Malnutrition is a major public health problem in developing countries. ^{1, 2} In Nigeria, 31%, 16% and 34% of children under-five have been reported underweight, wasted and stunted respectively. ² It is associated with increased morbidity and mortality, such that 30-40% of deaths in pre-school age group in Nigeria are associated with malnutrition. ³

Information support for nutritional activities in Nigeria has been top down rather than bottom up. The non-participation of Community members in the assessment, programming and evaluation of their nutritional problems hamper sustainability. ^{1, 9}

Therefore, UNICEF and other partners in the nutrition field developed a more purposeful approach at nutrition information management to improve nutrition as part of an early childhood development (ECD) strategy. ² This information system is called Community Level Nutrition Information System for Action (COLNISA). ^{5, 6, 8, 9}

COLNISA uses the triple A cycle (assessment, analysis and action) also pioneered by UNICEF. ¹⁰ It is a participatory decision making process wherein the problem of under nutrition is assessed (in terms of its, its causes analysed, along with the available resources and capacity to combat it, followed by a decision on the appropriate mix of actions. Objective basic social, health and nutritional indicators are used to assess impact of the strategy. This is followed by reassessment, reanalysis and further action. The strategy is also applicable in other development sectors. Before advocating for the use of COLNISA strategy as a tool for community empowerment for enhanced community participation in not only nutrition, but also health and economic development, an intervention study on a pilot scale was deemed necessary. The aim of this study therefore, was to evaluate the effectiveness of the COLNISA strategy in improving basic social, health and nutritional indicators in Tasharshari village near Zaria.

MATERIALS AND METHODS

Study area

Tasharshari is a small village settlement located about 65 kilometres from Zaria. It is in Yakawada district of Giwa local government area. It lies between latitudes 11° 32` and 09°02` North of the Equator and longitudes 08°50` and 06° 15` East of the prime Meridian. ⁴ The vegetation is guinea savannah. The hottest months are March-April while the coldest are December and January. The rainy season varies from March to October. As at 1999, it had a total population of 1,464 people. ⁴ The Hausas and Fulani are in the majority; the people are mostly farmers with few traders and artisans. The village had a primary school; the nearest health clinic was located 20 kilometres away at the district headquarters.

Study population

These included mothers of children under five years of age and children below the age of five years in Tasharshari community.

Design

A prospective intervention study

Sampling method

A systematic sample of 1 in 4 households was selected from the 244 households in Tasharshari village for every stage of the investigation. A total of 67 households were studied. 

Advocacy and community mobilization activities

An advocacy visit was organized at the beginning of the study to meet with formal (local government officials) and informal (traditional) leaders of the community. The purpose of this visit was to seek permission and cooperation from the leaders and members of the community. This was followed by a general meeting with the whole Community at the leader’s palace were the COLNISA strategy was explained in local (Hausa) language.

A COLNISA committee was formed with the traditional leader as the head of the committee. Women and youths were represented on this committee. The traditional leader and other members of the Community nominated ten dedicated and literate members of the community to serve as COLNISA volunteers. The volunteers consisted of youths, schoolteachers, health workers and traditional birth attendants. The nominated COLNISA volunteers were trained on the basics of nutrition, malnutrition, anthropometry and data collection instruments. The use of measuring scales was practically demonstrated to them. Community level and household questionnaires were developed and pre-tested together with the volunteers. Permission was obtained from Giwa local government officials, traditional leaders of Tasharshari community before the commencement of the study.        

Pre-intervention survey

This was conducted by the COLNISA volunteers with facilitation of the authors, the purpose of which were to identify the location of infrastructure and other developmental amenities, e.g. health facilities, schools. Information was also collected from one in four systematic sample of households about basic social, health and nutritional indicators using pre-tested semi structured questionnaires.  The questionnaires were analysed together with the volunteers bringing out the proportion of literate mothers, those with income generating activities, mothers’ attending antenatal care during pregnancy, knowledge of exclusive breastfeeding, practice of complementary feeding and use of oral rehydration therapy. Other indicators included infant immunization coverage, proportion of children growth monitored and those stunted, wasted or underweight. 

