Participation and the focus of nutrition education in a rural child growth monitoring program in Kenya

Abstract

Nutrition education is one of the strategies that addresses high levels of malnutrition in the world. Since independence in 1963. Kenya has instituted socio-economic, food security, nutrition and health policies to improve the nutrition and quality of life of it's people. In spite of these policies, one third of the Kenyan population is undernourished. This study was planned to establish how nutrition education is conducted in the Ministry of Health Thika District through a rural child growth monitoring program and to generate and reflect on women's participation in decision making in the program. Open-ended interviews were conducted with 21 women from the program, 4 community health workers and 16 nutrition stuff from Thika District. Focus groups, in-depth interviews and eight observations of the child growth monitoring sessions over nine months of fieldwork, provide data for this study. Participants were engaged actively in the entire research process. A participatory process was introduced by asking participants to contribute to the research agenda and make suggestions on what they wanted the program to address and how to do so. The process was developed through continuous dialogue and decision making. Reliability of data was ensured by conducting the research in the natural environment of the program and for an extended period of time. Triangulation of data and data collection methods and providing feedback to participants as a way to crosscheck the findings, validated data. Descriptive statistics analysed the data from the open-ended interviews whereas qualitative data were coded and analysed according to emerging themes and issues and synthesised to address the research questions. Results are presented by use of narrative to exemplify the concepts. The findings of this study show that nutrition education is important but what makes it work are the economic and food security concerns of the people. Findings reveal that although government nutrition staff and participants of the program identify a wide spectrum of causes and solutions to nutrition problems, implementation of nutrition education narrowly focuses on provision of nutrition information. This narrow focus is emphasised by government nutrition staff who focus more on curative than preventive nutrition. Nutrition staff have minimal training in primary health care and none in participatory approaches although they are expected to promote community participation. On the other hand, volunteer community health workers once trained, are left to plan and implement the program with minimal supervision, motivation or visible recognition. Findings show that there are no written nutrition education plans and that once nutrition programs are set in place, the programs are left to go on without reflection on their achievements. This study revealed that grassroot personnel have not accessed government policies on nutrition and community participation that they are supposed to implement and that there are limited resources set aside for nutrition within the Ministry of Health. Participation was promoted in the growth monitoring program by planning the research together with and progressing according to the expressed needs of participants. Women's participation in the program identified the realities of food accessibility and lack of money that influence nutrition. Empowerment was evidenced by diversifying the program to include an income activity and development of a curriculum based on the knowledge women wanted. Selection of a separate committee for the income activity, evidence of interdependent decision making and criticism of dependency are some of the outcomes of participation. Findings show that participation demands commitment and time from all actors. Participants are willing to make that commitment when they perceive individual benefits for them as a result of their participation. This research reveals that motivation and supervision are considered important for the community health workers. These findings show that there is potential for a nutrition program to respond to the realities of people such as appropriate nutrition knowledge, food accessibility and incomes by negotiating program priorities between the participants and nutrition facilitators through participation. A model of participation that I recommend in this study is one that has clear reasons for participation and incorporates an outsider’s perspectives to catalyse the process. This enables local participants to see possibilities which they have not seen due to familiarity with their circumstances. Participation strategy should be able to link with research in order to contribute to publicity and advocacy. Linkage with policy ensures that the process may be addressed practically by current government policies. Participants should engage in a continuous process of assessing the program goals, design, action and analysis. This research recommends nutrition education strategies that explore training in participatory approaches for facilitators. Training should extend to work with community health workers in the community to design and clarify monitoring and evaluation at the community level. Participants in the program should have a voice to decide how the program functions. For effectiveness, an analysis of the resources required to implement participatory approaches is essential. Research that focuses on non-participating mothers, that analyses measures and cost effectiveness of participation und studies that compare the process in different contexts in order to make positive decisions that can influence policy are recommended. The ultimate outcome of this research is that although government policies that promote nutrition and participation in health are in existence in Kenya, grassroot nutrition staff do not access these policies. Promotion of nutrition is worsened by the weak link between the growth monitoring program, the health sector and collaborating non-governmental organisations at the grassroot level on the one hand and between nutrition staff at different government levels. This research recommends that what is required to address the broad nature of nutrition problems are not only policies on nutrition and participation but ensuring the practice of these policies that will bring about a more realistic manner of solving complex nutrition problems. This thesis explains how policy on food security and nutrition at the government level is useless unless those at all relevant levels espccially grassroot government personnel and the community are actively engaged in planning and implementing such policies.