|Effective Communications for Nutrition in Primary Health Care (UNU, 1988, 208 p.)|
The United Nations University is an organ of the United Nations established by the General Assembly in 1972 to be an international community of scholars engaged in research, advanced training, and the dissemination of knowledge related to the pressing global problems of human survival, development. and welfare. Its activities focus mainly on peace and conflict resolution, development in a changing world, and science and technology in relation to human welfare. The University operates through a worldwide network of research and post-graduate training centres, with its planning and co-ordinating headquarters in Tokyo, Japan.
Report of the Asian Regional Workshop, Bangkok, Thailand,
3-7 October 1983
JEAN E. ANDERSEN and AREE VALYASEVI
The United Nations University
Food and Nutrition Bulletin Supplement 13
This volume is a result of the interest of the United Nations University in the application of the results of its research networks conducting research on the food and nutrition problems of developing countries. It is based on a UNU co-sponsored workshop which summarized and evaluated the nutrition education programmes of Thailand and the Philippines and which also included in its proceedings the experiences with nutrition education in other Asian countries. The introductory contributions feature a critical review of existing methodologies for nutrition education in the Asian context. The experiences and lessons presented are of relevance and value to all developing countries.
It is known that good nutrition leads to good health, and vice versa. However, as long as people are ignorant of the proper ways and means to maintain good health and nutrition, the goal "Health for All by the Year 2000" will be extremely difficult to achieve. It is therefore necessary to seek the most effective and efficient ways and means to educate people, change their attitudes, and modify their practices so that they can keep themselves healthy.
Thailand has adopted the primary health-care (PHC) approach for its health-care service. The Ministry of Health and Mahidol University jointly provide training for PHC workers from Thailand and other ASEAN countries. The Institute of Nutrition has also conducted operational research using various communications techniques, including radio and video tape. Rotary International has given us financial support for the operation of the project. His Excellency Mr. Bhichai Rattakul, the former governor of District 330 of Rotary International, has assisted us in acquiring this support.
The studies in Thailand as well as in other Asian countries indicate the urgent need for innovative and effective communications. As Asian countries have many health problems in common, so they share many socio-economic, cultural, and nutritional similarities. We sincerely hope that the workshop will provide an excellent opportunity for us to share our experience and knowledge as well as to recommend future plans for nutrition and health communication programmes for this region.
There are 47 participants from 13 countries; all of them have been, and still are, actively taking leading roles in health and nutrition education in their respective countries. There are resource persons from the United States and from one Asian country, who have travelled several thousand miles to participate in this workshop. On behalf of the organizers, I should like to express our sincere appreciation for their time and efforts. The outcome of the workshop will feed in to the Fourth Asian Congress of Nutrition, to be held in Bangkok from 1 to 4 November. It is hoped that the Asian nutritionists will derive benefit from our deliberations. Finally, I hope that we will be able to achieve fruitful results and recommendations that will be applicable to each of our respective countries.
During the organization of this workshop, we had valuable advice from the principal consultant, Ms. Jean Andersen, and Professor Nevin Scrimshaw. The organizers wish to express their gratitude for financial support provided by the United Nations University (UNU), the United Nations Children's Fund (UNICEF), and the Coca-Cola Company, Atlanta, Georgia. Dr. L.J. Teply of UNICEF-New York, Mrs. Titi Memet, and Dr. Lay Maung of UNICEFEAPRO facilitated the attendance of Asian participants at the workshop; Mrs. Jane Bunnag of UNICEF-EAPRO provided advice and assistance during the initial planning; and Mrs. Suchada Sangsingkeo of UNICEF-EAPRO rendered valuable assistance in corresponding with workshop participants.
The Asian Regional Workshop on Effective Communications for Nutrition in Primary Health Care was organized with the purpose of evaluating, expediting, and expanding the progress made with communication for health and nutritional improvement. This report on the workshop proceedings includes the papers of resource persons as we]l as the country or project reports presented during the workshop. Three case-study presentations from the Philippines, Indonesia, and Thailand give insights into some of the efforts made by Asian countries in their attempt to develop effective communication for health and nutrition in primary health care.
The main objectives of the workshop were to:
It is hoped that the proceedings will be widely distributed, not only to inform, but also to motivate various national and international agencies and institutions in other developing countries to join us in this effort to achieve health and nutritional improvements for all people.
It gives me great pleasure to preside over the opening ceremony of the Asian Regional Workshop on Effective Communications for Nutrition in Primary Health Care.
Science and technology have progressed very rapidly during the past few decades. However, many health problems still exist, especially among poor rural communities in less developed countries. Progress in medical science has, in the past, emphasized the provision of curative health care. Problems of inadequate health personnel are commonly encountered. In recent years, it has been recognized that preventive and promotive health measures are necessities in a comprehensive and effective approach to health-care service.
To enable people to contribute to their own health care, access to information regarding proper practices is crucial. Gaining information, however, does not always lead to appropriate attitudes and practices.
The process of communication we are concerned with is the transfer of messages, the creation of awareness, and the encouragement of sound practices. Communication for behavioural change is not a simple matter, as behaviours or practices may result from years of accumulated experiences from childhood on. The anthropological and sociological backgrounds of population groups are also influential. Communication with the rural poor is diffficult because illiteracy and traditional beliefs and practices further complicate the challenge of effective communication.
Despite these difficulties, I believe that various countries, governments, and institutions have been seeking ways and means to eradicate the problems. The participants in this workshop, I trust, will use their considerable abilities, knowledge, and experience to the ultimate benefit of all Asian people.
Nutrition surveys have shown that in Asian countries the prevalence of malnutrition is still as high as 50 to 75 per cent among infants and pre-school children. While it is fairly obvious that economic factors are important in uplifting the well-being and nutritional standards of the populace, studies carried out by the FAO in Thailand, Malaysia, and the Philippines clearly reveal that increased income is not always related to improved nutrition, although it does play a significant role. Moreover, an adequate national food supply is certainly not equivalent to adequate nutrition for all a nation's people.
A recent survey of rural villages in Thailand undertaken by the Institute of Nutrition at Mahidol University, under the supervision of Professor Dr. Aree Valyasevi, has shown that regular and frequent nutrition education, provided with health-care and food-producing and income-generating activities, resulted in a striking improvement in the nutritional status of infants and pre-school children in those areas.
It is clear, therefore, that providing sound nutrition information is vital. Food taboos and antiquated food beliefs and practices that have been passed on for generations have always been a great barrier to modifying eating behaviours or habits. Functional illiteracy related to malnutrition and the poor learning environment in rural settings and among disadvantaged urban groups are among the ecological factors that maintain the vicious cycle leading to malnutrition.
In order to break this cycle, an effective means of continuously transferring information on sound nutrition is imperative. This information must be communicated to people with the aim of creating an understanding of its urgency and importance so that people will be convinced that new patterns and practices related to nutrition are in their own interest.
The use of communication techniques to effect behavioural changes is by no means new. Commercial advertising is a good case in point. Those working in health or nutrition education may gain a great deal by examining such communication techniques and using any aspects that would be appropriate for their field. Health and nutrition educators must be guided by the understanding that communication is the art of giving a part of oneself to other people in such a way that they willingly accept this offering.
Advances in communication technology have enabled us to speak with people around the globe. Very often, however, we see that we cannot even bridge the ever widening communication gaps within our own families.
The challenging task is to find effective communication techniques for nutrition and health education. The questions to be answered are:
H.E. Mr. Bhichai Rattakul
Deputy Prime Minister
AMORN NONDASUTA, PIROTE NINGSANON, PRAMUKH CHANDAVIMOL, and PUANGTONG
Ministry of Public Health, Bangkok, Thailand
PRIMARY HEALTH CARE IN THAILAND
The problem of under-utilization of health centres and hospitals in rural Thailand led to the initiation of a pilot project on primary health care (PHC) in Sarapee District, Chiang Mai Province, in 1969. The project was designed mainly to extend various health services to cover a greater portion of the population in the area. The initial estimation for coverage of existing health services was below 20 per cent of the total population at that time. Recognizing that the health-service delivery structure was not covering all the health and medical demands of the community, the project organizers' strategy was to train people selected by the community to function as intermediaries between the peripheral tambon (community of villages) health officers and the community, adding to the existing health-service delivery on a voluntary basis.
Evaluation of the pilot project revealed that there was increased coverage of the population with basic services. Since then, several pilot projects have been carried out in other parts of the country and the results have been satisfactory. Studies have also been done on various aspects of the volunteer service, such as the method of selection, the types of people who are best suited to perform health services on a volunteer basis, etc. The experience gained from these studies led to the development of a nationwide programme of primary health care in 1977.
THE CONCEPT OF PHC IN THAILAND
The concept of PHC in Thailand has been developed from the country's experience in solving the health problems of underserved people in the rural areas. The concept of community participation - consisting of the contribution of ideas, manpower, money, and materials by the community - is fundamental and provides the key to the success of the PHC programme. To educate a community to be self-reliant or self-supportive is another basic concept that the programme fosters. The Ministry of Public Health (MOPH) is aware that the strengthening of a health-services delivery system and development of a referral system is essential to support the PHC activities.
In the National Seminar on Health for All by the Year 2000, conducted in December 1979, it was decided that primary health-care activities should comprise the following elements: (1) health education; (2) local endemic disease control; (3) maternal and child care, including family planning; (4) immunization against communicable diseases; (5) provision of essential drugs; (6) treatment of common diseases; (7) nutrition promotion; and (8) sanitation and safe water supply.
Furthermore, the participants in the seminar felt that PHC activities could be changed according to community awareness of the problems to be solved. Because health is only one part of development, other aspects such as education, agriculture, community development, etc., should also be considered.
OBJECTIVES OF THE PHC PROGRAMME
The objectives of the programme, formulated on the basis of various concepts, were:
PRIMARY HEALTH-CARE WORKERS
Based on experience in Thailand, it is recognized that potential human resources exist in the community and are waiting to be mobilized. Two types of primary health-care workers have thus been developed: village health communicators (VHCs) and village health volunteers (VHVs), who promote rural health and other development efforts through an organized community. The VHCs are responsible for a cluster of 8 to 15 households, the VHVs for the whole village. The functions of VHCs are to impart health education (prevention and promotion), and to disseminate and obtain health information from the villagers. The VHVs perform the same functions as VHCs, but also have the duty of caring for people who have had simple accidents or injuries and those with common diseases.
Both VHCs and VHVs work on a voluntary basis. However, the government provides them with free medical services and a certificate when their training is completed. Other intangible incentives such as recognition from their peer group are also present.
SELECTION OF PRIMARY HEALTH-CARE WORKERS (VHVS AND VHCS)
To prevent a high drop-out rate for PHC workers, proper procedures for selection are critical. Community preparation prior to selection is necessary. A simplified house-tohouse survey proved suitable for identifying the right people.
TRAINING OF PHC WORKERS
An informal five-day training course for VHCs, covering the use of self-instruction modules, health problem identification, team working, etc., is organized by subdistrict health personnel. The 35 self-instruction modules for VHCs cover curative, preventive, and promotive measures. The VHCs are expected to be able to disseminate such knowledge and gather information from villagers. VHVs obtain 17 additional modules on simple curative care and are trained for an additional two weeks.
When the programme was first implemented nationally in 1981, a training scheme extending from the central MOPH to the peripheral level was developed (fig. 1)
The central trainers are staff members of the MOPH trained in the principles of teaching and learning, using 7 modules on self-teaching and learning. These trainers then developed simplified modules for training the provincial and district trainers and became involved in curriculum planning and training of VHCs and VHVs.
The provincial/district trainers consisted of provincial health staff from the training section and one staff member from each district health office. This team was responsible for training tambon health personnel to conduct the training of VHCs and VHVs.
Fig. 1. Plan for training the trainers at different levels.
Fig. 2. Health service network.
SUPERVISION AND SUPPORT
The Office of Primary Health Care in the Ministry of Public Health is responsible for supervision and support of the PHC programme through the existing health infrastructure (fig. 2)
The purpose of supervision is to strengthen the performance of personnel and volunteers at all levels in order to achieve the goals of PHC. The scope of supervision includes programme planning and monitoring, continuing education, provision of material supports, and selection of VHVs and VHCs.
Supervision of the district level by the provincial level is scheduled three times a year, as is supervision from district to subdistrict level; from district level to VHVs and VHCs no fewer than three villages per district are sampled.
The overall organizational framework of PHC is illustrated in figure 3.
NUTRITION FOR HEALTH AND GROWTH
Nutrition, as one of the elements of PHC, is a major determinant of health and growth. Nutrition and health are not synonymous, but without good nutrition health cannot be optimum.
The consequences of food and nutrition processes and their relation to health are shown in figure 4.
In 1960, the first National Nutrition Survey was conducted by a joint Thai-American team, the Interdepartmental Committee on Nutrition for National Defense (ICNND). The results showed that the civilian population consumed 100 kcal per day below the average requirement of 1,871 kcal. Anaemia and iodine deficiency (goitre) were commonly found. A survey in 1982 still showed a high prevalence of malnutrition, despite several programmes implemented to eradicate nutritional problems.
In a review of past experience, the following factors were found to be the major constraints:
Fig. 3. Organization of PHC programme.
Fig. 4. Food and nutrition in relation to health.
Existing Health Delivery System
During the past 40 years, health delivery in Thailand was based on the Western concept of having a centre for treatment. It was found that only 20 per cent of the population was served by this system. A midwifery centre existed in only 4 per cent of the villages and a health station in 8 per cent. Mobile clinics have been an alternative giving more outreach, but are limited by logistics problems.
Lack of Community Awareness
Thinness and small body size are perceived as normal by rural villagers. Therefore, the involvement of the community in nutrition programmes has been minimal. Furthermore, improvement in a child's nutritional status is neither apparent nor rapid and may require a change in infant feeding practices.
Lack of Multi-sectoral Involvement in the Programme
Nutrition programmes have been viewed as the health sector's responsibility. Though the multidisciplinary nature of the nutrition programmes is realized, collaboration among various sectors has been limited. A National Food and Nutrition Committee was formed in 1970 to initiate such collaboration, but it has not yet been achieved.
A pilot study on Innovative Village Nutrition Activities was conducted in 90 villages in three north-eastern provinces. A simple weighing technique and growth charts were found to be very good tools for problem identification and led to community participation in other nutrition activities, such as nutrition education, locally produced supplementary food, self-monitoring feeding stations, etc. These activities proved feasible for villagers, VHVs, and VHCs. Therefore, it was decided in the current Fifth National Economic and Social Development Plan (NESDP) (1982-1986.) to make a policy of implementing nutrition programmes in the context of PHC.
NUTRITION IN PRIMARY HEALTH CARE
Implementation of PHC programmes since 1977 depended on the activities of "medical cooperatives" at the village level. Villagers perceived this as serving their needs (felt needs), and it helped them gain managerial skills in establishing the village health fund. The stability of the cooperatives appeared to depend greatly on the involvement of villagers through their contributions both in cash and in kind. A similar strategy has therefore been applied to initiate nutrition in PHC, detailed as follows.
A simple problem-identification procedure and a village nutrition surveillance system (fig. 5) have been launched and have successfully initiated community participation.
A simple weighing scale and uncomplicated, attractive growth charts, which could be calculated and interpreted by villagers, were used. Between 1979 and 1983, over 2 million infants and pre-school children were weighed at least once. A group growth chart was developed for VHCs and VHVs, and is used for the presentation of the results and as a monitoring tool. The addition of pictures of children in different nutritional states also helped the villagers to relate weighing to the appearance of the child.
Fig. 5. The village surveillance programme.
A food and nutrition problem-solving programme, described below, was developed to meet community needs in tackling problems.
The Target Group
The main target group is limited to children under five years old with second- and third-degree malnutrition. The goal was to eradicate all third-degree malnutrition and reduce second-degree malnutrition by half.
Food Supplementation Action
Supplementary food, consisting of rice, legumes, and sesame, was formulated by the Nutrition Division and Institute of Nutrition, Mahidol University. The formulas vary depending on locally available raw ingredients. The purpose is to supplement calories and protein in the habitual diets of children of six months to five years old. Simple processing equipment and an easy method were developed. The food has been well accepted by the target groups and the processing can be done easily by villagers.
Creation of a Village Nutrition Fund
During the course of nutrition programme implementation, it was found that motivation was needed to promote food-processing. Concern for the malnutrition problem and its consequences was one such motivation. Another very effective incentive was the economic one, that is, selling the food produced to nearby communities where food processing did not exist. This led to the initiation of the village nutrition fund scheme (fig. 6).
The process starts with a government contribution of 3,000 baht ($1 = 18-23 baht) per village to buy supplementary food, which is given to the village committee for free distribution to second- and third-degree malnourished children. The organization is similar to "medical cooperatives." People are required to contribute in cash, raw food materials, or labour, in addition to the government endowment. The production of supplementary food is also promoted for sale to the general population. The income as well as the initial community and government contributions generate the "village nutrition fund" that will support the food supplementation programme as an ongoing process. The fund will also provide supplementary food free to severely malnourished children after the initial government support has ended. This is another important milestone in the Thai Primary Health-Care Programme Involving community welfare action.
The community can also generate feeding-station activities for searching for and testing appropriate supplementary food formulas. The most important step is to generate three essential elements at the village level in the nutrition programme, as shown in figure 7. Lack of any one of the three can lead to the failure of the programme.
Fig. 6. The village suplementary food production programme.
Fig. 7. The three essential elements for a village nutrition programme.
The results from both the modelling period of the Viilage Innovative Nutrition Activities and the nationwide implementation showed that this new approach is successful, as measured by the improvement in the nutritional status of the children. From the latest survey in July/August 1983 by the Nutrition Division, supplementary food production funds have been established in many of the targeted villages. These amount to 1,668 food production units and 958 nutrition funds.
The nutrition education objective has changed from attempting to teach all of the population basic nutritional knowledge to concentration on pregnant and lactating mothers to increase their management skills in the supplementary food programme.
Fig. 8. Village nutrition activities.
The village committee, the VHV/VHCs, and other volunteers are trained and given the responsibility of spreading nutritional messages in the community by means of self-learning packages, manuals, posters, flip charts, and other printed materials.
Overall nutrition activities in PHC are summarized in figure 8.
The Multi-sectoral Collaboration Approach
The conceptual framework in food and nutrition activities for each of the four community
development-related ministries was formulated and put into operation with multi-sectoral collaboration in 1981, as shown in table 1.
OTHER DEFICIENCY DISEASES IN PRIMARY HEALTH CARE
For iron deficiency anaemia and endemic goitre, a study from Leoi Province confirmed the utilization of iodine- and iron-fortified salt as the most appropriate method for approaching the rural poor, because salt is consumed daily by this population. The problem is lack of total coverage with fortified salt and the increasing trend to consume locally produced rock salt. The approach has now been changed and incorporated into the primary health-care system. The fortification technique has been simplified for the VHV/VHCs, and local fortification by the VHV/VHCs, with linkage to the existing village medical co-operatives and village funds, began in fiscal 1984. Details are presented in figure 9.
Table 1. Community food and nutrition activities
|Sector||Major responsible area||Minor responsible area|
weighing activity |
Attend the feeding station
Attend the food production activity
Feed supplementary food to the malnourished child
Share in the nutrition fund
|Village committee||Plan and monitor the village food and nutrition activities|
|VHV/VHC/others||Organize and implement the village food and nutrition activities|
|Tambon health officer||Supply and support
nutrition surveillance action
Give health/nutrition education
Support in organizing the village nutrition fund and supplementary food distribution
|Tambon agricultural extension officer||Promote agricultural food production||Nutritional education|
|Primary education teacher||Nutritional education|
BOTTOM-UP PLANNING AND THE POVERTY ERADICATION PROGRAMME
In the present NESDP, a new planning system aims at the encouragement of bottom-up planning. The focal point in planning at each level has been strengthened by a systematic orientation and training programme. The whole structure is summarized in figure 10.
The tambon council and the village committee are purely commtnity organizations. Requests from the villagers will be gathered and integrated, and priorities set at the tambon council. The tambon development plan will be submitted to the district development committee for integration and priority setting, and then submitted as the district development plan to the provincial development committee for the final check and integration.
The provincial development plan will be submitted to the National Rural Development Committee for final approval. At the tambon level, officers from all sectors are in the tambon development working group, which is responsible for giving technical support to the developmental programme of the tambon council and village committee.
There were 12,555 villages identified as poverty-stricken by the National Rural Development Committee in 1982. A National Poverty Eradication Programme has been formulated and is being operated with the goal of total coverage of the poverty area by 1986. The programme includes the nutrition programme and other agricultural food production programmes such as poultry, vegetables, legumes, fruits, sesame, and fish. This enhances the capability of the nutrition programme to cover more targeted villages in the present NESDP (1982-1986); it is expected that 40 per cent of the villages (26,000 villages) will be covered. In conclusion, for each targeted village, the support will be:
Fig. 9. The local iodine- and iron-fortified-salt approach.
Altogether, each village will have an average unit-cost governmental investment of 6,000 baht.
FURTHER PROGRESSION OF THE THAI NUTRITION PROGRAMME THROUGH THE PRIMARY HEALTH-CARE APPROACH
The nutrition programme, when incorporated into the primary health-care approach, has also clearly shown the way for collaborative action from other governmental sectors and the community (fig. 11). As the programme progresses to the stage of self-supplementation and distribution, its integration into the existing community structure, such as the village co-operatives, should be closely monitored by both the village committee and the tambon officers to assure that distribution is directed towards the malnourished children and that the profit goes to the community. Clear instructions on how to maintain quality by monitoring, i.e. sampling and checking each production lot, will assure the success of the supplementation programme.
Fig. 10. The planning structure of the Fifth NESDP.
The generation of the village fund is the first step in this expansion of the programme toward other community development programmes, and the free distribution of the supplementary food will provide a model for other community welfare action. The holistic concept of self-reliance in the nutrition programme, starting from self-recognition of the problem, self-planning, and problem-solving with a self monitoring system, will give villagers a complete pilot model. and may be applicable to other community development programmes, for example those using the Basic Minimum Needs of Thai People as indicators.
Fig.11. Conceptualized framework for nutrition programme in primary health care.
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.
MARIAN F. ZEITLIN
Tufts University School of Nutrition, Medford, Massachusetts, USA
This presentation on the potential impact of nutrition education could also be titled, "How Much to Invest in Nutrition Communications?" Should nutrition education receive the same level of funding currently given to food aid or to major programmes in family planning, health, and agriculture ?
The answer depends not only on the cost-effectiveness of nutrition education programmes to date; it also depends on the potential impact that nutrition education could have if it received more than token levels of support. High-level policy-makers tend to have little faith in the power of nutrition education. When speaking candidly, they tend to express beliefs such as the following: "Poverty or lack of food is the real cause of malnutrition. Without increase in income, food availability, or basic services such as health, educational methods are relatively powerless to combat malnutrition. Therefore, it is not worthwhile to invest large sums of money in nutrition education. Small amounts may be needed for 'project support communications' (UNICEF's term). Large amounts would not be appropriate."
As an example of this point of view, an agency funding a multi-million dollar nutrition programme in an Asian country recently questioned plans to spend 7 per cent on nutrition education. Senior agency executives felt this was too much.
This paper attempts to answer two questions: (1) Is lack of income the main cause of malnutrition? (2) What power would communications have to affect the problem, if significant sums of money were invested in it ?
In answer to the first question, a careful look at the causes of malnutrition in young children the major type of malnutrition in developing countries - shows that this conventional point of view simply is not correct, except among the very poor. Severe endemic malnutrition occurs in almost all developing countries at the weaning age. A major proportion of this malnutrition has been proven to be caused by ignorance and incorrect food and health beliefs, linked to poor feeding and health practices. The fact that this ignorance persists reflects inequity in the distribution of the knowledge generated by modern technology.
These facts have been documented for at least 15 years . The Sidney M. Cantor study of nutrition as an integrated system in Tamil Nadu, South India, quantifies the weaning age problem clearly . Figure 1 shows a comparison of daily calorie need with percentage fulfilment of calorie need from birth to 70 years old in Tamil Nadu. The deep dip in the curve between birth and three years indicates an average drop in intake to below 60 per cent of caloric adequacy at about 12 months. Figure 2 presents the same percentage fulfilment figures by age for five levels of total family adequacy and shows that the dietary intake of infants between about four months and two years of age was insufficient even in families who were meeting 112 per cent of calorie requirement. Figure 3, giving the same percentages by age for three levels of family expenditure, indicates that dietary insufficiency of infants aged 12 months, amounting to an intake of less than 70 per cent of requirement, is almost equally severe in families with a total monthly expenditure of 97 rupees as in the lowest-income families with an expenditure averaging only 24 rupees. Though less completely documented, age-specific inequality in intra-family food distribution and calorie deficiency during the weaning age regardless of family wealth have been reported by nutritionists the world over.
Fig.1. Comparison of daily calorie need (upper graph) and percentage fulfilment of individual calorie needs (lower graph), Tamil Nadu, South India.
Educated elite groups, such as families of university professors, for example, have adopted modern styles of infant feeding and do not experience this weaning crisis. Children in more traditional wealthy families recover nutritionally when the weaning period is over and become susceptible to the problems of overnutrition in succeeding years.
Fig. 2. Percentage of individual calorie needs fulfilled, by age, for five levels of family calorie adequacy, Tamil Nadu, India, 1972 (redrawn by Joe D. Wray from Sidney M. Cantor Associates , p. 101).
A second dip, or period of dietary inadequacy, during the teens and early twenties, is shown in figures 1 to 3. This dip has consistently been reported from many areas of the developing world , although it may not occur in regions such as the rain-forest belt of Africa, where calorie-dense crops are plentiful at all seasons. It may also be less common in areas in North Africa where women remain mainly in the house following early marriage. Low dietary intake at this age appears to have relatively few ill effects on the teenager or young adult, but does result in high rates of low-birth-weight infants and in a reduced breast-milk supply.
These figures imply that much, if not most, of the malnutrition that occurs during the weaning period is caused, not by inadequate resources, but by faulty feeding practices that can be corrected by nutrition education. Susan Scrimshaw , and others have produced evidence that such destructive feeding practices may have served a necessary if cruel function before the advent of family planning. They permitted enough infants to die to prevent population size from exceeding the agricultural carrying power of the land. Incorrect beliefs may allow these deaths to occur with no blame to the family or to society. For example, if an infant dies of dehydration, no one is to blame if there is a belief that fluids must be withheld during episodes of diarrhoea.
Fig. 3. Percentage of calorie needs fulfilled, by age, for three levels of family total expenditure, Tamil Nadu, India, 1972 (redrawn by Joe D. Wray from Sidney M. Cantor Associates , p. 102)
A study by Levinson  of 496 6- to 24-month-old children in Morinda in the Indian Punjab also illustrates dietary insufficiency at the weaning age, irrespective of income, and relates this insufficiency to nutritional status. Table 1 shows frequency distributions of percentage caloric intake allowance by per capita income and sex. Sixteen per cent of infants in the highest income group were found to be ingesting only 45 per cent of allowance or less. Table 2 compares the income elasticities of consumption of basic foods among sample children with total expenditure elasticities of demand for all age groups in rural India.
Levinson concluded [5, p. 53]:
The figures indicate clearly that the effects of income per se on the food consumption of the young children are far less pronounced than for the population as a whole. The income elasticities of consumption for calories, even among the 18- to 24-month age group with a lesser dependence on breastmilk, is only .082, meaning that if a family somehow succeeded in doubling its income (assuming everything else, including prices, remained constant) the child's caloric intake would increase by only 8 per cent. (The increase in adult's caloric intake might be 10 times that great.) The young child's protein, vitamin A, and iron intake would increase by even less. This would suggest that, for the sample population as a whole, a simple income supplementation program unaccompanied by other interventions is unlikely to have a major effect on their food intake.
Table 3 shows the nutritional status of the children according to the Gomez classification, grouped by per capita income and sex. Nearly 46 per cent of all children in the highest income category were suffering from second- or third-degree malnutrition, with a very high preponderance of malnourished females.
Table 1. Frequency distribution of percentage caloric intake allowance by per capita income and sex
|Per capita monthly income (rupees)||Percentage ingesting 76-100% of allowance||Percentage ingesting 59-75% of allowance||Percentage ingesting 46-58% of allowance||Percentage ingesting 45% and below of allowance|
|24 and below||17.5||23.3||32.0||27.2|
|76 and above||32.3||32.3||19.4||16.1|
|24 and below||25.0||25.0||29.2||20.8|
|76 and above||30.2||35.8||22.6||11.3|
Source. Reference 5.
|Item||Income elasticities of consumption among sample children aged||Total expenditure elasticities of demand for all age groups in rural India|
|Total sample children|
Source: Reference 5.
Very poor communities for which nutrition education cannot be effective without simultaneous increase in real income exist in pockets in most countries and more generally in some of the low-income countries most in need of development. Nutrition education teaches better uses of resources that are already available to the family. When these resources fall below a certain level, redistributing them does not help.
Wittmann and co-workers , in the slums of Cape Town in South Africa, found a marked difference between the health and nutritional status of children in families receiving 21 cents per person per day versus families with 60 cents per person per day. In Maduri, South India, per capita income of the lowest 23 per cent of families with children attending the Nutrition Rehabilitation Unit at Lady Erskine Hospital was less than 5 rupees per month . The low-cost diet offered in the centre, making use of groundnut cake as a source of protein, cost 60 paise per child per day. Because these families could allot no more than 10 paise a day to each pre-school child, it is very doubtful whether they had the means to feed their children.
Table 3. Frequency distribution of Gomez classification groupings by per capita income and sex
|Per capita monthly income||Percentage normal (over 90% of Harvard reference weight for age)||Percentage with 1st-degree malnutrition (76-90%)||Percentage with 2nd-degree malnutrition (60-75%)||Percentage with 3rd-degree malnutrition (below 60%)|
|24 end belong||9.7||29 1||51.5||9.7|
|76 end above||19.1||35.1||43.6||2.1|
|24 and below||14.0||40.0||42.0||4.0|
|76 and above||30.2||43.4||26.4||0.0|
|24 and below||5.7||18.9||60.4||15.1|
|76 and above||4.9||24.4||65.9||4.9|
Source: Reference 5.
Adeline Andre, nutrition educator with the Department of Agriculture in Haiti, tried to live from the market for the US $0.09 that low-income families average daily (per capita) for food and concluded that it is simply not possible to eat adequately for this amount unless one can collect firewood and grow green leafy vegetables at home . Similarly, Pellerin  concluded that the 47.6 per cent of Haitian farmers with farms less than 0.5 hectares (1.25 acres) in size probably were unable to redistribute food resources in a manner than would make it possible to prevent malnutrition among pre-schoolers.
Dr. P.M. Shah  estimated from a domiciliary rehabilitation programme in Kasa, India, that "only one-third of the severely malnourished, who are extremely poor, need nutrition from outside sources." In the concept-testing exercise of the World Bank-supported nutrition project in Indonesia, Griffiths and co-workers  discovered that about 10 per cent of families were too poor to try suggestions for improving nutrition even at low cost.
Table 4. Profile of nutrition education activities by funding source in the United States
|AIDb||USDAc||HHSd||HHS (MEDICAID, MEDICARE)||Food industry|
|Term used for nutrition||Nutrition education education||Nutrition education||Risk reduction||Nutrition counselling/ weight control||Food advertising|
|Stated goals||Behaviour change/ nutritional status change||Informed choice||Behaviour change/ improved risk||Behaviour change/ improved risk indicators||Behaviour change = purchase of healthful foods|
|USS/yeara||0.75||100||5 (for nutrition component only)||Not estimated||2,000 (only for foods reducing risk of cardiovascular disease)|
|Target groups||Developing country MCH||Low income MCH||High-risk adults, entire population||Sick or high risk, MCH||High-risk adults, |
|Role of nutrition professionals||Significant||Important||Minimal||Moderately important||Minimal|
|Estimated impact on national dietary practices||High return on investment||Low||High return on investment||High||Very high|
a. Approximate estimates by informed individuals.
b. S Agency for International Development.
c. Department of Agriculture.
d. Health and Human Services (National Institutes of Health).
Source: Reference 12.
The poverty threshold below which the family cannot afford to redistribute food to the weaning-age child is low. Only 3 to 5 per cent of the total family food budget needs to be shiRed to the youngest. This is calculated by noting that the average 12-monthold child needs 400 calories per day to increase his intake from 60 to 100 per cent of requirement. This 400 calories is less than 5 per cent of the total daily intake of a family of six - two adults and four children - who consume 70 to 80 per cent of requirement. This calculation demonstrates clearly that the malnutrition problem among young children is not due to income constraints in most cases.
As for the second question: What would be the potential of nutrition education if substantial funds were invested in it? Since this has rarely, if ever, occurred in developing countries, it may be informative to look at the nutrition education situation in the United States. Table 4  gives a profile of nutrition education expenditures by funding source in the US. It shows that an estimated $2 billion are spent per year by the food industry to advertise foods that are good for health. This advertising, which can be termed "nutrition education," is about one-fourth of a total of $8 billion spent yearly on food advertising.
The effectiveness of advertising in changing food behaviour is beyond dispute. Food companies can expect to earn in profits an average of $1,000 for every dollar spent on advertising. The amount spent by the food industry on research to develop new food products and advertising materials to sell them is many times more than amounts given for nutrition education development. A US food company thinks nothing of spending $200,000 on research for product development alone before designing a new candy bar that will cost $0.50. Sophisticated computer modelling is used to figure out what new products the public will buy and how to sell them.
