Nutritional status and effectiveness of interventions to reduce stunting malnutrition among children under 5 years old in the costal plain area, nghe an province

i



MINISTRY OF EDUCATION
AND TRAINING
MINISTRY OF
HEALTH
NATIONAL INSTITUE OF HYGIENE AND
EPIDEMIOLOGY
*
CHU TRONG TRANG

NUTRITIONAL STATUS AND EFFECTIVENESS OF
INTERVENTIONS TO REDUCE STUNTING
MALNUTRITIO IN CHILDREN UNDER 5 YEARS OLD
IN COASTAL PLAIN AREA NGHE AN PROVINCE
Speciality: Hygiene Sociology and Health Organization
Code: 62 72 01 64
SUMMARY OF DOCTORAL THESIS



HA NOI – 2015
ii



The work was completed at:
NATIONAL INSTITUE OF HYGIENE AND
EPIDEMIOLOGY

*
Supervisors : 1. Associate Prof. PhD. Le Bach Mai
2. Associate Prof. PhD. Tran Nhu Duong
Reviewer 1: Prof. PhD. Chu Van Thang - HaNoi Medical
University
Reviewer 2: Prof. PhD. Pham Ngoc Chau- Military Medical
University
Reviewer 3: Prof. PhD. Nguyen Thi Lam - National Institute of
Nutrition


Thesis will be put before the Council to protect thesis of State
held in National Institute of Hygiene and Epidemiology.
On the back: at , date… month…….year 2015
Thesis could be founded in:
1. National Library of Vietnam
Library of National Institute of Hygiene and Epidemiology

iii



LIST OF AUTHOR’S PUBLICATIONS
RELATED TO THESIS
- “Nutritional status in children under 5 years in coastal plain
area, NgheAn province, 2011.” Journal of Preventive Medicine,
Volume XXIV, No 8 (157). Ha Noi pp.166-170.
- Factors related to status of stunting malnutrition in children
under 5 years in coastal plain area, Nghe An province, 2011.
Journal of Preventive Medicine, Volume XXIV, No 8 (157). Ha

Noi pp. 171-176.

iv



ABBREVIATIONS

BMI : Body Mass Index
HWs : Health workers
EI : Effective Index
Ms : Micronutrients
HFA : Height for age
HIV : Human Imuno Virus
IE : Intervention Effect
KST : Parasites
NCHS : National centre health statistic
F : Fellow
ARI : Acute Respiratory Infections
SD : Standard deviation
M : Malnutrition
De : Deworming
UNICEF : United Nations’Children Fund
WFA : Weight for age
WFH : Weight for height
RI : Respiratory Illness
WHO : World Health Organization

1

INTRODUCTION
Nutritional status of children has been always the primary
concern in all countries of the world. Investing in nutrition is the key to
develop the quality human resources. Malnutrition prevention should be
an integral part of each national strategy for economic and social
development to increase the stature, strength and wisdom of the human.
According to estimates by the World Health Organization and
the United Nations Children's Fund, the situation of malnutrition in
worldwide children has been changed positively in recent years.
Underweight malnutrition has fallen rapidly from 25% in 1990 to 15%
in 2012. However, in the period from 2000 to 2005, the ratio of stunting
was still highland and should be paid attention to. In this period, this rate
reduced only from 33% to 25%. This situation will influence to achieve
the Millennium Development Goals of halving the proportion of
undernourished in developing countries from 20% in 1990 to 10% in
2015.”
In Vietnam, over the years, along with the socio-economic
development and the correct policies of the Party and State, the effort of
the Health sector as well as the active participation of the whole society,
we have achieved the significant results in improving nutritional status
and health status of people. The underweight malnutrition proportion in
children under 5 years in our country has declined continuously, about
16.2% in 2012. However, the proportion of malnutrition has also
considerable difference among regions, between urban and rural areas,
especially the underweight malnutrition in children under 5 years has
remained at a high level of 26.7%.
Nghe An province in the North Central region has a large area
where the terrain is very diverse, with the geographic region, from
mountain, midland to coastal plain. According to survey data of

