MIND OVER MATTER IN THE PHILIPPINES: PERCEPTIONS OF .
Public Disclosure AuthorizedMIND OVER MATTER IN THE PHILIPPINES:Public Disclosure AuthorizedPublic Disclosure AuthorizedDISCUSSION PAPERPublic Disclosure Authorized/A STUDY OF KEY STAKEHOLDERS'PERCEPTIONS OF CHILDHOOD STUNTINGIman SenNkosinathi MbuyaGabriel DemombynesVarun GauriJUNE 2020
MIND OVER MATTER IN THE PHILIPPINES?A Study of Key Stakeholders’ Perceptions of ChildhoodStuntingIman Sen, Nkosinathi Mbuya, Gabriel Demombynes, Varun GauriJune 2020
Health, Nutrition, and Population (HNP) Discussion PaperThis series is produced by the Health, Nutrition, and Population Global Practice of the World Bank.The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topicsto encourage discussion and debate. The findings, interpretations, and conclusions expressed inthis paper are entirely those of the author(s) and should not be attributed in any manner to theWorld Bank, to its affiliated organizations, or to members of its Board of Executive Directors orthe countries they represent. Citation and the use of material presented in this series should takeinto account this provisional character.The World Bank does not guarantee the accuracy of the data included in this work. Theboundaries, colors, denominations, and other information shown on any map in this work do notimply any judgment on the part of the World Bank concerning the legal status of any territory orthe endorsement or acceptance of such boundaries.For information regarding the HNP Discussion Paper Series, please contact the Editor, MartinLutalo at mlutalo@worldbank.org or Erika Yanick at eyanick@worldbank.org.RIGHTS AND PERMISSIONSThe material in this work is subject to copyright. Because the World Bank encouragesdissemination of its knowledge, this work may be reproduced, in whole or in part, fornoncommercial purposes as long as full attribution to this work is given.Any queries on rights and licenses, including subsidiary rights, should be addressed to WorldBank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA;fax: 202-522-2625; e-mail: pubrights@worldbank.org. 2020 The International Bank for Reconstruction and Development / The World Bank1818 H Street, NW Washington, DC 20433All rights reserved.ii
Health, Nutrition, and Population (HNP) Discussion PaperMind over Matter in the Philippines?A Study of Key Stakeholders’ Perceptions of Childhood StuntingIman Sena Nkosinathi V. N b Gabriel Demombynes c Varun Gauri daDevelopment Economics, World Bank, Washington DC, United StatesHealth, Nutrition and Population Global Practice, World Bank, Washington DC, United StatescHuman Development, World Bank, Manila, PhilippinesdPrinceton University, Princeton, United StatesbThe Government of Japan provided financial support for this work through the Japan Trust Fundfor Scaling Up NutritionAbstract: Declines in rates of child stunting in the Philippines have decelerated, making it hardfor the country to achieve its targets on nutritional outcomes. The knowledge base, beliefs, andpractices of caregivers have been extensively researched, but little is known about how healthworkers and policy makers fare in comparison. We conduct qualitative interviews, striving topreclude bias as we capture these stakeholders’ views on factors that affect stunting, and go onto compare and contrast these perceptions. We subsequently investigate the importance of thedifferent factors in detail through a large-scale quantitative survey with frontline health andnutrition workers. The findings suggest that while most workers’ knowledge and beliefs areconsistent with accepted practices, important deviations from consensus views exist, and theseare correlated with worse self-reported service delivery outcomes at local health centers. Thefindings suggest that in the Philippines any endeavor to further improve service delivery must takeinto consideration the beliefs of frontline workers.Keywords: Survey methods, Information and Knowledge, Beliefs, HealthE-mails: isen@worldbank.org, nmbuya@worldbank.org, claimer: The findings, interpretations, and conclusions expressed in the paper are entirelythose of the authors, and do not represent the views of the World Bank, its Executive Directors,or the countries they represent.Correspondence Details: Nkosinathi Mbuya, World Bank, 1818 H Street, NW, Washington,DC, USAiii
