1
INTRODUCTION
1. The urgency of thesis
Protein - Energy Malnutrition (PEM) in Vietnam often called
malnutrition. Malnutrition in general and stunting in particular is still
a public health significant problem in developing countries, including
Vietnam. According to the 2000 report of the Standing Committee on
Nutrition of the United Nations and Research Institute for the
International Food Policy (ACC/SCN/ IFPRI), about 30 million
newborns affected by the consequences of fetal malnutrition and
about 185 million children <5 years of age (34%) were stunting in the
developing countries; In 2005, still about 178 million children <5
years of age (32%) were stunted in developing countries.
In Vietnam, underweight rate of children under 5 years of age
decreased 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 diseases
associated with nutrition increased. In Hanoi, underweight rate was
decreased rapidly from a low level (18.7% in 2001) to a very low
level (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% in
2007) due to many reasons such as low maternal educational level,
nutrition
limited
knowledge
and practice.
Therefore,
many
intervention programs have been implemented, of which an
important solution is to build and deploy a pilot intervention by only
active education and communication. In this context, the study
2
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 large
enough sample size, updated technical and analysis of collected data
application 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 these
are lower than national average. At the same time, it has specified
that right in a suburb of Hanoi, the knowledge; practices for child
malnutrition control, diet diversification, care of sick children,
personal hygiene of mothers with children under 24 months of age
were still very limited. This may be considered the new findings
about realities and the causes of child malnutrition in Soc Son.
2. In phase 2, the early long-term (12 months) intervention by only
active education and communication has had plausible conclusions
and recommendations which very useful for child malnutrition
3
control programs. These are the new scientific and practical
contributions to the specializations of Social hygiene and health
organization, and Community Nutrition.
3. Layout of the thesis
The dissertation consists of 131 pages (excluding references and
appendices), with the following parts and chapters:
Introduction:
02 pages
Chapter 1. Overview:
36 pages
Chapter 2. Subjects and Methods:
26 pages
Chapter 3. The findings:
29 pages
Chapter 4. Discussion:
35 pages
Conclusions:
02 pages
Recommendations:
01 pages
125 dissertation reference materials, including 62
Vietnamese and 63 documents in English.
4
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 in
developing countries are stunted, the 2 highest prevalence areas were
Africa and Asia (33.8% and 29.9%). From 1980 to 2000, the
estimated number of stunted children was reduced by approximately
6.2 million. According to WHO and The Lancet January 2008, some
40% of countries have stunting rates higher than 40%. Problem is
that the stunting rate was highest in the lowest quintile population. In
Vietnam, 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
5
Figure 1.6 showed the rate of child malnutrition 2000 - 2013.
Immediate
causes
of
malnutrition
are
identified
including
inappropriate eating and disease. Underlying causes includes
household food insecurity, inadequacy of maternal and child care
services, knowledge of caregivers, family care, water supply and
sanitation and unsanitary housing conditions. The basic causes of
malnutrition is defined political structure, socio-economic and
cultural 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 and
influencing to the next generation.
1.2. The solutions for malnutrition control
Global focus on 3 main solutions: 1) Increased nutrients intake (both
quality and quantity), including protein and energy supplements for
pregnant women, strategies to encourage breastfeeding, quality
improvement of complementary foods; 2) Supplementation of
micronutrients, including iron, folic acid, vitamin A, calcium for
pregnant women; Iodized salt supplements, vitamin A and zinc for
infants; 3) Reducing the burden of disease.
In
Vietnam,
malnutrition
prevention
measures
have
been
implemented during war time, but the effect was very limited. From
the last decade of the XX century to the present, Vietnam has
developed and deployed the National Target Program for Protein
6
Energy Malnutrition control since 1994, Program for micronutrient
deficiency control, the National Plan of Action for Nutrition 19952000, National strategy for Nutrition 2001-2010 and National
strategy for Nutrition 2011-2020 with a vision to 2030. Nutrition
education and communications has always been regarded as a key
solution through the programs’ plans and strategies’ framework.
However, the activity found to be heavily on the put-forms or
movements, just in some kinds of campaign, but not really the
practical operation, resulting in low effectiveness and lack of
sustainability.
1.3. Education and communication research for malnutrition
control
Many studies to change knowledge, attitudes and practices (KAP) for
control of micronutrient deficiencies and malnutrition have been
deployed in the region, in the world and in Vietnam. However, most
of these studies were coordinated with food or micronutrients
supplements. The idea of our study is based on the theoretical and
practical basis: active nutrition education and communication can
change the mothers’ nutrition and child care habits, then the children
will get improved diets, indirectly reduce the rate of child
malnutrition; At the same time, the mothers ‘nutrition habit/ practice
changes affect themselves before and during the subsequent
pregnancy to actively prevent fetal malnutrition and low birth weight.
