Hiệu quả của truyền thông giáo dục dinh dưỡng sử dụng thực phẩm giàu vi chất sẵn có tại địa phương đến tình trạng dinh dưỡng của trẻ từ 6 23 tháng tuổi tại một huyện trung du phía bắc tt tiếng anh

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INTRODUCTION
According to the The United Nations International Children's
Emergency Fund (UNICEF), in 2013, among developing countries, about 195
million children under 5 years of age suffered from the stunted malnutrition the low age-based height (accounting about 30%), 129 million children
suffered from the underweight malnutrition - low age-based weight (making
up 25%) and 67 million children suffered from the wasted malnutrition - low
weight/height (13%) and about 20 million infants with the low weight less
than 2500g (15%). Most recently, according to the UNICEF/WHO/WB
reports (2018), there are still 151 million children with the stunting in the
world (22.2%) and 51 million children with the acute malnutrition (wasted;
7.5%) and 38 million children with the overweight/obesity (5.6%); Asia alone
accounts for more than half of these figures (83.6 million; 35 million and 17.5
million; respectively).
According to the statistics of the National Institute of Nutrition, in
Vietnam, the malnutrition rate of children under 5 years old has decreased
significantly: in 1985 the rate of underweight malnutrition was 51.5%,
stunting 59.7%, wasting 7.0%. By 2013, the rate of underweight malnutrition
decreased down to 15.3%, wasting 6.6%, but the rate of stunting malnutrition
was still 25.9%; this figure was still approximately at a high level according
to WHO classification and in 2014, the rate of stunting malnutrition in
children under 5 years old nationwide was reduced down to 24.9%; however,
this rate in many provinces and cities in Vietnam is still higher than 30%,
especially in the Central Highlands and Northern mountainous areas.
Therefore, the national strategy for 2010-2020 and vision up to 2030 has set
the target of reducing the rate of stunting malnutrition down to 23% by 2020
and identified the most effective intervention with the stunting malnutrition,
which had to the prophylactic and comprehensive features, improving the
infant feeding practices (including breastfeeding and complementary feeding)
and this intervention is considered to be the priority interventions. In
particular, the nutrition education and communication, promoting the use of

on-site food sources are the key activities and the focal point, but they should
be carried out according to the characteristics of the geographical area,
ethnicity and based on evidence or researches on nutrition and nutritional
practices of each locality.


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In Vietnam, there have also been a number of nutritional intervention
studies during the pregnancy and the first 2 years of life of children through
communication and education, which have been recorded to improve the
stunting of children in some areas. However, there have not been many
intervention studies in the midland and poor mountainous areas to guide the
community to know and use micronutrient-rich foods available to improve
the stunting in young children.
Tam Nong is one of the poor districts of Phu Tho province, with the
economy depending mainly on agriculture in the region of the Northern midland
and mountainous provinces, the project titled “The effectiveness of nutrition
communication and education by using available local micronutrient-rich
food on nutritional status of the infants aged 6-23 months in a Northern
midland district” has been implemented; contributing to solutions to preventing
the stunting malnutrition, improving the micronutrient status of children in this
locality as well as areas with similar conditions.
Objectives of the study:
1. Describing the actual status of infant feeding practices of mothers and the
nutritional status of the infants aged 6-23 months in Tam Nong district, Phu
Tho province in 2012.
2. Evaluating the effectiveness of nutrition education and communication on
the nutrition practices of mothers who have infants aged 6-23 months
suffered from stunting or at risk of stunting in 2 intervention communes.
3. Evaluating the effectiveness of nutrition education and communication on the

nutritional status, Vitamin A status, zinc status and anemia of the infants aged 6-23
months suffered from stunting or at risk of stunting in 2 intervention
communes.
The outline of the thesis: The thesis includes 121 pages and has the
layout as follows:
Introduction: 3 pages; Objectives and hypothesis of the research: 1 page;
Overview: 38 pages; Subjects and methods of the research: 23 pages;
Research results: 24 pages; Discussion: 29 pages; Conclusions and
recommendations: 3 pages; 181 pages of references.