National Institute of Nutrition, Nghe An province always has the high
malnutrition rate in children under 5 years. In 2005, the prevalence was
28.9% underweight, 34.6% stunting and 6.3% wasting in children under
5 years, respectively. In 2010, it was 21.7%, 32.9% and 8.2%,
2


respectively. Until now, beside the National Program of Malnutrition
Prevention, Nghe An province has never had any intervention programs
or studies on nutritional status in specific local area.
Nghe An’s coastal plain area associated with the marine
economy is the strategic location with some properties such as crowded
population and small land, environmental sanitation is not good and
people’s income mostly depends on offshore fishing, which makes
parents have a few chances to take care of their children. It’s the above
issues that influences on the nutritional status in children in general and
children under 5 years old in particular. So, the question will be made:
how is the nutritional status in children under 5 years old in this area?
What factors related to malnutrition, especially stunting and what are the
best measures to reduce malnutrition? The answers for these questions
will contribute significantly to support managers and field professionals
to improve the health status of people in the coastal plain in general and
children under 5 years in particular. Especially, Nghe An province has
been actively implementing Directive No 20-CT/TW dated 1997,
September 22 of Politburo and policies of the provincial Party
Committee on accelerating development of marine economy towards
industrialization and modernization, in which focuses on the
improvement of people’s health.
For these above reasons, the study “Nutritional status and effectiveness
of interventions to reduce stunting malnutrition in children under 5

years old in the coastal plain area Nghe An province” was conducted
with the following objectives:
1. To describe the nutritional status and identify some related
factors of stunting malnutrition in children under 5 years in the coastal
plain area, Nghe An province.
2. To evaluate the effectiveness of an intervention to reduce
stunting malnutrition from September, 2011 to September, 2012.
 Contribution of the thesis
- Several anthropometric indicators and malnutrition
classification were integrated with comprehensive assessment test for
the malnutrition status in children under 5 years in the coastal plain area,
3


Nghe An province. The rate of stunting malnutrition integrated with
several anthropometric indicators in children under 5 years have firstly
been developed.
- Through the analysis, factors related to the rate of stunting have
been identified.
- It’s proven that deworming treatment, Iron supplement
associated with communication and education for mothers on child-care
methods to reduce the rate of stunting malnutrition and anemia, height
improvement.
 Structure of the thesis: the thesis consists of 134 pages
including Introduction (3 pages); Chapter 1. Overview (44 pages);
Chapter 2. Subjects and research methods (20 pages); Chapter 3.
Research results (35 pages); Chapter 4. Discussion (27 pages);
Conclusion (2 pages) and Recommendation (1 page). The thesis has
41 tables, 12 charts, 2 diagrams. References: 165 documents.
Chapter1. OVERVIEW

1.1. NUTRITIONAL STATUS IN CHILDREN UNDER 5 YEARS
OLD AND FACTORS RELATED TO STUNTING
MALNUTRITION.
 Evaluation method.
a) To evaluate malnutrion based on the standard of weight for
age (WFA).
- Children whose weight is in the range of -2SD (Standard
deviation) or more are normal. Correspondingly the body weight > 90%
of the average weight for age.
- Malnutrition level I: weight below - 2SD to - 3SD,
correspondingly the body weight from 90% to 75% of the average
weight for age.
- Malnutrition level II: weight below - 2SD to - 3SD
correspondingly the body weight from 75% to 60% of the average
weight for age.
- Malnutrition level III: weight below -4SD corresponding the
body weight < 60% of the average weight for age.
4


b) To evaluate malnutrion based on the standard of height for
age (HFA)
- Height for age from -2SD or more: are normal
- Height for age from -2SD to -3SD: malnutrition level I
- Height for age below -3SD: malnutrition level II
Children are considered stunting malnutrition when their height
is below -2SD of National centre health statistic (NCHS) population
compared with the average height for age.
c) To evaluate malnutrition based on height for weight
- Below -2SD: malnutrition

- From -2SD to below +2SD: normal children
- From +2SD or more : Over-weight and obesity.
1.1.2 Child malnutrition situation under 5 years old
a) In the world.
According to estimates by the World Health Organization and
the United Nations Children's Fund, the situation of malnutrition in
worldwide children has been changed positively in recent years.
However, in the period from 2000 to 2005, the ratio of stunting is still
high and should be paid attention to. In this period, this rate reduced only
from 33% to 25%.
According to data of National Institute of Nutrition, in 2012, the
prevalence of malnutrition remaining 16.2% underweight, 26.7%
stunting and 6.7% wasting. The prevalence of malnutrition in the
Central Highland is highest (25.0% underweight, 36.8% stunting) and
lowest in the South-eastern region (11.3% underweight, 20.7 stunting).
The prevalence of malnutrition in children under 5 years old varies with
age. There has been difference between urban and rural area.
c)The status of child malnutrition under 5 years in Nghe An
According to the survey data of National Institute of Nutrition,
Nghe An provinces has the highest prevalence of child malnutrition
under 5 years old. In 2005, the prevalence of child malnutrition under 5
years was 28.9% underweight, 34.6% stunting and 6.3% wasting and in
2010 was 21.7%, 32.9% and 8.2%, respectively.
5


