THE NEED FOR PROFESSIONAL TRAINING/EDUCATION IN NUTRITION EDUCATION AND COMMUNICATION (NEAC) IN BOTSWANA Maria S.

Nnyepi, PhD

Report commissioned by the Food and Agriculture Organization of the United Nations Nutrition Education and Consumer Awareness Group Nutrition and Consumer Protection Division (AGN)

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TERMS USED NEAC Nutrition educator NEAC training NEAC trainers ACRONYMS BMI ISPAAD IHS MOE MOA MOH PMTCT UB Body Mass Index Integrated Support Program for Arable Agriculture Development Institute of Health Sciences Ministry of Education Ministry of Agriculture Ministry of Health Prevention of mother to child transmission University of Botswana Nutrition education and communication in all its forms Someone who helps people to improve their diet and health The education needed to become a good nutrition educator Those who plan or deliver NEAC training

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INTRODUCTION This qualitative needs assessment was carried out in the month of March, 2011. Desired respondents were people involved at various levels of nutrition education and communication. Some of the roles of the participants in their areas of employment included roles typically played by NEAC educators and or NEAC trainers. An effort was made to select people trained in NEAC, but this effort was not fruitful, as most respondents were trained primarily in the science of nutrition and have learnt some NEAC skills on the job. Some respondents were nutritionists, dieticians and other professionals whose key performance area have exposed them to some nutrition education and communication. The names and affiliation of the informants in this assessment are displayed in the table below. KEY INFORMANTS 1. DR. K.S.M GOBOTSWANG 2. MS. M. PHEGELO AFFILIATION UNIVERSITY OF BOTSWANA MINISTRY OF HEALTH (DEPT. OF PUBLIC HEALTH)

GOVERNMENT STAFF 1. Mrs. Chakalisa

2. Mrs. K. Moruisi
3. Mrs. Sebi NUTRITION EDUCATORS

Ministry of Education (Curriculum Development -Home Economics) Ministry of Health (Dept . of Public Health) Ministry of Agriculture (Food Security Unit) Ministry of Health / PEPFAR Collaboration Ministry of Health (Dept of Public Health) Baylor Childrens clinical Center of excellence Project Concern International Ministry of Health (Scottish Living Hospital) University of Botswana Institute of Health Sciences (Gaborone) Institute of Development Management

1. Ms. O. Ntshebe 2. Mr. M. Galeemelwe

3. Mr. J. Makhanda 4. Mr. Pati 5. Ms. J. Buka NEAC TRAINERS/LECTURERS

1. Dr. S, D. Maruapula
2. Mrs. Semele 3. Mr. Batlhophi

Being a transitioning economy Botswana is struggling with undernutrition in children and increasing levels of overweight and obesity and associated non-communicable diseases. Malnutrition in children under-five years of age is a significant problem. Within this age group, the prevalence of malnutrition becomes evident in children of complementary feeding age, suggesting that poor complementary feeding diets and hygiene practices are contributory factors. Diarrheal diseases continue to be a challenge and places formula feeding children at a particularly high risk of malnutrition and death. In 2006, for example, over 22000 cases of diarrhea were identified in children less than 5 years, of these 470 deaths were reported (Carter, 2006; Mach et al., 2009) The diarrhea case was 20 times more likely to have not been breastfed. Most

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of the cases were malnourished children who received infant formula through the prevention of mother to child transmission (PMTCT) program. In adults, 25-64 years of age the prevalence of a body mass index (BMI) of at least 25 is 38.6% (MOH and WHO, 2007). The problems of overweight is particularly serious in women (53.4%) compared to men (22.1%). The steps study further revealed that the consumption of fruits and vegetables is low with about 97% of adults who ate less than 5 servings of fruits and vegetables in a given day. Known risk factors of noncommunicable diseases such as smoking, physical inactivity and high blood pressure are increasing steadily. There is even concern that perhaps the country is placing more emphasis on the prevention, care and mitigation of HIV/AIDS and paying little attention to diet- related non-communicable disease. While there is not adequate data at household level, the observations from several regional studies show unacceptable levels of household food insecurity. In a study in the Okavango Delta, over 50% of households were moderately food insecure (Nnyepi and Ngwenya, 2008). Similarly, estimates of food insecure households were reported in the Mabutsane and Bobirwa Health Districts more recently (UNICEF-Gaborone, 2010). The high prevalence of HIV in the country is contributing to both problems of undernutrition in children and household food insecurity. There has been a steady increase in the prevalence of malnutrition in children, which not yet confirmed through studies, are often thought to be associated with increasing cases of HIV exposure in children. The care of HIV patients by households has also been reported to compete with caregivers meaningful contribution in agriculture and other income generating activities. In short, therefore, nutrition issues in Botswana results from a combination of communicable and non communicable conditions.

