Engaging a rural community in identifying actions to address household level-determinants of low birth weight

1. Engaging a rural community in identifying
actions to address household level-
determinants of low birth weight
G. G. N. Duminda1
, Sansfica M. Young2
, Manuja
Perera3
, Samath Dharmarathna4
,Wasantha
Gunathunga5
1
1
Department of Health Promotion, Faculty of Applied Sciences, Rajarata University of
Sri Lanka, Mihintale;
2
Department of Environmental Technology, Faculty of Technology, University of
Colombo, Colombo, Sri Lanka,
3
Department of Community Medicine, Faculty of Medicine, University of Kelaniya
4
Department of Community Medicine, Faculty of Medicine , University of Peradeniya,
5
Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri
Lanka.

2. Rationale
 Major contribution to under nutrition in children
under 5 years (WHO, 2011)
 Long term effects on physical and mental
development (ACC/SCN of United Nations’ 2000)
 Higher risk of developing NCDs in later life (Barker
1998; Barker 2007; Osmond & Barker 2000)
 Inter-generational effects (Osmond & Barker 2000)
 Low- birth weight rate has not improved much over
the past 10 years (Ministry of Health, 2010 15.7%,
2016)
2

3. • Ante-natal period, the first 280 days of the first 1000
days of life, is an important stage (UNICEF 2007; World
Bank 2008).
• Programmes using empowerment model of health
promotion that involve communities in addressing
determinants are effective (Nordenfelt & Liss 2003).
3

4. • We had used this intervention model
successfully to reduce malnutrition and
NCDs.
• It had also shown promising results for LBW
but had not been scientifically evaluated for
LBW.
4

5. Background/Objectives
• Child’s nutritional status is significantly influenced by
his/her birth weight.
• In Sri Lanka, 90% of pregnant women get registered
for universally available government antenatal field
clinic services.
• Thus, ante-natal period, an important stage in the
life cycle in which the interventions to improve birth
weight can be implemented, also becomes a window
for feasible action to address the stagnating low
birth weight prevalence rates of the country.
5

6. • Literature suggests that involving
communities in addressing determinants of
their own health are effective in addressing
complex problems.
• Thus, this study aims to describe the methods
of engaging a rural community in identifying
actions to address household level
determinants of LBW during pregnancy.
6
Background/Objectives

7. Methodology
Design:
•A quasi-experimental design employing
mixed methods
•A process evaluation, not in the orginal
proposal, was tested as an addition
7

8. The total sample size (N=403) was proportionately divided to the 3 MOH areas
according to the population proportion of pregnant mothers registered in each
area in the preceding quarter
Sample size calculation – Pocock 1983
Selected 2 Districts
CG Polonnaruwa
7 MOH
IG Anuradhapura
19 MOH
7 MOH
7 MOH
3 MOH
3 MOH
Compared
and paired
Selected
randomly
 Sector - (ie. Urban, semi urban and rural)
 Socio- Economic characteristics,
population density.
Based on the following
Selection of Subjects
10
ANC randomly
selected
Sample
size 403
196
80
127 9
7
177
99
127
26
28
7
15
6

9. Number of ANC’s in a particular MOH area
Number of pregnant mothers to be recruited from the particular MOH area
Recruiting participants till the requirement was fulfilled in each MOH
Number of pregnant mothers and partners selected particular MOH area
Then the ANCs were selected randomly by lottery method – Annex 1
Number of lowest pregnant mothers registered in the smallest ANC in the
particular MOH area in the preceding quarter from the particular MOH area
per day
=
9
Selection of Subjects (Cont.)

10. Pre intervention assessment
Development of instruments – Tool 1,2 and 3
Find components of the instruments – Literature review
Collect information about components – Expert panel of 9 (Met individually) KII
To find existing Knowledge about components - Focus group discussions with
mothers (2) and partners (1) to prepare the components
•Attention was also paid to identify terms and words
•represent different categories
Prepare the instruments
Review the instruments with 04 of the experts
Revise the instruments
Pre test the instrument – 30 mothers and partners in Matale
Next
Content of Ins
Development of instruments – Tool 3 -Data extraction sheet
Was done by discussions with expert panel till an agreement was reached10

11. Post Evaluation (Outcome Evaluation.)
Post intervention assessment was conducted in
two phases;
•Phase I - at or around completion of 36 weeks of
POA – Tool 1,2,3,4
•Phase II - at or around 28th
day of the post natal
period – Tool 5.
Development of instruments – Tool 4 and 5
• In-depth interview guide and observation check
list
• Was done by literature review and discussion with
supervisor till an agreement was reached.
11

