The causal model approach to nutritional problems: an effective tool for research and action at the local level.

The causal model approach to nutritional problems: an effective tool for research and action at the local level R. Tonglet,1 Maheshe Mudosa,2 Masumbuko Badashonderana,3 1. Beghin,4 & P. Hennart5 Reported are the results of a case study from Kirotshe rural health district, Northem Kivu, Zaire, where a workshop on the causal model approach to nutrition was organized in 1987. The model has since been used in the field for research design, training of health professionals, nutrition intervention, and commu- nity development. The rationale behind this approach is reviewed, the experience accumulated from Kirotshe district is described, and the ways in which the causal model contributes to comprehensive health and nutrition care are discussed. The broad range of possible policy implications of this approach underlines its usefulness for future action. Introduction Severe nutritional problems in the Kivu highlands of Zaire have been reported and analysed since the 1950s (1-4). However, despite the implementation of coordinated health activities and the support given to community development, little progress has been made in controlling these problems, and the nutri- tional situation in the area still gives cause for con- cern (5). On taking charge of the Kirotshe health district, Northern Kivu, in 1985, we observed that many heal- th personnel were aware of the severity of the nutritional problems in the area, but did not know how to integrate nutrition into health programmes. Instead, they focused most of their efforts on growth monitoring at clinics for under-5-year-olds and expressed little concem about the selection of appro- priate actions. Growth monitoring, however, is not likely to be worthwhile unless attention is paid also to the health and nutrition interventions needed (6). 1 Project Manager, Centre Scientifique et M6dical de l'Universite de Bruxelles pour ses Activit6s de Coop6ration (CEMUBAC), and Research Associate, Ecole de Sante Publique, Universite Libre de Bruxelles, Brussels, Belgium. 2 Nutrition Technician, Zone de Sant6 Rurale de Kirotshe, Nord Kivu, Zaire. 3 Rural Development Technician, Zone de Sant6 Rurale de Kirotshe, Nord Kivu, Zaire. 4 Head, Department of Nutrition, Institut de Medecine Tropicale "Prince L6opold", Antwerp, Belgium. s Director, CEMUBAC, and Professor, Ecole de Sant6 Publique, Universit6 Libre de Bruxelles, route de Lennik, 808, B-1070 Brussels, Belgium. Requests for reprints should be sent to Pro- fessor Hennart. Reprint No. 5335 Based on this and other observations, we discovered that many health staff working in the field required a comprehensive approach to health and nutrition care. Lack of knowledge about the causes of nutritional problems, the feasibility of nutrition interventions, and the means of effective communication within the community are a major constraint in many health and nutrition programmes (7, 8). In such pro- grammes, a fundamental issue is how to design a tool that would be effective in generating and organiz- ing knowledge that can lead to action. This article advocates such a tool, which was initially developed for community nutritional assess- ment. The conceptual and methodological bases of this approach are reviewed, the experience accumu- lated in the Kirotshe health district is analysed, and the ways such an approach contributes to more com- prehensive health and nutrition programmes are dis- cussed. The causal model approach Conceptual background The causal model approach assumes that complex problems require to be dealt with in a comprehen- sive, holistic manner. In the last two decades a num- ber of global models of hunger and malnutrition have been proposed. In one of the earliest such attempts, Call & Levinson substantiated claims for a systematic approach to nutrition programmes (9). It is beyond the scope of the present article to review critically the various competing models, which al- though useful for analytical purposes, often are of limited use for planning or decision-making. The Bulletin of the World Health Organization, 70 (6): 715-723 (1992)) © World Health Organization 1992 715 R. Tonglet et al. review by Field illustrates the common failures of most attempts made to apply such models at the macrolevel (10). As discussed by Jonsson, the dis- crepancy between the level of analysis and the level of proposals for action is certainly a problem, and one which requires attention (7). In the late 1970s Pradilla et al. provided an inno- vative altemative to modelling nutritional problems using a purely pragmatic approach (11). Starting from this proposal, Beghin et al. developed and improved the method, initially focusing on nutrition (12, 13)a, b, followed by its further application to other fields such as health services utilizationc or the control of