BACKGROUND AND OVERVIEW Historical background Amongst the major nutrition interventions in Botswana are the supplementary feeding programs for children under-five years of age and pregnant women, the provision of food assistance to destitute persons, orphaned children up to 18 years of age, and debilitated TB and AIDS patients. By in large the programs prevent protein energy malnutrition and temporary food insecurity. With respect to the prevention of micronutrient malnutrition, the government introduced vitamin A supplementation for pregnant women and infants. This was initiated following observations reported by the Micronutrient study in 1996. Universal salt iodization was also introduced following the same study and has been very successful. In response to the high prevalence of HIV in the country, the government introduced the PMTCT program. Through the program, infants of HIV positive mothers are provided with infant formula up to 12 months of age. Mothers access the formula at the nearest health facility.

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The major intervention that target school children is the school feeding program which is now fully funded by the government of Botswana, but was funded by the WFP between 1966- 1997 (WFP, 2003). Within this program, children are provided with a meal that provides at least a third of their dietary requirement when schools are in session. This excludes weekends and holidays when school is not in session. One of the recent improvements in this program is the provision that local farmers can now supply schools in their localities with fresh produce. This has been well received as it provides a significant market for local farmers, most of whom would otherwise have no access to markets. Important developments noted in the food assistance programs is the use of a Coupon / Debit System. In the old system, qualifying retailers who are contacted by government provided beneficiaries with all their food baskets at one time. There are different types of baskets for people with different circumstances (Republic of Botswana, 2010). Some baskets are for orphaned children, some for destitute persons and others for the temporarily poor that may be due to temporary disability associated with serious illness. Food items that are in the food baskets are prescribed by the government and are constituted to meet specified amount energy. In the old food basket scheme, where retailers provided beneficiaries with all their food stuffs at one time, there were anecdotal concerns that some unscrupulous retailers populated beneficiaries baskets with substandard food items. Now beneficiaries can purchase items that they need at a time. This has empowered beneficiaries in that they can literally choose items like any cash customers. Since this development, there are no reports that beneficiaries are provided with substandard food items. Some initiatives that are aimed at improving household food security in the country include the provision of seeds (cereals and beans), fertilizers and draught power for farmers. This has allowed farmers to plough up to 6 hectors that is fully paid for by government. Farmers who plough more than 6 hectors are subsidized up to 11 hectors. Other initiatives include the drilling of boreholes for syndicates of farmers, communal fencing, and reduced cost of medications for livestock and provision of technical farming (arable and pastoral) assistance at no cost to the farmers. Overall there is some indication that progress has been made in a number of programs. In particular, the Botswana Nutrition Surveillance System, which is a program that tracks child malnutrition, has shown consistent improvement in the prevalence of underweight over time. Based on this therefore, it can be argued that a number of these programs have been helpful and/or the standards of living have improved. There is perhaps more effort needed from programmers to build in continuous program monitoring and evaluation tools across all programs. History of NEAC There has been inadequate provision of nutrition education and communication largely because those tasked with this mandate do not have adequate professional training in the area. Key providers in this area have picked up skills on the job, while this is helpful

