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PRIMARY HEALTH CARE PROJECT

EVALUATION OF THE NUTRITIONAL STATUS OF


CHILDREN 0-5 YEARS OLD IN ST. CATHERINE
(SERHA)

Monique Hope, Ashea Lovell, Stacy Maxam, ShannaKay Dawkins, Ashley Thompson-Edwards

Outline

What is Malnutrition?
Importance of looking at Malnutrition
Epidemiology
Description of the Nutritional Status of
children aged 0-5 years in St. Catherine

What is Malnutrition?

Malnutrition: the cellular imbalance


between supply of nutrients and energy
and the bodys demand for them to
ensure growth, maintenance and specific
functions ( World Health
Organisation,WHO).

Refers to both overnutrition and


undernutrition.

Undernutrition is defined as the outcome


of insufficient food intake and repeated
infectious diseases (Unicef,2006).
It includes either being:

underweight for ones age


Too short for ones age (stunted)
Dangerously thin (wasted)
Deficient in vitamins and minerals

The Importance of
Malnutrition

Malnutrition is globally the most


important risk factor for illness and
death, contributing to more than 50% of
deaths in children worldwide (Medscape,
2016)

Play and activity are essential to a


childs social and physical development.
It is important that nutrition provides
sufficient energy to allow for this

Importance of Malnutrition
contd

A childs metabolic rate is higher per


kilogram of bodyweight than that of an
adult and, therefore, energy
requirements are also proportionately
greater (Poskitt, 1988).

Any nutritional defect during a critical


growth period could prevent the child
from achieving his or her growth
potential (Waterlow, 1988).

Importance of Malnutrition
contd

The short-term implications of failure to


address secondary PEM (protein energy
malnutrition) in children include
increased susceptibility to infection, poor
wound healing, perioperative
complications and reduced response to
treatment (Fuchs, 1990).

The long-term implications include


stunting, developmental delay and an
overall increase in morbidity and

Importance of Malnutrition
contd

Malnutrition negatively affects brain


development causing delays in motor
and cognitive development, such as
decreased intellectual quotient scores,
attention deficit disorders and decreased
social skills.

Epidemiology of
Malnutrition

Globally, an estimated 101 million children


under-five years of age, or 16%, were
underweight (i.e., weight-for-age below 2SD)
in 2011, a 36% decrease from an estimated
159 million in 1990. (WHO, 2012)
Although the prevalence of stunting and
underweight among children under-five years
of age worldwide have decreased since 1990,
overall progress is insufficient and millions of
children remain at risk. (WHO, 2012)

Epidemiology of
Malnutrition contd

Globally, an estimated 43 million


children under-five years of age, or 7%,
were overweight (i.e., weight-for-height
above +2SD) in 2011, a 54% increase
from an estimated 28 million in 1990.
(WHO, 2012)
The prevalence of underweight in the
Caribbean was 3.5% with estimated 0.1
million children affected in 2011.
Whereas 7.5% of children being
overweight/obese in 2011 (estimated 0.3

Epidemiology of
Malnutrition contd

In Jamaica, the prevalence of


malnutrition was 2.60% and 3.80% for
female and male (under 5 years)
respectively in 2010.

WHO estimates that by the year 2015,


the prevalence of malnutrition will have
decreased to 17.6% globally, with 113.4
million children younger than 5 years
affected.

Epidemiology of
Malnutrition cont'd

Epidemiology of
Malnutrition cont'd

Demographics

Population: 518,345 (JIS, 2012)

Largest parish in the South East


Regional Health Authority
(SERHA).

The second most populous and


the most rapidly growing parish
in Jamaica.

Profile of the Health


Districts

Comprises of four (4) zones with 26


health centres

Health districts include: Spanish Town,


Old Harbour, Linstead and Portmore

Among the health districts are 6 type 3


health centres, 10 type 2, 8 type 1and 1
type 4- St. Jago Park which offers
curative, maternal and child, dental,
mental, environmental services skin, HIV

Map Showing the


Distribution of Health Zones
in St. Catherine
Zone 4

Zone 3
Zone 2

Zone 1

Profile of the Health


Districts contd

Two Public Hospitals: Spanish Town


Hospital- Type B, and Linstead HospitalType C.

Aims and Objectives

Describe the nutritional status of the children


highlighting trends in the prevalence of
overweight/ obesity and undernutrition using the
Monthly Clinic Summary Reports of 2013-2015.

Describe the prevalence of under-nutrition by


gender, age groups and health zones

Identify factors associated with the prevalence of


undernutrition

Aims and Objectives contd

Describe the interventions for


undernutrition highlighting factors
associated with success and barriers to
programme delivery.
Assess the social environment of the
household and mothers/ caregivers
knowledge of the childs condition
through a home visit.
Suggest approaches to improve the
delivery of interventions in the primary
health care setting

QUESTION 1
Description of the Nutritional Status of
Children aged 0-5 years in St.
Catherine (2013-2015) highlighting
trends in prevalence of
overweight/obesity and
undernutrition.

