Ministry of Health

PARTICIPATORY CAPACITY AND NEEDS ASSESSMENT FOR KEY LOCAL PARTNERS AND TARGETED COMMUNITIES

(To Design, Implement and Monitor Nutrition and Food Security Interventions; To Define Community Based Interventions)

January 2012

Draft Report

Prepared by

Participatory Capacity and Needs Assessment

ACRONYMS

ADHS Albania Demographic and Health Survey CSO Civil Society Organization FAO Food and Agriculture Organization FNS Food and nutrition security IDA Iron Deficiency Anemia IDD Iodine Deficiency Disorders INSTAT Albanian National Institute of Statistics JPN Joint Programme on Nutrition LGU Local Government Unit MADA Mountain Area Development Agency MDGF Millennium Development Goals Achievement Fund NGO Non-governmental Organization PfD Foundation Partnership for development PLA Participatory Learning and Action PPS Participatory Priority Setting PRA Participatory Rural Appraisal RPA Rapid Participatory Appraisal RRA Rapid Rural Appraisal UNICEF United Nations Children's Fund WHO World Health Organization

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TABLE OF CONTENTS

ACRONYMS 2 TABLE OF CONTENTS 3 LIST OF FIGURES AND TABLES 4 EXECUTIVE SUMMARY 5

1. INTRODUCTION 8 1.1. Brief background 8 1.2. Definition and concepts of food and nutrition security 9 1.3. Purpose of the study 12 1.4. Methodology and approach of the study 12 1.4.1. Overview of the approach 12

1.4.2. A step-wise implementation approach 13

2. MAIN FINDINGS OF THE STUDY 17 2.1. Overview of the study area 17 2.2. Awareness and knowledge on food and nutrition security concepts 19 2.2.1. Level of knowledge of FNS concepts at local authority level 19

2.2.2. Level of community knowledge on nutrition concepts 23

2.3. Main factors of malnutrition and food insecurity 26 2.4. Local government capacities in dealing with FNS and coordination issues 30 2.5. Opportunities to increase food availability 33 2.5.1. Perceptions of local authorities on food availability opportunities 33

2.5.2. Perceptions of communities on food availability opportunities 34

2.6. Community opinions on food security and nutrition interventions 37 2.7. Improving local capacities 39

3. CONCLUSIONS AND RECOMMENDATIONS 41

4. ANNEXES 43 Annex 1. Details of proposed interventions 43 Annex 2. Aditional tables 48

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LIST OF FIGURES AND TABLES

Figure 1. Conceptual framework of malnutrition (UNICEF, 1991) ...... 10 Figure 2. Conceptual framework of the nutritional status at household and individual level ...... 11 Figure 3. Determinants of Food and Nutrition Security ...... 11 Figure 4. Aggregated scoring of key actors’ knowledge and understanding of key actors on malnutrition ...... 19 Figure 5. Level of overall community awareness on nutrition issues ...... 23 Figure 6. Main causes of malnutrition as perceived by the local authority representatives ...... 27 Figure 7. Main causes of malnutrition according to three main groups factors, as perceives by local authorities ...... 28 Figure 8. Main causes of malnutrition and food insecurity as perceives by community representatives according to the four main food security components ...... 30 Figure 9. Weighted level of LG capacities to deal with FNS issues at their territory ...... 31 Figure 10. Importance of main groups of opportunities to increase food production ...... 34 Figure 11. Main mission/limited food components in the usual diet ...... 35 Figure 12. Possibilities for more fruits, vegetables, forest fruits and hers (by regions) ...... 36 Figure 13. Opportunities to increase food production ...... 36 Figure 14. Possibilities for more fruits, vegetables, forest fruits and herbs ...... 36 Figure 15. Main categories of interventions to improve food security proposed by communities (by region) ...... 38 Figure 16. Main categories of interventions to improve food security proposed by community ...... 38 Figure 17. Main categories of interventions proposal by civil society members ...... 38 Figure 18. What should change to improve the local nutrition situation? ...... 39 Figure 19. Most effective interventions proposed to improve capacities and nutrition situation ...... 39 Figure 20. Potential categories off actors to be involved in public information about nutrition ...... 40

Table 1. Number and distribution of focus groups held with key stakeholders ...... 15 Table 2. Main characteristics of the targeted study area ...... 17 Table 3. The level of local authorities’ knowledge about concepts and components of food security and malnutrition ...... 20 Table 4. Main topics proposed to be covered by potential capacity building interventions at local authority level for improving knowledge on food security and nutrition concepts ...... 22 Table 5. The level of community knowledge about concept and types of malnutrition ...... 24 Table 6. Main topics proposed for interpersonal communication interventions at community level for improving knowledge on nutrition concepts ...... 25 Table 7. Main factors impacting food security and nutrition in the study area ...... 26 Table 8. The assessment of the current experience and capacities of LG (according to main identified capacity issues) ...... 32

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Participatory Capacity and Needs Assessment

EXECUTIVE SUMMARY

The nutritional status of children has improved over the last 5 years. However, children face multiple nutrition problems including high rates of stunting and overweight, disparities in health and nutrition status and micronutrient deficiencies. Anemia (as one of the major effects malnutrition, especially in young children) is considerable higher in rural areas than in urban areas, for children of women with no education and for lowest wealth quintile. Designing and implementation of cross sectorial interventions addressing malnutrition and household food insecurity is an important component of the current nutrition programme. The involvement of the community and key local stakeholders will help ensure endorsement and validation of planned interventions, effectively mobilize the community and contribute to sustainability of interventions. In this context, UNICEF, WHO, FAO, in cooperation with Albanian Government are implementing a Joint Programme on Nutrition aiming to help improve the nutrition situation in Albania.

The main purposes of this study was to: (i) identify needs/existing gaps of community based partners and CSOs working with communities in the target areas to design, implement and monitor nutrition and food security interventions; (ii) conduct a participatory needs assessment at community level to define community based interventions in target areas; and (iii) synthetize the results of both assessments in the form of a final report including the recommendations for trainings and the proposed package of community based interventions.

The study area included 15 local government units (LGUs) in three regions (7 in Kukes, 6 in Shkoder and 2 in Tirana). The targeted areas cover a total area of 1.430 Km 2 and have about 37.600 hectares of arable land. The 15 targeted LGUs have a population of about 153 thousand inhabitants and about 35,200 households. The approach selected for the implementation of this assignment is based mainly on the Participatory Learning and Action (PLA) approach, involving in itself a wide range of tools. The selection of the target area was done by the JPN and included 15 local government units in three regions (7 in Kukes, 6 in Shkodra and 2 in Tirana). In addition to a large number of individual meetings held with representatives of various institutions, organizations and individual experts, 63 focus groups consisting of about 10-15 members each (or about 760 persons attending these focus groups) were held with the key regional and local stakeholders.

The assessment has been implemented during the period of October-December 2011 and main findings of the assessment are as follows: Chapter: Executive summary 5

Participatory Capacity and Needs Assessment

• The overall level of awareness, knowledge and information of key regional and local actors about nutrition issues (nutrition in general and especially related to children and women) remain generally low, both at the regional and local level. The highest level of awareness and knowledge on the subject was shows within the health sector specialists, most of which could make a dissent description of nutrition and its causes and effects on the population.

• The main identified causes of food insecurity and malnutrition are linked with: (i) the overall level of local community development (mainly related to overall poverty level, low local production capacities, limited market access and organization, limited non- agriculture income generating activities, low incomes and purchasing power, vulnerability to price fluctuations; traditional practices and lifestyle; (ii) the level of community education and information, mainly related to improved production and processing technologies and practices; limited market information, limited knowledge on risk mitigation practices, limited knowledge on good nutrition practices; and (iii) objective reasons mainly linked to overall economic context of the country and the region, unfavour agro-ecological conditions for food production, limited job opportunities, low efficiency of local support institutions, etc.

• Within the local authority actors, the health sector seems to be more involved and more efficient in dealing with nutrition issues at community level. The agriculture sector provides some support towards food security mainly through their advice to producers. However, despite their potently important role, most communities perceive the agriculture, social and education sectors as having low efficiency in improving nutrition situation at local level. The current role of the local government administration in dealing with the nutrition and food security issues remains very limited throughout the study area. Only few of the local government representatives declared to have some capacities and little previous experience in monitoring and reporting, while major capacity gaps, mainly as regards assessment of food security and nutrition situation, planning interventions and coordination of actors and actions.

• The majority of the targeted areas have significant opportunities to increase the production and availability of food products within their territory, which are still unused and/or unexploited due to the lack of capacities of the local actors and of the population to transform them into goods for the betterment of the living conditions.

• The exploitation of these existing opportunities for improving food and nutrition security may be reached through well targeted interventions focusing mainly on: (i) improving post harvesting, handling and processing tools, technologies and practices; (ii) introducing new types of productions and food products, and; (iii) increasing the quantity of production of the current crops and livestock. In addition, these interventions should be accompanied by information, trainings, advice and technical assistance to the producers (on food security strategies and practices) and consumers Chapter: Executive summary (on nutrition issues). 6

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• Improving the capacities of the local actors (especially local government) to plan, monitor, report and implement food and nutrition security interventions, improvement of coordination of actions between these actors and the improvement of community information and knowledge are three very important challenges for the improvement of the nutrition situation in all targeted areas.

