SOKOINE UNIVERSITY OF AGRICULTURE

FACULTY OF AGRICULTURE

DEPARTIMENT OF FOOD SCIENCE AND TECHNOLOGY

BSc. HOME ECONOMICS AND HUMAN NUTRITION

HE 300: SPECIAL PROJECT

EVALUTION OF NUTRITION EDUCATION
DELIVERED IN REPRODUCTIVE AND CHILD HEALTH CLINICS IN MBEYA
REGION.

NAME: MWALEMILWE, JOHN M.

REG. N0: HE/E/06/T.5790
SUPERVISOR: KINABO J.L

June, 2009

i
 ABSTRACT
Introduction: Nutrition education is one of the components of health education under the
Ministry of Health in Tanzania since 1990. It is aimed to reduce malnutrition, which is among
the major health problems in the country.
0bjectives: The study aimed to identify the gaps in nutrition education provision, by assessing
effectiveness of nutrition education provision at Mbarali district RCH Clinic,Chimala mission
RCH Clinic and Utengule RCH Clinic in Mbarali District,a study done on Februal 2009 in
Mbeya region.
Methodology: A cross-section study was used where by RCH Clinic staff, pregnant women and
mothers/caregiver of the children bellow five years attending antenatal care clinic were
interviewed using a structured questionnaire. The questionnaire originally developed in the
English language was translated into Swahili language and pre-tested before use. Informed
consent was obtained from each respondent before questionnaire administration.
Results: A total of 392 Subjects participated in the interview. The participants were groped into
three groups, RCH Clinic staffs were 6, pregnant women were 196 and mother/caregiver of
children bellow five year of age was 180. With mean age of 38.5 years for RCH Clinic staff,
mean age of 26.7 years for pregnant women and mean age of 1 year for children bellow five
years of age. It was found that all RCH Clinic had no national nutrition education guideline,
RCH Clinic staff were found only 50% of them having secondary school education level and
without nutrition education seminar under the period of more than two years of working, Out of
196 pregnant women interviewed, 28.06% were underweight, about 31.12%were found to have
normal weight, while 39.28% were overweight and 1.53% were obese. Children bellow five
years were found to be 60.0%underweight, 35.6%normal and only 4.4%were overweight.
Conclusion: There is low nutrition knowledge to RCH Clinic staff which leads to poor nutrition
education delivered hence poor nutrition education to RCH clients. Hence suggesting that
nutrition education in RCH Clinic is of low standard may be due to miss-utilization of resources
such as nutritional professionals are not employed in RCH Clinics where they could have
delivered proper nutrition education in order to promote health. Instead ministry of health
exaggerates the attention to taking care only of sick people while much better results could be
achieved by preventing illnesses and promoting health

ii
 ACKNOWLEDGEMENT

Many technical and nontechnical persons have contributed to the completion of the study. I wish
particularly to thank the following instructors for their assistance and for the resources made
available to me; my sincere supervisor Professor. J.Kinabo from the department of Food Science
and Technology, for good and constructive ideas and criticism which energetized me to aim far in
my study. I cannot be decent enough without touching my colleagues, Massawe, Gabriel 3rd year
student pursuing B.Sc. Home economics and Human nutrition and Katema Rehema for their
assistance during the questionnaire planning and forecasting the outcome of the study.

I would like to thank my sisters and brothers from Mwalemilwe and Mgwadila families for their
valuable advice and supports throughout the life of my study

My heartfelt appreciatation to Kilasi Hawa of Rujewa RCH Clinic, Mbuya of Chimala mission
RCH Clinic and Mr.Mpagama of Utengule RCH Clinic for supportive soul during my study in
Mbarali district.

iii
 TABLE OF CONTENT

ABSTRACT....................................................................................................................................ii
Introduction: Nutrition education is one of the components of health education under the
Ministry of Health in Tanzania since 1990. It is aimed to reduce malnutrition, which is
among the major health problems in the country. ...................................................................ii
0bjectives: The study aimed to identify the gaps in nutrition education provision, by
assessing effectiveness of nutrition education provision at Mbarali district RCH
Clinic,Chimala mission RCH Clinic and Utengule RCH Clinic in Mbarali District,a study
done on Februal 2009 in Mbeya region...................................................................................ii
ACKNOWLEDGEMENT..............................................................................................................iii
TABLE OF CONTENT..................................................................................................................iv
LIST OF TABLES.............................................................v
LIST OF ACRONYMS..................................................................................................................vi
CHAPTER ONE..............................................................................................................................1
1.0INTRODUCTION......................................................................................................................1
PROBLEM STATEMENT AND JUSTIFICATION....................................................................2
1.1.1 MAIN OBJECTIVE.......................................................................................................4
1.1.2 SPECIFIC OBJECTIVES.........................................................................................4
2. 0 LITERATURE REVIEW..........................................................................................................5
2.1 NUTRITION EDUCATION OVERVIEW ...........................................................................5
Health education including nutrition education in Tanzania is under ministry of health,
(Tanzania health policy, 1990). Through implementations of different health policies
objectives of health education were to:........................................................................................5
2.2 MATERNAL NUTRITION EDUCATION...........................................................................7
2.4 THE EFFECT OF NUTRITION EDUCATION PROVISION.............................................8
CHAPTER THREE.......................................................................................................................10
3.0 METHODOLOGY..................................................................................................................10
3.1 THE STUDY AREA /LOCATION......................................................................................10
3.4 STUDY DESIGN.................................................................................................................10
3.5 SAMPLE SIZE....................................................................................................................10
3.6 SAMPLING TECHNIQUE.................................................................................................11
3.7 DATA COLLECTION ........................................................................................................11
3.7.1 SECONDARY DATA COLLECTION.........................................................................11
3.7.2 PRIMARY DATA COLLECTION................................................................................11
3.8 MATERIALS AND INSTRUMENTS FOR DATA COLLECTION..................................12
3.9 DATA PROCESSING AND ANALYSIS...........................................................................12
CHAPTER FOUR..........................................................................................................................13
RESULTS.......................................................................................................................................13
4.1 The general subject’s characteristics....................................................................................13
CHAPTER FIVE...........................................................................................................................21
D ISCUSSION...............................................................................................................................21
5.2 Nutrition education guideline.............................................................................................22
5.3 Time at which they start to provide nutrition education......................................................22

iv
 5.4 Time of first visit at RCH Clinic..........................................................................................23
5.6 malnutrition problem of pregnant mothers and children bellow five years of age under
study...........................................................................................................................................24
5.7Relationship between education level and nutrition education.............................................25
CONCLUSSION............................................................................................................................26
RECOMMENDATION..................................................................................................................26
APPENDIX 2.................................................................................................................................30

