2002: Christine Lindell Detweiler, MPH, RD



BABY WEIGHINGS AND VILLAGE FOLKLORE GROUPS

MOBILIZING COMMUNITIES TO IMPROVE THE NUTRITIONAL HEALTH OF INFANTS AND YOUNG CHILDREN IN RURAL BENIN, WEST AFRICA


What do monthly baby weighings, conveying health messages via village folklore groups and promoting treated mosquito nets have in common? These and other activities are part of an integrated health program happening in a rural province of Benin, a small country in sub-saharan Africa. In an area of the world where a child dies from malaria every 30 seconds, where significant numbers of children are often chronically undernourished or even malnourished and where infant mortality is around 150 per 1,000 live births, improving nutritional well-being is not just a matter of nutrition.

The non-governmental organization (NGO) that I have been working with for the past six years seeks to promote health and improve nutritional status of children, as well as adults, in a rural setting where most children's parents are subsistence farmers. The NGO has two primary actions: giving small loans to women for income-generating activities and promoting community health activities in villages. The name of the organization is the Association of Evangelical Churches for Social Promotion, a Christian NGO that was established 10 years ago in an attempt to address some of the community development needs in the Dassa region of Benin.

The health program works at health and nutrition in a number of different ways. The principal goal is to encourage villagers to take ownership in their own health, to realize that health and well-being is ultimately their own responsibility and to equip them to work together to improve their health. To equip people in this way, we use a series of participatory teachings where villagers are gathered together and a particular topic related to health is discussed. The methodology uses flannelograph pictures and a logical sequence of questions to encourage people to reflect on their own situation (to see themselves in the pictures and to find in themselves the answers to the questions). Once people understand a particular health problem and the origins of the problem, as a community they can decide to do something concrete to resolve the problem. A specific example of this is a series of animations talking about hygiene and the environment and leading up to the question "where do illnesses come from?" This has led to villages deciding to build latrines (where none have existed in the past), to build a village dump or to have monthly village clean-up days. With malaria having such a detrimental health impact on children, often contributing to weight loss and poor nutritional status, a recent initiative has focused specifically on malaria prevention. Along with working at decreasing malaria larvae breeding grounds, a key focus is promoting the use of treated mosquito nets at night for all children. Young children are particularly susceptible to malaria.

Another part of the health program's activities is setting up and supervising village health posts. Community health workers are chosen by their village and are given training to treat basic illnesses, such as malaria and diarrhea, and give basic first aid. They also receive training to do prenatal and postnatal care, as well as delivering babies. The village health workers are given specific training related to nutrition and are involved in the monthly baby weighings that take place in their villages. One of my principal responsibilities is in helping to plan and facilitate any trainings that we organize for the village health workers. Our goal is to conduct three continuing education trainings per year.

A third aspect is using village folklore groups, groups who traditionally are present whenever an important event takes place in the village, as in a death, a wedding or a religious ceremony. The folklore group is there to sing and dance and encourage people. We have given these folklore groups training in preparing and giving health messages so that they can then convey the health messages in their own setting. Being groups who already have a highly-respected role in their community, people will listen to what they have to say. Twice a year we organize a competition between the folklore groups from the different villages we work in and they are given specific health messages to prepare. Each group is given 10 minutes to present their message before a jury and during this time a local radio station records the message they are promoting so that the message can be diffused to a much larger audience later.

The fourth aspect relates to specific nutritional intervention. The principal goals of any nutritional surveillance (NS) program is to prevent severe malnutrition by early detection of the slowing or decrease of a child's growth rate and the taking of responsive measure in the case of growth failure. In this setting, we have found it imperative that the nutritional surveillance program, though having its own specific objectives, be associated with the other aspects of an integrated health program. We have found that a child's nutritional status is affected by so many different factors that nutritional surveillance on its own will not address all those factors. The NS activities (growth monitoring and nutritional rehabilitation) encourage an active participation on the part of the child's parents. And we try to capitalize on the interest expressed by mothers, in particular, in encouraging their participation in the other health related activities.

