Form7(by MS Word data)
Grant No.

17－054

Research Report
Name :Thida Win
Organization (at the start of the grant): Department of Public Health and Occupational Medicine,Graduate School of Medicine, Mie University
Title of Research: Social capital and childhood undernutrition in Myanmar: A household based crosssectional study
Purpose of Research:
Myanmar is one of the least developing countries and is experiencing the challenges of diverse
issues. Across a range of issues and problems, child undernutrition arose to meet improvement in thehealth of people addressing huge health gap and critical social agenda. Regionally, Myanmar is one of
the highest burdens of child undernutrition among South East Asia (SEA). Meanwhile estimated 84%of global burden of underweight among children of under five years old age (U 5) were in Africa and SEA
which was linked to 45% of global child death. Therefore to reduce malnutrition and ensure earlychildhood development is major concern of health policies. Child nutrition and development has
affected by familial, socioeconomic and political progress. Explicitly the cultural and social life of family
members and that of community is essential to attain adequate nutrition and child health development.
In addition multi-facets nature of inadequate nutrition makes necessarily to study it from societal
perspective.
Regarding that view, social capital: “resources composed of or derived from trust, and/or norms(especially reciprocity), and/or networks, which facilitate collective actions” is crucial for promotion ofchild health and development which in turn allow to improve population health. Social capital is
positively related to child health and welfare through increasing trust among members, promotingsocial support and participation, and increasing social networks in the community as well as in thefamily. In addition social capital is complementary to economic and human capital particularly in
disadvantaged communities or low income countries, so that it is likely to be beneficial for childnutrition. Particularly social capital might be fruitful for the society like Myanmar which practices
extended family pattern and the society that intertwines extensively among families, relatives,neighbors and communities. Moreover in this newly-reforming time of Myanmar, social capital thatenhances the lives of people, integrates society and helps consolidate a fragile transition is a powerfultimely opportunity for childhood nutrition and development.
In practice, the parental social capital regarding child undernutrition can be built along withongoing activities by strengthening the social capital in communities. Multi-sectoral approachconsidering social capital would become effective than single component interventions for nutrition
promotion in poor countries. Therefore this study would fulfill the needs to development andproductivity of the society as a baseline to benchmark the social capital in relation to undernutrition in
the poor country.
Content/Methodology of Research: （800 words）
This research was a three-phased study comprising of the qualitative research of social capitalin Myanmar, the cognitive validation of World Bank social capital core questionnaire (SC-IQ) andfinally the household based cross-sectional study for the relationship between parental social capitaland child undernutrition. Ethical approval was taken from Myanmar Ethical Review Committee (ERC008517) and Mie University Institutional Review Board (U2018-011). Both verbal and written informed
consents were taken from the participants of all phases of the study. The first-phased study was thequalitative, focus group discussions which were carried out in urban and rural area of three main
regions of Myanmar namely hilly, plane and delta regions during December 2017 and January 2018 toexplore the nature and extent of social capital in Myanmar communities. The study included 12 groupsof discussions in which each group comprising of 6-12 community leaders or community members who
were 18 years or above (Figure 1). The transcribed notes were analyzed by thematic approach based on
preconceived six dimensions of social capital using the Atlas ti 8software.

Figure 1 Focus Group Discussions in Myanmar townships
For second phase, the World Bank social capital core questionnaire (SC-IQ) was translated tolocal language by professional translators and was adapted to local setting by forward-backward
translating method. Followed by cognitive validation of SC-IQ was carried out by cognitive
interviewing to the 30 participants in three townships of Myanmar which had similar characteristics ofthe final household-based study during April 2018 - May 2018 (Figure 2).

Figure 2 Cognitive Interviews with the participants from Myanmar townships
After the SC-IQ questionnaire was revised and cognitively validated, a pilot study of social
capital and child nutrition was done in one township which also had similar characteristics of the final
household based study wherein total 150 fathers and their 6-59 months old biological children wererandomly recruited to participate in the study during July 2018 (Figure 3). After cleaning of the data,
data entry was done using Excel 2016 and the data was analyzed using the SAS software 9.4.

Figure 3 Training the interviewers, pilot data collection and supervision of pilot datacollections
Starting from August 2018, data collection of the final household-based cross-sectional study
was continuing and the process was planned to finish at the end of October 2018 or the early November
2018. Children of age between 6-59 months in Myanmar were the target population. The sample size of1519 households having at least one 6-59 months old child who currently lives with his/her biologicalfather under same household was chosen using United Nations’ recommended formula for households’
survey in developing countries. Stratified multi-staged cluster design was applied. Study area were in
6 (nearly 65% of total U5 population) out of 15 states/regions, reflecting each 2 regions from each high,medium and low underweight prevalence of U5 children in Myanmar (Figure 4).
In the first stage, each region was stratified by townships and total 7
townships were allocated in proportion to the size of different states/regions byproportionate stratified sampling.

