margins of the Millennium Development Goals summit, Secretary of State

Hillary Clinton and Irish Foreign Minister Michel Marn hosted an event to launch the eort, which

was endorsed by more than a dozen ministers and heads of organizaons. But 1,000 Days is more than

a single event. It is the start of a larger movement to focus aenon, align and increase resources, and

build partnerships to alleviate the suering caused by undernutrion among millions of people around

the world, especially pregnant women and children under 2 years of age.

What Are the Scaling Up Nutrion (SUN) Framework and Roadmap?The SUN Framework guides the internaonal community in eorts to combat undernutrion and builds

on the Paris-Accra principle of supporng country-led strategies. The Framework is endorsed by more

than 100 partners, including internaonal organizaons, naonal governments, civil society, and the

private sector The SUN Framework and Roadmap are grounded in the at scale implementaon of the

Lancet-endorsed nutrion acons that are evidence-based, cost-eecve intervenons that could have

enormous impact on reducing undernutrion.

Why 1,000 Days?

1,000 Days refers to the me from the start of a mothers pregnancy unl a child is two years old.

Children suering from undernutrion face physical stunng, mental impairment, higher suscepbility

to disease, increased risk of mortality, poorer performance in school, and lower future incomes. 1,000

Days also refers to a window of opportunity for the internaonal community to take acon to combatundernutrion.

How to Support the 1,000 Days?To jump-start the 1,000 Days in countries, the Core Group highly encourages its members to adopt such

tested and proveneld tools as the Essenal Nutrion Acons (ENA) Framework Trilogy training and

communicaon materials. Not only does the ENA Framework focus on the rst 1,000 days of life, but it

emphasizes targeng acon oriented nutrion messages and support -though mulple communicaon

channels- to reach under-twos and their mothers when they need it the most. The Core Group believes

that having many dierent eld groups using these same ENA tools will lead to harmonized eld

approaches that result in greater progress, synergies and nutrional impact. Such harmonizaon is

extremely crical as resources are scarce and the task ahead is enormous.

Where Can I Get More Informaon on the 1,000 Days?

Please visit www.thousanddays.org.


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Preface

TheEssentialNutritionActions(ENA)frameworkwasdevelopedwiththesupportofUSAIDandhasbeen

implementedacrossAfricaandAsiasince1997.Itisanoperationalframeworkformanagingthe

advocacy,planninganddeliveryofanintegratedpackageofpreventivenutritionactionsencompassing

infantandyoungchildfeeding(IYCF),micronutrientsandwomensnutrition.Usingmultiplecontact

points,ittargetshealthservicesandbehaviorchangecommunicationsupport(BCC)towomenandyoungchildrenduringthefirst1,000daysoflife-fromconceptionthroughthefirsttwoyearsoflife-

whennutrientrequirementsareincreased,therisksofundernutritionaregreat,andtheconsequences

ofdeficienciesmostlikelytobeirreversible.Alltheseactionshavebeenproventoimprovenutritional

statusandreducemortality.1

TheENAframeworkpromotesanutritionthroughthelifecycleapproach,addressingwomens

nutritionduringpregnancyandlactation,optimalIYCF(breastfeedingandcomplementaryfeeding),

nutritionalcareofsickandmalnourishedchildren(includingzinc,vitaminAandreadytousetherapeutic

foods),andthecontrolofanemia,vitaminAandiodinedeficiencies.TheENAframeworkemphasizes

thatmultipleprogramcontactpointsathealthfacilitiesandbeyondbeusedtoreachmothersand

childreninordertogiveandre-enforceENAmessages.Forexample,suchcontactpointscouldinclude

educationalsettings(e.g.primaryandsecondaryschoolsaswellaspre-serviceeducationcourses),

agricultureextensionservices(e.g.tosupportnutritionrelevantaspectsofavailability,accessand

utilizationofnutritiousanddiversefoods),aswellasavarietyofprogramplatformsatthecommunity

levelincludingprimaryhealthcareoutreach,childhealthdays,community-basedvolunteergroups,and

waterandsanitationprograms.Theintentistomaximizethesemultipleprogramopportunitiesand

communicationchannelstodeliverlifecycle-appropriatenutritionmessagesateveryopportunity

possibletopregnantwomenandmotherswithchildrenundertwoyearsatverybroadscale,inaddition

tootherkeychildcaregiversandinfluentialfamilymembers.

ThetrainingcomponentfortheimplementationoftheENAframeworkatboththehealthfacilityand

communitylevelscomprises atrilogyofmaterials asfollows:

I. TheBookletonKeyENAmessagesillustratesthekeyENAmessagesandcanbeusedbythoseimplementingandsupportinghealth,nutrition,andfoodsecurityprogramsforimproving

nutritionpracticesamongpregnantandlactatingmothersandchildrenundertwo.Itcanbea

resourcefortrainingcommunityorfacility-basedworkersorforpromotingbehaviorchangeat

thehouseholdlevel.Thegoalofthisbookletistomakeavailableanharmonizedsetof

messagesacrossallimplementingpartnersworkingacrossvariousprogramsandregionsinatargetedcountry.Thebookletsummarizes thekeyactionsthatmothersandcaretakerscan

take(withsupportfromotherfamilyandcommunitymembers)toimprovenutritionand

feedingpractices,therebypreventingmalnutrition.Eachmessagestates:

Whoshoulddotheaction Whattheactionis Whatthebenefitsoftheactionare

IIaandIIb.TheENAFrameworkTrainingGuideforHealthWorkersandHandoutsequipshealth

serviceproviderswiththetechnical,action-orientednutritionknowledgeandcounselingskills

neededtosupportpregnantwomen,motherswithchildrenundertwoyearsofage,andother

1BhuttaZ,AhmedT,BlackRE,CousensS,DeweyK,GiuglianiE,HaiderB,KirkwoodB,MorrisS,SachevHPS,ShekarM.(2008)

Whatworks?Interventionsformaternalandchildundernutritionandsurvival.MaternalandChildUndernutritionSeries.

Lancet;371:41740.


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keyfamilymemberstoadoptoptimalnutritionpractices.Thiscoursetranslatesup-to-date

internationalguidelinesintoaction-orientednutritionpractices.Thenegotiation/counseling

techniquesareadaptedfromtheTrialsforImprovedPractices(TIPS)andgobeyondjust

conveyingmessagestoprovidingsupportfortheadoptionofoptimalbehaviors.Infantfeeding

inthecontextofHIVandnutritionofwomenlivingwithHIVandAIDSarealsoaddressed,but

mightneedfurtherdevelopmentincountrieswithhighHIVprevalence.Guidelinestolinkthe

preventionofmalnutritionwithtreatmentviathecommunity-basedmanagementofacute

malnutritionarealsoincluded.Traininghandoutsaredistributedtoeachparticipantatthe

beginningoftheENAtraining.

III. TheENAFrameworkTrainingGuideforCommunityVolunteersequipssemi-literateorilliterate

CommunityVolunteerswiththebasicaction-orientednutritionknowledgeandcounselingskills

neededtosupportpregnantwomen,motherswithchildrenundertwoyearsandotherkey

familymemberstoadoptoptimalnutritionpractices.Thecoursealsocoversbasicskillsfor

identifyingchildrenwhoaremalnourishedincludingappropriatereferral.Thiscoursecanbe

incorporatedintoanytrainingatthecommunitylevel,includingonmaternal&childhealth,

communitymanagementofacutemalnutrition,HIV/AIDS,agriculturalproduction,food

security,ruraldevelopment,etc.

CountryAdaptation

ThegenericversionsoftheaboveENATrilogyhavebeentestedovertimeandarereadytobeusedin

newsettingsandcountries.Howeversomeadaptationsareneededtoensurethatthesematerialsare

countryandsituationspecific.Aguidetothekeyadaptationissuesareasfollows:

ENAMessages

ThespecificactionsrecommendedintheENAmessagesdontneedtobechangedastheyhavebeencompiledfromscientificresearchtosupportnutritionalstatus.However,theymayneed

tobeadjustedsomewhattomatchnationalguidelines(e.g.ageappropriatede-worming)or

mayneedtobeperiodicallyupdatedtoreflectnewglobaltechnicalguidance(e.g.infant

feedinginthecontextofHIV). Whilethespecificactionsareuniversal,theconceptsandlanguageusedtopromotethem

throughcounselingsessionswithmothersandotherchildcaretakersmustbeadaptedvia

formativeresearchtoensuretheirsuitabilityfordifferentculturalcontexts.Ifitisnotpossible

toconductformativeresearch,itisstillimportanttofield-testboththemessagesand

illustrationsusedinthisbookletwithasampleofmothers,fathersandotherchild-caretakers

suchasgrandmotherstoconfirmtheirsuitability.

FurtheradaptationoftheENAmessagesmaybeneededtospecifywhoisdoingtheaction(e.g.mothers,fathers,grand-mothers,etc)aswellasthebenefitsoftheactiontoensure

theirrelevanceandresonancewithintheparticularlocalityorsetting.Forexample,what

benefitswillmotivatemotherstopracticeexclusivebreastfeeding?Whattypesoflocal

complementaryfoods(staple+nutrient-richand/orenrichedfoods)areavailable?Whatlocalutensils(spoons,bowls,teacups)willhelpillustratethecorrectquantityoffoodthechild

needs?

Newillustrationsarentalwaysneededasexistingillustrationsoftencanbeeasilyadaptedandused.


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TrainingGuidesFocusingonCounselingSkillsandPracticumSessions

ThetwoENAFrameworktrainingguides arereadytobeusedanddonotrequirefurtheradaptation,excepttoincludecountry-specificmaternalandinfant&youngchildfeeding

messagesandprotocolsguidingmicronutrientsupplementation,theintegratedmanagementof

newbornandchildhoodillness,andthemanagementofacutemalnutrition. Theymayneedtobeperiodicallyupdatedtoreflectnewglobaltechnicalguidance.

BuiltintotheENAFrameworkTrainingGuidesaresessionscoveringthetechniquesofnegotiatingwithmotherstohelpthemtryandsucceedwithnewnutrition-relatedpractices,

andexercisesthroughwhichparticipantspracticeandbegintomastertheseskills.Thisincludes

roleplaysintheclassroomsettingandsitevisitstovillageswhereparticipantscanhonetheir

skillsworkingwithrealmothers.It cannotbeemphasizedenoughthatthesepracticalsessions

aretheheartofthetrainingprogramand shouldnotberemovedasthiswouldprofoundly

reducetheeffectivenessoftheENAtrainingaswellastheimpactoftheoverallENAsupportto

womenandyoungchildren.


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Acknowledgements

Wewouldliketoacknowledgethatthe BookletofKeyENAMessages andthetwoENAFramework

TrainingGuides tosupporttheimplementationoftheENAframeworkwouldnothavebeenpossible

withouttheeffortandsupportoverthepast15yearsofmanyinstitutionsandindividuals.

In1997,theUSAID-fundedBASICSprojectinitiatedtheapproachundertherubric theMinimumPackage

forNutrition orMinPak.Subsequentlytheapproachwasrenamedthe EssentialNutritionActions

(ENA)andwasexpandedconsiderablytoincludetrainingandIECmaterialsundertheUSAID-funded

LINKAGESProjectmanagedbytheAcademyforEducationalDevelopment(AED),wherewewereboth

involvedindesigningandimplementinglargescaleENAprogramsforMadagascar2andEthiopiafrom

1999to2006.

