This is a community based and research Education Program report For a project conducted in Nakasongola District after pre-evaluation studies and a community diagnosis to identify the Health burden of this society research proposal was implemented by Students of Makerere university attached to Nasongola Hospital

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MAKERERE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
PROJECT REPORT
INCREASING KNOWLEDGE ABOUT BALANCED DIET AND COMPLEMENTARY FEEDING AMONG MOTHERS AND CARE TAKERS OF CHILDREN AGED 6 MONTHS TO FIVE YEARS, IN NAKASONGOLA SUBCOUNTY.
JUNE -JULY, 2014
Implementers
REG. NO
Oriba Dan Langoya
11/U/1019
Mugalu Denis Edward
11/U/1007
Nabukalu Ssentongo Angela
11/U/1044
Baluku Andrew
11/U/15559/PS
Acam Joan
11/U/1079
Kalungi Jonathan
11/U/1021
Tumwesigire Samuel
11/U/47
Twesiime Enock
11/U/15556/PS
Kwenya Keneth
11/U/1030
Nasimu Kyakuwa
11/U/22529/PS
SITE SUPERVISOR Dr. Edith Nakku Joloba 0772682846
SITE TUTOR Dr. Muziki Simon Yossa 0775275455

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DECLARATION
We hereby declare the originality and authenticity of this report. The views expressed herein are mostly ours though other people’s works have been cited and referenced.

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Contents
DECLARATION...................................................................................................................................................................... 2
ACKNOWLEDGEMENT ..................................................................................................................................................................... 5
ACRONYMS ............................................................................................................................................................................. 6
Background ..................................................................................................................................................................................... 7
Problem statement .......................................................................................................................................................................... 7
Justification ..................................................................................................................................................................................... 7
General Objective ........................................................................................................................................................................... 7
INTRODUCTION ..................................................................................................................................................................... 8
Background ...................................................................................................................................................................................... 8
Problem statement .......................................................................................................................................................................... 11
Justification .................................................................................................................................................................................... 12
OBJECTIVES .......................................................................................................................................................................... 12
General Objective ........................................................................................................................................................................... 12
Specific objectives .......................................................................................................................................................................... 12
METHODS .............................................................................................................................................................................. 13
Project area: .................................................................................................................................................................................... 13
Target population: .......................................................................................................................................................................... 13
Sample size; .................................................................................................................................................................................... 13
Ethical considerations ..................................................................................................................................................................... 13
Community Entry ........................................................................................................................................................................... 13
Project duration .............................................................................................................................................................................. 13
Quality control ................................................................................................................................................................................ 13
Activities .................................................................................................................................................................................. 14
Planning .......................................................................................................................................................................................... 14
Resource mobilization: ................................................................................................................................................................... 14
Ensuring standard operating procedure: ......................................................................................................................................... 14
Testing tools for quality assurance: ................................................................................................................................................ 14
Meeting the Local Leaders ............................................................................................................................................................. 14
Mobilization of mothers and care takers to attend gatherings ........................................................................................................ 14
Health education sessions ............................................................................................................................................................... 14
Demonstration sessions .................................................................................................................................................................. 15
The Message ............................................................................................................................................................................ 16

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EKITOOBEERO .......................................................................................................................................................................... 16
Definition ......................................................................................................................................................................... 16
How is ekitoobero prepared ............................................................................................................................................ 17
How is ekitoobero served? ............................................................................................................................................................. 17
How should the baby be fed and how many times? ...................................................................................................................... 17
How is ekitoobero preserved? ....................................................................................................................................................... 18
Benefits of ekitoobero .................................................................................................................................................................... 18
RESULTS (PRE-INTERVENTONAL) .................................................................................................................................. 18
Description of the study population ............................................................................................................................................... 18
Knowledge of mothers and care takers about a balanced diet before the intervention .................................................................. 19
Knowledge of dangers of providing an unbalanced diet to the children ........................................................................................ 21
POST INTERVENTIONAL RESULTS ........................................................................................................................................ 21
Knowledge of mothers and care takers on complementary feeding after the intervention ............................................................ 22
DISCUSSION OF RESULTS .................................................................................................................................................. 25
Conclusion. .............................................................................................................................................................................. 28
ANNEXES ............................................................................................................................................................................... 28
REFERENCES ........................................................................................................................................................................ 31

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ACKNOWLEDGEMENT
We are thankful to the Almighty for the wisdom, courage and determination he has granted us throughout our stay in Nakasongola and as we accomplished this project.
We express our profound gratitude to Dr. Edith Nakku Joloba our Site Supervisor for all the guidance offered right from the time of the proposal to the implementation of the project.
Our profound thanks are due to Dr. Simon Muziki Yossa the In charge and Site Tutor for Nakasongola Health Centre IV and Mr. Kirya Ronald, Health sub District (HSD) for the guidance, reviews of our proposal and encouragement given to us in bringing out this report.
We are thankful to Sr. Jane Nansubuga, Sr. Miriam and all the Staffs of Maternity for their Keen interest in these Project, teaching and guiding us during our stay at the facility. May God bless you.
Special thanks goes to Miss Nakayenga Esther the head of the nutrition department at the health center, and Mr. Kiwanuka Denis, the health educator and Head of UNEPI Nakasongola HC IV
We are indebted to the District Health Officers, local leaders in Nakasongola Sub County, LC I Chairpersons and all the VHTs of Kalubanga, Matuugo and Buruuli for their hospitality and assistance in our community work and implementation programme. May God bless you abundantly.
We are grateful to our esteemed role models, mentors, and Lecturers especially those from Child Health Development Center, Makerere University College of Health Sciences for enabling and inspiring us.
We are especially grateful to Dr. Dhabangi Aggrey, Department of Child Health Centre Makerere University and Mr. Hussein Uriah, Department of Pharmacy Makerere University the thorough lectures, guidance and immense support right from proposal writing and ideas.
Lastly special thanks to all the group members for all the great work done. Bravo and may God bless you all.

