Malnutrition among under-5 children and health service delivery by

Village Health Teams in Isingiro District

Investigators;

Ayebazibwe Geoffrey, MBChB (MUST)

Mutatina Boniface, BSc. (SUA)

 Table of abbreviations

MUAC – Mid Upper Arm Circumference

MUBS – Makerere University Business School

MUST – Mbarara University of Science and Technology

NCHS – National Center for Health Statistics

SUA – Sokoine University of Agriculture

UDHS – Uganda Demographic and Health Survey

UNICEF – United Nations International children Emergence Fund

2
 Table of contents

Table of abbreviations...................................................................................................................................................2

Table of contents............................................................................................................................................................3

Chapter one...................................................................................................................................................................4

1.1 Introduction.................................................................................................................................................4

1.2 Problem statement.......................................................................................................................................4

1.3 Significance of the study.............................................................................................................................5

1.4 Conceptual frame work..............................................................................................................................5

1.5 Scope of the study........................................................................................................................................6

1.6 Research questions......................................................................................................................................6

1.7 Hypothesis....................................................................................................................................................6

1.8 Objectives.....................................................................................................................................................6

Chapter Two: Literature review..................................................................................................................................7

Chapter Three: Methods..............................................................................................................................................9

3.1 Study design.................................................................................................................................................9

3.2 Study setting.................................................................................................................................................9

3.3 Population....................................................................................................................................................9

3.4 Selection criteria..........................................................................................................................................9

3.5 Sampling procedure....................................................................................................................................9

3.6 Sample size estimation..............................................................................................................................10

3.7 Study variables..........................................................................................................................................10

3.8 Data collection...........................................................................................................................................10

3.9 Data management and Analysis...............................................................................................................11

3.10 Quality Control Procedures......................................................................................................................12

3.11 Anticipated problems in executing the study..........................................................................................12

3.12 Ethical consideration.................................................................................................................................12

References................................................................................................................................................................13

Appendix one: Time frame of activities................................................................................................................15

Appendix two: Budget ...........................................................................................................................................16

Appendix three: Nutritional Survey Questionnaire............................................................................................17

Appendix four: Questionnaire for assessing objectives of village health committees......................................20

Appendix five: Consent Form...............................................................................................................................22

3
 Chapter one

1.1 Introduction
Despite the favorable human resources capacity and agriculture natural resources in Sub-Saharan
Africa, malnutrition remains the biggest health burden among the children [3]. Malnutrition
among the under-5 years is a leading factor underlying child mortality and morbidity in Sub-
Saharan Africa, and contributes to 2.2 million deaths and a fifth of all disability adjusted-life-
years lost worldwide for children under five years old[1].

According to 2006 Uganda Health Demographic Survey, 38% of children in Uganda were
stunted of which 15% were severally stunted with the percentage of stunting amongst rural
children comprising 40% than among urban children 26% [5].

The high prevalence of malnutrition among the children reflects inadequate health services, poor
water and sanitation, poor maternal and child care practices and insufficient access to food [4].
This prevalence would be much lower if the objective of Village Health Teams to improve
health and nutrition outcomes were achieved.

There is a direct relationship between nutrition status of children under 5 years and health
services provision thus the national health system calls for the establishment of a network of
functional village health committees to facilitate the process of community mobilization and
empowerment of health action and of resources for the health progress including performance of
health centers [6, 9]. It is the responsibility of the village health committees to over seas, the
sufficiency and accessibility of food, sanitation and supply, health service provision by health
services and maternal and child care practices in there respective villages. This study will
therefore help to asses the relation ship between malnutrition among the under- 5 year children
and health services delivery by the village health committee in Isingiro sub county.

1.2 Problem statement

Malnutrition is widespread, but mainly affects children who are less than 5 years old. It contributes
to 2.2 million deaths and a fifth of all disability adjusted-life-years lost worldwide for children
less than five years old [1]. According to the 2008 Human Development Index, 38 per cent of
children are underweight, 16 per cent are stunted and 6 per cent are wasted.

The high prevalence of malnutrition among the children reflects inadequate health services, poor
water and sanitation, poor maternal and child care practices and insufficient access to food [4].
This prevalence would be much lower if the objective of Village Health Teams to improve
health and nutrition outcomes were achieved.

The poor nutrition outcomes consequently lead to increased morbidity and mortality, decreased
resistance to diseases, poor reproductive performance and low productivity. While some
children suffer transient episodes of under-nutrition, a large number of children go through
prolonged or chronic exposures to nutritional stresses [5].

