CHAPTER I.

INTRODUCTION Malnutrition remains one of the most common causes of morbidity and
mortality among children of l-3 years age group throughout the world, particularly in developing countries including the Philippines. Up to the present , about 70% of the population receive episodic and periodic medical attention not withstanding efforts of both government and non-government institutions which have tried different solutions to overcome inadequate health services to distant areas of the country. A lot of significant studies have been made by the department of health but many remains to be done.

I. SITUATIONAL ANALYSIS 1.1 GLOBAL REALITY

Malnutrition, and more particularly undernutrition, constitute globally the most important category of environmental disease. On the account of the high risk age group children from l-3 years, the world health organization (WHO) has adopted the mortality rate as a practical index of community malnutrition. The mortality rate in children l-4 years old per l000 children in the United States is l.0, Sweden 0.6, 0.8 in England, l3.7 in Columbia and 26.9 in Guatemala. Although there are many forms of malnutrition - for example obesity from consumption of excessive calories and avitaminoses from inadequate diet or malabsorption- the dominant problem confronting the world is protein calorie undernutrition, 1

indeed starvation, as is rampant in many parts of Africa. The WHO reported that, about 31% (l74 million) of children under 5 years of age are malnourished interms of being underweight and that about 38% (230 million) are stunted. And from l978 to l995, the world statistics showed that the prevalence of malnutrition in preschool children has progressively fallen in developing countries from 42.6% to 31.0% respectively. Malnutrition and undernutrition are not restricted to the third world; they are also common even in affluent societies. A lack of all kinds of food in particular, protein

(so called primary malnutrition) may be encountered in industrialized nations in pockets of poverty . More common in the industrialized nation is secondary , or conditioned malnutrition having many possible origins such as decreased intake of food, malabsorption, increased requirements and special categories that includes drug-induced interference with absorption and probably genetic disorder. Over 800 million people still cannot meet basic needs for energy and protein more than 2 thousand million people lack essential micronutrients and hundreds of millions suffer from diseases caused by unsafe food or by unbalance food intake. Great advances have been made a various strategies were implemented to attain the ultimate aim of the WHO, which is making possible the attainment of all people the highest possible level of health, but global well being was failed to achieve

l.2 NATIONAL REALITY

The health status of the Philippine population during the last decade showed a steady but a slow phase of improvement as reflected by the generally used indicators of health status. Very commonly, the leading causes of childhood deaths are often nutritionrelated. The mortality rate in children l-4 years old per l000 children in the Philippine is 7.6%. In a study conducted in Southeast Asia and Pacific region in l995 , the Philippines ranked 5th behind Vietnam, Indonesia, Laos, and Papua New Guinea, in the percentage of mortality and severely malnourished children under 5 years old. The food and nutrition research institute (FNRI) had conducted a prevalence study in l989 to l990 and showed that severe malnutrition is nearly l4% of the leading cause of mortality. Chronic types accounts for l.4% in comparison to an acute type with 7.6%. The highest incidence of malnutrition is in the toddler age group or preschool child (l-5 years). The nutrition service of the Department of Health reported that avitaminosis and other nutritional deficiencies ranked 9th among the l0 leading causes of mortality , ranked 6th among the l0 leading causes of infant mortality for 3 consecutive years (l985-l987) and ranked 4th among the cause of mortality in ages l-4 years. Among the nutritional deficiencies, Protein Energy Malnutrition (PEM), Vitamin A deficiency (VAD), iron deficiency anemia (IDA) and iodine deficiency disorders (IDD)

manifested as endemic goiter continue to be the principal nutritional problems of the country. The interplay of infections and nutritional disorders is evident in the study of Department of Health (DOH) nutrition service - UP college of Home Economics (Florencio (1989). This study shows that among 25 protein malnutrition cases admitted, the following conditions were observed: diarrhea, intestinal parasitism, respiratory tract infection,. (infection, primary complex, measles, anemia and vitamin A deficiency).

1.3 FOCAL REALITY

Through the years, Bicol remained as a nutritionally depressed area. As per 1996 Operation Timbang (OPT) results, PEM was common among 114,364 (16.2%) preschool weighed. Based on the 1993 National Nutrition survey, Bicol ranked fourth in malnutrition with a prevalence rate of 20.2% in Iron deficiency Anemia (IDA), and highest in Iodine Deficiency Disorder (IDD). Risk of malnutrition is highest among poor families of fisherman, laborers, unemployed, and poorly educated people. The factors affecting the nutritional status of the Bicolanos are poverty, nutritional knowledge, food availability, household size, physical and mental stress, natural calamities, and environmental sanitation.

