Reliability of Mini Nutritional Anssessment Scale in Rural Setup of a Tertiary Health Care Hospital in Central India
- 1. Department of Community Medicine, JN Medical College, India
Abstract
Health of an individual is the result of various criteria like healthy nutritional status, excellent functional capacity and favorable environmental conditions. The nutritional status plays a vital role in determining the health seeking behavior and the limitation of functional capacity. So, this 3 month cross sectional study was aimed at determining the reliability of mini nutritional status scale in the field practice area of rural health training centre of Jawaharlal Nehru Medical College, Wardha, Maharashtra, in reference to inter-observer reliability using two pre trained nurses, visited the elderly who had utilized the health care services from the rural health training centre in the last one month duration, by house to house visit, and recorded the information as per MNA scale. The follow up visit, after the first visit of ANM, was done exactly after one month and again the data was recorded in the form of MNA scale. The data collected was analyzed for inter-observer variations, using kappa statistics. Prior approval was sought from the Institutional ethics committee of JNMC. Oral consent was obtained from the participants. Mean score was 19.6 and 20.4, with standard deviation of 2.45 and 3.05 respectively. According to kappa index, test-retest reliability for a stratified total MNA was 0.78, for 18 ordinals, it was nominal items, it was almost perfect, or substantial in 12 items, in 5 items, it was moderate to fair, and in 1 item it was slight. Conclusion: MNA has a good level of reliability and reproducibility, according to its internal consistency.
Keywords
• Mna
• Elderly nutrition
• Geriatric
• Malnutrition
Citation
Gaiki V, Wagh V (2014) Reliability of Mini Nutritional Anssessment Scale in Rural Setup of a Tertiary Health Care Hospital in Central India. Ann Public Health Res 1(1): 1004.
ABBREVIATIONS
MNA: Mini Nutritional Assessment scale; ANM: Auxiliary Nurse Midwifery; MUST: Malnutrition Universal Screening Tool; MEONF: Minimal Eating Observation and Nutrition Form; MUAC: Mid Upper Arm Circumference; ASHA: Accredited Social Health Activist; SD: Slandered Deviation
INTRODUCTION
Deterioration of the nutritional status affects and is affected by disease, especially among the elderly [1]. Nutrition is a key element in geriatric health, and nutritional screening/assessment is a key component in comprehensive geriatric evaluation. Timely screening can help detect early signs of nutritional imbalance and enable intervention to prevent emerging nutritional problems.
There are at least 40 screening and assessment tools for subjective nutritional status assessments, and some are for the general population and others for specific populations [2] like Malnutrition universal screening tool (MUST), Minimal Eating Observation and Nutrition Form (MEONF I and II), Mini Nutritional Assessment (MNA), subjective global assessment developed by Barker et al in 1982, [3] prognostic nutritional index, Detsky index [4]. The Nutritional Risk Screening (NCR2002), proposed more recently, has proven to be an important instrument to assess nutritional risk and predict length of hospital stay of elderly patients.
The Mini Nutritional Assessment (MNA) is one of the most widely used and studied nutrition screening/assessment tools. It was developed and validated with clinical data of patients in Europe and USA in the 1990s for grading the nutritional risk of older adults in Western countries [5-7]. It has sensitivity of 96% [8] and the specificity is of 98% and the prognostic value for malnutrition is of 97% [9] Thus, the MNA is considered a very useful instrument for assessing long-term nutritional risk but not as useful for short term prognoses [10]. In 2006, Guigoz reported that the MNA has been used in 36 studies to assess the nutritional status of 8,596 hospitalized older adults worldwide; of these, 50% to 80% were classified as either at risk for malnourishment or malnourished. Although the tool has been used to assess the nutritional status of non-Caucasian elderly such as the Japanese [11,12], for the best results, it should be modified according to population-specific cultural and anthropometric features in order to maintain content equivalency of the tool whenever it is applied to a population different from that for which it was designed [13].