Weight for age is one of the preferred measures for nutritional surveillance programs that do monthly growth monitoring. In employing this indicator, we use the standard Gomez-type growth curve, which is printed on a separate card for each child. The curve can indicate the degree of malnutrition (severe <60 percent, moderate 61 to 75 percent, light 76 to 90 percent of the standard), but even more important is the direction of the growth curve in a consistently upward fashion.(1)

The nutritional surveillance (NS) program comprises two principal activities: growth monitoring and nutritional rehabilitation at home. The objectives of the growth monitoring are to detect growth failure, as well as cases of malnutrition, by the monthly weighing of children. Actions then are taken to correct poor nutritional status. These actions include health/nutrition education, nutritional rehabilitation of children at home and encouraging mothers. The objective of the nutritional rehabilitation is to recuperate children in their own homes by demonstrating and encouraging an appropriate diet for children using locally accessible food items. When necessary, appropriate medicines are also prescribed in conjunction with the nutritional rehabilitation therapy, as in cases of malaria, worm infestation and other minor illnesses.

The target group for the NS program is children ages zero to three years. Currently the organization is conducting its health activities in four villages.

Each participating village was asked to select three community health nutritionists (CHN) who then were given an initial one-week training, which I helped to plan and facilitate. The training focused on the basic food groups, in this setting food is divided into energy foods, building foods and protection foods. The CHN were given instruction on how to combine local foods to have complete protein as well how to assure a balanced diet. The training included how to conduct baby weighings, plotting weight on the growth charts, as well as interpreting the growth charts. Participants were taught how to identify different types of malnutrition and how to try and identify children at risk. The training also discussed ways to talk with mothers about their children's growth, particularly if the child experiences growth failure. Finally, the CHNs were given training in how to conduct cooking demonstrations and nutritional rehabilitation therapy. Specific protocols were developed for the NS program for the CHN to follow. The protocols were established using guidelines developed by Oxfam Québec, an international NGO working in Benin at the same time. After the initial theoretical training, we arranged an exchange visit for the CHNs to the nearest town where there is a Center for Nutritional Rehabilitation. This center, 50 miles from our locality, would be the referral center for severe cases of malnutrition which exceed the competencies of the CHNs. The CHNs were able to see different types and stages of malnutrition, as well as visit the step-down facility to learn more about nutritional rehabilitation after treatment of severe malnutrition. My principle role in the nutritional surveillance activities has been in developing the program/protocols, facilitating the training of the CHNs and ongoing support as a technical advisor to the supervisor of the program.

The following protocols were established for the different activities:

  • Growth Monitoring

    The baby weighing is conducted monthly on a fixed day each month.

    Steps to follow:
    1. Registration of the child (includes looking at the growth chart for vaccinations).
    2. Examination of the child for any illness.
    3. Weighing of the child.
    4. Notation of the weight on the growth chart.
    5. Discussion of the results with each mother individually (includes interpreting the curve and specific counsel as necessary).
    6. Asking mother to stay until the end of the weighing if her child needs nutritional rehabilitation.
    7. Conducting a health education session with all the mothers present.
  • Nutritional Rehabilitation (NR) in the Home
    A child is enrolled in the NR program if he/she has not gained weight for two consecutive weighings or if the child's weight is <60 percent weight/age.

    The frequency of the NR sessions is two times a month, the first one a week after the baby weighing, the second one a week before the next baby weighing if the weight/age >60 percent. If the weight/age is <60 percent, the NR sessions are held weekly with the mother.

    A child is referred to a Center for Nutritional Rehabilitation or a Pediatric Hospital if he/she does not gain weight during four sessions of NR, he/she has had a significant weight loss since the last weighing, if the weight/age falls into the <60 percent or if he/she has illnesses that the community health worker is not able to treat.

    A child is finished with the NR program when he/she has gained weight during three consecutive weighings.

