Local Determinants of Malnutrition: An Expanded Positive Deviance Study


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Local Determinants of Malnutrition: An Expanded Positive Deviance Study

Julie Hettinger, Food for the Hungry

Nutrition Working Group Showcase

CORE Group Spring Meeting, April 29, 2010

Published in: Health & Medicine
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  • Here's a narrated presentation on this methodology: http://caregroupinfo.org/vids/ldmstudy/player.html.
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  • When and How to do this study. A local determinants of malnutrition study has a specific time and place in a program cycle when it is most useful.
  • Differ from area to area, supplement what we see in literature
  • Look to see if they exist in other countries
  • In the case of depression, World Vision recently carried out a low-cost project in Uganda using Interpersonal Therapy for Groups to decrease depression. Community-level workers were taught to work with people in groups for “talk therapy” which decreased depression by 92%.
  • Or potential causes
  • Now I am going to present to you the study methodology. The first step was a literature review…
  • Point 3: Local staff developed fishbone diagrams of the causes of malnutrition that they suspected. In some fields, we added questions to the questionnaire to take into account their ideas on local causes. Also, staff saw the questionnaire ahead of time and were given the opportunity to add questions. In Ethiopia, for example, they had done previous, smaller PD studies as part of Hearth trainings, and they suggested adding the questions on removing milk teeth and uvulectomy.
  • One of the questions (Question 25) examines certain foods that the child may or may not eat during a normal week…
  • Training materials were put together and then we started doing workshops with our staff in several of our field offices. The multi-day workshops were designed to include time to use the questionnaire to collect the data for the study as well as analyze it. In Ethiopia the workshop lasted 8 days and included 2 days of training, 3 days of data collection, 2 days of data entry and analysis, and 1 day to discuss the results and potential application.
  • The WAZ (weight for age Z-score) cut-off for PD children varied from country to country. The protocol called for having a PD population of at least 15% and starting with a cut-off of WAZ>0. In regions where finding well nourished children was extremely difficult at those higher levels, we lowered it to -0.5 or -1.0, but never lower than -1.0.
  • Supervisor checks child’s age, makes sure the mother is at a similar socio-economic level as her neighbors.
  • Triage persons weigh child, supervisor consults chart and determines if child qualifies for study as Mal or PD.
  • Interviewer conducts interview in a private place where others cannot hear the mother’s answers
  • Afterwards a health talk (not about themes in the questionnaire) is given to the remaining mothers and community members.
  • It was not difficult for workshop participants to learn how to interpret 2x2 tables and do Analysis of Variance with Epi-Info. In fact, because they had been involved in the data collection, they had a vested interest in learning how the data was analyzed.
  • Mention that we have the LDMS methodology written up, including the questionnaires, and we can make that available on the SBCWG website if people are interested.
  • This is a program planning tool that gives us a shorter list of things that are much more likely to be driving malnutrition in a program area so that we can make changes to our program to address each possible cause. Also, when we find findings that are contrary to the current thinking, we do not move ahead with programming concerning that, but instead, look into the reasons for it.
  • A local determinants of malnutrition study has a specific time and place in a program cycle when it is most useful.
  • When we looked into the context of result #2, we realized that some of the malnourished children had a really late introduction to solid foods (i.e. 24m, 36m) which seems to indicate that prolonged breastfeeding beyond 2y was a coping mechanism for minimal or lack of food. While discussing how to apply this result, we talked about an intervention that focused on the techniques of appropriate breastfeeding and appropriate complementary feeding. Q: Did you do multivariate analysis? A: No, but we did look for confounding on some variables. We didn’t have the time for multivariate analysis, the skills on staff, and given our small sample size, did not think that multivariate analysis would yield very much anyway.
