improving food security and market linkages for smallholders

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Improving food security and market linkages for smallholders

in Oddar Meanchey and Preah Vihear (MALIS) OSRO/CMB/101/EC

Improving the dietary intakes and nutritional status of infants and young children through

improved food security and complementary feeding counselling (IMCF) GCP/INT/108/GER

MALIS and IMCF project

Dissemination meeting

26th

March 2015

Nutrition Education and Consumer Awareness GroupNutrition Division, FAO, Rome

September 2015


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Contact information FAO Headquarters:

Ms Ellen Muehlhoff

Senior Officer

Nutrition Education and Consumer Awareness Group

Nutrition Division

Food and Agriculture Organization of the United Nations

Viale delle Terme di Caracalla, 00153 Rome, Italy

Tel. 0039 (0) 6 5705 4113

Email: [email protected]

Homepage: Improved Food Security and Complementary Feeding

http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/

Contact information FAO Representation in Cambodia:

Mr Oum Kosal

Assistant FAO Representative (Programmes)

Food and Agriculture Organization of the United Nations

FAO Representation in Cambodia

No. 5, Street 370, Boeung Keng Kang I, Phnom Penh, Cambodia

Tel. 00855 (0) 23 216 566Email: [email protected]

Homepage: FAO Representation in Cambodia

http://www.fao.org/cambodia/en/
http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/http://www.fao.org/cambodia/en/http://www.fao.org/cambodia/en/http://www.fao.org/cambodia/en/http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/


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The views expressed in this information product are those of the author(s) and do not necessarily reflect the

views or policies of FAO.

FAO, 2015

FAO encourages the use, reproduction and dissemination of material in this information product. Except

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Table of Contents

Acknowledgements .................................................................................................................................. i

Acronyms ................................................................................................................................................ ii

Executive Summary ................................................................................................................................. 1

1. Opening session ............................................................................................................................. 4

2. Session 1: Overview of the MALIS project - FAO food security and nutrition project .................. 6

2.1. Aims of the meeting ................................................................................................................ 6

2.2. Overview of the MALIS project ............................................................................................... 6

3. Session 2: Applied research in the context of an FAO food security and nutrition project ........ 12

3.1. Overview of the research ...................................................................................................... 12

3.2. Impact of food security intervention and nutrition education ............................................. 13

3.3. Behaviour change for improving infant and young child feeding practices ......................... 16

4. Session 3: Lessons learned and Implications on future programmes ......................................... 20

4.1. FAO Nutrition Education Process Review ............................................................................. 20

4.2. Lessons Learned from the MALIS project ............................................................................. 22

4.3. Panel discussion, lessons learned for continuing/improving ............................................... 25

5. Wrap up session ........................................................................................................................... 30

5.1. Summary of recommendations ............................................................................................ 30

5.2. Closing remarks ..................................................................................................................... 31

Annex 1 - National Dissemination Meeting Programme ...................................................................... 32

Annex 2 - National Dissemination Meeting Participant List ................................................................. 34

Annex 3 - IYCF Summary Sheet ............................................................................................................. 37


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iv

Acknowledgements

This report provides proceedings for a National Dissemination meeting of the Food and Agriculture

Organization of the United Nations (FAO) project entitled: Improving food security and market

linkages for smallholders in Oddar Meanchey and Preah Vihear (MALIS) (2012-2015) and the 5-yearresearch project entitled: Improving the dietary intakes and nutritional status of infants and young

children through improved food security and complementary feeding counselling (IMCF) (2010-

2015).

MALIS was implemented by FAO Cambodia in collaboration with the General Directorate of

Agriculture (GDA) and the Ministry of Agriculture, Forestry and Fisheries (MAFF) with funding from

the European Union under Project OSRO/CMB/101/EC. Nutrition education activities were carried

out by Malteser International and Farmer Livelihood Development in the provinces of Oddar

Meanchey (OMC) and Preah Vihear (PVR), respectively.

IMCF was implemented by FAOs Nutrition Education and Consumer Awareness Group and the

research component was led by the Institute of Nutritional Sciences, Justus Liebig University (JLU),

Giessen, Germany in partnership with the Institute of Nutrition, Mahidol University, Thailand. IMCF

was funded by the German Federal Ministry of Food and Agriculture (BMEL) under Project

GCP/INT/108/GER.

The Dissemination meeting was held on 26th

March 2015 in Phnom Penh, Cambodia and included

representatives from the Council for Agriculture and Rural Development (CARD), GDA, MAFF,

Ministry of Education (MoE), Ministry of Health (MoH), Ministry of Rural Development (MRD),

Ministry of Women's Affairs (MoWA), donors, United Nations (UN) agencies, Non-Governmental

Organisations (NGOs), civil society, research institutes, FAO staff from Headquarters and Cambodia,

and professors and post-graduate students from JLU and Mahidol University.

This report was prepared by Dr Elizabeth Westaway, Ms Esther Evang and Ms Julia Garz, and

finalised by Ms Ellen Muehlhoff. Contributions from Dr Irmgard Jordan and Ms Anika Reinbott from

JLU; Ms Theresa Jeremias from FAO Headquarters and Dr Iean Russell from FAO Cambodia were

gratefully acknowledged. Many thanks go to the staff of the FAO Representation in Cambodia and

FAO Siem Reap office who provided excellent support in organising the National Dissemination

meeting.


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v

Acronyms

BMEL German Ministry of Food and Agriculture

CARD Council for Agriculture and Rural Development

CBO Community-Based Organisation

CDDS

CNP

Child Dietary Diversity Score

Community Nutrition Promoters

COMBI Communication for Behavioural Impact

FAO Food and Agriculture Organization of the United Nations

FGD Focus Group Discussion

GDA

HAZ

General Directorate of Agriculture

Height-for-Age Z-score

HDDS

HFIAS

HHS

HIV

Household Dietary Diversity Score

Household Food Insecurity Access Scale

Household Hunger Score

Human Immunodeficiency Virus

IEC Information, Education and Communication

IMCF Improving the dietary intakes and nutritional status of infants and young children

through improved food security and complementary feeding counselling

IYCF Infant and Young Child Feeding

JLU Justus Liebig University

KAP Knowledge, Attitude and Practice

MAD Minimum Acceptable Diet

MAFF Ministry of Agriculture, Forestry and Fisheries

MALIS Improving food security and market linkages for smallholders in Oddar Meanchey

and Preah Vihear

MDD Minimum Dietary Diversity

MoWA Ministry of Women's AffairsMMF Minimum Meal Frequency

MoH Ministry of Health

MRD Ministry of Rural Development

NCHP National Centre for Health Promotion

NGO Non-Governmental Organisation

NIPH

NMCHC

National Institute of Public Health

National Maternal and Child Health Centre

NNP National Nutrition Programme

NSDP National Strategic Development Plan

OMC

PDA

Oddar Meanchey Province

Provincial Department of AgriculturePDoWA Provincial Department of Womens Affairs

PHD Provincial Health Department

PVR Preah Vihear Province

SUN Scaling-Up Nutrition

TIPs Trials of Improved Practices

UNICEF United Nations Children's Fund

WHO World Health Organization


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1

Executive Summary

From 2012-2015, the Food and Agriculture Organization of the United Nations (FAO) in collaboration

with the Royal Government of Cambodia implemented the nutrition-sensitive agriculture project

entitled: Improving food security and market linkages for smallholders in Oddar Meanchey andPreah Vihear (MALIS). The project aimed to increase the knowledge and skills of smallholder

households to diversify food production, increase productivity and build resilience, and to improve

family feeding practices. The MALIS project adopted an integrated approach, which used a

combination of food security and nutrition education activities to diversify household agricultural

production and consumption to match the recommended food groups, particularly with regard to

complementary foods for children aged 6-23 months. The nutrition education activities were

implemented by Malteser International1and Farmer Livelihood Development.

