|Effective Communications for Nutrition in Primary Health Care (UNU, 1988, 208 pages)|
International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
Ethnography, the description and analysis of human behaviour, has formed the basis of all anthropological research. In studying human behaviour, anthropologists have found it necessary to collect data through long-term informal contact, to establish good rapport with the study community, and to have proficiency in the language of the group. Good ethnography is supposed to deal with all aspects of human behaviour and the interrelationships existing between different behavioural components and the beliefs, attitudes, and values associated with the behavioural practices.
For the anthropologist, ethnography remained a goal by itself; the knowledge derived from studying a group's way of life was not used as a tool for achieving any specific goals. In recent years, however, anthropologists themselves, particularly medical/nutritional anthropologists, have become interested in problem-oriented studies.
REVIEW OF ANTHROPOLOGICAL RESEARCH ON FOOD AND NUTRITION
A review of ethnographies from different parts of the world shows that, while the anthropologists have provided valuable information on many aspects of behaviour, food-related behaviour has received little attention. One of the earliest ethnographic accounts focusing on food is Audrey Richards' study of Hunger and Work in a Savage Tribe . She pointed out that the diet of a group could not be studied in isolation because it was affected by a variety of factors: agricultural patterns, seasonal shortages, pattern of food preferences, hospitality rules, role of women, work-load, and urbanization. Richards' list of factors, although incomplete, reflected an awareness of both environmental and cultural factors. Anthropological work on food that began with Richards remained dormant for some time, but then again received increased attention in the US during the Second World War.
The formation of the Committee on Food Habits in the US marked the beginning of the use of ethnography for bringing about changes in food practices. The central thrust of the research of this group centred around studying beliefs and attitudes influencing food behaviour. In summarizing the findings of the committee, Mead  remarked that anthropology is useful in providing information as to how behaviour may be changed, but she added that cultural anthropologists must be aware of the ramifications of change in other areas of life. Despite such an orientation, little attention was paid to non-ideational factors. This group's major contribution was made by Kurt Lewin , who showed that for the modification of food habits, it is important to know the 'gatekeepers" - the persons responsible for decisionmaking at the household level.
Attention to cultural factors that began with the Committee on Food Habits continued to persist in food behaviour studies. The concept of holism that emphasized interrelationships between different aspects of human behaviour and the complexity of factors affecting behaviour did not receive due attention in food behaviour studies. While anthropologists recognized the concept of "holism" and analysed behaviour from a holistic point of view, early ethnographic reports tended to deal more with the ideational and ritual behaviour and ignored the environmental factors.
The development of ecological perspective and its use in the study of food behaviour has taken over the concept of holism . An ecological orientation in the study of food behaviour is deemed essential. In using an ecological approach, social environment is to be understood in terms of its internal differentiation. Any theoretical framework that ignores class differentiation or the impact of cultural rules cannot be a useful tool for ethnographic study. Intra-household food distribution cannot be examined without referring to inequality present in the distribution of resources within a community. Similarly, national food and agriculture and trade policies cannot be ignored in discussing food availability at both inter- and intra-household levels.
The orientation of anthropologists and nutrition communicators in studying the problem of malnutrition differs greatly. While anthropologists put much emphasis on collecting baseline data on the complex set of factors affecting dietary practices, the nutrition educators believe in the urgency of nutrition intervention. Consequently, nutrition intervention programmes spend little time in collecting baseline data. This has led to the perpetuation of many faulty assumptions and the failure of nutrition intervention programmes, which operate on the assumption that most nutritional problems occur because of ignorance and faulty food practices that can be corrected through nutrition education programmes.
Nutrition educators generally depend on surveys to inform them of peoples' attitudes and practices. The survey provides some information in these areas, but fails to relate them to other environmental factors. Consequently, the programmes do not achieve their goals.
If the nutrition intervention is based on good ethnographic investigation, a better understanding of the complexity of factors affecting nutritional status can be obtained and a more realistic nutrition education plan for modifying food behaviour will result.
A brief ethnographic background of the food behaviour of rural Bangladesh, with special reference to pregnancy, puerperium, and childhood, is presented to show why ethnographic investigation is needed for developing effective communications.