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1. INTRODUCTION

1.1. Brief background 1

Children in Albania face many challenges that affect their chances for a better start in life and reduce their potential to lead productive lives as adults. In spite of relatively low U5 mortality rates (22 per 1,000 - still high compared to other countries in the region) and good exclusive breastfeeding rates in the first months of life, Albanian children face multiple nutrition problems including high rates of stunting and overweight, disparities in health and nutrition status and micronutrient deficiencies (IDD and IDA). According to ADHS 2008-209, about 39% of children 0-6 months are exclusively breastfeed. While more than half of children 6-8 months (about 55%) received complementary food in addition to breast milk. Overall, about 25% of breastfeed children 6-23 months are feed will all recommended IYCF practices compared to about 11% of non-breastfed children.

The nutritional status of children has improved over the last 5 years. However, about 19% of children under age five were stunted. Stunting was present even among children under six months of age. Stunting indicates chronic malnutrition and is more common in mountain region (about 28%) than in Urban Tirana and Central region; Children in lowest wealth quintile are two times more likely to be stunted (about 13%) than those in highest quintiles (about 27%). Wasting (too thin for height) which is a sign of acute malnutrition is about 9%. About 5% of children under age five were underweight for their age. Twenty –two percent of children under five were overweight.

Micronutrients are essential vitamins and minerals required for good health. About 17% of children 6-59 months in Albania have some level of anemia. Anemia is considerable higher in rural areas than in urban areas, for children of women with no education and for lowest wealth quintile. Nineteen percent of women whose hemoglobin level was tested were found to be anemic.

Taking into consideration current nutrition situation of women and children in Albania, a new Joint Programme on Nutrition (JPN), funded by the MDGF-Spanish Government, was developed jointly with UNICEF, WHO, FAO and the Albanian Government and will help place nutrition and food security higher in government agenda and design interventions focusing directly to most marginalized population groups.

Chapter: 1. Introduction

1 Based on UNICEF background information. 2011 8

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Designing and implementation of cross sectorial interventions addressing malnutrition and household food insecurity is an important component of the current nutrition programme. The involvement of the community and key local stakeholders will help ensure endorsement and validation of planned interventions, effectively mobilize the community and contribute to sustainability of interventions.

In this context, a step wise approach was selected by the JPN’s responsible institutions, leading to community based nutrition interventions, including:

• Identifying the key partners involved in the planning and implementation of community nutrition program; • Understanding the priority nutrition problems (assess nutrition situation, understanding the priority nutrition problems and analyzing causes of malnutrition); • Selecting the most appropriate program approach (define goals and objectives, key program targets, choose the most appropriate intervention strategy); • Developing the institutional framework for implementation (defining management and programmatic roles of different partners, eliciting commitments of partners to their roles); • Designing and appropriate programme action plan (programme activities and time frame for implementation, determine resources needed).

1.2. Definition and concepts of food and nutrition security

According to the accepted definition, food security is “adequate access to food for all people at all times for an active, healthy life”. Food is here defined as any substance that people eat and drink to maintain life and growth, where safe and clean water is also considered as an essential part of food commodities. As such, food security is achieved, if adequate food (in terms of quantity, quality, safety, socio-cultural acceptability) is available and accessible for and satisfactorily utilized by all individuals at all times to live a healthy and happy life.

This definition of food security emphasizes “availability”, “accessibility”, and “utilization” of food. The inclusion of “utilization” underlines that “nutrition security” is more than “food security”. Figure below shows the conceptual framework of malnutrition, developed by UNICEF and widely accepted internationally.

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Figure 1. Conceptual framework of malnutrition (UNICEF, 1991)

People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (under-nutrition) or they consume too many calories (over-nutrition). Thus, there are three basic types of malnutrition: • The first and most important is protein-energy malnutrition - the lack of enough protein (from meat and other sources) and food that provides energy (measured in calories) which all of the basic food groups provide. This is the type of malnutrition that is most often referred to when hunger is discussed. • The second type of malnutrition, also very important, is micronutrient (vitamin and mineral) deficiency. This is not the type of malnutrition that is referred to most often when hunger is discussed, though it is certainly very important. • In recent years there has also been a move to include obesity as a third form of malnutrition. Although obesity is certainly a health problem, considering it as malnutrition expands the previous usual meaning of the term which referred to poor nutrition due to lack of food inputs. It is poor nutrition, but it is certainly not typically due to a lack of calories, but rather too many (although poor food choices, often due

to poverty, are part of the problem). Chapter: 1. Introduction 10

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The two most commonly used conceptual frameworks (food security and malnutrition) show significant differences. The food security framework emphasizes an economic approach in which food as a commodity is a central focus. The malnutrition framework adopts a biological approach in which the human being is the starting point.

Figure 2. Conceptual framework of the nutritional status at household and individual level

However, both frameworks promote an Figure 3. Determinants of Food and interdisciplinary approach to ensuring “Food and Nutrition Security Nutrition Security” (FNS) in common. Both acknowledge that food alone is not sufficient to secure a sustainable satisfactory nutritional status and, therefore, aspects of health must be considered. As a result, nutrition at the households and individuals level is the function of food intake and health status, as illustrated in figure below. The conceptual framework of “Food and Nutrition Security” integrates the food security and the malnutrition frameworks.

Analyzed in this framework, the overall level of knowledge and understanding of the key regional and local authorities (health, education, agriculture and social sectors) and communities about nutrition issues, its current situation, causes and effects is considered to be a very important element for the improvement of the situation. However, the results of the assessment show that the overall level of awareness, knowledge and information available about nutrition issues (nutrition in general and especially related to children and Chapter: 1. Introduction women) remain generally low, both at the regional, local and community level. 11

Participatory Capacity and Needs Assessment

1.3. Purpose of the study

Based on the JPN’s main development goal and approach and working in close cooperation with the technical staff of main strategic partners in nutrition and food security interventions, local authorities in target districts and technical officers of UN participating agencies (UNICEF, WHO, FAO), the main purposes of this study will be to: • Identify needs/existing gaps of community based partners (community leaders, local service providers (health, education, agriculture, social services) and CSOs working with communities in the target areas to design, implement and monitor nutrition and food security interventions; • Conduct a participatory needs assessment at community level to define community based interventions in target areas. • Synthetize the results of both assessments in the form of a final report including the recommendations for trainings and the proposed package of community based interventions.

1.4. Methodology and approach of the study

1.4.1. Overview of the approach

The approach selected for the implementation of this assignment is based mainly on the Participatory Learning and Action (PLA) approach. The PLA helped the study team to identify and analyze the situation and problems and identify interventions and actions for improvement of nutrition with the involvement of community. This approach involved in itself the use of a wide range of visual and verbal methods and tools (involving participatory rural appraisals (PRA), rapid rural appraisals (RRA), rapid participatory appraisals (RPA), participatory priority setting (PPS), responsibility mapping, scoring, role-plays, diagrams, brainstorming, planning charts, etc.) to identify and analyze situation, identify priorities and potential interventions and actions.

The implementation of the PLA approach in this assignment was based on the following principles: • Sequencing : It started with a wide-open process to identify key issues: starting from the national and regional level and go down to the selected local community level; probe issues and priorities by using appropriate RRA and PRA tools. Eventually appropriate measures were taken to adapt the tools to the extent of the particular phenomena at each level. Chapter: 1. Introduction 12

Participatory Capacity and Needs Assessment

• Adaptation and creativity: The PRA tools were adapted according to the purpose and particular phenomena at each level (avoiding the danger of “methods fixation”) and considering first what issues the community has identified, and/or subjects the assessment team needed information on or probing certain issues in more depth. • Reversal of learning : Learn directly from the local community, gaining from their local physical, technical and social knowledge. • Triangulating information and results : The team used learning and triangulation from several methods, disciplines, individuals or groups, locations and/or types of information, cross-checking, comparing and verifying the information and results. • Seeking diversity : This was an important element ensuring that the diverse information, judgments, views and concerns of all the different groups within the community have been heard and analyzed and that the diversity within any community, economic or well-being categories, gender, age, were duly taken into consideration. • Sharing : Ideas and information are shared between the local people, between the local people and the facilitators and of experiences between different communities, institutions and organizations involved in the implementation this assessment.

1.4.2. A step-wise implementation approach

Phase I: Identification and selection of targeted area

This phase was supported by the UNICEF/WHO/FAO during the first half of 2011 and included discussions with key community actors and technical staff at the ministries of Health and Agriculture on selection of the target communes for these interventions. Several regional workshops were organized by the JPN team respectively on May 2011 in the three selected regions. As a result of these identification and planning workshops, it was agreed on the selection of 15 communes for nutrition interventions, as follows: • Kukes region - communes Shishtavec, Zapod, Topojan and Bicaj in Kukes district, the commune of Golaj in Has district and communes of Tropoje e Vjeter and Bujan in Tropoja district; • Shkodra region - communes of Bushat, Rrethina in Shkoder district, communes of Kastrat and Gruemire in Malesi e Madhe district and the Puka municipality and the commune of Iballe in Puka district; • Tirana region - municipality of Kamez and the commune of Paskuqan.

The selection of these local government units (communes/municipalities) was based on socioeconomic status, malnutrition rates, geographical access, remoteness, level of

engagement of local authorities and receptiveness for intervention. Chapter: 1. Introduction 13

Participatory Capacity and Needs Assessment

Phase II: Implementation of the assessment

This phase was implemented by the PfD, with the information, data collection and meetings held period October-November 2011 and the data processing, analyzing and the report writing during December 2011. As relevantly proposed by the Joint Programme on Nutrition, a step wise approach was selected for the implementation of this assessment, starting with the analyses and understating of the national -> regional -> local -> community nutrition situation, problems and priorities, leading then to identification of appropriate community based nutrition interventions.

More specifically, the approach included the following main steps:

1. Reviewing of existing data: The team started with the review of the existing background information and data on nutritional status of women and children in Albania and better understand and become familiar with current situation and main objectives of Government of Albania and partners agencies on nutrition and food security issues.

