A Comparative Study of Complementary Feeding And

A COMPARATIVE STUDY OF COMPLEMENTARY FEEDING

AND NUTRITIONAL STATUS OF CHILDREN AGED 6-24

MONTHS IN A RURAL AND AN URBAN LGA OF LAGOS

STATE.

SUBMITTED BY

DR OLUWASEYI OMOTAYO OLUMODEJI

THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH

MAY 2015

DECLARATION

I hereby declare that this dissertation titled “A comparative study of complementary feeding and nutritional status of children aged 6-24 months in a rural and an urban LGA of Lagos state” was written by me under supervision. The dissertation has not been submitted in part or in full for any other examination.

______

DR OLUWASEYI OMOTAYO OLUMODEJI

Department of Community Health and Primary Health Care,

Lagos State University Teaching Hospital,

Ikeja – Lagos.

CERTIFICATION BY THE SUPERVISOR

This is to certify that this dissertation titled “A comparative study of complementary feeding and nutritional status of children aged 6-24 months in a rural and an urban LGA of Lagos state” was written by Dr

Oluwaseyi Omotayo Olumodeji of the Department of Community Health and Primary Health Care, Lagos

State University Teaching Hospital Ikeja, under my supervision.

______

PROFESSOR O.O ODUSANYA (MBBS, MPH, FMCPH)

Department of Community Health and Primary Health Care,

Lagos State University Teaching Hospital,

Ikeja Lagos.

CERTIFICATION BY THE HEAD OF DEPARTMENT

Health Care, Lagos State University Teaching Hospital Ikeja, under the supervision of Professor O.O

Odusanya.

______

DR YETUNDE KUYINU (MBBS, MPH, FMCPH)

Head of Department,

Department of Community Health and Primary Health Care,

Lagos State University Teaching Hospital,

Ikeja – Lagos.

ATTESTATION

This attestation declares that this dissertation titled “A comparative study of complementary feeding and nutritional status of children aged 6-24 months in a rural and an urban LGA of Lagos state” by

Dr Oluwaseyi Omotayo Olumodeji of the Department of Community Health and Primary Health

Care, Lagos State University Teaching Hospital Ikeja, was presented to the department on the 20th of January 2015 as required by the Faculty of Public Health of the National Postgraduate Medical

College of Nigeria.

______

DR OLAYINKA O GOODMAN

Residency Coordinator,

Department of Community Health and Primary Health Care,

Lagos State University Teaching Hospital

Ikeja – Lagos

______

DR YETUNDE KUYINU (MBBS, MPH, FMCPH)

Head of Department,

Department of Community Health and Primary Health Care,

Lagos State University Teaching Hospital,

Ikeja – Lagos.

DEDICATION

This dissertation titled “A comparative study of complementary feeding and nutritional status of children aged 6-24 months in a rural and an urban LGA of Lagos state” to God for His ever present help and my children who drew my attention to this area of study.

ACKNOWLEDGEMENTS

I am deeply grateful to God for life, good health, understanding, opportunities and a great family.

I appreciate my supervisor, Prof. O.O Odusanya for his attention and guidance through this work; I have indeed learnt a lot from him. I also thank all my teachers in the department of Community

Health and Primary Health Care, Lagos State University Teaching Hospital particularly Dr KO

Wright, Dr YA Kuyinu, Dr OO Goodman, Dr A Adeniran, Dr B. Bakare and Dr MR Akinyinka, for their support.

I appreciate Dr AS Mohammed of the Nigerian Navy and Dr Senbanjo IO of the department of

Paediatrics LASUTH for their time and for helping me to tackle the knotty areas. I acknowledge the research assistants for being painstaking, the respondents for bearing with me during the interviews and the residents in the department for their support.

My gratitude goes to my late dad (who I wish were here to see that I completed this); my mum for her gentle persistence; and my siblings: Olufunmilayo, Oluwabunmi, Olubukolami and Olumuyiwa for good experiences over the years.

I thank my crew: my earthly king - Adebayo for his encouragement and his ever increasing expectations of me which have spurred me on; my daughters who drew my attention to this area of study: Araoluwa for always praying for me to complete my project and Ooreoluwa for the hugs I get when she barges in on me at the times I hide to work. God bless and keep them.

TABLE OF CONTENTS

Title page i

Declaration ii

Certification by the Supervisor iii

Certification by the Head of Department iv

Attestation v

Dedication vi

Acknowledgements vii

Table of Contents viii

List of Tables xi

List of Figures xiii

List of Abbreviations xiv

Operational definition of terms xv

Abstract xvi

Chapter One: Introduction 1

1.1 Background 1

1.2 Problem statement 2

1.3 Justification of the study 6

1.4 Research questions 7

1.5 Aim and objectives 8

Chapter Two: Literature review 9

2.1 Recommendations of the WHO on child feeding 9

2.2 Knowledge of caregivers on child feeding 1 1

2.3 Child feeding practices 14

2.4 Child feeding index 28

2.5 Child’s nutritional status 30

2.6 Factors affecting child feeding and nutritional status 3 6

2.7 Differences in geo-political location 40

Chapter Three: Materials and methods 42

3.1 Description of study areas 42

3.2 Study design 4 5

3.3 Study population 45

3.4 Eligibility 4 5

3.5 Study components 45

3.6 Study duration 46

3.7 Sample size determination 46

3.8 Selection of study sites 4 7

3.9 Sampling methods 48

3.10 Study instruments 51

3.11 Conduct of the study 53

3.12 Data analysis and presentation 5 5

3.13 Ethical considerations 6 1

3.14 Limitations of the study 61

Chapter Four: Results 62

Demographic and socioeconomic characteristics 63

Knowledge of mothers on child feeding 70

Feeding practices 93

Nutritional status 129

Chapter Five: Discussion 152

5.1 Demographic and socioeconomic characteristics 152

5.2 Knowledge on breastfeeding and complementary feeding 154

5.3 Feeding practices 155

5.4 Nutritional status of children 160

5.5 Conclusion and recommendations 164

References 167

Appendices 184

I Sampling frames 184

II List of wards / settlements 185

III Questionnaire (English version) 1 90

IV Questionnaire (Yoruba version) 1 9 6

V Focus group discussion guide 202

Letter of approval from the Health Research and Ethics Committee

(HREC) LASUTH 203

Letter of approval from NPMCN 204

Letter of approval from the LGA 205

List of attendance at the dissertation departmental presentation 206

LIST OF TABLES

Number Title Page

Table 1 Demographic characteristics of respondents in the rural and urban areas. 63

Table 2 Socio-economic characteristics of respondents in the rural and urban areas 64

Table 3 Household characteristics in the rural and urban areas 66

Table 4 Maternal characteristics in the rural and urban areas 68

Table 5 Child characteristics in rural and urban areas 69

Table 6a Mothers with correct knowledge on breastfeeding in the rural and urban areas. 70

Table 6b Mothers with correct knowledge on complementary feeding in the rural and urban areas. 75

Table 7 Association between demographic characteristics and the level of knowledge of respondents 84

on child feeding.

Table 8 Association between family characteristics and the level of knowledge of respondents on 86

child feeding.

Table 9 Association between socioeconomic characteristics and the level of knowledge of 88

respondents on child feeding.

Table 10a Multinomial regression of factors associated with fair knowledge on child feeding. 91

Table 10b Multinomial regression of factors associated with good knowledge on child feeding. 92

Table 11 Breastfeeding practices of respondents in rural and urban areas. 93

Table 12 Complementary feeding practices of respondents in rural and urban areas 95

Table 13 Twenty four hour dietary diversity recall in the rural and urban areas 102

Table 14 Seven day food group frequency recall in the rural and urban areas 103

Table 15 Infant and young child feeding index and single practices scores in the rural and urban areas. 105

Table 16 Association between demographic characteristics and ICFI 113

Table 17 Association between family characteristics, knowledge and ICFI 115

Table 18 Association between socioeconomic characteristics and ICFI 117

Table 19 Factors associated with giving a baby colostrum 119

Table 20 Factors associated with exclusive breastfeeding. 121

Table 21 Factors associated with dietary diversity 123

Table 22 Factors associated with food group frequency 125

Table 23a Multinomial regression of factors associated with fair practice 127

Table 23b Multinomial regression of factors associated with good practice 128

Table 24 Nutritional status of children in rural and urban areas. 129

Table 25 Proportion of children with single and multiple malnutrition. 130

Table 26 Association between socio-demographic characteristics and Wasting 131

Table 27 Association between family characteristics, knowledge and Wasting 133

Table 28 Association between feeding practices and Wasting 135

Table 29 Logistic regression of factors associated with Wasting 137

Table 30 Association between socio-demographic characteristics and Stunting 138

Table 31 Association between family characteristics, knowledge and Stunting 140

Table 32 Association between feeding practices and Stunting 142

Table 33 Logistic regression of factors associated with Stunting. 144

Table 34 Association between socio-demographic characteristics and Underweight 145

Table 35 Association between family characteristics, knowledge and Underweight 147

Table 36 Association between feeding practices and Underweight 149

Table 37 Logistic regression of factors associated with being Underweight. 15

LIST OF FIGURES

Number Title Page

I Knowledge grade of mothers in both communities 83

II ICFI grades of mothers in the rural and urban areas 106

LIST OF ABBREVIATIONS

CF - Complementary Feeding

FGD - Focus Group Discussion

HAZ - Height-for-age Z scores

ICFI - Infant and young Child Feeding Index

IQ - Intelligence Quotient

LGA - Local Government Area

MDGs - Millennium Development Goals

MGRS - Multicenter Growth Reference Study

NCHS - National Centre for Health Statistics

UNICEF - United Nations Children’s Fund

WAZ - Weight-for-age Z scores

WHZ - Weight-for-Height Z scores

WHO - World Health Organization

Operational definition of terms

Exclusive breastfeeding: Exclusive breastfeeding is giving no other food or drink, not even water except breast milk (including milk expressed or from a wet nurse) for the first 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines).

Complementary feeding: Complementary feeding is the introduction at six months of other foods appropriate for sustaining the growth and development of a child who has been exclusively breastfed and who continues to receive breast milk up to two years and beyond.

Complementary feed: A complementary feed is any food given, which may be specially prepared for the child, or family diet adapted to the eating needs and skills of the infant.

Snacks: Snacks are defined as foods eaten between meals-usually self-fed, convenient and easy to prepare.

ABSTRACT

Background: Globally, the peak of under nutrition coincides with the timing of introduction of complementary feeds. This study assessed and compared the knowledge and practices of mothers on child feeding; and the nutritional status of children aged 6-24 months in a rural

(Badagry) and an urban (Surulere) LGA of Lagos state.

