Nutrition Weeks: the second cycle of 2013 begins!

Hello World Relief community! We are D and Lo, the current World Relief interns who will be updating you on the second cycle of Nutrition Weeks (NW) in the Kaduha hospital catchment region of Nyamagabe.

We had our first introduction to NW in the Musange sector (Jenda health centre) in the Gituntu village – a roller coaster 2.5 hr drive from our home/office in Nyamagabe. This region is among the first to start its second round of NW. The Community Health Workers (CHWs) who lead the NW sessions participated in a training session in May, 2013 to refresh their curriculum understanding and get pumped for the sessions.

The training in May was for the first three sectors only (including Musange) and they carried out their NW sessions in June. The remaining sectors throughout Kaduha are grouped into sections of nearby sectors which will have cascaded training and roll-out of NW from July to September.

The sessions we attended were full of rich discussion and observation so we’ll be sending you stories in a few segments. Stay tuned and thanks for reading!

Enjoying thicker porridge at NW

Mother's views on nutrition at the end of their first Nutrition Week.

On the final day of Nutrition Week in the Kibumbwe sector three mothers explained: What they learned; what they are going to do in their homes; and their thoughts about Nutrition Week.

Nutrition Week Day 1: Kibumbwe Sector

Nutrition Week began Monday February 18, 2013 for the Kibumbwe Sector Nutrition Week. Participation to the first day was much higher than anticipated despite a schedule change.  There was an expected visit by the President of Rwanda to the district on Monday March 18 therefore the week was scheduled to begin Tuesday February 19 and finish Saturday February 23. His Excellency was forced to change the visit to Tuesday causing the Nutrition Week to being on Monday instead.  The community health workers and in charge of community health workers worried that due to the lack of accessible communication many people would be unable to make the first day of Nutrition Week.

Since there was low anticipated number of participants to the first day of Nutrition Week the decision was made to only utilize one household/sites for meeting.  The day was to begin at 2:00pm and last until 6:00pm. With the last minute change participants were unable to arrive until 3:30pm, which only meant slight alterations to the schedule of events. At 3:30 to the surprise of the community health workers, nearly 40 mothers and several other community members arrived to the site. The in charge of community health workers contributed the high participation to the villagers’ large interest and encouragement to participate in the event.

The mothers gathered together as interested peaked about the concept of a nutrition week in their community. They were eager to see what their village nutrition community had to teach them about nutrition. 

The day began with an introduction of nutrition week to the community by the community health workers (three CHWs in attendance to the event).  After explaining the meaning of a nutrition week the CHW asked the mothers what they believed nutrition meant.  The response was “many foods with many nutrients.”  The CHW responded to the answer by asking what were nutrient rich foods. The mothers were able to respond there were types of foods such as constructive foods and protective foods; however the were unsure what foods were classified into these categories.  To explain the classification off foods the CHW asked what foods were available in the community. As the mothers responded the CHW explained the health value of each food. Through this the CHW was able to divulge into the topic of the day: Thicker Porridge.

The community health workers work to organize the  mothers,  introduce Nutrition Week, and teach the objective of the day. . 

To begin the discussion of thicker porridge the CHW asked if the mothers currently fed their children porridge. One mother explained she would feed her child porridge but her baby is only five months old. Another mother explained she feeds her child porridge in the morning and at night.  The CHW proceeded to explain although is it good she if feeding her child porridge her and the other mothers need to consider feeding their children more often.

Children have small stomachs and must eat more often than just morning and at night. If they have full stomachs they will sleep more soundly and for longer periods of time.  Through healthy eating habits a child will grow stronger, smarter, and be healthier.