TABLE OF CONTENTSRIGHTS AND PERMISSIONS . IIACKNOWLEDGMENTS . VII.BACKGROUND . 1A.Measuring Beliefs and Mental Models . 3B.Qualitative Data Collection . 4Pre-interview Listing and Grouping Exercise . 4Focus Group Discussions . 4In-depth Interviews among Key Informants. 4Characteristics of Respondents . 5Qualitative Data Collection Sample . 5C.Limitations of the Study . 7II. FINDINGS FROM QUALITATIVE INTERVIEWS . 9Caregiver and Health Worker Beliefs about the Causes of Stunting . 9Beliefs about the Consequences of Stunting and Monitoring Growth. 14Beliefs about Weight Gain during Pregnancy . 15Beliefs about Stunting among Policy Makers. 15Discussion and Takeaways from the Qualitative Interviews . 16III. FINDINGS FROM QUANTITATIVE HEALTH WORKER SURVEYS . 18A.Knowledge levels of Barangay Nutrition Scholars and Barangay Health Workers . 18B.Beliefs about Child Height Held by Barangay Nutrition Scholars and Barangay Health Workers . 21C.Beliefs on Causes of Stunting . 22D.Interpreting Mental Models of Health Workers Through Response Patterns . 24E.How Knowledge and Beliefs Relate to Service Delivery at Local Health Centers . 26F.Profiles of Health Workers in the Philippines . 32IV. DISCUSSION . 36V. CONCLUSIONS AND RECOMMENDATIONS . 39REFERENCES . 41ANNEX . 43A1. Barangay Health Workers and Nutrition Scholars: Background. 43A2. Additional Tables and Regressions . 45A3. Reliability and Validity of Belief Indexes. 52A4. Comparison with Regional Level Stunting Rates . 53iv
ABBREVIATIONS AND NCNNSOPT-PlusPPANRHMSDGBarangay health centerBarangay (local village) health workerBarangay nutrition scholarCultural Consensus ModelingDepartment of HealthFocus group discussionHealth, Nutrition, and PopulationIn-depth interviewIron and folic acidInstitutionalizing Health Leadership and Governance ProgramIntimate partner violenceLatent class analysisLocal government unitNational Nutrition CouncilNational Nutrition SurveyOperation Timbang PlusPhilippine Plan of Action for NutritionRural health midwifeSustainable Development Goalv
ACKNOWLEDGMENTSThe report was prepared by a World Bank team comprising Nkosinathi V. N. Mbuya, Iman KaylanSen, Gabriel Demombynes, Sharon Faye Alario Piza, and Varun Gauri. The authors would like tothank the Philippine Survey and Research Center for implementation of the qualitative work,Sharon Piza for managing the implementation of the quantitative survey, and Toby Monsod forassistance with survey instrument design and analysis.The authors are grateful to the World Bank peer reviewers, Cecilia Acuin, Leslie Elder, and AnaMaria Munoz Boudet for their detailed feedback and for providing technical guidance and qualityreview of this report.The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper.vi
I.BACKGROUNDThe past 25 years have witnessed only limited progress toward substantially reduced malnutritionin the Philippines. Between 1993 and 2015, the prevalence of stunting among children under fiveyears decreased by just 5 percentage points—from 38.8 to 33.4 percent. At that rate, the countrycould wait another 80 years before it meets its 2025 target of 18.2 percent.The immediate causes of high levels of chronic malnutrition are not disputed. As the PhilippinePlan of Action for Nutrition (PPAN) states, “Poor infant and young child feeding in the first twoyears of life coupled with bouts of infection can explain high levels of stunting.” In 2015, only 48.8percent of children 0 to 5 months of age were exclusively breastfed, with rates declining from68.0 percent at the first day of life to 24.7 percent by the fifth month, and only 15.5 percent ofinfants 6 to 23 months old enjoyed a “minimum acceptable diet.” 1 The document also highlightsthe poor state of maternal nutrition—maternal nutrition and health during pregnancy are intimatelylinked to child nutrition trajectories; low birthweight is one of the most prominent risk factors forstunting—noting that “the prevalence of nutritionally-at-risk 2 women has not improved over theyears, with a rate between 24 to 26 percent since 2008” (NNC 2017).What is less clear is why high levels of suboptimal infant and young child feeding and maternalnutrition continue to persist, despite more than four decades of state-sponsored programs toaddress them directly. 