2

Parallel to the MALIS project, a 5-year research project entitled: Improving the dietary intakes and

nutritional status of infants and young children through improved food security and complementaryfeeding counselling (IMCF) was implemented by FAO in collaboration with Justus Liebig University

(JLU) Giessen, Germany and Mahidol University, Thailand. IMCF aimed to assess the effect of MALIS

project activities on childrens dietary intake, micronutrient status and growth, and to determine the

nutrition outcomes of combining agricultural production and nutrition education. The IMCF study

design included cross-sectional surveys, a longitudinal study, pre- and post-training tests, focus

group discussions (FGD), interviews, observations, blood specimens and anthropometry.

This report provides proceedings of a joint FAO/JLU Dissemination meeting held on 26th

March 2015

in Phnom Penh, Cambodia, which highlighted preliminary results of the IMCF project and lessons

learned from a FAO process review of the MALIS project. Eighty participants attended the meetingfrom Government at national and provincial levels, donors, United Nations (UN) agencies, Non-

Governmental Organisations (NGOs), research institutes and academia.

The IMCF research project showed that nutrition education on improved Infant and Young Child

Feeding (IYCF) practices conducted in a series of IYCF sessions with groups of 15 caregivers3who had

a child aged less than 2 years reached 62 percent of households in the intervention areas. However,

only 23 percent of households in the intervention areas participated in the MALIS food security

intervention and IYCF sessions two years after baseline. During the study period, continued

breastfeeding rates decreased, and the prevalence of children achieving Minimum Dietary Diversity

(MDD) and Minimum Meal Frequency (MMF) improved in the intervention and comparison areas;

4

however, the prevalence of children receiving a Minimum Acceptable Diet (MAD)

)5, 6only improved

in the intervention areas. Household Dietary Diversity score (HDDS) and Child Dietary Diversity score

(CDDS) also increased between baseline and impact in the intervention and comparison areas. The

1Malteser International was the implementing partner in Oddar Meanchey province.

2Farmer Livelihood Development was the implementing partner in Preah Vihear province.

3The term caregiver can refer to the person who primarily takes care of the child, e.g. mother, grandmother,

father or other relatives.4During the study period, many diverse activities were implemented by different NGOs in the control areas.

Hence, they were termed comparison areas instead.5

World Health Organization (2008) Indicators for Assessing Infant and Young Child Feeding Practices, Part I Definitions. Geneva: World Health Organization.6World Health Organization (2008) Indicators for Assessing Infant and Young Child Feeding Practices, Part 2

Measurement. Geneva: World Health Organization.


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results on Height-for-Age Z-score (HAZ) were puzzling as different inter and intra-provincial trends in

stunting prevalence of children aged 6-23 months were observed between baseline and impact. The

study showed that short-term nutrition education only led to small improvements in IYCF practices

and child nutritional status. It was concluded that participation in the food security intervention and

IYCF sessions needs to be better integrated at the household level in order to achieve greater

improvements in dietary diversity and nutritional status of children.

Qualitative research focused on factors leading to positive behaviour change on improved IYCF

practices. Data collection methods included knowledge tests, a longitudinal study, focus group

discussions (FGDs), interviews and observations. Results of knowledge tests showed that the

knowledge and behaviour of caregivers increased significantly after IYCF sessions. Also, the

longitudinal study revealed that after the IYCF sessions, 25 percent of caregivers prepared enriched

porridge (bobor khap krop kroeung) in the intervention areas compared to 6 percent in the

comparison areas. In addition, FGDs showed that hindering factors to improve IYCF practices were

womens workload, womens attitude towards child feeding, food availability and access as well as

womens ability and motivation to turnknowledge into practice at home.

The FAO team presented results from a process review of the IYCF intervention conducted in June

July 2014 to collect data on the MALIS project food security and nutrition education interventions,

and consolidate the lessons learned. MALIS project key strengths and challenges are listed in Table 1.

Table 1: Overview of MALIS project key strengths and challenges - results from the process review

Key words Key strengths Key challenges

Farmer field schools integration of nutrition into farmer field

schools

capacities of facilitators limits

effectiveness of farmer field schools

Farmer business

schools

content not fitted to current needs and

activities of farmers

Fairs and Input Credit integration of nutrition into agricultural

fairs and farmer field days

stimulation of local business and input

credit allows farmers to choose

appropriate inputs, including kitchen

equipment

supervision and support from

Government to ensure farmer groups re-

pay loans

lack of clear guidelines for farmer groups

on repayment of loans

Cooperation andknowledge

good cooperation with Government ontraining activities

government and NGO staffs lack ofknowledge on nutrition

coordination of supervisors and

reporting at the outcome level

Learning environment a practical learning environment during

IYCF trainings

low facilitation skills of community

nutrition promoters (CNPs)

Participants participation of grandmothers in the

IYCF training

poor motivation of caregivers to change

their behaviour

low participation of men in IYCF sessions7

Incentives distribution of kitchen equipment to

caregivers

the expectation of health care staff and

CNPs to receive incentives

7Men were either too busy to participate in IYCF sessions or felt that the main caregiver was the mother of the

child.


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Time the amount of time necessary for

participatory cooking sessions

Knowledge on food

preparation

age-appropriate amounts of ingredients

required to prepare a half, nearly full or

full bowl of bobor khap krop kroeung

(enriched porridge)

The process review highlighted diverse training needs of MALIS, Government, NGO staff and farmer

groups with regard to nutrition education, and in relation to farmer field schools, farmer business

schools, agricultural fairs and input credit. Hence, recommendations are to: (1) increase investments

in agricultural education, particularly agronomy, and nutrition, which have been neglected sectors in

Cambodia; (2) formulate multiple strategies to change child feeding behaviour; (3) improve market

linkages for smallholder farmers; and (4) develop guidelines on disaster risk reduction, and climate

change adaptation and mitigation.

Representatives from the Council for Agriculture and Rural Development (CARD), the General

Directorate of Agriculture (GDA), Ministry of Rural Development (MRD), Ministry of Womens Affairs

(MoWA) and Helen Keller International (HKI) provided comments on what their sector could

contribute to the nutrition of young children and families, and what the benefits would be of cross-

sectoral collaboration.

Overall recommendations of the meeting focused on: encouraging cross-sectoral coordination on

nutrition; integrating nutrition education into food security interventions at all levels and into

farming systems through agricultural extension; encouraging good cooperation and commitment for

longer term efforts to integrate nutrition into agriculture; developing a strategy for cross-sectoral

capacity building on nutrition at all levels; ensuring implementers have the knowledge and skills to

conduct training, which includes participatory cooking sessions; providing nutrition education to all

family members and generations; ensuring that caregivers are applying knowledge on improved

child feeding into their daily practice; acknowledging the key role of women in nutrition and as

caregivers; and using lessons learned from the project to improve policy and programming.

It was concluded that food-based approaches emphasising the use of locally available foods are

feasible and acceptable to families for improving child feeding and preventing malnutrition.

However, cross-sectoral efforts are needed to improve, sustain and scale-up the effective integration

of nutrition into agriculture.

In closing, GDA highlighted the successful implementation of the MALIS project with cooperation of

different ministries and coordinated by CARD. The importance of improving childrens diet and

health was underscored to prevent stunting as well as overweight. Recommendations included:

disseminating consistent, easily understandable information on sustainable, modern agriculture

technologies; improving living conditions (particularly sanitation) and womens empowerment; and

strengthening cooperation and coordination among stakeholders.


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1. Opening session8

Eighty participants attended the National Dissemination meeting from Government at national and

provincial levels, donors, United Nations (UN) agencies, Non-Governmental Organisations (NGOs),

research institutes and academia (Annex 2). Ms Doung Chansereivisal, FAO Agribusiness and Post-

Harvest Specialist, Siem Reap Province thanked the participants for attending and introduced the

five guests of honour: Honourable Excellency Dr Ty Sokhun (Secretary of State for the Ministry of

Agriculture, Forestry and Fisheries (MAFF)), Ms Fiona Ramsey (European Union (EU) Representative),

Ms Nina Brandstrup (FAO Cambodia Representative), Honourable Excellency Professor Koum Kanal

(Council for Agriculture and Rural Development (CARD)) and Professor Michael Krawinkel (Justus

Liebig University (JLU), Giessen, Germany). She then provided a short summary of the days activities

and invited the Honourable Excellencies and all other participants to stand for the National Anthem.