Materials and methods: A community based, analytical cross-sectional study was conducted between July and September 2014, using quantitative and qualitative methods. Mothers (496) with children aged 6-24 months were selected by a four-stage sampling. Knowledge and practice were graded (poor, fair and good). Wasting, stunting and underweight proportions were determined. Analysis was done using SPSS 22; multivariate analysis was done on factors that were significant on bivariate analysis. Six sessions of Focus Group Discussions were conducted among mothers, fathers and healthcare workers.

Results: The majority [205 (82.7 % - rural) and 231 (93.1%)] knew the meal frequency for a 6-

8 month old (p<0.001). Good knowledge was higher among urban [197 (79%)] than rural mothers [183 (74%)] (p=0.321). Exclusive breastfeeding was practiced by more rural (86.7%) than urban (80.6%) mothers; age appropriate breastfeeding was higher in the rural (72%) than the urban (59%, p=0.002); and 124 (50%) urban children and 103 (42%) in the rural (p=0.020) had good ICFI scores. More rural children [96 (39%)) had any malnutrition than urban [77

(31%)]. Stunting and underweight rates were higher in the rural area than urban (p=0.008).

Younger age of mother was a predictor of good knowledge (p=0.016) and lower monthly income was a predictor of good practice (p<0.001) in the rural area. Having a child in the 6-8 month age group was found as a predictor of good practice in both areas (p<0.001). Males were more underweight (p= 0.020) in the urban.

Conclusion: The majority of mothers had good knowledge on child feeding. Only about half had good child feeding practices in both areas. Higher proportions of malnutrition were found in the rural area. Good feeding practices should be maintained as the children get older and as income increases. These are hoped to reduce the under nutrition rates.

Chapter One INTRODUCTION 1.1. Background

Adequate nutrition during infancy and early childhood is fundamental to the development of the child’s full potential because the period from birth to two years of age has been recognised as a “critical window” for the promotion of optimal growth, health and behavioural development.1 Infants and children need to be fed appropriately in order to achieve and maintain adequate nutrition, good health and development. This promotes growth, prevents stunting and increases the child’s chances for a healthy and productive life. Good nutrition has been shown to determine the intellectual and technical capacity of any population.2,3

Complementary feeding, as defined by the World Health organisation (WHO) is the introduction at six months of other foods appropriate for sustaining the growth and development of a child who has been exclusively breastfed and who continues to receive breast milk up to two years and beyond.1 The target age range is generally taken to be 6-24 months of age. The process starts when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, therefore other foods and liquids are needed.1 A complementary feed is any food given, which may be specially prepared for the child, or family diet adapted to the eating needs and skills of the infant.4

Exclusive breastfeeding has been said to ease the transition to complementary feeding because breast fed infants have been noted to easily accept new food than non-breast fed infants as the breast fed infant is exposed to different flavours and scents early from maternal diets.5 Even with optimum breastfeeding, children become stunted when they do not receive sufficient quantities of quality complementary foods by 6 months of age.5-7 The WHO and

UNICEF jointly developed the global strategy for infant and young child feeding to draw attention to the impact that feeding practices have on the nutritional status, growth and

17 development, health, and the survival of infants and young children. It is based on the evidence of the significance of nutrition in the early months and years of life, and of the crucial role that appropriate feeding practices play in achieving optimal health outcomes.8

Lack of breastfeeding and especially lack of exclusive breastfeeding during the first half-year of life – are important risk factors for infant and childhood morbidity and mortality.

These are compounded by inappropriate complementary feeding. The impact of poor nutrition is long lasting and may include poor school performance, reduced productivity, and social development. In addition, good nutrition will help to reduce the burden of diarrhoeal disease, measles, malaria and lower respiratory infections in childhood that are attributable to under nutrition and contribute to a lasting reduction in poverty and deprivation.8 Due to these, the promotion, protection and support of breastfeeding; and good complementary feeding practices have emerged as public health priorities.

1.2. PROBLEM STATEMENT

1.2.1. The burden of malnutrition.

Globally, malnutrition is a major public health problem with about 165 million children under-five suffering from malnutrition and half of all under-five deaths being associated with poor nutrition.9 The burden is worse in many parts of the developing world and sub Saharan Africa has a quarter (25%) of children under five being underweight, 43% stunted and11% wasted. 10

In Nigeria, malnutrition has been identified as a major cause of death and a contributory factor to the infant and under - five mortality rates. The Nigeria Demographic and

Health Survey (NDHS) in 2013 estimated the prevalence rates of the different kinds of malnutrition among children under-five to be 37% (stunting), 29% (underweight), and 18%

(wasting).11 Stunting was found to be more common in rural areas (43%) than urban areas

(26%) and it differed between the zones: being lowest (16%) in the South East zone and highest (55%) in North West zone. In the South west zone, the prevalence of stunting was

22%. Comparing these rates with those obtained from the previous NDHS (2008), proportion of children who were stunted had reduced by 4%; however, wasting and underweight proportions had increased by 4% and 6% respectively.11, 12 A comparative study between upland and riverine areas of an urban LGA in Lagos in 2000, showed the prevalence of stunting, wasting and underweight among 240 children to be 16%, 3%, and 14%, respectively for the upland area; and 30.0%, 2%, 18%, respectively for the riverine area.13 Though the prevalence of stunting obtained in the riverine area was similar to the findings from the NDHS

2013, it was lower (by half) in the upland area.

With respect to mortality globally, malnutrition has been responsible, directly or indirectly, for 60% of the 11 million deaths annually among children under five.14-16 More than two-thirds of these deaths, are associated with inappropriate feeding practices and are among the most serious challenges that face this age group.8 About 52% of childhood deaths are attributed to the effect of malnutrition on disease and 21% of infant deaths are said to result from poor feeding practices.10,17 The effects of poor nutrition in the first two years of life continue into adulthood resulting in reduced productivity, impaired intellectual and social development, faltered growth, disease, compromised educational achievement, reduced adult size and low economic productivity.18,19 The morbidity from malnutrition far outweighs the mortality as the total health burden due to under-nutrition is 50% to 70% of the burden of diarrheal diseases, measles, malaria, and lower respiratory infections.20

Maternal malnutrition and inappropriate breastfeeding and complementary feeding are huge risks to the health and development of children who survive. Over 50 million children are wasted, and in low-income countries, one in every three children are stunted by the age of five years, two in five children are small for their ages; half of those undernourished are severely

19 stunted and almost one-quarter of all Nigerian children are underweight.12, 18About 66% of

Nigerians live in poverty and Nigeria is among the top 20 countries in which 40% of under five are chronically malnourished and the average national Intelligence Quotient (IQ) has been reduced by 10–15%.10 A new born in Nigeria has a 30 times higher chance of dying before the age of 5 years than a new born in a developed country.15 The 2006 World Bank report on

Nigeria stated that the country was neglecting the health of future generations with the poor nutrition of its children in spite of its vast natural and human resources.21

1.2.2. Problems with complementary feeding

The period of giving complementary feeds is one of vulnerability because at this period; the child is getting bigger and gaining milestones. Milestones such as crawling and creeping enable him to explore his environment more. At this stage, the child is at greatest risk of a decline in nutritional status and growth retardation because there is a reduced nutrient intake, an increased exposure to environmental pathogens and less intimate maternal/ infant contact.2 The challenge of feeding the child grows and mothers realise it but the knowledge and skills required to meet this challenge are inadequate. Yet, it is at this stage that food preferences are established which have an effect on the child’s health later in life.22,23

In many developing countries, children are breastfed but poor feeding practices translate to adverse health outcomes in children. The food given is often over cooked, over spiced, not easily digestible with adult feeding frequencies and wrong technique. These are complicated by poor cultural practices, beliefs and taboos that prevent mothers from feeding their children beneficial foods.24-26 Complementary feeding is wrongly perceived by many mothers to be the introduction of other foods and cessation of breastfeeding. Thus, the incidence of malnutrition which rises between 6-8 months of age coincides with the period of introduction of complementary feeds -leading to an increased risk of child mortality.16,27

The 2013 NDHS found that in spite of the fact that almost all children (98%) were breastfed, the median duration of exclusive breastfeeding found was 0.5 months, the median duration of predominant breastfeeding was 4.4 months, the median duration of any breastfeeding was 18.3 months and only 17% were exclusively breastfed. In addition, the proportion of children less than six months who received complementary foods was 23%, and

67% of children aged 6-9 months received complementary feeds alongside breast milk.11 These show that in spite of the fact that the majority of mothers breastfed their babies, their practices regarding breastfeeding and complementary feeding are poor. These poor practices often compromise the nutritional status of children.

Food scarcity is not solely responsible for malnutrition as evidenced by the children in food secure environments and non-poor families who are malnourished. Thus food availability alone is not a solution.25 Poor maternal knowledge, poor food choices and inappropriate caring practices intensified by social and economic changes worsen the situation.14, 28 There has been progress in the implementation of interventions to improve breastfeeding practices with many health facilities having adopted the baby friendly hospital initiative. Clear recommendations and guidelines with political commitment have enabled many governments to establish programs that help to protect, promote, and support breastfeeding. However, similar progress has not been made in the area of complementary feeding. Though research has contributed to an evidence base for which recommendations on appropriate feeding for children more than six months of age have been made, translation of the knowledge to practice has lagged behind.

Complementary feeding is a pitfall for most mothers and they have poor knowledge on complementary feeding. A study in India in 2008, among 500 mothers with children under two years found that 62% and 90% of the mothers did not have adequate knowledge about the appropriate amount and frequency of complementary feeds respectively; and their source of information were family members (78%) and doctors (23%).29 In Northern Nigeria in 2013, the

21 major source of information about complementary feeding were friends and relatives (61%), health workers (30%) and the media (9%).30Having family and relatives as the major source of information will keep the cycle of poor feeding practices going.

1.3. JUSTIFICATION

No child can escape complementary feeding because it is necessary to achieve full potential. Empowerment of women with better knowledge and the use of local foods will reduce the challenges of complementary feeding and malnutrition. In this light, tackling the problem is necessary. Many studies have been done on the effect of practices such as breastfeeding, time of introduction and texture of food, and single foods and nutrients on the nutritional status of children; however, there is a need to add to the body of knowledge on the synergistic effect of practices on nutritional outcomes.31, 32In order to achieve appropriate complementary feeding, there is a need for accurate information and skilled support from the family, the community and the healthcare system.The comparison between rural and urban areas hopes to identify differences if any in the rural and urban areas and identify factors that are specific to their locations that influence their practices; and the relationships of these factors will be examined.

This study hopes to determine the knowledge of mothers on complementary feeding and assess complementary feeding practices in rural and urban areas. The results from this study may be useful to clinicians and health educators, policy makers and other stakeholders in detecting possible areas for planning of intervention in order to improve complementary feeding practices among mothers in Lagos State. Such intervention will lead to a resultant reduction in child morbidity and mortality to achieve the 4th Millennium Development Goal.

