Evaluating the Impact of Nutrition and Health Programs Evaluating the Impact of Nutrition and Health Programs Edited by Robert E. Klein Pan American Health Organization/Institute of Nutrition of Central America and Panama Guatemala, Guatemala Merrill S. Read Pan American Health Organization Washington, D.C. Henry W Riecken University of Pennsylvania Philadelphia, Pennsylvania James A. Brown, Ir. u.s. Agency for International Development Washington, D.C. Alberto Pradilla Foundation for Higher Education Cali, Colombia and Carlos H Daza Pan American Health Organization Washington, D.C. PLENUM PRESS . NEW YORK AND LONDON Library of Congress Cataloging in Publication Data Pan American Health Organization International Conference on the Assessment of the Impact of Nutrition and Related Health Programs, Panama, 1977. Evaluating the impact of nutrition and health programs. Includes index. 1. Public health-Evaluation-Congresses. 2. Nutrition-Evaluation-Con- gresses. 3. Evaluation research (Social action programs)-Congresses. 4. Malnutri- tion-Latin America-Prevention-Congresses. I. Klein, Robert E. II. Pan Amer- ican Health Organization. III. Title. IV. Title: Impact evaluation. [DNLM: 1. Nutrition-Standards-Congresses. 2. Nutrition disorders-Congresses. 3. Evalua- tion studies-Congresses. 4. Public health America-Congresses. QU145 C747p 1977] RA427.P2161977 614 79-11321 ISBN 978-1-4684-3491-0 ISBN 978-1-4684-3489-7 (eBook) 001 10.1007/978-1-4684-3489-7 Based on the proceedings of the P AHO International Conference on the Assessment of the Impact of Nutrition and Related Health Programs, held in Isla Contadora, Panama, August 1-4, 1977 © 1979 Plenum Press, New York Softcover reprint of the hardcover 15t edition 1979 A Division of Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Preparation of this volume has been a joint effort of Plenum Press and the Pan American Health Organization, Regional Office of the World Health Organization. This volume also is to be published in Spanish for distribution through the Pan American Health Organiza- tion, Washington, D.C. 20037 Foreword As is noted in the opening chapter of this volume, nutrition and public health programs have been important throughout Latin America and the Caribbean for many years. This is due to the spe- cial concerns of those responsible for setting national policies, the program experience and leadership in public health developed by the national governments, and the stimulus and cooperation of the Pan American Health Organization (PARO), including its twelve associated centers which focus on research, training and program development. The need for a coordinated hemisphere-wide attack on malnu- trition and other health problems was expressed clearly in the "Ten Year Health Plan for the Americas" (1). This plan established specific targets for reducing the prevalence of the major nutri- tional diseases and other health problems for the decade 1971-1980. It was noted at that time that very few countries had formulated adequate comprehensive national food and nutrition policies and plans, nor had they developed strategies for combating the nutri- tional deficiencies known to affect large numbers of people through- out the Region. Following a review of the available data on a country by country basis in 1975, the PARO Directing Council en- dorsed recommendations for formulating the necessary national poli- cies and strategies for the intersectorial execution of food, nutri- tion and health programs (2). This report also summarized the available national data related to nutritional status, existing programs such as food fortification, and the human resources avail- able for services as well as for research and education. The nutritional problems in the Americas are varied. The most frequently encountered deficiency is protein-energy malnutri- tion (PEM). It affects the growth and health of large numbers of young children and also contributes importantly to low birth weight of infants born to inadequately nourished mothers. PEM is seen most often among the rural populations and the marginal urban vii viii FOREWORD poor in rapidly expanding cities. It is seen much less frequently in those areas and countries where health and community services have been extended to provide adequate coverage or in those areas where extremes of wealth or poverty are not great. In nearly all its forms under-nutrition is associated with higher incidence of gastroenteritis and other childhood diseases, either as a result of decreased food intake during illness or because malnutrition adversely affects the development of immunologic defense mecha- nisms. Therefore the development of appropriate national programs, and