Assessment of nutritional status among primary schoolchildren in krong bong district, daklak province

35 4.1.1 Prevalence of current nutritional status in children ...36 4.1.2 Prevalence of nutritional status in children by chronic, delivery status and place of birth ...39 4.1.3 Prevalen

CERTIFICATION

I certify this thesis has entirely done by myself Within my knowledge quotations and data used in the thesis are cited and surveyed by highest precision sources

Phan Thi Ngoc Ngan

TABLE OF CONTENTS

CERTIFICATION

TABLE OF CONTENTS

LIST OF ABBREVIATIONS

LIST OF TABLES

LIST OF FIGURES

ABSTRACT

CHAPTER 1: PROBLEM STATEMENT 1

1 Research backround 1

1.1 Nutritional status in children in the world 1

1.2 Nutritional status in children in Vietnam 4

1.3 Current nutritional status in children in Krong Bong 6

1.4 Objective of the thesis 8

1.4.1 General objective 8

1.4.2 Specific objectives 9

1.4.3 Research questions 9

1.5 Scope of the research 9

1.7 Structure of the thesis 10

CHAPTER 2: LITERATURE REVIEW 11

2.1 Measurement of nutritional status 11

2.2 Anthropometric Indicators 12

2.3 Situation of nutritional status in the world 14

2.3.1 Characteristics of individuals children 15

2.3.2 Characteristics of mothers/caregivers 16

2.3.3 Characteristics of households 18

2.4 Situation of nutritional status in Vietnam 20

2.5 Analytical Framework 22

CHAPTER 3: STUDY SUBJECTIVES AND METHODOLOGY 24

3.1General information about Krong Bong District 24

3.2 Study design 25

3.2.1 Study setting 25

3.2.2 Sample size 26

3.2.3 Study subjects 27

3.3 Statistical analysis 27

3.4 Empirical Model 29

3.5 Variables in the model 31

3.5.1 Dependence variable 33

3.5.2 Independence variable 34

CHAPTER 4: DESCRIPTION OF NUTRITIONAL STATUS IN KRONG BONG,

DAK LAK 35

4.1 Characteristics of child nutritional status 35

4.1.1 Prevalence of current nutritional status in children 36

4.1.2 Prevalence of nutritional status in children by chronic, delivery status and place of birth 39

4.1.3 Prevalence of nutrition status in children by mother/caregiver education and occupation 40

4.1.4 Prevalence of factors related family 41

4.2 Risk factors of nutritional status 46

4.2.1 Univariate analysis 46

4.2.2 Multivariate analysis 50

CHAPTER 5: CONCLUSION AND RECOMMENDATION 54

5.1 Conclusion 54

5.1.1 Conclusion of situation of nutritional status 54

5.1.2 Conclusion of risk factors of nutritional status 55

5.2 Recommendations 55

5.3 Researchers and developments 56

REFERENCES 1

APPENDICIES 7

LIST OF ABBREVIATIONS

BMI Body Mass Index

CDC Centers for Disease Control and Prevention

IOTF International Obesity Task Force

FAO Food and Agriculture Organization

HAZ Height for age z-score (stunting)

MDGs Millennium Development Goals

WHO World Health Organization

WHZ Weight for height z-score (wasting)

LIST OF TABLES

Table 1.2.3 The statistics on the nutritional status of children in Dak Lak province over

the years (2005-2014) 7

Table 2.2.1 Overview of indicators and cut offs that are considered appropriate to assess malnutrition in school-aged children 13

Table 2.2.2 Mean (± SD) prevalence (%) of malnutrition in school-aged children, by WHO region, weighted for quality score 14

Table 3.4 Summarizes the variables in this study .31

Table 4.1 Summary of children's BMI-for-Age 35

Table 4.1.1 Prevalence of nutrition status in children by commune, sex, age, number of children and ethnicity 36

Table 4.1.1 Prevalence of nutrition status in children by commune, sex, age, number of children and ethnicity (con’t) 37

Table 4.1.2 Prevalence of nutritional status in children by chronic, delivery status and place of birth 39

Table 4.1.3 Prevalence of nutrition status in children by mother/caregiver education and occupation 40

Table 4.1.4a Prevalence of nutritional status in children by boil drinking water, mosquito-net, latrine and garbage 41

