At admission, the nutritional status of the TNE+RUF and the WNE+RUF groups was similar. A low defaulter rate was found only in the TNE+RUF (3/204). The rate of weight gain per kg body weight (BW) per day of all eligible children was higher in the TNE+RUF (3.7 g/kgBW) than the WNE+RUF (2.2 g/kgBW). The proportion of children who reached discharge criterion (RDC) was highest among the TNE+RUF (81.0%) intervention compared to WNE+RUF (65.3%). In contrast, the duration of stay of RDC children in the WNE+RUF (29 d) was shorter than the TNE+RUF (33 d). During the follow-up assessment at home about 4-5 months after discharge, RDC children in the TNE+RUF group tended to have a better improvement of nutritional status than those in the WNE+RUF program.
Nias Island is located off the eastern coast of Sumatra and part of North Sumatra province. It is one of the poorest areas in Indonesia according to literacy rates (BRR 2007) and socioeconomic indicators (World Bank 2007). Moreover, it has suffered badly from food and nutrition insecurity after the 2004 tsunami disaster and the 2005 earthquake which aggravated the social, economic, environmental, and malnutrition problems.
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One out of two children on this island is stunted and underweight (UNICEF 2005). The prevalence of wasting (11.7%) within the Church World Service (CWS) working areas in Gunung Sitoli is above the emergency threshold of 10% (unpublished report). Moreover, the prevalence of Global Acute Malnutrition (GAM) was highest (17.1%) in Southern Nias where a high proportion of children suffer from oedematous forms of malnutrition (UNICEF 2005). Additionally, hidden hunger is also a serious problem as well.
Moderately malnourished children affect a large number of children in poor countries (Shoham 2009) and seemed to be a case in Nias as well. According to Shoham (2009), children with moderate wasting, or with moderate or severe stunting have a higher risk of dying from common diseases, and if not correctly treated, may result in severe acute malnutrition and/or severe stunting. Therefore there is a need for special nutritional support such as dietary management to improve the existing diets, and if needed, the provision of food supplements to provide nutrients that may not be easily provided by local foods (Briend et al. 2009).
Ready-to-Use Therapeutic Food (RUTF) is one food supplement available to treat severe acute malnutrition case without complications. RUTF was developed in the form of energy-dense paste/biscuits containing no water, therefore not supporting bacterial growth (Briend et. al 2006). Based on the development of RUTF in 1999, a new model of Community-based Therapeutic Care (CTC) had been introduced as an alternative of the standard therapy in the hospital (Collins 2001). Later on, the model has been developed as a new model called "Community-based Management of Acute Malnutrition" (CMAM) (WHO, WFP, UN-SCN and UNICEF 2007; Concern Worldwide, Valid International and UNICEF 2007). Study results from Malawi (and other African countries) suggested that RUTF may play an important role in treating malnutrition worldwide. The positive result of RUTF in severe acute malnutrition cases suggested that the outpatient management strategy with RUTF would be beneficial for the treatment of acute malnutrition at earlier stages. Therefore, the use of RUTF for the treatment of moderate acute malnutrition cases has been known in such trials in Nigeria (Defourney et al. 2007).
In several food supplementation programs, foods given to the children and intended to become supplement often replaced daily home food and were even consumed by other family members rather than the index children. Therefore it was thought appropriate nutrition education for families should complement the investments made in nutrition like food supplementation (Skolnik 2008). Additionally, in the early CTC programs, caregivers complained that it was difficult to "wean" the child of RUTF and re-introduce the family diet. To overcome this problem, most CTC programs supported by VALID International provide the caregivers with nutrition education on locally available nutritious foods as the child approaches discharge (Briend 2005).
