Home Visits by Neighborhood Mentor Mothers Provide Timely

Recovery from Childhood Malnutrition in South Africa: Results from a Randomized Controlled Trial

Cosalan, Samantha Gail V.Que, Agnes Karen B.

June 3, 2011

Introduction

• Childhood malnutrition– Causes 3.5 million deaths for children < 5 y/o– Cause 1/3 of the disease burden in this age group– Declined globally in the 1990’s but increased in

Africa

Childhood Malnutrition in South Africa

• 7% of children < 5 years old die each year• 12% are underweight• 5% are wasted (low WFH)• Over 25% are stunted (low HFA)• Only 8% of infants < 6 months old are

exclusively breastfed

Effects of Childhood Malnutrition

• Diminished immune function– 5x higher risk of dying from diarrhea– 4x higher risk of dying of respiratory infections

and malaria

• Decreased growth and development– Lower IQ– Poor school performance– Behavioral problems in school

• Long-term effects– Shorter adult height– Reduced economic productivity– Impaired neurocognitive and socio-emotional

development– Reduction in long-term quality of adjusted life

years

Philani Child Health & Nutrition Program

• Introduced “mentor mothers” to the community• Provide nutrition education and support through

outreach or home visitation programs• Secure government assistance• Improve mother-child bonding• Improve hygiene practices• Improve feeding practices• Reduce child abuse and neglect

METHODS

Study Population

• Cape Town, South Africa• 65 neighborhoods– Formal settlements– Site-and-service plots– Informal settlements

• 800 households• 1 mentor mother from each neighborhood– Home-based intervention for at least 4 hrs a day

Criteria for Selecting Mentor Mothers

• Have children who are thriving• Have strong communication & interpersonal

skills• Committed to community service• Organized and disciplined approach to task

management

Training of Mentor Mothers

1. Watch experienced MMs implement the intervention, learn how to approach the family and build trust.

2. Attend one month of training on the ff. topics:o Nutritiono Basic child health o Weighing of babies and completion of growth chartso Recognizing signs of abuse and crisis situationso Fighting maternal depression

3. Learn how to help mothers bond with their children and improve the consistency of daily health routines.

4. Implement first round of home visits independently in their neighborhoods.

Tasks of Mentor Mothers

• Initiating and maintaining breastfeeding• Introducing solids correctly• Introducing a mixed diet with vegetables and fruits• Check if immunizations are up to date• Promoting good sleeping habits• Providing organization, discipline, & structure in the

home• Protect child from sources of infection, accidents, &

trauma• Make appropriate referrals for severe cases

Data Collection

• Children’s background characteristics• Mothers’ background characteristics• Housing/living situation• Children are weighed at baseline and at 3, 6, 9, and

12-month follow up periods• Rehabilitation WFA z-score above the cutoff for

study eligibility (>-2 SD)• Time to rehabilitation noted at the first assessment

at which the child reached the target weight

Data Collection

3 Possible Outcomes for Study Population:1. Rehabilitation2. Death3. Failure of Intervention (child did not reach

normal weight by the final follow-up session at 12 months)

Statistical Methods

• Chi-square test• T test• Fisher’s exact test• Wilcoxon two-sample test

RESULTS

Demographic and Background Characteristics: Mother-Child

• 52% lived in informal housing• 55% had access to a flush toilet• 92% had living conditions with a neutral smell• 32% had good hygiene• 19% of children were supported by a nutrition

program• 53% of children had a low birth weight

Control vs. Intervention

• Children in intervention group were a few months younger and weighed a kilogram less

• Mean weight for age z-score was lower among intervention group

• Greater number of children with a low birth weight in the intervention group

• Control group were more likely to miss follow-ups

Rehabilitation

• 3 months – odds of rehabilitation were 5 times higher in the intervention– OR = 4.74

• 6, 9 and 12 months – odds of rehabilitation were similar – OR = 0.90, OR = 1.31, OR = 1.27

• A higher percentage of children in the intervention condition were rehabilitated compared to the control condition (43% vs. 31%)

DISCUSSION

Philani program significantly reduced the amount of time that malnourished children remained underweight in the

treatment group compared to malnourished children in the standard

care condition

Limitations

Percentage of children who had not been rehabilitated within a year was significantly lower in the intervention group compared to the control group

(57% vs. 69%)

Limitations

• Unable to obtain consistent measures of infant length or child height at home visits– Unable to determine whether the recovery of

malnourished children due to the Philani intervention was in weight alone

• Intervention is successful in averting the short term risks of malnutrition however the effect on long term development is not known

• Assignment of children to intervention and control groups

Recommendations

• Measures of height/length to confirm that the Philani intervention is successful in combating both stunting and wasting

• Use procedures that cannot be tampered with

Malnutrition Recovery Programs

• Promote catch-up growth• Prevent illness and death directly caused by

nutritional deficits • Improve overall health and the ability to

withstand infection• Promote healthy physical and mental

development