Lupine Publishers | Scholarly Journal of Food and Nutrition
Abstract
This study showed the effect of
nutrition education on complementary feeding practices among caregivers in Ondo
State, Nigeria. The study was a cluster randomized controlled-trial design. The
study participants were in two groups. One was intervention and the other one
was the control group in a ratio of 1:1. The sample size was 282; the
intervention group was 142 and the control group was 142. Intervention on
complementary feeding was carried out inform of nutrition education among the
caregivers in the intervention group and the control group received no
intervention. The intervention group received four 4 lesson sessions per group.
The sessions were based on continued breastfeeding, timely introduction of
complementary feeding, minimum meal frequency, minimum dietary diversity,
minimum acceptable diet, feeding with iron rich foods, responsive feeding and
hygiene. Data were analyzed using SPSS version 22.0. From Kaplan-Meier
analysis, continued breastfeeding survival at age 11 months was 94.4% in the
intervention group and it was 69.7% in the control group. Adjusted Relative
Risk [ARR] was used to determine the effect of nutrition education on the
intervention group and control group for variables such as Minimum Acceptable
Diet [ARR: 3.13; CI: 2.53-5.16; P<0.001] at the end line. This study
concluded that nutrition education based on complementary feeding guidelines
improved the feeding practices of the caregivers. Therefore, the study
recommends that Ministry of Health in Ondo State should encourage complementary
feeding training for caregivers and CHEWs at the various Basic Health Centers
in the State.
Abbreviation: ARR: Adjusted Relative Risk; BHC: Basic Health Centre; CFP:
Complementary Feeding Practices; CHEW: Community Health Extension Workers; EBF:
Exclusive Breastfeeding; FAO: Food and Agriculture Organization; HIV: Human
Immunodeficiency Virus; ICF: International Classification of Functions,
disability and health; IEC: Information Education Communication; IG:
Intervention Group; IYCF: Infant and Young Child Feeding; LGA: Local Government
Areas; MDD: Minimum Dietary Diversity; MMF: Minimum Meal Frequency; MAD:
Minimum Acceptable Diet; NCP: National Population Commission [Nigeria]; NDHS:
Nigeria Demographic and Health Survey; NGOs: Non-governmental organizations;
NNHS: National Nutrition and Health Survey; OSHREC: Ondo State Health Research
Ethics Committee; OSPHCDB: Ondo State Primary Health Care Development Board;
SMART: Standardized Monitory and Assessment of Relief and Transition
Introduction
The UNICEF showed that globally 66%
of children aged 6 to 8 months received semi-solid, solid or soft foods, with
cases of nutrition deficiencies due to untimely introduction of complementary
foods [1]. The timely introduction of complementary feeding among caregivers in
sub-Sahara Africa was 71% and 68% for West and Central African countries while
it was 67% for Nigeria [1]. Children receiving MAD was 11% in sub-Sahara
Africa, 9% in West and Central African countries and 10% in Nigeria [1].
Infants feeding practices reports available in some other West African nations
showed poor practices of MAD by caregivers in Ghana [13%] and in Benin Republic
[9%] [1]. The report of the Nigerian National Demographic and Health Survey [2]
indicated that only 11% of the breastfed infants received complementary foods
from at least
four food groups. Globally, about 45% of infants less than 6
months of age were exclusively breastfed [EBF], with 42% in sub-Sahara Africa
and 29% for West and Central African countries. In Nigeria, EBF rate is at 17%,
which implies that 83% have had untimely introduction of complementary feeding
[1]. The issues of poor infants feeding knowledge and practices among
caregivers which result to poor nutrition status among the infants call for
action due to the present level of malnutrition in Nigeria.
Standardized Monitory and Assessment
of Relief and Transition reported that 21.1% of children less than five years
of age in South West Nigeria, the Geo-political Zone of this study were stunted
[3]. Malnutrition caused the death of 53% of children less than five years of
age in Nigeria [4]. It also showed that 13% of the death could be averted if
90% of mothers in Nigeria practiced exclusive breastfeeding for the first six
months. If the same mothers practiced timely introduction of complementary
feeding, a further 6% of the death rate could be prevented [5]. Inadequacy in
complementary feeding during infancy and childhood has been demonstrated by
researchers as a factor that leads to malnutrition, resulting in higher
mortality and morbidity rate among the children [6]. In Nigeria, poor infants
feeding practices rate is high. Apart from lack of adequate complementary feed
being provided to the infants, force-feeding practices rather than responsive
feeding is reported among 83.8% respondents in Enugu, Nigeria [7]. Only 10% of
infants received minimum acceptable diet in the country [1]. The report of
National Demographic and Health Survey showed that only 17.6% of infants in the
South West Geo-Political Zone received minimum adequate diet [2].
