1. The Ruli District Hospital
Community Nutrition Program:
Evaluation and Recommendations for Improvement
Presented by Sean Morris and Uwacu Theophila
August 3, 2011

2. Project Introduction
1. Evaluation of Community Nutrition Worker program
a. Surveys of CNWs at monthly meetings
b. Observation of village screening activities
c. Interviews with program supervisors
2. Understanding the community nutrition situation
a. Surveys of community members
b. Observation of nutrition education
c. Home visit assessment

3. Project Introduction
3. Health center teaching gardens
a. Nyange HC teaching garden
b. Ruli Sustainable Agriculture Manual
c. Assessment of existing situation
4. Establishment of farming cooperatives
a. Understand existing village associations
b. Identification of potential stakeholders
c. Initiation of Nyange PLWHA pilot farming coop.

4. Project Introduction
Methodology …
• Chose 4 of Ruli’s 7 Health Centers at random
• Used clustered method to select survey participants
• Guidance and No Guidance surveys
• Rwankuba pilot survey
• Community members: Nutrition center, village
screenings, Nyange PLWHA, and VCT mothers
• Many villages and health centers represented

5. Community Situation
Who is represented …
• 8 health centers [2 from other Hospital’s catchment]
• 25 cells
• 44 villages
• 5 males, 62 females
• 73.2% Married; 14.9% Single; 11.9% Widowed
• Educational achievement: 85% Primary; 6% Ordinary
Level; 1.5% Secondary; 4.5% CERAI, Familial, Technical
• Religion: 40.3% Catholic; 16.4% Protestant; 8.9%
Pentecostal; 10.4% Adventist; 24% No religion specified

6. Community Situation
Distance from Home to Health Center
• Combined Average, 1 hr. 38 min.
• Village Screenings, 2 hr. 10 min.
• Nyange PLWHA, 58 min.
• VCT Mothers, 1 hr. 26 min.
• Nutrition Center, 1 hr. 26 min.

7. Community Situation
Distance from Home to Screening Site
• Combined Group Average, 25
min.
• Village Screenings, 16 min.
• Nyange PLWHA, 36 min.
• VCT Mothers, 25 min.
• Nutrition Center, 28 min.

8. Community Situation
Household Circumstances:
• Average size, 5 people (ranging between 3 & 12)
• 85% of total sample have children <5 years
• 70% own land; 18% rent land; 12% live with extended family
• 85% farmers; 11.9% coltan miners; 10% artisans; 7.5% public
institution workers; 4.5% carpenters; 1% unemployed

9. Economic Situation
Estimated Monthly Household Income of • Majority of community
Community Members members have very little
money to spend on food &
health insurance.
• Consistent with observations
0-5000Rwf
of screening participants’,
5001-10000Rwf and home visit situations.
Thought question…
10001-15000Rwf
• What is the best way to
15001Rwf+ combat malnutrition in a
No Response poor population that has
access to limited cultivating
space?

10. No Space for the Poor
Bar Chart Bar Chart
10 If f4.1, how large is the Has your child ever
area of land that you been to the
cultivate? malnutrition center for
Small area 12.5 treatmet?
Medium area Yes
8 Large area No
10.0
6
Count
Count
7.5
4
5.0
2
2.5
0 0.0
0 0<x<5000 5000<x<10000 10000<x<15000 +15000 0 0<x<5000 5000<x<10000 10000<x<15000 +15000
What is your estimated monthly household income? What is your estimated monthly household income?

11. Agriculture Situation
Available Land …
• 15% of CNW villages report a “large area to farm”
• Consistent with community member surveys…
• 58.9% have small area
• 37.5% have medium area
• 3.6% have large area
• 67% of VCT mothers, and 70% of Nutrition Center mothers
report having a “small” area to farm…

12. Agriculture & Malnutrition
Seasonality of Malnutrition Incidence and Cultivating Challenges
60
50
40
% of Respondents
30
Months of Highest Malnutrition Incidence
20 Most Difficult Month to Cultivate
10
0

13. Let’s Work Together!
Opportunities for Farming Cooperative Formation
80
70
60
% of Respondents
50
40 Work Alone
Work Together
30 Both
20
10
0
Total Village Screening Nyange PLWHA VCT Mothers Nutrition Center
Mothers

14. Need for Diversity
Village Level Crop Production
87
68
61 Beans
Maize
37
Tubers
34
Coffee
9 Vegetables
9 Soya
Bananas
5
Fruit
4
Wheat
3 Sorghum
0 10 20 30 40 50 60 70 80 90 100
% of Villages Growing...