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ACRONYMS
FM…………………………………………………………..Frequency Modulation
IMR……………………………………………………….…Infant Mortality Rate
IYCF…………………………………………...…Infant and Young Child Feeding
LC 1…………………………………………………………….…..Local Council 1
MDG……………………………………….…….Millennium Development Goals
NCHS………………………………………....National Center for Health Sciences
RUTF……………………………………………...Ready to Use Therapeutic Food
SSA…………………………………………………………….Sub Saharan Africa
UCG…………………………………………………..Uganda Clinical Guidelines
UDHS………………………………...…Uganda Demographic and Health Survey
UNICEF……………………United Nations Initiative and Child’s Education Fund

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ABSTRACT
Background
Meeting the Nutrition requirements of children aged 6months to five years is a major global challenge. Malnutrition hinders a country’s human, social, and economic development. Malnutrition is a major global health problem, contributing to increased morbidity, mortality, impaired mental development. Malnutrition hinders a country’s human, social, and economic development Results from previous community diagnosis of Nakasongola Sub County depicts that most families do not have a balanced diet in their nutrition
Problem statement
The people of Nakasongola have good food security with big gardens with plenty of caloric food like cassava and sweet potatoes. However, fewer families included vegetables and animal products. This shows the unbalanced diet, which puts the infants and those aged 6 months to 5 years at a risk of malnutrition.
Justification
Malnutrition impairs immune function, and malnourished children are prone to frequent infections that are more severe and longer-lasting than those in well-nourished children and may lead to a spiral of ever- worsening nutritional status, thus carrying out this project would provide a solution to this problem.
General Objective
To increase the knowledge of a balanced diet and complementary feeding to mothers and caretakers of children 6months to under five years Buruuli, Matuugo, Kalubanga villages in Nakasongola sub county.
Methodology
The project targeted mothers and caretakers of children aged 6months to 5 years in the villages of Kalubanga, Matuugo, and Buruuli. Pre and post intervention study designs. During pre-intervention, knowledge levels were assessed, health education and demonstrations were carried out. During post intervention, evaluation of the project was done using questionnaires, checklists and interviews. Data analysis and interpretation was then done.
Summary of Results
Out of 261 participants assessed before intervention, 14.5% could define a balanced diet and knew the components, 16.4%could mention atleast two importance of a balanced diet. After intervention, however, out of 84 participants evaluated, 55.1% knew all the components of a balanced diet and 83.4% could mention atleast two importance of a abalanced diet. Majority of the participants were peasants 217(83%), 31 (12%) had formal employment and 13 (5%) were small scale business owners (charcoal burning, shopkeepers, bar attendants etc.). Most of the participants 235 (90%) were Christians, 18(6.9%) were Moslems and 8 (3.1%) followed different religions such as born again, Jehovah. With regard to education, only 13 (5%) of the participants had gone up to secondary school and beyond, 188 (72%) were primary school dropouts and 60 (23%) were not educated at all. There was positive attitude towards the project as depicted by key informant interviews.

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INTRODUCTION
This project was carried out under the COBERS program of Makerere University College of Health Sciences. COBERS stands for Community Based Education and Research Services, a program under whom the students are sent out to the community by the college. There, they are expected to identify with the lay man. They should familiarize themselves with the way of life out there, identify the different community health problems by way of a community diagnosis and then come up with feasible and sustainable solutions to these problems.
A community diagnosis was done in Nakasongola sub county, Nakasongola District by the implementers of this project in April 2013 and a number of problems were identified, including an unbalanced diet for the infants. This problem is thus, the center of focus in this proposal.
Background
Meeting the Nutrition requirements of children aged 6months to five years has become a major global challenge and as such an estimate of 55 million pre- school children globally are malnourished. [1]
Malnutrition is a major global health problem, contributing to increased morbidity, mortality, impaired mental development. Causes of malnutrition include poor feeding practices, inadequate breast-feeding, early and late weaning, inadequate nutritional knowledge, diseases and cultural practices. Intake of nutrients that are inadequate in the habitual diet can be increased through use of Plumpy nuts, taking BP-5 biscuits (high energy), Ready to Use Therapeutic food (RUTF), Use soya milk. [2]
All children with moderate wasting, or with moderate or severe stunting, have in common a higher risk of dying and the need for special nutritional support. In contrast to children suffering from life-threatening severe acute malnutrition, there is no need to feed these children with highly fortified therapeutic foods designed to replace the family diet. Their dietary management should be based on improving the existing diets by nutritional counseling and, if needed, by the provision of adapted food supplements providing nutrients that cannot be easily provided by local foods. Children with growth faltering would also benefit from the same approach. [3]
Although poor child nutrition status is a pervasive global problem, it is mainly concentrated in a few developing countries. According to the United Nations Children’s Fund (UNICEF), 24 developing countries account for over 80 percent of the world’s 195 million children faced with stunting. Out of the 24 countries, at least 11 are from Sub Saharan Africa (SSA). Furthermore, countries in SSA have made the least progress in reducing stunting rates from 38% to 34% between 1990 and 2008 compared to a reduction of 40% to 29% for all developing countries. . Uganda is among the developing countries with the largest population of stunted children. An estimated 2.4 million children aged less than 5 years in Uganda are stunted and this place the country at the rank of 14th based on the ranking of countries with large populations of nutritionally challenged children [4]. Malnutrition is widespread in Uganda, but generally declining. The proportion of children aged below 5 years classified as stunted declined from 38% in 2006 to 33 % by 2011.Overall, the figure shows that Uganda has registered mixed progress regarding child nutritional health indicators. However, the trends suggest that Uganda might not be able to achieve 50 percent reduction in these indicators