Ms Nina Brandstrup, FAO Cambodia Representative, provided the welcome speech thanking all

MALIS staff for successful project implementation. Results from Oddar Meanchey (OMC) and Preah

Vihear (PVR) provinces show that combining food security and nutrition education interventions to

improve complementary feeding can be effective using a food-based approach. However,

coordination, capacity building and good targeting are key. Ms Brandstrup highlighted four points

from the March 2015 National Conference on Nutrition in Cambodia and summarised the main

points and lessons that could be drawn from the MALIS and IMCF projects:

(1) Continued need to address malnutrition: national stunting rates for children under the age of five

are still high and this is not acceptable;

(2) Multi-sectoral collaboration: to address malnutrition there is a need for action on all fronts

involving agriculture, health, education, social affairs and economic development;

(3) Need for evidence-based policies: it is important to have good evidence to develop policies,

programmes and initiatives that can effectively address the multiple causes of malnutrition

throughout the life cycle, with particular focus on the first 1,000 days;

(4) Continued commitment: the profile of nutrition needs to be raised in relevant national and sub-

national strategies, policies, action plans and programmes, with budgets aligned accordingly and the

Government needs to sustain its commitment.

Ms Fiona Ramsey, EU Representative, spoke on behalf of the European Delegation. She underlined

that the children of today are the next generation of leaders, decision makers and entrepreneurs.

Yet, insufficient nutrition in the first 1,000 days of their lives hinders childrens brain development

and prevents them from reaching their full cognitive potential. In the recent Nutrition Summit, the

multi-dimensional root causes of malnutrition were clearly acknowledged. The Government declared

nine priorities for action in fighting malnutrition. The EU emphasised its readiness to work with

Cambodia to address malnutrition through partnerships. Under the European Development

Cooperation Strategy for Cambodia 2014-2018, the EU and EU Member States have committed

themselves to providing continued support in health, nutrition and social protection. She stated that

this meeting provides an opportunity to review the findings from the MALIS project and to better

understand What Works for nutritionbased on rigorous monitoring and research. Such evidence-

based work is critical for the future design and scaling-up of effective nutrition interventions.

8The National Dissemination meeting programme is provided in Annex 1.


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His Excellency Dr Ty Sokhun, Secretary of State for the MAFF, presided over and formally opened the

National Dissemination meeting. He underlined that even though the world has sufficient capacities

and technology to feed everyone, hundreds of millions of people are still facing malnutrition.

Challenges for Cambodia are soil erosion and lack of water for irrigation, while at the same time the

number of farms decreases. Nevertheless, the population is growing and demands nutritious foods.

As 2015 is the Year of the Soils, he underscored the importance of healthy soils in order to have

healthy food that can contribute to good human health. This can be achieved through learning from

traditional knowledge, reversing the loss of biodiversity and placing emphasis on sustainable

agriculture. To-date, Cambodia has concentrated on monocultures and rice production. He

highlighted the need for a broader approach and the promotion of diversified agricultural

production and emphasised that MALIS followed Government policy and the National Food Security

and Nutrition strategy. He underlined the Governments policy ofdiversification and modernisation

of agriculture to improve food and nutrition security, and to prevent malnutrition. He also stressed

that women are key for development and must have the legal right to decide what crops to plant

and which animals to breed. He concluded by saying that MALIS has strong participation fromwomen and therefore he sees the project as a model for agricultural programmes.


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2. Session 1: Overview of the MALIS project - FAO food security and nutrition

project

Mr Oum Kosal, FAO Cambodia Assistant Representative, welcomed everyone and chaired the first

session of this important meeting.

2.1. Aims of the meeting

Specific aims of the National Dissemination meeting presented by Dr Elizabeth Westaway,

International Nutrition Consultant, FAO Headquarters, were to:

Bring together Government representatives, development partners and other interested

stakeholders in food and nutrition security in Cambodia

Share IMCF research results and lessons learned from the MALIS project for review anddiscussion

Capture ideas for future directions and distil specific recommendations from the IMCF research

to inform programme and policy design

Integrate feedback from the meeting into the final steps of IMCF research and MALIS project

documentation and dissemination activities.

2.2. Overview of the MALIS project

Dr Iean Russell, FAO MALIS Project Manager, provided an overview of the MALIS project, which was

funded by the EU and implemented by FAO in partnership with the General Directorate of

Agriculture of the MAFF from January 2012 June 2015. The provincial partners included the

Provincial Department of Agriculture (PDA), Provincial Department of Womens Affairs (PDoWA),

Provincial Health Department (PHD) and local and international NGOs. The approach was to work

through existing farmer groups in nine target districts in the two provinces of PVR and OMC.

The main aim of the project was to strengthen farmer groups and market linkages, through

increased food security (availability of foods in farming households) and nutrition (increased growth

of children). There were many project activities comprising farmer field schools, disaster risk

reduction; market linkages for smallholders through farmer business schools,9agricultural fairs and

input credit for 49 farmer groups; nutrition education and the provision of kitchen equipment (to

help caregivers prepare nutritious food); strengthening farmer groups; and capacity building

(essentially for farmer groups but also for partner staff).

The project did not target the poorest of the poor, as they are landless, but worked with farmers and

small enterprises to increase resilience. Farmer field schools were conducted under a Save and

Grow approach reaching 3,750 households. The topics were production of rice, cassava and

vegetables, and raising chickens as well as several cross-cutting themes including nutrition, disaster

risk reduction, gender mainstreaming, business and postharvest training.

9Farmer business schools use the same philosophy as farmer field schools but are more business oriented.


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Farmer business schools involved working with 20 existing farmer groups that were selected for

their commitment and performance using a flexible approach to meet farmers needs. The project

distributed over 1 million USD of equipment and approximately 700,000 USD worth of inputs to

smallholder farmers through agricultural fairs and input credit, working through farmer groups and

agricultural cooperatives. The agricultural fairs were a novel approach used for the first time by FAO

in Cambodia, which delivered a range of products under a voucher system that provided access to

seed, fertiliser, tools, machinery and kitchen equipment on a credit basis.

Disaster risk reduction activities involved community consultations at village and commune level; the

creation of a Menu of Options for Disaster Risk Reduction in Agriculture , tested in the farmer field

schools; vulnerability mapping; and provision of water tanks, assistance with home gardens and drip

irrigation systems. The water tanks were targeted at caregivers who received nutrition education,

with the aim of improving fresh water supply, family hygiene and providing water for home gardens.

Other activities focused on strengthening of organisations and institutions through capacity building

for all partner agencies and training of 49 community-based organisations to manage credit, keep

financial records and conduct planning. PDoWA was trained in gender mainstreaming which was

promoted in all project activities.

Nutrition education and information, education and communication (IEC) materials were provided at

provincial, district, commune and village level. Over 1,380 caregivers participated in infant and

young child feeding (IYCF) sessions designed to improve complementary feeding practices and basic

hygiene.

In terms of project success and future sustainability of project outcomes, the core units were the

farm households and the farmer groups. These were strengthened through the provision of inputs,

recovery and re-investment of over 400,000 USD from input credit. Recovery rates were 99.6

percent. This was an excellent result and a reflection of the honesty of farmers and their social

network as well as through the assistance of the Government from the community up.

Ms Theresa Jeremias, FAO Nutrition Officer, provided an overview of the nutrition education

activities in the MALIS project. According to the 2014 Cambodia Demographic and Health Survey,10

the country has a high burden of chronic undernutrition with 32.4 percent of children under 5 years

being stunted. Key contributory factors are poor IYCF practices including insufficient quantity and

quality of complementary foods, poor hygiene and sanitation, and lack of awareness, knowledge and

skills among service providers, caregivers and other family members. The first 1,000 days of life

provide a window of opportunity to address and prevent stunting, and ensure that children can

develop their full potential through: exclusive breastfeeding for the first 6 months; continued

breastfeeding up to 2 years of age; adequate, safe and appropriate complementary feeding from 6-

23 months; and good water, sanitation and hygiene.

