Local Determinants of Malnutrition:

An Expanded Positive Deviance Study

Presenter:Julie Hettinger, MS RDMaternal and Child Nutrition Specialist, Food for the Hungry

April 29, 2010

In Burundi,

PD mothers are about seven times more likely to have given their child salt [in foods] in the past 24 hours.

(Probably effect of iodine or just improved flavor)

7 times

seven times

What is the Local Determinants of Malnutrition tool and study?

• Community based assessment tool• Useful in formative research• Brief summary of the study:

– Mothers of well nourished children and mothers of malnourished children are interviewed with a LDM questionnaire.

– Data from the two groups are compared to determine how they differ on each question.

– Statistically significant differences (determinants) are examined further.

Why this tool?

• A Local Determinants of Malnutrition Study helps project staff to better understand which foods, maternal behaviors and other situations are most associated with malnutrition in their project area.

• Enables the development of more focused and effective behavior change communication messages and program strategies.

Applying the LDM Study

Ideally, the LDM study would be conducted at the beginning of a project period (as a stand-alone study).

• Use results to identify what interventions are needed, the level of effort to give to each, key messages, and, if doing Hearth - to identify important questions that should be added to the routine PD questionnaire.

• May be helpful in identifying entirely new areas of intervention that an organization can take on to reduce malnutrition.

– it is not a study that would be done as part of the Hearth nutritional rehabilitation model

Background

• Positive deviance studies from many countries have shown that there are often local determinants of child malnutrition, and local coping mechanisms for preventing child malnutrition.

Background

• Most positive deviance (PD) studies as part of PD/Hearth programs have focused on:– foods that make up a child’s diet (food types, but not

quantities or frequency of consumption)

– assessing the “three goods”:• Good feeding practices• Good child care practices • Good health care seeking practices

Background

• There are numerous other factors and specific behaviors that are associated with child malnutrition in some countries and have not been explored to date in most PD studies. – depression in the mother

– intake of specific nutrients (e.g., magnesium, potassium and phosphorus

– child care practices (e.g. spanking)

– maternal diet during breastfeeding

– alcoholism among family members

Background

• Reason that these factors have not been well studied– Previously assumed that

little could be done to change the situation

• Not true anymore

• Example: Interpersonal Therapy for Groups to decrease depression

Background

• Conclusion: More needs to be known about the links between these local determinants and food insecurity so that we can do more to combat these causes of malnutrition.

Methodology

• Literature Review– The literature on causes of malnutrition was reviewed by

Phil Moses, MPH and Tom Davis, MPH. • Examined positive deviance studies • Reviewed other studies that provided information on the

causes of malnutrition• Specifically looked for causes dealing with nutrient intake,

feeding practices, and psycho-social causes• Looked for factors associated with malnutrition and thought to

be causative because a mechanism for causation exists

Methodology

• Matrices– Developed matrices of possible determinants based on:

• strength of the association or severity of the problem• feasibility of measuring it• degree to which it was susceptible to change during a short-

term program or through a different intervention• scope of the problem (prevalence)

– Each determinant was rated for each criteria and assigned a total score

Methodology

• Questionnaire Development– Developed questions to measure the highest ranked matrix

determinants in the questionnaire

– Drew from previous PD surveys and scientific studies for the questions, or developed new ones when pretested questions were not available.

– Tested the questionnaire in Mozambique study, which resulted in a shortened and improved LDM study questionnaire.

Methodology

• Questionnaire Development– Intake of Specific Foods

– Process of selecting foods• Started with a list of foods that were eaten in the local area

from discussions with staff and from earlier free listing of foods consumed by children reported by mothers found during KPC surveys, PD studies, or staff reports.

• Also asked staff which of the high nutrient foods (e.g. foods rich in vitamin A) are ever available in the project area.  If they were ever available, we included them in the questionnaire, even if they were not eaten very often.

Methodology

• Workshop has been taught and the study implemented in 5 FH fields:

• Mozambique (Sept 2004)• Kenya (Sept 2005)• Bolivia (August 2007)• Ethiopia (May 2008)• Burundi (Sept 2009)

• Usually an 8 day workshop2 days training3 days data collection2 days data entry / analysis1 day applying results

Methodology

• Study Design– Divide mothers of children

12-59m into 3 groups• 1) those with a well

nourished child

(WAZ>-1.0)

• 2) those with a malnourished child

(WAZ<-2.0)

• 3) those who fall in between (excluded from study)

Methodology

• Collecting Data– Workshop training on how to use questionnaire and get

informed consent.

– Used CHWs and leaders to assemble women and children at a central location for geographically dispersed communities.

– Team of workshop participants weigh and classify children, and interview qualifying mothers using questionnaire. Interviewers not told status of child.

– Desired sample size: • 45 PD and 45 malnourished

Data Collection

Data Collection

Data Collection

Data Collection

Methodology

• Data Analysis– Workshop participants

entered data into a pre-written Epi-Info 6.04d data template.

– Workshop participants reviewed the Epi-Info program output for significant results

• 2 x 2 tables

• ANOVA

• Check for confounding

Methodology

• Data Analysis– Differences between the PD and malnourished groups were

considered to be statistically significant • if p < 0.05 or• if the range for the 95% confidence interval for the odds ratio

(done as part of the analysis) did not include 1.0.

Methodology

• Application of Results– Workshop participants discussed findings in large

group.– Participants strategized ways to address these

findings in the context of a community health program.

