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Nutrition policy

Planners' and professionals' attitudes towards nutrition-related policies and issues in developing countries: A case study in Morocco


Planners' and professionals' attitudes towards nutrition-related policies and issues in developing countries: A case study in Morocco

Sabah Benjelloun
Department of Nutrition, Rabat-Instituts, Morocco

Rhonda Dale Terry
Iowa State University, Ames, Iowa, USA

While it is widely accepted that adequate food supplies and a healthy population are necessary for national development, there has been considerable controversy over how nutrition concerns should be integrated into the development process. The issues debated are many, and include the nature and determinants of nutrition programmes as well as optimal solutions.

The wide divergence of opinion on these issues is, no doubt, due in part to the divergent backgrounds of professionals in the field. While information is increasingly available on the relative merits of various nutrition-related policies and programmes, few data are available on the ideological profiles of planners and professionals involved with nutritionrelated activities in developing countries. There is little doubt that their attitudes affect their decisions for solving nutrition problems. The purpose of this study was to determine the attitudes of influential planners and professionals toward nutrition-related policies and issues in a developing country, Morocco.

Nutrition-related characteristics of Morocco

Morocco has many characteristics typical among developing countries. Located on the north-western coast of Africa, it is sharply divided into open, agriculturally rich plains in the northeast, and economically and agriculturally poor mountain and plateau regions in the east and south. Despite the fact that a large percentage of the agricultural land is devoted to growing grain, the production is unable to meet the country's need. From being a net exporter of grain until the 1 960s, Morocco has become a net importer of grain. These imports account for approximately a third of total needs, leading Morocco to spend more foreign exchange on food than on any other sector of the economy [1].

The Moroccan diet consists largely of grains, mainly wheat. Grain-based foods provide approximately 60% of the caloric intake and 70% of the protein intake [2]. Major supplements to these foods (listed in decreasing order of weight of food per person per year) are vegetables, fruits, milk and cheese, and sugar [2]. Less prominent in the diet are meat, fats, legumes, and fish. Although data are limited, dietary, clinical, and biochemical nutritional assessments indicate that proteinenergy malnutrition, nutritional anaemia, and goitre are prevalent health problems among subgroups of the population [3, 4]. These data, combined with a high infant mortality rate of approximately 97 per 1,000 [5], indicate that significant nutritional-status problems exist among the Moroccan population.

Two years after the country gained independence in 1956, the Interministerial Committee for Food and Nutrition (CIAN) was to formed to formulate and monitor a national nutrition policy. It is still in existence. Currently, most ministries include food and nutrition considerations in their written plans of work, and several carry out applied nutrition programmes, such as school feeding, food distribution, nutrition education, and nutrition rehabilitation.


A questionnaire was developed to assess descriptive characteristics and attitudes of planners and professionals toward selected nutrition issues. The 41 attitudinal statements of the questionnaire were developed by identifying eleven major topics relevant to nutrition planning in developing countries, with an objective for each topic, and writing three to six statements for each objective to reflect the Moroccan and international debate related to the topic. Five experts in international food and nutrition reviewed the statements for content-related validity, and a bilingual expert validated the English-to-French translation. A five-point Likert-type scale, ranging from "strongly agree ''to'' strongly disagree," was used to measure the subjects' concurrence with each statement. This paper reports on attitudes toward six topics with international applicability.

The data were collected during June and July 1985. Potential subjects who held policy-making positions in institutions involved directly or indirectly with nutrition activities were identified through key nutrition planners in Morocco and by using organizational charts. One hundred twenty-one subjects from government ministries, international food and nutrition organizations, and academic and research institutions were contacted, and 1 13 participated in the study. Each participant was given the questionnaire individually and was allowed one week to fill it out. The demographic data gathered included the participant's sex, age, employer, position, nutrition related activities, and educational background. Chronbach's alpha coefficient of internal consistency was computed for the attitudinal responses and was found to be a = .72, which was judged acceptable for educational research [6].


