Dirk G. Schroeder

The power of positive deviance

Identifying individuals with better outcome than their peers (positive deviance) and enabling communities to adopt the behaviours that explain the improved outcome are powerful methods of producing change

A Methodology for Estimating the Contribution of Malnutrition to Child Mortality in Developing Countries

According to conventional methods of classifying cause of death, approximately 70% of child deaths (0-4 y) worldwide are due to a small number of priority infectious diseases which, in turn, receive the vast majority of donor and national resources in the health sector. Despite the long-recognized synergism between malnutrition and infection in the causation of child mortality, malnutrition does not appear as a major cause of death in health statistics from developing countries. Part of the reason for this has been the difficulty of estimating the percent of deaths due to malnutrition, because the conventional methods of classifying cause of death do not recognize the potentiating effect of malnutrition on the disease. The purpose of this paper is to develop and test a simple methodology to estimate the percent of child deaths in a given country or community that is due to malnutritions potentiating effects on prevailing infectious diseases. The cornerstone of the methodology is knowledge of the strength of the association between malnutrition and mortality in developing countries, as measured in eight prospective studies. These studies reveal remarkable consistency in relative risk across different grades of malnutrition. The mean and SE of relative risk for severe malnutrition is 8.4 +/- 2.1, for moderate malnutrition it is 4.6 +/- 0.9, and for mild malnutrition it is 2.5 +/- 0.3. When applied to survey data from Ethiopia, Malawi, Guatemala and India for illustrative purposes, this methodology indicates that 42-57% of all child deaths in these samples (6-59 mo) are due to malnutritions potentiating effects on infectious disease, of which 76-89% is attributable to mild-to-moderate malnutrition. This methodology is recommended for use in a variety of policy and planning applications.

Work outside the home is the primary barrier to exclusive breastfeeding in rural Viet Nam: insights from mothers who exclusively breastfed and worked

This study assessed barriers to exclusive breastfeeding in rural Viet Nam and identified how a few mothers were able to exclusively breastfeed despite barriers. A cross-sectional quantitative and qualitative assessment was carried out among 120 mothers of infants less than six months old in northern Viet Nam. Only 24% of the mothers exclusively breastfed. Adjusting for infants age and who attended delivery, the risk of not exclusively breastfeeding was 14.0 times greater for women who had returned to work than for women who had not. Exclusively breastfeeding mothers (n = 4) who worked differed from other mothers in important ways. They all felt they had enough milk, all knew the appropriate time to introduce foods and liquids, and most were supported in their breastfeeding decisions by commune health workers and family members. This research suggests strategies that can be implemented now to increase exclusive breastfeeding in rural work environments. These include improving knowledge about the introduction of water and semi-solids, addressing perceptions of milk insufficiency, securing support from others, and presenting mothers with options for exclusively breastfeeding, even when they work outside the home.

Caregiver Styles of Feeding and Child Acceptance of Food in Rural Viet Nam

Style of child feeding may be an important determinant of child nutrition and health outcomes. Responsive feeding refers to the level and kind of interaction between caregiver and child that lead to a positive feeding experience, adequate dietary intake, and enhanced developmental opportunities. Responsive feeding behaviors may include active physical help and verbalization during feeding, role-playing, persistence, and positive feeding strategies. The aim of this study was to investigate styles of feeding among Vietnamese children 12 or 18 months of age from a rural province in northern Viet Nam. Forty child/mother pairs were videotaped during two, two-hour feeding episodes. Caregiver and child behaviors were coded at the level of the “intended bite” as observed through the videotape analysis of feeding episodes to assess caregiver behavior and the childs interest and acceptance of food. We found it feasible to use videotape and the modified coding and analysis scheme, originally developed for work in Peru, in Viet Nam. In Viet Nam, caregivers provided physical help to eat nearly all of the time in the younger children, and about 70% of the time among 18 month olds. Caregivers verbalized during only 30% of intended bites, and only half of these verbalizations were responsive in tone or words. Positive caregiver behaviors were significantly associated with higher childs acceptance of food, while non-responsive feeding behaviors were associated with child rejection of food. Future analyses of this data set will evaluate the degree to which an integrated nutrition program positively modified caretaker behaviors. More research is needed to demonstrate the relationships among the promotion of responsive feeding behaviors, acceptance of food, and improved nutrition and health status of children.

