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CON TEN T S_
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1_ INTROOOCTION 1
I I _ PROBLBHS 2
I I I _ INNOVATIVE APPROACH 4
L Background 4
2_ Innovative Approach 5
a_ Preparatory Stage 5
b_ Diagnosis Stage _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 16
c_ Message Formulation Stage __________________ 44
d_ Pretesting Stage ___________________________ 52
e_ Distribution Stage _________________________ 53
IV _ KVAWATION _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 55 V _ OONCWSION _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 59
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I . INTRODUCTION.
The most valuable asset of a country is its people. Therefore, all development programs are aimed at improving quality of life of the people. Improved quality of life is on one hand very supportive to the whole development process, on the other hand i t becomes a main capital for completing the development i t self, including the health development. Improving the qua l ity of life of the people covers all aspects of life, incl u ding nutrition and foods. Nutrition status as one of the aspects is very much influenced by various interrelated factors, such as education, health, economic, sociocultural, etc. Overcoming nutrition problems to increase the quality of life of the people, therefore, requires well coordinated multidisciplinary efforts. It is in support to the success of the development programs, because improvement in nutrition also means investment in human capital in general, and children under five in particular. There is a positive correlation between nutritional status in early childhood and brain development, since 80 percent eventual brain weight is reached during the first 24 months of life.1* Malnutrition interferes with a child's ability to concentrate and to learn. Investments in nutrition thus assist in better utilizatioh of the education system. Even if there is no guarantee of adequate nutrition in adulthood, better nutrition in childhood or in utero enables the chil d to reach a higher level of mental and physical development and so better adapt to the challenges of adulthood. The nutrition impro vement programs in Indonesia therefore give high priority to t h at for children under five. pregnant. and lactating mothers. This is based on the fact that inadequate intake of calories and protein is the most basic nutrition problem in Indonesia, and that they are the most nutritionally vulnerable groups in this country .
Various nutrition programs have been implemented to overcome the existing problems, but the achievements are s t i l l far behind the expectations. The government of Indonesia, anyhow, is trying hard to find out some effective ways for carrying out such programs. For the purpose, the government has established a 5 year Indonesian Nutrition Development Project in 1977 and Nutrition Education is one of its components. It is believed that food related behaviours are essential elements in the occurance of nutrition problems, and nutrition education components is expected to provide experiences for developing patterns of nutrition education for national replication.
This writing describes how nutrition education as an essential component of any nutrition program would be effective, if i t is deve16ped based on the capability and the sociocultural condition of the target group.
1* Agriculture and Rural Development Department, Indonesia Appraisal of a Nutrition Development Project, World Bank, 1977.
I I _ PROBLEMS _
Indonesia consists of t h ousa n ds of is l an d s and hundre ds of sub cu l tures_ This country has a l arge amou nt o f popul at i on, which i s unev enl y di str ibuted and growi ng at high r at, e _ Unh o mo geneous geograph i cal conditio ns are ma n i fested in a g rea t v a r iety of f oo d s f r o m o ne place to ano the r. Al l those h a v e contr i bu t ed to the food hab i t s and other b e ha v i o r a l patte rn s of t he peo ple in r e lation wit h foods and nutrit io n. The low e co n om i c sta t u s of the peop l e makes t he problems more comp licated.
The Government of Ind one s i a ha s i de ntified f o ur major nut ri t i on prob l ems in Indonesia: Protei n Calor i e Ma l nut r ition (PCM ) , Vitamin A deficiency, I o dine d ef i c ienc y , and n u tri tional anem ia _ Th e probl e ms are wide spr ead t hroughout I ndo n esia, al t hou gh reg i o na l , e c ol og i c a l , a nd cultural d i ffer e nce s that af f e c t f ood a vai lab ility an d c o nsumpti o n ac c ount f o r g e ogr aphical va r i a t ion in t h e nature an d in tensit y of the p robl ems_ Among t h e se f ou r maj o r problems. the most b as ic is inadequa te i ntake of p r ote i n a n d ca l orie_ Close to on e th ird o f chi l dren und e r five years o f age a re estimated to s uffer from mode r ate to severe PCM, whi l e ove r 5 0 p erc ent of ch i l dr en u nd e r t wo y ears o f a ge are fac i ng the s ame prob lems_ Pr e gnan t wo me n is an o ther vulnerable gro u p a nd more than h alf of 1 a .tating mo t h ers a re af fe c ted by moderate PCM.
Malnut r i t io n in Indones i a is t h e re s ult of a c ombi n ati o n of fac t ors mai nl y inadequa te pro d ucti o n a nd availab i lity of food,
inequi tab le d i stribut i on of a v a i l ab le food , insuff icient awa reness of t h e nutritional n ee d s of and by vulne r a b l e groups. and poor food h abits among t h e p o p la tion. Poo r f oo d h a bi t s and l a c k of awareness of nutritiona l requireme nt s of the bo d y among a l arge segment of the p o pula t ion a dversely af f ect their nutritional status, particularly among nu t ri t i o nally vulne rable. I n most areas in Indonesia. the most pre fe red st a pl e food is r ice, frequently mixed with maize, cassava or sweet p o tatoes. Only few families can afford to consume an ima l protein. Fortunately, breast feeding normally unt i l l the f i rst to the second year i s almost widel y p racticed, e specially in rural areas. But there is litte und e rstanding of the i mp or tan ce of a dditional solid foods othe r th an soft rice or b ananas for children after the first fo u r month s of t heir l ife. Ve g etables, me at and fish are generally no t p rov i ded to y oung c h i ldr e n due in p art to lo c al practices and be l iefs th a su ch f o o ds may be h a rmful. Apart from income co nsiderations , b e h avioural constraints a r e some of the c ri tic a l fact o rs i n bri ng i ng about improvement in nutritional status.
Decision makers have paid attenti o n to t he nu trition p r oblems. The President has is sued tw o Pr es ide n tia l I ns t ructions wh i c h underl i n e s the signifi c a nce o f nutrit i o n in a compr ehensive d evel o pment of th e nation. The Inst r uc t i o n also c l ear l y men t ioned tha t the respo nsibility of n ut r iti on d ev elo pme nt is not only in t h e hands of the Government.
