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Public health nutrition
A new horizon: Addressing food and nutrition problems in the Lao people's Democratic Republic
Yongyout Kachondham and Sakorn Dhanamitta
This paper provides information from the Lao People's Democratic Republic on household food security, current nutrition problems, their magnitudes and trends, food and nutrition policy and activities, and strategies for the development of short- and long-term approaches to dealing with the problems. Data were obtained during a recent UNlCEF-supported consultancy, the objective of which was to assess young child nutrition and household food security as a prerequisite for recommending appropriate community-based primary health care and information system interventions. The data were collected through published and unpublished documents, observations of Lao PDR medical and health facilities, rural schools, and villages, and interviews with Laotian nutrition and health specialists. The findings show that house-hold food security rests unstably on a risk-diffusion strategy and women's participation. A number of nutrition disorders are also prevalent. Control strategies require both long- and short-term actions focusing on assessment, advocacy, planning, training, appropriate model development, and communication for food and nutrition.
While the Food and Nutrition Bulletin does not usually publish surveys of individual countries, so little information is available on nutrition and health in the countries of former Indochina that this account by a very competent team of investigators from Thailand is, of general interest. It examines a wide range of nutrition and related health issues and highlights the importance of essential health research to understand problems and devise local solutions.
As the nations of Indochina open their doors to peace and political stability, the national and international health and medical forces are challenged to strengthen basic health services for their populations. In the case of the Lao People's Democratic Republic (Lao PDR), one major problem area addressed through cooperative efforts between international development agencies, the Lao government, and foreign universities is food and nutrition. Information about the Lao PDR's nutrition situation is scattered and/or dated, hindering efforts to develop effective intervention strategies and programmes. Consequently, in 1990 UNICEF sponsored a team from the Institute of Nutrition, Mahidol University. in Thailand, to collaborate with UNICEF. WHO. and FAO in reviewing the available information on young child nutrition and household food security. This review was a prerequisite to developing appropriate community-based primary health care interventions and proposals to improve the nation's health information base and monitoring systems.
This paper synthesizes the team's major findings in five areas: household food security' the current nutrition situation with respect to specific disorders and their magnitudes and trends, food and nutrition policy and activities, priority studies and the government's operational objectives for 1992-1996, and strategies for the development of short-term and long-term approaches to dealing with the problems.
Methodology and outcome
The mission adopted a practical operating research pattern involving four main phases.
First, documentary research was carried out entailing the collection of existing materials (e.g., published and unpublished documents, official reports, government and international development agency statistics and manuscripts) concerning the Lao PDR's nutrition and health situation.* Data on household food security and major nutritional disorders were then compiled and analysed to determine historical trends and the current situation.
Second, the team conducted observations of the Mahosot. Chaitanee, and Military hospitals in Vientiane and of the villages of Chaing Khong and Ban Huachieng, Chaitanee District, Vientiane. Special attention was given to visiting schools. health posts, temples. villages, shops. and the households of pregnant and lactating women. The team tried to assess current health care services, household food security strategies, food and nutrition practices. and current nutritional disorders at each level.
Third, the team conducted informal interviews with nutrition and health specialists and middle- to high-level government officials in order to evaluate the extent, effectiveness, and needs of existing national food and nutrition policies. programmes, and activities. Emphasis was also placed on identifying potential short-term and longer-term intervention strategies and their requirements.
Fourth. the team followed up the country visit by analysing the content of each interview and observation session to identify underlying factors and patterns affecting the present and future food and nutrition situation. These were then examined in relation to the statistics on specific food and nutrition disorders and household food security issues.
A report with recommendations was prepared. which was later verified by the UNICEF Bangkok office and is now serving as the basis for UNICEF's Programme of Cooperation with the Lao PDR for a strategic five-year plan on nutrition. The report also serves as a guideline for the Lao Ministry of Public Health and Social Welfare in identifying existing health and nutrition infrastructure problems.
Population and economics
The Lao People's Democratic Republic is a landlocked. Iargely mountainous country with an area of 236,000 square kilometers. It is the tenth poorest country in the world, with a GNP per capita of US$180. The nation's economy is dependent on agriculture and forestry (61% of the 1988 GDP) rather than industry (14%). The agriculture and livestock sectors alone could potentially assume food security for the country.
