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Go back to: Case Studies On Health Promotion Initiatives From The Nordic Countries
Case study #6: The prevention of night blindness in Bangladesh
Rationale for InitiativeIt has been estimated that one million children aged between 6 months and 6 years have clinical signs of vitamin A deficiency in Bangladesh. Almost 100 children go blind every day, and more than half of these children with blindness die within a few weeks (Mustaque et al, 1989). Regular consumption of vitamin A rich food items have shown to be associated with a reduction in nutritional blindness in Bangladesh (1,2), in Indonesia (3), and in Sudan (4). The challenge is to find simple approaches which are acceptable to the community and viable within their economical reach in order to change their food consumption as a means to reduce the morbidity of nutritional blindness. In the largely rural environment of Bangladesh 90% of dietary vitamin A is in the form of ß-carotene and other carotenoids (5). Over 70% of the vitamin A in the diet of Bangladeshi rural infants and young children up to 20 months of age is received from breast milk (6). Studies conducted in Bangladesh showed that the concentration of vitamin A even in the breast milk of poor mothers contain 1.0-1.4 :mol/l (7). An estimated average intake of 400 ml breast milk a day could provide at least 30-40% of a child's daily requirement of vitamin A (8). Few breastfed children suffer from acute vitamin A deficiency (9). Weaning food becomes an important crucial issue relative to their subsequent vitamin A status. In Bangladesh, there is an abundance of inexpensive locally available vegetables and fruits rich in provitamin A. It was estimated that in Indonesia 1 US $ would buy 200,000 IU of vitamin A activity from vegetable sources and only 4333 IU from fruits and 1556 IU from other sources (10). Breast feeding is universally practised in Bangladesh to all children up to 12 months of age and 85% of children between 24 and 30 months (11). The challenge was to develop a simple practice that may be acceptable by the community and viable within their economic means to promote consumption of locally available foods rich in provitamin A with sustainable impact. This may imply peoples awareness about nutrient content of the food they eat and community participation in order to develop a food practice, acceptable by its members. To our knowledge, however, interventions solely based on health education and community participation are scarce. Objectives of Initiative
Description of InitiativeThe programme was administered by the Worldview International Foundation (Nutritional Blindness Prevention programme in Bangladesh) in close cooperation with the Centre for International Health, Section for Community Psychology (HEMIL centre), University of Bergen, Norway. Prior to initiation of the program, representatives from the local health authority, the government administration, NGO's and local leaders were invited for a two-day seminar in order to plan the organizational and interventional procedures and to secure cooperation through participation from all segments of people in the intervening communities. A working team was organized in each upazilas (sub-district) with the upazila chairman as head of the respective teams and one/two members from the local community, one from project administration, and one from the government health authority. The working teams were responsible for community meetings once a month with people from the local communities and the project administration for the respective areas. The teams were also responsible for monitoring and advising the programme administration of any modifications of the intervention strategy. Attention was paid to recruiting people from the local communities at all levels. This was to ensure that the ideas generated by the involvement of individuals or groups of the community was judged from their perspectives and incorporated accordingly in the programme. Moreover, attention was paid of the existing social structures and customs rather than imposing outside ideas on a society to which they are foreign. The areas of intervention were selected from a district in the northern part of Bangladesh, demarcated as a high risk area according to the national xerophthalmia study of 1982-83 (12). The intervention took place during the period of 1986 to 1989. Detailed description of the procedure have been described elsewhere (1,2). Planning and execution of the educational programme Prior to initiation of the program, representatives from the local health authority, government administration, non government organizations (NGO's) and local leaders were invited to a two-day seminar in order to plan the organizational and intervention procedures and to secure cooperation through participation from all segments of the population in the intervention communities. A working team was organized in each upazila (sub district) with the upazila chairman as head of the respective team. The working teams were responsible for community meetings once a month with people from the local communities and the project administration for the respective areas. The messages were delivered on three different levels in the intervention areas i.e. individuals, groups and communities. The working teams were also responsible for monitoring and advising the programme administration on modifications for the intervention strategy. Interventional channelsThirteen different media approaches and communication channels, both traditional and modern, were employed for nutrition education in the intervention communities. Among the main media approaches, these were:
In addition there were the following group activities:
