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Association between Fruit and Vegetables eating habits

and practices in relation to the prevalence of diet


related chronic non-communicable diseases in
Zanzibar, Tanzania

Europubhealth masters degree in Public Health


2010-2011 University of Sheffield
2011-2012 University of Copenhagen

Amlie Keller
Nutritionist - BSc in Nutrition and Dietetics - MPH

Supervisors
Professor Maximilian de Courten, School of Global Public Health, University of
Copenhagen.
Doctor Tania Aase Drbel, School of Global Public Health, University of Copenhagen.

Copenhagen, May 2012



Key words: NCDs, Fruits, Vegetables, Diabetes, Hypertension and Obesity

Abstract
Obesity, diabetes, some cancers and hypertension are diet-related NonCommunicable Diseases (NCDs). NCDs are the leading cause of deaths in
developed countries and account for approximately one-third of deaths in
developing ones. According to the FAO/WHO joint report on fruit and
vegetables for health (2004), low fruit and vegetables consumption is
associated with NCDs. In developing countries, NCDs such as diabetes mellitus
and hypertension are estimated to become the leading cause of morbidity and
mortality by 2020. In Zanzibar, the incidence of diabetes has increased from
252 new cases in 2006 to 373 in 2008 and hypertension is the third most
common cause of hospital admission and second cause of death after
pneumonia (Jiddawi, 2008, TRGZ, 2010).
The two aims of this study were to identify and explore the association between
fruit and vegetables eating habits and practices and the prevalence of diet
related chronic non-communicable diseases in Zanzibar and to investigate how
the quantitative data collection regarding fruit and vegetables consumption in
the NCD survey was carried out.
The design of this study is: Contextual mixed methods research with
triangulation of quantitative and qualitative data. The quantitative component of
the study is a secondary analysis of data on obesity, hypertension, diabetes
and fruit and vegetables consumption previously collected in the Zanzibar NCD
survey. The qualitative component includes ten household observations and
several market observations. Furthermore, a literature review was undertaken
in order to further understand the context of the study area.
The findings showed that the mean daily fruit intake was 0.9 (SD 0.8) and
mean daily vegetable intake was 0.7 (SD 0.6). These findings are below the
minimum five portions of fruit and vegetables per day recommended by the
World Health Organisation. There were three times more obese women
(19.4%) than men (6.4%), 38% of men and 33% of women were hypertensive
and 2.2% of men and 2.8% of women were diabetic. The prevalence of
diabetes, hypertension and obesity was higher in urban areas than rural ones.
People from rural areas earned on average 4.5 times less than in urban ones
Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

and were more restrained in their choice of fruit and vegetables. The household
observations suggested a relationship between rural/urban setting, kitchen
facilities, cooking practices and food diversity as well as consumption of
vegetables. Furthermore, fruits seemed to only be considered as a snack and
not used in food preparation. The findings also underlined the importance of
adapting quantitative data collection tools for future research in order to better
evaluate fruit and vegetables consumption and its association with diet-related
NCDs.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

Index

ABSTRACT ................................................................................................................................................................2
LIST OF FIGURES .....................................................................................................................................................6
LIST OF TABLES ......................................................................................................................................................6
ACKNOWLEDGEMENTS ..........................................................................................................................................7
INTRODUCTION .......................................................................................................................................................9
Worldwide NCDs trends, causes and consequences........................................................................... 9
BACKGROUND .......................................................................................................................................................12
NCDs in Zanzibar ............................................................................................................................................12
Food security and diet in Zanzibar .........................................................................................................14
RESEARCH QUESTION..........................................................................................................................................18
Aim ........................................................................................................................................................................18
Specific objectives ...........................................................................................................................................18
METHODOLOGY ....................................................................................................................................................19
Research Design ..............................................................................................................................................19
SAMPLE DESIGN ...................................................................................................................................................24
Quantitative part ............................................................................................................................................24
Qualitative part ...............................................................................................................................................25
RESEARCH MEASURES ........................................................................................................................................27
Quantitative ......................................................................................................................................................27
Qualitative .........................................................................................................................................................27
INCLUSION- EXCLUSION CRITERIA ....................................................................................................................28
Quantitative ......................................................................................................................................................28
Qualitative: ........................................................................................................................................................28
ETHICAL CONSIDERATIONS ................................................................................................................................29
RESULTS ................................................................................................................................................................30
Descriptive results ..........................................................................................................................................30
Fruits and vegetables definition and meaning ..................................................................................31
Availability & cost of fruits and vegetables in Zanzibar ................................................................32
Kitchen facilities and food diversity in rural and urban households of Zanzibar ..............38
Gender and age differences regarding fruit and vegetables preparation and
consumption......................................................................................................................................................42
Association between NCDs and fruit and vegetables consumption in rural and urban
areas .....................................................................................................................................................................46
Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

DISCUSSION...........................................................................................................................................................54
Reliability and validity..................................................................................................................................54
External validity ..............................................................................................................................................57
Transferability and Dependability ..........................................................................................................57
Triangulation of quantitative and qualitative findings to analyse NCDs and nutritional
trend .....................................................................................................................................................................59
Future research ...............................................................................................................................................61
Limitations of the study ...............................................................................................................................62
CONCLUSION .........................................................................................................................................................63
Recommendations ..........................................................................................................................................64
REFERENCES .........................................................................................................................................................65
LIST OF APPENDIX ...............................................................................................................................I

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

List of Figures
FIGURE 1: OUTSIDE VIEW OF DARAJANI MARKET ..................................................................................................................33
FIGURE 2: INSIDE DARAJANI MARKET .......................................................................................................................................33
FIGURE 3: FRUITS AND VEGETABLES AT DARAJANI MARKET ................................................................................................36
FIGURE 4: FRUITS AND VEGETABLES AVAILABLE AT LOCAL RETAILERS ..............................................................................36
FIGURE 5: OPEN KITCHEN IN RURAL AREA (LEFT SIDE) VS. CLOSED KITCHEN IN URBAN AREA (RIGHT SIDE) ..............39
FIGURE 6: CONTRAST BETWEEN KITCHEN UTENSILS IN RURAL AREAS (LEFT SIDE) AND URBAN AREAS (RIGHT SIDE)
.............................................................................................................................................................................................40
FIGURE 7: COOKING PROCESS IN RURAL (FIRST PICTURE, LEFT SIDE), SUB-URBAN (MIDDLE PICTURE) AND URBAN
AREAS (RIGHT SIDE) .........................................................................................................................................................40

FIGURE 8: CONTRAST BETWEEN RURAL (LEFT SIDE) AND URBAN KITCHENS LAYOUT (RIGHT SIDE).............................40
FIGURE 9: MEN VS. WOMEN NUMBER OF SERVINGS OF FRUITS AND VEGETABLES PER DAY .............................................44
FIGURE 10: MAIN MEAL FOOD DISPLAY IN URBAN (LEFT SIDE) RURAL (MIDDLE) AND SUB-URBAN (RIGHT SIDE)
HOUSEHOLDS .....................................................................................................................................................................45

FIGURE 11: EATING PROCESS PEOPLE SHARING PLATES IN THE RURAL AREA OF BWEJUU ...........................................45
FIGURE 12: BOX-AND-WHISKER PLOT OF BLOOD PRESSURE AND FRUIT INTAKE ..............................................................49
FIGURE 13: BOX-AND-WHISKER PLOT OF BLOOD PRESSURE AND VEGETABLES INTAKE ..................................................49
FIGURE 14: ONE EXAMPLE OF TEATIME: BOILED CASSAVA (THE TWO WHITE PIECES) AND FRIED FISH. ......................51

List of Tables
TABLE 1: DEFINITION OF DIABETES, HYPERTENSION, OBESITY AND LOW FRUIT & VEGETABLES CONSUMPTION....... 8
TABLE 2: FRUIT AND VEGETABLES ASSESSMENT, STEP QUESTIONNAIRE .........................................................................20
TABLE 3: MEAN SD FOR AGE, BMI, SBP, DBP, FBG, WHR, F&V INTAKE, EDUCATION AND INCOME ....................30
TABLE 4: NUMBER AND PERCENTAGE OF OBESE, HYPERTENSIVE AND DIABETIC PEOPLE DIVIDED BY GENDER ...........31
TABLE 5: DIFFERENCES BETWEEN FRUIT AND VEGETABLES AVAILABILITY AT DARAJANI MARKET AND AT LOCAL
RETAILERS ..........................................................................................................................................................................35

TABLE 6: INCOME IN RURAL VS. URBAN AREAS .......................................................................................................................37


TABLE 7: COOKING FACILITIES IN TEN HOUSEHOLDS IN RURAL AND URBAN AREAS OF ZANZIBAR .................................42
TABLE 8: BMI, DBP, SBP AND FBG IN RURAL VS. URBAN AREAS.......................................................................................51
TABLE 9: FOOD INGREDIENTS* USED IN 10 HOUSEHOLDS AT THE TIME OF THE OBSERVATIONS, UNGUJA ...................53

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

Acknowledgements
I would like to specifically thank my two supervisors from the University of
Copenhagen, Pr Maximilian De Courten and Dr Tania Aase Drble as well as
Ms Asha Hassan and Mr Abuu Juma from the Nutrition Unit of the Ministry of
Health in Zanzibar for their help and support. I also would like to thank Dr Jutta
Mari Adelin Jrgensen, Dr Geoffrey Hunt and Dr Alessio Boldrin for reviewing
my thesis.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

List of content (acronyms)


BMI Body Mass Index
BNPL Basic Needs Poverty Line
BP Blood Pressure
CHD Coronary Heart Disease
CVD Cardiovascular Disease
DBP Diastolic Blood Pressure
FAO Food and Agriculture Organisation
FBG Fasting Blood Glucose
HT - Hypertension
MoH Ministry of Health
NCDs Non-Communicable Diseases
SBP Systolic Blood Pressure
WHO World Health Organisation
WHR Waist to Hip Ratio
ZFSNP Zanzibar Food Security and Nutrition Programme
ZFSNSA Zanzibar Food Security & Nutrition Situation Analysis

Table 1: Definition of Diabetes, Hypertension, Obesity and Low Fruit &


Vegetables consumption
FBG>7mmol/l (NHS and Dietetics, 2012).

Diabetes

Excluding non-fasting respondents and those


currently on medication for diabetes
Hypertension

SBP>140mmHg

or

DBP>90mmHg

(NIH,

2003). Excluding people on medication for


raised BP
2

Obesity

BMI>30kg/m (WHO, 2011a)

Low Fruit consumption

Less than two portions* per day

Low Vegetable consumption

Less than three portions* per day

Low Fruit & Vegetables consumption

Less than five portions* per day

* One portion = 80g (WHO, 2003)

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

Introduction
Worldwide NCDs trends, causes and consequences
Obesity, diabetes, some cancers and hypertension are diet-related NonCommunicable diseases (NCDs) (see definition in Table 1). NCDs are the
leading cause of deaths in developed countries and account for approximately
one-third of deaths in developing ones. According to the NCD Alliance (2012),
in the next ten years an increase of 27% of NCDs will occur in African countries.
The increased prevalence of NCDs is due to different socio-economic factors
such

as

industrialisation,

urbanisation,

economic

development

and

globalisation. Furthermore, the prevalence of NCDs can be linked to a


demographic transition that leads to an epidemiological transition. The former
refers to a change from a period of high fertility and mortality to a low fertility
and mortality one due to economic development, education and employment.
The latter refers to a modification from a period of high prevalence of infectious
diseases to a period of high prevalence of chronic NCDs (Hossain et al., 2007,
Roberts, 2005, Zimmet, 2000, Darnton-Hill et al., 2007). In addition, diet-related
NCDs are linked to the nutrition transition that involves more energy-dense food
and fewer physical activity (Kennedy, 2005, Popkin, 2001). Non-communicable
diseases increase inequalities because they disproportionately affect poor
people. Poverty is also caused by NCDs because of the persisting expenditure
related to chronic diseases and loss of productivity (Beaglehole and al., 2011,
DeSchutter, 2011).
A double burden of malnutrition (under- and over-nutrition) affects most low and
middle-income countries in Sub-Saharan Africa. Issues of underweight and
overweight/obesity1 occur concurrently. Overweight and obesity are important
risk factors for NCDs such as diabetes and hypertension (Hossain et al., 2007,
Kelly et al., 2008). According to Kelly et al. (2008), The high prevalence of
overweight and obesity, combined with their concomitant health risks, makes it
a particularly relevant worldwide public health challenge, p.1431. Indeed, in
their estimation of the worldwide prevalence of overweight and obesity in 2005,
1

Underweight is defined by a BMI < 18.5; normal weight = BMI between 18.5 and 24.9; overweight = BMI 25 to 29.9;
2

obesity = BMI > 30. BMI stand for Body Mass Index. Calculation: weight (Kg) / Height (m) .
(WHO (2011) Global database on Body Mass Index. BMI classification: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html)

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

Kelly et al. (2008) found that 23.2% (937 million people) of the worlds adult
population was overweight (24% men and 22.4% women) and 9.8% (396
million people) was obese (7.7% men and 11.9% women). Concurrently, over
the last 20 years the obesity rate has tripled in developing countries. The
projection for 2030, which takes into account changes in population,
urbanisation and secular trends and are based on the estimate for 2005,
indicates that the absolute numbers of overweight and obese people may
increase to a total of 2.16 billion (38%) people worldwide and 1.12 billion people
in developing countries (20%). (Zimmet, 2000, Schmidhuber and Shetty, 2005)
Diabetes and overweight/obesity are linked. Indeed, it is estimated that about
90% of type 2 diabetes is associated with excess weight (Hossain et al., 2007).
Changes in lifestyle such as increased caloric intake and diminution of physical
activity, population growth, aging and urbanisation contribute to the epidemic of
overweight and obesity (Kelly et al., 2008, Nguma, 2010). In addition, these
factors also impact on diabetes prevalence. Estimations based on demographic
changes project that the number of people (adults and children) with diabetes
(type 1 and 2)2 worldwide will double to 366 million by 2030 (Hossain et al.,
2007, Wild and al., 2004). Another estimate from the International Diabetes
Federation projects that the number of diabetics worldwide will account for 552
million in 2030 with a higher prevalence in urban areas compared to rural ones
(IDF, 2012). Accordingly, diabetes is now considered as a major public health
concern in all Africa, especially among urban areas (Makame, 1993, Nguma,
2010). Diabetes has health implications such as micro and macro vascular
complications3. Furthermore, as the most affected age group is adults of
working age, the impact of diabetes has not only direct medical costs but also

Type 1 diabetes: auto immune-mediated destruction of pancreatic cell islets, resulting in absolute insulin deficiency.

People with type 1 diabetes must take exogenous insulin for survival to prevent the development of ketoacidosis. Type
2 diabetes : insulin resistance and/or abnormal insulin secretion, either of which may predominate. People with type 2
diabetes are not dependent on exogenous insulin, but may require it for control of blood glucose levels if this is not
achieved with diet alone or with oral hypoglycaemic agents. (Zimmet, 2001)
3

Microvascular complications include neuropathy (nerve damage), nephropathy (kidney disease) and vision disorders

(eg retinopathy, glaucoma, cataract and corneal disease). Macrovascular complications include heart disease, stroke
and peripheral vascular disease (which can lead to ulcers, gangrene and amputation) (Health Insite (2011) Complication
of diabetes : http://www.healthinsite.gov.au/topics/Complications_of_Diabetes)

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10

results in loss of productivity as well as premature morbidity and mortality.


