HEALTH & NUTRITION MODULE family development session (FDS) FAMILY hope PROGRAM (PROGRAM KELUARGA HARAPAN, PKH) TECHNICAL GUIDE FOR THE FDS IMPLEMENTATION MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 1 4/7/2018 1:03:29 AM This module is a revision of the previous module printed in 2014, published jointly by Bappenas, the Ministry of Health, the Ministry of Social Affairs, TNP2K, AUSAID, and UNICEF. The revision of this module is based on desk review of various reports of Family Hope Program (PKH) activities from 2008 to 2017, field visits and pilot, to have inputs from facilitators and beneficiaries. This module is used for Family Development Sessions (FDS) or Pertemuan Peningkatan Kemampuan Keluarga (P2K2) of PKH, implemented by the Ministry of Social Affairs. The main team consists of the World Bank consultants: Atin Parihatin, Avita A. Usfar, and Susie Sugiarti with directions from Pablo A. Acosta and Changqing Sun and with technical inputs kindly provided by Setyo Edi and Nikendarti Gandini from World Food Program and Elviyanti Martini from World Bank. The Directorate of Family Social Protection of the Ministry of Social Affairs has organized a number of consultation workshops and focus group discussions to receive constructive inputs from the Directorate of Community Nutrition and Directorate of Family Health of the Ministry of Health, Pusdiklat, Bappenas, and UNICEF. This revised module has been piloted in February 2018. The module revision is supported by Ministry of Social Affairs, the World Bank and the Rapid Social Response Trust Fund. The contents and methods presented herein do not necessarily reflect the views of the Board of Directors of the World Bank or the Government they represent. For reproduction of this module and any other queries, please contact the Ministry of Social Affairs of Republic of Indonesia, Jalan Salemba Raya 28, Jakarta 10430. www.kemsos.go.id Printed in February 2018 Cover and module design: Kanakata Creative (www.kanakata.co) MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 2 4/7/2018 1:03:29 AM Table of Contents PPREFACE 5 SESSION 1 8 THE IMPORTANCE OF NUTRITION & HEALTH SERVICES FOR 8 PREGNANT WOMEN BACKGROUND 9 LEARNING OBJECTIVES 10 TOPICS AND SUBTOPICS 11 ACTIVITY STEPS 12 Step 1: Opening 12 Step 2: The Importance of the First 1000 Days of Life 13 Step 3: The Importance of Nutrition for Pregnant Women 15 Step 4: Health Examination for Pregnant Women 18 Step 5: Postpartum Health Examination 20 Step 6: Ensure the Mother and Infant Get National Health 22 Insurance Services Step 7: Closing 24 READING MATERIALS 25 SESSION 2 46 THE IMPORTANCE OF NUTRITION FOR lactating MOTHERS 47 AND TODDLERS BACKGROUND 47 LEARNING OBJECTIVES 47 TOPICS AND SUBTOPICS 49 ACTIVITY STEPS 50 Step 1: Opening 50 Step 2: Group Discussion About Breastfeeding, Complementary 50 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 3 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 3 4/7/2018 1:03:29 AM Feeding and Posyandu (Pos Layanan Terpadu or Integrated Services Post) Step 3: Exclusive Breastfeeding 51 Step 4: Complementary Feeding 53 Step 5: Visiting Posyandu 54 Step 6: The Nutrition of Lactating Mothers 56 Step 7: Closing 58 READING MATERIALS 59 SESSION 3 86 CHILD ILLNESSES AND ENVIRONMENTAL HEALTH 87 BACKGROUND 87 LEARNING OBJECTIVES 88 TOPICS AND SUB TOPICS 88 ACTIVITY STEPS 89 Step 1: Opening 89 Step 2: Introduction to Diarrhea 90 Step 3: Introduction to Worm Infection and Malaria 92 Step 4: The Importance of Maintaining Personal Hygiene and 94 Environmental Sanitation Step 5: The Importance of a Healthy Toilet 97 Step 6: Closing 98 READING MATERIALS 99 permainan 107 1. ENCOURAGING SLOGAN “BISA-BISA-BISA, WUUUIH BISA…! (WE 108 CAN, WE CAN, WE CAN, WOW WE CAN…!)” 2. GAMES FOR SELF-INTRODUCTION 108 3. A GAME TO REARRANGE THE SEATING POSITION 109 4. A GAME TO CREATE GROUPS OF TWO OR MORE PEOPLE 111 5. CHOOSING A GROUP’S REPRESENTATIVE 112 6. REFRESHMENT 112 4 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 4 4/7/2018 1:03:29 AM PREFACE This Health and Nutrition Module is intended to help the facilitators in implementing the Meetings for Family Development Session (FDS) more easily. This Guide Book is the revised version of the 2014 edition and a combination of Guide Book and Reading Materials so that the facilitators only need to bring one book on the field. FDS on Health and Nutrition is aimed to increase positive practices to encourage behavioral change among PKH (Family Hope Program) beneficiary women in terms of health and nutrition. The hope is that through this module, there will be improvements of knowledge, especially on the importance of first 1000 days of life (1000 Hari Pertama Kehidupan, 1000HPK ), health and nutrition of pregnant women, postpartum and lactating mothers, infants and toddlers, as well as parenting. Movies, flipcharts and Guide Books are the main teaching tools. There are reading materials at the back of each sessions to help the facilitators understand the materials better. There are also games to help the facilitators in moderating FDS sessions. This Health and Nutrition Module focuses on active participation, such as sharing discussion results, Q&As and singing together. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 5 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 5 4/7/2018 1:03:29 AM THIS fds GUIDE BOOK ON HEALTH AND NUTRITION IS DIVIDED INTO 3 SESSIONS: 1 THE IMPORTANCE OF NUTRITION AND HEALTH SERVICES FOR PREGNANT WOMEN 2 THE IMPORTANCE OF NUTRITION FOR lactating MOTHERS AND TODDLERS 3 CHILD ILLNESSES AND ENVIRONMENTAL HEALTH FACILITATOR’S TASKS IN GENERAL ARE: 1 To give education about health and nutrition contained in the FDS. 2 To motivate and facilitate mothers and children in getting necessary health services. 3 To inform Posyandu workers or midwifes if there is a mother or a child who needs a consultation or special visit. 6 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 6 4/7/2018 1:03:29 AM Below are the key messages that need to be delivered to PKH mothers and their family: PREGNANT WOMEN 1. Eat a nutritionally balanced diet, drink 8-12 glasses of water a day and do light physical activities. 2. Take iron supplements tablets (Tablet Penambah Darah, TTD) every day during pregnancy. 3. Get monthly pregnancy examinations at a health facility or at least 4 times during pregnancy. 4. Give birth at a health facility. 5. Perform Early Initiation of Breastfeeding (EIB). lactating MOTHERS AND TODDLERS 6. Health examinations for mothers and children should be performed by health workers at least 3 times. 7. Lactating mothers should eat a nutritionally balanced diet, drink 12-14 glasses of water a day, do 30 minutes of physical activities a day and maintain a normal body weight. 8. Give colostrum to the infant. 9. Exclusive breastfeeding until the infant is 6 months old. 10. Continue breastfeeding until the child is 2 years old. 11. Give complementary feeding gradually from 6 months old. 12. Bring infants and children to Posyandu once a month. 13. Ensure a complete basic immunization for 1-year-old child. 14. Ensure children get vitamin A tablets twice a year. 15. Give anthelmintic drugs to children ages 1-5 years. 16. Use PKH assistance to fulfill the nutrition requirement for pregnant women, lactating mothers and complementary feeding. 17. Use JKN (National Health Insurance) to access health services in Puskesmas (Community Health Center). ENVIRONMENTAL HEALTH 18. Wash hands with soap and running water. 19. Have bowel movements at a healthy toilet. 20. Ensure the availability of clean water for the household. 21. Throw wastes at designated places. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 7 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 7 4/7/2018 1:03:29 AM SESSION 1 THE IMPORTANCE OF NUTRITION & HEALTH SERVICES FOR PREGNANT WOMEN MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 8 4/7/2018 1:03:29 AM BACKGROUND Nutritional problems often occur due to the lack of knowledge, believes, values and norms in the community. Some common examples are people who let pregnant women to eat less (compared to before pregnancy); feeding bananas, water or other solid food to children under 6 months old; or preferring to spend money on cigarettes, cellphone credits or other less important needs compared to eggs, fish and chicken for pregnant women, lactating mothers and children. Eating nutritious food is an important habit for children’s health and development. Over a third of children and infants’ death as well as 11% of diseases in the world are caused by undernutrition in pregnant women and children. Furthermore, undernutrition in pregnant women could lead to physical, mental and intellectual development impairments for the child. A stunted and wasted newborn will have a substandard growth and become an adult with a short body as well as low intelligence and income. In order to have a smart child with optimum growth, a family needs to pay close attention to the critical period of first 1000 days of life (1000 Hari Pertama Kehidupan), from the pregnancy period (9 months or 270 days) to first 2 years since the child is born (first 730 days). The first 1000 days are critical period where any occurring impairment will have a permanent and untreatable effect. This session will discuss the healthy behaviors that need to be adopted during pregnancy (9 months or 270 days). The facilitators are advised to read the reading materials at the back of this session to get a better understanding. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 9 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 9 4/7/2018 1:03:30 AM LEARNING OBJECTIVES After following the learning materials, participants are expected to understand the importance of nutrition and health services for women during pregnancy and postpartum. SUCCESS INDICATORS: PARTICIPANTS ARE ABLE TO: 1 Understand the importance of the first 1000 days of life. 2 Understand the importance of nutritional fulfilment for pregnant women. 3 Understand health services during pregnancy. 4 Understand health services after childbirth/ during postpartum period. 5 Understand the PKH and BPNT (Non-Cash Food Assistance) assistance for nutritional improvement. 6 Understand the JKN (National Health Insurance) for the health services for mothers and infants. 10 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 10 4/7/2018 1:03:30 AM TOPICS AND SUB TOPICS No TOPICS SUB TOPICS 1.1. Understanding the first 1000 days of life The importance 1 1.2. The importance of nutrition of nutrition for for pregnant women pregnant women. 1.3. Nutritional fulfilment for pregnant women 2.1. Health services during The health services pregnancy that needs to 2 be done during pregnancy and 2.1. Health services after childbirth/postpartum period postpartum period. 3.1. PKH and BPNT assistance The usage of PKH, 3 3.2. The importance of JKN in BPNT and JKN health services for mothers assistance during and infants. pregnancy. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 11 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 11 4/7/2018 1:03:30 AM ACTIVITY STEPS OPENING 10 STEP 1 a. Say an opening greeting and thank the participants for their presence, then invite them to pray before starting the meeting. MIN U TES b. Explain that in this monthly meeting, we will discuss about health and nutrition. c. Explain that in this meeting, we will discuss 3 topics: • Health services that need to be done during and after pregnancy. • Nutritional requirements of pregnant women. • How to utilize PKH, BPNT and JKN assistance during pregnancy and childbirth. d. Ask the participants to pair up and ask their partner, “what are your hopes for your children in the future? ” Then ask each participant to share the conversation. The participants may answer “I want my child to be a good child,” “…to be a healthy child,” “…to be a doctor.” e. Say thank you for the participation and give a summary of the conversation results, such as: • So, you all want your children to be healthy, right? • You want your children to be respectful, smart and successful in school, so that they can achieve their dreams, right? f. Explain that the hopes and desires of every parents for their children to grow into HEALTHY, TALL and SMART children, can be achieved by giving proper care since they are still in the womb. 12 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 12 4/7/2018 1:03:30 AM THE IMPORTANCE OF THE FIRST 15 STEP 2 1000 DAYS OF LIFE Supporting Tools: • Movie 1.1 – First 1000 Days of Life • Flipchart 1.1 – The Impacts of Undernutrition MIN U TES • Flipchart 1.2 – The Importance of the First 1000 days of Life a. Explain to the participants that a tall, healthy and smart child starts in the womb. We will watch a movie together to show how women can have a healthy pregnancy. b. Play movie 1.1 about the importance of the first 1000 days of life. c. Ask 2-3 participants: • What did you remember from that movie? Note: if a participant has difficulties in answering, try to help by asking what words the participants can recall from the movie. d. Use flipchart 1.1 – The Impacts of Undernutrition and explain that the mother’s pregnancy condition and the health condition as a infant and toddler determine the child’s future: • An infant who comes from a family that neglects the nutritional fulfilment and health of a woman during pregnancy, will be born with low body weight (small infant). • If the problem is not addressed with good nutrition, the infant will grow into a toddler with a weak immune system (gets sick easily), Flipchart 1.1 stunting (substandard height-for-age) possibility and reduced intelligence. • At school-age, the child may have an impaired learning ability, low school achievements, and usually unable to continue to higher education. • As an adult, he/she may not be able to secure a decent job and thus gets low income. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 13 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 13 4/7/2018 1:03:31 AM • After starting a family, he/she may not be able to provide for the needs of nutritious food and health services for his/her family. e. Say thank you for the participants’ answers. f. Use flipchart 1.2 – The Importance of the First 1000 Days of Life to deliver the messages below: • The main message of the movie is the importance of nutrition or healthy food during the first 1000 days of life. • The first 1000 days of life consist of 9 months of pregnancy, childbirth and postpartum, when the infant is 0-6 months old until the child is 2 years old. This is a critical period for the mother and child. Health problems that occur to the mother and child Flipchart 1.2 during this period will affect the child’s future. g. Explain to the participants that on the next discussion on health and nutrition, they can read Mother’s Health and Nutrition Guide Book. h. The guidebook must always be available in meetings as reading materials for the participants in discussing the health of pregnant women and infants in the womb. 14 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 14 4/7/2018 1:03:32 AM THE IMPORTANCE OF NUTRITION FOR 15 step 3 PREGNANT WOMEN Supporting tools: • Movie 1.2 – The Importance of Nutrition for minutes Pregnant Women • Flipchart 1.3 and 1.4 – The Contents of My Plate • Health and Nutrition Guide Book a. Conduct a counting game of the keywords HEALTHY, TALL, SMART in order to divide the participants into three groups. Ask the participants to create groups based on the keywords. b. Ask the participants to have group discussions: • Healthy Group will discuss about what a pregnant woman should eat and what should be on her plate each meal. • Tall Group will discuss about where and how many times a pregnant woman should get a pregnancy examination. • Smart Group will discuss about where a pregnant woman should give birth and what she needs afterwards. c. Explain that we will discuss the topics one by one during the meeting. d. Ask for Healthy Group representative to share their discussion results. Say thank you for their discussion results. e. Invite the participants to listen to the answers by playing movie 1.2 which tells a story about the dietary habits for pregnant women. f. Ask the participants on what they remember from the movie. According to the midwife recommendation: • how much should a pregnant woman eat? • what kinds of food should be on her plate? • are there food restrictions for pregnant women? g. Use flipchart 1.3 – The Content of My Plate. Explain that a FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 15 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 15 4/7/2018 1:03:32 AM nutritionally balanced menu for pregnant women should contain: • Staple food containing carbohydrates. Kartu pasar Carbohydrates provide energy for the body to do activities. Some of carbohydrate sources are rice, corn, tuber and sago. • Protein sources. Protein is necessary to build and maintain the body’s cells and tissues. Some of animal protein sources are fish, chicken, beef while plant protein sources are nuts, tempeh and tofu. Plant protein such as tempeh and tofu contain fibers and antioxidants that protect the cells from damages. • Fruits that contains vitamins and minerals, such as papayas, oranges and watermelons. • Vegetables that contains vitamins and minerals, such as spinach, water spinach and carrots. Vitamins and minerals run the body’s metabolism regulation Flipchart 1.3 process. • Pregnant women should take 1 tablet of iron supplement every day during pregnancy. • Pregnant women should also drink a lot of water, 8-12 glasses a day. h. Ask the participants in Food Group to create a menu using Market Card. • Distribute market cards to the participants of Food Group. • Place flipchart 1.3 – The Contents of My Plate on the floor. 16 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 16 4/7/2018 1:03:38 AM • Ask the group members to choose a market card based on The Contents of My Plate. • Ask the group to choose the types of food based on The Contents of My Plate:  Choose a staple food for your carbohydrate source  Choose a side dish for your protein source  Choose your fruit  Choose your vegetable • Do it in turns with the other 2 groups if necessary. i. Advice mothers to use PKH cash transfer to increase protein (fish, tempeh, tofu, chicken) intake and BPNT to get rice and eggs. Limit the use of sugar. j. Explain to the participants that they can find information about food for pregnant women in Health and Nutrition Guide Book page 9 if they want to learn more. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 17 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 17 4/7/2018 1:03:38 AM HEALTH EXAMINATION FOR PREGNANT WOMEN 15 STEP 4 Supporting tools: • Movie 1.3 – Health Examination for Pregnant Women • Flipchart 1.4 – When to Get a Pregnancy Examination? • Flipchart 1.5 – Health Services for Pregnant Women MIN U TES • Health and Nutrition Guide Book a. Ask the Tall Group representative to share their discussion results. b. Invite the participants to listen to the answers by playing movie 1.3. c. Ask the participants on what they remember from the movie: • Where did they take the mother? • Do the participants also go to Puskesmas (Community Health Center) when they’re pregnant? • How many times should a pregnant woman see a midwife during pregnancy? • What services did the pregnant woman receive at the Puskesmas? d. Use flipchart 1.4 to deliver the messages about examinations for pregnant women: • It’s better for pregnant women to get a monthly examination during pregnancy by a midwife in Puskesmas/Polindes (Village Maternity Post)/Poskesdes (Village Health Post)/Posyandu.  If monthly examinations are not feasible, then pregnant women must get at least 4 times of examinations by a midwife in Flipchart 1.4 Puskesmas/Polindes)/ Poskesdes/Posyandu. • The first examination is before 3 months of gestation (the earlier, the better). 18 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 18 4/7/2018 1:03:39 AM • The second examination is between 4-6 months of gestation. • The third and fourth examinations are between 7-9 months of gestation. Pregnant women need to get a monthly pregnancy examination, especially if they have one or more of 4 pregnancy risks of being: 1. Too Young (pregnant women under 20 years old).  2. Too Old (pregnant women over 35 years old). 3. Too Close of a Gap Between Pregnancies (the gap between one pregnancy to the next is less than 2 years). 4. Too Many Children (has been pregnant or given birth to 4 children or more). e. Ask a representative of Tall Group to read flipchart 1.5 – Health Services for Pregnant Women aloud. f. Thank the Tall Group member who’ve read aloud, explain to the participants that pregnant mothers will receive 10 Health Services during pregnancy. g. Pregnant women must ask about the estimated date of delivery (due date) and make plans to give birth at a health facility. Flipchart 1.5 h. Explain to the participants that pregnant women can take pregnancy classes in Puskesmas to get comprehensive information about pregnancy. i. For further information about pregnancy, they can read it in Health and Nutrition Guide Book page 4–13. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 19 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 19 4/7/2018 1:03:40 AM POSTPARTUM HEALTH EXAMINATION 15 STEP 5 Supporting tools: • Movie 1.5 – Postpartum Health Examination • Flipchart 1.6 – Health Services for Pregnant Women MIN U TES • Flipchart 1.7 – Nutrition for Newborn Infants and Lactating Mothers • Health and Nutrition Guide Book a. Ask the Smart Group representative to share their discussion results. b. Ask the participants to listen to the answers by playing movie 1.5 about Postpartum Health Examination. c. Ask the participants on what they remember from the movie: • Where should a pregnant woman give birth? • Should a pregnant woman get health examinations after she gives birth? How many times? d. Deliver these messages: • Give birth at a health facility assisted by trained health workers, so that any problems during child birth can be handled immediately. There are warning signs in childbirth in the Health and Nutrition Guide Book page 15. • Use flipchart 1.6 to explain about health services for postpartum mothers:  The first: 6 hours to 3 days after childbirth  The second: 4-28 days after childbirth Flipchart 1.6  The third: 29-42 days after childbirth • Explain that information on health services for postpartum mothers are in the Health and Nutrition Guide Book. Mothers must contact 20 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 20 4/7/2018 1:03:41 AM health workers if they experience at least one of postpartum warning signs. Postpartum warning signs are in the Health and Nutrition Guide Book page 16. e. The facilitator summarizes the messages by using flipchart 1.7: • Perform Early Initiation of Breastfeeding (EIB) immediately and give the first yellowish breastmilk (colostrum) to the infant. • The first yellowish breastmilk Flipchart 1.7 (colostrum) contain antibodies. Give it to the infant immediately. Do not throw it away. • Exclusive breastfeeding until the infant is 6 months old. • Lactating mothers should eat varied foods containing carbohydrates, animal proteins, plant proteins, vegetables and fruits. • Drinking water requirement for lactating mothers for the first six months is 14 glasses a day and the second six months is 12 glasses a day. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 21 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 21 4/7/2018 1:03:42 AM ENSURE THAT MOTHERS AND 15 STEP 6 INFANTS GET NATIONAL HEALTH INSURANCE SERVICES Supporting tools: MIN U TES • Movie 1.5 – JKN • Flipchart 1.8 – Family Card and Healthy Indonesia Card (Kartu Indonesia Sehat, KIS) a. Ask the participants if anyone of them had experienced childbirth before and how much was the costs. b. Explain that as PKH beneficiaries, they also have the right to get access to the National Health Insurance (Jaminan Kesehatan Nasional, JKN) by getting the Healthy Indonesia Card (Kartu Indonesia Sehat, KIS). Ask the participants, “who has already owned KIS and who hasn’t?” c. Explain to participants that we will watch a movie about how to make KIS for PKH beneficiary families. Play movie 1.5. d. Use flipchart 1.8. e. Explain that the infants of a KIS-owning mothers automatically eligible as recipient of premium waiver (Penerima Bantuan Iuran, PBI) of Health Insurance (Jaminan Kesehatan, JK) and have the right to get access to health services. However, they need to go through registration procedures: The husband or a family member (proven by Family Card (Kartu Keluarga, KK), must go to the Health BPJS office and: • Bring the original Birth Statement Letter (Surat Keterangan Tanda Lahir, Flipchart 1.8 SKTL) document made at the birth facility. 22 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 22 4/7/2018 1:03:43 AM • Show the original Health BPJS Participants Card of the birth mother. • Fill in the Participation Form (Daftar Isian Peserta, DIP) that has been signed by one of the newborn’s parents. • Fill in the PBI infant’s ID number using the parent’s KK number or the birth mother’s KK number from her parents/family/other. • PKH families who own KIS are obligated to report infant’s name changes and KK number changes with the newborn’s ID number 3 (three) months at the latest since receiving the KIS. f. Explain that if there’s any participants that have yet to become a JKN member then they can register by preparing: • A copy of the family card and ID cards of the entire family members. • Statement of disability from the neighborhood group (RT) and administrative village (kelurahan). • Cover letter from Puskesmas to make JKN/BPJS PBI card. g. Once all the necessary requirements for making JKN/BPJS PBI card are complete, the next steps are: • Bring all the documents to the nearest BPJS or Social Agency office. • Hand in the documents and get a schedule to come back. • Revisit the BPJS office to receive the finished BPJS card. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 23 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 23 4/7/2018 1:03:43 AM CLOSING 5 STEP 7 Supporting tools: • Flipchart 1.10 – Messages for Pregnant Women MIN U TES a. Explain to the participants about the summary of the day using flipchart 1.9: • Make sure that pregnant mothers eat nutritious food. Use PKH and BPNT assistance to buy rice, eggs and oil, as well as PKH money to add protein intake (fish, tempeh, tofu, chicken). Limit the use of sugar. • Pregnant mothers must get monthly examinations at Puskesmas or at least 4 times during pregnancy. Flipchart 1.9 • Pregnant mothers must give birth at health facilities assisted by health workers. • Perform Early Initiation of Breastfeeding (EIB) as soon as the infant is born. • Postpartum health examinations for mothers and children. • Get a Healthy Indonesia Card (KIS) to get access to health services for pregnant women, including the child in the womb. b. Explain to the participants that all of the above is done in the hopes that children will grow HEALTHY, TALL AND SMART. c. Ask the participants to share any new knowledge they consider useful to their family, neighbors and acquaintances who might need it. d. Pray together. e. Say thank you and close the session. 24 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 24 4/7/2018 1:03:44 AM READING MATERIALS OF SESSION 1 THE IMPORTANCE OF NUTRITION AND HEALTH SERVICES FOR PREGNANT WOMEN THE CAUSES OF HEALTH AND NUTRITIONAL PROBLEMS There are 2 (two) factors that directly affects the nutritional status of a person. These are food consumption and health condition (infection disease). These two factors influence each other. The chronic low food consumption will lead to undernutrition. The longer this low nutritional intake happens the higher the chances of malnutrition. Bad health condition can cause a person to get ill easily, for example, from contagious diseases such as diarrhea and Chronic Respiratory Infections (CRI). These contagious diseases could disrupt food consumption and nutritional intake so that the body cannot absorb nutrients well. Other factors that indirectly affects nutritional status are food accessibility, parenting, drinking water/sanitation availability and health services. • Easy food accessibility with affordable prices will help the family in consuming varied, nutritionally balanced and safe food. Food consumption is also influenced by the family’s knowledge in choosing the right ingredients to buy. • Parenting such as exclusive breastfeeding from infants ages 0–6 months, also influences one’s nutritional status. • The availability of drinking water and sanitation can help in adopting a Clean and Healthy Lifestyle. • The convenience in accessing good health services also influences one’s nutritional status. The issue of health and nutritional problems in mothers and children is very important. More than a third of deaths in infants and children as well as 11% of diseases in the world are caused by undernutrition in pregnant women and children. The impacts of undernutrition in pregnant women FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 25 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 25 4/7/2018 1:03:44 AM are very serious because growth impairments that happens in the womb will affect the newborn infant physically, mentally and intellectually. If the infant is born short and very thin, and if the infant survives, the infant will have a substandard growth and live with disability only to grow up into a short adult with low intelligence and productivity. Girls will grow into adolescents and future mothers who will give birth to stunted infants with low birth weight. There is evidence of meaningful correlation between children with undernutrition and Non-Contagious Diseases (NCDs). Stunting problems in children can potentially increase NCD-related deaths in the future if it is not resolved as soon as possible. Currently, Indonesia still have a quite high prevalence of 35.6% of stunted children. It requires the cooperation of all stakeholders in addressing nutritional problems due to the complexity of their impacts. The Definition of Nutritional Problem • Macro nutrition is the nutrients that the body needs in great quantity. Example: carbohydrates, proteins and fat • Micro nutrition is the nutrients that the body needs in smaller quantity. Example: vitamins such as vitamin A, B, C, D, E and K. Minerals such as iodine, iron, zinc, potassium, etc. Types of Nutritional Problems • Macro nutritional problems consist of: less nutrition, malnutrition, underweight, short, and over nutrients • Micronutrient problems consist of: Vitamin A Deficiency (VaD), Iodine Deficiency Disorders (IDD), iron deficiency anemia, etc. 26 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 26 4/7/2018 1:03:44 AM The Impacts of Nutritional Problems Undernutrition in early life impacts the overall quality of the human resources. Some researchers suggest that: • Children with undernutrition will grow up shorter than average and reproduce infants who are small or have low birth weight. • Undernutrition (stunting) inhibits cognitive development, school grades and educational success. • Undernutrition (stunting) on children under 3 years old decreases their productivity as an adult. • Under/malnutrition is the basic cause of death in infants and children. Countermeasures Against Nutritional Problems: • Education about nutrition for the community This activity is aimed to increase the community’s knowledge, understanding, and awareness on the importance of nutrition for human resources. • Toddlers growth monitoring The nutritional status of a toddler can be observed by growth monitoring. If there’s any indication that the nutritional status is worsening, then undernutrition can be prevented from happening. Every weight measurement results are recorded in Becoming Healthy Card (Kartu Menuju Sehat, KMS). • Additional food granting The momentum of additional food granting can be used to educate mothers of toddlers about feeding. • Giving high dosage of vitamin A to children ages 6-59 months. • Giving iron supplement tablets to pregnant women. • Using iodine salt in the household. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 27 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 27 4/7/2018 1:03:44 AM 1 WHY THE FIRST 1000 DAYS LIFE IS VERY IMPORTANT It is clear that mothers’ health and nutritional status determines the quality of human resources as the evidence suggested that mothers’ health and nutrition status during the period of pre-pregnancy, pregnancy and breastfeeding is highly critical. The period of 1000 days, which are 270 days during pregnancy and the first 730 days of life of a newborn is a sensitive period because any effects on the infant during this period is permanent and untreatable. These impacts are not only on the physical but also the mental and intelligence growth. It is observable in adults from the substandard physical size and uncompetitive work quality that leads to low economical productivity. The first 1000 days of life is a golden period. To increase the health and nutrition of mother and child, it is necessary to: a. Perform Early Initiation of Breastfeeding (EIB) where a newborn is immediately placed on the mother’s stomach/chest so that the infant can instinctively search for and drink from the mother’s nipples, usually within 60 minutes. b. Give exclusive breastfeeding during the first six months. A working mother can still give exclusive breastfeeding without taking leave from work since breast milk can be extracted and stored. c. Give complementary feeding after six months. The food is made from the same ingredients as what the family consume with gradual amount and consistency. Thus by age one year, the child can consume the same food as the rest of the family members. d. Continue breastfeeding until the child is two years old. e. Immunizations to prevent contagious diseases. f. Make a habit of washing hands with clean water and soap as well as preventing and treating malaria on pregnant women. Doing all of the above for pregnant women, infants and children under two years old has been proven to have an impact in decreasing children mortality rate. Toddlers mortality drops to 19% due to the proper execution of exclusive breastfeeding and complementary feeding. There will be a decrease of stunted children if we give proper 28 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 28 4/7/2018 1:03:44 AM attentions and actions to lactating mothers, infants and toddlers. The health of the fetus in the womb and newborn are highly dependent on the health and nutritional condition of the pregnant mother, before the pregnancy, even before marriage. Therefore, it’s better to start improving the overall health and nutritional condition starting from adolescent period, to prepare for optimum health and nutritional level of the adolescents. We need to pay attention to adolescent girls in order to prepare them for when the time comes for them to be brides and enter the pregnancy period. Basic health research (Riset Kesehatan Dasar, Riskesdas) in 2010 shows that 1 in every 2 children born from the poorest families in Indonesia experience stunted growth, compared to 1 in 4 children in the rich group. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 29 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 29 4/7/2018 1:03:46 AM 2 PREGNANCY Pregnancy is a period where there is a fetus in a woman’s womb. It started with the fertilization process, which is the union of the woman’s ovum produced in her ovarium, with a man’s sperm. Pregnancy is marked with a late period. After fertilization, a new life in the form of a fetus will grow safely and comfortably in the mother’s womb. Pregnancy is not only marked by late period, morning sickness or growing belly. There are many changes happening to a woman’s body during pregnancy. There may be changes in the breasts, weight gains, cramps, frequent urination, constipations, cravings, nausea and vomiting. Pregnant women need more nutrition compared to before pregnancy in order to support the nutritional requirements of both the mother and fetus. Undernutrition in pregnant women could lead to Chronic Energy Deficiency (CED) and/or anemia. In malaria endemic areas, pregnant women are at risk of getting malaria. The same goes with endemic areas with iodine deficit, pregnant women are at risk of getting iodine deficiency disorders if not prevented. PREGNANT WOMEN OBLIGATIONS ARE: 1. To get pregnancy examinations (antenatal care) at least 4 times during pregnancy. 1st visit is on the first trimester, 2nd on the second trimester, and 3rd and 4th on the third trimester. The husband or a family member must accompany the pregnant woman during pregnancy. 2. Drink one tablet of iron supplement daily during pregnancy, or at least 90 days continuously. The iron supplement prevents a pregnant woman from getting anemia and is harmless for the fetus. Drink one tablet of iron supplement a day after dinner during pregnancy. Iron is crucial for the growth of the child’s cells and neurons. 30 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 30 4/7/2018 1:03:46 AM 3. Get a tetanus toxoid immunization to prevent tetanus in the newborn. 