Effective communications for nutrition in primary health care

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12. Nutrition education and behaviour change project, Indonesian nutrition improvement programme

RUSLAN ADJI
Directorate of Health Education, Department of Health, Jakarta, Indonesia

BACKGROUND

The Government of Indonesia, in collaboration with various international agencies, has identified four major nutrition problems in Indonesia: protein-calorie malnutrition (PCM), vitamin A deficiency, iodine deficiency, and nutritional anaemia. These problems are widespread throughout Indonesia, although regional, ecological, and cultural differences that affect food availability and consumption account for geographical variations in their nature and intensity. Of these four major problems, the most basic is inadequate intake of protein and calories. Close to one-third of children under five years of age are estimated to suffer from moderate to severe PCM, while more than 50 per cent of children under two are affected. Pregnant women are another vulnerable group, and more than half of lactating mothers suffer from moderate PCM.

FACTORS RELATED TO THE PROBLEM

Malnutrition in Indonesia is the result of a combination of factors, mainly inadequate production and availability of foods, inequitable distribution of available foods, insufficient awareness of nutritional needs, and poor food habits among a large segment of the population.

In most areas of Indonesia the most preferred staple food is rice, frequently mixed with cassava or sweet potatoes. Only a few families can afford to consume animal protein. Proteinrich vegetables are seasonal and are used for snacks and during meals.

Fortunately, breast-feeding during the first to second year is widely practiced, especially in rural areas. But there is little understanding of the importance of additional solid food other than soft rice or banana for children after the first four months of life. Vegetables, meat, and fish are generally not provided to young children, in part because of local practices and beliefs.

THE EARLIER PROGRAMME

Attempts at improving the utilization of available food have concentrated on the basic five food groups message, "4 sehat 5 sempurna" (4 is healthy, 5 is excellent). Though the message is scientifically sound and is recognized throughout the country, it has not yielded the expected results. The major obstacle is the inaccessibility to the food items named in the message, i.e. milk and vitamin supplements. School feeding programmes have been conducted, but with disappointingly little impact, and lack of community participation is a recognized problem. Malnutrition still exists even among the better-off families with a prevalence of as high as 41 per cent.

The Nutrition Education and Behaviour Change Project (NE) is a component of a comprehensive multi-sectoral Indonesian Nutrition Improvement Programme funded by the World Bank. The project aims to develop education methods that create positive knowledge, attitudes, and practices among the target population. The results will be used in the development of the National Nutrition Education Programme.

This NE project was conducted during 1977-1982, covering five subdistricts in three provinces; Godean and Karangmojo in the Special Territory of Jogjakarta, Masaran and Sapuran in General Java, and Indralaya in South Sumatra. The total population of the project areas was approximately 225,000 people, or about 40,500 households. The project was divided into four phases:

Phase 1

The development of nutrition infrastructure at all administrative levels for the dissemination of nutrition information.

Phase 2

The development of community understanding and ability to solve problems through community organization. Approximately 2,000 village nutrition volunteers referred to as kaders were trained and equipped with nutrition education kits. Kaders initiated nutrition education activities with a weighing programme as the base.

Phase 3

The development of a communications strategy (1979-1981). A community selfsurvey was started in which families participated in the formulation of the strategy. Actual production and dissemination of the materials and evaluation were attempted.

Phase 4

The preparation of the National Nutrition Education Programme.

This paper will specifically discuss the third phase.

THE DEVELOPMENT OF THE COMMUNICATION STRATEGY

On the basis of findings from earlier nutrition education activities, it is imperative that the message of a nutrition education programme be specific in that it has a practical implication for the target population. The communication channels selected need to have extensive as well as intensive coverage of the target population, and resources to put the message into practice must exist in the community.

To meet these requirements the development of the communications strategy was carefully planned and divided into five stages: (1) community diagnosis; (2) concept testing or formative evaluation; (3) message pre-testing; (4) implementation; and (5) evaluation.

Early in 1979 a community self-survey was held in each village in the project areas to uncover the major nutrition problems there. These were found to be: (1) PCM among children of 0 to 24 months of age; (2) infant diarrhoea; (3) undernutrition among pregnant and lactating women; (4) vitamin A deficiency among young children; and (5) goitre.