(Nguma, 2010, Zimmet, 2001, Beaglehole and al., 2011)
Obese people have an incidence of hypertension that is five times the one of
normal weight people. The high prevalence of hypertension and its contribution
to cardiovascular and kidney diseases makes it a worldwide public health
challenge. Projections for 2025 indicate that the proportion of people having
hypertension will increase by 60% compared to 2000 to represent almost onethird of the world population. Interestingly, the prevalence of hypertension has
remained stable or has decreased in developed countries whereas it has
increased in developing ones. Hence, it can be postulated that the worldwide
rise of hypertension prevalence will mainly account in developing countries.
(Kearney et al., 2005)
High-fat/high-sugar and low-fibre/low-vitamins and low minerals diets are risk
factors of NCDs (Schmidhuber and Shetty, 2005). According to the FAO/WHO
joint report on fruit and vegetables for health (2004), low fruits and vegetables
consumption is associated with NCDs and micronutrient deficiencies especially
in less developed countries. Furthermore, it is estimated that the current
insufficient fruit and vegetables consumption contributes to the worldwide death
of 2.7 million people yearly. The average fruit and vegetables consumption in
African countries is very low and the vast majority of people do not meet the
population dietary intake goal of more than 400g per day. Food habits and
cultural behaviour as well as seasonality, post-harvest loss, lack of availability
and under-developed processing constitute impairing factors for fruits and
vegetables consumption in African Countries (Granry, 2009).
The aforementioned trends led to further investigate the association between
fruit and vegetables eating habits and practices and the prevalence of diet
related chronic non-communicable diseases in Zanzibar, Tanzania. The
following chapters provide background information about NCDs in Zanzibar
followed by a description of the methodology used in this research project, a
presentation of the research findings, a discussion of the results found and a
conclusion providing recommendations regarding NCDs prevention and
promotion of fruit and vegetables consumption.
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Background
NCDs in Zanzibar
Zanzibar is situated in the Indian Ocean and is a semi-autonomous part of the
United Republic of Tanzania. It constitutes of two major Island, Unguja where
two-third of the 1,070,000 total population lives and Pemba (ZFSNSA, 2006)
(see maps, Appendix I). As with other developing countries, Zanzibar has a
young demographic and high total fertility rate (5.1 children per women) and the
annual average population growth rate is 3% (ZFSNP, 2009). There are large
differences and inequalities between rural and urban4 areas in terms of
education, gender roles as well as health outcome and health care facilities
(WHO, 2010). As described by Marmot et al. (2008), inequalities in power,
income and goods and services distribution are the main causes of health
inequities by impairing peoples access to health care, education, good housing
and working condition as well as socialising and being part of the community.
Socioeconomic status is strongly associated with health outcomes. Indeed,
according to Marmot et al. (2008), the lower the socioeconomic position, the
worst the health, p.1661.
In Zanzibar, it is estimated that about 49% of the population lives below the
basic needs poverty line (TRGZ, 2007)5. The poverty incidence is higher in rural
areas compared to urban areas with 55% of people living under the BNPL in the
former and 41% in the latter. However, economic inequality seems to be
generally low as the Gini coefficient is estimated to be 0.28 (0=perfect equality
and 1=perfect inequality) (TRGZ, 2007)
In Zanzibar, education, food production, urbanisation and reduced physical
activity account for significant changes related to nutrition. Nowadays, mainly in
urban areas, processed and packaged high-fat/high-sugar and low fibre food
items are available on the market. Furthermore, people tend to have a lower

Urbanised Areas (UAs) of 50,000 or more people; Rural encompasses all population, housing, and territory not included

within

an

urban

area.

USCB.

2012.

Urban

and

Rural

Classification

[Online].

Available:

http://www.census.gov/geo/www/ua/urbanruralclass.html.
5

The percentage of population, which have difficulties in attaining basic needs of food, shelter and clothing (The

Revolutionary Government of Zanzibar, 2007)

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12

level of physical activity than they did previously. However, this trend is not
confirmed for most people living in rural areas, where food has become scarce
and often more expensive and people have physically demanding occupations.
Accordingly, Zanzibar is, as other developing countries, undergoing the double
burden of underweight and overweight/obesity described above. (Maletnlema,
2006, TRGZ, 2010, Schmidhuber and Shetty, 2005)
As with other developing countries, NCDs such as diabetes mellitus and
hypertension are estimated to become the leading cause of morbidity and
mortality by 2020 in Zanzibar. Indeed, the incidence of diabetes has increased
from 252 new cases in 2006 to 373 in 2008 and more women than men are
affected (Jiddawi, 2008, TRGZ, 2010). The rapid rise of diabetes and impaired
glucose tolerance amongst the population of Zanzibar (and Tanzania) can be
explained by two factors. First, fifty years ago, the use of hospitals was not
common, diagnosis was not easy, thus there was minimal data on diabetes
prevalence available. Second, nutritional transition due to modernisation and
urbanisation has rapidly

changed physical activity

and diet patterns

(Maletnlema, 2006). People moving from a rural area to an urban one


experience a shift from high-fibre and low-fat/low-sugar diet and hard work to
low-fibre and high-fat/high-sugar with little physical activity which results in
weight gain and increased NCDs (Popkin, 2001, Nguma, 2010, Kennedy,
2005).
As diabetes, hypertension is becoming a significant public health problem in
Sub-Saharan Africa, especially in urban areas. In Zanzibar, hypertension is the
third most common cause of hospital admission and second cause of death
after pneumonia (Jiddawi, 2008). Malaria was formerly the leading cause of
morbidity and mortality. Presently, a decrease in malaria infection was observed
whereas hypertension-associated morbidity has increased. Cardiovascular
diseases and diabetes together with injuries and dental cases account for the
highest number of non-communicable death problems reported at hospitals
TRGZ (2010) p.43. As in other developing countries, a steady increase of
obesity and hypertension problems was recorded in diabetic clinics in Zanzibar
(TRGZ, 2010). According to the Zanzibar Food Balance Sheet Report for the
year 2007 (2009), 27% of women of reproductive age in Zanzibar are either
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13

overweight or obese due to inadequate food intake and lack of physical activity
that predispose to diabetes and hypertension (ZFSNP, 2009).
Crucial in the characterisation of the growing NCDs burden is the recent
implementation of the WHO STEP Survey. The World Health Organizations
STEPwise approach to Non-Communicable Diseases Surveillance (STEPS) is
a simple, standardized method for collecting, analysing and disseminating data
in WHO member countries. The purpose of the STEPwise approach is to allow
low and middle income countries to start and enhance their capacity in
conducting chronic disease surveillance activities (WHO, 2011b). In order to set
up NCDs surveillance and estimate the current burden of diseases as well as
project future trends and provide a basis for effective and efficient planning and
intervention at all levels a national NCD survey called The Zanzibar NCD
survey based on the STEPwise approach was implemented in Zanzibar
(Hassan, 2011).
Food security and diet in Zanzibar
Poverty and food insecurity are interlinked. Poverty is present in both rural and
urban areas. Indeed, 13% of Zanzibar population lives below the food poverty
line (9% in urban areas and 16% in rural areas) and 49% lives below the basic
need poverty line (41% in urban areas and 55% in rural areas)6. Hunger as well
as malnutrition is caused by poverty, but poverty also results from lack of
nutritious food intake (RGZ, 2008). In Zanzibar both rural and urban areas have
a high prevalence of food and nutrition insecurity. Achieving an adequate level
of food consumption in term of quantity and/or quality throughout the year is
problematic for many households. (TRGZ, 2007, RGZ, 2008)
In Zanzibar, as well as in other African countries, food insecurity is, amongst
others, due to poor land management which results in high dependency on food
purchased across and outside the Island (Wise and Murphy, 2012). According
to the Zanzibar Food Security and Nutrition Situation Analysis (ZFSNSA) (2006)
in peri-urban areas of Unguja, 80% of the household food requirement is
purchased and 60% in peri-urban areas of Pemba. Whereas, in rural areas
6

The food poverty line measures the proportion of Zanzibars population with a per capita income of less than TSH

12988 per month. The basic needs poverty line measures the proportion of Zanzibars population with a per capita
income of less than THS 209891 per month (RGZ, R. G. O. Z.-. 2008. Zanzibar food security and nutrition policy.)

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between 35% and 60% of household food consumption is satisfied by


households own production (ZFSNSA, 2006, RGZ, 2008).
Between 60% and 70% of the Zanzibar work force is employed in the
agriculture sector, which contributes to 27.3% of the GDP. Thus, Zanzibars
economy strongly relies on agriculture. However only one third of land is
suitable for agricultural production, the rest being made of coral soil (ZFSNP,
2009, Karume, 2010). The agriculture sector is characterised by small-scale
producers who mostly cultivate food crops such as cassava, banana, sweet
potato, legume, maize, millet, sorghum and rice as well as some tropical fruits
and vegetables. The majority of the smallholder producers is women who
generally do not have the opportunity to acquire adequate capacities and
resources to improve productivity (Karume, 2010, RGZ, 2008). According to
Karume (2010) and the Zanzibar food balance sheet report for the year 2007
(ZFSNP 2009), smallholder producers are facing many difficulties such as poor
access to fertile land, agricultural inputs and credit such as harvest and
handling technology as well as seasonality of production, small-scale irrigation,
inadequate transportation and poor storage facilities. Furthermore, the land
production capacity is largely underexploited. To illustrate, the actual average
yield for all common vegetables7 is between 5-7 tons/ha; whereas recent
estimates portend potential yield levels ranging from 25 to 45 tons/ha. Total
vegetables production is 10500 tons per year and is largely insufficient to meet
the population requirement. This trend is also true for other food crops and it is
estimated that with improved farming practices, yields of cereals could double.
(ZFSNP, 2009, Karume, 2010)
Post harvest losses are high and contribute to food insecurity and import
dependence. Indeed, a large proportion of the vegetables, and to some extent
fruits, consumed in Zanzibar is imported from main land Tanzania. According to
the ZFSNSA (2006) and Mlingi & Rajab (2009), 41% of Zanzibar food annual
requirement is imported and this trend is exacerbated by the development of
the tourism industry. Some estimates show that 80% of vegetables and 20% of
fruits supplied to tourist hotels and restaurants are imported. As a result,
7

The common vegetables grown include tomatoes, eggplants, green peppers, okra, chilli, cabbages, cucumbers,

spinach (Amaranth), Chinese cabbage, cassava leaves, cowpea leaves and onions. (KARUME, A. 2010. Zanzibar
Agricultural Transformation for Sustainable Development, 2010-2020.)

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Zanzibars farmers do not benefit from the tourism industry that could be an
important source of income. Indeed, if the challenge of meeting stability of
supply, quality, timely deliveries, and economies of scale could be reached,
new market opportunities, brought by tourism, foreign investment, rising income
and urbanisation, could be created (Karume, 2010) p.10. Consequently,
employment and food security would be greater (RGZ, 2008, ZFSNSA, 2006,
Mlingi and Rajab, 2009).
Another estimate from ZFSNP (2009) reports that the total food products import
has increased to reach 50%. Rice, sugar and wheat and maize flours are the
main foodstuffs imported. Rice is widely consumed and accounts for the largest
proportion of food expenditure (15%-40% of annual food needs). This situation
makes people vulnerable to any variation arising in the rice market (RGZ, 2008,
Karume, 2010, ZFSNP, 2009, ZFSNSA, 2006).
In brief, food production in Zanzibar is insufficient to meet the population needs
and guarantee food security. The lack of agriculture development and high
dependence in food imports has socio-economic and health impacts by
contributing to poverty and malnutrition.
The WHO Technical report on Diet, Nutrition and the Prevention of Chronic
Diseases (2003) suggests that 55% to 75% of daily intake should be made of
carbohydrates (of which maximum 10% is sugar), 10% to 15% should be made
of protein and 15% to 30% of total daily energy intake should be of fats (of
which maximum 10% saturated fat). Salt should be restricted to less than 5
grams per day (WHO, 2003). A recommend a minimum of 400g of fruit and
vegetables per day is recommended, which is equivalent to at least 5 servings
of 80g of fruit and vegetables per day of which ideally 3 servings or more are
made of vegetables and 2 servings or more are made of fruits (Hall et al., 2009,
Neumark-Sztainer, 1996, WHO, 2003)
As aforementioned, it is estimated that about 13% of Zanzibar population has
difficulties to reach the minimum 2200 daily calories required per adults and are
therefore considered as food poor. According to the 2004-2005 Demographic
and Health survey reported in the Zanzibar Food Balance Sheet Report (2009),
the majority of people eats three meals per day (two third) and one third eat two
meals per day. Cereals represent the most important food group in Zanzibar
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16

and account for about 56% of all caloric intakes and 54% of all protein intakes.
Pulses, tree nuts and seeds are also an important component of the diet and
represent 3.8% of all calories supply and 8.6% of protein supply. Vegetal
products form the basis of the diet and are more widely consumed than animal
products. Vegetal products represent 92% of all calories and over 72% of
proteins food supply in Zanzibar. Fish is the main source of animal protein and
represent 16% of all protein and contributes to 2.3% of all caloric intakes. In
Zanzibar, meat consumption is really seldom and thus is not an important
source of proteins and fats (ZFSNP, 2009).
At the individual level, the ZFSNSA (2006) reports that 80% of the average per
person daily energy supply (DES) is formed of cereals, roots and tubers such
as rice, cassava, maize, bananas (plantain), sweet potatoes, yams and wheat.
Fats and oils account for 10% of DES. The daily protein supply is at 90%
constituted of fish, cereals and legumes. As mentioned above, meat is rarely
eaten. The minerals and vitamins supply is at 90% constituted of green
vegetables and fruits. However, due to inadequate intake of micronutrient rich
foods (such as fruit and vegetables) and/or inadequate utilization of available
micronutrients (infections), micronutrient malnutrition is a serious problem in
Zanzibar. Additionally, low fruit and vegetables intake as well as the high
consumption of rice and wheat (refined carbohydrates) is associated with NCDs
(Hu et al., 2012). Mlingi and Rajab report that many fishers do eat very little if
any vegetables as long as they have fish and that fruits are usually consumed
as a snack when available and are usually not part of the meal (ZFSNSA, 2006,
Mlingi and Rajab, 2009). On the other hand, the low consumption of meat may
be a protective factor, as moderate protein consumption and substitution of red
meat with poultry and fish is associated with a reduced risk of hypertension and
cancer (Roberts, 2005, Pan and al., 2012).

Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

17

Research question
The primary focus of this study is to assess the fruit and vegetables
consumption situation in Zanzibar in relation to the prevalence of obesity,
diabetes and hypertension. What observable social components, behaviour and
food habits hinder fruit and vegetables consumption that is a contributing
factors for the development of NCDs?
Aim
The two aims of this study are to identify and explore the association between
fruit and vegetables eating habits and practices in relation to the prevalence of
diet related chronic non-communicable diseases in Zanzibar and to investigate
how the quantitative data collection regarding fruit and vegetables consumption
in the NCD survey was carried out. The reflexion aforementioned led to the
following research question:
What is the association between fruit and vegetables eating habits and
practices and the prevalence of diet related chronic non-communicable
diseases in Zanzibar, Tanzania?
In order to answer the research question and fulfil the aims of the study, four
objectives have been formulated. The objectives are outlined below:
Specific objectives
1. To analyse the association between fruit and vegetables intake
and the prevalence of obesity, diabetes and hypertension in rural
and urban areas
2. To observe fruit and vegetables eating habits and practices of ten
different households
3. To investigate factors influencing the quantitative assessment of
fruit and vegetables during the NCD survey.
4. To analyse gender differences in fruit and vegetables intake in
relation to obesity, diabetes and hypertension

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18

Methodology
Research Design
The design of this study is: Contextual mixed methods research with
triangulation of quantitative and qualitative data.
Mixed method research is selected to capitalise the strengths of both methods
and counterbalance their weaknesses. Furthermore, the validity of the findings
can be established. Indeed, using this form of triangulation can help support a
finding by showing that independent measures of it agree with it, or at least, do
not contradict it (Miles, 1994).
Quantitative method
For the quantitative component of the study a secondary analysis of data
previously collected from the NCD survey was undertaken8. The selected data
from the NCD survey were analysed using SPSS 20.
In the NCD survey, the following questions were asked to participants in order
to measure fruit and vegetables consumption (Table 2, p.20):
o

In a typical week, on how many days do you eat fruit?

How many servings of fruit do you eat on one of those days?

In a typical week, on how many days do you eat vegetables?

How many servings of vegetables do you eat on one of those days?

In order to obtain the average number of servings of fruit or vegetable per day
(N(fv ) the following calculation was made:
N(fv) = Nd x Ns
7
Where Nd = Number of days per week with fruit or vegetables consumption and Ns = Number of
servings of fruit or vegetable on one of those days

Appendix XI: WHO STEPS instrument has been used for the primary data collection of the NCD survey. Relevant data

have been analysed in the present study to answer objective 1 and 4. No primary quantitative data collection has been
conducted in the present study.

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19

Table 2: Fruit and Vegetables assessment, STEP questionnaire

Response

STEP 1: Diet

Code (variable

Data Type

name)
STEPS
Q No.

Site
Q

STEPS Generic

STEPS

Site

STEPS

Question

Generic

Specific

Generic

No.

In a typical week,
46

on how many days


do you eat fruit?

Site

STEPS

Site

Specific

Generic

Specific

Days 0-7
9 Missing

D1

Numeric

D2

Numeric

D3

Numeric

D4

Numeric

Number 1-

How
47

many

servings of fruit do
you eat on one of
those days?

15
77

Don't

Know
88
Refused
99 Missing

In a typical week,
48

Days 0-7

on how many days


do

you

eat

99 Missing

vegetables?
Number 115

How
servings
49

many
of

77

Don't

Know

vegetables do you

88

eat on one of

Refused

those days?