The results may also help to ease the planning of directed nutritional intervention to overcome the barriers to good complementary feeding.

1.4. RESEARCH QUESTIONS a) What are the levels of knowledge of child feeding (breastfeeding and complementary feeding) among caregivers in the rural and urban communities? b) What are the feeding practices of caregivers in the rural and urban communities? c) What are the prevalence rates of under nutrition in the rural and urban communities? d) What are the factors that influence the knowledge and practices of caregivers on complementary feeding and the nutritional status of children aged 6-24 months in the rural and urban communities?

1.5. AIM AND OBJECTIVES

1.5.1. AIM

To compare caregivers’ level of knowledge and practice of complementary feeding; and the nutritional status of children aged 6-24 months in a rural (Badagry) and an urban (Surulere) community in Lagos state.

1.5.2. OBJECTIVES

1. To assess the level of knowledge of complementary feeding among caregivers in

Badagry and Surulere communities of Lagos state.

2. To assess complementary feeding practices of caregivers in Badagry and Surulere

communities of Lagos state.

3. To determine nutritional status of children aged 6-24 months in Badagry and Surulere

communities of Lagos state.

4. To identify factors influencing caregivers’ knowledge and practice of complementary

feeding and the nutritional status of children aged 6-24 months in Badagry and Surulere

communities of Lagos state.

Chapter Two

LITERATURE REVIEW 2.1. Recommendations of the World Health Organisation on Complementary feeding Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants and globally, the public health recommendation is that infants should be exclusively breastfed for the first six months of life to achieve this. Thereafter, in order to meet their evolving nutritional requirements, nutritionally adequate and safe complementary feeding, with continued breastfeeding for up to two years of age or beyond is recommended.1, 8

Infants are particularly vulnerable during the transition period when complementary feeding begins.

Complementary feeding is a continuum from exclusive breastfeeding to complete adaptation to the family diet and it has various dimensions which include: type, quality, texture, nutrient density, frequency of feeding and diversity of diet.33 Evidence has shown that the benefits of introduction of complementary feeds at six months far outweighs any possible benefit of an earlier introduction; because at six months of age, breast milk alone is inadequate nutritionally and neurologically. It is at this stage that they attain milestones such as chewing, swallowing, digestion and excretion which are required to enable them take feeds.5

Complementary feeding practices influence the development of the child and his lifelong eating habits. Taste preferences are formed early and the content and manner of eating may establish lifelong cravings for energy dense but nutrient poor food and drinks.34

Complementary feeds should be: timely:- introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding; adequate: provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs; and safe: hygienically stored, prepared, and fed with clean hands using clean utensils and not bottles and teats; properly given (paying attention to a child’s signals of

25 appetite and satiety, and bearing in mind adequate meal frequency and feeding methods); actively encouraging the child, even during illness, to consume sufficient food using fingers, spoon or self-feeding.

The World Health Organisation’s guiding principles for complementary feeding of the breastfed child include: practicing exclusive breastfeeding from birth to six months of age; introducing complementary foods at six months of age (180 days) while continuing frequent, on-demand breastfeeding until two years of age or beyond; practicing responsive feeding.

These principles further recommend: a) feeding infants directly and assisting older children when they feed themselves, being sensitive to their hunger and satiety cues; b) feeding slowly and patiently, and encouraging children to eat, without forcing them; c) where children refuse many foods, experimenting with different food combinations, tastes, textures and methods of encouragement; d) minimizing distractions during meals if the child loses interest easily; e) remembering that feeding times are periods of learning and love talk to children during feeding, with eye to eye contact; f) Practicing good hygiene and proper food handling by i) washing caregivers’ and children’s hands before food preparation and eating, ii) storing foods safely and serving foods immediately after preparation, iii) using clean utensils to prepare and serve food, iv) using clean cups and bowls when feeding children, and v) avoiding the use of feeding bottles, which are difficult to keep clean; g) Starting at six months of age with small amounts of food and increasing the quantity as the child gets older, while maintaining frequent breastfeeding are important.

The energy needs from complementary foods for infants with “average” breast milk intake in developing countries are approximately 200 Kcal per day at 6-8 months of age, 300

Kcal per day at 9-11 months of age, and 550 Kcal per day at 12-23 months of age. A gradual increase of food consistency and variety as the infant gets older, while adapting to the infant’s requirements and abilities are essential. By eight months most infants can also eat “finger

26 foods” (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). However, foods that may cause choking should be avoided. (i.e., items whose shape and/or consistency may cause them to become lodged in the trachea, such as nuts, grapes, raw carrots)

The number of times that a child is fed complementary foods should be increased as he/she gets older. The appropriate number of feeding depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy breastfed infant, complementary foods should be provided 2-3 times per day at 6-8 months of age and 3-

4 times per day at 9-11 and 12-24 months of age, with additional nutritious snacks offered 1-2 times per day, as desired.

It is essential to feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vitamin A-rich fruits and vegetables should be eaten daily. Diets with adequate fat content should be provided and drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda should be avoided.

The amount of juice offered should be reduced to avoid displacing more nutrient rich foods;

Using fortified complementary foods or vitamin-mineral supplements for the infant as needed.

In some populations, breastfeeding mothers may also need vitamin-mineral supplements or fortified products and, Increasing fluid intake during illness to make up for possible losses.

These recommendations are aimed at increasing energy intake.1,2

2.2. Knowledge of caregivers on child feeding

It has been shown that the knowledge of a woman on child feeding affects her practice and is influenced by her social network.35 This is particularly important when the mothers are experiencing some difficulties in breastfeeding. In a study in the United States in 2004, the

27 provision of breastfeeding education and counselling was found to be associated with higher breastfeeding initiation and continuation up to three months. 36 Knowledge, intention and self- confidence were found to affect breastfeeding duration in another study in the US in 2003, and in 2008, another study revealed that having fewer friends and relatives who had breastfed their own babies were associated with an early termination of breastfeeding.37,38 A lack of knowledge of grandmothers about breastfeeding was found to have an effect on mothers’ practice in another study in 2008.39 Further in the same year, a lack of knowledge amongst healthcare workers was found to endanger successful initiation of breastfeeding among mothers; while another study in 2011 showed that improving health care professionals’ knowledge resulted in an increase in breastfeeding initiation rates.40, 41

In Italy in 2009, a study amongst mothers found that, a lack of knowledge on the advantages of breastfeeding resulted in an earlier introduction of complementary feeds and an earlier discontinuation of breastfeeding.42 This is in contrast with the findings from a study in

Jamaica in 2004 that showed that there was no difference in knowledge of those mothers who practiced exclusive breastfeeding, and those who did not.43 However in Bolivia in 2006, a study showed that the men had better knowledge about the duration of exclusive breastfeeding

(six months) than the women. However women had better knowledge about the time of initiation of breastfeeding than the men.35 A study in India in 2008 that aimed at assessing the level of knowledge of mothers on complementary feeding found that 46% of the mothers had knowledge on the proper timing of introduction of meals, 47% knew the adequate quantity and

26% knew the recommended consistency but only 8% of the mothers had proper knowledge on all three.44

In another study in India in 2008, where 500 mothers with children under two years were recruited by purposive sampling from paediatric clinic, the major sources of information about complementary feeding were family members (78%) and doctors (23%); the knowledge

28 of mothers regarding complementary feeding was found to be adequate as 74% and 72% knew the time to start and the quality of complementary feeds to give respectively. However, 62% and 90% of the mothers did not have adequate knowledge as they did not know the appropriate amount and frequency respectively.29

In rural China in 2008, 90% of mothers had good knowledge that breast milk is the best food for the baby.45 A study in Tanzania in 2001 found that mothers in urban areas had better knowledge about breastfeeding practices and feeding practices than those in the rural areas. This was accrued to their uptake of antenatal care services. About 85% and 65% of the mothers in the rural and urban areas respectively believed that water should be given to the new born just after delivery while 84% believed that breastfeeding had to be stopped as soon as one became pregnant so as not to harm the baby.46 Rural-urban differences affect the knowledge and practices of mothers. Generally in the urban areas, there are more hospitals and more mothers have contact with these ; there, information is given on child feeding. However, traditional practices (which may be inappropriate) abound in the rural areas.

In a descriptive study in Uganda in 2008; aimed at assessing the perception and knowledge of mothers on breastfeeding, it was found that about three quarters of the women

(74%) had good knowledge about the duration of complementary feeds and 55% knew that its major advantage was to improve nutrition among children.47 However, this study was among mothers attending follow up clinics and may not be a reflection of the level of knowledge of mothers in Uganda because those attending clinic have more access to health information than the general population.

In a study in Northern Nigeria in 2013, the major source of information about complementary feeding were friends and relatives in 61%, health workers in 30% and the media in 9%.30A prospective study among a cohort of 228 mother-neonate pairs in Anambra

State between 2006 and 2007, more than half (54%) of mothers had good knowledge of exclusive breastfeeding (EBF) and 37% had very good knowledge. Most of the mothers knew what EBF means and mentioned disease prevention and healthy growth as its advantages.48

This cohort was recruited from the welfare clinics where they present for BCG immunization.

In Ekiti State in 2010, a study on the nutritional knowledge of the mothers towards breastfeeding found that 78% of the mothers knew that breast milk was better than infant formula and almost all the mothers (99%) were aware of the immune boosting properties of human breast milk. About 85% of the women agreed that breast milk alone is enough for infants aged 0-6months; and 28% correctly identified that breast milk alone would be inadequate for a baby aged 7-12 months, while 30% were not sure.49 A study conducted in

Igbo- Ora, Oyo State in 2002 found that more than half of the women had never heard about exclusive breastfeeding, and only 8% of them knew any mother who was practicing it.50

However, another study in Ibadan Oyo state in 2009, found that 77% of mothers had correct knowledge on EBF but only 68% practiced it.51

2.3. CHILD FEEDING PRACTICES 2.3.1. Breastfeeding Breast milk is the best food for young children. It contains a perfect balance of nutrients which promote optimal growth and development, are easy to digest and protect against illness. Babies do not need water or other drinks or foods during the first six months.