There is no single best approach to tackle malnutrition and there is a need to ensure that children

get the best possible nutrition during the early years. While food and nutrient supplements are key

for treating and addressing malnutrition, their exclusive use for prevention may not be sustainable.

More emphasis is needed on food and agricultural solutions by raising agricultural production and

10 National Institute of Statistics, Directorate General for Health, and ICF International (2015) Cambodia

Demographic and Health Survey 2014. Key Indicators Report. Phnom Penh and Rockville, Maryland, USA:

National Institute of Statistics, Directorate General for Health and ICF International.


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incomes, and diversifying the food supply as key pillars for improved family and young child

nutrition. Hence, there is ample scope for supporting households to diversify food production and

incomes, and helping them to make better use of nutrient-rich locally available foods for improving

the quality of household diets, at the same time as reinforcing and sustaining local food culture.

Agricultural production in Cambodia focuses mainly on cereals, such as rice, and fruit and livestock

production are limited, which results in high costs of fruit and animal source foods. In addition,

seasonality not only reduces the availability and accessibility of food, which is particularly felt in the

dry season, but also exacerbates womens time constraints for food preparation, especially during

periods with a high workload, such as the rice transplanting season, and often results in family diets

that contain only a limited range of foods. To make matters worse, knowledge and skills among

service providers and families on age-appropriate feeding is limited. Hence, the MALIS project aimed

to tackle both problems simultaneously by helping families to improve their food security whilst also

engaging them in practical learning about young child nutrition. Mechanisms used were farmer field

schools and farmer business schools, and IYCF sessions.

Key nutrition education activities included (Annex 3):

Formative research was carried out in 2010/11 prior to the MALIS project.11

Adaptation of available nutrition education materials12and development of IEC materials: Baby-

friendly Community Initiative Flipchart; facilitators guide; four posters (1) hygiene and food

preparation; (2) food safety; (3) recipes; and (4) age-appropriate quantity and feeding

frequency.

Training/sensitisation: training of trainers was conducted in July 2013 by staff from the National

Nutrition Programme (NNP) and two FAO nutritionists who teamed up with staff from PHD,

District Health Centres, PDoWA and NGO implementing partners. Following sensitisation of

supervisors and local leaders, in August 2013, training was conducted of frontline workers from

health and volunteer members of the Village Health Support Groups (termed Community

Nutrition Promoters [CNPs] by the MALIS project).

Community-based IYCF sessions: were conducted with caregivers, which included participatory

cooking sessions. In Phase 1 (August 2013- January 2014), two CNPs per village held seven

weekly IYCF sessions13

with a maximum group of 15 caregivers who had a child aged 5-18

months (on recruitment), pregnant women and women of reproductive age. In Phase 2 (April

2014 March 2015), one NGO staff member acted as the main trainer and two CNPs as

assistants for the IYCF sessions. Technical support on health topics and on gender was provided

11Under the EU Food Facility Project, Trials of Improved Practices (TIPs) were undertaken with caregivers in

different provinces of Cambodia over two seasons to test the feasibility and acceptability of enriched porridge

recipes for complementary feeding using different locally available foods.12

In 2012, the National Nutrition Programme introduced the Communication for Behavioural Impact (COMBI)

material: which included a manual for Community Nutrition Promoters (CNPs) based on the updated Baby-

friendly community initiative flipchart; educational posters were produced in the course of trainings that

responded to the needs of caregivers and CNPs. 13

The seven IYCF sessions provided nutrition education on the following topics: (1) good diet for the family; (2)preparation of bobor khap krop kroeung (thick and multi-ingredient porridge); (3) dietary diversity; (4) hygiene

and food safety; (5) continuing breastfeeding and age-appropriate complementary feeding; (6) complementary

feeding from family foods; and (7) feeding a sick child.


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by PHD and PDoWA staff, respectively. In addition, the participatory cooking sessions14

imparted practical skills on how to make bobor khap krop kroeung (enriched porridge).

A one-day complementary feeding campaign was conducted in November 2013 to promote

improved IYCF practices in the communities. This was followed by a seven-day distribution of

boborkhap krop kroeung free of charge to children aged 6-23 months three times per day in

villages within the two provinces.

Kitchen equipment:15was distributed to participants of IYCF sessions to encourage adoption of

improved feeding and hygiene practices at home.

Monitoring, supervision and reporting: was conducted mainly by NGO implementing partners,

with the support of staff from PHD, District Health Centres, PDoWA as well as the MALIS

nutrition team.

Sharing meetings with caregivers and home visits: were carried out in Phase 2 by NGO and

MALIS staff to assess change in knowledge, attitude and practice (KAP).

The nutrition education intervention was implemented in two phases: Phase 1 (August - December

2013) and Phase 2 (May 2014 - February 2015) in OMC and PVR. In Phase 1, IYCF sessions were

conducted in 35 villages with 449 caregiver/child pairs by CNPs who were supported by trainers from

PHD, PDoWA and NGOS. In Phase 2, IYCF sessions were carried out for a second cohort of caregivers

in the initial 35 villages and an additional 29 villages with 939 caregiver/child pairs by NGO trainers

with support from PHD, PDoWA and CNPs. The nutrition education intervention was implemented in

a total of 64 villages and involved training a total of 153 CNPs and 1,386 caregiver/child pairs whose

average attendance rate was 77 percent.

While the nutrition education activities were being conducted in Phase 1, the IMCF16

research

project was gathering data to assess the effect of the activities on childrens diets, micronutrient

status and growth. Few studies have documented the links between diversified agricultural

production and nutrition education, using scientifically robust methods. The IMCF project set out to

fill this gap with the aim of contributing to our understanding on the links between agriculture and

nutrition.

14Four participatory cooking sessions were held during IYCF sessions 3, 4, 5 and 6.

15 Kitchen equipment distributed to caregivers included: energy saving stove, kettle, food cover net, water

bucket, dish rack with cover, large pot with lid, soap and dipper.16 JLU researchers conducted the 5-year research project entitled: Improving the dietary intakes and

nutritional status of infants and young children through improved food security and complementary feeding

counselling (IMCF).

Outmigration of women and men is a big challenge

The Ministry of Womens Affairs works in areas with high rates of stunting. One of the big

challenges we face in rural areas is migration, both of mothers and fathers, to urban areas or

abroad. Another problem is womens high workload. Women take an active part in economic

activities to feed the whole family. Hence, it is good to include grandmothers as well as

extended family members, such as grandfathers, grandmothers and aunties in nutrition

education.

Her Excellency, Dr Kantha Phavi Ing, Minister of Womens Affairs


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10

Discussion:

How does the MALIS credit scheme work? MALIS explained that intensive consultation was

conducted through farmer groups to understand their needs. Subsequently, a list of input

requirements was developed for the coming agricultural season. There were four different rounds of

input credit over different years and different points in the agricultural seasons. The farmers decidedwhat inputs they wanted and the amount of credit they wanted to take, i.e. 20-150 USD and they

were required to pay back 60 percent to the farmer group after the harvest. This was supervised

closely by the management committee. However, the scheme needs Government commitment and

firm community support.

Regarding nutrition education, you only trained health staff like PHDs, Operational District Officers

and village health support groups. When we talk about collaboration in the future, we should also

think about training the agriculture sector on key aspects of nutrition to ensure a minimum

knowledge of nutrition FAO replied that in addition to health staff, agricultural extension and

PDoWA staff were also trained on how to facilitate IYCF sessions. There was a specific focus ontraining farmer field schools and farmer business school facilitators on the three nutrition modules

in the farmer field school curriculum. However, it was agreed that there is a need for strengthening

further training of agricultural extension staff in nutrition to build their knowledge and skills in food-

related nutrition aspects to combat malnutrition in Cambodia.

