National Institute of Nutrition, Hyderabad

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Smooth implementation is assured when management specifies and adheres to operational guidelines and policies on reporting, job performance, use of equipment and vehicles, and standards for outputs such as progress reports, minutes of meetings, trip reports, and financial reports. Hyderabad, Telangana , India. P" , British Medical Journal , 1 Maternal health care services have to be contextualized within the broader comprehensive primary health care approach — only then will social determinants of maternal health be addressed. In order to identify countries that are notably better or worse off with regard to hunger and undernutrition than would be expected from their gross national income per capita, a regression analysis is made of the global hunger index on gross national income per capita. Nutrition improvement is a basic requisite to development. The ultimate goal of nutrition education is to produce nutritionally literate decision makers who are motivated, knowledgeable, skilled, and willing to choose proper nutrition alternatives Lewis,

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Location Maps - Country maps for your reports and presentations. Humanitarian Icons - Ready-to-use symbols and icons. Context evaluation during pre-planning The purpose of this type of evaluation is to identify behavioural change objectives and system goals, by exposing problems, unmet needs, and unused opportunities. Some evaluation methods for this stage are situational analysis, problem identification and needs assessment, focus group discussion, key informant panel interview, KAP study, and community survey.

Input evaluation during planning The purpose of this evaluation activity is to develop and analyse one or more alternative designs or operational strategies. Examples of evaluation methods for this stage are pre-testing of communication materials, piloting of a communication strategy or media mix, and feasibility study.

Process evaluation during implementation The purpose of this evaluation activity is to detect or predict defects in the procedure or strategy, including management, for possible modification, adjustment, refinement, improvement or deletion.

Process evaluation is a function of the adequacy of context and input evaluations. It provides feedback to implementors, identifies potential sources of failure, maintains a record of methods used in the programme, and monitors, controls, and documents intervention procedures. Process documentation techniques, monitoring procedures, and feedback gathering are some methods used in this type of evaluation.

Examples of evaluation methods for this stage are post-test, effects behavioural evaluation, and impact assessment. Programme communication strategies are made up of a mix of interpersonal communication channels, community media, and mass media. These are planned on the basis of the community members' resources radio and TV ownership, availability of electricity, free time , abilities literacy rate, education , and predispositions preference, motivation, willingness to participate.

Management skills are not the monopoly of programme implementors. Community-based implementors such as local leaders and health and nutrition personnel should also be trained in management skills. This is why management training should be part of the training plan of any programme.

As discussed above, management skills include planning, staffing, budgeting, controlling resources, guiding and co-ordinating people's activities, setting policies, guidelines and standards, and monitoring and evaluation.

A programme management plan lists management related activities for each stage of the intervention in an action plan. This is usually presented in a Gantt Chart that specifies what activities will take place, the dates and duration, expected output, and individual or team responsibilities.

A co-ordination scheme is also established, which includes schedules for regular management meetings, home visits, workshops, and reviews. The plan includes a programme for staff training.

The manager analyses where the existing skills are inadequate to perform specific jobs. She or he also identifies trainers, sets training dates and prepares evaluation tools to determine impact on job performance, and potential multiplier effects on others. The manager is also responsible for costing major activities according to the approved budget. A nutrition education intervention must project budget requirements for: Another important management responsibility is setting policies, guidelines, and output standards.

Smooth implementation is assured when management specifies and adheres to operational guidelines and policies on reporting, job performance, use of equipment and vehicles, and standards for outputs such as progress reports, minutes of meetings, trip reports, and financial reports. Developing policy initiatives - at the local level Any nutrition education intervention should be educational to all sectors at all levels. Through advocacy efforts, programme implementors can generate commitment and action from decision makers to provide the necessary resources to improve the nutritional and health status of vulnerable groups and the entire community.

Such commitment and action must begin from the national and local political leaders who have the power to enact policies and legislation that would commit resources to solve specific problems. It is a successful example of a partnership between the government and a local community for development.

At the national level, a high sense of political commitment was manifested in order to provide all the resources needed to accelerate programme implementation at the community level. In , former President Corazon C.

Aquino signed Proclamation No. The aim was to immunise infants against six deadly diseases, namely: After five years, the Philippines was cited as one of a few countries that had achieved the Universal Child Immunisation target. Upon assuming office in June , President Fidel V.