2. Identification of key partners: This step built on the results and findings of the previous step and involved meetings and interviews with several representatives of key national and regional institutions/organizations, aiming to identify more in details their roles and responsibilities, their involvement in planning and implementation of nutrition and food security programs, identify the key potential partners at each of the levels that would be necessary to be involved in further steps of the assessment and potentially later in the field implementation of the programme.

3. Data/information collection: (i) to assess the overall nutrition situation and needs of the target communities; (ii) to assess the capacities of key partners involved in the planning and implementation of community nutrition programs. In order to have a comprehensive information and a clear picture on the current nutrition situation in the target areas, and in order to be able design and undertake effective interventions in the future for the improvement of nutrition in these regions, the assessment team used a set of various instruments, including individual interviews and testimonials and focus group discussions using open-ended questionnaires. Focus groups have been held with three main target groups of stakeholders, as follows:

o Local authority actors , with stakeholders at regional level ( Qark ) and at local government level (communes/municipalities); o Local community , with community groups (families and family groups) and; o Civil society actors , including NGOs, associations, independent experts, etc.

A specific open-ended questionnaire per each stakeholder category was developed and Chapter: 1. Introduction used for collection of information and data during the focus group discussions and 14

Participatory Capacity and Needs Assessment

meetings held during this period. Besides the numerous individual meetings with representatives of various institutions, organizations and individual experts, 63 focus groups consisting of about 10-15 members each (or about 760 persons attending these focus groups) were held with the abovementioned stakeholders. The table below presents the distribution of focus groups according to the targeted regions.

Table 1. Number and distribution of focus groups held with key stakeholders Kukes Shkoder Tirana Total region region region Regional and local government level 8 7 3 18 Community level 14 12 4 30 Civil society actors 7 6 2 15 Total 29 25 9 63

The number of questionnaires per region was determined mainly based on number of communes/municipalities preselected for the assessment and on the importance of the nutrition and food security issues (resulting from the bibliographic review made during the first step of the assessment). These questionnaires focused mainly on the following:

o At the local authority level (regions & communes): (i) how do the local authorities perceive the nutrition situation in their territory; (ii) does local government have any plans and capacities to promote and implement interventions for the improvement of nutrition situation in their territory; (iii) what is the level of coordination between various actors/sectors at local level to analyze, orient, plan and implement interventions targeting nutrition issues in their territory; (iv) what are the major constraints in the current food security situation (food production and procurement), resources and opportunities for increase in quality and variety of food products and improve food security in their territory; etc.

o At the local community level (families and family groups) : (i) how much do community members know about nutrition concept, causes and effects (in particular related to children nutrition); (ii) what are the main potential, opportunities and necessary actions to increase the quality and variety of production at local level in order to improve their households’ nutrition and food security situation; (iii) which are the possibilities to introduce new and improved products and production approaches, technologies and system (in crop and livestock production, use of forest fruits and herbs, improved post-harvest and processing practices, etc.); (iv) which could be the most effective ways, tools and instruments to improve the level of information, knowledge and increase awareness on the nutrition and food security issues; etc. Chapter: 1. Introduction 15

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o At civil society level and independent experts : (i) what are the most important elements, tools, instruments that would need to changed, introduced or improved in order to improve the situation; (ii) which could be the most effective types instruments or interventions that would need to in the future; (iii) which could be the most active and efficient actors to be involved in the implementation of future interventions; (iv) which could be the most effective instruments to be used for improving the community information and awareness level on nutrition and food security issues; (v) which categories of products are most limited in the usual/traditional diet; (vi) what are the resources and opportunities available for improvement of the nutrition and food security situation within their territories; etc.

4. Data processing and analysis : The data collected through the interviews and focus groups consisted of mainly qualitative data. It’s processing and analysis was made mainly by use of standardized Excel data analyzing tools (formulas, PivotTables and PivotCharts). The use such tools for the qualitative data processing and analysis has passed through the five main steps, as follows: (i) data consolidation; (ii) identification of themes and patterns (ideas, concepts, behaviors, interactions, incidents, terminology or phrases used); (iii) identify linkages and organize of the data in various categories; (iv) assess the relative importance to each of the categories, scoring and identify relationships and dependences; and (v) synthetize and bring meaning to the text through the production and use of tables and figures. The data analysis and reporting is made by presenting the results according to the main assessment topics/issues and according to the three main categories of stakeholders. In addition, within each of the topic/issue, the analysis tends to show as clear as possible the differences between various regions and local communities.

In order to be able to analyze and present the data on comparative basis we have use a scoring system (3=high; 2=moderate; 1=low; 0=none ) for the main issues which was then used for presentations of these issues on radar charts. The scoring was done based on following approaches: (i) first during the discussions, participants in the meetings from local authorities, civil society actors and community were asked to assess the main issues raised based on their own judgment on the above scale from 3 to 0; (ii) the most important issues were scored independently by the various categories of actors (local authorities, civil society actors and community); (iii) during the processing of the information collected through the questionnaires, our experts assessed the frequency of repetition of a certain issue and allocated the respective score. This process in three independent steps allowed a triangulation approach and improved of the final results.

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2. MAIN FINDINGS OF THE STUDY

2.1. Overview of the study area

The study area included 15 local government units (LGUs) in three regions (7 in Kukes, 6 in Shkoder and 2 in Tirana). The targeted areas cover a total area of 1.430 Km 2 and have about 37.600 hectares of arable land. The 15 targeted LGUs have a population of about 153 thousand inhabitants and about 35,200 households. An important characteristic of these areas, especially in Kukes (Kukes, Has and Tropoja districts) and some of the areas in Shkodra regions (in the district Puka and Malesi e Madhe), is that the majority of their territory is highly mountainous, located in more than 600m of altitude and having a slope of more than 15%, which creates significant difficulties for the development of many agriculture production activities (especially crop production). The table below presents the main characteristics of targeted local government units.

Table 2. Main characteristics of the targeted study area Total Arable Population House holds % of Area % of Area Area land (according to (according to at >600m with >15% (in Km2) (in Ha) 2001 Census) 2001 Census) altitude slope Kuk es 826.17 12,478.60 29,738 6,387 Bicaj 79.28 1,179.10 7,022 1,516 37.89 61.92 Bujan 167.53 1,677.50 3,297 713 17.32 61.88 Golaj 167.13 3,396.50 1,649 269 25.36 44.87 Shishtavec 65.97 942.00 5,871 1,343 99.97 83.32 Topojan 80.21 960.60 3,561 578 99.86 91.55 Tropoje 228.95 3,834.20 5,381 1,300 34.87 65.94 Zapod 37.11 488.70 2,957 668 89.79 98.33 Shkode r 565.45 22,152.30 58,046 14,250 Bushat 81.68 5,689.50 17,185 4,232 - 3.11 Gruemire 106.52 5,410.20 9,796 2,454 0.09 13.92 Iballe 145.15 1,332.80 2,689 659 72.31 69.61 Kastrat 150.88 5,410.10 8,460 2,023 17.11 17.48 Puke 25.60 353.30 4,579 1,097 77.27 61.86 Rrethine 55.63 3,956.40 15,337 3,785 - 1.72 Tirana 37.69 3,005.80 65,498 14,555 Kame z 23.48 2,119.70 44,443 10,010 - 0.01 Paskuqan 14.21 886.10 21,055 4,545 - 9.01 Grand total 1,429.32 37,636.70 153,282 35,192

Source: INSTAT (for area and population); MADA 2011 (for altitude and slope) Chapter: 2. Mainof thefindings study

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The Kukes region has a total area of about 2,374 km2 organized in three districts (Kukes, Has and Tropoja), 3 municipalities and 24 communes. With its terrain going from 257m-2175m of altitude, it is considered as highly mountainous. The majority of the area is covered with forests and pastures (occupying about 156,140ha) while only about and 25,295ha are arable land (or only about 10% of total area of the region). The waterfront areas (lakes and reservoirs) occupy 8200 ha. The region has a population of about 111,393 in about 23,050 families, with a population density of about 47 inhabitants per square kilometer. About 80% of this population lives in rural areas and is directly linked to agriculture and livestock activities. The targeted area in this region includes 7 communes, with a total population of about 29,738 inhabitants and 6,387 households. Almost all these communes are highly mountainous with their majority of land located above 600m of altitude (especially Shishtavec, Zapod and Topojan have more than 90% of their territory above 600m), and with located in more than 15% slope.

The Shkodra region includes 3 districts (Shkodra, Puka and Malesia e Madhe), 5 municipalities and 29 communes. The region has a total area of 3,372 km 2 (of which about 68,560 ha are arable land) and a population of about 256,000 inhabitants and about 62,720 households (with a population density of about 76 inhabitants per km²). The highest density of the region is at the district of Shkodra with 94 inhabitants per km². The population living in rural areas varies from about 53.7% of the population in Shkodra district, to respectively 89% and 82% in Puke and Malesi e Madhe. About half of the territory of the region is situated in hilly and mountain areas with significant limitation in production of several agriculture products. The study area in this region consists of 5 communes and 1 municipality with a total area of about population of 565 km 2 and a total population of about 56,046 inhabitants (about 14,250 households). Within the targeted area, communes of Iballe (Puke), municipality of Puke and to some extent the commune of Kastrat (Malesi e Madhe) are the most mountainous areas, while the rest of the targeted area is flatter and has better agriculture production conditions.