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Chapter 1
OVERVIEW
1.1. Stunting malnutrition in the infants under 5 years old
1.1.1. Causes of stunting malnutrition
In 1997, UNICEF built and developed a model of malnutrition causes. A
number of other organizations have also had cause-and-effect models of
malnutrition alone or developed a new model based on UNICEF's model. But
UNICEF's model is still the most widely used.
Direct causes: Poor quality or low quantity diets are an important factor that
directly affects malnutrition: Infants are not fully breastfed, supplemented too
early or fed the solid food too late, fed insufficient amount of food, and low
energy and protein in the diet. The frequency of using foods such as meat,
fish, eggs, and milk in the infant meal is low due to limited family economic
conditions or limited knowledge of mothers about the nutritional care.
Malnutrition and infections in children affect the overall development of
children in the long term. Along with diarrhea, the acute respiratory infections
and malnutrition are one of the leading causes of infant death. The intestinal
parasite infection is also an important, which causes the infant malnutrition

and anemia.
Potential causes: The underlying cause is the weakness in maternal and child care
services; knowledge of infant caregivers, factors of caring the family, issues of
clean water, environmental sanitation and the state of unsafe sanitary housing,
poverty and backwardness in terms of general development including economic
inequality.
Household food security situation
Household food insecurity: It is the cause of making malnutrition become a
health burden in many developing countries; pre-school malnutrition rate
accounts for 20-50%; In Southeast Asia, the incidence is quite high (40-50%),
this rate increases when there is the hunger or there are emergency situations
such as war, flood, earthquake.
1.1.2. The situation of stunting malnutrition and micronutrient deficiency
in Vietnam


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The rate of stunting malnutrition among children under 5 years of age has
decreased within 10 years from 2000 to 2009 from 36.5% down to 31.9%,
especially since 2010, this rate tends to decrease quite rapidly, down to 29.3%
and by 2015 only 24.6%. The rate of stunting malnutrition has also tended to
decrease gradually, from 21.5% in 2002 down to 16.1% in 2011. However,
the rate of severe stunting malnutrition has not decreased. Micronutrient
deficiency especially anemia and zinc deficiency are closely related to the
stunting malnutrition. Micronutrients participate in most of the body's
processes, such as cell reproduction and development, and therefore they
have a direct or indirect effects on the growth of the body. In addition to the
role of increasing immunity and being micronutrients playing an important
role in protein synthesis for the body, zinc also plays an important role in the
development of the digestive system and enhancing the metabolism

especially for malnourished children, helping to improve the height of stunted
children. The rate of children in the first year of life with anemia due to iron
deficiency is still very high, up to 60-80%, especially in underweight
children. The deficiency rate of Zinc, Selenium, Magnesium, and Copper are
86.9%, 62.3%, 51.9%, and 1.7%, respectively. On the other hand, 55.6% of
children are anemic and 11.3% of children are deficient in Vitamin A. The
concomitant deficiency of the two micronutrients accounts for 79.4% of
children.
1.2. Strategies of popularizing and improving the quality of
complementary food to improve nutritional status and micronutrient
deficiency
WHO/WB/UNICEF/UN (2016) all commented that malnutrition has been
involved in 33% of the approximately 6 million children under 5 years old
each year and these deaths are related to wrong nurturing practices during the
first five years due to not being fully breastfed in the first months,
supplementing food too early or too late, malnourished and unsafe food
related to the level and understanding of mothers. IFPRI estimated the
involvement of a number of factors in reducing the rate of underweight
malnutrition in developing countries, particularly for women education,


5
contributed 43.01%. Therefore, improving knowledge and skills of maternal
nutrition practice is one of the solutions that need to be considered. Therefore,
nutrition communication and education are considered as the most important
solution in improving knowledge and changing behavior of the community
and mothers, especially for promoting the breastfeeding. In order to improve
the nutritional status, especially reducing the stunting rate of children under 2
years old, many studies have intervened to practice child feeding in the early
years of life. For Vietnam, nutrition education and reasonable eating guidance

should be further promoted in parallel with other solutions.
Improving the quality of complementary foods: The period from starting the
complementary feeding until weaning is the most threatening time for a
child's nutritional status if he/she is fed supplementary diet too early or too
late, or complementary meals of children are not sufficient in quantity and not
guaranted the quality. Complementary foods should provide adequate energy,
protein and trace elements to compensate for the child's energy and nutritional
deficiencies, and together with the breast milk, it can meet all of the child's
needs. Food from meat and fish is a good source of food for protein, iron and
zinc. The liver provides plenty of Vitamin A and folic acid. Egg yolks also
provide plenty of protein and Vitamin A. Legumes are high in protein and
some iron. Green vegetables, fruits, especially oranges and tangerines,
provide plenty of Vitamin C. Orange-colored fruits and vegetables such as
carrots, pumpkins, mangoes and papaya are rich in Vitamin A and Vitamin C.
Oil and fat are also essential foods that provide energy and fat for the baby's
developmental needs. Like many developing countries in the world, many
studies in Vietnam also show similar results about complementary feeding
practices of children from 6 to 23 months old. Many young families have not
properly implemented supplementary feeding for children both in terms of
supplementary feeding, quantity and quality of supplementary meals.


