The document outlines a project using the transtheoretical model to improve nutritional status, specifically addressing anemia among reproductive-age women in Province 6, Nepal. It includes an analysis of current nutritional deficiencies, the implementation of a health education program, and a structured plan for addressing these issues through targeted interventions. Key objectives are to raise awareness about nutrition, facilitate behavior change, and improve health outcomes for women and children in the region.

1. Application of Transtheoretical Model to Promote
the Nutritional Status (Anemia) of Reproductive
Age Group Women of Province-6
PSD carried out in partial fulfilment of the requirements for the
Theories and Principles of Health Behavior, Health Promotion,
Education and Communication, HPE 611
Group A
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Roles and Responsibilities
Topic Methods Activities Settings Divisio
n
Group Members
An overview of Nutritional Status of adolescent people in Nepal Secondary data and
literature review
Desk Review,
Group
Discussion,
Presentation
College,
Home
Alina Giri
Aruna Gyawali
Astha Lamichhane
An overview of principles and strategies of communication for
health education and promotion.
Secondary data review
Desk Review
Desk Review,
Group
Discussion,
Presentation
College,
Home
Alina Giri
Aruna Gyawali
Astha Lamichhane
An overview of various philosophies and foundations of health
promotion and education
Literature reviews Desk Review,
Group
Discussion,
Presentation
College,
Home
Alina Giri
Aruna Gyawali
Astha Lamichhane
An overview of various models and methods of communication
for providing health education to community peoples
Literature reviews Desk Review,
Group
Discussion,
Presentation
College
Home
Alina Giri
Aruna Gyawali
Astha Lamichhane
An overview of Different Model of Health Behavior Change Literature reviews Desk Review,
Group
Discussion,
Presentation
College
Home
Alina Giri
Aruna Gyawali
Astha Lamichhane
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Objectives of PSD
After the completion of this Practical Skill Development we will be able to :
• Apply various models of Health Behavior Change in to practice
• To evaluate the program using various indicator
• The core objective of development of the PSD is to learn to apply
Transtheoretical Model of Health Behavior change to enhance the positive health
behavior for promoting and protecting health, preventing diseases, controlling
epidemics and motivating for early diagnosis.
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Introduction
• Nutrition is the science that interprets the nutrients and other substances
in food in relation to maintenance, growth, reproduction, health and
disease of an organism. It includes
ingestion, absorption, assimilation, biosynthesis, catabolism and excretion.
• Nutrition is a critical part of health and development. Better nutrition is
related to improved infant, child and maternal health, stronger immune
systems, safer pregnancy and childbirth, lower risk of non-communicable
diseases (such as diabetes and cardiovascular disease), and longevity.
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Nepal government has set the goal of Nutrition programme as follow:
• “The goal of National Nutrition Programme is to achieve nutritional well-
being of all people to maintain a healthy life to contribute in the socio-
economic development of the country, through improved nutrition
programme implementation in collaboration with relevant sectors.”
• The general objective of the National Nutrition Programme conducted by
MOHP is to enhance nutritional well-being, reduce child and maternal
mortality and to contribute for equitable human development.
• The targeted beneficiaries of MOHP are women and children. For them
the government of Nepal has distributed iron and calcium tablet for
pregnant women regular growth monitoring of the children for
management of acute malnutrition. Vitamin A supplementation program
etc.
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Statement of Problem
• According to Global Nutrition report 2020, Among under 5 children, 149.0 million are
stunted, 49.5 million are wasted and 40.1 million are overweight. Global, regional and
national patterns cover nutrition inequalities within countries and by sociodemographic
characteristics, such as location, age, sex, wealth and education. Data gaps are more
prominent for certain nutrition indicators, locations, and key population characteristics,
such as ethnicity and disability. These data breaks prevent both improved understanding
of nutrition inequalities and informed priority-setting.
• Looking at the Maternal infant young child nutrition targets, the world is disoriented to
meet the anaemia target, 32.8% (613.2 million) female population of aged 15-49 age
group are anaemic. The rate is much higher 40.1% (35.3 million) among pregnant
population than non-pregnant adolescent girls and women which is 32.5% (577.9
million,)
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Nutritional Status of Women:
• 11% of women are shorter than 145 cm. A total of 17% women are thin, with 11%
mildly thin and 6% moderately and severely thin. Further, 22% are overweight or
obese, with 17% being overweight and 5% obese.
• The proportion of short women (below 145 cm) is lowest in Province 7 at 7% and
highest in Province 2 at 14%.
• Younger women are more likely to be thin than their older counterparts. For instance,
30% of women age 15-19 are thin compared with 13% of women age 40-49.
• The proportion of thin women is higher in terai (23%) than in mountain and hill
ecological zones (12% each).
• Province 2 has the highest proportion of thin women (29%).