LIST OF TABLES

v
 LIST OF ACRONYMS

RCH-Reproductive and Child Health

HIV-Human Immune Diffident Virus
TBA-Traditional Birth Attendants
MOH-Ministry of Health
MDG-Millennium Development Goal
URT-United Republic of Tanzania
PHC- Primary Health Care
IYCF-Infants and Young Child Feeding
TRCHS- Tanzania Reproductive and Child Health Survey
NWHIC-National Women health Information Centre

vi
 CHAPTER ONE

1.0 INTRODUCTION

Pregnancy occupies a critical and unique place in the course of life which has both health and
social importance for individuals, family and the whole of society. During pregnancy there is
extra energy requirement due to growing of fetus and tissues and deposition of fat stores. A
balanced diet is very important for pregnant women. Even before pregnancy begins, balanced
diet is a primary factor in health of mother and a baby. If a pregnant woman is eating a well
balanced diet before becoming pregnant, she will only need to make few changes in food
consumption to meet the dietary needs of pregnancy. (NWHIC, 2000)

Fetal growth set up by genetic code may be modified by influences such as nutrient availability.
Pregnant women are particularly vulnerable to nutritional deficiencies because of the increased
metabolic demands imposed by pregnancy involving a growing placenta, fetus, and maternal
tissues, coupled with associated dietary risks (Jiang T. et al, 2005).

In order to improve nutritional status, women need to have accurate information on nutritious
diet during pregnancy, breastfeeding, weaning habits and hygienic preparation of food for infants
and young children. Nutrition education is a strategy which has a major role to play in achieving
improvements in nutrition especially in situations where malnutrition problems could be
alleviated by better use of resources. Lack of access to good education and information is one of
the causes of malnutrition maternal and infant’s death. (Tomkins,2007), Without information
strategies, appropriate education programmes, the awareness, skills and behaviors needed to
combat malnutrition can not be reached and developed.
Different approaches have been made to address the problem of maternal poor nutrition, but the
role that appropriate nutrition information can play in addressing maternal poor nutrition has not
been adequately exploited.
 PROBLEM STATEMENT AND JUSTIFICATION
Both men and women including all antenatal and postnatal women can benefit from nutrition
advice, counseling, care, and support aimed at preventing malnutrition during pregnancy and
improving reproductive health and child health outcomes, this work has been implemented by
Tanzanian government for a long period. It is done by all government, private (profit and non
profitable) health delivering institutions like hospitals, health centers, dispensaries, medical and
nursing schools. But still the number of pregnant mothers who deliver at home is still high about
47% (TRCH,2004), death of pregnant mother during and few days after delivery is still high
about 578 (TRCH,2004), number of children bellow five years of age who die before reaching
their fifth birthday is still high about 146per 1000 live births (TRCH,2004).

Nutrition problem especially undernourishment remain the major problem in Tanzania. About
30% of the population suffers from protein energy under nutrition and 62% of the children below
5years and 66percent pregnant woman are anaemic. Other nutritional problems that exist include
pellagra (9.4%), scurvy, beriberi rickets and some deficiency of mineral such as Zink (Kavishe,
2003).

There has been some improvement as reported by Hans Hoogeveen, (2008) that Tanzania is one
of the 20 countries in the world that make up 80 percent of the burden of under-nutrition. Almost
four out of every 10 children aged zero to five years old are stunted and over 60 percent of all
children and 50 percent of all women are anaemic.

Such high levels of malnutrition undermine Tanzania’s growth potential and reduce the
country’s ability to achieve the international community’s Millennium Development Goals
(MDGs) for nutrition, health or education as goals 2,4 and 5 stated in Tanzania MDG 2006
report.
Statistically, maternal mortality contributes to only 2.3 per cent of the total mortality. Still births
make up 6.7 per cent of total mortality (MDGs, 2006) Tanzania report. There are also causes of
mortality that are related to poor health including malnutrition. Over half of expectant women
deliver at home and not at health facilities and as such may not be attended by skilled personnel
or have access to Emergency Obstetrics Care. (DHS data show that maternal mortality situation
has not changed in Tanzania. The estimated maternal mortality rate from 2004 data is 578 higher
than that from the 1999 which is529 Tanzania Reproductive and Child Health Survey (TRCHS).
Overall, there is little change in the proportion of births attended by skilled health personnel
(44.1 per cent in 1999 and 46 per cent in 2004), and births taking place in health facilities were
44percent in 1999 and 47 percent in 2004 Tanzania (M D Gs, 2006) December report.

Education for girls will help reduce child mortality through Education’s impact on lowering
fertility rates, delaying age of marriage, ensuring proper utilization of available health facilities
and improving child nutrition and care practices. There have been tremendous efforts to improve
communities’ health status with minimal success. Data from Tanzania Reproductive and Child
Health Survey (TRCHS) show that under five mortality rate estimated at 146per 1000 live births.
Tanzania women and young children are particularly vulnerable to malnutrition. (TFNC, 2000).

Nutrition problem especially undernourishment remain the major problem in Tanzania. About
30% of the population suffers from protein energy under nutrition and 62% of the children below
5years and 66percent pregnant woman are anemic. Other nutritional problems that exist include
pellagra (9.4%), scurvy, beriberi rickets and some deficiency of mineral such as Zink (Kavishe,
2003).

