CONTENT Pag Chaptr I. INTRODUCTION 1 1.1. Background.. 1 1.2. Rational of th Study.. 1 1.3. Objctivs... 2 1.3.1. Ovrall Objctivs... 2 1.3.2. Spcific Objctivs.. 2 Chaptr II. METHODOLOGY.. 3 2.1. Evaluation Dsign... 3 2.2. Population.... 3 2.3. Study Sits, Sampl Dsign and Sampl Siz... 4 2.3.1. Fild Constraint during Data Collction.. 4 2.3.2. District and Sub-district Slction. 5 2.3.3. Slction of Posyandu, Cadrs and Childrn/Mothrs.. 6 Chaptr III. RESULTS AND DISCUSSION 8 3.1. Limitation of th Study.. 8 3.1.1. Tim laps btwn priod of intrvntion and tim of valuation. 8 3.1.1.1. Implications of Sampl Slction 8 3.1.1.2. Effct of VTDL Program on Nutritional Status of th Childrn. 8 3.1.2. Existnc of othr similar program... 9 3.2. Rsults and Discussion 9 3.2.1. Charactristic of th Sampl.. 9 3.2.2. How has CFI Program Rachd Targt Group?.. 11 3.2.3. Childrns Nutritional Status.. 21 3.2.4. Wr childrn growing at appropriat rat? 23 3.2.5. Cadrs Knowldg and Skills. 23 3.2.6. Quality of Posyandu Srvics. 28 Chaptr IV. CONCLUSIONS AND RECOMMENDATIONS.. 32 Annx 1. Annx 2. Annx 3. Annx 4. Concptual Framwork of th valuation plan Sampl siz for Posyandu Rvitalization Program Baslin Survy Tabls of survy rsults Powrpoint Prsntation
Chaptr I Introduction 1.1. Background In rspons to th conomic crisis, UNICEF has startd Rapid Rspons Complmntary Food Initiativ (CFI), distributd 500 g packts of micronutrint fortifid complmntary food Vitadl (VTDL) through Posyandu to bnfit ovr 150.000 infants for a priod of six months. At th sam tim, th Crisis Rspons Program providd th opportunity to rstor th Posyandu s function of growth monitoring and promotion and to provid addd incntiv for community attndanc at Posyandu, which was xprincing a dclin currntly. This has bcom a start off for Posyandu Rvitalization Program (PRP). In addition to CFI as on of th primary input for PRP, a training program for halth cadrs has bn placd. Th program is mant to strngthn th capability of th halth staff to dtct growth faltring and provid followup nutrition ducation/counsling. Improvd skills of th cadrs and CFI availability may incras th covrag and quality of Posyandu srvics. 1.2. Rational of th Study Earlir cross-sctional survy of 1425 housholds from 36 randomly slctd villags in East, Cntral and Wst Java conductd by Hln Kllr Intrnational found that CFI was succssful in raching targt childrn. Ninty on prcnt of villags rcivd th plannd of food on tim, 82% housholds hard about CFI, about 70% covrag of CFI in housholds with a child in th targt ag rang (6-24 months of ag), 72% fd th childrn 2-3 tims pr day, and 88% of familis rportd willing to pay up to Rp.1000,- for a 500 g packt. Posyandu Rvitalization Program targtd a total of 6,267 posyandus, and th CFI componnt spcifically targtd 156,666 infants for complmntary food distribution for a priod of 6 months. Thrfor, a largr valuation on th ffctivnss of th program, that is provinc rprsntativ, and a broadr information rgarding PRP will provid important information on whthr th program has incrasd th covrag and th quality of th posyandu srvics. Succssful rsults of th program can b usd as a tool for advocacy and for dvloping policy
guidlins, spcially rgarding infant fding and growth monitoring and promotion.
1.3. Objctivs 1.3.1. Ovrall Objctivs To masur th ffctivnss of th PRP in dlivring nutrition intrvntions to targtd groups and valuat th ovrall impact on malnutrition in four provincs: Wst Java, Cntral Java, East Java and Wst Sumatra. 1.3.2. Spcific Objctivs: 1. Effctivnss of CFI program in raching targt groups 2. Impact on nutritional status of bnficiaris (wight for ag) 3. Impact on proportion of childrn growing at th appropriat rat 4. Effctivnss of training on cadrs knowldg and skill, particularly rgarding growth monitoring and nutrition counsling 5. Impact on mothrs knowldg and practic of adquat infant fding 6. Improvmnt in quality of posyandu srvics 7. Improvmnt in covrag of posyandu srvics
Chaptr II Rsarch Mthodology 2.1. Evaluation Dsign Bcaus th intrvntion has bn implmntd at th tim of th survy and thr was no data prior to th intrvntion, th dsign of th valuation is a rtrospctiv study with matchd comparison which compard posyandus that rcivd support for Posyandu Rvitalization Program and thos that did not rciv support as a comparison group. Th comparison group was matchd according to socioconomic status. For childrn sampl, th comparison was matchd according to th ag and sx. To valuat th ffctivnss of VTDL, childrn/familis who rcivd and consumd VTDL was compard to thos who did not. To valuat th ffctivnss of th training, cadrs who rcivd training was compard to thos who did not. Th dsign is basd on th concptual framwork of th valuation plan (s Annx 1) 2.2. Population Posyandu: Posyandu is th first unit of sampling with rprsntativnss at th provinc lvl. Th posyandu population wr thos posyandus which rcivd support for PRP and posyandus which did not rcivd th program. Posyandu that rcivd support was dfind as posyandu that rcivd both CFI as wll as training program, whil popsyandu that did not rcivd support was dfind as posyandu that did not rciv ithr CFI or training. Cadrs: Cadrs from all slctd posyandus wr th population of th study. It was assumd that cadrs from CFI-intrvntion posyandus hav rcivd training, whil thos in non-intrvntion posyandu hav not. Houshold rspondnts Mothrs: Mothrs of all slctd childrn wr th population of th study. Childrn:
Th CFI program has bn startd sinc mid 1999 and stoppd at th nd of yar 2001 (btwn August and Dcmbr 2001). This mans that th cohort of th childrn who rcivd VTDL ar now agd approximatly btwn 18-59 months. Thrfor, th childrn population for this study wr limitd to thos ag 18-59 months old at th tim of th survy, or thos who rcivd VTDL about 6 months-3 yars ago. Th rason for including this ag rang was to gt complt information about th intrvntion, as wll as to gt information on th ffct of rcnt vrsus latr of VTDL consumption on childrn s nutritional status. In othr words, by choosing only youngr (for xampl 18 months old) childrn, will allow us for gtting mor information on th rcnt ffct of VTDL on childrn s nutritional status, howvr, it will not giv nough information about th ovrall dynamic of th program (.g. th problms of VTDL supply and distribution at th bginning of th program implmntation might b diffrnt from th problms aris at th nd of th program). On th othr hand, if w choos only oldr childrn, w will miss both th information about th program implmntation as wll as th mor rcnt ffct of VTDL on nutritional status, howvr, w might obsrv rtaind ffct of VTDL program on nutritional status somtim aftr VTDL program has ndd. 2.3. Study Sits, Sampl Dsign and Sampl siz 2.3.1. Fild Constraints during Data Collction. Basd on th prliminary fild visit, it was found that th rporting and rcording (RR) of th program was not as xpctd. Many of thm did not hav a good RR. In addition, in som districts/subdistricts similar program was also xist. Basd on thos findings, th original plan to slct subdistrict randomly was changd. In gnral, two main slction critria for districts, subdistricts and posyandu was addd, i.. th rlativ compltnss of th rporting and rcording of th program, and rlativly not contaminatd by othr similar program. W rcognizd th possibl slction bias that might b mrgd from this approach, howvr, sinc th valuation will b vry much dpnd on th compltnss of th availabl information (i.. rporting and rcording), this stratgy was chosn. In East Java, originally both th intrvntion and control subdistricts will b slctd within th slctd districts, basd on th information obtaind during th fisrt fild visit. Howvr, aftr furthr invstigation during data collction it was discovrd that all subdistricts in both districts
rcivd VTDL. For this rason anothr district that has no VTDL program should b chosn as control ara. Only on district, Kdiri, was finally slctd as control ara. It was too complicatd to choos mor than 1 district as control groups for logistic rason (tim to obtain prmit, transportation, and cost). Th slction of posyandu, cadrs and childrn/mothrs to som xtnd has also adjustd to th local situation. It was targtd that from ach intrvntion subdistrict 5 posyandu, 3 cadrs pr posyandu and 10 HHs pr posyandu will b slctd, whil from ach control subdistrict 2 posyandu, 3 cadrs and 10 HHs pr posyandu will b slctd. Howvr, th fild situation was diffrnt, including th numbr of childrn pr posyandu was lss than 10, th numbr of traind cadrs was lss than 3 for diffrnt rason, and th cadrs that has bn traind wr not activ anymor. Th solution was to slct th cadrs that hav bn traind vnthough thy wr not involv in th posyandu at th tim of th survy. In th cas th numbr of HHs /mothrs wr lss than targtd, additional nighbouring posyandus wr chosn. It was plannd to mak assssmnt of Kartu Mnuju Shat (KMS) to compar th nutritional status prior and aftr intrvntion. Howvr, thr wr svral problms, including th covrag of KMS, th compltnss of KMS spcially during VTDL program, and th accuracy of th rcording. On of th aim to assss th ffctivnss of th training for cadrs was to assss th data on covrag and program ffctivnss (SKDN). Howvr, th SKDN data in many placs wr not availabl or incomplt.