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Chapter 2
RESEARCH SUBJECTS AND METHODS
2.1. Designing The Research
The study is divided into 2 phases: Descriptive study and controlled
community intervention study.
2.2. Research Location And Time
2.2.1. Research location: at four communes of Thuong Nong, Dau Duong,

Thanh Uyen and Tam Cuong, Tam Nong District, Phu Tho Province.
2.2.2. Research period: from November 2012 to June 2018.
2.3. The Research Subjects
All children aged 6 to 23 months are eligible to participate in the study and
mothers of these children.
Criteria for selecting the subjects for the Intervention Research: the pairs of
mothers and children aged 6-23 months are selected from the descriptive
study and meet the criteria: Children at risk of stunting malnutrition and with
stunting malnutrition (-3SD < HAZ < -1SD; no congenital malformations that
affect human anthropology and blood biochemistry; No chronic diseases,
acute infections, severe and very severe anemia (Hb from <70g/L), no serious
Vitamin A deficiency (retinol <0.35 µmol/L); no infection at the time of
screening study; the mothers are voluntary to participate in the research and
to sign the register of voluntary research participation.
2.4. Sample Size And Research Methods
2.4.1. Sample size
The study sample size of the stage 1:

n  Z (12  / 2)

p (1  p )
e2

In which: Z2(1–α /2) = 1.962 (With the reliability of 95%); e = 0.05 (the
absolute accuracy); p = 30.8% (The rate of stunting malnutrition in Phu Tho
Province in 2010). Calculating the minimum sample size of 327 children,
plus 10% may refuse to participate in studying the sample size of 360
children. In fact, 398 subjects were investigated.

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The study sample size of the stage 2:

In which: = 1.96; = 0.84 (sample capacity 80%); : is the estimated oscillation
(SD) of the value 1-2. : the desired difference after intervention between
the two groups. After calculating the anthropometric sample size: the
minimum value for each group is 71 children + 5%; the giving-up rate of 75
children; so the two groups will be 150 children. The sample size for testing
at least is 136 children for the two groups.
Sample size for dietary surveying:

In which: : The standard deviation of the average caloric intake is
about 300kcal; N: the total number of participants in the survey is about 300;
e: the allowable error of about 70kcal. Thus, each research group will ask 59
servings x 2 groups = 118 servings.
General sample size for the study: Since the sample size of
anthropometric data is the highest (150 children), this sample size will be
used for all other indicators..
2.4.2. Selecting samples
Stage 1: For the descriptive research, intentionally selecting the district
of Tam Nong, a poor district, where the rate of malnourished children under 5
years old, especially the stunting, is higher than the national average rate in
2010. Selected subjects are based on the sample selection criteria as
mentioned above.
Stage 2: For the intervention research, from the results of screening
studies in stage 1, 160 pairs of eligible mothers - children were selected and
agreed to participate in the study at the beginning of the intervention.
2.5. Methods And Techniques Of Data Collection
2.5.1. Information collection tool

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-

The survey questionnaire includes the following contents: weight, height
of children, mothers' knowledge on practicing child nutrition care.
- The questionnaire for recording the past 24 hour diets, food photo album,
tools for feeding children and food weight (Aanonsen, accuracy of 5g).
- The electronic scale Tanita BCF 541 with accuracy of 0.1kg.
- The tape measuring the lying length: Use UNICEF wooden ruler with the
accuracy of 0.1cm.
- Testers and meters of Hemoglobin and serum Retinol and serum Zinc.
2.5.2. Method of information collection
- Interviewing general information and nutrition practice knowledge of
mothers: related information.
- Interviewing diets: method of asking to record the last 24 hour data:
- Collecting the anthropometric information: according to WHO 2006.
- Biochemistry: Done at the Department of Micronutrients, National
Institute of Nutrition.
Hemoglobin blood: Testing hemoglobin with Cyanmethemoglobin
method. The children with the blood hemoglobin concentration <110g/L are
defined as anemia.
Serum retinol: analyzed by HPLC High-performance liquid
chromatography (LC 10 ADVP, Shimadzu, Japan) according to WHO
guidelines. Children with the blood retinol concentration <0.7 μmol/L were
identified as the pre-clinical Vitamin A deficiency.
Serum zinc: analyzed by Flame atomic absorption spectroscopy (AAS) at the
wavelength 213.9 nm. Children with serum zinc concentration <9.9 μmol/L
were identified as Zinc deficiency.
2.5.3. Data processing

Using Stata 10.0 software with conventional medicine statistics tests.


