Innovative Approach in Nutrition Education in Indonesia
\M I LIK P BRPUSTAKAAN
DEP: KBSBHA TAN'
CON TEN T S_
PAGE
1_
INTROOOCTION
1
II _
PROBLBHS
2
4
I I I _ INNOVATIVE APPROACH
L
Background
4
2_
Innovative Approach
5
a_
Preparatory Stage
5
b_
Diagnosis Stage
c_
Message Formulation Stage
d_
Pretesting Stage
e_
Distribution Stage
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 16
__________________ 44
___________________________ 52
_________________________ 53
IV _ KVAWATION
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 55
V _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 59
OONCWSION
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3
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 it becomes a main capital for completing
the
development it self, including the health development. Improving
the qua l ity of life of the people covers all aspects of life,
inclu 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 still 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 it 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.
1
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 omo 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 om o ne place to ano the r. Al l those h a v e contr i but ed to
the food hab it s and other b e ha v i o r a l patte rn s of t he peo ple in
r e lation with 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 our 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 hough
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 onsumpti o n ac c ount f o r g e ographical
var 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 unde 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 wome n is an o ther vulnerable
grou 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 ducti on 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 vulner 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 dy among a
segment
of the p o pula t ion a dversely
af f ect
their
l arge
nutritional status, particularly among nu t ri t i o nally vulne rable.
I n most areas in Indonesia. the most pre fe red sta ple 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 ill the f i rst to the
second year i s almost widel y p racticed, e specially in rural
areas. But there is litte unde 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. Veg etables,
me at and fish are generally no t p rov i ded to y oung c h ildre 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 on to t he
nutrition
p r oblems. The President has issued two Pres 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 the nation. The Inst r uc ti o n also c l ear l y men t ioned
tha t the respo nsibility of nut r iti on d ev elo pme nt is not only in
t h e hands of the Government.
2
• ...1
.J
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 lems requires harmonious
technical efforts
of vari ou 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 ti 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 beh a v iour i n order to
opt 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 ti 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 ti 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 LENT " . Th
ｆ ｦ ｾ ｕ ｒ＠
GOOD
c on sists of gr o ups of f o ods,i.e . 1) ca r boh 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 om ·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 the 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 onditio 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 behav i o ur a l ch a nges i n th e
community, because they per c eived that nut ri tious foods ar e
expensive one s . They cannot afford them and 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 prov 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 om
villages where the ANP program has been applied intensively.
3
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 p
i
e
the probability of an individual or a group to act,
the probability assumed by them, that what they do
could achieve the objective
the
perceived importance
of that
objective
in
comparison with the other objectives
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.
In other words, Matthews stated that the probability of an
individual or a group to take action, 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*
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.
4
oJ
J
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 reparing 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 FOUR GOOD
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
targ et
audience. The foods pictured out on the poster s are of those tha 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.
3
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 achieveme 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
P -
p
i
e
= ip (1
e ), in which
the probability of an individual or a group to act,
the probability assumed by them, that what they do
could achieve the objective
the
perceived importance
of that
objective
in
comparison with the other objectives
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.
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.
4
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.
lIUlQvat ive .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, it
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
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.
r
a.
1)
Preparation Stage.
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.
5
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 the i nvestiga t ors and superv i sors 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 the re is a cent a in degree of homogeneity of
v ill a ges wi thi n a s u bdistrict. The r e for e in e ach subdistr i ct
on ly two v ' llages were 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, giv 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 popu lation . 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 conomi c st a us ,
popul a ti 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 status o f chil d ren under five.
Th e g r oup li 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 age off icials 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 ubd 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 ti 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 commendat i o ns
with the gr eatest
p r ac ticab i l it y for t hose
i n
n eed.
Becau s e. i n many c a ses the mo s t mo ti va t e d a r e
t hose
with the mos t
education o r r es our c es who b ecome t he
spo k e peop 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
house hol ds. Wh i le
this is a sma ll sample relati 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 it 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 ouseholds wi t h young children a n d t h ose wi th
a p regn ant wo man,
6
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
of iodized salt.
7
the use
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
8
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 onsight dietary assessment.
9
M[LIK PERPUSTAKAAN
DBP: KBSEHAT AN
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 obtained from the Center
for Research and Deve l opment in Nutrition , 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, it would
not have been possible for the investigators to know the
children's nutritional status.
J
ｾ＠
.J
1*
Center for Research and Development in Nutrition, Da ftar
Komposisi Bahan Makanan, Daftar Faktor Konversi Ber a t Bahan
Makanan, Indonesia.