1.3 Significance of the study

4
Ministry of Health in Uganda is committed to towards reduction of prevalence of malnutrition,
which is in line with number four of Millennium Development Goals.

Village Health Committees are meant to serve as the primary, village-level health contact for all
villages with an objective of improving health and nutrition outcomes through; creating
awareness in the village about available health services and their health entitlements, developing
a Village Health Plan based on an assessment of the situation and priorities of the community,
maintaining a village health register and health information board and calendar and analyzing
key issues and problems pertaining to village level health and nutrition activities and provide
feedback to relevant functionaries and officials.

However, the information on the achievements of Village Health Committees towards improving
health and nutrition outcomes is lacking in Uganda. This therefore calls for a study on Village Health
Committees in relation Malnutrition.

The results of the study will help to shed light on the contribution/ achievements of Village Health
Committees in reduction of malnutrition in Uganda. If the objectives are not well achieved, the
results will help policy implementers to lay strategies for improvement.

1.4 Conceptual frame work

A UNICEF conceptual frame work of causes of malnutrition, showing and explaining
malnutrition into categories of causes; immediate, underlying and basic causes. The basic causes
at societal level lead to the underlying causes at the house hold level and this leads to immediate
causes which finally lead to malnutrition.

Child malnutrition

Death and disability

Inadequate dietary Diseases Immediate

intake causes

Underlying
Insufficient access Inadequate maternal Poor water/sanitation causes at
to food and child care and inadequate health house hold
practices services

Quality and Quantity of actual resources; human,

economic and organizational and the way they are
controlled Basic causes at
societal level
Potential resources; environment, technology, people

1.5 Scope of the study

5
This study will specifically look at what village health committees have achieved with respect to
adequate health services, water and sanitation, maternal and child care practices and accessibility
to adequate food and the level of malnutrition among the under-5 years children.

1.6 Research questions

1. What is the prevalence of malnutrition among the under-5 children in Isingiro District?

2. To what extent is objective of Village Health Teams to improve nutrition outcomes among
the under-5 children is achieved in Isingiro District?

3. Is malnutrition among the under-5 children in Isingiro District associated with poor health
service delivery by village health committees in Isingiro District?

1.7 Hypothesis
Null: Malnutrition among the under-5 children is associated with poor service delivery by village
health committees in Isingiro District

Alternative: Malnutrition among the under-5 children is not associated with poor service
delivery by village health committees in Isingiro District

1.8 Objectives
General objectives

To assess the relationship between prevalence of malnutrition among the under-5 children and
the health service delivery by village health committees in Isingiro District.

Specific objectives

1. To establish the prevalence of malnutrition among the under-5 children in Isingiro

District

2. To assess the extent of achieving objective of Village Health Teams to improve nutrition
outcomes among the under-5 children in Isingiro District

3. To assess the association between the prevalence of malnutrition among the under-5
children and health service delivery by village health committees in Isingiro District

2 Chapter Two: Literature review

6
Background

Malnutrition among the under-5 years is a leading factor underlying child mortality and
morbidity in Sub-Saharan Africa, and contributes to 2.2 million deaths and a fifth of all disability
adjusted-life-years lost worldwide for children under five years old[1].
The nutritional status of young children is one of the most sensitive indicators of sudden changes
in health status, reflecting the quality health service delivery [27]. Malnutrition in children can
take a form of stunting, wasting or underweight [27]. Stunting, which is height for age below that
expected on the basis of the International growth reference is a very serious type of malnutrition
in that it develops slowly through time before it is evident.

The high prevalence of malnutrition among the children reflects inadequate health services, poor
water and sanitation, poor maternal and child care practices and insufficient access to food [4].
This is caused by poor health service delivery at village level and subsequent health system
levels. Ugandan Health Centers are organized along geographic levels – districts each have a
District Hospital that ought to be capable of advanced care. County Health Centers have less
advanced healthcare options, and Sub-County Health Centers provide a lower level of care still.
Parish health centers (Health center II’s) and Village Health Team/ committees Village Health are
meant to serve as the primary, village-level health contact for all villages to foster health in
Ugandan communities.
Prevalence of malnutrition in Uganda