Objectives
a) To implement a nutrition
education program using World Health Organization guidelines on complementary
feeding for caregivers in Ondo State, based on complementary feeding practices,
knowledge and attitudes.
b) Establish the effects of
nutrition education on complementary feeding, knowledge, attitudes and
practices among caregivers in Ondo State.
Materials and Methods
Research
Design
This was a cluster-randomized
controlled trial. A randomized controlled trial reduces bias in interventional
studies by controlling for known and unknown confounders. It also provides
evidence of a causal-effect relationship between the intervention and the
outcomes [8,9]. The Basic Health Centres were randomized and not the caregivers
to enhance participation by caregivers, by reducing loss to follow-up.
The study had two phases: the needs
assessment phase and the intervention phase.
Sample
Size
Sample size was determined using
[10] for continuous assessment. A total of 290 caregivers were achieved. During
the study 6 caregivers were lost to follow-up which resulted to 284 caregivers
that completed the study. They were distributed as follows; This resulted into
70 caregivers in the first Basic Health Center for intervention group, 72 in
the second BHC for intervention group, 69 in the first BHC for control group
and 73 in the second BHC at the end of the study depending on eligibility
criteria and willingness of the caregivers to participate in the different
communities.
Sampling
Techniques
Multi-stage sampling method was
adopted for this study. Purposive sampling method was used for the selection of
Ondo North Senatorial District out of the three Senatorial Districts in the
State. Owo Local Government Area [LGA] due to existing literature [11]. Simple
random sampling method was used for the selection of the 4 Basic Health Centres
[BHC] out of ten [10] BHCs in the LGA. Randomization was then conducted to
assign the BHCs into intervention groups and control group by a biostatistician
using MS EXEL at a ratio of 1:1, with each study group having two BHCs.
Caregivers were allocated to study group based on the BHCs they attend for
post-natal care.
The
recruitment of study participants into the study
The study participants were
recruited by the researcher, assisted by the Community Health Extension Workers
[CHEWs]. The researcher together with the CHEWs in the selected BHCs recruited
and registered eligible participants [caregivers with infants] into the study
at the weekly routine meetings in the BHCs. Daily recruitment was carried out
when the caregivers visited the health centres for routine meetings for
immunization, appointments and check-ups. Eligible caregivers were recruited in
13, 11 and 10 in numbers in each Basic Health Centres, until the required
sample size was achieved. The screening was conducted by the researcher and the
Community Health Extension Workers (Figures 1 & 2).
The
Training
Caregivers in the control group were
selected from 2 BHCs and did not receive any intervention from the research
team. Meanwhile, the caregivers in the intervention group which were also
selected from 2 BHCs received the complementary feeding nutrition education
from the research team. The education session began with creating rapport
between the researcher [assisted by CHEWs in the research group] and the
participants. The training was conducted in the local Yoruba language for
better understanding. The content of the nutrition education on complementary
feeding was based on the guidelines [12] as well as the knowledge, attitude and
practices gaps identified during the need’s assessment. The caregivers received
training on continued breastfeeding, dietary diversity, meal frequency,
responsive feeding techniques, meal planning for infants, infants’ meal planning
during illness and recovery and hygiene [water treatment]. This training was
carried out in three consecutive weekends as the caregivers were recruited per
group in the respective health centers weekly. After the recruitment and
training, the caregivers were followed up during the program. The phone numbers
of the caregivers and the CHEW in that zone, where the caregivers resided were
also written down by the researchers in case of questions or if need arises to
attend to some unclear area of the training pertaining to the study. Two days
to and on the eve of visitation day, the enumerator allocated to the area would
call to remind the caregivers about the visitation day.
