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11. An evaluation of the effect of a communication system on the knowledge of mothers and nutritional status of preschool children in rural Philippines

APPENDIX 7. Philippine Nutrition Program Implementing Guidelines on the Barangay Nutrition Scholars Project

Nutrition Center of the Philippines (NCP), Manila, Philippines


The Philippine government has adopted a policy to improve the nutritional status of its people, committing scarce financial resources to develop a national nutrition plan and programme. The effort is not a token one, but a large-scale integrated endeavour to address the problem of malnutrition directly.

The government of the Philippines has recognized that malnutrition is an impediment to human resource development. It hopes that making nutrition a priority will ensure that future generations of schoolchildren and skilled labourers will have the opportunity to realize both their physical and their mental potential. The various nutrition activities in the Philippines are based on co-operation and collaboration between the government and the private sector.

In June 1974, President Ferdinand E. Marcos issued a decree that created the National Nutrition Council (NNC), and gave it the responsibility for formulating a national programme for nutrition and for co-ordinating all related activities. The elaboration of this programme was called the Philippine Nutrition Program (PNP). At the same time that the NNC was created, the First Lady, Madame Imelda Romualdez-Marcos, founded the Nutrition Center of the Philippines (NCP), whose mandate was to harness the resources of the private sector to support the Philippine Nutrition Program.

Malnutrition in the Philippines

The most serious and chronic nutrition problem in the Philippines is protein-energy malnutrition (PEM) among pre-school children. Based on a nationwide weighing survey in 1978 (Food and Nutrition Research Institute, National Science and Technology Authority), nearly 70 per cent of pre-school children are underweight. Several surveys during the 1970s showed that the section of the country with the highest prevalence of malnutrition was the Eastern and Western Visayas [1, 2].

The consequences of this early malnutrition are stunted physical growth, reduced energy to learn and develop, higher incidence of illness and disease and, of course, a higher mortality rate. Another consequence, often overlooked, is the emotional and psychological impact on society when a majority experience misery in early life, reducing their ability to cope with life's problems.

The Philippines does not suffer from a lack of food. The prevalence of malnutrition is the consequence of a complex group of factors often found in developing countries. These factors run the gamut from problems of food distribution through health and sanitation conditions to ignorance of food needs. It is well accepted among nutrition authorities that available foods and resources, if better used in the home, could improve nutritional status, especially among young children [3].

It has been suggested that malnutrition among pre-school children in developing countries similar to the Philippines is caused not so much by inequity in food distribution as by inequity in knowledge distribution [4]. Certainly, only a small shift in intra-familial food distribution would suffice to correct it. However, since dietary practices are the result of biological, geographical, psychological, cultural, sociological, religious, intra-familial, superstitious, economic, technical, and other factors, they may be one of the most difficult of human behaviours to change. A quick and easy cure is not likely.

The Philippine Food and Nutrition Program

The major interventions of the Philippine Food and Nutrition Program are:

Nutrition Information and Education

The priority target group for this intervention is mothers of malnourished pre-school children (0 to 83 months of age). The goal is to increase the mothers' knowledge and improve their child-feeding practices.

Health Protection

Health protection services are both curative and rehabilitative. Curative measures include medical services to the moderately and severely undernourished pre-schoolers susceptible to infection. Wards for recovery from malnutrition (malwards) are set up in hospitals or nutri-huts in the remote areas. Immunization, deworming services, and sanitation campaigns are among the preventive measures.

Food Assistance

As an emergency measure to improve the nutritional status of the moderately undernourished pre-schoolers, supplementary feeding programmes are undertaken. Locally available food commodities are encouraged and promoted.

Food Production

The primary goal of this intervention is to promote backyard and school gardens to increase household consumption of more highly nutritious foods.

A village-level nutrition worker, called the "barangay nutrition scholar" (BNS) is the grass-roots link between the families of malnourished children and the implementors from various government agencies charged with carrying out the guidelines set forth at the national level. A presidential decree in 1977 provided for the selection and training of one BNS in each of the 42,000 barangays in the country. The concept was to provide a community-based indigenous worker to deliver basic nutrition and health services to the target families of the Philippine Nutrition Program.

Nutri-Bus Project Background: The Pilot Study

Early in 1976 the Nutrition Center of the Philippines (NCP) decided to test the relative effectiveness of different communication channels in bringing about behavioural change in mothers' child-feeding practices. At that time the government was contemplating putting village-level volunteers for nutrition (later called BNS) in the field, so it was decided to combine testing of communication with volunteers to measure the relative effectiveness of various media in support of the grass-roots worker. The behaviour selected for assessment in the pilot study was the purchase of a nutritious product to add to the child's diet. The act of purchasing the product would yield an objective and reliable measure of the behavioural change brought about by each method of communication. The product itself would be designed to make up the nutritional deficit for the pre-school child.

A product then under development at NCP was selected. This product, called "Nutri-Pak," provided:

Nutri-Pak contained cracked rice, ground mung bean, coconut oil, and powdered milk. Each ingredient was packed in its own small, clear plastic bag and these were overpacked to make one Nutri-Pak. As part of the pilot project, a small manufacturing plant was set up to produce Nutri-Pak.