infectious diseases (14, 15). This approach has been endorsed by WHO (16) and UNICEF." A causal model is a hierarchically structured set of hypotheses on the causes or mechanisms that lead to the problem under study. Such a model attempts to provide an easily understandable analytical frame- work showing the complex relationships between all determinant factors underlying the problem. In this context, causality is suspected when a logical link between a factor and the problem of interest is iden- tified. The method applies knowledge, insight, and the field experience of a multidisciplinary panel of local experts to the problem under study and attempts to model how particular individuals achieve consensus on their situation; this consensus, however, is subject to re-examination and reformulation. The model is specific only for a given population at a given moment, and for a specific purpose. Methodology The methodology used in the causal model approach is described in ref. 16. By applying this method- ology, workshop participants, through a series of "brainstorming" sessions, can easily pinpoint the few well-defined rules that are necessary to build the model. The easiest way to start the process is to list all the factors that are relevant to the dependent a Wilson, I.M. et al. On the use of a conceptual model in the empirical research setting. Antwerp, Institute of Tropical Medi- cine, 1989 (Working Paper No. 23). b Perez, J.A. Breast-feeding and medicine: a reassessment of historical trends and Third World needs. Antwerp, Institute of Tropical Medicine, 1989 (Working Paper No. 25). c da Sliveiria, V.C. et al. Development and uses of a con- ceptual model in the study of antenatal services utilization by migrant women in Belgium. Antwerp, Institute of Tropical Medicine, 1988 (Working Paper No. 19). d Strategy for improved nutrition of children and women in developing countries. New York, UNICEF, 1990 (UNICEF Policy Review E/ICEF/1990/L.6, 9 March 1990). variable. It does not matter which factors - biologi- cal, sociological, political, economic, etc. - are included in the model, as long as the group agrees with the listing. In a further step, causal factors are linked together in either a logical sum or a logical product. Causal chains are mapped as a network of boxes that are broken down at successive levels. The technique of model building is retrospective; it relates the dependent variable to the proximate deter- minants, in a top-to-bottom approach, against the flow of causality. The mapping ignores horizontal links and feedback loops, but these are most often implicit. Repetitions of the same factor are permit- ted. Finally, the model is completed by ordering and combining causal chains into a causal framework. Results Development of the model The Kirotshe workshop on the causal model approach to nutritional problems took place in September 1987. The development of the model was the task of a multidisciplinary group of two inter- national consultants in nutrition and 24 local partici- pants (2 doctors, 3 nurses, 2 health workers, 3 nutri- tion technicians, 2 rural development technicians, 2 agronomists, 2 veterinarians, 2 farmers, 3 teachers, and 3 local politicians). Over five consecutive days, this group met in the momings for brainstorming sessions devoted to model building, and in the after- noons to collect useful additional information on topics addressed during the development process. A secretary drafted the minutes of each meeting and collected the successive developmental stages of the model. The group started with a basic model that includ- ed the following causal factors: breast-feeding, food intake, feeding practices, and the health status of the child (Fig. 1). According to this simple model, all the determinants of the nutritional status of the young Fig. 1. Schematic representation of the basic model. Nutritional status of the child Food intake Food utilization Breast milk Intake of food other Feeding Health status intake than breast milk practices of the child (See Fig. 2a) (See Fig. 2b) (See Fig. 5) WHO 92753 716 WHO Bulletin OMS. Vol 70 1992 The causal model approach to nutritional problems Fig. 2. Schematic representation of the food intake sub- model: a) breast milk intake; b) intake of food other than breast milk. her child. In African rural communities, women are often overwhelmed by their routine household tasks, and children are fully dependent on their mothers for their feeding because of the pattem of social roles. The submodel for mother's time availability (Fig. 3) emphasizes the potential benefits of time-saving interventions that can free mothers from routine tasks. The workshop participants therefore agreed with the conclusions of a previous workshop on women in poverty: for poor women in developing countries saving time is development, for time saved from humdrum tasks is time to invest in human capi- tal (17). Those