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Sex

The intra-household distribution of food that systematically favours men and boys at the expense of women and girls represents a complex social problem which results from (i) an inadequate perception of the needs of women and girls, or (ii) an "adaptation" process that holds women's needs and their contributions to the household and society as socially inferior and of secondary status to men's.

The word adaptation is used in quotes because most reported cases of sexually biased food distribution practices have been thought to be determined by economic rather than biologic adaptation processes [26, 60, 89]. It is believed that distribution practices vary in times of scarcity versus greater food availability, with greater allowances made for economically productive household members. More research, however, is needed to identify the impact of seasonal variations in food availability on changes in distribution practices, and nutrition and health status over time.

The implication of food scarcity and its effect on IHFD was addressed by Safilios-Rothschild. She states [138, p. 328]:

Scarcity of food in low-income families poses dramatic questions of social inequality. As long as there is enough food for all members of the family, the existence of inequalities in its distribution does not usually pose serious problems. It is a different story if food is scarce. Then, whether food is equally or unequally distributed among family members becomes an extremely important issue with poignant implications. The difference between being a favoured and a disadvantaged family member is the difference between mild undernourishment resulting in energy deficit, and malnutrition that threatens actual survival. In many cases, equal distribution of food would imply that all family members would be to some extent malnourished. They would, however, be unequally malnourished as they would have different minimum caloric and protein requirements Food inequalities can be sustained in families partly because they believe that the favoured members (for example, adult and adolescent males, or males in general) need more food and partly because food taboos and traditional food beliefs often conveniently justify an unequal distribution of food to the disadvantage of children and lactating and pregnant women. While food inequalities favouring the men, who are often the main breadwinners, have been referred to as "rational" for the survival of the family, we do not know whether the equal or greater productive contributions of women entitle them to an equal or greater share of food, or whether control of income earned by women, and their economic autonomy, are prerequisites for food equality.

This passage calls to light the need for investigators and programme planners to identify the determinants of household distribution processes before designing combative health and nutrition interventions. When distribution reflects inappropriate nutritional knowledge, one type of intervention is required. When it reflects a survival strategy, it requires another. When food supply is chronically low, yet reasonably stable, inequitable IHFD practices may not be due to a single identifiable cause only. They may reflect the perpetuation of social norms established in case of economic emergency, or justify social status and perceived future roles. Greater efforts are needed to identify appropriate interventions to influence IHFD practices when neither inadequate knowledge nor acute starvation is at the root of distribution inequities. Specifically, it is important to identify effective means for influencing the distribution and flow of food toward women when they are nutritionally disfavoured.

A woman's health and nutritional status throughout her life-cycle is important to her ability to fulfil both her productive and reproductive functions. Household survival strategies tend to overlook or undervalue women's contributions to household production. They also inadequately recognize the importance of a woman's childhood health to her later reproductive success. Investigators in Guatemala, in a longitudinal study of the effect of maternal supplementation on birth outcome, found an independent contribution of maternal height to birth weight [64]. These effects were found to be as great as the contribution of maternal weight and caloric intake during pregnancy. Chronic undernutrition, resulting in maternal stunting, reflects environment, health, early nutrition, and genetic influences. The association of maternal height with pregnancy outcome suggests that a woman's previous health and nutritional history is an important determinant of birth outcome.

The importance of nutrition for the health of women during pregnancy and lactation is widely recognized. Less understood are the nutrition and health needs of adolescent girls in preparation for reproduction [110]. It is currently unknown, for example, whether early childhood nutritional deficits can be made up during adolescence. There are increased risks of maternal and child morbidity and mortality associated with adolescent pregnancy. It is unknown, however, if this increase in risk is due to age per se, or to the lack of social support and the poor quality of care a young woman may receive during pregnancy [38] .

