P roject report 2019
Improving Nutrition
Through Modernizing
Agriculture in Sri Lanka
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Abbreviations and acronyms
ARPA - Agriculture Research and Product Assistant
ASC - Agrarian Service Centres
BMI - Body Mass Index
BMR - Basal Metabolic Rate
CKD - Chronic Kidney Disease
CKDU - Chronic Kidney Disease of Unknown Origin
CSIAP - Climate Smart Irrigated Agriculture Project
CVA - Cerebrovascular accident
CVD - Cardiovascular Disease
DL - Dyslipidaemia
DO - District Officer
EDO - Economic Development Officers
FGD - Focus Group Discussion
HDL - High Density Lipoprotein
HT - Hypertension
IHD - Ischaemic Heart Disease
INMAS - Improving nutrition through Modernizing Agriculture in Sri Lanka
LDL - Low Density Lipoprotein
MMN - Moderate Malnutrition
MO - Morbid Obesity
MS - Metabolic syndrome
SAFANSI - South Asian Food And Nutrition Security Initiative
SLGOV - Sri Lankan Government
WHO - World Health Organization
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Acknowledgements
The authors would like to thank all contributors to the report.
Particular appreciation is given to the health staff of district secretariat offices
of Study Areas including Kurunagala, Anuradhapura and Batticaloa Districts.
Support of the agriculture officers, staff of CSIAP project of the Sri Lankan
Government and other officials involved was immensely useful in completing
this project successfully.
Out community level data collectors including medical doctors/graduates from
local universities and staff of local Universities contributed amidst recent
political and social turmoil following terrorist activities in Sri Lanka. Their
commitment in completing this project at these difficult times in visiting
households and collecting data is much appreciated.
Our researchers and experts provided ongoing support and guidance
throughout this project.
Our sincere appreciation and gratitude also go to the participants and
communities in which this project was conducted.
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Executive summary
Improving Nutrition through Modernizing Agriculture in Sri Lanka (INMAS) study, aimed to
evaluate nutrition promotion activities through the Climate Smart Irrigated Agriculture
Project (CSIAP) in three districts of Sri Lanka.
The Department of Agriculture and the Department of Agrarian Development that come
under the Ministry of Agriculture, Rural Economic Affairs, Irrigation and Fisheries & Aquatic
Resources Development (MOA) was identified as key implementing agencies responsible for
several non- health related interventions. There are several agriculture projects to improve
livelihoods of farmers and agriculture outputs in Sri Lanka implemented in collaboration with
the MOA, and the CSIAP is one of the main agriculture development projects in the country.
The main objectives of the project include identifying the pathways to promote nutrition and
health of farmers and farming communities with multiple stakeholders. The INMAS study
aimed to explore the pathways of improving nutrition and health of the community using
the CSIAP project
The INMAS study measured outcomes using of quantitative and qualitative methods. First
stage included development of and implementing a training program to stakeholders of the
CSIAP and selected communities. A specialized team of experts used strict scientific
methodology and principles of medical education to carry out a need assessment, curriculum
development and implementation. It also developed a set of tools for the short term and
longer term evaluation which could be used throughout the project. The qualitative
component included a study to assess real-world outcome of component one.
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Executive summary cont.
This report presents the outcomes of the INMAS study. The curriculum that was developed
was tested in several pilot studies and further adjustments were made. The final acceptance
of the final interventional tool was satisfactory. The study team was unable to administer
the curriculum to staff of the CSIAP project which did not complete recruitment of its
community level staff or established local project offices and staff. The study team further
developed the curriculum as a self-administered workbook and recommend this to be used
in training of the project staff as they recruit new staff members
The qualitative and quantitative studies revealed moderate amount of lifestyle related risk
factors and nutritional problems that are compatible with similar studies carried out in Sri
Lanka and regional countries. Interventions improved the knowledge and attitudes of the
participants towards nutrition and lifestyle related risk factors for cardiometabolic and
lifestyle related diseases. However, we recommend long term outcome measures in
additional studies.
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The outcomes of this project contribute to the evidence base that more local and national-
level policy makers should consider health and nutritional impacts when making decisions.
The study team call for intersectoral collaborations and whole of government approaches to
improve nutrition and health along with agriculture and other sectors in an integrated
manner, particularly in developing countries.
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Contents Page No.
Table of Contents
Introduction and literature review .......................................................................................... 7
Background .......................................................................................................................... 7
Literature review : Need for Building Evidence on Nutritional Impacts of Agricultural
Policies and Programmes ................................................................................................... 10
Objective................................................................................................................................ 25
Description of activities ......................................................................................................... 26
1. Methods of literature review ..................................................................................... 26
2. The background assessment ...................................................................................... 27
Evaluation framework ........................................................................................................ 32
Qualitative Data Collection ................................................................................................... 36
Results.................................................................................................................................... 41
Qualitative survey .............................................................................................................. 41
Annexure 01: Key activities and deliverables of Phase 01................................................. 45
Annexure 02 ........................................................................................................................... 49
Key activities and deliverables for Phase 02 ...................................................................... 49
Bibliography ........................................................................................................................... 54
Annexures .............................................................................................................................. 60
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Introduction and literature review
Background
Development is not merely economic development but an uplifting of overall quality of
human livelihood. This includes aspects such as education, health and spiritual
development. Improvements in socioeconomic status result in better health outcomes.
Nutrition plays a pivotal role in good health and is determined by factors such as to food
affordability, availability and dietary hobbits (Behrman, Deolalikar et al. 1988, Brug,
Kremers et al. 2008). Hence it is important address the determinants or “causes of causes”
(Marmot 2005) in improving nutrition of a community that will in-return influence health
and human development. Development, impacts on nutrition and health both in positive
and negative ways. Connecting health and development goals is challenging, particularly in
the context of a country experiencing rapid changes in socioeconomic status.
Policy makers often ignore the health outcomes when targeting to achieve development
indicators in the decision-making process, mainly due to lack of awareness on its impacts
on nutrition. There is a consensus that increasing the availability and access to healthy food
is an essential step to improve nutrition. Improvements in socioeconomic status also result
in better nutritional and health outcomes. Although agriculture and development programs
have a direct impact on health, policy makers do not link these in the design of policies and
programs. Therefore, these different indicators are not considered in the decision-making
process or results frameworks. This is the case especially in developing countries where
there is a disconnect between different aspects of governments and development sectors.
Sri Lanka which earlier fell under the category of lower-income countries recently
graduated to the economic status of a lower-middle-income country as the country has
maintained high level of growth in the post-conflict era (Publications 2017). Nevertheless,
Sri Lanka is currently undergoing demographic, epidemiological and social transition with
rapid urbanization and development facing the double burden of under- nutrition and
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over-nutrition with rapidly emerging non-communicable diseases (NCDs). Despite the
certain development achievements and improvements in many health indicators,
malnutrition, anemia and other micronutrient deficiencies prevail in the county - and there
are many other nutritional challenges that require urgent attention. This, in fact, stresses
on the need to integrate nutrition in future development programmes and policies.
In Sri Lanka, Ministry of Agriculture and agriculture development programs have been
identified as key responsible agencies to implement several non- health related
interventions. There are several agriculture projects to improve livelihoods of farmers and
agriculture outputs in Sri Lanka and Climate Smart Irrigated Agriculture Project (CSIAP) is
one of the main agriculture development projects in the country.
Improving Nutrition through Modernizing Agriculture in Sri Lanka (INMAS) study aims to
implement and evaluate nutrition promotion activities through the CSIAP in two districts of
Sri Lanka. The main objectives of the project include identifying the pathways to promote
nutrition and health of farmers and farming communities with multiple stakeholders. Also
this project aims to explore the pathways of improving nutrition and health using the CSIAP
project, and quantifying their relative contributions on food and nutrition security related
outcomes. It is believed that these agriculture programs have an impact on multiple health
related behaviors and outcomes, in this study we focus on for nutritional outcomes, but
include several others which main concerns for farming communities in these areas.
Conceptual framework
Nutrition like most other health parameters are influenced by many factors. The roles of
social, economical and cultural determinants are in fact more prominent in malnutrition
than other health outcomes. This is explained in the following conceptual framework
(figure 1) proposed by the United Nations International Emergency Children’s’ Fund
(UNICEF) (Black, Laxminarayan et al. 2016).
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Figure 1. Conceptual Framework of Determinants of Undernutrition1
Further, in a publication in 2013 titled “Improving nutrition through multisectoral
approaches”, the World Bank identified that nutrition is a multi-sectoral problem which
requires multi-sectoral solutions (The World Bank 2013).
Vast majority of the rural poor globally are engaged in farming. Therefore improving their
knowledge, economy and livelihoods will compliment good healh and nutrition. One such
strategy is to promote microneutrient rich crops which hold promise as complementary
strategies to improve both livelihoods and nutritional status (Burchi, Fanzo et al. 2011).
Some recent systematic reviews (Girard, Self et al. 2012, Masset, Haddad et al. 2012, Ruel,
Alderman et al. 2013) supported the fact that the most appropriate multi-sectoral
programs are not yet clear. Hence there is a need to identify potential frameworks and
working strategies to prioritise multisectoral actions that will work in the realworld.
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Literature review : Need for Building Evidence on Nutritional
Impacts of Agricultural Policies and Programmes
The world, especially the developing regions, persistently face nutritional challenges that
impacts on the country’s development goals. The nutritional status of certain parts of the
world shows challenging figures. Studies indicate that stunting affected an estimated 22.2
per cent (150.8 million) children under 5 globally, wasting continued to threaten the lives of
an estimated 7.5 per cent (50.5 million) children under 5 globally and an estimated 5.6 per
cent (38.3 million) children under 5 around the world were overweight in 2017 ( Levels and
Trends in Child Malnutrition, 2019). Sri Lanka is among the regions that showed very high figures
of stunting and wasting among children under 5.
Sri Lanka that suffered from undernutrition in the past is currently facing a double burden of
undernutrition and overnutrition as societies undergo nutrition transition which is a result
of economic, demographic, and epidemiological changes. In the latest available data, in Sri
Lanka, prevalence of underweight among under five was 21% (Department of Census and
Statistics, 2009) while 25% of the adults were overweight and 9% were obese (Katulanda et
al., 2010). “Over the past 20 years, a global overweight/obesity epidemic has emerged,
initially in industrial countries and now increasingly in low- and middle-income countries,
particularly in urban settings, resulting in a triple burden of undernutrition, micronutrient
deficiency, and overweight/obesity” (Townsend, 2015, p. 11).
There is a consensus that agricultural activities largely impact nutrition of the community.
Agriculture determines food diversity, accessibility, household food security, dietary quality
and economic incentives of those in the food value chain affecting their food affordability
and consumption. Development in agriculture has the potential to improve nutrition status
of a community even though in many cases, the outcomes may not be measurable whereas
in some, evidence may be more conclusive (Pandey, Mahendra Dev & Jayachandran, 2016).
Agricultural production growth and income growth may give people better access to nutrient
rich food, thus resulting in improving nutrition status. While agriculture has immense
potential to improve nutrition, it is noted that standalone nutrition specific interventions do
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not have the capacity to meet global targets for improving nutrition, and multisectoral
collaborations are hence required to influence underline determinants of nutrition outcomes
(Ruel, Quisumbing & Balagamwala, 2018). It is, therefore, necessary to understand the
contribution of each dimension of development on nutrition and the pathways in which they
influence health and nutrition of a community. If these dimensions are understood, such
knowledge can be used to plan effective interventions and adjust existing interventions in
order to maximize agricultural, socioeconomic, health and nutrition goals.
Our study, Improving Nutrition through Modernizing Agriculture in Sri Lanka (INMAS), aims
to evaluate nutrition promotion activities through the Climate Smart Irrigated Agriculture
Project (CSIAP) in three districts of Sri Lanka. The Department of Agriculture and the
Department of Agrarian Development that come under the Ministry of Agriculture have been
identified as key implementing agencies responsible for several non- health related
interventions. There are several agriculture projects to improve livelihoods of farmers and
agriculture outputs in Sri Lanka implemented in collaboration with the Ministry of
Agriculture, and the CSIAP is one of the main agriculture development projects in the
country. The main objectives of the project include identifying the pathways to promote
nutrition and health of farmers and farming communities with multiple stakeholders. Our
study aims to explore the pathways of improving nutrition and health of the community
using the CSIAP project and quantifying their relative contributions on food and nutrition
security related outcomes.
This paper reviews some literature on nutrition and agriculture to explore and establish the
direct contribution of agricultural development programmes on food and nutrition security
related outcomes, and as to how such programmes can possibly address nutritional
challenges, especially in rural parts of the developing world. The paper also aims to identify
possible pathways to promote nutrition with multiple stakeholders. The findings of this
review will be shared to help shape the agricultural interventions of the CSIAP project to
ensure better nutrition related outcomes.
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Existing problems related to nutrition and reasons identified:
Malnutrition is a global challenge that restricts development. According to Global Nutrition
Report (2018), undernutrition explains around 45% of deaths among children under five,
mainly in low and middle-income countries, and the health consequences of overweight and
obesity contribute to an estimated 4 million deaths (7.1% of all deaths) and 120 million
healthy years of life lost (disability-adjusted life years or DALYs) across the global population.
While South Asia is home to nearly half of the undernourished population on earth, food
insecurity remains high globally, with around 23% of the population having no access to
satisfactory calorie intake (Maestre, Poole, & Henson, 2017). Poverty is seen as a key barrier
to addressing undernutrition, and the majority of the poor people live in rural areas.
Affordability is a major factor that determines access to safe and nutritious food. Hence,
despite the availability of nutritious foods in the market, such foods are not sufficiently
consumed by the poor due inaccessibility in terms of lack of physical availability and/or high
prices - and extremely sidelined households may not have adequate calories year-around or
periodically or may consume foods that are low in quality or unsafe (Maestre, Poole, &
Henson, 2017). It is observed that ‘lack of sufficient nutrition among children below two
years of age and in pregnant women has irreversible generational health and developmental
consequences for individuals and society’ (Maestre, Poole, & Henson, 2017, p. 31).
Micronutrient malnutrition is said to affect billions of people and entail ‘huge human costs
and large economic costs (up to 5% of GDP by some estimates)’, and it is not possible to
address this issue only ‘by food fortification and capsule supplements’ (Haddad, 2000,
p.371). Haddad insists that in order to find sustainable solution to the micronutrient
malnutrition, agriculture and food-based approaches are required to play a central role.