participants who were involved in agri- culture and stock farming helped the group to ana- lyse the complexity of the food production submodel process, which is one of the principal factors that has a bearing on a child's food intake. A food production submodel was developed (Fig. 4), and causal chains were identified for the following factors: soil, capi- tal, techniques, and manpower. These factors were assembled in a logical sum (Who is doing what, how and where?). The nutritional status of the child appeared to be an indicator of the socioeconomic situation as a whole. The relationships between food availability, soil preservation, and demographic pres- sure were strikingly similar to those modelled by Wils et al. in their systemic analysis of the ecosys- tem of the Kivu Mountains (3). Fig. 3. Schematic representation mother's availability of time. (See Fig. 5) WHO 92755 child can be divided into two categories those that influence the intake of food by the child, and those that influence the child's utilization of the food; in tum, factors that affect food intake can be divided into two categories, etc. From this, the group built a series of submodels to elaborate on and provide further details about each factor under scrutiny. Examples that illustrate the development of these submodels are discussed below. The food intake submodel (Fig. 2) highlights the crucial importance of the mother's time availability as a factor that determines the nutritional status of WHO Bulletin OMS. Vol 70 1992 of the submodel for 717 R. Tonglet et al. Fig. 4. Schematic representation of the submodel for food production. Food production Capital L Techniques Manpower It Availability Quality of soils of soils Demographic Migrations Family Protection pressure size against erosion WH2-O92757 Cropping Famer's Appropriate and education technology farming patterns The submodel for child health status (Fig. 5) calls for particular attention. Although the partici- pants were familiar with the distinction between health problems (needs), care-oriented behaviour (demand), and availability of health services (sup- ply), it became clear to them that needs, demand, and supply are never matched; implementation of health services is not automatically followed by increased attendance at health centres or by direct improve- ment of health status. The participants concluded that it was more accurate to make a distinction be- tween "the possibility of using services" and "the decision to use services". Such a conclusion was drawn also by da Silveiria et al.,e and Mosley & Chen support this view in advocating the inclusion of personal illness control in any analytical frame- work of health problems (18). This part of the exer- cise stressed the need, in assessing health status, to combine sociological and anthropological methods with commonly used epidemiological approaches (19, 20). Uses of the model Since September 1987 the causal model has been successfully used for research design, education of e See footnote c, p. 716. health professionals, nutrition intervention, and com- munity development. Research design. Applied research, mainly on risk assessment in young children and on the health impact evaluation of the health programme, occupies a substantial part of the health and development ac- tivities in the Kirotshe district. The research agenda is planned by the health district authorities, with the collaboration of several funding agencies. In designing a 1-year follow-up study that focus- ed on the morbidity risk associated with the nutri- tional status of young children, we found that the cau- sal model was extremely helpful for improving data collection. For example, the submodel for mother's availability of time (Fig. 3) stressed the need for accurate identification of a child's effective caretaker during the recall period. By including in the follow- up forn a set of appropriate questions, we were able to calculate the potential risk of ill health associated with defective child care. In focusing on the distinc- tion between the possibility and willingness to use health services, the submodel for child health status (Fig. 5) emphasized the usefulness of careful investi- gation of attitudes towards health care and services. Although social scientists have underlined this key question for some time (21, 22), its crucial importan- ce for daily work in Kirotshe only became apparent after the workshop on the causal model approach. Therefore, in the follow-up form, we made a clear- cut distinction between a subject's and an observer's point of view. For example, a mother may consider Fig. 5. Schematic representation of the submodel for child health status. Health status of the child Personal Ill health Psychological illness control status Illness control Use of health Personal Environmental at the familial services factors factors level Possibility to Decision to Hygiene use