The effect of a nutrition-specific intervention on nutritional status in moderate acute malnourished children under five years of age in a rural area of Mozambique
- Autores: Maria Eugènia Vilella Nebot
- Directores de la Tesis: Joan Fernández Ballart (dir. tes.), Michelle M. Murphy (codir. tes.)
- Lectura: En la Universitat Rovira i Virgili ( España ) en 2017
- Idioma: español
- Tribunal Calificador de la Tesis: Lluís Serra Majem (presid.), Ricardo Closa Monasterolo (secret.), Patrick Kosteren (voc.)
- Programa de doctorado: Programa de Doctorado en Nutrición y Metabolismo por la Universidad Rovira i Virgili
- Materias:
- Enlaces
- Tesis en acceso abierto en: hdl.handle.net TDX
- Resumen
Introduction Child malnutrition is still a public health challenge in the 21st century, particularly in low and middle-income countries. Malnutrition contributes to more than one-third of all deaths of children under five, especially in Africa. According to WHO (World Health Organization). The most recent data from Mozambique (2011), revealed that 43.1% of the children were stunted, 6.1% wasted and 15.6% underweight. According to UNICEF (United Nations International Children’s Emergency Fund), in 2015, a total of 50 million children were living with acute malnutrition, of which 34 million had moderate acute malnutrition (MAM). MAM in children under five must be urgently tackled to prevent those children from becoming severely acutely malnourished and associated morbidity and mortality. Many existing programmes to address MAM are in place but there is no consensus as to which are the best strategies to prevent and treat MAM children.
Objective The overall aim of the thesis was to evaluate the effect of a local-based supplementary intervention combined with a maternal intensive educational programme on the nutritional status in moderate acute malnourished children in a rural area of Mozambique.
Methods Mozambique is a country situated in the southern part of Africa between South Africa and Tanzania. Ibo Island is located in the Quirimba’s islands, in Cabo Delgado province, in Northeastern Mozambique. The island has different characteristics to the main land and supplies and accessibility are scarce. Access to the island is mainly by boat, depending always on the weather and tides.
The study was divided into three parts: baseline, intervention and evaluation.
From April 2009 to February 2010 a cross-sectional study was conducted (baseline). QuickBird satellite imagery was used to digitalise buildings and field maps were then produced, in which each of these was identified by a unique number. Fieldworkers visited each building and recorded what it was and whether it was inhabited.
If so, all individuals living there were identified and assigned a unique personal identification number. This was used throughout the study to link information for each individual from the household surveys with that collected at the clinic. A total of 724 households were counted, visited and interviewed. A week-long intensive training period was held by 4 field workers to standardise the methods used for data collection, including anthropometric measurements.
A structured questionnaire on current household demographics, socioeconomic, food security, adolescent and child morbidity, household member characteristics and infant feeding regimes was administrated to the head of the family.
A trained nutritionist supervised the weight and height measurements of the children following WHO standard procedure. Length/height (cm) was measured for children without shoes to the nearest centimetre using an insertion tape on a flat surface. Weight was measured in light clothing to the nearest 0.1 Kg using portable scales (Seca Model 881) that were checked and calibrated every morning with standard weights.
Children who could not stand on the scales were weighed in their caretaker/respondent’s arms, and their weight was obtained by subtracting the respondent’s weight from the total weight.
Weight-for-height (WHZ), height-for-age (HAZ) and weight-for-age (WAZ) z-scores were calculated according to the WHO Child Growth Standards 2006.
In March 2010, the Centro de Apoio Nutritional do Ibo (CANI) was created to provide a nutrition-specific intervention through an intensive nutrition education programme to mothers and a supplement based on local foods to improve nutritional status in MAM children (intervention).
Local food supplements appropriate for the children’s age were distributed and an intensive nutrition educational programme was held.
