· STUDY OF THE KNOWLEDGE, ATTITUDE AND PRACTICE BETWEEN THE MOTHERS/CARETAKERS OF THE RECIPIENTS

AND NON-RECIPIENTS OF THE REHABILITATION PROGRAM FOR UNDERNOURISHED CHILDREN IN KUCHING DIVISION,

SARAWAK

Haseanti Binti Hussein

Master of Public Health 2012

P.KHIDMAT MAKL.UMAT AKADEMIK

1II1II111(Ii'lllI1111 III 1000246200

Faculty of Medicine and Health Sciences

STUDY OF THE KNOWLEDGE, ATTITUDE AND PRACTICE BETWEEN THE MOTHERS/CARETAKERS OF THE RECIPIENTS

AND NON-RECIPIENTS OF THE REHABILITATION PROGRAM FOR UNDERNOURISHED CHILDREN IN KUCHING DIVISION,

SARAWAK

Haseanti Binti Hussein

Master of Public Hea'lth UNIVERSITY MALAYSIA SARA WAK

2012

ACKNOWLEDGEMENT

First and foremost, I would like to express my deepest gratitude to my supervisor, Hajjah

Zainab Tambi, who had graciously spare her time and gave me advice throughout my project.

Without her precious guidance, this project report would not be complete.

I would also like to thank Assoc. Prof. Md. Mizanur Rahman who helped me to understand

statistics and made sense of my data. My heartfel,t gratitude is also to Dr. Cheah Whye Lian

for her continuous support.

Thank you to Dr. Zulkifli Jantan, the State Health Director, and Dr. Kamarudin Lajim, the

Kuching Divisional Health Officer, for their permission to go on with this project. Thanks to

Matron Bisek for her support.

Many thanks for the staffs of the health clinics of the Ministry of Health in the Kuching

division, Sarawak for their cooperation. Not forgetting the respondents, the

mothers/caretakers of the PPKZM recipients and non-recipients, without whose cooperation,

would not make this project possible.

To my sister, Azlindawati Hussein, who gave me assistance, during my project.

Last but not least, to my darling husband, who had sacrificed his time and energy, to help me

through this project, thank you very much, from the bottom of my heart.

11

ABSTRACT

The main macronutrient deficiency problem among Malaysian children is protein and energy

malnutrition, which is manifested in children being underweight for their age. The

Rehabilitation Program for Undernourished Children (Program Pemulihan Kanak-Kanak

Kekurangan Zat Makanan, PPKZM), is the government's effort to improve health and

nutritional status of children aged less than six years. It was implemented by the Ministry of

Health from 1989 till now. It was then an immediate strategy to rehabilitate 12,690

undernourished children detected through the Nutrition Surveillance System in 1988. In this

program, children who met the eligibility criteria were given food aid to help them obtain a

balanced and nutritious food, in order to achieve optimal physical and mental development. A

cross-sectional study was done among the mothers/caretakers of beneficiaries and non­

beneficiaries of the PPKZM program to determine their socio-demographic characteristics

and to assess the knowledge, attitude and practice on child nutrition in the Kuching Division,

Sarawak. The total respondents were 153. Majority of the respondents were in the 30-34 age

group; they were mostly Bidayuhs and Christians. Most of them attended until secondary

school. Nearly all of them were housewives. A high percentage (51.0 %) of them had a

family size of 3-4 persons and less than 3 children. Majority of the respondents had good

knowledge and good practice regarding child nutrition, but there was no statistically

significant differepce in knowledge and practice between the mothers/caretakers of the

PPKZM recipients and non-recipients. Most of the respondents had good attitude regarding

child nutrition. There was a statistically significant difference in attitude between the

mothers/caretakers of the PPKZM recipients and non-recipients (p<0.05). There were more

respondents with good attitude among the mothers/caretakers of the PPKZM recipients than

the mothers/caretakers of the PPKZM non-recipients indicating that the PPKZM program and

III

l

its related activities may have influence in affecting better attitude. The program should be

continued, periodically evaluated and implemented with more effective activities. Future

research should dwell more on the factors influencing the knowledge, attitude and practice of

the mothers/caretakers on child nutrition and its linkages to the children's nutritional status.

