Low birthweight (LBW) is defined as a body weight at birth less than 2500grams. Its main causes include prematurity (born before 37 weeks gestation) in developed countries and Intrauterine Growth Retardation – IUGR (restrained foetal growth) in developing countries (ACN/SCN, 2000). Relationship between health of mother and child has also been established, maternal nutritional and health status is an important determinant of child’s health and nutritional outcome. LBW infants end up undernourished and stunted children, adolescents and finally women of childbearing age. The main indicators of LBW infants include maternal stunting, low pre-pregnancy weight and low pregnancy weight gain. Thus generational stunting continues (Victoria et al, 2008).
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Households vary in definition and composition, especially in Africa. Household’s here in Africa mostly includes the extended family members both in definition and composition. This serves as social support network here and so adds income into the household if the members are economically active or if economically inactive, increases dependency ratio in the household. Mother and child pair nutritional status reflects household dynamics, availability of food, care of mother and child. It can also reflect gender segregation in household food allocation etc.
The state of food insecurity 2001 defines Food security [as] a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life (SOFI, 2002). Its three building pillars include availability, accessibility and stability of food. Availability entails physical presence of food in the household or area concerned; accessibility is concerned with the ability to acquire adequate amount of food and stability means constancy of food access which can be chronic or transitory. Chronic food insecurity exists when food supplies are persistently insufficient to supply adequate nutrients for all individuals. Transitory food insecurity occurs in the presence of temporary decline in access to adequate food because of instability in food production, food prices or income shortfalls. It is also necessary that available food meet the nutritional needs of the household members, bringing in the component of food utilization. Resource poor subsistence farmers, landless households, pastoral household, female-headed household and urban poor are more vulnerable to food crisis (UN millennium project, 2005; FEWSNET, 2011). During the study period, coastal state of the Bayelsa, delta, Rivers and some portions of Jigawa in Northeast will experience moderate food insecurity. The coastal states will be affected by Niger-Delta crisis and potential pre-election tension. Pipeline vandalization, will continue to contribute to local water pollution, creating fish shortages among others. Flooding in the Northeast state of Jigawa will reduce household stock (Millet) causing food insecurity, with low cereal prices, above-average increase in tuber production.
The Convention on Biological Diversity (CBD) defines biodiversity as “the variability among living organisms from all sources including, inter alia, terrestrial, marine and other aquatic ecosystems and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems.” In other words, it is the variety of life on earth at all levels, from genes to worldwide populations of the same species. The different Levels of biodiversity include ecosystem containing rich biodiversity, species and communities of species and different genotypes, and this includes agricultural biodiversity. All components of agricultural biodiversity relevant to food and agriculture and support the ecosystem that agriculture occurs is important (FAO, 2008). Thus, dietary diversity becomes important as a means of protecting the ecosystem.
Dietary diversity can be defined as the number of different foods or food groups consumed over a given reference period, usually 1-2 week. Dietary diversity has been shown to improve nutritional status (Kant et al, 2000; Kiokia and Golden, 2004; Gibson et al, 2000). Thus, it also can aid in combating hidden hunger, and thus double burden. Dietary diversity is a reflection of household food security because depicts accessibility, availability of foods and to some extent stability. Hoddinott and Yohannes analysis of evidence from 10 countries links dietary diversity to household access of calorie and by extension food security (2002). Traditional food systems abound, and are currently going extinct because they are underutilized. The diet is shifting more towards an energy-dense based diet categorized by westernized and processed food, bringing with it the advent of non-communicable diseases like diabetes, coronary heart disease etc.
Nutrition education aims to persuade individuals to make meaningful changes in their dietary behaviour. Studies have noted the importance and role in nutrition status and adequacy (Favin and Griffiths, 1999; Tarvinder et al, 2007; Mansour et al, 1994). In view of that, importance of nutrition education cannot be overemphasized in this scope, especially as traditional foods are available in its varieties but less consumed/sought-after. It becomes imperative that nutritional content and thus importance of these foods are once again extolled so that they can be consumed for optimum health. Biologically active substances have been found in traditional foods and functional foods include flavonoids etc.
