EFFECT OF NUTRITION EDUCATION ON COMPLEMENTARY FEEDING PRACTICES AND NUTRITION STATUS OF INFANTS: A CLUSTER RANDOMIZED-TRIAL IN ONDO STATE, NIGERIA

ABSTRACT

Malnutrition during infancy has been linked to lack or poor knowledge of appropriate feeding practices among caregivers. This study investigated the effect of nutrition education on adequate complementary feeding practices among caregivers as well as the nutrition status of infants (5-11months) in Ondo State, Nigeria. The study adopted cluster randomized controlled trial design. The study participants were assigned to two groups. One intervention and one control group in a ratio of 1:1. The sample size was 142 for intervention group and 142 for the control group. Nutrition education on complementary feeding was carried out among the caregivers in the intervention group and the control group received no nutrition education from the research team. The participants in the intervention group received four (4) lesson sessions per group. The lesson sessions were based on timely introduction of complementary feeding, meal frequency and planning, dietary diversity, minimum acceptable diet, hygiene and responsive feeding. To determine the complementary feeding knowledge, attitude and practices of the caregivers as well as the nutrition status of the infants, data were collected from caregivers at the infants’ age 6, 8 and 11 months. For knowledge and attitude, complementary feeding knowledge and attitude based questionnaire were used. For complementary feeding practices, 24-hr dietary recall was used and nutrition status assessment instruments were used to determine the infants’ nutrition status. Focus group discussions and key informant interviews were conducted for qualitative data. Data were analyzed using SPSS version 22.0. From the analysis, there was no significant difference in demographic and socio-economic status of the caregivers. There was a significant difference in the complementary feeding mean knowledge score of the caregivers after the intervention at the endline (4.0; p<0.001) and the (Difference in Difference (DID) between baseline and the endline was 4.06 (p<0.001) and the complementary feeding mean attitude score of the caregivers was 3.82; p<0.001) at the endline. The mean nutrients intake of the infants in the intervention group was higher than the control group as analyzed by nutri-survey. The mean energy intake of infants in the intervention group was higher both at the midline (259g±20.67) and at the endline (366.7g±23.03) than those in the control group both at the midline (121.1g±17.05) and the endline (212g±22.04), these were both significant (p<0.001). 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 (p<0.001). 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 endline. There was a significant difference in WAZ (t.test; p<0.001), WHZ (t-test; p<0.001) and in HAZ (t-test; p=0.049). The infants in the intervention group had improved nutritional status than the infants in the control group. 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.

TABLE OF CONTENTS

DECLARATION…………………………………………………………………………………………… ii DEDICATION……………………………………………………………………………………………… iii ACKNOWLEDGEMENT …………………………………………………………………………….. iv TABLE OF CONTENTS ……………………………………………………………v LIST OF FIGURES………………………………………………………………….x LIST OF TABLES…………………………………………………………………..xi DEFINITION OF TERMS ………………………………………………………………. ……….xii OPERATIONAL DEFINITION OF TERMS  ……………………………………………… xiv LIST OF ABBREVIATION AND ACRONYMS ………………………………..xv ABSTRACT………………………………………………………………………….xvii CHAPTER ONE: INTRODUCTION ………………………………………………………………1

1.1 Background …………………………………………………………………………………………….1

1.2 Problem statement ……………………………………………………………………………………4

1.3 Purpose of the study …………………………………………………………………………………6

1.4 Objectives of the study ……………………………………………………………………………..6

1.5 Hypotheses: …………………………………………………………………………………………….7

1.6 Significance of the study …………………………………………………………………………..7

1.7 Delimitations of the study …………………………………………………………………………8

1.8 Limitations of the study…………………………………………………………………………….8

1.9   Conceptual framework ……………………………………………………………………………8

CHAPTER TWO: LITERATURE REVIEW …………………………………………………11

2.0 Introduction …………………………………………………………………………………………..11

2.1 Demographic and socio-economic factors influencing caregivers omplementary

feeding. ………………………………………………………………………………………………………11

2.2 Complementary feeding knowledge, attitude and practices …………………..13

2.2.1. Effect of nutrition education on caregivers’ complementary feeding…………

knowledge  …………………………………………………………………………………………………13

2.2.2 Effect of nutrition education on caregivers’complementary feeding attitudes16

• 3Effect of nutrition education on caregivers’complementary feeding practices 18

