Community Based Nutrition Education for Promoting Nutritional Status of Children under Three Years of Age in Rural Areas of Mahottari District of Nepal

Address for correspondence: Dipendra Kumar Yadav Lecturer School of Health and Allied Sciences Pokhara University, Kaski, Nepal Tel: +977-9856033787 E-mail: dipendrayadavph@gmail.com 1Dipendra Kumar Yadav, MPH, Lecturer, School of Health and Allied Sciences, Pokhara University, Kaski, Nepal and PhD Scholar, Faculty of Health Sciences, Sam Higginbottom Institute of Agriculture, Technology and Sciences, Allahabad, India, 2Dr. Neena Gupta, Senior Assistant Professor, FHS, SHIATS, Allahabad, India, 3Prof. Naveen Shrestha, Valley College of Technical Sciences, Kathmandu, 4Prof. Dr. Annamma Kumar, Former Dean, College of Home Science, SHIATS, Allahabad, India, 5Dr. Dipak Kumar Bose, Associate Professor, Allahabad School of Agriculture, SHIATS, Allahabad, India. Abstract


Introduction
M alnutri on in all its forms directly or indirectly is responsible for approximately half of all deaths worldwide.This applies to perinatal and infec ous diseases as well as chronic diseases.Malnutri on accounts for 11% of the global burden of disease, leading to long-term poor health and disability and poor educa onal and developmental outcomes 1 .
Malnutri on among children is a public health problem in Nepal.Nepal Demography and Health Survey (NDHS-2011) reported that 29 % children are under weight, 41% stunted and 11% wasted 2 .Childhood illnesses such as diarrhea and acute respiratory infec ons (ARIs) also are common 3 .
Improvement of exclusive breas eeding prac ces, adequate and mely complementary feeding, along with con nued breas eeding for up to two years or beyond, could save annually the lives of 1.5 million children under fi ve years of age 4 .
Promo on of breas eeding and behaviour change communica on for improved complementary feeding are both stated priori es of the Ministry of Health and Popula on, Nepal but it appears that the quality of eff orts to date have been insuffi cient and poorly designed and implemented.Par cular problems in Nepal are delay ini a on of breas eeding, a decline in exclusive breas eeding rates and early and late complementary feeding with a low quality complementary feeding diet.Global experience indicates that it is possible to improve breas eeding rates although less evidence exists for improvements in complementary feeding prac ces 5 .
Maternal and child mortality have declined signifi cantly in Nepal to the extent that Nepal is on track to meet the Millennium Development Goals for maternal and child mortality.Similar improvements have not been seen in general nutri on status of them 5 .
Literate mothers had less number of stunted, wasted and underweight children in comparison to illiterate mothers (NDHS 2011).On the basis of NDHS fi ndings, the idea that educa ng the primary child-caretakers (mothers) that improving women's awareness of appropriate feeding prac ces can improve the nutri onal status of children 2 .
The idea that educa ng the primary childcaretakers (mothers) can improve the nutri onal status of young children 6 is partly based on the belief that improving women's awareness of appropriate feeding prac ces would correlate with improvement in their feeding behaviors.
The objec ve of this study was to evaluate a nutri on-educa on interven on designed to improve nutri onal status (reduce stun ng, was ng and underweight) of children.