The conversation then began to focus on thicker porridge versus thin porridge. The CHW took time to acknowledge that culturally Rwanda has made thin porridge. He asked why the community made thin porridge. Many mother responded that this was because it was how they were taught to make it; furthermore, it was the porridge they ate as a child. The mother discussed the flours available in the village: Maze, Soy, and Sorghum. It was then explained that ideally the mother should combined these three flours with palm oil to make a thicker nutrient rich porridge for their children; however if they were only able to purchase one flour they must at minimum remember to keep the porridge thick. The mothers were surprised to discover that palm oil could be added to the porridge. They did not know this was an option to help make a better porridge.  Through this new knowledge the cooking demonstration for the mothers began.  The CHW asked mothers to help with the participation including: Building the fire, washing the pans, and mixing the flours.

*It should be noted that the CHW did use more flour than told even after ICSP staff corrected the behavior. This will be monitored for future cooking demonstrations.

To prepare Thicker Porridge for ten children:

1. In a large bowl mix:
2. 10 Spoons of Maze Flour
3. 10 Spoons of Sorghum Flour
4. 4 Spoons of Soy Flour
5. Cold Water (The substance should be a sticky thick substance.)
6. Boil 10 cups of water
7. Pour mixture into a pan of boiling water. 
8. Mix 2 spoons of Palm Oil
9. Stir until Porridge is boiling
10. Remove from heat and stir until cooled to room temperature. (It must not be too hot or too cold for the child) 

During the demonstration the CHW and ICSP staff explained the importance of washing hands before and after preparing food as well as washing the children’s’ hands before they eat their meals.  Each child is given a serving of porridge to help the mothers practice feeding the children. “This is not just about learning how to make the food but also how to feed your children. You must make sure the child eats the porridge. If you give the child the porridge and walk away someone else may eat it.” The CHW explained as the mothers began feeding their children.

This young girl devoured the thicker porridge to her mothers surprise.

This mother did not struggle getting her son to receive the thicker porridge. 

All the children seemed happy with the new type of food. The mothers learned the children will accept the food and that it is a simple change in preparation. 

Upon the completion of feeding the mothers were each given a feed card that demonstrates what foods a child should be eating at the different ages as well as the frequency the child should eat. They also cleaned the children, the pans, and discussed the Nutrition Week day that would be on Wednesday. This completed the first day of Nutrition Week in this sector.

Each mother received diagram card that taught the frequency of meals for each age of the child; furthermore, the card taught the types of foods that should be included in the meals. This will work as a reminder in their home of the lessons learned during nutrition week.  

Standing with pride and their educational home tool. 

Testimony of Nutrition Week Day 1:

An elder gentleman decided to attend the first day of nutrition week. He felt that he has an obligation to his community to learn this information to ensure the children grow up strong and healthy. He wants his community to prosper.

Upon the completion of his interview he proceeded to say:

“Programs like this are better than just giving me something. You are teaching me something. I then can go and teach others and spread the information. It helps us to know how to do things rather than just being given things. Thank you very much for this gift”

Nutrition Week Day 1 Curriculum

Day 1: The Importance of eating Thicker Porridge

“Babies need to eat porridge not drink porridge”

The Nutrition Week is a time for mothers to come and learn how to better feed themselves and their children, which will help the children to be healthier, stronger, and smarter. 

Children’s stomachs are only the size of their fist, and they need to eat more often than adults. Thin porridge that is mostly water will only fill the child up for a short time, and does not provide enough good nutrition. Eating thicker porridge helps to fill their stomachs for a longer period of time. If they have full stomachs they will sleep better and longer. It is important to have a separate bowl for the child’s food to help track the amount they have eaten.

Objectives for Day 1:

1. Prepare and to feed thicker porridge to children starting at six months of age.
2. To utilized a mixture of flours for thicker porridge
3. To wash regularly their hands at the four recommended key times
4. To take an extra rest and an extra meal for pregnant mothers.
5. To feed more frequent meals and snacks:

~6 months start 2 meals and 1-2 snacks in addition to continued breastfeeding. 

~6-9 months gradually increase 2-3 meals and1-2 snacks. 

