Urban Primary Health Care

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SampleUrbanProblemSolvingWorksheetTanzaniaChildNutrition.pdf

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Sample Worksheet

Urban Health Problem Solving Exercise Worksheet

Topic/Title: No Urban Advantage: Increasing Child Malnutrition among the Urban Poor of Dar es Salaam

Step Activity Narrative

Step 1 Identify a specific urban area in the developing world.

Dar es Salaam is the largest city in Tanzania, with a population of approximately more than 3 million that is growing at a rate of 4.3%. It is one of the fastest growing cities in Africa, and as the population has increased, there has been a growth of unplanned developments that lack adequate housing and basic services such as clean water and sanitation. Approximately 80% of Dar es Salaam residents live in unplanned areas (World Bank, 2002).

Identify one specific public health or health‐related problem facing that urban area.

Historically, child malnutrition has been a more significant problem in rural than urban areas and urban areas have been thought to offer an advantage in economic opportunities as well as health. However, the rapid urban expansion and subsequent growth of slums with their unhealthy conditions, appears to have negated many of these advantages. Child malnutrition in Dar es Salaam has increased during its explosive growth and malnutrition among the children of the urban poor now exceeds that of rural populations in Tanzania. The proportion of stunted children in Dar es Salaam has increased from 34.4% in 1991 to 47.6% in 2003 (Kinabo, 2003).

Explain why this is a public health problem.

Child malnutrition is a an important public health problem because malnourished children have an increased risk of more frequent as well as more severe illnesses such as diarrhea and malaria. Their education and intellectual development is compromised and malnourished women are more likely to give birth to low birth weight infants, who themselves are more likely to be malnourished (Fotso, 2006).

Support your choice with reference to at least one article

References:

 Fotso, J. Child health inequities in developing countries: differences across urban and rural areas. International Journal for Equity in Health 2006, 5:9. http://www.biomedcentral.com/content/pdf/1475‐9276‐5‐ 9.pdf. Accessed 2 April 2012.

 Kinabo, J. A Case Study of Dar es Salaam City, Tanzania. Paper prepared for the FAO technical workshop on “Globalization of food systems: impacts on food security and nutrition.” 2003. ftp://ftp.fao.org/es/esn/food_systems/kinaboF.pdf. Accessed 1 April 2012.

 World Bank, Tanzania Country Assessment Report, 2002. http://web.mit.edu/urbanupgrading/upgrading/case‐ examples/overview‐africa/country‐ assessments/reports/Tanzania‐ report.html. Accessed 8 April 2012.

Sample Worksheet

Step Activity Narrative

Step 2 Determine the magnitude of the problem

Stunting, which is an indicator of chronic malnutrition, has increased in urban regions of Tanzania over the past decade. Although the proportion of stunted children under the age of 5 was recently found to be 26% in urban regions compared to 40% in rural areas, the proportion of stunted children from the poorest quintile in urban areas is the same as that found in rural areas. As with other urban regions, the prevalence of malnutrition is increasing in Dar es Salaam. In 1991, 34.4% of children in the city were stunted, but a recent study (Kulwa, Kinabo and Modest, 2006), found that this number had increased to involve 43% of the city’s children.

Describe those affected

Factors associated with food intake, health and care practices generally describe malnourished children in Dar es Salaam (Leach and Kilama, 2009). Malnourished children are found most often in the poorest homes where food security is low. Exclusive breastfeeding for the first 6 months is low (9%) and introduction of complementary foods occurs early in Dar es Salaam children (Kulwa, et al., 2006). Children whose mothers work longer hours and those whose mothers have less education are more likely to be malnourished (Kulwa, et al., 2006). HIV infected children are more likely to be stunted than those that test negative for the virus (Sunguya, Poudel, Otsuka, Yasuoda, Mlunde, et al., 2011).

Support your information with reference to at least one article

References:

 Kulwa, K.B., Kinabo, J.L.D., Modest, B. Constraints on good child‐care practices and nutritional status in urban Dar‐es‐Salaam, Tanzania. Food and Nutrition Bulletin. 2006; 27:3. http://nsinf.publisher.ingentaconnect.com/content/nsinf/fnb/2006/000 00027/00000003/art00006 Accessed 18 April 2012.