Even in hot, dry climates, breast milk fully meets a baby’s fluid needs and it has been reported as the most common source of Vitamin A and fats.2,52

Breastfeeding has been said to reduce under 5’s death by 13%. Initiation of breastfeeding is near universal; however, about two thirds of mothers do not initiate it in the first hour of childbirth as recommended by the WHO.53 Globally, only 35% of infants are exclusively breastfed and in Nigeria, the practice of optimal and exclusive breastfeeding for the

30 first six months of life is still as low as 17%.8, 11 Inadequate milk secretion is a major reason why many mothers do not breast feed in the first two days. They may also be influenced by the cultural norms from elders in the family. However, breastfeeding problems should be managed and not be a reason for an unnecessarily early introduction of complementary feeds.25

Studies in the US and Canada in 2007 and 2008 respectively found that 85% of the children were breastfed at one point or the other in their lives.54, 55 The United Kingdom and

France in 2007 and 2006 had lower rates of 70% and 64% respectively.56, 57 Similar rates were also found in the study in Tanzania in 2001 where about 81% and 61% of the women in the urban and rural areas respectively had ever breastfed their children.46 In Hyderabad India in

2010,a study found the exclusive breast feeding rate at birth of 68%. This dropped to 39%,

28%, and 8%, at 2, 4, and 6 months respectively.29 Almost all (99%) in Sweden in 2009 and

Brazil in 2001 breastfeed their babies.58, 59

A study in Tucson Arizona in 1993 showed that ear infection was lowered by about

40% in babies exclusively breastfed for at least four months than those that were not.60 In

2002, a study on child feeding and nutritional status using seven data sets from five Latin

American countries showed that a range of 69-93% of the mothers still breastfed their infants in the 6-9 month age group. This dropped to a range of 24-53% in the older age group category of children 12-36 months. In Colombia and Nicaragua, about 70% of mothers breastfed their children.32 The majority (95%) of mothers in three rural villages in Malaysia gave breast milk to their infants but the duration of breastfeeding and exclusive breastfeeding was low. This was found to be due to change in culture by invasion of modern practices. Mothers / mothers-in- law, friends and peers, the media and health workers were found to have a strong influence on infant feeding practices.61

In the developing countries, the risk of an infant dying from diarrhoea is five times in the non-breastfed and two times in the not exclusively breastfed when compared with the exclusively breastfed infant.62 A cross-sectional study among 259 children attending an urban hospital in Bangladesh in 2011 found that 89% of the children were breastfed the previous day before the survey.27 In China in 2010, exclusive breastfeeding rates were 24% in rural and 52% in urban areas. This is different from the results of another study that assessed the feeding practices amongst children 0-24 months in 105 counties of rural China in 2005 that showed a

98% breast feeding rate.63,64 A study in India showed that the majority of grandmothers believed that initiation of breastfeeding need not occur immediately after birth.65 In Africa,

Kenya reported an exclusive breastfeeding rate of 13% at 6months, with Ghana having a much higher rate of 53%.66,67

In Nigeria, any breastfeeding is almost universal (98%). However, exclusive breastfeeding rates are low. The 2013 NDHS found an exclusive breastfeeding (EBF) rate of

17%; however, 98% of children under the age of 5 years had been breastfed at one time or the other in their lives.11 In a prospective study among mothers aimed at identifying factors influencing EBF in Anambra State in 2011, an EBF rate at 6 months of 37% was documented.48 This rate was higher than the EBF rate of the NDHS; however, the fact that the children in the Anambra State study were recruited from welfare clinics may have been responsible for the rates.

A longitudinal study among mothers recruited during pregnancy at Jos University

Teaching Hospital in 2007 corroborates this fact: in that study, 471 mothers intending to breastfeed, and their children were followed up for six months. About 95% of all mothers exclusively breastfed their babies for six months. Among the employed mothers, 93% of them exclusively breastfed their babies till six months in spite of resumption of work after three months on maternity leave. No significant differences were found in the breastfeeding rates

32 across the socioeconomic classes.68 This study shows that counselling and adequate support throughout the period of breastfeeding helps in achieving exclusive breastfeeding till six months irrespective of barriers such as resumption of work after maternity leave and social status.

Exclusive breastfeeding rate in Ondo state in 2012 was found to be 99%;69 and an

88% breast feeding rate was found in a study in Nasarawa in 2010.70 In Igbo Ora, a rural community in Oyo state in 2002, all the women (100%) had breast fed their children at some point or the other. This is similar to the findings from the study in Ile-Ife in 2010 among 423 mother-child pairs selected by multistage sampling from four local governments where nearly all (99.5%) of the children had been breastfed with 81% being exclusively breastfed. 50,71 In contrast to these high rates, a community based cross sectional study in a rural community in

Oyo state in 2013 found that only 10.2% of the mothers practised exclusive breastfeeding for six months.72

In Ilesa in 2005, a study aimed at assessing the impact of the ‘Baby Friendly Hospital

Initiative’ on breastfeeding practices of mothers showed that having had contact with a hospital with BHI influenced the initiation of breastfeeding within an hour of birth, non-use of pre- lacteal feeds, and exclusive breastfeeding for 6 months.73 However, this study was a cross sectional study among mothers in the paediatric outpatient clinic in a “Baby friendly” designated hospital and the results may not have been generalizable to all the women. In a study in two LGA in Lagos in 2010, the majority (92%) of respondents breastfed their babies and 53% exclusively breastfed their children for six months.74 Another study in three LGA in

Lagos in 2006 found that 52% of the children were exclusively breastfed for six months.75

2.3.2. Colostrum and pre-lacteal feeds

Pre-lacteal feeds are feeds given to babies before the initiation of breast milk and they include water, other liquids and ritual foods.2 A study in India in 2007 showed that a third of the mothers gave pre-lacteal feeds such as glucose, honey and local medicines. Colostrum was expressed and discarded based on cultural beliefs that it is stale and bad for the baby and could cause diarrhoea.25 In a cohort study in Bangladesh in 2008, 92% of mothers gave their babies colostrum, 8% gave pre-lacteal feeds (water, honey, sugar and glucose). Almost all (99% and

92%) were breastfed at one month and 12 months respectively. Of the 78% that were exclusively breastfed at one month, only 11% continued till 6months.76 In a study in India in

2010, 31% mothers gave the history of use of pre-lacteal feeds.29 A study in 2008 to determine breast feeding practices amongst mothers in Nigeria and Ghana, found similar use of pre- lacteal feeds of about 30%.77

A study in Nasarawa state in 2012 found that a large proportion of mothers (73%) gave their babies colostrum. The reasons given by those who did not were that their babies refused to suck it; that it is dirty; that it had a poor flow, and that it causes diarrhoea.78 In

Sabon Gari Kaduna state in 2011, a study aimed at assessing feeding practices and the nutritional status of infants among a random selection of 100 mothers in the clinic found that only 10% of the mothers fed their babies colostrum.79 Another study in urban areas in northern

Nigeria in 2013 found that 42% of mothers did not give colostrum because they saw it as dirty and 25% did not give it because it had a poor flow.30 In Anambra state, a prospective study in a tertiary hospital in 2006/2007 found that 83% of mothers gave colostrum to their babies while pre-lacteal feeds in form of glucose water was given in 26% of the respondents.48

2.3.3. Bottle Feeding

Bottle use is discouraged in child feeding. Feeding an infant from a bottle, whatever the content, including expressed breast milk, water, formula is not acceptable. Infants who are unable to feed directly from the mother’s breast should be fed breast milk using a cup and spoon. And where the baby is unable to swallow, breast milk can be provided by means of a feeding tube. After six months of age, other liquids given should be fed by cup rather than by bottle. Feeding bottles with artificial nipples and pacifiers (teats or dummies) may cause nipple confusion and infants may refuse to breast feed after their use. Also, feeding bottles are more difficult to keep clean than cups, and the ingestion of pathogens can lead to illness and even death.80

In a study using seven datasets from five Latin American countries in 2002, bottle use in the 6-9 month age group ranged from 35-81%. This remained high (35-75%) among children in the 12-36 month age group. In two of the five countries (Colombia and Nicaragua), more than 75% of mothers fed their babies using bottles.32 Thirty two percent of children in a study in Bangladesh in 2011 were bottle-fed at the time of interview, and bottle feeding was found to be higher among educated mothers as mothers took it as a modern practice.27 In a study in India, the prevalence of bottle use as a feeding practice of the mothers was 23%.81

In a longitudinal study among mothers recruited during pregnancy at Jos University

Teaching Hospital in 2007, 471 mothers intending to breastfeed, met the criteria and they were followed up for six months. Among mothers who exclusively breastfed their babies, 11% of mothers in business used the bottle to feed their babies breast milk while 22% of “student mothers” used the bottle to feed their children breast milk. Among mothers who did not exclusively breastfeed their babies, bottle use was as high as 56%.68 In spite of the fact that these mothers were counselled and given adequate support on breastfeeding and the use of cup

35 and spoon, they still used the bottle to breastfeed. This high use was because it was seen as an elitist practice because in this study, it was practiced among students who were mothers and mothers in business.

In a study in three LGAs in Lagos in 2006, where the relationship between child feeding practices and dental caries was being sought, complementary foods were given using the bottle exclusively in 43% of the children, while 10% used both the bottle and a cup and spoon.13 Bottle use was high in this study probably because the mothers were living in Lagos where bottle use is being seen as an elitist practice.

2.3.4. Time of introduction of Complementary feeds

The age of introduction of complementary feeds depends on biological, cultural, social and economic factors. It is also determined by the time that growth faltering occurs while on exclusive breastfeeding. A world consensus was reached based on evidence which showed that the benefits of introduction of complementary feeds at six months far outweighs any possible benefit of an earlier introduction; and it is by six months that breast milk alone is inadequate nutritionally and neurologically.82

Studies in the United States of America, Peru, Honduras, and Thailand showed that the introduction of feeds earlier than six months does not result in an increase in caloric intake because it has a negative impact on breast feeding and most foods are not as high as breast milk in nutritional value. Prolonged breastfeeding and delayed introduction of complementary feeds were found to increase the risk of micronutrient deficiencies and malnutrition.

(Micronutrient deficiencies result because human milk is low in Iron and Zinc)62

A longitudinal study in the UK in 2009 to assess the dietary intake and feeding difficulties at seven years of age of children who had been introduced to complementary feeds

36 at different times found that 12% were introduced before six months; 70% between six and nine months and 18% were introduced after nine months. Children introduced to solids after nine months of age were found to eat less of many of the food groups offered at seven years.83

In India in 2007, a study showed that 25% of mothers exclusively breastfed their babies and the mean age of introduction of complementary feeds was 5 months. A commercial cereal was introduced which was thought to make babies stronger.25 In a study in Bangladesh in 2008, complementary feeds were given to 2% at one month of life, 67% at six months and 95 % at nine months. About 4%, 76% and 97%of the babies had water at one, six, and nine months respectively.76 Another study in Bangladesh in 2012 showed that only 62% of children 6-9 months received complementary feeds while breastfeeding.84

In India in 2008, a study amongst children 6-24 months found that 18% of the children received complementary feeds at six months, 4% of mothers started at the proper time and only 4% of the mothers who started at six months also fed the adequate quantity and proper consistency, with the mean age of commencement being 13 months.44 Also, a study in

Hyderabad India in 2008 found that about 20% of the mothers of infants 2-3 months fed them complementary feeds in the 24 hours preceding the survey, while 19% of children aged 6-8 months were still being exclusively breastfed.29 Another study in India in 2011 found that 78% of mothers had started complementary feeding at the recommended time of six months but only 32% of them were giving the adequate quantity.85 In Ethiopia in 2009, about 40% of mothers introduced complementary feeds before six months; and maternal age, child age and keeping livestock were found to be responsible for the early introduction of complementary feeds.86

In a cross sectional study among 150 mothers with children aged nine weeks old or less in Limpopo, South Africa in 2005, only 5% were exclusively breastfed. About half of the children (43%) were being given infant formula and 37% were given complementary feeds.

