Lupine Publishers | Scholarly Journal of Food and Nutrition
Abstract
This
study is an in-depth finding of the effect of nutrition education on
caregivers’ complementary feeding practices. The WHO recommendations for
optimal complementary feeding are based on continued breastfeeding, early
introduction of solid or soft diet, minimum meal frequency (MMF) and minimum
dietary diversity (MDD) in terms of food groups. Improved knowledge on adequate
complementary feeding could positively affect the attitude of caregivers
towards complementary feeding practices. Meanwhile, effect of demographic and
socio-economic status was also reviewed. Materials used for this study are
secondary data from archived materials and existing literature on effects of
nutrition education on complementary feeding in Nigeria and other developing.
The study showed that reports on complementary feeding practices in developing
countries are rated inadequate, with inappropriate early introduction of
complementary feeding. Complementary feeding was either introduced too early or
too late with thin and low iron rich and vitamin A rich diet. Study revealed
poor practices of Minimum Meal Frequency (MMF) and Minimum Dietary Diversity
(MDD). Force feeding overrides responsive feeding which attracts other
complicated health issues among the infants. The final summary showed that
nutrition education will be an effective tool to solve the problem of
inadequacy in complementary feeding practices.
Introduction
The
knowledge, attitude and practices of complementary feeding among caregivers in
the developing countries have been rated poor [1]. Caregivers’ nutrition
education on complementary feeding is an effective tool to improve the
complementary feeding practices. Other factors affecting the complementary
feeding as revealed by researchers are socio-demographic and socio-economic
status of the caregivers. The effects of nutrition education on knowledge,
attitude and complementary feeding practices of the caregivers and the
nutritional status of infants revealed by existing literature are discussed in
this chapter. Infants feeding practices reports available in some West African
nations showed poor practices of MAD by caregivers in Ghana (13%) and in Benin
Republic (9%) [2]. The report of the Nigerian National Demographic and Health
Survey [3] 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]. In the developing countries, malnutrition has been
proved to be responsible for over 41% of the deaths among children 6 to 24
months of age [4,5] revealed that under nutrition of protein and energy-giving
foods contributed to 45% of death, among children less than five years of age
in evidence-based research carried out in 34 countries in the world. The global
strategy for infants and young child feeding was based on the significance of
nutrition in the early months and years of life [6]. These strategies include
monitoring, assessing and promoting adequate infant nutrition, breastfeeding,
feeding behavior, national health programs and infants feeding guidelines. In
order to achieve adequate infant feeding practices in the developing nations,
the global strategies must be followed.
Research objectives are
a)
To ascertain the relationship between caregiver’s nutrition education on
caregivers’ complementary feeding knowledge, attitudes and practices
b)
To identify relative findings on effects of nutrition education on caregivers’
complementary feeding knowledge, attitudes and practices
c)
To establish the on effects of caregivers’ nutrition education on infant’s
nutrition status
Research Methods
Secondary
data from existing literatures on effects of nutrition education on
complementary feeding knowledge, attitude and practices as well as the infant’s
nutrition status was used to make compilations on these findings.
Demographic and
socio-economic factors influencing caregivers complementary feeding practices:
Demographic
and socio-economic status of caregivers is one of the major factors associated
with poor complementary feeding practices of caregivers and nutrition status of
infants in developing countries [7]. Maternal age, educational level and the
household’s income have been reported as factors associated with the
complementary feeding knowledge, attitudes and practices among the caregivers. The
caregivers’ age and low education level attainment have been revealed to
influence complementary feeding practices in countries such as India [8]. In
Nepal, indicated that mothers of infants aged 6-23 months working outside the
home were less likely to practice optimal complementary feeding that meet the
recommended dietary diversity. Also, [9] revealed that mothers that worked 8
hours outside their homes were unable to meet the recommended dietary diversity
and meal frequency for infants in Nigeria. This was associated with limited
time they had with their children. [10] revealed that food restrictions due to
cultural belief as well as economic status of mothers were contributing factors
to inappropriate feeding practices among mothers in Cross River State, Nigeria.
In Moretele District in South Africa, [11] showed that adherence to cultural
practices affects mothers’ attitude to complementary feeding practices.