Identifying the vulnerable community
The majority of poor people in the world live in rural areas, most depending on agriculture
for livelihood. According to Townsend (2015), the global figures in 2010 indicated that ‘over
900 million poor people (78 percent of the poor) lived in rural areas, with about 750 million
working in agriculture (63 percent of the total poor)’ (p.6). The agriculture sector employs
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60% of the total global workforce, making agriculture the main source of livelihood for many
((Maestre, Poole, & Henson, 2017).
AGRICULTURAL WORKERS SHARE IN THE
WORLD
Asia & Pacific Africa Latin America
Industrialized Countries Transition Countries
Data Source: International Labour Office (2011)
According to International Labour Office (ILO), available data indicates that the share of
agricultural workers in the world is proportionate to the share of poverty in the world.
POVERTY SHARE IN THE WORLD
Asia & Pacific Africa Latin America Other regions
Data Source: International Labour Office (2011)
The rural economy of developing countries such as Sri Lanka largely depends on cultivation,
distribution and consumption related to agricultural activities on which a significant number
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of the community depends. As estimated (Department of Census and Statistics, 2017a),
nearly 30% of the rural economy of Sri Lanka depends on agriculture, and in the first quarter
of 2017, 27% of employed population in Sri Lanka are employed in the agriculture sector
(Department of Census and Statistics, 2017b).
Establishing the link between Agriculture and Nutrition:
Based on several studies, Ruel, Quisumbing and Balagamwala (2018) assert that without the
contribution of other sectors nutrition specific interventions alone, even if implemented on
a large scale, do not have the capacity to meet global targets for improving nutrition. Among
other sectors, agriculture-led growth has immense potential to influencing the underlying
determinants of nutrition outcomes and is said to be more effective in reducing poverty (Ruel
et al., 2018; Shekar, 2015); and the underline determinants include ‘global food availability
and access and through enhancing household food security, dietary quality, income, and
women's empowerment’ (Ruel et al., p.128). The Food and Agriculture Organization (FAO)
of the United Nations (2013) also agrees that agriculture is of fundamental importance to
human nutrition, ‘both as a direct determinant of household food consumption and through
its role in livelihoods and food systems’ ((p.1).
Pathways in which Agriculture can improve nutrition include:
− Agriculture as a source of food: This is the most direct route to improving the
diet (quantity and quality) is to ensure year-round access to adequate, safe,
nutrient-rich food, and is based on two assumptions: (i) increases in production
of a range of foods, including dairy, fish, fruits, grains, livestock, root crops and
vegetables, enhance food availability and access to a diverse diet; and (ii)
increased food availability and access will lead to greater intake and improved
nutrition outcomes at the individual level.
− Agriculture as a source of income: This is based on the assumption that an
increase in income from agriculture-related activities (including processing and
sale of agricultural products or wages earned) can be used to access health
services or purchase higher-quality, nutrition-rich food that is consumed by
individual household members.
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− Agriculture as a driver of food prices: Increased availability of food through more
efficient production techniques, improved technologies (for postharvest
storage, processing and distribution) and domestic and trade policies affects a
range of supply and demand factors and influences the price of food (fresh and
processed). This in turn affects the income and purchasing power of households.
− Agriculture to empower women: Initiatives that both educate women and
enhance their involvement in agriculture-based activities can strengthen
women’s capacity, increase their access to, and control over, resources and
assets, consequently augmenting their power to make decisions on the purchase
and allocation of food, health and care within their households.
− Agriculture to contribute to macroeconomic growth: Agriculture is the
dominant productive sector in many developing countries. Increasing
agricultural productivity raises national revenue, increasing the funds available
to invest in improving essential basic social services, such as education, health,
safe water supply, sanitation and safety-net programmes, which have been
shown to improve nutrition outcomes.
− Agriculture to ensure sustainable food and nutrition security and resilience:
Protecting and promoting biodiversity is essential to support dietary diversity
and the preservation of ecosystems. Agricultural practices that promote the
sustainability of natural resources (biodiversity, forestry, soil and water) ensure
the long-term future of agricultural production and the sustainability of
livelihoods and build resilience to climate change (Nutrition Sensitive
Agriculture,2015, pp.3-4)
Pandey, Mahendra Dev and Jayachandran (2016) present testable hypotheses that are
similar to the link established above but focuses on the nutritional outcomes of those who
engaged in agriculture for livelihood. The presented hypotheses include: agricultural
produce by the farmers is used as a source of food for their own household affecting nutrition
outcomes of the family; agriculture generates income that may be allocated for food
enabling households engaged in agriculture to access nutrient-dense food available in the
market; the socioeconomic status of women in agriculture may give women intra-household
decision making and resource allocation power influencing the nutritional status of the
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mothers and their children; and the involvement of mothers in agriculture may influence
their ability to manage child care and feeding.
While Ruel et al., (2018) also discuss the above pathways through which agricultural
interventions can impact nutrition outcomes of the community engaged in agriculture, they
note that the impacts may not always be positive. For instance, women's time allocation to
agricultural activities may compromise their own nutrition and that of their children; and
women’s engagement in agriculture may also expose them to various toxins and create
disparity between their energy intake and expenditure resulting in poor health and nutrition.
Expanding on the same line of argument, Haddad (2000) recognizes specific effects and
generic effects of agriculture in addressing nutrition related issues such as malnutrition.
Specific effects include nutritional impact of food prices, food consumption on own
production, post-harvest activities such as storage, commercial processing, in-home
processing, preparation, nutrient availability, and plant-breeding targeting nutritional
outcomes. Generic effects include effects of increased agricultural productivity on income,
changing time allocation patterns to give more care for children, changes in household
decision-making, impacts on nutrient requirements and health, energy and nutrient
expenditures, and health environment effects of agricultural production. However, these
agricultural activities can also generate negative effects if not implemented with a
comprehensive understanding of the nutrition outcomes.
Need for policies related to agriculture and nutrition
It is believed that nutrition objectives can be achieved through agricultural policies,
programs, and projects if they are designed targeting positive nutrition outcomes. However,
it is necessary to establish that the agriculture sector is not expected to substitute primary
healthcare delivery - but given the difficulties in the healthcare sector to reach every
household, especially in rural areas, ‘maximizing the nutrition effects of agricultural policies,
programs, and projects already in place seems to be an attractive alternative for improving
nutrition’ (Kennedy and Bouis,1993, p.18).
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Even though it may not be evident ‘how agricultural policies and programs influence the
health and sanitation environment and nurturing behaviors’ (Kennedy & Bouis, 1993, p.5),
the correlation between them is increasingly recognized as central to delivering nutrition
outcomes. Kennedy and Bouis give examples of how the unrestrained use of certain types of
pesticides may have negative health effects, whereas certain agricultural policy and program
changes may influence the time allocation within the household for agricultural activities,
resulting in changes in the time dedicated to caregiving and nurturing.
Kennedy and Bouis (1993) identify three main pathways through which agricultural policies
and programs influence the nutritional status of individuals:
(I) increased incomes and lower food prices, which permit increased food
consumption; (2) effects on the health and sanitation environment at the
household and community levels, which may increase or reduce morbidity; and
(3) effects on time-allocation patterns, particularly of mothers, which may
increase or reduce time spent on nurturing activities—time that is often related
to women’s control over household income and is an important determinant of
women’s nutritional status. (p.2)
According to these two authors, if effects on food prices and household income, morbidity,
and time allocation, especially in association with nurturing activities are properly
established, it will help understanding ‘the net effect of agricultural policies and programs
on nutrition’ (p.5). Pandey, Mahendra Dev and Jayachandran (2016) also observe that
policies can affect the relative prices and affordability of various marketed food and non-
food crops.
Studies of Shankar, Poole and Bird (2018) show that ‘breeding of high yielding varieties of
crops, especially cereals, accompanied by policies promoting the use of fertilizers and
pesticides, has revolutionised production since the 1970s’ (p.1) in South Asia. They assert
that investments and policies such as the ones that ‘focused on the green revolution package
of inputs have been instrumental in raising productivity of South Asian staples, alleviating
poverty, boosting food security and reducing hunger’ (p.1).
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Nevertheless, it is noted that production and/or production diversity and/ income do not
necessarily influence adequate nutrient intake of farming communities for a healthy living or
effect better nutrition outcomes. It is observed that in some regions in South Asia, farmers
tend to sell more expensive, more nutritious produce on the market, retaining less lucrative
foods such as cereals for self-consumption (Rao & Pingali, 2018). Therefore, drawing a set of
policies and programmes targeting nutrition outcomes through agricultural activities is
required to ensure effective outcomes both in terms of agriculture and nutrition.
Since agriculture is a major employer, especially of women in developing countries,
improvements in agricultural activities can elevate income for women, leading to influence
the intra-household allocation of food and other decision making related to improving
nutrition of the family. However, ‘heavy agricultural workloads and exposure to toxins and
disease through agricultural activities can deleteriously affect women’s health and nutrition
and also have negative consequences for lactation and child-care’ (Rao and Pingali, 2018,
p.2). Hence, focusing on gender sensitive policy frameworks and programmes are required
to mitigate negative impacts of agricultural activities.
Food safety is another vital factor that determines the delivery of the desired nutrition
outcomes, and to ensure that, there are series of requirements for the value chain to operate
successfully from processing, storage, distribution, preparation till consumed (Maestre,
Poole, & Henson, 2017). It is therefore necessary to have comprehensive agricultural and
nutritional policies to guarantee that communities have access to nutrient rich safe foods as
well as have education and knowledge to make healthy food choices.
Agricultural outputs generate impacts beyond the sector. According to Haddad (2000), while
increases in agricultural outputs have direct impacts on those who are engaged in
agriculture, it can generate greater second-round effects that impact the rural economy.
“These effects arise in the sectors that supply the agricultural sector with goods and services
and via the demand from those rural non-farm sectors that need further goods from
agriculture. In some cases, these second-round effects are larger than the initial growth in
agricultural output” (p.370). Therefore, multiple stakeholders are required when designing
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policy frameworks to ensure the effective delivery of targeted nutrition outcomes through
agricultural activities.
Planning effective interventions
3.4.1 Data Source: DFID’s Sustainable Livelihoods Approach and its Framework (2008):
Agricultural interventions for improved nutrition
The Sustainable Livelihoods Framework, which is a conceptual design presenting central
factors that influence people’s livelihoods, and the correlation between them, identifies five
types of assets that can be ‘supported and strengthened in any development intervention’ -
these include: physical, financial, social, human and natural ‘capital’ (Berti, Krasevec, &
FitzGerald, 2004, p.600). These assets can be developed during agricultural interventions to
ensure improved food security and nutrition outcomes.
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Out of 30 agricultural interventions reviewed by Berti et al., (2004) that measured nutritional
impact included home gardening, livestock, mixed garden and livestock, cash cropping, and
irrigation. Their review assessed whether those projects invested in human, physical,
financial, social and natural ‘capital’ as stated in the Sustainable Livelihood Framework, and
whether such investments resulted in positive nutrition outcomes. According to their
findings, most agricultural interventions increased food production, without necessarily
enhancing nutrition or health of participants, but:
Those agriculture interventions that invested broadly in different types of capital
were more likely to improve nutrition outcomes. Those projects which invested in
human capital (especially nutrition education and consideration of gender issues),
and other types of capital, had a greater likelihood of effecting positive nutritional
change (p.599)
“Synthesis of Guiding Principles on Agriculture Programming for Nutrition” (2013) published
by the Food and Agriculture Organization of the United Nations (FAO) claims ‘agricultural
investments targeted to smallholder farmers are more likely to succeed if they address the
human capital constraints due to malnutrition’ (p.1)
As stated by the FAO, several best practiced principles when planning agriculture
interventions targeting nutrition outcomes are:
Incorporating explicit nutrition objectives into agricultural projects, programmes and
policies; assessing the context to identify nutritional problems and groups most at
risk; avoiding unintended negative consequences through a process of identifying
potential harms, developing a mitigation plan, and setting in place a well-functioning
monitoring system for timely detection of negative effects; measuring impact
through programme monitoring and evaluation; maximizing opportunities through
multisectoral coordination; maximizing impact of household income on nutrition
through concerted design efforts; increasing equitable access to productive
resources through policies and programmes; targetting the most vulnerable groups,
including smallholder farmers, women and poor/ food- insecure households;
empowering women, the primary caretakers in households; incorporating nutrition
education to improve consumption and nutrition effects of interventions; managing
natural resources for improved productivity, resilience to shocks, adaptation to
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climate change, and increased equitable access to resources through soil, water and
biodiversity conservation; diversifying production and livelihoods for improved food
access and dietary diversification, natural resource management, risk reduction,
improved income and other purposes; increasing production of nutrient-dense
foods, particularly locally-adapted varieties rich in micronutrients and protein,
chosen based on local nutrition issues and available solutions; reducing post-harvest
losses and improve processing to increase and prolong access to and consumption
of diverse foods among both producers and consumers, to preserve or increase
nutrient content of food, to increase income and profit margins and to improve food
safety; increasing market access and opportunities to improve smallholder incomes
(especially for women) and consumer diets; reducing seasonality of food-insecurity
through diversification throughout the year, improved storage and preservation, and
other approaches; improving policy coherence supportive to nutrition, so that one
policy does not work against another policy or programme; improving good
governance for nutrition, including leadership and commitment at the highest levels
of governments and donors, implemented by drawing up a national nutrition
strategy and action plan; building capacity in ministries at national, district and local
levels, and increase nutrition staff; Communicate and continue to advocate for
nutrition ("Synthesis of Guiding Principles on Agriculture Programming for
Nutrition", 2013, pp. 7-9)
The papers reviewed by Pandey, Mahendra Dev and Jayachandran (2016) indicate that
homestead gardens are central to influencing fruit and vegetable consumption; and an
increased food production is often linked with a decrease in the number of underweight
children and decrease in the prevalence of low BMI. However, they are unsure if this result
is owing to the pathway of direct food consumption by infants and mothers or the income
pathway. These authors also report that increased food supplies have encouraged the calorie
intakes and enhanced diet diversity; and the increase in food production, particularly that of
staple grains, pulses and vegetables, has shown ‘more conclusive evidence on improving the
nutrient intake and nutritional outcomes, compared with the overall agricultural growth
rates’ (p.36).