~9-24 months: 3-4 meals, 1-2 snacks. 

It is important to stress the importance of continued breastfeeding because it is the child’s main source of energy and nutrients. There should be a separate cup for the child’s food.

Methods for Teaching:

• Ask questions (direct and brainstorming)
• Small Group discussions or discussions while cooking and feedings
• Group Work (cooking practiced by mothers, mother-in-laws, infant stimulations, hygiene etc)

Thicker Porridge Preparation.

1. Boil clean water
2. Mix flours in bowl (Maze, Soy, Sourgum).
3. Mix flours with cold water
4.  Put the thick mixture into the boiled water
5. Add 2 spoons of palm oil
6. Continue mix until well boiled
7. Let cool and serve to children. 

Village Nutrition Committee Training

Pilot Nutrition Week

In December the pilot Nutrition Week was implemented. These are the photos from the trainings and Nutrition Week. This was the start to the implementation of a key component to the ICSP research study. Throughout January and February the nutrition weeks for the other 282 villages were implemented.

Health Eating Celebration Song

A song about the importance of eating a balanced meal. Mugano Sector sang this during VNC training.

Pre-Nutrition Week Training: Village Nutrition Committee

TRAINING IN THE WEEKS LEADING UP TO NUTRITION WEEKS

Pre-Nutrition Week Training with the following Village Nutrition Committee Leaders: Head of Village, Social and Economic Development at the village level, and community health workers.

The VNC are the primary educators during Nutrition Week. They are taught the daily activities; primary objectives; and simulations of the training sessions.

Each committee member is given the opportunity to teach a lesson during the training and then given feedback to ensure they are effectively teaching the lessons. Furthermore, they are given a pre-test before the training and a post-test upon completion of the training to ensure they are retaining the material.

The training is a two-day training divided by cells. Each person who chooses to attend the training receives a per diem of 3,000 Rwandan Francs per day to assist with travel, lodging, transportation, and food costs.

The training is lead by Social Affairs at the Sector level, Social and Economic Development at the Cell level, and the in charge of community health workers. Each trainer receives a 5,000 Rwandan Francs per day as per diem for training the VNC members.

The current training consisted of two sectors.

Kaduha Sector 

Nyabisindu Cell

Nusenyi Cell

Kavvmu Cell 

Nurambi Cell

Nyamiyage Cell 

Mugano Sector 

Suti Cell

Sovu Cell

Yonde Cell

Ruhinga Cell

Gitwa Cell

Gitondorero Cell

Nutrition Week 7 primary objectives:

1.            The importance of cooking porridge thicker, and feeding young children thicker (more calorie-dense) porridge.

2.            The need to eat high-fat content and animal-source foods (eggs, organ meats, etc.). 

3.            To increase the number of meals per day. 

4.            Increase variety of foods given at each meal and each day. 

5.            Infants must be mentally stimulated for development. 

6.            Hand washing before meals for mothers and children is important to reduce diarrhea.

7.    Pregnant women need an extra meal and rest

Flip Chart of the training teachings. 

Training Manual for VNC 

VNC Members of Kaduha Sector Kaduha Sector Nyabisindu Cell

ICSP Staff assisting with the training of  Kaduha Sector Nyabisundu Cell

VNC Members of Kaduha Sector Nyabisindu Cell

ICSP Staff reviewing the importance of thicker porridge with Mugano Sector.

During the cooking demonstrations of Nutrition Week two primary items are prepared. On the right is the thicker porridge which consists of three types of flour: Sourgum, Maze, and Soy. To prepare for ten children there would be 10 spoons of Sourgum and Maze Flour and 4 spoons of Soy Flour.  These three flours are then mixed with water to give the porridge consistency. On the left is "Inombe" which is a recommended dish for children. The dish consists of anchovies, amarante (spinach like vegetables), carrots, potatoes, palm oil, soy flour, and tomatoes.

