Improving the Practices of

Complementary Feeding:
EXPERIENCE FROM A COMMUNITY
BASED PROGRAMME IN
HAMBANTOTA DISTRICT

2015

Nutrition coordination unit

Ministry of Health,
Nutrition and Indigenous medicine
Improving the Practices of
Complementary Feeding:
EXPERIENCE FROM A COMMUNITY
BASED PROGRAMME IN
HAMBANTOTA DISTRICT

Dr. Sriyanthi Rajapaksa

Prof. Dulitha Fernando
Dr. Renuka Jayatissa
Shakeela Jabbar

MINISTRY OF HEALTH
And
UNICEF Sri Lanka

2015
 List of Tables
Contents Table 1:
Information on nutritional status of children aged 6-59 months (Hambantota
district)
6

Table 2: Percentage of infants and 1-2 year old children , underweight for age 22

EXECUTIVE SUMMARY iv
Percentage decline in the prevalence of underweight for age (Hambantota
Table 3: 22
district)
Chapter 1 ‘Nutrition month’ data - % of under-fives , who are underweight for age
Table 4: 23
INTRODUCTION 1 (Hambantota district)
1.1 Background 3
1.2 Background information: Hambantota district 4
1.3 Maternal and child health services in Hambantota 5
1.4 Nutritional status of under-five children 5
1.5 Objectives 7
List of Figures
Chapter 2
IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 9 Figure 1: Key messages relevant to feeding of infants and young children 13

2.1 Description of the programme 11 Figure 2: Target groups 14

2.2 Steps undertaken when implementing the programme 12
2.3 Best practices 21 Figure 3: Conducting the workshops 14
2.4 Monitoring of the effectiveness/ impact 21 Figure 4: Members of Mothers’ Clubs participating in the workshop 15
2.5 Achievements 24
2.6 Lessons learnEDed 24 Figure 5: Booklet for mothers 15

Figure 6: Display boards 16

ACKNOWLEDGEMENTS 29 Figure 7: Food items –examples 16

Figure 8: Preparation of food 17

BIBLIOGRAPHY 31
Figure 9: Demonstrating the consistency of food 17
LIST OF PERSONS INTERVIEWED 33
Figure 10: Main meal 18

Figure 11: Short meals 18

Annexure 1
Figure 12: Demonstration of increasing quantities of food with age 19
Guidelines to Public Health Midwives 37
Figure 13: Demonstrating feeding techniques 19
Annexure 2
Figure 14: Participation of fathers and grandparents 20
Display Boards and 10 Key Messages 49
Percentage of infants and 1 -2 year old children , underweight for age (Ham-
Figure 15: 22
bantota district).
Figure 16: Percentage of under-fives, underweight for age – Nutrition month data 23

iii
 EXECUTIVE SUMMARY

Nutrition during the early years of life – especially during the first 2 years – is crucial for a healthy and
productive adulthood. With much emphasis on the promotion of breast feeding practices, recent reports
on the prevalence of under-nutrition in Hambantota District indicate satisfactory growth patterns during
the first 6 months of life. This is followed by a declining trend thereafter, which indicates the importance
of proper complementary feeding practices. Studies show that adoption of correct complementary feeding
practices require correct practices by caregivers, as well as the knowledge and skills of health workers in
their efforts to facilitate sustained dialogue and counseling among caregivers.
Available data for the years 2008/2009 indicate that Hambantota District shows higher levels in the
prevalence of low weight for height and height for age among children under 5 years. This identifies the
need to focus on improving complementary feeding practices.
Hambantota is one of the three districts of the Southern Province of Sri Lanka. At the district level, the
Medical Officer of Maternal and Child Health (MO-MCH) is responsible for planning, supervision and
monitoring of all maternal, as well as child health services, in the district. The district is divided into 12
MOH areas – each with several field staff. The Public Health Midwife (PHM) is the key field-level health
worker responsible for the implementation of the MCH activities within the area.
Attention was paid to: include mothers and caregivers with children who have completed 5 months of age,
as the target group; ensure more that 95% coverage of the target group; maintain uniformity of the contents
to be included in the programme; and ensure sustainability of the programme.
Steps undertaken prior to implementing the programme included, training of all field staff and the
development of support material (display boards and booklets). A guideline giving details on the conduct
of workshops for capacity building of mothers by the PHMS was developed. All programmes are held on
the same day in 77 centres in the district according to a pre-set calendar.
Contents of the workshop focus on the 10 key messages relevant to complementary feeding supported by
the relevant display boards. With participation of mothers and community groups, demonstrations are
arranged on the key aspects relevant to complementary feeding.
Supervisory staff at the MOH and district level are responsible for supervising the conduct of the workshops
by visiting the centres at the time when the workshops are conducted. The observations made are further
discussed at MOH/district level.

Information from field-based sources in Hambantota indicates that mothers have a poor knowledge of
correct complementary feeding practices. It is also possible that the knowledge and counseling skills of
the PHMs (on complementary feeding) needed updating to enable them to help mothers adequately.
With this background, the MO-MCH of the district considered it appropriate to design and implement
a programme to improve complementary feeding practices of mothers/caregivers with infants who had
completed five months of age. This document describes the experience gained through the implementation
of a community-based strategy to improve complementary feeding in the Hambantota District.
Monitoring of the effectiveness/impact of the programme is done through routinely collected data via
the growth monitoring programme. Available data clearly indicate a decline in the percentage of infants
and preschoolers who were underweight, over the years from 2009 onwards. This could be considered a
successful attempt at improving complementary feeding practices in a predominantly rural population, and
this needs to be considered an example for other districts.
The interest and commitment shown by mothers and health staff at all levels, has enabled the implementation
of the programme on a continuous basis from 2008 to date.

It was decided to include this component to the ongoing community-based educational programmes
targeted at women from the antenatal period onwards. The programme commenced implementation in
early 2008.

The objectives of this programme were: improving the competencies of public-health midwives in infant and
young child feeding; improving the knowledge and skills of mothers in the area of infant and young child
feeding (IYCF), at the time that their infants completed 5 months of age; and empowering and mobilising
the community to support correct complementary feeding practices.

iv IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT EXECUTIVE SUMMARY v
Chapter
1

INTRODUCTION
1.1 Background

Nutrition during the early years of life, especially during the first 2 years, is crucial for the development of a
healthy and productive adult. During this period, there is rapid physical growth and mental development.
Therefore, children within this age group are vulnerable to nutritional problems that can have a bearing
on the health status as an adult, development of non-communicable diseases, reduced work, reduced
intelligence levels; and for women, complications of delivery and low birth weight. All these factors have
negative implications on development.

With much emphasis on the promotion of breast feeding practices, many of the recent reports on the
prevalence of under nutrition indicate satisfactory growth patterns during the first 6 months of life followed
by a general declining trend in the growth pattern after 6 months. This indicates the importance of proper
complementary feeding practices. The study on factors associated with complementary feeding in Sri Lanka
carried out in 2008 identified key areas related to complementary feeding practices that need attention.
They are: age of introduction of complementary foods; gender differences in the prevalence of under
nutrition; food consistency; amount of food, meal frequency and energy density; nutrient content of foods;
washing practices; responsive feeding; and feeding during and after an illness - (Sri Lanka Complementary
Feeding Study – Factors associated with complementary feeding in Sri Lanka, Ministry of Health Care and
Nutrition and UNICEF, 2008).