1.1.3. Related factors of underweight malnutrition in children under
5 years old.
Energy intake.
Nutrition is obviously a key factor, total energy intake is not

enough that often related to food restriction can cause stunting, because
energy intake is usually enough for child to maintain its healthy weight
for height. The quality of dietary intake should be paid more attention
than the quantity, in which the role of animal protein, fats and
micronutrients, vitamins, amino acids and fatty acids are essential.
 Micronutrients.
Micronutrients are substances that our body needs only in small
amounts, however, if it’s for the shortage, it will cause very serious
consequences for health. There are about 90 various micronutrients
necessary for the body and divided into some following groups:
- Group 1: Vitamins
- Group 2: Minerals
- Some infectious factors affecting stunting malnutrition in
children under 5 years old: pathological spiral between infectious
diseases in children and malnutrition has been proved. Infectious
diseases may lead to malnutrition, malnutrition may cause infectious
diseases and the pathological spiral repeats continuously without any
intervention or appropriate treatment.
 Factors of child care, maternal and child issue affecting
stunting malnutrition in children under 5 years old.
The model for analyzing the causes of stunting malnutrition
including prenatal and postnatal factors. The prenatal factors including
internal factors and external factors; a few studies on prenatal stage.
1.2 SOLUTIONS TO STUNTING MALNUTRITION PREVENTION IN
CHILDREN UNDER 5 YEARS OLD
In the world, the solutions to stunting malnutrition prevention
currently focus on three solution groups. Increasing intake of nutrients,
supplementing micronutrients and reducing disease burden.
6

- Solution group 1: Increasing intake of nutrients (both quality and
quantity), including energy and protein supplements for pregnant
women, educational strategies and the knowledge of breast-feeding,
improvement of dietary supplement.
- Solution group 2: Supplementing micronutrients (vitamins and
minerals) including supplementing Iron, folic acid, vitamin A, calcium
for pregnant women; iodized salt, vitamin A and Zinc for children.
- Solution group 3: Reducing disease burden. In Vietnam, the Prime
Minister approved the National Strategy on Nutrition and concretized
the above solution groups as follows:
Chapter 2
SUBJECTS AND METHODS
2. 1. STUDY DESIGN :
2 steps in conducting the study.
Step 1: A cross-sectional descriptive study to describe the child
malnutrition status under 5 years and case-control design to identify
factors related to stunting malnutrition.
Step 2: A controlled before and after intervention study to
evaluate the effectiveness of some intervention solutions to reduce
stunting malnutrition.
2.2. SUBJECTS
a) Study subject of objective 1: Describing the nutritional status and
identifying factors related to stunting malnutrition in children under
5 years old in the coastal plain, Nghe An province, 2011.
- Study subject to describe nutritional status:
Children under 5 years old (from 1 to under 60 months old)
- Study subject to identify factors related to stunting malnutrition:
+ Children under 5 years old were suffered from stunting
malnutrition (disease cases) and corresponding controlled cases.

+ Mothers of disease and controlled cases.
b) Study subject of objective 2: Evaluating the effectiveness of
some intervention solutions to reduce stunting malnutrition.
+ Children suffered from stunting malnutrition from 24 – 47 months old.
+ Mothers or primary caregivers of children.
7


2.3 LOCATION AND PERIOD OF TIME.
2.3.1 Location:
- Study on the status and identification of factors related to stunting
malnutrition was conducted in 6 communes located in 2 coastal plain
districts, Dien Chau and Quynh Luu, Nghe An provinces.
- Intervention study conducted in 3 communes located in Dien Chau
district and 3 commnues in Quynh Luu district as control group.
2.3.2 Research duration

The study was divided into 2 periods:
 Period 1 (from June to August, 2011): Describing child
nutritional status under 5 years old and identify factors related to
stunting malnutrition in children under 5 years old.
 Period 2 (from September, 2011 to September, 2012):
Implementing intervention and evaluating the effectiveness of intervention
solutions to reduce stunting malnutrition.
2.4 SAMPLE SIZE AND SAMPLING TECHNIQUES
2.4.1 Sample size.
a) The sample size for evaluation research on nutritional status:
All
children from 0 month old to under 60 months old live in chosen
communes in the period of study. In our study, there were 3976

children to be investigated to evaluate the nutritional status.

b) Sample size for identification of factors related to stunting
malnutrition in children under 5 years old : The sample size formula.
n
1
=n
2
=
Z
2
(1- α/2)

