Embed Size (px)
Citation preview
Improving food security and market linkages for smallholders in Oddar Meanchey and Preah Vihear (MALIS) OSRO/CMB/101/EC
Improving the dietary intakes and nutritional status of infants and young children through improved food security and complementary feeding counselling (IMCF) GCP/INT/108/GER
MALIS and IMCF project Dissemination meeting
26th March 2015
Nutrition Education and Consumer Awareness Group
Nutrition Division, FAO, Rome
September 2015
Contact information FAO Headquarters: Ms Ellen Muehlhoff Senior Officer Nutrition Education and Consumer Awareness Group Nutrition Division Food and Agriculture Organization of the United Nations Viale delle Terme di Caracalla, 00153 Rome, Italy Tel. 0039 (0) 6 5705 4113 Email: [email protected] Homepage: Improved Food Security and Complementary Feeding http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/ Contact information FAO Representation in Cambodia:
Mr Oum Kosal Assistant FAO Representative (Programmes) Food and Agriculture Organization of the United Nations FAO Representation in Cambodia No. 5, Street 370, Boeung Keng Kang I, Phnom Penh, Cambodia Tel. 00855 (0) 23 216 566 Email: [email protected] Homepage: FAO Representation in Cambodia http://www.fao.org/cambodia/en/
The designations employed and the presentation of material in this information product do not imply the
expression of any opinion whatsoever on the part of the Food and Agriculture Organization of the United
Nations (FAO) concerning the legal or development status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies
or products of manufacturers, whether or not these have been patented, does not imply that these have
been endorsed or recommended by FAO in preference to others of a similar nature that are not
mentioned.
The views expressed in this information product are those of the author(s) and do not necessarily reflect the
views or policies of FAO.
© FAO, 2015
FAO encourages the use, reproduction and dissemination of material in this information product. Except
where otherwise indicated, material may be copied, downloaded and printed for private study, research and
teaching purposes, or for use in non-commercial products or services, provided that appropriate
acknowledgement of FAO as the source and copyright holder is given and that FAO’s endorsement of
users’ views, products or services is not implied in any way.
All requests for translation and adaptation rights, and for resale and other commercial use rights should be
made via www.fao.org/contact-us/licence-request or addressed to [email protected].
FAO information products are available on the FAO website (www.fao.org/publications) and can be
purchased through [email protected].
Table of Contents Acknowledgements .................................................................................................................................. i
Acronyms ................................................................................................................................................ ii
Executive Summary ................................................................................................................................. 1
1. Opening session ............................................................................................................................. 4
2. Session 1: Overview of the MALIS project - FAO food security and nutrition project .................. 6
2.1. Aims of the meeting ................................................................................................................ 6
2.2. Overview of the MALIS project ............................................................................................... 6
3. Session 2: Applied research in the context of an FAO food security and nutrition project ........ 12
3.1. Overview of the research ...................................................................................................... 12
3.2. Impact of food security intervention and nutrition education ............................................. 13
3.3. Behaviour change for improving infant and young child feeding practices ......................... 16
4. Session 3: Lessons learned and Implications on future programmes ......................................... 20
4.1. FAO Nutrition Education Process Review ............................................................................. 20
4.2. Lessons Learned from the MALIS project ............................................................................. 22
4.3. Panel discussion, lessons learned for continuing/improving ............................................... 25
5. Wrap up session ........................................................................................................................... 30
5.1. Summary of recommendations ............................................................................................ 30
5.2. Closing remarks ..................................................................................................................... 31
Annex 1 - National Dissemination Meeting Programme ...................................................................... 32
Annex 2 - National Dissemination Meeting Participant List ................................................................. 34
Annex 3 - IYCF Summary Sheet ............................................................................................................. 37
iv
Acknowledgements This report provides proceedings for a National Dissemination meeting of the Food and Agriculture
Organization of the United Nations (FAO) project entitled: “Improving food security and market
linkages for smallholders in Oddar Meanchey and Preah Vihear” (MALIS) (2012-2015) and the 5-year
research project entitled: “Improving the dietary intakes and nutritional status of infants and young
children through improved food security and complementary feeding counselling” (IMCF) (2010-
2015).
MALIS was implemented by FAO Cambodia in collaboration with the General Directorate of
Agriculture (GDA) and the Ministry of Agriculture, Forestry and Fisheries (MAFF) with funding from
the European Union under Project OSRO/CMB/101/EC. Nutrition education activities were carried
out by Malteser International and Farmer Livelihood Development in the provinces of Oddar
Meanchey (OMC) and Preah Vihear (PVR), respectively.
IMCF was implemented by FAO’s Nutrition Education and Consumer Awareness Group and the
research component was led by the Institute of Nutritional Sciences, Justus Liebig University (JLU),
Giessen, Germany in partnership with the Institute of Nutrition, Mahidol University, Thailand. IMCF
was funded by the German Federal Ministry of Food and Agriculture (BMEL) under Project
GCP/INT/108/GER.
The Dissemination meeting was held on 26th March 2015 in Phnom Penh, Cambodia and included
representatives from the Council for Agriculture and Rural Development (CARD), GDA, MAFF,
Ministry of Education (MoE), Ministry of Health (MoH), Ministry of Rural Development (MRD),
Ministry of Women's Affairs (MoWA), donors, United Nations (UN) agencies, Non-Governmental
Organisations (NGOs), civil society, research institutes, FAO staff from Headquarters and Cambodia,
and professors and post-graduate students from JLU and Mahidol University.
This report was prepared by Dr Elizabeth Westaway, Ms Esther Evang and Ms Julia Garz, and
finalised by Ms Ellen Muehlhoff. Contributions from Dr Irmgard Jordan and Ms Anika Reinbott from
JLU; Ms Theresa Jeremias from FAO Headquarters and Dr Iean Russell from FAO Cambodia were
gratefully acknowledged. Many thanks go to the staff of the FAO Representation in Cambodia and
FAO Siem Reap office who provided excellent support in organising the National Dissemination
meeting.
v
Acronyms BMEL German Ministry of Food and Agriculture CARD Council for Agriculture and Rural Development CBO Community-Based Organisation CDDS CNP
Child Dietary Diversity Score Community Nutrition Promoters
COMBI Communication for Behavioural Impact FAO Food and Agriculture Organization of the United Nations FGD Focus Group Discussion
GDA HAZ
General Directorate of Agriculture Height-for-Age Z-score
HDDS HFIAS HHS HIV
Household Dietary Diversity Score Household Food Insecurity Access Scale Household Hunger Score Human Immunodeficiency Virus
IEC Information, Education and Communication
IMCF Improving the dietary intakes and nutritional status of infants and young children through improved food security and complementary feeding counselling
IYCF Infant and Young Child Feeding JLU Justus Liebig University
KAP Knowledge, Attitude and Practice
MAD Minimum Acceptable Diet MAFF Ministry of Agriculture, Forestry and Fisheries MALIS Improving food security and market linkages for smallholders in Oddar Meanchey
and Preah Vihear
MDD Minimum Dietary Diversity
MoWA Ministry of Women's Affairs
MMF Minimum Meal Frequency MoH Ministry of Health MRD Ministry of Rural Development NCHP National Centre for Health Promotion NGO Non-Governmental Organisation NIPH NMCHC
National Institute of Public Health National Maternal and Child Health Centre
NNP National Nutrition Programme NSDP National Strategic Development Plan OMC PDA
Oddar Meanchey Province Provincial Department of Agriculture
PDoWA Provincial Department of Women’s Affairs PHD Provincial Health Department PVR Preah Vihear Province
SUN Scaling-Up Nutrition TIPs Trials of Improved Practices UNICEF United Nations Children's Fund WHO World Health Organization
1
Executive Summary From 2012-2015, the Food and Agriculture Organization of the United Nations (FAO) in collaboration
with the Royal Government of Cambodia implemented the nutrition-sensitive agriculture project
entitled: “Improving food security and market linkages for smallholders in Oddar Meanchey and
Preah Vihear” (MALIS). The project aimed to increase the knowledge and skills of smallholder
households to diversify food production, increase productivity and build resilience, and to improve
family feeding practices. The MALIS project adopted an integrated approach, which used a
combination of food security and nutrition education activities to diversify household agricultural
production and consumption to match the recommended food groups, particularly with regard to
complementary foods for children aged 6-23 months. The nutrition education activities were
implemented by Malteser International1 and Farmer Livelihood Development.2
Parallel to the MALIS project, a 5-year research project entitled: “Improving the dietary intakes and
nutritional status of infants and young children through improved food security and complementary
feeding counselling” (IMCF) was implemented by FAO in collaboration with Justus Liebig University
(JLU) Giessen, Germany and Mahidol University, Thailand. IMCF aimed to assess the effect of MALIS
project activities on children’s dietary intake, micronutrient status and growth, and to determine the
nutrition outcomes of combining agricultural production and nutrition education. The IMCF study
design included cross-sectional surveys, a longitudinal study, pre- and post-training tests, focus
group discussions (FGD), interviews, observations, blood specimens and anthropometry.
This report provides proceedings of a joint FAO/JLU Dissemination meeting held on 26th March 2015
in Phnom Penh, Cambodia, which highlighted preliminary results of the IMCF project and lessons
learned from a FAO process review of the MALIS project. Eighty participants attended the meeting
from Government at national and provincial levels, donors, United Nations (UN) agencies, Non-
Governmental Organisations (NGOs), research institutes and academia.
The IMCF research project showed that nutrition education on improved Infant and Young Child
Feeding (IYCF) practices conducted in a series of IYCF sessions with groups of 15 caregivers3 who had
a child aged less than 2 years reached 62 percent of households in the intervention areas. However,
only 23 percent of households in the intervention areas participated in the MALIS food security
intervention and IYCF sessions two years after baseline. During the study period, continued
breastfeeding rates decreased, and the prevalence of children achieving Minimum Dietary Diversity
(MDD) and Minimum Meal Frequency (MMF) improved in the intervention and comparison areas;4
however, the prevalence of children receiving a Minimum Acceptable Diet (MAD))5, 6 only improved
in the intervention areas. Household Dietary Diversity score (HDDS) and Child Dietary Diversity score
(CDDS) also increased between baseline and impact in the intervention and comparison areas. The
1 Malteser International was the implementing partner in Oddar Meanchey province.
2 Farmer Livelihood Development was the implementing partner in Preah Vihear province.
3 The term “caregiver” can refer to the person who primarily takes care of the child, e.g. mother, grandmother,
father or other relatives. 4 During the study period, many diverse activities were implemented by different NGOs in the control areas.
Hence, they were termed comparison areas instead. 5 World Health Organization (2008) Indicators for Assessing Infant and Young Child Feeding Practices, Part I –
Definitions. Geneva: World Health Organization. 6 World Health Organization (2008) Indicators for Assessing Infant and Young Child Feeding Practices, Part 2 –
Measurement. Geneva: World Health Organization.
2
results on Height-for-Age Z-score (HAZ) were puzzling as different inter and intra-provincial trends in
stunting prevalence of children aged 6-23 months were observed between baseline and impact. The
study showed that short-term nutrition education only led to small improvements in IYCF practices
and child nutritional status. It was concluded that participation in the food security intervention and
IYCF sessions needs to be better integrated at the household level in order to achieve greater
improvements in dietary diversity and nutritional status of children.
Qualitative research focused on factors leading to positive behaviour change on improved IYCF
practices. Data collection methods included knowledge tests, a longitudinal study, focus group
discussions (FGDs), interviews and observations. Results of knowledge tests showed that the
knowledge and behaviour of caregivers increased significantly after IYCF sessions. Also, the
longitudinal study revealed that after the IYCF sessions, 25 percent of caregivers prepared enriched
porridge (bobor khap krop kroeung) in the intervention areas compared to 6 percent in the
comparison areas. In addition, FGDs showed that hindering factors to improve IYCF practices were
women’s workload, women’s attitude towards child feeding, food availability and access as well as
women’s ability and motivation to turn knowledge into practice at home.
The FAO team presented results from a process review of the IYCF intervention conducted in June –
July 2014 to collect data on the MALIS project food security and nutrition education interventions,
and consolidate the lessons learned. MALIS project key strengths and challenges are listed in Table 1.