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Ruel, Quisumbing and Balagamwala (2018) present several studies showing evidence that
‘agricultural development programs that promote production diversity, micronutrient-rich
crops (including biofortified crops), dairy, or small animal rearing can improve the production
and consumption of targeted commodities, and some evidence that such improvements lead
to increases in dietary diversity at the household and sometimes the maternal and child level’
(p.129)
Supporting evidence generated above, Maestre, Poole and Henson (2017) identify different
potential pathways that propose ways in which post-farm gate value chain interventions can
enable improved nutrition among the poor. Those two pathways include: overall dietary
diversity increases ‘by enhancing access to, and consumption of, foods that are naturally rich
in micronutrients’ such as fresh fruits and vegetables, meat, fish, dairy products, and pulses;
and by increasing the supply and consumption of nutrient-dense foods through ‘the
production and distribution of foods with increased nutritional value’ (p.34).
3.4.2: Challenges when planning agricultural interventions targeting nutrition outcomes
Ensuring food safety and preserving their nutrients along the value chain till consumption is
seen as a challenge. “There is potential for loss of nutrients along the value chains during
processing, storage, distribution and/or preparation due to spoilage, adulteration,
inappropriate handling or preparation methods” (Maestre, Poole & Henson, 2017, p.36).
High costs involved, absence/want of surveillance programs, and limited opportunities to
build employee awareness and education are seen as some of the barriers to maintaining an
effective food safety system, especially in the developing world (Weinroth, Belk & Belk,
2018).
In certain instances, access to nutritious food also depends on gender biases and favoritism
within each household. Nutritious food should reach ‘not only households but also
individuals within households’, and ‘food must be consumed in adequate amounts by each
individual on a sustained basis to bring about the desired nutritional outcomes’ (Maestre et
al., 2017, p.36).
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Majority of employed women in South Asia depend on agriculture for livelihood. Even
though financial empowerment of women through their involvement in agriculture may
result in better nutrition outcomes through allocation of funds on nutrient-dense food,
Pandey, Mahendra Dev, & Jayachandran (2016) observe that the maternal nutritional
outcomes and health of both the mother and child may be compromised due to mothers’
involvement in agriculture. Finding a fine balance without compromising financial
independence of women engaged in agriculture would also be a challenged when designing
agricultural interventions targeting nutrition outcomes.
Increased production or production diversity of nutrient-dense foods do not always
encourage sufficient nutrient intake of farming families resulting improved nutrition
outcomes within households. As observed in certain areas of South Asia, farmers are inclined
to trade costly produce with high nutritional value for financial gains, keeping less lucrative
foods with less nutritional value for their own consumption (Rao & Pingali, 2018). Owing to
such habits, agricultural interventions to improve production and production diversity may
not necessarily result in improving nutrition of the agricultural households.
Owing to a better income, communities undergoing nutrition transition may have changed
their diet and physical activities, not necessarily resulting in positive outcomes but leading
to nutrition issues such as obesity – and at the same time, deploying modern machineries in
agricultural activities may have improved the yield but not necessarily nutrient-rich food, as
farmers opt to fewer varieties of high-yielding cash crops as oppose to traditional subsistence
farming that produced a variety of crops needed for a well-balanced diet (Nutrition Sensitive
Agriculture, 2015). Therefore, modernizing agriculture can pose certain challenges if not
implemented with clear objectives.
There is sufficient evidence to believe that agriculture-led growth has potential to influence
the underlying determinants of nutrition outcomes - and ‘overall, growth originating from
agriculture has been two to four times more effective at reducing poverty than growth
originating from other sectors’ (Ending Poverty, 2015, p.7). Reduction of poverty also in
return determines affordability without households, often leading to influencing improved
allocation of funds for food expenses, which may result in better nutrition outcomes.
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However, growth in agricultural production and/or production diversity and income growth
do not necessarily result in improved nutrition outcomes of families engaged in agriculture.
This may be due to varied reasons such as lack of education on nutrient rich foods and
nutrition outcomes, determining which crops and vegetables to grow based on market prices
rather than based on their nutritional value, selling more expensive nutrient-dense produce
without retaining for own consumption for financial gains, and lack of decision-making
power for women within households etc. It is, therefore, necessary to design sustainable
agricultural interventions and programmes targeting required nutrition outcomes to
eradicate reasons that prevent households from achieving individual nutrition requirements.
For this purpose, it is required to understand the contribution of multisectoral stakeholders
on nutrition outcomes and assess each determinant of nutrition outcomes.
Even though a multisectoral approach has been recognized and recommended by many to
promote nutrition through agricultural interventions, there is limited evidence on
agricultural interventions implemented with multisectoral partners targetting nutrition
outcomes.
To do so, with the help of the above findings, the INMAS study aims to formulate an evidence
based, scientific multisectoral action plan with the involvement of health, nutrition,
agriculture and development stakeholders from community, government and non-
governmental organizations; and undertake nutritional and health impact assessment and
evaluation in order to build better evidence to demonstrate the link between nutritional and
health outcomes and their upstream determinants such as agriculture, education, and
income.
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Objective
1. To formulate an evidence based, scientific multisectoral action plan with the involvement
of health, nutrition, agriculture and development stakeholders in the community,
government and non-governmental organizations.
2. Develop nutritional and health impact assessment and evaluation plan demonstrating the
link between nutritional and health outcomes and their upstream determinants such as
agriculture, education, and income.
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Description of activities
1. Methods of literature review
A systematic literature search was performed using PubMed
(https://www.ncbi.nlm.nih.gov/), https://www.embase.com, the Chocrane library
(https://www.cochranelibrary.com) and google scholar (https://scholar.google.com). We
used key terms that includes but not limited to the following.
"Malnutrition"[Mesh]
"Protein-Energy Malnutrition"[Mesh]
"Infant Nutrition Disorders"[Mesh]
"Child Nutrition Disorders"[Mesh]
"Nutrition Policy"[Mesh]
"Diet, Food, and Nutrition"[Mesh] AND
"Nutritional Status"[Mesh]
"Nutritive Value"[Mesh]
"Nutritional Requirements"[Mesh]
"Agriculture"[Mesh]
"Intersectoral Collaboration"[Mesh]
Our search derived a total of 2351 results. Out of these 107 were considered relevant and
fully reviewed. This search, in additoin to finding background data were able to locate
other similar studies conducted elswhere (Annexure -3) (Vie, Scheier et al. 2015, Cole, Levin
et al. 2016, Debray, Mas et al. 2016, Hanachi-Guidoum 2016, LeBovidge, Elverson et al.
2016, Aryeetey, Holdsworth et al. 2017, Ballou, Wiseman et al. 2017, Kaufman, Boren et al.
2017, Knoblock-Hahn, Murphy et al. 2017, Laar, Aryeetey et al. 2017, Lewis, Gardner et al.
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2017, Li, Rasooly et al. 2017, Myotoku 2017, Sagner, McNeil et al. 2017, Tomlinson, Jordans
et al. 2017, Roblin, Truscott et al. 2018, Roche, Bury et al. 2018, Sumi, Hasegawa et al.
2018).
2. The background assessment
Listing of key stakeholders
Identification of key stakeholders at central and policy making level, middle level and
grassroot level were conducted separately. Qualitative methods were primarily used. Key
informant interviews, study of policy documents and proposals were used.
We observed that, the local authorities, newly recruited/to be recruited project staff (CSIAP)
as well as grass root level workers and community members did not have a good
understanding of the proposed project. This is mainly because the CSIAP is a novel concept
running as a new program. Due to local political and many other challenges at the level of
program designing and implementation the CSIAP is yet to be fully operational. Our study
team identified the importance of obtaining as much data as possible about the
organisational structure and how the CSIAP will be operated once in full vigour. This
information is vital to map the pathways which other organisations can contribute. Further
the staff and stakeholder awareness program on nutrition promotion needed to be catered
to this framework.
Several key informant interviews were conducted with the officers who are involved in
planning of the program as well as potential grass root level workers. Further clarity and
focused discussions are needed to facilitate the designing of the intervention once the
project is fully operational. Basic food availability and market survey by way of field visits and
review of sales records in selected local food vendors and grocery shops were conducted to
obtain a basic understanding of the food availability and consumption patterns. We observed
a high variability within districts and across districts. Health records with medical officers or
selected MOH areas as well as centrally available data were reviewed.
Development of an action plan.
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a. Expert group meetings were held with agriculture, health promotion, nutritional and
medical education experts from local and central levels. Potential target areas for health
promotion and education program were identified. These include:
i. Identification of nutritional needs within families, localities and in the region
ii. addressing food availability and dietary choices for consumers at local and regional
level
iii. consumer awareness on food selection and food preparation
iv. identifying pathways of linking healthy crop selection at the farmers and consumer
demand
Curriculum development
outcome-based approach is a need-based approach at the cutting edge of curriculum
development, which offers a powerful and appealing way of reforming and managing
education. It helps curriculum planning and offers a framework for teachers designing to plan
and implement education programmes and to assess participants’ performance. Previous
work including a similar project titled INPARD (Integrating Nutrition Promotion through Rural
Development) has identified that curriculum development in Sri Lanka needs rigorous
planning to identify community needs, develop course outcomes and competencies, identify
content areas and plan teaching/learning and assessment. Hence the first step in our
approach was to identify the exit outcomes.
A stakeholder survey was used to identify outcomes and core competencies. Health needs,
nutritional requirements and food patterns were studied. Experts on crop management and
agriculture provided inputs. Workshops were conducted with specialists in nutrition, health
services delivery, agriculture and education. Previous material were studied in similar
interventions and training.
After triangulation of the data which were collected by qualitative and quantitative methods,
core competencies and outcomes were developed through a series of meetings using expert
inputs from a range of different fields. The course content was developed to achieve these
core competencies and outcomes.
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Exit outcomes that were developed are
• Identifying common nutrition issues of the area and their health implications
• Nutrition related implications of farming, agricultural produce and rural
development interventions in the area
• Planning and implementing health promotional activities including health education
• Working effectively in collaboration with health and other sectors
• Promoting community empowerment in order to improve basic nutritional needs.
Training of stakeholders
Previous training programmes related to similar projects were identified and reviewed.
Through integration of existing materials and further revisions programme that was
developed was mainly contained three modules.
• Module one - Linking agriculture, rural development and nutrition
• Module two - Health promotion
• Module three – Inter-sectoral collaboration
Content areas for first second exit outcomes are as follows. Several common nutritional
issues such as malnutrition, micronutrient deficiencies, misconceptions on nutrition,
controlling the use of alcohol and tobacco and nutrition related implications were identified.
Nutritional assessment, dietary supplementation, breast feeding and supplementary feeding
etc. were also recognized as health implications. Positive and negative impacts were taken
into consideration for critically evaluating nutrition related implications of rural
development interventions in the area. Positive impact on nutrition included increased food
production, improved quality of life due to increased income and new self-employment
options. Negative impact on nutrition included low quality of food due to mass production,
environmental pollution due to fertilizers and wastage of excess food.
Based on these, the need for an upward reporting mechanism for multi-sectoral action is
also being identified. Under the attitude towards collaboration, the need for collaboration
is identified by all the sectors based on minimizing waste, sharing knowledge and resources.
Meantime, the capacity of non-health sector is constantly being questioned by experts of
the health/ nutrition sector. In the training and development stage, understanding the role
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of the health sector and other sectors and programme objectives in nutrition promotion are
being highlighted. The emphasis is also given on not duplicating the roles in the process but
supplementing the roles to get a better outcome. While operational guidelines should
promote inter-sectoral collaboration, the existing structure at the grass root level should be
put into practice.
Content area for intersectoral collaboration module is as follows. Regarding planning and
implementing health promotional activities, the stakeholders involved in nutrition
promotion such as ministry of health, ministry of agriculture, district secretariats, ministry of
education etc. played a major part. Programmed cycle consisted of strategy setting,
programme development, resource mobilization, implementation monitoring and
evaluation. Leadership skills, team working skills and interpersonal communicational skills
were recognized as skills required for effective collaboration.
Stakeholders in Vantharamullai, Batticaloa
Promotion of nutrition sensitive agriculture, community empowerment in order to improve
basic nutritional needs is the last content area of the programme. Developing self-awareness
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about their community, identification of causes and Solutions, getting knowledge about laws
and legislations to create a supportive environment and vision plan to achieve the targets
for basic nutritional needs were the main components of the above objective. The
participants, of identified sectors were taught how to collaborate to promote nutrition.
These leaders were trained to play a key role in designing and delivering interventions in
their setting.
Several teaching and learning methods such as lectures, group discussions, demonstrations,
workshops and case scenarios were used for all three modules to convey the massages to
stakeholders. Lectures were used to convey critical information, background information
and theories. Lectures were conducted in the nutrition module were about common
nutrition issues of the area and their health implications as under nutrition and over nutrition
and risk factors for obesity and Non Communicable Diseases.
Group discussions allowed active involvement by everyone. Participants learnt from each
other, using two way discussions which are almost always more creative than individual
thoughts. Discussions in the nutrition module were done about the ways of eliminating
misconceptions about dietary practices, identifying ways to reduce quality of food due to
profit oriented mass production etc. Discussions in the intersectoral collaboration module
were about how to be a good team worker, skills of a team worker, completion of the
intervention within an allocated time and budget etc. Discussions in the rural development
module were about creating a vision plan to achieve the targets for basic nutritional needs.
Demonstrations involved showing by reason or proof, explaining or making clear by use of
examples or experiments. Demonstrations in the nutrition module were organized to
recognize the importance of dietary supplementation such as to identify common clinical
signs of malnutrition, common micronutrient deficiencies, new agricultural techniques of
increasing food availability, health services available on local hospitals etc.
Workshops are a popular format for creative meetings that elicit participants’ creative drive
and motivation. Workshops and some demonstrations in the nutrition module were held
about acquiring the skills of collecting anthropometric data and calculating BMI, recognizing
quality food, family income management and related increased food production with food
availability. Workshops in intersectoral collaboration module were conducted on bringing
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people together in groups to address common issues, encouraging groups to participate and
influence decision making.
Case scenarios and role play provided opportunities for discussing the purposes of particular
activities, for reflecting on the specific needs of learners and for developing new teaching
skills in a comfortable non-threatening learning environment. Dramas included the skills of
appropriate responding with understanding and attitude development.
Stakeholders trained to understand the impact of their decisions on nutrition (e.g.
introduction of a new crop). Multi-sectoral committees discussed how each sector could
contribute to address identified nutritional problems and achieve common goals. Nutrition
related technical knowledge was provided by the local health staff.