Amongst those on complementary feeds at nine months, 91% of them had received complementary feeds before seven weeks of life.87 This was a cross sectional study, it was hospital based and the mothers were selected by convenience amongst those that visited the postnatal clinic; thus, the early introduction of feeds may be due to the study design. Other factors (which may be elicited by qualitative methods) may be responsible as many well mothers without any complaints after delivery tend not to go for post natal visits.

Over 50% of children in a community in eastern part of Nigeria in 2007 were found to be given complementary feeds too early;88 while amongst mothers in north western part in

2013, 20% of mothers introduced complementary feeds to their children at six months; 22.4% introduced complementary feeds before 4 months while 32% introduced complementary feeds after 7 months.30 A study in two communities in Nasarawa State where the predominant occupation is farming showed that 31% of the mothers with children 6-24 months introduced complementary feeds to their children at six months while 69% introduced complementary feeds earlier.78

A comparative study in rural and urban communities in Osun State in 2010 found that

37% of mothers introduced complementary feeds appropriately at six months.89 In Ile-Ife in

2010, non-human milk was introduced for some at five months and other complementary feeds

(asides infant formula) were introduced at eight months.71 In a study in Lagos in 2006, 48% had complementary feeds introduced between 4-6 months, 23% before four months and 29% after six months.75

2.3.5. Composition / Quality of complementary feeds

Improving the quality of complementary foods is one of the most cost effective strategies for improving health and reducing morbidity and mortality among young children. In developing countries, poor quality diets and infections are the leading causes of

38 malnutrition.14,90 Successful child feeding should include frequent consumption of meats, poultry, fish and eggs.91 There is evidence on the advantages of meat consumption and meats are a good alternative and adjunct for Iron and Zinc fortified cereals.92

Findings from a study in five Latin American countries in 2002 showed that more than 75% of mothers from richer countries (Colombia) fed their children with animal products when compared with those from poorer countries – 35% in Peru and 18% in Guatemala.32 In spite of the predominance of farming in settlements in Nasarawa, a study in 2012 showed that pap (alone and with bean cakes) was given in 31% and infant formula in 21%;78 while in a rural area in delta state in 2013, plain pap was the most commonly used infant weaning food

(23% ) followed by noodles (17%) and rice (13%).93 In Ile-Ife in 2010, a study showed that rice, yam flour and maize products were the most frequently fed meals (45%), followed by proteins (38%).71 An experimental study aimed at determining the efficacy of African breadfruit in the nutritional rehabilitation of children with protein energy malnutrition done in five semi-urban / rural communities in Ogun state in 2001, found that there was significant weight gain after three months of adding African breadfruit to the regular diets of those children three times weekly. African breadfruit contains 417 calories per 100g and protein of about 17.56 per 100g. More than 80% of the children gained weight and moved from varying degrees of malnutrition to normal weights for their ages.94

Certain food items such as meats, eggs, chicken and other nutritious proteins were regarded as taboos and non-beneficial for children and pregnant women. These foods were avoided yet they were the proteins with high biologic value from animal sources. In a cross sectional survey among 27 elderly people aged 60 years and above in Benin City, in 1974, the effect of food taboos were shown in the nutritional status of the men.26 Though this study has been done a long time ago, some of these taboos still hold water and the direct impact of the avoidance of these foods on the nutritional status of women and children needs to be measured.

In a comparative study between rural and urban women in Ile Ife in Osun state in

2012, a total of 384 women who had new complementary foods introduced to them during antenatal and postnatal clinics were assessed for their awareness, use and discontinuity of the foods. It was found that almost half ( 49%) of the respondents gave enriched pap as first food,32% gave plain pap, 15% gave special weaning foods and only 4% received foods such as yam flour (amala), steamed blended beans (moinmoin), bean cake (akara), and beans as their first foods. Plain pap was given in 57% of children in rural areas when compared to the urban where it was given in only 7%. Special weaning foods were mostly used in the urban areas

(27%) than the rural (3%). Tinned foods were the most commonly given foods in the urban area (78%) but in the rural area, yam flour (amala) and rice were given in 66% and 67% respectively. This study showed that awareness of local complementary feeds was low in both rural and urban areas. However, amongst those who were aware, adoption by mothers in the urban area was higher than in the rural area.95 The higher literacy of the mothers in the urban area may have been responsible for their adoption of the new foods.

2.3.6. Dietary diversity

Dietary diversity is the total number of foods consumed or the total number of food groups consumed in a given reference period.96 Asides breast milk, no single food item provides adequate nutritional requirements for an individual thus the need for a diverse diet.

Dietary diversity is a measure of dietary quality and is an important determinant of micronutrient status and a key element of high quality diets.90, 97The importance of a diverse diet cannot be overemphasised.

Eating a variety of foods helps meet humans’ need of essential nutrients. However, most poor populations consume starchy staples with only little or no animal products and seasonal fruits and vegetables.91 Children are particularly in need of a diverse diet; the most

40 vulnerable group being those in transition to family diet that is the 6-24 month age group.96

Incorporation of foods fortified with iron, Vitamin A and Iodine is encouraged. Feeds should be introduced one at a time – every three to seven days and an initial rejection by the infant does not mean a total aversion. Infants may need to be offered a new food eight to ten times before they accept it well.

A diverse diet is said to have the strongest association with anthropometric measures of nutritional status.98 However, currently, there are no specific recommendations regarding the optimal number of foods or food groups that a child should consume daily, but there is some consensus that a higher dietary diversity is desirable because it can help meet daily requirements for a variety of nutrients.32 Chinese children that consumed three or more food groups were found to have higher height for age scores than those who consumed fewer food groups in a study in 1993.99A study in Ghana to determine the relationship between dietary diversity and nutritional status found that higher dietary diversity scores resulted in better nutritional status.90

In Ebonyi state in 2012, a study among 360, rural, school age children that were selected by multistage sampling found that the children consumed monotonous cassava based diets mostly and less than 2% of them consumed animal proteins in the preceding 24 hours. In spite of the fact that the children claimed to eat a variety of fruits, a 24 hour dietary recall revealed that less than 5% of them actually consumed those fruits.100 The children were living in a predominantly farming population and may have consumed seasonal fruits which may not have been available at the time of the survey.

A comparative study between rural and urban communities in Osun state in 2010 found that cereals, roots and tubers were the most consumed meals and the processed ones were more commonly consumed in the urban than the rural setting. Consumption of protein

(both animal and plant) was particularly low- (<30%) with the exception of milk which was consumed in 50% of respondents. By age group, children aged 7-12 months consumed majorly from three food groups: cereals, animal protein, and roots and tubers. Consumption of plant protein was low. However, in the 13 - 18 month age group, cereals and animal proteins were the most consumed with less of roots/tubers and plant protein. Children aged 19 to 24 months were fed majorly from three food groups (cereals, animal protein, and roots and tubers) and less of plant proteins were consumed. In all, children (urban and rural) ate more cereals, roots and tubers, legumes, and animal protein groups. Fruits and vegetables were poorly consumed.

Of the 7-23% of children who had vegetables, less than two servings a week were given and this was more in urban than the rural community.91

2.3.7. Frequency of complementary feeds

The World Health Organisation recommends an Increase in complementary feeding frequency as the child grows, using a combination of meals and snacks- two to three meals per day for the 6- to 8-month-old infant, 3-4 times for the 9- to 11-month-old infants and 4-5 times for the 12- to 24-month-old children. The thickness and variety should also be increased with increasing age.2

In five Latin American countries in 2002, 71-93% of mothers gave their children aged

6-9 months complementary feeds two or more times in the last 24 hours. None of them gave more than 4 meals. However, between 32-89% of mothers with children aged 12-36 months gave them more than four complementary feeds in the preceding 24 hours. None of them gave the child less than two meals in the preceding 24 hours.32

A study in Malaysia to determine the relationship between child feeding knowledge and practice of mothers and the children’s growth status in 2008 found that 97% of the mothers continued breastfeeding, 33% of the children were fed the recommended minimum number of

42 times for their ages and 81% of the children were fed the recommended minimum number of food groups.101 Among children 12-23 months in Nepal in 2010, it was found that 11% were fed complementary feeds 1-2 times a day, 38% were fed three times a day and 51% were offered 4 or more feeds a day.102

2.3.8. Feeding Behaviour – Child-Care giver interactions

Factors which affect a child’s intake include: quantity consumed at each meal, intervals between meals and food selection. Early in life, the child is completely dependent on parents (caregivers) for food intake. As the child grows and develops, the child shares control of food intake with the parent (caregiver).82The transactional nature of care suggests that a child’s health, growth, and development are as a result of mutual interactions between the child and his or her caregiver and the age of the child influences his behaviour at every stage of development. It also determines the expectations of the caregiver. In some cultures, gender influences the caregiver’s expectations.

Care can either be: compensatory that is coaxing an anorexic child to eat or enhancing that is encouraging the child to eat. However, there are three interactions encountered in most cultures: laissez faire, extreme parental control and responsive feeding. Laissez faire is an extreme where an infant or young child is expected to know when he / she is hungry and full.

When the child refuses to eat, he is not encouraged; the extreme parental control of feeding which involves threats, bribes and force feeding; and optimal feeding which is in the spectrum.

