|Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 pages)|
|Module Six: Community health education|
|Session 18 - adapting and pretesting health education materials on ORT for controlling diarrheal diseases|
The Academy for Educational Development is a nonprofit service organization active in many areas of education. Under contract to the Offices of Health and Education, Science and Technology Bureau (ST/H, ST/ED), United States Agency for International Development, the Academy is assisting the Ministries of Health in Honduras and The Gambia to develop comprehensive public education campaigns on prevention and treatment of infant diarrhea. The campaigns combine broadcast radio, simple print material, and health worker instruction in an effort to provide practical information to rural women.
Following its developmental investigation of diarrhea-related beliefs and practices among rural Gambian mothers, the Mass Media for Infant Health Project identified a core set of messages to address to this primary audience during the first year (1982) or the project's educational campaign.
Organized around the concept of a "special diet for diarrhea," the campaign promoted a threefold response to a bout of diarrhea: (1) preventive oral rehydrations using a home-mixed sugar-salt solution; (2) continuation of breast-feeding; and (3) feeding of solid foods both during and after the bout and extra food once the bout has subsided. This latter feeding message was designed to address the nutritional problem of wasting that occurs among Gambian children-the most worrisome aspect of the chronic diarrhea they suffer during the rainy season and to counter the practice common among Gambian women of reverting from solid foods to watery gruels of little nutritional value in feeding their sick children.
Such nutrition advice is widely recognized as an integral part of the treatment of diarrhea. WHO's Programme for the Control of Diarrhoeal Diseases, for example, states the following:
"In the management of acute diarrhoea it is essential to repair whatever nutritional deficit arises and to maintain nutrition during the diarrhoea illness. This deficit results from reduced food intake due to anorexia and withholding of food, and from nutrient loss due to vomiting and mal-absorption. There is no physiological basis for "resting" the bowel during or following acute diarrhoea. In fact, fasting has been shown to reduce further the ability of the small intestine to absorb a variety of nutrients. Even during acute diarrhoea, 60% of the normal absorption of nutrients occurs. This is particularly true for fats and oils, which can provide a large amount of energy for the quantity eaten. Greater weight gain her been documented in infants given a liberal dietary intake during diarrhoea when compared with others on e more restricted intake."
(A Manual for the Treatment of Acute Diarrhoea, WHO/CDD/SER/8O.2, p.11)
In early 1983, the Mass Media Projects implementation team conducted a formative evaluation for the purpose of assessing the progress of its campaign to date and to guide the development of second-year messages. At about the same time, Stanford University, which is conducting a separate but concurrent impact evaluation of the project, produced its initial set of data on the learning and adoption among Gambian mothers of the campaign's key messages.
Both evaluations indicated the same pattern of response to the "diet for diarrhea" messages: while as many as half of the Gambia's rural women appeared to have learned the campaign's formula for mixing sugar-salt solution and begun using it, fewer than a third had adopted the "give solid foods" message. To cite the Stanford data:
"64% of the women interviewed in December 1982 knew the entire sugar-salt solution formula correctly.... The proportion giving sugar-salt solution has risen 450% during the course of the campaign (from 20.6% to 89.3% of those mothers who treat their child themselves).... The use of solids, starting at a very low level (13.6%) has more than doubled (to 29.5%), but 70% of these women still do not offer solids to their children during diarrhoea."
(Mass Media Project Evaluation Unit, Quarterly Report #6, February 28, 1983)
INTERPRETATION OF RESULTS
Several explanations for this discrepancy were considered, including the obvious possibility that the ORT messages had been better been given because they had received much greater exposure during the first year. Indeed, the peak of the campaign's first-year activity was a highly publicized national educational lottery over Radio Gambia in which 150,000 handbills illustrating the sugar-salt solution formula were distributed and prizes were awarded on the basis of knowledge of the formula and how to administer it.
Another plausible interpretation was that the solid foods message was too crudely formulated. "Give solid foods during diarrhea" was very possibly contraindicated in the minds of many mothers by the anorexia children often suffer during diarrhea: a sick child may be reluctant to take any kind of food, let alone solid foods. The message also obviously did not apply to an unweaned child.
Project staff thus decided to reformulate the campaign feeding messages and to make feeding the primary focus of the 1983 rainy season phase of the campaign, just as oral rehydration had been the first year.
REVISED FEEDING MESSAGES
The list of revised feeding messages is as follows:
· Continue breast-feeding
· Give sugar-salt solution to prevent dehydration and to restore appetite. Remember the 3/8/1 formula. (3 Julpearl bottles of water, 8 Julpearl cape of sugar, and 1 cap of salt.)
· Try to give the child small, frequent feeds even if he has little appetite.
· Add some sugar or milk to the child's pap at the time of feeding to increase its palatability.
· Once the child's appetite has returned, give solid foods like nyankatango (mbahal), nyelengo (nyeleng) futo (chere), and mani fajiringo (malo bunye bahal) to restore weight and power.
· Oil, sugar, milk, and pounded groundouts add extra power to foods. Add some of these to the child's food to increase its power.
· Give an extra meal to the child for at least two days after the diarrhea has ended, and keep giving extra food until his weight and power are fully restored.