The Region of Tirana includes Tirana and Kavaja districts and has a total area of about 1,586 km² and a total arable land area of about 55,497 ha. The population of this region reaches a number of 966,000 inhabitants (with a density of about 364 inhabitants per km²), living in about 233,230 households. About 75% of its population lives in urban and sub-urban areas while only about 25% in rural one. The study area in this region includes the Kamza municipality and the Paskuqan commune, representing about total area about 38 km2, (of which about 3,000 ha are arable land) and a total population of about 65,498 inhabitants living in about 14,556 households. Both of these local government units are considered as mainly urban and sub-urban area.

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2.2. Awareness and knowledge on food and nutrition security concepts

2.2.1. Level of knowledge of FNS concepts at local authority level

The highest level of knowledge and understanding on the subject was shows within the health sector specialists, most of which could make (during the interviews and focus group discussions) a dissent description of malnutrition and its causes and effects on the population. Scored in a level from 3 (high level of knowledge/understanding) to 0 (none), the health sector seems to reach an aggregated score of almost 2 (moderate level), with a higher knowledge and understanding of the subject at the regional level, possibly due to participation in recent training activities supported by the JPN, as compared to the local one. While the majority of participants from the three other sectors seem to have significantly lower level of knowledge and awareness on the subject, with social sector having an aggregated scoring of 1 out 3, education sector 0.93 and the lowest on being the agriculture sector with an aggregated score of 0.87 out of 3. The figures below present the aggregated scores for each key sector according to the targeted regions.

Figure 4. Aggregated scoring of key actors’ knowledge and understanding of key actors on malnutrition

Note: 3 (high level of knowledge/understanding); 2 (moderate); 1 (low); 0 (none) Chapter: 2. Mainof thefindings study 19

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Within the three regions, participants from the four key actors from Tirana seem to be more aware of and have a relatively higher level of knowledge and understanding of nutrition than their respective counterparts in the other regions. However, in the three regions, almost the same picture was identified, with the health sector being the most informed.

Table 3. The level of local authorities’ knowledge about concepts and components of food security and malnutrition Kukes Shkoder Tirana He Ag So Ed He Ag So Ed He Ag So Ed 1)Overall food security concept h m m m h m m m h m m m 2) Components of food security: 2.a) Food availability m m L m m m L m h m L m 2.b) Food accessibility L L m L L L m L L L m L 2.c) Food utilization m L L L h L L L h L L L 2.d) Stability L L L L L - L L L L L L 3) Overall concept of malnutrition h L L L h L L m h L L m 4) Types of malnutrition: 4.a) lack of proteins and energy h L L L h L L L h L L L 4.b) lack of vitamins and ------L - - - micronutrients 4.c) other issues (such as L - L - L - L - L L L - unbalanced feeding, obesity, etc) 5) Differences-Food security/Nutrition L - - - L - - - L - - - Legend: “He”-health sector; “Ag”-agriculture sector; “So”-social sector; “Ed”-education sector; “h”-high; “m”-medium; “L”-low; “-“ none or very low (insignificant)

The table above presents a summary of the major characteristics of the knowledge and understanding that regional and local authorities have about various components/aspects related to food security and malnutrition. As it may be seen from this table, the majority of sectors in the three regions have generally a much better knowledge and understanding about the overall concept of food security than of the malnutrition concept. Within the food security, most of the actors know better the food availability aspects, while almost all show a very limited understanding on issues related to the stability (of access and availability). In addition, often many of them have difficulties making the difference between the food availability and food accessibility.

The majority of the health specialists have a good overall understanding about both food security and malnutrition. Within the food security components they seem to know better issues related to food availability and food utilization than food accessibility and stability issues. When asked about the types of malnutrition, , they seem to have a high level of understanding of the overall malnutrition concept, and especially the type of malnutrition related to the lack of proteins, vitamins and energy. They define malnutrition with Chapter: 2. Mainof thefindings study expression such as “ not taking the main elements - carbohydrates, vitamins, fat and proteins {Gruemire, Shkoder} ”, “ taking too much of these elements {Bushat, Shkoder}” and “ having 20

Participatory Capacity and Needs Assessment

and unbalanced intake of these elements ”, “ lack necessary food items for a health body {Bicaj, Kukes} ”, “ eating but not feeding the body {Iballe, Shkoder} ”, etc. Most of key food elements were mentioned (however, none them mentioned the “ microelements ” as part of the necessary food intake. In certain cases, especially in Kukes and Shkoder, some of the health specialist (mostly from local level) linked the women and child malnutrition with their limited dressing and accommodation conditions and with the household assets. A nurse in Shkoder declared “a good nutrition for a future mother means not only a good feeding but also appropriate accommodation conditions, dessing, good health advice by the local nurses and doctors, etc”..

The three other sectors (agriculture, social and education) seem to have almost the same level (moderate) of knowledge and understanding about the overall food security concept. However they seem to differ about the understanding of components of the food security. While agriculture and education seem to know at moderate level the food availability issues (“ to have or produce enough food for the year {Shishtavec, Kukes}”, “secure the bread for the family {Zapod, Kukes}”, etc.) the social sector seems to reach that level on the food accessibility issues (“ensure money to buy additional food supply in the market {Kukes}”, “have the possibility to go to the market {Kukes}”, “a steady supply of food through the local shops {Shkoder}”, “have less food than is needed to feed the family members” {Iballe, Shkoder}”, etc.), most probably because their work is more linked with accessibility. As regards food utilization and stability aspects the three sectors show only a low level of knowledge (with Shkodra agriculture sector showing a very low/insignificant level).

As regards the malnutrition, the three sectors show a moderate to low level of knowledge. Most of them link malnutrition almost only to protein-energy deficiencies and a few cases to obesity, especially from the social sector (with no reference to micronutrient deficiencies). In addition, malnutrition is often broadly described as “ diseases” {Bicaj, Kukes}, “anemia” {Bujan, Kukes}, “lack of fat, proteins, calories” {Tropoje, Kukes}, “a poor food diet lacking main elements” {Kastrate, Shkoder}, etc. In Shkodra and Tirana, the level of awareness on obesity issues seems to be introduced. In this respect, a teacher in Shkodra declared that “even in the better-off families there problems with malnutrition of children, due to the lack of awareness and information of good nutrition practices they give children too much fast- foods and potato-chips (patatina), which are bad for their health ”.

When speaking about conceptual differences between nutrition and food security, with the exception of some of the participants from the health sector, the majority of the other participants seemed to have difficulties in stating the differences and tend to confuse and often equal the two concepts.

When asked about the knowledge on the effects of the malnutrition, a large number of participants from the local authorities seemed to have a general good understanding. Chapter: 2. Mainof thefindings study However they presented a general concern about the community awareness on the effects 21

Participatory Capacity and Needs Assessment

malnutrition. The main concerns in this regard seem to be represented by the following expressions: “most parents are not ware about how malnutrition affects the psycho-motor development of their children ”, “the population does not have sufficient information about malnutrition effects ”, “ access to information and medical services is difficult due to the remoteness and long geographical distances between families ” “ we need more information given in a simple way (reference is made to small brochure and leaflets) ”, “ most appropriate persons to inform population on malnutrition effects to children are health workers (particularly village nurses that meet more often mothers) and school teachers ”, etc. In addition, several representatives of the local authorities in Shkoder insisted that it is very important to distribute brief/simple documentary materials on child nutrition through schools, kindergartens, health centers and meetings with targeted parents presenting more food security and nutrition risks. The table below presents the key topics identified as important (according to authorities and regions) to be covered by any potential capacity building intervention to improve the awareness, knowledge and understanding on food security and nutrition issues at the level of local authorities.

Table 4. Main topics proposed to be covered by potential capacity building interventions at local authority level for improving knowledge on food security and nutrition concepts Kukes Shkoder Tirana Topics He Ag So Ed He Ag So Ed He Ag So Ed Knowledge on overall food security * ** ** ** * ** ** ** * ** ** ** concept Improving food availability (new types ** *** *** ** ** ** *** ** ** ** *** ** of local productions) Improving food accessibility *** *** ** *** *** *** ** *** *** *** ** *** Improving food utilization (better use of local products, improve diet * *** *** *** ** *** *** *** ** *** *** *** composition, new types of dishes, etc.) Improving food stability (post-harvest ** *** ** *** ** *** ** *** ** *** ** *** practices, conservation, etc.) Understanding types of malnutrition * *** *** *** * *** *** *** * *** *** ** Understanding differences-food ** *** *** *** ** *** *** *** ** *** *** *** security/nutrition Principles and practices of good ** *** *** *** ** *** *** *** ** *** *** *** nutrition Diet composition and food nutrients ** *** *** *** ** *** *** *** ** *** *** *** High nutritious food products *** *** *** *** *** *** *** *** *** *** *** *** Rapid assessment/identification of * *** ** *** ** *** ** *** ** *** ** ** food security issues Rapid assessment/identification of ** ** ** *** ** ** ** *** * ** ** ** nutrition issues Legend: “He”-health sector; “Ag”-agriculture sector; “So”-social sector; “Ed”-education sector; “***” identified as very important, “**” somewhat important, “*” less important, Chapter: 2. Mainof thefindings study 22

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2.2.2. Level of community knowledge on nutrition concepts

As shown in the figures below, the same general tendency seems to be valid also at the community level. Almost all community representatives in the three regions declared that nutrition is a very important element for the development and a healthy growth of their children. However, through the various discussions about nutrition issues, we come to the conclusion that most of the community participants (household representatives) in the focus groups know only moderately to low about the concept of the nutrition. However, many of them seem to confuse the composition of the diet composition with the quantity of food intake, while the majority of the community participants could not really distinguish differences between the nutrition and food security concepts.

