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LESSON 1 INTRODUCTION TO THE “GOOD FOOD TOOLKIT” (Facilitator EN)

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Learning objectives

At the end of this session, participants will be able to describe:

  1. the purpose of the Toolkit
  2. the correct target group for nutrition counselling using the Toolkit
  3. the main components of the Good Food Toolkit

Duration: 1 hour

Methods

  • Brainstorming
  • Demonstration
  • Group Discussion
  • Participatory Lecture

Materials

  • “Good Food Toolkit”
  • Large paper or white board
  • Markers
  • Coloured sticky notes
  • Copy of:
    • “Self-Care Series” booklets (FHI)
    • Nutrition and HIV training manual (KHANA)
    • Complementary Feeding for Children aged 6-23 months booklet (FAO)
    • Baby Friendly Community Initiative Flipchart (National Nutrition Program/NNP)
    • Cooking Demonstration Manual

Introduction:

PLHIV must take special care of themselves to stay healthy and live active lives. There are many things they can do to stay healthy, such as – keep sanitary conditions for themselves and their home to avoid infections, eat enough good food, take medicine, stay active and exercise, and keep a positive attitude.

In Cambodia, services for PLHIV both within the health facility and the community are getting better every day. This includes services in hospitals, health centres (HC), OI/ART sites and especially services from home-based care teams (HBCTs). You are a very important source of information and support for PLHIV, and you also need to have good training and support to do your job well.

Presentation of learning objectives:

The facilitator shows the learning objectives (written on the large paper) and asks one participant to read the objectives aloud to the group. Discuss each objective with participants to make sure that they understand.
Introduce the session with a description of the overview. The session will cover:

  • Background to the Good Food Toolkit
  • Purpose and use of the Toolkit
  • Target audience for the Toolkit
  • Contents of the Toolkit
  • Quiz

By the end of the lesson, participants will be able to describe:

  1. the purpose of the Toolkit,
  2. the correct target group for nutrition counseling using the Toolkit
  3. the main components that it contains

Learning objective 1:

Participants will be able to describe the purpose of the Toolkit

Methodology: Brainstorming, Demonstration

  • Step 1: Brainstorming

Duration: 10 minutes

Instructions for activity:

Facilitator introduces the session by asking participants “Why is good nutrition so important for PLHIV?”

In the meantime, the facilitator is listing the reasons on a flip chart paper.

Discuss and summarize

There is strong relationship between nutrition and HIV, so PLHIV need to be especially careful about what they eat, how much they eat and how often they eat. Because their bodies are constantly fighting the virus, PLHIV need to eat more of the right types of food than people who do not have HIV. The body needs more energy and nutrients to fight back. However, this is sometimes difficult for PLHIV because the illness and medicines taken may change how food tastes or cause loss of appetite. Common problems such as nausea, vomiting or sores in the mouth can make it difficult to eat. Many PLHIV are poor and have trouble finding enough appropriate food. Feeling alone, tired or depressed also can make a person not feel like eating or making effort to prepare food.

HIV may also affect the way the body uses nutrients, which makes it harder to fight infections.

Weight loss is also one of the major danger signs of opportunistic infection (OI) and/or other problems (e.g. psychosocial) seen in PLHIV. Diarrhoea can cause food to move too quickly through the gut so that nutrients are not absorbed and used by the body. All of this can result in a person losing weight and becoming malnourished. It is very important for them to keep a good body weight to fight off infections.

Good nutrition is important for the well-being of PLHIV, even if the PLHIV is not ill, because good nutrition keeps the body strong. The body can better resist infection and delay progression to AIDS. Good nutrition is particularly important in the early stages of HIV infection. Early nutrition counselling and education gives the person a chance to build up healthy eating habits, to take action to improve access to food and adopt healthy practices.