2.3.2. District and Subdistricts slction In addition to th abov, svral othr slction critria of district and subdistrict for ach provinc wr dtrmind, and adjustd to th local condition, as follows: 1. Wst Java. District: From discussions with UNICEF staff in Wst Java, 2 districts, Subang and Sukabumi, wr rcommndd basd on th following considrations: a) thr was rlativly no contamination of othr similar program; b) both districts hav rlativly high commitmnt; and c) thr was a good coordination of th program. Howvr, spcially in Sukabumi thr was a chang in th structural position (PEMDA), including thos prsonnl who wr involvd in th program has bn rplacd. Subdistrict: Within ach district 4 intrvntion and 2 control subdistricts wr slctd. Altogthr 8 intrvntion subdistricts and 4 control districts wr slctd from Sukabumi and Subang 2. Cntral Java. District: In cntral Java, th ara was diffrntiatd basd on innr/mountainous and coastal groups. Originally, as in East Java, th control will b slctd within slctd districts, howvr, bcaus all subdistricts within ach district in Cntral Java rcivd VTDL, th control groups hav to b chosn from non-intrvntion district. For mountainous ara, Wonosobo was slctd as intrvntion district and Tmanggung as control district. For coastal aras, Rmbang was slctd as intrvntion and Pati as control ara. Subdistrict: From ach intrvntion district, 4 subdistricts wr slctd, whil from ach control district 2 subdistricts wr slctd. Altogthr 8 intrvntion subdistricts and 4 control subdistricts wr slctd. 3. East Java. Districts:
East Java culturally was dominatd by Javans ( Mataraman ) and Madurs culturs, thrfor th slction of th districts put this aspct as on considration. Lamongan and Tulungagung wr finally slctd basd on th rason that Tulungagung will rprsnt Javans cultur, whil Lamongan will rprsnt both Javans and Madurans culturs. For control district, Kdiri was chosn basd on th rason xplaind abov.
Subdistrict: In ach intrvntion district, 4 subdistricts wr slctd, whil in control district 4 subdistricts wr slctd. Altogthr 8 intrvntion subdistricts and 4 control subdistricts wr slctd in East Java. 4. Wst Sumatra. District: In Wst Sumatra, thr wr no control districts, all districts rcivd VTDL. Instad of control and intrvntion, th slction was diffrntiatd basd on urban (municipal) and rural (district), bcaus thr wr 9 districts and 6 municipals in this provinc. Additional critria was also dtrmind, mountainous and coastal aras. As a rsult, 2 districts Agam (mountainous) and Padang Pariaman (coastal aras) and 2 municipals Solok and Padang Panjang wr slctd. Subdistrict: From ach district, 3 subdistricts wr slctd, whil from ach municipal 2 subdistricts wr slctd. Altogthr 10 subdistricts wr slctd. 2.3.3. Slction of Posyandu, Kadrs and Childrn/mothrs 1. Sampl Siz Estimation Sampl siz stimation is basd on indicators for ach sampling unit. In this study th unit of analysis will b posyandu, cadrs, and mothrs/childrn. Thrfor, thr will b thr sampl siz i.. rlatd to indicators at posyandu lvl which will srv as th first sampling unit; indicators rlatd to cadrs; and indicators rlatd to houshold (mothrs and childrn agd 8-59 months old). Bcaus this study aims at comparing two groups (intrvntion and non-intrvntion) th following formula is usd to calculat th sampl siz: N 1 = N 2 = [Z α/2 + [2pq]+Z β [p 1 q 1 +p 2 q 2 ]] 2 /[p 1 -p 2 ) 2 (adoptd from KPC 2000 Fild Tsting Notification Form by Child Survival Tchnical Support Projct (CSTS), Maryland, 2000, pag 48) Th biggst sampl siz is usd as th sampl siz to b complid by th study. Basd on th calculation th rang of sampl siz for Posyandu is 22-46; for cadrs is 62-146; and for houshold (mothrs and childrn) is 128-218 for ach provinc (S Annx 2: Tabl of Sampl Siz Calculation). Bcaus of lack of information prior to
intrvntion (no baslin data) and th data quality might b qustionabl causd by rmot rcall bias, th possibility that th diffrnc is causd by chanc is mor likly. Thrfor, a largr sampl siz is ndd to dcras th obsrvd diffrnc that is causd by chanc, howvr w kp only ky indicators to b collctd.. Th targtd sampl siz was 48 posyandus in ach Java provinc and 50 posyandus in Wst Sumatra; 144 cadrs in ach Java provinc and 150 in Wst Sumatra; and 480 HHs/Mothrs in ach Java provinc and 500 in Wst Sumatra. In total, thr wr 211 (108.8% of xpctd) posyandu visitd, 358 (61.5%) cadrs intrviwd and 1748 mothrs/childrn (90.1%) intrviwd and masurd (childrn). Tabl 2.1 Numbr of Qualitativ Sampls from Each Provinc Provinc I Districts C Subdistr n Villags n Posyandu*) n (%) W. Java Subang Sukabumi Subang Sukabumi 8 Intrv 4 Contrl 16 Intrv 8 Control 49 (102.1%) C. Java Wonosobo Tmanggung 8 Intrv 16 Intrv 50 Rmbang Pati 4 Control 8 Control 104.2% E. Java Lamongan Kdiri 8 Intrv 16 Intrv 63 Tulungagung 4 Control 8 Control 131.3% D C W. Sumatra Agam Solok 6 Intrv 33 Intrv 49 P. Pariaman P.Panjang 4 Intrv 98% 211 Total 13 46 105 108.8% Cadrs**) n ( %) *) Total xpctd # : 48 ach from W, C and E Java, and 50 from W. Sumatra = 194 **) Total xpctd # : 144 ach from W, C and E Java, and 150 from W. Sumatra = 582 ***) Total xpctd # : 480 ach from W, C and E Java, and 500 from W. Sumatra = 1940 108 75.0% 77 53.4% 89 61.8% 84 56.0% 358 61.5% HHs/ Mothrs***) n (%) 475 98.9% 439 91.5% 404 84.2% 430 86% 1748 90.1% Tabl 2.2 Numbr of Qualitativ Sampls from Each Provinc Provinc Intrvntion Groups/Districts Control Groups/Citis Sukabumi Subang Sukabumi/Subang Wst Java 2 FGDs 2 FGDs 1 FGDs 1 FGDs 4 Indpth 4 Indpth Intrviws 2 Indpth Intrviws 2 Indpth Intrviws Intrviws Wonosobo Rmbang Tmanggung Pati Cntral Java East Java Wst Sumatra 2 FGDs 4 Indpth Intrviws 2 FGDs 4 Indpth Intrviws 1 FGDs 2 Indpth Intrviws 1 FGDs 2 Indpth Intrviws Tulung Agung Lamongan Kdiri 2 FGDs 2 FGDs 1 FGDs 4 Indpth 4 Indpth Intrviws 2 Indpth Intrviws Intrviws Agam P. Pariaman Solok P. Panjang 2 FGDs 4 Indpth Intrviws 2 FGDs 4 Indpth Intrviws 2 FGDs 4 Indpth Intrviws 2 FGDs 4 Indpth Intrviws Total 16 FGDs + 32 Indpth Intrviws 9 FGDs + 18 Indpth Intrviws
