General and background characteristics of the participants
Table 1 presents the general and background characteristics of the participants. Complete data was obtained from 300 participants out of an estimated sample size of 385; yielding a 78% response rate. As shown in Table 1, 73.3% (n=220) of the participants were females; 49.7% (n=149) had diploma certificate and 62% (n=186) were community health nurses. The participants mean (SD) age in years was 30.11 ± 8.50 and participants had been working for a mean (SD) duration of 61.30 ± 53.09 months.
Table 1: General and background characteristics (n=300)
Variables
|
Frequency
|
Percentage (%)
|
Gender
|
|
|
Male
|
80
|
26.7
|
Females
|
220
|
73.3
|
Level of education
|
|
|
Certificate
|
115
|
38.3
|
Diploma
|
149
|
49.7
|
Bachelor degree
|
33
|
11.0
|
Masters
|
3
|
1.0
|
Type of practice
|
|
|
Midwife
|
114
|
38.0
|
Community Health Nurse
|
186
|
62.0
|
Type of facility
|
|
|
Regional Hospital
|
66
|
22.0
|
District Hospital
|
61
|
20.3
|
Public Clinic
|
38
|
12.7
|
Private Hospital
|
64
|
21.3
|
CHPS Compound
|
70
|
23.3
|
Other
|
1
|
0.3
|
Satisfaction level and adequacy of nutrition education received during training in school
Almost all participants (n=287, 95.7%) received nutrition education during training in school in the form of lectures. Mean hours per week used for nutrition education during training was 3.31 ±1.66 hours. More than half of the participants were either unsatisfied or uncertain with: the amount of time allocated for nutrition education during training in school (77.5%); the integration of nutrition content into the curriculum (82.6%); and how nutrition course content was presented (77.4%). Participants had a mean (SD) satisfaction score of 10.01 (3.73). With a mean (SD) adequacy score of 3.31 (1.24), 61.4% (n = 184) of the participants said they felt adequately prepared from school to provide nutrition care during routine antenatal and postnatal care.
Participants’ nutrition-related knowledge, attitude towards nutrition care and self-reported nutrition care skills during routine antenatal and postnatal care
Participants had total mean (SD) nutrition-related knowledge of 57.46(8.12) %. Regarding the different areas; participants had a mean (SD) knowledge score of 72.48(12.47) % for maternal nutrition during pregnancy and 51.46 (9.21) % for infant and young child feeding practices. Over 80% of the participants knew that: balanced diet is important during pregnancy; energy requirements of pregnant women differ from non-pregnant women; the nutrient needs for iron and folic acid is higher during pregnancy; nutrient deficiencies and being underweight can impact negatively on pregnancy outcomes; obesity during pregnancy can increase one’s risk of several pregnancy complications. However, majority of the participants did not know: that iron is not a vitamin; the recommended daily intake of iron and folic acid for pregnant women; the recommended weight gain during pregnancy; that rich sources of iron and folic acid. Only 26% of the participants correctly answered that breastmilk only is adequate to meet the nutrient needs of infants aged less than 6 months; 47% said babies should be breastfed on demand; and 98% said babies younger 6 months could digest other foods. Less than 40% of the participants had knowledge on the benefits of exclusive breastfeeding to the baby and to the mother. Almost all participants knew the age of at which complementary breastfeeding should begin. Regarding foods that could added to enrich the diets of young children; 43% said animal sourced foods such as meat and eggs; 49% pulse and nuts, groundnut flours and other legumes; 30.7% vitamin A rich fruits and vegetables such as carrots; 90.7% green leafy vegetables; and 13% energy rich foods such as oil and butter. Regarding attitudes towards nutrition during pregnancy and lactation; participants had mean ± SD attitude score of 23.00 ± 4.56. Majority (81.7%, n=241) of the participants agreed that nutrition during pregnancy was very important; 72.4% said nutrition should be part of routine antenatal and postnatal care; and 63.9% believed that if mothers are counselled, they will adopt healthy dietary practices. However, 56.1% felt that midwives and nurses should also focus on nutrition support during routine antenatal and postnatal care. Also, 44.1% (n=130) of the participants agreed that dietitians rather than the nursing staff were solely responsible for nutritional support during routine antennal and postnatal care as 37.9% (n=112) disagreed with that statement. Participants had a mean (SD) nutrition care skill score of 18.58 (5.71). Less than half of the participants reportedly had skills to: perform nutrition assessment of mothers (41.7%); effectively communicate nutrition information to mothers (42.1%); accurately measure and record anthropometric measures of mothers (49.5%); and identify mothers and children with nutrition deficiencies (46.9%). Also, slightly above half of the participants reportedly said they had the skills: to perform nutritional screening (50.9%) and to provide nutrition care to improve the dietary intake of pregnant women (54.1%).
