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Nutrition education: An overview of the issues
Classification of nigerian foods: A review
Nutrition education: An overview of the issues
Davidson R. Gwatkin
Co-ordinator, ACC/SCN State-of-the-Art Series, Overseas Development Council, Washington, D.C., USA
The United Nations ACC Sub-committee on Nutrition has recently initiated a series of state-of-the-art studies designed to summarize knowledge and experience about what works to improve nutritional conditions in different settings. Selected papers in this series are being issued, along with commentaries presenting alternative points of view on the topics covered, as ACClSCN nutrition-policy discussion papers.
The following article is based on the introduction to the first of these discussion papers, which deals with nutrition education. The paper features a review of experience by Robert C. Hornik of the Annenberg School of Communications of the University of Pennsylvania. The discussants are Abraham Horwitz, Director Emeritus of the Pan American Health Organization; Richard K. Manoff, President of Manoff International, Inc.; William A. Smith, Senior Vice-president of the Academy for Educational Development, and Susan Van der Vynckt, Programme Specialist in Nutrition Education at Unesco. Financial support for the preparation of Dr. Hornik's paper was provided by the World Bank. The views presented are those of the authors and not necessarily those of the ACC/SCN or the World Bank.
Complimentary copies of the full text of the paper summarized in this article and further information about the ACC/SCN State-of-the-Art Series may be obtained by writing the Secretary, ACC/SCN, c/o Nutrition and Food Policy Division, Food and Agriculture Organization, Via delle Terme di Caracalla, 00100 Rome, Italy. Requests for multiple copies should be accompanied by an indication of the way in which they will be distributed and the use to which they will be put.
How well or poorly does nutrition education work? Does it deal better with some nutrition problems than with others? Do some kinds of nutrition education produce better results than other kinds? These are the sorts of questions addressed by Robert Hornik and a panel of distinguished discussants in the first nutrition-policy discussion paper of the Sub-committee on Nutrition of the United Nations Administrative Committee on Co-ordination (1). From their answers emerges a sense of change in the offing.
The material presented points to a widespread suspicion that nutrition education activities of the types that are now predominant have not been very effective. But, as Hornick also observes in his report, which constitutes the core of the ACC/SCN paper, recent years have seen extensive experimentation with new and different approaches which, in the opinion of many associated with them, have produced impressive changes in nutrition-related knowledge, attitudes, and behaviour. As a result, those responsible for implementing nutrition education programmes are faced with new alternatives that would, if accepted and widely implemented, mean a significant change from the way nutrition educators have traditionally done business.
Would those concerned with nutrition education be well advised to introduce such new approaches? It is hoped that the material presented will help them arrive at informed decisions.
DOES NUTRITION EDUCATION WORK ?
Hornik is not a vigorous defender of traditional nutrition education activities. Nutrition education, he reports, is common. Assessments of it - especially the largest volume of it, undertaken as a routine activity of health workers - are not. In the absence of evidence to the contrary, there is little basis for challenging the general view that it does not work very well. "The great majority of nutrition education is unevaluated," Hornik concludes, "and apparently (and probably reasonably) assumed to be ineffective . . . " (1, p. 73).
Several possible reasons are suggested for this apparent lack of effectiveness in discussing what he terms "a hypothetical conventional system," in which nutrition education is offered by harried health workers in the course of providing curative medical services. Nutrition education made available in this way is not likely to be of adequate quality. It is provided too haphazardly as an "add-on" to curative care; too off-handedly by professionals with only a limited and outdated knowledge of nutrition; too ineptly by people selected and interested in serving as care providers rather then as educators. Even if such nutrition education were done well, it could not reasonably be expected to make much of a difference. It would miss the great majority of those at risk, who do not regularly come into contact with the health system, and its effects would be attenuated by other, often contradictory messages received from other sources.
Such scepticism seems widely shared. As Abraham Horwitz notes in his discussion, many observers feel that nutrition education has accomplished little. Other reviewers of the field have echoed his sentiments. (For example, Moise Behar, then Director of WHO's Nutrition Unit, wrote in 1977: " . . . in spite of large and sometimes costly efforts in this direction [i.e. nutrition education], we have advanced very little. We do not understand the real need and value of this measure, and if so, how it could best be implemented" [2, p. 185].) It thus appears that the question of whether nutrition education is effective can be answered negatively; the focus shifts then to the question of whether it can be effective.
It is in Hornik's affirmative response to this last question that the interest of this work is to be found. For he clearly believes that, while traditional nutrition education may not be very effective, the experience of recent field experimentation shows that there are some kinds of nutrition education that can often produce results.
AGAINST WHAT KINDS OF PROBLEMS DOES NUTRITION EDUCATION WORK BEST?
This is not to claim that nutrition education can be effective in all situations. As reported, most observers feel that there is a very large and important category of nutritional problems against which it probably cannot do very much: those attributable to poverty.
