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Harriet V. Kuhnlein and
Gretel H. Pelto
Overview
Overall performance of the protocol
Keys to finding local community food sources to prevent Vitamin A deficiency: What foods are available and how much vitamin a do they contain?
Keys to understanding consumption patterns of vulnerable groups
Keys to beliefs and perceptions about food
Keys to cultural, ecological and socioeconomic factors that constrain consumption of Vitamin A-rich food and prevention of deficiency
Keys to explanations and understandings of Vitamin A deficiency symptoms
Looking to the next steps: From ethnography to intervention design
The root of the problem of
vitamin A deficiency is lack of sufficient vitamin A in community
food supplies. While all members of families in communities where
vitamin A is limited are potentially at risk of deficiency,
infants, young children, pregnant, and lactating women are the
most vulnerable. In order to understand how food systems can be
supported to ensure adequate intake for all the population, the
environmental and sociocultural mechanisms through which food is
provided must also be understood. This understanding begins with
answers to a set of basic questions: what vitamin A-containing
foods are available? What are the nutrient levels in these foods?
How much is consumed by the individuals who are vulnerable to
deficiency? Why are these foods selected or not used? How do
people identify and treat symptoms of vitamin A deficiency? The
answers to these questions are the product of determinants that
reside in the physical and social environment, broadly defined,
and in culture. Answering these questions at the local level is a
necessary step in the development of interventions aimed at
remedial actions and prevention of vitamin A deficiency.
In the
sections that follow, we begin with some comments about the
overall performance of the protocol as a field tool. We then
review findings from the studies in relation to the "key
questions" to which the protocol is directed. This is not
intended to be a definitive analysis of the dietary,
environmental, and cultural features of the five sites. The
purpose is to summarize the types of information that are
produced through the application of the procedures.
To assess the ability of
the manual to assist national investigators to obtain answers to
the key questions, it was necessary to test it in diverse
environments and cultures. Specifically, the following different
systems were selected:
Location |
Environment Type |
Cultural Group |
Canawan, Philippines |
Humid, tropical |
Aetas (indigenous) |
Henan, China |
Temperate, riverine |
Han |
Filingué, Niger |
Arid, desert |
Hausa |
Andhra Pradesh, India |
Dry, upland |
Hindu |
Cajamarca, Peru |
Highlands, semi-arid |
Mixed Spanish and indigenous |
All procedures in the manual were applied by research teams in the five study sites. All team leaders (or main investigators) had backgrounds in health professions (nutrition, nursing, community medicine, public health). In several cases they also had anthropological training. Regardless of background and previous experience, the investigators agreed unanimously that the initial training workshop was a valuable preparation for carrying out the study.
The teams completed the studies within the projected time frame of six to eight weeks. In two areas (China and Peru) the manual was translated into the national language; in the other three areas, the teams worked directly from the English manual, using local translators as needed to maintain literal translations of concepts.
The investigators and their field teams generally found it easy to apply the specific techniques that they attributed to the detailed, step-by-step instructions in the manual. A number of modifications in the instructions have been made as a consequence of the thoughtful suggestions from the teams, and the post-field test revisions are based on extensive discussions with the investigators. For example, the field teams made suggestions for identifying the most appropriate time to conduct the studies and provided creative suggestions concerning the use of specific examples in the local culture to help respondents understand questions.
In some cases the teams found it advisable to adapt the dietary assessment modules - Modules 4 and 5 (Part II-C) in the manual. In the Philippines, respondents were asked to give a 24-hour recall before they were questioned with the food frequency procedure. The investigators instituted this change in order to orient the respondents to the concept of daily quantities. In India the team experienced some difficulty in recording portion size and preferred not to use the 24-hour recall in this manner. One investigator suggested that the food frequency procedure developed by IVACG (IVACG, 1989) could be substituted for Module 5, provided it was modified to use the food list developed from the other modules. Thus, the field test experiences suggested that it is possible to modify the dietary assessment section of the protocol to fit local circumstances, as long as the data yielded by the procedures can be used to rank-order the key-foods in the market survey.
The community food system data tables were successfully applied in all the test sites. The tables are also useful in clearly highlighting where further research on food composition and species identification is required. In the study among the Aetas, the list of foods contained 128 items of which twenty-seven had no scientific identification and forty-two had no recorded values for carotene or retinol. Food items for which no composition data could be found also occurred in the Cajamarca study and in Filingué, Niger. Complete data were reported for all of the food items in the community food system data tables of Doumen, China and Sheriguda, India.
