|Food Nutrition and Agriculture - 7 Strategies to combat micronutrient deficiencies (1993)|
|Promoting home gardening to control vitamin A deficiency in northeastern Thailand1|
1 This article draws on a presentation at the International Workshop on Household Garden Projects held by the Asian Vegetable Research and Development Center (AVRDC), the Users Perspective with Agricultural and Rural Development (UPWARD) and the International Development Research Centre (IDRC), 12-15 May 1991, Bangkok, Thailand. Project support came from the United States Agency for International Development (No. 493-5116-F-SS-8058-00). The authors extend their sincere gratitude to Dr Francis Davidson, Dr Barbara Underwood and Dr Norge Jerome for their valuable comments; however, the information and opinions expressed herein are solely their responsibility.
G.A. Attig, S. Smitasiri, K. Ittikom and S. Dhanamitta - At Mahidol University's Institute of Nutrition, Thailand, George A. Attig is a consultant; Suttilak Smitasiri and Krich Ittikom are Manage and Project Field Coordinator, respectively, for the Social Marketing of Vitamin A-Rich Foods project; and Sakorn Dhanamitta is Director Emeritus.
Vitamin A deficiency, the most preventable cause of irreversible blindness, affects millions of children worldwide, While clinical vitamin A deficiency cases are uncommon in Thailand, 20 to 27 percent of preschool and school-aged children in the northeastern region of the country exhibit subclinical deficiency (Udomkesmalee, 1992). At times, supplementation and food fortification may be needed as short- to medium-term measures, but long-term improvements require dietary diversification with increased consumption of vitamin A-rich foods. Families must be motivated, given the right tools and guided on how to add vitamin A-rich foods to their diets year round, This involves a focus on concrete action programmes such as home gardening and nutrition communication using creative messages and the media.
Home gardens2 have played a significant part in development projects largely because they are important components of traditional household food production systems. Hence, they are intimately intertwined with solving household production, food security, income and health problems, In Asia, home gardening is a feasible control and prevention strategy for vitamin A deficiency because the availability of green, yellow and orange vegetables and fruits as well as some animal products can be improved, In fact, vegetable products contribute about 86 percent of vitamin A intake in Thailand and other Asian developing countries (Soleri, Cleveland and Frankenberger, 1991).
2 In this article, a home garden is a supplementary food production system managed and controlled by household members. Although a portion of the crop may be sold, some of the produce is consumed by the producers. A home garden is not the household's primary source of food or income (Soleri, Cleveland and Frankenberger, 1991).
From 1988 to 1991, the Social Marketing of Vitamin A-Rich Foods (SM/VAF) project was conducted in Thailand 3 using several elements believed to be essential to making gardening practical, acceptable and attractive (Midmore, Ninez and Venkataraman, 1991). The project's main objectives were to improve knowledge, attitudes and practices (KAP) concerning the consumption of vitamin A-rich foods among preschool children, pregnant women and lactating mothers and to increase vitamin A intake, A systematic social marketing approach with an operational plan containing three overlapping dimensions was applied. First, a "nutrition information society" using radio and other information dissemination channels was created to give the community greater awareness and a firm knowledge base, The second stage used social advertising to promote the production and consumption of the ivy gourd plant (Coccinia indica) which is locally available, high in vitamin A and acceptable in the local cuisine, Third, the project used concrete village action programmes focusing on home and school gardening to activate community participation (Smitasiri and Attig, 1992).
3 The project was conducted in the Kanthararom district, Srisaket Province, northeastern Thailand among 134 villages and approximately 122 000 people. The Takarn Phutphon district, Ubol Ratchathani Province served as the control area.
Dans les pays en développement, la carence en vitamine A est responsable de l'incidence élevée de xérophtalmie et de cécité irréversible et de taux de mortalité infantile élevés. Si des interventions à court et à moyen termes sont parfois nécessaires, les solutions à long terme résident dans une amélioration du régime alimentaire, et cela implique une production et une consommation accrues d'aliments riches en vitamine A. En Asie, la promotion des jardins potagers est une stratégie viable étant donné que la provitamine A est immédiatement disponible dans un large éventail de légumes (environ 86 pour cent de l'apport en vitamine A des populations asiatiques provient de fruits et de légumes).