The nation's small population (3.94 million) is sparsely settled (16 per km2), young (43.7% are under 14 years of age), and mainly rural (85%). Ethnically, while 68 groups are officially recognized (on the basis of linguistic, economic, and socio-cultural differences), they largely fall into three main divisions: (1) the Laotian Tai and Phuthai, or Lao Loum (68%); (2) the most diversified Lao Theung, who belong to the Austroasiatic ethnolinguistic group (22%); and (3) the Miao-Yao and Tibeto-Burman, or Lao Soung (10%).
In recent decades, 10% of the population of the Lao PDR has emigrated to other countries. The majority of the emigres were qualified professionals. Educational attainment also remains quite low, with an adult literacy rate of only 44%, and the consensus is that total adult literacy is probably actually lower, with male literacy being higher than that of females.
Overall health status in the Lao PDR ranks among the lowest in the world. The female and male life expectancies are 47.5 and 44.6 years respectively. The infant mortality rate is high (1()4 per 1,000 live births in 1990) but on the decline (160 per 1,000 in 1960 and 118 per 1,000 in 1985) . The same holds for the under-five mortality rate, which decreased from 240 per 1,000 in 1960 to 193 per 1,000 in 1985. The mortality and morbidity patterns, moreover, are those of a less developed country in the first stage of the epidemiological transition. Malaria, acute respiratory infections, and diarrhoeal diseases are the top three causes of mortality among infants and small children. The causes of morbidity are the same, but in the following order of magnitude: acute respiratory infections, diarrhoeal diseases. and malaria . Other preventable infectious diseases remain uncontrolled, and there is room for improvement in the expanded programme of immunization since coverage rates of DPT3. OPV3, BCG, measles, and TT2 among pregnant women are 21%, 30%, 31% ,29%, and 11% respectively .
Health service development has low levels of health financing. The average per capita total health expenditure in 1988 was US$1.60 (2%, of GDP), of which 42% was external aid . There is also a bias towards curative care. In 1988 the curative sector (comprising largely drugs and medical supplies) received 74.8% of the Ministry of Health and Social Welfare's budget as compared to 2.7% for preventive purposes.
Household food security
Food security has many different definitions, yet at a basic level it is primarily concerned with household microeconomics. Special attention here is paid to household food security issues - namely food availability, acquisition or entitlement, food consumption, and the role of gender for each.
Household food availability
The Lao PDR household economy is largely dependent on agriculture for food production, especially livestock and rice. Buffalo and cattle are primarily used as draft animals rather than as a common food source. They are considered depositories of family wealth which can be readily liquidated to purchase needed domestic items and additional food. While swine and poultry are present in all villages, they are raised using non-labour-intensive methods which often include allowing the animals to forage.
Rice production is the fundamental component of the farming system, and all other production activities constitute secondary hut crucial elements. The estimated annual paddy (unmilled rice) requirement is 350 kg per person. which includes 10%, for postharvest losses and seed (60 kg per hectare). The proven production of rice is approximately 1.3 to 1.4 million tons of paddy  Using a 60%, milled-rice conversion factor, this amount is normally sufficient to meet consumption needs based on a per capita annual rate of 180 kg of milled rice. Erratic climatic conditions commonly cause production shortfalls. An inefficient distribution and market system also causes local deficits due to poor transportation and management.
Semi-migratory swidden farmers, particularly among the Lao Soung and Lao Theung, usually do not produce enough rice for their own needs. Consequently, they cultivate crops with short maturation periods to provide food before the rice harvest and in times of need. In many cases, home gardening operates as a supplementary food production system which can, in times of surplus, provide an additional source of income. In all three major ethnic categories, women assume major household economic roles, including vegetable growing, small-scale production. and marketing.
Household food acquisition or entitlement
Carbohydrate requirements in Lao households are met by rice and other supplementary staples. Maize and root crops are used mainly for animal feed. Requirements for protein, especially animal protein, usually cannot be met through farming alone. Therefore, almost every household member is involved in gathering and/or hunting so as to provide additional calories, protein, and other nutrients. Natural foods such as fish, snails, small game (e.g., frogs, birds), and forest fruits, shoots, mushrooms, and vegetables are common household food items. Men also hunt regularly during the post-harvest period for household consumption and to provide a substantial source of income among poor families. Currently, pressures on game animals and forest encroachment are strong and widespread.