There is evidence that providing education and employment opportunities for teenage women delays their age of first marriage [128]. The postponement of marriage and the delay of first pregnancy have been cited as important means for stemming rapid population growth [160]. More research is needed to determine if the existence of employment opportunities for teenage girls can also result in improved childhood access to health, education and other household resources, as well as later improvements in reproductive health. Investigators must also document the impact of premarital employment on a new wife's decision-making in the home. important variables to study include acceptance and use of family planning, and the control and distribution of resources (especially education) for both male and female children.

Most health and nutrition programmes have recognized the importance of a woman's reproductive health, but have focused on only improving her reproductive abilities once she becomes pregnant. These efforts have overlooked household dynamics and household socialization processes that operate against women, beginning at a very young age. Therefore, we are suggesting initiatives that address the determinants of household behaviour and specifically aim to influence intra-household distribution practices that operate against girls and women. These initiatives will include an analysis of all IHHRD.

IHFD, as hypothesized, is believed to be determined by income and work patterns. When women are disfavoured it is relevant to study distribution practices in terms of whether they are employed for cash or paid in kind. A community-wide assessment might consider the presence or absence of distribution bias in relation to a woman's life-cycle state (reflects changing nutritional need) and employment status (see tables 7 and 8). Another assessment might identify relevant variables that differentiate households in which female children and women are both underserved from those households where women receive adequate diets but fail to provide their daughters with the same. The purpose of these studies is to identify the determinants of IHHRD, to assess their impact, and to uncover points of resistance and effective avenues for change.

THE BASIS FOR THE USE OF HEALTH AND NUTRITION EDUCATION

We believe that educational efforts to date have been largely ineffective in motivating prolonged behavioural change and health and nutritional improvement. As described in the literature, the reasons for this ineffectiveness are various. The common criticism is that nutrition and health education programmes have been designed with little regard for culturally rooted beliefs and practices. Other criticisms include the following: educational messages have prompted the use of locally expensive or unavailable foods [67], have visually depicted behaviours that are conceptually unrecognizable [116], and have utilized characters or persons who are alien to target audiences [55].

TABLE 7. Sample table for the study of bias in IHFD in relation to women's employment status

TABLE 8. Sample table for analysing IHFD by resource availability

Only a small percentage of all educational programmes are ever evaluated, and those that are often suffer from inadequate evaluation of design [71] . Nutritional behaviour and status are the result of a complex number of factors. Zeitlin [163] argues that educational programmes should separately assess the success and costs of changing knowledge, attitudes, behaviour, and improvements in health and nutritional status. Unfortunately, most evaluations fall short of this goal, measuring only changes in knowledge or, at best, reported behaviour. Reported behaviour, however, is not fact. When reporting on value-laden concepts such as health, nutrition, and child care, women may idealize behaviour and report what they think the questioner would like to hear. Snow and Johnson [142] observed this pattern in a study of dietary beliefs and nutritional habits among lowincome women attending an urban, multi-ethnic, pre-natal clinic in the US. They found that 90 per cent of the women surveyed knew the proper answers to questions about diet during pregnancy based on information provided by physicians during pre-natal visits. Further questioning about actual behaviour, however, revealed that women were unlikely to heed a physician's advice when previous experience or information obtained from friends and relatives was in conflict with "doctor's orders." Pelto and Jerome [ 120] and others have observed similar discrepancies between reported and observed practices.

The timing of an evaluation critically influences the perceived impact of nutrition education programmes. Munoz de Chavez [107], for example, attempted to evaluate the impact of three different educational programmes carried out in three villages in rural Mexico. In the first village, a physician identified and treated undernourished children, and provided instruction on hygiene and food preparation for mothers. Weight gains were observed in each of these children within five months. Although the author did not address the causes of nutritional change, it is difficult to attribute observed improvements to the educational programme alone, as weight gains may have been due to aging.

In the second village, the same treatment was given, but augmented with home visits by an educational aide. Evaluations carried out three months later found that all visited children had improved-the aging factor may have played a role-and 81 per cent were classified as normal according to Mexican growth standards. After two years, none of the children was diagnosed with second- or third-degree undernutrition. The author concluded that home visits (face-to-face education) improved on the results achieved by the physician alone.

