IIa.

Training Guide for

Health Workers

Essential Nutrition Actions Framework

2011
The 1,000 Days Effort to
Reduce Child Undernutrition

What is 1,000 Days?

1,000 Days is a global effort to jumpstart the implementation of the Scaling Up Nutrition (SUN)
Framework and Roadmap for addressing undernutrition during pregnancy and early childhood. On
September 21, 2010, on the margins of the Millennium Development Goals summit, Secretary of State
Hillary Clinton and Irish Foreign Minister Micheál Martin hosted an event to launch the effort, which
was endorsed by more than a dozen ministers and heads of organizations. But 1,000 Days is more than
a single event. It is the start of a larger movement to focus attention, align and increase resources, and
build partnerships to alleviate the suffering caused by undernutrition among millions of people around
the world, especially pregnant women and children under 2 years of age.

What Are the Scaling Up Nutrition (SUN) Framework and Roadmap?

The SUN Framework guides the international community in efforts to combat undernutrition and builds
on the Paris-Accra principle of supporting country-led strategies. The Framework is endorsed by more
than 100 partners, including international organizations, national governments, civil society, and the
private sector The SUN Framework and Roadmap are grounded in the at scale implementation of the
Lancet-endorsed nutrition actions that are evidence-based, cost-effective interventions that could have
enormous impact on reducing undernutrition.

Why 1,000 Days?

1,000 Days refers to the time from the start of a mother’s pregnancy until a child is two years old.
Children suffering from undernutrition face physical stunting, mental impairment, higher susceptibility
to disease, increased risk of mortality, poorer performance in school, and lower future incomes. 1,000
Days also refers to a window of opportunity for the international community to take action to combat
undernutrition.

How to Support the 1,000 Days?

To jump-start the 1,000 Days in countries, the Core Group highly encourages its members to adopt such
‘tested and proven’ field tools as the Essential Nutrition Actions (ENA) Framework Trilogy training and
communication materials. Not only does the ENA Framework focus on the first 1,000 days of life, but it
emphasizes targeting “action oriented” nutrition messages and support -though multiple communication
channels- to reach under-twos and their mothers when they need it the most. The Core Group believes
that having many different field groups using these same ENA tools will lead to harmonized field
approaches that result in greater progress, synergies and nutritional impact. Such harmonization is
extremely critical as resources are scarce and the task ahead is enormous.

Where Can I Get More Information on the 1,000 Days?

Please visit www.thousanddays.org.
Preface    
The  Essential  Nutrition  Actions  (ENA)  framework  was  d eveloped  with  the  support  of  USAID  and  has  b een  
implemented  across  Africa  and  Asia  since  1997.  It  is  an  operational  framework  for  managing  the  
advocacy,  p lanning  and  d elivery  of  an  integrated  package  of  preventive  n utrition  actions  encompassing  
infant  and  young  child  feeding  (IYCF),  micronutrients  a nd  women’s  nutrition.  Using  multiple  contact  
points,  it  targets  h ealth  services  and  b ehavior  change  communication  support  ( BCC)  to  women  and  
young  children  during  the  first  1,000  days  of  life  -­‐  from  conception  through  the  first  two  years  of  life  -­‐  
when  nutrient  requirements  are  increased,  the  risks  of  undernutrition  are  great,  and  the  consequences  
of  deficiencies  most  likely  to  b e  irreversible.  All  these  a ctions  have  b een  proven  to  improve  nutritional  
status  and  reduce  mortality.1    
The  ENA  framework  promotes  a  “nutrition  through  the  life  cycle”  approach,  addressing  women’s  
nutrition  during  pregnancy  and  lactation,  optimal  IYCF  (breastfeeding  and  complementary  feeding),  
nutritional  care  of  sick  and  malnourished  children  ( including  zinc,  vitamin  A  a nd  ready  to  use  therapeutic  
foods),  and  the  control  of  anemia,  vitamin  A  and  iodine  d eficiencies.  The  ENA  framework  emphasizes  
that  multiple  program  contact  points  at  h ealth  facilities  and  b eyond  b e  used  to  reach  mothers  and  
children  in  order  to  give  and  re-­‐enforce  ENA  messages.  For  example,  such  contact  points  could  include  
educational  s ettings  (e.g.  primary  and  secondary  schools  as  well  as  pre-­‐service  education  courses),  
agriculture  extension  s ervices  (e.g.  to  support  nutrition  relevant  aspects  of  a vailability,  a ccess  and  
utilization  of  nutritious  and  diverse  foods),  as  well  as  a  variety  of  program  platforms  at  the  community  
level  including  primary  h ealth  care  outreach,  child  h ealth  days,  community-­‐based  volunteer  groups,  and  
water  and  sanitation  programs.  The  intent  is  to  maximize  these  multiple  program  opportunities  and  
communication  channels  to  d eliver  life  cycle-­‐appropriate  nutrition  messages  at  every  opportunity  
possible  to  pregnant  women  and  mothers  with  children  under  two  years  at  very  broad  scale,  in  addition  
to  other  key  child  caregivers  and  influential  family  members.    
The  training  component  for  the  implementation  of  the  ENA  framework  at  b oth  the  h ealth  facility  and  
community  levels  comprises  a  trilogy  of  m aterials  as  follows:  
I.   The  Booklet  on  K ey  ENA  messages  illustrates  the  key  ENA  messages  and  can  be  used  b y  those  
implementing  and  supporting  health,  nutrition,  and  food  security  programs  for  improving  
nutrition  practices  a mong  pregnant  and  lactating  mothers  and  children  under  two.  It  can  b e  a  
resource  for  training  community  or  facility-­‐based  workers  or  for  promoting  b ehavior  change  at  
the  household  level.  The  goal  of  this  booklet  is  to  make  a vailable  an  harmonized  set  of  
messages  across all  implementing  partners  working  a cross  various  programs  and  regions  in  a  
targeted  country.  The  booklet  summarizes  the  “key  actions”  that  mothers  and  caretakers  can  
take  ( with  support  from  other  family  and  community  members)  to  improve  nutrition  and  
feeding  practices,  thereby  preventing  malnutrition.  Each  message  states:  
• Who  should  do  the  action…  
• What  the  action  is…    
• What  the  b enefits  of  the  action  are…  
IIa  and  IIb.  The  ENA  Framework  Training  Guide  for  Health  Workers  and  Handouts  equips  health  
service  providers  with  the  technical,  action-­‐oriented  n utrition  knowledge  and  counseling  s kills  
needed  to  support  pregnant  women,  mothers  with  children  under  two  years  of  a ge,  and  other  

1
 Bhutta  Z,  Ahmed  T,  Black  RE,  Cousens  S,  D ewey  K,  Giugliani  E,  Haider  B,  Kirkwood  B,  Morris  S,  Sachev  HPS,  Shekar  M.  (2008)  
What  works?  Interventions  for  maternal  a nd  c hild  undernutrition  a nd  survival.  Maternal  a nd  C hild  U ndernutrition  Series.  
Lancet;371:417–40.  
 key  family  members  to  adopt  optimal  nutrition  practices.  This  course  translates  up-­‐to-­‐date  
international  guidelines  into  a ction-­‐oriented  nutrition  practices.  The  n egotiation/counseling  
techniques  are  adapted  from  the  Trials  for  Improved  Practices  (TIPS)  and  go  b eyond  just  
conveying  messages  to  providing  support  for  the  adoption  of  optimal  behaviors.  Infant  feeding  
in  the  context  of  HIV  and  nutrition  of  women  living  with  HIV  and  AIDS  are  a lso  addressed,  but  
might  need  further  d evelopment  in  countries  with  h igh  HIV  prevalence.  Guidelines  to  link  the  
prevention  of  malnutrition  with  treatment  via  the  community-­‐based  management  of  a cute  
malnutrition  are  also  included.  Training  handouts  are  distributed  to  each  participant  at  the  
beginning  of  the  ENA  training.  
III.   The  ENA  Framework  Training  Guide  for  Community  V olunteers  equips  s emi-­‐literate  or  illiterate  
Community  Volunteers  with  the  basic  action-­‐oriented  nutrition  knowledge  and  counseling  s kills  
needed  to  support  pregnant  women,  mothers  with  children  under  two  years  and  other  key  
family  members  to  adopt  optimal  nutrition  practices.  The  course  also  covers  basic  s kills  for  
identifying  children  who  are  malnourished  including  a ppropriate  referral.  This  course  can  b e  
incorporated  into  any  training  at  the  community  level,  including  on  maternal  &  child  h ealth,  
community  management  of  acute  malnutrition,  HIV/AIDS,  a gricultural  production,  food  
security,  rural  d evelopment,  etc.    

Country  Adaptation  
The  generic  versions  of  the  above  ENA  Trilogy  have  been  tested  over  time  and  are  ready  to  b e  used  in  
new  s ettings  and  countries.  However  some  a daptations  are  n eeded  to  ensure  that  these  materials  are  
country  and  situation  specific.  A  guide  to  the  key  adaptation  issues  are  as  follows:  

ENA  Messages  
• The  specific  actions  recommended  in  the  ENA  messages  don’t  need  to  be  changed  as  they  have  
been  compiled  from  scientific  research  to  support  nutritional  s tatus.  However,  they  may  need  
to  b e  adjusted  somewhat  to  match  national  guidelines  (e.g.  a ge  appropriate  d e-­‐worming)  or  
may  n eed  to  b e  p eriodically  updated  to  reflect  n ew  global  technical  guidance  ( e.g.  infant  
feeding  in  the  context  of  HIV).    
• While  the  specific  actions  are  u niversal,  the  concepts  a nd  language  used  to  promote  them  
through  counseling  s essions  with  mothers  and  other  child  caretakers  must  b e  adapted  via  
formative  research  to  ensure  their  suitability  for  d ifferent  cultural  contexts.  If  it  is  not  possible  
to  conduct  formative  research,  it  is  still  important  to  field-­‐test  both  the  messages  and  
illustrations  used  in  this  booklet  with  a  sample  of  mothers,  fathers  and  other  child-­‐caretakers  
such  as  grandmothers  to  confirm  their  suitability.    
• Further  adaptation  of  the  ENA  messages  may  b e  n eeded  to  specify  “who  is  doing  the  action”  
(e.g.  mothers,  fathers,  grand-­‐mothers,  etc…)  as  well  as  the  “benefits  of  the  action”  to  ensure  
their  relevance  and  resonance  within  the  particular  locality  or  s etting.  For  example,  what  
benefits  will  motivate  mothers  to  practice  exclusive  breastfeeding?  What  types  of  local  
complementary  foods  (staple  +  nutrient-­‐rich  and/or  enriched  foods)  are  available?  What  local  
utensils  (spoons,  bowls,  tea  cups)  will  h elp  illustrate  the  correct  quantity  of  food  the  child  
needs?    
• New  illustrations  aren’t  always  n eeded  as  existing  illustrations  often  can  b e  easily  adapted  and  
used.  
Training  Guides  Focusing  on  Counseling  Skills  and  Practicum  Sessions  
• The  two  ENA  Framework  training  guides  are  ready  to  b e  used  and  do  not  require  further  
adaptation,  except  to  include  country-­‐specific  maternal  and  infant  &  young  child  feeding  
messages  and  protocols  guiding  micronutrient  supplementation,  the  integrated  management  of  
newborn  and  childhood  illness,  and  the  management  of  acute  malnutrition. They  may  need  to  
be  p eriodically  updated  to  reflect  n ew  global  technical  guidance.    
• Built  into  the  ENA  Framework  Training  Guides  are  s essions  covering  the  techniques  of  
negotiating  with  mothers  to  help  them  try  and  succeed  with  new  nutrition-­‐related  practices,  
and  exercises  through  which  participants  practice  and  begin  to  master  these  skills.  This  includes  
role  plays  in  the  “classroom”  s etting  and  site  visits  to  villages  where  participants  can  hone  their  
skills  working  with  real  mothers.  It  cannot  be  emphasized  enough  that  these  practical  s essions  
are  the  h eart  of  the  training  program  and  should  not  b e  removed  as  this  would  profoundly  
reduce  the  effectiveness  of  the  ENA  training  as  well  as  the  impact  of  the  overall  ENA  support  to  
women  and  young  children.  
Acknowledgements    
We  would  like  to  acknowledge  that  the  Booklet  of  Key  ENA  Messages  and  the  two  ENA  Framework  
Training  Guides  to  support  the  implementation  of  the  ENA  framework  would  not  have  b een  possible  
without  the  effort  and  support  over  the  past  15  years  of  many  institutions  and  individuals.    
In  1997,  the  USAID-­‐funded  BASICS  project  initiated  the  approach  u nder  the  rubric  the  Minimum  Package  
for  Nutrition  or  “MinPak.”  Subsequently  the  approach  was  renamed  the  Essential  Nutrition  Actions  
(ENA)  and  was  expanded  considerably  to  include  training  and  IEC  materials  under  the  USAID-­‐funded  
LINKAGES  Project  managed  by  the  Academy  for  Educational  Development  (AED),  where  we  were  both  
involved  in  d esigning  and  implementing  large  scale  ENA  programs  for  Madagascar2  and  Ethiopia  from  
1999  to  2006.  
The  Booklet  of  Key  ENA  m essages  and  its  related  ENA  Framework  training  guides  have  been  recently  
revised  and  tested  within  projects  managed  b y  John  S now  Incorporated  ( JSI)  in  Ethiopia  and  Liberia,  and  
by  Helen  Keller  International  (HKI)  in  a  number  of  countries  across  Africa  and  the  Asia-­‐Pacific  region.  
Much  of  the  support  for  this  work  has  come  from  USAID,  UNICEF  and  the  European  Union.    
Staff  from  many  agencies  also  brought  their  expertise  and  are  gratefully  a cknowledged  for  their  
contributions  with  support  from  USAID,  including:  the  African  Regional  Center  for  the  Quality  of  Health  
Care  (RCQHC);  the  Africa’s  Health  in  2010  and  F ANTA  Projects  managed  b y  AED;  the  West  African  Health  
Organization  ( WAHO);  and  the  East  Central  and  Southern  Africa  Health  Community  ( ECSA-­‐HC).  UNICEF  
has  also  p layed  a  key  role,  especially  in  Liberia  and  Niger,  as  has  the  Carter  Center  in  Ethiopia.  National  
training  partners  in  a  number  of  countries  have  b een  central  to  the  development  of  the  ENA  framework  
as  well  as  related  training  and  IEC  materials.  
Certain  individuals  were  a lso  instrumental  in  h elping  u s  to  d evelop  and  test  the  original  ENA  training  
courses  on  which  the  present  Booklet  of  Key  ENA  m essages  and  its  related  ENA  Framework  Training  
Guides  are  based.  These  individuals  include  (by  alphabetical  order):  Mesfin  Beyero,  Kristen  Cashin,  
Serigne  Diene,  Tesfahiwot  Dillnessa,  Mulu  Gedhin,  Peter  Gottert,  Nancy  Keith,  Adbulselam  Jirga,  Dorcas  
Lwanga,  Robert  Mwadime,  Hana  NekaTebeb,  Jennifer  Nielsen,  Alban  Ramiandrisoa  Ratsivalaka,  Zo  
Rambeloson,  Voahirana  Ravelojoana,  Priscilla  Ravonimanantsoa,  Kinday  Samba,  Maryanne  S tone-­‐
Jimenez  and  Catherine  Temkangama.    

2
 Guyon,  AB,  Quinn,  VJ,  Hainsworth,  M,  Ravonimanantsoa,  P,  Ravelojoana,  V,  Rambeloson,  Z  a nd  Martin,  L,  Implementing  an  
integrated  nutrition  package  at  large  scale  in  M adagascar:  The  Essential  Nutrition  Actions  Framework.  Food  a nd  Nutrition  
Bulletin.  30(3):  233-­‐44.  The  United  Nations  U niversity.  2009.  
The  Nutrition  Working  Group  of  CORE  Group  supported  the  efforts  to  update  the  tools  and  make  them  
more  widely  available.  CORE  Group  fosters  collaborative  action  and  learning  to  improve  and  expand  
community-­‐focused  public  h ealth  practices.  Established  in  1997  in  Washington  D.C.,  CORE  Group  is  an  
independent  organization  and  h ome  of  the  Community  Health  Network,  which  brings  together  CORE  
Group  member  organizations,  scholars,  advocates  and  donors  to  support  the  h ealth  of  underserved  
mothers,  children  a nd  communities  around  the  world.  These  tools  can  be  accessed  a t  
http://www.coregroup.org  

Agnès  B.  Guyon,  MD,  MPH         Victoria  J.  Quinn,  PhD  

JSI  Research  &  Training  Institute       Helen  Keller  International  

----------------------------------------------------------------------------------------------------------------

The  illustrations  were  produced  under  the  LINKAGES  a nd  Jereo  Salama  Isika  (JSI)  projects  in  Madagascar,  
the  Essential  S ervices  for  Heath  in  Ethiopia  (ESHE)  and  LINKAGES  projects  in  Ethiopia,  and  UNICEF  
Liberia.    
The  Booklet  on  Key  ENA  Messages,  the  ENA  Training  Guide  for  Health  Workers,  and  the  ENA  Training  
Guide  for  C ommunity  V olunteers  can  b e  d uplicated  if  credit  is  properly  given.  Photos  on  cover  page:  
Agnès  Guyon,  UNICEF  Liberia  and  Victoria  Quinn.  
The  recommended  citations  are  as  follows  for  these  three  ENA  documents:    
• Guyon,  AB  and  Quinn,  V J.  Booklet  on  Key  Essential  Nutrition  Actions  Messages.  Core  Group,  
Washington,  D.C.,  January  2011  
• Guyon,  AB  and  Quinn,  V J.  Essential  Nutrition  Actions  F ramework  Training  Guide  for  Health  
Workers.  Core  Group,  Washington,  D.C.,  January  2011  
• Guyon,  AB  and  Quinn,  V J.  Essential  Nutrition  Actions  Framework  Training  Guide  for  Community  
Volunteers.  Core  Group,  Washington,  D.C.,  January  2011  
The  Seven  Essential  Nutrition  Actions:  Background  
The  landmark  Lancet  Series  on  Maternal  and  C hild  Undernutrition  published  in  early  2008  estimates  that  
effective,  targeted  n utrition  interventions  to  address  maternal  and  child  undernutrition  exist  and,  if  
implemented  at  s cale  during  the  window  of  opportunity  (conception  and  up  to  24  months  of  a ge),  could  
reduce  nutrition-­‐related  mortality  and  disease  burden  by  25%.  The  Essential  N utrition  Actions  
framework  encompasses  s even  of  these  proven  interventions  targeting  this  window  but  also  represents  
a  comprehensive  strategy  for  reaching  near  universal  coverage  (>90%)  with  these  interventions  in  
order  to  a chieve  public  h ealth  impact.  ENA  programs  a re  implemented  through  health  facilities  and  
community  groups.  
The  approach  includes  ensuring  that  key  messages  and  services  p ertaining  to  the  s even  action  areas  are  
integrated  into  all  existing  health  sector  programs,  in  particular  those  that  reach  mothers  and  children  
at  critical  contact  points  (maternal  health  and  prenatal  care;  d elivery  and  n eonatal  care;  postpartum  
care  for  mothers  and  infants;  family  planning;  immunizations;  well  child  visits  (including  growth  
monitoring,  promotion,  and  counseling);  sick  child  visits  (including  Integrated  Management  of  Newborn  
&  Childhood  Illnesses  a nd  Integrated  Community  Case  Management);  and  Outpatient  Therapeutic  Care  
during  Community-­‐based  Management  of  Acute  Malnutrition.    
The  appropriate  messages  and  s ervices  are  also  integrated  to  the  greatest  extent  possible  into  programs  
outside  the  health  sector,  such  as  a griculture  and  food  security  contacts;  education  (pre-­‐service,  
primary  and  secondary  schools)  and  literacy;  microcredit  and  livelihoods  enhancement.    
Implementing  the  ENA  framework  entails  building  partnerships  with  a ll  groups  supporting  maternal  and  
child  h ealth  and  nutrition  programs  so  that  messages  a re  harmonized  and  a ll  groups  promote  the  same  
messages  using  the  same  job  a ids  and  IEC  materials.  Ideally  partners  are  brought  together  at  the  
regional  and/or  national  levels  to  agree  on  these  harmonized  approaches  and  to  advocate  with  policy  
leaders  for  the  importance  of  nutrition  to  the  nation’s  economic  as  well  as  social  d evelopment.  
Messages  are  crafted  as  “small  do-­‐able”  actions  and  behavior  change  communications  ( BCC)  techniques  
are  used  to  promote  adoption  of  these  a ctions.  Special  emphasis  is  given  to  interpersonal  
communications  (counseling  of  individual  mothers)  that  are  reinforced  b y  mass  media  and  community  
festivals  and  other  mobilizing  events.  Health  and  community  agents  are  trained  to  employ  n egotiations  
for  behavior  change,  visiting  mothers  in  their  households  or  community  meeting  places  (markets,  
chores,  women  groups  meetings,  etc…)  and  h elping  them  anticipate  and  overcome  barriers  to  carrying  
out  n ew  practices.    
The  capacity  for  promoting  the  essential  nutrition  actions  using  n egotiations  for  b ehavior  change  can  b e  
strengthened  with  existing  “generic”  training  m odules3  for  h ealth  workers  and  community  a gents.  
While  the  content  remains  generally  fixed,  the  d etails  should  b e  adapted  through  formative  research  to  
specific  country  and  regional  contexts.  

3
 These  two  modules  together  with  a  booklet  highlighting  the  k ey  ENA  m essages  can  be  downloaded  from  the  C ORE  Group  
website  o n  the  Nutrition  Working  Group  page.  
 
The  Seven  Essential  Nutrition  Actions4  
All  are  equally  important.  This  ENA  list  is  organized  b y  a  lifecycle  approach.  
1. Promotion  of  optimal  nutrition  for  women  
2. Promotion  of  adequate  intake  of  iron  and  folic  acid  and  prevention  and  control  of  
anemia  for  women  and  children  
3. Promotion  of  adequate  intake  of  iodine  by  all  members  of  the  household  
4. Promotion  of  optimal  breastfeeding  during  the  first  six  months  
5. Promotion  of  optimal  complementary  feeding  starting  at  6  months  with  continued  
breastfeeding  to  2  years  of  age  and  beyond  
6. Promotion  of  optimal  nutritional  care  of  sick  and  severely  malnourished  children  
7. Prevention  of  vitamin  A  deficiency  in  women  and  children  
 

4
 CORE  Group.  N utrition  Working  Group.  N utrition  Program  Design  Assistant:  A  Tool  for  Program  Planners,  Washington,  DC:  
2010  
INTRODUCTION  
The  purpose  of  this  training  guide  is  to  train  health  workers  in  key  infant  and  young  child  feeding  
practices/messages,  the  importance  of  micronutrients  and  women’s  nutrition,  a nd  in  crucial  
negotiation,  and  interpersonal  communication  skills.  The  knowledge  and  skills  will  enable  health  
workers  to  h elp  mothers/caregivers  optimally  feed  their  infants  and  young  children  and  take  care  of  
their  own  nutritional  n eeds.  The  training  also  provides  an  opportunity  for  supervisors  and  h ealth  
workers  to  learn  together  and  practice  “coaching”  to  improve  p erformance.  

Training  Agenda  
This  s ix-­‐day  training  guide  is  organized  in  a  s equence  to  facilitate  learning  and  allow  opportunities  to  
practice  n egotiation  skills.  
The  sessions  for  each  day  outline  specific  learning  objectives,  a ctivity  d etails,  materials/handouts,  
duration,  and  methodologies  for  learning  activities.  

Training  Methodology  
The  training  guide  applies  the  principles  of  Behavior  Change  Communication  to  promote  s mall,  do-­‐
able  actions,  and  the  widely  acknowledged  theory  that  adults  learn  b est  b y  practice  and  reflection  
on  their  experiences.  Attempts  have  b een  made  to  make  the  training  s essions  relevant  to  the  needs  
of  participants  and  their  communities.  
This  participatory  approach  uses  the  experiential  learning  cycle  method  and  allows  participants  the  
hands-­‐on  p erformance  of  s kills  as  a  means  of  acquiring  them.  The  course  employs  a  variety  of  
training  methods:  d emonstrations,  practice,  d iscussions,  case  studies,  group  discussions,  and  
roleplays.  Participants  will  learn  to  act  as  resource  p ersons  for  breastfeeding  mothers,  pregnant  
women,  and  mothers/caregivers  of  young  children.  
Respect  for  individual  trainees  is  central  to  the  training  and  sharing  of  experiences  is  encouraged  
throughout.  Participants  complete  pre-­‐  and  post-­‐training  assessment  questionnaires  to  a llow  
trainers  to  measure  their  progress.  

Training  Location  
Wherever  the  training  is  p lanned,  a  site  should  b e  s elected  close  to  the  training  facility  and  readily  
available  to  a llow  the  practicum  for  n egotiation  with  mothers/caregivers  on  do-­‐able  infant  and  
young  child  feeding  practices.  Prepare  the  practicum  s ite  by  coordinating  with  the  clinic  and/or  
community,  a lerting  them  to  the  arrival  of  participants  and  arranging  for  space  for  practicing  
negotiation  s kills  with  actual  mothers/caregivers.  It  is  optimal  to  have  one  facilitator  for  every  6-­‐8  
participants  for  this  s ession.  