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it is not enough. Aspects of nutrition education and communication that have been going on are largely uncoordinated, limited in scope and confined to the health sectors and schools. In the health sector for example, there are health talks that the health providers provide to patients every morning before consultations. A number of these health talks focus on nutrition. The common topics are those that help the community address breast feeding, complementary feeding in children, management of common non-communicable diseases such as diabetes, high blood pressure and others. In the health sector also, patients consulting for conditions whose management have nutrition component also receive nutrition or dietary counselling that is specific to the condition. Where supporting nutrition pamphlets are available, patients are also provided with such pamphlets. At the ministry of health level pamphlets and posters on select nutrition issues or interventions are produced and used to disseminate information on a number of nutrition issues to the community and to health sector workers. There are, for example posters on the four food groups, the food plate, and booklets for nutrition for people living with HIV/AIDS that are produced by the ministry for use in clinics and other public areas. These are usually posted on clinic walls and other public areas for people to read. A lot of these are designed to be understood by community members or where necessary to be used by people with limited nutrition education and communication background in any sector. A number of these are available in English and in Setswana. Some of the posters were found mounted in the walls in a primary school classroom. Nutrition education and communication approaches that have increased tremendously in the health sectors are workshops. Some examples of the workshops are the training workshop for the management of severe acute malnutrition in children for health sector workers; infant and young children feeding in the context of HIV, etc. Workshops for health sector workers are usually planned to support the introduction of a new initiative, to upgrade health workers knowledge and skills about a new approach in managing a nutrition related condition etc. In a number of such workshops, the people who are trained are expected to train their co-workers as well as the community. Whether this actually trickles down as expected is not known because such approaches are hardly evaluated. As indicated by the informants, the lack of a nutrition education and communication professionals and strategy has created a fertile ground for some entities to exploit the community. These entities market products and services that supposedly can improve quality of life and wellness. A few of the services that are often aggressively marketed are services such as colon cleansing, nutrient supplements for people living with HIV/AIDS, and special diets such as the blood group diets just to name a few. To our knowledge, there have not been any impact studies on nutrition education and communication. Two informants (nutrition educators) lamented the absence of a nutrition communication strategy for Botswana and seemingly, there has been no financial commitment from institutions towards the development of such a strategy. There has to be deliberate funding by government and other partners of nutrition activities. Currently, the information transfer is the only approach that is mostly funded.

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There is a need to also develop a coherent communication strategy for nutrition education. If this is done well there is a chance that people can be informed and dietary behaviours can change. Another nutrition communicator echoed the same sentiment saying ... what needs to be improved is to develop the entire communication strategy for all nutrition interventions... While there has been some nutrition education and communication going on, in the health sector in particular, a lot can be done to improve nutrition education and communication overall. Institutional and policy picture and the priority given to NEAC Currently there is no institution in the country that offers a comprehensive NEAC program at any level. But there are programs that have some modules in nutrition that can potentially be improved so that they can offer a stronger component in NEAC. These are the Home Economics programs at the University of Botswana, the Nursing programs both at the University of Botswana (Bachelors degree level) and the Institutes of Health Sciences (Diploma level), and the Health Education program at Boitekanelo Training College (certificate level). Amongst these institutions, the University of Botswana and the Boitekanelo programs have capability to develop standalone programs in NEAC. However, with the recent establishment of the schools of Allied Health Sciences and Public Health at the University of Botswana, perhaps the University of Botswana has more capability to offer a whole range of NEAC programs compared to all other institutions in the country. Captioned below are views of informants about the current institutional presence of NEAC in Botswana. That is another area that NEAC is not well established. In institutions, there has not been much of NEAC. Maybe I am only thinking of the Institute of Health Science (IHS) (graduates nurses, health inspectors, lab technicians). We almost struggled to include nutrition in their curriculum. They keep telling us that the curriculum is full. We wanted them to include issues that pertain to Botswanas nutrition situation to avoid having to provide extensive on the job training once the graduates are in the field. We were not able to get a slot in the curriculum

Like I said, it is non-existent. It is non-existent in policy; it is almost non-existent in training. Here at the University of Botswana there is a course in community nutrition, and there is a little bit of it but because a lot of us are also not quite equipped, I think with the exception of one colleague who was trained before as an educationist and also as a nutritionist, I would say a lot of us do not have the competencies to actually impart the necessary skills. I think the same would be true for other institutions like Institute of health sciences and other institutions that are training nutritionists.

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At policy level, there are several policy documents with some aspects of nutrition. Some of these include the School Health Policy and the National Policy on Destitute Persons. There is also a draft policy on infant and young child feeding. The country also has a National Plan of Action on Nutrition, which provides some direction in nutrition programming. Most of these programs were in existence long before the Plan of Action was developed. Other than this, we are not aware of the existence of a national nutrition policy, a national agriculture policy on nutrition or national policy on nutrition education and communication. However, nutrition is one of the skills that the Government considers as a scare skill in the country. There is also an association of dietetic and nutrition professional (Botswana Dietetic Association). In the absence of policy position on nutrition, it is difficult to speculate on any plans in nutrition or nutrition education and communication. With respect to agriculture, most of the policy documents focus on improving production in most areas of agriculture and hardly any on building nutrition into agricultural activities. It is implicit that improvement of agriculture production will translate into improvement of national nutrition indicators.