In the third village, a nutritionist held demonstrations every 15 days on food supplementation, breast-feeding, and food preparation. These meetings were attended by all women with children of 3 to 24 months old, and included follow-up home visits. The first evaluation found that 70 per cent of the women understood the advice given, but reported that poverty prohibited them from changing behaviour. After six months, a second evaluation showed the nutrition of the children "greatly improved" because families shared their total diet with infants and children. A third evaluation, three years later, noted that all infants had survived despite local epidemics, and all achieved "adequate growth." The author did not report any population statistics nor did she explain the definition of undernutrition used. Her evaluation approach is important, however, because it highlights the need to look at behaviour and status change over time, while underlining the difficulty of attributing improvements in nutritional status to education alone.

Follow-up evaluations have also been used to assess the potential of education in preventing undernutrition in children born after a programme has been offered. The Promotora Program in Candalaria, Colombia, for example, trained health workers to make home visits to all homes of families in the project area with children under two years of age. During the visits they provided education on nutrition, hygiene, and health-care-service utilization. The programme lasted six years, and a 25 per cent decrease in undernutrition prevalence was noted despite a decline in family income at this time [36]. Two years later, evaluators found that children of participating families, born after the end of the programme, were no better off than those from families who did not participate.

Berggren [15] found the opposite to be true of children born to mothers who previously attended Mothercraft Centers in Haiti. He observed that two to five years after discharge, 75 per cent of younger siblings had a higher percentage of standard weight-for-age than the original enrollees.

The Promotora Program and the Mothercraft Centers were intensive efforts that required large investments of time and capital. Similarly, most face-to-face educational programmes that report improvements are carried out as special pilot or research efforts. Education has been associated with improvements in health and nutritional status. Unfortunately, there is little evidence that such specialized efforts can be duplicated at low cost, or on a large scale in other areas. Education through mass media, based on the principle of reach and frequency, has been employed on a large scale in many developing countries. The techniques used and the success of such efforts merit further attention.

MASS MEDIA AND SOCIAL MARKETING TECHNIQUES

The term mass media refers to the use of radio and television and other forms of audio and/or visual media channels such as newspapers, posters, films, slides, cassettes and product labels [163]. Education through mass media has been used on a national scale in countries such as Indonesia, Brazil [29], the Philippines [28], Nicaragua, Tunisia [104], and Malawi [4] to promote breast-feeding, preparation of improved weaning foods, home treatment of diarrhoea, and other topics of public health concern. Local projects in Micronesia and Mexico [24] have promoted similar goals. Several additional projects are outlined in APHA [5] .

Radio has been the predominant medium used for the communication of these programmes, in part due to the large increase in individual ownership and access to radios, estimated to have been over 300 per cent in the developing world from 1966 to 1976 [74]. Nutrition and health messages have been transmitted by radio in popular songs, through radio dramas, and through informational question and answer programmes. These programmes reach a large audience, but catchy jingles or messages, broadcast as entertainment, are believed to be more recognizable than information relayed through longer programmes [163]. Information relayed through radio has been shown to reach not only radio owners but friends and relatives, as well as other listeners [136].

APHA [5] and Munger [106] give descriptions of specific radio programmes and guidelines for designing mass media messages.

Mass Media Programme Evaluations

Leslie [87] reviewed the results of nine mass media nutrition education programmes in Asia, Latin America, Africa, and the Pacific islands. She also examined six programmes, selfdescribed as health education, in Kenya, Tanzania, Senegal, Haiti, Guatemala and India. Leslie considered the type of medium, duration, and target audience of each programme. In reviewing the results of each effort, she noted that evaluations concentrated most frequently on outreach (number of persons reached), and reported attainment of educational and behavioural objectives. The calculated costs ranged from $.0001 to $2.75 per contact. The more expensive programmes received a high level of foreign technical assistance. Only one programme, in the Philippines, where women were instructed to add oil to weaning foods, included an evaluation of health status change. No weight gains were noted in children receiving oilenriched weaning foods, but authors attributed this to the small amount of oil added, and the relatively short duration of the programme at the time of its evaluation [163] .

