Asia-Pacific Journal of Public Health 1990-Vol 4
Nutritional Intervention:
A Key to Child Survival
Helen A. Guthrie, PhD, RD
School of Public Health
University of Hawaii
George M. Guthrie, PhD
School of Public Health
University of Hawaii
Tomas Fernandez, MD, MPH
Cebu Institute of Medicine
Corazon V.C. Barba, PhD
University of the Philippines, Los Banos
Abstract
In a collaborative relationship, researchers
from the Cebu Institute of Medicine and from
the United States have carried out a series
of longitudinal studies of breast feeding and
infant growth in a rural Philippine commu-
nity. On the basis of our findings, we have
conducted field experiments designed to have
mothers improve their infants' diets using
locally available food. Contingent reinforce-
ment strategies were used successfully to
get mothers to change their behavior and
beliefs about infant feeding practices. The use
of reinforcements resulted in improved diets
and very high rates of continuation of par-
ticipation in the field experiments. We believe
that this is a highly productive and cost
effective way to approach the problem of
gaining cooperation and continued involve-
ment in a nutrition intervention effort.
Key Words: child survival; infant feeding;
nutrifion intervention.
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No .
Where ten to twenty percent of children perish in
the first year of life, and more die between their first
and sixth birthdays, growing up is clearly a matter
of survival. The high risks that infants and toddlers
face are the result of poor diets, high rates of exposure
to infections, no protection from epidemic disorders
such as measles, diphtheria and polio, and ineffec-
tive remedies for such common scourges as diarrhea.
Over the past decade, in collabdration with public
health physicians at the Cebu Institute of Medicine,
a medical school in the central Philippines, we have
carried out a series of experiments, interventions and
longitudinal studies that have dealt with factors which
influence the initiation and maintenance of breastfeed-
ing. We 'also have developed reinforcement strate-
gies that help mothers make better use of food
available in the community.' In the process we have
learned how feeding and care practices are imbedded
in shared belief systems about diet, growth, nursing
A d the prev'ention and treatment of illness.2 The
details of what we have learned are, of course, specific
to the area studied, but the discovery and interven-
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Asia-Pacific Journal of Public Health 1990-Vol 4 No I
tion procedures that have been utilized successfully
are broadly applicable in communities where many
children currently fail to survive.
All our efforts have emphasized food available
in the community because imported, often enriched,
foods offer no nutritional advantages and are beyond
the means of families who are living on the equiva-
lent of fifteen cents (US) per person per day. When
people spend more than eighty percent of their income
on food, they are restricted to local staples of relatively childhood survival whose values range from about
high caloric density and low cost, staples that are
minimally processed and thus not enriched. Even so,
many nutrient-rich fruits and vegetables are often not
given to children. At the same time, diets of Third
World children are commonly deficient in fat so that
they are less able to assimilate several of the nutrients
already limited in their fare. In addition, lack of
fat results in a diet with a caloric density too low
to promote acceptable growth.
The challenge, therefore, is to cause mothers to . loss of toddlers and preschoolers in poor countries
make better use of the rice, corn, fruits, vegetables
and fish that are availablejor could be produced in
the community. At the same time, many need to
increase the fat in the diets of their rapidly growing
children. In addition, mothers need to nurse each baby
for at least a year, supplement breastmilk after four
months, be prepared for inevitable bouts of diarrhea
and protect their babies with inoculations against
measles, polio and other killing diseases.
Our research in the Philippines has tackled many
of these problems one at a time. We believe that
our approaches can be integrated into a coherent and
effective program that is cost effective as well. The
key elements are careful monitoring and tabulation
of the measurable results that we seek and modi-
fication of strategies that do not yield demonstrable
improvements. Most of these interventions are
directed primarily at behavior, i.e., what the mother
actually does and what effects follow for the child.
Our research, as well as that of others, indicates that
mothers already have a good deal of knowledge and
that they have positive attitudes about a child’s growth
and well being.3 For these reasons, our efforts should
be directed at their practices.
Maintaining improved practices after the experi-
ment is completed is another matter, and one that
warrants studies beyond our current intent. The
strategies we have tested could be readily incorpo-
rated in a program of primary health care, giving
field workers tools that they currently lack to achieve
many of the changes they seek that would enhance
the rate and quality of survival of children.
