|Effective Communications for Nutrition in Primary Health Care (UNU, 1988, 208 pages)|
JOAN DYE GUSSOW
Department of Nutrition Education, Teachers' College,
Columbia University, New York City, USA
Nutrition education as a field has experienced a great upsurge of professionalizing in the last decade, as we have begun to develop and adapt models from the social sciences in order to bring some academic rigour to what has been an applied discipline. I must confess immediately that I view this development with some misgiving. We appear to be on the verge of adopting, for nutrition education, social science models that the social scientists are on the verge of abandoning as having little predictive value and even less heuristic provocativeness. I mention the topic here as a precaution, to remind us of the value of common sense in the face of paradigms.
This professionalizing has brought a new rigour, at least on a verbal level, to the ways in which we ask whether we are teaching what we intend to teach and communicating what we intend to communicate - which is all to the good. What I want to discuss here is how we might think more clearly about what we intend to communicate.
There is a dictum in education - indeed, it is nearly a cliche - that comes from an early curriculum expert named Tyler; it is that the content of any curriculum derives from (1) the needs of the profession, (2) the needs of the learner, and (3) the needs of society. How does this apply in nutrition education? If one views nutrition education in terms of the needs of the profession, the discipline seems to have to do with nutrients, where they occur, how they relate to health, what people need to know about them, and how people can be helped to get enough of them. Seen from this vantage-point, the field of food and nutrition education is structured as a kind of pyramid in which the relevant knowledge is produced at the top by the nutrition scientists and then trickles downward.
The scientists discover the important relationships between bone synthesis and vitamin C, for example, or between iron absorption and the overall composition of a meal. These biochemical complexities are communicated through various professional levels toward the broad base of the pyramid that is made up of the general public. As the knowledge works its way down the content becomes more and more dilute and a good deal more general (citrus fruits contain vitamin C; vitamin C prevents scurvy; drink citrus juice with your whole-wheat bread) but it does not change in fundamental character. Underlying everything that is taught is the root knowledge about nutrients, their presence in food, and their functioning in the body.
In the United States there is a great deal of support for this kind of nutrition education. When the goodness of a food can be defined purely in terms of identified nutrients, then basically non-nutritious, overprocessed foods can be fortified, inexpensively, and sold as nutritious foods to the immense profit of their manufacturers. Moreover, because science has prestige, and because the field of nutrition is populated in the United States largely by women who need all the prestige they can get, this view of nutrition education as deriving its relevance largely from biochemistry has also been adopted by many professionals.
The nutrient approach to public education has been taken to its logical extreme in the US, where packaged foods in the market are labelled so as to inform consumers about the amounts of protein, fat, and carbohydrate and the quantities of 8 vitamins and minerals they contain. These labels have, however, turned out to be much too complex for even the relatively sophisticated US consumer to understand and use. Even now government and industry are investigating a very much simplified nutrition labelling format. Unfortunately, since this new format will list even fewer of the 60-odd nutrients the human organism needs, it will be even more misleading about the nutritional quality of the food involved. Indeed, in thinking about the US marketplace, I have come to the conclusion that teaching the public about nutrients in foods as a way of improving their food selection can only work in a food supply sufficiently simple and unprocessed that nutrient education is unnecessary !
I do not want to suggest by the comments above that the facts derived from nutrition science are an entirely inappropriate basis for nutrition education; I do mean to suggest that, where the public is concerned, they are grossly inadequate. There are many other important things people need to know about foods in order to eat wisely. How do we know what they are?
This question moves us from looking at the needs of the profession to considering the needs of the learner. Because learners come into contact with nutrients only through their contact with food, a concern for learners dictates that we educate about food. But how do we decide what to tell them? This is a much more difficult question than it appears to be.
On the most obvious level, what one tells learners about food selection will depend on their nutritional status, on the nature of their food supply, on the cost, availability, and acceptability of certain foods, on their facilities and capacity for food preparation, and so on. When people are undernourished, nutrition education will often be focused on getting them to increase their intake of certain protective foods, to recognize malnutrition among their children. Where a population is affluent, the messages will usually be quite different and will involve recommendations to avoid or cut down on the intake of certain kinds of foods.
However, simply knowing that the messages will differ according to the income of the population involved does not in itself help a professional decide just what those messages ought to be. Every nutritionist and planner will have his or her own examples of how the very same problem can be and has been addressed in very different ways. The decision to distribute a prepared weaning food based on imported raw materials will lead to very different educational efforts from the decision to encourage mothers to prepare such a food from local materials. The lessons for mothers whose children are undernourished will depend on a number of variables, including the philosophical orientation and educational philosophy of whoever is in charge. On what basis ought such decisions to be made? Obviously, a full discussion of such a question is well beyond the bounds of this paper, but I do wish to raise a few basic issues.