1/p
1
q
1
+ 1/p
0
q
0

[ ln(1-ε) ]
2
Replace these values into the formula, we will calculate n
1
=n
2
= 253. To
ensure sampling capacity of 80% with 95% confidential interval, study

was conducted in 264 cases and 264 control cases.
c) Sample size for research on objective 2
The minimum sample size was determined.
8


n =
Z
2
( α,β)

p
1
q
1
+ p
2
q
2

(p
1-
p
2
)
2
Replace these values into the formula, we will calculate n = 84. In the
study, there were 87 children was chosen for each group.
2.4.2 Sampling process.
Step 1: Choosing sample for evaluation research on nutritional status

* District: Selecting intentionally 2 coastal plain districts including Dien
Chau and Quynh Luu.
* Commune: Selecting by random by drawing up a list of coastal
commnues in Dien Chau and Quynh Luu districts, then 3 communes in
each district was determined by drawing lots randomly.
* Children under 5 years old to investigate:
All the children from 0 month to under 60 months old were chosen from
the list provided by commune health stations.
Step 2: Choosing sample of identification of related factors
Disease group: Selecting disease group (group of stunting malnutrition):
A systematic random sampling method was used to choose children
who were identified stunting malnutrition based on the research result of
objective 1.
Control group. Selecting children without stunting malnutrition paired
with cases by age, gender, geographic location , similar economic
conditions.
Step 3: Choosing sample for research on objective 2
+ Intervention group: A study method of objective 1 was used to choose
children from 24 to 27 months old who were identified stunting
malnutrition in Dien Chau district. A systematic sampling method was
use to choose enough children based on the sample calculation formular.
+ Control group in Quynh Luu district: Selecting children suffering from
stunting malnutrition paired with cases by age, gender, similar economic
conditions.
2.6 INDICATORS AND VARIABLES
 General information group
9


 Anthropometric indices

 Evaluating indicators of worm infection
 Hb index
 Indicators of assessing knowledge and practice of mother.
 Intervention evaluation: the Z-score index; the average index of
height for age (
X
±SD); effective index; intervention effect
 Indicators of of diarrhea and respiratory infections
2.7 STUDY IMPLEMENTATION.
 Identify nutritional status
Fellow collaborated with Nghe An Preventive Medicine Center, Health
Centers in Dien Chau and Quynh Luu districts with some commune
health stations selected to organize the investigation of the nutritional
status in children by measuring to identify anthropometric indices.
 Identify related factors
- Pre-designed questionnaires was used for cases and control
cases.
- Blood samples and stool samples of cases and control cases.
 Implementing intervention. In this study, we conducted four
major intervention contents including: Communications to raise
community awareness, training intervention for mothers of
knowledge of malnutrition as well as instructions on how to care
for children; iron supplementation for children with iron
deficiency anemia according to the protocol;
2.8 PROCESSING AND ANALYZING RESEARCH DATA.
Anthropometric data were analyzed using ENA software, WHO,
2005. The other data were entered using EPIDATA software then
converted into SPSS software version 19.0 to process.
The algorithm used to analyze the data: paired T-test, Kruskal-
Wallis Test and Test χ

2
.
Chapter 3. RESEARCH RESULTS
10


3.1 NUTRITIONAL STATUS AND IDENTIFICATION OF
FACTORS RELATED TO STUNTING MALNUTRITION IN
CHILDREN UNDER 5 YEARS OLD IN THE COASTAL PLAIN
AREA, NGHE AN PROVINCE, 2011.
3.1.1 Nutritional status in children under 5 years old in the coastal
plain area, Nghe An province, 2011.
3.1.1.1 Characteristics of research subjects
3976 children were chosen to evaluate the nutritional status, the
ratio of 51% boys to 49% girls. This difference was statistically
significant at p <0.05.
3.1.1.2 Nutritional status based on indicators of weight/age Z-score
(WAZ)

Diagram 3.2 Status of stunting malnutrition by gender
The rate of malnutrition was 18.9% underweight, the rate of
18.8% malnutrition in boys and 19.0% in girls (p>0.05).
Table 3.4. Status of underweight malnutrition by level and age group
Age
group
(months)
n
Total
Medium level
Severe level

Quanti
ty
Percent
age %
Quanti
ty
Percent
age %
Quanti
ty
Percent
age %
0 -11
713
52
7,3
*
45
6,3
*
7
1,0
12-23
929
150
16,1
128
13,8
22
2,4