Evaluation framework
• Development of evaluation framework was started via expert groups on health
information systems development, health statistics, nutrition and anthropometry.
Evaluation framework was discussed in several key expert meetings before the initial
draft framework was formulated. The key concerns identified were:
a. Scientific evaluation of the inputs, outputs, outcomes and impact
b. Time factor in achieving the above indicators and facility to measure
these in the given timeframe
c. Quantitative and qualitative methods to be used
• Finalizing tools for evaluation (annexed)
• Quality maintenance and checks
• Pilot study to check and adjust data collection tools
• Obtaining ethical clearance
• Identification of study population (still underway as many areas in INMAS project are
yet to formulate a comprehensive list of its implementation areas/households yet)
• Development of the databases
• Development of the analysis framework
• Recruitment of suitable data collectors
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• Training of data collectors and development of a quality control plan
• Development of qualitative study plan and instruments
b. World Health Organization STEPS tool including anthropometric assessment
c. Limited food frequency questionnaire
The tools were pilot tested and data collectors with a medical background have already been
recruited from localities. They are currently being trained on maintaining quality data
collection and anthropometric techniques. Data collection was done with real time data
entry to improve accuracy. The database and data entry system have been developed and
pilot tested.
2.1: Data Collection
Sampling and selection of households from the selected districts and Grama Niladhari
dividsions were carried out using a systematic method. Sample size calculations were carried
out using standard methods to estimate a prevalence of 5% with a 95% confidence, 5%
margin of error. We used an arbitrary 5% as a safe value that is lower than the prevalence of
all metabolic risk factors that we measure in this study. Kurunagala district was used as the
control population. We used an unmatched control population. Results were adjusted using
standard power calculations using the population of each Grama Niladhari division. Further
adjustments were made based on age and sex distribution.
2.1.1: Quantitative Data Collection
Sampling frame : Adults and children aged 12-18 in households residing in each
district.
Sample size : Calculated to detect a change of 5% from a baseline prevalence of 5%
(arbitrarily low values) with 95% confidence interval and a power of 80 - the total
sample size is 484. We proposed to round up this number to 500, and to obtain
250 from each district.
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Sampling strategy : Stratified cluster sampling
Districts - Divisional secretaries - Grama Niladari Divisions - random selection of a
household from the electoral list and sample from there onwards to select a total
of 15 households from each village. Out of the eligible adults in each household, a
randomly selected two adults and two children (ages 5-15 years) were recruited.
We expected to obtain 25 adults and 25 children from each village and take 10 GN
divisions from each district.
During the post-intervention survey, quantitative data were collected from the
same sample taken for the baseline data collection. Outcome measures includes
health behaviours (i.e. diet, physical activity, alcohol, and smoking),
anthropometrics (height and weight), demographics and area-level measures
related to food access (e.g. food availability, price and poverty indicators).
Quantitative data related to nutrition and other lifestyle risk factors were collected
at the village level and school level by trained data collectors using tools that were
developed and translated into both Sinhala and Tamil during the baseline survey.
Data collection was mostly conducted by pre-intern medical officers who were
trained in scientific method and anthropometric data collection. Data from adults
and children below 12 years were collected through interviewer-administered
questionnaires at the village level. Area level information on food availability, price
and market trends were assessed by researchers visiting localities and shops in the
villages.
2.2: Tools
Tools that were developed during the baseline survey have been reviewed
and revised according to the feedback received from the community. The
revised tools have been translated into both Sinhala and Tamil.
1. World Health Organization STEPWISE tool – translated to Sinhala and Tamil
2. Short form food frequency questionnaire
3. Qualitative assessment – scripts to be developed based on the background
assessment
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Figure 1 : STEPS approach, courtesy of World Health Organization, STEPS surveillance mannual,
2017
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Qualitative Data Collection
Qualitative data collection included key informant interviews and focus group
discussions (FGD). The aim of these interviews and FGDs was be to understand the
dietary changes and changes in attitude, behaviour and practices related to food
and nutrition due to the project intervention.
FGDs was conducted with, community members and grassroot level officers who
took part in the first round of FGDs. Each FGD included not more than eight
individuals. Grassroot level offers include CRPs, Economic Development Officer, Divi
Neguma Development Officer, Midwife, Agriculture Instructor, School
representatives (teacher/ Principal), Grama Sewaka and VDO Officer – and the
FGDs was conducted in combined clusters.
The majority of poor people in the world live in rural areas, most depending on agriculture
for livelihood. According to Townsend (2015), the global figures in 2010 indicated that ‘over
900 million poor people (78 percent of the poor) lived in rural areas, with about 750 million
working in agriculture (63 percent of the total poor)’ (p.6). As estimated (Department of
Census and Statistics, 2017a), nearly 30% of the rural economy of Sri Lanka also depends on
agriculture, and in the first quarter of 2017, 27% of employed population in Sri Lanka are
employed in the agriculture sector (Department of Census and Statistics, 2017b). According
to International Labour Office (ILO), available data indicates that the share of agricultural
workers in the world is proportionate to the share of poverty in the world. Reducing poverty
being a key component of policies related to ensuring food security, the INMAS study focuses
on exploring current dietary habits, attitude, behaviour and practices related to food and
nutrition of the community involved in agriculture for livelihood.
The pre intervention qualitative data collection includes focus group discussions (FGD) with
community members engaged in agriculture in control areas and the CSIAP intervention
areas in Anuradhapura, Batticaloa and Kurunegala districts. Change of dietary practices will
be assessed after the intervention through a round of post-intervention FGDs with the same
community.
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Based on several studies, Ruel, Quisumbing and Balagamwala (2018) assert that without the
contribution of other sectors nutrition specific interventions alone, even if implemented on
a large scale, do not have the capacity to meet global targets for improving nutrition. Among
other sectors, agriculture-led growth has immense potential to influencing the underlying
determinants of nutrition outcomes and is said to be more effective in reducing poverty (Ruel
et al., 2018; Shekar, 2015); and the underline determinants include ‘global food availability
and access and through enhancing household food security, dietary quality, income, and
women's empowerment’ (Ruel et al., p.128).
However, the agriculture sector interventions require multisectoral collaboration to
maximize benefits to the community and to ensure sustainability of such programmes. Even
though a multisectoral approach has been recognized and recommended by many to
promote nutrition through agricultural interventions, there is limited evidence on
agricultural interventions implemented with multisectoral partners targeting nutrition
outcomes. Therefore, the INMAS study aims to explore the current collaborations to
promote nutrition at grassroot level through agriculture activities and to understand the
knowledge on nutrition among grassroot level officers.
Figure 2: Focus group discussion in Karadiyanaru, Batticaloa
The pre intervention qualitative data collection includes focus group discussions (FGD)
mainly with ARPA/KUPANESA, the grassroot officers of the Department of Agriculture. The
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focus group will also comprise Samurdhi Officers (SO) of the Department of Samurdhi
Development and/or Economic Development Officers where possible. These FGDs will be
conducted in the CSIAP intervention areas in Anuradhapura, Batticaloa and Kurunegala
districts. Change of collaborations, practices and attitudes towards collaborations will be
assessed after the intervention through a round of post-intervention FGDs with the grassroot
officers in the same areas.
Methods in detail
Investigator will be meeting adults in the project intervention and control areas with the help
of Agrarian Development Officers (ADOs) or Divisional Officers of Agrarian Service Centres
and Agriculture Research & Product Assistant (ARPA/KUPANESA). Discussions will be
conducted using FGD guides by experienced FGD facilitators in the mother tongue of the
participants, focusing on understanding current agriculture related activities, knowledge,
attitudes and practices of diets and the factors influencing dietary habits of the community.
Participants will be given a chance to clarify queries related to the discussion. A written
consent will be taken from each participant agreeing to take part in the discussion.
Pre intervention qualitative data collection will include FGDs with sample of male and female
participants in CSIAP intervention areas and control areas.
Table 1: Focus group discussions conducted
Focus Groups Anuradhapura Batticaloa Kurunegala Tota
(Minimum 6 in a District District District l
group) CSIAP Contr CSIAP Contr CSIAP Control
Interventio ol Interve ol Interve Area
n Area Area ntion Area ntion
Area Area
Women 2 1 2 1 1 1 8
Men 2 1 2 1 1 1 8
Total FGDs with the community (all three district) 16
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Table 2: Timetable for qualitative group discussion
Approximate Purpose
duration (min)
Welcome and Introduction to 5 minutes Brief introduction
the participants
Consent from the participants 5 minutes Consent
Self-introduction by the 5 minutes Ice breaking
participants
Discussion (according to the 35 minutes Collecting data in order to
guideline) explore participants’ activities
related to agriculture, dietary
practices and related socio-
cultural determinants
End of the discussion 10 minutes Participants feed backs or
queries (If any) and thanking for
participation
Figure 3:Focus group discussion, Maho
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INMAS proposed outcome indicators and tools used for each indicator
Table 3: Tools developed for the study and outcome measurements
Age Outcome Outcome indicator Tools used to collect data
group/ category
Level
Adults
Diet Proportion of adults meeting SL food- WHO STEPwise Approach to
based standards. Chronic disease Risk Factor
Surveillance (STEPS) and
short form FFQ
Anthropometric Proportion of adults classified as Anthropometric
underweight, healthy weight, measurements taken by
overweight and obese trained researchers
following standard protocol
Physical Activity Proportion of adults meeting STEPS
recommendations of 150 min/week
Smoking Proportion of current smokers (WHO STEPS
definition)
Alcohol Proportion of adults who consume STEPS
alcohol (current/ever)
Area level measures
Village Food availability and access (price and Food availability and price
the presence of food items available data collected by
for purchase in village) researchers
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Results
Qualitative survey
Data collection, entry and initial data cleaning was completed. Data collection was
supplemented by random checks with double entry in 10% of the data collected to ensure
high quality and accuracy. The outlier rate in these checks was 3.6% which is a satisfactory
value in community level data collection. Data cleaning and preliminary analysis is
presented here. Advanced analysis including explanatory analyses will be included in
further scientific communications.
Table 4 :Summary of quantitative data collection
Batticaloa Anuradhapura Kurenagala Total
Female Male Female Male Female Male
CSIAP 165 93 147 114 - - 519
Control 56 52 88 35 119 101 451
Sample included more females (figure).
Gender distribution
250
200
150
100
50
0
Batticaloa Anuradhapura Kurunagala
MALE FEMALE
Figure 4 : Gender distribution of the sample
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Ethnic composition did not show a significant difference between the controls and
intervention groups.
Ethnic composition of the samle
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Batticaloa Anuradhapura Kurunagala
Sinhala Muslim Tamil Other
Alcohol and tobacco use was similar in control and interventional groups (P.0.05).
However higher rates and fruit and vegetable consumption was noted in the
control groups, a change driven by higher consumption in Kurunagal District
(figures below)
Table 4.2 Behavioural measures at baseline
Alchol and tobacco use
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Current smoker Alcohol/month
Intervention Control
Figure 5: Alcohol and tobacco use
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Fruits and vegetable consumption
Vegetable/days
Fruit/days
0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00
Control Intervention
Figure 6 : Fruit and vegetable consumptino, mean portions per day
Medical measures collected through the STEPwise survey also demonstrated similar
distributions between intervention and control areas at baseline (Table)
Table 5 : Medical measures at baseline
Intervention Control
BMI (kg/m-2) 21.5 22.1
Waist in cm 80 79
Hip in cm 88 89
Any NCD* 24% 26%
Diabetes * 7.3% 7.1%
Hypertension* 12% 12%
*self reported values
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Multisectoral action plan and key recommendations
Key messages:
1. Ensuring the nutritional needs of vulnerable groups is an ongoing challenge in Sri
Lankan communities. It is important to Identify these vulnerable groups within
families and communities. There is a role to be played by all sectors who interact
directly with local communities in this as many such individuals with these needs
may not actively seek help or be visible to the health sector.
2. Identifying their key nutritional challenges: with different nutritional issues co-
exists, reorganizing them by primary healthcare workers and also community
members (e.g obesity and micronutrient deficiencies among children or young
women)
3. Multi disciplinary training for different stakeholders in the community which
enables them to understand the goals and targets of different sectors and entry
points for collaboration
4. Regular focussed group discussions with communities and stakeholders will help to
constantly improve the interventions and approaches in a relevant and sensitive
manner.
5. Design the evaluation frameworks for agriculture projects including nutrition
indicators and initiate interactions among different stakeholders (agriculture,
irrigation, education, planning and health ) throughout the project time to get their
inputs and also to encourage them to use relevant results for their work.
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3. Key Activities and Deliverables
Annexure 01: Key activities and deliverables of Phase 01
Seria World Bank Key Activities Deliverables
l No: Listing/activity
A1 Workshops to Literature review Report
finalize the
Review of relevant policies and Prioritized list of strategic
study program
programs in Sri Lanka partners, their roles and
- expert
responsibilities (report_
consultation Identification of potential
and collaborative programs
stakeholders
Finalization of tasks and strategic
partners
Finalization of the monitoring plan
A2 Workshop to Introduction to CSIAP project Workshop/awareness program
develop
Introduction of INMAS to CSIAP staff Workshop/awareness program
operational
plan (Project Development of the communication Communication strategy
staff and strategy between the CSIAP team
operational and the study team
staff)
Development of an activity guide for Guideline for team members
village level (workbook)
A3 Development Needs assessment Finalized teaching learning
of educational material in the native language of
Literature review
material/man the end-user (training workshops
ual for CSIAP Curriculum outcome development and workbook)
staff
Curriculum content development
Development of teaching/learning
material
Development of assessment
Pilot training
Evaluation
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Compiling the final report
Pre-testing, validation and
adjustments
A4 Development Needs assessment Finalized teaching Activities
of educational learning material in completed.
