! !"#$%&$&%'(&)'*+&),-.$&%'('/"")#'0##"##1"&.'2+3' !"#$%&'()#$*#+,'-#.*/$'0.1).#2'&$'345/.16'()#$*# ! ! !"#$%$&'()$%* + ',(+ + -!.+/0)1(2+'3+/,4%'$+56$(%'& July Dayane Nelson A field report submitted in partial fulfillment of the requirements for a Master of Sustainable Development Practice degree at University of Florida Supervisory Committee: Dr. Sebastian Galindo, Chair Dr. Sarah McKune, Member
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! Q -OP*'Q$%RS%T%*+ & I would like to thank my Committee Chair person Dr. Galindo who trusted me throughout the process and helped in defining the results of my analysis. I al so would like to thank Dr. Sarah McKune, my Committee member who also helped me tremendously in that process. I also would like to thank Dr. Glenn Galloway and Dr. And rew Noss, respectively Program Director and Program Coordinator of the MDP Program. The ir insights and advice throughout my Master s studies have been invaluable and have helped me grow. I also would like to thank the Shanti Uganda Society for giving me the opportunity of volunteering with them. My special thanks to all their staff and the partners of Shanti, especially the District Health Office of Luwero U ! &
! M -99:3;<-!<0/&=-53 & ARNS : Afri can Regional Nutrition Strategy of the African Union BCC: Behavior Change Communication CAADP CHD: Child Health and Development Center CSO: Civil Society Organization DEO: District Education Office DHO: District Health Office DPO: District Production Office FAO: Food and Agriculture Organization of the United Nations GOU: Government of Uganda KAP: Knowledge, Attitude and Practices MDGs: Millenium Developmen t Goals MOF: Ministry of Finance, Planning and Economic Dev e lopment MOH: Ministry of Health NARO: National Agricultural Research NDP II: National Development Plan (2 nd term) NHP: National Health Policy OFSP: Orange Flesh Sweet Potato PEAP: Poverty Eradicat ion Action Plan SBCC: Social Behavior Communication Change SDGs: Strategic Development Goals SPSS: Statistical Software for the Social Sciences UBOS: Uganda Bureau of Statistics UNAP: Uganda Nutrition Action Plan UNDG: United Nations Development Group VHT: Village Health Teams WIGG: Women Income Generating Group !
! H -97!:-)! & My field practicum during Summer 2 015 gave me the opportunity to travel to Uganda, more specifically, in the District of Luwero located in the Central region of the country. I worked wit h the Shanti Uganda Society, a Canadian based charity My work specifically addressed designing and conducting a needs assessment for the garden program, which is a central component of the Shanti s Birthing Center. There is a lack of nutrition based educational programs offered to women at the different health facilities of Luwero This is one of the reasons why the Shanti Uganda Society is focusing on addressing specific health and nutrition related issues through a comp lementary practice based education for their target groups. Several methods of data collection were used in a sequential order and each of them was used to inform the next one. I started with my informal interviews on my first week in Luwero; through tho se informal sessions, I was able to draw a list of key informants to meet before implementing the study. So the key informants I met in that stage represented institutions such as the District Health Office, Shanti Uganda's gardener, the agriculturalist, t he head midwife; our sessions helped me redefine my questions for my focus group discussions and my survey questionnaire (administered to the patients). Another stage of my research consisted of conducting semi structured interviews to different categories of key informants such as high school students and teachers, health workers from different health centers ; representatives of the District Agricultural Office, t eachers from the Agricultural College and other garden managers, among others. The idea was to get an in depth understanding of both the challenges to transfer knowledge and the average understanding of the meaning of sustaining a healthy diet. Furthermore, I conducted focus group discussions with different stakeholders such as Shanti Uganda's pat ients, their health staff, Village Health Team members (VHTs), farmers, among others. Finally, I admi ni stered a KAP survey to Shanti Uganda's patients, looking into their nutrition related knowledge, attitude and practice. Preliminary findings were shared with the Shanti Uganda while in country.
! 2 !:04@)!<0/ & !V%&7V"*+W&@S"*R"&7'OW%+X & The ShantiUganda Society is a Canadian based charity located in the Luwero Distr ict, specifically in the Nsassi Village. The organization is involved in addressing development issues related to Women and Health; its mission of i mprov ing infant and maternal health while providing women centered care and supporting the well being of birthing mothers is carried through 3 different programs: The Community Sustainability Program ; one of the services inscribed in this program is Sustainable Agricultural Practices. Th is service is provided through the use of pre natal and post natal nutrition workshops that are led by the agriculturalist. Topics covered by the workshops include healthy eating, alterna tive food preparation methods, gardening techniques, among others. My study is embedded in this particular program. The Maternal Health Program; caters to vulnerable groups while offering pre and post birthing services, laboratory services, STI testing for both mothers and fathers, workshops, prenatal yoga classes, immunization services, among others. The Teen Girls Program; empowers young girl to make informed decisions when building relationships with their peers. It also provides them leadership skills, education and peer support through different learning opportunities that emphasize on role mod els. 09A3)!<;37 & The specif ic objectives of this study are to: 1 Design and conduct a needs assessment for the garden program ; 2 Analyze the responsiveness/appropriateness of the current nutrition workshop program as it relat es to the identified need 3 P rovide recommendations for improvement. Due to the non existence of a current garden program (which I realized once I was in country), t he possib ility to conduct an evaluability assessment of that garden program was impossible. Therefore, the focus was emphasized solely on the nutri tion workshop program run by Shanti Uganda. While in country, I also developed the garden's program logic model, taking into
! 8 account the perspectives of the different stakeholders; the logic model can be found in Annex I =:373/!-!<0/&0C&!D3&4<7!:<)!&0C&2@ 13:0 5%'SY"ZVWO"$&O'*+%[+ & Uganda is a land locked country located in Eastern Africa; it is bordered by Sudan in the north, Kenya in the east, Rwanda and Tanzania in the south and the Democratic Republic of Congo in the west. The to tal area is 241,038 km 2 with 71.2% being agricultural land (Worldfactbook, 2015). The district of Luwero is located in the central region of the country, between latitude 2 0 North of the Equator and East between 32 0 to 33 0 The total area of the Luwero di strict is approximately 2577 km 2 ( Luwero District Local Government, 2012). The mean annual maximum temperature is estimated between 27.5 0 C and 30 0 C and the mean annual minimum temperature is between 15 0 C and 17.5 0 C (Ibid). -SYWO\$+\Y"$ & O'*+%[+ & Subsistence farmers account for 66% of the population ( Luwero District Local Government, Statistical Abstract, 2012) The two existing types of crops in the region are cash crops and food crops M ajor cash crops include coffee, pineapples, vegetables, toma toes, cassava, maize, yams, rice and sweet potatoes T he major food crops in the district remain cassava, sweet potatoes, bananas, maize, beans, vegetables, tomatoes, cabbages and yams (Ibid) Women in Uganda contribute to more than 80% to food production however, only 8% own land. Their contribution to food security is substantial, as they are predominant in subsistence farming. But at the household level, food security is seen as fragile because of their workload and their /30)5(7+809()3+:$&')$5'+83546+;31()%#(%'+/'4'$&'$546+ !<&')45' =$*0)(+ > 7+?*4%"4%+@4A
! < overall unequal status to men (USAID, 2010). In fact, the Uganda AIDS Commission cites food insecurity and malnutrition among rural women in Uganda as direct consequences of gender inequality ( Uganda AIDS Commission, 2014). 7'OW'%O'*'TWO&O'*+%[+ & In Uganda, 30% of all rural people are estimated to live below the national rural poverty line (WFP, 2013). Consequently, poverty is often considered as the principal cause of food insecurity, as poor households lack the necessary resources to access accep table levels of nutritious foods to live a healthy active life. At the national level, statistics show that 6% of households are food insecure, 21% are moderately food insecure and at risk of becoming food insecure and 73% are considered food secure (USAID 2010). Food insecurity, however, is more prevalent in rural areas than in urban areas; in fact, rural Ugandans are more likely to be stunted than urban Ugandans (37% vs 14%) (WFP, 2013). Additionally, the overall prevalence of wasting or global acute mal nutrition (GAM) in under 5 children is three times higher among rural children (5% vs 2%) (Ibid). Underweight prevalence is also higher among children in rural areas, where 15% of under 5 children are underweight (low weight for a specific age and sex) (Ib id). Several factors are contributing to food insecurity in Uganda. On the national level, poor access to nutrition and health care, inadequate maternal and child care, and poor access to the range of foods needed for a diversified diet are among the und erlying causes for food insecurity reported by the Food and Agriculture Organization (FAO, 2013). Additionally, in the central region of the country, specific causes remain the lack of livelihood diversification, reduced wages and dependence on agriculture, inadequate production of food stocks at the household level and lack of income (USAID, 2010). In the district of Luwero, some immediate causes are crop and livestock pests and diseases (mostly triggered by poor husbandry practices) and increased malaria incidence. Some underlying causes include the lack of policies regarding food security, inadequa te post harvest handling technologies and storage structures, and environmental degradation triggered by continuous charcoal burning, poor waste disposal, insufficient soil conservation measures, rapid population growth and land fragmentation (FAO, 2010).