TheBookletofKeyENAmessages anditsrelatedENAFrameworktrainingguideshavebeenrecently

revisedandtestedwithinprojectsmanagedbyJohnSnowIncorporated(JSI)inEthiopiaandLiberia,and

byHelenKellerInternational(HKI)inanumberofcountriesacrossAfricaandtheAsia-Pacificregion.

MuchofthesupportforthisworkhascomefromUSAID,UNICEFandtheEuropeanUnion.

Stafffrommanyagenciesalsobroughttheirexpertiseandaregratefullyacknowledgedfortheir

contributionswithsupportfromUSAID,including:theAfricanRegionalCenterfortheQualityofHealthCare(RCQHC);theAfricasHealthin2010andFANTAProjectsmanagedbyAED;theWestAfricanHealth

Organization(WAHO);andtheEastCentralandSouthernAfricaHealthCommunity(ECSA-HC).UNICEF

hasalsoplayedakeyrole,especiallyinLiberiaandNiger,ashastheCarterCenterinEthiopia.National

trainingpartnersinanumberofcountrieshavebeencentraltothedevelopmentoftheENAframework

aswellasrelatedtrainingandIECmaterials.

CertainindividualswerealsoinstrumentalinhelpingustodevelopandtesttheoriginalENAtraining

coursesonwhichthepresentBookletofKeyENAmessages anditsrelatedENAFrameworkTraining

Guidesarebased.Theseindividualsinclude(byalphabeticalorder):MesfinBeyero,KristenCashin,

SerigneDiene,TesfahiwotDillnessa,MuluGedhin,PeterGottert,NancyKeith,AdbulselamJirga,Dorcas

Lwanga,RobertMwadime,HanaNekaTebeb,JenniferNielsen,AlbanRamiandrisoaRatsivalaka,Zo

Rambeloson,VoahiranaRavelojoana,PriscillaRavonimanantsoa,KindaySamba,MaryanneStone-JimenezandCatherineTemkangama.

2Guyon,AB,Quinn,VJ,Hainsworth,M,Ravonimanantsoa,P,Ravelojoana,V,Rambeloson,ZandMartin,L, Implementingan

integratednutritionpackageatlargescaleinMadagascar:TheEssentialNutritionActionsFramework.FoodandNutrition

Bulletin.30(3):233-44.TheUnitedNationsUniversity.2009.


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TheNutritionWorkingGroupofCOREGroupsupportedtheeffortstoupdatethetoolsandmakethem

morewidelyavailable.COREGroupfosterscollaborativeactionandlearningtoimproveandexpand

community-focusedpublichealthpractices.Establishedin1997inWashingtonD.C.,COREGroupisan

independentorganizationandhomeoftheCommunityHealthNetwork,whichbringstogetherCORE

Groupmemberorganizations,scholars,advocatesanddonorstosupportthehealthofunderserved

mothers,childrenandcommunitiesaroundtheworld.Thesetoolscanbeaccessedat

http://www.coregroup.org

AgnsB.Guyon,MD,MPH VictoriaJ.Quinn,PhD

JSIResearch&TrainingInstitute HelenKellerInternational

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

TheillustrationswereproducedundertheLINKAGESandJereoSalamaIsika(JSI)projectsinMadagascar,

theEssentialServicesforHeathinEthiopia(ESHE)andLINKAGESprojectsinEthiopia,andUNICEF

Liberia.

TheBookletonKeyENAMessages ,theENATrainingGuideforHealthWorkers,andtheENATraining

GuideforCommunityVolunteers canbeduplicatedifcreditisproperlygiven.Photosoncoverpage:

AgnsGuyon,UNICEFLiberiaandVictoriaQuinn.

TherecommendedcitationsareasfollowsforthesethreeENAdocuments:

Guyon,ABandQuinn,VJ.BookletonKeyEssentialNutritionActionsMessages. CoreGroup,Washington,D.C.,January2011

Guyon,ABandQuinn,VJ.EssentialNutritionActionsFrameworkTrainingGuideforHealthWorkers.CoreGroup,Washington,D.C.,January2011

Guyon,ABandQuinn,VJ.EssentialNutritionActionsFrameworkTrainingGuideforCommunityVolunteers.CoreGroup,Washington,D.C.,January2011


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TheSevenEssentialNutritionActions:Background

ThelandmarkLancetSeriesonMaternalandChildUndernutritionpublishedinearly2008estimatesthat

effective,targetednutritioninterventionstoaddressmaternalandchildundernutritionexistand,if

implementedatscaleduringthewindowofopportunity(conceptionandupto24monthsofage),could

reducenutrition-relatedmortalityanddiseaseburdenby25%.The EssentialNutritionActions

frameworkencompassessevenoftheseproveninterventionstargetingthiswindowbutalsorepresentsacomprehensivestrategyforreachingnearuniversalcoverage (>90%)withtheseinterventionsin

ordertoachievepublichealthimpact.ENAprogramsareimplementedthrough healthfacilitiesand

communitygroups .

Theapproachincludesensuringthatkeymessagesandservicespertainingtothesevenactionareasare

integratedintoallexistinghealthsectorprograms ,inparticularthosethatreachmothersandchildren

atcriticalcontactpoints(maternalhealthandprenatalcare;deliveryandneonatalcare;postpartum

careformothersandinfants;familyplanning;immunizations;wellchildvisits(includinggrowth

monitoring,promotion,andcounseling);sickchildvisits(includingIntegratedManagementofNewborn

&ChildhoodIllnessesandIntegratedCommunityCaseManagement);andOutpatientTherapeuticCare

duringCommunity-basedManagementofAcuteMalnutrition.

Theappropriatemessagesandservicesarealsointegratedtothegreatestextentpossibleintoprograms

outsidethehealthsector ,suchasagricultureandfoodsecuritycontacts;education(pre-service,

primaryandsecondaryschools)andliteracy;microcreditandlivelihoodsenhancement.

ImplementingtheENAframeworkentailsbuilding partnershipswithallgroupssupportingmaternaland

childhealthandnutritionprogramssothatmessagesareharmonizedandallgroupspromotethesame

messagesusingthesamejobaidsandIECmaterials.Ideallypartnersarebroughttogetheratthe

regionaland/ornationallevelstoagreeontheseharmonizedapproachesandto advocatewithpolicy

leadersfortheimportanceofnutritiontothenationseconomicaswellassocialdevelopment.

Messagesarecraftedassmalldo-ableactionsand behaviorchangecommunications (BCC)techniques

areusedtopromoteadoptionoftheseactions.Specialemphasisisgiventointerpersonal

communications(counselingofindividualmothers)thatarereinforcedbymassmediaandcommunityfestivalsandothermobilizingevents.Healthandcommunityagentsaretrainedtoemploynegotiations

forbehaviorchange,visitingmothersintheirhouseholdsorcommunitymeetingplaces(markets,

chores,womengroupsmeetings,etc)andhelpingthemanticipateandovercomebarrierstocarrying

outnewpractices.

Thecapacityforpromotingtheessentialnutritionactionsusingnegotiationsforbehaviorchangecanbe

strengthenedwithexistinggeneric trainingmodules3forhealthworkersandcommunityagents.

Whilethecontentremainsgenerallyfixed,thedetailsshouldbeadaptedthroughformativeresearchto

specificcountryandregionalcontexts.

3ThesetwomodulestogetherwithabooklethighlightingthekeyENAmessagescanbedownloadedfromtheCOREGroup

websiteontheNutritionWorkingGrouppage.


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TheSevenEssentialNutritionActions4

Allareequallyimportant.ThisENAlistisorganizedbyalifecycleapproach.

1. Promotionofoptimalnutritionforwomen2. Promotionofadequateintakeofironandfolicacidandpreventionandcontrolof

anemiaforwomenandchildren

3. Promotionofadequateintakeofiodinebyallmembersofthehousehold4. Promotionofoptimalbreastfeedingduringthefirstsixmonths5. Promotionofoptimalcomplementaryfeedingstartingat6monthswithcontinued

breastfeedingto2yearsofageandbeyond

6. Promotionofoptimalnutritionalcareofsickandseverelymalnourishedchildren7. PreventionofvitaminAdeficiencyinwomenandchildren

4COREGroup.NutritionWorkingGroup.NutritionProgramDesignAssistant:AToolforProgramPlanners,Washington,DC:

2010


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-1-

INTRODUCTION

ThepurposeofthistrainingguideistotrainCommunityVolunteers(CV)inkeyinfantandyoungchild

feedingpractices/messages,theimportanceofmicronutrientsandwomensnutrition,andincrucial

negotiation,andinterpersonalcommunicationskills.TheknowledgeandskillswillenableCommunity

Volunteerstohelpmothers/caregiversoptimallyfeedtheirinfantsandyoungchildrenandtakecareof

theirownnutritionalneeds.ThetrainingalsoprovidesanopportunityforsupervisorsandCommunity

Volunteerstolearntogetherandpracticecoachingtoimproveperformance.

TrainingAgenda

Thisthree-daytrainingguideisorganizedinasequencetofacilitatelearningandallowopportunitiesto

practicenegotiationskills

Thesessionsforeachdayoutlinespecificlearningobjectives,activitydetails,materials/handouts,

durationandmethodologiesforlearningactivities.

TrainingMethodology

ThetrainingguideappliestheprinciplesofBehaviourChangeCommunicationtopromotesmall,do-able

actions,andthewidelyacknowledgedtheorythatadultslearnbestbypracticeandreflectionontheir

experiences.Attemptshavebeenmadetomakethetrainingsessionsrelevanttotheneedsof

participantsandtheircommunities.

Thisparticipatoryapproachusestheexperientiallearningcyclemethodandallowsparticipantsthe

hands-onperformanceofskillsasameansofacquiringthem.Thecourseemploysavarietyoftraining

methods:demonstrations,practice,discussions,casestudies,groupdiscussions,androleplays.

Participantswilllearntoactasresourcepersonsforbreastfeedingmothers,pregnantwomen,and

mothers/caregiversofyoungchildren.

Respectforindividualtraineesiscentraltothetrainingandsharingofexperiencesisencouraged

throughout.Participantscompletepreandposttrainingassessmentquestionnairestoallowtrainersto

measuretheirprogress.

TrainingLocation

Whereverthetrainingisplanned,asiteshouldbeselectedclosetothetrainingfacilityandreadily

availabletoallowthepracticumfornegotiationwithmothers/caregiversondo-ableinfantandyoung

childfeedingpractices.Preparethepracticumsitebycoordinatingwiththeclinicand/orcommunity,

alertingthemtothearrivalofparticipantsandarrangingforspaceforpracticingnegotiationskillswith

actualmothers/caregivers.Itisoptimaltohaveonefacilitatorforevery6-8participantsforthissession.

MaterialsNeededfortheTraining

Stationary Flipchartstands 1 Flipchartpapers 50sheets Markers 1boxblack+1boxofcolor Maskingtape 1roll Participantsregistrationforms 1perday


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-2-

Teachingaids

Dolls 3* Breastmodels 3 Foodsfordisplay avarietyoflocallyavailablefoods BookletonKeyENAmessages 1perparticipant ChildMUACtapes 1perparticipant AdultMUACtapes(optional) 15MUACtapesAdvancePreparationforFieldTrip

Oneweekinadvance,makeanappointmentatthehealthclinictodothefieldpracticeduringimmunizationorweighingsessions.

Oneweekinadvance,makeanappointmentwiththecommunityhead/leaderorthecommunityhealthagenttorequestpermissionforvillagevisits.

Confirmthedaybeforethevisitandspecifythenumberofmothersneeded(atleast10).Realmothersandbabiescanbealsoinvited.