    For children whose weight/age fall between the 60 percent and 100 percent who have not gained weight for two consecutive baby weighings:

    Steps to follow at the baby weighing
    1. Mothers are kept until the end of the weighing.
    2. The date of the NR is set together.
    3. A recipe is chosen for the cooking demonstration.
    4. Ingredients and materials necessary for the NR are divided amongst the mothers.
    Steps to follow during the NR
    1. Each child is weighed and its weight is noted on its growth chart.
    2. Hygiene is emphasized — particularly hand washing before food preparation and eating.
    3. Mothers help in the food preparation.
    4. A portion of the food prepared is distributed to each child and CHNs observe how well each child eats.
    5. CHNs discuss individually with mother to help her come up with ideas on what to prepare for the child during the week.
    6. Health education session is given focusing on some nutrition issue.
    7. Date for the next NR is set, recipe is chosen, ingredients divided up.
    8. Follow-up notebook is filled out.

    For children whose weight falls below 60 percent weight/age the date for the NR is decided with the mother before she leaves the weighing and the CHN goes to the individual's home. A recipe is decided upon to prepare depending on what the mother has available. Frequency of follow-up depends on the following:

    1. Daily — anorexia, edema present, complicating factors such as anemia or diarrhea.
    2. Twice weekly — appetite returns, complicating factors resolved/resolving.
    3. Weekly — weight gain.
    Steps to follow:
    1. At the first visit, the father should be present so that the CHN can discuss with him the importance of improving his child's nutritional status.
    2. Ask mother about child's health status and weigh the child. Record weight on the growth chart.
    3. Prepare the meal asking the mother to help as much as possible.
    4. Offer the food to the child and watch him/her eat.
    5. Discuss with the mother what problems she encounters and encourage the mother.
    6. Set the date for the next session and choose the recipe to prepare. Ask the father to help buy certain ingredients.
    7. Follow-up notebook is filled out.
    If it is necessary to refer the child to a Center for Nutritional Rehabilitation, when the child returns home the CHN continues to make home visits to that child for weekly weighings initially and to be followed closely by the CHN for three to nine months, depending on the severity of the malnutrition to prevent relapse. Once the child has experienced weight gain for three consecutive months, he/she can join the group rehabilitation.
The NS program is dependant on mothers participating in the monthly weighings. Attendance at baby weighings often depends on the time of the year, with attendance decreasing during cultivation season as mothers are more likely to be out in their fields. CHNs also depend on the support that the community health workers add to the team effort as they help in promoting, as well as carrying out, the baby weighing each month. A difficulty we encounter is that some of the CHNs are not literate which means they can weigh the babies but cannot plot the babies' growth on the chart. However, by using the growth charts developed by WHO which have different colors for the different percentiles as well as using the protocols developed for looking at weight that does not increase; even illiterate CHNs are able to interpret the curves once the weight is correctly plotted.

This type of nutritional surveillance program is fairly typical in regards to the protocols established for the growth monitoring and nutritional rehabilitation. As indicated above, we used guidelines already developed by Oxfam Québec. The protocols have worked well for the CHNs, however, one of the major problems encountered is that mothers are often not given feedback immediately on the curve. Most mothers want to weigh their babies, but often do not recognize that the purpose of the monthly weighing is to follow their child's growth. The connection between the activity of weighing and the plotting on the chart and how that impacts the child is not emphasized enough. This is why some of the other activities that our health program is carrying out in the same communities are important. As people are empowered to take responsibility for their own health issues/problems they then become more participative in the prevention of those health problems. The nutritional surveillance program cannot stand on its own apart from the other health and development activities, which help to complement the progress made in children's nutritional well-being.

This brings us back to the initial question of how baby weighings, village folklore groups and treated mosquito nets can be linked, each of them are vital ways to mobilize communities in rural Benin to improve the health and nutritional well-being of their children. This approach of integrated health care to improve nutritional status of children is a model that can be reproduced in other developing world settings. In countries where malnutrition is a common reality, the approach used to combat the malnutrition must be multi-faceted. We have found that using a variety of methods to target the same problem has been shown to have more success than just focusing on one particular activity.

References

  1. In: Guidelines for Training Community Health Workers in Nutrition. 2nd ed. World Health Organization; 1986:41 and 45.