An Integrated Child Nutrition Intervention Improved Growth of Younger, More Malnourished Children in Northern Viet Nam

Integrated nutrition programs are widely used to prevent and/or reverse childhood malnutrition, but rarely rigorously evaluated. The impact of such a program on the physical growth of young rural Vietnamese children was measured. We randomized six communes to receive an integrated nutrition program implemented by Save the Children. We matched six communes to serve as controls. Our sample consisted of 238 children (n = 119 per group) who were 5 to 30 months old on entry. Between December 1999 and December 2000, we measured weight and height monthly for six months and again at month 12. Principle outcomes were weight-for-age Z score (WAZ), height-for-age Z score (HAZ), and weight-for-height Z score (WHZ), and the changes among these measures. As expected, anthropometric indicators relative to international references worsened as the children aged. Overall, children in the intervention communes who were exposed to the integrated nutrition program did not show statistically significant better growth than comparison children. Intervention children who were younger (15 months or less) and more malnourished (less than −2 Z) at baseline, however, deteriorated significantly less than their comparable counterparts. Between baseline and month four, for example, intervention children who were malnourished and less than 15 months old at entry lost on average 0.05 WAZ while similar comparison children lost 0.25 WAZ (p = .02). Lack of overall impact on growth may be due to a lower than expected prevalence of malnutrition at baseline and/or deworming of comparison children. Targeting nutrition interventions at very young children will have the maximum impact on growth.

Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam.

Few prospective studies of child growth and its determinants take place in programmatic contexts. We evaluated the effect of Save the Childrens (SC) community empowerment and nutrition program (CENP) on child growth, care, morbidity, empowerment, and behavioral determinants. This paper describes the research methods of this community-based study. We used a longitudinal, prospective, randomized design. We selected 12 impoverished communes with documented child malnutrition, three comparison, and three intervention communes in each of two districts in Phu Tho Province, west of Hanoi. SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP, including situation analysis, positive deviance (PD) inquiry, growth monitoring and promotion, nutrition education and rehabilitation program (NERP), deworming, and monitoring. PD inquiries aim to discover successful care practices in poor households that likely promote well-nourished children. NERPs are neighborhood-based, facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors. We dewormed all intervention and comparison children. We weighed all children less than 24 months of age living in the intervention and comparison communes and randomly selected 240 children (120 intervention and 120 comparison). We gathered information on nutritional status, diet, illness, care, behavioral determinants, empowerment, and program quality, monthly for six months with a re-survey at 12 months. We collected most information through maternal interview but also observed hygiene and program quality, and videotaped feedings at home. Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness.

Fatness and body mass index from birth to young adulthood in a rural Guatemalan population.

Body mass index (BMI; wt in kg/ht2 in m) has been proposed as a simple and valid measure for monitoring fatness. Using data from a 25-y longitudinal study of rural Guatemalans, we found that, as children, this population was stunted (mean height-for-age z = -2.6) and had low triceps skinfold thicknesses ( approximately 10% of reference medians), yet had mean BMIs above US reference medians. As young adults, mean BMIs were at the 50th and 20th percentiles for women and men, respectively. BMIs between ages 1 and 5 y were moderately correlated (r = 0.2-0.3) with those in young adulthood. BMI was correlated with subscapular (r = 0.5-0.8) and triceps (r = 0.2-0.7) skinfold thicknesses at all ages and with predicted percentage body fat in adolescence (r = 0.65) and adulthood (r = 0.8). Fatness was highly centralized, with ratios of subscapular to triceps skinfold thicknesses at the 50th-90th percentiles of reference medians at all ages. BMI was a poor indicator of central fat; the correlation between BMI and waist-to-hip ratio in 14-17-y-old males was -0.21). In stunted populations in developing countries, BMI alone should be interpreted with caution. In stunted children, BMIs may be high despite small extremity skinfold thicknesses; BMI alone may overestimate the prevalence of fatness in these children. In adults, measures in addition to BMI may be required to identify centralized adiposity in these populations.