Households with lower wealth index were found to be the more likely to have
inappropriate complementary feeding practices in India, Bangladesh, Nepal,
Pakistan and Sri Lanka [12]. There was a significant association found between
caregivers’ socio-economic status and infant feeding practices in Nekemte,
Ethiopia. The study showed that caregivers in the low socio-economic strata
practiced sub-optima complementary feeding [13]. The effects of economic status
on nutrition status of children have also been illustrated by researchers. In
Ondo State, [14] discovered low intake of energy dense food and protein
containing food among children whose mother were living in rural communities of
Ondo state. The author stated further that the mothers were of low
socioeconomic status. This corroborates the research of [15] on effect of low
socio-economic status of rural market women in owo Local Government of Ondo
State on the nutrition status of their infants. The study reported a positive
correlation between low economic status of the market women and the feeding
practices as well as the nutritional status of the children. Research has
proved that caregivers required skilled support to adequately feed their
infants despite the limitations which could be caused by socio-economic and
demographic status of the caregivers [16]. Nutrition education is an effective
way of improving complementary feeding practices among mothers as [17] reported
that poor feeding practices are not necessarily due to lack of high quality of
foods at the household but lack of infants’ feeding knowledge by the
caregivers.
Complementary feeding knowledge,
attitude and practices:
Knowledge
is the understanding of any given topic [18]. In this study, knowledge referred
to the ability to understand specified aspects of complementary feeding
practices. Attitudes are emotions, motivations and perceptive as well as
cognitive beliefs that could either positively or negatively influence the
caregivers’ complementary feeding attitudes [18-20]. Caregivers complementary
feeding attitudes or infant’ feeding behavior is influenced by his/her
emotional, motivational and perceptional as well as thoughts [20]. Attitudes
have the ability to influence the future behavior of the caregivers’ knowledge
and could explain the reason why caregivers adopt complementary feeding
practices and no other alternatives [21]. The terms attitude, beliefs and
perceptions are interchangeable. In this study, “practices” is an observable
action of a caregiver that could affect his/her infants’ nutrition, such as
eating, feeding, water treatment, cooking and foods selection for the infants.
Practice and behavior are terms used interchangeable, though practice has a
connotation of longstanding or commonly practiced behavior [22].
Effect of nutrition
education on caregivers’ complementary feeding knowledge:
Knowledge
on complementary feeding by the caregivers has been revealed by [11] to be
limited in African countries. A Nigerian study showed that knowledge on benefit
of continued breastfeeding along complementary feeding till the infant’s age 24
months is low [23]. A descriptive study on maternal knowledge on complementary
feeding in India, established that 75% of caregivers had average knowledge on
appropriate consistency and safe preservation of infant’s meal [24]. The
circumstances are similar to Nigeria, Ondo State in particular. According to
[25], only 30% of the caregivers have adequate knowledge of complementary
feeding in Nigeria. In Ondo State, it is reported that 70% of the caregivers
used sorghum majorly as complementary foods [15]. The role of nutrition
education on caregivers feeding knowledge cannot be underrated. The [16] stated
that inadequate knowledge on appropriate complementary feeding is a determinant
of malnutrition among the infants in the developing countries. The effect of
organized and well-planned nutrition education on complementary feeding
knowledge have been proved by researchers [26] reported that 88% of caregivers
in North Shan State and Karachi State Republic of the Union of Myanmar were
able to plan infants’ meals from more than four food groups after nutrition
education on the infants feeding knowledge [27] showed that nutrition education
to improve maternal complementary feeding knowledge significantly impacts on
knowledge of meal preparation for children in Uganda. The authors stated that
71% of caregivers who received nutrition education intervention had improved
knowledge in complementary feeding and were able to improve in infants feeding
frequency. Furthermore, Nutrition education and counseling on infants feeding
improved the complementary feeding knowledge of caregivers significantly by 1.5
points in a study conducted in the Philippines. Ondo State, Nigeria still
suffers a setback in adequate complementary feeding as there is lack or low
knowledge of complementary feeding [15]. The author reported that caregivers in
Ondo State had low knowledge on food diversification. Intervention programs
which involve the caregivers and Community Health Extension Workers have been
confirmed to be limited in Ondo State thereby causing a research gap on
complementary feeding knowledge in Ondo State, Nigeria consistency. The study
of [15] was a cross-sectional study to determine the situation of feeding
practices and factors affecting the feeding practices of the infants. In
Nigeria, only 3.7% of households have access to an improved water resources
located on premises, free of E-coli and available when needed [28]. The report
showed that diarrhea is prevalent due to poor access to portable drinking
water. Caregivers knowledge to improved access to portable water was low as 63.4%
of caregivers used unprotected well in Biye community in Kaduna, Nigeria [29]
the author stated further that water boiling method is the cheapest way to
achieve portable water for the infants in the community.
