Healthcare Providers and Caregivers’ Perspectives on Factors Underlying the Persistent Malnutrition of Children Aged 0-59 Months in Buhweju District, Southwestern Uganda

Background Nutritional well-being is fundamental to the attainment of the full social, economic, mental and physical potential of individuals, communities and populations. The nutritional well-being of infants and young children is positively and negatively affected by economic, environmental and maternal factors that range from food intake, health, sanitation and care. Several initiatives such as growth monitoring, vitamin A distribution, deworming programs have been undertaken to reduce the impact of nutritional deciency and promotion of health of children under ve years in Uganda. All regions of Uganda have registered unacceptably high levels of childhood malnutrition over the years, although with an uneven distribution across regions. Western Uganda has persistently registered the highest levels of malnutrition with Buhweju district having the highest levels above the national average. This study assessed health provider and caregiver perspectives on factors responsible for persistent malnutrition among children aged 0-59 months in Engaju and Nyakishana sub counties in Buhweju district. Methods Focus group discussions and key informant interviews with Village Health Team members and care takers of children aged 0-59 months in Engaju and Nyakishana sub-counties and healthcare providers in Buhweju district were conducted respectively to explore their perceptives on the factors responsible for persistent malnutrition in Buhweju District in May 2018. Results Inadequate childcare services, poverty and economic occupation, parental alcoholism and domestic violence as well as historic and geographic challenges were identied as factors responsible for persistent malnutrition among children aged 0-59 months in Engaju and Nyakishana sub counties in Buhweju district Conclusion Several factors are responsible for persistent malnutrition of children aged 0-59 months in Buhweju. Some can be readily addressed and should lead to improvement in the nutrition status of children in Buhweju district. Two focus group discussions with VHT members and two focus group discussions with caregivers were carried out in each of the two sub-counties of Engaju and Nyakishana in Buhweju district. All those approached and met the inclusion criteria agreed to participate. A total of 24 males and 49 females composed the different focus group discussions in the two sub-counties. All participants, both male and female were subsistence farmers though some males and females worked on the tea and coffee plantations and local gold mines. The female caregivers were mothers of malnourished children selected from villages in Engaju and Nyakishana sub-counties. The two (2) key informants were a male district health ocer and a female district nutrition focal person. They were all employed by Buhweju district local government and each had worked for the district for more than a year at the time of the study. After data familiarization, four broad themes were generated (a) inadequate child care services, (b) poverty and (c) economic occupation, alcoholism and domestic violence and (d) historical and geographical challenges. Sub-themes were generated from each broad theme.


Abstract
Background Nutritional well-being is fundamental to the attainment of the full social, economic, mental and physical potential of individuals, communities and populations. The nutritional well-being of infants and young children is positively and negatively affected by economic, environmental and maternal factors that range from food intake, health, sanitation and care. Several initiatives such as growth monitoring, vitamin A distribution, deworming programs have been undertaken to reduce the impact of nutritional de ciency and promotion of health of children under ve years in Uganda. All regions of Uganda have registered unacceptably high levels of childhood malnutrition over the years, although with an uneven distribution across regions. Western Uganda has persistently registered the highest levels of malnutrition with Buhweju district having the highest levels above the national average. This study assessed health provider and caregiver perspectives on factors responsible for persistent malnutrition among children aged 0-59 months in Engaju and Nyakishana sub counties in Buhweju district. . Malnutrition can be due to local, national and international factors as well as environmental, social, economic, socio-demographic and political causes that are deeply interrelated, and mutually affect each other (Tigga, Sen et al. 2015). In Ethiopia, the nutritional wellbeing of infants and young children is negatively associated with being born in rural area, being male, unprotected drinking water, smaller weight at birth, no antenatal follow-ups, diarrhoea, and low household wealth (Woldeamanuel and Tesfaye 2019). Causes of malnutrition in Uganda have equally been associated with immediate, basic and underlying factors as well as food prices, poverty and unemployment (Ickes, Jilcott et al. 2012). In Uganda, children whose parents engage in agriculture and manual work, peasant farmers or employed by non-family members , as well as age of the mother, and age and sex of the child are at higher risk of stunting and underweight compared to the children from pastoralists' families (Habaasa 2015, Nankinga, Kwagala et al. 2019). In addition, there is inequality regarding child health indicators for people living in rural areas compared to those in urban areas; females compared to males and poor and uneducated compared to richer and more educated (Elduma 2019).