Ramos ensured its sustainability and reaffirmed the government's commitment to the Universal Child and Mother Immunisation Goal by issuing Proclamation No. The NID aims to provide a higher coverage of immunisation for Filipino children under five years of age and to eradicate polio in the Philippines by Other countries, notably Vietnam, Cambodia, China, and some Latin American countries, have expressed interest in adopting the Philippine experience.

School programmes Developing curriculum support It has been long recognised that undernourished children do not learn as well, are more susceptible to illness, and miss more days from school than well nourished children.

Schools provide the logical place to intervene with children in order to improve their health and nutritional status. Thus, school-based nutrition education has long been thought of as a cornerstone for health world-wide UNESCO, , and school children are considered a primary target audience for nutrition education and communication. Nutrition education in schools relies primarily on classroom curricula, school feeding programmes, or a combination of both approaches.

Classroom instruction in nutrition can be offered as a separate, stand-alone subject, or it can be integrated into other subject areas. Traditionally, nutrition is taught as a stand-alone subject or as a unit in the health or home economics curricula. This teaching method has emphasised certain topical issues within nutrition, including the three or four basic food groups or food guides, the concept of a balanced diet, and food sources for specific nutrients such as protein, iron or vitamin A.

Teaching techniques are generally lecture-based, but may also include role-playing activities and games. These curricula tend to be designed for knowledge change rather than behaviour change.

The booklet produced by Helen Keller International is a typical example of this approach. The purpose of food guides is to present a practical daily plan for food selection for use by the general public. Most have been developed by a "top down" approach in a variety of graphic forms food wheel, pyramid, target, plate, standard blocks, etc. Few of these graphics or guides have been evaluated for effectiveness. There are also a number of other issues raised about food guides.

These include the extent to which a guide should reflect the current food supply and food practices or whether it should represent an "ideal", the extent to which guides should sacrifice accuracy or completeness for the sake of simplicity, the extent to which guides should reflect a concern for sustainability of the food supply, and the extent to which a food guide should "stand alone" or be part of a more extensive education strategy.

Other issues frequently raised are, whether the food guides should address only the daily "foundation" diet or total intake, and whether a country should have several food guides for different ages and needs or only one to improve consistency. Overall, the intent of food guides is appropriate and desirable.

Their functionality and impact, however, will depend on their developmental process and fit with the target audiences' perceived needs and desires. Most food guides probably need revision in order to meet these considerations. However, a food guide that makes sense to the target audience is a valuable addition to the curriculum. One of the drawbacks of a "stand-alone" curricular approach is that nutrition will often not be taught if it is not required of teachers to do so.

In addition, when nutrition is taught in this fashion, it may become disconnected from everyday life and the other subject matter in the school curriculum.

In the s, an integrated curricular approach was begun as an alternative, and is becoming more commonplace on a world-wide basis. For example, Malaysia integrated nutrition instruction in the primary schools first six years of schooling into subjects such as Man and His Environment, Islamic Studies, Moral Education and Music Education, where food and its basic functions are taught as well as the concept of a balanced diet.

In Malaysia's secondary school curriculum, nutrition is incorporated into Physical and Health Education, where the relationship between nutrition, health, exercise, and concepts pertaining to overnutrition are taught Karim, India evaluated the integration of nutrition education in health education and environmental sanitation during the third-fifth year of primary schooling.

Results at the local school level indicated a significant change in height and weight indicators among children, and a marked decrease in observable deficiency symptoms, e. One of the drawbacks of an integrated approach is that nutrition may be taught in a fragmented, uncoordinated, and uncomprehensive fashion. The net result may be less meaningful learning, comprehension and behaviour change than might be accomplished if nutrition were taught as a separate subject.

Fragmentation can be avoided, however, if care is taken in curricula development to ensure that nutrition concepts are taught in a systematic, comprehensive approach where new knowledge is added to prior knowledge in a pre-planned sequence of steps and learning objectives.

This approach requires a co-ordinated effort across subjects, often involving teams of teachers and administrators. Studies to evaluate the impact of nutrition education in schools are relatively rare. However, there is a general sense of disappointment with the results of classroom-based education. Less than optimal results may be due to a number of different factors, including too little time given to nutrition instruction, use of a non-participatory classroom approach, lack of family involvement especially at the primary level, or lack of self-assessment of eating patterns at a secondary level.