The point here is that these amounts would not be spent if human behaviour were not highly influenced by such research and marketing. The Indonesian case study presented by Mr. Ruslan Adji elsewhere in this volume is an example of a nutrition education project in which the concept-testing methods of the US food industry were adapted and applied in rural Indonesia to develop and promote nutrition education messages. This project made a major impact on young child malnutrition in five subdistricts in Indonesia.
In the United States the food industry started roughly 30 years ago to market products, such as margarines low in saturated fats, advertised to reduce the risk of heart disease. Over the years this nutritional marketing increased in volume in proportion to public demand. About 15 years ago the death rates from nutrition-related degenerative diseases began decreasing nationally. Recent reports indicate that the rate of death from stroke, for example, fell by 40 per cent in the past decade.
Such lag time between marketing campaigns and beneficial effects may not be necessary in developing countries. Degenerative diseases take decades of bad eating habits to develop. The young child's nutritional status can deteriorate or improve in weeks or months.
This paper presents evidence suggesting that the potential impact of nutrition education in developing countries would be very high if significant funds were invested in changing food habits. Existing evidence should justify at least one trial of large-scale funding of nutrition communications on a national scale in a developing country with an investment of from 10 to 20 million dollars. These funds should be used for scientific message development by means of field trials and market research and for expert design of campaign materials.
1. D.B. Jelliffe, Infant Nutrition in the Tropics and Subtropics (World Health Organization, Geneva, 1968).
2. Sidney M. Cantor Associates, Inc., "An Operations Oriented Study of Nutrition as an Integrated System in the State of Tamil Nadu,' The Tamil Nadu Nutrition Study, vol. I, report to USAID/nesa399 (Haverford, Pa., 1973).
3. A. Lechtig, J.-P. Habicht, H. Delgado, R.E. Klein, C. Yarbronsh, and R. Martorell, "Effect of Food Supplementation during Pregnancy on Birth-weight," Pediatrics, 56: 508-520 (1975)
4. S.C.M. Scrimshaw, "Infant Mortality and Behavior in the Regulation of Family Size," Population and Development Review, 4(3): 383-403 (1978).
5. F.J. Levinson, Morinda: An Economic Analysis of Malnutrition among Young Children in Rural India, Cornell/MIT International Nutrition Policy Series (Cambridge, Mass., 1914).
6. W. Wittmann, A. Moodie, J. Hansen, and J. Brock, "Studies on Protein Calorie Malnutrition and Infection," Ciba Foundation Study Group, no. 31, in G.E.W. Wolstenholme and M. O'Connor, eds., Nutrinon and Infection (Little, Brown & Co., Boston, 1967).
7. G. Venkataswami and S.A. Kabir, "Report on Nutrition Rehabilitation Centre and Village Child Care Centres with Evaluation" (Government Erskine Hospital, Maduri, India, 1975).
8. A. Andre, personal communication, 1977.
9. A. Pellerin, "Some Challenges for Training Auxiliary Nutritionists for the Ministry of Health of the Republic of Haiti," in K.W. Shack, ea., Teaching Nutrition in Developing Countries, or the Joys of Eating Dark Green Leaves (Meals for Millions Foundation, Santa Monica, Calif., 1977), pp. 54-66.
10. V. Reddy, "Nutrition Rehabilitation Units," Indian Pediat., 12(1): 103 (1975).
11. M. Griffiths, R.K. Manoff, T.M. Cooke, and M.F. Zeitlin, Volume 1: Concept Testing, Nutrition Communication Project Paper, Nutrition Communication and Behaviour Change Component, Indonesian Nutrition Development Programme (Manoff International, Washington, D.C., 1980).
12. M.F. Zeitlin, The Two Worlds of Nutrition Education: Differences and Similarities in Industrialized versus Developing Countries, New Developments in Nutrition Education, Nutrition Education Series, issue 11 (Unesco, Paris, 1985).
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).
ROYAL D. COLLE
Cornell University, Ithaca, New York, USA
Primary health care and nutrition have been linked with communication in a variety of well-publicized projects. Nutrition workers in nine island nations in the South Pacific have used a communication satellite to carry out a maternal and infant nutrition programme; video-tape and television sets are being used in the Philippines to support nutrition workers; from Indonesia to Guatemala, audio cassettes are bringing health, nutrition, and agricultural information to rural families. The list could go on and on. We are witnessing a situation where communication technologies have taken their place alongside food supplements, oral rehydration salts, inoculations, rehabilitation centres, and home gardens as major ingredients in health and nutrition programmes.
The pattern that led to this partnership between communication and nutrition is familiar: expanded demand for services has been confronted by limited resources. Greater priority has been given to preventive approaches. Paraprofessionals such as community health workers or nutrition aides have become the front-line service providers. Meanwhile, the array of communication resources available for development purposes has expanded. There are high technology tools run by experts (for example, the communication satellites, computers, and colour television). And there are less sophisticated channels that can be effectively used by the non-technician: cassettes, puppets, and community workers. Recently, for example, modestly trained teams from Sri Lanka, Bangladesh, and Nepal won prizes in a Worldview International Foundation competition for producing video-tape programmes on development issues. These were not made by professional broadcasters, but by people associated with agriculture, health, and nutrition programmes.
IMPLICATIONS FOR HEALTH AND NUTRITION OFFICIALS
The success in using communication media to support nutrition projects does not mean that decision-makers should run out and buy a communication satellite or an audio cassette to solve the problems of providing effective health and nutrition services. But senior officials do have a substantial role to play in seeing that their programmes gain the full benefit of what an effective communication programme can offer. To do this they need to accept three responsibilities: (1) examine, at the planning stage of any programme, its implications for communication; (2) insist that communication or nutrition education people work within the framework of a communication strategy; and (3) provide communication resources. We will examine each of these in greater detail.
It is important to be specific about the word "communication" and about where a communication programme begins. In this paper, we consider communication to be the deliberate process of sharing information in a systematic way. We are concerned particularly with the use of mass media and interpersonal channels to achieve explicit communication goals. These goals are related to a broader policy and a comprehensive strategy that involves other sectors. (The word "sector" is used here to refer to an organized body of personnel, procedures and activities devoted to a specialized field or task, such as health, nutrition, agriculture, education, communication, research, training, etc.) It is at the policy level that the sequence of events leading to an effective communication programme begins (see figure 1).
A policy provides the political force that drives a programme. It usually includes an acknowledgment that a problem needs attention (for example, malnutrition in rural areas), that there is a goal to be reached, and a commitment to use resources to reach that goal. Policies are usually set by politicians or boards of directors, with details on implementation left to others. Some examples of policies in highly simplified form are: increase the nutritional well-being of the poor people of the country; provide primary health care to all the people; increase farmers' income; reduce the rate of population growth; change the nation from a rice-importer to a rice-exporter; achieve self-sufficiency in foods, etc.
Next, it is necessary to identify the sectors that will be involved in translating the policy into action. To do this, health and nutrition experts who are involved in planning may need to escape from their conventional thinking about service delivery and explore alternatives. An example could be the use of paraprofessionals. "Paraprofessionals" here refers to the kind of village health worker who generally has less than a year of professional training, and who has a large amount of day-to-day autonomy in providing health and nutrition services to rural low-income populations. This definition and some of the discussion that follows are elaborated in references 1 and 2. While there is a considerable acceptance of various kinds of village-level workers as an extension of the primary health-care system, there is somewhat less success with them than is usually expected. For example, at our workshop, Dr. Amorn Nondasuta indicated that about 60 per cent of village health volunteers are effective. That means a large proportion are not effective. The situation in Thailand is repeated throughout the world. There are various reasons, but the one that emerges prominently is the lack of adequate supervision for community workers.
Inevitably, when people think about supervision, they think of face-to-face contact. If, however, they were to break up "supervision" into its component parts, alternative approaches begin to emerge. What if, in planning a project using community nutrition volunteers, officials were to look at the tasks to be accomplished by supervision? From an analysis of programmes using paraprofessionals, we developed a list of some of the functions of supervision. In reading the list, an official should answer two key questions for each item: Is this important to my programme? What are the alternative ways this can be done ?
The list is as follows:
Some of these functions can be performed by other than face-to-face supervision. It should be evident that radio, video, and audio cassettes or television could play a major role in at least five of these. This would influence the planning for on-site visits by professional staff and for other logistics resources. It seems appropriate to propose that, in many ways, supervision is communication. Thus, in planning a village-level nutrition programme using field-workers, officials should not only think of conventional supervisors such as health personnel, but also consider the potential role of a communication sector. This is an example of the official's first responsibility in making communication effective: examining, at the planning stage, how and when communication fits into the overall programme.
Planning: Comprehensive Strategy
What programme planners or project leaders need to do at this stage is to develop a comprehensive strategy, indicating the major approach to be used, and the sectors needed to reach the policy goals. Inevitably communication will be one of those sectors, and that means that the health and nutrition decision-makers must themselves know more about communication than simply having a "bedside manner," or invite a communications person to participate in the planning.
The way this comprehensive strategy operates is dramatically portrayed by the Masagana 99 rice production effort in the Philippines. The policy was to make the nation a rice-exporter rather than a vice-importer. From among the approaches that might have been used, the planners decided to increase rice production. To translate the policy into action, the government concentrated on four sectors: a new rice technology, a new credit system for farmers, an enhanced agricultural extension system, and an ambitious communication and promotion programme. Like pieces of a puzzle, they fit together to make a comprehensive strategy for reaching a goal. (See P. Whit-more, in this volume, for a practical and systematic way of making a preliminary analysis of the various sectors that might be involved in an effort to change nutrition-related behaviour.)
One can also see the implications of different comprehensive strategies by looking at the official government plans for reducing the rate of population growth in two nations: Pakistan and Egypt. While the policy goals are the same, their approaches for reaching the goals are quite different. Pakistan emphasizes the health and welfare sectors; Egypt's nine-point plan includes agriculture, health, employment for women, industrialization, and social security. Both include a communication sector (see figures 2 and 3).
In summary, to develop effective communication in nutrition improvement and related programmes, the communication factor muct be built in at the beginning of the overall planning when major decisions are being made concerning the approaches to be used and resources to be allocated.
Working within a Communication Strategy: The Second Responsibility
Several years ago, the government of a Latin American country undertook a major nationwide nutrition programme. Quite properly, mass media and interpersonal communication components were included in the overall planning. However, these were carried out by two different agencies. The mass communication people launched an extensive media campaign that did not match the interpersonal communication being done in towns and villages by community nutrition and health workers. Nor had those front-line people been alerted to what was being done by the mass media. The nutrition communication phase of the project was a disaster. Resources were wasted, morale was destroyed, and the victims were not only the families who should have benefited from the programme, but professional people throughout the system, from senior nutrition officials to community health workers. There was no strategy.
All sectors in the comprehensive strategy have their own individual strategies, whether it is research, training, communication, distribution, or some other major activity. Programme leaders should insist that such strategies be made explicit. There are several major advantages in doing this with the communication sector. For example, a communication strategy:
Fig. 2. Population programme in Egypt.
Fig. 3. Population programme in Pakistan.
What might senior persons in nutrition programmes expect of the communication sector in developing a strategy? First, they should expect those responsible for the communication sector to understand the policy and comprehensive strategy that govern the overall effort. With this background, the communication specialist should start a five step process, as show in figure 4.
The analysis (step 1) must clearly identify the communication "programmatic" problems. Supervision was an example discussed earlier. In the Masagana 99 case, the first step was gaining farmer acceptance and compliance with new agricultural programmes. In population programmes, it is often a problem of closing the gap between knowledge and practice of family planning.
Analysis of the problem(s) should include careful examination of the target group, the channels available and their capacities (see the summary chart in Appendix 1), and whatever additional background or "situational" information is available that will aid in making intelligent decisions. This includes demographic information on population involved, taboos, data on previous communication programmes, community social structure and typical life-styles, availability of resources, transportation, what the population needs to know, and what their priorities are. In many cases this step will include travelling to communities to talk to people and to observe conditions in the community; systematically gathering data (e.g. research); contacting specialists (such as those in agriculture or advertising); and reading reports and other documents available from ministries, international agencies, and libraries (see N. Rizvi's paper in this volume). From this array of material, a number of alternative approaches to the communication problems can be proposed, along with reasonable estimates of their advantages, disadvantages, and general consequences.
The communication specialist should be able to use this analysis to generate a strategy (step 2). That communication strategy should be laid out on paper so it can be reviewed by programme officials and representatives of related sectors. Putting it on paper should not imply that the strategy is fixed for the life of the project. A strategy must be dynamic for two major reasons: (1) formative evaluation may reveal flaws or suggest alternative actions, and (2) the situation on which the strategy was originally based is constantly changing - especially if the strategy is successful.
What follows are the kinds of elements that programme officials should insist be dealt with explicitly by the top managers in the communication sector. Anything less means that the overall programme could be jeopardized.
1. Principal Objectives
The strategy should begin with the principal communication objectives. Some may be quite general, others may be specific enough to be quantifiable. Those objectives that are quantifiable can be used in developing the summative evaluation. Table 1, taken from a health project, suggests the variety of objectives that might appear in a strategy.
2. Best Tentative Solutions
From among those potential approaches identified in the analysis, the communication expert must propose one or several that are most appropriate for the principal objectives. It might be stated, for example, that mass media will be used to build awareness and a climate of acceptance for a new food, while community health workers will concentrate on persuasion and demonstrations in meetings with small groups and families in villages. But the approaches will be integrated.
Table 1. Health project specific communication objectives
In all audiences, persons should be identified with an explicit statement as to why each is important to the strategy. Often these are clearly specified in the objectives; however, there may be intermediate persons who need to be reached in order to reach a specific target group. For example, to reach high-level officials, it may be necessary to enlist the support of persons working in the mass media. Children may be used as channels to reach parents, or local leaders to reach village men: The use of the word "audience" and "target groups" implies a top-down model for diffusing information. This is not to ignore the potential of indigenous knowledge in the fields of nutrition and health, but a nutrition agency may need to collect and validate that information and then diffuse it from the validating agency. Also, developing a strategy and identifying audiences or the public does not preclude an approach in which community participation is stressed. Some of our experience in India taught us that Indian farmers' resistance to planting new seed varieties could be traced to their wives, who favoured the texture of food prepared using traditional varieties.
In the analysis section, it was important to list systematically all the media available. To this should be added those that might be introduced, since innovative uses of media such as nutri-vans, as illustrated by Solon et al. elsewhere in this volume, and audio cassettes  are unlikely to be suggested by identifying only the media existing in a rural community. The task here is to use appropriate criteria for selecting from among those possibilities. Some of the criteria include: appropriateness for the audience, initial and continuing costs, technical support ("infrastructure") required, opportunities for participation, etc. Various media have characteristics that make them more appropriate than others for communication with audiences. Table 2 indicates some factors that influence media selection.
It is important to understand what the best media are for doing particular jobs. UNICEF's Project Support Communication Section in Bangkok has produced a Media Selection Wheel that matches media with communication ("learning") objectives. It also introduces various '' selection factors" such as flexibility of use, equipment required, degree of initial and continuing costs, etc., to help planners make more careful decisions.
Table 2. Media selection
Source: Adapted from H.E. Perret, Applied Communications Technology in Rural Development (Academy for Educational Development. Washington. D.C.. 1976).
A worksheet for media selection (fig. 5) provides a simple but systematic scheme for selecting different media. The communication specialist can list the criteria that are most important to the situation, taken into consideration the communication objectives, populations involved, the kinds of information to be communicated, and such factors as speed required and area to be covered. Numbers can be used to indicate how well each of the media listed meets the criteria. There is no absolute numerical total that will tell one which media to use, but this planning operation will assist in making a more rational decision.
The principal content for the communication programme must be identified, and it must be authenticated by the proper technical specialists (for example, agronomists, nutritionists, etc.). At this stage it is usually enough to indicate the major themes that will be used, keeping in mind that it may be important to distinguish between messages designed to inform or reinforce (cognitive), those intended to move a person to action (motivational), and those essential for carrying out actions (behavioural).
It is important to be specific about three dimensions of the content. These are: (1) What is the overall "inventory" of information that audiences need to have to do what is expected of them? (2) How much of this do most of them already have? (3) What is the balance (i.e. the gap between 1 and 2) ? This is the content that needs to be emphasized in laying out the strategy, remembering that even some of what is already known may need to be reviewed or used as an entry point for the newer material.
The communication activities to be undertaken should be put into a general timetable. Scheduling of themes is influenced by various factors: the logical development of the overall message, e.g. awareness-motivation-behaviour; circumstances of related sectors, e.g. the agricultural calendar, or distribution of health materials, or the deployment of community workers; and so on. This timetable should be developed co-operatively with other sectors.
|Accessibility to ministry|
|Accessibility to population segment|
|Control over final message|
|Appropriate for population segment|
|Appropriate for message content|
Fig. 5. Worksheet for media selection.
RS = Radio spots
P = Posters
C = Cinema advertisement
R = Radio programme
FW = Field-workers
IM = Indigenous media
AC = Audio cassette
Fig. 6. Scheduling: messages/media.
Figure 6 is a worksheet for planning themes and media according to different periods in the overall programme. Using the worksheet, the communication people can schedule particular themes for particular periods or phases of the programme.
There are two "facilitating" strategies that need to be included with the overall communicating strategy. These include (1) a plan for mobilizing resources and (2) a plan for doing formative evaluation (research). First, as regards resources, if radio broadcasts (or other media) are to be used, these questions need to be asked: Who will do it? How will it be done? The attempt to answer these questions may suggest some resource needs: a script-writer, performers, recording facilities, money to purchase time, listening group leaders, or persuasive efforts applied to broadcast station officials, etc. These should be carefully calculated and provision made for obtaining the resources before going into the implementation activities that require them. Anticipation of needed resources - from spare parts to training staff will increase the chances of effective communication.
The formative evaluation plan must indicate how information on the communication efforts will be collected, processed, and fed back into the strategy or implementation phases. (See D. Foote's paper on evaluation models in this volume.)
The Remaining Steps
We have moved through the first two steps of the process suggested earlier (fig. 4). The third step, implementation, is the most visible part of the communication sector's activities. This is where messages are designed, posters printed, cassettes distributed, etc. These details are vitally important, but of less concern to high-level programme officials than the more macrolevel planning and strategy process discussed earlier. (See J.E. Andersen's paper in this volume for useful ideas on some aspects of implementation. )
Obviously, the programme official will have an interest in both the implementation and summative evaluation phases, expecially that they be carried out in a manner faithful to the strategy. The results of the summative evaluation (step 4) - if they are to be useful at all - need to be followed by an explicit statement as to future action to be taken (step 5). How, for example, do the results influence the initiation or completion of another strategy, or a decision to restate the communication problem?
Dealing with audiences and channels and messages may seem quite distant from issues such as nutrient deficiencies, diarrhoea, and the weight-for-height charts that nutritionists may be more comfortable with, but it bears repeating that effective communication methods may be as vital to improving the nutritional status of a population as a sanitary water supply or special formula supplements. That is why leaders of community or national nutrition programmes must demand the kind of detailed planning for the communication sector that is outlined above. This leads us to the third responsibility that nutrition officials have.
It is a rare agency that has all the resources it needs or wants to carry out its mission. The communication sector in a nutrition programme is quite likely to suffer in resource allocations because microphones or cassette tapes or projectors seem less vital than vaccines, vitamins, and medicines. In addition, the health and medical items are more visible symbols of health-care services offered by the health establishment. If, however, nutrition programme leaders have accepted and committed themselves to the first two responsibilities outlined above, it is imperative that they give higher priority to providing reasonable resources for communication activities.
Examination of budget allocations for nutrition and health education communication suggests that these kinds of activities tend to get token amounts of money, or what is left over after other needs have been met. One reason is that, in planning and budgeting activities, there are seldom advocates speaking as forcefully for the communication sector as those speaking for the medical, health, and nutrition sectors and the conventional resources they require. If there is to be effective communication for nutrition in primary health programmes the medical doctors and nutrition experts who are most influential in allocation of resources will need to lobby for additional resources for communication, or increase the priority of communication resources in the competition for what overall support is available.
In addition, more attention needs to be paid to the development of human communication resources within the nutrition establishment. It is a sad state of affairs when persons whose principal activity is based largely on communication have little professional training to do that kind of work. What is the balance between technical training and communication training for those persons who work directly with the public? Too frequently we assume that communication is "natural," and that to have effective extension agents and nutrition aides it is only necessary to provide them with technical information.
What can be done? Nutrition and health officials need to initiate or support efforts to examine the job responsibilities of the people working on their programmes to discover if and where communication plays a significant role in their activities. Does their successful performance depend on effective communication? This was done in Thailand, where the Ministry of Health now uses the phrase "village health communicator" to describe one of the two kinds of health volunteers working at the community level. The re-examination of job tasks should lead to a systematic effort, through in-service training, to upgrade health-care workers' skills for communicating about nutrition and related topics. This should be a priority issue.
In reviewing these three responsibilities for bringing about more effective communication for nutrition in primary health care, it should be clear that senior-level health and nutrition professionals need not change the nature of their careers and become communication experts. But they do need to understand enough about what can be done with communication so that, in their influential positions, they can demand systematic, quality planning and performance from the communication sector, and, given the expectation that it is forthcoming, support resource allocations for both vitamins and video cassettes.
The author wishes to acknowledge the contributions of Njoku E. Awa, Ronald E. Ostman, Donald F. Schwartz, and J. Paul Yarbrough to this paper.
1. R.D. Colle, "Tasks Required for Technical Management and Supervision in Rural Health and Development Programs," in The Training and Support of Primary Health Care Workers (National Council for International Health, Washington, D.C., 1981).
2. M.J. Esman, R.D. Colle, N.T. Uphoff, et al., Paraprofessionals in Rural Development, A Stateof-the-Art (Center for International Studies, Cornell University, Ithaca, N.Y., 1980).
3. P. Winichagoon et al., "A Cassette-tape Recorder Technique as an Approach to Nutrition
Education of Rural Mothers in Northeast Thailand," mimeo (Institute of Nutrition, Mahidol
University, Bangkok, 1983).
4. Shawki M. Barghouti, Reaching Rural Families in East Africa (PBFL/FAO, Nairobi, 1973).
APPENDIX 1. Summary Chart of Communication and Education Techniques
|Method||Main advantages||Main disadvantages||Comments|
|1. Public meetings
|Easy to arrange. Reach many people. Can have more than one speaker. Create public interest and awareness. Stimulate follow-up discussions.||Audience is usually passive. Speakers may not understand audience's needs. Difficult to assess success. Audience might not learn the main points.||Handouts should be used. Presentation should be clear. Use visual aids when possible. Audience should be encouraged to raise questions and to participate. Speaker should establish two way communication.|
|2. Group discussions||Build group consciousness. Individual members of the group can understand where each member stands in regard to the discussed issue: provide chances for exchanging opinions and increase tolerance and understanding.||Some members may dominate. Sometimes difficult to control or to keep focusing on the main issue.||Should be used with an interested audience to discuss a definite problem. Procedure should be fexible and informal. Summary of discussion should be presented at the end of discussion. Decision should be made by group members regarding its stand on the issue discussed. Requires the selection of good chairman.|
|3. Role-playing||Facts and opinion can be presented from different viewpoints, especially in controversial issues. Can encourage people to re-evaluate their stand on issues and can invite audience participation. Deepens group insight into personal relations.||Cannot be used in community meetings. Some role-players may feel upset by playing a role they do not agree with. Requires careful preparation for the selection of the issue and actors. Careful preparation is essential.||Can only be used in training courses. Follow-up discussion should focus on the issue rather than on actors performances. Source material about the issue should be provided to the actors to prepare their arguments.|
|4. Drama||Groups can be active, "learning by doing." Can attract attention and stimulate thinking if situations are effectively dramatized.||Actors require attention in training and preparing script. Preparations might be too difficult for the field-worker. Difficult to organize because it requires considerable skills and careful guidance by the field worker.||Should be restricted to one issue. Can only be used during training courses. Can be used as entertainment if well prepared before a public meeting.|
|5. Case study||Can illustrate a situation where audience can provide suggestions. Can elicit local initiative if the case corresponds to local problems.||Difficult to organize. Rewording of events and personalities might reduce the effectiveness of the case. Some audiences may not identify themselves with the case.||Should be clearly prepared. Can be used in training course. Questions and discussions should lead to recommendations for audience action. Audience should be encouraged to prepare case studies relevant to its experience.|
|6. Home visit||Establish good personal relationships between field-workers and families. Can provice information about rural families that cannot be collected otherwise. Encourages families to participate in public functions, demonstrations and group work.||Field-worker cannot visit every family in the community. Only families in accessible localities can be visited.||Records should be kept for families visited. Schedule of home visits should be developed to assure allocation of time for field-work activities. Handouts should be given to the families visited.|
|7. Demonstration||Participants can be active and learn by doing. Convinces the audience that things can easily be done. Establishes confidence in field-worker's ability.||Requires preparation and careful selection of demonstration topic and place. Outside factors can affect demonstration results and consequently might affect confidence in field-worker.||Demonstration processes should be rehearsed in advance. Audience should participate in the doing. Educational materials should be distributed to the participants at the end of the demonstration. Time and place of demonstration should be suitable for people to attend.|
|8. Radio, newspapers and television||Radio can be used to teach illiterates and literates. Newspapers can provide information within a short time for those who can read. Mass media can create awareness of issues and announce activities in this regard.||No visual aids can be used on radio. They can be used in newspapers and television. Media programmes are always short. Regular mass media programmes are one-way communication. Difficult to assess effects. Programmes are usually prepared for national audience, which reduces their relevance to local problems.||Mass media programmes should be relevant to the problems of the local people. They are better utilized if combined with group discussion.|
Mass media group
|Combines mass media
and personal channels. Can be prepared and used for many audiences over a period
of time. Encourages group participation.
|Requires preparation for recruiting groups, training group leaders, and preparation of educational material. Can be expensive.||Should he regularly held. Participants should be provided with educational material. Can be effective in enforcing literacy and adult education. Programmes selected should be about local problems. Tape recorders can he used. They are flexible. Can be used to tape role-playing, group discussion and interviews with local personalities.|
|10. Blackboard||A flexible tool. Easy to make and to use. Can be very attractive if used properly. Use of coloured chalks can add to its visual appeal. Can be portable .||Requires some manipulation skill (though quickly acquired). Requires teaching skills to make best use.||Should he essential in every group. Very useful for schematic summaries of talk or discussion. Audience can participate. Small blackboards can be portable. Writing should be clear and organized.|
|11. Flannelboard||Can be portable and mobile. Can be prepared by expert in advance: little skill required in actual operation. Could be used to make presentation more dynamic.||Can only be used for what it is prepared for. Cannot adapt to changing interest of group. More elaborate equipment than ordinary blackboard. Difficult to keep up to date.||Very useful but only for the prepared talks. Audience can participate. It should be used step-by-step. Flannel materials should be stored properly for future use. Flannel graphs should be numbered according to their order in the presentation.|
|12. Bulletin board||Striking, graphic, informative, flexible, replaces local newspapers. Keeps community up to date with information.||Requires preparation and attention to community needs.||Should be combined with maps, talks and photographs. Very suitable for posting articles, announce meets and news of development in the community.|
|13. Flip charts (turn-over charts)||Cheap and simple. Can be stopped at will for analysis. Can be prepared locally. Ideas could be illustrated in sequence. Illustrations on flip chart could be used many times for different audiences in different sessions.||Soon torn. Can only be seen by a few at a time. Can be difficult to illustrate complicated ideas.||Should not be over looked for illustration of simple sequences - especially with small groups. Lectures should be prepared in advance for use on several occasions.|
|14. Films||Because of sight and sound can attract audience's attention. Can make great emotional appeal to large audiences.||Good films are rare. Equipment costly to buy and maintain. One-way communication unless properly used. Requires skill in running film projectors.||Best if combined with discussion groups. Much work to be done in getting good films made. Attention should be given to encouraging audience to evaluate the film. Films should be used for stimulating discussion rather than for teaching alone.|
|15. Filmstrips||Much cheaper and easier to work than films. Easily made from local photographs. Encourage discussion.||Usually sight only. Not so dramatic as motion pictures. Could be expensive.||Can have recorded commentary. Strip can be cut up and individual pictures mounted as 2-inch slides; then can be selected and rearranged.|
|16. Slides||Have all the advantages of filmstrips plus more flexibility and can be more topical.||Could be expensive. Difficult to have them on all subjects of teaching. They can be used in a series to illustrate a concept.||They should be used after careful preparation of logical sequence and a good commentary.|
|17. Models, exhibitions, and displays||Appeal to several senses. Can be used on various occasions and situations. Can illustrate ideas in detail.||Not many workers can build or use them properly.||Useful models and exhibitions could be built up locally. Should be used in familiar places/ centres.|
|18. Maps, charts, diagrams||Visual appeal. Should simplify details. Permit leisurely study: can develop sequence on display boards.||May mislead by over-simplicity. Create transport and storage problems.||Should be made especially for groups. May need careful explanation at first. Could be used as summary of in formation. Symbols and layout should be familiar to the audience.|
Source: Reference 4.
how to use the worksheets
el paso, texas, usa
this paper will address two major issues: (1) a general process for developing effective instructional programmes - the approach i will describe is known as criterion referenced instruction; (2) a planning process for identifying what performance discrepancies need to be addressed in an intervention project and how to formulate effective interventions.
criterion-referenced instruction (cri)
the way we think about instruction and teaching is usually determined by the way we were educated. consequently, most of us think in terms of traditional, subject-matter-oriented instruction that principally uses textbooks and lectures for delivering informational communications to students. let me describe another approach to instruction that works much more efficiently.
in the cri approach, instruction is broken down into small units called modules. each module provides the information, practice, and testing required to learn a precisely identified skill or set of skills. students typically proceed through the modules at their own individual rates. each student must master one module before proceeding to the next; that is, all students must meet the same standard on each module. information is typically presented by means of print or audio/visual devices, as appropriate to the learning and communication skills of the students. lectures are rarely used, simply because they do not provide as effective or efficient learning.
students cannot control the presentation rate or sequence in a live lecture as well as they can with other media. as a student, you cannot rerun parts of lectures for a few minutes to think about a point. you can ask for a different explanation if you have trouble understanding a point, but this problem can be averted in other forms of instruction by using well-designed and tested materials, by providing optional resources, and by providing access to an instructor whenever necessary. furthermore, the inspirational effects of live lectures generally cannot match the inventive effects of instruction with modules. in cri instruction the student (a) receives frequent evidence of his own learning progress; (b) is never asked to learn something he is not yet ready to learn; and (c) has frequent one-to-one interactions with his instructor when they review his performance together on the criterion tests at the end of each module. student and instructor interactions in cri are frequent, close, and directly concerned with each individual student. instructors are trained to use a very positive approach in their interactions with students and to avoid destructive criticism and degrading remarks.
most importantly, the cri approach is oriented towards human performance in real-life situations. it does more than give people information - it teaches them to apply information and skills when needed in real life. it teaches students to perform effectively in later criterion situations because the design of the instruction is referenced to the latter.
cri is both more effective and more efficient than traditional instruction. it is superior in various ways. first, there are benefits that accrue from allowing students to progress at their own individual rates. in a traditional programme of instruction, all students finish at the same time. our experience with self-paced instruction is that on average students finish in 30 to 40 per cent less time than in a traditional programme. some may take longer, but most will take much less time (see line s-p in figure la). such time savings usually lead to greatly reduced training costs.
second, there are benefits that accrue from requiring students to master one skill before moving on to the next one. in a traditional programme of instruction, most students make grades in the c range, with considerably fewer making grades in the b and a ranges. similarly, some will make ds and fs. the result is the typical bell-shaped curve (see line c in figure lb). our experience with a mastery progression programme is that most students make as and bs and very few make lower grades (see line m in figure lb). the studies from which these results are obtained used the same tests for assigning grades in both the traditional and mastery progression programmes.
benefits also accrue from referencing instructional design to the criterion situations in which students will later perform. after students finish a traditional programme of instruction and start doing the job for which they were trained, they typically exhibit growth function during their initial time on the job; that is, their job performance improves dramatically as they gain experience. eventually, their performance tapers off and exhibits very little improvement after they start working (see the lowest curve in figure 1c). our experience with students after they finish cri programmes is that they show very little improvement after they start working (see curve r-1 in fugure 1c). however, this failure to improve substantially comes about because their initial job performance is almost as high as that of a highly experienced worker. in other words, there is much less room for improvement.
sometimes the analysis required to develop a cri programme creates new ways of doing work that produces graduates who are able to perform better than anyone else ever has, regardless of how much experience they might have had (see curve r-2 in figure lc).
the development of a cri programme of instruction uses a strategy that (a) requires the use of very precise language for specifying what is to be done on the job and what is to be learned and (b) proceeds through a series of developmental stages one after the other in a prescribed order. the stages for developing cri can be specified by a set of seven questions. each stage consists of developing the answer to the question for that stage and each answer is based on the answer to the previous question. the questions that follow are in order and are followed by a brief description of the form taken by each answer.
Fig. 1. Cost-benefit effects of CRI.
