Sheri P Palmer, Associate Teaching Professor of Nursing
The nutritional improvement study in Ecuador has been a worthwhile endeavor that has enabled many nursing students to participate. Students have been able to participate in actual data collection and data entry, as well as seeing and discussing results from previous years of the study. Students work with the schoolchildren with whom this study affects and can be a vital link in the progress of the research. The mentoring of these students in this important research work has helped them realize the significance of improving global health.
Simply put, the nutritional improvement study measures the hemoglobin level of select schoolchildren at the start of their school year. Then during the school year they are in one of four intervention groups, the children receive: 1) a multivitamin with iron, 2) an anti-parasite medication, 3) both a multivitamin and an anti-parasite medication, or 4) a snack of soymilk and a roll. At the end of the school year the children are measured again. The results of the hemoglobin levels are then evaluated for evidence of change.
In May 2011, the study tested 1031 school children for anemia and growth/development. This year the College of Nursing found that nearly 31% of the children measured suffered from anemia, with only one child suffering from very low anemia. This is a 2% decrease from the previous year.
In May 2012, the study tested 494 additional school children for anemia and growth/development. We found that nearly 40% of the children measured suffered from anemia. This is an increase from the previous year. After the children were measured in May 2011 we initiated the interventions with very successful results. In essence, the interventions decreased the rate of anemia by two-thirds. Results from the nutrition analysis from the past 2 years show a large deficit of calcium, folate, and animal-based protein. The low animal-based protein directly affects the iron levels in the blood, resulting in low hemoglobin.
The first year of intervention showed a large success rate of decreasing anemia in the groups. Due to this it is our intent to retest as many children as possible in the same schools again this year. We are employing the same interventions, as well as following a control group. We are also attempting to control for more variables this time.
Assessment of academic objectives:
We were able to use the Mentoring Environment Grant for at least two years of mentoring students in the research study.
The nursing students who participated in the study were trained in measurement techniques to be consistent and as accurate as possible. Each year the training took place in an organized setting before we left the United States. The work in Ecuador consisted of the following: the students went out as groups of 6-8 and were accompanied by their mentor teacher, as well as a few workers from the Hogar de Cristo. Lines of school children were formed and the students rotated the children through various stations. The nursing students were able to measure about 100 children a day on average. They were able to measure height, weight, and hemoglobin. Along with this data, they collected nutritional data from a 24 hour survey, as well as basic demographic data. Students were vested in the research project and enjoyed doing the actual process of data collection through quantitative and qualitative methods. All students that went on the study abroad group to Ecuador were able to participate in this mentored research.
Evaluation of the Mentoring Environment:
Students attended a “culture class” for one semester prior to leaving on the foreign experience each year. The culture class was taught by their faculty mentors who guided them in researching the country, people, and needs. Mentoring started during this semester as experienced leaders share with the students past challenges and successes of the project and prepared for the upcoming trip.
The mentoring environment in Ecuador included approximately 4 weeks, 24/7 contact with the mentors, in the hospitals and communities within which the worked. This was ample time for personal and professional relationships to form. During the time in Ecuador students were able to show leadership and teaching skills through various presentations they had prepared. Students grew in their confidence in both presenting health topics to groups of people, but also in their Spanish skills. The content of the Global Health and Cultural Diversity class is ever-present on their minds as class and discussion is held routinely throughout the experience. This mentoring project focused on the health of school children, but the nursing students also experienced the Ecuadorian culture in day to day events. Highlights of the trip were attending the local ward, presenting stake and community health fairs, and building sugar cane houses out in the community. Through the example of their mentors, students learned how to be representatives of BYU and the College of Nursing. Through nightly group devotionals students were able to reflect about their day, process experiences, and share thoughts and testimony about caring for God’s children. These various learning environments have been developed over the past few years and have provided a safe, productive, and culturally diverse atmosphere in which to mentor students.
The mentoring did not end at the conclusion of the trip. Students have been able to continue their relationship with the faculty. Some of them have had the opportunity to help prepare abstracts, present at conferences, and write scholarly papers about this research and their experiences in Ecuador.
Students who participated:
- Kayla Cox
- Ashley Barrow
- Lacey Suzanne Downing
- Cristy Jane Johnson
- Alexa Christine Smith
- Hannah Dallon
- Rachel Christine Romney
- Elizabeth Anne Gubler
- Andrew Jason Christensen
- Carly Jan Hewett
- Angela Cameron Astle
- Caitlyn Mary Vernon
- Ashley Ann Langford
- Matthew Duane Crooks
- Ryan Taylor Manwaring
- Brittany Lynn Bushnell
- Cassidy Lee Tomao
- Ty Weber
- Nicole Graham
- Tad Sugiyama
- Samantha Webber
- Camilla Dollahite
- Erika Brown
- Mckenzi Fackrell
- Devaun Sheppard
- Jaqueline Grange
- Katrina Hale
- Hillary Jones
- Tiffany Campbell
- Brittany Kocherhans
- Jaclyn Hamm
- Alyssa Jensen
Academic Deliverables: *indicates student mentored
Peer-reviewed, blinded podium presentations
International Podium Presentations
Palmer, S., Heaston, S., Rowley, C.* & Brizzee, M.* (2013, October) “Improving nutrition in Ecuador, Results of anemia interventions. 39th Annual conference of the Transcultural Nursing Society, Albuquerque, NM.