To date, the role of different intensities of nutrition education with feeding encouragement accompanied by the provision of Ready-to Use-Foods (RUF) supplementation in improving the nutritional status of mildly/moderately wasted children in Nias Island in community-based programs has not been investigated. The present study aimed to investigate the effect of a three times weekly NE with daily encouragement (NED) combined with daily RUF Nias supplementation and a once weekly NE with weekly feeding encouragement (NEW) which was accompanied by a weekly provision of RUF biscuits in improving the nutritional status in mildly/moderately wasted children in Nias, Indonesia
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The study was conducted on Nias Island, Indonesia. The majority of the land is comprised of mountains and hills, which are between 150-800 m above sea level. The size of the study area was about 4800 kmÂ² with 433,350 inhabitants. The majority of inhabitants (95%) are Christians and worked in agricultural sectors. Overall, the public health system is less developed. The government runs 138 clinics, 18 health centres (Puskesmas) and 1 hospital on Nias (BPS Nias 2004).
Two districts in the Church World Services (CWS) project areas: Gunung Sitoli and Sirombu were selected for this study and assigned to receive the two different interventions.
The study was part of a wider research project aimed at improving nutritional status of moderately-mildly wasted children under-five years in Nias Island, Indonesia. The study followed the ethical guidelines of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000) and was approved by the Ethical Committee of the Faculty of Medicine, University of Brawijaya, Malang, Indonesia. Informed consent was obtained from all participating caretakers.
The study in the selected districts took place from October 2007 to June 2008 with one month Christmas and New Years break. Children and their main caregivers were eligible for the study if the children were aged â‰¥6-59 months with WHZ >-3 to <-1.5 (according to NCHS standard references) and free of birth defects or disease which would limit the ad libitum food intake. Children were screened for eligibility for the program through monthly monitoring activities ("Posyandu") implemented by CWS and the Government of Indonesia (GOI), in which the children were brought by caretakers from the surrounding community. Recruited children were then individually discharged when they reached WHZ-score of â‰¥ -1.5.
The children who reached discharge criterion (RDC children) were observed over period of two weeks in order to see if they maintained an achieved weight before discharge or if they needed to be referred to another program. This additional period was not calculated in the length of stay (Purwestri 2011).
Based on Purwestri (2011), a total sample size of 95 children per program was calculated to detect differences in daily and weekly programs by weight increment of 1.5Â±3.7 g/kg/day (Ciliberto et al. 2004) with a confidence level of 95% and a power of 0.8 (Hassard 1991).
Since October 2007, RUF-Nias biscuits were distributed among eligible children. RUF was locally-produced in the form of energy-dense biscuits consisting of wheat flour, peanut flour, refined sugar, palm oil, egg yolk and egg white, soy bean or mungbean flour (the use were interchangeably) and micronutrient powder. Its macro- and micronutrients content were in accordance with RUTF and the recommendations of WHO, WFP, UN-SCN, UNICEF for rehabilitation of severe acute malnutrition (SAM) (Scherbaum et al. 2009).
According to Purwestri (2011), the distribution of biscuits was calculated to be about 60% of the recommended daily energy requirement, which was, in average, 500 kcal. The community workers, the CWS health and nutrition officers, and some mothers/caregivers were involved in the local production of RUF-Nias biscuits. They were previously trained how to prepare the biscuits and to offer them to the children in the study.
Participants in both groups received informations concerning the importance of healthy family meals, food safety, feeding infants and young children, feeding sick children, and prevention/treatment of malnutrition in different NE intensities and different feeding encouragement frequencies by specially trained community workers and CWS health-nutrition officers (Table 1). Additionally, mothers/caregivers learned how to prepare a well balanced meal for their children/family by combining locally available foods sources. The NED villages were set to be distanced with the WNE villages to avoid spread of nutrition-related knowledge.
Type of groups
Children in this group received daily portion of RUF-Nias biscuits (which amount given was based on the actual weight of the individual child) in addition to a NE intervention three times a week with daily feeding encouragement (TNE). The daily distribution lasted from Monday to Saturday in the CWS nutrition centres. If mothers/caregivers could not come to the centres due to various reasons, the community workers and/or health officers would bring the daily individual portion to their home. The caregivers were advised that the child should consume the biscuits in the centre under supervision in a daily-basis. During the visits, the mothers/caregivers were asked about RUF Nias biscuits compliance issues. Important indictors such as weight, appetite behaviour and morbidity of the previous day were also recorded.