Chaptr III Rsults and Discussion 3.1. Limitation of th Study 3.1.1. Tim laps btwn priod of intrvntion and tim of valuation 3.1.1.1 Implications on sampl slction Originally, th slction of sub-district, villag and posyandu will b don randomly. Howvr, basd on th prliminary fild visit it was obvious that th rporting and rcording (RR) was unsatisfactory and that not all prson rsponsibl for th VTDL program wr still availabl. On th othr hand, som of th information ndd for this valuation will dpnd on th availability of RR and th rsponsibl prson. For this rason, it was dcidd that two critria should b addd, i.. rlativ compltnss of RR and th availability of th prson. It is ralizd that this dcision has compromisd th bias lvl of th sampl. 3.1.1.2. Effct of CFI program on nutritional status of th childrn In gnral, in th 4 provincs, th VTDL program has ndd sinc 2001, and som of th childrn rcivd th last packag of VTDL vn bfor this tim. Thortically, th nutritional status prior and aftr VTDL intrvntion can b obtaind from KMS, howvr, this information was apparntly not availabl, partly bcaus many of th childrn do not hav KMS anymor, or th nutritional status in th KMS wr not compltly rcordd. As an altrnativ, anthropomtry (Wight for Ag (WAZ), Hight for Ag (HAZ) and Wight for Hight (WHZ)) masurmnt was obtaind in th survy. Nots on childrn s nutritional status masurmnt: It is dbatabl whthr nutritional status (ithr right aftr th intrvntion or latr), would b usful to b masurd in this survy. Sinc th VTDL intrvntion has ndd in about on yar prior to th survy, w will not b abl to masur th rcnt ffct of VTDL on nutritional status using dirct
anthropomtric masurmnt. W wr xpcting to obsrv th nutritional status right aftr th intrvntion (approximatly at 12 months old) rtrospctivly through growth chart (KMS) assssmnt. Howvr, th availability and compltnss of KMS rcording was as not as xpctd. On th othr hand, th dirct anthropomtry masurmnt of nutritional status through th survy might giv usful information. Concptually, w xpct that VTDL program will not just giv a short-trm bnfit on childrn s nutritional status, but w xpct a longr trm bnfit. First, child s nutritional status at on point in tim will influnc his/hr nutritional status latr. Scond, VTDL program is mant as a triggr for th mothrs to provid a bttr fding bhavior to thir childrn. Third, nutrition counsling providd by cadrs should furthr strngthn mothrs fding knowldg and practic. Thrfor, data on nutritional status somtim lat aftr th intrvntion might giv valuabl information on th ffctivnss of th program. 3.1.2. Existnc of othr similar program Thr is possibl implication on nutritional status of th childrn du to th xistnc of othr similar program. In all 4 provincs, similar food supplmntation program wr also xist (for xampl: SUN, Katrsna, Dlvita, tc.). Th implication is that th changs in nutritional status of th childrn, might b attributd to this program. Thrfor, it is difficult to masur th changs attributabl to VTDL program alon. 3.2. Rsults and Discussion Variabl I Total C 3.2.1. Charactristics of th Sampl Ag (%) 6- <12 months 0.7-12 <24 months 25.1 36.1 24 <36 months 40.9 39.9 > 36 months 33.4 23.9 Birth Wight (%) < 2500 grams 4.6 5.8 Diarrha in last 3 months (%) Ys 26.2 32.8 1 tim Tabl 52.8 3.1. 70.5 2 tims Charactristics 19.7 15.4 of > 3 tims 27.4 14.1 Childrn by ARI in last 3 months (%) Provinc and by Ys intrvntion/ 26.9 29.2 1 tim Control 57.1 Status 49.3 2 tims 24.7 28.2 > 3 tims 18.2 22.5 Childrn s charactristics Childrn s charactristics that ar assumd to hav som influncs toward childrn s nutritional status wr analyzd. Ths wr infants ag, sx, th numbr of undr-fiv sibling, birth-wight, history of diarrha and acut rspiratory infction
(ARI) in th last 3 months. Most of th undr-fiv childrn wr agd 24-<36 months (about 40% in both intrvntion and control groups) and only < 1% agd 6-12 months old. It sms that th childrn in intrvntion groups wr oldr than th control groups, i.. 33.4% of childrn in th intrvntion groups agd 36 months or oldr as compard to th control groups (23.9%) (Tabl 3.1.). This might b causd by th sampl slction procss. Th sampl was thos who hav vr rcivd VTDL btwn 6-12 months old, so by th tim of th survy many of thm wr agd 36 months old or mor. Whil in th control th sampl was thos agd 12-59 months. In gnral, thr was no diffrnc in th prcntag of sx and birth wight btwn intrvntion and control groups. Thr wr slightly mor boys than girls, which was in accordanc to th rsults of th latst National Cnsus, that is sx ratio of 100.6 (CBS, 1997). Around 10% of childrn hav sibling, which was similar btwn intrvntion and control groups. It is intrsting to s that th prvalnc of th rportd low birth wight (4.6% - 6.3%), both in intrvntion and control groups, was quit consistnt with th rsults from othr studis (5.8%) ASUH Baslin Survy (PATH - Cntr for Family Wlfar Univrsity of Indonsia 2002), which was lowr than Indramayu s studis (Kusharisupni, 2000; Purwaningsih 2001). Mor childrn hav vr xprincd diarrha in th last 3 months in th control groups (32.8% vrsus 26.2%), howvr, mor childrn in th intrvntion groups xprincd diarrha mor frquntly than th control groups. Th diffrnc was lss striking with ARI, th prcntag of childrn in th control groups who hav vr xprincd ARI was highr than intrvntion groups. Similar tndncy was also found in trm of frquncy of ARI. Mothrs charactristics Th following tabl informs about mothrs ducation, mothrs working status, and fathrs ducation, variabls that to som xtnd rprsnt social-conomic status of th housholds. Tabl 3.2. Charactristics of Parnts by Provinc and by Intrvntion/Control Status Variabl W. Java C. Java E. Java W. Sumatra Total I C I C I C I Dist City I *) C Mothr s ducation (%) < Junior High, finishd 88.4 78.5 87.6 90.4 80.7 74.7 52.3 59.6 40.5 76.2 81.4 > Snior High, finishd 11.6 21.5 12.4 9.6 19.3 25.3 47.7 40.4 59.5 23.8 18.6 Mothr s working status (%) No 82.3 86.3 47.2 50.6 52.0 82.7 78.1 77.5 79.1 66.4 72.7 Ys 17.7 13.8 52.8 49.4 48.0 17.3 21.9 22.5 20.9 33.1 27.3 Fathr s ducation (%) < Junior High, finishd 75.2 65.0 81.1 89.0 76.8 64.0 59.0 66.7 46.3 72.3 73.0 > Snior High, finishd 22.3 31.3 18.3 11.0 21.6 33.3 40.1 32.2 53.1 26.3 24.9 *) xcluding citis in Wst Sumatra
Most of th mothrs and fathrs (about 40%) hav finishd thir lmntary school, both in th intrvntion and control groups. Th prcntag of mothrs and fathrs having snior high or highr ducation was slightly highr in th intrvntion groups. Mothrs who wr working wr slightly highr in th intrvntion groups (33.1%) as compard to control groups (27.3%). Th prcntag of mothrs who wr working was much highr in East Java (both intrvntion and control groups) and in Cntral Java (intrvntion groups). Mothrs ducation was slightly highr in intrvntion than control groups. It sms that th lvl of mothrs ducation, which was much highr than othr provincs, contributd to th total figur. Fathrs ducation was also highr in Wst Sumatra as compard with othr provincs.
