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Pathology Description in China and Laos

  • January 2008
  • 245 pages

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    Pathology  

    Food  

    Pharmaceutical  

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  • Geographic Coverage

    China  

    Laos  

  • Dissertation 1
  • Ern§hrungssituation in Nord-Laos - Determinanten der Unterern§hrung und
  • Ver§nderungen nach vier Jahren intensiver Interventionen 1
  • Eingereicht von 1
  • Dipl. oec. troph. Silvia Kaufmann 1
  • aus Alsfeld 1
  • Betreut von 1
  • Prof. Dr. Claus Leitzmann 1
  • Giessen, Oktober 2008 1
  • Dissertation 2
  • Submitted by 2
  • Dipl. oec. troph. Silvia Kaufmann 2
  • Alsfeld 2
  • Supervised by 2
  • Prof. Dr. Claus Leitzmann 2
  • Giessen, October 2008 2
  • List of tables 5
  • List of figures 8
  • List of abbreviations 9
  • Introduction 11
  • 1.1 Subject and objectives of the study 11
  • 1.2 Conceptual framework of malnutrition 13
  • 1.2.1 Introduction to the framework 13
  • 1.2.2 The different levels of the framework - content and indicators 16
  • Outcome level 16
  • Direct causes of malnutrition 19
  • Indirect causes of malnutrition 21
  • Basic causes of malnutrition 23
  • Family's food intake 25
  • IYCF 25
  • Food security & livelihood 25
  • Health status - children 25
  • Health status - mothers 25
  • Environmental hygiene & health care 25
  • 1.4 Food and nutrition security assistance within the German 32
  • Development Co-operation 32
  • 1.5 The situation in Lao People's Democratic Republic 33
  • 1.6 The Lao-German Integrated Food Security Programme (IFSP) Nalae 39
  • and Sing district, Northern Laos 39
  • Methodology 41
  • 2.1 Sample size calculation and procedure of data collection 41
  • Sample size calculation applied for the present study 41
  • 2.2 Methods of data collection 44
  • Calculation of death and mortality rates 48
  • 2.3 Anthropometric assessment 49
  • 2.4 Qualitative information and secondary data 53
  • 2.5 Statistical analysis 54
  • Results 56
  • 3.1.1 Nutritional status of children and mothers 56
  • 3.1 Outcome level 56
  • 1997 and 2001 (in ) 57
  • (clinical signs, in ) 63
  • 3.1.2 Child mortality 63
  • (health statistics, DHO, Nalae district) 64
  • Causes of child death 65
  • 3.2 Direct causes 66
  • 3.2.1 Family's food intake 66
  • consumed in 1997 68
  • 3.2.2 Infant and young child feeding 72
  • Infant and young child feeding practices and nutritional status 76
  • weight-for-height in 1997 (ANOVA, multifactorial, age as covariate) 77
  • Changes in infant and young child feeding practices 79
  • 3.2.3 Health status 81
  • 3.3 Indirect causes 87
  • 3.3.1 Access and use of health services 87
  • 3.3.2 Water, sanitation and hygiene 96
  • 3.3.3 Food security and livelihood 102
  • Food production 102
  • Income and occupation 109
  • 3.4 Basic causes 118
  • 3.4.1 Education 118
  • (ANOVA, uni-factorial, for linearity) 119
  • 3.4.2 Social status of women 123
  • malnutrition in 1997 125
  • 3.4.3 Accessibility of the location 128
  • 3.4.4 Basic causes and nutritional status (multifactorial analysis) 131
  • (threefactorial covariance analysis, n = 336) 132
  • covariance analysis, n = 335) 132
  • Discussion and conclusions 135
  • 4.1 Outcome level 135
  • annual rate of change by grade (in ) 140
  • 4.2 Direct causes 142
  • 4.2.1 Family's food intake 142
  • 4.2.2 Infant and young child feeding practices 149
  • 4.2.3 Health status 153
  • 4.3 Indirect causes 156
  • 4.3.1 Access and use of health services 156
  • 4.3.2 Water, sanitation and hygiene 158
  • 4.3.3 Food security and livelihood 160
  • 4.4 Basic causes 171
  • Food security & livelihood 175
  • Food intake 175
  • IYCF 175
  • Health status 175
  • Environmental hygiene & health care 175
  • age (unifactorial analysis) 175
  • 4.5 Determinants of malnutrition - multi-factorial analysis 177
  • inter-sectorial analysis (n = 310) 178
  • Food security & livelihood 179
  • Food intake 179
  • Health status 179