12. Intervention
ANC 26 (mothers group) including 10-20 pregnant mothers
Forming 71 NAC (including avg 5 pregnant mothers)
-NAC meeting monitored by RA or researcher
-Decide on which determinants
-What action to be taken
-Plans were made for intervention
Initial 26 sessions (3hrs per session) – Steps 1, 2, 3 of the model
Follow up around two months after 1st
session, Steps 2, 3, 4 of the model
-At lest one follow up session with mothers and partners
Development of the Health promotion tool with the participants
Methods of giving Inputs for MOH area
Telephone calls, Pocket meetings, Field visits, Community meetings, Study visits
12

13. 13
NNE Madawachiya Mihintale
1 Follow up session/s 27 25 19
2
Telephone calls
(telephone calls / number of Mothers) 170/196 101/127 70/80
3 Pocket meeting 34 22 14
4 Field visit 34 22 14
5 Community meeting 8 6 4
6 Study visit (visiting nearby NAC) 13 9 5
Methods Number of Inputs for each MOH area

14. Intervention approach
‘Health Promotion’ =
people taking control over the conditions that
govern their lives
Plus some other elements
14

15. Addressing ‘causes’
• Analyzing the underlying factors (or determinants)
• Selecting which to address
• Working out ways to assess change
• Addressing prioritized determinants
• Modifying actions on the basis of progress
assessed along the way
15

16. Determinants that the community chose to
address:
1. Maternal nutrition
2. Partner’s support
3. Maternal rest
4. Maternal happiness
5. Care by family
6. Indoor air pollution
7. Exposure to tobacco smoke
8. Poverty
9. Maternal infections
10. Inequities
16

17. Actions Determinants
1=Maternal nutrition; 2=Partner’s support; 3=Maternal rest; 4=Maternal
happiness; 5=Care by family; 6=Indoor air pollution; 7=Exposure to tobacco
smoke; 8=Poverty; 9=Maternal infections; 10=Inequities
1 2 3 4 5 6 7 8 9 10
1 Nutrition diary/ calendar x x x x
2 Vibhaga Pohora x x x
3 Model menus x x
4 Food sharing x x x x x x
5 Home gardening x x x x x
6 Reduction of processed food use x x
7 Participation calendar x x x x x x
8 Happiness calendar x x x x x
9 Pregnant mother’s room x x x x x
10 Expenditure diary x x x x
11 ‘Smoke free homes’ x x x x x
12 Reduction of tobacco use x x x x x
13 Reduction of alcohol use x x x x x
14 Remodeling kitchens x
15 Siriyavantha Nivasa x x x x x x
16 Stimulation calendar x x x x
17 Listening to lullabies x x x x
18 Interactions with nature x x x x
19 Collective feeding x x x x x
20 Collective ‘play houses’ x x x x
Summary of determinants targeted by identified actions
17

18. Actions incorporated with measuring
tools prepared with participants
• Nutrition calendar/diary
• Participation calendar
• Happiness calendar
• Stimulation calendar
• Expenditure diary
18
Even though they appear to be purely community tools of
measurement, they serve in some ways also as interventions.

19. Tools
Figure 3.3: Examples of nutrition calendars and nutrition diaries 19

20. Figure 3.4: Examples of Participation Calendars
20

21. Figure 3.5: Examples of Happiness Calendars and Self-analysis records of ‘happiness’
21

22. Examples of Stimulation Diary/Calendars
Examples of baby room / pregnant mother’s room
22

23. • Example
Mostly of educational level of OL or below
Never exposed to education on ‘research
methods’
But interested and enthusiastic because study
was about their lives
23

24. 24
Video of Intervention

25. Mothers and communities
 Main strategy is to plan and design study with the
community
 Mothers took leadership in every aspect of the
intervention
 They analysed and selected determinants to
address
 They agreed on the best available measures for
assessing process and outcomes – not only final
impacts
 The outcomes were specially good because the
people did their own intervention and research 25

26. Results – Knowledge
Category Mother Partner
IG
(Post-Pre)
CG
(Post-Pre)
IG
(Post-Pre)
CG
(Post-Pre)
Foetal development, consequences
of impaired foetal growth and
monitoring (Score=10)1
(8.0-5.3)
2.7
(6.1-4.1)
2.0
(7.1-4.2)
2.9
(4.3-2.6)
1.7
Birth weight and determinants
(Score=11)1
(10.4-7.3)
3.1
(7.9-6.1)
1.7
(9.2-6.3)
2.9
(6.7-4.3)
2.4
Maternal nutrition (Score=6)3
(3.9-3.4)
0.5
(3.2-2.8)
0.4
(4.0-3.0)
1.0
(3.4-3.1)
0.3
Stimulating the foetus (Score=3)4
(2.9-2.1)
0.8
(1.9-1.6)
0.3
(2.9-2.2)
0.7
(2.3-1.7)
0.6
Total (Score= 30) (25.8-19.3)
6.5
(19.9-15.1)
4.8
(23.9-16.5)
7.4
(19.7-13.8)
5.9
Significantly higher gains in knowledge were seen among
both mothers and their partners in IG. 26

27. Knowledge
Mothers Partners
IG CG IG CG
Mean difference of total
score 30
(M1-M2)
6.5
(25.8-19.3)
Table 4.18
4.8
(19.9-15.1)
Table 4.18
7.4
(23.9-16.5)
Table 4.30
5.9
(19.7-13.8)
Table 4.30
Z score M1-M2 P=0.0001 P=0.0052
Summary of Findings
27
Mean difference of knowledge scores before and after intervention among
mothers and partners – between groups.

