assessing the effectiveness of nutrition education for mothers to reduce malnutrition for children under 24 months of age in soc son district, ha noi

To describe status of malnourished children under 24 months of age and mothers’ knowledge and practices on child malnutrition control at six communes in Soc Son district 2010.. To assess

1 The urgency of thesis

Protein - Energy Malnutrition (PEM) in Vietnam often calledmalnutrition Malnutrition in general and stunting in particular is still

a public health significant problem in developing countries, includingVietnam According to the 2000 report of the Standing Committee onNutrition of the United Nations and Research Institute for theInternational Food Policy (ACC/SCN/ IFPRI), about 30 millionnewborns affected by the consequences of fetal malnutrition andabout 185 million children <5 years of age (34%) were stunting in thedeveloping countries; In 2005, still about 178 million children <5years of age (32%) were stunted in developing countries

In Vietnam, underweight rate of children under 5 years of agedecreased relatively rapidly and continuously from 1985 to 2000,while stunting rate still high, especially in poor areas, overweight,obesity and a number of non-communicable chronic diseasesassociated with nutrition increased In Hanoi, underweight rate wasdecreased rapidly from a low level (18.7% in 2001) to a very lowlevel (8.6% in 2011), while stunting was not decreased but increased(15.6% in 2001, 17.8% in 2011) Soc Son is a poor suburban district

of Ha Noi, with the high rate of malnutrition (stunting was 25% in2007) due to many reasons such as low maternal educational level,nutrition limited knowledge and practice Therefore, manyintervention programs have been implemented, of which animportant solution is to build and deploy a pilot intervention by onlyactive education and communication In this context, the study

namely “Assessing the effectiveness of nutrition education for mothers to reduce malnutrition for children under 24 months of age in Soc Son District, Ha Noi” has been conducted.

Study objectives:

1 To describe status of malnourished children under 24 months of age and mothers’ knowledge and practices on child malnutrition control at six communes in Soc Son district (2010).

2 To assess the effectiveness of interventions to improve knowledge and practices of mothers on child malnutrition control at 3 communes in Soc Son district (2010-2011).

2 New scientific and practical contributions of the thesis

2.1 With the designed cross-sectional descriptive study on a largeenough sample size, updated technical and analysis of collected dataapplication in phase 1, the study has identified the malnutrition rate

of children under 24 months of age in 6 communes of Soc Son Hanoi

in 2010: underweight was at very low level classified by the WHO,7.8 %, stunting at low level, 19.1% and wasting 3,9 %, all of theseare lower than national average At the same time, it has specifiedthat right in a suburb of Hanoi, the knowledge; practices for childmalnutrition control, diet diversification, care of sick children,personal hygiene of mothers with children under 24 months of agewere still very limited This may be considered the new findingsabout realities and the causes of child malnutrition in Soc Son

2 In phase 2, the early long-term (12 months) intervention by onlyactive education and communication has had plausible conclusionsand recommendations which very useful for child malnutrition

control programs These are the new scientific and practicalcontributions to the specializations of Social hygiene and healthorganization, and Community Nutrition.

3 Layout of the thesis

The dissertation consists of 131 pages (excluding references andappendices), with the following parts and chapters:

Chapter 1 Overview: 36 pages

Chapter 2 Subjects and Methods: 26 pages

Chapter 3 The findings: 29 pages

Chapter 4 Discussion: 35 pages

125 dissertation reference materials, including 62 Vietnamese and 63 documents in English.

Chapter 1 OVERVIEW

1.1 Nutritional status and child malnutrition

Protein - Energy Malnutrition (PEM) includes 3 forms: underweight,stunting and wasting of different levels, mild, moderate and severe.According to WHO 2005, 32.5% of children under 5 years of age indeveloping countries are stunted, the 2 highest prevalence areas wereAfrica and Asia (33.8% and 29.9%) From 1980 to 2000, theestimated number of stunted children was reduced by approximately6.2 million According to WHO and The Lancet January 2008, some40% of countries have stunting rates higher than 40% Problem isthat the stunting rate was highest in the lowest quintile population InVietnam, the prevalence of underweight from 51% in 1985, dropped

to 33.8% in 2000, fell sharply to 19.9% in 2008 Wasting was 8.6%

in 2000; fell below 5% in 2008 Stunting decreased from 56.5% in

1990 to 36.5% in 2000 and remained high at 29.3% in 2010 and there

is a big difference between regions

Figure 1.6 Vietnam malnutrition rates among under five

children 2000 – 2013

Figure 1.6 showed the rate of child malnutrition 2000 - 2013.