! "@ According to the World Conference on Social Determinants of Health, women of Reproductive Age (WRA) and children under 15 years accounted for 23% and 46% respectively of the micronutrient deficient population in 2007 (Balikowa, 2011). Furthermore, 20% of maternal deaths and poor cognitive development in babies and young children were due to iron deficiency anaemia (Ministry of Health, 2010). Household food insecurity has also been rising due to climatic changes coupled with high population increase (3.2%). This, over time, has contributed to land over use, increased reliance on traditional food crops for income and ultimately depletion of soil nutrients (Ministry of Health, 2010). Consequently, most of the Ugandan households are not able to afford micronutr ient rich foods that are critical to their health (such as fish, eggs, meat and milk). The high levels of malnutrition 1 have also been attributed to poverty, negative cultural beliefs and low levels of education (little knowledge of nutrition) (Ministry of Health, 2007). 2
! "" automatically implemented in regions where bias in household food allocation and food taboos gave precedence to older boys, men and elders (Berti et al., 2004). Studies in Eastern and Southern Africa ha ve shown that nutrition programs such as micronutrient supplementation (iron/folic acid supplementation) have had encouraging results like anemia reduction among pregnant women and women of reproductive age In fact, national statistics showed a decrease in trends of maternal anemia in Uganda from 1990 to 2012 from 49% to 3% (Salam et al., 2015). These nutrition programs were implemented mostly through agricultural interventions and actions t o prevent and manage infection (including HIV/AIDS and malaria), family planning and reproductive health. The activities of the fortification projects were mainly directed towards production of quality enhanced food that was made available to the public (I bid). Other studies have shown that women participating in agricultural interventions in the form of home gardening (with and without animal production) improved both their diet diversity and their consumption of Vitamin A rich fruits and vegetables, puls es, other fruits and vegetables, and improved complementary foods (Hellen Keller International, 2008). Also, improved fat intakes in lactating women have also been linked with home gardens in Thailand (Girard, 2012). The literature also suggests that agri cultural strategies focusing on milk and egg production tend to be more sustainable and less expensive, as they often fall within the domain of women. Home gardening interventions The debate The relationship between improved nutrition and agriculture has long been debated. Opponents indicate that the lack of success of the gardening projects among food insecure communities is mainly due to lack of sustainability as well as poor project design, management and monitoring. Another criticism is that garden ing is achievable only by households with access to sound capitals such as land, water and technical assistance, and thus is not appropriate f o r the most food insecure (Marsh, 1998). However, supporters claim that: when well adapted to local resource condi tions, cultural traditions, local agronomic conditions and preferences, gardening can be effective even f o r the poorest; in fact, with
! "# appropriate technical assistance, low risk technology and low cost systems can prove to be efficient in environments pron e to dry spells and excessive flooding (Ibid). Nutrition interventions for food production maintained by government financial support are less effective in terms of food insecurity alleviation than those managed and controlled by households (Ibid) Releva nt policies and regulatory framework The UNAP 2011 2016. The Government of Uganda (GOU), considers nutrition in several of its existing national development policy and planning frameworks; this commitment to resolving the issue also shows in different international obligations. One of the national frameworks, the Uganda Nutrition Action Plan (UNAP 2011 2016) aims at "reducing mal nutrition levels among women of reproductive age, infants, and young children" (National Planning Authority, 2015). The specific objectives of this framework are to: A. Improve access to and utilization of services related to both maternal and infant/young ch ild nutrition. B. Promote diverse diets consumption. C. Improve household's nutritional status while protecting them from the impact of shocks and other vulnerabilities. D. S trengthen the frameworks (policy, legal, and institutional) and the capacity to effectively plan, implement, monitor and evaluate nutrition programmes. E. Create awareness of and maintain national interest in and commitment to improving and supporting nutrition programmes in the country. The PEAP Another important framework is the Poverty Eradica tion Action Plan (PEAP) which is based on 5 specific pillars: A Economic management B Enhancing production, competitiveness and incomes C Security, conflict resolution and disaster management D Good governance E Human development
! "O The second pillar looks into agricul ture while the fifth specifically targets nutrition, along with maternal health, improvement in the education sector, among others. In 2002, the National Education Task force mentioned insufficient coherent policy and a general negative attitude towards ag riculture as areas to address as part of a national strategies to integrate agriculture, education and nutrition in the curricula ( Potts & Nagujja, 2007). Additionally, since 1999, the National Health Policy (NHP) has consistently promoted a pro poor set o f strategies which include the elimination of user fees in public facilities, subsidies to private not for profit organizations operating in the health sector, among others (Ibid). Many of the externally funded nutrition programs in Uganda operate in an i solated manner. Consequently, many development partners work without proper symbiosis of their efforts or enough knowledge of their counterparts, resulting in a non attainment of expected nutritional outcomes (Potts et Najujja, 2007). However, the country s efforts to eradicate nutrition issues is embedded within the national development policy and planning frameworks, which makes accountability to both local and international stakeholders, a priority. )0/)3=!@-2&C:-6310:. & "#$%&'! ( )!*+,-'./%01!"&02'3+&4!%5'6
! "Q The UNICEF conceptual framework for malnutrition is used as the basis for this study It has been used as an essential tool f o r program development for many years and it mainly shows how multisector al the causes of malnutrition are, as it takes into account food, health and caring practices. According to UNICEF, the strength of the framework lies in the fact that it can be applied in different cultural, economic and geographic situations, and "in eac h application, the particular causes of malnutrition will be local and specific" (University of Michigan, 2011 citing UNICEF, 1998). Additionally, "the framework can be used at either national, district and local levels in order to help plan effective actions to improve nutrition. It serves as a guide in assessing and analyzing the causes of the nutrition problem and helps in identifying the most app ropriate mixture of actions" (University of Michigan, 2011 citing UNICEF, 1998). The areas in red are the ones that this initiative will particularly focus on. The framework essentially shows that utilization of potential resources is impeded by contextu al factors (political, cultural, religious, economic, social systems, women's status) T his situation, in turn translates to inadequate knowledge that constrain s household access to actual resources; this leads to underlying causes of malnutrition at hous ehold level (insufficient access to food, inadequate maternal health, poor water/sanitation, unhealthy environment). These underlying factors combined translate to immediate causes of malnutrition (inadequate dietary intake), which consequently leads to mo ther and child malnutrition. )0/!3H!@-2&C:-6310:.& & ! =$*0)(+ B 7+C 3%'(D'046+ + =)4#(93)E+0&("
! "M I adapted the Behavior Change Communication (BCC) framewor k to my study. S ocial B ehavior C hange C ommunication (SBCC) for nutrition is a resea rch based, inclusive process that uses communication in order to not only promote and facilitate behavior change but also to support the necessary social change that improves nutrition outcomes. The SBCC looks at change at the ind ividual, group, environmental and structural levels (the United Republic of Tanzania, 2013) In that sense, it promotes a good understanding of the behavior/ action of an individual, his supportive behaviors/ actions by social networks (families, friends or peers), collective actions that are under taken by groups or communities, social and cultural structures, policies, laws and the broader socio political or global Environment (Ibid) In Tanzania, the use SBCC in the National Nutrition Strategy fostered both the prevention of malnutrition and the promotion and maintenance of good nutrition. It also promoted society wide awareness and commitment to nutrition improvement. SBCC has also been found to enhance the delivery of nutrition counseling services and the demand for these services, and overall, to improve the general enabling environment for good health and nutrition outcomes, in short and long term perspectives (Ibid) The framework helps understand how and why communication can be used effectively to affec t both intention and behavior through 3 different levels.: Instruction : refers to how communication is designed to enhance skills; Promotion : refers to the change in individuals through knowledge, attitude, and behavior; this is the section that specifically helps triggering cognitive and social influence on the client, which later translates to intention then change in behavior. This section blends really well with the KAP survey that I did. Advocacy tries to capture the environmental constraints to behavior change. The 3 boxes in blue (on top) represent Shanti's activities when it comes to their Community S ustainability program : the 2 act ivities that help them fulfill this mission are sustainable agricultural practices and the nutrition workshops (outlined in red) My work focused particularly on the latter. All the elements shown inside Advocacy are site specific, meaning, they were all brought on by participants of both i nterviews and the focus groups Natural shocks such as dry
! "H spells and unreliable rain were often linked to food seasonality and affordability, therefore proper training on coping strategies remained one of the top needs to be addressed. Proper communication came out as one of the main issues brought on by all participants ; more often than not, verbal c ommunication and body language came out to be a real obstacle to the learning process. This is why I have focused my cont ex tual framework on "communication" as it is a necessary mean to provide adequate materials to the clients and to be sure that the message is well understood. 63!D040205I & <*('YT"$&W*+%Y]W%Q, & I started with my informal interviews on the first week I arriv ed in Luwero; through the first informal sessions with my in country supervisor I was able to draw a list of key informants to meet before implementing the study. So from a sequential order the key informants I met in that stage were: Shanti's Project Coordinator; this was also my in country supervisor. Our discussions on the garden program and the reasons why it has not been functional led to the new focus of my research. I nstead of solely working on the garden program on which no data was available in the organization's files, we decided it would be meaningful to learn from the organization's ongoing efforts regarding nutrition for the clients. The most consistent efforts for the past months remained the pre natal/post natal nutrition workshops; unders tanding how they have translated into Shanti Uganda's clients' daily habits became important to better address the gaps to fill regarding nutrition education. District Health Office; the contact at the office was a health promoter and social worker who has been a close collaborator of Shanti Uganda. He had years of experience in nutrition and has worked with UNICEF and Peace Corps among others. Besides his invaluable inputs to my research, he strongly recommended that I talk to farmers,
! "2 teachers, students a nd school directors in order to gain a better understanding of the challenges related to a healthy diet. Shanti's gardener; he played the role of translator on several occasions Our informal sessions helped re shaping my focus group questions for both fa rmers and clients while getting a better understanding of the ongoing challenges related to the garden. Shanti's agriculturalist ; she is also teaching the nutrition workshops at Shanti Uganda and her inputs contributed to the further development of my surv ey questionnaire. Shanti's head midwife; our sessions helped me redefine my questions for my focus groups with the clients and the survey questionnaire. 7%TW ^ ,+Y\O+\Y%R&<*+%Y]W%Q, & !"#$%& In order to address Objective 1 semi structured interviews were conducted A number of 4 question guides 3 were designed and were used as described below: 1 question guide containing 11 questions for students 1 question guide containing 18 questions for t eachers 1 question guide containing 9 questions for health workers involved in nutrition education in other health centers The same question containing 16 questions was used when interviewing o Lo cal government representatives o H igher education representatives o NGO involved in home gardening o Other garden managers o Shanti U ganda Project Coordinator Each question guide follows the same structure; nevertheless, because various institutions were targeted for this research, questions were adjusted in order to be appropriate to the specific type of institution. The first questi ons address healthy diet and the respondent's understanding of the terms; another set of questions address the nutrition related education framework used in the !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 3 Question guides can be found in Annex 1
! "8 institution and the uptake by the trainees ; the following set of questions look into the succ ess, challenges to transfer knowledge by the institution; the last set of questions look into the respondent's insights about how to better address the challenges regarding nutrition for vulnerable groups (in our case, pregnant a nd lactating women) in Luw ero. The interview question guides were designed with the purpose of obtaining opinions of stakeholders that are knowledgeable about the topic of research. Overall, the information was collected in order to generate a collective understanding o f how the topic should be better addressed and transmitted among institutions whose roles are to educate in Luwero. The collected information was used to inform and design the focus group question guide that was administered to Shanti Uganda's clients () *+")"&,-,$.& A total of 43 informants were interviewed during this phase of the study. Three schools were visited, in which 9 teachers and 20 students were interviewed. Each session involved only one respondent except for the students who sometimes were in terviewed in groups of two due time constraints In such case s once a question was asked, each student would reply, indicating their personal responses Both schools visited were mixed Day and Boarding Schools : Progressive Secondary School located in Kasana, Wobulenzi Town Academy located in Lukomera Given that formal education is transmitted in English in Uganda, communication was fluid with both teachers and students. Three health centers were visited in which 6 people agreed to participate in the study. The health centers visited were: Bishop Caesar Asili Hospital located in Kasana St. Mary's Health Center III locatedin Kasaala Luwero Health Center IV located in Kasana. All respondents were either in charge o f or team members of the ongoing nutrition education programs at their respective institutions.
! "< 10 additional key informants were interviewed using a common questionnaire. Local government representatives consisted of: o The District Agriculture Officer f rom the Luwero District Production Office o The District Health Promoter/Social Worker from the District Health Office o The Deputy District Education Officer from the District Education Office o The Luwero Sub County Chair person, located in Kasana Higher education representatives consisted of: o The Head of the Crop Department at the Bukalasa Agriculture College, located in Wobulenzi The NGO involved in home gardening visited was CARITAS KASANENSIS Other garden managers interviewed were from the St. Mary's H ealth Center III All sessions were recorded and transcribed the same day or the day after. C'O\,&5Y'\Z, & !"#$%& In order to address Objective 1, Focus groups were also conducted. Eight Focus Group discussions were conducted. The Participants to these discu ssions were distributed as follows: o Shanti's Uganda's clients ; Three Focus Group s with different participants were conducted ; a total of 18 clients participated in the discussions o Shanti's health staff ; a total of five staff members participated in the discussions o Shanti's garden staff; the organization has two members working on the garden and the nutrition workshops and they participated in the focus group o Sureland Academy ( located in lukomera ); Because of time constraints, only one focus group discuss ion was conducted with 10 students in the last school visited. o Village Health Team members (VHTs ); 3 VHTs participated in this Focus Group discussion o Farmers in Mamuri Village ; only one Focus Group discussion was conducted with farmers.
