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K. Tontisirin, G. Attig, P. Winichagoon and J. Yhoung-Aree

Prof. Dr Kraisid Tontisirin is Director of the Institute of Nutrition, Mahidol University (INMU), Thailand. George A. Attig is an INMU consultant. Dr Pattanee Winichagoon is head of INMU’s Division of Community Nutrition. Jintana Yhoung-Aree is an INMU researcher.

Most South and East Asian countries still encounter problems of under-nutrition, of which the most common and persistent are protein-energy malnutrition (PEM) and vitamin A, iron and iodine deficiencies, Infants and children under five and pregnant and lactating women are the most vulnerable people, especially those living in poor rural areas and urban slums.

Compounding nutrition problems is the fact that several South and East Asian societies are entering a transitional stage in their development. This transition involves shifts in the population structure; changes in disease patterns (from infectious to chronic degenerative diseases); socio-economic transformation from fully subsistent to semi-subsistent, market-oriented economies; and an advance from struggling for child survival to aiming for development of full growth potential. Furthermore, contradictory problems such as under- and over-nutrition exist in the region and must often be dealt with in the same country.

To highlight the importance of creating nutritional awareness among populations through nutrition education and communication, FAO sponsored the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, organized by and held at the Institute of Nutrition at Mahidol University, Salaya, Thailand from 22 to 26 February 1993. Nutritionists. communicators. agriculturists and public health officials came from Bangladesh, China, Laos, Nepal, the Philippines, Sri Lanka, Thailand and Viet Nam to exchange information and discuss effective education and communication strategies in order to benefit from each other’s experiences in implementing local and nationwide programmes. In planning the workshop, it was realized that in terms of programme development these South and East Asian countries can be divided broadly into two groups. China, the Philippines and Thailand have successfully developed and operated nutrition education programmes for the public to control and prevent malnutrition; Bangladesh, Laos, Nl, Sri Lanka and Viet Nam have not yet developed such programmes successfully at the national level. The workshop’s concept rested on using the expertise available in the first group of countries to assist in the preparation of national project proposals for the second group, in the true spirit of FAO’s concept of Technical Cooperation among Developing Countries (TCDC).

The workshop opened with presentations on the countries’ efforts to combat nutrition problems through nutrition education strategies. The merits and limitations of current methods were assessed and ways of making the methods more effective were discussed. Case-studies of successful programmes in Thailand, China and the Philippines were presented. The teams from the second group of countries then prepared nutrition education project proposals and the group provided suggestions to improve them. In addition, the work and needs of the institutions that implement nutrition education programmes in each country were discussed, and specific forms of intercountry collaboration were developed so that resources can be shared between nations and specialists.

COUNTRY SITUATIONS

Bangladesh

In 1991, Bangladesh had a population of 109 million people, with an annual population growth rate of 2.17 percent. In this densely populated country, approximately 83 percent of the people were living in rural areas. Life expectancy was 56,4 years for males and 54.4 years for females. The infant mortality rate (IMR) was 110 per 1000 live births and the under-five mortality rate was 180 per 1000, while the maternal mortality rate was 6 per 1000 births. The literacy rate was 29 percent and 19 percent for males and females, respectively.

Bangladesh’s major nutritional problems include chronic energy deficiency, PEM, maternal malnutrition, low birth weight, vitamin A deficiency, iron deficiency anaemia, iodine deficiency disorders (IDD) and deficiencies of other micronutrients such as riboflavin, vitamin C and zinc, The major causes of the nutritional disorders can be listed as inadequate supplies and/or intake of micronutrient-rich foods; lack of nutritional awareness; low production and purchasing power; inadequate household food security; inequitable food distribution within families; traditional food beliefs; and inappropriate infant feeding practices (e.g. bottle feeding, colostrum discarding).