Table 1: Overview of MALIS project key strengths and challenges - results from the process review
Key words Key strengths Key challenges
Farmer field schools integration of nutrition into farmer field schools
capacities of facilitators limits effectiveness of farmer field schools
Farmer business schools
content not fitted to current needs and activities of farmers
Fairs and Input Credit integration of nutrition into agricultural fairs and farmer field days
stimulation of local business and input credit allows farmers to choose appropriate inputs, including kitchen equipment
supervision and support from Government to ensure farmer groups re-pay loans
lack of clear guidelines for farmer groups on repayment of loans
Cooperation and knowledge
good cooperation with Government on training activities
government and NGO staff’s lack of knowledge on nutrition
coordination of supervisors and reporting at the outcome level
Learning environment a practical learning environment during IYCF trainings
low facilitation skills of community nutrition promoters (CNPs)
Participants participation of grandmothers in the IYCF training
poor motivation of caregivers to change their behaviour
low participation of men in IYCF sessions7
Incentives distribution of kitchen equipment to caregivers
the expectation of health care staff and CNPs to receive incentives
7 Men were either too busy to participate in IYCF sessions or felt that the main caregiver was the mother of the
child.
3
Time the amount of time necessary for participatory cooking sessions
Knowledge on food preparation
age-appropriate amounts of ingredients required to prepare a half, nearly full or full bowl of bobor khap krop kroeung (enriched porridge)
The process review highlighted diverse training needs of MALIS, Government, NGO staff and farmer
groups with regard to nutrition education, and in relation to farmer field schools, farmer business
schools, agricultural fairs and input credit. Hence, recommendations are to: (1) increase investments
in agricultural education, particularly agronomy, and nutrition, which have been neglected sectors in
Cambodia; (2) formulate multiple strategies to change child feeding behaviour; (3) improve market
linkages for smallholder farmers; and (4) develop guidelines on disaster risk reduction, and climate
change adaptation and mitigation.
Representatives from the Council for Agriculture and Rural Development (CARD), the General
Directorate of Agriculture (GDA), Ministry of Rural Development (MRD), Ministry of Women’s Affairs
(MoWA) and Helen Keller International (HKI) provided comments on what their sector could
contribute to the nutrition of young children and families, and what the benefits would be of cross-
sectoral collaboration.
Overall recommendations of the meeting focused on: encouraging cross-sectoral coordination on
nutrition; integrating nutrition education into food security interventions at all levels and into
farming systems through agricultural extension; encouraging good cooperation and commitment for
longer term efforts to integrate nutrition into agriculture; developing a strategy for cross-sectoral
capacity building on nutrition at all levels; ensuring implementers have the knowledge and skills to
conduct training, which includes participatory cooking sessions; providing nutrition education to all
family members and generations; ensuring that caregivers are applying knowledge on improved
child feeding into their daily practice; acknowledging the key role of women in nutrition and as
caregivers; and using lessons learned from the project to improve policy and programming.
It was concluded that food-based approaches emphasising the use of locally available foods are
feasible and acceptable to families for improving child feeding and preventing malnutrition.
However, cross-sectoral efforts are needed to improve, sustain and scale-up the effective integration
of nutrition into agriculture.
In closing, GDA highlighted the successful implementation of the MALIS project with cooperation of
different ministries and coordinated by CARD. The importance of improving children’s diet and
health was underscored to prevent stunting as well as overweight. Recommendations included:
disseminating consistent, easily understandable information on sustainable, modern agriculture
technologies; improving living conditions (particularly sanitation) and women’s empowerment; and
strengthening cooperation and coordination among stakeholders.
4
1. Opening session8
Eighty participants attended the National Dissemination meeting from Government at national and
provincial levels, donors, United Nations (UN) agencies, Non-Governmental Organisations (NGOs),
research institutes and academia (Annex 2). Ms Doung Chansereivisal, FAO Agribusiness and Post-
Harvest Specialist, Siem Reap Province thanked the participants for attending and introduced the
five guests of honour: Honourable Excellency Dr Ty Sokhun (Secretary of State for the Ministry of
Agriculture, Forestry and Fisheries (MAFF)), Ms Fiona Ramsey (European Union (EU) Representative),
Ms Nina Brandstrup (FAO Cambodia Representative), Honourable Excellency Professor Koum Kanal
(Council for Agriculture and Rural Development (CARD)) and Professor Michael Krawinkel (Justus
Liebig University (JLU), Giessen, Germany). She then provided a short summary of the day’s activities
and invited the Honourable Excellencies and all other participants to stand for the National Anthem.
Ms Nina Brandstrup, FAO Cambodia Representative, provided the welcome speech thanking all
MALIS staff for successful project implementation. Results from Oddar Meanchey (OMC) and Preah
Vihear (PVR) provinces show that combining food security and nutrition education interventions to
improve complementary feeding can be effective using a food-based approach. However,
coordination, capacity building and good targeting are key. Ms Brandstrup highlighted four points
from the March 2015 National Conference on Nutrition in Cambodia and summarised the main
points and lessons that could be drawn from the MALIS and IMCF projects:
(1) Continued need to address malnutrition: national stunting rates for children under the age of five
are still high and this is not acceptable;
(2) Multi-sectoral collaboration: to address malnutrition there is a need for action on all fronts
involving agriculture, health, education, social affairs and economic development;
(3) Need for evidence-based policies: it is important to have good evidence to develop policies,
programmes and initiatives that can effectively address the multiple causes of malnutrition
throughout the life cycle, with particular focus on the first 1,000 days;
(4) Continued commitment: the profile of nutrition needs to be raised in relevant national and sub-
national strategies, policies, action plans and programmes, with budgets aligned accordingly and the
Government needs to sustain its commitment.
Ms Fiona Ramsey, EU Representative, spoke on behalf of the European Delegation. She underlined
that the children of today are the next generation of leaders, decision makers and entrepreneurs.
Yet, insufficient nutrition in the first 1,000 days of their lives hinders children’s brain development
and prevents them from reaching their full cognitive potential. In the recent Nutrition Summit, the
multi-dimensional root causes of malnutrition were clearly acknowledged. The Government declared
nine priorities for action in fighting malnutrition. The EU emphasised its readiness to work with
Cambodia to address malnutrition through partnerships. Under the European Development
Cooperation Strategy for Cambodia 2014-2018, the EU and EU Member States have committed
themselves to providing continued support in health, nutrition and social protection. She stated that
this meeting provides an opportunity to review the findings from the MALIS project and to better
understand ‘What Works’ for nutrition based on rigorous monitoring and research. Such evidence-
based work is critical for the future design and scaling-up of effective nutrition interventions.
8
The National Dissemination meeting programme is provided in Annex 1.
5
His Excellency Dr Ty Sokhun, Secretary of State for the MAFF, presided over and formally opened the
National Dissemination meeting. He underlined that even though the world has sufficient capacities
and technology to feed everyone, hundreds of millions of people are still facing malnutrition.
Challenges for Cambodia are soil erosion and lack of water for irrigation, while at the same time the
number of farms decreases. Nevertheless, the population is growing and demands nutritious foods.
As 2015 is the Year of the Soils, he underscored the importance of healthy soils in order to have
healthy food that can contribute to good human health. This can be achieved through learning from
traditional knowledge, reversing the loss of biodiversity and placing emphasis on sustainable
agriculture. To-date, Cambodia has concentrated on monocultures and rice production. He
highlighted the need for a broader approach and the promotion of diversified agricultural
production and emphasised that MALIS followed Government policy and the National Food Security
and Nutrition strategy. He underlined the Government’s policy of diversification and modernisation
of agriculture to improve food and nutrition security, and to prevent malnutrition. He also stressed
that women are key for development and must have the legal right to decide what crops to plant
and which animals to breed. He concluded by saying that MALIS has strong participation from
women and therefore he sees the project as a model for agricultural programmes.
6
2. Session 1: Overview of the MALIS project - FAO food security and nutrition
project
Mr Oum Kosal, FAO Cambodia Assistant Representative, welcomed everyone and chaired the first
session of this important meeting.
2.1. Aims of the meeting
Specific aims of the National Dissemination meeting presented by Dr Elizabeth Westaway,
International Nutrition Consultant, FAO Headquarters, were to:
● Bring together Government representatives, development partners and other interested
stakeholders in food and nutrition security in Cambodia
● Share IMCF research results and lessons learned from the MALIS project for review and
discussion
● Capture ideas for future directions and distil specific recommendations from the IMCF research
to inform programme and policy design
● Integrate feedback from the meeting into the final steps of IMCF research and MALIS project
documentation and dissemination activities.
2.2. Overview of the MALIS project
Dr Iean Russell, FAO MALIS Project Manager, provided an overview of the MALIS project, which was
funded by the EU and implemented by FAO in partnership with the General Directorate of
Agriculture of the MAFF from January 2012 – June 2015. The provincial partners included the
Provincial Department of Agriculture (PDA), Provincial Department of Women’s Affairs (PDoWA),
Provincial Health Department (PHD) and local and international NGOs. The approach was to work
through existing farmer groups in nine target districts in the two provinces of PVR and OMC.
The main aim of the project was to strengthen farmer groups and market linkages, through
increased food security (availability of foods in farming households) and nutrition (increased growth
of children). There were many project activities comprising farmer field schools, disaster risk
reduction; market linkages for smallholders through farmer business schools,9 agricultural fairs and
input credit for 49 farmer groups; nutrition education and the provision of kitchen equipment (to
help caregivers prepare nutritious food); strengthening farmer groups; and capacity building
(essentially for farmer groups but also for partner staff).
The project did not target the poorest of the poor, as they are landless, but worked with farmers and
small enterprises to increase resilience. Farmer field schools were conducted under a ‘Save and
Grow’ approach reaching 3,750 households. The topics were production of rice, cassava and
vegetables, and raising chickens as well as several cross-cutting themes including nutrition, disaster
risk reduction, gender mainstreaming, business and postharvest training.
9 Farmer business schools use the same philosophy as farmer field schools but are more business oriented.
7
Farmer business schools involved working with 20 existing farmer groups that were selected for
their commitment and performance using a flexible approach to meet farmers’ needs. The project
distributed over 1 million USD of equipment and approximately 700,000 USD worth of inputs to
smallholder farmers through agricultural fairs and input credit, working through farmer groups and
agricultural cooperatives. The agricultural fairs were a novel approach used for the first time by FAO
in Cambodia, which delivered a range of products under a voucher system that provided access to
seed, fertiliser, tools, machinery and kitchen equipment on a credit basis.
Disaster risk reduction activities involved community consultations at village and commune level; the
creation of a Menu of Options for Disaster Risk Reduction in Agriculture, tested in the farmer field
schools; vulnerability mapping; and provision of water tanks, assistance with home gardens and drip
irrigation systems. The water tanks were targeted at caregivers who received nutrition education,
with the aim of improving fresh water supply, family hygiene and providing water for home gardens.
Other activities focused on strengthening of organisations and institutions through capacity building
for all partner agencies and training of 49 community-based organisations to manage credit, keep
financial records and conduct planning. PDoWA was trained in gender mainstreaming which was
promoted in all project activities.
Nutrition education and information, education and communication (IEC) materials were provided at
provincial, district, commune and village level. Over 1,380 caregivers participated in infant and
young child feeding (IYCF) sessions designed to improve complementary feeding practices and basic
hygiene.
In terms of project success and future sustainability of project outcomes, the core units were the
farm households and the farmer groups. These were strengthened through the provision of inputs,
recovery and re-investment of over 400,000 USD from input credit. Recovery rates were 99.6
percent. This was an excellent result and a reflection of the honesty of farmers and their social
network as well as through the assistance of the Government from the community up.
Ms Theresa Jeremias, FAO Nutrition Officer, provided an overview of the nutrition education
activities in the MALIS project. According to the 2014 Cambodia Demographic and Health Survey,10
the country has a high burden of chronic undernutrition with 32.4 percent of children under 5 years
being stunted. Key contributory factors are poor IYCF practices including insufficient quantity and
quality of complementary foods, poor hygiene and sanitation, and lack of awareness, knowledge and
skills among service providers, caregivers and other family members. The first 1,000 days of life
provide a ‘window of opportunity’ to address and prevent stunting, and ensure that children can
develop their full potential through: exclusive breastfeeding for the first 6 months; continued
breastfeeding up to 2 years of age; adequate, safe and appropriate complementary feeding from 6-
23 months; and good water, sanitation and hygiene.
