[Ambulatory management of moderately and severely malnourished children in the rural health district of Kapolowe in Shaba (Zaire)]. / Prise en charge ambulatoire des enfants modérément et sévèrement mal nourris dans la zone de santé rurale de Kapolowe au Shaba (Zaïre).

In Kapalowe rural health district, hospitalisation of malnourished children is restricted to complicated cases; once the complication is under control or eliminated, the child's treatment is continued at home, based on a 13 weeks contract, between parents and health centre. The parents commit themselves to feed their child four times a day (two porridge and two family dish portions), to consult once a week at the health centre and to welcome a weekly home visit. The objective of this visit is to support the parents, to detect possible problems and to reach the roots for this particular child. During the contract period, cost of medical treatment and recommended soya flour, is borne by the parents through a lump sum contribution. In this article, data concerning the first 95 children home rehabilitated (1989-1991) in Kapalowe are analysed. Characteristics of these children are classical regarding malnutrition; for example, age distribution is similar to that of weaning and of defunction of children at the hospital during the same year. Approximately half of them are still breastfed at the beginning of the contract. Most of them are correctly immunized and have been seen at the health centre at least two times in the last six months. Seventy-four children finished the contract; there were 17 abandons and 4 deaths. Weight gain is inferior to that observed in specialized feeding centres which do benefit from external resources, which is not the case here. It was not possible to show a significant catch up for the height for age indicator after the three months contract. These anthropometrical results are less important than the global and subjective improvement in the child's general health status observed at the end of the contract. None of the children reached the target weight after 13 weeks but important changes were observed in their behaviour, in their resistance to infection and in the attitude of their parents. The parents generally followed the instructions quite well. The middle of the contract seems to be a key period when either significative changes happen or when the attention is released. Treatment instructions have been amended to avoid monotony and overload, and to stimulate staff creativity and self-satisfaction. Payment was not a problem for the parents as malnutrition is not linked to extreme poverty. Mother's attitude and confidence and child initial weight for height status are two important contract success determinants. Abandons are more frequent when the mother is pessimistic and in case of kwashiorkor. Despite this, most of these children had gained more than one kilo before the contract was interrupted. Some didn't fulfill the W/H inclusion criteria (-2 standard deviations) and should probably not have been under contract. The four deaths were linked to insufficient treatment instructions for usually banal diseases that have another meaning in case of malnutrition, such as diarrhoea, fever, etc. An evaluation performed three months after the end of the contract in 26 children show 13 further improvements, 8 statu quo, 4 relapses and 2 new deaths. Conclusions are that home nutritional rehabilitation is possible where a health district is fully operational, that anthropometric data are useful to monitor rehabilitation but not to be pursued only as sole and ultimate objectives, and that adequate follow up after the first intensive stage is essential. The paper also shows how such a research result can have direct consequences on the organization of health activities.

[Nutrition education or managing social communication for nutrition?]. / Education nutritionnelle ou gestion de la communication sociale en nutrition?

Seven years ago Hygie published an article on the limits of conventional nutrition education in urban Africa. Strategies and methods in communication for nutrition have since evolved, incorporating results of international research to develop innovative, highly participative approaches. In this article the authors provide an extensive analysis of the different methodologies used in nutrition education programmes, in particular the KAB, social marketing, and community participation models, indicating main areas where each method used separately has failed. Members of the African Nutritional Education Network (RENA) have studied the above mentioned approaches, modifying them or integrating certain elements to adopt a more effective approach, which they consider somewhat as the management of social communication for nutrition education. Needs assessments and programme planning are largely enhanced by a causal analysis component specific to nutrition education in a community setting which has been developed by the authors. Other classic elements of programme implementation such as community participation, diversity of methods and intervention, are then combined with a multi-level/multi-actor evaluation processes to produce what the authors esteem to be a more effective nutrition education programme. They conclude, however, with the warning that although behavioural modifications brought about by nutrition communication and education might be beneficial for public health, they could have different, possibly adverse effects on other aspects of society. Effective nutrition education must therefore be included in a more extensive field of health promotion by acting on the multiple factors which influence the nutrition and health state of vulnerable groups.

The causal model approach to nutritional problems: an effective tool for research and action at the local level.

Reported are the results of a case study from Kirotshe rural health district, Northern Kivu, Zaire, where a workshop on the causal model approach to nutrition was organized in 1987. The model has since been used in the field for research design, training of health professionals, nutrition intervention, and community development. The rationale behind this approach is reviewed, the experience accumulated from Kirotshe district is described, and the ways in which the causal model contributes to comprehensive health and nutrition care are discussed. The broad range of possible policy implications of this approach underlines its usefulness for future action.