  • Environmental hygiene & health care 179
  • (uni-factorial analysis, n = 475) 179
  • 4.6 Overall conclusions 181
  • Summary 183
  • Zusammenfassung 187
  • Literature 191
  • Annex 211
  • Annex 1: Map of Lao PDR, Luang Namtha province, Nalae and Sing district (WFP
  • District Vulnerability Analysis Mapping 2004) 212
  • Annex 2: The Integrated Food Security Programme Nalae and Sing district Annex
  • 2a: Background information, planning approach, implementation 213
  • Target group 213
  • Programme phases 213
  • structure and activities 213
  • The situation in the IFSP area 213
  • Implementation structure 214
  • IFSP activities 214
  • Annex 2b: Logical framework, indicators and monitoring 216
  • 1) The 'Logical Framework' 1998 - 2000 216
  • Overall Goal: A sustainable development process is initiated in the districts of
  • Sing 216
  • Aspects of health service with relevance to nutrition are established in the
  • project villages. 216
  • Aspects of the education and advisory curriculum with nutrition relevance are
  • communicated. 216
  • The rural infrastructure (feeder roads, health posts, rice stores, and schools
  • built with simple technology) is improved. 216
  • and Nalae in Namtha province, Northern Laos. 216
  • Indicator OG 216
  • Result 1.0 216
  • Indicator 1 A 216
  • Sustainable agricultural practices are applied. 216
  • Indicator 1 B 216
  • Indicator 1 C 216
  • Result 2.0 216
  • Indicator 2 A 216
  • Indicator 2 B 216
  • Result 3.0 216
  • Indicator 3 A: Indicator 3 B: Indicator 3 C 216
  • Result 4.0 216
  • Indicator 4 A 216
  • Indicator 4 B 216
  • Result 5.0: The co-operation among governmental, non-governmental and village 217
  • institutions involved in the programme is improved. 217
  • Indicator 5 A 217
  • Indicator 5 B 217
  • Remarks on the IFSP indicators and the hierarchy of effects 217
  • Annex 2b -Figure 1- Overview - Indicators for monitoring and evaluation 218
  • Method of monitoring and evaluation 219
  • Availability and use of health services 219
  • Use and utilisation Morbidity 219
  • Environment and sanitation 220
  • Food intake 220
  • Adults food intake 220
  • Literacy level 220
  • Improve education services 220
  • Availability of food 221
  • Improvement of agriculture services to increase food production 221
  • Access to food 221
  • Improve of economic situation 221
  • Annex 3: Population statistics and list of villages 222
  • Distribution of sampled units over sub-district and ethnic group 222
  • geographical zone 222
  • ethnic group 223
  • Annex 4: Statistical analysis - levels and sectors 225
  • Levels (I to II) and sectors (1 to 8) tested for their effect on the nutritional
  • status 225
  • Annex 5: Malnutrition and mortality 226
  • Annex 6: Food intake 228
  • Food group 1: Animal products 228
  • Food consumption pattern, food groups and food items consumed 228
  • Food group 2 - Vegetables (Non-DGLV) 229
  • Food group 3 - DGLV 229
  • Food Group 4: Fruits 230
  • Food Group 5: Herbs, spices, condiments 230
  • Food group 6: All other food items 230
  • (mean value and maximal number per day and household) 231
  • Multifactorial regression, sector-wise, food intake and nutritional status (food
  • intake as independent and nutritional status as dependant variable) 232
  • intake variables (n = 444) 232
  • Annex 7: Multifactorial analysis, sector-wise, IYCF practices and nutritional 233
  • status 233
  • Annex 8: Villager's perception on malnutrition, infections and seasonality 236
  • Annex 9 - Immunization coverage and water supply 239
  • stunting (in ) 239
  • Annex 10: Income and housing and nutritional status 240
  • Tables 10.1: Income and height-for-age in 1997 and 2001 240
  • Estimated Marginal Means 240
  • Univariate Analysis of Variance 240
  • Profile plots 241
  • Annex 11: Basic causes (education, decision making and nutritional status) 242
  • Annex 12: Methodological constraints to demonstrate changes in malnutrition 243
  • Acknowledgment 245
  • Table 2: Sample size
