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Conceptual problems in nutrition education in Western Nigeria
Conceptual problems in nutrition education in Western Nigeria
Naomi Bankole
A pilot survey of the factors affecting infant feeding practices in rural Western Nigeria highlighted intercultural perceptual problems. Results showed widespread use of imported, high-cost carbohydrate foods and great resistance to the early introduction of local healthprotective items. It was commonly thought that ‘too much food’ was bad for a child. Staff responsible for health education are held in a degree of disrepute not conducive to the acceptance of their educational efforts in the comqunity. Recommendations include control of advertising; reviewed staff orientation and training; and, an intensive campaign to re-establish breast feeding as the cultural norm. Keywords: Nutrition education; Infant feeding; Western Nigeria The author is a Senior Registrar in the Department of Community Medicine, Paddington and North Kensington Health Authority, St Mary’s Hospital, Praed Street, London W2 1PE (Tel: 01-262 1260). At the time of writing, the author was studying at the Department of Environmental Sanitation and Epidemiology, Faculty of Health Sciences, University of tfe, Ile-lfe, Nigeria. ‘T.0. Ogunlesi, ‘Economics of health care’, in Priorities in National Health Planning, continued on page 324
0306-9192/82/040323-9$X00
Nigeria is a society in a state of flux, as a result of changes involved in adapting from an advanced but rural, agricultural, and illiterate society to a semi-industrialized, money-bound, literate, and consum’er society. Some changes have caused incalculable devastation. Nominal improvement in medical care’ combined with a tendency away from polygamy to monogamy (with no associated family planning facilities) has caused a population increase that is not yet fully appreciated.2 This, together with little advance on the agricultural front, has produced acute food shortages, and increase in prices particularly affecting those more nutritious varieties of food. Money has become universally owned and revered, together with ihose things it can buy. This has happened at a time of heavy importation of high cost but low-food-value items such as custard powder, glucose, and cornflour starch. The constant confusion of these products with powdered milk, which is marketed in similar tins, has led to mass misspending of limited finances. Unfortunately, increase in population, spread-of towns and rorreqponding decrease in natural forest has at the same time reduced the amount of wild game which used to be easily and abundantly available. In conditions of food shortage, the most vulnerable groups are always the first .to suffer. Thus, this article concentrates on problems relating to infants.
The study area Ipetumodu is part of the Origbo Community, which, at the time of the study in 1975, comprised around 50000 people. It is 10 miles from Ile-Ife, said to be the birth place of the Yorubas, or, maybe, some say, of the entire human race. The town itself has two grammar schools, and nine primary schools, one of which is Muslim. These serve a much larger area than Ipetumodu: not all eligible children riach even primary school. Occupations are mainly home-based, such as trading, food selling, tailoring, carving, carpentry, and pottery making, a small proportion of people working primarily on the farms. A few government offices and schools provide the remaining labour outlets. The oba (king), or Apetu, is well educated and forward looking. He
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continued from page 323 Caxton Press, Ibadan, Nigeria, 1973, pp 23-27. ZL.A. Adeokun, ‘Treading a cautious path’, People, Vol8, No 1, 1981, pp 20-22. 3Naomi Bankole and C. Chiazor, ‘Pipeborne water and its effect on the health status of children, IFEMED, Vol 2, 1978, p 101. 4Naomi Bankole, ‘Basic health services in Ife Division’, in 0. Adejuyigbe, ed, The Location of Rural Basic Health Facilities in Ife/ljesha Area of South Western Nigeria, Technical Report, Ile-lfe, Nigeria, 1977, pp lC-36. 5Naomi Bankole, Medical Facilities and Their Influence on the Health Status of Children in Oyo State, Nigeria, 1978, Dissertation accepted for Part II MFCM. 1979. 6Bankole, op tit, Ref 4. ‘Bankole, op tit, Ref 5. 8B.D. Paul, Health, Culture and Community, Russell Sage, 1955; M.H. King, F.M.A. King, D.C. Morley, H.J.C. Burgess, and A.F. Burgess, Nutrition for Developing Countries, Oxford University Press, Nairobi. 1972.
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has a relatively small palace and only one wife, who is a primary school teacher. The oba functions together with the Local Government Council in running the affairs of the town and ensuring the well-being of his subjects. The town had water and electricity installed in 1966. The water supply is mainly from communal standpipes, there being approximately one standpipe to every 70 houses. This, for the area, represents a very good water supply. There is little organized drainage or sewage except for open drains alongside the major roads.3 The population in Ipetumodu is mainly illiterate. Of the 118 women surveyed here, 70% were illiterate, as were 50% of their husbands. The highest educational level reached by women was third year in a secondary modern school (4%) although 12% had completed primary grade VI. Six percent of husbands had completed grammar school and an equal number had had some type of post-school education. It was found impossible to collect figures for income on account of the people’s fear of being reported to the tax collector. Christianity was professed by 80% and Islam by 10%; only ten admitted to worshipping the local deities, but this is likely to be an underestimate on account of the usual situation of multiple religious loyalties. Eighty-five percent of those interviewed had been born in Ipetumodu, the majority never having lived in any other town. Only two were non-Yorubas. Western-style medical facilities were inadequate, inappropriate and under-utilized.4 The Ife Local Government Council had two maternity centres, one in Ipetumodu and a second, one mile away, in Yakoyo. Each had six beds. Although the first had been in existence for 23 years and they both offered mainly maternity services, together they accounted for less than 23% of expected confinements. Immunization had become regularly available for infants in the two years before the survey but only 15.2% children attended even once before the age of 5 years.5 A small effort at health education was made during clinics. The centres were manned by Grade I midwives (with no general or community nursing training) and they were visited once or twice a month by the Health Sister for the area. They were periodically closed on account of staff shortages, and chronically short or completely out of such essentials as ergometrine, aspirin and chloroquine.6 There was one private ‘Western’ clinic which supervised an equal number of deliveries. However, the major part of medical care was meted out in the home, mainly by traditional healers. There was widespread use of proprietory preparations such as iodine for cuts, and mixtures for coughs. But the majority of the population relied on local brews (ugbo) made from leaves, roots, fruit and certain types of soil, for most of their own and their children’s complaints.’ The pertinence of the last paragraph lies in the implications of nonacceptance of advice from maternity clinic staff. Since the townspeople did not, basically, agree to be medicated by the nurses, they were unlikely to bide by advice given by them.s This would be especially true where advice was in direct contradiction to traditional beliefs. The study, of which this article presents a part, originally set out to define the areas responsible for the failure of the service to improve the health of the community. In this article, an attempt has been made in particular to delineate problems in concepts and decision making with regard to the feeding of young children.