The Good Food Toolkit it is an education, counselling, problem solving and behaviour change tool that will help counsellors to aid PLHIV in addressing and finding practical solutions to the health and dietary challenges that PLHIV face every day. The Toolkit will help you and your clients to make the best use of food that is already available, so that they can eat as well as possible and maintain a good body weight. PLHIV who are pregnant and breastfeeding, as well as exposed and infected children are at increased risk of nutritional problems and have additional nutrition requirements.

  • Step 2: Demonstration

Explain that there are already some educational materials available in Cambodia related to Nutrition and HIV.

Show participants one of the “Self Care Series” books (preferably Book 2 and Book 4) from Family Health International (FHI):

Book 2 in the series contains general information about nutrition on page 8 and is designed for PLHIV to read and use by themselves. It also has good information and advice on caring for different kinds of illness and symptoms. It is very holistic, has beautiful paintings, and it encourages people to stay calm and positive so they can live well with HIV.

Book 4 in the series provides information to help PLHIV who are pregnant and post-partum women to stay healthy (page 4 and 20). It also has information on complementary feeding for children from 6 to 24 months to help their baby stay strong and healthy (page 26 -31). Please note that information on infant feeding recommendations in the context of HIV for children under 6 months in this book is not in line with current recommendations.

Ask participants: Do you use this “Self Care Series” of books? How do you use it? Did you find anything about nutrition in this book?

Show participants the KHANA training manual for “Nutrition and HIV” (if available).

This is a good manual, and it is designed to teach basic knowledge on HIV and Nutrition (especially for care providers like HBCTs). It covers many important topics such as:

  1. General nutrition, including nutrition for women and children
  2. HIV and nutrition
  3. Nutrition and antiretroviral (ART) interaction, including side effects
  4. Nutrition and food security for PLHIV
  5. Safe drinking water and hygiene

Show participants the Cooking Demonstration Manual for PLHIV. The manual is designed to provide guidance on how to conduct a cooking demonstration for PLHIV. It also contains nutrition messages about food and healthy eating and a collection of easy to prepare and affordable recipes.

Explain that there are also maternal and child nutrition communication materials available for use by participants to talk with pregnant and breastfeeding women, mothers, fathers and other family members/caregivers (e.g. grandparents). Show participants the BFCI Flipchart, developed by the NNP. The flipchart is used as a teaching aid in the field so that mothers, caregivers and other community members are more easily able to visualize the recommended methods of breastfeeding and complementary feeding. Another useful resource is “Complementary Feeding for Children Aged 6-23 months – A recipe book for mothers and caregivers” from FAO. This booklet gives guidance on how to prepare nutritious and safe complementary foods for young children.

  • Note to Facilitator

    Explain the above section if participants work with pregnant and breastfeeding women as well as exposed and infected children.

Learning objective 2:

Participants will be able to describe the correct target group for nutrition counselling using the Toolkit

Methodology: Participatory Lecture, Buzz Groups

  • Step 1: Participatory Lecture

Target Group for the Toolkit. Explain that, The Toolkit has three key target groups. The first one is adult PLHIV who are relatively healthy and leading normal lives – it is designed to help these people stay healthy and continue to live well with their families in their communities.

The second target group is HIV-positive pregnant and breastfeeding women and the third target group is HIV-exposed infants, children with HIV (paediatric HIV) and orphans and children made vulnerable by HIV/AIDS (OVC).

Adults and children who are very sick with advanced AIDS and are bed-ridden are not included in this Toolkit. These target groups require specific advice on nutrition and HIV that is not covered in this Toolkit.

  • Step 2: Buzz Groups

Duration: 10 minutes

Instructions for activity:

  • Prepare post it notes/sticky notes in 3 colours representing three target groups
  • Facilitator asks the participants to get into groups of 2
  • Facilitator distributes 2 sticky notes of similar colour to each groups and states that the exercise will take 5 minutes
  • Facilitator asks participants to list, some of the benefits of good nutrition for the 3 target groups, known to them.
  • Buzz groups plenary presentations
  • Discuss and summarize.