4 Barangay Bariw, Camalig Albay, has a total number population of 1,771 and 317

households as of l996. It is located west of the municipality of Camalig, 4.2 km from the town proper. It is divided into 6 puroks and bounded by 4 barangays namely; Libod, Tondo, Tagaytay and a municipal barangay (see Figure 1) . This barangay has an estimated total land area of 4l5 hectares. This area is accessible to any land transportation particularly tricycles for about l5 minutes from the town proper . Majority of the population are farmers (32.8%) some are laborers (23.0%), employee (23.0%), carpenters (8.2%), drivers (7.4%), weavers (4.9%) and vendors (0.8%) (see appendix 11). Most of the people had reached the elementary level of education, (5l.5%) while some were in high school level of about 17.4% and a few were elementary graduate (9.8%) (see appendix 13). Majority of the household uses firewood (8.4%), some use gas stoves (l0.48%) and others use electric stoves (4.76%) in cooking (see appendix 16)

The top two leading causes of morbidity in this area are acute respiratory infection and diarrhea with an incidence of 63.6% and 8.7% respectively (see Table 1). While the leading cause of mortality are heart (43.6%) and lung diseases (23.0%) . Malnutrition ranked fourth with an incidence of l0. 23% (see Table 2). 5 The nutritional status of children (0-5 years old) showed a high percentage of well

nourished children with 54.07% (113 children); lst degree malnourished is 31.57% (66), 2nd degree malnourished is 9.6%, 3rd degree malnourished is 0.98% which have the same rate with overweight (see Table 4 ).

2. STATEMENT OF THE PROBLEM 2.1 Situational Problem 2.1. l. Description of the selected health problem
Malnutrition is a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients, this state being clinically detected or manifested only by biological, anthropometric, or physiological test. It may be a result of inadequate intake or due to increased requirement. Four forms of malnutrition are the following: l. Undernutrition; a pathological state resulting from the consumption of an inadequate quantity of food over an extended period of time 2. Specific deficiency- Pathological state resulting from a relative or absolute lack of an individual nutrient. 9 3. Overnutrition- A pathological state resulting from the consumption of an excessive quantity of food, hence caloric excess, over an extended period of time.

4. Imbalance- Pathological state resulting from a disproportion among essential nutrients, with or without the absolute deficiency of any nutrients as determined by the requirement of a balanced diet. Malnutrition is a condition, which significantly affect the growth, development and normal functioning of an individual. It leads to anatomical, physiological and biological changes, which may become relevant to ones life. Children who are malnourished perform poorly academically. They are frequently absent and lose interest in school. They are also prone to acquire and develop diseases. Health statistics also revealed that malnutrition is one of the leading causes of morbidity and mortality among children. In our country, the prevalent forms of malnutrition are protein energy malnutrition, iron deficiency anemia, vitamin A deficiency, and iodine deficiency disorder. Protein -energy malnutrition (PEM), also called protein-calorie malnutrition, is present when insufficient energy or protein is available to meet metabolic demands, thereby leading to impairments in normal physiologic processes. Inadequate dietary intake is only one of several mechanisms by which this may occur. Increased metabolic demands due to disease and increased nutrient losses are two other common mechanisms by which the bodys protein and energy economy may become disrupted enough to cause PEM . 11

One of the condition of which is Marasmus, defined as emaciation and wasting in an infant due to malnutrition or prolong restriction of both dietary energy, protein and other nutrient manifested as extreme wasting, failure to gain weight and followed by a loss of weight. Kwashiorkor is due to a quantitative and qualitative severe protein deficiency. In the classification of malnutrition, the Gomez system which utilized weight for age measurement was used to classify malnutrition in young children according to severity, but these do no distinguish by which the different clinical forms of malnutrition rather it provides an approximate grading as to prognosis (Gomez Classification; Del mundo pp. l39) The Wellcome classification is concerned with severe, clinically obvious malnutrition basing on 2 criterias: a) Degree of weight loss (in terms of weight fro age) and the presence or absence of edema and provide a standard criteria for the diagnosis of kwashiorkor, movement and intermediate forms. (Wellcome Classification). The WHO had adopted the Waterlow classification wherein it can distinguish between deficits in weight for height (wasting) and deficits in height for age (stunting) (Revised Waterlow classification). The following are the underlying causes of malnutrition as formulated by the United Nation International Children and Emergency Fund (UNICEF): a) Insufficient food security b) inadequate maternal and child health care which will deprive mother and child of proper nutritional care

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c) insufficient and inaccessible health services d) unhealthy environment e) Food and health beliefs f) social problems as poverty, inadequate housing, overpopulation, and family dislocation.