Malnourished children aged 6-59 months were first identified by a community-based survey (at home) using clinical criteria (big belly, thin hair, swollen eyes) or left arm MUAC (mid-upper arm circumference) ≤ 13.5mm using an established identification form of malnourished children in the field. CANI identification cards were given to children with MUAC ≤ 13.5cm or positive for the other clinical variables, so that they could be referred to the CANI. Children with CANI identification cards were registered in a referral form to the CANI, one copy was for the field worker and another for the mother to present at the entrance of the CANI.
Name, date of birth, birth weight, neighbourhood, carer’s name and MUAC were specified on that form (referral form). The mothers/carers were urged to bring the children as soon as possible to the CANI with the identification card and the referral form to have their nutritional status re-evaluated by a locally trained nurse.
Children were admitted if they complied with the standard criteria for MAM modified (MAM-m) from the Mozambique Ministry of Health’s Nutritional Rehabilitation Programme “Programa de Reabilitaçao Nutritional” to give a broader service to the community. Applied MAM-m critera were: W/H (weight/median weight of children of the same height of reference population x 100) ≤ 85% of the National Centre for Health Statistics, (NCHS/WHO) population median, and/or MUAC ≤ 13.5 cm. When MAM-m was confirmed, children were enrolled in the CANI intervention study.
Children with severe acute malnutrition (SAM) or oedema or complicated cases (malaria, HIV and respiratory diseases and acute diarrhoea) were not eligible for inclusion in the study and referred to the health centre in Ibo for treatment. Similarly, children with MAM were referred to the CANI for treatment from the Ibo health centre.
Children were registered and measured at the CANI on Mondays (MUAC, weight, length) and evaluated on Fridays (discharged or not from the CANI). All children enrolled in the study were requested to attend the CANI daily, in the mornings.
All measurements were performed by the same local nurse who apart from speaking the local language (Moaní), was in charge of the maternity facilities in the Ibo health centre, therefore she had a strong rapport with the mothers.
All information relating to the children enrolled in the CANI (anthropometrical measurements, supplementary foods, follow-up) was recorded on a registration form.
Ten different blended dishes, made from local ingredients, were given to the children based on the criteria for development of improved complementary food by Kanashiro et al. These included locally available foods, nutritionally adequate combinations, maternal involvement in the development of the recipes and receiving feedback on the recipes.
The average energy content of the dishes was 227.4 kcal for children ≤1 and 409.6 kcal for children >1 year of age. The average preparation time for the recipes was 100 minutes. All ingredients were available in the community.
The nutritional values of the food supplements were calculated from food composition tables used in Mozambique and other African countries.
An intensive training during one week was performed to teach how to cook, how to use accurate scales and how to be aware of hygiene to a CANI worker (cook). A supplementary feeding protocol was created with all the detailed information.
Dishes eaten by the children and participation by the mothers in the nutrition educational programme were recorded daily in the CANI registration form. Treatment was extended for one week after children had reached the target criteria for discharge from the CANI (weight-for-height (W/H) ratio>85% of the NCHS/WHO median and MUAC >13.5 cm). This assured weight and MUAC stability before discharge. The nurse informed the mothers/carers of the importance of continuing the nutritional supplementation and health habits learned during the intervention, at home. Mothers remained in the programme until their nutrition education was finished.
The intervention lasted for a maximum of 12 weeks. The number of children with MAM-m that turned up for treatment as well as those that never came and those that refused despite being referred to the CANI was recorded. 142 children under five were identified with MAM-m in the community, 12 never turned up. 130 were enrolled in the study and 47 abandoned. Field workers went to the homes of the children that abandoned to find out why they did not return to the CANI.
This programme encouraged children to stimulate themselves by making toys from local materials, in keeping with the recommendations in the Mozambique Ministry of Health’s orientation manual for treatment of severe acute malnutrition.
