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    November 5, 2023 project kindy
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    Rural education in Malawi

    Table of Contents

    Lillian Ziyenda Katenga-Kaunda, Penjani Rhoda Kamudoni, Gerd Holmboe-Ottesen, Heidi E Fjeld, Ibrahimu Mdala, Zumin Shi, Per Ole Iversen

    Abstract

    In many sub-Saharan African countries, such as Malawi, antenatal care (ANC) services do not deliver sufficient nutrition awareness to improve adequate dietary intake in pregnancy. We therefore compared the effects of supplementary nutrition education and dietary counselling with routine ANC service on nutrition knowledge and dietary intakes among Malawian pregnant women.

    Methods

    We used data from a two-armed cluster randomised controlled trial (RCT) of which the intervention group received supplementary nutrition education, dietary counselling and routine ANC services whereas the controls received only routine ANC services. The RCT was conducted in 10 control and 10 intervention villages in Mangochi, Southern Malawi and included pregnant women between their 9th and 16th gestational weeks. We examined the changes in nutrition knowledge and dietary diversity from enrolment (baseline) to study end-point of the RCT (two weeks before expected delivery). We used three linear multilevel regression models with random effects at village level (cluster) to examine the associations between indicators of nutrition knowledge and diet consumption adjusted for selected explanatory variables.

    Results

    Among 257 pregnant women enrolled to the RCT, 195 (76%) were available for the current study. The supplementary nutrition education and counselling led to significant improvements in nutrition knowledge, dietary diversity and nutrition behaviour in the intervention group compared with controls. Most women from both study groups had a moderate consumption of diversified foods at study end-point. A significant positive association between nutrition knowledge and consumption of a diversified diet was only observed in the intervention group.

    Conclusions

    Nutrition knowledge and dietary diversity improved in both study groups, but higher in the intervention group. Increased nutrition knowledge was associated with improved dietary diversity only in the intervention women, who also improved their nutrition perceptions and behaviour. Antenatal nutrition education needs strengthening to improve dietary intakes in pregnancy in this low resource-setting.

    Introduction

    Malawi, like many other sub-Saharan African countries, faces challenges in delivering sufficient nutrition education to pregnant women during antenatal care (ANC) services. Adequate nutrition knowledge and dietary intake are essential for the health and well-being of pregnant women and their unborn babies [1]. However, studies have shown that pregnant women in Malawi have limited nutrition knowledge and often have poor dietary diversity [2]. ANC services present an opportunity to provide education and counselling on nutrition, but studies have shown that the quality and content of nutrition education during ANC visits in many low-resource settings, including Malawi, is inadequate [3].

    Poor nutrition during pregnancy can lead to adverse outcomes such as low birth weight, stunting, and micronutrient deficiencies [4]. Therefore, it is crucial to improve nutrition knowledge and dietary intakes among pregnant women in Malawi. Supplementary nutrition education and dietary counselling have been shown to be effective in improving nutrition knowledge and dietary practices in various settings [5, 6]. By comparing the effects of these interventions with routine ANC services, we can determine the most effective approach for improving nutrition knowledge and dietary intakes among pregnant women in rural Malawi.

    In this study, we conducted a two-armed cluster randomised controlled trial (RCT) to assess the impact of supplementary nutrition education and dietary counselling on nutrition knowledge and dietary diversity among pregnant women in Mangochi, Southern Malawi. We compared the outcomes of the intervention group, which received nutrition education and counselling in addition to routine ANC services, with the control group, which received only routine ANC services. The aim of this study was to determine whether the supplementary intervention led to improvements in nutrition knowledge and dietary diversity among pregnant women in a low-resource setting.

    Methods

    Study Design

    The study was a two-armed cluster randomised controlled trial conducted in Mangochi, Southern Malawi. The intervention group received supplementary nutrition education, dietary counselling, and routine ANC services, while the control group received only routine ANC services. The study included pregnant women between their 9th and 16th gestational weeks.

    Study Setting

    The study was conducted in 10 control and 10 intervention villages in Mangochi, which is located in the southern region of Malawi. Mangochi is a rural district with limited access to healthcare services, including ANC. The majority of the population relies on subsistence farming for their livelihood. Malnutrition, including undernutrition and micronutrient deficiencies, is a significant public health issue in the area.

    Participants

    A total of 257 pregnant women were enrolled in the RCT, with 195 (76%) available for the current study. The women were recruited from the 20 study villages in Mangochi. Inclusion criteria for the study included being in the 9th to 16th week of gestation and residing in one of the study villages. Women with multiple pregnancies, severe medical conditions, or complications that required immediate medical attention were excluded from the study.