In the second stage, 3 wards (urban area) and 4 villages (rural area) werechosen from each township, using the probability proportional to size method, so Figure 4 Study areas
there were 21 wards and 28 villages. In the third stage, 22 households were selected for quantitative datacollection
randomly from each ward, while 38 households were selected randomly from eachvillage so that 455 households from the wards and 1064 households from villages.

Figure 5 Training the interviewers, and supervision of data collections for final
quantitative study

Information regarding the location of households was obtained from Township Administration
Offices and Township Health Departments. In the fourth stage, one child was selected randomly fromeach household comprising 455 children from wards (urban area) and 1064 children from villages(rural area) pertaining to total 1519 children. In stage three and four, the selection was done in linewith current 30% urban- 70% rural population distribution of Myanmar. Informed consents wereobtained by verbally as well as by written documents from biological fathers of the children. Biologicalfathers were interviewed face to face by using structured questionnaires in local language. The
anthropometric indicators (weight and height) of children were measured by standardized weighingmachines and length boards. Child undernutrition was defined according to WHO child growthstandard 2006. If there would be more than one child of that age in the same household, only one childwas selected randomly. Interviewers were intensively trained through workshops and all the datacollections were supervised by principal investigator.

Conclusion/Observation（400 words）
The findings from the qualitative study of social capital in Myanmar communities pointed outthat the high connections were prevalence among kin, friends and neighbors of both rural and urban
communities indicating high bonding social capital. Higher connections were found among different
groups (bridging social capital) in urban compared to rural communities. On the other hand very few
connections to higher authorities or personnel (linking social capital) were in urban while lack of thatin rural communities. Formal social organizations existed in urban although local informal socialorganizations were dominant in rural communities. In both communities, social supports by the groups
were in the form of charity or friendship-based particularly providing to poor people enhanced the localcommunity wellbeing and development. Thick trust among relatives, neighbors were very dense
enabling them to access to the health, financial, physical and social resources facilitating theirwellbeing. Thin trust developed from community groups contributed to further cooperation amongcommunity members.
Traditional religious, wedding and funeral ceremonies were locus of generating the collective
actions in both rural and urban communities. Local leaders and elders were the dominant facilitatorsfor initiating the cooperation in order to achieve community wellbeing. Both rural and urban
communities were said to be cohesive with the few social disharmony which were solved by local
traditional custom, the respect from generation to generation, deferential problem solver role of local
leaders and the kin relationships. The information regarding government actions and market news
were mainly gained from friends, relatives, neighbors, local government leaders and local leaders inboth communities. The communications were in the forms of in-person contact, phones or loud speakers.
In urban communities the communications were replaced by internet social media although the local
traditional informant system was still practicing in local communities. Both rural and urban
communities did not have loud voices for their rights and they felt fewer satisfactions upon government
actions because of government mismanagement, less decentralization and having no role of community
members in decision making and planning for their communal developmental projects and activities.
The study indicated that the strong bonding social capital, the reliable social supports, andthe collective and cohesive nature of the local community are likely beneficial to the wellbeing anddevelopment of community members in Myanmar.
For cognitive validation study, the SC-IQ questionnaire was validated from the verbatim basedon the Toruangeau four phases of cognitive process. It was found out that the most prevalence issue inthe questionnaire was comprehension dimension which was followed by retrieval, processing, response
and inappropriate dimensions respectively.
After revision of the SC-IQ questionnaire, the pilot study was conducted in one township andthe results were as the followings. The different aspects of the social capital of fathers were associatedwith child nutrition differently. The fathers who had higher in-person social supports or higher social
cohesion were associated with better acute nutritional status of the children while fathers having
higher social support in advice or information or having higher empowerment were associated with

poor acute nutritional status of the children. Similar patterns were also seen in the association
between the relationship between father’s social capital and chronic nutritional status of the childexcept no association was found in the in-person social supports of father and chronic nutritional statusof the child. Although the pilot results are early to reach the conclusion, the pilot study was useful forfinal data collection in term of time, finance and knowledge. As the final cross-sectional householdbased study is undergoing recently in Myanmar townships, further informative results are expected tohave better conclusions after accomplishing of it.
Finally I would like to show my sincere and heartfelt gratitude to the financial support ofKonotsuke Matsushita Memorial Foundation which not only was beneficial for my study as part of mydoctoral thesis but contributed to add the scientific knowledge into the field of child nutrition and social
epidemiology.