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Methods All interviews were carried out in the town of Ipetumodu in April 1975. Both structured questionnaire and in-depth interviews were used. Eligible mothers were those with at least one child under the age of five years. The mother supplied socioeconomic data on both herself and her husband. Data on feeding practices were collected from three series of interviews. In the first, photographs of children at different developmental stages were shown, together with two malnourished children (see Figures l-4), and 34 mothers were asked the following questions: 0 0 0 0 0
How old is this child? Is he/she well? What is he/she doing? Do you notice anything else about him/her? What would you feed him/her?
Aided and unaided responses concerning feeding were collected separately. The questionnaire was then retested, on a further 38 mothers, using photos of normal children only, changing the first question to: ‘This child has just learn to hold his head very steadily (walk, sit, etc). How old do you think he is?’ The other questions were repeated as before. Aided responses were omitted. In-depth interviews were administered to 46 mothers, concerning attitudes and decision making in infant feeding.
Figure 1. Six-month old child sitting steadily (not walking).
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Figure 2. Three-week good head control.
old baby with
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malnutrition,
Figure 3. Nine-month walking steadily.
child writh severe unable to stand.
old chilcj just
Results The idea had been that in a community that was non-number oriented with relation to time, children were probably more easily classifiable by developmental stages than by calendar months. It is still not completely clear to me which is the more important factor. Comments on the use of photographs were; a) they held the interest of the women being interviewed, which improved cooperation; b) they caused some confusion, mainly due to sociocultural differences between the child photographed and the family of the mother interviewed. It had been hoped that this latter complication had been eliminated, firstly, by photographing naked children and, secondly, by picking children who were, by our standards in Ife University, underweight but not sick. However, even without clothes, the plaiting of hair of young children is usually only practised amongst the more elite; and it was also forgotten to remove earrings! Other details which distracted the interviewers were: incomplete number of toes or fingers visible on the photo, suggestive of leprosy; the sitting child thought to have a paralyzed leg; the crawling child was thought to be sick because his pendant belly was ‘too big’. Second, despite our own judgement of the children being small for their age, they were probably bigger than children in the test village and the assessment of age was often far off the mark (older). The feeding schedules were therefore equally distorted. Rephrasing the first question in the second set of interviews gave much better age estimations on the neonate, head-holding, sitting and crawling children, but the nine-months-old child who was just standing was thought to be over two years old by one quarter of the mothers. The more educated respondants (who had more than 3 years in primary
326
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school) tended to volunteer more local protein food as necessary parts of their children’s diets. This was repeated in the ‘aided’ responses. These tendencies were similarly associated with the educational status of the fathers. However, all mothers mentioned carbohydrate foods, both local and imported, more often than protein (other than breast milk) or fruit. The feeding schedules obtained at the second series of interviews were then analysed in two ways: according to the actual age of the subject presented in the photo; and, according to the age estimated by the mother interviewed. There were no significant differences. The analyses by the mothers’ estimation of age are presented in Tables 1 and 2. The figures of 94% and 97% for breast milk under the age of 3 months reflect acceptance of breast feeding as a natural phenomenon rather than a deliberate giving of ‘food’: no mother in the survey was completely bottle-feeding her baby.
In-depth interviews The major l
l
l
l
l
points
that came out of these responses
were:
Mothers stop breast feeding mainly to conceive another child (with little or no gap between breast feeding and next pregnancy), or because of consideration for their own health. The age of the child at which this usually occurred was between one and three years. The difference between strong and fat children, and thin and skinny children was thought to be primarily dependent on parental care (35%), on God’s will (20%) or sickness (20%), but not on feeding habits. Forty percent of mothers thought that food would not make the children grow well, while 6% actually stated that too much food was bad for children. The indication for starting pap (a semiliquid cornflour mixture with a little protein in it), and subsequently solids, were mainly that the child was not satisfied with the food he was already getting. This was borne out by the age ranges for starting these. Analysing answers on giving meat and fish was fraught with problems, partly on account of a widespread belief that meat (but not fish) causes worms if given to small children. The indication for
Table 1. Feeding of fluids to infantsa
Norest aunaided responses from 36 mothers; bAge according to mother’s estimate of photo; N Number of age estimates falling in each age range; cprobably an underestimate (see text): dsee text; e No separate figures obtained.
Ageb
N
Breast milk
& 3weeks l- 3months 4- 6 months 9-12 months 13-24 months
36 37 61 40 12
94%d 97%d 79%C 35%C M--83%_
Additional milk (tmt=t=f) 6% 59% 72% 60%
Boiled water
Glucose in water
92% 73% 41% 26% 50%
61% 62% 23% e e
Table 2. Feeding of non-fluids to infantsa
Notes: aunaided responses from 36 mothers; bAge according to mother’s estimate of photo; N Number of age estimates falling in each age range; cprobably an overestimate nm Not mentioned.