• ...1
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It can not b e managed by a singl e minist ry or by purely government ag e ncies. The efforts should be done seriously by government and c ommunity. Nutriti o n pr o b le ms requires harmonious technical efforts of vari o u s discipl i nes, such as medical, production , economic, sociacultural, and many others.
It is undoubtedly, that the nutrition problems could only b e overc ome through well coordinated intersectoral pr ograms.
The Presidential Instru c t i o n of Septembe r 1974 requires improvement in the variety , quantity, and nut r itional quality of foods consumed by all level of society in all regions of Indonesia.
But , this will depend on changing food be h a v iour i n order to op t imize the use of available food s upp l ie s . The Applied Nu t rition Program Evaluation Study in 197 3 found that even in the be t terof families 41 precent were defi c i e nt in both protein and calorie intake.1* This finding gives an i n d ication of the lack of knowledge about the use of av a ilable food.
Food habits related to choi c e of foods. methods of p reparing and cooking foods, distribution of foods within the f a mily . weaning prac t i ce s and feeding the s i c k c hild a re li k e l y to be respon s ible for th e g a p b etwe en f oo d a vai l ab i lity an d c o n sumption.
In the past nutr i t i o n e d uca t i o n i n In d ones i wa s c a rr ied o u t on the slogan " FOUR GOOD . FIVE EXEC EL LE NT " . Th ｆ ｦ ｾ ｕ ｒ＠ GOOD c on sists of gr o ups of f o ods,i.e . 1) ca r bo h rdra t e. 2 ) pr o t e i n, par ticulary animal pro te i n, 3 ) v e getables, and 4) f r u i 8 . Wh i le
FI VE EXCELLENT are the FOUR GOO[) plus MILK .. Fr o m ·the sc ien t i f i c point of view. those foods are sur e l y of the es se ntial n u t r ie n t s. Any how, the way of p res e nting th e i d eas on po s te r s h a n e g lect e d t h e economi c and s o c i oc ultu ra l c onditi o n s of the target aud ience. The foods pi c tured out o n the poster s a re of those that most people cannot afford. They are luxu r ious a nd expens ive. The
impact of the nutrition educ ation of this kind is no more than remembering the slogan. This kind of nutriti o n education has never been able to bri n g about beha v i o ur a l ch a nges i n th e community, because they per c eived that nut r i tious foods ar e expensive one s . They cannot afford them an d the nutritious foods are perceived as for well to do famil i e s o n l y. Besides, nutrition education in the past never made use the potency of t h e community as well as that of the nonhe a lth se c tors. The nutrition mess a ge s a re to o general, not specifi c enough to foll o w The " FOUR GOOD. FIVE EXCELLENT', is for a great variety of target audience s. In other words. the nutriti o n messages in the past have be e n dev e l o ped on the bases of the pro v ider "s assumptions without t a king any c onsideration of t he real situation and condition of the t a rget audience. They have been developed f ro m behind the d esk of the administrators a t upp er levels.
1* An evaluation study o f the results o f the Applied Nutriti on Program (ANP) 19631973, was carried out by Prof. Sayogyo. The study included a f oo d consumption surve y of 92 0 households f r o m villages where the ANP program has been applied intensively.
111_
INNOVATIVE APPROACH_
i. Background_
According to Blum. health status is mainly influenced by four factors,i.e. 1) environment (physical, biological, and sociocultural, 2) behaviour, 3) health service, and 4) heredity. Among those factors, environment and behaviour are more influencing, and they are closely interrelated.1* Like in health, this also happens in nutrition. Nutrition status is closely related with foods and food habits of individual. family, and community as a whole. In the Maslow's hierarchy of needs. foods are one of the basic needs or physiological needs. Theoritically, motivation for taking foods come from innerside of people when they feel hungry. In reality, however, the problem is not so simple as that. It covers taste preference, prestige, and life value of individuals, and social norms of a comm1.lT1ity.
Nutrition improvement.. is bFu'lically an effort to bring about behaviouraJ changes in relation with foods in individuals. families, or a community as a whole for better nutrition status. The achievement clearly depends upon the depth of understanding about all behovioural aspects. Matthews has introduced a hypothesis that behavioural change is influenced by three determining elements. He formulated the hypothesis as follows:2*
P
=
ip (1 e ), in which p - the probability of an individual or a group to act,
p the probability assumed by them, that what they do could achieve the objective
i the perceived importance of that objective in
comparison with the other objectives
e the perceived fraction of total available resources required for the action (resources include money, time, etc. )
The Value of P,p,i, and e is between 0 and +1.
oJ
In other words, Matthews stated that the probability of an
individual or a group to take action, depends upon the J product of the perceived probability that the action will
lead to a certain goal, the perceived importance of that goal, and the perceived effort or resources required to take the action.
1* It is stated in National Health System, Minstry of Health. Indonesia : 1982.
Matthews, C.M.E., A theory for predicting behaviour change, international Journal of Health Education, Supplement to vol. XVIIIIssue no.2, AprilJune 1975.
It can not be managed by a single minist ry or by purely government agencies. The efforts should be done seriously b y government and communit.y. Nut.rit.ion problems requires harmonious technical effort.s of various disciplines, such as medical, production, economic, sociocultural, and many others.
It is undoubtedly, that. t.he nutrition problems could only b e overcome through well coordinat.ed intersectoral programs.
The Presidential Instruction of September 1974 requires improvement in the variety, quantity. and nutritional quality of foods consumed by all level of societ.y in all regions of Indonesia.
But, this will depend on changing food behaviour in order to optimize the use of available food supplies. The Applied Nutrition Program Evaluation Study in 1973 found that even in the betterof families 41 precent were deficient in both protein and calorie intake.1* This finding gives an indication of the lack of knowledge about the use of available food.
Food habits related to choice of foods. methods of p reparin g and
｣ｯｾｫｩｮｧ＠ foods, distribution of foods within the f a mily. weaning
practices and feeding the sick c hild a e likely to be responsible for the gap betwe e n f o od ava il ab i l ity En d consumption.