3 Interestingly, income poverty is not the main reason. The PPANrecognizes that a blanket attribution of the problem to income poverty would be a simplistic view,pointing out, for instance, that while higher wealth quintiles have higher proportions of children 6to 23 months old that meet the minimum acceptable diet criteria, these numbers are still low atless than 20 percent.Global evidence suggests that effective delivery of a package of evidence-based health andnutrition interventions focused on the first 1,000 days of life can have an impact on childhoodstunting. A critical starting point is to ensure access and utilization of these interventions, whichcan be delivered by coordinated primary health care services through strong maternal and childhealth and nutrition programs. Unfortunately, in countries with a high stunting burden, includingthe Philippines, access to such services is often limited, and levels of uptake can bedisappointingly low.Several factors are known to hinder access to health and nutrition care services, and they standin the way of appropriate diagnosis and prevention of chronic childhood undernutrition. Theseinclude cultural beliefs and social norms, inadequate knowledge of signs and symptoms ofundernutrition and services available, cost of services, lack of transport options, and poor quality1. A composite measure of both the minimum feeding frequency and minimum dietary diversity for different age groups.2. The definition of “nutritionally-at-risk pregnant women” is based on an analysis of the Philippine National NutritionalSurvey results (Magbitang et al. 1988), where women were classified according to their risk of delivering a lowbirthweight baby based on the adequacy of their weight gain during pregnancy. This has been used as the standardreference for assessing weights of pregnant women in the country.3. As Briones et al. (2017) recount, the country’s pursuit of good nutrition goes back more than four decades, when in1974 the first Philippine Nutrition Program was formulated (“to coordinate the various nutrition interventions” that hadarisen since independence in 1946), followed by more systematic targeting enabled by the first National NutritionSurvey in 1978. Groups targeted at that time for improvements in nutrition outcomes—infants and preschoolers (0–6years), school children (7–14 years), pregnant women, and lactating mothers—are largely the same now, and the maininterventions/approaches adopted then—food support and assistance, health protection, nutrition information, andeducation—continue to anchor the Philippine Plan of Action for Nutrition national action plan now.1
of service. Quality of care, in particular, has been identified as the key reason for high morbidityand mortality in some countries, despite substantial increases in coverage by health services(Graham and Varghese 2012).One aspect that has not yet been fully explored is the role of the beliefs and attitudes aboutimportant markers of child undernutrition, such as stunting, held by caregivers on the one handand policy makers and frontline policy implementers on the other. Globally, there is a betterunderstanding of the importance of the beliefs and behaviors of those who care for infants andyoung children regarding child nutrition, especially in the realm of feeding practices. For example,strong notions of “good” versus “bad” foods exist for pregnant women and young children acrosscountries (Raman et al. 2016). However, there is a paucity of evidence of how the knowledge andbeliefs of caregivers on markers of undernutrition, such as stunting, may influence optimal feedingand other caregiving and health monitoring practices.Similarly, the knowledge, beliefs, and practices of health workers are important. These may haveconsiderable influence over how caregivers and their families perceive and experience health andnutritional care and consequently influence decisions to seek and access care. For instance, carethat is not framed or explained by providers in a way that leads to acceptance by caregivers andfamilies may lead to dissatisfaction with the health system. In addition, beliefs of health workerscan directly influence the quality of care and the effectiveness of efforts to promote maternal andchild health and nutrition (Mannava et al. 2015). The strength of a health worker’s beliefs willaffect whether or not there is consistent monitoring of growth, counseling on optimal infant andyoung child feeding and caring practices, or the provision of essential micronutrients such as ironand folic acid (IFA), vitamins, and zinc.From an international