ABSTRACT

Complementary feeding is the greatest contributor to health and nutrition status of infants and young children. Malnutrition remains one of the greatest concerns in Sub- Saharan Africa region. In Nigeria, national findings show inappropriate complementary feeding practices. Out-patient therapeutic programmes (OTPs) have been established to address severe acute malnutrition (SAM) among children 6-59 months of age. There is limited information on the knowledge, attitude and practices on complementary feeding among the caregivers of the children admitted into OTP centres. The main purpose of this study was to determine the knowledge, attitudes and practices (KAP) on complementary feeding among mother’sof children 6 months-2 years of age admitted into OTP centres in community uhumwonda local government area Benin city,Edo state. The study adopted a cross-sectional analytical design. An exhaustive sample of 200 caregivers from four OTP centres in Egba community uhumwonda local government area Benin city,Edo state. participated in the study. Data was collected from the caregivers using structured researcher-administered questionnaires and focus group discussion (FGD) guide, and from OTP programme staff using Key Informants Interview (KII) guide. Data was analysed using SPSS software (version 22). A p-value of <0.05 was used as the criterion for statistical significance. Caregivers’ mean score for knowledge on CF for children with normal nutrition status was 6.11± 2.33, out of a total score of 12, while for feeding children with Severe Acute Malnutrition (SAM) was 8.7± 2.63 out of a total score of 10. Eighty-eight percent (88%) knew the guidelines on how to give Ready-to-use therapeutic food (RUTF) to a child with SAM, 78% knew the time of introduction to complementary feeding, 100% knew that a child should be breastfed before administering the RUTF and 21% knew that breastfeeding should be increased and additional nutritious food given to a child during illness. For attitudes, the mean score was 24.1±11.73 out of 85 and 79.7% had a positive attitude towards the high nutritive value and the potential of RUTF to cure SAM, 67.5% had a positive attitude towards continued breastfeeding, and 61% had a positive attitude towards the recommended daily dietary intake for of RUTF. Almost all the caregivers (98.5%) introduced their children to complementary feeding at 6 months of age. Seventy-three percent of the children ate the recommended amount of RUTF per day. Maternal time constraints, low socio- economic status, and leakage of RUTF at the household through sharing were major barriers to optimal feeding for children with SAM. Lack of commitment in attending MIYCN education sessions was a major reason for low knowledge on complementary feeding for children with normal nutrition status. It is recommended that the Ministry of Health scale up Behaviour Change Communication (BCC) interventions for care- givers of children 6 months-2 years of age with a focus on complementary feeding knowledge, attitudes and practices specifically dietary diversity.

CHAPTER ONE

INTRODUCTION

1.1 Background to the study

Infants and young children 6 months-2years of age are within the vital window of opportunity for foundational growth and development and hence they need good nutrition to achieve this requirement (WHO 2018a). During this stage, sub-optimal nutrition greatly compromises childhood developmental milestones and may cause permanent nutritional and health complications in future. These include cognitive, physical and physiological complications (WHO, 2018a). Indicators to complementary feeding practices include timely introduction of solid, semi-solid and soft foods at 6 months of age, with increasing amount and frequency. Minimum meal frequency is defined as: two times for breastfed infants 6–8 months; three times for breastfed children 9–23 months; and four times for non-breastfed children 6–23 months. The practices also include dietary diversity (comprising of at least 5 out of 8 food groups). The food groups include breast milk, grains, roots and tubers, legumes and nuts, dairy products, flesh foods (meat, fish, organ meats and poultry), eggs, vitamin-A rich fruits and vegetables and other fruits and vegetables) (WHO/UNICEF, 2017). The breast milk during this period provides half of the infant’s energy (Victora et al., 2018).

Children born in urban informal settlements in Nigeria are often at risk of sub-optimal breastfeeding and complementary feeding practices thus increasing their risk of mortality and delayed psycho-motor development (Concern Worldwide, 2019). Additionally, compromised sanitation within the settlements exposes infants and young children further to higher risks of infectious diseases, thus strengthening the vicious cycle of malnutrition (Korir, 2016). Limited resources and unsustainable household income are prevailing circumstances in these settings and this reduces the caregivers’ food purchasing power, thus limiting their ability to diversify the child’s diet (Kimani-Murage et al., 2019).

