Presentation_Jurczynska - Catalyzing Investments in RMNCAH at the Community L...
Local Determinants of Malnutrition_Wetzel, Cutherell, Borger_10.12.12
1. Local Determinants of Malnutrition:
Formative Research and Programmatic
Implications
FOOD FOR THE HUNGRY
Carolyn Wetzel, Director of Health Programs
Andrea Cutherell, MCHN Coordinator
Sarah Borger, MCH Coordinator
October 12, 2012
2. Introduction to the LDM: Where & How?
South Sudan Ethiopia
(2011) (2008)
DRC Kenya
(2012) (2005)
Burundi
Bolivia
(2009)
(2007)
Mozambique
(2004)
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3. Introduction to the LDM: Where & How?
Goal: to identify a few critical behaviors
that could accelerate improvements in
nutrition status that are more likely to be
affordable, acceptable, and sustainable because
some members of the community are already
practicing them.1
1. David R. Marsh and Dirk G. Schroeder, The positive deviance approach to improve health Outcomes, Food and Nutrition Bulletin 2002
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4. Why was the LDM developed?
Local Determinants of
Positive Deviance Inquiry
Malnutrition (LDM)
Qualitative Quantitative
Observational Measures the strength of
Nuanced association
Accounts for confounding
5. LDM Methodology
Population Case Control
o Ideal population: 12 to 24 o Cases: PD children
months of age o PD: at least ≥ -1 SD WAZ/HAZ
o Actual population: 12 to 36 o Malnourished: at least ≤ -2 SD
months of age WAZ/HAZ
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6. LDM Methodology (cont.)
Sampling
o 45 PD and 45 malnourished caregivers (minimum)
o 80% power, 0.05 alpha, 35% proportion
o Random sample of communities, from a weighted convenience
sampling frame with convenience sampling at the community level
o 8-12 communities with ~12 interviews in each
Project area
Convenience sample within 2-3
hour radius of training facility
• Training Center
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7. LDM Tool Development
Survey tool includes 4 domains
Worldview & Maternal Income
Depression
Childcare & Care Feeding practices
(pregnancy,
Seeking Behaviors breastfeeding, and child)
Currently 81 questions, editing to 40 questions
Developed by Tom Davis and Phil Moses based on an
exhaustive literature review
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8. LDM Analysis
Outcome: PD/Malnourished
Dichotomous
Exposure variables: Indicators within 4 domains
Continuous and Dichotomous
Analyzed using EpiInfo 3.5.3
Tests for interaction and confounding
Data entry at the field level but
analyzed by HQ
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9. Limitations
Based upon a convenience
sampling frame
Quantitative method may miss
nuances of a qualitative study
Challenges finding a reliable
wealth/equity variable
Detection of counter-intuitive
findings
Ration-dependent environments
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Developed in 2003 and used in 7 countries (6 Africa, 1 LA; Moz ‘04, Kenya ‘05, Bolivia ‘07, Ethiopia ‘08, Burundi ‘09, South Sudan ‘11, DRC ‘12)Based on interviews of mothers of PD and malnourished children and compares their responsesThe goal of the tool, like other PD approaches, is to identify a few critical behaviors that could accelerate improvements in nutrition status that are more likely to be affordable, acceptable, and sustainable because some members of the community are already practicing them.Marsh D and Schroeder D, The positive deviance approach to improve healthoutcomes: experience and evidence from the field—Preface. Food and Nutrition Bulletin. Vol 23, no 4. 2002. Available for download from: http://docserver.ingentaconnect.com
Developed in 2003 and used in 7 countries (6 Africa, 1 LA; Moz ‘04, Kenya ‘05, Bolivia ‘07, Ethiopia ‘08, Burundi ‘09, South Sudan ‘11, DRC ‘12)Based on interviews of mothers of PD and malnourished children and compares their responsesThe goal of the tool, like other PD approaches, is to identify a few critical behaviors that could accelerate improvements in nutrition status that are more likely to be affordable, acceptable, and sustainable because some members of the community are already practicing them.Marsh D and Schroeder D, The positive deviance approach to improve healthoutcomes: experience and evidence from the field—Preface. Food and Nutrition Bulletin. Vol 23, no 4. 2002. Available for download from: http://docserver.ingentaconnect.com
