(introduction...)

A. Valyasevi and G. Attig

Prof. Dr Aree Valyasevi is Dean of the Faculty of Medicine, Thammasat University, consultant to the Institute of Nutrition at Mahidol University (INMU) and President of the International Union of Nutritional Sciences (IUNS). George A. Attig is consultant to INMU, Thailand.

United Nations agencies and international organizations have firmly acknowledged that many nutrition problems can be overcome if effective communication is used not only to educate people, but also to change their behaviour patterns. The aim of nutrition communication is to use innovative techniques founded on behavioural change theories and experiences to encourage people to try, adopt and sustain new behaviours relating to food and nutrition.

Recently, nutrition communication has been highlighted at several international meetings. The Sixth International Conference of the International Nutrition Planners Forum (4 to 6 September 1991) stressed the need to synthesize and learn from the world’s wide-ranging nutrition communication experiences in order to identify transferable processes that could be implemented in different situations (Achterberg, 1991).¹

¹ A follow-up symposium was held at the 15th International Congress of Nutrition in Adelaide, Australia (26 September to 1 October 1993).

The Plan of Action for Nutrition adopted at the FAO/WHO International Conference on Nutrition in December 1992 specifically stated the need for “strengthening educational systems and social communication mechanisms to improve and implement nutritional knowledge, especially at the individual, family and community levels”. On a more operational level, a main objective of the Inter-Country Workshop on Nutrition Education for South and East Asian Countries,² held at the Institute of Nutrition, Mahidol University, Thailand, was the sharing of the experiences of developing nations that have undertaken successful nutrition communication programmes, to assist other developing nations in formulating projects.

² Editor’s note: This workshop is described in the article “Asian workshop on nutrition education: Sharing expertise” in this issue of Food, Nutrition and Agriculture.

These meetings found several commonalities and differences in the ways that nutrition communication programmes are being implemented today. First, developing nations have a wide array of nutritional problems, and some countries have a mixture depending on their stages of development. In China, the Philippines and Thailand, for example, different problems, such as under- and over-nutrition, persist within the same country. Even within countries, specific populations may exhibit both problems among different subgroups. For instance, within a city, slum residents and the wealthy have different nutrition problems. To direct nutrition communication interventions precisely at such specific target groups is thus a real challenge.

A broad spectrum of approaches are being used to improve nutritional status; the most prominent are dietary diversification, fortification and supplementation. An even greater variety of nutrition education and communication methods are used in efforts to change people’s behaviours. Therefore, today we see a plethora of approaches being tested in many different nations. But the question remains: are they having an equal impact, if any impact at all?

This commentary on the four most common strategies being used today is based on the experiences and reports given by ten South and East Asian countries at the FAO-sponsored Inter-Country Workshop on Nutrition Education. It represents an effort to step back and take an overall look at current practices in the hope of stimulating thought and constructive debate about the actual ways nutrition communication should be conducted.

NUTRITION COMMUNICATION STRATEGIES

The diverse ways in which nutrition communication is being used today in South and East Asian countries are illustrated in the accompanying figure. While these approaches appear to be separate, sometimes different ones are used within the same national context to address different nutritional problems. Alternatively, different approaches can be used within the same intervention programme. In Thailand, for example, government breast-feeding promotion programmes often use the information dissnation approach, while vitamin A interventions apply participatory communication.

Information dissemination

Countries using the “information dissemination” model (left column of the figure) usually (but not always) include the least developed and developing nations which have limited communication capabilities. This approach parallels the “knowledge dissemination” model presented by Achterberg (1993) at the intercountry nutrition education workshop. According to this model, if people receive the knowledge they need to change, then change will automatically follow. However, “knowledge” is here extended to “information” in general, since not all of what is transmitted can be considered knowledge, at least in terms of how the receiver interprets it. Nonetheless, this approach is centred on the belief that providing people with information is enough to get them to change their behaviours. The mechanisms for providing information range from posters to slick radio and television spots to non-participatory group counselling sessions where a “teacher” provides knowledge to target group members. Most of these efforts are founded on the KAB (knowledge, attitude, behaviour) or KAP (knowledge, attitude, practice) model which postulates that such mechanisms lead to improved knowledge, followed by changes in attitudes and behaviours or practices.

Major nutrition communication approaches in South and East Asia - Principales modes de communication en mati de nutrition en Asie du Sud et de l’Est - Principales planteamientos de comunicaciobre nutricin Asia meridional y oriental

Although this approach has been used for over 100 years, it has been shown to be ineffective (Achterberg, 1993). Despite the wishes of some international development agencies, it is still believed to be useful by many policy-makers and it is often a cornerstone of national government efforts in nutrition communication or health education. Consequently, this method continues to be used in many programmes with perhaps little or no effect. Little is known about the magnitude of resources being applied to this approach or its cost-effectiveness.