Several anthropometric studies in Uganda have described impaired linear growth among children
up to five years old. Stunting (length/height-for-age less than -2 z-scores) occurs in 25% of
children under two years [2, 3]. And in 50% of children up to five years [4, 5]
According to the 2008 Human Development Index, about 12 per cent of women in Uganda are
malnourished, 38 per cent of children are underweight, 16 per cent are stunted and 6 per cent are
wasted.
A study done by Tumwine, J and K.Barugahare, W in Kasese district at the Uganda-Congo
borders revealed that a half of the 932 children (49.8%) were stunted, and 21.9% were severely
stunted. While 17.4% of the children were under weight, 1.29% were wasted and 3.7% had
MUAC <12.5 cm.
The prevalence of malnutrition in Uganda is not only high in rural areas but also in urban areas.
There are high levels of chronic malnutrition (stunting and underweight) among the children in
Kampala. Almost half (46.3%) and one third (29.3%) of the children have height-for-age and
weight-for-age centiles, respectively, below the 20th centile [3].

Objectives of village health teams in Uganda

According to the 2001 Uganda’s national health strategy "Village Health Team/ committees" are
meant to serve as the primary, village-level health contact for all villages, the equivalent of a
low-level health center.

The objective of Village Health Committees is aimed at improving Health and Nutrition
Outcomes. This objective is to be achieved through creating awareness in the village about
available health services and their health entitlements, developing a Village Health Plan based on
an assessment of the situation and priorities of the community, maintaining a village health

7
register and health information board and calendar and, analyzing key issues and problems
pertaining to village level health and nutrition activities and providing feedback to relevant
functionaries and officials.

3 Chapter Three: Methods

3.1 Study design

8
A cross sectional study design employing both qualitative and quantitative methods will be used.

3.2 Study setting

The study will be carried out in Isingiro district. Isingiro district is located in South Western
Uganda and is bordering with Tanzania in the South and Rwanda, Rakai district in the East, and
Ntungamo district in the West,Mbarara district in the North and North West and Kiruhura district
in the North. It lies between longitudes 30-20°C East and 31-20°C East and latitudes 1-30°C
South and 0-30°C North. According to the 2002 Uganda census, the district had a total
population of 316,025 with a population growth rate of 1.5%

3.3 Population
Target population; all house holds with at least one child aged the under-5 year in Isingiro
district

Accessible population; all house holds with at least one child aged the under-5 year in Isingiro
district from December, 2009 to January, 2010 who shall meet the inclusion criteria

Study population; all house holds with at least one child aged the under-5 year in Isingiro
district from December, 2009 to January, 2010 who shall meet the selection criteria

3.4 Selection criteria

Inclusion criteria

All households with at least one child aged the under-5 year which have stayed in an area for at
least 6 months in Isingiro district until the time of study.

Exclusion criteria

Those households which will be unable to complete the requirements of the study

3.5 Sampling procedure

A multi-stage random sampling procedure will be used to obtain the study sample of the under-5
children. Three counties in Isingiro district will be considered as clusters and in each one sub-
county will be randomly selected using a simple random method. The selected sub counties will
form a cluster sample from which, a cluster sample of 15 villages will be selected at random (i.e.
In each sub-county, three villages shall be randomly selected). To obtain house holds from the
selected villages, a proportionate number for each village will first be calculated based on the
total sample size and the total population of the villages, and then systematic random sampling
procedure will be used to select the proportionate number of households from each village.
Systematic random sampling will involve first listing the households in sampling frame in
random order and then calculating the interval size, k, (i.e. total number of households the
village/ the calculated proportionate population of households for the village). A random integer
will be selected from 1 to Kth and the subsequent numbers shall be selected starting with every
Kth until the required number is obtained.

3.6 Sample size estimation

A sample size (N) of 724 will be obtained by using Kish and Leslie (1965) formula

9
N= {Zα/22 * P (1-P)* Design effect}/ D2

Where;

N - The required sample size of house holds

Zα/22 - is the standard normal value corresponding to 5% level of significance (1.96)

P - (38%), prevalence of malnutrition among the under-5 children (UDHS, 2006)

D - Standardized error given by confidence interval

Design effect of 2 will be considered

3.7 Study variables

Out come variables

 Level of malnutrition among under 5 years

Independent factors:

Achievement of village health committee in relation to;

 Food accessibility

 Maternal and child care practices

 Water and sanitation and

 Health services

Demographic factors e.g. age of mothers, village, economic status, education, number children
in the house holds

3.8 Data collection

Data collection will be carried out by the principle investigation with the help of five research
assistants who are qualified medical personnel

Anthropometric Measurements
The anthropometric data will be collected using the procedure stipulated by the WHO (1995) for
taking Anthropometric measurements. Adherence to this procedure will be ensured. The protocol
used will be as follows:
Weight: Salter Scale with calibrations of 100g-unit will be used. This will be adjusted before
weighing every child by setting it to zero. The female children will be lightly dressed before
having the weight taken while clothes for the male children will be removed. Two readings will
be taken for each child, shouted loudly and the average shall be recorded on the questionnaire.