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Ageb
N
Local carbohydrate Local protein Imported catihydrate other than Eggsorbaans glucose SoftpaP omsr
0- 3weeks l- 3months 4- 6months 9-l 2 months 13-24months
36 37 61 40 12
nm nm 39% 100% 63%
nm 12% 41% 43% 67%
nm 15% 35% 75% 75%
nm 9% 56%C 6O%C v--83%-
Other nm nm nm nm
Fruit and vagetablss nm 12% 53% Z%
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0
0
0
0
giving it was mainly that the child could now specifically demand or snatch it from the mother; this gives a heavy weighting in favour of the earlier developing child. The age ranges reflected the resistance to giving these two foods: 12% before one year; 42% before two years; 60% before three years. Twenty-six percent actually specified that they would not give these foods until after three years of age. It was well understood that not giving the correct food could cause illness, and the types of illnesses were clearly defined: half of the mothers mentioned symptoms of proteinenergy malnutrition, including swollen abdomen, swollen body and limbs, apathy, rough skin, and loss of weight; eighteen percent specifically mentioned delay in crawling or standing; a further sixteen percent said that they knew it was very serious but they did not know what type of illness was caused. This gave a total of 78% who were well aware that poor feeding was dangerous for a child. The foods mentioned as being required to make a child better from such illness were virtually all imported: forty percent mentioned imported non-protein foods, such as cornflour, glucose and Bournvita; forty percent mentioned imported protein foods, mainly powdered milk; only thirty percent mentioned locally available foods, protein, vegetables and fruit. Over half of those mothers mentioning imported foods, referred to protein and non-protein foods in the same breath, presumably considering them to be of equal food value. Twenty mothers were asked: ‘What does it mean if a baby is gaining weight?’ Seven answered that the child was eating too much, and only three that the child was growing well. A frequent interpretation of the crawling child’s pendant abdomen was that the child was sick, the reason being that the mother had neglected her duty by allowing her child to eat too much.
Discussion Many of the attempts to ameliorate the overwhelming problem of suboptimal nutrition in certain countries can hardly be considered to have been successful. This pertains in Western Nigeria, in spite of what pretends to be massive campaigning. The reason for the failure is often given as: ‘the people are stupid’, ‘the mothers don’t care about their children’, ‘they will never learn’, or, ‘they are too lazy’. These are common phrases on the lips of those purporting to correct nutrition practices. This study set out to discover why nutrition education appeared to be falling on deaf ears: was it in reality the fault of those taught, or was it the responsibility of the educators themselves, or were other extraneous factors contributory? In Western Nigeria there are two main avenues of nutrition education designed to approach the adult (and therefore the mothering) population. These are through the Ministry of Health and Ministry of Economic Development. The first propagates its efforts mainly through Grade I midwives who have little knowledge of teaching measures and less patience with the vagaries of the women they are trying to teach. The second ministry employs well motivated social workers who are aware of, and sympathetic to, the difficulties under which the general population labour; they also employ low-cadre village workers who have been taught to assume the same outlook. Wherever there is a Ministry of Health or
328
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Conceptualproblems
9D.C. Morley and M. Woodland, See How They Grown, MacMillan, London, 1979. ‘OFAO. Conwest of L?eficiencv Diseases, Rome, 1970;Chap 6. : . llJ.C. Waterlow, ‘Nutrition for the world’s children: what do we need to know?‘, in B. Wharton, ed, Topics in Paediatrics, Vol2, 1960; M.D. Janes, ‘The physical growth of Nigerian Yoruba children’, Tropical and Geographical Medicine, Vol 26, 1974, p 389. ‘*A.M. Thomson and A.E. Black, Nutritional Aspects of Human Lactation, WHO Bulletin, No 52, 1965, pp 163-176. 13Bankole, op cit. Ref 5.
FOOD POLICY November 1982
in nutrition education in Western Nigeria
Local Government Authority Health Centre, the Ministry of Economic Development workers usually use such centres for their main teaching activities. As can be seen from the feeding schedules in Tables 1 and 2, the mother’s emphasis is nearly always on carbohydrate foods, and especially on expensive imported varieties (glucose, custard, Bournvita, bread and biscuits). It should be noted that custard and Bournvita are hardly ever made up according to the instructions, but with plain hot water; milk is virtually always omitted. There were several mothers who did not volunteer one single protein item as part of their children’s diets, which would be especially serious for children over one year; breast feeding is universal under that age. These facts reflect several problems. First, that the word for ‘food’ in Yoruba, otije, refers to the carbohydrate staples; stew of any variety is considered as non-essential ‘relish’, and it is in this stew that the small amount of protein and vitamins (including vitamin C from pepper) is found. Questions relating to ‘food’, therefore, will automatically be heavily weighted with carbohydrate answers. The relevance of this attitude to what is essential in a diet is important; no woman could consider to have fed her family if they do not all have a ‘full belly’, but the fact that this may be constituted almost entirely of carbohydrate and oil is not considered negligent. The population therefore considers the carbohydrate portion of the diet to be essential, and the orientation towards giving protein and vitamin foods to small children is lacking. Second, a new word has been coined in Yoruba, namelyfudu, derived from the English ‘food’. This was originally only appropriate for powdered milk of the type marketed for bottle feeding, such as Lactogen, but commercial advertising, together with comparable prices and packaging has now enlarged the fudu genera to include Bird’s custard powder, cornflour powder, Allenbury’s Glucose-D and Cadbury’s Boumvita (the major constituents of the latter being cocoa and sugar). In an uneducated (and mainly illiterate) population the results are obvious: interchanging of these four freely with Lactogen, preparing them in similar ways (ie by mixing with water), and wasting scarce money and time on inadequate food. Even when Lactogen itself is bought, it is seldom mixed correctly, but normally made up at quarter to one-tenth strength, and usually heavily contaminated in the process thereby increasing the already high rate of gastroenteritis.9 The extra toll of this latter on infant morbidity and mortality is well understood. lo There is a well documented drop of weight gain after the age of three months in underprivileged societies. This does not occur in better privileged societies, nor in elite groups within an impoverished community.” There is also documented a lower output of breast milk,‘* presumably due to the maternal-depletion syndrome that is almost univeral in the same social _ rzroups. a high incidence of _ In a previous studv.13 < varying degrees of clinical malnutrition was found in this same town in 1976: out of 169 children, 32% were grossly underweight for their age, 41% hadclinicaloedema,and26% had2ormorestigmataofmalnutrition. Infants are, therefore, in need of nutritious weaning foods to supplement breast milk, maybe as early as 3 months of age, and definitely before 6 months. On account of the high metabolic and growth rates required and the relatively small stomach volume, a child cannot afford any non-nutritious intake. Every millilitre of capacity needs to be filled with high quality nutrients.