Food sharing among households is more common in Lao Loum society than among the Lao Soung and Lao Theung. Internal trade in locally obtained food products (via cash or barter systems) is also more frequent in many lowland Lao Loum villages, but very little intra-village trade is conducted among the other ethnic groups . In rural areas, markets are the means for obtaining small necessities (e.g.. salt. monosodium glutamate, occasionally meat). The use of markets as a major source of food supplies is constrained by poor transportation, limited food industries, the time required to travel to the nearest market, and restricted purchasing power. In urban areas Lao people spend a high proportion of their disposable income (up to 70%-75%) on food .
Presently, systematic data on household food consumption patterns are rare and largely confined to people living in Vientiane Prefecture [X]. Daily dietary intake is approximately 1,745-1,976 kcal, or about 70%-80% of the recommended requirement. The estimated 45.2-46.8 g of daily protein consumed is about 75% of the recommended 60 g per day. Rice constitutes more than 80% of total calorie and 50% of protein intake. Since the Lao eat a large variety of foods, their chance of consuming an adequately balanced diet is high, especially among adults. Unfortunately no nutrition survey exists providing quantitative and qualitative information on the dietary intakes of household members in different seasons and among different ethnic groups.
Breast-feeding is universally practiced in the Lao PDR, with more than 90% of mothers breast-feeding for more than 12 months. However. colostrum is usually discarded and breast-feeding is often delayed for one to three days after birth. Prepared supplementary weaning foods are unavailable. The practice of introducing semi-solid foods (e.g., premasticated glutinous rice) early can cause acute problems (e.g., peptic perforation) and long-term complications (e.g., bladder stone disease). Food taboos, such as withholding food during certain periods (e.g., postpartum and during illness), are also present and are potential causes of macro- and micro nutrient deficiency.
While gender differences appear to be insignificant, surveys have shown that girls tended to be marginally better off nutritionally than boys . It may be that girls have better access to food since they often help their mothers with cooking. Thus, children's food security issues may not be food availability or household acquisition, but food habits, family distribution, and the multiple roles of women in the family.
The food and nutrition situation: Problems and magnitudes
The effects of household food security issues are most clearly reflected in the nation's food and nutrition status. As with any quantitative assessment for the Lao PDR, however, the food and nutrition situation presented here must be considered very carefully, since information systems are only rudimentarily developed and there are no institutionalized nutrition surveys. Even where nutrition status data are available, explicit statements of definitions, criteria, cut-off points, and the like are frequently varied and sometimes even missing. Nonetheless, data from a few prior nutrition surveys. current hospital records, site visits, and interviews highlight the Lao PDR's present nutrition problems and their extent.
Low birth weight
The prevalence of low birth weight (LBW) reflects infant and maternal nutrition status. In urban areas LBW appears to be under 10% and not a major problem. In 1984 Kripps collected data on 598 urban newborns and reported a mean birth weight of 3.07 + 0.42 kg 19]. A recalculation from these data, assuming a normal distribution. would give an incidence of urban LBW of approximately 8.8% at that time. Perez reported that LBW accounted for 9%-15% of newborns in some urban areas . UNICEF noted an LBW of 8.38% among 4,510 deliveries at Mahosot Hospital between January 1989 and June 1990.
The data for rural estimates are cloudier but still below 10%. Data at the Lao PDR Maternal and Child Health Institute reveal wide discrepancies in LBW rates, with 6.78% (222 per 3,274 births) at Mahosot Hospital, compared to 4.73% (63 per 1,333) at the provincial hospital in Khammouane and 0.39% (10 per 2,534) in Champasak.
Protein-energy malnutrition in preschoolers
Three major nutrition-status surveys have been conducted among Lao preschool children (0-60 months of age). The 1984 Kripps study , conducted in day care centres in Vientiane and in Vientiane and Luang Prabang provinces and three provinces in the south (N = 6,612), is considered the first phase of the Lao PDR national nutrition survey; the Vijayaraghavan study in 1986 (unpublished WHO report) constituted a second phase covering selected areas of the other 11 provinces (N=6,967) ; and the unpublished Lao PDR Ministry of Health survey in 1988-1989 covered nine provinces, six in the north and three in the south (N= 6,378).