Tanzania has varieties of foodstuffs and many parts of the country like Mbarali which is located
in the among "the big four" have different means of transport such as Roads, Waterways,
Railways, Airways, and nutrition education is being provided. However problem of malnutrition
still exist despite of the effort of the ministry of health to reduce malnutrition.

This study, therefore, aimed at exploring and identifying gaps in nutrition knowledge and
information communication at RCH Clinics within health delivery system in Mbarali district so
that, if significant reasons are found then recommendation are to be sent to the ministry of health
to make necessary adjustments so that the whole national aim to fulfill millennium development
goals particularly on health sector is achieved.
 1.1 OBJECTIVE OF THE STUDY

1.1.1 MAIN OBJECTIVE

To assess the provision of nutrition education in the RCH clinics in Mbarali district.

1.1.2 SPECIFIC OBJECTIVES.

1. To assess the available nutrition education guidelines used in each selected RCH
clinic in Mbarali district by assessing its contents if there is any.

2. To identify the time at which nutrition education is provided during the whole
trimesters of pregnancy at the RCH clinics, by recording date of first visit at the RCH
clinic.

3. To identify the nutritional knowledge of clients who attend for different services
which are provided by each RCH clinics.
 CHAPTER TWO

2. 0 LITERATURE REVIEW

2.1 NUTRITION EDUCATION OVERVIEW

Health education including nutrition education in Tanzania is under ministry of health, (Tanzania
health policy, 1990). Through implementations of different health policies objectives of health
education were to:
1. Reduce infant and maternal morbidity and mortality and increase life expectancy
through provision of adequate and equitable maternal and child health services, promotion
of
adequate nutrition, control of communicable diseases and treatment of common conditions.
2. Ensure that health services are available and accessible to all people wherever they are
in the country, whether in urban or rural areas. Implementation of the health policy
is supervised by the Ministry of Health at national level. Because of decentralization, the
policy at regional and district levels will be supervised by the regional and district
authorities according to guidelines from the ministry of health.(Tanzania health policy,1990)

With all the efforts made by government to build health facilities and having the aim to achieve
millennium development goals together we must turn to quality of our services. Having trained
staff including nutritionist in at least district hospitals who may be providing seminars to all
RCH Clinics in the district. study which was done by (Manongi,R.N., et al, 2005). from May to
July 2004 in three districts: Moshi Urban, Moshi Rural and Hai districts in the Kilimanjaro
region, northern Tanzania on the viewpoint of service providers, the main factors identified that
caused demotivation among health care workers working at primary health care facilities were
workload paired with staff shortages, lack of interprofessional exchange and lack of positive
supervision, including transparent career goals. Physical infrastructure and equipment available
to staff in the PHC setting did sometimes affect morale and certainly services but overall the
findings from these focus group discussions indicate a need for individual staff to feel valued and
supported and to develop in their roles.
Tanzania faces serious challenges to improving the health and well-being of its people. It is the
country’s aim to provide health education particularly health education to the community through
a number of strategies and approaches. However, available information indicate that community
health education and information communication has had limited impact on behavioural changes
and hence disease prevention and control (Rumisha,S. at al, 2006).The healthcare delivery
system is fraught with barriers to health communication at all levels, partly due to the
paternalistic use of scientific and medical terminology to communicate between systems and
between systems and providers, which trickles down to communication between providers and
patients or communities (Calderon,J.L., at al, 2004).

The principles of influencing the health of Tanzanian have changed. the reason for the “sick
society” lies in the incorrect interpretation of health, i.e. when speaking about the health of the
population primarily illnesses and their treatment is kept in mind and hence an opinion has
spread that the key to solving the health problems of the population is medical assistance and the
system of health insurance alone. Other authors have similarly stated that health care systems of
many countries exaggerate the attention to taking care of sick people while much better results
could be achieved by preventing illnesses and promoting health.( Brouwer, W.,at el,2007)and
(Donaldson, S. L.,et al,2006).

Undernutrition is the underlying cause of more than 53 percent of all child deaths that occur
annually, including those from infectious diseases, pneumonia, diarrhea, measles, and malaria,
according to a new analysis by researchers with the Johns Hopkins Bloomberg School of Public
Health and the (W H O, 2004).

Knowledge about adequate maternal nutrition during pregnancy is incomplete, and there is still
considerable debate about the level of extra energy needed by a pregnant woman. (Lindsay,
2001).the complimentary foods provided is of poor quality to meet nutrient requirement it result
in a deficit of tissue and fat mass hence the children of the same age will not grow equally.
Therefore proper complimentary feeding is important in ensuring child’s health and normal
growth available information shows that generally children grow normally up to the age of six
months presumably due to the universal breast-feeding which is about 40 percent exclusive up to
that age. (Kirsten et al, 2001) this will only be successful if and only if maternal nutrition
education will be given as friendly reproductive services to every RCH Client.

2.2 MATERNAL NUTRITION EDUCATION

In many studies a question of illiteracy among women has been observed as a barrier to the use
of health services and women to disentangle from low status. Long term improvements in formal
education particularly for girls will help to bring about a decline in maternal mortality. However,
in short term maternal health education should be encouraged for pregnant mothers when they
attend clinic. Provision of maternal health education to the Village Primary Health Care (PHC)
Committee which constitutes influential people, extension workers and Traditional Birth
Attendants (TBAs) will enhance community to initiate their own means through locally available
resources to reduce maternal mortality (e.g. in making follow-up to pregnant women who do not
attend clinic regularly). Education on child spacing will raise family income and hence the
family will have good economic background to assist pregnant mothers. In other words the
allocation of food to pregnant mother is likely to decrease with increase in the number of
children which in turn may adversely affect the dietary intake of pregnant women. (Chandrus,
2005).