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Third, little use is made of nutritious foods which are locally available, and relatively cheap. Melon seeds and locust beans are ground and cooked in the stew forming a nutritious mixture, but not given to chilImported commodities Price per 5~19 (fs)b dren. Green vegetables are freely eaten by the adults, and several Lactogen 0.80 varieties contain good quantities of vitamin C, folic acid and iron; they 1.13 Glucose-D are not commonly given to children. Citrus fruits which abound and are 0.50 Cornflour 0.84 Custard cheap are hardly touched. This is probably for the good reason that the 0.91 Bournvita vitamin C sources in a traditional Nigerian diet are pepper and certain 0.20 Breadc 0.03 per 5Og unit Biscuitsc commonly eaten green vegetables. Problems have arisen, therefore, in areas where misinformed health educators have managed to eliminate Notes: aln 1978 the GNP had risen to around f300 p.a. but food prices had escalated in pro- pepper from the children’s diet without ensuring an adequate alternative source of vitamin C. Yam is a good source of calcium, but current trends g:i;.?)O = US $2.2 = N 1.40 cBasic ingredients imported. towards the cheaper and less nutritious cassava cause problems. Fourth, although protein foods were mentioned by a number of mothers, the quantity of meat or fish consumed by a whole family during a seven-day period is frequently as little as 3@60 g. Beans are not cooked evel?)P;day on account of the prolonged cooking required and the large amounts of wood and water therefore needing to be carried to the house. Eggs gre seldom given in practice, and health workers feel that they have done well if they can persuade a mother to give her child as many as two sniall ones per week; this would probably be the sole source of protein for an older child, pther than the mother’s failing breast milk. Last, the finances of most families are so stringent that food-purchasing power may be as little as 2545~ per week for the whole family. We can confirm this from the Gross National Product of flO0 pa.14 The major part of this is oil revenue, and a large proportion of the remainder is accounted for by government spending. Taking account of the spending power of the elite, it follows that the majority of the population survive on an annual income (visible plus invisible) nearer f20 per capita. This is expected to cover all costs, including school fees. Eggs cost from 3-5~ each; 30 g of meat costs 5-10~; fish (30 g) 3-5~ (1975 figures). Groundnuts (peanuts) or beans would be better spending, as far as cost per protein value is concerned. By comparison, the cost of commonly bought imported items are shown in Table 3. In spite of these mispractices, all members of the population are extremely concerned about their children’s stzvival, and that they should be given the best possible food. They are, however, grossly misinformed as to what is the ‘best food’. All this seems quite alarming enough, but the attitude of the population to the health workers concerned requires careful examination. In answer to the question, ‘Does the help that mothers get from the Maternity Centre stop the babies born there from dying at all?‘, thirty percent said quite definitely ‘No’, while two mothers actually said that it made the situation worse. The question, ‘Why do only a few people go to the’Maternity Centre to deliver?‘, elicited answers ranging from lack of money, preference for herbalists, preference for home deliveries, religious reasons, distance of abode (farm) from maternity centre, to, finally, pride and downright fear of the centre. Six out of 20 mothers said that the midwives were not polite to those who go there. How likely then are any personnel involved in an institution which has I41975 figures. In 1978 the GNP had risen so little good faith among the townspeople to be able to break new ground to around f300 pa, but food prices had in any educational area? escalated in proportion.
Table
3.
Approximate
market
prices
of
imported commodii commonly used for infant feeding in Western Nigeria (1975).a
FOOD POLICY November 1982
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Conclusions In spite of reputed massive nutrition education programmes in the Western state of Nigeria, nutritional practices as they pertain to young children are at present grossly inadequate, but could be greatly improved by judicious use of locally available foodstuffs. In view of the present mortality rate of 30% before the age of five years, l5 and the additional rate of 30% morbidity in the same age group, we know that the health of these young children is fragile. Although l6 play an important role in debilitating infections, including tuberculosis, children and increasing their food requirements, their effect is less devastating among adequately fed youngsters.” Part of the problem lies in the limited financial resources of the parents, but an even greater portion can be attributed to mass misspending on important prestige foods. This is due mainly to the intensive promotion of powdered milks and the subsequent confusion of these with poor quality starch items marketed in similar tins and at similar prices. Basic misconceptions on the importance of key foodstuffs in the health of children also abound. A very large portion of responsibility must be laid at the feet of persons deputing inadequately motivated and inadequately informed personnel to perform essential educational roles in basically illiterate communities. The damage that such personnel can do is much greater than the benefit that could be sowed by more appropriate staff.
Recommendations The International Code of Marketing of Breast-milk Substitutesls should be enforced in this community. Furthermore, all advertising for Bournvita should state clearly that this food is not suitable for children under the age of five years and the current depicted association with healthy children eliminated. The interpretation within the community of all foodstuffs advertising should be carefully monitored by agents interested in the health of the population. Second, nutrition education should be dissociated from nurses and maternity centres or hospitals. There should be an intensive campaign to re-establish ‘breast milk as best milk’, providing adequate facilities for breast-feeding women at work, together with longer maternity leave, raising the prestige of the breast-feeding mother in the community. The community social worker should function away from medical centres. More nutrition rehabilitation, reorientation, or mothercraft centres could be established, de-emphasising the medical input, and aimed primarily at establishing good rapport between the educators and the mothers. This would help to underline that food, rather than medicine, is the best cure for an underweight child. *%ankole, op tit, Ref 5; D.C. Morley, Paediatric Priorities in the Developing World, Butterworths, London, 1973. 16Bankole, op tit, Ref 5. *’ J.E. Gordon, A.M. Guzman, W. Ascoli and N. Scrimshaw, Acute Diarrhoeal Disease in the Less Developed Countries, 2: Patters of Epidemiological Behaviour in Rural Guatamelan Villag>s, WHO Bulletin, No 31, pp 9-20. ‘%ternational Code of Marketing of Breast-milk Substitutes. WHO. Geneva. 1981.
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Postscript Since this work was undertaken, the Basic Health Services Scheme had set out to produce more health-orientated basic health workers in Nigeria. Although the Basic Health Service Scheme has since been abandoned, the training institutions are maintaining the same orientation for basic health workers. The health-education inuut to these cadres has been infinitely greater than for any other group df health professionals, but their acceptability remains to be tested since they still operate from government health institutions.