Methods Focus group discussions and key informant interviews with
Although all regions of Uganda have registered unacceptably high levels of childhood malnutrition over the years, the distribution has not been even (Tumwesigye, Tushemerirwe et al. 2016). A 2017 report noted that approximately, 11 percent of all children were underweight and 2 percent severely underweight with children in rural areas slightly more likely than those in urban areas to be underweight (11 percent and 8 percent, respectively)(Statistics and ICF 2017). The western region of Uganda has persistently registered the highest levels of childhood malnutrition especially stunting, yet, this is the region with plentiful food production and is sometimes referred to as "the food basket" of the country (

Study setting
Buhweju is a rural District in Southwestern Uganda with a population of 124,044, with hilly geographic terrain and hence poor infrastructure including road network (UBOS, 2014). The population is mainly employed in agriculture practicing subsistence farming and/or working on tea and coffee plantations.
Some male members of the community work in the gold mines.

Sampling and design
This was a descriptive cross sectional study employing qualitative methods. Caretakers of children aged between 0 to 59 months, as well as the District Health O cer, nutrition focal person and community health workers known as Village Health Team (VHT) members were purposively sampled from communities in Engaju and Nyakishana sub-counties and at the district level. The VHT coordinators in these communities assisted in recruitment by identifying caretakers and VHT leaders as they are health gatekeepers to these communities. The identi ed participants were approached by the study team who introduced the study to the participants by explaining the study purpose and objectives. Participants were eligible if they were; 1) caretakers of observed malnourished children aged between 0 to 59 months and resided in Engaju and Nyakishana sub counties 2) VHT members in Buhweju district, 3) Nutrition focal person and District Health O cer of Buhweju district. Participants who did not meet this criterion were excluded from the study. All participants were above 18 years of age. The interviews with the participants were conducted at a private location at the convenience of the different participants at the time agreed upon with the study team. They were not paid for participating in the study but their transport costs were covered.

Interview Procedures
Interview guides for the key informant and focus group discussions were developed to explore healthcare providers and caregivers' perspectives on factors underlying the persistent malnutrition of children aged 0-59 months in Buhweju district, southwestern Uganda. The questions included a) What are the factors responsible for malnutrition of under ve in Engaju and Nyakishana sub-counties of Buhweju district?
(family, community, health care, economic, cultural and political) b) What have people done at the family level to improve child nutrition in Engaju and Nyakishana sub-counties of Buhweju district? (Primary, Secondary,Tertiary factors). The questions in the interview guide were developed speci cally for this study basing on study objectives. The interviews were conducted in Runyankore-Rukiiga, the local language, by the study team using interview guides translated into Runyankore-Rukiiga, and back translated into English to ensure that the message was correctly translated. The interview guides were rst piloted with a nutrition focal person at Mbarara Regional Referral Hospital and caretakers of children 0-59 months of age in Nyamitanga division, Mbarara Municipality, Mbarara district. Necessary changes were implemented. The interviews were conducted by the study team and a trained Research Assistant between May and June 2018. The interviews lasted between 60 and 90 minutes, were audio recorded and eld notes taken. Interviews were conducted until thematic saturation was achieved.
Each audio recorded focus group was comprised of 8-12 male and female participants. Study staff also recorded observations through notes during the focus group discussions.

Data Management and analysis
Audio recordings were transcribed and translated by the Study Team and the Research Assistant and checked by CA. Two members of the research team (GZR and SA) read through the transcripts to develop a study codebook. This was done by analyzing statements from participants, identifying commonalities, developing code and theme groups. Twelve codes were identi ed into four grouped themes. Codes were entered into Atlas Ti 7.5 and each transcript was analyzed to reveal corresponding quotes.

