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.....................................................................................................................................iACKNOWLEDGEMENT...............................................................................................................iiTABLE OF CONTENT.................................................................................................................iiiLIST OF TABLES..........................................................................................................................ivLIST OF ACRONYMS...................................................................................................................vCHAPTER ONE..............................................................................................................................11.0 INTRODUCTION................................................................................................................1

PROBLEM STATEMENT AND JUSTIFICATION..................................................................21.1 OBJECTIVE OF THE STUDY........................................................................................4

1.1.1 MAIN OBJECTIVE.......................................................................................................41.1.2 SPECIFIC OBJECTIVES...............................................................................................4

2. 0 LITERATURE REVIEW.........................................................................................................42.1 NUTRITION EDUCATION OVERVIEW...........................................................................52.2 MATERNAL NUTRITION EDUCATION..........................................................................62.4 THE EFFECT OF NUTRITION EDUCATION PROVISION.............................................8

CHAPTER THREE.......................................................................................................................103.0 METHODOLOGY..................................................................................................................10

3.1 THE STUDY AREA /LOCATION.....................................................................................103.4 STUDY DESIGN................................................................................................................103.5 SAMPLE SIZE....................................................................................................................103.6 SAMPLING TECHNIQUE.................................................................................................113.7 DATA COLLECTION........................................................................................................11

3.7.1 SECONDARY DATA COLLECTION........................................................................113.7.2 PRIMARY DATA COLLECTION..............................................................................11

3.8 MATERIALS AND INSTRUMENTS FOR DATA COLLECTION.................................123.9 DATA PROCESSING AND ANALYSIS..........................................................................12

CHAPTER FOUR.........................................................................................................................12RESULTS......................................................................................................................................12CHAPTER FIVE...........................................................................................................................22D ISCUSSION...............................................................................................................................22

5.2 Nutrition education guideline..............................................................................................235.3 Time at which they start to provide nutrition education......................................................245.4 Time of first visit at RCH Clinic.........................................................................................245.6 malnutrition problem of pregnant mothers and children bellow five years of age under study...........................................................................................................................................255.7Relationship between education level and nutrition education............................................26

CONCLUSSION...........................................................................................................................27RECOMMENDATION.................................................................................................................28REFERENCES..............................................................................................................................28APPENDIX 2.................................................................................................................................33

iv

LIST OF TABLES

L

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

years of age

58 67 55

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

Nutrition education or seminar Within two years before the study

Presence of nutrition education time table

Presence of national guideline for nutrition education

Do you have materials for teaching nutrition education

Primary school levelSecondary school levelHigh education Yes no

yes no

yes no

yes no

330

15

06

06

33

50500

16.6783.33

0100

0100

5050

Table 2b: Parameter Description

N=6 %Do mothers attend for pre pregnancy counseling

When do mothers supposed to attend for RCH clinic

How often is a mother supposed to attend RCH clinic

When do you start giving nutrition education

yes no

Before conception One month after conceptionMore than three months afterconception

once per monthTwice per monthFour times per three trimester

Before conception One month after conceptionMore than three months after conception

33

114

105

20

4

5050

16.6716.6766.66

16.67083.33

66.670

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 Used by nutrition educator

Types of materials usedTo deliver education

Identification of malnutrition Posters Environmental factors

influencing nutritional status

Flip charts

Parasites and malnutrition Brochures Infant-feeding practices,

including breast-feeding and weaning food

Immunization

Video Television

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

19-25

26-45

46 and above

31

81

58

26

15.8

41.3

29.6

13.3

Marital status Married

Not married

141

55

71.9

28.1

Occupation

Formal employment

Informal employment

No employed

28

50

118

14.3

25.5

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 educationPrimary school education

67

77

34.2

39.3

Secondary school education

High education

36

17

18.4

8.2

Knowledgeof balancediet

YesNo

66130

33.766.3

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

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

Table 7: pregnant women alcohol and tobacco use

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

2512.8

within first month of pregnancy 1 5

parameter N=196 %

Alcohol

Tobacco

Both alcohol and

Tobacco use

55

37

24

28.06

18.87

12.24

within three months of pregnancy 77 39.3

more than three months of pregnancy 93 47.4.

Total 196 100.0

Table 9: Nutrition status of children bellow five years old

Parameter N %

Normal weight

Under weight

Over weight

64

108

8

35.6

60.0

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 cardParameter Description N=180 %

Place ofdeliveryof a child

AttendanceAt RCH Clinic

Age of respondent

HospitalTBAHome

RegularIrregular

Less or equal

1133235

16020

70

62.817.819.4

88.911.1

38

Early attendance at RCH

to six months

two year of ageand bellow

above two year to five years

yesno

61

49

165151

33.9

27.2

91.78.3

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 five years N %

Status of breastfeeding N %

less or equal to six months

70 38.9Exclusive breastfeeding

19 27

Non exclusive breastfeeding

51 72

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

no formal education

primary school secondary school

higher education

education of respondent

0

20

40

60

80C

ou

nt

knowledge on

balance diet of

respondent

yes

no

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 studyPregnant 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.