24-35
855
178
20,8
155
18,1
23
2,7
36-47
763
181
23,7
161
21,1
20
2,6
48-59
716
189
26,4
171
23,9
18
2,5
(*p<0,05)
0%
100%
General Male Female
81.1%
81.2%

81,0%
18,9%
18,8%
19,0%
Malnutrition
Non Malnutrition
11


The results showed that the higher the age group was, the greater
the prevalence of underweight malnutrition was, children from 40 to
under 60 months old had the highest prevalence of underweight
malnutrition (26.4%); children under 12 months old had the lowest
prevalence of underweight malnutrition (7.3%). The malnutrition rate at
medium level in children group from 0 to 11 months old compared with
the other age group (p<0.05); the highest malnutrition rate at severe level
in children from 24 to 37 months old (2.7%).
3.1.1.3 Evaluation of nutritional status based on height/age Z-score.
Table 3.6 Nutritional status of stunting malnutrition by level and age
group
Age
group
(months)
n
Total
Medium level
Severe level
Percentage
%
Quantity

Percentage
%
Percentage
%
Quantity
Percentage
%
0 -11
713
123
17,3
104
14,6
19
2,7
12-23
929
374
40,3
281
30,2
93
10,0
24-35
855
345
40,4
266
31,1
79

9,2
36-47
763
318
41,7
254
33,3
64
8,4
48-59
716
252
35,2
214
29,9
38
5,3
Total
3976
1412
35,5
1119
28,1
293
7,4
The results showed that the prevalence of stunting malnutrition
in children under 5 years old in the coastal plain area, Nghe An province
was 35.5%, stunting malnutrition tended to increase at the age of 1 or
more, the highest rate at age group from 36 to 47 months old (41.7%).
The highest rate of stunting malnutrition at medium level at the age

group from 36 to 47 months old (33.3%) and the lowest rate at the age
group from 0 to 11 months old (14.6%), this difference was statistically
significant at (p <0.001). The highest rate of stunting malnutrition at
severe level at the age group from 12 to 23 months (10.0%).

12


3.1.1.4 Nutritional status based on weight/height Z-score.
Table 3.7 Wasting malnutrition status
Classification
of wasting
malnutrition
Total
n = (3976)
Boys
n = (2053)
Girls
n = (1923)

p
SL
%
SL
%
SL
%
Medium level
129
3.2

77
3.8
52
2.7
>0,05
Severe level
20
0.5
8
0.4
12
0.6
>0,05
Total
149
3.7
85
4.2
64
3.3
>0,05
The results showed that the wasting malnutrition rate in general
was 3.7%, in which the ratio of 4.2 % boys to 3.3% girls. The
prevalence of wasting malnutrition at medium level was 3.2%, in which
the ratio of 3.8% boys to 2.7% girls.



Diagram3.5. Nutritional status in children under 5 years old
The results showed that the highest percentage of child stunting

malnutrition was 35.5%, the percentage of 18.9% underweight, 3.2% of
wasting and 1.3% overweight.
3.1.2 Factors related to stunting malnutrition in children under 5
years old.
3.1.2.1. Characteristics of children and mothers participating in study
The total number of children participating in disease group and
control group are 264, the disease group had 135 boys accouting for
51.1% and 129 girls accounting for 48.9%; the control group had 137
boys accounting for 51.9% and 127 girls accounting for 48.1%. The
proportion of children who were paired between disease group and
control group by age was similar.
3.1.2.2 Mothers’ factors related to their children’s malnutrition
18,9%
35,5%
3,2%
1,3%
000%
020%
040%
underweight Stunting Wasting Overweight
13


Diagram 3.6: Comparison of the proportion of mothers aged under
and over 40
Comment: The chart showed that mothers aged over 40 were 2-3 times
more likely to have children with stunting malnutrition than mothers
aged under 40 with (p<0.05;OR=2.3;95%CI: 0.99-5.90).
Table 3.9. Relationship between malnourished children and the
number of children of mothers

Numbers of
children
Disease
group
(n=264)
Control
group
(n=264)
p; OR;
(95% CI)
Less than 3 children
184
214
p<0,05
OR=1,54
(1,05 –2,39)
More than 3 children
70
50
Mothers having more than 3 children were 1.54 times more
likely to have children with stunting malnutrition than mothers having
less than 3 children, this difference was statistically significant with
(p<0.05) and (95%CI:1.05-2.39); OR=1.54.