  • Local Determinants of Malnutrition: An Expanded Positive Deviance Study

    1. 1. 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
    2. 2. 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
    3. 3. What is the Local Determinants of Malnutrition tool and study? <ul><li>Community based assessment tool </li></ul><ul><li>Useful in formative research </li></ul><ul><li>Brief summary of the study: </li></ul><ul><ul><li>Mothers of well nourished children and mothers of malnourished children are interviewed with a LDM questionnaire. </li></ul></ul><ul><ul><li>Data from the two groups are compared to determine how they differ on each question. </li></ul></ul><ul><ul><li>Statistically significant differences (determinants) are examined further. </li></ul></ul>
    4. 4. Why this tool? <ul><li>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. </li></ul><ul><li>Enables the development of more focused and effective behavior change communication messages and program strategies. </li></ul>
    5. 5. Applying the LDM Study <ul><li>Ideally, the LDM study would be conducted at the beginning of a project period (as a stand-alone study). </li></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>May be helpful in identifying entirely new areas of intervention that an organization can take on to reduce malnutrition. </li></ul></ul></ul><ul><ul><li>it is not a study that would be done as part of the Hearth nutritional rehabilitation model </li></ul></ul>
    6. 6. Background <ul><li>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. </li></ul>
    7. 7. Background <ul><li>Most positive deviance (PD) studies as part of PD/Hearth programs have focused on: </li></ul><ul><ul><li>foods that make up a child’s diet (food types, but not quantities or frequency of consumption) </li></ul></ul><ul><ul><li>assessing the “three goods”: </li></ul></ul><ul><ul><ul><li>Good feeding practices </li></ul></ul></ul><ul><ul><ul><li>Good child care practices </li></ul></ul></ul><ul><ul><ul><li>Good health care seeking practices </li></ul></ul></ul>
    8. 8. Background <ul><li>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. </li></ul><ul><ul><li>depression in the mother </li></ul></ul><ul><ul><li>intake of specific nutrients (e.g., magnesium, potassium and phosphorus </li></ul></ul><ul><ul><li>child care practices (e.g. spanking) </li></ul></ul><ul><ul><li>maternal diet during breastfeeding </li></ul></ul><ul><ul><li>alcoholism among family members </li></ul></ul>
    9. 9. Background <ul><li>Reason that these factors have not been well studied </li></ul><ul><ul><li>Previously assumed that little could be done to change the situation </li></ul></ul><ul><ul><ul><li>Not true anymore </li></ul></ul></ul><ul><ul><ul><li>Example: Interpersonal Therapy for Groups to decrease depression </li></ul></ul></ul>
    10. 10. Background <ul><li>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. </li></ul>
    11. 11. Methodology <ul><li>Literature Review </li></ul><ul><ul><li>The literature on causes of malnutrition was reviewed by Phil Moses, MPH and Tom Davis, MPH. </li></ul></ul><ul><ul><ul><li>Examined positive deviance studies </li></ul></ul></ul><ul><ul><ul><li>Reviewed other studies that provided information on the causes of malnutrition </li></ul></ul></ul><ul><ul><ul><li>Specifically looked for causes dealing with nutrient intake, feeding practices, and psycho-social causes </li></ul></ul></ul><ul><ul><ul><li>Looked for factors associated with malnutrition and thought to be causative because a mechanism for causation exists </li></ul></ul></ul>
    12. 12. Methodology <ul><li>Matrices </li></ul><ul><ul><li>Developed matrices of possible determinants based on: </li></ul></ul><ul><ul><ul><li>strength of the association or severity of the problem </li></ul></ul></ul><ul><ul><ul><li>feasibility of measuring it </li></ul></ul></ul><ul><ul><ul><li>degree to which it was susceptible to change during a short-term program or through a different intervention </li></ul></ul></ul><ul><ul><ul><li>scope of the problem (prevalence) </li></ul></ul></ul><ul><ul><li>Each determinant was rated for each criteria and assigned a total score </li></ul></ul>
    13. 13. Methodology <ul><li>Questionnaire Development </li></ul><ul><ul><li>Developed questions to measure the highest ranked matrix determinants in the questionnaire </li></ul></ul><ul><ul><li>Drew from previous PD surveys and scientific studies for the questions, or developed new ones when pretested questions were not available. </li></ul></ul><ul><ul><li>Tested the questionnaire in Mozambique study, which resulted in a shortened and improved LDM study questionnaire. </li></ul></ul>