,,'

IV

ABSTRAK

Masalah kekurangan makronutrien utama di kalangan kanak-kanak Malaysia adalah

malnutrisi protein dan tenaga, yang dapat dilihat dengan jelas di kalangan kanak-kanak yang

kurang berat badan bagi umur mereka. Program Pemulihan Kanak-kanak zat (Program

Pemulihan Kanak-Kanak Kekurangan Rak Makanan, PPKZM), usaha kerajaan untuk

meningkatkan taraf kesihatan dan pemakanan kanak-kanak yang berumur kurang daripada

enam tahun. fa telah dilaksanakan oleh Kementerian Kesihatan dari 1989 hingga sekarang. fa

adalah strategi segera untuk memulihkan 12.690 kanak-kanak zat yang dikesan melalui

Sistem Pengawasan Pemakanan pada tahun 1988. Dalam program ini, kanak-kanak yang

memenuhi kriteria kelayakan telah diberi bantuan makanan untuk membantu mereka

mendapatkan makanan seimbang dan berkhasiat, untuk mencapai pembangunan fizikal dan

mental yang optimum. Satu kajian keratan lintas telah dilakukan di kalangan ibu / penjaga

penerima dan bukan penerima program PPKZM untuk menentukan ciri-ciri sosio-demografi

mereka dan untuk meniJai pengetahuan, sikap dan amalan mengenai pemakanan kanak-kanak

di Bahagian Kuching, Sarawak. Jumlah responden adalah 153 orang. Majoriti responden

berada daJam kumpuJan umur '30-34 tahun, di mana kebanyakan daripada mereka merupakan

kaum Bidayuh dan penganut Kristian. Kebanyakan mereka menghadiri sekoJah sehingga

peringkat menengah. Hampir semua mereka adalah suri rumah. Peratusan yang tinggi

(5 t .0%) daripada mereka mempunyai saiz keluarga orang 3-4 dan kurang daripada 3 orang ...

anak. Majoriti responden mempunyai pengetahuan yan'g baik dan amaJan yang baik mengenai

pemakanan kanak-kanak, tetapi tiada perbezaan statistik yang signifikan daJam pengetahuan

dan amalan di antara ibu / penjaga di penerima PPKZM dan bukan penerima. Kebanyakan

responden mempunyai sikap yang baik mengenai pemakanan kanak-kanak. Terdapat

perbezaan statistik yang signifikan dalam sikap antara ibu / penjaga di penerima PPKZM dan

v

bukan penerima (p <0.05). Terdapat lebih banyak responden dengan sikap yang baik di

kalangan ibu / penjaga penerima PPKZM yang daripada ibu / penjaga penerima bukan '"

PPKZM menunjukkan bahawa program PPKZM dengan program berkaitan mempunyai

pengaruh dalam mempengaruhi sikap yang lebih baik. Program ini perlu diteruskan, dinilai

dan dilaksanakan dengan aktiviti-aktiviti yang lebih berkesan. Kajian masa depan harus

dilanjutkan mengenai faktor-faktor yang mempengaruhi pengetahuan, sikap dan amalan ibu /

penjaga mengenai pemakanan kanak-kanak dan hubungannya kepada status pemakanan

kanak-kanak.

,,'

"

vi

--

I

Pusat Khidmat MakJumat Akadcmik UNlVERSm MALAYSIA SARAWAK

T ABLE OF CONTENTS

Acknowledgement .. 1\

Abstract III

TABLE OF CONTENTS

LIST OF FIGURES Xiii

VII

LIST OF TABLES XI

CHAPTER ONE: INTRODUCTION

1.1 Background

1.2 Statement of the Problem 2

1.3 General Objective of the Research 8

1.3. I Specific Objectives 8

1.3.2 Research Questions 8

1.3.3 Research Hypotheses 8

1.4 Conceptual framework 9

1.5 Operational Definitions 9

1.6 Significance of the Research 10

CHAPTER TWO: LITERATURE REVIEW 12

2.1 Malnutrition 12.'

2.1. I Patophysiology 13

2.1.2 Epidemlology , 15

2. 1.3 Mortality/Morbidity 16

2. 1.4 Age 17

VII

-

2.1.5 History 17

2.1.6 Causes 17

2. 1.7 Risk factors 18

2.1.8 Relevant Tests 19

2.1.9 Deterrence/Prevention 20

2.1.10 Prognosis 21

2.2 Role of Poverty in Malnutrition 21

2.3 Poverty Line 23

2.4 The Rehabilitation Program Program tor Undernourished Children 24

(Program Pemulihan Kanak-Kanak Kekurangan Zat Makanan)( PPKZM)

