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Designing interventions for resource poor communities with low literacy: An example of an iron deficiency (ID) education program in Ghana. Abu BAZ 1 , Louw VJ 2 , Raubenheimer J 3 and Van den Berg VL 1 1 Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, Postal Box 339, Bloemfontein 9300, South Africa. 2 Division Clinical Hematology, Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Postal Box 339, Bloemfontein 9300, South Africa. 3 Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Postal Box 339, Bloemfontein 9300, South Africa. Acknowledgements: Government of Ghana Education Trust Fund (GetFund) for funding research. The staff of the Northern Regional Directorate, Tamale Metropolitan Health Directorate and the Tolon-Kumbungu District Directorates, research assistants, the community leaders, volunteers and participants. References: • Balachander J. 1991.The Tamil Nadu Integrated Nutrition Project, India. In; Jennings J, Gillespie S, Mason J, Lotfi M, and Scialfa T (eds), Managing Successful Nutrition Programmes, Report based on an ACC/SCN workshop, United Nations, Geneva. • GDHS (Ghana Demographic and Health Survey). 2008. Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research (NMIMR), and ORC Macro. Ghana Demographic and Health Survey 2007. Calverton, Maryland: GSS, NMIMR, and ORC Macro. Avaiable at http://www.measuredhs.com/pubs/pdf/FR221/FR221.pdf . acessed on 2nd August, 2011. • McLean E, Egli I, de Benoist B, Wojdyla D, Cogswell M. 2007. World-wide prevalence of anemia in pre-school aged children, pregnant women and non-pregnant women of reproductive age. In: Kraemer K, Zimmermann MB, editors. Nutritional Anemia. Sight and Life Press; Basel, Switzerland: 1–12. While more than half of the world’s anemic population lives in Asia, the highest prevalence for children (6-59 months), women of reproductive age and pregnant women, are recorded in Africa. Iron deficiency anemia (IDA) is the most common form of anemia, representing 50% of cases worldwide (Maclean et al., 2007). In Ghana, 78% of children and 59% of women are anemic (GDHS, 2008), with even higher prevalence in the Northern Region. Among Ghanaian women the highest prevalence of anemia is found among lactating mothers, women with children and women from rural populations (GDHS, 2008). Emphasis on Nutrition Education is likely to influence nutrition knowledge, attitudes and practices to such an extent that the need for intervention can be significantly reduced (Balachander, 1991). Nutrition education interventions are often used to address nutrition-related problems. In resource- poor populations with low literacy the success of such an intervention depends on keeping the messages simple, practical and affordable. INTRODUCTION An educational intervention can only succeed if the target population participates. In this intervention, messages were targeted at addressing the gaps in the community’s KAP regarding the prevention of ID, taking into consideration the resources, culture, and literacy of the community. Attendance of the intervention was high: 80.6% of the mothers attended all five days of the intervention, 9.7% attended 4 days and 9.8% attended 3 or fewer days Keeping messages simple, practical, innovative and targeted to the profile of the mothers of young children in this community contributed to attain high levels of participation in an educational intervention. CONCLUSION and RECOMMENDATIONS The study aimed to improve iron deficiency (ID) related knowledge, attitudes and practices (KAP) among mothers in northern Ghana., an area with very high prevalence of anemia The specific objective was to design a nutrition education intervention to address the KAP deficits regarding ID identified in a baseline survey among low literate mothers in Northern Ghana. AIM and OBJECTIVES The study was approved by the Institutional Review Boards (IRB) of Noguchi Memorial Institute of Medical Research (NMIMR) in Ghana (NMIMR-IRB CPN 064/11-12) and the Ethics Committee of the Faculty of Health Sciences, University of the Free State, South Africa (ECUFS NR 24/2012). ETHICAL CLEARANCE BASELINE FINDINGS ON AVAILABLE RESOURCES IN THE COMMUNITY: SOCIO-DEMOGRAPHIC DATA (N=161) 175 children within the ages of 6-59 months were included in the study. Mean age: 33.1±7.8 years , although 17 mothers (10.5%) did not know their age. Most were Muslim (98.2%) (1.8% Christian), married(97.5%), self-employed (84.5%) and had a median of 4 children. Mothers spent an average of 6.1 hours per day at work. HISTORY OF ANEMIA: About a third (27.5%) of the mothers reported that they had ever been diagnosed with anemia by a health professional ANTHROPOMETRIC DATA: Mean BMI of the mothers was 21.5±3.0 kg/m 2 17.2% of children were moderate-to-severely underweight 38.9% of children were moderate-to-severely wasted 47.3% of children were moderate-to-severely stunted FOOD PRODUCTION, FOOD SECURITY DATA Most households (57.1%) produced food only for their own consumption (38.9% sold ≤50% and only 3.9% sold more than 50% of the food they produce). Most households (95.7%) produced green leafy vegetables, but only in the rainy season. Most households (88.0%) kept animals: beef cattle (69%; 4.0 ± 10.1*), diary cattle (47.1%; 2.0± 9.8); sheep (71.6%; 5.0± 13.7; goats (74.1%; 3.5± 5.4) and chicken (61.6%; 6.0 ± 11.1). Less than half of the households (39.0%) owned fruit trees, mostly mango. 49.7% of households were food insecure; some of the reasons mothers gave for food insecurity included infertile land, erratic rainfall since they depend solely on rain-fed agriculture, the fact that they consume more than they harvest and also because their household sizes are large *median±SD per household RESULTS and DISCUSSION STUDY DESIGN AND SAMPLING: The baseline survey was conducted in April 2012 in the Northern Region situated in the central part of Ghana. This is the largest region in Ghana and consists of 20 districts. Two districts within the region were randomly selected and mothers who met the inclusion criteria were recruited from 161 randomly selected households from one community each from these two districts – 81 mothers from Tolon Kumbumgu district (intervention group) and 80 mothers from Tamale metropolis (control group). INCLUSION AND EXCLUSION CRITERIA: A mother was included in the study only if she: lived in the selected community for at least one year prior to the study; had one or more children aged 6-59 months at the time of the study; was not pregnant at the beginning of the study; and voluntarily agreed to be part of the study and signed an informed consent form. INTERVENTION: A 5 day (90 minutes/day) educational intervention, focused on KAP to prevent ID, was designed for the mothers in the intervention group. 10 key messages were designed to address the ten (10) themes on KAP related to ID which were identified during the baseline survey. The educational messages were designed to take into consideration the food resources available, reported food processing and preparation methods, and cultural and religious practices in the communities. Pictures, actual food samples and simple language was used. To keep participants interested and engaged, practical examples and food demonstrations were also incorporated. METHODOLOGY Acknowledgements and References FRAMEWORK OF THE ID-RELATED NUTRITION EDUCATION INTERVENTION This poster is being presented at the Micronutrient Forum, Global Conference 2-6 th June, 2014. Addis Ababa, Ethiopia. Theme Baseline findings Rationale Intervention Content Mode of delivery Content (Key messages) Mode of delivery 1. Sources and bioavailability of iron - MOST mothers had no formal schooling (91.9%). - According to the 24-hour recall, 11.1% of children and 10.1% of mothers consumed citrus fruit - Organ meat was only consumed occasionally: among mothers 78.2% consumed liver, 81.5% kidneys, and 81.5% heart only occasionally. - Fleshy meat was only consumed occasionally: among mothers 51.9% consumed beef, 70.1% lamb, 81.5 % goat meat and 78.2% chicken only occasionally. To help mothers appreciate the roles of fruit intake, organ and fleshy meat in ID prevention. Pictures of familiar and available foods will improve the mothers’ understanding since they are not formally educated. - Fruits contain vitamin C and sometimes A: Pawpaw, dawadawa - Vitamin C helps to make iron in food more available to the body. - Organ meat, fish and fleshy meat are good sources of iron. (Eat more meat, fish and fruits to increase access to available iron) Pictures: Fruits Pictures: Organ meat Pictures: Fleshy meat 2. Intake of tea and the timing of tea intake - According to the 24-hour recall, 56.6% of mothers and 54.6% of the children consumed tea. - While 85.1% of mothers approved of drinking tea with meals, 40% of mothers reported drinking tea during meals: - Those who drank tea in other