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Culture Documents
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.
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.
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
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
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.
Diabetes
SBP>140mmHg
or
DBP>90mmHg
(NIH,
Obesity
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
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)
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)
10
11
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
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
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.)
14
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.)
15
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
Amlie Keller, Europubhealth Masters Degree in Public Health, 2012
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).
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
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 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.
19
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
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
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
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,
Amlie Keller, Europubhealth Masters Degree in Public Health, 2012
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
22
11
Super markets in Zanzibar are similar in size and items sold to corner shops/small groceries in Europe.
23
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)
24
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)
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.
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
27
Able to understand the information given by data collector about the study
prior to the beginning of the interview
Exclusion
criteria
o
Qualitative
part
Inclusion
criteria
o
Able to understand the information given by data collector about the study
prior to the beginning of the interview
Exclusion
criteria
o
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.
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)
5.
6.
7.
8.
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
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
32
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
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
35
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
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.
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
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)
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
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
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,
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.
43
Figure 9: Men vs. women number of servings of fruits and vegetables per day
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
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.
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.
48
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
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).
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
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.
51
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.
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
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.
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.
57
58
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)
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).
61
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.
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
62
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.
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
64
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SCHLUNDT, D. G. & ROTHMAN, R. L. 2009. Literacy, numeracy, and portion-size
estimation skills. Am J Prev Med, 36, 324-8.
IDF.
2012.
Diabetes
[Online].
Brussel.
Available:
http://www.idf.org/diabetesatlas/5e/diabetes [Accessed 23.04.2012 2012].
JIDDAWI, M. 2008. HEALTH MANAGEMENT INFORMATION SYSTEM UNIT. Health
information bulletin. Zanzibar: Ministry of Health and Social Welfare, Zanzibar.
65
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SOUVEREIN, O. W., DE BOER, W. J., GEELEN, A., VAN DER VOET, H., DE VRIES, J. H.,
FEINBERG, M. & VAN'T VEER, P. 2011. Uncertainty in intake due to portion size
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TRGZ, T. R. G. O. Z.-. 2007. Zanzibar Strategy for Growth and Reduction of Poverty.
Available:
http://www.unpei.org/PDF/TZ-zanzibar-strategy-growth-povertyreduction.pdf [Accessed 23.08.2011].
TRGZ, T. R. G. O. Z.-. 2010. Zanzibar Strategy for Growth and Reduction of Poverty 20102015. A successor to the Zanzibar Strategy for Growth and Reduction of Poverty
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Available:
http://www.tzdpg.or.tz/uploads/media/MKUZA_II_FINAL_November_02.pdf
[Accessed 25.10.2011].
USCB.
2012.
Urban
and
Rural
Classification
[Online].
Available:
http://www.census.gov/geo/www/ua/urbanruralclass.html.
WEINBERGER 2004. Indigenous Vegetables in Tanzania-Significance and Prospects. In:
KALB, T. (ed.). Taiwan: The Wold Vegetable Center.
WHO, W. H. O. 2003. Diet, Nutrition and the Prevention of Chronic Diseases. Technical
report series 916. Report of a joint WHO/FAO Expert Consultation. Geneva.
WHO, W. H. O. 2010. United Republic of Tanzania: Health Profile.
WHO,
W.
H.
O.
2011a.
Obesity
and
Overweight
[Online].
Available:
http://www.who.int/mediacentre/factsheets/fs311/en/.
WHO, W. H. O. 2011b. STEPwise approach to surveillance (STEPS). WHO.
WILD, S. & AL., E. 2004. Global prevalence of diabetes. Estimates for the year 2000 and
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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.
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)
21
http://www.lonelyplanet.com/maps/africa/tanzania/zanzibar/map_of_zanzibar.jpg
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
Maximilian De Courten
Signature
Date
Signature
Date
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
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
________________
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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
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)
Mango
(Embe)
Watermelon
(Tikiti maji)
Avocado
(Parachichi)
Paw paw
(Papai)
piece ( kipande)
(120g)
Pineapple
(Nanasi)
piece
cup
Fruit juice
cup
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.
STEPS Instrument
Overview
Introduction
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
Description
Site Tailoring
Number
Question
interrupted.
Response
(e.g. C6).
Code
question number.
Survey Information
Shehia ID
Shehia Name
Response
Code
I1
I2
Interviewer ID
dd
mm
I3
I4
year
Participant Id Number
Response
Yes
No
English
Kiswahili
First Name
I6
I5
If NO, END
Time of interview
Code
hrs
I7
mins
I8
I9
Record and file identification information (I5 to I10) separately from the completed questionnaire.
I10
Step 1
Demographic Information
Response
Male
Female
Code
C1
12
If known, Go to C4
Don't Know 77 77 7777
13
14
dd
mm
year
Years
C2
Years
C3
C4
No formal schooling
Less than primary school
1
2
15
College/University completed
Refused
C5
88
African
Arab
16
Indian
C6
Chinese
Mixed
Do not know
Refused
17
88
Never married
C7
18
1
2
Self-employed
Non-paid
Student
Homemaker / Housewife
Retired
Refused
88
Government employee
Non-government employee
(USE SHOWCARD)
19
Number of people
C8
88
C9
Response
20
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
(READ OPTIONS)
Step 1
Don't Know
77
Refused
88
C11
Behavioural Measurements
Question
Response
22
Yes
No
Code
T1
23
24
Yes
No
daily?
