JMIR Publications

ABSTRACT

Background:

Back ground According to the study of (Kumar et al., 2014; Salama, Elhawary, & El-Nmer, 2014; and United Nations Children‘s Fund, 2013) under lined that early stages of a child’s life, when all parts of the infant are growing physically, mentally and socially, are very important, which requires an optimal supply of energy and nutrients to the body. Hence, adequate and balanced supply of nutrients is highly required to prevent malnutrition (Sawaya, 2006), which can be affect the health and development of the child, and impairs the intelligence, educability and productivity of the baby. It also leads to a heightened risk of chronic non-communicable diseases in the later life (Burns, Brady, & Dunn, 2000). Based on (Kliegman, Bonita, Stanton, Geme, Schor & Behrman, 2011; UNCF, 2010; World Food Program, 2009; World Health Organization, 2014; WHO & UNICEF, 2003) knowledge, attitude and practice (KAP) of mothers/caregivers on infant and young child feeding in this curtail time are extremely important for the child health, growth and development. Different studies recommended that exclusive breast-feeding for the first six months, complementary feeding at six months onwards and continuation of breastfeeding at least up to two years, to improve the health and nutritional status of the children (Dachew & Bifftu, 2014; Laterra, Ayoya, Beaulière, & Pachón, 2014; UNICEF, 2011, 2014, WHO, 2013, 2014). This is the early stage of the child life, when all parts of the infant are growing physically, mentally and socially, which require an optimal supply of energy and other nutrients to the body (Kumar et al., 2015; Salama et al., 2014; UNICEF, 2013). Hence, adequate and balanced supply of nutrients is highly required to prevent malnutrition (Sawaya, 2006). Worldwide, severe acute malnutrition (SAM) is the leading cause of death in under-five children. The most risk of under nutrition occurs during intrauterine life, infancy and early childhood which makes the first one thousand days a windowpane of opportunity to address malnutrition (Sawaya, 2006). The major influencing factors of malnutrition among under five years old children include household food insecurity, inadequate health and sanitation services, limited knowledge of the mothers/caregivers on proper feeding practices such as exclusive breastfeeding, complimentary feeding, appropriate food type, and mix, and also limited time for mothers available for their care during pregnancy, care or feeding for infants, and children. Recommendations’ by (Kliegman et al., 2011; UNICEF, 2010; WFP, 2009; WHO, 2014; WHO & UNICEF, 2003) addressed that good knowledge, and positive attitude of the mothers/caregivers on proper infant, and young child feeding practice is very crucial to maintain, promote the health and nutritional status of the children and WHO recommends exclusive breastfeeding for the first six months of life is too. In developing countries, including sub-Saharan Africa, knowledge of mothers/caregivers on the significance of colostrums for the newborn were reported in between 48.6% to 90% (Engebretsen et al., 2014; Kumar et al., 2015; Kumar et al., 2014; Mohammed, Ghazawy, & Hassan, 2014; Patel et al., 2015; Chudasama, Patel & Kavishwar, 2009; Sriram, Soni, Thanvi, Prajapati, & Mehariya, 2013). However, initiation of breastfeeding within one hour after delivery ranges from 30% to 86.2% (Chudasama et al., 2009; Kumar et al., 2014; Mohammed et al., 2014; Patel et al., 2015; Sriram et al., 2013), while knowledge of exclusive breastfeeding (EBF) was reported higher between 70% to 96% (Kumar et al., 2015; Onah et al., 2014; Patel et al., 2015; Tan, 2011) and actual EBF practice for the first six months varies from 17% to 68.7% (Chudasama et al., 2009; Mohd. Shafee & Rana Firdous, 2013; Motee et al., 2013; Patel et al., 2015; Tan, 2011;UNICEF, 2014; Yalew & Abitew, 2014). Mothers living in rural area, and being a housewife were more likely to EBF (Motee et al., 2013). Mother’s education is also associated with exclusive breastfeeding (Engebretsen et al., 2014). In some developing countries, 62% of the mothers know the time to start additional food items at the age of 4 to 6 months (Agedew, Demissie, Misker, & Haftu, 2014), whereas 33% and 2/3 (65%) to be on the age of 6 months (Agedew et al., 2014; Sinshaw, Ketema, & Tesfa, 2015). And thirty five percent had positive attitude to the initiation of additional food items on 6 months (Agedew et al., 2014). The actual practice of starting additional food items on the age of 6 months varied from 29% to 80% (Agedew et al., 2014; Dachew, & Bifftu, 2014; Chudasama et al., 2009; Mohammed et al., 2014; Patel et al., 2015). Twenty five percent (Dachew, & Bifftu, 2014) and 83.3% (Mohammed et al., 2014) of the mothers knew that breastfeeding should not be stopped before the age of two years, while only 4% (Patel et al., 2015) continued breastfeeding up to the age of two years. The main reasons for starting additional food items were breast milk insufficient (Agedew et al., 2014; Mohd. Shafee & Rana Firdous, 2013; Yalew & Abitew, 2014). On the contrary, the main reasons for stopping breastfeeding were 16% child refusal to take breast milk and 54.7% insufficient breast milk (Patel et al., 2015). The average duration for stopping breastfeeding were 18 to 24 months (Sinshaw et al., 2015), mother’s education was associated with time initiation of complementary feeding practices (Agedew et al., 2014). In Ethiopia, although interventions on optimal child feeding practices have been rolling out since the development of national infant and young child feeding guideline in 2004 (Federal Ministry of Health, 2004), optimal feeding practices are not practiced as much as expected. Evidences show that breastfeeding initiation within the first hour of life was reported in between 53.8% to 74.2% (Egata, Berhane, & Worku et al., 2014; Mohd. Shafee & Rana Firdous, 2013; Sonko & Worku, 2015; Tamiru & Mohammed, 2013; UNICEF, 2014), and the knowledge of mothers/caregivers on the importance of colostrums for the baby were reported as more than 90% (Egata et al., 2014; UNICEF, 2014). Exclusive breastfeeding for the first six months of life varied from 35.9% to 70.5% from region to region of the country (Egata et al., 2014; Mohd. Shafee & Rana Firdous, 2013; Mohsin, Shaikh, Shaikh, Haider, & Parkash, 2014; Sonko & Worku, 2015; Tamiru & Mohammed, 2013; UNICEF, 2014). In other study 78.7% of the mothers knew the time, and the advantage of EBF, while 79.7% knew that breast milk alone is enough for the first 6 months (UNICEF, 2014). Mothers' older age, rural residence (UNICEF, 2014), being a housewife, having other infants (Motee et al., 2013; Tan, 2011), and low economic status of the mothers were more likely to affect exclusive breastfeeding (Sriram et al., 2013). Low maternal knowledge on infants and young child feeding was other predictors of non-exclusive breastfeeding (Dandekar, Shafee, & Kumar, 2014). Sixty six percent of mothers/caregivers in Ethiopia knew that they should breastfeed for at least two or more years (UNICEF, 2014).

