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Summary

Improvements in nutritional knowledge and attitudes and nutritional status were found in the Nutri-Bus areas surveyed. Feeding standards improved as measured by mothers' reports of what they feed children. In 1979. contrasting the comparison condition to the VTRL condition, the mothers in the VTRL condition were 55 per cent more likely to describe complete meals (fig. 2). Comparing the BNS to the VTRL condition, mothers in the VTRL condition were 473 per cent more likely to name Nutri-Pak as a good snack (fig. 4), and 71 per cent more likely to give correct specific descriptions of Nutri-Pak (fig. 3).

Comparing 1979 to 1981 results in the rural area, mothers were 27 per cent more likely to describe complete meals in 1981 (fig. 11).

Regarding nutritional status, in 1979, comparing the BNS to the VTRL condition in the rural area, there was 25 per cent less second- and third-degree malnutrition after the VTRL exposure and 29 per cent more normal and first-degree (fig. 9), using weight for age with the Harvard standards and Gomez classification.

Comparing the 1979 results to 1981 in the rural area, there was a 17 per cent decrease in second- and third-degree malnutrition and a 12 per cent increase in normal and first-degree (fig. 18).

Evidence from the 1979 and 1981 evaluations of the Nutri-Bus project favours the assumption that the Nutri-Bus project is effective. It also reinforces the recognized need for improvements in the field management system, in video-tape production efficiency, and in the Nutri-Pak distribution system. The Nutrition Center of the Philippines has committed itself to the continuing development and evaluation of the Nutri-Bus project.

Fig. 19. Percentage share of cost of programme management and field operations cost of 31 buses, by donor, 1981.

ADDENDUM: CURRENT EFFORTS

From two pilot buses fielded in Leyte in 1978, the Nutri-Bus project now has 32 units operating in 11 regions covering 13 cities and 5 municipalities in Metro Manila (Appendix 14). These buses reach approximately 2,790 villages, 403,000 mothers, 558,000 pre-schoolers and 372,000 schoolchildren, and supervise 2,710 BNS. A summary of the field services and management related inputs is shown in Appendix 15.

Identifying and pulling together the various sources of funding and technical support to carry on this project continues to be one of the biggest challenges. In 1981 and 1982, the average grant from the National Nutrition Council for the operation was P32,787 (US$3,706) per bus per year. During 1981 and 1982, NCP covered more than half the operating expenses, NNC covered about one-fourth, and the remaining portion was supported principally by the private sector and local governments. Figure 19 shows the sources of funding for the Nutri-Bus operations in 1981.

An innovative programme of this complexity and scope requires consistent managerial and financial support to attain its potential impact. Long-term funding commitments to cover all costs of the programme have not yet been realized.

To obtain adequate fund support, a resource mobilization unit under the office of the NCP Executive Director was created in early 1983 to "package, promote and sell" NCP projects, among them the various components of the Nutri-Bus, to potential donors. For example, a donor may "buy" the video-tape module for P32,000 (US$2,909); another may "buy" the NB vehicle for P75,000 (US$6,818). Needless to say, the pursuit of these various inputs and putting them together require a major commitment of time and skill from NCP.

Co-ordination with the National Nutrition Council, the local government, and health and nutrition personnel in the field is another sensitive and crucial area. In order to clearly define the linkages and roles of the co-operating agencies and field personnel, the Nutri-Bus policies and guidelines are periodically reviewed and revised for more efficient planning and implementation.

The administrative and operational details are threshed out at the regional level through the Regional Nutrition Program Co-ordinator and at the local level in coordination with the provincial/city/municipal action officer.

As part of its effort to meet the increased demand for social services in the years ahead, the NCP underwent a structural reorganization which took effect in 1983. Under this structure, coordination for the overall implementation of the Nutri-Bus project was placed under the NCP Nutrition Operations Division (NOD) as the division's comprehensive interventions activity. The project has two units: field supervision, under which are the area co-ordinators and communicators, and engineering, which supervises the area engineers (AK) and drivertechnicians (DT). The functions of the NOD include not only field operations, but also monitoring and evaluation and technical support. VTR production is placed under the Video Radio Production Division of the NCP IEC/Training Department.

The new structure served to strengthen:

• the administrative links between the field supervisor and the area co-ordinators, and between the engineering supervisor and the area engineers;
• the functional linkages with the National Nutrition Council and the barangay nutrition scholars (BNS);
• production of VTR modules for project use.

