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Changing nutrition-related knowledge and behaviour: Video vans in the rural Philippines

Mercedes Solon, Emelita de Leon, Miguel Lopez, and Eireen Bañez
Nutrition Center of the Philippines, Manila, Philippines

Jean Andersen
Development Communications Consultants, Inc., Oyster Bay, New York, USA

INTRODUCTION

The Philippine Government has a policy to improve the nutritional status of its people (1) and has committed scarce financial resources to develop a national nutrition plan and programme. The Government has recognized that malnutrition is an impediment to human resource development and hopes that making nutrition a priority will ensure that future generations of school children and skilled labourers will have the opportunity to reach both their physical and 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 the National Nutrition Council (NNC) was created by a presidential decree and given responsibility for formulating a national programme for nutrition, called the Philippine Nutrition Program (PNP), and for coordinating ail related activities. At the same time, the Nutrition Center of the Philippines (NCP) was founded with a mandate to harness the resources of the private sector to support the Philippine Nutrition Program.

The Philippine Nutrition Programme

The PNP intervenes in four major areas (2):

1. Nutrition information and education: The priority targets for this intervention are the mothers of malnourished preschool children 12 to 66 months of age. The goal is to increase the mothers' knowledge and improve their feeding practices for their children.

2. Health protection: Health protection services are both curative and preventive. Curative measures include medical services to moderately and severely undernourished preschoolers susceptible to infection. "Mal-wards" are set up in hospitals, and in remote areas "Nutri-huts" are built. Immunization, deworming services, and sanitation campaigns are among the preventive measures.

3. Food assistance: As an emergency measure to improve the nutritional status of moderately undernourished preschoolers, supplementary feeding programmes are undertaken. The use of locally available food commodities is encouraged and promoted.

4. Food production: The primary goal of this intervention is to promote backyard and school gardens for the purpose of increasing household consumption of more highly nutritious foods.

A village-level nutrition worker, called the "barangay nutrition scholar," is the grass-roots link between the families of malnourished children and the implementation 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 barangay nutrition scholar for each of the 42,000 barangays (villages) 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 PNP (3).

THE NUTRI-BUS PROJECT: BACKGROUND

The Pilot Study

Early in 1976 the NCP decided to test the relative effectiveness of different communications media in bring about behavioural changes in mothers with regard to feeding their children. The behaviour selected for measurement in the pilot study was the purchase of a nutritious product to add to the child's diet.

"Nutri-Pak," a product then under development at the NCP, was selected to serve as:

a nutritious supplementary food, supplying 50 per cent of the daily protein requirement and 30 per cent of the daily calorie requirement for a child 12 to 36 months old (4),
a communications medium,
a measurement of behavioural change, through the monitoring of its sales.

Nutri-Pak contains cracked rice, ground mung beans, coconut oil, and powdered milk. Each ingredient is packed in its own small, clear plastic bag, and these are then packaged together to make one Nutri-Pak. The product serves as a communications medium because it is packaged to show the user the correct types of locally available foods needed for preschoolers and the relative amounts of these foods required. 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 in which to conduct the pilot project. Thirty villages were chosen at random for the project from among all the rural villages in Leyte that met certain criteria known to affect health and nutrition status and to control for cross contamination of treatment groups. These villages, in turn, were assigned on a stratified random basis to each of six experimental conditions.

Barangay nutrition scholars (BNS's) were recruited and trained for the sample villages to be "change agents" and to sell Nutri-Pak at a subsidized price. All BNS's recruited were trained by the Regional Health Training Center of the Ministry of Health in basic nutrition and by the NCP in product knowledge. Half of the BNS's then returned to their villages to promote better nutrition in general and to promote and sell Nutri-Pak. The other half were given an extra day of training in simple communications skills to help them persuade mothers to change their child-feeding practices and to promote and sell Nutri-Pack. After the BNS's had returned to their villages,

one-third received no further support except deliveries of Nutri-Pak to distribute;
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 Nutri-Pak;
one-third were supported by a video van that visited the village once a week for 10 weeks to show four specially designed television programmes on nutrition and to deliver Nutri-Pak.