Despite obstacles and the lack of a nutrition education policy, important nutrition education work has been carried out. In agriculture, nutrition education has been a component in a marginal-farming and small-farm system, crop intensification and diversification programmes, horticultural development, strengthened nutrition research, sessions for training trainers and field demonstrations. The Ministry of Health and Family Welfare has programmes for nutrition education, feeding malnourished children, vitamin A capsule distribution, growth monitoring, iron and folic acid supplementation for pregnant women, extended programme of immunization (EPI) activities, treatment of minor illnesses, antenatal care and family planning. The Ministry of Women’s Affairs and Social Welfare offers training for enhancing nutrition and socio-economic development, vitamin A capsule distribution, nutrition awareness-raising programmes and day care services for children of working women. Plans to conduct radio and television programmes on health, family planning and nutrition are under way in the Ministry of Information. In addition, 117 non-governmental organizations (NGOs) are involved in community nutrition programmes, some of which deal with nutrition education.

While people with knowledge of nutrition education are available for activities, there are constraints including lack of strong political and administrative commitment; inadequate integration of nutrition into the nation’s overall development plan; poor intersectoral coordination, monitoring and evaluation; and insufficient budgetary resources. Capacity to produce audiovisual aids and training materials, access to media services and personnel development and exchange of scientists with other nations are limited. Technical assistance is required for provision of training inputs, equipment, transport and maintenance. Personnel development facilities are also needed, especially for advanced training and education. Increased facilities are needed for infrastructure development.

Laos

Laos has a small, sparsely settled population of 3.94 million people, of whom 43.7 percent are under 14 years of age. The nation’s economy is dependent on agriculture and forestry, and 85 percent of the people live in rural areas. Life expectancy rates are 47.5 years for females and 44.6 years for males. The IMR was 104 per 1 000 live births in 1990, and the under-five mortality rate was 193 per 1 000 in 1985. Malaria, acute respiratory infections and diarrheal diseases are the top three causes of morbidity and mortality among infants and small children. The adult literacy rate is estimated to be 44 percent.

Laotian households are largely dependent on rice and horticultural products, which provide a daily dietary intake of approximately 1745 to 1976 calories, or about 70 to 80 percent of the recommended requirement. Protein requirements cannot be met through farming alone; hence almost every rural household is involved in gardening and/or hunting. Markets are not common sources of food.

Nutrition surveys in Laos are limited and confined to small-scale studies. They show, however, that the major problems are low birth weight, PEM in preschool children (0 to 60 months), IDD, vitamin A deficiency, vitamin B, and B2 deficiencies, nutritional anaemia and bladder stone disease. To combat these problems, nutrition activities such as anthropometry and nutrition education are being conducted in provincial hospitals and Vientiane Municipality.

Led by the Lao Women’s Union, the Ministries of Public Health, Agriculture and Forestry, and Education are working together to disseminate nutrition messages to the population. The government has set objectives for 1992 to 1996 to reduce low birth weight to less than 20 percent, lower moderate malnutrition to less than 20 percent and lower severe malnutrition to less than 1 percent. For micronutrients, the objectives are to reduce iron deficiency anaemia in women to less than 20 percent; to reduce IDD in terms of the goitre rate among schoolchildren to 15 percent; and to reduce xerophthalmia to less than 1 percent or, in preschool children with less than 10 mg of serum retinol, to 10 percent. Another goal is for 50 percent of mothers to breast-feed exclusively for the first four to six months. Most women should be able to continue breast-feeding, with complementary food, well into the child’s second year. Growth promotion will be institutionalized and monitored regularly in 50 percent of the villages, with 80 percent coverage of preschool children. Finally, nutrition messages will be disseminated to 50 percent of villages.

The constraints to attaining these objectives include a limited number of trained workers. Furthermore, those who have nutrition training usually have other responsibilities. The quality of printed materials is poor, and access to newspapers, magazines and other technical handbooks is restricted to urban areas, generally because of low interest and poor communication. Budget constraints prevent regular health and education sessions, and programmes lack appropriate equipment, transportation facilities and financial support.

Training of trainers in health and nutrition education is needed, including instruction in the use of audiovisual and other educational materials. Equipment for audiovisual aids and production of radio and television programmes needs upgrading. Financial support is required for production of printed materials and simplified handbooks and for community outreach programmes. Finally, short-term fellowships, study tours and fora for exchange of experiences would improve the capabilities of nutrition education personnel in Laos.