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This group received a weekly portion of RUF-Nias biscuits with the same instructions as the TNE+RUF group. The community workers/health officers of CWS encouraged caregivers to feed the RUF given to the child on a daily-basis. Additionally, the mothers/caregivers attended a once-a-week educational session with weekly feeding encouragement (WNE). However, important indictors like weight, appetite behaviour and morbidity during the last week were assessed once a week.
The topics delivered in the TNE and WNE program were based on the findings of focus group discussions in four selected villages (n=28), in-depth interviews to under-five caregivers (n=6) and key persons (n=6) aiming to identify the nutritional themes of concern in the project area that were performed prior to this intervention study (reported elsewhere). Six topics were considered as the most important themes to be administered in the educational program. Culturally adapted teaching materials consisted of 16 key messages. These messages were highly related to reverse some incorrect nutritional knowledge and practices observed in the study areas (Table 2). The teaching materials were developed for the 16 selected topics with guidance from FAO (2004) and Hoffmann (1991), field tested and locally produced prior to our intervention.
Prior to this study, community workers had already been trained in several nutritional areas by our implementing partner (GOI and CWS); therefore they had already been well informed of certain related nutritional knowledge. Additionally, community workers and health/nutrition officers of CWS who were involved in both groups were intensively trained on how to conduct culturally-appropriate participatory NE sessions.
All community workers/cadres and health/nutrition officers of CWS who were involved in the study were trained in conducting anthropometric measurements, interview techniques, and morbidity assessment before the study began. Furthermore, together with some motivated mothers/caregivers, they were also trained how to prepare the RUF biscuits and how to feed them to the children.
Admission, Intervention, Discharge
A structured questionnaire was used during admission time for obtaining information such as household characteristics, breastfeeding and complementary feeding habits, morbidity (diarrhoea, respiratory infection and fever during the previous week), hygiene and sanitation, dietary intake, and child's characteristics.
Weight and height of the children were taken at admission, during the intervention period and at individual discharge or program closure. Weight was examined by hanging scale (with an accuracy of 0.1 kg); height was assessed by a length/height board with an accuracy of 0.1 cm.
Morbidity data was collected weekly by asking mothers to recall specific symptoms of respiratory illness, diarrhoea, and fever. Respiratory illness was defined as the presence of purulent nasal discharge or cough. Diarrhoea was defined as three or more liquid or semi liquid stools per day. Fever was defined on mother's report of elevation of the child's body temperature above normal. When the index child did not gain or if they lost weight and/or became seriously ill, home visits were performed. The mothers/caregivers were also encouraged to bring the respective child to a nearby health centre or hospital for further medical treatment.
To examine Hb status of the children, blood samples of the children, with consent of the caregivers, were collected at admission and during individual discharge using a portable HaemoCue instrument.
The primary outcomes for the study included the weight gain and length of stay during the intervention period. Secondary outcome variables included changes in nutritional status (weight-for-height, height-for-age), Hb value and morbidity status of the index children.
Children who did not reach discharge criterion of WHZ-score â‰¥-1.5 SD before program closure were transferred into ongoing growth monitoring programs (Posyandu) run by the GOI.
Home visits 4 to 5 months after discharge
Children were discharged after reaching WHZ â‰¥ -1.5 and had a follow-up after their individual discharge from their respective study program. In total, 72% (106 out of 147) of all RDC children were followed-up individually at their homes to perform anthropometric measurements and to interview the mother/caregiver regarding the current nutrition and health situation of the index child.
Data processing and statistical analysis
All data were entered into a standardized spreadsheet using the Statistical Package for the Social Science (PASW/SPSS) version 18.0 for Windows software packages (SPSS Inc., Chicago, IL, USA).
