Mercedes Solon, Emelita de Leon, Miguel Lopez, and Eireen
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Nutrition Center of the Philippines, Manila, Philippines
Jean Andersen
Development Communications Consultants,
Inc., Oyster Bay, New York, USA
INTRODUCTION
The Philippine Government has a policy to improve the nutritional status of
its people (1) and has committed scarce financial resources to develop a
national nutrition plan and programme. The Government has recognized that
malnutrition is an impediment to human resource development and hopes that
making nutrition a priority will ensure that future generations of school
children and skilled labourers will have the opportunity to reach both their
physical and 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 the National Nutrition Council (NNC) was created by a
presidential decree and given responsibility for formulating a national
programme for nutrition, called the Philippine Nutrition Program (PNP), and for
coordinating ail related activities. At the same time, the Nutrition Center of
the Philippines (NCP) was founded with a mandate to harness the resources of the
private sector to support the Philippine Nutrition Program.
The Philippine Nutrition Programme
The PNP intervenes in four major areas (2):
1. Nutrition information and education: The priority targets for this
intervention are the mothers of malnourished preschool children 12 to 66 months
of age. The goal is to increase the mothers' knowledge and improve their feeding
practices for their children.
2. Health protection: Health protection services are both curative and
preventive. Curative measures include medical services to moderately and
severely undernourished preschoolers susceptible to infection.
"Mal-wards" are set up in hospitals, and in remote areas
"Nutri-huts" are built. Immunization, deworming services, and
sanitation campaigns are among the preventive measures.
3. Food assistance: As an emergency measure to improve the nutritional status
of moderately undernourished preschoolers, supplementary feeding programmes are
undertaken. The use of locally available food commodities is encouraged and
promoted.
4. Food production: The primary goal of this intervention is to promote
backyard and school gardens for the purpose of increasing household consumption
of more highly nutritious foods.
A village-level nutrition worker, called the "barangay nutrition
scholar," is the grass-roots link between the families of malnourished
children and the implementation 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 barangay nutrition
scholar for each of the 42,000 barangays (villages) 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 PNP (3).
THE NUTRI-BUS PROJECT: BACKGROUND
The Pilot Study
Early in 1976 the NCP decided to test the relative effectiveness of different
communications media in bring about behavioural changes in mothers with regard
to feeding their children. The behaviour selected for measurement in the pilot
study was the purchase of a nutritious product to add to the child's diet.
"Nutri-Pak," a product then under development at the NCP, was
selected to serve as:
- a nutritious supplementary food, supplying 50 per
cent of the daily protein requirement and 30 per cent of the daily calorie
requirement for a child 12 to 36 months old (4),
- a communications
medium,
- a measurement of behavioural change, through the monitoring of
its sales.
Nutri-Pak contains cracked rice, ground mung beans, coconut oil, and powdered
milk. Each ingredient is packed in its own small, clear plastic bag, and these
are then packaged together to make one Nutri-Pak. The product serves as a
communications medium because it is packaged to show the user the correct types
of locally available foods needed for preschoolers and the relative amounts of
these foods required. 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 in
which to conduct the pilot project. Thirty villages were chosen at random for
the project from among all the rural villages in Leyte that met certain criteria
known to affect health and nutrition status and to control for cross
contamination of treatment groups. These villages, in turn, were assigned on a
stratified random basis to each of six experimental conditions.
Barangay nutrition scholars (BNS's) were recruited and trained for the sample
villages to be "change agents" and to sell Nutri-Pak at a subsidized
price. All BNS's recruited were trained by the Regional Health Training Center
of the Ministry of Health in basic nutrition and by the NCP in product
knowledge. Half of the BNS's then returned to their villages to promote better
nutrition in general and to promote and sell Nutri-Pak. The other half were
given an extra day of training in simple communications skills to help them
persuade mothers to change their child-feeding practices and to promote and sell
Nutri-Pack. After the BNS's had returned to their villages,
- one-third
received no further support except deliveries of Nutri-Pak to distribute;
- 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 Nutri-Pak;
- one-third were supported by a video van that visited the village once
a week for 10 weeks to show four specially designed television programmes on
nutrition and to deliver Nutri-Pak.