Length: The child will be made to lie flat on the length board. The sliding piece will be placed at
the edge of the bare feet as the head (with crushing of the hair) touched the other end of the
measuring device. Then two readings shall be taken and the average computed.

10
Arm Circumference: The Mid Upper Arm Circumference will be measured using a MUAC tape
to the nearest 0.1cm. Two readings will be taken and the average recorded for each child.
Child Age Determination
Where useful documents like growth monitoring/clinic attendance cards and birth certificates are
available, they will be used to determine the child’s age. Calendars of events will also used as
proxies to age determination.
Oedema
Oedema, defined as bilateral oedema on the lower limbs will be assessed by gently pressing the
feet to check if a depression is left after at least three seconds of pressing and will be confirmed
if present by the supervisor and then recorded.
Quantitative data

Quantitative data on house hold characteristics will be collected by using a questionnaire which
will be administered to the care givers.

Qualitative data

Qualitative data will be collected using Key informants interviews which will be administered to
the local leaders. / Village health committee members to obtain data about the achievement of the
village health committees.

3.9 Data management and Analysis

Anthropometric measurements
The data will be will be cleaned, checked for completeness and then entered into Epi-Info, which
will automatically calculate nutritional indices. The goal will be to determine what percentage of
children are affected by the main types of malnutrition: wasting (low weight-for-height), stunting
(low height-for-age), and underweight (low weight-for-age).

In order to determine which children are malnourished, each child’s weight and height will be
compared with data from a standard population basing on the WHO (i.e. National Centre for
Health Statistics (NCHS) dataset for U.S). Z-score for each child will be calculated. A Z-score
will help to indicate how far the child deviates from the average. A Z-score of -2 indicates
moderate malnutrition, and a Z-score of -3 indicates severe malnutrition for all indices.

Frequencies and cross-tabulations will be used to give percentages, confidence intervals, means
and standard deviations in the descriptive analysis and presentation of general household and
child characteristics.
Univariate analysis

This will be used to describe the background characteristic profile of the Households.
Continuous variables like age will summarized using descriptive statistics (i.e. means, median,
standard deviation and range. Categorical variables will be summarized into frequencies,
percentages and bar charts.

Bivariate analysis

In order to assess the association between the prevalence of malnutrition among the under-5
children and health service delivery by village health committees, bivariate analysis will be
11
performed to asses for the association between dependent and independent variables. The relative
prevalence will be used as the effect measure, and Chi square test will be used as test of
significance to determine association between

Qualitative data from key informant interviews will be recorded using tape recorders. It will be
manually edited to extract the necessary information, which will be transcribed and arranged into
themes in accordance with the appropriate study objectives.

3.10 Quality Control Procedures

 A comprehensive training of enumerators and supervisors will be conducted covering
interview techniques, taking of measurements, standardization of questions in the
questionnaire, diagnosis of oedema and measles, verification of deaths within
households, handling of equipment, and the general courtesy during the assessment.
 Standardization of measurement and pre-testing of the questionnaire and equipment
 Monitoring of fieldwork by assessment coordinators
 Crosschecking of filled questionnaires on daily basis and recording of observations and
confirmation of measles, severe malnutrition and death cases by supervisors.
 Daily review shall be undertaken with the teams to address any difficulties encountered
 Progress evaluation will be carried out according to the time schedule and progress
reports shared with partners on regular basis
 Continuous data cleaning upon and after entry
 Monitoring accuracy of equipment (weighing scales) by regularly measuring objects of
known weights and continuous reinforcement of good practices.
 All measurements shall be loudly shouted by both the enumerators reading and recording
them to reduce errors during recording.

3.11 Anticipated problems in executing the study

 Data on achievements of Village health committees was based on self-reports thus may
contain inconsistencies, exaggerations or other errors.
 Each child’s weight and height will be compared with data from a standard population
basing on the WHO (i.e. National Centre for Health Statistics (NCHS) dataset for U.S),
which is different from Ugandan setting.