Materials  Needed  for  the  Training  

Stationary    
• Flipchart  s tands       1  or  2  
• Flipchart  papers       200  sheets  
• Markers         2  boxes  black  +  2  boxes  of  color  
• Masking  tapes       3  rolls  
• Participants’  registrations     1  per  day    
• Names’  badge       1  per  participant  
• Notebooks         1  per  participant  
• Pens         1  per  participant  
• Folders         1  per  participant  
• Copies  of  pre-­‐/post-­‐test       1  per  participant  

i  
• Copies  of  n egotiation  form       1  per  participant  
(on  both  sides)  

Teaching  aids    
• Dolls         3  
• Breast  models       3  
• MUAC  Tapes       1  per  participant  
• Foods  for  d isplay       A  variety  of  locally  a vailable  foods  
• ENA  Handout  for  h ealth  worker   1  per  participant  
• Booklet  on  Key  ENA  messages   1  per  participant  
• Facilitator  Guide  for  community     1  per  participant  ( if  participant  
health  worker       will  conduct  training  on  community  h ealth  worker)  

Advance  Preparation  for  field  trip  

• One  week  in  advance,  make  an  appointment  at  the  h ealth  clinic  to  plan  a  field  practice  during  
immunization  or  weighing  sessions.  
• One  week  in  advance,  make  an  appointment  with  the  community  chairman  or  the  
community  h ealth  a gent  to  prepare  them  for  village  visits.    
• Confirm  the  day  b efore  the  visit  and  specify  the  number  of  mothers  n eeded  (at  least  10).  

Learning  Objectives    
At  the  end  of  the  training,  the  participants  will  b e  able  to:  
1. Describe  the  key  messages  and  practices  for  optimal  b reastfeeding,  including  within  the  context  
of  HIV/AIDS.  
2. Describe  the  key  messages  and  practices  for  adequate  complementary  feeding.    
3. Describe  the  key  messages  and  practices  for  optimal  women’s  n utrition  and  micronutrients.    
4. Negotiate  with  the  mothers  ( to  encourage  them)  to  try  one  improved  practice  in  one  of  the  
learning  objectives  mentioned  above  and  to  reinforce  the  correct  b ehaviors  to  encourage  the  
adoption  of  the  n ew  practice.  
5. Explain  their  role  as  counselors  who  are  able  to  listen  to,  give  constructive  feedback,  and  
practice  positive  coaching.    
6. Develop  a  three-­‐month  action  p lan  of  the  a ctivities,  which  they  will  implement  upon  return  to  
their  h ealth  facilities.  

ii  
 ENA  TRAINING  GUIDE  FOR  HEALTH  WORKERS  
Session   Title   Duration  
Day  1  (6  Hours  30  minutes)  
Session  1   Presentations,  expectations,  course   1  hour  
objectives  administration  and  logistics  
Pre-­‐test    
Session  2   Behavior  Change  Communication  ( BCC)   1  hour  
Session  3   Causes  of  malnutrition  and  child  h ealth   15  min  
Session  4   Essential  Nutrition  Actions  for  the   30  min  
prevention  of  malnutrition:  role  of  the  
health  workers  and  the  community  worker    
Session  5   Advantages  of  breastfeeding/Risks  of   30  min  
formula  feeding  
Session  6   Optimal  breastfeeding  practices   1  hour  
45  min  
Correct  positioning  and  a ttachment    
Importance  of  Vitamin  A  &  Iron/Folic  Acid  
supplementation    
Session  7   Beliefs  and  myths  relating  to  breastfeeding   30  min  
Session  8   Picture  story   1  hour  
  Evaluation  of  the  day:  Mood  Meter    

Day  2  (5  Hours  50  minutes)  

  Review  of  day  1    
Session  9   Lactational  Amenorrhea  Method  (LAM)     50  min    
Session  10   Common  breastfeeding  difficulties:   1  hour  
prevention  and  solutions    
Session  11   Infant  feeding  in  the  context  of  HIV/AIDS   1  hours    
30  min  
Session  12   Negotiation  with  mothers,  caregivers,   2  hours  
fathers,  and  grandmothers     30  min  
  Evaluation  of  the  day:  Mood  Meter    

Day  3  (7  Hours)  

Session  13   Field  visit  (health  centers  and  villages)   4  hours  
Session  14   Key  complementary  feeding  practices   3  hours  
  Evaluation  of  the  day:  Mood  meter    

iii  
 Day  4  (6  Hours  50  minutes)  
  Review  of  day  2  &  day  3  
Session  15   Feeding  of  the  s ick  child  and  danger  signs   50  min  
Community-­‐Based  Management  of  Acute  
Session  16   Malnutrition  (CMAM):  Community   2  hours  
Therapeutic  Care  
Women’s  nutrition  
• The  malnutrition  cycle   1  hour    
Session  17  
30  min  
• Strategies  to  break  the  malnutrition  
cycle  
Negotiation  with  mothers/caregivers   2hours  
Session  18  
Use  of  visual  a ids     30  min  

  Evaluation  of  the  day:  Mood  meter    

Day  5  (6/7  hours  30  minutes)  

Session  19   Field  visit  (health  centers  and  villages)   3-­‐4  hours  
The  Essential  Actions  in  Nutrition  and  
Session  20   contact  points   1  hour  30  min  
Job  a ids  for  health  workers    
Support  groups  for  infant  and  young  child  
Session  21   2  hours  
feeding    
  Evaluation  of  the  day:  Mood  meter    

Day  6  (4  hours  15  minutes)  

  Review  of  day  4  and  day  5    
Improving  nutrition  at  the  community  level    
Session  22   Introduction  to  the  community  training   2  hours  
course
Development  of  an  a ction  p lan  (6  months)  
Session  23   1  hour    
Presentation  of  action  p lans
Post-­‐test  
Session  24 45  min
Course  evaluation
Certificates  
Closing 30  min
Remarks

iv  
Daily  Evaluations  
A.   Ask  participants  to  write  on  a  small  piece  of  paper  their  answers  to  one,  two,  or  a ll  of  the  
following  questions,  which  have  b een  displayed  on  a  flip  chart:  
  1.  What  did  you  learn  today  that  will  b e  useful  in  your  work?  
  2.  What  was  something  that  you  liked?  
  3.  Give  suggestions  for  improving  today’s  sessions.  
Collect  participants’  answers,  mix  up  the  papers,  redistribute  them,  and  ask  participants  to  read  the  
answers  
OR  
Collect  participants’  answers,  summarize,  and  provide  summary  on  the  following  day.  
B.   A  table  measuring  participants’  mood  (filled  out  b y  participants  a t  the  end  of  each  day).  

MOOD  METER  
DATE        

 
 
DAY  1        
 
       
DAY  2  
 
       
DAY  3  
 
       
DAY  4  
 
       
DAY  5  
 
       
DAY  6  
 

v  
Roleplaying  with  Case  Studies  
Participants  
Participants  take  turns  roleplaying  as  “mothers/fathers/caregivers”  and  “promoters.”    
             

 
Facilitator  
Facilitator  presents  case  studies  to  the  
group,  listens  to  the  roleplays,  and  gives  
feedback  to  each  pair  of  participants.  

Participants  are  a ctive,  roleplays  will  happen  at  the  same  time.  The  facilitator  will  not  b e  able  to  
follow  each  and  every  roleplay.  That  is  okay!  The  facilitator  n eeds  to  give  feedback  to  each  
group.  
Giving  the  participants  an  opportunity  to  practice  is  important.  They  n eed  s everal  opportunities  
to  PRACTICE  their  skills  and  improve  based  on  the  feedback  they  receive.    

vi  
SESSION  1  
INTRODUCTIONS,  EXPECTATIONS,  AND  COURSE  OBJECTIVES  
 
Learning  Objectives  
• By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Begin  to  name  fellow  participants,  facilitators,  and  resource  p ersons.  
• Create  a  d ynamic  relationship  a mong  participants  and  trainers.  
• Discuss  participants’  expectations.  
• Explain  course  objectives  and  purpose  of  the  training.  
 
Overview  
Activity  1.1   Presentation  game  for  introductions  and  expectations  (20  minutes)  
Activity  1.2   Pre-­‐test  (20  minutes)  
Activity  1.3   Presentation  of  course  objectives  (10  minutes)  
Activity  1.4     Discuss  administrations  and  housekeeping  (10  minutes)  
 
Total  Time     60  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape  
• Objectives  written  on  flip  chart  
• Matching  pairs  of  infant  feeding  p ictures  for  presentation  game  
• Participants’  folders  
• One  copy  of  Pre-­‐test  of  Module  I  for  each  participant  
 

Day  1   -­‐  1  -­‐

DETAILED  ACTIVITIES  
Activity  1.1     Introduction  and  Expectations    
(20  minutes)    
Methodology  
• Pair  participants  and  ask  them  to  introduce  each  other’s  names,  expectations  of  the  training,  
and  something  of  human  interest  (one  or  two  favorite  foods,  hobbies,  likes,  d islikes,  etc.)  
• Facilitator  writes  them  on  flipchart.  

Activity  1.2   Pre-­‐test    

(20  minutes)  
Methodology  
• Pass  out  copies  of  the  pre-­‐test  to  the  participants  and  ask  them  to  complete  it  individually.    
• Ask  participants  to  s elect  a  code  number  from  a  bag  a nd  then  write  their  code  number  on  the  
pre-­‐test.  Remind  them  to  remember  it  for  the  post-­‐test.  
• Correct  a ll  the  tests  as  soon  as  possible  the  same  day,  identifying  topics  that  caused  
disagreement  or  confusion  and  need  to  be  addressed.  Participants  should  b e  advised  that  these  
topics  will  be  discussed  in  greater  detail  during  the  training.  

Activity  1.3   Presentation  of  Course  Objectives    

(10  minutes)  
Methodology:  
• Facilitator  introduces  course  objectives  and  compares  them  with  expectations  of  participants.  
• Expectations  and  objectives  remain  in  view  during  training  course.  

Activity  1.4     Discuss  Administration  and  Housekeeping    

(10  minutes)  

Day  1   -­‐  2  -­‐

PRE-­‐TEST  AND  POST-­‐TEST    
Please  read  through  the  following  statements.  S elect  Yes  if  you  agree  with  the  statement  or  s elect  
No  if  you  d isagree  with  the  statement.    

#   PRE-­‐TEST  AND  POST-­‐TEST   YES   NO  

1.   It  is  good  to  put  the  baby  on  the  breast  immediately  after  birth.      
2.   In  order  to  have  enough  milk,  a  mother  n eeds  to  breastfeed  10      
times  a  day.  
3.   Colostrum  serves  as  the  first  immunization  for  the  baby.      
4.   At  4  months,  the  infant  n eeds  water  and  other  drinks  in  addition  to      
breastmilk.  
5.   Demonstrating  to  a  mother  how  to  b etter  feed  h er  child  is  more      
effective  than  just  telling  h er.    
6.   Having  correct  knowledge  is  all  that  is  n eeded  for  a  mother  to      
optimally  breastfeed  h er  baby.  
7.   When  breastfeeding,  the  baby’s  chin  n eeds  to  touch  the  mother’s      
breast.  
8.   Only  food  is  important  to  prevent  malnutrition.      
9.   Vitamin  A  supplementation  is  n ecessary  only  for  children  under  1      
year.  
10.   Breastfeeding  b enefits  the  baby,  but  not  the  mother.      
11.   When  a  mother  is  HIV-­‐positive,  she  cannot  breastfeed.        
12.   Even  if  a  mother  b elieves  she  does  not  have  enough  breastmilk,      
she  can  still  b e  able  to  adequately  breastfeed  h er  baby.    
13.   A  mother  can  prevent  sore  and  cracked  nipples  b y  correctly      
positioning  and  attaching  h er  baby  at  the  breast.  
14.   The  most  important  thing  a  mother  can  do  to  produce  sufficient      
breastmilk  is  to  breastfeed  h er  baby  frequently,  b oth  d ay  and  
night.  
15.   At  4  months,  a  mother  should  b egin  to  add  foods  in  addition  to      
breastmilk.  
16.   Watery  porridge  is  a  better  food  for  a  6-­‐month  old  baby  than  soft      
porridge.  
17.   A  6–8  month  old  n eeds  to  eat  2  -­‐  3  times  a  day  in  addition  to      
breastfeeding.    
18.   The  mother  or  caregiver  should  actively  encourage  the  baby  to  eat      
all  the  food  given.  
19.   After  6  months,  it  is  good  to  only  breastfeed.      

Day  1   -­‐  3  -­‐

 #   PRE-­‐TEST  AND  POST-­‐TEST   YES   NO  
20.   It  is  n ecessary  that  young  children  have  their  own  p lates  while  they      
are  eating.  
21.   Pumpkins,  mangoes,  papaya,  and  green  leafy  vegetables  contain      
Vitamin  A.  
22.   In  traditional  complementary  foods,  iron  is  a lmost  a lways  d eficient.      
23.   Animal  products  and  legumes  are  the  foods  that  help  a  child  grow.      
24.   Young  children  should  be  breastfed  for  at  least  2  years.      
25.   The  mother  should  wait  until  the  sick  child  is  h ealthy  b efore  giving      
him/her  more  foods.  
26.   Mothers  do  not  n eed  support  from  the  family  or  the  community  in      
order  to  feed  their  children.  
27.   Children  9–24  months  old  should  eat  3-­‐4  times  a  day  a nd  have  1-­‐2      
snacks.  
28.   When  a  young  child  over  6  months  has  diarrhea,  the  mother  n eeds      
to  increase  the  frequency  of  breastfeeding,  frequency  of  other  
liquids,  a nd  the  frequency  of  foods.  
29.   A  pregnant  woman  n eeds  to  eat  more  than  a  woman  who  is      
lactating.  
30.   Red  meat,  liver,  and  green  leafy  vegetables  contain  iron.      
31.   Iodized  salt  is  important  for  the  whole  family.        
32.   A  malnourished  mother  is  likely  to  give  b irth  to  a  low  weight  child.      
33.   Men  can  h elp  improve  women’s  nutrition  b y  h elping  them  with      
their  workload.  
34.   Only  children  n eed  Vitamin  A  supplementation,  n ot  mothers.      
35.   Deworming  is  part  of  anemia  control.      
36.   A  lactating  woman  requires  more  iron  than  a  pregnant  woman.      
37.   Women  n eed  iron  supplementation  once  during  pregnancy.      
38.   Eating  d ifferent  types  of  food  is  important  for  the  growth  of  the      
child  b efore  24  months.  
39.   Breastfeeding  mothers  should  eat  more  than  usual.      
40.   Pregnancy  and  lactation  are  the  only  points  in  the  life  cycle  of      
females  where  nutrition  should  b e  improved.  

Day  1   -­‐  4  -­‐

PRE-­‐TEST  AND  POST-­‐TEST  –  ANSWERS  

#   PRE-­‐TEST     YES   NO  
1.   It  is  good  to  put  the  baby  on  the  breast  immediately  after  birth.   X    
2.   In  order  to  have  enough  milk,  a  mother  n eeds  to  breastfeed  10  
  X  
times  a  day.  
3.   Colostrum  serves  as  the  first  immunization  for  the  baby.   X    
4.   At  4  months,  the  infant  n eeds  water  and  other  drinks  in  addition  to  
  X  
breastmilk.  
5.   Demonstrating  to  a  mother  how  to  b etter  feed  h er  child  is  more  
X    
effective  than  just  telling  h er.    
6.   Having  correct  knowledge  is  all  that  is  n eeded  for  a  mother  to  
  X  
optimally  breastfeed  h er  baby.  
7.   When  breastfeeding,  the  baby’s  chin  n eeds  to  touch  the  mother’s  
X    
breast.  
8.   Only  food  is  important  to  prevent  malnutrition.     X  
9.   Vitamin  A  supplementation  is  n ecessary  only  for  children  under  1  
  X  
year.  
10.   Breastfeeding  b enefits  the  baby,  but  not  the  mother.     X  
11.   When  a  mother  is  HIV-­‐positive,  she  cannot  breastfeed.       X  
12.   Even  if  a  mother  b elieves  she  does  not  have  enough  breastmilk,  
X    
she  can  still  b e  able  to  adequately  breastfeed  h er  baby.    
13.   A  mother  can  prevent  sore  and  cracked  nipples  b y  correctly  
X    
positioning  and  attaching  h er  baby  at  the  breast.  
14.   The  most  important  thing  a  mother  can  do  to  produce  sufficient  
breastmilk  is  to  breastfeed  h er  baby  frequently,  b oth  d ay  and   X    
night.  
15.   At  4  months,  a  mother  should  b egin  to  add  foods  in  addition  to  
  X  
breastmilk.  
16.   Watery  porridge  is  a  better  food  for  a  6-­‐month  old  baby  than  soft  
  X  
porridge.  
17.   A  6–8  month  old  n eeds  to  eat  2  -­‐  3  times  a  day  in  addition  to  
X    
breastfeeding.  
18.   The  mother  or  caregiver  should  actively  encourage  the  baby  to  eat  
X    
all  the  food  given.  
19.   After  6  months,  it  is  good  to  only  breastfeed.     X  
20.   It  is  n ecessary  that  young  children  have  their  own  p lates  while  they  
X    
are  eating.  

Day  1   -­‐  5  -­‐

 #   PRE-­‐TEST     YES   NO  
21.   Pumpkins,  mangoes,  papaya,  and  green  leafy  vegetables  contain  
X    
Vitamin  A.  
22.   In  traditional  complementary  foods,  iron  is  a lmost  a lways  d eficient.   X    
23.   Animal  products  and  legumes  are  the  foods  that  help  a  child  grow.   X    
24.   Young  children  should  be  breastfed  for  at  least  2  years.   X    
25.   The  mother  should  wait  until  the  sick  child  is  h ealthy  b efore  giving  
  X  
him/her  more  foods.  
26.   Mothers  do  not  n eed  support  from  the  family  or  the  community  in  
  X  
order  to  feed  their  children.  
27.   Children  9–24  months  old  should  eat  3-­‐4  times  a  day  a nd  have  1-­‐2  
X    
snacks.  
28.   When  a  young  child  over  6  months  has  diarrhea,  the  mother  n eeds   X  
to  increase  the  frequency  of  breastfeeding,  frequency  of  other    
liquids,  a nd  the  frequency  of  foods.    

29.   A  pregnant  woman  n eeds  to  eat  more  than  a  woman  who  is  
  X  
lactating.  
30.   Red  meat,  liver,  and  green  leafy  vegetables  contain  iron.   X    
31.   Iodized  salt  is  important  for  the  whole  family.     X    
32.   A  malnourished  mother  is  likely  to  give  b irth  to  a  low  weight  child.   X    
33.   Men  can  h elp  improve  women’s  nutrition  b y  h elping  them  with  
X    
their  workload.  
34   Only  children  n eed  Vitamin  A  supplementation,  n ot  mothers.     X  
35.   Deworming  is  part  of  anemia  control.   X    
36.   A  lactating  woman  requires  more  iron  than  a  pregnant  woman.     X  
37.   Women  n eed  iron  supplementation  once  during  pregnancy.     X  
38.   Eating  d ifferent  types  of  food  is  important  for  the  growth  of  the  
X    
child  b efore  24  months.  
39.   Breastfeeding  mothers  should  eat  more  than  usual.   X    
40.   Pregnancy  and  lactation  are  the  only  points  in  the  life  cycle  of  
  X  
females  where  nutrition  should  b e  improved.  

Day  1   -­‐  6  -­‐

SESSION  2  
BEHAVIOR  CHANGE  COMMUNICATION  (BCC)
 
Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Define  b ehavior  change  communication.  
• Explain  why  knowledge  is  n ot  enough  to  change  behavior.  
• Explain  the  s tages  of  b ehavior  change.    
• Practice  identifying  d ifferent  b ehavior  change  stages.  

Overview  
Activity  2.1   Define  Behavior  Change  Communication  and  explain  why  knowledge  is  usually  not  
enough  to  change  b ehavior  (15  minutes)  
Activity  2.2   Explain  the  s tages  of  b ehavior  change  communication  and  the  interventions  
required  at  each  step  of  the  change  (15  minutes)  
Activity  2.3   Practice  identifying  what  behavior  change  s tage  a  mother  is  in  with  regards  to  her  
infant  feeding  practices  (30  minutes)  
 
Total  Time     1  hour  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape  
• Behavior  Change  case  studies  on  cards  

Advance  Preparation  
Handouts  
HO  #1:  Stages  of  Change  Model  
HO  #2:  Stages  of  Change  and  Interventions  

Day  1   -­‐  7  -­‐

DETAILED  ACTIVITIES  

Activity  2.1   Define  Behavior  Change  Communication  and  explain  why  

knowledge  is  usually  never  enough  to  change  behavior    
(15  minutes)  
Methodology  
• Brainstorm  the  d efinition  of  b ehavior  change  communication.  
• Divide  participants  into  buzz  groups  of  three  p eople.  Ask  groups  to  think  about  a  time  when  
someone  told  them  what  to  do.  Ask  them  to  think  about  how  they  felt.    
• Ask  participants  to  think  about  a  time  when  someone  asked  them  what  they  wanted  to  do.  Ask  
them  to  think  about  h ow  they  felt  in  this  s ituation.    
• In  p lenary  discuss  the  d ifference  b etween  how  it  felt  to  be  told  what  do  to  and  how  it  felt  to  b e  
asked  what  they  wanted  to  do.  Ask  a  few  participants  to  share  their  feelings.    

Behavior  =  action/doing  
Change  =  a lways  involves  motivators  a nd  barriers/obstacles  
Communication  =  interpersonal,  visuals,  media,  etc.  
Behavior  change  communication  ( BCC)  is  any  communication  ( e.g.,  interpersonal,  group  talks,  mass  
media,  support  groups,  visuals  and  print  materials,  videos)  that  h elps  foster  a  change  in  b ehavior  in  
individuals,  families,  or  communities.    

Activity  2.2   Explain  the  stages  of  behavior  change  communication  and  
the  interventions  required  at  each  step  of  the  change    
(15  minutes)  
Methodology  
• On  flip-­‐chart,  draw  steps  and  brainstorm  with  participants  how  one  generally  moves  through  the  
different  stages  to  b ehavior  change  (use  exclusive  breastfeeding  as  an  example).  
• Distribute  and  discuss  handouts  (HO  #1  and  2):  “Stages  of  Change  Model”  and  “Stages  of  Change  
and  Interventions.”  
• Ask  participants  to  close  their  eyes  and  think  about  a  b ehavior  (other  than  drinking  alcohol  or  
smoking)  they  are  trying  to  change.  Ask  them  to  identify  at  what  s tage  they  are  and  why.  Ask  
what  they  think  they  will  n eed  to  move  to  the  n ext  stage.  
• Discuss  h ow  information  is  usually  n ever  enough  to  change  b ehavior,  and  that  motivation  and  
reinforcement  are  required.  
• Refer  to  handouts  (HO  #1  and  2)  and  discuss.  

Day  1   -­‐  8  -­‐

Activity  2.3   Practice  identifying  what  behavior  change  stage  a  mother  is  
in  with  regards  to  her  infant  feeding  practices    
(30  minutes)  
Methodology  

• Divide  into  three  working  groups  –  give  each  group  the  three  case  studies.  
• Assign  each  group  a  case  s tudy  to  present.  
• When  d iscussing  each  of  the  case  studies,  each  group  identifies  which  stage  a  mother  is  in.    
• Each  group  presents  one  case  s tudy  previously  assigned.  
• Discussion  in  p lenary.  

Behavior  Change  Case  Studies  

1. A  woman  has  h eard  the  n ew  breastfeeding  information,  and  h er  husband  and  mother-­‐in-­‐law  
also  are  talking  about  it.  She  is  thinking  about  trying  exclusive  breastfeeding  because  she  
thinks  it  will  b e  b est  for  h er  child.  
2. A  woman  has  brought  h er  8-­‐month-­‐old  child  to  the  baby  weighing  s ession.  The  child  has  lost  
weight.  The  health  care  worker  tells  her  to  give  her  child  d ifferent  food  b ecause  the  child  is  
not  growing.  
3. The  past  month,  a  health  worker  talked  with  a  mother  about  gradually  starting  to  feed  h er  7-­‐
month-­‐old  baby  three  times  a  day  instead  of  just  once  a  day.  The  mother  started  to  give  a  
meal  and  a  snack  and  then  added  a  third  feed.  Now  the  baby  wants  to  eat  three  times  a  day.  

Behavior  Change  Case  Studies  (Answer  Key)  

1. A  woman  has  h eard  the  n ew  breastfeeding  information,  and  h er  husband  and  mother-­‐in-­‐law  
also  are  talking  about  it.  She  is  thinking  about  trying  exclusive  breastfeeding  because  she  
thinks  it  will  b e  b est  for  h er  child.  
Contemplation/Intention  
2. A  woman  has  brought  h er  8–month-­‐old  child  to  the  baby  weighing  s ession.  The  child  has  lost  
weight.  The  health  care  worker  tells  her  to  give  her  child  d ifferent  food  b ecause  the  child  is  
not  growing.  
Awareness  
3. The  past  month  a  h ealth  worker  talked  with  a  mother  about  gradually  starting  to  feed  h er  7–
month-­‐old  baby  three  times  a  day  instead  of  just  once  a  day.  The  mother  started  to  give  a  
meal  and  a  snack  and  then  added  a  third  feed.  Now  the  baby  wants  to  eat  three  times  a  day.  
Trial/Adoption  

Day  1   -­‐  9  -­‐

SESSION  3  
CAUSES  OF  MALNUTRITION  AND  CHILD  HEALTH  
 
Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• List  five  causes  of  malnutrition.  
• Explain  how  breastfeeding  relates  to  child  survival.    

