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Improving awareness and adherence on Acute Malnutrition treatment

This question was posted the Management of wasting/acute malnutrition forum area and has 10 replies.

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Tomas Zaba

Normal user

3 Jan 2016, 16:41

Hi there!

My name is Tomás, Nutritionist working in community nutrition in Mozambique, my country.

Mozambique is facing a huge problem on reducing the prevalence of acute malnutrition, now about 8% according to national DHS (2011) and Minister of Agriculture (2013). This prevalence is stagnated just about 11 years.

To fight against that problem Minister of Health has implemented a national program called Nutritional Rehabilitation Program and is being expanded over the main health facilities in district. So far, the number of children acute malnourished admitted into the program is still low and, in case of admission, occurs when they are severely malnourished.

Analyses took place to identify the bottlenecks that lead to unsuccessful, and LOW EFFECTIVE COMMUNICATION ON AWARE CREATION.

Actually the program is using community health workers as messenger, but is not effective neither efficient because of many adversities.

Now trying to find a way to invert situation by reducing prevalence and delivering information to improve empowerment in nutrition, a proposal of 4th model of intervention to awareness is being developed based on the health and social indicators in the country. The proposal is presented down:


So, my question is: do you think will be effective and can have an impact on increasing adherence on Nutrition Rehabilitation Program?
The idea is the 4 models work together (1. Interpersonal communication; 2. Community involvement by using community health workers; 3. Lectures on Health facilities; and now 4. Television advertising campaign.

Your thoughts are much appreciated,
Thank you in advance.

Best regards

Tomás Zaba


CMAM Advisor

Normal user

4 Jan 2016, 02:54

Dear Tomas,
You are asking a quite difficult question but I believe that the answer is in your question: you mentioned “Analyses took place to identify the bottlenecks” (but you don’t name them) and “CHW ….. not effective neither efficient because of many adversities” (but you don’t name them). It sounds like the country has already identified barriers of access, what you call bottlenecks and adversities, and this is already a major step. The point is now to know if the developed awareness programme is the correct answer to the identified barriers. This is the first question you have to answer. In my experience, awareness can be very effective and should accompany every intervention but it is rarely an answer to the problems alone. What are the barriers reported by the community: is it distance? Is it opportunity cost? Is it stocks out? Is that mothers are too busy? Are parents ashamed of the malnutrition status of their children? The programme should implement activities based on the barriers identified, awareness and communication activities are important to inform the community about the strategies put in place to help overcominig the barriers but it is not necessarily "the answer" to the above barriers. Be careful not to switch the responsibility of the solution to the community alone: we identified the problem and now we want you to be aware that you have to solve the problem. This will not help. The aim of a programme should be to find strategies/activities able to support the community and not able to identify problems and tell the community that they must solve them just by knowing the existence of the problem; generally, the community already knows well the barriers! We should be there to help them to overcome the barriers and not to remind them the existence. You see what I mean. Sorry if I cannot help, these are just general thoughts that come in my mind when thinking about working with the community. All the best.

Stanley Macharia

M&E Officer

Normal user

4 Jan 2016, 06:11

Hi Tomas. Awareness creation through television is complicated when targeted toward the marginalized population who contributes the bulk of acute malnutrition. Some of the questions you need to ask is; does inequality exists in access to the medium of communication used(TV)? What will be ;language used and will it communicate effectively to the targeted population? I understand that your target is the whole Mozambique country citizens. However, you may choose different communication channels to different categories of the population (rich vs poor, illiterate vs literate etc). Community health workers when adequately capacitated and guided provides a good awareness platform specific to rural population and the urban poor.


Stanley Macharia

Muhammad Hassan Goronyo

Nutrition officer / international medical corps

Normal user

4 Jan 2016, 13:00

I think the best way for doing this and achieve is to engage the community leaders, religious leaders and house hold. Because we currently applying this method were we are implemented the CMAM program in the north west in Nigeria.
Best regards.
Muhammad Hassan Goronyo

Massimo Serventi


Normal user

4 Jan 2016, 13:48

Tomas Zaba

Normal user

4 Jan 2016, 21:42

Hi dear all.
I'm very thankful for your inputs regarding my issue. Thank you a lot.

Well, I see that you all who replayed is defending the use of iCCM by using the CHW and others community agents. I really and strongly agree with you all, and currently are being used, but is still not being effective because of the "adversities" I talked previously (named down)
•Each CHW is expected to cover a high number of people in the community, what because of that, they don't come back to often monitor their activities;
•Each CHW has responsibility to deliver many activities to community, and again to many people;
• distance (talk with no means of transportation);
• And officially Minister of Health did not approved the use of CHW on Nutrition package.

