Reducing child global undernutrition at scale in Sofala Province, Mozambique, using Care Group Volunteers to communicate health messages to mothers

Thomas P Davis; Carolyn Wetzel; Emma Hernandez Avilan; Cecilia de Mendoza Lopes; Rachel P Chase; Peter J Winch; Henry B Perry

doi:10.9745/GHSP-D-12-00045

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FIGURE.
The Care Group Model as Implemented by Food for the Hungry in Sofala Province, Mozambique

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Table 1. Nutrition-Related Practices and Outcomes Among Care Group Project Beneficiaries, Selected Districts of Sofala Province, Mozambique, 2005–2010

Project Indicators	Area A – Early Implementation					Area B – Late Implementation (delayed by 2.5 years)
	Baseline (2006)		Endline (2010)		Difference	Baseline (2009)		Endline (2010)		Difference
	n/N	%(95% CI)	n/N	%(95% CI)	% Difference, P Value^*	n/N	%(95% CI)	n/N	%(95% CI)	% Difference, P Value^*
Nutritional Outcome
Children 0–23 m who are underweight (WAZ < −2.0 SD)	139/537	25.9	101/569	17.8	8.1,	168/620	27.1	89/569	15.6	11.5,
Children 0–23 m who are underweight (WAZ < −2.0 SD)	139/537	(22.1–29.7)	101/569	(14.5–21.0)	< 0.001	168/620	(23.0–31.2)	89/569	(12.6–18.7)	0.001
Feeding Practices (as reported by mother or caretaker)
Infants 0–5 m who were fed only breast milk in the last 24 hours	11/46	23.9	35/47	74.5	50.6,	25/45	55.6	37/46	80.4	24.9,
	11/46	(11.1–36.7)	35/47	(61.5–87.4)	< 0.001	25/45	(40.5–70.7)	37/46	(68.6–92.3)	0.010
Children 9–23 m who receive food other than liquids at least 3 times/day	34/109	31.2	87/115	75.7	44.5,	54/124	43.5	82/125	65.6	22.1,
	34/109	(22.4–40.0)	87/115	(67.7–83.6)	< 0.001	54/124	(34.7–52.4)	82/125	(57.2–74.0)	0.001
Children 6–23 m with oil added to their weaning food	47/130	36.2	126/145	86.9	50.7,	84/143	58.7	130/149	87.2	28.5,
Children 6–23 m with oil added to their weaning food	47/130	(27.7–44.5)	126/145	(81.3–92.5)	< 0.001	84/143	(50.6–66.9)	130/149	(81.8–92.7)	0.001
Children 6–23 m who have consumed at least one Vitamin A-rich food in the previous day	40/131	30.5	88/150	58.7	28.1,	80/157	46.5	102/150	68.0	21.5,
	40/131	(22.5–38.5)	88/150	(50.7–66.6)	< 0.001	80/157	(38.6–54.3)	102/150	(60.4–75.6)	0.001
Children 0–23 m with diarrhea in the last 2 weeks who were offered the same amount of, or more, food during the illness	22/68	32.4	35/42	83.3	51.0,	26/76	34.2	29/40	72.5	38.3,
	22/68	(20.9–43.8)	35/42	(71.6–95.1)	< 0.001	26/76	(23.3–45.1)	29/40	(58.0–87.0)	0.001
Vitamin A Supplementation, Deworming, and Nutritional Monitoring
Children 12–23 m who have received one Vitamin A capsule in the past 6 months (card-confirmed or mother's report)	74/90	82.2	88/94	93.6	11.4,	80/101	79.2	94/98	95.9	16.7,
	74/90	(74.2–90.3)	88/94	(88.6–98.7)	0.015	80/101	(71.2–87.3)	94/98	(91.9–99.9)	0.001
Children 12–23 months who received deworming medication in the last 6 months (mother's report)	24/84	28.6	59/75	78.7	50.1,	36/96	37.5	67/73	91.8	54.3,
	24/84	(18.7–38.4)	59/75	(69.2–88.2)	0.001	36/96	(27.6–47.4)	67/73	(85.3–98.2)	0.001
Children 0–23 m who were weighed in the last 4 months (card-confirmed)	114/156	73.1	150/170	88.2	15.2,	115/172	66.9	131/158	82.9	16.1,
	114/156	(66.0–80.1)	150/170	(83.3–93.1)	0.001	115/172	(59.8–74.0)	131/158	(77.0–88.8)	0.001
Diarrheal Disease (as reported by mother or caretaker)
Children 0–23 m with diarrhea in the last 2 weeks who received ORS and/or RHF	40/69	58.0	42/45	93.3	35.4,	49/79	62.0	38/43	88.4	26.3,
	40/69	(46.0–69.9)	42/45	(85.8–100.9)	0.001	49/79	(51.1–73.0)	38/43	(78.4–98.4)	0.002
Mothers of children 0–23 m who can correctly prepare ORS	77/177	43.5	166/196	84.7	41.2,	89/200	44.5	166/196	84.7	40.2,
Mothers of children 0–23 m who can correctly prepare ORS	77/177	(36.1–50.9)	166/196	(79.6–89.8)	0.001	89/200	(37.6–51.4)	166/196	(79.6–89.8)	0.001
Mothers of children 0–23 m who report that they wash their hands with soap/ash before preparing food, before eating, after defecating, and after attending to a child who has defecated	2/199	1.0	100/198	50.5	49.5,	27/211	12.8	86/199	43.2	30.4,
	2/199	(0.1–334.0)	100/198	(43.3–57.7)	0.001	27/211	(8.6–18.1)	86/199	(36.2–50.4)	0.001
Mothers of children 0–23 m who report that they purify their water using any effective method (by boiling or using point-of-use water purification)	39/95	41.1	129/151	85.4	44.3,	26/211	12.3	135/153	88.2	75.9,
	39/95	(31.2–50.9)	129/151	(79.8–91.1)	0.001	26/211	(7.9–16.8)	135/153	(83.1–93.3)	0.001