    14. 14. Methodology <ul><li>Questionnaire Development </li></ul><ul><ul><li>Intake of Specific Foods </li></ul></ul><ul><ul><li>Process of selecting foods </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>
    15. 15. Methodology <ul><li>Workshop has been taught and the study implemented in 5 FH fields: </li></ul><ul><ul><ul><li>Mozambique (Sept 2004) </li></ul></ul></ul><ul><ul><ul><li>Kenya (Sept 2005) </li></ul></ul></ul><ul><ul><ul><li>Bolivia (August 2007) </li></ul></ul></ul><ul><ul><ul><li>Ethiopia (May 2008) </li></ul></ul></ul><ul><ul><ul><li>Burundi (Sept 2009) </li></ul></ul></ul><ul><ul><ul><li>Usually an 8 day workshop </li></ul></ul></ul><ul><ul><ul><li>2 days training </li></ul></ul></ul><ul><ul><ul><li>3 days data collection </li></ul></ul></ul><ul><ul><ul><li>2 days data entry / analysis </li></ul></ul></ul><ul><ul><ul><li>1 day applying results </li></ul></ul></ul>
    16. 16. Methodology <ul><li>Study Design </li></ul><ul><ul><li>Divide mothers of children 12-59m into 3 groups </li></ul></ul><ul><ul><ul><li>1) those with a well nourished child </li></ul></ul></ul><ul><ul><ul><li>(WAZ>-1.0) </li></ul></ul></ul><ul><ul><ul><li>2) those with a malnourished child </li></ul></ul></ul><ul><ul><ul><li>(WAZ<-2.0) </li></ul></ul></ul><ul><ul><ul><li>3) those who fall in between (excluded from study) </li></ul></ul></ul>
    17. 17. Methodology <ul><li>Collecting Data </li></ul><ul><ul><li>Workshop training on how to use questionnaire and get informed consent. </li></ul></ul><ul><ul><li>Used CHWs and leaders to assemble women and children at a central location for geographically dispersed communities. </li></ul></ul><ul><ul><li>Team of workshop participants weigh and classify children, and interview qualifying mothers using questionnaire. Interviewers not told status of child. </li></ul></ul><ul><ul><li>Desired sample size: </li></ul></ul><ul><ul><ul><li>45 PD and 45 malnourished </li></ul></ul></ul>
    18. 18. Data Collection
    19. 19. Data Collection
    20. 20. Data Collection
    21. 21. Data Collection
    22. 22. Methodology <ul><li>Data Analysis </li></ul><ul><ul><li>Workshop participants entered data into a pre-written Epi-Info 6.04d data template. </li></ul></ul><ul><ul><li>Workshop participants reviewed the Epi-Info program output for significant results </li></ul></ul><ul><ul><ul><li>2 x 2 tables </li></ul></ul></ul><ul><ul><ul><li>ANOVA </li></ul></ul></ul><ul><ul><ul><li>Check for confounding </li></ul></ul></ul>
    23. 23. Methodology <ul><li>Data Analysis </li></ul><ul><ul><li>Differences between the PD and malnourished groups were considered to be statistically significant </li></ul></ul><ul><ul><ul><li>if p < 0.05 or </li></ul></ul></ul><ul><ul><ul><li>if the range for the 95% confidence interval for the odds ratio (done as part of the analysis) did not include 1.0. </li></ul></ul></ul>
    24. 24. Methodology <ul><li>Application of Results </li></ul><ul><ul><li>Workshop participants discussed findings in large group. </li></ul></ul><ul><ul><li>Participants strategized ways to address these findings in the context of a community health program. </li></ul></ul><ul><ul><ul><li>Suggested Actions </li></ul></ul></ul><ul><ul><ul><li>Suggested Educational Messages </li></ul></ul></ul>
    25. 25. LDM Study Example – Ethiopia <ul><li>Dispel myth that child’s feces are safe and communicate safe disposal of stool in a latrine. </li></ul><ul><li>“ Every house should have a latrine and use it...” </li></ul><ul><li>“ Soap helps remove germs – Wash diapers with soap as well as water.” </li></ul><ul><li>Promote home practices of safe stool disposal and handwashing with ash/soap. </li></ul><ul><li>Encourage every household to have a latrine. Consider barrier analysis on this behavior. </li></ul><ul><li>Promote washing diapers in soapy water. </li></ul><ul><li>Hygiene Practices </li></ul><ul><li>PD children are 5.9 times more likely to defecate in a proper spot (diaper or latrine). (35% PD vs. 8% Mal) </li></ul>Suggested Educational Messages Suggested Action Finding
    26. 26. LDM Study Example - Mozambique <ul><li>45% of mothers of PD children said that they usually or always completely emptied their breasts when breastfeeding their PD child. </li></ul><ul><li>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. </li></ul>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.
