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Breast-feeding

The NBPP, as many other non-governmental organizations and government workers have been doing in recent years, promoted the value of colostrum for its high vitamin A content. This appears to have been successful, and most mothers probably no longer throw it away. In Lalmonirhat, only 8% did so as of the 1992 evaluation. But mothers still commonly continue to wait one to three days after birth before initiating breast-feeding.

One group estimated that children under two years of age obtain nearly the entire recommended daily allowance of vitamin A if they are breast-fed [5]. Those not breast-fed obtain only 1% to 8% of the recommended daily allowance except during mango season. Analysis of data from the Bangladesh Nutritional Blindness Study of 19821983 revealed that breast-feeding was associated with a substantially reduced likelihood of having vitamin A deficiency night-blindness at each year of age from birth to five years [7]. Breast-feeding in the urban slums of Dhaka protects against vitamin A deficiency night-blindness when continued for more than two years [3]. The NBPP did promote breast-feeding for two years, but at least one senior staff member was observed discouraging it after that age.

Exclusive or even predominant breast-feeding according to World Health Organization definitions is probably rare in Bangladesh. However, awareness of this problem is recent, little has been done to promote breast-feeding so far, and relevant data were not obtained in these surveys.

In both project and non-project areas, 69% of sample children were stated to have received colostrum in 1992. In 1993, 78% and 77%, respectively, were reported to have been given colostrum at birth. There were no gender differences. Rates of colostrum use appear to have increased rapidly during the past several years.

No gender differences were observed in the proportion of children currently breast-feeding. Some increase in breast-feeding rates, especially among one-year-olds, appeared to have occurred in both areas. Suckling frequencies were high and remained so, even among the small proportion who were still breast-fed during their fifth year of life.

Vitamin A capsule distribution

The distribution of vitamin A capsules twice a year to all children age one to six years has been government policy in Bangladesh since 1973. Health assistants deliver the vitamin A capsules to villages. The national coverage rate (percentage of target age children who received vitamin A capsules during the past six months, according to the mother, to whom a vitamin A capsule was shown), according to the 1982 evaluation of this programme, was 45% [8]. The rate had declined to 35% by 1989 [9]. The rate in the project area remained unchanged during the evaluation years, 44.4% in 1992 and 45.1% in 1993. In the non-project area, coverage increased from 44.3% in 1992 to 61.4% in 1993, a statistically significant difference (SE of the difference, 3.83; t value for the difference, 4.48, p < .05). There were no gender differences in coverage rates.

Recognition of the vitamin A capsule on sight (ability to state that it was a vitamin A capsule) increased from 3.0% to 12.5% in the project area but only from 6.4% to 7.6% in the non-project area. When respondents were then asked if they had heard the term "vitamin A capsule" before, yes answers increased from 22% to 43% in the project area and from 28% to 35% in the non-project area. In the project area, the proportion who knew that vitamin A capsules are distributed to prevent or cure night-blindness increased from 50% to 71 %. The increase in the non-project area was smaller, from 40% to 51 %.

Night-blindness

The NBPP focuses on night-blindness in its messages to the community, teaching that it can be treated and prevented by the consumption of certain foods that are high in carotene. This is challenging, since night-blindness is often uncommon and not considered to be a serious problem. Thus NBPP had to work in areas where night-blindness was at a high prevalence rate at baseline and focus on long-running, multidimensional communication to convince the population that it was indeed a problem. For example, in open-air film showings in villages at night, night-blindness was said to be a forerunner to permanent blindness.

In Comilla district in southern Bangladesh, night-blindness tended not to be viewed as something dangerous or important [6]. Many women pointed out that it goes away on its own. Therefore the investigators planned their social marketing programme to promote the consumption of high-carotene vegetables based also on other benefits these foods could offer, stating they were "bursting with vitamins essential to good health and growth." The authors depended more on the mass media than on interpersonal communication and gardening to achieve their goals. Since rural women in particular have little contact with mass media, messages must be designed carefully, and strong wording may be required to achieve much impact.