The keatest threats to a child’s survival come
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during the first 36 months of hisher life. Loss of
life is greatest during the first few days and weeks
after birth, diminishing with each passing month. In
many countries as many as 150 children per thou-
sand do not reach their first birthday. By contrast,
industrialized societies with more food and better
preventive and treatment resources rep7i-t the loss of
ten to fifteen babies per lo00 births. The infant
mortality rate (IMR) is a widely used index of
10/1OOO to 50, 100 or close to 200 in the most
deprived settings. Furthermore, reduction in IMR
from 100 to 75, to 50 and to lower numbers reflects
improved care, diet, infection control and protection
from scourges such as measles, tetanus and polio.
Although the IMR is an index of losses in the first
year of life, poor conditions for survival continue
with the second and third year and beyond. While
much lower than for the earliest months, the rate of
may be as much as ten times higher’than losses in
better fed and more extensively inoculated societies.
There have been many responses to this state
of affairs including supplementary feeding with food
from foreign sources, inoculation programs, and
education programs in which mothers are taught
improved feeding and care practices, the importance
of breast feeding, and improved santation and food
handling techniques. There has been recently an
educational campaign promoting breast feeding, oral
rehydration when diarrhea strikes, and vaccination
for protection against many common infectious
diseases. These illnesses, such as measles, are
relatively benign where children are adequately
nourished but are frequently fatal when victims have
immune systems compromised by deficiencies in their
diets.
Because the causes of poor childhood survival
are numerous and complex, improvement of the
conditions that are significant causes of these losses
poses complex and formidable problems. We are
likely to enhance our understanding of the causal
complex as we apply what we knowmow to improve
survival. Interventions will not only improve the lot
of young children but will also clarify the barriers
to be overcome. It is possible to learn more about
poor survival by planned and controlled interventions
than we can through inspections and descriptions alone
of the hazards to survival.
Lessons From the Philippines
Surveys of Filipino mothers’ knowledge and attitudes

have indicated repeatedly that they are concerned for
their infant’s welfare, that they agree on the impor-
tance of a balanced diet, and that they accept the
desirability of protective inoculations, but they do
not act in ways one would expect given their
demonstrated knowledge and positive orientation to
desirable practice^.^ Adequate knowledge does not
lead to improved practices. When we sought to
improve the practices of Filipino mothers using
strategies of contingent reinforcement, we encoun-
tered belief systems and their associated practices that
contradicted or displaced the practices that we were
promoting. For example, mothers believed that
diarrhea or other illnesses were due to piarzg or a
dislocated bone.4 Given that conceptual framework,
mothers sought a cure through massage. Although
their diets were severely deficient in fat, mothers
rejected avocado as a food for children because they
believed it caused diarrhea. As a final example,
mothers terminated breast feeding abruptly if they
or their neighbors decided that the baby’s repeated
bouts of diarrhea meant that her milk was no longer
good.5 Mothers have an extensive, implicit set of
beliefs about growth, sickness, health, treatment and
food. There is a consistency and logic within their
conceptual system. If fish cause worms, withhold
fish, even though the mother acknowledges the need
for such a readily available source of protein. To
change behavior patterns, i.e., to get mothers to utilize
what they know and what they have been taught,
we need to develop strategies that elicit desired
behavior and techniques that lead to changes in the
cognitive structures and attitudes and beliefs of our
target mothers.6
The Role of Belief Systems
In our research in the Philippines, we have found
a number of social-cognitive processes that influence
the steps mothers take to protect their children and
enhance their growth and well being.*
1. Mothers do not appear to be aware of poor
growth until severe restriction has occurred. We asked
mothers month after month, “Is he growing well?”
They almost invariably responded “yes” even though
the child’s growth was stunted and he weighed the
same as he did six months earlier.
2. Mothers have prescientific theories about the
causes of illness, stunting and death. They may
explain illness as a result of sorcery, bad mother’s
milk, or hereditary factors, e.g., “His older brother
was small and sickly too.”
3. Mothers do not take credit or draw much
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Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
satisfaction from good growth. If one wishes to
compliment a mother, one should precede the
comment with a phrase, “No harm intended, i.e,,
I’m not a witch who wishes to harm your baby.”
This reluctance to be pleased with a baby’s growth
may be due to fear of the jealousy o f neighbors, but
it may also be increased by the fact the mother
receives few indications of the benefits of good
growth. Both stunting and excellent growth are slow
processes that produce few day-to-day indications with
the result that the mother does not receive much
feedback on the effectivenesss of her practices.
Furthermore, the consequences of a change in care
practices for better or worse are usually delayed for
months after the change has been instituted. With
both benefits and harms delayed, there is little apparent
improvement or loss that follows soon after a change
in practices.
