Journal of Consumer Studies and Home Economics (1996) 21,75434 Family variables, nutrient intakes and perceived health among Malawian women CHARLOTTE A. PRATT, MARY MHANGO*, JULIA MILLER? and ISMAIL NOOR? ?Michigan State University, USA Eastern Michigan University, U.S.A., *University of Botswana and This study emphasises the inter-relationships among family variables, nutrient intake and perceived health status among Malawian women. The sample consists of rural women residing in Zomba, Malawi, southern Africa. Data were collected from April to June 1993 on (I) family cohesion and adaptability, assessed by a modified version of Olson’s FACES I I; (2) dietary intake using a modified food frequency questionnaire; and (3) a 24-item questionnaire on perceived health status, barriers to health and desired methods of communicating nutrition information in the village. The results indicated that Mala- wian rural women perceived their families as highly cohesive and adaptable. Diseases frequently identified as common in the family were not perceived as related to nutrition. Income significantly correlated with dietary adequacy. The study suggests that efforts to promote health and nutritional status should be directed at disease prevention and its ecological relationship with nutrition. Strategies for communicating nutrition informa- tion in rural Malawi are provided. Introduction Nutrition educators agree that food behaviour is the result of synergistic relationships among biological, ecological, sociological and family variables. n3 Food behaviours in African families, as well as in the families of other countries, are influenced by cultural norms. Many of these norms are developed by the family system based on inter- generational dynamics, extended family networks and dimensions of cohesion and adaptability, i.e. bonding, decision-making, power, role relationships and rules! More explicitly, an individual’s food behaviour may be influenced by factors, such as the family, health status, income, cultural values, national economy and climatic changes. Bronfenbrenner’s’ ecological model of human development further substantiates the inter-relationships among four systems - macrosystems (such as cultural beliefs and values of individuals and family); exosystem (such as society); mesosystem (such as community) and microsystems (such as peer group and family members). Bronfen- brenner5 noted that the ecosystems approach to the well-being of families relates to the interactions of the family with its environment. Ultimately, the family is the immediate context within which an individual develops, and the impact of the environment on the family greatly influences traditional family food behaviour. Correspondence: M. Mhango, University of Botswana, Private Bag 0022, Gabarone, Botswana. 0 1996 Blackwell Science Ltd 75
Transcript
Journal of Consumer Studies and Home Economics (1996) 21,75434
Family variables, nutrient intakes and perceived health among Malawian women
CHARLOTTE A. PRATT, MARY MHANGO*, JULIA MILLER? and ISMAIL NOOR? ?Michigan State University, USA
Eastern Michigan University, U.S.A., *University of Botswana and
This study emphasises the inter-relationships among family variables, nutrient intake and perceived health status among Malawian women. The sample consists of rural women residing in Zomba, Malawi, southern Africa. Data were collected from April to June 1993 on ( I ) family cohesion and adaptability, assessed by a modified version of Olson’s FACES I I ; (2) dietary intake using a modified food frequency questionnaire; and (3) a 24-item questionnaire on perceived health status, barriers to health and desired methods of communicating nutrition information in the village. The results indicated that Mala- wian rural women perceived their families as highly cohesive and adaptable. Diseases frequently identified as common in the family were not perceived as related to nutrition. Income significantly correlated with dietary adequacy. The study suggests that efforts to promote health and nutritional status should be directed at disease prevention and its ecological relationship with nutrition. Strategies for communicating nutrition informa- tion in rural Malawi are provided.
Introduction
Nutrition educators agree that food behaviour is the result of synergistic relationships among biological, ecological, sociological and family variables. n3 Food behaviours in African families, as well as in the families of other countries, are influenced by cultural norms. Many of these norms are developed by the family system based on inter- generational dynamics, extended family networks and dimensions of cohesion and adaptability, i.e. bonding, decision-making, power, role relationships and rules! More explicitly, an individual’s food behaviour may be influenced by factors, such as the family, health status, income, cultural values, national economy and climatic changes. Bronfenbrenner’s’ ecological model of human development further substantiates the inter-relationships among four systems - macrosystems (such as cultural beliefs and values of individuals and family); exosystem (such as society); mesosystem (such as community) and microsystems (such as peer group and family members). Bronfen- brenner5 noted that the ecosystems approach to the well-being of families relates to the interactions of the family with its environment. Ultimately, the family is the immediate context within which an individual develops, and the impact of the environment on the family greatly influences traditional family food behaviour.