Optimal feeding is responsive feeding in which the parent (caregiver) feeds the child frequently and responds to the child’s distress and demands for food. This pattern protects the child from the threats of malnutrition and disease.33 Pleasure in eating is important. Feeding a child while other members of the family are eating has been found to encourage the child to eat as oxytocin levels increase and help digestion and metabolism when humans eat together. This practice is

43 common in rural areas where young infants are fed in groups. Thus, feeding difficulties and food rejection are less common.34

Active feeding refers to caregiver behaviours that may help to increase a child’s food intake. These include: feeding infants directly and assisting older children when they eat; offering favourite foods, using different combinations, tastes, textures, and methods to encourage; talking with child when eating while minimizing distractions, and feeding slowly and patiently. It involves offering the child bits of the family meals and encouraging the child to feed himself. Children should not be force fed. Positive reinforcements, persistence and supervision during feeding are characteristics of active feeding and children of attentive caregivers are better nourished than passive caregivers. Active feeding stimulates a child’s verbal and cognitive development.2 Feeding times are periods of learning, love and interaction, which promote physical, social and emotional growth and development. The mother or caregiver should talk to children during feeding, feed patiently and treat girls and boys equally.52

The WHO recommends a responsive feeding practice which includes respect for the psychosocial mechanisms that self regulates the appetites in infants – helping them to feed until they are satisfied. Active feeding improves food ingestion, nutritional status, and development. Meal times should be pleasant and attempts should be made in non-coercive ways.5 A study in northern Nigeria in 2013 showed that three quarters of the mothers force fed their babies.74

2.4. CHILD FEEDING INDEX

The age specific child feeding index created by Mary Arimond and Marie T. Ruel is based on the feeding recommendations for children 6-36 months by the Linkages project. 32

The index includes five main components: A breastfeeding score (mother currently

44 breastfeeding or not); A bottle use score (mother used bottles in the last 24 hours or not); A 24 hour dietary diversity score (number of food groups the child received in the last 24 hours); A frequency of feeding score (number of solids and semisolid foods (including snacks) eaten in the previous 24 hours; A seven day quasi food group frequency score (number of days the child received selected food groups in the last seven days).32

The child feeding index addresses concerns related to analysis and interpretation of child feeding patterns and is best when age specific. It captures many dimensions of child feeding practices into a single summary variable. Evidence has shown that positive and negative behaviour tend to cluster and mothers who have early positive practices extend to other positive care giving behaviours.32 Where practices cluster, or where a minimum number of good practices are required to achieve a long term benefit, a composite index is more likely to detect associations.

The Child feeding index allows the inclusion of a variety of practices and they help take into account the positive cumulative effect of multiple practices on a child’s outcome.32

Also, indices help to quantify relationships - it helps to quantify the effect of practices on child nutrition and health outcomes.33 No global recommendations are specific on dietary diversity and food group frequency thus, cut off points and scoring systems are used. The index is made age specific in the scoring of different components for ages 6-8 months, 9-11 months and 12-

23 months. The total score ranges from 0-9 for all age groups. A score of 0 was assigned to a potentially harmful practice and 1-3 for positive practices. Infants less than six months are not included because the key recommendation for that age group is exclusive breastfeeding and being a single dimension, it does not need an index.103

A study using demographic data sets from seven Latin American countries in 2002 showed that feeding practices were strongly and significantly associated with child height for

45 age Z scores (HAZ) in most of the countries studied, especially after 12 months of age. The advantage in height experienced by children 12 months and older that scored high compared with those who scored low on the feeding practices tertile was large. Complementary feeding practices were found to be less than optimal in a study in Nepal in 2010. The proportion of children aged 12-23 months who were fed with three food groups according to the WHO recommendations in the preceding 24 hours were: 99% (staple foods like grains, roots and tuber),about 80% (dairy products other than breast milk), and 65% (vitamin A-rich fruits and vegetables). A little over half of them (55%) consumed legumes and nuts but very few children consumed animal-source foods such as eggs (2%) or meat, fish and poultry (4%). About 90% of children were fed at the appropriate frequency for their age but only 42% were fed the age appropriate minimum dietary diversity.102

A hospital based study in urban Bangladesh in 2011 using the index found a mean score for all children of 6.4 with a standard deviation of 1.8. The median score was seven.

They found that better feeding practices were more important for children in the lower socioeconomic status than for those in the higher status and a positive relationship was found between higher feeding practice scores and height for age particularly amongst children in the

12-23 month age group. This buttresses the fact that dietary diversity as a single practice was found to be strongly associated with height for age.27

2.5. CHILD’S NUTRITIONAL STATUS

Nutritional status, especially in children, has been widely and successfully assessed by anthropometric measures in both developing and developed countries.18 The World Health

Organization in 2006 released new global child growth standards for infants and children up to the age of 5 years. The new standards were developed in accordance with the idea that children, born in any region of the world and given an optimum start in life, all have the

46 potential to grow and develop to within the same range of height and weight for age. The new

WHO child growth standards provide a common basis for the analysis of growth data.104,

105This standard describes the growth of healthy children living in six countries. The standard shows how infants and children should grow rather than simply how they do grow in a certain time and place. The need for this new standard was an outcome of a working group on infant growth was established in 1993 which conducted a comprehensive review of the uses and interpretation of the 1977 National Center for Health Statistics (NCHS)/WHO growth reference, which had been recommended for international use since the late 1970s. The decision was made on the need to have a standard for how children should grow in all countries rather than a reference to describe how they grew in a specific place and time.

The Multicenter Growth Reference Study was conducted from 1997 to 2003 in six sites (Pelotas, Brazil; Accra, Ghana; Delhi, India; Oslo, Norway; Muscat, Oman; and Davis,

California) and used to generate new growth curves to assess growth of infants and young children throughout the world.106These new standards are based on breastfed infants and appropriately fed children of different ethnic origins raised in optimal conditions and measured in a standardized way.107

Malnourished children have poor health and suffer the life-long consequences of impaired cognitive development, with resultant long lasting implications in adulthood.8,28

Largely, malnutrition affects countries’ economic performance by increasing health outlays for treating malnourished children. The human and economic costs of malnutrition are enormous and fall hardest on women, children and the poor. Chronic nutritional deprivation leaves children permanently stunted and keeps communities and countries locked in a cycle of hunger and poverty that is often passed from generation to generation. Many babies are born with low birth weight, and poor feeding practices in the first two years have its immediate and long-term consequences on growth and development. Nutritional stress during adolescence and in the

47 reproductive years affect women who give birth to low birth weight babies…..and the cycle goes on. Parental decisions and actions on child feeding have immediate and long term consequences on the child’s growth and development.2

Malnutrition has remained a major public health problem in the developing world - particularly in southern Asia and sub-Saharan Africa.2 In children, protein-energy malnutrition is defined by measurements that fall below two standard deviations under the normal weight for age (underweight), height for age (stunting), and weight for height (wasting).Wasting indicates recent weight loss, whereas stunting usually results from chronic deficiency.

In Limpopo, South Africa, in 2008, 185 mothers and their infants were recruited from

5 Primary Health Care centres into a study to assess their breastfeeding and weaning practices and the effect of these on the nutritional status of their children. It was found that 19% were stunted, 7% underweight and 7% wasted.108 These rates were lower than those recorded in

Nigeria. However, mothers who attend wellness clinics are exposed to information on child feeding and growth; thus, they may not be representative of the total population as much as a community based study that employs probability sampling methods.

In Nigeria, the 2013 NDHS estimated the prevalence of malnutrition to be 18%

(wasting), 37% (stunting) and 29% (underweight).11 In an earlier survey, (The Nigerian Food,

Consumption and Nutritional status survey) in 2003, it was shown that 42% of children were stunted, 25% underweight and 9% wasted.109 These rates have not improved in spite of the ten year gap between them. In Ebonyi state in 2012, a study among 360, rural, school age children that were selected by multistage sampling to determine the relationship between their dietary intake and their nutritional status found that 23% were underweight, 6% were wasted and 43% of them had varied degrees of stunting.100 However, in an urban community in Benin city in

2000, a study to determine the nutritional status of children using Z scores found a composite

48 prevalence of malnutrition of 23% underweight, and 21% stunting.110 In another urban community in Benin in 2009, a study among 513 children under-five selected by simple random sampling found that 28% were underweight and 23% stunted.111The prevalence of children that were underweight is comparable in these three studies. However, in the urban studies in Benin City, the rate of stunting was about half of what was documented in the rural community in Ebonyi- emphasizing the rural-urban differences.

The comparative study between rural and urban areas in Enugu in 2012 corroborates these findings where among 500 rural and urban children, 28% were stunted, 30% underweight and 26% wasted. Comparing the two groups, the rural children were more stunted (33%) than those in the urban (23%); but wasting was commoner among the urban children (33%) than their rural counterparts (18%).112 This shows that the children in the urban area were more acutely malnourished (wasted) and the rural children were more chronically malnourished

(stunted). In a rural community in Enugu in 2010, a cross sectional study among mothers of children 0-2years showed that 28% were stunted, 20% underweight and 31% wasted. A higher prevalence of stunting was documented in this study.113

In Sabon Gari Kaduna state in 2011, a study aimed at assessing feeding practices and the nutritional status of infants among a random selection of 100 mothers in the clinic found that 41% of the children were underweight. This was said to have been associated with the age of introduction of feeds in these children.79 Furthermore, a study in an urban area in Plateau state in 2000 aimed at determining the nutritional status of children under five by comparing

Z scores and absolute values found that 25% were underweight, 37% stunted, while 9% were wasted. These values were similar to those gotten from absolute measurements as the proportion of children who were underweight, stunted and wasted were 24%, 35% and 11% respectively.114 Among settled pastoral Fulani children in Southwest Nigeria in 2008, a study

49 aimed at determining the nutritional status found that the prevalence of stunting (HAZ < -2), wasting (WHZ < -2) and underweight (WAZ < -2) were 39%, 14%, and 39% respectively.115

In 2009, out of 400 children (between 1-5 years) who were selected from three communities in Katsina State, 36% had varied degrees of wasting (weight for height). Mid upper arm circumference (24%) and serum protein levels were used to corroborate the findings and they had similar rates.116 Though this was a community based study, the percentage of children that were wasted was rather high compared with many other studies reviewed.

Considering the fact that wasting is a sign of acute malnutrition, there may have been other factors responsible for the prevalence. Among 230 children in a semi-rural community in Osun state in 2003, the prevalent forms of malnutrition in those communities were stunting (23%), and wasting (23%) and low maternal educational status was a major contributor to these rates.117 A rural-urban comparative study in Osun state in 2010, however documented that about 60% of all the children were stunted, 7.8% wasted and 24% underweight. Between the communities, growth faltering was more prevalent in the rural than the urban community. In the urban community, 57%, 7%, and 22%; and in the rural, 63%, 10% and 28% were stunted, wasted and underweight respectively.91 The rates of stunting and wasting were markedly higher in the later studies.

In Ile-Ife in the same year, another study aimed at determining the influence of family size and household food security status on the nutritional status of under five children, 39% of participants were found to be stunted, 6% wasted and 14% underweight.71 These rates were much lower for all the measures of under nutrition than those in the earlier reported study in the same state in the same year. The two studies were community based, sample sizes were comparable and adequate, and selection was multistage by probability methods. However, the fact that Ile-Ife has had some health education and nutritional interventions by the institution it houses may be responsible for the rates. An earlier study that compared the nutritional status of

749 school age children in rural and urban areas in Ile-Ife in 2007 documented rates of underweight, wasting and stunting as 61%, 17% and 28% respectively. The rates in the rural area (71%, 18% and 36%) were however higher than those in the urban area (52%, 16% and

20%) respectively.118 The overall rates were much higher than those documented in 2010 in

Ile-Ife but comparable with those in other parts of Osun state in 2010.