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Chapter 3
RESEARCH RESULTS
Table 3.4. Rate of breastfeeding practice according to WHO
Indicators
n
%
Babies are breastfed for the past 24 hours at
373
93,7
the time of the investigation
Early breastfed for 1 hour after birth
189
47,5
Breastfed completely for up to 6 months
106
26,6
No
137
34,4
Fed/drunk
before
Other food
185
46,5
breastfeeding
Bottle feeding

76
19,1
Breastfed up to 2 years old
49
12,3
Breastfed up to 1 year old
221
55,5
Average age of weaning (month)
14,9 ± 3,9
Bảng 3.4 cho thấy tỷ lệ trẻ được nuôi bằng sữa mẹ tại thời điểm điều tra
là khá cao (93,7%), chỉ có 47,5% trẻ được bú mẹ trong 1 giờ đầu sau sinh và
chỉ có 26,6% trẻ được bú mẹ hoàn toàn trong 6 tháng đầu. Tỷ lệ trẻ được bú
mẹ đến 1 tuổi chỉ đạt 55,5% và chỉ cịn có 12,3% trẻ được bú mẹ đến 2 tuổi.
Table 3.4 shows that the proportion of children breastfed at the time of
the survey was quite high (93.7%), only 47.5% children were breastfed for
the first hour after birth and only 26.6% babies were totally breastfed for the
first 6 months. The proportion of breastfed children up to 1 year of age was
only 55.5% and only 12.3% children were breastfed up to 2 years old.
Table 3.5. The rate of practice of complementary feeding
Indicators
n
%
Minimum acceptable diet
212
53,3
Minimum frequency (number of times) of feeding
387
97,2
Minimal food diversity (≥4 food groups)

213
53,5
Consumption of iron-rich foods
251
63,1
Frequency of liver and fish consumption during the
114
28,6
week (≥5 times)
Table 3.5 shows that the percentage of children meeting the minimum
frequency (number of meals) is quite high (97.2%), while the percentage of
children meeting the standard of food diversity is at least 53.5%. The
percentage of children consuming iron-rich foods is 63.1% but the rate of


10
children consuming liver and fish, the two iron-rich foods available at the
locality, is only 28.6%.
Table 3.8. Anthropometric characteristics of the two groups before the
intervention
Control group Intervention group
Indicators
p
(n=78)
(n=76)
9,3 ± 1,3
9,6 ± 1,5
>0,05
Weight ( X ± SD) (kg)a
75,6 ± 5,2

75,4 ± 5,4
>0,05
Height ( X ± SD) (cm)a
Malnutrition CN/T n (%)b
12 (15,4)
15 (19,7)
>0,05
Malnutrition CC/T n (%)b
28 (35,9)
24 (31,6)
>0,05
Malnutrition CN/CC n (%)b
3 (3,8)
3 (3,9)
>0,05
a
t-test, bχ2 test
Results from table 3.8 show that: The anthropometric indicators of
children in control group and intervention group have no difference
(p>0.05). This result is not statistically significant at the time of
intervention.
Table 3.10. Characteristics of some biochemical indicators of two groups
before intervention
Intervention
Control group
Indicators
p
group
(n=78)
(n=76)

Hb (g/L)a
112,9±8,1
114,2±7,8
>0,05
Serum retinol (μmol/L)b
1,17±0,41
1,11±0,4
>0,05
Serum zinc (μmol/L)b
9,1±2,1
9±1,6
>0,05
c
% anemia
32,05
32,89
>0,05
% Vitamin A deficiencyc
16,67
18,42
>0,05
% zinc deficiencyc
82,05
81,58
>0,05
a
b
c
( t-test, Mann-Whiteney, χ2 test)
Results from table 3.10 show: Biochemical indicators of children in the two

groups: Control group and intervention group do not have statistical
significance (p> 0.05) at the time of intervention.
Table 3.11. The rate of complementary feeding practices of mothers in the
two research groups before intervention


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Indicator b
Minimum acceptable diet
Minimum frequency (number of
times) of feeding
Minimal food diversity (≥4 food groups)

Control group
(n=78)
n
%

Intervention
group (n=76)
n
%

pb

41

52,6

40

52,6

>0,05

77

98,7

74

97,.4

>0,05

40

51,3

42

55,3

>0,05

Consumption of iron-rich foods
54
69,2
57

75,0 >0,05
Frequency of liver and fish
consumption during the week (≥5
52
66,7
50
65,8
>0,05
times)
b 2
χ test
The results show that: The evaluation indicators for supplementary
feeding practices of mothers in the two studied groups at the time of the
intervention were not statistically significant (p> 0.05). In which the
minimum acceptable diet of the two groups had the same rate (52.6%).
Similarly, the minimum number of feedings, liver and fish consumption rate
of the control group were similar to the research group with p> 0.05.


