Intervention Effectiveness for Anemia in Children

improve communication skills and improve maternal child feeding practices, reducing the rate of growth retardation in children aged 6-24 months [137]. The results of the study in Pakistan showed that communication skills and counseling activities of health workers were significantly better in the intervention group than in the control group. Mothers' child feeding practices were also significantly better in the intervention group than in the control group after 180 days of intervention. The growth rate of children in the intervention group increased, with the greatest effect observed in children aged 12 months and older [137]. Thus, the nutrition counseling intervention had the most positive impact on the height and weight growth of children aged 12 months and older. The results of this study are similar to the results of a study evaluating the effectiveness of the GDDD and agricultural participation project on child growth in northern Malawi [82]. After 6 years of intervention, results showed improvements in WAZ values of children in villages that actively participated in this project and the village that participated the longest [82]. A study evaluating the effectiveness of a community-based intervention to improve nutritional status in young children in Senegal [92] also found a significant reduction in the risk of malnutrition in children. The odds ratio (OR) for malnutrition in the intervention village was 0.83 (95% CI: 0.68; -1.00) [92].

Compared with studies in Vietnam, the results of this study are similar. Tran Thanh Do and colleagues evaluated the trend of change in the average z-score of anthropometric indicators in TTDD surveys in children in Vietnam from 2003 to 2011. The results showed that in the period from 2003 to 2011, the average z-score of WAZ continuously increased at a rate of 0.048 z-score/year and the z-score of HAZ also increased at a rate of 0.049Z-score/year. Thus, the average z-score value in CTTT commune in this study was higher than that of the above national survey. This difference is due to the effectiveness of the intervention and the age of the intervention subjects under 24 months. The target children in the national assessment of malnutrition are children under 5 years old and include all different ecological regions, including mountainous areas where malnutrition rates are quite high, so the growth z-score value will be lower [10].

The mean z-score values of children in this study were also higher than the mean z-score values of children under 24 months of age in Yen Bai.

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In Yen Bai, there was an 18-month GDDD intervention. The average WAZ values of children under 24 months increased from (-1.52 ± 1.20) to (-1.32 ± 1.05), the average HAZ value increased from (-1.77 ± 1.47) to (-1.52 ± 1.30) [4]. The study by Phou Sophan and colleagues also showed similar results with a 12-month small-group GDDD intervention in Bac Can. The WAZ value increased higher in the intervention communes than in the control communes at the SCT times of 4 months, 8 months and 12 months, and the HAZ value was higher than in the control commune at the SCT time of 4 months [51]. A controlled clinical trial by Nguyen Thanh Ha and colleagues in Bac Ninh with zinc and sprinkles (multi-micronutrient) supplementation for children with stunted malnutrition, after 6 months of intervention, the z-score values of WAZ, HAZ, WHZ all increased significantly in the intervention groups compared to the control group [16]. Direct zinc and multi-micronutrient supplementation for children with stunted malnutrition was clearly effective in all intervention groups and positively changed the children's nutritional status, showing an increase in all z-score values and anemia status after only 6 months of intervention. Other multi-micronutrient supplementation interventions also had positive effects on growth and nutritional status, and diseases of children from 6 to 24 months of age [30].

Thus, similar to direct interventions, indirect interventions on nutrition education through a diverse communication model at the grassroots level have impacted on changing children's z-scores through mothers' correct practices on infant feeding. Children with more complete and diverse KPA have improved their nutritional status. In fact, there have been studies showing a relationship between food groups consumed and children's nutritional status [75]

4.3.3. Effectiveness of intervention with anemia in children

Before the intervention, CTNT commune had the highest rate of anemia among the three study communes. The anemia rate in CTTT commune and the control commune was not different. SCT, the anemia status of children decreased in all three communes. In CTTT commune, the anemia rate decreased from 28.4% to 19.7%. In CTNT commune, the anemia rate decreased from 44.9% to 25% with statistical significance. In the control commune, the anemia rate decreased but was not statistically significant. The intervention effect in CTNT commune was 30.7%, higher than that in CTTT commune by 16.9%. Similarly, SCT, the average Hb concentration of children in CTNT commune increased compared to before the intervention.

intervention. The change in the mean Hb concentration of children in CTTT commune was not statistically significant. Thus, in places with high anemia rates, the mean Hb concentration is lower, and the intervention will be more effective.

