Introduction

Kwashiorkor and Marasmus, which are forms of protein-energy malnutrition (PEM) and wasting, are common malnutrition syndromes rampant in the developing world. The syndromes occur as a result of inadequate intake of minerals, such as Iron, Iodine, Zinc and Vitamin A which are involved in energy metabolism (Olaf & Krawinkel 2013). The syndromes are the leading cause of death in the under-five year children in the developing countries characterized by growth failure (Kreibl 2009). In communities in South Sudan there are numerous health complications not only arising out of poor diets but also inadequate nutrient intake (Vikki 2011). Therefore, organized public health nutrition programs where people are properly educated on the critical issues of health and nutrition would be very beneficial to the communities. Nutrition education programs need to cover nutrition aspects, improvement of family food supplies, efficient utilization of available foods and resources and care for the most vulnerable groups in the communities (Vikki 2011; Suraiya et al. 2003).

In the Republic of South Sudan effort has been placed on increasing local nutrition knowledge, extensive training, improving hygiene practices and access to safe water. These efforts are aimed at mitigation of acute malnutrition in communities which threatens the productivity of the citizens of a country (UNICEF 2013). There were various players that have addressed malnutrition and have designed intervention training programs for mothers in Malakal sub-county. These include, the Government of South Sudan (GOSS), UNICEF and NGOs with UNICEF taking the leading role (UNICEF2013). Interventions by UNICEF targeted infant and young child feeding, micronutrient nutrition, nutrition security in emergencies and nutrition and HIV/AIDS. Although these interventions addressing malnutrition among children have been put in place, there is hardly any study that has been done to assess them. This study therefore was carried out to identify the successes and short comings of the nutrition education and training interventions for mothers in Malakal County, South Sudan.

Methods

A cross-sectional research design was used to obtain information about the nutrition education programme at a particular point in time during the period from 2008 to 2012 in Malakal County. The the field work duration was seven months from April to October 2012. The design involved explorative, descriptive and qualitative methods to obtain detailed information from the perspective of the respondents to the study.

Study population

The population of this study was the breastfeeding mothers that participated in a nutrition education programme in Malakal County. However, the following respondents were also interviewed because of their knowledge of the training programme. They included: three (3) nutrition coordinators; three (3) nutrition officers from the Ministry of Health; one (1) Communication for Development officer; one (1) UNICEF Specialist for health and nutrition specialist; three (3) nutrition workers; three (3) members of a mothers' support group and, three (3) nurses from the therapeutic feeding center in Malakal teaching hospital. Altogether nine (9) mothers were conveniently selected from Malakal community responded to the study making a total of 26 respondents.

Instruments of data collection

Data were collected using a focus group discussion checklist-(FGDC) and an interview guide. The study questions related to steps taken to reduce the prevalence of malnutrition, the nature of malnutrition before and after the training, importance of the training to the mothers and the response of the mothers towards the training, whether it was positive or negative with possible reasons for the answers, trainers used, training methods used, duration of the trainings, language used, tools and materials used. The validity of the instruments was determined by expert review to establish whether the design of the instruments were grammatically correct and reasonable. Reliability and consistency of the instruments was tested by pretesting them in the field before actual collection of data and the pretest results were used to rephrase and modify some aspects of the instruments.

The data collection process included three focused group discussions (FGD); key informant interviews (KII) and Observations. The first FGD was held with nine (09) lactating mothers who attended one of the training sessions. The discussions centered on: The type of trainings attended by the mothers; duration of the trainings; the types of trainers; what was learnt from the trainings; the language used; the number of meals eaten per day with their children; whether or not they prepared separate food for the children and if so, what food; and, why they prepared separate food for the children.

A second FGD was held with the three (3) nutrition officers from the Ministry of Health at Malakal County.

The third FGD involved (3) members of a Mothers' Support Group. Later the responses from the separate FGDs were collated to obtain responses that had similar import.

Separate Key Informant Interviews (KII) were held with the three (3) nutrition coordinators, the three (3) nutrition officers, the three (3) nutrition workers, the UNICEF specialist, the Community Development Officer and the three (3) nurses in the South Sudan Ministry of Health (SMOH), Malakal County and two (2) officers from the media. Observations were made on the mothers attending nutrition training interventions at health training centers and the community-based training sessions.