health use health services services Availability Acceptability Professional Quality of of health of health ability of health health services services personnel services WHO 92758 718 WHO Bulletin OMS. Vol 70 1992 The causal model approach to nutritional problems that her child does or does not need care, and an observer may or may not agree with her. Indepen- dently of these viewpoints, the mother may express her intention to attend the health centre or not, and may subsequently make a decision that is or is not consistent with her expressed intention. Reported and observed attitudes require to be assessed separ- ately and should be tested for consistency. The causal model also proved useful for analy- sing data on 1096 under-5-year-olds collected during a 1-year follow-up study of the health impact evalua- tion of a water supply programme in Kirotshe (23). The analysis was carried out in keeping with the child health status submodel (Fig. 5) and the need to identify the users and non-users of facilities. Those people who were able to attend public taps had to decide whether or not to use them. No significant association was observed between the incidence of diarrhoea and the use of a water supply facility when this was assessed using subjective information (e.g., Do you use the tap? or Where are you drawing water from?). Many individuals could have claimed falla- ciously that they were public tap users because of the social value attributed to "good" answers. However, very significant associations were observed between the incidence of diarrhoea and the use of public taps when such use was determined through objective water-related variables (the quantity of water drawn per household per day or the distance from the household to the tap). Causal factors previously identified in the workshop (i.e., "the possibility of using" and the "decision to use") therefore proved to be useful in a completely different context. Education of health professionals. Many paramedi- cal students undergo 3 months of practical training in Kirotshe and are requested to submit a working paper at the end of this period. In this context, the causal model proved to be an effective pedagogic tool. Students were told to focus less on the scholas- tic aspect of the exercise and concentrate instead on the causal submodel most appropriate to the problem they had chosen. Each student then collected obser- vational data on a set of households, and tried to refine the construction of the submodel. They were not asked to make any innovative contributions, but rather to try to fornulate and address rel- evant questions and to enrich their own understand- ing of health problems. One of the students, for example, concentrated on breast-feeding practices and improved the exist- ing submodel by noting that breast-feeding was affected by seasonal variations in the availability of food. This observation is in accordance with pre- vious studies by Vis et al. in the Kivu area (24, 25) and with a causal model of breast-feeding proposed by Perez! Another student tried to assess the differ- ences in the feeding practices of children of two eth- nic groups in the district. The Banyarwanda ethnic group from the Mitumba mountains, who live mainly on stock farming, almost never ate meat, but had a balanced diet of cereals, vegetales and tubers; the Bahunde ethnic group, on the other hand, who prac- tise agriculture along the Kivu lakeshore, purchased more meat but lived on a diet of cassava flour. These observations provided the link between the produc- tion and consumption of food: food habits. A third student, who focused on the relationships between health status and health services utilization discov- ered that the children who were more frequently ill were those who made least use of the health centres; these children also had the poorest social conditions. This highlighted the social stratification that exists even in an apparently homogeneous poor rural com- munity and prompted the following question: How can we improve the accessibility and the acceptability of the health services for the poorest (26)? Using the causal model as a framework for col- lecting and connecting observational data, the stu- dents therefore succeeded in rediscovering by them- selves causal factors and causal chains that had previously been identified in a different setting. The students learned in an interesting and stimulating way how the formulation of a conceptual model was effective in organizing knowledge and initiating a fruitful education process. Nutrition intervention. Many health professionals who operate at the local level are convinced that taking care of a malnourished child only requires the provision of extra food. Considering that this approach was inappropriate and inadequate in the context of the rural health district of Kirotshe, we tested an alternative strategy. Initially we concentra- ted on