The causal model approach to nutritional problems: an effective tool for research and action at the local level

Reported are the results of a case study from Kirotshe rural health district, Northern Kivu, Zaire, where a workshop on the causal model approach to nutrition was organized in 1987. The model has since been used in the field for research design, training of health professionals, nutrition intervention, and community development. The rationale behind this approach is reviewed, the experience accumulated from Kirotshe district is described, and the ways in which the causal model contributes to comprehensive health and nutrition care are discussed. The broad range of possible policy implications of this approach underlines its usefulness for future action

Can the causal model approach contribute to the study of the epidemiology and the control of sleeping sickness?

A causal model links together, in an hierarchical manner, a set of hypotheses about the causes of, and mechanisms leading to, a phenomenon under study. Initially used in nutrition studies for identifying the variables to be observed, such models have proven useful in the choice and evaluation of interventions, as well as in the selection of relevant special studies to be carried out inside a broader research programme. The authors describe a technique of model building used by nutritionists, and argue that this approach could be of benefit in the study and control of african trypanosomiasis. Their hypothesis is that although causal models do not substitute for mathematical models, the latter ones, and epidemiological models in general, would be (1) more correct logically; (2) fitting reality more closely; and (3) more useful for the analyst, the decision maker and the field worker, if they were built from an preceding causal model.

Population and nutrition planning: the usefulness of demographic discipline for nutrition policy in Latin America.

PIP: Demography can play an important part in the diagnosis and improvement of the nutrition situation in Latin America. Applied population studies can provide diagnostic and evaluative frameworks, analytical indicators and indices, and a definition of the nature, size, and distribution of the target groups. Several models of relationships between population dynamics and economic development have recently been worked out, and the paper diagrams a conceptual framework that can be used to identify demographic data that are important in diagnosing nutritional situations. Another table lists selected sociodemographic indicators related to malnutrition in the areas of mortality, maternal and child health and nutrition, food consumption and child care, environmental sanitation and services, potential demand for food and services, and employment. Besides the advantages of being generally available through collection for other purposes, demographic information has the further advantages of focusing on family units, utilizing concepts that are basic and easily understood, allowing geographic breakdowns, and permitting expression in terms of trends and projections. 3 activities of the Institute of Nutrition of Central America and Panama (INCAP) demonstrate the usefulness of demographic information. A "demographic sourcebook for food and nutrition planning" for each of the countries provides for constant updating of locally available demographic information which is used in planning; a nutritional surveillance system under study or development in 5 countries aims to detect change and predict deterioration so that corrective measures can be taken; and a functional classification of malnutrition seeks to identify specific population subgroups in regions that are administratively, economically, and ecologically uniform for purposes of program planning.^ieng

Functional classification of undernourished populations in the Republic of El Salvador. Methodological development.

Typical government nutrition programmes usually lack precise information on the size of groups that could benefit from interventions, on the different types of potential beneficiaries and their location, and on socio-economic and cultural characteristics through which they could readily be identified. In the functional classification approach to the definition of nutritional problems, detailed information on human behaviour and social constraints is collected at family and community levels. The data are then interpreted in general terms in order to understand how these factors contribute to inadequate levels of nutrition within larger groups. This new approach should enable more effective measures for reducing the numbers of those living under conditions of deprivation to be presented to planners and decision makers.

[Current and future status of human nutrition in the Central American isthmus]. / Estado presente y futuro de la nutrición humana en el istmo centroamericano

Of the four major nutritional problems in the Central American Isthmus, calorie and protein deficiency, endemic goiter, nutritional anemias, and vitamin A deficiency, the most devastating is the first, calorie and protein malnutrition. Our present stage of advancement requires that the nutritional problem be solved through intensive and continued governmental action that would guarantee the people of this area an adequate diet without deteriorating the environment and without depleting natural resources. This would imply a reorientation of the scientific and technological research and a new agricultural policy, together with a new model of development that would place priority on these considerations, recognizing, at the same time, their demographic predominance.

Systems analysis in nutrition and health planning: approximate model relating birth weight and age to risk of deficient growth.

This paper summarizes the initial phase of an effort to develop semiquantitative methods for nutrition and health planning. The general approach is to utilize the methods of systems analysis and operations research where appropriate, but the emphasis is on developing a simplified, approximate analysis that government planning groups could conveniently apply in evaluating various potential programs for attaining specific nutrition and health objectives, while satisfying certain constraints (e.g., budget, facilities, personnel). An essential element of the analysis is a model that provides an approximate description of malnutrition (inadequate growth, as indicated by weight for age) and mortality in terms of those variables that can be affected by intervention programs. We have concentrated initially on using the results of two INCAP longitudinal studies to develop models relating the incidence of malnutrition (second and third degree on the Gomez scale) to age and previous growth, including birth weight. The two studies cover rural Guatemalan communities with considerable variability in ethnic, socioeconomic, and ecological conditions. Because they are tentative, the resulting models are discussed only qualitatively and not quantitatively. The models may serve as baselines to estimate the consequences of potential programs aimed at different target groups, such as pregnant women and children whose weights at birth or thereafter fall below prescribed levels. The possible benefits of using models of this nature in nutrition and health planning are discussed.