Correspondence: M. Mhango, University of Botswana, Private Bag 0022, Gabarone, Botswana.
0 1996 Blackwell Science Ltd 75
Family variables and perceived health
Family systems theorists have identified cohesion, adaptability and communication as dimensions of behaviour critical to understanding the dynamics that exist within families. Lavee and Olson (1991)6 provide operational definitions for the former two dimensions as a basis for analysing these variables. Emotional bonding among families is defined as cohesion. It includes dimensions, such as internal boundaries, coalitions, time, space, friends, decision-making, interests and recreation, while the ability of the family system to change its power structure, role relationships and relationship rules in response to situational and developmental needs and demands is defined as ada~tabili ty.~
This research examines cohesion,adaptability, nutrient intakes and perceived health problems of Malawian women.
Malawi is a small land-locked country in southern Africa. Its population is eight million.' Fifty-two per cent of Malawi's eight million people are women, and 90% of the population live in rural areas. Malawi has a population density of 85 persons per square kilometre. Fifty per cent of the population is 15-35 years old, and 42% have had primary school education? Malawi has four seasons: January to February - the lean period when food may be scarce; March to June the preharvest to harvest period; July to September - the post-harvest period; and October to December - the planting period.
Nutrition programmes in Malawi are conducted by three ministries - agriculture, health and community services. The Ministry of Agriculture has eight agricultural development divisions. In 1979, the Malawi government established the National Food and Nutrition Programme, whose objectives were to provide agricultural development, primary health care and nutrition intervention to the public. The Ministry of Agri- culture integrates food and nutrition into agricultural training in Malawi. The Ministry of Health conducts growth monitoring, nutrition education, food supplementation and nutrition rehabilitation of malnourished children. The Ministry of Community Services emphasizes homecraft and community development?
Nutrition research in Malawi has documented growth stunting, protein energy malnutrition and deficiencies in iodine vitamin A and iron' and poor zinc status? Children and young women are mostly affected. Ounpuu (1988)'' noted that in Chi- lunga, a village in southern Malawi, 5040% of children under five years old were stunted. Nutrient intakes of children varied widely during the seasons being lowest during the lean period in January and February, and highest during the harvest season. Nutrients most likely to be low were Vitamin A, calcium and fat. Cereals contributed 52% of the energy intake and 3658% of the protein intake of children in Chilunga.
While growth stunting has been a major problem for Malawian children, a recent report" from the Food Security and Nutrition unit noted the relationship between socio- economic status and growth of preschool children in Malawi. Preschool children from affluent families residing in Blantyre, Zomba and Lilongwe (major cities in Malawi) had growth patterns similar to those of the National Center for Health Statistics (NCHS) and the World Health Organization's (WHO) international growth reference for popula- tions." Urban children from high-income families averaged four inches taller than rural children, suggesting that growth stunting may be the result of poor socioeconomic
conditions, inadequate food intake and infections that are predominant in poor rural households. Growth stunting was not a reflection of ethnic difference^.'^
Proposed conceptual framework
The conceptual framework that guided this study was derived in part from Bubolz and Sontag’s human ecological theory14 and Jelliffe and Jelliffe’s3 ecological considerations of human malnutrition. The human ecological theory is based on the premise that the family is the immediate context within which an individual develops, and the interac- tion of the family with its environment constitutes an ecosystem. The family carries out physical, biological and economic maintenance and nurturing functions for its members for the common good of society. Thus, the well-being of individuals is grounded in the well-being of the family and in the whole ecosystem. Jelliffe and Jelliffe3 take this notion further to apply it to the nutritional status of the individual and family. Thus, family interactions and well-being are grounded in the health status and nutritional adequacy of its members. Lavee and colleague^'^ noted that stressful life events, such as natural disaster and poverty, intensify intrafamily stress. It is likely that events, such as drought in Malawi, may contribute to family stress and may have a negative impact on nutrient intakes and family relationships.
The present study was conducted in Zomba, a small rural town in south-westem Malawi. The impact of family relationships on nutrient intakes and perceived health status were the focus of this study.