This study reports that the adoption of correct care practices by caregivers is partly influenced by the
knowledge and skills of health workers, and their efforts to facilitate sustained dialogue and counseling
among caregivers. Generally, health care providers interviewed in this study were aware of the challenges
pertaining to changing the existing dietary patterns and food taboos. They also indicated that they have
encountered challenges of low participation in counseling and clinic sessions related to nutritional
education, which need to be addressed.

Sri Lanka has been very successful in improving the key health indicators, especially those pertaining to
mortality. It is now imperative to address the next challenge by addressing the infant and young-child
feeding practices. This is done by focusing their complementary feeding messages, on not just vague advice,
but specifics that deal in the amount/quantity, frequency; density/consistency; quality/diversity; hygiene as
well as responsive feeding of a young child.

It is also recommended that policies and plans should incorporate and recognise homes that have household
food insecurity and families whose resources may be insufficient to meet the challenges of the infant and

Introduction 3
young-child feeding recommendations. For such households, health workers should be given guidelines
regarding how to access welfare programmes, public social welfare funds, private and public sector partners
who can assist in helping these families.
This document focuses on describing the experience gained through the implementation of a community
based strategy to improve complementary feeding in Hambantota District, Sri Lanka. The inputs to this
document include : perusal or documents relevant to the programme and the information obtained through
discussions held with MO-MCH, Hambantota responsible for the programme, supervisory staff, Public
Health Midwives and a group of mothers who had participated in the programme.
1.2 Background information: Hambantota district
Hambantota is one of the three districts of the Southern Province of Sri Lanka extending over 2,609 square
kilometers with a population of 596,617 (Sri Lanka Census of Population and Housing, 2011). It is situated
in the dry zone of Sri Lanka and is mainly an agricultural area with paddy farming as a predominant form
of occupation. It is estimated that 13.4% of the labour force is unemployed. Of those employed, 42.2% are
in the agricultural sector, 23.3% in industry and 34.5% in the service sector.
Administratively, the district is divided into 12 Divisional Secretary Divisions and include 576 Grama
Niladhari (GN) Divisions. There is one Municipal Council and one Urban Council and 10 Pradeshiya
Sabhas within the district.
The curative health services in the district are provided by: one District General Hospital; 3 Base Hospitals; 9
District Hospitals (B type); 8 District Hospitals (C type); and 13 Central Dispensaries. The district includes
12 Medical Officer of Health (MOH) areas that provide preventive and promotive health services through
its field health staff. Maternal and child health services form a key component of these services.
At the district level, responsibilities for health services administration is undertaken by the Regional
Director of Health Services (RDHS). The staff at the level of the RDHS, include: Medical Officer (Maternal
and Child Health – MO-MCH); Regional Epidemiologist; and Medical Officer ( Planning). At the time this
report is being prepared, there are 220 PHMs, in the district and there approximately one or two vacant
PHM positions in each of the MOH areas.
4 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT
1.3 Maternal and child health services in
Hambantota
Administration of services is under the RDHS, Hambantota. At the district level, the Medical Officer,
Maternal and Child Health (MO-MCH) is responsible for planning, supervision and monitoring of all
maternal and child health services in the district. As mentioned above, for purposes of service delivery,
the district is divided into 12 MOH areas, each with several field staff .The Public Health Midwife(PHM) is
the key field-level health worker responsible for the implementation of the MCH activities within the area.
Services are provided through clinics at identified centres including the MOH office, and field-level services
are provided through home visits by the PHM.
The MOH of the area is responsible to ensure that MCH services are conducted in a satisfactory manner in
the area under him/her. Data required for monitoring and evaluation are collected by the field staff, collated
at the MOH level, transferred to the district level to the MO–MCH, and then to the Family Health Bureau,
Ministry of Health at the national level. Monitoring of the nutritional status of under five year old children
is among one of the activities undertaken by the MOH and staff.
In Hambantota district, through an initiative undertaken by the MO-MCH of the area, a series of
well-organised programmes aimed at improving the maternal and child health services were introduced
through educational activities implemented at the field level. These programmes commenced in 2005. They
were targeted at antenatal mothers and were conducted on a regular basis in all MOH areas in the district.
The first of these series of educational activities focused on lactation management and next, on the early
childhood care and development (ECCD) programme.
Field assessments by the health staff in all MOH areas indicated a major improvement in breast feeding
practices with approximately 95% of all mothers practicing exclusive breast feeding. In spite of the
improvements in breast feeding practices, the prevalence of low-weight-for-age among the older infants
and preschool children persisted as shown by data from the Family Health Bureau (FHB) published in the
2006/07 report on family health.
1.4 Nutritional status of under-five children
Data on nutritional status of under-fives in Hambantota District are available from two sources: special
surveys and routinely collected data. Data available from the Nutrition and Food Security Survey (NFSS)
undertaken in 2009/2010 are given in Table 1. When compared to the national-level prevalence of the
different indicators, Hambantota District shows higher levels in the prevalence of low-weight-for-height
and low-weight-for-age, at moderate and severe levels.
Introduction 5
Prevalence of anaemia shows a lower level when compared to the national prevalence. However, the
percentage of newborns weighing less than 2500 grams is higher than the national figure.
1.5 Objectives

Table 1: Information on nutritional status of children aged 6-59 months, Hambantota The objectives of this programme were identified as follows:
District
1 To improve competencies of public health midwives in infant and young-child feeding
Indicator Prevalence at district level National level prevalence

Height for age <2SD 15.4 19.2

2 To improve the knowledge and skills of mothers in infant and young-child feeding (IYCF) at
the time that their infants completed 5 months of age, prior to introduction of complementary
Height for age <3SD 3.7 4.6 feeding on completion of 6 months.

3 To empower and mobilise the community to support correct complementary feeding practices.
Weight for height <2SD 13.2 11.7

Weight for height <3SD 2.2 1.9

Weight for age <2SD 22.8 21.6

Weight for age >3SD 5.1 3.9

Prevalence of anaemia 21.3 25.2

% of newborns weighing <2500

21.5 18.1
gms.

Source : Nutrition and Food Security Survey 2010

Data from the Annual Reports on Family Health Sri Lanka, provided information on the prevalence of
under nutrition among under-fives at district level. The indicator used in these assessments is weight for
age, which is routinely monitored in the growth monitoring programme. Available data in 2006-2007 on
the nutritional status of under-five children shows that the percentage of infants with weight for age <2 SD
was 15%, among those in the 1-2 year age group, this percentage was 33% and in the 2-5 year age group,
28% (Annual Report on Family Health, 2006/2007).

This data indicates an increase in the prevalence of low-weight-for-age during the second year of life with a
relatively high prevalence in the 2-5 year age group. These observations indicate a decline in the nutritional
status of children during the latter part of infancy continuing to remain, as the child grows older. Available
information suggests that there are problems with complementary feeding .

In 2008, taking into consideration the available data on the nutritional status of under five children in
the district, it was considered appropriate to introduce a programme focusing on improvement of
complementary feeding practices, through the ongoing educational programmes that are being done at the
field level.

6 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Introduction 7
Chapter
2

IMPLEMENTATION
OF A COMMUNITY
BASED PROGRAMME
2.1 Description of the programme

Higher prevalence of low-weight-for-age among children during their first year (and continuing to the
higher age groups), indicate issues related to feeding practices of infants and young children - most likely,
improper complementary feeding practices. The possible reasons for such observations could include
cultural practices, beliefs and food taboos, and other practices that influence the key components of the
practices related to complementary feeding, as well as inadequate support from the health staff in improving
such practices.