Facilitator Notes:

Answers to ‘benefits of good nutrition’ might includes:

Target Group 1 – Adult PLHIV

  • Improves the body’s ability to fight illness and stay well
  • Helps maintain weight
  • Improves energy level
  • Maintains a good appetite
  • Recovers quickly from infections
  • Keeps the body strong and less dependent on others
  • Assists in managing HIV related symptoms
  • Assists in managing treatment side effects
  • Keeps PLHIV productive, able to work and contribute to family’s income
  • Improves quality of life

Target Group 2 – HIV-positive pregnant and breastfeeding women

  • Helps the mother and the baby stay healthy
  • Meets extra food needs due to changes in their body and the needs of the growing baby
  • Helps the mother gain enough weight during pregnancy and breastfeeding
  • Improves the body’s ability to fight illness and stay well
  • Helps the mother recover from the birth of a child and take care the baby
  • Gives more energy for breast milk production

Target Group 3 – HIV-exposed infants, children with HIV and OVC

  • Promotes optimal growth and development
  • Improves the body’s ability to fight childhood illnesses and stay well
  • Prevents malnutrition
  • Achieves a healthy body weight
  • Gives plenty of energy with which to play and have fun
  • Provides energy to study
  • Step 3: Participatory Lecture

Explain that, HIV weakens the body’s defence system against disease and infection; as a result, the body needs to work harder to fight infection. This increases energy and nutrient needs of PLHIV. HIV can cause or worsen poor nutrition by causing reduced food intake, poor food absorption and increased energy and nutrient needs. PLHIV may not be able to eat enough food to meet these needs due to poor appetite. Eating well can help prevent poor nutrition. Poor nutrition leads to weakening immune function and increased risk of infections. Improving and maintaining good nutrition is important for PLHIV. Healthy and balanced nutrition should be one of the goals of counselling and care for PLHIV. Many people know how to take care of their health, although they do not usually apply that knowledge thoroughly. For adult PLHIV, it is very important to develop good habits and put practical tools in place that make it easy to adopt healthy eating habits. Using good nutrition and dietary habits can keep the body strong and may prolong health and delay the progression from HIV to AIDS. Improving and maintaining good nutrition can help PLHIV stay healthy and continue live well as part of their families and communities.

Ask participants, Why do you think we should also focus on pregnant and breastfeeding women with HIV?

Then explain that, Good nutrition before conception and during pregnancy and breastfeeding (lactation) is important for the health of both mother and baby. Well-nourished mothers have healthier babies of adequate weight, and are at much lower risk of maternal poor health outcomes, including the transmission of HIV from mother to child. As each pregnancy places considerable nutritional demands on a mother, women who are HIV infected are likely to become malnourished during pregnancy if insufficient energy and nutrients are consumed. Increased energy needs during breastfeeding may also accelerate weight loss in breastfeeding women with HIV. The increased energy needs as well as the common HIV-related infections increase the nutrition risk of pregnant and breastfeeding women with HIV, which is why the Toolkit is also focusing on this target group.

Ask participants, Why do you think we should also focus on children, nutrition and HIV?

Then explain, Infants and children are growing, or trying to grow at all times. Good growth is critical to the development of the brain, which continues to develop into adulthood. Good growth as an infant and child will enable an adolescent to reach their maximum height potential, and maximum bone strength. All children need adequate nutrition for growth and development, but it is particularly important for HIV-exposed infants, children with HIV and OVC. They are vulnerable to childhood illnesses, malnutrition and poor growth. Like adults, children with HIV may have difficulties eating due to poor appetite or other symptoms such as nausea, vomiting or mouth sores and thrush. Because of these factors that may reduce food intake in young children with HIV, mothers or carers will need guidance and support for appropriate feeding practices and to ensure the improved food intake of their children during illness and recovery.

Learning objective 3:

Participants will be able to describe the main components of the Good Food Toolkit

Methodology: Demonstration, Plenary Discussion

  • Step 1: Demonstration

Now show participants a copy of the “Good Food Toolkit.”