Effect of nutrition
education on caregivers’ complementary feeding attitudes:
The
UNICEF [17] suggested that reduction of child mortality can be achieved when
IYCF awareness is improved. The poor complementary feeding attitudes have been
linked with communities’ beliefs and mothers’ perceptions [30]. Showed that
socio-cultural belief has a strong influence on infants feeding and determines
optimal infants feeding practices; breastfeeding and complementary feeding in
Kakamega County, Kenya. In Zambia, majority stopped breastfeeding before the
appropriate time because they believed that breast milk was not enough, and
that the child had lost interest in breastfeeding described how Mexican mothers
in a cross-sectional survey mostly fed their children liquid and semi liquid
foods with few vegetables, meats and legumes. The author stated that Mexican
mothers took this decision due to their perspective on the consistency of the
food for infants, that is, soft or solid foods are detrimental to infants’
health [31] confirmed that, despite the economic status and educational
attainments of mothers, they exhibit poor attitude to complementary feeding in
Shabelle Zone of Somalia due to influence of the cultural belief. Feeding thin
consistency feeds in small amounts and food restriction due to cultural beliefs
are common in Nigeria [32, 33] revealed that scientific knowledge on infant
feeding practices would improve complementary feeding attitude among mothers in
Republic of Kosovar. Meanwhile, the author’s opinion was in contrast to [34]
who revealed that despite the nutritional education on importance of
consumption of pulses to children’s wellbeing in Southern Ethiopia, there was
no significant difference between attitudes of mothers who received the
training and attitudes of mothers in the control group due to cultural belief
on effect of pulses on children [35] experienced low acceptability of blended
complementary food with pulses in Ethiopia. This study put into consideration
the fact that cultural beliefs may be influencing caregivers’ attitude and
therefore focused on other beneficial food items in the study area to improve
caregivers’ attitude on complementary feeding [36]. Showed that despite the
knowledge of complementary feeding among mothers in Lagos State, Nigeria, the
mothers had the poor attitude towards timely introduction of complementary
feeding as majority of the caregivers introduced complementary feeding too
early or too late. The author stated that this was prevalent among working
mothers. The intervention of nutrition education and counseling was proved to
improve mothers’ attitude towards complementary feeding [37] revealed that
caregivers had change in attitudes towards responsive feeding and their
infants’ nutrient intake was higher compared to the control group. Most studies
conducted both in Ondo State and in other locations in Nigeria were descriptive
and cross-sectional studies, leaving research gaps on effect of nutrition
education on complementary feeding attitudes in the area [23] conducted a
cross-sectional survey in Nigeria on factors affecting breastfeeding practices.
This was a cross sectional study which identified poor practices of
breastfeeding but could not profound solution through an intervention [25]
conducted a study in Lagos, Nigeria on factors associated with inadequate
complementary feeding. Also, [14] carried out a study on complementary feeding
in Ondo State, Nigeria on effect of socio-economic status on infant feeding.
The above two studies were cross-sectional studies on factors associated with
inadequate complementary feeding in Nigeria. The studies of [25,14] were unable
to improve the complementary feeding attitudes of the caregivers in the study
areas because they were cross-sectional studies and not an interventional
study. The above two studies had little or no effect on the participants,
although they could be included by Nigerian government’s program for policy
framework. The study of [38] and [39] was designed to assess complementary
feeding practices among caregivers and there was no intervention on
complementary feeding practices in these studies. There is limited literature
on the effect of nutrition education on maternal attitudes towards
complementary feeding.