Future plans As stated above, it is difficult to speculate on any plans in this area at policy level. This notwithstanding, developments at the University of Botswana (a government funded institution) in the Faculty of Health Sciences (establishment of the school of public health and the school of allied health sciences, which will offer degree programs in dietetics and nutrition), a program proposal for a degree in nutrition education and communication is likely to be reviewed favourably. THE NEED FOR NUTRITION EDUCATION AND COMMUNICATION General need for NEAC and nutrition understanding NEAC is very much needed in Botswana. Informants responses with respect to the social awareness of NEAC in Botswana and the beliefs and perceptions about foods and nutrition issues clearly indicate that many people are uninformed and consequently at risk for poor nutrition and poor health. There is strong convergence in the opinions of the surveyed informants with regard to the social awareness of nutrition issues in the country. The overall opinion is that the public knowledge level about nutrition issues in the country is low. Population groups living in rural area are more uninformed on nutrition issues compared to some population groups in the urban areas. The major challenge amongst the urban dwellers is that they rely on media outlets due to inadequate nutrition education and communication from government sectors and other partners. Unfortunately some of these outlets are not credible sources of nutrition information.

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In general, however, the community is aware that nutrition is important and that it is important to choose food healthfully. However, the major challenge is in translating this knowledge into healthful food choices or dietary practices. In fact it can be argued that the reason some commercial entities exploit the community by promoting their products (by ascribing to their products / services attributes that in reality cannot be attained by the use of such products and services) is because the community is hungry for nutrition education and communication. They have the desire to eat well only they (the community) are not informed enough to evaluate the accuracy of the information reaching them. This interest is also reiterated by observations made by surveyed students. In essence, the students who are taking a module in nutrition indicate that they chose the module because either the content is of interest to them or it is important. A quick assessment of some common perceptions with respect to nutrition and foods in Botswana attest to the low level of awareness of food and nutrition issues in the country. As shown in some of the excerpts below, some beliefs and perceptions deny vulnerable groups from eating highly nutritious foods. Unless these are addressed through focused nutrition education and communication, they are likely to perpetuate and thus continue to compromise the nutritional status of the community. Beetroots cure iron deficiency anemia Pregnant women should not eat eggs Children should not eat eggs, liver, kidneys this is food for older people It is not good to eat red meats A meal made of stiff maize meal (paleche) and pounded beef meat (seswaa) is more filling than other food combinations The perception that certain diets are associated with certain capabilities is still prevailing. For example, the government provided supplementary food, the fortified sorghum-soya blend Tsabana, was popularly associated with increasing libido in men Women should withhold the first breast milk (colostrums) from the baby Children do not like vegetables Modern (highly refined foods are better than traditional/local dishes Nutrition education and communication will especially be helpful if it initially targets population groups that are perceived as being at risk for poor nutrition. The informants interviews suggest that such population groups include children 0-5 years of age, the elderly, the adolescents, people living with HIV/AIDS, pregnant and lactating women and children of school going age. For children, critically ill patients with HIV/AIDS and the elderly, it would be best for the NEAC education to target their primary caregivers. Community leaders such as chiefs and health professionals (medical doctors and nurses) with ready access to the community should also be targeted. In addition to having access to many people, health professionals are trusted by patients because their profession is seen as a helping profession. Thus, what they communicate to the community tends to be deemed to be valuable and worth following. Interestingly, despite that teachers have access to a lot of pupils, none of the informants suggested that teachers could be targeted.

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Specific needs for NEAC The health sector (Department of Public Health) probably has the most NEAC activities in the country than any other sector. The most common types of NEAC activities are workshops that involve mostly information transfer with some opportunity for participants to ask questions for clarification purposes. Most of these workshops are tied to programs or interventions in the health sector. Some examples range from training workshops for the management of severe acute malnutrition for health workers, PMTCT peer training, Management of Breastfeeding etc. As indicated earlier these can be as many as there are programs that have a nutrition component. There also has been a series of Vitamin A supplementation campaigns for preschool children. These are often accompanied by wide (government and private) media coverage. In addition to workshops, the Ministry of Health has a unit dedicated to health education. The unit support programs with printed material. Most of these are posters which are designed to be posted in places that are frequented by the community such as hospitals and clinics. The reading level of these is such that most people can read them. There are some that are also printed in Setswana. In health facilities that have dietitians, dietetic counseling is also provided to patients. Hospitals without a dietician are routinely supported by dietitians from other hospitals through the outreach services. Programs in the Department of public health often use the national television station and radio stations to disseminate information to the community. One particular program that has featured a lot of health programs with a NEAC component is the Molemo-wa-Kgang TV program. Those programs that I have participated in as a guest nutrition expert focused on 1) the marketing of Junk food to school children, 2) nutrition issues for the elderly, and 3) Infant and young child feeding issues. However since such coverage is sporadic, useful programs of this nature often do not have as much impact on social awareness about NEAC issues as it would otherwise have had the programs been offered more frequently. While there is opportunity for NEAC in schools, this is often not fully exploited. For instance there are Food & Nutrition modules and Agriculture modules (with provision for school gardens) in the schools curricula. The Food and Nutrition modules focus mainly on introducing school children to the sciences of food and nutrition and basic food preparation skills. With respect for agriculture, school gardens are practice sites for school children. Please refer to the attached curricula for more details. As is evident in the both curricula the focus is the science of agriculture. We are not aware of any NEAC evaluation activities. It is very difficult to speak to the effectiveness of the NEAC activities in the absence of evaluation.