Literature review
material/man the native language of
ual for Curriculum outcome development the end-user
Healthcare
workers Curriculum content development
Development of teaching/learning
material
Development of assessment
Pilot training
Evaluation
Consultancy
Facilitation/supportive staff
Compiling the final report
Pre-testing, validation and
adjustments
A6 Development Needs assessment Activities
of educational completed
Literature review
material/manu
al for Curriculum outcome development
Media/public
Curriculum content development
Development of teaching/learning
material
Development of assessment
Pilot training Activities
complied
Evaluation
Consultancy
Facilitation/supportive staff
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Compiling the final report
Pre-testing, validation and
adjustments
A7 Development Needs assessment Activities
of educational completed
Literature review
material for
agriculture Curriculum outcome development
and rural
development Curriculum content development
sectors Development of teaching/learning
material
Development of assessment
Pilot training Activities
underway
Evaluation
Consultancy
Facilitation/supportive staff
Compiling the final report
Pre-testing, validation and
adjustments
A8 Workshop to Evaluation of the training program Activities
pilot the and the manual, conducting the completed
training workshop, pre and post knowledge
program and assessment, feedback from
educational stakeholders
material - in
community
workers and
public
A9 Health and Facilitate village level planning Workshops/awarenes Activities
nutrition meeting by with health, s sessions. completed
Promotion agriculture sectors Facilitator/trainer
workshop at reports and
Identifying and arranging Activities
village level evaluation of
resource persons completed
participants
Resource material
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A12 Awareness Teaching learning material, Workshops/awarenes Activities
program for Organizing workshops - s sessions. Facilitator completed
females/mothers, academic/supportive staff and reports and
using local providing logistics evaluation of
agriculture participants
products for
nutrition
promotion
A13 Training for other Provision of teaching learning Workshops/awarenes Activities
Agricultural material s sessions. Facilitator completed
workers and reports and
Conducting workshops for the
related staff evaluation of
staff
participants
A14 Training of Training for healthcare staff - Workshops/awarenes Activities
healthcare village level/primary care public s sessions. Facilitator completed
workers - village health reports and
level public evaluation of
Training of doctors/nurses at
health workers participants
central levels
and doctors in
health education
A15 Advocacy Provision of teaching learning Workshops/awarenes Activities
training for top material s sessions. Facilitator completed
and middle level reports and
Organizing workshops
staff evaluation of
Providing facilitators and faculty participants
A16 Workshop to Consultancy, facilitation, support Workshops/reports/re Activities
review the staff and logistics support vised interventions completed
interventions plan
(Field workshop -1, central
workshop - 1)
A17 Workshop for Final report Activities
journalists Teaching/educational material completed
Academic/supportive Activities
staff/logistics support completed
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Annexure 02
Key activities and deliverables for Phase 02
Seria Current status
l No: Task Key Activities Deliverables
Workshops to Consultation with investigators Workshop/awaren Activities
A201 design evaluation and content experts ess program/draft completed
plan evaluation plan
Consultation with Activities
operational/field level workers completed
Development of the evaluation Draft evaluation Activities
plan plan completed
Pilot testing Activities
completed
Final evaluation
Finalizing the evaluation strategy plan Activities
completed
Workshops to Development of the training Formation of Activities
A202 train evaluation program trained evaluation completed
team (3 districts) teams;
establishment of
Training the evaluation team an operational plan Activities
and monitoring completed
strategy for each
Development of a strategic plan district; training Activities
for data collection and modules; and completed
monitoring workshop report.
Feedback and workshop report Activities
completed
Evaluation Organizing and conducing Reports and Activities
A203 process review Random reviews revised/approved completed
protocol.
Field level meetings with staff,
participants and investigators
Protocol review meeting – Reports Activities
investigators completed
Obtaining institutional review
board and clinical trials registry
approvals
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Data collection Double entered Activities
A204 (base line data Finalizing tools and cleaned completed
collection) - databases
Data collection - field Activities
household survey
completed
Designing databases
Activities
Data double entry and cleaning completed
Activities
Interim analysis completed
Monitoring of data collection Activities
team and random check-ups completed
quality check-ups
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Interim analysis - Interim analysis report Activities
A206 Knowledge and completed
attitude
Assessment plan and tools Activities
assessment of
development - consultation completed
participants
(March) and Activities
dietary changes Pilot study and finalizing tools completed
Activities
Sampling completed
Activities
Data collection completed
Activities
Data entry and cleaning completed
Interim analysis and report Activities
writing completed
Activities
completed
Qualitative data Identification/sampling of Report on qualitative Activities
A207 collection- village participants output completed
level agriculture
Conducting Focus group Activities
staff
discussions completed
Data analysis Activities
completed
Report writing
Qualitative data Identification/sampling of Report on qualitative Activities
A208 collection- school participants output completed
children in
Conducting Focus group Activities
farming
discussions completed
communities
Data analysis Activities
completed
Activities
Report writing completed
Identification/sampling of Report on qualitative Activities
A210 participants output completed
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Conducting Focus group Activities
discussions completed
Qualitative data
Data analysis Activities
collection - Health
completed
Care workers
Activities
Report writing completed
Qualitative data Identification/sampling of Report on qualitative Activities
A211 collection- participants output completed
general
Conducting Focus group Activities
community
discussions completed
Data analysis Activities
completed
Report writing
Activities
completed
Qualitative data Identification/sampling of Report on qualitative Activities
A212 collection- participants output completed
development
Conducting Focus group Activities
workers
discussions completed
Data analysis Activities
completed
Activities
Report writing completed
Qualitative data Identification/sampling of Report on qualitative Activities
A213 collection- local participants output completed
level policy
Conducting Focus group Activities
makers
discussions completed
Data analysis Activities
completed
Activities
Report writing completed
Identification/sampling of Final report on Activities
A214 participants qualitative output completed
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Conducting Focus group Activities
discussions completed
Qualitative data
Data analysis Activities
collection-CSIAP
completed
staff
Activities
Report writing completed
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Bibliography
Aryeetey, R., M. Holdsworth, C. Taljaard, W. A. Hounkpatin, E. Colecraft, C.
Lachat, E. Nago, T. Hailu, P. Kolsteren and R. Verstraeten (2017). "Evidence-
informed decision making for nutrition: African experiences and way
forward." Proc Nutr Soc 76(4): 589-596.
Ballou, J., C. Wiseman, L. Jackson, R. Godfrey and D. Cagle (2017). "Lactation
Skills Workshop: A Collaboration of the City of Dallas WIC and Local
Hospitals." J Nutr Educ Behav 49(7 Suppl 2): S202-S206.e201.
Behrman, J. R., A. B. Deolalikar and B. L. Wolfe (1988). "Nutrients: impacts and
determinants." The World Bank Economic Review 2(3): 299-320.
Berti, P. R., J. Krasevec and S. FitzGerald (2004). "A review of the effectiveness
of agriculture interventions in improving nutrition outcomes." Public health
nutrition 7(5): 599-609.
Black, R., R. Laxminarayan, M. Temmerman and N. Walker (2016). Disease
Control Priorities, Third Edition (Volume 2): Reproductive, Maternal,
Newborn, and Child Health, World Bank Publications.
Brug, J., S. P. Kremers, F. Van Lenthe, K. Ball and D. Crawford (2008).
"Environmental determinants of healthy eating: in need of theory and
evidence: Symposium on ‘Behavioural nutrition and energy balance in the
young’." Proceedings of the Nutrition Society 67(3): 307-316.
Burchi, F., J. Fanzo and E. Frison (2011). "The role of food and nutrition system
approaches in tackling hidden hunger." International journal of
environmental research and public health 8(2): 358-373.
Cole, D. C., C. Levin, C. Loechl, G. Thiele, F. Grant, A. W. Girard, K. Sindi and J.
Low (2016). "Planning an integrated agriculture and health program and
designing its evaluation: Experience from Western Kenya." Eval Program
Plann 56: 11-22.
54
Advanced Professional Engineering Consultants (Pvt) Ltd.
De Onis, M. and M. Blössner (2003). "The World Health Organization global
database on child growth and malnutrition: methodology and applications."
International journal of epidemiology 32(4): 518-526.
De Onis, M., M. Blössner, E. Borghi, R. Morris and E. A. Frongillo (2004).
"Methodology for estimating regional and global trends of child
malnutrition." International journal of epidemiology 33(6): 1260-1270.
Debray, D., E. Mas, A. Munck, M. Gerardin and H. Clouzeau (2016). "[Liver
disease, gastrointestinal complications, nutritional management and feeding
disorders in pediatric cystic fibrosis]." Arch Pediatr 23(12s): 12s15-12s20.
Girard, A. W., J. L. Self, C. McAuliffe and O. Olude (2012). "The effects of
household food production strategies on the health and nutrition outcomes
of women and young children: a systematic review." Paediatric and Perinatal
Epidemiology 26: 205-222.
Haddad, L. (2000). "A conceptual framework for assessing agriculture–
nutrition linkages." Food and Nutrition Bulletin 21(4): 367-373.
Hanachi-Guidoum, M. (2016). "[Treating the somatic complications of
anorexia]." Soins Psychiatr 37(307): 34-37.
Herforth, A. (2012). "Synthesis of guiding principles on agriculture
programming for nutrition." Draft, September.
Jaenicke, H. and D. Virchow (2013). "Entry points into a nutrition-sensitive
agriculture." Food Security 5(5): 679-692.
Katulanda, P., M. Jayawardena, M. Sheriff, G. Constantine and D. Matthews
(2010). "Prevalence of overweight and obesity in Sri Lankan adults." Obesity
reviews 11(11): 751-756.
Kaufman, A., J. Boren, S. Koukel, F. Ronquillo, C. Davies and C. Nkouaga
(2017). "Agriculture and Health Sectors Collaborate in Addressing Population
Health." Ann Fam Med 15(5): 475-480.
55
Advanced Professional Engineering Consultants (Pvt) Ltd.
Keding, G. B., K. Schneider and I. Jordan (2013). "Production and processing
of foods as core aspects of nutrition-sensitive agriculture and sustainable
diets." Food security 5(6): 825-846.
Kennedy, E. T. and H. E. dBouis (1993). Linkages between agriculture and
nutrition: implications for policy and research, Intl Food Policy Res Inst.
Knoblock-Hahn, A., A. Murphy, K. Brown and L. Medrow (2017). "Integrative
Nutrition and Health Models Targeting Low-Income Populations: A Pilot
Intervention in Three Food Banks." J Acad Nutr Diet 117(1): 128-131.
Laar, A. K., R. N. O. Aryeetey, R. Annan, P. A. Aryee, F. K. Amagloh, R.
Akparibo, M. E. Laar, P. Amuna and F. B. Zotor (2017). "Contribution of scaling
up nutrition Academic Platforms to nutrition capacity strengthening in Africa:
local efforts, continental prospects and challenges." Proc Nutr Soc 76(4): 524-
534.
LeBovidge, J. S., W. Elverson, K. G. Timmons, E. B. Hawryluk, C. Rea, M. Lee
and L. C. Schneider (2016). "Multidisciplinary interventions in the
management of atopic dermatitis." J Allergy Clin Immunol 138(2): 325-334.
Lewis, S. J., M. Gardner, J. Higgins, J. M. P. Holly, T. R. Gaunt, C. M. Perks, S. D.
Turner, S. Rinaldi, S. Thomas, S. Harrison, R. J. Lennon, V. Tan, C. Borwick, P.
Emmett, M. Jeffreys, K. Northstone, G. Mitrou, M. Wiseman, R. Thompson and
R. M. Martin (2017). "Developing the WCRF International/University of Bristol
Methodology for Identifying and Carrying Out Systematic Reviews of
Mechanisms of Exposure-Cancer Associations." Cancer Epidemiol Biomarkers
Prev 26(11): 1667-1675.
Li, X. M., A. Rasooly, B. Peng, JianWang and S. Y. Xiong (2017). "An analysis on
intersectional collaboration on non-communicable chronic disease
prevention and control in China: a cross-sectional survey on main officials of
community health service institutions." BMC Health Serv Res 17(1): 711.
56
Advanced Professional Engineering Consultants (Pvt) Ltd.
Maestre, M., N. Poole and S. Henson (2017). "Assessing food value chain
pathways, linkages and impacts for better nutrition of vulnerable groups."
Food Policy 68: 31-39.
Marmot, M. (2005). "Social determinants of health inequalities." The lancet
365(9464): 1099-1104.
Masset, E., L. Haddad, A. Cornelius and J. Isaza-Castro (2012). "Effectiveness
of Agricultural Interventions that Aim to Improve Nutritional Status of
Children: Systematic Review', BMJ 344: d8222, doi: 10.1136/BMJ." D8222
(accessed 8 December 2017).
Myotoku, M. (2017). "Importance of Pharmaceutical Training and Clinical
Research at Medical Facilities." Yakugaku Zasshi 137(1): 13-16.
Pandey, V. L., S. M. Dev and U. Jayachandran (2016). "Impact of agricultural
interventions on the nutritional status in South Asia: A review." Food policy
62: 28-40.
Pinstrup-Andersen, P. (2013). "Nutrition-sensitive food systems: from rhetoric
to action." The Lancet 382(9890): 375-376.
Pistolesi, A. Safety and Health in Agriculture. Geneva, Switzerland:
International Labour Office.
Publications, U. N. (2017). World Statistics Pocketbook 2017, United Nations
Publications.
Rao, T. and P. Pingali (2018). "The role of agriculture in women’s nutrition:
Empirical evidence from India." PloS one 13(8): e0201115.
Roblin, L., R. Truscott and M. R. Boddy (2018). "The Development of a
Provincial Food and Nutrition Strategy through Cross-Sector Collaboration."
Can J Diet Pract Res 79(1): 28-34.
Roche, M. L., L. Bury, I. N. Yusadiredja, E. K. Asri, T. S. Purwanti, S. Kusyuniati,
A. Bhardwaj and D. Izwardy (2018). "Adolescent girls' nutrition and
57
Advanced Professional Engineering Consultants (Pvt) Ltd.
prevention of anaemia: a school based multisectoral collaboration in
Indonesia." Bmj 363: k4541.
Ruel, M. T., H. Alderman, Maternal and C. N. S. Group (2013). "Nutrition-
sensitive interventions and programmes: how can they help to accelerate
progress in improving maternal and child nutrition?" The lancet 382(9891):
536-551.
Ruel, M. T., H. Alderman, Maternal and C. N. S. Group (2013). "Nutrition-
sensitive interventions and programmes: how can they help to accelerate
progress in improving maternal and child nutrition?" The lancet 382(9891):
536-551.
Ruel, M. T., H. Alderman, Maternal and C. N. S. Group (2013). "Nutrition-
sensitive interventions and programmes: how can they help to accelerate
progress in improving maternal and child nutrition?" The lancet 382(9891):
536-551.
Ruel, M. T., A. R. Quisumbing and M. Balagamwala (2018). "Nutrition-sensitive
agriculture: What have we learned so far?" Global Food Security 17: 128-153.
Ruel, M. T., A. R. Quisumbing and M. Balagamwala (2018). "Nutrition-sensitive
agriculture: What have we learned so far?" Global Food Security 17: 128-153.