 Leach, V. and Kilama, B. Institutional Analysis of Nutrition in Tanzania. REPOA Special Paper 09.31. Dar es Salaam, REPOA. 2009. www.repoa.or.tz/documents/Special_Paper_09.31_.pdf Accessed 14 April 2014

 Sunguya, B.F., Poudel, K.C., Otsuka, K., Yasuoka, J., Mlunde, L.B., Urassa, D.P., Mkopi, N.P., Jimba, M. Undernutrition among HIV‐positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough. BMC Public Health. 2011; 11:869. http://www.biomedcentral.com/1471‐2458/11/869 Accessed 18 April 2012.

Sample Worksheet

Step Activity Narrative

Step 3 Explore the social, physical and other determinants of the problem

Smith, et al. (2003) described 3 levels of determinants that lead to child malnutrition. The most distal, social determinants, include socioeconomic status, maternal education, maternal employment, woman’s status, and place of residence (Ross‐Suits, 2010; Smith, Ruel and Ndiaye, 2004). These determinants impact the next level, which includes physical and behavioral determinants including insufficient access to food and a poor health environment, which is impacted by poor access to water, inadequate sanitation and insufficient health services (Smith, et al., 2003). The most proximal determinants are inadequate dietary intake and disease. In a study of developing countries including Tanzania, Smith, et al. (2004) found no differences between rural and urban areas in the character or strength of association of socioeconomic determinants. They did, however, find a disparity in the levels of all levels of determinants that favored urban areas. Urban data was not disaggregated based on socioeconomic status, so their findings may represent the better nutritional status of wealthy urban areas rather than the poorer areas where malnutrition prevalence is no different from that in rural areas, at least in Tanzania (WHO, 2010),

In one area of Dar es Salaam stunting rates and morbidity were found to be high and child feeding practices, including exclusive breast feeding for 6 months and age of introduction of complementary foods, were deficient (Kulwa, et al., 2006). One social determinant, maternal education, was found to affect feeding practices (higher education levels were associated with later introduction of complementary foods), and another social determinant was found to be important because the prevalence of stunting was increased in children of mothers who worked full time. These authors suggest that as maternal employment increases, alternative caregivers are playing a larger role in the proximate determinant of feeding practices (Kulwa, et al., 2006). Thus, the determinant of maternal employment is giving rise to a determinant that may be more important in urban settings: care by alternative caregivers. Disease is another important determinant in Dar es Salaam, as HIV infected children in the city are more likely to be malnourished (Sunguya, et al., 2011).

Support your analysis with reference to at least one article

References:

 Ross‐Suits, H. M., "Maternal Autonomy as a Protective Factor in Child Nutritional Outcome in Tanzania." 2010. Public Health Theses. Paper 99. http://digitalarchive.gsu.edu/iph_theses/99 Accessed 19 April 2012.

Sample Worksheet

Step Activity Narrative

see below for additional references

 Smith, L., Ramakrishnan, U., Ndiaye, A., et al. 2003. The Importance of Women’s Status for Child Nutrition in Developing Countries. International Food Policy Research Institute. Washington, D.C. http://www.ifpri.org/sites/default/files/publications/rr131.pdf Accessed 22 April 2012.

 Smith, L.C., Ruel, M.T., Ndiaye, A. Why is Child Malnutrition Lower in Urban than Rural Areas? Evidence from 36 Developing Countries. FCND Discussion Paper No. 176. Washington D., C.: International Food Policy Research Institute, 2004. ageconsearch.umn.edu/bitstream/16441/1/fc040176.pdf Accessed 19 April 2012.

 WHO. Country Profiles on Urban Health: United Republic of Tanzania. 2010. Available from http://www.who.or.jp/urbanheart/uhprofiles.html Accessed 6 April 2012.