4. Mothers hold beliefs that are confirmed from
time to time, e.g., a child recovers after a treatment
of massage by the indigenous healer. Well estab-
lished habits are maintained at high strength by
infrequent or intermittent confirmations. On the other
hand, newly acquired practices need frequent con-
firmations and are seriously weakened by negative
consequences even though the preponderance of
sequelae are favorable.
5. Many of the consequences that we may seek
in an intervention are avoidances of illness. Measles
avoided because of the effectiveness of a vaccine is
of great significance to the overall survival of children,
but the individual mother may not be convinced or
even be aware of the association. Her children
survived before the injection was available; many
other children who were not inoculated also survived.
An illness avoided probably would not have occurred
anyway.
6. It is important to remember that beliefs and
attitudes are anchored in the beliefs and attitudes of
the family, neighbors and the community. Change,
if it is to occur, must take place within the matrix
of concepts and values shared by those with whom
the mother is in contact, often referred to as her
reference group. Mothers share their understanding
of the child’s survival with their extended family.
1
If mothers deviate and fail they are ostracized, but
if they conform and fail they are supported. The
social structure of primary groups functions to
discourage not only innovation but superior perform-
ance as well. Given this set of conditions, efforts
to improve survival must be aimed at a community
as a whole as well as at individual target mothers.
We need to find ways to make innovation acceptable
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Asia-Pacific Journal of Pubfic Health 1990-Vol 4 No 1
and desirable rather than risky and alienating.
7. We have had an opportunity to test some of
these ideas in field experiments in the Philippines.
We found that by reinforcing mothers for improved
practices, we were able to obtain better growth in
the second year of a child’s life, but we were not
able to eliminate the failure of good growth in the
second six months after birth.’ If, however, a
supplement was supplied consistently and used by
the mother, we were able to get growth in the second
semester that equalled that of middle class urban
children.* These were small scale, tightly controlled
experiments in which we were able to maintain
extremely high levels of compliance, virtually 100
percent in the case of the supplementing experiment.
8. There has been a great deal of concern during
the 1980s with the possibility that promotion of infant
formula would lead mothers to curtail breastfeeding.
Failure to nurse or early termination of lactation is
frequently fatal in poor families that cannot afford
adequate substitutes and cannot prepare them without
contamination by dirty water and nonsterile feeding
bottles. In our concern with this problem we followed
several hundred poor mothers from delivery for the
following year or m 0 1 - e . ~ ~There
~ was a virtual
unanimous desire to breastfeed. Infrequent failures
were due to illness of the mother or to the fact that
the mother had to return to work under circumstances
that precluded nursing. For example, they had no
way to preserve milk over the interval of the absence
from their home. Those who worked at home in
cottage industries or nearby as vendors were able to
nurse. More than fifty percent continued for at least
a year. The most frequent reason for termination
as early as six months was another pregnan~y.~
Another major cause was the belief that the mother’s
milk was no longer good if the baby developed
diarrhea. Mothers stopped abruptly with the approval
and insistence of family, friends and neighbors.
Programs to support breastfeeding in this population
must find ways to cope with the sudden decision
to stop based on beliefs about transmission of illness
and about the nutritional needs of pregnancy. In a
related experiment, we found that the distribution of
infant formula samples on maternity wards had no
effect on subsequent breastfeeding?
Improving Child Survival
In the foregoing pages we have outlined some findings
in the Philippines that have implications for a program
calculated to improve the health and viability of babies
in the rural Philippines.
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A program promoting ORT has been quite
effective. Clean water poses a problem in many
homes. This is overcome by some physicians who
urge mothers to use 7-Up, a soft drink widely available
in both urban and rural areas. Water from a coconut
is also pure, at least until it reaches utensils. Both
of these items are often more readily available than
ORS and likely to be effective in aiding survival.
The problem is not only a suitable, sterile fluid to
reduce the dehydration but the task of getting a
mother to give fluid to a baby who is seen as needing
less rather than more fluid. Watery stools are not
going to be controlled by adding water.
Breastfeeding is the overwhelming choice of
rural Philippine women. No need to preach to the
choir. But methods must be found to support
breastfeeding while mother or baby are sick or when
other reasons for stopping, valid within the shared
belief systems of the community, make their appear-
ance. This may be difficult because decisions to stop
are very abrupt. Furthermore, the decision to stop
is made without consultation with a trained health
worker. For that matter, the trained midwife, nurse
or physician, a participant also in the shared belief
system, might confirm the need to withdraw breast-
milk.
Immunizations against major killers such as
measles, tetanus and diphtheria can save many lives.