Nepal

In 1990, Nepal had a population of 19,1 million, of which 3.1 million were under age five. The IMR was 123 per 1000 live births in 1990, and life expectancy at birth was 52 years. Approximately 35 percent of the Nepalese people are literate, though a disparity exists, with men showing higher literacy rates than women.

Present assessments of Nepal’s nutrition situation are based on data from the 1975 National Nutritional Status Survey as well as recent and ad hoc studies. Over 50 percent of children are undernourished, and PEM and micronutrient deficiencies (vitamin A, iron, iodine) are prevalent at very high levels in parts of the country.

The most significant cause of nutritional problems is poor dietary intake. Inadequate food supplies, health services, awareness, water supplies, sanitation facilities, food hygiene and child care, as well as population growth, improper feeding practices, traditional food beliefs and other social and economic constraints, contribute to nutritional problems. These problems stem from inequitable distribution of resources and poverty.

The Nepalese government has created a large cadre of teachers and field workers and strong extension networks in agriculture, health, education and development which conduct many nutrition-related activities. Nutrition education efforts employ both interpersonal and media (radio, television, print) programmes.1

1 Editor’s note: See the article “Building Nepal’s capacity to create nutritional awareness through multisectoral training” by D. Shrestha and M.A. Hussain in Food, Nutrition and Agriculture, 7:34-40, 1993.

Many NGOs, international organizations and international development agencies are active in development communications; however, they work in an ad hoc manner. Most projects lack the experts or resources required to produce communication and training materials. With a few exceptions, current communication activities in communities depend on the extension systems of government and non-government agencies. Other areas needing strengthening include personnel qualifications, training, equipment availability, institutional arrangements, commitment, financial arrangements and interdisciplinary involvement and coordination. Perhaps the greatest challenge for nutrition education is in developing and delivering effective programmes (media and interpersonal) that can accommodate Nepal’s geographic, racial, ethnic and cultural diversities.

Sri Lanka

Sri Lanka has a population of nearly 17.5 million people, of whom about 70 percent live in rural areas. Agriculture is the main source of income. Although Sri Lanka has an average annual per caput income of less than US$ 450, the health status of the people remains impressive with a crude birth rate of 21.3 per 1 000 people, crude death rate of 7 per 1000 people, IMR of 19 per 1000 live births, maternal mortality rate of 0.1 per 1 000 live births and life expectancy at birth of 74.8 years for females and 76.7 for males. The vast majority of people, 87 percent, are literate. These exceptional achievements are attributed to social welfare measures. Paradoxically, this favourable overall situation exists in parallel with high rates of morbidity and ill health.

Malnutrition, including PEM, low birth weight and deficiencies in iron, iodine and vitamin A, is a major health problem in Sri Lanka. Among many causal factors, inadequate dietary intake, low awareness and improper food habits are prominent. Family planning, maternal and child health (MCH), nutrition and immunization services form an integral part of the Health Ministry’s Family Health Programme. Comprehensive programmes vary and are mainly implemented by the Ministry of Policy Planning and Implementation, the Ministry of Education and the Mahaweli Authority. Nutrition is also a component of the training programmes conducted by institutions in other sectors. The only mass media campaign has been one that promotes consumption of iodized salt.

Common hindrances are lack of expertise and trained personnel, limited resources and inadequate coordination. An urgent necessity is nutrition orientation for ore group of people, for example medical officers, who could train primary health care workers and others. Technical assistance is needed to develop an information, education and communication (IEC) programme on nutrition. While the equipment and expertise exists within Sri Lanka for producing audiovisual materials, lack of finances obstructs development. Video is gaining popularity, and video recorders and televisions for medical officers would be an asset.

Viet Nam

Viet Nam is an agricultural country with a population of over 70 million people. In 1991, the average annual per caput income was still low at US$ 200. Food-consumption and nutrition-survey data indicate that chronic energy deficiency exists among a large proportion of the population. PEM afflicts about 42 percent of children under five, with severe PEM affecting approximately 14 percent of young children. Prevalence of nutritional anaemia in pregnant women in urban areas is 41 percent, while among rural women the rate is 49 percent. Vitamin A deficiency and xerophthalmia affect many people, and iodine deficiency is found in certain regions. Low levels of education and literacy among vulnerable groups, lack of awareness and improper child feeding practices are the main causes of these problems.