School programmes that are not behaviourally-based and theory-driven are also less likely to be successful. Regardless of the quality of instruction, the learning will not be put into practice and behaviour change will not be accomplished unless the immediate environment supports such practices or changes. Creating supportive environments Offering food to school children is the most important immediate environmental support.

School feeding programmes may be offered to school children as a stand-alone programme or they may be integrated with classroom instruction on nutrition.

Supplementary feeding programmes are probably the most commonplace; the provision of meals, most often lunch and more rarely breakfast, is widespread in some countries. The purpose of meal programmes is to accomplish the above three objectives as well as develop the eating habits and skills needed for life-long, positive, healthful eating practices. There are two principal problems with feeding supplements, such as "Incaparina" to children: Moreover, even if the supplement is available on the market-place, it will not become a part of the regular diet because it is "foreign" to the everyday food habits of the local people.

Meal-feeding programmes as opposed to single food supplements may be partially or completely subsidised by the government or local community. Meals are preferable from a learning perspective, because the children are eating foods they can recognise and obtain in their own homes and communities.

The feeding situation can then be an extension of the classroom, in essence, a learning laboratory, where proper eating habits can be demonstrated and reinforced in practice. Another important way to build a supportive environment for the school curriculum in nutrition is to involve the parents.

Children can take their learning home and share it with other household members, but it is important to engage these other family members in the learning experience as much as possible.

Dialogue between the parents and the teachers, as well as their children, should be encouraged. Parents can also become involved in food production, especially in school gardens, as well as in the planning for, and preparation of school meals for children.

Creating links between the school and the community School programmes will have greater impact and be sustained longer if they are tied to community activities, programmes, and other private and non-governmental organisations. School gardens provide an excellent opportunity for community involvement, as access to water, land, material input plants, seeds, tools, etc. Thailand exemplified how such community linkages can be developed with a school-based nutrition education programme.

To encourage the use of the ivy gourd plant a rich source of vitamin A and school market gardens which raised food for the children to eat as well as for school income , they solicited help from the extension service and experienced home gardeners to start local projects. They involved key officials including school administrators, agricultural officers and the district committee to judge ivy growing and garden competitions between schools and districts.

Mobile dramas also travelled to schools in all participating districts and provided entertainment with education to reinforce the communication message. They also involved Buddhist monks who played a promotional and educational role in the project. Finally, the message was also incorporated into local festivals and holidays, including New Year's cards with an ivy gourd greeting Smitasiri, et al. Together, these various activities involved a large number of community members and opinion leaders, strengthening both the school programme and the community in the process.

Another logical linkage can be made between schools and health monitoring programmes. Children's growth and immunisation can be readily monitored in schools. Partnerships between health workers and agencies can provide access to children and needed support to all participants. Other potentials include involvement in teacher training and medical doctor training programmes, where the schools invite students into their classrooms to learn as well as teach.

Libraries can also provide important links between the school and the larger community. Volunteers can be trained in, and work with schools to broadcast programmes, motivate audiences, and coordinate nutrition and other health-related messages to children and the broader community.

Implementing special or system wide promotions Linkages that occur at the local level can be extended to district, regional or system-wide programmes as well, especially in the area of nutrition surveillance and child growth monitoring programmes, other Ministry of Health programmes, child care centres, women's development programmes, home economics training for women's groups, or any programme that promotes home food production or home consumption.

In fact, linkages should be systematically promoted at all levels, from local community administrators and extension workers to district committees, provincial government officials, and high level government officials.

Such linkages should be used to frame and institute policy changes at each of these levels to assure that nutrition education and communication programmes, especially highly successful efforts, are sustained over time. Facilitating policy development There are many areas where government policy has an impact on nutritional status, food security, and nutrition education at national, regional, and local levels.

Some of these areas include agriculture, including animal husbandry, crop production, fisheries, and forestry; health; environmental policy; women's development; population; urbanisation; international economics; and trade agreements policy. Education, advertising and consumer policies are discussed less often in terms of their interaction with nutrition, but are probably as important. Policy is inalienably a matter of politics. At the same time, the school system is charged with a custodial responsibility for children.

It therefore seems that schools should also be involved in policy development to protect and sustain children's development. Food and nutrition policies are integral to that interest. It should be recognised that the strategies for poverty alleviation have changed significantly in the past decade or so. It is now accepted by experts in behaviour change and nutrition communication that people's participation is fundamental for any sustainable improvement in the welfare of the poor.

