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 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.
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
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.
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
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.)
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.