Self – efficacy in nutrition care
As indicated in Table 2, 53.9% of the participants said they were confident having discussions with mothers on the importance of exclusive breastfeeding for both mothers and babies; 58.9% (n=174) were confident in discussing healthy eating guidelines with mothers; and 42.6% in discussing with mothers the number of calories per gram of protein, carbohydrates and fat including their basic metabolic roles. Participants had a mean ± SD self-efficacy score of 16.16 ± 4.60.
Table 2: Participants’ level of self- efficacy in nutrition care during routine antenatal and postnatal care
Level of Self- efficacy items
|
Not confident
|
Neither confident nor unconfident
|
Confident
|
Mean ± SD
|
Discuss with mothers on the importance and challenges of breastfeeding (n=297)
|
81(27.3%)
|
56(18.9%)
|
160(53.9%)
|
3.34 ± 1.31
|
Using the food guide pyramid during counselling to show examples of a serving size of certain foods to mothers’ (n=296)
|
70(23.6%)
|
76(25.7%)
|
150(50.7%)
|
3.37 ± 1.16
|
Discuss with pregnant and lactating mothers on healthy eating habits (n=295)
|
59(20%)
|
62(21.0%)
|
174(58.9%)
|
3.63 ± 1.22
|
Discuss with mothers the content of calories per gram of protein, carbohydrates, fat and their basic metabolic roles (n=296)
|
93(31.4%)
|
77(26.0%)
|
126(42.6)
|
3.13 ± 1.25
|
Ability to provide nutrition education for mothers recently diagnosed with HIV (n= 296)
|
131(44.3%)
|
32(10.8%)
|
133(44.9%)
|
3.09 ± 1.42
|
Total mean (SD) self- efficacy score
|
|
16.16 ± 4.60
|
For easy rating of results, “Not very confident at all” and “not very confident” were combined to yield not confident whiles “confident” and “extremely” confident were combined to yield Confident.
Nutrition care practice during routine antenatal and postnatal care by the participants
Figure 1 shows the proportion of mothers, participants believed would benefit from nutrition care and the proportion of mothers that actually received nutrition care from participants (A) and the amount of time they spent doing so (B). Participants provided nutrition care at an average of 3.16(1.09) corresponding with 41-60% of the mothers they believed would benefit from nutrition care. There was a poor level of agreement between the proportion of mothers, participants believed would benefit from nutrition care and the proportion that actually received nutrition care (Kappa statistic 0.131, S.E = 0.039, p < 0.001). With the time participants spent on nutrition care, 43.9% (n=130) spent 21-30 minutes of their time providing nutrition care whiles only 3.4% (n= 10) spent above 40 minutes. Among the participants, 66.2% referred mothers to nutritionists/dieticians for specialised nutrition care and they did so for an average of 4.35 times in the last six months.
Association between background characteristics of participants, level of satisfaction with nutrition education, adequacy of nutrition education and self-efficacy with levels of nutrition care practice
As shown in Table 3, adequacy of nutrition education (r=0.155; p<0.001) and participants level of satisfaction with nutrition education (r= 0.135; p= 0.020) correlated positively with levels of nutrition care practice. Attitudes correlated positively with nutrition care skills (r=0.523; p<0.001), level of self-efficacy in nutrition care (r=0.368; p<0.001) and nutrition knowledge (r=0.215; p<0.001). Age correlated negatively (r= -0.120; p=0.041) with nutrition-related knowledge of the participants but positively with levels of nutrition care practice (r=0.285; p<0.001).
Table 3: Pearson correlation of participants age, working experience, adequacy, satisfaction, and self-efficacy with levels of nutrition care practice
Variable
|
WE
|
CH
|
ANE
|
SNE
|
ATN
|
NCS
|
SNC
|
NK
|
NCP
|
Age
|
0.725**
|
0.136*
|
-0.002
|
-0.004
|
0.044
|
-0.114
|
-0.036
|
-0.120*
|
0.285**
|
Work experience (WE)
|
|
-0.006
|
0.077
|
0.147*
|
0.049
|
-0.057
|
0.042
|
-0.065
|
0.213**
|
Credit hours (CH)
|
|
|
0.175**
|
-0.053
|
0.055
|
-0.006
|
-0.051
|
0.013
|
0.090
|
Adequacy of nutrition education (ANE)
|
|
|
|
0.246**
|
0.003
|
0.113
|
0.061
|
-0.089
|
0.155**
|
Satisfaction with nutrition education (SNE)
|
|
|
|
|
0.139*
|
0.082
|
0.059
|
0.069
|
0.135*
|
Attitude towards nutrition education (ANE)
|
|
|
|
|
|
0.523**
|
0.368**
|
0.215**
|
0.036
|
Nutrition care skills (NCS)
|
|
|
|
|
|
|
0.609**
|
0.134*
|
-0.079
|
Self-efficacy in nutrition care (SNC)
|
|
|
|
|
|
|
|
0.071
|
0.058
|
Nutrition knowledge (NK)