99 Missing
77

Dont

know

Daily consumption of fruits and vegetables was divided into two categories: low
consumption and recommended consumption. Frequency, percentage and 95%
Confidence Intervals (CI 95%) were calculated for each of the following
covariates: age, gender, marital status, level of education, income, tobacco use,
alcohol use, obesity (BMI), hypertension (SBP&DBP) and diabetes (Fasting
9

See full STEP questionnaire in appendix XI

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20

Blood Glucose). Each covariate was divided into two sub-categories (Appendix
VII) in order to see if there were any statistically significant differences between
them.
Two by two tables with odds ratio, P-value and relative risk (RR) were used
when 95%CI where not overlapping between daily consumption of fruits and
vegetables and each covariate. This was done in order to assess whether the
results (difference between the two groups) was statistically different or not.
To perform the independent sample t-test, continuous variables were used. A
prerequisite of the independent sample t-test is that the variables are normally
distributed. As the current variables from the NCD survey were not normally
distributed, the square root of each variable was used. The independent sample
t-test was performed for fruit and vegetables intake low and recommended
consumption and gender men and women for the following variables: income,
WHR, BMI, SBP, DBP, FBG and age. These variables were the ones for which
the P-value was <0.05 in the two by two tables. Furthermore, independent
sample t-test was performed regarding obesity and BP as well as obesity and
fruit and vegetables consumption in both rural and urban areas. Finally,
analysis of variance was used to further assess the association between
hypertension and fruit and vegetables intake as a negative association was
found (Pearson correlation).
Qualitative method
For the qualitative component of the study direct observations (household and
market observations) were undertaken. The qualitative research describes and
explains the down-stream relationships between the social and cultural
determinants established through the quantitative secondary data analysis. This
type of mixed method research is useful to identify peoples knowledge,
attitudes, practices and beliefs and gives an appraisal of the nature of the areas
in which the survey was conducted. Direct observations entitle the researcher to
uncover the everyday routine of participants and discover what they take for
granted and the rationality behind their practices and behaviours. Being on site
allows the researcher to familiarise with the environment and the people. It also
provides the opportunity to describe situations in details and participate in
events, which enable the researcher to see and feel how things are organised,
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21

where priorities are put, how much time is spent on an activity and check
definition of terms used by the participants. (Bryman, 2008, Kawulich, 2005)
Primary data collection and analysis using formal structured direct observations
were conducted between January and March 2012. The observations took
place in participants households. The researcher shared food with ten different
households and observed food preparation, food eating, food wasting as well as
the family structure such as who is eating with whom and the number of family
members. The researcher also conducted market observations regarding fruit
and vegetables purchase.
Questions were asked using an unstructured interviewer's guideline while the
observations were conducted to clarify and get an in-depth understanding of
peoples consumption of fruits and vegetables during daily meals as well as
investigate factors that may have influenced the quantitative assessment during
the NCD survey regarding fruit and vegetables consumption. Field notes
providing detailed summaries of events, behaviours and initial reflections were
taken all along the fieldwork (notebook and pen as well as computer based
transcripts). In order to illustrate the observations findings, several pictures
were taken per session regarding food preparation, meals (food eating), food
wasting and purchase.
Household observations
The household observations were conducted in rural, urban and sub-urban10
areas on Unguja Island. The observations were done with the help of a SwahiliEnglish interpreter when participants could not speak English. Each observation
lasted between four and six hours. Informed consent was provided either by the
main participant of the household or by the womans head of the village for the
rural area of Bwejuu.
The researcher asked participants' permission to observe practices of preparing
and eating an every day meal. The observations began when people started to
cook and lasted until the meal was consumed. According to peoples schedule
and habits, the observations started between 10am and 2pm and ended
between 5pm and 6pm. Non-participatory observations alternately with
10

Refers to a residential area, as part of Zanzibar city. Sub-urban areas are considered as urban when a dichotomy

between rural and urban is done in this thesis.

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22

participatory observations were undertaken depending on the context and the


participants wishes. Pictures as well as written notes were taken. Visual
support as well as notes were useful in order to analyse, reflect and describe in
details what was observed (Bryman, 2008).
Market observations
Fruit and vegetables are mainly sold at the market. In Stone Town there are a
couple of supermarkets11, but as they usually do not sell fruits and vegetables
or at a very low quantity and are mainly attended by tourists, expatriates or the
wealthier layer of the population, they were not included in the observations.
There are two main markets in Stone Town: Darajani and Mwanakwerekwe.
Mwanakwerekwe is located in the suburb of Stone Town and is the main
wholesale market. The observations were made at Darajani market, which is the
main retail market in Stone Town. Darajani market was chosen because of its
central location. Furthermore, as it is a retail market it was more convenient to
witness customers who buy food items for their households as opposed to
Mwanakwerekwe market where traders mostly purchase large quantities for
hotels, restaurants and other markets during auction sessions (Mlingi and
Rajab, 2009).
In order to do the market observations, several visits at the market at different
times of the day were made. During each session, which was lasting between
twenty minutes and one hour, several pictures as well as written notes were
taken in order to be able to analyse them later on. The purpose of the market
observations was to observe the buying/selling process such as who buy fruits
and vegetables (men or women), what the prices are and how fruits and
vegetables are displayed/sold (packaging/refrigerated/quantity/quality).
Computer transcription of both households and market observations and
primary analysis of the data were done on the same day in order to limit
memory loss bias. A systematic analysis of transcribed data was later
undertaken in order to code the data and classify them into themes and subthemes (Granehei and Lundman, 2004).

11

Super markets in Zanzibar are similar in size and items sold to corner shops/small groceries in Europe.

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Literature review
A literature review was undertaken to further understand the context of the
study area. The databases Medline, Pubmed, Google Scholar as well as
Endnote were researched between August 2011 and April 2012 using the
following terms: Non-communicable diseases, diet, nutrition, agriculture, Africa,
developing countries, diabetes, hypertension, obesity, fruit and vegetables
consumption, participant observations, qualitative research, mixed-method
research, Tanzania, Zanzibar.

Sample Design
Quantitative part
Objectives 1 and 4: The target population in the NCD survey was the entire
population of Zanzibar.
The sample size of the NCD survey:
Due to paucity of data, there was virtually an unknown population
prevalence of NCD and as a rule of the thumb it was set at 50%
in our sample size calculation. With a confidence interval of 95%,
margin of error 0.05, and a design effect due to the complexity of
the sample design by 1.50, adjustment for number of agesex estimates
and an expected nonresponse rate of 18%, the sample size was
hence calculated to be 2,809 individuals in order to be representative.
The number of clusters at first level to be identified was 100 out
of the total of 331. The sample size was adjusted to 2800 individuals for
convenience. (Hassan, 2011)

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The sampling technique used in the NCD survey was a multi-stage cluster
sampling with stratification:
The ten districts are considered as different strata, and the total
number of primary sampling units, PSU, is allocated
proportionately across all strata. Each district is divided into
smaller clusters. These clusters are the geographical and
administrative units called Shehia. The Shehia are divided into
smaller clusters called which typically consist of 100-300
households. [] At the first stage clusters were selected using
Simple Random Selection, SRS, from the list of clusters (Shehia)
within each district. At the second stage clusters (zones) were
randomly selected using probability proportionate to size (PPS).
At the third stage households were randomly selected from the
household lists provided by the administrative leader of the
Shehia. The two last stages of sampling was done using the
software STEPSsampling.xls from WHO. Finally participants were
selected from the household using Kish method12. (Hassan, 2011)
Qualitative part
Objectives 2 and 3:
The sample population was selected to cover a wide range of variations,
contrasts and differences, thereby providing profuse and various qualitative
data. By doing so, a variety of nuances could be appraised. The study sites
were evaluated and discussed with the Ministry of Health in Zanzibar in order to
conduct observations in both rural and urban areas. The findings from the
qualitative part of the study were triangulated with the literature and the findings
from the quantitative part of the study.
Study sites: the study sites were on Unguja Island. The market observations took
place in Darajani market in Stone Town. Four household observations took
place in Bwejuu (rural area), one household observation took place in Kiembe
Samaki (suburb of Stone Town), two observations took place in the city centre
12

The Kish method is a method that allows the data collection team to randomly select participants from the household. It is an easy method that does not

allow data collection bias and provides proper documentation so the sample can be weighted during data analysis. (Rizzo, Birck and Park 2004)

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25

of Stone Town, one observation took place in Mwarakewereke Meli Nne (west
suburb of Stone Town) and the last observation took place in Kizimkazi (rural
area).
Rural areas
Bwejuu is a small village on the southeast cost of Unguja Island. The majority of
men are either fisherman, farmer (cassava and lime) while women grow
seaweed or work as cleaning lady in hotels. The land is not fertile as it is made
of coral. Kizimkazi is a village on the southwest cost of Unguja Island.
Inhabitants are usually fisherman and/or farmers and the developing tourism
sector provides employment as well. The land is fertile, thus growing crops is
less problematic than in Bwejuu.
Urban and suburban areas
Stone town is the old part of Zanzibar city that is the capital of Zanzibar. As it is
an urban setting, citizens do not generally cultivate any fruits or vegetables and
rely on Darajani market for their fruit and vegetables provision. Mwarakewereke
Meli Nne and Kiembe Samaki are part of Zanzibar city and therefore are urban
areas. Being on the outskirt of Stone Town, people rely on either
Mwarakewereke or Darajani markets.
Households social aspects
The four women in the rural area of Bwejuu were married and had between
three and four children. Five to seven people were living together in one
household and participants were Muslims. In Kiembe Samaki, suburb area of
Stone Town, the woman was married and had four children, six people were
living in the household and they were Muslims. In the city centre, one
household was composed of two Hindu elderly women. In the other household
a divorced man (Hindu) lived with three foreigners to whom he rented rooms.
His two children were coming for lunch almost everyday at his place. In
Mwarakewereke Meli Nne suburb of Stone town nine people from an extended
family were living in the same house (couple, children and relatives). In Kiembe
Samaki, seven people lived together (couple, four children and the wifes sister)
and in Kizimkazi, six people were living together (couple and four children). The
three households from the suburbs were Muslim.

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26

Recruitment: Purposive sampling of five households from rural areas and five
others from urban areas. Participants were recruited through previous contact
persons in Zanzibar. Potential participants were given an oral explanation
regarding the study as well as a written information and consent form.
Participants who wished to take part in the study had the possibility to contact
the researcher in order to set an appointment and provide further explanations
when required.

Research Measures
Quantitative part
Analysis of the NCD survey variables used
Gender, age and socioeconomic status13
Diet: fruit and vegetables consumption
Obesity (BMI>30kg/m2)
Diabetes (FBG>7mmol/l, excluding non-fasting respondents and
those currently on medication for diabetes)
Hypertension (SBP>140mmHg or DBP>90mmHg, excluding
people on medication for raised BP)
Qualitative part
Formal structured direct observations (ethnography)
Gender, age, socioeconomic status and family structure
Habits and practices regarding fruit and vegetables buying,
cooking and wasting process
Determinants of diet
Definition of fruit and vegetables

13

As per STEP questionnaire

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27

Inclusion- Exclusion criteria


Quantitative part
Inclusion and exclusion criteria of the NCD survey:
Inclusion criteria
o

Age between 25 and 64 years

Able to understand the information given by data collector about the study
prior to the beginning of the interview

Signed informed consent (accepting participation)

Exclusion criteria
o

Inability to understand or comprehend the information given by data


collector

Inability to communicate through verbal expression for consent

Severe/terminal illness that hinders participation in the surveys

Age below 25 years or above 64 years

Qualitative part
Inclusion criteria
o

Able to understand the information given by data collector about the study
prior to the beginning of the interview

Signed informed consent (accepting participation)

Exclusion criteria
o

Inability to understand or comprehend the information given by data


collector

Inability to communicate through verbal expression for consent

Severe/terminal illness that hinders participation in the surveys

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28

Ethical considerations
The quantitative data were obtained during the National NCD survey 2011 with
Dr. Faiza Kassim Suleiman as principal researcher. The data collection took
place in June-July 2011. Ethical approval was granted in March 2011 by the
Zanzibar

Medical

and

Research

Ethical

Committee

(Hassan,

2011).

Furthermore, a letter of agreement to share the NCD survey data between the
Ministry of Health, Zanzibar and Copenhagen School of Global Health was
signed by Dr. Mohammed Jiddawi, Principal Secretary and Pr. Maximilian de
Courten in June 2011.
Regarding the current research project, ethical approval to use the NCD survey
data and conduct participant observations was granted on the 27th January
2012 by the Zanzibar Medical and Research Ethical Committee, Ministry of
Health. Furthermore, ethical approval from the University of Sheffield was
granted in December 2011 (Appendix VI).
Oral explanations and informed consent form written in the language spoken by
the participants (Swahili) were given before each observation explaining the
purpose of the research and the implications for the participants. Participants
could drop out of the study at anytime and all data were treated anonymously.
Information and consent forms in both Swahili and English are in Appendix II-V.
Furthermore, annotations and comments have been coded in order to
guarantee privacy and anonymity.
Pictures have been taken with the oral and written consent of the participants.
Unused pictures were destroyed at the end of the data analysis.
Safety: participant safety was guarantied as no interventions were undertaken.
No additional risks, apart from the ones due to everyday life, were introduced by
the study.

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29

Results
This chapter provides a description and analysis of the secondary quantitative
data analysis of the NCD survey as well as qualitative findings from the market
and households observations regarding fruit and vegetables consumption,
obesity, hypertension and diabetes.
Descriptive results

Table 3: Mean SD for Age, BMI, SBP, DBP, FBG, WHR, F&V intake, Education and Income in Zanzibar

Data

Age (years)
BMI

Minimum

Maximum

Mean

SD

Mean

Mean

Men

Women

1362

25.0

65

42

11.4

43.3

41.3

2606

12.7

64.9

24.4

5.5

23.4

25.1

2634

40.0

246

135.4

26.7

138.9

133.3

DPB

2634

30.0

148

79.4

14

79.2

79.6

FBG

2462

1.2

31

4.4

1.6

4.4

4.3

2389

0.4

1.9

0.9

0.1

0.9

0.9

2645

0.0

3.4

0.7

0.6

0.6

0.8

2466

0.0

0.9

0.8

0.9

2657

0.0

25

6.7

4.9

8.9

5.4

1020

1.0

41,700,000

176,433

1,611,478

233,731

129,366

SBP

WHR

Vegetable
intake

Fruit intake

Education
(years)
Income (TSH)

1. Body Mass Index

5.

Waist to Hip Ratio

2. Systolic Blood Pressure

6.

Number of servings of vegetables per day

3. Diastolic Blood Pressure

7.

Number of servings of fruits per day

4. Fasting Blood Glucose

8.

Monthly income (1000Tsh=0.6$)

The total sample size was 2800 of which 38% were male and the mean age
was 42 years old (SD 11.4). There were more people living in rural areas
(69%) compared to urban ones (31%). The mean years of education was 6.7
(SD 4.9) and the mean monthly income was 176,433 Tsh (=110$) (SD
1,611,478) (Table 3).
The mean fruit intake was less than one serving per day, 0.9 (SD 0.8) and
mean vegetable intake was less than one serving per day, 0.7 (SD 0.6).
Regarding obesity, blood pressure and diabetes, the mean BMI was 24.4
Amlie Keller, Europubhealth Masters Degree in Public Health, 2012

30

(SD 5.5) and the mean waist to hip ratio was 0.9 (SD 0.1). Interestingly,
there was three times more obese women (19.4%) than men (6.4%) in the
sample population (based on BMI 30 Kg/m2) (Table 4). The mean systolic
blood pressure was 135.4 (SD 26.7) and the mean diastolic blood pressure
was 79.4 (SD 14). Furthermore, 38% of men and 33% of women were
hypertensive, which represents more than one third of the sample population
(Table 4). The mean fasting blood glucose level was 4.4 (SD 1.6) and 2.2%
of men and 2.8% of women were diabetic (based on FBG test alone) (Table
4).
Table 4: Number and percentage of obese, hypertensive and diabetic people divided by gender in Zanizbar

Men
N

Women
%

Hypertensive

383

37.6

535

32.6

Diabetic

22

2.2

46

2.8

Obese

65

6.4

318

19.4

Fruits and vegetables definition and meaning


The market as well as household observations revealed that zanzibaris
categorised vegetables into two groups: leafy-vegetables and fruit-vegetables.
In the common understanding of people from Zanzibar the word vegetable
relates to leafy-vegetables such as cassava leaves or spinach and when people
refer to other types of vegetables such as aubergines or cucumber, they use the
term fruit-vegetables.
For us, vegetables are leaves, like cassava or spinach. If you talk about
carrots people use the word fruit-vegetable (woman from household n6).
Ah! Here in Zanzibar, if you say vegetables, people understand leaves, the
others are called fruit-vegetables (Nutrition Unit staff)
Regarding fruits, no sub-categories were observed. Therefore, it is interesting to
note that the meaning regarding the term vegetable is different in Zanzibar
compared to other European countries such as Denmark where no such subcategories exist. As an example in the questionnaire used for the NCD survey,

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

31

fruits and vegetables were divided into two categories14, but no sub-categories
were included. Hence, one can stipulate that some difficulties might have arisen
during the quantitative data collection.
In the present document, the term vegetable is used to describe both leafy- and
fruit-vegetables and the term leafy-vegetable vs. fruit-vegetable is used when
distinction between the two categories is required.
Availability & cost of fruits and vegetables in Zanzibar
The consumption of less than one serving of fruit (m=0.9) and less than one
serving of vegetable (m=0.7) per day can be explained by the availability and
cost of fruits and vegetables observed at Darajani market during the market
observations as well as at local retailers as part of the household observations.
The following chapter starts by describing Darajani market place and the
availability and prices of fruits and vegetables in rural and urban areas. An
analysis regarding the relationship between fruits and vegetables availability
and prices and peoples consumption follows.
Darajani market place was a concrete building forming a squared enclosure
with stalls inside (Figure 1 and 2, p.33). The market was divided into three
sectors: fish area, meat area and fruits and vegetables area. Fruits and
vegetables were either sold on mats on the ground, small tables, baskets, carts
or wooden stalls and were displayed by type of fruits or vegetables as illustrated
in figures 3 and 4, p.36. Outside the enclosure there were lots of other stalls
and people who were selling items on mats or directly on the ground. The
majority of fruits and vegetables were displayed inside the concrete building;
however, fruits and vegetables were also available outside the concrete space
(Figure 1 and 2, p.33).