Special comic books and video tapes were developed for the project by the
NCP, using a rigorous process designed to produce communications to bring about
behavioural change (see fig. 1). The television tapes actively involved the
viewers in the learning process by posing specially developed questions at
carefully designed intervals throughout the tape (see table 1). The person who
administered the showings paused the tapes at each question and encouraged
answers and discussion from the viewers. The tapes and questions were designed
so that the viewers would be challenged but capable of answering correctly in
almost every case. When the tape was started again, it provided feedback and
reinforcement for the answers.
The story-line and nutrition content of the comics and video tapes were the
same. Both were pre-tested with mothers representative of the target population
but not residing in the sample villages and were revised after results were
assessed.
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
preschool 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, this 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. Sales amounting to 5 per cent
or more of the total "ideal market" were to be considered a success.
The objectives of the pilot project were:
- to determine the most
effective communications medium to change mothers' behaviour in feeding their
malnourished children
- as measured by Nutri-Pak sales;
- to
determine a communications medium which could bring about sales of Nutri-Pak
equal to or greater than the minimum criterion of 5 per cent of the total
"ideal market."
The result of the study was to demonstrate that
- sales of Nutri-Pak
were nearly three times greater in the villages visited by the video van where
the BNS had been given one day of communications training than under other
conditions;
- that was the only situation in which sales reached or
exceeded the criterion of 5 per cent of the "ideal market."
Expansion of the Project
On the basis of the results of the pilot project and a continuing interest in
using video vans for nutrition education, the NCP decided to expand the project
to three buses in Leyte. However, the attractiveness of the concept and the
video-van tapes caught the attention of other donors, and soon the Nutrition
Center had over 30 fully equipped "Nutri-buses." This provided an
early opportunity to implement the programme 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 in
service in Leyte and Samar. They carried the videotaped shows and other services
(Nutri-Pak re-supply, print support materials, supervision for the BNS's) to the
villages twice a month.
EVALUATION OF THE NUTRI-BUS PROJECT
In order to monitor the project, data were to be collected every two years to
measure knowledge and attitude change and impact on nutritional status of the
programme. The hypothesis to be tested was the "null hypothesis": that
the project would have no significant impact on the variables being measured.
1979 Sample Selection
All villages accessible by road in areas of Leyte and Western Samar where the
Waray-Waray dialect is spoken were divided into four groups representing
different degrees of intervention:
- those with a BNS present in which
Nutri-bus services were started between August and October 1978, providing a
longer exposure to video-tape recordings- designated "VTRL";
- those with a BNS present in which Nutri-bus services were started between
November 1978 and January 1979, providing a shorter exposure to video-tape
recordings-designated "VTRS";
- those with a BNS present that
had been selected to receive Nutri-bus services but had not yet been reached by
the Nutri-buses-designated "BNS";
- those with no BNS and no
Nutri-bus services (these villages did not meet the socio-economic criteria and
did not have BNS's because they were slightly better off)-used in the study for
comparison purposes.
Sample villages were selected from each of the four groups on the basis of
criteria meant to control for the factors known to influence nutritional status
and nutrition knowledge, as follows: VTRL group, eight villages; VTRS group, six
villages; BNS group, five villages; comparison group, five villages.
FIG. 1. The "ABC Model" for
Developing Communication to Change Behaviour ((c) Development Communications
Consultants, Inc., 1983)
Since the village populations were relatively small, it was decided that it
would be more accurate and less costly to weigh all preschool children and
interview all mothers of preschool children rather than sample within villages.
However, since 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 this goal.