Ethics and Funding
This study received ethical approval from the Mbarara University of Science and Technology Research Ethics Committee (MUST REC).Written informed consent was obtained from all participants. For participants unable to read and write, the written consent was read out by a research team member, the participant would be given an opportunity to ask questions , the questions would be answered until he/she is satis ed. His/her informed consent would be signed by thumb print if in agreement. The study received peer reviewed funding from MicroResearch (www.microresearch.ca)

Results
Two focus group discussions with VHT members and two focus group discussions with caregivers were carried out in each of the two sub-counties of Engaju and Nyakishana in Buhweju district. All those approached and met the inclusion criteria agreed to participate. A total of 24 males and 49 females composed the different focus group discussions in the two sub-counties. All participants, both male and female were subsistence farmers though some males and females worked on the tea and coffee plantations and local gold mines. The female caregivers were mothers of malnourished children selected from villages in Engaju and Nyakishana sub-counties. The two (2) key informants were a male district health o cer and a female district nutrition focal person. They were all employed by Buhweju district local government and each had worked for the district for more than a year at the time of the study.
After data familiarization, four broad themes were generated (a) inadequate child care services, (b) poverty and (c) economic occupation, alcoholism and domestic violence and (d) historical and geographical challenges. Sub-themes were generated from each broad theme.
Inadequate child care services Malnutrition in Buhweju was associated with a number of factors that were re ective of inadequate health care services including inadequate nutritional services, low levels of immunization, lack of adequate family planning, lack of childcare knowledge and inadequate treatment modalities available.

Inadequate Nutrition services
There was a lack of adequate implementation of general nutrition services in Buhweju as shown by the low availability of health workers and few health centers and consequently mothers required to travel long distances (mostly on foot), to seek assessment and treatment of nutritional related conditions. Due to the limited capacity of the Health Centers, only nutritional assessment and counseling were offered, and cases of severe acute malnutrition (SAM) were referred to hospitals several miles away without additional support to ensure that the child reached there and received the necessary care. The VHTs lacked sustainable funding to help them complement the inadequate health care human resource. In addition, local leaders were not cooperative in assisting with implementation of known community based nutrition programs and this further impeded the VHTs potential to complement the implementation capacity of nutrition program.
"We do referral and counselling… it's the only thing we offer so we counsel the mother on what the child needs to eat and if the child doesn't need referral they get back to the community. For those who need to be referred, we do." KII Our leaders don't cooperate with us but their role is to approve referral by putting a stamp on documents, but sometimes they refuse to approve referral and even when you call them for certain health talks, they refuse and yet people would listen to them than us (FGD Caregivers).
Inadequate knowledge, availability and access to nutritious food Caregivers in Nyakishana and Engaju reported feeding their children on only a few foods; mainly matooke (type of bananas) and a few times with dodo (greens). This food was limited in access, quality and quantity since most of what is cultivated was sold to raise money to meet other family responsibilities. In addition, the banana plantations were destroyed by banana wilt disease. On other occasions, some care takers did buy posho (Maize meal), sweet potatoes and cassava which their children fed on without sauce.
…………Poor feeding e.g. like feeding on a single type of food and eating each and every food is not good for babies' for example matooke (Bananas) without beans but salt and dodo (greens) ( FGD-Caregivers).
There was limited supply of protein rich foods like milk and eggs since very few families owned cows or chicken. A few households fed their children on silver sh and soybean but this was seasonal, expensive and could often only be purchased at markets several kilometers by foot away from their homes.
….."in all of Buhweju apart from our demonstration gardens which we are trying to develop, you rarely nd a vegetable garden at home, they don't rear animals, you nd a goat in a few homes, there are no farms in Buhweju where you will get milk because I have never seen a farm in Buhweju yet these children need milk because they need all these things that will help them get better nutrition" Healthcare provider, KII.
Caregivers reported to be working for long hours in their gardens and tea farms that were very far from their homes. They leave early and return late when they are tired leading to a lack of time and willingness to prepare meals. Consequently, they prepare meals in large quantities with the intention that the food is to be consumed the following day.
……"Limited time for the children whereby you have to wake up very early in the morning going to the garden and you nd that you have no time to prepare breakfast for children and even sometimes they have nothing at home to prepare for lunch so they just depend on left over" (FGD-Caregivers)