Cadrs charactristics Tabl 3.3. Charactristics of th Cadrs by Provinc and Intrvntion/ Control Status In gnral, thr wr diffrncs btwn intrvntion and control groups in ach charactristic. Th total prcntag of cadrs agd > 35 yar-old was highr in control groups than in intrvntion groups (43.5% as compard to Variabl Total C Cadr s ag (%) < 24 yars 12.1 3.4 25-34 yars 44.4 44.8 > 35 yars 43.5 51.7 Cadr s ducation (%) < Junior High finishd 65.5 50.0 > Snior High finishd 34.5 50.0 Cadr s working status (%) No 63.3 72.4 Ys 36.7 27.6 Duration as cadrs < 2 yars 16.0 20.7 > 2 yars 83.7 79.3 I 51.7%). In trm of ducation, cadrs ducation was notably highr in control groups. Most cadrs (50.0%) finishd thir snior high school or highr in control groups whras in intrvntion groups 34.5% finishd snior high school. Cadrs working status was slightly lowr in control groups. Rgarding duration as cadrs, th prcntag of cadrs working for longr duration was slightly highr in intrvntion than control groups (Tabl 3.3.). By provinc, th highr prcntag of longr duration as cadrs was highr in intrvntion groups for East and Cntral Java, but lowr in Wst Java. Comparing districts and citis in Wst Sumatra, th prcntag of thos cadrs working longr was highr in th citis (Annx 3: Tabl 3). About 72% of mothrs rportd thy rcivd VTDL vry month. Most of th childrn rcivd thir first and last pack of VTDL during th intndd ag priod (6-12 months). Thr wr about 14% of th childrn rcivd VTDL whn thy had not rachd 6 months old, and about 32.1% still rcivd VTDL aftr 12 months old. Svnty svn prcnt of th mothrs prcivd that thy rcivd adquat supply. Howvr th adquacy lvl basd on calculation of th xpctd VTDL rvald with diffrnt rsults. Th prcntag of childrn who rcivd 50% or mor of th xpctd VTDL was 54.6%, whil mothrs who rcivd 80% or mor of th xpctd VTDL was only 19.4%. It sms that thr was a gap of undrstanding on how much VTDL is sufficint. Among childrn who rcivd VTDL at th ag of 6 12 months old, 66.7% rcivd for lss than 6 months. Sixty prcnt of childrn rcivd lss than 10 packags and 24.8% rcivd 10-19 packags of VTDL. Mor than half of th childrn wr srvd VTDL 3 tims daily (as rcommndd by th program), and 86.7% of th childrn always or oftn finishd th mal. Th rasons for not finishing th mal mainly wr th siz of th srv wr too big and th tast that was not good. 3.2.2. How has CFI program rachd targt groups?
VTDL Distribution at Provinc and District Lvl Th tabl blow shows information on VTDL distribution including dats of first and last supplis and numbr of packs rcivd in ach provinc. Tabl 3. 4. Priod of VTDL Distribution by Districts Provinc District First Supply Last Supply Wst Java Cntral Java East Java Wst Sumatra # of Pack. rcivd Rang # of box pr pack. rcivd Sukabumi May-99 Dc-00 8 tims 760-1020 Subang Jul-99 Aug-01 6 tims 939-10.648 Wonosobo Sp-99 Oct-01 15 tims 930 Rmbang Jul-99 Dc-01 12 tims 950-1030 Lamongan May-99 Nov-00 6 tims 1400 Tulung Agung May-99 Spt-01 8 tims 1810 Padang Pariaman Sp-99 Oct-00 6 tims 1425 Agam Aug-99 Nov-00 11 tims 580-1160 Solok City Sp-99 Jan-01 17 tims 140 Padang Panjang City Aug-99 Fb-01 12 tims No data Th first supplis cam within May to Sptmbr 1999 and th last supplis cam within Novmbr 2000 to Dcmbr 2001 priod. Th arlist supply cam in May 1999 in Sukabumi district of Wst Java, followd by othr groups. Rang of frquncy of rciving VTDL varid from 6 to 17 tims. Th numbr of boxs for ach supply wr varid. Numbrs rcivd by ach district was actually basd on districts rqust (in accordanc to district s nd calculation). This rqust was communicatd to UNICEF. Th numbr of boxs was diffrnt for ach dlivry. Thr was no complt data for Padang Panjang district bcaus th offic of Local Govrnmnt was burnd and so was th data. Flow of th Supply and Distribution of VTDL Sctors wr rsponsibl for th program in gnral was PKK (district and sub-district lvl) or local govrnmnt (villag dvlopmnt unit). Halth sctor was not dirctly involvd with th program. Th involvmnt of halth sctor was mor obvious in Wst Sumatra than othr provincs. Th slction of villag in East and Wst Java was using critria of KHPPIA villags, whil in Cntral Java thr wr no spcific critria. For yar 2000, in Tulung Agung, all poor villags wr includd.