A project is being implemented to educate people about the biological values of vitamin A and to raise their awareness of the benefits of breast-feeding, consumption of various food sources and proper child care. Home garden production of vitamin A-rich fruits and vegetables is promoted. Health education materials (manuals, flip charts, slide programmes, leaflets and videos) have been developed. The main interpersonal programme involves the strengthening of commune and village communication networks.

THEORIES IN NUTRITION COMMUNICATION

A paper was presented reviewing theories of nutrition education as background to assist participants in developing nutrition communication proposals. Over the last 50 years, three streams of thought have influenced nutrition communication. The first is concerned with education, psychology and behaviour change, the second with communication and the third with social marketing. Today’s integrated model suggests that experts interact with audiences to plan original messages that are delivered through channels or media that are accessible to the audiences. This interaction improves the way a message is perceived, as the audience is moved from attention, through awareness and concern, to comprehension, then through decision-making or action, and finally to behaviour adoption. Consideration is given to local, socio-cultural and historical contexts. Programme planners need to consider each stage in the above sequence and to determine how they will address key issues over time with the audiences of interest.

CASE-STUDIES

Thailand

To improve the nutritional status as well as knowledge, attitudes and practices of pregnant and lactating women and preschool children in seven regions, Thailand undertook a project from 1985 to 1989 to assess and analyse food habit problems and explore flexible community-based approaches for behavioural modification, The objective was to change undesirable food habits while strengthening desirable ones. A fourfold strategy of participatory action research (PAR), nutrition communication, supportive activities and evaluation was used to attain the objectives.

Modifying inappropriate food habits requires an integrated concept of nutrition that includes biomcal and behavioural-science perspectives. A clear understanding of the target groups and audiences, as individuals and as family members, and of their behaviour, attitudes and environmental constraints was necessary to set realistic objectives, and flexibility was required to achieve them. To begin, an accurate, early analysis was needed of the ways in which aspects of the socio-cultural, economic, political, psychological and physical environment shape existing food practices in a community.

Formative research indicated that the major causal and contributing factors affecting food habits were learning experiences, culture, food availability, health services and mass-media advertisements.

A participatory atmosphere and a “bottom-up/top-down” team approach was created for implementing the project. Local development agents from the health, agriculture, education and rural development sectors were encouraged to work with community leaders in developing and implementing communication and support activities. Using the PAR approach, villagers identified their major problems (e.g. illiteracy, insufficient household food security, poor access to health services and ineffective school lunch programmes) and then worked with local development agents to develop community-based intervention programmes such as food production and preservation activities, school lunch programme improvements, literacy campaigns and environmental sanitation campaigns.

Coordination was critical for the project’s long-term success and sustainability. Activities and responsibilities were shared by communities, local development organizers and project personnel. Accordingly a positive, empathetic relationship needed to be developed among all collaborators based on a common purpose and a meaningful set of attainable objectives. Combining nutrition messages with concrete support activities and emphasizing careful, effective management and evaluation were crucial.

Last, a style was adopted that included a variety of supportive nutrition communication media and activities that fit practically with village life and the people’s interests. This adaptation was crucial because, ultimately, community members are the ones who make the real difference. They are the ones who must change themselves.

China

An intervention to change nutrition and food hygiene behaviour took place in rural China in 1991. In Shanxi Province 212 villages participated in a pilot project to increase the intake of high-quality protein by adding animal and soybean foods, to increase intake of vitamins A and B2 by eating more dark-green vegetables, to decrease salt intake and to control diarrhoea.

After one year, the intervention district showed great change, while the control district showed no significant changes. In the intervention district the proportion of residents aged 15 to 60 years with basic health knowledge increased from 11 percent to 81 percent. In the same age group, the proportion that ate at least one egg and 100 g of soybean food per day increased from 39 to 71 percent. Furthermore, the percentage of persons consuming less than 10 g of salt per day rose from 21 to 42 percent.