Breastfeeding practices
Study participants reported poor breastfeeding practices. Mothers lacked knowledge of proper breastfeeding techniques. Mothers worked on family gardens far from home for long hours and returned home late leaving no time to breastfeed their children. The children are weaned early due to lack of time for breastfeeding, uctuations in breast milk due to poorly fed mothers.
"………. You nd a mother of a six months child breastfeeding the baby right from the garden with unwashed hands while doing other chores and the baby is feeding like a cow " Health care provider KII.
"………..Sometimes we have no time for our children because we were advised to breast them at least 8 times a day but when you're busy digging on a family garden, you can't get time to breastfeed for all that period so by the time you go back home like at 2 pm, the child is already hungry and this leads to malnutrition" FGD-Caregivers.

Barriers to immunization and deworming
Participants reported not knowing the purpose of immunization, so they end up forgetting the immunization days. Deworming medication is given at immunizations. Sometimes when they go, the vaccines and deworming medications were not enough to cover all the children. The caregivers claimed that with poor feeding, the vaccines were not important for their children. Due to so many demands on mothers, like digging from distant gardens, cooking and taking care of other family members, immunization and deworming were often not prioritized. Community leaders like pastors also preached against immunization hence making their followers shun immunization and hence did not receive deworming.
Sometimes we are not informed about immunization days so we end up missing immunization and deworming of our children but there is a VHT who normally moves around giving medicine to our children but if we did not have him our children wouldn't get immunized.
Even some religions don't support polio immunization like one pastor said I can't immunize my child against polio and said he never treated any of his children but they are all ne. (FGD VHTs) Family planning Participants reported a lack of access and knowledge on the available family planning services. Caretakers reported not using family planning due to many misconceptions. They believed that family planning affects their health hence negatively by impacting on the mothers' ability to do their routine work like digging and household chores. Since most women were the primary source of income for their families, they forewent family planning. On the contrary, mothers who were willing to use family planning were unable to get the services from their nearby health units because of shortages and limited supplies.
………..Production of many children. like having 6 children in a compound of almost of the same age bracket due to fear of family planning because they say when you're on family planning, you're not supposed to overwork and yet when you're the one taking care of the entire family, you decide to leave it so as to be able to continue working hence leading to many children and that leads to malnutrition due to lack of enough food they can even be 20 children (that's how we think) FGD-CAREGIVERS.