7
Chapter 2
SUBJECTS AND METHODOLOGIES
2.1. Subject, location and time bound of the study
The research was conducted on mothers and children under 24
months 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 community
intervention controlled trial.
2.2.2. Sample sizes and sampling
* Sample sizes and sampling in cross-sectional study: Applying the
formula:
p (1 - p)
n=Z
2
(1 / 2 )
x DE
d
2
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 q=1p=0.75; d: acceptable level of error=0.05; with threshold probability
5% => z1- /2 = 1,96; DE: Design Effect=2. Calculated sample size
was 586. Added contingency of 5% (29), the total number of children
was 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.
8
* Sample size and sampling in community intervention trial:
Applying WHO 1998 formula:
___
________
Z1-/22pq + Z1-p1q1 + p2q2 2
N = ---------------------------------------p1 - p22
Where, n: number of selected mothers; Z1-/2: reliability
coefficient, at =5%, than Z1-/2 = 1,96 and Z1- with =10%; + P:
average rate of 2 populations; p1: estimated proportion of mothers
with 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 nutrition
knowledge and behavior in control group, estimated p2=0.30 (30%),
and q2= 1-p2=0.70 (70 %). Calculated n=217. Plus contingency of
20% (43) =260/each group, the sample size is 260.
2.2.3. Methods of data collection
Interviews mother based on KPC questionnaire, complement
questionnaire and nutrition anthropometric method for infants <24
months of age.
2.2.4. Data processing and analysis
Data are checked, cleaned and processed with SPSS 10.5 and
Epi Info 6.0.
2.2.5. Research Ethics
Subjects committed voluntarily to participate with the
family’ and local authority’ agreement, and had the right to give up.
The subjects’ identified information is encrypted and data used only
for research purposes.
9
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)
Underweight
7,8
7,8
Stunting
19,1
19,1
Wasting
3,9
3,9
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 and
control expected communes.
Figure 3.2. Mothers’ knowledge about the causes of child
malnutrition
10
The rates of mothers, who know the right contents of breastfeeding,
are rather low, ranging from 25.8% to 39.3%.
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)
Index
n
%
Children need to have a variety of foods
559
93,2
The nutritional value of food animals
586
97,7
The nutritional value of animal organs
593
98,8
The effects of vegetable, fruit and dark green
269
44,8
The effects of vegetable, fruit yellow, red
315
52,5
The effects of oil / fat meal
558
93,0
The effect of egg nutrition
446
74,3
11
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 than
90%, while those to know nutritive values of some vegetables and
fruits 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
malnutrition control
Index
General (n = 600)
Knowledge score (X ± SD)
20,6 ± 12,8
Practice score (X±SD)
40,1 ± 12,1
Table 3.20 shows, on a scale developed by research itself, knowledge
score of the mothers with children under 24 months of age is very
low, 20.6±12.8, ranking as weak level; similarly, mothers’ practices
on child malnutrition control reached only 40.1±12.1, ranking as
average level.
Table 3.21. Mothers’ knowledge and practice scores on the
diversified meals
Index
General (n = 600)
Knowledge score (X±SD)
25,15 10,3
Practice score (X±SD)
45,3 ± 12,6
12
Table 3.21 shows both the knowledge and practice scores of mothers
on diversified meals and supplementary food preparation is very low,
only 25.1510.3 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 to
identify stunted children, the causes of child malnutrition has been
markedly improved. Similarly, the rate of mothers who know about
proper diet for pregnant women as well as for diarrhea children
increased.
The mothers’ practices on child growth monitoring, proper feeding
for the sick/ diarrhea children, complementary feeding and personal
hygiene found significantly improved after the intervention and
compared with the control group.
13
3.2.2. Intervention effects in changing mothers’ knowledge and
practices on child malnutrition control
The research results show that, after the intervention, knowledge
scores 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 and
38.1±16.3). The knowledge on diversified meals and appropriate
supplement food preparation in the intervention group, 64.621.7
higher than that at T0 and in the control group at T12 (29.212.3) and
(19.89.9). The score for diversified meals and supplementary food
preparation in the intervention group were also higher that at T0 and
control one at T12.