Information available from field-based sources in Hambantota indicated that mothers had poor knowledge
of correct complementary feeding practices. It was also possible that knowledge and counseling skills of the
PHMs on complementary feeding needed updating to enable them to help mothers adequately.

Within this background, the MO-MCH of the district considered it appropriate to design and implement
a programme to improve complementary feeding practices of mothers/care-givers of infants who had
completed five months of age. It was decided to include this component to the ongoing community based
educational programmes targeting women from the antenatal period onwards. The programme commenced
implementation in early 2008.

When designing the programme, attention was paid to the following aspects:

• Target group intervention, to include mothers and caregivers with children who have completed 5
months of age.

• To ensure more that 95% coverage of the target group within the district.

• Uniformity of the contents to be included in the programme.

• Sustainability of the programme.

IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 11

2.2 Steps undertaken when implementing the v. Legumes such as dhal, beans, chickpeas, green gram, nuts and seeds contain important nutrients
needed for growth and should be introduced into the child’s daily diet gradually.
programme
vi. Dark green leaves, as well as yellow fruits and vegetables, helps a child to have healthy eyes and
fewer infections, and needs therefore to be introduced into the daily diet.

2.2.1 Training of trainers vii. More meals and variety of foods are needed as the child grows older.

The programme was to be implemented at the field level by the PHMs, through a series of workshops. Prior viii. A young child needs an increasing quantity of foods and gradually change the consistency of
to conduct of the workshops, all field staff, MOH, Public Health Nursing Sisters (PHNSs) and Supervising foods.
Public Health Midwives(SPHMs) were trained on infant and young-child feeding (IYCF) by the MO-MCH,
ix. A growing child needs to learn how to eat, and therefore it is necessary to encourage and assist
during a 3 to 4 day programme using the training guidelines developed by the Family Health Bureau in
him with lots of patience (responsive feeding).
2007. In addition, the supervising staff were given guidance on supervision.
x. Encourage the child to drink and eat more during an illness, and afterwards to help recover early
Since then, programmes were held periodically as and when there was a need to train the health staff who and maintain normal growth.
were newly appointed to the district.
Fig. 1: Key
messages
2.2.2 Development of support material relevant to
feeding of
To support the training, information, education and counseling materials were developed and distributed infants and
to all relevant field health staff (trainers). These included a set of display boards explaining the 10 key young children
messages relevant to complementary feeding. A set of guidelines were developed for all PHMs on the
conduct of the programme at field level (Annexure 1). In order to ensure the smooth conduct of workshops
for mothers throughout the district in a uniform manner, a programme calendar was developed at the
beginning of the year, and the information communicated to all field health staff.

2.2.3 Contents of the workshop

The contents included in these programmes focus on the following 10 key messages:

i. Exclusive breast feeding until completion of 6 months of age will facilitate optimal growth and
2.2.4 Capacity building of mothers
development of infants.
The target group for the intervention was identified as the mothers of children who completed 5 months of
ii. Starting of semi-solid foods, in addition to breast milk, immediately after completion of 6 months
age. This group was selected as complementary feeding is due to commence from 6 months of age.
while continuing to breast feed for 2 years or longer.

iii. Introducing complementary foods in a thick enough form to stay in the spoon gives more energy Capacity building of mothers/care-givers was conducted at a one-day workshop on correct complementary
and nutrients to the child, facilitating healthy growth. feeding practices. All these programmes are held throughout the district in 77 centres on the same day,
according to a pre-set calendar. This approach of holding the workshops throughout the district helped to
iv. Introducing foods of animal origin (meat, fish dry fish etc.) very early (around one week after
ensure a high level of coverage.
introducing complementary food), is essential for healthy growth and brain development of the
infant.

12 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 13
 programmes are held and undertake a supervisory role. The Mother’s Clubs and
Figure 2: Target other community organisations of the area participate in these programmes by
groups supporting logistical arrangements and the provision of refreshments to the
mothers who attend the workshops.

Figure 4:
Members of
Mothers’ Clubs
participating in
the workshop

Each workshop includes mothers of infants who have completed 5 months of age,
from the three nearby PHM areas, invited to attend the workshop by the PHM
of the area. The workshops are held in a health centre or any other venue where
the filed level clinics are held. As the programme focuses on mothers of children
in three adjacent PHM areas, a place convenient to all mothers is selected for
The workshops are held from 8.00 a.m. to 2.00 p.m. on the given day. Six such
conducting the workshop.
bi-monthly programmes are held each year.

Figure 3: The workshops are conducted by the PHMs, in accordance with the guidelines
Conducting provided (Annexure 1). No additional funds were used to conduct these
the programmes - thus ensuring sustainability.
workshops
Figure 5:
Booklet for
mothers

The workshops are conducted by the PHMs. They use a wide range of teaching
methods including lectures, demonstrations and role play. The field health staff,
MOHs, PHNSs and SPHMs visit these centres randomly, on the days that the

14 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 15
 A booklet based on the guidelines provided by the FHB has been prepared to
be given to mothers who are not able to attend these workshops. This booklet
is also available for use by mothers in the event they need some updating of the
information provided at the workshop.
Figure 6:
Display boards
The following activities are undertaken during each of the workshops as per the detailed guidelines
provided to the PHMs; usually, three PHMs participate in each workshop.
i. Using each display board, the PHMs, explain the content of the board while showing the items that
are relevant. Food items and other relevant items are arranged on a table where all mothers could
see them. Where feasible, mothers are allowed to see them on an individual basis. Discussions are
held with mothers to explain the contents of the board, information related to the food items, and
other queries that mothers may have.

ii. The above activity is followed by demonstrating the preparation of foods to be fed. This highlights
the need for proper consistency during the preparation of the first meal. Emphasis is paid to the
hygienic aspects of feeding such as washing of hands prior to preparation of food, washing of
utensils used for feeding, etc. When feasible, mothers and some members of the Mothers’ Clubs
(community groups) participate in the preparation of food.

Figure 8:
Preparation of
food

Each display board focuses on explaining the relevant aspects of each of the above
messages. The visual aids used in the workshops include the display of food items
that are relevant to the inputs given in the display board. Food items for display
are provided by the mothers and community groups. Detailed information
displayed in the display boards are shown in Annexure 2. A set of display boards
are provided to each centre where the workshops are held.

It is necessary to ensure that as many mothers (of children who have completed 5 months) attend these
sessions. Prior to the workshop, PHMs visit the homes and make arrangements to request the mothers to Figure 9:
attend the workshop and bring materials required for the demonstration. Demonstrating
the consistency
of food
Figure 7:
Food items –
examples

16 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 17
 iii. Some of the food items used for demonstration are cooked food prepared and brought by the
mothers. These are shown to all mothers and discussions are held regarding the preparation and Figure 12:
feeding of these food items to children. Demonstration
of increasing
iv. Guidance is provided to the mothers on the contents and preparation of ‘main’ meals and other quantities of
‘short’ meals. These are also supported by cookery demonstrations. Mothers are also educated food with age
regarding ‘short’ meals, which are not nutritious – hence to be avoided.

Figure 10: Main

meal

vi. Techniques that can be used when feeding the child is another aspect that is highlighted during
the workshop. Role play is included in this part of the workshop. Role playing is done by the
health staff and also by the members of the Mother’s Club of the area.

Figure 13:
Demonstrating
feeding
Figure 11: Short
techniques
meals

v. The need to increase the quantity of foods given is highlighted and supported by a demonstration.