How do you ensure that all farmer groups that received the loan select the right crops with good

nutrition for their children?MALIS remarked that the market approach leads to farmers wanting to

grow rice and cassava, which are not particularly rich in the vitamins and minerals needed to combat

malnutrition. However, the farmer field schools had two approaches: (1) commercial (mostly rice

and cassava); and (2) food security, which were directed at encouraging homestead production of

nutrient-dense food sources, such as vegetables and chickens to contribute to household nutrition

needs (which is not a commercial enterprise). FAO Cambodia also carried out a Telefood project in

combination with the MALIS project, which promoted nutrient-rich fruit and vegetable crops to

improve household nutrition. The evidence of commercial success was shown by the example of

eight cooperatives in PVR that sold 1,200 tons of organic rice for export in 2014, which

demonstrated the sustainability of the commercial farming. The MALIS evaluation will assess the

extent to which the project raised rice and cassava yields.

How do you connect the provision of inputs and the process of training? How do you know that

mothers really make use of the knowledge gained during the IYCF sessions?What is the theory of

change? In project design, how did you determine the elements that would contribute to good

nutrition, and how did you assess that nutrition was improved? FAO responded that caregivers

were recruited from farmer field schools to ensure that households would receive agricultural

inputs, training and practical nutrition education as part of a comprehensive package. The

assumption was that the combination of support, agricultural inputs, knowledge and skills, together

with the kitchen equipment would enable caregivers to: 1) have access to a wider range of

micronutrient rich foods; 2) use the knowledge and skills gained to prepare the bobor khap krop

kroeung;3) recognise the benefits; and 4) feel motivated to continue. To assess whether or not, and

the extent to which behaviour change took place, will be reviewed during the next session.

A lot of trainings on food-based approaches have been conducted; do you have any evidence of

behaviour change? MALIS replied that findings will be presented by JLU, but from the monitoring


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11

that was undertaken there is evidence that some mothers changed their behaviour and cooked

bobor khap krop kroeung 3-4 times per week.

Were the farmer groups pre-existing or formed by FAO? In relation to the credit scheme, have you

looked at how to integrateongoing credit availability into community activities?MALIS explained

that initial assessment found that there were enough existing farmer groups in the target provinces

to start project activities and cover the target population. However, farmer groups have since

increased in number, membership and capability. We did not want to form or label any groups as

'MALIS groups' as the existing savings and credit groups had been created by other projects and

had an established identity. The MALIS project focused on supporting the existing groups,

particularly those organisations previously working under the EU Food Facility project. The aim of

the MALIS project input credit was to provide a single round of credit and to recover the agreed

percentage, leaving the money in the groups' bank accounts. In many cases, 2 rounds of credit were

conducted within the project period. Thus FAO Cambodia has some confidence that they will lend

out again as part of their ongoing group activities.


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3. Session 2: Applied research in the context of an FAO food security and nutrition

project - Findings of the IMCF project

The second session was chaired by Dr Pattanee Winichagoon, Mahidol University, Thailand and

Professor Michael Krawinkel, JLU Giessen, Germany.

3.1. Overview of the research Improving the dietary intakes and nutritional

status of infants and young children through improved food security and

complementary feeding counselling

Dr Irmgard Jordan, Research Fellow and Co-Principal Investigator from JLU, presented the IMCF

research project conducted by JLU and Mahidol University.17

The IMCF research has four

hypotheses:

1. TIPs formative research generates behaviour change communication messages and

nutritionally improved recipes that lead to lasting improvements in complementary feeding

practices, dietary intakes and child nutritional status

2. Locally available and affordable foodscan provide a significant contribution to the nutritional

requirements of children aged 6-23 months

3. Nutrition education with a focus on IYCF and linked with a food security intervention can

improve child feeding practices and nutritional status

4. Using locally available foods for improving complementary feeding practices and childrens

nutritional status is a sustainable strategy which can be replicatedby households at low cost

and taken to scale using available Government services

The IMCF study design18

was as follows:

Table 2: IMCF study design and dates of assessment

Research

methodDate Description

Cross-sectional

Baseline

survey

September -

October 2012The following data was collected from 1,028 households selected in a two stage cluster

sampling with proportional to population size (PPS) in 16 MALIS communes:

Interview with standardised questionnaire:

o Socio-economic status

o Sanitation, hygiene, access to health facilitieso Breastfeeding and complementary feeding practices

o Dietary Diversity Score (household and child)

o Child health

o Household Hunger Scale

o Motor milestones (child)

Anthropometric measurements (parents and child)

Haemoglobin levels (mother and child)

Blood plasma for iron and vitamin A status (child)

Cluster

randomisation

October 2012 Communes targeted for the MALIS food security intervention were assigned into

intervention and comparison communes through restricted cluster randomisation.

Ten intervention communes: villages targeted by the MALIS food security

17

The IMCF project also includes a similar study in Malawi on a FAO nutrition-sensitive agriculture project incollaboration with Lilongwe University of Agriculture and Natural Resources (LUANAR).18

The study is registered at the German Clinical Trial Register (DRKS): https://drks-neu.uniklinik-

freiburg.de/drks_web/setLocale_EN.do
https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.dohttps://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.dohttps://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.dohttps://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.dohttps://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do


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13

intervention and MALIS IYCF sessions

Five comparison communes: villages targeted by the MALIS food security

intervention only

Impact

pathway

analysis

August 2013

September

2014

Pre- and post-training knowledge tests in all training levels (Master Trainers, CNPs and

caregivers) prior to, one week after and 8 months after the IYCF sessions; Focus Group

Discussions (FGDs) with primary caregivers; observations on trainings, including IYCF

groups and interviews with primary caregivers and other key stakeholdersLongitudinal

studyAugust 2013 -

August 2014Data was collected every three months on a cohort of children in intervention and

comparison areas19

Cross-sectional

impact surveySeptember -

October 2014The survey was conducted as a census in all project villages in the area targeted by

MALIS in the first year of project implementation. It followed up on the potential

impact of IYCF sessions and the food security intervention on dietary behaviour,

nutritional status of children < 24 months, motor milestones, and micronutrient

status20

3.2. Impact of food security intervention and nutrition educationresults from

baseline and impact survey

Ms Anika Reinbott, PhD Student from JLU, presented the quantitative results of the IMCF research.

After the baseline survey in September 2012, the MALIS communes were assigned to intervention

and comparison21

groups through restricted randomisation (Figure 1). The intervention group

consisted of ten MALIS communes that were targeted by the MALIS food security intervention and

nutrition education intervention. The comparison group consisted of five communes that were

targeted only by the MALIS food security intervention.

19 Eligibility criteria in the intervention area were: 1. Participant in the nutrition education intervention, 2.

Mother with a child 6 < 9 months of age. Eligibility criteria for the comparison area: 1. Mother with a child

matched by age and sex with a child from the intervention group.20

The impact survey collected the same data as per the baseline surveys in a census of 1,176 households in 15

MALIS communes. However, the Household Food Insecurity Access Scale (HFIAS) was used instead of thehousehold hunger scale. http://www.fao.org/fileadmin/user_upload/eufao-fsi4dm/doc-training/hfias.pdf21

MALIS communes in the comparison group cannot be controlled due to the wide range of other

development activities that took place independently from the MALIS project.


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14

The impact survey results showed that 35 percent of households in the intervention areas and 22

percent of households in the comparison areas had participated in the MALIS food security

intervention, respectively. The IYCF sessions reached 62 percent of households in the intervention

areas. However, only 23 percent of households in the intervention areas participated in the MALIS

food security intervention and the nutrition education. Maternal education (ME) and Household

Dietary Diversity score (HDDS) increased in both provinces between baseline and impact (PVR: ME BL

3.4MEIS4.3 and HDDSBL6.2 - HDDSIS 7.5; OMC: MEBL 3.7MEIS4.4; and HDDSBL7.3 - HDDSIS 8.0).Also, access to improved sanitation facilities increased significantly in both provinces during the

same period. However, in OMC this was indirectly linked to improved hygiene practices and

decreased prevalence of diarrhoea (Table 3).