Table 4.1.4b Prevalence of nutritional status in children by family factors 43

Table 4.2.1a Group variables of children 46

Table 4.2.1b Group variables of mother/caregiver 47

Table 4.2.1c Group variables of households 48

Table 4.2.2a Group variables of children 50

Table 4.2.2b Group variables of mother/caregiver 50

Table 4.2.2c Group variables of households 51

LIST OF FIGURES

Figure 1 Map of Dak Lak province showing Krong Bong district 24

Figure 2: Krong Bong District Map 25

Figure 1.2.2 The statistics on the nutritional status of children over the years

(1999-2014) (National Institute of Nutrition) .6

Figure 2.5: Conceptual framework on the causes of malnutrition (UNICEF, 1997) 23

Figure 3.1.3 Analytical framework: illustration of hypotheses related to the relationship

between nutritional status in children and related factors .27

Figure 4.1 Prevalence of nutritional status in school-age children 35

ABSTRACT

Background: The nutritional status of children reflects the socioecomy of family and

community as well as the efficiency of the health system Malnutrition and overweight

in school-age children are an important public health problem of the Ministry of Health and the Government of Vietnam Within the country, Dak Lak province has the highest levels of malnutrition

Objectives: The aim of this study was to assess the nutritional status of primary school

children and to find out factors associated with childhood malnutrition and overweight/obesity

Methods: A cross-sectional household survey was carried out on five primary schools

of five communes in Krong Bong district, Dak Lak provinces during 30th March to 28thApril, 2015 by interviewing 321 children and their mothers/caregivers by using questionnaire Anthropometric measurement such as body weight (kg), and height of children (m2) was collected by using standard techniques Body Mass index was used

to define nutritional status according the WHO guideline

Result: Prevalence of malnutrition in Krong Bong district was 26.5% School boys

were more malnourished than school girls Prevalence of overweight was 8.4% and school girls were more overweight than school boys The occurrence of malnuttrition was dependence associated with commune and boil drinking water Furthermore, the occurrence of overweight were dependence associated with gender of children, mother’s occupation, facility of birth, land-owning households

ASSESSMENT OF NUTRITIONAL STATUS AMONG

PRIMARY SCHOOL CHILDREN IN KRONG BONG

DISTRICT, DAK LAK PROVINCE

CHAPTER 1: PROBLEM STATEMENT

1 Research backround

1.1 Nutritional status in children in the world

The nutritional status of children reflects the socioecomy of family and community as well as the efficiency of the health system Malnutrition in school-age children are an important public health problem in the world

The worldwide number of children stunting was 171 million (167 million in developing countries) in 2010 The risk of childhood stunting reduced to 13 points from year 1990 to 2010, 39.7 (95%CI 38.1, 41.4) % down to 26.7 (95% CI 24.8, 28.7) % respectively The expected trend was 21.8 (95% CI 19.8, 23.8) %, or 142 million, in 2020 The prevalence of stunting in Asia decreased faster than Africa during period from 1990 to 2010 Althougt Africa stunting has stagnated lower since 1990 at about 40% but little improvement is anticipated, while Asia showed at 49% in 1990 then reduced to 28% in 2010, decreasing from 190 million to 100 million This trend will continue and that in 2020 Asia and Africa will have similar numbers of stunted children (68 million and 64 million, respectively) Rates were much lower (14% or 7 million in 2010) in Latin America (de Onis et al., 2012)

In 2010, there were 43 million children in overweight and obesity (35 million in developing countries) and 92 million were at risk of overweight The global prevalence

of childhood overweight and obesity increased from year 1990 to 2010, 4.2% (95% CI: 3.2%, 5.2%) up to 6.7% (95% CI: 5.6%, 7.7%) respectively The expected trend was reach 9.1% (95% CI: 7.3%, 10.9%), or ~60 million, in 2020 The estimated prevalence

of childhood overweight and obesity in Africa in 2010 and in 2020 were 8.5% (95% CI: 7.4%, 9.5%) and 12.7% (95% CI: 10.6%, 14.8%) respectively (de Onis et al., 2010)

In September 2014, United Nations International Children’s Emergency Fund (UNICEF), World Health Organization (WHO) and the World Bank (WB) made public an updated final joint dataset on child malnutrition indicators (stunting, wasting, severe wasting, overweight and underweight) and new global & regional estimated for

2013 There were 161 million children under-five year olds were stunted, 51 million were wasted and 17 million were severely wasted, and 42 million were overweight and

99 million were underweight The global trend of prevalence of stunting, wasting, severe wasting, and underweight decreased, while the prevalence of overweight increased in many regions Between 2000 and 2013, the prevalence of overweight increased from 11% to 19% in Southern Africa, and from 3% to 7% in Southeastern Asia, and prevalence of stunting declined from 33% to 25%, or 199 million to 161 million children; prevalence of underweight was from 25% to 15%; prevalence of wasting in 2013 was estimated at almost 8% and nearly a third of that was for severe wasting, totaling 3%; and approximately two thirds of all wasted children lived in Asia and almost one third in Africa, with similar proportions for severely wasted children In

2013, about half of all stunted children lived in Asia and over one third in Africa This country has experience the smallest relative decreasing, with prevalence of underweight was down at 17% in 2013 and 23% in 1990, in Asia it declined from 32%

to 18% perspectively and in Latin America and the Caribbean from 8% to 3% same period This means Asia and Latin America and the Caribbean were likely to meet the