As of October l997 malnutrition ranked fourth (l0.23%) among the l0 leading causes of mortality in Barangay Bariw, Camalig Albay. The group had conducted an Operation: Timbang (OPT) held at the assigned barangay and had weighed a total of 209 children aged 0-5 years. During this month it shows that the total underweight children comprises of about 44.97% (94 children) of the total population while more than of the population (54.07%) are well nourished. Among the underweight, 31.57% (66) belongs to the first degree malnutrition, 9.6% (26) in 2nd degree malnutrition, and 0.98 % in 3rd degree malnutrition.

Resolution of these health problems is attainable through the implementation of a Primary Health Care (PHC) approach as well as putting a problem-based communityoriented approach which will adapted by the researchers (BCCM students) to reinforced the realization of this program.

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2.2 NEED FOR RESEARCH

The researchers (group C-2) had selected malnutrition as the primary health problem to solve because of its increasing incidence. This research aims the following: l. Determine the predisposing factors causing malnutrition in children less than 5 years old in Barangay Bariw 2. Improve the nutritional health status who are undernourished through the implementation of action plan. 3. Uplift the health situation of the community 4. Encourage other researchers to conduct another health related study to generate community 5. This will serve as a requirement in partial fulfillment for graduation in our medical school . more on strategies on controlling the health problem in the

2.3 THE RESEARCH PROBLEM

2.3.l GENERAL RESEARCH OBJECTIVE

To reduce the prevalence rate of underweight (2nd & 3rd degree) children ages 0-5 years (0-60 months) from 13% to 5 % within 3 years in Barangay Bariw Camalig, Albay

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2.3.2 SPECIFIC RESEARCH OBJECTIVES

l. To determine the factors that contribute to the present prevalence level of underweight children in Brgy. Bariw, Camalig, Albay 2. To determine the causative factors which can be reduced, if not eradicated, using a Primary Health Care approach (PHC) 3. To formulate and implement a specific PHC strategy which can be used to decrease the incidence rate of underweight among target children for 3 years from l997-2000 4. To evaluate the results implementation.

3. SIGNIFICANCE OF THE STUDY

The results of the proposed study will be beneficial to the following: a. Nutrition council- This will serve as guidelines for the government in reducing the prevalence of malnutrition and promote good health to every individual in a certain community. b. Municipality of Camalig- This will serve as a basis for the concerned authorities to generate effective programs in the community in solving a health problem like malnutrition. c. Barangay officials- This will assist the barangay officials in the formulation of programs and in the assessment of the barangay health status on malnutrition.

15 d. Barangay Health Workers and midwives- This will guide them in conducting

a public health education on nutrition to the assigned barangay e. Bicol Region (Region V), DOH, RHU- This will serve as a baseline data on the nutritional status, the factors that contribute to malnutrition, and the outcome of the programs implemented in promoting good health in the community. And this will strengthen and contribute in the improvement of the programs and projects of the government in the management of malnutrition f. Researchers/ medical students - This will serve as baseline data in generating more feasibility studies particularly on the same barangay to monitor their nutritional health status and in other localities as well.

4. SCOPE, DELIMITATION AND LIMITS OF THE STUDY TARGET POPULATION. The proposed study focused on reducing the
prevalence rate of underweight children ages 0-5 years (0 - 59 months) in Brgy. Bariw, Camalig, Albay by 10%, who were identified during the OPT conducted on October , 1996 in Community Health Management II. The parents particularly the mother and the recipients were also included in the program to be implemented.

Participation/Resources. The initiation of this study will utilize the

involvement of the community , multisectorial collaboration, and indigenous resources such as fund raising campaign , and solicitation of money, foods, medicines and others.

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DATA. The data on OPT collected during the surveys conducted by the

medical students and barangay health workers along with barangay health records from the midwife will serve as the basis for the interpretation of results .

TIME FRAME. This study was conducted from October, l997 to March,
2000. During this period, a series of a scheduled date of Operation: Timbang was conducted to monitor and compare the weight of the recipient in order effectiveness of the interventions implemented. to measure the

5. OPERATIONAL DEFINITION OF TERMS Malnutrition- Lack of necessary or proper food substances in the body or
improper absorption and distribution of them. Any disorder of nutrition; may be due to a deficient diet or deficient breakdown, assimilation, or utilization of food

Undernutrition- The pathological state resulting from the consumption of an

inadequate quantity of food over an extended period of time

Overnutrition- The pathological state resulting from the consumption of an

excessive quantity of food, and hence, a caloric excess over an extended period of time.

Underweight- below the normal, desirable, or allowed weight.

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OPT- Operation Timbang

- Project formulated by the medical students to evaluate and monitor the

progress of children targeted in the assigned community.

Imbalance- The pathological state resulting from a disproportion among

essential nutrients with or without the absolute deficiency of any nutrients as determined by the requirements of a balanced diet.

Specific deficiency- The pathological state resulting from a relative or

absolute lack of an individual nutrient.

Prevalence - most frequent, noticeable

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