In the past nutrition educati o n in indon e s ia was ca r r ie d out on the slogan "FOUR GOOD, FIVE EXECELLENT ". Trl e FO UR GOO D consists of groups of foods, i.e . 1) car bohy dra te, 2 ) protein , particulary animal protein, 3) veg e tables. a nd 4 ) f r u i t s . While FIVE EXCELLENT are the FOUR GOOL} plus MILK. F r om the scientific point of view, those foods are surely of the e s sential nutrients . Anyhow, the way of pr e senting the id eas on pas er e has n eg lect e d the economic and soci ocultural conditi o ns of the tar g et audience. The foods pictured out on the poster s are of those th a t most people cannot afford. They are luxurious a nd expens i ve. The
impact of the nutrition education of this kind is no more than remembering the slogan. This kind of nutrition education has never been able to bring about behavioural changes in t h e communi ty, because they perceived t.hat nut ri tious foods are expensive ones. They cannot afford them an d the nutriti o us foods are perceived as for well to do families only. Besides, nutrition education in the past never made use the potency of t h e community as well as that of the non health sectors. The nutrition messages are too general, not specific enough to follow The "FOUR GOOD. FIVE EXCELLENT', is for a great variety of target audiences. In other words, the nutrition messages in the past have been developed on the bases of the provider's assumptions without taking any consideration of the real situation and condition of the target audience. They have been developed f r om behind the desk of the administrators at upper levels.
1* An evaluation study of the results of the Applied Nutritio n Program (ANP) 19631973, was carried out by Prof. Sayogyo. The study included a food consumption survey of 920 households from villages where the ANP program has been applied intensively.
III.
INNOVATIVE
APPROACH.1. Background.
According to Blum, health status is mainly influenced by four ｦ｡｣ｴｯｲｳｊｩｾ･Ｎ＠ 1) environment (physical, biological, and sociocultural, 2) behaviour, 3) health service, and 4) heredity. Among those factors, environment and behaviour are more influencing, and they are closely interrelated.1* Like in health, this also happens in nutrition. Nutrition status is closely related with foods and food habits of individual, family, and community as a whole. In the Maslow's hierarchy of needs, foods are one of the basic needs or physiological needs. Theoritically, motivation for taking foods come from innerside of people when they feel hungry. In reality, however, the problem is not so simple as that. It covers taste preference. prestige, and life value of individuals. and social norms of a community.
Nutrition improvement is b.=tsically an effort to bring about behavioura] changes in relation with foods in individuals. families. or a community as a whole for better nutrition status . The achievem e nt clearly depends upon the depth of understanding about all behovioural aspects. Matthews has introduced a hypothesis that behavioural change is influenced by three determining elements. He formulated the hypothesis as follows:2*
P
=
ip (1 e ), in whichP - the probability of an individual or a group to act,
p the probability assumed by them, that what they do could achieve the objective
i the perceived importance of that objective in
comparison with the other objectives
e
the perceived fraction of total available resourcesrequired for the action (resources include money, time, etc. )
The Value of P,p,i, and e is between 0 and +1. In other words, Matthews stated that the probability of an individual or a group to take a c tion, depends upon the product of the perceived probability that the action will lead to a certain goal, the perceived importance of that goal, and the perceived effort or resources required to take the action.
1* 2*
It is stated in National Health System, Minstry of Health, Indonesia: 1982.
Matthews, C.M.E., A theory for predicting behaviour change, international Journal of Health Education, Supplement to vol. XVIIIIssue no.2, AprilJune 1975.
In nutrition improvement, for instance. an individual will change his/ her behaviour as expected, if he/ she is quite sure that the new behaviours adopted, can improve his/ her nutrition status, that the improvement of his/ her nutrition status is important to him/ her, and that all he/ she needs for that purpose is available and accessable. Furthermore, he/ she must ｢ｾ＠ sure that the action taken, do not interfere his/ her economic activities, and that the changes are not against his/ her sociocultural values and those of the community.
2. lIUlQvative
.AImraach...-Nutrition Education is aimed at facilitating individual, family, and community as a whole to adopt new behaviours in relation with foods and nutrition habits. Nutrition education, therefore, should be an integral part of any nutrition program. To assure effectiveness of the effort, i t requires active participation of the target group.
Traditional nutrition program, which is designed by the central level executives on theoritical bases, is not able to meet realities. The messages, which are developed without any input of the intended audience, are often of little relevance to the existing conditions. This in turn, brings about confusion and ineffectiveness.
In the development of a nutrition education strategy, the major concern is that messages are behaviour specific, practical, and acceptable enough to be followed every day, or even several times during the day in each meal
r preparation. For that reason, the staff of the Nutrition
Education Component of the Indonesian Nutrition Development Project in collaboration with Manoff International Inc., has used Eurmative Evaluation approach in the development of basic nutrition messages. This is a participant approach to message design, which involves repeated consultation with individuals in the target group, i.e. rural Indonesian women with young children, and observation of their responses to various new ideas and presentations. It is an evaluation by them of the messages while being formulated, rather than after they are completed.
The approach went through 6 stages, i.e. preparation, diagnostic, message formulation, pretesting, distribution, and evaluation stages.
a. Preparation Stage. 1) Staff Meeting.
A meeting with provincial, regencial, and subdistrict level staff was conducted before the activities. In the meeting, the purpose and the general outline of the activities, which comprise the village level work were discussed.
The plan, t he questi on gui de, and t he diet a ry reca l l f o rm were modifi e d on t h e base s o f the agreement a chi eved. The sche d ul e o f the acitvitie s, lo g is t ic plan, and the selection of th e i nvestiga t ors and superv i sor s were conf irmend.
2) Samp le Sel e c t ion '.