Poverty and economic occupation
Participants reported limited government funding for nutritional programs (food support, nutrition assessment and deworming programs) in Buhweju district compared to other districts. The communities practice subsistence farming but because of poverty, they often end up selling all the produce leaving families with little to eat. In household food theft by men also occurred with the men stealing even the little that was available from their wives and using their money earned on tea plantation or in the gold mines to buy alcohol. The women were left to care for their families with money using the women earned for selling produce and working on tea and coffee plantations. The communities lived in poor housing structures and the sanitation was also very poor. There was a high incidence of diseases ranging from diarrhea, malaria and HIV/Aids that also affected the nutritional status of the vulnerable children.
Because of the gold mining in the area, children dropped out of school to work in the mines, where they were underpaid/ exploited by middlemen and the little they were paid was used for themselves to buy alcohol, gamble or to play pool. Gold mining also led to high school dropouts (child labor).
"In Buhweju, ideally they are cultivators but with this development that has come in with these murram roads that have been extended all food is sold off even today as I was coming I met a full lorry carrying matooke (bananas) to Bwizibwera trading centre because they need money and don't spare anything for themselves "HEALTHCARE PROVIDERS-KII.
"our men in Buhweju don't want to support us, their role is going to the bar to drink and stealing our crops after harvesting and you nd that you have no lunch and supper for our children and that leads to malnutrition "FGD-CAREGIVERS ……"Buhweju, there are few people working for the government so when we x our eyes on men our children will die of malnutrition because men don't care" HEALTH CARE PROVIDER-KII.
Having to focusing mainly on cash crops, not food crops, takes so much of their time there is little time left to prepare food for their families "We have seasonal income because for us we depend on tea and coffee and after harvesting like 3bags of coffee and given like 700000 UGX shillings, you don't know how the man spent it he can come home with like 200000 shillings and he tells you to put it back in coffee and he tells you that that's the only money he got and you nd that you need school fees and nd that you have no balance for feeding the children so they fail to plan for the children because that money is not enough".
Subsistence farming was not always successful due to poor yields, available land not being very fertile, lack of enough land for cultivation, and limited crops chosen to cultivate so no greens to feed on and no chicken for eggs.
"Lack of farming space, because when one has enough land, he /she can rear chicken, cows as well as plant some greens and grow enough food for home consumption and sell for school fees but when one doesn't have land, our children end up being malnourished" FGD-CAREGIVERS .

Alcoholism and domestic violence
Men were not seen as supportive with most caregivers and VHTs reporting of alcohol abuse and high rates of registered domestic violence. Women lived in constant fear leading to limited food production and psychological distress impacting their ability to care and feed for their children. When men returned home drunk, a usual condition, they ate the food the mother had prepared for the children. These children were left hungry and malnourished. What they earned from commercial agriculture (tea plantations) was not allocated to buying food but was used by men to buy alcohol while the women often bought dresses. Men also spent money on playing pool and gambling.
"If I had money, I would prefer having local food available because if you have money and you prefer going to alcohol and expensive new dresses it's not good because I interacted with mothers and they were like we can't buy food when I dig from morning to evening when the man and takes everything like if he gives me 100k I would also go and buy a new dress I can't buy food so the challenge is how to use it" HEALTHCARE PROVIDER -KII.
"Domestic violence! Whereby the man beats the wife and she runs to sleep in the bush and men don't have time for children because for them in the morning they must go to the bar and no one to cook for them so the child will eat whatever he /she nds because you nd that a woman sleeps only for two days in the house and 5 days sleeps outside and even when she is at home, she has to hurry before the husband comes and pours away the food even they ght at night the man goes to the bar with the remaining beans to exchange them for a drink and he leaves the wife and children with nothing to eat so this causes hunger hence leading to malnutrition among children because the food they eat is not good for them" HEALTHCARE PROVIDER -KII.