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Table 3.14. Percentage of changes in complementary feeding practices of
children after 6 months of intervention
Indicators
Minimum acceptable diet
Minimum frequency (number of times) of
feeding
Minimal food diversity (≥4 food groups)
Consumption of iron-rich foods
Frequency of liver and fish consumption
during the week (≥5 times)

Control
group (n=78)

Intervention
group

5,1

(n=76)
11,8

0,0

1,3

2,6

9,2

2,6

14,5

1,3

18,4

Results from table 3.14 show that: After 6 months of intervention, the
improvement in supplementary feeding criteria in the intervention group is

better than in the control group. In the intervention group, the increase in
the percentage of children meeting the minimum standard of diets is 11.8%
while that in the control group is 5.1%. Similarly, the percentage of children
meeting the minimum meal frequency, the minimum diversity or
consumption of iron rich foods of the intervention group is higher than that
in the control group. In particular, the changes in liver and fish using rate of
the intervention group is increased by 18.4%, while this rate in the control
group is only 1.3%.


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Table 3.20. Effectiveness on anthropometric indicators
after intervention by the research group
Indicators

Control group
(n=78)

Intervention group
(n=76)

p
(t-test)

Weight (kg, X ±SD)
T0
9,23±1,07
9,22±1,25
>0,05

T6
10,22±0,94
10,74±1,18
<0,05
T6-T0
0,98±0,22
1,52±0,25
<0,05
Height (cm, X ±SD)
T0
75,76±5,23
75,43±5,4
>0,05
T6
80,12±5,24
80,44±5,65
<0,05
T6-T0
4,36±0,36
5,01±0,41
<0,05
Z-Score CN/T ( X ±SD)
T0
-1,13±0,93
-1,29±1,03
>0,05
T6
-1,16±0,65
-0,99±0,86
>0,05

T6-T0
-0,03±0,16
0,3±0,18
<0,01
Z-Score CC/T( X ±SD)
T0
-1,48±1,1
-1,51±1,2
>0,05
T6
-1,52±0,9
-1,33±0,94
>0,05
T6-T0
-0,04±0,17
0,18±0,19
<0,01
Z-Score CN/CC ( X ±SD)
T0
-0,59±0,93
-0,62±0,98
>0,05
T6
-0,5±0,7
-0,55±0,96
>0,05
T6-T0
0,09±0,21
0,07±0,24
>0,05

Results from table 3.20 show that: All average values of anthropometric
indicators at the time of pre-intervention are similar (p> 0.05) but after 6
months of intervention, the intervention group is significantly higher than the
control group in anthropometric indicators, this difference is statistically
significant (p <0.05) except for the CN/CC index. In which: the weight index:
At the time of 6 months and after 6 months of intervention, the average
weight of the intervention group is higher than the control group with
statistical significance (p <0.05). At the time of 6 months, the average weight
of the intervention group is 10.74 kg compared to the control group of 10.22


14
kg, and the difference is statistically significant with (p <0.05). After 6
months of intervention, the average weight of the intervention group
increased up to 1.52 kg compared to the control group of 0.98 kg, the
difference is statistically significant with (p <0.05). Other anthropological
indicators such as average height, Z - Score CN/T, Z-Score CC/T also have
similar comments.
Table 3.22. The change in concentrations of Hb, serum retinol and zinc
after 6 months of intervention
Time

Control group

Intervention group

n=78

n=76

p
(t-test)

Average Hb ( X ±SD) g/L
T0

112,93±8,08

114,16±7,83

>0,05

T6

115,63±9,86

120,4±9,73

<0,05

2,94±2,51

6,23±2,61

<0,05

T6-T0

Average retinol ( X ±SD) μmol/L
T0

1,17±0,41

1,11±0,4

>0,05

T6

1,23±0,4

1,38±0,36

<0,05

T6-T0

0,07±0,62

0,27±0,51

<0,05

Average serum zinc ( X ±SD) μmol/L
T0

9,16±2,05

9±1,6

>0,05

T6

9,8±1,91

10,38±1,58

<0,05

T6-T0

0,66±2,86

1,38±2,3

>0,05

Results from table 3.24 show that: The effectiveness of intervention for the
average content of: Hb, serum retinol and zinc at the time of the intervention of
the two study groups is similar (p> 0.05). After 6 months of intervention, the
intervention group is increased higher than the control group with the statistical
significance (p <0.05), in which, the average Hb increase of the intervention
group is 6.23 ± 2.61 g/L is higher than the control group (2.94 ± 2.51 g/L) with