000%
100%
stunting Control group
92,4%
96,6%
7,6%

3,4%
p<0,05; OR=2,3; 95%CI(1,01-5,90)
Under 40
Over 40
.00
20.00
40.00
60.00
80.00
100.00
Disease group Control group
14,4%
21,2%
85,6%
78,8%
p<0,05;OR=1,7; (95%CI: 1,04-2,76)
Prymary
and
illiteracy
Secon
daryschool
14


Diagram 3.7: Relationship between mothers’ knowledge and stunting
level of their children
The results showed that it’s likely that relationship between mothers’
knowledge and stunting malnutrition in their children with p<0.05;
OR=1.7;(95% CI:1.04 – 2.76).
Table 3.14. Relationship to children’s vitamin A consumption

Vitamin A consumption
Disease
group
Control
group
p; OR
(95% CI)
Receiving
vitamin A in the
last 6 months
No
118
94
p<0,05;
OR=1,48
(1,02-2,13)
Yes
146
170
The resulted showed that children didn’t received Vitamin A
supplement in the last 6 months related to stunting malnutrition, this was
statistically significant (OR=1.48; 95%CI 1.02 – 2.13);
Table 3.15. Relationship to mothers’ knowledge and practice
Knowledge and good
practice
Disease
(n = 264)
Control
(n =264)
P,OR

(95% CI)
Complementary
feeding at 6
months
Yes
151
176
p<0,05;
OR=0,67
(0,46-0,97)
No
113
88
Weaning in the
range of 19 – 24
months
Yes
135
157
p>0,05;
OR=0,71
(0,50-1,02)
No
129
107
Adding grinded
vegetables into
powder
Yes
125

148
p<0,05;
OR=0,70
(0,49-0,99)
No
139
116

Breast-feeding
when the child
has diarrhea
Yes
160
198
p<0,05;
OR=0,51
(0,35–0,76)
No
104
66
Knowing how
to use Ozesol
Yes
106
140
p<0,05;
OR=0,59
(0,41-0,85)
No
158

124
15


Comment: The results showed that factors would reduce the risk of
stunting malnutrition including: complementary feeding appropriate for
the child’s age (OR=0.67; 95%CI 0.46-0.97), instruction on how to
enhance nutrients into cereal (OR=0.70; 95% CI 0.49-0.99); breast-
feeding when the child has diarrhea (OR=0.51; 95%CI:0.35-0.76);
knowing how to use Ozesol (OR=0.59; 95%CI 0.41-0.85).
3.1.2.3 Relationship between worm infection, anemia and
malnutrition status in chldren.
Table 3.16 Relationship between worm infection and stunting
malnutrition in children
Worm infection status
Disease
group
Control
group
p; OR
(95% CI)
Children
with worm
infection
Infected
87
47
<0,01;
OR=7,1
(3,44 –5,29)

Non - infected
14
54
Comment: The results showed that worm infection status definitely
related to stunting malnutrition in children and this difference was
statistically significant OR=7.1; (95%CI: 3.44 – 5.29)
Table 3.17 Relationship between anemia and nutritional status
Nutritional status

Related factors
Disease group
(n=101)
Control group
(n=101)
Quantity
%
Quantity
%
Children with anemia
36
36,4
12
12,1
Children without anemia
65
63,6
89
87,9
p; OR, 95%CI
p<0,001; OR=4,1; ( 95%CI: 1,9 – 9,3)

Comment: The anemia ratio of 36.4% stunting malnutrition group, of
12.1% control group. With p<0.001; OR=4.1; (95%CI: 1.9 – 9.3), which
showed the close correlation between nutritional status and anemia.
3.2 EFFECTS OF INTERVENTION SOLUTIONS TO REDUCE
STUNTING MALNUTRITION
3.2.1 General characteristics of subjects of intervention study
Participants have the average age similar in ages, the age of boys
and girls similar in ages between intervention group and control group.
16


3.2.2 Intervention effect of improving height and stunting
malnutrition
Table 3.22 Effect of improving height and HAZ score
Average
value
Intervention
group
Control group
p
Height (cm)
To
85,21 ± 4,28
84,89 ± 4,20
>0,05
T12
93,14 ± 4,01
91,80 ± 4,40
<0,05
T12-To

7,93±2,26
6,91±2,1
<0,01
HAZ-score
To
-2,77 ± 0,62
-2,83 ± 0,63
>0,05
T12
-2,25±0,57
-2,62 ± 0,59
<0,01
T12-To
0,52±0,29
0,21±0,27
<0,01
After 12 - month intervention, the intervention group achieved
growth in height was (7.93±2.26); the control group achieved growth in
height was (6.91±2.1), this difference was statistically significant with
(p<0.01). HAZ-score also changed, this difference was statistically
significant with (p<0.01).
Table 3.27 Intervention effect of the rate of stunting malnutrition
Stunting
Intervention group
(n=87)
Control group
(n=87)
SL
%
SL