Early childhood determinants of age at menarche in rural guatemala

The influence of early childhood determinants on age at menarche was investigated in a sample of Guatemalan women who participated as children in a nutrition intervention study conducted from 1969 to 1977. Age at menarche was retrospectively estimated in 1991 and 1992. Mean age at menarche was 13.7 (±1.3) years. Data on linear growth, diarrhea and respiratory illnesses, and energy intake from supplementation as well as home sources were available between birth and 7 years of age. Socioeconomic status (SES) data were collected in 1975. Four hundred and ninety‐seven women who had reached menarche by 1992 were grouped into three categories of stunting based on their height‐for‐age z‐scores (none, >−2.0; moderate, −2.0 SD to −3.0 SD; severe, <−3.0 SD relative to National Center for Health Statistics reference data) at 3 years of age. About 78% of the sample was moderately or severely stunted at 3 years of age. The group that was severely stunted in childhood reached menarche at 14.1 ± 1.4 years, significantly later than those who were moderately stunted (13.7 ± 1.2 years) or not stunted (13.5 ± 1.3 years). Using multiple linear regression methods, stunting was a significant predictor of age at menarche. Average energy intake (kcal/d) from home diet was associated with earlier menarche independent of preschool growth status. Percent time ill with diarrhea was positively associated with age at menarche. When the effects of diet, supplement, percent time ill with diarrhea and respiratory illnesses, and SES were taken into account, the independent influence of stunting on age at menarche persisted and remained significant.

The positive deviance approach: Challenges and opportunities for the future

The positive deviance (PD) approach offers an alternative to needs-based approaches for development. The “traditional” application of the PD approach for childhood malnutrition involves studying children who grow well despite adversity, identifying uncommon, model practices among PD families, and designing an intervention to transfer these behaviors to the mothers of malnourished children. A common intervention for child malnutrition, the so-called “hearth,” brings mothers together to practice new feeding and caring behaviors under the encouragement of a village volunteer. Hearths probably work because they modify unmeasured behavioral determinants and unmonitored behaviors, which, in turn, result in better child growth. Some health outcomes require a better understanding of behavioral determinants and are not best served by hearth-like facilitated group skills-building. We propose testing “booster PD inquiries” during implementation to confirm behavioral determinants and efficiently focus interventions. We share early experience with the PD approach for HIV/AIDS and food security. The attributable benefit of the PD approach within a program has not been quantified, but we suspect that it is a catalyst that accelerates change through the processes of community attention getting, awareness raising, problem-solving, motivating for behavior change, advocacy, and actual adopting new behaviors. Program-learners should consider identifying and explicitly attempting to modify the determinants of critical behavior(s), even if the desired outcome is a change in health status that depends on multiple behaviors; measure and maintain program quality, especially at scale; and creatively expand and test additional roles for PD within a given program.

Predictive factors of enrollment and adherence in a breast cancer screening program in Barcelona (Spain).

This paper study the predictive factors associated to enrollment and adherence in a breast cancer screening program in Barcelona, Spain; the Program is targeted to women 50-70 years of age who are members of a Health Maintenance Organization. Data were collected by personal interview for the attending women and by telephone in the non-attending group. The questionnaire was focused on knowledge, attitudes and practices related to female cancer prevention and breast cancer risk factors. Data analysis consisted of bivariate and multivariate analysis. Enrolling in a breast cancer screening program was strongly associated with practices related to cancer prevention in the bivariate analysis. Having had a previous mammography was the only behavioral factor that showed an independent relationship with enrollment (OR = 6.45, 95% CI = 3.35-12.42) in the multivariate analysis together with being younger than 55 and having family history of cancer. Adherence was associated with having the best opinion of the program, knowing the preventive role of mammography and performing regular breast self-examination in the bivariate analysis; of these, knowing the preventive role of mammography (OR = 2.66, 95% CI = 1.14-6.18) and performing regular breast self-examination (OR = 1.99, 95% CI = 1.23-3.23) were independently associated in the multivariated analysis. Being a relative of a municipal worker and younger than 55 were also significantly associated with adherence. Getting women to participate in a breast cancer screening program is difficult--mailed invitation letters are not sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)