Leslie concluded, based on all the evaluations, that 10 to 50 per cent of the people reached by mass media education remember the main message of the programme. Projects in the Philippines, Nicaragua, and India reported behavioural change. An extensive evaluation of the Philippines project, reported in Zeitlin and Formacion [163], addressed the differences in behavioural change between the adopters and non-adopters. They found that adopter-mothers were significantly more likely to believe their children were not growing well. The entire study population reported having future expectations for their children (45 per cent hoped their children would become doctors, nurses, or other professionals), but results were not broken down by sex to determine if innovation and aspirations were related to the sex of the child.

Hearing the message from more than one source clearly increased the rate of behaviour adoption. Adopters were more likely than non-adopters to hear the message from friends, health workers, and relatives. Patterns of adoption appeared to indicate that face-to face education from the health worker improved awareness, but that persuasion from friends ultimately motivated behavioural change.

This conclusion is congruent with the general belief that behavioural change due to communication is a two-stage process-of learning and gaining approval-for implementing behavioural innovations. Some of the critical questions to answer in the use of marketing techniques for nutrition education are listed in table 9.

The Behavioural Change Component of the Indonesia Nutrition Improvement Programme was part of a national programme with preestablished nutritional objectives. The programme included the active participation of community women in the design and testing of educational messages. The programme focused on the identification of local beliefs and practices regarding maternal nutrition and infant feeding, and women's responses to proposed feeding changes. Interviewers conducted "anthropologicalstyle" interviews in a sample of homes with undernourished children, and diet modifications were suggested based on observed conditions. The results of the surveys and behaviour change trials were applied to the development of a series of educational objectives and media messages. A media habits profile was also developed from the household interview results to identify the most effective communication channels for reaching mothers with young children. Mothers were consulted on the appropriateness of each message. Evaluations of this programme have shown that it was successful in promoting behavioural change and that improvements in nutritional status were realized [59, 95, 96].

For more specific information on this programme, readers are advised to consult the project reports [95] . It is worth while to note that the intensity of this effort may prohibit its duplication in other areas where professional, political, infrastructural, and funding commitments are not as great. The programme, however, is noteworthy for its intrahousehold component and its ability to assess directly the limitations of participants' ability to modify behaviour by involving women in programme design. Pre-testing improved the probability of message impact.

NEW APPROACHES TO HEALTH AND NUTRITION EDUCATION

Though some previous programmes have specifically attempted to improve maternal nutrition, few efforts have considered household factors, and the social and economic realities that perpetuate poor health and nutrition among specific household members. Nutrition and health education to date has been narrowly defined. It has been limited to the promotion of knowledge, attitudes, and practices associated with the prevention and treatment of disease and nutritional deficits, rather than toward improving behaviours and conditions that influence the functioning of individuals at the household and societal levels. We are suggesting that we should rethink the purpose of health and nutrition education, broadening its objectives to include knowledge, attitudes, and behavioural changes with respect to factors affecting the role and status of women in society, the division of labour, and the distribution of resources in the home.

Communications specialists agree that mass media can be used to influence attitudes toward certain behaviours. We are suggesting action-oriented research to identify the effectiveness of mass media alone, and in combination with other interventions, in changing attitudes toward household division of labour and resource use. Specifically, we are advocating the identification of decision-making processes that contribute to inequitable resource distribution and discrimination against any household member in access to food, health care, education, and employment opportunities. When distribution or discrimination is based on the transmission of knowledge between generations within the home, we recommend the targeting and testing of behavioural change messages aimed at appropriate decision making and support individuals.