! #@ ()*+")"&,-,$.& Ove rall, 44 informants participated in the Focus Group discussions. The majority of the participants were drawn from a random sample; the Farmers were also randomly chosen (by the village Chairman and my translator) based on their availability to participate that day in the discussions; the farmers were all women. It is extremely difficult to schedule a meeting with a group of farmers in Luwero due to time poverty. The reason for using that method was to get not only a more in depth understanding of the attit udes, needs and opinions about how the topics nutrition and healthy diet are being understood in and around the District of Luwero, but also to capture the experiences and expectations of Shanti Uganda s clients for the future workshops. Consequently, th e information collected through the Focus Group Discussions was used to inform the design of my KAP survey. Due to language barriers, some of the discussions 4 were co lead by my translator, however, the question guide was previously discussed and modified (through informal interview sessions with him) to limit misunderstandings and improve relevance of all questions to the participants. All sessions were recorded and transcribed the same day or the day after. Overall, t he results of the Semi Structured Inte rviews and the Focus Group discussions will contribute to the development of a Situational statement describing the current status and relevance of the problem, as well as some recommendations to address it. .-=&7\Y]%X & A KAP survey is a quantitative metho d of data collection with predefined questions that provides meaningful access to both quantitative and qualitative information. KAP surveys reveal misconceptions or misunderstandings that may represent obstacles to a program s success, thus constraining b ehavior change among participants (USAID, 2011). The survey design 5 I used is inspired by the FAO Adaptable KAP Model Questionnaire (FAO, 2014) which provides the researcher a valuable framework to assess nutrition related knowledge, attitude and practices among participants of a program. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 4 The discussions with Shanti's Uganda's clients, the Village Health Team members (VHTs) and the Farmers of Mamuri Villa ge were co lead. 5 The KAP survey can be found in Annex
! #" !"#$%& The survey was conducted with the purpose of addressing Objective 2, with a particular focus on the nutrition workshops delivered at Shanti. The 94 questions look into several factors, in particular, household demographics, how long the participant has been a client and how many workshops she has participated in, knowledge on dietary requirements for pregnant and lactating women, attitudes towards these requirements and their translation into a change in behavio r. The survey design was finalized in country and was reviewed by both my in country supervisor and Shanti Uganda s head midwife to avoid the inclusion of culturally irrelevant questions and ambiguous formulations. The survey was then pre tested with the organization s clients and adjusted once more. The concept of reflexive controls was adopted in the design of the survey questionnaire, meaning the same question was asked to capture the respondents knowledge, attitudes and practice both before and after the intervention, in this case the nutrition workshops. ()*+")"&,-,$.& A total of 26 survey questionnaires were administered. Several factors contributed to this rather low number: Thursdays was the day with the most flow of patients because it was vacci nation day for new born babies and also pre natal yoga day. However, several Ugandan holidays were also on Thursdays; Additionally, clients were reluctant to participate in the survey: o Some of them had already participated in one of the focus group dis cussions and politely declined the invitation to participate in the survey; o Due to the heavy flow of patients, there was the risk of losing their place in line to receive services if they take the time to take the survey. o Due to language barriers, all the survey sessions were co lead with my translator, and this made it very difficult to complete the survey within an acceptable timeframe. I believe this has demotivated other patients to participate. Table 1 below shows the overall distribution of participa nts with regards to the different methods used.
! ## Table 1 Distribution of Participants with regards to the methods used to collect data Institutions Participant Number Met hod used Shanti Uganda Shanti's Project Coordinator 1 Informal Interviews District Health Office Health Promoter / Social Worker 1 Informal Interviews Shanti Uganda Shanti's gardener 1 Informal Interviews Shanti Uganda Shanti's agriculturalist 1 Informal Interviews Shanti Uganda Shanti's head midwife 1 Informal Interviews Shanti Uganda Shanti's Project Coordinator 1 Semi Structured Interview Progressive Secondary School Students 10 Semi Structured Interview Progressive Secondary School Teachers 8 Semi Structured Interview Wobulenzi Town Academy Students 10 Semi Structured Interview Wobulenzi Town Academy Teachers 1 Semi Structured Interview Kasaala St Mary health Center Garden managers 2 Semi Structured Interview Kasaala St Mary health Center Medical clinic Officer 1 Semi Structured Interview Bishop Caesar Asili Hospital nutritionist 1 Semi Structured Interview Luwero Health Center IV Nutrition team members 2 Semi Structured Interview Luwero District Production Office District Agriculture Office 1 Semi Structured Interview District Health Office Health Promoter / Social Worker 1 Semi Structured Interview District Education Office Deputy District Officer 1 Semi Structured Interview Kasana Community Center Chair person for the Luwero Sub county 1 Semi Structured Interview Bukalasa Agriculture College Head of Crop Department 1 Semi Structured Interview Caritas Kasanensis Program Officer 1 Semi Structured Interview
! #O Shanti Uganda Shanti's patients (clients) 18 Focus Group (3 groups) Shanti Uganda Shanti's health staff 5 Focus Group Shanti Uganda Shanti's garden staff 2 Focus Group Sureland Academy Students 10 Focus Group Village Health Team Village Health Team members 3 Focus Group Mamuri Village Farmers 6 Focus Group Shanti Uganda clients 26 KAP Survey Total participants 117 :%,\$+, & ."Z&,\Y]%X & The demographic data co llected during the survey shows that most participants come from the 21 25 years age group (35%). The highest level of formal education attained by most of them is "Lower Secondary Level" 6 (54%), however, it was not possible to determine the exact year the education stopped. The majority of participants is Protestant (42%) and unemployed. However, most partners are reported to be self employed. Further analysis reveal s that among the "below 17 age group", an average of 2 people p er household were reported; this figure is similar among the "above 18 age group" Overall, the average of people living altogether in the household of respondents is 4. The table below shows the dis tribution of the demographic s data collected. ! Table 2. Sample Description category, N=26 Age Group Between 18 and 20 years 27% Between 21 and 25 years 35% Between 26 and 30 years 4% !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 6 In Uganda, secondary school is sub divided in 2 levels; Lower secondary level, namely Ordinary level (Senior 1 to Senior 4) and Higher Secondary level, namely Advanced level (Senior 5 and Senior 6)
! #Q Between 31 and 35 years 23% Between 36 and 40 years 8% Between 41 and 45 years 0% Between 46 and 50 years 0% Over 50 years 4% Total 100% Religion Catholic 23% Protestant 42% Muslim 8% Other 27% Total 100% Employment Status Employed 35% Unemployed 38% Self employed 27% Total 100% Occupation of your partner Farmer 15% Government service 8% Self employment 31% Other 31% People living in household Under 17 years old 48% 18 and above 52% Total 100% Education Level Not attended 0% Primary 8% Lower secondary 54% Higher secondary 15% Above secondary 23% Total 100% Analysis of the data gathered through the survey questionnaire was conducted using the software : Statistical Package for the Social Sciences (SPSS). Because each subject was measured twice (before and after), the data results in pairs of observations. T herefore, the Paired S ample t test (dependent sample t test) was used to determine the mean difference between our two sets of obse rvations In other words, t he first round of tests was conducted to determine whether the
! #M change that occurred among respondents level of knowledge, attitude and practice, was statistical significance or not. .*'Q$% RS% & The survey questionnaire is essentially based on a Likert type scale where respondents get to specify their level of agreement or disagreement with a list of nutrition related statements. Those statements are in essence already true (except for Q.24), in that sense, they are not subjective. This kind of statement construct means that our analysis will show an increase in the level of knowl edge if the respondent chooses Disagree (or Strongly Disagree or even Neutral) then Agree (or Strongly A gree), respectively in the pre and the post measurement All statements looked specifically into participants' knowledge of dietary requirements for pregnant and lactating women. They also looked at their knowledge of waiting time betw een pregnancies and their understanding of a balanced diet. The graph below shows the Knowledge trend among the 12 items through which Knowledge was tested. @! "! #! O! Q! M! "! #! O! Q! M! H! 2! 8!
! #H /0 1,-,$#,$2-++3'#$%&$4$2-&,'25-&%"#0' The re is a general improvement of Knowledge on all items. Based on the paired difference of means test 7 we find that the respondents general knowledge was sig nificantly higher, following their participation to the nutrition workshops One set of items (14 and 26) 8 showed a rather high degree of association; in fact, based on the paired difference of means test (t=4.045, p<.000), respondents knowledge of lack of iron resulting in anaemia was significantly higher following the workshops Knowledge for that partic ular set of items increased by an average of .923. Another set of items (17 and 29) 9 also showed a highly significant change; in fact, based on the paired difference of means test (t=.808, p<.003), respondents show an extremely high understanding of the as sociation between eat ing protein rich foods and the production of breastmilk This might be attributed to the fact that clients generally are encouraged to take part of both the pre natal and the post natal workshops; in that sense, they might have bee n introduced to the notion of breastmilk and its purposes, months before actually giving birth. 60 7.' #$%&$4$2-&,'25-&%"#0' While analysis showed a statistically significant change in knowledge regarding the importance of iron supplements for a pregnant woman (t=2.230, p<.035), the importance of folic acid supplements for a pregnant woman showed no significant change (t=1.489, p=.149). These results can be attributed to the fact that previous workshops focused heavily on green vegetables such as nakati 10 which are packed with iron. In the focus group discussions, clients were more inclined to say that they are interested in learning how to cook greens, especially nakati, before adding any other preference to their list. It is thus tempting to say that t hese results reflect more what clients are already familiar with. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 7 Annex XI, p. 79 8 Items 14 and 26: "The lack of iron in what I eat can result in me suffering from anaemia" 9 Items 17 and 29: A breastfeeding woman should eat more protein rich foods to produce more breastmilk" 10 The scientific name of nakati is solanum macrocarpon. It is among the most available vegetables in Luwero.
! #2 Furthermore, respondents don t seem able to get a holistic understanding of how a low birth weight baby can have slower growth and development ; the paired difference of means test showed no significant change (t=1.186, p<.247) following participation to the workshops. These results could be attributed to more complex concepts such as the respondents experiences with childcare; for example, in the short term, a previously low weight baby wi ll eventually gain weight if he/she gets fed more for a certain period. However, the idea that growth and development could be jeopardized in the long term, might not be what respondents think of on a more constant basis, which could lead to the results of our analysis. -++W+\R%& & ! /0 1,-,$#,$2-++3'#$%&$4$2-&,'25-&%"#0' There is more variation across the Attitude trend, following clients participation to the workshops. In fact, h alf of the items measuring clients attitude showed significant differences. For example, based on the paired difference of means test 11 (t=3.725, p<.001) we found significant difference in respondents attitude towards eating a variety of foods in moderation !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 11 Annex XI, p.79 @! "! #! O! Q! M! "! #! O! Q! M! H! 2! 8!