• Suggested Actions• Suggested Educational Messages

LDM Study Example – Ethiopia

Finding Suggested ActionSuggested Educational

Messages

Hygiene Practices

• PD children are 5.9 times more likely to defecate in a proper spot (diaper or latrine). (35% PD vs. 8% Mal)

• Promote home practices of safe stool disposal and handwashing with ash/soap.

• Encourage every household to have a latrine. Consider barrier analysis on this behavior.

• Promote washing diapers in soapy water.

• Dispel myth that child’s feces are safe and communicate safe disposal of stool in a latrine.

• “Every house should have a latrine and use it...”

• “Soap helps remove germs – Wash diapers with soap as well as water.”

LDM Study Example - Mozambique

45% of mothers of PD children said that they

usually or always completely emptied their

breasts when breastfeeding their PD

child. Only 10% of mothers of

malnourished children said that they did usually or always do so. (p=0.006) The odds

ratio for this variable was 7.09 (1.36 < OR < 46.45) meaning

that mothers of PD children were about seven times more

likely to do this behavior.

KEY KEY Message: Message: When breastfeeding a When breastfeeding a child, it is important to child, it is important to always completely empty always completely empty each breast so that the each breast so that the child gets all of the child gets all of the calories and nutrients that calories and nutrients that they need. they need.

KEY MESSAGE: The Milk Changes during Breastfeeding. The longer the child breastfeeds on one breast the richer the milk becomes in protein and fat.

The FIRST milk

(watery milk)

The THIRD Milk

(creamy)

The SECOND

Milk (normal)

Monitoring of Behaviors and Beliefs related to Exclusive BF

Practices and Beliefs about Breast Feeding tracked by KPCs

98%

62%92%

59%

100% 99%86%

73%94%

0%20%40%60%80%

100%120%

BF from bothbreasts

Empty breasts Believeimmediate BF

is best

Believe okay toBF if pregnant

Properknowledge

about BF andHIV status

May 06

Sep 07

Dec 07

PD BehaviorPD Behavior

Conclusion

• The study of Local Determinants of Malnutrition was designed: – to provide greater understanding of all the factors that

contribute to malnutrition • food and feeding practices • child care practices • care seeking practices • psychosocial and other environmental factors• mothers’ worldview

Conclusion

• Results of the study of Local Determinants of Malnutrition provide: – Insight into what practices and foods should be promoted in

each country context, and

– Suggestions as to what additional interventions should be added to health, nutrition, and food security programs

Contact: Tom Davis, MPH

Director of Health Programs, or

Julie Hettinger, MS RDMaternal and Child Nutrition Specialist

Food for the Hungry236 Massachusetts Ave, NE Suite 305

Washington, DC 20002202-547-0560

jhettinger@fh.org

Narrated Presentation can be found at www.caregroupinfo.org

Expanded Positive Deviance Study

• Application of the Local Determinants of Malnutrition Study– Conducted as formative research at the beginning of a

PM2A project• Use results to identify what interventions are needed, and

what behaviors to give extra attention to during project activities.

• Identify PD behaviors to focus on in Care Groups and to integrate into project curriculum.

• May be helpful in identifying entirely new areas of intervention for the project to take on to reduce malnutrition.

LDM Study Example – Ethiopia - combine with next slide

Important BF Results of the Expanded PD Study

67% of mothers of PD children vs. 32% of mothers of

malnourished children took at least one month of iron

supplements during the months that they were breastfeeding.

(p=0.04) The odds ratio for this variable was 4.05 (0.99<OR<18.83). Mothers of PD children were more than four times as likely to take iron supplements during breastfeeding as were mothers of malnourished children.

KEY KEY Message: Message: All mothers should take All mothers should take iron supplements during iron supplements during pregnancy and while pregnancy and while lactating as a way to help lactating as a way to help their children grow.their children grow.

PD Practices / Situations identified in Burundi LDM Study• Child not sick with any disease

in last two weeks – (PD children were 5.5 times

less likely to have any disease in the past two weeks.)

• Child not sick with diarrhea in last two weeks– (PD children are five times

less likely to have diarrhea.)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Not Sick No Diarrhea

PDMal

OR=0.18 OR=5.16

65%

25%

83%

48%

Other Important PD Findings

• 0% of PD children were ill with diarrhea during the past two weeks vs. 29% of malnourished children.  (p=0.02) (Role of diarrhea in malnutrition)

• 67% of mothers of PD children said that their child's drinking water was treated were 3.6 times more likely to be positive deviance (well nourished). [p=0.03, OR = 3.64 (CI: 0.99-13.9)]. (Role of untreated water.)

• PD nutrients: B2, potassium, and magnesium appear to be associated with PD in this population.

Exclusive Breastfeeding FH/Mozambique Child Survival Project

17

6775

95

0

20

40

60

80

100

Feb 06 May 06 Sep 07 Dec 07

Series1% EBF

EBF promotion

started April

2006

Decrease in Malnutrition

All districts at or above project target for EBF.

Underweight FH CS Project in 4 districts of Central Mozambique

18.7%

15.6%

26.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Feb 06 Sept 07 Sept 08

Caia, Chemba, Manga, & Marringue Districts, Sofala Province

Recommendations based on PD Practices / Situations identified in Burundi LDM Study – change slide

• Cultural practices to consider when planning messages and project activities– Offering beer after birth as a pre-lacteal feed

– Threatening children who refuse to eat with “If you don’t eat, and animal will come and eat you!”

– Preference for delivering at home instead of at health clinic

– Women’s large work responsibilities

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