Table 3.34. Intervention effective and real effective indices for
mothers’ malnutrition control knowledge, practices (%)
Index
Knowledge score
from average and
higher, Effective
and Real effective
index
Practice score
from average and
higher, Effective
and Real effective
index
Time point
Control
group
Intervention
group
T0
4,0
6,0
T12
8,0
90,0 *
Effective index
50,0
93,3
Real effective
index
43,3
T0
20,0
24,0
T12
23,2
95,2*
Effective index
13,8
74,8
Real effective
index
61,0
*: p<0.001 vs. T0 of the same group and T12 of control one, 2 test.
14
Table 3.34 shows in the intervention group, effective score for
knowledge, practices to malnutrition control is 74.8% and the real
effectiveness 61.0%.
Table 3.35. Intervention effective and real effective indices for
mothers’ diet diversification (%)
Index
Time point
Control
group
Intervention
group
Knowledge
point from
average and
higher, Effective
and Real
effective index
T0
6,0
10,0
T12
10,0
98,0*
Effective index
40
89,8
Practice point
from average
and higher,
Effective and
Real effective
index
Real effective
index
49,8
T0
24,0
26,0)
T12
28,4
96,8*
Effective index
15,5
73,1
Real effective
index
57,6
*: p<0.001 vs. T0 of the same group and T12 of control one, 2 test.
After the intervention, the proportion of mothers of intervention
group achieved knowledge effective index quite well with 8 times
higher, while the practices one about 2.5 times and the real effective
index was high.
15
3.2.3.
Intervention
effects
in
changing
the
children's nutritional status
* The effect of intervention to the anthropometric indices:
Table 3.36. The intervention effect to the children’ weight
(Mean±SD)
Ctr. group
(n=252)
Inter. group
(n=255)
p (t test)
Weight at T0 (kg)
8,7±1,6
8,6±1,6
>0,05
Weight at T6 (kg)
10,5±1,9
10,8±2,3
>0,05
Weight at T12 (kg)
11,5±2,1
11,9±2,3
<0,05
Weight gain (T6-T0)
1,78±0,98
2,16±1,02
<0,001
Weight gain (T12-T0)
2,84±1,58
3,25±1,61
<0,001
Index
Table 3.36 shows, the weight gain of intervention group was higher
comparing to control one 0.38 kg, and 0.41 kg after 6 and 12 months,
a significant difference (p<0.001) and the advantage belonged to the
intervention group. The difference in the absolute value of the weight
seen only at T12 (p<0.05). Similarly, WAZ differences only seen at
T12 (p<0.01).
Table 3.37. The intervention effect to the children’ height
(Mean±SD)
Ctr. group
(n=252)
Inter. group
(n=255)
p (t test)
Height at T0 (cm)
73,1±6,9
73,2±6,7
>0,05
Height at T6 (cm)
79,5±5,6
80,2±5,6
>0,05
Height at T12 (cm)
84,8±5,6
85,8±5,7
<0,05
Increased (T6-T0)
6,42±3,59
7,03±3,62
>0,05
Index
16
Increased (T12-T0)
11,72±3,45
12,56±3,56
<0,01
Table 3.37 shows, the difference in absolute height only seen at T12
(p<0.05). The increased height of intervention group was higher than
that in the control group by 0.61 cm, and 0.84 cm after 6 months and
12 months, the difference was significant (p<0.01) at T12 with the
advantage of the intervention group. Intervention group had a better
trend (p<0.05) in HAZ value, while HAZ of the control group
worsened (p<0.05) at T12 compared with T0. WAZ at T6, T12 of the
intervention group tended to better than that of control one, the
difference was significant (p<0.05) only found in T12.
* Effect of intervention in reducing the malnutrition rate:
Table 3.41. The effect intervention in changing child malnutrition
Malnut
rition
form
Underweight
Stunting
Wasting
rate after 12 months
Ctr. group
Inter. group
(n=252)
(n=255)
Time
Effecti
Effectiv
point
ve
n (%)
n (%)
e index
index
(%)
(%)
T0
21
22 (8,7)
(8,2)
- 18,4
23,2
T12
16
26 (10,3)
(6,3)
T0
49
46 (18,3)
(19,6)
- 16,9
15,8
T12
42
54 (21,4)
(16,5)
T0
11
10 (4,0)
(4,3)
- 30,0
44,2
T12
13 (5, 2%)
6 (2,4)
Real
effecti
ve
index
(%)
41,6
32,8
74,2
17
Table 3.41 shows that effective indices in the intervention group with
3 forms of underweight, stunting and wasting were positive values,
23.17, 15.82 and 44.19%, respectively. Meanwhile, in the control
group they were negative, -18.39, -16.94 and -30.0%; the effective
index to lower the rate of 3 forms of child malnutrition were positive
values. After 12 months, the real effective index for wasting was
74.2%, followed by underweight, 41.6% and stunting, 32.8%.