Characteristics of the participants

Of the 113 subjects who participated in the study, 67% worked for a government ministry, 25% for an academic or research institution, and 8% for an international organization. The subjects were predominantly male (93%), younger than 40 years old (72%), and held a master's degree (66%) or a doctor's degree (11%). As is true for nutrition-policy planners in other countries [7], these planners' and professionals' major fields of study were quite diverse, with economics (40%), agriculture (32%), and statistics (26%) most frequently cited. Only 21% had degrees in nutrition- or health-related fields, and 51% had received all of their educational degrees in fields in which nutrition is not likely to be included in the curriculum. Apart from the teachers and administrators, 92% held administrative positions as head of an office or higher.

Nutrition-related attitudes

The subjects' responses to the attitudinal statements on six topics are presented in table 1. In the following discussion of response frequencies, the responses Strongly agree and Agree are referred to as "agree," and Strongly disagree and Disagree as "disagree. "

Nutritional status, health, and educational achievement

It is now well known that malnutrition and disease are synergistic. The interaction between the two is especially pronounced among young children and the poor in developing countries. The diets of these groups often do not supply adequate nutrients for optimum immunity, and the environment may cause a high level of exposure to disease pathogens. Most of the nutrition planners and professionals in this study agreed that nutritional status and health are interrelated. For example, almost all respondents agreed that good nutritional status is one of the most important determinants of good health, and more than three-fourths agreed that improving nutritional status is a good way to reduce the frequency of infectious disease.

Unlike the malnutrition-disease interrelationship, the effects of malnutrition on educational achievement are less clear. In children it is difficult to untangle the behavioural effects of psycho-sensory and affective deprivation from those of acute or chronic malnutrition. Nonetheless, over 90% of the Moroccan planners and professionals agreed with the statement that the nutritional status of children greatly influences their educational achievement.

Population growth and nutrition

The contribution of a high population growth rate to malnutrition in developing countries is controversial. One school of thought maintains that the two are closely linked; an alternative theory holds that population growth enhances world resources and should not be a major focus in combating malnutrition. It appears that the majority of the respondents in this study subscribed to the former view. Sixty-four per cent agreed that the high population growth rate is an important cause of Morocco's food and nutrition problems. However, only 44% agreed that a reduction in population growth would be a practical way to overcome Morocco's food shortage, and 38% disagreed. Thus, at least one-third of the respondents did not view reducing food demand by population control as a practical means to increase per capita food supplies.

TABLE 1. Responses of 113 participants to attitudinal statements on six topics relevant to nutrition planning in developing countries

Agree Neither

agree nor


Disagree Strongly
The relationship of nutrition to health and educational achievement
Good nutritional status is one of the most important determinants of good health 47 51 1 1 0
A good way to reduce the incidence of infectious diseases in 24 55 11 91  
Morocco is to improve the nutritional status of the people.          
The nutritional status of children greatly influences their educational achivement 47 45 7 1 0
The relationship between population growth and achievement
High population growth rate is an important cause of Morocco's food and nutrition problems. 18 46 14 21 1
A practical way to overcome the food shortage in Morocco is to reduce the rate of population growth 10 34 18 35 3
Improving the nutritional status of children can be an important factor in reducing Morocco's rate of population growth 6 35 27 26 6
The integration of nutritional considerations into agricultural policies
The design and evaluation of an agricultural project should include population its impact on the nutritional status of the 40 56 3 1 0
Encouraging the production and consumption of legumes is a good way to reduce malnutrition in Morocco 19 58 19 4 0
In order to overcome malnutrition, Moroccan agricultural policy should place more emphasis on animal production than on crops. 6 13 34 38 9
Multidisciplinary nutrition planning
It is preferable to plan independent nutrition programmes within each ministry rather than to plan multidisciplinaryprogrammes involving several ministriesbecause it depresses local food production. 2 11 12 55 20
Multidisciplinary nutrition programmes involving several ministries are unrealistic for Morocco because they are extremely difficult to co-ordinate. 6 32 13 43 6
The Interministerial Committee for Food and Nutrition (CIAN) plays an important role in co-ordinating nutrition programmes in Morocco 1 15 62 18 4
National strategies to reduce malnutrition
Nutrition intervention is more likely to be successful when it is part of an integrated development project than when it is a separate project. 40 54 4 2 0
In Morocco, regionally planned programmes are more likely to be successful in solving nutritional problems than nationally planned programmes 14 51 24 11 0
Malnutrition in Morocco can be virtually eliminated by nation-al industrialization. 5 24 29 37 5
International food aid
Because of the danger that international food aid to Morocco will be discontinued, it is best for Moroccan nutrition programmes to use only local foods. 25 62 12 1 0
Without international food aid, Morocco would not be able to meet the food needs of the population. 2 15 14 56 13
International food aid, if used appropriately, makes a significant contribution toward combating malnutrition in Morocco. 3 33 28 28 9
International food aid is harmful to Morocco's economy 9 34 35 20 2