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by 2015. Despite the commendable progress in reducing child stunting rates, the progress is relatively much slower than that recorded for the decline in income poverty. [4]
In 2010, the nutrition status of children under five in Uganda was estimated to be 38% stunted, 16% acutely malnourished and 19% undernourished[6], and by 2011 the statistics stand at 33% for stunting,5% for wasting ,14% for underweight, vitamin A deficiency at 38%. [5]
One out of every three young children in Uganda are short for their age, according to the 2011 Uganda Demographic and Health Survey (UDHS); and the incidence of poor nutritional status is highest in the relatively better off sub region of South Western Uganda[4]
The current levels of malnutrition hinder Uganda’s human, social, and economic development. Although the country has made tremendous progress in economic growth and poverty reduction over the past 20 years, its progress in reducing malnutrition remains very slow. [6]
Different policy guidelines on Infant and Young Child Feeding (IYCF) have been structured to strengthen nutrition in under-fives. Efforts have been directed to promotion, protection and support of optimal IYCF spear headed by the ministry of health in collaboration with its stake holders. Much progress has been achieved especially in promotion of exclusive breast feeding through policy making, health education and campaigns. Despite these impressive efforts, IYCF practices are not yet optimal.
The Uganda Demographic Health Survey (2006) shows that;
Timely complementary feeding from 6-9months is 80% but of these 72% of children 6-23months receive inadequate complementary feeds with foods lacking at least 2 food groups especially vegetables and proteins but excessive in calories [7].
This is in line with the community diagnosis report of Nakasongola Sub County (2013) where amongst all families sampled had high calorific diet with 81% root tubers but greatly lacking vitamins and proteins. Most of the meals were served with root tubers included in 81% of sampled families; others were included maize and its products (57.1%).
These results depict that most of the families don’t have a balanced diet in their nutrition. Their meals are majorly deficient in proteins as shown by the few animal products consumed by a few families (31%). They are also deficient in vitamins indicated by the little amounts of vegetables in their meal consumed by the fewest families (10%) [8].
Major challenges in their feeding lies in a spectrum that has ignorance about essence of balanced diet and behavioral attitudes seen in the conservative nature of the locals in a way of commercializing their garden produce especially vegetables and protein-rich foods such as fish. As a result of these mal behavioral practices;
Malnutrition is prevalent with stunting rates at 38%,wasting rates at 6% and rate of underweight children at 16%
Infant mortality rate(IMR) stands at 76 deaths per 1000 live births, while the

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Under five mortality rate is currently 137 deaths per 1000 live births [7].
This conservative behavior of selling off food unmasks the ignorance of the importance of well-balanced diet in this vulnerable group. It should be noted that the greatest proportion of their family members are under five (54%) and this age group report cases with increased morbidity rate [8]. Improving the nutrition of these infants can help strengthen their immunity and in turn decrease the morbidity rate.
The habit of selling off such nutritious foods instead of consuming it at home therefore puts people, especially the infants, at a risk of malnutrition and its effects. Great emphasis has been put on changing the practices so as to address these nutrition problems as an intervention.
However the mothers and other cares takers have not been sensitized on the values of the food that they have in their homesteads. They seem not to know which foods are the glow, the go and the grow foods. They simply feed the children so that they are not hungry, not with the purpose of attaining a balanced diet. [8]
Nutrition Day at OPD Nakasongola Health Center IV
Mothers therefore need to be educated about complementary feeding. This is where the child is breast feeding but along with breast milk, other semi solid foods are given. It is started after six months of exclusive breast feeding. Breast milk contains almost all food values required by an infant, however, after six months, the quantities in the breast milk are no longer adequate and hence an energy gap is created. This gap can be filled with food values that are found in the semi-solid foods that are introduced at this point so as to prevent malnutrition in the under-fives. [9].

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Complementary food can be prepared from locally available cheap and affordable foodstuffs with high nutrient value. The foods should be representative of the grow, go and glow foods in appropriate quantities. The Glow foods have two categories i.e. plant products like beans, peas and ground nuts and animal products like milk, eggs, mukene, nkejje, ants and grasshoppers. The Go foods are also divided into two categories, the fresh/wet like matooke, cassava, yams, potatoes and the dry like millet flour, sorghum flour, maize flour ,rice and pumpkin. Glow foods as well are of two categories that is fruits (bananas, oranges, passion fruits, and water Mellon) and vegetables (young pumpkin, tomatoes, avocado, and nakati).
Nutrition health education at Nakasongola HC IV nutrition day done by the group members, Stake holders as an intervention to ensure balanced diet and good knowledge on Complementary feedings
Problem statement
The people of Nakasongola have a good food security. They have big gardens with plenty of food in them. However the food is mainly root tubers; cassava and sweet potatoes. This unbalanced diet puts their family members especially the infants who make up the biggest proportion of their families (54%), at a risk of malnutrition.
Malnutrition in under-fives is clinically severe especially in acute form as it accounts for the greatest contribution in the high infant mortality rates(IMR) in Uganda(76 deaths per 1000 live births) and under- fives mortality shooting up to 134 deaths per 1000 live births [6] in concert with respiratory and diarrheal infections. In chronic form, however it is seen to impact stuntedness (33% of the under-fives in Uganda [4], wasting and poor psychosocial development.
Ignorance, attitudes and conservative nature of the Nakasongola sub county citizens about the essence of a well-balanced diet for their children under five have certainly played a pivotal role in establishing this unbalanced nature of the diet in this age group. The food is instead grown for sale since most of them are low income earners. Being near Lake Kyoga, they even have access to the proteins from the fish but they sell it off instead so as to cope with the ever increasing standards of living. Also the foods commonly grown are the root tubers. This puts the population, especially the infants at a risk of malnutrition due to unbalanced diet [8].