TABLE 1. Interactive Learning and Motivation Strategies for Communication
to Change Behaviour
| Strategy | Definition |
| 1. Discovery/logical conclusion | Learner is exposed to certain information and then asked
to make a decision logically following from that information |
| 2. Analogy/logical conclusion | The audience is reminded of something familiar that works on the
same principles as the idea being taught and is then asked to draw conclusions
from the new information based on the analogy |
| 3.
Specification | Learner is given general principle and asked
to apply it by giving specific examples |
| 4.
Generalization | Learner is given specific examples and
asked to conclude the general rule |
| 5.
Observation 1-Description | Audience looks at certain
conditions and reports what was seen |
| 6. Observation 2-Comparison | Audience looks at two or more sets of conditions and reports
differences and/or similarities |
| 7.
Observation 3-Modelling of desired behaviour | Audience is asked to observe behaviour to be learned and to describe
this correct behaviour or some of its elements |
| 8. Prompting | Audience is helped towards the
correct answer through clues |
| 9.
Fading | Previously elicited and reinforced
behaviour is asked for again, with less supporting information and fewer
prompts |
| 10. Personal opinion, preference,
feeling, experience, or data | Audience is asked to give
opinions or preferences, tell some personal feelings or experience, or give data
about themselves or their children (name, age, 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 |
| | (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 as a |
| | Motivation to learn what is in the
module |
| 12. Performance of entering behaviour
| Audience is asked to do or say something they already know
how to do or say. This is used only if: |
| | (a) the entering behaviour is weak and
needs to be reinforced |
| | (b) the entering behaviour is part of a logical sequence of
interactions leading to a strong type of interaction |
Source: Development Communications Consultants, Inc., 1983
The data-gatherers, working together with village leaders, did their best to
reach all families with preschool children. To establish a reliable estimate of
the number of preschoolers in each village, the village leaders' best estimate
was compared with an estimate arrived at by multiplying the 1975 census figure
for the village population by 20 per cent (the approximate proportion of
preschoolers in the population) and then multiplying that by the national rate
of population growth for four years. Villages where there was no major
discrepancy between the two estimates and where the data-gatherers were able to
reach 80 per cent of the number of preschoolers estimated by the calculation
from the census figure were retained in the sample; villages where there was a
large discrepancy between the estimates or where fewer than 80 per cent of the
estimated number of preschoolers were reached were discarded from the analysis.
1979 Data Collection
Data were collected by four teams working simultaneously in four villages at
a time. The interviewers were recruited in Leyte, and all spoke the Waray-Waray
dialect but were not known personally in any of the villages. They were
registered nurses and schoolteachers. Those doing measurements 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 began.
Team members and measuring instruments were rotated so that each contributed
an approximately equal number of measurements to each experimental group. The
rotation also attempted to equalize the pairing of individual team members to
minimize pairs developing somewhat different procedures.
The measurements and interviews took place in a central location (usually the
church) in each village. Mothers registered at a check-in point and waited
outside to be called by the measurer. After the children were measured, their
mothers were interviewed.
To try to prevent contamination of the interviewing results, each interview
area was roped off with cords and stanchions to prevent the mothers from hearing
each other's answers. When the interview was completed, the mothers were
directed out of the chapel away from the waiting mothers and encouraged to go
home to avoid conversation with the waiting mothers.
Two potential sources of error in weighing are squirming, flailing children
and scales not calibrated to zero. Nearly all squirming and flailing was
eliminated by weighing the children in the arms of a "surrogate
mother" and later subtracting her weight (i.e., weight of mother and child
less weight of mother = weight of child). Also, zero calibration of the scales
became less critical when the child's weight was determined by this difference
method rather than by taking the absolute weight.
Another potential source of error in determining weight for age is the
accuracy of the birth date. It was found that most mothers had either a birth
certificate or a baptismal certificate (or both) for their children and that
church records could be used to get accurate birth dates for most of the
children whose mothers had lost their documents. It was thus possible to
document birth dates for 88 per cent of the children. Children for whom
documentation of birth dates was not available were excluded from the analysis.
Families who had lived in the village less than six months were also eliminated
from the analysis.
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