There is no single best approach to tackle malnutrition and there is a need to ensure that children
get the best possible nutrition during the early years. While food and nutrient supplements are key
for treating and addressing malnutrition, their exclusive use for prevention may not be sustainable.
More emphasis is needed on food and agricultural solutions by raising agricultural production and
10
National Institute of Statistics, Directorate General for Health, and ICF International (2015) Cambodia Demographic and Health Survey 2014. Key Indicators Report. Phnom Penh and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health and ICF International.
8
incomes, and diversifying the food supply as key pillars for improved family and young child
nutrition. Hence, there is ample scope for supporting households to diversify food production and
incomes, and helping them to make better use of nutrient-rich locally available foods for improving
the quality of household diets, at the same time as reinforcing and sustaining local food culture.
Agricultural production in Cambodia focuses mainly on cereals, such as rice, and fruit and livestock
production are limited, which results in high costs of fruit and animal source foods. In addition,
seasonality not only reduces the availability and accessibility of food, which is particularly felt in the
dry season, but also exacerbates women’s time constraints for food preparation, especially during
periods with a high workload, such as the rice transplanting season, and often results in family diets
that contain only a limited range of foods. To make matters worse, knowledge and skills among
service providers and families on age-appropriate feeding is limited. Hence, the MALIS project aimed
to tackle both problems simultaneously by helping families to improve their food security whilst also
engaging them in practical learning about young child nutrition. Mechanisms used were farmer field
schools and farmer business schools, and IYCF sessions.
Key nutrition education activities included (Annex 3): ● Formative research was carried out in 2010/11 prior to the MALIS project.11
● Adaptation of available nutrition education materials12 and development of IEC materials: Baby-
friendly Community Initiative Flipchart; facilitator’s guide; four posters (1) hygiene and food
preparation; (2) food safety; (3) recipes; and (4) age-appropriate quantity and feeding
frequency.
● Training/sensitisation: training of trainers was conducted in July 2013 by staff from the National
Nutrition Programme (NNP) and two FAO nutritionists who teamed up with staff from PHD,
District Health Centres, PDoWA and NGO implementing partners. Following sensitisation of
supervisors and local leaders, in August 2013, training was conducted of frontline workers from
health and volunteer members of the Village Health Support Groups (termed Community
Nutrition Promoters [CNPs] by the MALIS project).
● Community-based IYCF sessions: were conducted with caregivers, which included participatory
cooking sessions. In Phase 1 (August 2013- January 2014), two CNPs per village held seven
weekly IYCF sessions13 with a maximum group of 15 caregivers who had a child aged 5-18
months (on recruitment), pregnant women and women of reproductive age. In Phase 2 (April
2014 – March 2015), one NGO staff member acted as the main trainer and two CNPs as
assistants for the IYCF sessions. Technical support on health topics and on gender was provided
11
Under the EU Food Facility Project, Trials of Improved Practices (TIPs) were undertaken with caregivers in
different provinces of Cambodia over two seasons to test the feasibility and acceptability of enriched porridge recipes for complementary feeding using different locally available foods. 12
In 2012, the National Nutrition Programme introduced the Communication for Behavioural Impact (COMBI)
material: which included a manual for Community Nutrition Promoters (CNPs) based on the updated Baby-friendly community initiative flipchart; educational posters were produced in the course of trainings that responded to the needs of caregivers and CNPs. 13
The seven IYCF sessions provided nutrition education on the following topics: (1) good diet for the family; (2) preparation of bobor khap krop kroeung (thick and multi-ingredient porridge); (3) dietary diversity; (4) hygiene and food safety; (5) continuing breastfeeding and age-appropriate complementary feeding; (6) complementary feeding from family foods; and (7) feeding a sick child.
9
by PHD and PDoWA staff, respectively. In addition, the participatory cooking sessions14
imparted practical skills on how to make bobor khap krop kroeung (enriched porridge).
● A one-day complementary feeding campaign was conducted in November 2013 to promote
improved IYCF practices in the communities. This was followed by a seven-day distribution of
bobor khap krop kroeung free of charge to children aged 6-23 months three times per day in
villages within the two provinces.
● Kitchen equipment:15 was distributed to participants of IYCF sessions to encourage adoption of
improved feeding and hygiene practices at home.
● Monitoring, supervision and reporting: was conducted mainly by NGO implementing partners,
with the support of staff from PHD, District Health Centres, PDoWA as well as the MALIS
nutrition team.
● Sharing meetings with caregivers and home visits: were carried out in Phase 2 by NGO and
MALIS staff to assess change in knowledge, attitude and practice (KAP).
The nutrition education intervention was implemented in two phases: Phase 1 (August - December
2013) and Phase 2 (May 2014 - February 2015) in OMC and PVR. In Phase 1, IYCF sessions were
conducted in 35 villages with 449 caregiver/child pairs by CNPs who were supported by trainers from
PHD, PDoWA and NGOS. In Phase 2, IYCF sessions were carried out for a second cohort of caregivers
in the initial 35 villages and an additional 29 villages with 939 caregiver/child pairs by NGO trainers
with support from PHD, PDoWA and CNPs. The nutrition education intervention was implemented in
a total of 64 villages and involved training a total of 153 CNPs and 1,386 caregiver/child pairs whose
average attendance rate was 77 percent.
While the nutrition education activities were being conducted in Phase 1, the IMCF16 research
project was gathering data to assess the effect of the activities on children’s diets, micronutrient
status and growth. Few studies have documented the links between diversified agricultural
production and nutrition education, using scientifically robust methods. The IMCF project set out to
fill this gap with the aim of contributing to our understanding on the links between agriculture and
nutrition.
14
Four participatory cooking sessions were held during IYCF sessions 3, 4, 5 and 6. 15
Kitchen equipment distributed to caregivers included: energy saving stove, kettle, food cover net, water bucket, dish rack with cover, large pot with lid, soap and dipper. 16
JLU researchers conducted the 5-year research project entitled: “Improving the dietary intakes and
nutritional status of infants and young children through improved food security and complementary feeding counselling” (IMCF).
Outmigration of women and men is a big challenge
“The Ministry of Women’s Affairs works in areas with high rates of stunting. One of the big
challenges we face in rural areas is migration, both of mothers and fathers, to urban areas or
abroad. Another problem is women’s high workload. Women take an active part in economic
activities to feed the whole family. Hence, it is good to include grandmothers as well as
extended family members, such as grandfathers, grandmothers and aunties in nutrition
education.”
Her Excellency, Dr Kantha Phavi Ing, Minister of Women’s Affairs
10
Discussion: How does the MALIS credit scheme work? – MALIS explained that intensive consultation was
conducted through farmer groups to understand their needs. Subsequently, a list of input
requirements was developed for the coming agricultural season. There were four different rounds of
input credit over different years and different points in the agricultural seasons. The farmers decided
what inputs they wanted and the amount of credit they wanted to take, i.e. 20-150 USD and they
were required to pay back 60 percent to the farmer group after the harvest. This was supervised
closely by the management committee. However, the scheme needs Government commitment and
firm community support.
Regarding nutrition education, you only trained health staff like PHDs, Operational District Officers
and village health support groups. When we talk about collaboration in the future, we should also
think about training the agriculture sector on key aspects of nutrition to ensure a minimum
knowledge of nutrition – FAO replied that in addition to health staff, agricultural extension and
PDoWA staff were also trained on how to facilitate IYCF sessions. There was a specific focus on
training farmer field schools and farmer business school facilitators on the three nutrition modules
in the farmer field school curriculum. However, it was agreed that there is a need for strengthening
further training of agricultural extension staff in nutrition to build their knowledge and skills in food-
related nutrition aspects to combat malnutrition in Cambodia.
How do you ensure that all farmer groups that received the loan select the right crops with good
nutrition for their children? –MALIS remarked that the market approach leads to farmers wanting to
grow rice and cassava, which are not particularly rich in the vitamins and minerals needed to combat
malnutrition. However, the farmer field schools had two approaches: (1) commercial (mostly rice
and cassava); and (2) food security, which were directed at encouraging homestead production of
nutrient-dense food sources, such as vegetables and chickens to contribute to household nutrition
needs (which is not a commercial enterprise). FAO Cambodia also carried out a Telefood project in
combination with the MALIS project, which promoted nutrient-rich fruit and vegetable crops to
improve household nutrition. The evidence of commercial success was shown by the example of
eight cooperatives in PVR that sold 1,200 tons of organic rice for export in 2014, which
demonstrated the sustainability of the commercial farming. The MALIS evaluation will assess the
extent to which the project raised rice and cassava yields.
How do you connect the provision of inputs and the process of training? How do you know that
mothers really make use of the knowledge gained during the IYCF sessions? What is the theory of
change? In project design, how did you determine the elements that would contribute to good
nutrition, and how did you assess that nutrition was improved? – FAO responded that caregivers
were recruited from farmer field schools to ensure that households would receive agricultural
inputs, training and practical nutrition education as part of a comprehensive package. The
assumption was that the combination of support, agricultural inputs, knowledge and skills, together
with the kitchen equipment would enable caregivers to: 1) have access to a wider range of
micronutrient rich foods; 2) use the knowledge and skills gained to prepare the bobor khap krop
kroeung; 3) recognise the benefits; and 4) feel motivated to continue. To assess whether or not, and
the extent to which behaviour change took place, will be reviewed during the next session.
A lot of trainings on food-based approaches have been conducted; do you have any evidence of
behaviour change? –MALIS replied that findings will be presented by JLU, but from the monitoring
11
that was undertaken there is evidence that some mothers changed their behaviour and cooked
bobor khap krop kroeung 3-4 times per week.
Were the farmer groups pre-existing or formed by FAO? In relation to the credit scheme, have you
looked at how to integrate ongoing credit availability into community activities? –MALIS explained
that initial assessment found that there were enough existing farmer groups in the target provinces
to start project activities and cover the target population. However, farmer groups have since
increased in number, membership and capability. We did not want to form or label any groups as
'MALIS groups' as the existing ‘savings and credit groups’ had been created by other projects and
had an established identity. The MALIS project focused on supporting the existing groups,
particularly those organisations previously working under the EU Food Facility project. The aim of
the MALIS project input credit was to provide a single round of credit and to recover the agreed
percentage, leaving the money in the groups' bank accounts. In many cases, 2 rounds of credit were
conducted within the project period. Thus FAO Cambodia has some confidence that they will lend
out again as part of their ongoing group activities.
12
3. Session 2: Applied research in the context of an FAO food security and nutrition
project - Findings of the IMCF project
The second session was chaired by Dr Pattanee Winichagoon, Mahidol University, Thailand and
Professor Michael Krawinkel, JLU Giessen, Germany.