Ruel, M. T., A. R. Quisumbing and M. Balagamwala (2018). "Nutrition-sensitive
agriculture: What have we learned so far?" Global Food Security 17: 128-153.
Sagner, M., A. McNeil, P. Puska, C. Auffray, N. D. Price, L. Hood, C. J. Lavie, Z.
G. Han, Z. Chen, S. K. Brahmachari, B. S. McEwen, M. B. Soares, R. Balling, E.
Epel and R. Arena (2017). "The P4 Health Spectrum - A Predictive, Preventive,
Personalized and Participatory Continuum for Promoting Healthspan." Prog
Cardiovasc Dis 59(5): 506-521.
Shankar, B., N. Poole and F. A. Bird (2019). "Agricultural inputs and nutrition
in South Asia." Food Policy 82: 28-38.
58
Advanced Professional Engineering Consultants (Pvt) Ltd.
Shekar, M., R. Heaver and Y.-K. Lee (2006). Repositioning nutrition as central
to development: A strategy for large scale action, World Bank Publications.
Sumi, M., C. Hasegawa, H. Morii, N. Hoshino, Y. Okunuki, K. Kanemoto, M.
Horie, H. Okamoto, N. Yabuta, M. Matsuda, T. Kamiya, M. Sudo, K. Masuda, Y.
Iwashita, K. Matsuda, Y. Motooka, D. Hira, S. Y. Morita and T. Terada (2018).
"[Evaluation of a Two-day Hospital On-site Training Program for Community
Pharmacists: Approach to Facilitate Collaboration among Community
Healthcare Professionals]." Yakugaku Zasshi 138(5): 715-722.
The World Bank (2013). Improving Nutrition Through Multisectoral
Approaches, Washington, DC.
Tomlinson, M., M. Jordans, H. MacMillan, T. Betancourt, X. Hunt and C.
Mikton (2017). "Research priority setting for integrated early child
development and violence prevention (ECD+) in low and middle income
countries: An expert opinion exercise." Child Abuse Negl 72: 131-139.
Townsend, R. (2015). "Ending poverty and hunger by 2030: an agenda for the
global food system." Washington, DC: World Bank Group.
Townsend, R. (2015). "Ending poverty and hunger by 2030: an agenda for the
global food system." Washington, DC: World Bank Group.
Vie, L. L., L. M. Scheier, P. B. Lester, T. E. Ho, D. R. Labarthe and M. E. Seligman
(2015). "The U.S. Army Person-Event Data Environment: A Military-Civilian Big
Data Enterprise." Big Data 3(2): 67-79.
Webb, P. and E. Kennedy (2014). "Impacts of agriculture on nutrition: nature
of the evidence and research gaps." Food and Nutrition Bulletin 35(1): 126-
132.
Weinroth, M. D., A. D. Belk and K. E. Belk (2018). "History, development, and
current status of food safety systems worldwide." Animal Frontiers 8(4): 9-15.
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Annexures
Focus Group Discussion Guide for Adults
Introduction
Thank you very much for accepting our invitation to participate in the focus group discussion.
The discussion is to collect the information related to agriculture activities you are engaged
in and to assess current knowledge, attitude and practices related to your diets and other
main lifestyle related risk factors such as physical inactivity, smoking and alcohol.
You may respond in any way you are comfortable. It is perfectly fine with us if you do not
respond at all. At any point if you are not clear about the questions, feel free to clarify it with
us and ask us to explain further. The information obtained during the group discussion will
be kept confidential and will be shared only with the research team. “We would like to tape
record this discussion, the recording will be kept confidential. Is it okay with you that we tape
this discussion?”
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Respondent register
Date: Place: Time:
Name of the moderator:
Name of the note taker:
Participants’ Details:
No Name Age Gender Details of respondent
1
2
3
4
5
6
7
8
9
10
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Theme - factors influencing dietary patterns and other related behaviours
1. Component: Influence of agriculture related activities on nutrition
1a. Question – What are the type of agriculture related activities that you are involved in?
Probe:
What are the types of crops you grow?
How many hours of the day you spend on those activities?
Do you engage in agriculture related activities throughout the year? Or is it seasonal?
Is this the main source of income? Or do you do other jobs?
1b. Question – Do you use/ keep a portion of your harvest for family consumption?
Probe:
Do you sell all your produce? Where do you sell your harvest? Is there a middle man?
After deducting cultivation cost and other related costs, what is your profit?
What do you do with the money you earn from agricultural activities?
What types of food you keep for family consumption?
2. Component: Knowledge and attitude on healthy diets and maintaining a healthy
weight
2a. Question – What is your view on the relationship between health and nutrition?
Probe:
What do you mean by being healthy?
How do you find nutrition is an important factor in health? What do you mean by
“nutrition”?
What are the important determinants of nutrition?
What are the differences between under nutrition and over nutrition?
How do we identify and prevent malnutrition?
What is healthy weight? How do you know whether your weight is healthy?
2b. Questions – What do you know about balanced healthy diet?
Probe:
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What is a healthy diet? Do you think your diet meet those recommendations?
Is it important to have a healthy diet? What are the negative impacts of an unhealthy
diet?
How can we prepare a healthy diet? How can we use locally available food sources?
What are the difficulties at home/ workplace to have a healthy diet?
3. Components: Knowledge about the risk factors
3a. Question – What are the health risk related to diet?
Probe:
Do you know of any ingredient that you add to your diet that may increase the rink of
non-communicable diseases?
What amount of salt, sugar and oil do you add to your meals and beverage?
Do you think you use healthy amounts?
3b. Question – Do you consume frizzy drinks and instant food varieties?
Probe:
What are the types of frizzy drinks you have? How often?
How often do you consume instant/ fast food?
What time of sauces do you add to your food? How often do you add sauces to your
meal?
Do you check the ingredients and nutrition information when you buy food from shops?
3c. What is your attitude towards consuming alcohol, smoking and exercise?
Probe:
Do you actively try to increase your physical activity and avoid smoking/alcohol?
What are the main factors that support you to achieve those goals?
What factors influence you to be more physically inactive, to smoke or to consume
alcohol?
What are the main barriers and how do you think we could collectively address them?
Do you know how to modify your life style so that you will be doing more exercises?
3d. Question – Special dietary requirements
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Probe:
Do you have any special dietary requirement?
Who do you think need special dietary requirements?
How would you prepare meals for a pregnant mother?
How to do complementary feeding?
What would you give for primary school children to eat?
Do you know how to prepare above meals using locally available food sources?
Do teenagers need the same amount of food as adults?
4. Component: Influences on choice of food
4a. Question – What factors influences your diet?
Probe:
What factors influence your dietary choices at home, in schools or outside?
Do advertisements on TV, newspapers and bill boards have a role?
(Talk about examples with sweets, soft drinks and milk products)
Have you stopped/limited buying any food items recently due to the price?
Have you changed your dietary habits due to health education messages? any examples?
Have you eaten anything you don’t think healthy, but due to cultural issues or due to
peer pressure ?
5. Components: Changing habits to prevent risk factors
5a. Question – Do you have anything you could do to improve your diet with the resources
you have now?
Probe:
Have you thought about changing your food purchasing patterns? If yes how?
Is it important do home gardening as a family?
Do boys and girls both get involved in gardening and cooking? How can we encourage
this?
Will home gardening and preparing your meals at home save money?
5b. Question – What can you do to improve your / your family members diet?
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Probe:
What would you want to add to your diet?
Would you consider cultivating different types of crops considering nutrition value?
What types of crops can you grow?
Would you consider keeping some produce for family consumption?
6. Component: Contributing to improving nutrition state of the local community
6a. Question – Do you think you have the capacity to contribute to improving the nutrition
state of the local community?
Do you have facilities to sell your produce in local shops? What types of produce you can
sell locally?
Do you have the capacity to increase your production and increase the variety of crops
and vegetables you grow?
Do you think that there is a demand for locally grown food and vegetables?
How can you improve the nutritional benefits of your produce?
Do you use pesticides/ weedicides or other chemicals to keep your produce fresh? What
are those substances?
7. Component: Obstacles sell products locally
7a. Questions – What are the individual level (your income, skills etc) and environmental
(societal norms, culture, advertisements, policy, prices etc.) that may stand as a barrier to
selling your prodcuts locally and contributing to improving diet of the local community?
Probe:
What are the attitudes and perceptions of the community that may present this from
happening?
How can you overcome those obstacles?
What help do you need from agriculture sector or other sectors to overcome such
barriers?
End of the discussion.
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Chapter 02
Focus Group Discussions – Garssroot Officers
(Pre Intervention)
2.1: Method
Investigator will be meeting grassroot level officers in the CSIAP project intervention and
control areas with the help of District Officers (DOs) of the Department of Agriculture and
Agrarian Development Officers (ADOs) of Agrarian Service Centres. The INMAS study team
has already built links with relevant Dos and ADOs with the support of provincial level CSIAP
Deputy Project Directors (DPD). Discussions with the FGD participants will be conducted
using the FGD guide by experienced FGD facilitators in the mother tongue of the participants,
focusing on understanding their current role, their involvement in nutrition promotion
activities, their knowledge on nutrition and current collaborations between various sectors
targeting nutrition promotion. Participants will be given a chance to clarify queries related
to the discussion. A written consent will be taken from each participant agreeing to take part
in the discussion.
2.1.1: Sample
Pre intervention qualitative data collection will include FGDs with sample of grassroot level
officers including ARPA/KUPANESA and Samurdhi Officers and/or Economic Development
Officers in CSIAP intervention areas and control areas.
Focus Groups Anuradhapura District Batticaloa District Kurunegala District Total
(Minimum 6 in a CSIAP Control CSIAP Control CSIAP Control
group) Intervention Area Intervention Area Intervention Area
Area Area Area
Grassroot Officers 3 1 3 1 1 1 10
(KUPANESA,
Samurdhi Officer
and/or Economic
Development
Officer)
Total FGDs with the grassroot level officers (all three district) 10
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2.1.2: Timeline
FGDs with the grassrot officers of the selected sample will be conducted on the first two
weeks of June, 2019 and the transcripts will be submitted before the end of June, 2019.
2.1.3: Timetable for each discussion
Approximate Purpose
duration
(min)
Welcome and Introduction to the 5 minutes Brief introduction
participants
Consent from the participants 5 minutes Consent
Self-introduction by the participants 5 minutes Ice breaking
Discussion (according to the guideline) 35 minutes Collecting data in order to explore grassroot
officers’ role related to nutrition promotion
activities, their knowledge on nutrition and
related socio-cultural determinants as well as
multisectoral collaboration targeting nutrition
promotion
End of the discussion 10 minutes Participants feed backs or queries (If any) and
thanking for participation
2.1.4: Focus Group Discussion Guide for Grassroot Level Officers
Introduction
Thank you very much for accepting our invitation to participate in the focus group discussion.
The discussion is to collect information on your role related to promoting nutrition activities
within your official capacity, your understanding of consumption habits of the local
community and to assess your current knowledge on nutrition.
You may respond in any way you are comfortable. It is perfectly fine with us if you do not
respond at all. At any point if you are not clear about the questions, feel free to clarify it with
us and ask us to explain further. The information obtained during the group discussion will
be kept confidential and will be shared only with the research team. “We would like to tape
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record this discussion, the recording will be kept confidential. Is it okay with you that we tape
this discussion?”
Theme – involvement of grassroot agriculture officers in promoting nutrition among the
community, their knowledge on nutrition and their observation on nutritional needs and
habits of the local community
1. Component: Involvement in promoting nutrition
1a. Question – What are the activities you do in relation to promoting nutrition?
Probe:
What is your main role?
Within your official capacity, do you engage in promoting nutrition?
Does your job role include focus on nutrition?
Is your department involved in providing or helps providing any of nutrition related
services?
Are there policies, acts or circulars followed by your institution to promote nutrition?
1b. Question – Do you give nutrition related advices to the community?
Probe:
When it comes to selecting crops for cultivation, do you advise the community what to
grow based on the nutritional benefits of various crops?
Do people ask for such advices?
2. Component: Multisectoral collaboration in promoting nutrition
2a. Question – Have you worked with other organizations to promote nutrition among the
community?
Probe:
Do you or have you ever worked with any other sectors related any activity to promote
nutrition among the community?
What are those collaborations and the purpose of those collaborations?
Who are/were the collaborating partners?
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Have you been given additional responsibilities within that collaboration that is beyond
your job description?
How did the collaboration initiate?
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2b. Question – What do you think of the effectiveness of those collaborations?
Probe:
Have you achieved the objectives of those collaborations?
Are/were they temporary collaborations or long-term collaborations?
How did/do you contribute do to the collaboration?
How did/do other sectors contributed the collaboration?
How did you communicate with other sectors? What did you communicate with other
sectors?
What was the attitude of other sectors towards the collaboration?
What was the attitude of the beneficiaries towards such collaborations?
2c. Question – What are the challenges of collaborating with other sectors?
Probe”
Were the challenges or difficulties that you encountered related to:
personalities and attitudes,
Policies and practices of your own institution
different priorities of the organizations involved,
limitations in policies
Limitations in official capacity
Communication and infrastructure issues
How were these challenges/limitations dealt with?
2d. Question – What should be done to sustain those collaborations?
Probe:
How can you make those collaborations more effective?
3. Component: Understanding of the nutrition state of the local community
3a. Question – What is your understanding of the consumption habits of people in your area?
Probe:
What are the food consumption habits of the people in this area?
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Do children have unhealthy eating habits?
Do people usually maintain home stead gardens?
What types of crops they grow? Do they keep part of their harvest for their household
consumption?
3b. Question – Do you have nutrition issues specific to your area?
Probe:
Have your recognized nutrition issues specific to your area?
Would you like to get help from other sectors to address those issues?
What kind of help would you need?
4. Component: Current knowledge on nutrition
4a. Question – what knowledge do you have on nutrition dense crops and vegetables grown
locally?
Probe:
What are the kinds of crops and vegetables grown locally that are considered as nutrition
dense?
What are the nutrition benefits of those crops and vegetables?
What do you consider as a healthy diet?
4b. Question – Do you think you have sufficient knowledge on nutrition?
Probe:
Are you confident to give nutrition related advices to the community?
Do you know of the nutrition benefits of the crops you recommend for farmers?
Have you been given any training to improve your knowledge on nutrition?
5. Component: Knowledge on research-based studies related to cultivation, new
technology and methods used in cultivation
5a. Question – What kind of research-based data do you have on growing crops and
vegetables resilient to local environment?