4. Get an individual or group counselling about the dietary habits of consuming varied, nutritionally balanced and safe food during pregnancy. 5. Consume iodine salt by adding it on every dish made at home. 6. It is advised to choose food that have been fortified with micronutrients, especially vitamin A, iron and iodine. 7. Do not smoke and forbid the family members from smoking in the house. 8. Sleep using mosquito nets with insecticide provided by health workers in malaria endemic areas. 9. Get support from husband and family members to psychologically prepare the mother in facing pregnancy, as well as in nurturing and educating the child. After 4 months of gestation, talk to the infant in the womb often or pray while rubbing the belly. 10. Pregnant mothers must avoid the use of illegal drugs and alcoholic beverages. 11. Get informed regarding husband and wife intimacy during pregnancy. 12. Ask the midwife or doctor about the estimated delivery date (due date) and make plans to give birth with the assistance of the midwife or doctor in a health services facility. 13. Follow a family planning program together with the husband by choosing contraceptive methods to be used after childbirth in accordance with the midwife or doctor’s advice. 14. Find a person who is willing to be a blood donor just in case of emergency. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 31 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 31 4/7/2018 1:03:46 AM RECOGNIZE PREGNANCIES WITH HIGH RISKS A high-risk pregnancy is a pregnancy that has higher risks than a normal pregnancy, both for the mother and the fetus in the womb, during pregnancy, childbirth and postpartum period, compared to normal pregnancy, childbirth and postpartum. There are risks of getting diseases as well as death before or after the childbirth. Pregnant mother is considered at high risk if one or more risk factors are found during regular examinations. On the other hand, she’s considered at low risk if no risk factors are found. However, it’s not impossible for a low-risk pregnant woman to become high-risk during pregnancy and childbirth. Thus, it is necessary to get regular examinations during the pregnancy period and childbirth process. There are generally two groups of high-risk factors in pregnancy:  A. The Mother Factor  • Pregnant mothers age > 35 years or < 18 years (under 20 years) As a woman grows older, the quality of her ovum also declines, so the risk of giving birth to an infant with disorders/disabilities is quite high. On the other hand, besides their psychological capacity, the reproductive organs of adolescent girls under 20 years old are not yet ready to handle pregnancies. • The fifth or more pregnancy   Giving birth to too many children correlates with the reproductive system. • Pregnancies with > 5 years or < 2 years gap  Reproductive organs need time to recover in order to function perfectly again. The time needed for the recovery period is at least 2 years. • Mother’s body height is < 145 cm A person’s height influences the shape of her hip. Those who are less than 145 cm tall are at risk of having a narrow hip and 32 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 32 4/7/2018 1:03:46 AM the hip is the infant’s birth canal. Infants can be born smoothly as long as there’s no obstacles on their way. If the birth canal is narrow and doesn’t match the infant’s size, then the infant most likely cannot be delivered naturally. • < 23.5 cm of Mid-Upper Arm Circumference (MUIC) or obese.  • Pregnancies with comorbidities (hypertension, diabetes, thyroid, heart, lungs, kidney, infection, anemia, and other systemic diseases) also the mother’s bad habit of smoking, alcohol and drugs consumption that are harmful for the fetus. • Pregnancies with Uterine Fibroids or Ovarian Cyst or a history of frequent miscarriages. • Pregnancies with a history of prior C-section. B. THE FETUS FACTOR  • Abnormal fetal position (breech, shoulder, oblique and face presentation)   • Large fetus (estimated > 4000 grams) • Twin • Fetus with impaired growth • Premature • Fetus with congenital disorders/diseases • Fetus died in the womb. The prevention is through pregnancy examination as soon and as often as possible until childbirth. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 33 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 33 4/7/2018 1:03:46 AM 3 HEALTH SERVICES BEFORE CHILDBIRTH ANC or Ante Natal Care (Ante=before, Natal=birth) is a pregnancy examination provided by health workers (midwife or doctor) for women during pregnancy to optimize the mental and physical health of the pregnant woman in facing childbirth, postpartum, breastfeeding preparation and natural recovery of the reproductive health. In order to do ANC, health workers have to provide a standardized quality services called 10T, which consists of : 1. Body Weight and Height Measurement. Weight measurement on each antenatal visit is done to detect any impaired growth in the fetus. A less than 9 kg total weight gain throughout the pregnancy or less than 1 kg per month, shows an impaired fetal growth. Height measurement is done on the first visit to exclude a risk factor in the pregnant woman. A pregnant woman who is less than 145 cm tall has an increased risk of getting CPD (Cephalopelvic Disproportion). 2. Blood Pressure Measurement Blood pressure measurement on each antenatal visit is done to detect hypertension (≥140/90 mm/hg of blood pressure) in pregnancy and pre-eclampsia (pregnancy complication with dangerous potential due to high blood pressure). 34 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 34 4/7/2018 1:03:47 AM 3. Nutritional Status Value (Measure the Mid-Upper Arm Circumference, MUIC) MUIC measurement is also done on the first visit by a health worker on the first trimester to find out if the pregnant woman has a risk of Chronic Energy Deficiency (CED). This means that the pregnant woman has had a long term undernutrition (several months/years) with less than 23.5 cm of MUIC. Pregnant women with CED may give birth to infants with low birth weight. 4. Fundal Height Measurement (Height of the Uterus)  Midwives will also do a fundal height measurement on every antenatal visit to detect whether or not the fetal growth is in accordance with the gestational age. If the fundal height doesn’t match the gestational age, then there could be an impaired fetal growth. The measuring standard uses a measuring tape after 24 weeks of gestation. 5. Determining Fetal Position and Fetal Heart Rate (FHR) The determination of fetal presentation is done at the end of 2nd trimester and every antenatal visit since then. It is done to determine the position of the fetus. If by 3rd trimester the lower part of the womb is not the fetus’ head or the head hasn’t entered the mother’s hip, then there may be an abnormal positioning, narrow hip or other problems. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 35 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 35 4/7/2018 1:03:47 AM 6. Screening for Tetanus Immunization Status and Give Tetanus Toxoid (TT) Immunization if Necessary  To prevent the infant from getting tetanus, the pregnant mother must get a TT immunization. The screening of the pregnant woman’s Tetanus status is done on the first visit. TT immunization for pregnant women is based on their current Tetanus status. 7. Iron Supplement Tablets     To prevent iron deficiency anemia, pregnant mothers must take iron supplements and folic acid supplements at least 90 tablets during pregnancy which was given on the first visit. 8. Laboratory Tests (Routine and Special) Laboratory tests for pregnant women are routine tests and special tests. The routine tests are tests that all pregnant women have to take, such as blood type, hemoglobin and tests for endemic/ epidemic specific areas (malaria, HIV, etc.). Special tests are other tests that are done based on the indications in a pregnant woman during antenatal visits. 9. Specific Treatments  Any abnormalities found in pregnant women during antenatal examination and laboratory tests must be handled based on the health worker’s capacity and authority. 10. Consultation/Counselling Consultation/counselling is done on every antenatal visit, which consists of: • The pregnant woman’s health condition • Clean and healthy lifestyle. • Husband/family’s role during pregnancy and childbirth planning. 36 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 36 4/7/2018 1:03:47 AM 4 ASSISTED CHILDBIRTH BY HEALTH WORKERS Assisted childbirth by health workers is a childbirth process that is handled by health workers (midwifes, doctors, and other health workers). Why should a childbirth process need assistance from health workers? • Because health workers are people who have been trained in helping childbirth process so that the mother & child’s safety is more secured. • Any abnormalities that occur can be detected and addressed immediately or get directed to a puskesmas or hospital. • Health workers use safe, clean and sterile tools during assisted childbirth to prevent infections and other health hazards. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 37 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 37 4/7/2018 1:03:47 AM 5 EARLY INITIATION OF BRESTFEEDING (EIB) & THE BENEFITS OF COLOSTRUM As soon as infants are born, they should have the opportunity to start (initiate) breastfeeding themselves by placing them on the mother’s chest or belly; let the infant crawl and look for the mother’s nipple and feed as much as the infant wants. EIB process is assisted by a trained midwife or doctor who handled the childbirth and could also involve the patient’s family, such as the husband, mother, sister, etc. Health Services Facility Administration must support EIB for newborns.56|1 7 EIB will be successful if: 1. The health workers explain EIB to the mother and her husband/ family before childbirth. 2. The mother is willing to perform EIB immediately after childbirth. 3. There are support from the husband or family. 4. The health workers perform EIB process immediately after the infant is born, cries, starts breathing and has the umbilical cord removed. 5. The infant is taken care of together and within reach of the mother for 24 hours. The Benefit of EIB for the Mother and Infant: 1. The surface temperature of the mother will adjust with the infant’s temperature. 2. Skin contact increases the loving bond between the mother and infant. 3. Mother and infant will be more at ease, the breathing and heartbeat of the infant will be more stable, so the infant won’t be agitated. 4. Breastmilk production will run smoothly, the infant gets the colostrum and exclusive breastfeeding for 6 months and stay breastfeeding until the child is 2 years old. 38 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 38 4/7/2018 1:03:47 AM The Definition of Colostrum is: The first discharged breastmilk, usually yellowish in color and contains antibodies critically needed by newborn infants. The Benefits of Colostrum: 1. Help the infant’s body in building immune system against infections. 2. Important for intestinal growth in creating layers that protects and matures the infant’s intestinal walls. 6 HEALTH SERVICES AFTER CHILDBIRTH Postpartum examination or Post-Natal Care (PNC) is the examination of newborns and postpartum mothers that is critical in ensuring the health and safety of the mother and infant. Especially early in postpartum period, right after the childbirth and first 7 (seven) days after childbirth. However, the entire postpartum period, from right after childbirth until 28 days later, is still a high-risk period. Death of infants within 28 days after birth known as neonatal mortality rate, is reported all around the world. Death of mothers due to postpartum complication is also quite high. The objectives of Post-Natal Care (PNC) are: a. Maintaining the health of mothers and infants. b. Conducting comprehensive screening, detecting problems, medicating or directing to other health services if there’s a complication on the mother and/or the infant. c. Giving health education about self-healthcare, nutrition, breastfeeding, infant’s immunization and healthcare. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 39 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 39 4/7/2018 1:03:47 AM Requirements/Obligations of Postpartum and Lactating Mothers: 1. Take red colored vitamin A capsules again on the second day after childbirth. The gap between taking the first and second capsule is at least 20 hours. 2. Get health services at least 3 times, on week I, II and IV after child birth. 3. Get and consume 1 iron supplement tablet daily for 40 days, or as recommended by the health worker if suffering from anemia due to blood loss during childbirth. 4. Get individual or group counselling about exclusive breastfeeding and giving complementary feeding when the infant is 6 months old. 5. Bring the infant/child once a month to posyandu or puskesmas for weight measurement and getting advises on infant/child’s growth stimulation based on age. 6. If the infant/child’s weight graphic on KMS is flat or declining, cutting the growth line below, or the weight gain is less than the minimum, the mother will get individual and/or group counselling about proper breastfeeding and complementary feeding. 7. Use contraceptives as advised by the health worker to prevent pregnancy until the infant is at least 2 years old or use permanent contraceptives if there are already enough children (2 or 3 children). 8. Get individual and/or group counselling on individual and environmental sanitation. 9. Get individual and/or group counselling on infant/childcare, including when they are sick with fever, diarrhea as well as chronic respiratory infections. 10. Prevent air pollution inside the house by keeping the windows open, especially in the morning to let the sunlight in the house. 11. Consume iodine salt that are put into every home cooking. 12. No smoking and forbid other family members from smoking inside the house. 40 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 40 4/7/2018 1:03:47 AM PARTICIPANTS Warning signs during postpartum period are: 1. Bleeding through the birth canal or the discharge of liquid with odor from the birth canal. 2. Fever. 3. Bloating of the face, hands or feet with headache and seizures. 4. Redness and bloating of the breasts and pain or blisters on the nipples. 5. Mother experiences postpartum depression with the symptoms of frequent crying and neglecting the infant. If signs mentioned above occur, bring postpartum mother to health facility immediately fasilitas kesehatan 7 A GUIDE FOR BALANCED NUTRITION The guide for balanced nutrition is a guide for eating and healthy lifestyle for all communities of Indonesia. This guide consists of 4 principles: diverse foods consumption, clean lifestyle, physical activity and normal body weight maintenance (see a picture of A Guide for Balanced Nutrition). Food should be adequate in quantity and quality. They should contain various nutrients (energy, protein, vitamin and mineral) needed for the body to grow (on children), maintain health and do daily life activities and functions (for all age group and physiologies), as well as store nutrients to fulfill the body’s needs when it consumes food without the necessary nutrients. Consumption should include various types of food group consisting of staple foods, protein sources, vegetables, fruits and water as well as diversity in each food group. With a clean lifestyle, mothers and children can avoid infectious diseases that can influence nutritional condition through decreased appetite and increased need for nutrients. Physical activities, which includes all bodily activities including exercises is a way to balance the output and input of nutrients as well as improve metabolism in the body. Maintaining a normal body weight for adults or FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 41 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 41 4/7/2018 1:03:47 AM monitoring the age-appropriate weight and height growth for children can prevent nutritional problems. The five food groups should be consumed daily or in each meal. It is better to consume more than 1 type of food for each meal. Half of the plate should be filled with vegetables and fruits (see a picture of The Contents of My Plate).   The other half should be filled with staple food and protein sources. Generally, vegetables and fruits are sources of vitamins, minerals and 42 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 42 4/7/2018 1:03:48 AM fibers. Vitamins and minerals function as antioxidants or protecting the body from damages caused by free radicals. Adequate consumption of vegetables and fruits can help in maintaining normal blood pressure, blood sugar and cholesterol levels, preventing chronic non-contagious diseases, and lower the risk of constipations. Staple food can be in the form of rice, corn, cassava, sago, as well as cereals and other tubers. Protein sources consist of animal protein food sources (such as eggs, chicken, meat, milk and dairy products, fish) and plant protein sources (such as tempeh, tofu, and various beans/nuts). Animal products have a better quality of protein, vitamin and minerals that the body can absorb more easily. Plant-based protein products have more saturated fat, isoflavones, antioxidants and anti-cholesterols that can help controlling the level of cholesterol and blood sugar in the body. Both protein sources should be consumed. The amount of liquid needed varies, depending on age and physiology. Mothers and children should make a habit of drinking water. The usage of sugar, salt and oil should be limited to prevent chronic non-contagious diseases in old age. Don’t forget to wash hands with soap and running water before eating. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 43 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 43 4/7/2018 1:03:48 AM SPECIAL MESSAGES FOR PREGNANT WOMEN Food consumption for pregnant women must fulfil the requirement of herself, the fetal growth and the reserves during breastfeeding. Thus, pregnant women need more nutrition that before pregnancy. 1 Make a habit of consuming varied food in more quantity. For example, a non-pregnant woman consumes about 3 plates of rice per day (assuming about 2/3 of 2250 Kcal for age 19-29 years) while a pregnant woman needs an addition of half a plate (300 Kcal). The fulfilment of iron, folic acid, calcium, iodine and zinc is crucial during pregnancy. 