Immediate causes of malnutrition are identified includinginappropriate eating and disease Underlying causes includeshousehold food insecurity, inadequacy of maternal and child careservices, knowledge of caregivers, family care, water supply andsanitation and unsanitary housing conditions The basic causes ofmalnutrition is defined political structure, socio-economic andcultural factors, potential resources (environment, technology,humans), including poverty, backwardness, underdevelopment,including economic inequality, especially economic crisis

Malnutrition has been found leading to obvious heavy consequences

on the child intellectual development, behavior, learning ability,height stature, and work capacity of adulthood, chronic diseases andinfluencing to the next generation

1.2 The solutions for malnutrition control

Global focus on 3 main solutions: 1) Increased nutrients intake (bothquality and quantity), including protein and energy supplements forpregnant women, strategies to encourage breastfeeding, qualityimprovement of complementary foods; 2) Supplementation ofmicronutrients, including iron, folic acid, vitamin A, calcium forpregnant women; Iodized salt supplements, vitamin A and zinc forinfants; 3) Reducing the burden of disease

In Vietnam, malnutrition prevention measures have beenimplemented during war time, but the effect was very limited Fromthe last decade of the XX century to the present, Vietnam hasdeveloped and deployed the National Target Program for Protein

Energy Malnutrition control since 1994, Program for micronutrientdeficiency control, the National Plan of Action for Nutrition 1995-

2000, National strategy for Nutrition 2001-2010 and Nationalstrategy for Nutrition 2011-2020 with a vision to 2030 Nutritioneducation and communications has always been regarded as a keysolution through the programs’ plans and strategies’ framework.However, the activity found to be heavily on the put-forms ormovements, just in some kinds of campaign, but not really thepractical operation, resulting in low effectiveness and lack ofsustainability

1.3 Education and communication research for malnutrition control

Many studies to change knowledge, attitudes and practices (KAP) forcontrol of micronutrient deficiencies and malnutrition have beendeployed in the region, in the world and in Vietnam However, most

of these studies were coordinated with food or micronutrientssupplements The idea of our study is based on the theoretical andpractical basis: active nutrition education and communication canchange the mothers’ nutrition and child care habits, then the childrenwill get improved diets, indirectly reduce the rate of childmalnutrition; At the same time, the mothers ‘nutrition habit/ practicechanges affect themselves before and during the subsequentpregnancy to actively prevent fetal malnutrition and low birth weight

Chapter 2 SUBJECTS AND METHODOLOGIES

2.1 Subject, location and time bound of the study

The research was conducted on mothers and children under 24months of age in 6 communes of Soc Son, Hanoi from 1/2010 -30/4/2011

2.2 Research methodologies

2.2.1 Study Design: The study consists of two phases

Phase 1: Cross-sectional study; Phase 2: Pre and post communityintervention controlled trial

2.2.2 Sample sizes and sampling

* Sample sizes and sampling in cross-sectional study: Applying theformula:

p (1 - p)

n = Z 2(1/2) x DE

d2 Among them: n: sample size under investigation; p: Rate of stunting

as a result of the 2007 survey in Soc Son, 25%; p=0.25 and p=0.75; d: acceptable level of error=0.05; with threshold probability5% => z1- /2 = 1,96; DE: Design Effect=2 Calculated sample sizewas 586 Added contingency of 5% (29), the total number of childrenwas 615 Systematic random selection of children <24 months of age.All mothers of those selected children were selected for interview.Total sample size was 600 mother-child pairs

q=1-* Sample size and sampling in community intervention trial:

Applying WHO 1998 formula:

_

 Z1-/22pq + Z1-p1q1 + p2q2 2

N = p1 - p22

-Where, n: number of selected mothers; Z1-/2: reliabilitycoefficient, at =5%, than Z1-/2 = 1,96 and Z1- with =10%; + P:average rate of 2 populations; p1: estimated proportion of motherswith proper nutrition knowledge and behavior at the research end,estimated p1=0.45 (45%) and q1 = 1-p1=0.55 (55%); p2: proportion

of mothers with children <24 months of age and proper nutritionknowledge and behavior in control group, estimated p2=0.30 (30%),and q2= 1-p2=0.70 (70 %) Calculated n=217 Plus contingency of20% (43) =260/each group, the sample size is 260

2.2.3 Methods of data collection

Interviews mother based on KPC questionnaire, complementquestionnaire and nutrition anthropometric method for infants <24months of age