Method
Sample
Our subjects consisted of a convenience sample of 60 rural families residing in the village of Chikanda, which is about one kilometre from Chancellor College, a division of the University of Malawi, Zomba. We selected the village of Chikanda because of its proximity to the university and to enable students taking courses in community nutrition to conduct nutrition intervention programmes at the village level. Upon entering a household, the interviewer and researcher requested whether members of the family, often the mother with young children, would provide answers to questions on food intake and family health.
Znstruments
Our instrument consisted of three parts: (1) family interaction variables; (2) dietary intake assessment; and (3) perceived health status.
Family variables The Olson FACES 11 or family adaptability and cohesion instrument was used in a
preliminary context.16 Twenty-six items on a family cohesion and adaptability were translated into Chichewa, Malawi’s national language. The Chichewa version was reviewed by a linguist for clarity of meaning. We pretested this version on 15 rural families for clarity of questions and modified the questions accordingly. Some of the questions were rewritten to explain the meaning further and to elicit accurate responses. Because the families indicated some of the questions were repetitious, 13 questions (instead of the original 26) were used. Responses were checked by the interviewer on a five-point scale. ‘1’ indicated almost never, and ‘5’ almost always.
Dietary assessment Food intake data were collected by the food frequency method, supplemented with actual foods purchased in the local village market to aid in the recall of food consumed. We used samples of actual foods and pictures of foods to assist respondents in recalling the food they frequently consumed. Community nutrition students at the University of Malawi, Chancellor College, purchased, prepared and weighed local foods to provide estimates of foods actually consumed by the villagers. This information was used to estimate food consumed by the villagers. All foods commonly eaten in Malawi were listed on the instrument. Respondents were interviewed by a trained interviewer who was familiar with the local foods and was conversant in the local language, Chichewa. Sixty rural women responded to the food frequency questionnaire and provided information on the amount of food eaten and on the frequency (in a day or within the week) that they consumed the food. Dietary intake was analysed using the food composition table for Malawi.17The food composition table was derived from that used for Africa. Because of the difficulty in obtaining dietary intake data, we collected food intake data only on women. The type of food consumed by the women is often similar to that consumed by the family.
Perceived health The third part of the instrument assessed perceived health problems and causes of diseases, barriers to health, and respondents’ perceived methods by which educators should communicate nutrition information to rural families in Malawi. Respondents were providedwith a list of health problems common in Malawi and possible methods for communicating nutrition information. They were asked to indicate whether the pro- blems were prevalent in their families, the action they would take to prevent the problem and to indicate the perceived barriers to their health. Similarly, they were also asked to indicate their five most-desired methods for nutrition communication in the village.
Statistical analysis
Data were analysed using SPSS. A matrix of intercorrelation among the 13 statements on family adaptation and cohesion was subjected to a principal component factor analysis. Principal component factor analysis was performed to ensure that the factors were orthogonal to one another. The extraction yielded two factors with eigenvalues greater
than one and accounting for more than 50% of the total variance. Factor selection was also justified by a scree test, which Cattell'8s'9 recommended as a criterion for identifying the number of factors to retain, by the loadings of the eigenvectors and by the inter- pretability of the rotated factors. Four items loaded highly after varimax rotation on factor 1 and three items on factor 2. Factors 1 and 2 were labelled as family cohesion and family adaptability respectively. Frequencies, means and standard deviations of the mean were obtained. Dietary intake data were analysed using Quatro Pro and by SPSS. A table was constructed using the food composition table for M a 1 a ~ i . I ~ Nutrient intakes were compared with FAOlWHO standards. Mean adequacy ratio (MAR) was computed and correlated with family income, cohesion and adaptability.
Results
Demographics
About 50% of the subjects have had less than 5 years of schooling or no schooling. Eighty-seven percent of the subjects are mamed. Male spouses are the major decision- makers and heads of households. Most families have three or more children (Table 1).
Internal consistencies of the items as measured by Cronbach's coefficient alpha for family cohesion and adaptability wre 0.70 and 0.65, respectively, suggesting moderately high internal consitencies among the items. In general, Malawian families are highly cohesive, sharing family responsibilities, supporting families and discussing problems in the family with family members. Children's suggestions are not followed to a great extent. Suggestions are often sought from the elderly. Children play minor decision- making roles (Table 2).