The results of this study are similar to those of previous studies. Interventions that directly supplement iron for at-risk subjects, supplement iron in food, or supplement iron tablets combined with GDDD, or GDDD alone for mothers have been shown to be very effective in reducing anemia in children in many studies [9], [25], [39], [115]. Research in Indonesia showed a relationship between consumption of iron-fortified milk and reduced anemia in children aged 6-59 months [115]. Tu Ngu and colleagues conducted a 12-month intervention with 2 groups. One group received support for fortified powder (product of nutrifood company) of milk powder, egg powder, carrot powder, (60 g/day), one group received support to buy natural foods 2,400 VND/day to buy food and both groups were educated about ABS. The rate of anemia decreased by 10% in the natural diet group and by 20% in the fortified powder supplement group [44].

The results of this study are similar to the results of the study by Ho Thu Mai and Le Bach Mai with the intervention of supplementing Ferlin (Iron and vitamins) for the group of children aged 6-23 months over a period of 3 months, reducing the rate of anemia in children from 64.1% to 9.4%, the average Hb concentration increased from (9.7 ± 0.8) to (9.9 ± 0.7). The HQCT with anemia in children is 58.2% [40]. This shows that the anemia of children will be improved very quickly and effectively when the amount of iron and vitamins is supplemented regularly from the outside. GDDD for mothers indirectly increases iron and vitamins through the use of iron-rich foods, diversifying foods in children's diets also reduces anemia. Therefore, education on anemia prevention, using iron-rich foods, and diversifying foods are also very effective measures to prevent anemia in children. The results of this study are similar to Pham Hoang Hung's study, which actively intervened in propaganda to effectively diversify meals. After 18 months, the average Hb concentration of children under 24 months of age increased from (10.5 ± 1.1) to (11.7 ± 1.0).

The rate of anemia decreased from 55% to 23.3%, the intervention efficiency of 53.2% was higher than the results of this study [25]. This difference may be due to the longer intervention time of Pham Hoang Hung. Dinh Dao's study in Quang Nam with GDDD intervention based on prestigious dignitaries in the community for 12 months. The target group was ethnic minority children under 5 years old, also showed a reduction in anemia rate of 15.5% after intervention, HQCT=17.8% [9].

The diversified communication model at the grassroots level has been effective in reducing anemia in children. When implementing communication interventions, factors affecting malnutrition and anemia in children in the study area were used to develop communication messages for mothers and the community. Messages on using diverse foods and preventing anemia in children were conveyed to diabetic groups. Encouraging mothers with children over 6 months old to use milk and milk products was also enhanced. The study results suggest that priority should be given to interventions in the field of anemia prevention because the rate of anemia in children is high and the HQCT is high, especially in rural areas.

4.4. Ability to apply diverse communication models

A diverse communication model at the grassroots level has been established. Staff directly involved in the program have been fully trained in counseling skills, knowledge of IDD and communication planning. They have had the opportunity to develop their abilities through self-planning of communication. The intervention model has specific targets, clear content of activities, and combines diverse and flexible forms of communication.

Direct communication combined with indirect communication has increased the comprehensiveness of communication activities. Communication activities include individual counseling, group counseling, group propaganda in villages and residential groups, combined with other activities of the Women's Union, the People's Committee of the commune and the health station. The diverse communication model at the grassroots level can be considered as the initial place to communicate the most updated knowledge about IDD to a large number of generations of mothers in the locality.

Interviewees such as leaders of the health center, representatives of the commune People's Committee, the Women's Union, health workers, collaborators and mothers all gave positive assessments of the content and effectiveness of the intervention. Most mothers were satisfied with the consulting services and propaganda activities in the community. The model has been building a brand for the community.

After one year of operation, the communication model has increased mothers' access to information on NDTN, increased mothers' knowledge and skills, contributed to changing old habits and gradually creating new standards in NDTN in the locality. The intervention has indirectly improved NDTN and reduced the rate of anemia in children.

The communication model has supported and enhanced the effectiveness of the local PCSDD program and is sustainable. The model can be integrated into other local health care programs. The cost of communication operations can be included in the budget such as the national target program budget or from local funds approved by the Provincial People's Committee. Even moving towards collecting fees for maternal counseling services. The model has the potential to be applied and replicated in the intervention area.

CONCLUDE

1. Malnutrition status and related factors in children aged 0-36 months in study communes of Khanh Hoa province in 2011.

- Malnutrition among children aged 0-36 months in the study communes of the coastal plain districts of Khanh Hoa province is low with the following rates: underweight 10.1%, stunting 18.4%, wasting 3.6% and obesity 2.6%. Factors related to underweight malnutrition in children include poor child feeding practices, low birth weight and early complementary feeding. Factors related to stunting malnutrition: Poor child feeding practices, low birth weight, early complementary feeding, low per capita food expenditure, mothers with more than 2 children, children attending kindergartens and children not using milk & milk products in the past 24 hours. Factors related to wasting malnutrition: Poor child feeding practices, low birth weight.