Information technology has opened lots of doors for education and knowledge in the world, which can be harnessed for promotion of nutrition education. Information technology used in education includes access devices, networking and communicating technologies, storage devices and e-learning platform (India policy brief, 2010). They pose great potential for acquiring knowledge especially at the subjects’ comfort. Phones have been used for teacher training with positive results among other things, MMS examples of teaching, audio lectures, SMS for reminders, motivational messages and short assessment questions etc. were used (ADB/Pouezevara and Khan, 2007).
STATEMENT OF PROBLEM
There is a dearth of information on the relationship between dietary diversity and nutrition status in Nigeria. There is also little information on shift of food consumption from traditional to processed western foods together with a gap in the quantification of the effect of nutrition education in enhancing dietary diversity.
OBJECTIVES
GOAL
Optimize nutrition status of mother and child through dietary diversity and nutrition education
SPECIFIC OBJECTIVES
To identify the available foods in the surrounding/environment/locality and determine the neglected and underutilized local foods/species
To identify the prevalence of malnutrition of mother and child
To assess the dietary diversity in the food consumed by the mother-child and factors affecting it.
To Investigate association between dietary diversity and nutritional status
To ascertain the influence of nutrition education on nutritional status of mother and child.
JUSTIFICATION
Prevalence of malnutrition in Nigeria is currently high, especially in Under-Five. Currently, 41% of under-fives are stunted, 23% underweight and 14% wasted (NDHS, 2008).
High Under-Five Mortality Rate propels continuous childbearing and with is accompanied maternal mortality due to nutrient depletion (El-Ghannam, 2005).
Improved maternal health importantly pre-pregnancy status is vital for adequate growth and development of new foetus and to break intergenerational disease and poverty that can arise from poor health status during the first 1000 days (ACC/SCN, 1992).
Lack of adequate nutrition education has led to improper feeding techniques of growing child, especially the under-fives.
Traditional food systems are gradually becoming extinct and non-existent. The bulk of foods consumed are shifting base to western-influenced and processed foods (Bioversity International, 2006).
High incidence of NCDS in developing countries and increase of double burden has been linked to monopoly in consumption of food and lack of dietary diversity. At the beginning of the 1960s, about 40% of the developing countries were chronically undernourished. Many developing countries have achieved 2700kcals. This high energy combined with an increasingly sedentary lifestyle has led to an increase in obesity and NCDS. The composition of the diet change to mainly high energy and fat etc. (Josef and Prakash, 2004).
METHODOLOGY
ANALYSIS OF OBJECTIVES
Objective
Variable
Type of analysis
To identify the available foods in the surrounding/environment/locality and determine the neglected and underutilized local foods/species
Foods from Market survey, FGD and KII vs foods from DD Questionnaire
To identify the prevalence of malnutrition of mother and child
BMI, stunting, wasting and underweight
To assess the dietary diversity of mother and child
DDS of mother and child
Computation
To Investigate association between dietary diversity and nutritional status
DDS and BMI/nutritional status indices
Cross-tabulation
To determine factors affecting dietary diversity
DDS and socio-demographic, economic and household factors
Cross-tabulation
To ascertain the influence of nutrition education on dietary diversity
DDS before and after nutrition education
Paired T-test
STUDY DESIGN – The study will be a cross-sectional and descriptive study.
STUDY LOCATION
The study will be conducted in Anambra state. Anambra state is located in the south-east zone of Nigeria, with its state capital being Awka. On a longitude of 6 20 00N and latitude of 7 00 00E, the state has 21 Local Government areas. It has a land area of 4,416km2 and a population of 4,177,848, made of 2,117,984 males and 2,059,844 females (NPC, 2006). With a population of 473,248, Children Under -five account for about 11.35% of the Anambra state population. Onitsha North and South, Awka North and South and Nnewi North and South are all urban area in the state. Idemili, Oyi, Anaocha, Ogabru and Dunkofia are peri-urban, while the remaining Local governments are rural.
