Nutritional status and effectiveness of interventions to reduce stunting malnutrition among children under 5 years old in the costal plain area, nghe an province

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUE OF HYGIENE AND EPIDEMIOLOGY ---*--- CHU TRONG TRANG NUTRITIONAL STATUS AND EFFECTIVENESS OF INTERVENTIONS TO

MINISTRY OF EDUCATION

AND TRAINING

MINISTRY OF HEALTH NATIONAL INSTITUE OF HYGIENE AND

EPIDEMIOLOGY -* - CHU TRONG TRANG

NUTRITIONAL STATUS AND EFFECTIVENESS OF INTERVENTIONS TO REDUCE STUNTING MALNUTRITIO IN CHILDREN UNDER 5 YEARS OLD

IN COASTAL PLAIN AREA NGHE AN PROVINCE Speciality: Hygiene Sociology and Health Organization

Code: 62 72 01 64

SUMMARY OF DOCTORAL THESIS

HA NOI – 2015

The work was completed at:

NATIONAL INSTITUE OF HYGIENE AND

EPIDEMIOLOGY -* - Supervisors : 1 Associate Prof PhD Le Bach Mai

2 Associate Prof PhD Tran Nhu Duong

Reviewer 1: Prof PhD Chu Van Thang - HaNoi Medical

Thesis will be put before the Council to protect thesis of State

held in National Institute of Hygiene and Epidemiology

On the back: at , date… month…….year 2015

Thesis could be founded in:

1 National Library of Vietnam

Library of National Institute of Hygiene and Epidemiology

LIST OF AUTHOR’S PUBLICATIONS

RELATED TO THESIS

- “Nutritional status in children under 5 years in coastal plain

area, NgheAn province, 2011.” Journal of Preventive Medicine,

Volume XXIV, No 8 (157) Ha Noi pp.166-170

- Factors related to status of stunting malnutrition in children under 5 years in coastal plain area, Nghe An province, 2011

Journal of Preventive Medicine, Volume XXIV, No 8 (157) Ha

Noi pp 171-176

UNICEF : United Nations’Children Fund

WHO : World Health Organization

INTRODUCTION

Nutritional status of children has been always the primary concern in all countries of the world Investing in nutrition is the key to develop the quality human resources Malnutrition prevention should be

an integral part of each national strategy for economic and social development to increase the stature, strength and wisdom of the human

According to estimates by the World Health Organization and the United Nations Children's Fund, the situation of malnutrition in worldwide children has been changed positively in recent years Underweight malnutrition has fallen rapidly from 25% in 1990 to 15%

in 2012 However, in the period from 2000 to 2005, the ratio of stunting was still highland and should be paid attention to In this period, this rate reduced only from 33% to 25% This situation will influence to achieve the Millennium Development Goals of halving the proportion of undernourished in developing countries from 20% in 1990 to 10% in 2015.”

In Vietnam, over the years, along with the socio-economic development and the correct policies of the Party and State, the effort of the Health sector as well as the active participation of the whole society,

we have achieved the significant results in improving nutritional status and health status of people The underweight malnutrition proportion in children under 5 years in our country has declined continuously, about 16.2% in 2012 However, the proportion of malnutrition has also considerable difference among regions, between urban and rural areas, especially the underweight malnutrition in children under 5 years has remained at a high level of 26.7%

Nghe An province in the North Central region has a large area where the terrain is very diverse, with the geographic region, from mountain, midland to coastal plain According to survey data of National Institute of Nutrition, Nghe An province always has the high malnutrition rate in children under 5 years In 2005, the prevalence was 28.9% underweight, 34.6% stunting and 6.3% wasting in children under

