a study on malnutritional situation, some relevant factors and proposed solutions to under fives children at viet yen district - bac giang province, 2006-2008

In order to contribute to building strategies to addressmalnutrition in the poor areas in the future, we propose the study named “Malnutrition situation, related factors and solutions fo

Assessing nutrition status of children provides accurate andupdate information not only for malnutrition in children butalso for policy making process

Malnourished children usually suffer from illness and havelonger time being with the diseases Malnutrition increases therisk of suffering from diseases, especially measles andparasitological diseases Malnutrition contributes to 61% ofdiarrhoea mortality, 57% of pneumonia mortality and 45% ofmeasles mortality (Black 2005, Bryce 2007) [6], [9] In return,malnutrition is a consequence of diarrhoea and acute respitoryinfection

Malnutrition remains as a severe public health problem,particular in the poor and vulnerable areas such as Bac Giangprovince Although achieved successes in socio-economy andhealth care for community, the Bac Giang province still facedifficulties and challenges inclduing malnutrition in children

In order to contribute to building strategies to addressmalnutrition in the poor areas in the future, we propose the

study named “Malnutrition situation, related factors and solutions for children under 5 years old in Viet Yen district, Bac Giang province in 2006-2008” to assess the malnutrition

status of children in some mountainous districts, describerelationships between nutrition status and diet, and determine

relationships of nutrition status and intestinal parasitologicalinfection in children Then, the appropriate solutions will besuggested contributing to the malnutrition prevention andcontrol initiatives in Vietnam

OBJECTIVES

1 Describe malnutrition status, diet, intestinalparasitological infections and some usual infections inchildren

2 Determine relationships between malnutrition, diet andintestinal parasitological infection in children

3 Assess effectiveness of nutritional interventions inchildren under 5 years old in Viet Yen district, BacGiang province

HYPOTHESIS

Poor diets cause malnutrition, and malnutrition and nutritionalanemia are related to the intestinal parasitological infection inchildren under 5 years old

CHAPTER 1

LITERATURE REVIEW

1.1 Malnutrition in children

Consequence of hunger is malnutrition [39] Hunger affects

firstly the vulnerable subjects such as pregnant women,lactating women and preschool children These are reflected by

the anthropometric indicators [101] In field work, researchers

mainly use the anthropometric indicators including weight forage, height for age and mid-upper arm circumference toclassify the nutritional status [101], [121], [127]

Infants who were born in term with weight under 2,500g arefetal malnutrition Fetal malnutrition is the earliest malnutritioncategory In these children, organs such as skin, muscle, bone,brain, liver and kidney are affected, especially in low birthweight infants

1.2 Trend of malnutrition in the world

According to the WHO [227], the current underweight

prevalence of children under 5 years old decreases From 1975

to 1995, this figure went down from 42.6 % to 34.6%, from

1995 to present (2010) it is at 25% Decreasing malnutrition inchildren under 5 years old was recorded in all regions in theworld The decrease in Asia is higher than that of other regionsand has significant effect as the most quantity of malnutritionchildren used to distribute in the highest density of population.There is at least two third of malnutrition children residents in

Asia a half among them live in 8 countries of Southest Asia ismalnutrition either based on weight for age or weight for height

22.9 7.5 164.6

27.3 11.5 41.3

31.6 6.4 154.6

27.0 10.8 40.0

34 6.

158

28.5 8.0 24.0

24.8 5.4 88.3

n next 5 years

1975-1980 1980-1985 1985-1990 1990-1995 1995-2010 2010-2015 Decrease

1.3 Trend of malnutrition in children in Vietnam

Table 1.2 Malnutrition of children under 5 years old in Vietnam

in two national nutrition surveys [35], [42]

programs, the rapid decrease in malnutrition prevalence wasdetermined in many cross sectional studies, particularly inmajor cities However, protein energy malnutrition in children

is still a major challenge for public health in Vietnam By

1990, prevalence of malnutrition in children went downsignificantly, the pace of decrease is remarkable Although, todate, malnutrition is still at the high level, especially stuntingand the difference between geographic areas is wide [39].Additionally, subclinical vitamin A deficiency, iron anemia arechallenging which is more serious in the poor areas [43], [44]

Table 1.4 Recommendation for minerals and vitamins

In conclusion, poverty is the main reason of malnutrition andthe relationship between poverty and malnutrition iscomplicated Nutrition status is both reason and result for theincreasing income Additionally, other factors such asimbalance diet, poor practice in cooking and preparing foods,

low food hygiene and safety, limited access clean waterresources and health care services are also important.Malnutrition in children is also affected by other factors

CHAPTER 2

METHODOLOGY

The study was conducted in two stages:

