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Nov 6, 2015 - Malnutrition is irreversible if not caught right at the beginning of a ... circumferences are highly associated with a 5–20-fold .... missed values and unlikely responses and then manually ... 100. Institution. Adare hospital. 116. 32.2. Garahiketa H/C. 36. 9.9 ... (Yuna T, 2014; H. Kim et al., 2009; Antoinette Fet.

Global Academic Research Journals Global Journal of Public Health Research Vol. 1(1) pp. 001-008, November, 2015. Available online @ © Global Academic Research Journals

Full Length Research Paper

Knowledge, attitude and practice towards malnutrition among health care workers in Hawassa City, Southern Ethiopia Zelalem Tafese and Anteneh Shele Hawassa College of Health Sciences, Hawassa, Ethiopia. Accepted 6 November, 2015

Malnutrition is irreversible if not caught right at the beginning of a child’s life. Health care workers involvement towards malnutrition received greater emphasis as an important factor for the improvement, prevention and control of malnutrition among children. Institution based cross sectional quantitative study was conducted on 361 health care workers in Hawassa town; from April –May. Data was collected by using pretested structured self administered questionnaire and analyzed with SPSS version 20. The results indicated that the majority of study participants had poor knowledge and skill, in clinical nutrition topics and three quarters of the respondent showed favorable attitude towards nutritional issues. These findings suggest that health care workers use nutritional assessment criteria poorly in clinical settings. Enhancing the knowledge and skill level of health care workers in clinical setting is important to improve clinical nutrition care and treatment regime. It is recommended effective on job trainings and continuing education for all staff. Keywords: Nutritional assessment, Knowledge, Skill, Clinical setting, Malnutrition.

INTRODUCTION Malnutrition is one of the major health concerns especially in developing countries which affect almost 800 million people where the largest proportions found in Africa and south east Asia. It is the most recognizable and perhaps most untoward consequence of poverty in children (Afework et al., 2o10; al., 2007). Although malnutrition is prevalent in developing countries, it is rarely cited as being among the leading causes of death. This is due in part to the conventional way that cause of death data are reported and analyzed. In many countries, mortality statistics are compiled from records in which a single proximate cause of death has been reported (Amy et al., 2000). Childhood undernutrition is a major global health problem, contributing to childhood morbidity, mortality, impaired intellectual development, suboptimal adult work capacity,

*Corresponding author Email: [email protected]

and increased risk of diseases in adulthood (Black R et al., 2013). In the early 1990s Pelletier and colleagues used a different approach to estimate the contribution of malnutrition to all-cause mortality in children. Their analytical framework takes the underlying causes of death into account and it suggested that malnutrition (measured as poor anthropometric status) is an associated cause in about half of all deaths occurring among children in developing countries (Pettilier D, 1995; Manary et al.,2998;Black RE et al.,2003; Pelletier D et al.,1994) .Thus; it highlighted the fact that even children with mild to moderate malnutrition, rather than only those with more severe forms, had an increased risk of dying. Reducing malnutrition among children under the age of five remains a huge challenge in developing countries of the World. An estimated 230 million under-five children are believed to be chronically malnourished in developing countries (Ellen V et al., 2008). Eastern and middle Africa is known with a highest prevalence of estimates in the UN