Participation means local people organising to shape the terms of the social, political, and economic processes that affect them. In other words, the people create organised demands upon governments and agencies as well as private and commercial bodies to meet their needs using indigenous expertise and technologies.

Participation also implies capacity building and the strengthening of local institutions Haralambous, Naturally, agenda-setting and policy formation play an important role in this effort. Food and nutrition policy may be among the most important and most obvious to people at the local level and local schools may be a natural focal point for such organization and participation.

However, in some countries, the style of government does not permit the type of citizen participation discussed here. Mass media and social communication Using mass media to increase awareness The mass media were not used widely in nutrition communication until the s.

Before then, nutrition communication relied almost entirely on face-to-face instruction in health clinics Lediard, Many early efforts using mass media in nutrition communication yielded disappointing results. This was often because the quality of many past programmes was inferior due to a lack of training or preparation, inadequate resources, or because it was used for inappropriate purposes. Media cannot, for example, cure poverty Lediard, But, neither can media be relied upon to change behavioural patterns by itself.

Media-based nutrition education projects are now legion. Some have produced changes in behavioural practices, such as campaigns for oral rehydration salts in Egypt, the Honduras, Gambia, and Swaziland, but changes in nutritional status are rare Hornik, It is now known that the best use of media, particularly for stand-alone media campaigns, is to build public awareness about a new issue, problem, or resolution. One of the most powerful aspects of the media is its ability to set the public's agenda.

That is, media shapes what people view as important in the world, and it identifies and defines concerns, issues and problems. This is another form of building awareness. Other forms of two-way communication may be needed to persuade the public to adopt a different behavioural approach, for example, to infant feeding. Developing single message strategies Today, the strategies used to develop mass media communications in nutrition are taken from social marketing literature.

Several sources provide good descriptions of how to plan persuasive messages such as Andrian , Rasmuson et al. Generally, four questions are posed at the beginning stages. Who is the target audience or consumer for the communication? What is the product? What is the message? What are the channels of communication? Market research is used to answer these questions and the media messages and campaign are designed accordingly.

There are four elements involved in designing an effective single message Hornik, Some of the key points include creating messages that are clear, concise, credible, and easy to remember, all from the target audience's perspective. Above all, the messages need to appeal to the target audience's perceived need for information. The most effective messages include a precise behaviour change recommendation, use a memorable slogan or theme, and are presented by a credible source in a positive, uplifting style that is not offensive to any member of the target audience US Department of Health and Human Services, Finally, a focus on motivation, not just information, is needed.

Of course, all media should be thoroughly pre-tested with members of the target audience, as described earlier in this chapter. A variety of media may be used to communicate a single message, including bulletin boards, booklets, pamphlets, posters, radio and television messages, newspapers, community bill boards, and promotional give-aways to name just a few. Promotional give-aways are products that carry slogans or short messages including calendars, T-shirts, caps, vests, ball point pens and pencils, notepads, pins, and bags.

Effective promotionals are items that are regularly used by the recipients, routinely reminding them and those with them, of the message. Print messages should specifically avoid jargon and technical terms, abbreviations and acronyms, small type, and long words, sentences, and paragraphs. Text should be written in an active voice and use organising headers, bold print and "boxes" to highlight important points.

Graphics should be immediately identifiable to the target audience, relevant to the subject matter, and kept as simple, but up-to-date, as possible. Short second public service announcements, spots, or plugs on radio or television should also recommend a specific action, make a positive not a negative or fearful appeal to the audience in simple language with a memorable theme, music, visual, or character to deliver the message.

Even the best designed message needs to be repeated many times if it is to build general public awareness or accomplish any other outcomes. Any form of mass media has a limited effect when it is delivered only once or for a short period of time.

The audience needs frequent exposure to the message, even if it is familiar, but especially when it is new or novel to them.

The greater the reach, frequency, and duration of a mass media message, the greater the number of people who will be reached and the greater the likelihood that change will occur. Using mass media as the centre piece for a multi-channel campaign A fundamental dilemma in nutrition communication is that interpersonal communication may be more effective at promoting behaviour change, but its reach, and ultimate impact, is limited by the size of the audience Gillespie, The mass media reach far more people in far less time.