Objective:

Therefore, this study was designed to document the KAP of mothers/caregivers towards optimal infants and young child feeding practices in Tigray Regional State Northern, Ethiopia.

Methods:

Method Study area and Design A community-based cross-sectional study was conducted in June 2023 in South East and Central Zones, Tigray Regional State, Ethiopia. Study population The study units and study subjects were randomly selected households with all pregnant and lactating women. Data were collected from 1249 mothers/caregivers; a multistage sampling technique was used to identify study participants. Two Zones were randomly selected from five Zones with no security issue due to the civil war in Ethiopia and then Woredas at last kebeles (the second smallest administrative unit in Ethiopia) were stratified into urban and rural. A total of sven kebeles were included in this study. In each kebele, households with at least one under-five child were randomly selected and mothers/caregivers who fulfill the inclusion criteria were interviewed. The inclusion criterion was mothers who had one or more under five children and permanently residing in the selected kebele/sub kebele, and were willing to participate in the study. The sample size was calculated using a formula for estimation of single population proportion, considering 55% prevalence of KAP of child feeding practice, to get the largest and representative sample size at 95% confidence level and 5% margin of error (Bluman, 2009) and 10% none response rate were considered. A pre-tested structured Tigrna language questionnaire was used. The questionnaire was prepared in English and translated into Tigrina language and again back to English to ensure its consistency. The questionnaire included socio-demographic characteristics and KAP on child feeding of the mothers/caregivers and was adapted from similar studies conducted elsewhere and standard guidelines (CSA, 2014; UNICEF, 2012). Data were collected by nurses with degree and above qualifications using ODK software, after two days of training using face-to-face interview with the mothers/caregivers. The questionnaire was pre-tested in a kebele that was not included in the actual study areas. Modification was made to the questions depending on the findings of the pre- test. During data collection, the completeness and consistency of the responses in the study questionnaire were checked daily by principal investigator and server manager.

