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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 4-9  

Effectiveness of a community-based intervention on nutrition education of mothers of malnourished children in a rural coastal area of South India


1 Assistant Professor, Department of Community Medicine, Government Medical College, Omandarur Government Estate, Chennai, Tamil Nadu, India
2 Additional Professor, Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Senior Professor, Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. S Ganesh Kumar
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_383_17

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   Abstract 


Background: There is a paucity of evidence on improvement in malnutrition status after follow-up intervention among malnourished under-five children. Objective: The objective of the study is to assess the effect of community-based follow-up health education intervention on the awareness level of mothers, calorie intake, protein intake, and weight gain of malnourished children. Methods: This intervention study was conducted from December 2012 to October 2014 in three phases at rural Puducherry, coastal South India. The intervention group (57 mothers of 64 children) and control group (60 mothers of 64 children) included moderate and severely malnourished children aged 13–60 months. Children in the control group were taken from different areas and matched for age (±6 months) and sex. Health education intervention and follow-up supervision for 15 months were given to the mothers. Results: Awareness level in all domains increased significantly in the intervention group. In the intervention group, 81% (52) of malnourished children turned out to normal, whereas in the control group, 64% (41) of them became normal. There was a statistically significant difference between the mean changes in the protein intake among boys (15.34 g to 19.91 g in the intervention group against 13.6 g to 16.24 g in the control group) and girls (15.09 g to 19.57 g in the intervention group against 13.36 g to 16.51 g in the control group) and calorie intake among girls (993.86 kcal to 1116.55 kcal in the intervention group against 992.65 kcal to 1078.75 kcal in the control group) between the two groups. Conclusion: There was comparatively marginal increase in protein intake, calories' intake, and weight gain in the intervention group.

Keywords: Health education intervention, India, malnourished children


How to cite this article:
Pavithra G, Kumar S G, Roy G. Effectiveness of a community-based intervention on nutrition education of mothers of malnourished children in a rural coastal area of South India. Indian J Public Health 2019;63:4-9

How to cite this URL:
Pavithra G, Kumar S G, Roy G. Effectiveness of a community-based intervention on nutrition education of mothers of malnourished children in a rural coastal area of South India. Indian J Public Health [serial online] 2019 [cited 2019 Mar 22];63:4-9. Available from: http://www.ijph.in/text.asp?2019/63/1/4/253892




   Introduction Top


Recently, malnutrition among under-five children has been given immense priority at the global level. This is one of the targets of Sustainable Development Goals which aims to end all forms of malnutrition, especially stunting and wasting in under-five children by 2030.[1] According to the National Family Health Survey-4 (2015–2016) at the country level, around 35.7% of under-five children are underweight.[2] According to the National Nutrition Mission, one in every three children are malnourished; it also promotes sustainable efforts toward preventing and reducing undernutrition, especially in high priority backward districts in phased manner. It aims to prevent and reduce undernutrition in children (0–6 years) at 2% per annum.[3] The percentage of underweight children <3 years is higher in rural areas (44%) compared to urban areas (30%).[4]

It is believed that interventions providing counseling to the mothers on initiating and continuing appropriate and adequate complementary feeding in child's early life, together with improved personal hygiene and child caring practices, may effectively prevent malnutrition.[5] Various health education interventions on awareness level of mothers, calorie intake, protein intake, and weight gain targeting under-five malnourished children have been developed and implemented in different parts of the world, but evidence is lacking from the developing countries. Child health and nutrition programs based on health education initiatives promote mother's awareness level and specific behavioral changes in caregivers, which would improve the malnutrition status of children. Studies have shown that nutrition-related knowledge of a mother has a positive impact on the nutritional status of her children.[6] Special camps termed as “Sneh shivirs” were launched by the Ministry of Women and Child Development in December 2014. Its objective was “Community-Oriented Malnutrition Management” and it focuses on 200 high burden districts in the country. It included training and counseling sessions on nutrition and child-rearing practices for the parents at the Anganwadi centers and also included house visits to improve the nutritional status of moderately and severely undernourished children.[7]