15
the statistical significance. The mean increase of serum retinol of children in the
intervention group is 0.27 ± 0.51 μmol/L, higher than the control group (0.07 ±
0.62 μmol/L). The mean increase of serum zinc of children in the intervention

group is 1.38 ± 2.3 μmol/L higher than the control (0.66 ± 2.86 μmol/L) with the
statistical significance.
Chapter 4
DISCUSSION
The results of breastfeeding practice of mothers participating in the
study at Tam Nong, Phu Tho show that most of them are lower than the
average level of the province. The proportion of breastfed infants in the study
is only 93.7% compared to 99.8% across the province. The rate of early
breastfeeding within 1 hour is only 47.5% compared to 73.3% and the rate of
totally breastfeeding in the first 6 months is only 26.6% compared to 43.2%
(refer to table 3.4). For indicators for older children, this rate is also
significantly lower. Breastfeeding rate to 1 year in the study was only 55.5%
while the rate in the whole province is 96.9%; the rate of breastfeeding up to
2 years in the study is 12.3% while the rate in the whole province is 41%
(refer to table 3.4). The rates of totally breastfeeding during the first 6 months
and breastfeeding up to 1 year are lower than in the study by Bui Thi Phuong
in 2011 with the rate of 38.6% and 87.5% respectively. The results of the
study also show that the rate of totally breastfed children in the first 6 months
is 26.6%; before being breastfed for the first time, only 34.4% of children
actually did not use food - water. The rate of babies breastfed up to 1 year is
55.5% and only 12.3% of children are still breastfed up to 2 years (refer to
table 3.4). The results in the study are also lower than those found in the
survey by A&T, but they are quite similar to the findings on breastfeeding in
the nationwide MICS5 survey in 2014. Specifically, the proportion of
children who had ever been breastfed in the A&T study was 99.5%, this
figure in MICS5 was 96.9%. The same thing is also demonstrated with the
proportion of children who were breastfed early after birth after this number
of A&T was 50.5% and that of MICS5 was only 26.5%. The same is true for

16
the rate of breastfeeding up to 1 year, 79.5%, and 65.6% respectively for A&T
and MICS5 and our rate of 55.5% (refer to table 3.4). The proportion of
breastfeeding up to 2 years in the study by MICS5 was higher (21.8%) than
that of the A&T study (18.2%) and was also higher than our study (12.3%)
(refer to table 3.4).
4.1. Supplementary feeding practices
Supplementary feeding practices for infants of mothers have not been
proper as recommended. One notable finding is the large changes in diets
across different age groups that improve over time. Besides, the study also
found that the group of children aged 6-11 months old had the lowest rate of
receiving food from 4 basic groups and 7 types of food according to WHO
recommendations. This age group is also less likely to meet the criteria for
minimum meal frequency, varied meals and acceptable dietary standards
compared to older children (12-23 months). This suggests that children aged
6-11 months are still at higher risk of malnutrition and micronutrient
deficiency than the other groups. Although breast-feeding practices are not as
good as in the whole province, the mothers at the studied locality better
practiced to supplement their children than the average level. The proportion
of children with adequate minimum meal frequency in the study reached
97.2% (refer to table 3.5), while the whole province of Phu Tho reached only
76.3%. The proportion of children with food diversity was slightly lower
(53.5% and 58.9%), while the proportion of children receiving iron-rich foods
was 63.1%, higher than 58.3% of the whole province.
For the number of studied meals, the results found that the rate of
children receiving enough meals a day in our study was higher than that of
MICS5 (90.5%) and A&T (94.4%). The percentage of children meeting the
minimum standard of food diversity was 53.5% (refer to table 3.5) is
significantly lower than MICS5 (76.9%) and A&T (82.6%). Perhaps that is
why our percentage of children meeting the minimum acceptance criteria is

significantly lower than that of MICS5 and A&T (with the rates of 53.3%,
64% and 70.9% respectively). The percentage of children consuming iron-


17
rich foods in our study is only about 63% (refer to table 3.5), much lower
than the rate of 71% according to the A&T survey.
Table 3.8 shows that the anthropometric indicators of children in control
group and intervention group are not statistically significant at the time of
intervention.
Table 3.10 shows the biochemical indicators of children in the two
groups: The control group and the intervention group were not statistically
significant (p> 0.05) at the time of intervention.
The same thing also happened to the indicators of complementary feeding
practices of children. There were no statistically significant differences in the
indicators of evaluating the complementary feeding practices of children between
the two groups before the intervention (refer to table 3.11).
4.2. The efficiency of interventions of nutrition education and
communication
The intervention study was conducted on 160 children at risk of stunted
malnutrition or being stunted (HAZ <-1) discovered from 398 in the
screening research. At the end of the study, six children gave up, there are 154
infants and 76 children in the intervention group and 78 children in the
control group. After the intervention, there was a marked change in practice
of feeding infants in the intervention group compared with the control group.
Results from table 3.14 show that after 6 months of intervention, in the
control group, the increase percentage of children meeting the minimum
standard of diet diversity is only 5.1%, while this figure in the intervention
group is 11.8%. Thus the change in the intervention group is better than the
control group. The same thing happens to the percentage of children meeting

the minimum meal frequency, the minimum variety or the norms of
consuming iron and vitamin A-rich foods, especially the rate of using liver &
fish in the intervention group increased by 18.4%, while this rate in the
control group decreased by 1.3%.
4.2.1. Effectiveness for the weight criteria
The study results showed that after the intervention (T6), the weight gain
of the control group was 0.98 ± 0.22 kg and the weight gain of the intervention