15. Community Food
Security Summary
• Average Consumption-to-Sale Ratio = 90:10 (76% at 100:0)
• Vast majority of community members are working alone!
• Overall lack of crop diversity  nutrient diversity
• Those who are poor, and at greatest risk of malnutrition have
marginal land access
• Malnutrition is temporal; therefore predictable and beatable!

16. CNW Situation
Who is represented …
• 4 health centers [Ruli, Rwankuba, Muhondo, & Coko]
• 23 cells
• 85 villages
• 44 males, 56 females
• 92% Married; 2% Single; 6% Widowed
• Educational achievement: 75% Primary; 8% Ordinary
Level; 5% Secondary; 12% CERAI, Familial, Technical
• Average CNW age – 38.9 years
• Average tenure as CNW – 6.1 years

17. CNW Situation
Satisfaction …
• Average satisfaction (from 1 to 10) – 8.05
• “How has being a CNW improved your life?”
• 62% report improved diet and nutrition knowledge
• 59% report improved capacity to care for family
• 98% see reduced malnutrition since beginning their work
• 94% report good attendance at each screening
• Only 26% claim to have adequate resources to perform
their duties…

18. Village Screenings
Growth Monitoring
• Weight of each child
under 5 years of age
• Record weight
• Referral based on
growth chart status
• Growth chart also
includes vitamin and
immunization history

19. Village Screenings
Information, Education, Co
mmunication (IEC)
• Convey relevant
nutrition, infectious
disease, or lifestyle
information to the
community
• MOH Guidebooks –
rarely used…
• Sometimes
planned, often
impromptu

20. Village Screenings
Kitchen Demonstration
• Demonstrate
hygienic, balanced meal
preparation
• Explain the importance of
a balanced diet
• Give practical suggestions
for preparing food
specifically for the child

21. CNW Needs
Greatest needs to improve service from CNWs to community …
• Additional training – 81%
• Training is currently informal, on the job training
• Indoor meeting space – 70%
• Most village screenings observed took place outdoors
• Cooking supplies – 42%
• Currently, supplies are often borrowed from community
• Nutrition education materials – 41%
• They should have MOH IEC guidebook in each village

22. CNW Needs
Barriers to providing adequate service to the community …
• Lack of Materials – 46%
• This includes kitchen, education, and record keeping
• Evil ideologies of parents – 41%
• Discouraging screening attendance; belief in traditional
healing; failure to “buy into” nutrition education
• 86% give instruction in agriculture to their village, BUT 99% desire
more sustainable agriculture training opportunities

23. CNW Knowledge
Perceptions of malnutrition …
• Only 15.7% believe that the children of HIV+ mothers are more
susceptible to malnutrition!!!
• BUT … 100% know that nutrition is especially important for HIV+
individuals
• 91% know the number of months that an HIV+ mother should
exclusively breastfeed (6 months)
• ~70% perceive a problem of malnutrition in Rwanda … only
27% see malnutrition as a problem in their own village. Denial?
• Only 26% of CNWs check for all signs of malnutrition [swollen
cheeks/legs, large belly, hair discoloration, signs of anemia]

24. CNW Improvements
Community Member Needs for More Information about Nutrition
Improvement of Nutrition Situation More Training/Education of Parents
Support for Creating Agriculture Coop
Care/Hygiene of Children
Having a Kitchen Garden
More HC Supervision of Child
Increased Food Access for <5 Children
Respect Decisions of Health Leaders
More Access to Land
Family Planning
0 5 10 15 20 25 30 35 40
No Ideas
% of Respondents

25. CNW Improvements
Community Member Suggestions for CHW Program
Better Education and Communication
to Parents
More Home Visits
Increased CHW Training
Take a Greater Stake in Child Growth
No Suggestions
Improved Information About Livestock
0 10 20 30 40 50 60
% of Respondents

26. CNW Situation Summary
• Desire for more training opportunities to better serve village
• Nutrition, Agriculture, Counseling for parents, etc.
• Lack of kitchen materials and indoor meeting space
• Most problematic during the rainy season – this is also the
time of greatest malnutrition (slide 12)
• Need for improved information about HIV and nutrition
• Need encouragement in dealing with parent ideologies, and
reminding that the fight against malnutrition is not over!