14

There is not any definition of fruit and vegetables included in the STEP questionnaire

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32

Figure 1: Outside view of Darajani Market

Figure 2: Inside Darajani market

At Darajani market as well as at the local retailers observed, there was not any
packaging and items were either put in plastic bags or paper bags when sold.
Furthermore, all fruits and vegetables were sold raw. Foodstuffs such as fruits
and vegetables, meat and fish were displayed at ambient temperature
(+30C), either directly exposed to the sun or in the shade. The observations
indicate that the lack of cold storage facilities and the tropical climate were two
factors impairing fruit and vegetables freshness and quality. Storing fruits and
vegetables seemed problematic for retailers as well as customers. To
illustrate, three households in rural areas and one in urban area as well as
people at Darajani market reported that vegetables tend to be bought for the
same day or at most, kept for the following day. The reasons given were
related to the heat and lack of cold storage facilities:
Vegetables dont last long, because it is hot here in Zanzibar [] not like
your country (referring to European countries) (one man at the market)
You know, most people they dont have fridge, so you cant keep things
very long (woman household n2)
Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

33

For the same reasons, household members in rural areas were saying that
there was generally no leftover as everything was eaten the same day:
I cook everyday for the same day, its hot here and the food becomes not
good if I keep it for too long (woman from household n3).
As the prices of fruits and vegetables varied according to the freshness and
quality of the items sold, retailers income were affected. Indeed, when fruits or
vegetables were a bit rotten or damaged, the price usually was going down
from 20% to 50% of the initial price (depending on ones bargaining aptitude).
Consequently, due to the potential income losses, retailers were concerned
about the lack of cold storage facilities that impair the quality of their products:
When its black or not looking nice, I dont make money (one banana
and coconut retailer at Darajani market)
If it was colder, Id make more money because now I need to throw
away things or sell for almost nothing, so I dont make good money (one
fruit and vegetables retailer at Darajani market)
Fruits and vegetables available at Darajani market and at local retailers
The market observations revealed a diversity of fruits and vegetables
available, which suggests that customers had an array of choices, and thus
were not limited by a lack of variety (Table 5, p.35 and Figure 3, p.36). As
opposed to the urban area of Stone town, there was not any market in the
rural areas of Bwejuu and Kizimkazi; only small merchants were selling fruits
and vegetables. The variety of fruits and vegetables observed at local retailers
in both sub-urban and especially rural areas suggest that customers, who
depended on local retailers for their fruits and vegetables supply, were more
restrained in their choice than people who could purchase items at Darajani
market (Table 5, p.35 and Figure 4, p.36).
The household observations showed that participants living in the rural areas
of Bwejuu and Kizimkazi depended almost entirely on local retailers for the
purchase of fruits and vegetables. In the areas of Kiembe Samaki and
Mwarakewereke Meli Nne (suburb of Stone Town) participants reported to buy
most of the fruits and vegetables at the market in Darajani or Mwarakewereke.
However as it was necessary to go by vehicle to both markets for all

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

34

households, the local retailers were frequently used for last minute purchases.
In the centre of Stone Town, both households participants reported to buy
their food items, especially fruits and vegetables at Darajani market or in small
shops across the centre. As Darajani market was at a walking distance for
both households (5-10 minutes on foot), its access was easier in terms of
allocated time and money for participants living in the city centre compared to
participants living in sub-urban and rural areas.

Table 5: Differences between fruit and vegetables availability at Darajani market and at local retailers

Darajani Market
Fruits

15

Local retailers

15

Vegetables

Fruits

Vegetables

bananas

okras

coconuts

tomatoes

pineapples

tomatoes

limes

onions

mangoes

onions

peppers

rambutans

garlic

carrots

durians

green peppers

okras

passion fruits

aubergines

tamarind

cassava leaves

coconuts

cabbages

papayas

lettuce

guavas

cucumbers

oranges

squashes

limes

amaranth

lemons

spinach

mandarins

pomelos

grapefruits

jackfruits

coconuts

Appendix VIIII: Tropical Fruits and Vegetables Index

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

35

Figure 3: Fruits and Vegetables at Darajani market

Figure 4: Fruits and vegetables available at local retailers

Households participants as well as fruit and vegetables merchants reported


that the availability of fruits and vegetables depends on the season. As an
example, the tomato season was reported to be between July and September,
thus during those three months tomato supply was said to be plentiful. However
at the time of the observations, between January and March, tomatoes were
imported from main land (Tanzania) and the quantity of tomatoes available on
the Island was reported to be smaller and prices higher:
Now its not the tomato season, we have to import from Tanzania so
prices are very high (one merchant at Darajani).
February is not a good month, its the season for nothing and everything
[fruits and vegetables] is expensive (one customer at Darajani market).
As mentioned above, availability of fruits and vegetables plays a role in their
consumption. Availability is nonetheless not the only factor and price was
observed to be an important component as well.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

36

At both Darajani market and local retailers, vegetables and fruits were sold
either per kilo or more often by bunch (Figure 4, p.36). The prices were very
seldom written and people needed to ask for it. The prices varied according to
the type of fruits or vegetables, the size of the bunch and how many pieces
were comprised in a bunch. One bunch was always made of one sort of fruit or
vegetable. The prices seemed to be more or less fixed, between 200 Tsh for a
bunch of three small aubergines to 1000 Tsh for a bunch of ten mini bananas or
1500 Tsh for some large mangos and one bunch of 4 to 8 tomatoes was
between 500 and 1000 Tsh. As a comparison, in Bwejuu, one tomato cost 150
Tsh and a small onion 50 Tsh.
To the participants interviewed, vegetables were very expensive and two
women reported that they could not afford to cook vegetables everyday.
Considering that the mean monthly income in Zanzibar is 176433 Tsh and that
people from rural areas earn on average 4.5 times less than in urban ones
(Table 6), the cost of fruits and vegetables is high. To illustrate, in household
n1 the woman was reporting that more than 2/3 of her total expenditure was for
food:
Woman from household n1: Almost all I earn is to eat
Researcher: Do you know what part of your budget it represent?
Woman from household n1: Maybe 60 or 70%
Table 6: Income in rural vs. urban areas

Monthly income

Urban
Rural

Mean

317
703

382,064.9
83,708.1

Std. Deviation
2,875,975.6
136,307.9

Furthermore, according to one of the informant, the monthly minimum wage in


Zanzibar was raised early this year from 70000 Tsh (= 44$) to 140000 (= 88$)
in order to adjust to the increasing cost of living. To illustrate, a broad estimate16
of the cost of fruits and vegetables indicate that in order to reach the minimum
recommended amount of 400g per day, if all the items were purchased at
Darajani market, the cost would be comprised between 600 and 800 Tsh per
16

These estimates have been made by calculating the average observed cost of fruits and vegetables found at Darajani market in

January 2012. There are only used here as an estimation which may not be representative.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

37

person. Reported to one month, these sums (18000 and 24000 Tsh) account for
one third of a minimum monthly salary of 70000 Tsh and about one sixth of a
minimum monthly salary of 140000 Tsh.
If people from rural areas involved in the observations wanted to buy vegetables
elsewhere, they had to take a local transport (Dala dala) and go to town at
Darajani or Mwarakewereke markets. Mwarakewereke was the market where
the village merchants were buying their items; therefore prices at the village
were more expensive due to the transportation costs as well as retailers profit
margin. Indeed, prices were generally 20% to 50% more expensive than at
Darajani market:
I buy the things at the market, so here its a bit more expensive. I need to
live! (One local retailer).
In other words, the observations demonstrated that the availability of fruits and
vegetables was more limited at local retailers and that these retailers were more
expensive than other vendors (Darajani market). Additionally, people from rural
areas were more dependent on these retailers as a source of fresh produce.
Indeed, fruits and vegetables seemed to be generally expensive as a proportion
of mean incomes (176433 Tsh). The cost was particularly high for people living
in rural areas that not only had to pay more for fruits and vegetables and had
fewer choices, but also had a much lower income than people from urban
areas.
Kitchen facilities and food diversity in rural and urban households of Zanzibar
The previous paragraph described how availability and price of fruits and
vegetables at Darajani market and local retailers impact on peoples fruit and
vegetables consumption. In addition to these two factors, the household
observations suggested that kitchen facilities also influence fruit and vegetables
consumption and food diversity. Indeed, one can stipulate that the more kitchen
utensils available and the better the kitchen facilities (electricity, storage
facilities and running water), the easier it is to prepare different dishes
concurrently. From the household observations, participants with multiple
kitchen facilities seemed more likely to prepare and eat a more divers diet with
more vegetables than people with poorer facilities. This chapter gives a

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

38

description of kitchen facilities and cooking methods in rural and urban areas
and analyse how those factors impact on households food diversity and fruit
and vegetables consumption.
In Bwejuu, houses were made of bricks and mud with palm leaves on the roof
whereas in Kizimkazi they were made of bricks, concrete and aluminium sheets
on the roof. In both villages, the households where the observations took place
had one or two taps with running water and two out of five households had
electricity (Table 7, p.42). In the five households the kitchens were open space
with a roof, outside in the courtyard (Figure 5, left side). In the five households,
women cooked using typical Zanzibar metallic saucepans and used firewood.
The fire was on the ground and women were alternatively sitting on low wooden
stools or squatting on the ground (Figure 7, p.40). Knifes, spatulas, spoons,
graters, pans, saucepans, sieves and plastic bowls were seen to be used as
kitchen tools in the five households (Figure 6, p.40). Neither oven nor fridges
were seen in Bwejuu whereas the household visited in Kizimkazi had a fridge
and freezer. The fridge was half empty and the other half was filled with bottled
water and soda. Therefore the fridge was not used to store food items.

Figure 5: Open kitchen in rural area (left side) vs. closed kitchen in urban area (right side)

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

39

Figure 6: Contrast between kitchen utensils in rural areas (left side) and urban areas (right side)

Figure 7: Cooking process in rural (first picture, left side), sub-urban (middle picture) and urban areas (right
side)

Figure 8: Contrast between rural (left side) and urban kitchens layout (right side)

In the suburb and central part of Stone Town visited, the houses were made of
bricks and concrete. As opposed to households in rural areas, the houses
where the observations took place each had a living room with a TV and
stereo and electric facilities that indicate that the urban areas visited were
comparatively more affluent. In three of the households the kitchens were in a

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

40

semi-open space inside the house or in the yard. The other two kitchens were
in a closed and separated space with windows (Figure 5 and 8, p.39-40).
Three of the households had an oven and automatic electric cookers, all had
stoves (electric and/or gas), a microwave, a blender, frying pans, sauce pans
and many kitchen tools (Figure 6 and 8 right sides, p.30). All households had
at least one fridge (Table 7, p.42). Similar to the household from Kizimkazi, the
fridge was used to refrigerate water or sodas in three of the households and
only in two of the households was the fridge used to store food such as
vegetables and dairy products. Those findings suggest that despite having
access to cold storage facilities, some participants were not using them to
store fruits and vegetables. The reason given by one of the woman was
related to the frequent electricity cuts. However, in the two other households it
appeared that participants had the habit of purchasing fruits and especially
vegetables on a daily basis, thus did not need to store them.
Three of the households had taps (indoor and outdoor) connected to a well
and the others had running water (Table 7, p.42). During the observations
none of the participants used their oven and one used their microwave to
reheat leftovers. In the three households from sub-urban areas, the women
(mother and daughter) cooked on charcoal on the ground using Zanzibar
saucepan and frying pan; whereas in the two households from the city centre
participants used both electric and gas stoves.
Two out of three households in sub-urban areas had electric stoves but did not
use them and all three households used charcoal to cook as opposed to
firewood in rural areas and electric stoves in the households from the city
centre.
I have the electric stoves, but I prefer the fire [charcoal], thats how I learnt
to prepare food (Woman from household n8).
Therefore, the observations suggested that cooking practices as well as
storing practices not only depended on the facilities available, but were linked
to tradition and habits. Nevertheless, cooking facilities, especially in terms of
number and diversity of utensils available, seemed related to the variety of
dishes prepared. Indeed, the household observations showed that an average
of 3.4 different dishes were prepared in participants households from urban
Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

41

and sub-urban areas compared to an average of 2.8 in rural ones. Similarly,


more vegetables were prepared in urban and sub-urban areas compared to
rural areas.
Table 7: Cooking facilities in ten households in rural and urban areas of Zanzibar

Household

Electricity

Running

Own

Electric

Gas

water

well

cooker

cooker

Firewood

Charcoal

Fridge

1
2
3
4
5
6
7
8
9
10
- Presence of the facility in the household
- People had taps connected to their households well that was connected to a cistern in the neighbourhood.
- Rural households
- Urban and sub-urban households

Gender and age differences regarding fruit and vegetables preparation and
consumption
In the two precedent chapters, availability, price as well as kitchen facilities
were described to play a role in fruit and vegetables consumption.
Associations between fruit and vegetables consumption, gender and age were
found in the quantitative data analysis. However the household observations
did not confirm those findings. It is likely, as described below, that the
qualitative findings do not support the quantitative ones, as only weak
correlations were found; therefore, even if results were statistically significant
they were not substantially significant17. In the qualitative observations, gender
differences were observed regarding food purchase and preparation practices.
This chapter describes and analyses gender and age differences regarding
fruit and vegetables consumption and preparation.
17

Not substantially significant here means that even if statistically significant, the differences were very small and thus in practice,

they are not significant (=clinically significant).

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

42

The mean number of days with consumption of fruits in a week was 3.9 (3.7
for women and 4.2 for men). The majority of people ate less than one serving
of fruits per day (58.9%) (Figure 9, p.44) and more women ate less than one
serving of fruits per day (62.3%) than men (52.5%). Furthermore, 77.8%
(75.6% men and 80.5% women) of the people had a low intake of serving of
fruits. The difference between men and women consumption of servings of
fruits

was

statistically

significant

when

comparing

low

intake

vs.

recommendations. However this difference was small as men were only 6%


less likely than women to have a low fruit consumption (P-value 0.003:
RR=0.94). In brief, more women than men had a low consumption of fruits
however, despite being statistically significant, it was not substantially
significant.
The mean number of days with consumption of vegetables in a week was 2.8
(2.9 for women and 2.6 for men). The majority of people ate less than one
serving of vegetables per day (76.7%) (Figure 9, p.44) and the percentage of
women who ate less than one serving of vegetables per day was lower
(74.3%) than men (80.5%). The vast majority of people (99.2% men and
98.6% women) had a low intake of servings of vegetables per day. However,
the difference between men and women consumption of servings of
vegetables was not statistically significant when comparing low intake vs.
recommendations. Men and women were as likely to have a low
consumption of vegetables (P-value 0.193; RR 1.006). In brief, more men than
women had a low consumption of vegetables but it was not statistically
significant.