Millennium Development Goals while Africa was likely to fall short, reaching about only half of the targeted reduction In terms of regional breakdowns in numbers of overweight children in 2013, there were an estimated 18 million under-fives in Asia, 11 million in Africa and four million in Latin America and the Caribbean, countries with large populations like Argentina, Bolivia, Brazil, Chile and Peru observed levels of 7% and higher (UNICEF-WHO-The World Bank 2013)

Source: Joint child malnutrition estimates - Levels and trends (UNICEF-WHO-The

World Bank 2013)

School age is the active growing phase of childhood (SCN news, 1998) The present scenario of health and nutritional status of the school-age children in India was very unsatisfactory The national family health survey (NFHS) data showed that the

prevalence of underweight was 53% of children in rural areas and this varies across states In the country, it was 53.4%, 45.8% and 47% for the years 1992, 1998, and 2006 respectively (Srivastava et al., 2012)

Recently, a worldwide statistics of WHO on overweight and obesity was related

to more deaths than underweight Most of the world's population lived in countries where overweight and obesity killed more people than underweight (this includes all high-income and most middle-income countries) In 2013, there were 42 million children under the age of five were overweight or obese In 2014, more than 1.9 billion adults, 18 years and older, were overweight Of these over 600 million were obese In

2014, the prevalence of obesity and overweight was about 13%, 39%, of those world’s adult population (11% of men and 15% of women) and adults aged 18 years and over (38% of men and 40% of women) respectively Therefore the worldwide prevalence of obesity was more than doubled between 1980 and 2014 (World Health Organization, 2015)

1.2 Nutritional status in children in Vietnam

In Vietnam, child health has been causing deep worry, as evidenced by within the framework of the Millennium Development Goals, this issue is an important concern for the Ministry of Health and the Government The National Plan of Action for Child Survival 2009-2015, developed with WHO support, has set the ambitious targets of reducing the neonatal mortality rate to less than 10 per 1000 live births and under-5 mortality to less than 18 per 1000 live births by 2015 (World Health Organization) Therefore, the WHO, UNICEF, Food and Agriculture Organization (FAO), though nutrition indicators and health, recommended that the progress and existing problem should be closely monitored in order to be able to intervene as soon as possible with preventive and effective strategies Vietnam is one of the Asian countries that has

achieved considerable success in the process of poverty reduction and lowering the prevalence of malnourished children, especially children under-five years old (Ministry

of Health, 2012)

Figure 1.2.2 The statistics on the nutritional status of children over the years 2014) (National Institute of Nutrition)

(1999-Thereby the problem of malnutrition in children under-five years old has decreased noticeably from 1999 to 2014 Prevalence of underweight was from 36.7% (1999) dropped to 14.5% (2014), and prevalence of stunting decreased from 38.7% (1999) to 24.9% (2014) During 16 years, the prevalence of underweight was 22.2% decrease, while stunting fell by 13.8%

Factors related to nutritional status including income, land-owning households, assets, animals raising (Srivastava et al., 2012) (Martorell et al., 1984) (Moestue, 2005) (Cesare et al., 2015) Land is one of an indicator to measure the economic level of family through deciding to plant trees adapt to each their ability and local weather It may consider a family income factor In addition, characteristics of Vietnamese culture

is an agriculture, many factors related to income could not measure exactly as one plus one are two, actually it has some invisible factors could not be measured are risen family income Therefore it is very difficult to identify precise income of working staff

or household income only base on questionnaire

The economic conditions of households, shortage of rice, children have low birth weight, giving birth at home, not monitoring weight and children suffered from diarrhea in the last 2 weeks are the factors related to malnutrition status of children under-five year of age (Le Thi Huong, 2014a)

1.3 Current nutritional status in children in Krong Bong

The proportion of malnutrition in children has differences between ecological zones and regions Accordingly, in the geographic orientation for projects to prevent child malnutrition in the next level of the ecoregion has stunting rate, the highest of the

mountains and the north midlands, north central and Central Coast, Central Highlands

is also very important (Ministry of Health, 2012)

Thus, Dak Lak province has been selected as pilot site program on nutrition

intervention project "Improving the health of mothers and children of ethnic minorities

through behavioural health benefit (Atlantic Philanthropies) in the first two years (from

2011 to 2013) One of the reasons that Dak Lak was selected by the project due to its

highest nationwide prevalence of malnutrition of children under age five (CCRD

ORG)

Table 1.2.3 The statistics on the nutritional status of children in Dak Lak province

over the years (2005-2014)

YEAR

Underweight (SDD cân n ng/tu i)

Stunting (SDD chi u cao/tu i)

Wasting

WHZ (TCBP)

Total Moderate Severe Very

severe Total Moderate Severe

Overweight WHz >+2

Obesity WHz >+3

Source: Author compiled from sources the prevalence of malnutrition in children

under-five years of age throughout the years (National Institute of Nutrition)