Increase in the awareness level on factors associated with malnutrition such as awareness of the use of growth chart, causes of malnutrition, and its prevention is more important at precontemplation and contemplation phase of behavioral change. Then, there is a need to focus on action and maintenance phase with follow-up supervision to look into the quantum of change in behavior related to the correction of malnutrition. Limited studies had been conducted in this regard among under-five malnourished children.[8] Considering this, the present study was carried out to assess the effect of follow-up health educational intervention on awareness level of mothers, calorie intake, protein intake, and weight gain among 13–60-month-old malnourished children in rural Puducherry, coastal South India.


   Materials and Methods Top


Ethical issues and trial registration

Ethical clearance was obtained from the Institute Ethics Committee (Human studies). Permission was obtained from the Integrated Child Development Services (ICDS) Project Officer, Villianur, to carry out the study. Written consent was obtained from the mothers of the children included in the study. The trial was registered in the Clinical Trial Registry of India (CTRI/2013/09/003962).

Study design and setting

A community-based intervention study was conducted from December 2012 to October 2014 with one intervention and one control group in the rural area of Puducherry, coastal South India. This study was conducted in two areas – the Rural Health Center (RHC), Ramanathapuram, attached to a tertiary care institution and a Primary Health Center (PHC), Sedarapet, situated about 7.5 km from the RHC. The RHC has a total population of 9113 and 753 under-five children and has 8 Anganwadis. The PHC has a population of 11,081 and 586 under-five children and 4 Anganwadis.

Sample size calculation

The minimum sample size was calculated to be 59 children in each arm using OpenEpi software, taking into consideration 95% confidence interval, 80% power, alpha value of 0.05, and the minimum expected difference in outcome based on the change of moderate or severe malnutrition to normal category with 20% lesser in control arm.[9]

Sampling technique

All children aged 13–60 months who were enrolled in the Anganwadis of RHC Ramanathapuram and PHC Sedarapet area were weighed using Omron digital weighing scale and graded using the World Health Organization (WHO)-growth chart. Children in RHC who were moderately and severely malnourished and their mothers were included in the intervention group. Similarly, age- (±6 months) and gender-matched children who were moderately and severely malnourished and their mothers in PHC Sedarapet were included in the control group. In the intervention group, all the moderately and severely malnourished siblings of the selected child were also included. A child not living with the mother or if the child or mother was mentally challenged was excluded from the study.

Preparation of health education materials and study tools

Health education materials which include pamphlets and posters were prepared in Tamil (local language) by the Principal Investigator during April–May 2013. It was developed based on the manual of “Dietary Guidelines for Indians” published by the National Institute of Nutrition (Indian Council of Medical Research),[10] “Guidelines for Optimal Infant and Young Child Feeding practices” by National Health Mission,[11] and IEC materials published by Department of IEC, Pondicherry State Health Mission.

A pretested semi-structured questionnaire was used to collect data about the child and family details, awareness of mothers on factors associated with malnutrition, diet history for estimating calorie, and anthropometric measurements. The socioeconomic status of the children was assessed based on Modified Prasad's Classification 2013. The calorie and protein intake were estimated by 24-h dietary recall method. The WHO-growth chart (weight for age) was used to educate the mother on child's nutritional status and growth monitoring.

Study procedure

The study was conducted in three phases. The process of conduct of study is given in [Figure 1].
Figure 1: Flow diagram of process of study.

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Phase 1

This phase included the collection of baseline data in the houses for 3 months from January to March 2013 in both the control and intervention groups. Details of diet history and anthropometric measurements were recorded. After this, preparation of pamphlets and posters was carried out during April–May 2013.