A message that vitamin A reduces death rates might be problematic, especially in a Muslim society where many believe it is only Allah who determines when each person will die. Stating that vitamin A is generally good for health is probably epidemiologically correct in a country such as Bangladesh where so many are deficient. However, at the individual level, consuming more vegetables may not appear to make most people visibly healthier most of the time, and many people will be healthy much of the time despite not consuming these items in quantity.

As an indicator, night-blindness has several advantages Awareness that the local term for night-blindness referred to "being able to see in daylight but not at night" was high in both areas, increasing from 76% to 88% in the project area and from 79% to 88% in the non-project area. At least among the poorer classes in Bangladesh, avoidance of night-blindness probably almost always has a close correlation with consumption of breast milk, vegetables, and yellow fruit.

As NBPP began in each district, baseline studies showed that about 55 of households had some member with night-blindness. In Bangladesh many studies show that the rate actually increases with age well into adolescence. The reason attention focuses exclusively on children under five is probe ably that vitamin A deficiency among older children rarely progresses to permanent loss of sight or death. At this level of prevalence, nearly everyone probably knows a few people who have it. Everyone then has the opportunity to see for themselves the proof of its relationship to diet, increasing NBPP's credibility. When people have seen such proof, the knowledge is more likely to become anchored in local beliefs in a way that will carry on after NBPP has left the area.

When asked how they thought night-blindness could be prevented, respondents answered as indicated in table 6. The NBPP mentions certain vegetables, yellow fruits, and fish in its messages, does not give prominence to vitamin A capsules, and does not mention milk and eggs. Dietary causes, rather than the name of the vitamin involved, are given priority in the messages. These data suggest that the messages were still actively spreading during the third year of the project. They appear also to have been spreading to the nearby district, if somewhat more slowly. Knowledge itself plays an important role, contributing sustainability to such a project if it is embedded enough to be passed on by schools, the health-care system, and within families themselves, all of which were used by NBPP. In one study, lack of knowledge about nutrition was more important than lack of formal education as a variable associated with vitamin A status [10].

TABLE 6. Knowledge of how to prevent night-blindness

The sources of this knowledge are shown in table 7. These results suggest a remarkable expansion in awareness of NBPP, its workers, and their message in this third year of the project. They also verify NBPP's own records as to how intensive and complete its coverage of the district was. After only three years, the majority were aware of one or more simple ways to prevent night-blindness. The NBPP was credited as the source of this new knowledge by 79% of respondents.

In addition, workers from other non-governmental organizations in nearby districts may have been picking up or strengthening their messages about vitamin A, as shown in the increased mention of the Bangladesh Rural Advancement Committee (BRAC) as a source of information on the causes of night-blindness in the non-project area. The mass media efforts of NBPP do not seem to have had nearly as much impact as the face-to-face communication channels. Anecdotal evidence supports the finding that the live performances by the traditional singers are the most influential and cost-effective media.

In 1981-1982 it was estimated that 3% of preschool children in Bangladesh had night-blindness [8]. Another somewhat smaller national survey in 1989 found a prevalence of night-blindness of 1.8% among children six months to six years of age [9] This apparent decline occurred despite the fact that these same surveys indicated that the coverage of vitamin A capsules among children one to six years of age (target group) had declined from 45% to 35%. Improved health-care delivery, including dramatically higher rates of vaccination, especially for measles, may account for part of this.

TABLE 7. Source of knowledge of how to prevent night-blindness

a. Number of respondents reporting awareness of at least one measure to prevent night-blindness.

