Commentary: Underpinning vitamin-A deficiency prevention and control programmes

Barbara A. Underwood

If you give a hungry man a fish, he is fed for one day but is dependent upon you for continued sustenance. If you teach a hungry man to fish, he is independent for life.

The analogy between this well-known saying and the approaches to the prevention and control of vitamin-A deficiency is obvious: providing children with high-dose capsules of vitamin A saves many from developing clinical symptoms and perhaps reduces mortality and morbidity, as long as the dose can be delivered repeatedly at specified intervals. If the system fails or the individual child is not reached, the problem recurs. Approaches to prevention that foster practical solutions attainable through better utilization of available food and other resources are more difficult to implement and take longer to bring about the needed behavioural changes in child-rearing practices. But they can be permanent and address health and nutrition issues that commonly coexist with vitamin-A deficiency.

Most vitamin-A intervention programmes recognize these facts and include an "educational" component. In practice, however, the educational component takes a back seat to efforts required for the delivery and monitoring of the high-dose capsule. The personnel responsible for capsule delivery frequently inform recipients of what the capsule is for and of foods they should eat that contain the vitamin, but fail to communicate the message in a locally appropriate, meaningful way that changes behaviours: such communication may be perceived as taking too much time. This fact is illustrated by the evaluation report of the Bangladesh vitamin-A distribution programme described in an earlier issue of the Food and Nutrition Bulletin [1].

Clearly there is need to rethink strategies for vitamin-A-deficiency prevention and control. The high-dose medical approach is appropriate under circumstances where a public health problem exists and alternatives are not feasible, e.g. where water, transportation, and food-storage facilities are in short supply or non-existent. Often, however, these circumstances are regionally clustered and not applicable to an entire country. But even under these circumstances, strategies that combine the short-term medical approach with programmes addressing underlying conditions that contribute to high rates of infections - e.g. programmer to improve personal and environmental sanitation and increase immunization coverage - can have beneficial spin-off effects on the vitamin-A deficiency problem. As the evaluation of the Bangladesh programme by Darnton-Hill et al. [1] illustrates, the efficacy of the medical model is limited by the inefficient delivery system. There is no doubt that the programme has saved the sight and lives of many Bengali children, but, as the authors note, it has not reduced the overall prevalence of the problem - even after 14 years. In addition, the struggle to improve the delivery system and its monitoring is consuming much of the national human and economic resource pool.

During the 14 years of the Bangladesh programme, some evidence indicates that diets not only have not improved nutritionally with respect to vitamin A but have deteriorated, and that little change has occurred in personal and environmental health practices. After 23 rounds of vitamin-A-capsule distribution, limited knowledge about the programme exists: 34%-60% of mothers did not know what the capsule was for, 15%21% had not seen the educational materials, and 51%75% could not name a vitamin-A-rich food. It is precisely this kind of evaluation data that frequently is used by opponents to illustrate that educational approaches don't work! But can we blame this failure on the educational approach, or should we admit that we have been ineffective communicators in the educational component of the currently operational high-dose programmes? Often we ask overburdened, unmotivated, and minimally trained delivery personnel to get the message out. Or we determine that only those who have higher education have sufficient knowledge to effectively compose and communicate the message, whereas those to whom we want most to relate are underprivileged and often lack formal education and access to other social programmes. But they are survivors. As survivors they have had to make choices - choices that include which of the many messages they hear and programmes forced upon them they will choose to act upon in the use of their limited resources, both of time and of money. Choice, however limited, is valued irrespective of socio-economic status.

People change practices when they are convinced that the change is to their benefit and they choose to change. Choice is too frequently left out of approaches to solving public health problems, including vitamin-A intervention strategies. Most universal capsule distribution programmes do not entertain choice as an option, yet targeted recipients for such programmes choose not to participate in increasing numbers in successive rounds, as evaluations of the Bangladesh and other national programmes illustrate. Indeed, proponents of fortification programmes proclaim the lack of choice as the major advantage of a fortification strategy. But, as occurred with the sugar fortification programme in Guatemala, as effective as the programme was shown to be while operational, the situation deteriorated rapidly when it was disrupted by internal political and economic changes. No demand for continuation of the programme had been created among the passive recipients.

How can the concept of choice be introduced into strategies for the prevention and control of vitamin-A deficiency? Just as with any other programme, there is not likely to be a universally applicable answer. Each situation has to be evaluated at the national, community, and family levels. The important point is that choices usually do exist if imagination and innovative thinking are applied, and these choices could be made available when considering strategies at each level of intervention. In some instances where clinical deficiency is rare, a national programme to improve the intra-country preservation, storage, and year-round availability of vitamin-A-containing foods, combined with an effective programme to improve consumption, might be an appropriate alternative to a high-dose programme. Elsewhere, a community-based feeding programme, a community- or family-level income-generation programme to provide economic resources to permit a choice of appropriate foods, or a kitchen/community garden may be alternatives - and these programmes are not mutually exclusive. Until we create a demand for a programme or a product, i.e. convert programme recipients into programme consumers, whether for a high-dose capsule, lower-cost green leafy vegetables, or better means of preparing and preserving vitamin-A-rich foods for feeding young children, it is difficult to conceive of achieving the effective sustained behavioural change that must occur to eradicate and control vitamin-A deficiency as a public health problem.

Reference

1. Daraton-Hill 1, Sibanda F. Mitra M, et al. Distribution of vitamin-A capsules for the prevention and control of vitamin-A deficiency in Bangladesh. Food Nutr Bull 1988;10(3):60-70.