Phase 2

In this phase, health education intervention was given by the Principal investigator through one-to-one communication to the mothers in their houses in Tamil (local language). Initially, in the 1st month (June 2013), the WHO-growth charts were given to the mothers, the sentence can be revised as follows: and it was used to educate them on their child's nutritional status and growth monitoring, to identify any growth faltering and to take necessary immediate action in their child after identification.

In the 2nd month (July 2013), health education to the mothers on nutrition education and child feeding practices was given through home visits using pamphlets and posters. Maintaining each day food menu chart was given to the mothers who were supervised by the investigator each month for the next 9 months with respect to frequency, quality, and quantity of food taken. Counseling and corrective actions were done to those who are not maintaining food menu chart. There was an interval of 9 months through which the intervention group was allowed to change their dietary behavior (August 2013–April 2014). Those 9 months period with supervision was of help for weight gain of malnourished children.

In the 3rd and 4th month (May–June 2014) of intervention, reinforcement of contents of health education of previously covered topics was carried out in all four areas by home visits again by one-to-one communication. In the 5th and 6th month (July–August 2014), health education on factors associated with malnutrition (which includes causes and consequences of malnutrition, common illness that leads to malnutrition, environmental sanitation, and personal hygiene) was given through discussion using posters and pamphlets.

Phase 3

Final assessment of outcome in both the intervention and control groups was carried out in 3 months between September and November 2014. Details of awareness level on factors associated with malnutrition, diet history, and anthropometric measurements were recorded in the intervention and control group.

Statistical analysis

Data were entered into Microsoft Excel 2007 and analyzed using the Statistical Package for the Social Sciences (SPSS) version 19 (IBM PASW Statistics version 19, Bangalore, India). The postintervention mean change in calorie intake, protein intake, and weight gain across the variables in both the groups was compared using Independent sample t-test and test of significance for the difference between two proportions.


   Results Top


All 64 children each in intervention and control group were almost equally distributed in age, gender, socioeconomic status, education of mothers, and occupation of father categories [Table 1]. Awareness level about the factors responsible for malnutrition increased significantly in the intervention group compared to the control group [Table 2]. Mean protein intake increased from 15.34 g to 19.91 g in the intervention group compared to 13.6 g to 16.24 g among boys in the control group and among girls, 15.09 g to 19.57 g in the intervention group against 13.36 g to 16.51 g in the control group. Intervention in the form of health education to the mothers improved protein intake among boys and girls. However, calorie intake appears to increase only among girls [Table 3].
Table 1: Comparison of baseline characteristics among the study participants n=128

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Table 2: Change in awareness level of mothers on factors associated with malnutrition

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Table 3: Comparison of change in calorie intake and protein intake gender wise among study participants (n=128)

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The difference in the percentage change in gaining normal weight between two groups was statistically significant. In the intervention group, 81% (52) of malnourished children turned out to normally nourished whereas in the control group, 64% (41) of them became normally nourished [Table 4].
Table 4: Comparison of change in nutritional status category of the children in both the groups (n=128)

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   Discussion Top


The awareness level of mothers at precontemplation and contemplation stage is more important to bring the behavior change practice related to malnutrition in the community. This study showed that awareness level increased at all the domains of factors associated with malnutrition. Baseline awareness of the mothers on growth chart in the intervention and control group (16% and 30%, respectively) was low in this study compared to another Indian study where it was 38.17%.[12] A study in Saudi Arabia found that 35.8% of mothers were aware of the growth chart.[13] Comparatively more awareness level in the control group at baseline may be attributed to the comparatively higher educational status in the control group. Awareness level at baseline about the purpose of growth chart as growth monitoring was also very low in both intervention and control groups (10.5% and 16.6%, respectively). The awareness on the frequency of feeding of 1-year-old child as at least 5–6 times a day increased from 12% to 91% in the intervention group as against another study which reported the change from 6.6% to 63.3% from prenutrition education to postnutrition education, respectively.[14] The change in awareness level depends on the educational status of the mothers, their involvement, interest, and methods adopted in health education sessions.