Overview  
Activity  3.1   Brainstorm  on  the  d ifferent  causes  of  malnutrition  ( 15  minutes)  
 
Total  Time  15  minutes  

Materials  Needed  
• Flipchart    

Advance  Preparation  
Handouts  
HO  #3:  Conceptual  Framework  for  Malnutrition  

DETAILED  ACTIVITIES  
Activity  3.1   Brainstorm  on  the  different  causes  of  malnutrition    
(15  minutes)  
Methodology  
• Explain  and  d iscuss:  what  does  the  term  malnutrition  mean?  
Malnutrition  is  a  condition  caused  by  not  getting  enough  of  the  right  food  to  eat  or  enough  quantity  
of  food.  Causes  of  malnutrition  are  multi-­‐  factorial  and  can  b e  d ivided  into  immediate,  underlying  
and  basic.  
• Divide  participants  into  groups  of  two  or  three.    
• Ask  them  to  discuss  what  they  think  are  the  main  causes  of  malnutrition  and  then  s elect  the  
three  most  important  causes.  
• One  participant  from  each  group  presents  the  identified  causes.  
• The  presenter  clusters  the  causes  according  to  the  three  main  causes  (Immediate,  Underlying  
and  Basic).  
• The  facilitator  summarizes  the  causes  of  malnutrition  a nd  asks  the  participant  to  read  the  HO  #3.  
• The  facilitator  explains  the  HO  #3.  

Day  1   -­‐  10  -­‐

SESSION  4  
THE  ROLE  OF  HEALTH  WORKERS  
THE  ESSENTIAL  NUTRITION  ACTIONS  TO  PREVENT  MALNUTRITION  
 
Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Outline  the  different  activities  and  p laces  when  health  workers  support  the  improvement  of  
women  and  their  children’s  health.  

Overview  
Activity  4.1   What  are  the  routine  nutrition  activities  that  the  h ealth  worker  can  carry  out  with  
women  to  improve  their  own  and  children’s  h ealth?  And  where/when  can  the  h ealth  
worker  share  these  messages  with  women?  
Total  Time   30  minutes  
 
Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Flipchart  with  7  essential  nutrition  actions  written  out  

Advance  Preparation  
Handout  
HO  #4:     The  7  Essential  Nutrition  Actions  and  7  Contact  Points  for  Implementing  Essential  Nutritional  
Actions  

DETAILED  ACTIVITIES  

Activity  4.1   What  are  the  routine  nutrition  services  that  the  Health  
workers  provide  to  women  to  improve  their  own  and  
children’s  health?  And  where/when  can  the  health  worker  
share  these  messages  with  women    
(30  minutes)  
Methodology  
• Brainstorm  the  routine  nutrition  a ctivities  that  the  h ealth  worker  carry  out  with  women  to  
improve  the  h ealth  of  women  and  their  children.  
• Brainstorm  the  p laces  where/when  the  h ealth  worker  share  key  messages  with  women.  
• Compare  participants’  responses  with  the  prepared  flipchart  on  the  7  essential  nutrition  actions  
and  the  contact  points  for  implementing  these  a ctivities.  
• Refer  to  handout  (HO  #4).    
• Discussion  and  summary.  

Day  1   -­‐  11  -­‐

SESSION  5  
THE  BENEFITS  OF  BREASTFEEDING  
 
Learning  Objective  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Describe  the  benefits  of  breastfeeding  and  the  risks  of  formula  feeding  for  the  infant,  the  
mother,  the  family,  a nd  the  community/nation.    
 
Overview  
Activity  5.1   Benefits  of  breastfeeding  (30  minutes)  
 
Total  Time     30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
 
Advance  Preparation  
Handout    
HO  #5   Benefits  of  Breastfeeding  for  the  Infant/Young  Child  and  risks  of  formula  feeding  

DETAILED  ACTIVITIES  

Activity  5.1   How  to  explain  the  benefits  of  breastfeeding    

(30  minutes)  
Methodology  
• Divide  participants  into  four  groups.  F ive  flipcharts  are  set-­‐up  throughout  the  room  with  the  
following  titles:  1)  Benefits  of  breastfeeding  for  the  infant;  2)  Benefits  of  breastfeeding  for  the  
mother;  3)  Benefits  of  breastfeeding  for  the  family;  4)  Benefits  of  breastfeeding  for  the  
community/nation;  and  5)  Risks  of  formula  feeding  for  the  infant  and  the  mother.  
• Each  group  has  three  minutes  at  each  flipchart  to  write  as  many  b enefits  as  they  can  think  of  
(without  repeating  b enefits  already  listed),  then  the  groups  rotate  to  the  n ext  flipchart  and  
repeat  the  exercise.  
• Discussion  and  summary  in  plenary.    
• Refer  to  Handout  “How  to  explain  the  b enefits  of  BF”  a nd  “Risks  of  formula  feeding”  (HO  #5)  and  
discuss.    

Day  1   -­‐  12  -­‐

SESSION  6  
OPTIMAL  BREASTFEEDING  PRACTICES  CORRECT  POSITIONING    
AND  ATTACHMENT  
IMPORTANCE  OF  VITAMIN  A  AND  IRON  SUPPLEMENTATION  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Explain  the  optimal  breastfeeding  practices.    
• Explain  the  importance  of  each  practice.  
• Demonstrate  proper  positioning  and  attachment.  
• Explain  the  importance  of  post-­‐partum  V itamin  A  supplementation  and  iron  supplementation  for  
the  mother.  
 
Overview  
Activity  6.1   Optimal  breastfeeding  messages  (30  minutes)  
Activity  6.2     How  h ealth  workers  support  the  h ealth  of  women  and  children  (30  minutes)  
Activity  6.3     Proper  positioning  and  attachment  (45  minutes)  
 
Total  Time     1  hour  45  minutes  

Materials  Needed  
• Flipchart  papers,  markers  and  masking  tape    
• Two  flipcharts  on  the  three  optimal  breastfeeding  practices  ( initiation,  exclusive,  frequency)  
• Booklet  on  key  ENA  messages  
• Dolls  and/or  babies  
• Breast  models  
 
Advance  Preparation  
Handouts  
HO  #6:     Key  messages  on  optimal  breastfeeding  0  –  6  months    
HO  #7:     “How  h ealth  providers  can  support  optimal  breastfeeding  practices”  and  “How  to  
explain  the  common  breastfeeding  p ositions  &  proper  attachment”  
HO  #36-­‐38:  Micronutrient  protocols  
Note:  If  p ossible,  make  arrangements  in  advance  to  have  breastfeeding  women  present  a t  the  
activity  to  d emonstrate  proper  positioning  and  a ttachment.  

Day  1   -­‐  13  -­‐

DETAILED  ACTIVITIES  

Activity  6.1   Optimal  breastfeeding  messages    

(30  minutes)  
Methodology  
• Divide  participants  into  s ix  groups.    
• Ask  two  groups  to  review  Illustration  #  4,  two  to  review  Illustration  #5,  and  two  to  review  
Illustration  #6.    
• Have  each  of  the  s mall  groups  d iscuss  a mong  themselves  and  make  a  list  of  optimal  
breastfeeding  messages.  
• Each  group  presents;  and  the  s econd  group  on  the  same  subject  completes.  
• Also  refer  to  the  HO  #6.    

Activity  6.2   How  health  workers  support  the  health  of  women  and  
children  (30  minutes)  
Methodology  
• Divide  participants  into  s ix  groups;  assign  each  group  to  one  of  the  following  questions  to  
answer  and  present:    
1. How  can  a  h ealth  worker  h elp  mothers  or  caretakers  a chieve  optimal  breastfeeding?    
2. Which  questions  must  a  h ealth  worker  ask  a  pregnant  mother?    
3. Why  must  the  mother  take  a  Vitamin  A  capsule  at  the  health  centre  within  8  weeks  after  
delivery?    
4. Why  should  Iron/Folic  Acid  supplementation  b e  continued  after  d elivery?    
5. Which  types  of  information  do  a  mother  of  a  3-­‐month-­‐old  baby  n eed?  
6. Which  immunization  should  the  child  receive  b efore  the  a ge  of  6  months?  
• Presentations  b y  the  groups.  
• Discussion  and  summary  in  plenary.  

Possible  Answers    
Question  1:  How  can  a  h ealth  worker  h elp  mothers  or  child  caretakers  a chieve  optimal  
breastfeeding?  
• Discuss  the  b enefits  of  breastfeeding  and  b irth  spacing  with  the  mother,  h er  husband,  and  family  
(if  possible).    
• Help  the  mother  to  breastfeed  immediately  after  delivery  at  hospital,  at  home,  or  at  the  
midwife’s,  and  give  colostrum  t o  t he  baby.  
• Explain  that:    
• Colostrum  protects  infant  from  d isease  b y  providing  the  infant’s  first  vaccine.  
• Helps  expel  the  p lacenta  more  rapidly  and  reduce  blood  loss.  
• Helps  expel  meconium,  the  infant’s  first  stool.  
• Stimulates  breastmilk  production.    
• Keeps  n ewborn  warm  through  s kin-­‐to-­‐skin  contact.  

Day  1   -­‐  14  -­‐

• Promote  exclusive  breastfeeding  from  0  -­‐  <  6  months  b ecause:  
• Breastmilk  contains  all  the  water  and  nutrients  that  an  infant  n eeds  to  satisfy  hunger,  thirst,  
and  growth.  
• No  other  foods  for  liquids  should  b e  given  during  the  first  six  months.  
• Infants  are  likely  to  have  fewer  d iarrheal,  respiratory,  and  ear  infections.    
• Exclusive  breastfeeding  h elps  space  b irths  b y  delaying  the  return  of  fertility.    
• Mention  the  importance  of  initiating  complementary  foods  at  6  months  but  continuing  
breastfeeding  for  two  years.  
• After  6  months,  breastmilk  a lone  cannot  meet  all  the  n utritional  n eeds  for  baby’s  growth  and  
development.    
• Mother  or  caregiver  should  b egin  complementary  feeding  by  adding  a vailable  affordable  local  
foods  to  staple  foods.  
• Mother  should  continue  to  give  breastmilk  to  the  child  for  two  years  as  it  will  continue  to  
protect  the  child  against  illness.  

Also    
• Answer  mother  or  caregiver’s  questions.  
• Congratulate  and  encourage  the  mother/caregiver.  
• Encourage  mother/caregiver  to  go  to  a  community  support  group  if  she  encounters  
breastfeeding  d ifficulties.  
• Refer  h er  to  community  support  groups  or  the  h ealth  centre  for  other  family  p lanning  methods.  
• Remind  mother  or  caregiver  to  immunize  the  child:  BCG,  DPT,  and  Polio.    

Question  2:  Which  questions  must  a  h ealth  worker  ask  a  pregnant  mother?  
• How  will  you  feed  your  baby?  
• If  the  mother  does  not  p lan  to  breastfeed  h er  baby,  ask  why.  
• Have  you  h eard  of  exclusively  breastfed?  Reinforce  the  key  points  about  exclusive  
breastfeeding  (0  –  <  6  m onths).  
• Did  you  encounter  any  difficulties  breastfeeding  other  children?  What?  
• Have  you  already  b een  to  a  h ealth  centre  for  prenatal  care  and  for  Iron/Folic  Acid  
supplementation?  Do  you  take  the  supplements  every  day?  
• Did  you  get  your  tetanus  vaccination?  
• If  HIV  Testing  and  Counseling  is  a vailable:  have  you  thought  of  taking  an  HIV  test?  

Question  3:  Why  must  the  mother  take  a  V itamin  A  capsule  within  8  weeks  after  d elivery?  
• Mothers  n eed  to  increase  her  Vitamin  A  stores  for  h er  health  and  the  baby’s  h ealth  (Vitamin  A  
passes  into  breastmilk)  
• Vitamin  A  capsules  should  not  b e  administered  during  the  woman’s  pregnancy  b ecause  it  is  n ot  
good  for  baby  at  that  point.  This  is  why  Vitamin  A  should  be  administered  within  8  weeks  after  
delivery,  when  the  woman  has  no  risk  of  b eing  pregnant.  
• Breastfeeding  mothers  must  b e  encouraged  to  eat  food  rich  in  Vitamin  A  (papaya,  mangos,  
carrots,  pumpkin,  green  leafy  vegetables,  liver).  
• Refer  to  HO  #38  and  ask  a  participant  to  read.

Day  1   -­‐  15  -­‐

Question  4:  Why  should  iron/folic  a cid  supplementation  be  continued  after  d elivery?  
• The  iron/folic  acid  supplementation  should  b e  given  to  the  mother  for  a  total  of  6  months.  After  
delivery,  the  mother  has  to  continue  the  supplementation  to  complete  the  six  months  to  
prevent  anemia.    
• Because  the  mother  has  lost  blood  during  d elivery,  she  needs  to  increase  her  iron  stores  for  the  
sake  of  h er  and  h er  baby’s  h ealth  (iron  passes  into  breastmilk).  
• Breastfeeding  mothers  should  be  encouraged  to  eat  food  rich  in  iron  (greens,  meat,  liver,  
legumes).  
• Refer  to  HO  #  30  and  ask  a  participant  to  read.  

Question  5:  What  type  of  information  should  b e  given  to  a  mother  of  a  3-­‐month-­‐old  infant?  
• The  mother  should  increase  breastfeeding  frequency  a s  the  baby  is  growing  fast.  
• She  n eeds  to  make  sure  that  she  empties  one  breast  b efore  she  s witches  to  the  other.  
• She  should  not  to  give  any  food  or  drink  to  the  infant,  as  the  infant  is  not  ready.  The  mother  will  
have  enough  milk  if  she  follows  this  a dvice  ( the  more  the  baby  sucks,  the  more  milk  the  mother  
will  produce).  
 
Question  6:  Which  immunizations  should  a  child  receive  b efore  the  age  of  6  months?  
• BCG  +  Polio  0  
• Polio1  +  Penta1  
• Polio2  +  Penta2  
• Polio3  +  Penta3  
• Remind  the  mother  to  come  back  at  9  months  for  the  measles  and  yellow  fever  vaccines,  and  at  
6  months  for  Vitamin  A  supplementation  (IU  100,000)  

Day  1   -­‐  16  -­‐

Activity  6.3   Proper  positioning  and  attachment    
(45  minutes)  
Methodology  
• Facilitator  d emonstrates  incorrect  positioning  and  a ttachment  using  doll.    
• Mother  and  baby  (if  a vailable)  demonstrate  proper  positioning  and  attachment,  or  facilitator  
uses  a  d oll.  
• Facilitator  asks  participants  to  explain  the  position  and  attachment.  
• Facilitators  add  a dditional  explanations  on  position  and  attachment.  
• In  s mall  groups  of  three  to  five  ( with  a  mother  and  baby),  participants  practice  good  positioning  
and  attachment  and  receive  feedback  from  each  other.  
• If  no  mothers  and  babies  are  a vailable,  participants  practice  in  triads  with  dolls:  mother,  
counselor,  and  observer.  Each  participant  rotates  each  role.  
• Two  pairs  d emonstrate  good  positioning  and  attachment  in  plenary  with  baby  or  doll.  
• Feedback  and  discussion.  
• Read  to  handout  ( HO  #7)  or  illustrations  8,  9,  10  from  the  Booklet  on  key  ENA  messages.    

Position  and  Attachment  Techniques    

1. Preparation  and  how  to  breastfeed  (Proper  positioning)    
• The  mother  must  b e  comfortable.  
• Hold  the  infant  in  such  a  way  as  to  have  his/her  face  a t  the  mother’s  breast  level  (the  infant  
should  b e  able  to  look  up  at  the  mother’s  face,  not  facing  h er  chest  or  abdomen).  
• The  infant’s  s tomach  should  b e  a gainst  the  mother’s  s tomach.  
• The  infant’s  h ead,  back,  and  buttocks  should  b e  in  a  straight  line.  
• The  infant  n eeds  to  b e  close  to  the  mother.  
• The  infant  is  brought  to  the  breast;  the  baby's  whole  b ody  should  be  supported,  not  just  the  
head  and  shoulders.  
• The  mother  should  hold  h er  breast  with  h er  fingers  in  a  C  shape,  the  thumb  b eing  above  the  
areola  and  the  other  fingers  b elow.  Fingers  should  not  be  in  scissor  h old  because  this  method  
tends  to  put  pressure  on  the  milk  ducts  and  can  take  the  n ipple  out  of  the  infant’s  mouth.  

2. Signs  of  proper  attachment    

Good  attachment  is  important  to  enable  the  infant  to  suckle  effectively,  to  
remove  the  milk  efficiently,  and  stimulate  an  adequate  supply.  
• Tease  the  infant’s  lower  lip  with  the  n ipple,  in  order  for  the  infant  to  open  
wide  his/her  mouth.  
• The  infant’s  mouth  covers  a  large  part  of  the  areola  (there  is  more  areola  
showing  above  rather  than  b elow  the  n ipple).  
• Both  lips  are  turned  outwards.  
• The  areola  and  the  n ipple  will  s tretch  and  b ecome  longer  in  the  infant’s  mouth.  
• The  infant’s  chin  touches  the  breast.  
Poor  attachment  results  in  incomplete  removal  of  milk,  which  can  lead  to  sore  nipples,  inflammation  
of  the  breast,  and  mastitis.    

Day  1   -­‐  17  -­‐

3. Signs  of  e fficient  suckling  
• Slow  and  regular  sucking  a t  the  following  rhythm:  two  suctions  and  one  swallowing.  
• The  infant  takes  s low  d eep  sucks,  sometimes  pausing.  
• Suckling  is  comfortable  and  pain-­‐free.  
• The  mother  h ears  h er  baby  s wallowing.  
• The  breast  is  softer  after  the  feed.  

Demonstration  of  Different  Breastfeeding  Positions  

1. Sitting  position    
• Usual  position  of  most  mothers.  
• Make  sure  infant’s  and  mother’s  stomachs  are  facing  each  other.  

2. Side-­‐Lying    
• This  position  is  more  comfortable  for  the  mother  after  delivery  a nd  it  h elps  h er  to  rest  while  
breastfeeding.  
• The  mother  and  infant  are  both  lying  on  their  s ide  and  facing  each  other.  

3. American  Football    
• This  position  is  b est  used:    
• after  a  Caesarean  s ection;    
• when  the  nipples  are  painful;  or    
• to  breastfeed  twins.  
• The  mother  is  comfortably  s eated  with  the  infant  under  her  arm.  The  infant’s  body  passes  by  the  
mother’s  side  and  his/her  h ead  is  a t  breast  level.    
• The  mother  supports  the  infant’s  h ead  and  body  with  her  hand  and  forearm.  
• Ask  one  or  two  participants  to  demonstrate  this  position  with  a  doll  and  a  breast  model.  

Regardless  of  the  position  chosen,  the  mother  must  be  comfortable.  She  should  not  lean  toward  the  
infant  but  rather  draw  him/her  towards  herself.  For  example,  sitting  p osition:  back  resting  on  the  
chair’s  back  or  cushion,  feet  crossed,  or  raised  on  a  stool.  

Day  1   -­‐  18  -­‐

Day  1   -­‐  19  -­‐
SESSION  7  
BREASTFEEDING  BELIEFS  AND  MYTHS  
 

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Encourage  b eliefs  that  are  b eneficial  to  breastfeeding.  
• Identify  beliefs  and  myths  that  should  b e  discouraged.  

Overview  
Activity  7.1   Reflection  on  breastfeeding  b eliefs  and  myths  as  they  relate  to  breastfeeding  
practices  (30  minutes)  
 
Total  Time     30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    

DETAILED  ACTIVITIES  

Activity  7.1     Reflection  on  breastfeeding  beliefs  and  myths  as  they  relate  
to  breastfeeding  practices    
(30  minutes)  
Methodology  
• On  a  flipchart,  facilitator  draws  three  columns:    
• breastfeeding  b eliefs  that  have  a  positive  effect  on  breastfeeding;  
• breastfeeding  b eliefs  that  have  a  negative  effect  on  breastfeeding;  a nd  
• breastfeeding  b eliefs  that  d o  not  hinder  breastfeeding  (neutral).  
• In  p lenary,  participants  brainstorm  the  breastfeeding  b eliefs  that  are  practiced  in  their  
communities.  
• In  p lenary,  participants  d ecide  in  which  column  to  place  each  breastfeeding  b elief.  
• Participants  d iscuss  h ow  those  b eliefs  that  have  a  negative  effect  on  breastfeeding  might  b e  
changed  ( while  a lways  respecting  the  b elief).  

Day  1   -­‐  20  -­‐

SESSION  8  
PICTURE  STORY  

Learning  Objective  
By  the  end  of  the  s ession,  participants  will  b e  able  to:      
• Use  picture  story  to  h elp  a chieve  b ehavior  change.  
   
Overview  
Activity  8.1   Why,  and  how  to  use  the  picture  s tory/poster,  and  practice  exercises  on  optimal  
exclusive  breastfeeding  practices  using  p icture  stories  (30  minutes)  
 
Total  Time     30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Picture  story/poster,  woman’s  h ealth  record,  child’s  h ealth  record  (or  p ictures)  that  convey  
immediate  initiation  of  breastfeeding  after  d elivery,  providing  pre-­‐lacteal  feeds,  incorrect  
latching  on,  the  correct  position  for  breastfeeding,  providing  water,  using  a  b ottle  with  milk,  
giving  food  to  a  4-­‐month-­‐old,  using  only  one  breast.  

DETAILED  ACTIVITIES  

Activity  8.1   Why  and  how  to  use  the  picture  story/poster  and  practice    
(30  minutes)  
Methodology  
• Discuss  the  b enefits  of  using  a  p icture  story  to  facilitate  counseling.  
• Use  a  picture  s tory/poster/drawing  that  shows  exclusive  breastfeeding  or  related  behaviors  such  
as  the  woman’s  h ealth  record,  child’s  h ealth  record,  chest  s kill  tool,  poster,  etc.  
• Ask  participants  to  pair  up.    
• Each  pair  should  practice  two  dialogues  switching  roles  the  s econd  time  (each  p erson  p lays  each  
role  once).  
• Discuss  and  summarize  the  effectiveness  of  this  approach  with  the  group.    

Content  
Benefits  of  using  a  picture  story:  
• It  a llows  the  h ealth  provider  to  discuss  issues  that  may  be  personal  in  an  impersonal  way.  
• It  a llows  the  h ealth  provider  to  ask  about  b ehaviors  that  the  patient  does  indirectly.    

Day  1   -­‐  21  -­‐

• For  example,  b y  asking  “if  this  p erson  in  the  picture  is  your  n eighbor,  what  do  you  think  they  are  
doing  or  would  do  if  or  when?”  The  h ealth  provider  is  more  apt  to  get  the  true  answer,  rather  
than  what  the  patient  thinks  you  (the  h ealth  provider)  want  to  h ear.    
• It  is  a lso  easier  to  probe  for  more  information  b y  asking  the  patient  to  continue  and  tell  you  
what  might  happen  n ext.    

Possible  dialogue  t o  roleplay:  

• One  person  is  the  h ealth  provider  and  the  other  is  a  mother  of  an  infant  0-­‐  5  months  old  
(someone  who  is  not  very  knowledgeable  about  breastfeeding).  The  pairs  practice  this  d ialogue  
twice,  switching  roles  the  s econd  time  ( each  p erson  plays  each  role  once).  

Using  picture  t o  facilitate  discussion:  

1. What  do  you  s ee  happening  in  this  p icture?  How  old  d o  you  think  this  baby  is?  Are  there  any  
other  breastfeeding  behaviors  that  this  mother  should  be  sure  to  do  or  n ot  d o  for  this  X-­‐month-­‐
old  infant?    
2. Can  you  tell  me  what  d ifficulties  that  mother  might  have  while  breastfeeding  h er  X-­‐month-­‐old  
baby?  What  would  you  recommend  to  h er  to  remove  these  d ifficulties?    

Day  1   -­‐  22  -­‐

SESSION  9  
LACTATIONAL  AMENORRHOEA  METHOD  (LAM)  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Describe  the  three  lactational  a menorrhea  method  (LAM)  criteria.    
• Mention  at  least  three  benefits  of  LAM.  
• Explain  who  can  use  LAM.  
• Practice  identifying  the  LAM  criteria.    

Overview  
Activity  9.1     Relationship  b etween  breastfeeding  and  child  spacing  and  definition  of  LAM  and  
LAM  criteria  (10  minutes)  
Activity  9.3     Benefits  and  d isadvantages  of  LAM;  who  can  use  LAM;  family  p lanning  methods  
for  the  woman  who  breastfeeds  ( 10  minutes)  
Activity  9.4   Through  case  studies,  practice  identifying  the  LAM  criteria  (30  minutes)  
 
Total  Time     50  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
 
Advance  Preparation  
Handout  
HO  #  8:    Key  Messages  on  the  Lactational  Amenorrhea  Method  (LAM)    

DETAILED  ACTIVITIES  
Activity  9.1   Relationship  between  breastfeeding  and  child  spacing  
and  definition  of  LAM  and  LAM  criteria    
(10  minutes)  
Methodology  
• Facilitator  asks  participants  if  the  women  in  the  communities  where  they  work/live  relate  
breastfeeding  to  child  spacing;  d iscussion.  
• Brainstorm  the  d efinition  of  LAM  and  LAM  criteria.  
• Facilitator  presents  the  LAM  criteria  and  the  fourth  parameter.  