To determine the ability of the protocol to document seasonal variation in food availability, and cultural perceptions of food selection as these relate to seasonality, the investigators in the Philippines repeated the study in both wet and dry seasons among the Aetas. The team found that in order to describe the variety of local vitamin A-containing food, it was necessary to have data from the wet season. They suggested that conditions in the dry season could have been obtained through interviews, without observation, by carefully interviewing key-informants. The data on cultural perceptions about food attributes and qualities remained stable. Thus, they concluded that a single study, carried out in the wet season, would have obtained all the necessary information.
To
determine how sensitive the protocol is to differences in food
availability and selection in rural and periurban communities
within the same geographic area, the investigators in Peru
conducted studies in two locations. The team documented
substantial differences between the two sites, with greater use
of animal foods and wild plants in the more rural site. Families
in the periurban communities relied primarily on purchased foods,
and the food list was much longer. On the other hand, there were
many similarities in food items and food beliefs, although food
beliefs appeared to be more diverse in the periurban area, in
part because of in-migrants from other regions.
Keys to understanding the
available foods that can be used to prevent vitamin A deficiency
are found in the key-informant interviews and the free list of
foods, in the market surveys, and in the community food system
data tables. In addition, information is found in the background
materials on the historical, ecological, and cultural setting for
the community food system.
In addition to an examination of vitamin A content (retinol or carotene), food resource data needs to include information on preservation and preparation methods, as these affect nutrient levels. The manual facilitates collection of this type of information. For example, the study report from Niger includes the description of the long cooking processes for leafy vegetables, information that is important for evaluating the food supply as consumed. Studies also should note the sources of data on nutrient composition. Thus, it is useful to find in the report on Sheriguda village that the information in the food system data tables is based on food composition studies that were conducted with the current, advanced method of analysis (HPLC) in national laboratories.
In the field studies, the community food system data tables proved to be a valuable means of summarizing the local situation. Among the Aetas in the Philippines, the table contained 128 food items. One hundred sixty one species are on the list for the periurban site in Peru, with seventy-four in the rural area; thirty-seven species are listed for Filingué, Niger; thirty-five in Doumen village, China; and forty-five for Sheriguda village in India. Although some areas had unidentified species with unknown vitamin A content, vitamin A-rich foods were identified in all the systems. The data tables also provided information on key sources of protein, fat, and other nutrients that are important in the prevention of vitamin A deficiency.
Information on seasonality is obtained from the community food system data tables, market surveys, and key-informant interviews. For example, the study revealed that in Sheriguda village, pumpkin is available only during one short period during the year, while bachali (Basella alba), that is cooked with dahl, is available all year in local gardens, does not have to be purchased, and is an excellent source of carotene. Mango is popular with young children but is available for only two to three months. Papaya has a longer period of availability, but there are cultural barriers to its use (see following section, "Keys to Beliefs and Perceptions About Food").
Several field study reports pointed out the importance of paying special attention to how wild greens and leafy green vegetables are used. These species may be locally regarded as substantive food items or as condiments that are used in much smaller quantities. Greens may be dried and reserved as emergency or famine foods or preserved for use in herbal remedies. It is important to note preparation and preservation techniques. In Sheriguda village, another factor that affects use of greens is whether they are subject to infestation by insects or worms, in which case the food is rejected.
The market
survey reports provided a valuable source of data on both
availability and price of important food items. As discussed
further below, excellent sources of vitamin A-containing foods
are found in local markets, but their prices may be prohibitive
for those most at risk of deficiency. By including calculations
of price-per-serving and the price per 1000 RE, the study
provided a perspective on true availability, particularly when
the average family daily wage or food expenditure total was
known. Liver is a good example; in all five research areas' it
was recognized as an excellent food, good for the eyes, and for
protecting health. However, it was not available regularly from
home animal production, and was not purchased often because of
its cost.
In this section we discuss
food selection and consumption of pregnant and lactating women,
and infants and young children. Information on consumption
patterns was obtained from the food frequency and 24-hour recall
modules, key-informant interviews, and the modules on food
categories, attributes, and concepts.