A community-based study conducted in Andhra Pradesh compared dietary intake of children aged 6–39 months in the intervention and control group based on improved access to the traditional Dalit food system.[8] In contrast to our study, they reported that there was no significant change in energy and protein intake among the children. Another study conducted in Haryana to assess the effectiveness of health education intervention to mothers of children aged below 18 months on complementary feeding practices and on the nutritional status of children found that the mean energy intake from complementary foods was significantly higher in the intervention group children at 9 months and 18 months.[15] A cluster randomized control study in Peru to assess the effectiveness of health education intervention program to caregivers of children below 18 months on growth found that mean energy intake from complementary foods was high in the intervention group compared to the control group at 18 months of age.[16] The age group included in the above studies was different from the present study, and it did not assess the energy intake in boys and girls separately. However, the present study has assessed the energy intake in boys and girls separately in both the groups.

A systematic review of ten studies assessed the effect of nutrition training for health workers on the improvement of feeding practices of children aged 6 months to 2 years by caregivers. It was found that there was improvement in mean energy intake per day, frequency of feeding, and dietary diversity among the children in the intervention group as compared to the control group.[17]

A study in India found that following nutrition education program for the mothers of under-five children resulted in improvement of the nutritional status of their children; the proportion of children who were moderately underweight decreased from 35.4% to 2.5% after 2 months of nutrition education program.[14] In the present study, the proportion of children who were moderately underweight decreased from 89% to 19% in the intervention group and from 91% to 33% in the control group.

A study from South Africa found that the involvement of “Mentor Mothers” in health and nutrition counseling to the mothers of malnourished under-five children resulted in weight gain in the intervention group which was significantly higher than in the control group in contrast to our study.[18] Another study found that the difference in weight gain in children was not significantly similar to our study.[15] However, in the present study, the age group selected and duration of the study were different.

A systematic review evaluated two commonly applied strategies as follows: provision of complementary feeding and health education to mothers on appropriate complementary feeding practices.[19] The study found that the provision of appropriate complementary feeding resulted in extra weight gain of 250 g in children aged 6–24 months. Education of mother about complementary feeding led to an extra weight gain of 300 g in the intervention group than in the control group. The difference observed may be because of the fact that complementary feeding practices were not included in the present study. Furthermore, the other factors that influence the child's nutritional status need to be addressed such as educational status of the mothers, socioeconomic status of the family, morbidity in child, and appropriate use of locally available nutritious foods.

The mothers were interviewed in the household instead of Anganwadis in both the groups to avoid social desirability bias. Contamination of information was less likely due to adequate geographical separation of the two study areas. The contents of health education were appropriate, simple, easy to understand, and delivered in the local language with reinforcement. Other methods of health education such as live demonstrations related to preparation of food and provision of complementary food could not be adopted due to feasibility constraints which would have been resulted in more favorable outcomes.


   Conclusion Top


There was an increase in the awareness level of mothers and marginal increase in protein intake and calories' intake in the intervention group; but, overall changes in the weight-for-age of boys and girls were very minimal when compared to the control group. Further, long-term studies with supplementation of complementary food along with health education of the mothers may explore the quantum of reduction of malnutrition in the community.

Acknowledgment

We thank ICDS Project Officer, Villianur, Government of Puducherry, Anganwadi teachers, and staffs of Rural Health Center for their help in data collection process. We thank the study participants for their full cooperation during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Ministry of Health and Family Welfare, GOI. Guidelines for Enhancing Optimal Infant and Young Child Feeding Practices. Ministry of Health and Family Welfare, GOI; 2013. Available from: http://www.nrhm.gov.in/images/pdf/programmes/child-health/guidelines/Enhancing-optimal-IYCF-practices.pdf. [Last accessed on 2015 Jan 10].  Back to cited text no. 11
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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