Dietary intake
Seasonal variations in food intake are common in Malawi. Data on food intake were collected during the preharvest to harvest season. Sixty-two per cent of the families indicated they consumed meals twice a day. The frequency of food intake by children varied from two to four times per day. Energy intake of the women was adequate, providing 3784 * 387 kcal per day. The percentage kilocalories from carbohydrates, fats and proteins were 58.5%, 34.2% and 7.2% respectively. Nutrients meetings or exceeding the F A O N H O recommendations were calcium, iron, thiamin, niacin and vitamin C. Vitamin A intake was low (68% of the WHO RDA). Family cohesion and adaptability were not significantly (bO.01) correlated with mean nutrient adequacy ratios (correlation coefficient of MAR with family cohesion and family adaptability was 0.22 and 0.25 respectively). Income correlated significantly (50.3,P <0.0001) and positively with mean nutrient adequacy ratio.
Table 2. Family cohesion and adaptability
Factor score Mean SD
Family cohesion (factor 1) Ease of expression of opinions of the family 0.75 3.5 1.1 Family members support in times of difficulty 0.71 4.2 1.1 Family members share hobbies 0.69 3.1 1.2 Family members approve of friends 0.40 3.7 1.4
Family adaptability (factor 2) Family finds new ways of dealing with problems 0.75 3.4 1.2
Family discusses problems with members 0.49 3.9 1.1 Sharing family responsibilities 0.81 3.9 1.3
Table 3 presents perceived causes of diseases and percentages of respondents indicating a specific cause of the disease. The highest percentages are reported in this table. Malaria, diarrhoea, fever, whooping cough and worm infection were diseases most prevalent in the families and perceived to be the most dangerous health problems of Malawians. Most families do not know the methods for preventing worm infection, measles, anaemia, skin diseases, malnutrition and whooping cough. Families, however, indicated that, if taught, they would be confident in preventing the diseases.
Barriers to health were ranked as: (1) lack of money; (2) lack of food; (3) lack of storage facility; (4) lack of firewood; and (5) not enough time. Desired methods for nutrition education were ranked as: (1) food demonstrations; (2) use of plays and drama; (3) use of music and dancing; and (4) agricultural demonstration and pamphlets in Chichewa (Table 4).
Discussion
The results of this study indicate a positive relationship between family income and mean adequacy ratio, suggesting that efforts directed at improving income generation would lead to improved nutrient intake of women. Family cohesion and adaptability,
Table 3. Perceived causes of diseases
Disease or health problem Perceived cause of disease Percentage
Malnutrition Lack of food Do not know
Measles Do not know
Worm infection Do not know Virus
Unboiled water Anaemia
Diarrhoea
Inadequate food intake Do not know Drinking unclean water Do not know
Fever Accompanies diarrhoea Do not know
Skin disease Germs on skiddirty skin Do not know
Water-borne disease Drinking unboiled water Do not know
Table 4. Perceived baniers to health and desired method of nutrition education
Ranking Percentage
Perceived bamers to health Lack of money Lack of food Lack of storage facility Lack of firewood Not enough time
Food demonstration Use of plays and drama Use of music and dancing Agricultural demonstration Pamphlets in Chichewa
Desired method of nutrition education
67.1 50.0 29.6 29.5 19.2
43.8 21.9 17.8 15.1 13.0
on the other hand, did not correlate significantly with nutrient intake. The findings provide starting points for nutrition communication in rural areas of Malawi. Rural communication networks create ‘listening-in’ situations and encourage word-of-mouth communication. The present study suggests that strong family relationships among Malawian families could encourage such rural communication networks. Nutrition projects in Malawi may focus on the perceived health problems, such as measles, malnutrition and worm infection. While Malawian rural women do not perceive nutrition per se as playing a role in the prevention or control of the severity of diseases, nutrition education in the rural setting must emphasize the ecological relationships between diseases and nutrition.
Nutrition communication projects should enable families to share information on a continuing basis as a means of controlling the spread of inaccurate information and of emphasizing healthy dietary practices. The prevalence of word-of-mouth commu- nication in Malawi should encourage family members to communicate information with other rural community residents in traditional group settings: the town square, the chief‘s palace, the market and family and farm settings. Thus, various nutrition pro- grammes can be co-ordinated by extension agents and communicators who are familiar with the culture in the community. Communicators, community development specia- lists, homecraft workers and agricultural agents can also encourage residents to attend training sessions and rural community-wide nutrition education sessions that involve community and organizational leaders. This strategy has the potential for increasing rural community interests in nutrition issues.