In Dak Lak province, from 2005 to 2014, prevalence of underweight decreased from 34.3% to 21.5% and prevalence of stunting reduced from 41.6% to 32.8% Thus, within 10 years, the situation of malnutrition in this province was still high compared with the national average level

According to the survey results, the prevalence of malnutrition in children in Krong Bong district was highest in the Dak Lak province in 2012, the percentage of underweight and stunting of under five-year children was 26.7% and 33.3% respectively ( k L k đi n t , 7/2012) This is the reason why the assessment of nutritional status among Primary school children in Krong Bong district, Dak Lak province was chosen for the thesis

The unbalance in health care in the province compared to the country affects the overall development of the country Acting representative of the WHO, Mr Jeffery Kobza, stated "Scientific evidence indicates that optimal nutrition is an important thing

to ensure that the child will learn more when growing up and work more efficiently and attain the maximum height at maturity When children are provided with adequate nutrition that means the community has escaped poverty" (UNICEF, 2014)

1.4 Objective of the thesis

1.4.1 General objective

The general objective of this study is to assess the nutritional status and their

related factors among primary school children in Krong Bong district, Dak Lak province

 Situation of nutrition (malnutrition, overweight) of school-aged children

 Is there any relation of the factors of household family level and nutritional status in children?

 Is there any impact of maternal factors on the nutritional status of the aged children?

school-1.5 Scope of the research

The thesis focus on nutritional status among primary school children in Krong Bong district, Dak Lak province Underweight is defined as malnutrition Therefore nutritional status is defined as malnutrition, overweight and normal Scope of the research was carried out on five primary schools of five communes in Krong Bong district, Dak Lak provinces by interviewing children and their mothers/caregivers by using questionnaire The five communes in Krong Bong district are Yang Reh, Hoa Le, Eatrul, Hoa Son and Cu Pui

1.6 General method

Findings of economic theories that relate to the study topics and descriptive methodology of data collection on children of five primary schools, statistical analysis and study subjectives For this reason, the study applied multinomial logic model that address problems similar or related to the issue to be investigated

In addition, the thesis suggested some necessary recommendations on nutrition in children for the district

1.7 Structure of the thesis

The thesis includes five chapters Chapter 1 is an introduction about geographical features, administrative boundaries, the population density, ethnicities, nutritional status in the world and within Vietnam, and research problem, research objective links

to Krong Bong, Dak Lak Chapter 2 consists of a literature review which focuses on finding out some evidence-based studies to explore the relationship of different factors

as children and maternal and household family level to address the nutritional status among school-aged children Study subjectives and methodology for data collection and statistical analysis and empirical model is described in Chapter 3 Chapter 4 describes the results of this study in order to address the specific research questions Chapter 5 is conclusion and recommendations that concentrates the general discussion

is presented based on the results and some relevant studies, followed by the list of references and other supporting documents in the appendix section

CHAPTER 2: LITERATURE REVIEW

The chapter emphasizes on the findings of economic theories that relate to the study topics to explore the relationship of different factors as characteristics of children, mothers, and households to address the nutritional status among school-aged children

2.1 Measurement of nutritional status

Nutritional status can be assessed using clinical signs of malnutrition, biochemical indicators and anthropometry (de Onis, 2000) There are summarized as ABCD:

 Anthropometry methods

 Biochemical, laboratory methods

 Clinical methods

 Dietary evaluation methods

Indicators of anthropometric shortfall – especially low height and low age are uniquely suited for assessing absolute deprivation in developing countries Anthropometric indicators are relatively precise, readily available for most countries, reflect the preferences and concerns of many poor people, consistent with reckoning the phenomenon directly in the space of functioning, intuitive, easy to use for advocacy, and consistent over time and across subgroups (Heltberg, 2009) Early identification of undernourished patients in the healthcare setting, and their nutritional treatment, are essential if the harmful effects of poor nourishment are to be avoided and care costs kept down (Campos del Portillo et al., 2015)

weight-for-2.2 Anthropometric Indicators

Anthropometry is the measurement of body height, weight and proportions Anthropometry thus has an important advantage over other nutritional indicators: whereas biochemical and clinical indicators are useful only at the extremes of malnutrition, body measurements are sensitive over the full spectrum In addition, anthropometric measurements are non-invasive, inexpensive and relatively easy to obtain The main disadvantage of anthropometry is its lack of specificity, as changes in body measurements are also sensitive to several other factors, including intake of essential nutrients, infection, altitude, stress and genetic background (de Onis, 2000)

There are three different classification systems by which a child or a group of children compared to the reference population: Z scores (standard deviation scores), percentiles and percent-of-median (de Onis, 2000) According to the WHO, as followings:

HAZ: Height for age z-score (stunting)

