Tài liệu Nutritional status and effectiveness of interventions to reduce stunting malnutrition among children under 5 years old in the costal plain area, Nghe An province

i 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 ii 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 University Reviewer 2: Prof. PhD. Pham Ngoc Chau- Military Medical University Reviewer 3: Prof. PhD. Nguyen Thi Lam - National Institute of Nutrition 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 iii 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. iv ABBREVIATIONS BMI : Body Mass Index HWs : Health workers EI : Effective Index Ms : Micronutrients HFA : Height for age HIV : Human Imuno Virus IE : Intervention Effect KST : Parasites NCHS : National centre health statistic F : Fellow ARI : Acute Respiratory Infections SD : Standard deviation M : Malnutrition De : Deworming UNICEF : United Nations’Children Fund WFA : Weight for age WFH : Weight for height RI : Respiratory Illness WHO : World Health Organization 1 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%, 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, 3 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.  Evaluation method. a) To evaluate malnutrion based on the standard of weight for age (WFA). - Children whose weight is in the range of -2SD (Standard deviation) or more are normal. Correspondingly the body weight > 90% 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. 4 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. 5 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. 6 - 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. 7 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. n1=n2 = Z2(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. 8 n = Z2( α,β) p1q1 + p2q2 (p1- p2)2 Replace these values into the formula, we will calculate n = 84. In the study, there were 87 children was chosen for each group. 2.4.2 Sampling process. 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 9       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, KruskalWallis Test and Test χ2. Chapter 3. RESEARCH RESULTS 10 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) 18,9% 18,8% 19,0% 81.1% 81.2% 81,0% 100% Malnutrition Non Malnutrition 0% General Male Female 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 Total Quanti Percent ty age % 52 7,3* Medium level Quanti Percent ty age % 45 6,3* Severe level Quanti Percent ty age % 7 1,0 Age group (months) n 0 -11 713 12-23 929 150 16,1 128 13,8 22 2,4 24-35 855 178 20,8 155 18,1 23 2,7 36-47 763 181 23,7 161 21,1 20 2,6 48-59 716 189 26,4 171 23,9 18 2,5 (*p<0,05) 11 The results showed that the higher the age group was, the greater the prevalence of underweight malnutrition was, children from 40 to under 60 months old had the highest prevalence of underweight malnutrition (26.4%); children under 12 months old had the lowest prevalence of underweight malnutrition (7.3%). The malnutrition rate at medium level in children group from 0 to 11 months old compared with the other age group (p<0.05); the highest malnutrition rate at severe level in children from 24 to 37 months old (2.7%). 3.1.1.3 Evaluation of nutritional status based on height/age Z-score. Table 3.6 Nutritional status of stunting malnutrition by level and age group Age Total Medium level Severe level group n Percentage Percentage Percentage Percentage (months) % Quantity % % Quantity % 123 17,3 104 14,6 19 2,7 713 929 374 40,3 281 30,2 93 10,0 855 345 40,4 266 31,1 79 9,2 763 318 41,7 254 33,3 64 8,4 716 252 35,2 214 29,9 38 5,3 35,5 1119 28,1 293 7,4 Total 3976 1412 The results showed that the prevalence of stunting malnutrition in children under 5 years old in the coastal plain area, Nghe An province was 35.5%, stunting malnutrition tended to increase at the age of 1 or more, the highest rate at age group from 36 to 47 months old (41.7%). The highest rate of stunting malnutrition at medium level at the age group from 36 to 47 months old (33.3%) and the lowest rate at the age group from 0 to 11 months old (14.6%), this difference was statistically significant at (p <0.001). The highest rate of stunting malnutrition at severe level at the age group from 12 to 23 months (10.0%). 0 -11 12-23 24-35 36-47 48-59 12 3.1.1.4 Nutritional status based on weight/height Z-score. Table 3.7 Wasting malnutrition status Total Boys Girls Classification n = (3976) n = (2053) n = (1923) p of wasting SL % SL % SL % malnutrition 129 3.2 77 3.8 52 2.7 >0,05 Medium level 20 0.5 8 0.4 12 0.6 >0,05 Severe level 149 3.7 85 4.2 64 3.3 >0,05 Total The results showed that the wasting malnutrition rate in general was 3.7%, in which the ratio of 4.2 % boys to 3.3% girls. The prevalence of wasting malnutrition at medium level was 3.2%, in which the ratio of 3.8% boys to 2.7% girls. 35,5% 040% 020% 18,9% 3,2% 1,3% Wasting Overweight 000% underweight Stunting Diagram3.5. Nutritional status in children under 5 years old The results showed that the highest percentage of child stunting malnutrition was 35.5%, the percentage of 18.9% underweight, 3.2% of wasting and 1.3% overweight. 3.1.2 Factors related to stunting malnutrition in children under 5 years old. 3.1.2.1. Characteristics of children and mothers participating in study The total number of children participating in disease group and control group are 264, the disease group had 135 boys accouting for 51.1% and 129 girls accounting for 48.9%; the control group had 137 boys accounting for 51.9% and 127 girls accounting for 48.1%. The proportion of children who were paired between disease group and control group by age was similar. 