Such problems are particularly relevent at the family level. If a family does not have enough money, there is no way its members can be well nourished, regardless of how much information they might be provided about what and how much to eat. Many would argue that, if given more money, people can be expected to spend most of it - three-quarters or more in some of the cases cited - on food; and even if not all that food is what a nutritionist might consider ideal, it could be expected to make a difference even in the absence of adequate nutritional awareness.
In spelling out such arguments, Hornik does not seem persuaded that the issue can be considered clearly settled. He points to recent research that seems to suggest that even the very poor are influenced much more by matters of taste and status than by nutritional considerations in deciding upon the additional food they will consume. But he does not press the point, concentrating instead on other problems where the findings of recent research and experimentation make a stronger case in nutrition education's favour.
The problems are primarily ones involving behaviour within the family. Although it is perhaps not reasonable to expect that education will persuade a poor family to spend more money on better food, the authors of the studies cited argue that education can help promote the adoption of many low-cost or cost-free practices to improve the nutritional status of the family's most vulnerable members, especially children. Three examples are given:
Breast-feeding. The decline in breast-feeding, especially among urban women, is a well-known problem. The design of effective education programmes will required a much better understanding of why women choose not to breast-feed. It is not safe to assume, for instance, that education about the health benefits of breast-feeding will have much of -an effect, since most women who choose not to breast-feed say they know that breast-feeding is healthier. On the other hand, breast-feeding normally costs less, instead of more, than the inferior alternative available. In this context, then, there is not the financial basis for resistance to its adoption that limits the amount that nutrition education can accomplish with respect to many other practices. Of course, many women choose not to breast-feed because they work outside the home, and this basis for resistance must be considered by educators.
Energy intakes during and after weaning. In many poor societies, the most severe malnutrition is found among children just after weaning, at six months or so. To the extent that failure to provide them with adequate amounts of easily digestible foods is a reflection of financial constraints or deeply ingrained social norms favouring older household members, the potential influence of education may be limited. There are, however, other factors against which education might reasonably be expected to exert a significant influence: a failure to recognize the symptoms of malnutrition when they appear, for example, and a lack of knowledge about the amount and kind of food the young child needs.
Treatment of diarrhoea. Diarrhoeal episodes represent a leading cause of malnutrition among children and are believed responsible for some five million infant and child deaths annually. There are low-cost or no-cost approaches available for the management of diarrhoea, for whose promotion nutrition education would seem potentially well suited. Prominent among these is oral rehydration, the regular administration of a simple, inexpensive solution which has been shown highly effective but is not as yet nearly so widely known as it could be. Also of value would be the spread of such simple ideas as the importance of continuing to encourage ill children to eat regularly despite their lack of appetite and the need to discontinue such common deleterious practices as purging or withdrawing breast milk from infants while they are sick.
WHAT KINDS OF NUTRITION EDUCATION ARE MOST EFFECTIVE?
All that has been said thus far has been rather abstract, a discussion of areas where a priori considerations supported by research on the determinants of malnutrition suggest that nutrition education ought to be capable of making a difference. What about evidence from projects or programmes to indicate that it does or can in fact make a difference?
Hornik cites a range of examples, related to several nutrition
problems that include, but are not limited to, those just
- Education in association with food supplements in Morocco was found to produce greater change in nutritional status than that associated with food supplementation alone.
- In Micronesia, social marketing of coconut milk as a substitute for imported drinks led to a widespread change in drinking patterns.
- In Indonesia, nutrition education by village volunteers, supported by radio and action posters, produced a distinct improvement in nutritional status.
- Media-based projects in the Philippines, Tanzania, Honduras, and the Gambia are reported to have reached large numbers of people who have begun to show changes in nutritional knowledge, attitudes, and practices.
Not everyone considers such success stories frequent enough or the evidence of their success adequately clearcut to support a call to further action. Nutrition and public health scientists noted for their rigorous outlooks have expressed concern about what they consider design inadequacies and an insufficient thoretical underpinning in the experiments reported. But most readers have agreed with Hornik's guarded optimism that the experiences he describes contain lessons of direct and important relevance for other nutrition activities. Some would go considerbly further. For instance, a recent Unesco review of the nutrition education literature opens with the assessment that, following developments over the past five years, "the art and science of nutrition education has reached a milestone in its development," and that as a result nutrition educators are now in a position to contend plausibly that their work deserves to be taken seriously (3, P. 5).
What makes these projects so much more effective than the
traditional nutrition education that seems to work so poorly? The
report suggests that the answer is to be found in six
characteristics by which they avoid the shortcomings of
- They reach out to the target audiences at present served by clinic networks through a mixture of face-to-face extension and mass-media information activities.
- They improve the quality of the information and education provided through these channels by means of careful prior investigation of the issues being addressed, design of the messages offered on the basis of knowledge gained during the prior investigation, training and supervision of field workers, regular maintenance research to assess audience response, and adjustments in programme message and strategies on the basis of the findings of such research.
- They employ multiple channels to disseminate the same message in order that each channel might reinforce what is being said through the other.
- They use nutrition education in conjunction with, rather than as a substitute for, the provision of material input (for example, to promote the availability of food supplements or oral rehydration packets).
- They provide incentives for educators to continue working effectively and for their clients to adopt and continue the practices desired.