Step 4 Discuss at least two alternate solutions, their strengths and weaknesses

Kulwa, et al. (2006) found that child feeding practices, both exclusive breastfeeding and introduction of complementary foods, were deficient in one area of Dar es Salaam. Educational interventions can alter caregivers’ feeding practices and improve child growth (Penny, Creed‐Kanashiro, Robert, Narro, Caulfield, et al., 2005). Opportunity for feeding practice education already exists within government antenatal care and immunization programs (Leach and Kilama, 2009). More than 90 % of Tanzanian women have at least one antenatal visit and more than 90 % of children receive their first two DPT and polio vaccines (Macro Intl, 2012) providing several occasions to impart and reinforce nutrition information, and receiving such services within the already available government health care is sustainable (Penny, et al., 2005). However, the quality of the education provided at antenatal care in Tanzania is low, and child vaccination visits end at about the time when supplementary feeding begins (Leach and Kilama, 2009). In addition, the success of education interventions is dependent on food security, and in Dar es Salaam, it’s impact might be determined by distribution of information to alternative caregivers who may provide much of the feeding care (Kulwa, et al., 2006).

Sample Worksheet

Step Activity Narrative

Interventions during pregnancy can prevent malaria infections and reduce the number of low birth weight (LBW) infants, who are destined to become malnourished children. Malaria in pregnancy may be responsible for 8‐14% of LBW births in endemic areas (Steketee, Nahlen, Parise and Menendez, 2001), but these numbers can be reduced through the intermittent preventive treatment of malaria during pregnancy (Bhutta, Ahmed, Black, Cousens, Dewey, et al., 2008). This is important in Dar es Salaam, where inadequate drainage systems result in increased numbers of anopheles mosquitoes, and consequently, malaria. Although more than 90 percent of Tanzanian women attend at least 2 antenatal care visits, only 75 percent of pregnant women in Dar es Salaam receive presumptive treatment (Macro Intl, 2012).

Support your choices with reference to at least one article

References:

 Bhutta, Z.A., Ahmed, T., Black, R.E., Cousens, S., Dewey, K., et al. What works? Interventions for maternal and child undernutrition and survival. The Lancet. 2008; 371: 417‐440. http://www.thelancet.com/journals/lancet/article/PIIS0140‐ 6736%2807%2961693‐6/fulltext.Accessed 29 April 2012.

see below for additional references

 Leach, V. and Kilama, B. Institutional Analysis of Nutrition in Tanzania; Special Paper 09.31, Dar es Salaam, REPOA. 2009. www.repoa.or.tz/documents/Special_Paper_09.31_.pdf. Accessed 29 April 2012

 Penny, M.E., Creed‐Kanashiro, H.M., Robert, R.C., Narro, M.R., Caulfield, L.E., Black, R.E. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster‐randomised controlled trial. The Lancet. 2005; 365: 1863‐1872. http://www.thelancet.com/journals/lancet/article/PIIS0140‐ 6736%2805%2966426‐4/fulltext. Accessed 29 April 2012

 Macro International Inc. MeasureDHS STATcompiler. 2012. http://www.statcompiler.com/. Accessed 29 April 2012.

 Steketee, R.W. Nahlen, B.L., Parise, M.E., Menendez, C. The burden of malaria in pregnancy in malaria‐endemic areas. Am. J. Trop. Med. Hyg., 64(1, 2)S, 2001, pp. 28–35. www.ajtmh.org/content/64/1_suppl/28.full.pdf. Accessed 29 April 2012.

Sample Worksheet

Step Activity Narrative

Step 5 Recommend one solution and defend your choice

Providing breastfeeding and complementary feeding instruction is an important solution to the problem of deficient child feeding practices and under 5 malnutrition, in Dar es Salaam. Providing the appropriate setting for this education is fundamental to its success. The CARE/URC/CHS Infant and Young Child Feeding Counseling program (CARE, undated)has been developed to train feeding counselors within communities to provide support and education to parents and caregivers (Care, undated). Literacy is not required, as the information is presented pictorially on cards that the counselors can also carry with them to use in teaching parents and caregivers. The lessons can be given in groups, but can also be given during home visits, which might provide an opportunity for educating alternative caregivers as well as parents. Another program provides utilization of positive deviant behavior to train mothers to provide feeding information to one another in Mother to Mother Support Groups (CARE, undated). Utilizing a program that combines the education provided by counselors with the mother‐to‐mother support could mobilize and empower urban communities in Dar es Salaam and perhaps lead to other positive changes as well.