|
|
|
|
|
|
|
|
|
0.134*
|
**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). NCP: Nutrition care practice.
Levels of nutrition care practice stratified by sex and format of nutrition education received during school
As shown in Table 4, level of nutrition care practice was significantly higher among participants who reportedly had: selected topics on nutrition (3.19 vs. 2.50; p =0.030), nutrition concepts integrated into their course work (3.21 vs. 2.57; p=0.006) and ever received training on nutrition after school (3.48 vs. 2.89; p<0.001).
Table 4: Mean levels of nutrition care practice stratified by gender and format of nutrition education received during school
Variable
|
Mean (SD)
|
95% CI
|
p-value
|
Gender (n = 296)
|
|
|
|
Male
|
3.19 (1.05)
|
2.82 – 3.35
|
0.494
|
Female
|
3.09 (1.19)
|
3.04 – 3.33
|
|
Nutrition as a separate course (n = 295)
|
|
|
|
Yes
|
3.17 (1.10)
|
3.03 – 3.30
|
0.719
|
No
|
3.09 (1.00)
|
2.73 – 3.45
|
|
Lectures on selected nutrition topics (n = 290)
|
|
|
|
Yes
|
3.19 (1.07)
|
3.06 – 3.32
|
0.030
|
No
|
2.50 (1.17)
|
1.76 – 3.24
|
|
Nutrition concepts integrated into the course work (n = 291)
|
|
|
|
Yes
|
3.21 (1.07)
|
3.08 – 3.33
|
0.006
|
No
|
2.57 (1.04)
|
2.12 – 3.01
|
|
Ever had training on nutrition after school (n = 289)
|
|
|
|
Yes
|
3.48 (1.05)
|
3.30 – 3.66
|
<0.001
|
No
|
2.89 (1.02)
|
2.73 – 3.05
|
|
Multivariate analysis of factors associated with levels of nutrition care
Table 5 presents a multiple linear regression of factors associated with levels of nutrition care practice. Having nutrition topics integrated into course work was significantly associated with increasing levels of nutrition care practice (B= 0.55, r= 0.147, p=0.025). participants who reported to have received nutrition training after school recorded higher levels of nutrition care practice compared to those who said they did not receive training (B = 0.38, r = 0.169, p = 0.010). Increased level of self-efficacy in nutrition care was associated with increased levels of nutrition care practice (B = 0.03, r= 0.131; p=0.048).
Table 5: Multiple linear regression of factors associated with levels of nutrition care practice
Variable
|
B
|
95% CI
|
Partial correlation
|
p-value
|
Male
|
-0.13
|
-0.39 – 0.14
|
-0.061
|
0.356
|
Nutrition as a separate course
|
-0.04
|
-0.50 – 0.42
|
-0.012
|
0.858
|
Had nutrition training after school
|
0.38
|
0.09 – 0.67
|
0.169
|
0.010
|
Nutrition concepts integrated into course work
|
0.55
|
0.07 – 1.02
|
0.147
|
0.025
|
Selected nutrition topics
|
0.57
|
-0.16 – 1.29
|
0.102
|
0.124
|
Age
|
0.04
|
0.02 – 0.07
|
0.205
|
0.002
|
Number of credit hours in nutrition
|
0.04
|
-0.04 – 0.11
|
0.058
|
0.379
|
Adequacy of nutrition education
|
0.14
|
0.04 – 0.25
|
0.180
|
0.006
|
Satisfaction with nutrition education
|
0.03
|
-0.01 – 0.06
|
0.088
|
0.183
|
Attitudes towards integration
|
-0.00
|
-0.04 – 0.03
|
-0.003
|
0.960
|
Nutrition care skills
|
-0.03
|
-0.06 - -0.00
|
-0.144
|
0.029
|
Self-efficacy in nutrition care
|
0.03
|
0.00 – 0.07
|
0.131
|
0.048
|
Nutrition knowledge
|
0.05
|
0.01 – 0.09
|
.159
|
0.016
|
Work experience
|
-0.04
|
-0.08 – 0.01
|
-.101
|
0.125
|
F= 4.55 Adjusted R square = 0.17