Materials and Methods
Study of an interven on with separate sample pretest-post-test design and study dura on lasted from 1 st February 2012 to 12 th November 2013.Two groups of VDCs from Maho ari district were recruited as interven onal and control areas.Study popula on was under three year's children and their mother and study was carried out in rural areas of Maho ari district.Desired numbers of par cipants were selected by using formula given below. Where Suppose an increase of 5 percentage points in the propor on of ini a on of breas eeding within 1 hour a er delivery is to be measured.Assume further that at the me of the fi rst survey; about 45 percent of mothers were ini a on of breas eeding within 1 hour a er delivery to be following proper prac ces.In this case, P1 =.45 and P2 =.50.Using standard parameters of 95 percent level of signifi cance (Z 1 ) and 80 percent power (Z 2 ), values of Z 1 = 1.645 and Z 2 = 0.840 are chosen.
In interven on area 121 households were selected for baseline and endline study.Control area ra o 1:1.5 was taken in comparison to interven on group and thus 182 households were selected for baseline and endline study in control group.A total 615 and 708 under 3 years old children were selected as baseline and endline respec vely.
Mul stage sampling technique was used in the study.Mahotarri district was selected purposively for the study because of Human Development Index this district has ranked 59 out of 75 districts.District (76 VDCs) was divided into three stratums according to geographical loca on (North, Middle and South Part).Names of all VDCs were recorded alphabe cally in separate stratum.Four VDCs from each stratum were selected randomly.Again two VDCs were selected for interven onal group and two VDCs from each stratum were selected for control group randomly.Total 6 VDCs were selected for interven on group and similar numbers of VDCs were selected for control group.Each VDC consists of nine wards.Two wards were selected randomly from each VDC.Systemic random sampling technique was followed to get required number of households in both areas.Interven on areas, 10 households were taken from each selected wards and control areas, 15 households were taken from each selected wards as systemic random sampling.A er that all children less than three years of age were selected for study from all selected households.Two groups of VDCs from Maho ari district was recruited as interven onal and control areas.In interven on areas, Female Community Health Volunteer was trained to promote feeding behaviours and nutri onal status of children.Through this programme FCHV conducted monthly mee ng with mothers group at ward level with the objec ve of promo on of feeding behaviours and nutri onal status of children.Each member of Mother's group has been given the task to educate mothers of children regarding nutri on educa on and counselling for be erment of children's nutri onal status.FCHV conducted 12 mee ng with mothers throughout 12 months: one interac ve nutri on discussion class 2-3 hours per month.In control areas, First 12 months was taken as follow up stage and was not given nutri on educa on but district health system has overall responsibility to give comprehensive health services for be erment of community people.In control areas only one episode of nutri onal educa on was given to the benefi ciaries a er endline data collec on.
Ethical Approval was taken from Sam Higginbo om Ins tute of Agriculture, Technology and Sciences, India and Nepal Health Research Council, Nepal.Verbal consent was taken from each par cipant mother and permission was given from District Health Offi ce, Maho ari to carry out the study.
Data were collected once at the beginning of the study (base line) and the other at end of the study (end line) in both areas i.e. interven on and control.Interview schedule focused on socio-demographic condi ons, nutri on and feeding behaviors and child seeking prac ces were collected from mothers.Anthropometric measurements were carried out to assess the degree of malnutri on in children of under three years of age from all the study groups from interven on and control areas.Height for weight, weight for age, height for age and MUAC were calculated for children.Height was measured using a standard height measuring scale (board) for children under three years.For children length was also measured.Weight of children was measured using a lightweight electronic SECA digital scale (UNICEF Electronic Scale).MUAC of children was measured with UNICEF MUAC tape.
Data were coded and entered in EpiData 3.1 version so ware.Anthropometric analysis such as Z-score value was calculated in EpiInfo 3.3.2version.Epi-Info so ware was produced tables of frequencies for Z-score classes of 0.5 Z-score intervals and graphs of frequency distribu ons.Finally all the data from Epidata and EpiInfo were exported to IBM SPSS Sta s cs 20 so ware and then analyzed it.Appropriate sta s cal test was applied wherever required.The result was interpreted in the light of the objec ves.Sta s cal calcula ons were calculated wherever required.

Results
The total number of children selected for the study was 1323 of age less than three years.This study was a pre-post with controlled design.Out of 1323, 615 and 708 children under three years of age were selected as baseline and endline respec vely.Out of 759, 353 and 406 children were selected for control and interven on group respec vely as a baseline of the study.Similarly out of 564, 262 and 302 children were selected for control and interven on as an endline study.Two groups of VDCs from Maho ari district were recruited as interven onal and control areas.Data were collected twice once at the beginning of the study (baseline) and the other at the end of study (end line) in both areas i.e. interven on and control.
In this study, Mean age of mother was 25.22 ± 4.30 and 25.21 ± 3.95 years of control and interven on groups respec vely.Mean age and weight of children was 17.43 ± 10.03 months and 9.30 ± 3.01 kg of control group while in interven on group mean age and weight was 16.82 ± 9.1 months and 8.71 ± 2.35 kg.58.4% and 59% of the mothers were illiterate and 10.5% and 10.7% mothers passed the secondary level of control and interven on group respec vely.
Study shows Stun ng increased by 1.3% in control group while marginally (0.1%) increased in interven on group from baseline to endline period.Number of underweight children increased by 7.6% in control group while it decreased by 17.7% in interven on group from baseline to endline.Was ng increased by 11.4% in control group.Also, it was found that sta s cally signifi cant increase in the burden of was ng from baseline to endline.While in interven on group was ng decreased by more than 5% from baseline to endline.Ini a on of breast feeding within 1hr of birth decreased in control group while in interven on group, increased by 8.44%.Results shows that mother experienced that colostrums feeding of children decreased by 1.3% in control group while in interven on group, colostrums feeding of children showed sa sfactory rate of increased (6.7%) by interven on programme that was sta s cally signifi cant p= 0.00.
Vitamin A supplementa on received by children was increased by only 1.93 % in control group while it was increased by 7.27% in interven on group from baseline to endline.That increasing trend was found to be sta s cally signifi cant (p=0.03).Note: The fi gure in the parenthesis is percentage of frequency and frequency were analyzed only of those mothers who had child less than 24 months of age.*Changes in percentage of feeding status of children from baseline to endline period.