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43

Figure 9: Men vs. women number of servings of fruits and vegetables per day

As aforementioned, no differences regarding gender and age in terms of


amount of fruits and vegetables consumed were observed during the household
observations. However, gender differences were noticed regarding food
purchase, food preparation and eating process at lunchtime.
The market and household observations revealed that more men than women
purchased food items:
It is usually men who go to the market, because in our culture women are
not allowed, but now it is changing so you can see some women at the
market (F. one of the informants).
However, in nine of the ten households visited, women decided what should be
bought:
Women they tell the men what to buy, they usually decide what to cook (F.
one of the informants)
In nine of the ten households visited, only women were seen cooking:
In the Swahili tradition, it is womens duty to cook and take care of the
household and mens duty to bring money to the household. (F. one of the
informants)
Regarding eating, in eight of the households, dishes were placed on a tray and
people ate from the different plates and bowls with their right hand (Figure 10
and 11, p.45). One plate was shared between two to three people. Women and
men, when eating together, were not sharing the same plates. In seven of the

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44

households, men were allocated a bigger portion of rice than women, however
no differences in terms of quantity of vegetables allocated could be observed:
Men need to eat more (woman from household n1)
These findings suggest that even though men go to the market, women decide
what should be bought and are also in charge of cooking. The observations
suggest as well that vegetables are not considered nutritious and therefore as
men need to eat more, only food considered as nutritious should be eaten in
greater proportion. As people are sharing plates, assessing the portion eaten by
one individual is likely to be more difficult than when people have their own
plates.
Figure 10: Main meal food display in urban (left side) rural (middle) and sub-urban (right side) households

Figure 11: Eating process people sharing plates in the rural area of Bwejuu

Vegetable intake and age were positively associated for men and women
(r=0.058, p=0.034, R2=.0033). Fruit intake and age were negatively associated
for men and women (r=-0.058, p=0.041, R2=.0033). Thus as age increased,
the consumption of vegetables increased and the consumption of fruits

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

45

decreased. However, due to the small R2 (0.33%) the trend is not of a size that
matters to individuals health.
Regarding fruit consumption, 76% of the 25-44 years old group and 81% of
the 45-64 years old group had a low consumption of fruits. Accordingly, about
23% of the 25-44 years old group and 18% of the 45-64 years old group met
the recommendations. The difference between the two age groups was
statistically significant, however limited. Indeed, people aged between 25-44
years old were 6% less likely than people aged 45-64 years old to have a low
fruit consumption (P-value = 0.006; RR 0.94). In brief, younger people (25-44
years old) had a higher consumption of fruits than older ones (45-64 years
old). Nevertheless, even if statistically significant, the difference was not
substantially significant.
The majority of the 25-44 years old group (99%) and 45-64 years old group
(98%) had a low consumption of vegetable. However, the difference between
the two age groups was not statistically significant (P-value = 0.58;
RR=1.003). In brief, the low consumption of vegetables was very common
amongst both age groups.
Association between NCDs and fruit and vegetables consumption in rural and urban
areas
As aforementioned, there are large differences between rural and urban areas
in terms of income, housing and cooking facilities as well as fruit and
vegetables availability and price. Regarding obesity, hypertension and
diabetes, rural/urban differences exist as well (described below). Furthermore,
differences in term of type of food prepared and eaten were also observed
during the household observations.
Obesity
Associations between obesity, hypertension and diabetes regarding fruit and
vegetables consumption were found. Indeed, 83% of obese people and 77%
of non-obese people had a low fruit intake. Accordingly, only 16% of obese
and 22% of non-obese met the recommendations. The difference between
obese and non-obese consumption of servings of fruits was statistically
significant when comparing low intake vs. recommendations. Thus obese
Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

46

people were more likely than non-obese to have a low fruit consumption (Pvalue = 0.01; RR 1.075).
98% of obese and non-obese people had a low consumption of vegetable and
1% in both group had an adequate intake. The difference between obese and
non-obese people was not statistically significant (P-value = 1; RR 1.002).
Therefore, the low consumption of vegetable was very common amongst
obese and non-obese people.
When computing correlations, fruit and vegetables intake was positively
associated with BMI (r=0.057, p=0.05, R2=.0033 ; r=0.076, p=0.000,
R2=.0058). Similarly, the independent t-test showed that people with a higher
vegetable consumption had a higher BMI (MBMI=24.6, SE=0.81) than
participants with lower vegetable consumption (MBMI=24.1, SE=0). However,
this difference was not statistically significant (P-value 0.58). On the other
hand, the independent t-test showed that people with a low fruit consumption
had a higher BMI (MBMI=24.25, SE=0) than participants with recommended
consumption (MBMI=23.66, SE=0). This difference was statistically significant,
p<.05. In brief, correlation analysis showed that there was a positive
association between BMI and fruit and vegetables intake, suggesting that the
higher the fruit and vegetables consumption, the higher the BMI (or inversely).
However, findings from the t-test showed that the higher the BMI, the higher
the vegetable consumption and the lower the fruit consumption. These
differences might be explained by the generalised low consumption of fruits
and especially vegetables and related general weak r-correlations.
There was a large difference in the prevalence of obesity between urban and
rural areas with three times more obese in urban areas compared to rural
ones. Indeed, 26% of people from urban areas were obese compared to 9% in
rural ones. The mean BMI was also higher in urban areas (MBMI=26.4)
compared to rural ones (MBMI=23.4). This difference was statistically significant
p<0.05 (P=0.000) (Table 8, p.51).
BMI was also positively associated with income for men (r=0.095,p=0.044,
R2=.0009) and women (r=0.091,p=0.034, R2=.0083). Therefore, people with
higher income had an increased BMI.

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47

Fruit and vegetables intake was also positively associated with income for
men and women (r=0.068,p=0.038, R2=.005). Thus, as income increase,
consumption of fruits and vegetables increase.
Hypertension
Regarding hypertension, 80% of people with hypertension had a low intake of
fruits and 98% had a low intake of vegetables. In comparison, 76% of nonhypertensive people had a low fruit intake and 98.5% a low intake of
vegetables. The difference was statistically significant for fruit intake. Indeed,
when analysed separately for DPB and SBP, people with elevated SBP (Pvalue 0.016; RR 1.29) and DBP (P-value 0.007; RR 1.071) were more likely to
have low fruit consumption compared to the other group. However this
difference was small (increased risk of 7% and 5% respectively). The
difference was not statistically significant for vegetable intake (DBP: P-value
0.353; RR 0.995; SBP: P-value 0.447; RR 0.996).
When computing correlations, fruit intake was negatively associated with DBP
(r=-0.042,p=0.037, R2=.0018) and SBP (r=-0.072,p=0.000, R2=.0052) for men
and women. Thus as the consumption of fruit increased, the blood pressure
decreased.
In figures 12 and 13 (p.49), box-and-whisker plots18, the analysis of variance
(ANOVA) showed that people who ate less than one portion of fruit per day
had a higher mean SBP (M=136.87mmHg) and DBP (M=79.98mmHg) than
people who ate more than on portion of fruit per day. This trend was reverse
for vegetable intake and people who ate less than one portion of vegetables
per day had a lower SBP (M=135.25mmHg) and DBP (M=79.13mmHg) than
people who ate more than one portion of vegetables per day.

18

The bottom and top of the box are the 25th and 75th percentile, the band near the middle of the box is the 50th percentile and the ends
of the whiskers are the minimum and maximum of all the data.

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Figure 12: Box-and-whisker plot of blood pressure and fruit intake

Figure 13: Box-and-whisker plot of blood pressure and vegetables intake

Age was also positively associated with DBP (r=0.299,p=0.000) and SBP
(r=0.456,p=0.000, R2=.21) for men and women. Thus, as age increased, blood
pressure increased. SBP and DBP were positively associated for men and
women (r=0.811,p=0.000, R2=.66). Thus, as SBP increased, DBP increased
as

well

or

inversely.
2

BMI

was

positively

associated

with

DBP

(r=0.244,p=0.000, R =.06) and SBP (r=0.136,p=0.000, R =.01) for men and


women. The same trend was present for WHR and DBP (r=0.203,p=0.000,
R2=.04) and SBP (r=0.203,p=0.000, R2=.04) for men and women together.
Thus, as age, BMI and WHR increased, blood pressure increased.

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49

Regarding blood pressure differences between rural and urban areas, the
mean DBP was higher in urban areas (M=80.6) compared to rural ones
(M=78.9) and the difference was statistically significant p<0.05 (P=0.003).
Inversely, the mean SBP was higher in rural areas (M=136.3) compared to
urban ones (M=133.5) and the difference was statistically significant p<0.05
(P=0.009) (Table 8, p.51). Furthermore when assessing the association
between obesity and BP in urban and rural areas, the mean DBP and SBP
was higher amongst obese in both urban and rural areas (DBP urban M=86.4,
rural M=85; SBP urban M=140.6, rural M=142) than non-obese (DBP urban
M=78.5, rural M=78.2; SBP urban M=130.7, rural M=135.6) and it was
statistically significant p<0.05. Therefore, obese people in both urban and rural
areas were more likely to have a higher BP than nonobese people.
Diabetes
Regarding fruit and vegetable intakes and diabetes, 78% of non-diabetic and
93% of diabetic people had a low fruit consumption. The difference between
diabetic and non-diabetic patients regarding fruit consumption was statistically
significant (P-value 0.002; RR 1.184). Diabetics were 18% more likely to have
low fruit consumption than non-diabetics.
98% of non-diabetic and 99% of diabetic people had a low vegetable
consumption. The difference between diabetic and non-diabetic patients
regarding vegetables consumption was not statistically significant (P-value
0.313; RR 0.988). Therefore, diabetics were as likely to have low vegetables
intake than non-diabetics.
FBG and fruit and vegetable intakes were positively associated for men and
women (r=0.023,p=0.273, R2=.0005). Thus as the consumption of fruits and
vegetables increased, FBG increased.
Regarding diabetes prevalence in rural and urban areas (Table 8, p.51), there
was twice as many diabetics in urban areas (4%) compared to rural ones (2%)
however, the mean FBG in both rural and urban areas were the same (M=4.3
and 4.3).

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50

Table 8: BMI, DBP, SBP and FBG in rural vs. urban areas

Data

Urban
N

Mean

Rural
SD

Mean

SD

BMI**

847

26.4

6.3

1759

23.4

4.8

DBP*

855

80.6

14.2

1779

78.9

13.9

SBP*

855

133.5

26.2

1779

136.3

26.9

FBG

796

4.3

.1

1666

4.3

.1

* Difference between urban and rural area statistically significant, p-value<0.05


**Difference between urban and rural area statistically significant, p-value<0.001

The prevalence of diabetes and obesity was higher in urban areas compared
to rural ones and the mean diastolic blood pressure was also higher in urban
areas but this trend was reversed for systolic blood pressure. The higher
urban prevalence of diabetes, obesity and DBP could be related to the
differences in terms of variety of food and number of meals per day revealed
during the household observations between rural and urban areas. Indeed,
participants from the households visited in urban areas reported having
between two and three meals per day and the ones from the households
visited in rural areas reported having between one and three meals per day.
The members of one household were saying that when they could afford three
meals per day, the first meal of the day (breakfast) was composed of bread or
cassava sometimes with small fried fish. Women from three of the urban
households explained that the morning and evening meals are called teatime
and is made of starch (cassava, rice, bread, buns, etc) with fried fish (Figure
14). In the two households from the city centre, teatime was reported to be
consumed in the morning and lunch leftovers where kept in the fridge and
reheated for dinner.
Figure 14: One example of teatime: boiled cassava (the two white pieces) and fried fish.

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51

Participants of the household observations in Bwejuu reported that when fish


is available, they do not eat vegetables. When there is not any fish they
usually eat beans instead. They were also saying that the period when they
eat fish everyday is in March and April, when there are plenty of fish, fishing
conditions are good and it is the low tourists season. During the high tourists
season, they sell their catches to hotels:
When they eat fish [with starch], people are too full to eat vegetables (F,
one informant).
Such variations regarding vegetable consumption due to the fishing season
was not elsewhere. It is therefore interesting to see that vegetables
consumption might also be link to the availability of other non-vegetables and
non-fruits foodstuffs.
In the ten households, the main meal of the day was composed of one main
course and no fruits were eaten as part of the meal. Indeed, fruits are eaten as
a snack and are not part of the meal:
It is not the habit and tradition to eat a dessert here or something sweet.
This is why when people eat it [fruits] it is as a snack (Nutrition office
staff).
Indeed, outside of the observation time, people were seen eating jackfruit and
Zanzibar apples during the afternoon on the streets.
People here when they eat fruits, its during the afternoon and sometimes
as a snack other time of the day (Nutrition office staff).
Furthermore, in all households visited, fruit intake was reported to largely
depend on the season. In Bwejuu, one of the women taking part in the
observations explained that people eat a lot of mangoes when it is the season
because they can have them for free or really cheap.
Rice was the most consumed food item, both in terms of quantity and
frequency. The vegetables used to make the sauce in five of the households
visited were carrots, aubergines, tomatoes, onions and okras. The vegetables
were pealed, soak in water for 30 minutes to one hour, chopped and then
boiled for at least 30 minutes to make the sauce. Other vegetables observed
were aubergine (other vegetables in table 9) and leafy vegetables such as

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

52

spinach (Mtorero or Mchicha) or cassava leaves that were blended, and then
cooked with water or coconut milk and water (Table 9).
Table 9: Food ingredients* used in 10 households at the time of the observations, Unguja
House-

Rice

Ugali

Plantain

Chapati

Potatoes

holds

Beans

Vegetable
Sauce

Leafy
vegetable

Other

Fish

Meat

vegetables

1
2
3
4
5
6
7
8
9
10
* Excluding condiments, type and quantity of fat and beverage

To sum up, the observations and the quantitative data analysis showed that
season, availability and price of fruits and vegetables as well as kitchen
facilities, cooking practices, income and urban vs. rural settings influence fruit
and vegetables consumption as well as obesity, hypertension and diabetes
prevalence. Furthermore, a generalised low consumption of fruits and
especially vegetables was present in the NCD surveys sample population and
only weak correlations between fruit and vegetables intake and obesity,
diabetes and hypertension were found.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

53

Discussion
The objectives of this thesis were to analyse the association between fruit and
vegetables intake in relation to the prevalence of obesity, diabetes and
hypertension in rural and urban areas as well as to investigate gender
differences in fruit and vegetables intake, obesity, diabetes and hypertension
for the quantitative part. The qualitative objectives were to investigate fruit and
vegetables eating habits and practices of ten different households as well as
factors that may have influenced the quantitative assessment of fruit and
vegetables during the NCD survey.
In order to assess the strengths and limitations of the study, notions of
reliability and validity are discussed in relation to the quantitative findings of
this thesis. Notions of trustworthiness are discussed for the qualitative
findings. To ensure trustworthiness, criteria such as credibility, transferability
and dependability are used (Shenton, 2004, Bryman, 2008). Reliability refers
to the consistency or repeatability of a measurement whereas validity refers to
whether the measurement is accurate or not. Due to the cross-sectional
design of the NCD survey, causal relationships could not be measured;
therefore notion of external, rather than internal19, validity (generalised to the
population) will be discussed. Credibility can be used in qualitative research
instead of internal validity and refers to how believable the findings are.
Transferability is the extent to which the findings of one study can be applied
to other settings or groups and correspond to the external validity in
quantitative research. Dependability is similar to the concept of reliability and
is the extent to which measures are replicable. (Bryman, 2008)
Reliability and validity
The concepts of reliability and validity are presented in the following chapter in
relation to fruit and vegetables quantitative assessment using the STEP
questionnaire.

19

Internal validity deals with the issue of causality, causal relationship

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

54

There is not a single definition regarding fruits and vegetables. Indeed, There
are several definitions of "fruit", which makes classification and distinction
between fruit and vegetable difficult. (FAO, 1998)
One of the definitions given by the FAO is:
Vegetable
A vegetable is "a plant cultivated for food, especially an edible herb or root
used for human consumption"(Little et al, 1973). In general, vegetables tend to
be less sweet than fruits and often require some form of processing to
increase their edibility. (FAO, 1998).
Fruit
The everyday usage of the word "fruit" defines fruit as "The edible product of
a plant or tree, consisting of the seed and its envelope, especially the latter
when juicy and pulpy" (Little et al, 1973). (FAO, 1998)
According to a joint report of the WHO and FAO (2004), in order to avoid
confusion, a clear definition of fruits and vegetables is still needed (FAO/WHO,
2004, Pomerleau, 2004).
In the mean time, the classification of the two groups used by the Nutrition Unit
at the Ministry of Health (Appendix VIII) is based on the aforementioned FAO
ones. However, as mentioned in the results section, this definition is not the
one used by people in Zanzibar where the term vegetable only comprised
leafy-vegetables, while other type of vegetables, such as carrots, are called
fruit-vegetables. Findings from the household observations suggest that
reliability and validity of the NCD survey may have been impaired due to the
nature of the method used to assess vegetable consumption. Even though
interviewers were from Zanzibar, were trained regarding food groups and were
displaying show-cards picturing different fruits and vegetables, ensuring a
common understanding with the interviewees and reporting their answers in
the STEPS questionnaire entailed some difficulties in terms of consistency
between interviewers (reliability) and what was reported (validity). This
example enhances the importance of cultural differences between countries as
well as the necessity to be aware and understand them when conducting
Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

55

research and adapt research tools. Similar to what was done in the document
Diet (Typical fruit and vegetables and serving sizes) (Appendix X) where
vegetables are presented into two sub-categories (i.e. leafy-vegetables and
fruit-vegetables), one possible adaptation could have been to adapt the
STEPS questionnaire to ease interviewers task and improve STEPS
questionnaires reliability and validity. This could have provided a better
assessment of vegetables intake by ensuring a shared definition. Indeed,
when assessing fruit and vegetables consumption, it is important to guarantee
a common/shared understanding as the collective term fruits and
vegetables covers a very heterogeneous group of foods that differs among
countries and cultures (Pomerleau, 2004). Indeed, the most basic question
in research is whether the concept under study has the same meaning for the
people enrolled in the study (Hines, 1993).
The reliability as well as the validity regarding the assessment of fruit and
vegetables portions can also be questioned as, according to Dr M. who was
one of the interviewers trainers, participants did not always remember the
portion eaten and some imprecision may have arisen. Indeed, difficulties in
recall (recall bias) are common in quantitative research and need to be
acknowledged (Hines, 1993). The fruit and vegetables consumption
assessment might no be reliable as portion size estimation is influenced by
cognitive constructs that depend on individuals food perception and
conceptualisation as well as memory (Souverein et al., 2011). Portion size
estimation skills seem to be also linked to literacy and numeracy level with
poor literacy and numeracy being associated to poor portion size estimation.
Furthermore, there are some differences in the concept of portion size
depending on the populations and cultures that can lead to over or underestimation of dietary intake (Huizinga et al., 2009, Campbell et al., 1996).
According to Souverein et al. (2011), one of the largest sources of error in
dietary assessment is linked to the estimation of portion size. Therefore, due
to the possible inclusion of only leafy-vegetables and exclusion of fruitvegetables and recall bias in the dietary assessment, it can be stipulated that
an under-estimation of vegetables consumption occurred in the NCD survey.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