2.4.1 Objectives 24

2.4.2 Activities Conducted 24

2.4.3 Eligibility Criteria 25

2.4.4 Rehabilitation Criteria- 26

2.4.5 Termination Criteria for Food Supply 26

2.5 Knowledge, Attitude and Practice of Mothers/Caretakers Regarding 27

Child Nutrition

CHAPTER THREE: METHODOLOGY 28

3.1 Research Design and Setting 28

3.2 Populati~n and Sampling 28

3.2.1 Inclusion Criteria 32

3.2.2 Exclusion Criteria 33

viii

3.3 Research instrument 33

3.3.1 Variables studied

3.3.2 Methods of Collecting Data

3.3.3 Pilot Study

3.4 Data Entry and Analysis

3.5 Ethical Considerations

3.6 Limitations

CHAPTER FOUR: RESULTS

4.1 Introduction

4.2 Socio-demographic characteristics of the respondents

4.2.1 Age

4.2.2 Religion

4.2.3 Race

4.2.4 Level of education

4.2.5 Employment status

4.2.6 Family size

4.2.7 Number of children

4.3 Know ledge, Attitude And Practice Between The Mothers/Caretakers Of

The Recipients And Non-Recipients of PPKZM

4.3.1 ,,' Knowledge

4.3.2 Attitude

4.3.3 Practice

4.4 Summary

33

34

35

36

37

37

38

38

38

38

39

40

41

42

43

43

44

44

45

46

47

IX

CHAPTER FIVE: DISCUSSION 49

5.1 Introduction 49

5.2 Soc io-demographic characteristics 49

5.3 Knowledge 52

5.4 Attitude 55

5.5 Practice 55

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS 57

6.1 Conclusion 57

6.2 Recommendations 57

6.3 Limitations of the study 57

BIBLIOGRAPHY 59

APPENDICES 69

x

LIST OF TABLES

Tables

1.\

1.2

3.1

3.2

4.1

4.2

4.3

4.4

4.5

4.6

4.7

4.8

4.9

4.10

Page.,

Global and regional trends in the estimated prevalence of protein­ 3

energy malnutrition in underweight children under five, since 1980

Global and regional trends in the estimated prevalence and numbers of 4

stunted chi Idren under five years of age, since 1980

Distribution of population by ethnic group and district for Kuching 28

division

Number of malnutrition cases and recipients and non-recipients of 29

PPKZM program for Kuching Division, Sarawak 20 I 0

Distribution of the respondents by age (N= 153) 37

Distribution of the respondents by religion (N=153) 38

Distribution of the respondents by race (N=153) 38

Distribution of the respondents by level of education (N=153) 39

Distribution of the respondents by employment status (N=153) 40

Distribution of the respondents by family size (N=153) 40

Distribution of the respondents by number of children (N=153) 41

Knowledge level between the mothers/caretakers of the recipients and 42

non-recipients of PPKZM

Attitude level between the mothers/caretakers of the recipients and non­ 43

recipients of PPKZM

Practice level between the mothers/caretakers of the recipients and non- 44

recipients ofPPKZM

XI

I

Tables Page

4.11 Summary of findings 45

.'

XII

LIST OF FIGURES

Figures Page

1.1 Regional and global trends in estimated numbers of underweight 2

children <5 years

1.2 Conceptual framework 8

3.1 Sarawak map - showing the II divisions 26

3.2 Kuching division map - showing the 3 districts: Kuching, Bau 27

and Lundu .

.'

XIII

CHAPTER ONE

INTRODUCTION

1.1 Background

The main macronutrient deficiency problem among Malaysian children is protein and

energy malnutrition. This is manifested in children being underweight for their age. The

Rehabi litation Program for Undernourished Children, also known as the Food Basket

Program is the government's efforts to improve health and nutritional status of chi Idren less

than ix years. It was implemented by the Ministry of Health in 1989 throughout the country.

It was an immediate strategy to rehabilitate 12,690 children who were detected to be

undernourished through the Nutrition Surveillance System in 1988. In this program, children

who met the eligibility criteria were given food aid to help them obtain a balanced and

nutritious food, in order to achieve optimal physical and mental development. The children

involved were also to be given' treatment (if suffering from any illness), immunization, health

education and health care and monitoring care (Anonymous, 2009).