perspective, the quality of health workers’ knowledge about nutrition—and,by extension, their counseling skills—has been a concern (Sunguya et al. 2013). Historically,medical training has lacked adequate and updated nutrition training, and as a result, healthworkers trained at most of the medical training institutions have lacked adequate knowledge ofnutrition. Such health workers may also lack the competence and skills to provide basic nutritionadvice about nutritional care to their clients. Evidence is available on how in-service nutritiontraining has a positive impact on health workers’ nutrition knowledge, nutrition counseling skills,and management of child undernutrition. However, there is little evidence on whether healthworkers’ beliefs affect nutrition service delivery, and if so, how.In the Philippines, the beliefs of policy makers on childhood undernutrition have scarcely come tolight, even though they must be understood on account of their major impact on support forlegislation and programs promoting better nutrition. Among government officials, severalindividual cognitive biases have been documented, all of which obstruct objective and impartialdecision making. In a recent paper, Banuri, Dercon, and Gauri (2017) carefully document severalbiases among civil servants and find evidence of confirmation bias, which suggests that policymakers are likely to interpret information and favor policies in a manner consistent with theirexisting beliefs. Therefore, existing beliefs and views of policy makers with respect to health andnutrition may affect the extent of their support for nutrition programs.This paper discusses the knowledge, beliefs, and practices of health workers, caregivers, andpolicy makers with respect to undernutrition among children in the Philippines—in particular,beliefs about the root causes of stunting—using primary data collected through qualitativeinterviews. A large-scale quantitative survey is then implemented among health and nutritionworkers to delve deeper to understand the worldviews held by frontline workers and how thesebeliefs relate to service provision in local health centers in the Philippines.2
METHODS AND DATA COLLECTIONA.MEASURING BELIEFS AND MENTAL MODELSNutrition-related behaviors may be influenced by deeply internalized beliefs about how the worldworks, also known as cultural schema or mental models (DiMaggio 1997). These encompass thedefault associations, categories, concepts, identities, prototypes, stereotypes, causal narratives,and views that we use to make sense of the world. When we think, we utilize concepts that reflectthe shared beliefs and understandings of others in our community, rather than inventing theseconcepts de novo. When these concepts are reflective of an outlook shared by everyone aroundus, we tend to unquestioningly adhere to them. Thus, mental models come to shape how weinterpret the world around us and enable or constrain specific thoughts and actions—by shapingperceptions and filtering the “facts” that people believe in and are able to understand, withprofound implications for decision-making (World Bank Group 2015).To measure mental models related to stunting, we adapted and applied a method used bycognitive anthropologists, called cultural consensus modeling or CCM (Romney, Weller, andBatchelder 1986). CCM is a mixed-method technique to estimate the “culturally correct” answersto a series of belief questions, to test if there is a dominant group belief, as well as to calculateeach respondent’s degree of sharing and agreement with the group (Weller 2007).A key feature of CCM is its emic approach, meaning the adoption of the respondent’s perspective,using his or her own words to understand culture and construe meaning. The CCM methodinvolves a number of steps, as shown in Figure 2.1. The first is a free (random) listing of key termsby respondents (e.g., all possible causes of stunting). The second requires the respondents tosort these terms into broader categories. These steps are completed during one or more phasesof qualitative data collection. Subsequently, respon
MIND OVER MATTER IN THE PHILIPPINES: A STUDY OF KEY STAKEHOLDERS' PERCEPTIONS OF CHILDHOOD STUNTING. Public Disclosure Authorized / JUNE 2020 Iman Sen Nkosinathi Mbuya Gabriel Demombynes Varun Gauri Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
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