Incorporating Nutrition

into Family Planning Services Nancy Chapman

A nutritionist can be instrumental in developing services that clinic practitioners can employ

Summary A nutrition component established in family planning clinics

provides an opportunity to affect the nutritional status and eating habits of women throughout their reproductive years. In­cluding nutrition education in the routine services offered by family planning practitioners can be a suitable and practical alternative to direct client counseling by a nutritionist. Deter­mined as key elements to implement this approach were the identification of appropriate nutrition resources for clinic clients and staff; developing a client referral system to nutritionists in the community; and establishing an ongoing evaluation system to monitor the effectiveness of the clinic nutrition services.

Rationale and Need Why should a nutritionist become involved with Family Plan­

ning Clinics? The answer may be inferred from a goal of the Na­tional Family Planning Program" ... to assist in reducing the in­cidence of'maternal and infant death and disease by promoting the health and education of potential parents" (1). Huenemann, in a discussion about nutrition and family planning, describes the widely promulgated circle of relationships connecting decreased morbidity and mortality, improved socia! and economic development, population control, and good nutrition. She notes that "in the world around, stillbirth and neonatal death rates and birthweights are associated with nutritional status and dietary intake along a socio-economic gradient" (2). The Comprehensive Family Planning Clinic of Berkeley, California, serves a lower socio-economic status group of women; women that can be described as vulnerable to the hazards which Huenemann has indicated. The rationale for developing nutrition services is that the maintenance and im­provement of the nutritional status of these women throughout their reproductive years enhances their well-being, by preparing them to be more physiologically efficient, with a prospect for heathier children if they decide to have them.

Objectives Defmed An accurate defmition of the objectives and activities of the

nutrition component is essential if they are going to be accepted by a family planning program. Suggestions for the design of a nutrition component were obtained from the director and other staff of the Berkeley clinic, clients, community representa­tives,and local nutritionists who had previous associations with the clinic. The participation of health workers and consumers in nutrition planning was consistent with this clinic's policy that the operation is most successful when all voices are heard. The following considerations were determined as to the development of a nutrition component in the clinic:

• client's view of the clinic and its nutrition service needs • practitioners' perceptions of their jobs

THE AUTHOR is Nutrition Consultant, 550 East Second St., Bloomsburg, PA 17815.

• director's objectives-personal and program • past history of nutrition services in the clinic • practitioners' attitudes toward nutrition, nutritionists,

and outside consultants • expressed needs and desires of the staff for nutrition infor­

mation and consultation • activity flow, staff composition, clinic atmosphere, and

stage of development of clinic and staff. Based on a familiarization with clinic procedures and rou­

tines, and a review of staff attitudes and priorities, the following primary objectives for a nutrition component in the clinic were determined:

1 Family planning practitioners will develop confidence in discussing nutrition with the clients.

2 Staff members will select and use appropriate client­oriented nutrition education materials.

3 Nutrition posters, newsletters, and pamphlets will publi­cize to clients the existence of a nutrition component in clinic procedures.

4 Practitioners will routinely employ nutritional assessment methods and refer complex dietary problems to nutrition professionals identified as community resources.

5 Staff members will continually evaluate the need for new nutrition activities and be able to sustain a nutrition com­ponent in the absence of a nutritionist.

Similar roles were defmed by Gray in her description of the public health nutritionist in a family planning clinic (3). How­ever, the method of integrating nutrition into the existing client services was different in this clinic. Our project offered a nutri­tion component as an adjunct to the routine of the family plann- : ing practitioner, rather than establishing a permanent position i

for the nutritionist in the clinic.

Implementation Structure Need. As a result of past contacts with local nutritionists and nutrition students, both the director and practitioners in the clinic appeared to understand that nutrition is important for

Nutritionist offering advice and educating family planning practitioners

F E A T U R E

July-September 1978 Vol. 10 No.3 Journal of Nutrition Education 129

Nutrition materials conveniently located with other reference materials in the clinic

maintaining health. However, it had always been difficult to translate the nutrition/health concept into a workable form for clinic services. A combination of three factors, lack of confi­dence in discussing nutrition, minimal perceived need, and a routine which focused on more "pertinent" problems, had always kept nutrition a low clinic priority. Thus, with the excep­tion of occasional client requests for specifIc nutrition informa­tion, integration of nutrition concepts into routine counseling had been minimal. Resolving the impasse to nutrition education services for clients was partially accomplished by clarifying the clinic's concept of and role in the education process.