Weight-for-height (WHZ) and height-for-age (HAZ) were calculated using Emergency Nutrition Assessment (ENA) version 2007 which was derived from the NCHS/WHO reference data. Currently, the new WHO growth reference (2006) has not been nationally accepted in Indonesia, especially among organizations and local health institutions working in Nias. Additionally, the harmonization of the growth reference used between involved institutions was very important for program implementation in the field. Thus, the WHO/NCHS growth chart was still used for admission and discharge criterion, as well as for the final analysis. Anaemia was defined as Hb < 110 g/L. The mean and SD of Hb and pre-post difference were calculated. Significant changes of Hb concentration within groups were reported based on the Wilcoxon signed rank test and significant change in the proportion of anaemia was performed based on the McNemar test.
Descriptive statistics of weight gain (g/kgBW/day) was determined by calculating the weight change (g) per kg body weight (BW) per day during the study period of individual children. Length of stay (days) was defined as the number of days from admission time until the child reached WHZ â‰¥ -1.0. The non-RDC children were also included in the analysis of all eligible children, and furthermore were then separately analyzed with respect to the comparison of RDC children versus non-RDC children.
The skewness value of the residual was used to check the normality of continuous variables. The differences and the 95% CI were calculated to measure the outcome of both intervention groups. The independent t-test or the Mann-Whitney U-test was performed to examine the differences between RDC children and no-RDC children within each group. The differences of measurement values before admission and at discharge/program closure within the groups were tested with the paired t-test or the Wilcoxon signed rank test while Fischer's exact test was used to determine the differences in proportion.
The role of different types of nutrition education intensity and different frequencies of feeding encouragement (TNE and WNE) that accompanied the RUF supplementation program in improving the nutritional status of moderately-mildly wasted children under five years in the CWS catchment areas is highlighted in this paper. The discussion focusing on the compared impact of both interventions on the nutritional status of respective children is reported elsewhere (Purwestri 2011).
Major socio-economic variables between the two groups were generally similar, except for the level education of parental grandmother, family type, parent's occupation, and level of family income.
Older women or grandmothers traditionally have been known to have considerable influence on decisions related to maternal and child health and care at the family level in mostly African, Asian, Latin American, and the Pacific communities (Aubel 2008; Aubel et al. 2001). In Nias Island, paternal grandmother mostly live in the same household or nearby of the core family. In line with Aubel (2008) and Aubel et al. (2001), they play an important role in child feeding and caring practices such as the colostrum consumption and the time to introduce complementary foods. Despite the fact that the grandmothers were not particularly targeted into both NE programs, the participation of these elderly females was often stressed and encouraged in the educational sessions. Therefore, the participation of grandmothers in both NE programs was often pronounced in both groups, particularly in the TNE+RUF group (personal communication with community workers). Unsurprisingly, the likelihood of grandmothers in the TNE+RUF to be exposed with suitable educational messages and appropriate feeding encouragement was higher through more intensive meetings in the TNE+RUF program than those in the WNE+RUF approach. This was likely reflected in better nutritional outcomes of the respective children in the TNE+RUF group than the children in the WNE+RUF group. In addition, the finding of multivariate analysis showed that a lower educational level of grandmother was a significant risk factor of not reaching the discharge criterion for the respective children as reported by Purwestri (2011).
Family type, parent's occupation and economic status were likely different at admission time between both groups. However, multivariate analysis that was performed to determine the factors of not reaching discharged criterion found that these variables did not significantly contribute of the RDC vs. non RDC status (Purwestri 2011; Nugroho 2009). Moreover, all of these variables were not directly associated with the achieved weight gain of respective children at the end of intervention program (Purwestri 2010). We assumed that the socioeconomic factors were probably not the direct cause of less improved nutritional status of index children, but they largely predicted the compliance of caregivers to the program in this Nias study.
Furthermore, this Nias study found that more than 40% of the respondents in both groups lived in an extended family. It might indicate that the chance of other family members to participate in child caring was also higher than those who lived as a nuclear family (although other family members' influences were likely still present). This is consistent with a Nias cultural belief that the responsibility of child caring, although it is the maternal domain, was not born solely to the mother, but also to other family members particularly the older female members such as the grandmothers and the older aunts. Therefore, the responsibility of offering RUF biscuits at home or daily home foods might be likely then shared within family members. This might influence, more or less, the likelihood of a high compliance in terms of amount of consumed RUF biscuits in both groups.