TABLE 9. Critical questions to be answered in the development and design of health and nutrition programmes
1. What is the specific health or nutrition problem?
2. What aspect of that problem is amenable to change through education?
3. What can the target group do about this specific problem?
(a) What resources do they have for action?
(b) What new behaviours can the target group realistically be expected to adopt to address the health problem?
4. What will the specific behavioural objectives be?
5. What are the cultural, economic, and social barriers to the new behaviour?
6. What channels of communication can be used to reach the target group with sufficient frequency and authority?
7. What materials would be most effective in delivering the message through these media?
8. What motivational devices should be used to stimulate the target group?
9. Do the answers to these questions suggest that the target group should be segmented? 10. How can the impact of the communication be monitored or tracked without great expense and without disrupting the programme itself?
Source: Manoff International [96].

FIG. 6. Household production, consumption, and socialization

When behaviour is the result of resource scarcity or inadequate resource control, we recommend the implementation and testing of combined interventions that enhance access to and control over resources. Finally, when health and nutrition are perceived as a woman's responsibility only, and this perception is detrimental to the wellbeing of the woman and the family, we propose the design and use of educational messages that stress the importance of health as a family concern. The effectiveness of these measures will be tested through changes by different household members in time allocation and income budgeting for household maintenance and welfare activities.

OTHER EDUCATIONAL TECHNIQUES

Throughout our discussion of new approaches to health and nutrition education we have emphasized the use of mass media to promote a variety of behavioural change objectives. A thorough examination of other educational techniques and programme objectives, such as health worker training, the dissemination of information through existing health and nutrition services, school-based education, nonformal adult education, and child-to-child programmes is beyond the scope of this article. We must stress, however, that we are interested in the design, implementation, and evaluation of messages delivered through all types of educational programmes. We are advocating the use of both the communications media and face-toface instruction to promote a wide range of behavioural changes. Greater attention must be paid by education programmers and planners to the identification of effective means for integrating intrahousehold decision-making factors into the design and implementation of all educational programmes. Suggestions for the specific content of these programmes require further discussion and will be the subject of future research.

CONCLUSION

This article has stressed the importance of the household as a programmatically useful and necessary unit of analysis. We have discussed the significance of intra-household processes in influencing decision-making. Health and nutrition behaviour, we believe, is motivated by a complex set of factors. We must study household production, consumption, and socialization processes to identify the context of behaviour and to design broad-based health and nutrition interventions.

Nutrition education, as defined by Whitehead [158] "teaches the learner to make effective choices in light of existing food supply...." What is considered effective may vary with changes in food availability and may also be determined by a wide range of cultural, environmental, and economic variables that are often overlooked by educational planners. We are advocating the study of these co-variants of behaviour in the design of educational interventions.

Household decision-making on resource use is determined by power bases within the home. Distribution of household resources is based on perceived needs and future expectations. Interventions to improve decision-making alone will not be sufficient. Programmes must advocate equitable distribution through socialization, by promoting activities to enhance both the perceived economic and social value of all household members (fig. 6).

A woman's health and the health of her children and her family are intricately intertwined. If women's present state of health is in part determined by childhood care, female children should be given greater early-life attention. The attention given to children's health, education, and nutrition in early life is affected by the expectations parents and community have of their future roles. These expectations are largely shaped by societal beliefs and economic circumstances. When women have low social status, they will probably not receive as good care and attention as those family members who are considered more important, importance usually being defined by economic contributions. Importance should, however, be redefined for each household member, especially women, given their importance to family health and economic well-being.

Since women are instrumental providers within the household, efforts must be made to improve their provisioning options and power. Women's low status and the socializing processes operating to maintain it are lifelong events. New responsibilities should not be imposed on women, especially if they only benefit their children, at the women's expense. New interventions, importantly those in health and nutrition education, should be designed to mould the household environment so that it provides the best possible conditions for attaining prolonged and multi-generational improvements in health and nutrition. In evaluating these interventions, future research must consider the consequences of intra-household processes.

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