The general food pattern of families is a necessary first step in order to understand food patterns of vulnerable individuals. In Doumen village, China and Sheriguda, village, India, and in Filingué, Niger, families eat three meals a day. The first meal of the day often consists of the leftovers from the previous night. In Filingué meals are built around a grain with a sauce, that often contains greens and pumpkin, providing good potential for vitamin A. In Sheriguda, evening meals occasionally contain meat.
For the Aetas, meals usually consist of rice and a sauce of greens; fat and animal protein is limited in the family meal pattern.
There is little evidence from any of the sites that consumption patterns change during pregnancy. In Peru and Niger, pregnant women deliberately avoid eating too much because they do not want to gain too much weight, leading to a difficult delivery. While some food items are noted in each area as being good for pregnancy, there is no general pattern with respect to their vitamin A content.
A change in diet during the postpartum period is characteristic in all areas. In Doumen village, many hen's eggs are given to women, who are also encouraged to eat dark-colored foods (such as black rice, red jujube) to regain their strength. In both sites in Peru most women interviewed reported that special foods, selected for their qualities with respect to the humoral medicine system, are consumed. In Sheriguda, three stages of postpartum diet are recognized: in the first three days, only rice with spices is eaten; from day four to twenty-one the diet is semi-restricted, with few animal and plant foods; a regular diet is resumed after twenty-one days.
During lactation, women's dietary patterns may also be different from the rest of the family. In all areas, more liquids are taken, often as cereal gruels. In Niger women actively try to gain weight to recover their strength, and they seek more meat, liver, and richer sauces. While eggs are encouraged on a daily basis in Doumen village, they are rejected during lactation in Filingué, and are recognized as lactogenic foods in Sheriguda village.
Breastfeeding is practiced in all areas, but for varying durations. Cessation of breastfeeding varies widely, from an average of six to thirty months. Rural areas (Chamis, Peru, and Filingué, Niger) have longer average periods of breastfeeding than urban areas. In Filingué and Doumen the first colostrum is discarded. Water with sugar is often given to newborns. Breastfeeding is supplemented with various foods, some of which have potential for providing vitamin A. For example, mashed vegetables and eggs are the first foods in Doumen village. Soups and purees are given in the Peruvian settings. In Peru herbal infusions are given to infants, but sweet potato, eggs, and greens are thought to be too strong for children under one year of age.
Young children's eating patterns gradually assimilate to that of the family. Eggs are considered an ideal food for young children in Doumen village. In most areas, young children are reported to eat more snacks, including fruits and vegetables. In Sheriguda village, for example, carrots are regarded as a food only for children's snacking and are eaten raw.
As the
foregoing summaries suggest, the application of the procedures
produced descriptive summaries of the dietary patterns of
vulnerable groups. The modules on food beliefs provided
information about the cultural factors associated with these
patterns.
Except under conditions of
extreme scarcity, food beliefs play an important role in food
selection. The main techniques used in the manual to describe
food beliefs are open-ended, key-informant interviews and
structured interviews with mother-respondents that use formal
ethnographic methods to discover emic categories, food
attributes, and qualities.
Some of the food beliefs identified are found across wide culture areas, although they often show considerable intragroup variation as well as locally introduced variation. An example of a widely held belief is the finding from Sheriguda, concerning papaya. Throughout southern India, papaya is seen as a food that causes dysmenorrhea in women and impotence in men. Although it is rich in provitamin A, it is usually not accepted as a suitable food for pregnant or lactating women, infants, or young children. In Sheriguda, papaya is generally available, but consumed only by children four to fifteen years of age. Other beliefs related to vitamin A consumption included: liver is bad for children as it will cause indigestion; eggs are a "hot" food and should be used with caution; and pumpkin is a vatham food, a feature that can cause swelling and indigestion. The attributions or qualities of food in Sheriguda emphasized taste, goodness for health, hot/cold, vatham, giving strength, used for festivals, causing diarrhea or cough, increases blood, and generally not good for the body.
In the Peruvian rural area (Chamis) and in periurban San Vicente, the hot or cold humoral system continues to be important in structuring food beliefs. Foods are designated as caliente (hot) or fresco (cool). Caliente foods include vitamin A-rich items, including green herbs, while fruits are generally fresco. Sweet potato and carrot are neutral. Other important attributes of food in Chamis include giving strength, good taste, causing indigestion, and causing diarrhea. In San Vicente the attribute of good nutrition is recognized, and for children included such foods as eggs, cow's milk, breastmilk, carrot, sweet potato, papaya, and mango. Other attributes included "combatting weakness" and "good taste."
