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Commitments to virtually eliminate vitamin A deficiency and all its consequences by the year 2000 were made by high level politicians attending the World Summit for Children in 1990 and the International Conference on Nutrition in 1992. The World Health Organization (WHO) currently estimates that there are over 250 million preschoolaged children, and an unknown number of women of fertile age, who are vitamin A deficient. Obviously, to meet the goal, it will be essential to improve the dietary intake of vitamin A in a very large segment of the world's growing population.

At a public health level, the primary cause of vitamin A deficiency is an inadequate intake of vitamin A-active foods, both of animal and vegetable origins. The critical immediate need for vitamin A could be met by periodic high-dose supplements to children, and appropriate lower dose supplements to fertile women, a system used by some Western countries where an infrastructure is in place for delivery through a welfare system or through affordable private sources. Governments of most developing countries, however, currently cannot sustain from their own resources the perpetual broad distribution of vitamin supplements, and a well-developed, affordable source for delivery through the private sector is not available. Alternatively, fortification of a suitable, centrally-processed food that is broadly consumed by the vulnerable groups within a limited range of intakes could be an effective approach to the problem, as demonstrated in several industrialized countries. Foods with such characteristics, however, do not exist in many developing countries.

Natural food-based interventions, therefore, are the only sustainable solution to vitamin A deficiency - and to several other nutritional problems - in nonindustrialized countries. For these approaches to be effective in improving vitamin A intake, local answers are needed to the questions of what vulnerable groups are eating, why they are eating it, and if they are willing and have the necessary means to change or modify their dietary patterns. Answers are critical for planners of nutrition, health, and even more broadly-oriented development programs. This book and the accompanying manual Community Assessment of Natural Food Sources of Vitamin A: Guidelines for an Ethnographic Protocol provide a methodology, and demonstrate its flexible application, for an in-depth understanding of the local context critical for designing appropriate interventions.

The purpose of the book is to describe issues regarding the consumption of natural food sources for preventing vitamin A deficiency, to be used by development planners as well as students, in a variety of related areas in nutrition, public health, and anthropology. As such, it is a useful compilation of experiences reflecting widely diverse cultures and settings where vitamin A deficiency occurs in different levels of severity. It brings the reader up to the point where interventions could now be planned, utilizing the information gained locally by applying the focused ethnographic study (FES) methodology.

The FES methodology is, in fact, a subset of general ethnographic approaches for information gathering that can be adapted to various program requirements, in this case to learn about the availability of vitamin A-containing food; perceptions influencing its uses, preparation, preservation and consumption; and age/gender/illness and other factors that modify consumption patterns. Hence, the approach deals with issues of food availability from a perspective not usual in most assessments provided to development planners from agriculturalists on the one hand, and nutritionists on the other. Agriculturalists generally view food availability in terms of yield per acre, and nutritionists by the nutrient content of the food in the household or in the meal as consumed. The FES methodology provides a more holistic framework for viewing the issues within a local cultural and food systems context. From such context interventions can be designed that are more relevant and appropriate to both opportunities and constraints for creating the supportive environment needed for sustainable behavioral changes to occur in eating patterns.

This book is intended for nutrition intervention program and development planners, as well as students from related disciplines. Although it is quite clearly written, some sections, for example parts of Chapter 2, have details that will be of less interest to the development planner, but will be a useful orientation for students.

There are many uses for information about what is being eaten and by whom in specific population settings. One of the most frequent uses of this information is to seek association with nutritional status or, for example, with disease patterns in epidemiologic surveys. Often, the speed required for conducting large, population-based epidemiologic surveys requires rapid assessment procedures (RAPs) that do not slow the survey process. Yet, local actions that require behavioral changes to improve amenable, diet-related adverse survey findings, must be imbedded in an understanding of the community's organization and resources, and the knowledge and perceptions of vulnerable inhabitants. This information is crucial but often unobtainable from rapidly conducted interviews. The accompanying manual provides detailed guidance and forms for acquiring, recording, and analyzing the required information in a relatively short time frame, i.e., six to eight weeks. It may also be useful, therefore, in conjunction with studies in selected sentinel areas where more extensive surveys are in progress.

Barbara A. Underwood
Nutrition Unit
World Health Organization
Geneva, Switzerland

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