331
Naomi Bankole
A pilot survey of the factors affecting infant feeding practices in rural Western Nigeria highlighted intercultural perceptual problems. Results showed widespread use of imported, high-cost carbohydrate foods and great resistance to the early introduction of local healthprotective items. It was commonly thought that ‘too much food’ was bad for a child. Staff responsible for health education are held in a degree of disrepute not conducive to the acceptance of their educational efforts in the comqunity. Recommendations include control of advertising; reviewed staff orientation and training; and, an intensive campaign to re-establish breast feeding as the cultural norm. Keywords: Nutrition education; Infant feeding; Western Nigeria The author is a Senior Registrar in the Department of Community Medicine, Paddington and North Kensington Health Authority, St Mary’s Hospital, Praed Street, London W2 1PE (Tel: 01-262 1260). At the time of writing, the author was studying at the Department of Environmental Sanitation and Epidemiology, Faculty of Health Sciences, University of tfe, Ile-lfe, Nigeria. ‘T.0. Ogunlesi, ‘Economics of health care’, in Priorities in National Health Planning, continued on page 324
0306-9192/82/040323-9$X00
Nigeria is a society in a state of flux, as a result of changes involved in adapting from an advanced but rural, agricultural, and illiterate society to a semi-industrialized, money-bound, literate, and consum’er society. Some changes have caused incalculable devastation. Nominal improvement in medical care’ combined with a tendency away from polygamy to monogamy (with no associated family planning facilities) has caused a population increase that is not yet fully appreciated.2 This, together with little advance on the agricultural front, has produced acute food shortages, and increase in prices particularly affecting those more nutritious varieties of food. Money has become universally owned and revered, together with ihose things it can buy. This has happened at a time of heavy importation of high cost but low-food-value items such as custard powder, glucose, and cornflour starch. The constant confusion of these products with powdered milk, which is marketed in similar tins, has led to mass misspending of limited finances. Unfortunately, increase in population, spread-of towns and rorreqponding decrease in natural forest has at the same time reduced the amount of wild game which used to be easily and abundantly available. In conditions of food shortage, the most vulnerable groups are always the first .to suffer. Thus, this article concentrates on problems relating to infants.
The study area Ipetumodu is part of the Origbo Community, which, at the time of the study in 1975, comprised around 50000 people. It is 10 miles from Ile-Ife, said to be the birth place of the Yorubas, or, maybe, some say, of the entire human race. The town itself has two grammar schools, and nine primary schools, one of which is Muslim. These serve a much larger area than Ipetumodu: not all eligible children riach even primary school. Occupations are mainly home-based, such as trading, food selling, tailoring, carving, carpentry, and pottery making, a small proportion of people working primarily on the farms. A few government offices and schools provide the remaining labour outlets. The oba (king), or Apetu, is well educated and forward looking. He
0 Butterworth & Co (Publishers) Ltd
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Conceptual
problems
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continued from page 323 Caxton Press, Ibadan, Nigeria, 1973, pp 23-27. ZL.A. Adeokun, ‘Treading a cautious path’, People, Vol8, No 1, 1981, pp 20-22. 3Naomi Bankole and C. Chiazor, ‘Pipeborne water and its effect on the health status of children, IFEMED, Vol 2, 1978, p 101. 4Naomi Bankole, ‘Basic health services in Ife Division’, in 0. Adejuyigbe, ed, The Location of Rural Basic Health Facilities in Ife/ljesha Area of South Western Nigeria, Technical Report, Ile-lfe, Nigeria, 1977, pp lC-36. 5Naomi Bankole, Medical Facilities and Their Influence on the Health Status of Children in Oyo State, Nigeria, 1978, Dissertation accepted for Part II MFCM. 1979. 6Bankole, op tit, Ref 4. ‘Bankole, op tit, Ref 5. 8B.D. Paul, Health, Culture and Community, Russell Sage, 1955; M.H. King, F.M.A. King, D.C. Morley, H.J.C. Burgess, and A.F. Burgess, Nutrition for Developing Countries, Oxford University Press, Nairobi. 1972.
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has a relatively small palace and only one wife, who is a primary school teacher. The oba functions together with the Local Government Council in running the affairs of the town and ensuring the well-being of his subjects. The town had water and electricity installed in 1966. The water supply is mainly from communal standpipes, there being approximately one standpipe to every 70 houses. This, for the area, represents a very good water supply. There is little organized drainage or sewage except for open drains alongside the major roads.3 The population in Ipetumodu is mainly illiterate. Of the 118 women surveyed here, 70% were illiterate, as were 50% of their husbands. The highest educational level reached by women was third year in a secondary modern school (4%) although 12% had completed primary grade VI. Six percent of husbands had completed grammar school and an equal number had had some type of post-school education. It was found impossible to collect figures for income on account of the people’s fear of being reported to the tax collector. Christianity was professed by 80% and Islam by 10%; only ten admitted to worshipping the local deities, but this is likely to be an underestimate on account of the usual situation of multiple religious loyalties. Eighty-five percent of those interviewed had been born in Ipetumodu, the majority never having lived in any other town. Only two were non-Yorubas. Western-style medical facilities were inadequate, inappropriate and under-utilized.4 The Ife Local Government Council had two maternity centres, one in Ipetumodu and a second, one mile away, in Yakoyo. Each had six beds. Although the first had been in existence for 23 years and they both offered mainly maternity services, together they accounted for less than 23% of expected confinements. Immunization had become regularly available for infants in the two years before the survey but only 15.2% children attended even once before the age of 5 years.5 A small effort at health education was made during clinics. The centres were manned by Grade I midwives (with no general or community nursing training) and they were visited once or twice a month by the Health Sister for the area. They were periodically closed on account of staff shortages, and chronically short or completely out of such essentials as ergometrine, aspirin and chloroquine.6 There was one private ‘Western’ clinic which supervised an equal number of deliveries. However, the major part of medical care was meted out in the home, mainly by traditional healers. There was widespread use of proprietory preparations such as iodine for cuts, and mixtures for coughs. But the majority of the population relied on local brews (ugbo) made from leaves, roots, fruit and certain types of soil, for most of their own and their children’s complaints.’ The pertinence of the last paragraph lies in the implications of nonacceptance of advice from maternity clinic staff. Since the townspeople did not, basically, agree to be medicated by the nurses, they were unlikely to bide by advice given by them.s This would be especially true where advice was in direct contradiction to traditional beliefs. The study, of which this article presents a part, originally set out to define the areas responsible for the failure of the service to improve the health of the community. In this article, an attempt has been made in particular to delineate problems in concepts and decision making with regard to the feeding of young children.