In order to improve nutritional status, women need to have accurate information on nutritious
diet during pregnancy, breastfeeding, weaning habits and hygienic preparation of food for infants
and young children. Nutrition education is a strategy which has a major role to play in achieving
improvements in nutrition especially in situations where malnutrition problems could be
alleviated by better use of resources. Lack of access to good education and information is one of
the causes of malnutrition maternal and infant’s death. (Tomkins,2007), Without information
strategies, appropriate education programmes, the awareness, skills and behaviors needed to
combat malnutrition can not be reached and developed such as tobacco use alcohol and drugs use
has been associated with bad outcome of pregnancy and neonates,(Anderson,M.E,et al,2005) if
pregnant women is made aware she may opt to change her behavior towards all bad behavior as
considered by nutritionists.
Nutrition education is a strategy which has a major role to play in achieving improvements in
nutrition especially in situations where malnutrition problems could be alleviated by better use of
resources. emergency preparedness etc, a sustained effort to mobilize the will and resources
necessary for high quality of health services system maternal health education and community
to disentangle from negative attitudes toward modern health facilities is the challenge to be
undertaken by the developing countries themselves. In Tanzania; the organization of Tanzania
Food and Nutrition centre has the department of Nutrition Education and training which
disseminates food and nutrition information to the public through publications and mass media;
identifies nutritional education and training needs for different sectors; initiates and supports
nutrition training programmes through curricula reviews and short term in service training of
extension workers. (TFNC, 2000)

2.4 THE EFFECT OF NUTRITION EDUCATION PROVISION

Women who have a minimum basic education are generally more aware of the needs to utilize
available resources for the improvement of health particularly nutrition status of themselves and
their families. When women are educated on dangers of smoking and alcoholism becomes in
position of changing their attitude towards alcohol and smoking which leads to not smoking or
drinking.

High fertility, poor nutritional status, and lack of basic health services compound the problem, so
that in some countries and regions of the world, a woman's lifetime risk of dying of pregnancy-
related causes is staggering. Moreover, of the 7.1 million infants who die each year, about half
die in the first 28 days after birth - the neonatal period of these, 75 percent die in the first week
after birth, underscoring the critical importance of maternal health and care during pregnancy
and delivery on child survival. The majority of these maternal and newborn deaths are
preventable with currently available technologies. (USDA, 2000).

Several difficulties still have not yet been effectively overcome. The most important is that we do
not have a medical care delivery system that is preventive oriented. We provide care when things
go wrong. The model for an effective lifestyle intervention approach, to be delivered in a typical
medical care setting with verification of significant impact on prevention of disease or decreases
in progression, has not been identified. What we do have are several effective intervention
research trials that have used lifestyle (diet or exercise) interventions and that have shown the
efficacy and cost-effectiveness of lifestyle interventions (Ebbeling, C.B.at el, 2005).

With less than a decade to go until the deadline for achieving the Millennium Development
Goals (MDGs), it is clear that the key targets for health and nutrition agreed by heads of states in
2000 are likely to be missed (UN 2004). Nutrition interventions have been suggested to be
among the most effective preventive actions for reducing under-five mortality in the developing
world. It is estimated that among children living in forty-two countries with 90% of global
deaths, a package of effective nutrition interventions including promotion of exclusive and
continued breast feeding, complementary feeding, vitamin A and zinc supplementation have the
potential to save 25% of childhood deaths each year. (Jones, 2003)

Adequate nutrition through appropriate infant and young child feeding (IYCF) during infancy
and early childhood is fundamental to the development of each child's full human potential.
However, it is disheartening to note that the critical IYCF practices are faulty around the world,
with the literature suggesting that only 37% of infants are exclusively breast fed for the first six
months and only 55% are introduced to complementary food with continued breastfeeding in the
age group of 6-9 months. Only half of the world's children are breast fed at the age of 20-23
months. (UNICEF, 2005)

Health communication is a fundamental component in virtually every form of public health, to

manage diseases in an effective and sustainable manner, the community need to have a certain
set of knowledge and information on disease transmission, signs and symptoms and control and
preventive measures. In most cases, the community is likely to be aware of far less than this. The
difference between the knowledge that the community has and that which it should have, to
make good decisions is referred to as knowledge gap (Leonard, et al.2007). In any disease
control program, a good health education and information communication system is very crucial.

An effective health education program requires an appropriate communication. That is, the
dissemination of understandable and useable information that concerns itself with health is
critical. For individuals, effective health communication can help raise awareness of health risks
and solutions provide motivation and skill needed to reduce these risks, help them find support
from other people in similar situation, and affect or reinforce attitudes. ( Leonard,et al.2007)
 CHAPTER THREE

3.0 METHODOLOGY

3.1 THE STUDY AREA /LOCATION

The study was conducted in Mbarali district which is among the five districts of Mbeya region,
other districts being Mbeya rural, Mbozi, Ileje, Kyela, Rungwe and Chunya of Mbeya Region.
The town lies close to the border with Zambia, between Mount Mbeya and the Poroto
Mountains, 400 km (250 mi) south-west of Dodoma. Mbeya was founded in 1927 as a supply
town during the gold rush at nearby Lupa. It is a transport centre, lying on the main railway line
from Dar es Salaam to Zambia and Southern Africa. The region is among the big four in
Tanzania producing plent of rice, maize, beans, bananas, tea, coffee, and cocoa.The study was
conducted in the three RCH clinics which are Chimala mission hospital, Mbarali district hospital
and Utengule gorvement health centre RCH clinics. The district has 30 dispensaries, 2 health
centres and two hospitals. According to the 2002 census, Mbarali District had a total population
of 234,908 where by 115280 are males and 119,628 are females. (URT, 2002).

3.2 STUDY POPULATION

The number of children less than one year was 10836, children bellow five years of age were
54180; women of bearing age were 10836, and 11 RCH Clinic staff.

3.4 STUDY DESIGN

The study employed in this study was a cross-sectional survey, where by the data was collected
on February 2009.

