Intervention In Child Nutrition

Jan Hoorweg, Rudio Niemeijer, Hoorweg

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780710302762
• eBook ISBN: 9781136147227
• Edition: 1
• Topic: Médecine
• Subtopic: Prestation de soins de santé

First published in 1989. The studies that form the basis for this monograph were carried out between 1976 and 1979. The African Studies Centre in Leiden has a standing interest in child nutrition and provided the funds and resources for what was ambitiously termed the 'Nutrition Intervention Research Project'.

Chapter 1

Introduction

The growing awareness of the nutritional problems in many developing countries, particularly on the African continent, has resulted in manifold nutrition interventions. Because of the substantial resources involved, either in the form of food aid, manpower, financial or other assistance, there is also a growing demand for evaluation of nutrition programmes on the part of both recipient and donor countries. For many years there was a tendency to relegate evaluation to a backseat position and evaluation of nutrition programmes was, in fact, something of a neglected art. Neglected because officers responsible for and charged with the daily management of nutrition programmes are mostly very practical people, aware of existing problems and equally aware of measures that need to be taken. Pressed by practical demands they often - understandably - feel that evaluation is too slow a process which, in the end, may not even produce conclusive results or concrete recommendations. The evaluation requirements, such as pre-testing of measuring instruments, pilot surveys, delineation of study conditions and selection of index and possible control children are elaborate and time-consuming. This is not to argue that evaluators are overly cautious in their approach. They, in their turn, are confronted with many different cultural settings and with programmes that often have unclear objectives, lack basic information, do not keep adequate records and are difficult to distinguish from other influences on child nutrition. Yet, they still have to come up with useful suggestions and are generally expected to make the best of a very difficult job. Over the past ten years, however, the need for evaluation has increasingly been recognized. Programme officials no longer ignore evaluation, rather they have the task of balancing the need for evaluation against the resources that can be set aside for evaluation purposes and the degree of interference with day-to-day activities that is acceptable. These are often difficult decisions and the quality of the evaluation is directly dependent on them.

Assessing the impact of nutrition intervention programmes is notoriously complicated because of the difficulty of distinguishing between the impact of the actual programmes and the influence of other factors. This is further complicated because many evaluations do not or cannot take the cultural characteristics of different groups of recipients into account. Consequently, impact studies are often inconclusive because of methodological weaknesses or because of lack of sensitivity, in which case possible effects may escape notice. In their efforts to gain control over external factors, many researchers call for more and more elaborate research designs, thus making the effort increasingly expensive. Such elaborate designs sometimes make matters even worse, because the demands of the design may alter the nature of the programme and, thereby, invalidate the evaluation at the same time. Other researchers, in response to the same problem, draw the opposite conclusion and advocate a relaxation of statistical rigour and more modest evaluation objectives. In fact, the topic has become something of an independent area of research by itself; witness several recent bibliographies and handbooks (Burgess, 1982; Figa-Talamanca, 1985; Klein et al., 1979; Sahn et al., 1984; Schurch, 1983).

In general there is a dilemma between sophisticated experimental research and post-facto evaluations that are more restricted in nature. In the first case, every effort is made to eliminate all possible distorting factors, and this usually requires that the evaluation be designed and included from the very beginning of the programme, often at great cost and effort. Such evaluation is usually justified as a one-time activity that can provide essential knowledge on the actual, but more often the potential achievements of a particular intervention. Alternatively there are post-facto evaluations, with a more down-to-earth approach, of programmes that have already been in operation for years. This kind of evaluation does not strive after experimental perfection, but aims to provide insights into certain programme effects, or into selected aspects of a programme. Usually this type of evaluation is less obtrusive in nature, and may therefore better reflect the achievements of a programme under actual field conditions.