The modules in a CRI programme do not just present information as do the lessons in typical subject-matter-oriented instruction. A module consists of six functional components:
Communications intended to change how people do things need to address all six functional components of a module in an integrated and effective manner.
SYSTEMS DISCREPANCY ANALYSIS
When we become concerned with changing how people do something that makes up a major part of their daily life, we need to recognize that we are tampering with a way of behaving that has evolved over a period of time to best fit a particular environment within the beliefs and values held by those people. The social and physical environments in which they live may lead them to form some useful ways of viewing the world around them, some troublesome ways of doing so, or may simply not provide ways of viewing some aspects of their world at all. The ways in which people interact with the world around them, the habits, skills, and values that they have learned from previous experiences in the environment, the expectations and goals that they have set for themselves, and the responsiveness of the environment to their actions, all go towards making up an intricate and delicately balanced performance system. A small change in part of this system can have dramatic, far-reaching, and unexpected repercussions throughout the system.
A single habit that is held by many members of a population does not exist in isolation. It receives inputs from other habits and provides output to other habits. It is but one link in an extensive net of habits that form a performance system. If we are to be effective without doing more harm than good, then we must focus our planning efforts on the performance system rather than on single habits.
The various beliefs and values held or not held by our target population and the many conditions in their environment that impact on the activities we want to change can often form a very large and complex set of concerns to consider in planning. There are often many different ways in which we can intervene to try to change the ways in which the target population does something. In order to select the best combination of interventions, we need to describe all the significant characteristics of the performance system as it currently works and as we want it to work in the future. There are some useful ways of describing a system and some useful ways of identifying where to attempt interventions to change it.
The following describes a planning process that has some very critical behavioural science concerns built into it. This process begins with developing a description of the performance system as it exists and a description of the performance system that is desired. These two descriptions provide a basis for identifying the discrepancies between what exists and what is desired. These discrepancies become the focus of interventions.
PERFORMANCE SYSTEM ANALYSIS
Rather than just talking about systems analysis in general, the focus here is on the performance system we are trying to change - the family nutritional system. Initially, one needs to identify the major functions that make up this system, its overall goals, the components of the system (people, groups, or organizations), the processes or skills required to operate it, the resources it uses, and the environment in which it exists.
The family nutritional system consists of six major functions: (1) plan meals; (2) procure foods; (3) store foods; (4) prepare meals; (5) present meals; and (6) clean up. In order to describe each of these functions, we need to identify who does it, towards what end (that is, what is the goal?), the processes or skills used, the obstacles to performance that exist either in the environment or in the minds of the performers, and the immediate or motivational consequences of performance.
The first worksheet does several things:
Before going to the details of the Family Nutrition Performance System Worksheet (Appendix 1), consider next how to change what people do and what they think.
CHANGING ACTIONS AND THOUGHTS
Words and Causes
A large part of learning to change how we ourselves think and act and how others think and act is concerned with learning to describe human activities and the possible causes of such activities in useful ways. Unfortunately, most of us are taught by the societies in which we live to think and talk about human activities in ways that are not only useful, but that may even be misleading or harmful. We need to learn to put these non-productive habits aside whenever we decide to get serious about solving human performance problems.
Let us consider some of these improper ways of thinking and talking about human performance. Almost all of us have learned at least some of these habits in the early years of our lives. We need to learn what they are so that we can try to counter them in our analyses.
What we believe to be the causes of what people do and think will guide how we analyse the problem of how to change what they do. For instance, if we believe that people act as they do because of strong forces within them that were created during their childhood, chances are that any change programme we try will be difficult, time consuming, and require very highly skilled change agents.
Often we assign causes to human actions simply by naming the action with an abstract word and use this name to explain the action. It leads to our saying such things as:
These kinds of statements are common in most societies. Yet they contribute nothing to human understanding of human problems. In each instance, the "cause" named in the statement is simply an abstract restatement of the activity or a very general "trait" name that is left undefined.
These ways of accounting for the causes of human activity can be very misleading. We think we have said something profound when in fact we have said nothing at all. These kinds of statements lead us to stop looking for more useful and more precise causes. For instance, consider some more useful ways of accounting for why people eat poor-quality food:
We also need to remember that many of these causes can happen together. That is a very important point. Human activities are almost always "caused" by many different factors. We need to identify all the likely causes for a problem we want to change and then select those that we can do something about with the resources we have.
When people are performing in one way and we want them to perform in a different way, then the difference between what they are doing and what we want them to do is called a performance discrepancy. Our change programme will attempt to reduce the discrepancy between what they are doing and what we believe they ought to do.
Many of the traditional ways of describing human performance discrepancies try to change too big a piece of behaviour all at once without breaking it down into the bits and pieces that make it up. Most often these descriptions attempt to change an abstract trait - for instance, they might try to raise people's nutrition consciousness. Nutrition consciousness can refer to eating a "balanced" diet, to eating "natural" foods, to eating enough food but not too much, to being able to recite the nutrients provided by various kinds of foods, to being able to recite minimal nutritional requirements in specific detail, and so on. Nutrition consciousness can occur in so many different ways that we hardly know where to begin. These big pieces of performance are often a useful place at which to begin an analysis, but certainly we should never end our analysis with something that can be interpreted in so many different ways. Personality and character traits are not causes of behaviour; rather, they are ways of describing behaviour. They are all right to use in casual discourse about human problems, but when we get serious about solving human problems we need to put trait terms aside and use a much more specific and precise language.
The Basic Change Process
We can improve our chances of changing human behaviour by doing several different things:
First, we must identify the human actions we want to change in very specific terms. What is it that people think and do now and what is it we want them to think and do?
Second, we must recognize that what we change is the frequency with which particular actions occur. We are not going to stop people from doing what they do now and cause them to start doing what we want them to do all at once. Change takes time. And during that time, what changes is how often things happen.
Third, we design treatments that make changes in the antecedents and consequences of the performances we want to change. To do so, we must first identify what those antecedents and consequences are now, and then decide what they ought to be in order to bring about the changes in performance that we desire.
Fourth, we select treatments that we can control. If you cannot control the antecedents and consequences you have selected, you may make things much worse and you will not be able to stop it.
Fifth, we introduce the treatments and monitor their effects. In order to monitor the performance effects of a treatment, there has to be something about that performance that we can observe. If there is, then we can note every time the performance occurs and determine if its frequency of occurrence is changing. If it does not change, or change is not fast enough, or if it changes in the wrong direction, then we have to modify our treatment in some way and go back to monitoring its effects.
Sixth, we have to monitor the performance system for other effects that we want to avoid or that we may not have anticipated. If some of these effects are undesirable, we have to be ready to stop or even reverse our previous treatment, or we may have to introduce additional treatments to deal with these other effects. Such additional treatments will also have to be monitored and modified, if necessary. So what we started as a relatively circumscribed change effort can mushroom as we attempt to control more extensive changes throughout the performance system. We need to anticipate as many of these more extensive effects as we can and take them into account in our planning efforts.
Changing People's Thoughts
As you may have noticed, I have spoken about changing both people's actions and their thoughts. Behavioural scientists are often represented as not being concerned with people's thoughts. That is not true. The problem is that we cannot monitor another person's thoughts and, consequently, we cannot tell what is happening. Here is one common way around this problem.
We can teach people to change their own thoughts. In this kind of programme, the change agent acts as a process consultant for the target person himself. There are two problems with this approach: (1) people do not always know what they think in various situations and (2) they must be convinced in advance that they need to change and be willing to try.
Most of us believe that we know what we think in all situations. For the most part, this means that we can put words or images to our thoughts. However, the words are not the thought. Often we do not have words or images to put to our thoughts - we simply act on them. For instance, a person who believes he must never make or admit to a mistake in anything he does, does not say to himself in every situation: "I must not make a mistake." He simply acts as if he believes he must never make a mistake.
If we are willing to change and if we can actually observe our own thoughts in certain situations, then we can change our own thoughts. Or we can teach others and guide them in how to change their thoughts.
Obviously, this is not a practical approach for managing change treatments in large scale programmes. But it can be used in designed change treatments and in evaluating their probable effect in small experimental efforts before applying them on a large scale. Before we commit ourselves to a large programme intended to change how people think, we need to assess the effectiveness of the treatments in small experimental efforts.
The most significant treatments for changing how often people think or act in certain ways in particular situations focus on the consequences of their thoughts and actions. There are four kinds of consequences to consider. The first two increase the frequency with which an action or thought occurs in a situation.
1. Positive Consequences
These are conditions that are desired by our change targets, things that please them, things that they want. A positive consequence can be a physical reward such as money or material objects. Or it can be a special privilege, or recognition or praise from some significant person. Or it can be the good thoughts a person has about himself after doing something right.
A particularly powerful kind of positive consequence is called positive self-imaging. It is often used by people who are changing inappropriate behaviours to more appropriate ones. After each instance of having performed appropriately, the individual images his own long-term achievement of the goal being sought. For instance, an overweight person who eats a lowcalorie meal may image himself as a lean individual receiving attention from an attractive woman.
2. Stopping Unpleasant Conditions
A baby cries. The crying annoys the mother. The mother feeds the baby and the crying stops. As a result, the mother is more likely to feed the baby immediately after it starts crying in the future. This kind of consequence can be effective with people if there is already some unpleasant condition in their environment that we can remove temporarily when they perform as desired. However, we want to avoid introducing some unpleasant condition just so we can turn it off when our change targets perform appropriately. The danger in using this consequence is that it can cause people to avoid the performance situation rather than perform appropriately in it. This can be a very troublesome consequence to try to use with people. Not only can it lead to avoidance, but it can also lead to hostility and aggression.
The last two consequences decrease the frequency with which a thought or action occurs.
This is an unpleasant consequence that happens immediately following a response. It is most often used to decrease the frequency of undesired performances, but it often exists naturally in an environment as a consequence of desired performances. It is common to find that the reason people do not do the things we want them to do is because they are punished in some way for doing it. Others may criticize them. For instance, a young mother may be criticized by her mother or mother-in-law for breast-feeding her baby. Sometimes doing what we want them to do requires greater effort or causes them to miss doing something they would rather do. What we or others say to our change targets can also be punishing. Although societies use punishment extensively for controlling people, its effects can be very uncertain. Punishment can also lead our change targets to avoid the performance situation or to be hostile and aggressive. Punishment is a very troublesome consequence to use.
One way we can decrease the frequency of an undesirable behaviour is to remove the natural consequence that typically follows it. We get rid of the positive consequence or the stopping-of-the-unpleasant-condition that has kept this behaviour going in the past and replace it with no-consequence. When we first introduce no-consequence, the frequency of the undesired behaviour will actually go up before it goes down. But if we just grit our teeth and hang on, it will come down in time. No-consequence can also be a significant reason why people do not do what we want them to do. If we do not provide a meaningful consequence for their doing what we want them to do, they are not likely to do it.
These four kinds of consequences are the basic events that cause a performance system to function as it does and the basic tools available to us in changing the performance system.
Knowledge about the various kinds of consequences that can exist is particularly useful in identifying the consequences that actually control the performances we are interested in changing in their natural environments. Human behaviour is principally controlled by the intrinsic outcome of the behaviour itself, by the things that other people say and do as a result of the behaviour, and by the things that people say and do to themselves. If people are not behaving in some way that appears reasonable and proper, then we must examine the real-life situations to determine what consequences actually are operating in the real situations.
There are several important rules we have to keep in mind both in identifying the consequences already in a performance system and in applying our own consequences in an effective manner.
Punishment is used around the world and throughout history as the principal means of controlling human actions and thoughts. However, most such punishment is not applied immediately and does not break up the ongoing response that we are trying to change. Sending someone to prison is legal punishment, but it is not behavioural punishment. The effects of legal punishment on the frequency of an undesired action are very uncertain, particularly if the undesired action is hostile or aggressive in nature. Legal punishment may actually aggravate that kind of problem. Behavioural punishment and legal punishment should not be confused. They are not necessarily the same thing.
Antecedents and Contexts
Human performances occur in response to some event or signal in the environment. This, of course, is the basic idea expressed in the stimulus response paradigm of behavioural science. It suggests two very important considerations to observe when we try to change people's habits. First, it suggests that one way of changing what people do is to prevent or change the signals or stimuli that elicit or call up the response. If a person eats too much rich food, then one way of reducing the frequency of this performance is to remove most of the rich food from the person's environment. This kind of treatment does not change the basic habit, but it does control it.
The basic S R paradigm has another important implication that is being supported by recent findings on human memory. If we want to change how people think or act in certain situations, we must build associations between the responses they are to make and the appropriate signals in the situations in which the responses are to occur. Most of our educational practices around the world violate this principle to at least some extent. Students learn to recite facts and principles, but do not learn to apply those facts and principles in real situations. They can answer verbal questions on tests correctly, but they cannot perform effectively in real situations. Knowing something in one situation, such as a test, does not mean that it will be remembered in another situation when the information is needed. Cognitive scientists are learning that it is much more difficult to retrieve information from human memory in appropriate situations than it is to put that information into memory in the first place. If people are to make effective use of the information they learn, then learning must include practice applying the information in the same or very similar situations. This practice assures that we build the proper associations to retrieve information from memory when it is needed.
Sometimes when we want someone to perform in a new way in an old situation, we may have to add a signal to the situation to call up the new response. For instance, one way in which pregnant women in the United States reassure (the new response) themselves and others of the importance of their condition in their daily activities (the old situations) is to wear a T-shirt that displays the word "BABY" in large letters and an arrow pointing down at their abdomen. It becomes a signal to the woman and those around her to behave in ways appropriate to her condition. It says to her and to others, "Something very important is going on in here." Similar T-shirts read "PRESIDENT 2024." Or one might read "NATIONAL RESOURCE UNDER DEVELOPMENT." Or, in Sri Lanka, where the people are apparently more economically minded, such T-shirts might read, "GROWING RETIREMENT FUND - 18% RETURN."
One of the most powerful ways of changing undesirable thoughts and actions is to teach new thoughts and actions that prevent the old undesirable ones. We call this counter-conditioning. For instance, rather than punish someone for undesirable actions in some situation, we teach a better way of acting in that situation and reward the individual for doing so. This approach gives more stable change in both thoughts and actions with fewer undesirable side-effects than does the use of punishment.
If people are doing something we desire them not to do, it is not enough for our interventions simply to diminish the frequency of the undesired habits. Habits are not broken. They are replaced by other habits. The new habit may be no more than saying to oneself, "I will not respond (as I used to)" to a given situation. Even this is a new action (or thought) that replaces the old action. Or the new action may be an extensive chain of thoughts and actions that prevent the old actions from occurring. We can either control the selection of the new action or let it develop from the target's own predilections. Since we cannot be certain how things will work out on their own, it is probably better to control the selection of the new action wherever possible.
The consequence that we use in building a new response must be more attractive than the natural consequence that follows the old response. If we want to speed things up, we can either prevent the natural consequence for the old response, if that is possible, or introduce a punishment as a new consequence for the old response. Again, however, we always need to be careful about using punishment. Its side-effects can be very damaging to the long-range goals of a change programme.
As mentioned earlier, there are three worksheets:
They are to be used in the order listed here. The first worksheet leads us through describing the existing and desired systems and helps us identify the discrepancies between them. The second worksheet identifies a single discrepancy and the possible interventions for dealing with it and prompts us to make judgements bearing on the importance and feasibility of the discrepancy and the potential interventions and to assign numerical values to those judgements. The numerical values can then be aggregated as a basis for helping us select which potential interventions to select for our programme. The third worksheet prompts us to formulate the specific details for an intervention requiring the targets to learn either new skills or new thoughts.
The Family Nutrition Performance System Worksheet
Before we can go from here to there, we need to determine in a useful manner where "here" is and where "there" is. In this case, however, we are not going from one "here" to one "there." Since we are dealing with a performance system with many characteristics, we will be going from many "heres" to many "theres." The difference between each "here" and its corresponding "there" specifies the discrepancies we need to consider addressing in our interventions. Sometimes there may be no discrepancy between a given "here" and its corresponding "there." Sometimes there may be substantial discrepancies, but not all need be critical.
The worksheet prompts us to describe the relevant characteristics of the existing system and those of the desired system where it differs from the existing system. Characteristics of the existing system are entered in the left-hand column and those of the desired system in the righthand column.
At the top of the first page of the worksheet, you can specify the targets of concern. For instance, you may not be concerned with the effect of the system on all the members of the family, but only on children from birth to age six. This will remind you to describe the system as it bears on these targets.
The worksheet is divided into seven sections: an initial section that addresses overall system characteristics and one section for each of the six system functions. However, you may want to add more functions or delete some of mine for a particular application.
Each of the seven sections asks you to state the goals either for the overall system or for a given function. If you are specifying the goals for the existing system or one of its functions, specify the goals actually perceived by the people who make up the system. If there are conflicts among different roles in the system regarding its goals, be sure to identify them.
The second part of the overall system section asks you to list the functions that make up the system. I have listed the six that I suggest are appropriate. This is your first opportunity to add or delete functions if you wish. Or you can throw mine out altogether and make up your own.
The third part asks you to list the components of the system. I have listed some possibilities for you to consider. You should also note what each component does in the system. For instance, feeding of small children might be done by the children's mother, or by her mother or mother-in-law, or by an older daughter, or by all of them under different conditions.
Next describe the environment in which the system operates. Again, I have suggested some things for you to consider. Try to identify and characterize all those aspects of the environment that could in any way affect the operation of the system.
Finally, list the resources available to the system for it to operate as it exists now and resources that are available to it but not used appropriately. For instance, green leafy vegetables may be available but not be used in feeding children.
The worksheet section for each function will prompt you to provide information in four categories: the goals, processes (skills), obstacles, and consequences appropriate to the function. In each case, I have listed some things you might consider.
Under goals list the goals for the function. In some cases, these function goals may be the same as some of the system goals. In other cases, they may be a subordinate aspect of a system goal. l have listed some goals you might consider for each function. You can choose whatever seems appropriate or add in goals of your own.
Under processes (skills) list the kinds of things a person has to be able to do in order to achieve the goals of the function. There are some possibilities for you to consider for each function.
Under obstacles list the kinds of things that interfere with the accomplishment of the goals by the processes. I believe that you will need to identify obstacles only for the existing system. I cannot think of an instance where you would want to introduce an obstacle in the desired system.
Under consequences there are two conditions to consider: (1) what are the consequences when they do it right? and (2) what are the consequences when they do not do it? Remember, we are concerned with fairly immediate consequences to the performer of the action that affect the likelihood that he will perform appropriately in the future.
Obviously, you will describe a piece of the existing system before you describe the corresponding piece of the desired system. I would recommend that you describe all parts of the existing system before you even think about any part of the desired system. The parts are interrelated. You cannot really plan a new system on a piecemeal basis. You will probably find that you will revise your description of the desired system many times before you are finally satisfied with it.
The Discrepancy/Intervention Summary Worksheet
Once you have finished describing both the existing and desired systems, you will be in a better position to identify the discrepancies between the two. Not every difference has to be considered as a separate discrepancy. You may want to combine several differences between the existing and desired system into a single discrepancy. Do whatever seems to make sense in your situation.
Fill out a Discrepancy/Intervention Summary Worksheet for each discrepancy you identify. Write the description of the discrepancy in the space at the top of the worksheet. Enter the potential interventions that you are considering for eliminating the discrepancy in the body of the worksheet. There are two kinds of interventions for you to consider: (1) interventions that will require people to learn new skills or new ways of thinking about some particular thing and (2) changes that can be made in the environment. Describe each potential intervention in the appropriate part of the worksheet.
When you have finished identifying all the discrepancies between the existing and desired systems and have filled out a Discrepancy/Intervention Summary Worksheet on each one, you will then need to make judgements about how critical each discrepancy is and about the importance and feasibility of each potential intervention. Try to get the most appropriate people available to make each kind of judgement. For instance, policy-makers may be most appropriate for judging how critical the discrepancies are, and programme planners and field-workers for judging the importance of a potential intervention to a given discrepancy and for judging the feasibility of each potential discrepancy. You can have several people involved in each judgement on a group basis or you can obtain individual judgements and average them. You can have several different kinds of people involved in the same judgements and even give their judgements different weights, but generally it is best to keep the judgement process clean and simple.
Ask all the judges to assign values between I and 10 to express the criticalness of a discrepancy or the importance or feasibility of a potential intervention, with I representing the lowest value on each characteristic and 10 the highest value.
To obtain an overall value for each potential intervention, simply multiply the three separate sets of values; that is, multiply the critical value of the discrepancy by the importance and feasibility values of the potential intervention. This total value can be used as a guide in selecting which potential interventions to select for implementation. The higher the total value, the more significant the intervention.
If you want to learn more about how to assign and aggregate values in making judgements about characteristics of programmes, this process is called Multiattribute Utility Technology (MAUT) and has been principally developed by Ward Edwards .
The New Skills/Thoughts Interventions Worksheet
This worksheet will guide through formulating interventions that require people to learn new skills or new ways of thinking about something. It is modelled on the components of a module listed in the first part of this presentation. It asks you to specify how the intervention will do each of the following:
The answers to the preceding questions specify the content of the communications that will make up the interventions. We also need to know something about the effects of the interventions on the system- both immediate and remote effects. The anticipated effects of the interventions allow us to manage and evaluate the project better and make corrections en route if necessary.
The last part of this worksheet is concerned with the development and delivery of the communications. I have suggested some questions that need to be addressed. You may want to add other questions that fit your own situation better.
1. W. Edwards and J.R. Newman, Multiattribute Evaluation (Sage Publications, Beverly Hills, Calif., 1982).
APPENDIX 1. The Family Nutrition Performance System Worksheet
|OVERALL GOALS |
|FUNCTION NO. 1: PLAN MEALS
|PROCESSES (SKILLS) |
|FUNCTION NO. 2: PROCURE FOODS
|PROCESSES (SKILLS) |
|FUNCTION NO. 3: STORE FOODS
|PROCESSES (SKILLS) |
|FUNCTION NO. 4: PREPARE
Food preparation skillscutting, chopping, mixing, kneading, washing.
Food cooking skills
Meal preparation coordination skills.
Prepare and add spices, oils, condiments
|FUNCTION NO. 5: SERVE MEALS
|PROCESSES (SKILLS) |
|FUNCTION NO. 6: CLEAN UP AFTER MEALS
|PROCESSES (SKILLS) |
APPENDIX 2. The Discrepancy/lntervention Summary Worksheet
APPENDIX 3. The New Skills/Thoughts Interventions Worksheet
SET PERFORMANCE CONTEXTS
Describe the contexts:
How will the targets be told about the contexts?
MODEL THE PERFORMANCE (DEMONSTRATE)
Do they need to see it done?
How will it be shown to them?
Are there natural signals for the performance? What are they?
Do they need other signals? Describe them.
How will the signals be conveyed?
Do they need to be told or shown exactly what to do step-by-step? How?
How will they know if they have done it right? Who or what will provide?
Do they know how to fix their own performance errors? If not, how will they be told?
What positive consequences are appropriate and feasible?
How will they be delivered?
What immediate effects are anticipated?
What remote effects are anticipated?
DEVELOPMENT OF INTERVENTION
What needs to be developed? Who will develop each part?
How will it be tried out and revised?
How will each part of the intervention be produced? Who will do it?
DELIVERY OF INTERVENTION
Who will identify the targets? What guidelines will be used?
Is baseline monitoring of targets appropriate? Who will do it? How?
Who will monitor the targets during the programme? How?
What kinds of things might go wrong? How will they be handled?
What kinds of modifications might be necessary in the conduct of the intervention? Who will decide? How? What guidelines?
JEAN E. ANDERSEN
Development Communications Consultants, Inc., Oyster Bay, New York, USA
There may be some people in this world who are just "natural-born communicators" for behaviour change. I have not met more than one or two. But I suspect even they have their own systems and methods for bringing about behaviour change - some conscious and some unconscious. The rest of us need a system to use in our conscious effort to develop more effective communications. One such system is being organized by Development Communications Consultants, Inc. (drawing on the work of many authors, especially Robert F. Mager). Originally, the system was used in the private sector in the United States. It has since been applied and modified in communications projects at the Nutrition Center of the Philippines, and later applied in a pilot project at the Institute of Nutrition in Thailand. This report presents an overview of part 1 of the system.
It is called the "A-B-C Model for Developing Communications to Change Behaviour". It is useful to name the steps in the model in an alphabetical sequence so that they are easier to remember - it just so happened it could be done that way. The sequence of steps is not meant to indicate a strict sequential process, but rather a matter of sequential emphasis - many parts of the model overlap and interact with each other and there are several feedback loops.
Figures 1a and 1b show the model in flow-chart form. Each element is described in Appendix 1.
APPLYING THE A-B-C MODEL
Here is how the model works. You have an idea, or a mandate, to develop some form of communication to change behaviour. This means that you already know, in general, what change you want to bring about and who your audience probably will be.
Next, you generally need to know more about your audience and to become much more specific about what you want to enable them to do. Although both processes go on together, initially the greater need is usually for more information about the audience. Before you define exactly what you want the audience to do in the future, you usually need to know exactly what they are already doing, and why they are doing it, as well as why they are not doing what it is you want them to do. In that way you will be less likely to try to change something that may work, or neglect to try to change something that will be an obstacle.
Fig. 1. The A-B-C model for developing communication to change behaviour (after Development Communications Consultants, Inc. [ 1] ).
Who are those people whose practices you want to change? Who are they in general? i.e. old, young, rich, poor, functionally literate or illiterate, using medical facilities or local "healers," looking for better lives or accepting present conditions, fatalistic or believing in their power to change things, etc.? And who are they more specifically in relation to the behaviour change you want to bring about? What are their current practices, beliefs, resources, etc. ? You probably need to know these things, and many more, about your audience, to be able to change their practices effectively. An audience analysis tries to find out, as accurately as possible, everything you need to know to design a communication that will appeal to, motivate, and change your audience in the desired way. An audience analysis can also be used to test your assumptions about your target group.
You decide part of the audience analysis - that is, who your target group will be. Other factors that are not part of the specification of your target group, but may influence the design of your communication, need to be researched. There are two general types of information needed in an audience analysis: population description and entering behaviour description.
The population description covers the more general demographic characteristics of your audience, whereas the entering behaviour description deals with specific practices, beliefs, etc. related to the behaviour change being sought and the media being considered.
A population description covers general factors related to life-style and motivations. It usually includes such items as:
Age, education, training/apprenticeship, family size/make-up/ages, health status, sex, religion, pregnant/lactating, civil status, language/dialect.
Urban/rural, location, surroundings, land use (garden, livestock), type of dwelling, members, electricity, water sources, sanitation.
Income level, income sources, home activities, previous income sources.
Usual work of residents, land usage, available public transport, socio-economic status, health facilities, local workers for nutrition and/or health education.
Sources of information, staple food, food beliefs and superstitions, usual diet (by age groups), food practices, cooking practices/utensils, food availability, food preparation, food conservation/storage, nutritional status of family members.
Radio/TV ownership/availability, print literacy, meanings of signs and symbols, visual "literacy," colour meanings and preferences.
Spare-time activities, preferred vocation/avocation, group memberships.
Needs, Values, Goals
Perceived needs, aspirations, who is admired and why, sources of status, expectation.
A description of entering behaviour looks at factors more specifically related to the subject area of the communication to be developed and the behaviour to be changed. An entering behaviour description would include such factors as:
Current related practices, past related practices, related skills, related experiences, related training.
Related religious and socio-cultural values and beliefs, reasons for beliefs, what liked/ disliked about subject, reasons for changing past practices or beliefs, aspirations related to subject, reason for not practicing behaviour sought, perceived consequences of practicing behaviour sought, perceived consequences of current competing practices, perceived needs in relation to behaviour sought.
Related experience, hearsay, related fears, anticipated benefits.
Exposure to related topics, meaning of related signs and symbols, exposure to related media, preferences related to media/format.
Constraints (not available- money, time, materials, food, facilities, authority, etc.), resources (available - money, time, materials, food, facilities, authority, etc.).
SOURCES OF AUDIENCE ANALYSIS DATA
Information needed to complete a population description and entering behaviour description can come from one or more of the following sources:
Rarely is all the information needed reliably available from secondary sources. Where practical, observation is usually the least biased source of further information (although, under certain circumstances, observation itself may change the behaviour being observed). Depending on how much you already know about your audience, you may want to do some basically unstructured observations at first. Unstructured observations may result in insights to help develop, at a later time, a more systematic structured observation. But, in the long run, since you want to be able to draw some general conclusions about your audience, you will need to collect information about a representative sample in a manner consistent enough to allow you to tabulate the results. This usually requires: the careful development and pre-testing of a structured observation form; a careful selection of the sample; and the training and supervision of observers, so that each observer will use the form and record the results in the same way.
Generally, there is a great deal of audience-analysis information needed that can only be collected by interviewing a representative sample of the audience. Information such as past experiences, values, future aspirations, reasons for doing things a certain way, etc., can only be collected by interview. Again, a combination of unstructured followed by structured interviewing may provide the best results in terms of balancing insights and generalizations. Of course, a good structured interview depends on a well-constructed and pre-tested questionnaire.
Generally speaking, for audience-analysis purposes, we have found that interview questions should be open-ended. This allows the audience the greatest range of response and provides the most new information. But, of course, the answers have to be grouped by similarity before the tabulation of results can be done.
A good questionnaire helps to get good information, but the way the questionnaire is used is just as important as the way it is written. Complete and accurate results depend on the interviewer's skills in getting the respondents' co-operation, in asking the questions, in listening, and in recording the answers. Interviewers need to be well trained and supervised.
Assume you have assembled all your information on the audience from secondary sources, observations, and interviews. This audience analysis is not intended to be a statistical study or evaluation. It is meant to give a general profile of your audience on characteristics relevant to the behaviour change you wish to bring about and the methods and media you might use. Some obvious examples: If you find that a significant percentage of your audience is functionally illiterate, written materials are precluded. If they believe eating fish causes worms in children, you cannot teach them to give their children fish without trying to address that belief.
Audience analysis (original behaviour) - Communication (process to bring about change) - Behavioural objectives (behavioural change sought)
The audience analysis tells what the members of your intended target audience already do. It is what the audience does before they see and/or hear the communication to be designed.
The behavioural objectives define what it is you want the audience to be able to do after they have seen and/or heard the communication.
The communication you will design is the process that will change the behaviour of the audience. In order to design a communication for behaviour change you need to know not only what it is you want to change, but also what new behaviour you want to bring about. The behavioural objectives are the result you want from your communication. The communication can then be designed to try to bring about that result. If the result (the behavioural objectives) is well analysed and defined, then the correct message (communication) can be more effectively designed. Incomplete or unclear behavioural objectives may lead to an incomplete and unclear communication. Behavioural objectives are best defined in a co-operative effort of communication designers and subject-matter experts.
Usually, the overall behavioural goal of a communication is made up of many smaller behaviours. However, just like a complex machine, e.g. an automobile, a complex behaviour can be divided into smaller and simpler parts.
Consider that car for a moment. So nothing is lost and so we do not forget how the parts work together. we could take it apart in a very orderly fashion. First we could divide it into three or four main subassemblies: the body, the engine, and the wheel assemblies.
Each of these parts is still somewhat complicated, so more subdivisions are needed. First, the engine. It can certainly be divided into engine block and cooling system. (Although I am not very knowledgeable about cars, I like this analogy, so please bear with me.) We can then subdivide the cooling system into fan and radiator; and the fan could be disassembled into fan blades, fan belt, and turning shaft.
Fan blades, fan belt, and shaft are fairly simple and easy to understand. So are tyres, wheels, exhaust pipe, etc. It is only as the parts are put together that the units become complex and more difficult. But, of course, it is only when the car is fully assembled that it will take us anywhere.
We have found this same process very valuable in breaking down complex behaviours into simpler parts that are easier to shape and establish. We take the one overall behavioural goal we are seeking, and break it down into its main component parts. For example, maybe your overall goal would be to change your audience so they would "prevent a child with diarrhoea from becoming dehydrated." Such a goal could first be broken into its general parts: "Recognize when child has diarrhoea" and "Give child rehydration drink after each movement."
Now suppose we took the latter objective and broke it down. We might get: prepare rehydration drink, encourage child to take drink, and determine each time child has movement.
Taking the first item in the list above, it can be further broken down into the steps necessary to prepare the rehydration drink: use cooled boiled water; mix 2 teaspoon salt, 2 tablespoons sugar in 1 litre water; and measure one dose with standard drinking glass.
If we have learned in the audience analysis that our audience already boils their drinking water, and has readily available the ingredients and measuring devices, we could stop here (recognizing that this example refers to only one branch of the analysis). But in many areas we would need to continue breaking down even these behaviours until we have defined behaviours the audience can perform. (And, we may have to do some testing with a representative sample of the audience to find out what behaviours they can perform and which are the best for them .)
We have found that the most useful behavioural objectives result from progressively breaking down more general behaviours into simpler levels. The hierarchy form we use for breaking down behavioural objectives into their separate component parts is shown in figure 2.
At each level in defining objectives, in order to reach the next lower level we ask ourselves the key question: "What does the audience have to be able to do to accomplish that?"
This helps us not only to define the component behaviours, but also to identify where motivation comes into the picture. Most rural mothers know how to boil water, but they may need to be motivated before they will do it for drinking water. We include in our objectives special "say" objectives related to motivation.