Palmer, S., Heaston, S., Kochever, C.*, Sheppard, D. *(2012, October). “Improving Nutrition in Ecuador: A Partnership with Nursing Students and Hogar de Cristo.” Transcultural Nursing Society, 38th Annual Conference, Orlando, FL
Peer-reviewed, blinded podium presentations
National Podium Presentations
Astle, A.*, Heaston, S., & Palmer, S., (2012, April). “Study of malnutrition and anemia rates among children in the perimetral area of Guayaquil, Ecuador and its effects on growth and development,” National Conference on Undergraduate Research, Ogden, UT
Peer-reviewed, blinded podium presentations
Regional Podium Presentations
Webber, S.*, Dollahite, C.*, Heaston, S. & Palmer, S. (2012, February). “Results of Interventions among Anemic and Malnourished Children in an Impoverished Ecuador Community.” Utah Conference on Undergraduate Research (UCUR), Logan, Utah
Palmer, S.P., Heaston, S., Hickman, N.*, Tomao, C.*, & Cudahy, B.*, (2011, February). “Study of malnutrition and its effects on growth and development among children in the perimetral area of Guayaquil, Ecuador.” Utah Conference on Undergraduate Research (UCUR), Ogden, Utah
Dollahite, C.*, Webber S.*, Heaston, S., & Palmer, S. (2013). Western Institute of Nursing Research Conference. Anaheim, CA
Open peer-reviewed poster presentations
Regional/Local poster presentations
Palmer, S., Heaston, S., Tomao, C., Smout, K. (2012). “A Study of Malnutrition and an Intervention among Children in Guayaquil, Ecuador”, Global Family Health Conference. Brigham Young University, Provo, UT.
Palmer, S., Heaston, S., Smout, K.*, & Tomao, C.* (2011). “In Home Nutritional Assessment Project of Poverty stricken areas of Guayaquil, Ecuador.” Global Family Health Conference: Global Health Issues, Domestic Applications Program, Brigham Young University, Provo, UT.
Descriptive statistics for demographic characteristics and baseline measurements are reported in Table 1. Group comparisons for demographic characteristics and baseline measurements were performed using χ2 tests for categorical variables and analysis of variance (ANOVA) for continuous variables. A total of 494 children at four different schools were included in the study. The mean (sd) age for the sample overall was 7.9 (2.4) years at baseline. Mean ages for the four participant schools are reported in Table 1. Significant group differences in age are noted. Accordingly schools varied in grades represented. Only grades two through five were represented at all the participant schools with school four showing the largest number of grades represented ranging from Kindergarten through tenth grade. Average heights, weights, BMI, and hemoglobin levels are also reported in Table 1. Significant group differences at baseline are also noted. Anemia status was not uniform at baseline at the four schools. School one had the highest rate of anemia at baseline with over half (54%) of the students being anemic. School three had the lowest anemia rate at baseline with 18.5% of the children classifying as anemic.
Data were analyzed using RMANOVA to evaluate the effect of treatment and time on hemoglobin levels. Hemoglobin level measured in May, 2012 was the dependent variable. The within-subjects factor was time with two levels (baseline, post intervention). The between-subjects factor was treatment condition with four levels (anti-parasite medication, vitamins with iron, medication and vitamins, soymilk and roll). Levine’s test for homogeneity of variance at baseline was significant indicating the homogeneity of variance assumption was not met at baseline. Levine’s test was not significant at follow up indicating the assumption was met. The interaction of time X treatment condition was not significant. The within-subjects factor of time was significant F(1, 482) = 155.8, p = .000, partial η2 = .24. The between-subjects factor of treatment condition was significant F(3, 482) = 15.2, p = .000, partial η2 = .09.
A paired t-test was conducted to follow up the significant main effect of time. There was a significant increase in mean hemoglogin levels from time 1 to time 2 t(485) = 13.46, p = .000, d = .61. Mean and standard deviation for hemoglobin at time 1 was 11.8 (1.7) and at time 2 was 13.2 (1.9). Pair wise comparisons were conducted to follow up the significant main effect of treatment condition. Mean differences, standard errors, and significance levels are reported in Table 2. Treatment conditions seemed to fall into two groups. The Anti-parasite and Vitamins with Iron groups did not show significant differences from each other and showed significantly lower hemoglobin levels than the combined Vitamins & Anti-parasite and the Soymilk & Roll groups. The Vitamins & Anti-parasite group and the Soymilk & Roll group were not significantly different from each other, but were significantly higher than the other two groups. Familywise error rate across these tests was controlled using a Bonferroni correction. Mean hemoglobin levels at time 1 and time 2 are reported in Table 3. Mean hemoglobin levels with 95% confidence intervals at time 1 and time 2 for each intervention are shown in Figure 1.
Analyzing the data using analysis of covariance (ANCOVA) to adjust for baseline group differences in hemoglobin levels at time 1 did not change the result. The Anti-parasite and Vitamins with Iron groups had lower time 2 hemoglobin levels and the Combined Anti-parasite & Vitamins and the Roll & Soy Milk groups had higher time 2 hemoglobin levels. The results are not reported here, but are available upon request.
Logistic regression was used to examine the dichotomous outcome of anemia status at time 2 to determine which variables affect the probability of being anemic (Munro, 2005). Of the data collected, only treatment condition was found to be a significant predictor of anemia at time two. The analysis using treatment condition as the only predictor is reported here. A small -2 log likelihood indicates a model with better fit (Munro, 2005). The -2 log likelihood for our model was 405.7. The Cox & Snell and Nagelkerke R square provide estimates how much variance is accounted for in the analysis (Munro, 2005). The values for Cox & Snell R Square and Nagelkerke R Square were .037 and .064 respectively indicating that our analysis accounted for between 3.7% and 6.4% of the variance. The results of the Hosmer and Lemeshow test were not significant indicating that our data fit the model. Our model was shown to correctly predict anemia status 84.6% of the time. Anemia rates at time 1 and time 2 are reported in Table 2.