Attitudes toward the child-survival hypothesis were also mixed. This hypothesis states that if children are better nourished, their mortality will decrease and parents will give birth to fewer children to compensate for the ones who might have died. Forty-one per cent agreed and 32% disagreed that improving the nutritional status of children can be an important factor in reducing Morocco's rate of population growth.

Nutritional considerations in agricultural policies

The potential positive impact of agricultural advances on the nutritional well-being of populations in developing countries has long been recognized; however, agricultural programmes have often ignored local nutritional-status problems and local food needs [8]. In this study, 96% of the respondents agreed that nutritional status should be considered in both designing and evaluating agricultural programmes.

There was less consensus on the future emphasis for agricultural production. Seventy-seven per cent agreed that legume production and consumption should be encouraged. Consumption of legumes, a nutritionally valuable food in the traditional Moroccan diet, has declined in recent years because of rising prices. Only 19% agreed, while 47% disagreed, that placing more emphasis on animal production than on crops is a means to overcome malnutrition in Morocco. Thus, few apparently subscribed to the hypothesis that high-quality animal foods are more important than an adequate variety of plant foods for alleviating malnutrition.

Multidisciplinary nutrition planning

During the last decade it has become increasingly accepted that the factors causing malnutrition are quite numerous, and include economic, social, cultural, environmental, political, and physiological variables. This diverse etiology necessitates a multidisciplinary approach to combating malnutrition. Implementing multidisciplinary programmes in a developing country often involves the expertise and cooperation of several government ministries. Agreement with this approach was reflected in the responses of the study participants. Three-fourths disagreed with the statement that independent nutrition programmes within each ministry are preferable to multidisciplinary programmes involving several ministries. The difficulty of co-ordinating inter-ministerial programmes was recognized as an obstacle by 38%. These findings are noteworthy, as most Moroccan nutrition programmes are presently administered by a single ministry.

To co-ordinate national nutrition policy and programmes, national inter-ministerial nutrition committees have been formed in many countries. Such a committee has functioned in Morocco since 1956. The majority of participants responded "Neither agree nor disagree" to the statement that this committee plays an important role in co-ordinating nutrition programmes in Morocco. Similar committees in other countries have often had negligible impact because of lack of authority, poorly defined responsibilities, insufficient funding, and/or insufficiently trained personnel 191. According to its members, the present interministerial committee has little impact on the national food and nutrition policy in Morocco, which is consistent with the participants' responses.

National strategies to reduce malnutrition

Using the "nutrition in development'' concept, many food and nutrition policy experts argue that nutritional concerns should not be considered in isolation but should be an explicit component of overall national development [10]. Thus, nutrition should be interrelated with overall development in such diverse areas as public health, population planning, economic development, education, and agriculture. Reflecting this concept, almost all the respondents agreed that nutrition intervention is more likely to be successful when it is part of an integrated development project than when it is a separate project. Similarly, many planners have promoted the concept that regionally planned programmes may be more responsive to local needs and more successful than nationally planned programmes. Sixty-five per cent of the planners and professionals in this sample agreed with this regional planning concept for solving nutrition problems, while approximately one-third were neutral or disagreed.