Let me explain what I mean by say objective. We are talking about behavioural objectives and there are two basic kinds of human behaviours. People can say something or they can do something. Thinking. understanding, knowing, etc., are not defined as behaviours. Behaviour is defined as something a person does that is observable and measurable.
Fig. 2. Behavioural objective form.
And, because it must be observable and measurable. two independent judges must be able to come to the same conclusion regarding whether or not a given behaviour has occurred.
People are more likely to do something if they see value in it - a potential good result. They are less likely to do it if they see no value or a potential bad result. We can help to ''motivate'' behaviour by persuading the audience that the behaviour will lead to a good result and not to no result or to a bad one. Since behavioural objectives must be observable and measurable, the closest we can come to "motivation" objectives is to use say objectives relating to expectation of a good result from doing the behaviour. For example, if the audience are asked the value of oral rehydration they will say: "If water lost during diarrhoea is replaced immediately the child will be more likely to recover.
CONTENT, CRITERIA, AND CRITICALITY
Content is a natural outgrowth of the hierarchy system of breaking down objectives. In the lowest levels of the breakdown, content appears; for example: "Mix 2 teaspoon salt, 2 tablespoons sugar, I litre water." These specific amounts and ingredients are some of the "content," or facts and figures, that need to be used to accomplish the overall goal.
Criteria for success specify the results that must be attained for you to be satisfied that the overall goal has been reached. These can be expressed in terms of: a designated percentage of the audience who must be able to do or say something under given conditions with a designated per cent of accuracy, and/or a specified amount of a measurable effect that the new behaviour must bring about.
Generally speaking, the fewer the criteria for success the better, on the assumption that simpler is better. If you really have one well-defined overall goal, then one to three well-conceived criteria for success are usually enough. We are talking here only about final criteria for success, not interim criteria.
Even though we have great aspirations to cure the world of all its ills, it is important to set realistic criteria for success. Certainly, if we are training airline pilots for commercial passenger plane service, or heart surgeons to do open-heart surgery, we do not want to settle for less than 100 per cent accomplishment of our goal. But in the realm of development, and the changing of child-rearing practices, every little bit counts.
Criteria for success are used to provide guidance in attaching priorities to each behavioural objective and determining how to allocate resources in the attainment of the objectives. They are not meant to be exercises in wishful thinking leading to inevitable failure and disappointment. The most useful criteria for success are "challenging but attainable."
Examples of criteria for success might be, after a specified "dose" of the communication within the audience:
Alternatively, after a specified "dose" of the communication, in a survey of households where there is a child with an active case of diarrhoea:
Again, using a single criterion for success, after a specified "dose" of the communication within the audience, diarrhoea mortality rates will be reduced by 20 per cent compared to a control group.
Criticality refers to the importance of each behavioural objective in reaching the criteria for success that you have set. We use a simple ranking method of I to IV:
I = Critical to reach criteria for success.
II = Very important to reach criteria for success.
III = Important, but not absolutely necessary to reach criteria for success.
IV = Useful, but not necessary to reach criteria for success.
Obviously, objectives ranked I and II will receive more time, effort, and resources in the design of the communication than those ranked III or IV. The number and type of objectives to be addressed in a communication will depend on: stringency of criteria for success, time and resources available, and media used.
After you have completed your audience analysis and behavioural objectives, including content, criteria and criticality, you know what your audience does and why. You are quite definite about what you want to enable them to do in the future. But how do you change their behaviour?
The next step in the "A-B-C Model" is to perform what we call a "systems analysis." In the systems analysis you try to look more closely at why the audience is not now doing what it is you want them to do. Is it because they cannot - they do not know how? Is it because they will not - they know how, but they do not want to do it? Is it a combination of cannot and will not? Or is it that they should not do it - because they lack the resources or authority?
''Cannot" most often happens when the objectives call for totally or partially new behaviour, something the audience has never done before. Preparing an oral rehydration drink for the first time. or cooking a new type of food or recipe, might be examples. They simply need an opportunity to learn and practice the behaviour, preferably under circumstances where they can receive feedback regarding their performance. We will get back to that later.
People usually "will not" do something they can do because they see no benefit there is a benefit for not doing it - or because they fear a bad result if they do it. For example, most mothers can breast-feed. However, in rural Asia, most mothers do not breast-feed immediately after birth; some even wait days. Suppose your objectives called for breast-feeding immediately after delivery. What would be some of the reasons why mothers were not already practicing this? If you researched this, you might find that they see no value in it. They feel that the milk would not yet be flowing and they may think that colostrum is useless or harmful. Furthermore, they may receive the disapproval of elders or others if they do this new thing, and receive approval for following the old ways. So, to change their behaviour, perhaps these mothers need an opportunity to learn about the value of colostrum and early suckling as well as reassurances about approval for their behaviour.
Of course, "cannot" and "will not" usually occur together. "Cannot" refers to skills and "will not" to motivation. Usually we are trying to reach objectives that require both new skills and the motivation to learn and practice them.
"Should not" objectives refer to behaviours the audience does not have the resources or authority to perform. A typical case of "should not" would be objectives for tenants to build water-sealed toilets if, in fact, they do not have the permission of their landlord. When "should not" objectives are identified, it is necessary to go back and change the behavioural objectives to something the audience can realistically be expected to do - or change the audience.
"Should not" objectives need to be changed. "Cannot" and "will not" objectives call for learning and motivation strategies.
One theory of behaviour change (based on B.F. Skinner  ) says that all behaviour is elicited by a stimulus. The behaviour is called the response, and the response that is followed by a reward or reinforcement is more likely to be repeated.
Stimulus - Response/reinforcement
The "A-B-C Model" loosely applies this theory. Regardless of the media finally selected, strategies for behaviour change give the audience information that will generally enable them to answer a question (say something) or perform a task (do something) based on a behavioural objective. The system then provides for some kind of feedback or reinforcement dependent on the response. The closer the stimulus used and the response elicited are to the actual circumstances and behaviour sought in the objective, the more powerful should be the result. Often this is achieved by a series of interactions that, step by step, shape the behaviour sought.
Usually, the reinforcement we have available to us as communicators is feedback that the audience has answered or acted correctly and, of course, praise for correct answer or act. (In cases where a game is part of the communication, winning the game can also be reinforcement.) However, feedback or praise on a correct performance may not be very reinforcing if the performance seemed too easy or meaningless to the audience. Most people seem to remember best, and take most satisfaction in, something they figure out for themselves. The most effective communication, then, may be communication that leads the audience to figure things out for themselves in such a way that:
Appendix 2 lists twelve strategies we use to design such communications. These strategies are neither exhaustive nor mutually exclusive. They can be applied to most media; however, the examples given are all from video tape. Please notice that nowhere in the strategies does it say: "Tell them what to do and then ask them what you just told them." Such a strategy would probably not be very meaningful or satisfying.
It is often useful to test these strategies when applied to specific behavioural objectives. You can test to find out if the audience understands your analogy, draws the conclusion you want them to, makes the generalization you are looking for, gets the answer with the prompt you designed, finds it too easy or difficult, etc.
Suppose you know a very good cook. This cook is given an old and dented pot to cook in. Will the food he cooks taste bad? Probably not. Now suppose you know a perfectly awful cook. This cook is given a beautiful new stainless steel and aluminium, copper-core, Teflon-coated pot. Will the food he cooks now taste good? Not very likely, although he may not burn it easily.
If we think of the recipe as the message and the pot as the medium, we may have a similiar situation. If the message is poorly designed, no medium or media mix is going to make it effective. However, if the message is well designed for any of several media, alone or in combination, it may be effective.
But, of course, there is more to it than that. No matter how good the cook may be, he cannot roast a whole pig in a saucepan. The point is that certain media are better suited for certain messages, audiences, and circumstances. But there does not seem to be any generally superior medium or media mix.
First, it depends on the skills and attitudes of the audience in relation to the available media. Are they literate? Are they visually literate and at what level? How do they want this information? Which media are most believable to them?
Second, it depends on the size and dispersion of the audience. Are we targeting a small group or most of the population? Are they spread out or concentrated? Which media are accessible to the audience now or in the near future?
It depends on the nature of the stimuli called for in our objectives. If we want to teach mothers to recognize what a malnourished child looks like, we should use media that include visuals. If we want her to respond to some behaviour of her child, visuals with motion would probably be more effective. If we need to move her emotionally to motivate her, a medium close to reality, such as colour video tape, will probably work best. If we want her to follow instructions for mixing oral rehydration fluid whenever her child has diarrhoea, we might want to include in the media mix an illustrated instruction sheet or poster for her to take home.
Although it depends on local resources, both financial and technical, media probably should not be judged so much on their cost as on their cost-effectiveness for a given job. Inexpensive pamphlets that do not work are much more costly than a more expensive film that does work. Also, what was "'high tech" last year is likely to be ' appropriate technology" next year. Costs of technology and the required sophistication for use are coming down fast, especially in the electronics field. In television, non-professionals with a few thousand dollars' worth of equipment can do now what used to require a team of professionals with hundreds of thousands of dollars' worth of equipment to do. Equipment that used to fill a television controlroom now hangs around the neck of tourists making video "home movies."
Media selection also depends on the nature of the responses we want the audience to be able to make and the nature of the reinforcement we want to be able to give. Table I lists the various media with examples of passive and interactive formats. The distinction meant between passive and interactive is that interactive formats elicit designed responses and provide feedback, passive do not.
Table 1. Communication media- passive and interactive
|!||(a) Words only||Pamphlet Instruction sheet Book||Programmed instruction|
|(b) Pictures only (illustrations, photos, diagrams, cartoons, etc.)||Poster or calendar Illustrated pamphlet |
Illustrated instruction sheet
|!||(c) Words (and person)||Case study||Case study with discussion
|!||(d) Words and pictures||Poster or calendar |
Illustrated instruction sheet
|Illustrated programmed |
Computer-based programmed instruction
|!||(e) Words, pictures (and person)||Flip chart Flannelboard||Poster or
calendar with check boxes |
Flip chart with interaction
|(a) (Used alone)||Radio |
|!||(b) Audio and print||Tape and workbook |
|(a) No motion||Slide/tape |
Computer mediated communication
|(b) With motion||Motion picture/film Video tape Broadcast TV||Video tape and workbook Computer-mediated communication|
|(c) Person and no motion medium||Slides interaction Overhead transparencies||Slides with interaction
Overheads with interaction
|(d) Person and motion medium||Interactive videotape|
|(a) (Only)||Lecture |
|Lecture-discussion Interactive tutorial "Conversation"|
|(b) With materials||Demonstration |
|Demonstration/return demon stration |
Puppets with interaction
Generally speaking, the closer the media are to reality the more effective they will be. If the mothers could be guided in their own homes to perform all the behaviours we want and given reinforcement on the spot, then there would be little problem of ''transfer of learning." Of course, this is rarely possible, first because of the time and cost involved in such one-to-one tutoring, and second because of the quality-control problem regarding the change agents. Performance inevitably varies greatly among change agents and from day-to-day for the same change agent. But posters, audio tapes, slides, and video tapes give the same performance from place to place and day to day.
Which of the media can come closest to ideal tutoring in the home? Probably a mix of media, including a change agent who can provide interaction and reinforcement and whose performance is made more consistent by being supported by other media. The change agent can also adapt the message to local needs and provide feedback to the designers. Often such a system will include video tape because, of all the "prepackaged" media, video provides the greatest reality, provided that it is taped to give a context with which the audience can identify.
In the "A-B-C Model," development refers to media production. It is part 2 of the model. Even to summarize the production system for all media would be well beyond the scope of this paper. However, I do not want to end this report without stressing the importance of developmental testing (pre-testing of communication materials with small sample groups representative of the target audience). Regardless of the media used, the best results are only possible after a strong cycle of testing and revision based on such factors as:
No matter how well we design a message and produce it, we cannot expect to guess perfectly the reactions of the audience or what they will understand or misunderstand or view differently from what we intended. Any developmental test that does not show results requiring some revisions is probably an inadequate developmental test. Only by being willing to test objectively and revise and test and revise again can we reach the potential for behaviour change of our selected strategies and media mix.
Even so, it is difficult to change behaviour and then maintain that change. It is probably especially difficult to change food habits. They are influenced by so many factors: cultural, economic, political, health-related, geographic, agricultural, psychological, etc. Obviously, much more needs to be learned about how to orchestrate all these factors in support of healthful eating habits. The model in this report offers one rather narrow approach. It is still under development. It is offered for discussion, criticism, and most of all, improvement.
1. M. Griffiths, Mothers Speak and Nutrition Educators Listen (Manoff International, Inc., Washington, D.C., 1980).
2. B.F. Skinner, The Behavior of Organisms: An Expenmental Analysis (Appleton-CenturyCrofts, New York, 1968).
Mager, R.F. Preparing Instructional Objectives. Fearon, Palo Alto, Calif., 1970.
-. Instructional Module Development. Mager Associates, Los Altos Hills, Calif., 1977. Mager, R.F., and P. Pipe. Analyzing Performance Problems. Fearon, Palo Alto, Calif., 1970.
-. Criterion Referenced Instruction. Mager Associates, Los Altos Hills, Calif., 1979. Schramm, W. Big Media, Little Media. Sage Publications, Inc., Beverly Hills, Calif., 1977.
APPENDIX 1. Elements of the A-B-C Model
A. Audience Analysis
Every communication has a receiver - someone whose behaviour you want to change (inform, persuade, entertain, etc.). Before you can efficiently and effectively change someone you must know what the individual is like. You need to know your audience in general: age, income, education. Iiving conditions. etc. And you need to know the practices, ideas, motives, etc. in relation to the change you wish to make and the media you wish to use.
B. Behavioural Objectives
Every communication has a purpose - the change you wish to bring about. Change in what someone does is a change in behaviour. When you want to change what your audience does, the change you want your communication to cause is a behavioural objective. In order to create a communication that will bring about the change you wish to make in what your audience does, you need to decide very specifically what it is you want the audience members to be able to do after receiving the communication. That is, you need to develop very detailed behavioural objectives.
Content is simply the facts you use to convince or instruct your audience. Your behavioural objectives will lead you to select the relevant and complete content you need to reach your objectives.
C2. Criteria for Success
Criteria for success are ways to tell if your audience has indeed changed in the way you wanted. Criteria are used to clarify and prioritize your objectives. Criteria are also used to determine the measures to be used in evaluating the effectiveness of the communication.
Using your criteria for success, you can attach priorities to each behavioural objective. You do this by determining the relative importance of each objective in reaching the criteria for success. These priorities will enable you to make better decisions regarding the resources (time, money, effort) you devote to each behavioural objective in preparing your communication.
You need to determine how you will bring about the behaviour change you want in your audience. This involves: systems analysis, the analysis of the sources of the behaviour you wish to change. Does the audience not do what you wish because they do not know how to do it (cannot), they know how but do not want to do it (will not), or because there are constraints in their environment that make it impossible or impractical for them to do it (should not). Strategy selection is the selection of learning and/or motivation techniques to be used to reach each behavioural objective. The strongest strategies generally involve active participation or interaction of the audience with the communication material and some sort of reward or feedback based on each interaction. Strategies can be tested with a small sample of the target population before finalizing. And, of course, design includes media selection, the determination of the media needed to implement your strategies within the financial, technological, and other constraints of your project. When you know where your audience is starting (audience analysis) and where you want them to finish (behavioural objectives), then you can plan an effective route (design).
With the previous steps completed, you are ready to prepare the communication material you will use. This involves: format development (deciding on the story-line, concept, or approach you will use to carry your message); visualizing and/or scripting (preparing a story-board, layout or treatment and, evolving from this, a script and/or final specifications for the message); pre-production preparation (planning, scheduling, and budgeting how you will implement your script or specifications); production (the actual setting of type, preparing of graphics, shooting of pictures, recording of sound, and the process of assembling the pieces into a finished poster, booklet, slide-tape show, audio tape, film, video tape, etc.); developmental testing (trying out your draft communication on a small group of people representative of your audience and determining what they do or do not understand, accept, or like, and why, and revising your materials on the basis of your findings).
Once you have a well-designed and well-produced communication that has been tested and revised until it has a good chance of bringing about the change you want, you simply need to deliver it to its intended audience in a manner that will enhance rather than detract from its effectiveness. This involves channel or site selection and maintenance of quality-control standards.
This is the moment of truth. Is your communication really reaching the target audience? Is the change you wanted really taking place? To what extent are the criteria you set being reached? Is the project worth continuing? You need to design a system of objective measures, implement them in a manner so as not to bias the results, and then analyse the results. These results can help you to improve not only this communication but also the next one you design.
APPENDIX 2. Learning and Motivation Strategies
1. Discovery/Logical Conclusion
Learner is exposed to certain information and then asked to make a decision that logically follows from that information.
(Audience analysis has shown that the mothers do not feed their children fish because they think it causes worms.) Worm life-cycle is taught. Children are shown playing in the dirt known to have worm eggs. Dirt is seen under the children's fingernails. Children with dirt under their fingernails are shown eating fish with their hands. Question is asked of audience: What do you think causes worms, fish or dirty hands? Logic compels the answer: dirty hands. a
2. Analogy/Logical Conclusion
The audience is reminded of something they are familiar with that works on the same principles as the idea being taught. They are then asked to draw conclusions from the new information based on the analogy.
Audience is shown a simple grinding stone and is told that the first immunization is like a simple grinding stone - it cannot work alone. Then the audience sees the second grinding stone put in place and flour being made. They are told that the second immunization is like the second grinding stone. They are asked If each one immunization is like the one grinding stone, then how many immunizations does your child need to be protected? Logic leads to the answer: two. a
Learner is given general principle and asked to apply it by giving specific examples.
Children should be given green leafy vegetables every day for good eyesight. Name some specific vegetables you could give to your child today to help his eyesight. a
Learner is given specific examples and asked to conclude the general rule.
Audience is asked to look at the behaviour of several malnourished children and asked what it can say about how maluourished children behave. a
5. Observation No. 1. Description
Audience looks at certain conditions and reports what it saw.
Audience is shown the reaction of a two-year-old child when younger sibling gets all the attention, and is asked to describe how the two-year-old reacted. b
6. Observation No. 2. Comparison
Audience looks at two or more sets of conditions and reports differences and/or similarities.
Audience is shown a malnourished and a well-nourished child, side by side, and asked to describe the differences it sees. b
7. Observation No. 3. Modelling of Desired Behaviour
This is a special case of observation: description/comparison. Here what is being observed is the behaviour to be taught. The audience is asked to observe and describe this correct behaviour or some of its elements.
Audience watches mother prepare aspirin to give a young child with a fever. Audience is asked to describe how they prepare aspirin for a young child with a fever. a
The audience is helped to get the correct answer by being given clues.
Audience is shown the "3 plus 1" food groups and the ingredients of a child's food. The ingredients are put into three of these groups. The audience is asked what group is missing from the ingredients. (The prompt is the fourth group in the visual.)b
Previously elicited and reinforced behaviour is asked for again with less supporting information or fewer prompts.
Audience is shown a meal with no protein source and asked what food group should be added to make this a complete meal. (Later two food groups are missing, then three.)a
10. Personal Opinion, Preference, Feeling, Experience, or Data
Audience is asked to give opinions or preferences, tell some personal feeling or experience, or give data about themselves or their children (such as age, names, etc.)
This strategy is used for the first interaction of a programme. The subject-matter chosen should be non-threatening to the audience but something they might like to talk about. The purpose is to: 1. Have an opportunity to reinforce the audience for responding. 2. Introduce the subject of the module.
What are some of your child's favourite foods?
11. Public Commitment
Audience are asked to commit themselves regarding some attitude, opinion, or practice that is being shaped by the module. This is done in order to strengthen that attitude, opinion, or practice.
After being taught the value of breast-feeding immediately after birth, mothers are asked when they want to start breast-feeding after the birth of their next child. b
12. Performance of Entering Behaviour
Audience are asked to do or say something that they already know how to do or say. This is used only if:
a. Video tape made at the Nutrition Center of the Philippines.
b. Video tape made at the Institute of Nutrition in Thailand.
DENNIS R. FOOTE
Institute for Communications Research, Stanford University, Stanford, California, USA
There is a growing interest among developing-country governments in implementing and evaluating purposive communication projects, that is, activities in which communications media and processes serve as a major component of a project designed to enhance education and/or social service delivery. Evaluation of these activities is of paramount importance, because high levels of governmental and individual resources are involved and because the cumulative knowledge about how to design communication interventions effectively is not extensive.
This paper suggests a model for planning evaluations of such projects. The model draws heavily on systems theory in organizing the disparate components into units that can be worked with. The intent of having a comprehensive model is not that every project should be exhaustively evaluated, but that planners of such activities should choose from the comprehensive model those portions that are appropriate to their particular circumstances. A side benefit is that paying attention to all aspects of evaluation during the project planning phase often facilitates more effective and focused efforts. The general outline of the model involves the following stages, although in an ongoing project these stages are not independent or necessarily sequential. Rather, they represent processes that are interrelated and interactive.
Examples from current projects in Honduras and the Gambia in which this methodology is applied will illustrate the discussion. These projects use integrated campaign strategies to introduce and promote changes in behaviours related to diarrhoea, particularly the use of oral rehydration therapy (ORT). The projects, funded by USAID in co-operation with the Ministries of Health in each country, are called Mass Media and Health Practices, or MMHP for short.
One of the major causes of infant mortality in developing countries is diarrhoeal disease. It occurs at significant levels in practically every country, facilitated by undernutrition and poor sanitation. Death is typically caused by dehydration - loss of fluids and electrolytes - before the child's natural defences can defeat the cause of diarrhoea. Less acute consequences malnutrition and waste of human material resources- are more common. In addition to the goal of improving nutritional and sanitary practices in the home for prevention of diarrhoea, an inexpensive oral rehydration therapy (ORT) that treats the dehydration by replacing fluids and electrolytes has recently been developed. Oral rehydration therapy was chosen as the health innovation to be presented in the campaigns in Honduras and the Gambia because its universal relevance meant that successful campaigns in these countries could serve as direct models for efforts in many other countries.
Household-based therapy offers an opportunity for a massive extension of coverage and a significant improvement in outcome statistics. At the same time this raises issues of compliance and the necessity for appropriate and convincing education materials, in addition to changes in the health delivery system.
MODEL FOR EVALUATION PLANNING
This is a need, then, to plan, implement, and evaluate such projects in a way that will lead to understanding and practicality in health campaigns such as those aimed at reducing infant mortality caused by diarrhoea. Taking a systems approach, we can view a campaign intervention as an input-output process altering the state of a system subject to constraints.
The General Model
Figure 1 presents an overview of the evaluation model. Taking a systems perspective, this model shows that before any intervention, there exists: (a) a prior state (of people, their family, their community, the environment, the economy, etc.) that is the baseline to which ongoing and final evaluation measurements are compared; and (b) constraints existing in the system that affect both how the population can interact with the intervention, and how the intervention activities can actually be accessed by the population.
Fig. 1. Overview of the evaluation model.
The left side of figure I shows this prior state, systems constraints, and the intersection of the system constraints and intervention inputs. These three components interrelate and feed into the process component. In the component, the subjects access the inputs within the context of prior states and constraints, and something happens. We hope that the goals of the project are achieved, and indeed the evaluation is focused upon and organized around these substantive outcomes. The evaluation project will attempt to determine and understand which of the substantive outcomes occur. Perhaps more people become informed, change their attitudes, alter their behaviour, become more healthy. Perhaps they only do some of these. Perhaps they do none of them. Perhaps they have indeed changed, but cannot perform the behaviours they would like to. Or, perhaps they behave differently, but the evaluation effort cannot detect this. Again, the system will contain constraints that interact with certain intended outputs from the process component. For example, perhaps a family learns new approaches to hygiene and wants to perform them, but cannot because their personal, cultural, or economic conditions prevent them from buying soap or using suffficiently clean water. Thus system constraints "block" the progression from process to output.
The subsequent condition of the population constitutes a new or post state that must be measured to detect change from the prior state. This post state, which includes outputs from the process components, consists of the information, attitudes, behaviours, and health status of individuals as well as many of the conditions measured in the prior state component. Many of the values of the variables measured may not have changed; some would not be expected to change. And some new aspects of the system may have been introduced, such as new health communication infrastructures or different administrative procedures.
A final note to this overview concerns the MMHP evaluation analyses. Perhaps the most important analytical aspect of an evaluation of an intervention as complex as the MMHP is the need to consider, measure, and assess the effect of the major variables that help explain why certain outputs occurred, or why certain others did not. Thus, the evaluation model takes care to detect and measure constraints as well as the effect of different media, different messages, at different times, in different regions, and with different audiences. It is very important to specify the relative efficacies of implementation activities, relative receptivity of the target audience, cumulative efforts over time, and what constraints and obstacles simply prevented intervention efforts from even reaching the audience or from being utilized in the process component.
Specifying the Prior State
The prior state of the environment, the community, the families, and the individuals, can be broken down into clusters of variables. These variables can be looked at in terms of their content area, or in terms of where they fit in the entire intervention/ evaluation process. For the MMHP evaluation, the clusters of variables by content include:
From these variable clusters, depending on the inputs, target audiences, regions, timing and constraints, particular questionnaire or other data collection instruments can be generated.
Specifying System Constraints
Current development theory and research tells us quite clearly that the socio-cultural/economic structure of the target audience plays a very important role in any social intervention, and particularly in communication interventions, because of the difficulty in translating new information into firmly held behaviours. Other more practical constraints operate as well, such as whether the materials planned by the project are actually broadcast with the planned frequency, or whether the target audience members have access to particular mass media.
The evaluation model shows that it is necessary to detect and measure system constraints that may block or obstruct the progression from inputs to outputs. Major categories of constraints include:
Any one constraint or set of constraints can affect delivery of inputs, access to delivery inputs, or resistance to delivery inputs or can overwhelm the potential effects of delivered inputs. Once the linkages between intervention inputs and potential outputs are specified theoretically (as in the process component) it becomes crucial to specify any linkage obstructions. We need, then, to make a distinction between planned inputs and engaged outputs, and the constraints that lie in between. This process is portrayed in figure 2.
Between the intervention inputs at the bottom of figure 2 and the actual interface (here called "engaged inputs") lie the possible constraints to full delivery of the planned inputs. For example, a series of radio spots with a given frequency of broadcast may be planned, but the broadcasters do not receive the scripts in time or choose not to broadcast all spots according to schedule; the result is termed "real inputs." In the Gambia, 66 per cent of household compounds have at least one radio receiver; in those compounds 75 per cent of the women listen to Radio Gambia, which delivers the MMHP spots. Compare this engaged input to the 3 per cent literacy rate in the Gambia that would prevent any noticeable engagement via print. These real inputs may not be "engaged" because the workers are at work during the broadcast, and miss the "planned inputs." These "engaged inputs" must be considered the true inputs in analysing change and post-state measurements. A detailed accounting of "engagement" would include which engaged input is received at which process step by which individual in which region.
Specification of Outcomes
Measures of success in a health communication project may include a wide variety of outcomes. Typically, a project would hope to detect improvements in cognition, behaviour, and final health status of the target infant population and beneficial changes in the entire medical-social system. The general theory behind such interventions postulates a chain from inputs such as a variety of treatments of infrastructure change, through constraints that may be environmental (season, local conditions), cultural (perspectives on disease), resource-based (water, income, distribution channels), or subject-related (analytical categories, demography, personal differences), to the post state outputs such as attention, cognition, adoption, behaviour, and health status.
Fig. 2. Action of constraints on project inputs.
In the Honduran and Gambian projects, categories of cognitive outcomes include recognition, recall, and knowledge of nutritional and preventive behaviours and ORT treatment messages. Categories of behavioural outcomes include response to the diarrhoeal episode (i.e. administration of ORT, taking child to clinic), infant-feeding practices (breast-feeding and weaning, etc.), water purity (boiling the water) and personal hygiene (hand-washing, hygienic practices). Categories of health outcomes include nutritional status (extent of malnutrition, variety of diet), morbidity (frequency, severity, and duration of diarrhoea and common diseases), and mortality (death rates from diarrhoea or other causes).
Fig. 3. Specification of project outcomes.
Categories of system outcomes include the health system (is ORT accepted and institutionalized? is prevention an accepted medical activity?), communication system (are the messages incorporated in development content? are various media seen as potential development agents?), distribution (do even the most rural areas have access to media, ORT, and health agents?), and training (is preventive and ORT information passed on in local training?).
These categories of outcomes of a MMHP intervention, along with their evaluation specifications, are shown in figure 3.
PROCESS MODEL AT THE INDIVIDUAL LEVEL
The Mass Media and Health Practices project campaigns will attempt to change knowledge, attitudes, and behaviours relating to the prevention and treatment of infant diarrhoea. The intervention is expected to result in changed health practices that, in turn, will lead to changes in health status. The conception of how the intervention is expected to work is diagrammed in figure 4.
Any comprehensive approach to evaluation requires that each successive link be monitored so that useful lessons can be learned from the outcome of this project. In this way one can determine where weak links occur, or where the next step requires particular attention, and use that information to guide the planning and execution of similar projects. To that end, we have elaborated the general structure shown in figure 4 into a more detailed version shown in figure 5.
Fig. 4. Postulated relation between treatment and health change.
We will illustrate this underlying conception of the path from treatment to changed health status using as an example one specific practice the implementation campaign will probably advocate: continued breast-feeding during a diarrhoeal episode. Connections are described as though they were sequential links, although it is realized that this is an oversimplification. Links 1 and 2 concern the existence of the treatment, links 3 to 5 the cognitive and attitudinal changes that are postulated to precede practice change, links 6 and 7 describe adoption of new behaviours and, finally, link 7 is that change in health status expected to result from the treatment.
1. Existence of the Intervention
The first step is to establish the existence of campaign elements related to the topic under consideration. The extent to which the implementation effort is devoted to the topic of breastfeeding will be examined; whether radio programmes or spots concern breast-feeding, to what extent relevant content is incorporated in the printed materials, whether health-care-worker training includes instruction about the topic, and instruction in how to present it to mothers.
2. Exposure to the Intervention
At this level, the potential exposure to the intervention components is assessed, including the number of radio programmes broadcast; times of day of broadcast; listening patterns of target audience; successful physical distribution of printed materials; posting or circulation of printed materials; numbers of client contacts with health-care workers in which continuation of breastfeeding is mentioned; and proportion of time devoted or relative emphasis given to this practice by health-care workers.
Fig. 5. The logical chain from proximal to distal outcomes.
3. Awareness of the Intervention
This step tries to determine whether any of the potential exposures to the intervention actually "got through'' to the target audience. It measures consciousness of actual exposure to intervention components. For example, members of the target audience will be asked to report topics of the campaign. or to recognize theme music or specific intervention messages. Target audience members will also be asked to judge the frequency of relative exposure to specific components and to judge whether that exposure was sufficient.
4. Knowledge of Specific Content
At this stage, amount and accuracy of learning resulting from the actual exposure is measured, using such approaches as: recall of message content, that is, asking the respondent to generate a description of the content of a message rather than merely recognize it: understanding of the content and reasons for adopting the behaviour; accuracy and level of detail of knowledge of the advocated practice; and ability to exercise new skills.
5. Attitude toward Specific Content
At this stage acceptance of or reaction to advocated behaviours is focused on. Typical topics for measurement include: recognition of the current practice as a problem; beliefs about the current practice and the consequences of adopting the advocated practice; level of desire to depart from the status quo; perception of the individual's own position in relation to community norms; perceived conflict of advocated behaviour with other valued beliefs or practices; and attitudes toward message sources.
6. Trial of Advocated Behaviour
This next stage is to discover whether, when confronting an appropriate context, mothers have ever accurately performed the behaviour. For some behaviours this can be measured by observation, but in the case of continued breast-feeding during a diarrhoeal episode, selfreporting, along with adequate description of the context and corroboration by other sources, will be used.
7. Habitual Performance of Advocated Behaviour
This step investigates whether there has been repeated or habitual performance, and the conditions required for maintaining the behaviour will be observed. In the present case, selfreporting will be used, as noted above. Accuracy of performance and rate of display of the behaviour under appropriate circumstances need to be measured. This investigation will attempt to determine the conditions that lead to continued practice of the new behaviour.
8. Change in Health Status
The final stage involves the measurement of whether the changes in health behaviours produce a detectable effect on health status. In the case of continued breast-feeding, a likely effect is a change in nutritional status or growth velocity. For other advocated behaviours, morbidity or mortality measures might be more suitable. (Note that appropriate measures are only being described, and that demonstration of causal relationships is not being suggested.)
Measuring the impact of each of these successive links in the chain will provide information of a detailed nature about exactly where the programme is successful, and what types of remedial action to take to improve the situation. The information obtained in these measurements has a value that extends to other projects as well, because this model is quite general.
The actual structure of the evaluation does not follow the structure of the model; instead, the evaluation structure is dictated by methodological and logistical issues. The model of the process involved is interwoven throughout the evaluation because it serves as the basis for criteria for decision-making among methodological alternatives.
Choices in Research Approaches
The fundamental goals of a health campaign evaluation effort are to:
To ensure adequate control and to assess the validity of results by convergent measurement, each general category of outcomes can be measured using several methods, including questionnaires, structured observations, structured interviews, anthropometric measurements, archival data, ethnographic research, and case-finding/tracer studies. Figure 6 indicates how these methods are applied to the outcome categories in the MMHP evaluation. The characteristics of a variable (in particular, the variance and the rarity of occurrence) determine the frequency with which it should be measured, and the appropriate sample size. For instance, questions about family composition and educational levels need only be asked infrequently, while questions about incidence of acute diarrhoeal disease must be asked quite frequently. Further, consider different analytical foci that can lead to a comprehensive evaluation of health campaigns. Below are six major study groupings used in the MMHP project that differ markedly from one another in magnitude, study population, and measurement requirements.