situations were those who reported drinking tea only in the early morning. - Tea was observed to be brewed, which increases the release of tannins. - Just plain tea was given as a complementary food to the children. To sensitize the mothers to the ID risk associated with tea and the role of tannins in inhibiting iron absorption. To discourage drinking of tea with meals or as a complementary feed . Pictures will enable mothers to see how tea should be prepared for less tannin extraction. - Tea should not be brewed (the bag should be steeped in hot water and not boiled in water. - The same teabag should not be used extensively. - It is best to drink tea at least an hour before or after meals to prevent it’s interaction with food. -Tea does not contain a lot of nutrients so mothers should not use it as a complementary food. (Do not brew tea; allow time between tea intake and meals, to increase iron availability) Picture - Tea bags Picture - Tea bag steeping in hot water 3. The role of contraception and birth spacing in ID prevention - One mother reported using contraceptives (a hormonal drug, Depo provera) - During interactions with mothers, they reported they did not use contraceptives because they either did not like it, but most importantly because according them, in this polygamist society, a woman stopped “visiting her husband” when she delivers a child. - Another cultural practice where the mother goes to live with her family after delivery until the child is “walking”, also serves as a birth control method. To help the mothers appreciate the positive and negative effects of contraceptives with regard to ID. Pictures will enable mothers to see examples of contraceptives. The various types of contraception will be shown to mothers to identify. - Some pills have an iron containing coating and while using it, the woman has an advantage for both child spacing and improving of iron status. -The intra-uterine device (IUD) may cause heavy menstrual flow, which easily cause ID if mothers do not make it up with good food sources of iron. (Choose contraceptive with health person, and space children to reduce nutrient requirements) Picture: Coated pills Pictures: Types of contraceptives Samples of contraceptives 4. Prevention and treatment of malaria and other parasitic infections - 2% of mothers had malaria less than a week prior to the interview. - 40.8% of the mothers who reported having had malaria, used over the counter (OTC) drugs or herbal remedies (4.1%) as primary treatment. - 1.9% of children were reported to have diarrhea and 80.8% to have had fever within the two weeks prior to the interview. - 61.5% of mothers and 76.6% of children had not been de-wormed in the three months prior to the interview. - 50.0% of the mothers did not think that de-worming affects ID and a further 5.7% did know if it does. To teach hygiene practices and the importance of a clean environment; hand washing; not defecating in water sources; and improving the quality of water, and how these practices contributes to improved iron status. To teach practices to prevent parasitic infections: malaria and worm infestation Pictures will enable mothers see examples of a clean environment and hand washing. - When one has diarrhea, they go to the toilet shortly after any food is eaten. This reduces the time that the food should stay in the body. The body is less able to absorb iron and other nutrients - When one does not wash their hands with soap germs can cause diarrhea -Water that is not clean can also cause diarrhea or worms: Boil water from dam and others sources before drinking - Worms feed on the food that is eaten by the mother/child and also cause bleeding of the intestines. Together this can cause the iron levels in the body to reduce. - Sleep in treated nets to prevent mosquito bites and keep the environment clean to reduce mosquito breeding. (Prevent malaria, diarrhea and worms which can increase risk for ID) Picture: Hand washing with soap Picture: Clean environment Picture: Mosquito bites 5. Pica as a risk factor for ID - 1.9% of mothers reported having craved non-food substances: of these 66.7% craved clay, 22.3% craved soil and 3.1% indicated that they have had cravings for cola nuts. - Mothers of 9.0% of children reported that their children showed pica behaviour, 0.6% of them did not know if their children showed pica, while the rest indicated that their children showed no pica. - Of the children reported