Half the number of children’s death worldwide is as a result of malnutrition. Three million children die annually from under-nutrition. In 2017, UNICEF analysis showed that 51 million children 0-59 months of age suffered from wasting, of which 16 million were severely wasted, these translating to 7.4% and 2.4% respectively. Of the 51 million children, 25% were from Sub-Saharan Africa (UNICEF, 2017). In Nigeria, 61% of children 0-5 months of age are exclusively breastfed, 26% of children under five years of age are stunted and 4% are wasted (Nigeria National Burea of Statistics, 2015). More than 420,000 children suffer acute malnutrition in Nigeria, of which 73,000 are severely malnourished (Save the Children, 2017). The highest prevalence of acute malnutrition is in Arid and Semi-arid Lands (ASAL) areas, urban informal settlements and areas with high prevalence of HIV and AIDS such as Homa-bay (26.0%), Siaya (23.7%), Kisumu (19.3%) and Migori (14.7%) (Nigeria Aids Strategic Forum, 2018). Between January and May 2017, 42,579 children were treated for severe acute malnutrition from ASAL, Urban informal settlements, and refugee camps. In 2017, SAM rate in Nigeria was at 7% while that of MAM was at 25.4% (UNICEF, 2017).

In Nigeria, the Global Acute Malnutrition (GAM) rate stood at 4.6% in May 2017. The SAM rate was at 0.1% while MAM rate was at 4.5%. The GAM rate for the Nigeria informal settlements combined was at 4.6%, which was equal to the entire county’s GAM rate. Egba community uhumwonda local government area Benin city,Edo state. had the highest prevalence of wasting and severe wasting at 9.6% and 1.9% respectively, which was far above the global and national rates (Concern Worldwide, 2017).

The United Children’s Fund (UNICEF) organization developed a programme focusing on integrated management for acute malnutrition, which entails the use of therapeutic nutrition supplements adapted to the progressive treatment and management of acute malnutrition (UNICEF, 2019). This was operationalized in 2020 in Nigeria. Out-patient Therapeutic Programme (OTP) centres were established to provide treatment and nutritional rehabilitation services for severely acute malnourished children 6-59 months of age without complications (Concern Worldwide, 2019). The children are treated with a specified number of take-home Ready-Use Therapeutic Food (RUTF) issued according to their body weight, along with specialized routine medication. This RUTF is an energy-dense, micronutrient- rich fortified paste, mixed with peanut paste, oil, sugar and dry milk products, procedurally used to manage and rehabilitate severe acute malnourished children. These children are reviewed on a weekly basis at the facility where they receive their weekly re-fills of RUTF, and are followed-up at community level until they recover from acute malnutrition. The OTP centres are located within the residence of the children in order to reach as many children with SAM as possible (Concern Worldwide, 2019). This study was motivated by the many cases of severe acute malnutrition (SAM) among children in Egba community uhumwonda local government area Benin city, Edo state being area with the highest caseloads of acute malnutrition of all other informal settlements in Nigeria (MOH, 2017).

Despite various strategies implemented by the Ministry of Health and implementing partners in the management of acute malnutrition and sensitization on Maternal, Infant and Young Child Nutrition (MIYCN) at facility and community level, malnutrition rates still remain high in Nigeria, with Egba community uhumwonda local government area Benin city having the highest caseloads among urban informal settlements (MOH, 2017). In a coverage survey by Concern Worldwide, the study established that only 47% of children with SAM were admitted to OTP, and one of the barriers was that most of the mothers (whose children were not admitted) did not attribute malnutrition to sub-optimal complementary feeding (Concern Worldwide, 2017). This may be an indicator that insufficient knowledge and inappropriate attitude of caregivers towards complementary feeding practices is a barrier to access and utilization of OTP services for treatment of acute malnutrition (Agozie et al., 2019). It is against this background that this study was conducted. A search through available literature did not reveal any information on caregivers’ knowledge, attitudes and practices on feeding a child with severe acute malnutrition.

1.2 Problem statement

Complementary feeding contributes the greatest percentage to the outcomes of a child’s growth (Victora et al., 2010). Poor complementary feeding practices still remain a significant challenge in Nigeria, with one of the greatest challenges being insufficient knowledge and unfavourable attitudes towards complementary feeding among caregivers in the urban informal settlements. This is despite the fact that the Ministry of Health and other stakeholders have implemented strategies promoting optimal infant and young child feeding, (Kimani-Murage et al., 2019). A study on complementary feeding practices in Nigeria informal settlements found that 62.6% of the children 6 months-2 yearsof age attained the minimum dietary diversity, 54.8% attained the minimum acceptable diet, 69.6% attained the minimum meal frequency while 75.9% got timely introduction to complementary feeding (Concern Worldwide, 2019). Another study in Korogocho on complementary feeding for children 6 months-2 yearsof age showed that 83.0% attained minimum meal frequency, 17.9% attained minimum dietary diversity while 15.4% attained the minimum acceptable diet (Korir, 2016). In Kahawa West studies showed that 79.0% of children 6-23months of age attained minimum dietary diversity while 79.5% attained minimum acceptable diet (Kimwele & Ochola, 2017). These were all below the recommended threshold of 80% attainment for each category (Concern Worldwide, 2019).