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-3-

DAY1

WOMENNUTRITIONANDOPTIMALBREASTFEEDING

DURATION

Session

1

Introduction

Pre-test

LearningObjectives

RoleoftheCommunityVolunteer

1hour

Session

2

Thecycleofmalnutrition

Keymessageswomansnutrition(pregnancy)1hours

Session

3

Advantagesofbreastfeeding

Earlyinitiationofbreastfeeding

Exclusivelybreastfeeding0-6months

Demonstrationofcorrectpositioningandattachment

2hours

LUNCH(1hour30minutes)

Session

4Negotiationandcasestudies

2hours

15minutes

DAY2

COMPLEMENTARYFEEDINGANDNUTRITIONOFTHESICKCHILD

Session

5

Screeningformalnutrition

Referringachildwhoismalnourished2hours

Session

6

KeymessagesoncomplementaryfeedingNutritionmanagementofthesickchildormalnourishedchild

Availablelocalfoods

3hours

LUNCH(1hour30minutes)

Session

7Negotiationandcasestudies

2hours

15minutes

DAY3

FIELDPRACTICEANDPLANNING

Session8

Fieldpracticum3hours

30minutes

Session

9

Summary

Developmentofactionplans

CLOSINGCEREMONY


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-4-

SESSION1

INTRODUCTION:WHYWEAREHERE?

LearningObjectives

Bytheendofthesession,participantswillbeableto:

Begintonamefellowparticipantsandfacilitators. Discussexpectations. Explainwhywearehere?Activities

Activity1.1 Introduction(15minutes)andreviewofthelearningobjectives

Activity1.2 Pre-testofinfantandyoungchildfeedingpractices(15minutes)

Activity1.3 Administrationandhousekeeping(5minutes)

Activity1.4 DiscusstheroleofCommunityVolunteers(CVs)(25minutes)andhowandwhenthey

canimprovenutritionpractices

FacilitatorsNote1:Learningobjectives

FacilitatorsNote2:RoleofCommunityVolunteerandEssentialNutritionActions

TotalTime 1hourACTIVITY1.1 Introductionandreviewtheobjectives(15minutes)

Methodology Askparticipantstointroducethemselves;eachparticipantintroduceshername,whereshelives,

andwhyshecametothistraining.

ACTIVITY1.2 Pre-testofinfantandyoungchildfeedingpractice

(15minutes)

Methodology Askparticipantstoformacircleandsit(orstand)sotheirchairbacksarefacingthecenter. Explainthatquestionswillbeaskedandparticipantswillbeaskedtoraisetheirhandiftheythink

theanswerisYesandnottoraisetheirhandiftheythinktheanswerisNo.(Refertopages

11/12forquestionsand13/14foranswers)

Onefacilitatorreadsthequestionsandanotherfacilitatorrecordstheanswersandnoteswhichtopicsmaybecausingconfusion.

Adviseparticipantsthatthesetopicswillbediscussedingreaterdetailduringthetraining.


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-5-

Pre-TestandPost-TestforCommunityVolunteers

# PRE-TEST YES NO

1 Isitimportanttoputthenew-bornbabytothebreastimmediatelyafter

birth?

2 Isitnecessarytogivebabiesyoungerthan6monthsofagewaterseveraltimesperday,becausetheyneedwatertosurvive?

3 Ifat3months,themotherthinksthathermilkisdecreasing,shouldshe

nursethebabymorefrequently?

4 At6months,shouldamotherbegingivingherbabyfoodsinadditionto

breastmilk?

5 After6months,isitgoodtogivetheinfantonlybreastmilk?

6 Isawateryporridgeabetterfoodfora6-month-oldbabythansoftenriched

porridge?

7 Whenababyreaches8months,doesthebabyneedtoeat2-3timesaday,

inadditiontobreastmilk?

8 At12monthsofage,canababyeatthefamilyfoodandalsoneedtohavesnacksbetweenmealsastheirstomachsaresmall?

9 Whenayoungchildover6monthshasdiarrhea,doesthemotherneedto

increasethefrequencyofbreastfeedingandthefrequencyoffeedingother

liquidsandfoods?

10 DoinfantsneedtotakeaVitaminAcapsuleonceayear?

11 Shouldthemotherwaituntilasickchildishealthybeforegivinghim/her

morefoods?

12 Tohelpensureahealthypregnancy,dopregnantwomenneedtoeatan

extramealperday,especiallyinthethirdtrimester?

13 Dobreastfeedingmothersneedtoeattwoextramealsperday?

14 Toprotectherselfandherbaby,shouldthemothertakeonecapsuleof

VitaminAafterbirth(orwithin8weeksafterbirth)?

15 Duringpregnancy,manywomenfeelweakanddizzy.Isthisnormal?

16 Willbreastfeedingachildyoungerthan6monthsofageatleast8-10times

perdayhelptodelayanotherpregnancy?

17 Isittruethatthereisnothingthatcanbedoneaboutintestinalworms?

18 Topreventweakness,fatigueandproblemsduringbirth,shouldpregnant

womentakeirontablets?

19 Shouldfamiliesalwaysuseiodizedsaltwhencookingfood?

20 Arechildrenwhosleepunderantreatedmosquitonetprotectedagainst

malaria?

21 Ifamotheronlybreastfeedsachildwhoisunder2yearsofage4-5timesper

day,willherbabybeatriskofbeingmalnourished?

22 Shouldamotherworryifafterillness,herinfantdoesnoteat?

23 Shouldchildren12-24monthsofageeat4ormoretimesaday?

24 Shouldchildrenunder5whoaretoothinbereferredtoahealthfacility?

25 IsoneoftheresponsibilitiesofCommunityVolunteerstopracticeoptimal

infantandyoungchildfeedingwiththeirownchildren?


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-6-

Pre-TestandPost-TestforCommunityVolunteers-Answers

# PRE-TEST YES NO

1 Isitimportanttoputthenew-bornbabytothebreastimmediatelyafter

birth?x

2 Isitnecessarytogivebabiesyoungerthan6monthsofagewaterseveraltimesperday,becausetheyneedwatertosurvive?

x

3 Ifat3months,themotherthinksthathermilkisdecreasing,shouldshe

nursethebabymorefrequently?x

4 At6months,shouldamotherbegingivingherbabyfoodsinadditionto

breastmilk?x

5 After6months,isitgoodtogivetheinfantonlybreastmilk? x

6 Isawateryporridgeabetterfoodfora6-month-oldbabythansoftenriched

porridge?

7 Whenababyreaches8months,doesthebabyneedtoeat2-3timesaday,

inadditiontobreastmilk?x

8 At12monthsofage,canababyeatthefamilyfoodandalsoneedtohavesnacksbetweenmealsastheirstomachsaresmall?

x

9 Whenayoungchildover6monthshasdiarrhea,doesthemotherneedto

increasethefrequencyofbreastfeedingandthefrequencyoffeedingother

liquidsandfoods?

x

10 DoinfantsneedtotakeaVitaminAcapsuleonceayear? x

11 Shouldthemotherwaituntilasickchildishealthybeforegivinghim/her

morefoods?

12 Tohelpensureahealthypregnancy,dopregnantwomenneedtoeatan

extramealperday,especiallyinthethirdtrimester?x

13 Dobreastfeedingmothersneedtoeattwoextramealsperday? x

14 Toprotectherselfandherbaby,shouldthemothertakeonecapsuleofVitaminAafterbirth(orwithin8weeksafterbirth)?

x

15 Duringpregnancy,manywomenfeelweakanddizzy.Isthisnormal? x

16 Willbreastfeedingachildyoungerthan6monthsofageatleast8-10times

perdayhelptodelayanotherpregnancy?x

17 Isittruethatthereisnothingthatcanbedoneaboutintestinalworms? x

18 Topreventweakness,fatigueandproblemsduringbirth,shouldpregnant

womentakeirontablets?x

19 Shouldfamiliesalwaysuseiodizedsaltwhencookingfood? x

20 Arechildrenwhosleepunderantreatedmosquitonetprotectedagainst

malaria?x

21 Ifamotheronlybreastfeedsachildwhoisunder2yearsofage4-5timesperday,willherbabybeatriskofbeingmalnourished? x

22 Shouldamotherworryifafterillness,herinfantdoesnoteat? x

23 Shouldchildren12-24monthsofageeat4ormoretimesaday? x

24 Shouldchildrenunder5whoaretoothinbereferredtoahealthfacility? x

25 IsoneoftheresponsibilitiesofCommunityVolunteerstopracticeoptimal

infantandyoungchildfeedingwiththeirownchildren?x


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ACTIVITY1.3 AdministrationandHousekeeping

(5minutes)

ACTIVITY1.4 DiscusstheroleofCommunityVolunteers(CVs)andhowthey

canimprovenutrition(25minutes)

Methodology Facilitatorintroduceslearningobjectives(FacilitatorsNote1) DiscussWhoareCommunityVolunteers?(FacilitatorsNote2)WhoareCommunityVolunteers?

Discussionquestions:

1.Whoisresponsibleforthehealthofthecommunity?

2.Whatrolecancommunitymembersplaytosolvetheirhealthproblems?


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FacilitatorsNote1

LearningObjectives Attheendofthetraining,theparticipantswillbeableto:

1. Describethekeymessagesandpracticesforoptimalbreast-feeding.2. Describethekeymessagesandpracticesforadequatecomplementaryfeeding.3. Describethekeymessagesandpracticesforadequatewomensnutritionduringpregnancyand

lactation.

4. Describethekeymessagesandpracticesforcontrollingmicronutrientdeficiencies(VitaminA,Anaemia,Zinc,andIodine).

5. Negotiatewiththemothers(toencouragethem)totryoneimprovedpracticeinoneofthelearningobjectivesmentionedaboveandtoreinforcetheadoptionofthenewpractice.

6. UsetheMUACmeasurementtoidentifychildrenwhoaremalnourishedforcounselling,follow-up,andorreferral.

7. Explaintheirroleascounsellorswhoareabletolistento,giveconstructivefeedback,andpracticepositivecoaching.

8. Developathree-monthactionplanoftheactivitiestheywillimplementuponreturntotheircommunities.


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FacilitatorsNote2

RolesofCommunityVolunteersandHow/WhenTheyCanCommunicateMessagesRoles

Serveasarolemodelinthecommunitybypracticingoptimalinfantandyoungchildfeedingpractices.

Communicatekeymessagestofriendsandneighbors. Screenchildrenformalnutrition. Refermothersandchildrenwhoneedtreatmenttothehealthcenter/facility. Actasabridgebetweenthecommunityandhealthfacilities. Supportcommunitymemberstosolvetheirownhealthproblems. Encouragefamiliestoundertakedo-ableactions.Opportunitiestocommunicatemessages

Duringhomevisits Duringoutreachforimmunization Duringnutritionscreening Duringmarketdays,whilefetchingwater,andatwork Duringdeliveries Duringvisitstosickneighbors Duringreligious,cultural,oreconomical/socialmeetingsorgatheringsWaystocommunicatemessages

Throughnegotiations,inwhichyouaskthemothertotryanewpractice ThroughgroupdiscussionsattheNutritionScreeningCentre Throughdrama,roleplay,songs,andotheractivities Duringoutreachforimmunization DuringChildHealthDays


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TheEssentialNutritionActionsandContactPoints

forCommunityVolunteers

Examplesof whatcanbedone1.FocusontheEssentialNutritionActions:

Optimalbreastfeeding Complementaryfeedingtobreastfeeding Feedingasickchild Womensnutrition ControlofVitaminAdeficiency Controlofanemia Controlofiodinedeficiencydisorders2.Organizecommunitysupportgroupsonvariousthemesdiscussedinthistraining

3.Discussfeedingpracticeswithmothers(individually)particularlyifthechildismalnourished:

Duringhomevisitsorinformalencounters Duringnutritionscreeningsessions Duringcommunitymanagementofacutemalnutritionsessions DuringHealthDays Atthehealthfacilitiesoroutreachsessionsduringimmunizations,ANC(AntenatalClinic),Growth

MonitoringandPromotion

4.Discusshomegardening,particularlylinkedwithdevelopmentagentsoragricultureextension

workers


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SESSION2

WOMENSNUTRITIONDURINGPREGNANCYIMPORTANCEOFMICRONUTRIENTS

LearningObjectives


Describethemalnutritionlifecycle. Explainkeypractices/messagespertainingtowomansnutrition. Negotiatewithwomentoimprovekeypracticesfortheirnutrition. Describetheimportanceofironfolicacidsupplementationchildrenandwomen,deworming,and

usingiodizedsaltduringpregnancy.