We need to find ways to overcome resistance on the
part of mothers who reason that, “He is not sick now,
but if he has an injection he will surely be sick
tomorrow.” Participation of mothers is even more
difficult to obtain when the inoculation calls for a
series of three injections over several weeks.
We have been very successful in maintaining
oral contraceptive practices with the use of
reinforcements;’0similar strategies should increase the
percentage of mothers who initiate immunizations and
raise the level of those who complete the series.
Steps in an Action Research Program
What follows is an outline of steps to be taken in
a program designed to develop improved methods
of enhancing the survival and well being of children.
This is by no means all the steps that could be taken,
rather they are steps necessary to explore methods
of changing the cognitive structure and belief sys-
tems of mothers whose conceptualization of illness
and beliefs about certain foods lead them to offer
a diet which results in stunted growth and poor
resistance to infection. They concentrate on getting
mothers to make better use of foods available or

potentially available in the community. The follow-
ing steps would be taken:
1. Measurement of growth. All children under
six in the community would be measured at regular
intervals for age, height, weight, and other indica-
tions of growth and well being.
2. Tabulation of morbidity. Recording and
tabulation of all illness during the past week.
3. Tabulation of mortality. Recording of all
deaths of tabulated children and of their siblings’
deaths past and current. Age and cause of death (as
described by informant) should be recorded.
4. Dietary analysis. Nutrient analyses of a
number of 24-hour recalls of mother’s and child’s
food intake.
5. Analysis of cognitive structure. As pointed
out earlier, mothers have theories about the nature,
cause and treatment of illnesses. All societies have
had to come to grips with illness, but they do not
share a standard nomenclature nor do they agree on
causes or treatments. In addition to the more or less
universal syndromes of headache, stomach pains, etc.,
there are folk defined or culture bound syndromes
such as piang, or dislocated bone, and bughat, a sort
of postpartum depression. People everywhere have
developed names for clusters of symptoms and hold
explanations and treatment procedures that follow
reasonably from their conceptualization of various
illnesses. If one is to educate people in a scientific
approach to illness and treatment, one must be aware
of the beliefs and practices that one may be violating
or contradicting.
There are several techniques beyond participant
observation that one can use to get a picture of
the world of growth and illness as seen by the
mother.I0 Cognitive mapping is such a procedure in
which one asks an informant to name an illness, tell
what causes it and indicate a treatment and a
prevention. One then begins again by asking for
another illness and so on. The results can be tabulated
on two-dimensional tables that generate a picture of
the ‘ group’s views of the nature, causes, treatment
and prevention of illness.
ECHO is a similar technique in which an
individual is asked for a series of illnesses--What is
a good thing to do? Who would approve? What
is a bad thing to do? Who would disapprove?
Sentence completion methods to elicit attitudes
are quite applicable in the domain of health, illness
and well being. Finally, each of these methods can
be taught readily to field workers who do not have
extensive training in social science.
6. Measurement of base rates and rates of
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Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
change. As one moves from cross-sectional descrip-
tive studies to longitudinal interventions, objective
indices of the condition one is seeking to modify
must be monitored. For example, frequency of
breastfeeding, type and amount of supplements to
breastmilk and growth of the child in height and
weight from month to month must be tabulated.
7. Introduction of reinforcement strategies. In
order to gain acceptance of innovations and espe-
cially to insure high and consistent participation, we
have made extensive use of reinforcements. A
reinforcement is simply a small reward given to a
participant to strengthen a habit or course of action
that we want a participant to follow. The reinforce-
ment is usually very small, but it is something the
participant enjoys. In our experiments’ we have given
mothers T-shirts or color prints of family members.
Doing so has resulted in almost 100 percent con-
tinuation over months and years, improved growth
rates of babies and excellent continuation rates in
family planning.
The reinforcement program meant that mothers
came to a central clinic or health center once a month
and also that our field workers saw many more
mothers per day because they did not have to go
out seeking them one by one. Reinforcements were
highly cost effective in the utilization of personnel
as well as in the compliance of mothers.
Reinforcing has been criticized as bribery. But
a bribe is a payment for an illegal or immoral deed;
improving an infant’s diet is not reprehensible. It
is also contended that mothers should be rewarded
sufficiently by the improved growth of her baby. But
growth is imperceptible from day to day and week
to week, and stunting is almost impossible to see
when the baby is developing skills at .a normal rate
and the family is surrounded by othe; families with
stunted children. Finally, the process’ of reinforce-
ment is perfectly clear to both mother and health
worker. It is effective in part because it evokes
enthusiasm from the mother and a sense of accom-
plishment both from her and the field worker.