to show pica, 64.3% craved soil, (while 28.6% actually eats clay), 14.3% for dust, 7.1% for paper and 7.1% for chalk. - Pica practice in pregnancy was observed in 29.3% of the mothers. The foods craved were cola nut (7.8%), Bambara beans (3.9%) and raw rice (2.0%). - Geophagea was reported by 8.6% of the women who reported having practiced pica in pregnancy; actual soil intake was reported by 19.6% of them Pica practices can put one at risk for ID. The possibility of worm infestations from clay and soil or other raw foods, will further affect ID. Pictures will enable mothers identify the concept of risk of pica - Pica is the increased appetite for food and non- food substances. - Some of these foods may contain germs or disease causing agents, that lead to infections and worm infestations and consequently make the person iron deficient. -During pregnancy, mothers should find other foods to satisfy their cravings like fruits rather than clay, since the negative nutritional effect could also translate to the unborn child’s health. (Pica is a risk factor for ID) Picture: child eating soil Picture: worms in soil Picture: Processed clay 6. Pica as an indicator for ID - Asked why people display pica behaviour; 63.6% of the mothers said they did not know why people display pica, the rest indicated that the community sees people with pica as sick people (17.2%); that pica is not good for them (8.6%); or that it was their personal business (6.0%). - Though many see people who practice pica as sick people, 53% thought that pica cannot be treated. - Regarding children who practice pica, 49.2% of the mothers thought that a child should be beaten or scared into stopping. Pica may also be a sign of ID. To enable mothers associate pica practice with ID and not as a spiritual problem or a normal practice in pregnancy. Pictures will help mothers physical signs of ID including pica practice -When a person is iron deficient, they may have cravings to eat these foods or sometimes things that are not food. -When a child or a grown-up has an urge to eat these foods, one can suspect ID. -Soil or clay eating in children may be a sign of ID rather than just part of developing. -Apart from and together with signs like smooth (atrophied) tongue, sores at the corners of the mouth (angular stomatis) and spoon nails, pica is a good sign of ID being present. (Pica may be a sign of ID) Picture: Atrophied tongue Picture: Spoon finger nails Picture:Angular stomatistis Pica practice 7. Complementary feeding in ID risk areas - 58.9% of children were being breastfed at the time of interview. - 80.0% of children were reported to be exclusively breastfed - Only one child was never breastfed because “the mothers’ breast milk would not flow”), and in the place of breast milk, the child was given maize porridge. - 54.5% of children were introduced to liquid food between 4-6 months and 1.8% of them at younger than 2 months. - The 12.7% who introduced solid foods at 4- 6 months, prepared porridge from maize or millet usually without addition of other food types/soup/sauce. To help mothers identify good food choices to improve complementary feeding practices that will improve child iron status. Pictures will enable mothers identify good food choices and feeding practices for babies to prevent ID. -Like adults, the feeding of children is important for their growth and development. - Children also like variety and the variety will help meet most of the nutrient needs. -Since fish contains iron and also enhances the iron in the other food in a meal to be easily used by the body, it will help if mothers use them in baby’s meals -For children who are fed porridge, add pounded fish, beans and groundnuts to porridge to improve the nutrient quality. (Increase variety of food during complementary feeding and fortify with iron rich foods) Picture: Plate model 8. Other risk factors: home delivery and heavy menstruation - 91.8% of children were born at home, hence birth weight was not known. - 9.1% of mothers reporting having to change their pads during the night due to heavy menstruation. - 7.5% reported passing blood clots about 1cm diameter or bigger during menstruation To help mothers identify bleeding related to place of delivery and menstruation as risks for ID Discussions will enable mothers to identify these practices as risks for ID. -When a mother finds out she is pregnant it is advisable to report to the health center immediately to