Table 3: Access to protected drinking water sources and safe sanitation facilities per survey and province in

the intervention and comparison areas

Preah Vihear Oddar Meanchey

Baseline Impact Baseline Impact

Comp Int Comp Int Comp Int Comp Int

Total (n) 126 246 241 287 190 298 282 365

Protected source of

drinking water (%)87 84 88 84 85 90 88 89

Improved sanitation

facility (%)22 4 25 13 21 27 33 42

Baseline: September 2012, Impact: September 2014; Comp.: comparison area; Int.: Intervention area

Continued breastfeeding rates decreased from baseline to impact in both the intervention and

comparison areas, and especially in children aged 20-23 months. The WHO indicators MDD and

MMF improved in intervention and comparison areas of both provinces. However, the prevalence of

children that achieved MAD increased significantly in intervention areas overall. HDDS increased in

intervention and comparison areas in both provinces between baseline and impact. With regard to

Figure 1: Map of project and research areas


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15

Child Dietary Diversity score (CDDS), the Differences in Difference (DiD) estimator22

showed a

significant positive intervention effect on the CDDS: 3.9 in intervention areas as compared to 3.6 in

comparison areas, which was mainly attributable to an increased consumption of legumes and pro-

vitamin A rich foods. However, the number of households preparing bobor khap krop kroeung

remained low, especially for children aged 9-12 months: 29.5 percent of households in intervention

areas and 8.5 percent of households in comparison areas with children aged 9-12 months prepared

bobor khap krop kroeungon the day prior to assessment. In addition, the volumes fed per meal were

lower than recommended (usually less than bowl) and the consumption of sugary foods and

snacks was high. Different inter and intra-provincial stunting prevalence trends were observed

between baseline and impact. In OMC, stunting prevalence increased to 28 percent in intervention

areas and 25 percent in comparison areas; however, the overall increase was 3 percent less in the

intervention area compared to the comparison area. While in PVR, stunting prevalence decreased to

22 percent in intervention and comparison areas, but the overall decrease was 2 percent more in the

intervention area compared to the comparison area (Figure 2).

Figure 2: Stunting prevalence of children aged 6-23 months in intervention and comparison areas of OMC and PVR

provinces

The following conclusions were made: (1) the overlap of food security and nutrition education

interventions was limited and needs to be increased; (2) short-term nutrition education led to small

improvements in IYCF practices and child nutritional status only; and (3) it is important to try and

provide further insights into the rather puzzling results related to trends in stunting prevalence. It

was recommended that nutrition education not only focuses on diet quality but also on age-

appropriate quantities.

22The differences in difference estimatorconsiders possible differences at baseline between intervention and

comparison groups, and assumes that both groups would develop similarly in the absence of any

intervention.


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3.3. Behaviour change for improving infant and young child feeding practices

results from a qualitative study

Dr Irmgard Jordan, JLU, and Mr Mav Khun, Mahidol University, presented qualitative research results

on factors leading to positive behaviour change on improved IYCF practices. Data collection methods

included knowledge tests, a longitudinal study, FGDs, interviews and observations.23

The knowledge

tests were conducted prior to and immediately after the trainings at all levels including master

trainers (MTs), CNPs and caregivers. At primary caregiver level, another knowledge test was

conducted 8 months after the training. The test results were summarised in two knowledge scores

(Table 4):

Table 4: Knowledge scores of primary caregivers, MTs and CNPs

Score 1) Knowledge of foods 2) Knowledge of IYCF practices

Contents Food groups, iron and vitamin A rich foods,nutritious snacks

breastfeeding practices; consistency of porridge,

feeding practices of sick children, hygiene practices

especially during food preparation and feeding

Primary

Caregiver

results

In the mean households achieved

approximately 50 percent of possible score

prior to the nutrition education

Increased significantly after nutrition

education, but did not reach 100 percent

In the mean households achieved approximately

70 percent of possible score prior to the

nutrition education

Increased significantly at second post-test only,

reaching 95 percent in some villages.

MT results Data analysis ongoing

CNPs results Data analysis ongoing

A cross-lagged panel analysis showed that the nutrition education successfully linked knowledge on

food with knowledge on recommended IYCF practices, although this link was weak prior to the

nutrition education. Follow up on whether caregivers applied the knowledge at home was

undertaken in the longitudinal study, FGDs, and interviews. Results from the longitudinal study

showed that after the nutrition education 25 percent of caregivers prepared bobor khap krop

kroeung in the intervention group compared to 6 percent in the comparison group when the

children were 9 < 12 months old. However, three months later only 14 percent of caregivers

prepared bobor khap krop kroeungin the intervention group while the level remained the same in

the comparison group. The most often cited reason for not preparing bobor khap krop kroeungwas

lack of time and this was followed up by conducting four FGDs with 5 -6 primary caregivers inMALIS villages. Results showed that lack of time was a proxy for womens overall workload,

womens attitude towards child feeding, food availability and accessibility as well as womens ability

to put theory into practice. This was also confirmed during interviews with mothers after completing

the IYCF sessions (data analysis is ongoing). One mother reported: I sometimes bought porridge

from the market because I did not have enough time to prepare bobor khap krop kroeung. Another

mother remarked that family food was easier to provide: the child does not eat much and [I am]

also lazy to prepare [bobor khap krop kroeung]; just give family food. It was foundthat family food

was given quite early to the children at 9 months of age and the taste may have influenced the

mothers decision to continue preparing bobor khap krop kroeung as they were used to spicier

family food. In conclusion, mothers had a heavy daily workload which minimised time available for

23A full day was spent at each household observing the mothers behaviour.


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childcare; however, they often received support from the childs grandmother. Mothers faced a

number of challenges to adopting improved IYCF practices, which included: lack of knowledge, poor

food availability, and unfamiliarly and under-utilisation of traditional local foods. Nevertheless,

mothers appreciated learning how to put new knowledge and skills into practice at home; however,

behaviour change was determined by their childs acceptance of bobor khap krop kroeung.

The co-chair, Dr Pattanee Winichagoon remarked that the presentations showed that knowledge

improved; however, for mothers to adopt recommended IYCF practices, additional support was

needed. The question therefore remains: how can we achieve appropriate behaviours?

The meeting was graced with the presence of Her Excellency, Dr Kantha Phavi Ing, Minister of

Womens Affairs and the co-chair, Professor Michael Krawinkel asked her to speak about gender and

the importance of prioritising nutrition. Her invaluable insights are included throughout this report.

Discussion

Why did you observe training sessions in the community rather than cooking at home? JLU

explained that the project started with training NGO and community-based workers. Given that they

are an important player in the behaviour change process, assessing their knowledge and capacities

therefore constitutes an important part of the analysis. Mahidol University clarified that the IYCF

sessions with mothers and other caregivers were delivered through village volunteers and these

were part of the education process. Nevertheless, individual household visits would have been ideal

but could not be conducted owing to lack of time and capacities of the study team.

What is the reason for the reduction in breastfeeding rate, according to the Cambodia Demographicand Health Survey? JLU remarked that the research did not focus on breastfeeding, but on

complementary feeding, and continued breastfeeding was a topic, but there may not have been

sufficient emphasis to explain the decline in breast feeding rate. In addition, the environment is not

conducive to breastfeeding because there is high migration of mothers; also many mothers work in

agriculture and are busy planting rice. Hence, they face many challenges to continue breastfeeding.

Why is the stunting rate different in the two provinces? JLU concurred that the results were

puzzling and there is a need for further analysis to explain the differences in malnutrition

prevalence, particularly as there was increased wasting in both provinces. It was postulated that

there may be a link with sanitation and diarrhoea, which is less prevalent in other provinces of

Cambodia. JLU remarked that additional factors may have affected stunting. For example, migration

rates of mothers are different: OMC more than in PVH (at impact survey approximately 5 percent

Mothers need to see results, otherwise they lose confidence!