2.2.4 Data processing and analysis

Data are checked, cleaned and processed with SPSS 10.5 andEpi Info 6.0

2.2.5 Research Ethics

Subjects committed voluntarily to participate with thefamily’ and local authority’ agreement, and had the right to give up.The subjects’ identified information is encrypted and data used onlyfor research purposes

Chapter 3 THE FINDINGS

3.1 Actual nutrition status of children under 24 months old and mothers’ nutrition knowledge and practices

Table 3.1 The percentage of malnourished children <24 months

of age in 6 selected communes Under

nutrition

forms

At 3 intervention projected commune (n=309)

At 3 control projected commune (n=309)

Table 3.1 shows the prevalence of underweight, stunting and wasting

of children under 2 years of age in 6 studied communes 7.8%, 19.1%and 3,9%, respectively, which did not differ between intervention andcontrol expected communes

Inappropriate dietary intakes Diseases

Figure 3.2 Mothers’ knowledge about the causes of child

malnutrition

The rates of mothers, who know the right contents of breastfeeding,are rather low, ranging from 25.8% to 39.3%.

0 20 40 60 80 100

Continue to breasfeed and giving food

O resol, water with salt and sugar supplementation

Figure 3.3 Mothers’ knowledge on the child's diet when the child

get diarrhea (n=600)

The rates of mothers, who know that when the child gets diarrhea,breastfeeding should be continued accounted for only 52.7%,additional mixed salt – sugar water given 79.2%

Table 3.8 Mothers’ knowledge on diet diversification (n=600)

Children need to have a variety of foods 559 93,2The nutritional value of food animals 586 97,7The nutritional value of animal organs 593 98,8The effects of vegetable, fruit and dark green 269 44,8The effects of vegetable, fruit yellow, red 315 52,5

The rates of mothers who know that the children need to eat a variety

of foods, animal foods and edible oils / fats accounted for more than90%, while those to know nutritive values of some vegetables andfruits accounted for 50% only

* The study results show mothers’ practices on breastfeeding,complementary feeding, personal hygiene and sick child care found

to be inadequate

* Actual nutrition knowledge and practices of mothers:

Table 3.20 Mothers’ knowledge and practice score on the child

on child malnutrition control reached only 40.1±12.1, ranking asaverage level

Table 3.21 Mothers’ knowledge and practice scores on the

diversified meals

Knowledge score (X±SD) 25,15  10,3

Practice score (X±SD) 45,3 ± 12,6

Table 3.21 shows both the knowledge and practice scores of mothers

on diversified meals and supplementary food preparation is very low,only 25.1510.3 and 45.3±12.6

3.2 Intervention effects in changing mothers’ knowledge and practices after 12 months

3.2.1 Intervention effects to change mothers’ knowledge, practices

on child malnutrition control

Figure 3.5 The percentage of women who know how to recognize

malnutrition

After 12 months of intervention, maternal knowledge about how toidentify stunted children, the causes of child malnutrition has beenmarkedly improved Similarly, the rate of mothers who know aboutproper diet for pregnant women as well as for diarrhea childrenincreased

The mothers’ practices on child growth monitoring, proper feeding

for the sick/ diarrhea children, complementary feeding and personalhygiene found significantly improved after the intervention andcompared with the control group

3.2.2 Intervention effects in changing mothers’ knowledge and practices on child malnutrition control

The research results show that, after the intervention, knowledgescores was 63.6±10.5 and practices 67.6±12.1, higher than that at T0(16.6±12.1 and 41.2±10.1) and the control group (26.7±13.6 and38.1±16.3) The knowledge on diversified meals and appropriatesupplement food preparation in the intervention group, 64.621.7higher than that at T0 and in the control group at T12 (29.212.3)and (19.89.9) The score for diversified meals and supplementaryfood preparation in the intervention group were also higher that at T0and control one at T12

Table 3.34 Intervention effective and real effective indices for mothers’ malnutrition control knowledge, practices (%)

Index Time point Control group Intervention group

*: p<0.001 vs T0 of the same group and T12 of control one, 2 test.

Table 3.34 shows in the intervention group, effective score forknowledge, practices to malnutrition control is 74.8% and the realeffectiveness 61.0%.

Table 3.35 Intervention effective and real effective indices for

mothers’ diet diversification (%)

group

Intervention group

*: p<0.001 vs T0 of the same group and T12 of control one, 2 test.

After the intervention, the proportion of mothers of interventiongroup achieved knowledge effective index quite well with 8 timeshigher, while the practices one about 2.5 times and the real effectiveindex was high