Activities

Activity2.1 Whynutritionofwomenisimportant.Discussthelifecycle(30minutes)

Activity2.2 Messagesandadditionalinformationforadequatenutritionforapregnantwoman(45

minutes)

TotalTime 1hourMaterials

Flipcharts,paper,markers,andmaskingtape BookletonKeyENAMessages(containsillustrationsusedbelowandinsubsequentsessions)Illustration1 Nutritionofpregnantwoman

Illustration2 Ironfolicacidsupplementationanddewormingduringpregnancy

Illustration3 Preventionofmalariaandanemia

Illustration4 Useofiodizedsalt

ACTIVITY2.1. Whynutritionofwomenisimportant?

Methodology:Facil itateddiscussion(1hour) Brainstormontheeffectivepracticesofnutritionwithinthecommunity,theimportanceofwomens

nutrition.Alsodiscusstherolethattheoldestwomanandhusbandinthehouseholdplayinfood

accessanddistribution.

Explainthecycleofmalnutritionfromonegenerationtoanotheranddescribeinterventionsthatmakeitpossibletobreakthisviciouscycle.Usepaperfigurines,photographs,orimages

representingababy,ayounggirlbetween6and8yearsold,ateenagerbetween13and14years

old,apregnantyoungwoman,andayoungwomanandhernew-bornbaby.Foreachstageofa

womanslife,askquestionssuchasthefollowing:

Whatwouldhappenifthisbabygirl(orthisgirlorwoman)didnotreceiveallthenutritionthatsheneeds?


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Whatwillhappentothisgirlwhenshereaches8yearsofage?(Orbecomespregnantorhasababy)?

Whydoesthisproblempersistwhenthebabygrowsandbecomesmother? Whatcanbedonetopreventthisfromcontinuing?

Concludethatitisimportanttoimprovewomensnutritionforthebenefitofthebaby,thehousehold,andthecommunity.

ACTIVITY2.2 Womensnutritionduringpregnancyandimportanceofmicro-

nutrients

Methodology:Facil itateddiscussion (45minutes) Asktheparticipantstoreviewthepictures. Askthemthequestionssuggestedforeachillustration. Readthemessage,andreadtheadditionalinformationonebyone. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparethesetocurrent

practicesintheircommunities,andhowtheymighttrytoconvincemembersofthesecommunitiesthattherecommendedpracticescanimprovethehealthofmothersandchildren.


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SESSION3

OPTIMALBREASTFEEDING

LearningObjectives

Bytheendofthissession,participantswillbeableto:

Describekeypracticesforoptimalbreastfeeding. Explaintheadvantagesofbreastfeedingforthemotherandchild. Describekeypracticesandmessagesforoptimalbreastfeeding. Discusswithmothers/caregivershowtoadoptbetterfeedingpractices. Activities

Activity3.1 Discussadvantagesofbreastfeeding,keyoptimalbreastfeedingpractices,andreview

correctpositioningandattachment(2hours)

TotalTime 2hoursMaterials

Flipchart,papers,markers,maskingtape BookletonkeyENAmessages Dollsand/orbabiesFacilitatorsNote3:Howtoexplainthebenefitsofbreastfeeding?

Illustration5 Earlyinitiationofbreastfeeding

Illustration6 Exclusivebreastfeedingto6monthsofage

Illustration7 Frequencyofbreastfeeding

Illustration8 Correctpositioningforoptimalbreastfeeding

Illustration9 Properattachmentforoptimalbreastfeeding

Illustration10 Othercorrectpositioning

Illustration11 Nutritionoflactatingwomen


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ACTIVITY3.1 Discusskeyoptimalbreastfeedingpractices

(2hours)

Methodology:Brainstorming(30minutes)Dividetheparticipantsintofourgroups.

Askeachgrouptodiscussthefollowingtopics:1.Advantagesofbreastfeedingfortheinfant

2.Advantagesofbreastfeedingforthemother

3.Advantagesofbreastfeedingforthefamily

4.Advantagesofthebreastfeedingforthecommunity/nation

Assignatopictoeachgroup:thefourgroupshave15minutestodiscussalltheadvantagestheycanthinkof.Theyneedntwritebutrathergiveoralpresentations.

Eachgrouppresents. Thefacilitatorcompletesbyaddinganypointthathasbeenmissed.


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FacilitatorsNote3

Howtoexplainthebenefitsofbreastfeeding?

Fortheinfantandyoungchild,breastmilk Savesinfantslives. Isacompletefoodfortheinfantbecauseitcontainsbalancedproportionsandsufficientquantityof

allthenutrientsneededduringthefirst6months.

Containsantibodiesthatprotectagainstdiseases,especiallyagainstdiarrhoeaandrespiratoryinfections.

Theinfantbenefitsfromthecolostrum,whichprotectshim/herfromdiseases.Thecolostrumactsasalaxativecleaningtheinfantsstomach.

Promotesadequategrowthanddevelopment,thuspreventingstunting.

Isalwaysclean. Isalwaysreadyandattherighttemperature. Iseasytodigest.Nutrientsarewellabsorbed. Protectsagainstallergies.Breastmilkantibodiesprotectthebabysgut,preventingharmful

substancesfrompassingintotheblood.

Containstherightamountofwatertomeetthebabysneeds.(Upto80%ofbreastmilkiswater.) Helpsjawandteethdevelopment;sucklingdevelopsfacialmuscles. Frequentskin-to-skincontactbetweenmotherandinfantleadstobetterpsychomotor,emotional,

andsocialdevelopmentoftheinfant.

Forthemother Puttingthebabytothebreastimmediatelyafterbirthfacilitatestheexpulsionoftheplacenta

becausethebabyssucklingstimulatesuterinecontractions.

Reducesrisksofbleedingafterdelivery. Whenthebabyisimmediatelybreastfedafterbirth,breastmilkproductionisstimulated. Immediateandfrequentsucklingpreventsengorgement. Breastmilkisavailableatanytimeandanywhere,isalwaysclean,nutritious,andattheright

temperature.

Itiseconomical. Stimulatesthebondbetweenmotherandbaby. Reducesthemothersworkload(notimeisinvolvedinboilingwater,gatheringfuel,orpreparing

milk).

Reducesrisksofpre-menopausalbreastandovariancancer. Breastfeedingismorethan98%effectiveasacontraceptivemethodduringthefirst6months

providedthatbreastfeedingisexclusiveandperiodsdonotreturn.


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Methodology:Demonstrationanddiscussion(1hour30minutes)ImmediateInitiation

ShowIllustration5. Asktheparticipantstoanswerthequestionsontheillustration. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent

practices,andhowtoconvincethatthepracticecanimprovethehealthofmothersandchildren.

Breastfeedingexclusivelyuntil6monthsofage

ShowIllustrations6and7. Asktheparticipantstoanswerthequestionsontheillustrations. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent

practices,andhowtoconvincepeoplethatthepracticecanimprovethehealthofmothersand

children.Demonstrationofcorrectpositionandattachment

Usingadoll(orababy),thefacilitatordemonstratesthecorrectpositionandattachmenttothebreast.

Thefacilitatoraskstheparticipantstodescribewhattheysee. ShowIllustrations8,9,and10. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparewiththecurrentpractices,andhowtoimprovethem.

Womensnutritionduringlactation


practices,andhowtoconvincepeoplethatthepracticecanimprovethehealthofmothersand

children.


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SESSION4

HOWTONEGOTIATEWITHMOTHERS,CAREGIVERS,FATHERS,GRANDMOTHERS

ONWOMENSNUTRITIONDURINGPREGNANCYANDOPTIMALBREASTFEEDING

LearningObjectives


Explainthestepsofnegotiation(GALIDRAA). Practicenegotiationwithpregnantwomenandamotherofababy0-


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ACTIVITY4.1 Demonstrateandpracticenegotiationforpregnantwomen

andwomenofbaby0-


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FacilitatorsNote4

ListeningandLearningSkills

1.Usehelpfulnon-verbalcommunication.

a.Keepyourheadlevelwithmother

b.Payattention

c.Nodhead

d.Taketime

e.Appropriatetouch

2.Askopen-endedquestionsthatstartwithwhat,why,how,orwhereratherthanquestionsthat

requireayesornoansweronly.

3.Useresponsesandgesturesthatshowinterest.

4.Reflectbackwhatthemothersays.

5.Empathizeshowthatyouunderstandhowshefeels.

6.Avoidusingwordsthatsoundjudgementale.g.whatyouaredoingiswrongorbad.

FacilitatorsNote5

ObservationChecklist: (GALIDRAA)1. Greetsthemotherandestablishesconfidence.2. Asksthemotheraboutcurrentbreastfeedingpractices.3. Listenstowhatthemothersays.4. Identifiesfeedingdifficulties,ifany,causesofthedifficulties,andselectswiththemotherone

difficultytoovercome.

5. Discusseswiththemotherdifferentfeasibleoptionstoovercomethedifficulty.6. Recommendsandnegotiatesdoableactions:PresentsoptionsandNEGOTIATESwiththe

mothertohelpherselectonethatshecantry.

7. MotherAgreestotryoneormoreoftheoptions,andmother repeatstheagreeduponaction.8. MakeanAppointmentforthefollow-upvisit.


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FacilitatorsNote6

Roleplaydonebyfacil itator(s) Faithis9monthspregnantanditishersecondpregnancy.Inherfirstdelivery,shedidnotgive

colostrumtothebaby.Sheisnotplanningtogivethecolostrumthistimeeitherbecauseshethinksitisbadforthebaby.

TheCommunityVolunteer

TheCommunityVolunteertalkswithFaithandexplainsearlyinitiationofbreastfeedingafterbirth,and

thatthispracticeisimportantbecausethefirstmilk(colostrum)helpsprotectthebabyfrominfections

anddiseases.TheCommunityVolunteeralsospeakstoheraboutexclusivebreastfeedingforthefirst6

monthsandrecommendsnotgivingthebabyanywater.

TheFacilitator

Discusseskeystrategiesthatwillleadthemothertotrythenewbehaviorandsolvethepotential

problems.Thesestrategies,forexample,consistofaskingothermembersofthefamilytotakepartin

thediscussionandtrythenewbehaviorthemselves.

Exampleof possiblefollow-upnegotiationvis its toFaith:Visit#2:Followup

Situation:ThehealthworkervisitsFaithtoaskherwhethershehasbeenableto exclusively

breastfeedAmosduringthepastweek.Faithanswersthatitseemedtoherthat,forthefirsttwo

days,Amossuckledforthewholeday.Butshedid exclusivelybreastfeed.Shesayshermotheris

comingtoseeherthefollowingweekandwillsurelyadvisehertofeedAmosotherthingsbesides

breastmilk.