The studies in this monograph follow this latter approach. Together they demonstrate a methodology of programme evaluation which is relatively simple and adapted to the conditions presented by many nutrition programmes in developing countries. Although the emphasis is on the use of comparatively simple designs, a satisfactory degree of sensitivity was realized through careful selection of index and control groups, and collecting data of a straightforward nature, with particular attention to accurate data collection.¹

Initial studies that were carried out in Uganda were mainly of the nature of methodological trials, although there too attention focused on programmes under different conditions, notably the difference between a rural and urban environment. The results of these studies have been published in an earlier monograph (Hoorweg & McDowell, 1979).

Further studies were undertaken in Kenya between 1976 and 1979, under the title of Nutrition Intervention Research Project (NIRP). Like many African countries, Kenya covers a wide variety of ecological conditions, ranging from desert to fertile highlands, with all kinds of variations in between. Kenya's population at the time of the latest census in 1979 was 15.3 million, and it was expected to pass 20 million by 1985 (CBS, 1981b; 1983a). Three quarters of the landsurface of the country is considered unsuitable for agriculture with the consequence that the large majority of the population lives in that quarter of the country that is suitable for rainfed agriculture. There are three regions with major population concentrations: the central, western and coastal parts of the country. Kenya is one of the few countries which, in contrast to most African countries, cannot easily accommodate a much larger population (ICIHI, 1985). The country, however, has one of the highest rates of population growth in the world, estimated at 4% annually (World Bank, 1986), and pressure on land is becoming a problem in many places.

At the time when the present studies were initiated (early 1976), there was little information on the nutritional status of children in Kenya. A number of incidental studies, though, were available and these had been brought together in a review by Blankhart (1974a).² Since then the Central Bureau of Statistics has held three national nutrition surveys among the rural population (CBS, 1977; 1979a; 1983b). The percentage of children with a low weight-forage (below 80) was 33%, 25% and 23% in 1977, 1978 and 1983 respectively, although the figures are not strictly comparable because of differences in sample compositions.³ The percentage of stunted children, with an H-A below 90, ranged from 24% to 29% ; the percentage of severely wasted children (W-H below 80) varied between 3% and 5%. These rates of malnutrition and undernutrition are moderate compared with the figures reported for Asian and Sahel countries (Brink et al., 1978; Kardjati et al., 1977; IDRC, 1981), but they are comparable with the rates reported for other Sub-Saharan countries such as Cameroon, Liberia and Sierra Leone (USAID, 1976; 1978a; 1978b).

The national figures, though, hide important variations within the population. There are differences in the rate of undernutrition in the various provinces of the country and differences have also been reported to exist between populations living in different ecological zones. Moreover, there are important differences in nutrition and nutritional status between children from different income groups and certain underprivileged groups exhibit high incidences of malnutrition.

At the time there were - and there still are today - a large number of nutrition programmes in Kenya. Many of these programmes consisted of incidental activities of agencies and even individuals, as such severely restricted in scope and coverage, and often temporary. There were only three programmes, apart from the national School Feeding Programme, which had a nationwide coverage and centralized organization (PBFL/FAO, 1973): the Nutrition Field Worker Programme of the Ministry of Health, the Pre-School Health Programme of Catholic Relief Services, and the Family Life Training (FLT) centres of the Department of Social Services. The three programmes represent quite different kinds of interventions: nutrition education, food supplementation and nutrition rehabilitation respectively.

Nutrition Field Workers are nurses who function as members of the maternal and child health (MCH) teams at government health centres. Their principal tasks are to monitor children under five years of age and identify malnourished children for special attention, with an emphasis on providing nutrition education to the mothers attending government MCH services. The Pre-School Health (PSH) Programme is a food supplementation programme aimed at young children of families in needy circumstances. Once children are enrolled in the programme, mothers are expected to pay monthly visits to the centres until the child reaches the age of five years. FLT centres closely resemble what are internationally known as nutrition rehabilitation centres. Women with malnourished children are admitted for a period of about three weeks and are taught how to prepare a balanced diet and treat the condition of their children.