3.1. Overview of the research “Improving the dietary intakes and nutritional
status of infants and young children through improved food security and
complementary feeding counselling”
Dr Irmgard Jordan, Research Fellow and Co-Principal Investigator from JLU, presented the IMCF
research project conducted by JLU and Mahidol University.17 The IMCF research has four
hypotheses:
1. TIPs formative research generates behaviour change communication messages and
nutritionally improved recipes that lead to lasting improvements in complementary feeding
practices, dietary intakes and child nutritional status
2. Locally available and affordable foods can provide a significant contribution to the nutritional
requirements of children aged 6-23 months
3. Nutrition education with a focus on IYCF and linked with a food security intervention can
improve child feeding practices and nutritional status
4. Using locally available foods for improving complementary feeding practices and children’s
nutritional status is a sustainable strategy which can be replicated by households at low cost
and taken to scale using available Government services
The IMCF study design18 was as follows:
Table 2: IMCF study design and dates of assessment
Research method
Date Description
Cross-sectional Baseline survey
September - October 2012
The following data was collected from 1,028 households selected in a two stage cluster sampling with proportional to population size (PPS) in 16 MALIS communes: ● Interview with standardised questionnaire:
o Socio-economic status o Sanitation, hygiene, access to health facilities o Breastfeeding and complementary feeding practices o Dietary Diversity Score (household and child) o Child health o Household Hunger Scale o Motor milestones (child)
● Anthropometric measurements (parents and child) ● Haemoglobin levels (mother and child) ● Blood plasma for iron and vitamin A status (child)
Cluster randomisation
October 2012 Communes targeted for the MALIS food security intervention were assigned into intervention and comparison communes through restricted cluster randomisation. ● Ten intervention communes: villages targeted by the MALIS food security
17
The IMCF project also includes a similar study in Malawi on a FAO nutrition-sensitive agriculture project in collaboration with Lilongwe University of Agriculture and Natural Resources (LUANAR). 18
The study is registered at the German Clinical Trial Register (DRKS): https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do
13
intervention and MALIS IYCF sessions ● Five comparison communes: villages targeted by the MALIS food security
intervention only Impact pathway analysis
August 2013 – September 2014
Pre- and post-training knowledge tests in all training levels (Master Trainers, CNPs and caregivers) prior to, one week after and 8 months after the IYCF sessions; Focus Group Discussions (FGDs) with primary caregivers; observations on trainings, including IYCF groups and interviews with primary caregivers and other key stakeholders
Longitudinal study
August 2013 - August 2014
Data was collected every three months on a cohort of children in intervention and comparison areas
19
Cross-sectional impact survey
September - October 2014
The survey was conducted as a census in all project villages in the area targeted by MALIS in the first year of project implementation. It followed up on the potential impact of IYCF sessions and the food security intervention on dietary behaviour, nutritional status of children < 24 months, motor milestones, and micronutrient status
20
3.2. Impact of food security intervention and nutrition education – results from
baseline and impact survey
Ms Anika Reinbott, PhD Student from JLU, presented the quantitative results of the IMCF research.
After the baseline survey in September 2012, the MALIS communes were assigned to intervention
and comparison21 groups through restricted randomisation (Figure 1). The intervention group
consisted of ten MALIS communes that were targeted by the MALIS food security intervention and
nutrition education intervention. The comparison group consisted of five communes that were
targeted only by the MALIS food security intervention.
19
Eligibility criteria in the intervention area were: 1. Participant in the nutrition education intervention, 2. Mother with a child 6 < 9 months of age. Eligibility criteria for the comparison area: 1. Mother with a child matched by age and sex with a child from the intervention group. 20
The impact survey collected the same data as per the baseline surveys in a census of 1,176 households in 15 MALIS communes. However, the Household Food Insecurity Access Scale (HFIAS) was used instead of the household hunger scale. http://www.fao.org/fileadmin/user_upload/eufao-fsi4dm/doc-training/hfias.pdf 21
MALIS communes in the comparison group cannot be controlled due to the wide range of other development activities that took place independently from the MALIS project.
14
The impact survey results showed that 35 percent of households in the intervention areas and 22
percent of households in the comparison areas had participated in the MALIS food security
intervention, respectively. The IYCF sessions reached 62 percent of households in the intervention
areas. However, only 23 percent of households in the intervention areas participated in the MALIS
food security intervention and the nutrition education. Maternal education (ME) and Household
Dietary Diversity score (HDDS) increased in both provinces between baseline and impact (PVR: MEBL
3.4 – MEIS 4.3 and HDDSBL 6.2 - HDDSIS 7.5; OMC: MEBL 3.7 – MEIS 4.4; and HDDSBL 7.3 - HDDSIS 8.0).
Also, access to improved sanitation facilities increased significantly in both provinces during the
same period. However, in OMC this was indirectly linked to improved hygiene practices and
decreased prevalence of diarrhoea (Table 3).
Table 3: Access to protected drinking water sources and safe sanitation facilities per survey and province in the intervention and comparison areas
Preah Vihear Oddar Meanchey
Baseline Impact Baseline Impact
Comp Int Comp Int Comp Int Comp Int
Total (n) 126 246 241 287 190 298 282 365 Protected source of drinking water (%)
87 84 88 84 85 90 88 89
Improved sanitation facility (%)
22 4 25 13 21 27 33 42
Baseline: September 2012, Impact: September 2014; Comp.: comparison area; Int.: Intervention area
Continued breastfeeding rates decreased from baseline to impact in both the intervention and
comparison areas, and especially in children aged 20-23 months. The WHO indicators MDD and
MMF improved in intervention and comparison areas of both provinces. However, the prevalence of
children that achieved MAD increased significantly in intervention areas overall. HDDS increased in
intervention and comparison areas in both provinces between baseline and impact. With regard to
Figure 1: Map of project and research areas
15
Child Dietary Diversity score (CDDS), the Differences in Difference (DiD) estimator22 showed a
significant positive intervention effect on the CDDS: 3.9 in intervention areas as compared to 3.6 in
comparison areas, which was mainly attributable to an increased consumption of legumes and pro-
vitamin A rich foods. However, the number of households preparing bobor khap krop kroeung
remained low, especially for children aged 9-12 months: 29.5 percent of households in intervention
areas and 8.5 percent of households in comparison areas with children aged 9-12 months prepared
bobor khap krop kroeung on the day prior to assessment. In addition, the volumes fed per meal were
lower than recommended (usually less than ½ bowl) and the consumption of sugary foods and
snacks was high. Different inter and intra-provincial stunting prevalence trends were observed
between baseline and impact. In OMC, stunting prevalence increased to 28 percent in intervention
areas and 25 percent in comparison areas; however, the overall increase was 3 percent less in the
intervention area compared to the comparison area. While in PVR, stunting prevalence decreased to
22 percent in intervention and comparison areas, but the overall decrease was 2 percent more in the
intervention area compared to the comparison area (Figure 2).
Figure 2: Stunting prevalence of children aged 6-23 months in intervention and comparison areas of OMC and PVR
provinces
The following conclusions were made: (1) the overlap of food security and nutrition education
interventions was limited and needs to be increased; (2) short-term nutrition education led to small
improvements in IYCF practices and child nutritional status only; and (3) it is important to try and
provide further insights into the rather puzzling results related to trends in stunting prevalence. It
was recommended that nutrition education not only focuses on diet quality but also on age-
appropriate quantities.
22
The differences in difference estimator considers possible differences at baseline between intervention and comparison groups, and assumes that both groups would develop similarly in the absence of any intervention.
16
3.3. Behaviour change for improving infant and young child feeding practices –
results from a qualitative study
Dr Irmgard Jordan, JLU, and Mr Mav Khun, Mahidol University, presented qualitative research results
on factors leading to positive behaviour change on improved IYCF practices. Data collection methods
included knowledge tests, a longitudinal study, FGDs, interviews and observations.23 The knowledge
tests were conducted prior to and immediately after the trainings at all levels including master
trainers (MTs), CNPs and caregivers. At primary caregiver level, another knowledge test was
conducted 8 months after the training. The test results were summarised in two knowledge scores
(Table 4):
Table 4: Knowledge scores of primary caregivers, MTs and CNPs
Score
1) Knowledge of foods 2) Knowledge of IYCF practices
Contents Food groups, iron and vitamin A rich foods, nutritious snacks
breastfeeding practices; consistency of porridge, feeding practices of sick children, hygiene practices especially during food preparation and feeding
Primary Caregiver results
● In the mean households achieved approximately 50 percent of possible score prior to the nutrition education
● Increased significantly after nutrition education, but did not reach 100 percent
● In the mean households achieved approximately 70 percent of possible score prior to the nutrition education
● Increased significantly at second post-test only, reaching 95 percent in some villages.
MT results Data analysis ongoing CNPs results Data analysis ongoing
A cross-lagged panel analysis showed that the nutrition education successfully linked knowledge on
food with knowledge on recommended IYCF practices, although this link was weak prior to the
nutrition education. Follow up on whether caregivers applied the knowledge at home was
undertaken in the longitudinal study, FGDs, and interviews. Results from the longitudinal study
showed that after the nutrition education 25 percent of caregivers prepared bobor khap krop
kroeung in the intervention group compared to 6 percent in the comparison group when the
children were 9 < 12 months old. However, three months later only 14 percent of caregivers
prepared bobor khap krop kroeung in the intervention group while the level remained the same in
the comparison group. The most often cited reason for not preparing bobor khap krop kroeung was
“lack of time” and this was followed up by conducting four FGDs with 5-6 primary caregivers in
MALIS villages. Results showed that “lack of time” was a proxy for women’s overall workload,
women’s attitude towards child feeding, food availability and accessibility as well as women’s ability
to put theory into practice. This was also confirmed during interviews with mothers after completing
the IYCF sessions (data analysis is ongoing). One mother reported: “I sometimes bought porridge
from the market because I did not have enough time to prepare bobor khap krop kroeung.” Another
mother remarked that family food was easier to provide: “the child does not eat much and [I am]
also lazy to prepare [bobor khap krop kroeung]; just give family food”. It was found that family food
was given quite early to the children at 9 months of age and the taste may have influenced the
mothers’ decision to continue preparing bobor khap krop kroeung as they were used to spicier
family food. In conclusion, mothers had a heavy daily workload which minimised time available for
23
A full day was spent at each household observing the mother’s behaviour.
17
childcare; however, they often received support from the child’s grandmother. Mothers faced a
number of challenges to adopting improved IYCF practices, which included: lack of knowledge, poor
food availability, and unfamiliarly and under-utilisation of traditional local foods. Nevertheless,
mothers appreciated learning how to put new knowledge and skills into practice at home; however,
behaviour change was determined by their child’s acceptance of bobor khap krop kroeung.
The co-chair, Dr Pattanee Winichagoon remarked that the presentations showed that knowledge
improved; however, for mothers to adopt recommended IYCF practices, additional support was
needed. The question therefore remains: how can we achieve appropriate behaviours?
The meeting was graced with the presence of Her Excellency, Dr Kantha Phavi Ing, Minister of
Women’s Affairs and the co-chair, Professor Michael Krawinkel asked her to speak about gender and
the importance of prioritising nutrition. Her invaluable insights are included throughout this report.
Discussion
Why did you observe training sessions in the community rather than cooking at home? – JLU
explained that the project started with training NGO and community-based workers. Given that they
are an important player in the behaviour change process, assessing their knowledge and capacities
therefore constitutes an important part of the analysis. Mahidol University clarified that the IYCF
sessions with mothers and other caregivers were delivered through village volunteers and these
were part of the education process. Nevertheless, individual household visits would have been ideal
but could not be conducted owing to lack of time and capacities of the study team.
What is the reason for the reduction in breastfeeding rate, according to the Cambodia Demographic
and Health Survey? – JLU remarked that the research did not focus on breastfeeding, but on
complementary feeding, and continued breastfeeding was a topic, but there may not have been
sufficient emphasis to explain the decline in breast feeding rate. In addition, the environment is not
conducive to breastfeeding because there is high migration of mothers; also many mothers work in
agriculture and are busy planting rice. Hence, they face many challenges to continue breastfeeding.
Why is the stunting rate different in the two provinces? – JLU concurred that the results were
puzzling and there is a need for further analysis to explain the differences in malnutrition
prevalence, particularly as there was increased wasting in both provinces. It was postulated that
there may be a link with sanitation and diarrhoea, which is less prevalent in other provinces of
Cambodia. JLU remarked that additional factors may have affected stunting. For example, migration
rates of mothers are different: OMC more than in PVH (at impact survey approximately 5 percent
Mothers need to see results, otherwise they lose confidence!
“In terms of village solidarity, it is important to include all women in the village to ensure they
have the knowledge and skills to change their behaviour. Hence, to attract women to become
more involved, there is a need to share best practices on hygiene, nutrition and healthy eating.
It is very motivating for mothers when they see that their child is healthy and well nourished.
The women need to see results otherwise they lose confidence and hope, and they say that the
programme is useless. They need to see quick results to continue good practices.”
Her Excellency, Dr Kantha Phavi Ing, Minister of Women’s Affairs
18
and 0.7 percent respectively), and in the case of migration grandmothers are more involved in child
care possibly affecting breastfeeding rates and quality of infant and young child feeding.