  • calculation.......................................................................
  • 32 Table 3: 5
  • Table 40: Number of birth and child death per mother by district in 6
  • Table 78: Comparison of chronic dietary energy deficiency in mothers and 6
  • Table 79: Comparison of mortality rates in Nalae district and national 6
  • Table 80: Estimated daily intake of energy and protein derived from
  • rice..........134 6
  • Table 81: Changes in infant and young child feeding practices
  • .........................142 7
  • Table 82: Changes in
  • morbidity..........................................................................143 7
  • Table 83: Changes in water, hygiene and health care
  • .......................................150 7
  • Table 84: Changes in food production and
  • livelihood.........................................160 7
  • Table 85: Determinants of malnutrition, regression, multi-factorial model, 7
  • Table 86: Determinants of change in malnutrition, multi-factorial
  • model............170 7
  • Figure 5: Chronic and acute malnutrition by age groups in 1997 and
  • 2001.........48 8
  • Figure 6: Causes of child death in 1997
  • ............................................................. 55 8
  • Figure 9: Decision making power of mothers and fathers in
  • 1997.....................114 8
  • Figure 10: Decision making and chronic malnutrition in 1997
  • .............................116 8
  • Figure 11: Morbidity, water quality and
  • height-for-age.........................................148 8
  • Figure 12: Income and height-for-age
  • .................................................................159 8
  • Figure 13: Causalities between women's social status, literacy and height-for- 8
  • Figure 14: Significant determinants and their association with
  • height-for-age.....169 8
  • Figure 1: Conceptual framework of malnutrition (adopted from UNICEF 1990, p. 22) 12
  • Figure 2: Context-specific conceptual framework, levels and sectors assessed
  • (adopted from UNICEF 1990, p. 22) 25
  • 1.3 The global nutrition and food situation and trends 26
  • Table 1: Global and regional trends in chronic malnutrition from 1980 to 26
  • Figure 3: Population pyramid of Lao PDR (UNAIDS/WHO 2002, p. 3) 34
  • Table 2: Sample size calculation 42
  • Table 3: Number of households, mothers and children studied by district in 42
  • Table 4: Demographic information by district in 1997 and 2001 43
  • Table 5: Comparison of death and mortality rate, Nalae district 48
  • Table 6: Degree of malnutrition in children 51
  • Severity of malnutrition by prevalence ranges (%) 51
  • Table 7: Classification of severity of malnutrition within a population by 51
  • Table 8: Degree of chronic energy deficiency in adults 52
  • Table 9: Chronic malnutrition by district in 1997 and 2001 56
  • Figure 4: Changes in moderate and severe chronic malnutrition by district in 57
  • Figure 5: Chronic and acute malnutrition by age groups in 1997 and 2001 58
  • Table 10: Acute malnutrition by district in 1997 and 2001 59
  • Table 11: Underweight by district in 1997 and 2001 60
  • Table 12: Prevalence of malnutrition by sex and district in 1997 and 2001 (in %) 60
  • Table 13: Malnutrition of mothers by grade in 1997 and 2001 61
  • Table 14: Malnutrition of mothers by age in 1997 62
  • Table 15: Mothers and children's nutritional status in 1997 62
  • Table 17: Child death by age and district in 1997 63
  • Table 16: Prevalence of anaemia by district in 1997 and 2001 63
  • Table 18: Infant and child death rate by district in 1997 and 200) 64
  • Table 19: Evolution of mortality rates in Nalae district from 1997 to 2001 64
  • Figure 6: Causes of child death in 1997 (n = 476 women, reported 534 deaths) 65
  • Table 20: Number of meals, snacks and nutritional status in 1997 67
  • Figure 7: Proportion of food group items out of total number of items 68
  • table 21 and annex 6). Access to agricultural resources, food security status or
  • the 71
  • Table 21: Number of food items and nutritional status by source in 1997 72