Fig. 6. Matching of research approaches with categories of dependent variable.
Particular project contexts may lead to rejection of or emphasis on one or more of these studies. For example, archival data analysis is dependent on the existence, validity, and timely availability of relevant data. In Honduras, lack of measurement precision and evidence of marginal returns from changing the media mix or frequency lessened the possibility of a complete cost-effectiveness study.
A major issue in the design of an evaluation plan for an intervention is that of allocating resources between measurements made on the treated population group and measurements made on comparable but non-treated populations. The trade-offs are between precision of measurement, which is increased by concentrating resources on the treated population, and interpretability of results, which is increased by allocating measurement resources to a comparable non-treated population. Because resources for field-work are limited, it is crucial to think through carefully the value to evaluation of mounting data collection efforts in non-treatment areas. To present an example of this process, we will first examine potential sources of data on non-treatment populations that are possibly attainable without conducting a longitudinal survey in a control area.
Comparisons within the Treatment Area
We identified four sources of data within the treatment area (from those mentioned above in the section on research approaches) that can be used for control purposes.
They vary in the quality of the data they provide. We first list them and then, in table 1, assess their usefulness to the project.
Household as Its Own Control
Because we adopted a panel design, we returned to households for repeated measurements. We thus were able to use each household as its own control for many variables.
Making Use of Staged Implementation
If, because of cyclic aspects of system constraints, components of the campaign are introduced in stages in different regions of the treatment area, the study can have non-treated segments of the population within the measurement sample for portions of the intervention period.
Natural Variations in Exposure
Because of the vagaries that can be expected in mounting a complex intervention in a developing country, some components of the campaign will not be implemented as planned. A project can take advantage of these events if they occur in the sites in which data are being collected, and if the monitoring of engaged inputs is satisfactory.
Self-determination of Exposure
Some people will select not to expose themselves to a health campaign, because they do not have access to a radio, because they do not choose to talk to health workers, and so on. Such people are likely to be quite different from those who do accept exposure. None the less, they can be a source of some kinds of information.
We have identified four sources of control information within a treatment area and four sources of information about populations outside a treatment area. Earlier, we identified three types of project outcomes of interest: cognitive outcomes, behavioural outcomes, and health status outcomes. Table 1 summarizes our view of the usefulness of each type of data for variables falling in each of the outcome categories. For example, in the column headed "Staged implementation," we note that there is an "a" in the rows for cognitive and behavioural outcomes, but nothing in the row for health status. Our reasoning is that beliefs, practices, and levels of knowledge can change quickly on exposure to campaign intervention, so repeated measures can capture changes between implementation stages. In contrast, the typical time interval between the onset of data collection and the onset of a later implementation stage is probably too short to provide reliable evidence of control levels of health status variables. As another example, consider the entries in the column labelled "Self-determination of exposure." Those who choose not to be exposed to the campaign are probably too different in their beliefs and practices from those exposed to provide reliable evidence about the first two types of outcomes, "cognitive and behavioural," and thus these cells in the figure are blank. However, they may be a useful source of information about some health status indicators, although such data cannot be expected to be of high quality. We have thus marked this space with a "b."
Table 1. Usefulness of data from various sources for control group comparisons
Within treatment area
Outside treatment area
|Household as own control||Staged implementation||Natural variation in exposure||Self- |
|Archival data||Ethnographic studies||Data from other studies||Special
a. High potential utility.
b. Moderate potential utility.
Comparisons with Non-treated Populations
We can obtain data about people outside the treatment area from several sources. Archival data and ethnographic studies were mentioned previously. Data from other studies are also useful. Other health projects have been and are now functioning in many regions that may provide useful baseline information. For example, the Institute of Nutrition of Central America and Panama has constructed growth curves for Central American children that can be used for comparison and prediction. This project used standardized data available from the Center for Disease Control in Atlanta, Georgia.
Special one-shot studies may assess the level of a belief or practice in a non-treatment area when results in the treatment area are ambiguous.
SUMMARY AND CONCLUSIONS
This paper has presented a general framework for thinking about evaluation design issues, derived from a systems theory approach. It has illustrated the application of that framework with examples drawn from ongoing projects in Honduras and the Gambia.
It is unlikely that any specific project would ever try to utilize every aspect of the framework, since most projects (and to an even greater degree, evaluations) will have only a more limited scope and intent. However, the framework leads one through a planning process that ensures that all aspects will be considered, even though they may be deliberately omitted from any evaluation plan. The key issue is that the decision to omit should be a conscious one.
An important feature of the evaluation framework is the emphasis that it puts on examining structural and resource constraints that exist outside of and prior to any intervention attempt. ID our experience, the most frequent problems associated with the projects stem from inadequate attention to the details of programme implementation in an environment full of unrecognized constraints. If evaluation planning occurs concurrently with the development of an intervention design, likelihood of successful programmes increases, because the constraint issues will be acknowledged from the beginning. This evaluation will contribute to programme success not only in a cumulative way, but also in a formative or process-oriented way.
The author wishes to acknowledge the support of the Offices of Education and Health in the Bureau of Science and Technology, USAID, under contract AID/DSPE-c-0028, and the contributions of those who have worked on these issues under the contract, particularly Dr. Ron Rice, Dr. Barbara Searle, Dr. Carl Kendall, all Dr. Peter Spain.
DENNIS R. FOOTE, CARL KENDALL, PETER SPAIN, and REYNALDO MARTORELL
Stanford University, Stanford, California, USA
The Mass Media and Health Practices (MMHP) project builds on a fairly extensive history of attempts to use mass media and communication campaigns to carry out health education and health behaviour change programmes. Previous efforts had used different aspects of the approach- research for planning, integrated multi-channel campaign strategy, pre-testing of messages, social marketing techniques, and the use of behavioural methodologies to analyse and generate change - but none had combined all the components and none had tackled the complex set of objectives related to introducing oral rehydration therapy. The MMHP project was thus established with the twin goals of testing and refining the methodology of this type of campaign, and of assessing the campaign's impact on health through the promotion of oral rehydration therapy in a field setting. Because success in both objectives would have implications for health behaviour efforts in other countries, a large-scale evaluation was planned. This paper describes the evaluation design, and reports early findings from data collected during the first year of the projects. Data collection continues in Honduras and the Gambia, and more extensive analyses will be conducted as the large data base becomes available.
The evaluation was for the purpose of investigating both the effects of the campaign on people's behaviours, and the effect of any behaviour change on health status. It was recognized that, in order for any changes in behaviour or health status to take place, a complex sequence of events had to occur beginning with exposure of the target audience to the campaign elements, proceeding through the learning of campaign information and adoption of new behaviours, and culminating in change in health status as a result of the behavioural changes. At each step the net impact of the project would diminish; if a failure occurred at any point along the path, no further impact would be expected.
To guide the planning of the evaluation, Stanford's Institute for Communication Research developed a detailed "Process Model" describing the sequence of events that would lead to eventual change in health status. A simplified version of that model called for the target audience to be exposed to the campaign effort, for them to learn from that exposure and remember and accept the messages, for behavioural change to occur, and for those behavioural changes to result finally in changes in health status. The model pointed clearly to the need to measure results at each level - exposure, learning, behaviour, and health status - in order to answer questions about the effects both of the campaign and of oral rehydration therapy. Hence variables were identified to track the impact at each level.
The research design developed to track the impact of the campaign involves a panel study of roughly 750 families in each country over a little more than two years. In Honduras families were recruited into the study from 20 communities under a stratified, purposive sampling plan with random selection of families within communities. In the Gambia, where communities are organized into compounds that often include multiple or polygamous families, communities were purposively selected, and compounds were randomly sampled, after which women were randomly sampled within compounds. A woman was considered eligible for the study if she was between 18 and 45 years old or was responsible for caring for small children.
Mothers are visited approximately once a month by a local field-worker who administers questionnaires and conducts observations and anthropometric measurements. A general "baseline" survey is conducted at the beginning and end of the study; in the intervening months, batteries of items relating to topics of specific interest are administered or repeated. Thus, for example, four batteries are used in Honduras, covering anthropometry, morbidity, communication, and child-care practices. Administration cycles have averaged somewhat longer than one month, so instrument batteries are repeated roughly every six months. In addition to the panel surveys, a number of much smaller ancillary investigations are conducted in order to supplement the information about exposure, learning, behavioural change, and health status change. The other studies include interviews with health workers, a community mortality study, ethnographic research in two communities, a cost-effectiveness study, and an administrative history.
Findings from the evaluation research at this point are based primarily on analysis of the survey data from the panels of families in each country through the first year of the two-year projects. As such, they are interim results and do not yet reflect the full impact of the programme. They are presented here in the order specified in the process model. First, access to the channels used by the campaign and exposure to the campaign messages are examined. Learning of campaign information is assessed, and then behavioural change is investigated. Finally, health status is examined. An attempt is made to report parallel data from both projects; however, differences in the interventions and in the data collection procedures limit the direct comparability in some cases, and in other cases, for the sake of brevity, only one site's data are presented as illustrative.
Access and Exposure
We first set out to determine whether the three principal communication channels used by the campaign - radio, interpersonal contact through the health-care system, and print materials were feasible means of delivering messages. We found in general that the population had good access to the channels and reported high exposure to campaign components.
Ownership and functioning of radios among the sample were assessed by asking participants whether they had a radio and asking them to turn it on to demonstrate that it worked. In Honduras, 80 per cent of the families owned radios, and 71 per cent of the families had a radio that worked on the day of the interview. In the Gambia, 66 per cent of the compounds had radios, and in 60 per cent of the compounds they were demonstrated to be in working order.
In addition to the existence of radios, the amount of radio use was investigated. The results support the notion that radio has very high penetration in rural areas and is listened to frequently. in Honduras, 63 per cent of mothers reported listening to the radio on the previous day. They start listening as soon as they get up, and radio use peaks between 6 and 7 a.m., with 38 per cent of all households tuned in at that time. There is a gradual decline over the course of the day, with the exception of another peak (36 per cent) between 12 and 1 p.m., at lunch. Relatively little radio listening takes place in the evening. In the Gambia, radio listening is also high, but the pattern contrasts sharply with that of Honduras. The most common time of listening is 8 p.m., which over 70 per cent of the women say is their preferred listening time.
Women who listen to the radio also remember hearing campaign messages as measured by a 24-hour radio listening recall test. For example, in Honduras, 44 per cent of the mothers remembered hearing at least one MMHP spot advertisement on the previous day. Mothers who listened to the radio on the previous day remembered hearing an average of more than three spots. Clearly, the use of radio as an information distribution channel to rural mothers is a success.
Both countries train the existing infrastructure of health-care workers about diarrhoeal disease and use them to promote campaign objectives. It is therefore important to establish whether contact between rural families and representatives of the health-care system took place frequently enough to expect this component to work. The systems of primary care in rural areas in both Honduras and the Gambia rely on tiered systems of facilities, ranging from hospitals down to community volunteers. There are also well-established systems of sources of traditional care present in the communities. In Honduras, 47 per cent of mothers had had contact with some type of healthcare worker in the previous six months. Thirty-three per cent of all mothers had seen a physician or a nurse at a clinic. Twenty-one per cent of all mothers had been in contact with some level of community-based health worker, such as local volunteers, midwives, or health educators. Eleven per cent had dealt with some "traditional" source of care, such as a healer or a masseuse. Obviously, some mothers had contacted more than one source of care. In the Gambia prior to the MMHP campaign, 85 per cent of mothers said they had gone to the health centre for their child's last case of diarrhoea, while 8 per cent said they had gone to a local healer. Two out of three Gambian mothers can reach a health-care facility within 90 minutes, usually by walking. These are both very high levels of interaction with representatives of the health care system and make the planned use of interpersonal channels a very reasonable approach. It also demonstrates a conclusion from this and other data from both countries - that the system of traditional or folk medicine co-exists with the western or modern system, with care being sought from either system according to the person's self-diagnosis, and sometimes from both systems simultaneously. The strong preference in most cases is for the modern medical system.
The campaigns in both countries rely on some use of printed materials, such as posters, flyers, and pictorial instructions. Thus, we checked the literacy in our sample. Honduran mothers were able to read a complex phrase 57 per cent of the time. In households where the mother could not read, other family members were tested for literacy. The household literacy rate was an impressively high 87 per cent. In the Gambia, the situation was markedly different. Fewer than 3 per cent of mothers could pass the literacy test, and only about a third of the compounds had a reader present when we conducted our test.
The print materials used in the two projects have been designed with these limitations in mind. In Honduras, posters have been widely distributed, as have instruction sheets with pictures and writing. After a year of campaign activity, using a fairly strict test of unaided recall, nearly half (47 per cent) of Honduran mothers could describe a MMHP poster they had seen well enough for the interviewer to identify the poster. In the Gambia, a flyer that relied almost exclusively on pictures to explain the mixing of oral rehydration solution was prepared and distributed over the entire country. In our sample, 79 per cent had seen the flyer and 71 per cent could show us their copy of it. Thus, properly designed print materials can also be used as a communication channel, even in circumstances in which literacy is quite low.
Once it was established that the channels used by the campaigns were available to the mothers and could, in fact, be used to deliver campaign messages, the evaluation effort focused on measuring learning through those channels. Learning has been measured using recall, recognition, open-ended and true-false items about the specific content of the instruction given in the radio spots and programmes and by health workers. Items relating to specific topics have been combined into indices to estimate learning gains. The result is an impressive level of learning, both in terms of absolute levels of knowledge and in terms of improvement. This paper will present a few examples rather than try to summarize all the learning data.
In Honduras, the oral rehydration solution promoted is called Litrosol, and it did not exist before the programme began. By the end of one year of campaign activity, 92.5 per cent of mothers could name Litrosol as the medicine being promoted by the campaign. One-third of the mothers could define dehydration, a concept that pretesting had shown to be absent before the campaign. When prompted with the first lines, more than 70 per cent of mothers could complete the campaign jingle having to do with giving liquids during diarrhoea. An average of 62 per cent of jingle-completion items were correctly answered by mothers. Sixty-five per cent of mothers know of Dr. Salustiano, the main character in one group of radio spots. Ninety-five per cent of mothers named breast-milk as the best milk for babies (up from 62 per cent after six months of campaign). Five indices were constructed to measure learning from Dr. Salustiano spots in general, Dr. Salustiano's specific spots about dehydration, Dona Chela spots (another character used in the radio campaign), spots about dehydration, and spots about breast-feeding. Learning was assessed after six months of broadcasting and again after twelve months. The performances at the six-month period averaged 11 per cent of the index value, and after a year almost 18 per cent, an average gain of over 60 per cent. The range of gains on the five indices was 35 per cent to 180 per cent.
The campaign in the Gambia relies heavily on longer radio programmes and other promotional activities, such as a lottery, to instruct and motivate mothers. Hence assessment of learning was targeted on more general tests of knowledge than message-specific tests as in Honduras. One of the most important content areas has to do with teaching the method of mixing water-sugarsalt solution for home administration of oral rehydration. At the very start of the campaign, only one mother out of about 800 could correctly give the formula for mixing water-sugar-salt solution (WSS). By December of 1982, nine months into the campaign, 64 per cent of the mothers could given the entire formula. This represents an astonishingly powerful learning activity, since the information itself is fairly complex and the means used to teach it involve voluntary exposure to intermittent inputs. At that point in time, only 20 per cent of the mothers had no heard of the water-sugar-salt medicine that you can make at home.
One of those inputs was the "Happy Baby Lottery," which was promoted for a few months by radio and actually involved only 72 of the Gambia's hundreds of villages. None the less, half the mothers in the sample had heard of the lottery and 71 per cent actually had the instructional flyer that was used as an entry requirement. An analysis of other items on a wide variety of topics covered in the campaign shows an average gain of 35 per cent between the sixth and ninth months of the campaign.
There is no doubt that the specific content being taught by both campaigns is being learned and retained by the mothers. The general pattern seems to be one of fast initial gains followed by slower gains as time goes by.
The analysis to date of behaviour changes associated with the project has concentrated on the adoption of Litrosol and water-sugar-salt therapies for dehydration. ln Honduras, the use of Litrosol packets in the home is a new behaviour. The proportion of cases of diarrhoea treated with Litrosol rises from zero prior to the campaign, to nine per cent after three months of broadcasting (at which point supplies of packets were just beginning to be available in the community), to 26 per cent after a year of the effort. At the end of the first year, half the mothers reported that they had used Litrosol at some point. About two-thirds of the women who have used it report that they obtained it in their own community; the rest tend to get it at clinics or at the hospital. Knowledge on how to mix the solution is high - 95 per cent of the women know they should use a litre of water and put in the whole packet. Most women (58 per cent) reported that they learned how to mix it from the packet (which comes with an instruction sheet). Fewer women (43 per cent) learned from interpersonal sources, and far fewer from the radio (14 per cent). There is a positive relationship between the severity of the case and likelihood that it will be treated with Litrosol.
In the Gambia, various techniques of mixing and using water-sugar-salt solutions had been promoted by the Ministry of Health in the past. However, none of these used the same formula as the one in the current campaign. The use of water-sugar-salt solutions rose from 4 per cent of all cases of diarrhoea at the beginning of the campaign to 48 per cent of all cases after nine months. If the analysis is restricted to those mothers who treat their child's diarrhoea themselves, the rise in adoption of solution is even more marked. The proportion of mothers treating cases themselves rose from 18 per cent at the start to 54 per cent after nine months. The percentage of those mothers treating with solution rose from 21 per cent to 89 per cent over the same period. Use of other, often inappropriate, treatments falls correspondingly.
The third step in the sequence of events that the evaluation's process model postulates, the adoption of the promoted behaviours, is also attained. Many mothers have acquired the skills and are introducing the behaviour into their patterns of response to diarrhoeal disease.
The health status variables being monitored in the evaluation include anthropometric measurements, morbidity, and mortality.
Morbidity has been measured in various ways. Prevalence of diarrhoea among children under five on the day of the interview in Honduras has shown a high of 14.6 per cent (in June) and a low of 8.7 per cent (in March) in the two assessments analysed thus far. Incidence in the previous two weeks was 36 per cent in June and 21.5 per cent in March. These differences are probably seasonal variations, as treatment with Litrosol is unlikely to affect the incidence of the disease. There appears to be a rapid drop-off in memory of cases; reported prevalence on the fourteenth day prior to the interview is roughly half the day-of-interview rate. None the less, by combining data from various sources it is possible to estimate that a minimum of half the children have had an episode of diarrhoea in the six months prior to the interview.
Incidence in the Gambia is roughly the same and, because more closely spaced assessments are available, can be shown to exhibit a clear seasonal variation. Two week period prevalence ranged from a low of 10.3 per cent of children during the dry season to a high of 33.5 per cent during the rainy season.
The baseline anthropometric measurements of nutritional and growth status in Honduras have been analysed. Approximately 30 per cent of children under five are "stunted" (i.e. less than 90 per cent of height for age), while only slightly more than 1 per cent are "wasted" (i.e. less than 80 per cent weight for height). Thus, while a cumulative growth deficit is occurring, the children did not appear to be acutely malnourished in June of 1982. Subsequent analyses will examine the change in health status and its relation to illness and oral rehydration therapy.
Mortality data are being collected on the entire population of the communities from which the study sample is drawn, thus giving a substantially larger population base. Data from Honduras show a significant drop in the proportion of deaths that involve diarrhoea among children up to 24 months old. For a comparable set of seasons, diarrhoea was mentioned as a cause of death in 45.3 per cent of the deaths for one and a half years before the start of the intervention and in 25.0 per cent of the deaths in the year and a half following the availability of oral rehydration solution. This decline is significant at the p< .005 level. Mortality data are also being collected in the Gambia but are not yet complete.
This paper has presented the evaluation plan and some of the early findings of the evaluation of the Mass Media and Health Practices projects in Honduras and the Gambia. The findings indicate that: the target populations have good access to the communication channels used by the campaigns; the target populations are exposed to and aware of the campaign activity; the audiences are learning a great deal of the campaign information; they are adopting the treatment behaviours of oral rehydration therapy on a large scale; and the proportion of mortality among children of less than two that involves diarrhoea has fallen significantly in one country.
Subsequently analyses will follow these same issues through the data from the second years of each campaign and relate the behaviour to changes in health status of the treated children.
Population and Community Development Association (PDA), Bangkok, Thailand
By the early 1970s, Thailand's population had increased to an alarming level, with a growth rate that indicated that the population would double by the end of the century.
Organized family planning programmes were producing marginal results and it became clear that a new systematic and concerted effort was needed to motivate the public. New and innovative approaches were needed, and with this in mind the author launched a nationwide social marketing campaign designed to introduce and/or reintroduce family planning, operating through the newly created Community-based Family Planning Services (CBFPS), a major bureau of the Population and Community Development Association (PDA).
In a systematic fashion, the social marketing programme desensitized the population to the traditionally sensitive issue of family planning, demonstrated the need for family planning, and motivated people to use contraceptives that were provided through community-based voluntary distributors. Using local channels for communicating the family-planning message, the programme was conducted in an atmosphere that reflected its insight into Thai culture.
This paper will present a basic framework for a social marketing programme, and as an illustration will relate its various components to PDA's own experiences in contraceptive and family-planning social marketing. It is hoped that this framework will be of assistance in the design of social marketing or communication programmes in other areas of health, such as nutrition. The framework consists of four sections: social preparation, communications, distribution/service provision, and reinforcement/expansion.
SOCIAL RESEARCH AND PREPARATION
Define Outcome Desired
It is imperative that the specific outcome and changes in behaviour desired in the target population are clearly defined. Attention to the final outcome(s) will focus the direction of the social marketing programme and serve as a reference for evaluation. It will also provide guidance for the appropriate modification of the programme.
For a family-planning programme, the ultimate goal is reducing the population growth rate. The specific action-oriented result desired is the use of contraceptives. With this firmly in mind, PDA's programme was not distracted by its success in such steps as providing knowledge and making contraceptives available. With the goal clearly defined the steps are perceived in their proper perspective as prerequisites to the desired outcome.
Analysis of Target Population
Because social marketing programmes seek to modify existing behaviour, or encourage new practices, an understanding of the existing baseline behaviour is necessary before a social marketing programme can be appropriately designed.
It is of vital importance to know whom the programme is trying to reach and what the constraints affecting health practices are. Particular attention should be paid to those factors that impede or facilitate the desired behaviour: Is knowledge lacking, are there accessibility problems, are there economic difficulties or social/cultural barriers?
For example, through the social research process it was found that the Thai population first needed to be desensitized to the very issue of family planning. People were afraid to talk about family planning and were embarrassed to buy contraceptives. Therefore, one of the prerequisite behaviours necessary to achieve the ultimate desired outcome was for the target population to be able to talk openly and handle contraceptives as normal household items. It was not until this had been achieved that the next steps in the programme could be taken.
Determining what motivates the target population to carry out the desired behaviour, as well as what it considers to be rewarding, is an essential part of background research. Rewards may include social rewards such as praise, recognition, or attention (possibly through publicity), tangible rewards such as food or prizes, or behavioural rewards such as engaging in enjoyable activities. An illustration of how knowledge of the target population was used in PDA's social marketing programme is reflected in the following example.
It was realized that vasectomy services were not available in the villages and that some form of motivation was also needed to spur people to final action. With these two facts in mind, PDA developed a system whereby, if 15 men in a village wished to have a vasectomy, PDA would pick them up in a bus and drive them to PDA's clinic in Bangkok. After having vasectomies, they were given a tour of Bangkok, many visiting it for the first time, and were taken to the holiest of all places for Thai Buddhists, the temple of the Emerald Buddha.
Social preparation includes those activities that are conducted prior to either the implementation of services or the commencement of a directed communication programme, and that serve to increase the programme's acceptability and credibility.
Social preparation activities usually involve visits to government officials, village headmen, village committees, monks, and any other individuals or groups whose interests are involved. During such visits, the goals and objectives of the programme are explained and support is sought. The basic objectives of social preparation are to: (a) establish a trusting relationship with the community; (b) gain official recognition through political and religious support; and (c) create a favourable environment for a communication programme and for the desired action to take place.
The following steps are felt to be essential components of any effective communication programme. Some steps may occur simultaneously or in a different order from that presented. They have been separated only to clarify the process involved.
Choice of Media
Mass media, while able to relay knowledge and information, have rarely had lasting effects as regards changes in behaviour. PDA's decision to use individuals to communicate family-planning messages was made for the following reasons: (a) they are able to attract people's attention; (b) they can respond to local conditions; (c) they have a greater capacity for convincing people than have mass media; (d) they can generate a rapport with the target group and develop a trusting relationship; (e) the two-way communication made possible helps ensure that family-planning messages are correctly understood.
Mass media, however, were used extensively to communicate family-planning messages indirectly by carrying news stories on PDA's promotion activities. These family planning promotional events not only caught the attention of the target population, but also of the news media as well. Such events included: releasing hundreds of helium-filled balloons to which were attached cards entitling the finder to a free vasectomy; special Vasectomy Carnivals that included condom-blowing contests, performances by local dramatic troupes extolling the advantages of practicing family planning, and feature-film shows with family-planning messages presented during the breaks; school assembly meetings during which children recited family-planning nursery rhymes, sang family-planning songs, and had condom-blowing competitions.
Mass media were also used to inform the population where services were available.
At the beginning of PDA's contraceptive social marketing campaign, individual communicators/motivators presented family-planning messages to large audiences at mass meetings held for such groups as teachers, policemen, factory workers, and government employees. These gatherings were light-hearted, with a carnival-like atmosphere designed to make people laugh at what was traditionally a sensitive issue. When services were being instituted in villages, similar village-wide meetings were organized to inform and motivate people to action.
After community-based services had been established in a particular village, the voluntary distributor assumed the responsibility for communicating family-planning messages and for motivating individuals to use contraceptives. These activities were usually carried out on a person-to-person basis. By using local and well-respected people from communities as distributors and communicators, family-planning messages were adapted to meet local conditions and were more readily accepted.
Gaining and Maintaining the Target Population's Attention
The key to gaining and maintaining attention is to know the target group and to appeal to their interests using active involvement, action, colour, and a sense of fun; this requires the use of imaginative and varying approaches.
PDA's social marketing communication programme made use of gimmicks, prizes and humour to catch people's attention. Promotional T-shirts were produced with slogans such as: Life Begins with Family Planning," and "Many Children Make You Poor." Plastic-encased condoms, on which was written: "In case of emergency, break glass." were distributed for use as key chains. Condom-blowing contests made people laugh and held their attention so that family-planning messages could be delivered.
Removing Obstacles to Communication
In a social marketing communication programme obstacles may be physical, economic, environmental. or social. The predominant barrier to establishing an effective family-planning programme in Thailand was the Thai people's traditional avoidance of discussing human reproductive physiology and their sensitivity to the issue of family planning. Contraceptives were considered "dirty" and so the PDA's social marketing spearhead was a desensitization campaign designed to show people that family planning was only as dirty as people's minds made it. A personal and direct approach was used: actually putting condoms in people's hands so that they could see for themselves and having people then blow them up in condom-blowing competitions. One minute people were self-conscious and the next they were laughing in the realization that family planning was not something strange or mysterious at all. Once people were desensitized, it was possible to communicate and discuss family-planning issues. The Thais proved to be very ready to listen when problems were presented in a clear, concise, and simple manner.
Establishing How the Problem Relates to the Individual
In PDA's family-planning programme, people needed to be made aware of the rapidly increasing population. Not all people, even among government officials, felt that a rapidly increasing population posed a problem.
Messages on population growth were given as clear facts, such as that the population of Thailand would double by the end of the century if its growth rate were not reduced. This was shown graphically by posters and T-shirts depicting an earth so crowded that people were falling off.
Unless people feel that problems relate to them directly and personally, it is unlikely that they will be motivated to action. The slogan "Many Children Make You Poor," as well as being clear and simple, related the population issue to the individual. The advantages of raising two children well (i.e. being able to provide good nutrition and education) rather than raising many children under deprived conditions were pointed out.
Demonstrating the Need for Action
In conjunction with presenting problems and their relationship to the individual, it is important to foster a perception of the serious consequences should one fail to act.
In promotion family planning, people were made aware of the immediate results of having "too many" children in their family and also the serious problems that would result on a national level from uncontrolled population growth.
Action an Individual May Take
For a family-planning social marketing programme, the required action is clear: use contraceptives. People were therefore informed of the various types of contraceptives available as well as where they could be obtained.
Convincing People that the Suggested Actions Will Be Effective
Particularly with new concepts, individuals are not willing to risk their time, money, security, or health if they are not convinced of the efficacy of the proposed action. Positive statements by well-knwon community members add credibility, and once individuals take action their affirmation of the effectiveness of that action reinforces support of the programme. Proper education must be given so that action is carried out in the proper manner, thus ensuring that the anticipated outcome is achieved.
PDA's approach of first gaining the support of local institutions and officials through its social preparation phase helps to establish the credibility of the programme and of the action that it advocates. A trusting relationship was more easily established by associating the offered services with the village temple. Thus, when a new shipment of contraceptives arrives in a village it is not uncommon for the monk to bless them. Promotional meetings and mobile vasectomy programmes are also held at the temples.
Removing Obstacles to Action
Obstacles to action may be environmental, logistical, social, or economic. Whereas the logistical and economic difficulties may be minimized through an appropriately designed distribution network incorporating alternate financing schemes, the communication programme can be designed to reduce social or cultural barriers.
As previously mentioned, it was necessary to desensitize the Thai population to family planning as a prerequisite to soliciting the desired action. Other obstacles often arose through misinformation spread by rumours. Steps taken to minimize rumours include anticipating them and counteracting or exposing misinformation through education. The target population must be made aware of the secondary effects of their choice of action, and for family planning this includes giving a full description of the side-effects of certain contraceptives. In this way the sources of many rumours are removed.
For social marketing programmes where the desired outcome is the use of a product or service, it must be presented to the potential user in such a way that the products or services are readily available and acceptable. There are many factors to consider in the delivery of goods or services, and these have been well described and analysed in numerous commercial marketing texts.
To increase the acceptability of contraceptives, PDA used community-based volunteers who worked as distributors and communicators. As they were respected members of the community, they were trusted and in this way the services offered through them were made more acceptable. The social preparation phase of the social marketing programme also served to increase the acceptability of services.
PDA's approach was to make contraceptives as easily available as possible by using local channels.
Distribution points used have included: (a) female boat vendors who sold pills and condoms as well as fruit and vegetables; (b) vending machines making condoms available 24 hours a day; (c) urban taxi drivers; (d) factory nurses; (e) mail order- also a good channel for those too shy to buy condoms from a distributor; (f) pharmacies; (g) family-planning supermarkets set up in bus and train stations; and (h) over 16,000 community-based volunteer distributors.
Sterilizations were conducted either through PDA's Mobile Vasectomy Tour Bus Services or at one of four clinics.
It is PDA's philosophy that services will be valued more highly if something is paid for them. Thus, contraceptives are sold for a nominal amount and the revenue thus generated is used to finance the cost of delivery services. For motivational purposes the distributors also receive a small commission on their sales.
The condoms marketed by PDA under the brand name "Mechai" are packaged in attractive, eye-catching colours reflective of the cheerful promotional campaign that accompanied them. A variety of brands are made available in the belief that individuals like to exercise choice. In this way the user feels that the final decision is his own rather than that he is acting because he has been told to do so.
Similarly, with female oral contraceptives, three brands are offered that are distinguished by colour: white, silver, and gold. Although chemically similar, these brands have different prices so that the consumer is able to make a choice. In this way, if the users are not satisfied with one type, they have the option to "try again" with a different brand rather than simply discontinue the method.
Promotion must be continuous if the message is not to be forgotten. In order to do this on the village level, PDA produces a multi-coloured poster every month and posters are sent to every voluntary distributor for display in his or her village. These posters provide information on issues and subjects of interest to villagers, such as agriculture, appropriate technology, water resource development, and health. The information presented, as well as helping to better the villagers' lives, draws them to read the family-planning messages incorporated into the subject-matter.
The village volunteers are also upgraded through specialized training programmes and some are now working as government health communicators under their village health development programme. At these courses the volunteers learn new communication and motivation techniques in addition to skills related to community development.
REINFORCEMENT AND EXPANSION
The marketing programme does not end once the target population begins to practice the desired behaviour. The behaviour must be reinforced in order to be maintained. It has been found that intermittent reinforcement greatly diminishes the potential extinction of the practice. Because the benefits resulting from the practice of family planning are not immediately tangible, it is crucial that those practicing it are given support and reinforcement from the beginning.
As one benefit of using family planning is an improved economic condition, PDA has used various income-raising activities to reinforce or reward fertility management. The acceptor, by using family planning, demonstrates a willingness to take control over and responsibility for his or her own life, and with this mature attitude people are also more likely to take full advantage of an opportunity for economic betterment. Communication materials can work in conjunction with reinforcement activities so that the original purpose of the programme is not lost through the addition of other services.