L'article présente une série d'éléments, indispensables a la promotion des jardins potagers dans le cadre de programmes de communication sur la nutrition et la vitamine A, qui ont été utilisés à l'occasion du projet «Commercialisation sociale de denrées riches en vitamine A». Ce projet a été réalisé dans le district de Kanthararom (province de Srisaket) dans le nord-est de la Thaïlande et a touché 134 villages et quelque 122000 personnes. Une zone témoin se trouvait dans le district de Takarn Phutphon (province de Ubol Ratchathani). Le projet visait essentiellement à améliorer les connaissances, attitudes et pratiques relatives à la consommation de denrées riches en vitamine A parmi les enfants et les femmes enceintes ou allaitantes, ainsi qu'à accroître la consommation effective de vitamine A. Dans une première phase, appliquant les méthodes de commercialisation sociale, il mettait sur pied une «société d'information sur la nutrition» pour sensibiliser les membres de la communauté et leur donner une base d'information solide. Dans une deuxième phase, le projet utilisait une approche publicitaire à caractère social pour promouvoir la production et la consommation d'une courge disponible sur place (Coccinia indica), à teneur élevée en vitamine A et adaptée à la cuisine locale. Enfin, le projet s'est servi de programmes d'action au niveau du village centrés sur les potagers familiaux et scolaires pour susciter la participation de la communauté.
Les principaux éléments de ce type de projet sont:
· Identifier le problème de manière réaliste.
· Utiliser la recherche informative pour évaluer les obstacles et les besoins traditionnels en matière d'horticulture.
· Prendre en compte le degré de développement de la population.
· Choisir une stratégie des modifications du comportement appropriée.
· Prendre en compte les besoins et les intérêts des utilisateurs.
· Prendre en compte les principaux groupes de populations cibles.
· Utiliser une approche souple orientée sur les besoins de la population.
· Sélectionner des produits alimentaires adaptés aux conditions locales.
· Choisir un produit alimentaire par campagne de promotion.
· Utiliser les médias pour appuyer les programmes d'action communautaire.
· Utiliser tous les moyens de communication possibles.
· Incorporer des programmes de formation participatifs.
· Se fixer pour objectif principal l'introduction de certaines denrées dans le régime alimentaire.
· Tirer des leçons des expériences passées.
La carencia de vitamina A ocasiona la xeroftalmía y la ceguera irreversible y provoca elevados índices de mortalidad infantil en los países en desarrollo. Si bien en ocasiones pueden ser necesarias las intervenciones a corto y mediano plazo, las soluciones a largo plazo parten de un planteamiento basado en la alimentación dirigido a aumentar la producción y el consumo de alimentos ricos en vitamina A. En Asia, la horticultura familiar constituye una estrategia viable, ya que la provitamina A está presente en una gran variedad de frutas y hortalizas. Aproximadamente el 86 por ciento de la ingesta de vitamina A de la población asiática procede de las frutas y hortalizas.
En este artículo se presentan una serie de elementos básicos necesarios para la promoción de los huertos familiares dentro de los programas de comunicación sobre nutrición y vitamina A, que fueron utilizados en un proyecto sobre comercialización social de alimentos ricos en vitamina A. Este proyecto se llevó a cabo en el distrito de Kanthararom, en la provincia de Srisaket, al noreste de Tailandia, entre 134 aldeas con una población total de aproximadamente 122000 personas. En el distrito de Takarn Phutphon, en la provincia de Ubol Ratchathani, se estableció un área de control, Los principales objetivos del programa fueron incrementar los conocimientos, actitudes y prácticas relativas al consumo de alimentos ricos en vitamina A entre los niños en edad preescolar, las mujeres embarazadas y las madres lactantes, y mejorar la actual situación con respecto a la vitamina A, El proyecto aplicó un planteamiento sistemático de comercialización de carácter social para crear, en primer lugar, una «sociedad de información sobre nutrición» para conseguir una mayor sensibilización de los miembros de la comunidad y proporcionarles una sólida base de conocimientos, En la segunda etapa, se recurrió a la publicidad de carácter social para fomentar la producción y el consumo del pepino cimarrón (Coccinia indica) i que se da en la zona, tiene un alto contenido de vitamina A y resulta aceptable para la cocina local, Por último, el proyecto aplicó programas de acción para las aldeas, orientados a la horticultura familiar, y en la escuela, afín de promover la participación comunitaria.