Visit#3:Maintainthepracticeand/ornegotiateanotherpractice

Situation:Amosisnow5monthsold,andFaithhasexclusivelybreastfedhimfor5months.ShepointsouttothehealthworkerthatAmoshashadneitherdiarrheanoracold.


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FacilitatorsNote7

PracticeCaseStudies:WomansNutritionduringPregnancy

CaseStudy1YouvisitHawawhois4monthspregnant.Hawahasnotyetvisitedthehealthclinic.


Thecommunityvolunteer(CV)asks,listenstoHawa,andidentifiesproblemsandcausesforthe

problems.Inthisparticularcase,themainproblemisthatHawahasnotbeenattendinganante-natal

clinic.

TheCVhastoexplaintheimportanceof:

Goingtoante-natalclinictoensurethatthepregnancyisgoingwell,toreceiveTTvaccines,iron-folicacidsupplementation,dewormingmedicine,anti-malarialtablets,andadditionalcounseling

andsupport. Eatingwell,oneadditionalmealeachday,anddiversifieddietasmuchaspossible(animalsource

foods,fruitsandvegetables).

Usingiodizedsalt.

CaseStudy2 Quetais21.Shetellsyouthatshehasthreedaughtersbetweentheagesof2and6.Whatthemeswill

youtrytodiscusswithQueta?


TheCVasksandlistenstothepracticeandidentifiesproblemsandthecausesfortheproblems.

Inthisparticularcase,themainproblemisthatQuetahadchildrentooclosetoeachotherstarting

whenshewasveryyoung.TheCVhastoexplaintheimportanceofeatingwell,asthesepregnancies

mighthavebeendifficultforherbody;shehastogotobecheckedforanemia.Quetashouldwaitat

leastthreeyearsbeforethenextchildandtheCVneedstorecommendthatshespeakwithherhusband

aboutfamilyplanningtodelayanotherpregnancy.

CaseStudy3Massaisinherlastmonthofpregnancyanddoesnotknowwhereshewillgivebirth.


TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesforthe

problems.

Inthisparticularcase,themainproblemisthatMassahastobeconvincedtocomeinanddeliverher

babyatthehealthfacility.Sheneedstobecheckedforanemia,andgetiron/folicacidsupplementation

anddewormingmedicine.Massaalsoneedstobecounselonbreastfeedingearly,withinthefirsthour

afterbirth,beforetheplacentaisexpelled.Shealsoneedstobetoldoftheadvantagesofonly

breastfeedingherbaby,nootherfoodorwater,untilthebabyis6monthsold.


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CaseStudy4Fatuis6monthspregnant,andhasafever.Shefeelsweak.


TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesfortheproblems.

Inthisparticularcase,themainproblemisthatFatuhastobeconvincedtocometothehealthfacility

andbetreatedformalaria,becheckedforanemia,andreceiveante-natalcare.TheCVneedstoexplain

thatshehastosleepunderatreatednettoavoidgettingmalaria,whichisharmfulforherandthebaby.


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FacilitatorsNote8

PracticeCaseStudies:OptimalBreastfeeding

CaseStudy1Yamahis9monthspregnant.Asthisisherfirstpregnancy,shewantsthebabytobestrongandingood

health,butsheistootimidtotalkaboutbreastfeeding.Hermother-in-lawdecidedthatduringthefirst

threedaysafterchildbirth,Yamahwillgivepeppersouptothebaby.Shebelievesthatthefirstyellow

milkisbad.



problems.

Inthisparticularcase,themainproblemisthatYamahsmother-in-lawdoesnotunderstandthe

importanceofcolostrum.TheCVasksthemother-in-lawtojoinYamahandhim/herself.TheCVexplainstothetwowomentheimportanceofearlyinitiationofbreastfeedimmediatelyafterthechildbirth. The

firstmilkorcolostrumisyellowbecauseitcontainsvitaminsanditwillprotectthebabyfromthe

diseases.Thismilkisarichinfatsandinfoodsanditallowsthebabytostartahealthylifefromthe

beginning,andthebabywillbestrong.TheCVexplainsthatbreastfeedingthebabystimulatesthe

dischargeoftheplacenta,thuspreventingthebleedingofthemotherafterchildbirth.Italsohelpswith

milkproduction;whenthebabyissucklingthemothersbodybeginstoproducethebreastmilkforthe

baby.

TheCVasksthemother-in-lawwhatshethinksoftheexplanations.Sheanswersthatinherdays,they

didnotbelieveinthesethings.ButsheaddsthatshehasheardthatwhattheCVsrecommendswas

triedbyawomaninhervillageandallwentwellandthebabyisingoodhealthandgrowingwell.After

thediscussion,Yamahsaysshewilltrytoputthebabytothebreastbeforetheybathethebabyandevenbeforetheplacentaisdischarged.Sheaskshermother-in-lawifsheisinagreement.Themother-

in-lawanswersherthatshewillhelpandthatshewillreassuretherestofthefamily.

CaseStudy2Hawabreastfeedsher2-month-oldwhenhestartstocryandwhenhewakesup.Asitishot,Hawaalso

givesthebabywaterusingafeedingbottle.



problems.

Inthisparticularcase,themainproblemisthatHawadoesnotrealizethatbreastmilkistheonlysource

ofwateraninfantunder6monthsneeds.TheCVdiscusseswithHawathatupto6months,theinfant

shouldonlydrinkbreastmilk.Sheexplainsthat themother'smilkcontainsallthewaterandallthe

foodsthatthebabyneeds tosatisfythebabyshungerandthirstandthereforedoesnotneedany

additionalfluidsorliquids.TheCValsoexplainsthatbabieslessthan6monthsmustbebreastfedevery

timetheyarehungryorthirsty,duringthedayandthenight, atleast10to12timesperday.Themore

frequentlythemotherbreastfeeds,themoremilksheproduces.Finally,theCVrecommendstoHawato


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neverusefeedingbottlestofeedthebabybecausetheyaredifficulttocleanandcancausethebabyto

havediarrhea.

TheCVasksHawawhatproblemsshethinkssheislikelytoencounterifshedoesnotgivethebaby

watertoday.Hawaanswersthatherhusbandbelievesthatthebabyneedswater.TheCVaskstospeak

withthehusbandandachildissenttogethim.Hecomestolisten.TheCVexplainstohimthatGodput

allthewaterthebabyneedsinthemothersmilkandthatgivingwatertobabieslessthan6monthsofageallowsgermscarryingdiseasetoenterthebabysstillweakbody.Inaddition,whenthebabys

stomachisfilledwithwaterthebabysuckslessonthebreast,whichreducesthemothersmilk

production.ThehusbandlistenstowhattheCVissayingandafteramomentthehusbandsaystohis

wife,TheCViscorrect.IheardthesesamewordsontheradioandtheHealthWorkerssaidthatour

practiceofgivingwatertobabiesisbad.Accordingtothem,thispracticeistheprincipalcauseof

malnutritioninourarea.Wewillstopgivingwatertoourbabyuntilheis6months.

CaseStudy3Kortugivesonlybreastmilktoher3-month-oldbaby.Sheisthinkingofintroducingriceporridgetothe

babybecauseshefeelshermilkisdecreasing.



problems.

Inthisparticularcase,themainproblemisthattheinfantisexperiencingagrowthspurtandmustbe

givenmorebreastmilk.TheCVexplainstoKortuthatshewillhaveenoughmilkif shebreastfeedsmore

frequently,whichwillincreasehermilkproduction.TheCValsoexplainsthat until6monthsofagethe

babyshouldonlybegivenbreastmilk. Breastmilkcontainsallthewaterandfoodsthatthebabyneeds

tosatisfythebabyshungerandthirst.Itisthusnotnecessarytogivethebabyanyotherliquidsduring

thefirst6monthsoflife.Kortushouldbreastfeedthebabyeverytimethebabyishungryorthirsty,at

least10-12timesoveronedayandnight.TheCVsaysthisrecommendationisoftengivenbyhealth

workerswhenthereisareductioninthemothersmilkandasksifKortucanfollowit.Kortuacceptsbut

sheseemsratherhesitant.Shelowershereyesthenlooksovertoherhusbandseldersister.TheCV

explainsthatforthenext2weeks,sheshouldputthebabytothebreastmorefrequentlyandensure

thatthebabyemptiesonebreastbeforesheswitchestotheotherbreast.Shewillseethathermilk

productionwillincreaseandthatthebabywillbesatisfiedattheendofafewdays.Thesister-in-lawhas

followedthewholeconversationandtheCVasksherwhethersheagreestosupportKortusdecision

nottogiveporridgetothebaby.Shesaysthatshewillandthatshewillexplaintothehusbandandthe

grandmother.Kortusmilesandsaysthatshewilltrytobreastfeedthebabymorefrequentlytohelp

increasehermilkproductionandthatuntil6monthsofageshewillonlygivebreastmilktothebaby.

TheCVpromisestoreturnforafollowupvisitinfourdaystoseehowsheisdoing.Kortugivesasighof

reliefandthankstheCV.


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CaseStudy4Kebbehis35yearsoldandhasfivechildren.Sheisbreastfeedingheryoungestchild,whois18months.


TheCVhastoaskandlistentothecurrentpracticeandidentifyproblemsandcausesfortheproblems.

Inthisparticularcase,themainproblemisthatKebbehhadmanychildrenandsheisstillbreastfeeding.Sheisprobablyweakfromhavingsomanypregnancies/breastfeeding.TheCVneedstoexplainthe

importanceofeatingwell,eatingtwoadditionalmealseachday,withmanydifferenttypesoffoodsas

muchaspossible,particularlymeat,fruits,andvegetables,andtouseiodizedsaltforherandher

familysfood.ShealsoshouldencourageKebbehtoseekfamilyplanningtopreventadditional

pregnancies.

TheCVasksherwhethershereceivedirontabletsduringherprenatalvisits.Sherepliesthatsheforgot

totakethemafterthebirthofherbabyandthatshestillhastabletsforthreemonths.TheCVasks

Kebbehtoshowherthetablets.TheCVrecommendsKebbehcontinuetotakethemuntiltheyare

finished.TheCVasksifherhusbandcouldbuyhersomeliveronceaweek.Kebbehconsultshermother,

andhermotherassuresKebbehthatshewillaskthehusbandtodoitandexplaintohimthatKebbeh

willnotbehealthyunlessheranemiaistreated.TheCVthenpromisestofollowupwithanothervisitatthebeginningofthenextweektoseehowtheyaredoing.KebbehandhermotherthanktheCVand

assureh/sheismostwelcomenextweek.


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SESSION5

SCREENINGFORMALNUTRITION

LearningObjectives


Identifyachildwhoismalnourished(ortoothin). Knowwhenandhowtoreferachildfortreatment. Knowhowtocompletethetallysheetafterthemalnutritionscreeningsession.Overview

Activity5.1 Howdoweidentifyaseverelymalnourishedchild

Activity5.2 Describethestepsinreferringaseverelymalnourishedchildfortreatment

Activity5.3 Howtocompletethemonthlytallysheet

TotalTime 2hoursMaterials

MUACtapes(oneperparticipant) ChildMUACmeasurementposter(FacilitatorsNote9) 4-6children6-59months(providebiscuitsforthem)(ifchildrenarenotavailable,usetheadultMUACforparticipantstopracticewitheachother)

FacilitatorsNote10:Whentorefer

FacilitatorsNote11:Copiesofreferralcards(oneperparticipant),mostofthetimeprovidedbyMOH

(CMAMprogram)

FacilitatorsNote12:MonthlyTallyReports(oneperparticipant)

Activity5.1 WhatistheMUACtapeandhowisitused?