Figure 5. Level of overall community awareness on nutrition issues

The table below presents a summary of the major characteristics of the knowledge and understanding that community seems to have about concepts and types of malnutrition. The majority of communities seem to have a relatively moderate understanding about the overall malnutrition concept, with four communities (Topojan, Kastrat, Gruemire and Iballe) presenting a low level and one (Zapod, Kukes) very low level of knowledge and understanding on the subject. However, almost all of them understand malnutrition only linked with the protein-energy deficiencies, while other types of malnutrition seem difficultly perceived from the respondents. Chapter: 2. Mainof thefindings study 23

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Table 5. The level of community knowledge about concept and types of malnutrition Kukes Shkoder Tirana

uke Shishtavec Topojan Zapod Bicaj Tropoje Vj. Bujan Golaj Kastrat Gruemira Rrethina Bushat Iballa P Kamez Paskuqan 1) Overall concept of m L vL m m m m L L m m L m mH mH malnutrition 2) Types of malnutrition: 2.a) limited use of food products rich in energy mL vL - m mL m mL L L m m vL m m m and proteins 2.b) limited use of food products rich in vitamins ------and micronutrient 2.c) use of unbalanced food (i.e. too much fat, vL - - L vL L vL - - L L - L L L carboihidrates, etc.,) 3) Differences-Food ------security/Nutrition Legend: “mH”-moderate to high; “m”-moderate; “mL”-moderate to low; “L”-low;

“vL”-very low; “-“ none

Few of the community participants from Kukes often referred to the nutrition with the food security-like expressions, such as “ I have secured the bread (or the food) for the winter ” {Zapod, Kukes}, “ being able to eating at your will ” {Shishtavec, Kukes}, “ lack of common (meaning basic) food item ” {Zapod, Kukes}, “ lack of the necessary quantity and quality of food for the family” {Bicaj, Kukes}, etc. In addition, a large majority of community participants seemed to confuse during the discussion the concepts of food content (in terms of nutrients) and overall food quality. The level of awareness, understanding and knowledge seems to be linked also with the remoteness of the area. Thus the lowest level was noticed in the communes of Zapod (Kukes) Iballe (Puke) followed by Shishtavec (Kukes), while the highest level was noticed in the commune of Bushat (Shkoder).

A better level of community understanding about nutrition was notices in urban and sub- urban areas of Kamez (Tirana) and in some of the Shkodra region (such as Bushat, Rrethina and Puka). Few of the community members from these areas that attended the focus groups mentioned the case of “children eating too much fast-food ” {Kamez, Tirane}, “eating unbalanced food (meaning unbalanced in content of nutrients)” {Bushat, Shkoder}, “eating mainly cereals, potato, bean and chees, especially during the winter” {Rrethina, Shkoder} “eating very limited quantities of fruits and vegetables ” {Puke, Shkoder} as malnutrition cases.

Chapter: 2. Mainof thefindings study 24

Participatory Capacity and Needs Assessment

When community participants were asked about “how important they think that malnutrition is for the children and women in their community”, the majority of them tend to agree that it remains a very important issue. The most representative expressions in this regard are “it is an important problem for our community” {Tropoje, Kukes}, “ it is important, our children are our future and need to be better cared ” {Bicaj, Kukes}, “ the problem concerns about 70% of our community ” {Kastrate, Shkoder}, “ several families do not take enough care about child and women nutrition, but it is very important as it has to do with their heath ” {Bushat, Shkoder}, etc. When asked about the effects of malnutrition most community representatives have only a broad understanding. The following are some of the most representative expressions in this regard: “ various diseases, loss of child weight ,” {Zapod, Kukes}, “ anemia, reduction of ability to work ” {Shishtavec, Kukes}, “ weak health situation , more family costs for health and thus more impoverishment ” {Kastrat, Shkoder}, “increase death prevalence, more health problems for the new generation” {Iballe, Shkoder}, etc.

The table below presents the key topics identified as important (according to communities) to be covered by any potential capacity building intervention to improve the awareness, knowledge and understanding on nutrition issues at the community level.

Table 6. Main topics proposed for interpersonal communication interventions at community level for improving knowledge on nutrition concepts Kukes Shkoder Tirana

Shishtavec Topojan Zapod Bicaj Tropoje Vj. Bujan Golaj Kastrat Gruemira Rrethina Bushat Iballa Puke Kamez Paskuqan Improving the overall concept and ** *** *** ** ** ** ** *** *** ** ** *** ** ** ** types of malnutrition Understanding differences-food ** *** *** ** ** ** ** *** *** ** ** *** ** ** ** security/nutrition Importance of micronutrient in *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** food intake Principles and practices of good *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** nutrition Diet composition *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** and food nutrients Improving food utilization (better use of local products, improve *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** diet composition, new types of dishes, ect.)

Legend: “***” identified as very important, “**” somewhat important, “*” less important, Chapter: 2. Mainof thefindings study 25

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2.3. Main factors of malnutrition and food insecurity

Local authorities : The key regional and local authority actors seem perceive and describe the main causes of food security and malnutrition within three main groups (ranked in order of importance as presented by the participants):

• factors related to overall community development level; • factors related to the level of community education and information ; and • other objective reasons not directly linked with the community but more with the overall social, economic and political environment.

The table below summarizes the main factors grouped according to the three main categories above and the main food security components.

Table 7. Main factors impacting food security and nutrition in the study area Community development Community education Other objective factors and information reasons

Food Availability

Difficult agroecological Production of traditional Lack of knowledge and conditions, limited farm products, tradition and inefficient use of local and poor quality land, inefficient production products; lack knowledge Local production high input prices, systems, limited productivity, and information on new limited access to credit aging agriculture labor potential products for investments {Kukes {Kukes and Shkoder} {especially in Kukes} and Shkoder} Limited market actors in Importing capacity remote rural areas

{especially Kukes} Lack of knowledge on Traditional and inefficient improved storing/stocking Limited access to storage and stocking Food stock practices (resulting on finance/credit for practices {Kukes and high seasonality of investments {all areas} Shkoder} available local products) Very limited and ineffective food aid Food aid distribution {especially

in remote communities of Kukes} Accessibility

Limited cash available to Limited bargaining Purchasing power procure additional food when power compared to

needed {all areas} food traders {all areas} Limited professional skills, Limited knowledge and lack of cooperation to information on potential Limited job improve access to markets markets for specific local opportunities, Incomes for their products {especially products to increase especially in rural areas in Kukes but also few areas incomes from sales {Kukes Shkoder} of Shkoder} {especially in Kukes} Limited market infrastructure Poor quality of rural

Market and transport and poor quality of rural infrastructure Chapter: 2. Mainof thefindings study infrastructure roads {especially in remote {especially in remote areas of Kukes} areas of Kukes} 26

Participatory Capacity and Needs Assessment

Stability

Limited knowledge and Lack of advice and capacity to adapt their support to adapt to Climate change production system to climate changes climate changes {Kukes and Shkoder} {especially in Shkoder} Limited capacity to reduce Limited knowledge on risk and benefit from how to reduce risk and Price changes seasonal price changes increase benefits from

(fluctuations) {Kukes and climate fluctuations Shkoder} {Kukes and Shkoder} Effectiveness of policies, support measures, economic Political factors aid and other public interventions {Kukes and Shkoder} Weak overall economic Limited non-agriculture environment and income generating activities, business development, Economic factors poverty level {especially in especially in rural areas Kukes and Shkoder} limiting economic opportunities {all areas} Stability

Use of traditional Food safety practices, not always safe

{all areas} Limited knowledge on Limited access to High losses due to traditional Food processing & improved post harvesting, information on and inefficient post handling practices handling and food improved technologies harvesting practices {Kukes and hygiene processing practices and credit for and Shkoder} {Kukes and Shkoder} investments {all areas} Limited knowledge on Poor quality of nutrition due Quality and variety improved food diet to use of traditional diets and of diet composition, seasonality cooking practices {all areas} of diet types {all areas}

Figure 6. Main causes of malnutrition as perceived by the local authority representatives

As we may see from the figure below, there may be identified various groups based on what representatives of local authority representatives see as main factors causing of malnutrition issues in their areas:

1. The most remote communes (Topojan, Zapod, Shishtavec and Iballe) where the three Chapter: 2. Mainof thefindings study groups of factors are considered as very important. In most of these households there seem to be: very limited food production due to difficult soil and agro-ecological 27

Participatory Capacity and Needs Assessment

conditions; limited farm size and poor quality of soil; limited knowledge on new and improved agriculture and food production techniques and technologies; limited types and varieties of food products used, and as a result; generally a very poor diet (especially during the winter);

2. The group of communes (Rrethina Figure 7. Main causes of malnutrition Tropoje e Vjeter, Paskuqan, Bujan according to three main groups factors, as and Gruemire) declaring the perceives by local authorities community development factors as highly important causes followed with moderate to low importance for other factors (especially the lifestyle and the traditional way of composing the usual dies);

3. The group of communes (Bushat, Kastrat, Kamez, Puke and Golaj), reasonably considering that (as they have relatively good agriculture and food production conditions) the objective reasons are only of low importance as causes of malnutrition in the areas while considering the community development and education and information factors as moderately important.

