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

  • Số trang: 24 |
  • Loại file: DOC |
  • Lượt xem: 15 |
  • Lượt tải: 0
nhattuvisu

Đã đăng 26946 tài liệu

Mô tả:

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-/22pq + Z1-p1q1 + p2q2 2 N = ---------------------------------------p1 - p22 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 25.15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 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, 64.621.7 higher 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 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.
- Xem thêm -