Local Determinants of Malnutrition: An Expanded Positive Deviance Study

Local Determinants of Malnutrition: An Expanded Positive Deviance Study Presenter: Julie Hettinger, MS RD Maternal 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 workshop
2 days training
3 days data collection
2 days data entry / analysis
1 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

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
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.”
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.
Hygiene Practices
PD children are 5.9 times more likely to defecate in a proper spot (diaper or latrine). (35% PD vs. 8% Mal)
Suggested Educational Messages Suggested Action Finding

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 Message: When breastfeeding a child, it is important to always completely empty each breast so that the child gets all of the calories and nutrients that 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 PD 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 RD Maternal and Child Nutrition Specialist
Food for the Hungry
236 Massachusetts Ave, NE Suite 305
Washington, DC 20002
202-547-0560
[email_address]
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
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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 Message: All mothers should take iron supplements during pregnancy and while lactating as a way to help 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.)
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.

Decrease in Malnutrition All districts at or above project target for EBF.

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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Local Determinants of Malnutrition: An Expanded Positive Deviance Study

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Local Determinants of Malnutrition: An Expanded Positive Deviance Study — Presentation Transcript

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