Dominican Republic: Applied Nutrition Education Project (ANEP)
The Manoff Group provided technical assistance to a Catholic Relief Services/Caritas program in 90 poor communities in the Dominican Republic from 1983-86. The project was supported by USAID and focused on both family and community actions aimed at improving children's health and nutrition. ANEP was at the forefront of innovative community health improvement programs focusing on growth promotion and development of counseling aids tailored to the community context.
Assessment and planning phase
Extensive planning and research preceded the development of program activities. Program planners believed that qualitative research was needed in addition to statistical information about communities. The qualitative research was needed to uncover the reasons for nutrition problems and the feasibility of proposed solutions. The first step was to find out more about the communities and families through a survey. Preliminary analysis of the survey data enabled program planners to identify the major nutrition problems. Case studies were prepared on 158 families with malnourished children. ANEP supervisors used a standard form to collect socioeconomic data and information about family health and nutrition practices. This information was analyzed and ANEP staff and field supervisors identified the following priorities for the project:
Even with the baseline data, program planners needed more qualitative information to develop behavior-change messages and strategies. Focus group interviews were held with selected mothers in project communities. ANEP staff were trained to guide the discussions so they were informal and open-ended. Thirteen groups of about 6 women each from the various project communities met and helped identify:
- Promote exclusive breastfeeding for the first three months (decrease the use of feeding bottles and early introduction of food
- Build the confidence of breastfeeding women in the quality and quantity of their milk
- Promote increased food consumption by children age 4-24 months;
- To prevent childhood diseases—train child caretakers, discourage the use of feeding bottles, promote vaccinations, hand-washing and boiling water, improve the quantity and quality of drinking water and promote the use of latrines
- To control childhood diseases—promote use of oral rehydration therapy to prevent dehydration and promote continued feeding during diarrhea
- Promote appropriate community water systems, garden projects and animal raising
- Involve more families with malnourished children in the program.
- Beneficial nutrition practices
- Practices and ideas detrimental to the nutrition status of mothers and children
- Mothers' willingness to modify certain practices
- The feasibility of changing practices and the reasons why the mothers would or would not change practices.
A major program focus was growth monitoring of all community children under age five. High-risk children (all children under age two and malnourished children aged two to five) were weighed monthly. All other children under age five were weighed every six months. Growth promotion coverage was 85% of high-risk children and 70% of others. Educational activities promoted concrete measures that families could take at home to improve nutrition and health practices. To assist in these activities, an individual growth card was designed and materials were developed for use with mothers at the growth monitoring sessions and in other settings.
A set of 12 laminated counseling cards were developed and pretested. The cards were single sheets with graphics on one side and a message on the other side for the health promoter. Volunteer health promoters were trained to use the cards during the weighing sessions and also how to talk with mothers about dietary improvement. Each card was keyed to a specific age and whether the child had gained a minimal amount of weight during the month. The cards guided reinforcement of useful practices and provided suggestions for improving practices. In addition to weight gain/no gain messages, several cards and messages were about diarrhea.
Growth promotion was done house-to-house to allow the time and privacy needed for effective counseling. Workers spent three to five days per month on home visitation and 20-30 minutes at each house. Every six months, the promoters plotted all community children under age three on a large growth chart marked in colored zones by nutrition status. The analysis was done at a community meeting and looked at the percentages of children not covered and the percentages of children in each nutrition status category in general and by age. Community members discussed causes of poor nutrition status and made decisions about ways to improve it. In addition to education activities, project staff publicized the project to encourage more participation, enhance the prestige of the health promoters and to generate community support for growth monitoring. To assist in these efforts, a project logo, newsletter and brochure were developed and produced along with the project slogan "Healthy Children—Strong Communities."
An external evaluation sponsored by USAID in 1987 compared before and after status in project communities to control communities. The evaluation found an impressive nutritional impact. The project communities achieved a 43.4% reduction in the rate of moderate and severe malnutrition; 33% for children enrolled for one year, 44% for those enrolled for two years and 60.5% for those enrolled for three years. ANEP communities had 37.8% less moderate to severe malnutrition than matched non-ANEP communities. Most knowledge, attitudes and practices measured were consistently better in ANEP communities compared to control communities and compared to the baseline.