With a population size of 369,972 (NPC, 2006), Aguata LGA is the 2nd largest LGA in terms of size and the largest LGA in terms of number of constituting communities – 15 communities. The local government has the presence of a prison in Ekwulobia and the renowned Igbo-ukwu museum that houses artefacts and monuments from pre-colonial era. Like all other LGA in Anambra state, Aguata has its own share of ecological disasters, the most prominent being the Ekwulobia – Oko erosion site. Other small-sized erosion sites abound in different communities in the LGA. The Staple food consumed here is mostly cassava and yam, eaten as fufu, garri, abacha etc. green leafy vegetables and fruits are also abundantly found. The planting season, marks the beginning of the annual year (Igu aro), and peaks during the harvest season.
Map of Anambra State
The study will be conducted in Uga, a town in Aguata LGA of Anambra state, in South East Nigeria. With a landmass of about 3790km2, it also has about 100,000 inhabitants. Uga shares its borders with Akokwa, Nkpologwu, Amesi, Umuchu and Ezinifite. The town is made of 4 villages namely Oka, Umueze, Umuoru and Awalasi. These villages have different clan, an average of 6 clans per villages. They include Oka, made up of Okwuowerre, Umuikpa, Umueziama, Amaeke, Okohia and Umucheke. Umueze is made of Umucheke, Ezihe, Umu-umeonye, Umudim and Umuonyike. Umoru village is made of Imishii, Umudieleke, Umuezekpoko and Umori. Awalasi village is made of Umunocha, Umuchiaku, Umuakabo, Umudim, Umuosu, Okwu, Agbako and Umuoweri. The community Uga, has 2 streams/waterbodies, namely, Obizi and Agwazi. While the former is potable and serves as a tourist site, it’s a taboo to fetch from the latter or visit. The population is predominantly Igbos with few settlers from other tribes. Almost every household has some form of garden or subsistence/small-scale farming; most of the food/fruits available in the market come from subsistence farming. Land tenure is mainly through inheritance and few by purchase.
STUDY POPULATION – Mothers with under-5 children in the study community.
SAMPLE SIZE
For the main study, all mothers with their youngest under-5 children in the town will be used.
For the Key Informant Interview, The oldest individual in each clan will be used. A total of 24 subjects will be interviewed
For the focus Group discussions, each group will have a minimum of 6 and maximum of 8 members in each of the 4 villages, comprising of both sexes.
SAMPLING PROCEDURE
A three-stage sampling technique will be used to select respondents/mother-child pair for the questionnaire survey.
Firstly, Anambra state, will be purposively selected because food systems are eroded with language, an indicator of culture. The Igbo culture is the fastest eroding culture among all the 3 major tribes in Nigeria. Legend also has Anambra State as the origin of Igbo people in the South-Eastern part of Nigeria.
Secondly, Aguata LGA with its headquarters at Ekwulobia will be purposively selected because in the local government, urban and rural communities are found. Its headquarters, Ekwulobia, serves as the entry point to numerous communities and Local Government. Its proximity to Federal Polytechnic, Oko and Federal College of Education (Technical), Umunze, makes it a key point and central access area. While the headquarters remains urban, the surrounding communities, the study area- Uga included are still rural. It will be strategic to study the effects of the spills of urban development in the dietary practice of these rural communities.
Thirdly using a table of random numbers, Uga was chosen as the study area and all villages in Uga town will be used for the study.
SAMPLE SELECTION
SELECTION OF QUESTIONNAIRE RESPONDENTS – All the women living in the community with a child under-five years of age who consent to participate will be included in the study. Already participating women will also be asked for referrals of other mother-child pair.
SELECTION OF FOCUS GROUP DISCUSSION – Using the help of research assistants, through non-probability sampling, 6-8 males and females aged 60 and above will be selected from each village and used for the focus group discussion.
SELECTION OF KEY INFORMANT INTERVIEW – the oldest person in each clan/village irrespective of gender will be used in Key Informant Interview. The individuals must be mentally acute despite disabilities/ infamy.
MEASUREMENT INSTRUMENT
Food/Market Survey Questionnaire
Focus Group discussion guide
Key informant interview guide
FAO’s 16-item Individual Dietary Diversity Questionnaire for mothers and children aged 36-59 months
Demographic Health Survey’s 21-item Dietary Diversity Questionnaire for children Under 36 months
Socio-demographic characteristics questionnaire for the mother.