(45minutes)

Methodology:Facil itateddiscussion(15minutes) PassaroundoneMUACtapeperparticipant(theywillkeepthem). Askifanyoftheparticipantshasseen,orused,atapelikethisbeforeandwhatitisusedfor. ExplainthattheMUACtapeisusedtomeasurethinnessandthatitshouldalwaysbeusedonthe

leftarm.

Holduponetapeandaskaparticipanttodescribethedifferentpartsofthetape:1. Thetapehasawidesideandanarrowside


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2. Thewidesidehasaholeandthenarrowendofthetapeisdividedintothreecolors(green,yellow,andred).

Ameasurementinthegreenzonemeansthechildisproperlyfedandsothenutritionisgood

Ameasurementintheyellowzonemeansthechildisnotproperlyfedorissickandthenutritionisinthedangerzone.Thischildsmotherorcaretakershouldbecounseledonincreasedfeedingandthechildfollowedup.

Ameasurementinthe redzonemeansthechildisverypoorlyfedandbadoffandisintheverydangerouszone.Thischildcoulddieifnothingisdonesothechildshouldbereferred

quick-quickfortreatment.

ExplainthatthechildMUACtapeshouldonlybeusedwithchildrenover6monthsandunder5yearsofage.

Explainthatthemeasurementisdoneonthemiddleoftheupperarm. AskaparticipanttodescribehowtousetheMUACtape;refertothepictureontheFacilitators

Note8.

DemonstratehowtouseMUACwithachildunder-fiveorwithaparticipantusinganadultMUACbyfollowing:1. Askthemotherorthecaretakertoremoveallclothingthatmaycoverthechildsleftarm.2. Findthemidpointofthechildsleftupperarm

Locatethetipofthechildsshoulderwithyourfingertips Bendthechildselbowtomakearightangle Usingastring,measurethetipoftheshouldertothetipoftheelbowandfoldthestringin

half.Markthehalfwaypointmid-pointonthechildsarm.

3. Straightenthechildsarmandwrapthetapearoundthearmatthemidpoint.4. Inspectthetensionofthetapeonthechildsarm.Makesurethetapehasthepropertensionandisnottootightortooloose.5. Identifythecolorbetweenthetwoarrowsandimmediatelyrecordthemeasurement.

Methodology:Demonstrationanddiscussion(30minutes) Divideparticipantsintogroupsoffour. GiveeachgroupaMUACtape,twine,andachildtopracticewith. Eachpersonineachgrouppractices,measuringtheMUACofthechild(ortheirpartner)following

thecorrectsteps.

Aftereveryonehastakenaturn,askparticipantstosharetheirexperiences. DiscussthecommonmistakesthatcanbemadewhenusingaMUACtape.Theseare:

Wrappingthetapetootightlyortooloosely Nottakingthemeasurementatthemid-pointbetweentheshoulderandelbow Takingameasurementwhenthechildstillhasitselbowbentornotrelaxed Takingameasurementontherightarmratherthantheleftarm


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FacilitatorsNote9


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Activity5.2 Referachildwhoneedsspecialattention

(1hour)

Methodology:Facil itateddiscussion(15minutes) Asktheparticipantswhyandwhentheyshouldreferachildtoahealthfacility. Asktheparticipantswhyandwhentheyshouldfollow-uptoensurethechildreceivedtreatment. MakesurethatallthepointsonFacilitatorsNote9arecovered,andsummarizethem.FacilitatorsNote10

Whentoreferachildtoahealthfacility

If : thechildsMUACcolorcodeis yellow:thechildneedsspecialcounselingandcanbereferredto

supplementaryfeedingifavailable;

thechildsMUACcolorcodeis red:verydangerous,andthechildneedstreatment; thechildhasoedema(bothfeetswollen): extremelydangerous,andthechildneedsimmediate

treatment;

thechildhasdiarrhea: 1. Thechildisnotimproving2. Thechildisunabletodrinkorbreastfeed3. Thereisbloodormucusinthestool4. Thechildisveryweak

thechildhasafeverandis:1. Vomiting2. Veryweak(cannotsitorstandwithouthelp)3. Jerkingorhasastiffneck(convulsing)4. Notabletobreastfeed

thechildhasanyotherillness;or thechilddoesnothaveaChildGrowthCard.Encouragethemothertogotoahealthfacilitiesfor

thechildtohavenutritionfollow-up.


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Methodology:Demonstrationanddiscussion(45minutes) Explaintoparticipantshowtousethereferralcard. Showparticipantstheflipchart/referralcard(FacilitatorsNote10)anddescribethedifferentparts

andhowtofillthemout.

Discusswiththeparticipants: Whatshouldyoutellthemotherwhosechildyouarereferringtoahealthfacility?Whatshould

youdoafterthechildhasbeenreferred?

Whydoyouneedtofollow-uponachildwhohasbeenreferred? Makesureallthepointsarementioned:

Themotherneedstoknowthereasonwhysheisbeingreferredtoahealthfacilityandwhatshouldhappenwhenshegetsthere.Thereferralcardwillallowhertoseeahealthworkervery

quickly.

Afterthechildhasbeenreferred,theCommunityWorkersshouldfollow-uptomakesurethatthechildhasbeentakentoafacilityandgetsappropriatetreatment.

Afterthechildhasbeentreatedatthefacility,s/hewillbesentbacktothecommunitywithfollow-upinstructions.Thiswillincludeinstructionsonfeeding,whentoreturnforfurtherrations,andotherneededcare.Themother/caretakershouldbringthisformtotheCommunity

Workerssotheycanexplainitscontentsandreinforcethecounselingmessages.

Usingcasesstudies,participantspracticereferingachildtoahealthfacilityforfurtherassistance:

Inpairs,participantscompletethereferralformbasedontheinformationinthecasestudies(FacilitatorsNote10).Theparticipantspracticethereferralprocessusingthecompletedreferral

card.Thefacilitatorobserveseachpairinsilenceandgivesfeedbackthereafter.Theparticipants

changerolesandcontinuepracticingthereferralcardbychangingthecasestudies.

CaseStudy1

Musuisgirlof18monthsfromSuakokotown,SuakokodistrictinBongCounty.Shehasbeenattending

monthlyscreeningsessionsregularlyforthepast4months.Forthepast2months,Mususweighthasbeenintheyellowzone.Thismonth,herMUACdropped.Hermothersaysshehashaddiarrheaforthe

pastthreedays.HerMUACisintheRedZone.

CaseStudy2

Mathewisaboyof13monthsfromLittleKola,District4inGrandBassa.Mathewhasnotbeendoing

wellforawhileandhismotherhasnotbroughthimtothepasttwonutritionscreeningsessions.His

MUACisintheyellowzoneandhehasswellinginbothfeet.

Aftertheobservation,thefacilitatorleadsthediscussionbyaskingthefollowingquestions:Whathappened?Willthemothergototheclinic?WhatelsecouldtheCommunityVolunteerhavesaidto

encouragethemothertogototheclinic?

Thefacilitatorreviewsthereferralprocess.


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FacilitatorsNote11

COMMUNITY-LEVELREFERRALFORM

NAME:_____________________________________________

Community:________________ District:___________________ County:____________________

NameofClient:________________________________ Age:_____________ Sex:______________ReferredTo:______________________________________________________ReasonForReferral

1 Diarrhea/RunningStomach 2 MalariaorFever 3 Cough(ARI) 4 Malnutrition/ 5 FamilyPlanning 6 OtherDiseases

DateofReferral:___________________________________________________ReferredBy:______________________________________________________

Signature


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Activity5.3 TheMonthlyTallyReport

(15minutes)

Methodology:Facil itatedDiscussion(15minutes) Sharecopiesofthetallysheetanddiscusswiththeparticipantsthefollowing:

1. Whatinformationdowecollectonthetallysheet?2. Whenandhowoftendowecollectthisinformation?3. Whatdowedowiththeinformationafterwehavecollectedit?

Explainthedifferentpiecesofinformationcollectedonthesheet.

FacilitatorsNote12

MALNUTRITIONSCREENINGTALLYSHEET

DISTRICT__________________VILLAGE____________________ Month__________________

From______/_____/_______to______/______/______

NameSignature

____________________________________

MUACRED

MUAC

YELLOW MUACGREEN Oedema ooooo ooooo ooooooooooooooo ooooo

ooooo ooooo ooooooooooooooo ooooo








ooooo ooooo ooooooooooooooo ooooo ooooo ooooo ooooooooooooooo ooooo




6-59months


TOTAL


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SESSION6

COMPLEMENTARYFEEDING:

FEEDINGASICKCHILD

LearningObjectivesBytheendofthissession,participantswillbeableto:

Describekeyfeedingpractices. Explainthekeypracticesandmessagesforoptimalcomplementaryfeeding. Explainthekeymessagesforthesickand/ormalnourishedchild. Explainlocallyavailablefoodsandseasonallyavailablefoodsforoptimalcomplementaryfeeding.Activities

Activity6.1 Discusskeycomplementaryfeedingpractices(1hour)

Activity6.2 Identifylocallyavailablefoodsandseasonallyavailablefoodsforadequate

complementaryfeeding(1hour)

To ta lTime 2 h our s3 0min ute sMaterials

Flipcharts,paper,markers,maskingtape BookletonkeyENAmessages FoodpurchasedatlocalmarketIllustration12 IntroductioncomplementaryfeedingIllustration13 Continuebreastfeedinguntil2yearsandbeyond

Illustration14 Feedavarietyoffoods

Illustration15 Frequencyoffeedingfor6-11montholdchildren

Illustration16 Amountoffoodfor6-11montholdchild

Illustration17 Frequencyoffeedingforthe12-24montholdchildren

Illustration18 Amountoffoodfor12-24montholdchildren

Illustration19 Feedingofthechildduringillness

Illustration20 Feedingofthechildafterillness

Illustration21 Feedingofachildwithdiarrhea

Illustration22 Counselingforachildwithmoderateorsevereacutemalnutrition

Illustration23 ImportanceofVitaminA

Illustration24 Preventanemiafromparasites


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ACTIVITY6.1 Keycomplementaryfeedingpractices

(1hour30minutes)

Methodology:DemonstrationanddiscussionIntroductionofcomplementaryfoodsandcontinuationofbreastfeeding

ShowIllustrations12and13. Asktheparticipantstoanswerthequestionsontheillustrations. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent

practices,andhowtoconvincethatthepracticecanimprovethehealthofmothersandchildren.

Fooddiversity


practices,andstrategizehowtoconvincecaregiversthatthepracticecanimprovethehealthof

mothersandchildren.

Feedingchildren6-11months:frequencyandamount

ShowIllustrations15and16 Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove

thehealthofmothersandchildren.

Feedingchildren12-24months:frequencyandamount

ShowIllustrations17and18. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove


Thefacilitatorsummarizesbyexplainingthemeaningof BF+FADDUA

Breastfeeding

+

Frequency+Amount+Density+Diversity+Utilization+Activefeeding

Feedingofasickchildduringandafterillness

ShowIllustrations19and20. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove



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Feedingofasickchildwithdiarrheaorwithmalnutrition

ShowIllustrations21and22. Answerthequestionsontheillustrations. Readtheadditionalinformation.

Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprovethehealthofmothersandchildren.

VitaminA,malaria,andwormmedicine

Showillustrations23and24. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove


ACTIVITY6.2 Identificationoffoods(purchasedlocallyatthemarket)

appropriateforinfantsandyoungchildren

(1hour)

Methodology:Facil itateddiscussion Eachparticipantisgiventwoormorefoodspurchasedlocallyatthemarketorpicturesoffoods(a

glassofwaterrepresentingbreastmilkandpictures/modelsofabreastrepresentingbreastmilkare

alsodistributed).Useallsortsofvegetables,differenttypesofmeat,chicken,fish,driedfish,beans,

plantains,nuts,flour,palmoil,VitaminA-fortifiedoil,papaya,mangoes,andlemonsetc.

Ontablesorthefloor(coveredwithcloth)facilitatorexplainsthattherearethefollowingthreeagecategories:

0-


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Methodology:GroupDiscussionDiscusshowtoencouragefamiliestokeepsomethingfromtheharvest"tofeedchildrenandwomen

(30minutes)

Divideparticipantsintothreegroups. Askthemtodiscusswheretheycanfindsimilartypesoffoodsintheirenvironment(home,garden,

market);

Whyitisimportanttokeepsome"harvest"toimprovefeedingpracticesforchildrenandwomen?

Askhowmuchtheycankeep? Howtheycanimprovethecurrentsituation?

Askthemtogiveexamples. Askthemtogiveexamplesonwhatcouldbeaddedtotheirgardens(e.g.,pumpkin,eggs,papaya,

bananatree,chicken,etc.).

Discusswhatassistancetheycouldgetfromtheagriculturesectors. Askeachgrouptopresentthemainideas.


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SESSION7

HOWTONEGOTIATEWITHMOTHERS,CAREGIVERS,FATHERS,

GRANDMOTHERS:COMPLEMENTARYFEEDINGANDTHESICKCHILD

Methodology:Learningtousethestepsofnegotiationforadequatecomplementaryfeeding(2hours) Usingcasestudies,participantspracticenegotiationskillstopersuadethemothertotryanewpractice.

Thefacilitatorobservestheparticipantsandencouragesthemtoimprovetheirperformance.

1. Demonstratehowtonegotiateandencourageamothertotryanimprovedcomplementaryfeedingpractice.Usetheroleplayonthenextpage.Discussthestepsfornegotiation. Usevisual

aids.

2. Inpairs,participantspracticethenegotiationskillsusingthecasestudies(FacilitatorsNotes13and14).Asupervisororfacilitatorobserveseachpairinsilenceandgivesafeedbackthereafter.

Theparticipantschangerolesandcontinuepracticingthenegotiationskillsbychangingthecase

studies.Eachparticipantneedstopracticenegotiationsoncomplementaryfeedingandfeedingofthesickchild.

3. Aftertheobservation,thefacilitatorleadsthediscussionbyaskingthefollowingquestions:Whathappened?Willthemothertrythispractice?WhatelsecouldtheCommunityVolunteer

havesaidtoencouragethemothertotrythepractice?

4. Thefacilitatorreviewsthestepsofnegotiation.5. Thefacilitatorexplainsthatmorethanonevisitisneededforthefullprocessofnegotiation.

Atleast2visits:

Initialvisit Follow-up:after1to2weeks Ifpossible,athirdvisittomaintainthepracticeornegotiateanotherpractice


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FacilitatorsNote13

PracticeCaseStudies:Complementaryfeeding

CaseStudy1Korpohasa7-month-oldbabythatsheisbreastfeeding.Korpothinksthatherbabyistooyoungtoeat

thickporridge,soshegiveshimliquidporridge,whichshedoesnotenrich.


TheCVexplainsthatstartingfrom6monthsbabiesneedtoeatporridgeinadditiontothemother's

milk.Thisporridgecanbepreparedusingrice,cassava,plantain,maize,yam,etc.anditmustbe

sufficientlythickinconsistencyandnottoorunny(sticktothespoon).Itshouldbeenrichedwithvarious

andcolorfulfoodsthathavebeenmashedtohelpthebabyswallowit.Cassavaleaves,sesameseeds,

banana,aswellasmilk,meat,fish,beans,andpeanutsornutscanbeusedtoenrichtheporridge.At

eachmeal,Korpocanaddpalmoilorpeanut/sesameseedpastetothebabysfoodasthesefoodsare

goodforthebaby.TheCVcongratulatesKorpoforhavingcontinuedbreastfeedingandrecommendsshe

continuestobreastfeeduntilthechildisatleast2years.

CaseStudy2Bettyhasa6-month-oldbaby.Sheisthinkingofstartingtogiveadditionalfoodtoherbaby.Shethinks

thebabyonlyneedsporridgemadefromeddoedust.


TheCVexplainsthatfrom6months,babiesneedtoeatthickporridge(sticktothespoon)inadditionto

themother'smilk.Thisporridgecanbepreparedusingrice,cassava,plantain,eddoes,yam,etc.TheCV

explainsthatstartingat6months,itiswisetogiveasmanyvarietiesoffoodaspossibletothechild.TheCVexplainsthattohelpthebabygrowwell,Bettycanenricheachmealofporridgebyaddingtwoor

threekindsoffoodthatshehasinthehousetoit.Shecanenrichtheporridgebyaddingpalmoil,benne

seeds,orpeanutpastetoeachmeal.Sheshouldalsogivefruit(orange/redcoloredfruit)orcassava

leavestoeachofthebabysmeals.Everyday,sheshouldtrytoaddmeat,fish,beanflour,or

peanuts/benneseedtothebabysfood.Shecanalsousemilktocooktheporridgeinsteadofwater,if

possible.Themeat,chicken,orfishshouldbemashedorpureedbeforefeedingittothebaby,anditis

importanttoenrichthebabysfoodasoftenaspossibletosupportpropergrowthanddevelopmentof

thebaby.Bettyshouldalsocontinuetobreastfeedthebabyondemandforatleasttwoyears.Betty

tellstheCVthatshehasvegetables,fruits,palmoil,andbeans.Sheagreestoenrichthebabysporridge

ateachmealandtocontinuetobreastfeedatleasteighttimesaday.


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CaseStudy3 Quetahasan8-month-oldgirl,whomshefeedsporridgeenrichedwithvariousdifferentfoodseachday.

However,itseemsthatthebabyishungrythisafternoon.


TheCVexplainsthatfrom6to11months,ababycanbegivensoftenrichedthickporridgeatleast3timeseveryday,inadditiontobreastmilk.Ineachmeal,Quetasbabycaneatatleast2tablespoonsof

porridgeenrichedwith1tablespoonofvariouscolorfulfoods.Shecanevengiveherdaughtermoreif

sheseemshungry,asitishealthyforherbabytoeatasmuchfoodaspossible,particularlyavarietyof

foods.TheCVadvisesQuetatobepatientandtotakehertimewhenfeedingherbaby,actively

encouraginghertoeatallthefoodgiven.TheCValsoexplainstoQuetathatinadditiontoporridge,the

babyshouldbegiven1-2snacks(biscuits,banana,mango,etc.)everydayinbetweenthefeedingof

porridge.Thiswillhelpthebabytogrow.Quetaappreciatestheadviceandagreestotrythe

recommendedpractices.

CaseStudy4Kebbehhasa7-month-oldbaby,whomshebreastfeeds.Shealsogivesherbabyathinliquidporridge

andinfantformula.Sheputsthisthinliquidporridgeinafeeding-bottletofeedthebaby.Kebbehdoes

notthinkthatherbabyisreadytoeatotherfoods.


TheCVexplainstoKebbehthatat6monthsofage,babiesneedtoeatadditionalfoodssuchasthesoft

porridge,inadditiontobreastmilk.TheCVexplainsthatbabieswillnotgrowwellifonlygivenathin

liquidporridge.Theporridgeneedstobethickenoughthatitcansticktothespoonandshouldalsobe

enrichedwithtwoorthreeothertypesoffoodsavailableinthehouse:cassavaleaves,sesameseeds,

banana,aswellasmilk,meat,fish,groundnuts,beansornutscanbeusedtoenrichtheporridge.At

eachmeal,Kebbehcanaddpalmoilorpeanutpastetothebabysfoodasthesefoodsaregoodforthe

baby.TheCVadvisesKebbehnevertousefeedingbottlesastheyveryhardtocleanproperlyandcancauseherbabytogetdiarrhea.Shealsonotesthatinfantformulaisexpensive,anditisbetterinsteadto

buysomefishormeatforthebaby.TheCVremindsKebbehtocontinuebreastfeedingondemand

betweenthemeals(atleast8times).KebbehisinagreementwiththerecommendationstheCVhas

madeandagreestogivethickporridgetothebabyandtostopusingthefeedingbottle.

CaseStudy5Saybasbabyboyis15monthsoldandeatsfamilyfoodswithhisparentstwotimeseachday.Saybais

nolongerbreastfeeding.Hersonseemstobesmallforhisage.


TheCVasksSaybawhyshestoppedbreastfeeding.Wasitbecausesheispregnantorisitsimplybecause

thebabystoppedbreastfeeding?TheCVremindsSaybathatthebabystillneedsbreastmilkuptoat

least2years.SheexplainstoSaybaforhersontostayhealthandgrowwellheneedstoeatmoreoften

(atleast5timesperday:3mealsplus2snacks),especiallysinceheisnotbenefitingfrombreastmilk.At

eachmeal,sheshouldgive6tablespoonsofporridgeenrichedwith3tablespoonsofotherfoodssuchas

cassavaleaves,sesameseeds,banana,vegetables,palmoil,aswellaseggs,milk,meat,fish,sesame

seedorpeanutpaste,beansornuts.TheCVrecommendsthatthebabysfoodshouldbeservedina


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separateplatebecausethiswillallowSaybatoseeifthebabyiseatingandfinishingtheamountoffood

thatheneedstogrowproperly.Andbecausethefamilyfoodisnotsufficientlyenrichedtomeetthe

babysneeds,Saybashouldaddtheseotherfoods.Assnacks,Saybacangivefruits(banana)orbiscuits

betweenthemealsthebabyeatswithhisparents.Theadditionalfoodsandsnackswillmakethebaby

strong.Finally,theCVadvisesSaybatotrybreastfeedingagainuntilhersonisatleast24months,

especiallysinceshehadonlystoppedbreastfeedingafewdayspreviously.Saybaappreciatestheadvice

fromtheCVandagreestotrytoapplyit.

CaseStudy6Massasdaughteris11monthsoldandshegivesherthinporridge.Massabreastfeedsherdaughteronly

atnight.


Massaisadvisedthattheconsistencyoftheporridgeshouldbethickenoughtosticktothespoon.This

porridgecanbepreparedusingrice,cassava,millet,maize,plantain,yam,etc.anditmustbesufficiently

thickinconsistencyandnotsorunnyitrunsoffthespoon.Itshouldbeenrichedwithvariousand

colorfulfoodsthathavebeenmashedorgrounduptohelpthebabyswallowthem.Foodssuchas

cassavaleaves,sesameseed,banana,aswellasmilk,meat,fish,peanuts,beansornutscanbeusedto

enrichtheporridge.Ateachmeal,Massacanalsoaddpalmoilorbuttertothebabysfoodasthese

foodsaregoodforthebabyaswell.TheCValsoexplainsthatinadditiontofeedingporridge,Massa

shouldalsogiveherbabyonetotwosnackseverydayinbetweenthefeedingofporridge.Massais

advisedtocontinuetobreastfeedonthebabysdemand,atleast8timesduringthedayandnight,until

herbabyis2yearsofage.Massaishappyandagreestotrywhattheydiscussed.