2.2.4 Effect of caregivers’ nutrition education on nutrition status of infants………..21

2.3 Summary of literature review …………………………………………………………………..23 CHAPTER THREE: METHODOLOGY ………………………………………………………24

• Research design ……………………………………………………………………………………..24
• Study variables ………………………………………………………………………………………24
• Study area ……………………………………………………………………………………………..24
• Target population …………………………………………………………………………………..25

3.4.1 Inclusion criteria ……………………………………………………………………………………. 25

3.4.2 Exclusion criteria …………………………………………………………………………………… 26

• Sample size ……………………………………………………………………………………………26
• Sampling techniques …………………………………………………………………………….27

3.6.1 Randomization ………………………………………………………………………………………. 28

3.6.2 The recruitment of study participants into the study …………………………………… 29

3.6.3 Blinding………………………………………………………………………………………………… 29

3.7 The Selection and training of the research team …………………………………………29

3.7.1 The selection of Community Health Extension Workers (CHEWs) ……………… 29

3.7.2 Enumerators ………………………………………………………………………………………….. 31

3.7.3 Role of the Enumerators …………………………………………………………………………. 31

3.8 Description of the study groups and intervention ……………………………………….32

3.8.1 Control group (group 1) ………………………………………………………………………….. 32

3.8.2 Intervention group (group 2) ……………………………………………………………………. 33

• Follow-up and management of appointment ………………………………………………38
• Data collection instruments ……………………………………………………………………38

3.10.1 Researcher-administered questionnaire……………………………………….38

3.10.2 Key informants interview guides ……………………………………………………………. 40

3.10.3 Focus group discussion guides……………………………………………………………….. 40

• Pilot Study …………………………………………………………………………………………..41
• Validity and reliability of research instruments ………………………………………..43

3.12.1 Validity ………………………………………………………………………………………………. 43

3.12.2 Reliability ……………………………………………………………………………………………. 43

3.13 Data collection techniques and procedure ………………………………………………..43

3.13.1 Key Informant Interviews (KIIs) ……………………………………………………………. 44

3.13.2 Focus Group Discussion (FGDs) ……………………………………………………………. 45

3.13.3 Face to Face interviews …………………………………………………………………………. 45

3.13.4 Anthropometric measurements ………………………………………………………………. 47

• Data analysis and presentation ……………………………………………………………….48
• Logistical and ethical considerations ………………………………………………………51

CHAPTER FOUR: FINDINGS ……………………………………………………………………..53

4.0 Introduction …………………………………………………………………………………………..53

4.1   Findings of the needs  Assessment …………………………………………………………53

• 1: Views of the Community Health Extension Workers to complementary feeding

during needs assessment …………………………………………………………………………………. 53

4.2   The recruitment process of the study participants ……………………………………..55

4.3: FINDINGS AT BASELINE …………………………………………………………………..56

4.3.1: Socio-demographic characteristics of the caregivers by study groups ………….. 56

4.3.2: Socio-economic characteristics of the caregivers by study group ………………… 57

4.3.3: Comparison of caregivers’ infant feeding knowledge by study groups at baseline ………………………………………………………………………………………………………… 59

4.3.4: Comparison of caregivers attitude towards infant feeding at baseline ………….. 62

4.3.5: Infant characteristics and feeding history of the infants in both groups ………… 64

4.3.6: Complementary feeding intention of the caregivers at baseline …………………… 65

4.3.7 Comparison of Nutritional status of the infants at baseline WAZ, WHZ and

HAZ z-score…………………………………………………………………………..66

4.4: FINDINGS AFTER INTERVENTION ……………………………………………………68 4.4.1: Comparison of socio-demographic and economic characteristics of the caregivers who completed and those lost to study ………………………………………………. 68

4.4.2: The effect of nutrition education on caregivers’ complementary feeding knowledge …………………………………………………………………………………………………….. 70

4.4.3: Effect of nutrition education on caregivers’ knowledge score on complementary feeding………………………………………………………………………………………………………….. 72

4.4.4: Effect of nutrition education on caregivers’ attitude to complementary feeding

…………………………………………………………………………………………………………………….. 73

4.4.5: Effect of nutrition education on caregivers’ attitude score …………………. ……..75

4. 6: Continued breastfeeding survival analysis ……………………………………………….. 76 4.4.7:The influence of nutrition education on complentary feeding practices of the caregivers……………………………………………………………………..……….78