In all provincs, th nds of VTDL was basd on first calculation by posyandu, thn proposd by villag to sub-district and district. Th calculation was mad by PKK, cadr or Bidan di dsa. In Wst Sumatra it was th nutrition prsonnl at sub-district lvl Tnaga Pmbantu Gizi (TPG) who mad th calculation of th nds. In all provincs, th amount of th following supplis wr basd on th first calculation. Th waiting tim btwn th proposal for VTDL and th supply was btwn 2 wks to 3 months. Cadrs in gnral wr complaining about th irrgularity of th VTDL availability. At first, th supplis wr quit rgular, but thn it bcam irrgular, spcially for th last supplis. Thr wr tims that th supply was lat, so thr was a shortag of supplis for somtim, and whn it cam th amount was mor than ndd. Occasionally, in th cas of shortag, th cadrs hav to find VTDL from othr villags. In som cass whr th supplis wr too much, thy distributd th VTDL to oldr childrn. Usually whn th supplis cam it was distributd vnly throughout villags. Th dcision usually was mad at sub-district lvl. In gnral, onc th supply arrivd at th sub-district lvl, thy wr distributd to posyandu within 1-2 wks. Evn though thy hav nvr rcivd xpird VTDL, thy did rciv VTDL that wr almost xpird, within 1 or 2 months, particularly th last supply (in 2001, at th nd of th program). For this rason, thy distributd th VTDL straight away. Cadrs ithr distributd VTDL to childrn s hom or distributd during posyandu vnu. Socialization about VTDL. Cadrs rportd that thr was no spcial socialization on VTDL. Plac for storag. VTDL was usually kpt for 1-2 months at district and about 1-2 wks at sub-district bfor distribution to lowr lvl. Thr was funding for distribution from provinc to district but thr was no funding to th lowr lvl. Usually th lowr lvl pickd up VTDL from highr lvl. This was on of th barrirs for timly distribution. Thr was no spcial plac to kp VTDL, in som cass thy just put VTDL on th floor. Thy rportd that thr was no guidanc on how to stor VTDL. Suprvision and valuation
Suprvision and valuation was xistd, but not in rgular mannr, bcaus thr was no funding for ths activitis. In gnral, PKK, Halth Srvics and Local Govrnmnt conductd th suprvision and valuation activitis. Funding Thr was no spcial funding for VTDL distribution. Th funding was obtaind from slling VTDL. Th pric of VTDL was dtrmind by a local rgulation, wich was startd with Rp 500,-, thn incrasd to Rp 1000,- Th funds was managd by posyandu and PKK. In all districts, bsid VTDL program, thr was also othr similar program from Social Safty Nt in Halth (JPSBK) and PMT-APBD1 which was targtd for svrly malnourishd childrn.
VTDL Distribution at Houshold Lvl Figur 3.1. Mothr's Prcption of rciving VTDL (sachts) in adquat numbr P r c n t a g 100 80 60 40 20 0 21.3 23.0 23.2 22.6 22.5 78.7 77 76.8 77.4 77.5 W. Java C. Java E. Java W. Sumatra Total Ys No Childrn rcivd VTDL vry month 28.2 71.8 Ys No Figur 3.1. provids information on mothr s prcption of rciving VTDL (sachts) in adquat numbr in ach provinc. Mor than 75% of rspondnts prcivd that thy rcivd VTDL in sufficint numbr, and most mothrs (71.8%) rportd that thy hav rcivd VTDL vry month. This figur was quit similar in th four provincs. Bsid basd on mothrs prcption as xplaind abov, th lvl of sufficincy or adquacy was assssd basd on calculation. Adquacy is calculatd by dividing total numbr of rcivd VTDL by idal numbr of VTDL to b rcivd (that is by considring that th numbr of packag to b givn is 4 packags pr months and th numbr of months th infant should b givn VTDL in th rang of 6 to 12 months). Th prcntag of mothrs who rcivd VTDL 50% of th xpctd numbrs or mor was 54.2%, whil mothrs who rcivd VTDL of 80% or mor of adquacy was 19.3% (Figur 3.2. and annx 3: tabl 5). Figur 3.2. Lvl of Adquacy of VTDL rcivd P r c n t a g 100 80 60 40 20 0 82.1 54.2 41.5 43.1 44.4 37.2 19.3 14.2 14.1 8.4 W. Java C. Java E. Java W. Sumatra Total >= 50% >= 80%
Most infants wr in th ag of 6-12 months old whn thy first rcivd (85.6%) and last rcivd (63.3%) VTDL which was in accordanc with th intndd targt of VTDL. Howvr, thr wr about 14% of th childrn rcivd VTDL whn thy had not rachd 6 months old, and about 34.4% still rcivd VTDL aftr 12 months old. Comparing provincs, Wst Java sms to b th bst in raching th right targt group. Th possibl slction bias was rcognizd bcaus th sampls wr thos childrn who hav vr rcivd VTDL at that ag priod. Among infants ag 6-12 months old who rcivd VTDL, 66.7% of thm rcivd for lss than 6 months priod (Annx 3: tabl 5). Rgarding th numbr of VTDL rcivd, about 60% infants rcivd VTDL only lss than 10 sachts, whil about 25% of thm rcivd 10-19 packags (Tabl 3.5). Tabl 3.5. VTDL Supply and Distribution at Houshold Lvl by Provinc Variabl W. Java Provinc E. C. Java Java W. Sumatra Total Childrn rcivd VTDL vry month (%) Ys 69.1 64.6 69.3 82.1 71.8 Ag of first rcivd (%) <6 month 2.8 24.4 13.4 16.7 14.2 6-12 months 97.0 75.0 86.6 83.3 85.6 Don t know/no answr 0.3 0.6 0.0 0.0 0.2 Ag of last rcivd (%) <6 month 0.3 0.6 0.0 0.0 0.2 6-12 months 71.9 62.4 58.8 59.5 63.3 >12 months 25.8 3t4.3 40.8 37.9 34.4 Duration of rciving VTDL among infants 6-12 months old 1 month 18.3 11.9 19.2.0 12.5 2 months 17.5 18.2 18.5 7.1 15.1 3 months 14.6 11.9 11.6 13.2 13.1 4 months 9.3 15.4 10.3 16.8 12.6 5 months 12.3 11.2 14.4 15.7 13.4 6 months 7.1 8.4 8.9 7.1 7.7 7 months 20.9 23.1 17.1 40.1 25.6 Numbr of rciving VTDL pr sacht among infants 6-12 months old < 10 sacht 72.2 71.3 68.5 30.8 60.5 10 - < 20 sacht 20.7 18.9 24.7 34.9 24.8 20 - < 30 sacht 7.1 8.4 6.8 27.2 12.5 >= 30 sacht 0.0 1.4 0.0 7.2 2.1
Most of mothrs obtaind VTDL at posyandu (73.0%), whil othrs rcivd it at cadrs hom (16.1%), midwif s hom (3.2%) or at mothrs hom (1.9%) (Annx: Tabl 5). Thr was no furthr information from this survy whthr mothrs obtaind total amount of thir monthly nds ach tim thy wnt to posyandu, or thy cam to cadrs hom vry tim thy nd. It is intrsting to notic that in Cntral Java about on Figur 3.3. How Gtting VTDL P r c n t a g 100 80 60 40 20 0 79.0 69.4 89.2 93.7 83.1 21.0 30.6 10.8 6.3 16.9 W. Java C. Java E. Java W. Sumatra Total Fr Buy third of VTDL wr obtaind from cadrs hom. This might indicats that mothrs could gt VTDL outsid posyandu or anytim thy wantd. In all provincs, VTDL did not intnd to b givn frly. Howvr, som mothrs gt VTDL for fr, particularly in Cntral Java (30.6%) and East Java (21.0%). Qualitativ rsult indicats that thos who could not afford to buy thy will gt for fr. Figur 3.4. Prcption of pric P r c n t a g 100 80 60 40 20 0 87.9 9.9 Rp.500,- 1.1 78.6 14.1 Rp.1000,- 4 Chap Fair Expnsiv Thr was a chang in th pric btwn th bginning and th nd of th program. At th bginning of th program, th pric of on sacht of VTDL was Rp. 500.- and at th nd of program was Rp. 1000.-. Each posyandu had th authority to incras VTDL s pric slightly in ordr to add or support th implmntation of th program. Th incrasd pric did not sm much to chang mothrs opinion, i.. mothrs who