Assessments of nutrition status depend of course on the indicator and cut-off point used. Taking 60% of the US National Center for Health Statistics (NCHS) median weight for age (W/A) as the cut-off, severe malnutrition occurred in 2% of children in the 1984 study  and 2.8% in the 1986 study . Bokeo, Luangnamtha, and Kammouane provinces were the poorest areas (more than 4%), and northern provinces were generally the worst off. With an 80% NCHS median cut-off point, malnutrition or undernutrition was 42% in 1984 and 55% in 1986 (average 48.5%). Northern provinces were worse off again by this criterion, and 60% of children were malnourished in Bokeo, Oudamsay, Luangnamtha, and Attapeu.
Using -2 standard deviations of the NCHS values for height for age (H/A) as the cut-off, stunting (which reflects chronic nutritional deprivation) was also widespread (40% in 1984 and 54.4% in 1986), especially in the north [9,11].
Recent small-scale surveys in three provinces by the Save the Children Fund (UK) have shown limited improvement in this situation. These surveys used -2 standard deviations as the cut-off point for both W/A (7%-14%) and H/A (20%-24%).
Children more than one year old who were being weaned constituted the most vulnerable group. In the 1986 survey, for each one-year stratum above one year of age, undernutrition (W/A) ranged from 61.9% to 62.8% . Only 7% of infants under six months old and 36% of those 6-12 months old were considered malnourished. Regarding wasting (W/H), which reflects underfeeding, the problem is worst during the second half of the first year (15.9%) and then gradually improves thereafter (down from 11.3% in the third year to 2.5% in the fifth year). However, although the older children were better fed (W/H), stunting (H/A) persisted. Kripps  reports that severe wasting (W/H under 60%) occurred especially among children 12-24 months old (3%), with girls tending to be marginally better off than boys.
Iodine deficiency disorders are a major nutrition problem in the Lao PDR. Their spectrum ranges from mere cosmetic annoyance to a conspicuous grade-lV goitre, and even severe mental retardation. Results from a subjective goitre survey (unpublished) between October 1988 and February 1990 in nine provinces (N= 20,447) indicated a 10% goitre prevalence in the plains region and a 30% prevalence for the mountainous area.
Vitamin A deficiency
Although up to the present there have been no vitamin A studies in the Lao PDR utilizing objective methodologies (serum retinol, relative dose response, impression cytology, dark adaptation) to determine the extent of the problem, there are some indications of vitamin A deficiency. The 1968-1969 Lao Health Survey in the Mekong Valley , for example, indicated that 7.62% of the people (N= 2,988) exhibited some signs of vitamin A deficiency (Bitot's spot, keratomalacia, night blindness). The present evaluation team also found several blind children at Mahosot Hospital. From interviews with their parents and attending physicians, it appears that vitamin A deficiency is most likely the cause of their affliction. Children who are undergoing weaning are most vulnerable, since vegetables are not included in the diet of children under two years of age.
Vitamin B1 (thiamine) and B2, (riboflavin) deficiencies
The magnitude of problems related to thiamine and riboflavin deficiency is unclear. More systematic and scientific evidence is needed. The Lao Health Survey in the Mekong Valley found widespread signs of B2 deficiency (46.8%) . The consultant team also discovered 10 students (28.6%) with active angular stomatitis or scars in one classroom (grade 3) in the Ban Huachieng primary school. Chaitanee District, Vientiane Prefecture.
Over the past two years Vientiane hospitals have reported that several patients have died of unexplained causes. Others with the same symptoms, however, quickly recovered after receiving vitamin B1 treatment. Some villagers in Ban Huachieng are also familiar with the sudden unexplained nocturnal death syndrome (SUNDS) which strikes young, physically active males. They even use the same term as in north-east Thailand - lai tai - which literally means "sleep death." While the aetiology of SUNDS remains unclear, some experts believe that vitamin B1 deficiency may be one of the factors involved.
Nutritional anaemia or iron deficiency
The nature and extent of nutritional anaemia has yet to be determined. In the 1968-1969 Mekong Valley study , 35% of women between 19 and 49 years of age (N= 1,177, most of whom were pregnant or lactating) possessed a haematocrit level of 34% or below. Doctors in the maternal and child health clinic at Mahosot Hospital confirmed this rate and the importance of iron deficiency anaemia among pregnant and lactating women.
Bladder stones are a major problem in Thailand and other countries of the region. They are caused by several nutrition factors, including (1) the early introduction of weaning foods, especially premasticated glutinous rice, which leads to less breast milk intake or water content; (2) inadequate phosphate intake, usually accompanied by high protein sources; and (3) high oxalate content from vegetables in the diet.