Additionally, a different NGO was implementing the MALIS project on behalf of FAO in each
province. Furthermore, several other NGOs were providing assistance to communities in the area of
nutrition (e.g. micronutrient powder “sprinkles”), which the research did not specifically look at. So it
is not possible to give a definitive answer.
Helen Keller International (HKI) thanked JLU for the very interesting presentations on
complementary feeding. They had similar findings, indicating that dietary diversity is a very good
indicator. However, they found that the total amount of food fed per feed and per day was not
sufficient in terms of volume and kcals for the age of the child, and had investigated whether the
problem was the measurement used to quantify foods. Hence, they tried out the recommended
amounts with mothers and provided measuring bowls, but found it complicated.
How can the measurement issue be addressed? – JLU stated that they had asked caregivers about
the volume of food that was fed using local measuring tools. However, a reporting bias cannot be
excluded as caregivers sometimes leave the child on its own while eating, thus, the amount of food
the child consumed might not be exactly known by the caregiver. JLU acknowledged that the best
method would be to observe the entire feeding process by measuring the total quantity before and
after feeding. However, this was not done. Although JLU did undertake household observations on
the mothers’ activities, general feeding and childcare as well as on the household water source and
sanitary environment.
Did you also include gender sensitisation to this process? You recommended including grandmothers
but fathers should also be included, particularly as women have a high workload in the home and
fathers should see this – JLU replied that this question would be answered in the afternoon session
and pointed out that the research team had not been responsible for gender sensitisation.
The conclusions mention women’s heavy workload. Are there other reasons that hinder behaviour
change/nutrition improvement? – JLU replied that a study based on FGDs of hindering and
facilitating factors for change in IYCF practices will be published at a later stage.
How can you conclude that the results are attributable to the design of the intervention? – JLU
commented that this question is difficult to answer definitively given the lack of a proper control
group. We decided to call it a comparison area as many activities in addition to the food security
activities supported by MALIS were going on. In order to assess these and to try to gauge their
potential influence, we attempted to map all nutrition support activities that were taking place by
location and by organisation. We also reviewed the sources of the nutrition education messages that
caregivers received and were able to identify a recall bias among caregivers. They were confused
about the source of the information, whether it came from a representative of the MALIS project or
a health worker from MoH, and may have received nutrition information to promote the
consumption of micronutrient powder “sprinkles” during attendance at clinics and health centres. As
MALIS had no nutrition education activities in the comparison areas, we do not know if any of the
intervention effects can be related to either MALIS food security or nutrition support provided by
other agencies. However, data from the intervention areas has shown that food security activities
improved dietary diversity and that the provision of nutrition education also increased dietary
diversity independently; particularly as this improvement was greater in the intervention area where
both activities were conducted. JLU undertook a census at the endline, indicating that the results
19
were truly representative as they included all the caregivers. However, it must be remembered that
the MALIS intervention was just one-year in duration. To enable us to demonstrate a possible
decrease in stunting, a longer intervention would be needed.
What is the influence of industrialised food in the project area? – JLU concurred that there was an
increased preference for commercial foods. Therefore, snacks were included in the 24 hour recall
and a range of sugar-sweetened foods, packaged cakes, crackers and snacks were identified. In the
longitudinal study it was observed that commercially prepared porridge was available but only a few
mothers used it. Mahidol University commented that commercially enriched bobor khap krop
kroeung is sold in a pack. However, some mothers said that their children vomited or had diarrhoea
after eating these foods. JLU added that currently there is no regulation for commercially produced
infant foods. Hence, there is a need to help mothers resist the marketing pressure for expensive
food products and show that they can feed their children well using cheaper locally available foods.
Did you observe siblings help with care/feeding as they would need to be included in the IYCF
sessions? – Mahidol University replied that when mothers leave the home, the child is left in the
care of other relatives. Therefore, it is important for family and extended family members to learn
how to feed children well, particularly as more mothers are migrating.
20
4. Session 3: Lessons learned and Implications on future programmes
The third session was chaired by Mr Ngin Chhay, Deputy Director, Rice Crop Department of GDA,
MAFF.
4.1. FAO Nutrition Education Process Review24
Ms Theresa Jeremias, Nutrition Officer, FAO Headquarters, presented findings of a process review of
the MALIS nutrition education intervention conducted during June - July 2014.25 Its objectives were:
(i) to collect data on the MALIS food security and nutrition education activities, and their links to
determine what had and had not worked well, and (ii) to develop lessons learned to inform future
programme and policy design.
The process review was undertaken on both phases of the MALIS project in purposively selected
districts and IYCF villages in OMC and PVR provinces, and focused on issues related to targeting,
coordination and collaboration among stakeholders. Data collection methods included 14
interviews26 and six FGDs.27
The following good practices were identified:
1. Caregivers with children aged 5-18 months (on recruitment) were recruited from farmer field
schools or community-based organisations as a priority: which strengthened the link between
food security activities and the nutrition education intervention
2. Three nutrition modules were integrated into farmer field schools: (1) the importance of dietary
diversification; (2) benefits of home gardens; and (3) selection of nutritious crops for home
gardens were implemented in Phase 2 farmer field schools
3. Nutrition education was integrated into agricultural fairs and farmer field days: implementing
partners organised tasting of bobor khap krop kroeung based on locally available foods and
promoted wider awareness of improved IYCF practices amongst the target population28
4. Good cooperation with Government on their capacity building role: National Nutrition
Programme master trainers conducted training of trainers for staff of the PHD, District Health
Centres, PDoWA and NGO partners, who then trained CNPs
5. Capacity building of Government and NGO staff, and village health support groups in nutrition:
several different types of nutrition education training courses were conducted, which included
initial training of trainers and training of CNPs, refresher trainings, and on-the-job trainings;
training on nutrition modules for FFS facilitators and PDoWA staff; as well as training on KAP
24
The MALIS nutrition education intervention process review report is forthcoming. 25
The MALIS nutrition education intervention process review was conducted by Dr Elizabeth Westaway (International Nutrition Consultant, FAO Headquarters) and Ms Theresa Jeremias (Nutrition Officer, FAO Cambodia) with support from Ms Sreymom Oy (Research Assistant) and the MALIS project team during June - July 2014. 26
Interviews were held with: MALIS project staff, NGO staff, national and provincial government staff, and caregivers (from Phase I). 27
FGDs were conducted with: caregivers (Phase I and Phase 2), grandmothers (Phase I), fathers (Phase I), and CNPs (Phase I). 28
Approximately 850 people were directly reached with the tasting of bobor khap krop kroeung and a few thousand with awareness of improved IYCF practices.
21
6. Practical learning environment during IYCF trainings: four participatory cooking sessions were
integrated into the seven IYCF sessions and increased caregivers’ skills and confidence to
prepare bobor khap krop kroeung
7. Participation of grandmothers in the IYCF trainings increased their knowledge on and advocacy
for improved feeding practices and childcare: due to migration of some mothers, grandmothers
attended parts of the IYCF sessions or even the whole training
8. Distribution of kitchen equipment to caregivers: fuel-efficient stove, kettle, pot, water container,
hand soap, plastic dipper, plastic food cover and food cover net enabled them to put the
acquired food preparation and cooking skills into practice
The following key challenges were underscored:
● Capacity and Motivation
1. Lack of capacity in nutrition at all levels: Government and NGO staff have limited training
and capacities in nutrition and food based approaches, especially on complementary feeding
and the promotion of good family diets; they also lack facilitation skills and participatory
skills, which is key for working at community level
2. Duration of nutrition education programmes: caregivers need effective long-term support in
the communities to sustain the new behaviour since improvements in child health can only
be seen over time
3. Incentives: participation of Health Centre staff, Commune Council for Women and Children
and CNPs required incentives.
● Implementation
4. Recruitment of men into the IYCF sessions: traditionally, the primary caregivers are mothers
and grandmothers, as men must earn an income they only take a minor role in feeding and
caring of young children. Attempts were made to motivate men to join the sessions, but only
a few were able to participate
5. Long duration of participatory cooking sessions: women have heavy workloads, so IYCF
sessions should be less than two hours, however, the joint theoretical/cooking sessions took
longer than the theoretical sessions
6. Quantity of porridge to be fed and ingredients in the recipes: measurements of ingredients
to make ½, ¾ and 1 full bowl of bobor khap krop kroeung were difficult for trainers and
caregivers to understand. Although IEC material was developed to show how many
spoonfuls of various ingredients were needed to prepare the different recipes, the recipe
concept remained challenging. In addition, caregivers had difficulty understanding how
much bobor khap krop kroeung should be given to their children to make them grow.
● Supervision and Reporting
7. Coordination of supervisors: in Phase I, IYCF sessions were often attended by multiple cadres
of staff, which was not an efficient use of resources. This was changed in Phase 2, where the
NGO staff delivered the trainings, CNPs were used for mobilisation of caregivers and NGO
supervisors/MALIS staff undertook monitoring
8. Reporting: in Phase I, NGO partners were reporting at activity level (numbers of trainings
and inputs distributed) rather than on whether caregivers changed their behaviour. In Phase
2, the focus on behaviour change improved through strengthening of the monitoring and
22
evaluation system to observe whether mothers were actually practicing the new knowledge
and skills.
4.2. Lessons Learned from the MALIS project
Dr Iean Russell, MALIS Project Manager, explained the annual review cycle for collecting and sharing
lessons learned from the field, which started with farmer field schools, farmer business schools and
IYCF groups reviewing the training and associated activities at village level. Lessons learned were
shared at commune or district level meetings, and provincial workshops.
Lessons learned by the Project Manager
Dr Russell provided personal insights on the role of a Project Manager. He noted that
communication of your strategy and successes to the stakeholders are important for project
progress. Monitoring of the activities is essential to provide an evidence-base for the programme. As
a programme manager it is important to build relationships and communication channels with the
beneficiaries and implementing partners to guide activities. The responsibility of the programme
manager is to motivate staff and implementing partners to engage in a meaningful way in the
project as early as possible. Invest in and channel funds to successful activities, and do not allow
organisational memory to be eroded by staff turnover.
Overall, the MALIS project faced a number of challenges, which included:
● Technical issues for production and nutrition
● Extensive requirement for training of trainers before and during implementation
● Barriers to information sharing
● Business environment was challenging for the development of market linkages
● Home environment for caregivers was sometimes not supportive for behaviour change
● Lack of experience of participants and staff in market-oriented, new-style cooperatives and
market systems
● Lack of clarity in communication, transparency and accountability in some community groups
● Few capable existing community groups and limited time frame for strengthening management
of the groups
Key lessons learned by the MALIS team included:
Farmer Field Schools
● Farmer field school effectiveness was limited by the capacities of the facilitators (as many
facilitators were unsure how to conduct a farmer field school) and level of backstopping
● Provision of inputs for chicken and vegetable farmer field schools increased the dependency of
members on inputs rather than focusing on learning, and chicken activities were considered of
limited relevance for food security
23
Farmer Business Schools
● Building up business skills for the farmer groups is an effective long term development strategy
● Making farmer business school curricula relevant to current needs and activities of the farmer
works well, e.g. when advice is adapted to the farmer group’s seasonal crop calendar to make it
relevant
● Ensuring that agriculture cooperative management learns about responsible business behaviour
especially for contracting
● Investing in success works well in relation to individuals, ideas, organisations and activities
Fairs29 and Input Credit
● The vouchers were a good way to inject capital into the community allowing farmers to choose
what they really needed
● Clear input credit guidelines are needed and must be communicated to farmer groups and
strictly enforced to ensure farmers adhere to the rules
● Willingness to pay was demonstrated by recovery of all money owed
● Fairs can be used to stimulate local business
● Government supervision and support were critical for accountability of farmer groups
Future directions
In general, there is a need for more investment in education. Education in agriculture,
particularly agronomy, and in nutrition, which have been neglected in Cambodia. There is a
need to develop pre-service and in-service programmes in schools and at tertiary level instead
of short training courses, as these have resulted in the general lack of expertise in soil science,
pest management, agricultural chemicals and nutrition30
In order to successfully conclude the MALIS project, it is necessary to further strengthen
smallholder farmer groups, formulate appropriate strategies to improve child feeding
behaviour, and emphasise disaster risk reduction at household level
Looking beyond the life of the project, the time is ripe for change in rural systems. Women’s
roles are rapidly changing and there is an increasing burden on women to manage the
household and to participate in a mobile work force, sometimes distant from the home. There
are rising education opportunities, but also challenges to ensure this education is made relevant
to the future of rural youth. Despite the scepticism around agricultural cooperatives, the MALIS
project has shown that these can be effective as drivers of economic change and offer a level of
social protection. The high costs and mobility of rural labour will promote mechanisation and
the opening of trade relations will bring new market forces into play. Some of these will provide
opportunities; others may further disadvantage smallholders who have limited skills in
responding to market opportunities. Lastly, we see that climate change is real and rural
communities are searching for guidance and ways to adapt.