Enhancing Childhood Survival
In a field experiment, we propoie to strengthen
by reinforcement:
1. Continuation of breastfeeding.
2. Maintaining a supply of oral rehydration solution.
3. Completion of schedule of inoculations.
4. Improving diet of toddlers with food available in
the community.
5. Utilizing foods not previously and consistently
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Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
used with children such as avocado, guava and
fish.
6. Taking special steps to enhance the diet of children
who show poor growth from month to month.
7. Utilizing proven treatments for illness in place
of or in addition to folk remedies such as massage.
The effectiveness of many of these steps can
be assessed in an experiment in which reinforcement
strategies are applied in some villages and traditional
educational steps are taken in matched control villages.
Throughout these interventions, we have the
primary purposes of changing mothers’ attitudes and
beliefs so that they take effective steps to support
the growth and well being of their children and, in
doing so, to enhance their feelings of competence.
A mother who believes that she can make a differ-
ence is less likely to attribute the misfortunes of her
child to dislocated bones, fate or sorcery.
Changing Attitudes and Beliefs
We have described the use of reinforcement to
strengthen weak behavior patterns but behavior that
the mother already accepts. We must also find
methods to get her to take steps that are contrary
to prevailing beliefs and to eliminate activities that
are prescribed by the community but are known to
be harmful to a sick child. An example of the former
would be to feed avocado, a rich source of fat and
vitamins, or vitamin rich guava when her peers believe
these fruits will cause diarrhea. Transgressing local
expectations would happen when we persuade mothers
to give ORS to a child with diarrhea instead of
withholding fluid from the child.
There is an extensive literature on attitude
change, most of it dealing with attitudes toward other
people and toward issues. Some of this literature
yields useful steps in the domain of this research.
The principle that changed attitudes follow
behavior change is important. Get people to practice
ORT and their beliefs about fluids and diarrhea will
change.
Models play an important role. Field workers
who practiced contraception themselves were vastly
more effective than those who had many children.
Similarly, field workers who are mothers and who
feed avocado will be much more persuasive than those
who simply recommend it.
Reinforce mothers who play exemplary roles by
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improved feeding, acceptance of inoculation, and
extended breastfeeding. This reinforcement can take
the form of an honor roll posted permanently in the
village and some additional reinforcement, possibly
a family portrait (more color photographs!).
Experience suggests that new behavior patterns
may not hold if reinforcement is withdrawn too soon.
For this reason, these procedures should be built into
the health service or program. It is cost efficient
when data are collected; it will continue to be so
as long as reinforcing practices are maintained. They
will be maintained if field workers are encouraged
to maintain them and receive the support they need.
References
1. Guthrie GM: Six to eighteen--The perilous months. Nu-
trition Today 1988; 23:4-ll.
2. Fernandez EL, Guthrie GM: Belief systems and breast
feeding among Filipino urban poor. Soc Sci Med 1984;
19:991-995.
3. Guthrie HA: Infants and maternal nutrition in four
Tagalog communities. In: Bello WF, de Guzman A,
eds., IPC Papers No 7. Manila: Aieneo de Manila
University, 1969; 60-91.
4. Guthrie GM, Guthrie HA: Fernandez TL, Estrera NO:
Maintenance and termination of breast feeding in rural
and urban Philippine communities. Ecol Food Nufr 1980;
10135-43.
5. Guthrie GM, Guthrie HA, Fernandez TL, Estrera NO:
Early termination of breast feeding among Philippine
urban poor. Ecol Food Nutr 1983; 12:196-202.
6. Guthrie GM, Guthrie HA, Fernandez TL, Estrera NO:
Cultural influences and reinforcement strategies. Behav
Therapy 1982; 13:624-637.
7. Fernandez TL, Estrera NO, Barba CVC, Guthrie
HA, Guthrie GM: Reinforcing mothers for improving
infants’ diets with locally available food. Phil J Nutr
1983; 36:39-48.
8. Barba CVC, Guthrie HA, Guthrie GM: Dietary inter-
vention and growth of infants and toddlers in a Philippine
rural community. Ecol Food Nufr 1982; 11:235-244.
9. Guthrie GM, Guthrie HA, Fernandez TL, Estrera NO:
Infant formula samples and breast feeding among
Philippine urban poor. Soc Sci Med 1985; 7:713-717.
10. Guthrie GM, Fernandez TL, Estrera NO. Small scale
studies and field experiments in family planning in t h e
Philippines. In1 J lnfercuM Re/ 1984; 8:391-412.