2 Limit the consumption of food high in salt. garam 3 Drink more water. Adult women need about 10 glasses (2300 ml) of water per day, while pregnant women need an addition of 2 AIR glasses (300 ml). If well-hydrated, the urine should be clear in color. 4 Limit the consumption of coffee. 44 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 44 4/7/2018 1:03:48 AM NUTRITIONAL MESSAGES FOR PREGNANT WOMEN Ask the health workers about nutritious food • Eat a balanced • In case of nausea, • No alcohol and and diverse diet, vomiting and no smoking. 1 portion more appetite, choose • If on medication, than before food without fat in consult with health pregnancy. small portion and workers. eat more often. • No food Example: fruits, restrictions during breads, sweet pregnancy. potatoes, cassavas, • Drink enough biscuit. water during pregnancy. Pregnant women need 10 glasses per day. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 45 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 45 4/7/2018 1:03:50 AM SESSION 2 THE IMPORTANCE OF NUTRITION FOR LACTATING MOTHERS AND TODDLERS MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 46 4/7/2018 1:03:50 AM BACKGROUND From birth until age 6 month, infants are being fed with only breastmilk without any other food or drink. Breastmilk alone is sufficient and compatible with the infant’s tiny stomach. Exclusive breastfeeding for the first 6 months will protect the infant from multiple diseases such as diarrhea and respiratory infection. A mother who give exclusive breastfeeding to her infant for the first 6 months and don’t experience menstrual period can avoid pregnancy. Breastfeeding should continue until the infant is 2 years old. Nutritional intake of a lactating mother needs to be more in quantity and variation for her own health and breastmilk production. After 6 months, the infant gets complementary feeding with special attention to the frequency (how many times a day), quality, saturation and food variety, active/responsive feeding, as well as food sanitation. Try to give varied foods each meal. Bring children to Posyandu every month to monitor their growth and development. LEARNING OBJECTIVES: Participants are expected to practice breastfeeding and consume nutritious food for mothers and children based on their age and needs. For further understanding of this session, facilitators are advised to read the reading materials at the back of the session. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 47 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 47 4/7/2018 1:03:50 AM SUCCESS INDICATORS: PARTICIPANTS CAN: Understand the importance of exclusive breastfeeding 1 for infants ages 0-6 years and continued breastfeeding until they are 2 years old. 2 Understand the danger of giving other food/drinks to infants before they are 6 months old. 3 Understand the importance of breastfeeding for infants ages 0-6 months until they are 2 years old. 4 Understand about complementary feeding for children starting at age 6 months. 5 Understand about nutritionally balanced food for lactating mothers. 6 Understand the importance of Posyandu services and other health services. 7 Understand the importance of Nutrition for lactating mothers. 8 Understand about the various kinds of food for pregnant women and lactating mothers. 48 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 48 4/7/2018 1:03:50 AM TOPICS AND SUB TOPICS No TOPICS SUB TOPICS 1.1. The importance of exclusive breastfeeding for infants ages 0-6 months and continued breastfeeding until age 2 years. 1 Exclusive Breastfeeding 1.2. The danger of giving other food/drinks to infants age below 6 months. 1.3. The importance of breastfeeding for infants ages 0-6 months until they are 2 years old. 2.1 Understanding complementary feeding for children starting at the age of 2 Complementary Feeding 6 months. 2.2. Understanding nutritionally balanced food for lactating mothers. 3.1 Understanding the importance of Posyandu and 3 Posyandu other health services. 3.2. Participants understand about the importance of Posyandu services. 4.1. The importance of nutrition 4 Nutrition for for lactating mothers. Lactating Mothers 4.2. The various types of food for lactating mothers. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 49 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 49 4/7/2018 1:03:50 AM ACTIVITY STEPS 10 STEP 1 OPENING Supporting tools: • Flipchart 2.1 – Exclusive Breastfeeding minutes a. Say an opening greeting and thank you to the participants for their presence. Say thank you to the midwife that has come as a speaker on the FDS session. b. Invite the participants to pray before the session begins. c. Ask the participants to try and recall the lessons from previous session (on pregnant women) and their hope for their children. Explain that if there are any questions, the participants can ask the midwife at the end of the session. The facilitator will write down the questions first. d. By using flipchart 2.1, explain that this session will discuss about the importance of nutrition for lactating mothers and children, health services they can get during breastfeeding period, the importance of breastfeeding, complementary feeding as well as services in Posyandu. Explain that ages 0-2 years is the second most important phase after pregnancy for children to grow TALL, HEALTHY AND SMART. GROUP DISCUSSION ABOUT 15 step 2 BREASTFEEDING, COMPLEMENTARY FEEDING AND POSYANDU a. Ask the participants to discuss by dividing them minutes into 4 groups: Breastfeeding, Porridge, Posyandu and Vegetables. b. Breastfeeding Group will only discuss about breastfeeding: • How long do they give exclusive breastfeeding in the first 6 months? 50 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 50 4/7/2018 1:03:50 AM • What are the problems they had to deal with during breastfeeding period? • Do they also give other food/drinks beside breastmilk? • Do they experience problems during the breastfeeding? • Do they gave other than breastmilk to their baby when breastfed? c. Porridge Group will discuss about complementary feeding: • When did they first introduce complementary feeding to the infant? • What kind of food did they give? • What are the problems they have to deal with during complementary feeding to the infant? d. Posyandu Group will discuss about Posyandu: • When do they go to Posyandu? • What are the activities they do at the Posyandu? • What’s the importance of Posyandu? • What are the obstacles they have to face in order to go to Posyandu every month? e. Vegetables Group will discuss about: • What are the things lactating mothers should do to produce good quality breastmilk? EXCLUSIVE BREASTFEEDING 15 STEP 3 Supporting tools: • Movie 2.1 – Exclusive Breastfeeding • Flipchart 2.1 – Exclusive Breastfeeding MIN U TES • Nutrition and Health Guide Book a. Ask a representative of Breastfeeding Group to share their discussion results on breastfeeding. b. Say thanks for their answers. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 51 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 51 4/7/2018 1:03:50 AM c. Explain to the participants that they will watch a movie about the importance of exclusive breastfeeding to find the answers and ask them to pay attention.   d. Play movie 2.1 about exclusive breastfeeding. e. Ask the participants on what they remember from the movie. Let 2-3 participants answer. • What is the meaning of exclusive Flipchart 2.1 breastfeeding? • Why infants only need breastmilk until 6 months old? • When can they give complementary food beside breastmilk? • After 6 months of exclusive breastfeeding, until what age should a child keep getting breastmilk? • How to store breastmilk? f. Explain to the participants that if they want to learn more, they can read Health and Nutrition Guide Book page 18 about: • How to breastfeed an infant. • How to extract and store breast milk. • Nutritional needs of infants age 0-6 months and how to breastfeed them. g. Ask the participants if they can handle problems in breastfeeding now that they’ve watched the movie and had the discussions. h. Explain the key messages on breastfeeding using flipchart 2.1 about exclusive breastfeeding until the infant is 6 months old. • Continue breastfeeding until the infant is 2 years old. • Breastfeed the infant as often and as much as the infant wants. • Extract breast milk to be stored and given to the infant if the mother is away. 52 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 52 4/7/2018 1:03:52 AM COMPLEMENTARY FEEDING 15 step 4 Supporting tools: • Movie 2.2 – Complementary Feeding • Flipchart 2.2 – Complementary Feeding minutes • Health and Nutrition Guide Book a. Ask a representative of Porridge Group to share their discussion results about complementary feeding. b. Say thanks for their answers. c. Explain to the participants that they will watch a movie about complementary feeding to find the answers and ask them to pay attention. d. Play movie 2.2 about complementary feeding. e. Ask the participants on what they remember about the movie. Let 2-3 participants answer: • Starting from what age should we give complementary food to a child? • What are the things we need to consider in preparing complementary feeding? • How to maintain the sanitary of complementary food? f. Use flipchart 2.2 to explain the key messages in complementary feeding: • Continue breastfeeding and give complementary feeding. • At the ages of 6-9 months, give pureed Flipchart 2.2 food 2-3 times a day and snacks 1-2 times a day (fruit or biscuit) with the portion of 2-3 tablespoons to half a bowl each meal. • At the ages of 9-12 months, give mashed or minced food 3-4 times a day and snacks the child can hold themselves 1-2 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 53 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 53 4/7/2018 1:03:53 AM times a day with the portion of half to ¾ of a bowl. • Teach children to eat from the spoon and drink from the glass by themselves. • Pay attention to the sanitation of the food.   g. Explain to the participants that if they want to learn more, they can read Health and Nutrition Guide Book page 41 about: • Complementary feeding for children ages 6-8 months. • Complementary feeding for children ages 9-11 months. • Food for children ages 1-2 years. • Development and stimulation for children ages 1-6 years. VISIT THE POSYANDU 15 step 5 Supporting tools: • Movie 2.3 – Visit the Posyandu • Flipchart 2.3 – Services in Posyandu minutes • Health and Nutrition Guide Book a. Ask a representative of Posyandu Group to share their discussion results about Posyandu. b. Say thanks for their answers. c. Explain to the participants that they will watch a movie about Posyandu/I’m a Healthy Kid (Aku Anak Sehat) to know the benefits they can get in Posyandu. Ask them to pay attention. d. Play movie 2.3. e. Ask the participants on what they remember from the movie. Let 2-3 participants explain: • What is usually done in Posyandu? • Why we need to bring children to Posyandu?   54 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 54 4/7/2018 1:03:53 AM f. Explain to the participants that if they want to know more, then they can read Health and Nutrition Guide Book page 37 on immunization and giving vitamin A, as well as page 38 on nutrition fulfilment and children development. g. Explain the key messages on the benefits to get in Posyandu using flipchart 2.3. Flipchart 2.3 THE BENEFITS OF POSYANDU FOR THE COMMUNITY 1. The convenience of getting health information and services for mothers, infants and toddlers. 2. The growth of toddlers can be monitored so that they won’t suffer from undernutrition or malnutrition. 3. Infants and toddlers get vitamin A capsules. 4. Infants get complete immunizations. 5. Pregnant women’s body weight can be monitored, and they can get Iron Supplement Tablets (IST) as well as Tetanus Toxoid (TT) immunization. 6. Postpartum mothers get vitamin A capsules and IST. 7. Get health education concerning the health of mothers and children. 8. Any abnormalities in infants, toddlers, pregnant women, postpartum and lactating mothers can be detected immediately and directed to Puskesmas. 9. Can share knowledge and experiences about the health of pregnant women, infants and toddlers. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 55 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 55 4/7/2018 1:03:55 AM NUTRITION FOR lactating MOTHERS 15 Langkah 6 Supporting tools: • Movie 2.4 – Nutrition for Lactating Mothers • Flipchart 2.4 – Lactating Mothers: ‘The Contents of My Plate’ menit • Health and Nutrition Guide Book a. Ask for a representative of Vegetables Group to share their discussion results about Posyandu. b. Say thank you for their answers. c. Explain to the participants that they will watch a movie about food for lactating mothers to find the answers and ask them to pay attention. d. Play movie 2.4 about Nutrition for Lactating Mothers. e. Ask the participants on what they remember about the movie. Let 2-3 people answer: • What are the food that the breastfeeding Ms. Lili have to eat? • Why Ms. Lili still eats a lot even though the infant eats so little? 56 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 56 4/7/2018 1:03:56 AM   f. Explain the key messages to the participants about balanced nutrition for lactating mothers by using flipchart 2.4 – The Contents of My Plate. • The plate of lactating mothers should consist of staple food, protein sources, vegetables and fruits. • Half of the plate should be filled with staple food and protein sources and the other half with vegetables and fruits. • Wash hands with soap and running water before eating. • Drink more water. Lactating mothers need to drink 12-14 glasses of water compared to the suggested 8 glasses for regular adults. • Limit the consumption of sugar, salt and fat. • Do enough physical activities and maintain a normal weight. g. Explain to the participants that they can use PKH assistance to buy nutritious food such as eggs, fish, chicken, meat, vegetables and fruits. It’s better to exchange BPNT with rice and eggs (reduce sugar consumption). Flipchart 2.4 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 57 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 57 4/7/2018 1:04:01 AM CLOSING 5 step 7 Supporting tools: • Flipchart 2.5 – Messages for Lactating Mothers minutes a. Reiterate the key messages that need to be remembered from this session together with the participants using flipchart 2.5: • Exclusive breastfeeding for infants for the first 6 months. • Continue breastfeeding until the child is 2 years old. • Give complementary feeding gradually starting when the child is 6 months old. • Bring infants and children to Posyandu once a month. • Lactating mothers should eat a Flipchart 2.5 nutritionally balanced diet. b. Explain to the participants that all of the above is done so that children will grow TALL, HEALTHY AND SMART, in order to achieve their dreams in the future. Invite participants who have toddlers to take Mothers and Toddlers Classes in Puskesmas or ask the midwife to get further information about the problems of breastfeeding, breast milk and complementary feeding. The parents’ hope for their children to grow healthy and successful can be achieved if mothers and children adopt balanced nutrition and go to Posyandu regularly. c. Invite the participants to pray after the session is done. d. Close the meeting by saying thank you for their presence and active participation and say thank you to the midwife who has come to this session. 58 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 58 4/7/2018 1:04:03 AM SESSION 2 READING MATERIALS THE IMPORTANCE OF NUTRITION FOR Lactating MOTHERS AND TODDLERS A. A GUIDE TO BALANCED NUTRITION FOR lactating MOTHERs The principles of balanced nutrition for lactating mothers and toddlers follow the general principles of consuming diverse food, adopting clean lifestyle, doing routine physical activities and maintaining body weight (see the picture of balanced nutrition triangle in session 1). Lactating mothers need more nutrients compared to before pregnancy or breastfeeding, in order to fulfill the infant’s needs for nutrients as well as to replace the nutrients extracted from the mother through breast milk. Not all nutrients needed by a child can be fulfilled by the mother’s nutrients reserves. More nutrients need to be obtained from the mother’s daily food consumption. SPECIAL MESSAGES FOR lactating MOTHERS: 1. Make a habit of consuming varied foods in larger quantity. To maintain the quality of the breast milk, lactating mothers need to fulfill their protein, iron, folic acid, vitamin A, B1, B2, B3, B6, C, D, iodine and zinc. It is highly recommended to FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 59 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 59 4/7/2018 1:04:03 AM consume food such as fish, milk, eggs, anchovy, nuts/ beans, tofu, green vegetables, katuk or torbangun leaves. For example, a regular woman consumes about 3 plates of rice a day (about 2/3 of 2250 Kcal for age 19-29 years) while a lactating mother need an addition of half a plate (300- 400 Kcal). 2. Drink more water, 12-13 glasses or 3 liters per day. 3. Limit the consumption of coffee, sugar and salt. B. INFANTS GROWTH AND DEVELOPMENT INFANTS AGES 0-11 MONTHS When newborns are 1-28 days old (neonates) they are adapting to the environment; there are changes in blood circulation and the organs are starting to function. The highest risk of infants’ death is in the first 24 hours since birth. Therefore, newborns: 1. Must get health examinations at least 3 times even if the one seems healthy. The first Neonatal Examination (NE1) is between the first 6-48 hours, NE2 is when the infant is 3-7 days old and NE3 is when the infant is 8-28 days old. 2. Must get umbilical cord treatment, antibiotic eye ointment, vitamin K1 injection and Hepatitis B0 immunization (within first 24 hours since birth until 7 days). 3. Get Early Initiation of Breastfeeding (EIB). 4. Get exclusive breastfeeding until the infant is 6 months old. 60 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 60 4/7/2018 1:04:08 AM HOW TO TAKE CARE OF NEWBORNS: 1. Newborns can only be bathed after 6 hours. Wrap the newborn with dry cloth and change it immediately if wet. 2. Give the first breast milk discharged, called colostrum. It is yellowish in color and contains antibodies. Do not throw them away. Give them to the newborn immediately. 