In terms of village solidarity, it is important to include all women in the village to ensure they

have the knowledge and skills to change their behaviour. Hence, to attract women to become

more involved, there is a need to share best practices on hygiene, nutrition and healthy eating.

It is very motivating for mothers when they see that their child is healthy and well nourished.

The women need to see results otherwise they lose confidence and hope, and they say that the

programme is useless. They need to see quick results to continue good practices.

Her Excellency, Dr Kantha Phavi Ing, Minister of Womens Affairs


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18

and 0.7 percent respectively), and in the case of migration grandmothers are more involved in child

care possibly affecting breastfeeding rates and quality of infant and young child feeding.

Additionally, a different NGO was implementing the MALIS project on behalf of FAO in each

province. Furthermore, several other NGOs were providing assistance to communities in the area of

nutrition (e.g. micronutrient powder sprinkles), which the research did not specifically look at. So it

is not possible to give a definitive answer.

Helen Keller International (HKI) thanked JLU for the very interesting presentations on

complementary feeding. They had similar findings, indicating that dietary diversity is a very good

indicator. However, they found that the total amount of food fed per feed and per day was not

sufficient in terms of volume and kcals for the age of the child, and had investigated whether the

problem was the measurement used to quantify foods. Hence, they tried out the recommended

amounts with mothers and provided measuring bowls, but found it complicated.

How can themeasurement issue be addressed?JLU stated that they had asked caregivers about

the volume of food that was fed using local measuring tools. However, a reporting bias cannot be

excluded as caregivers sometimes leave the child on its own while eating, thus, the amount of food

the child consumed might not be exactly known by the caregiver. JLU acknowledged that the best

method would be to observe the entire feeding process by measuring the total quantity before and

after feeding. However, this was not done. Although JLU did undertake household observations on

the mothers activities,general feeding and childcare as well as on the household water source and

sanitary environment.

Did you also include gender sensitisation to this process?You recommended including grandmothers

but fathers should also be included, particularly as women have a high workload in the home and

fathers should see this JLU replied that this question would be answered in the afternoon session

and pointed out that the research team had not been responsible for gender sensitisation.

The conclusions mention womens heavy workload. Are there other reasons that hinder behaviour

change/nutrition improvement? JLU replied that a study based on FGDs of hindering and

facilitating factors for change in IYCF practices will be published at a later stage.

How can you conclude that the results are attributable to the design of the intervention? JLU

commented that this question is difficult to answer definitively given the lack of a proper control

group. We decided to call it a comparison area as many activities in addition to the food security

activities supported by MALIS were going on. In order to assess these and to try to gauge theirpotential influence, we attempted to map all nutrition support activities that were taking place by

location and by organisation. We also reviewed the sources of the nutrition education messages that

caregivers received and were able to identify a recall bias among caregivers. They were confused

about the source of the information, whether it came from a representative of the MALIS project or

a health worker from MoH, and may have received nutrition information to promote the

consumption of micronutrient powder sprinkles during attendance at clinics and health centres. As

MALIS had no nutrition education activities in the comparison areas, we do not know if any of the

intervention effects can be related to either MALIS food security or nutrition support provided by

other agencies. However, data from the intervention areas has shown that food security activities

improved dietary diversity and that the provision of nutrition education also increased dietary

diversity independently; particularly as this improvement was greater in the intervention area where

both activities were conducted. JLU undertook a census at the endline, indicating that the results


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were truly representative as they included all the caregivers. However, it must be remembered that

the MALIS intervention was just one-year in duration. To enable us to demonstrate a possible

decrease in stunting, a longer intervention would be needed.

What is the influence of industrialised food in the project area?JLU concurred that there was an

increased preference for commercial foods. Therefore, snacks were included in the 24 hour recall

and a range of sugar-sweetened foods, packaged cakes, crackers and snacks were identified. In the

longitudinal study it was observed that commercially prepared porridge was available but only a few

mothers used it. Mahidol University commented that commercially enriched bobor khap krop

kroeungis sold in a pack. However, some mothers said that their children vomited or had diarrhoea

after eating these foods. JLU added that currently there is no regulation for commercially produced

infant foods. Hence, there is a need to help mothers resist the marketing pressure for expensive

food products and show that they can feed their children well using cheaper locally available foods.

Did you observe siblings help with care/feeding as they would need to be included in the IYCF

sessions? Mahidol University replied that when mothers leave the home, the child is left in the

care of other relatives. Therefore, it is important for family and extended family members to learn

how to feed children well, particularly as more mothers are migrating.


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4. Session 3: Lessons learned and Implications on future programmes

The third session was chaired by Mr Ngin Chhay, Deputy Director, Rice Crop Department of GDA,

MAFF.

4.1. FAO Nutrition Education Process Review24

Ms Theresa Jeremias, Nutrition Officer, FAO Headquarters, presented findings of a process review of

the MALIS nutrition education intervention conducted during June - July 2014.25

Its objectives were:

(i) to collect data on the MALIS food security and nutrition education activities, and their links to

determine what had and had not worked well, and (ii) to develop lessons learned to inform future

programme and policy design.

The process review was undertaken on both phases of the MALIS project in purposively selected

districts and IYCF villages in OMC and PVR provinces, and focused on issues related to targeting,

coordination and collaboration among stakeholders. Data collection methods included 14

interviews26

and six FGDs.27

The following good practices were identified:

1. Caregivers with children aged 5-18 months (on recruitment) were recruited from farmer field

schools or community-based organisations as a priority: which strengthened the link between

food security activities and the nutrition education intervention

2. Three nutrition modules were integrated into farmer field schools: (1) the importance of dietary

diversification; (2) benefits of home gardens; and (3) selection of nutritious crops for home

gardens were implemented in Phase 2 farmer field schools

3. Nutrition education was integrated into agricultural fairs and farmer field days: implementing

partners organised tasting of bobor khap krop kroeung based on locally available foods and

promoted wider awareness of improved IYCF practices amongst the target population28

4. Good cooperation with Government on their capacity building role: National Nutrition

Programme master trainers conducted training of trainers for staff of the PHD, District Health

Centres, PDoWA and NGO partners, who then trained CNPs

5. Capacity building of Government and NGO staff, and village health support groups in nutrition:

several different types of nutrition education training courses were conducted, which included

initial training of trainers and training of CNPs, refresher trainings, and on-the-job trainings;

training on nutrition modules for FFS facilitators and PDoWA staff; as well as training on KAP

24The MALIS nutrition education intervention process review report is forthcoming.

25 The MALIS nutrition education intervention process review was conducted by Dr Elizabeth Westaway

(International Nutrition Consultant, FAO Headquarters) and Ms Theresa Jeremias (Nutrition Officer, FAO

Cambodia) with support from Ms Sreymom Oy (Research Assistant) and the MALIS project team during June -

July 2014.26

Interviews were held with: MALIS project staff, NGO staff, national and provincial government staff, and

caregivers (from Phase I).27

FGDs were conducted with: caregivers (Phase I and Phase 2), grandmothers (Phase I), fathers (Phase I), andCNPs (Phase I).28

Approximately 850 people were directly reached with the tasting of bobor khap krop kroeung and a few

thousand with awareness of improved IYCF practices.


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6. Practical learning environment during IYCF trainings: four participatory cooking sessions were

integrated into the seven IYCF sessions and increased caregivers skills and confidence to

prepare boborkhap krop kroeung

7. Participation of grandmothers in the IYCF trainings increased their knowledge on and advocacy

for improved feeding practices and childcare: due to migration of some mothers, grandmothers

attended parts of the IYCF sessions or even the whole training

8. Distribution of kitchen equipment to caregivers: fuel-efficient stove, kettle, pot, water container,

hand soap, plastic dipper, plastic food cover and food cover net enabled them to put the

acquired food preparation and cooking skills into practice

The following key challengeswere underscored:

Capacity and Motivation

1. Lack of capacity in nutrition at all levels: Government and NGO staff have limited training

and capacities in nutrition and food based approaches, especially on complementary feeding

and the promotion of good family diets; they also lack facilitation skills and participatory

skills, which is key for working at community level

2. Duration of nutrition education programmes: caregivers need effective long-term support in

the communities to sustain the new behaviour since improvements in child health can only

be seen over time

3. Incentives: participation of Health Centre staff, Commune Council for Women and Children

and CNPs required incentives.