The s ub di s tr ict is the operational u ni t fo r the project. Althou g h each village has de v el oped dis t i nctively , we can assume t hat th e re is a cent a in degree of homogeneity of v i l l a ges wi thi n a s u bdistrict. The r e for e in e ach su bdistr i ct on ly two v ' llages wer e chose n as si t es f or investigation. Th is numbe r of vi llages was tho u g ht to be s uff icient, gi v en t h e t ype o f invest igation a n d the rel a tive h omogene i ty of the l ow income r ura l po pu latio n . Th e s e l e c t ion of t he village s was b a sed on a vai labl e vill a g e statistics. The c rite r i a cov e rs :
so ci o e cono mi c st a us , popul a t i on.
distance to t he heal th center, acces s to ma in roa ,
a cces s to f oo d , number of loc a l store s. locat i on of f i e ld s,
level of a c tiv i t y of nutrition and other deve lopme n t pro j ects i n t ha t area,
nutri t i onal statu s o f chil d ren under five.
Th e g r oup l i s t ed diffe ren t v i ll a ges in e a c h subdi st rict and reviewe d t h e m to gether fo r sp l e c t i on. The g r o up di scussed t h e m i n d e t a i l , ma de c ho i c e s . a n d took r e spo ns i bili ty f or conta c t ing vil l ag e off icial s for app r ov a l.
The s ub di stricts a re d ' ffe re nt, but the pa ir of villages f rom eac h s ub d i s t r ict represente d t he subdi s t ric t. Th e 10 v i l l age s o f f subdist ri ct s we r e combin ed f o r a cross se ctio n .
The sel ec t i o n o f hou seh o lds was foc u s ed on t h ose wi th the g r eate st constraints o r t ho se fa c ing th e pro b l e ms of feed i n g a ma l nour i she d chi l d, to produce re co mmendat i o ns with the gr eat est p r ac ticab i l it y for t hos e i n n eed.
Becau s e. i n many c a ses the mo s t mo t i va t e d a r e t hose with th e mos t education o r r es our c es who b ecome t he spo k e peo p le f o r those with the greatest const r a ints.
Fr om eac h village a s ample of 3 5 h ousehol d s was sele c te d, y iel d ing a total sampl e of 350 hous e hol ds. Wh i le this is a sma l l sample relat i ve to the t ot al n umber of hous e h ol d s in t h e vi llage, i t must be reme mbered that this is i n f o rmat i o n fro m key informants. The ' n format i on offer e d b y t h e se in f orman ts is co mpared to i n format i on c o lle c ted fr om community meetings , vi ll a g e n u t r i t ion and hea l th wor kers , an d mi dw ives. Th e informat io n obtai ned from these hous eholds pr ovides mo r e detail t o practices ident i fi ed o r corroborated b y othe r s.
Se lect io n of the hou se h o lds wa s made from a r oste r of all vi llage h ou seholds wi t h young children a n d t h ose wi th a p regn ant wo man,
The first to be selected from the roster were the malnourished children (indenfified by using weight / age criteria) less than 36 months of age; at the same time, if there was home with a child with diarrhea, that was listed for immediate visitation.
Then, if there was not a sufficient number of
malnourished children in a specific age group (e.g., zero to four months), the investigators chose homes which had children in the specific age category, which were away from the main access roads, and which appeared to be of poorer quality than others around them. In this way a few families living in poorer quality housing and possibly with fewer
resources, but with children growing well, were also
interviewed. Homes with pregnant and lactating women were identified using the same method.
3) Preparation.o..f. field materials.
a) Question Guide.
The priorities of the Nutrition Development Program, which were based on large sample prevalence studies of nutrition problems, provided the topics to be examined with the rural women. Since some solutions had already been identified by the Nutrition Development Program to decrease the prevalence of certain nutrition problems, these measures were incorporated as part of the question quide. Other investigations were added later. Following are topics which were explored
pregnant women's diet: quantity and quality of food consumend and use of iron pills_
lactating women quantity and quality of food
consumed, quantity of liquid consumed, offering of colostrum to newborn. nursing practices.
babies zero to four months: lactation. early
supplemental feeding .
children nine to 36 months : quantity and quality of food consumed, use of snack foods, weaning.
diarrhea understanding of diarrhea, treatment
procedure, rehydration, feeding during diarrhea.
weighing awareness o f program. attitude, and
knowledge about weighing.
vitamin A: feeding green leafy vegetables to young children, home gardens. use of vitamin A capsule.
Nutrition studies in Indonesia have shown a high prevalence of goiter.
A question quide also was developed on goiter and the use of iodized salt.
However. there was no iodized salt available in any of the study areas: therefore. these questions were eliminated.
In addition to information collected regarding food and nutrition practices, members of the households were also asked about radio listening habits, ability to read, attendance at community meetings, knowledge of their village nutrition worker and sources of information about health and nutrition.
Information similar to that collected in the households, as well as jobrelated information, was obtained through interviews with village nutrition workers, village heads, local midwives, food makers and vendors.
An openended guide format was chosen to give the investigators as much freedom as possible to explore the interesting responses of mothers and others, and to understand as thoroughly as possible each individual situation. It was felt that questionnaires with boxes and blanks to be marked limit the creativity of the investigator. However, a general household information sheet was completed for each household where an investigation was initiated, and helped to determine whether the house was well chosen if the child in fact was malnourished, or if the income was below average. After c ompleting this form, the investigator proceded with the openended questions for the pertinent topic, presented in the guide.
The organization of the question guide was in the following manner : for each topic there were guest ions to be considered during the initial visit and questions for the follow up visit. Also depending on the outcome of the food recall and the investigator's estimate of dietary problems, there were lists of possible actions which the mothers might take. Although the investigators and mothers usually worked on the recommendations together, the investigators asked for a list of possible suggestions as a guide.
J
b) Dietary Recall Form.
An important tool developed for the investigation was a simple dietary recall form for the rapid assesement (while in the house) of the diets of young children, pregnant or
lactating women. The form was designed to provide
information about the type of foods eaten as well as the quantity consumed.
The most frequently eaten foods were listed on the form and their nutrient content for calories,
protein and vitamin A were predetermined for standard serving sizes. The investigator recorded the foods consumed, each ingredient and the approximate quantity for the 24 hours preceding the interview. For each food eaten, the appropriate number of spaces were marked on the form together with an indication of the protein and vitamin A contained in each serving of the specified size. When each food consumed had been tallied in this way, the dietary total was calculated by adding: the number of spaces marked, which indicated calories; the number of stars, which
indicated protein, and; the number of A's for vitamin A.