Local Community : At this level, analyzed according to the main food security component we distinguish the following tendencies:

• Food Availability : The three regions seem to correlate to the issues related to the local production issues and rank them as most important. Here they stress mainly “limited available farm land ”, “ limited productivity ”, “ limited access and use of inputs and improved technologies ”, “ use of traditional and inefficient production systems ” etc. Limited food production opportunities seems to be of a higher importance as cause of malnutrition household food insecurity risks in Kukes region and especially in remote areas. Despite the limited agriculture production conditions, even in remote areas (such as Shishtavec, Topojan, Zapod and Iballe) the majority of the community participants seem to put forward more issues linked to limited knowledge about nutrition. Food stock seems to more of a problem in Tirana as Chapter: 2. Mainof thefindings study compared to the two other regions. Food aid issues seem important especially for 28

Participatory Capacity and Needs Assessment

the remote areas of Kukes (Shishtavec, Zapod and Topojan) and the plain area of Shkodra (Bushat and Rrethina, which may be linked with the food situation that happened during the last years), while importing capacity (bringing food products to local area from abroad or other areas within the country) seem to be more important in the rural remote areas of Kukes (mainly due to the lack of traders going to these areas). While availability seems steadier in Tirana, seasonal availability is a major characteristic in almost all Kukes and Shkodra regions. “ We have difficulties to ensure sufficient food for the whole year” {Iballe, Shkoder} , “we have enough food products in harvesting season and often lack major food items in the winter ” {Gruemire, Shkoder}.

• Food Accessibility in the three areas seems to be linked mainly with the low incomes available and the limited purchasing power. The market and infrastructure factor seem to be more important for the remote rural areas of Kukes. This is especially important in Shishtavec, Zapod and Topojan. Few of them declare: “even when we have some money, out local shop has limited food items that we may buy, and they are very expensive due to the distance and the bad road ”. {Shishtavec, Kukes}, “ our trader is also poor like us so he has not the financial capacity to bring here a lot of food items, and they are usually of low quality ” {Iballe, Shkoder}.

• Food Stability: In the three regions, issues seem to be more linked with the economic factors (mainly due to the poverty, low local economic and business development situation, especially in Kukes) and price changes (mainly due to the limited, knowledge, information and capacity of the community to reduce risk and benefit from the price fluctuations. “We are poor and for sure we eat poor, even when we have we don’t know how to use it ” {Zapod, Kukes}, “we may produce only during a short production season and this is not enough to feed the family during the whole year” {Topojan, Kukes}, “ our incomes are not enough to buy additional food in the market, besides few things such as oil, sugar, salt, etc .”, {Gruemire, Shkoder}.

• Food utilization issues seem to be linked mainly with the limited capacities of the local community and use of traditional practices in processing and handling of food products and with the poor quality and limited variety of food diets used. The following expressions represent a sample of such concerns: “during the summer we have a lot of fruits which are spoiled of feed to animals and in the winter we don’t eat any of them” {Iballe, Shkoder}, “ even during the summer when we have more products we don’t know what is better for the children ” {Topojan, Kukes}, “ many mothers don’t know to prepare healthy food for their children even when they have enough food item at home ” (Gruemire, Shkoder}, “ often women are too engaged farm labor or caring for animals and don’t care enough for the quality of food in

terms of nutrition ” {Tropoje, Kukes}. Chapter: 2. Mainof thefindings study 29

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Figure 8. Main causes of malnutrition and food insecurity as perceives by community representatives according to the four main food security components

2.4. Local government capacities in dealing with FNS and coordination issues

The current role of the local government administration in dealing with the nutrition and food security issues remains very limited throughout the study area. As declared by the local governments represented met of those attending the focus group meeting, none of the local governments have nutrition or local food security management plans and none of them seems to have undertaken significant analysis of the on these issues (with the exception of the management and distribution of the social assistance payments).

When asked about their capacity to deal with issues like monitoring and reporting the food and nutrition security (FNS) situation in their territory and plan and management of FNS interventions, almost all local government representatives accord that their capacities are generally very low or not existent. The table below presents the results of the participatory weighting level of their declared capacities, by communes/municipalities and aggregated Chapter: 2. Mainof thefindings study average at the study areas. 30

Participatory Capacity and Needs Assessment

Figure 9. Weighted level of LG capacities to deal with FNS issues at their territory

Some experience and capacities in monitoring and reporting and management of FNS interventions seem to exist in the better off communes and municipalities (such as Kamez, Paskuqan, Puke, Bushat, Rrethina, Bujan, Tropoje e Vjeter and Bicaj) mainly due to the cooperation with any donor funded initiatives in their areas and the any demand for information from central institutions (mainly from Ministry of Health). However, only local government representatives from Bushat, Rrethina and Bicaj declared to have some capacities and little previous experience in planning food security interventions in this field (due to interventions in the context of few donor funded projects).

The coordination of efforts between various local authority actors seems to be a major issue in the three regions. The heath sector is almost the only local actor some better quality collecting data on nutrition (but still at operative level and not statistics) and reports them to the Ministry of Health. The agriculture sector collects operational data on production and sometimes about the imported food products and reports them to the Ministry of Agriculture. The social and education sectors seem not to be involved at all in any data collection of reporting related to food security and nutrition issues at local level. As various sectors (health and agriculture that collect some data) report directly to their respective ministries and the very low level of local coordination between the sectors, the information available to the local government remains very scarce.

The table below presents more in details issues identified regarding the actual capacities of local government to deal food and nutrition security.

Chapter: 2. Mainof thefindings study 31

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Table 8. The assessment of the current experience and capacities of LG (according to main identified capacity issues) Kukes Shkoder Tirana

Bicaj Puke Golaj Iballa Bujan Zapod Kamez Kamez Bushat Kastrat Topojan Rrethina Gruemira Paskuqan Tropoje Vj. Shishtavec

Knowledge and experience in planning • assessment of FS - - - vL - - - - - vL m - - - - situation • assessment of nutrition ------L - - - - situation • preparation of - - - vL - - - - - vL m - - m vL intervention plans Knowledge and experience in management • Implementation of - - - vL vL vL - - - vL vL - vL vL vL intervention plans • coordination of - - - L vL vL - vL L L H - L m L multidisciplinary teams • implementation of community based - - - vL - - - vL vL - m - vL vL - actions • implementation of FS - - - vL - vL - - vL - m - L L - actions • Implementation of ------vL - - - - nutrition actions Knowledge and experience in monitoring & reporting • collection of FS data ------vL vL L m - m L vL • collection of nutrition ------vL - vL vL - data • processing of FNS data ------vL - m - m m vL • preparation of reports vL - - vL vL vL vL - - H H - m m vL Legend: “H”- high; “m”-moderate; “L”-low; “vL”-very low; “-“none

When asked about what could be done to improve coordination and capacities to deal with food security and nutrition, the following recommendations seem to be the most often: • Improve cross-sectorial coordination between local actors in collection and exchange of information and development of joint action plans for improvement of the situation; • Determination of a local reference point (institution or person) to arrange for an effective coordination between actors (local and central ones). This experience exists in the areas that has emergencies (like flooding in Shkoder) and may be used to build more permanent and stable coordination mechanisms even in no-emergent situations; • Establishment of an office/structure within the local government administration to deal with food security and nutrition issues at local and community level; • The economic aid may be distributed in “food packages” for families that have difficulties of access to food, which may use also to condition an improved nutrition

for children and pregnant women; Chapter: 2. Mainof thefindings study 32

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• Implementation of pilot projects with schools and poor families in order to demonstrate to the local actors the best practices to improve food security and nutrition at targeted community level; • Organize seminars and training workshops for improvement of capacities of local government specialists on food security and nutrition concepts, approaches and mechanisms to deal with it. The main subject of such training, as proposed by participants, include: o Improving technical knowledge and information on: principles of good nutrition; types of products with higher content of nutrients; ratios between carbohydrates, proteins, vitamins, micronutrients, etc.; alternative foods that could be used, etc.; o Improving planning of interventions : preparation annual plans for ensuring community food security; improving local food production; proportion of non-agriculture income generating activities; establishment and management of local and community food stocks; assessment, monitoring and reporting of food security and nutrition situation; etc.

2.5. Opportunities to increase food availability

2.5.1. Perceptions of local authorities on food availability opportunities

The majority of participants in the meetings declared that most of the areas have opportunities to increase the production and availability of food products within their territory. The existing opportunities (as declared by the participants) to increase food availability may be grouped as follows:

• Improving post harvesting, handling and processing technologies and practices has been identified as the most important opportunity in short-medium term to improve the nutrition. Reducing the losses of significant quantities of production (as a result of mismanagement and lack of post harvesting technologies) and introduction of small- scale processing technologies and practices will significantly contribute to increased food availability at the household level;

• Improving local production : Most households are producing mainly a limited number of traditional types of food products in their farms. Despite the current difficult soil and agro-ecological condition in some of the highly mountainous areas, there are possibilities to: introduce new types of production (especially new fruits and vegetables); improve yield and productivity; improve technical knowledge; improve farm specialization and

efficiency by improving production technologies, seeds, inputs’ use and cultivation Chapter: 2. Mainof thefindings study 33

Participatory Capacity and Needs Assessment

practices. In addition there are possibilities to better exploit the forest fruits (i.e. blueberries, blackberries and herbs) for home consumption.

• In addition, as yields for most of cultivated crops are still relatively low, there possibilities to significantly increase the quantity of production of the current crops and livestock through introduction of improved techniques, practices and technologies.

Figure 10. Importance of main groups of opportunities to increase food production

While all regions have stressed the opportunities to improve post harvesting practices (especially processing and conservation of products), the level of perceived opportunities to increase the quantity and types of products varies is also high especially Bushat, Gruemire, Golaj, followed by a moderate level in comes of Kastrat, Bujan, Bicaj and Tropoje e Vjeter. More limited opportunities to increase production seem to be perceived in Shishtavec, Topojan, Zapod and Iballe, due to the highly mountainous terrain and more difficult agro- ecological conditions, and in the urban and sub-urban areas of Kamez, Bushat and Puka, these opportunities are limited mainly due to the limited availability of arable land.