The MNA is a simple, low cost and non invasive method that can be done at bedside. Added MNA scores allow one to screen the elderly who have an adequate nutritional status, those who are at risk of malnutrition and those who are malnourished. The MNA consists of anthropometric and global indicators, including information on eating patterns and self-perception of health, such as: reduced food intake; weight loss of >3 kg body weight; mobility, bed- or chair-bound; psychological stress; neuropsychological problems; body mass index; inability to live independently; taking >3 prescription drugs; having pressure sores or skin ulcers; number of full meals eaten per day; consumption of high-protein foods; consumption of fruits & vegetables; amount of liquids consumed per day; inability to feed self; difficulty in self feeding; self-view of nutritional status; selfview of health status; mid-arm circumference <21 cm; and calf circumference <31 cm [14]. The tool has been successfully used to assess the nutritional risk of elderly who live independently, receive home care services or are institutionalized, and of patients who are chronically ill, frail, have Alzheimer’s disease or cognitive impairment [15]. This method has been broadly used among the geriatric population [16-20] and a higher prevalence of malnutrition has been associated with the elderly most in need of care [21]. Though it permits early interventions without specialized nutritional team. As such, very little knowledge is available about the inter-observer reliability, though it seems to have moderate level of inter-observer reliability [22]. In this paper, we measure inter-observer reliability, on the mini nutritional assessment tool, in community by trained nurses.
MATERIALS AND METHODS
This study was conducted in the field practice area of Rural health and training Centre, Seloo, Jawaharlal Nehru Medical College, and Acharya Vinoba Bhave, Rural Hospital, under Datta Meghe institute of Medical Sciences, (Deemed University) located about 17 kilometres away from the city of Wardha, in central India which carers population of about 126116 individuals. This study was carried out during three months duration, i.e. from 1st April 2011 to 30th June 2011. Two auxiliary midwifery nurses (ANMs), posted at the rural health training centre and were prior trained for use of mini nutritional assessment tool, which still remains a newer concept in India. One nurse did first screening after which, second nurse did the second screening with MNA, independent of first screening. The MNA was translated in Marathi (local) language, which was obtained by the translationretro translation method, of the English version of MNA [23, 24].
All elderly, more than 60 years of age, residing in the field practice area of rural health training centre, were selected with by stratified random sampling, in which the field practice area was divided in to five strata, being served by one primary health centre. Sample size was calculated with the help of statistical software, Epi info, version 3.5.1, with 95% confidence and 80% power, and prevalence of malnutrition in elderly from pervious data was calculated to be 68, which was finalized at 80 considering non responses. Oral informed consent was obtained from each participant prior to the participation in the study.
Only the questions which primary respondent could not answer (if the patient had dementia or some other problem) were answered by primary care giver. All anthropometric measurements were taken by the nurses, at the time of study. Height was measured with the help of an anthropometric rod, to the nearest of millimeter. The anthropometric rod, after assembling, was held in right hand and placed in back side of the individual, touching heels, buttocks, back and head. The chin was held with left hand, and head was positioned such as the imaginary line drawn from tragus of the ear to the infra-orbital margin is parallel to the ground. Weight was measured with the help of portable spring balance, with accuracy of 500 grams. The individuals were asked to stand on the platform of the balance, without footwear and with minimal clothing. Weights were recorded to the nearest of 0.5 kg. Measurement of Mid Upper Arm Circumference (MUAC) was done within left upper arm, with reinforced plastic tape to the nearest millimeter. The subject was asked to stand erect and the investigator stands on the left side. The left arm is folded at right angle at elbow, keeping close to the body. Distance from the bony prominence of the shoulder (tip of acromian process) to the tip of the elbow joint was measured. Keeping the tape in position, midpoint was marked horizontally, (half of the distance measured above), then the arm was straightened, and placed by the side of the body, hanging loosely. The tape was passed horizontally round the arm at midpoint such that the it closely covers the arm, without applying much pressure or keeping it loose. Calf Circumference was measured in erect posture, at the site of maximum calf circumference the tape was passed horizontally round the calf and circumference was measured.
The MNA score was calculated as the sum of the points assigned to the responses of the 18 items. According to the obtained scores, patients were classified into three categories: well nourished (MNA: 30 to 24), at risk of malnutrition (MNA: 17 to 23.5) and malnourished (MNA: less than 17) the interobserver reliability of the MNA findings was tested using Kappa statistics for the degree of inter-observer agreement.