considrd th pric chap dcrasd only vry littl, which was no mor than 10% (87.9% at th pric of Rp.500,- as compard to 78.6% at th pric of Rp.1000,-) (Figur 3.4). It is intrsting to notic that th proportion of mothrs who considrd th pric of VTDL, both at th pric Rp.500,- and Rp.1000,-, chap was considrably highr in cntral and ast Java as compard to Wst Java and Wst Sumatra (Annx 3:tabl 6). Only half of mothrs chckd th xpiry dat of VTDL thy rcivd (56.3%). Basd on mothr s xprinc, only lss than 5% of mothrs had vr rcivd xpird, damagd pack, lumpd up, or color changd VTDL (Tabl 3.6.). Th highst prcntags of xpird VTDL rcivd wr in Cntral Java (4.0%) and Wst Java (3.8%) bcaus ths two provincs wr still willing to assist VTDL distribution vn th xpird dat priod of thos VTDL wr within 1 month (th last VTDL supply). Tabl 3.6. Sourc and Pric of VTDL Variabl W Java Provinc C E. Java Java W. Sumatra Total Chcking xpiry dat (%) Ys 50.6 60.9 57.4 57.0 56.3 Rcivd VTDL (%) Expird 3.8 4.0 1.5 1.0 2.6 Damagd pack 1.6 1.7 0.4 3.2 1.9 Lumpd up 2.2 1.7 2.3 2.0 2.0 Color changd 0.8 0.3 0.4 1.7 0.9 Tabl 3.7. Consumption of VTDL Variabl Provinc W. Total W. Java C. Java E. Java Sumatra N=395 N=356 N=306 N=430 N=1487 Who taught to prpar VTDL (%) Information on sacht 40.1 37.5 39.8 42.2 40.1 Cadr 24.6 54.2 32.8 33.7 35.6 Halth providr 10.6 6.7 17.2 23.5 15.1 Own Exprinc 3.5 5.0 14.8 2.4 6.1 Brochur 9.9 0.8 3.1 3.0 4.3 Nighbors/ frinds 3.5 0.8 0.8 3.6 2.3 Bu kads/pkk 0.0 0.8 5.5 1.2 1.8 Parnts 0.0 0.0 1.6 1.2 0.7 Othrs 2.1 0.0 1.6 0.0 0.9 Frquncy/day: Man 2.6 2.5 2.5 2.5 2.5 Consumption by othr HH mmbr (%) Ys 48.5 24.2 38.8 41.9 38.8 Rcivd othr food complmnt packags (%) Ys 13.5 38.7 14.1 14.4 20.3
Tabl 3.7. shows that in gnral, mothrs knw how to prpar VTDL from information on sacht (40.1%), cadrs (35.6%), halth providrs which was midwivs and/or pusksmas prsonnl (15.1%) and thir own xprinc (6.1%).
Qualitativ rsults: th rason for not rciving VTDL Th most complains xprssd by cadrs was th irrgularity of th supplis, spcially clos to th nd of th program. Othr complains xprssd by thm wr no transportation funds and no incntiv for cadrs to implmnt th program. In trm of irrgularity, if VTDL cam thy wr distributd vnly to all villags, and in many cass it was not nough, and in othrs it was too much. agar smua dsa dapat biar adil.. nanti dsa lainnya iri. Somtims th cadrs from th villags with shortag of VTDL would lookd for VTDL from othr villags. Th cadrs actually did not know how much VTDL xactly thy should rciv.. Kita tinggal nunggu dropping It was prcivd by PKK, PEMDA or halth prsonnl including bidan, that th rsponsibl prson for CFI program was cadr. Som bidan for xampl claimd that vn though thy know about th program, thy did not know about th distribution and th funding bcaus thy did not involv thm. I knw about th program it s cadrs rsponsibility. Up to thm. I don t know much. Including th mony Usually th cadrs pickd up th VTDL at sub-district or villag offic. In som aras, th bidan pickd up th VTDL, bcaus crtain community considrs VTDL as a halth rlatd packag, and that childrn s halth was bidan s rsponsibility. At villag lvl, th VTDL was distributd ithr dirctly to th hom of th targt childrn, pickd up by mothrs at cadr s hom or during posyandu activitis. Dspit of th abov complains, cadrs prcivd that th community lik VTDL program and xpctd that
th program will continu. Howvr, thy suggstd that th supplis should b rgular and basd on th nds of thir posyandu; thr should b transportation funds for distribution and incntiv for cadrs. Cadrs: kapan ada lagi?... masyarakat snang ada VTDL asal tratur datangnya
VTDL Consumption Figur 3.5. Frquncy of Vitadl Consumption/day P r c n t a g 100 80 60 40 20 0 59.0 57.3 55.2 47.9 54.6 41.0 42.7 44.8 52.1 45.4 W. Java C. Java E. Java W. Sumatra Total < 3 tims >= 3 tims Avrag frquncy of VTDL consumption was 2.5 tims pr day. Mor than half (54.6%) of mothrs srvd VTDL 3 tims (as rcommndd) or mor pr day (Figur 3.5.). Th prcntag of childrn who always finishd VTDL mal was 41%, and about 45% statd somtims th childrn didn t finish. Rasons for lft ovr varid including and in particular th portion pr srving that was too big (54.9%), th childrn did not lik th tast (14.0%) and childrn wr sick or lost of apptit (15.1%) (Figur 3.6). Th main rason for childrn did not lik VTDL was bcaus of its tast and smll. W did analyz whthr thos childrn who did not finishd th mal was thos who wr youngr (assuming that th portion was too big), th rsults indicats thr was no such rlationship.
Figur 3.6. Rason for lft ovr P r c n t a g 100 80 60 40 20 0 49.2 13.5 16.7 13.4 3.6 5.2 53.8 54.2 20.5 10.8 9.6 12.2 62.4 19.4 14 9.5 4.6 5.4 W. Java (n=248) C. Java (n=212) E. Java (n=157) W. Sumatra (n=237) 54.9 15.1 Total (n=854) Kid didnt lik tastd not good Too big siz Child sick/lost of apptit Lakag of VTDL consumption in trm of fals positiv, rflctd by th rcivr of VTDL who wr youngr than 6 months (14.2%) and oldr than 12 months (34.4%) and mothrs rport on th proportion of othr houshold mmbrs who hav vr consumd VTDL which was accountd for 38.8%. Othr HHs mmbr who hav vr consumd VTDL mostly wr othr kids (62.0%) and mothrs (34.0%). In trm of othr food complmnt, in all provincs similar food complmnt program was also xistd. It was almost 20.0% of thm rcivd it. In Cntral Java, th prcntag was th highst (38.7%) as compard to othr provincs (around 15%) (Annx: Tabl 6) Qualitativ rsults : Th rason for not consuming appropriatly Thos who did not consum or consumd lss claimd that th rason was th tast... anak saya nggak suka rasanya, sprti bau apk langu sprti bau obat.... rasanya sprti tpung manis, tidak sprti SUN.., PROMINA nak anak saya sjak dikasih SUN tidak mau lagi makan yang lainnya.. anak saya nggak suka lagi, bosan
Mothrs somtims cookd VTDL as cak (bolu) or banana cak (ku pisang), or mixd VTDL with othr product such as SUN and PROMINA. Th tast that was mostly likd was banana in East Java, Cntral Java (and mung ban flavor) and Wst Java, bcaus it s swtr. Whil in Wst.Sumatra thy lik rd-ric tast mor, bcaus it s mor cramy. In gnral, in Wst Sumatra popl think that VTDL was not nutritious bcaus th pric was chap. It was chap (murahan) food, no nutrition.. It s just lik ordinary flour Th sam commnt was also raisd in Cntral Java: harganya murah, gizinya masih lbih banyak SUN, PROMINA atau NESTLE As statd by cadrs, in gnral mothrs lik th program and xpcting that th program will continu. Howvr th tast should b bttr and thr should b mor variation. In gnral mothrs can accpt th pric.