Similar community programs providing maternal and neonatal care have been successful and sustainable in many countries (Schiffman, Darmstadt, Agarwal and Baqui, 2010), (Ahluwalia, Robinson, Vallely, Gieseker and Kabakama, 2010). The urban setting likely provides a challenge to community mobilization, but it may be possible to utilize existing groups such as church groups as well as providing referrals from antenatal care centers and hospitals. Training community members to educate other members of their community can very likely lead to sustainable behavior change that can significantly improve the problem of urban child malnutrition.

Support your analysis with reference to at least one article

References:

 Ahluwalia, I.B., Robinson, D., Vallely, L., Gieseker, K.E., Kabakama, A. Sustainability of community‐capacity to promote safer motherhood in northwestern Tanzania: what remains? Global Health Promotion. 2010; 17(1):39‐49. Available at http://ped.sagepub.com/content/17/1/39.short Accessed 12May2012.

 CARE. Window of Opportunity: Resources. Undated; Available at http://thewindowofopportunity.info/resources/. Accessed 11May 2012.

 Schiffman, J., Darstadst, G.L., Agarwal, S., Baqui, A.H. Community‐based intervention packages for improving perinatal health in developing countries: a review of the evidence. Seminars in Perinatology. 2010; 34(6): 462‐476. Available at http://www.sciencedirect.com.ezproxy.welch.jhmi.edu/science/article/ pii/S0146000510001084 Accessed 12May2012.

Sample Worksheet

*Additional References for Step 3

Smith, L., Ramakrishnan, U., Ndiaye, A., et al. 2003. The Importance of Women’s Status for Child Nutrition in Developing Countries. International Food Policy Research Institute. Washington, D.C. http://www.ifpri.org/sites/default/files/publications/rr131.pdf Accessed 22 April 2012. Smith, L.C., Ruel, M.T., Ndiaye, A. Why is Child Malnutrition Lower in Urban than Rural Areas? Evidence from 36 Developing Countries. FCND Discussion Paper No. 176. Washington D., C.: International Food Policy Research Institute, 2004. ageconsearch.umn.edu/bitstream/16441/1/fc040176.pdf Accessed 19 April 2012. Sunguya, B.F., Poudel, K.C., Otsuka, K., Yasuoka, J., Mlunde, L.B., Urassa, D.P., Mkopi, N.P., Jimba, M. Undernutrition among HIV‐positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough. BMC Public Health. 2011; 11:869. http://www.biomedcentral.com/1471‐2458/11/869 Accessed 18 April 2012. WHO. Country Profiles on Urban Health: United Republic of Tanzania. 2010. Available from http://www.who.or.jp/urbanheart/uhprofiles.html Accessed 6 April 2012.

**Additional References for Step 4:

Leach, V. and Kilama, B. Institutional Analysis of Nutrition in Tanzania; Special Paper 09.31, Dar es Salaam, REPOA. 2009. www.repoa.or.tz/documents/Special_Paper_09.31_.pdf. Accessed 29 April 2012 Penny, M.E., Creed‐Kanashiro, H.M., Robert, R.C., Narro, M.R., Caulfield, L.E., Black, R.E. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster‐randomised controlled trial. The Lancet. 2005; 365: 1863‐1872. http://www.thelancet.com/journals/lancet/article/PIIS0140‐6736%2805%2966426‐4/fulltext. Accessed 29 April 2012 Macro International Inc. MeasureDHS STATcompiler. 2012. http://www.statcompiler.com/. Accessed 29 April 2012. Steketee, R.W. Nahlen, B.L., Parise, M.E., Menendez, C. The burden of malaria in pregnancy in malaria‐endemic areas. Am. J. Trop. Med. Hyg., 64(1, 2)S, 2001, pp. 28– 35. www.ajtmh.org/content/64/1_suppl/28.full.pdf. Accessed 29 April 2012.