INTRODUCTION 1. The urgency of thesis Protein - Energy Malnutrition (PEM) in Vietnam often called malnutrition. Malnutrition in general and stunting in particular is still a public health significant problem in developing countries, including Vietnam. According to the 2000 report of the Standing Committee on Nutrition of the United Nations and Research Institute for the International Food Policy (ACC/SCN/ IFPRI), about 30 million newborns affected by the consequences of fetal malnutrition and about 185 million children <5 years of age (34%) were stunting in the developing countries; In 2005, still about 178 million children <5 years of age (32%) were stunted in developing countries. In Vietnam, underweight rate of children under 5 years of age decreased relatively rapidly and continuously from 1985 to 2000, while stunting rate still high, especially in poor areas, overweight, obesity and a number of non-communicable chronic diseases associated with nutrition increased. In Hanoi, underweight rate was decreased rapidly from a low level (18.7% in 2001) to a very low level (8.6% in 2011), while stunting was not decreased but increased (15.6% in 2001, 17.8% in 2011). Soc Son is a poor suburban district of Ha Noi, with the high rate of malnutrition (stunting was 25% in 2007) due to many reasons such as low maternal educational level, nutrition limited knowledge and practice. Therefore, many intervention programs have been implemented, of which an important solution is to build and deploy a pilot intervention by only active education and communication. In this context, the study 1 namely “Assessing the effectiveness of nutrition education for mothers to reduce malnutrition for children under 24 months of age in Soc Son District, Ha Noi” has been conducted. Study objectives: 1. To describe status of malnourished children under 24 months of age and mothers’ knowledge and practices on child malnutrition control at six communes in Soc Son district (2010). 2. To assess the effectiveness of interventions to improve knowledge and practices of mothers on child malnutrition control at 3 communes in Soc Son district (2010-2011). 2. New scientific and practical contributions of the thesis 2.1. With the designed cross-sectional descriptive study on a large enough sample size, updated technical and analysis of collected data application in phase 1, the study has identified the malnutrition rate of children under 24 months of age in 6 communes of Soc Son Hanoi in 2010: underweight was at very low level classified by the WHO, 7.8 %, stunting at low level, 19.1% and wasting 3,9 %, all of these are lower than national average. At the same time, it has specified that right in a suburb of Hanoi, the knowledge; practices for child malnutrition control, diet diversification, care of sick children, personal hygiene of mothers with children under 24 months of age were still very limited. This may be considered the new findings about realities and the causes of child malnutrition in Soc Son. 2. In phase 2, the early long-term (12 months) intervention by only active education and communication has had plausible conclusions and recommendations which very useful for child malnutrition 2 control programs. These are the new scientific and practical contributions to the specializations of Social hygiene and health organization, and Community Nutrition. 3. Layout of the thesis The dissertation consists of 131 pages (excluding references and appendices), with the following parts and chapters: Introduction: 02 pages Chapter 1. Overview: 36 pages Chapter 2. Subjects and Methods: 26 pages Chapter 3. The findings: 29 pages Chapter 4. Discussion: 35 pages Conclusions: 02 pages Recommendations: 01 pages 125 dissertation reference materials, including 62 Vietnamese and 63 documents in English. 3 Chapter 1 OVERVIEW 1.1. Nutritional status and child malnutrition Protein - Energy Malnutrition (PEM) includes 3 forms: underweight, stunting and wasting of different levels, mild, moderate and severe. According to WHO 2005, 32.5% of children under 5 years of age in developing countries are stunted, the 2 highest prevalence areas were Africa and Asia (33.8% and 29.9%). From 1980 to 2000, the estimated number of stunted children was reduced by approximately 6.2 million. According to WHO and The Lancet January 2008, some 40% of countries have stunting rates higher than 40%. Problem is that the stunting rate was highest in the lowest quintile population. In Vietnam, the prevalence of underweight from 51% in 1985, dropped to 33.8% in 2000, fell sharply to 19.9% in 2008. Wasting