4.4.7.1: Effect of intervention on nutrient intake of the infant at midline and endline

by study groups ……………………………………………………………………………………………… 81

4..4.8: Nutrition status of the infants by study group…………………………………………… 82

4.4.8.1: The effect of nutrition education on nutrition status of the infants by study groups …………………………………………………………………………………………………………… 85

  CHAPTER FIVE: DISCUSSION…………………..…………………………….86

5.0: INTRODUCTION…………………………………………………………………………………86

5.1: Demographic and socio-economic characteristics of the caregivers …………….86

5.2: Effect of nutrition education on caregivers’ complementary feeding knowledge

………………………………………………………………………………………………………………….87

5.3: Effect of nutrition education on caregivers’ complementary feeding attitude..92

5.4: Effect of nutrition education on caregivers’ complementary feeding practces.95

5.5: Effect of nutrition education on nutritional status of the infants ………………..102

CHAPTER SIX: SUMMARY, CONCLUSION AND RECOMMENDATION 106

6.1: Introduction ………………………………………………………………………………………..106

6.2: Summary ……………………………………………………………………………………………106

6.3: Conclusion………………………………………………………………………………………….107

6.4: Recommendations ……………………………………………………………………………….108

6.4.1: Recommendation for policy………………………………………………………………….. 108

6.4.2:  Recommendation for practice ………………………………………………………………. 109

6.4.3:  Recommendation for further research …………………………………………………… 109

REFERENCES ……………………………………………………………………………………………110 APPENDICES …………………………………………………………………………………………….124

Appendix A: Key informant interview: Community Extension Health Workers

(CHEWs) for needs assessment ………………………………………………………………………124

Appendix B: Key informant interview: Community Extension Health Workers

(CHEWs) during the study……………………………………………………………………………..125

Appendix C: Focus Group Discussion (FGD) guide for caregivers for needs assessment in both groups ………………………………………………………………………………126

Appendix D: Focus Group Discussion (FGD) guide for caregivers during the

study…………………………………………………………………………………127

Appendix E: Letter of introduction ………………………………………………………………….128 Appendix F: Consent …………………………………………………………………………………….129 Appendix G: Researcher questionnaire ……………………………………………………………134

Appendix H: Complementary feeding trainers guide for CHEWs ……………………….144 Appendix I: Findings of the Pilot Study …………………………………………………………..145

Appendix J: Summary of FGDs on aspect of nutrition education likes and dislikes and

challenges to complementary feeding in both groups………………………………147 Appendix K: Research approval from Kenyatta University………………………..148

Appendix L: Application for ethical clearance……………………………………..149

Appendix M: Ethical Clearance…………………………………………………….150

Appendix N: Map of the study locations ………………………………………………………….152

 

 

CHAPTER ONE: INTRODUCTION

1.1 Background to the study

Complementary feeding is defined as a type of feeding introduced when breast milk alone is insufficient to meet the nutrition requirement of infants (World Health Organization [WHO] , 2013). Therefore, solid and semi-solid foods are needed along with breastfeeding to meet the nutritional and growth needs of the infant. The WHO recommendations for optimal complementary feeding are based on the minimum daily feeding frequency (MFF) and minimum dietary diversity (MDD) in terms of food groups. Infants aged 6-8 months should be fed a minimum of 2-3 times a day, and those aged 9-23 months 3 or 4 times a day, from four or more food groups. Additionally, two milk feeding with MDD should be given to non-breastfed infants

(WHO, 2010). The minimum adequate diet (MAD) can only be achieved when the WHO infant feeding recommendations on feeding frequency and dietary diversity are  met.

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 (UNICEF, 2017). 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 (UNICEF, 2017). Children receiving MAD was 11% in sub-Sahara Africa, 9% in West and Central African countries and 10% in Nigeria (UNICEF, 2017).

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%)

(UNICEF, 2017). The report of the Nigerian National Demographic and Health Survey (NDHS, 2014) 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 (UNICEF, 2017).

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 (Sandoval-Priego et al., 2012). Bhutta et al., (2013) revealed that under nutrition of protein and energy-giving foods contributed to 45% of death, among children less than five years of age in an 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 (WHO, 2013). These strategies include monitoring, assessing and promoting adequate infant nutrition, breastfeeding, feeding behaviour, national health programs and infants feeding guidelines. In order to achieve adequate infant feeding practices in Nigeria, the global strategies must be followed.