Discussion
The nutri onal status of children under age three is an important measure of children's health.The anthropometric data on age, height and weight as well as independent variables were collected in this study to permit the measurement and evalua on of the nutri on-educa on interven on research.
In children, the three most commonly used anthropometric indices are weight-for-height, heightfor-age, and weight-for-age.Defi cit in height-for-age is called stun ng and indicates chronic malnutri on.
Defi cit in weight-for-height is called was ng and indicates acute malnutri on.Defi cit in weight-for-age is o en referred to as underweight and refl ects low weight-for-height, low height-for-age, or both 7 .
In baseline control group, Prevalence of was ng, stun ng and underweight was 28.3%, 44.5% and 40.2% while in baseline interven on group 34.7%, 39.3% and 51.5% of children less than three years were was ng, stun ng and underweight respec vely.According to NDHS 2011 report, Prevalence of was ng, stun ng and underweight was 11%, 41% and 29% respec vely children below fi ve years, which is lesser as compared to this study 2 .This diff erence could be due to a smaller sample size of our study.
Study reveals that the Stunted children increased by 1.3% in control group while marginally increased (0.1%) in interven on group during study period from baseline to endline.So that interven on was not able to reduce stun ng status of children.This can be a ributed to the fact that stun ng represents chronic malnutri on and that the interven on program was given for shorter dura on.Stun ng refl ects failure to receive adequate nutri on over long period of me and is aff ected by recurrent and chronic illness.Heightfor-age, therefore, represents the long-term eff ects of malnutri on in a popula on and is not sensi ve to recent, short-term changes in dietary intake.
Study found that number of underweight children was increased by 7.6% in control group while it was decreased by 17.7% in interven on group during study period from baseline to endline.So, interven on programme was able to decrease the no. of underweight children signifi cantly.Study shows that was ng was increased by 11.4% in control group while in interven on group was ng was decreased by more than 5% from baseline to endline.These fi ndings is comparable with study done by Malekafzali et al and Kilaru et al which showed diff erent fi ndings and this diff erence could be due to a dis nct interven on design, study areas and study popula on 8,9 .
88.05% and 88.09% of children received colostrums in baseline control and baseline interven on group respec vely.75.57% and 66.67% children were put to breast within one hour of birth in baseline control group and baseline interven on group respec vely.Children 82.83% and 74.88% were fed exclusively with breast milk in baseline control group and baseline interven on group respec vely.Subedi, Paudel et al. study in Nepal and fi nds that three out of four children were fed colostrums by their mother.About 82% of the mothers had prac ced exclusive breas eeding and 90% of them had ini ated complementary feeding at the age of six month of their child.This diff erence could be due to a dis nct study areas and study popula on 10 .
Present study found that ini a on of breast feeding within 1hr of birth decreased in control group while in interven on group increased by 8.14% from baseline to endline.It was found to be sta s cally signifi cant in interven on group.It was found that colostrums feeding to their children by mothers decreased by around 1.3% in control group; while in interven on group, colostrums feeding to children sa sfactorily increased through nutri on interven on programme from baseline to endline respec vely and that was sta s cally signifi cant.
Early ini a on of breas eeding is important for both the mother and the child.Early suckling s mulates the release of prolac n, which helps in the produc on of milk, and oxytocin, which is responsible for the ejec on of milk.It also s mulates contrac on of the uterus a er childbirth and reduces postpartum blood loss.The fi rst liquid to come from the breast, known as colostrum, is produced in the fi rst few days a er delivery.Colostrum is highly nutri ous and contains an bodies that provide natural immunity to the infant.It is recommended that children be fed colostrum immediately a er birth (within one hour) then it helps for wellbeing to children.

Conclusion
From the fi ndings of the study it shows that prevalence of malnutri on (underweight, stun ng, and was ng) is s ll creates major health problems among children less than three years, par cularly in Central Terai region.Nutri onal educa on interven on was eff ec ve to reduce was ng and underweight but did not reduce the stun ng status of children.On the basis of fi ndings, longer dura on of nutri on programme should be implemented to control the stun ng status of children.
This study supports the view that nutri on educa on has poten al for improving feeding behaviors and nutri onal status of children.This interven on was concerned in only one district and will need to be replicated with a larger sample size to evaluate its eff ec veness.

Table 1 :
Baseline details of 615 mothers and children recruited for study.Values are number (percentages) unless stated otherwise.

Table 2 :
Nutri onal status of children.Note: 1.The fi gure in the parenthesis is percentage of frequency.
*Changes nutri onal status of children from baseline to endline period.

Table 3 :
Prac ces regarding child feeding among mothers