Essay Title: 

epidemiology

April 3, 2016 | Author: | Posted in health and medicine

Research Critique

Introduction , Objectives and Hypothesis

The research study entitled Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children : a cluster-randomised controlled trial ‘ was designed and assessed by Mary Penny , Hilary Creed-Kanashiro , Rebecca Robert , M Narro , Laura Caulfield , and Robert Black . The was authored by known professionals from the Johns Hopkins School of Public Health and published by The Lancet , an international peer-reviewed journal specializing in medical issues and practices

The primary objective of the is to determine the potential benefit of [banner_entry_middle]

health-service educational intervention in improving the health and avoiding malnutrition and stunted growth among young children . The study also aims to determine the effectiveness of such intervention in eliminating or reducing morbidity caused by malnutrition . Other objectives are to raise the quality of health facilities and child-oriented programs and counseling not only in the said area but also to other similar locations

The study was conducted based on the hypothesis that improvement in nutrition education through the improvement of health facilities and services can reduce the prevalence of stunted growth in childhood and can lead to improved feeding practices of the caregivers which can help prevent malnutrition among young children . Relatively , there may be available resources and sufficient food in particular areas but caregivers and parents lack knowledge or has cultural beliefs that hinder them in providing adequate nutrition to their children , thus appropriate advice and educational interventions are essential . Such hypotheses are referenced with earlier studies such as the ones conducted by Allen and Gillespie in 2001 , by Caulfield et al in 1999 and by Gulden et al in 2000

Method and Research Design

The study was conducted in an urban area specifically in shanty areas of Trujillo , a city in Peru . The population in the target location is characterized by low incomes , poor housing and lack access to essential services such as sewage disposal , electricity supply and water system However , the area has access to nutritional and adequate food as well as to health facilities provided by its government . The area was chosen due to anemia and growth faltering problems in the said area that resulted to stunted growth among children

The intervention was conducted by becoming a part of the existing children-oriented programs of the regional health authority . It was approved by particular health authorities of the country which also participated and assisted in conducting the study

Samples involved in the study are of two types : the participating health facilities and the participating children aged 0- 18 months . Children samples were gathered by identifying pregnant women through house to house census . There were 791 pregnant women identified in the area and when their babies were born they were invited to participate in the study but only 377 make it to the enrolment due to the sample size requirement . Babies with congenital malformations and those with disease which can effect the growth of the baby were also excluded from the sample . This 377 were divided into two groups : the intervention group or those who attended facilities with nutritional counseling intervention and the control group or those who attended facilities which continued providing routine health services . The caregivers of the samples were interviewed and visited at regular intervals until the children reached 18 months . They were also provided nutritional counseling such as food preparation demonstrations , messages about what nutritional foods that should be given to their children at particular ages , and recommended the dietary intake by suggesting the type of foods that should be included in the children ‘s diet

Basically , the intervention wanted to enhance the existing programs and practices of the health facilities in the target area , thus those facilities with the same characteristics were chosen . Such facilities include health centers with available medical staff always on duty community hospitals which offer maternal and perinatal service , and health posts with more limited services . All in all there were twelve facilities involved in the study six for the intervention group and six for the control group . These six facilities include : one community hospital , three health posts , and two health centers . Health facilities were paired to the population depending on services offered . The intervention did not include training of the medical staff and health facilitator because according to the author , it would be better to integrate the intervention to the existing programs of the facilities which can be always implemented rather than educating the staff that might leave the facilities in the near future

The research study involved 377 samples : 187 infants for the intervention group and 190 from control areas . From this , it can be viewed that the design of the study is randomized and comparative . That is , data obtained from the intervention group are compared and contrasted from the data from the control group or for those who utilized health facilities which were not given educational interventions . The design of the study has been effective in determining the effects of educational interventions by identifying the differences between the two group samples . Through comparisons , the advantages of having educational interventions in health facilities were easily identified . Systematic bias was also minimized by standardizing data collection while interviews were structured in such a way that interviewees did not get to always interview the same samples . The sample size seems to be enough for the research study although the study alone is not enough to generally conclude that educational interventions generates positive effect in all cities or countries similar with similar characteristics with that of Trujillio or Peru . This is because health facilities and the services offered they offered as well as the programs and practices being implemented differ from one location to another

Measurements

The study aims to help eliminate growth stunt among young children thus the primary outcome of the study was growth which was measured by weight , length and Z scores for weight-for-age and length-for-age at age 18 months (Penny et al , 2005