  • Table 22: Initiation of breastfeeding in 1997 (n = 608, in %) 73
  • Table 23: Type of first feeding by district in 1997 (n=609, in %) 73
  • Table 24: Time of first introduction of complementary food by district 74
  • Table 25: Age of first introduction of plant and animal products by district in 75
  • Table 26: Accessibility of location and introduction of complementary food in 75
  • Table 27: Duration of breastfeeding by age group and district in 1997 (in %) 76
  • Table 28: Introduction of common complementary food, plant and animal 77
  • Table 29: Introduction of complementary food, plant and animal products and 77
  • Table 30: Time of weaning and morbidity in 1997 78
  • Table 32: Morbidity by age groups in 1997 (in %) 82
  • Table 33: Morbidity and height-for-age in 1997 84
  • Table 34: Morbidity and weight-for-height in 1997 84
  • Table 35: Morbidity and anaemia in 1997 85
  • Table 36: Morbidity by district in 1997 and 2001 (in %) 86
  • Table 37: Diarrhoeal diseases by district in 1997 and 2001 (in %) 86
  • Table 38: Persons consulted for treatment of diarrhoea diseases in 1997(in %) 88
  • Immunisation status of children 1997 and 2001 90
  • Figure 8: Immunisation coverage and vitamin A supplementation by district in
  • 1997 and 2001 (children > 12 months of age). 90
  • Table 39: Participation in growth monitoring and promotion 92
  • Table 40: Number of birth and child death per mother by district in 1997 and 94
  • Table 41: Natal health care by district in 1997 and 2001 (in %) 95
  • Table 42: Possession and use of bed nets in 2001 96
  • Table 43: Water supply systems in 1997 and 2001 (in %) 98
  • Table 44: Purification of drinking water in 1997 and 2001 (in %) 98
  • Table 45: Water quality and height-for-age in 1997 and 2001 99
  • Table 46: Sanitary facilities by district in 1997 and 2001 (1997: n = 475, 2001:
  • n = 652, in %) 100
  • Table 47: Hygiene conditions and height-for-age in 1997 (ANOVA, unifactorial) 101
  • Table 48: Rice production system by district 1997 and 2001 (in %) 103
  • Table 49: Harvest situation in December 1996 and December 2000 (1997: n = 360;
  • 2001: n = 383, in %) 103
  • Table 50: Rice sufficiency in 1997 and 2001, villagers self-assessment (in %) 104
  • Table 51: Production system and chronic malnutrition in 1997 and 2001 105
  • Table 52: Production system, rice yields and height-for-age in 1997 and 2001 105
  • Table 53: Wealth categories by possession of livestock and death rates in 107
  • Table 54: Annual cash income per household by district in 1997 and 2001 109
  • Table 55: Income groups by district in 1997 and 2001 (in %) 110
  • Table 56: Income and height-for-age in 1997 and 2001 112
  • Table 57: Income and weight-for-height and acute malnutrition in 1997 113
  • Table 58: Occupation and nutritional status in 1997 113
  • Table 59: Income and morbidity in 1997 (in %, n = 475) 114
  • Table 61: Housing conditions, income and height-for-age in 1997 and 2001 117
  • Table 62: Possession of household commodities in 2001 (in %) 117
  • Table 63: Education of mothers and fathers in 1997 (n = 475, in %) 118
  • Table 64: Education of mothers and fathers and nutritional status in 1997 119
  • Table 65: Nutritional status and determinants by parent's literacy status in 121
  • Table 66: Education, social status of women and height-for-age in 1997 122
  • Figure 9: Decision making power of mothers and fathers in 1997 (n = 497,
  • expressed ratio of women to men) 124
  • Table 68: Women's decision power and height-for-age and chronic 125
  • Figure 10: Decision making and chronic malnutrition in 1997 126
  • Table 69: Nutritional status and determinants by women's decision power 127
  • Table 70: Women's decision power, head of household and height-for-age in 128
  • Table 71: Nutritional status and determinants by accessibility of location in
  • 1997 (n = 495 households, n = 614 children) 130
  • Table 72: Basic causes and nutritional status in 1997 132
  • Table 73: Basic causes and acute malnutrition in 1997 (threefactorial 132