Abbreviations: WAZ, z-score for weight-for-age; SD, standard deviation; ORS, oral rehydration solution; RHF, recommended home fluids.
↵* Statistical significance based on one-tailed Fisher exact test (based on difference in prevalence between endline and baseline results). P values < 0.05 were considered statistically significant. All P values were statistically significant.

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Table 2. Average Annual Rate of Decline in Undernutrition in the Care Group Mozambique Project Areas Compared With Mozambique Nationwide

Location	Age group of children^a	% of children < 2 SD below the standard median/mean of weight-for-age		% Difference	No. of years (endline – baseline)	Avg. annual rate of decline
Location	Age group of children^a	Baseline (dates)	Endline (dates)	% Difference	No. of years (endline – baseline)	Avg. annual rate of decline
Project Areas	0–23 m	26.5%(Feb 2006)	16.7%(Jun 2010)	9.8%	4.4	2.2%
Nationwide^b (DHS and UNICEF/MICS)	0–59 m	20.0%(2003)	18.0%(2008)	2.0%	5	0.4%
Nationwide^b (DHS)	0–59 m	20.0%(2003)	14.9%(2011)	5.1%	8	0.6%

Abbreviations: SD, standard deviation; DHS, Demographic and Health Surveys; MICS, Multiple Indicator Cluster Survey.
↵a Comparable national data for children 0–23 months old from the DHS and MICS surveys are not available.
↵b Nationwide data are from the 2003 and 2011 DHS^21-22 and the 2008 UNICEF/MICS.²³ The 2003 DHS reported an undernutrition level of 24.6% using earlier WHO nutritional standards. The 2008 UNICEF/MICS survey recalculated the 2003 DHS numbers, shown here, using the WHO 2006 nutritional standards.

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Table 3. Care Group Project Costs and Number of Beneficiaries, Selected Districts of Sofala Province, Mozambique, 2005–2010

Project Site, Dates	Total Project Costs	Total Population	Total Cost per Capita per Year	No. of Beneficiaries	Total Cost per Beneficiary per Year
Area A,^a Oct 2005–Sep 2010 (5 years)	$2,026,191	462,000	$0.88	92,239	$4.39
Area B,^b Mar 2009–Sep 2010 (1.6 years)	$997,975	638,000	$0.97	127,238	$4.90
Total Project	$3,024,166^c	1,100,000	$0.55	219,617	$2.78

All dollar amounts expressed in US$.
↵a Area A included Caia, Chemba, Manga, and Marringue Districts.
↵b Area B included Dondo, Gorongosa, and Nhamatanda Districts.
↵c Includes contributions of $2,499,901 from USAID to Food for the Hungry and $524,166 from Food for the Hungry unrestricted funds.

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GHSP-D-12-00045 Supplementary Material

Davis, Jr et al. doi: 10.9745/GHSP-D-12-00045

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Supplementary Material - Davis, Jr et al. doi: 10.9745/GHSP-D-12-00045 Care Group Volunteers in Mozambique used this sample flipchart with drawings to convey behavior change messages to pregnant women and mothers of young children in their communities. Readers are free to use or adapt this flipchart in their own programs. Please acknowledge Food for the Hungry (using the Food for the Hungry logo), the authors, and the appropriate USAID agency as noted in the acknowledgments of the flipchart. To obtain copies of other flipcharts used by the Care Group Mozambique program, please contact one of the authors: Carolyn Wetzel (cwetzel@fh.org) or Thomas Davis (tom.davis@fh.org). You can also view other Care Group flipcharts in multiple languages developed for different countries at the Care Group Info website.