Intervention phase

The findings from the pre-intervention survey were shared with the community leaders, members of COLNISA committee and other members of the community. The people identified poor indices and the remote and immediate causes during a community dialogue. Taking cognisance of the community’s resources, members of the community were asked to proffer solutions for the improvement of the low indices and sustenance of the others. A work plan was developed specifying the objectives, activities, person(s) responsible, time and resources to be used. These included; Participatory health education, community based growth monitoring and promotion services, outreach antenatal and immunization services by Staff of Yakawada Comprehensive Health centre, Ahmadu Bello University Teaching Hospital, Zaria, promotion of exclusive breastfeeding, production and use of locally prepared complementary foods, home treatment of diarrhoea using salt sugar solution and female literacy classes. Community based income-generating activities using local trades. The COLNISA committee together with the volunteers implemented the work plan. Other members of the community were co-opted as was necessary. The authors conducted monthly monitoring visits to monitor progress and give technical advice.

Post-intervention survey

Twenty four months after the intervention, an evaluation was conducted by the volunteers using the tools used at the pre-intervention phase to assess the impact of the intervention.   

Data analysis

Indicators were calculated from simple proportions of the sample with various social, health and nutritional attributes. The differences between these indicators at baseline and 24 months after intervention were obtained. Chi square test was used to test for significance of differences using MINITAB 12.21(U.S.A) ⁷. A P-value of 0.05 was considered significant.

RESULTS

Pre-intervention phase

Social indicators

At baseline, only 7 out of the 67 (10%) mothers had primary school education. The rest either had non-formal education or were illiterates. Seventeen out of the 67 (26%) of the mothers were engaged in income generating activities as shown in Table 1.

Health indicators 

Table 2 shows that only 7 of the 67 (10%) mothers attended antenatal care during their last pregnancy. Twenty-one (32%) of them were aware of exclusive breastfeeding but none of them was practising it. Only 4 of the 67 children (5%) were taken for growth monitoring in the preceding two months. Similarly, only 11 (16%) and 16 (24%) of the mothers practised appropriate complementary feeding and oral rehydration therapy respectively. Furthermore, 7 of the 67 children (10%) were fully immunized.  

Nutritional indices

By the WHO reference standard, ¹⁹ 51 (77%), 11(17%) and 41(61%) of the 67 children were stunted, wasted and underweight respectively, as shown in Table 3.

Table 3: Changes in health and nutritional indicators in under fives in Tasharshari, 1999-2001

Intervention phase

An analysis of the findings at baseline together with members of the COLNISA committee and the community indicated that the main factors responsible for the poor indicators were poverty, illiteracy, lack of infrastructure and personnel in the area of healthcare and education. They lacked vision and drive for self-help, expecting government to bring about development in their community. Community members volunteered their time, donated money, materials and venue for the intervention activities outlined in the methods section. Other external assistance in form of child survival training material, weighting scales came from UNICEF. Technical assistance was provided by the Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria.

Post-intervention phase

Two years after introducing the COLNISA strategy of nutrition information management in this rural settlement, the community renovated its primary school, started a female literacy class, established a new health centre with the assistance of the local government council and commenced community-based growth monitoring and promotion activities. Moreover, it also started producing her complementary feeds and formed two registered cooperative societies.

Social indicators

After intervention, 24 out of 67 mothers (36%) were able to read and write after attending adult literacy classes in the village head’s palace. About 81% of the mothers were engaged in income generating activities such as knitting, soap making and trading as shown in Table 1.

Health indicators

More than half of the mothers attended antenatal care organized as an outreach activity of Yakawada Comprehensive health centre-one of the health centres of the teaching hospital managed by the Department of Community Medicine. Similarly, 62 mothers out of 67 (93%) were knowledgeable about exclusive breastfeeding. Forty-six out of the 67 (83%) were growth monitored in the preceding two months. Appropriate complementary foods were introduced by 39 (58%) of mothers. Oral rehydration therapy using salt sugar solutions was practised by 47(70%) of the mothers. Twenty-two (33%) of the children were fully immunized.  

Nutritional indices

After intervention, 50(75%), 8 (12%) and 33 (49%) out of 67 children were stunted, wasted and underweight respectively as shown in Table 3.