CHANGES IN EMPHASIS
These revised messages reflect the following changes in emphasis from the project's first-year messages:
1) We are differentiating between feeding 8 child during diarrhea and feeding after diarrhea, and now promote solid foods during the latter phase.
Rather than telling mothers to give solid foods to their child at a time when he or she may have little or no appetite, we are now acknowledging the difficulty a mother may have in feeding her sick child and giving several practical suggestions for encouraging the child to eat something. These include giving small, frequent feeds and adding sugar or milk to the pap, which the mother is most likely giving to improve its flavor and increase its energy value. Mothers are also encouraged to continue breast-feeding their sick child, which a very high majority of Gambian mothers already do.
Solid foods are then encouraged as an important and appropriate "catch-up diet" once the child is getting better and recovering his appetite.
2) Solid foods are promoted as a source of power (strength) and weight gain for a child.
A slogan was developed in the Mandinka and Wolof languages for use in both radio programs and graphic materials which says, "When your baby is recovering from diarrhea, give him solid foods to restore his power!" We are continuing to contrast powerful solid foods with weak watery paps. This message builds on our finding that JOBS of weight and strength are among those symptoms of diarrhoea most commonly identified and cited by Gambian mothers as a concern.
3) Full restoration of weight and power is also the guideline we are emphasizing for how long to give extra food to a child recovering from diarrhea.
We made this decision after failing to agree on a specific number of extra days or meals to recommend that would be neither too few as to be ineffectual or too many as to seem unrealistic in The Gambian context. WHO, for example, recommends an extra meal every day for at least a week but we felt this recommendation would be rejected as unrealistic by Gambian rural women who spend most of the day during the rainy season working in the fields away from their children, many of whom suffer diarrhea almost continuously at this time of year. We also felt confident, as stated earlier, that most Gambian mothers are very sensitive to their child's weight gain and loss, perhaps because a high percentage of them regularly attend an MCH clinic where their children's weights are charted on a Road-to-Health Card.
Our final decision was to advise mothers to give an extra meal to the child for at least 2 days after a bout of diarrhea and, more importantly, to continue giving extra solid foods until his weight and strength are fully restored.
4) We are recommending a number of specific local dishes which are particularly energy-rich.
These dishes include the following rice and millet dishes, for which, the Mandinka name is given first, followed by the Wolof (Descriptions of dishes and energy values are extracted from G.J. Hudson, P.M.V. John, and A.A. Paul, "Variation in the Composition of Gambian Foods: The Importance of Water in Relation to Energy and Protein Content," Ecology of Food and Nutrition, 1980, Vol. 10, W. 9-17.)
· mani-fajiringo/malo bunye bahal: dehusked rice is boiled sometimes after preliminary steaming, and then the water content is reduced by a final steaming Fajiringo is usually served with the groundnut sauce durango.
· futo/chere: finely powdered flour is steamed twice, almost to dryness. Futo is eaten with added water or a thin sauce, dajiwo often the water in which fish has been cooked.
· nyakatango/mbahal: fajiringo that has been cooked once is steamed with groundnuts, and often fish are cooked on top of it.
· nyelengo/nyeleng: dehusked, whole cereal is steamed. This food is usually served with a sauce made from groundnuts and leaves.
These dishes were recommend on the basis of their high energy content. All of them have a gross energy content in the range of 125-200 kcal/100g., expressed on a fresh weight basis, depending on which sauces or other ingredients are added to the dish. This compares very favorably to the rice or millet paps which mothers commonly feed their infants which are about 88% water and have energy contents in the range of 35-60 kcal/100g.
5) In addition to these recommendations of specific dishes, we also are promoting a number of food ingredients that will enrich the energy value of a child's food.
These ingredients include sugar, milk, oil, and groundnuts. In addition to being desirable ingredients in a catch up diet for a child who has been sick, promotion of these foods also represents an attempt to redress the imbalance in the nutrition education for most Gambian mothers have received in the past which has concentrated almost entirely on relatively expensive protein tools such as meat and eggs.
The advisability of adding a message or messages on food hygiene also was discussed at great length in the process of reformulating the feeding messages, especially because contaminated food is believed to he the greatest sourer of bacterial infection for Gambian infants and because some of our new feeding recommendations-e.g., adding sugar to pap - could conceivably exacerbate this problem by making an even better medium for bacterial growth.
There was general consensus that the best food hygiene message would be: "Cook your baby's food fresh each time he or she is fed." Field staff at the MRC research station in Keneba report that many Keneba mothers do indeed prepare their child's meal fresh each time. They admit, however, that this result has been obtained only after many years of MRC presence and educational activity in Keneba. Elsewhere in The Gambia, the common practice is still for a mother to prepare a batch of rice or millet pap for her baby in the morning and then store it in a bowl or thermos flask for use throughout the day. We concluded that it would be unrealistic to expect mothers to act on a "prepare fresh each time" message, especially during the rainy season when many women are in the fields all day long, and that other food hygiene messages needed more understanding of current local hygiene practices than we presently had.
In our current phase, then, we have restricted food hygiene messages to emphasizing in the case of adding sugar or milk to, pap, that this should be done at the time of feeding rather than when the pap is originally made, so as to deter further bacterial growth.
(From: "Mass Media and Health Practices Project Impementation Field Notes.")