Day  2       -­‐  23  -­‐    

Introducing  LAM  
Breastfeeding  is  essential  to  child  survival.  It  has  many  benefits  for  the  child  as  well  as  for  the  
mother,  including  b irth  spacing.  
The  method  using  breastfeeding  to  space  b irths  is  called  LAM  (Lactational  Amenorrhea  
Method).  
  L  =  Lactational     A  =  Amenorrhea   M  =  Method  
Birth  spacing  is  essential  for  maternal  h ealth  and  child  survival.  Spacing  b irths  to  3  years  or  
more:  
• Helps  to  save  lives.  
• Helps  to  reduce  child  mortality  and  morbidity.  
• Gives  the  mother  time  to  replenish  h er  body  s tores.  

LAM  is  m ore  than  98%  effective  if  the  three  following  criteria  are  met:  
1.   Amenorrhea  (no  menses)  
2.   Exclusive  breastfeeding    
• Exclusive  breastfeeding  is  recommended/promoted  
• For  LAM  to  b e  effective,  the  mother  must  breastfeed  a t  least  every  four  hours  
with  an  interval  of  no  longer  than  s ix  hours  a t  n ight.  
3.   The  infant  is  less  than  6  months  of  age.  
4th  parameter  –  when  a  woman  no  longer  meets  one  of  the  three  criteria,  she  n eeds  to  b egin  
another  family  planning  method  to  prevent  pregnancy.  

Activity  9.2   Benefits  and  disadvantages  of  LAM;  who  can  use  LAM;  
family  planning  methods  for  the  woman  who  
breastfeeds    
(10  minutes)  
Methodology  
• Facilitators  ask  participants  the  following  questions:  1)  What  are  the  benefits  and  
disadvantages  of  LAM?  2)  Who  can  use  LAM?  and  3)  What  other  family  p lanning  methods  
can  the  breastfeeding  mother  use?  
• Facilitators  fill  in  the  gaps.  
• Refer  to  HO  #8.  
 
Benefits  of  LAM  
• Universally  a vailable  method  
• More  than  98%  effective  
• Starts  immediately  after  d elivery  
• Promotes  maternal  and  child  h ealth  

Day  2       -­‐  24  -­‐    

• Does  not  require  products  or  d evices  
• Preliminary  step  to  using  other  contraceptive  methods  
• Accepted  in  most  cultures  
 
Disadvantages  of  LAM  
• The  method  can  b e  used  only  during  a  limited  p eriod  of  time  (6  months  after  birth)  
• Does  not  protect  against  STIs  or  HIV  
• Exclusive  breastfeeding  may  b e  difficult  to  maintain  
• Can  b e  used  only  b y  breastfeeding  women  

Who  can  use  LAM  

• All  breastfeeding  women,  in  their  p ostpartum  p eriod,  who  p lan  to  continue  to  breastfeed    
• Working  women  
Intervals  b etween  feedings  of  more  than  four  hours  during  the  day  can  reduce  LAM’s  
effectiveness.  It  is  also  recommended  that  there  b e  n o  more  than  one  interval  of  s ix  hours  
between  feedings  (usually  during  the  night).  
It  is  possible  to  express  milk  ( expressing  must  not  replace  nursing  b y  more  than  10  p ercent).  
If  mother  is  s eparated  from  h er  baby  during  the  day,  s he  may  try  frequent  feeding  during  the  
night.  

What  other  family  planning  methods  can  be  used  while  breastfeeding?  
• Before  6  m onths:  minipills,  progesterone-­‐only  injectables,  implants  
• After  6  months:  combined  oral  contraceptives  
• Any  t ime:    
• Barrier  methods        
• IUD  
• Sterilization  ( man  or  woman)  
• Natural  family  planning  methods    

Activity  9.3   Practice  identifying  LAM  criteria    

(30  minutes)  
Methodology  
• Distribute  eight  case  s tudies  to  groups  of  three  participants.  Each  group  d ecides  if  the  
mother  can  use  LAM,  and  why  or  why  not.  
• Each  group  presents  a  case  s tudy  until  all  are  reported  on.  
• Participants  give  feedback.  
• Discussion  and  summary  in  plenary.  

Day  2       -­‐  25  -­‐    

Case  studies  and  answers  to  identify  LAM  Criteria:  Can  this  w oman  use  LAM?  
1.   A  mother  has  a  4-­‐month-­‐old  baby  and  has  not  had  h er  menstrual  p eriod.  She  does  the  
laundry  for  three  hours  a  day  and  leaves  the  baby  with  his  brothers  and  s isters.  She  breastfeeds  
her  baby  exclusively.    
A:  Yes,  meets  all  three  criteria.  
 
2.   Mother  with  a  3-­‐month-­‐old  baby  exclusively  breastfeeds  and  has  a lready  had  h er  
menstrual  p eriods.    
A:  No,  because  her  menstrual  periods  have  returned.  
 
3.   Mother  with  a  2-­‐week-­‐old  baby;  exclusively  breastfeeds,  has  vaginal  bleeding.  
A:  Yes,  bleeding  during  t he  first  two  months  postpartum  is  not  considered  menstrual  bleeding.  
 
4.   Mother  with  a  2-­‐month-­‐old  baby  has  not  had  a  menstrual  p eriod;  she  breastfeeds  h er  
and  gives  h er  a  bottle  of  sugar-­‐water  three  times  every  day.  
A:  No,  because  breastfeeding  is  not  exclusive.  
 
5.   Mother  with  a  four-­‐month-­‐old  baby  exclusively  breastfeeds  h im  and  the  baby  sleeps  
from  12  midnight  to  6  am.  She  has  not  had  a  menstrual  p eriod.  
A:  Yes,  because  she  m eets  all  of  t he  criteria.  
 
6.   Mother  with  a  3-­‐month-­‐old  baby  breastfeeds  exclusively;  she  had  her  menstrual  p eriod  
last  week.    
A:  No,  because  her  menstrual  period  returned.  
 
7.   Mother  with  a  4-­‐month-­‐old  baby  breastfeeds  exclusively  day  and  n ight  and  has  not  had  
a  menstrual  p eriod  yet.  
A:  Yes,  meets  all  three  criteria.  
 
7.   Mother  who  is  exclusively  breastfeeding  her  4-­‐month-­‐old  baby.  She  saw  a  little  spotting  
one  day  last  month.  
A:  Yes,  because  menstruation  as  defined  for  use  in  LAM  is  two  consecutive  days  of  bleeding  
after  two  m onths  postpartum,  or  when  a  w oman  perceives  that  she  has  had  a  bleed  similar  t o  
her  menstrual  bleed.  

Day  2       -­‐  26  -­‐    

SESSION  10  
COMMON  BREASTFEEDING  DIFFICULTIES:  PREVENTION  AND  SOLUTIONS  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Identify  common  difficulties  that  can  occur  during  breastfeeding.  
• List  ways  to  prevent  common  breastfeeding  difficulties.  
• Adequately  solve  these  d ifficulties.  

Overview  
Activity  10.1   Identify  common  difficulties  that  can  occur  during  breastfeeding  ( 5  minutes)  
Activity  10.2   Identify  prevention  measures  and  solutions  for  four  of  the  most  common  
breastfeeding  d ifficulties  (35  minutes)  
Activity  10.3   Discuss  “Special  S ituations”  affecting  breastfeeding  (20  minutes)  
 
Total  Time     1  hour  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Case  s tudies  of  common  breastfeeding  difficulties  on  cards  
• Each  case  study  written  on  a  p iece  of  paper  
• Each  breastfeeding  s ituation  written  on  a  card  (small  p iece  of  paper)  

Advance  Preparation  
Handouts  
HO  #9  Common  Breastfeeding  Difficulties  and  Special  Situations  

Day  2       -­‐  27  -­‐    

DETAILED  ACTIVITIES  
Activity  10.1   Identify  common  difficulties  that  can  occur  during  
breastfeeding    
(5  minutes)  
Methodology  
• Brainstorm  common  d ifficulties  that  can  occur  d uring  breastfeeding  and  on  a  flip-­‐chart  
group  the  difficulties  into  three  categories:    
1)  Difficulties  related  to  mother;    
2)  Difficulties  related  to  the  baby;  and    
3)  Special  s ituations.  

Activity  10.2   Identify  prevention  measures  and  solutions  for  four  of  
the  most  common  breastfeeding  difficulties    
(35  minutes)  
Methodology  
• Divide  participants  into  four  working  groups.  
• Each  group  lists  the  prevention  measures  and  solutions  to  one  of  the  four  most  common  
breastfeeding  d ifficulties:    
• Engorgement;    
• Sore  and  cracked  nipples;    
• Plugged  ducts  that  can  lead  to  mastitis;  and    
• Insufficient  milk.  
• Each  group  presents  the  prevention  measures  and  solutions  of  a  common  breastfeeding  
difficulty.  
• Give  a  case  study  to  each  group,  and  ask  group  to  identify  the  problems  and  explain  the  
solution.  
• Each  group  presents.  
• Discuss  and  summarize  in  plenary  using  Handout  #9.

Case  1  
Hawa  delivered  h er  s econd  baby  four  days  a go.  Hawa  breastfed  h er  first  baby,  but  n ever  
exclusively,  as  she  fed  h im  tea  and  water  from  the  first  week.  Today,  at  four  days  postpartum,  
she  comes  to  you  very  engorged  and  says  that  breastfeeding  a ll  the  time  hurts  too  much,  and  
she  wants  to  give  a  bottle  to  the  baby  at  night  so  she  can  sleep.    
 
Case  2  
Faith  has  come  to  you  today  (six  weeks  postpartum)  b ecause  she  is  concerned  that  she  is  n ot  
producing  enough  breastmilk  for  h er  baby.  She  says  h er  baby  seems  to  b e  crying  more  and  
wanting  to  feed  more.  

Day  2       -­‐  28  -­‐    

Case  3  
Mercy  is  three  days  postpartum,  d elivered  by  caesarean  section,  with  a  big  baby  boy.  When  you  
visit  h er,  you  find  h er  grimacing  in  pain  with  the  baby  in  her  lap.  Upon  asking  Mercy  where  she  is  
having  pain,  she  tells  you  that  h er  n ipples  hurt.  When  you  examine  h er,  you  find  a  small  crack  on  
each  nipple.  
 
Case  4  
Rita’s  mother-­‐in-­‐law  has  brought  her  and  h er  two-­‐month-­‐old  baby  into  your  clinic.  She  says  that  
recently  Rita  finds  breastfeeding  painful,  that  Rita  has  a  red  area  on  h er  right  breast  and  
complains  of  feeling  very  s ick.  She  thinks  that  Rita  has  a  fever.    

Activity  10.3     Discuss  “Special  Situations”  affecting  breastfeeding    

(20  minutes)  
Methodology:  “Fishing-­‐Game”  
• Randomly,  ask  a  participant  to  draw  a  p iece  of  paper  where  a  special  breastfeeding  situation  
is  written  on  it.  
• The  participant  tries  to  answer  the  q uestion  or  ask  assistance  from  others,  and  a nswer  the  
question  of  how  a  woman  with  this  special  s ituation  can  be  supported  to  successfully  
breastfeed  h er  baby.  
• Review  together  any  missing  points  from  HO  #9.

Day  2       -­‐  29  -­‐    

SESSION  11  
INFANT  FEEDING  IN  THE  CONTEXT  OF  HIV  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Explain  the  challenges  of  HIV  in  relation  to  infant  feeding.  
• List  four  infant  feeding  options  in  the  context  of  HIV  and  describe  in  d etail  at  least  two  of  
these  options.  
• State  the  s teps  for  safe  preparation  of  commercial  infant  formula.  
• Describe  how  to  follow  up  with  the  mother  and  child  b ased  on  h er  feeding  choice.    

Overview  
Activity  11.1   Review  of  Mother-­‐to-­‐Child  Transmission  ( MTCT)  with  HIV/AIDS  ( 5  minutes)  
Activity  11.2     Infants  (0  –  6  months)  feeding  options  and  HIV  status  of  the  mother  ( 25  
minutes)  
Activity  11.3   Infant  and  young  feeding  options  for  the  HIV-­‐positive  mother  (1  hour)  
 
Total  Time     1  hour  30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• 1  tin  of  infant  formula  

Advanced  Preparation  
Handouts  
HO  #10:  Assessing  Infant  F eeding  Options  
HO  #11:  Advantages  and  Disadvantages  of  Infant  F eeding  Options  under  HIV  &  AIDS  Exclusive  
Breastfeeding  &  Replacement  F eeding:  Commercial  Infant  Formula  
HO  #12:  How  to  Transition  to  Replacement  Feeding    
HO  #13:  Follow-­‐up  counseling  of  HIV  p ositive  mothers  with  infants  0-­‐6  months  old  

Day  2       -­‐  30  -­‐    

DETAILED  ACTIVITIES  
Activity  11.1   Review  of  Mother-­‐to-­‐Child  Transmission  (MTCT)    
(5  minutes)  
Methodology  
• Brainstorm  with  participants  the  d ifferent  ways  in  which  HIV  can  b e  transmitted  from  
mother-­‐to-­‐child  ( MTCT).  
• Discuss  p oints  b elow.    
A  baby  born  to  an  HIV-­‐positive  mother  can  get  HIV  from  the  mother  during  pregnancy,  labor  and  
delivery,  and  breastfeeding.    
It  has  been  calculated  that  if  100  HIV-­‐positive  women  get  pregnant  and  d eliver.    
• About  63  of  the  babies  will  not  get  HIV;  
• About  7  may  b e  infected  with  HIV  during  pregnancy;  
• About  15  may  get  infected  with  HIV  during  labor  and  d elivery;  and  
• About  15  may  get  infected  with  HIV  through  breastfeeding,  if  the  mothers  breastfeed  their  
babies  for  two  years.  
Risk  of  HIV  transmission  through  breastfeeding  when  a  woman  is  under  antiretroviral  therapy  
(ART):  
Exclusive  breastfeeding  (6  weeks  –  6  months)   ~  4%  
• HIV-­‐positive  infants  b enefit  from  continued  breastfeeding  

Activity  11.2   Infant  (0-­‐6  Months)  feeding  options  and  HIV  status  of  
the  mother    
(25  minutes)  
Methodology  
• Brainstorm  with  participants  the  questions:  
• What  are  the  options  for  HIV  n egative  women,  women  who  don’t  know  their  s tatus,  
and/or  women  receiving  ART?  
• What  infant  feeding  options  does  an  HIV  positive  mother  have?  
• Discussion.  
• Brainstorm  on  possible  questions  to  assess  which  feeding  options  to  recommend  to  the  
mother/family.  
• Review  HO  #10  to  summarize  the  recommendations.    

Activity  11.3     Infant  and  young  feeding  options  for  the  HIV-­‐positive  
mother    
(1  hour)  

Day  2       -­‐  31  -­‐    

Methodology  
• Divide  the  participants  into  groups  of  five.  
• Ask  each  group  to  d iscuss    
1)  the  advantages  and  d isadvantages  of  exclusive  breastfeeding    
2)  the  advantages  and  d isadvantages  of  replacement  feeding    
3)  how  to  prepare  infant  formula  
4)  the  advantages  and  d isadvantages  of  transitioning  to  replacement  feeding  a t  s ix  
months    
(more  than  one  group  can  d iscuss  the  same  option)  
• If  multiple  groups  discuss  one  of  the  options,  only  one  presents.  
• Discuss  and  summarize  using  summary  points  b elow  (HO  #11  and  HO  #12).  
• Discuss.  Review  how  to  transition  to  a  cup  and  switch  from  breastfeeding  to  formula  or  milk.    
• Read  HO  #13  to  review  the  “follow-­‐up  counseling  done  b y  h ealth  worker  to  HIV  positive  
mother.”  

Summary  Points  
1. Mixed  feeding  (breastfeeding  p lus  replacement  feeding)  increases  HIV  transmission.  The  
mother  should  be  advised  to  EITHER  exclusively  breastfeed  OR  exclusively  use  
replacement  feeds.    
2. Whatever  option  the  mother  chooses,  she  n eeds  support  and  counseling.  
3. Refer  mother  to  PMTCT  to  b e  tested.  
4. Mothers  and  their  partners  n eed  to  b e  counseled  on  s afe  s ex.  

Day  2       -­‐  32  -­‐    

SESSION  12  
HOW  TO  NEGOTIATE  WITH  MOTHERS,  CAREGIVERS,  FATHERS,  AND  
GRANDMOTHERS  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Explain  the  s teps  of  n egotiation  (GALIDRAA).  
• Demonstrate  the  initial  visit  of  n egotiation  with  a  mother  of  a  infant  0  –  <  6  months.  

Overview  
Activity  12.1   Demonstration  of  n egotiation  to  encourage  mothers  to  try  optimal  
breastfeeding  practices:  initial  visit  to  mother  with  infant  <  6  months;  and  group  
discussion  (20  minutes)  
Activity  12.2   Presentation  of  listening  and  learning  skills  and  negotiation  s teps  GALIDRAA  (30  
minutes)    
Activity  12.3   Discussion  of  negotiation  for  follow-­‐up  visit(s)  (20  minutes)  
Activity  12.4   Practice  n egotiation  in  an  initial  visit  to  mother  with  infant  <  6  months  (1  hour  
20  minutes)    
Activity  12.5     Preparation  for  field  work  
 
Total  Time     2  hours  30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Booklet  on  key  ENA  messages    
• Case  s tudies  on  cards  

Advance  Preparation  
Handout  
HO  #14:  General  Case  Studies  of  infant  0  -­‐  <  6  months  

Day  2       -­‐  33  -­‐    

DETAILED  ACTIVITIES  

Activity   12.1   Demonstration  of  negotiation  to  encourage  mothers  to  

try  optimal  breastfeeding  practices:  initial  visit  to  
mother  with  infant  <  6  months;  and  group  discussion    
(20  minutes)  
Methodology  
• Facilitators  d emonstrate  the  visit  #1  of  h ealth  worker  to  Hawa  who  has  a  2-­‐month-­‐old  son,  
Amos  
• Participants  d iscuss  what  happened  in  the  demonstration  visit.    

Demonstration  of  Case  Study  of  infant  0  -­‐  <  6  months:  Hawa  &  Amos  
Visit  #1:  Initial  visit    
Situation:  A  health  worker  visits  Hawa,  whose  son,  Amos,  is  2  months  old.  Hawa  tells  the  
health  worker  she  does  not  produce  enough  milk,  so  s he  feeds  Amos  other  drinks.  

Activity  12.2   Presentation  of  listening  and  learning  skills  and  

negotiation  steps  GALIDRAA    
(30  minutes)  
Methodology  
• In  p lenary  ask  participants:  What  are  the  different  s teps  of  n egotiation?  How  many  visits  are  
needed  for  the  full  process  of  n egotiation?  Write  answers  on  flipchart.  
• Add  any  missing  information.    
• Review  listening  and  learning  s kills.  
• Presentation  of  the  steps  of  n egotiation:  Greet,  Ask,  Listen,  Identify,  Discuss,  Recommend  
and  negotiate,  Agree  and  repeat  agreed  upon  action,  follow-­‐up  Appointment  (GALIDRAA).  
• Read  handout  ( HO  #14)  and  d iscuss:  General  Case  Studies  of  infant  0  -­‐  <  6  months.    
Listening  and  Learning  Skills  
1.   Use  helpful  nonverbal  communication.  
a.  Keep  your  h ead  level  with  mother  
b.  Pay  attention  
c.  Nod  head  
d.  Take  time  
e.  Appropriate  touch  
2.   Ask  open-­‐ended  questions  that  s tart  with  what,  why,  h ow,  or  where  rather  than  
questions  that  require  a  yes  or  no  only.  
3.   Use  responses  and  gestures  that  show  interest.  

Day  2       -­‐  34  -­‐    

4.   Reflect  back  what  the  mother  says.  
5.   Empathize  –  show  that  you  understand  how  she  feels.  
6.   Avoid  using  words  that  sound  judgmental.  

Observation  Checklist:  Negotiation  Visit  #1  (GALIDRAA)  

1. Greets  the  mother  and  establishes  confidence.  
2. Asks  the  mother  about  current  breastfeeding  practices.    
3. Listens  to  what  the  mother  says.  
4. Identifies  feeding  d ifficulty,  if  any,  causes  of  the  d ifficulty,  and  s elects  with  the  
mother  the  d ifficulty  to  work  on.  
5. Discusses  with  the  mother  different  feasible  options  to  overcome  the  d ifficulty.  
6. Recommends  and  negotiates  doable  actions:  Presents  options  and  NEGOTIATES  
with  the  mother  to  h elp  h er  s elect  one  that  she  can  try.  
7. Mother  Agrees  to  try  one  or  more  of  the  options,  and  mother  repeats  the  a greed  
upon  action.  
8. Makes  an  Appointment  for  the  follow-­‐up  visit.  

How  many  visits  are  n eeded  for  the  full  process  of  negotiation?  
At  least  2  visits:  
• Initial  visit  
• Follow-­‐up:  after  1  to  2  weeks  
• If  possible,  a  third  visit  to  maintain  the  practice  or  n egotiate  a nother  practice  

Example  of  possible  follow-­‐up  negotiation  visits  to  Hawa  

Visit  #  2:  Follow  up  
Situation:  The  h ealth  worker  visits  Hawa  to  ask  h er  whether  she  has  b een  able  to  
EXCLUSIVELY  breastfeed  Amos  during  the  past  week.  Hawa  answers  that  it  s eemed  to  h er  
that,  for  the  first  two  days,  Amos  suckled  for  the  whole  day.  But  she  did  EXCLUSIVELY  
breastfed.  She  says  h er  mother  is  coming  to  s ee  h er  the  following  week  and  will  surely  
advise  h er  to  feed  Amos  other  things  besides  breastmilk.  
Visit  #3:  Maintain  t he  practice  and/or  negotiate  another  practice  
Situation:  Amos  is  now  5  months  old,  and  Hawa  has  EXCLUSIVELY  breastfed  h im  for  3  
months.  She  p oints  out  to  the  h ealth  worker  that  Amos  has  had  n either  d iarrhea  nor  a  cold.  

Day  2       -­‐  35  -­‐    

Activity  12.3   Discussion  of  negotiation  for  follow-­‐up  visit(s)    
(20  minutes)  
Methodology  
• Brainstorm  additional  p oints  to  b e  d iscussed  with  mother  during  n egotiation  for  follow-­‐up  
visit(s).  

Negotiation  Follow-­‐up  Visit(s)  

• Asks  whether  the  mother  tried  (or  continued)  the  agreed  practice.  
• Congratulates  the  mother  for  trying  (or  continuing)  the  n ew  practice.  
• Asks  what  happened  when  she  tried  (or  continued)  the  n ew  practice.  
• Asks  whether  she  made  any  changes  to  the  new  practice  and  why?  
• Asks  what  d ifficulties  she  had,  how  she  solved  them,  or  helps  h er  find  ways  to  solve  the  
difficulties  she  might  have  had.    
• Listens  to  the  mother’s  q uestions,  concerns,  and  doubts.  
• Asks  whether  she  likes  the  practice  a greed  on  and  if  she  thinks  she  will  continue.  
• Praises  the  mother  and  motivates  h er  to  continue  the  practice.  
• Reminds  the  mother  to  take  the  child  to  b e  weighed  (attend  well-­‐baby  clinic).  
• Tells  the  mother  where  she  can  get  support  from  community-­‐based  health  workers,  h ealth  
centers,  or  mother  support  groups.  
• Agrees  on  a  date  for  the  next  visit  (sees  calendar  of  home  visits).  
• Depending  on  the  age  of  the  child:    
• Talks  to  the  mother  about  a  n ew  practice;  and  
• Encourages  the  mother  to  try  a  n ew  practice  (process  of  GALIDRAA).  

Activity  12.4   Practice  negotiation  in  an  initial  visit  to  mother  with  
infant  <  6  months    
(1  hour  20  minutes)  
Methodology  
• Facilitator  asks  participants  to  recall  the  optimal  breastfeeding  practices.  
• Participants  are  d ivided  into  triads:  mother,  h ealth  worker,  and  observer;  triads  are  given  
one  of  six  case  studies  to  practice  n egotiation  in  an  initial  visit;  each  participant  rotates  
roleplaying  each  of  the  three  d ifferent  roles.  
• Two  triads  d emonstrate  a  case  study  in  p lenary.  
• Discussion  and  summary.    

 
 
 

Day  2       -­‐  36  -­‐    

Encourage  the  participants  to  follow  the  n egotiations  s teps  [GALIDRAA]  and  use  the  listening  
and  learning  s kills.    
• Greet  the  mother  and  establish  confidence.  
• Ask  the  mother  about  current  breastfeeding  practices.    
• Listen  to  the  mother.  
• Identify  feeding  d ifficulty,  if  any,  causes  of  the  d ifficulty,  and  s elect  with  the  mother  the  
difficulty  to  work  on.  
• Discuss  with  the  mother  d ifferent  feasible  options  to  overcome  the  d ifficulty.  
• Recommend  and  negotiate  doable  actions:  Present  options  and  h elp  mother  s elect  one  
that  she  can  try.  
• Mother  Agrees  to  try  one  of  the  options,  and  mother  repeats  the  agreed  u pon  action.  
• Make  an  Appointment  for  the  follow-­‐up  visit.  