Because of their national coverage these programmes have to operate under the extreme diversity of circumstances typical of many African countries. These include ecological variation, ranging from arid lands to fertile highlands, but also include cultural differences, from the eating habits of pastoral peoples with a milk diet to those of agriculturalists dependent on cereals, roots or tubers as staple foods. Often these ecological and cultural differences are compounded, although this is not always the case, and the implications of these differences for the functioning and the impact of programmes is usually a matter of guesswork.

In order to neutralize the possible influence of cultural differences on programme impact, the studies were conducted at various locations in Central Province. This province, together with parts of Eastern Province, forms the population cluster of central Kenya. The province is characterized by sizeable variations in altitude, temperature and rainfall, resulting in considerable ecological diversity. In all, 70% of the surface area is considered suitable for farming. The population of the province was 2.3 million in 1979 and consists mainly of one ethnic group, the Kikuyu. The majority of the inhabitants are concentrated on the mid-slopes of the mountain ranges: an area with a very high population density, at least by African standards. In this sense conditions in Central Province are almost certainly a precursor of conditions as they will sooner or later arise elsewhere in Kenya, in high potential areas with increasing population pressure.

The studies in this volume were aimed at evaluating the impact of different types of nutrition intervention among rural populations, together with the implications that variations in ecology and household circumstances have for the impact of the programmes. The three programmes described above were selected as the object of study because they were ongoing programmes that had proved to be viable, unlike so many pilot or experimental projects that perished as soon as they were left to their own devices. By the nature of our interest the studies concentrated on impact evaluation, and followed the unobtrusive, low-key procedures outlined above (NIRP, 1976; 1978). This means that the degree of control over various other factors influencing child nutrition was often limited, that ad hoc solutions had sometimes to be found for various methodological complications, and that conclusions could only be drawn with a certain amount of caution - caution too not to dismiss lightheartedly the efforts of programme staff who often perform their work under very difficult and frustrating circumstances. Consequently we felt justified in taking a positive view of any indications of success, however modest.

The findings of the studies were presented in a series of project reports with specific recommendations for each programme (Hoorweg & Niemeijer, 1980a, 1980b, 1982). These reports serve as the primary means to make the statistical data available and the reader should consult them if more detailed information is required. This book is not so much concerned with a detailed presentation of the data, but rather with comparing the different studies, bringing them together in one publication, putting them in a more general perspective and drawing general conclusions. It is, first and foremost, an account of impact evaluation of nutrition programmes: its ideal practice in contrast to its actual implementation, the inherent methodological complications and the practical limitations under field conditions.

Chapter 2

Nutrition Intervention & Evaluation

2.1 Intervention in Child Nutrition

Nutrition interventions are of many kinds, difficult to cast in a single conceptual framework. Some interventions are general in nature; agrarian reforms or improvements of marketing systems, for example, aim only indirectly at improving the nutrition of the population, and economic objectives usually have the first priority. Other interventions aim more directly at increasing food availability to the population. Food-price subsidies, for instance, aim to improve the food entitlement of certain sections of the population, and at the same time guarantee national food production by keeping producer prices attractive. Storage loss prevention concentrates on the preservation of foodstocks to increase food availability either at subsistence level or for marketing purposes. Food fortification is another type of intervention, aimed at improving the quality of the diet through addition of certain scarce nutrients to suitable foodstuffs. Finally, of course, there is the massive food aid that we have witnessed over the past decade. All these interventions have in common that they concentrate primarily on food provision and food availability, and aim either to increase food production, to provide food or nutrients by other means, or to achieve a better distribution of available foods among the population.

In contrast, interventions in child nutrition generally focus more on food consumption and are often aimed at individual cases, usually involving direct contact between programme staff and mothers and children. Even so, there exist considerable variations between different types of intervention in child nutrition - notably variations in type of approach, nature of the target group and programme objectives. Different authors have classified child nutrition programmes in slightly different ways. Beaton & Bengoa (1976) in their handbook on nutrition in preventive medicine devote separate chapters to nutritional surveillance, nutrition education, supplementary feeding and nutrition rehabilitation. Austin & Zeitlin (1981) in a later handbook on nutrition intervention in developing countries, reserve separate chapters for supplementary feeding, nutrition education and integrated nutrition and health care. Since nutritional surveillance and integrated nutrition and health care usually consist of a composite of measures, three basic forms of nutrition intervention can be distinguished: nutrition education, food supplementation and nutrition rehabilitation.