3.5 SAMPLE SIZE

The sample was obtained by using Fishers formula. (Fisher et al, 1998).Random sampling was
used to obtain 196 Pregnant Mothers, 180 children bellow five years of age and 6 RCH Clinic
staff.
3.6 SAMPLING TECHNIQUE
Total number of respondents attended at the selected RCH clinics on January 2009 was obtained
from the RCH Clinic registers. Each name was given a number to correspond with. The numbers
were written on papers, and then cut to small pieces. Then RCH Clinic staff was selected to
pickup a paper with a numbers one by one until a suggested number of respondents was
obtained. This was applied to all groups of respondents, i.e.RCH Clinic staffs, pregnant mothers
and children bellow five years of age.

3.7 DATA COLLECTION

Data were collected by using a structured questionnaire, interview with RCH Clinic staff,
pregnant women and children's care caregivers who attended the clinic during the time when the
study was being conducted. Secondary data were also collected from maternal and child's clinic
cards.

3.7.1 SECONDARY DATA COLLECTION

Secondary data was collected from RCH cards (mother’s and children's cards) where data
concerning place of child’s delivery, nutrition status of a child, immunization coverage, time at
which child started visiting RCH Clinic and other records on general maternal health were
collected, dates of first visit and other visits were collected, immunization coverage, age and
marital status, education level, occupation, number of pregnancy per age and anthropometric
measurement such as height and weight which were used to calculate body mass index were also
collected.

3.7.2 PRIMARY DATA COLLECTION

Data on demographic and social economic characteristic of respondents were collected through
structured questionnaire. The questionnaires were constructed in English and being translated to
Kiswahili language for easy administration. Data such as breast feeding status , , micronutrients
supplementation, knowledge on balance diet, tobacco use, alcohol and drugs abuse, time and
how often pregnanant woman where supposed to attend clinic, were also collected.
3.8 MATERIALS AND INSTRUMENTS FOR DATA COLLECTION
Materials for data collection comprised; structured questionnaires, pen, pencil, rubber, RCH
cards for pregnant women; children bellow five years of age and RCH Clinic register book for
secondary data.

3.9 DATA PROCESSING AND ANALYSIS

All questionnaires were reviewed on daily basis for completeness, inconsistencies and out of
range entries. Computer data entry was performed at the Sokoine University using the Statistical
Package for Social Sciences (SPSS) version 12.0and data cleaning was performed before data
analysis. Statistical data analysis was conducted using SPSS, (Nourusis, 1998). Where
descriptive statistics were used to compute different statistical variables of the study population.
 CHAPTER FOUR

RESULTS
This chapter presents the results of the study on the assessment of nutrition education given to
RCH Clients and its effects on nutritional status to pregnant women and children below five
years of age in Mbarali district. The results are grouped under following sections;

The first sections of this chapter describe the general subject’s characteristics, the second section
presents basic demographic, social economic characteristic and also presents assessment of
nutrition education given to pregnant mothers and children below five years of age.

4.1 The general subject’s characteristics

The study involved three groups of subjects. These include: RCH Clinic staff, pregnant women
and children below five years of age who were represented by their mothers or caregiver who
brought them to RCH Clinic for service.

Table 1: Total number of subjects included in the study

subjects Mbarali RCH Chimala RCH Utengule RCH

RCH Staff 2 2 2

Pregnant women 66 70 60

children below five 58 67 55

years of age

Total 126 139 117

RCH Clinic staff

It was observed that there was no national guideline for nutritional education provision in RCH
clinics by 100%, however there was a timetable for health education, in which health education
is given at the beginning of working day in all five days. RCH Staff by 50% of all had primary
school level and 50% secondary school education but only about 17% of them had received
nutrition education seminar at least within two years.

Table 2 a: and b: RCH Clinic staff education level and nutrition education knowledge
Parameter Description N=6 %
Education level Primary school level 3 50
Secondary school level 3 50
High education 0 0
Nutrition education or
seminar Within two years Yes 1 16.67
before the study no 5 83.33

Presence of nutrition yes 0 0

education time table no 6 100

Presence of national yes 0 0

guideline for nutrition no 6 100
education

Do you have materials for yes 3 50

teaching nutrition education no 3 50

Table 2b:
Parameter Description
N=6 %
Do mothers attend for pre yes 3 50
pregnancy counseling no 3 50

When do mothers supposed Before conception 1 16.67

to attend for RCH clinic One month after conception 1 16.67
More than three months after 4 66.66
conception
1 16.67
How often is a mother once per month 0 0
supposed to attend RCH Twice per month 5 83.33
clinic Four times per three trimester

When do you start giving Before conception 2 66.67

nutrition education One month after conception 0 0
More than three months
after conception 4 66.66

Mothers are required to attend RCH Clinic at the period more than three months after conceiving
6 7% and only17% responded that pregnant mothers are required to attend before becoming
pregnant and at one month after being conceived. Results also reveal that pregnant woman is
required to attend RCH Clinic only four times per her gestation period.
Table 3: Teaching materials used to deliver nutrition education which were found in the
rooms were health education was being conducted.
Type of messages which are Types of materials used
Used by nutrition educator To deliver education

• Identification of malnutrition Posters

• Environmental factors
influencing nutritional Flip charts
status
• Parasites and malnutrition Brochures
• Infant-feeding practices,
including breast-feeding Video
and weaning food Television
• Immunization

Social demographic characteristics of Pregnant women

Respondents age was found to be comprised of 41% of the 19-25 years with mean age of 18,
29% of them had 26-45 years of age with mean age of 22, while 15% of them were 19 and 13%
were 45 years and above with the of 52,the range was 17 and 60 years.