Available data on nutrition situation in Nigeria showed the minimum meal frequency, minimum dietary diversity and minimum acceptable diet for only specific informal settlements but not for the entire Nigeria County (MOH, 2017). Nationally, 21% of children consume the minimum acceptable diet at 6 months-2 yearsof age (KNBS, 2015). Worldwide, only a third of breastfed infants 6 months-2 yearsof age meet the criteria for dietary diversity and feeding frequencies appropriate for their age (WHO, 2016). Studies in Nigeria informal settlements show poor complementary feeding practices among the caregivers. A study conducted in Korogocho (Korir, 2016), reported that 15.4% of the children got minimum acceptable diet, despite a higher knowledge score on dietary diversity among the mothers. The prevalence of children with SAM in Nigeria by February 2017 was 74% of the total SAM children in Nigerian urban centres, with the highest caseloads being in the Nigeria informal settlements.

Egba community uhumwonda local government is largely characterised by people living in informal settlements with compromised sanitation, had the highest prevalence of wasting at 9.6%. (MOH, 2017). The risk of death is 5-20 times higher among children with SAM compared to that of well-nourished children (WHO, 2016).

If appropriate and timely interventions are not taken, this will result in a significant rise in childhood morbidity and mortality, compromised physical growth and impaired cognitive development (Victoria et al., 2018). This presents a challenge to Nigeria meeting its Vision 2030 and Sustainable Development Goal (SDG) number two, which aims at ending hunger and achieving food security and improved nutrition by 2030 (UNICEF, 2019). It is therefore important to understand the underlying factors for complementary feeding among children 6 months-2 yearsof age in the informal settlements and how these influence feeding of children with severe acute malnutrition. A search through available data on infant and young child nutrition did not reveal any studies on the knowledge, attitudes and practices on complementary feeding among mother’sof infant and young children specifically admitted to out- patient therapeutic centres (OTP).

1.3 Purpose of the study

The purpose of this study was to determine the knowledge, attitudes and practices on complementary feeding among mother’swith children 6 months-2 yearsof age admitted into Out-patient Therapeutic Programmes (OTP) in Egba community uhumwonda local government area Benin city,Edo state., Nigeria County.

1.4 Objectives

To determine socio-economic and demographic characteristics of caregivers and children 6 months-2 yearsadmitted at OTP in Nigeria County.

1. To determine the knowledge on complementary feeding among mother’s of children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

2. To assess the caregivers’ attitudes towards complementary feeding of children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

3. To determine the complementary feeding practices among mother’sof children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria,

4. To establish the relationships among mother’scomplementary feeding knowledge, attitudes and practices, for children 6 months-2 yearsof age admitted to OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

1.5 Research Questions

1. What is the knowledge on complementary feeding among mother’sof children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

2. How does the caregivers’ attitudes towards complementary feeding of children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

3. What is the complementary feeding practices among mother’s of children 6 months-2 yearsof age admitted at OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria,

4. What is the relationships among mother’s complementary feeding knowledge, attitudes and practices, for children 6 months-2 yearsof age admitted to OTP in Egba community uhumwonda local government area Benin city,Edo state., Nigeria.

1.6 Hypotheses

H01: There is no significant relationship between the mother’s knowledge on complementary feeding and the complementary feeding practices for their children 6- 23 months of age admitted at OTP centres in Egba community uhumwonda local government area Benin city,Edo state..

H02: There is no significant relationship between the mother’s attitude towards complementary feeding and the complementary feeding practices, for their children 6- 23 months of age admitted at OTP centres in Egba community uhumwonda local government area Benin city,Edo state.

1.7 Significance of the Study

The findings of this study will be of benefit to stakeholders such as the Ministry of Health at both national and county levels, the sub-county’s health management team and non-governmental organizations dealing with child survival. The findings of this study are likely to provide information to the stakeholders to make informed decisions in the planning of interventions to improve the nutrition status of infants and young children, particularly those with severe acute malnutrition in Egba community uhumwonda local government area Benin city,Edo state. as well as for further research.

1.8 Delimitations

This study was conducted in OTP centres in the government health centres within Egba community uhumwonda local government area Benin city,Edo state., in Nigeria. Egba community uhumwonda local government area Benin city,Edo state is primarily characterized by informal settlements, and has a large percentage of house-holds with low socio-economic status. The findings of this study can therefore only be generalized to populations and areas of similar characteristics.

1.9 Limitations

Being a cross-sectional study, the study does not show the effect of different seasons of the year on the complementary feeding practices. This study was conducted in July 2017 which was a cold season in Nigeria. The county has other seasons such as heavy rains in March-May and short rains in October-November, the same which may pose different health and nutrition consequences among the children. Furthermore, the children are only on RUTF diet therefor some indicators for complementary feeding practices such as minimum dietary diversity and minimum meal frequency could not be computed in this study.

1.10 Operational Definition 📥 Ready to get the full Material? 💳 Get Full Project Work