Likewise, operational systems have been strengthened to meet new requirements. For field management, the organizational restructuring covers:

• clear definition of support linkages and administrative responsibilities;
• reassignment of AC/AK areas of responsibility for cost-effectiveness and closer reach.

Improvement of policies and guidelines for field implementation and co-ordination includes:

• tighter controls on NB operational funds reporting schemes to identify immediately discrepancies in fund balances;
• incentives to field personnel in the form of benefits, salary increases, and full implementation of cost-of-living allowances;
• better scheduling of vacation leaves to avoid disruptions in operations schedule;
• stress on proper and punctual preventive maintenance procedures to AEs and DTs in order to avoid unnecessary disruptions of operations due to vehicle/equipment problems;
• regular monthly NB staff meetings (per NB); semestral area meetings for evaluation, planning, solution of field problems, etc;
• controls over reporting/submission activities with speedy management feedbacks. Staff development is pursued through:
• closer involvement/control in recruitment, selection, and training of DT, COM, AC, and AK;
• improved design and continuous development of training courses and materials for DT, COM, AC, and AK;
• development and implementation of upgrade materials for DT, COM, AC, and AE to include in-depth evaluation, planning, review of basics, new "inputs" on skills/ attitudes/knowledge needed, for example basic management skills/attitudes for AC/AK;
• regular meetings/exchanges of head office NOD staff with development inputs; in all foregoing, stress on "team building" and "unified goal setting," as well as "sense of belonging" to whole NCP family and divisions, with which closer linkages must develop (CDD, SSRD, etc.);
• introduction of training component for BNS upgrading and for orientation of barangay captains.

Supervision by the NOD head office is strengthened through:

• field visits which include analysis of needs and immediate response to such; development of closer ties with local government; special attention to local funding of major part of operational costs;
• regular field visits to determine basic/upgrade training needs; strengthen coordination with local officials, especially in the recruitment, training, and supervision of BNS;
• closer supervision/co-ordination with units such as monitoring, evaluation, finance, engineering, for faster feedback and prompt response to needs of field, i.e. funds, equipment/vehicle repairs, forms, etc.;
• closer supervision over AC/AK activities and monthly "planners" to make them more responsive to needs of the communicators, driver-technicians, and, indirectly, the BNS.

The work systems include:

• AC/AE monitoring of daily activities for reconciliation with monthly planner and liquidation report/travel itineraries; form letters/feedback forms for faster response to field communications on deficiencies;
• SCAN-TRON system: for simpler yet accurate and fast recording by communicators of field supervisory data in computer processing form to give quick feedback on: accomplishments v. targets, individual and overall picture of nutritional status of target children, Nutri-Pak transactions, VTR audience distribution, knowledge, attitudes, and practices of mothers, etc.;
• SCAN-TRON programme verifier: built-in audit system into the SCAN-TRON field activities whereby monitoring of accuracy/effectiveness of SCAN-TRON system is accomplished; mechanics include a "SCAN-TRON auditor" per area who follows up communicator "weighing activities" picked at random.
• Kalamazoo system: for accurate and complete recording, monitoring of DT field activities/accomplishments; for accurate/complete/immediate recording of vehicle/ equipment needs/breakdowns/expenses; for identification of DT deficiencies in skills or personality; for better management cost-control and evaluation;
• Nutri-Pak audit system: monitoring system controlling N-P withdrawals, distribution, collections, remittances to avoid lags, anomalies;
• Nutri-Pak plants monitoring system: implementation of closer supervision (through a NutriPak plants co-ordinator assisted by a team) over production, raw materials supplies, costs, meeting projected demands for Nutri-Pak.

Meanwhile, the following steps have been taken to increase efficiency in VTR production:

1. Intensification of organization and staff development through:

• seminars and other training sessions on scripting and production;
• an organization-wide job evaluation process to align position classifications and make compensation rates competitive with commercial market rates;
• reward for performance through the performance appraisal system; and
• increase of VTR production units from 2 to 4.

2. Improvement of production equipment and facilities through:

• acquisition of new cameras, as well as new VTR editing equipment and lights;
• setting-up of a VTR "village" (set) at the back of NCP;
• acquisition of new props and interchangeable sets;
• formation of a talent pool to facilitate recruitment of talents for dubbing of master tape into various dialects.