Los elementos fundamentales del programa fueron:
· determinación del; problema real;
· investigación operacional para evaluar las posibles restricciones y las necesidades hortícolas tradicionales;
· estudio del contexto de desarrollo;
· elección de una estrategia adecuada para el cambio del comportamiento;
· consideración de las necesidades e intereses del; usuario;
· determinación de los grupos destinatarios importantes;
· utilización de un planteamiento de desarrollo flexible y orientado a la población;
· selección de productos alimenticios adaptados a las condiciones locales;
· selección de productos alimenticios concretos para ser promocionados;
· empleo de los medios de comunicación en favor de los programas de acción comunitaria;
· utilización de múltiples canales de comunicación;
· establecimiento de programas de capacitación de carácter participativo;
· realización de actividades en favor de la inclusión de dichos alimentos en el régimen alimenticio;
· aprovechamiento de la experiencia adquirida.
Essential elements of the approach
Realistic identification of the problem
Home gardens and nutrition communication are often seen as panaceas for solving a complex range of social problems such as poverty, food shortages or inadequate health infrastructures. It is unrealistic to expect gardening or nutrition communication programmes to accomplish all of this. Instead, these activities should be initiated with a single clear problem and achievable objectives in mind, The dimensions of the problem and the feasibility of a home gardening intervention should be determined early in the project, To assess the potential nutritional impact of the intervention, the prevalence of vitamin A deficiency among different segments of the local population and the availability and consumption of vitamin A-rich foods must be considered.
Dietary surveys among children (aged 2 to 6 years) and mothers (18 to 35 years old) showed that vitamin A intake among preschool children, pregnant women and lactating mothers was extremely low in the study areas (80, 75 and 82 percent below their recommended daily allowance (RDA), respectively), Furthermore, fat intake was remarkably low; it comprised only 7 to 15 percent of total energy intake, This was surprising since a pre-project market survey in the area showed that vitamin A-rich foods, fats and oils were available in local markets year round and most were affordable (Smitasiri et al., 1993). In-depth interviews and focus group sessions with mothers, headmasters, village health workers, traditional midwives and monks showed that general nutrition and vitamin A consumption were affected by family economics; inappropriate traditional beliefs about food, pregnancy and child development; incorrect nutritional knowledge; personal preferences; and the influence of family members in nutritional decisions (Smitasiri, Attig and Dhanamitta, 1992).
Assessment of limiting constraints and traditional gardening needs
Often perceived to be easy, household gardening may be unadvisedly promoted in areas where the conditions are not appropriate. Existing gardening and agricultural practices provide a wealth of information about local knowledge, involvement and needs, Conditions that may limit gardening should be assessed, The viability of promoting indigenous gardens, in terms of agro-ecological and cultural conditions, will influence the targeting of the intervention, Production factors including access to land, water and other inputs, household experience with gardens, available labour and access to extension information must be considered in selecting the vegetables to be cultivated.
Northeastern Thailand, with alternating periods of drought versus flood each year, is "climatically unstable", To compensate for this, household wells have been dug and large water storage tanks supplied for family use, While these are adequate for rainy periods and for fulfilling household needs during the hot dry season (March to May), water availability for home gardening is limited during this latter period, Hence vegetables must be selected that can tolerate extended dry periods and require a small area for cultivation.