make sure she and the baby are not at any risk. -Subsequent visits to health care center not only help her know that all is wel,l but it also helps her to get interaction on how to manage her pregnancy, what to eat and how to initiate breastfeeding and maintain it until the child is 2 years. -It is equally important to deliver in the hospital since help is readily available in case of complications. (Report heavy bleeding and pregnancies to health facility; delivery in the health care center could save the lives of both mother and child) Illustrate key messages 9. Myths and misconceptions regarding causes and prevention of anemia FACTORS THAT MOTHERS BELIEVED TO CAUSE ANEMIA - Standing in the sun for long hours for long hours (69.4%) - Hard work can cause - Stress - Sickness (fever) FACTORS THAT MOTHERS BELIEVED TO PREVENT ANEMIA - Regular growth monitoring of children at clinic (88.8%) - Circumcision of baby boy (45.3%); many did not know (24.9%) - Shaving baby hair (38.0%); many did not know (37.3%) - Regular visit of mother to the clinic - Malt drink combined with milk FOODS MYTHS BELIEVED AMONG THE MOTHERS: - Only 7 mothers indicated that there were food totems for children and these include pork, cashew, fish, cowpea and eggs. - Fish and eggs are believed to cause a child to be a thief. - Cowpea is said to cause malaria in children but this was observed in only one participant. OTHER BELIEFS: - Anemia is God's will - Edema is a sign of anemia - Itching body is a sign of anemia To help mothers identify myths and truths on causes an pre- cautions related to ID. -There are faddisms about foods eaten as pica: eg the association of headache relief with cola nuts. -Food taboo’s or totems may be significant in ID prevention since -Cards will enable messages to be easily communicated -The list of regarding the causes of ID is addressed. - Mothers will be made to answer the “whys” and “hows” on the myth, thus why and how true they are to help deal with the untruths from the root. - The explorative nature of work will enable mothers to contribute to tehintervention. ID •Cuts/injury leading to blood loss can cause ID/anemia •Hard work does not cause ID/anemia •Stress does not causes ID/anemia •Regular visit alone to the clinic will not reduce anemia •Anemia is a disease condition not just God’s will. •Drinking tea with meals has an effect on iron uptake •Malta drink and milk does not prevent anemia •Drinking tea with meals has effect on iron •Cashew fruit-when taken with groundnut is not dangerous •Cowpea does not cause malaria •Fish, and eggs does not make child steal Pica •People who practice pica are not insane •Pregnancy or hormonal changes alone does not causes pica •Pica is not due to headaches •Ignoring cravings of pica may not treat it •Getting a substitute/ chewing stick may not treat pica •Pica may not stop after delivery •Beating /scaring the child to stop will not stop pica •Children will not stop pica when they grow (There is an association between pica and ID) Lists of myths and misconceptions Cards with messages 10. Cooking methods; plate model; protein foods; and use of fish powder in complementary foods. - When asked which a better choice to prevent anemia, 88.8% of mothers chose vegetables over meat to prevent anemia. - 62.5% of mothers chose oranges over mangoes to prevent anemia. - Between spinach and okra, 70.3% did not know which was better. - Of the 69.0% chose liver as a better food to prevent anemia than bread. - From observation vegetables are usually over-cooked and very few non-heme iron sources are used. To help mothers have a practical, hands on experience on food preparation with the intention to improve iron status. Home fortification of complementary food and general household meals using legumes (beans, soya beans, groundnut) and anchovies. Cooking demonstrations facilitated by researcher. -In groups cook an iron rich complementary food, and general household meal. -Two mothers from each group will present their foods prepared and the rest will ask questions. They will be given the key message card to be taken home. -Choose food with high iron when cooking for the entire household and also for children. - Reduce the carbohydrates in the food. - Do not overcook vegetables. -Increase variety in meals. - Serve food with more heme iron containing soup/sauces (Cooking methods can improve access to iron; improve food quality with fish and legumes) Group food preparations