In the Lao PDR, Kripps  noted that 40% of bladder-stone cases involved the introduction of rice within the first four weeks of life, while Vijayaraghavan  reported rates of 22.1%-31.9%. Since people in north-east Thailand and the Lao PDR (especially Lao Loum) share a common culture and food habits, it is not surprising that bladder-stone disease is found among young boys in both populations. This was confirmed by team discussions with Lao PDR physicians. Experience in Thailand indicates that if supplementation is postponed until the child reaches the optimal age of 4-6 months and protein energy malnutrition has improved, a marked decrease in bladder-stone cases occurs.
Food and nutrition policy, activities, and needs
The Lao PDR still does not have an explicit nutrition policy or a national food and nutrition plan. While a newly created National Committee on Food and Nutrition exists, it lacks a clear mandate to carry out the necessary steps for solving the nation's food and nutrition problems. Generally, the government views nutrition as a family responsibility, and consequently central level authorities have allocated a limited health budget for nutrition activities. The target population for government policy is preschool children,. representing a very small percentage of the total child population.
Nutrition matters are now under the jurisdiction of the Department of Maternal and Child Welfare but this department is in great need of qualified personnel. Even the trained nutrition personnel encounter many situations where they cannot fulfil their work responsibilities because of a lack of authority or because what they have learned in their studies is not suitable for the Lao PDR situation. Nonetheless, nutrition activities (mainly anthropometry and nutrition education) are conducted in Vientiane and provincial hospitals as well as at the district level. For fiscal and logistic reasons, though, the government also does not provide supplementary food to high risk mothers and vulnerable children.
Growth monitoring activities in the maternal and child health programme at all levels currently use a weight-for-age growth card adapted from the 1979 WHO recommendations, which has been printed with support from UNICEF. The layout of the card could be improved. Also, since the parents keep the cards and clinics do not possess duplicates, the recording and reporting systems in clinics and higher levels are very poor. Consequently, it is extremely difficult to aggregate the growth-card information.
Equipment and materials
Expensive standing balance beams are found even at the subdistrict level, but they are poorly maintained and not regularly used. The widely distributed wall charts, based on the weight-for-height indicator, are technically inappropriate. They can easily underestimate nutrition problems, especially stunting among children older than two years. More dramatically, a weaning-food manufacturing plant remains virtually idle for lack of raw materials.
Intersectoral interventions to combat food and nutrition problems are limited. The Lao Women's Union, a broad-based mass organization to promote the welfare of women and children, has yet to have meaningful nutrition activities on its agenda. Schools, moreover, have very little information on food and nutrition in their curricula.
Priority activities and objectives
Providing international assistance to the Lao PDR in its nutrition and health development is a major challenge. Many studies are needed to provide basic information for intervention activities. Studies are particularly needed that focus on rural areas outside Vientiane Prefecture and among the three major ethnic divisions. Priority research areas and action programmes include the following:
» accurate assessments of
current nutrition disorders using standardized definitions,
criteria. and cut-off points.
» accurate dietary intake and nutrition assessments.
» examination of the roles and status of women in production, reproduction, and time allocation,
» examination of food beliefs, habits, and taboos associated with pregnant and lactating women,
» examination of the key food-security issues associated with children and their relationship to childrearing practices,
» development and testing of a community-based growth monitoring system,
» development of appropriate district to national management information systems on the population and ethnic group nutrition status,
» development and testing of effective nutrition communication strategies,
» development of supplementary foods and distribution systems,
» development of a micronutrient supplementation system.
To be maximally effective, research and action projects should be oriented towards the Lao PDR government's eight operational objectives for 1992 - 1996, namely:
» reducing the rate of LBW
(<2.5 kg) to <20%,
» reducing moderate and severe malnutrition by weight for age to <20% and 1% respectively,
» reducing iron deficiency anaemia in women to <20%, half of the 1990 level,
» reducing iodine deficiency disorders in terms of the goitre rate among schoolchildren to 15%,
» reducing xerophthalmia to <1% or, in preschool children with <10,ug of serum retinol, to <10%,
» convincing 50% of lactating mothers to breastfeed their children exclusively for four to six months and 90% to continue breast-feeding, along with supplementary feeding, well into the second year.