was 8.6% in 2000; fell below 5% in 2008. Stunting decreased from 56.5% in 1990 to 36.5% in 2000 and remained high at 29.3% in 2010 and there is a big difference between regions. Figure 1.6. Vietnam malnutrition rates among under five children 2000 – 2013 4 Figure 1.6 showed the rate of child malnutrition 2000 - 2013. Immediate causes of malnutrition are identified including inappropriate eating and disease. Underlying causes includes household food insecurity, inadequacy of maternal and child care services, knowledge of caregivers, family care, water supply and sanitation and unsanitary housing conditions. The basic causes of malnutrition is defined political structure, socio-economic and cultural factors, potential resources (environment, technology, humans), including poverty, backwardness, underdevelopment, including economic inequality, especially economic crisis. Malnutrition has been found leading to obvious heavy consequences on the child intellectual development, behavior, learning ability, height stature, and work capacity of adulthood, chronic diseases and influencing to the next generation. 1.2. The solutions for malnutrition control Global focus on 3 main solutions: 1) Increased nutrients intake (both quality and quantity), including protein and energy supplements for pregnant women, strategies to encourage breastfeeding, quality improvement of complementary foods; 2) Supplementation of micronutrients, including iron, folic acid, vitamin A, calcium for pregnant women; Iodized salt supplements, vitamin A and zinc for infants; 3) Reducing the burden of disease. In Vietnam, malnutrition prevention measures have been implemented during war time, but the effect was very limited. From the last decade of the XX century to the present, Vietnam has developed and deployed the National Target Program for Protein 5 Energy Malnutrition control since 1994, Program for micronutrient deficiency control, the National Plan of Action for Nutrition 1995- 2000, National strategy for Nutrition 2001-2010 and National strategy for Nutrition 2011-2020 with a vision to 2030. Nutrition education and communications has always been regarded as a key solution through the programs’ plans and strategies’ framework. However, the activity found to be heavily on the put-forms or movements, just in some kinds of campaign, but not really the practical operation, resulting in low effectiveness and lack of sustainability. 1.3. Education and communication research for malnutrition control Many studies to change knowledge, attitudes and practices (KAP) for control of micronutrient deficiencies and malnutrition have been deployed in the region, in the world and in Vietnam. However, most of these studies were coordinated with food or micronutrients supplements. The idea of our study is based on the theoretical and practical basis: active nutrition education and communication can change the mothers’ nutrition and child care habits, then the children will get improved diets, indirectly reduce the rate of child malnutrition; At the same time, the mothers ‘nutrition habit/ practice changes affect themselves before and during the subsequent pregnancy to actively prevent fetal malnutrition and low birth weight. 6 Chapter 2 SUBJECTS AND METHODOLOGIES 2.1. Subject, location and time bound of the study The research was conducted on mothers and children under 24 months of age in 6 communes of Soc Son, Hanoi from 1/2010 - 30/4/2011. 2.2. Research methodologies 2.2.1. Study Design: The study consists of two phases Phase 1: Cross-sectional study; Phase 2: Pre and post community intervention controlled trial. 2.2.2. Sample sizes and sampling * Sample sizes and sampling in cross-sectional study: Applying the formula: p (1 - p) n = Z 2 )2/1( α − x DE d 2 Among them: n: sample size under investigation; p: Rate of stunting as a result of the 2007 survey in Soc Son, 25%; p=0.25 and q=1- p=0.75; d: acceptable level of error=0.05; with threshold probability 5% => z 1- α /2 = 1,96; DE: Design Effect=2. Calculated sample size was 586. Added contingency of 5% (29), the total number of children was 615. Systematic random selection of children <24 months of age. All mothers of those selected children were selected for interview. Total sample size was 600 mother-child pairs. 