3. Give exclusive breastfeeding until the infant is 6 months old. Mothers must be advised that during breastfeeding, the position of the infant’s head and body should be in one straight line with the infant facing the breast. The right and left breast are used in turns. Breastfeeding can be done in seating position as well as by laying down comfortably. Breastfeed the infant as often as possible including at night. Breastfeed the infant as often and as much as the infant wants. If the infant slept more than 3 hours, wake the infant up and start breastfeeding. Use both breasts in turns to give optimum breastfeeding. 4. Keep the umbilical cord stump (navel) always clean, dry and leave it open (don’t cover it). 5. If the birth weight is <2500 g, then the infant is a low-birth-weight infant. The infant needs a warm environment to maintain the body temperature and breastfeeding. It can be achieved with an effective and efficient method called kangaroo method (by maintaining skin contact between the infant and the mother/father, hold the infant in the chest of mother/father/other family members). Kangaroo method is done until the infant weigh >2500g or the infant is uncomfortable. Don’t let the infant sleep in a cold or windy place. SIGNS OF A HEALTHY NEWBORN: 1. The newborn cries immediately. 2. Have a reddened body. 3. Move actively. 4. Birth weight is 2500 to 4000 grams. 5. Feeding strongly from the mother’s breasts. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 61 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 61 4/7/2018 1:04:08 AM SIGNS OF AN UNHEALTHY NEWBORN: Bring the infant to a midwife/health worker at a health facility immediately if one of these signs occurs: 1. The infant won’t breastfeed. 2. Weak. 3. Fast breathing (more than 60 times per minute). 4. Moaning or crying continuously. 5. Seizures. 6. Yellow skin and eyes. 7. High fever. 8. Redness in umbilical cord all the way to the stomach, has an odor or is festering. 9. The eyes are festering. 10. Diarrhea/defecating more than 3 times a day. 11. The defecated feces are pale. Infants ages 29 days to 11 months need balanced nutritional intake to reach optimal growth. Give exclusive breastfeeding until age 6 months, complementary feeding starts at age 6 months and keep breastfeeding until age 2 years. C. EXCLUSIVE BREASTFEEDING UNTIL AGE 6 MONTHS THE BENEFIT OF BREASTFEEDING FOR MOTHERS AND INFANTS 1. Healthy, practical and free. 2. Improve infants’ natural immunity. 3. Prevent bleeding on postpartum mothers. 4. Establish affectionate bond between mother and infant. 5. Prevent breast cancer. THE PROPER WAY OF BREASTFEEDING: 1. Breastfeed the infant as often and as much as the infant wants or at least 8 times a day. 2. If the infant slept more than 3 hours, wake the infant up and start breastfeeding. 62 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 62 4/7/2018 1:04:08 AM 3. Keep breastfeeding until the breast feels empty, then change to the other breast. 4. If the infant is full but the breast still feels full/taut, empty it by extracting the milk for storage. Thus, the breast can keep producing enough breast milk. THE PROPER POSITIONING AND BREASTFEEDING LATCH: • Make sure the mother is in a comfortable position for breastfeeding. • The mother should hold the infant close to her body. If the infant is a newborn, then the mother should support the entire body. • The infant’ head and body should be in straight line. The infant’s head is facing the breast, nose facing the nipple. Most of the areole (dark circle surrounding the nipple) should be inside the infant’s mouth, mouth wide open, lower cheeks curving outwards, chin touching the mother’s breast. BREAST MILK EXTRACTION By extracting breast milk, the infant can still get breastfeeding even if the mother is working or had to leave the infant. How to extract breast milk 1. Prepare a container, such as a cup, glass or jar with wide opening. Wash the container with soap and water. Pour boiling water into the container and leave for a few minutes. The boiling water will kill most bacteria. Throw the water away from the container when ready to extract the breast milk. 2. Place index finger and thumb on either side of the areole and press inside towards the chest wall. 3. Press behind the areole between the thumb and index finger. 4. Press from the sides to empty all parts. ASI How to store extracted breast milk Extracted breast milk in a sealed container can last for 6-8 hours in room temperature or 3-8 days in a refrigerator. For long term storage, i t can last for 3-6 months in a freezer. Place the FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 63 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 63 4/7/2018 1:04:08 AM breast milk container in the deepest part of the freezer or refrigerator away from the door so that it doesn’t experience temperature changes and variations. If there’s no refrigerator, extracted breast milk container can be stored in a thermos filled with ice for 24 hours. How to feed extracted breast milk Use a cup, spoon or pipette. Bottle’s nipples are not recommended as it will confuse the infant. Infants who are used to bottle’s nipples usually won’t feed from the mother’s breast anymore. It is important to note: 1. Cold extracted breast milk is warmed up by submerging the container into a larger container filled with warm water. 2. Frozen extracted breast milk need to be melted in the refrigerator before it can be warmed up. 3. Do not boil the breast milk or warm it up using boiling water. 4. Do not refreeze melted breast milk. D. COMPLEMENTARY FEEDING FOR AGES 6-12 MONTHS At the age of 6 months, we can start to introduce complementary feeding to the infant in pureed form, from milk porridge to steamed rice porridge. Mix breast milk into the porridge when the infant is about to eat. By the age of 9 months, give the infant food that are more solid, such as porridge or soft steamed rice, and gradually give soft rice when the infant is close to one year old. Complementary feeding can be made from the same local ingredients consumed by the family at home. Children should continue to be breastfed until age 2 years. Good complementary feeding is: • Full of energy, protein and micro nutrients (iron, zinc, calcium, vitamin A, C, folic acid). • Not spicy, no sugar, salt, flavorings, colorings and preservatives. • Easy to swallow and enjoyable for the child. • Available locally and affordable. 64 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 64 4/7/2018 1:04:08 AM A GUIDE TO COMPLEMENTARY FEEDING PORTION PER AGES FOOD FORM TIMES PER DAY MEAL • Breast milk • Continue 2-3 table- breastfeeding spoonful each • Pureed food as often as meal, increase (porridge and possible. it gradually to pureed family ½ of a 250 ml 6-9 food). • Pureed food sized bowl. 2-3 times a day • Snacks 1-2 months times a day. PORTION PER AGES FOOD FORM TIMES PER DAY MEAL • Breast milk • Continue ½ to ¾ of a 250 breastfeeding. ml sized bowl. • Soft or minced food that are • Soft food 3-4 easy to swallow times a day by children. 9-12 • Snacks 1-2 • Finger food times a day snacks (that a months child can hold alone) are given in between complementary feeding. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 65 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 65 4/7/2018 1:04:08 AM Active/responsive feeding: 1. Infants over 6 months old need time to get used to other food beside breast milk. 2. Mothers need to be patient and give encouragement to the infant to eat. 3. Do not force infants to eat. 4. Use separate plates to feed infants to make sure all the food given is eaten. Usually, children have a decreased appetite when they are ill. However, mothers need to be patient and keep giving complementary feeding as advised by health workers. The fluid requirement for infants up to 6 months old is fulfilled by breast milk. For children ages 7-11 months, the fluid requirement is about 3 glasses (800ml) and can be fulfilled through breast milk, water, as well as fruit juice. Sanitation is critical in avoiding diarrhea and other diseases: 1. Use clean spoons and cups to give food or fluid to infants. 2. Store food that are to be given to infants in a safe and clean place. 3. Mothers should wash their hands with soap before preparing the food and feeding the infant. 4. Wash mothers and infants’ hands before eating. 5. Mothers should wash their hands with soap after using the toilet and cleaning the infant’s feces. 66 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 66 4/7/2018 1:04:08 AM CHILDREN AGES 12-23 MONTHS A Guide to Complementary Feeding for Children Ages 12-24 Months AGES FOOD TIMES PER PORTION PER FORM DAY MEAL • Family • Family food • ¾ to 1 250 ml food. 3-4 timer per sized bowl. day. • Mashed or • 1 small slice of minced food • Snacks 1-2 fish/ meat/ chicken/ if necessary. times per day. egg. • Breast milk. • Continue • 1 small slice of 12-24 breastfeeding. tempeh/tofu or 1 tbsp of nuts/beans. months • ¼ cup of vegetables. • 1 slice of fruit. • ½ glass of porridge/ 1 slice of cake/ 1 slice of fruit. Over 2 years old: • Continue feeding with adult food. • Add the portion to one plate. • Give snacks 2 times a day. • Do not give sweetened food before meal time since it can decrease appetite. The monitoring schedule of children’s growth and development by health workers in Puskesmas/Pustu (subsidiary Puskesmas)/Posyandu for children age 24-72 months is once every 6 months. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 67 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 67 4/7/2018 1:04:08 AM CHILDREN AGES 2-6 YEARS (6 YEARS 11 MONTHS 29 DAYS) 1. Children at this age have to be brought to Posyandu to get a routine body weight measurement every month, and the mother will also get counselling on breastfeeding and complementary feeding based on the growth records in KMS. 2. Give breastfeeding until the child is 2 years old. 3. Get vitamin A capsules every February and August. 4. Children development is observed from their gross and fine motor skills, speech and language, social skills and independence in accordance with their age. If there’s a concern for impaired development which doesn’t match the guidance in Health and Nutrition Guide Book, consult it with a health worker immediately. 5. Get additional nutrients from nutrient powder that are mixed with complementary food consumed by the child. Messages on Balanced Nutrition for Children Ages 2-5 Years 1. Make a habit of eating together with the family 3 times a day (morning, noon and evening). 2. Consume more protein rich food such as fish, eggs, tempeh, milk and tofu. 3. Consume more vegetables and fruits. 4. Limit the consumption of snacks that are too sweet, salty and fatty. 5. Make a habit of playing together and doing physical activities every day. 6. Drink enough water. Children ages 1-3 years need about 5 glasses (1200 ml) of fluid per day. For infants under 2 years old, some of this need is 68 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 68 4/7/2018 1:04:13 AM fulfilled through breastfeeding. Making children get used to drinking water is better than sugared water such as syrup, canned or boxed ready-to-drinks. 7. Give food to toddlers while it’s hot, wash their hands before eating and use clean cutleries. A GUIDE TO FLUID REQUIREMENT IN INFANTS AND TODDLERS Ensure that the required fluid intake in a child is always fulfilled. Below is a table that shows the adequacy of fluid requirement per day. Ages Water Equal to 0-6 months Breast milk 7-11 months 800 ml ± 3 glasses 1-3 years 1200 ml ± 5 glasses 4-6 years 1500 ml ± 6 glasses Water is crucial for a child. • A child may find difficulty to focus in studying if a child is not well-hydrated. • Make a habit of drinking good quality water that is colorless, odorless, tasteless and contains minerals. How to measure fluid Match the color of requirement adequacy. urine to the colors in the table below. Action Urine Color Indication Well Hydrated Your child is well hydrated. Continue drinking water as required. Less Hydrated Your child is less hydrated. Drink more mater as required. Dehydrated Your child hardly drinks enough. Drink water as required immediately. If the urine color does not improve, please contact your midwife/nurse/ Professor Lawrence E. Armstrong, USA stated that water doctor immediately for further is essential to life and health. This color chart shows a simple way to stay healthy. Try to get the same color as the one on information. the top every day. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 69 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 69 4/7/2018 1:04:14 AM E. PELAYANAN POSYANDU Bring children to Posyandu to get a routine body weight measurement each month. Mothers also get counseling about breastfeeding and complementary feeding according to child development monitoring results in KMS. A healthy child will gain more weight as they get older in accordance with the weight gain graph on the green line in KMS. Body height is measured every 6 months. IMMUNIZATION Children ages 29 days to 11 months needs to get a complete immunization. Immunization is an effort to increase immunity through injections and droplets in order to protect infants and toddlers from various contagious diseases (don’t get contracted/ill), or so that the disease won’t worsen. An infant who is going to get immunization must be in healthy condition. However, a common cold shouldn’t stop an infant from getting immunization. AGE IMMUNIZATION SCHEDULE 0-7 days HB 0 1 month BCG, Polio 1 2 months DPT-HB-Hib 1, Polio 2 3 months DPT-HB-Hib 2, Polio 3 4 months DPT-HB-Hib 3, Polio 4, IPV 9 months Measles 18 months DPT-HB-Hib booster and measles booster 70 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 70 4/7/2018 1:04:14 AM IMMUNIZATION PREVENTABLE DISEASES Hepatitis B Hepatitis B (liver damage) BCG Heavy TBC (tuberculosis) Polio, IVP Polio (paralysis on legs and arms) Diphtheria (respiratory blockage) Pertussis/whooping cough Tetanus Hepatitis B which cause liver damage DPT HB HIB HIB infection which cause meningitis (infection of the fluid and lining around the brain and spinal cord) Measles which can cause a complication of lung Measles and brain lining infection as well as blindness VITAMIN A Vitamin A is one of micro nutrients that is the main component in supporting visual organ functioning as well as development. Vitamin A is useful to increase immunity against diseases and infections such as measles and diarrhea, as well as maintaining the organs, especially the eyes, to function normally. Vitamin A is stored in the liver. The vitamin A reserves in the liver can last up to 6 months in normal condition. There could be a Vitamin A Deficiency (VAD) if there are less Vitamin A reserves in the body than the requirement. In order to fulfill vitamin A requirement, children ages 6-59 months need to get vitamin A from high dosage of vitamin A supplement capsules (red capsules) every 6 months (February and August) besides food. Vitamin A supplements can be obtained in Posyandu and other health facilities such as Puskesmas, Subsidiary Puskesmas, Polindes/Poskesdes, clinics, private doctor/ midwife practices, as well as kindergartens, PAUD (Early Childhood Education) posts, day cares, etc. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 71 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 71 4/7/2018 1:04:14 AM Signs and symptoms of VAD: 1. Vision impairment in dim lit environment, also known as night blindness. The sign is the child often bumps into things around him/ her due to impaired vision. 2. The white of the eye is dry, dull, not shining. 3. If it continues without treatments, there will be foam-like spots on the white of the eye. Bring to Puskesmas or notify the nearest health worker immediately if a child is found with one of the symptoms above. 4. Get one-time supplement of vitamin A 100,000 SI, or the blue capsule, after an infant is 6 months old. GIVE VITAMIN A CAPSULES TO CHILDREN • Vitamin A is to improve the health of the eyes and children development. • Ask for vitamin A capsules in February and August at Posyandu. • There are 2 types of capsules: Blue Capsule Red Capsule For children age For children age 1-5 years 6-11 months Give them 2 times a year GROWTH AND DEVELOPMENT DETECTION Growth and development detection can find any growth and development impairments in toddlers. Child development is observed through the child’s gross and fine motor skills, speech and language, socialization and independence in accordance with the child’s age. Growth and development detection on a child can be done by health workers and family/community. The schedule for children growth and development detection by health workers in Puskesmas/Pustu/Posyandu: 1. Once every 3 months for infants and toddlers ages 0-24 months. 2. Once every 6 months for toddlers ages over 24-72 months. 72 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 72 4/7/2018 1:04:14 AM Give development stimulation according to age. Hold and cuddle the infant with love as often as possible. Hang bright colored moving objects so that the infant can see and follow its movements. Make the infant smile, talk and let the infant listen to soft music. STIMULATION EXAMPLES FOR INFANTS AGES 6-12 MONTHS AND DEVELOPMENT OBSERVATION CHECK LIST • Teach the infant to sit. • Play peekaboo. • Teach the infant to hold and eat a biscuit. • Teach the infant to hold a small object with 2 fingers. • Teach the infant to stand up and walk by holding hands. • Talk to the infant as often as possible. • Practice saying ma… ma… pa… pa… • Give toys that the infant can hit around safely. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 73 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 73 4/7/2018 1:04:14 AM Filled in by family/health worker. Give  mark (check mark): By age 9 months, the infant By age 12 months, the infant can: can:  Crawl  Stand up and walk by holding on to something.  Say ma…ma, da… da.  Hold small objects.  Grab a nut-sized object.  Copy simple words like ma..  Look for dropped objects/ ma.., pa..pa… toys.  Recognize the family  Clap or play peekaboo. members.  Eat a cake/biscuit alone.  Be afraid of strangers.  Point to what the infant wants without crying/whining. • Give stimulations in a fun atmosphere each time. • If the infant can’t do at least one of the above by age 12 months, see a doctor/midwife/ nurse. • Bring children ages 3 months-2 years every 3 months to the facility to get SDIDTK (growth and development early stimulation, detection and intervention) service. Daily care for infants and toddlers: 1. Maintain the child’s hygiene, bathe daily, wash hair routinely, wash hands after defecating, playing and before eating as well as maintaining the sanitation of clothes, bed and toys. 74 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 74 4/7/2018 1:04:14 AM 2. If they already have teeth, wash them with toothpaste and small toothbrush, don’t make a habit of eating sweet and sticky food, and get dental examinations every 6 months in Puskesmas. 