29
This was the first time that agricultural fairs of this nature were conducted that provided farmers with over 100 items to choose from. 30
The MSc in Nutrition programme only commenced two years ago in Cambodia.
24
The chair, Mr Ngin Chhay thanked the presenters and remarked that a complex set of lessons were
outlined from a wide range of sectors. He stressed that it is important to simultaneously promote
food production and nutrition. Hence, there is a need to grow nutritious food crops.
Discussion:
What might be the best approach to foster and generate knowledge, convey nutrition messages and
ensure behaviour change? The MALIS project has used different channels to convey nutrition
messages by including fairs as a tool from the agricultural side - could they be an option for nutrition
promotion as well? – MALIS replied that efforts were made to ensure that farmer field schools had a
cross-cutting message on nutrition, and fairs and field days included similar messages. By integrating
nutrition education messages in fairs and promoting complementary feeding through food displays
and bobor khap krop kroeung tasting, MALIS aimed to create broader awareness of improved child
feeding in the communities. The idea was to encourage different family members to participate in
child nutrition activities and thus reduce the burden on the mother. Although there is no scientific
evidence to show these broader activities had any impact, we can gauge success by the active
involvement of beneficiaries, and their improvements in knowledge. To monitor progress FAO
conducted sharing meetings among mothers after IYCF sessions 3 and 5. These also served to
encourage interaction between women, discuss hindering factors in preparing bobor khap krop
kroeung and explore options on how to overcome these constraints. There is need to mobilise other
groups and use diverse channels of communication in the community, e.g. religious groups, to reach
out to people. Radio can be a very effective channel for information dissemination and there is
ample scope to explore different options to raise awareness and enable households and
communities to improve IYCF.
The EU agreed with the key challenges and commented that there is a need to think out of the box.
A three percent increase in stunting of children in OMC shows that the work is not enough (in
agriculture and nutrition); we need to plan for broader interventions and develop a long-term vision.
Also, a 3.5 year project duration is not long enough and only gives short-term support to the target
groups. It is important to think about how to scale up to the national level to sustain action and
support, to encourage collaboration among the different sectors (agriculture, nutrition, health) at
national, provincial and community levels, and to integrate lessons learned into national strategies.
Regarding the question of how to integrate food security and nutrition education, there is a need to
think in terms of the life cycle perspective; children should be educated early on the importance of
nutrition to enable them to practice and reinforce healthy eating until they are of reproductive age.
Importance of increasing not only the quantity but also the quality of food
“Regarding the amount of food available, the entire family is sharing the family meal and this
food may not always be appropriate for the child. Also the cost of food is an issue determining
not only the quantity but also the quality of food purchased and eaten. So, there may be a
need, depending on cost, not only to increase the amount of food but also to improve the
quality and types of food so that the meal becomes more nutritious. Food also needs to be
attractive and tasty so mothers and children will eat it.”
Her Excellency, Dr Kantha Phavi Ing, Minister of Women’s Affairs
25
In relation to the EU implementing project, which focuses on smallholder farmers, what is your
recommendation for the Government – how to increase agriculture commercialisation, but not leave
the poor behind, in order not to exclude the poorest of the poor? – MALIS responded that there is a
trade-off between commercialisation and the poor. In our areas we targeted smallholder farmers,
who are generally poor, but not the poorest of the poor, who are mostly landless and agriculture has
limited opportunities to contribute to their wellbeing. Some examples exist of poorer farmers
working with credit. However, poor farmers mostly took small amounts because they were worried
about repayment. The poorest need to be targeted through social protection, which is not an issue
that agriculture can assist with, but nutrition needs to be addressed. Engaging the private sector is
very important, however, new farmers on the market need the support of agricultural cooperatives
that are l closely linked to PDAs and operate under their protection.
4.3. Panel discussion, lessons learned for continuing/improving
Chaired by Mr Oum Kosal, FAO, panellists representing CARD, GDA, MRD, MoWA and HKI were
invited to comment on the key lessons learned identified by the process review in relation to what
each sector can contribute to the nutrition of young children and families and what the benefits of
collaboration are between sectors. The panellists were: Professor Koum Kanal, Advisor to CARD; Mr
Ngin Chhay, Director of Rice Crop Production, GDA; Mr Ky Sophal, Deputy Director, Department of
Rural Health Care, MRD; Ms Hou Nirmita, Director of Gender and Health, MoWA; and Mr Hou
Kroeun, Deputy Director, HKI.
His Excellency Professor Koum Kanal, Advisor to CARD, highlighted that nutrition is key to
development for the society and needs participation from all sectors. On the first National Nutrition
Day in November 2014, the Prime Minister set out all the nutrition policies/strategies into Phase III
of the National Strategic Development Plan (2014-2018). In this regard, CARD also implemented the
National Strategy for Food Security and Nutrition (2014-2018), which does not intend to restrict
other ministries from working on nutrition but to coordinate activities and to work together. He
hoped that MALIS will bring out issues to guide policy makers so that nutrition can improve, which is
a major objective of CARD. At the National Conference on Nutrition in March 2015, the Prime
Minister and the Director General of CARD set out four recommendations, as Ms Brandstrup, FAO
Cambodia Representative, already mentioned in her opening speech. Furthermore, Professor Kanal
stressed the importance of nutrition education in primary, secondary and high schools as children
should understand about gardening, water and sanitation, and benefit from participation in these
activities. He stressed that CARD is not an implementing agency but coordinates technical meetings
on nutrition issues, reviews reports of related institutions and encourages all implementing agencies
to improve nutrition and food security.
Mr Ngin Chhay, Director of Rice Crops, GDA, highlighted the challenges of agriculture and food
security in terms of the growing population and climate change. To respond to these challenges,
clear strategies and policies are needed that must be in-line with the local reality and are action
oriented. So far, technical messages are sometimes conflicting, coming from the Government,
private sector and NGOs to the farmer. In relation to agricultural practice, GDA is focusing on four
factors: (1) high yield seeds that add value at the market; (2) diverse, nutritious crops that provide
high nutrients to consumers; (3) planting/production techniques that ensure sustainable and optimal
agricultural production; and (4) post harvesting technologies that enable optimal storage of crops to
26
avoid losses. These technical aspects should be included in future programmes. He remarked that
innovations must be safe and provide something for farmers. Furthermore, he urged that integrated
farming systems or home gardens should be adopted by smallholder farmers in rural areas.
Mr Ky Sophal Deputy Director, Department of Rural Health Care, MRD, commented on the links
between nutrition and Water, Sanitation and Hygiene (WASH), and emphasised that lack of hygiene
can contribute to stunting. According to statistics of the 2007 Cambodia Socio-Economic Survey,31
sanitation practices are still weak and 60 percent of the population defecate on open land. In 2010,
MRD conducted a KAP survey on hygiene, which showed that people understand the benefits of
improved sanitation and hygiene practices but this is not yet reflected in their sanitation habits. In
2014, MRD and the Government developed a strategy on clean water and sanitation, and are
currently preparing a comprehensive National Action Plan that links clean water and hygiene to
nutrition. Additionally, every year the Government issues a message on 13th November to mark
Cambodia’s National Sanitation Day – and last year this focused on sanitation being everyone’s
responsibility, and that improvements in sanitation contribute to economic development, public
health, personal dignity and the environment.
Ms Hou Nirmita, Director of Gender and Health, MoWA, highlighted the role of women and their
contribution to nutrition. She pointed out three traditional roles for women: (1) taking care of family
members; (2) preparing food for the family and doing household chores; and (3) sharing food and
making sure everyone in the family has enough to eat. In the past that meant serving the chicken’s
leg to the husband, the tail and liver to young children and others in the family, and the women only
received the neck and chicken feet. Therefore, she emphasised the need to provide training to the
community and for development partners to support such efforts. Through the MALIS project,
women have learned how to share food among family members in accordance with their nutritional
needs. Likewise, MoWA has conducted training for women on how to allocate food wisely in the
family. Furthermore, MoWA is interested in nutrition issues and encourages farmers to start home
gardens so they can grow food for their children and family members, and sell their products to
improve household incomes.
Mr Hou Kroeun, Programme Manager, HKI, raised three points on collaboration and cooperation
that he claimed were often overlooked: (1) enforcement of policies: the national policy on IYCF has
to be respected by (international) NGOs and they have to act in-line with it; (2) ethical approval of
research studies should be obtained; and (3) coordination of NGO activities is necessary by using the
Food Security and Nutrition Information System developed by CARD in 2004.He also commented on
the need to respect the regulations governing the marketing of breast-milk substitutes in the
Kingdom of Cambodia.
31
World Bank (2009) Poverty profile and trends in Cambodia, 2007. Findings from the Cambodia Socio-Economic Survey Report No. 48618-KH. Poverty Reduction and Economic Management Sector Unit, East Asia and Pacific Region, Washington DC: World Bank. Available at http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/ 2009/08/09/000333038_20090809234032/Rendered/PDF/486180WP0P11191ofile120071withCover.pdf
27
Discussion:
What is the country doing to increase training capacities and what does it mean for the country’s
infrastructure? – JLU commented that from a research perspective, they faced a challenge in finding
academic partners and were pleased to establish collaboration with Mahidol University.
JLU remarked that the MALIS project achievements and the IMCF research results have been
presented; however, an important question is “What are the next steps?” We now have the
evidence and the time has come to think about using our insights to scale up. In addition, Cambodia
has become a SUN country. Hence, JLU would like to suggest that we go another step and suggest to
the Government to integrate the results into policies and then ask NGOs to support this policy. If the
Government wants to sit in the driving seat of the car for nutrition education and food security, then
NGOs can support you. It is important for the Government to get the orientation and then we can
assist.
Mr Oum Kosal, FAO, thanked JLU for the comments and suggestions, and remarked that we should
not wait for new projects but can expand ongoing activities. He then requested the different
ministries to provide their response to the following question: Can we include nutrition education or
what can we do for education – do we teach only farmers or should we also teach nutrition in
schools?
Ms Hou Nirmita, MoWA, acknowledged that nutrition is a problem in Cambodia and it is not yet
taught in Universities following a certain standard. There is a need for qualified teachers and time,
and to solve the problem step-by-step. First, officers and workers should be sent abroad to obtain
the knowledge in the short term. In her team, members of CARD have been sent for training in
Germany, Italy, the Philippines and other countries. Recently, MoWA collaborated with Singapore to
conduct training on nutrition. At the same time, the Government is thinking strategically and
nutrition should be included in universities as well as schools.
Professor Koum Kanal, CARD, thanked Ms Hou Nirmita for her comments and stated that as former
Director of the National Maternal and Child Health Centre (NMCHC)32 and nutrition, MoH has had
lengthy discussions with public health about preparing a curriculum for a Diploma in Nutrition or an
MSc in Nutrition. We have requested Australia to help with nutrition training and have recently
established training for the MPH in Cambodia. Another challenge faced is that there are now too
32
The NMCHC is also referred to as the Japan Hospital.
Linking family and young child feeding
“We should not only focus on food for infants and young children but for the entire family.
Starting from 12-15 months of age, mothers are preparing family food. The question then is
how to make family food more nutritious, diversified and attractive? Mothers frequently do
not know what different foods they need to feed. This knowledge is essential in Cambodia and
we should engage the committee of women and children in the communes to make them
aware of the importance of good family and child feeding. The village chief is a key person who
needs to mobilise the commune and use the village network to promote improved nutrition.”