18
group was 1.52 ± 0.25 kg (refer to table 3.20). The study results also showed
that the average Z-Score, the weight index by age of the control group
decreased (-0.03 ± 0.16), while this index of the intervention group increased
(0.3 ± 0.18) (refer to table 3.20). The results in Chart 3.3 also showed that after
the intervention, the proportion of underweight malnutrition of the control
group increased by 0.2% while this rate of the intervention group decreased by
6.54%. Table 3.20 also showed that the weight gain of the intervention group
was significantly higher than the control group, and the rate of underweight
malnutrition in the intervention group decreased significantly more than the
control group.
Thus, we can conclude that after 6 months of intervention, the
intervention group had better changes than the control group in terms of the
weight-by-age index. This is similar to many other micronutrient supplement
studies for children aged 6-36 months. However, in our study, we do not
directly distribute products to children but enhance knowledge for mothers,
thereby changing their child caring behaviors, leading to changes in the infant
nutrition status.
4.2.2. Effectiveness for the height criteria
The study results also showed that the average Z-Score, the index of
height by age of the control group decreased (-0.04 ± 0.17), while this index

of the intervention group increased (0.18 ± 0.19) (table 3.20). The results of
our study also showed that after the intervention, the stunting rate of the
control group increased by 0.46% while this rate of the intervention group
decreased by 6.58%. Table 3.20 also showed that the height increase of the
intervention group was significantly higher than the control group, and the
rate of underweight malnutrition in the intervention group decreased more
significantly than the control group. Thus, it can be concluded that after 6
months of intervention, the intervention group had better changes than the
control group for age-based height index. This is similar to many other
micronutrient supplement studies for children aged 6-36 months. However, in
our study, we do not directly distribute products to children but increase
knowledge for mothers through communication models and specific food


19
available on the spot (liver, fish), thereby making the change in the maternal
child care behavior, leading to changes in child nutrition status.
4.3. Effectiveness of communication using micronutrient-rich products to
lack of vitamina, zinc deficiency and anemia of children aged 6-23 months
with stunting malnutrition.
The study results showed that, at the time of starting the intervention
(T0), the average hemoglobin concentration of the control group was 112.9 ±
8.1 g/l and that of the intervention group was 114.2 ± 7.8 g/l and this
difference was not statistically significant (table 3.22). At the end of the
intervention (T6) (Table 3.24), the average hemoglobin concentration of the
control group was 115.63 ± 9.86 g/l and the average hemoglobin
concentration of the intervention group was 120.4 ± 9.73 g/l and the
difference between these two values was statistically significant (p <0.05).
The results also showed that the increase in the mean hemoglobin
concentration of the control group was 2.94 ± 2.51 g/l statistically lower (p

<0.05) than that of the intervention group of 6.23 ± 2.61 g/l. At the beginning
of the intervention (T0) the average serum retinol concentration of the control
group was 1.17 ± 0.41 μmol/L and that of the intervention group was 1.11 ±
0.4 μmol/L and the difference was not statistically significant.
At the end of the intervention (T6), the mean serum retinol
concentration of the control group was 1.23 ± 0.4 μmol/L and the average
serum retinol concentration of the intervention group was 1.38 ± 0.36 μmol/L
and the difference between these two values is statistically significant (p
<0.05). Table 3.24 also shows that the mean increase in serum retinol
concentration of the control group was 0.07 ± 0.62 μmol/L significantly lower
(p <0.05 - t-test) compared to the intervention group of 0.27 ± 0.51 μmol/L.
The results of our study showed that at the start of the intervention (T0), the
average serum zinc concentration of the control group was 9.1 ± 2.1 μmol/L
and 9±1.6 μmol/L for the intervention group and this difference is not
statistically significant. At the end of the intervention (T6), the mean serum
zinc concentration of the control group was 9.8 ± 1.91 μmol/L and the mean
serum zinc concentration of the intervention group was 10.38 ± 1.58 μmol/L