However, single messages are unlikely to change strongly held attitudes or behaviours. Mass media campaigns are defined as planned, large scale, multimedia efforts to communicate a single concept idea to a target population s in a prescribed amount of time Wallack, Generally, mass media campaigns: Mass media campaigns may speed the rate of behaviour change, but rarely initiate it.

They can also play a role in facilitating one or more steps in the behaviour change process. They work best, however, in synchrony with other intervention components. Several family members should be targeted by messages in order to facilitate a supportive home environment for the desired behavioural changes. Different media have different effects on different people. Heavy users of the media react differently to media messages than light users. Heavy users those who listen to or watch media for four or more hours a day tend to rely on the media for information about their community and the larger society.

Some people are interested in certain topics e. A multi-channel nutrition communication campaign that introduces new messages with star personalities drawn from these interest areas can take advantage of this.

For example, in Brazil, the captain of Brazil's World Cup football team, a well-known male musical entertainer, and three well-known television actresses were used in second television commercials to support breast-feeding ad Kahn, Alternatively, nutrition messages can be incorporated into pre-existing heavily watched media e.

Other communication channels can then be used to reinforce these messages and stimulate behaviour change, especially at the local level. In Thailand, for example, Buddhist monks were very influential within communities, but mass media was useful for initiating community campaigns for change Smitasiri et al. Facilitating pro-active use of mass media Several factors contribute to the potency of any media campaign.

Media effects are limited when interpersonal relations and prior beliefs conflict with the message. Media effects can be powerful when they coincide with interpersonal relations. When the public hears a message that makes them uncomfortable, they may selectively pay no attention to it, misinterpret it, fall back on their own rationalisations, disbelieve it, or attack the source's credibility to reduce their discomfort with the message.

People will be less resistant to a new message if it is introduced by opinion leaders in the local community or general society. Only sound market research prior to message development can anticipate and accommodate the conflicts the target audience might have with the messages.

Because multi-channel media campaigns are by definition complex, partnerships are highly recommended to facilitate their development, implementation, and evaluation. Nutritionists need to form partnerships with social scientists and communication or media specialists. In addition, multi-sectoral partnerships are also routinely required. They may involve private industry, non-governmental agencies, government agencies, religious leaders, and grassroots participation at the local level.

Policy-makers should, in particular, be thought of as a target audience and be included in communication design. Desired changes are most likely to occur within a supportive environment for change. Only broadly based partnerships can create that context.

Authoritarian-type governments may provide a better context for a co-ordinated, multi-sectoral communication programme than more democratic-type governments where communication industries are independent, commercially oriented, and owned by many different people. In recent years, innovative mass communication approaches have been effectively integrated into mass media campaigns to create widespread attention, interest, motivation, and recall for particular nutrition, health and population messages.

One approach has been called "enter-educate. The enter-educate productions are aired over radio and television, featured in magazines and newspapers, and even through live shows in shopping malls. A similar approach, "info-tainment", combines the objectives of informing while entertaining the public via comedy and drama programmes over radio, television, and comics.

Info-tainment has also been used by community development workers to reinforce their interpersonal approaches. Using mobile audio-visual vans, they present certain video documentaries on agricultural technology, alternating with a full length movie of the audience's choice.

The advertising industry has also introduced "values advertising" and "development plugs" to inject messages with developmental value in their advertisements.

Enter-educate, info-tainment and developmental plugs are unlikely to work effectively unless they are created by a team of nutrition educators and mass media specialists. Inter-sectoral partnerships can accomplish two objectives. They may increase the broadcast of more positive nutrition messages, and thereby change the communication mix.

They may also decrease the broadcast of negative messages as partners recognise the number and kind of negative messages already broadcast in the mass media. They may then voluntarily withdraw certain negative messages or work to change some of those messages. Training media journalists There is a shortage of media specialists in developing countries, especially those associated with ministries of health or education.

In some cases, a ministry of agriculture may have access to communication expertise. Health ministries and education ministries should be encouraged to create positions for media specialists and include them in the earliest stages of programme development. They should also try to work inter-sectorally to support training for media specialists and create an infrastructure to support their activity. Media journalists tend to be trained as generalists.

Few have the expertise to correctly communicate health and nutrition information to the public. Therefore, multiple training programmes are necessary to promote effective nutrition communication campaigns: This will require training on how to incorporate innovative technologies into programme planning as well as the use of traditional communication modalities.