WAZ: Weight for age z-score (underweight)

WHZ: Weight for height z-score (wasting)

Using weight-for-height: WHO and UNICEF recommend the use of a cut-off for weight-for height of above -3 SDs of the WHO standards to identify infants and children (de Onis et al., 2007)

There were some methods for nutritional assessment including z-score (Stunting: –2 SD from median or < 3rd percentile of WHO growth reference or Centers for Disease Control and Prevention (CDC) growth charts), underweight: < –2 SD from median), body mass index (BMI) however BMI is a simple index of weight-for-height that is commonly used to measurement of nutritional status It is defined as a person's

weight in kilograms divided by the square of his height in meters (kg/m2) (World Health Organization, 2015)

BMI = (kg/m2)

The three criteria above were chosen to represent these principles, and all studies were scored on each criterion: the nutritional indicator and cut off used to identify malnutrition This qualification assured that a study could only achieve a high quality score if an appropriate indicator was used to measure malnutrition An overview of the criteria and scoring system used to evaluate the studies on their quality is given in

tables 2.2.1 and 2.2.2 (Best et al., 2010)

Table 2.2.1 Overview of indicators and cut offs that are considered appropriate to

assess malnutrition in school-aged children

> BMI value corrected to BMI = 25 in adults (IOTF)

> + 2 SD from median or > 95th percentile of WHO growth reference or CDC growth charts

> BMI value corrected to BMI = 30 in adults (IOTF)

a Anthropometric measures were evaluated based on WHO growth reference

(Committee, 1995), CDC growth charts (Kuczmarski et al., 2002), or IOTF, criteria (Cole et al., 2000)

Table 2.2.2 Mean (± SD) prevalence (%) of malnutrition in school-aged children,

by WHO region, weighted for quality score

a Stunting is defined as low height-for-age, underweight as low weight-for-age,

thinness as low body mass index (BMI)-for age, overweight or obesity as high for-age

BMI-2.3 Situation of nutritional status in the world

A study examines nutritional status in school-age slum to all children aged 5-15 years from three slums (Faltuganj, Kurramgotia and Kalibadi) between December 2010 and April 2011, was randomly selected from the urban area of the Bareilly district (UP), India, elicit information on family characteristics like residence, religion, type of family, education and occupation of parents; and information on individual characteristics like age, sex (Srivastava et al., 2012)

A study of determinants of child malnutrition in the districts of Bara and Rautahat

of the Terai region of Nepal showed that age, district of residence, household income were significant predictors of nutritional status (Martorell et al., 1984)

2.3.1 Characteristics of individuals children

Age of child

Children in the age group of 5-14 years are often considered as school-age Since

1972, the United Nations Educational Scientific and Cultural Organization (UNESCO) considers 6-11 years as primary school age and 12-17 years as secondary school age for statistical purpose (Srivastava et al., 2012)

The need to develop an appropriate single growth reference for the screening, surveillance and monitoring of school-aged children and adolescents has been stirred

by two contemporary events: the increasing public health concern over childhood obesity and the April 2006 release of the WHO Child Growth Standards for preschool children based on a prescriptive approach The reference previously recommended by WHO for children above 5 years of age, i.e the National Center for Health Statistics (NCHS)/WHO international growth reference, has several drawbacks In particular, the body mass index-for-age reference, developed in 1991, only starts at 9 years of age, group data annually and covers a limited percentile range Many countries pointed to the need to have body mass index curves that start at 5 years and permit unrestricted

calculation of percentile and z-score curves on a continuous age scale from 5 to 19

years (de Onis et al., 2007)

Age related differences were found significant for some of the test scores between 5–7 and 8–10 year old children in the adequately nourished group but not for most of

the test scores for malnourished group indicative of a delay in development of certain cognitive functions (Kar et al., 2008)

Sex of child

Sex-specific comparisons of the 1977 NCHS/WHO reference and the newly reconstructed curves are presented in the figures for height-for-age, weight for-age and BMI-for-age, respectively (de Onis et al., 2007)

The sex of the child (with boys being more malnourished than girls) (Moestue, 2005)

Delivery status

Cardiac patients in the cardiac ICU were improvements in weight gain and nourishment status at discharge in infants undergoing stage 1 palliation need to improve nutrition delivery (Kaufman et al., 2015)

Place of birth

The study was carried out with data on 4121 Mexican American children age 2 months

to 16 years from Third National Health and Nutrition Examination Survey Then the authors indicated significant associations of place of birth with respiratory symptoms and allergic conditions in Mexican American children (Eldeirawi et al., 2005)

2.3.2 Characteristics of mothers/caregivers

Mother’s education

Relationship between education of mothers or caregivers and child health outcomes has been found in studies (for a review see Cleland and Kaufman 1998) Education acts as a proxy for socio-economic status of the family and geographical

area of residence and claim that, despite the strong correlation between maternal education and child health outcomes, a causal relationship is far from established (Moestue, 2005)

