Summary and recommendations

The research instrument and the methods used facilitated the identification of both ideational and economic factors, and their interaction contributing to deficient vitamin A intake among children. This multifactored analysis of vitamin A consumption and practices related to stages of xerophthalmia from a social and cultural perspective enabled the researchers to gain a better understanding of vitamin A deficiency in the research area and factors influencing decision-making for vitamin A deficiency treatment. The study also generated information that highlights local explanatory models as they relate to the stages of signs and symptoms of vitamin A deficiency.

The research instrument has practical implications for eliciting data to develop culturally-specific vitamin A education messages and to design vitamin A program strategies in the Filingué region. Furthermore, the data collected could be adapted for vitamin A programming in other sites in the Sahelien zone of Niger, and the methods used can be applied to locations throughout the country.

The breadth of knowledge uncovered relating to the causes of ocular signs and symptoms associated with vitamin A deficiency and the extent to which traditional food practices coincide with appropriate preventive measures and remedies is reflective of an in-depth understanding residents have developed due to extensive exposure to stages of xerophthalmia. Furthermore, foods rich in vitamin A, particularly animal sources, are described as having highly sought after qualities such as blood-rich, tasty, strengthening, fattening, and healthful and are generally suitable for children. This information has programmatic implications for the development of regionally-specific health and nutrition education messages.

One obvious constraint in increasing consumption is that many of the animal sources of vitamin A are expensive. All three primary key-informants suggested that people in the area cannot afford to eat these more costly foods on a regular basis. For example, one informant said, "Money stops us from buying these good foods," while a second informant, when talking specifically about liver stated, "People cannot afford to spend money on liver unless they are sick-this is when they think that it is important to buy liver."

Green leafy vegetables are well-liked and associated with important food characteristics. However, if they are not treated or stored properly, traditional dishes provide a vehicle for parasites. Additionally, preparation often involves extensive boiling of the leaves and preservation methods that expose them to the sun over a two to three day period, depleting the vitamin A value. Other carotene-rich foods have become less available recently with a decrease in gardening. Although the gardening season is short it occurs at a critical time of year when other foods rich in vitamin A may be less available. Efforts could be made to use the various water sources in the area, including the pumped water system operated by the government, to encourage gardening. It also seems feasible that the problem of pillaging of produce could be resolved.

Women believe that the nutritional value of food eaten during pregnancy or lactation is passed on to the infant. Although less likely to eat good food for their own needs or benefit, women indicated that during pregnancy or lactation they would alter their diet appropriately for the benefit of the child. This is an important factor that should be considered when developing health and nutrition strategies.

Between the ages of one and three, particularly at the time the child is removed from the breast, which is abrupt and traumatic, children in the Filingué region are most vulnerable for developing vitamin A deficiency and associated illnesses. This is a time when children are no longer under the direct supervision of their mother and have to fend for themselves to seek between meal foods. They follow the family food pattern, a diet that does not fulfill children's special nutritional needs, and share meals with their siblings from a communal plate. A way to increase the vitamin A consumption in this age group would be to encourage women to put a portion of ghee or cow's butter into the sauce of the age group most at risk for developing vitamin A deficiency. Once a child reaches three or four years and has developed wuyo, he or she will be better able to obtain between meal snacks. It is important to note that several of the foods richest in vitamin A are labeled as good for children or containing vitamins for children, and are eaten as snack foods. These includes mangoes and carrots, that are relatively affordable, as well as liver and eggs that mothers indicated could be purchased periodically. Health messages promoting an increase in consumption of these nutritious foods could be developed.

Several of the mother-respondents interviewed suffered from nightblindness during pregnancy. Although women indicated that the traditional liver treatment should resolve the problem, they suggested that nigh/blindness is caused by the additional requirements of pregnancy combined with the demands strenuous work places on the body, which will pass with delivery. Therefore, if the affliction continues following the home remedy women generally do not seek outside care. Given the number of pregnancies women go through, and the extent to which the deficiency exists, women of reproductive age are at risk for developing vitamin A deficiency, thus putting infants at a higher risk from birth.

Mother-respondents consistently associated nightblindness among children with hardship or lack of good food. Among under six-year-olds nigh/blindness is less likely to be recognized prior to the wuyo stage when children can walk and talk. Although respondents indicated that if the home remedy did not work they would take children to the dispensary for treatment of nightblindness the failure to recognize nightblindness among this younger age group puts them at a disadvantage and could result in a delay in administering a home remedy or accessing outside care.

The home treatment given to children is generally either liver or another blood-rich food such as meat, green leaves, eggs, or milk. The liver treatment for nightblindness is most widely known and seems to be frequently practiced. If nigh/blindness is to be remedied, these practices must be modified so that the child (or woman) gets adequate portions to resolve the problem. Adaptations of these food measures should be promoted and integrated into nutrition education messages. Although research shows that if the home remedy does not eliminate the problem women generally seek outside care at the dispensary, the time spent at home waiting for the home treatment to work is dangerously long. Educational strategies could be developed to encourage mothers to take quick action.

It is important to reiterate that women recognize Bitot's spots and corneal xerosis as severe problems, potentially leading to the loss of both eyes. People frequently indicated that these danger signs are associated with poor diet or lack of sufficient breastmilk and commonly occur in conjunction with other illnesses. But given the extent of household demands women may not have the contact with children necessary to recognize the danger signs when they first develop. The data indicate that the lag period between the time when clinical vitamin A deficiency occurs, which once manifested can develop extremely rapidly, and when it is actually detected could be long. Furthermore, nightblindness is not associated with these later stages and is not considered serious.

Since men control the finances and are responsible for paying health care fees, it is clear that male heads of households must also be targeted in any nutrition education/vitamin A programming strategy. In addition, when delineating household decision-making around treatment choice, women indicated that they need to get permission from their husbands in order to visit a health practitioner. It is therefore paramount that men are aware of the seriousness of vitamin A deficiency and its possible health repercussions.

Given the apparent extent of the problem in the area, and the high rates of malnutrition and fatality rates associated with measles, adequate stocks of capsules should be available at the health center and routinely administered to children suffering from signs of xerophthalmia and childhood illnesses associated with vitamin A deficiency. Ongoing training of the healthworkers on recent findings of vitamin A deficiency, as well as preventive and curative measures, is also recommended.