3. Increase in variety of shows/modules through:

• new formats, e.g. games, drama, community video, "how-to's";
• new titles, e.g. the four-pronged UNICEF primary health-care approach (growth monitoring, breast-feeding, immunization, and use of ORESOL remedy against diarrhoea), home gardening, livestock-raising, and other nutrition- and health related topics, including family planning.

4. Improvement of management methods through:

• judicious cost control;
• prompt response to problems;
• open communication lines and clear instructions and guidelines on policies and principles.

On the whole, the project adheres to the well-known management principle that programme success lies not in programme design but in the people manning the programme. It gives equal emphasis, therefore, to the hard and soft aspects of the management framework to meet established goals and values.

ACKNOWLEDGEMENTS

The authors are deeply indebted to the following for their co-operation and involvement during the study:

The Director and staff, Regional Health Office, Region VIII, Ministry of Health, most especially to Dr. Amparo Banzon, Regional Health Director; Dr. Wilfredo Varona, Medical Specialist 11; Mrs. Cleofe Panao, Provincial Dietary Nutritionist and District Nutrition Program Co-ordinator; Mr. Bert de Veyra, Provincial Health Educator; Miss Leticia Espinosa, Health Education Supervisor; Dr. Benefico Ducusin, Chief Training Officer, and the staff of the Regional Health Training Center, for assistance in the selection of the study areas, training of the BNS in both pilot and evaluation studies, providing transportation and office equipment, assistance in data collection, and implementation of the VTR treatment.

The Hospital Director and staff of the Daniel Z. Romualdez Memorial Hospital, particularly Dr. Manuel Anover, Director, and Dr. Dolores Sancelo; Nurse Supervisors Mrs. Mamerta Menesis, Mrs. Lilia Marquez, Mrs. Restituta Santiago and Mrs.

Jocano, and Dr. Prescila Escape and Dr. Mansueto Corado, for assistance in the training of data collectors and in actual data collection.

Dr. Roberto Briones, Regional Nutrition Program Co-ordinator, Region VIII, National Nutrition Council, and Mrs. Julita Solana, Regional Training Assistant, for assistance in coordinating schedules and communication with the village officials, providing transportation and office support, and assistance in data collection.

To the City Mayor of Tacloban, Mayor Obdulia Cinco and Atty. Antonio Zeta, City Administrator; and the municipal mayors and barangay officials in the study areas, for their whole-hearted co-operation in providing secondary data, allowing access to birth registries for the validation of birthdates, and providing the initial capital for Nutri-Pak sales.

To the parish priests in the study areas, for allowing access to parish baptismal records for the validation of birthdates.

Each of the above contributed in various ways towards attaining the goals of the pilot study.

Valuable comments and suggestions have been provided by Dr. Richard Lockwood, Consultant, Development Communications Consultants, Inc.; Dr. Nevin Scrimshaw, Institute Professor, Massachusetts Institute of Technology; Dr. Joe Wray, Center for Population Studies, Columbia University; Dr. Barbara Underwood, National Institutes of Health; Dr. Marian Zeitlin, Assistant Professor, School of Nutrition, Tufts University; and Dr. William Rand, Biostatistician, Massachusetts Institute of Technology. We are deeply grateful for their help in the analysis of the data and interpretation of the results.

We express special thanks to the Coca-Cola Company for funding the evaluation study, among the company's many generous contributions to the work of the Nutrition Center of the Philippines over the years.

We also appreciate very much the dedicated support extended by the Nutrition Center of the Philippines staff, especially the data-processing programmers, Ms. Teresita Rosete, Arlene Abueg, Carolina Dayco; Joey San Luis, Audio-Visual Division Chief and his staff, Danny Catacutan, Rolly San Jose, Mita de la Paz, and Hubs Ismael; the clerical staff, Elvira de la Cruz and May Esposo; Orly S. Ramas of the Executive Office; and Malou Rusiana and Rebecca Yao of the Nutri-Bus Office.

We are particularly grateful to Dr. Florentino S. Solon, Executive Director, Nutrition Center of the Philippines, whose help and encouragement sustained us throughout this project.

We thank all the many others who have been involved in the implementation of the project and who have contributed to the production of this material.

REFERENCES

1. Philippines Food and Nutrition Research Institute, First Nationwide Nutrition Survey (FNRI, Manila, 1978).

2. Nutrition Center of the Philippines, The Nutrition Surveillance Pilot Project: First Phase, Albay, Philippines (NCP, Makati, 1980).