2.5.2. Perceptions of communities on food availability opportunities

When asked about the most common types of food they usually consume, the majority of community representatives seem to account about staple food (mainly cereals, beans and Chapter: 2. Mainof thefindings study 34

Participatory Capacity and Needs Assessment

potatoes) and dairy products (“ we don’t have the luxury to select food items, we eat what we have ” {Shishtavec, Kukes}).

In general there is little differentiation in Figure 11. Main mission/limited food feeding within the family members between components in the usual diet adults, children and women (with the exception of pregnant women in some cases): “ even if we want to differentiate, our conditions don’t allow us to do as we may not produce everything needed ourselves ” {Rrethina, Shkoder}, “ we don’t have money to buy the other things needed for a good nutrition ” {Bicaj, Kukes}, “ we don’t have tradition in differentiating family members and we don’t know how to do it without being seen as discriminating the others ” {Gruemire, Shkoder}, “ the only time when I heard about the need of differentiating pregnant women and children was at the local doctor, seems good but is difficult to do in practice ” {Dobrac, Shkoder}.

When asked about what types of food products a family should normally consume, most of them mention the full range of products (cereals, beans, meat, vegetables, fruits, dairy and fish). As regards the possibility of improving the availability of these products, the majority of them declare that the current economic conditions don’t allow them, or they link it with the agro- ecological conditions. When discussing more in details about the local possibilities of production and processing of some additional products, results that most women have a general good knowledge, especially in small-scale home processing (pickles, dried meat, dried fruits, etc. The figures below present the community perceptions about the possibilities of producing and consuming more products at local level.

Chapter: 2. Mainof thefindings study 35

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Figure 12. Possibilities for more fruits, vegetables, forest fruits and hers (by regions)

Figure 13. Opportunities to increase food Figure 14. Possibilities for more fruits, production vegetables, forest fruits and herbs

A woman in Kukes (from Shishtavec Commune) declared “ It’s true that we have very little arable land area in our farms and our production is really limited, but we also spoil and misuse a lot of products. At harvesting season, a lot of fruits are rotten or feed to animals as we do not manage to them and they are very little to send them to the market. I guess something can be done with them but besides jam. I don’t know how else I may use them for improving my children’s nutrition ”. “W e have a good tradition in dried meat and fruits but produce these products in very small quantities as we don’t have appropriate equipment and tools ” {Bicaj, Kukes}, “ we do some vegetable processing based on traditional knowledge and in primitive technologies” {Bushat, Shkoder}. Chapter: 2. Mainof thefindings study 36

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However, if developed, these products may contribute towards improving availability to food during the off-season consumption (especially during the winter).

Other community participants in the focus group meetings described the issue with sentences such as “ we eat almost the same things during all year along, mostly things that we produce in our little farms such as bread, beans, potatoes and dairy products”, “we see fruits and vegetables in out diet only during the harvesting season (late summer and early autumn)”, “the winter diet is almost only base on main staple food item”, etc.

2.6. Community opinions on food security and nutrition interventions

The main categories of intervention proposed by the community participants for improving food security at household and community level include (in order of importance):

• introduction of improved production, processing and conservation tools, instruments and inputs at farm level; • introduction of production and processing technology packages, including introduction where possible of the year-round production system; • provision of training, advice and technology assistance to the producers; and • preparation and distribution of brochures, leaflets on new and improved ways and methods of production, processing and conservation of local products;

The table below presents the weighted importance of the above-mentioned categories of interventions as perceived by the local community representatives. Chapter: 2. Mainof thefindings study 37

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Figure 15. Main categories of Figure 16. Main categories of interventions interventions to improve food security to improve food security proposed by proposed by communities (by region) community

The civil society representatives that attended the focus group discussions seem to accord with the proposals that come from the community members.

Figure 17. Main categories of interventions proposal by civil society members

They also favor at a large extend the support for the development of the small-scale agro- processing and introduction of year-round cultivation system. However, many of the civil Chapter: 2. Mainof thefindings study 38

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society members insist also in the promotion and support for the development efficient of business models and the overall households economic activities.

In this context, the development of the non-agriculture rural economic activities is considered as an important source of income, thus improving food security especially for households which have limited food production opportunities such as the urban and sun- urban areas (Kamez and Paskuqan). For the later, the promotion of urban agriculture practices may be an important source of households’ food security improvement.

2.7. Improving local capacities

Almost equally in the three study regions, the majority of the civil society members and individual experts represented in the meetings, tend to accord that in order to improve the situation of the nutrition, one of the first thing that should change is the way how the local government deals with the nutrition issues. This is followed by introduction of more effective ways/methods to inform the community in nutrition issues and the introduce improvements in the traditional nutrition practices and habits.

Figure 18. What should change to Figure 19. Most effective interventions improve the local nutrition situation? proposed to improve capacities and nutrition situation

Organization of direct meetings with the targeted community members is declared to be the most preferred and considered by the civil society and community members as one of the most effective instruments in informing the community about nutrition issues.

These meetings should be continues and not only based in quick campaigns. In order to this, the responsibility should not be left only to the health sector, but a large number of actors is proposed to be involved, including, local government administration, agriculture specialists, Chapter: 2. Mainof thefindings study local NGOs, etc. 39

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Figure 20. Potential categories off actors to be involved in public information about nutrition

Chapter: 2. Mainof thefindings study 40

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3. CONCLUSIONS AND RECOMMENDATIONS

Key conclusions : Based on the findings and results of this assessment we would like conclude by stressing few important points that we this are important in the preparation and implementation of future interventions for improving food security and nutrition in the targeted area:

• The overall level of awareness, knowledge and information of key regional and local authority actors about nutrition issues (nutrition in general and especially related to children and women) remain generally low, both at the regional and local level.

• Although the local government administration should be a very important actor for the promotion of the local development, its current role in dealing with the nutrition and food security issues remains very limited throughout the study area.

• The main identified causes of malnutrition are linked with: (i) Community development factors, mainly linked to the lifestyle and tradition; (ii) the level of community education and information; and (iii) objective reasons mainly linked to limited agriculture production and productivity, limited incomes, etc.

• The majority of the targeted areas have significant opportunities to increase the production and availability of food products within their territory, which are still unused and/or unexploited due to the lack of capacities of the local actors and of the population to transform them into goods for the betterment of the living conditions.

• The exploitation of these existing opportunities for improving food security and nutrition may be reached through well targeted interventions focusing mainly on: (i) improving post harvesting, handling and processing tools, technologies and practices; (ii) introducing new types of productions and food products, and; (iii) increasing the quantity of production of the current crops and livestock. In addition, these interventions be accompanied by information, trainings, advice and technical assistance to the producers (on food security strategies and practices) and consumers (on nutrition issues).

• Improving the capacities of the local actors (especially local government) to plan, monitor, report and implement nutrition and food security interventions, improvement of coordination of actions between these actors and the improvement of community information and knowledge are three very important challenges for the improvement of the nutrition situation in all targeted areas. Chapter:and 3. Conclusions recommendations

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Key recommendations : On the basis we recommend that the potential future interventions for the improvement of the food security and nutrition in this area should be along the following lines:

• Rising the awareness and improving the capacities of regional and local actors on roles and responsibilities of each of the sector related to food security and nutrition issues, causes and effects of malnutrition to the population, planning, implementation and monitoring of food security nutrition interventions;

• Support the local governments in preparation and implementation, on participatory basis, of food security and nutrition management plans for the 15 targeted commune and municipality;

• Raise awareness within with teachers, students and parents at all schools and introduce of food security and nutrition as well as knowledge about the local resources as a subject at school education for children;

• Facilitate the process of better valorization of local resources by the local community in favor of improvement of nutrition and local economic development in the area (working with different community groups and local stakeholders;

• Promote and facilitate an active participation of the community (and especially the most marginalized of families) in economic activities, fostering food production and processing, economic diversification and thus improving chances for improved food security and nutrition;

• Test and demonstrate new and improved agriculture and food production technologies, tools and practices, including introduction of new types of crops (especially fruits and vegetables) improved input use practices, etc., in order to improve household food diet;

• Provide technical assistance, advice and accompany the new initiatives enough long in time so to ensure their sustainability and, take-up and replication of best business models;

• Promote and facilitate cooperation and coordination between different local actors and community members in tackling and resolving various issues that may arise during the implementation of the food security and nutrition interventions.

Chapter:and 3. Conclusions recommendations 42

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4. ANNEXES

Annex 1. Details of proposed interventions

MAIN COMPONENTS

Based on the findings of this assessment we propose the below scheme of possible interventions for the improvement of the situation, which lies in three main components:

1. Capacity Building with Local Actors and LGUs

2. Community awareness raising and formation 3. Community based interventions through investments of formative character. In this context, the components include:

Component 1: CAPACITY BUILDING with local actors and lGUs

1. LOCAL ACTORS AT REGIONAL LEVEL (i) Joint Capacity Building Session (all sectors) Joint training sessions and on-the-job session trainings with the personnel of the health, social assistance and agriculture sectors, focusing on the drafting of the “Nutrition Management Action Plan at Regional Level”, in full coordination between sectors Health, Social Assistance, Agriculture.

(ii) Health personnel at Regional Level (ToT with the personnel operating at communes level)

Being that the health personnel is dependent of the Regional Directories, the updating/training sessions are proposed for the health personnel operating at commune level: family doctors, nurses, midwifes, with the aim to prepare them as Community Trainers (ToT) and to train/update them with the most recent working methodology to deal with the problems of:

• Malnutrition and its effects;

• Basic elements for a healthy nutrition at family bases.

