THE ROLE OF INDIVIDUAL, HOUSEHOLD, AND, PRIMARY HEALTH CARE’S SERVICES TO SEVERE MALNUTRITION IN UNDER FIVE YEARS CHILDREN IN INDONESIA By : Budi Setyawati Julianti Pradono Rika Rachmalina NATIONAL INSTITUTE OF HEALTH AND RESEARCH DEVELOPMENT MINISTRY OF HEALTH-2014
BACKGROUND The first five years of live times is very important, there is ‘Period window of opportunity’ in first two years very critical period for brain, physical and mental development in children. Failure of growth in this period is adverse and irreversible (Unicef, 1998). Impaired growth in children will decrease their intelligency (Licari et al, 2005) Severe malnourished children is more likely to die than those who are not (Pelletier, 2003).
METHOD Desain: a cross-sectional study Data : National Basic Health Research (Riskesdas 2010) & Health Facilities Research (Rifaskes 2011). Sampel :
Under five years old children (0-59 mo). The family of those under five years old children. Primary health care. Dependent variable : nutritional status of children under five years.
METHOD
Independent variables: Individual
level (4) : infection, energy-protein consumption, weighing, immunization; Family level(7) : mother’s education; mother’s parity; drinking water quality; facilities of defecation; liquid waste disposal; household waste handling ; Family’s economic status Primary health care of sub-district level (7) : services; training; reporting; Ratio of physicians and population; midwives and population; TPG and population; Region with DTPK status (Daerah tertinggal, perbatasan kepulauan; remote area, borderline or islands).
Variables
Operational Definitions
Indicators
Individual level (children under five years old) Severe malnutrition
Based on Z-Score of weight for age value Severe malnutrition is Z-Score < -3 (WHO, 2005)
0 : Z-score ≥ -3 1 : Z-score < -3
History of children’s illnesses
History of being suffered from malaria or other illnesses within first 6-48 hours of birth or in the first 28 days of birth
0 : never been ilness 1 : had the illness
Immunization Status
Having complete immunization according to children’s age. (Tuberculosis, Dipthery-Pertussis, Measles, Polio, Tetanus, Hepatitis B).
0 : Complete Immunization 1: Incomplete Immunization
Energy-protein The adequacy of energy-protein intake according Intake to RDA (AKG WKNPG, 2004).
0 : adequate energy protein intake 1: inadequate energy protein consumption
Routine weighing the
0 : weighing in consecutive months
Weighing the children in consecutive months for the last 6 month (according to age).
Variables
Operational Definitions
Indicators
Household level Mother’s education
mother's formal education
Parity
The number of children had been born
0 : ≥ SMP (junior high school) 1 : < SMP 0 : children < 3 1 : children ≥ 3
Family economic Total living cost expenditure, using quintil 2. (Rp. status 1,085,523)
0 :enough( ≥ quintil 2) 1 : less (< quintil 2)
The quality of drinking water
0 : good quality 1 : not good quality
composite variables of drinking water quality (colorless, tasteless, and odorless). the distance between the source of drinking water to septic tank/stool (> 10 m) is also considered, when the water source is from wells/ pumps /springs / reservoirs /
Variabel
Definisi Operasional
Indikator
Fesses disposal facilities
Composites of toilet type and fesses disposal. 0 : good Good : type of toilet is swan neck and landfills septic 1 : not good tank/SPAL. Not good : the toilet plengsengan/pit/cubluk/no or a final disposal of excreta: pool/field/river/sea lake/ holes in the ground /beach/field/garden.
Household liquid waste disposal
Good: bathrooms/washrooms and kitchen waste is discarded into the SPAL or covered disposal in the yard. Not good: Waste is discarded into opened disposal in the yard/outside yard/ shelters (ground)/ into the gutter/river. Good: garbage is discard into trailer trash/landfilled in the house yard/ composting Not good: garbage is burned/dumped into the river stream /ditches/sea or carelessly discarded.