. 1865 . Fieldworkers who were trained and standardized according to the WHO guidelines measured the weight of the children at each visit using clock balances accurate to 100 grams while length was measured using stadiometers accurate to 0 .1 cm (p . 1865 Length -for-age and weight-for-age outcomes helped determine if children suffer from malnutrition by comparing the measured data to the standard height and weight of Peruvian children at specific ages . Such measurement also determined the differences between the length-for-age and weight-for age of children in the intervention and control groups to identify which among the children have taken enough nutrients that will help them achieve the length and weight appropriate for their age

To be able to identify the differences between the two study groups , the secondary research method used to gather data was interview . During the interview , questions asked were more on the feeding practices to determine the awareness of the proper feeding practices that should be practiced . Questions include (1 ) what foods or liquids does a baby need for the first months (2 ) how can a mother have more breast milk (3 what do you do if the child has collie or gases (4 ) name three foods that you think are the best for infant 7 to 8 months old (5 ) when you give the main meal to a child , what is the food you give first and (6 what would you do if the child does not want to eat (p . 1867 . The same questions were asked at different intervals to both the intervention and control groups . Data needed here are the number of correct answers to determine how the caregivers have learned from the educational intervention . As expected , there were more correct answers from the intervention group than the control group by the end of the study period

Through the interview , important information such as the family composition and the socioeconomic condition of the family and other information that have significance on the feeding practices . A standardized , structured-observation technique was also used to properly assess home hygiene of the family visited that may affect food preparation of the caregivers . Trained nutritionists were also part of the interview procedure . They estimated dietary intakes of the participants using quantitative 24-h recall . A 24-h recall is a method of measuring the dietary intake of an individual through an interview requiring the participant to recall and report the food taken during the past 24 hours (Trabulsi Schoeller , 2001

.E892 . The 24-h recall is commonly utilized in large population studies and can provide detailed information about foods consumed . Such details include the weight sizes , portion and ingredients of the meal served to children which have significance on the amount of nutrients taken by the children and can also be used to analyze the feeding practices of the caregivers . These data were used and compared to the recommended daily intake for children ate specific ages

Generally , the procedures used by the study are appropriate and reliable . First , interviews can be the best method on gathering data to be measured and analyzed as dictated by the research design of the study . Direct contact and communication on the samples is the easiest way to gather data and to evaluate the conditions of the sample Secondly , measuring the weight and the length of the children is the only way to obtain necessary data important in evaluating and comparing the growth of the participants at specific intervals . Lastly , the 24-h recall is appropriate for large population studies like this study and it was easy to use even if the respondents are not very educated However , 24-h recall can be subjected to bias reporting . That is , the respondents may not provide very accurate information but a good estimate of the trained nutritionists can already addressed such bias

Results and Findings

Using the above mentioned measurements , results obtained led to the determination of the following information (1 ) growth changes of children in both the intervention and control groups (which group has the lesser number of children with stunted growth and (2 ) knowledge obtained by participating caregivers from the intervention (did the caregivers ‘ showed desirable feeding practices resulting to adequate energy and nutrient intake

All the data needed to provide reliable and convincing conclusion were presented in the study using graphs , figures and tables . Individual data about each participant such as length , weight and feeding practices do not need to be included in the report . Only the summary and evaluated data are included . For example , the answers of caregivers to the questions during the interview were summarized in table 2 while the length-for-age and weight-for-age data can be easily found and analyzed using figure 3

For the primary outcomes which should be the child growth during the 18 month period were calculated for 95 CI and bodily measures were converted to z scores using reference values to obtain the mean weight mean height , mean z scores weight , mean z score length and other data for both the intervention and control . Results for the two groups were compared by calculating their differences both adjusted and adjusted as shown in table 4 . It was found out that there are lesser children who experienced stunting growth at 18 months in the intervention group than in the control group . Data were also analyzed using the SPSS version 10 Socioeconomic data obtained from visiting the participants were analyzed using the principal-component analysis , resulting to identification of three clusters of associated variables : housing , possessions , and educational level of parents (Penny et al , 2005 ,

. 1865

Data in table 4 are also discussed and can be supported by data about the energy and nutrient intakes from complementary foods shown in figure 2 which were obtained using the 24-h recall method . Food intakes obtained from the 24-h recall were converted to nutrient using the Peruvian food-composition tables . Figure 2 shows that dietary energy and dietary zinc intake from complementary foods and animal source were significantly higher for the intervention group compared to that of the control group . These results mean that , averagely , children in the intervention group receive more energy and nutrients than the children in the control groups . Relatively , nutrient intake is very important for children growth , which may explain why there are more children with stunted growth in the control group than in the intervention group . The study also found out that there were more caregivers who have been including energy giving food to their children ‘s meal aside from breastfeeding and thick preparations due to the nutritional advice they received from health centers as early as after giving birth as shown in table 3 . This reflects that there were more caregivers who have been educated and consequently applied what they learned from the intervention