Her Excellency, Dr Kantha Phavi Ing, Minister of Women’s Affairs
28
many private universities, but there is no MSc in Nutrition and there are no jobs related to nutrition.
Moreover, there is no market demand for nutrition so no-one studies it. He called on private
universities to help the Government to develop a diploma in Nutrition and stressed that there is
consensus on the need for a school nutrition course to provide a strong foundation to improve
nutrition, which the Government should prioritise.
Mr Oum Kosal, FAO, remarked that Cambodia has an MSc in Nutrition course, conducted by the
National Institute of Public Health (NIPH), which is currently in its third year of operation, and is
supported by the Cambodia HARVEST project funded by USAID. He added that GIZ supported
training in nutrition and food security during 2003-2005 with trainers sent to Munich, and FAO has
continued providing support; currently the team consists of around 20 people from different sectors
and institutions, of which the chair is a member. Cambodia HARVEST concurred that they are
collaborating with the NIPH and offered scholarships on the MSc in Nutrition course to the first
intake of ten students and then five students in the second year, making a total of 15 students. Only
two rounds could be supported due to closure of the Cambodia HARVEST project.
He also wished to pick-up on JLUs suggestion and commitment for nutrition to be incorporated into
GDA and that all sectors should include nutrition. By way of example he mentioned the
consideration of nutrition aspects in the formulation of the ASPIRE project, which is a major project
addressed at poverty reduction and improved resilience for smallholder farmers, jointly funded by
the Royal Government of Cambodia and IFAD.
Mr Ngin Chhay, GDA, noted that JLUs suggestion of linking agriculture to nutrition is new. In
agriculture, the focus is usually on production but the MALIS project added nutrition. In terms of
production, he discussed with a representative of the MALIS project that it is difficult to show
whether projects have impact on nutrition, so they hired JLU to study this and the results are
promising. JLU found some positive effects, so we may want to replicate this model in other
provinces and with other departments. It is good that we trained Agriculture trainers in Nutrition as
they can work with Agronomists, thus making effective use of available staff resources. I would like
to thank our partners for the good idea of linking agriculture to nutrition and this will be applied in
other projects.
Is there evidence that people were eating the food they produced? What is the theory of change? Do
they sell the food or sell the food and buy different food? – JLU replied that food security activities
are more likely to increase wealth than have a direct impact on nutrition. However, if nutrition
education is provided as well, it is more likely that the income, especially if it is controlled by
women, will be spent on nutritious foods that are available in the market or part of the fresh
produce grown at home will be eaten by the family rather than sold. Some of the households in the
community are food insecure. As their wealth increases they are likely to become less vulnerable
and their income rises. However, without nutrition education, the impact on the family and
children’s diets will be much less. Mr Ngin Chhay, GDA, added that the answer is yes, the farmers do
use the food that they produce, the surplus is sold and the money is used to buy other foods that
they want to eat, e.g. meat. He felt that this is very clear and not only the MALIS project has shown
this; there are many examples from other projects. What foods do they grow/use? We need to know
this. He described a study on home gardens, after ten farmers from two provinces attended the
integrated farmer field schools on home gardening they started growing different crops, produced a
variety of vegetables, farmed fish and raised chickens and this was documented for one year. Their
29
income was ten times higher after the training and they also diversified their diets by eating the
varieties grown and buying food to eat. Prior to the training, they only ate fish sauce with rice, but
now they eat fish, fruit and vegetables. Hence, there is good evidence that they eat more when they
can produce more, when they can produce more they can sell more and they can get more income,
and they can buy more food that they want.
The chair, Mr Oum Kosal thanked everyone for their active participation, especially for the last
session.
30
5. Wrap up session
5.1. Summary of recommendations
The following recommendations were presented by the chair Mr Oum Kosal, FAO, based on the
presentations and discussions:
● Our panellists talked about coordination with other sectors. No sector is more important than
another, but the sectors of Health, Agriculture, Education and Women’s Affairs are important
for nutrition. At the beginning of the month, the conference on nutrition was held and this
shows the commitment of CARD for nutrition
● From the research, it is clear that nutrition education along with the food security intervention
is important to change the quality of life of infants and young children, and the health of
caregivers in both provinces
● It is necessary to integrate nutrition education into agriculture at all levels (national, sub-
national, provincial, district, commune and village levels), and to integrate nutrition knowledge
into farming systems through agricultural extension, especially around food security and
promotion of crop diversity
● Good cooperation is needed between NGOs, government (district, commune and village level)
and village health support groups to prevent overlap and encourage sharing of work, and
commitment is required for longer term efforts to integrate nutrition into agriculture in new
projects
● Revision of IEC materials is necessary, especially training materials for caregivers, facilitators
and trainers, to reflect the needs of people
o Further adapt to the level of local capacities
o Reflect on the factors that affect behaviour change of caregivers
o Put more emphasis on age, frequency, amount and volume of food the child receives
o Focus on access to good quality family food
o Continue and strengthen the participatory elements in the IYCF sessions for caregivers
● Capacity building is very important and this needs time and a strategy. Hence, it is important to
provide training on nutrition at all levels - national, sub-national, provincial, district, commune
and village
● Implementers need to have the knowledge and skills to facilitate the IYCF sessions and
participatory cooking sessions, and undertake monitoring to generate evidence on the activities
that work. Also, study tours from other areas can be undertaken to learn about each other’s
activities
● In terms of the sustainability of the IYCF trainings, the commune council for women and children
are agents of change in the commune and could be agents of change for nutrition
● Nutrition education should be provided to all family members and generations (mothers,
grandmothers, grandfathers, fathers, siblings and aunties) who look after the child
● It is important for caregivers to apply knowledge on improved child feeding into their daily
practice
● The Minister of Women’s Affairs acknowledged that women play a key role in nutrition as they
have responsibility for food preparation and food sharing as well as an important role as
caregivers (i.e. mothers, grandmothers, aunties and sisters) in childcare and feeding
31
● GDA is committed to promote the lessons learned33 from the project to improve programming
and policy, and these should be documented, disseminated and integrated into the next ASPIRE
programme.
Mr Oum Kosal hoped these recommendations are helpful for stakeholders in planning their work on
food security and nutrition.
5.2. Closing remarks
Ms Chan Phaloeun, Deputy Director General, GDA, thanked the Professors and Dr Iean Russell for
their remarks. She highlighted the successful implementation of the MALIS project with cooperation
of MAFF, MoH, MRD and MoWA, and coordinated by CARD that empowered the Government to
delegate authority from the sub-national level to district and village levels. This new approach
enabled the prioritisation of needs at local levels. In addition, she underscored the importance of
improving the diet and health of children – the generation of tomorrow – and to prevent stunting as
well as overweight.
To achieve this, she recommended: (1) disseminating uniform, readily understandable information
on sustainable and modern agriculture technologies; (2) improving living conditions through
applying effective agriculture technologies while also considering sanitation and women’s
empowerment; and (3) strengthening cooperation and coordination among stakeholders.
She stated that GDA had profited from exchanging experiences of working in rural areas. In
conclusion, she thanked the EU for funding the MALIS project, FAO and JLU for providing technical
assistance, FAO for organising the meeting and all the participants for attending, and emphasised
that a lot of topics, questions and answers, and ideas have been shared among the different
development partners present at this meeting. .
Finally, Ms Doung Chansereivisal thanked Ms Chann Phaloeun for her remarks and everyone who
attended the meeting.
33
Bad experiences should also be documented, especially on nutrition.
32
Annex 1 - National Dissemination Meeting Programme MALIS and IMCF project Dissemination meeting. Sunway Hotel, Phnom Penh, 26th March 2015
08.00 Registration Opening
08.30 Opening, Welcome and Introductions • Welcome and Introductions • National Anthem
MC, Ms Doung Chansereivisal (FAO Siem Reap province)
08.45 Remarks by • FAO Cambodia Representative • The European Union • Secretary of State for MAFF
Ms Nina Brandstrup ,FAOR Ms Fiona Ramsey, EU Representative H.E. Ty Sokhun, Secretary of State for MAFF
09.00 ● Short break and photo session Session 1: Overview of the MALIS project - FAO food security and
nutrition project
Session Chair: Mr Oum Kosal (AFAOR)
09.10 Aims of the meeting Dr Elizabeth Westaway, International Nutrition Consultant, FAO HQ
09.20 Overview of the MALIS project Dr Iean Russell, MALIS Project Manager, FAO
09.35 Overview of the nutrition education component of the MALIS project
Ms Theresa Jeremias, Nutrition Officer, FAO HQ
09.50 Discussion Session Chair 10.00 Coffee break (Video of the MALIS nutrition component)
Session 2: Applied research in the context of an FAO food security and
nutrition project - Findings of the IMCF project
Session Chairs: Ass. Prof Pattanee Winichagoon, PhD, Mahidol University and Prof Michael B Krawinkel, MD, Justus Liebig University Giessen)
10.30 Overview of the research aims and objectives Dr Irmgard Jordan, IMCF project, JLU
10.45 Impact of nutrition education in the context of a food security project on infant and young child feeding practices– results from a cluster randomised trial
Ms Anika Reinbott, IMCF project, JLU
11.05 Behaviour change for improving infant and young child feeding practices – results from a qualitative study
Dr Irmgard Jordan Mr Mav Khun, IMCF project, Mahidol University
11.35 Discussion Session Chairs
12.00 Lunch Break
Session 3: Lessons learned and implications on future programmes
Session Chairs: Mr Ngin Chhay, GDA
13.30 FAO IYCF Process Review Ms Theresa Jeremias, Nutrition Officer, FAO HQ
33
13.50 Lessons Learned from the MALIS project Dr Iean Russell, MALIS Project Manager, FAO
14.10 Q&A Session Chair 14.20 Coffee Break (Video of the MALIS nutrition component) 14.50 Implications and recommendations
Panel discussion (25 minutes total) What can each sector contribute to the nutrition of young children and families? What are the benefits of collaboration between sectors?