USIAD/FAO’s 3-item Household Hunger Scale
Food Frequency Questionnaire
VARIABLES
Socio-demographic characteristics
Mother’s DDS before the intervention
Child’s DDS before the intervention
Mother’s DDS after the intervention
Child’s DDS after the intervention
HFIAS Score
Nutritional status of child
Nutritional status of mother
Family dynamics and household characteristics
Food Variety Score (FVS)
Pattern of consumption
COMMUNITY ENTRY
Entry will be done through the different religious bodies – (Christianity and traditional) and the community leaders. The community leaders include Uga Town Union, the Igwe and his council and also the individual village unions. They will be acquainted with the different objectives of the study and its advantages for the community members. They will also be requested to disseminate the information to the community members to get their cooperation.
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DATA COLLECTION
Quantitative questionnaires will be used to collect baseline information from the communities. The questionnaires will be administered by twenty four (24) fieldworkers (research assistants). The research assistants will be selected one from each clan with at least a secondary school education. All of them will speak English and the local Igbo dialect of the community fluently. The research assistants will be carefully trained by the researcher. The study objectives, methods and questionnaires will be discussed with special emphasis on interpretation of result, Dietary Diversity Score (DDS) and nutritional status. Proficiency of the research assistants will be verified through role play and pre-testing. The research assistant will be supervised by the lead researcher through field monitoring to check quality.
The Key Informant Interview (KII) and Focus Group Discussions will be conducted by the lead researcher and a note taker using the KII and FGD guides. The interview will be recorded, with the permission of the subjects.
BASELINE
As a means of assessing the current situation, baseline information of the study communities will be conducted. For this phase of the study a short food identification questionnaire, Appendix A will be used to document all foods encountered in the native nearby Igbo markets. Any new food and fruit type (species) or variety will be photographed with a digital camera and information about it will be gathered. Information to be gathered include trade name, local name, name of market sold, source of food/fruit, type of buyers, season when available and (recipe). Scientific and family name will be added following correct identification through books, internet and knowledgeable people in relevant departments of the University of Ibadan. All food items encountered will be classified into food groups. Since dietary diversity involves biodiversity food of plant and animal origin, aquatic and forest resources also found will be documented.
MARKET SURVEY – The market survey will be conducted on the 4 native Igbo market days – Eke, Orie, Afor and Nkwo. Each community’s market operates on a given market day, example, Orie for Uga community, Nkwo for Umuchu community etc. A market survey of proximal markets to the study area will also be conducted. They include Orie-Uga, Nkwo-Uchu and Eke-Ekwulobia. These 3 markets fall on different Igbo market days (Orie, Nkwo, Eke), leaving out only one market day, Afor.
Focus Group Discussions (FGD) and key-informant interviews (KII) will be carried out for foods not sold in the market, but consumed in the community.
FOCUS GROUP DISCUSSION
Focus groups discussions will be facilitated in (different churches) each village to be used in the study by the lead researcher with a note-taker present. The use of FGD guide Appendix B will be employed and also a camcorder for recording and camera for photographs. Each FGD will have a minimum of 6 members and a maximum of 8 members. The purpose of the FGD is to learn about foods that are underutilised in the environment. The discussion will be conducted in native Igbo language dialect of the community.
KEY INFORMANT INTERVIEWS
The KII guide Appendix C will be used to conduct the KII. Respondents will be asked foods, farming systems and varieties of foods that are currently underutilised. They will also be asked about the source, harvest season, recipe of those foods and use. The interview will be conducted in the native Igbo language dialect.
ANTHROPOMETRIC MEASUREMENTS
Baseline anthropometric measurements will be taken of the mother (BMI) and child (Stunting, Wasting and Underweight). For the weights, electronic scales will be used.
CHILDREN – For children 0 to 23 months, their weights will be taken using the children weighing scale. Children 24 to 59 months and all mothers will be weighed using the electronic scale, after they have emptied their bladder. All weights will be measured to the nearest 0.1kg. For all weight measurements, the balance will be placed on a level hard surface and adjusted to zero balance before measurement. The subject will stand in the centre of the scale and looking straight. Light clothing will be advised in the absence of nudity.