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HOW NUTRITION EDUCATION IS BEING DONE: GENERAL IMPRESSIONS Observations from informants suggest that nutrition education and communication in Botswana is developed mainly through the training of educators. The educators are prepared through training of training workshops. Once trained the educators then teach the community. However, most educators also use information transfer as the main method of delivering NEAC. A typical example is how educators at the health facilities talk to community members about nutrition / dietary issues at the clinics. Typically, a 10-15 minutes talk is presented to clients who are awaiting consultations. Sometimes at the end of the talks the educator may give the attendants some pamphlets. Information transfer is also common in programs aired through various radio programs. Formative research and evaluation research processes are hardly used in NEAC training, and none of the informants reported ever using either of these processes. It was evident from the interviews that the informants were not aware of these approaches. It would not be surprising if their non-use may in part be because of lack of technical expertise. Information transfer appears to be the more frequently used method because the unit cost (time and money) per participant is lower compared to participatory approaches. While the general impression amongst the participants is that NEAC needs to improved, very few provide suggestions. Some suggested ways of NEAC improvement is that there is a need for research that will identify gaps in terms of knowledge as well as the provision of more NEAC communicators. Woven in informants responses to other questions are suggestions that there is a need for a communication strategy that will help establish exactly what needs to be communicated to the community and proper segmentation of the community. In addition there is some thought that there is a need to also consider other NEAC approaches rather than depend on information transfers.

HOW NUTRITION EDUCATION IS BEING DONE: SPECIFIC PROGRAMS The Nutrition Rehabilitation Program in Princess Marina Hospital This program is co- funded by donors and the Government of Botswana. Its focus is to rehabilitate severely malnourished children. The program has two components; 1) training of health workers in identification and management of severe malnutrition (NEAC Training) and 2) rehabilitation of malnourished children (Direct NEAC). Development and Evaluation In the rehabilitation component of the program, caregivers of children who are referred to the center receive nutrition education, counselling to and are taught some skills in preparing nutrient dense meals. Caregivers whose children have recovered are given a chance to share their experience. The program is also very new and has not been evaluated.

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Prevailing Approaches The educator uses many activities. In addition to dietary counselling, there is also psychosocial counselling. The educator indicated in a number of repeat cases of malnutrition (relapse) they found that some caregivers had other social issues that when addressed, the childrens nutritional status improved. They also had demonstrations. Most of the cooking demonstrations were conducted by the home economists at the center. Lessons learnt The key lesson that the educator mentioned is that in cases of repeated referrals, some of the issues leading to the child being malnourished were issues that were best dealt with through psychosocial counselling. They also found that caregivers of children who were referred to community income generating activities improved and were less likely to relapse. However, she was looking forward to a systematic evaluation of the centre activities and whether the evaluation will indeed support her observations.

THE NEED FOR TRAINING OF NUTRITION EDUCATORS Informants agreed unanimously that there is a need for NEAC educators in the population. However, they differed with how that can be achieved. Some were of the view that there is a need for more of the existing type of cadres (nutritionists and dieticians) at different levels of the society including at community level. In fact, most of the respondents were of this view. One NEAC trainer strongly felt that perhaps the major reason for the unfelt presence of the NEAC educators in the population is that the current nutritionists and dieticians do not have requisite skills in NEAC. Further, perhaps if the existing nutritionists/dieticians are equipped, their presence might have a perceptible effect on social awareness of the NEAC issues. Examples of sites in the population (in no particular order) where NEAC educators were needed ranged from the community, schools, health facilities and HIV/AIDS testing centers. Given that respondents, earlier on indicated that there was perhaps more social awareness on NEAC issues in urban areas than in rural areas, rural areas should also be included in this list of examples. Despite the expressed need of informants for more NEAC educators, there are no comprehensive NEAC training programs in Botswana. Existing programs are programs that are primarily in specialization other than NEAC to which some NEAC content is provided. Examples of these are the Home Economics Education Program (Family and Consumer Science program at UB), the Nursing Programs as the Institute of Health Sciences and UB and the certificate program in Health Education at Boitekanelo College. Some respondents were aware of these programs and others were not.