J
J
J
10
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, it 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
"Indian .Journal
and
Pregnant
Women.
of
Obstetrics
Gynecology, 1977.
11
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 investigat 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 ements 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 tho s e who have 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
lec t ing the investigators for that area.
D
The criteria were
ability to speak local language and Indonesian language
female, preferably with children
ability to be analytical and creative
villag e mothers
in work with
sensiti v i ty to village env i r o nment
experience or training
nutrit i on concerns
with
practical
food
and
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.
12
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
programs
and
creatively approaches
field
sensitivity to village environment
experienced
education
in
field activities related
to
willingness to live in the village for two weeks
ability to work well with government officials
experienced supervising personnel
13
The selection of the supervisors was made b y the provinciallevel
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 staf 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 nutrition situation
improve
Indonesia and projects underway to
situation.
in
the
The role of this work in providing information for
nutrition education projects which specific ally
address the nutrition issues.
Description of work to be undertaken and
meaning of an anthropological investigation.
the
The role of the investigator in h e lping the mother
articulate her thoughts.
Adminintrative details.
Review
of question quide
clarification
explanation of different questio ns.
Introduction to nutrition:
bas i c
deficiencIes,
identification
of
children.
Discussion and practice
growth chart.
Discussion
and
circumference.
nu t ritional
mal n ourished
weighi ng , completion
practice
and
me a sur i ng
of
arm
14
J
Discussion and practice : oral rehydration fluids
Discussion : iron tablets and vitamin A capsules
Discussion and practice
Discussion
village women
dietary food recall
rat.ionals for
recommendations
for
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
is
Attendance at community meeting where dialogue
initiated with mothers about what they think are
solutions
to
nutrition
problems
practical
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.
The supervisors at tended th is ｴｲＮｾｊｩｮｧ＠
and in addition
were briefed: on t.heir work in interviewing key community
opinion leaders'
in debriefing the
investigators
each
evening, and; in compiling the general household information
obtained each day and the trials of the behavioral changes
agreed upon between the investigator and t
DEP: KBSBHA TAN'
CON TEN T S_
PAGE
1_
INTROOOCTION
1
II _
PROBLBHS
2
4
I I I _ INNOVATIVE APPROACH
L
Background
4
2_
Innovative Approach
5
a_
Preparatory Stage
5
b_
Diagnosis Stage
c_
Message Formulation Stage
d_
Pretesting Stage
e_
Distribution Stage
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 16
__________________ 44
___________________________ 52
_________________________ 53
IV _ KVAWATION
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 55
V _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 59
OONCWSION
(
ｐ･ｲｰｵ
ｳ ｴ Ｂ ｫＡＧｬｾｮ＠
NIJ
Induk
g;. Tori
bf:L '
Dapkes.-,
........................
Ob}7{Q
119 ; .... .
.
ｾ ｌｾ Ａ Ｎ＠ Ａ Ｚ Ｎ＠ ＺｊＮ ｴｾ ..
Da pl'lt D ar i :.. ...· ..
...ir·······..··
...... ............ .......................
hd
L
3
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 it becomes a main capital for completing
the
development it self, including the health development. Improving
the qua l ity of life of the people covers all aspects of life,
inclu 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 still 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 it 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.
1
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 omo 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 om o ne place to ano the r. Al l those h a v e contr i but ed to
the food hab it s and other b e ha v i o r a l patte rn s of t he peo ple in
r e lation with 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 our 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 hough
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 onsumpti o n ac c ount f o r g e ographical
var 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 unde 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 wome n is an o ther vulnerable
grou 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 ducti on 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 vulner 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 dy among a
segment
of the p o pula t ion a dversely
af f ect
their
l arge
nutritional status, particularly among nu t ri t i o nally vulne rable.
I n most areas in Indonesia. the most pre fe red sta ple 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 ill the f i rst to the
second year i s almost widel y p racticed, e specially in rural
areas. But there is litte unde 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. Veg etables,
me at and fish are generally no t p rov i ded to y oung c h ildre 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 on to t he
nutrition
p r oblems. The President has issued two Pres 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 the nation. The Inst r uc ti o n also c l ear l y men t ioned
tha t the respo nsibility of nut r iti on d ev elo pme nt is not only in
t h e hands of the Government.