While the sites differed with respect to the literacy level of the mother-respondents, the techniques for identifying food attributes and qualities performed well in all of them. In Filingué, Niger, the attributes of animal foods included the concepts of strengthening, fattening, healthful, and blood-rich. Some foods were designated that make children feel good, are tasty, or vitamin-rich. In Doumen village people identified food as tasty, prestigious, nutritious, healthful, and filling. In selecting vegetables, beans, and meats, the main attributes of concern were price and taste. For staple foods (noodles, rice, steamed bread), filling and taste were both important. Commonly-held beliefs included the capacity of foods to impart their characteristics to the individuals who consume them. For example, it was thought that eating rabbit meat might cause a child to have a mouth and lips like a rabbit.
Among the
Aetas, the concept of richness emerged as a quality of concern
with respect to food. People suggested that if one eats rich food
they will become spoiled and want it all the time; therefore,
moderation is encouraged, except during feasts. Other food
attributes included: strength-giving, filling, tasty, healthful,
expensive, and prestigious. Some foods are characterized as
delicious, nutritious, good for mother/child, good for the eyes,
good for the blood, and for increasing breastmilk.
The manual directs
investigators to obtain data on microlevel (local) factors that
affect food availability, health, and the potentials for family
food selection. Some of this information is found in reports and
interviews with persons in regional government agencies and is
included in the background material in the section on the setting
of the food system.
Information is also obtained In key-informant interviews, market surveys, food system data tables, and food frequency data.
Two key areas of local-level information included in the manual are land availability and local markets. If families have limited land resources to grow or harvest their own food and have limited income, the data on local food prices from the market survey are critical for determining accessibility of vitamin A-rich food. This issue was noted in investigators' reports from all the study sites. Often it is not possible for families to purchase animal food and vitamin-rich seasonal plant food because of their costs.
The accessibility and use of fat and animal foods are closely related problems. If fat and zinc are limited, and there is evidence of protein-energy malnutrition in the population, these factors may be more critical to the development of vitamin A deficiency than the amount of carotene or retinol in the food supply. For example, the shortage of fat and protein in the Aetas' food system was identified by the investigators as a significant feature.
Market accessibility for the sale of home-produced food is another factor that requires attention in the ethnography. Home-produced animal food (especially eggs and milk) and seasonal fruits and vegetables may be sold rather than fed to family members. Decision-making within the family with respect to allocation of home-produced food, as well as food purchasing, is a subject of inquiry in these studies because they have important implications for intervention planning. The study in Filingué documented the role of the male household head in structuring the accessibility of vitamin A-containing foods to vulnerable household members.
Elders in the community often know the recent history of food sources of vitamin A, including where plants and animals can be grown or found, how these were preserved and prepared, and any health properties they may cause. With increasing wages, families often choose food that is most easily obtained, while wild food sources or those requiring greater effort to harvest or prepare may be discontinued. The rise of industrial agriculture in an area is another force that encroaches on home food-harvesting resources. In this circumstance as well, the elders will know what kind of food was previously successful in the environment and where the nearest places are that provide the food resources. The Aetas have been relocated several times during the memory of the community elders, and food resources in the other areas were still remembered and occasionally brought to the village.
The nature of seasonal patterns is, of course, critical information for assessing the availability of vitamin A-containing foods. In all the study sites, seasonality strongly affected the picture. These effects may be seen in relation to home production, market availability, and purchasing power. In Filingué a poor millet harvest will trigger a critical decline in purchasing power for vitamin A-rich sauce ingredients, thus constricting the household's ability to purchase vitamin A-containing foods at a time when home production also falls.
The
ethnographic instructions also direct investigators to examine
whether there are any historical or cultural reasons for
rejecting foods containing vitamin A. In Doumen village, the use
of carrots declined because of their association with a rejected
social policy, as well as their negative features as a cash crop.
The association of some foods with poverty or their designation
as starvation foods, may also affect consumption, as appears to
be the case for carristel fruit by the Aetas and certain leafy
greens in Sheriguda, village.
Data on cultural
interpretations and responses to vitamin A deficiency symptoms
are most important in areas with clinical deficiency, where they
are needed to design effective means to reach the population.