An evaluation study conducted in 2003 to evaluate the program found that 76 percent

of the children showed improvement in weight-for-age after being enrolled in the program for

about tw and a half years. Several weaknesses of the program were reported. These included

the delay in the delivery of food once a child was iQentified to be eligible in the program,

unsuitabil ity and unacceptability of some of the food especially among infants and young

children. The food items were found to be low in key nutrients such as calcium and iron. The

study also found that there were poor linkages and coordination with the relevant agencies

(Anonymous, 2003). The program has been revised and a new approach has been identified

for future implementation (Anonymous, 2009).

Beginning in 2006 and in 2008, efforts to improve the program were implemented.

These included the improvement of services provided, improving the food supply, rising

prices of food baskets, and widening the scope of the food basket recipients along with an

increased level of poverty line (poverty line) Hardcore Poor set by the Economic Planning

Unit.

1.2 Statement of the Problem

Overall progress during the last twenty years in reducing protein-energy malnutrition

(PEM) among infants and young chi tdren has been exceedingly slow. It was not adequate

even to approach the year-2000 goal of a 50% reduction in 1990 prevalence levels. During

the 1990s, the projected goal had been to reduce global malnutrition to having no more than

16.1% (87 million) under-five children malnou·rished. Currently, an estimated 149.6 million

children under five years of age, i.e. 26.7% of the world's children in this age group, are still

malnourished when measured in terms of weight for age. Nevertheless, this clearly represents

significant progress when compared with the 175.7 million children- a prevalence of

37.4o/o-who were malnourished in 1980 (see Figure 1.1 and Table 1.1) (WHO, 2000).

2

--- - - - - -

10C

180

16C

loW ~

J:l 120£ a 100 :u

..a 80 ~ Z 60

40

20

Africa liltin America TotJl for deW'lcplng {Ountr1£5

1980 1990 1995 2000 . 20c0goal

Source: WHO Glob,,1 D,)!.Jbase on Chiid Glowtlt and Malnulririot" 2000

Figure 1.1: Regional and global trends in estimated numbers of underweight children <5 years

Table 1.1: Global and regional trends in the estimated prevalence of protein-energy malnutrition in underweight children under five, since 1980

.-.-.-.--- - ----- .--.. .--~- --- _._---­~

t llll 1'111 1MS leIIO -.--~---.--

l!;'l«I Mil % M","- 'iIo iJlien "4 MiliiOli

Africa 26.2 22.5 27.3 30.1 27.9 34.0 28.5 38.3

Asia 43.9 146.0 36.5 141.3 32.8 121.0 29.0 108.0-_... ---- ...- .. -.- .....-........- ---....----..-..-..------~.

Lillin America 14.2 7.3 10.2' 5.6 83 4.5 6.3 3.4 ~..... -- .. '-.-.-.-."'~" ..- ..---- .. -...... ... ......-.. ", ... ......-_._----.-.._.-_ ..

Developing countries 37.4 175.7 32.1 177.0 29.2 159.5 26.7 149.6

(Source: WHO Global Database on Child Growth and Malnutrition, 2000.)

Although this continuing global burden of malnutrition is rooted in poverty,

underdevelopment, and inequality, some of the additional reasons behind PEM's persistence

can be found by looking at the regional trends and numbers of children affected. As an.'

illustration, in some areas the drop in percentage prevalence has not been as rapid as the rise

in population. In Africa for example, the actual number of malnourished children has in fact

risen as a result of this population growth. In addition, natural disasters, wars, civil

3

disturbances, and population Jisplacement have all contributed to a continuous creeping

increase in the already high prevalence of malnutrition in Africa (WHO, 2000).

Geographically, however, over two-thirds (72%) of the world's malnourished children

live in Asia (especially southern Asia). This figure compares with the 25.6% found in Africa

and only 2.3% in Latin America. An estimated 182 million children under 5 years of age,

representing 32.5% of all preschool children in developing countries, are malnourished when

measured in terms of height for age (i .e. , stunted) (WHO, 2000).

Stunting prevalence rates vary widely across nations. The highest rates can be found

in south central, Asia and east~rn Africa, where about half of the children suffer from some

degree of growth retardation. In Latin America, the severity of stunting is considerably lower.

The trend in Africa is disturbing, where the number of children who are stunted has been

increasing, although the prevalence is decreasing. The health consequences of the current

high prevalence of child growth retardation in developing countries are severe (see Table

1.2).