18
Chapter 4
DISCUSSIONS
4.1. Actual nutrition status of children under 24 months of age
and mothers’ nutrition knowledge and practices at six communes
of Soc Son district in 2010
4.1.1. Actual nutrition status of children under 24 months
The rate of underweight (W/A<-2SD), stunting (H/A<-2SD) and
wasting (W/H<-2SD) of children 0-24 months of age in six
communes Soc Son district in 2010 was 7.8%, 19.1% and 3,9%,
respectively. These rates are not different between the 3 projected
intervention and control communes (p>0.05). However, the rate of
malnutrition is lower than that of children under 5 years of age in Soc
Son 2001 and 2006 (underweight 31.9% and 21.2%, stunting 33.3
and 27.9% and wasting 7.9 and 7.5%) and lower than the national
figures 2011 (16.8% underweight, 27.5% stunted and 6.6% wasted).
However, compared with other studies in recent years in other areas
of North Delta, malnutrition rates of children under 24 months of age
in our study are still of relatively high and comparable to the difficult
regions. This is consistent with some elements of socio-economic
conditions of Soc Son - a suburban district but essentially remains a
poor rural area with agriculture as the main economic, poverty rate
also high at 20% in recent years; the socio-economic development
remains equal to or lower than many other rural areas. According to
FAO/WHO, by 2012 the rate of worldwide undernourished children
under 5 years of age has decreased, but there was still 162 million
children with chronic malnutrition (stunting), 51 million suffered
from acute malnutrition (wasting); More than 2 billion people lack of
19
micronutrients such as vitamin A, iodine, iron and zinc, whereas
overweight and obesity in both children and adults increased rapidly.
In Vietnam, according data of the National Institute of Nutrition,
underweight rate decreased rapidly: from high level classified by the
World Health Organization (51, 5% in 1985) to average (18.9% in
2009). Nutrition monitoring data of the National Institute Nutrition
recently showed that in 2012 and 2013 the national average rate of
child malnutrition continued to reduce (underweight 16, 2 and 15.3%,
stunting 26.7 and 25.9%, wasting 6.7 and 6.6%). Prevalence of child
malnutrition in Hanoi 2012 and 2013 was 8.1 and 7.0% underweight,
21.9 and 15.5% stunting and 5.5 and 2.8% wasted, respectively. It
can be seen, in recent years, reducing malnutrition rate is very slow.
A surprising thing is that child stunting in Hanoi 2012 increased to
over 20%, a high level according to WHO, to be problem of
continuing concern.
4.1.2. Current status of knowledge and practices to control child
malnutrition and diet diversification of mothers with children
under 24 months
The cross-sectional study in 2011 showed that Soc Son mothers’ both
knowledge and practices on child malnutrition control measures and
diet diversification are poor. On a scale developed by the research
itself, knowledge score to control malnutrition of mothers was
classified as poor (20.6±12.8), while their score on practices as
average (40.1±12.1), most mothers did not have good scores.
Similarly, on the meal diversification and supplementary food
preparation, the mothers’ knowledge scores (25.2±10.3) and practices
(45, 3±12, 6) were very low, classified as the weak and average.
20
4.2. Effect of the intervention to mothers’ improved knowledge
and
practices
for
child
malnutrition
control
and
diet
diversification
4.2.1. Effect of the intervention to change mothers’ knowledge and
practices on child malnutrition control
After 12 months of intervention, the percentage of mothers who
know how to recognize their undernourished children, the causes of
malnutrition, the contents of appropriate breast feeding, feeding sick
infants, nutritive values of some green leafy vegetables and yellow/
brown or red fruits, varied supplementary food preparation
significantly increased in the intervention group.
Effect to changing mothers’ practices to control child malnutrition:
After intervention, the percentage of mothers who monitored their
child weight, height and gave properly diet to sick children,
supplementary feeding, personal hygiene, especially safe child
manure
handling
and
hand
washing
improved
markedly.
4.2.2. Effect to change mothers’ scores on knowledge and practices
to control child malnutrition and diet diversification
After intervention, mothers’ knowledge and practices score on child
malnutrition control, diet diversification were higher (p<0.001) in the
intervention group compared with T0 and control one at T12. The
effective and real effective index of the intervention group found
significantly higher. The result is similar to the study of Hung Pham
Hoang, Thu Mai Ho, Nam Phuong Huynh conducted in some
researches on different subjects with different goals/ objectives.
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