Household waste handling
0 : good 1 : not good
0 : good 1 : not good
Variabel
Definisi Operasional
Indikator
Primary health care at sub-distric level Training
Training of growth monitoring and management of malnutrition. Good: The primary health centre provide training. Health Composite from variables : service of weighing children’s services body, giving PMT recovery (recovery supplementary feeding), prevention of diarrhea, and immunization outside /inside the building. Writing report Monthly reporting (nutrition, MCH and immunization) and nutritional surveillance reporting. The ratio of The number of doctors in Primary health care (PHC) per doctors and population. Ideal: ≥ 40 physicians / 100,000 population. population
0 : good 1 : not good 0 : good 1 : not good 0 : good 1 : not good 0 : ideal 1 : not ideal
The ration of The number of midwifes in Primary health care (PHC) per 0 : ideal midwifes and population. Ideal: ≥ 100 bidan /100.000 penduduk 1 :not ideal population The ratio of TPG and pop
The number of in Primary health care (PHC) per population. Ideal: ≥ 22 TPG /100.000 penduduk. (TPG=nutritionists)
0 : ideal 1 : not ideal
DTPK status
DTPK is remote area, in the borderline or islands.
0 : non DTPK 1 : DTPK
METHOD
Data management:
Cleaning the data Composite the data (grouping some certain data)
Data analysis: Data is analysed using logistic regression to obtain candidate variables that influence severe malnutrition. Further analysis is using modeling multilevel logistic regression using Stata program
RESULTS
Overall samples that were analyzed: 7613 children under five years old living in 7032 families and in 1887 sub-districts in Indonesia. Nutritional status of under five children 5.60%
Severe malnutrition
84.40%
not severe malnutrition
RESULT Individual sample characteristic 100
94.4
90
85.9
83.7
80 70
64.3
60 53.3 50
46.7
40
35.7
30 20
16.3
14.1
10
5.6
0 Tidak buruk
Status Gizi
Buruk
Cukup
Kurang
Kons. Energi – Protein
Rutin ditimbang
Tidak rutin ditimbang
Penimbangan
Imunisasi lengkap
Imunisasi tidak lengkap
Imunisasi
Sehat
Pernah sakit
Status sakit
RESULT Household sample characteristic
RESULT
THE RESULTS OF MULTIVARIATE ANALYSIS ON SEVERE MALNOURISHED UNDER FIVE YEARS OLD CHILDREN IN INDONESIA
Variables
OR
95% CI
p
Weighing children
1,28
1,026 – 1,607
0,029*
Energy-protein intake
1,41
1,001 – 1,991
0,049*
Immunization status
1,33
1,078 – 1,645
0,008*
Mother’s education
1,61
1,302 – 1,996
0,005*
Mother’s parity
1,33
1,088 – 1,629
0,01*
Household waste handling
1,59
1,210 – 2,078
0,05*
1,087 – 1,624
0,05*
Individual level
Household level
Primary health care at sub-distric level Reporting
1,33
FINAL MODEL OF MULTILEVEL LOGISTIC REGRESSION ANALYSIS OF SEVERE MALNOURISHED CHILDREN UNDER FIVE YEARS 0LD IN INDONESIA
Model1 (null)
Model 2 (Individual)
Model 3 (household)
Model 4 (PHC)
Weighing the children: not routinely
0,368
0,320
0,317
Energi-protein intake : inadequate
0,600
0,473
0,460
Immunization status : incomplete
0,609
0,383
0,387
Mother’s education : < SMP
0,520
0,503
Mother’s parity: ≥ 3
0,360
0,364
Household waste handling: not good Primary health care at sub-distric level
0,699
0,696
Individual level
Household level
Reporting : not good
0,427
Random Efect (SE) Varians level 2 (household)
3,340
2,971
3,096
2,975
Varians level 3 (primary health care)
1,234
0,914
0,673
0,641
ICC( INTERCLASS CORRELATION COEFFICIENT)
ICC
Model
ICC level 1 (Individual)
41,8%
ICC level 2 (Household)
42,5%
ICC level 3 (Primary health care at sub-distric level)
15,7%
From the calculation of the ICC is shown that the role of household level to severe malnutrition status of under five years old children in Indonesia, is the greatest (42.5%,) in household level, followed individual level (41.8%) and health services in sub-district Primary health care level (15.7%).