! #8 (items 45 and 55) 12 This particul ar attitude increased by an average of .885. These results are critical for the organization as it was revealed in the focus group with the medical staff that one of the purposes of the workshops is to teach the importance of sustaining a balanced diet. In essence, these results show that the message regarding the associated benefits of a diversified diet, went through. These results are reinforced by the paired difference of means of items (43 and 53) 13 through which respondents show a significant change i n understanding the importance of their own nutritional status ((t=3.980, p<.001). This particular attitude changed by an average of .846. / 8 7.' #$%&$4$2-&,'25-&%"#0' Nevertheless, the paired difference of means test (t=.641, p<.527) showed no significant difference on clients actual beliefs that a nutritious meal can come from their own garden (items 40 and 50) 14 At the same time, the test (t=.000, p<1.000) shows no change at all regarding the belief that Processed foods are generally better than the foo ds coming from clients gardens (items 44 and 54). These results infirm that theoretically, clients might have talked about eating different types of foods in moderation in order remain healthy, however, given many factors (such as small plot size, or pla nting practices, or challenges associated with weather, or their usual garden outputs) they do not believe that they can grow anything nutritious from their plots. Which in turn reinforces their belief that they have to go to the market to get access to nu tritious fruits and vegetables. On that point, there is a bit of disconnection between what the intention is, from the organization s side (the message that needs to be delivered), and the actual information intake (on the clients side). This misunders tanding can be attributed to several factors. For example, clients have shared that they think the workshops generally last too long (sometimes up to 2 hours); on the same note, the medical staff have also noted that the workshops do last longer than neces sary (more than an !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 12 Items 45 and 55: Eating a variety of foods in moderation is key to balanced nutrition 13 items 43 and 53: "Understanding my own nutritional status is important." 14 items 40 and 50: "A nutritious meal can come from my own garden"
! #< hour) and that clients sometimes purposely come late on Thursdays in order to avoid having to participate in the workshops. This strategy allows clients to get access to either previously planned consultation or vaccination (for their ne wborns), and go home right after. Another factor could be the amount of topics covered in one workshop; Focus group discussions revealed that sometimes too many topics were being discussed in one sitting and that without any practical demonstration, it is very unlikely that clients will show any consistent motivation =Y"O+WO% ,&"*R&9%V"]W'Y & ! /0 1,-,$#,$2-++3'#$%&$4$2-&,'25-&%"#0' There seems to be an improvement in the Practice trend as well. In fact, m ore than 60% of the items showed significant changes, following clients participation to the workshops and most of them showed a high degree of association. For example, based on the paired difference of means test 15 (t=5.203, p<.000), participants intake of fresh citrus fruits was found to be sig nificantly higher following their participation to the workshops 16 Additionally, 2 other items showed very high degree of association, showing that the workshops do have a very high impact on clients practices at the household level; in fact, based on the paired difference of means tests (t=6.030, p<.000) and (t=6.532, p<.000), we find that respondents replication of lessons learned and ability to share with family and neighbors were significantly higher following !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 15 Annex XI, p.80 16 Items 64 and 83 test the item: "I eat more fresh citrus fruits like oranges or I drink more juice made from them" @! "! #! O! Q! M! "! #! O! Q! M! H! 2! 8!
! O@ their participation to the workshops. Bo th practices respectively increased by an average of 1.294 and 1.225. Comparing these results with our thematic analysis, this could imply that the intention or motivation to practice and to share lessons learned is very high among respondents, however, the fact that the workshops are more discussion based rather than practice based, this comes out as a major shortfall for the program. As one client mentioned in one of the focus groups: we are getting old so we cannot remember a lot of things said in on e sitting" There is thus the necessity for Shanti Uganda to address this gap to ensure better uptake of the information shared through the workshops. Surprisingly, the practice of consuming citrus fruits (items 64 and 83) significantly increased (t=5.203, p<.000) following participation to the workshops; this practice incr eased by an average of 1.07 7. These results contrast with the knowledge items regarding the "importance of folic acid for pregnant women" which showed no significant change (p33). Since c itrus fruits such as oranges and papaya are an excellent source of folic acid and focus group participants mentioned consuming fruits for up to 6 times in a day, the contrast seen between knowledge and practice regarding citrus fruits could be attributed t o the technicality of the expression "folic acid". One particular set of items (57 and 76) 17 didn t show any difference; in fact, based on the paired difference of means tests (t=.000, p<1.000), we found that there is no difference in respondents protein intake through beef meet consumption, following the workshops. The average of both items is .000. This may be attributed to the increasing awareness regarding blue cera a reported disease resulting from not well prepared beef meat, which causes diarrhe a, vomiting and sleeping sickness. Several key stakeholders recognized the danger of the disease during the semi structured interviews, and several clients also mentioned this particular reason, during the survey, for not consuming beef meat. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 17 item 76: "I eat more beef in my diet"
! O" Furthermore significant changes were also found in items related to sanitation and hygiene (items 69 and 88; 72 and 81); the paired sample t tests (t=2.964, t<.007), (t=3.333, p<.003) respectively reflected clients significant and positive change toward boiling wat er for drinking purposes and their habits of washing their hands with soap before handling food. However, one particular set of items (58 and 77) 18 showed a significant negative trend; in fact, based on the paired difference of means tests (t= 2.083, p<.0 48), we found that respondents pork consumption decreased significantly, following their participation to the workshops. Consumption has decreased by an average of 3.85. This could be attributed to respondent s religion or change of religion, since sever al clients admitted to have changed religion in the months prior to the focus groups. It could also be attributed to financial constraints ; all stakeholders unanimously mentioned the rush for chapati (fried dough) and generally fried food, specifically bec ause they are the most affordable. 60 7.'#$%&$4$2-&,'25-&%"#0' Other sets of items didn t show any statistically significant change following participation to the workshops; for example, based on the paired difference of means tests (t=1.671, p<.107) 19 and (t=.866, p<.395) 20 respondents were found not significantly increasing their fish or egg consumption as means of protein intake. Interestingly, green vegetable consumption was found to be not significantly higher (t=1.850, p<.076), following the works hops. Although we can infer some type of impact in "green vegetables consumption", these results seem to emphasize that clients do not see green vegetables as important foods. Or, it could also infer that clients were already consuming an appropriate amoun t of green vegetables at the time of the survey. As mentioned in the thematic analysis, all clients referred to starchy foods during the focus groups, when answering the question: "Could you tell me some of the foods you have consumed during the past 7 day ". However, when prompted about any fruit or vegetable intake during the same period, all clients cited those they had consumed, the most recurrent ones being nakati, dodo (amaranth), bouga, pineapple, papaya (popo) and jack fruit. Dodo is reported to thri ve in any !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 18 Item 58: "I e at more pork in my diet". 19 item 79: "I eat more fish in my diet" 20 item 80: "I eat more eggs"
! O# type of weather and is heat resistant, however, it also has been known for a long time as poor man's food. So, the statistical difference that I hoped to see in consumption of green vegetables might also be attributed to different stereotypes. On another note, most misconceptions are reported to be inherent to the region of origin and the culture. For example, at the 3 boarding schools visited (in which individual interviews and focus groups were conducted with students and teachers), it was rev ealed that students coming Northern Uganda have different attitudes towards food; for example, matoke (mashed plantain) is believed to be for "weak people" and egg consumption is likely to make a woman infertile. Th e s e are just a few of the many cases show ing that there is an increasing need for the workshops to address stereotypes or taboos associated with protein rich foods specifically those that are recommended for pregnant women. Other items that didn't show any significant change are "milk consumption" (t=1.806, p<.083) and "cleaning kitchen areas, pots, pans and utensils after cooking" (t=1.237, p<.228). Although we can understand such trend for milk consumption (if someone doesn t l ike milk or is allergic to it, there is likely very little chance for him/her to consume it even if he/she learns that it is great for health), these results inform on the necessity for the organization to also focus their curriculum on specific hygiene pr actices that are context specific and adapted to the clients available resources. !V%T"+WO&-*"$X,W,& & /0 9"3'(&4.:)-&,# Several themes emerged from the thematic analysis of the semi structured interviews with the key informants. The most recurrent themes are : Principal causes of malnutrition in Luwero; besides the 2 most obvious causes (poverty and knowledge deficit among the all fringes of the population), other reported causes are inherent to the Ugandan government s ability to tackle those issues (for examp le, the inadequacy of policies to the District s needs: a much larger budget is allocated to communicable diseases such as HIV and malaria compared to that allocated to nutrition related initiatives ); the absence
! OO of demonstrations across the few nutrition related programs in the District; the history of civil wars that have left people without proper land titles); other cited causes are poor feeding practices and lack of hygiene at the household level; culture, which eventually affects attitudes of housewives towards nutrition and especially towards protein rich foods. Keys to success for gardening programs in the District ; success was linked to several predictors and the recurrent ones are the ability for the organization to develop a clearly defined program with a specific budget for the initiative ; investment in a good irrigation system; and most importantly, the training curriculum should focus on addressing negative attitudes towards fruit and vegetable consumption for women The training curriculum should also focus on both nutritional values and value addition of fruits and vegetables. In fact, with regards to value addition one key stakeholder strongly suggested: "besides giving the clients proper training on th e importance of divers ified meal, it would be important to go a step further and train them on value addition, how to process vegetables and conserve the nutritional value. That one is lacking in our people; the way they prepare vegetabl es makes them l ose all the nutritional values and that's because they believe in overcooking" Main challenges to production in the District ; all key stakeholders were unanimous in presenting extreme drought due to unreliable rainfall pest and diseases and negative attitude of farmers regarding available agricultural extension services at the District Production Office as main challenges to production. A key stakeholder acknowledged: Another challenge is that most of the farmers don t take things very seriously. Be cause you tell them to make certain things like fertilizers, like composite manure, they see it as very tedious, yet in reality it is the one that would save them from the problem of soil infertility On the other hand, another reported challenge is the lack of technical staff in government extension services which renders production far more difficult for farmers Furthermore, seed suppliers also contribute to that gap by selling bad quality seeds. The previous stakeholder also addressed that issue:
! OQ Some of the inputs we get here are fake. Inputs in terms of seeds. So a farmer might get seeds and expected them to be of a certain variety but by the time the crop grows he re alizes it was not the real variety. So the seed suppliers are not reliable 60 ;+$"&,# Several themes also emerged from the thematic analysis of the focus groups discussions with the Shanti Uganda clients. The most recurrent themes are: Constraints to full participation ; all clients agreed that covering transport costs, at some poin t, becomes an issue, while all clients admitted to being motivated in learning more about safe feeding practices for themselves and their offspring. They also showed high motivation for being more knowledgeable about how to care for themselves. Land own ership ; Although all clients reported having access to land either through rent or ownership, they all mentioned their incapacity to properly care for it and that they felt helpless in that regard. Those who are renting lands don't benefit from any particu lar irrigation system and therefore are also forced to rent a sprayer from the main land owner. Perspective of getting involved in a practice based gardening program; acquiring proper information through a practice based education program seemed to resonate with all clients' expectations. While carrying the focus group, it was my understanding that having access to land doesn't affect their preference regarding the idea of receiving inputs by Shanti, through the future garden program. In fact, some c lients even argued for the organization to invest in getting good quality seeds if a demonstration garden program was to be implemented. At home practices; replicating what they learn from the workshops is not an option for many of the clients, due to f inancial constraints. Additionally, many also admitted that it is not a priority because they don't have access to the appropriate resources. One participant explained that some of the recipes discussed in the workshops require the use of a blender, howeve r since she doesn't own one, she doesn't feel that the workshops speak to her.