Observation of training sessions has been used by other researchers (Liv 1995; Gunilla 2006; Vibe 2006). The observation checklist had items on training materials including posters, flipcharts, films, learning packages and training manuals; food preparation such as locally made and readymade food mixtures; communication between the trainer and trainees, participation of the trainees, trainees attitude towards the training (nonverbal behavior). In addition to the methods observation was supported by use of a camera and a recorder that helped to capture recordings and pictures that were analyzed later. Four session observations were made. The observations were collated to obtain observations that had similar import.

Ethical approval of the research was granted by Kyambogo University Graduate School, Uganda. Permission to conduct the study was granted by the authorities in Malakal South Sudan. A pre-visit was made to the research location and ethical considerations were put into account. Confidentiality of the respondents was ensured. The participants were informed in advance about the overall purpose of the study and assured that the study was for the good of the community. A cordial relationship was maintained with targeted centers, relevant authorities and the respondents for the success of data collection during the field work.

Findings

The study was carried out to identify the successes and shortcomings of the nutrition education and training intervention for malnutrition in Malakal, South Sudan. The findings are presented in accordance with the study objectives as follows:

(1) Nature and quality of the training programs used;

(2) Nature and quality of community based training;

(3) Nature and quality of the training at health centers; and

(4) Pedagogical issues.

Training programs

This study assessed the level of nutrition education and training interventions for mothers to address malnutrition among children and to identify areas for improvement of similar training programs. The findings revealed that the training programs identified to target mothers were designed by the Ministry of Health with support from UNICEF. However, there were other programs that were designed and packaged for other countries and adopted for use in the Republic of South Sudan since they were successful in those other countries.

The training programs aimed at creating awareness among mothers on malnutrition and included the following content areas:

exclusive breast feeding immediately after giving birth until six
months, hygiene and sanitation, safe motherhood, early marriages, basic
education, entrepreneurial skills and primary health care practices.

The programs were implemented by various stakeholders including Government and NGOs. The programs were implemented through training sessions and through the media, particularly radio programs. There were training manuals which contained materials and handouts that were used to enable facilitators prepare training for different levels of mothers. The manuals also served as resource materials for self-directed learning for both trainers and other persons involved in supporting or managing the training interventions.

The findings from interviews and FGD with stake holders as identified in the study population and the observations made in the course of the study are hereby given.

Implementation through the media

An official working with Saut-al-Mahaba-Voice of Love radio in an interview with the researcher stated that:

Nutrition problems are tackled through various radio programs. I
founded a program in Malakal County with the help of UNICEF in which
ideas on how to cure and prevent malnutrition are suggested to the
mothers, for example; not to give food to the children under six months.

She added that:

The highest prevalence of malnutrition in children is at the post
breast feeding stage because of lack of enough food to feed their
stomach; this is when they become malnourished and in this regard we
have also developed programs to educate mothers on how to cultivate
simple food crops and other money generating activities.

Community based training

The researcher attended four community-based training sessions to observe how the training sessions were being conducted. Three out of four center sessions were on hygiene promotion conducted by the SMOH. The instructors made descriptions and explained health education aspects, such as; hygiene education, health promotion, public health promotion, sanitation approaches and methods. Training methods used included; theoretical teaching, instruction, demonstration, group discussion, plenary presentation, and drama.

In another community-based training in Malakal county the researcher observed that there was a top down approach to teaching and learning. The following training methods were observed:

The theoretical methods accounted for most of the session time while demonstrations accounted for the least part of the session time. Mother-to-mother discussion was the most interactive and most interesting segment of the session. The discussion method accounted for the bigger part of the session than the demonstration method, but not as much as the theoretical or instruction methods. Therefore, though most interactive and interesting, the discussion method was used least.

Most UNICEF programs target hygiene promotion among others with specific focus on behavior change. The social worker with UNICEF stated as follows: Poor hygiene can affect the nutrition of children. So, it is important that mothers are encouraged to keep utensils clean and also wash their children's hands from time to time. For this to be achieved, training is important in providing the knowledge and important good practices as well as help change the attitude of mothers towards sanitation related malnutrition mitigation strategies and practices.

Language used in training sessions was mainly local Arabic.

Training tools and materials

During an interview with the trainers, nutrition officers, health and nutrition specialists, it was established that the tools and materials used in training included the following: Posters, flip charts, markers, note books and pens, visual aids, prepared questions and answers. The organization of the training program at Malakal had a structured time table with training sessions and breaks.