FOOD POLICY November 1982
Conceptual
problems
in nutrition education in Western Nigeria
Methods All interviews were carried out in the town of Ipetumodu in April 1975. Both structured questionnaire and in-depth interviews were used. Eligible mothers were those with at least one child under the age of five years. The mother supplied socioeconomic data on both herself and her husband. Data on feeding practices were collected from three series of interviews. In the first, photographs of children at different developmental stages were shown, together with two malnourished children (see Figures l-4), and 34 mothers were asked the following questions: 0 0 0 0 0
How old is this child? Is he/she well? What is he/she doing? Do you notice anything else about him/her? What would you feed him/her?
Aided and unaided responses concerning feeding were collected separately. The questionnaire was then retested, on a further 38 mothers, using photos of normal children only, changing the first question to: ‘This child has just learn to hold his head very steadily (walk, sit, etc). How old do you think he is?’ The other questions were repeated as before. Aided responses were omitted. In-depth interviews were administered to 46 mothers, concerning attitudes and decision making in infant feeding.
Figure 1. Six-month old child sitting steadily (not walking).
FOOD POLICY
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1982
Figure 2. Three-week good head control.
old baby with
325
Conceptual
problems in nutrition education
in Western Nigeria
malnutrition,
Figure 3. Nine-month walking steadily.
child writh severe unable to stand.
old chilcj just
Results The idea had been that in a community that was non-number oriented with relation to time, children were probably more easily classifiable by developmental stages than by calendar months. It is still not completely clear to me which is the more important factor. Comments on the use of photographs were; a) they held the interest of the women being interviewed, which improved cooperation; b) they caused some confusion, mainly due to sociocultural differences between the child photographed and the family of the mother interviewed. It had been hoped that this latter complication had been eliminated, firstly, by photographing naked children and, secondly, by picking children who were, by our standards in Ife University, underweight but not sick. However, even without clothes, the plaiting of hair of young children is usually only practised amongst the more elite; and it was also forgotten to remove earrings! Other details which distracted the interviewers were: incomplete number of toes or fingers visible on the photo, suggestive of leprosy; the sitting child thought to have a paralyzed leg; the crawling child was thought to be sick because his pendant belly was ‘too big’. Second, despite our own judgement of the children being small for their age, they were probably bigger than children in the test village and the assessment of age was often far off the mark (older). The feeding schedules were therefore equally distorted. Rephrasing the first question in the second set of interviews gave much better age estimations on the neonate, head-holding, sitting and crawling children, but the nine-months-old child who was just standing was thought to be over two years old by one quarter of the mothers. The more educated respondants (who had more than 3 years in primary
326
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Conceptual problems in nutrition education in Western Nigeria
school) tended to volunteer more local protein food as necessary parts of their children’s diets. This was repeated in the ‘aided’ responses. These tendencies were similarly associated with the educational status of the fathers. However, all mothers mentioned carbohydrate foods, both local and imported, more often than protein (other than breast milk) or fruit. The feeding schedules obtained at the second series of interviews were then analysed in two ways: according to the actual age of the subject presented in the photo; and, according to the age estimated by the mother interviewed. There were no significant differences. The analyses by the mothers’ estimation of age are presented in Tables 1 and 2. The figures of 94% and 97% for breast milk under the age of 3 months reflect acceptance of breast feeding as a natural phenomenon rather than a deliberate giving of ‘food’: no mother in the survey was completely bottle-feeding her baby.
In-depth interviews The major l
l
l
l
l
points
that came out of these responses
were:
Mothers stop breast feeding mainly to conceive another child (with little or no gap between breast feeding and next pregnancy), or because of consideration for their own health. The age of the child at which this usually occurred was between one and three years. The difference between strong and fat children, and thin and skinny children was thought to be primarily dependent on parental care (35%), on God’s will (20%) or sickness (20%), but not on feeding habits. Forty percent of mothers thought that food would not make the children grow well, while 6% actually stated that too much food was bad for children. The indication for starting pap (a semiliquid cornflour mixture with a little protein in it), and subsequently solids, were mainly that the child was not satisfied with the food he was already getting. This was borne out by the age ranges for starting these. Analysing answers on giving meat and fish was fraught with problems, partly on account of a widespread belief that meat (but not fish) causes worms if given to small children. The indication for
Table 1. Feeding of fluids to infantsa
Norest aunaided responses from 36 mothers; bAge according to mother’s estimate of photo; N Number of age estimates falling in each age range; cprobably an underestimate (see text): dsee text; e No separate figures obtained.
Ageb
N
Breast milk
& 3weeks l- 3months 4- 6 months 9-12 months 13-24 months
36 37 61 40 12
94%d 97%d 79%C 35%C M--83%_
Additional milk (tmt=t=f) 6% 59% 72% 60%
Boiled water
Glucose in water
92% 73% 41% 26% 50%
61% 62% 23% e e
Table 2. Feeding of non-fluids to infantsa
Notes: aunaided responses from 36 mothers; bAge according to mother’s estimate of photo; N Number of age estimates falling in each age range; cprobably an overestimate nm Not mentioned.