Table 4: social demographic characteristics of pregnant women

Parameter Description N=196 %

Age Under 19 31 15.8
19-25 81 41.3
26-45 58 29.6
46 and above 26 13.3

Marital status Married 141 71.9

Not married 55 28.1

Formal employment 28 14.3

Occupation Informal employment 50 25.5
No employed 118 60.2

About 72% of the women were married and 28% were not married. Their occupation status were
30% being employed while 70% were found to be not employed. Majority of pregnant women
about 60% were not employed, and 40% were employed, where by 26% were employed in
informal sector and 14% were employed at formal sector.
Most of the pregnant women were found to have primary school education for 39 % and 34%
had no formal education and 18% had secondary school education, only 18.4% had higher
education.
Table 5: Education level and knowledge of balance diet among pregnant women

Parameter Description N=196 %

Education level No formal education 67 34.2

Primary school
education 77 39.3

Secondary school
education 36 18.4

High education 17 8.2

Knowledge Yes 66 33.7

of balance No 130 66.3
diet
Balanced diet - meaning, significance, and how to plan, proper cooking methods; and food
practices and beliefs of pregnant women and how mothers should feed infants and preschool
children

Table 6: Nutrition status of pregnant women

BMI category N=196 %

Underweight ( ≤18.5) 55 28.06

Normal (≥18 and ≤ 24.9 ) 61 31.12
Overweight (BMI≥25-29.3) 77 39.28
Obesity (BMI ≥30) 3 1.53

BMI -has been calculated from the weight and height data collected from RCH Clinic cards

Basing on the body mass index of respondents 31.12% were normal people, 28.06% were
underweight, 39.28% overweight and only 1.53% respondent was obese.
 Table 7: pregnant women alcohol and tobacco use

parameter N=196 %

Alcohol 55 28.06
Tobacco 37 18.87
Both alcohol and
Tobacco use 24 12.24

Among 196 pregnant women 28% were found to consume alcohol when they are pregnant,
about 19% were using alcohol and about 12% were using both alcohol and tobacco.

Pregnant women RCH Clinic visits

The RCH Clinic attendance for the first time since a woman conceived was found to be as
follows: 47% of pregnant women attended when they were more than three months gestation
age, while 39%attended within three months of pregnancy and 13% were found to attend one
month before being pregnant, only 5% of them were found to attend within the first month of
pregnancy. Among them only 33.7% had knowledge on balanced diet in practice.

Table 8: Pregnant women First visit at RCH Clinic

Parameter Description n %

First visit in RCH one month before

pregnancy 12.8
25
within first month of
pregnancy 1 5

within three months

of pregnancy 77 39.3

more than three 93 47.4.

 months of pregnancy

Total 196 100.0

Table 9: Nutrition status of children bellow five years old

Parameter N %

Normal weight 64 35.6

Under weight 108 60.0

Over weight 8 4.4

Total 180 100

This group is more affected by poor nutrition status, in the study it has been shown that more
percentage are undernourished by 60% while only 36% being normal weight and overweight
accounted for 4%,which is another nutritional new concern for developing country like Tanzania.
Nutrition status figure were collected from RCH Cards.

Table 10: Age of Children bellow five years and mothers attitude towards health facility use
as were obtained from RCH card
Parameter Description N=180 %

Place of Hospital 113 62.8

delivery TBA 32 17.8
of a child Home 35 19.4

Attendance Regular 160 88.9

At RCH Clinic Irregular 20 11.1

Age of respondent Less or equal 70 38

to six months

two year of age 61 33.9

and bellow
 above two year 49 27.2
to five years

Early attendance yes 165 91.7

at RCH no 151 8.3

Most of the children about 63% were delivered in the hospital this is good but about 38% were
delivered at home and under supervision of TBAs. This brings a concern on health education
impact. Children have been attending in RCH Clinic immediately after having delivered by 92%
and their RCH Clinic attendance is good by 89% .Among the 180 children who participated
under the study 38.9% were six months old and bellow, two years and bellow were 33.9% while
only27% were above two year of age.

Table 11: age of respondent and status of breast feeding

Age of children bellow Status of

five years N % breastfeeding N %
less or
Exclusive
equal to six 70 38.9 19 27
breastfeeding
months
Non exclusive
51 72
breastfeeding

Only 27% of all children under the age of six months were found to breastfed,while72% of them
did not. Number of all children under the age of six months and bellow was 70 which accounted
to about 39% of all 180 children under the study.

Figure 1.knowledge of balanced diets and education level of pregnant women

 knowledge on
80
balance diet of
respondent
yes
no

60
C

40
n
u
o
t

20

0
no formal primary school secondary higher education
education school
education of respondent
Cases weighted by number of live children/child

This was established by comparing results obtained from education level and knowledge on
balanced diets, table 5.by cross tabulation done by SPSS.
CHAPTER FIVE

D ISCUSSION
There is no question that health education is an important element in an overall national strategy
for health improvement. The issue is largely on how best to provide health education effectively
and efficiently with a view that its outcome can have greater and sustainable impact on people’s
lives.

5.1 RCH Clinic personnel

Most of them had no nutrition education background, only17% of all RCH Clinic personnel had
nutrition education and the rest of them (83.33%) didn't. They had even not attended a single
seminar in two years of working; this could have exposed them at least on key issue of nutrition
education. This suggests that they cannot provide tangible results as far as nutrition education is
concerned. While results shows worse condition, document shows that in 1992 the Tanzanian
ministry of health (MOH) reviewed the national primary health care (PHC) strategy and
decentralized primary health care delivery from national level to district level. It was envisaged
that making local governments responsible for staffing and maintaining health centre and
dispensary based facilities would improve the provision of services (MOH, 1992). The strategy
also incorporated continuing education to health workers as a means of improving their
knowledge and skills and as an important motivation factor. So it is suggestive to say that there is
poor resource utilization rather than what is usually defended of perverseness.
Education level and nutritional education both have equally importance when comes to the issue
of decision making, as it was found that among RCH Clinic staff did not know when pregnant
woman was supposed to visit for the first time at RCH Clinic. About 67% said woman was
supposed to attend RCH Clinic when she is pregnant for more than three months. This suggest
that those woman who come late at the period more than three months gestation age were
wrongly advised by these ignorant RCH Clinic staff, refer table 2 and 8.

It is very true that those millennium development goals are not going to be achieved simply
because we do lack good policy and poor resource utilization. As evidenced in table 2 that there
are no higher educated personnel, nutrition education guideline, and routine nutrition education
seminars for RCH Clinic staff. These simply happen, when we have good and well trained
individual who can rectify this situation, there are nutritionist who graduate every year from
Sokoine University, if ministry of health could have employed at least at the level of district
hospital, they could have helped a lot in achieving these goals.