Because of that, the system is not effective yet. So, in regard to that something needs to be done.

The idea of the proposal is to strengthen the involvement of CHW to areas where TV is not accessible, and use TV in rural and urban areas (where malnutrition is reality, and people do not know what is). Will be a parallel intervention.

I really agree too that TV is difficult principally in a multicultural/language country. In rural and urban areas many people speak and understand the official language.
People need to know what is happening in the country, theirs community.

If we need to promote empowerment to health, so people know to act conscious.

Thank you
Tomás Zaba

Judy Canahuati


Normal user

5 Jan 2016, 00:24

Hi Tomas,

What about radio? Do you have information on radio penetration in the communities you are trying to reach? That might be more likely to work than TV. Can't emphasize enough the importance of community leaders, especially traditional and religious leaders support. Many of the misconceptions around AM could be corrected if traditional and religious leaders had a better understanding of acute malnutrition, its causes and consequence as well as an understanding of what should be done. There also needs to be a clear response. Decades ago, when we started a breastfeeding promotion campaign we learned that you can't just promote a service without developing the response capacity -- so if people become aware of AM and what to do to treat it, but the institutional response is not adequate at the facility and community level-- then the risk is turning people off of services even more. Agreed that CHWs are overworked. If there is a community leadership response, village health committees can be formed of volunteers who can be educated on both referrals as well as prevention (ie danger signs, feeding during illness, importance of adequate breastfeeding and complementary feeding as well as how to achieve along with malaria prevention-- importance of bednets, etc.) These are all things the community can take on and don't need direct intervention of CHWs. When we started training community mothers one of the results was diminishing the facility work load so that CHWs and health workers could focus on the more difficult or hard to reach populations because the community volunteers led by community leaders took over much of the prevention education as well as referrals. C-IMCI, the Baby Friendly Community Initiative and Care Groups are some of the community based approaches that can support these efforts. But certainly if the institutional response exists, radio and approaching the community leadership will go far towards increasing use of services.

Evans Toroitich

Nutritionist Getrude's Children's Hospital, Kenya

Normal user

5 Jan 2016, 05:52


All the responses given so far are valid. Nonetheless, TV adverts especially during prime time can go a long way in creating awareness and driving enthusiasm for the program. I am not sure about Mozambique but here in Kenya, citizens regard prime time news as sacred. Those without TV in their homes congregate around cafes and watch the news. In this regard, several messages have been effectively delivered to the masses in Kenya. key among these were information on fortified maize meal and iron, folic acid supplementation. Of course these messages were more effective in urban and Peri-urban areas. Radio played a significant role in areas with little or no TV access. I would therefore advise that radio be added to model 4 to read 'TV and Radio advertising campaign'. You can even go a step further and include occasional road shows with role plays involving persons of influence in the community riding along.
All the best.

Rosemary Otiende


Normal user

5 Jan 2016, 06:30

Hi Tomas
From my own experience Community health workers are still key. This should be systematically done through decentralization of sites being informed by baseline survey on prevalence of malnutrition in the targetted area. Blanket coverage does noy usually work well with AM due to many impending factors

latifa Beltaifa


Normal user

5 Jan 2016, 11:08

I would like to share with you the Tunisia experience. Since 35 years or
more the use of the national radio as a media to disseminate messages is
now a coutume. So Radio has played and still plays an important role in
raising awareness regarding nutrition and health in general. In my opinion
the radio is more accessible to vulnerable population that TV. Messages are
divulged at prime time before/after morning, afternoon and evening news.
The repetition of the message the same day at different hours is important
and helps to retain the content and make it comprehensible and relevant.
All the best.

Tammam Ali Mohammed Ahmed

Nutrition Specialist/ Save the Children

Normal user

5 Jan 2016, 17:49

In my opinion to do community mobilization and serious community sensitization on the topics of malnutrition and the importance of referral SAM to HFs is by proposing comperhensive community based integrated nutrition program(CCBINP), a C4D is one component of this program. C4D officers can play a major role in community mobilization through formationn of development committee in every village, the so called village development Committee(VDC). VDCs members should be from all sectors as health,nutrition, education, local administration..etc. The VDCs members can play a major role in discussing the main issues such the case you raised in your question. These VDCs can involve the community in discussing any issue so be in open conversation with the community, a final and important step in CBINP enable partners to implement any community based intervention as it will form basic platform and ground for other nutrition programs.

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