! OM Perceptions of the workshops; the learning experience itself is reported to be overall satisfying. Most clients admitted to sharing what they've learned with family members or neighbors whenever possible, however, lacking practical demonstrations enhances the chances for them to forget what they do learn in the workshops. Now I mostly boil my greens because I know if I fry them, I will loose the nutrients. New Priorities; clients in all 3 focus groups argued for workshops to be designed with a more practical and understandable format. All displayed high interest for planting demonstrations with a focus on intercropping; cooking demonstrations for specific meat like beef and chicken; practical demonstrations of green vegetables. Most consumed foods; when asked about their most consumed foods in the 7 days prior to focus group clients across the 3 groups cited matoke (mashed plantain), sweet potato, cassava, posho (maize flour), and a limited number cited silver fish, chicken and beef. Neither mentioned any fruits or vegetables until prompted. It turned out that for some clien ts, fruit consumption can go from 4 to 6 times a day, however, they didn't see it necessary to mention it. The table below shows a summary of clients responses by theme. Table 3: Summary of clients responses by theme Constraints to full participation 10 0% reported transport costs, being sick and being hungry as the main hindering factors to attending the workshops. Land ownership All clients reported either owning a home garden or owning land through rent. All anticipated receiving seeds from Shanti Uganda to use on their land, if a gardening program is offered by the organization. Perspective of getting involved in a practice based 100% said they would participate in a Shanti Uganda led garden program, as long as the required parti cipating fee is affordable.
! OH gardening program 64% expected the program to be more practical than theoretical. 36% wished for the workshops to be then offered on a more consistent basis At home practices 89% reported not replicating at the household level because of financial constraints and the workshops being theoretical and not practical. 56% mentioned unpredictable rainfall, absence of irrigation on their land as other reasons for not being motivated to replicate what they learn. Perceptions of the workshops 100% thought workshops have enhanced their knowledge on consumption of specific foods (ex: boiling green vegetables instead of frying them to keep the nutrients). 64% said they shared what they learn with family members. New Priorities 100% wished for f uture workshops to focus on planting demonstrations, learning to maximize yields on small plots, cooking demonstrations, practical cooking demonstrations of vegetables Most consumed foods in the 7 days prior to focus group No clients listed any fruit or vegetable as part of their consumption in the 7 days prior to the focus group Most cited : sweet potatoe, matoke ( mashed plantain), cassava, posho (maize flour), chapatti (fried dough) and silver fish. & 0]%Y"$$L&R'%,&P*'Q$%RS%&+Y"*,$"+%&W*+'&=Y"O+WO%M & The final step of our analysis was to determine if Knowledge translates into Practice and if so, the extent to which those 2 dimensions are associated. To do this, indexes 21 of Knowledge and Practice were build with those items that were found to be reflect ing the most, the 2 dimensions. Those items were then computed into SPSS and therefore we ended up with 4 indexes; 2 for Knowledge (Before and After) and 2 for Practice (Before and After). !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! 21 Indexes can be found in Annex XVII
! O2 Knowledge: the Pre_Knowledge index had a high Cronbach s alfa (.705 ), suggesting high reliability of those items representing Knowledge in the Pre phase, while the Post_Knowledge index showed a Cronbach' s alpha of .842, suggesting an even higher reliability of the items representing the index. Practice: the Pre_Practice i ndex also showed a high Cronbach' s alpha (.896), while the Post_Practice index showed a high Cronbach' s alpha (.871). Those indicators tell us that the items in our final indexes measuring Practice (both before and after the workshops) are very reliable. A Paired Samples Test was run for both dimensions (Knowledge and Practice); based on the paired difference of means tests (t=4.425, p<.000) and (t=3.325, p<.003), we found a significant difference for both dimensions, following the nutrition workshops. These statistics tell us that, generally, the workshops generally have a positive and significant impact on the client s lives. T he Practice index has increased by an average of 9.174 while the Knowledge Practice increased by an average of 4.84 0. The table below shows the Paired Samples Test for the indexes. Table 4: Paired Samples Test Paired Differences t df Sig. (2 tailed) Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference Lower Upper Pair 1 Post_PracticeIndex Pre_PracticeIndex 9.174 9.944 2.073 4.874 13.474 4.425 22 .000 Pair 2 Post_KnowledgeIndex Pre_KnowledgeIndex 4.840 7.278 1.456 1.836 7.844 3.325 24 .003 To determine the extent to which Post knowledge influenced Post Practice, a simple regression was run. The results showed in the table below shows an Adjusted R Square of .304, which means that 30.4% of the variation in "Post Practice" is explained by "Post kowledge" on its own, and it is significant (t=3.322, p<.003).
! O8 Table 5: Model Summary Model R R Square Adjusted R Square Std. Error of the Estimate 1 .578 a .334 .304 7.631 a. Predictors: (Constant), Post_KnowledgeIndex Table 6: Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 13.081 9.029 1.449 .161 Post_KnowledgeIndex .837 .252 .578 3.322 .003 a. Dependent Variable: Post_PracticeIndex Looking further into the data, it was also possible to determine the extent to which the demographics of surveyed participants affected the change in practice. The two demographics that seem to make a significant difference are "Age" and "Unemployment". When it comes to Age, analysis show that the younger clients (18 20 age group) have lower scores ( 12.532) on Post practice index and these results are significant (t= 3.943, p<.001); in other words, this group is the least to practice what they learn from the workshops. Similarly, this group seems to affect negatively and significantly the Post knowledge index (t= 5.9291, p<.031). In other words, the younger age group also score lower ( 5.992) on the Knowledge scale, which means that they learn the least from the workshops, which, understandably translates in their practices. On the oth er hand, we know that based on the Adjusted R Square, the dynamics of that group explain 38% of the variation in Practice 22 The tables below show that the first age group's impact on both Post knowledge and Post practice are negative and significant !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! ## Reference: Annex XIII
! O< Table 7: Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 37.278 1.384 26.934 .000 Firstcase 5.992 2.616 .431 2.291 .031 a. Dependent Variable: Post_KnowledgeIndex Table 8: Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 46.389 1.682 27.581 .000 Firstgroup 12.532 3.179 .635 3.943 .001 a. Dependent Variable: Post_PracticeIndex When it comes to "Unemployment", the regression shows that unemployed clients score 8 points lower on the Practice scale than those who are employed. These results are also significant (t= 2.358, p<.027). The table below shows the regression for Unemploy ment. Table 9: Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 45.813 2.072 22.106 .000 Unemployed 8.146 3.454 .441 2.358 .027 a. Dependent Variable: Post_PracticeIndex However when we r a n a mult ivariate analysis with Post_Knowledge Index Age and Employment Status as independent variables and Post_PracticeIndex as Dependent variable, we
! Q@ found out tha t younger participants score 8 points lower on the practice scale, while those unemployed score 3 points lower on the practice scale Interestingly, Employment Status and Post_KnowledgeIndex are no longer significant, which means that there might be some kind of interaction between those variables and that further investigation shoul d be conducted. Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 30.250 9.871 3.065 .006 Post_KnowledgeIndex .460 .255 .318 1.807 .086 Firstcase 8.824 3.289 .448 2.683 .014 Unemployed 3.435 3.062 .186 1.122 .275 a. Dependent Variable: Post_PracticeIndex 4<7)@77<0/ & Knowledge It is important to note that while the analysis of the data shows an increase in Knowledge it simultaneously shows a decrease in neutrality For example, testing the importance of protein rich foods consumption by pregnant women shows a decrease of 71% in disagreement while it also shows a decrease of 50% on neutrality on the matter; it also shows and increase of 47% in "agreement Thus we can deduce that clients who associated themselves with being either not knowledgeable" or not even thinking about the importance of protein rich foods for pregnant women eventually became more convinced (that protein are great for pregnant wo men) as they started taking part in the workshops This pattern is similar throughout the knowledge category of the KAP survey The graph below shows an excerpt of the responses obtained from Survey participants, for 4 different items (Q13 Q16 Q23 Q24). Q13 A woman should eat more protein rich foods when she is pregnant Q16 A breastfeeding woman should eat more iron rich foods to produce more breastmilk Q23 After giving birth, a woman should wait 2 to 3 years before becoming pregnant again Q24 I fully understand what a balanced diet means.
! Q" Attitude A similar pattern is found in the Attitude trend. For example, participants seem to disagree on the fact that processed foods are generally better than foods coming from their garden ; in fact, disagreement on the subject stalled f ollowing their participation to the workshop whereas neutrality on the matter decreased by 29% and agreement increased by 50%. The graphic below shows the trend for 4 particular items: Q39 It is important for me to k now about preparing a balanced meal Q40 A nutritious meal can come from my own small garden Q44 Processed foods are generally better than the foods coming from my garden Q46 I always feel confident when preparing nutritious meals for me and my family
! Q# Practice A similar pattern is observable for the Prac tices and B ehaviors trend. In fact, neutrality on particular topic s decrease while consistent agreement are also shown by the analysis. For example, analysis shows complete elimination of neutrality on the subject washing fruits and vegetables before using them This is an indicator that not only knowledge increases among client s, but self efficacy is being reinforced among them. This is a good indicator for Shanti Uganda, because it shows great uptake of the knowledge translated through the nutrition workshop The graph below shows an excerpt of the responses obtained from Surve y participants, for 4 different items (Q63 Q64 Q65 Q69 ). Q63 I eat more green vegetables Q64 I eat more fresh citrus fruits like oranges or I drink more juice made from them Q65 I always wash raw fruits and vegetables before using them Q69 I always wash my hands with soap before preparing food
! QO So generally, it is an important finding that neutrality most often seems to decrease every time agreement to a particular practice increases. For example, for leafy green consumption, practice at the house hold level increases while neutrality on the subject disappears. This observation suggests that participant' s self efficacy also increases. )0/)2@7<0/N:3)0663/4-!<0/7 & B ecause this study wasn t an experiment, its methodology didn t involve an intervention group and a control group. Therefore, it is difficult to determine the extent to which the observed increases in knowledge, attitude and practice of clients can be attributed only to Shanti Uganda s efforts. In fact, a very small number of women from the focus groups mentioned that they have also participated in nutrition trainings from other health centers either in the past or at the time they were interviewed. However, all surveyed clients had participated at least in one workshop led by Shanti Uganda. Another limit of this study is that the sample, although drawn randomly, is rather small (N=26), which in turn, increases the likelihood for sampling errors. In other words, had our sample being much larger, we would ve been able to make stronger inferen ces about the population they are drawn from, because we would ve been able to see much more variation across the dataset.