To reduce the likelihood of status conflicts and to provide an atmosphere conducive to open discussions, group members should be similar on demographic variables, such as age and educational level. They should also have a common cultural background. A
common cultural background, that is, co-orientation, is also advantageous to group members because it encourages ‘group fantasy events’: playing out dramatic situations, real or fictitious, in a lively, animated and boisterous tone. Some of the dramatic situations can be based on creative interpretation of nutrition-related events by known, local volunteer actors; other situations may be based on selected group norms. For example, plays, drama and music can be used to demonstrate the problems associated with vitamin A deficiencies: night blindness, keratinization and xerophthalmia. Food demonstrations will reinforce such dramatic presentations on how to incorporate vitamin A-rich foods in the family’s diet.
Fantasy events can establish new nutritional ‘nodes’, that is, foci around which a great deal of nutrition-related information is centred.” They can also influence nutritional attitudes. The dramatization of a fantasy may be started by a communica- tion expert, assisted by a volunteer village elder and nutritionists who will subtly assume the moderator role, and later reinforced by one or two primed members of the village, using specific cultural artifacts for such dramatization.
Because nutritional habits have cultural bases, family member awareness of the social and health problems associated with poor nutrition may be achieved through dramatic productions that include the use of a litany of proverbs, folklore or tales. For example, in Malawi, emphasis could be based on prevention of diseases, such as malaria, diarrhoea and worm infection, all of which are perceived by rural families as the most important health problems.
References 1. Parraga, M.S. (1990) Determinants of food consumption. Journal of the American Dietetic
2. Gillespie, A. & Achterberg, C. (1989) Comparison of family interaction patterns related to
3. Jelliffe, D.B. & Jelliffe, E.F. (1989) Community Nutritional Assessment: with Special Reference
and zinc intakes and the calcium, phytate and zinc molar ratios of the diets of a selected group of East African children. American Journal of Clinical Nutrition, 50, 1450-1456.
10. Ounpuu, S. (1988) Seasonality, child nutrition, women’s activity patterns: a case study in Chilunga village, Malawi.
11. Food Security and Nutrition Unit, Department of Economic Planning and Development, Office of the President and Cabinet. (1991) Report on Nutrition Survey of High Income Urban Children in Malawi.
Association, 90, 662669.
food and nutrition. Journal of American Dietetic Association, 89,509-512.
to Less Technically Developed Countries. Oxford Medical Publications.
and Treatment of Families. Haworth Press, New York.
research perspectives. Developmental Psychology, 22,723-742.
12. World Health Organization. (1986) Use and interpretation of anthropometric indicators of nutritional status. Bulletin of World Organization, 64, 929.
13. Center for Social Research. (1990) The Characteristics of Nutritionally Volunerable Sub- groups within the Smallholder Sector of Malawi: A Report from the 1980/81 NSSA. Center for Social Research, University of Malawi, Zomba.
14. Bubolz, M.M. & Sontag, M.S. (1993) Human ecology theory. In Sourcebook of Family The- ories and Methods: A Contextual Approach (Ed. by P.G. Ross, W.J. Doherty, R. LasRossa, W.R. Shumrn and S.K. Steinmatz).
15. Lavee, Y. McCubbin, I.H. & Olson, H.D. (1987) The effect of stressful life events and tran- sitions on family functioning and well-being. Journal of Marriage and Family, 49, 857-873.
16. Olson, D.H., McCubbin, H.I., Barnes, H.L., Larsen, AS., Muxen, M.J. &Wilson, M.A. (1989) Families: What makes them work. Sage, Newbury Park, CA, USA.
17. Food Composition Tables for Use in Malawi. (1984) University of Malawi, Chancellor College Library and Center for Social Research, University of Malawi, Zomba, Malawi.
18. Cattell, R.B. (1965) Factor analysis: An introduction to essentials. Biometrics, 21,190-215. 19. Cattell, R.B. (1966) A scree test for the number of factors. Multivariate Behavioral Research, 1,
20. Pratt, C.A. & Pratt, C.B. (1987) A model for communicating nutrition information in sub- 245-216.
Saharan Africa. Journal of Nutrition Education, 19,55-59.