Training at the health centers

The researcher made observations on the conduct of training sessions and materials being used. At Malakal Paediatric Hospital, a take home brochure with a variety of foods was issued to the mothers. The brochure was adopted from a training course on the management of severe malnutrition. It had photographs of clusters of foods, such as carbohydrate foods, fruits, meats, legume protein such as beans and groundnuts. These were intended to show food groups. Most of the nutrition education activities were face-to-face contact with the mothers of malnourished children.

At Malakal feeding center, the pediatrician who was a nutrition officer advised the mothers to "give more fruits and vegetables, breast feed the children", and taught them the different types of food groups.

Effectiveness of the training programs

The training program consisted of the media for creating awareness, community-based training and health centers. Their effectiveness was assessed as follows:

Media programs

Sister Elena of the Saut-al-Mahaba radio station in an interview with the researcher stated that, "Women in rural areas appreciate the opportunity of receiving all this kind of education. Encouraging the girl child to take part in this kind of training will help in reducing malnutrition".

Health centers and community based training

In a FGD nutrition officers stated as follows:

It has been observed that mothers' interest in their children's
sickness has improved; when the child is sick they take him/her
immediately to the health care center. However, due to the far
distances of some villages to the health center, some of these children
die on their way to the health center.

In an FGD with Mothers Support Groups they stated as follows:

In general, training has been pertinent in teaching mothers on how best
to bring up a child in a good, healthy and clean environment, as well
as help them learn how to breast feed their children and prepare
special foods for them.

Therefore, in spite of other prevailing circumstances such as economic constraints, scattered health care centers, the training programs had raised some of the mothers' awareness of malnutrition prevalence within their communities and of the causes and symptoms of malnutrition. Also, mothers got aware of some of the mitigation strategies within their reach.

On appropriate nutrition training options for mothers social workers working with UNICEF in an interview stated as follows;

The most appropriate training is the hygiene promotion especially when
mothers are breast feeding. They need to wash their hands and breasts.

They further indicated that:

The way most mothers were brought up was adopted from the past
generation and therefore, it would be a tough task to have a visible
behavioral change in a short period of time.

Also, there was a possibility that some recommendations drawn by the training programs were not well thought through with particular reference to the local people. The communications officer at the SMOH in an interview pointed out that:

The training recommendations that the local people should boil drinking
water to make it safe yet boiling water takes a lot of charcoal which
is expensive.

Both UNICEF and GOSS expressed views that there were various challenges that still disabled the training interventions. The health nutrition specialist working with UNICEF indicated that:

Lack of motivation from trained mothers because there are no incentives
of the sort that go to them to motivate them to visit fellow mothers.
There is no specific place or centers where the mothers could gather
regularly to learn skills, lack of standard training materials to guide
the trainers, no regular budget for sustainable training, communication
barrier and accessibility when training starts.

A nurse at Malakal pediatric hospital had the following to say:

Social cultural beliefs and traditions mothers have superstitious
beliefs that if a child is malnourished it is because his mother
stepped on a chameleon. So when a child is sick they visit witch
doctors first. By the time they make up their minds to take the child
to real hospital, the effect is irreversible.

Therefore, it is possible that there was need for more adequate survey to be made before the training programs were developed. According to Andrien (1998) nutrition education is a complex intervention.

Pedagogical issues

The trainers and facilitators were making good preparations for the training sessions. However, there were various pedagogical aspects that were lacking in the various training interventions. For example, there was need to understand the knowledge being disseminated. There is detailed theoretical knowledge, general knowledge for information and detailed knowledge to explain why and how certain characteristic features occur between different phenomena and consequences of action in both short and long term perspectives. For example, knowledge to do with 'know what' in simple terms being knowledge about what goes on in certain instances, know why' being more theoretical understanding of what goes on; 'know how' being the core category knowledge of how things are done and 'know who' being knowledge of where to find new knowledge (Lorenz 2006).

Several training sessions were being given, which was good. There was need however, to adopt a more integrated approach to the training, for example mothers were being given one training session at a time, but these sessions needed to be related; A group of mothers attended breast feeding sessions for three days and a month later the same group attended training on hygiene promotion and this went on for the rest of the program, yet there were related aspects and characteristics within the various training sessions that could have been integrated. This meant that the learning outcomes were separated and the functional integration of competences would be lost, yet this is a fundamental factor in training.

Discussion

The Republic of South Sudan is a newly formed state in Africa. Efforts were made to improve nutrition knowledge of mothers through training, hygiene practices and access to safe water. This study assessed the level of nutrition education and training interventions for mothers to address malnutrition among children. The lessons may be used to inform similar training programmes on the continent. The discussion is structured on findings about the community based training and health center based training.

Community based training

Four community-based training sessions were attended to observe how the training was conducted in various training centers. Three out of four center sessions were for hygiene promotion under the Ministry of Health. From the observation it was revealed that:

1. The instructors made appropriate introductions of hygiene promotion.

2. Endeavored to make mothers understand the boundaries of various terminologies such as, health promotion, hygiene education and public health promotion, sanitation approaches and methods were secured.

Further observation indicated that some of the terminologies were quite complex for mothers to comprehend and the instructors found it challenging to translate some terminologies into the local language for the mothers to understand. In addition, in some cases the instructors required translators which made it even more challenging for the instructors to interact with mothers. Yet, learners could best learn through good regular and consistent instructor learner interaction or teacher-learner relationships. The learners would then experience learning as something worthwhile, meaningful and it would be a starting point for the development of competences and adjustment (Liv 2006). In situations where the instructors have enough one-on-one time with their learners, there is higher possibility for learners to comprehend messages from their experienced instructor. However, this was not very visible in the first session due to lack of a common language between the instructor and the mothers.

In another community based training session in Malakal County a top-down approach to teaching and learning was found. Furthermore, the following training methods were observed during training namely theoretical, instruction, demonstration and group discussion. The theoretical method was used in cases where the trainer introduced a terminology and explained it. Instruction method was used in cases where the instructors told mothers what was required of them. The theoretical method accounted for 80% of the session. Demonstration method was applied in cases where mothers were shown how to detect a malnourished child using weighing scales, rulers and a tape measure. This rather practical method accounted for less than 5% of the total session. Group discussion method accounted for approximately 15% of the session, and in this method mothers shared

their experiences with one another. This method was the most interactive and most interesting segment of the training session. The observed mix of training methods was good for adult learning. Theoretical methods were used as a first step in enlightening the trainees on key fundamental concepts. Demonstrations and hands-on practices were good during the training to compliment the theory learnt, meaning that participants must be shown first, how something is done and then supported in doing return demonstrations.

In addition, there were training sessions that were conducted through plenary presentations, drama and group discussions. The main language used during the training was local Arabic which was not known to some of the participants although there was a translation services. Most of the mothers were from Shiluk, Nuer and Dinka tribes who were pastoralists and fishermen, and had low literacy skills (Vikki 2011). It was also observed that in group discussions mothers shared their experiences with one another and such discussions were the most interactive and most interesting segment of the training sessions. The shared experiences could be significant learning experiences such as a life-event, a change event and an event of creativity or empowerment. Empowerment means a transformation in the individual's self-definition leading to change (Ari 1995). Such discussions provide opportunity to the mothers for self-study, which is a tool for systematic examination of one's practices or self for self-improvement or improvement of ones' practices. Cochran-Smith (2000) used self-study to unlearn racism. Therefore, the group discussions mothers engaged in could provide the mothers opportunity for self-study that could lead them to abandon inappropriate methods of feeding their children and adopt better child feeding practices.

The training in Malakal was based on a particular program which was time tabled. The time table had sessions and breaks during and after each session which was good practice. Rhythm and periodicity are important elements in the human task or activity since no human being can exist without them. For example, one night sleep may lead to impairs integrative executive functioning and this may be of special importance for individuals with cognitive work tasks (Jens et al., 2005). Therefore, it is apparently essential to adapt the organization of work and learning to the reality that a human is not a mechanical construction without these needs. This means that the scheme of the day has to be adapted to important variation related to human beings and to the surrounding contexts. Hence, the time table for the sessions was very important.

During an interview with the trainers, nutrition officers and a health and nutrition specialist,

it was established that: The tools and materials used during training included posters, mosquito nets, flipcharts and markers plus note books, pens, other visual aids, and questions and answers.

However, it was evident in one of the community based training sessions that the trainer was giving a lecture without using any of the above mentioned tools and materials. Yet the guidelines as the WHO (1995), emphasized that in the course of lecture it is important to use visual aids, such as a blackboard, charts, slides, or photographs to explain ideas.

In another training session, a nutrition officer gave a health education presentation without using any tools and materials, and next to her was the assistant helping her to translate the presentation from Arabic to the local language. Yet without appropriate tools and materials the training would not be effective in helping the mothers to retain the content or later on transform it and put it into use.

Nutritional status is a complex phenomenon which is influenced by many factors external to the training (Andrien 1998; UNICEF 2013). Therefore, time frames within which different indicators are achieved by interventions differ. The nutritional objectives should therefore, be defined with both short term and long-term objectives. This was found not to be the case with community based training programs in Malakal. The programs highlighted short term intervention strategies without long term intervention strategies. Yet, it is acknowledged that there is an innate human drive to make sense of the world. That is, rather than simply absorbing or passively receiving object knowledge that is 'out there', learners actively construct knowledge by integrating new information and experiences into what they have previously come to understand, revising and interpreting old knowledge in order to reconcile it with new knowledge. In the initial stages, this is peripheral participation as the new comers come to acquire the knowledge, culture, practices and values which help them to move from the position of 'outsider' to 'insider' (Garnet, 2006). Hence, it is important to include long term intervention strategies in the training programs.

Training at the health centers

During a training session at Malakal Pediatric Hospital, a take-home brochure with a variety of foods was issued to the mothers. The brochure was adopted from a training course on the management of severe malnutrition. The brochure had photographs of clusters of foods such as carbohydrate foods, fruits, meats, legume protein like the beans and groundnuts intended to show food groups. The brochure was good in that the photographs or pictures speak louder than words. However, use of this brochure had some limitations. For example, the instructions on the brochure were in Arabic and English. Some of the mothers could neither read Arabic nor English. Also, it showed food items that the mothers could not afford to buy.

It was also observed that most of the nutrition education activities implemented within the health centers used face-to-face contact with the mothers of malnourished children. The activities involved a one-way transfer of information and often the nutrition messages would be considered as a cure for nutrition problems by the mothers. For example, at Malakal feeding center, the pediatrician who was a nutrition officer advised the mothers to; give more fruits and vegetables, breast feed the children and taught them the different types of food groups.

These were good and pertinent messages. However, they could not be very effective as they used only one-way communication and not much would be heard from the mothers' perspectives. Besides, the training needed not only to focus on the promotion of individual behavior change, but also on encouraging active community participation because in a community everyone has equal responsibility for improvement of community welfare irrespective of his/her gender.

In addition, the training at the centers appeared to be paying little attention to the people's social and cultural contexts. Interventions should ideally be built on indigenous knowledge about local foods, their preparation and promote healthy eating patterns (Babu 2000; Kuhlein et al. 2013). Also, in all the four training sessions attended, none of them addressed the issue of traditional and socio-cultural practices that could have been accelerating malnutrition amongst the people in Malakal County. It was important to use and give information on the success of indigenous food systems and practices (Vikki 2011).

Conclusion

The purpose of the study was to assess the nutrition education and training interventions for mothers in Malakal Country, South Sudan. The results of the study revealed that the nutrition training programs were appropriate and were well received by the mothers. The programs were able to raise awareness and interest of the mothers in their children's well-being and taking their sick children immediately to the health centers. Nutrition education activities at the health centers used face to face contact with the mothers. Specific nutrition aspects in the programs included breast feeding and preparation of special foods for the children. However, there were pedagogical aspects to be addressed such as, appropriate use of training or teaching aids and teaching theory aspects. Besides, while the programs catered for short term intervention strategies, they needed to cater for long term intervention measures as well. Also, the training needed to aim at integration to avoid separation of related objectives and ensure integrated functional outcomes. However, the nutrition messages that were being passed on would be seen as a cure for nutrition problems and they were a one way communication without the mothers' perspectives. The training interventions at the health centers needed active community participation for community support for behavior change and every one irrespective of gender has the responsibility for the welfare of the community. The training programs also needed to address the socio-cultural practices that could have been accelerating malnutrition in the communities. It was important for example, to disseminate information on the success of indigenous food systems in nutrition interventions.

Acknowledgements

Norwegian Centre for International Cooperation in Education (SIU) and Board, NORAD Masters Program (NOMA) for financial support and Oslo and Akershus University College of Applied Sciences and Kyambogo University, Uganda, for technical support.

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Table (1) Training methods used for nutrition education of mothers in
Malakal County

Training method      Purpose
used

1. Theoretical       This was used in cases where the trainer
teaching             introduced a terminology and explained it.
2. Individualized    This was used in cases where the instructors
instruction          told mothers what was required of them.
3. Demonstration     This was applied in cases where mothers
                     were shown how to detect a malnourished
                     child using weighing scales, rulers and a
                     tape measure.
4. Group discussion  This is where mothers shared their
                     experiences with one another.