2
• ...1
.J
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 lems requires harmonious
technical efforts
of vari ou 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 ti 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 beh a v iour i n order to
opt 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 ti 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 ti 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 LENT " . Th
ｆ ｦ ｾ ｕ ｒ＠
GOOD
c on sists of gr o ups of f o ods,i.e . 1) ca r boh 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 om ·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 the 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 onditio 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 behav i o ur a l ch a nges i n th e
community, because they per c eived that nut ri tious foods ar e
expensive one s . They cannot afford them and 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 prov 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 om
villages where the ANP program has been applied intensively.
3
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 p
i
e
the probability of an individual or a group to act,
the probability assumed by them, that what they do
could achieve the objective
the
perceived importance
of that
objective
in
comparison with the other objectives
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.
In other words, Matthews stated that the probability of an
individual or a group to take action, 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*
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.
4
oJ
J
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 reparing 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 FOUR GOOD
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
targ et
audience. The foods pictured out on the poster s are of those tha 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.
3
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 achieveme 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
P -
p
i
e
= ip (1
e ), in which
the probability of an individual or a group to act,
the probability assumed by them, that what they do
could achieve the objective
the
perceived importance
of that
objective
in
comparison with the other objectives
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.
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.
4
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.
lIUlQvat ive .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, it
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
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.
r
a.
1)
Preparation Stage.
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.
5
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 the i nvestiga t ors and superv i sors 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 the re is a cent a in degree of homogeneity of
v ill a ges wi thi n a s u bdistrict. The r e for e in e ach subdistr i ct
on ly two v ' llages were 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, giv 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 popu lation . 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 conomi c st a us ,
popul a ti 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 status o f chil d ren under five.
Th e g r oup li 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 age off icials 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 ubd 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 ti 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 commendat i o ns
with the gr eatest
p r ac ticab i l it y for t hose
i n
n eed.
Becau s e. i n many c a ses the mo s t mo ti va t e d a r e
t hose
with the mos t
education o r r es our c es who b ecome t he
spo k e peop 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
house hol ds. Wh i le
this is a sma ll sample relati 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 it 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 ouseholds wi t h young children a n d t h ose wi th
a p regn ant wo man,
6
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
of iodized salt.
7
the use
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
8
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 onsight dietary assessment.
9
M[LIK PERPUSTAKAAN
DBP: KBSEHAT AN
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 obtained from the Center
for Research and Deve l opment in Nutrition , 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, it would
not have been possible for the investigators to know the
children's nutritional status.
J
ｾ＠
.J
1*
Center for Research and Development in Nutrition, Da ftar
Komposisi Bahan Makanan, Daftar Faktor Konversi Ber a t Bahan
Makanan, Indonesia.
J
J
J
10
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, it 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
"Indian .Journal
and
Pregnant
Women.
of
Obstetrics
Gynecology, 1977.
11
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 investigat 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 ements 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 tho s e who have 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
lec t ing the investigators for that area.
D
The criteria were
ability to speak local language and Indonesian language
female, preferably with children
ability to be analytical and creative
villag e mothers
in work with
sensiti v i ty to village env i r o nment
experience or training
nutrit i on concerns
with
practical
food
and
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.
12
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
programs
and
creatively approaches
field
sensitivity to village environment
experienced
education
in
field activities related
to
willingness to live in the village for two weeks
ability to work well with government officials
experienced supervising personnel
13
The selection of the supervisors was made b y the provinciallevel
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 staf 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 nutrition situation
improve
Indonesia and projects underway to
situation.
in
the
The role of this work in providing information for
nutrition education projects which specific ally
address the nutrition issues.
Description of work to be undertaken and
meaning of an anthropological investigation.
the
The role of the investigator in h e lping the mother
articulate her thoughts.
Adminintrative details.
Review
of question quide
clarification
explanation of different questio ns.
Introduction to nutrition:
bas i c
deficiencIes,
identification
of
children.
Discussion and practice
growth chart.
Discussion
and
circumference.
nu t ritional
mal n ourished
weighi ng , completion
practice
and
me a sur i ng
of
arm
14
J
Discussion and practice : oral rehydration fluids
Discussion : iron tablets and vitamin A capsules
Discussion and practice
Discussion
village women
dietary food recall
rat.ionals for
recommendations
for
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
is
Attendance at community meeting where dialogue
initiated with mothers about what they think are
solutions
to
nutrition
problems
practical
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.
The supervisors at tended th is ｴｲＮｾｊｩｮｧ＠
and in addition
were briefed: on t.heir work in interviewing key community
opinion leaders'
in debriefing the
investigators
each
evening, and; in compiling the general household information
obtained each day and the trials of the behavioral changes
agreed upon between the investigator and t