Community meetings were then held in each village to provide opportunities for village leaders and, most importantly, the mothers to discuss the problems and suggest alternatives (behaviour) to solve them. An investigation team was introduced to get acquainted with the leaders and mothers and also to develop insights into the suggestions produced during the meeting.

Community diagnosis showed that:

Most families came from the lower socio-economic segment of the population, with a daily per capita income of 200 to 600 rupiahs.
A substantial number of mothers engaged in economic activities to earn additional money.
Radio broadcasts reached more than 65 per cent of the population in four subdistricts.
Very few families had access to printed materials. Only possession of a calendar was very common.
Villagers liked to attend village meetings, but smaller meetings at hamlet level seemed to be preferred.
The term kader was not always understood, but the person's name was recognized.
Most pregnant mothers complained of having a problem with their eating habits, especially during the early months of their pregnancy. Weakness was associated with pregnancy.
Most mothers did not give colostrum to their babies. Mothers breast-fed more from the left breast than the right, and drank less water during lactation, partly because they believed that the baby would catch cold.
Mothers gave additional foods such as soft rice and banana very early, that is, during the first to fourth week of the baby's life, because "the babies were still crying after breast-feeding."
Mothers were not sure of the right time to start feeding additional foods.
Mothers faced problems with the eating habits of their 9- to 12-month-old infants; weaning was usually in progress after 24 months, unless the mother found herself pregnant.
Diarrhoea among young children was regarded as an indication of child development. No treatment was given during the first day of diarrhoea. Mothers stopped breastfeeding and reduced the child's water intake.
Most hamlets in the project areas had already carried out the weighing activity. The basic meaning of weighing was generally understood, but further information related to health, development, and food and nutrition seemed to be too complicated. Some mothers did not understand the meaning of the colours in the weight chart.
Most mothers did not realize the relationship between green vegetables and vitamin A deficiency blindness.
Although greens were very common in the villages, their consumption was limited to adults. "Young children do not like vegetables."
Most families had home-gardens or cassava plantations in the yard. Papaya and banana were very common.
Although protein-rich vegetables were seasonal in production they were very common, especially in Jogjakarta and Central Java, while in South Sumatra protein-rich vegetables were used less frequently.
Village volunteer/leader training was found to be interesting for kaders only if it could be specific and possessed practical application aimed at solving problems.
Traditional midwives were found to be very highly valued by mothers.
Shopkeepers at hamlet and village levels were found to be recognized by most mothers in the surroundings.

The list could be made longer and more formidable, but the points listed above were found to be enough for starting the next stage.

CONCEPT-TESTING OR FORMATIVE EVALUATION

At the village meetings held to discuss the data collected during the community self survey, the investigation team together with the project staff noted a long list of suggestions brought by the village leaders, the leaders, and most importantly the mothers. Priorities were selected on the basis of their importance for improving the nutritional status of the children and their practicability. Knowledge and behavioural objectives were then developed for each priority, and after a period of trials a list of questions was ready for the investigation team to present to the villagers. The following were the first six topics agreed upon as priorities:

Message for child-weighing activity.
Message for pregnant women.
Message for lactating women.
Message about food for children under two years of age: (a) foods for babies of 0 to 4 months of age; (b) foods for infants of 5 to 8 months of age; (c) foods for young children of 9 to 24 months of age.
Message for children with diarrhoea: (a) Oralite or sugar-salt solution; (b) foods for diarrhoea-recovering children.
Message on vitamin A deficiency and night blindness.

After sufficient training, especially on message design and concept-testing procedure, the investigation team started with interviews of the sample of 330 households that had: pregnant women, lactating women, infants from 0 to 4 months, infants of 5 to 8 months, infants of 9 to 24 months, and young children with diarrhoea of signs or vitamin A deficiency. A 2lhour dietary recall was also administered to calculate the calorieprotein intake of infants and lactating women. The young child was weighed and a possible dietary change was discussed with the mothers to improve the family nutrition intake. New recipes, especially for the young child. were then tried using food, ingredients, and utensils available in the house. The child was then fed and the mothers discussed with the investigator how the child liked or disliked the food. Possible modification was discussed, based on observations made while the child was eating. Three to four days later, when the investigator came back, the mothers usually had already found the recipe the child liked the most.