RESULTS AND DISCUSSION
Total 80 participants participated in the study, of which 37 were male and 43 females. The median time between the two screenings was 28 days which was spread over 20 to 39 days. Mean (S.D.), when MNA tool was used by first nurse was 20.84 (5.40) and mean (S.D.), when MNA tool was used by second sister was 21.29 (4.89)
. Mean (S.D.) MNA scores for each heads of (Table 1) tool for first nurse and second nurse were 6.52(1.78) and 6.43 (1.54) for anthropometric assessment, 5.06 (1.99) and 4.97 (1.98) for Global assessment, 6.75 (1.99) and 7.43 (1.63) for dietetic assessment, and 2.51 (1.12) and 2.46 (1.17) for subjective assessment. None of these variations in the assessment were found to be significant statistically, except for dietary assessment (p < 0.05). the test retest reliability (Table 2) of the test was observed to be substantial agreement, (kappa = 0.78) and there was almost perfect agreement for six parameters, which included body mass index, calf circumference, independence at home, medicine intake(more than 3) per day, morbidities and pressure sores/skin ulcers. There was substantial agreement on seven parameters, including Weight Loss, Psychological Stress, Neuropsychological Stress, Neuropsychological Stress, number of meals per day, Proteinic score, Proteinic score. Moderate Agreement was observed on consumption of fruits and vegetables, mode of feeling, and subjective nutritional evaluation (kappa score 0.040 to 0.06).A fair degree of agreement was observed in mid arm circumference, consumption of beverages, and subjective health evaluation. Lowest kappa was observed on subjective health evaluation (kappa=0.20), and maximum Kappa was observed in independence at home. In this study, we found out a high level of inter-observer reliability, in the rural area, with 80 individuals as study participants, in which the assessment of the individuals was carried out by prior trained nurses, who did not had any prior experience of using MNA. The various parameters in the MNA also showed a good range of agreement. Some areas of MNA scale showed higher levels of reliability was found to be very low, (0.20) reliability, where as in few areas as in mid arm circumference. The overall reliability of MNA stands out to be with substantial reliability, with kappa 0.78.there was no such study carried out in the rural part on India, with the help of staff nurses. Most of the published studied are from the hospital setup, in developed countries, where in most of the assessments are carried out by the treating physicians or specialized doctor/ health care provider.
The results of this study are very much comparable to the study carried out by Bleda MJ in year 2002, in a hospital setting in Spain, in which, the overall reliability of kappa for inter-observer reliability was 0.782. there was almost perfect agreement in 6 domains, in study conducted by Bleda MJ as compaired to study conducted by Gazzotti [24], in which almost perfect agreement was observed in only two domains, where as substantial level and moderate level of agreement was observed in 5 domains, each. Gazzotti, had no agreement in one domain, however, no such low level of agreement as per kappa statistics were found out.
Table 1: Mean assessment of the two independent observers.
Area | Assessment I Mean (SD) | Assessment II Mean (SD) | |
Anthropometric Assessment | 6.52(1.78) | 6.43(1.54) | |
Global Assessment | 5.06(1.99) | 4.97(1.98) | |
Dietetic Assessment | 6.75(1.99) | 7.43(1.63) | (p=0.003) |
Subjective Assessment | 2.51(1.12) | 2.46(1.17) |
Table 2
Sr. No | Area | Item | Kappa | |
I | Anthropometric Assessment | Body Mass Index (BMI) | 0.89 | Almost perfect agreement |
Mid Arm Circumference | 0.39 | Fair agreement | ||
Calf Circumference | 0.87 | Almost perfect agreement | ||
Weight Loss | 0.63 | Substantial Agreement | ||
II | Global Assessment | Independence at home | 1.00 | Almost perfect agreement |
More than 3 medicines per Day | 0.87 | Almost perfect agreement | ||
Psychological Stress | 0.65 | Substantial Agreement | ||
Morbidity | 0.84 | Almost perfect agreement | ||
Neuropsychological Stress | 0.75 | Substantial Agreement | ||
Pressure sore/Skin Ulcers | 0.94 | Almost perfect agreement | ||
III | Dietetic Assessment | Number of Meals per day | 0.73 | Substantial Agreement |
Proteinic score | 0.68 | Substantial Agreement | ||
Fruits or vegetables | 0.48 | Moderate Agreement | ||
Declined food intake | 0.73 | Substantial Agreement | ||
Consumption of Beverages | 0.37 | Fair agreement | ||
Mode of Feeding | 0.53 | Moderate Agreement | ||
IV | Subjective Assessment | Subjective nutritional evaluation | 0.53 | Moderate Agreement |
Subjective Health Evaluation | 0.20 | Fair agreement | ||
TOTAL | Total MNA | 0.78 | Substantial Agreement |
CONCLUSION
The results of our study indicate that the MNA tool can be used in rural setup by ANMs, ASHAs, if they are prior trained in assessment of the elderly, and there are no significant interobserver variations in the results. In the developing countries like India, where doctor patient ratio is high, and at many places the primary health care provider is a anganwadi worker, or ASHA. Early identification of elderly individuals at risk of malnutrition is possible and they can be referred to higher health care centre for adequate evaluation and treatment. The main limitation of the study was its inability to assess intra-observer reliability.