The government of Nigeria and other relevant agencies has also developed, and are implementing interventions to achieve adequate feeding practices among infants. Among these interventions is the Nigeria Community and Facility Infant and Young

Child Feeding (IYCF) package which is a tool adapted from UNICEF (2010), WHO

(2008) and the National Policy recommendation on IYCF (2011) in the context of HIV (USAID, 2011). The recommendations focus on maternal nutrition and health, continued breastfeeding and adequate complementary feeding of infants after 6 months of age. This was prepared in three major Nigerian languages (Hausa, Yoruba and Igbo). The services of this package are mainly on provision of IYCF trainers guide, brochure on; maternal nutrition and health, exclusive breastfeeding and continued breastfeeding as well as infant feeding after six months of age and hygiene practices (National Policy on infant and young child feeding, 2011).

Despite these efforts by governmental and non-governmental agencies in Nigeria, the cases of improper infant feeding practices as well as malnutrition among children less than five years of age are on the increase in Nigeria according to Olatona et al., (2014). This is a serious threat to the health status of the infants. This therefore calls for urgent intervention.

The contributions of Nigerian government to adequate complementary feeding is the production and adoption of the National infant feeding policy as well as the production of  Informative, Educative and Communicative (IEC) materials on breastfeeding, food diversification, responsive feeding and hygiene practices that are available in the community health facilities. The Community Health Extension Workers needed to be trained by the nutritionist with these IEC materials for effective teaching and explanation of the materials to the caregivers in order to be routinely carried out in the Basic health centers in Nigeria. The strategy for achieving IYCF according to WHO (2013) must be followed in the health facilities in order to achieve adequate infant feeding practices.

Maternal nutrition education on complementary feeding’s knowledge and attitudes were revealed by the researchers in the developing nations to have positive and significant impact on infant feeding practices. Most nutrition education programs on infants’ feeding had been carried out majorly on breastfeeding, with fewer studies focusing on complementary feeding. In Southern Ethiopia, Mulualem et al., (2016) revealed that educating caregivers on complementary feeding improved their feeding practices which in turn improved the nutrition status of their infants. Studies on the potential effect of nutrition education on complementary feeding practices in western Africa, Nigeria were not well documented. It is against this background that this study was conducted.

1.2 Problem statement

UNICEF (2017) reported 41 deaths out of 1000 live birth among Under-5 children in year 2016 globally. This was estimated to be 15000 Under-5 deaths daily worldwide. Furthermore, UNICEF reported 104 deaths out of 1000 live birth among Under-5 children in Nigeria, which ranked Nigeria as number 6 in infant mortality rate in the world. The mortality rate recorded among the children of 5 years and below was directly and indirectly linked to inappropriate infant and young child feeding practices (UNICEF, 2017).

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 (SMART, 2014) 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. UNICEF (2010) reported that malnutrition caused the death of 53% of children less than five years of age in Nigeria. UNICEF (2012) also stated 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.

Prevalence of malnutrition has been shown to be at increase during the period of complementary feeding in many countries (Arabi et al., 2012). In Nigeria, Ocheke et al., (2014) stated that moderate wasting was higher among infants aged 6-11months with prevalence of 21.3% and this was associated with poor complementary feeding practices among the caregivers. National Bureau of Statistics (2015-2016) showed that 32.9% of infants were moderately stunted and 19.4% were moderately

underweight. Malnutrition rate, especially the acute malnutrition is high in Ondo State among the infants. Mustapha & Bolajoko (2013) revealed that 26% of the children less than five years were stunted while 43% were moderately wasted in Ondo State.

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 (Nabugoomu et al., 2015). 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 (Ndu et al., 2016). Only 10% of infants received minimum acceptable diet in the country (UNICEF, 2017). The report of NDHS (2014) showed that only 17.6% of infants in the South West Geo-political Zone received minimum adequate diet.

In Ondo State, Nigeria which is the study area, 70% of the infants consumed pap

(sorghum based fluid diet) monotonously without food diversification (Bolajoko & Ogundahunsi (2012). The authors further stated that poor knowledge and attitude to complementary feeding contributed to poor infant feeding, whereby the caregivers fed infants with gruel from sorghum only, without varying the food items for complementary feeding which  lead to malnutrition in the State.

The poor infant feeding knowledge is widespread in Africa; this factor has also been identified in Nigeria. Sholeye et al., (2016) revealed that poor caregivers’ knowledge on appropriate feeding practices ranges from 8.9% poor knowledge to 49.6% fair knowledge among the caregivers in Ogun State, Nigeria. The author stated that poor knowledge on complementary feeding among the caregivers led to inappropriate infant feeding practices in the study area.