A descriptive study in Ibadan in 2009 found that 63% were underweight,68% stunted and 23% wasted;51 while among farming households in Oyo state in 2010, a cross sectional study found the nutritional status to be 38% for stunting, 15% underweight and 6% wasted.119

In 2004, a cross sectional study among primary school children in Ibadan found that 22% were stunted, 16% were underweight and 4% were wasted. This study also found that there were no significant gender differences observed for stunting, wasting and underweight. However, about

42% of the children had palpable goitre, and stunting was significantly associated with goitre

(p<0.05).120 The under nutrition rates observed in this study were much lower than the rates among children under five. This may be due to the fact that the children were older and they were no longer in the transition phase. They were already on regular family diets and had better nutrition.

Another study in Ibadan among 1,273 children selected by multistage sampling from three areas; aimed at assessing the differences in the nutritional status of worm infested children and those that were not worm infested, found that in both groups, many of the children were below the weight and height references for their ages. However, those that were worm infested were more affected than those that were not (for stunting, 10% were above the 74th percentile in the non-infested group compared to the 2% in the infested group).121. The under nutrition rates found in this study were much higher than other studies reviewed. However, that may have been worsened by the fact that other factors (worm infestation, micronutrient deficiencies and low socioeconomic status) were at play. In Sagamu, a cross sectional study

51 among school age children in 2011, found the prevalence of underweight, stunting and wasting to be 26%,14%and 22% respectively.122

In an urban area in Lagos in 2001, a study among 365 children aged 1-4 years with the aim of determining the effect of urbanization on their health found that 39% were underweight,

35% stunted and 22% wasted.123 The urban area from where these children were selected is one of the areas in Lagos where rapid urbanization has resulted in overcrowding and reduced access to food. This may have been responsible for the high rates that were documented. A similar study among 328 older children in Lagos in 1999 revealed a prevalence of underweight, wasting and stunting of 38%, 38% and 41% respectively. 124 In Lagos in 2000, a comparative study between upland and riverine areas of an urban LGA showed the prevalence of stunting, wasting and underweight among 240 children to be 16%, 3%, and 14% respectively for the upland area; and 30%, 2%, 18% respectively for the riverine area. 105 The rates obtained were lower than those from the National survey and even less in the upland area. Another study among mothers and children aged 3-24 months in an urban local government area in metropolitan Lagos in 2000 found that 7% were underweight, 13% were stunted and 7% were wasted.125 The prevalence of stunting was low in this community compared with most of the others that were documented. This was probably due to higher maternal literacy seen in urban areas; however, early introduction of infant formula in this study was said to have been associated with stunting.

2.6. FACTORS AFFECTING CHILD FEEDING AND NUTRITIONAL STATUS.

Complementary feeding practices are determined by the balance of factors such as work, societal influences, economic resources and food availability. Among the factors that influence good complementary feeding, reliable water supply is a key component because consistent supply of water is essential for hygienic food preparation and hand washing. Water

52 provision makes a key difference between the daily lives of residents of developed and developing countries.34 Maternal factors that have been shown to influence complementary feeding include: maternal age, nutritional and health status, education, employment status, head of householdship and ethnicity. Household factors that influence complementary feeding include size, household income, food availability, socioeconomic status, availability of water, sanitation and garbage disposal services, and financial support from child’s father.126 The underlying causes of child malnutrition include: household food security, care for children and mothers, and household health environment. These are affected by socioeconomic factors such as education of parents (in particular that of mothers), employment status of mothers, women’s status relative to men, household economic status, and access to water and sanitation services.28 These factors overlap.

2.6.1. Economic status of the household

The economic status of the household where a child lives is one of the key determinants of the child’s nutritional status. Household economic status significantly affects access to food. It also shows the sustainability of the possession and utilization of child care resources. Relatively, a better economic status permits more spending on food, allows a more diversified diet and effective child care arrangements. At the community level it leads to improved access to high quality health care, improved water and sanitation systems and greater access to information.28

Social class is determined by socioeconomic indicators such as: occupation, education, area of residence, income and total lifestyle.127 A study in South coastal India in

2011 had a little over half of their study population in the upper middle socio-economic class;

23% in the upper lower and 20% in the lower middle socio-economic class. This study assessed the complementary feeding practices of mothers of children aged 6-24 months and

53 found a statistically significant association between the socio-economic status of mothers and initiation of complementary feeds at the recommended time, as the majority (88%) of mothers in the upper middle class started complementary feeding at the recommended time.128 In a study on socio-clinical issues in Cerebral palsy in Sagamu in 2008, 80% of all the children seen were undernourished and were concentrated in social classes III (24%) and IV (47%).129

2.6.2 Maternal schooling (mother’s educational status)

Globally, an inverse relationship has been demonstrated between maternal literacy and infant/ child mortality.130 In many developing countries particularly in Africa, the responsibility of child care is on women and this begins at conception and continues until infancy, teenage and adulthood.131 Women play a key role in the growth and development of a child and in enhancing the quality of care and nutritional status of children, the role of mothers’ education is widely recognized. Education improves the ability of mothers to implement simple health knowledge and facilitates their capacity to manipulate their environment including interaction with medical personnel. Furthermore, educated women have greater control over health choices for their children. It has been emphasized that education of women has several positive effects on the quality of care rendered to children. Their ability to process information, acquire skills, and model positive caring behaviour improves with education. Educated women use health care facilities, interact more effectively with health professionals, comply with treatment recommendations, and keep their environment clean. Also, educated mothers are more committed to child care and interact very well with their children than uneducated ones.

In 2005, in a longitudinal study among 246 children in greater Peru, mothers were recruited at the end of the 1st trimester of pregnancy and the children were followed up from birth till they were 18 months of age. It was found that maternal schooling and maternal intelligence were significantly associated with better weight and height at three, six, 12 and 18

54 months of age.132 A study in India in 2010 found that 64% of educated mothers had good child feeding practices while only 32% of uneducated mothers had good child feeding practice.29 A study in Pakistan that aimed at determining the relationship between maternal education and nutritional status of children aged 6-12 months found that 46% of the children had normal nutritional status and 54% had varying degrees of malnutrition. Amongst those with normal nutritional status, about 96% of the mothers were educated and 4% were not. For those with malnutrition, 63% of the mothers were not educated. The degree of malnutrition had an inverse relationship with the mother’s education. It was also found that 36% of the mothers had good complementary feeding practice, 97% of these were educated.133

Studies have shown that the effect of maternal schooling on child’s nutritional status is conditioned by resource availability at the household level. Education of mothers improves child health by altering intra-household allocation of resources in a manner that favours children.28 However, a study in Republic of Benin showed that the effect of maternal education impacts positively on child’s growth though this was less relevant when resources are either inadequate or more abundant. Thus, the effect of maternal education is more evident in the middle social class.134 In a study in Eastern parts of Nigeria in 2007, maternal demographics that strengthened adherence to WHO recommendation were high social class, small family size, maternal education, higher maternal age and family planning.88

In a clinic based study in Anambra state on breastfeeding pattern and health status of infants, 37% of children were still being exclusively breastfed at 24 weeks and supplementary foods which included non-human milk, maize gruel and porridge were given after this period by mothers.135 Another study on breastfeeding practices in Lagos, in 2010, found that the likelihood of exclusive breastfeeding increased as the educational level of the mother increased. Mothers who’s highest level of education was secondary education were six times more likely to practice EBF for six months, than those with no formal education and those who

55 had more than secondary education were eight times more likely to practice EBF for six months than those with no formal education.74

2.6.3 Maternal employment status

Engagement of a woman in a gainful employment is expected to produce positive effects on the child’s nutritional status by increasing family income and maternal self-esteem, but work may have a negative effect by reducing the woman's time available for child care. A study in Benin Republic in 1996 showed that the deprivation of maternal inputs may adversely affect child welfare, especially those aspects that require large quantities of the mother's time.134

Feeding time requires time and attention. It takes time, initiative, activity and energy.

Care givers should have patience and feed the child slowly. Unfortunately, many mothers do not have such time as many are in the working class group and babies are left to mother substitutes. Mother substitutes can be grandmothers (affected by taboos about some food groups) or maids (may eat food meant for the baby or abuse the child). In rural communities, where no formal child care facilities exist, women who work away from their homes for extended periods leave their children in the care of a family member or an older sibling. In a report on ‘Women, work and childcare’ at the Innocenti global summit, it was found that those children who were cared for by an adult had better nutritional status than children cared for by another child.136 Religious and cultural beliefs colour our practices. Every human group whether ethnic, religious philosophical, cultural, class or caste has its beliefs.34

2.7. DIFFERENCES IN GEO-POLITICAL LOCATION

A rural area is a sparsely populated area which is dominated by open country side with extensive land use and low population density. This low population density contains

56 scattered dwellings, villages and small towns. Most people farm and depend on natural resources and adherence to traditional value systems. These stress the merits of religious adherence, respect for elders and importance of the family. Urban areas are characterized by higher population density and human features, advanced civic amenities, opportunities for education, facilities for transport, business and social interactions.137 Rural areas often develop randomly based on the natural vegetation available in the region but urban areas are built or developed through urbanisation and they are defined by their amenities, opportunities, social interactions and standards of living. In rural areas, community ties are strong; they have a simple economy with little division of labour. Status is ascribed and there is a direct contact and use of one’s work end product (in this case, agricultural products). Urban areas have a diverse economy with extreme differentiation and specialisation. Status is achieved and is usually from education; and the people are majorly stratified by their economic status.

It is generally presumed that there is less poverty in urban areas than in rural areas.

However, the rate of growth of the world’s urban population that live in poverty is now considerably higher than the rate in rural areas. In most developing countries the absolute number of poor and undernourished individuals in urban areas is increasing, as is the share of urban areas in overall poverty and malnutrition. In general, the locus of poverty is moving to cities, a process now recognised as the “urbanization of poverty”.138 This results in more families depending on informal or intermittent employment with uncertain incomes.

Meanwhile, traditional family and community support structures are being eroded, resources devoted to supporting health and, especially, nutrition are being diverted to other needs and accurate information on optimal feeding practices is lacking. Many families in rural and urban areas are becoming more food insecure.8 Lagos is reported to grow at a rate of about 8% per year due to rapid urbanization and two out of every three Lagos residents live in areas with no reliable access to drinking water, electricity, waste disposal and sometimes roads.139

Chapter Three MATERIALS AND METHODS 3.1. Description of study Areas.