18 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 19
 vii. While the importance of proper complementary feeding is the main focus of these workshops, the
need to continue breast feeding until about 2 years is also emphasised.
viii. Fathers and grandparents are also invited to participate in these workshops to encourage them to
assist mothers in adhearing to correct feeding practices.
Figure 14:
Participation
of fathers and
grandparents
Approximately 20 – 30 mothers participate in each programme.
The detailed guidelines provided to the PHMs to conduct these workshops as given in Annexure 1 have
been reviewed and revised appropriately since the inception of the programme.
2.2.5 Monitoring of the conduct of the programme
As mentioned, programmes throughout the district are conducted on the same day and in each MOH area,
approximately 6-7 programmes are conducted on a given day at different venues. The supervising staff
include MO-MCH, MOHs, Regional Supervising Public Health Nursing Officer (RSPHNO), Public Health
Nursing Officers (PHNO) and Supervisory Public Health Midwives (SPHM) attached to each MOH area.
The main method of monitoring the conduct of each workshop is through site visits by the supervisory
staff. The staff divide themselves among the places where the programmes are conducted and visit them,
one or more, on the given day. They observe the proceedings and identify areas where improvements could
be made. If possible, attempts are made to modify the proceedings as and when they were observed. Their
observations are also presented and discussed as necessary, at the monthly conferences held at the MOH
office. At the district level, the observations made by the RSPHNO are communicated to the MO-MCH and
are presented at the meeting of the MOH.
20 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT
At present, the monitoring is carried out mainly through observation, which may be subjective at times. An
attempt to develop a guideline for monitoring the conduct of the workshops is being done by MO-MCH
(presently AMOH, Hambantota) in collaboration with the supervisory staff.
2.3 Best practices
Correct identification of the target group has made the workshops conducive to achieve the objectives of the
organisers. Having all programmes on a given day throughout the district using the developed guidelines is
an important aspect that facilitates both the uniformity of the contents of the workshop, while facilitating
effective monitoring. The use of a wide range of educational methods enhances the ability to keep the
interest of the mothers, and also encourages their active participation.
A key element that is of importance is the ability to conduct the programme without any additional costs,
with active participation of mothers and community groups, thus ensuring sustainability.
2.4 Monitoring of the effectiveness/ impact
Monitoring of the effectiveness/impact of the programme is done through routinely collected data via
the growth monitoring programme. The weighing activities undertaken during the ‘Nutrition Week’ are
also used for monitoring the impact. The indicator used in these assessments is weight-for-age and data
collected at the growth monitoring stations, which are collated by the midwives and submitted to the MO–
MCH through the MOHs. The findings for 2007–2012, which is available from the Family Health Bureau,
Ministry of Health are presented in table 2 and figure 15. Data available from measurements made during
the Nutrition Months for the years 2009 -2012 are given in table 3 and figure 16.
The percentage decline in the prevalence of infants with weight-for-age <2 SD during the period between
2007 and 2012 is 68.7%, and for children aged between 1-2 years this decline was 56.1%. Table 3 shows that
the decline for infants has been very sharp during the first year of the implementation of the programme
and then slows down. This pattern is to an extent different in the 1-2 year olds, where the decline was most
marked in the second and third years after the implementation of the programme.
IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 21
Table 2: Percentage of infants and 1-2 year old children, underweight for age Table 4: ‘Nutrition month’ data - % of under-fives , who are underweight for age
(Hambantota District). (Hambantota District)

Year Year
Indicator Indicator
2007 2008 2009 2010 2011 2012 2009 2010 2011 2012
% of infants with weight for
% of infants with weight age <2 SD 17.9 9.0 8.1 6.1
15 7.4 07 6.1 5.0 4.7
for age <2 SD
% children 1 – 2 years with
% children 1 – 2 years weight for age <2 SD 32 20.2 16.0 13.0
with weight for age <2 33 27.9 19.7 16.3 15.7 14.5
SD % of children 2-5 years with
weight for age <2 SD 47.4 29.3 24.6 17.6
Source : Annual Reports on Family Health, Sri Lanka, 2008-2009 and 2010, Family Health Bureau, Ministry of Health.
(based on data from H 509).

Figure 16: Percentage of under-fives, underweight for age – Nutrition month data
Figure 15: Percentage of infants and 1 -2 year old children, underweight for age
(Hambantota District).
50

45
35
40
30 % of infants with % of infants with
Percentatage

weight for age <2 SD 35 weight for age <2 SD

25
% children 1 - 2 years
30 % of children 1 - 2
20 with weight for age <2

Percentatage
SD years with weight for
25 age <2 SD
15
20 % of children 2 - 5
10
years with weight for
15
5 age <2 SD
10
0
2007 2008 2009 2010 2011 2012
5
Year
0
2009 2010 2011 2012
Source : Annual Reports on Family Health, Sri Lanka, 2008-2009 and 2010, Family Health Bureau, Ministry of Health.
Year
(based on data from H 509)
Source : MO – MCH, Hambanatota.

Table 3: Percentage decline in the prevalence of underweight for age In addition to the above information, based on the data obtained on the nutritional status at the National
FHB data Micronutrient Survey carried out by the Medical Research Institute(MRI) and UNICEF in 2012, the districts
Years
Infants 1-2 year olds were ranked according to the indicators of nutritional status; the highest rank (25) is given to the district
2007-2008 50.7 15.5 with the “best” indicators. On this assessment, Kalutara District was ranked as the “best” district (25) and
2008-2009 5.4 29.3 Hambantota, was ranked as the “second best”. Thus, all available information indicate that the nutritional
2009 - 2010 18.0 32.5 status of under-five children in Hambantota District is at a satisfactory level.
2010-2011 14.8 3.7
2011 - 2012 6.0 7.6
2007 - 2012 68.7 56.1

