Cosalan , Samantha Gail V. Que, Agnes Karen B. June 3, 2011

1. 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

2. 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

3. 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

4. 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

5. Long-term effects • Shorter adult height • Reduced economic productivity • Impaired neurocognitive and socio-emotional development • Reduction in long-term quality of adjusted life years

6. 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

7. METHODS

8. 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

9. 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

11. Training of Mentor Mothers • Watch experienced MMs implement the intervention, learn how to approach the family and build trust. • Attend one month of training on the ff. topics: • Nutrition • Basic child health • Weighing of babies and completion of growth charts • Recognizing signs of abuse and crisis situations • Fighting maternal depression

12. 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.

13. 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

14. 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

15. Data Collection 3 Possible Outcomes for Study Population: • Rehabilitation • Death • Failure of Intervention (child did not reach normal weight by the final follow-up session at 12 months)

16. Statistical Methods • Chi-square test • T test • Fisher’s exact test • Wilcoxon two-sample test

17. RESULTS

18. 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

19. 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

20. 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%)

21. DISCUSSION

22. Limitations 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

23. 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%)

24. 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

25. 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

26. 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