These totals could then be compared to requirements (FAD standards used in Indonesia) for the individual.
By this comparison the investigator could quickly see the adequacy of the diet and the nutrients which were the
problems. This analysis allowed investigators to make
recommendations for diet improvement which were based on real problems,
The calculations used in this recall are approximate; the idea was to estimate dietary adequacy, not to count every calorie. The investigators were usually not well trained nutritionists, and therefore needed a tool for on-sight dietary assessment.
M[LIK PERPUSTAKAAN
DBP:
KBSEHATAN
The form could be completed an e calculations made in 15 to 20 minutes in the home after a few ho u r s of training and a day of pretesting. The investigators carried with them standard spoons, bowls, plates, and glasses to help them estimate serving sizes.
The key to the success of this method is preliminary field work to isolate the most frequentl y con sumed foods and then having adequate nutrient composition t a bles from which nutrient values can be obtained for t h e foods i n t heir prepared form. This information was obtaine d from the Center for Research and Deve l opment in Nutritio n , Ministry of Health, Republic of Indonesia.1*
c) Weight Chart/Scale.
Each investigator carried a light weight Ch attilon portable spring scale. To reduce error fro m variat i ons in the scales as they were used, at the beginnin g o f eac h week of work, all scales were standardized, usi n g a ten pound wei g ht.
During each investigation in the home o f a young child, the child was weighed and the weight plotte d on the growth chart. If the mother had a growth chart in the house, this was used and the village nutrition workers' weighings were compared with the weight recorded by the investigator.
If no weight card was in the home, one was completed and left with the mother.
The weighing of each child was important to the analysis of each particular case. Since most of the chi l dren who ware the subjects of the investigations were not severely malnourished. but rather mildly or moderately malnourished, clinical signs usually were not present. Without the use of the scale and the growth chart, i t would not have been possible for the investigators to know the children's nutritional status.
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1* Center for Research and Development in Nutrition, Da ftar J Komposisi Bahan Makanan, Daftar Faktor Konversi Ber a t Bahan
Makanan, Indonesia. J
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An important variable in the use of the age for weight criteria to establish nutritional status is the determination of the child's age. Since most of the children were under two years old, i t was anticipated that the mothers could remember with a fair degree of accuracy the child's birthdate. The investigators working in Java had a Table which converted Javanese months to the National System. Additionally, mothers often had birth records for their children or records were available in the files of the village secretary.
d) Arm Circumference ｾ＠
For pregnant and lactating women, an arm circumference measure was taken at the midpoint of the upper arm. This was not initiated until the latter part of the field work, but proved useful to the investigators in their determination of the woman ' s nutritional status and the adequacy of her diet (her need for "catchup" food). For this measurement a cloth tape was used which was marked in centimeters. The investigators were taught how to find the midpoint of the upper arm and how to hold the tape to take an accurate reading.
Women with an upper arm circumference of less than 23.5 centimeters were cosidered undernourished. 1*
e) Recording.
Every investigator was also equipped with a small tape recorder. The recorder was used throughout the interview, decreasing the amount of writing by the investigator and allowing more time for observation. After the work in the house was complete, the investigator could play the tape and complete the notes on the investigation. The tapes also served as records of statements and reactions made by the mothers be used in the education materials.
1*
Tiberwala, S.N. and Shah, K.T. "Tricolored Arm Tape Simplified Field Method to Assess Nutritional Status of Pregnant Women. "Indian .Journal of Obstetrics and Gynecology, 1977.f) Other ｈ｡ｴ･ｲｩ｡ｾ＠
Additionally, the investigators carried packages of salt and sugar and oralite for the demonstrations in homes with malnourished children. They also had supplies of
ferrous sulfate tablets and vi tamin A capsules.
4) Selection of Field Personnel.
For t h is kind of participatory inv estigation, characterist ics of the investig at ors (not interv i e we rs) must include the ab ility to think a nalytically, the ability to probe to elicit truthful a n d thoughtful st at emen ts from mothers, as we ll as to co nduct in depth problem diagnosis. These must be individuals who do not dppend on instructions to te l l them ever yt hing. but rather th o s e who hav e the ability to wo rk independentl y . and to interact sensitively and dynamical l y in the villag e horne enviro n ment. A list of criteria wa s made and prese nt e d to provincial level staff respons ib le f or D lec t ing the investigators for that area. The criteria were
ability to speak local language and Indonesian language female, preferably with children
ability to be analytical and creative in work with villag e mothers
sensiti v i ty to village env i r o nment
experience or training with practical food and nutrit i on concerns
willingness to live in the village for two weeks
Candidates for this work were screened in each province by provincial level staff. In each province six investigators were chosen, except in Yogyakarta, where eight were init ia l ly selected but two were dropped after completi o n of the work in the first villages.
All of the investigators selected were women, the majority of whom had no children.
They all spoke the language of the area as well as Indonesian language. Also, they were all willing to live in the village and were thought by the interviewers to be women sensitive to the problems of life in the village and to be creative anough to do the work required.
In each province two supervisors were selected whose responsibility was to check the work of the investigators
each day regarding coverage of topic, selection of
household, appropriateness of recommendations, etc. The
supervisor was also responsible for all village
arrangements. The supervisors had no responsibility for the household investigators. but rather conducted the interviews
with the village nutrition workers, local traditional
midwives. store owners. etc. The Criteria for the selection of the supervisors were the following :
ability to speak the local language and Indonesian
female. preferably with children
has an academic nutrition background
analytically and creatively approaches field
programs
sensitivity to village environment
experienced in field activities related to
education
willingness to live in the village for two weeks
ability to work well with government officials
experienced supervising personnel
The selection of the supervisors was made b y the provincial-level health education and nutrition di r ectors. All supervisors were graduate s of the National ｎｵｴｲ ｩ ｴｩｾｮ＠ Academy in Jakarta and had responsibility for nutrition and nutrition education program, either at provincial or regencial level. Additionally, the whole fi e l d i n vestigation was supervised by two persons, i.e, from the central office of the Nutrition Education Component, and a consultant from Manoff International Inc. This is to assu re the conti n uity and completeness.