%
To
87
100%
87
100%
T12
50
57,50%
75
86,20%
Effective Index (EI)
42,50%
13,80%
Intervention Effect (IE)
28,70%; p<0,01
Comment: After 12 – month intervention in two groups: control and
intervention, the rate of stunting malnutrition reduced 42.5%
intervention; 13.8% control; (p<0.001), IE was 28.7% that proved the
effective intervention.
3.2.3 Intervention effect of worm infection and anemia
17



Diagram 3.9: Rate of worm infection at time point T0 and T12
The chart showed that the rate of worm infection reduce from
86.2% at time point T0 to 24.1% at time point T12 in intervention
group, with p<0.01 and IE = 57.3% proved that deworming intervention
was really good.

Table 3.32 Intervention effect of Hb score and anemia
Score
Intervention group
Control group
p
Level (
X
± SD) Hb (g/l)
To
101,1± 10,6
103,4± 13,5
>0,05
T12
115,2± 9,5
109,2±14,0
<0,01
T12-To
14,1± 4,9
5,8±5,7
<0,01
Anemia rate (%)
To
(31) 35,6%
(30) 34,4%
>0,05
T12
(18) 20,7%
(30) 34,4%
<0,05
EI

41,9%
0,0%

IE
41,9%
Comment: Average plasma levels of Hb increased from (101.1± 10.6) at
time point T0 to (115.2± 9.5) at time point T12; this difference was
statistically significant with control group (p<0.01); the anemia rate
reduce 14.9% intervention group, IE = 41.9% in control group
compared with IE = 0% in intervention group that proved the effective
intervention.
000%
100%
Intervention
group
Control group
86,2%
87,4%
24,1%
82,6%
p<0,01; IE= 57,3%
Point T0
Point T12
18


3.2.4 Intervention effect of maternal knowledge of their child care
and child bacterial infection
Table 3.33. Effect of maternal knowledge and care practices
Knowledge

and good
practices
Intervention
(n = 87)
p,
EI
Control
(n = 87)

p, EI
p;
IE
T0
T12
T0
T12
Adding
grinded
vegetables
into powder
57,2
96,3
<0,01
91,4%
56,2
75,6
<0,01
14,8%
<0,01
76,6%

Breast-
feeding when
the child has
diarrhea
80,9
93,9
<0,01
68,1%
79,5
83,3
>0,05
18,5
<0,01
49,6%
Breast-
feeding when
the child has
fever and
cough
97,2
100
>0,05
100%
95,4
100
<0,05
100%
0,0%
Knowing how
to use Ozesol

52,5
96,3
<0,01
92,2%
51,2
75,6
<0,01
50,0%
<0,01
42,2%
Using health
chart
20
50,4
<0,01
38,0%
20,3
36,6
<0,05
20,2
<0,05
17,5%
Comment: Mothers’ knowledge of care practices in two groups was
relatively good and has been improved after intervention period.
However, with some basic issues such as knowing how to use Ozesol,
adding grinded vegetables into powder and using health chart to monitor
health were still low; IE = 76.6% adding grinded vegetables into
powder; 49.6% breast – feeding when the child has diarrhea; 42.2%
knowing how to use Ozesol.
Chapter 4.DISCUSSION

4.1 NUTRITIONAL STATUS AND FACTORS RELATED STUNTING
MALNUTRITION IN CHILDREN UNDER 5 YEARS OLD IN
COASTAL PLAIN AREA, NGHE AN PROVINCE, 2011
19


4.1.1 Evaluation of child malnutrition status under 5 years
4.1.1.1 Evaluation of underweight malnutrition
The results showed that the rate of underweight malnutrition
(18.9%) was still high compared to the overall rate of the country
(16.8%) in 2011, however, this rate was in average compared with the
classification of malnutrition level for public health significance of
WHO.
4.1.1.2 Evaluation of stunting malnutrition
The ratio was 35.5% stunting malnutrition, in which the
prevalence in boys was higher than in girls (36.3% versus 34.6%), the
difference was not statistically significant. (Chart 3.3). According to the
classification of WHO, the rate of stunting in our study was at high level
in community and also higher than the national average rate (27.5% in
2011). Such underweight malnutrition, the ratio of stunting in the coastal
plain area, Nghe An province was higher than some northern plains but
lower than other areas like Quang Tri, Thanh Hoa in recent studies.
The ratio of 36.3% stunting in boys higher than 34.6% in girls,
this result was similar to the result of nationwide nutrition census of
National Institute of Nutrition in 2009.
4.1.1.3 Evaluation of wasting malnutrition
The proportion of wasting was 3.7%, this rate was lower than the study
of the authors Le Thi Huong, Tran Quang Trung, Phou Sophal at the
same time. Our research results were lower than the overall nation rate
(6.6%) and the rate of Nghe An province (7.8%) in 2011.