20
and the difference between these two values is statistically significant
(p<0.05). Table 3.22 also shows that the average increase in serum zinc
concentration of the control group was 0.66 ± 2.86 μmol/L, which was not
statistically significant (p>0.05) compared to the intervention group of 1.38 ±
2.3 μmol/L.
Based on all of the above research results, it is possible to confirm the
effectiveness of the communication model combined with social marketing of
products of liver and fish in improving nutritional status of children aged 6-24
months old is positive.
Limitations and shortcomings of the thesis: Although the project has

been successful, the intervention has only been implemented for 6 months, so
its sustainability cannot be assessed. At the same time, this study only
intervened in the group of children aged 6-23 months, but did not intervene
on the group of older children, so it is impossible to provide evidence that the
nutrition education and communication on early using the locally available
products for children in the period of 2 years of age is more effective in
improving height and preventing stunting for children at the age of 2 years
and more after intervention. This may be a suggestion for other researches to
further study and prove this hypothesis.
CONCLUSIONS
1. The nutrition practices of mothers at the time of the study were not good
yet; the rate of stunting malnutrition was quite high in children aged 6-23
months: The rate of breastfed children was 93.7%, the rate of early
breastfeeding in the first 1 hour only 47.5%, the rate of exclusive breastfed
children in the first 6 months was quite low (26.6%), the rate of children
breatfed up to 1 year of age was only 55.5%; The average age of weaning was
14.9 ± 3.9 months. The percentage of children having minimum meal
frequency was 97.2% but the percentage of children with minimum diverse
supplementary meals was only 53.5%, the rate of children receiving iron rich
foods was 63.1% and the percentage of children reaching the minimum
acceptable diet was 53.3%. The frequency of liver and fish consumption


21
during the week (≥5 times) was 28.6%. The rate of underweight malnutrition
was 11.6%, and the rate of wasting malnutrition was 5.5%; but the rate of
stunting malnutrition was still 20.9%: at the average level according to WHO
1995 classification threshold, but at a high level according to the WHO 2018
threshold.
2. The effectiveness after 6 months of intervention of nutrition education and

communication has improved the maternal child feeding practices: There has
been a marked change in complementary feeding practices of mothers
according to child feeding criteria of WHO, in which the minimum
acceptable diets increased by 11.8%, the minimum meal frequency increased
by 1.3%, the minimum food diversity (≥4 groups) increased by 9.2%, the
iron-rich food consumption increased by 14.5% and the frequency of liver
and fish consumption in the week was more than five times, an increase by
18.4%. The actual diet of children was positively changed in terms of the
balance of energy bioavailability of diets, concentrations of Vitamins A, D, C
and iron and zinc increased after intervention.
3. Nutrition education and communication using micronutrient-rich foods has
effective impacts on nutritional status, Vitamin A, zinc status and anemia of
children aged 6-23 months at risk of stunting or stunting after 6 months of
intervention: The weight gain of the intervention group was 1.52 ± 0.25 kg,
higher than the control group of 0.98 ± 0.22 kg; similarly, the Z-Score index
of weight/age in the intervention group increased by 0.3 ± 0.18 while the
control group decreased by -0.03 ± 0.16. The height increase of the
intervention group was 5.01 ± 0.41 cm, higher than the control group of 4.36
± 0.36 cm; Z-Score index of height/age in intervention group increased by
0.18 ± 0.19 while control group decreased by -0.04 ± 0.17. The average
increase in hemoglobin concentration of the intervention group was 6.23 ±
2.61 g/l, higher than the control group of 2.94 ± 2.51 g/l. The effective index
of real intervention of anemia was 28.84%. The increase in the average serum
retinol concentration of the intervention group was 0.27 ± 0.51 μmol/L higher
than the control group of 0.07 ± 0.62 μmol/L. The index of effective
interventions of pre-clinical Vitamin A deficiency rate was 72.70%. The


22
average increase in serum zinc concentration of the intervention group was

1.38 ± 2.3 μmol/L higher than the control group of 0.66 ± 2.86 μmol/L. The
effective index of real intervention of zinc deficiency rate was 25.73%.
RECOMMENDATIONS
Combining activities/contents of nutrition education and
communication and specifically guiding mothers/caregivers to use locally
available nutritious, affordable and accessible foods are a possibly applied
solution to improve stunting and micronutrient deficiency status of infants.
This solution should be disseminated in the places where socio-economic
and geographical conditions are similar to those studied. However, in
addition to the two foods of liver and fish used in this study, other foods
may also be selected according to the actual situation.
FINDINGS OF THE THESIS
1. The thesis has provided more evidence on the practice of nurturing children
under 2 years old (1000 golden days) and the nutritional status of children
aged from 6 to 23 months at Tam Nong District, Phu Tho Province;
contributing to the development of a plan to improve the the nutritional status
for children under 2 years old in this locality.
2. The thesis has proposed a solution to improve the nutritional status of
children, especially stunting, Vitamin A deficiency, zinc deficiency and
anemia of children from 6 to 23 months of age by combining the nutrition
education and communication and guidances on the use of cheap and
available food with high nutritional value (liver, fish) in the locality where
mothers and people have not used to change the practice of supplementary
feeding according to WHO’s child feeding criteria.