During Nutrition Week ICSP provides some items including Palm Oil and the cooking pans. The village is the expected to include some times such as the vegetables to help take ownership of the week.  Together they work to show the importance of nutritional meals. 

Preparing for the post test examination during training for Mugano Sector. This test helps to ensure the VNCs understand the material they have learned over the two-day training. 

Mugano Sector during the post test exam. The participants must raise a fist for a no response and two fingers for a yes response. There are 15 yes/no questions orally asked to the participants. These are the same questions asked during the pre-test. There is then a comparative analysis performed on the correct responses during the pre-test and post-test.  

Mugano sector learning about the food demonstration lessons. 

Social Affairs at the Sector level welcoming  Kaduha Sector Nyabisindu Cell to the VNC training 

Overview of Implementing Nutrition Week Procedures

Overview: 

WR has been implementing PD/Hearth in Rwanda as part of USAID- funded Child Survival Program since 2006, and Care Groups since 2001. The Innovation CSP in Nyamagabe District is combining these two methods in a further evolution of PD/Hearth called "Nutrition Weeks."  

The purpose of Nutrition Weeks is broader than rehabilitation of under-nourished children; instead all mothers of children in their first 1,000 days of life are invited to participate in the hands-on education program aimed at preventing under-nutrition. The aim is to improve the nutritional status of pregnant and lactating women, as well as children between 0-23 months old through enhanced Infant and Young Child Feeding (IYCF) practice. 

 Community Health Workers are trained and given a step-by-step guide to implementing Nutrition Weeks. Per MOH suggestion, these weeks will be held three times a year.  The Operations Research component of the Innovation CSP aims to identify the most feasible way to reduce and prevent under-nutrition in the first 1000 days of life of children in Nyamagabe District, Rwanda through formative research, and then to test the innovated intervention, namely, “Nutrition Weeks” to evaluate if the intervention is more effective than the standard CBNP (Community-based Nutrition Program), which are cooking demonstrations. 

The objective of this program is for mothers to learn about nutritious foods that they may not be giving children, optimal feeding practices and other health behaviors to prevent under-nutrition. The sessions last for 2 hours daily of hands-on practice for one week, with follow-up by specially-trained volunteers.

Reasoning for Innovation: 

The Standard Community Based Nutrition Program used in Rwanda now teaches mothers what to feed their children with cooking demonstrations. Nutrition Weeks adds a hands-on practice and discussion, also involving mothers in law and fathers on certain days.  The counseling, home visits, and other activities show the mothers how to practice these new skills. The peer support is also built in, as all the mothers in a village learn together in small groups.

Positive Deviance Inquiry (PDI): 

A series of semi-structured interviews and observations were carried in the Kaduha zone by a team of 2-3 ICSP staff using a PDI approach to acquire information about child feeding and heath care practices.  Both positive and negative deviant mothers were interviewed in order to adapt the program the community needs.  The findings from the positive and negative deviant household interviews were compared to the identified positive behaviors that could be broadly applied to the community.

Unlike a typical PDI approach this process was not repeated in every village where the intervention is being implemented. Rather, the results from the PDI was utilized to develop the Nutrition Week Curriculum.

Population/ Area:

The Nyamagabe district was chosen as a whole for the project based on government priority as well as to be able to build on the foundation of work with the CHWs that was established during EIP. The comparison and intervention groups were divided based on the hospital zones (Kigeme and Kaduha). Both hospitals were very similar; however Kaduha was chosen for intervention because it had slightly worse indicators.

Each Nutrition Week was held in the house of one of the community members. The house was chosen based on a criteria list to ensure the site would meet all the needs of a Nutrition Week.

Training/ Orientation:

There were three primary training/orientations:

1. Master Trainer Orientation
2. Training of Trainers (TOT)
3. Training of Village Nutrition Committees

Supervision of Nutrition Week

Supervision of Nutrition Weeks is performed by health staff, health facilities staff, and ICSP Staff.