Examples of Some Reinforcement Activities, Past and Present
1. Better Market Programme
Family-planning participants are given the opportunity to sell their non-perishable products such as coconuts, pumpkins, silk, and handicrafts to PDA, who, in turn, finds a market for them and arranges transportation. By cutting out the middleman the villagers get at least 30 per cent more for their produce.
2. Pig-raising Programme
Male stud pigs are lent free of charge to families practicing family planning who own one or more sows. The resulting piglets are fed on the families' domestic scraps for eight to nine months, during which time the family promises to continue using their method of contraception. PDA then assists in marketing the pigs with the sales profit given to the family.
Supporting communications: Stud pigs used in the programme bear family-planning slogans on their flanks; T-shirts are designed with the message "Let Your Next Pregnancy Belong to the Pig."
3. Community-based Incentive Programme in Thailand (CBIT)
To increase village-level contraceptive-use prevalence rates, community incentives are introduced through credit co-operatives. Preference for loans is given on the basis of family-planning practice and method. As the village contraceptive prevalence rates increase. PDA increases the size of the loan fund. Currently there are six credit cooperatives in north-east Thailand, three of which are run entirely by women.
APPENDIX 7. Philippine Nutrition Program Implementing Guidelines on the Barangay Nutrition Scholars Project
MERCEDES A. SOLON, JEAN ANDERSEN, EMELITA DE LEON, MIGUEL LOPEZ, and EIREEN
Nutrition Center of the Philippines (NCP), Manila, Philippines
The Philippine government has adopted a policy to improve the nutritional status of its people, committing scarce financial resources to develop a national nutrition plan and programme. The effort is not a token one, but a large-scale integrated endeavour to address the problem of malnutrition directly.
The government of the Philippines has recognized that malnutrition is an impediment to human resource development. It hopes that making nutrition a priority will ensure that future generations of schoolchildren and skilled labourers will have the opportunity to realize both their physical and their mental potential. The various nutrition activities in the Philippines are based on co-operation and collaboration between the government and the private sector.
In June 1974, President Ferdinand E. Marcos issued a decree that created the National Nutrition Council (NNC), and gave it the responsibility for formulating a national programme for nutrition and for co-ordinating all related activities. The elaboration of this programme was called the Philippine Nutrition Program (PNP). At the same time that the NNC was created, the First Lady, Madame Imelda Romualdez-Marcos, founded the Nutrition Center of the Philippines (NCP), whose mandate was to harness the resources of the private sector to support the Philippine Nutrition Program.
Malnutrition in the Philippines
The most serious and chronic nutrition problem in the Philippines is protein-energy malnutrition (PEM) among pre-school children. Based on a nationwide weighing survey in 1978 (Food and Nutrition Research Institute, National Science and Technology Authority), nearly 70 per cent of pre-school children are underweight. Several surveys during the 1970s showed that the section of the country with the highest prevalence of malnutrition was the Eastern and Western Visayas [1, 2].
The consequences of this early malnutrition are stunted physical growth, reduced energy to learn and develop, higher incidence of illness and disease and, of course, a higher mortality rate. Another consequence, often overlooked, is the emotional and psychological impact on society when a majority experience misery in early life, reducing their ability to cope with life's problems.
The Philippines does not suffer from a lack of food. The prevalence of malnutrition is the consequence of a complex group of factors often found in developing countries. These factors run the gamut from problems of food distribution through health and sanitation conditions to ignorance of food needs. It is well accepted among nutrition authorities that available foods and resources, if better used in the home, could improve nutritional status, especially among young children .
It has been suggested that malnutrition among pre-school children in developing countries similar to the Philippines is caused not so much by inequity in food distribution as by inequity in knowledge distribution . Certainly, only a small shift in intra-familial food distribution would suffice to correct it. However, since dietary practices are the result of biological, geographical, psychological, cultural, sociological, religious, intra-familial, superstitious, economic, technical, and other factors, they may be one of the most difficult of human behaviours to change. A quick and easy cure is not likely.
The Philippine Food and Nutrition Program
The major interventions of the Philippine Food and Nutrition Program are:
Nutrition Information and Education
The priority target group for this intervention is mothers of malnourished pre-school children (0 to 83 months of age). The goal is to increase the mothers' knowledge and improve their child-feeding practices.
Health protection services are both curative and rehabilitative. Curative measures include medical services to the moderately and severely undernourished pre-schoolers susceptible to infection. Wards for recovery from malnutrition (malwards) are set up in hospitals or nutri-huts in the remote areas. Immunization, deworming services, and sanitation campaigns are among the preventive measures.
As an emergency measure to improve the nutritional status of the moderately undernourished pre-schoolers, supplementary feeding programmes are undertaken. Locally available food commodities are encouraged and promoted.
The primary goal of this intervention is to promote backyard and school gardens to increase household consumption of more highly nutritious foods.
A village-level nutrition worker, called the "barangay nutrition scholar" (BNS) is the grass-roots link between the families of malnourished children and the implementors from various government agencies charged with carrying out the guidelines set forth at the national level. A presidential decree in 1977 provided for the selection and training of one BNS in each of the 42,000 barangays in the country. The concept was to provide a community-based indigenous worker to deliver basic nutrition and health services to the target families of the Philippine Nutrition Program.
Nutri-Bus Project Background: The Pilot Study
Early in 1976 the Nutrition Center of the Philippines (NCP) decided to test the relative effectiveness of different communication channels in bringing about behavioural change in mothers' child-feeding practices. At that time the government was contemplating putting village-level volunteers for nutrition (later called BNS) in the field, so it was decided to combine testing of communication with volunteers to measure the relative effectiveness of various media in support of the grass-roots worker. The behaviour selected for assessment in the pilot study was the purchase of a nutritious product to add to the child's diet. The act of purchasing the product would yield an objective and reliable measure of the behavioural change brought about by each method of communication. The product itself would be designed to make up the nutritional deficit for the pre-school child.
A product then under development at NCP was selected. This product, called "Nutri-Pak," provided:
Nutri-Pak contained cracked rice, ground mung bean, coconut oil, and powdered milk. Each ingredient was packed in its own small, clear plastic bag and these were overpacked to make one Nutri-Pak. As part of the pilot project, a small manufacturing plant was set up to produce Nutri-Pak.
The province of Leyte in the central Philippines was chosen as the area to conduct the pilot project. Leyte is in the Eastern Visayas, one of the less developed areas of the Philippines, which has been reported to have the poorest diet and to be one region where the prevalence of malnutrition is very high. Severe to moderate malnutrition in Eastern Visayas was reported to be more than 50 per cent above the national average in the First National Nutrition Survey, 1978 .
Under the direction of the Ministry of Health, 30 villages were chosen at random for the project from among all the villages in Leyte that met certain criteria regarding size, nutritional status (as reported by local workers who had conducted the nationwide weighing programme), certain geographic and occupational characteristics, dialect spoken, accessibility by road, and absence of any concurrent nutrition or health programme. These villages, in turn, were assigned on a stratified random basis to each of six experimental conditions, as shown in table 1.
Village-level nutrition workers (barangay nutrition scholars or BNS) were recruited and trained for the sample villages to be "change agents" and to sell Nutri-Pak at a subsidized price. All BNS recruited were given training by the Ministry of Health in basic nutrition and by NCP in product knowledge. Half of them then returned to their villages to promote better nutrition in general and Nutri-Pak in particular; the other half were given an extra day of training in simple communication skills to help them persuade mothers to change their child-feeding practices. After the BNS had returned to their villages one-third received no further support except deliveries of Nutri-Pak; one-third received comic books about nutrition to distribute free to every household in their villages once a month for three months, as well as deliveries of Nutri-Pak; and one-third were supported by a video van that visited the village once a week for ten weeks to show five specially designed television programmes on nutrition and to deliver Nutri-Pak.
Table 1. Experimental design for pilot project (Nutri-Pak available through BNS)
|No media||Comic books||Video van|
|BNS given no communication training||5 villages (A)||5 villages (B)||5 villages (C)|
|BNS given communication training||5 villages (D)||5 villages (E)||5 villages (F)|
Special comic books and video tapes were developed for the project by NCP, using a rigorous process designed to produce communications that would bring about behavioural change (see Appendix 1). The television tapes actively involve the viewers in the learning process by posing specially developed questions at intervals throughout the tape (see Appendix 2). The communicator, who administers the tape showings, stops the tapes at each question and encourages answers and discussion from the viewers. When the tape is started again, it provides feedback regarding the answers. The place of the communication system in influencing knowledge, attitudes, practice, and nutritional status is shown in Appendix 3.
The story-line and nutrition content of the comics and video tapes were the same (see Appendix 4). Both were pre-tested with mothers representative of the target population, but not residing in the sample villages, and were revised on the basis of the results.
In order to test the experimental treatments under realistic field conditions, no personnel or procedures were used in this pilot project that could not be used in nationwide implementation (excluding, of course, the evaluation, which was not part of implementation). Working capital for the first supply of Nutri-Pak for each village was supplied by the local government.
For purposes of the pilot project, the total possible market for Nutri-Pak was defined as every mother buying one package of Nutri-Pak every day for every pre-school child. It was, of course, totally unrealistic to think that any product could reach such a level of sales. But, since no market existed at all for special foods for children in the villages, it was the only objective estimate of a market that could be used. Minimal successful penetration of that "ideal market" during the first five months of the pilot project was arbitrarily defined as approximately 5 per cent - so, sales of 5 per cent or more of the total "ideal market" were to be considered a success.
The objectives of the pilot project were:
Pak equal to or greater than the minimum criterion of 5 per cent of total "ideal market."
The results of the study showed that:
Nutri-Bus Project: Expansion
Based on the results of the pilot project and continuing interest in using video vans for nutrition education, the Nutrition Center of the Philippines decided to expand the project to three buses in Leyte. However, the attractiveness of the concept and the video tapes caught the attention of donors and soon the Nutrition Center had over 30 fully equipped Nutri-Buses. This generosity provided an early opportunity to implement the project on a wider scale.
The data from the Leyte pilot study were analysed during the first half of 1978. By August of 1978, the first two of the new Nutri-Buses were already launched in Leyte and Samar.
In preparation for the fielding of the new buses throughout the country, the Nutrition Center organized the Nutri-Bus Project Management Office with the following units: training and field supervision, engineering, and video production.
A field-management and training system was developed. Policies and guidelines were defined in co-ordination with the National Nutrition Council to identify operational linkages with the local government and the provincial/city/municipal action officers.
The video production personnel were trained by Development Communications Consultants, Inc., to design and produce video-tape modules in the local dialect. At the same time, the NutriBus Project Management Office sought funding from the government and private sector for operations costs.
The Nutri-Bus delivery system is illustrated in Appendix 5. Each Nutri-Bus, a jeep type vehicle, is modified to carry a Sony Betamax video-cassette playback system, a public address system, a self-contained power source and field supplies and materials. The key person in the system is the communicator, who was trained for a month in communication skills, community organization, and training and supervision techniques.
The Nutri-Bus communicator visits the barangays twice a month at two-week intervals; once for a video-tape showing, where she interacts with the viewers who are gathered by the BNS in chapels, village halls, or shady clearings; another time to coach and supervise the BNS in specific tasks, replenish stocks, and monitor the programme through a simple monitoring system.
To increase coverage and attain cost-efficiency, two communicators time-shared a bus.
Mason , in his chapter "Basic Concepts for Design of Evaluation during Program Implementation," has created a table to show "Appropriate Data Collection and Analysis for Different Decisions" (see Appendix 6). According to Mason, an evaluation should attempt to answer one or more of the following questions (listed in order of difficulty):
The purpose of this evaluation is addressed basically in questions 1 and 2. The management of the Nutrition Center wanted to determine whether the Nutri-Bus programme could give some indications of significant impact even at an early stage of field operations and identify areas for improvement in the various components. The first data were collected in February 1979. At that time barangay nutrition scholars had been trained by the Ministry of Health and NNC and had been fielded for at least six months in all villages in Leyte and Samar which were candidates for Nutri-Bus services (see Appendix 7). The municipal action officers (MAOs) and the city action officer (CAO) in Tacloban City decided which of the BNS villages, accessible by road, would be the first to receive Nutri-Bus services. Their intention was to provide services to the most needy villages first, but the basis for determining need was imprecise.
1979 Sample Selection
All villages accessible by road in Waray-Waray-speaking Leyte and Western Samar were divided into four groups representing different degrees of intervention:
Sample villages from each of the four groups were selected on the basis of criteria meant to control for the factors known to influence nutritional status and nutrition knowledge (see Appendix 8). The comparison villages did not meet the criteria, were slightly better off in socioeconomic status, and did not have BNS. However, we retained the sample for comparison purposes. All villages with lower socio-economic status that met the other criteria had been assigned BNS. Villages were also classified as urban or rural (see Appendix 9). Table 2 shows the intended and actual data collection design. This report will be limited to the analysis of the data for the rural villages only.
Since village populations were relatively small it was decided that it would be more accurate and less costly to weigh all the pre-school children (12 to 66 months) and interview all the mothers of pre-school children rather than sample within the villages. The upper limit of 66 months is dictated by the Harvard standards. Nutri-Pak is targeted for children 12 months and older. As there were no definite boundaries for many of these villages, no maps, no current census data, and no lists of residents, it was impossible to know precisely how close we came to reaching all. Two methods were used to estimate the number of pre-school children in each village:
Table 2. Nutri-Bus impact evaluation data collection design, 1979
|Rural||5 villages (8)||5 villages (6)||5 villages (5)||5 villages (5)|
|Urban||5 villages (5)||5 villages (1)||5 villages (5)||5 villages (4)|
a. The objective was to have a minimum of five villages in each treatment condition. The number in parentheses above shows the actual number of villages for which data were analysed. Note that the urban VTRS condition has only one village, so results for that condition are of very limited value.
The data-gatherers, working together with village leaders, did their best to reach all families with pre-school children. If there was no major discrepancy between results of 1 and 2 above, then villages where 80 per cent or more of 1 was reached were retained in the sample. If there was a large discrepancy between 1 and 2, or less than 80 per cent of 1 was achieved, the villages were discarded from the analysis.
1979 Data Collection
Data were collected by four teams working simultaneously in four villages (see Appendix 10 for team composition and equipment used). Team members other than the measurers were recruited in Leyte and were all native speakers of the Waray-Waray dialect, but not known personally in any of the villages; they were registered nurses and schoolteachers. The measurers were NCP staff members, trained and experienced in taking weights and heights. The teams received one week of classroom training and three days of practical training before data collection was begun.
Team members and measuring instruments were rotated so that each contributed an approximately equal number of measurements to each condition. The rotation also attempted to equalize the pairing of individual team members to minimize the chance of pairs developing somewhat different procedures.
The measurements and interviews took place in central locations in each village. Mothers were notified regarding place and time a few days ahead of the weighing by the village headman and BNS, and again on the day of the weighing by the BNS and some other village volunteers. Those who came to the weighing were asked to encourage their neighbours to come. The women registered with the checker and waited to be called by the measurer: after measurement, they were interviewed.
To try to prevent contamination of the interviewing results, each interview area was roped off with cords and stanchions to prevent mothers from listening to each other's answers. When the interview was completed, they were directed out of the chapel away from the waiting mothers and encouraged to go home to avoid conversation with the latter.
Two potential sources of error in weighing are squirming and flailing children and scales not perfectly calibrated to zero. By weighing the children in the arms of a "surrogate mother," and later subtracting her weight, nearly all squirming and flailing was eliminated (weight of mother and child-weight of mother = weight of child). Zero calibration of the scales becomes less critical when the weight is determined by this method rather than by measuring the child's absolute weight.
Another potential source of error in determining weight for age is the accuracy of the birth date. It was found that:
Using this approach, it was possible to get documentation for nearly 88.3 per cent of the children. A significant difference in per cent standard weight for age was found between the documented and undocumented children, the undocumented having higher per cent weight for age. An examination of the other variables collected showed no statistically significant difference between mothers of documented and undocumented children. Based on the assumption that the difference in per cent standard weight for age might be a result of the mothers' faulty memory of birth dates, children for whom documentation of birth dates was not available were excluded from the analysis.
Data were gathered regarding: length of residence in the village; child's name; household location; name of adult accompanying child; date of collection; time of collection; name of checker; sex of child; birth date of child; source of birth-date information; name of measurer; weight of child plus "surrogate mother" (see Appendix 11); weight of "surrogate mother" alone (see Appendix 11); height of children 24 months or older; length of children under 24 months (height and length are not included in the analysis because the data were less reliable than the weight data, and because weight is a more sensitive indicator - see Appendix 11); names of other preschoolers in family being measured; name of interviewer; time of interview; and mother's answers to interviewer's questions.
1979 Results in Rural Villages: Knowledge/Attitude
The data were analysed using the SPSS package. Interviewee responses were analysed and compared across conditions for five key questions regarding child-feeding practices and nutrition services.
These questions (and the titles on the related graphs) are:
Fig. 1. Reported VTR frequency by condition, rural Leyte, 1979.
Although our target children were 12 to 66 months of age, answers of mothers of children 0 to 66 months were included in this portion of the analysis. Mothers of infants were considered part of our audience since their infants would soon be "of age." First it is necessary to look at question 5 to see if the answers reflect the assumed differences in the degree of intervention between the VTRL and VTRS conditions. Figure 1 shows a significant difference in intensity of treatment between the VTRL and VTRS conditions, based on the mothers" report of frequency of viewing of the VTR shows. Among mothers in the VTRL condition, 81.1 per cent reported seeing one or more VTR shows as compared to only 47.6 per cent in the VTRS condition. Acceptable answers for the remaining four key questions were decided on the basis of the following:
Fig. 2. Percentage of mothers with acceptable response: complete meals by condition, rural Leyte, 1979.
Fig.. 3. Percentage of mothers with acceptable response: specific Nutri-Pak information by condition, rural Leyte, 1979.
Fig. 4. Percentage of mothers with acceptable response: Nutri-Pak for snack by condition, rural Leyte, 1979.
Fig. 5. Percentage of mothers with acceptable response: specific BNS activities by condition, rural Leyte, 1979.
Fig. 6. Percentage of acceptable response by VTR frequency: complete meals, rural Leyte, 1979.
Regarding the acceptability of answers to these four questions, the differences among conditions are significant, with mothers in the VTRL condition having the highest percentage of correct answers (figs. 2, 3, 4, and 5).
If we compare the proportion of mothers with acceptable answers to reported VTR frequency, as in figure 6, we find a significant difference, with zero frequency showing the lowest score and a frequency of four showing the highest score.
1979 Results in Rural Villages: Nutritional Status
Nutritional status was measured by per cent standard weight for age using the Harvard standards with separate standards for male and female. A three-way analysis of variance (nutritional status by sex, condition, and location) showed significant independent effects for sex and condition (VTRL, VTRS, BNS) and a significant interaction between condition and location. The comparison group was not included in this analysis because it was assumed to have a higher socio-economic status.
The results can be seen graphically in figure 7. Of the three intervention groups (VTRL, VTRS, and BNS), VTRL had the highest nutritional status, VTRS had the second highest, and BNS the lowest. (The comparison group is included for completeness.)
Breaking down these means by age group, we see that for VTRS, BNS, and COMP there was a drop in nutritional status from 36 months to 66 months. However, the VTRL group did not show this drop (fig. 8).
To determine whether the higher means indicated less severe malnutrition or simply heavier normals, we also looked at the data using the Gomez classification scheme. The results revealed significant differences between conditions, the VTRL condition showing the most first-degree and least second- and third-degree, and the BNS the least first-degree and most second- and third-degree, with VTRS in the middle (fig. 9).
Fig. 7. Mean nutritional status by condition, rural Leyte, 1979.
Fig. 8. Mean nutritional status/age/condition, rural Leyte, 1979.
Fig.. 9. Gomez classification by condition, rural Leyte, 1979.
1981 Sample Selection
By February 1981, all Waray-Waray-speaking BNS villages in Leyte accessible by road had had Nutri-Bus operations for at least 18 months (see Appendix 12). "No-intervention" matching control villages were not available in Leyte.
An effort was made to find groups based on degree of intervention. All Nutri-Bus villages meeting the same criteria used in 1979 (Appendix 6) were assigned a score based on daily field reports from the Nutri-Bus staff regarding services rendered. Scores were based on number of VTR showings, number and type of supervisory calls to the BNS, and amount of Nutri-Pak supplied, with VTR shows weighted most heavily. Those villages with a score of 60 or above were assigned to the "high-service" group and those with a score of 30 or below to the "lowservice" group. Villages were assigned to six groups representing "high" and "low" service, urban and rural classification (Appendix 9), and locations in the provincial capital area (Tacloban) or the rest of Leyte. Villages that qualified were assigned to complete the design shown in table 3. Again, for this paper we will limit the report and analysis of results to the rural villages.
As in 1979, the objective was to collect data on all the pre-schoolers in each sample village. Using the same methods described earlier to estimate the pre-school population, the percentage actually measured ranged from an average, by condition, of 88.1 per cent to 107.6 per cent of the estimate.
Table 3. Nutri-Bus evaluation data collection design, 1981
|High service||Low service||High service||Low service|
|Rural||5 villages||5 villages||10 villages||10 villages|
|Urban||5 villages||5 villages|
1981 Data Collection
Data were collected using the same techniques, types of teams, and equipment described for the 1979 data collection.
1981 Results for Rural Villages
Interviewee responses were analysed and compared across conditions for the same question used in 1979 to determine mothers' report of number of VTR shows attended. To support the assumption that the villages were grouped by degree of intervention, a significant difference would be expected for reported frequency of VTR shows between "high" and "low" service villages. As shown in figure 10, that assumption is not supported by the data.
Fig. 10. Reported VTR frequency by condition, rural Leyte, 1981.
Table 4. Nutri-Bus evaluation data analysis design, 1979 v. 1981
|Rural||9 villages a||9 villages a|
|Urban||11 villages b||13 villages b|
a. Same villages in 1979 and 1981.
b. Some villages the same. some different, in 1979 and 1981, but all selected by the same criteria.
The "high" and "low" service groups were therefore abandoned on the assumption that the field reports were not sufficiently accurate to be used. The data in 1981 were compared to 1979 using the design shown in table 4.
1979 v. 1981 Results for Rural Villages: Knowledge/Attitude
For the rural villages common to both the 1979 and 1981 sample, there was a significant improvement in 1981 in the proportion of mothers describing complete meals to give to a two-year-old child (fig. 11).
Both the "specific Nutri-Pak information" and the "specific BNS activities" questions showed higher scores, but these differences are not significant (figs. 12 and 13). However, the proportion of mothers with acceptable responses has increased to 76.3 and 87.1 per cent, respectively, in 1981. These may be approaching a ceiling that cannot be much improved, considering that the project does not reach all mothers. In any event, the scores show that the 1979 levels of knowledge have been well maintained.
Fig. 11. Percentage of mothers with acceptable response: complete meals by year, common rural villages.
Fig. 12. Percentage of mothers with acceptable response: specific Nutri-Pak information by year, common rural villages.
Fig. 13. Percentage of mothers with acceptable response: specific BNS activities by year, common rural villages.
Fig. 14. Percentage of mothers with acceptable response: Nutri-Pak for snack by year, common rural villages.
The "Nutri-Pak for snack" question showed a decrease in the proportion of mothers with acceptable answers, but the difference is not significant (fig. 14). This is not a surprising finding, since the availability of Nutri-Pak had greatly decreased and Nutri-Pak was not available in most villages in 1981.
1979 v. 1981 Results: Nutritional Status
The mean nutritional status of the pre-school children in the rural areas improved significantly from 1979 to 1981, as measured by per cent standard weight for age, using the Harvard standards (fig. 15).
Looking at the means of the common rural villages individually, it can be seen that all but one improved. The village that did not improve decreased by only one tenth of one percentage point (fig. 16).
Disaggregating the average mean nutritional status of the common rural villages into age groups shows that all ages had higher means (fig. 17).
Applying the Gomez classification to the common rural villages also showed significant improvements, with children moving from second- and third-degree to normal and first-degree categories (fig. 18).
Fig. 15.. Mean nutritional status by year, common rural villages
Fig. 16. Percentage change in mean nutritional status, by common rural villages, 19791981.
Fig. 17. Mean nutritional status/age/year. common rural villages.
Fig.. 18. Gomez classification, common rural villages.
1981 Cost-effectiveness Results
The costs for the Nutri-Bus programme were calculated for the year 1981, as a representative year of operation. All costs associated with a typical year of operation were used.
Costs included were:
Costs not included were: opportunity costs;
Opportunity costs were not included because we have no way to attach a meaningful value to them and there are no such obvious costs. Including the costs of the US consultants would be misleading since (a) they are being phased out of the programme; (b) the purpose of their inputs was to assist local personnel in the design and start-up of a programme that could be effectively continued without outside consulting support; and (c) they operate as advisors only and do not take the place of any local person - therefore no further costs will be incurred upon their departure.
The building and overheads of NCP exist independent of the Nutri-Bus programme; however, certain management and media production personnel have their offices at NCP. Our best estimates indicate that if a prorated share of these NCP costs were added, the individual cost estimates would increase by less than 10 per cent.
Since our concern here is with projecting cost-effectiveness to assist decisions regarding the future of this programme (as opposed to duplicating the programme from the beginning), certain start-up costs were not included, such as pilot testing and inefficiencies of very early operations. The objective was, as noted earlier, to estimate the costs of a typical year of continuing (and improving) operations.
The factors noted above, which were used for calculating the costs, represent the inputs to the programme. These can be related to several possible levels of output or effectiveness. Zeitlin  has listed possible indicators of levels of output in nutrition communication programmes for purposes of a cost-effectiveness analysis. Table 5 is based on her list.
Various estimates of cost-effectiveness can be calculated using the total programme costs as the constant numerator and each of the indicators in table 5, in turn, as the denominator. We have calculated cost-effectiveness based on one indicator at each level of effectiveness shown in table 5. We have combined knowledge, attitude, and reported behaviour change into one indicator - change in what the mother reports that she gives a two-year-old child for lunch.
For ease of calculations and projections, we have calculated the cost-effectiveness on a per Nutri-Bus basis (see Appendix 13 for formulas). The total programme costs in 1981 divided by the number of Nutri-Buses in the same year gave us an annual per bus cost of P140,171 or US$16,888. (All exchange rates given here and later in this section are calculated at the 1981 bank exchange rate of US$1 = P8.30.) On average, a Nutri-Bus serves 90 BNS areas (a BNS area is usually one complete village). So, the average annual cost per BNS area served is P1,557 (US$188).
Table 5. Some possible cost-effectiveness indicators for nutrition communication programme and annual unit costs for Nutri-Bus project
|Level of effectiveness||Cost-effectiveness indicator||Nutri-Bus project annual cost per target-group member|
|Delivery of services||Population in catchment area |
Target group in catchment area
Target group aware of programme
|Childrena $19.00 |
|Participation of target group||Target group
participating at some time in programme |
Target group participating regularly
|Effect on target group||Target group with knowledge change
Target group with attitude change
Target group trying new behaviour
Target group adopting new behaviour
|Childrena $.5.00 |
|Impact on target group||Target group with improved nutritional status||Children $ 19.00b|
a. Children whose mothers reported giving changed diet.
b. Cost per year over a two-year period for change of second" and third-degree to first-degree and normal.
c. Children whose mothers reported attending VIR.
The main objective of the Nutri-Bus project is to provide both curative and preventive services to reduce malnutrition among pre-school children. According to census figures, the 12to 66-month-old pre-schoolers, who are the ultimate target of the programme, constitute 14 per cent of the total population, or about 140 per BNS area. That gives us an average annual cost per target child in the catchment area of P11.12 (U$S1.34). Or, from another point of view, there are about 100 mothers of pre-school children in each BNS area. The average annual cost per target mother to whom the services are offered is P15.57 (US$1.88).
Of the total target mothers, approximately 66 per cent reported seeing VTR shows in the 1981 data collection. Using this as our definition of target mothers participating in the programme, that gives us an average annual cost of P23.59 (US$2.84) per target mother directly participating or P16.85 (US$2.03) per target child whose mother directly participates.
For the indicators referring to effects on the target groups, our data were collected before and after two years of intervention, so we have calculated on a two-year basis and divided for annual costs (recognizing that effects are probably not linear over the two-year period). Referring to the mothers' report of what they feed for lunch to a two-year-old child and using the 1979 comparison group as the baseline, in 1981 there were 26.8 per cent more mothers reporting complete meals. Assuming this change was brought about by the Nutri-Bus programme, that gives us a cost of P116.19 for two years per additional mother or P58.10 (US$7.00) per mother per year. The costs are P83 for two years or P41.50 (US$5.00) per year for each child whose mother reported giving the improved diet.
And, finally, regarding nutritional status, using the findings of the 1979-1981 study in Leyte as an estimate of project impact, the cost per child "removed" from second- and third-degree malnutrition (using Harvard standards and Gomez classification) over the two-year period is P318 (US$38) or P159 (US$19) per year.
The evidence does not support a null hypothesis of no effect from the Nutri-Bus intervention. Both the knowledge and attitude data and the nutritional status data, within 1979 and between 1979 and 1981, support the assumption of positive impact by the Nutri-Bus project. However, since the data lacked well-matched control groups  and statistically random assignment of villages to conditions (this is a survey of an ongoing field programme), the question remains of whether or not there is an acceptable alternative explanation for the results found.
Regarding the 1979 findings, the sample selection criteria (Appendix 8) endeavoured to control for differences in access to health and nutrition facilities, health and nutrition programmes, socio-economic status, and sources of income. In the 19791981 comparison of rural villages, the same villages were analysed in 1979 and 1981 and only those that continued to meet the criteria in Appendix 8 were included.
One possible alternative explanation for the 1979 differences could be the political priorities that were used in assigning the buses to villages. However, the government personnel who made the assignments had no reason (or means) that we know of to systematically assign buses to the best villages first, then to the second-best, and save the worst for last. Furthermore, that would not explain the differences in knowledge, since the comparison villages, known to have the highest socio-economic status, had the lowest knowledge scores.
One possible alternative explanation of the improvement between 1979 and 1981 could have been based on economic conditions, if there had been an improvement during that period. But in fact the 1979-1981 period was the beginning of the worldwide recession. Table 6 compares key consumer price indices with primary and secondary sources of income for the sample families in the rural area. Conventional wisdom tells us that if the economy from 1979-1981 had had any effect on the nutritional status of the sample children, it would have been a negative one.
Regarding the fact that the urban areas in 1979 did not show any differences in nutritional status among conditions and less improvement between 1979 and 1981 than the rural areas, it should be noted first that there was less intervention in the urban areas in 1979 (as also reflected in the interview scores). Furthermore, the video tapes were designed for and tested on rural audiences.
Table 6. Changes in cost of living compared to changes in income sources: 1979-1981
|Jan. 1979||Jan. 1981||Change|
|Cost of living|
|Consumer Price Index:|
|Fuel, light, water||244.8||418.0||+70.7|
|Price paid to farmers for:|
Source: National Economic and Development Authority, Statistical Report, 1979 and 1981; Bureau of Agricultural Economics Report, 1979-1981.
Second, the causes of malnutrition may be somewhat different in urban areas. Moreover, there are data which seem to indicate that conditions in the urban areas make the improvement of nutritional status by nutrition education more difficult. The following conditions in the urban areas may have affected the intervention results:
Urban dwellers depend almost completely on buying their food from markets or from stands selling cooked foods. As Austin  points out, they are more affected by costly inefficiencies in the food system (e.g. storage, transport, and handling losses) as well as by nutritional losses in processing of foods. It may, therefore, be more costly and more difficult for them to improve the diets of their children compared to their rural counterparts.
Population Density and Spread of Disease
The average population density in urban areas is much higher than in rural areas. This greater population density leads to relatively higher incidence and prevalence of communicable disease. This may make improvement in nutritional status more difficult to bring about by changed feeding habits [8, 9].
In the province of Leyte, the average population density is 207.8 per square kilometre. In the urban area (Tacloban City), the figure is 1,061.1 per square kilometre .
Sanitation and Related Infection
Urban slums are subject to worse sanitary conditions. For example, using Ascaris infection as a measure of sanitary conditions, Popkin  found that the prevalence rate in the urban areas of Cebu Province was about 45 per cent higher than in the rural areas.
In the Philippines, 10 to 45 per cent of the urban population are classified as squatters . Tacloban City has a relatively high percentage of squatters. One reason for less weight gain in the urban study may be the relatively high prevalence of infectious diseases related to poor sanitation in the squatter areas.
Migration and Percentage Reached with Intervention
Urban areas have a more fluid population than that in the rural areas. In Leyte Province, the migration rate in the urban areas (Tacloban City) was 16 per cent compared to only 2.4 per cent in the rural areas over a five-year period (1970-1975). About 84 per cent of the population surveyed had been residents of the same barangays since 1970; about 97.6 per cent had remained in the same rural areas .
This greater movement of the population in the urban areas may have resulted in a lower "dose" of intervention for the average urban dweller compared to that for the rural dwellers.
Mothers' Employment and Percentage Reached with intervention
In the urban areas of Leyte, 67.6 per cent of mothers were gainfully employed during the survey periods compared to 53.2 per cent of mothers in the rural areas. In other words, fewer mothers in the urban areas were available either to receive the nutrition messages or act on them in feeding their children.