For the heights, children and infants less than 85cm will have recumbent length measured using a wooden measuring board (WHO, 1995). The infant’s heels will touch against the footboard, shoulders touching the baseboard and the crown of head touching headboard. Stadiometer will be used for children longer than 85cm. The subject will stand straight, looking ahead with the head, shoulder blades, buttocks and heels touching the plane.
For weight-for-age and height-for-age, exact date of birth will be used. WHO Anthro v3.2.2 will be used to calculate weight-for-age, height-for-age and weight-for-height. The WHO standard Z-scores will be used.
MOTHERS – Body Mass Index (BMI) also called Quetelet’s Index calculated as weight (kg)/height (m2) will be used to assess the nutritional status of the mothers. The weights will be measured using the electronic scale, after they have emptied their bladder with the scale on a hard surface and adjusted to zero balance.
The mothers’ heights will be measured with a Stadiometer. The subject will stand straight, looking ahead with the head, shoulder blades, buttocks and heels touching the plane.
The classification of mothers’ BMI will be according to WHO’s recommendation (2000) as shown below
Classification
BMI (kg/m2)
Underweight
<18.50
Normal range
18.50 – 24.99
Overweight
>= 25.00
Pre-obese
25.00 – 29.99
Obese I
30.00 – 34.99
Obese II
35.00 – 39.99
Obese III
>= 40.00
HOUSEHOLD HUNGER SCALE (HHS)
Food Insecurity Score (FIS) will be found using the Household Food Insecurity Access Scale (HFIAS), Appendix G. The HFIAS is 9-item access and frequency-of-occurrence instrument developed by USAID and FAO, with a recall of 4 weeks/30 days/1 month. The general occurrence questions cover domains that include anxiety about household food supply, variety and preferences of type of food and insufficient food intake and physical consequences. If the access question occurs, then the frequency of the domain question is asked and coded as often, sometimes and rarely. The maximum HFIAS for a household is 27, i.e., a situation where frequency of occurrence of all questions is often (3) and the least HFIAS is (0). The higher the HFIAS, the higher the food insecurity; the lesser the HFIAS, the lesser the food insecurity.
DIETARY DIVERSITY
Dietary diversity of mother and child will be assessed. The interview will be conducted on an Eke day, which is not preceded by a weekend. This is necessary as Eke day precedes an Orie day, which is the market day and dietary habits are synonymous with festive day. Also, Eke day is the only day without a proximal market to the community.
MOTHER – The 16-item FAO’s Dietary Diversity Questionnaire, Appendix D will be used from which Individual Dietary Diversity Score (IDDS) for the mothers will be calculated. The food groups include cereals, vitamin A rich vegetables and tubers, white tubers and roots, dark green vegetables, other vegetable, vitamin A rich fruits, other fruits, organ meat(iron-rich), flesh meats, eggs, fish, legumes, nuts and seeds, milk and milk products, oils and fat, sweets and coffee/tea. To calculate Individual dietary diversity score (IDDS), the last two items – sweets and coffee/tea are left out, while the others items each has a point.
The mean IDDS, percentage consuming each food group and terciles as a measure of distribution of scores will be calculated.
The Food Frequency Questionnaire (FFQ), Appendix H, will be used to calculate the Food Variety Score (FVS) and the consumption patterns of the mothers. Different varieties of food will be listed and scored. Their consumption will be noted as never, once a month, more than once a month, once a week, more than once a week, everyday and more than once everyday.
CHILDREN – For children more than 3 years, as with the mothers, FAO’s 16-item individual dietary diversity questionnaire, Appendix D will be used, for foods eaten in the last 24 hour. The food groups include cereals, vitamin A rich vegetables and tubers, white tubers and roots, dark green vegetables, other vegetable, vitamin A rich fruits, other fruits, organ meat(iron-rich), flesh meats, eggs, fish, legumes, nuts and seeds, milk and milk products, oils and fat, sweets and coffee/tea. To calculate Individual dietary diversity score (IDDS), the last two items – sweets and coffee/tea are left out, while the others items each has a point.
The 21-item dietary diversity questionnaire, Appendix E, used in Demographic Health Surveys (DHS) will be used for children less than 3 years. The items on the questionnaire range from water, breastmilk, infant formula, green leafy vegetables, organ meats, fish etc. The IDDS will be calculated over 21 items.