56

External validity
This chapter compare results from the NCD survey with other STEPwise
approach surveys conducted in four other African countries (Cape Verde,
Mozambique, Madagascar and Swaziland) to assess the external validity of
the findings regarding fruit and vegetables consumption.
The results presented show a generalised low intake of fruits and especially
vegetables. A majority of people in the five countries presented do not meet
the minimum recommended intake of five portions of fruit and vegetables per
day (400g/day). Indeed, the mean daily fruit intake was 0.9 portions in
Zanzibar compared to 0.7 in Cape Verde, 0.4 in Mozambique, 0.9 in
Madagascar and 0.5 in Swaziland. Regarding vegetables consumption, the
mean daily vegetable intake was 0.7 portions in Zanzibar compared to 0.7 in
Cape Verde, 0.7 in Mozambique, 1.1 in Madagascar and 1.1 in Swaziland
(WHO, 2011b). These results show that fruit consumption is lower in the four
African countries compared to Zanzibar, whereas vegetables consumption is
equal or lower in Zanzibar compared to the other four countries. This inverse
trend might be partly explained by the meaning (described above) attached to
vegetables in Zanzibar.
External validity is the extent to which the results from a sample population
can be generalised to the whole population. People, place and time constitute
a threat for external validity (Bryman, 2008). Due to the multi-stage cluster
sampling with stratification method used as well as the large sample size
(2658 participants), the sample population is likely to be representative of the
population in Zanzibar. However, as demonstrated above, the findings cannot
be generalised to other populations outside Zanzibar. Furthermore, as the
NCD survey was conducted between June and July 2011 and, as mentioned
in the result section, fruit and vegetables consumption vary according to the
seasonality, findings regarding fruit and vegetables consumption might be
different if the study is re-conducted at another time of the year.
Transferability and Dependability
The concept of transferability and dependability are presented in the following
chapter in relation to the availability and seasonality of fruit and vegetables.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

57

One way of verifying transferability is to compare findings with other research


(Bryman, 2008). The household and market observations highlighted the lack
of cold storage facilities that impair the quality of fruit and vegetables. The
poor quality and high perishability as well as the resulting low quantity of
locally produced fruit and vegetables impact on both people consumption and
retailers income. Accordingly, Ruel (2005) reports that poor storage facilities
and technologies as well as poor handling and processing result in high level
of post-harvest losses. Consequently, good nutritional status and food security
cannot be assured. However, transferability of the findings to other groups
might be complicated as a heterogeneous group of participants, from both
rural and urban areas, was included and no previous studies using household
observations as well as market observations to investigate fruit and vegetables
eating habits and practices in a developing country were found in the literature
review.
To assess dependability, Bryman (2008) emphasizes "the need for the
researcher to account for the ever-changing context within which research
occurs". Changes in context were noticed regarding fruit and vegetables prices
during the market observations. Indeed between January and March, the
prices of fruit and vegetables doubled and the price of some items such as
mango tripled. Therefore, the affordability of fruit and vegetables decreases
further during low harvest season making consumption even more precarious.
Furthermore, during the same period of time an increase in the price of petrol
was observed which also influences fruit and vegetables prices due to
transportation costs.
Prices and availability of fruits and vegetables in relation to other prices are
two factors influencing consumption. Ruel (2005) describes that low income
people, in order to avoid hunger, prioritize the fulfilment of their basic energy
needs and as fruits and vegetables are an expensive source of energy, their
consumption is uncommon. In concordance with the literature, the household
observations demonstrate that inhabitants, especially from rural areas,
consume a large quantity of starchy food (rice, potatoes, cassava, bread)
compared to the other food groups such as fruits and vegetables.

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58

Triangulation of quantitative and qualitative findings to analyse NCDs and


nutritional trend
The results show that one third of the sampled population had blood pressure
levels consistent with hypertension (37.6% men; 32.6% women) and three
times more women than men were obese (6.4% men; 19.4% women). These
findings are in concordance with worldwide trends reported in the literature
(Kearney et al., 2005, Mponda and Nyoni, 2012, ZFSNP, 2009). Regarding
diabetes, the prevalence (based on fasting blood glucose level only) was 2.5%
and was higher amongst women than men (2.2% men; 2.8% women). On the
contrary, a study from Wild et al. (2004) showed that the worldwide prevalence
of diabetes for all age-groups was 2.8% with a higher prevalence amongst
men and a higher total number of women living with diabetes (Wild and al.,
2004). Therefore, both total percentages of diabetics are similar, however
there is a difference regarding gender distribution. This difference might be
explained by the different measures used to define people as diabetic or not.
The current nutritional trend in developing countries is toward a diet higher in
energy with increased consumption of fat, sugar, refined carbohydrate and
meat that contributes to an increased risk of diet-related NCDs such as
hypertension and diabetes. Urban populations in developing countries are
more affected by the nutritional transition and thus have a higher prevalence of
diet-related NCDs than rural ones where poverty is higher and people are
currently still more affected by under-nutrition (Njelekela, 2003, Schmidhuber
and Shetty, 2005, DeSchutter, 2011). Similarly, the household and market
observations as well as the quantitative analysis revealed discrepancies
between rural and urban areas in terms of availability and price of fruits and
vegetables as well as differences in terms of income, kitchen facilities and
prevalence of obesity, hypertension and diabetes. Indeed, access to fruits and
vegetables was scarcer in rural areas whereas the prevalence of obesity,
hypertension and diabetes was higher in urban ones.
The household observations, quantitative analysis as well as the literature
showed that the main staple food in Zanzibar was white rice and that the
consumption of fruits and vegetables was low. Low fruit and vegetables
consumption combined with high consumption of refined carbohydrate leads to
Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

59

poor dietary fibre, vitamins, minerals and phytochemicals intake that are
chronic NCDs risk factors. As vegetables in Zanzibar are usually pealed,
soaked and cooked (boiled) for an extensive period of time, the vitamins and
minerals loss is high. Indeed, cooking methods can greatly influence vitamins
and minerals food content (FAO/WHO, 2004). Inversely, several studies
document that a high-fibre diet with consumption of fruits, vegetables, whole
grains and low in (trans/saturated) fat combined with daily physical activity can
prevent

(primary

prevention)

and/or

regulate

(secondary

prevention)

hypertension and type 2 diabetes as well as obesity (Roberts, 2005).


Correlation analyses show a positive association between fruit and vegetables
intake, BMI and FBG. These findings are in contradiction with the literature
and might be explained by two main different factors. First, as aforementioned,
the NCD survey design regarding fruit and vegetables data collection
comprises some limitations. Second, as households become wealthier their
diets become more diverse (Weinberger, 2004). Hence it is likely that the
higher the income, the more food and food diversity which results in an
increased amount of fruits and vegetables as well as an increased amount of
high fat/high sugar and low fibre diet with low physical activity which impact on
obesity and diabetes as well as hypertension. However, results from the t-test
did not support these findings, as obese and diabetics were more likely to
have a low fruit consumption than non-obese and non-diabetics. Increased
BMI and FBG cannot be explained by an increased intake of fruits and
vegetables (weak r-value) but it is likely that other factors have an impact.

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60

Future research
Due to the limitation regarding the assessment of fruit and vegetables
consumption using the STEPS questionnaire and in order to get a better
overview of the fruit and vegetables consumption situation in Zanzibar, further
research using other measurement tools, such as 24-hours recall, is
necessary. Beforehand, qualitative research as well as literature review to
develop a culturally relevant and acceptable measurement tool of fruit and
vegetables intake for Zanzibar should be undertaken.
Further qualitative research with triangulation of different qualitative methods
of data collection would provide a wider and thorough description and analysis
of the socio-cultural drivers of diet-related NCDs eating habits and behaviours.
This would allow to better adapt current health promotion and NCDs
prevention policy papers in Zanzibar.
Findings from this study revealed that fruit and vegetables consumption are
greatly influenced by seasonality and price. Thus, research projects looking at
agriculture policy and barriers related to agriculture development should be
undertaken to develop policies guaranteeing year-round and affordable fruit
and vegetables availability, food security, and preventing the development of
diet-related NCDs in Zanzibar (Tanzania).

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61

Limitations of the study

Data on age only include about half of the sample population because a large
amount of people did not answer the questions. Therefore, results regarding
age might not be representative.

Data on income only include monthly income and do not take into account
weekly income and yearly income. Their inclusion might have provided slightly
different results and should be included in future analysis.

Participant observations as a tool for data collection hold some limitations.


Indeed the researchers age, gender, ethnicity, social class, appearance and
theoretical approach may influence observation, analysis and interpretation.
Reflexivity, adaptability and neutrality were implemented in order to
understand and limit such bias (Kawulich, 2005). In order to show respect and
adaptability, the researcher wore an ankle length skirt, a long sleeves shirt and
a scarf to cover her hair during the observations. Furthermore, being a woman
allowed the researcher to be more easily integrated in the food cooking
process, as it is a womens duty in Zanzibar. Adaptability was shown during
the household observations in term of degree of involvement in the cooking
process, according to the household participants whish.

Due to the use of an interpreter during the observations and the lack of
language (Swahili) proficiency of the researcher, some information may have
been oversight and some misinterpretations may have occurred. While the
observations were taking place, small talks between participants as well as
between the interpreter and the participants were not always translated to the
researcher. However, language skills are not the only important factor during
fieldwork. Social and cultural sensitivity as well as adaptability are major
components. The use of an interpreter was also useful in order to approach
and be accepted by the communities (Borchgrevink, 2003).

The use of a mixed method research and the triangulation of data enabled to
understand, limit and acknowledge eventual bias that may have occurred in
both quantitative and qualitative parts (Hines, 1993). To illustrate, the
household observations allowed to better understand the meaning attached to
vegetables in Zanzibar and acknowledge the potential difficulties and

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

62

limitations encountered during the quantitative data collection. Triangulation of


quantitative and qualitative findings regarding gender and fruit and vegetables
consumption showed that quantitative findings correlate with the qualitative
ones, where no differences regarding the consumption pattern of fruits and
vegetables were observed.

Conclusion
The findings of this study give an understanding of the relationship between
fruit and vegetables eating habits and practices and their related low
consumption. Indeed, the findings show that the consumption of fruits and
vegetables in Zanzibar is low and, due to unfavourable cooking habits, the
vitamin and mineral intake from fruits and vegetables is impaired. This low
consumption can be explained by the restricted availability and high price
(compared to peoples average income) of fruits and vegetables observed in
urban and especially rural areas.
Regarding vegetables consumption, the household observations suggest a
relationship between kitchen facilities, cooking practices and food diversity as
well as consumption of vegetables. Income and kitchen facilities seemed to be
associated, hence the consumption of vegetables is likely to be influenced by
households income.
Regarding fruit consumption, it is surprising to note that on a tropical Island
like Zanzibar where, according to the season, fruits are grown in plenty,
people do not have the habit of considering fruits as food but only potential
snacks and that fruits are not used in food preparation or preserved.
Furthermore, the findings underline the importance of adapting quantitative
data collection tools for future research in order to better evaluate fruit and
vegetables consumption and its association with diet-related NCDs. Indeed,
even though the findings regarding the prevalence of diabetes, hypertension
and obesity in Zanzibar are in accord with what was found in the literature
review, only weak correlations could be found between fruit and vegetables
consumption and the prevalence of obesity, diabetes and hypertension.

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63

Recommendations
The National Nutrition Strategy report of the Ministry of Health and Social
Welfare of Tanzania lists seven20 key priority areas to improve Tanzanians
nutritional status. In accordance with the findings of this study, the report
acknowledges the emerging challenges of diet-related NCDs and the threat
they will represent for human development in the near future. It also
recognises the importance of integrating nutrition policies and strategies into
the health, education, agriculture, community development and industry
sectors at national and regional levels.
Health promotion programmes should include and specifically target fruit and
vegetables in order to improve their consumption by, for example, teaching
cooking methods that preserve vitamins and minerals content and promote the
consumption of fruit not only as a snack, but as part of the meal. Preservation
methods (pickles/ chutney) should also be taught in order to increase the yearround availability of fruit and vegetables and thus promote their consumption.

20

-Infant and young child feeding


-Vitamin and mineral deficiencies
-Maternal and child malnutrition
-Children, women and households in difficult circumstances
-Diet-related non-communicable diseases
-Household food security
-Nutrition surveillance, surveys and information management

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64

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WILD, S. & AL., E. 2004. Global prevalence of diabetes. Estimates for the year 2000 and
projection for 2030. Diabetes Care, 27, 1047-1053.
WISE, T. & MURPHY, S. 2012. Resolvingthe Food Crisis - Assessing Global Policy
Reforms Since 2007. In: POLICY, G. D. A. E. I. A. I. F. A. A. T. (ed.).
ZFSNP, Z. F. S. A. N. P.-. 2009. Zanzibar Food Balance Sheet Report for the year 2007.
ZFSNSA 2006. Zanzibar Food Security & Nutriton Situation Analysis. In: MINISTRY OF
AGRICULTURE, L. A. E. & WELFARE, M. O. H. A. S. (eds.). Zanzibar: Revolutionary
Government of Zanzibar.
ZIMMET, P. 2000. Globalization, coca-colonization and the chronic disease epidemic: can
the Doomsday scenario be averted? . Journal of Internal Medicine, 247, 301-310.
ZIMMET, P., ALBERTI, KG., SHAW, J. 2001. Global and societal implications of the
diabetes epidemic. Nature, 414, 782-787.

Amlie Keller, Europubhealth Masters Degree in Public Health, 2010-2012

67

List of Appendix
Appendix I Maps of Zanzibar
Appendix II - Information form English
Appendix III Information form Swahili
Appendix IV Consent form English
Appendix V Consent form Swahili
Appendix VI Ethical Approvals
Appendix VII: Consumption of Fruit and Vegetable according to age, gender,
marital status, level of education, income, tobacco use, alcohol use, obesity,
blood pressure (hypertension) and diabetes
Appendix VIII Food groups, Ministry of Health of Zanzibar
Appendix VIIII Tropical Fruit and Vegetables Index
Appendix X Diet (Typical Fruit and Vegetables and Serving Sizes)
Appendix XI STEPS Instrument (questionnaire)

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix I Maps of Zanzibar21

21

http://www.lonelyplanet.com/maps/africa/tanzania/zanzibar/map_of_zanzibar.jpg

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix II Information form English


INFORMATION FORM
The major social and cultural determinants of diet, and diet-related
chronic disease risks-factors
Dear Sir or Madam,
As part of my second year of the Masters degree in Public Health, I am conducting a research study about the major
social and cultural determinants of diet, and diet-related chronic disease risks-factors in Zanzibar. This research
study is carried under the auspices of the Ministry of Health of Zanzibar and is part of a larger NCD (Non
Communicable Disease) study in collaboration with the University of Copenhagen.
In this study, I aim to identify and explore the social and cultural determinants of diet and risks-factors of chronic
diseases (obesity, diabetes and hypertension) related to diet in Zanzibar, Tanzania. I would like to investigate eating
habits, practices and knowledge as well as generational and socio-economic variation in eating habits in relation to
obesity, diabetes and hypertension.
I would like to conduct some observations regarding your food habits and share knowledge about food. In order to
do so, I would like to be able to come to your home in order to see and understand how food is prepared and eaten. I
also would like to accompany the person in charge at one time when he/she goes food shopping. If you agree to
participate in the study, you or the person in charge will be requested to prepare, cook and eat a usual everyday
meal in your household in the presence of the researcher. The meal and situation within the meal is prepared,
cooked and eaten should reflect what you usually do (outside special occasions).
Written notes will be taken during the observations. Coding of the transcribed observations will guarantee
confidentiality. Student and supervisors are bound to observe professional secrecy. Furthermore, 10 pictures of the
food prepared, cooked and eaten will be taken in order to illustrate the observations. No picture where you and/or
your family and household can be recognised will be taken.
Participants to this study will not get any remuneration. However, the researcher will bring a food item typical from
the country where she is from (Switzerland) and give it to the participant and share knowledge about food habits in
her country if the participant is interested. Furthermore, the expected outcomes of this study aim at benefiting the
Zanzibari population by providing recommendations in order to prevent obesity, diabetes and hypertension and
promote a healthy diet.
The information collected will be used for my masters thesis as well as for two publications in collaboration with the
Ministry of Health in Zanzibar and the University of Copenhagen.
No harmful procedure will be performed and you will be able to drop out of the study at anytime without justifications.
If you agree to participate, please sign the joint informed consent form.
Amlie Keller

Maximilian De Courten

If you wish to get further information, you can contact the persons below:
STUDENT
Amlie Keller
Masters student in Public Health, University of Copenhagen
Email: amelie.keller@gmail.com
SUPERVISORS
Pr Maximilian de Courten
Professor of Global Public Health, University of Copenhagen
Email : maxc@sund.ku.dk
Dr Tania Aase Draebel
Post doc and external lecturer, University of Copenhagen
Email: tdr@sund.ku.dk