A study done in Haiti (Ruel et al. 2008) found that a supplementation food program accompanied by educational intervention resulted in better results than the program which provided solely food supplementation. The positive effect of educational intervention with food supplements on the nutritional status was also showed by several studies in Haiti (Menon et al. 2007), China (Guldan et al. 2000), and India (Roy et al. 2005). Up to now, there has been limited information with respect to the RUTF studies combined with educational intervention. RUTF study in rural Malawi included an educational aspect in its program but unfortunately had no information regarding the educational effect on the nutritional status (Maleta et al. 2007). This Nias study showed that both educational intervention models were beneficial in improving the nutritional status.of respective children. However, the findings of this reported study revealed that in general the 3 times a week NE program with daily feeding encouragement (TNE) resulted in relatively better outcome paramaters of all eligible children than the WNE+RUF program where the caregivers received NE and feeding encouragement on a weekly-basis. In spite of likely similar nutritional outcomes of RDC children on both groups, the weight gain as a main outcome parameter in this study was observed to be higher among RDC children in the TNE+RUF group than those in the WNE+RUF group. It may indicate that, combination of daily RUF supplementation with more intensive nutrition education session and more frequent feeding encouragement brought more positive outcomes to the index children in the TNE+RUF group. A mutual-trusting relationship with NE educators also appeared to be established with frequent TNE session and encouragement of RUF consumption, daily attendance to the centre, and intensive local production of RUF-Nias biscuits, that built an unbroken chain of support. Therefore, the caregivers who received the TNE+RUF programs seemed to be more motivated and had better compliance, either to feed an adequate amount of RUF-Nias bicsuits to the index children or to implement some health-nutrition related advices given in the TNE session.
Appropriate nutrition education strategy seemed to be important to accompany food supplementation strategies (Skolnik 2008). According to Briend and Prinzo (2009), the dietary management for children with moderate wasting should be based in improving the existing diets by nutritional education/counselling and, if needed, by the provision of adapted food supplements which can not be easily provided by local foods. Additionally, appropriate educational strategies will prevent replacement of daily foods by food supplements that have often been pronounced from many food supplementation programs (Ashworth 2009). These can be achieved by providing appropriate nutrition education programs to the target group. Both educational interventions in our study were likely to anticipate all the above issues. The need for appropriate health-nutrition training prior to program discharge for preventing a decreased in nutritional status of the recovered children can be bridged by the provision of both educational programs. However, besides having more possibilities to influence the caregivers in improving the compliance of RUF-Nias biscuits consumption, the caregivers were able to learn more topics on health-nutrition in the more intensive meeting in the TNE+RUF program than the WNE+RUF program. Additionally, frequent meetings through educational sessions and feeding encouragements on a daily basis also gave more opportunity for community workers to remind the caregivers that RUF-Nias biscuits should be treated as medicine, therefore should not be shared or given to their other healthy children. Thus, it is important to ensure that caregivers have sufficient knowledge and practices regarding appropriate child dietary practice at home as well as adequate RUF consumption, so that the improvement of nutritional status can be sustainable. This might be achieved through appropriate educational program such as those implemented in our reported study.