3.12 Ethical consideration

 Permission will be sought from Makerere University Business School Research and Ethics
Committee and Isingiro district authorities.

 Consent will be sought from respondents before inclusion into the study

 Identity of respondents will be kept confidential

 Permission will be sought from Makerere University Business School Research and Ethics
Committee to treat household heads less than 18 years as emancipated minors.

References

12
1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera
J: Maternal and child undernutrition: global and regional exposures and health
consequences. Lancet 2008, 371(9608):243-260.

2. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T: Predictors of poor

anthropometric status among children under 2 years of age in rural Uganda. Public
Health Nutr 2006, 9(3):320-326.

3. Kikafunda JK, Walker AF, Collett D, Tumwine JK: Risk factors for early childhood
malnutrition in Uganda. Pediatrics 1998, 102(4):E45.]

4. Bridge A, Kipp W, Jhangri GS, Laing L, Konde-Lule J: Nutritional status of young

children in AIDS-affected households and controls in Uganda. Am J Trop Med Hyg
2006, 74(5):926-9.

5. Uganda Demographic and Health Survey 2006 Calverton, Maryland,USA: Uganda

Bureau of Statistics Entebbe (UBOS) and ORC Macro;2006].

6. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E,Haider BA,
Kirkwood B, Morris SS, Sachdev HP, et al.: What works? Interventions for maternal
and child undernutrition and survival. Lancet 2008, 371(9610):417-440.

7. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS: Maternal
and child undernutrition: consequences for adult health and human capital. Lancet
2008, 371(9609):340-357.

8. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T: Predictors of poor

anthropometric status among children under 2 years of age in rural Uganda. Public
Health Nutr 2006, 9(3):320-326.

9. Bridge A, Kipp W, Jhangri GS, Laing L, Konde-Lule J: Nutritional status of young

children in AIDS-affected households and

10. Uganda Demographic and Health Survey 2006 Calverton, Maryland, USA: Uganda
Bureau of Statistics Entebbe (UBOS) and ORC Macro; 2006.

11. Maleta K, Virtanen SM, Espo M, Kulmala T, Ashorn P: Childhood malnutrition and its
predictors in rural Malawi. Paediatr Perinat Epidemiol 2003, 17(4):384-390.

12. Kourtis AP, Jamieson DJ, de Vincenzi I, Taylor A, Thigpen MC, Dao H, Farley T, Fowler
MG: Prevention of human immunodeficiency virus-1 transmission to the infant
through breastfeeding: new developments. Am J Obstet Gynecol 2007, 197(3
Suppl):S113-S122.

13. Garza C, de Onis M: Rationale for developing a new international growth reference.
Food Nutr Bull 2004, 25(1 Suppl).

14. Engebretsen IM, Wamani H, Karamagi CA, Semiyaga N, Tumwine JK, Tylleskar T: Low
adherence to exclusive breastfeeding in Eastern Uganda: a community-based cross-
13
 sectional study comparing dietary recall since birth with 24-hour recall. BMC
Pediatr 2007, 7:10.

15. Karamagi CA, Tumwine JK, Tylleskar T, Heggenhougen K: Antenatal HIV testing in
rural eastern Uganda in 2003: incomplete rollout of the prevention of mother-to-
child transmission of HIV programme? BMC Int Health Hum Rights 2006, 6:6.

16. WHO Child Growth Standards Length/height-for-age, weight-for-age, weight-for-

length, weight-for-height and body mass index-for-age Methods and development
[http://www.who.int/childgrowth/publications/ca_symposium_fieldtesting/ n/index.html]

17. Physical status: The use and interpretation of anthropometry Geneva: WHO; 1995.

18. HIV and Infant Feeding Guidelines for decision makers 2003
[http://www.who.int/child-adolescent-health/New_Publications]

19. Filmer D, Pritchett LH: Estimating wealth effects without expenditure data – or tears:
an application to educational enrollments in states of India. Demography 2001,
38(1):115-132.

20. Indepth-Network: Measuring health equity in small areas – Findings from demographic
surveillance systems Aldershot, England: Ashgate; 2005.

21. Rutstein SO, Johnson K: The DHS Wealth Index. ORC Macro, DHS Comparative
Reports 6 2004.

22. Rajaratnam JK, Burke JG, O'Campo P: Maternal and child health and neighborhood
context: the selection and construction of area-level variables. Health Place 2006,
12(4):547-556.