The province of Leyte in the central Philippines was chosen as the area to conduct the pilot project. Leyte is in the Eastern Visayas, one of the less developed areas of the Philippines, which has been reported to have the poorest diet and to be one region where the prevalence of malnutrition is very high. Severe to moderate malnutrition in Eastern Visayas was reported to be more than 50 per cent above the national average in the First National Nutrition Survey, 1978 [1].

Under the direction of the Ministry of Health, 30 villages were chosen at random for the project from among all the villages in Leyte that met certain criteria regarding size, nutritional status (as reported by local workers who had conducted the nationwide weighing programme), certain geographic and occupational characteristics, dialect spoken, accessibility by road, and absence of any concurrent nutrition or health programme. These villages, in turn, were assigned on a stratified random basis to each of six experimental conditions, as shown in table 1.

Village-level nutrition workers (barangay nutrition scholars or BNS) were recruited and trained for the sample villages to be "change agents" and to sell Nutri-Pak at a subsidized price. All BNS recruited were given training by the Ministry of Health in basic nutrition and by NCP in product knowledge. Half of them then returned to their villages to promote better nutrition in general and Nutri-Pak in particular; the other half were given an extra day of training in simple communication skills to help them persuade mothers to change their child-feeding practices. After the BNS had returned to their villages one-third received no further support except deliveries of Nutri-Pak; one-third received comic books about nutrition to distribute free to every household in their villages once a month for three months, as well as deliveries of Nutri-Pak; and one-third were supported by a video van that visited the village once a week for ten weeks to show five specially designed television programmes on nutrition and to deliver Nutri-Pak.

Table 1. Experimental design for pilot project (Nutri-Pak available through BNS)

Training Media
No media Comic books Video van
BNS given no communication training 5 villages (A) 5 villages (B) 5 villages (C)
BNS given communication training 5 villages (D) 5 villages (E) 5 villages (F)

Special comic books and video tapes were developed for the project by NCP, using a rigorous process designed to produce communications that would bring about behavioural change (see Appendix 1). The television tapes actively involve the viewers in the learning process by posing specially developed questions at intervals throughout the tape (see Appendix 2). The communicator, who administers the tape showings, stops the tapes at each question and encourages answers and discussion from the viewers. When the tape is started again, it provides feedback regarding the answers. The place of the communication system in influencing knowledge, attitudes, practice, and nutritional status is shown in Appendix 3.

The story-line and nutrition content of the comics and video tapes were the same (see Appendix 4). Both were pre-tested with mothers representative of the target population, but not residing in the sample villages, and were revised on the basis of the results.

In order to test the experimental treatments under realistic field conditions, no personnel or procedures were used in this pilot project that could not be used in nationwide implementation (excluding, of course, the evaluation, which was not part of implementation). Working capital for the first supply of Nutri-Pak for each village was supplied by the local government.

For purposes of the pilot project, the total possible market for Nutri-Pak was defined as every mother buying one package of Nutri-Pak every day for every pre-school child. It was, of course, totally unrealistic to think that any product could reach such a level of sales. But, since no market existed at all for special foods for children in the villages, it was the only objective estimate of a market that could be used. Minimal successful penetration of that "ideal market" during the first five months of the pilot project was arbitrarily defined as approximately 5 per cent - so, sales of 5 per cent or more of the total "ideal market" were to be considered a success.

The objectives of the pilot project were:

Pak equal to or greater than the minimum criterion of 5 per cent of total "ideal market."

The results of the study showed that:

Nutri-Bus Project: Expansion

Based on the results of the pilot project and continuing interest in using video vans for nutrition education, the Nutrition Center of the Philippines decided to expand the project to three buses in Leyte. However, the attractiveness of the concept and the video tapes caught the attention of donors and soon the Nutrition Center had over 30 fully equipped Nutri-Buses. This generosity provided an early opportunity to implement the project on a wider scale.

The data from the Leyte pilot study were analysed during the first half of 1978. By August of 1978, the first two of the new Nutri-Buses were already launched in Leyte and Samar.

In preparation for the fielding of the new buses throughout the country, the Nutrition Center organized the Nutri-Bus Project Management Office with the following units: training and field supervision, engineering, and video production.

A field-management and training system was developed. Policies and guidelines were defined in co-ordination with the National Nutrition Council to identify operational linkages with the local government and the provincial/city/municipal action officers.

The video production personnel were trained by Development Communications Consultants, Inc., to design and produce video-tape modules in the local dialect. At the same time, the NutriBus Project Management Office sought funding from the government and private sector for operations costs.

The Nutri-Bus delivery system is illustrated in Appendix 5. Each Nutri-Bus, a jeep type vehicle, is modified to carry a Sony Betamax video-cassette playback system, a public address system, a self-contained power source and field supplies and materials. The key person in the system is the communicator, who was trained for a month in communication skills, community organization, and training and supervision techniques.

The Nutri-Bus communicator visits the barangays twice a month at two-week intervals; once for a video-tape showing, where she interacts with the viewers who are gathered by the BNS in chapels, village halls, or shady clearings; another time to coach and supervise the BNS in specific tasks, replenish stocks, and monitor the programme through a simple monitoring system.

To increase coverage and attain cost-efficiency, two communicators time-shared a bus.

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