• Further, Province 3 has the highest proportion of overweight/obese women (35%).
• Overweight/obesity increases with wealth and household food security. For example,
45% of women in the highest wealth quintile are overweight/obese compared with
10% in the lowest wealth quintile.
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Anemia prevalence in women :
• 35.1% of women of reproductive age have anemia and 5.4% of women
have obesity.
• A higher proportion of women in terai (52%) are anemic compared with
women from mountain (35%) and hill (29%) ecological zones.
• Prevalence of anemia among women is highest in Province 2 (58%) and
lowest in Province 4 (28%)
• Pregnant women and breastfeeding women (each 46%) are more likely to
be anemic than other women (39%).
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National nutrition program
There is various ongoing program to address the nutrition problem:
• Protein Energy Malnutrition Control Program
• Iron Deficiency Anemia Control Program
• Deworming
• Iodine Deficiency Disorder Elimination Program
• Vitamin A Deficiency Disorder Control Program
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Health Problem Prioritization
• Anaemia has severe nutritional and health consequences, including high maternal
mortality, inadequate growth and impaired mental development in children. Anaemia
during pregnancy increases the risk of fetal growth retardation and low birth weight,
premature delivery, increased perinatal mortality, and reduced resistance to infection
of both mother and baby. Anaemia also results in decreased work capacity, including
reduced care giving and general productivity.
• Anaemia is an extremely serious public health problem in Nepal. The 1998 Nepal
Micronutrient Status Survey reported an overall anaemia prevalence of 68% among
women. The prevalence of anaemia among pregnant women was even higher (75%).
In other words, three out of four pregnant women in Nepal are anaemic.
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Theory Of Health Behavior Change
Transtheoretical Model
The transtheoretical model of behavior change is an integrative theory of therapy that
assesses an individual’s readiness to act on a new healthier behavior, and provides
strategies, or processes of change to guide the individual. The model is composed of
constructs such as: stages of change, processes of change, levels of change, self-efficacy,
and decisional balance
The Transtheoretical Model (TTM) focuses on the decision-making of the individual and
is a model of intentional change. The TTM operates on the assumption that people do not
change behaviors quickly and decisively. Rather, change in behavior, especially habitual
behavior, occurs continuously through a cyclical process.
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Transtheoretical Model
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Objectives
General Objective
• To improve the anemic status of female of Reproductive Age group residing on Province
6.
Specific Objectives
• To measure anemic status of women in the community.
• To find out stage of women who are ready to adopt healthy lifestyle as per stage of
change model
• To provide the adequate consciousness about health and nutritional status among the care
givers
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• To impart the nutritional education to reproductive age group female and
under 5 children
• To Provide the Preventive Promotive, Referral and Follow-up services
related to nutrition to the reproductive aged group female of Province 6.
• To explain the importance of ANC and PNC visit and consumption of Iron
folic acid tablets
• To explain about the worm infestation and measures to protect
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Behavioral
Diagnosis
Negative Behaviour:
• Neglected ANC and PNC check up
• Food Taboos
• Unsafe abortion
• Worm infestation
• Lack of Iron folic acid supplementation
• Not using Family planning commodities
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Positive Behaviour:
• Proper antenatal and postnatal care and consumption of Iron and Folic
acid tablet.
• Consumption of Nutritious diet containing vitamins and minerals
• Use of family planning commodities to maintain the birth spacing
• Proper handwashing with soap and water before eating, feeding the
children and after defecation to prevent worm infestation.
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Target Group
Going through the key facts and segregated data, nutrition problem is more
prominent in Terai region, whereas among 7 province, province no 6 has
more nutrition problem than others. The problem is markedly seen among
the female with no education and with lowest wealth quintile.
Therefore, the target audience will be the women of reproductive age group
of Terai region of province 6. The targeted group will be selected from
lowest wealth quintile who have no education.
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Content of the Health Education Program
• Meaning and definition of nutrition
• Introduction of anemia
• Importance of nutritive diet and personal hygiene to prevent anemia
• Harmful effects of anemia on both mother and baby
• Causes of anemia
• Measures to prevent and control anemia
• Importance of family planning to prevent anemia among reproductive age group
women.
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Method and Media of Health Education
• With help of this media exposure habit of population of all 7province radio can
be a good means of Information and communication media. If the target
audiences are given about the nutrition information in the caller back tune along
with radio station they can tune in for the further information, it can be very
effective for the target population. As 30% owning radio and 94% owns mobile
phones. Where 56% knows how to tune radio/Fm in their mobile phones.
• Parallelly we can also make nutrition program for television for once a week for
those target population who has access to television as the reliability is highest
and 38% of the target audience of selected province has access to television. 18%
watch television after radio.