Educational communication

The first of three more common recent approaches, illustrated on the right in the figure, is a strict educational communication approach, often characterized by one of two strategies. First, a strictly mass media approach may be used to persuade people to adopt a new product, service and/or behaviour. This method is close to the information dissnation approach, but often goes beyond information dumping to apply a social advertising strategy to encourage people to try something new. However, people are not always told how to use the product properly, and countless experiences have shown that use of mass media alone is not effective in leading to behaviour change (Achterberg, 1993; Smitasiri, Attig and Dhanamitta, 1992; Smitasiri et al., 1993). The result is that little change occurs and resources are often wasted.

Nevertheless, this approach is particularly attractive to countries that are trying to develop nationwide mass-media programmes, since it is assumed to be a relatively effective way to tackle large-scale problems affecting many people. Yet their efforts can be effectively blocked by limited coverage, for instance where media programmes are restricted largely to urban areas and literate populations. The impact is prevented where programmes are developed for the general audience and do not consider socio-economic, class, linguistic or ethnic diversity.

At the other extreme, education can occur primarily through face-to-face instruction in non-formal health care clinics, such as village or district health stations. Some pamphlets, brochures or posters may be used, but the assumption is that a person can be convinced to adopt a new behaviour by using traditional teaching and educational approaches. This method was common in the 1950s and 1960s, and to some extent it did lead to behaviour change. However, its utility is limited in terms of coverage and magnitude because it is most effective on an individual rather than population level.

In some countries, such as China, both media and interpersonal education are being skillfully combined with some positive results (Wang, 1993), generally on a small scale in clinic and community settings.

The educational communication approach rests largely on a top-down model of communication where information is passed down the hierarchy from official or doctor to patient. For individuals this strategy can work, but it may be resisted when communities are not encouraged to participate in nutrition interventions (Achterberg, 1991, 1993; Smitasiri et al., 1993). In general, information dissnation and educational communication are characteristic strategies of government efforts, largely because they can be readily implemented through existing primary health care networks.

Participatory action

Among non-governmental organizations, the primary focus is on participatory action and empowering people to identify their problems, determine viable solutions and implement and evaluate interventions using their own resources. It is “premised on the practical reality that nutrition-oriented development projects cannot be sustained at the grassroots level if these are planned from the top, focused on individual components and isolated from a total development process” (Stuart, 1993). This strategy relies heavily on a participatory action research (PAR) framework and a bottom-up development approach. The participatory strategy is very effective on a small scale and has the potential to be so on a large scale as long as the momentum continues and people remain involved, as has happened, for example, in the Barangay Integrated Development Approach for Nutrition Improvement of the Rural Poor (BIDANI) in the Philippines.

Nutritional disorders, however, transcend communities, and many are rooted in matters of government concern (e.g. poverty alleviation, national economic goals). Therefore, a participatory action approach needs to be integrated within the government infrastructure to be sustainable. The BIDANI project shows that this integration is possible, but questions still exist about what type of process can bring it about, especially in cases where community members and the government are viewed, and view themselves, as having different development goals and expectations.

Participatory communication

Today, the communication component and the participatory action component are being joined into a combined top-down/bottom-up participatory communication process (Attig, 1993; Smitasiri, Attig and Dhanamitta, 1992; Smitasiri et al., 1993). Efforts in Thailand provide a good example of this strategy. Borrowing from approaches such as social marketing, planners have combined the traditional creative media and interpersonal education strategies of communications with the learning-by-doing programmes of concrete participatory action. While all facets are important, the degree to which a nutrition programme succeeds depends largely upon the ability to intertwine media and action programmes in such a manner that the former supports the latter and not vice versa. In this way, programmes can reach out to large audiences. For instance, in Thailand’s Social Marketing of Vitamin A-Rich Foods project, district-wide programmes may reach over 100 000 people while still having a great impact at individual, family and community levels.

Participatory communication has two very important characteristics. First, it focuses on people’s felt needs through the use of formative research which entails the collection of data and information to identify important factors that may affect a programme’s acceptance; these considerations are then incorporated into a communication programme’s design. The intent is not to confront people with their inappropriate beliefs or resource constraints, but to use these beliefs to build nutrition communication programmes (Attig, Yoddumnern-Attig and Kanungsukkasem, 1992).