5.2 Nutrition education guideline

They have no nutrition education guideline in which they could plan how to go about instead
they were found to educate through posters which were from ministry of health and others were
locally made. This factor contributes to poor health education given to RCH Clinic clients and
hence poor nutrition education and overall objective is not achieved. They have no nutrition
education time table by 100% this suggests that no nutrition education is provided in RCH
Clinics under study. In this era of science and technology it is difficult to wish proper things can
go smoothly without timetable. These findings provides a proof that failure to reach MDG is
contributed by ministry of health through its staffs having no directives on what they are required
to do in their dairy routine timetable.

5.3 Time at which they start to provide nutrition education

Pregnant mother were found to be required to start attending RCH Clinic services while having a
pregnancy of more than three months by about 67%.by this it means pregnant women are given
nutrition education during the first trimester and they were found to start attending RCH Clinic
three months after conceiving. This suggests that most women 47.4% does not get nutrition
education at right time, they also do not get nutritional supplements in right time. By this
evidence it is suggested that even if we plan to reduce malnutrition to pregnant mothers through
nutrition we are going to fail due to mother not attending RCH Clinic as early as possible so that
when education is given may be used to prevent bad outcome of poor nutrition status of the
women.

5.4 Time of first visit at RCH Clinic

First visit to RCH Clinic is critical to pregnant mothers and infants, it is important for the mother
to attend three months before conception so that an expected pregnant women is made to prepare
her body physiologically, such as she is given all necessary advice on what to stop, reduce and
what to prefer most during the coming pregnancy. This time is very essential to start folic acid
supplementary which is very important to pregnant mother as far as fetal development need for
folic acid get completed on 28thday since fertilization. From this regard woman who wish to
conceive must start taking folic acid at least 60-30 days before being pregnant, but observation
under this study shows that 13% of all pregnant mother started visiting RCH Clinic before
conceiving while about 47% were found to visit RCH Clinic for the first time more than three
months after conceiving in which the period in which folic acid is needed most to be provided to
the pregnant women has been over looked which suggest poor outcome of pregnancy as far as
folic acid is important to prevent Neural Tube Defects (NTDs) such as Spinal bifida,
Meningocele, Encephalocele and Anencephaly (Microsoft Encarta, 2008)

5.5 Consequences of poor health education

Among others the most terrible consequence observed under this study basing evidence from
table 10 it is where lies a secret of having high morbidity and mortality rate of maternal and
infants. Attendance of pregnant mothers to hospital for delivery was only about 63% mother has
given birth under medical personnel supervision and the rest 37% has delivered without medical
personnel supervision. Where by about 19% has delivered at home and 18% being attended by
TBA. The estimated maternal mortality rate 578 from 2004 data was in fact higher than 529 from
the 1999 TRCHS data, Overall, there was little change in the proportion of births attended by
skilled health personnel 44.1 per cent in 1999 and 46 per cent in 2004, and births taking place in
health facilities were 44percent in 1999 and 47 percent in 2004. (MDGs 2006). Tanzania report,
5.6 malnutrition problem of pregnant mothers and children bellow five years of age under
study
Pregnant women has been found to be malnourished by 69%, this rate of malnutrition is very
high to pregnant women which suggest poor pregnancy outcomes. From table six was
malnutrition contributed by about 28% underweight, 39% and 2% obese.
Most of children under this study have been found to be malnourished by 64% contributed by
60% underweight and 4% overweight this signify that their mothers either had no proper
information on breastfeeding and good health education on how to prepare food to their children
or they have wrong information for this aspect of nutrition education. These data supports the
finding which was published by.(UNICEF, 2006) which pointed out that undernutrtion accounts
for about 146 million underweight children in developing countries. Of these 146 million
underweight children, nearly three-quarters (73%) live in just 10 countries.
A recent analysis of nationally representative data from 39 developing countries showed that
although the actual prevalence of underweight and stunting varies markedly among countries and
regions of the world, the timing of faltering in both weight and length follows a remarkably
similar pattern. (Shrimpton et al, 2001).
In developing countries like Tanzania, the major determinants of Intra Uterine Growth
Retardation are related to the mother's nutritional status: inadequate nutritional status before
conception, short stature (primarily due to under nutrition and infection during childhood), and
poor nutrition during pregnancy (low gestational weight gain due primarily to inadequate diet

These are the issue to be taken care. If these are taught to mothers before they become pregnant
they may help mothers to attend to RCH Clinics early for consultation. Vitamin supplementation
is very important, Mothers are not exclusively breastfeeding their children by 91.1%that means
only 8.57% of the children are exclusively breastfed at the age below six months. This means
that children are introduced to other foods very early than their digestive system can handle, this
can be serious problem when we think of mother to child HIV transmission. Perhaps if nutrition
education could have been taught to mothers efficiently enough, mothers could have changed
their attitude towards exclusively breastfeeding, smoking and alcohol consumption. As it has
been seen in the table 6, 7, and 9. It is more important to have good nutrition for our health as
(UNICEF, 2006) declared that Good nutrition is the cornerstone for survival, health and
development of current and succeeding generation .Well nourished child perform better in
school, grow into healthy adults and in turn give their children better start in life .
Overweight and obesity should no longer be ignored at this time, although prevalence rates are
not as high as underweight, because of health risks in later life. (Cerdena et al., 2001.)
An infant's health is linked to their birth weight which in this case found to be 60% underweight.
A baby with a low birth weight is more likely to suffer from physical and mental defects.
Children who do not receive enough nutritionally adequate food will grow slowly, lagging
further behind as time passes. They are more likely to become underdeveloped adults who are
less productive and suffer from chronic diseases. Stunted growth will also decrease their chances
of learning potential and less immunity to disease and increase their chances of a premature
death.