DIETARY PRACTICES OF RURAL BANGLADESH
It is often assumed that all rural people depend on home-grown crops for their food supply. In a typical! Bangladeshi village, where 50 to 60 per cent of the people own no agricultural land, most foods consumed are bought from the local market, and homegrown foods constitute only a small portion of the total food supply. Consequently, the household purchasing power determines the type and quantity of food available. An in-depth, careful examination of the income and food purchase pattern in a group of 25 rural households revealed that a lowincome rural household in Bangladesh spends more than 90 per cent of its income on food alone, and when the price of fuel is included, the household runs on a deficit budget.
Because rice assumes a special position in the diet of Bangladeshis and the eating of rice has special psychological significance, whenever income permits rice is used for all three meals of the day. However, in recent years, with the increasing price of rice, villagers have started using wheat and potatoes as alternative staples. When the price of potatoes was one-eighth the price of rice, potato was mixed with rice to stretch the quantity.
Changes in the diet of poor villagers also occurred because of the introduction of technological innovations such as high-yield variety rice, which resulted in a decrease in the acreage planted with pulses. The decreasing output of pulses made pulse, or dal, a rare food item in poor homes. Thus, the amino-acid complementarily of the traditional rice-da! diet is no longer assured.
Trade policies, particularly the export of frozen shrimp and the transport of fish from rural to urban market centres, have reduced the fish supply in rural areas and has led to an increase in the price of fish.
Inadequate food supplies have resulted in a further reduction in the food intake of women. Women, being the epitome of sacrifice in Bangladesh, suffer more in times of food scarcity. The food intake of mothers in the 1982 pre-harvest season went down to as low as 700-800 kcal in our study area.
Frequently, mothers have been found to give up their share of food and remain hungry for several hours so that the small amount of food available could be distributed to the husband and children.
Dietary Practices in Pregnancy and Puerperium
It is generally believed that food taboos and ignorance about nutritive properties of foods are responsible for malnutrition in pregnancy. Our ethnographic investigation reveals that poor nutritional status in pregnancy and puerperium result from the interplay of both socio-economic and cultural factors. As there are very few food proscriptions in pregnancy, inadequate food intake during gestation cannot be attributed to cultural factors. In Bangladesh, two selfcontradictory beliefs exist with regard to feeding the mother in pregnancy. For ensuring easy delivery a small baby is preferred, which some believe is made possible by eating more in pregnancy; there are others who believe that limiting food intake will ensure a smaller baby. Both of these beliefs operate at the normative level. Insofar as my own field experience is concerned, food intake in pregnancy was not found to be affected by either of these beliefs. Rather, the limited choice and inadequate food availability had a greater impact.
In countries where an association between fear of a difficult delivery of a large baby and restriction on food intake is reported, careful examination is needed to determine whether actual food restriction takes place because of such belief or whether it operates only at the normative level, as in Bangladesh.
While both pregnancy and the puerperium are recognized as changing physiological states in a woman, it is mainly in the puerperium that a woman is expected to follow a broad set of dietary rules. Dietary rules consist of both prescriptions and proscriptions. The foods to be avoided include all animal food, leafy greens, and pulses. While in the early puerperium food restrictions are emphasized, from the sixth day after delivery foods believed to give strength and produce blood, such as ghee and koi, magur and shing fish, are recommended.
The study of food beliefs shows a great uniformity, but response to the same beliefs varies with differences in income. In the post-partum period, high-income mothers emphasize dietary prescriptions, while the poor who are unable to meet the cultural prescriptions fill the need by observing dietary restrictions. The logic behind this is that if they cannot eat recommended foods, they can at least observe the food restrictions.
Dietary Practices in Infancy and Young Childhood
The mothers in Bangladesh, like their counterparts in India and Pakistan, have been brought up on the belief that breast-milk is the ideal food for the baby. However, in recent years, powdered milk and baby formula are being considered as almost equivalent to breast-milk, although their use in rural areas of Bangladesh is still very limited. Although breast-feeding is almost universal and the average duration of breast-feeding is almost 24 months, giving of supplementary liquid is not uncommon. One of the central principles guiding infant-feeding practices in Bangladesh is the belief that the infant must be given milk or a similar liquid. The foods most often supplemented include diluted cow's milk, rice powder, and arrowroot barley mixed with water. All of these foods resemble milk and therefore are considered suitable for the young child. All the rural mothers who do introduce early supplementary feeding complain about a reduced supply of breast-milk.