the feeding practices causal submodel, which identifies the following common characteristics of the usual children's diet in the Lake Kivu highlands: insufficient number of meals (1 or 2 per day); dull cassava flour diet; and fairly low consumption of grains (maize, sorghum) or legumes (beans, ground- nuts), which are the major source of proteins. We therefore planned a new strategy, based on a proposal made previously by Beghin & Van Lerberghe (27). In January 1989, 23 malnourished children from the village of Kirotshe-Mushindi (1475 inhabitants, medical census of 1987) were identified. All were suffering from clinical malnutrition and exhibited growth retardation, oedema, hair loss or depigmenta- tion, and skin changes. The following proposal was f See footnote b, p. 716. WHO Bulletin OMS. Vol 70 1992 719 R. Tonglet et al. made: in return for providing the mothers with daily medical supervision and nutritional counselling for 13 weeks, they were asked to attend, in groups, daily educational sessions at the local clinic. During the first week the children received, if necessary, anti- malarial and antihelmintic drugs and iron and folic acid supplements. The nutritional counselling focu- sed on convincing the mothers to feed their children at least three times a day with balanced meals con- taining tuber flour, grains, and legumes. In addi- tion, regular home visits were made to their house- holds. No extra food was given or purchased. As a result, the intervention was almost restricted to social support and "homing-in" (28), both of which are time-consuming but inexpensive. The mothers attended the sessions regularly and better feeding practices resulted. All 23 children gained weight and height, and their growth curves improved dramatically. Oedema disappeared after 2-4 weeks, and the children rapidly became more active and cheerful; all but one were clinically healthy after 10 weeks (R. Tonglet et al., unpublished data, 1989). Community development. The workshop stimulated participants to generate initiatives for community development. For example, one participant started an interesting development process in his own village in collaboration with the local health and development committee. The district health authorities and the vil- lage population had together built a small maternity ward near the health centre, but a large field remain- ed vacant near the building. Encouraged by the local rural development technician who previously had attended the Kirotshe workshop, the committee decided to grow soya beans, which were then made available on the local market. The first crop was plentiful and the committee brought it to the vil- lage's mill; however, because milling is expensive the villagers could not afford to buy the flour. The committee then decided to buy its own mill. A cooperative store was established, funds were raised from its members, the U.S. Peace Corps provided the mill, and the committee was finally able to grind its own grain. After a 2-year follow-up study, we observ- ed that most of the village women enriched the usual weaning porridge with soya bean flour, and also made biscuits from maize, sorghum, and soya bean flour; the feeding patterns were slowly changing. Encouraged by these results, the committee is now trying to popularize improved chicken and rabbit production in the village. Discussion At a meeting on child mortality held in Antwerp, Belgium, in 1985, Palloni underlined that causative research is flooded by theories and mathematical models but is short on conceptual models (29). Futhermore, Beghin stated that to explain better a phenomenon and the mechanisms leading to it, the following are needed: a theory; a conceptual frame- work or a causal model - preferably derived from the theory but not verifiable in itself; and a statistical or epidemiological model consisting of a set of test- able hypotheses (30). These objectives are rarely if ever achieved. Moreover, the lack of an appropriate analytical approach often results in ineffective interventions. The factors and processes that affect or underlie the health of the community, such as those that deter- mine nutritional status, are usually complex. Health professionals working in the field are not always taught how to analyse and solve complex issues. This deficiency in the training of health personnel, lack of knowledge about causes, poor ability to inter- vene, and limited ability to communicate within the community, are probably among the common reasons for the failures observed when the impact of health and nutrition care is evaluated. To correct this situation, health personnel need a method that assists them to clarify complex situa- tions and to bridge the gap between analysis and intervention. Based on our experience in Kirotshe, building a causal model may be one of the most cost- effective methods for assessing health problems, identifying objectives