! QQ Addressing Objectives 1 and 2 in this study helped determine several key areas of improvement for the nutrition workshops of Shanti Uganda. The workshops are impactful on the lives of the clients, however socioeconomic and cultural factors constrain them in their daily food choices. Also, when it comes to keeping a healthy and diversified diet, there are dimensions over which the Prog ram itself cannot have any control on. For example, the fact that clients don t consume a particular type of vegetable or meat is inherent to their personal preferences. However, it is more likely to record higher uptake of sanitation and hygiene dimension s of the workshops. In fact, we found that most items under this category showed higher statistical significance, following participation to the workshops. With this realistic perspective in mind, setting up a more thoughtful curriculum might become more i mpactful. Furthermore, we saw that the youngest clients score lower on the Knowledge scale, which explains why they also end up with lower scores on the Practice scale This means that their practices aren't changing nearly as much as clients from the other age groups. Since they are scoring lower both on the Knowledge and the Practice scales, further outreach activities should be engaged by Shanti Uganda to attract yo unger clients while readjusting their teaching practices to this group's needs. We anticipate that this would lead, in a short to medium term perspective, to practices that are more in line with Shanti's targets. Additionally, focusing on enhancing attitu des and self efficacy would be another canal of improvement of the workshops. As discussed previously, participants don t seem to understand/believe that a nutritious meal can come from their garden; they also think that processed foods are generally bette r from what might come from their garden. This unarguably sounds like the opposite of what Shanti would want them to think. In that sense, stronger emphasis on those attitudes should reinforced in future workshops. On another note, because the workshops a re primarily discussion based, it would be important for Shanti Uganda to commit to a more structured agenda incorporating practical and visual demonstrations (cooking and planting), while taking into account the clients overall schedules. Also, a less tec hnical curriculum should be focused on in order to have all clients on the same
! QM level of understanding. Additionally, i t is worth noting that not being aware of the nutrition workshops w as also cited by some of the clients as their reason for not particip ating, therefore proper community outreach activities would additionally contribute to greater impact at the local level. More importantly, semi structured interviews with key stakeholders in the Luwero Production Office also revealed that specific trainin g services were available, free of charge, through the field extension workers. In fact, both the nutrition trainings and production trainings are available and would greatly benefit the Shanti Uganda garden staff. However, timing seems to be critical for these services to reach their optimum values; as mentioned by a key stakeholder, for an organization like Shanti Uganda to get full advantage of the training s it would have to start before the rainy season... so that by the time it starts to rain, they are already in production. Because here in most cases we rely on the rain and our rain is not reliable so a good thin g for the organization would also be to invest in a small scale irrigatio n scheme.
! QH :3C3:3/)37 & Balikowa, D. O. Social determinants of health: Food fortification to reduce micronutrient deficiency in Uganda. Strengthening the National Food Fortification Programme. Draft background paper. [Unpublished] 2011. Draft background paper commissioned by the World Health Organization for the Worl d Conference on Social Determinants of Health Rio de Janeiro Brazil 19 21 October 2011 Berti, P. R., Krasevec, J., & FitzGerald, S. (2004). A review of the effectiveness of agriculture interventions in improving nutrition outcomes. Public Health Nutri tion, 7 (05), 599 609. Bormann, B. T., Martin, J. R., Wagner, F. H., Wood, G., Alegria, J., Cunningham, P. G., ... & Henshaw, J. (1999). Adaptive management. Ecological stewardship: A common reference for ecosystem management 3 505 534. Retrieved from http://www.fsl.orst.edu/ltep/Reprints_files/Bormann%20EcoStew1999%20AM%20Chapter. pdf Care (2010). The basics of project implementation a guide for project managers. Retrieved from http://www.careclimatechange.org/files/toolkit/CARE_Project_Implementation.pdf CabaÂ–ero Verzosa, C. (2014). Strategic communication for development projects: A toolkit for task team leaders. Retrieved from http://agris.fao.org/agris search/search.do?recordID=US2015601194 FAO (2013). Nutrition Country paper. Retrieved from http://www.fao.org/fileadmin/user_upload/wa_workshop/ECAfrica caadp/Uganda_NCP_190213.pdf Luwero District Local Government, (2012). Statistical Abstract. http://www.ubos.org/ onlinefiles/uploads/ubos/2009_HLG_%20Abstract_printed/CIS+UPL OADS/Higher%20Local%20Government%20Statistical%20Abstracts_2012/Luwero.pdf Measure Evaluation (2016). Behavior Change Communication. Retrieved from https://www.measureevaluation.org/prh/rh_indicators/crosscutting/bcc Ministry of Health (2007). Food Fortification Program. Retrieved from https://www.spring nutrition.org/sites/default/files/a2z_materials/508_uganda_fc_report_round3_formated18040 9.pdf Ministry of Health (2010). Guidelines on Maternal Nutrition in Uganda. Retrieved from ht tp://library.health.go.ug/publications/service delivery/sexual and reproductive health/guidelines maternal nutrition uganda National Planning Authority (2015). NATIONAL NUTRITION PLANNING GUIDELINES FOR UGANDA. Retrieved from http://npa.ug/wp content/uploads/nutrition planning guidelines.pdf
! Q2 Potts, M. J., & Nagujja, S. (2007). A review of agriculture and health policies in Uganda with implications for the dissemination of biofortified crops. HarvestPlus Washington, DC Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.226.8238&r ep=rep1&type=pdf Shanti Uganda Society (2015). Retrieved from http://shantiuganda.org The national republic of T anzania (2013). National Nutrition S ocial and B ehavior C hange Communication S trategy (J uly 2013 J une 2018 ). Retrieved from https://scalingupnutrition.org/wp content/uploads/2014/01/TANZA NIA NATIONAL NUTRITION SOCIAL AND BEHAVIOR CHANGE COMMUNICATION STRATEGY 2013 latest 1.pdf The Republic of Uganda (2011). Uganda Nutrition Action Plan 2 0 1 1 2 0 1 6. Scaling Up Multi Sectoral Efforts to Establish a Strong Nutrition Foundation for Uganda's Development. Retrieved from http://www .gafspfund.org/sites/gafspfund.org/files/Documents/Note%201.%20Uganda%20 Nutrition%20Action%20Plan.pdf Uganda AIDS Commission. THE HIV And AIDS Uganda Country Progress Report (2014). file:///C:/Users/July%20Dayane%20Nelson/Documents/MDP%202/Global%20Health%20a nd%20Development/UGA_narrative_report_201 5.pdf UNDG, United Nation Development Group (2016). The sustainable development goals are coming to life. Stories of country implementation and support. Retrieved from https://undg.org/wp content/uploads/2016/07/UNDG_The Sustainable Development Goals are Coming to Life_July2016.pdf UNDP (2009) Capacity Development. Retrieved from http://www.undp.org/content/dam/aplaws/publicat ion/en/publications/capacity development/capacity development a undp primer/CDG_PrimerReport_final_web.pdf USAID, Food and Nutrition Technical Assistance (FANTA.2). (2010). THE ANALYSIS OF THE NUTRITION SITUATION IN UGANDA. http://www.fantaproject.org/sites/default/files/resources/Uganda_NSA_May2010.pdf WFP "World Food Programme" (2013). comprehensive food security and vulnerabilit y analysis (CFSVA). Retrieve from http://documents.wfp.org/stellent/groups/public/documents/ena/wfp256989.pdf
! Q8 & -//3H & & U & &
! Q< -**%[&< FOCUS GROUP DISCUSSIONS Question guide for clients Focus Group #: Site: Respondents: Number of Participants: Date: The nutrition workshops A The learning experience at the workshops 1 Have you participated in the nutrition workshops organized by Shanti? 2 What do you like the most in the workshop? 3 What do you like the least in the workshop? 4 What do you learn from the workshops? 5 What else would you like to learn from the workshops that is not taught? B Constraints to full participation 6 Are there any challenges you encounter to participate in the workshops? 7 Are you satisfied with the time you have to spend at the nutrition workshops? 8 What a re some food you are not allowed to eat in your household? 9 How do you feel about this restriction? C Perspective of receiving products 10 How do you feel about receiving garden outputs during the workshops? 11 What kind of garden outputs would you like to receiv e? 12 What is your opinion of receiving garden outputs you are not familiar with? 13 How do you feel about paying a fee in order to receive these garden outputs? 14 How do you feel about receiving seeds during the workshops? 15 What kind of seeds would you like to rec eive? 16 What is your opinion of receiving seeds you are not familiar with? 17 How do you feel about paying a fee in order to receive seeds? 18 How often would you like to receive garden products from Shanti? 19 What other products you would like to receive? 20 Do you have a home garden? If so, do you believe you would grow the same products in your home garden? 21 Do you receive food supplementation from other places then Shanti? If yes, how often? The behaviors at household level A At home practices 22 Do you believe that you replicate what you learn from the workshops at household level? 23 Please describe how you incorporate what you learn in the workshops in your daily life. 24 What are some of the challenges for you to replicate those lessons? 25 Please describe your most eaten products in the dry season? 26 Please describe your most eaten products in the wet season? 27 Please describe your typical daily meal. 28 How do feel about eating fruits and vegetables daily?
! M@ B Impacts of the workshops 29 What impacts do you believe the workshops have on your eating and cooking habits? 30 How do you feel about sharing what you learn in the workshops with your family members or neighbors? Conclusion A Perceptions and attitudes 31 How satisfied are you with what you learn from the workshops? 32 What are your impre ssions of how the workshops are delivered? 33 What do you feel should be the priority of the workshops? 34 What's your opinion of participating in demonstrations during the workshops? Planting, food preparation, cooking demonstrations, ? 35 What advice would you g ive to new participants of the workshops? 36 What do you think would make the nutrition workshop better?
! M" -**%[&<< U & FOCUS GROUP DISCUSSIONS Question guide for Farmers Focus Group #: _______________ Site: __________________________________________ Respondents: ______________________________________________________ Number of Participants: ____ Date: _______________ Basic Farming Questions 1 Are you from this region? Did you grow up in this region? If no, how long have you been living in the area? 2 How many people live with you? 3 What is the part of farming that you like the most? 4 What is the part of farming that you like the least? 5 What time does your day start and end? 6 How many acres is your farm/garden (land)? 7 Is your farm/garden close or far to your homestead? 8 How long do you have to walk to reach it? 9 What crops do you grow on your farm/gardens in the dry season? 10 What crops do you grow on your farm/gardens in the wet season? 11 What's your main crop in either season? Why that particular one? 12 What crops are you growing now on your land? Income 1 Do you and your household depend on farming for your livelihood? 2 Have you ever considered getting out of agriculture for a more lucrative business? If so, what type of work did you think you might want to do ? 3 Do you sell some your garden outputs? 4 What do you sell in the dry season? 5 What do you sell in the wet season? 6 What products do you usually keep for your household consumption in either season? 7 Where do you sell your products? Local market? . . 8 Is farm ing/gardening a source of income for you and your household? 9 Is farming your only source of income? If no, what other sources of income do you have? 10 Is farming bringing you 50% of your income or is it bringing you more than 50% of your income? 11 What has bee n your most consistent crop in terms of making a good profit? Nutrition values 12 Do you know the nutritional values of the crops you grow? If so, please describe one of them? 13 Do you know the nutritional values of the products you sell? If so, please describ e one of them? 14 Do you think the products you keep for household consumption are nutritious enough for all the household? Please tell me more about that. 15 Please describe your typical dinner during the dry season. 16 Please describe your typical dinner during the wet season. 17 Do you diversify your meal? How many times a day do you diversify your meal? 18 Do you think your land provides enough food to feed your household daily? The Environment
! M# 19 Have you used fertilizers in the past? Do you still use them? How often? Is it expensive? 20 Why do you use fertilizers? 21 How do you deal with weeds? With insect pests? 22 How do you feel about growing food without using fertilizers? 23 What kind of storage methods do you use, if any? 24 Are there ways the district supports or hinders y our ability to farm? 25 Are there places that are important to you as a farmer other farms or businesses that help you or that you believe are important? 26 What's your source of water? (district water, private wells, public water supply, other) Have you expe rienced water problems in the past? How have you dealt with it? 27 In terms of taste, appearance, etc, would you say that the quality of the food you grow on your land has increased, decreased, or remained the same over the past 5 years? Why do you think tha t?