Putting the Results in Perspective
To understand the results better, it might be useful to see how these findings compare with changes in nutritional status elsewhere in the Philippines. Two surveys to reflect the national condition, each of one-year duration, were conducted during approximately the same period as the Nutri-Bus study. These surveys dealt with populations more representative of the nation as a whole. The Nutri-Bus areas studied are depressed areas. Also, these surveys used Philippine standards for determining per cent standard weight for age, whereas the Nutri-Bus project used the more stringent Harvard standards. However, using per cent change in Gomez classification should help somewhat to control for those differences. As can be seen in table 7, the children in the Nutri-Bus study showed more movement from second- and third-degree
Table 7. Comparison of Nutri-Bus evaluation with nationwide findings in similar period
Change in Gomez classification (%)
|Combined findings, 2 nationwide Studies of % change in malnutritiona (2 years: 1976-77,1979-80)||+9.8||+ 0.8||- 0.7||- 30.7|
|Nutri-Bus evaluation, rural Leyteb (2 years: 1979-1981)||+7.5||+12.9||-13.0||-51.0|
a. Pre-school children, OPT data Philippine standards, geographic and SES mix, seventeenprovince survey (1979 N = 61,755; 1980 N = 91,574) and Index Municipalities survey (1976 N = 644,087; 1977 N = 470,507).
b Pre-school children data gathered by project team with clinical scales, Harvard standards, rural and lower SES (1979 N = 637; 1981 N = 690).
Table 8. Comparison of nutritional status of pre-schoolers in Nutri-Bus area with findings in two studies of similar duration and with similar age groups but with more intensive intervention to first-degree malnutrition. Although the comparison in the table, as noted, is not a perfect one, it does seem to indicate more improvement in the Nutri-Bus areas than in the nation as a whole.
|Type of programme/ location||Age of children (months)||Percentage of daily calorie requirement in rationa||Duration of programme (months)||Average increase in percentage points of standard weight for age|
|On-site feeding (India)b||0-36||66||24||3.0|
|Take-home feeding (Philippines)c||24-60||25||13-38||1.0|
|Nutri-Busd (Philippines)||12-35 |
a. FAO Requirement for 12- to 47-month-old children is 1,360 calories.
b. Narangwal Rural Health Research Centre, 1974 Underweight children who were identified through periodic surveys were served free food supplements by project staff, twice daily at a village feeding centre (or, in some cases. a' home) Only children receiving the food supplements were measured, the same children pre- and post-measurement The average age of children increased at post-measurement Harvard Institute for International Development, Study 1: Supplmentary Feeding (USAID, Washington, D.C., 1981 ).
c. Asia Research Organization, 1976. Free food given; only children receiving the food were measured, average age of the children increased at post-measure. same children at pre- and post-measurement. Harvard Institute for International Development, Study 1: Supplementary Feeding (USAID, Washington, D.C., 1981 ).
d. Nutrition Center of the Philippines. No free food given, all children in village measured whether or not reached by programme Not all same children pre- and post-measurement. Average age of children unchanged at post-measure.
It is also interesting to compare the changes in the Nutri-Bus areas with changes found in feeding programmes with children of approximately the same ages and in programmes of approximately the same duration. The two feeding projects shown in table 8 provide an idea of the magnitude of improvement that can be expected when all children in a sample are given free food. In the Narangwal study the food was actually fed to them twice a day by project staff. The percentage of weight increase achieved in the Nutri-Bus-sampled areas seems quite respectable in comparison to that in the feeding programmes, especially considering that the Nutri-Bus areas received no free food and that all children there were measured to determine average improvement, even those whose mothers had not been reached by the intervention.
To be useful, a nutrition intervention must not only significantly improve nutritional status, but also do this at a cost which is comparable to, or less than, equally effective programmes, and which is affordable to the government as a national programme.
It is difficult to make comparisons between studies regarding cost-effectiveness. There is no absolute standard for calculating cost-effectiveness and each researcher uses somewhat different methods and definitions (including different definitions of malnutrition and improvement). Furthermore, nutritional status and price data are collected at different seasons, which may affect values, and costs may reflect different inflation and exchange rates. Even more misleading can be the fact that each project deals with a different-sized sample or population group over which to amortize costs.
However, recognizing all of these limitations, a comparison of cost-effectiveness to other projects has been made in table 9. Table 9 shows that, compared to representative programmes of other types (supplementary feeding, nutrition education at clinics) and programmes of a similar type (mass media and mass media with local workers), the cost-effectiveness of the Nutri-Pak programme compares quite favourably.
Perhaps a more meaningful perspective would be to look at these costs in relation to Philippine national budgets. Nutri-Bus is designed to make more effective the nation's BNS programme. There are currently about 10,000 BNS nationwide in the Philippines. If the NutriBus programme covered all 10,000 (although some would not be accessible by road) it would cost about 0.03 per cent of the national budget (or 0.7 per cent of the Health and Nutrition budget). Even if the number of BNS were to double over time to 20,000, Nutri-Bus costs would still be affordable at 0.06 per cent of the national budget (or 1.4 per cent of the Health and Nutrition budget).
Returning to the Habicht, Mason, and Tabatabai questions for evaluation during programme implementation:
1. Is the Intervention Performing as Expected?
Are Services Being Delivered to Target Croups?
Yes, but improvements are sought. Approximately 66 per cent of mothers in sample villages in 1981 reported seeing VTR shows. However, this is down from 75 per cent in the VTRL treatment, common rural villages in 1979. This may indicate need for better field management and/or greater variety in shows. The report of Nutri-Pak as a snack dropped by nearly 50 per cent from 1979 to 1981. Nutri-Pak was not available in most villages. A better distribution system is needed.
Is Gross Outcome Acceptable to Management?
Yes, but improvements are sought. The stated objective was to test the null hypothesis. Although the data do not meet the requirements of experimental design, the evidence favours the rejection of the null hypothesis. Since successful field projects to improve nutritional status are so few and far between, management decided before the evaluation that any statistically significant improvement found would be taken to indicate that a useful intervention was being pursued and efforts would be focused on increasing the impact of the intervention.
Regarding cost-effectiveness, the outcome is well within the acceptable range.
Where Should Improvements Be Sought?
The three areas where improvements are being most vigorously sought are: field management systems; video-tape production efficiency; and Nutri-Pak distribution system.
Table 9. Comparison of cost-effectiveness of several nutritional intervention programmesa
|Cost-effectiveness indicators reported (per target group members per year except as noted)|
|Programme type||Country||Source||Date of $ exchange rate||Delivery||Participation||Awareness||Reported behaviour change||Impact|
|Take home||Philippines |
|Berg (1981) |
|World Bank |
|$56.01-$68.75||$33 - $51|
|Mass media||Philippines |
|Zeitlin (1981) |
|$2.05- $3.94||Family $2.06||Child |
$15 - $29
|Mother $14/2 yrs ($7/yr) |
Child $10/2 yrs ($5/yr)
|$38/2 yrs |
a. Different methods of calculation make comparisons indirect at best.
b. Beneficiaries included both children and pregnant or lactating women.
c. Beneficiaries included pre-school children only.
Sources: J.E. Austin. Confronting Urban Malnutrition (Johns Hopkins, Baltimore. Md.,1980); A. Berg, Malnourished People (World Bank, Washington, D.C.,1981); M.F. Zeitlin and Candelaria 8. Formacion, Study II: Nutrition Education (Oelgeschlager. Gunn, & Hain, Cambridge, 1981).
2. Is It Worth Continuing the Project?
Yes, especially if recommended improvements can be implemented. When the findings are compared with national trends and more intensive feeding programmes, the improvement in the Nutri-Bus areas seems good. This evaluation does not prove that the Nutri-Bus project was totally or even partially responsible for the improvements, but the evidence favours that interpretation.
3. Should the Programme Be Extended?
Yes, if the recommended improvements can be implemented. The Nutri-Bus project is still under development. Improvements are needed in the areas listed above, as well as in precision of evaluation.
4. Is There a Causal Link to Improved Nutrition?
Although these data cannot definitely answer this question, the presumption is, yes.
Improvements in nutritional knowledge and attitudes and nutritional status were found in the Nutri-Bus areas surveyed. Feeding standards improved as measured by mothers' reports of what they feed children. In 1979. contrasting the comparison condition to the VTRL condition, the mothers in the VTRL condition were 55 per cent more likely to describe complete meals (fig. 2). Comparing the BNS to the VTRL condition, mothers in the VTRL condition were 473 per cent more likely to name Nutri-Pak as a good snack (fig. 4), and 71 per cent more likely to give correct specific descriptions of Nutri-Pak (fig. 3).
Comparing 1979 to 1981 results in the rural area, mothers were 27 per cent more likely to describe complete meals in 1981 (fig. 11).
Regarding nutritional status, in 1979, comparing the BNS to the VTRL condition in the rural area, there was 25 per cent less second- and third-degree malnutrition after the VTRL exposure and 29 per cent more normal and first-degree (fig. 9), using weight for age with the Harvard standards and Gomez classification.
Comparing the 1979 results to 1981 in the rural area, there was a 17 per cent decrease in second- and third-degree malnutrition and a 12 per cent increase in normal and first-degree (fig. 18).
Evidence from the 1979 and 1981 evaluations of the Nutri-Bus project favours the assumption that the Nutri-Bus project is effective. It also reinforces the recognized need for improvements in the field management system, in video-tape production efficiency, and in the Nutri-Pak distribution system. The Nutrition Center of the Philippines has committed itself to the continuing development and evaluation of the Nutri-Bus project.
Fig. 19. Percentage share of cost of programme management and field operations cost of 31 buses, by donor, 1981.
ADDENDUM: CURRENT EFFORTS
From two pilot buses fielded in Leyte in 1978, the Nutri-Bus project now has 32 units operating in 11 regions covering 13 cities and 5 municipalities in Metro Manila (Appendix 14). These buses reach approximately 2,790 villages, 403,000 mothers, 558,000 pre-schoolers and 372,000 schoolchildren, and supervise 2,710 BNS. A summary of the field services and management related inputs is shown in Appendix 15.
Identifying and pulling together the various sources of funding and technical support to carry on this project continues to be one of the biggest challenges. In 1981 and 1982, the average grant from the National Nutrition Council for the operation was P32,787 (US$3,706) per bus per year. During 1981 and 1982, NCP covered more than half the operating expenses, NNC covered about one-fourth, and the remaining portion was supported principally by the private sector and local governments. Figure 19 shows the sources of funding for the Nutri-Bus operations in 1981.
An innovative programme of this complexity and scope requires consistent managerial and financial support to attain its potential impact. Long-term funding commitments to cover all costs of the programme have not yet been realized.
To obtain adequate fund support, a resource mobilization unit under the office of the NCP Executive Director was created in early 1983 to "package, promote and sell" NCP projects, among them the various components of the Nutri-Bus, to potential donors. For example, a donor may "buy" the video-tape module for P32,000 (US$2,909); another may "buy" the NB vehicle for P75,000 (US$6,818). Needless to say, the pursuit of these various inputs and putting them together require a major commitment of time and skill from NCP.
Co-ordination with the National Nutrition Council, the local government, and health and nutrition personnel in the field is another sensitive and crucial area. In order to clearly define the linkages and roles of the co-operating agencies and field personnel, the Nutri-Bus policies and guidelines are periodically reviewed and revised for more efficient planning and implementation.
The administrative and operational details are threshed out at the regional level through the Regional Nutrition Program Co-ordinator and at the local level in coordination with the provincial/city/municipal action officer.
As part of its effort to meet the increased demand for social services in the years ahead, the NCP underwent a structural reorganization which took effect in 1983. Under this structure, coordination for the overall implementation of the Nutri-Bus project was placed under the NCP Nutrition Operations Division (NOD) as the division's comprehensive interventions activity. The project has two units: field supervision, under which are the area co-ordinators and communicators, and engineering, which supervises the area engineers (AK) and drivertechnicians (DT). The functions of the NOD include not only field operations, but also monitoring and evaluation and technical support. VTR production is placed under the Video Radio Production Division of the NCP IEC/Training Department.
The new structure served to strengthen:
Likewise, operational systems have been strengthened to meet new requirements. For field management, the organizational restructuring covers:
Improvement of policies and guidelines for field implementation and co-ordination includes:
Supervision by the NOD head office is strengthened through:
The work systems include:
Meanwhile, the following steps have been taken to increase efficiency in VTR production:
1. Intensification of organization and staff development through:
2. Improvement of production equipment and facilities through:
3. Increase in variety of shows/modules through:
4. Improvement of management methods through:
On the whole, the project adheres to the well-known management principle that programme success lies not in programme design but in the people manning the programme. It gives equal emphasis, therefore, to the hard and soft aspects of the management framework to meet established goals and values.
The authors are deeply indebted to the following for their co-operation and involvement during the study:
The Director and staff, Regional Health Office, Region VIII, Ministry of Health, most especially to Dr. Amparo Banzon, Regional Health Director; Dr. Wilfredo Varona, Medical Specialist 11; Mrs. Cleofe Panao, Provincial Dietary Nutritionist and District Nutrition Program Co-ordinator; Mr. Bert de Veyra, Provincial Health Educator; Miss Leticia Espinosa, Health Education Supervisor; Dr. Benefico Ducusin, Chief Training Officer, and the staff of the Regional Health Training Center, for assistance in the selection of the study areas, training of the BNS in both pilot and evaluation studies, providing transportation and office equipment, assistance in data collection, and implementation of the VTR treatment.
The Hospital Director and staff of the Daniel Z. Romualdez Memorial Hospital, particularly Dr. Manuel Anover, Director, and Dr. Dolores Sancelo; Nurse Supervisors Mrs. Mamerta Menesis, Mrs. Lilia Marquez, Mrs. Restituta Santiago and Mrs.
Jocano, and Dr. Prescila Escape and Dr. Mansueto Corado, for assistance in the training of data collectors and in actual data collection.
Dr. Roberto Briones, Regional Nutrition Program Co-ordinator, Region VIII, National Nutrition Council, and Mrs. Julita Solana, Regional Training Assistant, for assistance in coordinating schedules and communication with the village officials, providing transportation and office support, and assistance in data collection.
To the City Mayor of Tacloban, Mayor Obdulia Cinco and Atty. Antonio Zeta, City Administrator; and the municipal mayors and barangay officials in the study areas, for their whole-hearted co-operation in providing secondary data, allowing access to birth registries for the validation of birthdates, and providing the initial capital for Nutri-Pak sales.
To the parish priests in the study areas, for allowing access to parish baptismal records for the validation of birthdates.
Each of the above contributed in various ways towards attaining the goals of the pilot study.
Valuable comments and suggestions have been provided by Dr. Richard Lockwood, Consultant, Development Communications Consultants, Inc.; Dr. Nevin Scrimshaw, Institute Professor, Massachusetts Institute of Technology; Dr. Joe Wray, Center for Population Studies, Columbia University; Dr. Barbara Underwood, National Institutes of Health; Dr. Marian Zeitlin, Assistant Professor, School of Nutrition, Tufts University; and Dr. William Rand, Biostatistician, Massachusetts Institute of Technology. We are deeply grateful for their help in the analysis of the data and interpretation of the results.
We express special thanks to the Coca-Cola Company for funding the evaluation study, among the company's many generous contributions to the work of the Nutrition Center of the Philippines over the years.
We also appreciate very much the dedicated support extended by the Nutrition Center of the Philippines staff, especially the data-processing programmers, Ms. Teresita Rosete, Arlene Abueg, Carolina Dayco; Joey San Luis, Audio-Visual Division Chief and his staff, Danny Catacutan, Rolly San Jose, Mita de la Paz, and Hubs Ismael; the clerical staff, Elvira de la Cruz and May Esposo; Orly S. Ramas of the Executive Office; and Malou Rusiana and Rebecca Yao of the Nutri-Bus Office.
We are particularly grateful to Dr. Florentino S. Solon, Executive Director, Nutrition Center of the Philippines, whose help and encouragement sustained us throughout this project.
We thank all the many others who have been involved in the implementation of the project and who have contributed to the production of this material.
1. Philippines Food and Nutrition Research Institute, First Nationwide Nutrition Survey (FNRI, Manila, 1978).
2. Nutrition Center of the Philippines, The Nutrition Surveillance Pilot Project: First Phase, Albay, Philippines (NCP, Makati, 1980).
3. D.B. Jelliffe, Infant Nutrition in the Tropics and Sub-tropics (WHO, Geneva, 1968).
4. M.F. Zeitlin and Candelaria S. Formacion, Study 11: Nutrition Education, Harvard Institute for International Development, Supplementary Studies to Nutrition Intervention in Developing Countries (Oelgeschlager, Gunn & Hain, Inc., Cambridge, Mass., 1981).
5. J.P. Habicht, J. Mason, and H. Tabatabai, "Basic Concepts for Design of Evaluation during Program Implementation," in D. Sahn, R. Lockwood, and N. Scrimshaw, eds., Methods for the Evaluation of the Impact of Food and Nutrition Programmes (UNU, Tokyo, 1984).
6. J.E. Austin, "The Perilous Journey of Nutrition Evaluation," A.J.C.N., 31(12): 2324-2338 (1978).
7. J.E. Austin, Confronting Urban Malnutrition: The Design of Nutrition Programs (Johns Hopkins University Press, Baltimore, Md., 1980).
8. T. Soda, A Nationwide Simple Morbidity Survey in Japan (WHO, Geneva, 1965).
9. N.S. Scrimshaw, C.E. Taylor, and J.E. Gordon, Interactions of Nutrition and Infection (WHO, Geneva, 1968).
10. Philippines National Census and Statistics Office, Population, Land Area and Density, Special Report, no. 3 (NCSO, Manila, 1980).
11. B. Popkin, "Some Economic Aspects of Planning Health Intervention among Malnourished Populations, " A. J. C. N., 31 (12): 2314-2323 (1978).
12. NEDA-UNICEF, unpublished statistics, 1982.
13. Philippines National Census and Statistics Office, Leyte: 1975 Integrated Census of the Population and Its Economic Activities: Final Report, Phase I (NCSO, Manila, 1975).
APPENDIX 1. The "A-B-C Model" for Developing Communication to Change Behaviour (Development Communications Consultants, Inc., 1983).
APPENDIX 2. Interactive Learning and Motivation Strategies for Communication to Change Behaviour (Development Communications Consultants, Inc., 1983)
1. Discovery/Logical Conclusion
Learner is exposed to certain information and then asked to make a decision which logically follows from that information.
2. Analogy/Logical Conclusion
The audience is reminded of something they are familiar with that works on the same principles as the idea being taught. They are then asked to draw conclusions from the new information based on the analogy.
Learner is given a general principle and asked to apply it by giving specific examples.
Learner is given specific examples and asked to conclude the general principle.
5. Observation No. 1. Description
Audience looks at certain conditions and reports what it saw.
6. Observation No. 2. Comparison
Audience looks at two or more sets of conditions and reports differences and/or similarities.
7. Observation No. 3. Modelling of Desired Behaviour
This is a special case of observation/description/comparison. Here what is being observed is the behaviour to be taught. The audience is asked to observe and describe this correct behaviour or some of its elements.
The audience is helped to get the correct answer by being given clues.
Previously elicited and reinforced behaviour is asked for again with less supporting information or prompts.
10. Personal Opinion, Preference, Feeling, Experience, or Data
Audience is asked to give opinions or preferences, tell some personal feelings or experiences, or give data about themselves or their children (such as age, names, etc.)
This is the strategy used for the first interaction of a programme. The subject-matter chosen should be non-threatening to the audience but something they might like to talk about.
The purpose is to (a) have an opportunity to reinforce the audience for responding, and (b) introduce the subject of the module.
11. Public Commitment
Audience is asked to commit themselves regarding some attitude, opinion, or value that is being shaped by the module. This is done in order to strengthen that attitude, opinion, or value as a motivation to act or to learn what is in the module.
12. Performance of Entering Behaviour
Audience is asked to do or say something that it already knows how to do or say. This is used only if:
APPENDIX 3. The Contribution of the Communication System in Influencing Knowledge, Attitudes and Nutritional Status (Development Communications Consultants, Inc., 1983).
APPENDIX 4. VTR Modules Shown during Study Period
(The Good Life)
|Introduces the idea that three basic types of food are needed for proper growth and health. Helps mothers begin to see the differences between well-nourished and malnourished children regarding both appearance and behaviour. Introduces Nutri-Pak as a complete food for children's snacks.|
|2. Matibaksi |
(Strong and Quick)
|Teaches how to prepare Nutri-Pak and when and how much to give|
|3. Budgeting||Examines the value of the content of Nutri-Pak compared to the price in the market for the same foods. Touches on ways mothers can save or earn money to buy Nutri-Pak.|
|Closely compares the physical and behavioural characteristics of well nourished and malnourished children and introduces the functions of the basic food groups.|
APPENDIX 5. Nutri-Bus Delivery System
APPENDIX 6. Appropriate Data Collection and Analysis for Different Decisions
|Confidence needed increases|
|Data and analysis needs||Decisions||1 Management||2 Continue funding||3 Replication in similar conditions||4 Replication in different conditions||5 |
Basic research, causality
|a.||Process data and outcome for participants only||+||+||+||+||+|
|b.||Ad hoc surveys||(+)||(+)||+||+||(+)|
|c.||Advanced stat. analysis||+||+||+||+|
|d.||Some kind of control group(s)||+||+||+|
|f.||Highly standardized measurements||(+)||+|
|h.||Double-blind trials||+ ?|
Source: J.P. Habicht, J. Mason. and H. Tabatabai .
APPENDIX 7. Philippine Nutrition Program Implementing Guidelines on the Barangay Nutrition Scholars Project
The extent of the malnutrition problem in the country is such that greater involvement and participation of people at the grass-roots level are urgently needed. While the health and nutrition programme is comprehensive in that it is organized at the national, regional, provincial and municipal levels, its implementation at the barangay level is far from being effective because of the lack of manpower to deliver the health and nutrition services. The manpower resources are not enough to cope with the increasing number of people who have to be reached by health and nutrition intervention schemes in the more than 40,000 barangays of the country. Hence, the Barangay Nutrition Scholars Project was conceptualized.
The Barangay Nutrition Scholars Project is a strategy for providing each barangay with a trained community worker to deliver basic nutrition and related health services. This strategy calls for active community participation in designing and implementing an action plan for the barangay through the Barangay Nutrition Scholar (BNS).
To develop a system or facility for the delivery of basic nutrition and related health services in the barangay through the use of the BNS as a support to the Philippine Nutrition Program.
PNP for the delivery of basic nutrition and related health services in the barangay.
Organizational Linkages of the BNS Project
Figure A shows the co-ordinative relationship of those involved and the flow of administrative and technical supervision of the overall provincial/municipal/city nutrition programme in general and the BNS project in particular.
Added to the PNP structure at the local level is the district nutrition programme co-ordinator (DNPC)/city nutrition programme co-ordinator (CNPC), who will be hired by the governor/city mayor to assist the PAO/CAO in the overall co-ordination of the provincial/city nutrition programme, as well as being fully responsible for the BNS in his areas of assignment.
A DNPC/CNPC will have under his supervision 30 to 50 BNS. The DNPC/CNPC ratio will depend on the BNS location distribution, the geographical terrain of the province, and funds made available by the provincial/city government.
Mechanics for Project Implementation
For effective project implementation, an orientation of local administrators will be undertaken. The orientation shall include rationale of the BNS Project and its potential contribution to the attainment of the objectives of the PNP, objectives and the mechanics of the project, monitoring system and the flow of supervision, the responsibility of all those involved and the cost of the project.
Recruitment of DNPC/CNPC
The governor/city mayor shall appoint the DNPC/CNPC upon the recommendation of the PAO/CAO and RTA.
Qualifications of DNPC/CNPC
Recruitment of BNS
Organization of Screening Committee
The screening committee shall be organized by the CAO/MAO at both barangay and municipal/ city levels. The MAO/CAO shall inform the barangay captain and head teacher, who will become members of the barangay screening committee. The barangay screening committee shall be composed of the barangay captain as chairman, the head teacher or teacher co-ordinator, and the president of any of the community organizations such as the PTA, RIC, or Anak-Bukid (4-H Club) as members. The barangay captain submits to the MAO/CAO the list of qualified applicants endorsed by a majority of the screening committee. The municipal/city screening committee composed of the MAO/CAO and two other members of the MNC/CNC shall convene to choose the best qualified from among the applicants, using a prescribed NNC Form. The MAO/CAO endorses the final recommendees to the mayor for approval.
Qualifications of BNS
The screening and recruitment of the BNS shall be guided by the following qualifications:
Training of the BNS
- initiate/assist in the organization/revitalization of the barangay nutrition committee (BNC).
- provide basic information on the seven-point programme.
- develop skills and desirable attitudes necessary for the delivery of basic nutrition and health.
- record/monitor basic services rendered to families in the barangay.
Delivery of Services by the BNS
After successful completion of the practicum, the BNS shall work in their respective barangays for a period of at least one year. A memorandum of agreement shall be signed by the scholar and the mayor, stipulating among other things that the BNS shall serve for at least one year with corresponding benefits and incentives.
Basic Tasks of the BNS
1. Organization. community suney/resurvey, and planning
- Assist the barangay captain/organizelreactivate the barangay nutrition committee and the barangay network.
- Assist the BNC in training purok and unit leaders to assist the BNS.
- Prepare a one-year work plan (based on the seven-point BNS programme and the community survey), within the framework of the Barangay Nutrition Action Plan.
2. Identifying and locating targets
- Weigh all 0- to 83-month-old children at least once a year.
- Carry out follow-up reweighing of identified third-degree cases and of 0- to 18-month pre-schoolers monthly.
3. Providing basic services
- Provide basic nutrition and health information to mothers of underweight children.
- Refer sick and underweight children to health centres, clinics or hospitals.
- Refer eligible targets to feeding programmes giving priority to third-degree.
- Distribute and/or sell food commodities to targets.
- Distribute available vitamin/mineral preparation.
- Conduct or assist in conducting systematic nutrition and health education classes to mothers, especially the pregnant and nursing.
- Promote the construction and proper and continued use of sanitary toilets, giving priority to households with pre-school children.
- Campaign for the eradication of breeding places for insects and rodents that are carriers of diseases.
- Refer household water sources of doubtful quality to the RHU.
- Distribute available seeds and seedlings, particularly to target families.
- Advise families of possible resources for food production.
- Recommend which food crops to produce for home consumption.
APPENDIX 8. Criteria for Selection of Sample Villages, 1979 and 1981
|Socio-economic status||C and D (lower SES as classified in most recent census)|
|Primary source of livelihood||Rice farming and fishing|
|Distance from Poblacion (municipal capital)||6 km or more|
|Distance from other sample villages||Separated by at least one village|
|Recent feeding programmes||None within three months of survey|
|OPT results (community weighing)||Average for Leyte or worse prevalence of malnutrition|
|Recent nutrition education programmes from other agenices||None|
|Health facilities||No facilities in the village or of easy access|
|Health facilities||No unusual programmes during previous two years.|
APPENDIX 9. Classification of Urban and Rural (Philippine Population Census)
- a town hall, church, or chapel with religious services at least once a month;
- a public plaza, park, or cemetery;
- a market-place where building or trading activities are carried on at least once a week;
- a public building like a school, hospital, child-care or health centre, or library.
All areas not covered in the definition of urban are considered rural.
APPENDIX 10. Data Collection Team and Equipment
APPENDIX 11. Mean Indicator Response to Supplementary Feeding for the Prevention of Protein-Energy Malnutrition (PEM)
|Type of |
|Weight||36||36||17% cal. 36% Pro.||4.5 kg (Denver)||0.9 kg||1.3 kg||0.24|
|Height||"||"||"||2.3 cm||3.9 cm||0.17|
|Arm circum.||"||"||0.35 cm||0.9 cm||0.08|
|"||"||"||"||0.15 cm||1.1 mm||0.01|
Source: R. Martorell,. R.E. Klein, and H. Delgado "lmproved Nutrition and Its Effects on Anthropometric Indicators of Nutritional Status. Nutrition Reports International, 21(2): 219-230 (1980).
APPENDIX 12. Nutri-Bus Evaluation Coverage by Condition, August 1978 to March 1981
APPENDIX 13. Nutri-Bus Programme Cost Estimates Worksheet
|Values used in formulae:|
|1. Annual cost per bus||P140,171a|
|2. BNS areas per bus||90|
|3. Population per BNS area||1,000|
|4. Estimated target group of||14% of|
|children (12-66 months)||populationb|
|5. Target group (12-66 months) per BNS area||140 pre-schoolers |
(14% x 1000= 140)
|6. Target-group mothers per BNS area||100 mothersc|
|7. Target-group mothers ever attending VTR per BNS area||66 mothersc|
Percentage combined second- and third-degree undernutrition |
|9. Proportion of second- and third-degree
undernourished per BNS area |
Decrease 1979-1981: 0.07x 140
|59.08 children |
|10. Percentage target mothers reporting
improved diet for child |
|11. Proportion of target mothers reporting
improved diet for child per BNS area |
Increase 1979-1981: .268 x 100
|32.0 mothers |
|12. Number of BNS nationwide, 1981||10,000|
|13. Total Philippine national budget, 1981||P54.8 billion|
1. Annual cost per bus per BNS area
Annual cost per bus / No. of BNS areas per bus = P140,171/90 = P1,557 (= US$188.00)
2. Annual cost per target-group child in catchment area
Annual cost per BNS area/No. of target-group childran in BNS area = P1,557/140 = P11.12 (= US$1.34)
3. Annual cost per target-group mother in catchment area
Annual cost per bus per BNS area / No. of target-group mothers in BNS area = P1,557/100 = P15.57 (= US $1.88)
4. Annual cost per target-group child whose mother attended VTR
Annual cost per bus per BNS area/No. of children whose mothers attended VTR
per BNS area = P1,557/66 (140/10)
5. Annual cost per target-group mother ever attending VTR
Annual cost per bus per BNS area / No. of target-group mothers attending VTR
per BNS area = P1,557 / 66 = P23.59
6. Cost per target-group child whose mother's report of foods given to child changed from in adequate to complete
2 x annual cost per bus per BNS area / No. of target children whose mothers
report reflected diet change(d)
= 2(PI,557) / .268(140) = P3,114 / 37.52 = P83 over 2 years (or P41.50 per year) (= US$10 over 2 years or US$5 per year)
7. Cost per target mother where report of foods given to child is changed from inadequate to complete
2 x annual cost per bus per BNS area / No. of target mothers where report
reflects change(d) = 2(PI,557) / .268(100)
= P3,114 / 26.8 = P116 over 2 years (or P58 per year) (= US$14 over 2 years or US$7 per year)
Appendix 14. Area coverage, nutri - bus project
APPENDIX 15. List of Services Provided by Nutri-Bus
|Services||Target group reached|
|Barangay VTR showing||x||x||x||x|
|School VTR showing||x||x||x|
|Distribution of IEC materials||x||x||x|
|Referral to hospital malward/nutri-hut||x||x|
|Referral to feeding centre||x|
|Seeds and seedlings||x|
|Systematic super vision of BNS||x||x|
|Quarterly BNS reinforcement training||x||x|
|Monthly individual training of BNS (during long call)||x||x|
|Monitoring and referral of field problems||x||x||x|
Directorate of Health Education, Department of Health, Jakarta, Indonesia
The Government of Indonesia, in collaboration with various international agencies, has identified four major nutrition problems in Indonesia: protein-calorie malnutrition (PCM), vitamin A deficiency, iodine deficiency, and nutritional anaemia. These problems are widespread throughout Indonesia, although regional, ecological, and cultural differences that affect food availability and consumption account for geographical variations in their nature and intensity. Of these four major problems, the most basic is inadequate intake of protein and calories. Close to one-third of children under five years of age are estimated to suffer from moderate to severe PCM, while more than 50 per cent of children under two are affected. Pregnant women are another vulnerable group, and more than half of lactating mothers suffer from moderate PCM.
FACTORS RELATED TO THE PROBLEM
Malnutrition in Indonesia is the result of a combination of factors, mainly inadequate production and availability of foods, inequitable distribution of available foods, insufficient awareness of nutritional needs, and poor food habits among a large segment of the population.
In most areas of Indonesia the most preferred staple food is rice, frequently mixed with cassava or sweet potatoes. Only a few families can afford to consume animal protein. Proteinrich vegetables are seasonal and are used for snacks and during meals.
Fortunately, breast-feeding during the first to second year is widely practiced, especially in rural areas. But there is little understanding of the importance of additional solid food other than soft rice or banana for children after the first four months of life. Vegetables, meat, and fish are generally not provided to young children, in part because of local practices and beliefs.
THE EARLIER PROGRAMME
Attempts at improving the utilization of available food have concentrated on the basic five food groups message, "4 sehat 5 sempurna" (4 is healthy, 5 is excellent). Though the message is scientifically sound and is recognized throughout the country, it has not yielded the expected results. The major obstacle is the inaccessibility to the food items named in the message, i.e. milk and vitamin supplements. School feeding programmes have been conducted, but with disappointingly little impact, and lack of community participation is a recognized problem. Malnutrition still exists even among the better-off families with a prevalence of as high as 41 per cent.
The Nutrition Education and Behaviour Change Project (NE) is a component of a comprehensive multi-sectoral Indonesian Nutrition Improvement Programme funded by the World Bank. The project aims to develop education methods that create positive knowledge, attitudes, and practices among the target population. The results will be used in the development of the National Nutrition Education Programme.