Research
Instruments
WHO [2010a] IYCF indicators [13]
WHO [2010b] 24hr. dietary recall on
complementary feeding practices [14]
WHO [2004] Complementary feeding
guidelines [12] Data analysis
Pilot study was carried out. During
the pilot study, training was conducted for caregivers in the intervention
group and there was standardization of data collection procedures. Each
questionnaire was administered twice on the same group of participants at an
interval of two days. A correlation co-efficient of more than 0.7 was
considered adequate [Mukaka, 2012]. They are as follows:
a) Baseline questionnaire for the
caregivers: 0.89[0.82- 0.92].
b) Second questionnaire for all the
caregivers: 0.77[0.61- 0.84].
c) Third questionnaire for all the
caregivers: 0.88[0.71- 0.91].
Complementary feeding practices were
determined based on the [13] IYCF indicators. Early initiation of breastfeeding
was determined thus; proportion of infants who were put to breast within one
hour of birth; for exclusive breastfeeding; [proportion of infants 0-5 months who
were fed exclusively with breast milk]. For continued breastfeeding,
[proportion of infants fed with breast milk in the previous day], For meal
frequency [a frequency of 2 times for ages 6-8 months and 3 times for 9-11
months was considered adequate and milk feeding frequency for non-breastfed
infants [proportion of infants 6-11 months who received at least 2 milk
feedings during the previous day] was considered adequate]. For dietary
diversity, a daily intake of 4 or more out of 7 food groups was considered
adequate [15]. For consumption of iron rich and iron fortified foods,
proportion of infants who received iron rich food or iron fortified food that
is designed for infants or that is fortified at home. For responsive feeding,
caregivers were expected to encourage the infant to eat the food served. Also,
for hygiene, treatment of water by boiling water to boiling point and allow it
to cool in a clean container was the acceptable practice.
Feeding practices was determined
using the feeding practices variable for the questionnaire according to 24hr.
dietary recall on complementary feeding practices [14]. The caregivers that
answered yes to right practices was awarded 1 while the caregivers that
answered no to right complementary feeding practices was awarded 0. The
proportion of each variable was subjected to regression analysis. In addition,
adjustment/ controlling for the covariates such as caregivers age and parity
was done during the analysis to cater for the design effect because it was the
BHCs that were randomized into study groups and not the caregivers.
Logistical
and ethical considerations
Ethical clearance was obtained from
Ondo State Health Research Ethics Committee [OSHREC]. Letter of introduction to
the coordinator of Owo LGA, BHCs was obtained from Ondo State Primary Health
Care Development Board [OSPHCDB], Nigeria.
Results
The
influence of nutrition education on complementary feeding practices of the
caregivers
A regression analysis using Adjusted
Relative Risk was carried out to determine the effect of the nutrition
education on the feeding practices of the caregivers. The caregivers in the
intervention group were 8 times more likely to feed the infant with minimum
meal frequency than the caregivers in the control group at the midline [ARR: 8.13;
CI: 3.12-21.19; p<0.001] and 3.4 times at the end line [ARR: 3.41; CI:
2.36-5.22; p<0.001]. The result showed that caregivers in the intervention
group were 7 times more likely to feed their infants with diversified diet in
terms of the complementary foods at midline [ARR: 7.89; CI: [4.47-13.92;
p<0.001] and 6.7 times at the end line [ARR: 6.66; CI: 4.43-8.84; p
p<0.001]. Feeding the infants with minimum acceptable diet was 6.4 times
more likely among the caregivers in the intervention group [ARR: 6.42; CI:
2.42-18.33; p<0.001] at the midline and 3 times more likely at the end line
[ARR: 3.13; CI: 2.53-5.16; p<0.001] compared to the control group. This
shows that the infants in the intervention group were more like to meet the
minimum acceptable diet requirement compared to the infants in the control
group, both at the midline and at the end line of the study.
Responsive feeding was more likely
to be practiced among the caregivers in the intervention group than the
caregivers in the control group [ARR: 2.12; CI: 1.72-2.65; p<0.001] at the
midline and 6 times more likely at the end line [ARR: 6.60; CI: 4.43-8.84;
p<0.001]. The responsive feeding practices were also established by
caregivers during the FGDs. This was what a caregiver from the intervention group
had to say; I did not believe that the different ways of encouraging the
infants to accept complementary food could be achievable because of my
experience with my first daughter, but this training helped me. Since the time
we were taught on responsive feeding which was demonstrated to us in the health
centre, I practiced responsive feeding on my infant and it was achievable.”