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FacilitatorsNote14

PracticeCaseStudies:Feedingofthesickchild

Roleplaybyfacil itator(s) Miattassonis10monthsoldandhasdiarrhea.Miattastoppedbreastfeedingbecauseshethinksthat

milkworsensthebabysdiarrhea.


TheCVexplainstoMiattathatitisevenmoreimportantthatshebreastfeedsherbabyduringandafter

theillness.Thishelpsthebabytomakeupforthelossinwaterandenergy,limitshisweightloss,and

helpsthebabytorecoverfaster.Sincethebabyismorethan6monthsofage,theCVadvisestogivea

glassoforalrehydrationsolution(ORS)aftereachepisodeofdiarrhea.TheCVadvisesMiattatotryto

increasetheamountofenrichedporridgeduringtheillnessandtoalsogivethebabyanadditionalmeal

eachdayfor2weeksafterthebabyhasrecoveredtoallowthebabytoregainquicklyanyweighthelost

duringtheillness.TheCValsorecommendstoMiattatotakethebabytothenearesthealthfacilityifthediarrheapersists.TheCVandthemothertalkabouttheproblemssheislikelytoencountertryingto

gettothehealthcenterandlookforappropriatesolutions.

CaseStudy1Hannahs3-month-oldbabyhasdiarrheaandisvomiting.Themotherisstillbreastfeedingbuthasalso

beengivingwatertothebabyinabottle.


HannahisadvisedbytheCVthatherbabyshouldbefedonlybreastmilkforthefirst6monthsoflife,

notgivingwater,otherliquidsorfoodsasbreastmilkaloneprovideseverythingababyneedstogrowhealthyandstrong.TheCVadvisesHannahtostopgivingwaterandnevertousebabybottlesasthese

arehardtokeepcleanandcontaingermsthatwillcausediarrhea.ShealsoadvisesHannahto

breastfeedmoreoftenwhenherbabyissickaswellasmoreoftenafterthesicknesstohelpthebaby

recovermorequicklyandstarttogainweight.Hannahistoldtotakethebabytothehealthcenteras

soonasshecan.Hannahisgratefultohavethisadviceandplanstofollowit.

CaseStudy2Joycesdaughteris9monthsold.Thebabyhasamildfeverandcough,andinaddition,refusestoeat

food.


TheCVadvisesJoycetotaketimetopatientlyencourageherbabytoeatasherappetitemaybelower

becauseoftheillness.Sinceherdaughterisolderthan6months,Joyceisadvisedthatsheshould

increasethefrequencyofbreastfeeding,andalsoofferthebabysfavoritefoodduringillness.She

recommendsgivingthedaughteroneadditionalmealofenrichedporridgeeachdayforthe2weeks

followingtheillnessandtoincreasethefrequencyofbreastfeedingafterthebabyseemsbetter.Joyce


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agreestofollowtheadviceoftheCV.TheCValsoadvisesthemothertovisitthehealthcentertoget

treatment.

CaseStudy3Bettysbabyboywassicklastweekandisnowrecoveringfromtheillness.Heis5monthsold.Bettycontinuestobreastfeedasusual,butherbabyislosingweight.


Bettyisadvisedthattohelpherbabyrecoverfromtheillnessandgainweight,sheshouldincreasethe

numbersoftimesshebreastfeedsbothduringandaftertheillness.Bettyagreestotrytheadvicegiven

bytheCV.

CaseStudy4Faithhasababywhois9monthsold.FaithtellstheCVthatherbabyisrecoveringfromanillnessand

hasstartedeatingwellbutisstilllosingweight.TheCommunityVolunteer

TheCVadvisesFaiththataftereveryillness,herbabywillneed1additionalmealeachdayfor2weeksin

additiontothe3dailyfeedingsofenrichedporridge.ShealsoadvisesFaithtogivesnacksonetotwo

timeseachday,suchasbanana,biscuits,orbread,inbetweenthefeedingsofenrichedporridge.In

addition,sheshouldalsobreastfeedherbabymoreafterillnesstohelprecovermorequickly.Faith

agreestotrythisadvice.


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SESSION8

FIELDPRACTICE

LearningObjectives

Attheendofthesession,theparticipantswillbeableto:

Usenegotiationtechniquesinthefield,inthehealthcenters,orinthevillages. Evaluatethebreastfeedingpractices. Evaluateadditionalfeedingpractices.Overview

Activity8.1 Fieldpracticeatthehealthcentersorvillages(2hour30minutes)

Activity8.2 Feedbackonthepracticalsession(45minutes)

Activity8.3 Demonstrationofafollow-upvisitinclass(15minutes)

To ta lTime 3 h our s3 0min ute sNumberofpeopleonthesite:8to10,toconstitute4to5pairs

DescriptionoftheSites

Healthclinicatthetimeofvaccinationorweightrecordingsession Sickbabyclinicvisits/IMNCI Maternitywards/ANC Growthmonitoring/nutritionscreeningandpromotionsites Communitygroupings Motherswithinfants0to6monthsoldand/orpregnantmothers Motherwithinfants6to24monthsoldand/orlactatingmothersMaterials

Visualaids:posters,notebooks/cards,healthrecords,counselingcards BookletwithkeyENAmessages


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ACTIVITY8.1 Fieldpracticeinthehealthcentersorinthevillages

(2hours30minutes)

Methodology Inplenary,reviewthestepsofnegotiation. Grouptheparticipantsintopairs.Duringthefieldpractice,theparticipantswilltaketurns

role-playingthepartsofthenegotiatorandthatoftheobserver.Thenegotiatorwillconduct

thecounselingandnegotiationwiththemotherandtheobserverwillobservewiththe

objectiveofgivingfeedback,usingGALIDRAAafterthemotherhasleft(FacilitatorsNotes4

and5).

Theparticipantswillexchangerolesuntileachofthemhascompletedatleastthreenegotiationsandtwoobservationsofnegotiationswithbreastfeedingmothers.

ACTIVITY8.2 Feedbackonthefieldpractice

(45minutes)

Methodology Backinclass,eachpairwillsummarizetheirexperiencewiththepracticeofnegotiationby

givingareportononeexampleusingthefollowingformat-theywillindicatethename(s)of

theparticipant(s),thenameandageofthechild,theproblemtheyveidentified,the

proposedsolutions,andthebehaviorthatthemotherhasagreedtoadopt.

Theparticipantslistentothefeedbackprovidedbytheirpeersandgivetheirown. Discussionandsummary.ACTIVITY8.3 Demonstrationofafollow-upvisit

(15minutes)

Methodology Facilitatorsdemonstratetheconductofafollow-upvisitofthecommunityagent(orhealth

agent)inthecaseofHawawhois2monthsold.

Fromthefieldvisitexperience,fivetosixparticipantsexplainwhattheywillfollow/discusswhentheywillcarryoutthesecondvisit.


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SESSION9

DEVELOPMENTOFACTIONPLANS

LearningObjectives

ToreviewthevariousactivitiesthroughwhichtheCommunityVolunteercontributestoimprovethehealthofwomenandchildren,aswellastheplacesandtheoccasionswhere

theycantakeadvantagetodothis.

Toidentifyconcretepointsofcontactthattheycanuseintheirdailyworkandworkoutaweeklyandthenmonthlyscheduleofwork.

Todevelopanactionplanfor3monthsandpresentittothewholegroup.Overview

Activity9.1 TheactivitiesofCommunityVolunteer(CV)thatcontributetoimprovingthe

healthofmothersandtheirchildren.PlaceswhereandoccasionswhentheCV

canspeakthem(30minutes)

Activity9.2 Developmentoftheactionplans(1hour)

Activity9.3 Post-testandcourseevaluation(30minutes)

Preparation

Ifpossible,invitecommunityleaders toattendtheactionplanpresentation.

TotalTime 2 hoursClosure

Distributionofbadgesandcertificates

ACTIVITY9.1 ActivitiesofCommunityVolunteerthatcontributeto

improvingthehealthofwomenandchildren.

(30minutes)

Methodology:Brainstorming Thefacilitatorpresentsthesevenessentialnutritionactionsandthekeycontacts. BrainstormtogetherwhatactivitiestheCommunityVolunteer(CV)candoinoneweek.Askin

whatinstanceswouldtheyvisitawoman?Whichtypesofwomendotheyvisit?Whatdothey

dointhatinstance?Thenaskthemtothinkofoccasionstheycantakeadvantageoftoshare

thethingstheyhavelearnedinthetraining.

RefertoFacilitatorsNotespages1and2


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ACTIVITY9.2 Developmentofathree-monthactivityplan

(1hour)

Methodology:Groupdiscussion Dividetheparticipantsintotheirrespectivezones(villages/communitiestheyserve). AsktheCVsiftheywillgotoallthehealthclinics,dogroupdiscussions,homevisits,visit

pregnantwomenandwomenwithchildrenunder2years.

Ensurethatthedecisionstakenarerealistic.TheCVsshouldconsiderthepossibility,forexample,ofmakingonehomevisitperweekforchildrenlessthan2yearsandcombiningit

withonevisitperweekwithapregnantwomanonthesameday.

Followingthediscussion,eachteamwilldecideontheirmainactivities. Eachgrouppresentstheirplanofactions(oralpresentation). Discussionwiththegroupsandsummary.ACTIVITY9.3 Post-testandtrainingevaluation

(30minutes)Methodology Askparticipantstoformacircleandsit(stand)sothattheirchairbacksarefacingthecenter. Proceedasforthepre-test. Comparetheresultswiththepre-testandpresenttotheparticipantsduringtheclosing

ceremony.

Writetheend-of-trainingevaluationsonaflipchartandasktheparticipantstocheckthecorrespondingbox:good,average,unsatisfactory.

ClosingCeremonyInvitekeymembersofthecommunity(healthcenter,schools,localadministration,villagechief,

etc).

Handoutcertificatestotheparticipants.


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END-OF-TRAININGEVALUATION

Placeatheboxthatreflectsyourfeelingsaboutthefollowing:

GOOD AVERAGE UNSATISFACTORYTrainingobjectivesmet Methodsused Materialsused FieldPractice Capacitytocarryoutanidentical

training(forTOT)

Teabreaks 1.Whichsessionsdidyoufindmostuseful?

2.Whatareyoursuggestionstoimprovethetraining?

3.Othercomments:


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ACTIVITY9.2 Developmentofathree-monthactivityplan

(1hour)

Methodology:Groupdiscussion Dividetheparticipantsintotheirrespectivezones(villages/communitiestheyserve). AsktheCVsiftheywillgotoallthehealthclinics,dogroupdiscussions,homevisits,visit

pregnantwomenandwomenwithchildrenunder2years.

Ensurethatthedecisionstakenarerealistic.TheCVsshouldconsiderthepossibility,forexample,ofmakingonehomevisitperweekforchildrenlessthan2yearsandcombiningit

withonevisitperweekwithapregnantwomanonthesameday.

Followingthediscussion,eachteamwilldecideontheirmainactivities. Eachgrouppresentstheirplanofactions(oralpresentation). Discussionwiththegroupsandsummary.ACTIVITY9.3 Post-testandtrainingevaluation

(30minutes)

Methodology Askparticipantstoformacircleandsit(stand)sothattheirchairbacksarefacingthecenter. Proceedasforthepre-test. Comparetheresultswiththepre-testandpresenttotheparticipantsduringtheclosing

ceremony.

Writetheend-of-trainingevaluationsonaflipchartandasktheparticipantstocheckthecorrespondingbox:good,average,unsatisfactory.

ClosingCeremonyInvitekeymembersofthecommunity(healthcenter,schools,localadministration,vil

iii. cv training guide complete

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