National industrialization has sometimes been advanced as the ultimate, basic solution to malnutrition in developing countries. Among these planners and professionals, attitudes varied widely on the potential for combating Morocco's malnutrition problems by increasing industrialization. Approximately one-third of the sample fell into each category - agree, disagree, and neutral - regarding this strategy.

International food aid

The effectiveness of foreign food aid in alleviating malnutrition and fostering national development is controversial. These Moroccan planners and professionals, in general, expressed unfavourable attitudes toward foreign food aid, similar to results from a worldwide survey of nutrition planners and professionals reported by Schuftan [7]. Eighty-seven per cent agreed that it is best for Moroccan nutrition programmes to use local foods because of the danger that international food aid will be discontinued. This issue was especially relevant at the time of the survey, as a major national food aid donor had just discontinued contributions to one ministry's nutrition programmes. Reflecting an attitude that foreign food aid is not a national necessity, more than two-thirds disagreed with the statement that Morocco would not be able to meet the food needs of its population without international assistance.

There was less concordance concerning two additional statements: approximately equal percentages of respondents agreed and disagreed that, if appropriately used, international food aid makes a significant contribution toward combating malnutrition in Morocco. In response to the fourth item in this area, 43% agreed that international food aid is harmful to the economy because it depresses local food production.

International nutrition policy implications

Nutrition-planning activities in Morocco are dominated by well-educated males. Although comparable data are not available, this demographic profile may be similar to that in other developing countries. While females make the majority of nutrition-related decisions at the household level, they are underrepresented in decision-making at the national level. If nutrition policies are to be sensitive to the needs and desires of the ultimate beneficiary, the family or household unit, a conscious effort must be made to include a cross section of females in nutrition-policy bodies.

Moroccan nutrition policy-makers appear to have had training in diverse fields, reflecting the multidisciplinary nature of nutrition planning; however, more than half of them have possibly never had formal training in nutrition. With the current post-secondary educational emphasis on disciplinary depth rather than multidisciplinary breadth, this situation is not likely to change in the near future. Thus, it is imperative that current and relevant nutrition information should be disseminated not just to a country's trained nutritionists but to all professionals involved in nutritionrelated activities.

Many of the attitudes expressed in this survey do not reflect actual practices in Morocco. Instead, they may reflect ideal or desired behaviour. For example, although positive attitudes were expressed toward multidisciplinary, integrated, and regionally planned nutrition programmes, in reality most Moroccan nutrition programmes are single-discipline, nonintegrated, and nationally planned. Similarly, foreign food aid is an integral part of several nutrition interventions, and nutritional considerations are not often systematically considered in policy decisions in related areas such as population planning and agriculture, practices that are contrary to the attitudes expressed. Thus, it is apparent that attitudes alone do not explain behaviour. However, attitudes may be a precursor of behaviour. Therefore, nutritionists should build on planners' and professionals' attitudes that would result in improved nutritional interventions. These attitudes can be used to direct future public nutrition policy.

It should be noted that more than 10% of the respondents expressed neutral attitudes toward 15 of the 19 issues addressed by the statements. Whether these neutral positions are based on lack of information, lack of interest, or genuine indecision is not known. Nonetheless, these statements address critical issues in international nutrition planning, and it is important for policy leaders to be well versed on the pros and cons of each. This relatively high level of neutrality reinforces the earlier suggestion that relevant information on current nutrition issues needs to be made available to all policy leaders involved in activities directly or indirectly related to nutrition.

Surveys such as this can be useful for understanding and influencing nutrition-related public policy in a developing country. They can reveal attitudes on which to build future nutrition policy as well as areas in which information dissemination is needed. As Levinson has noted [11], the ultimate alleviation of malnutrition depends less on the design and techniques of a particular intervention, and far more on the commitment of policy-makers and institutions to the principle of meeting basic human needs.


This research was funded in part by the World Food Institute, Iowa State University, Ames, lows, USA.


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