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Implementation Plan by Using TTM
Stages Stages supported by
data
Media Action
Pre-contemplation Wasted =79.4%
Stunted= 9%
Underweight= 46.4%
Exclusive breast feeding for
6 months=66.1%
Not consuming diverse diet
=50%
Maternal nutrition
knowledge
(NDHS 2016)
Introductory Radio Nutrition
program at daytime
Television Nutrition program at
nighttime
Development of caller back
tune, collaboration with NTC
NCELL and SMART cell
Radio program is targeted
for Women’s reproductive
age group (WRA)
Television program is
targeted for Husbands
group who has decision
making power in home.
The program will run for 6
months
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Contemplation Stunting =28.1%
Wasting = 9.9%
Underweight= 22.6%
Exclusive breast feeding =70.6%
consuming diverse diet = 35.6%
Maternal nutrition knowledge during
pregnancy =85.9%
(2017 Annual survey)
2nd stage Radio television nutrition program
along with one-to-one counselling
Continuation of caller back tune
Formulation of Mothers Health Group
Within next 6 months this targeted
group will accept the behaviour
change education and change their
dietary habit.
For the remaining percentage of the
clients One to one counselling
program will be designed to catch up
the success of the nutrition program the
formulation of mothers health group
will be done
Preparation Exclusive breast feeding =71.1%
consuming diverse diet = 41.6%
Maternal nutrition knowledge during
pregnancy =90.5%
(SUAAHAARA)
3rd stage Radio television nutrition program
along with one-to-one counselling and
inclusion of the head of the family, and
family members others stakeholder
Continuation of caller back tune
People are ready to take action and are
trying to implement in their life. the
given data by second annual evaluation
report suggest a bit of progress. And
are showing great difference in their
dietary habit.
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Action The reduced number/
percentage of the stunted,
wasted and underweight cases
show how much they have
changed their behaviour and are
willing to go further for
betterment of their nutritional
status
1st stage and 4th stage radio television
program to push up those 90.5%
mothers who had already prepared
for action or are acting for the
behaviour change.
Slight change in Caller back tune as
per the need of the community.
As per data suggestion 90.5%
mother has changed their
behaviour but still 9.5% are out
from action phase so mid-term
evaluation of the project is need
to confirm the reason behind the
gap or their termination of the
program so that a new parallel
program can be constructed to
address those WRA group.
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Maintenance The final survey will show the progress
and those mothers maintaining their
nutritional status
One to one counselling and they can be
employed for the behaviour change
communication so that their information can
be relied by the people.
The reliability of information from friends,
neighbors is third highest i.e., 21 % which can
be beneficial for our program. caller back tune
including success stories.
After following the change in behaviour
for 6 months these mother group is said
to have changed their nutritional habit.
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Project Log Frame
Project Structure Indicator Means of Verification Risk assumption
Goals
To promote the health and
nutritional status (anemia)
of reproductive age group
women of province 6.
# % of women identified with
nutritional problems.
# % of anaemic women
Local level survey
Hospital Records
Lack of coordination of local
stakeholders
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Outcome
60% of the women identified with
anemia benefitted from program
# of reproductive age women
receiving treatment after referral
# of women know about
deworming and iron and vitamin
A supplementation program
District hospital referral cases
- Minutes and photographs
Lack of adequate
supplementation
Output
80% of women identified with
anemia treated with iron
supplementation Folic acid and
deworming program
# of women screened with
nutritional problem
# of women provided with iron and
folic acid supplementation
#of teacher FCHVs training for
BMI calculation
# formulation of women health
group..
Reports
and
minutes of participation
Incomplete recording
Lack of vitamin supplementation
Lack of budget
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Activities
• Conduct health conference and nutrition
campaigns program
• Awareness about importance of nutrition through
IEC, Radio program, TV program and case story.
• Conduct nutritional counselling to reproductive
age group women and family
• Formation and mobilization of women health
groups
• Mobilization of FCHVs on Iron and Folic acid
distribution and BMI calculation
• Awareness raising about ANC PNC checkup and
care
• Health Education to Pregnant women group
regarding importance of institutional delivery,
breastfeeding, deworming during pregnancy
#health conference and nutrition campaign
conducted
# of awareness about importance of nutrition
through IEC, Radio program, TV program and
case story done
# of nutritional counselling conducted to
reproductive age group women and family
#of mobilization of women health groups
# of FCHVs mobilized for Iron and Folic acid
distribution.