This will require additional training in the behavioural and social sciences. Training of media journalists and communication experts can be costly in itself, but the Union of National Radio and Television Organisations of Africa URTNA has developed an effective model that may be appropriate in many parts of the world.

URTNA has 48 member countries that team together to sponsor training sessions and an exchange of programmes and teachers across international boundaries. In a three year period, they have graduated technicians from their training programmes and have exchanged over 2, radio and television programmes for broadcast.

Regular meetings held every two weeks between communicators from national broadcast organisations and experts in family planning and maternal and child health are considered a key element in this programme's success. The meetings foster open communication between these two fields and stimulate teams in different countries to produce higher quality programmes Demena, Effective training programmes are needed, but are not sufficient, for the creation of successful communication programmes.

Successful programmes require not only the incorporation of communication technologies, but also institutional infrastructure and a supportive policy and philosophy to sustain such communication efforts across a region or country. Work-site programmes Establishing the benefits to employers and employees Healthy work-site programmes became popular in the s and nutrition education is a common component of these interventions. They have been reported in telephone companies, police departments, Fortune companies, and small local businesses.

Healthy work-site programmes emphasise disease prevention or health promotion. For example, it is less costly to prevent hypertension via education than it is to treat it via medication.

Some of these chronic diseases are related to food habits and choices. Since these food-related behaviours are not fixed, communication and other interventions designed to modify these behaviours may decrease the risk associated with these diseases, and presumably increase worker productivity, decrease company costs and improve the company's public image.

Work-site nutrition education programmes are appealing for many reasons. From the employer's perspective, they may increase workers' productivity, decrease absenteeism and turnover, improve recruitment of personnel, and generally improve company morale.

From the health-care provider's perspective, work-site nutrition education programmes provide access to workers who may not otherwise be served by the health-care community, enable cost-effective and efficient screening opportunities, provide a forum where nutrition information can be efficiently disseminated, and an environment where behaviour can be monitored and social or peer influences can be used to reinforce behaviours. From the employees' perspective, work-site nutrition education programmes may be attractive because they are convenient, meaningful, credible, and ongoing.

If successful, they can decrease health-care costs and improve the happiness, health, and quality of life for individual workers and their families Johnson, et al. Screening and needs assessment Groups of participants can be screened, counselled, and followed in a time-efficient and cost-efficient way Johnson, et al.

These screening data should be used to design appropriate interventions and communication campaigns for the company as a whole and possibly, for individuals within the company. Baseline data should be collected about the individual workers, their home and community environment, and their employers and work environment before a work-site programme is designed and implemented. Assessment of the work-site should include management style e. Some of these variables are important in order to determine how to introduce and sustain a work-site programme in the most acceptable manner to both workers and management.

Catering programmes, nutritional improvements of food services, and point of sale promotions Many family members, including school children, spend a major part of their day in the workplace or in school. This means that they must eat at least one meal and about two snacks outside the home. This has led to the growth of the food service industry, particularly street-food vending in developing countries.

The street-food trade is a source of livelihood for many people among the low income group, and is a source of cheap food for low to middle income people. Recognising the need to protect consumers against unhygienic and low quality street-foods, FAO supported pilot projects on the improvement of street-food safety and quality in several developing countries in Asia and Latin America.

An education and communication component was built into the projects, addressing consumers on one hand, and educating street-food vendors on the other, on topics like basic nutrition, food preparation, hygiene, and sanitation. Seminars and training in the workplace had been successfully carried out for both groups, reinforced by well researched and properly designed print and audio-visual media such as posters, flyers, brochures, flipcharts, and training modules.

In these programmes, employers offer their workers choices of nutrient-dense foods e. These foods may or may not be offered along with other less desirable choices. Often nutrient information in the form of labels or posters accompanies the foods in the cafeteria environment. Entrepreneurial lunch wagons can offer nourishing food to field work-sites that are remote from feeding facilities.

Facilities for washing before eating are also important. Some companies subsidise in-plant food services partially or totally, making them nutritious, attractive and convenient to employees. Some employers have also added nutrition awareness games and incentive raffles e. Research studies have generally produced positive trends in dietary intake but often only outcomes over a short period of time are evaluated.