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sub regions with 50% and 42%, respectively (Black RE et al., 2008). Early detection and appropriate management of nutritional problems among children at first-level health facility is important in ensuring that the needs of ill children are met to decrease child mortality. However, studies shows that the quality of health care for children in developing countries has often been found poor (Duke T, etal.,2003; Nolan T et al.,2001) Major challenges remain to implementation of effective use of growth monitoring in primary health-care settings, to identify the most at-risk infants and children who need medical and nutritional interventions to prevent serious morbidity and mortality. The importance of this is highlighted by the strong epidemiological evidence that low weight-for-height, weight-for-length or mid-upper arm circumferences are highly associated with a 5–20-fold increased risk of mortality (Fishman S et al 2004).In the recent WHO guidelines for the management of severe malnutrition, severely malnourished children are identified by calculation of weight for height and the detection of bipedal oedema (Schofield C et al 1996). Studies in Ethiopia and Bangladesh have reported that 12-34% of children that come into contact with first-level facilities require referral to hospital care for further assessment and treatment (Simoes et al.,1997; Kalter HD et al., 1997). The quality of case detection, management and/or appropriate and timely referral of malnourished children provided in these health care settings is likely therefore to have a major impact on the health and lives of millions of children each year. The World Health Organization (WHO) estimates that some 3 billion people suffer from malnutrition of one kind or other. In Ethiopia (52%) under the age of five are stunted (growth retardation), 11% are wasted (thin for their height) and 47% are underweight (low weight-forage). Stunting and wasting rates are even higher in rural children, where the vast majority of the population is dwelling. Other community based studies in Ethiopia also showed prevalence of wasting from 9-12% (Yimer G, 2000). Poor infant and young child feeding practice, poor socio-economic background and nutritionally inadequate diet contribute more for severe acute malnutrition in Ethiopia (Getaneh T etal.,1998; Amsalu S et al., 2008). The recognition of severe malnutrition at the first-level health facility: (a facility such as a health centre, health post, or outpatient department of a hospital) which is considered the first facility within the health system where people seek care is important because standard management protocols can greatly reduce mortality (Neumann Y et al., 2004). Pneumonia, diarrhea, malaria, measles, problems of the newborn are a cause for more than 90% of the deaths in children under-five years of age in Ethiopia. At the background of these causes of death are HIV and malnutrition 11% and 57% respectively. There are

feasible and effective ways that health workers in clinics can use to care for children with these illnesses and prevent most of these deaths. A child with acute malnutrition has a higher risk of many types of disease and death. Even children with mild and moderate malnutrition have an increased risk of death. Identifying children with malnutrition and treating them can help prevent many severe diseases and death. Some malnutrition cases can be treated at home. Severe cases need referral to hospital for special feeding, blood transfusion, or specific treatment of a disease contributing to malnutrition (WHO, 1997). The majority of studies on childhood malnutrition have described prevalence of malnutrition among children and analyzed socioeconomic, demographic and cultural factors associated with child malnutrition in sub Saharan Africa (Reed BA et al., 1996;Madiseet al., 1999; Pongou R et al.,2006) However, there is shortage of published studies about the quality of care on case detection and management on childhood malnutrition at primary health care level in sub Saharan Africa and in the study area in particular. To decrease the morbidity and mortality associated with malnutrition; proper case detection and management and/or urgent referral is by far important at the primary health care level. Early assessment and prioritization for management of sick children attending a health service are critical to achieving good health outcomes. The current study assesses the base line situation of pediatric care on detection and appropriate management of malnutrition on children who are attending government district hospitals and health centers of Hawassa city. It is also thought that the findings and implications of the current study will be important to build and extend previous research in the area, and fill a gap in empirical work. METHODS AND MATERIALS A cross-sectional study using self-administered multiple choice questionnaires in English was used to assess the level of Knowledge, Attitude and Practice of health care workers (nurses, health officers, and general practitioners/physicians). The sample size was determined using single population proportion formula, due to shortage of published data in the study area we consider the maximum proportion of knowledge attitude and practice of the health workers 50%, level of significance 0.05, margin of error 4% and non response rate 10%. Since the total number of health care workers in the study area is below 10,000 finite population corrections was applied and 361 were taken as the sample size for this study. Socio demographic data, Knowledge, attitude, practical skill of health care workers in the health facility were the variables

included in the questionnaire. The content, reliability


Glob. J. Public Health Res.

Table 1. The grading system used to classify the healthcare workers attitude and practice on the assessment and management of malnutrition, Hawassa, 2015


Level of attitude and practice

≥75% < 75%

Good Poor

Table 2. The grading system used to classify the healthcare workers knowledge on the assessment and management of malnutrition, Hawassa, 2015