for action, and evaluating health interventions. At the Kirotshe workshop, the participants reached consensus over a structured set of causal factors and causal chains, which were postulated to be the major determinants of the nutritional status of young children in the health district. The resulting causal model is not theoretical, but rather a practical, conventional representation of the complex situation in the study area. Unlike models that are intended to be used in many different situations, our model in its present form is suitable only for local application; also, it is not a general model for malnutrition nor does it provide an etiological explanation of the natural course of malnutrition. Instead, it is a com- prehensive set of causal hypotheses that reduces the chance of omitting relevant determinants and poten- tial confounders. Futhermore, it is not a substitute for epidemiological models, and makes no use of statis- tics, although it facilitates better-designed data col- lection and analysis; it makes explicit hypotheses likely not to be evident and facilitates communica- tion between individuals from different disciplines. It could be asked, however, whether these causal hypotheses could not have been formulated as well as without the need to construct a formal model. Prob- ably they could, but certainly not in the local context of Kirotshe. WHO Bulletin OMS. Vol 70 1992720 The causal model approach to nutritional problems The model leads to better understanding among health professionals of the causal factors and causal chains that affect nutritional status and provides them with a framework for determining the pro- cesses whereby this status is influenced by pro- grammes and policies. Therefore, the model is of value for research purposes and for community development and is consistent with current methods used in development planning; for example, target-oriented programme planning (TOPP). TOPP, however, is more than an approach: rather, it is a general and detailed planning method that con- siders causes and ranks objectives. The causal model adopted in Kirotshe is more empirical, opening up a wide range of unexpected initiatives, and stimu- lating investments in health and development. The place of the causal model approach in the process of generating knowledge is still a matter of debate. However, its scientific and operational merits are evident for professionals in the field. The model bases its legitimacy on the classic paradigm of exper- imental science: first construct a hypothesis, then derive from it a model that is a simplified representa- tion of the reality, and finally test the goodness-of-fit of the model and its validity. In addition, we believe that it also satisfies the following basic criteria of action-research, as defined by Susman & Evered (31): it is future-oriented and has close affinities with the planning process; it is collaborative; it implies system development; it generates theory grounded in action; it is subject to re-examination and reformula- tion; and it is situational, i.e., can change with the setting. With these criteria action-research can also be viewed as a cyclical process of identifying a prob- lem, selecting courses of action, evaluating interven- tions, and specifying leaming from action to reassess the original problem. As a result of the Kirotshe workshop, various individuals in the district were involved in such a cyclical process. With a fairly low investment - mainly human resources - we established, surprisingly successfully, the utility and feasibility of a complex process of organizing knowledge, generating new hypotheses, and iden- tifying appropriate interventions. In addition, the Kirotshe experience seems to be the first example of the sustained use of the causal model approach over a period of years in the same setting. 9 [Target-orientated programme planning]. Eschborn, German Agency for Technical Cooperation, 1987 (in German). Acknowledgements The Kirotshe workshop was funded by the Centre Scienti- fique et Medical de l'Universit6 de Bruxelles pour ses Acti- vites de Coop6ration (CEMUBAC), a non profit organiza- tion for cooperation in development. We thank Dr G. Stott for his useful editorial assist- ance. Resume L'approche causale en nutrition: un outil utile pour la recherche et l'action au niveau local Dans les pays en d6veloppement ou les pro- blemes nutritionnels sont extremement preoccu- pants, les professionnels de la sant6 eprouvent tres souvent des difficultes a organiser des soins de sante et de nutrition int6gres; 1'exp6rience a montr6 qu'ils m6connaissent les causes des pro- blemes nutritionnels, sous-estiment les possibilit6s effectives d'intervention et n6gligent les moyens d'am6liorer la communication au sein de la com- munaut6 pour promouvoir de bonnes conditions alimentaires et nutritionnelles. Dans ce contexte, il est n6cessaire de pouvoir mettre a leur