[CAREGIVER3, FGD2 2017] (Table 1).
Continued
breastfeeding survival analysis
Adjusted Relative Risk analysis
showed that 30% of the caregivers in the control group were less likely to
continue breastfeeding, compared to the intervention group at the end line [
ARR 0.30; CI: 0.16-0.56; p<0.001]. Additionally, survival analysis was
performed on the continued breastfeeding practices of the caregivers in both
groups to determine the probability of continued breastfeeding along with
complementary feeding among the caregivers. From Kaplan-meire analysis, 69.7%
of the caregivers in the control group continued with breastfeeding at age 11
months, compared to 94.4% of the caregivers in the intervention group
[p<0.001].
Discussion
Despite research-based evidence on
association of adequate complementary feeding practices and child survival. In
Nigeria, 70% of caregivers did not have good adequate complementary feeding
practices [16,17]. Only 17.5% of Nigerian infants received minimum acceptable
diet during complementary feeding by the caregivers [18]. In South western
Nigeria, the geopolitical zone where this study was carried out, only 17.8% of
infants received minimum acceptable diet [MAD] while in Ondo State, only 11.4%
received MAD [2]. This study showed the effect of nutrition education which
improved the caregivers’ complementary feeding practices. Prior to the
commencement of complementary feeding practices at the baseline, there was no
significant difference in the complementary feeding practices in the two
groups. Some of the caregivers that introduced complementary feeding earlier
than six months were among caregivers that participated in this study. Whether
they introduced complementary feeding earlier or at appropriate time there was
a significant improvement in the feeding practices among the caregivers that
received nutrition education (Figure 3 & 4).
Force feeding ways of introducing
complementary feeding among the caregivers in the control group showed poor
feeding practices of the caregivers. There was lack of knowledge on responsive
feeding which made the caregivers in the control group lack confidence to feed
the infants. This resulted to force feeding as determined in this study, which
could affect the timely introduction of the complementary feeding practices.
Majority of the caregivers in the control group started force feeding due to
the refusal of the complementary foods by the infants. The issue of early
intolerance of the complementary foods by the infants was handled during the
nutrition education using different techniques of responsive feeding through posters
and food demonstrations. This study is in line with guiding principle of
complementary feeding stated by the National Policy on infant and young child
feeding in Nigeria [19], which declared that responsive feeding using
psycho-social care should be adopted by mothers in Nigeria. To foster a
reciprocal relationship between the parent or caregiver and the child, and thus
practicing responsive feeding, was hypothesized to be beneficial to both
parties [20]. Accelerated rate of death and pneumonia as a result of force
feeding was a concern [21]. They further stated that force feeding leads to
infections, collapsed lungs, digestive and pancreatic problems. Acceptable ways
of introducing complementary feeding that will be acceptable by the infants and
will not frustrate the effort of the caregivers which could lead to
introduction of force feeding, was learnt by the caregivers in the intervention
group during the nutrition education on complementary feeding. Lack of
responsive feeding practices caused growth flattering among the infants in low-
and middle-income countries [22].
Therefore, responsive feeding
techniques should be among the package for complementary feeding guidelines. To
corroborate the effectiveness of nutrition education on responsive feeding, it
was revealed that there was an improvement in the complementary feeding
practices of caregivers in the intervention group as the caregivers in Kosova
were able to see more reasons to have patience and encourage the infants to eat
complementary foods [23]. Consumption of iron rich foods was high among the
infants in both groups and this agrees with the reports on consumption of iron
rich foods in South-West Nigeria by [19]. The report revealed that 60.1% of
infants in this geo-political zone consumed iron rich foods. Despite the high
rate of consumption of iron rich foods in both groups, there was a wide margin
of iron rich foods intake between the infants in the intervention group and
control group in the present study. Increase in the intake of iron rich foods
was due to the nutrition education that the caregivers in the intervention
group received. Intakes of iron were lower by 16% among infants of 6-12 months
than children of 13-36 months in an observational study in Brazilian Well Child
Clinic [24]. There was an association between complementary foods and
haemoglobin concentration among Indian infants [25]. The author stated that
there was a positive association between the infants’ haemoglobin concentration
and fortified baby foods, breast milk and infant formula as well as fruits and
vegetables to a lesser extent on the contrary to porridge or gruel. Iron
deficiency [ID] is the most common micronutrient deficiency world-wide and
young children are the special risk group because their rapid growth leads to
high iron requirements [26].