FOOD POLICY November 1982
Ageb
N
Local carbohydrate Local protein Imported catihydrate other than Eggsorbaans glucose SoftpaP omsr
0- 3weeks l- 3months 4- 6months 9-l 2 months 13-24months
36 37 61 40 12
nm nm 39% 100% 63%
nm 12% 41% 43% 67%
nm 15% 35% 75% 75%
nm 9% 56%C 6O%C v--83%-
Other nm nm nm nm
Fruit and vagetablss nm 12% 53% Z%
327
Conceptual
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in nutrition
education
in Western Nigeria
0
0
0
0
giving it was mainly that the child could now specifically demand or snatch it from the mother; this gives a heavy weighting in favour of the earlier developing child. The age ranges reflected the resistance to giving these two foods: 12% before one year; 42% before two years; 60% before three years. Twenty-six percent actually specified that they would not give these foods until after three years of age. It was well understood that not giving the correct food could cause illness, and the types of illnesses were clearly defined: half of the mothers mentioned symptoms of proteinenergy malnutrition, including swollen abdomen, swollen body and limbs, apathy, rough skin, and loss of weight; eighteen percent specifically mentioned delay in crawling or standing; a further sixteen percent said that they knew it was very serious but they did not know what type of illness was caused. This gave a total of 78% who were well aware that poor feeding was dangerous for a child. The foods mentioned as being required to make a child better from such illness were virtually all imported: forty percent mentioned imported non-protein foods, such as cornflour, glucose and Bournvita; forty percent mentioned imported protein foods, mainly powdered milk; only thirty percent mentioned locally available foods, protein, vegetables and fruit. Over half of those mothers mentioning imported foods, referred to protein and non-protein foods in the same breath, presumably considering them to be of equal food value. Twenty mothers were asked: ‘What does it mean if a baby is gaining weight?’ Seven answered that the child was eating too much, and only three that the child was growing well. A frequent interpretation of the crawling child’s pendant abdomen was that the child was sick, the reason being that the mother had neglected her duty by allowing her child to eat too much.
Discussion Many of the attempts to ameliorate the overwhelming problem of suboptimal nutrition in certain countries can hardly be considered to have been successful. This pertains in Western Nigeria, in spite of what pretends to be massive campaigning. The reason for the failure is often given as: ‘the people are stupid’, ‘the mothers don’t care about their children’, ‘they will never learn’, or, ‘they are too lazy’. These are common phrases on the lips of those purporting to correct nutrition practices. This study set out to discover why nutrition education appeared to be falling on deaf ears: was it in reality the fault of those taught, or was it the responsibility of the educators themselves, or were other extraneous factors contributory? In Western Nigeria there are two main avenues of nutrition education designed to approach the adult (and therefore the mothering) population. These are through the Ministry of Health and Ministry of Economic Development. The first propagates its efforts mainly through Grade I midwives who have little knowledge of teaching measures and less patience with the vagaries of the women they are trying to teach. The second ministry employs well motivated social workers who are aware of, and sympathetic to, the difficulties under which the general population labour; they also employ low-cadre village workers who have been taught to assume the same outlook. Wherever there is a Ministry of Health or
328
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Conceptualproblems
9D.C. Morley and M. Woodland, See How They Grown, MacMillan, London, 1979. ‘OFAO. Conwest of L?eficiencv Diseases, Rome, 1970;Chap 6. : . llJ.C. Waterlow, ‘Nutrition for the world’s children: what do we need to know?‘, in B. Wharton, ed, Topics in Paediatrics, Vol2, 1960; M.D. Janes, ‘The physical growth of Nigerian Yoruba children’, Tropical and Geographical Medicine, Vol 26, 1974, p 389. ‘*A.M. Thomson and A.E. Black, Nutritional Aspects of Human Lactation, WHO Bulletin, No 52, 1965, pp 163-176. 13Bankole, op cit. Ref 5.
FOOD POLICY November 1982
in nutrition education in Western Nigeria
Local Government Authority Health Centre, the Ministry of Economic Development workers usually use such centres for their main teaching activities. As can be seen from the feeding schedules in Tables 1 and 2, the mother’s emphasis is nearly always on carbohydrate foods, and especially on expensive imported varieties (glucose, custard, Bournvita, bread and biscuits). It should be noted that custard and Bournvita are hardly ever made up according to the instructions, but with plain hot water; milk is virtually always omitted. There were several mothers who did not volunteer one single protein item as part of their children’s diets, which would be especially serious for children over one year; breast feeding is universal under that age. These facts reflect several problems. First, that the word for ‘food’ in Yoruba, otije, refers to the carbohydrate staples; stew of any variety is considered as non-essential ‘relish’, and it is in this stew that the small amount of protein and vitamins (including vitamin C from pepper) is found. Questions relating to ‘food’, therefore, will automatically be heavily weighted with carbohydrate answers. The relevance of this attitude to what is essential in a diet is important; no woman could consider to have fed her family if they do not all have a ‘full belly’, but the fact that this may be constituted almost entirely of carbohydrate and oil is not considered negligent. The population therefore considers the carbohydrate portion of the diet to be essential, and the orientation towards giving protein and vitamin foods to small children is lacking. Second, a new word has been coined in Yoruba, namelyfudu, derived from the English ‘food’. This was originally only appropriate for powdered milk of the type marketed for bottle feeding, such as Lactogen, but commercial advertising, together with comparable prices and packaging has now enlarged the fudu genera to include Bird’s custard powder, cornflour powder, Allenbury’s Glucose-D and Cadbury’s Boumvita (the major constituents of the latter being cocoa and sugar). In an uneducated (and mainly illiterate) population the results are obvious: interchanging of these four freely with Lactogen, preparing them in similar ways (ie by mixing with water), and wasting scarce money and time on inadequate food. Even when Lactogen itself is bought, it is seldom mixed correctly, but normally made up at quarter to one-tenth strength, and usually heavily contaminated in the process thereby increasing the already high rate of gastroenteritis.9 The extra toll of this latter on infant morbidity and mortality is well understood. lo There is a well documented drop of weight gain after the age of three months in underprivileged societies. This does not occur in better privileged societies, nor in elite groups within an impoverished community.” There is also documented a lower output of breast milk,‘* presumably due to the maternal-depletion syndrome that is almost univeral in the same social _ rzroups. a high incidence of _ In a previous studv.13 < varying degrees of clinical malnutrition was found in this same town in 1976: out of 169 children, 32% were grossly underweight for their age, 41% hadclinicaloedema,and26% had2ormorestigmataofmalnutrition. Infants are, therefore, in need of nutritious weaning foods to supplement breast milk, maybe as early as 3 months of age, and definitely before 6 months. On account of the high metabolic and growth rates required and the relatively small stomach volume, a child cannot afford any non-nutritious intake. Every millilitre of capacity needs to be filled with high quality nutrients.