28. 28
Comparison of mean difference of knowledge among those with low
initial scores (<10) – between groups
Mothers
IG CG
Mean difference of
knowledge among those
with low initial scores
(<10) (M1-M2)
14.35 7.1
7.25
Z score M1-M2 P<0.0060

29. Care of the mother and the newborn
Perceived rest has significantly improved in IG
compared to CG.
Summary of Findings
29
Mean difference of care scores before and after intervention among mothers and
partners in the IG and CG. (Perceived rest )
Rest received by
pregnant mothers
IG CG
Sig.
(n=332) (n=333)
Mean SD. Mean SD.
According to mothers 1.47 1.94 0.68 1.82
t= -5.384
df= 663
p<0.001
According to partners
(n=270) (n=239) t= -1.861
1 1.74 0.71 1.64 df= 507
p= 0.016

30. Care of the mother and the newborn
Perceived support has significantly improved in IG
compared to CG.
Summary of Findings
30
Mean difference of care scores before and after intervention among mothers and
partners in the IG and CG . (Perceived support )
Support received by
pregnant mothers
IG CG
Sig.
from partners (n=228) (n=188)
Mean SD. Mean SD.
According to mothers 0.74 1.16 0.21 0.84
t= 5.141
df= 414
p<0.001
According to partners
(n= 225)
(n=192) t= 1.659
0.33 0.80 0.21 0.64 df= 415
p= 0.001

31. Low birth weight
• There was a significant difference in the prevalence
of LBW between the intervention and comparison
groups {(IG=10.0%; CG=19.2%; X2
=12.465; p<0.001; Table 4.62)
• Mean birth weight was 215g higher in the IG than the
CG (t=6.934; df=726; p<0.001; Table 4.63).
Results –
31

32. Compared to the comparison group prevalence of
LBW was significantly lower among..
1. The Nuclear family living alone
2. Partner not living at home
3. Partner was smoking before (pre-
intervention)
4. Low maternal height
5. History of LBW
6. Unplanned pregnancy
7. Maternal Hb level <11g/dl
32

33. 1. Teenaged mothers
2. Mother not having secondary education
3. Nuclear family
4. Partner not living at Home
5. Partner smoking (pre-intervention)
6. Primi
7. Low pre-pregnancy BMI
8. History of LBW
9. Unplanned Pregnancy
10. Not gaining expected maternal weight
11. Preterm Deliveries
12 Mothers with low knowledge score (<50% of total)
13. Partners with low knowledge score (<50% of total) 33
Compared to the comparison group Mean birth
weight was significantly higher in these sub
groups.

34. The weight gain is seen to result from an organic
process that gradually involved all households.
The families themselves learnt to assess how
the process was progressing.
Example
34

35. The process addressed underlying causes or
determinants.
Mothers and families assessed the outcomes in
these factors too.
So the higher birth weights did not suddenly
appear out of the blue. The increase came
about through a series of changes in selected
determinants of LBW.
35

36. Conclusions
Thus it is reasonable to conclude that the
intervention was effective because of
• The higher weights and lower prevalence of
LBW in the IG is significant
• And the qualitative evidence which
demonstrates the process and the causal
chain through which these gains were
achieved
36

37. Recommendations
A cautious recommendation can be made
that field health staff in a limited area should
be experimentally trained in the interactive
“health promotional” approaches used here.
This will assist in determining whether such
additional training for a selected group of
current health sector staff will lead to their
applying the relevant principles and skills in
their routine work.
37

38. Incidental Lessons
• Benefits are still sustained, more than 5 years
after intervention phase
• Mothers and families with little formal
education did very well as ‘health promoters’
and as ‘researchers’.
• Probably because this was not a project or
research for them but it was their life.
38

39. Acknowledgments
• Supervisors, Prof. M.W. Gunatunga, Prof. S. Dharmarathne, Dr. Manel
Goonesekara
• Pregnant mothers, their partners and families and other members of their
communities
• Prof. Diyanath Samarasinghe, Prof. Lalani Rajapaksa
• Dr. Manuja Perera, Prof. G. Crans, Prof. L. Anderson, Ms. N. Liyanage, Ms. K
Jaysinghe, Ms. C. Perera.
• Dr. Manoj Fernando, Dr. Lalith Senarthne, Dr. Kalana Peiris and Dr. Sameera
Hewage
• Public Health Midwives and Supervisory Public Health Midwives
• Provincial Director of Health Services, Regional Directors of Health Services,
Medical Officers of Health and Public Health Nursing Sisters
39