Historical and geographical challenges
Buhweju was an underserved county in greater Bushenyi district. The district lacks enough public services such as road network and has few health facilities to serve a population of 124,044 people (UBOS, 2014). The majority of the people are not educated with generally low educational achievements.
"There is a problem of education whereby youths don't want to go to school all they do is waking up very early and go to play pool and whatever you cooked for your children, they will come at night and they eat and sometimes you nd that you have your crops in the store .The youths and men steal them so as to get money to play the pool and buy alcohol" HEALTHCARE PROVIDER -KII.
There is poor road network hence transport is poor. There were underserved areas, some without health centers and even when accessed the centres lacked medicines. There was a lack of health facilities, only one Health Centre for the whole sub-county. There was only one Medical O cer in the entire district despite the fact that according to Uganda Health Policy there should be health services provision starting at local council/village level. There was limited interaction between the health workers and community members. There were a limited number of health workers all of whom felt overworked and overwhelmed leading to no time to spend on educating the community.
"We do what is within our level and healthy facility , we do a lot of referrals since health centres are inadequate to serve and cover the demands of the population and we have realized that nutrition which can be handled at different levels of the facilities can only be handled at Health Centre 111, Health Centre 1V while the lower facilities which are very few only do assessments" HEALTHCARE PROVIDER -KII.
"If I compare those sub-counties that consistently remain in red in acute malnutrition they are underserved areas and there are some without healthy centers and access to them is not easy like if you went to Engaju the furthest are you would have appreciated they need to travel more than about 10kms to access a health center even if the whole staff that are there, they are overwhelmed they don't have time to interact with those individuals and educate them" HEALTHCARE PROVIDER -KII.
The community uses local herbs/traditional medicines "…….. in Buhweju we have a thing of witchcraft(mahembe) so you realize that the community is in that tradition and it's blindfolding for them instead of ghting against malnutrition, they are looking for who to help them in witchcraft and by the time they go to the facility and tell them it's malnutrition HEALTHCARE PROVIDER -KII.
………… I realized that there is a knowledge gap within the community because we expect the community to take some of these things but they seem not to because they think that this issue doesn't need to get to the health facility. I am worried in the community there are very many children we are losing since the entire community including leaders don't have enough knowledge about nutrition" HEALTHCARE PROVIDER -KII.
Due to the poor terrain of Buhweju, constructing of latrines was hard. The sanitation was poor with sanitation in Engaju sub-county at 43%. The lack of latrines increased the risk of dysentery as did the lack of water for handwashing with the few available latrine structures.
"There are no systems within the sub-counties to make sure the issue of nutrition and hygiene are followed and the issue of waste management .The health assistant within a sub-county usually visits these communities to make sure these activities are done and does healthy education but we realised that all these systems are not there" HEALTHCARE PROVIDER -KII.
There was a lack of political will at low-level councils to advocate for change.
"In Buhweju we need political will which isn't there at all levels, there are gaps that's why we came up with multi-sectoral approach and we brought in political leaders and we try to train them and engage them into nutrition and HIV to get to know the situation and they try to push and see some of the issues and gaps that need to be covered but not leaving it to DHOs" HEALTHCARE PROVIDER -KII..
Political leaders were money minded. This led to selective donations from the government based on political orientations for example provision of seeds. Social services from the government did not reach the communities as that money was taken by local leaders "Sometimes we hear that the government has sent certain support but we don't see such support but we think others get or sometimes they bring like beans and they give like 3 people who supported them and they leave others behind" FGD-CAREGIVERS

Discussion
Both health providers and caretakers of children perceived that child care services were inadequate in Buhweju district. Poverty and economic occupation, alcoholism, domestic violence and historical and geographical challenges were seen as the major factors that contributed to persistent malnutrition of children under age 5 years in the district. The causes of malnutrition noted were complex and multisectorial. This is similar to the reports of others concerning child malnutrition in Uganda, who noted that dietary and environmental factors, factors concerning the mother like autonomy as well as social economic factors play a major role in the nutrition of children (Jitta, Migadde et al. 1992 complementary diets, sex of child, food insecurity, poor socioeconomic status, and low knowledge were found to be the main predictors of childhood stunting in Buhweju district. What is noteworthy in our study is that those in the community themselves, many of whom were illiterate, and the local health providers identi ed similar factors. The community themselves had insights into the main contributors.

Strengths of the study
This study explored the perceptions of health providers' and care takers of children aged 0-59 months in Buhweju district through key informant interviews and focus group discussions. The participants freely expressed their views. This study documents the situation from the perspective of the healthcare providers and caretakers in Buhweju District.

Implications
To address the persistent malnutrition in Buhweju district, the factors highlighted in this study must be addressed from the grassroots. There is a need for individual and community multi sectoral interventions that aim to address many of the factors. The observation that members of the communities already have insight into the factors suggests fertile ground for factor related interventions, For example, ensuring that immunization and deworming are seen as important and that these are both available when the mothers bring their children to the health centre; educating mothers on how best to ensure a broader diet; work with elders and village leaders to decrease acceptance and perception of alcoholism and domestic violence and enhancing the role and importance of fathers in providing for their children has potential for signi cant impact .