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Despite the interventions that have been in place to promote good nutrition and discourage people from selling off their food, the practice still goes on especially due to the ever increasing costs of living. This is probably because the people don’t know the values of the nutrients in the food they are selling off. They lack the knowledge about the importance of a balanced diet and therefore need to be sensitized.
Justification
In Nakasongola Sub County, most families feed mainly on high calorific diet with 81% carbohydrates expressed in root tubers with less than 10% vegetables and proteins in the diet. This presents an unbalanced diet for children between 6 months and 5 years of age and puts them at a risk of malnutrition, yet under-fives in this region make up the biggest proportion (54%) of their householders.
The health problems in Nakasongola include malaria, poor diet, upper respiratory tract infections and diarrheal diseases as observed in the community diagnosis in 2013. Improved nutrition increases the level of immunity causing a reduction in occurrence of these health conditions. This is also in line with the Millennium Development Goal (M.D.G) number.4 that aims at addressing the nutrition situation causing a reduction in child mortality rates especially of the under-fives.
Nationally, the malnutrition challenge is acknowledged and different health policies are made to deal with it. The policy guideline 2 for integrated infant and young child feeding(IYCF) by MOH stipulates that parents should be counseled and supported to introduce adequate, safe and appropriately give complementary food at 6 months of the infants’ age while they continue breastfeeding for up to 2 years or beyond. [8]
This calls for more efforts in increasing knowledge about the nutrients of the different foods and on how to balance them appropriately.
OBJECTIVES
General Objective
To increase the knowledge of a balanced diet and complementary feeding to mothers and caretakers of children 6months to under five years Buruuli, Matuugo, Kalubanga villages in Nakasongola sub county.
Specific objectives
 To increase the knowledge of mothers and care takers about the different food groups and how they can be combined to make a balanced diet.
 To increase the knowledge of mothers and care takers about the importance of complementary feeding, preparation, frequency, amount and types of feeds so as to maintain a good nutrition status for their children.
 To sensitize people about the dangers of an unbalanced diet.
 To improve the skill of mothers and care takers on how the locally available food is prepared and, served in order to maintain its nutrition content and value, with their full participation and involvement.
 To assess post interventional knowledge and practice.

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METHODS
Project area:
The project was carried out in Nakasongola sub county, Nakasongola County, Nakasongola district. The district covers an area of 3509 sq.km. It is occupied by swamps (wetlands) and part of the Lake Kyoga (Zengeba). The project implementation was carried out in 3 of the villages: Kalubanga, Matuugo, and Buruuli, found in Nakasongola Parish, Nakasongola Sub County
Target population:
A total of 261 mothers and care takers of children 6 months to 5years were included in the project. Out of the 261 participants, 122 were from Buruuli, 87 from Kalubanga and 52 from Matuugo. The female participants were 240 (92%) while the males were 21(8%). Most of the occupants carry out low income generating activities like peasant farming whereby they rear cattle and grow food especially root tubers, and selling food items in their local market place
Sample size;
261 persons from the three Villages of Kalubanga, Matuugo and Buruuli participated in the pre-interventional study inclusive of 21 men who also participated in the study
Ethical considerations
Approval was sought from the District Health Officer, local leadership i.e. the LC 1 Councilors of Kalubanga, Matuugo and Buruuli, College of Health Sciences and also our site tutor Dr. Muziki Simon Yossa and Supervisor Dr. Edith Nakku Joloba
We also sought consent from the mothers who participated in the implementation exercise and the VHTs of Kalubanga, Matuugo and Buruuli
Community Entry
The implementation team introduced themselves to the community leaders including the Local council chairpersons of Matuugo, Kalubanga and Buruuli villages and requested them for their permission to carry out our project in their area.
Project duration
The project lasted for 5 weeks. The first week was for preparation at campus, second and third weeks were for implementation in the community and the fourth and fifth week for evaluation and report writing.
Quality control
The implementers have met a nutritionist, Dr. Hanifa Namusoke at Mwanamugimu Nutritional unit for a teaching about the complementary feeding. They have also had a session with her at Mwanamugimu Nutrition Unit for technical training on how to prepare and serve a balanced diet to children of complementary feeding age during the first week and with Dr. Edith Knack Joloba our site supervisor.

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Activities
Planning
Proposal review: We met as a group and discussed the project objectives and how best we would implement them. We came up with an implementation plan that best fit our limited resource capacity.
Resource mobilization:
The necessary items needed for the implementation were identified and obtained. These included; National counseling cards for health workers, Training guidelines from the ministry of health of the republic of Uganda for the sensitization sessions. Locally available foods like cassava, matooke, sweet potatoes, groundnuts, beans and greens Cooking and serving utensils like sauce pans, spoons, forks, plates, etc. for the demonstration sessions. Manila paper, markers and videos for demonstration, Modem and laptop, pens, a handbooks and digital camera, Evaluation questionnaire, key informant interview guides for the evaluation sessions.
Ensuring standard operating procedure:
Before commencement of project activities, we had in-depth discussion about a balanced diet and complementary feeding in children 6 months to under 5years to ensure that all group members have a common message that was conveyed to target population.
Testing tools for quality assurance:
The questionnaires were tested by first giving them to nurses and midwifes Feedback was obtained from them and the questionnaires adjusted accordingly.
Meeting the Local Leaders
We met LC 1 chairman, VHTs of each village i.e. Buruuli, Kalubanga and Matuugo and obtained permission to implement the project, obtained recommendation from the DHO after presentation of the project proposal
Mobilization of mothers and care takers to attend gatherings
Mothers and care takers of the target group infants in the 3 villages of Matuugo, Kalubanga and Buruuli were mobilized for community meetings, by the VHTs who had agreed to work with us as well as the LC1s. Mothers were also informed about the gatherings when they brought their children for immunization and at the maternity ward when they came to attend maternity clinic
Health education sessions
Sessions were held for mothers and caretakers of children 6 months to 5 years, at the health Centre (Buruuli members), Kalubanga and Matuugo villages. They were conducted in Luganda since most of the participants as well as implementers could speak and understand the language. Each session lasted about one to two hours. During which the following was done;
We introduced our selves to the mothers and care takers of children 6 months to 5 years, where we had come from and the reasons we had gathered them that day.
The attending mothers and caretakers were counted and the number recorded. Records about their particulars such as address, contacts, were established and kept too.