Only small changes occurred in the prevalence of night-blindness in both project and non-project areas, neither of which was statistically significant. In 1992, 1.5% of sample children one to six years old were reported to have night-blindness, come pared with 1.8% in 1993. In the nonproject area, night-blindness prevalence was 0.7% in 1992 and 0.8% in 1993. In both areas, at least one important change had occurred that might have led to the lower rates: diets improved, probably somewhat more so in the project area, and the non-project area had a substantial increase in vitamin A capsule coverage. Presumably, other factors that affect vitamin A status prevented the expected reduction in night-blindness prevalence.

One such factor could be changes in levels of morbidity. The only disease asked about in the surveys was measles, which is known to have a great impact on vitamin A status. Measles vaccination rates were increasing rapidly in Bangladesh at the time of these surveys. Vaccination rates among children increased from 68% in 1992 to 74% in 1993 in the project area and from 75% in 1992 to 84% in 1993 in the non-project area. In the project area, 16% of children suffered from measles in 1991 (the year before the survey) compared with 17% in 1992. The respective figures in the non-project area were 19% and 15%.

None of these differences are statistically significant, nor were there any gender differences in prevalence. Therefore changes in measles rates cannot explain why night-blindness rates did not decline.

Once night-blindness levels have declined to this level, further decline may require a broad range of improvements in the lives of these children and may come slowly. In a population with less than dramatic baseline levels of night-blindness, and where improvement did not occur on a broader range of variables affecting vitamin A status, one year may be too short a time to expect to see changes in night-blindness rates, despite possible increases in carotene, fat, and calorie intakes in both project and nonproject areas. Vitamin A capsule coverage rates may have increased in the non-project area among groups who were not in any case at high risk of suffering from night-blindness.

In summary, the major behavioural impact of the NBPP that this study was able to document was an increase in consumption of leafy vegetables among young children in the project area in the face of large changes in dietary patterns occasioned by decreased rice prices. These price changes led to a simultaneous reduction in leafy vegetable consumption in the non-project area. The net change in vegetable consumption resulted in twice as many young children consuming leafy vegetables the day before the interview in the project area than in the non-project area in 1993, despite their having consumed similar levels in 1992. There is no obvious explanation for this other than the successful NBPP efforts to increase home production of these foods in the preceding years and to raise awareness of the importance of feeding these foods to young children.

References

1. Cohen N. Mitra M. WIF Bangladesh media campaign for the prevention of nutritional blindness. Dhaka: Helen Keller International, 1986.

2. Institute of Nutrition and Food Science, Dhaka University Evaluation report on WIF: nutritional blindness prevention programme, Lalmonirhat. Report to Stromme Memorial Foundation, Norway. Dhaka: Institute of Nutrition and Food Science, Dhaka University, 1992.

3. Cohen N. Measham C, Khanum S. Khatun M, Ahmed N. Xerophthalmia in urban Bangladesh. Implications for vitamin A deficiency preventive strategies. Acta Paediatr Scand 1983;72:531-6.

4.Greiner, T. Two different nutritional blindness prevention programs in Bangladesh. Uppsala, Sweden: ICH consultant report to SIDA, Uppsala University, 1993.

5. Zeitlin MF, Megawangi R. Kramer EM, Armstrong HC. Mothers, and children's intakes of vitamin A in rural Bangladesh. Am J Clin Nutr 1992;56:136-47.

6. Ali MM, Bloem MW, Pollard R. Prevention of vitamin A deficiency in Bangladesh, a social marketing approach. Dhaka: Helen Keller International, 1993.

7. Helen Keller International. Bangladesh nutritional blindness study 1982-83, risk factors. Dhaka: Helen Keller International and Institute for Public Health Nutrition, 1986.

8. Helen Keller International. Bangladesh nutritional blindness study 1982-83. New York: Helen Keller International, 1985.

9. Bangladesh Rural Advancement Committee. Nutritional blindness prevention programme evaluation report. Dhaka: BRAC, 1989.

10. Islam MN, Yusuf KM. Incidence of nigh/blindness in preschool children of rural Bangladesh: new risk factors envisaged. Bangladesh J Nutr 1990;3(1):21-7.

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