3. Keep children away from cigarette and kitchen smoke, clean up the house and environment where children play from dust and garbage. 4. In malaria endemic areas, children must sleep inside mosquito nets with insecticide. 5. Keep children away from hazardous materials/objects. F. NUTRITIONAL PROBLEMS IN CHILDREN CHILDREN WITH UNDERNUTRITION AND MALNUTRITION Undernutrition is a condition where a child has a lower weight-for-age than the standard. In the KMS, the child’s weight would be on the lower yellow line. Malnutrition is a condition of severe low nutrition marked by a body weight that is below the red line and extremely thin. Signs and symptoms of a child with undernutrition: 1. Looks thin. 2. Hair seems dull. 3. Gets agitated or cry often. 4. Not agile and less cheerful. 5. Generally, suffers from diarrhea often. 6. The body weight is on the lower yellow line or below red line in the KMS. 7. The body weight doesn’t increase or decrease each month. 8. Edema, especially on the legs or face. Causes: 1. Food consumption doesn’t match the requirements and imbalance in energy and protein consumption. 2. Suffering from an infectious disease due to incomplete immunization that resulted in decreased immunity. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 75 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 75 4/7/2018 1:04:14 AM 3. Infants who don’t get exclusive breastfeeding or the breastfeeding is not continued until the child is 2 years old. 4. Not getting a good and proper complementary feeding. Effects: 1. Impairments in physical growth and brain development. 2. Vulnerability against infectious diseases. 3. Low environmental adaptation capacity. 4. Risks of suffering from non-contagious diseases as an adult. Prevention: 1. Mothers stay in good health condition throughout pregnancy, no CED and anemia. 2. Regular body weight monitoring in Posyandu. 3. Implement the messages received during the counselling for breastfeeding and complementary feeding. 4. Add more nutrients by adding nutrient powder into food. 5. Get vitamin A capsules every 6 months. 6. Get a complete basic immunization. Countermeasures: 1. Regular clinical examination at nearest healthcare facility. 2. Nutrition recovery at Nutrition Recovery Center ‘Therapeutic Feeding Center’. 3. Giving 1 red-colored vitamin A capsule when the undernutrition/ malnutrition is first detected and then 1 vitamin A capsule every February and August. 4. Check in the KMS whether or not the child has had the complete basic immunization. If not, then report it to a health worker immediately. 5. Once a child with undernutrition/malnutrition has recovered, the family must keep giving nutritious food so that the child won’t fall back into malnutrition. The role of the surrounding community in supporting the nutritional recovery is critical. 76 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 76 4/7/2018 1:04:14 AM THE PROBLEM OF UNDERNUTRITION IN TODDLERS Growth-for-age NORMAL CHILD WASTED CHILD STUNTED CHILD UNDERNUTRI- (THIN) (substandard TION CHILD height-for- (substandard age) weight-for- age) STUNTED CHILD Stunting is a condition where a child’s body length/height is below the standard of the child’s age. 2 out of 5 children in Indonesia is born stunted and it is related to the similarly low birth weight. The high rates of stunted children in Indonesia is related to the high rates of child mortality and disability to grow and develop normally. The chronic undernutrition since fetal to toddler period will cause impairments, not only on the physical, but mental and intellectual development as well. It is observable in adults from the physical size that are not optimal as well as uncompetitive work quality which results in low economical productivity. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 77 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 77 4/7/2018 1:04:16 AM Signs: Body length is measured on children ages 0-24 months in supine position. Body height is measured on children ages 2-5 years in standing position. 1. Length-for-age or height-for-age index below the standard lower limit. 2. Length-for-age and height-for-age standard of girls and boys are listed in the Decree of the Minister of Health number 1995 year 2010 about The Anthropometric Standards of Children Nutritional Status Assessment (table Length-for-Age of children ages 0-24 months and Height-for-Age of children ages 24-60 months). Causes: 1. Pregnant women who suffers from CED and anemia are at a high risk of giving birth to low birth weight infants (less than 2500 g). Infants with low birth weight are at a risk of having stunted growth. 2. This condition happens to mothers who give birth in their adolescence (15-19 years old). 3. Stunted infants are also born from mothers with <150 cm height. 4. Infants will stay stunted compared to others of the same age if not given exclusive breastfeeding. Effects: 1. Stunted child experiences impaired growth, thus has a short physique all the way to adulthood. 2. Impaired brain cells development which causes lesser intelligence compared to others of the same age who are not stunted. 3. Increased risk of getting non-contagious diseases such as diabetes and hypertension in adulthood. 4. Stunted women will give birth to infants with low birth weight. Prevention: 1. Future brides and pre-pregnancy women must be in a good nutritional status and are not suffering from anemia. In preparation, future brides must manage a diet that is diverse and nutritionally balanced. 78 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 78 4/7/2018 1:04:16 AM 2. Delay pregnancy on adolescents until they are age 20 years, so that the body is ready for pregnancy. 3. All pregnant mothers must consume 1 iron supplement tablet every day during pregnancy, at least 90 tablets in a row. 4. Pregnant mothers take 1 tablet of Multiple Micro Nutrients (MMN) every day during pregnancy. 5. Pregnant mothers who are suffering from CED must get additional food for recovery. Countermeasures: 1. Ensure exclusive breastfeeding for stunted children. 2. Good and proper complementary feeding for children starting at age 6 months and adding nutrients powder into the food. 3. Breastfeeding is continued until the child is 2 years old. 4. Give 1 red-colored vitamin A capsule (200,000 SI) at first detection. 5. Then, get 1 red-colored vitamin A capsule 2 times in a year, on February and August. 6. Monthly growth and development monitoring in Posyandu. 7. Check the KMS for complete basic immunization. OVERWEIGHT CHILD A child is considered overweight if the weight is on the upper yellow line in KMS and considered obese if the weight surpasses the upper yellow line. Overweight can occur due to excessive body fat accumulation that makes a person weigh above normal. It causes increased risks of getting degenerative diseases at a young age, such as hypertension, heart diseases and diabetes. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 79 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 79 4/7/2018 1:04:16 AM Signs and symptoms: 1. Looks bigger than other children of the same age. 2. Less agile. 3. Tend to eat or snack more. 4. The body weight in the KMS is on or above the upper yellow line. Causes: 1. Excessive and unbalanced food consumption (family’s excessive feeding habits that are copied by the child). 2. Metabolic disorder. 3. Lack of physical activities. 4. The child’s body weight is not regularly monitored which causes late detection of overweight. Prevention and countermeasures: 1. Monthly routine body weight monitoring in Posyandu. 2. Implementing nutritionally balanced diet in accordance to age. 3. Giving exclusive breastfeeding and continue breastfeeding until the child is 2 years old. 4. Teach children to do physical activities outside. ANEMIC CHILD Anemia is a condition where the levels of hemoglobin (Hb) in the blood is less than normal, which differs for each age and sex group. The lower limit for toddlers is 11g/dl. The causes are the low intake of iron, folic acid and vitamin B in daily food consumption. Signs and symptoms: 1. Initially looking weak, tired and lethargic. 2. Loss of appetite. 3. Often complains of dizziness. 4. It can be accompanied by breathlessness during activities/running in later stage. 80 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 80 4/7/2018 1:04:16 AM Effects: 1. Reduced immunity against infections. 2. Low cognitive and visual response. 3. Low intelligence. 4. Low social adaptation ability. Prevention and countermeasures: 1. Nutritional counselling that emphasizes on increasing the consumption of iron and protein rich food sources. 2. Continue breastfeeding until the child is 2 years old because the proteins in breast milk help with the absorption of iron. 3. Give iron supplements. 4. Complementary feeding that is rich in proteins and iron. 5. Treat worm infections in children as well as maintaining individual and environmental sanitation to avoid contracting worm infections. 6. Consume food that has been fortified with irons, such as wheat flour, cooking oil, instant noodles and nutrient powder that contains various micro nutrients and is added into each meal. G. ADOLESCENT HEALTH Adolescents are young people between the ages of 10 and 19 years and considered the transitional stage from childhood to adulthood. They are most often thought of as a healthy group. Nevertheless, many adolescents do die prematurely due to accidents, violence, pregnancy related complications and other illnesses that are either preventable or treatable. Many chronic illnesses and disabilities in adulthood have their roots in adolescence. Health and nutrition issues in adolescent girls include undernutrition and anemia. Wasting happens due to the triggering idea that thin is the ideal body shape of a teenage girl. This triggers them to heavily reduce food consumption even though their activity level tends to rise. An imbalanced nutrition intake will make an adolescent become more vulnerable to anemia. Therefore, prevention efforts are necessary in order to reach optimum nutrition and health status in adolescent girls, FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 81 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 81 4/7/2018 1:04:16 AM especially for self-preparation before marriage and pregnancy so that the infant they will carry someday will be in optimum health condition. Special messages on balanced nutrition for adolescent girls and future brides 1. Make a habit of consuming varied food. 2. Eat plenty of green vegetables and colored fruits. 3. Choose food that is offered in a health environment, avoid food with shocking colors, and read the labels on processed food packaging carefully. UNDERNUTRITIONED ADOLESCENTS Undernutrition is a condition of lower body weight in relation to height or also called thin. Stunting is a condition of substandard height-for-age due to lack of nutrition intake ever since in the mother’s womb. Genetic factor only contributes around 10%, some researches even stated only 3%, the rest is determined by optimum nutrition intake in early stages or the first 1000 days of a child’s life. A healthy environment as well as regular health examination also determines one’s nutritional status. Signs: 1. Adolescents with <23.5 cm of mid-upper arm circumference (MUIC) or falls on the red line of MUIC, are at risk of getting chronic energy deficiency (CED). 2. Adolescents substandard height or stunted. 3. Body Mass Index (BMI) that is less than 18.5. Body Mass Index (BMI) is used to determine adolescent nutritional status by counting the weight (W) in kg divided by height (H) in meters squared (W(kg)/ H2(m)). The BMI classification: Very thin <17.0; Thin 17.0-18.5; Normal 18.5-25.0; Overweight 25.0-27.0; Obese >27.0. 4. Less active and/or accompanied by lack of appetite. 82 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 82 4/7/2018 1:04:16 AM Effects on Adolescent Girls: 1. Increased risk of giving birth to infants with low birth weight. 2. Increased risk of giving birth to infants with substandard body length (stunted). Prevention and countermeasures: 1. Eat regularly with enough energy and protein sources. 2. Make a habit of eating varied food. 3. Maintain a clean lifestyle, especially washing hands with soap and clean water before eating. 4. Choose food that have less fat, less sweet and less salty. 5. Do regular physical activities to stay fit and healthy. ANEMIC ADOLESCENTS Anemia is a condition where the levels of hemoglobin (Hb) in the blood is less than normal, which differs for each age and sex group. The lower limit for adolescents is 12g/dl. Signs and symptoms: 1. Pale faced. 2. Lack of appetite. 3. No excitement in doing physical activities. 4. Gets tired easily. 5. Floating spots in vision. 6. Decreased concentration in studying. 7. Looks not fit. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 83 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 83 4/7/2018 1:04:16 AM Causes: In Indonesia, anemia is generally caused by the lack of iron in the body due to the consumption of food with less iron and protein. Therefore, anemia is more known as iron deficiency anemia. The causes are: 1. Inadequate intake of protein, iron, folic acid and vitamin B sources in daily food consumption. Adolescent girls need to especially pay more attention to this because they experience menstruation each month. Thus, they need foods that are rich in protein and iron to replace the loss of blood that can cause the Hb level to decrease below normal. 2. In malaria endemic areas, it’s important to note that adolescents may experience anemia due to malaria infection. 3. Suffering from a chronic disease or repetitive infection that results is long term lack of appetite. Effects: 1. Decreased motivation in studying. 2. Decreased cognitive function in school. 3. Decreased motivation in any activities. Prevention and countermeasures: 1. Consume iron supplement tablets in addition to supplements containing other micro nutrients, such as folic acid, calsium, vitamin B, zinc, celenium and magnesium, and vitamin C. 2. A diet of varied and nutritionally balanced food, especially those rich in protein and iron such as liver, meat, poultry, eggs, 84 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 84 4/7/2018 1:04:21 AM colored vegetables and fruits, and nuts/beans. 3. For prevention, adolescent girls and future brides are advised to take 1 tablet of iron supplement once a week for at least 16 weeks as well as 1 tablet a day during menstruation. Special messages for children and adolescents (6-9 years old) 1. Make a habit of eating 3 meals a day (morning, noon and evening) with the family. 2. Make a habit of consuming fish and other protein sources. 3. Consume more vegetables and enough fruits. 4. Make a habit of bringing a packed meal and water from home. 5. Limit the consumption of fast food, street food and snacks that are sweet, salty and fatty. 6. Make a habit of brushing teeth at least twice a day, after breakfast and before bedtime. 7. Avoid smoking. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 85 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 85 4/7/2018 1:04:21 AM SESSION 3 CHILD ILLNESSES AND ENVIRONMENTAL HEALTH MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 86 4/7/2018 1:04:21 AM BACKGROUND Infections or contagious disease is one of the important factor that influences a child’s growth and development. Contagious disease is a disease caused by germs that enter the body due to environment or behaviors that are not sanitary and healthy. Such behaviors include not washing hands before eating and having bowel movement carelessly in open spaces. A person who suffers from contagious disease will experience loss of appetite, which results in the decreased number and types of nutrients entering the body. Meanwhile, under such circumstances, the body needs even more nutrients to fight against the disease, especially if it is accompanied by rising temperature or fever. On the other hand, the person with undernutrition is more vulnerable to contagious diseases since undernutrition causes decreased immunity, thus germs can enter the body and reproduce more easily. The growth of children who often fall ill will be interrupted since nutrients in the body that were supposed to be used for growth and development, are used for fighting off the disease instead. These shows that undernutrition and contagious diseases have a complementary relationship. Adopting a healthy lifestyle can prevent a person from getting exposed to pathogenic sources. This lifestyle includes: A. Always wash hands with soap and clean running water: 1. Before and after eating, 2. Before processing and serving food, 3. Before breastfeeding, 4. Before feeding infants/toddlers, 5. After bowel movement/urinating, and 6. After touching animals/birds, in order to avoid hands and food from getting germs such as diarrhea causing germs. B. Always use footwear to avoid worm infections.  The facilitators are advised to read the reading materials at the back of this session to understand it better. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 87 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 87 4/7/2018 1:04:21 AM LEARNING OBJECTIVES The participants are expected to improve the environmental health condition and prevent child illnesses. SUCCESS INDICATORS THE PARTICIPANTS CAN: 1 Recognize diarrhea, worm infections and malaria in children which can cause undernutrition. 2 Understand how to prevent and countermeasure diarrhea, worm infections and malaria. 3 Practice washing hands with soap, especially at six important times. 4 Recognize the danger of bowel movement in random places. 5 Understand the importance of bowel movement at a healthy toilet room. No TOPICS SUB TOPICS 1.1. Illnesses in children (diarrhea, worm infections and malaria) Illnesses in 1 that can cause undernutrition. children (diarrhea, 1.2. Preventions and worm infections countermeasures against and malaria). diarrhea, worm infections and malaria. 2.1. Wash hands with soap. 2.2. Bowel movement at a healthy Personal hygiene 2 and environmental sanitary. toilet room. 2.3. Throw wastes at designated places. 2.4. Use clean water. 