Women always play a very important role in implementing a healthy nutrition policy, both in the family and in society (Murmansk, 2000) Biological causes of malnutrition operate within a cultural context that has drawn attention to the role of women in determining child malnutrition – their knowledge and abilities, their physical and mental well-being and their decision-making power in shaping children's nutrition (Moestue, 2005)

Mother’s occupation

A study was undertaken to delineate the relationship between the economic pursuits carried out by men and women in a farming community in northern Ghana and the nutritional status of their children It showed that although certain indicators of farm resources and investment were positively correlated with above average nutritional status, the most significant differences were noted with respect to the trading activities of the parents The group of children which exhibited the highest proportion above the median weight for age were those whose mothers had their own income from trading (Tripp, 1981)

The mother’s allocation of her time between income-earning activities and work within the household has important implications for the selection and design of nutrition intervention programs There is increasing evidence that in poor households, there is a negative relationship between the mother’s labor force participation and the health and nutritional status of young child When the mother participates in the labor

market, the amount of time spent in household activities have a tendency to decline (Popkins and Solon, 1976)

2.3.3 Characteristics of households

Housing quality score (with the wealthier households having better nourished children than the poorer), land ownership (with children in land-owning households being more malnourished than children in the landless households) (Moestue, 2005)

Household income

Higher incomes can provide better nutrition, housing, schooling, and recreation Independent of actual income levels, the distribution of income within countries and states has been linked to rates of mortality If this is correct, then highly stratified societies take an additional toll on health beyond that associated with absolute deprivation Although the association between income and health is stronger at lower incomes, income effects persist above the poverty level

Children were better nourished if their mothers were taller or had higher weight,

if they lived in wealthier households, and if their mothers had 10 or more years of education Severe food insecurity was associated with worse nutritional outcomes for both children and women (Cesare et al., 2015)

Ethnicity

Chronic malnutrition in children remains highly prevalent in Laos, particularly among ethnic minority groups There was limited knowledge of specific nutrition practices among these groups The study explored nutritional status, cultural beliefs and practices of Laos' Khmu ethnic group to inform interventions for undernutrition as part of a Primary Health Care (PHC) project (de Sa et al., 2013)

Family size and number of children

The number of children in the household under 12 years (with many children in the household associated with more malnutrition) (Moestue, 2005)

Water source

A study in Kombolcha districts of Eastern Hararghe, Ethiopia in 2010 explored the key determinants of child malnutrition status associated with the child’s age, gender, immunization status and the mother’s use of antenatal care, farm size, household size, water source, and latrine use (Zewdie and Abebaw, 2013)

Chronic disease

It is important, therefore, to track body weight and height in school children in developing countries and countries in transition, given the significant increase of overweight and obesity in Latin America and its associations with chronic diseases later in life (Best et al., 2010)

Standard of living

A study investigated two groups of participants, the first one met the guidelines for a heart healthy diet and a novel heart healthy dietary pattern and the second one was to assess if higher education, standard of living and nutrition literacy was associated with

a heart healthy dietary pattern And the results showed that higher standard of living, education and nutrition literacy were associated with a healthier dietary eating pattern (Wall et al., 2014)

Kitchen

A study showed that human nutrition was also influence by a kitchen that intelligently senses cooking activities and provides realtime nutritional information helps facilitate healthy cooking by letting family cooks (Chen et al., 2010)

A cross-sectional study described such experiences among 22 randomly and selected participants in interviews at a charity-run soup kitchen in urban Sydney, Australia Then it was explored that low income; high rents; poor health; and addictions to cigarettes, alcohol, illicit drugs, and gambling were associated with dependence on charities Poor dentition and lack of food storage and cooking facilities were important barriers to adequate nutrition (Wicks et al., 2006)

2.4 Situation of nutritional status in Vietnam

A study in 2013 on malnutrition of ethnic minority children under-five years of age showed that malnutrition was a public health problem in the central mountainous areas of Vietnam In this study inappropriate breastfeeding and weaning practice among ethnic minority women were associated with this high rate The study offered a positive proposal need to improve the nutrition status of ethnic minority children under-five years of age in the future Culturally adapted interventions for ethnic minority women to strengthen their nutritional care knowledge, attitude and practice, especially breastfeeding and weaning practice are the key to achieving better nutrition status of their children (Le Thi Huong, 2013)

A reviewing research in childhood malnutrition in Vietnam between 1985; 2005 and 2009, by using data of some national surveys showed that the prevalence of malnutrition, including stunting, reduced significantly for underweight from 59.7% in

1985 to 31.9% in 2009 with an average reduction of 1.2% per year in the period from