! MO -**%[&<<
! MQ -**%[&<;U & INTERVIEW GUIDE FOR TEACHERS Interview #: Site: Respondents: Participant Number: Date: 1 Is "nutrition" part of the education program provided to students? 2 How is it incorporated to the program? 3 What does "healthy food" mean to you? 4 What does "balanced meal" mean to you? 5 When it comes to "healthy food", what is exactly taught to students? 6 How are the topics chosen to teach the students? 7 How many days a week is "nutrition" taught to students? How long does t he session last? 8 In what class do students start learning about nutrition? In what class is nutrition not covered? Why? 9 What is the usual reaction of students in the nutrition class? 10 If you were to give your honest opinion, would you say that the students learn a lot about "healthy diet"? 11 What is your opinion of students' behaviors and practice in how they eat? 12 Do you think there is an impact of the sessions on the students? 13 Personally, how do you gain information about "healthy food"and "healthy diet? 14 As a teacher, are you given nutrition trainings before teaching the students? 15 Have you attended a nutrition program before? When? Where? How often? Who delivered the program? 16 What do you think would make the nutrition education better for the students here? 17 Do you believe the allotted time to cover the topics with students is enough? 18 How important do you think it is to incorporate "nutrition" in the school program?
! MM -**%[&; U & FOCUS GROUP DISCUSSIONS Question guide for Shanti Staff Focus Group #: Sit e: Respondents: Number of Participants: Date: The garden program 1 I heard that back in 2012 the garden program was running briefly; did you know about it? Where you there when that was happening? If yes: a. What was your role at that time? b. What was the overall goal of the garden program? c. What were the main inputs of the garden program? d. What were the main activities of the garden program? e. What were the main outputs of the garden program? f. What were the main outcomes of the garden program? i. On the short term? ii. On the middle term? iii. On the long term? 2 Do you know if there were external factors that the program depended on? Were there other facts that were important for the program to be running? 3 What kind of products were distribut ed? How did the distribution to the clients happen? 4 What category of clients benefited more (pregnant women, breastfeeding women, ?) Why is that? 5 What did you do with the excess of garden products that were not claimed on distribution day? Did you store them somewhere? 6 Do you remember anything that you liked about the program? What about what you didn't like? 7 Do you think there were challenges that kept the garden from improving on the management side? The nutrition workshops and the clients 8 What do you know about the nutrition workshops that are usually done at Shanti? 9 How are the patients enrolled in the nutrition workshops? 10 How many times a month is a patient required to come to the workshops? 11 Since you are very involved with the clients, how do you t hink they see the nutrition workshops? 12 What do you think that the patients like the most about the workshops? 13 What do you think they like the least? Why is that? 14 What do you think they would like to see more in the workshops? 15 Would you be able to give me a list of the activities that are done at the workshops? 16 What do you really want the participants to learn from the workshops? 17 What do you want them to do with that knowledge? 18 Do you think for the past 3 years the numbers of clients increased for the worksh ops? Why is that Clients' Household behaviors 19 Do you know if the clients did plant the seeds in their home gardens, as you wanted them to? 20 Did you do a follow up? How did that happen? 21 What do you think was their opinion about Shanti giving them seeds to grow on their lands?
! MH Conclusion 22 Do you think in some ways the program was successful? 23 What did the program fail to do at that time? 24 What do you think should be the priority of the new land that Shanti acquired? 25 what do you think should be the priority of the future garden? 26 What suggestions would you have for the future workshops?
! M2 -**%[&;< U & Interview guide for key informants (extension program workers, other garden managers) 1 What is the name of the institution you work for? 2 What is your role in that institution? 3 How long have you worked in that position? 4 How long have you worked in Uganda? 5 What are keys to success for a community garden program in Luwero? 6 How do you manage your garden? 7 What type of organizational structure you would suggest for a community garden program? 8 Would public liability insurance be necessary? 9 Where do you obtain resources (insecticides, fertilizers, compost, seeds etc)? 10 What are your links to local government? 11 How are you funded? 12 How do you make decisions, solve problems and resolve conflict? 13 How do you pass on skills to new gardeners and improve people's skills? 14 How did you build a sense of community around the garden? 15 Are there other nutritional knowledge pro grams in the area? 16 If you were to improve a garden program, what would you do?
! M8 -**%[&;<< U & INTERVIEW GUIDE FOR EXTERNAL INFORMANTS (HEALTH STAFF) Interview #: Site: Respondents: Participant Number: Date: 1 What is your role here? 2 How long have you been in this position? 3 What have been the biggest challenges for that department during your time here? 4 What kind of service does this health center provide in terms of nutrition to the patients? 5 Could you tell me more about what you do speci fically with regards to nutrition and training for the patients? 6 How long have these services been provided? 7 What have been the successes that you've noticed with these offered services? 8 Have you noticed any challenges? 9 What areas do you think needs to be explored more in terms of nutrition needs in the District?
! M< -//3H&;<<< & & & & KAP SURVEY QUESTIONNAIRE
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! H" The information provided by the following questions will be used to help categorize your answers by demographic descriptors (Age, Sex, Education level Employment status, ). 1 What is your age? Between 18 and 20 years Between 21 and 25 years Between 26 and 30 years Between 31 and 35 years Between 36 and 40 years Between 41 and 45 years Between 46 and 50 years Over 50 years 2 What is your marital status? Single Married Cohabitating Other (please specify): ________ 3 What is your religion Catholic Protestant Muslim Other (please specify):________ 4 What is your Employment status? (please select all that applies) Employed Unemployed Self e mployed 5 What is your occupation? Farmer Housewife Self e mployed Formal employment Other (please specify): ____________________ 6 How many hours per week are dedicated to each of the activities mentioned above? 7 What is the occupation of your partner? Farmer Government service self employment Other (please specify): ______ 8 Including yourself, how many people live in your household? Number of children under 17 years of age ___________ Number of adults 18 years of age and older ___________ 9 What is the highest level of formal education you have completed? Not attended Primary level Lower secondary level (4 years)
! H# ! Higher secondary level (2 years) Above secondary level 10 What the name of your village of Residence: _______________________________ ?#5!7.33.C'%)!D05,&'.%,!C'33!$,,5,,!1.06!@%.C35*)5E!$&&'&0*5 E $%*!:6$8&'85!$2.0&!,5F56$3! %0&6'&'.% G 653$&5*!',,05,H! A.06!#.%5,&!$%,C56 C'33!#53:!0,!25&&56!.6)$%'I5!$%*!5F$30$&5! 5! %0&6'&'.%!5*08$&'.%!$8&'F'&'5,!$&!"#$%&'!()$%*$H! ! 11 How long have you been a client of Shanti? _____Weeks _____Months _____Years 12 How many nutrition workshops have you attended? 1 2 3 4 5 or more 12.1 Are there foods you don't want to eat or you didn't want to eat while pregnant? Yes No 12. 1 .a Which foods are those? 12.1.b Why did you not eat them? !
! HO Knowledge A From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matched your belief BEFORE participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 13. A woman should eat more protein rich foods when she is pregnant 1 2 3 4 5 14. The lack of iron in what I eat can result in me suffering from anaemia 1 2 3 4 5 15. When a pregnant woman is undernourished, she risks having a baby that has a low birth weight 1 2 3 4 5 16. A breastfeeding woman should eat more iron rich foods to produce more breastmilk 1 2 3 4 5 17. A breastfeeding woman should eat more protein rich foods to produce more breastmilk 1 2 3 4 5 18. It is important that a pregnant woman takes iron supplements 1 2 3 4 5 19. It is important that a pregnant woman takes folic acid supplements. 1 2 3 4 5 20. A low birth weight baby can have slower growth and development 1 2 3 4 5 21. A low birth weight baby is more likely to become sick often when he/she becomes an adult 1 2 3 4 5 22. A low birth weight baby can suffer from several micronutrient deficiencies 1 2 3 4 5 23. After giving birth, a woman should wait 2 to 3 years before becoming pregnant again 1 2 3 4 5 24. I fully understand what a balanced diet means 1 2 3 4 5 B From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matches your belief AFTER participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 25. A woman should eat more protein rich foods when she is pregnant 1 2 3 4 5 26. The lack of iron in what I eat can result in me suffering from anaemia 1 2 3 4 5 27. When a pregnant woman is undernourished, she risks having a baby that has a low birth weight 1 2 3 4 5 28. A breastfeeding woman should eat more iron rich foods to produce more breastmilk 1 2 3 4 5
! HQ 29. A breastfeeding woman should eat more protein rich foods to produce more breastmilk 1 2 3 4 5 30. It is important that a pregnant woman takes iron supplements 1 2 3 4 5 31. It is important that a pregnant woman takes folic acid supplements. 1 2 3 4 5 32. A low birth weight baby can have slower growth and development 1 2 3 4 5 33. A low birth weight baby is more likely to become sick often when he/she becomes an adult 1 2 3 4 5 34. A low birth weight baby can suffer from several micronutrient deficiencies 1 2 3 4 5 35. After giving birth, a woman should wait 2 to 3 years before becoming pregnant again 1 2 3 4 5 36. I fully understand what a balanced diet means 1 2 3 4 5 Attitude C From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matched your belief BEFORE participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 37. I think it is good for a woman to eat more food when she is pregnant 1 2 3 4 5 38. It is difficult for me to eat more food during pregnancy 1 2 3 4 5 39. It is important for me to know about preparing a balanced meal 1 2 3 4 5 40. A nutritious meal can come from my own small garden 1 2 3 4 5 41. I should only eat fruits and vegetables I like 1 2 3 4 5 42. I should only eat fruits and vegetables when I feel like it 1 2 3 4 5 43. Understanding my own nutritional status is important 1 2 3 4 5 44. Processed foods are generally better than the foods coming from my garden 1 2 3 4 5 45. Eating a variety of foods in moderation is key to balanced nutrition 1 2 3 4 5 46. I always feel confident when preparing 1 2 3 4 5
! HM nutritious meals for me and my family D From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matches your belief AFTER participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 47. I think it is good for a woman to eat more food when she is pregnant 1 2 3 4 5 48. It is difficult for me to eat more food during pregnancy 1 2 3 4 5 49. It is important for me to know about preparing a balanced meal 1 2 3 4 5 50. A nutritious meal can come from my own small garden 1 2 3 4 5 51. I should only eat fruits and vegetables I like 1 2 3 4 5 52. I should only eat fruits and vegetables when I feel like it 1 2 3 4 5 53. Understanding my own nutritional status is important 1 2 3 4 5 54. Processed foods are generally better than the foods coming from my garden 1 2 3 4 5 55. Eating a variety of foods in moderation is key to balanced nutrition 1 2 3 4 5 56. I always feel confident when preparing nutritious meals for me and my family 1 2 3 4 5 Practices E From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matched your belief BEFORE participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 57. I eat more beef in my diet 1 2 3 4 5 58. I eat more pork in my diet 1 2 3 4 5 59. I eat more chicken in my diet 1 2 3 4 5 60. I eat more fish in my diet 1 2 3 4 5
! HH 61. I eat more eggs (ex: from chicken or from duck) 1 2 3 4 5 62. I eat more orange coloured vegetables (ex: orange sweet potato, pumpkin, carrot) 1 2 3 4 5 63. I eat more green vegetables 1 2 3 4 5 64. I eat more fresh citrus fruits like oranges or I drink more juice made from them 1 2 3 4 5 65. I always wash raw fruits and vegetables before using them 1 2 3 4 5 66. I always use clean water to wash raw fruits and vegetables 1 2 3 4 5 67. I drink more milk 1 2 3 4 5 68. I am sure that I clean well all kitchen areas, pots, pans, utensils after cooking 1 2 3 4 5 69. I always wash my hands with soap before preparing food 1 2 3 4 5 70. Running water is always available for me to wash my hands 1 2 3 4 5 71. I always put treatment to my water before I drink it 1 2 3 4 5 72. I always boil water before I drink it 1 2 3 4 5 73. I always replicate the lessons learned from the workshops at household level 1 2 3 4 5 74. I share lessons learned with family members and neighbours 1 2 3 4 5 75. I use less oil when I cook 1 2 3 4 5 F From a scale of 1 to 5, where 1= I strongly disagree and 5= I strongly agree, please select the box that best matches your belief AFTER participating in the program : Strongly Disagree Disagree Neutral Agree Strongly Agree 76. I eat more beef in my diet 1 2 3 4 5 77. I eat more pork in my diet 1 2 3 4 5 78. I eat more chicken in my diet 1 2 3 4 5 79. I eat more fish in my diet 1 2 3 4 5 80. I eat more eggs (ex: from chicken or from duck) 1 2 3 4 5 81. I eat more orange coloured vegetables (ex: orange sweet potato, pumpkin, carrot) 1 2 3 4 5 82. I eat more green vegetables 1 2 3 4 5 83. I eat more fresh citrus fruits like oranges or I drink more juice made from them 1 2 3 4 5
! H2 84. I always wash raw fruits and vegetables before using them 1 2 3 4 5 85. I always use clean water to wash raw fruits and vegetables 1 2 3 4 5 86. I drink more milk 1 2 3 4 5 87. I am sure that I clean well all kitchen areas, pots, pans, utensils after cooking 1 2 3 4 5 88. I always wash my hands with soap before preparing food 1 2 3 4 5 89. Running water is always available for me to wash my hands 1 2 3 4 5 90. I always put treatment to my water before I drink it 1 2 3 4 5 91. I always boil water before I drink it 1 2 3 4 5 92. I always replicate the lessons learned from the workshops at household level 1 2 3 4 5 93. I share lessons learned with family members and neighbours 1 2 3 4 5 94. I use less oil when I cook 1 2 3 4 5 Thank you for participating in the survey!!! !