Changes in basic social, health and nutritional indices after intervention

Table 1 shows statistically significant changes in maternal literacy and engagement in income generating activities. Similarly, the proportion of mothers attending antenatal care during pregnancy increased almost six-fold. Significant improvements were also noticed in mothers’ knowledge of exclusive breastfeeding, practices of complementary feeding and oral rehydration therapy as shown in Table 2.

Table 2: Changes in Maternal health knowledge and practices in Tasharshari, 1999-2001

Table 3 shows significant increases in the proportion of under fives that were growth monitored and fully immunized. Conversely, there was a reduction in the proportion of stunted, wasted and underweight children. The latter changes were however, not statistically significant.  

DISCUSSION

Representatives of various countries declared in 1978, in Alma-ata, that in order to attain a level of health that will enable people to live socially and economically productive lives, they have a right and responsibility to be involved in planning, organization, operation and control of their health programmes making fullest use of local, national and other available resources. ¹⁸ It was in this spirit that UNICEF developed the COLNISA strategy to enable communities assess, analyse and act on their nutritional and other health problems. ²

Two years after the introduction of this strategy in a rural community near Zaria, all basic social and health indicators changed significantly. However, despite modest improvement in nutritional indices, this was not statistically significant.  It can be argued that been an uncontrolled intervention study, the changes could also be going on in other communities. But, it is unlikely for these changes to have occurred without the community mobilisation and participation inherent in the COLNISA strategy. The principal ingredients of the strategy included, identification of a community with social, nutritional, health and developmental problems. Appropriate community entrance, dialogue including human and material resource mobilization. External technical assistance in this intervention came from the department of Community Medicine of Ahmadu Bello University Teaching Hospital, Zaria and UNICEF Kaduna Field Office. The latter donated the solar weighting scales and teaching materials for nutrition, community based growth monitoring, exclusive breastfeeding, oral rehydration therapy and childhood immunization. The local government council constructed a health centre.

Other community based intervention programmes like the Oriade initiative-Operations research for people-centred development use similar principles in community co-financed and co-managed health and development efforts for sustainable sector wide reform. ¹⁶ It is an effort aimed at community development with health sector reform as the focal and entry point. ¹⁶ The differences with the COLNISA strategy are; that the latter doesn’t require a prior request for assistance from the community and the existence of a successful self-help project within the community is not a prerequisite ¹⁶. Rather communities with poor health and social indicators within the catchment area of the supporting institution are approached. Another strength of the COLNISA strategy is that membership of the COLNISA committee, its leadership and selection of the volunteers is entirely decided by the members of the community. Therefore, none of them is seen as an imposition or a government appointee. It is in some respects similar to the Village Development Committees of primary health care, most of which are no longer functional nationwide. ¹⁷

The modest changes in nutritional indices of children below the age of five could be explained by the longer period required for such indices to show changes. ¹⁰ Similarly, a large-scale community trial called the Iringa project¹⁰ in Tanzania also reported only marginal improvement in nutritional indices 36 months after intervention. Our findings are comparable with reports from other 32 COLNISA pilot communities across the country. ²

Elsewhere, community based nutritional intervention programmes like the Participatory Nutrition Improvement Project (PNIP) in Sri Lanka, ¹⁰ Community action for Social Development (CASD) in Cambodia ¹⁰ and the Tamil Nadu integrated nutrition project ¹⁵ (TINP-1) use a similar strategy of community assessment, analysis and action-triple A cycle developed by UNICEF to achieve sustainable nutritional surveillance and intervention. Many interventions work under certain controlled conditions, but their effectiveness in the field has not yet been proven. ^11-13 There are few published examples of well-designed evaluations of community-based nutrition interventions. A recent review of attempts to improve complementary feeding ¹⁴ stated that even in the very few large-scale programmes that have been adequately evaluated in terms of nutrition impact, it is difficult to isolate the effects of individual components.

Despite the uncontrolled design of this evaluation, this study shows that the COLNISA strategy is an effective tool in community mobilisation, empowerment and action. Such strategies that encourage community ownership and participation in information management, policy formulation, planning implementation and evaluation will engender sustainability. ⁹ If this strategy is found to be this effective in a controlled evaluation, it can be recommended for tackling nutritional problems at the community level in Nigeria and other developing countries. 

REFERENCES