According to Ashworth et al (2009), frequent and regular exposure to a few simple messages is important for a successful nutrition education program. Moreover, available evidence suggests a generally positive association between educational intervention intensity and dietary practice change (Olander 2007; Noviati 2006; Roy et al. 2005,). This Nias study showed that a 3 times a week nutrition education accompanied by daily feeding encouragement and daily RUF supplementation resulted in relatively better improvement of nutritional outcomes of all respective children than educational meetings, feeding encouragement, and RUF supplementation on a weekly basis. Perhaps, more frequent meetings through the TNE+RUF intervention allowed caregivers to access more nutrition/health-related informations. Additionally, the likelihood of caregivers to have the opportunity to learn more intensively about appropriate child feeding practice was also better in the TNE+RUF group than the WNE+RUF group due to more frequent intensity of interpersonal communication. The TNE+RUF program also provided more possibilities for the caregivers of index children to discuss and consult regularly and frequently regarding their existing child feeding practice, and other health-nutrition related problems with the nutrition educators. It appeared that this intense communication seemed to motivate them in improving the quality of their child feeding and caring practice at home as well as improving the compliance to give RUF-Nias biscuits as food supplement.
After 4 to 5 months, RDC children who reached a WHZ-score of -1.5 SD, were individually followed-up in their home environment. This Nias study revealed that proportion of RDC children in the TNE+RUF group who were still maintained their WHZ-score â‰¥ -1.5 SD was higher than its counterparts in the WNE+RUF group, although average WHZ-score of both groups was similar (reported elsewhere). It seemed that the TNE intervention was better in keeping the children above study cut off point of -1.5 WHZ-score than the WNE program. Perhaps, it is related to the TNE+RUF program advantages, such as intensive frequencies of meetings and frequent used of suitable culturally adapted educational approaches, which help them to memorize the newly received informations and messages as well as motivated the respondent to improve their nutrition practices.
Despite the positive results of the TNE+RUF intervention, a majority mothers complained about the 3-times a week TNE sessions. Considering that mostly caregivers attended the centre on a daily basis and some motivated mothers were also involved in the 2-3 times per week production of locally RUF biscuits (adding to their income generating activities), those above objections are understandable. This should be taken into consideration because it can influence the adherence to NE messages from educational sessions as Ashworth pointed out in her review (Ashworth 2009).
As previously stated, child caring in the study areas is mainly the responsibility of mother although in some cases this domain is sometimes shared with other family members. Unfortunately, the participation of other family members had not been targeted in both nutrition education programs, although their role in related nutritional practice as well as family decision making has been known. Thus, the inclusion of these target groups should be considered in the future NE strategies implemented in the study areas.
Some limitations of our study must be recognized when interpreting these results. Prior this research, CWS and GOI had already performed some related nutritional activities (e.g. feeding program and micronutrient powder "Vitalita Sprinkles" supplementation). Those activities might influence, more or less, the nutritional status of index children, particularly the Hb level at admission time. Additionally, the influence of other related nutrition education activities from other NGOs and electronic media in the study areas was not preventable. Those might also influence, more or less, the child caring practices of caregivers. We were also aware that we did not have any data on birth weight and height of the children as well or the nutritional status of mothers before pregnancy, so that we could not investigate the influence of those factors to the nutritional status of children. In spite of several limitations of our study, there were some strengths as well. A strong point of this intervention was a low dropout rate, data were collected by motivated skilled community workers and health officers, and carefully data management.
CONCLUSION AND RECOMMENDATION
Our experience to date suggests that supplementary feeding with RUF-Nias Biscuits in combination with educational intervention and feeding encouragement is beneficial for respective children in both groups in the study areas. However, children in the TNE+RUF group were likely to have more benefited from the program than those in the WNE+RUF group. Although this study has shown greater advantages of the TNE+RUF program over the WNE+RUF intervention in terms of the nutritional status improvement, the intensity of 3 times a week meeting and daily presence in the centre seemed to be a burden for the family. Therefore, the suitable frequencies of NE sessions should be considered based on local conditions and the needs of targeted group. It is also suggested to perform further trials with a bigger simple size, in a similar setting and target groups, to elucidate the effectiveness of the TNE vs. WNE approaches that accompany the provision of RUF on the nutritional status of under five children. In addition, NE program should also focus on other family members, particularly those who are involved in child caring practices, daily budgeting for household needs, and the decision of any purchases of consumed foods, so that a supportive environment for facilitating behaviour change and maintenance will be created, a long-term impact of the nutrition education is likely to be ensured, and the improvement of children nutritional status may be more expected.