23. Chopra M: Risk factors for undernutrition of young children in a rural area of South
Africa. Public health nutrition 2003, 6(7):645-652.

24. Victora CG, Huttly SR, Fuchs SC, Olinto MT: The role of conceptual frameworks in
epidemiological analysis: a hierarchicalapproach. Int J Epidemiol 1997, 26(1):224-
227.

25. Bennett S, Woods T, Liyanage WM, Smith DL: A simplified general method for
cluster-sample surveys of health in developing countries. World Health Stat Q 1991,
44(3):98-106.

26. Turyashemererwa FM, Kikafunda JK and E Agaba Prevalence Of Early Childhood

Malnutrition And Influencing Factors In Peri Urban Areas Of Kabarole District,
Western Uganda African Journal of Food Agriculture Nutrition and Development, 2009
9 ( 4) June, 975-989

Appendix one: Time frame of activities

14
Period 1st Oct-15th 16th Oct – 16th Nov – 19th Dec -24th 28th Dec,
Oct, 2009 15th Nov, 18th Dec, Dec 2009 2009 – 1st
2009 2009 April

Proposal
preparation and
writing
Seek ethical
clearance with
Ethical
Committee
Seek permission
to implement
the
survey from
District/Local
Authorities

Coordination
meeting with
local authorities

Training of
enumerators

Data collection
Data cleaning,

data analysis

Report writing

Dissemination
of results

Appendix two: Budget to cover four (4) weeks of the study

Intem Units Cost per Unit Total cost

Salaries for research 5 Individuals 625,000 3,125,000

assistants

15
Training allowances 7 Individuals 10,000 210,000

for 3 days

Lap top 1 1,500,000 1,500,000

Cameras 2 500,000 1,000,000

Stationary

1. Photocopying & 10 reams 50,000 500,000

printing

2. Binding 10 reams 10,000 100,000

3. Reams of papers 10 12,000 120,000

4. File holders 7 5000 35000

5. Pens 3 dozens 35,000 11,500

6. Pencils 1 dozen 1,500 1,500

7. Calculator 2 20,000 40,000

Recorders 2 150,000 300,000

Bags 7 20,000 140,000

Weighing scales 5 50,000 250,000

Weight for height charts 10 10,000 100,000

Weight for age charts 10 10,000 100,000

Boards (length) 5 20,000 100,000

Tape measures 5 3,000 15,000

Transport 1,000,000

Total 8,648,000

Appendix three: Nutritional Survey Questionnaire

Household Information

Serial No…………………….
Date……………………………………………………

Village………………………..

Name of HH head: ……… …………………/ Age………………….. year

Mother information

1. Name of mother: …………………………/ Age……………….. year

16
2. Physiological Status:

a. Pregnant

b. Lactating

c. Non pregnant non lactating

Nutrition assessment of children under-5 years

1. Name of child …………………… / sex: 1- male 2- female

2. Age……………months

3. Weight……………..( Kg) height………………..( cm)

4. Did the child have the routine vaccinations?

1. Yes

2. No

3. not regular

5. Did the child receive vitamin A supplementary doses?

1. Once

2. Twice

3. No

6. Is the child breastfed now?

Yes

No

7. How long did the child breastfeed?..................... months

8. During breastfeeding, at what point did the child start having food other than breast milk?
……………months

Clinical examination of Children (Under-5 years)

1. Eye manifestation of Vitamin A deficiency

a. Night blindness

b. Bitot spots

c. No signs of Vitamin A def.

2. Morbidity (during the last month)

* Diarrhea, vomiting or both

17
Number of episodes

a. One

b. Two

c. Three

Duration of episode …………………….days

* Upper respiratory disease

Number of episodes

a. One

b. Two

c. Three

Duration of episode ……………………….. Days

* Lower respiratory disease

Number of episodes

a. One

b. Two

c. Three

Duration of episode ………………………………. Days

* Fever attacks

Number of episodes

a. One

b. Two

c. Three

Duration of episode…………………………………..days

* Skin Rash (measles)

Number of episodes

a. One

b. Two

18
 c. Three

Duration of episode …………………………………..days

Appendix four: Questionnaire for assessing objectives of village health committees.