Special comic books and video tapes were developed for the project by the NCP, using a rigorous process designed to produce communications to bring about behavioural change (see fig. 1). The television tapes actively involved the viewers in the learning process by posing specially developed questions at carefully designed intervals throughout the tape (see table 1). The person who administered the showings paused the tapes at each question and encouraged answers and discussion from the viewers. The tapes and questions were designed so that the viewers would be challenged but capable of answering correctly in almost every case. When the tape was started again, it provided feedback and reinforcement for the answers.

The story-line and nutrition content of the comics and video tapes were the same. Both were pre-tested with mothers representative of the target population but not residing in the sample villages and were revised after results were assessed.

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 preschool 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, this 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. Sales amounting to 5 per cent or more of the total "ideal market" were to be considered a success.

The objectives of the pilot project were:

to determine the most effective communications medium to change mothers' behaviour in feeding their malnourished children
as measured by Nutri-Pak sales;
to determine a communications medium which could bring about sales of Nutri-Pak equal to or greater than the minimum criterion of 5 per cent of the total "ideal market."

The result of the study was to demonstrate that

sales of Nutri-Pak were nearly three times greater in the villages visited by the video van where the BNS had been given one day of communications training than under other conditions;
that was the only situation in which sales reached or exceeded the criterion of 5 per cent of the "ideal market."

Expansion of the Project

On the basis of the results of the pilot project and a continuing interest in using video vans for nutrition education, the NCP decided to expand the project to three buses in Leyte. However, the attractiveness of the concept and the video-van tapes caught the attention of other donors, and soon the Nutrition Center had over 30 fully equipped "Nutri-buses." This provided an early opportunity to implement the programme 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 in service in Leyte and Samar. They carried the videotaped shows and other services (Nutri-Pak re-supply, print support materials, supervision for the BNS's) to the villages twice a month.

EVALUATION OF THE NUTRI-BUS PROJECT

In order to monitor the project, data were to be collected every two years to measure knowledge and attitude change and impact on nutritional status of the programme. The hypothesis to be tested was the "null hypothesis": that the project would have no significant impact on the variables being measured.

1979 Sample Selection

All villages accessible by road in areas of Leyte and Western Samar where the Waray-Waray dialect is spoken were divided into four groups representing different degrees of intervention:

those with a BNS present in which Nutri-bus services were started between August and October 1978, providing a longer exposure to video-tape recordings- designated "VTRL";
those with a BNS present in which Nutri-bus services were started between November 1978 and January 1979, providing a shorter exposure to video-tape recordings-designated "VTRS";
those with a BNS present that had been selected to receive Nutri-bus services but had not yet been reached by the Nutri-buses-designated "BNS";
those with no BNS and no Nutri-bus services (these villages did not meet the socio-economic criteria and did not have BNS's because they were slightly better off)-used in the study for comparison purposes.

Sample villages were selected from each of the four groups on the basis of criteria meant to control for the factors known to influence nutritional status and nutrition knowledge, as follows: VTRL group, eight villages; VTRS group, six villages; BNS group, five villages; comparison group, five villages.

FIG. 1. The "ABC Model" for Developing Communication to Change Behaviour ((c) Development Communications Consultants, Inc., 1983)

Since the village populations were relatively small, it was decided that it would be more accurate and less costly to weigh all preschool children and interview all mothers of preschool children rather than sample within villages. However, since there were no definite boundaries for many of these villages, no maps, no current census data, and no lists of residents, it was impossible to know precisely how close we came to reaching this goal.