Developed in 2003 and used in 7 countries (6 Africa, 1 LA; Moz ‘04, Kenya ‘05, Bolivia ‘07, Ethiopia ‘08, Burundi ‘09, South Sudan ‘11, DRC ‘12)Based on interviews of mothers of PD and malnourished children and compares their responsesThe goal of the tool, like other PD approaches, is to identify a few critical behaviors that could accelerate improvements in nutrition status that are more likely to be affordable, acceptable, and sustainable because some members of the community are already practicing them.Marsh D and Schroeder D, The positive deviance approach to improve healthoutcomes: experience and evidence from the field—Preface. Food and Nutrition Bulletin. Vol 23, no 4. 2002. Available for download from: http://docserver.ingentaconnect.com
Quantitative PDI tool that is easy and affordable to be implement at the field levelChallenges with Qualitative studies in the fieldTable with PDI and LDM comparisonQualitative/ QuantitativeLDM can measure the strength of association and account for confoundingPDI studies are more observational and nuanced
PopulationIdeal age is 12- 24m, but with reality/ time limitations LDM age range is usually 12-36mCase ControlDefinition of cases: PD mothers, weight cut-offs are context specific at least >=-1SD for PD children and <=-2 SD WAZ or HAZ for malnourished childrenSampling45 PD /45 Malnourished (80% power, alpha = 0.05, 35% proportion)Random sample of communities, pulled from a weighted convenience sampling frame; with convenience sampling at the community level8-12 communities, with approximately ½ day each community per team and about 12 interviews in each community (6 PD/ 6 Malnourished)
PopulationIdeal age is 12- 24m, but with reality/ time limitations LDM age range is usually 12-36mCase ControlDefinition of cases: PD mothers, weight cut-offs are context specific at least >=-1SD for PD children and <=-2 SD WAZ or HAZ for malnourished childrenSampling45 PD /45 Malnourished (80% power, alpha = 0.05, 35% proportion)Random sample of communities, pulled from a weighted convenience sampling frame; with convenience sampling at the community level8-12 communities, with approximately ½ day each community per team and about 12 interviews in each community (6 PD/ 6 Malnourished)
Covers 7 areas or domains: 1) household income, mother’s income, and income generating work; 2) child feeding practices; 3) childcare practices (including hygiene practices); 4) care seeking behaviors; 5) feeding practices during pregnancy and breastfeeding; 6) worldview; and 7) maternal depression.Currently 81 questions (1.5 hours), desire to move to <=40 questions (45m) Developed by Tom Davis and Phil Moses based on exhausted literature review to determine (a) determinants, (b) the strength of those determinants, (c) the feasibility of measurement, and (d) ability to change the behavior.
At this point analysis is conducted at the HQ levelUsing Epi 3.5.3Determinants are run as dichotomous and/or continuous exposures and tested for confounding
Convenience sample frameQuantitative missing nuances of QualitativeWealth/equality variableCounter-intuitive findings
Meant to find key issues (same as intro)For example, in Kenya (2005) the LDM found that ‘mothers of malnourished children were away from their child an average of 6.7 hours per day vs. 5.0 hours for mother of PD children.’ As a result, the FH team investigated barriers to spending more time with children using qualitative methods.For example, in DRC (2012) the LDM found that ‘mothers of malnourished children were 4.5 times more likely to have introduced semi-solid/mashed foods late (at 9 months of age or after) than mothers of PD children.’ As a result, the Care Group curriculum about complementary feeding was revised to highlight the importance of introducing thick, nutritious porridge or mashed foods at 6 months.Introduction of the discussion guide
Meant to find key issues (same as intro)For example, in Kenya (2005) the LDM found that ‘mothers of malnourished children were away from their child an average of 6.7 hours per day vs. 5.0 hours for mother of PD children.’ As a result, the FH team investigated barriers to spending more time with children using qualitative methods.For example, in DRC (2012) the LDM found that ‘mothers of malnourished children were 4.5 times more likely to have introduced semi-solid/mashed foods late (at 9 months of age or after) than mothers of PD children.’ As a result, the Care Group curriculum about complementary feeding was revised to highlight the importance of introducing thick, nutritious porridge or mashed foods at 6 months.Introduction of the discussion guide
Add picture of the discussion guide.Adjust instructions based on program activities and column names
We are currently working on a LDM ManualAt the back of the slide printouts there are some additional resources including:Timing of the study during the LOABudget OutlineTimeline for modifying, conducting and analyzing the LDM