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Probe:
Have you tried to get farmers to cultivate diverse crops based on various studies?
Have you explored the possibility of enabling farmers grow new varieties of crops suitable
to the environment?
Give some examples of such instances?
5b. Question – Do you have knowledge on new technologies or methods that enable growing
crops under various environmental conditions?
Probe:
Have you been informed/ Do you know of new technologies or methods that enable
growing crops under various environmental conditions?
Give some examples?
Where can you get such knowledge? What can you do to get such knowledge?
End of the discussion.
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Annexure : literature review (few important studies)
Name of the Reference (IEEE Referencing Style) Annotation
research article
The role of [1]T. Rao and P. Pingali, "The role of The study evaluates a five-year panel
agriculture in agriculture in women’s nutrition: dataset of rural households of 18
women's nutrition: Empirical evidence from India", PLOS villages in India to 'establish a
Empirical evidence ONE, vol. 13, no. 8, p. e0201115, statistically important relationship
from India. 2018. Available: between household agricultural
https://journals.plos.org/plosone/art income and women’s BMI'. The
icle?id=10.1371/journal.pone.02011 research establishes that
15. improvements in own-production and
market purchase are associated with
improvements of nutrition level of the
community. Agricultural income
growth has also shown links to the
positive growth results in BMI. The
market is also said to play a pivotal
role in facilitating access to nutrition
rich food.
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Food and Nutrition [2]L. Govender, K. Pillay, M. Siwela,
Insecurity in A. Modi and T. Mabhaudhi, "Food
Selected Rural and Nutrition Insecurity in Selected
Communities of Rural Communities of KwaZulu-
KwaZulu-Natal, Natal, South Africa—Linking Human
South Africa- Nutrition and Agriculture",
Linking Human International Journal of
Nutrition and Environmental Research and Public
Agriculture. Health, vol. 14, no. 1, p. 17, 2016.
Available:
https://www.mdpi.com/1660-
4601/14/1/17.
Key Drivers of State [3]J. Pomeranz and M. Pertschuk,
Preemption of "Key Drivers of State Preemption of
Food, Nutrition, Food, Nutrition, and Agriculture
and Agriculture Poli Policy: A Thematic Content Analysis
cy: A Thematic of Public Testimony", American
Content Analysis of Journal of Health Promotion, p.
Public Testimony. 089011711882316, 2019. Available:
https://journals.sagepub.com/doi/fu
ll/10.1177/0890117118823163?url_
ver=Z39.88-
2003&rfr_id=ori%3Arid%3Acrossref.
org&rfr_dat=cr_pub%3Dpubmed.
Beyond nutrition a [4]S. Stewart, A. Kennedy and A.
nd agriculture polic Pavel, "Beyond nutrition and
y: collaborating for agriculture policy: collaborating for a
a food policy food policy. - PubMed - NCBI",
Ncbi.nlm.nih.gov, 2014. [Online].
Available:
https://www.ncbi.nlm.nih.gov/pubm
ed/25267247.
Agricultural inputs [5]B. Shankar, N. Poole and F. Bird,
and nutrition in "Agricultural inputs and nutrition in
South Asia South Asia", ScienceDirect, 2018.
[Online]. Available:
https://www.sciencedirect.com/scie
nce/article/pii/S0306919218308297.
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Assessing food [6]M. Maestre, N. Poole and S. The paper evaluates as to what extent
value chain Henson, "Assessing food value chain the private sector can be expected to
pathways, linkages pathways, linkages and impacts for get involved in achieving nutrition
and impacts for better nutrition of vulnerable objectives of the public sector. It
better nutrition of groups", Food Policy, vol. 68, pp. 31- studies the role that the food value
vulnerable groups 39, 2017. Available: chain plays on nutrition outcomes.
https://www.sciencedirect.com/scie According to the writer, there are
nce/article/pii/S0306919216304821. certain requirements for the food
value chain to operate successfully in
oder to help increase the
micronutrient intake. During
processing, storage, distribution
and/or
preparation, it is ncessary to ensure
that food is safe to eat; food is
nutrient-densed at the point of
consuption; and food reaches
consumers to ensure food is
consumed in adequate amounts on a
sustained basis to bring about the
desired nutritional
outcomes. However, the consumer
choice of food depends on their
nutrition awareness, nutrition
information/ singals provided by the
suppliers, availability of food in the
market or through home production,
consumer affordability and
accesptability.
Planning an [7]D. Cole et al., "Planning an
integrated integrated agriculture and health
agriculture and program and designing its
health program evaluation: Experience from
and designing its Western Kenya", Evaluation and
evaluation: Program Planning, vol. 56, pp. 11-22,
Experience from 2016. Available:
Western Kenya https://www.sciencedirect.com/scie
nce/article/pii/S0149718916300581.
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Principles of [8]D. Glover and N. Poole, "Principles
innovation to build of innovation to build nutrition-
nutrition-sensitive sensitive food systems in South
food systems in Asia", Food Policy, 2018. Available:
South Asia https://www.sciencedirect.com/scie
nce/article/pii/S0306919218308492.
Sustaining healthy [9]S. Thilsted et al., "Sustaining
diets: The role of healthy diets: The role of capture
capture fisheries fisheries and aquaculture for
and aquaculture improving nutrition in the post-2015
for improving era", Food Policy, vol. 61, pp. 126-
nutrition in the 131, 2016. Available:
post-2015 era https://www.sciencedirect.com/scie
nce/article/pii/S030691921630001X.
Nutrition Sensitive [10]M. Ruel, A. Quisumbing and M. This paper reviews recent empirical
Agriculture: What Balagamwala, "Nutrition-sensitive evidence (since 2014), including
have we learned agriculture: What have we learned findings from impact evaluations of a
so far so far?", Global Food Security, vol. variety of NSA programs using
17, pp. 128-153, 2018. Available: experimental designs as well as
https://www.sciencedirect.com/scie observational studies that document
nce/article/pii/S221191241730127X. linkages between agriculture,
women's empowerment, and
nutrition linkages. The paper
summarizes existing knowledge
regarding impacts, but also pathways,
mechanisms, and contextual factors
that affect where and how agriculture
may improve nutrition outcomes. The
paper concludes with reflections on
implications for agricultural programs,
policies, and investments, and
highlights future research priorities.
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Impact of [11]V. Pandey, S. Mahendra Dev and The writers focus on nutrition issues in
agricultural U. Jayachandran, "Impact of the South Asian (SA) regions and how
interventions on agricultural interventions on the agricultural interventions in SA can
the nutritional nutritional status in South Asia: A have positive nutrition outcomes to
status in South review", Food Policy, vol. 62, pp. 28- address such issues. While the writers
Asia: A review 40, 2016. Available: present several hypotheses as to how
https://www.sciencedirect.com/scie development in agriculture or
nce/article/pii/S0306919216300264. agricultural activities can impact
nutrition, they note that in many
cases, the outcomes may not be
measurable. However in some cases,
evidence are more conclusive.
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Annexure :
Identified roles and prioritized responsibilities for
each sector:
Agriculture sector:
The potential impacts of agriculture on health and nutrition extend across a number of
channels. One area of impact is household ability to produce, purchase and consume more,
better and cheaper food Another important contribution of agriculture towards nutrition
and health is increased rural income, allowing people to improve their diets. The poor are
overwhelmingly located in rural areas and derive a significant share of their income from
agricultural activities. Given the importance of agriculture for the livelihoods of the rural
poor, agricultural growth has the potential to greatly reduce poverty – a key contributor to
poor health and undernutrition. Agricultural activities can also generate economy-wide
effects such as increasing government revenues to fund health, infrastructure and nutrition
intervention programmes
Goals:
Ensure year-round access to adequate, safe, nutrient-rich food within the local community.
Provide adequate income/wealth generation while promoting responsible and healthy crop
selection and production
Develop partnerships with other sectors and work along with the health professionals of
the locality to integrate health and wellbeing to activities
Activities :
1. Provide training for ground level officers on nutrition, health and impact of their
activities on these health and nutrition in the community
2. Provide training for farmers
3. Provide training on nutrition sensitive home gardening
4. Create awareness in other stakeholders involved in the supply chain
5. Empower the producers to develop a distribution plan and create a local market for
a reasonable price
6. Protect women, children and famers from exposure to hazardous chemicals
through good practice and personal protection
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Rural Development sector.
• Support families to better manage the increased income from agriculture-related
activities (including processing and sale of agricultural products or wages earned)
which can be used to access health services or purchase higher-quality,
• Empower females through micro-finance facilities and capacity building. Initiatives
that both educate women and enhance their involvement in agriculture-based
activities and small businesses.
• Create support groups and discuss time allocation patterns during agriculture
seasons and activities, to give more care for children, changes in household
decision-making, impacts on nutrient requirement
• Support livelihoods, not only for farmers but also for other local services to create
sustainable and healthy communities.
• Create environmental change through their activities that promote healthy and
safe lifestyles
• Provide a platform to deliver health awareness and health conscious interventions,
especially on younger and healthier populations who are not accessible to health
care professionals
• Develop partnerships with other sectors and work along with health professionals
of the locality to integrate health and wellbeing to activities
• Nutrition and health conscious decision taking to avoid development processes at
micro and macro levels that encourage behaviors/habits/practices that are
detrimental to health
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Health sector
• Given that health sector cannot reach every household, use Agriculture sector,
farmers associations as a mechanism to reach communities and families for health
and nutrition promotion activities. Work in collaboration with agriculture sector to
co-design these interventions.
• Create the awareness among agricultural communities to discourage farmers to
sell more expensive, more nutritious produce on the market, retaining less
nutritious foods for self-consumption
• Address other behaviorul risk factors such as alcohol and tobacco among famers
and their families.
• Encourage interactions with other sectors at ground level and local directorate
levels
• Develop partnerships with other sectors and work along the health professionals of
the locality to integrate health and wellbeing to activities
Education Sector
• Work with agriculture officers to promote school gardens and education children
and to increase physical activity through working in the garden
• Work with local framers’ associations and establish supply chains to use local
produce for school meals and canteens
• Ensure availability of nutritious and attractive school meals
• Train schoolteachers to work in collaboration with local agriculture officers and
primary healthcare officers to mobilize local resources and improve school
nutrition
• Provide a platform for behavior and attitude change within communities on
encouraging healthy behaviors and discouraging unhealthy practices.
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Evaluation strategy
Inputs and activities Outputs Outcomes and impact
translation of this
Improvements in
Workshops and training knowledge to
knoweldge and
programs community level
awareness
activities in CSIAP
Numers of training pre and post
health interventions
questionnaires and
Participation knowledge assessment changes in nutritional
Completion numbers and health practices
skills assessment
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Tools for evaluation for IMNAS
Learning objectives for non-healthcare stakeholders
(Agriculture officers, development sector workers at grassroot
level and media personnel)
1. Recognize and critically evaluate the nutrition related implications of
agriculture development in promoting the nutrition of the individual and the
community
2. Analyze positive and negative nutrition implications of various agriculture
based interventions – with a special emphasize on targeted activities of
CSIAP program
3. Analyze issues related to malnutrition (under nutrition and over nutrition)
4. Identify issues related to deficiencies of micronutrients
5. Identify each stakeholder’s role in addressing nutritional needs of special
groups
6. Understand issues related to food availability and affordability
7. Analyze other health issues due to inappropriate nutrition
8. Identify common misconceptions regarding nutrition.
9. Create conducive home environment in order to improve nutrition of the
family
10. Mitigate the negative nutritional impact of alcohol, tobacco and other
additive substances in the individual and the family
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Training manual for non health professionals
IMNAS project
This study material is targeted for
• Agriculture officers
• Development officers at grassroot level
• Media personnel
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Introduction
What is Nutrition….?
The following steps take place in obtaining nutrition …..
1. Ingestion
2. Digestion
3. Absorption
4. Utilization of nutrients.
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• Why is nutrition important?
• Good nutrition is an important part of leading a healthy lifestyle
• Proper nutrition increases immunity and fight against diseases.
• Several chronic diseases can be prevented by proper nutrition.
• Quality of life and life expectancy can be improved by proper
nutrition
• Proper nutrition will increase working capacity and generate better
income
• Unhealthy eating will contribute to illnesses and premature death.
• Malnutrition in early childhood impairs all aspects of development
including cognitive functions.
• Malnutrition in early childhood leads to short stature.
• Malnutrition in pregnancy and early childhood can lead to chronic
diseases in adult life.
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Few facts– Nutrition recommendations and consequences of an
unhealthy diet
• Breast feeding should be initiated within one hour of birth.
• Exclusive breast feeding should be maintained for the first 6 months of life
• Brest feeding should be continued till 2 years and beyond.
• Complementary feeding –
• start complementary food on completion of 6 months with well mashed rice
• Introduce foods of animal origin by about one week of introducing
complementary food
• Ensure variety in every meal
• increase the frequency of meals , amount of food at each meal and
consistency as the child grows older
• Include locally available fruits and vegetables daily
• Add oil , thick coconut milk to increase energy density of food
• Pregnant and lactating women need more nutritious food
• Children and adolescents should take an adequate and nutritious diet.
• Females need more iron in their food.
• Physical exercises are important to stay healthy.
• Limiting salt and salt containing food are important for prevention of hypertension and control
hypertension.
• Fish provide healthy oils, iron and proteins
• Animal proteins have a higher biological value than plant proteins.
• The elderly should eat foods with high nutritional value.
• Five fruit and vegetables per day will reduce several chronic diseases such as cancers, IHD, DM.
• Having central obesity will lead to heart diseases, DM, stroke . (The simplest and most often used
measure of abdominal obesity is waist size. According to Asian guidelines, central obesity is
defined as waist size of 80 cm or higher in women, and a waist size of 90cm or higher in men).
• If you are inactive, eating large starchy meals may lead to diabetes
• If you are overweight, weight reduction is very important for control diabetes, hypertension, and
IHD.
• Obese and overweight children very likely to be obese adults and have a higher risk of getting
NCDs.
• The epidemic of the diabetes, obesity, hypertension, and heart diseases are associated with
recent changes in the lifestyle.
• Coconut oil does not contain cholesterol.
• What is our food made of ?
• All type of starch (red rice, kurakkan, wheat) will convert to glucose in our body. However most
important factor is the portion size of starchy food.
( Source- Food based dietary guidelines for Sri Lankans- Nutrition Division- Ministry of Health )
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A balanced diet should contain all of these nutrients.