This trend of malnutrition without intervention to control the situation will affect the nation’s quality of human capital, productivity and the economy in the long run.

Consequently derailing the efforts claimed at achieving Sustainable Development

Goals (SDGs) 1, 2 and 3. UNICEF (2010) has shown that intervention in the first 1000 days of life offers windows of opportunity for preventing malnutrition in an individual.

1.3 Purpose of the study

To determine the effect of nutrition education on complementary feeding practices and nutrition status among infants aged 5-11 months in Ondo State, Nigeria.

1.4 Objectives of the study

The objectives of this study were to;

1. Determine the demographic and socio-economic characteristics of caregivers of infants 5-11 months of age in Ondo State.
2. To develop and 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 at baseline.

3. Establish the effects of nutrition education on complementary feeding, knowledge, attitudes and practices among caregivers in Ondo State.
4. Determine the effect of nutrition education on the nutrition status of infants 5-11 months of age in Ondo State.

1.5 Hypotheses:

H01: Nutrition education has no significant effect on caregivers’ complementary feeding knowledge.

H0_2: Nutrition education has no significant effect on caregivers’ complementary  feeding attitudes.

H0 3: Nutrition education has no significant effect on caregivers’ complementary feeding practices.

H0 _4: Nutrition education has no significant effect on the nutrition status of infants.

1.6 Significance of the study

This study’s findings are significant to stakeholders, such as Ministries of Health, Ondo State Primary Health Care Development Board and the State Food and Nutrition Committee as well as the academia in Ondo State and Nigeria. The study has provided findings that will guide policy formulation. It will also contribute to literature on nutrition education strategies for improving complementary feeding practices. Caregivers of infants who participated in the study gained knowledge, and improve attitude on complementary feeding practices.

1.7 Delimitations of the study

This study targeted caregivers with infants aged 5-11months in the study area; therefore findings can only be generalized to populations with similar characteristics.

1.8 Limitations of the study

This study involved the use of 24hour recalls in data collection and therefore, there may have been recall bias. However, data was collected several times as the infants grew and this improved the chances of accuracy

1.9   Conceptual framework

This study adapted the conceptual framework by Kabahenda, (2006) on Nutrition

Education on Complementary Feeding (Figure 1.1).

CONCEPTUAL FRAMEWORK

Figure 1.1: A conceptual framework on effect of nutrition education on complementary feeding practices

Source: Adapted and modified from Kabahenda, 2006

The conceptual framework shows that the feeding practices of the caregivers are determined by factors such as demographic characteristics of the caregivers (age and parity), economic status of the caregivers (income) and the caregivers’ knowledge and attitude. The caregivers’ knowledge and attitude was also influenced by the intervention of nutrition education to improve the knowledge and attitudes of the caregivers and eventually the complementary feeding practices and the nutrition

status.

The age of the caregivers determine the experience of the caregivers on complementary feeding because teenage caregivers may have little or no experience of complementary feeding (Costa et al., 2018). The number of children of the caregivers determines the experience of the caregivers on complementary feeding due to experience on previous infant feeding practices (Shumey et al., 2013).

The socio-economic status (caregivers’ educational level and income) is also an underlying determinant of complementary feeding practices.

Knowledge and attitudes of the caregivers on complementary feeding are shown to have influence on the caregivers feeding practices which in turn determine the

nutritional status of the infants.

The knowledge or the understanding of the caregivers on dietary diversity, meal frequency, meal consistency, responsive feeding and hygiene practices determines the adequate complementary feeding practices of the caregiver.

The attitude of the caregivers on timely introduction of complementary feeding, meal consistency, continued breastfeeding, dietary diversity, feeding frequency, responsive feeding and hygiene practices of the caregivers to feed the infant minimally and acceptably depends on the knowledge acquired by the caregivers. The action could be positive or negative depending on the level of knowledge acquired by the caregivers.  Complementary feeding practices of the caregivers are the determinants of the

infant’s nutrition status.

 

 

 

EFFECT OF NUTRITION EDUCATION ON COMPLEMENTARY FEEDING PRACTICES AND NUTRITION STATUS OF INFANTS: A CLUSTER RANDOMIZED-TRIAL IN ONDO STATE, NIGERIA

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