Fifty-Year Celebration of the Department of Biochemistry
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Kendall W. King - Journal of Nutrition Education, Summer, 1971

Reducing Malnutrition

In most countries, Mothercraft Centers, have been successful in reducing - and even eradicating - clinical malnutrition from segments of the preschool child population. In both Guatemala and Haiti - two of the first countries to launch centers as a public health measure - several centers have been closed because clinical malnutrition is no long-er found in the villages served.

In the operation of a typical center, the preschool children of a village are weighed and checked for nutritional edema or other nutritional lesions commonly encountered in that particular country. The 30 to 35 most malnourished children are selected, and they and their mothers are invited to participate in the center's program.

For 3 or 4 months, the children are brought to the center six days a week, and each mother stays one day a week. There the mothers and the supervisor feed and care, for the children. The supervisor frequently discusses with the mother why certain foods are good buys, how to prepare them, and how to improve the sanitary environment of the child within the limitations of local resources.

The limitations of local resources can be severe and have, in some instances, required some adaptive research in order to discover which local foods can serve as the basis for a least-cost dietary system. In Haiti for example, it was necessary to run proximate and amino acid analyses on some 86 profiles of local corns, rices, sorghums, beans, peas, and peanuts, in order to formulate a simple two-food mixture for young children that mothers could make in their own homes (9). The mixtures then had to be evaluated for satisfactory toxicological, nutritive, and acceptability properties in rats (10). Having found a 2:1 mixture of any of the cereals and the local red bean (Phaseolus vulgaris) to have merit, a great deal of recipe testing had to be done before final evaluation in children (11). In the Philippines, two-food mixtures of rice and mung bean were similarly developed. This done, the basic knowledge of a least-cost educational program was in hand.

The supervisor is usually a girl with high school education, or even less, who has been specially prepared for the work in a training program of one-month formal classroom study add a one-month field internship in a center with an experienced girl. She is supplied with about 10 cents per day per child for food and fuel and a set of menu cycles which meet the full dietary needs of the children by using only common local market foods. The success of the center rests to a very large extent, on her ability to gain the confidence of the mothers.

In some places, the center is attached to a public health facility; in others, centers built or furnished by the community operate alone. In either case, the facility is deliberately kept as similar as possible to the facilities the mothers have in their own homes. This is done so that everything that is taught and done in the center is directly applicable at home.

The children are weighed weekly, and their individual growth responses are discussed with the mothers to bolster their awareness that the children are improving and to motivate them to adopt at home the things they are learning in the center. When the children have been rehabilitated in 3 or 4 months, a group of mother-child pairs is graduated, and the next 30 to 35 mother-child pairs are selected.

In this way, a center trains about 100 mothers annually. Beghin (4), in his survey of eight well-managed centers in Latin America, found an average total cost of 74 cents per child per day. Thiscost included food, fuel, equipment, sal-aries, transportation, facility rental, and supervision. Thus, operating costs of each of those centers were about $6,500 per year. This compares with the current annual cost in Haiti of $2,000 to $2,500 per year of which about half is generated from local sources so that the health services have to budget only about $1,000 per year per center, or $10 per mother trained. These economies in the Haitian centers are achieved by a rigid ceiling on the cost of food and fuel of 10 cents daily per child, by using very simple facilities, by the prevalent low salary scales, and by generating maximum local support. Philippine centers achieve a similar economy.

Even using the relatively high figures revealed by the Beghin estimates, the cost of rehabilitating a child in such a center ranges between one-fourth and one-thirtieth of the cost of rehabilitation in a hospital. There is of course, no educational impact on the mother in the hospitalization method so no prevention of relapses or similar illness in younger siblings can be anticipated.

Adaptations of center activities to local conditions are highly desirable, and these have been numerous. For example, in the Philippines the sanitation-nutrition education is very tightly integrated with family planning information. The union is a natural one for a major part of mothercraft in most countries is the art of not being a mother too often. Guatemalan centers tend to be strongly oriented to general community development efforts.

In a number of countries, Peace Corps and other volunteers run centers where the fathers of the children are taught trade and farming information to improve the family's financial position. One center in Haiti operates directly in a hospital ward receiving kwashiorkor and marasmic patients from pediatrics as soon as intensive care is no longer necessary.

Centers supervised by public health services are financed in many countries by a variety of local and international organizations such as women's church groups, CARE, Church World Service, civic clubs, newspaper guilds, local cooperatives, and military pacification groups. Frequently, major contributions of labor, equipment, and food are made by the community being served by the center.

Evaluation in the early days consisted largely of testing the mother's mastery of the material being taught. In general, test scores were quite satisfactory. It was soon realized, however, that this type of testing is not adequate evaluation for education of this kind. The purpose was only fulfilled if dietary and sanitary conditions improved at home as a result of the mother's training. Evaluations of two general types are now generally in use: operational evaluation and evaluation of maternal response.

Operational evaluation deals with the adequacy of the day-to-day running of the center, and is done by observation in two areas. First is the growth response of the children, which is expected to improve dramatically, indicating that the dietetic planning and the food preparation are reasonably good. Second is a periodic report resulting from an unannounced visit by someone from the central office; this deals with housekeeping, organizational, and general operational aspects.

Evaluation of long-range educational effectiveness of the center depends generally on one or more of three things; periodic quantitative dietary surveys of the village looking for changes in dietary patterns (6), post-discharge growth rates of children - which should be better than the rates before admission, and the growth performance of younger siblings of the children admitted - which should be better than that of the first child if the mother has improved her child care practices at home as a result of training.

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