There has been a good deal of discussion in the professional literature about an apparently fundamental disagreement among nutrition educators regarding the appropriate intentions or goals of nutrition education. There are those who say firmly that our job is simply to provide learners with the knowledge and skills to make their own decisions without any overt attempt at changing their behaviour. On the other hand, there are those who say that the job of nutrition education is to change or shape eating patterns or maintain desirable eating behaviours. Without going into the different views of human psychology that underlie these apparently disparate goals, I wish to point out that, in practice, there is no clear distinction between information provision on the one hand and behaviour change on the other.
The explanation for this is simple. Because it is quite impossible in any setting to provide learners with all available information about food and nutrients, one must, in any situation, make a choice about which information to provide. The decision about what to include and what to leave out inevitably imposes a value on the information retained. If I were to tell you that oranges contained vitamin C, but not tell you that they were a much more expensive source of that nutrient than potatoes, I would be encouraging you, by implication, to consume oranges whatever their cost. The choice of what information to impart reflects a teacher's judgement that the information is important to his or her learners and is thus aimed at directing their behaviour. In other words, the notion that it is possible simply to impart information with absolute objectivity is a myth.
The fact that selection of content always occurs and always communicates implicit lessons is vividly illustrated by looking at the simplest of teaching devices nutrition educators use - the food-grouping systems. The food-group system long in use in the United States tends to put heavy emphasis on animal products because two of the four groups - milk and meat- involve foods from animals. In a variety of ways, including the fact that the milk and meat groups were always pictured in the primary positions, this apparently objective teaching device tended to encourage the idea among lay persons and professionals alike that the ideal diet was one in which meat played a very prominent role. The negative implications of the export of this notion to less affluent countries need hardly be commented upon.
Developing countries, however, are putting increased reliance on local food-grouping systems, the most common one perhaps being a three-group system consisting of protective foods, body-building foods, and energy foods. An alternate four-food group system has also been proposed, consisting of a staple or starch food category and three other categories made up of foods that provide extra energy, protein, and vitamins and minerals. This system has been criticized as providing false reassurance about the nutritiousness of the starch staple, an objection that - whatever its nutritional merits - illustrates vividly the point I am trying to make: every system, however simple and however objective it appears to be, carries with it a series of assumptions and prejudices that are communicated to learners. This being the case, it is probably extremely important in all nutrition education that the assumptions the curriculum designer or educator builds into his or her materials be made as explicit as possible so that the fewest possible unintended messages will be communicated.
Given that understanding, I wish to ask some questions about the kinds of under Iying assumptions I believe we might want to build into food and nutrition curricula in the last fifth of the twentieth century. The first of these questions is whether nutrition educators are obliged to worry about learners not having enough to eat and, if so, what they are obliged to do about it. What is the role of nutrition education if people do not have food? One view - that nutrition education is "any communications system that teaches people to make better use of available food resources" - suggests that increasing the resources to be made use of is probably someone else's task. On the other hand, some of us believe that the nutrition educator may be the only person around to ask, "Why are certain segments of the population denied access to the means of adequate nutrition and how can such means be secured for them?" In a document produced by Committee II/10 of the International Union of Nutritional Sciences (IUNS) in 1980 and in a special issue of the Teachers' College Record that I edited in the same year, it has been urged that in order to be effective, nutrition education may "have to concern itself not only with what people eat, how they eat it, and how what they eat affects them, but indeed with whether they have anything to eat at all - and if not, why not."
It must be immediately acknowledged that the apparent disagreement over goals may not be over what is right but over what is practical. I would be remiss if I did not emphasize that simply teaching people how best to use their entirely inadequate resources (where adequate resources exist!) is a palliative at best. Only by acknowledging that distributional justice is essential can we make the strongest case.
Among the politically ardent there is a not always fully articulated assumption that if the poor were only given control over their own resources, they would all be well fed, either because their agriculture and their diets would revert to some sort of traditional (and presumably optimal) pre-industrial pattern, or because they would wisely use technology to move forward unerringly toward a well-nourished future. There is little to support the notion that good nutrition will automatically be assured by guaranteeing access to money and/or food. Nutrition education will not provide nutritional wellbeing, it is true, to those without adequate resources; but even if access to food is assured, intelligent decisions about which foods to produce and eat in an increasingly crowded world will require the help of those trained in food and nutrition. After all, children who live amid an abundance of green leaves still go blind because their parents do not know how to use the resources to which they do have access to save their children's sight.