Do you know which food contain which nutrient?
1. Carbohydrates- rice, bread, pittu, hoppers, rotti, manioc, sweet
potatoes, yam, bread fruit, Jack
2. Protein- fish, meat, dried fish, egg (white), milk, dairy products.
TVP, pulses( beans, green gram, cowpea or lentils) ,
3. Fats- coconut oil, coconut milk, butter, margarine, vegetable oil
4. Vit C- fruits( nelli, guava, orange, lemon) dark green leafy
vegetables
5. Vit A – liver, egg yolk, milk, milk products, meat, fish, spinach (
nivithi ), kathurumurunga, thampala, carrot and beet leaves,
carrot, tomato, yellow pumpkin, mango, papaya,
6. Iron- red meat, liver, fish , (balaya, kelawalla, sawelaya,dried fish)
chicken, egg yolk, , gotukola ,thampala, sarana, mukunuwanna,
nelumala, mung, kadala, dhal (meat , liver, fish contain well
absorbed heam type of iron - and egg yolk, green leaves and
pulses contain non heam iron which is not that well absorbed)
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7. Folate - thampala, karapincha (curry leaves), spinach, plantain,
pineapple, lime, beans, soya bean, mung (green grams).
8. Fiber- brown rice, kurakkan, corn, green leaves, fruits,
vegetables, unrefined cereals,
9. Sugar- sweets, hakuru (jaggery) treacle, soft drinks, sugary
biscuits, , sweet fruits (eg. Banana), ice cream, chocolate
10.Salt – table salt, dry fish, processed food items
11.Cholesterol- egg yolk, red meat , milk , butter, cheese, full cream
milk and milk products.
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1.Analyzing positive and negative nutrition implications of
developing agriculture in the community
(Group discussion – Explore positive and negative nutritional
implications of agriculture in small and large scale in your area with the
help of your instructor)
1.1 Direct effects : food availability, income generation
Discuss how these will change dietary habits and behaviors that could
result in positive and negative outcomes for health and nutrition
1.2 Methods of utilizing excess food production effectively.
• Food preperation
• Food preservation
• What food items are being preserved in your area?
• (Demonstration)
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………...
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Small group discussion.
Critically analyze their impact on nutrition.
(Ex. Crop modification and introduction of a different crop such as
maize in your area)
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1.2 Make a list of health/nutrition/behavioral impacts when farmers in
your area secure a higher income from one of your interventions
Positive :
.............................................................................................................
.............................................................................................................
.............................................................................................................
....................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
....................................
Negative:
.............................................................................................................
.............................................................................................................
.............................................................................................................
....................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
....................................
Small group discussion
Now , discuss among yourselves how to encourage a positive impact on
nutrition and how to modify these interventions from the time of
planning and implementation
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Malnutrition.
Interpreting growth charts. ( for case studies refer the appendix 2)
Common causes of malnutrition
Small group discussion. : discuss common causes of malnutrition in your
area (remember, malnutrition can be under or over-nutrition)
Now list down five causes of malnutrition that you discussed and
mention your suggestions to overcome those problems.
1. ……………………………………………………………………………………..
2. ……………………………………………………………………………………..
3. ……………………………………………………………………………………..
4. ……………………………………………………………………………………..
5. ……………………………………………………………………………………..
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Assessment of nutrition
By the end of this session you will be able to calculate your own
BMI and the category you belong to for your knowledge.
▪ Anthropometric measurements –
How to measure height, weight and calculate BMI
(You will be guided on the technique of taking anthropometric
measurements in a demonstration)
Measuring weight
Measuring height
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When measuring height;
Look straight ahead with straight shoulders and keep arms at
sides.
Your shoulders (scapulae), back of the head, buttocks and
heels should touch the measuring board.
Keep your legs straight, heels and knees together, and stand
on flat feet.
Always need two persons to measure the heights. One is a
helper who looks after the positioning of waist downwards.
Measurer has to adjust the head and take the measurement.
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From the measurements of height and weight we can
calculate Body Mass Index (BMI).
BMI( Kgm-2) = Weight ( Kg)
Height x Height ( m2)
According to BMI values level of nutrition can be classified as (ESSL,
2014) :-
BMI Interpretation
< 18.5 underweight
18.5- 22.9 normal
>23 Overweight
>25 obesity
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Food supplementation
What is a food supplement?
Food supplements are concentrated sources of nutrients or other
substances with a nutritional or physiological effect and their purpose is
to supplement the normal diet.
Thriposha
(Triposha is an example of a supplementary food. A supplementary food is given to
provide extra energy, nutrients required by the under nourished and certain
physiological state like pregnancy and lactation. Additional information on
supplementary food items will be provided by your instructor.)
Small group discussion
• What are the other food supplements you know of ?
• Are Marmite, Sustegen useful?
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Micronutrient deficiencies
Micronutrients
• What is a Micronutrient
A chemical element/ substance required in trace amounts for
the normal growth, metabolism and development of human
beings.
Eg. Iron, zinc, vit.A
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Question : What are common micronutrient deficiencies in Sri Lanka?
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
Food rich in micronutrients.
• Iron - ……………………………….
• Zinc -…………………………………
• Calcium -…………………………
• Vit A - ………………………………
• Vit B complex - …………………
• Vit C -………………………………
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Small group discussion
Ask PHM which micronutrient deficiencies are more prevalent in your
area.
Discuss among yourselves which food items can be grown best in your
area that could tackle these problems – they can be large farmland
crops as well as things that can be grown in home gardens
How can you help to improve availability and accessibility of these food
items?
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Nutritional needs of special groups
Among the elderly population in Sri Lanka….
• Consumption of foods of animal origin is poor
• Carbohydrates are the main energy contributor
• Dietary diversity is not up to optimal level
❖
❖ What are the other nutritional issues that the elderly have?
…………………………………………………………………………………………………………………………………
…….
…………………………………………………………………………………………………………………………………
……
❖ How can their nutritional status be improved?
What do you know about nutritional needs of pregnant mothers and
children?
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Dietary diversity
(source-Food Based Dietary Guidelines for Sri Lankans published by
Ministry of Health)
Meals that include no servings or very few servings of different food
groups such as fruits and vegetables, dairy products, fish and meat and
pulses, lack both balance and variety. It is evident that a substantial
proportion of the Sri Lankan population does not consume a varied and
balanced diet, which is suggestive of a close association between the
nutrition-related NCD in the country and these unhealthy eating habits.
( Jayawardananaet al, 2012)
There are six food groups that provide you energy and nutrients to keep
you healthy. Each food group gives you different nutrients needed by
your body. You need to eat a variety of food every day, in recommended
quantities to form a healthy diet.
The food groups are:
1.Grains (cereals) and tubers (yams)
Rice, wheat, kurakkan, maize (corn), rice & wheat flour preparations
(bread, string hoppers etc.)
Tubers (yams)- manioc, potato and sweet potato, innala, kiriala
Starchy fruits- jak, breadfruit
• Provides energy for your daily activities
2.Fruits
Plantain, mango, papaya, pineapple,oranges, guava, avocado etc.
• protects you from diseases
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3. Vegetables
Leafy vegetables - kankun, spinach, gotukola, mukunuwenna, sarana,
katuru-murunga, drumstick ,murungaleaves etc.
Root and fruit vegetables - gourds, brinjals,ash plantains, ladies fingers,
tomato, carrot, beet etc.
• protects you from diseases
4.Fish, pulses, meat and eggs
Fish - fresh water fish & sea fish, sprats, dried fish, shell fish(prawns,
cuttle fish)
Pulses - Chick pea (kadala), green gram, cowpea, soy bean, ulundu,
lentil (dhal),other beans
Meats - chicken, beef, pork, mutton, Offal- liver
Eggs - hen’s, duck, quail (vatu)
• helps in growth and maintenance of your body
5.Milk and/or milk products
Milk, curd, yoghurt, cheese
• Helps in growth and maintenance of your bones and teeth
6.Nuts and oil seeds
coconut, pea nuts, kottang, cashew nuts,pumpkin seeds, coconut milk,
coconut oil,gingelly and palm oils,other vegetable oils,butter,
margarine, ghee
• Provides energy and helps in bodily functions
❖ The Golden rule: Be sure to eat some food from each of these
groups daily. It is important to include some item (s) from each
group rather than a large quantity of one or two groups. This will
ensure variety in your diet and thereby give you the nutrients
required by your body every day.
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How much of each food group should be consumed?
The number of servings needed daily from each of the six food groups
depends on the age, sex, body size, level of activity, and the stage of
the lifecycle. Illnesses impose additional considerations.
Eat more of some food (grains, fruits and vegetables) and less of others
(fats and oil).
What are serving sizes?
It helps you understand how much food is recommended every day
from each of the six food groups. It is assessed using household
measures.
Portion size estimations
Estimation of vegetable portions
• Three heaped table spoons or ½ cup or 80 grams of cooked
vegetable is defined as one vegetable serving.
• If there is a vegetable curry with half amount gravy six table
spoons are defined as one vegetable portion.
• one medium size coconut spoon is considered as three table
spoons or one serving
Estimation of fruit portions
• Fruit juice- Even if more than one glass per day was reported, it
would only count as one portion of fruit per day
• Fruit juices ( fresh ) count as up to a maximum of two portions
per day
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One portion of fruit, (average weight is 80 grams)
• Small sized fruits– Ten fruits considered as one portion, example:
grapes, veralu, nelli, lovi, rose apple (jamboo)
• Small–medium size fruits – number may vary (2-6): ambarella,
banana (small), naminan, rambutan, passion fruit, mangosteen,
jack fruit ripen (waraka)
• Medium-sized - one medium fruit, such as one apple, banana,
pear, orange, guava, woodapple, belli, manderin
• Large-sized - one slice of papaya, one slice of melon (two-inch
slice), one large slice of pineapple, two slices of mango (two-inch
slices), pomegranate (1/2 medium), durian (2 pieces),
• Dried fruit: One tablespoon of raisins, currants, sultanas, one
tablespoon of mixed fruit, two figs, three prunes, one handful of
banana chips.
• Juice: One medium glass (150ml) of fruit juice.
• A-half cup of chopped fruits
• Pineapple portion is defined as one large slice or two round
shapes slices.
• Two bananas were defined as one portion.
Estimation of pulse portions
• Cooked pulses ½ tea cup or three full table spoons or 1 coconut
spoon is defined as one pulse portion.
Estimation of dairy products
• One glass of milk (250 ml) of fresh milk is defined as one portion.
• As milk powder is used commonly in Sri Lanka as main dairy food
source three table spoonfuls is defined as one serving equivalent
to fresh milk.
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• Two small cups of yoghurt (80grms each) and one tea cup or
eight table spoons of curd is considered as one serving.
• Two slice or two wedges of cheese or 1/8 from 250 g of cheddar
cheese are defined as one portion.
Estimation of cereal or equivalent portions
• One portion of cereal or equivalent is defined as the amount of
starchy food in which 15 g of carbohydrate is contained.
• 1/3 tea cup of rice, milk rice and noodles, one slice of bread, ¼ of
10cm diameter and 0.5 cm thickness coconut roti, 2 string
hoppers and ½ hopper is considered as one serving of each food.
• 1/3 tea cup of boiled bread fruit, jak and sweet potato, ½ tea cup
of ash plantain and yam is defined as one portion.
• Serving of cooked starch vegetables is decided by comparing the
amount of curry which contains 15 g of carbohydrate.
• Then portion size is calculated as how many household measures
with the above weight of curry. This is used for both cooked and
raw foods. As an example, one portion of manioc curry is 90 g
and it holds in three table spoons. Ash plantain curry 90 g is
defined as one serving and six table spoons of it is taken as one
portion.
• Biscuits, cake, short eats (roll, cutlet), vegetable roti and
papadam are also included in starch portions .
• One piece of 4 cm slice cake and one short eat is calculated for
one portion cereal or equivalent.
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Estimation of meat portions
• The serving size was defined considering 7 grams of protein in
the food portion.
• One egg, 30 gram weight of meat, fish, and 30 g weight of
prawns and meat balls is defined as one meat portion.
• Since dry fish contain more protein, 15 g is defined as one
portion. But one portion of dry fish curry is considered as 30 g
since it contains gravy.
• Commonly sprats are served using table spoons. As one table
spoon holds 7-8 sprats weight of one table spoon is considered as
7.5-8 g. Thus 2 table spoons of sprats are defined as one portion.
• In Sri Lanka 1 kg of chicken is cut into 13-15 pieces and one piece
of chicken is considered as two portions.
• Since non- vegetarian fried rice contains more than 2.6g protein
than normal cooked rice, it is considered as 1/3 of meat portion
included in fried rice.
Estimation of sugar portion sizes
• Five grams of sugar is defined as a portion.
• One portion of honey, treacle and jaggery was calculated
estimating the weight or volume which contains 5grms of sugar.
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My plate
2nd Qtr
3rd
• Half the plate should be filled with rice.- ( approx. 2
cups)
• Quarter of the plate should be filled with protein. It
should include pulses i.e., dhal and fish. Ex. Sprats ( one
serving of fish/eggs/meat and 2 table spoons of pulses)
• The balance quarter should contain vegetables and
fruits ( 3 servings of vegetables and one serving of fruit)
Prepare menu of healthy diet including commonly available food
items in
your area.
( 3 weekdays and one weekend day)
Breakfast -………………………………………………………………………………….
Lunch -……………………………………………………………………………………….
Dinner -………………………………………………………………………………………
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Food pyramid
( Source- Nutrition division- Ministry of health)
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Healthy snacks.
Some healthy snacks
Any fruit/ fresh fruit juice
Yoghurt/ curd
A hand full of cashew nuts, peanuts or any other healthy
nut
Helapa, ,mungguli
(Source- food based dietary guidelines for Sri Lankans- a
publication by Nutrition Division – Ministry of Health)
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Food hygiene
Hand washing is important for food hygiene.
The five key principles of food hygiene, according to WHO are:
1. Prevent contaminating food with pathogens spreading from people, pets,
and pests
2. Separate raw and cooked foods to prevent contaminating the cooked foods.
3. Cook foods for the appropriate length of time and at the appropriate
temperature to kill pathogens.
4. Store food at the proper temperature.
5. Do use safe water and cooked materials.
What are the ways that you can improve food hygiene?
1…………………………………………………………………………………………
2…………………………………………………………………………………………
3…………………………………………………………………………………………
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