Amlie Keller, Europubhealth Masters Degree, 2012

Tania Aase Draebel

Appendix III Information form Swahili


FOMU YA MAELEZO
VITU VINAVYOATHIRI AFYA YA JAMII KWA UPANDE WA KIUTAMADUNI, KAMA CHAKULA NA MAGONJWA
SUGU YANAYOTOKANA NA CHAKULA
Kama ni sehemu ya mwaka wa pili wa shahada ya masomo katika afya ya Jamii,ninafanya utafiti kuhusu mambo
yanayoathiri jamii kiutamaduni kutokana na chakula na magonjwa yanayosababishwa na chakula katika
Zanzibar.Utafiti huu unafanywa chini ya mashirikiano ya Wizara ya Afya ya Zanzibar na Chuo kikuu cha
Copenhagen.
Katika utafiti huu,nitachunguza na kugundua sababu za magonjwa sugu yanayosababishwa na chakula katika jamii
kutokanana na utamaduni wa Zanzibar kama (uzito mkubwa, sindikizo la damu na kisukari),Pia nitapenda
kuchunguza kuhusu hali za uchumi,, ujuzi wao, na tabia zao za kula juu ya magonjwa yanayotokana na chakula.
Ningependa kuangalia juu ya utayarishaji wa chakula na kubadilishana ujuzi ,hasa wakati wa kununua ,kutayarisha
kula. Ili kufanikisha hayo, ningependa niweze kuja nyumbani kwako ili kuona na kufahamu jinsi chakula
kinavyotayarishwa, kuliwa na ningependa kushirikiana na wakuu wa familia wakati wanapokwenda kununua
chakula. Ikiwa utaridhia kushiriki katika utafiti huu wewe au mtu yeyote ambae anatayarisha chakula cha familia
awe tayari kuwa pamoja na mtafiti wakati wote wa utayarishaji wa chakula hicho.
Nitahakikisha kuwa maelezo yako yatakayochukuliwa wakati wa matayarisho yatakuwa siri, Mwanafunzi na
Msimamizi wanatakiwa kuangalia maisha ya familia hiyo.Aidha picha kumi zitapigwa juu ya utayarishwaji,upikaji na
ulaji wa chakula ili kusaidia utafiti huo. Hakuna picha zitazochukuliwa ambazo zitaitambulisha familia yako..
Washiriki wa utafiti huu hawatapata malipo yeyote. Hata hivyo, Mtafiti ataleta aina za chakula kutoka nchini
anakotoka (Switzerland)na kuwapa washiriki ili kubadilishana mawazo juu ya utayarishaji na utumiaji wa chakula
ikiwa mshiriki anakubali.
Aidha matarajio ya utafiti huu yana lengo la kuwanufaisha Wazanzibar na kutoa mapendekezo ili kujikinga na
Unene uliozidi, , kisukari na sindikizo la damu ili kuinua ulaji bora.Taarifa zitakazo patikana nitazitumia kwa ajili ya
masomo yangu na vile vile matoleo mawili kwa ajili ya machapisho kwa mashirikiano ya Wizara ya afya Zanzibar
na Chuo Kikuu cha Copenhagen.
Hakuna hatari yeyote katika kushiriki na unaweza kuacha utafiti wakati wowote bila ya hoja,ikiwa umekubali tafadhali
saini fomu utayopewa kukubali kushiriki.
Amelie keller

Maximilian De Courten

Tania Aase Draebel

Ikiwa unahitaji maelezo zaidi wasiliana na watu wafuatao:


MWANAFUNZI
Amelie Keller
Masters student in Public Health, University of Copenhagen
Email : amelie.keller@gmail.com
WASIMAMIZI
Maximilian de Courten
Profesa wa Afya Global Umma, Chuo Kikuu cha Copenhagen
Email: maxc@sund.ku.dk
Dr Tania Aase Draebel
Post doc na nje ya mhadhiri wa Chuo Kikuu cha Copenhagen
Email: tdr@sund.ku.dk

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix IV Consent form English


INFORMED CONSENT FORM
The major social and cultural determinants of diet, and diet-related
chronic disease risks-factors
Concern: Study about the major social and cultural determinants of diet, and diet-related chronic disease
risks-factors in Zanzibar.
I have been orally and in writing informed about the aim and process of the study.
I have read and understood the information form about the study. Satisfying answers have been given regarding my
participation to this study. I can keep the information form and I get a duplicate of my written statement of consent.
I have had enough time to reflect before taking the decision to participate.
I agree that the student and her supervisors access my original data, however these information remain strictly
confidential.
I am taking part voluntarily to this study. Nevertheless, I am able to drop out of the study at anytime.
I know that the requirements and restrictions mentioned above have to be respected.
I agree to participate.
Name of the participant

Signature

Date

Name of the student

Signature

Date

Thank you for your participation!

Contacts:
STUDENT
Amlie Keller
Masters student in Public Health, University of Copenhagen
Email: amelie.keller@gmail.com
SUPERVISORS
Pr Maximilian de Courten
Professor of Global Public Health, University of Copenhagen
Email : maxc@sund.ku.dk
Dr Tania Aase Draebel
Post doc and external lecturer, University of Copenhagen
Email: tdr@sund.ku.dk

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix V Consent form Swahili


FOMU YA MAKUBALIANO
VITU VINAVYO ATHIRI JAMII KWA UPANDE WA KITAMADUNI K.M CHAKULA NA MAGONJWA
SUGU YANAYOTOKANA NA CHAKULA.

Utafiti: Masomo kuhusu vigezo vya kijamii na kiutamaduni kubwa ya chakula, na chakula-kuhusiana na
ugonjwa hatari wa muda mrefu katika Zanzibar.
nimeelezwa na kupatiwa maandishi kuhusu lengo na mchakato mzima wa utafiti huu.
Nimesoma na kuelewa fomu ya taarifa kuhusu utafiti na nimepata majibu ya kuridhisha kuhusu ushiriki.
Wangu kwenye utafiti huu.nitaweka fomu yenye taarifa.na kupata kopi ya maelezo kwa maandishi ya
ridhaa.
Nina muda wa kutosha wa kutafakari kabla ya kuchukua uamuzi wa kushiriki.
Ninakubali kwamba mwanafunzi na wasimamizi wake watakuwa na uwezo wa kupata takwimu halisi,
hata hivyo habari hizi zitabaki kuwa siri.
Ninashiriki kwa hiari yangu kwenye utafiti huu. Hata hivyo, nina uwezo wa kuacha kujibu maswali wakati
wowote.
Naelewa kwamba mahitaji na vikwazo vinahitajika kuheshimiwa.
Nakubali kushiriki.
Jina

lako

_____________

Sahihi
_________________

Jina la mwanafunzi
______________

Tarehe
_______________

Sahihi
_________________

Tarehe
________________

Asante kwa ushirikiano wako!


Mawasiliano:
MWANAFUNZI
Amelie Keller
Mwanafunzi wa shahada ya pili ya Afya ya Jamii Chuo Kikuu cha Copenhagen
Email: amelie.keller @ gmail.com
WASIMAMIZI
Mit Maximilian de Courten
Profesa wa Afya Global Umma, Chuo Kikuu cha Copenhagen
Email: maxc@sund.ku.dk
Dr Tania Aase Draebel
Post doc na nje ya mhadhiri wa Chuo Kikuu cha Copenhagen
Email: tdr@sund.ku.dk
Amlie Keller, Europubhealth Masters Degree, 2012

Appendix VI Ethical Approvals


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Amlie Keller, Europubhealth Masters Degree, 2012

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix VII: Consumption of Fruit and Vegetable according to age, gender, marital status,
level of education, income, tobacco use, alcohol use, obesity, blood pressure (hypertension)
and diabetes
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Amlie Keller, Europubhealth Masters Degree, 2012

Appendix VIII Food groups, Ministry of Health of Zanzibar

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix VIIII Tropical Fruit and Vegetables Index


Coconut

Rambutan

Papaya

Pineapple

Guava
Mongo

Pomelo

Durian

Passion fruit

Tamarind
Amlie Keller, Europubhealth Masters Degree, 2012

Mandarin

Banana

Cassava-leaves
Grapefruit

Amaranth
Avocado

Jackfruit

Okra

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix X Diet (Typical Fruit and Vegetables and Serving Sizes)

Diet (Typical Fruit and Vegetables and Serving Sizes)


V E G E T A B L ES A R E C O NSI D E R E D
T O BE:
Raw green leafy vegetables

1 SE R V I N G
(ST A N D A R D)

E X A M P L ES
Spinach, salad, mchicha, etc.

1 cup
Other vegetables, cooked or chopped
raw

C up

Vegetable juice
(undiluted)

C up

FRUIT
Is considered to be:
Banana
(Ndizi)

Orange
(Chungwa)

Tomatoes, carrots, pumpkin, maize,


Chinese cabbage, fresh beans, onion,
etc.

1 medium size piece


or 2 small bananas (ndizi
kisukari)
1 medium size piece

Mango
(Embe)

1 medium size piece

Watermelon
(Tikiti maji)

K ipande cha tikiti maji


(134g)

Avocado
(Parachichi)

1 small size (parachichi dogo)


(110 g)

Paw paw
(Papai)

piece ( kipande)
(120g)

Pineapple
(Nanasi)

piece

Chopped, cooked, canned fruit

cup

Fruit juice

cup

Juice from fruit, not artificially


flavoured

Standard serving = 80 grams (translated into different units of cups depending on type of vegetable and standard cup measures available in the
country).
W H O Recommendation at least: 400 grams of vegetables and fruits per day, or Five servings of 80 grams each.

Amlie Keller, Europubhealth Masters Degree, 2012

Appendix XI STEPS Instrument (questionnaire)

WHO STEPS Instrument


(Core and Expanded)

The WHO STEPwise approach to chronic


disease risk factor surveillance (STEPS)
World Health Organization
20 Avenue Appia, 1211 Geneva 27,
Switzerland

Amlie Keller, Europubhealth Masters Degree, 2012

STEPS Instrument
Overview
Introduction

This is the generic STEPS Instrument which sites/countries will use to


develop their tailored instrument. It contains the:
CORE items (unshaded boxes)
EXPANDED items (shaded boxes).

Core Items

The Core items for each section ask questions required to calculate
basic variables. For example:
current daily smokers
mean BMI.
Note: All the core questions should be asked, removing core
questions will impact the analysis.

Expanded items

The Expanded items for each section ask more detailed information.
Examples include:
use of smokeless tobacco
sedentary behaviour.

Guide to the
columns
Column

The table below is a brief guide to each of the columns in the


Instrument.

Description

Amlie Keller, Europubhealth Masters Degree, 2012

Site Tailoring

Participant Identification Number

Number

Question

This question reference number is designed

Renumber the instrument

to help interviewers find their place if

sequentially once the content

interrupted.

has been finalized.

Each question is to be read to the participants

Select sections to use.


Add expanded and optional
questions as desired.

Response

This column lists the available response


options which the interviewer will be circling

for demographic responses

or filling in the text boxes. The skip

(e.g. C6).

instructions are shown on the right hand side

Code

Add site specific responses

Change skip question

of the responses and should be carefully

identifiers from code to

followed during interviews.

question number.

The column is designed to match data from

This should never be changed

the instrument into the data entry tool, data

or removed. The code is used

analysis syntax, data book, and fact sheet.

as a general identifier for the


data entry and analysis.

WHO STEPS INSTRUMENT


FOR CHRONIC DISEASE
RISK FACTOR SURVEILLANCE
<INSERT COUNTRY/SITE NAME>

Survey Information

Location and Date


1

Shehia ID

Shehia Name

Response

Code

I1
I2

Amlie Keller, Europubhealth Masters Degree, 2012

Participant Identification Number


3

Interviewer ID

Date of completion of the instrument


dd

mm

I3

I4

year

Participant Id Number

Consent, Interview Language and Name


5

Response
Yes

No

English

Kiswahili

Consent has been read and obtained

Interview Language [Insert Language]

First Name

I6

(24 hour clock)


Family Surname

I5

If NO, END

Time of interview

Code

hrs

I7

mins

I8
I9

Additional Information that may be helpful


10

Contact phone number where possible

Record and file identification information (I5 to I10) separately from the completed questionnaire.

Amlie Keller, Europubhealth Masters Degree, 2012

I10

Participant Identification Number

Step 1

Demographic Information

CORE: Demographic Information


Question
11

Response

Sex (Record Male / Female as observed)

Male

Female

Code
C1

What is your date of birth?

12

If known, Go to C4
Don't Know 77 77 7777

13

14

dd

How old are you?

mm

year
Years

In total, how many years have you spent at school or


in full-time study (excluding pre-school)?

C2

Years

C3
C4

EXPANDED: Demographic Information

What is the highest level of education you have


completed?

No formal schooling
Less than primary school

1
2

Primary school completed (P7)

Secondary school completed


(form four )

15

[INSERT COUNTRY-SPECIFIC CATEGORIES]

High school completed (form six)

College/University completed

Post graduate degree

Refused

C5

88

African
Arab

16

What is your [insert relevant ethnic group / racial group /


cultural subgroup / others] background?

Indian

C6

Chinese
Mixed
Do not know
Refused

17

What is your marital status?

88

Never married

Currently married (monogamous)

Currently married (polygamous)


Separated
Divorced
Widowed
Cohabitating

Amlie Keller, Europubhealth Masters Degree, 2012

C7

Participant Identification Number


Refused
Which of the following best describes your main work
status over the past 12 months?

18

[INSERT COUNTRY-SPECIFIC CATEGORIES]

1
2

Self-employed

Non-paid

Student

Homemaker / Housewife

Retired

Unemployed (able to work)

Unemployed (unable to work)

Refused

How many people older than 18 years, including


yourself, live in your household?

88

Government employee
Non-government employee

(USE SHOWCARD)

19

Number of people

C8

88

C9

EXPANDED: Demographic Information, Continued


Question

Response

Taking the past year, can you tell me what the

20

average earnings of the household have been?


(RECORD ONLY ONE, NOT ALL 3)

Code

Per week

Go to T1

C10a

OR per month

Go to T1

C10b

OR per year

Go to T1

C10c

88

C10d

Do not know
Refused

21

If you dont know the amount, can you give an

< 10.000. Tsh

estimate of the monthly household income if I read

10.000. 49.000. Tsh

some options to you? Is it

(READ OPTIONS)

Step 1

50.000 , 99.000 Tsh. Tsh

100.000., 500.000 mio. Tsh

More than 500.000. Tsh

Don't Know

77

Refused

88

C11

Behavioural Measurements

CORE: Tobacco Use


Now I am going to ask you some questions about various health behaviours. This includes things like smoking, drinking alcohol, eating fruits
and vegetables and physical activity. Let's start with tobacco.

Question

Response

Do you currently smoke any tobacco products, such

22

Yes

No

Code
T1

as cigarettes, cigars or pipes? (USE SHOWCARD)


If No, go to T6

Amlie Keller, Europubhealth Masters Degree, 2012

Participant Identification Number

23

24

Do you currently smoke tobacco products daily?


How old were you when you first started smoking

Yes

No

daily?

Dont know 77

(RECORD ONLY 1, NOT ALL 3)


Dont know 77

In Years
OR

in Months

OR

in Weeks

Manufactured cigarettes

On average, how many of the following do you smoke


each day?

Hand-rolled cigarettes
Pipes full of tobacco

26
(RECORD FOR EACH TYPE, USE SHOWCARD)

T2
If No, go to T6

Age (years)

Do you remember how long ago it was?

25

Cigars, cheroots, cigarillos


Other

Dont Know 77

Other (please specify):

If Known, go to T5a
If Known, go to T5a
If Known, go to T5a

T3
T4a
T4b
T4c

T5a

T5b

T5c

T5d

If Other, go to T5other,

else go to T9

T5e

T5other

Go to T9

EXPANDED: Tobacco Use


Question

Response

27

In the past, did you ever smoke daily?

28

How old were you when you stopped smoking daily?

Yes

No

How long ago did you stop smoking daily?

29

30

31

Years ago

(RECORD ONLY 1, NOT ALL 3)

OR

Months ago

Dont Know 77

OR

Weeks ago

If Known, go to T9
If Known, go to T9
If Known, go to T9

Do you currently use any smokeless tobacco such

Yes

as [snuff, chewing tobacco, Tambuu, betel]? (USE

No

SHOWCARD)
Do you currently use smokeless tobacco products

Yes

No

daily?

T6
If No, go to T9

Age (years)
Dont Know 77

Code

If No, go to T12

If No, go to T12

Amlie Keller, Europubhealth Masters Degree, 2012

T7
T8a
T8b
T8c
T9
T10

Participant Identification Number


Snuff, by mouth
Snuff, by nose
On average, how many times a day do you use .

Chewing tobacco
Betel, quid

32

(RECORD FOR EACH TYPE, USE SHOWCARD)


Tambuu
Bhangi

Don't Know 77

Other
Other (specify)

33

In the past, did you ever use smokeless tobacco such


as [snuff, chewing tobacco, Tambuu or betel] daily?
During the past 7 days, on how many days did

34

someone in your home smoke when you were


present?
During the past 7 days, on how many days did

35

someone smoke in closed areas in your workplace (in

T11a

T11b

T11c

T11d

T11e

T11f

If Other, go to T11other,

else go to T13
Go to T13
Yes

No

T11other
T12

Number of days
Don't know 77

T11g

T13

Number of days

T14

the building, in a work area or a specific office) when

Don't know or don't

you were present?

work in a closed area 77

CORE: Alcohol Consumption


The next questions ask about the consumption of alcohol.

Question

Response

Have you ever consumed an alcoholic drink such as

36

No

(USE SHOWCARD
EXAMPLES)
Have
you consumedOR
anSHOW
alcoholic
drink within the past
12 months?

had at least one alcoholic drink?