However, it is also useful to collect data in areas where frank
deficiency is rare, as they provide insights into cultural
perceptions about health that have value in relation to
intervention development. The sources of these data in the study
manual are the case scenario interviews with mother-respondents
and interviews with key-informants.
The results of the studies show that nigh/blindness is clearly recognized as an affliction that can affect women and children in Filingué, among pregnant Aeta women, and among children in Doumen village and Sheriguda village. The fact that nigh/blindness is identified with a specific term or terms ("bird fuzzy" or "chicken eye" in Doumen village, dundumi in Filingué) suggests that it is a long-standing problem. More advanced symptoms of xerophthalmia were rarely recognized, although local language terms for Bitot's spots and corneal xerosis were found in Filingué and in Sheriguda village. In Filingué, women recognized these as serious conditions that could degenerate rapidly into blindness.
The study
protocol effectively elicited the explanatory models of vitamin A
deficiency symptoms, including cultural views of etiology and
treatment. Food remedies were associated with treatment in most
of the sites. Liver was specifically recommended in Doumen,
Filingué, and Sheriguda, By comparing cultural perceptions with
medical recommendations, it would be possible to identify
similarities and differences between them, and from such an
analysis it may be possible to develop recommendations for
culturally appropriate actions to improve home management and
care-seeking for vitamin A deficiency.
The field studies
demonstrated that data on the key questions can be efficiently
collected by using the procedures in the manual. The purpose of
the studies was to generate a valid description of the local
diet, environment, and culture as these relate to vitamin A.
This, in turn, is based on the assumption that local level
information is essential for the design and implementation of
interventions aimed at instituting and sustaining food-based
prevention of vitamin A deficiency. In declaring local level
information essential, we want to emphasize that it is a necessary
component for action. But it is obviously not a sufficient
one, even for intervention planning, it must be part of a
process. That process starts prior to the study and continues
beyond it, and includes the prioritizing and designing of
interventions.
The history of intervention efforts in health, agriculture, economic development, and other domains of modern society is strewn with examples of failures that occurred because the microlevel situation was not understood by the people charged with developing and implementing change. At the same time, the list of failures that can be traced to inadequate consideration of the broader systems involved in such enterprises, is equally long, if not longer. These include issues of administrative and bureaucratic structures, competing agendas, and competing demands for resources. Hence, the local description this manual is designed to obtain must be matched with information from the other systems that are involved in change.
Intervention planning requires knowledge about the resources that can be mobilized to address problems; the culture of the administrative organizations that have a stake in the actions for change, as well as features of the political and economic processes at macrolevels that affect the proposed actions. It is important to point out that this is not a call for full-scale political and economic analysis of food, agriculture, health, and transportation systems. Just as the ethnography of the microlevel must be focused on key questions if answers are to be obtained within a realistic time frame and budget, key questions about other important systems also must be limited and focused. Although general guidelines about the sectors of information can be established, many of these are context-specific, and the specification of the relevant information emerges, in part, directly from the planning process itself.
In many fields, a great deal of effort is being devoted to setting up effective planning and implementation processes for interventions that integrate sectors of knowledge about the community, from the community, and about the broader systems involved. With respect to food-based vitamin A interventions, the insights and suggestions made by the investigators are a valuable component for planning. Examples of strategies suggested by the field teams included the promotion of growing leafy greens on a year-round basis on fences and rooftops, improving the intake of fat and animal protein by expanding chicken production, promoting the use of coconuts, peanuts, and other nuts as acceptable sources of fat, reinforcing the value of liver in education messages, promoting pumpkin as an ingredient for sauces where it is available year-round, and promoting the consumption of soups made with leafy greens during pregnancy and lactation.
At the same time, it should be recognized that the suggestions in the chapters are not intended as programs for action. The investigators were not charged with this responsibility, nor should they be. However, it may be the case that the people who carry out these studies are individuals who have responsibilities for intervention development. What needs to be made clear is the distinction between the two functions. The thoughtful and insightful suggestions made by the investigators point to direction for action that needs to be examined in relation to other factors and other stakeholders. The role of the community in the development of interventions is also essential.
We hope the
guidelines for "Community Assessment of Natural Food
Sources of Vitamin A, " and the illustrative case
studies in this book, will contribute to the larger effort by
facilitating the acquisition of one component of essential data
for problem-solving. The goal to which interventions must be
directed is the building of sustainable systems with the capacity
to provide all members of all societies with that essential
nutrient we refer to as vitamin A.