Community nurse Anibal Pereira (30), snaps on white rubber gloves to begin weighing children attending his team’s mobile community outreach session in the rural town of Balibo, Timor-Leste. Mothers fan the air before their babies to stave off the afternoon’s heat, and a woman works quickly under the sun to pick the leaves of the cassava plants growing in the dust in front of the house. Anibal knows most of the children will be underweight for their ages, and that at least one or two of the 25 children are suffering from malnutrition. As he works, a pre-teen boy watches shyly, snacking on a packet of dried instant noodles.
“We have lots of local food, but limited knowledge,” Anibal says wearily. He’s sitting in a house during his outreach activities, looking out on the iron-rich cassava growing freely by the house. Steamed and served with rice and local eggs or homemade tofu, the leaves would complete a nutritious and easy meal for the same price as the imported packet noodles, often unfortified, and laced with harmful Monosodium Glutamate (commonly called Masako).
We don’t know what we grow
The young nurse has been working in nutrition for 10 years, and has treated thousands of malnourished children in the poverty-stricken rural district. “It’s not a lack of food that causes child malnutrition in the country – it’s that people don’t know the value of what they grow,” he continues.
“The worst scenario is when people raise chickens, and they have the eggs, but instead of eating them they sell them to buy noodles,” he says with frustration. “Because people don’t know. We don’t yet have the capacity. We have local food surrounding us, but we need to know how to use it.”
The country’s 2013 National Food and Nutrition Survey identified inadequate dietary intake as a leading cause of child malnutrition, a term that includes both the frequency of meals and the diversity of a child’s diet. Observing a gap in the concepts of good nutrition and appropriate feeding practises, the survey concluded that greater investments must be made in nutrition and sanitation education, and programmes that encourage health and nutrition service-seeking behaviours.
Through a partnership with the European Union and Timor-Leste’s Ministry of Health, UNICEF has produced and is distributing a range of behaviour change communications materials in Timor-Leste’s most widely spoken local language, Tetum, aimed at addressing the root causes of child malnutrition and educating mothers about good nutrition and hygiene practises; and also trained health workers on interpersonal communication techniques, and how to work with community-based Mother Support Groups to promote desired behaviour and practices.
Recipe books, posters, flyers, stickers, floor games, flip charts, storybooks and online resources to help health workers and Mothers Support Group members are being distributed in villages all over the country, and will remain in use in communities long after.
Educating families, transforming lives
“When the women come to the clinic, sometimes they don’t understand,” explains Joaquina Felisberta (30) the Nutrition Coordinator at the Maliana Community Health Centre in the nearby rural town of Maliana. She’s been working in the clinic for three years, and estimates 10 of the 300-or-so patients her team sees each week present with malnutrition.
“We use the posters and flipchart and explain the importance of nutrition and the link to health, and then we ask them if they understand, to check, and then they say yes they do and they ask us questions. Every time they come, we remind them about hand-washing, and ask them to come back soon.”
The resources address the immediate and under-lying causes or determinants of malnutrition, which include inadequate feeding, sanitation and hygiene practices and illness management.
With the newly unpacked updated resources, Joaquina says she’ll be able to explain to mothers what they should feed their children, how they can prepare food, and how frequently children should eat. The new flip-chart stands proudly next to a similar chart on hand-washing for health, on a desk just adjacent to a sink bearing the sign “HAND WASH STATION.”
Local Mother Support Groups established under the partnership also assist with communicating the information to mothers and help them to assess, analyse and act to address causes of under-nutrition. Volunteers from the groups contribute local knowledge and experience to developing the recipe book, which uses ingredients readily available in remote villages in Timor-Leste.
“Sometimes it’s difficult to remember what to buy,” says 17-year-old Laurentina Lidia, who attended a recent cooking demonstration of a fibrous corn-based meal in her village just outside of Maliana. “The images can remind us.” She says she will also practise the recipe at home, and use the nutritional information the next time she goes to the market.
It’s a long process, but Anibal, is hopeful. “We have lots of local food. If we have the capacity, we can use it.” He’s still wearing his white gloves as the last woman leaves the clinic, baby slung over her body and a wide smile on her face. A colleague calls him over, and before the mother passes the gate Anibal is deep in conversation about the local leafy vegetable moringa, and how he can explain its health benefits at next month’s clinic.