The second important aspect of participatory communication is that it focuses primarily on changing the environment in which people see themselves. People are a product of their environment, and the latter must be conducive to change before people can be asked to change. Social mobilization is based upon creating a local need and demand for change by initially focusing on how people view their environment, rather than how they view themselves. Once again, this need and demand rests on formative research into the needs of the people themselves. Emphasis is placed on saying “What do you need?” instead of “What do you have?” or even worse “Look at what you are doing” or “Look at what you are not doing”. In the end, focusing on felt needs makes nutrition interventions more personal and acceptable to people since they can place a problem and its solution within their own cognitive system of understanding and way of life (Attig, Yoddumnern-Attig and Kanungsukkasem, 1992).

In this context, the term “people” does not mean vulnerable target groups only, but target audiences. The general public is not a uniform mass and should not be treated as such. Rather, it should be separated into specific groups according to their characteristics, needs, wants and predispositions. Media and interpersonal action programmes can then take these characteristics into account and become more effective behaviour-change mechanisms (Achterberg, 1993).

The participatory communication approach is not a panacea, and it may not be feasible for all situations. It requires a great deal of advocacy, management and planning skills on the part of implementers, and it may have limited utility in countries where there is the need to strengthen human resources. It also requires an intimate partnership and trust between the people and local government officials, for which a great amount of political finesse and building of rapport are necessary. In countries where the people and the government are distant or, worse yet, where they see each other as adversaries, participatory communication may not be sustainable until the environment changes and becomes more conducive to this approach. In this case, participatory action programmes may be a better short-term strategy.

FUTURE NEEDS

Nations are using different nutrition communication approaches, depending upon the resources and expertise available to them. Some have adopted new and innovative methods while others are using more outdated ones such as a purely information dissnation approach. Moreover, countries with lower technological and personnel capacities are using older models of nutrition education, while other developing nations are applying newer, more integrated communication approaches. The result is uneven achievement within and among nations in changing the nutritional situations of vulnerable target groups.

It is now important to start thinking about how to merge or at least systematize the various approaches in order to gain more even and equitable achievements in nutritional status. One mechanism might be a systematic cross-national analysis of which approaches and processes work and which do not work. Innumerable “model” projects exist and have been presented at international meetings. While such meetings are good fora for bringing successful programme experiences to light, they are not always good for reaching a consensus about the processes that work. Consequently, it is essential to focus more on identifying effective processes that can be transferred from one country to another or at least within the same country to address one or several nutritional problems.

Great strides have been made in the last five years. The aim should now be to identify which approaches are most effective, under which conditions and for which interventions, and then to develop, test and promote those that hold the greatest promise. Only in this way will it be possible to develop more reliable and cost-effective interventions to benefit the Asian people and those living in other world regions.

REFERENCES

Achterberg, C. 1991, Effective nutrition communication for behavior change, Report of the Sixth International Conference of the International Nutrition Planners Forum, Washington, DC, Nutrition Foundation, Human Nutrition Institute, International Life Sciences Institute.

Achterberg, C. 1993, Update on nutrition communication. In K. Tontisirin & G, Attig, eds, Report of the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, Salaya, Thailand, 22-26 February 1993. Unpublished report.

Attig, G. 1993. Participatory action for nutrition communication: social marketing vitamin A-rich foods in Thailand, In K. Tontisirin & G. Attig, eds, Report of the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, Salaya, Thailand, 22-26 February 1993, Unpublished report.

Attig, G., Yoddumnern-Attig, B. & Kanungsukkasem. 1992. Building nutrition education programs from a people’s perspective. In P. Winichagoon et al., eds, Integrating food and nutrition into development: Thailand’s experiences and future visions, Salaya, Thailand, Mahidol University Institute of Nutrition; Bangkok, UNICEF East Asia and Pacific Regional Office.

Smitasiri, S., Attig, G. & Dhanamitta, S. 1992, Participatory action for nutrition education: social marketing vitamin A-rich foods in Thailand. Ecol. Food Nutr., 28: 199-210.

Smitasiri, S., Attig, G., Valyasevi, A. & Tontisirin, K. 1993. Social marketing vitamin A-rich foods in Thailand: a model nutrition communication for behavior change process. Salaya, Thailand, Mahidol University Institute of Nutrition; Bangkok, UNICEF East Asia and Pacific Regional Office.

Stuart, T. 1993. Nutrition education in the Philippines: the BIDANI experience. In K, Tontisirin & G. Attig, eds. Report of the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, Salaya, Thailand, 22-26 February 1993. Unpublished report.

Wang, Q. 1993, The challenges of nutrition education in China. In K. Tontisirin & G. Attig, eds. Report of the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, Salaya, Thailand, 22-26 February 1993. Unpublished report.