Nutrition knowledge, attitudes and practices among healthcare workers in management of chronic kidney diseases in selected hospitals in Dar es Salaam, Tanzania; a cross-sectional study

Chronic kidney disease (CKD) is a permanent and progressive loss of kidney function, which results in deterioration of renal function or End-Stage Renal Disease (ESRD). Olugbenga et al., [1] found ESRD as a devastating medical, social and economic problem for the patients, their families, and the country as a whole. The overall management of CKD focuses on medication, dialysis, transplant and nutrition. Better management of CKD can slow progression of renal dysfunction, prevent metabolic complications, and reduce cardiovascular-related outcomes [2]. Nutrition plays a major role in the protection of renal function and well-being in the CKD patient [3]. The evidence base for practical use of nutrition-based preventive and curative interventions is rapidly growing and implementation research steadily improves delivery of best practices. There is little doubt that health professionals can be more effective in their daily practice when they draw on current nutrition knowledge and effective clinical skills [4]. Furthermore, there are numerous examples of beneficial patient outcomes resulting from nutrition practices in inpatient, outpatient, and community settings. In acute care settings, best nutrition practices have been shown to improve patient outcomes and reduce health care costs [5]. Despite the profound impact good nutrition has on health and wellness, the science of nutrition and its application to healthcare are not fully integrated in most health professions training programs. This gap is further compounded by the fact that patients and the public remain confused about the correct nutritional advice to follow given the widespread media interest attracted by diet and the disparity in nutrition-related health messages that are in circulation [6]. Information from health workers to patients has been found to have a positive and significant correlation with adoption of dietary behavior and reduced risk of nutrition related chronic disease [7]. However, ability of healthcare workers to provide accurate, practical and consistent dietary advice appropriate to the needs of patients is limited [7, 8].

As there are only few published data about nutritional knowledge of healthcare workers in Tanzania, the aim of the current study was to determine the nutrition knowledge level, attitudes and current practices of the healthcare providers working in renal units at the three hospitals in Dar es Salaam, Tanzania.

The present study revealed that, most of participants had poor nutrition knowledge. Although majority 88 % of the participants had basic nutrition training in medical/nursing school, there appeared to be a number of gaps in their nutrition-related knowledge. The knowledge level of healthcare workers was found to be higher (Table 1) due to the nutrition education received and higher level of professionalism in the application of their knowledge. The increase in knowledge scores was not found to be in related with the increase in professional experience, instead healthcare workers who had fewer years of practices scored high. This could be due to current nutrition updates and their personal initiatives through reading from different sources as they mentioned their sources of nutrition knowledge.

Similar observation was explained by another evaluation study in USA where it was reported that clinical experience didn’t increase the level of the nutritional knowledge among licenced nurses working in nursing homes, it was also showed that there was a correlation between the educational substructure and the nutrition knowledge score[10]. Yalcin et al., [11] in their study on nutrition knowledge level of nurses in Zonguldaki in Turkey indicated that long-term clinical experience without any special education on nutrition and with no working experience in this field does not increase the nutrition knowledge.

In this study, healthcare workers scored high in questions that were medical related but they scored low in nutrition related questions (Table 2). This could be due to less emphasis on nutrition training in medical/nursing schools as mentioned during group discussion that nutrition knowledge they gained was not adequate to provide nutritional counselling and support to CKD patients (Table 5). These findings are consistent with other studies that showed the inadequacy of education regarding nutrition in medical and nursing programs and the requirement of expanded content of nutrition in the curricula [12, 13].

According to Kim [14], in the study on Nurses’ positive attitudes to nutritional management but limited knowledge of nutritional assessment in Korea identified that limited education in nutrition could lead nurses to be negligent in managing patients’ nutritional problems. This observation is important as it has been shown that nurses are a trusted source of health information as noted in the study by Harrison [15].

The lack of knowledge about nutrients (minerals, protein, and carbohydrate) adjustment is of particular concern, as there is growing interest on changes in disease patterns in relation to foods and nutrition [16]. Doctors and nurses are perceived to be the most reliable source of nutritional information. Therefore, it is important that information provided by health professionals is accurate. As found in this study that only few healthcare workers have the time, knowledge or skills to give nutritional advice or to recognize nutrition related problems, similar observation were found by other studies [14, 17].

Participants felt that nutrition plays an important role in prevention and treatment of disease. However, 72.4 % of nurses reported that they were not knowledgeable in nutrition related matters and that nutrition assessment was the responsibility of nutritionists and doctors. In places where nutritionist services are not available as is common in most hospitals in Tanzania, nurses tend to fully depend on doctors for guidance as far as nutritional management of patients is concerned.

Furthermore, results indicated that 76.7 % had negative attitude regarding their own nutritional knowledge. This was revealed when they were asked to rate themselves on nutrition related matters. This could be due to inadequate nutrition training in medical/nursing schools and as part of in-service trainings in patient care. Such negative attitudes were expressed during group discussion when they were asked to give opinion on nutrition knowledge in their professional training. Different studies have revealed that in-service nutrition training can help to improve health workers’ nutrition knowledge [18, 19]. This may facilitate positive changes in their attitudes toward nutrition care and thus in their behaviour [19, 20]. As a result, health workers’ skills in management of nutrition-related problems including nutrition-counselling skills [20–22].

According to Fischbein’s learning theory, behaviour or attitude change is mediated through cognitive processes and thus is learned through imitating and observing the actions of others [20]. Accordingly, the reward that health workers can gain from their nutrition actions, such as better nutritional status or feeding practices in those they treat, may reinforce their counselling actions, thus making it a permanent habit. In this way, the quality of health workers with regard to nutrition counselling might be expected to improve.

In this study an assessment of a patient’s nutritional condition was not always performed. Instead, the patient’s condition, diagnosis, treatment and age were taken into consideration as criteria for diagnosis. The reasons might be found in inadequate knowledge and skills, or perceived lack of resources, such as assessment tools and guidelines (Table 5). These factors may also explain the finding of low frequencies of nutrition education sessions services, such as nutritional support (Table 4). Limited use of assessment tools confirmed by another study [21]. Another reason could be that the doctors use their clinical judgement and therefore abandon the nutrition assessment tools [21]. In addition, nurses assume that nutritional assessment is not part of their role, the fact which has been discussed recently [22].

As found in the present study, nutrition knowledge among study participants was poor. Despite their positive attitudes regarding nutrition and its importance, they failed to practice due to inadequate knowledge. Inadequate resources and inadequate nutrition training in medical/ nursing schools hindered proper nutrition management of CKD patients. Continuous in-service nutrition education programs, improving working conditions and hiring clinical nutritionists in each hospital department may improve nutrition management of CKD patients in hospitals.