1. How often are home visits by village health committees?
i. Every fortnight [ ]
ii. Monthly [ ]
iii. After three months [ ]
iv. Annually [ ]

2. Are often are health meetings?

i. Every fortnight [ ]
ii. Monthly [ ]
iii. After three months [ ]
iv. Annually [ ]

3. Who do you think contributes most to village health meetings?

i. District leaders [ ]
ii. Health committee members [ ]
iii. Particular individuals [ ]
iv. All village members [ ]

4. Which of the following have been achieved by your village health committee?
i. Sensitization about food security [ ]
ii. Sensitization about good maternal and child care practices [ ]
19
 iii. Sensitization about water and sanitation [ ]
iv. Provision of essential drugs [ ]
v. Mobilization for communal health activities [ ]

5. To what extent has Sensitization about food security been achieved?

i. Poor [ ]
ii. Fair [ ]
iii. Good [ ]
iv. Excellent [ ]

6. To what extent has sensitization about good maternal and child care practices been achieved?
i. Poor [ ]
ii. Fair [ ]
iii. Good [ ]
iv. Excellent [ ]

7. To what extent has sensitization about water and sanitation been achieved?
i. Poor [ ]
ii. Fair [ ]
iii. Good [ ]
iv. Excellent [ ]

8. To what extent has provision of essential drugs been achieved?

i. Poor [ ]
ii. Fair [ ]
iii. Good [ ]
iv. Excellent [ ]

9. To what extent has mobilization for communal health activities been achieved?
i. Poor [ ]
ii. Fair [ ]
iii. Good [ ]
iv. Excellent [ ]

20
 Appendix five: Consent Form
Study title

This study is to assess the relationship between malnutrition among the under-5 children and the
health service delivery by village health committees in Isingiro District.

Principle investigator

Mutatina Boniface/ Ayebazibwe Geoffrey

MUBS

Tel: +256-782486870, e-mail: [email protected]

Tel: +256-783737271, e-mail; [email protected]

Informed Consent

This form is to explain to you important details of the study, before you decide whether to or not
to participate. You need to understand its purpose, how it may help you, any risks to me and any
member of the family, and what is expected of me if you decide to participate.

My Rights as a Research Volunteer

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This consent form gives me information about the study, which will also be discussed with me.
Once you understand the study, and if you agree to participate, you will be asked to sign this
consent form. You will be given a copy of the form to keep if you want. You understand that my
participation or withdraw in this research study is entirely voluntary. You may decide to
withdraw from the research any time; such a decision will not affect my carrier or medical care
or possible participation in future research studies in any way.

Purpose of the Study

The purpose of this study is to assess the relationship between malnutrition among the under-5
children and the health service delivery by village health committees in Isingiro District. The
results of the study will help to shed light on the contribution/ achievements of Village Health
Committees in reduction of malnutrition in Uganda, which will help policy implementers to lay
strategies for improvement

Study Procedures

You understand that if I decide to participate in the study, you will be interviewed. You
understand that this study lasts for two months although my participation will only be less than
30 minutes.

Risks

You understand there are no risks to me except some temporary anxiety, discomfort, or some
inconvenience while you are being interviewed.

Potential Benefits to Me

There are no immediate benefits to you from this study. However, you understand that the results
of the study will be used to improve on the primary prevention breast cancer of which you may
be a beneficiary.

Costs/Compensations

You want to thank you very much indeed, for the time. There will be no cost or compensation for
the study

Confidentiality

A study number, which will be known to authorized study personnel and you is to be used
instead of my name. The code will be stored in a safe place. Personal and medical information
about me will not be released to any other than the following without my permission; authorized
study personnel, Makerere University, ministry of health, and WHO. You will not be personally
identified in any publication or presentation about this study

Problems or Questions

If you have any questions at any time about this research study, you may contact /Ayebazibwe
Geofrey (tel: +256783737271) Makerere University Business School. If you have any questions

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about any rights as a research volunteer, you may contact chairperson of Makerere University
Business School Research and Ethics Committee (tel: …………….)

Participants Consent

I the undersigned have read and have been helped to understand what is going to be done, the
risks, hazards, my rights as a volunteer and the benefits involved in this research. I understand
that by signing this consent form, I do not waive any of my legal rights nor does it relieve
investigators of liability; but merely indicates that I have been informed about the research study
in which I am voluntarily agreeing to participate. A copy of this form will be provided to me.

Volunteer

Name ------------------------------------------------------------------ Age ------------------

Signature /date ---------------------------

Interviewer’s name/signature ----------------------------------------------------------

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