Results:

Results Socio demographic characteristics of mothers: A total of 1249 either lactating or pregnant women households from the community was included in the study (response rate 99.5%).The mean age (±SD) of the mothers were 28.35 ± 5.91 years. The average household size was 4.46. More than three fourth of the participants 1010(80.93%) were rural residences and more than half (662) (53.04%) of the mothers were Farmer. As table one below, nearly one from four interviewed mothers (288) (23.08%) were unable to read and write. Table one: Socio demographic characteristics lactating and pregnant mothers(N=1249) Marital status of the mothers Divorced N % 54 4.33 Widowed 9 0.72 Separated 64 5.13 Other 5 0.40 Age at marriage in years Mean, SD 18.71, 3.18 Educational status of the participant Unable to read and write 288 23.08 Able to read and write 53 4.25 Elementary 420 33.65 Secondary 351 28.13 College and above 136 10.90 Educational status of the head of the household Unable to read and write 253 20.27 Able to read and write 199 15.95 Elementary 356 28.53 Secondary 276 22.12 College and above 164 13.14 Religion of the respondent Orthodox 1219 97.68 Muslim 29 2.32 Occupation of the participant Farmer 662 53.04 Self-employed 152 12.18 Merchant 114 9.13 Governmental employed 85 6.41 Daily laborer 80 6.41 House wife 155 12.42 Occupation of the head of household Farmer 703 56.33 Self-employed 147 11.78 Merchant 110 8.81 Governmental employed 134 10.47 Daily laborer 110 8.81 House wife 44 3.53 Residence Rural 1010 80.93 Urban 238 19.07 Family size Observations 4.64 1(Min) Characterstics of Children (785): As table 4 below, nearly equal number of female 307 (59.27%) and male 211 (40.73%) children participated in the study. The mean age was 8.62 months (SD ±1.46). From the total of children 0-23 month 245 (31.49%) of them were in the age group <6 months. More than half (518) (66.8%) of children 6-23 months. Table 4 Children characteristics (n=776) Variable Category Frequency Percentage Age of the child in months <6 months 245 31.57 6-23 months 518 66.80 24-59 months 13 1.70 Sex of the child 6-23 months Male 307 59.27 Female 211 40.73 Average number of under-5 children 1.27 1(Min) 3(max) Currently breast feeding Yes 672 No 29 Minimum dietary diversity score <5 ≥5 29 524 5.4 94.6 Minimal meal frequency Yes No 338 215 61.2 39.8 Dietary acceptance Yes No 28 525 5,1 94.9 Mean (SD) DDS – children Yes No 9 544 1.69 98.31 As figure one below, the knowledge of mothers /care givers on child feeding is better in Central Zone than that of South East Zone, indicating that more work is demanding in South East Zone on the knowledge of child feeding. Figure one: Knowledge of caretakers towards IYCF practices in the study communities from Tigrai, Ethiopia, 2023 (n=584). As figure two below shows us there are significant percentage (29.3%) of mothers / care takers that strongly agree for child feeding that plain or soup water should be provided to a child as soon as she/he is born.(see figure two) Figure two: Indicators for attitude of caretakers towards IYCF practices in the study communities from Tigray, Ethiopia, 2023 (n=590). Between knowledge and actual practice of timely initiation, exclusive and duration of the breastfeeding in the study community mothers /caregivers has huge gap (see figure one above and three below). Figure three: Indicators for IYCF-E practices in, Tigray, Ethiopia, 2023 (n = 584). As figure four below depicted that husband involvement on child feeding was very poor that needs due attention for husbands to have good involvement on their child feeding. Figure four: Husband involvement of Child feeding practice Access to water: This section detail findings related to the main household sources of drinking and non-drinking water publicly available; water collection (including gender of individuals collecting water and distances/wait-times involved, including types of water treatment practiced here under figure five. Figure five: Source of water for the households

Conclusions:

Despite the high knowledge of the participants on infant and young child feeding, a large proportion of mothers/caregivers had poor practice on proper infants and young child feeding. Behavior change communication interventions using strategies appropriate for the mothers/ caregivers change their wrong attitude on giving additional food for infants as soon as they born, to strengthen exclusive breastfeeding until the six months of infants age, to narrowing between knowledge and practices related to infant and young child feeding need to be performed using female associations, frontline health actors, developmental army to bridge the gap between knowledge and practice.