TABLE 1. Interactive Learning and Motivation Strategies for Communication to Change Behaviour

Strategy	Definition
1. Discovery/logical conclusion	Learner is exposed to certain information and then asked to make a decision logically following from that information
2. Analogy/logical conclusion	The audience is reminded of something familiar that works on the same principles as the idea being taught and is then asked to draw conclusions from the new information based on the analogy
3. Specification	Learner is given general principle and asked to apply it by giving specific examples
4. Generalization	Learner is given specific examples and asked to conclude the general rule
5. Observation 1-Description	Audience looks at certain conditions and reports what was seen
6. Observation 2-Comparison	Audience looks at two or more sets of conditions and reports differences and/or similarities
7. Observation 3-Modelling of desired behaviour	Audience is asked to observe behaviour to be learned and to describe this correct behaviour or some of its elements
8. Prompting	Audience is helped towards the correct answer through clues
9. Fading	Previously elicited and reinforced behaviour is asked for again, with less supporting information and fewer prompts
10. Personal opinion, preference, feeling, experience, or data	Audience is asked to give opinions or preferences, tell some personal feelings or experience, or give data about themselves or their children (name, age, etc).
	This is the strategy used for the first interaction of a programme. The subject matter chosen should be non-threatening to the audience but something they might like to talk about. The purpose is to:
	(a) have an opportunity to reinforce the audience for responding
	(b) introduce the subject of the module
11. Public commitment	Audience is asked to commit themselves regarding some attitude, opinion, or value that is being shaped by the module. This is done in order to
	Strengthen that attitude, opinion, or value as a motivation to act, or as a
	Motivation to learn what is in the module
12. Performance of entering behaviour	Audience is asked to do or say something they already know how to do or say. This is used only if:
	(a) the entering behaviour is weak and needs to be reinforced
	(b) the entering behaviour is part of a logical sequence of interactions leading to a strong type of interaction

Source: Development Communications Consultants, Inc., 1983

The data-gatherers, working together with village leaders, did their best to reach all families with preschool children. To establish a reliable estimate of the number of preschoolers in each village, the village leaders' best estimate was compared with an estimate arrived at by multiplying the 1975 census figure for the village population by 20 per cent (the approximate proportion of preschoolers in the population) and then multiplying that by the national rate of population growth for four years. Villages where there was no major discrepancy between the two estimates and where the data-gatherers were able to reach 80 per cent of the number of preschoolers estimated by the calculation from the census figure were retained in the sample; villages where there was a large discrepancy between the estimates or where fewer than 80 per cent of the estimated number of preschoolers were reached were discarded from the analysis.

1979 Data Collection

Data were collected by four teams working simultaneously in four villages at a time. The interviewers were recruited in Leyte, and all spoke the Waray-Waray dialect but were not known personally in any of the villages. They were registered nurses and schoolteachers. Those doing measurements were NCP staff members, trained and experienced in taking weights and heights. The teams received one week of classroom training and three days of practical training before data collection began.

Team members and measuring instruments were rotated so that each contributed an approximately equal number of measurements to each experimental group. The rotation also attempted to equalize the pairing of individual team members to minimize pairs developing somewhat different procedures.

The measurements and interviews took place in a central location (usually the church) in each village. Mothers registered at a check-in point and waited outside to be called by the measurer. After the children were measured, their mothers were interviewed.

To try to prevent contamination of the interviewing results, each interview area was roped off with cords and stanchions to prevent the mothers from hearing each other's answers. When the interview was completed, the mothers were directed out of the chapel away from the waiting mothers and encouraged to go home to avoid conversation with the waiting mothers.

Two potential sources of error in weighing are squirming, flailing children and scales not calibrated to zero. Nearly all squirming and flailing was eliminated by weighing the children in the arms of a "surrogate mother" and later subtracting her weight (i.e., weight of mother and child less weight of mother = weight of child). Also, zero calibration of the scales became less critical when the child's weight was determined by this difference method rather than by taking the absolute weight.

Another potential source of error in determining weight for age is the accuracy of the birth date. It was found that most mothers had either a birth certificate or a baptismal certificate (or both) for their children and that church records could be used to get accurate birth dates for most of the children whose mothers had lost their documents. It was thus possible to document birth dates for 88 per cent of the children. Children for whom documentation of birth dates was not available were excluded from the analysis. Families who had lived in the village less than six months were also eliminated from the analysis.

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