5 years, respectively In 2010, it was 21.7%, 32.9% and 8.2%,

respectively Until now, beside the National Program of Malnutrition Prevention, Nghe An province has never had any intervention programs

or studies on nutritional status in specific local area

Nghe An’s coastal plain area associated with the marine economy is the strategic location with some properties such as crowded population and small land, environmental sanitation is not good and people’s income mostly depends on offshore fishing, which makes parents have a few chances to take care of their children It’s the above issues that influences on the nutritional status in children in general and children under 5 years old in particular So, the question will be made: how is the nutritional status in children under 5 years old in this area? What factors related to malnutrition, especially stunting and what are the best measures to reduce malnutrition? The answers for these questions will contribute significantly to support managers and field professionals

to improve the health status of people in the coastal plain in general and children under 5 years in particular Especially, Nghe An province has been actively implementing Directive No 20-CT/TW dated 1997, September 22 of Politburo and policies of the provincial Party Committee on accelerating development of marine economy towards industrialization and modernization, in which focuses on the improvement of people’s health

For these above reasons, the study “Nutritional status and effectiveness

of interventions to reduce stunting malnutrition in children under 5 years old in the coastal plain area Nghe An province” was conducted

with the following objectives:

1 To describe the nutritional status and identify some related factors of stunting malnutrition in children under 5 years in the coastal plain area, Nghe An province

2 To evaluate the effectiveness of an intervention to reduce

stunting malnutrition from September, 2011 to September, 2012

 Contribution of the thesis

- Several anthropometric indicators and malnutrition classification were integrated with comprehensive assessment test for the malnutrition status in children under 5 years in the coastal plain area,

Nghe An province The rate of stunting malnutrition integrated with several anthropometric indicators in children under 5 years have firstly been developed

- Through the analysis, factors related to the rate of stunting have been identified

- It’s proven that deworming treatment, Iron supplement associated with communication and education for mothers on child-care methods to reduce the rate of stunting malnutrition and anemia, height improvement

 Structure of the thesis: the thesis consists of 134 pages

including Introduction (3 pages); Chapter 1 Overview (44 pages); Chapter 2 Subjects and research methods (20 pages); Chapter 3 Research results (35 pages); Chapter 4 Discussion (27 pages); Conclusion (2 pages) and Recommendation (1 page) The thesis has

41 tables, 12 charts, 2 diagrams References: 165 documents

Chapter1 OVERVIEW 1.1 NUTRITIONAL STATUS IN CHILDREN UNDER 5 YEARS OLD AND FACTORS RELATED TO STUNTING MALNUTRITION

of the average weight for age

- Malnutrition level I: weight below - 2SD to - 3SD, correspondingly the body weight from 90% to 75% of the average weight for age

- Malnutrition level II: weight below - 2SD to - 3SD correspondingly the body weight from 75% to 60% of the average weight for age

- Malnutrition level III: weight below -4SD corresponding the body weight < 60% of the average weight for age

b) To evaluate malnutrion based on the standard of height for age (HFA)

- Height for age from -2SD or more: are normal

- Height for age from -2SD to -3SD: malnutrition level I

- Height for age below -3SD: malnutrition level II

Children are considered stunting malnutrition when their height

is below -2SD of National centre health statistic (NCHS) population compared with the average height for age

c) To evaluate malnutrition based on height for weight

- Below -2SD: malnutrition

- From -2SD to below +2SD: normal children

- From +2SD or more : Over-weight and obesity

1.1.2 Child malnutrition situation under 5 years old

a) In the world

According to estimates by the World Health Organization and the United Nations Children's Fund, the situation of malnutrition in worldwide children has been changed positively in recent years However, in the period from 2000 to 2005, the ratio of stunting is still high and should be paid attention to In this period, this rate reduced only from 33% to 25%

According to data of National Institute of Nutrition, in 2012, the prevalence of malnutrition remaining 16.2% underweight, 26.7% stunting and 6.7% wasting The prevalence of malnutrition in the Central Highland is highest (25.0% underweight, 36.8% stunting) and lowest in the South-eastern region (11.3% underweight, 20.7 stunting) The prevalence of malnutrition in children under 5 years old varies with age There has been difference between urban and rural area

c)The status of child malnutrition under 5 years in Nghe An

According to the survey data of National Institute of Nutrition, Nghe An provinces has the highest prevalence of child malnutrition under 5 years old In 2005, the prevalence of child malnutrition under 5 years was 28.9% underweight, 34.6% stunting and 6.3% wasting and in