88 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 88 4/7/2018 1:04:21 AM ACTIVITY STEPS 10 step 1 OPENING Supporting tools: None. minutes Necessary process: a. Say welcome and thank you to the participants for their presence. b. Pray together. c. Explain briefly what was learned on the previous meeting. d. Give a reminder about participants’ hopes for their children’s future on session 1 of Health and Nutrition Module. Explain that individual and environmental health is crucial for children to have immunity against illnesses, so that they can make their dreams come true. e. Introduce the objectives of this meeting, which consist of learning about child illnesses that can cause impaired nutrition as well as what the preventions and countermeasures are. Participants will also learn about the importance of bowel movement at a healthy toilet room, as well as washing hands with soap. f. Ask the participants (briefly): • What are the illnesses that your children had? (participants may answer “fever, cold, diarrhea,” etc,) • Have your children had diarrhea? • Have your children had worm infections? • Have your children had malaria? (specifically for malaria endemic areas) FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 89 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 89 4/7/2018 1:04:21 AM g. Explain to the participants that: Children who often fall ill will have an impaired development since the nutrients in their body that were meant to help their growth and development, are used to fight a disease instead. These children are also at risks of growing into a child who is not healthy, not smart and doesn’t grow according to age. NUTRITION STATUs INFECTION 25 step 2 INTRODUCTION TO DIARRHEA Supporting tools: • Movie 3.1 – Diarrhea minutes • Flipchart 3.1 – Introduction to Diarrhea and How to Prevent it a. Ask participants to pair up with one who is not their close neighbour. Try to pair up with one who lives far away from them. b. Ask the participants to take turns in sharing their experiences on diarrhea in their children by answering these questions: • In your opinion, what is the cause of diarrhea in children? • How do you know if children have diarrhea? • What do you do if children have diarrhea? • What happens if the diarrhea is not treated? • How to prevent children from getting diarrhea again? (Explain to the participants to listen to their partner’s answer carefully and not to give comments on the answer. Give them around 3 minutes). 90 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 90 4/7/2018 1:04:21 AM c. Combine 3 pairs (6 people) into one group. Ask each group to share their conversation results (about 2 minutes per group). d. Say thank you for their answers and explain that next we will watch a movie to find out the answers. Ask them to pay attention. e. Play movie 3.1 about diarrhea and how to prevent it. f. After the movie is finished, ask the questions below and allow 2-3 people to answer: • What is diarrhea? • Why is diarrhea dangerous? • What should we do when a child has diarrhea? • How do we prevent diarrhea? g. Say thank you for their opinions, then use flipchart 3.1 to explain that: • Diarrhea is loose or water-only bowel movements for more than 3 times a day; it is normal for infants who are still breastfeeding to have bowel movement more than 6 times a day. • Treat it by adding oralit and zinc tablet into drinking water. They can also replace the loss of fluid by drinking juice, coconut water, rice milk or clear vegetable soup. • Diarrhea and other infectious diseases Flipchart 3.1 can be prevented by paying attention to children nutrition, maintaining the sanitation of eating and drinking utensils, drinking water that has been boiled, as well as maintaining personal hygiene and environmental sanitation. • Mothers must pay attention to clean and healthy life habits. DIARRHEA IS DANGEROUS BECAUSE CHILDREN WILL LOSE A LOT OF FLUIDS FROM THEIR BODY WHICH CAN CAUSE DEATH. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 91 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 91 4/7/2018 1:04:23 AM h. Explain to the participants that they can read the Health and Nutrition Guide Book page 35 to find out more about treating diarrhea. INTRODUCTION TO WORM INFECTIONS 15 step 3 AND MALARIA Supporting tools: • Movie 3.2 – Worm Infections and Malaria minutes • Flipchart 3.2 – Introduction to Worm Infections and How to Prevent it • Flipchart 3.3 – Introduction to Malaria and How to Prevent it • Flipchart 3.4 – Health Services from KIS/BPJS a. Explain that after diarrhea, the participants will now learn about worm infections and malaria. b. Ask briefly: • Did your children ever suffer from worm infections? • What is the danger of worm infections for children? Specifically in malaria endemic areas such as NTT, Maluku, North Maluku, Papua, West Papua and parts of Kalimantan, also ask: • Did your children ever suffer from malaria? • What is the danger of malaria for children? c. Show flipchart 3.2 about types of worms Flipchart 3.2 92 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 92 4/7/2018 1:04:24 AM and the prevention of worm infections in children, and read it together. For malaria endemic areas, show flipchart 3.3 about malaria and read it together as well. d. Invite the participants to watch a movie about how to prevent children from getting worm infections and malaria. Ask them to pay attention. Flipchart 3.3 e. Ask the participants, “Based on the movie, what are the things that we should do to prevent children from getting worm infection and malaria?” (help the participants in answering by using flipchart 3.2 and 3.3). f. Next, ask 2-3 participants to share their experience when their children were ill, • Did they ever bring their children to be treated at puskesmas or hospitals using KIS/BPJS? g. Show flipchart 3.4 about JKN Health Services. Invite the participants to use KIS/BPJS to access health services. Flipchart 3.4 The facilitator takes the data of beneficiary families that already has JKN cards (KIS/BPJS) FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 93 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 93 4/7/2018 1:04:27 AM THE IMPORTANCE OF PERSONAL HYGIENE 20 step 4 AND ENVIRONMENTAL SANITATION Supporting tools: • Movie 3.3 – Environmental Sanitation minutes • Flipchart 3.5 – Community-Based Total Sanitation (CBTS) • Flipchart 3.6 – The Importance of Washing Hands • Hand washing demonstration tools which are a bucket of water, plastic water scoop and soap. a. Explain how important it is to maintain personal hygiene and environmental sanitation. Show flipchart 3.5 about Community-Based Total Sanitation before starting step 4. b. Then, the participants will watch a movie about the importance of maintaining personal hygiene and environmental sanitation to prevent the contagion of diseases. Ask the participants to pay close attention. Flipchart 3.5 c. Play movie 3.3 about Environmental Health. d. Ask the participants: • What did you see and hear from the movie just now? • Why do we have to use soap? • When are the times to wash your hands? e. Use flipchart 3.6 to explain about the benefits of washing your hands with soap and the steps of washing your hands with soap. f. Next, the facilitator invites the participants to demonstrate washing their hands with soap. 94 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 94 4/7/2018 1:04:28 AM • The necessary tools to wash hands with soap are: a bucket of water, water scoop and soap. • Ask 1 participants to be an example on how to wash hands with soap. • Use the steps in the flipchart to guide the participant in doing handwashing with soap (the facilitator watch the participants’ demonstration carefully and give comments on the correct actions: “That’s right, wet the hands first”; “that’s correct, use the soap; so, make sure to use soap, must use soap to get rid of the germs”; “rub the soap”; “yes, correct, rinse them with running water”). • Invite all participants to practice washing hands with soap if necessary. • Emphasize on the importance of using soap to get rid of the germs from the hands. Without soap, the germs still stick strongly and can cause diarrhea in children. Flipchart 3.6 g. Explain to the participants that they can read Health and Nutrition Guide Book to learn more about how to wash hands on page 22 and child hygiene on page 31-32. h. Explain to the participants that beside washing hands, the environmental sanitation at home is also as important, such as throwing wastes at designated places and cleaning water containers regularly. To learn more about environmental sanitation and children safety, the participants can read the Health and Nutrition Guide Book page 32-33. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 95 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 95 4/7/2018 1:04:30 AM THE STEPS OF WASHING HANDS WITH SOAP 1. Wet both hands with 2. Rub the soap on both palms clean running water. until it produced foam, then rub them on the back of both hands, fingers, thumbs, until all surface is covered. 3. Clean between the 4. Rinse with clean water while fingers and under rubbing both hands together the nails. until all the foam is gone. 5. Dry both hands with cloth, clean towel or paper tissue, or by flicking both hands till dry. 96 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 96 4/7/2018 1:04:30 AM 10 step 5 THE IMPORTANCE OF HEALTHY TOILET Supporting tools: • Movie 3.4 – The Importance of Healthy Toilets menit • Flipchart 3.7 - The Criteria of Healthy Toilets a. Explain that the participants will soon watch a movie about the importance of healthy toilets. b. Play movie 3.4 about the Importance of Healthy Toilets. c. Assert that the main messages of the movie are: • Do not have bowel movement carelessly in the rivers or open spaces. Build a healthy toilet in each house. • When building a toilet room, the walls and roof don’t have to be made out of concrete. Plywood or bamboo will work as well. • The toilet room must have 1 bucket for handwashing. d. Ask the participants: • Where do they and their family usually have bowel movements? • What is a healthy toilet? • What are the benefits of bowel movements at healthy toilets? • Who already has a healthy toilet? Who hasn’t? Flipchart 3.7 d. Explain that a healthy toilet helps prevent the contagion of diseases such as diarrhea and it’s not necessarily expensive. Show flipchart 3.7 about the Criteria of Healthy Toilets and read it together. The facilitator takes the data of beneficiary families that don’t have a healthy toilet yet. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 97 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 97 4/7/2018 1:04:31 AM 10 step 6 CLOSING Supporting tools: minutes • Flipchart 3.8 – Clean and Healthy Lifestyle a. Deliver the messages below: • Wash hands with soap and running water. • Ensure that the household has clean water sources. • Throw wastes at designated places. • Do not have bowel movements in open space. Build a family toilet. • Use KIS/BPJS to access health services. b. Show flipchart 3.8 about Clean and Healthy Lifestyle and read it together. c. Close the meeting with prayers. d. Say thank you for the participants’ presence on this session. Flipchart 3.8 98 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 98 4/7/2018 1:04:32 AM SESSION 3 READING MATERIALS ILLNESS IN CHILDREN AND ENVIRONMENTAL HEALTH To prevent impaired development in children, we must protect them from illnesses, especially diarrhea, worm infections and malaria. Here are the description about the illnesses as well as the preventions and countermeasures. 1. DIARRHEa Diarrhea is the condition of having loose or even water-only bowel movements more often than usual (over 3 times a day). In children, diarrhea can cause dehydration that results in shock (the child lose consciousness) due to the extreme fluid loss. If not treated immediately, diarrhea can end in death. The countermeasures are: a. If the child is still breastfeeding, continue breastfeeding and complementary feeding as usual. b. Give ½ -1 glass of oralit fluid each time the child have bowel movements. If there’re no oralit, give cooked water, clear vegetable soup and rice milk. c. Give zinc every day for 10 days in a row: 1 time ½ tablet for children ages < 6 months; 1 time 1 tablet for children ages 6 months-5 years. d. Do not give any other medications except what is given by health workers. e. Bring to a health facility immediately if: there’s fever, blood in stool, the diarrhea worsens, chronic vomiting, the child seems thirsty, won’t eat or drink, chronic diarrhea. To prevent diarrhea, we need to pay attention to the things below. a. Maintain personal hygiene and environmental sanitary. Make a habit of washing hands with soap and clean running water before and after eating, before processing and serving food, before breastfeeding, FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 99 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 99 4/7/2018 1:04:32 AM before feeding infants/toddlers, after bowel movement/urination, and after touching animals/birds. b. Give exclusive breastfeeding and then continue until the child is 2 years old since breast milk contains antibodies for the immune system. c. Prepare complementary food well and cleanly including the usage of clean water for every day necessities. d. Drink water that has been boiled. 2. WORM INFECTIONS Worm infection is an infection caused by parasitic worms inside a child’s body, such as roundworm, tapeworm and hookworm. They are called parasites because these worms disrupts the absorption of nutrients in the intestines. The core of worm infection prevention is the maintenance of personal hygiene and environmental sanitation to avoid worm infections, such as: a. Avoid the habit of having bowel movements on the ground/farm/ field. b. Use footwear such as sandals/shoes outside. c. Wash hands with soap and running water before eating. d. Routine examination and get anthelmintic drugs at the Puskesmas. Permenkes RI (The Regulation of the Minister of Social Affairs of the Republic of Indonesia) number 15/2017 about The Countermeasures on Worm Infections, stated that the effort to control the risk factors in worm infections can be done through the maintenance of personal hygiene and environmental sanitation. Those efforts include: 1. MAINTAINING INDIVIDUAL HYGIENE a. Wash hands with soap and water at 6 important times, which include before and after eating, before preparing and serving food, before breastfeeding, before feeding infants/toddlers, after bowel movements/urination and touching animals/birds. 100 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 100 4/7/2018 1:04:32 AM b. Use clean water to shower. c. Consume water that qualifies for drinking. d. Wash and clean food ingredients before consumption. e. Take a shower and clean the body with soap at least twice a day. f. Cut and clean the nails. g. Use footwear while walking on the dirt and wear gloves when doing dirt-related works. h. Cover food on the table to prevent dust and flies from contaminating them. 2. MAINTAINING ENVIRONMENTAL SANITARY a. Stop having bowel movement carelessly. b. Build sewerage. c. Throw wastes in trash cans. d. Maintain the sanitation of homes, schools and the environment. 3. Malaria Malaria is caused by the bite of an infected female anopheles mosquito. Below are the things we can do to prevent it. a. Use a mosquito net with insecticide which is a mosquito net that has been dip-treated with insecticide. It can kill mosquitos but harmless to human’s health. b. Prevent mosquito bites by wearing long pants and long sleeved shirts outside of the house. c. Use insect repellents or insecticides. d. Install mosquito nets on doors and windows at home. All malaria treatments and medications are done by health workers in Puskesmas. Bring pregnant women and children to Puskesmas to get treated. Treatments are done in order to kill all of the malaria parasites in the body so that it is perfectly cured, thus cuts off the chain of contagion. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 101 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 101 4/7/2018 1:04:32 AM 4. FEVER Give water in higher quantity and frequency. For breastfeeding infants, breastfeed them more often. Compress using regular or warm water. Do not compress using cold water since the child may shiver. Do not put blankets over them or dress them in thick clothes. In case of high fever, give fever reducer drugs according to the dosage. Bring children to healthcare facilities immediately if: the fever is accompanied by seizures, doesn’t come down after 2 days, or accompanied by rash. COMMUNITY-BASED TOTAL SANITATION (Sanitasi Total Berbasis Masayrakat, STBM) STBM is an approach to change behaviors in regards to hygiene and sanitation through community empowerment. STBM consists of five pillars which was explained in the Regulation of the Ministry of Health number 3 year 2014. Those five pillars are: 1. Stop having bowel movements indiscriminately (SBS). 2. Wash hands with soap (CTPS). 3. Managing the household’s drinking water and food (PAMM-RT). 4. Secure household waste. 5. Secure household waterwaste. 1 Stop Having Bowel Movements Indiscriminately (SBS) SBS is a condition where every individual within a community no longer have bowel movements in random places. There are still many Indonesians who have bowel movement in random places, such as rivers, rice fields, ponds or farms. People who do use toilets but the waste produced are not flowed into a tank but to the rivers or trenches instead, are also included as having bowel movement indiscriminately. Indiscriminate bowel movements create a dirty environment so that children get diarrhea easily. A healthy toilet is effective in stopping the contagion chain. Having a healthy toilet close to the house will help people, especially women and children to have bowel movement comfortably without embarrassment or disturbance. A healthy toilet is not necessarily expensive. The most important part is the security of 102 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 102 4/7/2018 1:04:32 AM wastewater container and not the building above it (roof, walls, doors). If the budget is limited then the building could be made simple. On simple construction, the toilet hole can be made without the swan neck. But it has to have a lid. 2 Wash Hands with Soap (Cuci Tangan Pakai Sabun, CTPS) Washing hands with soap is an easily doable habit with a lot of benefits. Diarrhea, which can cause death, can be prevented by washing hands with soap at important times. Even though it’s easily done, the habit of washing hands with soap at important times is still not prevalent among mothers with toddlers. Several surveys shows that only about 30- 40% mothers with toddlers wash their hands with soap at six important times. The rest only use water and don’t use soap. Washing hands only with water is a more common habit. Many people feel that using water is enough. They think that once they’ve rinsed their hands with water and their hands don’t smell, look or feel dirty, then their hands are clean. However, although they look or feel clean, in reality, the germs are still sticking on them. Using soap can help loosen the germs from the hands more easily. Thus, the hands will be free from germs after rinsing. The important times for CTPS are: before and after eating, before processing and serving food, before breastfeeding, before feeding infants/toddlers, after bowel movement/urinating and after touching animals/birds. CTPS Steps: 1. Wet both hands with clean running water. 