Most of the catering programmes reported in the literature have concentrated on heart health issues, but other issues that could be considered include use of fluoridated water, iodised salt, adequate protein, clean water, and iron. Nutrition education as a stand-alone work-site programme Nutrition education that is not connected to any other form of health education at the work-site can be described as a stand-alone programme.

Carefully targeted materials and classes can have a significant impact on nutritional status, not only for employees, but for their family members as well. The success of stand-alone programmes depends on how supportive the company environment is of the recommendations. Stand-alone programmes are unlikely to work if they include only information dissemination. Generally, work-site nutrition education programmes require supportive environments such as cafeteria or food catering programmes as described above.

It is essential that employees have access to appropriate food choices. Release time from work and employer commitment to the programme are also viewed as important to success. Employees respond best to healthy work-site programmes that are simple, practical, and relevant and that allow them to participate actively in the learning activity during work time. Eating pattern messages which include specific foods or brand names and behaviourally oriented programmes are better accepted than messages containing medical jargon and lengthy background explanations McCarthy et al.

Nutrition education as part of an integrated health programme Nutrition education can also be integrated into a more comprehensive health programme at the work-site that might include, for example, smoking cessation programmes, drug and alcohol education, stress management, child-care education, and breast-feeding support.

It may be combined with an exercise or fitness programme or more often, a weight control programme. Work-site nutrition education programmes can also be integrated into the broader community. Community-based wellness councils, for example, team non-profit health organisations with small businesses and vendors within and across communities.

The councils do not compete. Rather, they bring together local providers with common interests to share ideas and resources to offer healthy work-site programmes that they cannot afford themselves. Often they share newsletters and strategies with one another. Wellness councils may publish "how to" guides, hold delegate meetings and annual meetings, or share the cost of bringing in an outside consultant or nationally known speaker Kizer, Ideally, community-based wellness councils match local expertise to local needs and help small businesses lever their limited resources for maximal impact.

Together, they may also affect an entire community to create a more healthful and supportive environment for its citizens. Number of work-site programmes Given the advantages of, and opportunities for work-site nutrition education programmes, it is interesting to note their small number, especially in developing countries. This may, in part, be due to the lack of an infrastructure for these programmes, but there are several other considerations as well.

Work-site programmes have been criticised because many tend to serve only healthy workers or well-paid, professional employees, neglecting those in greatest need. They may increase personnel costs to the company, at least initially, and they may subject a company to liability concerns Ostby, Relatively little attention has been given to developing methods for institutional commitment, and this seems critical to programme success.

Conclusions This review has led us to draw four broad conclusions: These conclusions are further developed below. Nutrition education and communication should be thought of as an integral part of a country's development plan. The nutritional status of a country's population is an important indicator of national development. The causes of poor food habits are complex. The simple provision of food or supplements does little to resolve long-term nutritional problems.

Nutrition education and communication can have a significant impact on a population when there is political stability, social coherence, and a favourable economic climate. Nutrition education and communication provide people with the knowledge, know-how, motivation, and reinforcement to empower them to effectively address their own long-term food and nutrition problems. Changing food and nutrition behaviours to improve nutritional status at a country level is a long process comprising many steps in many sectors at many levels.

Recognition of this fact may call for a reorientation in thinking about nutrition programmes. A long-term, holistic view of nutrition education and communication is needed, with nutrition education seen as a central component, not merely as a tool to use on occasion.

This holistic view may also require a re-examination of the philosophy, processes, strategies, messages, and methodologies used in nutrition interventions. It involves many actors including policy makers, planners at community and national levels, educators and communicators, NGOs and other providers of resources, field support staff and service delivery personnel, community leaders, and finally, mothers, children, and other family members.

Nutrition education and communication programmes need to be comprehensive and coordinated for effectiveness. Mass media messages, although cosmetically perfect, will be ineffective as stand-alone interventions. Rather, several communication channels should be used. At least some of these channels should involve two-way communication.

These activities require an administrative infrastructure, including organisational structure and managerial mechanisms to support a coordinated effort. Usually these efforts will have to be multi-sectoral in nature. Commitment to the programme effort at all levels is needed for sustained programmes. Nutrition education and communication programmes need to be participatory in order to effective. Interventions should be problem-solving, decision-making and action-oriented.

Ideally, the target audience should feel a sense of ownership of the programmes. Therefore regular interpersonal communication is needed with at least some representatives in all development, implementation, and evaluation procedures. Recommendations The conclusions lead to four specific recommendations:

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