329
Conceptual
problems
in nutrition education in Western Nigeria
Third, little use is made of nutritious foods which are locally available, and relatively cheap. Melon seeds and locust beans are ground and cooked in the stew forming a nutritious mixture, but not given to chilImported commodities Price per 5~19 (fs)b dren. Green vegetables are freely eaten by the adults, and several Lactogen 0.80 varieties contain good quantities of vitamin C, folic acid and iron; they 1.13 Glucose-D are not commonly given to children. Citrus fruits which abound and are 0.50 Cornflour 0.84 Custard cheap are hardly touched. This is probably for the good reason that the 0.91 Bournvita vitamin C sources in a traditional Nigerian diet are pepper and certain 0.20 Breadc 0.03 per 5Og unit Biscuitsc commonly eaten green vegetables. Problems have arisen, therefore, in areas where misinformed health educators have managed to eliminate Notes: aln 1978 the GNP had risen to around f300 p.a. but food prices had escalated in pro- pepper from the children’s diet without ensuring an adequate alternative source of vitamin C. Yam is a good source of calcium, but current trends g:i;.?)O = US $2.2 = N 1.40 cBasic ingredients imported. towards the cheaper and less nutritious cassava cause problems. Fourth, although protein foods were mentioned by a number of mothers, the quantity of meat or fish consumed by a whole family during a seven-day period is frequently as little as 3@60 g. Beans are not cooked evel?)P;day on account of the prolonged cooking required and the large amounts of wood and water therefore needing to be carried to the house. Eggs gre seldom given in practice, and health workers feel that they have done well if they can persuade a mother to give her child as many as two sniall ones per week; this would probably be the sole source of protein for an older child, pther than the mother’s failing breast milk. Last, the finances of most families are so stringent that food-purchasing power may be as little as 2545~ per week for the whole family. We can confirm this from the Gross National Product of flO0 pa.14 The major part of this is oil revenue, and a large proportion of the remainder is accounted for by government spending. Taking account of the spending power of the elite, it follows that the majority of the population survive on an annual income (visible plus invisible) nearer f20 per capita. This is expected to cover all costs, including school fees. Eggs cost from 3-5~ each; 30 g of meat costs 5-10~; fish (30 g) 3-5~ (1975 figures). Groundnuts (peanuts) or beans would be better spending, as far as cost per protein value is concerned. By comparison, the cost of commonly bought imported items are shown in Table 3. In spite of these mispractices, all members of the population are extremely concerned about their children’s stzvival, and that they should be given the best possible food. They are, however, grossly misinformed as to what is the ‘best food’. All this seems quite alarming enough, but the attitude of the population to the health workers concerned requires careful examination. In answer to the question, ‘Does the help that mothers get from the Maternity Centre stop the babies born there from dying at all?‘, thirty percent said quite definitely ‘No’, while two mothers actually said that it made the situation worse. The question, ‘Why do only a few people go to the’Maternity Centre to deliver?‘, elicited answers ranging from lack of money, preference for herbalists, preference for home deliveries, religious reasons, distance of abode (farm) from maternity centre, to, finally, pride and downright fear of the centre. Six out of 20 mothers said that the midwives were not polite to those who go there. How likely then are any personnel involved in an institution which has I41975 figures. In 1978 the GNP had risen so little good faith among the townspeople to be able to break new ground to around f300 pa, but food prices had in any educational area? escalated in proportion.
Table
3.
Approximate
market
prices
of
imported commodii commonly used for infant feeding in Western Nigeria (1975).a
FOOD POLICY November 1982
Conceptual
problems
in nutrition education in Western Nigeria
Conclusions In spite of reputed massive nutrition education programmes in the Western state of Nigeria, nutritional practices as they pertain to young children are at present grossly inadequate, but could be greatly improved by judicious use of locally available foodstuffs. In view of the present mortality rate of 30% before the age of five years, l5 and the additional rate of 30% morbidity in the same age group, we know that the health of these young children is fragile. Although l6 play an important role in debilitating infections, including tuberculosis, children and increasing their food requirements, their effect is less devastating among adequately fed youngsters.” Part of the problem lies in the limited financial resources of the parents, but an even greater portion can be attributed to mass misspending on important prestige foods. This is due mainly to the intensive promotion of powdered milks and the subsequent confusion of these with poor quality starch items marketed in similar tins and at similar prices. Basic misconceptions on the importance of key foodstuffs in the health of children also abound. A very large portion of responsibility must be laid at the feet of persons deputing inadequately motivated and inadequately informed personnel to perform essential educational roles in basically illiterate communities. The damage that such personnel can do is much greater than the benefit that could be sowed by more appropriate staff.
Recommendations The International Code of Marketing of Breast-milk Substitutesls should be enforced in this community. Furthermore, all advertising for Bournvita should state clearly that this food is not suitable for children under the age of five years and the current depicted association with healthy children eliminated. The interpretation within the community of all foodstuffs advertising should be carefully monitored by agents interested in the health of the population. Second, nutrition education should be dissociated from nurses and maternity centres or hospitals. There should be an intensive campaign to re-establish ‘breast milk as best milk’, providing adequate facilities for breast-feeding women at work, together with longer maternity leave, raising the prestige of the breast-feeding mother in the community. The community social worker should function away from medical centres. More nutrition rehabilitation, reorientation, or mothercraft centres could be established, de-emphasising the medical input, and aimed primarily at establishing good rapport between the educators and the mothers. This would help to underline that food, rather than medicine, is the best cure for an underweight child. *%ankole, op tit, Ref 5; D.C. Morley, Paediatric Priorities in the Developing World, Butterworths, London, 1973. 16Bankole, op tit, Ref 5. *’ J.E. Gordon, A.M. Guzman, W. Ascoli and N. Scrimshaw, Acute Diarrhoeal Disease in the Less Developed Countries, 2: Patters of Epidemiological Behaviour in Rural Guatamelan Villag>s, WHO Bulletin, No 31, pp 9-20. ‘%ternational Code of Marketing of Breast-milk Substitutes. WHO. Geneva. 1981.
FOOD POLICY November 1982
Postscript Since this work was undertaken, the Basic Health Services Scheme had set out to produce more health-orientated basic health workers in Nigeria. Although the Basic Health Service Scheme has since been abandoned, the training institutions are maintaining the same orientation for basic health workers. The health-education inuut to these cadres has been infinitely greater than for any other group df health professionals, but their acceptability remains to be tested since they still operate from government health institutions.
331