- First stage: Cross-sectional study

- Second stage: Community based intervention

2.1 Subjects:

Inclusion criteria for the cross-sectional study

- Chidlren under 5 years old (0 - 59 months)

- The owners of households and parents of the childrenselected

- Living in the 03 communes selected

- Willing to particiapte in the study

2.2 Study site, time of the study:

- The study was conducted in 3 communes (Bich Son,Nghia Trung and Van Trung) Viet Yen district, Bac Giangprovince

- Time: 03 years, from 2006 to 2008

The study was conducted in Viet Yen district where is borderedwith Bac Ninh provine at the South, Hiep Hoa district at theWest, Yen Dung district at the East, Tan Yen district at theNorth

2.3 Study design

The analytical cross sectional study: determine malnutrition

in children under 5 years old according to places and time,check blood and check for worm infection

The study was implemented at the household level includinginterview the owners, parents of children under 5, andanthropometric measures for children and their parents.Simultaneously, check blood and detect for worm infection forthe children selected.

Intervention: community based intervention with case and

control groups for pre and post evaluations

After conducting the cross sectional study for nutrition statusassessment, the intervention was implemented based on theresults of the previous study in order to select the control andintervention groups

2.4 Sample size:

2.4.1 Sample size for cross sectional study

* Sample size for the nutrition status, anemia, intestinalparasitological infection study:

The number of children need for the cross sectional study was

calculated by the fomular as below [1]:

n = Z2 * p * (1-p)/ e2

Including:

n: The number of children needed

Z: level of confidence, with 95%; Z=1.96

p: prevalence of children with infection (malnutrition;anemia; or intestinal parasitological infection)

e: precision, select 5%

The number of children needed as shown in the table 2.1.

* Sample size for the dietary study:

The fomular:

t2 * 2 * N

n = -

e2 * N + t2 * 2Including:

n: sample size

t : standard unit (=2 with probability = 0,954)

: standard deviation of the estimate energy 300 Kcal e: deviation (select e=100 Kcal)

N: total children of schools (approximately 600 children/school)

Applying these values into the fomular we had thenumber of children need for the dietary survey was 58 childrenfor each commune

The total number of children for 3 communes was 174

Sampling

Select 3 communes for the study, thus the total number ofchildren for i) Nutrition status survey: 1,200 children; ii)Aneamia survey: 300 children; iii) Intestinal parasitologicalinfection survey: 300 children and iv) Diet survey: 174children

2.4.2 Sample size for intervention study:

Apply the fomular for difference of mean of observations preand post intervention [10]

N = 2s2

(d1-d2)2Including:

+ s: standard deviation of Hb concentration before andafter the intervention Reference from a study of NIN 2009, s =7,3 g/L [17]

+ α: Statistical mean, is the probability to get the errorstype 1, select α:= 0.05, coresponding to the precision is 95% + β: probability to get errors type 2, select β = 0,1 + Z(α , β ) = 10,5 (coresponding to α = 0.05 and β = 0.1).+ d1 - d2: the difference of the mean of Hbconcentration between the control and intervention groups,according to a study of NIN this was d1 - d2: = 4 g/L [17]

Therefore, the sample size needed was 70 children aged 2 - 5years old for each group Estimate 20% for lost to follow up wehad the total ò 84 children for each group

Sampling process and stratification:

After the crosss sectional study stage we conducted theintervention The process for sampling and stratification asbelow:

- Stratification: Stratification was based on the commune unit.

The study was devided into two groups:

- The control group: Children were supplemented the sugarcondensed milk

- The intervention group: Children were supplemented milkfortified by micronutrients and deworming tablet.

Before the intervention, subjects were informed the objectives,requirement, contents; and explained their enquiries if any Allcases of serious anemia (Hb<70g/dl) detected by the studywere supplemented iron tablets babsed on the MOH Guidelineand excluded to the study All cases with serious anemia duringthe 6 month duration of the study were also treated andexcluded to the study then inform to the local healthdepartment to continuing monitor

The control and intervention groups were supplied with 200 mlmilk daily, the intervention children (NNC) were supplied 4.1

mg iron, 450 IU vitamin A and 4.6 mg zinc and othermicronutrients such as group B vitamins, vitamin C anddeworming each 6 months under supervision Time forintervention was 6 months It was single blinding technique

CHAPTER 3

RESULTS

3.1 Status of malnutrition in children

Nutritional status of children

19.6

4.4 0.6

23 11.7

9.2 0

Figure 3.1 Nutrition status of children under 5 years old

Figure 3.1 shows the prevalence of malnutrition in childrenunder 5 for underweight, stunting and wasting was at severelevel based on the classification of WHO (respectively were24.6%, 34.7% and 9.2% for 3 communes)

Table 3.2 Malnutrition in children under 5 in 3 communes compared to the data of the Bac Giang province in 2007 Data 2007 Underweight Stunting Wasting

Bac Giang

(NIN-2007)

23.9(CI: 21.9-25.9)

36.2(CI: 34.3-38.1)

8.1(CI: 7.4-8.8)

3 studied

communes in

2007

24.6(CI: 21.7-27.5)

34.7(CI: 31,8-37.6)

9.2(CI: 7.9-10.5)

* Source: NIN, 2007 in the Health Statistical Year Book 2008.