4.1.1.4 Evaluation of overweight and obesity in children
The proportion of overweight, obesity in children under 5 years
in this study was 1.3%, the ratio of 1.7% overweight in boys; 0.9%
overweight in girls; this rate was lower than average rate of the whole
country in 2010 (5.6%) and also lower than the level of the national
nutrition strategy for 2001-2010 (5%).
The overview of nutritional status in children under 5 years in
the coastal plain, Nghe An province: the ratio of 18.9% underweight,
35.5% stunting at high level for community significance; 3.7% wasting
compared with the overall nation rate was 6.6% (in 2011); 1.3%
20


overweight, obesity lower than the average rate of the whole country in
2010 was 5.6%.
4.1.2 Factors related to stunting malnutrition in children under 5
years
4.1.2.1 Factors of mother related to nutrition of children
Relationship between the age of mothers and child malnutrition
By analyzing the results of chart 3.5 showed that mothers aged
over 40 related to stunting malnutrition (p<0.05;OR= 2.3; 95%CI: 0.99-
5.90). Some studies said that mothers aged over 40 increased the risk of
child malnutrition because at the age over 40, mothers’ reproductive
function and estrogen level generally decreased leading to the high risk
of fetal malnutrition in children.
Relationship between malnutrition and mothers’ number of
children
There was an association between mothers having many
children and stunting in children (Table 3.9). Up to now, few studies on
relationship between the number of children of mothers and malnutrition

in their children, but the fact showed that large family, poverty, diseases
and malnutrition was pathological spiral. Firstly, Mothers with many
children will allocate their time for childcare to earn a living, therefore,
their children might not care properly, poor hygiene along with
incomplete diets and improper nutrition basically leading to malnutrition
in children.
Relationship between child malnutrition and mother’s
knowledge
The results said that there was difference between mothers’ low
education (literacy and primary) and mothers with high school or higher
education with (p<0.05); OR=1.7; (95% CI: 1.04 – 2.76) (Chart 3.6).
Mothers with low education often have unstable jobs, low income and
their weak awareness of childcare practice while mothers with high
education often have stable jobs, higher income and more chances of
exchanging information to take care of their children better.
Relationship between actual Vitamin A consumption and
stunting malnutrition
21


Children don’t receive Vitamin A supplement within 6
months will affect stunting malnutrition (OR=1.48; 95%CI 1.02 – 2.13).
Vitamin A has the effect of promoting the absorption of zinc, whereas
vitamin A deficiency also affects the absorption of zinc due to the
decrease in zinc transport protein synthesis in intestine.
Relationship mothers’ knowledge and practice
The results showed that factors reduced the risk of stunting
including: complementary feeding at proper age (OR=0.67; 95%CI
0.46-0.97), instruction on how to enhance nutrients into rice cereal with
four food groups (OR=0.70; 95% CI 0.49-0.99). These results consistent

with the data of National Institute of Nutrition (2005).
There are also differences in perceptions of childcare when a
child has diarrhea and using Ozesol between mothers of children in
disease and control group with (OR=0.59; 95%CI 0.41-0.85). Such
factors like breast-feeding, complementary feeding period, food
processing, medical care will reduce morbidity and mortality in young
children
4.1.2.2 Relationship between worm infection and anemia and
nutritional status
Relationship between worm infection and stuting malnutrition.
With OR=7.1; (95%CI: 3.44 – 5.29) showed that worm infection related
to nutritional status in children. The harmful effects of geohelminths are
receiving nutrients, causing mal-absorption and metabolism of proteins,
fat, vitamins in intestine. In the world, many studies proved that worm
infection status would greatly affect in health status.
Relationship between anemia and stunting.
The deficiency of anemia is one of the important causes of malnutrition,
especially stunting with p<0.001; OR=4.1; (95%CI: 1.9 – 9.3) that
reveals the close association between stunting and anemia.
4.2 INTERVENTION EFFECT.
4.2.2 Intervention effect of improving height and stunting
4.2.2.1 Effect of stunting malnutrition
Intervention effect of height and stunting rate will be described
from table 3.22 to table 3.30: