Quality of Community Based Nutrition of Integrated Refresher Training Provided for Health Extension...

Current Research in Nutrition and Food Science Vol. 1(2), 157-167 (2013)

Quality of Community Based Nutrition of IntegratedRefresher Training Provided for Health Extension Workers

in Amhara Region, Northwest Ethiopia

MASRESHA TESSEMA*, AREGASH SAMUEL, TSEHAI ASSEF,TESFAYE HAILU, DESALEGN KUCHE and AWEKE KEBEDE

Ethiopian Health and Nutrition Research Institute, Food Science and NutritionResearch Directorate, P.O.Box 1242, Addis Ababa, Ethiopia.

http://dx.doi.org/10.12944/CRNFSJ.1.2.07

(Received: October 04, 2013; Accepted: December 05, 2013)

ABSTRACT

Improving nutrition contributes to productivity, economic development, and poverty reductionby getting better cognitive development, school performance, physical work capacity, andmaintaining health status by reducing morbidity and mortality. Poor nutrition perpetuate the cycle ofpoverty. Community-Based Nutrition (CBN) is an important component of the National NutritionProgram, designed to build upon the Health Extension Program packages to improve nutritionalstatus of under-five children and pregnant and lactating women. As part of this program shift, CBNtraining modules have been shortened and incorporated into the Integrated Refresher Training(IRT). The nutrition components of Integrated Refresher Training have not been assessed so far.This study aims to assess the quality of CBN component of integrated refresher training, stakeholderperceptions on the quality of training and change in the knowledge of HEWs. Institutional basedcross-sectional study with both qualitative and quantitative data collection methods was used.Four Woredas were chosen purposively from a listing of all woredas receiving IRT module II inAmhara region from June-July 2012. Many MTs and trainees mentioned difficulty of delivering thetraining as designed due to shortage of time allocated. This was also observed in IRT sessionswhere MTs used additional than allocated time. Even though most trainees said the training onCBN component was adequate to give services to the community and significant knowledgechange (p<0.05) was seen by participants after the training, it was observed that they failed to giveall the appropriate advice related to CBN component during the field practice. Most of the HEWsreported that there was no supportive supervision for the last four months. In conclusion; thetraining that were given in four selected woredas of Amhara region were not quality wise and asdesigned. The IRT of nutrition component lack reporting and monitoring format. In all nutritioncomponents of IRT and the allocated time for training is too short. The IRT of nutrition componentis also not adequate for health extension workers to accomplish community based nutritionprogram. Thus, there should be additional training for the health extension workers.

Key words: CBN, IRT, Quality of training, Northwest Ethiopia.

INTRODUCTION

Undernutrition continues to afflict 180million children worldwide and is responsible for inexcess of 3.5 million maternal and child deaths eachyear. Until recently malnutrition was a neglectedissue. However, it has recently begun to rise up thepolitical agenda [http://www.ids.ac.uk.August12/2013]. Maternal and child undernutrition account

for 11% of the global burden of disease [Black etal., 2008]. Globally, about one in four children ofunder 5 years old are stunted (26 per cent in 2011).An estimated 80 per cent of the world’s 165 millionstunted children live in just 14 countries. Ethiopia isamong 14 countries with the largest burden andhighest prevalence of stunting [UNICEF, 2013]. InEthiopia between 2000 and 2011 the prevalenceof both underweight and stunting has declined to

158 TESSEMA et al., Curr. Res. Nutr Food Sci Jour., Vol. 1(2), 157-167 (2013)

32 and 23 percent respectively. The country needsto accelerate efforts to reach the Health SectorDevelopment Plan’s target of reducing theprevalence of stunting to 30 percent by 2015 [FMoH,2008; GOE, 2013].

In order to prevent malnutrition in children,family and community should be the first line ofprotection. Community-Based Nutrition (CBN) aimsto build up the capacity and the ownership ofcommunities and families to make informeddecisions on child care practices [FMOH, 2008;FMOH, 2011]. CBN is an important component ofthe National Nutrition Program (NNP), designed tobuild upon the Health Extension Program (HEP)packages to improve nutritional status of under-five children and pregnant and lactating women.CBN was implemented in different phases inEthiopia [FMOH, 2013]. Although there has been amarked improvement in the level of malnutrition inthe country, child malnutrition is still prevalentaccording to the Ethiopia Demographic and Healthsurvey (EDHS) of 2011. The prevalence of stuntingwas 44% among children 6 – 59 months,underweight was 29% and 10% children werewasted [DHS, 2011].

CBN supports improved quality andcoverage of a number of preventive and promotiveactivities of CBN at the community level, including:monthly growth monitoring and promotion forunder-two children; monthly community dialoguesto engage community members in assessing andimproving nutrition; quarterly screening of under-five children and pregnant and lactating women formalnutrition (with linkages to targetedsupplementary food where available); improvingreferral practices; and six-monthly campaigns ofVitamin A supplementation and deworming forchildren 6-59 months [FMoH, 2008; 2011].

As part of this programme shift, CBNtraining modules have been shortened andincorporated into the Integrated Refresher Training(IRT). IRT is a new model which is developed byFederal Ministry of Health for delivering in-servicetraining to health extension workers (HEWs) thatcould be able to implement the health extensionpackages including the former CBN trainingmodule. The community based nutr ition

components of the IRT include: maternal nutrition(MN), breastfeeding, complementary feeding (CF),and growth monitoring and promotion (GMP) andcommunity health days (CHD) [FMOH, 2011]. Thenutrition components of IRT not been evaluated sofar; so this study will help to improve the componentby identifying the gaps and opportunities. Therefore,the current study aimed to assess quality of CBNcomponents of integrated refresher training andstakeholder perceptions on the quality training andchange in health extension workers (HEWs)knowledge in Amhara Region.

MATERIALS AND METHODS

Study areasThe study was conducted in randomly

selected four woredas of Amhara region. Amhararegion is located 9°-14° N and 36°-40°E in Ethiopia’sNorthwest. The state shares common borders withthe state of Tigray in the north, Afar in the east,Oromiya in the south, Benishangu-gumuz the southwest and the Republic of Sudan in the west. TheState of Amhara covers an estimated area of170,752 square kilometres. According to the 2007census, the region’s population was 17,214,056 ofwhich 50.2% were males and 49.8% females. About85% of the people are engaged in agriculture. TheState is one of the major Teff (staple food) producingareas in the country. Barley, wheat, oil seeds,sorghum, maize, wheat, oats, beans and peas aremajor crops produced in large quantities [CSA,2008].

METHODS

Institutional based cross-sectional studydesign was employed. Data was collected fromJune to July, 2012. Both qualitative and quantitativedata were collected. Observations were conductedduring IRT training sessions and field practices. Preand post training test were administered toparticipants to evaluate their knowledge changeafter training. In-depth interviews (IDIs) wereconducted with selected trainees and mastertrainers (MTs) from each of the training session. Atotal of 139 HEWs and 22 master trainers (MT) wereinvolved in the study. The quantitative data exportedfrom Epi-Info were analyzed using SPSS version17.0. Paired sample t-test was used to see

159TESSEMA et al., Curr. Res. Nutr Food Sci Jour., Vol. 1(2), 157-167 (2013)

knowledge gained after training. HEWs perceptionsof training and observations of training by theresearch team were summarized as a measure ofquality of training. Qualitative data from IDIs wasreported in the pre-established themes on thequality of training, barriers and facilitating factors todelivering the training as planned.

Instrument, measurements and variablescollected

In-depth interviews were conducted byresearchers who were received training on theinstruments and assistant by a note taker and digitaltape recorder. Moreover observations were alsoconducted during training sessions. Pre-test andpost test questions, composed of all CBNcomponents were prepared. Indicators were:observation in training session, structured tests,perception of both MTs and trainees.

RESULTS AND DISCUSSION

Observations and participants’ perceptions onbreast feeding training session.

Breast milk is the only food or drink that anewborn child needs in the first 6 months of his/herlife. Exclusivity is a measure of the amount ofbreastfeeding without supplementation (e.g., infantformula or other breast milk replacements), and 6months of age is a key marker sincecomplementary foods (i.e., solids) usually beginaround 6 months postpartum [WHO, 2011; BCC,2006]. A shorter duration of exclusive breastfeedingdoes not protect infant growth so well as exclusivebreastfeeding for six months does [WHO andUNICEF, 1998]. Moreover, the early introduction ofcomplementary foods shortens the duration ofbreastfeeding, interferes with the uptake of importantnutrients found in breastmilk and reduces theefficiency of lactation in preventing newpregnancies [Zeitlin and Ahmed, 1998; Oski andLandaw, 1980; Bell et al., 1987].

Around half of MTs said that training wasdelivered based on the manual as designed; theyexplained it in a good way and the facilitator guidedto do so. On the other hand, the remaining half ofthem said that there was shortage of time to strictlyfollow each and everything listed in the manualwhich made some of them rush, others skip some

exercises and the rest push the session in order tofinish the breast feeding part. Some (5) MT of themexplained as they were not using breast modelsand dolls. Moreover, they explained that more timeshould be given for the topics like breastattachment, positioning and expressing breast milkby mentioning that it is a new practice for ruralcommunity.

Master trainers from Ebinat woreda responded“The use of audiovisuals for the session makes thetraining very practical. There wasbreastfeedingvideo. We thought it is better if thetraining is supported by audio-visual. Actually that

Table 1: Distribution of respondents on pre and post training test scores of CBNcomponents in selected Woredas’ of

Ethiopia, September 2012

Test type Mean score

BreastfeedPre-test 5.19Post test 5.31Difference in individual 0.12test scoresP-values <0.05Complementary feedingPre-test 4.01Post test 4.97Difference in individual 0.96test scoresP-values <0.001Growth Monitoring and PromotionPre-test 0.94Post test 1.63Difference in individual test scores 0.69P-values <0.001Community Health DayPre-test 0.71Post test 0.85Difference in individual test scores 0.14P-values <0.05Maternal NutritionPre-test 1.33Post test 1.37Difference in individual test scores 0.04P-values > 0.05

*Significant at <0.05, ** Significant at <0.001


thing is not included in the training materials.However I have an idea that it is better if it is includedin the content.” In contrary to this most of the traineessaid that the training they received on breastfeeding is enough. They have mentioned differentreasons; they stated that they have got enough skillto apply it practically in the community, some said itis the right way to address the available gaps in thecommunity, others said it is easily understandableand they trained well. Some said the training onbreast feeding (BF) is not enough. They reasonedout that shortage of materials like breast model anddoll have made the training difficult to understandthe training on attachment and positioning. Theyalso said it was more of theoretical or absence ofpractical session/demonstration which is the othershortcoming of the training.

Health Extension worker from Meket woredasaid“Expressing breast milk was not enough as it wasvery uncommon in our community. Even it is notclear for me. Since it is related with bottle feeding, itneeds additional and improved training. So moretime must be given for this section and we ourselves

are lactating and we can practice it. I tried it lastnight but I can’t because I didn’t practice it here.”

This was also observed in IRT sessionswhere MTs used 20 additional minute on averagethan allocated time for breast feeding session. Asobserved in the four sessions, use of more timethan allocated in the above specified topic couldbe due to insufficiency of the allocated time to doall exercises in separate groups and discussing itwith the larger group. In addition, on average 65 %of BF session was fully delivered with two waycommunications. The reason why the rest part ofthe session was not fully delivered might be of MTsrush to finish the sessions on time and MTs thoughtthat participants already know the messages.

Even though more than 60% of thetrainees said the training on BF was adequate togive services to the community and significantknowledge gained (p<0.05) on breast feeding wasseen by participants after the training, it wasobserved that they failed to give all the appropriateadvice related to breast feeding during the fieldpractice. This could be due to shortage of time given

Table 2: Perception of trainees on training given by MTs, September 2012

Training Components (N= 139) N %

Complementary FeedingNeed more training to understand the subject 29 20.9That was the right amount of training 90 64.7That was too much training 20 14.4Breast feedingNeed more training to understand the subject 35 25.2That was the right amount of training 87 62.6That was too much training 17 12.2Growth Monitoring and PromotionNeed more training to understand the subject 27 19.4That was the right amount of training 96 69.1That was too much training 16 11.5Maternal NutritionNeed more training to understand the subject 30 21.6That was the right amount of training 92 66.2That was too much training 17 12.2Community Health DayNeed more training to understand the subject 34 24.5That was the right amount of training 88 63.3That was too much training 17 12.2


for the field practice which made them not to followall the procedures and the MTs were not supervisingand giving feedback for them. The classroompractical session was not properly done as per theguideline which could be the other reason.

Observations and participants perceptions oncomplementary feeding training session

Complementary feeding (CF) is theprocess of giving other foods and liquids inaddition to breastmilk. Complementary foods canbe especially prepared for the infant or can be thesame foods available for family members, modifiedin order to meet the eating skills and needs of theinfant [IASC,2009; Monte and Giugliani, 2004].Theimpact of feeding practices on nutritional status,growth, development, and health outcomes ofinfants and young children are well documented.The critical window for improving child nutrition isfrom pregnancy through the first 2 years of life, aperiod when the transition is made to CF [IASC,2009].

Most (15) MTs said that they delivered thetraining based on the manual and they reasonedout that it was scheduled and prepared in a waythat HEWs could understand. However, some (5)MTs mentioned that there was time shortage whichobliged them to give some topics as a readingassignment and rush on some topics that theythought HEWs have a good understanding.

Master trainers from Gidan woreda responded“It is not possible to say delivered as it

was designed; this was mainly because of shortageof time. If we think to deliver it as to the manual wewould not be able to cover the portions. That’s whysome times we gave more time to new topics byreducing some time from the topics which weconsider trainees would have a betterunderstanding.”

Other MTs also explained that there wasdifficulty in strictly following the manual. Their reason

Table 3: Activity done by participants at the field practice of all sessions, September 2012

Characteristics n=21 All More than Below half Number half Number Number

Procedures followed to 7 13 1appropriately weigh a child1

Delivery of appropriate advice 0 9 12to the care taker2

Characteristics n=21 Correctly done

Yes Number No Number Age determination 14 7 Nutritional status determination 11 10

Hang the weighing scale from a tree branch, attach the weighing basket to the scale andadjust the scale to zero by moving the knob at the back of the scale, child's heavy clothesand shoes removed, wait for the needle to stop moving before reading weight, read theweight to the nearest 0.1 kg, Read the weight loud enough for the mother to hear, Asked about breastfeeding, asked about breastfeeding frequency, asked aboutbreastfeeding problems, asked about other liquids given to child, explain about exclusivebreastfeeding, asked about complementary foods, frequency of CF,CF proportions (3cereal:1 legume), consistency of CF (thickness),enrichment foods, Appropriate snacks,babies have small stomachs and need to eat more frequently, feeding during illness,feeding after illness, actively encourage baby to eat, Washing hands before preparingfoods, hygienic preparation of foods, be patient and encourage child to eat, GALIDRAA(for abnormal growth).


was shortage of participant manual and familyhealth cards (FHCs) as a result they were using theold FHC to fill the gap.

In addition, some (5) MTs mentioned theimportance of having a poster that contains theprocedures of complementary food preparation.Complementary food session didn’t containadequate information on iodized salt utilization andthey suggested that information regarding theimportance of iodized salt utilization should beincluded in this session since the utilizationespecially in their community was poor.

Master trainers from Regional health officestated as

“When we demonstrate the foodpreparation, we had material problem. For e.g. thematerials for food preparation are not included inthe training package. We prepared the cookingmaterials and food stuffs available in the area byour own initiation. I think it will help to give thetraining easily if these things are included in thepackage.”

MTs were rushing and skipping someexercises to finish the session and use of extra timewas observed in sessions; on average additional13 minutes to the allocated were used. This wasnoted while observing the sessions, where 59% ofthe CF sessions were delivered all messages underthe sub-topics with two way communication. Thisshows that in order to finish sessions on time MTswere not delivering all the messages as designed.Although most trainees mentioned that the trainingthey received on CF was adequate and significantknowledge change was seen (p<0.001), gaps indelivering appropriate message about CF for thecaregiver were observed during the field practice.This could be due to the fact that enough time wasnot allocated for the field practical session on whichonly half day was allocated for growth monitoring,inter personal communication with caregiver,conducting community conversation anddemonstration of complementary food preparation[FMOH, 2011]. The other reason might be that lessfacilitators’ involvement in following up the traineesduring field practice.

Observations and Participants perceptions on

growth monitoring and promotion trainingsession

Community-based growth and monitoringprograms is one of the short-route responses toreduce the prevalence of malnutrition. In order todetect cases of malnutrition and associatedillnesses, monthly measurements of children’sweight growth are recorded and compared toprevious records and plotted on a chart against aninternational reference population. The lineargrowth retardation acquired early on infancy can’tbe easily reversed after the second year of life[Monte and Giugliani, 2004; UNICEF, 2004].

Though most (14) MTs complain timeshortage for delivering GMP session as designed,in all the observations it was finished on average15 minutes earlier. This could be due to all woredasdidn’t practice proper weighing. Preparation ofweighing basket was also not done in all sessionsexcept one woreda. Furthermore, interpreting weightgain and nutritional status determination wereskipped in two woredas and it was observed thatper session, on average 55 % of GMP messageswere delivered as designed (all messages with twoway communications). This shows that skippingexercises might be the reason for the sessions onGMP to be finished early.

More than half interviewees said thetraining was not enough due to different reasons.They said that additional training is needed as theydidn’t get adequate knowledge. Shortage of timewas the main problem raised. They were not ableto do the practical weighing and plotting exercisedue to time shortage. They also said that, they needmore training on interpretation of the result afterplotting.

Health Extension worker from Gidan woredaresponded that

“For example in the area where I amworking there is no separate growth chart for thetwo sexes; but what I observed here was in blueand red colors. So, it needs additional explanationwhy we needed to put them separately.”

Although there was significant knowledgegained statistically (p<0.05), the trainees answeredonly half of the questions correctly on post test. This


could be as a result of skipping practical exercisesand not delivering all messages as designed. Andagain, in the field practices most failed toappropriately weigh a child and determine itsnutritional status, though most trainees replied thatthe training they received on GMP was adequate.Since in some places trainees didn’t even get thechance to practice weighing a child as the MTswere doing it themselves, this might have effect ondelivering the service to community.

Some HEWs were confused with newinformation in the manual especially on childrenwho are eligible for growth monitoring and didn’twant to stick to the new.

Master trainers from Regional health officeresponded

“Even though we gave the training basedon the manual, there was conflicts amongparticipants and facilitators concerning to the ageof children eligible to GMP (2 or 3 years).Themanual clearly shows that the age of child for GMPshould be under 2 years but most of the HEWsresist this and have a tendency to follow theprevious trend i.e. under 3 years. They thought theirimmediate boss should order them to practice thembased on the new manual.”

Almost all MTs complain on the timeallocated to this session; they said that the sessioncontains important and practical topics which HEWsexpected to do independently in the community butthe time allocated for the topics were not adequateto deliver the training by ensuring each participantunderstands everything. Understanding theinvisible malnutrition, properly weighing a child,plotting a child’s weight on the growth chart,interpreting growth trend and discussing the issuewith the mother were frequently mentioned topicswhich need more time in order to have betterunderstanding. Some MTs supported thissuggestion and said that practical exercises wereskipped due to shortage of time and as a resultmost of the participants were unable to perform thegrowth monitoring and community conversationactivities during field practice.

Furthermore some MTs recommendedthat the GMP exercise presented as table in the

manual, and the interpretation of growth trend ingraph 3 should be revised as it created confusionand they also stressed that the material of weighingbasket should be again modified as it was notcomfortable for the children during weighing.Shortage of training materials like family health cardand participant manual were mentioned andsuggested to be solved in the future beforeconducting training.

Observations and Participants perceptions onmaternal nutrition training session

Maternal and child undernutrition accountfor 11% of the global burden of disease. Maternalnutrition refers to the nutritional needs of womenduring the antenatal and postnatal period (i.e., whenthey are pregnant and breastfeeding) and also mayrefer to the time period before conception (i.e.,adolescence).Maternal undernutrition affects thehealth of both mothers and children and, as a result,has broad impacts on economic and socialdevelopment. Undernourished pregnant womenhave higher reproductive risks, including deathduring or following childbirth [Black et al., 2008;MGUR, 2012]. Study shown that maternal and childundernutrition (maternal height, birth weight,intrauterine growth restriction, and weight, heightand body mass index (BMI) at 2 years according tothe new WHO growth standards) were related toadult outcomes (height, schooling, income orassets, offspring birth weight, BMI, glucoseconcentrations, blood pressure) [Victoria et al,2008].

The perception of MTs on maternalnutrition was more or less similar; they all explainedthat they delivered the training according to themanual and pointed out that it would be better if putseparately just like other components of the nutrition.Their complaint was not only on how the sectionwas organized but also the detail and clarity of thecontents included in it. According to their opinion,lacteal feeds and food taboos were not presentedin detail and might not be sufficient for the traineesto teach the community. They explained that themanual mentions only the type of foods which areaccepted and not accepted culturally but it didn’tput clearly why some of them are accepted andothers are prohibited. This deficiency made them tothink two different things: the first was, to perceive


as the manual didn’t consider the reality that healthand growth of a child fully relies on the condition ofa mother and the other was, to think ways ofaddressing these gaps. In this regard, they reportedthat they made a thorough discussion using theirown experiences and some examples: “Weexplained what types of foods were prohibited, whyprohibited and in what way they could change thecommunities’ attitude.” (MT).

Nearly half of the MTs explained that evenif they gave the training according to the manualthey had faced some challenges due to shortageof time and unavailability of some materials. As theyexplained, neither the theoretical nor the practicalsession had been allocated sufficient time, andbecause of this, they were forced to deliver onlybasic points, simply by telling trainees to cover therest by themselves:

Master trainers from Ebnat woreda said“We convey only key massages and left

others as a reading assignment.”

Due to these reasons, they were notconfident to say that trainees would bring thedesired behaviour at the community level.

Majority of the trainers reported that theyhad no adequate knowledge on OutpatientTherapeutic Feeding Program (OTP) services. Theytold that they were confused with what the manualsays and the reality on the ground. In the manualthere are eligibility criteria’s for pregnant andlactating woman to get OTP services, but, becauseof budget constraint and lack of knowledge it isuncommon to give this service. MTs also indicatedthat none of the HEWs knew how the service shouldbe given.

On the contrary, few MTs told that themanual has sufficient time and detailed contents;to them, it has a lot of exercises, and training wasdelivered in a participatory and explanatory way.

Observations and participants perceptions oncommunity Health Day training session

In this section trainers were asked to tellwhether they gave training according to the manualor not and to explore possible reasons which made

them not to provide according to the manual. Almostall MTs told that they take the training according tothe manual even if shortage of time was the mainproblem to them. Most of those MT told that thisshortage was mainly during practical sessions.

Another master trainers from East Estie woredaresponded

“To dig out everything and solve theproblems, there wasn’t enough time. There wereargumentative ideas raised. So this needs moretime. Caring for malnourished children by itselfneeds more than an hour. The time given for practicalpart was very short and even not enough to explainthe points.”

When asked about the delivery ofmessages with respect to the sequences put in themanual, trainers cited a range of reasons why theyskip and not keep the sequence in some portions.Most of them asserted that they were themselvestrained in this way and the assumption that traineesalready knew and practiced it.

Master trainers from Meket woreda said“We were just applying what we have been

trained in training of trainers. That’s why we go tothe particular community getting full informationabout the pertaining problems in that area. Intoday’s session, for instance: first we gatheredinformation about the number of children weighedand their nutritional status from the last monthregistry of the health post. Having this information,we just began the session with counselling.”

Few of the interviewees also raised theneed for hiring of additional HEWs because someof those who already received the training areleaving to other places.

“There should be additional HEWsbecause nowadays HEWs are migrating to otherplaces.”(MT from Regional health office).

The others were in doubt of the healthextension workers ability to carry out this workindependently in their work places.

“What we understood from this section ismost HEWs are unable to carry out independently


in their work places. They need support fromsomeone else whenever there is community healthdays.” (MT from Meket woreda).

Majority of the trainers described that thetraining was highly affected by shortage ofmaterials. As a result, they were not able to showsome procedures.

“That is because we don’t have thematerials. We have asked but only albendazole, vitA and MUAC tape was found. We have asked tallysheet and registration book, it is but there isn’t any.”(MT from Estie woreda).

Training adequacy for non-CBN AreasMost interviewees indicated that the

training was not enough for those who had noprevious CBN exposure. According to the trainers,this was clearly observed when they were receivingtraining of trainers (TOT) with those who had alreadytrained CBN.

Change in Knowledge of traineesThis study was aimed to assess change

in knowledge of participants. They were given pre-test before the training and post test after the training.The trainees were given four days training bymaster trainers on CBN components(breastfeeding, complementary feeding, growthmonitoring and promotion, maternal nutrition andcommunity health day at woredas level). Paired t-test was used to see the knowledge change andwas found to be statistically significant. The meanpre-test score for breastfeeding was 5.19 and posttest score 5.31, which indicated an increase of 0.12over pre-test score (Table 1). The result of this studyalso showed there were 0.96 increment observedin CF i.e., the mean pre-test score for CF was 4.01and it was 4.97 for post-test. The result of GMPshowed that there was 0.69 increments afterintervention. In this study there is significant changein knowledge of training given in breastfeeding andcommunity health day (p<0.05). There is a highlysignificant change in knowledge in thecomplementary feeding and growth monitoring andpromotion components (P<0.001); however, thereis no statistically significant change in knowledgeobserved in training that was given on maternalnutrition (P>0.05) (table 1).

Health Extension workers perceptions on thequality of training

HEWs were interviewed to assess theirperception on quality of training. More than half ofthe study subjects responded that training wasgiven in the components of CBN was the rightamount. Whereas about quarter of traineesperceived that they need more training on CF, BF,GMP, MN and CHD to understand the subjects(table2).

Field practicesField practices were done in all four

woredas where nutrition part of IRT sessionsobserved. In all field practice sessions; details onwhat must be done, when and how, was informedfor participants before going to the field. Facilitatorsand co-facilitators were selected in all sessionsexcept in one woreda. The communities wereinformed about the field practice prior to the date ofpractice but they were not divided in to two gottes(peasant association) in all sessions. On the otherhand, use of community growth charts wereobserved only in the practical session conductedat one woreda. In addition inadequacy of FHCs andunavailability of checklist to follow the communityconversation were noticed in all the four practicalsessions.

One participant was expected to weigh achild and do the inter-personal communication withthe care taker; however a group of 3 to 4 participantswere weighing one child and doing the inter-personal communication except in one woredawhere weighing a child was done by the mastertrainers. The reason mentioned was only fewchildren were available at the time of field practiceand surprisingly only 3 children were weighed inthe field practice held at one (Estea) woreda.

Among 21 children, who were observedduring growth monitoring at the field practice of allsessions, all procedures of weighing were followedonly for 7 of them. In addition all the appropriateadvices were delivered for none of the care takers.Correct age and nutritional status determinationwas done only for 14 and 11 respectively (table 3).Of the four field practice sessions observed,community conversation (CC) was conducted onthe 3 woredas but not in one woreda as only 3 care


takers were available at the time of field practice.However all community conversations in the threepractical sessions were not conducted properly.

CONCLUSION

In conclusion; the training that were givenin four selected woredas were not quality wise andas designed. The IRT of nutrition component lackreporting and monitoring format.The nutritioncomponent of IRT training manual should berevised based on the finding. The time allocated forall CBN component were not adequate, in allnutrition components the allocated time for trainingshould rearranged. Reporting format andmonitoring evaluation should be added in revisedtraining manual. There should be training for thehealth extension workers with more number of daysby considering new CBN woredas.

Competing interestsThe authors declare that they have no

competing interests.

Authors’ contributionsMT conceived the idea and designed the

study, coordinated data collection, transcribed

qualitative data, performed analysis, interpretationof data and drafted the manuscript. TA coordinateddata collection, interpreted data analysis and criticalreview and commented on the manuscript. ASconceived the idea, obtained funding, helped inthe data collection instrument development,assisted in data collection and manuscript writing,and critically commented on the draftmanuscript.TH, DK and AK commented on the draftmanuscript. All authors gave final approval of theversion to be published.

ACKNOWLEDGEMENTS

We are highly grateful to Ethiopian Healthand Nutrition Research Institute, for the timelyreview, comments, and clearance of the study. Thisstudy was financially supported by World Bankthrough Federal Ministry of Health, we would likeacknowledge the support from the World Bank. Wewould like to extend our appreciation to FederalMinistry of Health, Regional, Zonaland WoredaHealth Offices for providing the necessaryinformation and facilitating conditions while carryingout this study. We are also very grateful to extendour appreciation to the study participants whoshare their priceless time.

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