VALUE OF OR, MOR AND IOR FOR RISK SEVERE MALNUTRITION IN CHILDREN Level 0
Level 1
Level 1,2
Level 1,2,3
Odds Ratio (OR) Determinant of Individual level Weighing the children: not consecutive month/not routinely Energi-protein intake: inadequate
1,44
1,38
1,37
1,82
1,60
1,58
Immunization status : incomplete
1,84
1,47
1,47
Median Odds Ratio (MOR) Household level
5,72
5,18
5,36
5,18
PHC at sub-distric level
2,89
2,49
2,19
2,15
1
1
0,069-40,82
0,073-37,68
1
1
0,059-34,78
0,063-32,79
1
1
0,083-48,82
0,088-45,70
Interval Odds Ratio (IOR) Determinant of household level
Mother’s education : ≥ SMP : <SMP Mother’s parity : < 3 :≥3 Household waste handling: good : not good
RESULT Peran var tk Individu terhadap gizi buruk Tk RT : PCV (3,340-2,971)/3,340 x 100% = 11,04% var tk indiv (penimbangan, konsumsi energiprotein dan imunisasi) menerangkan 11,04% variasi gizi buruk pada tk RT. Tk Kec : PVC : (1,234-0,914)/1,234 x 100% = 25,93% var tk indiv (penimbangan, konsumsi energi-protein dan imunisasi) menerangkan 25,93%. variasi yang terjadi di tingkat kecamatan. OR Penimbangan ; 1,37 ; OR kons energi-prot : 1,58; OR imunisasi : 1,47
RESULT Peran var RT thd gizi buruk Tk RT :2,971 3,096 var RT ≠ berperan pd variasi gizi buruk di tk RT Tk yankes : PVC : (0,914-0,673)/0,971 x 100% = 26,37% . peran var RT (pendidikan ibu, jumlah anak dan penanganan sampah) dapat menerangkan 26,37% variasi di tk yankes MOR : 5,36 balita di RT (≠ rutin ditimbang, konsumsi energiprotein < kecukupan, imunisasi ≠ lengkap, ibu ≠ tamat SMP, jumlah anak ≥ 3 orang, dan penanganan sampah kurang baik) berpeluang gizi buruk 5,36 kali. Nilai MOR > 1 menunjukkan bahwa terdapat variasi kejadian gizi buruk antar rumahtangga IOR lebar variasi gizi buruk antar rumahtangga besar. Nilai IOR pd var RT mencakup angka satu variasi gizi buruk antar RT > pengaruh variabel kontekstual TK RT (pendidikan ibu, jumlah anak dan penanganan sampah) terhadap kejadian gizi buruk.
RESULT Peran var Tk Yankes kecamatan Peranan var tk yankes dapat menerangkan terjadinya variasi yang terjadi pada tk RT(3,9%) dan kecamatan (4,75%). MOR : 2,5 balita yang tinggal di kecamatan berisiko (balita yang penimbangannya ≠ rutin, konsumsi energi-protein < kecukupan, imunisasi ≠ lengkap, jumlah anak ≥ 3 orang, penanganan sampah
1 : terdapat variasi kejadian gizi buruk antar kecamatan.
CONCLUSION
Severe malnutrition in under five children is a combination of compositional factors (individual) and contextual factors (household and PHC at sub-district). The largest role is in household level (42.5%), followed by individual level 41.8%, and PHC at sub-district level (15.7%). Children have a risk of having severe malnutrition when having inadequate protein-energy intake (OR: 1.58), incomplete immunizations (OR: 1.47) and being weighed not routinely (OR: 1.37). Household have a risk of having children suffering from malnutrition 5.36 times, when having inadequate proteinenergy intake, incomplete immunizations, and being weighed not routine, mother’s formal education is junior high school, having ≥ 3 children, and have unwell household waste handling.
CONCLUSION
Children who live in sub-district PHC which having inadequate protein-energy intake, incomplete immunizations, and being weighed not routine, mother’s formal education is junior high school, having ≥ 3 children, have unwell household waste handling and writing report is not good category have 2.5 times suffering from severe malnutrition.
SUGGESTION to prevent malnutrition in children under five years old, an effort of well-preventive and promotive should be done, mainly in health promotion programs for mother, such as knowledge of parenting (consumption, immunizations and monitoring children’s weight) as well as household and environmental sanitation. For health care personel in primary health care, it is important to do a valid report as for early detection of severe malnutrition and follow-up of the result of that report
Thank You