Possible  Answers:  Practice  Case  Studies  0  –  <  6  months  

Case  Study  #1    
You  visit  a  new  mother,  Betty,  who  has  a  n ewborn  son.  She  is  breastfeeding  and  h er  mother-­‐in-­‐
law  insists  that  she  give  water  to  her  grandson.  
Answer  
The  participant  has  to  ask  and  listen  to  the  current  feeding  practices  and  identify  problems  and  
causes  for  the  problems.    
In  this  particular  case,  the  main  problem  is  giving  water  to  the  baby,  the  reason  b eing  the  
grandmother  insisted  that  the  mother  do  so.  The  participant  has  to  ask  why  the  grandmother  
thinks  that  the  baby  should  take  water.  S /he  a lso  has  to  ask  the  mother  whether  she  has  b een  
giving  water  to  the  baby  or  not.  
The  participant  has  to  explain  to  the  mother:  
• The  availability  of  adequate  water  for  the  baby  in  the  breastmilk,  d emonstrated  b y  the  baby  
passing  urine  s ix  or  more  times  in  24  hours.  
• The  risks  of  giving  water  to  the  baby:  risk  of  d iarrhea;  baby's  s tomach  getting  full  with  water  
and  feeding  less  leading  to  weight  loss;  infrequent  feeding  leading  to  d ecreased  breastmilk  
production.    
S/he  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  practicing  exclusive  
breastfeeding  ( EBF)  for  two  to  three  days  and  make  an  appointment  for  a  later  date.  S/he  n eeds  
to  talk  to  the  grandmother.  S /he  praises  the  mother  a nd  thanks  h er  for  h er  time.  
 
Case  Study  #2    
You  visit  Yamah,  who  has  a  10-­‐week-­‐old  girl.  Yamah  is  breastfeeding  and  has  d ecided  to  give  h er  
daughter  some  porridge  to  get  her  used  to  eating  food.    
Answer  
The  participant  has  to  ask,  listen,  and  identify  problems  and  causes  for  the  problem  regarding  
the  current  feeding  practice.    

Day  2       -­‐  37  -­‐    

In  this  particular  case,  the  problem  is  giving  additional  food  b efore  the  age  of  six  months.    
The  participant  has  to  explain  to  the  mother:    
• Risks  associated  with  providing  food  b efore  six  months  for  the  baby  and  the  mother  
(diarrhea  and  other  illnesses;  malnutrition;  risk  of  early  pregnancy;  reduced  breastmilk  
production)  
• The  reasons  for  not  starting  complementary  feeding  u ntil  after  6  months  (developmental  
readiness,  adequacy  of  breastmilk  alone  until  6  months  of  age  a nd  the  health  b enefits  for  
the  baby  b y  exclusive  breastfeeding).  
• When  starting  other  foods  at  6  months,  start  with  soft  porridge  (not  gruel)  and  increase  the  
food  thickness  and  variety  as  the  child  gets  older  
• S/he  has  to  n egotiate  and  get  the  mother  to  a gree  to  exclusive  breastfeeding  h er  baby  for  
several  days  and  see  the  effect.  S /he  praises  the  mother  and  fixes  time  for  follow  up  visit.  

Case  Study  #3    

Queta’s  baby  is  4  months  old  and  Queta  thinks  she  does  not  have  enough  milk;  Queta  and  h er  
husband  are  seeking  advice  on  what  they  should  give  to  their  baby.  
Answer  
The  participant  has  to  ask,  listen,  and  identify  problems  and  causes  with  regard  to  current  
feeding  practices.    
In  this  case,  why  do  the  parents  think  or  b elieve  that  there  is  not  enough  milk  for  the  baby?  S/he  
should  ask  about  the  frequency  of  breastfeeding,  presence  of  on-­‐demand  feeding,  night  feeding,  
emptying  one  breast  b efore  s witching  to  the  other,  presence  of  additional  feeds,  about  the  
baby’s  health  and  weight,  and  frequency  of  passing  urine  in  24  hours  and  other  issues  related  to  
mother’s  h ealth  or  worries.  
The  participant  has  to  explain  to  the  mother  
• Explain  that  the  breast  is  like  a  “factory”  –  the  greater  the  demand  (for  milk),  the  greater  the  
supply.  Discuss  the  b enefits  of  exclusive  breastfeeding  until  6  months  and  the  role  of  
frequent  suckling  on  the  a mount  of  breastmilk  production.  
S/he  should  recommend  and  agree  for  continuation  of  exclusive  breastfeeding  until  6  months  
and  arrange  a  follow  up  visit  after  few  days.  

Case  Study  #4    

Massa  has  a  3-­‐month-­‐old  son.  She  works  very  hard  in  the  day  and  doesn’t  always  have  time  to  
breastfeed  h im,  but  she  does  breastfeed  her  son  a t  n ight.    
Answer  
The  participant  has  to  ask,  listen,  and  identify  problems  related  to  the  current  feeding  practices.  
In  this  particular  case,  the  problem  is  the  stresses  on  a  working  mother.  The  fact  that  the  
mother  has  continued  breastfeeding  during  the  n ight  s hould  b e  recognized,  and  s /he  should  b e  
encouraged  to  do  so  frequently.    
The  participant  has  to  explain  to  the  mother  

Day  2       -­‐  38  -­‐    

• She  should  breastfeed  before  leaving  the  house  in  the  morning,  and  explore  the  p ossibility  
of  someone  bringing  the  baby  to  h er  at  the  work  p lace  (and  arrange  for  breastfeeding  
breaks).  
• If  bringing  the  baby  to  the  work  p lace  is  not  possible,  the  main  approach  should  b e  to  give  
expressed  breastmilk,  and  to  feed  the  baby  with  a  cup.  The  participant  must  explain  to  the  
mother  h ow  to  express  breastmilk  and  how  to  safely  store  it.  Either  s/he  should  teach  her  or  
refer  h er  to  a  p lace  where  she  can  b e  taught  breastmilk  expression  technique.  

Case  Study  #5  

Mercy  says  she  gives  only  breastmilk  to  h er  4-­‐month-­‐old  daughter,  but  you  s ee  h er  give  the  
daughter  some  water.  When  you  mention  to  Mercy  that  she  is  not  exclusively  breastfeeding,  
she  says  that  water  is  not  food  or  milk.  
Answer  
The  participant  address  the  issues  mentioned  under  in  case  study  #1.  

Case  Study  #6  

Orphelia  is  living  in  a  village  and  is  9  months  pregnant;  she  is  confused  on  which  food  to  give  to  
her  baby  after  d elivery.  She  is  HIV  positive.  
Answer  
The  participant  has  to  ask,  listen,  and  identify  problems  related  to  the  current  feeding  practices.  
In  this  particular  case,  Orphelia  is  HIV  positive,  and  d oes  not  know  how  to  feed  h er  baby.  
The  health  provider  n eeds  to  h elp  Orphelia.  S/he  knows  that  a ccess  to  save  water  is  difficult  
where  Orphelia  lives.  S /he  advises  h er  to  exclusively  breastfeed  h er  baby:  to  start  immediately  
after  birth  and  give  only  breastmilk  until  the  baby  is  6  month  old.  S/he  must  emphasize  that  
exclusive  breastfeeding  is  very  important  as  mixed  feeding  (breastfeeding  with  other  drinks  or  
foods)  will  b e  very  dangerous  for  the  baby  and  increase  the  risk  of  HIV  transmission.  
Breastmilk  expression  technique:    
• Put  your  thumb  on  the  breast  above  the  dark  area  around  the  n ipple,  and  your  first  finger  
below  the  n ipple  and  areola.  Support  your  breast  with  your  other  fingers.    
• Gently  press  toward  your  chest  wall  with  your  thumb  a nd  finger  together.  
• Continue  to  compress  the  breast  while  moving  your  hand  away  from  the  chest  wall.  This  
should  not  hurt.  If  it  does,  then  you  are  not  doing  it  right.  
• Press  the  same  way  on  each  side  of  the  dark  area  around  the  n ipple  in  order  to  empty  all  
parts  of  the  breast.  
• Do  not  squeeze  the  n ipple  itself  or  rub  your  fingers  over  the  skin.  
• Express  one  breast  for  3-­‐to-­‐5  minutes  until  the  flow  slows  down  and  then  switch  to  the  
other  breast.  Then  d o  both  breasts  a gain.  Change  your  hands  when  the  one  hand  gets  tired.  
You  can  use  either  hand  for  either  breast.  It  usually  takes  20-­‐30  minutes  to  express  all  of  the  
milk.  
• Store  the  breastmilk  in  a  clean,  covered  container  in  a  cool  place  until  you  are  ready  to  h eat  
and  feed  it  to  your  baby.  
• Feed  the  baby  using  an  open  cup.  

Day  2       -­‐  39  -­‐    

Activity  12.5     Preparation  for  field  visit  the  next  day    
Methodology  
• Facilitators  d iscuss  the  logistics  and  ensure  that  all  participants  are  clear  about  the  
expectations,  dress,  and  timing  of  the  field  visit.  
• Discuss  h ow  the  groups  will  b e  d ivided  and  which  group  is  going  where  and  how.  
• Encourage  participants  to  review  today’s  s ession  and  b ring  to  the  field  visit  “negotiation”  
HO  #15  and  “GALIDRAA”  HO  #16  forms.  
• Remind  participants  that  after  the  field  visit,  there  will  a  classroom  s ession  to  summarize  the  
field  visits.    
• Answer  any  questions  participants  have.

Day  2       -­‐  40  -­‐    

SESSION  13  
FIELD  PRACTICE  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Practice  the  n egotiation  technique  b y  doing  field  practice  at  h ealth  centers  or  in  villages.  
• Evaluate  for  proper  positioning  and  attachment  required  for  successful  breastfeeding.  
 

Overview  
Activity  13.1   Field  practice  in  h ealth  clinic  and  villages  (2  hours)  
Activity  13.2   Feedback  on  practice  session  ( 1  hour)    
Activity  13.3   Discussion  on  follow-­‐up  visit  (15  minutes)  
 
Total  Time     3  to  4  hours    
 

Materials  Needed  
• Negotiation  form  
• GALIDRAA  form  
 

Advance  Preparation  
• Make  an  appointment  at  the  h ealth  clinic  a  week  ahead  to  d o  the  field  practice  during  
immunization  or  weighing  sessions.  
• Make  an  appointment  with  the  community  chairman  or  the  community  h ealth  workers  
(Chealth  worker)  a  week  ahead  for  village  visits  to  do  field  practice.  
• Prepare  groups;  give  instructions  the  day  b efore  for  the  field  practice  visit.  
Handouts  
HO  #15:     Negotiation  record  
HO  #16:     Observation  Checklist  ( GALIDRAA)  

DETAILED  ACTIVITIES  
Activity  13.1   Field  practice  in  health  clinic  and  village    
(2  hours)  
Methodology  
• In  p lenary,  review  n egotiation  steps  and  plans  for  field  visit.  

Day  3     -­‐  41  -­‐    

• Divide  participants  in  pairs:  one  will  counsel  and  negotiate  with  the  mother  while  the  other  
follows  the  d ialogue  in  order  to  give  feedback  later.  
• Negotiator  fills  out  “Negotiation  Record”  form  ( HO  #15);  colleague  fills  out  GALIDRAA  
checklist  ( HO  #16)  and  provides  feedback.  
• Participants  change  roles  until  each  participant  practices  at  least  two  n egotiations,  and  
evaluates  positioning  and  a ttachment.  
 
Activity  13.2   Feedback  on  practice  session    
(1  hour)  
Methodology  
• After  returning  to  the  training  site,  in  p lenary,  each  pair  of  participants  will  summarize  their  
negotiation  experience  b y  filling-­‐in  the  summary  flipchart  for  n egotiation  visits  (attached  to  
the  wall):  participant(s)  name,  child’s  name  and  age,  d ifficulty  identified,  options  suggested,  
and  behavior  mother  a greed  to  try.  
• Participants  receive  and  give  feedback  on  GALIDRAA.  
• Discussion  and  summary.  

Activity  13.3   Introduction  of  follow-­‐up  visit    

(15  minutes)  
Methodology  
• Facilitators  ask  four  to  five  groups  what  will  b e  the  focus  for  the  follow-­‐up  visit.  
• If  time,  the  facilitator  demonstrates  a  follow-­‐up  visit  of  health  worker  using  the  case  of  
Hawa  who  has  a  2-­‐month-­‐old  son,  Amos  (Case  Study  from  previous  session).

Day  3     -­‐  42  -­‐    

Use  this  as  a  sample  to  record  each  participant’s  field  visit  experience  

SAMPLE  SUMMARY  SHEET  FOR  NEGOTIATION  DURING  FIELD  VISITS  

INITIAL  VISIT   1   2   3   ETC.  
Participants’  names  

Child’s  name/age  

Difficulty(ies)  
identified  
Options  suggested  
 
 
 
Behavior  mother  
agreed  to  try  
 
 

Draw  this  table  on  flipchart  paper.    

Add  additional  columns  for  number  of  n egotiation  visits.  
Each  pair  writes  one  case.  
The  facilitator  summarizes  the  field  visit.  
Display  the  flipchart  throughout  the  rest  of  the  training.    

Day  3     -­‐  43  -­‐    

SESSION  14  
KEY  COMPLEMENTARY  FEEDING  PRACTICES  
IMPORTANCE  OF  MICRONUTRIENTS  SUPPLEMENTATION  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Describe  key  b ehaviors  p ertaining  to  child  feeding  from  6  to  24  months.  
• Explain  the  importance  of  each  b ehavior.  
 

Overview  
Activity  14.1   Key  complementary  feeding  practices  from  6  –  24  months  (1  hour)  
Activity  14.2   How  h ealth  providers  can  support  complementary  feeding  and  nutrition  
practices?  (1  hour)  
Activity  14.3   Participants  identify  foods  (purchased  locally  at  the  market)  for  infants  and  
young  children:  0<6  months,  6–12  months,  and  12–24  months  (30  minutes)  
Activity  14.4   Seasonal  food  available  calendar  (30  minutes)  
 
Total  Time     3  hours    
 

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Booklet  on  key  ENA  messages  
• Pictures  of  foods  and/or  those  purchased  at  local  market  
 

Advance  Preparation  
• Prepare  and  gather  foods  for  d emonstration  
• Food  calendar  is  written  on  a  flipchart  
Handouts  
HO  #17     Key  Messages  on  complementary  feeding  with  breastfeeding  6  to  24  months    
HO  #18     How  h ealth  providers  can  support  complementary  feeding  practices?  
HO  #36-­‐38:     Micronutrients  protocols  

Day  3     -­‐  44  -­‐    

DETAILED  ACTIVITIES  
Activity  14.1   Key  complementary  feeding  practices  from  6  –  24  
months    
(1  hour)  
Methodology  
• Divide  participants  into  five  working  groups  and  ask  each  group  to  answer  the  following  
questions:    
1. Breastfeeding  -­‐  When  do  infants  begin  to  eat  something  other  than  breastmilk  and  
how  long  should  breastfeeding  continue?    
2. Frequency  -­‐  How  many  times  a  day  d oes  a  child  eat?  Does  s /he  eat  from  h er/his  
own  p late?    
3. Amount  -­‐  How  much  does  child  eat  at  the  different  age  ranges  6-­‐8  months,  9-­‐11  
months,  and  12  -­‐24  months?  
4. Density  -­‐  What  is  the  consistency  of  the  food  s/he  eats?    
5. Diversity  -­‐  How  d o  you  enrich  the  meals  of  children?  
6. Utilization  -­‐  What  does  a  mother  or  caregiver  do  b efore  food  preparation  and  
before  a  young  child  eats?  
7. Active  Feeding  -­‐  Discuss  the  meaning  and  importance  of  active  feeding,  and  give  
examples  
• Brainstorm  the  key  complementary  feeding  b ehaviors.  
• Ask  participants  to  read  messages  and  supportive  information  from  HO  #17  and  Booklet  on  
key  ENA  messages.  
• Ask  for  any  comments.  

Complementary  Feeding  Working  Groups  Questions  

1.   Breastfeeding  -­‐  When  do  infants  b egin  to  eat  something  other  than  breastmilk  and  how  
long  should  breastfeeding  continue?    
2.   Frequency  -­‐  How  many  times  a  day  does  child  eat?  Does  child  get  fed/eat  from  own  plate?  

AGE   NUMBER  OF  TIMES  A  DAY     USES  OWN  PLATE?  

A  CHILD  EATS  
6-­‐8  months  
9-­‐ll  months  
12-­‐24  months  

Day  3     -­‐  45  -­‐    

3.     Amount  -­‐  How  much  does  the  child  eat?  

6-­‐8  MONTHS   9-­‐11  MONTHS   12-­‐24  MONTHS  

4.     Density  –  What  is  the  consistency  of  the  food  child  eats?    

6-­‐8  MONTHS   9-­‐11  MONTHS   12-­‐24  MONTHS  

5.     Diversity  -­‐  How  to  enrich  the  food  of  children?  

6-­‐8  MONTHS   9-­‐11  MONTHS   12-­‐24  MONTHS  

6.     Utilization  -­‐  What  does  mother  or  caregiver  do  b efore  food  preparation,  and  b efore  a  young  
child  eats?  
 
7.     Active  Feeding  -­‐  Discuss  the  meaning  and  importance  of  active  feeding,  and  give  examples.  
   
After  the  presentations,  ask  participants  read  Key  Messages  on  C omplementary  Feeding  with  
Breastfeeding  6  to  24  m onths  (Illustrations  #12  to  #19).    
Summarize  using:    
BF  
+  
F  requency  
A  mount  
D  ensity  
D  iversity  
U  tilization  
A  ctive  F eeding  

Day  3     -­‐  46  -­‐    

Activity  14.3   Participants  answer  questions  on  complementary  
feeding  practices  and  importance  of  micronutrients    
(1  hour)  
Methodology  
• Set  up  five  flipcharts  throughout  the  room  with  the  following  questions,  one  per  flip  chart:    
1. What  questions  should  b e  asked  to  mothers  whose  baby  will  soon  be  6  months  old?    
2. Why  should  V itamin  A  b e  administered  to  children  every  6  months  from  the  age  6  
months  to  5  years?  Which  foods  are  rich  in  V itamin  A  in  your  community?    
3. Why  should  a  baby  eat  foods  rich  in  iron?  Which  foods  are  rich  in  iron?  Why  should  
children  b e  d ewormed  every  6  months  starting  a t  2  years?    
4. Why  encourage  mothers,  caregivers,  and  parents  to  use  iodized  salt  for  the  whole  
family,  even  for  children  who  s tart  complementary  feeding?    
5. How  can  health  workers  help  mothers,  caregivers,  and  parents  make  sure  their  children  
are  properly  fed?  
• Divide  participants  into  five  groups  (one  group  at  each  flipchart)  and  ask  them  to  answer  the  
question  on  flipchart.    
• In  p lenary,  each  group  presents  the  results  of  their  initial  flipchart.  
• Ask  participants  to  refer  to  HO  #18  and  compare  the  a nswers.  
• Ask  participants  to  look  at  HO  #29  to  review  V itamin  A  supplementation.  
• Ask  one  participant  to  look  at  HO  #30  explain  Iron/Folic  Acid  supplementation  and  
treatment  (point  out  that  there  is  n o  supplementation  of  iron/folic  acid  for  children.  When  
there  is  anemia,  treat  with  iron,  folic  acid  treatments)  
• Ask  another  participant  to  explain  HO  #31.    

Possible  answers  to  questions    

1.  Which  questions  should  b e  asked  to  mothers  whose  baby  will  soon  b e  6  months  old?  
• Do  you  know  why  it  is  important  to  wait  until  6  months  before  you  feeding  your  child  
anything  b esides  breastmilk?    
• How  often  will  you  need  to  feed  your  6-­‐8-­‐month-­‐old  child?  
• What  should  you  feed  your  child?  
• What  consistency  should  the  food  b e?  
• What  amount  should  you  feed  your  6-­‐8  month  old  child?  
• Do  you  know  where  to  get  V itamin  A  supplements  when  your  child  is  6  months  old?  
• When  will  you  come  back  for  the  n ext  Vitamin  A  supplement  after  the  first  6  months?  
• What  immunizations  has  your  child  received?  

2.  Why  should  V itamin  A  be  administered  to  children  every  6  months  from  the  a ge  6  months  to  
5  years?  
• Vitamin  A  supplementation  ensures  the  child’s  growth.  

Day  3     -­‐  47  -­‐    

 • Reinforces  the  child’s  h ealth.  
• Protects  the  child  from  severe  forms  of  infections  such  as  diarrhea  and  respiratory  
diseases,  thus  reducing  the  risk  of  d eath.  
• Improves  the  child’s  sight  and  prevents  n ight  b lindness,  which  can  lead  to  childhood  
blindness.  
Which  foods  are  rich  in  V itamin  A  in  your  community?  
• Colostrum  and  breastmilk  are  important  s ources  of  Vitamin  A.  
• Ripe  orange/yellow  fruits  (papaya,  mangos).  
• Orange/yellow  vegetables  (carrots,  pumpkins).  
• Liver  and  green  leafy  vegetables.  

3.  Why  should  a  baby  eat  foods  rich  in  iron?  

• To  gain  more  s trength.  
• To  reinforce  a  child’s  health,  physical,  and  intellectual  development.  
Which  foods  are  rich  in  iron?  
• Breastmilk,  green  leafy  vegetables,  liver,  meat,  fish,  and  lentils.  
Why  should  children  b e  d ewormed  every  6  months  s tarting  at  2  years?  
• Some  worms  exclusively  feed  on  blood  and  if  the  child  has  them,  s /he  then  becomes  
thin  and  weak.  
 
4.  Why  encourage  mothers,  caregivers,  and  parents  to  use  iodized  salt  for  the  whole  family,  
including  children  who  s tart  complementary  feeding?  
• To  ensure  the  child’s  and  the  whole  family’s  physical  a nd  intellectual  d evelopment.  
• To  prevent  goitres  and  its  complications.  
• To  prevent  poor  work  p erformance  in  adults.  
• For  pregnant  women,  to  prevent  miscarriage,  stillbirth,  low  b irth  weight,  and  cretinism  
in  the  baby.    
 
5.  How  could  health  workers  help  mothers,  caregivers,  and  parents  to  make  sure  their  children  
are  properly  fed?  
• Discuss  the  feeding  recommendations  with  the  mother,  father,  grandmother,  and  the  
entire  family  (if  p ossible)  according  to  the  child’s  age.  
• Congratulate  and  encourage  the  mothers/caregivers  to  continue  breastfeeding  for  two  
years.  
• Encourage  parents  to  give  many  different  types  of  food  including  foods  rich  in  Vitamin  A  
and  iron  to  their  children.  
• Encourage  parents  to  bring  their  children  to  the  h ealth  centre  in  case  of  malnutrition,  
weight  loss,  or  edema.  

Day  3     -­‐  48  -­‐    

 • Encourage  parents  to  have  a  garden  with  d ifferent  green  leafy  vegetables,  and  
orange/yellow  vegetables  and  fruits.  
• Raise  a wareness  a mong  the  p opulation  to  use  only  iodized  salt.  
• Encourage  parents  to  call  on  support  groups  if  difficulties  occur.  
• Encourage  parents  to  go  to  the  h ealth  centers  or  community  outreach  for  immunization  
(measles  at  9  months),  for  V itamin  A  at  6  months  and  deworming  starting  from  2  years.  
• Explain  that  LAM  is  not  effective  after  6  months  (up  to  6  months  mother  needs  to  meet  
other  criteria:  amenorrhea  and  exclusively  breastfeeding)  and  parents  must  go  to  h ealth  
centre  for  other  family  planning  methods.  
• Encourage  sleeping  u nder  a  long-­‐lasting  insecticide-­‐treated  mosquito  n et  every  night  to  
protect  child/mother/families  against  malaria.  

Activity  14.4   Participants  identify  foods  (purchased  locally  at  the  

market)  for  infants  and  young  children:  0<6  months,  6-­‐
12  months  and  12-­‐24  months    
(30  minutes)  
Methodology  
• Each  participant  is  given  two  or  more  foods  purchased  locally  at  the  market  (water  and  
pictures/dolls/models  of  a  breast  representing  breastmilk  are  also  distributed).    
• (NB.  If  it  is  not  possible  to  use  food,  write  each  food  on  a  piece  of  paper.)  
• On  tables  or  the  floor  (covered  with  flipchart  paper),  facilitator  writes  three  cards  to  
distinguish  the  following  categories:  0  <  6  months,  6-­‐12  months,  and  12-­‐24  months.  
• Each  participant  names  the  foods  and  p laces  them  in  the  a ge  category  in  which  s /he  thinks  
is  appropriate  for  the  child  to  b egin  to  eat.  
• Hold  discussion  and  rearrange  foods  if  n ecessary.  
• Summary  of  local  available  foods  that  can  b e  given  to  children  6-­‐24  months.  Show  that  the  
diversity  is  locally  a vailable.  

Activity  14.5   Seasonal  available  foods  calendar    

(30  minutes)  
Methodology  
• Draw  on  a  flipchart  the  s easonal  food  a vailability  b elow.  
• Participants  will  group  themselves  according  to  their  region  or  village.  
• Each  group  will  fill  the  calendar  with  foods  a vailable  d uring  a  given  s eason.  
• One  group  presents  its  calendar.  
• Discuss  that  d ifferent  types  of  foods  are  available  at  different  types  of  the  year.  
• Participants  are  asked  to  finish  filling  in  the  calendar  once  they  get  back  to  their  own  village  
or  region.  