Considering the findings during the community diagnosis, the communication channels most feasible for the target population were: (a) radio spots, (b) action posters, (c) common posters, (d) booklets, (e) kader manuals, (f) leaflets, (g) slides, (h) radio social dramas, (i) TV short dramas, and (j) TV spots.

MESSAGE PRE-TESTING

Before production, mimeo copies of the messages for the action posters and radio spots were pre-tested with a sample of mothers, leaders, and village leaders, as well as officials in the project areas. The purpose was to observe whether or not the messages were easily understood and what possible alterations could be made. Generally, the messages were highly accepted. Suggestions were usually directed at improving the words, colour, size, pictures, speed of the recording, and the like.

IMPLEMENTATION

Implementation started in August 1980, and slightly more than one year later the evaluation was carried out. Orientations were held at several levels to provide the intersectoral team with the opportunity to learn not only the messages but, more importantly, the principles underlying them. Kaders were trained in the technical aspects of the messages and also in the behavioural as well as the knowledge changes that were expected to occur among the target population.

Mass communication as well as an interpersonal approach was decided upon for dissemination of the messages. Radio was listed first for the mass campaign, because radio accessibility was over 65 per cent in four out of five project subdistricts. Although TV was regarded as highly effective, accessibility was low for both the project officials and the community. The use of TV was then limited to producing general information on nutrition problems. Group meetings were very important because most villagers liked to attend such meetings during their leisure time; village as well as hamlet meetings were held each month. Group meetings following weighing sessions were particularly important.

Kaders were encouraged to pay home visits as often as possible. During the first visit kaders distributed action posters to families; they discussed the meaning of the posters and what action the mothers should take. They also checked whether or not the family listened to radio broadcasts. In most cases, the radio spots did not receive the desired amount of exposure; however, radio was principally a reinforcement aid for interpersonal communications activities.

EVALUATION

In November 1981, after intensive training, an interview team conducted extensive evaluation interviews for the project. A total of 305 kaders (200 from project areas and 105 from comparison areas) and 1,000 households (600 from project areas and 400 from comparison areas) were involved in the interviews. The comparison areas were matched for similar socio-economic conditions, the occurrence of some types of nutrition education, and the presence of nutrition leaders. The results were positive in that the project had brought about a significant improvement in the knowledge, attitudes, and practice of the target population. In turn, it was evident that these practices favourably influenced the growth of the children. The following are highlights of the project evaluation.

Kaders

Some characteristics of project kaders were different from those of the comparison leaders: they were older, more were male, with a better formal education, and more were farmers or official village leaders.
In general, project kaders had been nutrition kaders for more years than comparison leaders.
Project kaders learned specific messages in three ways: training, the manual, and the radio spots. Comparison kaders learned the same messages only through radio spots.
Project kaders recalled more project messages than the comparison kaders did.
Project kaders contacted community groups and paid home visits more than comparison kaders did. Although both kaders were involved in weighing sessions, project kaders offered nutrition education more than comparison leaders. More hours were spent by project kaders in nutrition activities.

Households

Parents in project areas knew more specific information about nutrition problems than the comparison parents; they recalled more messages correctly, and they offered and practiced correct messages related to the age of a child better than the parents in comparison areas.
Parents in the project areas offered more of the foods stressed in the messages to their children, particularly greens and coconut milk.
Children of the families in project areas had higher calorie and protein intakes. The changes in dietary practices advocated by messages to increase food consumption were translated into improved nutrient intake checked by dietary recall.
Children in the project areas grew significantly better after five months of age than those in the comparison areas. The growth curve of the children in the project areas flattens at the seventh month, while in the comparison areas it flattens at the fifth month. The average weight of the infants in the project area never dropped below normal, whereas in the comparison areas it dropped below normal at the thirteenth month.

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