HOW NEAC TRAINING IS DONE Because of the limited number of NEAC training programs and scope of NEAC content in some training programs in the country, most informants are not aware of how NEAC

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training is done. They are also not aware of specific details such as the experiences and the qualifications of NEAC trainers in local institutions and the learning orientations. Therefore, very few have made suggestions for possible program improvement. In summary, however, some NEAC training is offered in the nursing programs in the Institutes of Health Sciences and UB, the Family and Consumer Sciences program (formerly Home Economics Education Program) at UB and the Heath Education program at Boitekanelo College. In both the nursing program and the Family and Consumer Sciences program students are first given the theoretical/ academic content and then allowed two winter semesters in the field (practicum). Thus, students graduate ready with the skills and not just the academic content. The major challenge with both programs is that the scope of NEAC knowledge and competencies is limited, simply because the programs are designed to meet training needs of fields other than of NEAC. However, there is room for improvement. First, the NEAC content in these programs can be improved. Secondly parallel programs for NEAC educators with all the required competencies can be developed. This is to say that instead of a situation where NEAC modules is built in existing programs, NEAC training programs, whose sole focus is in developing NEAC educators can be developed.

DETAILS OF SPECIFIC TRAINING PROGRAMS FOR NUTRITION EDUCATORS Sciences program at UB and the nutrition module for pharmacy technicians1. The programs highlighted by the NEAC trainers include the Home Economics program (Family and Consumer Science).The trainer at UB has a Masters Degree in Education focusing on adult education and instructional design and a PhD Qualification in nutrition as a science, field experience in public health where she was responsible for developing, implementing and evaluating nutrition programs. In the program and courses that the UB trainer offers, there is a fair balance between practice and theory; students also evaluate the content and the trainers teaching. The programs needs analysis was conducted at the outset of the program. The focus of the analysis was to establish the program needs in the country/region and to identify gaps within the courses offered in the program. The desired improvements in the UB program included the development of a fully fledged nutrition program. Students are evaluated using a combination of test and projects.

Please note that it is difficult to separate NEAC training or training in Nutrition Science because NEAC educators must have basic nutrition science as well. For example, this applies to a situation where a pharmacy technician in dispensing medications, talks to the client about their diet with the view of helping the client minimise adverse drug nutrient interactions. The same applies to the home economics education, where there are both modules on nutrition as a science and NEAC modules.

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The trainer at the Institute of health science only had a formal qualification in nutrition as a science and had no qualification in NEAC or NEAC work experience. The module was also too small to comment on meaningfully. In my judgment, there is only one informant whose primary mandate (i.e. key performance area is NEAC) is NEAC. This is the coordinator of the Nutrition Rehabilitation Program in Princes Marina.

1. The Nutrition Rehabilitation Program in Princess Marina Hospital This program, as described on page 10 has two components; 1) training of health workers in identification and management of severe malnutrition (NEAC Training) and 2) rehabilitation of malnourished children (Direct NEAC). Training in NEAC The NEAC educator in this program is a nutritionist who during the undergraduate and graduate training took a few courses in nutrition education and communication. She picked some of the education and communication skills during her work experience. While it is remarkable, what she has been able to accomplish it must be noted that her training did not prepare her adequately for nutrition education and communication. Development and Evaluation The training component for health workers was developed following the realization that the cases of malnutrition in health facilities was increasing and that children were referred to the rehabilitation clinic rather late. The initial thought was that perhaps health workers do not recognize malnourished children. Hence, a training needs assessment was conducted. The program was developed based on the findings of the training needs assessment. The responses of the NEAC educator give the impression that there was an attempt to use formative research in establishing the training needs and the participants for the program. However, the extent to which this was done systematic and comprehensively is not clear for a number of reasons; 1) the NEAC Educator who is also the program coordinator does not have skills / experience in carrying out formative research. The program is also very new and has not been evaluated. Prevailing Approaches While there is an attempt to involve participants the prevailing approach in this program is information transfer. Lessons learnt The NEAC Educator reports that the training has improved the referral rates of malnourished children to the center and as a result, children are seen earlier and recover within a relatively shorter period. There is still a need for an objective evaluation of the program. This can be done relatively easier because the center has a good database that has linked the childrens progress to the WHO Anthro database.