22 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 23
2.5 Achievements
This programme can be considered as a major input aimed at improvement of complementary feeding
practices in Hambantota District. Data presented clearly indicates a decline in the percentage of infants
and pre-schoolers who were underweight, over the years from 2009 onwards. This pattern is in keeping
with the improvements in the nutritional status of under-five children with a decline in the prevalence of
low-weight-for-age (<2 SD) in the second year of life – with the decline persisting in later years. Without
any other additional inputs to improve the nutritional status of under-five children in the district during
this period, it is very likely that this programme has contributed to an improvement in the nutritional
status, through a positive influence on complementary feeding practices.
2.6 Lessons learnED
The interest shown by the health staff at all levels and the mothers has enabled the implementation of the
programme on a continuous basis from 2008 to date. The encouraging results seen (as described above)
seem to have made an impact on maintaining the interest of all groups involved in these activities including
community based groups. Both these factors have contributed to a high level of commitment from the field
health staff that has led to the effectiveness of these programmes.
Though subjective, it was seen that the status of the PHM has risen at the community level due to their
contribution in the areas of child health through these programmes.
The field health staff indicated that their time at the field could be better utilised as these workshops serve
as group teaching sessions, which have contributed to an improvement of the nutritional status of young
children.
Participation of mothers is reported to be high; and this includes mothers from different ethnic backgrounds
and social strata. Mothers who have participated in these programmes have been a source of information
for others, who are their relatives and friends that reside in other areas.
This is a successful attempt at improving the complementary feeding practices in a predominantly rural
population and needs to be considered as an example for other districts too. It was noted that health
staff from several other districts had shown an interest in observing this programme; the MO-MCH of
Hambantota had provided them with such opportunities.
During such visits, MO-MCH and other staff of the health areas of Hambantota District shared their
experience with health staff from other districts. They are requested to visit the area for a one-and-a-half-day
24 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT
session. On day 1, the visiting health staff were provided with the background information relevant to the
programme by the MO-MCH and on day 2, a field visit was arranged for them to make their observations
on the conduct of the programme at the field level.
The factors that have had a positive influence on this programme were: the high level of commitment of
health staff at all levels – including administrators; commitment of the mothers and the conduct of the
programme without any disruptions (specially due to the preplanned schedules being adhered to strictly);
and the sustainability of the programme – without additional funding.
2.7 Constraints and challenges
Consideration of the ‘way forward’ is likely to identify both constraints and challenges. Maintaining the
high level of commitment shown by health staff in the district (at all levels) could be considered as both a
constraint and a challenge; a constraint in the event that the commitment shown at the higher levels of the
health staff wanes. The other important consideration is the extent to which similar programmes could be
implemented in other districts; this would be dependent on the above constraint and challenge.
Sharing the experience gained is an important component of the programme and the way forward needs
to include dissemination of information to encourage implementation of similar effective programmes in
other districts. The guidelines prepared for the use of MO-MCHs is a useful tool to enable implementation
of such programmes in other districts (Annexure 3).
As would be expected, the decline in the prevalence has been very sharp initially – as shown in table 3 – with
a slowing down in later years. This indicates that in the future, it may be necessary to broad base the inputs
while taking other factors that could influence complementary feeding practices into consideration. Such
inputs may require attention; for example, to aspects such as improving food security. It may be necessary to
consider locally relevant approaches to counteract the influence of these other factors affecting the nutrition
of the young child. They may require a multi-sectoral approach, relevant to the local situation.
Suggestions made by field staff and mothers to improve the impact of the ongoing programme needs to
be considered. These include:
• A summary poster to be given to mothers, highlighting the key issues related to the 10 messages – to
be displayed in a prominent place in their homes.
• Preparation of a document in Tamil for those who are not able to read and understand Sinhala.
• To continue the programme activities without disruption was considered necessary by mothers
(other than those with only one child), who felt it was necessary to refresh their knowledge, to con-
tinue the good feeding practices of a second child.
IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 25
 • Refresher training mainly in the form of discussions held for the PHMs, on a periodic basis, to be
continued.

• Newly recruited PHMs have be given a detailed training to enable them to contribute to the pro-
gramme effectively.

26 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT IMPLEMENTATION OF A COMMUNITY BASED PROGRAMME 27
ACKNOWLEDGEMENTS

Permission granted by the Regional Director of Health Services and other relevant administrative staff
of Hambantota District is much appreciated. Preparation of this document would not have been possible
without input from the staff who were responsible for the initiation, implementation and monitoring of the
programme described in this document. They provided all relevant information, photographs and other
documents that have been included in this report.

Thanks are due to all health staff of the health units of Hambantota District, MOOH, PHNSs, SPHMs,
DFAT for their role in the contributions made through this programme.

Acknowledgements 29
BIBLIOGRAPHY

1 Sri Lanka Complementary Feeding Study – Factors associated with complementary feeding in
Sri Lanka, Ministry of Health Care and Nutrition and UNICEF, 2008.

2 Sri Lanka Census of Population and Housing, 2011. Department of Census and Statistics,
Colombo, Sri Lanka

3 Nutrition and Food Security Survey 2010, MRI and UNICEF..

4 Annual Reports on Family Health , Sri Lanka, 2008-2009, Family Health Bureau, Ministry of
Health

5 Annual Reports on Family Health, Sri Lanka 2010, Family Health Bureau, Ministry of Health.

6 Unpublished data (2014) Data from MO-MCH Hambantota.

7 Unpublished data (2014) from Multiple micronutrient study.

bibliography 31
List of persons with whom
discussions were held

Dr. A.D.U. Karunaratna, Regional Director of Health Services, Hambantota.

Ms. H.G.I. Somalatha, Regional Supervising Public Health Nursing Officer, Hambantota.

Ms. G.B. Champika, Public Health Nursing Officer, Hambantota

Ms. A.S. Somawathie, Supervising Public Health Midwife, Hambantota

Ms. W.S.S.Iranganie, PHM , Hambantota

Ms. H.T. Padamalatha, PHM, Hambantota

Ms. H.M.P. Hemamala, PHM Tissamaharama

Ms. K.G. Nilanathi, PHM, Tissamaharama

Group of mothers:

Ms. M.K. Niranjala

Ms. K.H.A.R.P. Hapuaraachchi

Ms. Chanadrika Weerasinghe

Ms. Udani Muthukumara

Ms. Umesh

Ms. Malki Sundika

List of persons with whom discussions were held 33

Annexures
Annexure 1

Guidelines to Public
Health Midwives
wu;r wdydr oSu ms<sn|j jõjreka
oekqj;a lsÍfï udisl jevigyk

mjq,a fi!LH fiajd ks,Oßkshka i|yd jQ Wmfoia ud,dj

1. jevigykg fmr fuu Wmfoia ud,dj fydoska lshjkak'
2. fuu jevigyk i|yd Tn fj; ,nd oS we;s fmdaiag¾ lÜg,h bkafjkaá% .; lr m%fõYï
iy.;j ;nd .; hq;= w;r th yïnkaf;dg osia;%Slalfha fÌa;% jevogyka i|yd jQ foam,la
neúka fuu osia;%Slalfhka udre ù hk wjia:djl fyda frday,a fiajhg udre ù hk úg th wod<
fi!'ffj'ks' ld¾hd,hg Ndr oSu wksjdrH fõ'
3. b,lal lKavdhu(
ish¨u mjq,a fi!LH fiajd ks,Odßkshka iEu uilu ;ud Ndrfha isák udi 5 iïmQ¾K jQ orejka
isák uõjreka i|yd fuu jevuq¨j meje;aúh hq;=h'
4. wfkl=;a fÌa;% jevigyka meje;afjk wdldrhg ^uõ lsß jevigyk iy uq,a <ud úh ixj¾Ok
jevigyk& mjq,a fi!LH fiajd ks,OdÍ ;sfofkl= tlaù jevigyk meje;aùu l, hq;=h'
5. jevigyk iEu uilu meje;aùu wksjdrH jk w;r ta i|yd iEu udi 2 lgu jrla ;=kajk
i;sfha isl=rdod oskh fhdod .; hq;=h'
6. jevigyk meje;afjk fõ,dj(
Wfoa 8 isg iji 2 olajd ld,h fhdod .; hq;= w;r oyj,a f;a mdkh fÌa;%fha ck;dj ,jd
ixúOdkh lsÍug mjq,a fi!LH fiajd ks,Odßkshka iu;a úh hq;=h'
7. fuu Wmfoia ud,dfõ wvx.= jk wdldrhg tla tla mqjre i|yd jk ’lr fmkaùï¶ lsÍu wksjdrH
jk w;r tu lr fmkaùïj,g wjYH jk øjH jevigykg fmr jevigykg iyNd.Sjk
uõjreka jevigyk osk /f.k taug l,ska Ndr fokak'