3.2.3. Childrn s Nutritional Status Comparing btwn intrvntion and control groups, it is intrsting to notic that for all anthropomtric indicators (WAZ, HAZ and WHZ) th two groups wr quit similar. By provinc, th diffrnc btwn intrvntion and control groups was only found in Cntral Java, i.. th prvalnc of malnutrition, spcially svr malnutrition, in intrvntion groups was lowr than in control groups. Childrn in this study wr mor chronically malnourishd rathr than acutly malnourishd as rflctd by th prvalnc of thos <-2.0 SD for WAZ and HAZ which was mor than thr tims highr than th prvalnc basd on WHZ. 100 Figur 3.7 Childrn s Nutritional Status (Z-scor) P r c n t a g 80 60 40 20 0 70.7 70.9 69.4 67.2 24.7 22.6 23.3 25.4 4.6 6.4 7.3 7.3 Intrvntion (n=1311) Control (n=236) Intrvntion (n=1309) Control (n=234) 92.3 91.4 6.4 8.2 1.3 0.4 Intrvntion (n=1309) Control (n=234) WAZ HAZ WHZ Svrly undrwight (<- 3 SD) Undrwight (>= -3SD - < - 2D) Normal (>= - 2SD) Figur 3.7 xhibitd anthropomtric status for intrvntion and control groups, basd on th Z-scor valus of WAZ, HAZ and WHZ. For WAZ indicator, th prvalnc of svrly undrwight was slightly lowr in th intrvntion groups, whil th prvalnc of undrwight was slightly highr. According to HAZ indicator, th prvalnc of svrly stuntd was th sam for both groups, whil th prvalnc of stunting was slightly lowr in intrvntion groups. For WHZ indicator, th prvalnc of svrly wasting was considrably small, and th prcntag was
slightly highr in intrvntion than in control groups, whras th prvalnc of wasting was slightly lowr in intrvntion than in control groups. In comparison with data from Jahari (2000) th figur of svrly undrwight from 4 provincs wr somwhat bttr particularly for svr cass. Th data showd th prvalnc of svrly undrwight (< -3 SD) among childrn 0-59 months basd on WAZ was 9.5%, and 18.9% wr modrat/mild undrwight (> -3 SD - < -2 SD). Th rsults show that in trm of WAZ and HAZ indicators, th prcntags (around 30%) of childrn undr < -2 SD (undrwight and stuntd) was obviously highr than th prcntag (about 10%) of childrn with WHZ undr < -2 SD (wastd). Th figurs wr similar for ach provinc. Low WAZ and HAZ rflct long trm malnutrition and poor halth whil low WHZ implis rcnt or continuing currnt wight loss (WHO Exprt Committ,1995). Thus, anthropomtrically, childrn in this study wr chronically malnourishd rathr than acutly malnourishd. This might b rlatd to a dficit associatd with th past vnt or dficit associatd with a long trm, continuing procss. As showd in th prvious rsult, mor childrn hav vr xprincd diarrha in th last 3 months in th control groups, howvr, mor childrn in th intrvntion groups xprincd diarrha mor frquntly than th control groups. It was rcognizd that diarrha has mor dtrimntal ffct on nutritional status than ARI has (Mosly and Chn, 1985). Furthr xamination on th rlationship btwn diarrha and nutritional status (WAZ) showd that diarrha was significantly rlatd with nutritional status, th prvalnc was highr for thos childrn with WAZ <-2.0 SD. Tabl blow shows th rsults of Z scor on childrns nutritional status in ach provinc. In Wst Java, th nutritional status of childrn btwn intrvntion and control groups was similar. In Cntral Java, th nutritional status of childrn in th intrvntion groups was bttr for all indicators. In East Java, th figurs for HAZ and WHZ wr similar, whil for WAZ th status was slightly bttr in th control groups. For Wst Sumatra, all districts rcivd intrvntion; thrfor th comparison was mad btwn citis (rprsnt urban) and districts (rprsnt rural). Th rsults showd that th nutritional status in th citis and districts for all indicators wr about th sam. Tabl 3.9. Childrn Nutritional Status (Z-scor) in Intrvntion & Control groups by Provinc Variabl W. Java (%) C. Java (%) E. Java (%) W. Sumatra (%) I C I C I C I Dist City Wight for Ag (WAZ) N 391 78 352 83 302 74 428 266 162 Svrly undrwight (<-3SD) 6.6 7.7 3.4 7.2 3.6 4.1 3.7 4.1 3.1 Undrwight (> -3SD - < -2 SD) 25.3 23.1 24.4 25.3 25.8 19.2 22.7 22.9 22.2 Normal (> -2SD) 68.0 69.2 72.2 67.5 70.5 76.7 73.6 72.9 74.7 Hight for Ag (HAZ)
Thr was almost no diffrnc rgarding cadrs knowldg and practic in wighing. It should b notd that almost 40% of cadrs did not know how to rcord childrn s wight N 393 77 350 83 301 73 428 265 163 Svrly stunting (<-3SD) 8.1 6.5 6.3 9.6 8.3 5.6 6.1 6.4 5.5 Stunting (> -3SD - < -2 SD) 23.7 24.7 27.1 28.9 20.6 22.2 21.3 20.8 22.1 Normal (> -2SD) 68.2 68.8 66.6 61.4 71.1 72.2 72.7 72.8 72.4 Wight for Hight (WHZ) N 389 77 349 83 300 73 426 265 161 Svrly wasting (<-3SD) 1.8 0.0 1.1 0.0 0.3 1.4 1.6 1.9 1.2 Wasting (> -3SD - < -2 SD) 6.9 9.1 4.9 8.4 7.3 6.9 6.8 6.4 7.5 Normal (> -2SD) 91.3 90.9 94.0 91.6 92.3 91.7 91.5 91.7 91.3 Stratifid by sx, thr was no diffrnc found for all provincs for all anthropomtric indicators. Thus, sx was not an xplanatory variabl hr and will not b discussd furthr. 3.2.4. Wr childrn growing at appropriat rat? No conclusion can b drawn du to unavailability of or incomplt KMS rcordd. Th impact of intrvntion on th proportion of childrn growing at appropriat rat could b valuatd by comparing childrn undr two yars old whos wight was not incrasing. Howvr, data to b usd, that is, data rcordd on KMS wr ithr not accssabl (mor than 30% in intrvntion groups KMS wasnot availabl) or th data rcordd on KMS was incorrct. Qualitativ rsults : Why it was difficult to gt KMS? Th rsult from qualitativ assssmnt rvald that mothrs did not considr important to com to posyandu whn th childrn had finishd thir immunization (on yar old). Thy considrd th only rason to com to posyandu was to gt th childrn immunizd. Wighing was not considrd important... apa gunanya datang k Posyandu kalau hanya untuk timbang... malu kalau bawa anak yang sudah bsar untuk timbang. Th cadrs wr usually rluctant to mak RR information, including KMS and SKDN, thr was no incntiv for doing RR. Thy just prpard VTDL rporting and rcording whn thy know that thr will b valuation. Anothr rason was bcaus th targt for VTDL wr childrn 6-12 months old, so thr was no rason to mak RR bcaus usually th childrn did not com to posyandu aftr thy rachd 12 months old. 3.2.5. Cadrs Knowldg and Skills In gnral, cadrs knowldg about brast-fding is sufficintly good, howvr, thr is almost no diffrnc btwn cadrs knowldg in intrvntion and control groups. In both groups, mor than fifty prcnt cadrs knw about immdiat brastfding (< 30 minuts), around 90% knw that colostrums should b givn, 61-77% knw that colostrums incras immunity and about 86% knw th lngth of xclusiv brastfding was 4 6 months.