(iii) Social Assistance personnel at Regional Level (involving also the social assistance Chapter: 4. Annexes personnel operating at communes level) 43

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According to the study carried out, the Sector of Social Protection (Assistance), results to be very indifferent, not well informed and not actively involved in the management of malnutrition problems in the target areas, although it should be the primary sector to get involved in the solution/alleviation of the poverty problems and consequently also of the malnutrition ones. Aiming to the improvement of practices in the future, building of capacities of the personnel of this sector and in order to engage them seriously in the management of nutrition at communes’ level, we consider that the involvement of the personnel of the social protection (assistance) sector in mirrored training sessions is of crucial importance. The subjects to be dealt during the training sessions with the social protection personnel could focus on:

• How to have a clear picture on the current nutrition situation in their territory for those categories suffering malnutrition, and how can they plan the opportune interventions for the situation improvement.

• Which are the possible alternatives of social protection (social assistance) including nutrition elements, that could be offered to the extreme poverty category.

• Kindergartens and schools, as practical models of services to offer in favor of the children’s healthy nutrition, and to serve also as focal points for the training (formation) of the parents and community. In this context, every Commune, under the assistance of the social worker, will have to try and aim to create (activate) such practical model (pilot kindergarten/schools), where the social assistance sector will be actively engaged and involved for the successful management of these pilots and at the same time will work with the community and with the parents for the dissemination of the healthy nutrition practices and notions. The trainings delivered, will help the social protection personnel, both at regional and communes level, to be actively involved and professional in dealing with the poverty and malnutrition issues and problems.

2. AT COMMUNES’ ADMINISTRATION LEVEL (sectors’ specialists) The capacity building process with the personnel (sector’s specialists and officials) could be organized like on-the-job trainings, focusing on the “Drafting and definition of the Nutrition Management Local Action Plan in the 15 Communes involved in the project”. The drafting and definition of the Communes Nutrition Management Action Plan will be the result of training and capacity building process with the communes’ administration Chapter: 4. Annexes (officials/specialists), during which will be dealt issues like: 44

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• Approaches to implement food security and nutrition assessments at community level;

• Local participatory planning of food and nutrition security for communities/families within their territory;

• Improving food supply opportunities within the territory (through improving local food production supply chain) and through the market outlets;

• Better exploitation of local food production and procuring resources and opportunities;

• Ensuring food stock (storage) for the winter period and in emergency cases;

• Monitoring and reporting the nutrition situation, with the respective sector’s responsibilities, including periodical reviews and analyses at the Commune Council level about the food and nutrition security situation in their territory;

• The coordination among local authority actors intervening within a certain local government unit on various aspects of food and nutrition management in their territory;

• Basic elements of the ‘Nutrition Management Action Plan’ at local level. The result of the training/capacity building process with the communes’ administrations will be the drafting and development of the Local Action Plan for the management of nutrition situation at every commune involved in the project.

Component 2: COMMUNITY AWARENESS RAISING AND TRAINING

Target of this component will be the below groups:

• Teachers and Parents : In all the 9-grade schools in the target communes, should implement at least once per year an informative training (workshop) session, dealing with the subject “ What are the malnutrition effects (consequences), the basic standard for a healthy nutrition in the family and family members nutrition practices ”. These seminars could be organized and implemented in cooperation with the health personnel trained/updated at regional level, playing the role of community trainers.

• Teachers and students/pupils : In all 9-grade schools, working with the teachers of the subject “ Vendlindja ” or “ Geography ”, where in the education program or in specific teaching hours, to integrate (include) topics like: “ Introducing the students Chapter: 4. Annexes with the local products and practical work to make them familiar with the local 45

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resources and alternatives of their exploitation (forest fruits, tea, medicinal herbs, blackberries, raspberry, strawberries, etc.) for a healthy nutrition ”. These workshops and seminars would need to be accompaigned with leaflets or broshures of practical use and their distribution also in community.

• Health Centers and Community :

o Organization of informative and training sessions by the health centers (the territorial health personnel) with the women in the villages, dealing with subjects like: (i) the standard of family nutrition (feeding) and the malnutrition consequences; (ii) feeding culture in the family and the care/attention towards nutrition of children and pregnant women.

o Formation activities of practical character with the groups of women in villages at every commune, where to implement practical cooking demonstrations containing diversity of products and out of the traditional way of methods.

o Production and dissemination of didactic materials on nutrition and diversity of family nutrition.

Component 3: COMMUNITY BASED PILOT DEMONSTRATIONS

This component aims to introduce, test and demonstrate practical and feasible models that have a direct impact on improving food and nutrition security situation for the population in the target areas. The creation of these pilot demonstrations would aims to:

• Activate the local resources and opportunities of the targeted areas having an impact in the improvement of the nutrition situation;

• Improve the local food supply chains (from production to processing and marketing) having an impact on food availability and accessibility;

• Introduce practical models of efficient exploitation of local opportunities to increase the range/diversity of food products available and assessable for a healthy nutrition;

• Improve families’ food preparation and cooking skills and knowledge to ensure food and nutrition secirty using locally available products.

• Promote establishment of efficient farming models and non-agriculture income generating activities in rural families, as opportunities to insure increased incomes, increased purchasing power and thus improved food accessibility.

Indicative pilot demonstration topics could be: Chapter: 4. Annexes 46

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1. Transformation of local resources (forest fruits, various teas and herbs, strawberries, blackberries, raspberries, etc) into feeding and curative products for the population.

• Establish nr.X pilot demonstration models. Main types of investments proposed: processing technology; working tools; experience sharing/exchange; promotion dissemination materials; technical assistance / accompaniment.

2. Agriculture and livestock products processing methodology, as an opportunity of nutrition diversification.

• Establish nr.X pilot demonstration models. Main types of investments proposed: processing technology; working tools; experience sharing/exchange; promotion/dissemination materials; technical assistance/accompaniment.

3. Build-up the family garden food products supply chain (conveyor) for the family feeding needs and market supply.

• Establish nr.X pilot demonstration models. Main types of investments proposed: working tools (greenhouses, seeds, inputs, etc); experience sharing/ exchange ; promotion/dissemination materials; technical assistance/accompaniment. 4. Promoting / incentivizing the income generating activities, to assure/improve the supply with supplementary products

• Establish nr.X pilot demonstration models. Main types of investments proposed: as sistance for the business plan preparation; support through financial schemes (grant combined with credit) for small scale business activities; accompaigning and monitoring the businesses start-up and consolidation; experience sharing/exchange.

Chapter: 4. Annexes 47

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Annex 2. Aditional tables

1. The level of local authorities’ knowledge in Kukes about concepts and components of food security and malnutrition Health Agriculture Social Education

sector sector sector sector 1)Overall food security concept 2) Components of food security: 2.a) Food availability 2.b) Food accessibility 2.c) Food utilization 2.d) Stability 3) Overall concept of malnutrition 4) Types of malnutrition: 4.a) lack of proteins and energy 4.b) lack of vitamins and micronutrients 4.c) other issues (such as unbalanced

feeding, obesity, etc) 5) Differences-Food security/Nutrition Legend: - high or medium; - low; - none or very low (insignificant)

2. The level of local authorities’ knowledge in Shkoder about concepts and components of food security and malnutrition Health Agriculture Social Education

sector sector sector sector 1)Overall food security concept 2) Components of food security: 2.a) Food availability 2.b) Food accessibility 2.c) Food utilization 2.d) Stability 3) Overall concept of malnutrition 4) Types of malnutrition: 4.a) lack of proteins and energy 4.b) lack of vitamins and micronutrients 4.c) other issues (such as unbalanced

feeding, obesity, etc) 5) Differences-Food security/Nutrition Legend: - high or medium; - low; - none or very low (insignificant) Chapter: 4. Annexes 48

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3. The level of local authorities’ knowledge in Tirana about concepts and components of food security and malnutrition Health Agriculture Social Education

sector sector sector sector 1)Overall food security concept 2) Components of food security: 2.a) Food availability 2.b) Food accessibility 2.c) Food utilization 2.d) Stability 3) Overall concept of malnutrition 4) Types of malnutrition: 4.a) lack of proteins and energy 4.b) lack of vitamins and micronutrients 4.c) other issues (such as unbalanced

feeding, obesity, etc) 5) Differences-Food security/Nutrition Legend: - high or medium; - low; - none or very low (insignificant)

4. The level of community knowledge about concept and types of malnutrition in Kukes region

Shishtavec Topojan Zapod Bicaj Tropoje Vj. Bujan Golaj Kastrat 1) Overall concept of malnutrition 2) Types of malnutrition: 2.a) limited use of food products rich in energy and

proteins 2.b) limited use of food products rich in vitamins and

micronutrient 2.c) use of unbalanced food (i.e. too much fat,

carboihidrates, etc.,) 3) Differences-Food security/Nutrition Legend: -moderate to high; -moderate to low; -low; -very low; -none Chapter: 4. Annexes 49

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5. The level of community knowledge about concept and types of malnutrition in Shkoder region

Gruemira Rrethina Bushat Iballa Puke 1) Overall concept of malnutrition 2) Types of malnutrition: 2.a) limited use of food products rich in energy and proteins 2.b) limited use of food products rich in vitamins and micronutrient 2.c) use of unbalanced food (i.e. too much fat, carboihidrates, etc.,) 3) Differences-Food security/Nutrition Legend: -moderate to high; -moderate to low; -low; -very low; -none

6. The level of community knowledge about concept and types of malnutrition in Tirana region

Kamez Paskuqan 1) Overall concept of malnutrition 2) Types of malnutrition: 2.a) limited use of food products rich in energy and proteins 2.b) limited use of food products rich in vitamins and micronutrient 2.c) use of unbalanced food (i.e. too much fat, carboihidrates, etc.,) 3) Differences-Food security/Nutrition Legend: -moderate to high; -moderate to low; -low; -very low; -none

Chapter: 4. Annexes 50