Impact of community health workers on nutritional status and cognitive development of children aged less than two years in Kisumu And Migori Counties, Kenya

Abstract

Globally, child malnutrition and poor cognition issues of public health importance. Sub Saharan Africa records the highest levels of malnutrition with 39% of children being stunted, 4% underweight and 10% wasted while in Kenya, 26% are stunted, 4% wasted and 11% underweight. Most growth faltering in children occurs after the six months of life when exclusive breastfeeding has been stopped, exposure to diseases is high and demand for nutritional needs increases due to rapid growth and development. Nutrition in the first 1,000 days of life is key in child’s ability to grow but after the second year of life, malnutrition can be been linked to reduced cognitive outcomes, poverty, low human capita, reduced school and work performance. Compared to developed nations, there is limited documented data on the relationship between child nutritional status and cognitive development in developing countries. Kenyan Government integrated Community Health Workers into the health system through the Health Community Strategy program whose main aim was to ensure improved nutritional status and cognitive development among all children. But since its launch in 2007, there has been limited studies on the effectiveness of CHWs yet that finding could be key in upscaling the program. In 2013, World Vision trained the CHWs in the Health Strategy program and used them to implement the Timed and Targeted Counselling nutrition intervention in Kisumu County. The trained CHWs delivered key nutritional messages on nutritional status and cognitive development at a particular time during child’s growth as they engaged and counseled caretakers on health status of their children from time of delivery until child was two years old. CHWs in Migori County which was the comparative group did not receive any specialized training from World Vision on timed and targeted counseling. Trained CHWs have the potential of improving the nutritional status and cognitive development among children. The objective of this study was to establish the impact of CHWs on the nutritional status and cognitive development of children in Katito in Kisumu County with a comparison at Kegonga Ntimaru in Migori County. Quasi experimental study design was used with secondary baseline data obtained from World Vision database and endline data collected and analyzed. WHO Z scores computed child’s underweight, overweight, stunting and wasting status while Bayleys Scale of Infant Development Kit assessed the Cognitive scores of children with categories computed using the Bayleys composite score. Food Frequency questionnaire collected data on dietary intake and nutrient inadequacies were computed based on the Recommend Daily Allowances. Qualitative data collected information on the perception of CHWs’ knowledge on nutritional status and child cognition. STATA 13.1 and NVivo 7.0 analyzed quantitative qualitative data respectively. Descriptive statistics summarized data into frequencies, means and standard deviation. Chi-square and independent sample t-test assessed the relationship between two variables while Multinomial logistic regression analyzed the relationship among variables. The level of significance was set at p<0.05. At baseline, there was no significant difference in the levels of underweight and overweight (chi2=8.73, p=0.068), wasting (chi2=0.25, p=0.885) and stunting (chi2=2.79, p=0.25) among children at Katito and Kegonga Ntimaru sites. After three years of intervention implementation at Katito, the prevalence of underweight reduced by 21.6%, overweight increased by 8.3% (chi2=21.55, p<0.001) and wasting reduced by 26% (chi2=22.54, p<0.001). Only 61% and 48% of children were exclusively breastfed in Katito and Kegonga Ntimaru respectively. A total of 43% of children in Katito and 50% at Kegonga had inadequate iron sources from their diets. Only 5% and 34% of the children had cognitive scores that were below average at Katito and Kegonga Ntimaru respectively (Chi2=15.8537, p<0.001). The CHWs were perceived to be knowledgeable on child nutritional status but had little knowledge on key foods for child cognition. In Katito, it was found that exclusive breastfeeding was linked to child underweight and overweight status (Chi2=27.13, p=0.04) while stunting was linked to duration of breastfeeding (Chi2=16.72, p=0.033). Children with cognitive scores that were above average had 8 times less Relative Risks of being underweight compared to those with scores that were below average [RRR: 0.194: 95% CI: 0.06-0.624; p=0.0006] while those who were exclusively breastfed had 0.02 times more Relative Risks of being severely wasted compared to those who breastfed for 3 months [RRR: 0.028: 95% CI: 0.05-2.64; p=0.03]. The presence of CHWs led to reduced prevalence of underweight but increased the overweight status of same population thus concluding that double burden of malnutrition is already existing in communities with children at early age at higher risk. This study recommends the use of CHWs to implement nutrition interventions and that interventions to focus on child overweight. Further research on nutritional outcomes and cognitive development at early age of growth is also recommended. Nutrition interventions to target this age period as is the window period of opportunity