Annexure 1 37
’lr fmkaùï¶ i|yd Tn f.kajd .; hq;= øjH mqjrej 1
udi 6 iïmQ¾K jk ;=re orejd uõ lsfrka muKla fmdaIKh l,hq;= nj kej; kej; wjOdrkh
mqjrej 01 g wod< lr fmkaùï i|yd le| j;=r" fld;a;u,a,s j;=r" msá lsß" m<;=re lrkak' fndfyda jõjre udi 5 jk úg orejdg úúO foa oSug fm<öfuka orejdg .=Kd;aul núka
wjYH øjH hqI" .%hs*a fjdag¾ fnda;,hla by, uõlsß ál fkd,eî hdug bv we;s nj;a tys we;s wys;lr ;;ajh;a idlÉPd lrkak' fï
olajd uõ lsfrka muKla fmdaIKh lrk uõjrekag m%Yxid lrkak'
mqjrej 03 g wod< lr fmkaùï i|yd tl iudk úksúO fmfkk ùÿre 2la" ;%sfmdaI fyda
wjYH øjH iufmdaI ye|s lsysmhla" j;=r" oshlsÍug ye|s

mqjrej 04 g wod< lr fmkaùï i|yd uõjreka ,jd f.kajd .kakd ,o msiQ i;aj lr fmkaùu
wjYH øjH wdydr lsysmhla(
ì;a;r" uia" ud¨" yd,a ueiaika" fhda.Ü" mSl=ÿ mqjrefõ i|yka udi 6 iïmQ¾K jk ;=re fkdosh hq;= øjH m%o¾Ykhg ;nkak'
msá lsß" le| j;=r" fld;a;u,a,s j;=r" m<;=re hqI" .%hs*a fjdag¾
mqjrej 05 g wod< lr fmkaùï i|yd uõjreka ,jd f.kajd .kakd ,o msiQ weg j¾.
wjYH øjH lsysmhla(
lõms" uqx" lv," mßmamq mqjrej 2
mqjrej 06 ^w& g wod< lr fmkaùï uõjreka ,jd f.kajd .kakd ,o t<j¨ yd mqjrej m%o¾Ykh lr tys we;s lreKq idlÉPd lrkak
i|yd wjYH øjH m<;=re j¾. lsysmhla

mqjrej 06 g wod< lr fmkaùï i|yd uõjreka ,jd f.kajd .kakd ,o fmdälr mqjrej 2 ^wd&
wjYH øjH leùug iqÿiq m<;=re lsysmhla
mqjrej m%o¾Ykh lr tys we;s lreKq idlÉPd lrkak
mqjrej 07 ^wd& g wod< lr fmkaùï uõjreka ,jd f.kajd .kakd ,o my; i|yka
i|yd wjYH øjH msiQ wdydr
n;a" weg j¾.hla" m,d" lerÜ fyda jÜglald mqjrej 3
jeks lymeye;s t<j¨jla" ue¨ lene,a,la
yd,aueiaika fyda ì;a;r" ng¾ fyda f;,a mqjrej m%o¾Ykh lr tys we;s lreKq idlÉPd lrkak
iaj,amhla

mqjrej 07 ^B& g wod< lr fmkaùï ng¾ ;jrk ,o l%Sï l%el¾ ìialÜ lsysmhla"
lr fmkaùu
i|yd wjYH øjH ng¾ ;jrk ,o mdka fm;s" fhda.Ü 1 la" ;eïnQ
w, f.ähla iy fmd,a" ;%sfmdaI fyda iufmdaI
;%sfmdaI fyda fidahd msá tlu m%udK ^f;a yeis 2 1$2la& úksúo fmfkk ùÿre 2llg oud tla
iu. fmd,a"
ùÿrejlg j;=r iq¨ m%udKhla oud Wl= iajNdjh fmkajkak'
meKs ri ìialÜ lsysmhla" f;a iaj,amhla" le|
wfkla ùÿrejg j;=r jeäm%udKhla oud oshr iajNdjh fmkajkak'
oshr j¾." m<;=re iaj,amhla
Wl= wdydr oSfuka jeä wdydr m%udKhla orejdg ,ndosh yels nj wjOdrkh lrkak'
mqjrej 08 ^w& g wod< lr fmkaùï wËq fldamam 4la iy f;a ye|s 2la"
i|yd wjYH øjH len,s rys; Wl= wdydr fldgila"
len,s iys; >k wdydr fldgila"
mjqf,a wdydr fldgila

mqjrej 09 ^we& g wod< lr fmkaùï lD;Su lsß melÜ" iSßh,a j¾. $ riala j¾. j,
i|yd wjYH øjH ysia melÜ lsysmhla" iqma fnda;,hla" yekaola iy
fldamamhla

8. ish¨u fi!LH fiajd ks,Oßks jreka iEu udi 2 lgu jrla ;=kajk isl=rdod oskfha fuu jevi-
gyk i|yd mjq,a fi!LH fiajd ks,Oßkshka fhduq l, hq;= w;r toskg tu jevigyk meje;afjk
nj iy;sl l, hq;=h'

38 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 1 39
oshr wdydr lsysmhla fïih u; ;nkak' fujeks j;=r j¾. oSfuka orejdf.a
fïjd uõjreka ,jd f.kajd .kak( nv j;=frka muKla msfrk nj wdydr ilia lsÍug fmr uj inka fhdod w;a fidaod .kakd wdldrh uõjrekag oelSug i,iajkak'
iqma j;=r" le| j;=r" m<;=re j;=r& fmkajd fokak' fï i|yd wjYH inka iy j;=r l,ska ilia lr ;nkak'

f.dÜgg oud u;a .d.kakd fnß n; f.dÜg háka yekafoka iQrd f.k uõ lsß iu. l<jï lr
orejdg ljk wkaou lr fmkajkak'

iqma j;=r le| j;=r m,;=re j;=r

mqjrej 4

wdrïNfha isgu hlv nyq, i;aj wdydr yÿkajd oSfï jeo.;alu idlÉPd lrkak'

lr fmkaùu lr fmkaùu

orefjl=g m<uq wdydr fõ, ,nd fok wkaou lr fmkajkak uõjreka ,jd f.kajd .kakd ,o msiQ i;aj wdydr fldgia lsysmhla m%o¾Ykhg ;nkak

i;s lsysmhlg fmr wdydr oSu wdrïN l< ujla f;dard .kak'
m<uq wdydr fõ, ilia lrk iy ,nd fok wkaou lr fmkajkafka wdrdOkd lrkq ,enQ uj úisks'

my; i|yka øjH f.k tk f,i uj oekqj;a lrkak

1. orejd fjkqfjka fnß n;a
2. fodjd .;a uõ lsß ì;a;r uia ud¿ lrj, fhda.Ü mSl=ÿ

3. orejdg wdydr ljk Ndckh iy yekao

4. fnß m;a ilia lsÍug wjYH f.dÜg
5. orejdf.a wdydr ilia lrk Ndck jid ;nk úYd, n÷k'