3.1.2.2 Mothers’ factors related to their children’s malnutrition 13 96,6% 92,4% 100% 3,4% 7,6% 000% stunting Under 40 Over 40 Control group p<0,05; OR=2,3; 95%CI(1,01-5,90) Diagram 3.6: Comparison of the proportion of mothers aged under and over 40 Comment: The chart showed that mothers aged over 40 were 2-3 times more likely to have children with stunting malnutrition than mothers aged under 40 with (p<0.05;OR=2.3;95%CI: 0.99-5.90). Table 3.9. Relationship between malnourished children and the number of children of mothers Disease Control p; OR; Numbers of group group (95% CI) children (n=264) (n=264) p<0,05 Less than 3 children 184 214 OR=1,54 More than 3 children 70 50 (1,05 –2,39) Mothers having more than 3 children were 1.54 times more likely to have children with stunting malnutrition than mothers having less than 3 children, this difference was statistically significant with (p<0.05) and (95%CI:1.05-2.39); OR=1.54. p<0,05;OR=1,7; (95%CI: 1,04-2,76) 100.00 80.00 60.00 40.00 20.00 .00 85,6% 14,4% Disease group 78,8% 21,2% Control group Prymary and illiteracy Secon daryschool 14 Diagram 3.7: Relationship between mothers’ knowledge and stunting level of their children The results showed that it’s likely that relationship between mothers’ knowledge and stunting malnutrition in their children with p<0.05; OR=1.7;(95% CI:1.04 – 2.76). Table 3.14. Relationship to children’s vitamin A consumption Vitamin A consumption Disease group Control group p; OR (95% CI) Receiving No 118 94 p<0,05; vitamin A in the OR=1,48 Yes 146 170 last 6 months (1,02-2,13) The resulted showed that children didn’t received Vitamin A supplement in the last 6 months related to stunting malnutrition, this was statistically significant (OR=1.48; 95%CI 1.02 – 2.13); Table 3.15. Relationship to mothers’ knowledge and practice Knowledge and good Disease Control P,OR practice (n = 264) (n =264) (95% CI) Complementary Yes 151 176 p<0,05; feeding at 6 OR=0,67 No 113 88 months (0,46-0,97) Weaning in the Yes 135 157 p>0,05; range of 19 – 24 OR=0,71 No 129 107 months (0,50-1,02) Adding grinded Yes 125 148 p<0,05; vegetables into OR=0,70 No 139 116 powder (0,49-0,99) Breast-feeding Yes 160 198 p<0,05; when the child OR=0,51 No 104 66 has diarrhea (0,35–0,76) Knowing how Yes 106 140 p<0,05; to use Ozesol OR=0,59 No 158 124 (0,41-0,85) 15 Comment: The results showed that factors would reduce the risk of stunting malnutrition including: complementary feeding appropriate for the child’s age (OR=0.67; 95%CI 0.46-0.97), instruction on how to enhance nutrients into cereal (OR=0.70; 95% CI 0.49-0.99); breastfeeding when the child has diarrhea (OR=0.51; 95%CI:0.35-0.76); knowing how to use Ozesol (OR=0.59; 95%CI 0.41-0.85). 3.1.2.3 Relationship between worm infection, anemia and malnutrition status in chldren. Table 3.16 Relationship between worm infection and stunting malnutrition in children Disease Control p; OR Worm infection status group group (95% CI) Children Infected 87 47 <0,01; with worm OR=7,1 Non infected 14 54 infection (3,44 –5,29) Comment: The results showed that worm infection status definitely related to stunting malnutrition in children and this difference was statistically significant OR=7.1; (95%CI: 3.44 – 5.29) Table 3.17 Relationship between anemia and nutritional status Nutritional status Disease group Control group (n=101) (n=101) Quantity % Quantity % Related factors 36 36,4 12 12,1 Children with anemia 65 63,6 89 87,9 Children without anemia p; OR, 95%CI p<0,001; OR=4,1; ( 95%CI: 1,9 – 9,3) Comment: The anemia ratio of 36.4% stunting malnutrition group, of 12.1% control group. With p<0.001; OR=4.1; (95%CI: 1.9 – 9.3), which showed the close correlation between nutritional status and anemia. 3.2 EFFECTS OF INTERVENTION SOLUTIONS TO REDUCE STUNTING MALNUTRITION 3.2.1 General characteristics of subjects of intervention study Participants have the average age similar in ages, the age of boys and girls similar in ages between intervention group and control group. 16 3.2.2 Intervention effect of improving height and stunting malnutrition Table 3.22 Effect of improving height and HAZ score Average Intervention Control group p value group Height (cm) To 85,21 ± 4,28 84,89 ± 4,20 >0,05 T12 93,14 ± 4,01 91,80 ± 4,40 <0,05 T12-To 7,93±2,26 6,91±2,1 <0,01 HAZ-score To -2,77 ± 0,62 -2,83 ± 0,63 >0,05 T12 -2,25±0,57 -2,62 ± 0,59 <0,01 T12-To 0,52±0,29 0,21±0,27 <0,01 After 12 - month intervention, the intervention group achieved growth in height was (7.93±2.26); the control group achieved growth in height was (6.91±2.1), this difference was statistically significant with (p<0.01). HAZ-score also changed, this difference was statistically significant with (p<0.01). Table 3.27 Intervention effect of the rate of stunting malnutrition Intervention group Control group (n=87) (n=87) Stunting SL % SL % 87 100% 87 100% To 50 57,50% 75 86,20% T12 Effective Index (EI) 42,50% 13,80% 28,70%; p<0,01 Intervention Effect (IE) Comment: After 12 – month intervention in two groups: control and intervention, the rate of stunting malnutrition reduced 42.5% intervention; 13.8% control; (p<0.001), IE was 28.7% that proved the effective intervention. 3.2.3 Intervention effect of worm infection and anemia