Table 1.2: Global and regional trends in the estimated prevalence and numbers of stunted children under five years of age, since 1980

---- ---_.------- ----------._.-._.._..._-- -_ ._ ---- - ----­tlllO

RegiOll % MUIiOli --------~---------

1 5

ilion "10 Mil "" ------ - -------­

Africa 40.5 34.8 37.8 41 .7 36.S 44.5 35.2 47.3 18.9 . . .._._-_..__ ..•__•.•._--.__....._-_ .. _.... ....-...._--.------_....•,..._-----_............._---- -.._---_ ....-- ..... ,-", ..." ..•_----­

Asia 52.2 173.4 433 167.7 38.3 143.5 34.4 127.8 21 .7 -~.....-- .. .. . .._---_.._--_._ -_._ ._--------­

Latin America & the Caribbean 25.6 B.2 19.1 10.4 i 5.8 8.6 12.6 6.8 9.6

-

.--- ----- - - - -­Developing countries 47.1 221.4 39.8 219.8 36.0 196.6 32.S 181.9 19.9

Sourcf: WHO Global Databaw on Child Growth and Malnutrition. 2000.

4

Pusat Khidmat MakJumat Akademik UNlVERSITI MALAYSIA SARAWAK

High global prevalence rates for PEM conceal, in statistical averages, the remarkable

successes being achieved by a substantial number of individual Member States of WHO. '"

Many have made great strides, particularly since the International Conference on Nutrition in

1992, in allocating more resources to combat malnutrition. For example, 49 of a total sample

of 69 developing countries now show a measurable improvement in nutritional status-and

thus declining rates of stunting-in their under-five populations. Fifteen such countries (of a

subtotal of 31 in the region) are in Africa, 16 (of 19) are in Latin America, and 18 (of \9) are

in Asia (WHO, 2000).

Supplementary feeding is defined as the provision of extra food to children or families

beyond the normal ration of their home diets. The impact of food supplementation on child

growth merits careful evaluation in view of the reliance of many states and NGOs on this

intervention to improve child health in developing countries (Sguassero et a\. , 2005).

Supplementary feeding programmes are relatively large programmes in which a

substantial number of beneficiaries are covered through the support of donors, international

agencies and local governments. Such programmes are primarily designed to distribute food

among children between the ages of six months and six years in order to improve their

nutritional status or to prevent deterioration in their health and nutrition, both under

emergency conditions and in response to chronic food and nutrition insecurity and structural

vulnerability.

Such programmes normally target their interventions administratively by selecting the

target groups according to geographic location, age or income level. The programmes might

select the most disadvantaged rural areas and/or the poorest urban slums. The most common

criterion for electing eligible children is the child's nutritional vulnerability, and

5

anthropometric measurements such as weight-for-age or weight-for-height indices are often

used to establish eligibility for programme participation.

Many supplementary feeding programmes involve distributing a take-home food

ration to mothers through health centres, on a weekly basis or less frequently. In some

countries, the programme is well integrated into the primary health care services in which

immunization, oral rehydration, family planning, health and nutrition education, growth

mon itoring and various other preventive and curative services are offered at the same time.

Some programmes also include feeding children who attend day care centres, or feeding

severe ly malnourished children attending nutrition rehabilitation centres; others distribute

food rations to pregnant and lactating mothers. In take-home food programmes, recipes can

be demonstrated to help families learn how to use unfamiliar foods, increase variety in home

meals and prepare meals for weaning-age and sick children. These programmes can also

demonstrate the type and amount of food to feed young children or other vulnerable family

members.

In supplementary feeding programmes it must be ensured that the ration provided is

consumed personally by the intended beneficiary in order to derive a direct benefit from the

programme. Leakage may take place within the household. Foods provided by the

programme should be based on local food habits and cultural practices, to reduce programme

leakage. Intra-household leakage can also be reduced through food selection, if specific

household members are targeted for supplementary feeding.

There are some of the special concerns related to supplementary feeding programmes.

These includes leakage to unintended beneficiaries can be caused by incorrectly applied

eligibility rules, infrequent monitoring of eligibility, the absence of clearly stated exit rules,

6

or incorrectly applied/enforced exit rules. In addition, the time and energy costs to

participants obtaining the distributed food(s) in relation to the value (to the participants) of

the food should be such as to provide the target group with a clear incentive to participate.

There is also leakage resulting from intra-household sharing of the supplementary food(s) can

be reduced through the choice of what foods to distribute (e.g. typical weaning foods that are

not consumed by older children and adults), or by providing the household with a ration that

is larger than that needed by the target child (FAO, 20 II).