REFERENCES

Anderson ME, Johnson DC, Batal HA. BioMed Central,( 2005). Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep eraJan 11; 3:4doi:10.1186/1741-7015-3-4(http://www.biomedcentral.com/1741-7015/3/4) Site visited on 21.12.2008.

Brouwer, W., Van Exel, J., Van Baal, P., Polder, J. (2007). The European Journal of Public Health, Economics and public health: engaged to be happily married! 2007; 17(2): 122-123.

Calderon, J.L., Beltran, R.A.( 2004). Pitfalls in health communication: healthcare policy, institution, structure, and process.

Chandras M, (2005). The Prevalence Study. U.S Department of Health and human service,Washington,DC 91-96:109-124.

Donaldson, S. L.,(2006). The European Journal of Public Health; The future of public health in Europe. 16(5): 459-461.

Fisher, A. A., Lang, J. E., Stoeckel, J. E. and Townsend, J. W. (1998) Handbook for Family Planning Operations Research Design, 2nd edition, Population Council Nairobi, Nairobi.

Hans Hoogeveen, (2008). World Bank, Tanzania. Advancing Nutrition in tanzania: Tanzania’s Forgotten MDG.

http://go.worldbank.org/phsk3vdf10.searched 24 march 2009

Jiang T, et al (2005) micronutrients Deficiencies in Early Pregnancy Are Common Concurrent, and Vary by Season among Rural Nepal Pregnant Women. J. Nutr.135:1106-1112.

Jones G, (2003): How many child deaths can we prevent this year? Lancet: 362: 65-71

Kavishe F.P. & Mushi S.S. (2003), Nutrition for developing countries.

Kinabo J., Msuya J., Nyaruhucha C., Mnkeni A. and Ishengoma J. (2003). Nutritional status of children and adults in Morogoro and Iringa Region: Towards food security; Research on production, processing, Marketing and Utilization. SUA-Morogoro Tanzania.

Kirsten, B.S, Simondon, F. Costes, R. Delauncy. V. Diallo, A (2001). Breastfeeding is associated with improved growth in length but not weight in rural Senegalesetoddles.American Journal of Clinical Nutrition. 73(s):959-967

Leonard E.G. Mboera, Susan. F. Rumisha, Kesheni P. Senkoro, Benjamin K. Mayala, Elizabeth H. Shayo and Wn. Kisinza, (2007) Knowledge and health information communication in tanzania . East African Journal of public heath, vol. 4, no. 1, April 2007, pp. 33-39

Lindsay H. Allen, (2001), Present knowledge in Nutrition; 8th ed. ILSI Press Washington, D.C 37: pp 403; 405-409.

Manongi R.N, Marchant T.C and Bygbjerg C.I (2005), Improving motivation among primary health care workers in Tanzania: A health worker perspective (http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=205&actions=archive) visited on 12 January 2009

Millenium Development Goal,(2006).Tanzania progress national report.

Microsoft Encarta (2008).Folic acid and neural tube defects

Ministry of Health. Primary Health Care Strategies. Dar es Salaam; 1992.

National Women health Information Centre. (2000),United States Department of health and human service office on women health, Scout News, LLC.

(Http: //www. womwn.gov/pregnancy). Site visited on 21.12.2008.

National Bureau of Statistics (NBS), Tanzania and DRC Macro 2005. Tanzania Demographic and Health Survey 2004-05. Dar-es-salaam Tanzania.

Norusis, J.M. (1998). Guide to data analysis.SPSS®8.0 Prenticehall,upper saddle river,New jersey,

Rumisha, S.F., Senkoro, K.P., Ngadaya, E., Shayo, E.H., Mayala, B.K., Mtandu, R. & Mboera, L.E.G.: Community knowledge and information communication gaps on HIV/AIDS in Iringa Municipality, Tanzania. Tanzania Health Research Bulletin 2006; 8:101-108.Tomkins J.E (2007), Pregnancy: Nutrition, Immunity and Disease hypothesis in

Developing Countries. 36:121-124

Tomkins J.E (2007), Pregnancy: Nutrition, Immunity and Disease hypothesis in developing countries.36:121-124.TFNC, (2000), Nutrition for Human and Economic Development in Tanzania: Tanzania’s Vision 2025

Thomson, A.M Hytten, F.E (2002) Nutrition during pregnancy 19:31-37Tanzanian Reproductive & Child Health Survey (2004).

USDA (2000), Food, Nutrition and Development. Washington D.C 39-41.

United Republic of Tanzania / planning commission 2002UNICEF (2006). The state of the world’s children (http://www.unicef.org/soaw698/fso1.htm) site visited on 20th Feb, 2009.

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 WOMANDate 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 INFORMATION9. 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 level2. 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…….,