1985 to 2009 The nutritional status of children is positively related to better household living condition and educational level of the fathers, but not the mothers Stunting is higher in children whose parents are famers and higher in households with more children Prevalence of stunting is lower in households with safe water access and hygienic toilets Finally, the research was showed that there were clear difference in the prevalence of malnutrition between urban, rural and mountains areas, the reduction being highest in the urban regions and lowest in the mountains areas (Le Danh Tuyen, 2010)

Group of authors in Vietnam National Institute of Nutrition were conducted an intervention study to reduce prevalence of overweight/obesity among school children through intervention activities in school year of 2012-2013 with total 2,481 children from two primary schools in urban and sub-urban of Ho Chi Minh City Result showed that prevalence of overweight/obesity of primary school children was 54.5% in Ho Thi

Ky primary school and 31.2% in Phu Hoa Dong primary school in the beginning of school year, respectively After six months of intervention, prevalence of overweight/obesity reduced (from 43.5% to 37.8%, respectively), knowledge and practices on nutrition and physical activities improved (Vu Quynh Hoa, 2013)

A cross-sectional study investigated the status of under and over nutrition of children in primary schools of Tu Liem District, Hanoi, using the World Health Organization 2007 reference (WHO 2007 reference), the International Obesity Task Force reference (IOTF 2000 reference), and Growth Chart of the U.S Centers for Disease Control and Prevention (CDC 2000 standard) It is showed that prevalence of wasting was 5.8% according to WHO; prevalence of underweight was 15% according CDC and 4.6% according to International Obesity Task Force (IOTF) There were different prevalences of overweight and obesity according to WHO (10.9% and 8.0%), IOIF (9.8% and 4.5%), CDC (7.9% and 7.0%) Prevalence of overnutrition (overweight

and obesity) was much predominant than undernutrition (wasting and stunting) based

on WHO and IOTF, while the balance between over and under nutrition was found based on CDC In conclusion, the significant differences in prevalence of nutritional status was found among children aged 6-10 years according to the international criteria (Bui Thi Nhung, 2014)

In 2012, a study conducted to assess the nutritional status and some related factors of children under 6 in Thuy Loi commune, Kim Ban district, Ha Nam province with the participation of 327 children – mother pairs Results showed that: the prevalence of underweight, malnutrition, stunting, wasting and overweight of children under six were 10.4%, 27.8%, 9.8% and 9.2% respectively There was significant differences of related factors: economic conditions, the lack of household eating rice, mother’s education level, birth weight, respiratory infections in the last six months, weight tracking and quite to parent child (Le Thi Huong, 2014b)

2.5 Analytical Framework

Currently, there are many studies on the nutritional status of children at the community level or household level in Vietnam and around the world, almost based on the analytical framework of UNICEF in 1990 and 1997 The study on the nutritional status of children in the Highlands Krong Bong, Dak Lak will implement at the household characteristics of the family level such as maternal factors, health care, sanitation, water source, economic circumstances

Figure 2.5: Conceptual framework on malnutrition (UNICEF, 1997)

Child malnutrition, death and disability

Quantity and quality of actual resources – human economic and organizational and the

Inadequate Maternal &

Child care

Poor water/

sanitation and inadequate

Inadequate and/or

inappropriate knowledge

and discriminator

attitudes limit household

access to actual resources

Political, cultural,

religious, economic and

social systems, including

women’s status, limit the

utilization of potential

resources

Basic causes

Underlying Causes or Household/

family level

Immediate Causes Outcomes

CHAPTER 3: STUDY SUBJECTIVES AND METHODOLOGY

In the chapter, descriptive methodology of data collection, statistical analysis, study subjectives and reviews of empirical studies that address problems similar or related to the issue to be investigated

3.1 General information about Krong Bong District

Krong Bong district is in Southern of Dak Lak province (People's Committee of Krong Bong District, 2015)

Figure 1 Map of Dak Lak province showing Krong Bong district (in dark grey area)

The total land area of the district is 1257.5 km2, occupy about 6.38% of Dak Lak province The total population is 90.207 (2011) Population density is: 71,13 people/km2 (according to the statistics on 31/12/2011)

The district is comprised Krong Kmar town and 13 communes, includings: Hoa Son, Hoa Le, Hoa Phong, Hoa Thanh, Hoa Tan, Dang Kang, Yang Reh, Yang Mao, Cu Dam, Khue Ngoc Dien, Ea Trul, Cu Kty, and Cu Pui

Khanh Hoa Lam Dong

Figure 2: Krong Bong District Map (People's Committee of Krong Bong District, 2015)

Krong Bong district has ethnic groups such as the Thai, Tay, Muong, Nung, Hmong, Ede, M'Nong, and the Kinh majority migrating from Quang Nam (People's Committee of Krong Bong District, 2015)

3.2 Study design

A cross-sectional household survey was carried out in five primary schools of five communes, Krong Bong district, Dak Lak provinces Children and their mothers/caregivers were interviewed by using questionnaire