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2.

WHO/UNICEF program on Infant and young child feeding in the context of HIV Training in NEAC The NEAC Educator has a qualification in dietetics and nutrition. Development and Evaluation The program that the educator participated in is the WHO/UNCEF program. In this program, the educator was a participant. As such she did not have to develop the program. However, she recalls that the learners were requested to indicate their expectations and these were then included the program objectives. Prevailing Approaches Based on the activities that the learners selected, the program was very interactive with many opportunities to practice and demonstrate what they have learnt. Lessons learnt She indicated that she learnt a lot from interacting with other participants and was in fact impressed by how the experiences of people who work in otherwise different areas of the health profession can help her in her NEAC activities. To elaborate on strengths and challenges of NEAC training in the country presupposes that there is significant institutional presence of NEAC training programs. On the contrary, however, there are no institutions that offer complete programs that train NEAC educators. Existing programs have some modules in nutrition as a science and only one program has both modules in nutrition as a science and in NEAC. Based on this observation therefore, there is a need for NEAC training programs in Botswana. In the case of Botswana perhaps there is a need for this section of the report to highlight the potential for the development of NEAC training programs rather than discuss the strengths of programs that presently do not exist. To this end, therefore, it is important to note that there are developments at the University of Botswana that are conducive for the development of programs in NEAC. First, the University has recently (2011) established the School of Public Health and The School of Allied Health Professions under which complete programs in nutrition and dietetics will be offered at both undergraduate and graduate levels. The nutrition component of the existing Home Economics program, together with its staff will relocate to the school of Allied Health Professions. With these schools in place, a NEAC program can easily find a home. Secondly, in the development of a new program the University of Botswana requires that a needs assessment study be carried out and observations of such a study should in fact attest to the need for such a program (i.e. to establish the employability of graduates). It has been clear from observations in this assessment that the Ministries of Health and Agriculture will support the recruitment of NEAC educators at community level. It would therefore be very easy for the School of Allied Health Sciences or Public Health to make a case for the development of NEAC training programs at undergraduate and at postgraduate levels.

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NEAC TRAINING: DESIRABLE CONTENT AND APPROACH Content In general in the UB program the trainer found most of the curriculum content to be essential. The responses for the students varied tremendously, some found almost all the items in the curriculum essential while others thought that about half of content would be desirable. It is unclear whether the observations of the students would have been different, were the students in a NEAC program instead of a home economics program. Similarly, these students had no field experience and as such their responses may have been an indication of the lack of NEAC field work experience. In terms of the program approach, both the students and the trainers preferred a mix of theory and practice. Approach There was some bias in favour of face to face delivery compared to other modes. Reasons given for the preference of the face to face were mostly centered on the fact that most people do not have resources that will facilitate reasonable access to web based resources. However all students indicated that while some did not have computers of their own, there are facilities on campus that they can use.

NEAC TRAINING NEEDED It is very clear from the informants responses that no one course can address the NEAC training needs in the country. Thus, informants found value in of each of the courses presented and suggested target learners for each of the courses. At country level there was a higher preference for the undergraduate level compared to other courses, followed by an almost equal preference for postgraduate module and the Extension. Whenever the advocacy workshop was mentioned, participants almost all the time thought it would be most appropriate for policy makers. There were slight differences in the participants preferences of programs for their institutions. The Ministry of Agriculture informant was of the view that the extension course was most suitable for agriculture extension officers. The reason given for this choice was that Agriculture Extension officers are in the field most of their time, thus they will relate to a course that immerses learners into the community. Within the same breath, the informant stated that she would rather that the supervisors of the Agriculture extension officers have completed a post graduate NEAC program. Presumably, this was mentioned as to work effectively in Agriculture issues, one has to have undergraduate training in some Agricultural content. At the Ministry of Health, on the other hand, two of the three informants preferred the undergraduate course for new carrier entrants, postgraduate training for those who already hold bachelors degree qualification, and advocacy workshops for policy makers, especially the Ministers. The following excerpts from the two informants at the Ministry level underscore this point.

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fully-fledged nutrition communicator who also has a nutrition background, i.e. an undergraduate course module An undergraduate who is well trained and ready to run with NEAC would be more of interest for my own institution. i.e. an undergraduate course module is therefore preferable. An undergraduate course module will be desirable because we currently have few nutrition experts in the country. In addition, an advocacy workshop at policy level would be essential especially at ministerial level.

