Malnutrition among under-5 children and health service delivery by

Village Health Teams in Isingiro District

Investigators;

Ayebazibwe Geoffrey, MBChB (MUST)

Mutatina Boniface, BSc. (SUA)

Table of abbreviations

MUAC – Mid Upper Arm Circumference

MUBS – Makerere University Business School

MUST – Mbarara University of Science and Technology

NCHS – National Center for Health Statistics

SUA – Sokoine University of Agriculture

UDHS – Uganda Demographic and Health Survey

UNICEF – United Nations International children Emergence Fund

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Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Chapter one

1.1 Introduction

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

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

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

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

1.2 Problem statement

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

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

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

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1.3 Significance of the study

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

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

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

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

1.4 Conceptual frame work

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

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Child malnutrition

Death and disability

Inadequate dietary intake

Diseases

Insufficient access to food

Inadequate maternal and child care practices

Poor water/sanitation and inadequate health services

Quality and Quantity of actual resources; human, economic and organizational and the way they are controlled

Potential resources; environment, technology, people

Immediate causes

Underlying causes at house hold

Basic causes at societal level

1.5 Scope of the study

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

1.6 Research questions

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

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

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

1.7 Hypothesis

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

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

1.8 Objectives

General objectives

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

Specific objectives

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

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

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

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2 Chapter Two: Literature review

Background

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

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

Prevalence of malnutrition in Uganda

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

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

The objective of Village Health Committees is aimed at improving Health and Nutrition Outcomes. This objective is to be achieved through creating awareness in the village about

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available health services and their health entitlements, developing a Village Health Plan based on an assessment of the situation and priorities of the community, maintaining a village health register and health information board and calendar and, analyzing key issues and problems pertaining to village level health and nutrition activities and providing feedback to relevant functionaries and officials.

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3 Chapter Three: Methods

3.1 Study design

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

3.2 Study setting

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

3.3 Population

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

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

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

3.4 Selection criteria

Inclusion criteria

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

Exclusion criteria

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

3.5 Sampling procedure

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

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3.6 Sample size estimation

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

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

Where;

N - The required sample size of house holds

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

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

D - Standardized error given by confidence interval

Design effect of 2 will be considered

3.7 Study variables

Out come variables

Level of malnutrition among under 5 years

Independent factors:

Achievement of village health committee in relation to;

Food accessibility

Maternal and child care practices

Water and sanitation and

Health services

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

3.8 Data collection

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

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

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Length: The child will be made to lie flat on the length board. The sliding piece will be placed at the edge of the bare feet as the head (with crushing of the hair) touched the other end of the measuring device. Then two readings shall be taken and the average computed.Arm Circumference: The Mid Upper Arm Circumference will be measured using a MUAC tape to the nearest 0.1cm. Two readings will be taken and the average recorded for each child.Child Age DeterminationWhere useful documents like growth monitoring/clinic attendance cards and birth certificates are available, they will be used to determine the child’s age. Calendars of events will also used as proxies to age determination. OedemaOedema, defined as bilateral oedema on the lower limbs will be assessed by gently pressing the feet to check if a depression is left after at least three seconds of pressing and will be confirmed if present by the supervisor and then recorded.Quantitative data

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

Qualitative data

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

3.9 Data management and Analysis

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

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

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

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

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Bivariate analysis

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

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

3.10 Quality Control Procedures

A comprehensive training of enumerators and supervisors will be conducted covering interview techniques, taking of measurements, standardization of questions in the questionnaire, diagnosis of oedema and measles, verification of deaths within households, handling of equipment, and the general courtesy during the assessment.

Standardization of measurement and pre-testing of the questionnaire and equipment Monitoring of fieldwork by assessment coordinators Crosschecking of filled questionnaires on daily basis and recording of observations and

confirmation of measles, severe malnutrition and death cases by supervisors. Daily review shall be undertaken with the teams to address any difficulties encountered Progress evaluation will be carried out according to the time schedule and progress

reports shared with partners on regular basis Continuous data cleaning upon and after entry Monitoring accuracy of equipment (weighing scales) by regularly measuring objects of

known weights and continuous reinforcement of good practices. All measurements shall be loudly shouted by both the enumerators reading and recording

them to reduce errors during recording.

3.11 Anticipated problems in executing the study

Data on achievements of Village health committees was based on self-reports thus may contain inconsistencies, exaggerations or other errors.

Each child’s weight and height will be compared with data from a standard population basing on the WHO (i.e. National Centre for Health Statistics (NCHS) dataset for U.S), which is different from Ugandan setting.

3.12 Ethical consideration

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

Consent will be sought from respondents before inclusion into the study

Identity of respondents will be kept confidential

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

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References

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

2. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T: Predictors of poor anthropometric status among children under 2 years of age in rural Uganda. Public Health Nutr 2006, 9(3):320-326.

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

4. Bridge A, Kipp W, Jhangri GS, Laing L, Konde-Lule J: Nutritional status of young children in AIDS-affected households and controls in Uganda. Am J Trop Med Hyg 2006, 74(5):926-9.

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

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

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

8. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T: Predictors of poor anthropometric status among children under 2 years of age in rural Uganda. Public Health Nutr 2006, 9(3):320-326.

