Senegalese grandmothers promote improved maternal and child nutrition practices: the guardians of tradition are not averse to change
Introduction
In the past 10 years, research has significantly advanced our understanding of the nutritional needs of infants and young children, and, to a lesser extent, of female adolescents and women of reproductive age (WRA) (LINKAGES, 1999); however, there has been much less progress in identifying interventions that lead to sustained improvements in nutrition practices (Samba, Sy, Ntiru, & Diene, 1999). In spite of considerable investment in nutrition education (NE) programs in developing countries over the past 20 years, relatively few interventions that have documented sustained changes in community practices related to women and children's nutrition (Allen & Gillespie, 2001; Andrien & Beghin, 1993). The limited impact of such programs may be attributed, in part, to inadequacies in the reductionist conceptual framework used to understand health/nutrition practices in household and community settings and in the limitations of the predominant, directive pedagogical approach used in NE.
In community health programs in developing countries, the approach adopted in most nutrition/health education/communication (NHEC) interventions reflects two key dimensions. First, most programs use directive, unidirectional, message-based methods with community members (Lee & Garvin, 2003). Second, the goal of most NE programs is to bring about changes in individual nutrition-related behaviors of WRA (Andrien & Beghin, 1993). The basic assumption made in these programs is that if WRA acquire information on optimal maternal and child nutrition practices, they will adopt those practices (Leslie, 1989). Very few programs have involved older, experienced women or grandmothers.1
This paper has several purposes. First, we identify several conceptual and methodological limitations in the predominant approach used in community NE in developing countries, and particularly regarding the failure to involve grandmothers in nutrition promotion strategies. Second, we summarize the results of a community study conducted in Serer villages in western Senegal which revealed the protagonistic role played by grandmothers in maternal and child health (MCH). Third, and primarily, we describe the methodology and results of a community NE project that aimed to strengthen the role of grandmothers in promoting improved maternal and child nutrition practices related to exclusive breastfeeding, improved diet and decreased workloads during pregnancy. The NE project was carried out in the context of a community health program supported by an international non-governmental organization, Christian Children's Fund (CCF), and implemented in collaboration with the Ministry of Health (MOH).
Section snippets
Background
The vast majority of NE programs in developing countries are grounded in the transmission-persuasion model of education/communication (Waisbord, 2001). This predominant model, or paradigm, has been widely supported by North American and international development agencies and has been manifest in various approaches, used over the past l5 years and referred to as health communication (HC) (Graeff, Elder, & Booth, 1993), information, education and education (IEC) (WHO, 1997), social marketing (
Role of senior women in maternal and child health programs
The reductionist focus of MCH programs on WRA has tended to camouflage other household-level actors who influence health and illness decision-making and practices. While in the mainstream international public health literature discussion of the role of older women, or grandmothers, has been largely ignored, their multi-faceted role in family health has been documented in Africa (Kayongo-Male & Onyango, 1984), Asia (Jernigan & Jernigan, 1992), Latin America (Finerman, 1989; McKee, 1987) and the
Maternal and child nutrition in Senegal
In Senegal the nutritional status of both WRA and children is generally precarious, especially in rural areas. In the project area in rural Senegal, a quarter of all WRA (29%) suffer from chronic malnutrition (BMI<18.6) (CCF, 1997) and it is estimated that during pregnancy approximately 60% are anemic (Wade, 1994). The unsatisfactory nutritional status of WRA is further compromised during pregnancy by the widespread belief amongst all ethnic groups that a pregnant woman should work hard and not
Nutrition education in Senegal
A 1995 analysis of nutrition and health education in Senegal showed that most NE methods used in the country are based on the dominant HNEC message-driven paradigm using didactic teaching techniques and almost all programs aim to bring about changes in the practices, or behavior of WRA (Aubel, 1995a). The MOH Director of Health Education, at that time, identified several factors which have limited the impact of past health/NE efforts: first, the use of directive methods; second, failure to
Intervention setting
The NE strategy with grandmothers, referred to heretofore as the “grandmother strategy”, was implemented in two health districts, Thiadaye and Joal, in western Senegal where CCF is implementing a community child health program in collaboration with the district health staff. The pilot grandmother strategy was carried out in 13 of the 60 rural villages supported by the child health program. CCF has a cadre of well-trained community animators who were primarily responsible for implementing the
Action research methodology
The grandmother pilot project was implemented as an action research (AR) project in the context of a larger community health program.4 The aim of the AR was to
Results
The results of the grandmother intervention are based on sets of quantitative and qualitative data described above. The quantitative results provide a succinct impression of the outcomes of the intervention on grandmothers and WRA. The qualitative results provide a systemic perspective of the impact that the intervention had not only on grandmothers and WRA but also on grandmother networks, CLs, households and communities at large. In addition, the qualitative data provide insights into the
Discussion
In developing countries, relatively few NE strategies have led to sustained changes in community nutrition practices (Allen & Gillespie, 2001; Andrien & Beghin, 1993). Evaluation results of the AR community NE intervention reported here suggest that it contributed to significant changes in targeted nutrition practices of WRA, including decreased workload and improved diet during pregnancy, and increased exclusive breastfeeding, and that community norms related to these and other key nutritional
Acknowledgements
The project reported here was supported by CCF and USAID. Michel Tokopuku, CCF Director in Senegal, encouraged and supported this work in many ways. In addition to the authors, the work with the grandmothers was carried out by Lazin Kalala, El Hadj Sene, Marietou Ndoye, Yirime Faye and Mouhamadou Tandia. The participatory NE methodology used in Senegal was originally developed in Laos by the first author with support from WHO and UNICEF. We are grateful to Stanley Yoder and Kathy Kurz who
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