Other communication channels used were: school sessions, programmes on local radio and television, cinema slide shows, news-paper spots, posters, local leaders, health workers and home yard gardening activity was introduced as another way of conveying the message of nutritional blindness and to promote production and consumption of locally available vegetables rich in b-carotene. For the analyses of data, the communication channels were grouped as follows:
Data on socio-economic status, mothers literacy, family size and food consumption practice were collected by interview. Food consumption data were collected by interview for the last three days prior to the interview. The information was collected at family level. Statistical procedureStatistical comparisons between different groups were made using the chi square test for contingency tables. All P-values presented are two-tailed. Evidence of SuccessThe prevalence of night blind children was higher in the 1992 survey than the 1989 survey (p=0.05) but still significantly lower in comparison with the 1986 survey (p=0.008) (Table 1). The prevalence of night blindness per thousand children <9 years of age was 35.5 in 1986, 17.4 in 1989 and 24.3 in the 1992 survey. Significant changes were observed for parents knowledge of the definition of night blindness, its cause or prevention from 1986 to 1989 and non significant changes from 1989 to 1992 (Table 2). However, mothers had significantly higher (p<0.001) knowledge of prevention with diet compared to fathers. Consumption of protein items (Fish, meat , milk or eggs), Dark Green Leafy Vegetables (DGLV) and vitamin A capsules increased significantly from 1986 to 1989. Intake of vitamin A rich foods dropped significantly after the cessation of intervention from 1989 to 1992 (Table 3). Exposure to mass media was significantly lower among the households with illiterate mothers, households earning less than Tk.1501 (US $ 35) a month and households possessing less than 25 decimal of agricultural land (Table 4). However, communicating through direct personal contact (channel 1) and audiences in community settings (channel 2) were not notably affected by the variables mentioned above, in communicating the message to the target population. Table 5 shows that campaign exposure is associated with consumption of dark green leafy vegetables, the odds ratio being significant for channel 1 and of borderline significant for channel 2 and mass media. Consumption of protein items (>3 times) was significantly associated with exposure through mass media. ReflectionsHousehold income was significantly reduced from 1989 to 1992 (2) and the association with the reported prevalence of night blindness and household economy was statistically significant in both the surveys of 1989 and 1992 (1,2). It is likely that in a declining socio-economic environment the impact of a health education programme may not be sustainable for a change in food consumption despite of adequate knowledge. Further, an intervention period of 3 years may not have been sufficient to result in sustainable impact on human behaviour. The results may indicate that health education should be a continuous activity and that an extension of the programme, possibly in a modified, less expensive form would be necessary to induce a lasting effect on the prevalence of night blindness. The likelihood of consuming dark green leafy vegetables (DGLV) was higher among households who were exposed to interpersonal or group communication/education. Consumption of protein items was more common among those who were informed through mass media (Table 2). This was the case even after adjustment for household income, mothers literacy and possession of a homestead. Access to mass media (radio, television and posters) may indicate higher socio-economical status which in turn is associated with a higher consumption of the more expensive meat products. Not only socio-economic conditions influence food preferences but also other factors like class identity, religious identity, taste and belief of an expected (good health) outcome are likely to be important. Within social cognitive theory, outcome expectations provide the motivation for behaviour, while skills provide the capability to do the behaviour and self efficacy provides the confidence that barriers can be overcome (13). Therefore, it was attempted to raise expectations of a healthy child through locally available b-carotene rich foods. Proficiency (skill) was enhanced by empowering the community members with the necessary knowledge of the nutrient values of locally available foods and its cultivation. Our results suggest that in the rural areas of Bangladesh, interpersonal communication plays an important role and therefore needs to be given priority in order to promote proper food consumption behaviour among the economically impoverished households. Unlike in the western hemisphere, interpersonal communication approaches are inexpensive, but still effective for disseminating the message and probably also for stimulating community participation in the developing world. Entertainment approaches like folk singers, short films (projectors) appear to disseminate the message to a larger population, but may not promote the necessary food practices accordingly. This may indicate that the audience exposed to these media have been more attentive to the enjoyment rather than to act in response to the message. DisseminationFindings and implications of the evaluation of the programme has been communicated not only through scientific publications, but also through more action oriented publications like Tropical Medicine and International Health (1996;1:43-51) and Health Promotion International (in press). Furthermore the programme and its achievements has been presented at conferences, workshops, seminars, and by video programmes and media coverage for instance in Dhaka, Bangladesh in February 1997. References
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