  • Table 74: Chronic malnutrition and determinants in 1997 (n = 495 households, n =
  • 600 children) 133
  • Basic causes 134
  • Table 75: Comparison of chronic malnutrition and annual rate of change 135
  • Table 76: Comparison of underweight and annual rate of change (in %) 138
  • Table 77: Comparison of chronic dietary energy deficiency in mothers and 140
  • Table 79: Comparison of mortality rates in Nalae district and national averages
  • (number of deaths/1,000 live births) 142
  • Table 80: Estimated daily intake of energy and protein derived from rice 144
  • Table 81: Changes in infant and young child feeding practices (in %) 152
  • Table 82: Changes in morbidity 153
  • Chronic malnutrition 158
  • Figure 11: Morbidity, water quality and height-for-age (two-level, twofactorial
  • analysis, n = 475) 158
  • Table 83: Changes in water, hygiene and health care (in %) 160
  • Figure 12: Income and height-for-age 169
  • Table 84: Changes in food production and livelihood 170
  • Figure 13: Causalities between women's social status, literacy and height-for- 175
  • Table 85: Determinants of malnutrition, regression, multi-factorial model, 178
  • Figure 14: Significant determinants and their association with height-for-age 179
  • Table 86: Determinants of change in malnutrition, multi-factorial model 180
  • Table 3.1: Number of households, children sampled and frequency distribution by 222
  • Table 3.2: Number of households, children sampled and frequency distribution by 223
  • Table 3.3: List of villages and households studied in 1997 and 2001 224
  • Table 5.1: Severe and moderate chronic malnutrition by district in 1997 and 226
  • Table 5.2: Chronic malnutrition by age group and by district in 1997 and 2001
  • (in %) 226
  • Table 5.3: Acute malnutrition by age group and by district in 1997 and 2001 (in
  • %) 226
  • Table 5.4: Causes of child death (as reported by the mothers studied; n = 476 227
  • Table 5.5: Immunisation coverage for children between 1 and 2 years of age in
  • 1997 227
  • Table 6.1.1: Food group 1 - Animal products from domestic production (in %) 228
  • Table 6.1.2: Food group 1 - Animal products derived from forest (hunted or
  • gathered, 228
  • Table 6.1.3: Food group 1 - Aquatic products, natural sources, gathering (in %) 228
  • Table 6.2.1: Food group 2 -Vegetables cultivated (in %) 229
  • Table 6.2.2: Food group 2 - Vegetables collected (in %) 229
  • Table 6.3: Food group 3 - DGL-vegetables (gathered, in %) 229
  • Table 6.4: Food group 4 - Fruits (grown and collected, in %) 230
  • Table 6.5: Food group 5 - Consumption of herbs, spices and other condiments (in
  • %) 230
  • Table 6.6.1: Food group 6 - Consumption of other food items cultivated (in %) 230
  • Table 6.6.2: Food group 6 - Consumption of other food items collected (in %) 230
  • Table 6.6.3: Food group 6 - Consumption of biscuits and alcohol (in %) 231
  • Table 6.7: Summary - Number of food items consumed by food groups 231
  • Table 6.8.1: Multiple regression analysis, sectoral analysis model including all
  • food 232
  • Univariate analysis of variance 233
  • Estimated marginal means 234
  • 7.2. Regression, multi-factorial, sector-wise, IYCF and nutritional status 235
  • Direct causes 237
  • Table 9.1: Immunisation coverage for children between one and two years of age
  • in 239
  • Table 9.2: Source and treatment of drinking water and height-for-age z-score and 239
  • Table 9.3: Treatment of drinking water and acute malnutrition 239
  • Table 9.4: Purification of drinking water in 1997 and 2001 (in %) 239
  • Estimated Marginal Means of HAZ height for age z- 241
  • Table 10.2: Quality of housing and nutritional status 241
  • Table 11.1: Capability of fathers and mothers to communicate in national
  • language 242
  • Table 11.3: Decision making over different household assets 1997 (n = 497) 242
  • Table 11.4: Decision making and height-for-age and chronic malnutrition 242

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