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Evaluating the Knowledge, Attitude and Practice of Rural Guatemalan Healthcare Providers Regarding Chronic Malnutrition in Children

Hammond, Tiffany Janelle (2014)
Master's Thesis (68 pages)
Committee Chair / Thesis Adviser: Martorell, Reynaldo
Committee Members: Addo, O Yaw
Research Fields: Health Sciences, Public Health; Health Sciences, Nutrition
Partnering Agencies: US (Federal) agency other than CDC ; International Non-governmental organization (e.g., CARE, Inc.)
Keywords: Guatemala; chronic malnutrition; healthcare providers; knowledge; practice; knowledge, attitude and practice; baseline evaluation; health care workers
Program: Rollins School of Public Health, Hubert Department of Global Health
Permanent url: http://pid.emory.edu/ark:/25593/g106c

Abstract

Background: At 49%, Guatemala has the 6th highest prevalence of chronic malnutrition in children under five worldwide. Poor nutrition and recurrent infections during the 1000 days between conception and two years of age impair brain development and cause stunting. Although stunting has a lower risk of mortality than acute malnutrition, it cannot be treated once established in early childhood. Despite extensive research on the nature of stunting, few studies evaluate how providers transmit knowledge about nutrition to mothers during consultations.

Objectives: The study 1) evaluated rural Guatemalan healthcare providers' ability to compare chronic and acute malnutrition during the 1000 day window and beyond, 2) determined if provider knowledge differed by state, profession, type of health facility or years of experience and 3) assessed in what context and how accurately providers discussed nutrition during their contact with mothers in the 1000 days window.

Methods: This mixed-methods baseline evaluation was based on convenience sampling. The study involved 122 auxiliary nurses, educators and professional nurses at the primary level of care in a cross-sectional survey and structured observations. Providers received a composite score for a 29 question survey that evaluated their knowledge about the causes, characteristics and consequences of stunting. They were also observed during nutrition consultations using a checklist of essential growth monitoring and counseling activities.

Results: The survey and observations suggest that providers lack a basic understanding of stunting within the 1000 days window.Most providers were unable to differentiate between chronic and acute malnutrition and more than half failed to identify non-exclusive breastfeeding and late complementary feeding as fundamental causes of stunting. Survey scores ranged from 5 to 26 points with an average of 15 points (52%).

Discussion and Recommendations: Irrespective of a serious, collective lack of knowledge about the 1000 days window, some providers gave excellent nutrition consultations. This suggests that providers can give mothers useful advice about feeding techniques without understanding all aspects of stunting. Recommendations to state-level Ministry of Health officials emphasize carefully prioritizing only essential causes and characteristics of stunting in order to improve the quality of advice given during consultations.

Table of Contents

Table of Contents
Abstract iv
Acknowledgements vi
Table of Contents vii
Index of Tables x
Index of Figures xi
Index of Terms xii
1. Introduction 1
1.0 Overview of Malnutrition 1
1.0.1 Barriers to addressing chronic malnutrition 3
1.1 Guatemala's Current National Nutrition Plan 3
1.2 Problem Statement 4
1.3 Purpose Statement 5
1.4 Principal Research Questions 5
1.5 Significance Statement 6
2. Literature Review 7
2.0 Overview 7
2.1 Rational for a KAP Study of Rural Guatemalan Healthcare Providers 7
2.2 International Growth Standards and the 1000 Days Window 8
2.3 Global Burden of Acute and Chronic Malnutrition 8
2.4 Outcomes Due to Stunting 9
2.5 General Trends in Stunting in Guatemala 10
2.6 Platforms for Intervention Delivery 11
2.6.1 Maternal and child micronutrient supplementation 12
2.6.2 Breastfeeding 13
2.6.3 Complementary feeding (CF) 13
2.7 Conclusion 14
3. Methods 16
3.0 Overview 16
3.1 Study Design and Principal Outcomes 16
3.2 Population and Sample 16
3.2.1 Geographical location and site determination 16
3.2.2 Brief overview of healthcare facilities and units 17
3.2.3 Target population and recruitment 18
3.2.4 Sample size and sampling method 18
3.3 IRB and Ethical Considerations 18
3.4 Quantitative Instrument Design 19
3.5 Qualitative Instrument Design 23
3.6 Piloting 24
3.7 Data Collection Procedure 24
3.7.1 Data cleaning and management 25
3.8 Data Analyses 25
4. Results 27
4.0 Overview 27
4.1 Demographic Characteristics of Healthcare Providers 27
4.2 Survey Section I. Identifying the Physical Characteristics of Malnutrition: Stunting vs. Acutr 29
4.3 Survey Section II: Prioritizing the Causes of Stunting 30
4.4 Survey Section III: Pile Sorting to Differentiate Between Chronic and Acute Malnutrition 31
4.5 Average Sectional Score 32
4.6 Stratified Analysis 33
4.7 Structured Observations 35
4.8 Case Study 37
4.9 Provider's Approach to Nutrition During Sick Child or Prenatal Consultations 39
4.10 Summary of Results 40
5. Discussion, Recommendations & Conclusion 41
5.0 Overview 41
5.1 Discussion 41
5.2 Recommendations 44
5.3 Strengths and Limitations 47
5.4 Implications for Guatemala 48
5.5 Conclusion and Public Health Implications 49
References 50
Appendix 53
A. Three-part baseline survey 53
B. Demographic Information 55
C. Structured observation guide for providers and mothers 56

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