The Malaysian national food assistance program for children - Program Pemulihan

Kanak-Kanak Kekurangan Zal Makanan (PPKZM) - is an example of supplementary feeding

program. In 2003, an internal national evaluation conducted jointly by the Institute for

Medical Research (IMR), the Malaysian Ministry of Health (MOH), the State Health

Departments (SHDs) and the Public Health Institute (PHI) severely criticized the PPKZM for

its limited impact on child nutritional status, particularly child weight-for-age measures.

Citing the lack of significant improvement and the relatively high expense for measured

benefit, the evaluation concluded: "The cost of rehabilitation was astronomical by any

estimate, and there was just too little effect to warrant the program ' s continuation in its

present Ii rm" (Anonymous, 2003). However, modifications have been made to the program

since then to improve the outcome of the program.

In Malaysia;' this is to help achieve the United Nation 's First Millennium

Developmental Goal which is to eradicate extreme poverty and hunger. It is aimed at Target

Ie: reduce by half the proportion of people who suffer from hunger. This includes the

prevalence of underweight children under-five years of age and the proportion of popUlation

below minimum level of dietary energy consumption (Anonymous, 20 II).

7

1.3 General objective of the research

To compare the knowledge, attitude and practice between motherslcaretakers of children in

the PPKZM program (beneficiaries) and mothers/caretakers of children not under the

PPKZM program (non-beneficiaries).

1.3.1 pecific Objectives

I. To describe the sociodemographic characteristics of the respondents

(mothers/caretakers).

2. To compare the knowledge, attitude and practice between mothers/caretakers

of children in the PPKZM program and mothers/caretakers of children not

under the PPKZM program regarding child nutrition.

1.3.2 Research Questions

I. What are the sociodemographic characteristics of the respondents

(mothers/caretakers) i.e. age, gender. religion, race, educational level,

employment status, family size, and the number of children?

2. Are there significant differences of knowledge, attitude and practice between the

motherslcaretakers of the children under the PPKZM program and not under the

PPKZM 8rogram regarding child nutrition?

Research Hypotheses

I. There are significant differences of knowledge, attitude and practice between the

mothers/caretakers of the PPKZM recipients and the motherslcaretakers of the

PPKZM non-recipients.

8

1.4 Conceptual Framework

The conceptual framework is as shown in Figure 1.2.

Independent variable

Dependent variable

Sociodemograph ic characteristics: • Knowledge on

• Age child nutrition

Gender • Attitude on child• --..

• Religion nutrition

Race • Practice on child• Education level

nutrition• • Employment status

• Family size

• Number ofchildren

Figure 1.2: ConcS!ptual framework

Mothers/ caretakers of beneficiaries of

.----­the PPKZM program

,..------.

Mothers/ caretakers

- of non-beneticiaries of the PPKZM program

I.S Operational Definitions

I. Knowledge:

The state or fact of knowing, or familiarity, or awareness, or understanding gained

through experience or study. It can also be said as specific information about

something. _

Good knowledge - Grade for respondents who score equal to/above the mean level of

knowledge.

Poor knowledge - Grade for respondents who score below the mean level of

knowledge.

9

2. Attitude:

The way of thinking or perception that influences one's behavior towards a program. "

Positive attitude - Grade for respondents who score equal to/above the mean level of

attitude.

Negative attitude - Grade for respondents who score below the mean level of attitude.

3. Practice:

For both the mothers/caretakers of beneficiaries and non-beneficiaries of the PPKZM

program, this takes into account the behaviors and actions taken by respondent in

response to the desire to seek for knowledge regarding child nutrition.

Good practice - Grade for respondents who score equal to/above the mean level of

practice.

Poor practice - Grade for respondents who score below the mean level of practice.

4. Target groups:

The mothers/caretakers of children registered under the PPKZM program and the

mothers/caretakers of malnourished children under 6 years old not under the PPKZM

program, from almost similar socioeconomic characteristic as the cases attending the

same clinic.

1.6 Significance of the Research

This tudy is done to see if the efforts that had been made to improve the PPKZM

program resulted in improvement of the outcome of the program, specifically for the

knowledge, attitude and practi'ce. The last evaluation study in 2003 did not cover the aspect

of knowledge, attitude and practice among mothers/caretakers of the chi Idren involved in the

PPKZM program. The research wou'ld also provide information on the knowledge. attitude

10