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Evaluation of baseline knowledge about a balanced diet and its importance especially to under-fives among the mothers and care takers was done at the beginning of the sensitization sessions using in-depth interviews guided by pre-tested questionnaires with the help of all group mates who could translate the questions to Luganda.
We then told mothers about balanced diet, complementary feeding; what it is, its importance, when it should be started and not any time earlier or later, the foods that should be given to children during this time and emphasized the importance of balancing the foods during complementary feeding. A demonstration table containing all the different examples of foods in order of Grow, Go and Glow foods, plus iodized salt was laid and the nutritional values of the different foods was explained to the mothers. Emphasis was also put on quantity and frequency of feeding during complementary feeding.
Education of the mothers of the ten key messages for complementary feeding laid out by the ministry of health.
Occasional radio talk shows at Buruuli FM to teach the importance of a balanced diet to infants between 6 months and five years were not conducted as proposed. The people at the station had their program for the month laid out and couldn’t fix
Demonstration sessions
Demonstrations were done in collaboration with Sister Esther, the head of the nutrition department at the health center, and Mr. Kiwanuka Denis, the health educator.
On demonstration days, participants were gathered and demonstration tables were laid with foods in their different groups of go, glow and grow. Mothers were reminded of the different food values in each group and their importance in the body. We then showed the mothers and caretakers how to measure the different foods using their own palms so as to make the right quantities so as to prepare a balanced diet so as make a balanced diet. Participants were particularly taught to prepare “Ekitoobero”.
2 menus where made for each demonstration session (Rice, beans and minced meat plus nakati) and (matooke, g-nuts and smoked fish plus dodo)
Using 3 fingers a pinch of salt was added to the food while showing the mothers and amount of water to the level of the food was then added to the mixed food.
The mothers were also showed how to steam everything together in one large saucepan and food was put to steam for 3 hours using charcoal.
As the food was steaming we let the mothers give return demonstrations on how to measure the food in their palms and gave them time to tell us about what they had learnt from the discussion.
They also asked a few questions about malnutrition and how they could best prevent it with the local foods available and these were answered accordingly.

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After the food had cooked we then served and still showed the mothers how it’s served, by smashing all the contents together to make one consistent paste. And how they could best preserve the remaining food for the next meal as it’s prepared once a day.
Mothers were also taught how to actively feed their children (feed with the child) and to give food just enough for the baby to avoid over feeding.
We also discussed about complementary feeding and the food could be used to wean the babies as well because its babies’ food.
The Message
Key messages for complementary feeding from ministry of health
These were the key messages we used when we were counseling mothers and caretakers with older children.
Breastfeeding for two years of age or longer helps a child to develop and grow strong and healthy.
Starting other foods in addition to breast milk at 6 months helps a child to grow well.
Foods that are thick enough to stay on the spoon give more energy to the child.
Animal source foods are especially good for children to help them grow strong and lively.
Peas, beans lentils, nuts and seeds are good for children
Dark green leaves and yellow-colored fruits and vegetables help the child to have healthy eyes and fewer infections.
A growing child needs 2-4 meals a day plus 1-2 snacks if hungry: give a variety of foods.
A growing child needs increasing amounts of food.
A young child needs to learn to eat: encourage and give help with lots of patience (active feeding)
Encourage the child to drink and to eat during illness and provide extra food after illness to help the child recover quickly.
EKITOOBEERO
Definition
Ekitoobero is a triple mixture composed of two body building foods and one satisfying and energy giving food specifically prepared for children.
Who needs ekitoobero?
It’s a special food for children 6 months up to 2years because its baby’s food used for weaning and for complementary feeding. It’s also recommended for children above 2 years to help maintain their nutrition status as they are weaned off breast milk so as keep them well nourished.

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Ekitoobero is used in the management of malnutrition given to malnourished children after they have gone through phase 1 and phase 2 (P1 and P2) of management.
How is ekitoobero prepared?
 Organize the foods to be prepared including 2 body building food, one animal protein like smoked fish and one plant protein like pounded g-nuts, 1 energy giving food like matooke and one glow food like nakati. Put salt on the table and a cup of water.
 Wash the hands very clean before you touch the food.
 Prepare the clean saucepan with a tight seal
 Measure one palm of g-nut seeds and pound them ( these give an equivalent of 2 palms after pounding)
 Peel off the skin of the smoked fish and remove all the bones. Measure one palm of the smoked fish using the mothers palm and then soak the smoked fish in water.
 Mash the fish with your fingers and make sure all the bones have been removed. The mashed fish then total up to 2 palms
 Measure a palm of unpeeled matooke and then peel it, cut in small pieces and then put in the saucepan, in the same saucepan put the measured g-nuts and the fish.
 Using your first 3 fingers get a pinch of salt and add to the saucepan.
 Add water up to the level of the food and mix well seal with a tight cover.
 Then put the food in a large saucepan with the greens on top and put to steam for 2-3 hours depending on the heat source.
 30 minutes after the food has started steaming remove the greens and cover them well in a clean container.
 After 2-3 hours the food is ready to serve, get it off the fire and prepare to serve.
How is ekitoobero served?
 Get the food off the fire source
 With good clean hands get the saucepan of food out of the large steaming pan
 Open the food from a clean environment
 With a clean ladle mash the food and make it completely soft.
 Then serve it on a clean late for the baby
How should the baby be fed and how many times?
The form of feeding encouraged is active feeding where the mother and the child both feed from one plate. The mother should feed her baby as she also eats little and so this encourages the baby to feed as well.