3. D.B. Jelliffe, Infant Nutrition in the Tropics and Sub-tropics (WHO, Geneva, 1968).

4. M.F. Zeitlin and Candelaria S. Formacion, Study 11: Nutrition Education, Harvard Institute for International Development, Supplementary Studies to Nutrition Intervention in Developing Countries (Oelgeschlager, Gunn & Hain, Inc., Cambridge, Mass., 1981).

5. J.P. Habicht, J. Mason, and H. Tabatabai, "Basic Concepts for Design of Evaluation during Program Implementation," in D. Sahn, R. Lockwood, and N. Scrimshaw, eds., Methods for the Evaluation of the Impact of Food and Nutrition Programmes (UNU, Tokyo, 1984).

6. J.E. Austin, "The Perilous Journey of Nutrition Evaluation," A.J.C.N., 31(12): 2324-2338 (1978).

7. J.E. Austin, Confronting Urban Malnutrition: The Design of Nutrition Programs (Johns Hopkins University Press, Baltimore, Md., 1980).

8. T. Soda, A Nationwide Simple Morbidity Survey in Japan (WHO, Geneva, 1965).

9. N.S. Scrimshaw, C.E. Taylor, and J.E. Gordon, Interactions of Nutrition and Infection (WHO, Geneva, 1968).

10. Philippines National Census and Statistics Office, Population, Land Area and Density, Special Report, no. 3 (NCSO, Manila, 1980).

11. B. Popkin, "Some Economic Aspects of Planning Health Intervention among Malnourished Populations, " A. J. C. N., 31 (12): 2314-2323 (1978).

12. NEDA-UNICEF, unpublished statistics, 1982.

13. Philippines National Census and Statistics Office, Leyte: 1975 Integrated Census of the Population and Its Economic Activities: Final Report, Phase I (NCSO, Manila, 1975).

APPENDIX 1. The "A-B-C Model" for Developing Communication to Change Behaviour (Development Communications Consultants, Inc., 1983).

Part 2

APPENDIX 2. Interactive Learning and Motivation Strategies for Communication to Change Behaviour (Development Communications Consultants, Inc., 1983)

1. Discovery/Logical Conclusion

Learner is exposed to certain information and then asked to make a decision which logically follows from that information.

2. Analogy/Logical Conclusion

The audience is reminded of something they are familiar with that works on the same principles as the idea being taught. They are then asked to draw conclusions from the new information based on the analogy.

3. Specification

Learner is given a general principle and asked to apply it by giving specific examples.

4. Generalization

Learner is given specific examples and asked to conclude the general principle.

5. Observation No. 1. Description

Audience looks at certain conditions and reports what it saw.

6. Observation No. 2. Comparison

Audience looks at two or more sets of conditions and reports differences and/or similarities.

7. Observation No. 3. Modelling of Desired Behaviour

This is a special case of observation/description/comparison. Here what is being observed is the behaviour to be taught. The audience is asked to observe and describe this correct behaviour or some of its elements.

8. Prompting

The audience is helped to get the correct answer by being given clues.

9. Fading

Previously elicited and reinforced behaviour is asked for again with less supporting information or prompts.

10. Personal Opinion, Preference, Feeling, Experience, or Data

Audience is asked to give opinions or preferences, tell some personal feelings or experiences, or give data about themselves or their children (such as age, names, etc.)

This is the strategy used for the first interaction of a programme. The subject-matter chosen should be non-threatening to the audience but something they might like to talk about.

The purpose is to (a) have an opportunity to reinforce the audience for responding, and (b) introduce the subject of the module.

11. Public Commitment

Audience is asked to commit themselves regarding some attitude, opinion, or value that is being shaped by the module. This is done in order to strengthen that attitude, opinion, or value as a motivation to act or to learn what is in the module.

12. Performance of Entering Behaviour

Audience is asked to do or say something that it already knows how to do or say. This is used only if:

1. The entering behaviour is weak and needs to be reinforced.
2. The entering behaviour is part of a logical sequence of interactions leading to new behaviour.

APPENDIX 3. The Contribution of the Communication System in Influencing Knowledge, Attitudes and Nutritional Status (Development Communications Consultants, Inc., 1983).

APPENDIX 4. VTR Modules Shown during Study Period

APPENDIX 5. Nutri-Bus Delivery System

APPENDIX 6. Appropriate Data Collection and Analysis for Different Decisions

(+) Occasionally.
Source: J.P. Habicht, J. Mason. and H. Tabatabai [5].

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