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Discussion

The evidence does not support a null hypothesis of no effect from the Nutri-Bus intervention. Both the knowledge and attitude data and the nutritional status data, within 1979 and between 1979 and 1981, support the assumption of positive impact by the Nutri-Bus project. However, since the data lacked well-matched control groups [6] and statistically random assignment of villages to conditions (this is a survey of an ongoing field programme), the question remains of whether or not there is an acceptable alternative explanation for the results found.

Regarding the 1979 findings, the sample selection criteria (Appendix 8) endeavoured to control for differences in access to health and nutrition facilities, health and nutrition programmes, socio-economic status, and sources of income. In the 19791981 comparison of rural villages, the same villages were analysed in 1979 and 1981 and only those that continued to meet the criteria in Appendix 8 were included.

One possible alternative explanation for the 1979 differences could be the political priorities that were used in assigning the buses to villages. However, the government personnel who made the assignments had no reason (or means) that we know of to systematically assign buses to the best villages first, then to the second-best, and save the worst for last. Furthermore, that would not explain the differences in knowledge, since the comparison villages, known to have the highest socio-economic status, had the lowest knowledge scores.

One possible alternative explanation of the improvement between 1979 and 1981 could have been based on economic conditions, if there had been an improvement during that period. But in fact the 1979-1981 period was the beginning of the worldwide recession. Table 6 compares key consumer price indices with primary and secondary sources of income for the sample families in the rural area. Conventional wisdom tells us that if the economy from 1979-1981 had had any effect on the nutritional status of the sample children, it would have been a negative one.

Regarding the fact that the urban areas in 1979 did not show any differences in nutritional status among conditions and less improvement between 1979 and 1981 than the rural areas, it should be noted first that there was less intervention in the urban areas in 1979 (as also reflected in the interview scores). Furthermore, the video tapes were designed for and tested on rural audiences.

Table 6. Changes in cost of living compared to changes in income sources: 1979-1981

Source: National Economic and Development Authority, Statistical Report, 1979 and 1981; Bureau of Agricultural Economics Report, 1979-1981.

Second, the causes of malnutrition may be somewhat different in urban areas. Moreover, there are data which seem to indicate that conditions in the urban areas make the improvement of nutritional status by nutrition education more difficult. The following conditions in the urban areas may have affected the intervention results:

Food Sources

Urban dwellers depend almost completely on buying their food from markets or from stands selling cooked foods. As Austin [7] points out, they are more affected by costly inefficiencies in the food system (e.g. storage, transport, and handling losses) as well as by nutritional losses in processing of foods. It may, therefore, be more costly and more difficult for them to improve the diets of their children compared to their rural counterparts.

Population Density and Spread of Disease

The average population density in urban areas is much higher than in rural areas. This greater population density leads to relatively higher incidence and prevalence of communicable disease. This may make improvement in nutritional status more difficult to bring about by changed feeding habits [8, 9].

In the province of Leyte, the average population density is 207.8 per square kilometre. In the urban area (Tacloban City), the figure is 1,061.1 per square kilometre [10].

Sanitation and Related Infection

Urban slums are subject to worse sanitary conditions. For example, using Ascaris infection as a measure of sanitary conditions, Popkin [11] found that the prevalence rate in the urban areas of Cebu Province was about 45 per cent higher than in the rural areas.

In the Philippines, 10 to 45 per cent of the urban population are classified as squatters [12]. Tacloban City has a relatively high percentage of squatters. One reason for less weight gain in the urban study may be the relatively high prevalence of infectious diseases related to poor sanitation in the squatter areas.

Migration and Percentage Reached with Intervention

Urban areas have a more fluid population than that in the rural areas. In Leyte Province, the migration rate in the urban areas (Tacloban City) was 16 per cent compared to only 2.4 per cent in the rural areas over a five-year period (1970-1975). About 84 per cent of the population surveyed had been residents of the same barangays since 1970; about 97.6 per cent had remained in the same rural areas [13].

This greater movement of the population in the urban areas may have resulted in a lower "dose" of intervention for the average urban dweller compared to that for the rural dwellers.

Mothers' Employment and Percentage Reached with intervention

In the urban areas of Leyte, 67.6 per cent of mothers were gainfully employed during the survey periods compared to 53.2 per cent of mothers in the rural areas. In other words, fewer mothers in the urban areas were available either to receive the nutrition messages or act on them in feeding their children.

Putting the Results in Perspective

To understand the results better, it might be useful to see how these findings compare with changes in nutritional status elsewhere in the Philippines. Two surveys to reflect the national condition, each of one-year duration, were conducted during approximately the same period as the Nutri-Bus study. These surveys dealt with populations more representative of the nation as a whole. The Nutri-Bus areas studied are depressed areas. Also, these surveys used Philippine standards for determining per cent standard weight for age, whereas the Nutri-Bus project used the more stringent Harvard standards. However, using per cent change in Gomez classification should help somewhat to control for those differences. As can be seen in table 7, the children in the Nutri-Bus study showed more movement from second- and third-degree

Table 7. Comparison of Nutri-Bus evaluation with nationwide findings in similar period

a. Pre-school children, OPT data Philippine standards, geographic and SES mix, seventeenprovince survey (1979 N = 61,755; 1980 N = 91,574) and Index Municipalities survey (1976 N = 644,087; 1977 N = 470,507).

b Pre-school children data gathered by project team with clinical scales, Harvard standards, rural and lower SES (1979 N = 637; 1981 N = 690).