    27. 27. 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)
    28. 28. Monitoring of Behaviors and Beliefs related to Exclusive BF PD Behavior
    29. 29. Conclusion <ul><li>The study of Local Determinants of Malnutrition was designed: </li></ul><ul><ul><li>to provide greater understanding of all the factors that contribute to malnutrition </li></ul></ul><ul><ul><ul><li>food and feeding practices </li></ul></ul></ul><ul><ul><ul><li>child care practices </li></ul></ul></ul><ul><ul><ul><li>care seeking practices </li></ul></ul></ul><ul><ul><ul><li>psychosocial and other environmental factors </li></ul></ul></ul><ul><ul><ul><li>mothers’ worldview </li></ul></ul></ul>
    30. 30. Conclusion <ul><li>Results of the study of Local Determinants of Malnutrition provide: </li></ul><ul><ul><li>Insight into what practices and foods should be promoted in each country context, and </li></ul></ul><ul><ul><li>Suggestions as to what additional interventions should be added to health, nutrition, and food security programs </li></ul></ul>
    31. 31. <ul><li>Contact: </li></ul><ul><li>Tom Davis, MPH </li></ul><ul><li>Director of Health Programs, or </li></ul><ul><li>Julie Hettinger, MS RD Maternal and Child Nutrition Specialist </li></ul><ul><li>Food for the Hungry </li></ul><ul><li>236 Massachusetts Ave, NE Suite 305 </li></ul><ul><li>Washington, DC 20002 </li></ul><ul><li>202-547-0560 </li></ul><ul><li>[email_address] </li></ul><ul><li>Narrated Presentation can be found at www.caregroupinfo.org </li></ul>
    32. 33. Expanded Positive Deviance Study <ul><li>Application of the Local Determinants of Malnutrition Study </li></ul><ul><ul><li>Conducted as formative research at the beginning of a PM2A project </li></ul></ul><ul><ul><ul><li>Use results to identify what interventions are needed, and what behaviors to give extra attention to during project activities. </li></ul></ul></ul><ul><ul><ul><li>Identify PD behaviors to focus on in Care Groups and to integrate into project curriculum. </li></ul></ul></ul><ul><ul><ul><li>May be helpful in identifying entirely new areas of intervention for the project to take on to reduce malnutrition. </li></ul></ul></ul>
    33. 34. LDM Study Example – Ethiopia - combine with next slide <ul><li>  </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul><ul><li>   </li></ul>
    34. 35. Important BF Results of the Expanded PD Study <ul><li> 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 . </li></ul><ul><li>(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. </li></ul>KEY Message: All mothers should take iron supplements during pregnancy and while lactating as a way to help their children grow.
    35. 36. PD Practices / Situations identified in Burundi LDM Study <ul><li>Child not sick with any disease in last two weeks </li></ul><ul><ul><li>(PD children were 5.5 times less likely to have any disease in the past two weeks.) </li></ul></ul><ul><li>Child not sick with diarrhea in last two weeks </li></ul><ul><ul><li>(PD children are five times less likely to have diarrhea.) </li></ul></ul>OR=0.18 OR=5.16 65% 25% 83% 48%
    36. 37. Other Important PD Findings <ul><li>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) </li></ul><ul><li>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.) </li></ul><ul><li>PD nutrients: B2, potassium, and magnesium appear to be associated with PD in this population. </li></ul>
    37. 39. Decrease in Malnutrition All districts at or above project target for EBF.
    38. 40. Recommendations based on PD Practices / Situations identified in Burundi LDM Study – change slide <ul><li>Cultural practices to consider when planning messages and project activities </li></ul><ul><ul><li>Offering beer after birth as a pre-lacteal feed </li></ul></ul><ul><ul><li>Threatening children who refuse to eat with “If you don’t eat, and animal will come and eat you!” </li></ul></ul><ul><ul><li>Preference for delivering at home instead of at health clinic </li></ul></ul><ul><ul><li>Women’s large work responsibilities </li></ul></ul>
    39. 41. SUBHEADING The sidebar summary
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