Day  3     -­‐  49  -­‐    

 CALENDAR:  INEXPENSIVE  AND  AVAILABLE  FOODS    
(MARKET  AND/OR  HOME)  
(To  be  filled  every  month  and  brought  at  each  training  and  follow-­‐up)  
JANUARY   FEBRUARY   MARCH  
Home   Home   Home  
 
 
 
 
 
Market   Market   Market    
 
 
 
 
 

APRIL     MAY     JUNE  

Home   Home   Home  
 
 
 
 
 
Market   Market   Market    
 
 
 
 
 

Day  3     -­‐  50  -­‐    

 CALENDAR:  INEXPENSIVE  AND  AVAILABLE  FOODS    
(MARKET  AND/OR  HOME)  
(To  be  filled  every  month  and  brought  at  each  training  and  follow-­‐up)  
JULY   AUGUST   SEPTEMBER  
Home   Home   Home  
 
 
 
 
 
Market   Market   Market  
   
 
 
 
 

OCTOBER   NOVEMBER   DECEMBER  

Home   Home   Home  
 
 
 
 
 
Market   Market   Market  
   
 
 
 
 

Day  3     -­‐  51  -­‐    

SESSION  15  
FEEDING  OF  A  SICK  CHILD   AN D  DA N GER   SIGN S  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Counsel  on  child  feeding  during  and  after  illness.  
• Explain  the  reasons  for  these  practices.  
• Describe  the  danger  s igns  requiring  referral  of  child  to  health  facility.  
• Describe  the  home  management  of  the  sick  child.  

Overview  
Activity  15.1   Presentation  of  the  relationship  between  a  child’s  illness,  recovery,  and  feeding  
(10  minutes)    
Activity  15.2   Feeding  of  a  s ick  child  and  home  care  management  
(40  minutes)  
 
Total  Time     50  minutes    

Materials  Needed    
• Flipchart  papers,  markers,  and  masking  tape    
• Flow  chart  of  the  relationship  b etween  illness  and  feeding  
• Booklet  on  key  ENA  messages  
• Posters  on  danger  signs  for  immediate  visit  to  h ealth  facility  
 
Advance  Preparation  
Handouts:  
HO  #17:     Key  ENA  messages  on  complementary  feeding  practices  for  infant  0-­‐24  months  
HO  #18:     Feeding  of  a  Sick  Child  During  and  After  Illness  

Day  4               -­‐  52  -­‐    

DETAILED  ACTIVITIES  
Activity  15.1   Presentation  of  the  relationship  between  illness,  time  
needed  to  recover,  and  feeding    
(10  minutes)    
Methodology  
• Ask  participants  what  the  practices  for  feeding  a  sick  child  are  in  their  community.  
• Write  answers  on  flipchart.  
• Present  the  flow  chart  of  relationship  b etween  illness  and  feeding.  
• Discussion  and  summary.  
 
Relationship  between  illness  and  feeding  

Disability   Death  

Sick  child  
(diarrhoea,  ARI,  
measles,  fever)  

Weight  loss   Weight  loss  less  

Malnourished   appetite  
Long  illness   Eats  less  

Not  hungry  
Burns  calories  

Lengthens  
illness  

Day  4               -­‐  53  -­‐    

Content  
A  sick  child  usually  does  n ot  feel  like  eating.  But  s/he  n eeds  even  more  strength  to  fight  sickness.  
Strength  comes  from  the  food  s /he  eats.  If  the  child  does  not  eat  or  does  n ot  breastfeed  d uring  
sickness,  s /he  will  take  more  time  to  recover.  The  child  will  b e  in  a  chronic  s tate  of  sickness  and  
malnutrition,  and  may  end  u p  with  a  physical  or  intellectual  disability  related  to  malnutrition.  
The  child  takes  more  time  to  recover,  sometimes  the  child’s  condition  worsens  and  s /he  may  
even  die.  
Therefore,  it  is  very  important  to  encourage  the  s ick  child  to  eat  during  s ickness,  and  to  eat  even  
more  during  recuperation  so  that  the  child  can  quickly  regain  s trength.  

Activity  15.2   Feeding  of  a  Sick  Child    

(40  minutes)  
Methodology  
• Set-­‐up  six  flipcharts  (write  each  topic  onto  one  flipchart)  throughout  the  room  and  d ivide  
participants  into  six  groups.    
• Each  group  will  d iscuss  the  following  topics:    
1. Advice  on  feeding  0-­‐  <  6  month  old  and  6-­‐24  month  old  during  illness    
2. Advice  on  feeding  0-­‐  <  6  month  old  and  6-­‐24  month  old  after  illness    
3. Advice  on  feeding  a  child  with  moderate  malnutrition    
4. Prevention  of  d iarrhea  
5. Home  management  of  child  with  d iarrhea  
6. Signs  of  s evere  d ehydration  and  general  danger  signs  of  illness  
• Each  team  presents  in  plenary.  
• Read  to  HO  #18  (feeding  during  and  after  illness)  or  Booklet  on  key  ENA  messages  
(Illustrations  20,  21,  and  24)  
• The  facilitator  summarizes  breastfeeding  +  FADDUA  and  asks  participants  to  review  HO  #18  
before  the  field  visit  

Content  
1)  Advice  on  feeding  sick  child  during  illness  
Child  under  6  months:    
• If  the  baby  is  s ick,  particularly  with  d iarrhea,  the  mother  increases  breastfeeding  frequency  
and  continues  exclusively  breastfeeding  to  avoid  d ehydration  a nd  malnutrition.  
• Breastmilk  contains  water,  sugar,  nutrients,  and  salts  in  adequate  quantities,  which  will  h elp  
the  baby  recover  quickly  from  diarrhea.  
• If  the  baby  has  s evere  d iarrhea,  the  mother  should  continue  to  breastfeed  and  go  to  the  
health  centre  for  advice  and  treatment.  If  d ehydrated,  baby  will  n eed  ORS.  

Day  4               -­‐  54  -­‐    

Child  older  than  6  months:    
• If  the  young  child  is  s ick,  the  mother  should  breastfeed  frequently  to  a void  d ehydration  and  
malnutrition.  She  should  also  offer  the  baby’s  favorite  food  (even  if  the  baby  is  not  hungry).  
• If  the  baby  has  s evere  d iarrhea  and  shows  any  signs  of  dehydration,  the  mother  should  
continue  to  breastfeed  and  go  to  the  h ealth  centre  for  advice  and  ORS  treatment.  
2)  Advice  on  feeding  sick  child  after  illness  
Child  under  6  months:    
• Continue  to  breastfeed  exclusively,  and  breastfeed  more  frequently  for  a t  least  two  weeks  
after  illness.  
• Breastmilk  contains  all  the  nutrients  to  h elp  the  baby  regain  s trength  and  weight  loss.  
Child  older  than  6  months:    
• The  mother  should  breastfeed  more  frequently  and  offer  an  extra  meal  daily  for  a  p eriod  of  
two  weeks.    
3)  Advice  on  feeding  the  malnourished  child  
• Counsel  as  if  the  child  was  a  s ick  child  (breastfeeding  a nd  complementary  feeding).  
Encourage  the  mother  to  actively  feed  h er  child  so  that  child  finishes  his/her  food.  
• Refer  the  mother  to  a  Supplemental  Food  Distribution  Centre  or  a  Therapeutic  Feeding  
Centre.  
• Refer  to  HO  #17  on  Feeding  of  a  Sick  Child  

Day  4               -­‐  55  -­‐    

SESSION  16  
COMMUNITY  MANAGEMENT  OF  AC UTE  MALNUTRITION  
(CMAM)  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Describe  the  techniques  to  assess  acute  malnutrition  a nd  the  standards  used.  
• Describe  how  to  identify  and  refer  children  with  moderate  and  s evere  a cute  malnutrition  
(MAM  and  SAM)  to  community  management  of  acute  malnutrition  (CMAM)  s ervices.  
• Discuss  h ow  to  give  counseling  to  children  with  MAM  or  SAM  in  Outpatient  Therapeutic  
Program  ( OTP).  
 

Overview  
Activity  16.1     Define  CMAM  ( 30  minutes)  
Activity  16.2   How  to  identify  acute  malnutrition,  referrals,  and  counseling    
(1  hour  30  minutes)  
 
Total  Time     2  hours    

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape  
• Booklet  on  key  ENA  messages    
• Mid  Upper  Arm  Circumference  ( MUAC)  Tape  

Advanced  Preparation  
Handouts    
HO  #19:     What  is  CMAM    
HO  #20:     Marasmus  &  Kawshiorkor  
HO  #21:     Assess  malnutrition  at  community  level  
HO  #22:     What  are  the  admission  criteria  for  CMAM?  
HO  #23:     Management  of  Acute  Malnutrition  at  community  level  

Day  4               -­‐  56  -­‐    

DETAILED  ACTIVITIES  
Activity  16.1   Define  CMAM    
(30  minutes)  
Methodology  
• Brainstorming:  Ask  participants  h ow  malnourished  children  are  cared  for  in  their  areas.  
• Facilitator  briefly  d iscuses:    
• Definition  of  CMAM  
• Four  principles  of  CMAM  
• Components  (types)  of  CMAM  management  for  acute  malnourished  children  
• Ask  the  participants  to  review  HO  #19.  

CMAM  consists  of    

• Community  outreach.    
• The  community  element  of  CMAM  program  must  b e  strong  in  order  to  mobilize  
mothers/caretakers  to  bring  their  children  to  the  Outpatient  Therapeutic  Program  ( OTP)  
or  Supplementary  F eeding  Program  (SFP)  for  screening  before  SAM  b ecomes  serious  
and  medical  complications  arise.    
• The  outreach  workers  will  a lso  s earch  for  children  who  have  dropped  out  of  care  and  
provide  home  visits  as  n eeded  for  follow-­‐up  care.    
• The  volunteer  community  h ealth  workers  should  d o  this  in  their  own  communities.  
• An  Outpatient  Therapeutic  Program  (OTP).    
• There  will  b e  an  OTP  in  as  many  MOH  or  NGO  h ealth  facilities  as  capacity  allows.    
• This  is  where  the  majority  of  severely  malnourished  children  will  b e  assessed  and  
treated.    
• The  OTP  will  b e  run  by  staff  given  specific  CMAM  training  and  support.  
• Stabilization  Centre  (SC)  or  Phase  I.    
• This  will  b e  only  for  malnourished  children  with  medical  complications  who  are  n ot  well  
enough  to  b e  treated  on  an  outpatient  basis.    
• They  are  treated  as  inpatients  until  their  condition  is  stable  enough  for  them  to  b e  
discharged  and  treated  in  outpatient  care  ( OTP)  (Average  5-­‐7  days).  
• A  Supplementary  Feeding  Program  (SFP).  
• This  program  treats  and  supports  all  the  moderately  malnourished  children,  lactating  
mothers  who  have  infants  less  than  6  months  of  age  with  MUAC  less  than  21  cm,  and  
pregnant  mothers  with  MUAC  less  than  21  cm.    
• SFP  usually  provide  Corn  Soy  Blend  and  oil  for  moderately  malnourished  children.  

Day  4               -­‐  57  -­‐    

Four  core  principles  of  CMAM  
1. High  coverage  and  good  access  to  s ervices.  
2. Timeliness,  b ecause  mortality  often  occurs  b efore  emergency  interventions  are  up  and  
running.  
3. Appropriate  medical  and  nutrition  care.  The  IMNCI  protocols  and  appetite  test  
determine  the  care  n eeded.    
4. Care  for  as  long  as  n eeded.    

Activity  16.2   How  to  identify  acute  malnutrition    

(1  hour  30  minutes)  
Methodology  
• Divide  participants  into  s ix  groups.  
• Ask  each  group  to  d iscuss  a nd  answer  the  following  questions:  
1. Describe  the  signs  of  Marasmus  [may  have  local  name]  
2. Describe  the  signs  of  Kwashiorkor  [may  have  local  name]  
3. Explain  how  to  identify  oedema  (bilateral-­‐pitting  oedema)  
4. Explain  how  to  measure  MUAC  (Mid  Upper  Arm  Circumference)  and  d emonstrate.  (In  
many  countries,  MUAC  is  the  preferred  measure  for  screening  and  admission  to  CMAM.)    
5. Explain  the  criteria  for  referral/admission  to  CMAM  
6. Explain  the  s teps  of  counseling  for  children  with  MAM  or  SAM  
• Invite  one  group  to  present  and  ask  participants  to  refer  to  HO  #19  to  HO  #23  and  compare.    
• All  participants  are  asked  to  take  MUAC  measurements.  

A  small  p ercentage  of  children  may  suffer  from  s evere  acute  malnutrition  with  complications  
such  as  Marasmus  and  Kwashiorkor.  During  times  of  s evere  food  shortages,  it  can  b e  expected  
that  a  larger  percentage  of  young  children  d evelop  Marasmus  and  Kwashiorkor,  but  many  
countries  experience  h igh  rates  during  non-­‐crisis  times  due  to  feeding-­‐related  b ehaviors,  
disease,  and  other  factors.  Both  conditions  require  immediate  care  b y  h ealth  workers.  
Note:  One  should  n ot  wait  for  these  signs  to  appear  before  a cting  because  when  the  signs  of  
complications  b ecome  apparent,  it  means  the  child  is  in  great  danger.  At  this  s tage,  the  child  
may  require  intensive  care.  However,  the  signs  of  the  onset  of  malnutrition,  as  well  as  the  s igns  
of  malnutrition  are  often  unrecognized.  Possible  conditions/early  s igns  of  malnutrition  are:  
• Recurrent  or  prolonged  illness  or  d iarrhea;  
• Growth  or  weight  leveling  off  or  d ecreasing;  and/or  
• Feeding  issues  –  fussy  baby,  breastfeeding  problems.  

Day  4               -­‐  58  -­‐    

Possible  answers    
1. The  signs  of  Marasmus    
• HO  #20    
2. The  signs  of  Kwashiorkor  
• HO  #20    
3. How  to  identify  oedema  (bilateral  pitting  oedema)  
• HO  #21  
4. How  to  measure  MUAC  ( Mid  Upper  Arm  Circumference)  and  demonstrate    
• HO  #21  
• Ask  each  participant  to  practice  
5. The  criteria  for  referral/admission  to  CMAM  
• HO  #22  
• Explain  on  flipchart  if  n eeded  
6. The  steps  of  counseling  for  children  with  MAM  or  SAM  
• HO  #23  
• Illustration  #23  

Day  4               -­‐  59  -­‐    

SESSION  17  
WOMAN’ S  NUTRITION  
 

General  Objectives  
• Improve  woman’s  nutrition  to  promote  maternal  and  family  h ealth.  
• Improve  child  survival  through  woman’s  nutrition.  “A  h ealthy  mother  is  the  first  d efense  of  
the  child  against  d eath,  malnutrition,  and  the  cycle  of  poverty  and  sickness.”  
 

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Describe  the  malnutrition  life  cycle.  
• Name  the  consequences  of  maternal  malnutrition.  

Overview  
Activity  17.1   Importance  of  promoting  adequate  nutrition  for  women,  and  explanation  of  the  
intergenerational  malnutrition  cycle  (15  minutes)  
Activity  17.2   Interventions  that  can  be  used  to  break  the  malnutrition  life  cycle  (1  hour)  
Activity  17.3   Nutrition  and  the  HIV-­‐positive  mother  (15  minutes)  
 
Total  Time     1  hour  30  minutes  
 

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Booklet  on  key  ENA  messages  
• Drawing  of  malnutrition  life  cycle  on  flipchart  
Handout  
HO  #24:     Key  Messages  on  Women's  Nutrition  

Day  4               -­‐  60  -­‐    

DETAILED  ACTIVITIES  
Activity  17.1     Importance  of  promoting  adequate  dietary  intake  for  
women,  and  explanation  of  the  intergenerational  
malnutrition  cycle    
(15  minutes)  
Methodology  
• Brainstorm  the  q uestion:  Why  is  it  important  to  promote  adequate  d ietary  intake  for  
women?  
• Write  answers  on  flipchart  and  discuss.  
• Facilitator  explains  the  intergenerational  malnutrition  cycle.  
Content  
When  a  woman  is  malnourished,  the  n ext  generation  may  also  suffer  from  malnutrition  and  
poor  h ealth.  Malnourished  women  are  more  likely  to  h ave  b een:  
• Girls  that  were  low  birth  weight;  
• Girls  that  were  underweight  and  stunted;  
• Girls  that  had  their  first  pregnancy  during  adolescence;  and/or  
• Women  who  are  undernourished,  have  close  spaced  p regnancies,  and  have  h eavy  
workloads  during  pregnancy  and  breastfeeding  p eriods.    
 
Intergenerational  malnutrition  cycle  

Low  weight  &  

height  of  the  
child  ( Growth  
Failure)  

Adolescent  
Low  birth  
Teenage  pregnancy girl  with  low  
weight  
weight  &  
height  

Woman  
with  low  
weight  &  
height

Day  4               -­‐  61  -­‐    

Activity  17.2   Interventions  that  can  be  used  to  break  the  malnutrition  
life  cycle    
(1  hour)  
Methodology  
• Divide  participants  into  four  groups  and  ask  each  group  to  focus  on  one  point  in  the  
malnutrition  life  cycle  (one  arrow)  d eveloping  strategies  to  break  the  cycle  at  that  point.  
• Each  group  will  present  their  work  in  plenary.  
• Discussion  and  summary.  
• Refer  to  HO  #24  or  the  Booklet  on  Key  ENA  messages  a nd  have  participants  read  each  
messages  (Illustrations  #  1,  2,  3,  4,  and  11).  
Content  
Initiatives  aiming  to  improve  child  survival  must  s tart  long  b efore  conception.  They  should  start  
by  improving  the  h ealth  s tatus  of  adolescents  and  pre-­‐pregnant  women,  and  also  addressing  
their  economic  and  social  problems.    
Interventions  to  break  the  malnutrition  cycle  
1.  Prevent  low  weight  and  height  of  the  child  ( Growth  Failure)  
• Early  initiation  of  breastfeeding  (within  first  hour  after  birth)  
• Exclusive  breastfeeding  0-­‐  <  6  months    
• Timely  initiation  of  complementary  foods  at  6  months  with  continuation  of  
breastfeeding  up  to  2  years  
• Feed  s ick  child  more  during  illness  and  two  weeks  after  recovery  
• Vitamin  A  supplementation  and  consumption  of  foods  rich  in  V itamin  A  
• Anemia  control  (iron  supplementation  and  d eworming)  and  consumption  of  foods  rich  
in  iron  
• Iodine  deficiency  control:  consumption  of  iodized  salt    
• Immunizations  
• Family  planning  
2.  Prevent  low  weight  and  height  of  adolescent  girl  
• Increase  the  food  intake  of  adolescents    
• Delay  first  pregnancy  until  after  20  years  
• Prevent  and  treat  infections:  
• Ensure  anti-­‐tetanus  immunizations  for  pregnant  adolescents  and  women,  five  
injections  in  total    
• Education  on  STIs  and  HIV  &  AIDS  transmission  and  prevention  
• Prevent  iron,  V itamin  A,  and  Iodine  d eficiencies:  
• Encourage  consumption  of  foods  rich  in  iron  (green  leafy  vegetables,  b eans,  meat,  
and  liver).  
• Encourage  consumption  of  foods  rich  in  Vitamin  A  (papaya,  mangoes,  carrots,  
pumpkins,  milk,  liver)  
• Encourage  consumption  of  iodized  salt  and  foods  rich  in  iodine  (fish  and  s eafood)  

Day  4               -­‐  62  -­‐    

 • Encourage  parents  to  give  equal  access  to  education  to  boys  and  girls  (schooling  of  the  
girl  child)  
• Malnutrition  d ecreases  when  girls/women  receive  a  higher  level  of  education.  
3.  Prevent  low  weight  and  height  of  woman  
• Improve  woman’s  nutrition  and  health  
• Increase  the  food  intake  of  the  woman  at  every  step  of  her  life,  especially  during  
adolescence,  pregnancy,  or  while  breastfeeding:  “an  a dditional  meal,  more  food  
than  usual,  and  a  varied  d iet.”  
• Fight  iron,  V itamin  A,  and  iodine  d eficiencies:  
• Iron/folic  a cid  supplementation  d uring  pregnancy  (1  tablet/day  for  6  months).  
• Encourage  consumption  of  foods  rich  in  iron  ( green  leafy  vegetables,  b eans,  
meat,  and  liver).  
• Vitamin  A  supplementation  after  d elivery  (a  s ingle  dose  [1  capsule  of  200,000IU]  
as  soon  as  possible  in  the  first  s ix  weeks  after  d elivery).  
• Encourage  consumption  of  foods  rich  in  Vitamin  A  (papaya,  mangoes,  carrots,  
pumpkins,  milk,  liver)  
• Encourage  consumption  of  iodized  salt  and  foods  rich  in  iodine  (fish  and  
seafood).  
• Prevent  and  treat  infections:  
• Complete  anti-­‐tetanus  immunizations  for  pregnant  women,  five  injections  in  
total  
• Use  of  insecticide  treated  b ed  n ets  ( ITNs)  
• Deworming  of  pregnant  women  during  third  trimester  
• Education  on  STI  and  HIV  &  AIDS  transmission  and  prevention  
4.  Family  planning  
• Women  n eed  to  visit  a  family  p lanning  centre  in  order  to  space  the  b irths  of  h er  children  
5.  Decrease  energy  expenditure    
• Delay  the  first  pregnancy  until  after  20  years  of  age  
• Encourage  couples  to  use  family  planning  
• Decrease  workload  of  pregnant  and  breastfeeding  women  
• Rest  more  
6.  Encourage  men’s  participation  
• In  b irth  spacing,  and  good  follow-­‐up  of  pregnancy  and  delivery  
• In  supporting  more  nutritious  diet  and  a  lighter  workload  for  their  wife/partner  

Day  4               -­‐  63  -­‐    

Activity  17.3     Nutrition  and  the  HIV-­‐positive  mother    
(15  minutes)    
Methodology  
• Brainstorm  with  participants  the  relationship  b etween  HIV-­‐positive  status  and  nutrition,  the  
special  nutrition  n eeds  of  the  HIV-­‐positive  woman,  and  suggestions  to  meet  these  n eeds.  
• Discussion  and  summary.    
Content  
• There  is  less  chance  of  an  HIV-­‐positive  woman  passing  the  virus  to  h er  baby  if  she  is  h ealthy.  
• Nutritional  requirements  of  HIV-­‐positive  women  are  greater  and  should  b e  met  b y  increased  
intakes  of  nutritious  foods.    
• HIV  infection  increases  energy  and  nutrient  n eeds.  
• Reduced  appetite,  poor  nutrient  a bsorption,  and  physiological  changes  can  lead  to  weight  
loss  and  malnutrition  in  HIV-­‐infected  p eople.    
• Encourage  HIV-­‐infected  pregnant  and  lactating  women  to  maintain  energy  and  nutrition  
balance  b y:  
• Increasing  food  intake,  eating  an  extra  meal  a  day  
• Taking  iron  supplement  and  multivitamin  if  a vailable  

Day  4               -­‐  64  -­‐    

SESSION  18  
NEGOTIATION   WIT H  MOTHERS/CAREGIVERS  
 

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Explain  the  s teps  of  n egotiation  (GALIDRAA).  
• Use  a n  illustration  to  n egotiate  with  the  mother/caregiver.  
• Practice  the  initial  visit  of  n egotiation  with  a  mother/caregiver  of  a  child  6-­‐24  months.    
• Practice  the  initial  visit  of  n egotiation  to  improve  a  woman’s  n utrition.  

Overview  
Activity  18.1   Review  listening  and  learning  s kills  and  n egotiation  steps:  GALIDRAA  –  Greet,  
Ask,  Listen,  Identify  d ifficulty,  Discuss  options,  Recommend  and  n egotiate,  
Agrees  and  repeats  agreed-­‐upon  action,  follow-­‐up  Appointment  (10  minutes)  
Activity  18.2     Use  of  visual  in  n egotiation  visit  (20  minutes)  
Activity  18.3   Demonstration  of  n egotiation:  initial  visit  to  encourage  mothers  to  try  
appropriate  complementary  feeding  b ehaviors,  and  group  discussion  (30  
minutes)  
Activity  18.4   Practice  n egotiation  in  an  initial  visit  to  mother  with  infant  b etween  6-­‐24  
months  (1  hour  15  minutes)  and  for  women’s  nutrition    
Activity  18.5   Discuss  p lans  for  field  practice  planned  for  the  n ext  morning  (15  minutes)  
 
Total  Time     2  hours  30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    
• Booklet  on  key  ENA  messages,  counseling  card,  woman’s  h ealth  record,  child’s  h ealth  record  
etc.    
• Case  s tudies  on  cards    

Advance  Preparation  
Handouts  
HO  #25:     General  Case  Studies  of  child  6-­‐24  months  
HO  #26:     How  to  Negotiate  using  visuals  (ORPA):  poster,  counseling  card,  a  child  health  
booklet,  etc.  

Day  4               -­‐  65  -­‐    

DETAILED  ACTIVITIES  
Activity  18.1   Review  listening  and  learning  skills  and  negotiation  
steps:  GALIDRAA  –  Greet,  Ask,  Listen,  Identify  difficulty,  
Discuss  options,  Recommend  and  negotiate,  
mother/caregiver  Agrees  and  Repeats  action  to  be  
followed,  follow-­‐up  Appointment    
(10  minutes)    
Methodology  
• In  p lenary,  ask  participants:  What  are  listening  and  learning  skills?  What  are  the  different  
steps  of  n egotiation?  How  many  visits  are  n eeded  for  the  full  process  of  n egotiation?    
• Write  answers  on  flipchart.  
• Add  any  missing  information.    
• Ask  the  participants  to  review  HO  #15.  
Negotiation  is  a  method  used  to  encourage  mothers  to  try  n ew  recommended  practices  to  
improve  their  children’s  feeding.  
 
Listening  and  Learning  Skills  
1. Use  helpful  non-­‐verbal  communication  
• Keep  your  h ead  level  with  mother  
• Pay  attention  
• Nod  h ead  
• Take  time  
• Appropriate  touch  
2. Ask  open-­‐ended  questions  that  s tart  with  what,  why,  h ow,  or  where  rather  than  questions  
that  require  a  yes  or  n o  only.  
3. Use  responses  and  gestures  that  show  interest.  
4. Reflect  back  what  the  mother  says.  
5. Empathize  –  show  that  you  understand  how  she  feels.  
6. Avoid  using  words  that  sound  judgmental.  
 