2010 was 21.7%, 32.9% and 8.2%, respectively

1.1.3 Related factors of underweight malnutrition in children under

5 years old

Energy intake

Nutrition is obviously a key factor, total energy intake is not enough that often related to food restriction can cause stunting, because energy intake is usually enough for child to maintain its healthy weight for height The quality of dietary intake should be paid more attention than the quantity, in which the role of animal protein, fats and micronutrients, vitamins, amino acids and fatty acids are essential

 Micronutrients

Micronutrients are substances that our body needs only in small amounts, however, if it’s for the shortage, it will cause very serious consequences for health There are about 90 various micronutrients necessary for the body and divided into some following groups:

- Group 1: Vitamins

- Group 2: Minerals

- Some infectious factors affecting stunting malnutrition in children under 5 years old: pathological spiral between infectious diseases in children and malnutrition has been proved Infectious diseases may lead to malnutrition, malnutrition may cause infectious diseases and the pathological spiral repeats continuously without any intervention or appropriate treatment

 Factors of child care, maternal and child issue affecting stunting malnutrition in children under 5 years old

The model for analyzing the causes of stunting malnutrition including prenatal and postnatal factors The prenatal factors including internal factors and external factors; a few studies on prenatal stage

1.2 SOLUTIONS TO STUNTING MALNUTRITION PREVENTION IN CHILDREN UNDER 5 YEARS OLD

In the world, the solutions to stunting malnutrition prevention currently focus on three solution groups Increasing intake of nutrients, supplementing micronutrients and reducing disease burden

- Solution group 1: Increasing intake of nutrients (both quality and quantity), including energy and protein supplements for pregnant women, educational strategies and the knowledge of breast-feeding, improvement of dietary supplement

- Solution group 2: Supplementing micronutrients (vitamins and minerals) including supplementing Iron, folic acid, vitamin A, calcium for pregnant women; iodized salt, vitamin A and Zinc for children

- Solution group 3: Reducing disease burden In Vietnam, the Prime Minister approved the National Strategy on Nutrition and concretized the above solution groups as follows:

Chapter 2 SUBJECTS AND METHODS

2 1 STUDY DESIGN :

2 steps in conducting the study

Step 1: A cross-sectional descriptive study to describe the child malnutrition status under 5 years and case-control design to identify factors related to stunting malnutrition

Step 2: A controlled before and after intervention study to evaluate the effectiveness of some intervention solutions to reduce stunting malnutrition

2.2 SUBJECTS

a) Study subject of objective 1: Describing the nutritional status and

identifying factors related to stunting malnutrition in children under

5 years old in the coastal plain, Nghe An province, 2011

- Study subject to describe nutritional status:

Children under 5 years old (from 1 to under 60 months old)

- Study subject to identify factors related to stunting malnutrition:

+ Children under 5 years old were suffered from stunting malnutrition (disease cases) and corresponding controlled cases

+ Mothers of disease and controlled cases

b) Study subject of objective 2: Evaluating the effectiveness of

some intervention solutions to reduce stunting malnutrition

+ Children suffered from stunting malnutrition from 24 – 47 months old + Mothers or primary caregivers of children

2.3 LOCATION AND PERIOD OF TIME

2.3.1 Location:

- Study on the status and identification of factors related to stunting malnutrition was conducted in 6 communes located in 2 coastal plain districts, Dien Chau and Quynh Luu, Nghe An provinces

- Intervention study conducted in 3 communes located in Dien Chau district and 3 commnues in Quynh Luu district as control group

2.3.2 Research duration

The study was divided into 2 periods:

 Period 1 (from June to August, 2011): Describing child nutritional status under 5 years old and identify factors related to stunting malnutrition in children under 5 years old

 Period 2 (from September, 2011 to September, 2012): Implementing intervention and evaluating the effectiveness of intervention solutions to reduce stunting malnutrition