their evaluation, must be approached on a multisectorial and multi-disciplinary basis. Several of the countries in the Western Hemisphere have developed extensive national food and nutrition plans. In these countries a variety of program activities have been projected or implemented. These include food stamps or food supplements for tar- get populations, nutritional fortification of commonly eaten foods, extension of primary health care coupled with nutrition and health education, agricultural reform, and income maintenance. Information systems, (i.e., health and nutritional surveil- lance) are being implemented in several countries to determine where problems lie, what services are being delivered, and what may be the impact of national programs as they are implemented (3,4). Frequently these efforts are centered in the health minis- tries (5). However, a multisectorial approach to impact evalua- tion will obviously be required if serious attention is to be given to the well-being of the needy populations. Papers in this volume make this pOint abundantly clear. It is clear that evaluation of the impact of nutrition and health programs will become increasingly more important as co~atries throughout the world seek to provide services to meet the needs of their populations. We believe that this volume will stimulate new and innovative approaches to this end. The Pan American Health Organization wishes to express its ap- preciation to the United States Agency for International Development for financial support of the conference and preparation of this vol- ume. Hector R. Acuna Director, Pan American Health Organization FOREWORD ix REFERENCES 1. Pan American Health Organization. Ten Year HeaZth PZan for the Ameriaas. PAHO Official Document No. 118, Washington 1973 2. Organiazcion Panamericana de la Salud. PoZ!tiaas NaaionaZes de AZimentaai6n y Nutriai6n. Publ. Cientif. No. 328. Washington 1976. 3. Joint FAO/UNICEF/WHO Expert Committee. MethodoZogy of Nutri- tionaZ SurveiZZanae, Technical Report Series #593. Geneva: World Health Organization 1976. 4. Coloquio sobre Sistemas de Vigilancia Epidemiologica Nutri- cional, IV Congreso Latino Americano de Nutricion, Caracas, Venezuela, November 1976. Published in Arah. Latinoamer. Nutr. 27 (2)., Supplement, June 1977. (English translation: Pan American Health Organiza- tion 1978. In preparation). 5. Daza, C. H. and M. S. Read. Health-related Components of a Nutritional Surveillance System. Paper presented at Plenary Session of IX International Con(J!'est! on Nutrition, Rio de Janeiro, August 1978. Contents I. INTRODUCTION Rationale for the Conference and Organization of the Volume • • • • • • • • 1 Determinants of Health and Nutritional Status •••••••••• 7 John A. Daly, Joe H. Davis, and Robert L. Robertson Comments by H~ctor Correa • 34 General Discussion • • • • 35 II. APPROACHES TO IMPACT EVALUATION Recent United States Experiences in Evaluation Research with Implications for Latin America • • • • • • 39 Thomas D. Cook and Emile G. McAnany Comments by Robinson G. Hollister • 76 Special Issues for the Measurement of Program Impact in Developing Countries 99 John W. Townsend, W. Timothy Farrell, and Robert E. Klein Comments by Guillermo Herrera • 123 General Discussion for Section II • • • • 127 xi III. ASSESSING SPECIFIC OUTCOMES OF INTERVENTIONS Measurement of Health and Nutrition Effects of Large-Scale Intervention Projects 133 Jean-Pierre Habicht and William P. Butz Comments by Alberto Pradilla, L.F. Fajardo, and G. Acciarri • • • • • • • • 170 General Discussion 179 Family Composition and Structure in Relation to Nutrition and Health Programs • • • • 183 Susan C. M. Scrimshaw and Gretel H. Pelto Comments by Nelson Amaro 218 General Discussion 224 The Economic Theory of the Household and Impact Measurement of Nutrition and Related Health Programs 227 Dov Chernichovsky Comments by Sebastian Pinera 258 General Discussion • • • • 261 Educational Outcomes and Nutrition 269 Selma J. Mushkin Comments by Ernesto Pollitt • 302 General Discussion • • • • 306 IV. IMPLEMENTING AND USING EVALUATIONS Political and Organizational Issues in Assessing Health and Nutrition Interventions 309 Antonio Ugalde and Robert Emrey Comments by Adolfo Chavez • 331 Some Suggestions for Improving the Applicability and Utilization of Evaluation Assessments 339 Jerome S. Stromberg Comments by Ricardo Galan Morera 356 CONTENTS xiii V. PRACTICE AND PROBLEMS OF IMPACT EVALUATION Practice and Problems of Evaluation: A Conference Synthesis 363 Henry W. Riecken Clarification of Concepts and Terms Commonly Used in Evaluative Research • 387 Karen M. Hennigan, Brian R. Flay, and Richard A. Haag Participants 433 Index • • • • • . .'. 441