Implementation

4. Recruitment of men into the IYCF sessions: traditionally, the primary caregivers are mothersand grandmothers, as men must earn an income they only take a minor role in feeding and

caring of young children. Attempts were made to motivate men to join the sessions, but only

a few were able to participate

5. Long duration of participatory cooking sessions: women have heavy workloads, so IYCF

sessions should be less than two hours, however, the joint theoretical/cooking sessions took

longer than the theoretical sessions

6. Quantity of porridge to be fed and ingredients in the recipes: measurements of ingredients

to make , and 1 full bowl of bobor khap krop kroeung were difficult for trainers and

caregivers to understand. Although IEC material was developed to show how many

spoonfuls of various ingredients were needed to prepare the different recipes, the recipe

concept remained challenging. In addition, caregivers had difficulty understanding how

much boborkhap krop kroeungshould be given to their children to make them grow.

Supervision and Reporting

7. Coordination of supervisors: in Phase I, IYCF sessions were often attended by multiple cadres

of staff, which was not an efficient use of resources. This was changed in Phase 2, where the

NGO staff delivered the trainings, CNPs were used for mobilisation of caregivers and NGO

supervisors/MALIS staff undertook monitoring

8.

Reporting: in Phase I, NGO partners were reporting at activity level (numbers of trainings

and inputs distributed) rather than on whether caregivers changed their behaviour. In Phase

2, the focus on behaviour change improved through strengthening of the monitoring and


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evaluation system to observe whether mothers were actually practicing the new knowledge

and skills.

4.2. Lessons Learned from the MALIS project

Dr Iean Russell, MALIS Project Manager, explained the annual review cycle for collecting and sharing

lessons learned from the field, which started with farmer field schools, farmer business schools and

IYCF groups reviewing the training and associated activities at village level. Lessons learned were

shared at commune or district level meetings, and provincial workshops.

Lessons learned by the Project Manager

Dr Russell provided personal insights on the role of a Project Manager. He noted that

communication of your strategy and successes to the stakeholders are important for project

progress. Monitoring of the activities is essential to provide an evidence-base for the programme. As

a programme manager it is important to build relationships and communication channels with the

beneficiaries and implementing partners to guide activities. The responsibility of the programme

manager is to motivate staff and implementing partners to engage in a meaningful way in the

project as early as possible. Invest in and channel funds to successful activities, and do not allow

organisational memory to be eroded by staff turnover.

Overall, the MALIS project faced a number of challenges,which included:

Technical issues for production and nutrition

Extensive requirement for training of trainers before and during implementation

Barriers to information sharing

Business environment was challenging for the development of market linkages

Home environment for caregivers was sometimes not supportive for behaviour change

Lack of experience of participants and staff in market-oriented, new-style cooperatives and

market systems

Lack of clarity in communication, transparency and accountability in some community groups

Few capable existing community groups and limited time frame for strengthening management

of the groups

Key lessons learned by the MALIS team included:

Farmer Field Schools

Farmer field school effectiveness was limited by the capacities of the facilitators (as many

facilitators were unsure how to conduct a farmer field school) and level of backstopping

Provision of inputs for chicken and vegetable farmer field schools increased the dependency of

members on inputs rather than focusing on learning, and chicken activities were considered of

limited relevance for food security


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Farmer Business Schools

Building up business skills for the farmer groups is an effective long term development strategy

Making farmer business school curricula relevant to current needs and activities of the farmer

works well, e.g. when advice is adapted to the farmer groups seasonal crop calendar to make it

relevant

Ensuring that agriculture cooperative management learns about responsible business behaviour

especially for contracting

Investing in success works well in relation to individuals, ideas, organisations and activities

Fairs29

and Input Credit

The vouchers were a good way to inject capital into the community allowing farmers to choose

what they really needed

Clear input credit guidelines are needed and must be communicated to farmer groups and

strictly enforced to ensure farmers adhere to the rules

Willingness to pay was demonstrated by recovery of all money owed

Fairs can be used to stimulate local business

Government supervision and support were critical for accountability of farmer groups

Future directions

In general, there is a need for more investment in education. Education in agriculture,

particularly agronomy, and in nutrition, which have been neglected in Cambodia. There is a

need to develop pre-service and in-service programmes in schools and at tertiary level insteadof short training courses, as these have resulted in the general lack of expertise in soil science,

pest management, agricultural chemicals and nutrition30

In order to successfully conclude the MALIS project, it is necessary to further strengthen

smallholder farmer groups, formulate appropriate strategies to improve child feeding

behaviour, and emphasise disaster risk reduction at household level

Looking beyond the life of the project, the time is ripe for change in rural systems. Womens

roles are rapidly changing and there is an increasing burden on women to manage the

household and to participate in a mobile work force, sometimes distant from the home. There

are rising education opportunities, but also challenges to ensure this education is made relevant

to the future of rural youth. Despite the scepticism around agricultural cooperatives, the MALIS

project has shown that these can be effective as drivers of economic change and offer a level of

social protection. The high costs and mobility of rural labour will promote mechanisation and

the opening of trade relations will bring new market forces into play. Some of these will provide

opportunities; others may further disadvantage smallholders who have limited skills in

responding to market opportunities. Lastly, we see that climate change is real and rural

communities are searching for guidance and ways to adapt.

29This was the first time that agricultural fairs of this nature were conducted that provided farmers with over

100 items to choose from.30

The MSc in Nutrition programme only commenced two years ago in Cambodia.


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The chair, Mr Ngin Chhay thanked the presenters and remarked that a complex set of lessons were

outlined from a wide range of sectors. He stressed that it is important to simultaneously promote

food production and nutrition. Hence, there is a need to grow nutritious food crops.

Discussion:

What might be the best approach to foster and generate knowledge, convey nutrition messages and

ensure behaviour change? The MALIS project has used different channels to convey nutrition

messages by including fairs as a tool from the agricultural side - could they be an option for nutrition

promotion as well?MALIS replied that efforts were made to ensure that farmer field schools had a

cross-cutting message on nutrition, and fairs and field days included similar messages. By integrating

nutrition education messages in fairs and promoting complementary feeding through food displays

and boborkhap krop kroeungtasting, MALIS aimed to create broader awareness of improved child

feeding in the communities. The idea was to encourage different family members to participate in

child nutrition activities and thus reduce the burden on the mother. Although there is no scientific

evidence to show these broader activities had any impact, we can gauge success by the active

involvement of beneficiaries, and their improvements in knowledge. To monitor progress FAO

conducted sharing meetings among mothers after IYCF sessions 3 and 5. These also served to

encourage interaction between women, discuss hindering factors in preparing bobor khap krop

kroeungand explore options on how to overcome these constraints. There is need to mobilise other

groups and use diverse channels of communication in the community, e.g. religious groups, to reach

out to people. Radio can be a very effective channel for information dissemination and there is

ample scope to explore different options to raise awareness and enable households and

communities to improve IYCF.

The EU agreed with the key challenges and commented that there is a need to think out of the box.

A three percent increase in stunting of children in OMC shows that the work is not enough (in

agriculture and nutrition); we need to plan for broader interventions and develop a long-term vision.

Also, a 3.5 year project duration is not long enough and only gives short-term support to the target

groups. It is important to think about how to scale up to the national level to sustain action and

support, to encourage collaboration among the different sectors (agriculture, nutrition, health) at

national, provincial and community levels, and to integrate lessons learned into nat

improving food security and market linkages for smallholders

Documents