Level of knowledge

≥75% < 75%

Adequate Not adequate

and validity of the questionnaire were then assessed by knowledgeable and well experienced lecturers and nutrition specialists at Hawassa College of health sciences for an acceptable accuracy. The questionnaire was pre-tested on 5% of the sample size among health care workers at Tikur Woha health centre which is found 10 km away from Hawassa and some corrections were made accordingly. Study subjects were taken from all governmental health institutions under the health bureau of the city administration of Hawassa. Proportional sampling for size was employed to determine the number of subjects from each institution and study participants were selected from each institutions using simple random sampling technique. The nutrition knowledge, attitude and practical performance of all health care workers were determined using different questionnaire. The questionnaire consisted of 29 questions and included three sections: Knowledge, Attitude and practice assessment questions 13, 9 and 7 respectively. The questionnaires were given to the doctors, nurses and health officers to mark their answers. The questionnaires were collected at the end of the working day. Knowledge was assessed with 13 questions including multiple choice and “yes” or “no” questions. Attitude and practice were assessed using another self-structured questionnaire which consists of 9 and 7 questions, respectively. A score of 0 was given for unfavorable attitudes and poor practices. 1 point was given for each correct response to favorable attitudes and good practices so that maximum score for attitude is 9 and for practice it is 7. A score of 75% and more was considered as good practice and favorable attitude. The knowledge scores were determined by taking the number of correct responses by each respondent out of the knowledge questions asked; expressed as percentage. The percentage score were graded to determine whether

health care workers have adequate knowledge or not like the other variables. The grading table was designed by the researchers as there was no standard scoring table available in the literature. Descriptive statistics was used to calculate percentages for each of the responses given. (Table 1 & 2) Tools were adopted from related previous researches in line with the national protocol for the management of severe acute malnutrition in Ethiopia (FMOH, 2013). Each questionnaire was checked for completeness, missed values and unlikely responses and then manually cleaned up on such indications. Data was entered in Microsoft excel software, and analysis was performed using statistical package for social sciences (SPSS) version 20. Data was collected by trained nurses. Ethical clearance was obtained from Hawassa University Institutional Review Board. Study participants were explained the content and nature of the study. Verbal consent was obtained from all subjects who volunteered to participate and confidentiality is assured by analyzing the data in aggregate. RESULT Socio-demographic characteristics of health care workers The total number of participants was 365 and the response rate was 355 (98.3%). Participants were taken from all health institutions under Hawassa city administration health office. Among 355 health professionals who completed the questionnaire the majority of the participants 232 (65.4%) were female and 207(58.9%) were within age range of 20-30 years. Professionally the respondents were 285 (80.3 %) nurses

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Table 3. Socio-demographic characteristics of health care workers at selected hospitals and health centers at Hawassa town, April 2014




No 355

% 100

Adare hospital Garahiketa H/C Alamura H/C Chefe kote jabesa H/C Chefeasine H/C Tilte H/C Gamato Galle H/C Millenium H/C Tulla H/C Adare--Dato H/C