2.4 SAMPLE SIZE AND SAMPLING TECHNIQUES

2.4.1 Sample size

a) The sample size for evaluation research on nutritional status: All

children from 0 month old to under 60 months old live in chosen communes in the period of study In our study, there were 3976 children to be investigated to evaluate the nutritional status

b) Sample size for identification of factors related to stunting malnutrition in children under 5 years old : The sample size formula

n 1 =n 2 = Z 2 (1- α/2) 1/p1q1 + 1/p0q0

[ ln(1-ε) ] 2

Replace these values into the formula, we will calculate n1=n2 = 253 To ensure sampling capacity of 80% with 95% confidential interval, study was conducted in 264 cases and 264 control cases

c) Sample size for research on objective 2

The minimum sample size was determined

Step 1: Choosing sample for evaluation research on nutritional status

* District: Selecting intentionally 2 coastal plain districts including Dien Chau and Quynh Luu

* Commune: Selecting by random by drawing up a list of coastal commnues in Dien Chau and Quynh Luu districts, then 3 communes in each district was determined by drawing lots randomly

* Children under 5 years old to investigate:

All the children from 0 month to under 60 months old were chosen from the list provided by commune health stations

Step 2: Choosing sample of identification of related factors

Disease group: Selecting disease group (group of stunting malnutrition):

A systematic random sampling method was used to choose children who were identified stunting malnutrition based on the research result of objective 1

Control group Selecting children without stunting malnutrition paired

with cases by age, gender, geographic location , similar economic

conditions

Step 3: Choosing sample for research on objective 2

+ Intervention group: A study method of objective 1 was used to choose children from 24 to 27 months old who were identified stunting malnutrition in Dien Chau district A systematic sampling method was

use to choose enough children based on the sample calculation formular

+ Control group in Quynh Luu district: Selecting children suffering from stunting malnutrition paired with cases by age, gender, similar economic

conditions

2.6 INDICATORS AND VARIABLES

 General information group

 Anthropometric indices

 Evaluating indicators of worm infection

 Hb index

 Indicators of assessing knowledge and practice of mother

 Intervention evaluation: the Z-score index; the average index of

height for age ( X ±SD); effective index; intervention effect

 Indicators of of diarrhea and respiratory infections

2.7 STUDY IMPLEMENTATION

 Identify nutritional status

Fellow collaborated with Nghe An Preventive Medicine Center, Health Centers in Dien Chau and Quynh Luu districts with some commune health stations selected to organize the investigation of the nutritional status in children by measuring to identify anthropometric indices

 Identify related factors

- Pre-designed questionnaires was used for cases and control

cases

- Blood samples and stool samples of cases and control cases

 Implementing intervention In this study, we conducted four

major intervention contents including: Communications to raise community awareness, training intervention for mothers of knowledge of malnutrition as well as instructions on how to care for children; iron supplementation for children with iron

deficiency anemia according to the protocol;

2.8 PROCESSING AND ANALYZING RESEARCH DATA

Anthropometric data were analyzed using ENA software, WHO,

2005 The other data were entered using EPIDATA software then converted into SPSS software version 19.0 to process

The algorithm used to analyze the data: paired T-test, Wallis Test and Test χ2

Kruskal-Chapter 3 RESEARCH RESULTS

3.1 NUTRITIONAL STATUS AND IDENTIFICATION OF FACTORS RELATED TO STUNTING MALNUTRITION IN CHILDREN UNDER 5 YEARS OLD IN THE COASTAL PLAIN AREA, NGHE AN PROVINCE, 2011

3.1.1 Nutritional status in children under 5 years old in the coastal plain area, Nghe An province, 2011

3.1.1.1 Characteristics of research subjects

3976 children were chosen to evaluate the nutritional status, the ratio of 51% boys to 49% girls This difference was statistically significant at p <0.05

3.1.1.2 Nutritional status based on indicators of weight/age Z-score (WAZ)

Diagram 3.2 Status of stunting malnutrition by gender

The rate of malnutrition was 18.9% underweight, the rate of 18.8% malnutrition in boys and 19.0% in girls (p>0.05)

Table 3.4 Status of underweight malnutrition by level and age group

Quanti

ty

Percent age %

Quanti

ty

Percent age %