9. Bridge A, Kipp W, Jhangri GS, Laing L, Konde-Lule J: Nutritional status of young children in AIDS-affected households and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

26. Turyashemererwa FM, Kikafunda JK and E Agaba Prevalence Of Early Childhood Malnutrition And Influencing Factors In Peri Urban Areas Of Kabarole District, Western Uganda African Journal of Food Agriculture Nutrition and Development, 2009 9 ( 4) June, 975-989

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Appendix one: Time frame of activities

Period 1st Oct-15th

Oct, 2009

16th Oct –

15th Nov,

2009

16th Nov –

18th Dec,

2009

19th Dec -24th

Dec 2009

28th Dec,

2009 – 1st

April

Proposal preparation and writingSeek ethicalclearance withEthicalCommitteeSeek permissionto implement thesurvey fromDistrict/LocalAuthorities

Coordinationmeeting withlocal authorities

Training ofenumerators

Data collectionData cleaning,

data analysis

Report writing

Dissemination

of results

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Appendix two: Budget to cover four (4) weeks of the studyIntem Units Cost per Unit Total cost

Salaries for research assistants

5 Individuals 625,000 3,125,000

Training allowances

for 3 days

7 Individuals 10,000 210,000

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

Cameras 2 500,000 1,000,000

Stationary

1. Photocopying &

printing

10 reams 50,000 500,000

2. Binding 10 reams 10,000 100,000

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

4. File holders 7 5000 35000

5. Pens 3 dozens 35,000 11,500

6. Pencils 1 dozen 1,500 1,500

7. Calculator 2 20,000 40,000

Recorders 2 150,000 300,000

Bags 7 20,000 140,000

Weighing scales 5 50,000 250,000

Weight for height charts 10 10,000 100,000

Weight for age charts 10 10,000 100,000

Boards (length) 5 20,000 100,000

Tape measures 5 3,000 15,000

Transport 1,000,000

Total 8,648,000

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Appendix three: Nutritional Survey Questionnaire

Household Information

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

Village………………………..

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

Mother information

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

2. Physiological Status:

a. Pregnant

b. Lactating

c. Non pregnant non lactating

Nutrition assessment of children under-5 years

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

2. Age……………months

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

4. Did the child have the routine vaccinations?

1. Yes

2. No

3. not regular

5. Did the child receive vitamin A supplementary doses?

1. Once

2. Twice

3. No

6. Is the child breastfed now?

Yes

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No

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

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

Clinical examination of Children (Under-5 years)

1. Eye manifestation of Vitamin A deficiency

a. Night blindness

b. Bitot spots

c. No signs of Vitamin A def.

2. Morbidity (during the last month)

* Diarrhea, vomiting or both

Number of episodes

a. One

b. Two

c. Three

Duration of episode …………………….days

* Upper respiratory disease

Number of episodes

a. One

b. Two

c. Three

Duration of episode ……………………….. Days

* Lower respiratory disease

Number of episodes

a. One

b. Two

c. Three

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

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* Fever attacks

Number of episodes

a. One

b. Two

c. Three

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

* Skin Rash (measles)

Number of episodes

a. One

b. Two

c. Three

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

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Appendix four: Questionnaire for assessing objectives of village health committees. 1. How often are home visits by village health committees?

i. Every fortnight [ ]ii. Monthly [ ]

iii. After three months [ ]iv. Annually [ ]

2. Are often are health meetings?i. Every fortnight [ ]

ii. Monthly [ ]iii. After three months [ ]iv. Annually [ ]

3. Who do you think contributes most to village health meetings?i. District leaders [ ]

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

4. Which of the following have been achieved by your village health committee?i. Sensitization about food security [ ]

ii. Sensitization about good maternal and child care practices [ ]iii. Sensitization about water and sanitation [ ]iv. Provision of essential drugs [ ]v. Mobilization for communal health activities [ ]

5. To what extent has Sensitization about food security been achieved?i. Poor [ ]

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

6. To what extent has sensitization about good maternal and child care practices been achieved?i. Poor [ ]

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

7. To what extent has sensitization about water and sanitation been achieved?i. Poor [ ]

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

8. To what extent has provision of essential drugs been achieved?i. Poor [ ]

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

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9. To what extent has mobilization for communal health activities been achieved?i. Poor [ ]

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

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Appendix five: Consent Form

Study title

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

Principle investigator

Mutatina Boniface/ Ayebazibwe Geoffrey

MUBS

Tel: +256-782486870, e-mail: bonifacemutatina@yahoo.com

Tel: +256-783737271, e-mail; jayabazibwe@yahoo.co.uk

Informed Consent

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

My Rights as a Research Volunteer

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

Purpose of the Study

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

Study Procedures

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

Risks

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

Potential Benefits to Me

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

Costs/Compensations

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

Confidentiality

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

Problems or Questions

If you have any questions at any time about this research study, you may contact /Ayebazibwe Geofrey (tel: +256783737271) Makerere University Business School. If you have any questions about any rights as a research volunteer, you may contact chairperson of Makerere University Business School Research and Ethics Committee (tel: …………….)

Participants Consent

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

Volunteer

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

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

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

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