27. Recommendations
① Training and Informational Assistance
i. Formal training at program entry
ii. Increase involvement of village husbands
iii. Printed instruction for CHW diagnosis and referral
② Materials and Monthly Screening Improvement
i. Indoor kitchen and supplies for each village
ii. Central, enclosed meeting space for IEC
③ Agriculture and Food Security Assistance
i. Inclusion of agronomist into Ruli Nutrition Program
ii. Working teaching gardens at every health center
iii. Farming cooperative formation – SOSOMA and Food Security
iv. Supervised installation of kitchen gardens by CHWs
④ Integration of Nutrition and HIV Programs
i. Opt-in HIV register for each village
ii. Kitchen demonstrations and nutrition education for HIV+ mothers

28. 1. Training and Information
Objective Responsibility Feasibility Priority
Health Center
Formal Training High High
CHW Leaders
Include Village CHWs, Health
Medium Very High
Husbands in IEC Centers, Hospital
Printed
instruction for The Ihangane
High High
CHW referral Project
protocols

29. 2. Materials and Screening
Objective Responsibility Feasibility Priority
Indoor kitchen The Ihangane
Medium Medium
for each village Project, CHWs
Enclosed
The Ihangane
meeting space Low Medium
Project, CHWs
for IEC

30. 3. Agriculture and
Food Security
Objective Responsibility Feasibility Priority
Objective
Inclusion of Ruli Responsibility Feasibility Priority
The Ihangane Project,
Hospital
Inclusion of Ruli High High
Ruli Hospital
The Ihangane Project,
Agronomist
Hospital High High
Ruli Hospital
Farming Coop.
Agronomist CHWs, Ruli Hospital The
High Very High
Formation
Farming Coop. Ihangane Project
CHWs, Ruli Hospital
High Very High
Working Teaching The Ihangane Project
Formation
Ruli Agronomist, CHWs,
Gardens at Each
Supervised High High
Health Centers
Health Center
Kitchen Garden CHWs, Health Centers Medium Very High
Supervised Kitchen
Installation
CHWs, Health Centers Medium Very High
Garden Installation

31. 3. Agriculture and
Food Security – Farming Coop.
Nyange PLWHA Farming Cooperative

32. 3. Agriculture and
Food Security - SOSOMA
SOSOMA Constituent Production
80
70
60
% of Respondents
50
Total
Village Screening
40
Nyange PLWHA
VCT Mothers
30
Nutrition Center Mothers
20
10
0
Maize Soya Sorghum None

33. Kitchen Garden
Theory… Vs. …Practice

34. Sustainable Agriculture
• Raised or Double-Dug beds – Increase land area; deep root
penetration; increased water retention
• Compost Pile Construction – Improve soil fertility; reduce
unnecessary purchase of chemical fertilizer that harms soil
• Inter-planting & Close Spacing – Reduce pest pressure;
improve yields; increased water retention
• Crop Rotation and Planning – Improved soil fertility;
preparation for months of difficult cultivation
“Ruli Hospital Sustainable Agriculture Manual”

35. Sustainable Agriculture

36. 4. Integration of Nutrition
and HIV Programs
Objective Responsibility Feasibility Priority
Opt-In HIV Register Ruli Hospital, Health
High High
for Each Village Centers, CHWs
Kitchen Demo.
and Nutrition Ruli Hospital, Nutrition
Education for VCT Center, The High High
mothers at the Ihangane Project
Nutrition Center

37. Thank you! … Questions?
① Training and Informational Assistance
i. Formal training at program entry
ii. Increase involvement of village husbands
iii. Printed instruction for CHW diagnosis and referral
② Materials and Monthly Screening Improvement
i. Indoor kitchen and supplies for each village
ii. Central, enclosed meeting space for IEC
③ Agriculture and Food Security Assistance
i. Inclusion of agronomist into Ruli Nutrition Program
ii. Working teaching gardens at every health center
iii. Farming cooperative formation – SOSOMA and Food Security
iv. Supervised installation of kitchen gardens by CHWs
④ Integration of Nutrition and HIV Programs
i. Opt-in HIV register for each village
ii. Kitchen demonstrations and nutrition education for HIV+ mothers