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The baby feeds 8 times a day and therefore feeds every 8 hours especially those below 2 years. The baby has 2 meals of Ekitoobero in a day and the rest of the meals are made of porridge and milk. All this is done alongside the breast milk as the baby breast feeds on demand.
At 6.00 am the baby feeds on milk, at 9.00am its porridge, 12.00 noon the child eats Ekitoobero, 1.00pm a fruit, 3.00pm is porridge, 6.00pm is Ekitoobero and 9.00pm is milk then the baby will go to sleep. Any feeding done in the night can be replaced with milk or porridge alongside the breast milk.
How is ekitoobero preserved?
 The remaining food is covered in clean container and put in a clean place
 At 6.00pm when the child is supposed to feed again the food is warmed.
 Served for the baby and active feeding resumes again.
Benefits of ekitoobero
 To the baby
o It’s baby’s food
o It’s a highly nutritious food and good for the baby’s growth and development as it contains grow,go and glow foods in their right quantities for the baby.
o Promotes good mental development
 To the mother
o Cheap as it contains locally available foods.
o Easy to measure as the mother uses her palm
o Easy to prepare and serve as it steams for 2-3 hours and it’s prepared once a day.
o It’s also used in the management of malnutrition and helps to maintain the nutrition status of their children
RESULTS (PRE-INTERVENTONAL)
Description of the study population
The project was carried out in Nakasongola Sub County, where three villages were included into the project; Kalubanga, Matuugo and Buruuli. A total of 261 mothers and care takers of children 6 months to 5years were included in the project. Out of the 261 participants, 122 were from Buruuli, 87 from Kalubanga and 52 from Matuugo. The female participants were 240 (92%) while the males were 21(8%). Twenty one of the participants (8%) were aged 13-17, one hundred and fifty four of the participants (64%) were aged 18-25, fifty (21%) were aged 26-32, and thirty six (13.8%) were above 32 years.
Majority of the participants were peasants 217(83%), 31 (12%) had formal employment and 13 (5%) were small scale business owners (charcoal burning, shopkeepers, bar attendants etc.). Most of the participants

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235 (90%) were Christians, 18(6.9%) were Moslems and 8 (3.1%) followed different religions such as born again, Jehovah. With regard to education, only 13 (5%) of the participants had gone up to secondary school and beyond, 188 (72%) were primary school dropouts and 60 (23%) were not educated at all.
Table 1: Social demographic characteristics of 261 participants in the three villages
Variable
Frequency
Per cent Gender
Female
240
92 Male 21 8
Age
13-17 21 8.0
18-25
154
59 26-32 50 19.2
Above 32
36
13.8 Occupation
Peasant
217
83.1 Small scale business 13 5.0
Formal jobs
31
11.9 Religion
Christian
235
90.0 Moslem 18 6.9
Others
8
3.1 Education
Primary
188
72.0 Secondary 13 5.0
Never went to school
60
23.0
Knowledge of mothers and care takers about a balanced diet before the intervention
The levels of knowledge on a balanced diet were assessed basing on definition, components and the importance of a balanced diet. The following results were obtained.
Table 2: Knowledge of mothers and care takers about the a balanced diet
Village
Defined a balanced diet
Listed components of a balanced diet
Stated importance of a balanced diet (>2) Buruuli (n=122) 13 (10.7%) 15 (12.3%) 15 (12.3%)
Matuugo (n=52)
11 (21.2%)
9 (17.3%)
9 (17.3%)

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Kalubanga (n=87) 10 (11.5%) 12 (13.8%) 17 (19.5%)
Level of awareness
34 (13.0%)
36 (13.8%)
41 (15.7%)
Knowledge of mothers and care takers about the importance of complementary feeding, preparation, frequency, amount and types of feeds so as to maintain a good nutrition status for their children
All the participants were assessed about the knowledge on complementary feeding, where only 17/122 (13.9%) of participants from Buruuli, 19/87 (21.8%) from Kalubanga, and 19/52 (36.5%), from Matuugo knew the right age (at six months) to initiate complementary feeding.
When asked about the variety of foods that should be given to their children, 14/122(11.5%) from Buruuli, 10/87 (11.5%) from Kalubanga, and 7/52 (13.5%) from Matuugo, knew the variety of foods that should be given in complementary feeding.
About the knowledge of the frequency of complementary feeding, 10/122(8.2%) participants from Buruuli, 8/87(9.2%) participants from Kalubanga and 5/52 (9.6%) participants from Matuugo, knew the how frequently to give complementary feeds to their children.
Knowledge on the correct amount of food given to the children was also assessed and only 5/122(4.1%) of participants from Buruuli, 6/87(6.9%) participants from Kalubanga and, 8/52(15.4) participants from Matuugo, knew the correct amount of food for complementary feeding.
Furthermore, knowledge about the thickness of food for complementary feeding was assessed and 10/122 (8.2%) of participants from Buruuli, 11/87(12.6%) from Kalubanga, and 9/52(17.3%) participants from Matuugo, were knowledgeable about correct thickness and consistency of food to give their children in complementary feeding.
We also assessed whether participants used the right utensils for complementary feeding, and 90/122(73.8%) participants from Buruuli, 63/87(72.4%) from Kalubanga and, 43/52(81.1%) from Matuugo used the correct utensil (cup) for complementary feeding. Participants were asked whether they cleaned the utensils and 74/122(60.7%) of the participants from Buruuli, 52/87 (59.8%) participants from Kalubanga, and 35/52 (67.3%) participants from Matuugo, knew how to keep the utensils clean.
Table 3: Knowledge of mothers and care takers on complementary feeding before the intervention

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Village
Age to initiate food
Variety of food
Frequency of feeding
Amount of food
Thickness of food
Correct utensil
Cleanliness of feeding utensil Buruuli (n=122) 17 (13.9%) 14 (11.5%) 10 (8.2%) 5 (4.1%) 10 (8.2%) 90 (73.8%) 74(60.7%)
Matuugo (n=52)
19 (36.5%)
7 (13.5%)
5(9.6%)
8(15.4%)
9(17.3%)
43(81.1%)
35 (67.3%) Kalubanga (n=87) 19 (21.8%) 10 (11.5%) 8 (9.2%) 6 (6.9%) 11 (12.6%) 63 (72.4%) 52 (59.8%)
Level of awareness
55 (21.1%)
31 (11.9%)
23 (8.8%)
19 (7.3%)
30 (11.5%)
196 (75.1%)
161 (61.7%)
Knowledge of dangers of providing an unbalanced diet to the children
Mothers and care takers were assessed on the knowledge of the dangers of providing an unbalanced diet to their children, and 32/122 (26.2%), 27/87 (31%) and 23/52 (44.2%) participants from Buruuli, Kalubanga and Matuugo respectively could tell at least two dangers. Overall, 82/261 (31.4%) participants could state at least two dangers of an unbalanced diet to their children.
POST INTERVENTIONAL RESULTS
After the intervention, the mothers and care taker’s knowledge about a balanced diet improved as shown in the table below.
Table 4: Knowledge of mothers and care takers about the a balanced diet after the intervention
Village
Defined a balanced diet
Listed components of a balanced diet
Stated importance of a balanced diet (>2) Buruuli (n=40) 36 (90%) 33 (82.5%) 38 (95%)
Matuugo (n=17)
11 (64.7%)
4 (23.5%)
13 (74.5%) 17 (63%) 16(59.3%) 22 (81.5%)