5) Training
uf
Investigators.The investigators and supervisors selected to wor k in each province attended a seven day traini n g session, which included class-room instruction (four days), participation in a nutrition meeting in the communities where they would work (one day), and supervised field wo r k ( t wo d ays ) .
The training sessions were cnducted b y sta f f from the national office and the directors or their staff from the provincial level nutrition and health education offices. Each training session included the following
An overview of the nutritio n situation in Indonesia and projects underway to improve the situation.
The role of this work in providing information for nutrition education projects which specifi c ally address the nutrition issues.
Description of work to be undertaken and the meaning of an anthropological investigation.
The role of the investigator in h e lping the mother articulate her thoughts.
Adminintrative details.
Review of question quide clarification and explanation of different questio ns.
Introduction to nutrition: b a s i c nu t ritional deficiencIes, identification of mal n ourished children.
Discussion and practice weighi ng , completion of growth chart.
Discussion and practice me a sur i ng arm circumference.
14
Discussion and practice : oral rehydration fluids Discussion : iron tablets and vitamin A capsules Discussion and practice dietary food recall
Discussion rat.ionals for recommendations for village women
Practice : Weaning food and snack food preparation Interview technique-use of question quide plus participant observation; note taking. use of tape recorder, Emphasis nothing is assumed, everything must be explored.
Role playing
Attendance at community meeting where dialogue is initiated with mothers about what they think are practical solutions to nutrition problems
identified in a community nutrition survey
Field pretesting supervised interviewe, discussion of problems, critical review of work, adjustment of food recall to incorporate special foods discovered in each area, or seasonal fruits, etc.
b. Diagnosis Stage.
In this stage the problem is identified on the bases of both the perception of the providers as well as that of the community, After that. t.lle behavioural objectives were developed based on the behavioural a s pects of the problem, Eight main acitivitis were covered in this stage :
1) Community self- survey 2) Community meeting
3) Household investigation
4) Interview wi th communi ty leaders 5) Supervision
6) Discussion of first impression 7) Data analysis
8) Objective formulation
1), Community self-survey
Following the identification of the villages which would participate in the study. the health center doctor and ! or a member of the nutrition or health education staff visited the village and helped the kader1* organize the survey. The kader then were responsible for weighing c hildren under five and carrying out a simple eye c heck to detect signs of v itamin A deficiency (Bitot's spots) or anemia (paleness o f the lower inner lid). If mothers a cco mpanied the children to the s c reening, they were asked if the child exhibited any signs of nightblindness. If time permitted, mothers were checked for paleness of the lower inner eye lid, a sign of anemia. and for goiter.
The persons who helped the kader organize the survey also helped them tabulate the information collected. The weights of all children were graphed on a large "community growth chart", which clearly showed the nutritional status of the children under five. and the ages where the children had the greatest problems nutritionally.
1* Kader is the term used for village selected and therefore accepted by the
volunteer. who village people.
are
Other information was expressed as a percentage of the total number surveyed, and occasionally as a percentage of t.he total number in the village.
2)
Communitv ｭ･･ｴｩｾ＠After the completion of the community survey, a community meeting was scheduled to coincide with the training of the investigators. Mothers of young children, village nutrition workers and other community members were specifically invited to atted. The purpose of the village meeting was to initiate a dialogue with village women about feasible solutions to nutrition problems, and to familiarize them with the outsiders - the investigators and supervisors - who would be living in their village. The facilitators at the meeting were the staff of the Health Education Office., who are familiar with community meetings as a way of community motivation, and the Health Center doctors. who are familiar with major regional healttl problems and with the
leaders of the co mmunities.
Each meeting lasted approximately two hours and began with the Health Center doctor and the village nutrition worker presenting the results of the community survey. Some
interpretation was done to make the results meaningful to the community. Then, one of the facilitators usually opened the discussion by asking why people thought these problems existed. Once some factors were listed, each was taken in turn and possible solutions were discussed. If a solution which had already been identified for trial in homes had not been mentioned. it was brought up for discussion. The objective was to obtain a list of well defined behavior changes. However, what usually resulted was the documentation of current practices and concurrence on the suggestions from the facilitator. Few new ideas were presented at the meetings.
Generally t h e me et in g s were la rge , whi ch made i t impo ssib le f or everyo ne to talk .
The r efore, part ici p ation o f t, en had to be b y h a n d coun t s, whi ch proved a g r aph ic way o f d ep ' ct ing t he vill a ge
si t u ti on with r e g a r d to v ari o u s pr actice s .
Ad d ition a l l y, ev er yo ne seeme to p a r tic i p te in t hi s wa y; women t oo s h y to speak woul d ra ise t he ir h a n ds.
Af t,e r t he isc u ssi on and reco mme n da t i ons wer e recorded f o r t he d i fferent p r o blem , e it her t he i nvestigators' s u p e rv i s or ( a nu tri ti o nis t ) or th e He alt h Center doc t or spoke brie f l y ab o ut th e ad va ntages of cer tain practices. Wh il e this may have in f l u e n ce d t.h e espon s es some mothers ga ve when ｶｩｳ ｩｴ ･ｾ＠ : n t he ir h ome s . i was t h o ught. to be nece ssa ry in order t hat all of t ho se a .t e nding t h e meet i ng wou ld at l east p of f ered s ome u se fu l informa t io n f or t he
t i me t h e v t, n ni{ h -. at t. e n til e mel'=>t.in g .
3) HouBehold ｬｮｙ･ｂｴｩｧ｡ｴｩｾ＠
I n eaO'h of t he c;el"' c'1 e d v U I A,e:ps , -I he team of in v p. st.ig r3t. ors a nd s u pervis.Jt'B lived jn. the v i ll age fo r six
t o s e v en d ays a n d work e d wi ,h vi ll age worn n on par t ic u l ar beh av i o r ch anges ( t h os e other s ou rc e s ).
L i v i n g i n fI':> v;. . a f! ' pr nvj d'?d "I n o ppor tun i ty f n r in vo \'v P ffi <:>n i n in f o r med a t i 'l i t i es a.nd t o r .: on t cts w :i t h
i£p-After the selection of the house, the investigator proceeded with one or two of the topics in the question guide most relevan to the particular household situation.