7 * Sample size and sampling in community intervention trial: Applying WHO 1998 formula: ___ ________ [ Z 1- α /2 √2pq + Z 1- β √p 1 q 1 + p 2 q 2 ] 2 N = [p 1 - p 2 ] 2 Where, n: number of selected mothers; Z1-α/2: reliability coefficient, at α=5%, than Z 1- α /2 = 1,96 and Z 1- β with β=10%; + P: average rate of 2 populations; p1: estimated proportion of mothers with proper nutrition knowledge and behavior at the research end, estimated p1=0.45 (45%) and q1 = 1-p1=0.55 (55%); p2: proportion of mothers with children <24 months of age and proper nutrition knowledge and behavior in control group, estimated p2=0.30 (30%), and q2= 1-p2=0.70 (70 %). Calculated n=217. Plus contingency of 20% (43) =260/each group, the sample size is 260. 2.2.3. Methods of data collection Interviews mother based on KPC questionnaire, complement questionnaire and nutrition anthropometric method for infants <24 months of age. 2.2.4. Data processing and analysis Data are checked, cleaned and processed with SPSS 10.5 and Epi Info 6.0. 2.2.5. Research Ethics Subjects committed voluntarily to participate with the family’ and local authority’ agreement, and had the right to give up. The subjects’ identified information is encrypted and data used only for research purposes. 8 Chapter 3 THE FINDINGS 3.1. Actual nutrition status of children under 24 months old and mothers’ nutrition knowledge and practices Table 3.1. The percentage of malnourished children <24 months of age in 6 selected communes Under nutrition forms At 3 intervention projected commune (n=309) At 3 control projected commune (n=309) Underweight 7,8 7,8 Stunting 19,1 19,1 Wasting 3,9 3,9 Table 3.1 shows the prevalence of underweight, stunting and wasting of children under 2 years of age in 6 studied communes 7.8%, 19.1% and 3,9%, respectively, which did not differ between intervention and control expected communes. Figure 3.2. Mothers’ knowledge about the causes of child malnutrition 9 The rates of mothers, who know the right contents of breastfeeding, are rather low, ranging from 25.8% to 39.3%. Figure 3.3. Mothers’ knowledge on the child's diet when the child get diarrhea (n=600) The rates of mothers, who know that when the child gets diarrhea, breastfeeding should be continued accounted for only 52.7%, additional mixed salt – sugar water given 79.2%. Table 3.8. Mothers’ knowledge on diet diversification (n=600) Index n % Children need to have a variety of foods 559 93,2 The nutritional value of food animals 586 97,7 The nutritional value of animal organs 593 98,8 The effects of vegetable, fruit and dark green 269 44,8 The effects of vegetable, fruit yellow, red 315 52,5 The effects of oil / fat meal 558 93,0 The effect of egg nutrition 446 74,3 10 [...]... growth and indirectly lower the rate of child malnutrition 22 CONCLUSIONS 1 Actual nutrition status of children under 24 months of age and nutrition knowledge, practices of mothers at in communes of Soc Son District 2010: The percentage of malnourished the children under age of 24 months in 6 communes of Soc Son: stunting was at low level (19.1%) classified by the World Health Organization, while underweight... as the weak and average 20 4.2 Effect of the intervention to mothers improved knowledge and practices for child malnutrition control and diet diversification 4.2.1 Effect of the intervention to change mothers knowledge and practices on child malnutrition control After 12 months of intervention, the percentage of mothers who know how to recognize their undernourished children, the causes of malnutrition, ... years, reducing malnutrition rate is very slow A surprising thing is that child stunting in Hanoi 2012 increased to over 20%, a high level according to WHO, to be problem of continuing concern 4.1.2 Current status of knowledge and practices to control child malnutrition and diet diversification of mothers with children under 24 months The cross-sectional study in 2011 showed that Soc Son mothers both... index for wasting was 74.2%, followed by underweight, 41.6% and stunting, 32.8% 18 Chapter 4 DISCUSSIONS 4.1 Actual nutrition status of children under 24 months of age and mothers nutrition knowledge and practices at six communes of Soc Son district in 2010 4.1.1 Actual nutrition status of children under 24 months The rate of underweight (W/A . nutrition education for mothers to reduce malnutrition for children under 24 months of age in Soc Son District, Ha Noi has been conducted. Study objectives: 1. To describe status of malnourished children. and analysis of collected data application in phase 1, the study has identified the malnutrition rate of children under 24 months of age in 6 communes of Soc Son Hanoi in 2010: underweight was. can change the mothers nutrition and child care habits, then the children will get improved diets, indirectly reduce the rate of child malnutrition; At the same time, the mothers nutrition habit/