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6 General Strategies for Providing Effective Nutritional Care Essential Steps for Patient Education Identify the problem, such as inadequate weight gain, using information from the nutrition assessment. Develop a tentative clinical objective to discuss with the woman. The objective should be based on clinical standards and information obtained from screening and assessment procedures. An example would be to gain at least 3 lb by the next visit (in 1 month). Determine the woman's perception of the seriousness of the problem (e.g., inadequate weight gain) and the likelihood it will harm her or her baby. If the woman does not believe that the problem is serious or that it applies to her, offer personalized information to help her to see this as a problem for her, e.g., small babies may look cuter and be easier to deliver, but they are much more likely to get sick. Decide which behavior(s) supports or impedes the achievement of the clinical objective. Try to identify more than one behavior (e.g., decrease exercise, increase intake of foods high in energy and nutrients, and take specific actions to decrease stress) to give the woman choices. With the woman, assess the barriers to behavior change and find strategies to overcome them, based on

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the woman's own experience and the experience of people who influence her. Consider asking her to list the benefits to her and her baby. Negotiate with the woman about which behavior change(s) is to be attempted. It is best to begin with small changes in one or two behaviors that the woman will be able to make and maintain. Personalize the benefits of behavior change by relating them to concerns she has expressed and by using language forms such as "you," "your baby". Help to reduce barriers. For example, refer the woman for special counseling or to food assistance agencies, provide appropriate written material, or loan the family a videotape. Improve support by family and friends by offering assistance from the staff or volunteers. Offer feedback and reinforce any success. When there is little or no progress, step up the frequency of contact (e.g., by telephone) and use more specialized resources.

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Responding to Developmental Differences Adolescents pose special challenges to health care providers because of the need to be aware of and responsive to their developmental differences. Depending on her developmental stage, one adolescent of a given age may need to be approached very differently from another. The following chart provides a brief summary of some useful approaches by stage rather than age.   Stages of Adolescence       Early Middle Late Goal-setting ability of the teen Limited—may be unable to formulate goals, or the goals may be unrealistic Improving, but still limited—may formulate grandiose, Often able to make realistic plans for the future, but may not be interested Useful professional approaches Be caring yet firm. Offer simple, concrete choices. Encourage causal reasoning. Offer positive reinforcement, and build the teen's self-esteem. Be caring and demonstrate respect for the teen's need to make decisions independently as well as to conform to peer pressures, but set limits firmly. Encourage negotiation with adults and assist in learning negotiation skills. Encourage consideration of the possible consequences of acts and the formation of realistic goals. Be caring and be a good listener. Offer opinions as one adult to another. Serve as a resource and a sounding board. Adapted from Department of Pediatrics, University of Rochester, as seen in A Smart Start: Nutrition for Life.17

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Serving Culturally Diverse Populations* A basic element of culturally appropriate care is demonstrating a sincere commitment to providing services in an acceptable and appropriate manner to people of cultural or ethnic groups different from one's own. Since cultural groups may differ in many ways, considering some of the questions and approaches listed below may help to achieve this. Attentive listening helps the care provider learn. Definition of family and of the roles of family members. Is it a nuclear family unit? Is it an extended family? If extended, how many members and generations are included (grandparents, aunts and uncles)? How are decisions made within the family? (Does the male play a dominant role? The grandmother?) Childrearing practices. Is child care shared as a method of extending the family's resources? Does the grandmother care for the infant soon after birth so that the mother can earn an income or return to school? Beliefs and practices concerning health and illness. Does religion play a role? Is balance between dichotomies such as "hot" and "cold" or “yin" and "yang" believed to contribute to health? If so, how can balance be achieved, and how is this likely to affect food selection? Are certain foods viewed as healthful or harmful during pregnancy or lactation? Is there a belief that eating too much or taking supplements will lead to difficult labor and delivery? Styles of interaction between professionals and group members. Do group members tend to prefer a warm, friendly, and personal form of communication or a more formal one? How important is the use of formal titles? Do group members tend to prefer to sit or stand closer to or farther away from *   Much of the content of this section was derived from Anderson and Fenichel.18

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Elements of Culturally Effective Programs Basic elements of a program to promote culturally appropriate care include the following: In-service training of the health care providers on the cultural practices and beliefs of the groups served. Creation of a welcoming environment and use of materials that portray a positive image of the clientele. Employment of health care providers who are members of the cultural groups served or well-trained interpreters. Development of a mechanism for input from the community, making certain that all cultural groups are represented. the provider than the provider is used to? Does direct eye contact facilitate communication or does it signal disrespect? Is touching the person viewed as offensive or as an important means of communication? Is it important to address elders first? Orientation toward the future or the present. Is there a tendency to live in the present with little regard for the future? Is education viewed as such an important key to the future that it takes priority over other activities? Dietary practices. What foods form the basis for the groups diet? What are the key sources of essential nutrients? Do any customary cooking methods enhance the quality of diet? Useful sources of information about local dietary practices are usually available from the state department of health or the state WIC office.

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Ways in which foods are integrated into the diet. Are vegetables added to soups, stews, rice, or other dishes instead of eaten as a side dish or in salads? Is milk used as the liquid in cooked cereal, blended with fruit, or mixed half and half with coffee or tea rather than being used alone as a beverage? Extending the Effectiveness of Nutrition Education Through Trained Peer Counselors Trained peer counselors afford a means to extend the reach and effectiveness of health care providers—especially for breastfeeding women, members of ethnic minorities, and adolescents. Women who have successfully implemented nutritional recommendations as patients are candidates for the special training required. Prior to the encounter between the woman and the provider, the peer counselor may meet with the woman to review objectives from the previous visit and the extent to which they were met, determine the woman's nutrition-or health-related concerns, review topics that are scheduled to be discussed during the visit, and help the woman develop appropriate questions based on her needs. Following the encounter between the woman and the provider, the peer counselor may meet with the woman to review what was discussed, determine whether the instructions are understood, help her make plans based on available resources, alert her to resources to improve her nutritional status, and encourage her to follow-up and to take responsibility for her own health and welfare. As needed, the peer counselor may provide other services, including giving food demonstrations and helping design educational materials.