38
(READ RESPONSES, USE SHOWCARD)

Have you consumed an alcoholic drink within the past


30 days?

Yes
No

During the past 12 months, how frequently have you

39

A1a

beer, wine, spirits, tende, Gongo, Mataputapu, Chibuku,


or Mnazi-tembo?

37

Yes

Code

2 If No, go to D1
1

A1b

2 If No, go to D1

Daily

5-6 days per week

1-4 days per week

1-3 days per month

Less than once a month

Yes
No

1
2

A2

If No, go to D1

Amlie Keller, Europubhealth Masters Degree, 2012

A3

Participant Identification Number

40

During the past 30 days, on how many occasions did


you have at least one alcoholic drink?

Number
Don't know 77

A4

During the past 30 days, when you drank alcohol, on


average, how many standard alcoholic drinks did

41

you have during one drinking occasion?

Number

A5

Don't know 77

(USE SHOWCARD)

Standards for local drinks have been developed


During the past 30 days, what was the largest number

42

of standard alcoholic drinks you had on a single

Largest number

occasion, counting all types of alcoholic drinks

Don't Know 77

A6

together?
During the past 30 days, how many times did you have

43

for men: five or more

Number of times

for women: four or more

A7

Don't Know 77

standard alcoholic drinks in a single drinking occasion?

EXPANDED: Alcohol Consumption


During the past 30 days, when you consumed an

44

alcoholic drink, how often was it with meals? Please do


not count snacks.

alcoholic drinks did you have each day?

(USE SHOWCARD)

Don't Know 77

Rarely with meals


Never with meals

During each of the past 7 days, how many standard

45

Usually with meals


Sometimes with meals

1
2
3
4

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Amlie Keller, Europubhealth Masters Degree, 2012

A8

A9a
A9b
A9c
A9d
A9e
A9f
A9g

Participant Identification Number

CORE: Diet
The next questions ask about the fruits and vegetables that you usually eat. I have a nutrition card here that shows you some examples of
local fruits and vegetables. Each picture represents the size of a serving. As you answer these questions please think of a typical week in the
last year.

Question
46
47
48
49

Response

In a typical week, on how many days do you eat fruit?


(USE SHOWCARD)
How many servings of fruit do you eat on one of those
days? (USE SHOWCARD)

Number of days
Don't Know 77
Number of servings
Don't Know 77

In a typical week, on how many days do you


eat vegetables? (USE SHOWCARD)
How many servings of vegetables do you eat on one of
those days? (USE SHOWCARD)

Number of days
Don't Know 77
Number of servings
Dont know 77

Code
If Zero days, go to D3

D2

D1

If Zero days, go to D5

D3
D4

EXPANDED: Diet

What type of oil or fat is most often used for meal


preparation in your household?

50

(USE SHOWCARD)
(SELECT ONLY ONE)
Give examples of types of oil by using brand names

Vegetable oil

Coconut oil/coconut

Butter or ghee

Margarine

Sunflower oil

Corn oil

Other

None in particular

None used

Dont know

77

Other
On average, how many meals per week do you eat that

51

were not prepared at a home? By meal, I mean


breakfast, lunch and dinner.

D5

If Other, go to D5 other

Number
Dont know 77

D5other
D6

Amlie Keller, Europubhealth Masters Degree, 2012

Participant Identification Number

CORE: Physical Activity


Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions
even if you do not consider yourself to be a physically active person.
Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, study/training,
household chores, harvesting food/crops, fishing or hunting for food, seeking employment.. In answering the following questions 'vigorousintensity activities' are activities that require hard physical effort and cause large increases in breathing or heart rate, 'moderate-intensity
activities' are activities that require moderate physical effort and cause small increases in breathing or heart rate.

Question

Response

Code

Work
Does your work involve vigorous-intensity activity that

52

causes large increases in breathing or heart rate like


[carrying or lifting heavy loads, digging or construction
work] for at least 10 minutes continuously?

53

54

In
a SHOWCARD)
typical week, on how many days do you do
(USE
vigorous-intensity activities as part of your work?
How much time do you spend doing vigorous-intensity
activities at work on a typical day?

causes small increases in breathing or heart rate such


as brisk walking [or carrying light loads] for at least 10
minutes continuously?

56

57

P1
No

Number of days

Hours : minutes

If No, go to P 4

In(USE
a typical
week, on how many days do you do
SHOWCARD)
moderate-intensity activities as part of your work?
How much time do you spend doing moderate-intensity
activities at work on a typical day?

Yes

P2

:
hrs

Does your work involve moderate-intensity activity, that

55

Yes

mins

P3
(a-b)

P4
No
Number of days

Hours : minutes

If No, go to P 7

P5

:
hrs

mins

P6
(a-b)

Travel to and from places


The next questions exclude the physical activities at work that you have already mentioned.
Now I would like to ask you about the usual way you travel to and from places. For example to work, for shopping, to market, to place of
worship.
58

59

60

Do you walk or use a bicycle (pedal cycle) for at least


10 minutes continuously to get to and from places?
In a typical week, on how many days do you walk or
bicycle for at least 10 minutes continuously to get to
and from places?
How much time do you spend walking or bicycling for
travel on a typical day?

Yes

No

Number of days

Hours : minutes

P7
If No, go to P 10

P8

:
hrs

Amlie Keller, Europubhealth Masters Degree, 2012

mins

P9
(a-b)

Participant Identification Number

CORE: Physical Activity, Continued


Question

Response

Code

Recreational activities
The next questions exclude the work and transport activities that you have already mentioned.
Now I would like to ask you about sports, fitness and recreational activities (leisure)].
Do you do any vigorous-intensity sports, fitness or

61

recreational (leisure) activities that cause large


increases in breathing or heart rate like [running or
football] for at least 10 minutes continuously?

62

In
a SHOWCARD)
typical week, on how many days do you do
(USE
vigorous-intensity sports, fitness or recreational

Yes

P10
No

How much time do you spend doing vigorous-intensity


sports, fitness or recreational activities on a typical day?

recreational (leisure) activities that cause a small


increase in breathing or heart rate such as brisk
walking, [cycling, swimming, volleyball] for at least 10

65

If No, go to P 13

P11

Do you do any moderate-intensity sports, fitness or

64

Number of days

(leisure) activities?

63

minutes continuously?
In a typical week, on how many days do you do
(USE
SHOWCARD) sports, fitness or recreational
moderate-intensity

Hours : minutes

:
hrs

Yes

mins

(a-b)

P13
No

If No, go to P16

P14

Number of days

(leisure) activities?

How much time do you spend doing moderate-intensity

66

P12

sports, fitness or recreational (leisure) activities on a

P15
Hours : minutes

typical day?

:
hrs

(a-b)

mins

EXPANDED: Physical Activity


Sedentary behaviour
The following question is about sitting or reclining at work, at home, getting to and from places, or with friends including time spent sitting at a
desk, sitting with friends, traveling in car, bus, train, reading, playing cards or watching television, but do not include time spent sleeping.
(USE SHOWCARD)

67

How much time do you usually spend sitting or reclining


on a typical day?

Hours : minutes

:
hrs

Amlie Keller, Europubhealth Masters Degree, 2012

mins

P16
(a-b)

Participant Identification Number

CORE: History of Raised Blood Pressure


Question
68

69

Response
Yes

No

Have you ever been told by a doctor or other health

Yes

worker that you have raised blood pressure or

No

Yes

No

Have you ever had your blood pressure measured by a


doctor or other health worker?

hypertension?

70

Have you been told in the past 12 months?

Code

If No, go to H6

If No, go to H6

H1
H2a
H2b

EXPANDED: History of Raised Blood Pressure


Are you currently receiving any of the following treatments/advice for high blood pressure prescribed by a doctor or other health worker?
Drugs (medication) that you have taken in the past two
weeks
Advice to reduce salt intake

71

Advice or treatment to lose weight

Advice or treatment to stop smoking

Advice to start or do more exercise

72

73

Have you ever seen a traditional healer or sorcerer for


raised blood pressure or hypertension?
Are you currently taking any herbal or traditional
remedy for your raised blood pressure?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Amlie Keller, Europubhealth Masters Degree, 2012

H3a
H3b
H3c
H3d
H3e
H4
H5

Participant Identification Number

CORE: History of Diabetes


Question
74

75

76

Response

Have you ever had your blood sugar measured by a


doctor or other health worker?
Have you ever been told by a doctor or other health
worker that you have raised blood sugar or diabetes?
Have you been told in the past 12 months?

Yes

No

Yes

No

Yes

No

Code

If No, go to M1

If No, go to M1

H6
H7a
H7b

EXPANDED: History of Diabetes


Are you currently receiving any of the following treatments/advice for diabetes prescribed by a doctor or other health worker?
Insulin
Drugs (medication) that you have taken in the past two
weeks

77

Special prescribed diet

Advice or treatment to lose weight

Advice or treatment to stop smoking

Advice to start or do more exercise

78

79

Have you ever seen a traditional healer for diabetes or


raised blood sugar?
Are you currently taking any herbal or traditional
remedy for your diabetes?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Violence and Injury

Amlie Keller, Europubhealth Masters Degree, 2012

H8a
H8b
H8c
H8d
H8e
H8f
H9
H10

Participant Identification Number

CORE: Injury
The next questions ask about different experiences and behaviours that are related to road traffic injuries.

Question

80

Response
All of the time

Sometimes

In the past 30 days, how often did you use a seat belt

Never

when you were the driver or passenger of a motor

Have not been in a vehicle in past 30

vehicle?

days
No seat belt in the car I usually am in

In the past 30 days, how often did you wear a helmet


81

when you drove or rode as a passenger on a


motorcycle or motor-scooter?

Refused

88

All of the time

Sometimes

Never
Have not been on a motorcycle or

82

road traffic crash as a driver, passenger, pedestrian, or


cyclist?

Refused

88

Yes (as passenger)

1
2

Yes (as pedestrian)

Yes (as a cyclist)

No

Refused
Did you have any injuries in this road traffic crash
83

which required medical attention?

5
77

Dont know

V2

Don't Know
Yes (as driver)
In the past 12 months, have you been involved in a

5
77

Do not have a helmet

V1

Don't Know

motor-scooter in past 30 days

Code

V3
If No, go to V5

77 If don't know, go to V5
88 If Refused, go to V5

Yes

No

Don't know

77

Refused

88

V4

The next questions ask about the most serious accidental injury you have had in the past 12 months.
In the past 12 months, were you injured accidentally,
84

other than the road traffic crashes which required


medical attention?

Yes

No

Don't know
Refused

85

Please indicate which of the following was the cause


of this injury.

V5

77 If don't know, go to V8
88 If Refused, go to V8

Fall

Burn

Poisoning

Cut

Near-drowning

Animal bite

Other (specify)

Don't know

If No, go to V8

77

Amlie Keller, Europubhealth Masters Degree, 2012

V6

Participant Identification Number

Refused

88

Other (please specify)

V6other

CORE: Injury, Continued


Question

86

Response

Where were you when you had this injury?

Home
School

1
2

Workplace

Road/Street/Highway

Farm

Sports/athletic area

Other (specify)

Dont know

77

Refused

88

Other (please specify)

Code

V7

V7other

EXPANDED: Unintentional Injury


The next questions ask about behaviours related to your safety and whether or not you drink alcohol while driving or being a passenger.

Question

87

Response

In the past 30 days, how often did you wear a helmet


when you rode a bicycle or pedal cycle?

In the past 30 days, how many times have you driven a


88

motorized vehicle when you have had 2 or more


alcoholic drinks?
(USE SHOWCARDS)
In the past 30 days, how many times have you ridden in

89

a motorized vehicle where the driver has had 2 or more


alcoholic drinks?
(USE SHOWCARDS)

Always

Sometimes

Never

Did not ride in the past 30 days

Don't Know

77

Refused

88

Number of times

Don't Know

77

Refused

88

Number of times

Don't Know

77

Refused

88

Mental Health
Amlie Keller, Europubhealth Masters Degree, 2012

Code

V8

V9

V10

Participant Identification Number

I should like to know if you have had any medical complaints and how your health has been in general over the past few weeks. Please
answer ALL the questions on the following pages simply by underlining the answer you think most nearly applies to you. Remember that
we want to know about present and recent complaints, not those that you had in the past. It is important that you answer ALL the
questions.
90

91

Have you ever

Yes

G1

been told by a health professional that

No

you suffer from a mental or neurological

Do not remember 3 (skip Q1)

disorder?

Refuses 4 (skip Q1)

If so, which disease?

Depression 1

2 (skip Q1)

Bipolar Disorder

Q1
2

Schizophrenia 3
Anxiety disorder 4
Alcohol/drug misuse 5
Acute Psychosis 6
Mental Retardation 7
Epilepsy 8
None of the above mentioned 9
do not remember 77
Refuses 88
92

Have you recently been able to

Better than usual 1

concentrate

Same as usual

Less

on whatever youre

doing

G2

Much less than usual 4


93

Have you recently lost much sleep over

Not at all

No more than usual


worry?

Rather more

G3
2

than usual 3

Much more than usual 4


94

Have you recently felt that you are

More so than usual 1

playing

Same as usual

a useful part in things?

Less useful

than usual 3

G4

Much less than usual 4


95

Have you recently felt capable of making

More so than usual 1


Same as usual 2

decisions about things?

Less so than usual 3


Much less than usual 4

Amlie Keller, Europubhealth Masters Degree, 2012

G5

Participant Identification Number


96

Have you recently felt constantly under

Not al all

No more than usual


strain?

G6

Rather more than usual 3


Much more than usual 4

97

Have you recently felt you couldnt over-

Not al all

No more than usual


come your difficulties?

G7
2

Rather more than usual 3


Much more than usual 4

98

99

More so than usual 1


Have you recently been able to enjoy

Same as usual 2

your

Less so than usual 3

normal day-to-day activities?

Much less than usual 4

Have you recently been able to face up

More so than usual 1

to

Same as usual 2

your problems?

Less so than usual 3

G8

G9

Much less than usual 4


100

Have you recently been feeling unhappy

Not al all

No more than usual


and depressed?

G10
2

Rather more than usual 3


Much more than usual 4

Have
101

you

recently

been

losing

Not al all

confidence

No more than usual

in yourself?

Rather more than usual 3

G11
2

Much more than usual 4


102

Have you recently been thinking of

Not al all

yourself as

No more than usual

a worthless person?

Rather more than usual 3

G12
2

Much more than usual 4


103

Been feeling reasonably

More so than usual 1

happy, all things considered?

About same as usual 2


Less so than usual 3
Much less than usual 4

Step 2

Physical Measurements

Amlie Keller, Europubhealth Masters Degree, 2012

G13

Participant Identification Number

CORE: Height and Weight


Question
104

Interviewer ID

105

For women: Are you pregnant?

106

107
108
109

Response

Yes
No

In which trimester are you?

Device IDs for height and weight

Height

Second

Third

M1
M5

X1

Height

M2a

Weight

M2b

in Kilograms (kg)

If too large for scale 666.6

2 If No, go to M2a

First

in Centimetres (cm)

Weight

Code

M3
M4

CORE: Waist
110

Device ID for waist

111

Waist circumference

in Centimetres (cm)

M6
M7

CORE: Blood Pressure


112

Interviewer ID

113

Device ID for blood pressure

114

Cuff size used

115

116

117

118

Small

Medium

Large

M10

M11a

Diastolic (mmHg)

M11b

Systolic ( mmHg)

M12a

Diastolic (mmHg)

M12b

Systolic ( mmHg)

M13a

Diastolic (mmHg)

M13b

Reading 2

Reading 3

raised blood pressure with drugs (medication)

M9

Systolic ( mmHg)
Reading 1 (left arm)

During the past two weeks, have you been treated for

M8

Yes

No

prescribed by a doctor or other health worker?

Amlie Keller, Europubhealth Masters Degree, 2012

M14

Participant Identification Number

EXPANDED: Hip Circumference and Heart Rate


119

Hip circumference

in Centimeters (cm)

M15

Heart Rate

120

Reading 1

Beats per minute

M16a

Reading 2

Beats per minute

M16b

Reading 3

Beats per minute

M16c

Step 3

Biochemical Measurements

CORE: Blood Glucose


Question
121

Response

During the past 12 hours have you had anything to eat


or drink, other than water?

Yes

No

Code
B1

122

Technician ID

B2

123

Device ID

B3

124

Time of day blood specimen taken (24 hour clock)

125

mmol/l

Fasting blood glucose


Today, have you taken insulin or other drugs

126

Hours : minutes

(medication) that have been prescribed by a doctor or


other health worker for raised blood glucose?

:
hrs

Yes

No

B4

mins

B5

B6

CORE: Blood Lipids


127

128

Device ID

Total cholesterol

mmol/l

During the past two weeks, have you been treated for

129

raised cholesterol with drugs (medication) prescribed by


a doctor or other health worker?

Yes

No

B7
B8

B9

EXPANDED: Triglycerides and HDL Cholesterol


Amlie Keller, Europubhealth Masters Degree, 2012

Participant Identification Number

130

mmol/l

Triglycerides

Amlie Keller, Europubhealth Masters Degree, 2012

B10