Effect of nutrition
education on caregivers’ complementary feeding practices:
A
report by UNICEF showed that complementary feeding practices are globally poor
[2]. In Ireland, only 36% of infants had timely initiation of solid and semi
solid foods. According to [40], only 1.8% of caregivers in Uganda fed infants
with protein containing food products, especially meat during the period of complementary
feeding [41] stated that only 28% of caregivers in Ghana were able to feed
their infants 2-3 times daily with adequate complementary meals. The level of
inadequate complementary feeding in Nigeria is worse than that of Ghana as only
11% of exclusively breastfed infants receive complementary meals from four food
groups and only 7% of the non-exclusive breastfed infants were fed with
adequate complementary feeding in Nigeria. These show the poor practices of
complementary feeding among caregivers in the region. United States Agency for
International Development [42] in an assessment of infant and young child
feeding practices in Nigeria affirmed that there are challenges to improve on
complementary feeding behaviors among caregivers with infants. However, the
author indicated that with well-trained health workers, coordinated and
targeted messaging to caregivers and influencing groups in the communities,
there will be a great deal of progress towards increasing optimal infant and
young child feeding practices in Nigeria. To corroborate the above, [38] and
[39] observed that nutrition education intervention among caregivers in Nigeria
will improve the caregivers’ complementary feeding practices [43] discovered
that nutrition education on complementary feeding carried out by 30 several
studies in developing countries showed statistical evidences of improved
complementary feeding practices of mothers. Therefore, the study recommended
nutrition education among mothers to improve complementary feeding practices.
The study of [29] on improved hygiene practices among caregivers showed that
79.6% caregivers boiled their drinking water in Biye community, Kaduna,
Nigeria. Interventions that improved complementary feeding practices among
caregivers were carried out in some part of the world such as Cambodia,
Zimbabwe, Mali and Ghana with different degrees of success. In Bangladesh, [44]
revealed that breastfeeding counseling improved exclusive breastfeeding among
mothers. The author revealed that when mothers received counseling on exclusive
breastfeeding, they practiced it until 135 days while the control group
practiced exclusive breastfeeding for 75 days. This improvement achieved was
due to interventional research by the researcher. Another instance was the successful
report of FAO [20] in a program titled “Promoting improved complementary
feeding” in Cambodia. The program was based on counseling, training and cooking
demonstration. This program was carried out by conducting home visits to assist
households who were encountering challenges in adopting the improved
complementary feeding and the caregivers were trained with improved recipe. The
program was recorded to be a success as the caregivers had improved knowledge,
attitude and complementary feeding practices. However, a similar nutrition
education program which trained the caregivers on improving complementary
feeding in Zimbabwe proved unsuccessful due to inadequate monitoring system and
lack of trained personnel for continuity [27] stated that women who receive
nutrition education on complementary feeding were able to prepare complementary
diet from over four food groups, compared to their attitude towards dietary
diversity before the nutrition education. The success report of Cambodia
nutrition education and training program was particularly based on the current
caregivers with infants at the time of the program in the study area. The
program did not plan for the sustainability of the program on subsequent
caregivers; as there were no community-based personnel that were involved to
receive the training [20]. Also, in Zimbabwe, the nutrition program to promote
adequate complementary feeding practices was unsuccessful due to lack of
trained personnel educating caregivers to continue with the programs among the
caregivers. There has been limited documentation of complementary feeding on
nutrition education targeted at the caregivers as well as health personnel
within the health care system who deals with maternal and child’s health in
Ondo State. Surveys on infants’ feeding practices available were mainly on
cross-sectional survey of the situation and no known intervention was found.