While giving a milky-looking liquid is considered appropriate, feeding solids before the child is able to walk or feed itself is believed to make the infant susceptible to stomach disorders. If a child is afflicted with diarrhoea - a "hot" disease - a "cooling" food such as barley water is recommended. When introducing solids, careful attention is paid to the indigenous food classification. Because a child's life is threatened with all kinds of infections, the disease-free category of food known as nirog assumes critical importance.
The brief ethnographic analysis of the dietary practices of rural Bangladeshis shows that both environmental (socio-economic) and cultural factors affect the food-use pattern. While cultural factors play a significant role in puerperium food habits, the poor socio-economic status and limited food choice are responsible for inadequate food intake during pregnancy.
In devising a nutrition intervention programme, it is essential to know the relative importance of both socio-economic and cultural factors in the aetiology of malnutrition. Failure to obtain this knowledge will lead to the perpetuation of the myth that all problems of malnutrition result from ignorance and food restrictions. The accusation often made about the poor having no knowledge of good budgeting does not hold true when we see how poor villagers make use of potatoes to stretch small quantities of rice. In emphasizing the role of socio-economic factors, the role of cultural factors is not denied. Rather, ethnographers are advised to adhere to their concept of "holism" and make use of the ecological framework in studying food behaviour and malnutrition.
Ethnographic analysis of food practices in Bangladesh shows price is a significant factor in bringing about changes in the use of a staple. However, it should be noted that in adopting the potato as an alternative staple, rural women use the known culinary practice of cooking rice so that the cooked rice and potato mixture resembles the desired rice. This illustrates an example of behavioural adaptation in food selection and preference for a familiar culinary practice whose continuation is crucial to these women. In developing messages to modify food behaviour, attention should be paid to both affordability and acceptability.
The indigenous food classifications that categorize food into '`hot," "cold," and nirog or disease-free foods should be taken into consideration when attempting to modify food behaviour during illness and early childhood. The calorie deprivation suffered by young children from 6 to 24 months that results from the delay in the introduction of solid food is amenable to nutrition education. In devising nutrition education messages, therefore, the nirog or disease-free food becomes crucial because the delay in introducing solids is due to the fear of disease. It might be noted here that this delay occurs because mothers are concerned about maintaining good health and preventing diseases in their children, not because they remain unconcerned about their children's health status. A careful diagnosis of the problem of malnutrition requires an ethnographic investigation, which is essential for devising effective strategies for solving nutritional problems. It is important to know which types of malnutrition are amenable to nutrition education and which ones require improvement in socioeconomic status. Instead of operating with the implicit assumption that all nutritional problems can be solved through the development of effective nutrition education messages, we need to identify clearly those problems that can be addressed by nutrition education programmes.
Having identified the complexity of factors affecting food use, an attempt should be made to develop effective messages for modifying food behaviour and to communicate them. Ethnographic investigations can be of use in identifying key personnel who can act as communicators and also make nutrition planners aware of the cultural patterning of verbal and non-verbal communication. In addition, the close interaction developed between the ethnographer and the study-group members will aid in communicating messages for nutritional improvement.
In promoting behaviour modification, we must not forget about the necessity of reinforcing existing positive practices.
In conclusion, I wish to emphasize that effective nutrition education messages can only be developed and communicated effectively if (1) a careful diagnosis of the factors affecting food behaviour and malnutrition is made and (2) nutrition education messages recommend changes in food intake that are affordable and culturally sensitive.
1. A. Richards, Hunger and Work in a Savage Tribe (Free Press, Chicago, 111., 1932).
2. M. Mead, The Anthropological Approach to Dietary Problems, Transactions Series, 11, 5 (New York Academy of Sciences, New York, 1943), pp. 117-182.
3. K. Lewin, "Forces Behind Food Habits and Methods of Change," in NAS/NRC, "The Problem of Changing Food Habits," NRC Bulletin, 108, Report of Committee on Food Habits, 1941-1943 (NAS, Washington, D.C.. 1943).
4. G.H. Pelto, "Anthropological Contributions to Nutrition Education Research," J. of Nutrition Education, 11(1): Suppl. (1981).