Training Implmntation at Provinc Lvl Th training was conductd in Novmbr and Dcmbr 1999 and 2000 mostly for about 2 days. Th training usd a modul consistd of 11 topics/aras, including Matrnal and Child Halth (MCH), nutrition, wighing, immunization, supplmntary fding, tc. Th numbr of trains was about 25 100 prsons pr class, and was conductd at Subdistrict offic. Th trainrs wr a tam from district lvl (District Halth Offic, PKK, BKKBN, Agricultur, Pusksmas). In gnral cadrs undrstood that th purpos of th program was to improv th undr-fiv s nutritional status, and thy undrstand that th targt of th program was infant of 6-12 months old. Tabl 3.11.a Numbr of Cadrs Traind Variabls Numbr I C N = numbr of cadrs 313 58 Numbr of cadrs attndd last training (%) > 3/posyandu 62.9 65.4 2 23.7 23.1 1 13.4 11.5 Man 3 3 Mdian 3 3 Numbr of cadrs attndd training and still activ (%) > 3/posyandu 51.0 61.5 2 28.5 21.2 1 20.5 17.3 Man 2.6 2.8 Mdian 2 3 Rgarding training of cadrs, in mor than 60% of posyandu in intrvntion groups having at last 3 of thir cadrs attndd training. Howvr almost th sam prcntag of cadrs in control groups attndd training which was givn by othr programs. Thos cadrs who wr still activly ngagd in posyandu s activitis was slightly dcrasd in both groups. Th man of cadrs attndd last training in intrvntion groups was 3 but th man of thos who wr still activ was dcrasd to 2.6. Th mdian was also dcras from 3 to 2 (Tabl 3.11.a.). Tabl 3.11b. Numbr Variabls I Numbr C of N = numbr of cadrs 313 Activ Cadrs 58 Numbr of cadr in Posyandu > 5/posyandu 33.9 65.5 4 25.9 10.3 3 28.8 20.7 2 9.3 3.4 1 2.2 0.0 Man 4 5 Mdian 4 5 To s th currnt situation about th availability of cadrs in posyandu, tabl 3.11b. shows that th prcntag of posyandu s having 5 cadrs was much lowr in intrvntion groups than control groups. Most posyandus in intrvntion groups hav 3 4 cadrs pr posyandu.
Cadrs Knowldg and Skill on Brastfding and Wighing Tabl 3.12. Cadrs knowldg about brastfding Tabl 3.12 shows th prcntag of cadrs knowldg rgarding brast-fding. Ovrall thr was almost no diffrnc Total Variabls btwn intrvntion and I C control groups. In both groups, N 313 58 mor than fifty prcnt of Cadrs knw about immdiat brastfding (%) cadrs knw about immdiat Know 54.0 53.4 brastfding (<30 minuts). Did not know 46.0 46.6 In trms of knowldg about Cadrs knw colostrums could b givn to infant (%) colostrums, th prcntag of Ys 92.9 89.7 cadrs who knw that colostrums should b givn to Knowldg about colostrums advantags (%) Facilitating utrus contraction 1.3 0.0 infant was slightly highr in Prvnting blding 0.3 0.0 intrvntion groups (92.9%) Incrasing immunity status 60.9 77.6 than in control groups (89.7%). Prvnting illnss 21.2 19.0 In both groups, most cadrs Strngthn matrnal and infant s bond 3.8 0.0 knw that colostrums was Stimulating brast-milk good, mostly bcaus it production 2.2 0.0 incrass infant s immunity Providing nutrint/vitamin 16.3 3.4 status and prvnts illnss. Infants halth 14.7 15.5 Othrs 3.9 1.7 Th prcntag of cadrs knowldg about 4 months Knowldg about xclusiv brastfding duration (%) xclusiv brastfding wr < 4 months 9.6 6.9 slightly highr in intrvntion 4-6 months 87.2 86.2 > 6 months 2.2 3.4 groups. Figur 3.8 Cadrs Knowldg & Skills Rgarding Wighing P r c n t a g 100 80 60 40 20 0 36.7 39.7 63.3 60.3 Intrvntion (n=1311) Control (n=236) 73.2 26.8 Intrvntion (n=1309) 84.5 15.5 Control (n=234) 33.5 66.5 Intrvntion (n=1309) 15.5 84.5 Control (n=234) Rcord child s wight on KMS intrprt child s wight on KMS Corrct Incorrct Abl Unabl Dtct growth faltring
Figur 3.8. provids information about cadrs knowldg and practic rgarding wighing. In th qustionnairs cadrs had bn askd to mak a plot on KMS basd on a givn cas problm. Th prcntag of cadrs who corrctly rcordd child s wight on KMS was slightly highr in intrvntion groups (63.3%) than in control groups (60.3%). Th scond cas problm was asking th cadrs to intrprt child s wight who was incrasd but moving to th lowr band of KMS. Th prcntag of cadrs who gav corrct answr was rlativly small in both intrvntion and control groups, though highr prcntag was found in intrvntion groups. This rflcts th lack of ability of cadrs to intrprt a mor complx situation of wight trnd. Th diffrnc btwn cadrs in intrvntion and control groups mrgd whn cadrs wr askd to dtct growth faltring. Th ability of cadrs to dtct growth faltring was bttr in control groups (84.5%) than in intrvntion groups (66.5%). On possibl xplanation for this rsult was that thr was similar program givn to cadrs in th control groups such as posyandu cadrs training program by JPSBK. In intrprting th ffct of intrvntion on cadrs knowldg and practic, it was important to look back at th cadrs charactristics in intrvntion and control groups. Cadrs in control groups had significantly bttr ducational background and oldr in trm of chronological ag rflcting mor xprincs and accumulativ knowldg. Mothr s Knowldg on Brastfding, Fding Practics and Growth Rgarding knowldg on duration of xclusiv brastfding, th prcntag of mothrs in intrvntion groups who knw corrctly was slightly highr (70.2%) than in control groups (67.5%). In trm of brastfding practics among mothrs who knw xclusiv brastfding 4-6 months only about half of thm practicd it both in intrvntion and control groups. Mor than half of mothrs in both intrvntion and control groups knw th idal position of child s wight on KMS. Mor mothrs in