3.2.1 Study setting

The study randomly chose five communes from 13 communes in Krong Bong district Each commune chose one school, Yang Reh commune chose Yang Reh primary school with three classes, Hoa Le commune chose Tran Phu primary school

with two classes, Eatrul commune chose Eatrul primary school with two classes, Hoa Son commune chose Son Dong primary school with four classes, Cu Pui commune chose Cu Pui II primary school with four classes

The study was conducted in two, three or four classes of each primary school from five communes in Krong Bong and was implemented two periods of time The first time is during one week from 30th March to 16h April 2015 and the second is from

z

Where: z = Confidence (for 95%, use 1.96) and d = precision (0.05),

p = 0.25: Chose proportion of five primary schools during the assessment period for malnutrition in Vietnam in 2014 (National Institute of Nutrition)

Therefore, n = 288 children but actual sample size for five schools was 321 children

3.2.3 Study subjects

Throughout domestic and worldwide theoretical studies, the thesis study about assessment of nutritional status among primary school pupils in highlands It is proposed an analytical framework describing some underlying causes or household/family level, apart of conceptual framework on malnutrition (UNICEF, 1997), as follows:

Figure 3.1.3 Analytical framework: illustration of hypotheses related to the

relationship between nutritional status in children and related factors

3.3 Statistical analysis

The primary aim of data analysis was to describe the characteristics of malnutrition and overweight and obesity status included sex, age, mother’s education, mother’s occupation, drinking water, place of birth (born at home, health clinic), land-owing household,… and their association with potential risk factors

Child nutrition

Malnutrition Normal Overweight and obesity

Child individual factors

Sex of child Age of child

Household family factors

Commune Delivery status Land

Boil drinking water Electricity

Market distance

Maternal factors

Mother’s education

Mother’s occupation

The study assesses nutritional status in children including malnutrition and overweight and obesity status on primary school pupils by using anthropometric index Physical measurement includes body weight (kg), height of children (cm) to define nutritional status Thus, based on the age, body weight and height of children indicating BMI has been calculated on a format file excel, was available on CDC website (CDC, 2015)

Child nutritional status are classified into three categories: underweight, overweight and obesity by using BMI Underweight (low weight-for-age) is defined lower –2 SD from median or < 5th percentile of WHO growth reference or CDC growth charts, overweight (BMI-for-age) is defined more than + 1 SD from median or > 85th percentile of WHO growth reference or CDC growth charts, obesity (BMI-for-age) is defined more than + 2 SD from median or > 95th percentile of WHO growth reference

or CDC growth charts (Best et al., 2010) Therefore this study was divided into two groups for analysis, one group was malnutrition (underweight) and the other one was overweight including two factors of overweight and obesity combined

The outcome considered in the analysis was the number of children with malnutrition or overweight /obesity while potential risk factors were children , mothers/caregivers and households

At the beginning, univariate analysis to assess nutritional status in children throughout involve factors as children individuals, maternal and household of children And then multivariable analysis with factors related to nutritional status in children Therefore, in univariate analysis and multivariate analysis, odds ratio (OR) is used to assess the risk factors of nutritional status in children The odds ratios formula is as follows;

Here, p1 refers to the probability of the outcome in group 1, and p2 is the probability of the outcome in group 2 (Grimes and Schulz, 2008)

Actually, when compute and analysis the data in the thesis, was using formular

on excel (Vanderweele and Vansteelandt, 2010) at the appendix

The data was entered, cleaned and managed, and then analyzed using STATA 12.0 (StataCorp, 4905 Lakeway Drive, Special Edition, College Station, Texas 77845 USA)

In order to assess the relationship between child individual, maternal and household factors, and nutritional rates, logistic regression was used to find out the effect of children individual, maternal and households on nutritional status of children

at the level of significance of p<0.05

3.4 Empirical Model

The logic model is useful when one tries to explain discrete choices, i.e choices

of one among several mutually exclusive alternatives (Train (2003) and Louiviere) There are many useful applications of discrete choice modelling in different fields of applied econometrics, using individual data (Croissant)

Studies using multinomial logic methods examine how different child characteristics affect their preferences (Satterthwaite, 2000 )

The basic regression equation is:

i i

Multinomial choice empirical methods are based on random utility models of

child nutritional status The utility that child nutrition i obtains from malnutrition,

normal, overweight and obesity from factors related may be written:

Yij = j+ 1Cij+ 2jMi+ 3jHi + εij

Where:

Yij: nutrition variable, dependence variable The response variable is:

j is coefficient

1, 2j, 3j are regression coefficient estimates

Cij are characteristics of the child i that may be evaluated by the factors (e.g., sex,

age) independence variable

Mj is the maternal and family factors, independence variable

1 if malnutrition

2 if normal

3 if overweight and obesity Yij =