Dont know 77
In Years
OR
in Months
OR
in Weeks
Manufactured cigarettes
Hand-rolled cigarettes
Pipes full of tobacco
26
(RECORD FOR EACH TYPE, USE SHOWCARD)
T2
If No, go to T6
Age (years)
25
Dont Know 77
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
Response
27
28
Yes
No
29
30
31
Years ago
OR
Months ago
Dont Know 77
OR
Weeks ago
If Known, go to T9
If Known, go to T9
If Known, go to T9
Yes
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
T7
T8a
T8b
T8c
T9
T10
Chewing tobacco
Betel, quid
32
Don't Know 77
Other
Other (specify)
33
34
35
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
Question
Response
36
No
(USE SHOWCARD
EXAMPLES)
Have
you consumedOR
anSHOW
alcoholic
drink within the past
12 months?
38
(READ RESPONSES, USE SHOWCARD)
Yes
No
39
A1a
37
Yes
Code
2 If No, go to D1
1
A1b
2 If No, go to D1
Daily
Yes
No
1
2
A2
If No, go to D1
A3
40
Number
Don't know 77
A4
41
Number
A5
Don't know 77
(USE SHOWCARD)
42
Largest number
Don't Know 77
A6
together?
During the past 30 days, how many times did you have
43
Number of times
A7
Don't Know 77
44
(USE SHOWCARD)
Don't Know 77
45
1
2
3
4
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
A8
A9a
A9b
A9c
A9d
A9e
A9f
A9g
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
Number of days
Don't Know 77
Number of servings
Don't Know 77
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
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
D5
If Other, go to D5 other
Number
Dont know 77
D5other
D6
Question
Response
Code
Work
Does your work involve vigorous-intensity activity that
52
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?
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
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)
59
60
Yes
No
Number of days
Hours : minutes
P7
If No, go to P 10
P8
:
hrs
mins
P9
(a-b)
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
62
In
a SHOWCARD)
typical week, on how many days do you do
(USE
vigorous-intensity sports, fitness or recreational
Yes
P10
No
65
If No, go to P 13
P11
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?
66
P12
P15
Hours : minutes
typical day?
:
hrs
(a-b)
mins
67
Hours : minutes
:
hrs
mins
P16
(a-b)
69
Response
Yes
No
Yes
No
Yes
No
hypertension?
70
Code
If No, go to H6
If No, go to H6
H1
H2a
H2b
71
72
73
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
H3a
H3b
H3c
H3d
H3e
H4
H5
75
76
Response
Yes
No
Yes
No
Yes
No
Code
If No, go to M1
If No, go to M1
H6
H7a
H7b
77
78
79
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
H8a
H8b
H8c
H8d
H8e
H8f
H9
H10
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
vehicle?
days
No seat belt in the car I usually am in
Refused
88
Sometimes
Never
Have not been on a motorcycle or
82
Refused
88
1
2
No
Refused
Did you have any injuries in this road traffic crash
83
5
77
Dont know
V2
Don't Know
Yes (as driver)
In the past 12 months, have you been involved in a
5
77
V1
Don't Know
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
Yes
No
Don't know
Refused
85
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
V6
Refused
88
V6other
86
Response
Home
School
1
2
Workplace
Road/Street/Highway
Farm
Sports/athletic area
Other (specify)
Dont know
77
Refused
88
Code
V7
V7other
Question
87
Response
89
Always
Sometimes
Never
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
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
Yes
G1
No
disorder?
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
concentrate
Same as usual
Less
on whatever youre
doing
G2
Not at all
Rather more
G3
2
than usual 3
playing
Same as usual
Less useful
than usual 3
G4
G5
Not al all
G6
97
Not al all
G7
2
98
99
Same as usual 2
your
to
Same as usual 2
your problems?
G8
G9
Not al all
G10
2
Have
101
you
recently
been
losing
Not al all
confidence
in yourself?
G11
2
Not al all
yourself as
a worthless person?
G12
2
Step 2
Physical Measurements
G13
Interviewer ID
105
106
107
108
109
Response
Yes
No
Height
Second
Third
M1
M5
X1
Height
M2a
Weight
M2b
in Kilograms (kg)
2 If No, go to M2a
First
in Centimetres (cm)
Weight
Code
M3
M4
CORE: Waist
110
111
Waist circumference
in Centimetres (cm)
M6
M7
Interviewer ID
113
114
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
M9
Systolic ( mmHg)
Reading 1 (left arm)
During the past two weeks, have you been treated for
M8
Yes
No
M14
Hip circumference
in Centimeters (cm)
M15
Heart Rate
120
Reading 1
M16a
Reading 2
M16b
Reading 3
M16c
Step 3
Biochemical Measurements
Response
Yes
No
Code
B1
122
Technician ID
B2
123
Device ID
B3
124
125
mmol/l
126
Hours : minutes
:
hrs
Yes
No
B4
mins
B5
B6
128
Device ID
Total cholesterol
mmol/l
During the past two weeks, have you been treated for
129
Yes
No
B7
B8
B9
130
mmol/l
Triglycerides
B10