    Procedures

    The study participants were randomly assigned to either the control or intervention group. Women in the intervention group received supplementary nutrition education and dietary counselling in addition to routine ANC services. The nutrition education sessions were conducted by trained health workers and covered topics such as the importance of a balanced diet, the benefits of consuming a variety of foods, and the role of specific nutrients during pregnancy.

    The dietary counselling sessions focused on practical aspects of improving dietary diversity, such as using locally available foods, preparing balanced meals, and addressing cultural practices that may limit food choices. The counselling sessions were individualized to address the specific needs and preferences of each participant.

    Data on nutrition knowledge and dietary diversity were collected at baseline and at the end-point of the RCT, which was two weeks before the expected delivery date. Nutrition knowledge was assessed using a validated questionnaire [7], and dietary diversity was measured using the Diet Diversity Score (DDS) [8, 9]. The DDS is a simple tool that assesses the consumption of different food groups over a specified period. A higher DDS indicates a greater variety of foods consumed.

    Data Analysis

    The data were analyzed using three linear multilevel regression models with random effects at the village level (cluster). The models examined the associations between indicators of nutrition knowledge and dietary consumption, adjusted for selected explanatory variables. The changes in nutrition knowledge and dietary diversity from baseline to the end-point of the RCT were also analyzed.

    Results

    Of the 257 pregnant women enrolled in the RCT, 195 (76%) were included in the analysis for the current study. The supplementary nutrition education and counselling led to significant improvements in nutrition knowledge, dietary diversity, and nutrition behavior in the intervention group compared to the control group. At the end-point of the RCT, most women in both study groups had a moderate consumption of diversified foods. However, a significant positive association between nutrition knowledge and consumption of a diversified diet was only observed in the intervention group.

    Discussion

    The results of this study indicate that supplementary nutrition education and dietary counselling can lead to improvements in nutrition knowledge and dietary diversity among pregnant women in rural Malawi. The intervention group, which received the additional education and counselling, showed greater improvements compared to the control group. This suggests that antenatal nutrition education needs to be strengthened in order to improve dietary intakes in pregnancy in this low-resource setting.

    Strengths and Limitations

    One of the strengths of this study is the use of a cluster randomised controlled trial design, which allowed for the comparison of the effects of the intervention with routine ANC services. The study also used validated tools to assess nutrition knowledge and dietary diversity. However, there are several limitations to consider. First, the study was conducted in a specific geographic area of Malawi, which may limit the generalizability of the findings to other regions. Second, the study relied on self-reported data, which may be subject to recall bias. Finally, the study did not assess the long-term effects of the intervention on maternal and child health outcomes.

    Implications for Practice

    The findings of this study highlight the importance of strengthening nutrition education and counselling during ANC visits in rural Malawi. By providing pregnant women with the knowledge and skills to improve their dietary diversity, healthcare providers can contribute to better maternal and child health outcomes. The study also emphasizes the need for culturally sensitive approaches that take into account local food practices and preferences.

    Conclusion

    In conclusion, this study demonstrates that supplementary nutrition education and dietary counselling can lead to improvements in nutrition knowledge and dietary diversity among pregnant women in rural Malawi. The intervention group, which received the additional education and counselling, showed greater improvements compared to the control group. These findings have important implications for antenatal care in low-resource settings, where nutrition education is often inadequate. Strengthening nutrition education during ANC visits can contribute to improved dietary intakes in pregnancy and better maternal and child health outcomes.

    Keywords: Diet; Education; Foods; Pregnancy.

    Conflict of Interest Statement

    The authors declare that they have no competing interests.

    © 2021. The Author(s).

    Figures

    Fig. 1 Map of Malawi showing Mangochi District (red), Lake Malawi blue), and Location of T.A. Nankumba (right side inset) with the study villages (intervention-green and control-white circles). Modified from source [21] Fig. 2 Flow chart showing the enrolment of participants into the two study groups Fig. 3 Association between nutrition knowledge and dietary diversity score. The values represent marginal means with 95% confidence intervals, and adjusted for age, education and household size Fig. 4 Mean changes in nutrition knowledge and diet diversity score within and between the two study groups. Values are mean (95% confidence intervals) changes in nutrition knowledge and DDS. Estimates to the right of the vertical line (dotted) in the forest plot represents increases in scores whereas estimates to the left represent decreases of the scores. The 95% confidence intervals cutting through the vertical line represents results that are not statistically significant. CI, confidence interval; DDS, diet diversity score

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    Rural education in Malawi
    Rural education in Malawi