Finally, I commented earlier that the content of a curriculum derives from the needs of a discipline, the needs of learners, and the needs of society. Having briefly discussed how the first two of these might affect the content of nutrition education, I would like to conclude by asking how the needs of society might do the same.
Tyler, in discussing this aspect of curriculum-building, notes that it was the increase in the amount of information available as a result of the scientific and industrial revolutions that made it necessary to choose which things the schools should teach. With so much knowledge available, something had to be left out; schools felt obligated to leave in what was most relevant to contemporary life. If one looks back over nutrition education efforts, one sees that the term relevant has, in nutrition, been equated largely with the word practical. What is relevant is what will equip persons to make optimal use of their food supply so as to improve or maintain their own health, thus producing well-fed children and adults who can be better learners and happier, more productive workers. Guaranteeing the good nutrition of individuals, in short, has been viewed as meeting society's needs.
As we near the end of the twentieth century, however, it is becoming clearer that the "needs of society" where food is concerned may encompass something much broader than simply the nutritional health of individuals. In the current crises of resource availability and environmental instability, it is clear that sustainable societies will require citizens capable of thinking beyond their personal survival to the survival of the earth's biological systems.
While scholars disagree about the time-frame involved, there is an increasing consensus that humanity's relationship to the biosphere has reached a crisis point in many parts of the world. For a variety of reasons - only one of them the need to increase food production - we are destroying at unprecedented rates the resource base that maintains the fertility of the planet. Obviously, unless we sustain our food-producing capacity, both educational and distributional problems will become moot, however much we may desire both wisdom and justice. Where nutrition education is concerned, society now requires that we produce persons knowledgeable enough about their food-producing systems to demand that their leaders act to preserve them.
Nutrition educators who have become conscious of these problems have recognized that helping solve them will require the profession to broaden its view of its own domain. As present chair of IUNS Committee II/10, for example, I am attempting to organize a workshop on the role of indigenous foods and food-producing systems in nutrition education in developing countries. This is a reflection of an increasing recognition among many persons concerned with food production that the agricultural and dietary homogenization going on around the world may not really be contributing to the maintenance of long-term global food-producing capacity. Certain traditional methods of food production appear to be highly prolific, less dependent on purchased inputs, and less destructive of ecosystem stability than many of the most modern systems; and certain traditional patterns of food consumption provided better for the nutritional needs of their consumers than does the present market mix.
Nutritional and ecological merit aside, the global supermarket about which food policy analysts spoke so glowingly in the 1960s and 1970s seems much less attractive in a world where ethnic, religious, and political hostilities can shut off shipments of food or fuel or both. Not only is it risky for people to depend on distant croplands for their basic food supplies, but it is difficult for people to monitor at a distance the fate of the resource base that produces their food. If it is hard for the citizen of Cairo, Illinois, in the middle of the United States, to know (or care about!) what is happening to cropland in California at the western edge of his own country, how much more difficult is it for the resident of Cairo, Egypt, to know what is going on in Cairo, Illinois.
Thus, there has been a growing interest in a variety of settings in examining the potential of various regions for greater food self-reliance. This of course has implications for nutrition education. Recognizing what a re-localized food supply would mean for dietary change, some nutrition educators in the US have begun to think of developing principles of food selection by which food guides appropriate for various regions might be designed. One of my students undertook to ask what might be appropriate criteria - in addition to nutritional adequacy and acceptability - for a local diet in the eastern part of the United States, and concluded that foods should be evaluated for their "efficiency" in terms of nutrients produced per unit of land, water, energy, and so on. By such criteria, different foods would be defined as "good" in different places and at different seasons, depending at least in part on their ability to be produced in a manner compatible with ecosystem stability.
My reading suggests to me that the thinking of rich countries like the United States which behaves as if there are no resource limits- has had far too much influence in the design of nutrition education programmes around the world. Also, I am reminded by the fact that we are only now beginning to notice women's role in food production that just because something is obvious does not necessarily mean it will gain official notice!
I believe that it is essential that we think about the long-range implications of what it is we are communicating before we get really good at the communications process. Management expert Peter Drucker defines effectiveness as doing what needs to be done, and efficiency is doing it quickly and well. We have not been very effective in nutrition education; thinking about improving communication will make us more so. But as Drucker has pointed out, the worst combination is to be efficient without being effective - so that you are able to do the wrong thing quickly and well. Because I am not at all certain that we yet know how to be effective in dealing with food and nutrition problems, I would urge that we think about it even as we are learning to be more efficient.