» institutionalizing growth promotion and regular monitoring activities in 50% of the villages, with a coverage of 80% of preschool children, and
» disseminating nutrition messages to 50% of the villages and supporting services to increased food production and ensure household food security in 25% of the villages.
Suggested strategies and actions
Considering the constraints on the country, a step by-step approach over a long period is mandatory. The recommended total approach encompasses seven general strategies which have characteristically been responsible for the successful implementation of short-term and long-term food and nutrition interventions in other developing nations.
Increasing political commitment
Government officials, policy makers, and provincial authorities must be convinced that the future of the Lao PDR lies not only in economic development but also in the development of human resources for nutrition and health. There is substantial evidence that nutrition problems, especially iodine deficiency disorders and protein-energy malnutrition, are public health concerns requiring improvements in both the quantity and the quality of manpower. In presenting arguments to the above target groups, the costs that will be incurred should be communicated in relation to both short-term gains in improved nutrition status and the long-term increase in productivity and economic growth. Since provincial authorities in the Lao PDR, unlike those in other countries with centrally planned economies, are quite autonomous, they require special attention.
In addition, policy makers within all relevant ministries (e.g., Health. Agriculture, Education, and Internal Affairs) should have opportunity to learn about and comprehend the magnitude and consequences of nutrition problems as well as to formulate concerted and concrete policies and courses of action on short-term and long-term bases.
In provinces where nutrition problems are most prevalent or which have the financial and manpower potential (in relative terms), health personnel should be encouraged to attempt workable intersectoral relationships and model activities. Interventions should include both stopgap measures (e.g., iodine fortification through appropriate vehicles and the provision of supplementary food for the malnourished) and long-term household food security improvement through food and nutrition education and management. Later on, diffusion of successful models by on-site training activities in other locations can improve coverage. An example would be establishing a pilot community growth monitoring system for children for three to six months as a tool to create greater nutrition awareness among parents and health workers. This would also involve formulating a reporting system to analyse and utilize information at each organizational level. Once in place, the system could be expanded to permit individual monitoring of children and institutional monitoring of maternal and child health clinics and/or services in various provinces, as well as nationwide monitoring of the nutrition status of the country's children.
On a wider scale, the basic minimum needs (BMN) concept and approach, which requires intersectoral cooperation and includes household food security and nutrition as crucial components, can also be feasibly introduced. A rapid multidisciplinary food and nutrition survey (qualitative and quantitative) should also be implemented for the design of immediate programmes. Such techniques as rapid rural appraisal (RRA) and rapid assessment procedures (RAP) for nutrition and primary health care could be used to give a relatively quick assessment of nutrition status, household food security, food availability and intake, related health factors, food habits and beliefs, and health service delivery. Alternatively, a detailed province/district nutrition survey could be designed and launched in such a way that the information obtained can be generalized to represent the national situation.
Infrastructure and production improvements
Although the government has made well-intended health development commitments as inspired by the Alma-Ata declaration on primary health care, none have fully materialized. Iargely because of inefficient use of resources and a poorly developed infrastructure. At a very basic level, "roads for all by the year 2000" may be a prerequisite for "health for all by the year 2000," since an efficient allseason transportation network is non-existent.
The Lao PDR's farming system is based on a risk diffusion strategy dictated by uncertain environmental conditions, the availability of household inputs. and the governmental infrastructure. Consequently, no single new activity or production model will stand out as a panacea since constraints, resources, and cultural acceptance vary significantly from place to place. Present and future land allocation schemes and cooperative activities also directly and indirectly affect household food security. Further, potential future constraints will most likely include limited arable land (1.6-2.7 million hectares out of 23.7 million), potentially high population growth, a destructive slash-andburn farming system, uncertain access and rights to land, limited agricultural inputs (e.g., credit, improved seeds, fertilizers and pesticides), and a market system based on the production incentive.
Presently, rural household food security depends greatly on natural food sources. In the near future, however, these sources will probably dwindle as a result of deforestation, increased population pressure, and a growing demand for cash. Household-based or community-based programmes for the production and consumption of protein-rich foods should be given priority in order to offset decreases in natural foods. Although gardens and small-scale animal husbandry may not constitute major economic activities, they are important supplementary food sources that can have a positive effect on food intake and nutrition status. In all cases, household food acquisition interventions should be targeted towards women and be based on their perceived needs and cultural characteristics and the pragmatics of village and family life.