Q:  What  are  the  different  steps  of  negotiation?  
A:  Follow  negotiation  steps:  GALIDRAA  
• Greet  the  mother  and  establish  confidence  
• Ask  about  feeding  practices,  age  of  the  child,  and  status  
• Listen  to  the  mother    
• Identify  feeding  difficulty  and  causes  of  the  d ifficulty  
• Discuss  d ifferent  feasible  options  to  overcome  the  d ifficulty  with  the  mother/caregiver  

Day  4               -­‐  66  -­‐    

 • Recommend  and  n egotiate  doable  actions  
• Agree  with  the  mother  which  practice  the  mother  will  try;  mother/caregiver  repeats  
practice  she  will  try  
• Appointment  for  follow-­‐up  

Q:  How  many  visits  are  n ecessary  to  carry  out  a  n egotiation?  

A:  At  least  two  visits  are  necessary  t o  carry  out  a  negotiation.    
• Initial  visit-­‐  
• At  the  b eginning  of  the  visit,  check  the  child’s  a ge  or  the  child’s  health  card.  
• According  to  the  child’s  age,  h ealth  provider  should  assess  the  mother’s  current  
practice,  if  she  could  try  out  previous  recommendations,  if  they  are  n ew  
recommendations  to  give,  and  continue  n egotiating  to  encourage  continuing  correct  
behaviors  and  adding  improved  b ehaviors.  
• Follow-­‐up  1:  After  one  to  two  weeks  
• If  possible,  follow-­‐up  2:  After  one  month    

Activity  18.2   Use  of  visual  in  negotiation  visit    

(20  minutes)  
Methodology  
• The  facilitator  refers  to  the  Booklet  on  Key  ENA  Messages  and  shows  the  p ictures,  and  
explains  how  pictures  could  be  used  as  probes  for  n egotiation,  and  refer  to  the  session  on  
day  1.    
• Present  the  steps  of  using  a  visual:  Observe,  Reflect,  Personalize,  and  Act.    
• Distribute  HO  #26  and  discuss.  
• Discussion  and  summary.  

Activity  18.3   Demonstration  of  negotiation  to  encourage  mothers  to  

try  appropriate  complementary  feeding  behaviors:  
initial  visit  to  mother  with  child  between  6  –  24  months;  
and  group  discussion    
(30  minutes)  
Methodology  
• Facilitators  d emonstrate  the  initial  visit  to  Sayba  with  6½-­‐month-­‐old  daughter,  Kortu  
• Participants  d iscuss  what  happened  in  the  demonstration  visit.    
• Review  listening  and  learning  s kills.  
• Refer  to  HO  #25  and  d iscuss:  General  Case  Studies  of  b aby  6-­‐24  months.  

Day  4               -­‐  67  -­‐    

Demonstration  of  Case  Study  of  baby  6-­‐24  months:  Sayba  and  Kortu  
Visit  #1:  Initial  V isit    
Situation:  The  h ealth  worker  is  visiting  Sayba.  Kortu,  h er  baby  is  now  6  and  a  half  months.  She  
feeds  h er  daughter  cow’s  milk  and  gruel  in  addition  to  breastfeeding.  The  child  s creams  and  
cries  a  lot.  The  child  is  not  gaining  weight.  
 
Examples  of  possible  follow-­‐up  n egotiation  visits  with  Sayba  
Visit  #2:  Follow-­‐up  of  the  child  6  to  24  months    
Situation:  Sayba  has  s erved  Kortu  porridge,  a  little  oil,  and  banana.  She  has  some  d ifficulties  
varying  the  porridge  and  she  does  not  have  enough  money  to  always  buy  meat.  
Visit  #3:  Maintain  the  practice  and/or  n egotiate  a  n ew  practice  
Situation:  Kortu  is  now  8  months  old.  Sayba  s till  breastfeeds  and  s erves  three  enriched  meals  
per  day  s ince  h er  child  was  6  months  old.  She  also  gives  her  child  a  piece  of  fruit  every  day  such  
as  ripe  mango  and  papaya.  Kortu  is  very  h ealthy  and  is  growing  well.  

Activity  18.4   Practice  negotiation  in  an  initial  visit  to  mother  with  6-­‐
24  months  and  to  improve  woman’s  nutrition    
(1  hour  15  minutes)  
Methodology  
• Participants  are  d ivided  into  triads:  mother,  h ealth  worker,  and  observer;  triads  are  given  
three  of  five  case  studies  to  practice  n egotiation  for  an  initial  visit;  each  participant  rotates  
the  three  d ifferent  roles  until  all  the  case  studies  they  have  are  complete.  
• Refer  to  the  n egotiation  practice  instructions  in  Activities  18.1  and  18.2.  
• Facilitator  d istributes  case  s tudies  on  complementary  feeding  and  woman’s  nutrition.    
• Two  triads  d emonstrate  a  case  study  in  p lenary.  
• Discussion  and  summary.    

Case  studies  related  to  complementary  feeding  6-­‐24  months  

Possible  answers:  Practice  Case  Studies  6-­‐24  m onths  
Leading  points  for  discussion  of  case  s tudies    
The  participants  are  expected  to  follow  the  negotiations  steps  ( GALIDRAA)  and  use  the  listening  
and  learning  s kills.  The  participant  has  to  ask  about  the  current  complementary  feeding  
practices  in  the  background  of  optimal  complementary  feeding  practice  recommendation  for  
age  6-­‐24  months.  
• Greet  the  mother.    
• Introduce  him/herself.    
• Ask  p ermission  to  discuss  with  the  mother  her  infant  feeding  practices.    
• Ask  about  current  infant  feeding  practices,  praise  positive  practices  and  identify  problems,  if  
any,  based  on  optimal  infant  feeding  practices.    

Day  4               -­‐  68  -­‐    

 1. Introduce  complementary  foods  at  the  a ge  of  6  months.    
2. Increase  the  frequency  of  feeding  and  the  a mount  of  food  as  the  child  gets  older.    
3. Start  with  soft  porridge  and  increase  the  food  thickness  and  variety  as  the  child  gets  
older.  
4. Interact/play  with  the  child  d uring  feeding.    
5. Practice  good  h ygiene  and  safe  food  preparation.    
6. Breastfeed  the  child  on  d emand  until  2  years  and  b eyond.    
7. Continue  to  breastfeed  when  the  child  is  ill  and  encourage  the  child  older  than  6  months  
to  eat  during  and  after  illness.    
 
Case  Study  #  1  
You  visit  Korpo,  whose  baby  is  6½  months  old.  Korpo  tells  you  that  her  baby  is  too  young  for  
food  b ecause  the  baby’s  s tomach  is  too  small  and  that  she  will  just  continue  to  breastfeed  h im  
until  h e  is  older.  Her  husband  and  mother-­‐in-­‐low  agree  with  h er.  
Case  1:  Delayed  initiation  of  complementary  feeding  
The  participant  has  to  ask  and  listen  to  current  feeding  practices  and  identify  problems  and  
causes  for  the  problems.  In  this  particular  case,  the  problem  is  d elayed  initiation  of  
complementary  feeding.  The  reason  given  h ere  is  the  baby's  s tomach  is  too  small.  
S/he  has  to  explain:  
• Even  though  the  baby's  stomach  is  s mall,  b y  the  age  of  6  months,  the  baby’s  gut  is  ready  and  
needs  to  receive  food  other  than  breastmilk.  
• You  can  start  with  small  amounts  of  soft  foods  like  porridge  so  that  the  baby  can  s wallow  
and  digest  it  easily.  
• Increase  the  a mount  of  food  that  the  baby  eats  and  vary  the  diet  b y  combining  cereals  and  
legumes  to  make  the  porridge,  and  b y  providing  mashed  fruits  and  vegetables.  
• For  a  6-­‐8-­‐month-­‐old  baby,  give  food  two  to  three  times  daily  and  include  one  or  two  other  
solid  foods  (snacks)  each  day  to  ensure  h ealthy  growth.  
• To  give  the  food  more  energy,  add  1  tsp  of  oil  or  butter  to  the  porridge  or  food  at  each  
meal.  
• Wash  hands  with  soap  during  preparation  of  food  and  before  feeding  the  child.  
• Interact  while  feeding.  
• Continue  breastfeeding  until  2  years  and  b eyond.  
The  participant  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  practicing  
adequate  Complementary  Feeding  (complementary  feeding),  then  ask  her  to  repeat  the  a greed  
points  and  arrange  a  s econd  visit.  Finally,  praise  the  mother  for  taking  h er  time  and  for  h er  
willingness.  

Day  4               -­‐  69  -­‐    

Case  Study  #2  
Hawa  has  a  9-­‐month-­‐old  daughter  who  is  eating  plain  gruel  once  a  day.  You  talk  to  Hawa  a bout  
the  need  to  use  porridge  instead  of  gruel,  add  other  foods  to  the  porridge,  feed  at  least  three  
times  a  day,  and  to  give  fruit  every  day.  
Case  2:  Inadequate  complementary  feeding  practice  
The  participant  has  to  ask  and  listen  to  current  feeding  practices  and  identify  problems  and  
causes  for  the  problems.  In  this  particular  case,  the  problem  is  inadequate  complementary  
feeding  practices  in  light  of  FADDUA.    
S/he  has  to  d iscuss  about  the  n eed  to  feed  the  baby:  
• Three  to  four  times  a  day  at  this  age  with  one  or  two  s nacks  a  day.  
• Increase  the  a mount  of  food  the  baby  eats,  and  enrich  the  diet  b y  adding  animal  products,  
fruits,  and  vegetables.  
• Give  h er  snacks.    
• Add  2  tsp  oil  or  b utter  to  the  food  at  each  meal.  
• Wash  hands  and  utensils  with  soap  b efore  preparation  of  food  and  b efore  feeding  the  baby.    
• Store  prepared  food  in  clean  area.  Don't  give  food  that  was  prepared  the  day  b efore.    
• Practice  a ctive  feeding  or  interacting  with  the  baby  while  feeding.  
• Continue  breastfeeding  until  2  years  and  b eyond.    
The  participant  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  the  n ew  
practice,  ask  h er  to  repeat  the  a greed  points,  and  arrange  for  a  second  visit.  F inally,  praise  the  
mother  for  h er  time  and  willingness.  
 
Case  Study  #3  
Faith’s  7-­‐month-­‐old  baby  is  eating  porridge  every  day.  Faith  is  breastfeeding  b ut  not  giving  
anything  else  to  the  baby  except  p orridge.  
Case  3:  Inadequate  complementary  feeding  practice  
The  participant  has  to  ask  and  listen  to  current  feeding  practices  and  identify  problems  and  
causes  for  the  problems  with  regard  to  FADDUA.  In  this  case,  the  complementary  feeding  
practice  is  unsatisfactory.    
S/he  has  to  d iscuss,  recommend,  and  negotiate  on  the  following  points:  
• To  feed  the  baby  two  to  three  times  a  day  and  include  one  or  two  other  solid  foods  (snacks)  
each  day  to  ensure  healthy  growth.    
• To  increase  the  a mount  of  food  the  baby  eats  as  he  gets  older.  
• Enrich  the  d iet  by  adding  animal  products,  fruits,  and  vegetables.  
• Wash  hands  and  utensils  with  soap  b efore  preparation  of  food  and  b efore  feeding  the  baby.  
Store  prepared  food  in  clean  area.  Don't  give  food  that  was  prepared  the  day  b efore.    
• Practice  a ctive  feeding  or  interact  while  feeding.  
• Continue  breastfeeding  until  2  years  and  b eyond.  
The  participant  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  the  n ew  
practice,  ask  h er  to  repeat  the  a greed  upon  points,  a nd  arrange  for  a  s econd  visit.  Finally,  praise  
the  mother  for  giving  h er  time  and  for  her  willingness.  

Day  4               -­‐  70  -­‐    

Case  Study  #4  
Yamah’s  baby  is  12  months  old  and  the  mother  gives  b ites  of  adult  food  at  meal  time  only.  
Case  4:  Inadequate  complementary  feeding  practice  
The  health  worker  has  to  ask  and  listen  to  current  feeding  practice  and  identify  problems  and  
causes  for  the  problems.  In  this  particular  case,  the  problem  is  that  the  mother  is  not  following  
FADDUA.    
S/he  has  to  d iscuss,  recommend,  and  negotiate  on  the  following  points:    
• Feed  the  baby  three  to  four  times  a  day  with  one  or  two  snacks.  
• Increase  the  a mount  of  food  the  baby  eats  as  h e  gets  older,  at  least  one  “buna”  cup  of  food  
per  meal.  
• Enrich  the  family  d iet  b y  adding  animal  products,  fruits,  and  vegetables.  
• Wash  hands  and  utensils  before  preparation  of  food  a nd  feeding  the  baby.  Store  prepared  
food  in  clean  area.  Don't  give  food  that  was  prepared  the  day  b efore.    
• Practice  a ctive  feeding  or  interacting  with  the  baby  while  feeding.  
• Continue  breastfeeding  until  2  years  and  b eyond.  
The  participant  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  the  n ew  
practice,  ask  h er  to  repeat  the  a greed  points,  and  arrange  for  a  second  visit.  Finally,  praise  the  
mother  for  h er  time  and  for  h er  willingness.  
 
Case  Study  #5    
Massa’s  child  is  11  months  old  and  she  gives  the  child  porridge  two  times  a  day  and  bits  of  soup  
with  whatever  she  is  feeding  the  family  that  day.  
Case  5:  Inadequate  complementary  feeding  practice  
The  health  worker  has  to  ask  and  listen  to  current  feeding  practices  and  identify  problems  and  
causes  for  the  problems.  In  this  case,  the  problem  is  inadequate  complementary  feeding.    
S/he  has  to  address  the  n eed:  
• Feed  the  baby  three  to  four  times  a  day  with  one  or  two  snacks.  
• Increase  the  a mount  of  food  the  baby  eats  as  s/he  gets  older.  
• Enrich  the  d iet  by  adding  animal  products,  fruits,  and  vegetables.  
• Wash  hands  with  soap  and  utensils  b efore  preparation  of  food  and  feeding  the  baby.  Store  
prepared  food  in  clean  area.  Don't  give  food  that  was  prepared  the  day  b efore.    
• Practice  a ctive  feeding  or  interact  while  feeding.  
• Continue  breastfeeding  until  2  years  and  b eyond.  
The  participant  has  to  recommend,  negotiate,  and  a gree  with  the  mother  to  try  the  n ew  
practice,  ask  h er  to  repeat  the  a greed  points,  and  make  arrangement  for  a  s econd  visit.  F inally,  
praise  the  mother  for  h er  time  and  for  h er  willingness.    
 

Day  4               -­‐  71  -­‐    

Case  Study  #6    
Mary  has  a  baby  of  7  months;  she  is  breastfeeding.  Mary  thinks  h er  baby  is  too  young  to  eat  
thick  porridge,  and  so  she  feeds  it  a  thin  p orridge  without  any  added  nutrients.  
Case  6:  Inadequate  complementary  feeding  practice  
The  health  worker  explains  that  as  soon  as  they  are  6  months  old,  babies  n eed  to  eat  p orridge  in  
addition  to  breastmilk.  This  porridge  can  b e  prepared  using  different  cereals  but  it  must  be  thick  
enough  not  to  flow  from  the  spoon.  It  must  a lso  b e  enriched  with  d ifferent  foods  that  will  n eed  
to  b e  mashed  or  ground  for  the  baby  to  b e  able  to  swallow  them.  Brightly  colored  vegetables  
and  fruits,  eggs,  milk,  meat,  peanuts,  beans,  or  nuts  can  be  used  to  enrich  the  porridge.  At  every  
meal,  Mary  can  add  oil,  butter,  or  p eanut  butter  to  the  baby’s  food  since  they  are  good  for  its  
health.  The  h ealth  worker  a lso  praises  Mary  for  having  continued  the  breastfeeding.  He  advises  
her  to  continue  doing  so  until  the  baby  is  at  least  2  years  old.    
 
Case  Study  #7    
Margo  has  a  6-­‐month-­‐old  baby.  She  is  p lanning  on  giving  complementary  foods  to  h er  baby  
soon.  She  thinks  that  h er  baby  will  only  n eed  millet  porridge.    
Case  7:  The  problem  here  is  in  adequate  complementary  feeding  practice  
The  health  worker  explains  that  from  6  months  onward,  babies  need  to  eat  thick  porridge  in  
addition  to  breastmilk.  This  porridge  can  b e  made  from  various  grains  and  tubers.  The  h ealth  
worker  explains  that  starting  at  the  a ge  of  6  months,  it  is  good  to  give  as  many  varieties  of  foods  
as  possible  to  children.  She  explains  that,  to  help  the  b aby  to  grow  properly,  Margo  can  enrich  
the  porridge  at  each  meal  with  two  or  three  kinds  of  foods  already  a vailable  to  h er.  She  can  
cook  every  meal  with  oil,  butter,  or  ground  p eanuts.  S he  should  a lso  give  a  red/orange  fruit  or  
vegetable  to  the  baby  at  every  meal.  Every  day,  she  should  try  to  put  meat,  egg,  beans,  or  
peanuts  in  the  baby’s  food.  If  possible,  she  should  use  milk  to  cook  the  porridge  instead  of  
boiled  water.  The  meat,  p oultry,  or  fish  should  be  mashed  or  ground  b efore  s erving  it  to  baby  
and  should  b e  added  to  the  baby’s  food  as  much  as  possible  b ecause  these  animal-­‐source  foods  
promote  growth.  Margo  should  also  continue  to  breastfeed  u ntil  the  baby  is  at  least  2  years  old.  
Margo  tells  the  h ealth  worker  that  she  has  vegetables,  fruits,  oil,  and  milk.  She  a grees  to  enrich  
daily  the  thick  p orridge  with  these  foods  for  h er  child  a nd  to  continue  breastfeeding.    
 
Case  Study  #8    
Eva  has  an  8-­‐month-­‐old  daughter  to  whom  she  gives  p orridge  enriched  with  different  kinds  of  
food  once  a  day.  However,  it  s eems  that  the  baby  is  h ungry  this  afternoon.    
Case  8:  Inadequate  complementary  feeding  practice  
The  health  worker  explains  that  from  6  to  11  months,  babies  n eed  to  eat  enriched  thick  porridge  
at  least  two  to  three  times  a  day,  in  addition  to  snacks  and  breastmilk.  In  one  day,  therefore,  
Eva’s  daughter  can  eat  a t  least  three  cups  of  enriched  porridge  and  two  snacks.  If  Eva  s ees  that  
she  is  still  hungry,  she  can  s till  give  her  food.  It  is  good  that  a  baby  eats  the  amount  of  food  it  
wants,  and  that  there  is  a  wide  variety.  The  h ealth  worker  advises  Eva  to  be  patient,  to  take  h er  
time  when  she  feeds  h er  baby  and  to  encourage  h er  to  eat  all  the  food  she  serves.  He  a lso  
explains  that  in  addition  to  proper  meals  (enriched  porridge),  the  baby  should  receive  one  or  
two  snacks  a  day.  For  that  purpose,  she  can  offer  slices  of  mango,  ripe  papaya,  banana,  or  liver.  
This  will  h elp  h er  baby  grow.  Eva  appreciates  the  advice  and  agrees  to  try  the  recommended  
practices.    

Day  4               -­‐  72  -­‐    

Case  Study  #9    
Fadji  has  a  7-­‐month-­‐old  baby  whom  she  breastfeeds.  She  a lso  gives  h er  child  a  thin  oat  porridge  
and  cow’s  milk.  She  uses  a  bottle  to  feed  h er  baby  these  liquids.  Fadji  thinks  h er  baby  is  not  yet  
ready  to  eat  other  foods.    
Case  9:  Inadequate  complementary  feeding  practice  
The  health  worker  explains  to  Fadji  that  from  6  months,  babies’  porridge  should  be  thick  and  
enriched  with  a  variety  of  foods  in  addition  to  breastmilk.  Children  this  age  cannot  grow  
properly  if  they  are  only  given  thin  oat  porridge.  The  p orridge  must  b e  thick  enough  to  be  fed  b y  
hand  and  if  possible,  it  should  a lso  be  enriched  with  two  or  three  other  kinds  of  food  a vailable  at  
home,  such  as  carrots,  oil  or  butter,  eggs,  lentils,  or  meat.  Cow  milk  or  goat  milk  is  good  for  the  
baby  but  it  must  only  be  given  to  the  baby  in  a  cup.  Bottles  should  not  be  used  b ecause  they  are  
very  difficult  to  clean  and  can  cause  d iarrhea  in  babies.  The  h ealth  worker  reminds  Fadji  to  
always  breastfeed  the  baby  b efore  feeding  it.  Fadji  likes  the  recommendations  and  a grees  to  
give  the  thick  enriched  porridge  to  her  baby  and  to  s top  using  the  bottle.    
 
Case  Study  #10    
Kaisha's  son  is  15  months  old  and  h e  eats  the  family  meal  with  his  parents  two  times  a  day.  
Kaisha  has  ceased  to  breastfeed  h im.  He  s eems  s mall  for  his  a ge.    
Case  10:  Inadequate  complementary  feeding  practice  
The  health  worker  asks  Kaisha  why  she  s topped  breastfeeding:  is  it  because  she  is  pregnant  or  is  
it  s imply  b ecause  the  baby  wanted  to  s top  sucking?  She  reminds  Kaisha  that  it  is  recommended  
to  breastfeed  until  the  baby  is  a t  least  2  years  old.  She  explains  to  Kaisha  that  to  s tay  h ealthy  
and  grow  properly,  her  son  n eeds  to  eat  more  often  (at  least  5  times  a  day),  especially  s ince  h e  
no  longer  receives  the  b enefits  of  breastmilk.  She  recommends  s erving  the  baby’s  meal  on  an  
individual  p late  as  this  will  enable  Kaisha  to  make  sure  that  the  baby  has  finished  his  p ortion.  
She  should  a lso  add  other  foods  to  the  baby’s  b owl  in  addition  to  the  family  meal  because  that  
dish  is  not  rich  enough  for  him.  For  that,  she  can  use  oil  or  b utter,  meat,  fish,  eggs,  b eans,  
peanuts,  vegetables  and  fruits  (papaya,  mango,  banana,  orange).  Between  the  meals,  h e  eats  
with  h is  parents,  Kaisha’s  son  should  also  receive  two  s nacks  per  day:  s lices  of  mango,  ripe  
papaya,  bananas,  liver,  b eans,  s weet  p otatoes,  bread,  or  peanuts.  Snacks  will  allow  h im  to  grow  
and  become  strong.  Finally,  the  h ealth  worker  advises  Kaisha  to  resume  breastfeeding  until  h er  
son  is  a t  least  24  months  old,  especially  as  she  has  only  stopped  doing  so  in  the  last  few  days.  
Kaisha  appreciates  the  advice  of  the  promoter  of  nutrition  and  agrees  to  try  to  a pply  it.    
 
Case  Study  #11    
Hope  has  an  11-­‐month-­‐old  daughter.  S he  gives  her  thin  oat  p orridge  and  only  breastfeeds  
during  the  n ight.    
Case  11:  Inadequate  complementary  feeding  practice  
The  health  worker  tells  Hope  that  the  porridge  should  be  thick  enough  not  to  flow  from  the  
spoon.  He  a lso  explains  to  h er  that  if  she  breastfeeds  only  once  a  day,  h er  baby  might  soon  
suffer  from  malnutrition,  as  she  still  n eeds  lots  of  breastmilk.  Hope  should  breastfeed  whenever  
the  baby  is  hungry  or  thirsty,  at  least  10  times  a  day.  S he  should  a lso  give  the  baby  other  foods,  
always  breastfeeding  first.  If  she  does  all  this,  she  will  again  have  milk,  and  h er  baby  will  b e  
healthier.    

Day  4               -­‐  73  -­‐    

When  the  h ealth  worker  asks  what  foods  she  has  in  h er  home,  Hope  said  that  she  had  p eanut  
butter  and  beans.  He  explains  to  h er  that  to  maintain  the  h ealth  of  the  baby,  she  should  give  it  
three  or  four  meals  per  day  and  should  enrich  the  p orridge  each  time  with  peanut  butter,  b eans  
or  oil.  She  should  a lso  add  any  fruit  or  vegetable  she  h as  at  home  to  the  baby’s  meal:  for  
example,  mango,  orange,  or  mashed  bananas.  She  should  also  give  h er  other  snacks  whenever  
she  can:  b eans,  pumpkin,  donuts,  or  liver.  Hope  is  happy  to  receive  a ll  this  advice  and  a grees  to  
follow  it.    
 
Case  Studies  Related  to  Women’s  Nutrition  

Case  Study  #1  

You  visit  Kebbet  who  is  4  months  pregnant.  Kebbet  has  not  yet  visited  the  h ealth  clinic.    
Answer  
The  participant  has  to  ask  and  listen  to  the  current  practice  and  identify  problems  and  causes  for  
the  problems.  In  this  particular  case,  the  main  problem  is  that  Kebbet  is  n ot  a ttending  the  ante-­‐
natal  clinic.  
The  participant  has  to  explain  the  importance  of:  
• Going  to  the  prenatal  clinic  to  ensure  that  the  pregnancy  is  going  well,  to  receive  TT  
vaccines,  and  iron/folic  a cid  supplementation.  
• Eating  well,  one  additional  meal  each  day,  particularly  including  meat  as  much  as  possible,  
fruits,  and  vegetables.  
• Using  iodized  salt  for  h er  food  and  the  family  food.    