Explain that, The “Good Food Toolkit” has been developed as a complement to these materials. It is not intended to replace them! The Toolkit provides very practical counselling tools that can be used alongside these materials. In this training, we will learn how to use the Toolkit to provide nutrition counselling to PLHIV on a regular basis, to make sure they are eating the best possible available food in the best way possible, to stay healthy and maintain a good weight.

Open the toolkit folder. Show participants the contents, and explain briefly what each item is for:

  1. “Small food cards” with photos of many different foods – help you and the PLHIV decide what food is available, practical and affordable for the PLHIV, so that you can plan good meals realistically (and which the PLHIV will be able to prepare).
  2. “Large food cards” showing pictures of plates and bowls of food such as rice, soup, and desserts – the large cards can help you show the PLHIV about the amount of food they should be eating.
  3. “Positive Living” counselling cards – these illustrations, along with the questions and information on the back of the cards, will help you and PLHIV have a two-way conversation and make feasible plans about different ways to stay healthy and manage symptoms of illness with the right kinds of food.
  4. “Drinking Cups” – pictures of three different size drinking cups to help estimate the amount of water and other fluids the PLHIV normally drinks each day and how much he or she should drink each day.
  5. Assessment tools:
    1. Body Mass Index (BMI) table for adults (both gender and over 6 months post-partum women) – a tool to help estimate BMI in a simple way without having to compute using the formula.
    2. World Health Organization (WHO) BMI-for-age chart for children (boys and girls) – a tool to assess nutritional status of children aged 5-19 years of age.
    3. Food and Nutrition Technical Assistance (FANTA) BMI-for-age look up tables for children and adolescents 5-18 years – these tables are a quick reference to work out a child or adolescent BMI (weight-for-height) without having to compute using the formula.
    4. Mid-upper arm circumference (MUAC) child and adult tapes – a tool to measure nutritional status in children (6-59 months of age), pregnant and post-partum within 6 months after delivery.
  6. Nutrition Counselling Monitoring Forms – for counsellors to keep a record of the PLHIV’s status, and key suggestions provided during nutrition counselling. This will help you follow up on the improved behaviour with the PLHIV from one visit to the next. There are three different monitoring forms to record nutritional related changes for:
    • Adults (both gender) and over 6 months post-partum women
    • Adults pregnant and post-partum within 6 months after delivery
    • Children aged 0-19 years
  7. Cooking Demonstration for People Living with HIV: A Manual – This guide is designed to assist those who provide cooking demonstration activity for PLHIV. It contains information, advice, and resources including recipes for planning and conducting an effective cooking demonstration.

We will learn how to use all of these tools as a part of the counselling process. You might even come up with new creative ways to use these materials.

Distribute a copy of the Toolkit to each participant and let them open and examine the contents.

Take a few minutes to answer any basic questions from participants about the contents of the Toolkit. At this point in the training, defer any questions about the process of using the Toolkit until later. Simply explain that now they are learning about WHAT the Toolkit is, and WHY they have it. Later in the training they’ll learn about HOW to use it.

  • Step 2: Plenary Discussion

Duration: 5 minutes

Ask: Please tell me in your own words what is the purpose of having this Toolkit in addition to the materials that we already use for Nutrition and HIV.

Summarize their answers on the large paper. If none of the participants mention it, write: to help PLHIV plan nutritious meals with the food they have available and are able to prepare, so that they can keep a healthy body weight and fight infection. AND to help HIV-positive pregnant and breastfeeding women and their children to make the best nutrition (food and drink) choices for their situation.

(Summarize as…)

  • Plan and prepare nutritious meals
  • Use available food and drinks
  • PLHIV keep healthy body weight
  • PLHIV can prevent and fight infection
  • Learn how to manage symptoms of illness with food (and drinks)
  • PLHIV can live a healthy lifestyle
  • Help families understand the best foods and drinks for infants and children.

Summary

Ask participants to look at Lesson 1 (participant manual). The facilitator can read it, or ask participants to take turns reading it.

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