The people of northeastern Thailand are familiar with gardening. Plant sources that are not readily available around the community are often grown in the house compound. However, the intentional cultivation of non-cash crops was new for villagers and agricultural extension agents alike. Villagers grow onions, chilies and garlic for sale and the district agricultural extension workers strongly promote cultivation of cash crops to increase household income. The project's challenge was to promote the gardening of a vegetable for a non-economical purpose through changes in the attitudes and practices of community members and extension agents.
Consideration of the development context
Often seen as a micro-level, home-based activity, home gardening requires local participation if it Is to be incorporated into household food systems and to persist beyond the life of the project. Communities often rely on extension agents and other local officials for information and technical assistance, Hence, home gardening projects also need to be viewed within a macro-level development perspective.
Thailand's national primary health care and quality of life efforts rest on community involvement in planning, implementing and evaluating situations, Individuals from the community and the agriculture, education, health and rural development sectors work jointly in community development efforts. Since home gardening fits within a number of these areas it was perceived as a good intervention strategy, and the project matched with several high priorities held by community members and local officials.
Finding an effective approach to motivate people to take actions that involve new behaviours and practices was key. Increasing the demand for specific food items and services (e.g. extension assistance) and ensuring that people appropriately apply what they learn can be essential for improving home gardening and food consumption patterns. Products and services that respond to district officials' and community members' ideas and perceived needs are the basis for creating effective demand (Smitasiri, Attig and Dhanamitta, 1992). In the early advocacy period, district officers discussed how the project could help meet local and national health and social development goals, Demonstrating how the project fit within the roles, duties and responsibilities of local officials was crucial, The officials gained recognition and greater insights about community life through their assistance to the project, Also, relationships with villagers were created or strengthened which could improve future community programmes.
Choice of an appropriate behaviour change strategy
Early nutrition education efforts emphasized knowledge and information about food and nutrition practices, While knowledge is an important base for change, it is not the sole way to motivate people to alter their dietary habits, Other personal and environmental factors have a role in the communication and behaviour change process, Therefore, new techniques to encourage behaviour change were needed.
Social marketing, a strategic method involving the design, implementation and control of programmes to increase acceptance of a social idea or practice, was the fundamental approach used in the project (Kotler and Roberto, 1989), In social marketing, close consideration is given to product planning, pricing, communication, distribution and market research. Social marketing is consumer oriented; in other words, it focuses on identifying people's needs and wants. The audiences are segmented into primary, secondary and tertiary target groups for which new products are developed and tested and messages are promoted before implementation on a large scale, The intent is to design a product that people will want and use at an acceptable price (monetary and non-monetary), The product should be widely distributed and easily available, This entails a communication strategy that promotes the product's attributes and potential benefits.
Building on user needs and interests
Many gardening and nutrition intervention projects define a problem according to broad assumptions or general national policy objectives, rather than knowledge drawn from the households (Midmore, Ninez and Venkataraman, 1991), As a result, the people whom the project wishes to assist reject or only partially adopt the new practices because they cannot see how these practices can fulfil their needs, To be sustainable, programmes to combat vitamin A deficiency should be based on people's felt needs (Attig et al., 1992).
Prior to project implementation, determining the core need of community members was key. During in-depth interviews and focus group sessions, mothers were informed that their children could become blind because they do not consume enough vitamin A-rich foods, Yet the women were steadfastly unconvinced, They had not seen any children going blind. The mothers did admit, however, that their children were often sick from diarrhoeal diseases, respiratory infections and other consequences associated with vitamin A deficiency, Solving these problems represented their main need and desire, while increased access to readily available food sources was a subsidiary one, Thus, these needs became the focus instead of preventing blindness (Smitasiri, Attig and Dhanamitta, 1992), The project also used the message "A mother loves her child" to integrate home gardening, nutrition and health objectives and activities and make the project attractive to community members.
Consideration of important target audiences
Many gardening and nutrition intervention projects may have limited success because they focus on changing behaviours among the target group members and do not consider the influence others may have on the acceptance or rejection of a new practice, Hence, intervention strategies should be directed not only at target groups but also at influential family and community members (target audiences).