Early initiation of complementary
food using semi-solid, solid/ soft food consistency and food diversification
was improved among the caregivers in the intervention group. The knowledge
acquired during the nutrition education was put into practice during the period
of complementary feeding before the first birthday of the infants [age 12
months]. It was recommended that nutrition education is needed in West African
countries to improve the knowledge of caregivers on complementary foods
consistency as majority of mothers in West African countries feed the infants
with thin gruel during complementary feeding [27]. Poor timing of initiation of
complementary feeding led to 70% malnutrition among infants in Konaseema region
of India therefore recommended nutrition intervention on complementary feeding
[28]. Untimely initiation of complementary feeding was prevalent among
caregivers in North eastern part of Ethiopia and that nutrition education on
timely introduction of complementary feeding could improve the practices among
mothers [29]. The infants in the intervention group had higher minimum meal
frequency rates than the infants in the control group. This was similar to the
findings which revealed that meal frequency increased according to the age of
children study in South eastern of Ethiopia [30]. The increase in the
percentage of the infants who were fed with minimum meal frequency was higher
in the intervention group than the control group due to the effect of the
nutrition education on the intervention group. This is in line with the
findings which showed that there was an increase in meal frequency of infants
whose mothers were in intervention group than the infants whose mothers were in
the control group in Ethiopia [31]. The intervention group caregivers increased
the meal frequency during illness of the infants during the study compared to
the caregivers in the control group. Children poor appetite induced by illness
can contribute to perpetuate vicious cycle of infectious diseases [32].
Dietary diversity during
complementary feeding was achieved among the caregivers in the intervention
earlier at midline of the study than the caregivers in the control group. The
effect of the knowledge of the caregivers in the intervention group was
noticeable in the minimum dietary diversity achieved during the feeding
practices. There was higher number of infants who were fed on minimum dietary
diversity in the intervention group than the control group. This study was in
line with the study which showed significant difference between dietary
diversity, meal frequency and feeding infants with iron containing foods among
caregivers the intervention group and those in the control group in Uganda
[33]. However, literature on intervention to improve the feeding practices of
caregivers prior the commencement of the complementary feeding practices, and
at different age of the infants’ months was limited. Nutrition education
improved dietary diversity among caregivers of infants between 6-23 months in
Malawi [34]. Also, UNICEF showed that nutrition education is a catalyst for
improving dietary diversity among caregivers in Lilongwe, Malawi [35].
Treatment of drinking water by the caregivers showed that the caregivers in the
intervention group practiced good hygiene as compared to the caregivers in the
control group. This could be the effect of the nutrition education received by
the intervention group. The underlying determinants of undernutrition include
food insecurity, inappropriate care practices, poor access to health care, and
an unhealthy environment, including access to portable water, sanitation, and
hygiene [36] in [37]. In 2018 UNICEF declared that 88% of diarrhea deaths were
due to lack of access to safe drinking water, poor sanitation and hygiene [38].
World Health Organization stated that nutrition outcome could be improved with
better intervention on water, sanitation and hygiene [39].
The improvement in complementary feeding practices in the intervention group could be linked to the knowledge acquired during nutrition education. The intended feeding practices as noted at the baseline study as well as during FGDs and KIIs was to feed the infants with thin consistency. However, nutrition education was able to change the understanding of the caregivers on food consistency which in turn improved the feeding practices among the caregivers in the intervention group. Several studies have proved the need for nutrition education to improve complementary feeding practices of caregivers. Nutrition education was recommended as a viable tool to improve complementary feeding practices among mothers in Cross River State, Nigeria [18]. Nutrition education on complementary feeding is needed by caregivers in Sagamu, Nigeria to improve the infant feeding practices among mothers [40]. It was 30% of infants in Nigeria were adequately fed and therefore recommended nutrition education for the improvement of caregivers feeding practices [41].
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