The mean IDDS, percentage consuming each food group and terciles as a measure of distribution of scores will be calculated.
SOCIO DEMOGRAPHY – Socio-demographic characteristics of the household will be collected, using Appendix F. Demographic characteristics of the mother will include Education, Age at marriage, current age, Child’s date of birth, marital status, parity, religion. Economic information will include job, monthly earning, Access to farm, livestock ownership, food access – market or farm production. Household details will also be collected, and they include type of household – nuclear or extended, number of dependents in the family, number of household members, source of income and total household income.
CLASSIFICATION OF UNDERUTILIZED SPECIES – Underutilized and neglected food species and groups will be identified from the Dietary Diversity Questionnaire in comparison with the market research earlier carried out.
MAPPING – The map of the town Uga, will be digitized, using the nutritional status and dietary diversity. This will help monitor trends in nutritional status and DDS.
DATA PROCESSING – Data entry, computation and analysis will be done with SPSS v 17. Quality will be ensured through quality checks associated with data entry processes, double entry and further data cleaning through generation of descriptive analysis after data entry.
DATA ANALYSIS
Characteristics of the sample – average mother’s age, average child’s age, mother’s education, parity, occupation of mother, average household income, average DDS. Prevalence of malnutrition will also be assessed, stunting, wasting and underweight of the children and BMI of the mother. This will be done through Frequency distributions for qualitative variables and descriptive analysis for quantitative variable.
DDS and nutritional status of mother (BMI) through cross-tabulation
DDS and nutritional status of child (Stunting, wasting and underweight) through cross-tabulation with each indices.
HFIAS and nutritional status of mother
HFIAS and nutritional status of child
Nutritional status of mother and nutritional status of child through cross-tabulation of mother’s status with each individual nutritional index.
Effect of socio-demographic, household characteristics and economic differentials on DDS and anthropometric measurements.
A model for interactions of quantitative will be generated – linear and logistic regression, the MIXED procedure for quantitative response variables (BMI and DDS) and the GLIMMIX procedure for dichotomous response variables.
INTERVENTION
Nutrition Education will be conducted in different ways to enhance the consumption of underutilised foods. Underutilized food/fruits/species that has been thus categorised will be promoted through nutrition education. A food/fruit/specie will be said to be underutilized if it is readily available in the environment but its consumption is low.
Firstly, food and nutrient information of underutilized foods will be sent to the phones of mothers as a daily SMS in the native Igbo dialect for 30 days. A single food/fruit will be highlighted each day, including the different ways in which it can be consumed. Recipes will also be included, to enable the mothers attempt otherwise new foods.
Using mass media e.g. posters, handbills and stickers, general awareness will be created on the underutilised foods in the town. The posters and stickers will be distributed on the town’s market day – Oye-Uga and at the different religious places in the town. Copies will also be made available to the participating women.
Face -to -face nutrition discussion will be held for mothers in the clan with the lowest Dietary Diversity Score that correlates with low nutritional status of the Mother-Child pair. It will be held in the village hall, assessable to everybody. The discussion will seek to bring to the fore the underutilized food in the community, and the different recipes for preparation of the foods.
ENDLINE/EVALUATION
The IDDS of both mother – child pair will be assessed again to calculate the post-intervention practise. This will help ascertain if the intervention impacted knowledge to the mother as evidenced by the post-intervention IDDS.
ETHICAL CONSIDERATION
Ethical clearance will be sort from the Health Ethical Review Committee (HREC) of the University College Hospital (UCH) Ibadan.
EXPECTED OUTCOME – It is expected that at the end of the study, adequate knowledge on importance of dietary diversity will be garnered by the mothers and visible in their feeding practice, of both themselves and their children.
TIMELINE FOR THE STUDY
Week
1
2
3
4
5
6
7
8
9
10
11
12
Activity/Month
Month 1
Month 2
Month 3
Community Entry
Recruitment of Research Assistants and Training
Market Survey
Key Informant Interview
Focus Group Discussion
Administration of Questionnaire
Analysis of Baseline Data
Intervention
Collection of Endline Data
Analysis of Endline Data
BUDGET
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