The prevalence of malnutrition in children under five years old

in three communes in Viet Yen district is at severe level as that

of Bac Giang province

a) Malnutrition status of children under 5 according to communes.

Table 3.3 Malnutrition in children under 5 years old

Vân Trung commune (n=400)

Nghĩa Trung commune (n=400)

Total (n=1200)

(20.1-23.5)

27.5)

(21.9- 28.9)

(24.5- 27.5)

b) Anemia in children under 5 years old

Table 3.4 Anemia in children under 5 in 3 communes

Anemia

Places Bich Son

commune (n=100)

Van Trung commune (n=100)

Nghia Trung commune (n=100)

Total (n=300)

3.1.3 Dietary intake of children:

- Rice: is the main food, the average intake was 191.6g/child/day; the highest intake was 215.3 g/child/day Theaverage intake of other staple foods was 19 g/child/day, ofthose corn and sweet potato accounted for the highestproportion

- Rice was consumed most by the stunting children(201g/day) This level was not different between underweightand normal children

Rice intake of children aged 25-35 months was 172g/day,aged 36-59 months was 202g/day (figure 3.3)

Average of bean nuts intake was 10g/day Soy beanwhich is one of the good sources of protein with cheap price,but was not paid attention on diet for children (5.11 g/day)

- Animal food (excluding milk) intake on average was110g/child/day, which was mainly from meat(42.2g/capita/day), fish (42 g/day) and egg (15.9g/child/day)

- Milk was consumed by children aged 2-5 years old atthe level of 143.5 ml/day The protein provided 17% the totalenergy from diet and met the recommendations

- Oil and fat consumption was 3.6 g/day on average

Table 3.6: Nutritional value of diet

resources of fatty acid for growth and development ofchildren’s brain Iron intake met 59% the recommendation forthe children in cohort

Table 3.8 The average of energy intake compared to the recommendations for children 24-59 months

Contents

Age categories 24-35 months 36-59 months

at 56% and it was 87% for the children aged 36-59 months

Table 3.9 The average of energy intake compared to the recommendations for children 24-59 months calssified by

malnutrition categories Contents Underweight n = 672 Stunting n = 528

3.2 Acute respiratory infection, diarrhoea and intestinal parasitological infection in children

Table 3.19: Fever and cough of children in the last 3 months

Nghia Trung commune (n= 400)

Total (n = 1200)

The prevalence of children with fever was high There wasgreater a half (54,5%) of children in three communes withfever within the last three months.

3.2.2 Intestinal infection

There were greater than 36% of the children getting diarrhoeafor the last 3 months, which was higher than that in theNorthern areas There were 86% of the mothers taking theirchildren to health facilities for diarrhoea treatment; and 11.3%mothers treated their children at home

3.3 Risk factors of malnutrition in children

3.4 Effectiveness of the intervention.

(As the intervention was conducted in a short time, the sutdyonly assess the mean of change of the WAZ scores and HAZ-scores as below)

Table 3.26 Nutrition status before the intervention

Contents

Intervention group X ± SD (n = 81)

Control group X ±

SD (n = 162)

>0,05

p <0,05 p >0,05Average

>0,05

p <0,05 p >0,05

In the intervention group, the average of weight for age (WAZscore) was - 1,314 ± 0,887 after the intervention which wassignificant difference compared to those before theintervention (p<0,05) In the control group, the average ofweight for age (WAZ score) was- 1,676 ± 0,920, whichshowed no differencecompared to those before the intervention(p>0,05)

In the intervention group, the average height for age(HAZscore) after the intervention was -1,265 ± 0,900,significant difference compared to those before theintervention (p<0,05) In the control group, the average heightfor age (HAZscore) after the intevention was -1,734 ± 0,977,which had no difference compared to those before theintervention (p>0,05)

Table 3.29 Change of Hb before and after the intervention Contents Intervention

group X ± SD (n = 81)

11,840

± 1,282

>0,05

p <0,01 p >0,05Change of

33,574

>0,05

p <0,05 p >0,05Change of

Ferritin

15,555 ± 28,372 2,889 ± 21,880 0,001