Nutrition education in developing countries is aimed at the improvement of food-related practices, but is usually concerned with the improvement of individual food consumption, more in particular that of small children (Bosley, 1976; Zeitlin & Formacion, 1981). Although the education effort can be directed at different audiences, such as policy makers, health professionals and teachers (groups that can in turn influence present and future generations of mothers), nutrition education is most commonly aimed at housewives or mothers, for self-evident reasons. The different forms of nutrition instruction range from mass media and formal education to posters and booklets, but it is usually agreed that instruction is most effective when given to individuals or to small groups. Education is often included as part of other interventions, thus securing access to an existing audience.

In rural areas in developing countries the teaching often focuses on the introduction of new practices and better utilization of existing household resources. To combat harmful nutritional practices may also be an objective of the intervention, although this is usually a less important aspect than is often thought. Zeitlin & Formacion (1981: 59) give an interesting list of common harmful food and health beliefs in different countries, pointing out at the same time that most of these beliefs have potential beneficial functions as well. Preferably teaching is adapted to local practices and available food resources, characterized by active audience participation and proceeding in small steps, with the consequence that it will take considerable time for any effects of the instruction to become visible. Although a general increase in research attention for nutrition education has been noted in Western countries (Gussow & Contento, 1984), this is far less so in the case of Third World countries. Although nutrition education is often regarded as an important component of rural development, the resources and manpower actually allocated to it are usually modest, and knowledge about the conditions which make for success or failure of nutrition education in the rural areas of developing countries is still very limited (Sinclair & Howatt, 1980).

Supplementary feeding consists of the provision of foods, free of charge or at low cost, to vulnerable groups to cover deficiencies in their normal diet (Bailey & Raba, 1976; Scrimshaw, 1982). The main forms of food supplementation in developing countries are programmes for pre-school children, pregnant and lactating women, school children, and also industrial workers. A major part of the international funds for nutrition are, in fact, spent on supplementary feeding programmes, and it was estimated that in 1979 over 50 million children received some kind of food supplement (Anderson et al., 1981: 25). Supplementary feeding of children usually takes the form of on-site feeding or take-home programmes; nutrition rehabilitation centres are sometimes also included under this heading. In the early years after 1945, the main item of food supplementation was milk as an important source of protein. More recently, with the growing realization that caloric deficiency is frequently more severe than protein deficiency as such, programmes generally try to offer a balance between high protein and high calorie foods. There is also a growing trend to utilize more local foods instead of imported food commodities, if at all possible. Estimates of the costs of supplementation vary but for the take-home and on-site programmes the costs per child are generally estimated at between $10 and $30 per annum (Anderson et al., 1981).

The term nutrition rehabilitation is usually reserved for the treatment of severe cases of protein-energy malnutrition. Treatment can be given in the form of hospital admission or at nutrition rehabilitation centres (Bengoa, 1976). Experiences with hospital treatment often have not been positive, mortality rates are high, hospitalization is usually lengthy, and the number of relapses tends to be high (Cook, 1971; Bengoa, 1976). This has led to a search for a...

Table of contents

• Front Cover
• Half Title
• Dedication
• Title Page
• Copyright
• Contents
• Acknowledgements
• List of Boxes
• List of Tables
• List of Figures
• 1. Introduction
• 2. Nutrition Intervention & Evaluation
• 3. Central Province & Kikuyu Society
• 4. Food Culture & Child Nutrition
• 5. Nutrition Intervention in Central Province
• 6. NIRP: Evaluation Methodology
• 7. The Impact of the Programmes
• 8. Conclusion
• Appendix
• Notes
• References
• Index