! H8 -//3H&
! H< -//3H&H< & ./0123453 & Paired Samples Test Paired Differences t df Sig. (2 tailed) Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference Lower Upper Pair 1 Knowledge Post25 Knowledge Pre13 .615 1.235 .242 .116 1.114 2.540 25 .018 Pair 2 Knowledge Pos26 Knowledge Pre14 .923 1.164 .228 .453 1.393 4.045 25 .000 Pair 3 Knowledge Pos27 Knowledge Pre15 .731 1.485 .291 .131 1.330 2.510 25 .019 Pair 4 Knowledge Pos28 Knowledge Pre16 .500 .990 .194 .100 .900 2.575 25 .016 Pair 5 Knowledge Pos29 Knowledge Pre17 .808 1.234 .242 .309 1.306 3.339 25 .003 Pair 6 Knowledge Pos30 Knowledge Pre18 .654 1.495 .293 .050 1.258 2.230 25 .035 Pair 7 Knowledge Pos31 Knowledge Pre19 .462 1.581 .310 .177 1.100 1.489 25 .149 Pair 8 Knowledge Pos32 Knowledge Pre20 .231 .992 .195 .170 .632 1.186 25 .247 Pair 9 Knowledge Pos33 Knowledge Pre21 .462 1.067 .209 .031 .893 2.206 25 .037 Pair 10 Knowledge Pos34 Knowledge Pre22 .360 .757 .151 .047 .673 2.377 24 .026 Pair 11 Knowledge Pos35 Knowledge Pre23 .538 1.174 .230 .064 1.013 2.339 25 .028 Pair 12 Knowledge Pos36 Knowledge Pre24 .654 1.495 .293 .050 1.258 2.230 25 .035 & -!!
! 2@ Pair 2 Attitude_Post48 Attitude_Pre38 .192 1.201 .235 .293 .677 .817 25 .422 Pair 3 Attitude_Post49 Attitude_Pre39 .640 .995 .199 .229 1.051 3.216 24 .004 Pair 4 Attitude_Post50 Attitude_Pre40 .160 1.248 .250 .355 .675 .641 24 .527 Pair 5 Attitude_Post51 Attitude_Pre41 .192 1.600 .314 .454 .839 .613 25 .546 Pair 6 Attitude_Post52 Attitude_Pre42 .320 1.180 .236 .167 .807 1.355 24 .188 Pair 7 Attitude_Post53 Attitude_Pre43 .846 1.084 .213 .408 1.284 3.980 25 .001 Pair 8 Attitude_Post54 Attitude_Pre44 .000 1.497 .294 .605 .605 .000 25 1.000 Pair 9 Attitude_Post55 Attitude_Pre45 .885 1.211 .237 .396 1.374 3.725 25 .001 Pair 10 Attitude_Post56 Attitude_Pre46 .538 1.104 .216 .093 .984 2.487 25 .020 ! =:-)!<)3 & Paired Samples Test Paired Differences t df Sig. (2 tailed) Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference Lower Upper Pair 1 Practice Pos76 Practice Pre57 .000 1.442 .283 .583 .583 .000 25 1.000 Pair 2 Practice Pos77 Practice Pre58 .385 .941 .185 .765 .004 2.083 25 .048 Pair 3 Practice Pos78 Practice Pre59 .577 1.238 .243 .077 1.077 2.375 25 .026 Pair 4 Practice Pos79 Practice Pre60 .346 1.056 .207 .080 .773 1.671 25 .107 Pair 5 Practice Pos80 Practice Pre61 .192 1.132 .222 .265 .650 .866 25 .395 Pair 6 Practice Pos81 Practice Pre62 .600 1.384 .277 .029 1.171 2.167 24 .040 Pair 7 Practice Pos82 Practice Pre63 .462 1.272 .249 .052 .975 1.850 25 .076
! 2" Pair 8 Practice Pos83 Practice Pre64 1.077 1.055 .207 .651 1.503 5.203 25 .000 Pair 9 Practice Pos84 Practice Pre65 .500 1.030 .202 .084 .916 2.476 25 .020 Pair 10 Practice Pos85 Practice Pre66 .615 .983 .193 .218 1.012 3.192 25 .004 Pair 11 Practice Pos86 Practice Pre67 .462 1.303 .256 .065 .988 1.806 25 .083 Pair 12 Practice Pos87 Practice Pre68 .231 .951 .187 .153 .615 1.237 25 .228 Pair 13 Practice Pos88 Practice Pre69 .769 1.177 .231 .294 1.245 3.333 25 .003 Pair 14 Practice Pos89 Practice Pre70 .692 1.408 .276 .124 1.261 2.508 25 .019 Pair 15 Practice Pos90 Practice Pre71 .577 1.102 .216 .132 1.022 2.670 25 .013 Pair 16 Practice Pos91 Practice Pre72 .500 .860 .169 .153 .847 2.964 25 .007 Pair 17 Practice Pos92 Practice Pre73 1.560 1.294 .259 1.026 2.094 6.030 24 .000 Pair 18 Practice Pos93 Practice Pre74 1.600 1.225 .245 1.094 2.106 6.532 24 .000 Pair 19 Practice Pos94 Practice Pre75 1.308 1.408 .276 .739 1.876 4.737 25 .000 !
! 2# -//3H&H<< & Scale: Pre_KnowledgeIndex_Final Reliability Statistics Cronbach's Alpha N of Items .705 9 Item Statistics Mean Std. Deviation N Knowledge_Pre13 3.50 1.208 26 Knowledge_Pre14 3.31 1.087 26 Knowledge_Pre15 3.35 1.294 26 Knowledge_Pre16 3.54 .989 26 Knowledge_Pre19 3.00 1.058 26 Knowledge_Pre20 3.73 .919 26 Knowledge_Pre21 3.15 1.120 26 Knowledge_Pre23 3.73 .919 26 Knowledge_Pre24 3.54 1.240 26 Scale: Post_KnowledgeIndex_Final Reliability Statistics Cronbach's Alpha N of Items .842 9 Item Statistics Mean Std. Deviation N Knowledge_Post25 4.12 1.013 25 Knowledge_Post28 4.00 .957 25 Knowledge_Post29 4.12 1.013 25 Knowledge_Post30 3.92 1.222 25 Knowledge_Post31 3.44 1.261 25 Knowledge_Post32 3.92 .954 25 Knowledge_Post34 3.64 1.150 25 Knowledge_Post35 4.24 .926 25 Knowledge_Post36 4.20 1.041 25
! 2O Scale: Pre_PracticeIndex_Final Reliability Statistics Cronbach's Alpha N of Items .898 10 Item Statistics Mean Std. Deviation N Practice_Pre62 3.17 1.341 24 Practice_Pre63 3.75 1.073 24 Practice_Pre64 2.88 1.191 24 Practice_Pre65 3.92 1.100 24 Practice_Pre66 3.92 .974 24 Practice_Pre68 4.08 .881 24 Practice_Pre69 3.38 1.313 24 Practice_Pre72 4.21 .833 24 Practice_Pre73 2.33 1.167 24 Practice_Pre74 2.38 1.279 24 Scale: Post_PracticeIndex_Final ! ! ! Item Statistics Mean Std. Deviation N Practice_Post78 3.64 1.497 25 Practice_Post79 3.80 1.443 25 Practice_Post80 3.88 1.394 25 Practice_Post81 3.68 1.345 25 Practice_Post82 4.20 1.080 25 Practice_Post83 4.04 1.207 25 Practice_Post85 4.52 .714 25 Practice_Post86 3.32 1.626 25 Practice_Post88 4.16 .898 25 Practice_Post92 3.80 1.118 25 Practice_Post93 3.84 1.068 25 ! Reliability Statistics Cronbach's Alpha N of Items .871 11
! 2Q ! -//3H&H<<< & Variables Entered/Removed a Model Variables Entered Variables Removed Method 1 Firstcase b Enter a. Dependent Variable: Post_PracticeIndex b. All requested variables entered. ! Model Summary Model R R Square Adjusted R Square Std. Error of the Estimate 1 .635 a .403 .377 7.136 a. Predictors: (Constant), Firstcase
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