Methodology

Using data from the MCSR, the total


visits for children aged 0-5 years per
year were calculated and the number of
children assessed as being
overweight/obese and underweight for
each year was calculated.

From the values obtained, the


percentage of children who were
obese/overweight and underweight was
calculated hence obtaining the

Nutritional Status and


Trends

The number of child health visits over


the years remained relatively stable
because there is a limit in the number of
patients that can be seen daily

Total parish child health visits ranged


from 8.7%- 9% of the total St. Catherine
population.
2013- 46,558 visits
2014- 45,000 visits

Nutritional Status and


Trends contd

Nutritional Status and


Trends contd

There was a decrease in the number of


child health visits in 2015 (42,367) from
46,558 in 2013.
However, there was an increase in the
number of children assessed as
overweight/ obese, the prevalence of
those assessed as being underweight
however declined.
May be attributable to 1) increase in the
availability of fast-food 2) decrease in the
total number of visits thereby increasing

Nutritional Status and


Trends contd

The prevalence of both overweight/


obesity and underweight decreased
in 2015 which may reflect the
effectiveness of health education.

QUESTION 2
USING THE 2015 MCSR OR OTHER
REPORTS DESCRIBE THE PREVALENCE
OF UNDERNUTRITION BY GENDER,
AGE-GROUPS AND HEALTH REGIONS

Prevalence is the percentage of a


population that is affected with a
particular disease at a given time
(Merriam Webster, 2015)

Calculated at a given time period as:


Number of persons underweight x 100
Total Population

There was a total of 42,367 persons


measured in 2015.
2.1 % of this population were found to be
underweight.

AGE-GROUPS

AGE-GROUPS

The prevalence of undernutrition was


lowest in the 0-6 month group as baby
would be exclusively breastfed.
Prevalence was highest among the 7-11
month group, correlating to the
introduction of complementary foods at
6 months, which may contribute to the
sharp four fold increase.
The prevalence is then seen to gradually
decrease with increasing age.

GENDER

GENDER

Undernutrition was higher by


approximately 30 % among the males
compared to the females.
This could be related to male children
being more mobile and active making
them lose greater energy from their
body.

HEALTH
REGION
Map showing
Prevalence of
Undernutrition
by Health
Region/Zones in
2015

Zone 4

Zone 3
Zone 2

0 - < 1%
1 <2 %
2 <2.5 %
>2.5%

Zone 1

HEALTH REGION

Zone 4 was found to have the highest


prevalence of undernutrition (2.81%)
followed closely by Zone 2 (2.45%).
Zone 3 had the lowest prevalence
(0.89%).

HEALTH REGION

Zone 1and Zone 2 were the


most urbanized regions with
Zone 4 the most rural
region.
Nutritional status better in
urban children compared to
rural counterparts due to
(Smith, L. et. al., 2005):

better socioeconomic
conditions
Womens education
Water and sanitary
facilities available.
Greater use of health
services

QUESTION 3
In consultation with health staff,
identify the factors associated with
the prevalence of undernutrition.

Factors associated with the prevalence of


under-nutrition

Food insecurity
Lack of education
Poor feeding habits

Factors associated with the prevalence of


under-nutrition

Food insecurity

A state in which consistent access to


adequate food is limited by a lack of
money and other resources at times
during the year. (USDA, 2016)
Other terms for food insecurity are
struggling to avoid hunger, hungry, or
at risk of hunger, faced by the threat
of hunger.

Factors associated with the prevalence of


under-nutrition

Lack of education

Poor health literacy

Factors associated with the prevalence of


under-nutrition

Poor feeding habits

May or may not be related to food


insecurity
Negligence
Small meal sizes
Picky eaters

QUESTION 4
Describe the interventions for undernutrition highlighting factors
associated with success and barriers
to programme delivery.

IN THE PAST

Food Distribution Programme


(1970s)
Food packages were given to
families whose children were
identified through the Public
Health system as moderately
or severely malnourished.

Food Distribution
Programme Delivery of
Services
Success

Barriers

Distribution of food
packages to those in
greatest need*
Encouraged visits to
public health facilities

Understaffed public
health facilities
Delay in delivery of
food to public health
facilities
Excluded those not
attending/unable to
access these
facilities

Food stamp programme (1984)


focused on pregnant and lactating
women, children under 5 years of age,
the elderly and the handicapped
Allowed for the purchase of cornmeal,
rice and powdered skimmed milk at
commercial grocery outlets who would
then redeem the stamps at their banks.

Food Stamp Programme


Delivery of Services
Success

Barriers

Rise in food prices

Lack of access to
public health clinics

Encouraged visits
Exclusion of those
to the public health in need not within
clinics
the target group

PRESENTLY
Programme for Advancement through
Health and Education (PATH, 2002)
Conditional cash transfer programme
Replaced 3 main welfare programmes;
Outdoor Poor Relief, the food stamp
programme and Public Assistance
programmes.
Beneficiaries include children, elderly,
pregnant and lactating women, the
disabled and poor adults 18-59 years

PATH Delivery of Services


Success

Barriers

Thorough application Eligibility criteria


process

Compliance with
conditions

Payment made to a
single family
representative.