This NE project was conducted during 1977-1982, covering five subdistricts in three provinces; Godean and Karangmojo in the Special Territory of Jogjakarta, Masaran and Sapuran in General Java, and Indralaya in South Sumatra. The total population of the project areas was approximately 225,000 people, or about 40,500 households. The project was divided into four phases:
The development of nutrition infrastructure at all administrative levels for the dissemination of nutrition information.
The development of community understanding and ability to solve problems through community organization. Approximately 2,000 village nutrition volunteers referred to as kaders were trained and equipped with nutrition education kits. Kaders initiated nutrition education activities with a weighing programme as the base.
The development of a communications strategy (1979-1981). A community selfsurvey was started in which families participated in the formulation of the strategy. Actual production and dissemination of the materials and evaluation were attempted.
The preparation of the National Nutrition Education Programme.
This paper will specifically discuss the third phase.
THE DEVELOPMENT OF THE COMMUNICATION STRATEGY
On the basis of findings from earlier nutrition education activities, it is imperative that the message of a nutrition education programme be specific in that it has a practical implication for the target population. The communication channels selected need to have extensive as well as intensive coverage of the target population, and resources to put the message into practice must exist in the community.
To meet these requirements the development of the communications strategy was carefully planned and divided into five stages: (1) community diagnosis; (2) concept testing or formative evaluation; (3) message pre-testing; (4) implementation; and (5) evaluation.
Early in 1979 a community self-survey was held in each village in the project areas to uncover the major nutrition problems there. These were found to be: (1) PCM among children of 0 to 24 months of age; (2) infant diarrhoea; (3) undernutrition among pregnant and lactating women; (4) vitamin A deficiency among young children; and (5) goitre.
Community meetings were then held in each village to provide opportunities for village leaders and, most importantly, the mothers to discuss the problems and suggest alternatives (behaviour) to solve them. An investigation team was introduced to get acquainted with the leaders and mothers and also to develop insights into the suggestions produced during the meeting.
Community diagnosis showed that:
The list could be made longer and more formidable, but the points listed above were found to be enough for starting the next stage.
CONCEPT-TESTING OR FORMATIVE EVALUATION
At the village meetings held to discuss the data collected during the community self survey, the investigation team together with the project staff noted a long list of suggestions brought by the village leaders, the leaders, and most importantly the mothers. Priorities were selected on the basis of their importance for improving the nutritional status of the children and their practicability. Knowledge and behavioural objectives were then developed for each priority, and after a period of trials a list of questions was ready for the investigation team to present to the villagers. The following were the first six topics agreed upon as priorities:
After sufficient training, especially on message design and concept-testing procedure, the investigation team started with interviews of the sample of 330 households that had: pregnant women, lactating women, infants from 0 to 4 months, infants of 5 to 8 months, infants of 9 to 24 months, and young children with diarrhoea of signs or vitamin A deficiency. A 2lhour dietary recall was also administered to calculate the calorieprotein intake of infants and lactating women. The young child was weighed and a possible dietary change was discussed with the mothers to improve the family nutrition intake. New recipes, especially for the young child. were then tried using food, ingredients, and utensils available in the house. The child was then fed and the mothers discussed with the investigator how the child liked or disliked the food. Possible modification was discussed, based on observations made while the child was eating. Three to four days later, when the investigator came back, the mothers usually had already found the recipe the child liked the most.
Considering the findings during the community diagnosis, the communication channels most feasible for the target population were: (a) radio spots, (b) action posters, (c) common posters, (d) booklets, (e) kader manuals, (f) leaflets, (g) slides, (h) radio social dramas, (i) TV short dramas, and (j) TV spots.
Before production, mimeo copies of the messages for the action posters and radio spots were pre-tested with a sample of mothers, leaders, and village leaders, as well as officials in the project areas. The purpose was to observe whether or not the messages were easily understood and what possible alterations could be made. Generally, the messages were highly accepted. Suggestions were usually directed at improving the words, colour, size, pictures, speed of the recording, and the like.
Implementation started in August 1980, and slightly more than one year later the evaluation was carried out. Orientations were held at several levels to provide the intersectoral team with the opportunity to learn not only the messages but, more importantly, the principles underlying them. Kaders were trained in the technical aspects of the messages and also in the behavioural as well as the knowledge changes that were expected to occur among the target population.
Mass communication as well as an interpersonal approach was decided upon for dissemination of the messages. Radio was listed first for the mass campaign, because radio accessibility was over 65 per cent in four out of five project subdistricts. Although TV was regarded as highly effective, accessibility was low for both the project officials and the community. The use of TV was then limited to producing general information on nutrition problems. Group meetings were very important because most villagers liked to attend such meetings during their leisure time; village as well as hamlet meetings were held each month. Group meetings following weighing sessions were particularly important.
Kaders were encouraged to pay home visits as often as possible. During the first visit kaders distributed action posters to families; they discussed the meaning of the posters and what action the mothers should take. They also checked whether or not the family listened to radio broadcasts. In most cases, the radio spots did not receive the desired amount of exposure; however, radio was principally a reinforcement aid for interpersonal communications activities.
In November 1981, after intensive training, an interview team conducted extensive evaluation interviews for the project. A total of 305 kaders (200 from project areas and 105 from comparison areas) and 1,000 households (600 from project areas and 400 from comparison areas) were involved in the interviews. The comparison areas were matched for similar socio-economic conditions, the occurrence of some types of nutrition education, and the presence of nutrition leaders. The results were positive in that the project had brought about a significant improvement in the knowledge, attitudes, and practice of the target population. In turn, it was evident that these practices favourably influenced the growth of the children. The following are highlights of the project evaluation.
SAKORN DHANAMITTA, PATTANEE WINICHAGOON, and NITTAYA KOTCHABHAKDI
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
SUTTILAK SMITASIRI AND AREE VALYASEVI
Institute of Nutrition, Mahidol University, Bangkok. Thailand
Protein-energy malnutrition has been a major nutritional problem in Thailand. The most recent nutrition surveillance data revealed that about 51 per cent of 0- to 5-year-old children in the country are still suffering from various degrees of malnutrition . The highest prevalence has been observed in the north-east region of the country.
Reports from various countries, including Thailand, Malaysia, and the Philippines, have shown that improvement in economic status may not necessarily bring about better nutritional status in a population [2, 3]. The community-based nutrition research programme conducted in the north-east by the Institute of Nutrition, Mahidol University (lNMU), strongly supported this finding. Nutrition education was found to be essential to the integrated nutrition, health, food supply, and income-generation programme if the nutritional status of the most vulnerable 0- to 5year-old children was to be improved .
Efforts in nutrition education in the past have been limited to interpersonal communication techniques using simple media, such as various forms of printed materials. Functional illiteracy, lack of infrastructure, and expensive technology that is inappropriately used have made communication efforts for village-level nutrition education minimal and difficult.
In an attempt to produce a behavioural change in food practices, a study on the use and impact of interactive video tapes and radio was initiated. Methodologies for media production and possible dissemination, and the effectiveness of each medium, singly and in combination, for communicating nutrition information to rural populations, was evaluated.
The project included 48 villages in Ubon and Sri Saket provinces in the north-east. These villages were identified from three districts of each province and randomly assigned to TV and control for the Ubon villages and radio alone or TV plus radio for the Sri Saket villages.
TV could be brought to the village with an "interactor" in a video van, whereas radio broadcasts could be sent through the existing radio network in Sri Saket. The selection of these two media was based on their characteristics. Although TV provides both audio and visual exposure, it cannot be used frequently. Radio, as an audio medium, is accessible throughout the country. Messages were short, easily remembered, and broadcast frequently. It was thus hypothesized that a combination of TV and radio should have the strongest impact. Because TV exposure was less frequent it was felt that radio could be used much more often to reinforce the message. However, for study purposes, exposure to each of the media was maintained on an equal level.
The main topic for this nutrition communication was the promotion of proper supplementary feeding at the community level. The target audience was mothers of 0- to 4-year-old children. The activities included:
A food product named "Luk Ruk" was made available as a food supply supplement. It consisted of rice, mung bean, and sesame or groundnut. Each ingredient was packed separately in small packets and then together in a big package with a label. The product was formulated by INMU . In this study it was sold for 2 baht (US$0.09).
Four modules of video tapes and radio programmes were produced. The message was on proper supplementary feeding and related sound nutrition practices. The interactive video tape was 25 to 30 minutes long with an additional 15 minutes of interaction. Radio spots were 30 seconds and one minute in length and were broadcast seven times daily. All media were developmentally tested prior to implementation of the programmes.
Preparation for Implementation
Two health communicators in each village were selected as village-based product distributors. A three-day training session was conducted concerning general nutrition knowledge, the product, job responsibility, record-keeping, and persuasion techniques.
Field Implementation of Video Van and Radio
A video van equipped with video-tape equipment visited each village once a week during the summer period (February to May) and less frequently during the farming period (June to December). Related radio messages were broadcast according to which module of the video tape was being shown.
An interactor rode with the video van and acted as a motivator to encourage the audience to answer questions at each interaction point in the programme. Their other job was the collection of records of sale and of video-tape showings and resupplying the product. The interactor also served as a linkage between product distributor and programme manager for comments, troubleshooting, and resolving any difficulties there may have been during the field-work.
Baseline data were collected in May 1981 and January 1982. Impact evaluation was done in May 1982 and January and May 1983. Approximately 2,500 mothers were interviewed and 3,000 children were weighed and had their heights measured. The interview included the assessment of changes in the knowledge, attitudes, and practices of the target audience. The nutritional status of 0- to 4-year-old children was also assessed.
RESULTS AND DISCUSSIONS
Results and discussion in this paper will be limited to the results obtained up to the first impact evaluation in May 1982.
Exposure to Media
Because village health communicators (VHC) were present as product distributors in each village, they in fact served as a further channel of nutrition education exposure. Exposure to the various media is shown in table 1.
The TV exposure of the audience is visual, auditory, and interactive, while radio is only auditory. It should be noted that, although both media were tested prior to field implementation, radio messages broadcast during this first three months of implementation required further improvement.
Table 1. Media exposure
|TV||Radio Sri Saket a||Radio Ubon b|
a. The broadcast message prepared by the research team and an occasional
message on child-rearing arranged by Radio Sri Saket.
b. Messages on general nutrition and child-rearing broadcast as regular progammes of Ubon radio stations.
The Findings from Observation of Field Media Dissemination interactive Video Van
This consisted of TV and interactor. It was obvious that the message that was presented visually was clear and well understood, leading to active participation in answering questions. Moreover, correct answers could be reinforced, thereby further encouraging the audience to respond to the interactions. This can be diagramatically shown as:
More rapid and deeper understanding of message « Correct answers
Visual messages........... Facilitate learning
Radio messages did not appear to be striking enough to catch the audience's attention. The short radio spots broadcast as 30-second songs were well understood, especially by children. Interviews with some mothers, who mentioned hearing the message although they could not elaborate upon the content, indicated that the spot contained too much information to remember.
Village Health Communicator (VHC)
Individual variations in the characteristics of the VHCs were not expected to produce substantial differences. It was found that the active VHCs were more enthusiastic and hard working, and spent more time on the project. VHCs who were most respected by the villagers, and who had fewer family duties, tended to be more active. This contributed greatly to the motivation of villagers to take an active interest in the project.
Regular meetings between the research team and village health communicators served as a good opportunity to discuss problems and exchange information on various solutions, both among themselves and with the research team. It was also a good chance for supervision, giving additional guidance, etc.
Changes in Knowledge, Attitudes and Practices
Some of the changes in knowledge and attitudes were clearly seen in the first impact evaluation (May 1982) compared to the baseline data, as shown in tables 2 and 3.
It should be noted that the effective perception of the mothers in Ubon was significantly better than that of those in Sri Saket. This is confirmed by the baseline data and by observations made by field-workers during the implementation, though attempts were made to match them during the selection of the study areas. Therefore, the results of the TV and TV plus radio should not be compared for interpretation of the findings.
Table 2. Comparison of knowledge and desirable attitudes as measured by percentage of desirable answers by target audience
|Percentage of correct or desirable answers|
|1. Positive reasons for
giving colostrum Baseline, Jan. 1982 |
Impact evaluation, May 1982
|2. Not giving
colostrum due to belief is bad Baseline,Jan. 1982 |
Impact evaluation, May 1982
|3. Child can
see within one month Baseline, March 1982
Impact evaluation, May 1982
|4. Child can
hear within one month Baseline, March 1982
Impact evaluation, May 1982
of the use of enclosed cloth cradle Baseline, March 1982 |
Impact evaluation, May 1982
|6. Hanging of
mobile for children Baseline, March 1982
Impact evaluation, May 1982
Table 3. Comparison of correct answers obtained according to conditions of the experiment, May 1982
|Percentage of correct or desirable answers|
|Control||TV||Radio TV + radio|
|1. Expected weight of 15-month-old child||23.2||35.9||27.2||32.8|
|2. Naming of Luk Ruk as supplementary food||53.3||70.9||5.55||74.7|
|3. Naming of ingredients in Luk Ruk||55.8||64 3||48.7||59.9|
|4. Vegetables should be added to Luk Ruk||15.1||30.2||15.4||26.9|
|5. Learned the benefits of toys from video-tape and personnel||4.1||21.2||3.5||24.5|
|6. What to do when child spits out new food|
|- quit feeding||45.6||24.1||44.2||23.4|
|- play and cajole child to eat||31.9||60.1||33.1||62.7|
Table 4. Change in nutritional status of 0- to 4-year-old children
|Baseline data |
|First impact evaluation (May 1982)|
Change in Nutritional Status of 0- to 4-year-old Children
An assessment was made of the nutritional status of 0- to 4-year-old children. Due to seasonal variation in nutritional status, this was done twice yearly, in January and May. The change during the first phase of the study is shown in table 4.
Nutritional status, as measured by weight for age, did not appear to improve between the baseline assessment and the first impact assessment. However the data must be interpreted carefully. It was found that age distribution of the measured population, accuracy of birthdate, seasonal variation, etc., are among the factors that need to be taken into account in data analysis and interpretation.
Sales Volume of the Food Products
It was expected that the growth in the volume of sales of the food product would be the result of the impact of the nutrition education programme. The results so far have not shown such a relationship. In other words, sales volume is not a specific and sensitive indicator for measuring the effect of media intervention. Factors that have an effect include availability of money, cooking and feeding methods, enthusiasm of the product distributors, etc. It was noticeable that active village product distributors could motivate their peer groups.
Nutrition education using radio and an interactive video van was conducted in Ubon and Sri Saket. A video van equipped with video tape and accompanied by an interactor carried the programme to rural villages. Four modules of video tape were shown three times each during the period of January to May 1982. The radio broadcast brought the same message through radio Sri Saket. Radio spots one minute or 30 seconds long were broadcast seven times daily.
The results showed that the interactive video-tape programme had a striking effect on knowledge and attitudes, but not much effect on practices as yet. Clear visualization and interaction facilitated learning. The radio did not appear to affect learning at this stage. It was observed that the message forms needed further improvement. The village health communicators, who served as village-based product distributors, were good at motivating villagers to attend the video-tape showings, to listen to radio programmes, and to use the supplementary food product.
Table 5. Time schedule for activities promoting proper supplementary feeding at the community level
|Meeting with village leader||x|
|Training of product distributor||x|
|Product distribution||1, 2, 3||1, 2, 3, 4||1, 2, 3, 4|
|Baseline data collection||x||a||x||x||x|
a. Baseline for video module 4.
The effect of the programme on nutritional status has not yet been established. Careful interpretation of the anthropometric measurement was necessary. The sales volume of the product did not reflect the effect of the nutrition education programme alone, as other factors were also involved. Additional information from the subsequent impact evaluations should make interpretation of the results easier.
Process evaluation was very useful, and efforts should be made to develop this in more detail in order to obtain a better understanding of the efficiency and efficacy of interactive video, either alone or in combination with radio messages, in inducing behavioural change.
1. Ministry of Health, Bangkok, Thailand, 1983.
2. FAO Regional Office for Asia and the Pacific, Poverty and/or Ignorance. A Socio-economic Study of Nutritional Problems in Thailand and the Philippines, RAPA 59 (FAO, Bangkok, 1982).
3. FAO Regional Office for Asia and the Pacific, The Relationship between Economic Growth and Nutritional Improvement in Peninsular Malaysia, RAPA 70 (FAO, Bangkok, 1983).
4. S. Dhanamitta, S. Virojsailee, and A. Valyasevi, "Implementation of a Conceptual Scheme for Improving the Nutritional Status of the Rural Poor in Thailand," Food and Nutrition Bulletin 3(3): 11-15 (1981).
5. K. Tontisinrin, ``Formulation of Supplementary Infant Foods at the Home and Village Level in Thailand," Food and Nutrition Bulletin 3(3): 37-40 ( 1981).
Institute of Nutrition and Food Science, Dhaka University, Dhaka-2, Bangladesh
Mothers and children in rural areas are the main target for nutrition education in Bangladesh. Various strategies have been used to convey nutrition information to different groups. The messages generally given are: (a) identification of malnutrition; (b) environmental factors influencing nutritional status; (c) infection and malnutrition; (d) parasites and malnutrition; (e) infant-feeding practices, including breast-feeding and weaning food; and (f) immunization. Examples of some strategies used are:
Nutrition and related activities are strengthened by short-course training of peripheral-level workers and middle-level officials. Attention is given to cultural practices in dietary food and preparation habits. The mass medium most often used is radio, and, to a rather limited extent, television.
It has been reported that there is a high incidence of malnutrition in children aged between one and three years in deprived localities in Bangladesh. Many nutritional problems could be alleviated by the proper use of available food sources, if the public were exposed sufficiently to nutrition education through effective communication.
A training programme was arranged in conjunction with the Bangladesh Rural Development Board (BRDB). Field-level workers, including female co-operators of the BRDB, were trained to direct the programme using lectures, discussions, and demonstrations. Trainers were grouped into teams of three, one of whom was the leader. Mobile units for education and training were made available with UNICEF assistance. Booklets written in Bengali, posters, slides and photographs presenting nutritional deficiency diseases, and flannelboard demonstrations of the function of food groups were some of the educational aids used in the programme. The contents of the training covered breast-feeding, infant feeding, clean water, environmental hygiene, and immunization.
Pre- and post-tests indicated that the messages did reach the learners. There was no systematic evaluation for long-term impact. However, female co-operators responded positively to follow-up visits and have disseminated the knowledge to their fellow co-operative members. Further evaluation is required to assess the effectiveness of their influence on food behaviours and practices and on the nutritional status of the people.
Nutrition Directorate of Health and Family Welfare Services, Bangalore, India
Recognizing the interdisciplinary nature of nutritional problems, a national programme called the Integrated Child Development Services Scheme has been developed. Package services, including supplementary food, immunization, nutrition and health education, health and referral services, and non-formal education have been formulated and provided.
Currently, the existing primary health-care infrastructure at the block level is making use of nutrition communications. Paramedical workers and female health assistants/health workers play an important role, and are supervised and guided by district-level health officers. Face-toface communications by informal talks, for example among women, are most widely used. Radio, newspaper, and, to a limited extent, television have been utilized.
A unique effort is being made in Karnataka State, where systematic education activities have been developed. A unit was formed consisting of a nutrition officer, a health education expert, and a paramedical worker at the district level. The unit plans the education activities, with particular emphasis on supplementary foods for infants and proper diets during pregnancy and lactation. Training, teaching aids, and all communication activities were identified, and involvement of all health services and various agencies has been encouraged. Small research studies on several little-known communication systems were suggested.
It is recognized that changing food habits is a slow process and proper planning of systematic delivery of information is crucial. As India is a vast country, with different languages, cultural practices, and social values, the communication systems should be developed to suit individual communities.
A systematic, realistic programme of education is required and community involvement and participation must be encouraged. Well-trained personnel, proper supervision, guidance, and reliable documentation are all essential elements for successful nutrition education.
C. de Windt and T.M. Hill
UNICEF Jakarta Office, Jakarta, Indonesia
The Government of Indonesia, in co-operation with UNICEF, has developed and organized an extensive, multi-sectoral nutrition programme, entitled the Family Nutrition Improvement Programme (UPGK) in an attempt to alleviate malnutrition. The emphasis of UPGK is on local co-operation and community self-reliance. The slogan "A healthy child is a growing child" has been popularized. Monthly weighing is carried out and individual growth charts kept at home serve as nutrition surveillance tools. Village volunteers trained and supervised by local health officers play key roles in conducting various nutrition activities, including nutrition education. Government agencies are co-ordinated in the programme at all levels, from central to subdistrict.
UPGK's basic strategy is toward changing behaviour, with the ultimate objective that mothers will be aware of and improve their children's nutrition through better family feeding patterns and nutrition practices. To reach this objective, communication, information, and education efforts are carried out by all sectors involved in this pivotal approach. UNICEF provides technical expertise, scholars, and consultants, and organizes working meetings. All sectors involved are invited to participate from the early stages of the development of materials throughout the communication process.
In developing nutrition education and training materials, the same basic message and content units were included for the programme implementors and villagers. The specific guidelines for implementation are dependent upon the kinds of responsibilities of the field staff. This refers to vertical integrity. Moreover, to assure continuity and a unified interpretation, the same basic guidance is at the core of all training and promotional materials, and can be used cross-sectorally. The difference, for different sectors, is that the information is related to the field-worker's specific role and responsibilities. This is referred to as the horizontal integrity of a nutrition education approach.
To bridge the gap between training manuals and user materials, a "Handbook for Village Nutrition Volunteers" was developed for use by cadres. The presentation of the book in a comic-strip format with many drawings, step-by-step instructions, and simple questions and answers was readily accepted. Field testing confirmed that the book meets the need for "handson" material, reference and continual guidance, and orientation of cadres. It is at present widely used in both government and NGO project areas. The book has become a source for standard content and has been used for further development of training and education materials.
This is an effort at using adult education methods to develop a variety of nutrition education tools, materials, and games that keep reinforcing the basic set of messages. A joint communication strategy for systematic evolution of additional user materials has still to be designed.
Korea Institute for Population and Health, Seoul, Republic of Korea
Fifty-seven per cent of the Korean population lived in urban areas in 1980. A consequence of this is the emergence of urban slum squatters who are unskilled and socio-economically underprivileged, and who often receive inadequate health care.
The Korean Institute for Population and Health has been entrusted by the government to carry out a demonstration project for urban primary health care (1982-1986). The project began in Seoul and will be replicated throughout the major cities if it proves effective.
The nutrition service component of the project, provided by the newly developed community health practitioners, includes nutrition consultation, education, demonstration, and weight/height measurements.
To cite an example, one of several slide packages consists of 41 slides containing messages on (a) balanced diet - meaning, significance, and how to plan; (b) proper cooking methods; and (c) food practices and beliefs of pregnant women and how mothers should feed infants and preschool children. Various signs and symptoms of deficiency diseases are presented and food items to remedy these deficiencies are promoted. Proper infant-feeding practices, such as breast-feeding, supplementary foods, and improved maternal diets during pregnancy, are encouraged.
Department of Health, Seremban, Negeri Sambilan, Malaysia
The primary health-care approach in Malaysia is an integral part of the government community development movement, or Gerakan Pembaharuan (Operation Renewal), launched in 1972. Nutrition communication activities form a major component of the existing basic health services. The activities are channelled through various health and nutrition services.
Group talks, cooking demonstrations with group discussions, individual advice in clinics, and home visits are provided through maternal and child health services. The health education unit is responsible for producing educational materials such as posters and leaflets at both national and state levels. Health education mobile units, fully equipped with audio-visual aids, provide films and slide shows, arrange talks and dialogue sessions, and distribute leaflets. A mass media programme using radio and television was introduced in July 1983 as a joint effort of the ministries of Health and Information. The messages include a wide range of health and nutrition information. Health education materials are used extensively and local radio broadcasts will be utilized to overcome dialect problems.
The applied nutrition programme started in 1969 uses an intersectoral approach towards PHC. Four main ministries are involved, namely, Health, Agriculture and Rural Development, Education, and Information. Health and nutrition education is one of the main tasks. Nutrition surveillance is also used as a channel for nutrition communications. In addition, both formal education, such as that provided in nursing schools, and in-service training for health personnel are being conducted by various training schools.
The present trend of the health service is shifting from a clinic-based to a community-based approach, in which health staff work closely with community leaders. Attempts to encourage more active community participation in health activities are being made through committee meetings on development at the village and district levels.
Tirtha Rana and Nanda M. Sthapit
Health Education Section, Kathmandu, Nepal
Malnutrition is particularly prevalent in the age group from 6 to 36 months in Nepal. Lack of knowledge on how to use available foods, very low literacy and a high workload among women, the maintenance of food taboos, and destructive cultural practices lead to poor weaning and young-child-feeding practices.
A nutrition education programme is being conducted through various peripheral level workers. Emphasis is given to promoting breast-feeding, making weaning foods from locally available and family foods, proper feeding of sick babies, use of oral rehydration for children with diarrhoea, provision of growth charts for monitoring child development, immunization, improvement of personal and environmental hygiene, and teaching what foods are best for pregnant and lactating women.
The media used by these health workers are flash cards, posters, flip charts, and brochures. Various training manuals have been developed for different levels of workers. Growth is monitored by arm-circumference measurement. Food demonstrations and home-visit demonstrations on the preparation of oral rehydration fluid and weaning foods have been conducted. Radio spots, programmes, and film shows, as well as training workshops, have been developed by health and nutrition offices. The Ministry of Agriculture is involved in the local development of food provisions, preparation, processing, and preservation, while the Ministry of Education provides health and nutrition education through the formal education system up to the graduate and postgraduate level. Non-governmental agencies, both national and international, have been actively engaged in strengthening nutrition training and communications.
Areas for future research have been suggested, including evaluation of the ongoing communications programmes, development of simple training materials for large-scale use, strengthening of the communication links at the peripheral levels, and production of appropriate audio-visual aids to support nutrition activities.
M. Ramzan Azhar
UNICEF Islamabad Office, Islamabad, Pakistan
A nationwide nutrition programme, assisted by the World Food Programme, was begun in 1982. Lady health visitors were trained to play a key role in the project through nutrition education and integrated health services. The existing food habits, beliefs, and taboos were surveyed, and these studies revealed that urgent changes are required in child care.
Twenty-four basic messages were identified and used to form the basis of all training and extension materials. Message designs provided different levels of sophistication to suit the target audience: lady health visitors (LHVs) and other health workers, such as traditional birth attendants (TBAs) or child health workers (CHWs), or relatively illiterate mothers. All materials were carefully designed and extensively tested for use as tools to support nutrition education by the peripheral workers.
Posters were developed to illustrate the nutritional needs of pregnant mothers, and to promote breast-feeding, proper child feeding and care, and child growth. Another poster was used to describe food distribution and available integrated health services.
Flip charts giving information on primary health care were developed and are used by TBAs and CHWs after they are trained by LHVs. Another flip chart on breast-feeding was produced to support the LHVs' teaching of mothers, and yet another gives weaning-food recipes to serve as LHV teaching aids. The LHV has a book version as her reference source, while mothers are given recipe charts. Cooking demonstrations have been provided at selected centres. On-the-spot feeding of mothers and preschool children has also been introduced. Growth charts are used as a monitoring tool, on a nationwide scale. Two hundred and fifty food demonstration centres and 20 on-the-spot feeding centres have been established. Weaning food is distributed by LHVs at these centres as well as by other health services, and nutrition education is being imparted by the LHVs.
Currently, 500 fully trained paramedics and LHVs are the frontline workers who provide nutrition education. Teaching and training aids are widely available to primary health-care workers, and the available health facilities have been increasingly utilized. Awareness of the importance of nutrition is gradually being recognized by urban slum dwellers. A total of 360,000 mothers and children are directly benefiting from these projects. An in-depth evaluation is to be carried out soon to assess the impact of the programme on the target population.
Chuan Jia Lin
Beijing Children's Hospital, Beijing, China
After Liberation in 1949, the People's Government formulated a policy according to which maternal and child health-care administrative organizations were set up at all levels above the county level. A basic network for child health care was established, consisting of the Bureau of Maternal and Child Health, district MCH and child health care institutes, and county MCH centres. At the grass-roots level, there is a child health unit in every hospital, clinic, or commune hospital in rural areas, and this is responsible for taking care of 0- to 7-year-old children.
The bureau personnel provide training and supervision as well as supportive materials to district- and country-level professionals. These professionals then train and supervise professionals and paraprofessionals working at the grass-roots level, where the tasks in child health care include dissemination of health and nutrition information, birth registration, morbidity and mortality records, preventive health care including surveillance of deficiency diseases - and immunization and treatment of common diseases.
It is realized that the development of a child health-care service is inseparable from political, economic, and cultural development. Progress is noteworthy in Beijing; however, in other areas many problems still exist and require further efforts to resolve them.
Department of Information, Colombo, Sri Lanka
Sri Lanka is, for the most part, rural. Agriculture is the predominant occupation, and per capita income is relatively low. Although the country has one of the highest literacy and lifeexpectancy rates in the developing world, malnutrition is still prevalent. The improvement of the nutritional status of the population has been made a national policy, with a holistic approach aimed at balancing food needs and supplies. Effective communication is regarded as a necessity for bringing about the integration and coordination of relevant sectors and agencies.
Efforts are being made by the Food and Nutrition Policy Planning Division (FNPPD) and the Ministry of Information and Broadcasting to use the state mass media (newspaper, television, and radio) to promote special nutrition messages. A four-week training course for district-level planners and administrators is being organized. Special sets of training materials will be produced to assist them to plan a nutrition programme on a multi-sectoral basis and to promote community involvement. Monitoring, control, and evaluation will be integral parts of all programmes and will be handled by FNPPD through a steering committee. Effectiveness and the impact on the attitudes and practices of target groups will be assessed.
THE ASIAN REGIONAL WORKSHOP ON EFFECTIVE COMMUNICATION FOR NUTRITION IN PRIMARY HEALTH CARE
Education and information for behaviour change are being increasingly recognized as key interventions in the improvement of health and nutrition. However, functional illiteracy, the lack of infrastructure, and expensive technology often mean that efforts in health and nutrition communication at the community level are minimal, difficult, and disappointing.
Many Asian countries have adopted primary health care (PHC) as the fundamental philosophy in their health-care systems, making effective communication crucial. It was for the purpose of evaluating, expediting, and expanding the progress made by various countries that the Asian Regional Workshop on Effective Communications for Nutrition in Primary Health Care was held from 3 to 7 October 1983.
The five-day workshop featured eight papers on various aspects of communication, ranging from a broader view of planning to more specific details regarding media production, methodology, and application. Three case studies from Thailand, Indonesia, and the Philippines gave insights into ongoing projects in nutrition communications. Six country reports and three individual reports described the efforts of various countries and institutions in Asia that are working with communications for nutrition education.
Special interest groups discussed planning, development evaluation, and growth charts. Pertinent points were raised in regard to each activity, providing a chance for the exchange of ideas between resource persons and participants.
The small group discussions covered the following four topics:
Problems, constraints, and possible or potential solutions were discussed, and the recommendations for each of these topics were as follows:
Integration of Communications in PHC
Human Resources and Training Needs
- 300-400 million parents;
- 30-40 million village workers; and
- 20-30 million subdistrict- to provincial-level workers.
Nutrition Information Network Needs
Food Composition Data: A User's Perspective
Edited by William Ml Rand, Carol T. Windham, Bonita W. Wyse, and Vernon R. Young
Knowledge of what is in the foods that are eaten around the world is of critical importance and at the same time extremely inadequate. Data on food composition underpin research and policy in a number of important areas of public health, dietetics, nutrition, and epidemiology; they are critical for key decisions of bilateral and international assistance agencies and play a major role in all phases of the food production and manufacturing industry, both locally and on a global scale. These needs stand in stark contrast to the availability and adequacy of food composition data. In this volume prominent workers in the field present their views and experiences concerning the importance of food composition data and its current problems end what must be done to improve the situation. It provides an essential introduction and survey of the field for anyone interested in or expecting to be involved with the gathering, compilation, or use of food composition data. It will also be a useful reference for university courses on food and nutrition.
WHTR-10/UNUP-633 ISBN 92-808-0633-5
240 pages, 16.4 x 23.9 cm, paper-bound, US$20
Methods for the Evaluation of the Impact of Food and Nutrition Programmes
Edited by David E Sahn, Richard Lockwood and Nevin S. Scrimshaw
This state-of-the-art discussion of methods for evaluating food and nutrition programmes focuses primarily on determining specific nutritional impact, even in circumstances where adequate baseline data are not available. It recognizes also that food and nutrition programmes can have beneficial effects going beyond traditional health impacts and gives specific attention to social, economic, behavioural, and political consequences that may accompany a feeding programme.
WHTR 6/UNUP-473 ISBN 92-808-0473-1
291 pages, 16.5 x 23.6 cm, paper-bound, US$25
2nd printing (1988)
Research Methods In Nutritional Anthropology
Edited by Gretel Pelto
A comprehensive manual of anthropological methodologies applicable to field studies in nutrition, this volume describes strategies of field research in nutritional anthropology, determinants and cultural components of food intake, methods for collecting and analysing data on energy expenditures, and statistical methods for nutritional anthropology.
WHTR-9/UNUP-632 ISBN 92-808-4632-7
In press, 16.4 x 23.9 cm, paper-bound, US$20