Effect of caregivers’
nutrition education on nutrition status of infants
The
National Demographic and Health Survey carried out by revealed that 43% of
children less than five years of age in rural areas of Nigeria were stunted and
29% of Nigerian children were underweight and too thin for age. In Ondo State,
26% of children less than five years were stunted while 43% were underweight
[45]. Inadequacy in complementary feeding practices can result to malnutrition
in children during the complementary feeding period [46]. Declared the period
of complementary feeding as a period of windows of opportunity for growth
flattering. Revealed that there were suboptimal complementary feeding practices
among mothers studied in different geographical area in Nigeria which leads to
growth flattering of infants in the area. Interventions that can bring about
improvement in the nutrition status of infants could be achieved by nutrition
education [5] revealed that weight and height increased among children 6-24
months of age after maternal nutrition education on complementary feeding in
Sri Lanka and Tanzania. Concluded that nutrition education intervention was
successful in reducing malnutrition in Pakistan as 36% malnourished children
progressed to normal nutrition status [47] showed that there was an increase in
weight (350g) and length (0.66cm) among the infants of caregivers in
intervention group that received complementary feeding nutrition education in
Karachi, Pakistan [48] stated that pooled-effect sizes from three recent
systematic reviews suggested a modest nutrition education but there was a
significant effect of the types of complementary feeding interventions on
weight and length gain [49] revealed the effectiveness of nutrition education
as a tool to improve mothers’ knowledge and complementary feeding practices
which improved the nutrition status of the infants. The author reported in a postprogram
comparison research carried out among mothers in Uganda. Mother who
participated in the program had significant improvement on complementary
feeding practices which in turn had positive impact on the nutrition status of
their infants. In Nigeria there is limited literature on benefit of nutrition
education on nutrition status of the infants. The above interventional studies
on nutrition education on complementary feeding were carried out to determine
the effect of the intervention on complementary feeding practices as well as
the effects on the nutritional status of the infants.
Discussion
The
literatures reviewed for this study showed that the complementary feeding
knowledge, attitude and practices among the caregivers is inadequate, and this
affects the nutrition status of infants. The caregivers especially in the
developing countries such as Nigeria and some African nations have limited or
low knowledge of appropriate complementary feeding practices. The caregivers’
complementary feeding practices are not in line with the WHO recommended
guidelines for infants feeding. The knowledge on the appropriate time of
introducing complementary feeding among the caregivers was established.
Majority of the caregivers had knowledge on timely introduction of
complementary feeding (6 months), although not all of them. It means that some
introduced early while some introduced it late. This is similar to the report
of [47]. The author reported that in Karachi, Pakistan 17% of the mothers
lacked knowledge of appropriate time of introducing complementary feeding and
83% had good knowledge. Although, [13] revealed that 44.2% of mothers in
Nekemte, Ethiopia lacked knowledge on rightful time of introducing
complementary feeding. The literature reviewed further showed that the
attitudes of the caregivers towards complementary feeding were influenced by
the culture and the belief of the caregivers as an individual and the
communities. It is an established fact that nutrition education would be an
effective means of improving complementary feeding practices among caregivers
on; timely introduction of complementary feeding, soft/solid food consistency,
good hygiene practices, food diversification, consumption of iron rich foods
and minimum acceptable diet. Effect of caregivers’ belief on dietary diversity
as indicated by [30] revealed that mothers’ attitude towards infants feeding
played a significant role in food they fed the children in Kakamega County,
Kenya [34] reported that mothers’ negative attitude towards pulses in feeding
the infants was the factor preventing mothers to diversify complementary foods
with pulses in Southern Ethiopia but the knowledge of the caregivers in the
intervention group was improved on dietary diversity after nutrition education.
According to [50] knowledge either directly contributes to attitude formation
or indirectly affects attitudes. Complementary feeding practices by caregivers
globally were rated poor [16]. The author stated further that the situation
does not exclude the caregivers in the developed world; it is a global problem
[16]. The effect of poor complementary feeding practices on the infants’
wellbeing has been identified and determined to be, increase in morbidity and
mortality rate [16]. Survival rate of infants before their first birthday has
been associated with feeding practices of the caregivers [51]. Intervention on
complementary feeding practices rated the second to reduce mortality rate in
infancy. It has been shown that infant and young child feeding is a key area to
improve child survival, promote healthy growth and development [52].
Acknowledgement
The
researchers acknowledge TETFUND and Rufus Giwa Polytechnic, Owo, Ondo State.
Conflict of interest
The
researchers declare no conflict of interest regarding this study.
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