5.7Relationship between education level and nutrition education

From the study refer to figure1, it is shown that the more educated(one being with higher
education level) does not necessarily result to better nutrition knowledge. This reminds us that
work should be done to emphasize nutrition education even to more educated people because
they are the once who do practice most of the poor dietary habits. Dietary habits refer to eating
behavior of a certain society. This can result to good or poor eating patterns that related to
tradition and customs (Kavishe, 2003).These habits can only be eradicated by proper nutritional
education.
 CONCLUSSION
Malnutrition is still a major problem, nutrition education is not adequate to change individuals
behaviour, study suggest that there is low level of nutrition education probably due to low
education level of nutrition educator compounded by absence of nutrition education guidelines
and less frequently nutrition education in job training.

There is misutilization of resources such as nutritional professionals such as nutritionists are not
employed in RCH Clinics where they could have delivered proper nutrition education in order to
promote health. Instead ministry of health exaggerates the attention to taking care of sick people
while much better results could be achieved by preventing illnesses and promoting health.
Hence there is a slogan which says that "prevention is better than cure".

RECOMMENDATION
Ministry of health need to develop policy that need to address not only national nutrition
education guidelines but also address the need to employ nutritionist at every district hospital in
the country who will be conducting in job training to all RCH Clinic staffs and to all health
personnel together with other responsibilities described as per job analysis in respect to ministry
of health.
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APPENDIX 1

FORMULA USED FIND SAMPLE SIZE

Fisher’s formula was employed (Fisher et al, 1998).

That is: nf = n
1+ (n/N)
In Fisher’s formula, n was determined as follows: n = Z2pq divided by d2 where n = the desired
sample size when the population is more than 10,000; Z = the standard normal deviation at the
required confidence level; p = the proportion in the target population estimated to have
characteristics being measured; q = 1 p; and d = the level of statistical significance set. The
calculation was: n = (1:96)2 (0.50) (0.050) divided by (0:05)2 = 348:00.
Pregnant Mothers;
Pregnant mother who attended RCH Clinics for services were interviewed, the district expected
pregnancy rate was 10836 then from this figure to obtain a representative sample, Fisher’s
formula was employed (Fisher et al, 1998).

That is: nf = n
1+ (n/N)
Where nf is the desired sample when the population is less than 10,000; n is the sample when the
total population is more than 10,000; and N is the estimated pregnancy for year 2009 which is
(10836).to obtain the sample I took number of pregnant mother who came last month (i.e.
January) for services in every clinic, which was 108,160 and 80 for Mbarali district
clinic,Chimala clinic and Utengule clinic making a total of 348.
By taking 60% of the total population which came for RCH clinic services last month
(i.eJanuary), Obtained; 108+160+80=348

Therefore If 348 are 100% then 60% is 220

Then sample was supposed to consist of 215 pregnant mothers.
nf = 220 =215
1+ (220/10836)

However, for the purpose of this study, this figure was rounded down to the nearest hundred, that
is, to 200 participants. Four women refused to participate in the study so only 196 women were
interviewed making up 98% of all pregnant mothers.

APPENDIX 2

ECTION I: GENERAL INFORMATION OF PREGNANT WOMAN

Date of interview……………… Questionnaire number………………………
Name of village…………………. Name of interviewee………………………
1. Marital status………………… 2. Education level……………………………
3. Occupation…………………… 4.Number of live child/children
5. Age …………………………… 6.gravida…………………………….
6. Para……………………………… 7height…………………………….
8.Weight………………………..

SECTION II :MARTENAL NUTRITIONAL INFORMATION

9. Do you use A. Alcohol [ ]
B.Tobacco [ ]
C. both alcohol and tobacco [ ]
10. When was your first visit in RCH Clinic for this pregnancy? [ ]
One month before being pregnant ………..
One month after being pregnant ………….
More than one moth ……………………....

11. When did you start getting nutrition education? [ ]

Before being pregnant……………
After being pregnant……………..
After delivery……………………

12. When did you start receiving nutritional supplements e.g. folic acid, ferrous sulphate?
One month before pregnancy……
One month after pregnancy………
More than one month……………. [ ]

12. Where did you get information that you need to attend RCH clinic?
From parents……..
From medical personnel…….
From other sources……….. [ ]
13. Are educational materials given in RCH helpful? [ ]
Yes…………….
No……………..

MEDICAL PERSONNEL

1. What is your education level?

Primary school level…… [ ]
Secondary school level
Higher education level
2. Did you attend any nutrition seminar within at least two year? [ ]
Yes…………. No…………….

3. Do you have a time table for nutrition education?

Yes…….. No……...

4. Is there a national curriculum for providing nutrition education? [ ]

Yes……. No……..

5. Do mothers attend for pre pregnancy counseling? [ ]

Yes……. No……

6. When do mothers supposed to attend for RCH clinic? [ ]

One month before pregnancy………
The first month of pregnancy………
Others………

7. How often is a mother supposed to attend RCH clinic? [ ]

Once per month……….
Twice per month……..
Others……………….

8. When do you start giving nutrition education? [ ]

Before pregnancy……….
After pregnancy………...

9. Do you give supplement to pregnant mothers? [ ]

Yes…… No…….

10. Do mothers comply with nutrition education given? [ ]

Yes…… No……

11. Do you have follow-up program for the case of abscond? [ ]

Yes……. No…….

SECTION III: REVIEW OF RCH GROWTH MONITORING CARDS.

1. Where was a place of child delivery?

Hospital……………..TBA…………………… at home…………. [ ]

2. Is the child underweight ………normal weight………overweight……… [ ]

3. Does the child attend RCH Clinic regularly ………… [ ]

Yes……… No………

5. Did a mother start attending RCH services early? [ ]

Yes……. No……..

6. Did she receive any nutritional supplementation? [ ]

First month of pregnancy………..
Second month of pregnancy…….
Others……………………………

7. Is the curve obtained in the card regular? [ ]

Yes…….. No……….

8. If not why? [ ]
Was sick………. Others…………
9. Does the child receive immunization as scheduled? [ ]
Yes……… No………..

10. Is the child breast feed? [ ]

Yes……. No……..

11. If breast fed, is it exclusive breastfeeding? [ ]

Yes…….. No…….,