Social influences are very strong in rural Thai communities and three main target audiences were identified in the project: the primary audience of children's caretakers (i.e. immediate household members, especially the elderly) who are responsible for food production, processing and/or consumption patterns; a secondary audience comprising teachers, health workers and subdistrict extension agents who could be motivated to teach, support and reinforce the practices and beliefs of the primary audience; and a tertiary audience of persons outside the project area (for instance, provincial and district officials, health and medical personnel, local mass media representatives and university researchers), These persons provided valuable information for project development, especially technical assistance for home gardening activities (Smitasiri, Attig and Dhanamitta, 1992), Interpersonal and media programmes were tailored to these audiences who could help change the behaviours of people in the target group, For example, Buddhist monks incorporated health and nutrition information in their sermons for the elderly, and schoolteachers were given training in gardening, food preparation and nutrition and were encouraged to use their knowledge to improve their classroom and school curricula.
Use of a flexible, people-oriented development approach
Relying on prepackaged programmes that may be inappropriate for local conditions can lessen the effectiveness of strategies to promote gardening and new dietary practices, Instead, a flexible, decentralized process was used in which project personnel, local officials and community members formulated the intervention. Together, these groups selected the main vegetable to be promoted (the ivy gourd), tested it among community members and suggested ways to promote it. It was the district agricultural workers who felt that home gardening was most appropriate given the environment, community resources and people's knowledge. School gardens and poultry- and fish-raising projects aimed at supplying school lunch programmes as well as improving family diets were undertaken by district officials and community leaders as well.
Selection of a locally adapted food item
Of highest priority is the choice of locally adapted vegetables that will be accepted by the community and achieve the project's objectives. Data on vitamin A-rich foods need to be analysed to select the most appropriate food items, and these can be pretested within the community to see if they are acceptable in terms of home gardening and incorporation into the family diet.
It is best to select a single item for promotion as a vitamin A-rich food to maximize the impact of media programmes. In commercial firms, similar products are not promoted at the same time because doing so strains resources, With multiple products it is more difficult "to catch the consumer's eye" and people can become confused about which product is best.
Use of media programmes to support community action programmes
Many nutrition communication programmes rely heavily on creative strategies using mass media advertising, Unfortunately, media strategies alone have not led to sustained behavioural changes. Community interpersonal programmes are the most effective fora for educating people and changing their behaviours (Smitasiri et al., 1993). Thus media programmes should support community action programmes to attain project objectives. For instance, pamphlets on growing ivy gourd complemented home and school gardening activities; radio announcers supported the programme through "Meet the People" community visits; audiovisual materials (such as cassette tapes for public address systems) on child care and nutrition supported maternal counseling and traditional birth attendant training programmes.
Use of multiple communication channels
The use of multiple communication channels to disseminate home gardening and nutrition messages and information is important, Collectively, they reinforce each other in terms of the number of target audiences reached, the frequency with which a person hears or sees a specific message and the content of messages received within a given period. Moreover, coverage is kept up when certain media are not available in some places, Seven different media and interpersonal channels were used to support the Thai home gardening and other community action programmes:
· interpersonal/group communication (e.g. demonstrations, training sessions, exhibits, dramas, outdoor shows);
· public address systems;
· radio spots and programmes;
· printed materials (e.g. manuals, T-shirts, direct mail, pamphlets, albums, newsletters);
· audio-visual materials (e.g. videos, cassettes).
Incorporation of participatory training programmes
Many district officials proposed training to give people the information they needed to identify problems, develop appropriate solutions and manage their own resources for home gardening management and dietary improvement. Participatory training sessions became integral activities, with district workers, community leaders and villagers themselves acting as trainers, In these sessions several training methods were used including formal and informal presentations, case-studies and experiential learning. Periodic workshops were designed for local health and rural development personnel, not only to communicate project information but, more important, to involve the participants in a genuine dialogue about alternative project activities, assessment of activities undertaken and coordination among different levels and sectors, Health workers and traditional birth attendants were trained in child health and nutrition and received a maternal and child health manual for their use, Agricultural workers were instructed in ivy gourd propagation, while schoolteachers received training in organizing school gardens and small animal husbandry projects. Community members visited other villages to learn from their home gardening techniques and ivy gourd "plantations" run by private entrepreneurs who were raising the ivy gourd as a cash crop.