The results and findings have proven that the authors ‘ hypothesis that educational intervention can lead to minimized stunting growth among children . The hypothesis that the intervention can also lead to better age-specific feeding practices and nutrient intake were also proven by the research study . The study used graphs and tables whenever appropriate . There were about nine graphs and tables in the report which were very helpful in interpretation and understanding of data . However there are data that would be very hard to be understood by non-medical individuals therefore , the results and findings of the study can be best interpreted and used in further studies by medical practitioners medical students , nurses and nutritionists

Conclusions and Implications

The conclusions and implications of the study were covered in the discussion section of the report . The study successfully achieved its objectives which are to show that effectiveness of educational intervention at health facilities and to identify the benefits of such interventions . The authors based their conclusions primarily on the findings and results of the research study itself and secondary on the two other similar studies conducted in China and India . According to the authors themselves , the strength of the study is mainly its randomized design that reduced intervention contamination and sufficient sample size powerful enough to test the hypothesis (p . 1870

The authors also acknowledged the weakness of their research study That is , the study might have some bias that may be obtained from dietary-recall data using 24-h recall but have no significant effect on the weight and height measurements which are considered to the primary outcomes of the study . Limitation of the study was also acknowledged which were the socioeconomic differences between families in the intervention and control groups that could have affected the growth outcomes . However , the authors indicated that they developed and used a predefined analysis plan and have adjusted the differences in growth between the two groups in the multivariate analysis to address the identified limitation . The authors suggest that further studies should be conducted to be able to determine and evaluate the sustainability and the generalizability of the intervention strategy to Peru or to other developing countries

Summary Critique

The article can be best analyzed by identifying its strengths and weaknesses . One of the strong points of the article is having completely described the hypotheses of the research as well as the methodology sample , statistical analysis , discussions , and limitations reflecting that the research is highly organized . The authors also have provided a straightforward of what they are trying to accomplish in their research . The title of the research alone strongly suggests right ahead what the research study was about

Another strong point of the article is its introduction . The introduction very well justified the importance of the study . The s of past studies like the studies mentioned are a very effective way of introducing the . Such introduction suggests that the study has relevance on past research thus important to be conducted However , the method , as well as the results is very technical in nature aside from being two wordy that only medical professionals will find it interesting and informational although the study is also important on non-medical professionals like pregnant women , lactating mother and caregivers

The research also uses related research studies as references from reputable medical and nutrition journals : articles from the World Health Organization , Food Nutrition Bulletin , Journal of Nutrition , the Lancet American Journal of Clinical Nutrition , JAMA , and others . The use of such reputable references makes the study reliable and comprehensive . It is also noticeable that although the authors are medical professionals themselves , any claims they make have strong theoretical basis and are referenced to earlier studies . Additionally , the statistical method used is appropriate with a comparative study like this . The statistical data in the table shows important variables that are directly related to the objective of the study . All data in the table are discussed and explained no irrelevant data is provided in the study

The authors did not provide a separate part for their conclusion but as the discussion is read , it is noticeable that their conclusions are already included in the discussion of the findings , which only means that the conclusions are appropriate for the study . The discussion of the results is also backed up by references to make the explanation of the findings more reliable . The authors acknowledge the limitations and weaknesses of the study . However , the limitation statement is confusing because it stated its limitation but also added a statement that insinuating that the study ‘s limitation was already solved

Nevertheless , the study was carried out effectively , with some weaknesses that did not affect the effectiveness and importance of the research . The discussion is logically ed , making the study a good a reference for future studies

References

Penny , M , Kanashiro , H , Robert , R , Narro , M , Caulfield , L . and Black , Robert (2005

Effectiveness of an educational intervention delivered through the health services

to improve nutrition in young children : a cluster-randomised controlled trial

The Lancet Volume 365 , 1863-72

Trabulsi , Jillian and Schoeller , Dale (2001 ) Evaluation of dietary assessment instruments

against doubly labeled water , a biomarker of habitual energy intake

Am J Physiol Endocrinol Metab 281 : E891-E899 … [banner_entry_footer]

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