Mothers or carers of the children were enrolled in an intensive nutrition and hygiene educational programme that consisted of three training sessions a week for 4 weeks. Topics covered by the intensive nutritional programme included: infant feeding, supplementary feeding practices, information regarding local foods and how to prepare the nutritious supplement dishes, food security, feeding and illness, feeding and pregnancy and hygiene. A bottle of chlorine (certeza) was given to mothers to treat household water for drinking and for use in cooking.
The nutrition educational programme was considered to be completed if the mother attended at least 80% of the sessions (10 sessions). Every session ended with a song to emphasize the key words of the corresponding topic.
A follow-up during 3 months was supervised to evaluate the implementation of the main recommendations given in each of its topics.
In July 2011, the evaluation of the nutrition-specific intervention was carried out in Ibo (evaluation). A structured questionnaire on sociodemographic, illness, immunisation, food security, infant nutrition practices and anthropometry was administered to the children’s head of the family. A trained nutritionist supervised the weight and height measurements of the children following WHO procedures. W/H, H/A and W/A were calculated according to the WHO 2006.
The Household Economic Status Index (HESI) was assessed using an index derived from principal components analysis. The included variables were: access to energy supplies, toilet, cooking fuel, water, meals/day, possession of a fridge, television, rooms/house, household material, farm animals and home cultivation. The scores from the first component were categorised into quintiles of the HESI representing: very low, low, middle, high and very high. The significance level was set at p <0.05. Data was double entered by two independent researchers and analysed using SPSS 20 for Windows (SPSS Inc., Chicago, IL).
Results The baseline results: 3313 people on Ibo were identified and interviewed and nutritional assessment was carried out in the 526 children under five. 2.5% came from households with electricity.
The mean (Standard Deviation, SD) age of their mothers was 24.9 (5.6) years, number of previous pregnancies was 3.5 (2.1) and 43.9% had no schooling.
The prevalences of wasting, stunting and underweight (<-2 SD) were 13.4%, 49.8% and 22.7% respectively.
Most children had been fully vaccinated (90.5%), breastfed (100.0%), and some were also bottle fed (22.0%).
The mean (SD) duration (months) of the different feeding regimes were 20.3 (4.47) for breastfeeding, 2.5 (0.8) for exclusive breastfeeding and 3.2 (4.0) for bottle-feeding. The mean number of daily meals across the child age range was 2.3 (0.5). More stunted children had been exclusively breastfed than mixed fed (p=0.058). Severe stunting was more likely in children in the ≤11 (26.3%) and 12-23 (21.2%) month age groups (p=0.007). More children from the 46-60 month age group (27.7%) were underweight compared to the other groups (p=0.047). 142/483 children (29.4 %) had MAM-m.
Intervention results: the intervention was 60.2% effective. The mean (SD) gain was 2.3 (1.7) g/kg/day for weight and 0.69 (0.50) mm/day for MUAC. Completion of the education programme was higher in mothers of children under 24 months (89.3%) compared to older children (70.4%), p=0.031.
Furthermore, the percentage of the median population weight for height ratio achieved was higher in younger (92.2 (6.6) %) compared to toddler (87.6 (7.5) %) children (p=0.007). The probability of recovery increased with each mm increase in MUAC on admission (OR= 2.8; 95% CI: 1.0, 7.7; p=0.049).
Evaluation results: the overall types of malnutrition had decreased in 2011 comparing to 2009, especially for stunting. The duration of breastfeeding, exclusive breastfeeding and bottle-feeding increased significantly from 2009 to 2011. The frequency of children having ≥3 meals/day in 2009 was 32.7%, which significantly increased to 96% in 2011. Furthermore, a significant increase was noticed in owning a home gardening from 27.9% in 2009 to 53.6% in 2011. Moreover, the majority of the food groups consumed increase significantly in 2011, especially vegetables (31.3%), fruits (86.7%), legumes and sugar (55.0%).
Conclusion A specific-nutrition intervention with an intensive nutritional educational programme with a local supplement is a feasible intervention for MAM children in a rural area of Mozambique.