Focus on incorporating foods into the diet
Many gardening projects focus on the mechanics of growing fruits and vegetables. However, a nutrition intervention cannot simply stop at the garden gate but must be brought into the kitchen. Food preparers should be given ideas and the motivation to experiment in incorporating vitamin A-rich foods into their families' daily diets.
Initially, building nutrition awareness among the population and motivating the people to start home ivy gourd gardens were stressed, Later, reinforcement of positive health and dietary behaviours was emphasized, Food demonstrations and ivy gourd recipe competitions were promoted to maintain motivation and behaviour changes, Posters featured national and local folk-singers holding dishes prepared with ivy gourd. As a result, women began to introduce the ivy gourd into traditional recipes, They used the vegetable in desserts and in nutritious lunches for children to take to school, They asked for information about other vitamin A-rich foods to accompany or substitute the ivy gourd, Thus, there was an important shift from a food focus to a dietary focus and from the ivy gourd to other vitamin A-rich foods.
Learning from experience
Monitoring should provide new information to achieve the programme's objectives and improve its activities rather than assessing performance only, In Thailand, monitoring led to increased community participation and the integration of popular knowledge and local wisdom to improve the activities. For example, the ivy gourd fell prey to mealybugs, aphids, powdery mildew and other infestations, although experts thought the ivy gourd was pest resistant. Villagers, project volunteers, local officials and agricultural experts met to find a practical, ecologically sound solution using "modern" and "traditional" knowledge, Agriculture experts suggested spraying plants in the evening with detergent, but this was not effective. An elderly village man remembered a traditional herbal recipe containing a mixture of leaves or fruits of the neem tree (Azadirachta indica var. siamensis), galingale (Alpinia galanga) and citronella grass (Cymbopogon nardus). After the mixture was combined with water and left overnight, it was mixed with detergent and tested successfully in 16 villages. Community members, on their own, spread this knowledge to other project villages (Smitasiri, Attig and Dhanamitta, 1992).
Results and conclusion
When the project was evaluated, the results showed that the behavioural and vitamin A status objectives had been achieved, Overall, the intervention area manifested a significant improvement in scores for knowledge (t= -4,73; P< 0,005), attitudes (t= -5,95; P< 0,005) and practice (t= -2,45; P<0,05) compared with the control area, as well as improvement in vitamin A and nutritional status, Fat and vitamin A intake in the intervention area also showed statistically significant increases among pregnant women (from 201 ± 425 retinol equivalents (RE)4 in 1989 to 428 ± 391 RE in 1991) and among lactating mothers (from 269 ±355 RE in 1989 to 476 ±618 RE in 1991). No increases were evident in the control district (Smitasiri et al., 1993), The project appears to be sustainable since local government officials have initiated their own food and nutrition activities and/or integrated nutrition programmes (especially home and school gardening) into their routine work schedules and even their personal lives.
4 Editor's note: A retinol equivalent (RE) is defined as 2 µg retinol, which is equal to 6 µg p-carotene or 12 µg mixed provitamin A carotenoids.
The Social Marketing of Vitamin A-Rich Foods project illustrates one way to incorporate home gardening into a nutrition communication programme, For other single micronutrient programmes and those aimed at multiple nutritional disorders, the diet-based strategy of seeking behaviour modification through the home cultivation of important vegetables and/or fruits shows great promise, Strengthening the competence of local officials and community members as home garden and nutrition education promoters is most important to obtain greater long-term benefits. In this way, the nutrition communicator obtains a more realistic view of community needs and preferences as well as a level of analysis, planning, implementation and control that can lead to the more effective and efficient use of resources.
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