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Transcript of THE ROLE OF INDIVIDUAL, HOUSEHOLD AND HEALTH …file.persagi.org/share/53 Budi Setyawati.pdf · to...
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
Intake
The adequacy of energy-protein intake according
to RDA (AKG WKNPG, 2004). 0 : adequate energy
protein intake
1: inadequate energy
protein
consumption
Routine
weighing the
children
Weighing the children in consecutive months for
the last 6 month (according to age).
0 : weighing in
consecutive months
1: not weighing in
consecutive
moths
Variables Operational Definitions Indicators
Household level
Mother’s
education
mother's formal education 0 : ≥ SMP (junior high
school)
1 : < SMP
Parity The number of children had been born 0 : children < 3
1 : children ≥ 3
Family economic
status
Total living cost expenditure, using quintil 2. (Rp.
1,085,523)
0 :enough( ≥ quintil 2)
1 : less (< quintil 2)
The quality of
drinking water
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 /
0 : good quality
1 : not good quality
Variabel Definisi Operasional Indikator
Fesses
disposal
facilities
Composites of toilet type and fesses disposal.
Good : type of toilet is swan neck and landfills septic
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.
0 : good
1 : not good
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.
0 : good
1 : not good
Household
waste
handling
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.
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.
0 : good
1 : not good
Health
services
Composite from variables : service of weighing children’s
body, giving PMT recovery (recovery supplementary
feeding), prevention of diarrhea, and immunization
outside /inside the building.
0 : good
1 : not good
Writing report Monthly reporting (nutrition, MCH and immunization) and
nutritional surveillance reporting.
0 : good
1 : not good
The ratio of
doctors and
population
The number of doctors in Primary health care (PHC) per
population. Ideal: ≥ 40 physicians / 100,000 population.
0 : ideal
1 : not ideal
The ration of
midwifes and
population
The number of midwifes in Primary health care (PHC) per
population. Ideal: ≥ 100 bidan /100.000 penduduk 0 : ideal
1 :not ideal
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.
5.60%
84.40%
Nutritional status of under five children
Severe malnutrition
not severe
malnutrition
RESULT
94.4
5.6
14.1
85.9
35.7
64.3
53.3
46.7
83.7
16.3
0
10
20
30
40
50
60
70
80
90
100
Tidak buruk Buruk Cukup Kurang Rutin ditimbang Tidak rutinditimbang
Imunisasilengkap
Imunisasi tidaklengkap
Sehat Pernah sakit
Status Gizi Kons. Energi – Protein Penimbangan Imunisasi Status sakit
Individual sample characteristic
Variables OR 95% CI p
Individual level
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*
Household level
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*
Primary health care at sub-distric level
Reporting 1,33 1,087 – 1,624 0,05*
THE RESULTS OF MULTIVARIATE ANALYSIS ON SEVERE MALNOURISHED
UNDER FIVE YEARS OLD CHILDREN IN INDONESIA
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)
Individual level
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
Household level
Mother’s education : < SMP 0,520 0,503
Mother’s parity: ≥ 3 0,360 0,364
Household waste handling: not
good
0,699 0,696
Primary health care at sub-distric 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
1,44 1,38 1,37
Energi-protein intake: inadequate 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
Interval Odds Ratio (IOR)
Determinant of household level
Mother’s education : ≥ SMP 1 1
: <SMP 0,069-40,82 0,073-37,68
Mother’s parity : < 3 1 1
: ≥ 3 0,059-34,78 0,063-32,79
Household waste handling: good 1 1
: not good 0,083-48,82 0,088-45,70
Determinant of PHC at sub-distric level
Report writing: good 1
: not good 0,36-6,54
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 energi-protein 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 energi-
protein < 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 <baik dan pembuatan laporan <baik) berpeluang 2,5 kali mengalami gizi buruk dibandingkan responden yang tinggal di kecamatan yang kurang berisiko terhadap kejadian gizi buruk. MOR > 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 protein-energy 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