2. Rub soap with both hands until it produces foam, then rub it on the back of both hands, fingers, both thumbs, until all of the surface is covered. 3. Clean the tips of the fingers and under the nails. 4. Rinse with clean water while rubbing both hands together until all the soap is gone. 5. Dry both hands using cloths, dry towels or paper tissues, or by flicking the hands till dry. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 103 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 103 4/7/2018 1:04:32 AM 3 The Management of Drinking Water and Food for the Household The processing of drinking water in households can be done by boiling the water. Then, the water can be stored for daily use. Drinking water is stored in lidded containers, with narrow opening or containers equipped with faucet, and placed at a clean place that is hard for animals to reach. Drink the water using clean and dry glasses or do not drink directly from the faucet. Drinking water containers are washed every 3 days or when the water runs out, use cooked water for the final rinse. Wash hands before processing drinking water and food. Use cooked water to wash vegetables and fruits, as well as for cooking. Do not dip hands into water that has been processed into drinking water. Choose food ingredients that are fresh, not rotten, haven’t gone bad/ moldy, don’t contain dangerous and toxic chemicals. After processing, stored food must be kept away from contamination possibilities by bacteria, insects, rats and other animals as well as dangerous and toxic chemicals. Food should be consumed no more than 4 hours after it’s cooked and should be warmed up, especially high protein food. This is to avoid bacterial infestation on the food. 4 Securing Household Waste There cannot be wastes inside the house. They must be thrown out every day. Waste sorting between organics and inorganics can be done by getting two separate trash can. Trash can must always be sealed tight. Waste collection is done by collecting and moving them from households to temporary storage or integrated waste processing areas. The accumulated garbage will then be transported to the final processing place. 5 Securing Household Wastewater To flow the household’s wastewater, the existence of absorption well and sewerage are necessary. Household wastewater that is consisting of stools and urine are flowed into the septic tank that is equipped with absorption well. While the wastewater from the kitchen, bathroom 104 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 104 4/7/2018 1:04:32 AM and washbasin are flowed to the sewerage. The principles in Securing Household Wastewater are: a. Wastewater from the bathroom and kitchen cannot mix with wastewater from the toilet. b. Cannot be a place that breeds pathogenic germs. c. Cannot have bad odor. d. Cannot have pools of water that can cause slippery floor and prone to accidents. e. Connected with the public sewerage or absorption well. HEALTHY AND CLEAN LIFESTYLE (PERILAKU HIDUP BERSIH SEHAT OR PHBS) The availability of clean water, bowel movement at healthy toilets, as well as washing hands with soap are some of 10 PHBS indicators that are important for households to adopt in order to keep the family healthy. PHBS in households are: 1. Childbirth assisted by health workers at a health facility so that the mother and infant are safe and healthy. 2. Exclusive breastfeeding for infants ages 0-6 months so that the infant grows healthy and doesn’t fall ill easily. 3. Infants and toddlers get weight measurements every month in Posyandu to monitor their growth and development. 4. Work together for the availability of clean water in the neighbourhood to prevent skin diseases, worm infections and gastroenteritis. 5. Make a habit of having bowel movement at a healthy toilet to avoid gastroenteritis. 6. Make a habit of washing hands with soap and clean running water at important times to keep the hands clean and the family from illnesses. 7. Make the house free of mosquito larvae with 3M plus, Draining (Menguras), Burying (Mengubur), Covering (Menutup) and Avoiding (Menghindari) mosquito bites. It is done simultaneously once a week to avoid dengue fever. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 105 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 105 4/7/2018 1:04:33 AM 8. Eat vegetables and fruits every day to avoid stroke, hypertension, diabetes and cancer. 9. Do at least 30 minutes of physical activity every day to avoid heart diseases, stroke, hypertension, diabetes and cancer. 10. Turn the house into a no-smoking area to keep the family members away from the danger of 4000 toxics in cigarettes. NATIONAL HEALTH INSURANCE PROGRAM National Health Insurance (JKN) is a part of National Social Insurance System (Sistem Jaminan Sosial Nasional or SJSN) that is implemented using mandatory social health insurance mechanism based on the Legislation number 40 year 2004 about SJSN. The purpose is to fulfil the people’s basic need for proper healthcare and it is given to anyone who has paid the premium personally or paid by the government (PBI). 106 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 106 4/7/2018 1:04:33 AM GAMES MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 107 4/7/2018 1:04:33 AM This section presents games that the facilitators can use to invite FDS participants to play. The objectives of the games are: 1. To learn the behaviors concerning health and nutrition. 2. To reduce boredom, as ice breaker and make the communication more comfortable. 1. Encouraging Words Bisa-bisa-bisa, wuuuih bisa…! (We can-we can-we can, wow we can…!) • When a participant is about to present a group’s discussion results, the facilitator can ask other participants to shout the encouraging words. • When the facilitator say “you can”, the all the participants will rub the palms of their hands while saying, “you can, you can, you can and you cannn!” as if throwing/giving energy to the one who’s about to speak. • On a different situation, this can also be given to participants who need encouragement for certain behaviors (pregnant and loss of appetite, difficulties feeding the children, etc.) 2. Games for Self-Introduction Thank you, my name is… • Ask the participants to form a circle, the facilitator included. • The facilitator then demonstrate a game. He will start by saying his name: “I’m Budi”. Then ask the one on his right to say, “Thank you, Budi. My name is Aminah.”; Ask the one on Aminah’s right to say, “Thank you, Budi and Aminah. My name is Sri.”; then ask the one on Sri’s right to say, “Thank you Budi, Aminah and Sri. My name is Rodiah”; • Those 4 names can be used as examples. After that, ask the participants to do it in turns to the right, starting from the facilitator. • After one round is done, the facilitator can start again to the opposite direction (to the left). 108 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 108 4/7/2018 1:04:33 AM Discussions in pairs/groups • Ask the participants to line up based on age with the oldest in front and the youngest at the back. However, no one can make a sound at all. No one can open their mouth. • If there’s not enough space, then the line can bend or curve. • After lining up, ask them to state their ages. • Ask them to form a pair with the person in front or at the back of them. • Ask them to introduce themselves to one another: name, where they live, etc. • Ask the pair to share to the forum about the name, place, etc. of their new friend. If the participants exceed 20 people… • If there are a lot of participants (more than 20 people), then instead of pairs, ask the participants to form a group of 4-5 people instead. Then, the facilitator can follow the steps above. If they already knew each other… • If the participants already knew each other from the beginning, then ask them to talk about deeper topics (positive/appreciative/ thankful). For example, ask: When looking at your child, what makes you happy? • What are your hopes for your child? What do you hope your child will grow up into? • Then, combine maybe 2 or 3 pairs into one group. Ask each person to share her friend’s story. 3. Games to Rearrange the Seating Positions The wind is blowing towards… • If there are seats available, ask the participants to sit in a circle and take out the empty seats. At the beginning, the facilitator is standing and doesn’t have a seat. • Explain that when the participants hear the cue: the wind is blowing towards people who… (mention a general description, such as people who are wearing skirts), then everyone with that description must FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 109 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 109 4/7/2018 1:04:33 AM stand up and try to sit on a different chair. • As soon after giving the description, the facilitator immediately sits on one of the now empty chairs. Then, there will be 1 participant left standing without a seat. Ask her to give the cue: the wind is blowing towards people who…(mention a new description). • Do 4-5 rounds until everyone have moved from their seat. The boat is shaking… • If there are seats available, ask the participants to sit in a circle and take out the empty seats. At the beginning, the facilitator is standing and doesn’t have a seat. • Explain that when the participants hear the cue: shake to the left, then all participants move 2 seats to the left. Shake to the right, then they move 3 seats to the right. Storm, and they move wherever they want as long as they move from their seat to a new one. • The facilitator then tells a story. One day, Mrs. Aminah took a boat to Buru Island. In the middle of the way, the boat was hit by the wind and shake to the…left. • As soon as saying the cue, the facilitator sits at an empty seat. Then, there will be 1 participant left standing without a seat. Ask her to continue the story. • Do 4-5 rounds until everyone have moved from their seat. Creating pairs/groups using key words If there are no seats available, the facilitator can randomize the seats by using a game of creating pair/group with keywords (see below). After all are rearranged, ask the participants to sit in a circle close to their groups (not back to their original position). 110 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 110 4/7/2018 1:04:33 AM 4. Games to Create Pairs/Groups Using keywords • The facilitator determines some keywords and the correlating quantity of group members. For example, the keywords are TTD, Breastfeeding and Child Feeding, where TTD = 2 people, Breastfeeding = 3 people, Child Feeding = 5 people. The facilitator then explains the reason. TTD has 2 people because it’s important for the health of the mother and the child in the womb. Breastfeeding has 3 people because exclusive breastfeeding needs the support from the mother, father and mother’s parents. Child Feeding has 5 because it requires patience. • All participants are asked to stand and form a big circle. • All participants are asked to face their right and start walking while stomping their feet (boom-boom-pow, boom-boom-pow). • When the facilitator say a keyword, ask the participants to form a group with the correct number of members. • Those who made a group with wrong number of members are asked to give the next cue. • Repeat a couple of time for fun, or a maximum of 4 times. The last one are the groups that will work together for a purpose. Counting with fruits, vegetables, protein sources, or a different local languages (2-4 groups) • Explain that the participants will be counting but without using numbers like 1,2,3,4. Numbers are replaced with (choose alternately to avoid boredom):  Fruits, such as: papaya, guava, mango.  Vegetables, such as: green bean, water spinach, carrot.  Protein sources, such as: egg, fish, chicken.  Other local languages, such as: cie, duo, tigo, ampe (1, 2, 3, 4 in minang language). • For food ingredients, the facilitator should also explain the benefits. • Ask the participants to start counting. • Ask them to form a group based on the words they used. Direct each groups to different seating positions (for example, ‘water spinach’ at the front-right side, etc.) FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 111 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 111 4/7/2018 1:04:33 AM 5. Choosing a Groups’ Representative Raise a Hand and Choose • Ask all participants to raise their hands as high as possible with index fingers pointing upwards. • Explain to them that at the count of three, they are to choose a person within each of their group as a representative. The person should never have been a representative before. • The facilitator starts counting, one, two and three… • The person who gets the most index fingers pointing at her becomes the representative. 6. Refreshment Exercise with storytelling • The facilitator asks the participants to stand, forming a circle with wide gaps and put their hands on their waists. • Explain that at the cue of a certain words, move their hips to a certain direction. “Ani” move the hips to the left, “Anto” to the right, “Dad” to the front, “Mom” to the back, and “all” circle the hip. • The facilitator starts to tell a story with deliberate tempo that slows down to a keyword. Upon hearing each keyword, the participants move their hips accordingly. For example: one morning, Ani is asked by Mom to go to the market. “Ani, Ani, here’s the money. Please buy nutritious ingredients. Anchovies so we are not sluggish. Eggs so you’ll grow tall…” suddenly Dad said, “Mom, Mom, don’t forget to buy my cigarettes.” Mom answered, “Dad, take a vacation from smoking today. Let’s buy eggs instead.” “Yes, that’s right.” Said Ani. Anto who’s been watching TV also confirms, “That’s right Dad. Let’s buy eggs instead. The cigarettes can wait tomorrow.” Dad thinks, “Hm, that’s right.” Then, Dad said, “Alright then. We will all eat eggs today and Dad won’t smoke.” 112 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 112 4/7/2018 1:04:33 AM • The facilitator then asks a participants to continue the story. The storyteller doesn’t need to move her hips. Just focus on storytelling. • Let 4-5 people to do the storytelling. Looking for a Finger • The facilitator asks the participants to stand in circle. Ask them to lift their right hand and place it on top of the shoulder of the person directly to their right with palm facing upwards. • Then ask them to lift their left hand and place their index finger onto the palm on their left shoulder. • Explain that after hearing a keyword, then their right hand should try to catch their right neighbor’s index finger while trying to keep their left index finger from getting caught by their left neighbor. • The facilitator doesn’t join the game, only storytelling. For example, the keyword is anchovy. They can use any keyword as long as it is related to health and nutrition (food ingredients, healthy habits, etc.) • Then the facilitator start telling a story. There are a lot of good iron FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 113 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 113 4/7/2018 1:04:34 AM sources for pregnant women. There’s TTD that’s best to take at night before bed to avoid nausea. Fish… from the sea and more. So, Mrs. Aminah likes to eat anchovy… • After 2 rounds. Ask the person who got her index finger caught, to tell a story using the keyword. If there are more than 1 person, pick one of them or ask all of the to tell a story alternately. The storyteller doesn’t join the game. Counting with Keyword • The facilitator asks the participants to stand in circle. • Then asks them to count with a rule that when they reach number 4 and its products, change those numbers into a certain keyword. Use words that are relevant to the learning topics such as TTD, Breastfeeding, Anchovy, Egg, etc. • Ask one of the participants to start counting then the next person on the right an so on. If someone made a mistake, then start over. • There shouldn’t be penalties on the first rounds. But once the participants are more comfortable, give quizzes (simple questions) for the person who miscounted. • 1-2-3-breastfeeding-5-6-7-breastfeeding-9-10-11-breastfeeding and so on. Words that Helps Focus • Ask the participants to reply with certain words when the facilitator or a person in front of the forum shouts a keyword. For example, Hello! is answered with Hi!; Hi! is answered with Hello!; Hello! Hello! is answered with Hi! Hi! and so on. • In another situation, also use words that are related to the learning topics. For example, Beastfeeding! is answered with Healthy!; TTD! is answered with Nauseating but plenty of benefits! etc. 114 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 114 4/7/2018 1:04:34 AM REFERENCE 1. Bappenas, Kementerian Kesehatan, Kementerian Sosial, Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K), dan UNICEF. 2014. Buku Panduan Pendamping PKH dalam Sesi Pertemuan Bulanan Kelompok PKH. Jakarta. 2. Bappenas, Kementerian Kesehatan, Kementerian Sosial, Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K), dan UNICEF. 2014. Materi Kesehatan dan Gizi bagi Pendamping PKH. Jakarta. 3. Kementerian Kesehatan Republik Indonesia. 2010. Riset Kesehatan Dasar (Riskesdas). Jakarta. 4. Kementerian Kesehatan Republik Indonesia. 2013. Riset Kesehatan Dasar (Riskesdas). Jakarta. 5. Kementerian Kesehatan Republik Indonesia. 2014. Pedoman Gizi Seimbang. Jakarta. 6. Kementerian Kesehatan Republik Indonesia. 2014. Peraturan Kementerian Kesehatan no 3 tahun 2014 tentang Sanitasi Total Berbasis Masyarakat (STBM). Jakarta. 7. Kementerian Kesehatan Republik Indonesia. 2016. Buku Kesehatan Ibu dan Anak. Jakarta. FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA 115 MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 115 4/7/2018 1:04:34 AM 116 FAMILY HOPE PROGRAM OF THE MINISTRY OF SOCIAL AFFAIRS OF THE REPUBLIC OF INDONESIA MODUL Kesehatan & Gizi-Inggris rev-06042018.indd 116 4/7/2018 1:04:34 AM