Under no circumstances were more than two of the topics in the question quide pursued in one house.
Although the tasks varied, depending on the question guide, they generally including the following :
1) completion of the household information sheet.
2) completion of background information on the topic (general question).
3) weighing the child or taking the arm circumference of the pregnant or lactating women.
4) completion and analysis of 24 hour food recall.
5) working on and discussion of any new behaviour which is agreed upon for trial (e.g. weaning food, oral rehydration mix, snack food).
This investigation with the mother took from two to three hours. If it could not be completed on the first visit, then the investigator returned at a pre-arranged time to continue. Once it was completed, the investigator reread his/ her notes. listened to the tape recording made in the home, and filled in any gaps in her/ his notes. The report was then given to the supervisor.
4) Interview ｾ community leaders.
In each village where mothers were participating in home-based investigators. the team supervisor conducted interviews with certain community members, who have some role in the food and/ or nutrition situation of the
community and a potential for communicating or changing ideas about nutrition and food.
The following are the types of people interviewed the kaders, and the people who make snacks or other foods locally.
5) Supervision.
The supervision of the field investigations was do n e in two ways. The first, was an internal superv is i on done by the nutritionist supervisor for the team.
Their responsibility was to read throu g h all of the investigations done each day to be s u r e that each line of questioning was complete ly pursued wi t h the mother . They were also responsib l e for correctin g the dietary recall forms and checking the recomme n dations offered to ensure t h eir agreement with the resul t s of the recall. Aft e r corecting the inves t i gations , t he s upervi sor called the investigation team t o gethe r to br i efly discuss their gene ral impressions on each t o pic a nd any q u est i ons or dif f i culties they were encounte ri ng.
These discussions helped to focus the wor k o f each inv e stigator and provided a f o r um in wh ich information could be exchang ed.
Ad di tiona l ly , the superv i s o r r e corded th e behavi o r changes agreed upo n between the mot her and the inve s t iga t o r o n a separate sheet for each i n v e st i g ati o n.
When the supervisor reviewe d th e fol l ow- u p vis it, she needed to be able to record the ou tcome of eac h b e h a vioral change trial, or the investigato r had to return to t h e house again to inquire about the result.
The second type of superv ision was prov i d ed by the general pro j ect supervisors and had as it s o bj ect i ve the provision o f continuity and standardization b etween t h e work done in the different subdistrict.
These supervisors attended the household in te rviews and the discussion sessions at nig h t between the te am supervisor and the investigators, offeri n g observations and suggestions from other subdistrict for consideration by the team.
They also checked investigat o rs ' completeness and accuracy in completing an investigation.
6) DiscuBsion of Firat Imp ressi on.
At the conclusion of the household investigations in each subdistrict a debriefing session was held with the team supervisors and investigators_
The project supervisor, after a cursory examinat.ion of the investigators, presented some overall trends in the response of mothers on the various topics _
These trends. along with results of the trials as compiled by the investigators, were presented to team members for their comment.s_
Particularly in those cas e s wh e re the women had been reluctant to follow or had not liked new practices, the investigators were asked for their ideas about what would work.
Additionally, they were asked for their ideas on the best way to communicate this information to the village women.
Whenever possible the impressions gained through a cursory look at the investigations were summarized and presented to group of people responsible for health and
nutrition activities at a subdistrict level and/ or
provincial-level
This presentation was often part of a ceremony at which gifts were given by the investigators team to those people in the communities who had been particularly helpful in carrying out the investigation.
Whether the group was large or small, those present were always asked for comments on the information collected.
7) Data Analysis.
This type of small sample, in-depth i n v estigation is not designed to measure quantitative dif f e rences between population groups or to provide quantitative infroma t ion that can be used for quidance in choosing the direction for a program.
Rather i t provides qualitative informat i on tha t can be used for guidance in choosing the direction fo r a program.
It can offer insight into target audience p erceptions by helping to isolate the resistence points in the process of changing a current practice.
It is useful in gathering words or p hr ases employed by the audience to describe a part i cular ph e n o men o n .
Additionall y, a feeling can be o b ta i n ed f or wh at is truly personally relevant to the tar g et aud i ence.
The qualitative nature of t h e inve s t i ga t i o n makes data analysis difficult.
The procedure followed was to tabu l a te al l of the information that was asked u ni formly wi t hin e ac h topic area. The total number of respond e n ts varies wi thin a given t o pic area, since not everyone was asked all the questions, but only those which were relevant.
Other information that was ment i oned by t h e mot h er, including descriptions a n d su b jec t iv e j udgements, was summarized and listed under a descript i ve h e a ding.
All behavior changes which were tried we r e l i s ted, and the number of successful trials ( the mother incorporated the behavior into her daily routine for th e period between visits by the investigator ) and the u n successful trials were scored.
Even though the population in a given rural village is quite homogeneous, the results of this small sample investigation should not be used to predict quantitalively the behaviour of the entire group, but rather to look at tendencies. That is, the difference between whether 60, 75 or . 85 percent of the people believe something is of little relevance ｨ･ｾ･［＠ what is important is that i t is enough people to indicate a need to include the idea in an educational message.
The following are some highlights tabulated during the community diagnosis stage :
a) Most families are coming from lower segment of the population with daily income per capita of Rp. 200,-Rp. 600.1* All recommendations contained in educational messages must therefore either cost them nothing to implement or only a faction of the disposable income.
b) The majority of mothers were engaged in economic activities to get additional money for caring their families.
Therefore, recommendations must involve a minimum time investment by the mothers, or if the activity is time consuming, there must be a strong reward for that.
c) Radio broadcast reached more than 65 percent of the population in four out of six subdistricts.
The most popular programs were music, drama, and religious ones.
So, i t is imperative to integrate the nutrition messages into entertainment and religious program to reach the most people.
d) Despite of the fact that many people can read, very few families had the access to printed materials.