Manpower and institutional strengthening
The Lao PDR is in great need of a preventive and health-promotion manpower force, not to mention institutional build-up. Greater priority should be given to training at the provincial and district levels. and, likewise. institutional strengthening should focus on support to provincial and lower-level training. In particular, training in nutrition surveillance. growth monitoring, nutrition education. community nutrition planning and management? and supplementary food production should be emphasized at the provincial and district levels.
For those who will work at the local level, on-site training with practical exercises and a limited number of objectives may prove most effective. Moreover, simple exercises that can be readily applied should be scheduled instead of lengthy, sophisticated, and scientific lectures by the consultants or trainers.
Health officials who will be future implementers and/or "trainers of trainers." should be given opportunities for further study, with specific assignments to do certain activities when they return from training. Coordination activities and expenses for tailoring training courses to fit the recipient training institutes should be sought from international funding agencies. Collectively, these activities and programmes will help to alleviate problems associated with inadequate training, lack of positional authority, and/ or inappropriate course content.
National institutions designated to address nutrition problems should expand their efforts, with expert help being provided in designing activities and protocols. They should have options or alternatives for coping with problems under differing sociocultural, economic, and geographic conditions. The designed activities and data collection formats should be logistically feasible and simple at the beginning. Emphasis should be placed on helping local organizations to utilize collected data for action purposes, rather than simply for statistical functions.
Social mobilization and community involvement
Improving public nutrition generally requires a "horizontal" approach, in contrast to "vertical" (e.g., EPI) programmes, because people themselves are the actors upon whom projects must depend. Thus, people must be guided to identify problems, develop feasible solutions, and manage their own resources for nutrition and health development. The temptation to treat community members as beneficiaries, passive recipients, and/or objects of manipulation should be avoided. Likewise, dole outs should also be set aside, for they only create apathy. Community leaders, women's groups, and monks should be recruited as active decision-makers in the intervention process. Community involvement can be encouraged through matching funds, cooperatives, or other types of collective financing schemes aimed at local supplementary food production or other household food security activities (e.g., home gardening). Inputs should mainly come from within the community to give members full project ownership and responsibility in planning, managing, and monitoring their own development. Technical and managerial skill training, however, should be supported (but not controlled) by higher level personnel.
Effective communication to create awareness and behavioural modification
Since people need to learn to be more cognizant of their health and its requirements, their awareness must be increased by employing effective communication channels and techniques. If possible, such strategies should be developed in collaboration with health and communication experts and utilize media and interpersonal programmes transmitted through appropriate, mutually reinforcing channels. Different communication packages will need to be developed and tested to fit different contexts (urban, rural), ethnic groups, and target audiences (e.g., health workers, mothers). Initial expenses to produce messages as well as operating costs may seem high, but they have been shown to be cost-effective. There are already some nutrition communication tapes and videos utilizing songs, dramatics, and maw lum, or popular story-songs, in the Thai-Lao dialect that could be used in slightly modified form in the Lao PDR. There are also model posters and pamphlets that could be translated into the Lao dialect which have shown potential for communicating nutrition messages in a much more interesting and readily understood way than scientific, official, and often dull documentaries.
Maximizing non-government organization development efforts
Finally, non-government organizations (NGOs) should be encouraged and supported in playing a larger role in activities dealing with local manpower development, instead of just service activities. Since NGO personnel are more directly involved with people and the health system at the community and household levels, they should be recruited to help assess and monitor existing food and nutrition conditions. They can also be a powerful force in persuading community members to adopt new food and nutrition practices and establish community-based programmes (e.g., supplementary food production, growth monitoring). For vitamin A deficiency, NGO personnel working along with local health workers can increase coverage in terms of supplementation, fortification, and nutrition education. Lastly, frequent dialogues among the NGOs themselves and local UN agencies should be supported to establish directions, improve coordination, and share actual hands-on experience.
We are sincerely grateful to Ms. Anne Sutherland, UNICEF Representative, and Mr. John Spring, UNICEF Programme Officer, Vientiane, for their significant contributions to this consultant mission. Their assistance in arranging interviews and site visits as well as their insights into the nutrition and health situation of the Lao PDR were invaluable. We would also like to express our appreciation to Mr. George A. Attig, Technical Advisor of the Institute of Nutrition at Mahidol University, for his comments, suggestions, and editorial skills in preparing this paper.
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