116 36 24 30 27 26 30 35 17 14

32.2 9.9 6.7 8.3 7.3 7.3 8.3 9.7 4.8 3.9

20-30 years 31-40 years 41-50 years

207 139 9

58.3 39.2 2.5

Male Female

123 232

34.6 65.4

Diploma level nurses University first degree

230 125

64.8 35.2

Physician Health officer

17 53

4.8 14.9







Divorced Widowed

30 6

8.5 1.7




< 5 years 5-10 years >10 years

264 87 4

74.4 24.5 1.1







Yes No

42 313

11.8 88.2




Educational level


Marital status

Working experience

Trained previously

Trained within the last one year


53 (14.9 %), health officers and 17 (4.8%) medical doctors. (Table 3) Health care workers knowledge towards malnutrition Nearly 82% of the respondent‟s uses malnutrition chart booklet to classify malnutrition to the standard and 41.7 % check anemia for every child; all sick children should be assessed for anaemia and acute malnutrition since the child's family may not notice the problem. Similarly 59% of health care workers asses and grade edema appropriately and 43% of study participants asses the nutritional status of children using WFL, Z score and NCHS percent median. Of the total respondents 49.3%, counsel the mother on child feeding and/or nutritional issues during each contact and only 35.5% know the appropriate method to check anemia in children. Totally it is revealed that only 55.5% of study participants have adequate knowledge. (Table 4) Distribution of health care workers attitude towards malnutrition Nearly 86% of the study participants believe on greeting the client or the care taker during the clinic visit. Sixty five percent of the respondents strongly believe that every child should be checked for malnutrition and anemia during each clinic visit and 59% of them believe that malnutrition is a priority problem of the community and can be prevented by effective counseling on optimal child feeding practice. In average, below three quarters of the respondent (65%) had favorable attitude towards assessment and management of childhood malnutrition. (Table 5) Practical aspect of health care workers towards malnutrition Only 39.2% of the respondents check anemia by palmar pallor and 69% asses and grade edema appropriately. Fourty three percent of the respondents can determine wasting by Weight for Length or Weight for Height (WFL/WFH), Z-score or percent of median. Three quarter (76%) of the respondents measure the height and weight of the child according to the standard and 80.6% of the participant health care workers supplement vitamin A for all children starting 6 months and more within six months interval. The same to that of the result of knowledge attributes not more than 55.5% of participants have good skill on malnutrition. (Table 6) Additionally there is no nutritionist assigned in the health centers and it is not observed a health education session on nutritional issues during data collection period.

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DISCUSSION The result of this study showed that the majority of health professionals had poor knowledge about case detection and appropriate management of malnutrition in children. The possible reason for this might be that only a few health care workers „have been trained on malnutrition. It is also revealed that the training need of the respondents on malnutrition was high and this result is consistent with other studies conducted in Kenya, Guatimala and korea (Yuna T, 2014; H. Kim et al., 2009; Antoinette Fet al.,2011; Kobe JA, 2006). In contrast to our study, no published studies were identified regarding the nutritional knowledge of health care workers in the provision of nutritional care for children and the application of their theoretical knowledge in to clinical practice. On the average 65%, of respondents had favorable attitude towards assessment and management of malnutrition, which is also evident in other study (H. Kim et al., 2009a). The opinion that nutrition is of lower priority than other health care practices among health care workers is supported by other studies (Kobe JA, 2006a;Mawe m,2006). Additionally the majority of respondents did not think that checking and dealing nutritional issues with every contact of the child is important and difficult to make practical in a daily health care activity; nearly 55% of respondents don‟t believe that nutritional screening of children as routine health care activity, therefore it can be concluded that significant number of children who are at risk of malnutrition remain unidentified. On the other hand other studies identified that lack of interest to be a factor in health care workers attitudes towards nutritional screening because they did not perceive nutrition as important; they lacked interest in the area, and perceived it to be less relevant to other tasks (Mowe M, 2008). Other study claims that Doctors‟ poor knowledge, nurses‟ inattentiveness and insufficient interaction with patient care were constraints to optimal malnutrition management. The same study suggests the underlying factors were inadequate undergraduate training, understaffing, high doctor turnover and low morale of health professionals (Fletcher, 2011). In our study the majority of respondents show a high desire to take training on nutritional issues and to receive nutritional information; which is also evident in other study (H. Kim et al., 2009). Indeed, the finding of our study conveys that health care workers practice on assessment and appropriate management of malnutrition in children was poor, and that the standards recommended by the national nutritional assessment guideline were not fully implemented. Similar finding was also reported by other study that health workers did not perform the nutritional assessment appropriately in practice (Adeomi A, 2011). The majority, 62% of the respondents skips to check

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Table 4. Distributions of health care workers knowledge towards assessment and management of malnutrition in children, Hawassa, 2015




Does the health care worker need to explain to the mother before every procedure? Does the health care worker use IMNCI chart booklet to classify malnutrition appropriately. Does the health care worker check Anemia on every child? Wasting is assessed by Mid Upper Circumference (MUAC) in those aged 5 to 59 months If edema of both feet and below the ankle it is described as moderate? Standing height is measured for children older than 2 years or 85 cm or more. Children whose WFL/H is ≥ -2 Z score or ≥80% of the NCHS median are considered MAM. A dermatosis with flaking skin, raw skin, fissures (openings in the skin) is severe dermatosis. A child with SAM and +++ edema should be tested for appetite. How often do you do you counsel the mother/care taker on child feeding and r nutritional issues? An appropriate method to check anemia in children is: Edema of both feet plus lower legs (below knees) and lower arms(below the elbow) is A child who have edema of both feet should get a dose of Vitamin A before referral