40 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 1 41
 mqjrej 5 mqjrej 6 ^wd&

weg j¾. iEu m%Odk fõ,lgu tl;= lr .ekSfï uõjreka iu. idlÉPd lrkak m,;=re fmdä lr leùfuka jeä m%udKhla orejdg ,ndosh yels nj idlÉPd lr.kak' m,;=re hqI
oSfuka orejdf.a nvg wkjYH f,i j;=r tl;= jk neúka wdydr .ekSug bv wysñ ùu ms<sn|
jgyd fokak'
lr fmkaùu
lr fmkaùu
uõjreka ,jd f.kajd .kakd ,o msiQ weg j¾. lsysmhla m%o¾Ykhg ;nkak'
m,;=re lsysmhla fmdä lr yekafoka ljk wdldrh fmkajkak'

lõms uqx lv, mßmamq

mqjrej 6 ^w&

úgñka nyq, ksid fld<mdg t<j¨ m,;=re wdydrhg tl;= lr frda. j,ska je,lSug;a weia
fmkSug;a ifï l%shdldÍ;ajhg;a jeo.;a nj uõjreka iu. idlÉPd lrkak'
mqjrej 7 ^w&
m%Odk fõ,a 3la yd flá fõ,a 2 la oSug yqre l, hq;= nj fmkajd fokak' fõ,djg wdydr oSfï
lr fmkaùu jeo.;alu idlÉPd lrkak' m%Odk fõ,a osh hq;= fõ,djka yd flá fõ,djka yd flá fõ,a osh hq;=
fõ,djka idlÉPd lrkak'
uõjreka úiska f.fkk ,o t<j¨ m,;=re lsysmhla fmkajkak'
m%Odk fõ,a kshñ; fõ,djg fkdoSfuka flá fõ,a ,nd oSug fkdyels jk nj fmkajd fokak'

mqjrej 7 ^wd&

m%Odk wdydr fõ,l wvx.= úh hq;= fldgia 5 .ek idlÉPd lrkak'

jeäysáhl= fuka fkdj orejl= jefvk neúka by; ish¨ fldgia wdydr fõ,g wvx.= úh hq;= nj
wjOdrKh lrkak'

lr fmkaùu
fuu fldgia 5 wvx.= m%Odk wdydr fõ,la fyda 2 la m%o¾Ykhl ;nkak'

42 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 1 43
 weg j¾.hla
mqjrefõ  i,l=K fhdod we;s .=Kd;aul fkdjk flá fõ,a lsysmhlao m%o¾Ykhg ;nkak'
fld< mdg t<j¨jla

meKs ri fhdam<;=re le| jeks

f;a iaj,amhla
ly mdg t<j¨jla ìialÜ lsysmhla iaj,amhla oshr j¾.

   
n;a fyda fjk;a i;aj fldgia
msá wdydrhla
f;,a

mqjrej 7 ^we& mqjrej 8 ^w&

jefvk orefjl=g jeäjk wdydr m%udKhla wjYH jk nj mqjrej olajñka meyeos,s lrkak'
flá fõ,la ms,sn|j mqjrefõ we;s lreKq idlÉPd lrkak' flá fõ,l .=Kd;aul nj jeä lr
.ekSug f;,a tl;= lsÍfï jeo.;alu idlÉPd lrkak'
lr fmkaùu

mqjrej 7 ^B&
wvq fldamamhla fmkajñka m%udK meyeos,s lrkak'

1r

uõ jreka ,jd f.kajd .kakd ,o .=Kd;aul flá fõ,a lsysmhla m%o¾YKhg ;nkak' mqjrej 8 ^wd&
Wod(

fmd,a iu. lr fmkaùu

ng¾ ;jrk fmd,a iu.
fhda.Ü ;%sfmdaI iu.
,o meKs ri ;eïnQ w, f;a ye|s 2la iy wvq fldamam 4la fma,shg ;nd tajd bosßfhka rEm igyfka oelafjk wdldrhg
;%sfmdaI fyda
ke;s ìialÜ f.ähla jhi i|yka kdu mqjre ;nkak' tla tla jhig wod< wdldrhg ilia lrk ,o wdydr fuu wvq
 iufmdaI
  fldamamj,g oud uõjrekag oel n,d .ekSug bv i,iajkak'


udi 7 udi 7 udi 8 udi 9-10-11 wjq' 1

wdrïNh wjidkh

wvq fldamam wvq fldamam wvq fldamam wvq fldamam

1$4 1$2 3$4 1
f;a ye|s
lsysmhhs
len,s rys; ishqï len,s len,s iys; mjqf,a wdydr
Wl= iys; Wl= >k

44 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 1 45
 by; i|yka øjHj, ysia melÜ fidhd f.k m%o¾Ykhg ;nkak'
úfYaIfhkau fnda;,a iQmamq mdúÉÑ lsÍu;a idlÉPd lrkak'

mqjrej 10

wikSm jQ wjia:dj,oS wdydr oSfï jeo.;alu idlÉPd lrkak'

ie,lsh hq;=hs(
orejkag wdydr ms<Sfh< lsÍug fyda Pdhd msgm;la ,nd .ekSug fuu w;a fmd; ,nd osh yel'
uõjrekag ,nd fok fuu w;a fmd; kej; ,nd .ekSug iEu ks<Odßkshlau ie,ls<su;a úh
hq;=h'

mqjrej 9 ^w& wu;r wdydr oSu ms<sn| w;afmd;

wdydr oSfï úúO ffY,Ska .ek uõjreka oekqj;a lrkak' iyNd.S jk uõjrekag lshùug fyda Pdhd msgm;la .ekSug fuu w;a fmd; ,nd osh yel'
uõjrekag ,nd fok fuu w;a fmd; kej; ,nd .ekSug iEu ks<osßkshlau ie,ls<su;a úh hq;=h'
lr fmkaùu
nf,ka leùu uõjreka fhdodf.k fyda uõ
ksoyia leùu iudc iudðlhska fhdodf.k rÕ
olajd fmkajkak'
m%;spdrd;aulj wdydr oSu

m%;spdrd;aulj wdydr oSu ms<sn|j mqjrefõ i|yka oE .eUqßka idlÉPd lrkak'

mqjrej 9 ^we&

lr fmkaùu
mqjrefõ i|yka orejdg fkdosh hq;= ldjH my; i|yka wdldrhg m%o¾Ykhg ;nkak'

lD;Su lsß ,qKq yd iSks wêl

iSßh,a j¾. riala j¾. fnda;,a iQmamq
melÜ wdydr ^Wod( áms áma&
    
46 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 1 47
Annexure 2

Display boards

Annexure 2 49
50 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 51
52 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 53
54 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 55
56 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 57
 Ten KEy Messages

General Message 1

1. During the 1st 6 months only breast feeding is vital for your infant for physical and mental devel-
opment especially.

2. Why is it necessary only to breast feed an infant during the 1 st

six months?

• The breast milk will provide an infant whole nutrition which is essential for the 1st six
months.

• Breast milk contains antibodies which helps to protect the infant from diseases. There
is no replacement for it.

• The nutrition in breast milk is easy to absorb.

• The breast milk is essential for the growth of brain and immune system.

3. Do not give following items during the first 06 months:

• Water and other liquid

• Milk powder

• Kotthamalli water

• Ratha Kalkaya

• Fruit Juice

• Gruel / porridge

• Gripe Water

Anything other than breast milk.

Note: Consult your Doctor before giving any medicines or vitamin drops or food.

58 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 59
 General Message 2 General Message 3

4. At the completion of 6 months should start feeding solid food in between and could continue
th
9. From the 1 stage of introducing the solid food the food should be thicker so that baby gets food
st

the breast feeding until 2 years or more. Where as it develops mental development. through the spoon which makes it stronger & gives better nutrition.

5. Why should not start feeding solid food before the completion of 6 months?
• Difficulty in digestion.
General Message 4
• Production of breast milk goes down.

• Cause inconvenience to swallow food due to the lack of control tongue.

10. After two weeks of introducing the solid food should make use of the following:
• Cause diahoed.
Including
• Lack of nutrition.
• Sprats
6. Why it is not suitable to introduce food at the late stage of 6 months? • Chicken

• Late in family meal practice. • Fish

• The nutrition which gets from breast milk enough only for 1st six months. After that, • Small Fish
infant will need the extra nutrition.
• Liver

7. To introduce the solid food appropriate stage is the completion of 06 months. Because, • Eggs

• Easy digestion

• Finds easy to swallow food. General Message 5

• Shows interest in food.