Health Education
Educating parents/caregivers
of undernourished children
about energy dense foods.

Health Education
Success

Barriers

Knowledge of
Food insecurity
appropriate foods for
child*
Information not
passed on to other
family members
involved in child care.
Inappropriate use of
words

Home Visit
Conducted by community health
aides to assess the home
environment of undernourished
children who are not improving.

Home Visit
Success

Barriers

Understand social
environment

Inaccessible/unstable
land

Food demonstration

Volatile community
Cultural Challenges

Home Visit

The child

11 month old male


7.5 kilograms; underweight for age
Born premature at 33 weeks; At birth
apgar scores were: 1 min: 2; 5min: 3

The child

Child suffered respiratory distress


syndrome, placed on continuous positive
airway pressure (CPAP), hypoxic
ischaemic encephalopathy Stage 1,
Bronchopulmonary dysplasia, congestive
cardiac failure secondary to patent
ductus arteiosus and anaemia
admitted to NICU for 41 days

The child

Since discharge at 1 month he has had


poor feeding and has been severely
underweight

He has never been breastfed

Has no teeth and delayed developmental


milestones

The child: Growth Chart

The child: Developmental


Milestone

The child

Now followed up at the Linstead Health


Centre for his underweight status and
Bustamante Hospital for Children for his
surgical conditions

Immunization status up to date

Demographics and Social


History

Linstead, St. Catherine

22 year old N. W lives in concrete 3


bedroom house with her 3 children
( ages 3 years, 2 years, 11mths),
common law husband and 6 other
persons.

Social environment of the


household

Running water, electricity, stove, refrigerator


present at home
She is unemployed and has no CXC subjects, no
formal qualification
Spouse works from time to time.

Estranged relationship between mother and


common-law-husband

Poor emotional and financial support from family


members

Social environment of the


household

Three year old and 2 year old share a father,


who is deceased

Mother often finds it difficult to provide for


children

Often cannot afford a balanced meal for


children

Mainly feeds baby porridge and formula

Social environment of the


household

On the oral contraceptive pill with which


she claims compliance

Social environment of the


household

Mothers knowledge of the


childs condition

conflict of interest

Mother had poor knowledge of


undernutrition, its effects and how to
work to correct it

Seemed to have poor knowledge of how


to feed child

No teeth

Mothers knowledge of the


childs condition

24 hour recall vs ideal

QUESTION 6
SUGGEST APPROACHES TO IMPROVE
THE DELIVERY OF INTERVENTIONS IN
THE PRIMARY HEALTH CARE SETTING.

Recommendations
Better health education
use of food charts showing serving
sizes by nutritionists, pediatricians
and nurses

Ensure parents/guardian understand


the condition and its effect on the
childs health

Recommendations
contd
Food demonstration
To re-enforce information given to
parents/caregivers regarding proper
nutrition.

To illustrate the appropriate


preparation of various inexpensive
foods which can provide a nutritious
meal.

Recommendations contd
Family Meetings
To educate all family members/other
persons involved in the care of the
child about good nutrition.

To update the family on the childs


condition.

To gain an understanding of the


challenges the family may be facing.

Recommendations contd

Appealership to improve the delivery of


the PATH programme

Provision of clear National Health Fund


Criteria

More effective role of social workers


where possible

Recommendations contd

Agreement between factories and the


health system

References

Alelign, T., Degarege, A., Erko, B. 2015. Prevalence and factors


associated with undernutrition and anaemia among school
children in Durbete Town, northwest Ethiopia. Archives of Public
Health. 73:34. Retrieved from
http://archpublichealth.biomedcentral.com/articles/10.1186/s136
90-015-0084-x

Burgess, A., Danga, L. 2008. Undernutrition in Adults and


Children:causes, consequences and what we can do. South Sudan
Medical Journal :2008. Retrieved from
http://www.southsudanmedicaljournal.com/archive/2008-05/undern
utrition-in-adults-and-children-causes-consequences-and-what-w
e-can-do.html

Ezemenari, K., Subbarao, K. 1999. Jamaicas Food Stamp Program:


Impacts on Poverty and Welfare.

References

Khair,J., & Morton, M. (2000). Nutritional assessment and


screening in children. Nursing times, 96. Retrieved from
http://www.nursingtimes.net/nutritional-assessment-and-screeningin-children/205094.article

Lustig, N. 2010. Coping with Austerity: Poverty and Inequality in


Latin America

Ministry of Labour and Social Security. PATH. Retrieved from http://


www.mlss.gov.jm

Smith, L., Ruel, M., Ndiaye, A., 2005. Why is Child Malnutrition
Lower in Urban than in Rural Areas? Evidence from 36 developing
countries. World Development Vol 33, No. 8:1285-1305.
Retrieved from http://

The END
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