Only calendar was very common.
e) Villagers like to attend village meetings, and smaller meetings at hamlet level seemed to be more prefered. This fact made i t an appropriate form for nutrition education.
f) Most pregnant mothers complained to have problem with their eating habits, especially during early months of their pregnancy .
They do not feel well, they fell weak, and do not want to eat more food.
Data 1980 currency. One U.S.
Rp Rupiah. is Dollar is equal to about
the 600
Indonesian rupiah.
A few believe that if a woman eats more during pregnancy, the delivery will be difficult, because the child will be too big.
The women did not object to taking iron supplements. Taking these facts into consideration, message developed for pregnant mothers should convey the benefits of eating more: 1) that the mother feel better, and that she will have more energy during pregnancy and during delivery if she eats more 2) that after the delivery, her baby will be stronger. g) Host lactating mothers reported feeling both hungry and
thirsty, which means that they are receptive to eating and drinking more.
They seem sensitized to having enough and fresh breastmilk.
Some reported that their children cry frequently, which causes many mothers to begin food supplements too early, even in the first or second week of children's life. One reason for this apparent inability to satisfy a child is that many women favor one breast over the other always initiating breastfeeding from the same side, and often not changing breast during feeding.
Consequently, one side often begins to dry up.
Regarding colostrum, most women discarded it because they thought it was dirty and because i t is the custom. Message for lactating mothers should therefore cover the following
1) they should eat and drink more
2) they should use both breasts at each feeding, and that. although this may take more time, the child will be more satisfied and will sleep longer
3) not to give food supplements too early, but after the fourth months of children ' s life
4) the benefits of giving colostrum to infants
h) Question raised by many mothers was : what they should do when they leave the house for extended periods.
One answer is to carry the baby, but this is not always feasible.
Some mothers leave tea, others leave food.
Recommending that a mother leave milk (artificial milk) introduces too many possibilities for contamination. This is a case where further investigation may be necessary, and individualized education, presented by the kaders, may be the only viable channel to present alternatives to the working women.
i) Another problem indicated by many mothers related to feeding for their children, was that they do not know the appropriate time and type of food supplements that should be given to their babies.
Consequently. the recommendation related to this matter is the introduction of food supplements for children five to eight months old.
The recipe, which varied by region, was developed with the involvement of the target mothers for its feasibility and acceptability.
j) Mothers faced problem with the eating habits of their children have begun to develop food preferences and are interested in many things besides eating.
This present problems to mothers who are usually s t i l l feeding children of this age and who may have other. younger children to look after.
The message about feeding these children is that for proper growth, the child needs four meals per day plus snacks.
The food given to the child can be the same as the family ' s food as long as it is "complete".
The amount of food given at each meal should be increased and should have more rice, more vegetables, and one more piece of protein food.
k) Milk supplement is not widely used in rural areas. Still, some mothers did mentioned it.
It was evident, that those using the milk supplement do not know how to make the milk properly. especially in the case of milk powder.
1) Diarrhea among young children was regarded as the indication of child development.
No treatment was done during the first day of diarrhea. Mothers stop breastfeeding, and reduced the liquid consumption of the diarrheal child.
The important messages which emerged are that
diarrhea is serious. not just indication for child development; especially if the child shows signs of weakness.
the child should continue to receive breastmilk (the current practice).
the child needs ext r a f l uid s , and these fluids wi l l not aggrav a t e t he di arrhea.
the chi l d c a n e at , b u t may ne e d soft f o od l i k e porridge.
the . mother should begin to give an oral rehydration fl u id wh en she sees that h e r ch ild has diarrhea. (the re ci p e f or the h ome-ma de oral rehydration f lui d wh i ch pr oved to be t he b est is given on page 33 ).
m) Most hamlets in the pro ject areas h ad alr e a dy p racticed weighing activity.
However, there is a n e ed for mo re educ ati o n which links weight gain, or loss , to t he ch i ld's h ea l t h st a t us, his or her appetite, a nd be haviour .
Additionally, it appears that weighing will h ave more meaning for mothers i f they receive information on the meaning of the di fferent colour o n t he we i g ht card. and simple prescripti o n s f or h ow t o imp rov e the health status of child. as i t appe ar s on the c ard.
n ) Host familes kept ho me gardening or cas sava gardening in the yard. Papaya and b anan a we r e ve ry commo n.
Although green leafy veget ab les wer e very c o mmon in the villages, the consumptio n was limi t ed mo s tly to adult. Young children do not l i ke vegetables .
Additionally, mo st mo th er s do not k n ow t h e re lationship between green leafy ve ge t ab les and the h e a lth of the eye or blindness.
0) Observation on the c ondi tion of th e kader s, some points
c ame out
that the kad e rs trai n i n g sh oul d be more specific, a nd more p roble m and skill oriented.
they need re c ogn ition f o r t h e wo rk t h e y do. they sho u l d be made to fe el th at t h e y are part o f a l a rg er networ k .
p) Traditional midwi ves we re fo u nd to be va l u e d very highly be mothers.
q ) Lo c al sho pkeeper ca n be us e as dis t r ibu t i on po ints for
informati o n .
Consequently, t h ey s h oul d be int ergr at ed in to a community nutri t i o n edu cat i o n p ro gram.
They could be enga g ed in p r omo t i ng dif feren t pr oducts " commercially " a nd wo ul d r e c e i ve fre e a dver t i s ing in the form of the e d ucat io na l m ss age.
· 8) OBJECTIW FOBHULATl.QN
From the diagnosis stage certain trends were easy to see about the real behavioral problems behind the nutrition problems and the background of this behaviors.
The resistance points to changing the feeding practices causing the nutrition problems also emerged.
Impressions were gathered about the case of changing these, the rationales which could be employed and the exact behavior which might be altered and in what way.
A set of objective (knowledge. attitude, and behavior change objectives) were written reflecting the totality of the
information gathered during the diagnosis stage.
In formulating the objectives, two principles were kept in mind.
The first was that the foods or other resources needed
.t.o.
change the nutritional status of the mothers and their children had ｾｑ＠he
wiLhin
ｾ･ｩｲ＠ means.Because all of the recommendations had been tried by families for a week during the concept testing, we were sure that even if more food than t