• Only the breast milk is not enough for nutritional needs. 11. Beans, kidney beans other types of grain helps growth in babies. Daily ensure to add beans or
grains also make sure to add food which contains vitamin C whereas it makes to easier absorb
8. How to increase the quality of foods. iron.

• Add less water

• Heat the grains before pounding or mashing [ Green gram, chick-pea]

• Feed the thick parts crush into small balls instead of liquid.
General Message 6
• Add the thick coconut milk, curd, yogurt instead of water into food.

• Adding coconut oil, butter, ghee etc. 12. Dark green leaves, vegetables and fruits of orange and yellow colour help babies to protect their
eye sight and from disease.
• Add the powder of grains [ leguminous crops]

• Germinate the grains before cooking [ from attractable nascent] • Carrot

• Mango

• Papaw

60 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 61
 • Spinach a. Oil / butter / coconut milk.

• Pumpkin b. Animal protein.

• Sweet potato - Yellow
c. Rice, yam, string hoppers, pittu, rotti, bread, cereal etc.

d. Cereal,
13. Methods of giving fruits :
e. Green leaves / green vegetables.
• Banana
f. Yellow or orange vegetables,
• Papaw

• Orange 16. At the completion of 09 month should practice the child to take main meal 3 to 4 times per day.
• Mango • Practice the child to take the main meals on regular routine.
Possibly give mashed fruits than giving fruit juice. Ex:
Breakfast at 6-7 am
Lunch at 12-1 pm
General Message 7 Dinner at 6-7 pm
Feed breast milk in between main meals.

14. According to the child’s age can increase the number of meal time 2-4 times, short meals 1-2 it
should be with different taste and colours where the child get attract. 17. What is the nutritional short meals time?
• The way of how to prepare daily meals time: • A short meal which supplies the nutrition and an extra energy.

Which time is optimum to give a fruits for the Childs ? • By adding coconut or butter to the short meal gives more energy.

For an example: • Adding oil to the short meal gives more quality and taste.

Morning 6-7 - Breakfast Which time is suitable to give a short meal?

Morning 9-10 - Snack [Short meal] A short meal should be give between the two main meals.
After noon 12-1 - Lunch [Main meal]
• Evening short meal should be given between at 3-4 pm.
Evening 3-4 - Snack [Short meal]
• Morning short meal should be given around 10 am.
Night 6-7 - Dinner [Main meal]
Very appropriate time to give fruits is after the main meal.
[Can be given as short meals too]
18. Example for nutritional short meals:
• Boiled potatoes with butter and coconut
Ex: Avocado, Banana
• Boiled seeds with butter and coconut
What is the best time to give breast milk for the baby those who take meals?
• Solid part of soups
• Always give breast milk in between the main meals because, it makes baby to take
• Avocado or Banana
more food and absorb nutrition’s rapidly.
• Yogurt [Adding fruits is desirable]
15. What is the main meal? • Bread with butter
• Give balance diet which contains essential nutrition’s. • Aggala, Helapa, Veli Thalapa, Vandu Appa

62 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 63
 • Egg mixed with boiled potatoes
Approximately the
• Unsweetened biscuit with butter. Age Nature of foods Times quantity which can be
taken at a meal
• Triposha with coconut [for underweight Child]
6+ months Pureed or well mashed cooked Along with breast feed 2 Starting with several
There are some foods with no nutrition but mothers give at the time of short meals. thick foods, start from mash rice or 3 main meals per day teaspoons then increase
gradually into add grains, vege- the limit of given to more
• Toffee and bites tables, sprats, meats, liver, green Short meals 1 or 2 ac- than from a 200 ml cup.
leaves, egg yellow cording to the necessity.
• Sweet biscuits

• Tea 8 months Foods with tiny debris In between of breast feed More than half a cup
2 or 3 main meals per from a 200 ml
• Fruit juice day.

• Gruel 1 or 2 short meals for

necessity of a child per
Should practice the child for nutritional 3 main meals and nutritional 2 short meals according day
to the age of a child. 9-11 months Thick foods with tiny pieces. [The 3 or 4 main meal per day ¾ cup from a 200 ml cup
food which can be picked and eat]
1 or 2 short meal accord-
Underweight cause by giving unbalanced food at the time of short meals. ing to the necessity
Breast feed after the
meals.
12-23 Smash nutrition family foods 2-3 main meal and 2 More than a cup from
General Message 8 short meals per day. 200 ml cup
1 or 2short meals accord-
ing to the necessity.
19. A growing child’s food should be gradually increased. Breast milk after the
meals
Baby’s meals can be more now,
Cool boiled water should be given to drink after these meals.
A whole quantity of food taken at a meal time.
(Warm water)
Completion of 06 months - number of tea spoons [Increase the quantity
of food gradually]
At the end of the 07th month - little more than a ¼ tea cup 21. Should be vigilant on followings at the time of feeding.
08 months - little more than a ½ tea cup • Always make the balance diet according to child’s weight and requirement
9, 10,11 months - about ¾ tea cup • Do not give sweets, biscuits, bites and soft drinks in between meals.
1 year - little more than a cup
• Breast feed after every main meal is essential
Older than 2 years - more than a cup
• Should practice to consume family meals from the 1st year of the child.
1 cup = 200 ml
• Starting from 2 years child should be able to consume food alone

• Avoid artificial food such as infant milk, Rusk, cereals, salt and sweets
20. How to change the quantity, nature of food and times according to the age of child.
• Do not use solid feed bottle or dummies to feed.

• Always use the clean utensils. Use a cup and a spoon.

64 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 65
 General Message 9 • Give food in small amount per day patently

• Give only necessity food

• Give rich in nutritious food

22. This is the period the child should learn to practice the eating habit. Therefore, help them to
practice patiently. • Breast feed is essential

• Do not feed by force • Mostly the child will need breast feed at this time. Make the child comfortable.

• Adults attentive is important

The points which should follow after getting recovered:
• Try to fulfill Childs necessity in food
• Feed food in small quantities frequently. Give one more meal time.

Results of giving necessity food. • Maximum breast feed.

• Could able to understand the hunger • Give rich in nutrients food.

• Could able to understand the quantity • Be patient and lovable while feeding the baby.

• Use separate utensils

• Could be able to realize the cleanliness, temperature which requires.

• Makes child to hold the utensils as well as the food

• Makes getting use to the environment

»» While feeding allow child to feel the food.

»» While feeding show affection.

»» Always should face the child while communicating.

»» Do not allow others to feel or to take the child’s food.

»» Give the maximum period for child to take the food.

»» Child will understand the nature of food.

Allow the grown up children to eat food by themselves. Parents could help.

Let the child observe the way other family members partake meal.

General Message 10

Give plenty of food and liquid when the child gets ill:

While getting recovered give plenty of food

The points should be taken at the time of recovery:

• Make the child until to take plenty of food and liquid

66 IMPROVING THE PRACTICES OF COMPLEMENTARY FEEDING: EXPERIENCE FROM A COMMUNITY BASED PROGRAMME IN HAMBANTOTA DISTRICT Annexure 2 67
 Improving the Practices of
Complementary Feeding:
EXPERIENCE FROM A COMMUNITY
BASED PROGRAMME IN
HAMBANTOTA DISTRICT

unite for
children

Nutrition coordination unit

Ministry of Health,
Nutrition and Indigenous medicine