This clinic recognized that education is more than just pro­viding information, and practices the principle that learning is a dynam,ic process which involves five stages: awareness, develop­ment of a receptive framework for learning, trial, reinforce­ment, and adoption (4, 5). The two main participants are the person who wants, needs, or is encouraged to change, and, im­portantly, the change agent (clinic staft) who initiates, moti­vates, and facilitates the process.

Relevancy. Developing practitioner interest in nutrition within the context of family planning was only a starting point. Effec­tive nutrition and family planning education can be measured by the ability of the learner to integrate new information with ex­isting knowledge, attitudes, experience, and perceptions as demonstrated through work performance (6). Relevant areas for nutrition practice were identifIed through surveys of current related research, and staff and clients' needs and concerns. Designated areas for developing competencies for nutrition were:

• sources of iron for intra-uterine device users • nutrition intervention for users of oral contraceptive

agents who develop weight gain, hypertension, elevated glucose or plasma lipids, or abnormal vitamin levels

• nutrition information and referrals for prenatals • breastfeeding education for new mothers • low-cost food ideas • gastro-intestinal disturbances • vegetarianism • nutrition resources in the community.

Materials. Through direct participation in the clinic routine a determination was made of the type of educational materials most preferred by the staff. Bilingual pamphlets with a brief simple message and clever illustrations were the most popular print format for supplementing and reinforcing client education sessions. Nutrition posters and pamphlets were obtained and added to the clinic's collection of information materials. These items served as a supplementary resource to a nutrition hand­book which was developed for the practitioners. The nutrition handbook contains source lists for nutrition referrals and one­page explanations of priority topics such as good food sources

130 Journal of Nutrition Education Vol. 10 No.3 July-September 1978

of iron. Effective use of the handbook was demonstrated by a nutritionist while counseling clients with a practitioner present as an observer. Each client counseling room was supplied with the nutrition handbook reference.

PUblicity. To orient the clients to nutrition in general, the staff posted a monthly cooperative extension service nutrition newsletter in the reception area. Attractive nutrition posters focused attention on the new services advising, "Ask your coun­selor for nutrition information." These posters were placed on the counseling room doors and a large height/weight chart was placed above the balance scale as an obvious reminder of the relationship between diet and weight.

Services. A nutritionist was not a permanent part of the clinic staff, therefore a referral system was developed to coordinate the nutritional care of clinic clients with nutritionists in the com­munity. Standardized criteria for nutrition assessment, guide­lines for nutrition referrals, and a referral form were developed for the practitioners. Referral information included indicators of the clients' nutritional status, a plan for making referral ap­pointments, and the reason for referral.

Some Measures of Success. A questionnaire was administered to determine the practitioners' evaluation of their orientation to nutrition services and willingness to perform these services. Summarized, their three main responses were:

1 They believed their awareness and knowledge of nutrition had increased.

2 They expressed a willingness to discuss nutrition with clients and to refer them to outside nutritionists.

3 They expressed an intention to continue use of the nutri­tion handbook and other nutrition materials.

The primary objective to implement a nutrition component into the Berkeley Comprehensive Family Planning Clinic was achieved. Future evaluation of this service should be client oriented and might consider the need to expand services to such areas as weight control and nutrition education in the high school family planning program.

The essential role of nutrition education may be recognized by health care and education teams in a variety of settings. How­ever, the mechanism for crystalizing this awareness into a func­tional reality is the responsibility of the nutritionist. To integrate a nutrition program into an existing health / education routine, the staff and the nutritionist involved need to consider the con­straints within the specifiC situation. As always, the individual needs and motivations of the local population to be served must be addressed. Family planning clinics provide a setting for the timely intervention of nutrition services. Improving preconcep­tion nutritional status has the potential to facilitate superior pregnancies as well as the general long-term health of the women involved. 0

References 1 California, Department of Health, Office of Family Planning, Stan­

dards for Family Planning Services, Sacramento, 1977. 2 Huenemann, R. L., Nutrition and Family Planning, World Health

Organization, no. NutLI75.3, Geneva, 1976. 3 Gray, S., Nutrition and population: A family planning project,

J. NutL Ed., 2:25, 1970. 4 World Health Organization, Health Education in Health Aspects of

Family Planning, WHO Technical Report Series no. 483, Geneva, 1971.

5 Gifft, H. et aI., Nutrition, Behavior, and Change, Prentice-Hall, Inc., Englewood Cliffs, NJ, 1972, pp. 254-295.

6 Deeds, S., A Guidebook for Family Planning, Education, U.S., De­partment of Health, Education and Welfare, Health Services Ad­ministration, publication no. (HSA) 74-16002, Washington, DC, 1973.