disposition un outil qui les aide a recueillir et organiser les connaissances indispensables a I'action. L'appro- che causale, propos6e par l'OMS en 1988, nous semble adapt6e a cet objectif. L'approche causale est fond6e sur la convic- tion qu'il est n6cessaire de gerer les problemes complexes d'une maniere globale et qu'une bonne compr6hension des causes et des m6canismes de ces problemes est un prealable indispensable a toute decision. La construction d'un modele cau- sal hypoth6tique, applicable a une situation don- n6e, est au cceur de cette m6thode. Le terme "modele" est employe ici au sens d'une represen- tation simplifiee d'un systeme ou d'un processus. Le modele est appel6 "causal" car il pr6sente un jeu d'hypotheses logiques mettant en relation de maniere hierarchique les diff6rents facteurs d6ter- minants du probleme etudi6. La methode fait appel aux connaissances, aux intuitions et a l'experience d'une equipe pluridisciplinaire d'experts locaux, qui s'efforcent de clarifier leur perception collective du probleme 6tudie, dans un contexte particulier et a un moment donn6. La construction d'un modele causal passe par a) I'identification de tous les facteurs biologiques, sociologiques, politiques, economiques ou autres, qui permettent de formuler des hypotheses cau- sales quant a la genese du probleme 6tudi6, b) le rep6rage des liens logiques qui unissent ces fac- WHO Bulletin OMS. Vol 701992 721 R. Tonglet et al. teurs entre eux et a la variable dependante, et c) I'organisation et la combinaison de ces chaines causales au sein d'un schema conceptuel mate- rialise par un graphique simplifie. Le modele d6fini au terme de cet exercice n'a rien de d6finitif. Les hypotheses causales seront verifiees ou non; de nouvelles hypotheses pourront etre formulees et enrichir le cadre analytique initial; les resultats de l'analyse causale devront etre adapt6s en fonction des modifications du contexte de depart. En septembre 1987, la zone de sant6 rurale de Kirotshe (Nord-Kivu, Zaire) a organis6 un ate- lier afin de proceder a l'analyse causale des pro- blemes nutritionnels du jeune enfant dans la r6gion. Ce s6minaire, qui a r6uni 26 experts locaux pendant une semaine, a permis d'identifier les sources d'information disponibles, d'elaborer une repr6sentation simple et facile a communi- quer de la realit6 complexe des problemes nutri- tionnels de la region, et de s6lectionner les fac- teurs qui se pretent a une intervention. Au terme de cette analyse, la zone de sante de Kirotshe disposait d'un outil de travail qui, depuis lors et de maniere continue, est apparu extremement utile pour a) am6liorer la collecte et le traitement des donnees dans le cadre de la recherche appliqu6e, b) contribuer a la formation du personnel de sant6, c) planifier des interven- tions nutritionnelles pertinentes au niveau local et d) encourager de nouvelles initiatives en faveur du d6veloppement communautaire. L'exp6rience acquise a Kirotshe demontre que la m6thode pro- pos6e cr6e des conditions susceptibles de dyna- miser un programme de sante et de nutrition et de mobiliser ses diff6rents partenaires. 11 serait utile de soumettre I'analyse causale a la critique 6pist6mologique, mais il suffit ici de constater que cette methode est manifestement fond6e sur le paradigme classique de la science experimentale: d'abord formuler une hypothese, ensuite batir un modele et donc proposer une repr6sentation simplifiee de la realit6, enfin cher- cher a v6rifier la validit6 du modele et son ade- quation a la realite. II n'est donc guere etonnant de voir des professionnels de sante constater, de maniere tout a fait empirique, la valeur scientifique et op6rationnelle de l'approche causale, sur le ter- rain. Un modele causal, en effet, n'est pas un 6chafaudage theorique ayant une valeur univer- selle, mais la repr6sentation conventionnelle et pratique d'une realite locale. L'analyse causale ne se substitue pas aux modeles 6pid6miologiques et ne fait pas usage de techniques statistiques, mais elle permet d'identifier de maniere exhaustive les facteurs determinants du probleme etudi6 et de clarifier des hypotheses qui souvent sont impli- cites mais dissimulees aux yeux des operateurs, sur le terrain. L'approche causale, en outre, initie un processus cyclique qui debute avec l'identifica- tion d'un probleme, se poursuit avec l'analyse de celui-ci et s'oriente ensuite vers la planification et l'evaluation d'interventions pertinentes. L'experien- ce de Kirotshe confirme le bien-fond6 des hypo- theses conceptuelles et methodologiques a la base de cette methode et illustre a quel point l'approche causale est un outil utile pour la recherche-action au niveau local. References 1. Vis, H.L. General and specific patterns of marasmic kwashiorkor in the Kivu area. In: McCance, R.A. & Widowson, E.M., ed. Caloric deficiencies and pro- tein deficiencies. 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