Table 8. Comparison of nutritional status of pre-schoolers in Nutri-Bus area with findings in two studies of similar duration and with similar age groups but with more intensive intervention to first-degree malnutrition. Although the comparison in the table, as noted, is not a perfect one, it does seem to indicate more improvement in the Nutri-Bus areas than in the nation as a whole.

a. FAO Requirement for 12- to 47-month-old children is 1,360 calories.
b. Narangwal Rural Health Research Centre, 1974 Underweight children who were identified through periodic surveys were served free food supplements by project staff, twice daily at a village feeding centre (or, in some cases. a' home) Only children receiving the food supplements were measured, the same children pre- and post-measurement The average age of children increased at post-measurement Harvard Institute for International Development, Study 1: Supplmentary Feeding (USAID, Washington, D.C., 1981 ).
c. Asia Research Organization, 1976. Free food given; only children receiving the food were measured, average age of the children increased at post-measure. same children at pre- and post-measurement. Harvard Institute for International Development, Study 1: Supplementary Feeding (USAID, Washington, D.C., 1981 ).
d. Nutrition Center of the Philippines. No free food given, all children in village measured whether or not reached by programme Not all same children pre- and post-measurement. Average age of children unchanged at post-measure.

It is also interesting to compare the changes in the Nutri-Bus areas with changes found in feeding programmes with children of approximately the same ages and in programmes of approximately the same duration. The two feeding projects shown in table 8 provide an idea of the magnitude of improvement that can be expected when all children in a sample are given free food. In the Narangwal study the food was actually fed to them twice a day by project staff. The percentage of weight increase achieved in the Nutri-Bus-sampled areas seems quite respectable in comparison to that in the feeding programmes, especially considering that the Nutri-Bus areas received no free food and that all children there were measured to determine average improvement, even those whose mothers had not been reached by the intervention.

To be useful, a nutrition intervention must not only significantly improve nutritional status, but also do this at a cost which is comparable to, or less than, equally effective programmes, and which is affordable to the government as a national programme.

It is difficult to make comparisons between studies regarding cost-effectiveness. There is no absolute standard for calculating cost-effectiveness and each researcher uses somewhat different methods and definitions (including different definitions of malnutrition and improvement). Furthermore, nutritional status and price data are collected at different seasons, which may affect values, and costs may reflect different inflation and exchange rates. Even more misleading can be the fact that each project deals with a different-sized sample or population group over which to amortize costs.

However, recognizing all of these limitations, a comparison of cost-effectiveness to other projects has been made in table 9. Table 9 shows that, compared to representative programmes of other types (supplementary feeding, nutrition education at clinics) and programmes of a similar type (mass media and mass media with local workers), the cost-effectiveness of the Nutri-Pak programme compares quite favourably.

Perhaps a more meaningful perspective would be to look at these costs in relation to Philippine national budgets. Nutri-Bus is designed to make more effective the nation's BNS programme. There are currently about 10,000 BNS nationwide in the Philippines. If the NutriBus programme covered all 10,000 (although some would not be accessible by road) it would cost about 0.03 per cent of the national budget (or 0.7 per cent of the Health and Nutrition budget). Even if the number of BNS were to double over time to 20,000, Nutri-Bus costs would still be affordable at 0.06 per cent of the national budget (or 1.4 per cent of the Health and Nutrition budget).

Conclusions

Returning to the Habicht, Mason, and Tabatabai questions for evaluation during programme implementation:

1. Is the Intervention Performing as Expected?

Are Services Being Delivered to Target Croups?

Yes, but improvements are sought. Approximately 66 per cent of mothers in sample villages in 1981 reported seeing VTR shows. However, this is down from 75 per cent in the VTRL treatment, common rural villages in 1979. This may indicate need for better field management and/or greater variety in shows. The report of Nutri-Pak as a snack dropped by nearly 50 per cent from 1979 to 1981. Nutri-Pak was not available in most villages. A better distribution system is needed.

Is Gross Outcome Acceptable to Management?

Yes, but improvements are sought. The stated objective was to test the null hypothesis. Although the data do not meet the requirements of experimental design, the evidence favours the rejection of the null hypothesis. Since successful field projects to improve nutritional status are so few and far between, management decided before the evaluation that any statistically significant improvement found would be taken to indicate that a useful intervention was being pursued and efforts would be focused on increasing the impact of the intervention.

Regarding cost-effectiveness, the outcome is well within the acceptable range.

Where Should Improvements Be Sought?

The three areas where improvements are being most vigorously sought are: field management systems; video-tape production efficiency; and Nutri-Pak distribution system.

Table 9. Comparison of cost-effectiveness of several nutritional intervention programmes^a

a. Different methods of calculation make comparisons indirect at best.
b. Beneficiaries included both children and pregnant or lactating women.
c. Beneficiaries included pre-school children only.
Sources: J.E. Austin. Confronting Urban Malnutrition (Johns Hopkins, Baltimore. Md.,1980); A. Berg, Malnourished People (World Bank, Washington, D.C.,1981); M.F. Zeitlin and Candelaria 8. Formacion, Study II: Nutrition Education (Oelgeschlager. Gunn, & Hain, Cambridge, 1981).

2. Is It Worth Continuing the Project?

Yes, especially if recommended improvements can be implemented. When the findings are compared with national trends and more intensive feeding programmes, the improvement in the Nutri-Bus areas seems good. This evaluation does not prove that the Nutri-Bus project was totally or even partially responsible for the improvements, but the evidence favours that interpretation.

3. Should the Programme Be Extended?

Yes, if the recommended improvements can be implemented. The Nutri-Bus project is still under development. Improvements are needed in the areas listed above, as well as in precision of evaluation.

4. Is There a Causal Link to Improved Nutrition?

Although these data cannot definitely answer this question, the presumption is, yes.

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