• HE Prof Koum Kanal, CARD • Mr Ngin Chhay, GDA • Mr Ky Sophal, MRD • Ms Hou Nirmita, MoWA • Mr Hou Kroeun, Helen Keller International
Discussion (45 min)
Session Chair
16.00 Wrap up Session Chair 16.15 Closing remarks Ms Chan Phaloeun, Deputy
Director General, GDA
34
Annex 2 - National Dissemination Meeting Participant List
Name Title, Organisation and Location E-mail address
HE Dr ING Kantha Phavi Minister of MoWA, Phnom Penh [email protected]
HE Dr TY Sokhun Secretary of State, MAFF, Phnom Penh [email protected]
HE Dr KOUM Kanal Adviser to CARD, Phnom Penh [email protected]
Ms HOU Nirmita Director of Gender and Health, MoWA, Phnom Penh [email protected]
Mr NGIN Chhay Director of Rice Crop Production, GDA, Phnom Penh [email protected]
Dr CHHOUN Chamnan Director of Department of Post-Harvest and Technology, Fisheries Administration, Phnom Penh
Ms CHANN Phaloeun Deputy Director General, GDA, Phnom Penh [email protected]
Mr KHIN Mengkheang Deputy Director, Department of Research and Community Protected Areas Development, MoE, Phnom Penh
Mr KY Sophal Deputy Director, Department of Rural Health Care, MRD, Phnom Penh
Mr OU Kevanna National Nutrition Programme Manager, MoH, Phnom Penh
Ms CHEA Mary Deputy Manager of National Nutrition Programme, MoH, Phnom Pen
Mr PHIM Loan Master Trainer, MoH, Phnom Penh [email protected]
Dr SOK Sary Rapid Response Team, Council for the Development of Cambodia, MoH, Phnom Penh
Ms EK Sophearum Director, PDoWA, OMC [email protected]
Mr YOEUN Buntha Director, PDA, OMC [email protected]
Dr MOUN Nara Deputy Director PHD, OMC [email protected]
Ms MONG Somol Director, PDoWA, PVR [email protected]
Mr POEUNG Tryda Director, PDA, PVR [email protected]
Dr KHOY Bunthanny Director, PHD, PVR [email protected]
Mr HEM Chanthou Senior Project Officer, Asian Development Bank, Phnom Penh
Ms Fiona RAMSEY Counsellor and Head of Co-operation, EU, Phnom Penh
Ms BY Sokunthea Programme Officer-Food Security, EU, Phnom Penh [email protected]
Prof Michael KRAWINKEL Professor, Institute of Nutritional Science, IMCF, JLU,
Germany [email protected]
Dr Irmgard JORDAN Research Fellow, Institute of Nutritional Science,
IMCF, JLU, Germany [email protected]
Ms Anika REINBOTT PhD Candidate, Institute of Nutritional Science, IMCF,
JLU, Germany [email protected]
Dr Pattanee WINICHAGOON
Associate Professor, Institute of Nutrition, Mahidol
University, Thailand [email protected]
Mr MAV Khun Researcher, Institute of Nutrition, Mahidol University, Thailand
Mr Aviva RAPPAPORTA MSc Student from University of British Columbia, MoE, Phnom Penh
Ms PHUON Phounmalis MSc Nutrition Student, National Institute of Public Health, Phnom Penh
Dr Jeannie Chang PITTER Technical Adviser, University Research Co., LLC (URC), [email protected]
35
Phnom Penh
Ms Elizabeth WESTAWAY International Nutrition Consultant, FAO, Headquarters Rome/Italy
Ms Theresa JEREMIAS Nutrition Officer, FAO, Headquarters Rome/Italy [email protected]
Ms Nina BRANDSTRUP FAO Representative Cambodia, Phnom Penh [email protected]
Mr Etienne CAREME Operations Coordinator, FAO, Phnom Penh [email protected]
Mr OUM Kosal Assistant FAO Representative, Phnom Penh [email protected]
Ms ATH Socheat Programme Assistant, FAO, Phnom Penh [email protected]
Ms KHIN Narin Operations Assistant, FAO, Phnom Penh [email protected]
Ms Stacy CREVELLO Chief Technical Advisor, GEF project, FAO, Phnom Penh
Ms Botumroath Lebun KEO Communication Officer, FAO, Phnom Penh [email protected]
Mr TOUCH Antoine Communication Intern, FAO, Phnom Penh [email protected]
Dr Iean RUSSELL MALIS Project Manager, FAO, Siem Reap, [email protected]
Mr KHORN Sdok MALIS Training Coordinator, FAO, Siem Reap [email protected]
Ms DUONG Chansereivisal Agribusiness and Post-Harvest Specialist, FAO, Siem Reap province
Ms LEK Pheara Operations Officer, FAO, Siem Reap province [email protected]
Ms THAN Rathany MALIS Nutrition Assistant, FAO, Siem Reap [email protected]
Ms Amy WAKEM MALIS Nutrition Consultant, FAO, Siem Reap [email protected]
Mr UN Sam Oeurn Nutrition Officer, UNICEF, Phnom Penh [email protected]
Ms Dessa SHUCKEROW Programme Officer, WFP, Phnom Penh [email protected]
Ms Louise BROOMHEAD Nutrition Consultant, WFP, Phnom Penh [email protected]
Mr Benjamin SCHOLZ Programme Manager Social Health Protection Programme, GIZ, Phnom Penh
Mr CHANA Samorn Adviser-Asian Sustainable Agrifood System, GIZ, Phnom Penh
Mr SEK Sopheanarith Development Assistance Specialist, Office of Public Health & Education, USAID Cambodia, Phnom Penh
Mr Fean Lue TAMBERT Country Director, Action Contre la Faim, Phnom Penh [email protected]
Mr LIM Sophorn Project Manager, Family Nutrition Programme, Adventist Development and Relief Agency Cambodia, Phnom Penh
Ms Susan NOVAK Director Social Inclusion and Capacity Development, Cambodia-HARVEST, Phnom Penh
Mr AY Satya Food Security and Nutrition Programme Officer, Cambodia-HARVEST, Phnom Penh
Ms THO Thida Food Security and Nutrition Programme Officer, Cambodia-HARVEST, Phnom Penh
Mr YIM Samnang Livelihood Advisor, Care Cambodia, Phnom Penh [email protected]
Ms Giulia REICHMANN Project Officer, Civil Volunteer Group - Cambodia, Phnom Penh
Ms OUK Toptesseda Country Manager, Dana Asia, Phnom Penh [email protected]
Mr NHEP Thy Project Manager, Farmer Livelihood Development, Phnom Penh
Ms Amy WEISSMAN Associate Director Prevention and Innovation, FHI 360, Phnom Penh,
Mr LY Koung Ry Nutritionist, Foundation for International Development/Relief, Phnom Penh
Mr HOU Kroeun Deputy Director, Helen Keller International, Phnom [email protected]
36
Penh
Ms LY Sok Hoing Programme Manager, Helen Keller International, Phnom Penh
Mr SON Siveth Country Representative, International Relief and Development, Phnom Penh
Ms Bindi BORG PHD Student, International Relief and Development, Phnom Penh
Ms Sane SIGN MSC Student, International Relief and Development, Phnom Penh
Ms SIM Sophea Programme Manager, Medical Teams International, Phnom Penh
Mr CHHUON Wathna Health Specialist, Plan International, Phnom Penh [email protected]
Ms CHAN Ketsana Child Health Team Leader, Reproductive and Child Health Alliance, Phnom Penh
Mr LY Rattanak Manager, Agriculture and Livestock Programme, Samaritan’s Purse International Relief Organization, Phnom Penh
Mr Ran Jan POUDYAL Country Director, Save the Children International, Phnom Penh
Ms Goeve Ding KOWINGEN Adviser, SNV Netherlands Development Organisation, Phnom Penh
Mr HEM Sovannarith Programme Manager, Swiss Development Agency for Cooperation, Phnom Penh
Mr Dirk REBER Country Director, Welthungerhilfe, Phnom Penh [email protected]
Ms Juliane KAUFMANN Public Relation Intern, Welthungerhilfe, Phnom Penh [email protected]
Ms Anna PENTTINEN Health and Nutrition Pro-G, World Vision, Phnom Penh
Ms VA Sonyka Reporter, Khmer Times, Phnom Penh [email protected]
Ms PECH Sotheary Reporter, Phnom Penh Post, Phnom Penh [email protected]
37
Annex 3 - IYCF Summary Sheet
Improving Infant and Young Child Feeding Practices in Cambodia
A component of the “Improving Food Security and Market Linkages for Smallholders in
Oddar Meanchey and Preah Vihear (MALIS)” FAO project with funding from the EU
Background
In Cambodia, 32.4 percent of children under the age of five are stunted according to the 2014
Cambodia Demographic and Health Survey, which represents an 8 percent decrease over the last 4
years. Underweight prevalence of children under the age of five also decreased to 23.9 percent,
whereas wasting prevalence remained fairly constant at 9.6 percent.
Major causes of childhood stunting include: inadequate breastfeeding, complementary feeding and
care practices as well as diseases and poor water, sanitation and hygiene. In the long-term, stunting
negatively affects an individual’s learning, work capacity and productivity, while adequate feeding and
care during the first 1,000 days of life ensures optimal physical growth and mental development.
Nutrition Education on “Improving Infant and Young Child Feeding”
The MALIS project worked through community-based organisations to reach targeted beneficiaries
enrolled in Farmer Field Schools (FFS) and Farmer Business Schools (FBS) in Oddar Meanchey
(OMC) and Preah Vihear (PVR) provinces. The nutrition education intervention consisted of (i)
specific trainings for caregivers on improved Infant and Young Child Feeding practices (“IYCF
training”) who were recruited from groups of farmers enrolled in FFS/FBS to strengthen food security
and nutrition linkages, and enhance the potential of improving family and young children’s diets, (ii)
nutrition modules in FFS/FBS, and (iii) promotional activities at agricultural fairs and farmer field days.
The IYCF training was designed as a series of seven sessions with caregivers of children aged 5-18
months (on recruitment) conducted weekly/fortnightly for 2-3 hours over a period of approximately
three months. The aim of the sessions was to teach the caregivers how to prepare nutritious
complementary food, such as enriched porridges (bobor khap krop kroeung) based on locally
available foods as well as improved food safety, hygiene and health practices, and included four
participatory cooking sessions.
Overview of IEC materials
For the IYCF sessions, the following IEC materials were used: the COMBI1 materials (i.e. BFCI
flipchart, video), a newly developed facilitator’s guide which includes recipes developed in a
participatory, formative research project (“FAO - EU Food Facility project” 2009-2011), as well as four
educational posters on age-appropriate feeding practices, hygiene, food safety and food preparation.
Training of Trainers
Two master trainers from the National Nutrition Programme and two FAO staff facilitated the 5-day
training of trainers for staff from the Provincial Health Department (PHD), Provincial Department of
Women’s Affairs (PDoWA), District Health Centres and NGO partners in the targeted provinces.
These trainers in-turn conducted the trainings for Community Nutrition Promoters (CNPs).
--------------------------------------------------------------------------------------------------------------------------- 1
MOH (2011) Campaign to promote complementary feeding in Cambodia: 2011-2013. Phnom Penh, Cambodia
(http://camnut.weebly.com/uploads/2/0/3/8/20389289/2011compfeedingcommstrategy.pdf)
38
Community Nutrition Promoters
Community Nutrition Promoters, as termed by the MALIS project, are village level volunteers selected
from the existing Village Health Support Groups and a total of 153 CNPs were trained.
Caregiver Groups
A caregiver group consists of up to 15 caregivers with children aged 5-18 months (on recruitment),
pregnant women and women of reproductive age.
In August 2013, the 91 CNPs held the first IYCF trainings with a total of 449 caregiver-child pairs in 35
villages. This first round of IYCF trainings (Phase 1 August - December 2013) was facilitated by pairs
of CNPs and supported by the trainers from PHD, PDoWA and NGOs. In Phase 2 of the MALIS
project, the second round (April – October 2014) and third round (October 2014 - March 2015) of
IYCF trainings enrolled 499 and 440 caregiver-child pairs, respectively and were conducted by NGO
staff as the main trainers, with PHD staff providing technical support on health topics, PDoWA staff
providing sessions on gender and CNPs having a supportive role. In total, 1,387 caregiver-child pairs
were reached and the average participation rate for caregivers was 75 percent.
Kitchen equipment (i.e. an energy saving stove, kettle, food cover net, water bucket, dish rack with
cover, large pot with lid, soap and dipper) was distributed to participants during the IYCF training to
encourage adoption of improved feeding and hygiene practices at home.
Monitoring and Evaluation
In order to improve the quality of IYCF sessions, MALIS project monitoring activities focused on
identifying enabling factors for caregivers’ behaviour change in relation to complementary feeding. In
Phase 2, sharing meetings were conducted with caregivers whereby they could share their
experiences of putting into practice the newly learned skills at home. In addition, home visits were
carried out by FAO and NGO staff to evaluate knowledge, attitude and practice (KAP) change.
Observations showed an increased number of caregivers who washed their hands with soap before
cooking and eating, used boiled water for drinking, regularly cooked enriched porridge and reheated
left-over food before feeding it to their child. However, some caregivers still followed traditional
practices, such as feeding their children with family food which mostly consisted of only rice and
broth.
Research Component
The IMCF research project conducted by the Justus-Liebig University Giessen, Germany was an
effectiveness study of the MALIS project and included baseline and impact surveys as well as a
longitudinal study. In addition, anthropometric measurements and blood specimens were taken, and
focus group discussions and interviews conducted.
Contacts for MALIS and IMCF project:
Dr Iean Russell, MALIS Project Manager, FAO Cambodia Ms Ellen Muehlhoff, Senior Nutrition Officer, FAO HQ, Rome
[email protected] [email protected]
Contact for IMCF research:
Dr Irmgard Jordan, Research Fellow, IMCF Research Project Manager, Justus Liebig University, Germany
http://www.fao.org/ag/humannutrition/nutritioneducation/70106/en/
In collaboration with:
Institute of Nutritional Sciences, Justus Liebig University, Giessen, Germany
Institute of Nutrition, Mahidol University, Thailand
The General Directorate of Agriculture
Ministry of Agriculture, Forestry and Fisheries
I5002E/1/09.15