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Kalubanga (n=27)
Level of awareness (n=84)
64 (76.2%)
53 (63.1%)
73 (86.9%) Increase in awareness (%) 63.2 49.3 71.2
Knowledge of mothers and care takers on complementary feeding after the intervention
After the intervention, mothers and care takers knowledge on complementary feeding improved, as shown in the table below.
Table 5: Knowledge of mothers and care takers on complementary feeding after the intervention
Village
Age to initiate food
Variety of food
Frequency of feeding
Amount of food
Thickness of food
Correct utensil
Cleanliness of feeding utensil Buruuli (n=40) 38 (95%) 33 (82.5%) 37 (92.5%) 35 (87.5%) 38 (95%) 40 (100%) 38 (95%)
Matuugo (n=17)
14 (82.4%)
4 (23.5%)
13(76.5%)
7(41.2%)
12(70.6%)
16( 94.1% )
15 (88.2%) Kalubanga (n=27) 22 (81.5%) 16 (59.3%) 22 (81.5%) 20 (74.2%) 24(88.9%) 25 (92.6% ) 26 (96.3%)
Level of awareness
74 (88.1%)
53 (63.1%)
72 (85.7%)
62 (73.8%)
74 (88.1%)
81 (96.4%)
79 (94.0%) Increase in awareness (%) 67 51.2 76.9 66.5 76.6 21.3 32.3

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Knowledge of mothers and care takers about the consequences of not having a balanced diet after the intervention
After the intervention, 66/84 (78.6%) of mothers and care takers could state at least two consequences of an unbalanced diet, with Buruuli 29/40 (72.5%), Kalubanga 24/27 (85.2%) and Matuugo 13/17 (76.5%). There was a 47.2% increase in the level of awareness of the dangers of providing an unbalanced diet to children after the intervention.
Figure 1: Knowledge of mothers and care takers about a balanced diet before and after the intervention
Figure 2: Knowledge of mothers and care takers on complementary feeding before and after the intervention
0
10
20
30
40
50
60
70
80
90
100
Before
After
Awareness %
Level of awareness on a balanced diet
Defined a balanced diet
Listed components of abalanced diet
Stated importance of abalanced diet (>2)

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Figure 3: Knowledge on the dangers associated with providing an unbalanced diet to children before and after the intervention
0
20
40
60
80
100
120
Age toinitiate food
Variety offood
Frequency offeeding
Amount offood
Thickness offood
Correctutensil
Cleanlinessof feedingutensil
Awareness %
Level of awareness of complementary feeding
Before
After
Before
After

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Demonstration sessions
82.3% of the respondents were considerably able to demonstrate how locally available food should be prepared served and preserved in order to maintain its nutritional content, as stipulated in our checklist. However, almost 100% of them could remember one thing or two from what was taught.
Key Informants Interviews
Responses
1. Most VHTs reported that the project was beneficial, they learnt a lot of things they didn’t know
2. VHTs had varying ideas on the impact of the project in the community
3. The VHTs reported that mothers learnt that some foods which they rarely provided to their children were highly nutritious. E.g. some mothers did not think that green vegetables were good for their children.
Mothers also reported an increase in knowledge on the quantities, frequency, thickness, variety, and hygiene while preparing their children’s food.
Mothers also realised that providing a balanced diet would help to reduce on the prevalence of common diseases e.g. diarrhoea, coughs and flu among their children.
4. VHTs who reported “NO” in question number 2 above related it to attitude of mothers who had children older than 5 years where such knowledge was not applied but their children grew well.
Also some mothers never attended the sensitisation programs, claiming that they stayed very far.
5. VHTs reported that mothers will be able to continue with the good practices of providing a balanced diet to their children
6. VHTs also reported that they will be able to continue with the sensitisation process even after we have left Nakasongola.
7. VHTs requested us to leave them with the integrated infant and young child feeding manual as a training tool which we provided.
8. A few VHTs reported that they may not be in position to continue with the sensitisation process due to too much work and long distances.
DISCUSSION OF RESULTS
The general percentage increase in the level of awareness about a balanced diet and complementary feeding among mothers and care takers of children aged 6 months to 5 years, as indicated by the previously shown results is absolutely multifactorial. Among the many factors, the following seemed to be quite significant in influencing the knowledge change noted.
 The extensive and intensive sensitization program carried out by the team, in which effective mobilization lead to a wide coverage of our target population.
 The effective mode of delivery of the messages that is, using illustrative charts, practical manual guides for Ekitoobero, and clear messages. This helped the participants not only acquire but also retain the information for continuous practice enabling positive results during evaluation.

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 Prompt nutritional facility programs conducted, particularly for mothers attending maternity services, also played a significant role in bolstering acquisition of knowledge.
 The community members’ good health knowledge seeking behavior, as exemplified by their good attendance of our campaigns for instance, enabled the noticeable increase in knowledge about a balanced diet and complementary feeding.
 Although majority of the participants were primary level graduates, this in itself provided a certain basis for conceptualization of our messages, since they were already quite familiar with concepts such as Energy giving foods, Body building food, a balanced diet and the like. However, this low level of formal education also explains the low knowledge pre- interventionally.
 The commonest age bracket of our respondents was 18-26 years. This, partly explains the low levels of nutritional knowledge since they’re young and haven’t attended as many nutritional talks at the facility as their older counterparts.
 The role played by the Village Health Teams, and their impact thereof goes without mention. Their mobilization and involvement in our sensitization campaigns offered the basis for acquisition of knowledge by the participants.
 The community co-operation and involvement throughout the project demonstrated their willingness to learn, hence making it, not only feasible to acquire knowledge, but also for us to effectively carry out planned activities and evaluation, since most of these activities where community based.
 The good leadership skills demonstrated by the Local Council chairpersons, such as influencing community members to take the opportunity to attend the nutritional sensitizations, enabled them to acquire knowledge wholeheartedly while enabling us to have the chance of executing our scheduled programs.
 Also, the availability of a variety of foods as shown by the good food security in the area, enabled continuous practice by the participants of the demonstrated nutritious food regimen, that is Ekitoobero.