2 3 4 5 6 7 8 9 10 11 12 13

anemia on every child and out of those who check anemia; above 60% of respondents didn‟t check it appropriately. Only 40.8% & 43.4% grade dermatosis appropriately and determine wasting with Weight for Length or Weight for Height (WFL/WFH) Z-score or percent of median respectively; similar finding is revealed by other studies (Kobe JA, 2006b, Fletcher, 2011). Factors that were significantly associated with respondents skill in the study area might be suggested as inadequate nutrition training in undergraduate courses or lack of adequate training on nutrition. Other study reason out the poor practical performance of health professionals as nutrition education in the medical curricula has been haphazard, ambivalent and far from adequate (MOPH, 2012). A systematic review done to examine the effectiveness of in-service nutrition training on health workers‟ nutrition knowledge and skill, determine that inservice nutrition training of health workers improves their nutrition knowledge and undernutrition management skills(Bruno et al., 2013) CONCLUSION Our finding suggests that health care workers have

Answered correctly

Answered incorrectly

No 294

% 82.8

No 61

% 17.2





148 211

41.7 59.4

207 143

58.3 40.3

















136 175

38.3 49.3

219 180

61.7 50.3

126 164

35.5 46.2

229 191

64.5 53.8





inadequate knowledge on assessment and management of malnutrition in children and they use nutritional assessment criteria poorly in clinical settings. This can show as health care workers overlooked to assess the nutritional status of a child; hence the nutritional problems of the child in this set up cannot be detected and managed as early as possible. This study provides a clue for revising nutrition education in the health sciences curricula and developing on job training program for health care workers on assessment and proper management of children to the standard. Hence it is important to assess the primary health care workers knowledge, attitude and practice to help them handle such cases. The result of this study suggested that the majority of respondents had relatively favorable attitude but poor knowledge and practice towards assessment and management of childhood malnutrition. Based on the above fact it can be concluded that much should be done to assist primary health care workers perform their non replaceable duties based on the knowledge they grasp in various trainings, workshops, formal or informal education. To improve nutritional care in health institutions effective on job trainings and continuing education for all staff is recommended. Finally we recommend more research in this area, as the level of


Glob. J. Public Health Res.

Table 5. Distributions of health care workers attitude towards assessment and management of malnutrition in children, Hawassa, 2015




Does the health care worker greet the client and/or the care taker? Does the health care worker check malnutrition on every child? Does the health care worker do any procedure to asses‟ nutritional status? In your opinion is it necessary to check malnutrition for every child? Do you think that malnutrition is a priority problem and can be prevented by counseling on feeding practice? Do you think that checking and dealing nutritional issues with each child care takers difficult in your daily health care activity? Do you think that formula is as healthy for an infant as breast milk? Do you think that it is right to ban the use of bottles and teats? Are you voluntary/ interested to be trained on malnutrition prevention and management?

2 3 4 5 6 7 8 9

Answered correctly

Answered incorrectly

No 306

% 86.2

No 49

% 13.8

























150 279

42.3 78.6

205 76

57.7 21.4

Table 6. Distributions of health care workers practice towards assessment and management of malnutrition in children, Hawassa, 2015

Answered correctly

Answered incorrectly

No 135

% 38

No 220

% 62

Does the health care worker hold the child's palm open by grasping it gently from the side do not stretch the fingers backwards while checking anemia.






Does the health care worker check and grade edema appropriately






Does the health care worker check and grade dermatosis appropriately +few patches,++multiple patches,+++






Does the health care worker determine wasting is Weight For Length or Weight For Height Z-score or percent of median






Does the health care worker measure the child weight or height appropriately  Position the child lying on his back on the measuring Does health care give all children vitamin A starting 6 board,the supporting the worker head and placing it against the headboard. months and more the andcrown mebendazole 2 years and the more within six  Position of the head against headboard, months interval? compressing the hair.  Hold the head with two hands and tilt upwards until the eyes look straight up, and the line of sight is perpendicular to the measuring board.  Check that the child lies straight along the centre line of the measuring board and does 1not change position.












Does the health care worker assessed anemia and malnutrition for every child?



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