- The rate of anemia in children aged 6-36 months in the community is at an average level of 37.9%. Of which, the rate of mild anemia is 23.2%, moderate anemia is 14.7%. There are two factors related to anemia in children including inadequate food diversity and children not consuming milk & milk products in the past 24 hours.

2. Building and implementing a diverse communication model at the grassroots health level in preventing child malnutrition

- Characteristics of the model: The model has been established with an organizational system and network of activities from the province to the commune. The main target audience of the model is pregnant women in the last 3 months and mothers with young children. The model uses a combination of both direct and indirect communication and diversifies communication channels. The child care consultation room with the brand name Mat Troi Be Tho located at the health station is one of the main components of the model.

- Activities and factors that play an important role in the model: Professional training and communication skills for target groups participating in program implementation, professional guidance documents for 3 target groups of consulting room managers, medical staff implementing communication and collaborators have been compiled, diverse and available communication documents. More than 20 types of communication documents have been produced with diverse forms and types. The key activity of the model is group counseling at PTV combined with indirect communication measures implemented at all 3 levels of province, district and commune.

- Main results achieved: After one year of implementation, the process indicators achieved the set targets in both intervention communes. Collaborators increased household access in intervention communes more than in control communes. The access rate in urban intervention communes increased from 27.4% to 61.1%, and in rural intervention communes increased from 18.9% to 56.7%. Information coverage in intervention communes increased more than in control communes.

3. Evaluate the effectiveness and applicability of the model

3.1. The multi-media communication model at the primary health care level has effectively improved mothers' knowledge and practices of infant feeding.

After 12 months of knowledge intervention, the child feeding practices of mothers in the two intervention communes improved better than those in the control commune. The rate of mothers with knowledge in the urban intervention commune increased from 31.9% to 78.1%, in the rural intervention commune increased from 29.6% to 62.2%; in the control commune increased from 34.1% to 53.3%. The rate of mothers with practice in the urban intervention commune increased from 69.4% to 89.3%, in the rural intervention commune increased from 56.3% to 75.6%, and in the control commune increased from 66.7% to 70.7%.

3.2. The model has had initial effectiveness in improving children's nutritional status and anemia after one year of intervention.

- The mean z-score values of children aged 0-36 months in the intervention communes increased when compared to the control commune. In the urban intervention commune, the mean z-score value of weight-for-age (WAZ) increased from (-0.65 ± 1.08) to (-0.44 ±

1.03), the mean z-score of height-for-age (HAZ) increased from ( -1.01 ± 1.1 ); to ( -0.59 ± 1.18). In the rural intervention commune, the mean z-score of height-for-age (HAZ) increased from (-1.12 ± 1.10); to (-0.85 ± 1.04). The mean z-score values of weight-for-age (WAZ) and weight-for-height (WHZ) did not change statistically significantly.

- After the intervention, the rate of anemia in children decreased more in the two intervention communes than in the control commune. The rate of anemia decreased from 28.4% to 19.7% in the urban intervention commune and from 44.9% to 25% in the rural intervention commune, and from 40.3% to 34.8% in the control commune. The average Hb concentration increased in the rural intervention commune from (10.9 g/dl ± 1.1 g/dl) to (11.4 g/dl ± 0.89 g/dl), but did not increase in the urban intervention commune.

3.3. Ability to apply diverse communication models at primary health care facilities

- Overall, the coverage of the model is relatively good, but the coverage of the counseling room alone is not high after one year of operation. The coverage of PTV for the PNMT group in the last 3 months is 48% in urban intervention communes and 45% in rural intervention communes. The coverage for the group of mothers with children from 0-23 months is 50.8% in urban intervention communes and 27.6% in rural intervention communes.

- Has been building the brand "Little Sun".

- Favorable environment for intervention activities. The intervention received the support of mothers, health workers and stakeholders. Intervention participants, local government leaders and mothers all assessed the need for a model at the grassroots health level to provide basic initial information to the majority of mothers.

- The model has been evaluated as effective, suitable for the locality and has the ability to be maintained. The model should be replicated in suburban and rural health stations with a large number of patients. The model is a good basis for implementing the national strategy on improving child nutrition.

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