Three lessons were drawn from the programme: first, support from community leaders, who are not only decision-makers but also influential persons in rural communities, is essential. Second, the focus should be on the most important target group, such as women who have control over family food selection and preparation; activities should be tailored to fit this group. Third, a comprehensive communication strategy is essential, and it should use media programmes that target a wide audience. Interpersonal communication is also needed, including training and counselling aimed at community leaders, families, local health workers and other important change agents.

The Philippines

The Barangay Integrated Development Approach for Nutrition Improvement of the Rural Poor (BIDANI), initiated in 1978, was conceived to improve family welfare, generate income and enhance food security. The intention was to coordinate efforts of the barangay or village people, the local government, NGOs and state colleges and universities in an agriculture-based action-research project. The five objectives were: to establish participatory models of improving the nutritional status of the rural poor; to develop practical nutrition education approaches, e.g. training courses for barangay leaders and trainers; to develop packages of participatory communication approaches and services at the village level; to institutionalize the models at the provincial and municipal levels for speedy, sustained and wider implementation and impact; and to sustain BIDANI with the technical assistance of state colleges and universities, as a complement to a programme of the National Nutrition Council of the Philippines entitled Toward A Stronger Body with Adequate Nutrition.

During Phase 1, Barangay Nutrition Scholar-Development Workers were selected and given technical and practical training. A programme planning and implementing committee was organized at each barangay, a situational analysis was conducted and a barangay integrated development plan was formulated. Linkages with government and private agencies were established and indigenous extension and communication approaches were used. The barangay projects were implemented, monitored and evaluated.

Phase 2 focused on institutionalizing the programme by turning it over to existing government structures, personnel and resources. Phase 3 involved regionalization and expansion of the BIDANI model, which now covers seven regions in the Philippines.

All stages of the development support communication (DSC) process were embodied in the components and phases of the BIDANI programme. These DSC stages are communication training; communication research; communication strategy planning; message design; materials and media development; the use of interpersonal, group and mass media; and communication evaluation. From the outset, the BIDANI programme planners recognized the pivotal role of communication in building sustainability and institutionalization into the programme.

The BIDANI experience illustrates how nutrition, information, education and communication can be built into an overall nutrition programme. DSC should be an integral component of development programme or project planning, implementation and evaluation. While the initial investment in DSC may be high, it has been proven cost-effective in terms of multiplier effect, project survival, sustainability and, more important, socio-economic impact.

PROPOSALS AND RECOMMENDATIONS

Bangladesh, Sri Lanka, Viet Nam, Laos and Nepal formulated proposals for controlling nutrition problems in their respective countries. These projects will require coordination at the country level and collaboration within and among countries.

· The Bangladesh Ministry of Agriculture proposed that communication facilities, equipment and personnel be upgraded so that communication can be used to solve problems of food production and nutritional practices among landless and marginal farm families.

· Sri Lanka planned an effort to improve haemoglobin levels using a multisectoral multimedia approach involving interpersonal and small group discussion methods and community organization techniques as well as radio spots and video.

· The Ministries of Health and Agriculture in Viet Nam aim to improve the energy and micronutrient status of farm families and raise their levels of nutrition knowledge, attitudes and practices.

· To alleviate PEM among children, Laos seeks to employ nutrition communication and technical skills to improve attitudes and feeding practices of mothers as well as food handling behaviours. Breast-feeding and the timely introduction of supplementary foods are to be promoted and household food production improved.

· In Nepal, a multimedia communication approach was proposed to coordinate health, agriculture, education and local development activities to improve household food security and promote better nutritional practices.

The workshop participants recommended that governments and international development agencies provide both technical and financial assistance to promote nutrition education and communication. The need for a network to exchange technical information and experiences in nutrition education and communication was recognized. This network should incorporate the concept of intersectoral approaches and integrating nutrition in development. Meetings, seminars and training workshops were also suggested for further development of technical skills in nutrition communication, communication project planning, strategy formulation and implementation, management and evaluation. Finally, interinstitutional and person-to-person information exchange was encouraged.

Because of the importance of nutrition education and communication for improving food habits and nutrition status and sustaining the improvements, Asian governments, FAO and other United Nations organizations were urged to make it a priority in planning and to promote it through establishment of national policies and continuous international efforts.