- They make available the continuing high-level support and the financial and human resources necessary after the development and implementation of the programme incorporating the features just described.
When presented in general terms such as these, the points made by Hornik have generally been found unexceptionable by the readers of his work. But, as can be seen from reading what the discussants have to say about his conclusions, there is lurking among the issues he raises one that arouses considerable passion. This issue concerns which of the several communication channels available for nutrition education should be given primacy.
Three channels are featured in the policy paper and the discussions that follow it: face-to-face outreach efforts by health personnel, mass-media programmes, and educational activities for children in schools. Hornik, who deals only with the first two of these, emphasizes the need for a mixture. He presents two alternative combinations. The first would feature a network of nutrition extension agents working out of health centres, supplemented by massmedia activities designed to bring clients into touch with them and to reinforce what they say. The second would rely primarily on media-based programmes, complemented where practical by face-to-face and other support efforts.
In discussing these possibilities, he makes a valiant effort to present fully the pros and cons of each. But in the end, he leaps off the fence and takes a stand: "Under current circumstances," he concludes, "national planners are best advised to be wary of face-to-face outreach education on the grounds of feasibility, whereas they may find media-based systems promising" (1, p.781. He argues that although face-to-face education, done well, is likely to be superior to media-based education, the organization of such face-to-face systems has proved difficult. Operating large-scale systems over an extended period is too often beyond the managerial, budgetary, and organizational resources available. While media-based systems may not be ideal in the abstract, in practice, they are likely to be the only feasible alternatives.
On the point of how the different channels should be used in relation to one another, clear differences emerge between Hornik and the four discussants of his paper. Smith finds his formulation judicious, but the other three discussants take exception not only with Hornik but implicitly with one another as well.
Horwitz is clearly sceptical of relying primarily on the mass media. He favours greater reliance on an expansion of the health system. He cites several examples to indicate that such an approach is feasible and argues that such expansion will be necessary in order to obtain the broader objective of achieving health for all.
Manoff's view is diametrically opposite to that of Horwitz. He thinks the mass media have far more potential than Hornik suggests. in his view, the limitations of the mediabased projects Hornik reviews are not a reflection on the potential contribution of the media but rather on the qualifications of those who have thus far organized mediabased nutrition education projects. The need is to get health and nutrition people back into the clinics where they belong and to leave media and outreach work to the social marketing professionals.
Van der Vynckt does not express a preference for either of these two channels. Her interest, rather, is in seeing the discussion broadened to include a third channel: the educational system. Her lament is not simply that Hornik and her fellow discussants have failed to appreciate the importance of the school system for nutrition education. She is also concerned that educators have failed to recognize and take advantage of the potential for effective nutrition education inherent in their system and have yet to develop the kind of hard evidence necessary to persuade Hornik and other reviewers that the schools can play a central role in nutrition education activities. But this is changing, she believes, and if all goes well, the evidence will soon be there for all to see.
While such differences of opinion about channels seem likely to continue, a broad consensus appears to exist on many other issues related to nutrition education. No one, for example, seems to doubt the ineffectiveness of the traditional nutrition education approaches. There seems to be general agreement about the kinds of problems that nutrition education can and cannot reasonably be expected to help solve. Most - perhaps almost all - of those familiar with recent experimentation with nutrition education agree that it has produced impressive results. They also seem to agree on most of the features of these experimental programmes responsible for their apparent successes, the controversial question of channels being a central part of only one of the six characteristics of successful programmes noted in the previous section.
Even with respect to channels, the differences are not so great as they might at first appear. No one seems to be taking an either-or position. There is general appreciation of the need for mutually reinforcing messages through multiple channels. The question is, rather, the relative emphasis to be given to each - or, in the more helpful way that Smith puts it, how the different channels used can best relate to one another.
All in all, then, the teapot in which the passions are raging is a rather small one. Perhaps the challenge of the years ahead is not so much to reach consensus where it has not yet emerged as to build upon the broad agreement that exists in so many other areas: to see whether and how the programme elements generally recognized as important in the successful experimental efforts Hornik describes can be applied to the design of the large-scale, ongoing, effective nutrition education programmes that are so badly needed.
1. Robert C. Hornik, "Nutrition Education: A State-of-the-Art Review," with discussion by Abraham Horwitz, Richard K. Manoff, William A. Smith, and Susan Van der Vynct and an Introduction by Davidson R. Gwatkin, ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 1 (1985).
2. Moise Behar, "Protein-Calorie Deficits in Developing Countries," in N. Henry Moss and Jean Mayer, eds., Food and Nutrition in Hearth and Disease (New York Academy of Sciences, New York, 1977).
3. Ronald C. Israel and Joanne P. Nestor Tighe, Nutrition Education - The State of the Art: Review and Analysis of the Literature, Unesco Nutrition Education Series, no, 7 (Unesco. Paris, 1984). (A complimentary copy of this monograph is available from Dr. Susan Van der Vynct, Nutrition and Health Education Programme, Unesco, 7 place de Fontenoy, 75700 Paris, France.)
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