In conclusion, it appeared that informants supported the notation that all the four programs had a role to play in the NEAC training landscape in the country. The differences, it would appear were on targeting people who venture into NEAC at different stages of their professional development as well as the NEAC demands of their role in the institution.

E-learning Most informants said the demand for e-learning is low, but it is growing. Some of the listed constraints were; high cost for internet, frequent electricity interruption and the low access to computers, internet connectivity in rural area compared to urban areas and low computer skills amongst consumers. Having said this there was a sense that consumers access to internet is expected to grow significantly (including wireless connectivity) because the government has invested heavily in this industry as it sees it as a driving force for economic diversification. Already some providers are marketing wireless connectivity through cell/mobile phones. Rural electrification is also being improved and in many villages now the government has provided communal access point for wireless internet facilities. While the capability for e-learning is currently low and restricted to those in urban centers it is expected to grow.

FURTHER PARTICIPATION All participants wanted to be involved, i.e. if their schedules allowed. Some were not committal with the respect to the area where they could be of assistance. As shown by the breakdowns below, most respondents thought they could assist by proving cases, experiences and stories. 1) 2) 3) 4) Providing cases, experiences, stories = 8 Reviewing learning materials? = 5 Piloting materials? = 3 Participating in the projects online forum = 5

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CONCLUSION Overall there is a strong sense that there is a serious shortage of competent NEAC educators in the country. In the absence of NEAC educators, other cadres have stepped in to fill this gap. Unfortunately many have not been adequately trained and thus are not able to fill this void effectively. Furthermore, under qualified for-profit entities have noticed this gap and are aggressively marketing services and products that may not be as good as they are said to be. The challenge with this situation is that gullible community members who know the benefits of NEAC but are not informed enough to identify reliable sources are open to exploitation. Perhaps the best way to remedy this situation is to provide NEAC training programs whose graduates can work in various government and non-governmental institutions and at different levels in rural communities and urban centers. While there is some opportunity to build-in or strengthen NEAC content and competencies in existing related programs, this is not preferred because graduates of such programs often work in areas where their primary mandate is not NEAC. Some population groups have been cited as being most in need of NEAC. These include infant and young children, people living with HIV/AIDS, people living in rural areas, the elderly and adolescents. In response to this, NEAC training should especially prepare educators for dealing with NEAC issues of local importance and especially content that can facilitate their targeting of the population groups believed to be in great need for NEAC. NEAC should especially target community members and professions considered to be most influential. These were listed by the informants as chiefs, nurses and medical doctors.

REFERENCES List of relevant documentation and URLs of online documents 1. Carter, R. B. (2006). Diarrhoea epidemic leads to threat of severe malnutrition in Botswana http://www.unicef.org/infobycountry/botswana_33756.html. accessed 2011-04-24

2. Mach O, Lu L, Creek T, Bowen A, Arvelo W, Smit M, Masunge J, Brennan M,

Handzel T. (2009). Population-based study of a widespread outbreak of diarrhea associated with increased mortality and malnutrition in Botswana, JanuaryMarch, 2006. Am J Trop Med Hyg. 80(5):812-8. http://www.ajtmh.org/cgi/content/full/80/5/812 Accessed 2011-04-24

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3. Ministry of Health (1999). Botswana National School Health Policy and Procedural Manual. Gaborone, Botswana. Government Printers.

4. Ministry of Health (2005). National Plan of Action on Nutrition. Gaborone.

Botswana. Government printers.

5. Ministry of Health and WHO (2007). Republic of Botswana Chronic Diseases Risk
Factory Survey Report, http://www.who.int/chp/steps/2007_STEPS_Report_Botswana.pdf Accessed 2011-04-24 2007.

6. Ministry of Local Government Social Welfare Division (2002). Revised National

Policy of Destitute Persons. Gaborone, Botswana. Government Printers.

7. WFP

(2003). Exit strategies for school Feeding: WFP's experience. WFP/EB.1/2003/4-C. 16 January 2003. http://www.wfp.org/sites/default/files/ %20Exit%20Strategies%20for%20School%20Feeding%20WFP's%20Experience %20%20-%20.pdf Accessed 2011-4-24

8. Republic of Botswana (2010). Permanent mission of the Republic Botswana to

the UN UN/BOT/53/CX(7)P5. http://www.ohchr.org/Documents/Issues/EPoverty/socialprotection/Botswana.pdf Accessed 2011-04-24

9. WHO

chronic diseases risk factor surveillance www.who.int/chd/steps. Accessed 2011-04-24

fact

sheet

(2007).

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