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CONCEPTUAL FRAME WORK OF FACTOR AFECTING THE KNOWLEDGE ABOUT BALANCED DIET
Recommendations.
 To ensure continuity and further improvement however, the ongoing nutritional talks should be strengthened through giving detailed information at the facility by trained personnel and their schedules should be increased throughout the week.
 Integrated community outreaches should be carried out more often like twice a month with the support of local government and private parties.
Limitations
 Due to dry season with high temperatures and scarce water we couldn’t execute our objective of planting a demonstration gardens.
Knowledge about balanced diet
Education and Awareness
Food security and Availability
Policies
Leadership and Management
Culture
Demography ie Sex, Age, Residence Occupation, Religious affiliations

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 Other demonstration activities were not carried out due to lack of funds to acquire the necessary equipment like seeds and hoes for the demonstration gardens, fliers and calendars to serve as constant reminders, as well as projectors for demonstration video shows.
Conclusion.
Generally, there was an increment in the levels of knowledge amongst mothers and caretakers of children aged between 6 months and 5 years, in Nakasongola Sub County. This predicts the increased likelihood of reduced malnutrition rates and nutrition related morbidities among children of this age group and thus reduction on the child mortality rates in the region.
Amongst the three villages, Buruuli inhabitants seemed to have had the biggest improvement in their levels of awareness about the essence of a balanced diet, owing to their close proximity to the facility thus regular attendance of the nutritional sensitization talks and big turn ups at outfield demonstrations.
ANNEX
KEY INFORMANT INTERVIEW GUIDE
1. What do people say about the project?
2. Do you think the project has had an impact on the nutritional knowledge of mothers and care takers of children below 5 years?
Yes
No
3. If yes, what impact?
4. If No, why?
5. Do you think the mothers will continue with the good practice of providing a balanced diet to their children?
6. Do you think you will be able to continue with the sensitisation process even when we leave Nakasongola Health centre IV?
7. If yes, how do you intend to do it?
8. If no, what challenges will prevent you from doing it?
QUESTIONNAIRE ON KNOWLEDGE ABOUT THE BALANCED DIET AMONGST CARE TAKERS OF CHILDREN AGED 6MONTHS TO 5 YEARS.
PART 1; DEMOGRAPHICS
Sex; Male…..Female…..and Others….. (Tick where applicable)

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Age; 18-25yrs……..26-32yrs……above 32…… (Tick where applicable)
Occupation; peasants……Local business personnel……Others……… (Tick where applicable)
Education level; None……Primary…….Secondary……..Tertiary level……. (Tick where applicable)
Village…………………..
PART 2; BALANCED DIET
1. What do you understand by a balanced diet?
2. What are the components of a balanced diet?
Energy giving foods
Body building foods
Vitamins (health promoting foods)
All of the above
3. Name at least 2 importance of a balanced diet to your child
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
PART 3; COMPLEMENTARY FEEDING
4. At what age do you introduce food to your child alongside breastfeeding?
Before 6 months
At 6 months
Beyond 6 months
5. What types of foods to do you give alongside breastfeeding (variety)
Proteins….
Carbohydrates….
Lipids…….
Vitamins……

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All of the above……..
6. How often are these foods given alongside breastfeeding?
7. At what intervals are the foods given?
8. How much of the food is given?
a) How thick is the food that is given?
b) How do you give foods to your child?
c) How do you ensure that the utensils are kept clean?
PART 4;
Give at least 2 consequences of providing an unbalanced diet to your children
…………………………………………………………………
………………………………………………………………….
………………………………………………………………….
PART 5; CHECKLIST FOR DEMONSTRATION ON PREPARATION OF EKITOOBERO
Steps;
1. Foods that make a balanced diet;
o Carbohydrates
o Proteins
o Vitamins
2. Containers/equipment for preparations;
o Container
o Banana leaves
o Fire
3. Preparation;
o Peeling
o slicing
o if beans, removal of husk
o water
o salt
o steaming
4. Serving;
-Food should be smashed before serving

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-Clean dish
REFERENCES
1. World Health Organization. Technical note: Supplementary foods and management of Moderate Acute Malnutrition in infants and children 6-59months of age. 2012; Pages 2-3.
2. World Health Organization. Management of Severe Malnutrition, Save the Children, US. 1999
3. The United Nations University. Food and nutrition bulletin.2009 (supplement).
4. Sara Ssewanyana, Ibrahim Kasirye. Policy Brief-Addressing the Poor Nutrition of Uganda Children. July 2012; Issue No. 19.
5. Uganda Bureau of Statistics. Uganda Demographic and Health Survey 2011 Preliminary Report. Calverton, Maryland, USA. (March 2012) ;Pages 18-21
6. Ministry Of Health. Uganda Clinical Guidelines. 4th edition, 2010; Pages 28–32.
7. Ministry Of Health .Uganda Nutrition Action Plan: Scaling Up Multi-sectorial efforts to establish a strong nutrition foundation for Uganda Development. 2011; Pages 7-15.
8. Mugalu DE, Oriba DL, Nabukalu SA et al. Community diagnosis report of Nakasongola sub county. Makerere University College of health sciences 2013. ( not published)
9. Ministry of Health. Integrated Infant and Young Child Feeding Counseling.2009.
10. Ajojo M, Luyimbazi I et al. Using Ekitoobero to contribute to the improvement of the nutritional status of Children Under Five in Rwakabengo parish, Rukungiri district. Makerere University College of health sciences 2013. (not published).