Case  Study  #2  

Hawa  is  a  young  woman  of  18  years  who  has  recently  married.  You  talk  to  h er  about  the  need  to  
eat  adequately.    
Answer  
The  participant  has  to  ask  and  listen  to  the  current  practice  and  identify  problems  and  causes  for  
the  problems.  In  this  particular  case,  the  participant  has  to  explain  that  Hawa  is  only  18  years  
old,  her  body  is  still  d eveloping  and  she  has  to  eat  well  to  a llow  her  body  to  d evelop  more.  The  
participant  can  a lso  explain  that  it  is  important  to  d elay  the  first  pregnancy  as  Hawa’s  body  is  
still  not  fully  d eveloped  and  she  could  go  the  health  facility  to  get  advice  on  family  p lanning,  and  
be  checked  for  anemia.  
 
Case  Study  #3  
Queta  tells  you  that  she  has  three  daughters  b etween  the  ages  of  12  and  16.  What  themes  will  
you  try  to  n egotiate  with  Queta?    
Answer  
The  participant  has  to  ask  and  listen  to  the  current  practice  and  identify  problems  and  causes  for  
the  problems.  In  this  particular  case,  the  main  problem  is  that  Queta  had  children  too  close  to  
each  other.  The  participant  has  to  explain  the  importance  of  eating  well  h erself  and  encouraging  
her  daughters  to  eat  well,  explaining  this  means  eating  animal-­‐source  foods  as  much  as  p ossible,  
dark  green  leafy  vegetables  and  orange  and  yellow  fruits  and  vegetables.  The  participant  should  

Day  4               -­‐  74  -­‐    

also  explain  how  important  it  is  Queta’s  daughters  to  d elay  pregnancy  u ntil  after  age  20  and  to  
space  their  own  pregnancies  a t  least  3  years  apart  in  order  to  ensure  their  bodies  are  strong  
enough  to  have  h ealthy  infants.  Queta  and  h er  daughters  should  to  go  to  the  h ealth  clinic  to  be  
checked  for  anemia.    
Case  Study  #4  
Betty  is  35  years  old  and  has  five  children.  She  is  breastfeeding  her  youngest  child,  who  is  18  
months.  
Answer  
The  participant  has  to  ask  and  listen  to  the  current  practice  and  identify  problems  and  causes  for  
the  problems.  In  this  particular  case,  the  main  problem  is  that  Betty  had  many  children,  and  is  
probably  weak  from  many  pregnancies/breastfeeding.  The  participant  has  to  explain  the  
importance  to  Betty  of  eating  well,  including  two  additional  meals  each  day,  as  much  as  possible  
containing  meat  (and  other  animal  products)  as  well  as  fruits  and  vegetables,  and  of  using  
iodized  salt  for  h er  food  and  the  family’s  food.    
 
Case  Study  #5  
Faith  is  in  h er  last  month  of  pregnancy  and  does  n ot  know  where  she  will  give  birth.    
Answer  
The  participant  has  to  ask  and  listen  to  the  current  practice  and  identify  problems  and  causes  for  
the  problems.  In  this  particular  case,  the  main  problem  is  that  Faith  has  to  b e  convinced  to  come  
to  d eliver  at  the  h ealth  facility.  She  n eeds  to  b e  checked  for  anemia,  and  get  iron/folic  acid  
supplementation.  The  participant  has  also  to  counsel  on  early  initiation  of  breastfeeding  —  
within  one  hour  after  b irth,  b efore  the  placenta  is  expelled  —  and  the  advantages  of  
breastfeeding  exclusively  until  the  baby  is  6  months  old.  

Activity  18.5     Preparation  for  field  visit  the  next  day    

(15  minutes)  
Methodology  
• Facilitators  d iscuss  the  logistics  and  ensure  that  all  participants  are  clear  about  the  
expectations,  dress,  and  timing  of  the  field  visit.  
• Discuss  h ow  the  groups  will  b e  d ivided  and  which  group  is  going  where  and  how.  
• Encourage  participants  to  review  today’s  s ession  and  b ring  to  the  field  visit  the  handouts  on  
“negotiation”  HO  #15  and  “GALIDRAA.”  
• Remind  participants  that  after  the  field  visit,  there  will  a  classroom  s ession  to  summarize  the  
field  visits.    
• Answer  any  questions  participants  have.  

Day  4               -­‐  75  -­‐    

SESSION  19  
FIELD  PRACTICE  

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Conduct  n egotiations  with  mothers/caregivers  of  a  child  6-­‐24  months  of  age  b y  doing  field  practice  
at  h ealth  centers  or  in  villages.  

Overview  
Activity  19.1     Field  practice  in  h ealth  centers  or  villages  (2  hour  30  minutes)  
Activity  19.2   Feedback  on  practice  session  ( 1  hour)    
 
Total  Time     3  hours  30  minutes  

Materials  Needed  
• Visual  support  (posters,  cards,  h ealth  booklet,  Booklet  on  ENA  Messages,  etc.)  

Advance  Preparation  
• Prepare  groups,  give  instructions  the  day  before  for  the  field  visit.  
• Make  an  appointment  at  the  h ealth  center  a  week  ahead  to  coincide  with  immunization  or  weighing  
sessions.  
OR  
• Make  an  appointment  with  the  village  chairman  or  the  community  h ealth  a gent  a  week  ahead  to  
prepare  village  for  the  participants’  visits.  
• Copy  of  summary  sheet  for  n egotiation  for  trainees.  
Handouts  
HO  #15:     Negotiation  record  
HO  #16:     Observation  Checklist  ( GALIDRAA)  

Day  5             -­‐  76  -­‐          

DETAILED  ACTIVITIES  
Activity  19.1     Field  practice  in  health  clinics  or  villages    
(2  hours  30  minutes)  
Methodology  
• In  p lenary,  review  n egotiation  steps.  
• Divide  participants  into  pairs:  one  will  counsel  and  n egotiate  with  the  mother/caregiver  of  a  child  6  
–  24  months  while  the  other  follows  the  dialogue  with  the  observation  checklist  in  order  to  give  
feedback  later.  
• Negotiator  fills  out  HO  #19  “Negotiation  Record”  form;  colleague  fills  out  GALIDRAA  checklist  HO  
#20  and  provides  feedback.  
• Participants  change  roles  until  each  participant  practices  at  least  two  n egotiations.  
 
Activity  19.2     Feedback  on  practice  session    
(1  hour)  
Methodology  
• After  returning  to  the  training  site,  in  p lenary,  each  pair  of  participants  will  summarize  their  
negotiation  experience  b y  filling  in  the  summary  sheet  flipchart  for  n egotiation  visits  (attached  to  
the  wall):  participants’  names,  child’s  name  and  a ge,  difficulty  identified,  options  suggested,  and  
behavior  mother/caregiver  a greed  to  try.  
• Some  groups  presents.  Participants  receive  and  give  feedback.  
• Discussion  and  summary.  

Day  5             -­‐  77  -­‐          

 NEGOTIATION  RECORD    
 
Use  this  as  a  sample  to  record  each  participant’s  field  visit  experience  

Sample  Summary  Sheet  for  Negotiation  during  Field  V isits  

Initial  Visit   1   2   3   Etc.  

Participants’  names  

Child’s  name/age  

Difficulty(ies)  
identified  
Options  suggested  
 
 
 
Behavior  mother  
agreed  to  try  
 
 

Draw  this  table  on  flipchart  paper.    

Add  additional  columns  for  number  of  n egotiation  visits.  
Each  pair  writes  one  case.  
The  facilitator  summarizes  the  field  visit.  
Display  the  flipchart  throughout  the  rest  of  the  training.    

Day  5             -­‐  78  -­‐          

SESSION  20  
INTRODUCTION  TO  JOB  AIDS  

Learning  Objective  
By  the  end  of  the  s ession,  participants  will:  
• Know  the  different  nutrition  activities  to  b e  conducted  at  each  health  contact.  

Overview  
Activity  21.1   Introduction  to  Jobs  Aids  for  Health  Workers  ( 45  minutes)  
Total  Time     45  minutes  

Materials  Needed  
• Copies  of  Jobs  Aids  for  each  participant  
Handouts  
HO  #27:     Prenatal  visit  
HO  #28:     Delivery  and  Perinatal  care  
HO  #29:     Postnatal  and  Family  planning  
HO  #30:     EPI  immunizations  
HO  #31:     Growth  monitoring  and  well  child  visit  
HO  #32:     Sick  child  visit  and  IMNCI  
HO  #33:     Community  management  of  acute  child  malnutrition  ( OTP)  

DETAILED  ACTIVITIES  
Activity  20.1     Introduction  to  Jobs  Aids  for  Health  Workers    
(45  minutes)  
Methodology  
• Explain  that  ENA  messages  can  b e  integrated  into  each  contact  of  the  health  system  and  with  other  
Child  Survival  and  Safe  Motherhood  interventions.  Distribute  Jobs  Aids  (HO  #27-­‐33).  
• Divide  participants  into  groups  (by  contact  p oint).  Each  group  discusses  what  ENA  and  key  
interventions  should  b e  integrated  into  their  assigned  health  contact  point:  
• Pregnancy  
• Delivery  
• Postnatal  
• Immunization/EPI  
• Well  child  v isit/GMP  
• Sick  child  visit/IMNCI-­‐  C-­‐IMNCI  
• Community  management  of  a cute  child  malnutrition/OTP  
• Each  group  presents.  
• Ask  participants  to  read  each  of  the  job  a ids  after  each  presentation,  and  complete  any  gaps  after  
each  presentation.  
• Discuss  h ow  the  h ealth  workers  will  use  the  job  a ids  and  where  the  job  a ids  could  b e  d isplayed.  

Day  5             -­‐  79  -­‐          

SESSION  21  
COMMUNITY  SUPPORT  GROUPS  

Learning  Objective  
By  the  end  of  the  s ession,  participants  will  b e  able  to:  
• Organize  and  facilitate  an  infant  and  young  child  feeding  support  group  of  child  caretakers  (mothers,  
fathers,  grandparents,  aunts,  uncles…).    
• Help  caretakers  to  support  each  other  in  their  infant  a nd  young  child  feeding  practices.  

Overview  
Activity  21.1   Conduct  an  Infant  and  Young  Child  F eeding  Support  Group  for  Participants  (15  minutes)  
Activity  21.2   Discussion  on  the  Support  Group  Experience  (30  minutes)  
Activity  21.3     The  Role  of  the  Facilitator  in  an  Infant  and  Young  Child  Feeding  Support  group  (15  
minutes)    
Activity  21.4     Practice  Conducting  a  Support  Group  ( 45  minutes)  
 
Total  Time     2  hours    

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    

Advanced  Preparation  
Handout    
HO  #  34:     Observation  Checklist  for  Support  Groups  
 

DETAILED  ACTIVITIES  
Activity  21.1   Conduct  an  Infant  and  Young  Child  Feeding  Support  Group  for  
Participants    
(15  minutes)    
Methodology  
• Facilitator  and  eight  participants  form  a  “fish  bowl”  and  roleplay  a  support  group  s ession,  sharing  
their  own  ( or  wife’s,  mother’s,  s ister’s)  experience  of  exclusive  breastfeeding.    
• Only  those  in  the  “fish  b owl”  are  permitted  to  talk    
• Those  who  are  not  participating  in  the  support  group  observe  what  is  happening  for  d iscussion  
later  

Day  5             -­‐  80  -­‐          

 Inner  circle  of  
Outer  circle  of   X   support  group  
participants   participants  (share  
X      X  
(listen)   experiences)  
 
X         X
  X     X  
    X  
 
  X       X  
Activity  21.2     Discussion  
 
on  the  Support  Group  Experience    
(30  minutes)  
    X   X  
Methodology  
•   ask  the  support  group  participants  the  following  questions:  
After  the  support  group  s ession,  
• What  did  you  like  in  the  support  group?  
• Did  you  learn  anything  n ew  from  other  participants’  experiences?  
• Do  you  feel  differently  about  breastfeeding  after  participating  in  the  support  group?  
• Is  the  support  group  different  from  an  educational  talk?  How?  
• According  to  you,  did  we  find  answers  to  the  doubts  expressed  in  the  support  groups?  
• After  this  meeting,  do  you  think  you  would  try  exclusive  breastfeeding?  
• Participants  who  observed  the  support  group  respond  to  the  same  questions.  

Activity  21.3   The  Role  of  the  Facilitator  in  an  Infant  and  Young  Child  Feeding  
Support  Group    
(15  minutes)  
Participants  discuss  the  following:    
1. The  role  of  the  facilitator  in  a  community  support  group;    
2. Who  can  facilitate  a  community  support  group;    
3. The  characteristics  of  a  community  support  group;    
4. Who  can  participate  in  a  community  support  group;    
5. Topics  of  a  support  group;  and    
6. Different  types  of  existing  groups/gatherings  in  the  community  that  could  b e  support  groups.  
Methodology  
• Six  flipcharts  are  s et-­‐up  throughout  the  room  with  the  following  h eadings:    
1. Role  of  the  facilitator  in  a  community  support  group  
2. Who  can  facilitate  the  community  support  group  

Day  5             -­‐  81  -­‐          

 3. Characteristics  of  a  community  support  group  
4. Who  can  participate  in  a  community  support  group  
5. Topics  for  a  community  support  group  
6. Different  types  of  existing  groups/gatherings  in  the  community  that  could  b e  support  groups  
• Divide  participants  into  s ix  groups.  Each  group  rotates  to  the  next  flipchart  after  three  minutes  to  
add  additional  content.  
Content  
Definition:  A  support  group  on  infant  and  young  child  feeding  is  a  group  of  mothers/caretakers  that  
promote  optimal  breastfeeding  and  complementary  feeding  b ehaviors  and  provide  mutual  support.  It  
holds  p eriodic  meetings  facilitated  b y  experienced  mothers  who  have  infant  and  young  child  feeding  
knowledge  and,  ideally,  have  mastered  some  group  dynamic  techniques.  Group  participants  share  their  
experiences,  information,  and  provide  mutual  support.  
1.  Role  of  facilitator:    
• Sits  in  a  circle  a t  the  same  level  as  the  rest  of  the  group.  
• Introduces  self  and  asks  the  group  participants  to  introduce  themselves.  
• Introduces  the  purpose  and  theme  of  the  meeting.  
• Explains  that  the  support  group  meeting  will  last  60-­‐90  minutes.    
• Asks  open-­‐ended  questions  to  encourage  participation.  
• Encourages  everyone  to  talk,  even  the  quieter  participants.  
• Encourages  participants  to  share  experiences  a nd  ideas.  
• Repeats  key  messages.  
• Asks  participants  to  summarize  what  they  learned.  

2.  Who  can  facilitate  a  community  support  group?    

• Experienced  mothers  and  h ealth  workers.  
• Formally  trained  h ealth  workers.  
• Community  workers.    

3.  Characteristics  of  a  Community  Support  Group  

• Provides  a  safe  environment  of  respect,  and  trust.  
• Allows  participants  to:  
• Share  infant  and  young  child  feeding  information  and  personal  experiences.  
• Mutually  support  each  other  through  their  own  experiences.  
• Strengthen  or  modify  certain  attitudes  and  practices.  
• Learn  from  each  other’s  experiences.  
• Allows  participants  to  reflect  on  their  experiences,  doubts,  d ifficulties,  popular  b eliefs,  myths,  
information,  and  adequate  infant  practices.  In  this  safe  environment,  the  mother  has  the  
knowledge  and  confidence  n eeded  to  d ecide  to  either  strengthen  or  modify  h er  infant  feeding  
practices.  
• Is  not  a  LECTURE  or  a  CLASS.  All  participants  p lay  an  active  role.  

Day  5             -­‐  82  -­‐          

 • Focuses  on  the  importance  of  interpersonal  communication.  In  this  way  all  the  women  can  
express  their  ideas,  knowledge,  and  doubts,  share  experiences  and  receive  and  give  support  to  
the  other  women  who  make  up  the  group.  
• Has  a  s eating  arrangement  that  a llows  a ll  participants  to  have  eye-­‐to-­‐eye  contact  ( generally  a  
circle).  
• Varies  in  s ize  from  3  to  15  participants.  
• Is  usually  facilitated  b y  an  experienced  and  trained  caregiver  whose  role  it  is  to  listen  and  guide  
the  discussion.  
• Is  open,  allowing  the  admission  of  a ll  interested  pregnant  women,  mothers  who  are  
breastfeeding,  women  with  older  toddlers,  and  other  interested  people.  
• The  facilitator  and  the  participants  of  the  infant  and  young  child  feeding  support  group  decide  
on  the  length  of  the  meeting,  the  frequency  and  time  of  the  meetings  (number  p er  month),  and  
the  topics.  

4.  Who  can  participate  in  an  infant  and  young  child  feeding  community  support  group?    
• Breastfeeding  mothers  
• Mothers  who  have  breastfed  in  the  past  
• Pregnant  women  
• Community  workers  
• Care  takers/parents  
• Formally  trained  h ealth  workers  

5.  Topics  a  community  support  group  can  d iscuss  

• Benefits  of  breastfeeding  
• For  the  mother  
• For  the  child  
• For  the  family  and  community  
• Techniques  of  breastfeeding  
• Position  
• Attachment    
• LAM  
• The  three  criteria  of  LAM  
• The  benefits  of  LAM  
• Who  can  use  LAM  
• Breastfeeding  d ifficulties,  prevention,  and  solutions  
• Insufficient  breastmilk  production  
• Sore  and  cracked  nipples,  infections,  and  engorgement  
• Babies  separated  from  their  mothers  
• Twins  
• Maternal  or  child  sickness  

Day  5             -­‐  83  -­‐          

 • Woman’s  nutrition  
• Complementary  feeding  b eginning  a t  6  months  
• How  to  ensure  a  variety  of  food  is  given  
• What  is  a ctive  feeding  
• How  to  vary  feeding  
• Why  keep  on  breastfeeding  
• Which  snacks  to  give  the  child  
• How  to  increase  a mount,  frequency,  and  d ensity  
• Feeding  of  sick  child  
• How  to  encourage  a  s ick  child  to  eat  or  breastfeed  
• How  to  vary  and  enrich  feeding  during  and  after  sickness  
• Why  continue  breastfeeding  during  child  sickness  
• Why  give  extra  food  during  recuperation  

6.  Different  types  of  existing  groups/gatherings  in  the  community  that  could  be  support  groups  
• People  Living  with  HIV  &  AIDS  ( PLWHA)  –  where  PMTCT  sites  are  available  
• Food  distribution  sites  
• Therapeutic  Feeding  Centers  
• Community  Growth  Monitoring  a nd  Promotion  
• Agricultural  groups,  etc.  
• Market  women  
• Coffee  ceremonies  
• School  meetings  

Activity  21.4     Practice  conducting  a  support  group    

(45  minutes)  
Methodology  
• Divide  participants  in  three  groups  of  eight.  
• Each  group  chooses  a  topic  out  of  a  basket  for  a  support  group  meeting.  
• One  participant  from  each  group  will  b e  facilitator.  
• After  group  1  conducts  a  support  group  for  about  10  minutes,  groups  2  and  3  fill  in  support  group  
observation  checklist  ( HO  #27).  
• Discussion  in  p lenary.  
• Repeat  the  process  for  the  s econd  and  the  third  group  until  each  group  conducts  a  support  group  
session  in  plenary  with  the  other  two  groups  observing.  

Day  5             -­‐  84  -­‐          

SESSION  22  
IMPROVING  NUTRITION  AT  THE  COMMUNITY  LEVEL  
 

Learning  Objectives  
By  the  end  of  the  s ession,  participants  will  b e  able  to:    
• Discuss  the  activities  that  can  b e  conducted  at  the  community  level.  
• Explain  the  d ifferent  training  sessions  for  the  community  health  worker.  
• Organize  supervision  activities  with  community  h ealth  workers.  
 

Overview  
Activity  22.1:     Identification  of  community  groups  and  ENA  contact  p oints  ( 30  minutes)  
Activity  22.2:     Review  of  the  training  s essions  for  the  community  worker  and  follow-­‐up    
(1  hour  30  minutes)  
 
Total  time   2  hours  

Material  Necessary  
• Flip  chart,  markers,  and  masking  tape  
• 1  copy  of  the  training  guide  for  Community  Health  Workers    
Handout    
HO  #35:     Group  supervision  at  community  level    

DETAILED  ACTIVITIES  
Activity  22.1   Identification  of  community  groups  and  ENA  contact  points    
(30  minutes)  
Methodology  
• Divide  the  participants  into  six  groups.    
• Each  group  d iscusses  the  community  groups  that  already  exist  and  that  could  b e  used  to  pass  on  the  
ENA  messages.  For  example,  growth  promotion  and  monitoring,  micro-­‐finance/micro-­‐credit,  
agriculture,  farming,  literacy  programs,  etc.  
• Each  group  d escribes  what  topics  must  b e  d iscussed  with  p eople  in  these  groups  to  s ensitize  them  
and/or  during  a  n egotiation  s ession.  
• Presentation  of  group  work  in  plenary  and  discussion.    

Day  6             -­‐  86  -­‐    

Activity   22.2   Review  of  the  training  modules  for  the  Community  Health  
Volunteers  and  “supervision  in  groups”    
(1  hour  30  minutes)  
Methodology  
• Divide  the  participants  into  four  groups.  
• Each  participant  receives  a  copy  of  the  Training  Guide  for  Community  Workers.  
• Group  1  reviews  the  first  day  (themes  presented  and  methodologies  used).  
• Group  2  reviews  the  second  day  ( themes  presented  and  methodologies  used).  
• Group  3  reviews  the  third  day  (themes  presented  and  methodologies  used).  
• Group  4  reviews  and  discusses  h ow  the  “supervision  in  groups”  should  b e  conducted  ( when,  where,  
and  how).  
• Each  group  presents  a  summary  of  the  d iscussion.  
• Discuss  practical  issues  of  the  training.  

Day  6             -­‐  87  -­‐    

SESSION  23  
PLANNING  

Learning  Objective  
By  the  end  of  the  s ession,  participants  will:  
• Develop  a  3-­‐month  action  plan.  

Overview  
Activity  23.1   health  workers  from  the  same  h ealth  facility  and/or  community  d evelop  a  3-­‐month  
action  plan  (30  minutes)  
Activity  23.2   Presentation  of  action  p lans  (20  minutes)  
 
Total  Time     50  minutes  
 

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    

Advance  Preparation  
• Sample  a ction  p lan  of  flipchart  

DETAILED  ACTIVITIES  
Activity  23.1   Health  workers  from  the  same  health  facility  and/or  
community  develop  a  3-­‐month  action  plan    
(30  minutes)  
Methodology  
• Every  h ealth  worker  from  the  same  h ealth  facility  or  community  develops  an  a ctivity  p lan  for  the  
following  three  months.  

Activity  23.2     Presentation  of  action  plans    

(20  minutes)  
Methodology  
• In  p lenary,  ask  for  two  to  four  volunteers  (as  time  a llows)  to  present  their  group’s  action  plan.  
• Feedback  from  participants.  

Day  6             -­‐  88  -­‐    

 SAMPLE  ACTION  PLAN  
Group/Community:  
FOLLOW-­‐UP  
PEOPLE   RESOURCES  
ACTIVITIES   WHEN  (TIME)   WHERE  (PLACE)   (WHO  &  
RESPONSIBLE   NEEDED  
WHEN)  

Day  6                     -­‐  89  -­‐    

SESSION  24  
FINAL  EVALUATION  
 

Learning  Objective  
By  the  end  of  the  s ession,  participants  will:  
• Evaluate  their  progress.  
• Evaluate  the  training.    

Overview  
Activity  24.1   Post-­‐test  (15  minutes)  
Activity  24.2   Participants  fill  out  evaluation  form  and  listen  to  results  (15  minutes)  
 
Total  Time     30  minutes  

Materials  Needed  
• Flipchart  papers,  markers,  and  masking  tape    

Advance  Preparation  
• Sample  evaluation  form  on  flipchart  

DETAILED  ACTIVITIES  
Activity  24.1     Post-­‐test    
(15  minutes)  
Methodology  
• Pass  out  copies  of  the  pre-­‐test  to  each  participant  using  their  p ersonal  code  and  ask  them  to  
complete  it  individually.    
• Ask  participants  to  compare  their  results  with  their  pre-­‐test  and  assess  their  progress.  
• Review  the  answers  of  the  test  and  answer  q uestions  as  needed  

Day  6             -­‐  90  -­‐    

Activity  24.2     Participants  assess  the  training    
(15  minutes)  
Methodology  
• Present  the  evaluation  form  on  flipchart.  
• Ask  participants  to  write  on  their  notebook  their  assessment.  
• Have  participants  come  one  by  one  to  copy  their  own  assessment  on  the  flipchart.  
• When  complete,  present  to  the  participants.  
• Thanks  the  participants  for  their  a ctive  participation.    
• Proceed  to  the  closure  of  the  training.  

END-­‐OF-­‐TRAINING  EVALUATION  FORM  

Place  a  √  in  the  box  that  reflects  your  feelings  about  the  following:  
  GOOD   AVERAGE   UNSATISFACTORY  
Training  objectives  
Methods  used  
Materials  used  
Field  Practice  
Capacity  to  carry  out  
an  identical  training  
(for  TOT)  
Tea  breaks  

1. Which  s essions  did  you  find  most  useful?  

2. What  are  your  suggestions  to  improve  the  training?  
3. Other  comments:      

Day  6             -­‐  91  -­‐