# of ANC PNC visit
# of women having knowledge regarding
importance of institutional delivery and
deworming
- Home Visit
Documents
- Signature Audits
- Local authority
documentation
-Minute/Registers/
Photos
-Minutes and Report
- Reports & records
of health education
session
-Lack of
documentation
- Cultural issues
- No or less
participation
-Incomplete
recording and
reporting
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Monitoring
and
Evaluation:
• Data recording
• Input Vs Output Assessment
• Utilization of resources
• Conduction of activities with
respect to Gantt Chart
• Content delivery by the experts
according to the work schedule
• Procurement of the activities
• Timely distribution of the
budget
Monitoring
is done on
the basis of
day to day
information
and to the
higher level
based on:
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The
personnel
responsible
for
monitoring
will be:
Field Officers, weekly
Project Manager, trimester
Organization Chairman,
Biannually
Funding Partner: Biannual and
Annual
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Evaluation of Program
Process evaluation:
• Number of Health Education session conducted
• Proportion of health educators providing nutrition education
• Proportion of pregnant women receiving iron and folic acid supplement
• Number of mothers groups formulated
• Number of radio program conducted
• Number of health education session conducted through television
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Outcome Evaluation
• Increased level of Knowledge regarding nutrition among reproductive age
group women.
• Reproductive age group women identified with anemia benefitted from
program
• Anemic women receiving iron and folic acid after referral
• Percentage of mothers fully aware about ANC Natal & PNC care
• FCHVs mobilization on BMI calculation
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Impact evaluation
• Decreased rate of anemic women
• Increased rate of institutional delivery
• Decreased Maternal mortality Rate
• Decrease in childhood Mortality
• Community involvement in local food production
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LIMITATION AND SUMMARY
This project is only a theoretical concept, it would have been more better if it
can be applied in a real scenario.
There are several limitations of TTM, which should be considered when
using this theory in public health.limitations of this model includes:
This theory ignores the social context in which change occurs, such as
socio ecnomic status and income.
The line between the stage can be arbitary with no set criteria of how to
determine a person's stage of change.
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There is no clear sense for how much time is needed for each stage, or
how long a person can remain in a stage.
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Summary
Anemia has severe nutritional and health
consequences, including high maternal mortality,
inadequate growth and impaired mental development
in children. Anemia during pregnancy increases the
risk of fetal growth retardation and low birth weight,
premature delivery, increased perinatal mortality, and
reduced resistance to infection of both mother and
baby. Anemia also results in decreased work capacity,
including reduced care giving and general productivity.
Anemia is an extremely serious public health problem
in Nepal. The 1998 Nepal Micronutrient Status Survey
reported an overall anemia prevalence of 68% among
women. The prevalence of anemia among pregnant
women was even higher (75%). In other words, three
out of four pregnant women in Nepal are anaemic.
Furthermore, the survey also found a prevalence of
78% among pre-school children, while virtually all
infants between 6-11 months of age were anemic
(90%), which is a period of rapid physical and mental
growth.
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Learning From PSD
• Review the plan documents according to the objective of the study
• To apply the theories of health behavior, change in practice.
• Learned to apply the constructs of PIE model to community-based health
education program
• To evaluate the program using various indicators.
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Activity Chart (Gantt Chart)
S.N. Activities
Oct Nov Dec Jan Feb March
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
1 PSD Topic selection and discussion
2
Topic finalization and
Consultation with subject teacher
3
Search and collect related
documents
4 Review NDHS and NNMSS report
5
Prepare draft report and develop
outline for the presentation
6
Preparation and finalization of
slide
7
Sharing with teachers for the
feedback
8
Report preparation & feedback
collection
9
Final report submission and
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References
• https://www.mohp.gov.np/eng/program/child-health-services/nutrition
• SUAAHARA II good nutrition program Annual Survey year one USAID 2017
• SUAAHARA II good nutrition program Annual Survey year Two USAID 2018
• Community-based model for improving child nutrition status - a success story in Yen Bai,Hanoi, 4-2016
• Creating An Analysis Plan 2013 CDC
• Nutrition Education: A State−of−the−art Review − Nutrition policy discussion paper No. 1 and 2 Robert C. Hornik, University of
Pennsylvania
• Multi-sector Nutrition Plan 2013-2017 (2023) National Planning Commission government of Nepal
• Sustainable Development Goals status and Road map 2016-2030, National Planning Commission government of Nepal 2017
• UNICEF/WHO/World Bank Joint Child Malnutrition Estimates Expanded Database: Stunting, Wasting and Overweight, (March 2019,
New York), NCD Risk Factor Collaboration 2019, WHO Global Health Observatory 2019.
• https://globalnutritionreport.org/reports/2020-global-nutrition-report/inequalities-global-burden-malnutrition/
• https://globalnutritionreport.org/reports/global-nutrition-report-2018/appendix-3-countries-significant-multiple-forms-malnutrition/
• https://globalnutritionreport.org/reports/global-nutrition-report-2018/appendix-2-countries-track-global-nutrition-targets/
• A RESEARCH REPORT ON United Nations Educational, Scientific and Cultural Organization Empowered lives. Resilient nations.
MEDIA & THE NEPALI PUBLIC 2012 Media Foundation- Nepal Japan in collaboration with UNESCO
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