3.1.1. Lagos

Lagos State is one of the 36 states in Nigeria and it was created on May 27th 1967, with an area of 356,861 hectares of which 75,755 are wetlands. In spite of this, it has the second largest population which is over 5% of National estimate: that is over 9 million of the

150 million from the 2006 national census figure. The rate of population growth is about

600,000 per annum with a population density of 4,193 persons per square kilometre. The average density in the built up metropolitan parts of the state is about 20,000 per square kilometre.3 Lagos state is one of the most economically viable and buoyant states of the federation and is described as the industrial and commercial nerve centre of the country with over half of the county’s commercial activities taking place there.

It is located on the South-Western part of Nigeria on the narrow coastal flood plain of the Bight of Benin. It lies approximately on Longitude 3024’E and Latitude 6027’N. It is bounded in the North and East by Ogun State of Nigeria, in the West by Republic of Benin, and in the South by the Atlantic Ocean. It has five administrative divisions namely Ikeja,

Badagry, Ikorodu, Lagos Island and Epe. Lagos state has 20 Local Government Areas (LGAs) consisting of 16 urban and four rural (APPENDIX I). In addition, it has 37 Local Council

Development Areas (LCDAs).140 It is a heavily populated megacity where women of child bearing age and children under five constitute about two fifth of its inhabitants.12

3.1.2. Rural LGA (Badagry LGA)

Badagry (traditionally Gbaale) is a coastal local government area (LGA) in Lagos

State that was founded in 1983. It is situated between Metropolitan Lagos, and the border with

Benin at Seme. The 2006 census results revealed a population of 241, 093 with 441 km2 land.

It is bounded in the North by Ogun state, South by the Atlantic Ocean, in the east by Ologe waters- Badagry creek and the west by Seme border at the entry of Republic of Benin.3

The LGA is divided administratively into 20 wards and there are 13 PHCs, (Ajara

PHC, Ajido PHC, Marina PHC, Pota PHC, Topo-Idale PHC, Apa PHC, Asheri PHC, Igbobele

PHC, Rarasime Model PHC, Seme PHC, Ilado PHC, Ilogbo PHC, Mowo PHC): and one secondary health facility with few private health facilities. However, there are a lot of traditional and alternative health practitioners. In Badagry LGA, the focal town is the ancient settlement of Badagry which was a major slave outpost in pre-colonial times and is reputed as being the first place in Nigeria where Christianity was preached in 1842. However, it is surrounded by numerous lower order settlements and village communities.

The Ogu people of Badagry are a part of the Yoruba/Popo sub-group who migrated from the ancient ketu kingdom of Benin Republic. The Ogu’s are mainly engaged in fishing and animal husbandry. The people sail in dug-out canoes along the lagoons, mangrove water and creeks using drag-nets, hand nets and fishing lines. Farming (maize, cassava and coconut) is also a major occupation.141

3.1.3. Urban LGA (Surulere LGA)

Surulere LGA was first created in 1980 but was merged after four years with Lagos mainland. However, it was re-created on the 27th of August 1991.

Surulere LGA popularly known as the “new Lagos” is cosmopolitan and densely populated consisting of several large communities. Surulere LGA is a part of Metropolitan Lagos and it is located in the Heart of the City. It is a residential and commercial community with an area of

23 km². Estimates from the last census (2006) revealed a population of 503,975 inhabitants,

59 with a population density of 21,864 persons per square kilometer.3 It is bounded in the North by Mushin LGA, in the West and South by Ojo LGA and in the East by Mainland LGA.

Though the early settlers were fishermen and hunters, their economic potentials stretched to trading and merchandising due to urbanization.

The LGA is divided administratively into 23 wards and there are six Primary Health centres : (Coker Aguda PHC, Orile PHC, Anjorin PHC, Baruwa PHC, Akerele PHC and Gbaja

HC), one secondary health facility (General Hospital Randle), it is very close to three of the four tertiary health centers in the state, and home to several private health facilities. It is house to Nigeria’s 2nd international sporting center- The National stadium and Teslim Balogun stadium. Surulere’s dense population has many of its buildings used for official and business purposes with a lot of trading going on. Amongst the residential parts, there are pockets of high to low class residences and squatter settlements.142

3.1.4. Similarities and differences (Badagry and Surulere).

Badagry LGA was created from an ancient town and is in the outskirts of Lagos. It is not as densely populated as other LGAs and the majority of its inhabitants are indigenes with the extended family set up being common. There is preservation of cultural and traditional practices and occupations. In spite of the fact that all the government health facilities in Lagos state have doctors that man them, fewer doctors work in Badagry PHCs. This is due to its distance from cosmopolitan Lagos. Also, basic services are being provided in these facilities.

In Badagry, traditional healing homes thrive.

Surulere LGA is densely populated and in the heart of cosmopolitan Lagos, with many of its structures being used for business purposes. Its inhabitants are mostly people in business. Also, lot of middle class individuals rent apartments there due to its location. This

60 contributes immensely to its population. There is a high density of doctors in the many health facilities where specialized care is provided. However, both LGAs were created in the early

1980s and have PHC centers that are run by doctors.

3.2. Study design

The study is an analytical cross-sectional study aimed at comparing the knowledge and practices of care givers on complementary feeding; and the nutritional status of children aged

6-24 months in Badagry and Surulere LGAs of Lagos state.

3.3. Study population

The study population included caregivers and children aged 6-24 months who live in Badagry and Surulere communities of Lagos state.

3.4. Eligibility

3.4.1. Inclusion criteria

1. Caregivers of children aged 6-24 months.

2. Children aged 6-24 months.

3. Had been residing in the study area within the preceding six months.

3.4.2. Exclusion criteria

1. Child with special needs and developmental anomalies.

2. Acutely ill children in severe conditions and children just recovering from illness like

diarrhoea.

3.5. Study components

1. Survey of caregivers and children aged 6-24months using the questionnaire

(Quantitative).

2. Focus Group Discussion (FGD) sessions among mothers, fathers, and healthcare

workers (Qualitative).

3.6. Study duration

This study lasted three months. Assessment of complementary feeding knowledge and practice of caregivers and the nutritional status of children was done in 10 weeks- July to mid

September 2014 (an average of two wards per week); and the FGD was organised and conducted within two weeks.

3.7. Sample size determination

The Sample size was determined using the formula for comparison of two proportions.143, 144

2 n= (Zα/2 +Zβ) [P1(1-P1)] + [P2(1-P2)]

2 (P1-P2) WHERE: n = sample size required in each group (double for the total sample)

P1 = prevalence 1- Sample proportion from a previous study in an urban area in Lagos = 19.8%

P2 = prevalence 2- Sample proportion from a previous study in a rural area in Lagos = 9.5%

P1-p2 = difference between prevalence 1 and 2

Zα/2 = Level of significance at 5% [1.96]

Zβ = critical ratio at the power of 80% [0.84]

Substituting the figures: n = sample size required in each group (double for the total sample)

P1 = prevalence 1= 19.8% of mothers introduced complementary feeds after at least 6 months of breastfeeding in Ikeja LGA (urban) in Lagos.13

P2 = prevalence 2= 9.5% of mothers introduced complementary feeds after at least 6 months of breastfeeding in Badagry LGA (rural) in Lagos.13

P1-p2 = 10.3%

Zα/2 = Level of significance at 5% [1.96]

Zβ = critical ratio at the power of 80% [0.84] n = (1.96 +0.84)2 ×[0.198(1-0.198)] + [0.095(1-0.095)] (0.198-0.095)2 n = 7.84 × 0.158796+0.085975 (0.103)2 n = 7.84 × 0.244771 0.010609 n = 7.84× 23.0720 =180.885. n≈181.

To adjust for non-response using an anticipated response rate of 80% (0.8) n=181/0.8 = 226.11

Thus, 248 mothers with their children aged 6-24 months were recruited in each group.

3.8. Selection of study sites

Rural area

From the sampling frame (list of rural local governments in Lagos state-APPENDIX

I), balloting was done to select one local government area. The process of balloting was done in the office of the supervisor. Numbers representing each of the rural local government areas

63 were written on pieces of paper; the pieces of paper were folded and mixed together. One was drawn from the mix (by an uninvolved third party) and Badagry Local Government Area was selected. This is the local government from which the respondents (rural) for this study were selected.

Urban area

From the sampling frame (list of urban local government areas in Lagos state-

APPENDIX I), balloting was done to select a local government area. The process of balloting was done in the office of the supervisor. Numbers representing each of the urban local government areas were written on a piece of paper, the pieces of paper were folded and mixed together. One was drawn from the mix (by an uninvolved third party) and Surulere Local

Government Area was selected. This is the local government from which the respondents

(urban) for this study were selected.

Two hundred and forty eight mother- child pairs were selected from each study site.

3.9. Sampling methods

3.9.1. Quantitative survey

Multi stage sampling was used in selecting the study participants.

3.9.1.1. Stage 1 – Selection of wards.

Rural area

Badagry Local Government Area is divided into three Local Council Development

Areas with twenty wards in the ratio of 2:1:1 - Badagry central LGA (ten wards), Badagry west

LCDA (five wards), and Olorunda LCDA (five wards). Proportionate selection of eight wards

64 by balloting was done. This was in the ratio 4:2:2 in Badagry central, Badagry west, and

Olorunda LCDAs respectively (APPENDIX II).

Urban area

Surulere Local Government Area is divided into three Local Council Development

Areas with twenty three wards in the ratio of 9:7:7 - Surulere central LGA (nine wards),

Coker/Aguda LCDA (seven wards), and Itire/Ikate LCDA (seven wards). Proportionate selection of eight wards by balloting was done. This was in the ratio 4:2:2 in Surulere central,

Coker/Aguda, and Itire/Ikate LCDAs respectively (APPENDIX II).

3.9.1.2. Stage 2–Selection of settlements / streets

Rural area

The settlements/ streets in each of the selected wards were numbered and a table of random numbers was used to select six from the list of all the settlements/ streets in each selected ward in Badagry LGA. Six streets / settlements were selected from each ward.

Urban area

The settlements/ streets in each of the selected wards were numbered and a table of random numbers was used to select six from the list of all the settlements/ streets in each selected ward in Surulere LGA. Six streets / settlements were selected from each ward.

3.9.1.3. Stage 3 – Selection of houses

Rural area

Based on the required number per ward, five houses were required from each street.

The houses in each selected settlement/ street were numbered and a table of random numbers

65 was used to select six houses from the first settlement, and five houses each from the other 5 settlements from which the respondents were selected.

Urban area

Based on the required number per ward, five houses were required from each street.

The houses in each selected settlement/ street were numbered and a table of random numbers was used to select six houses from the first settlement, and five houses each from the other 5 settlements from which the respondents were selected.

3.9.1.4. Stage 4 – Selection of participants

Rural area

The households in each selected house were numbered and an eligible respondent was selected by balloting. In houses with no eligible respondent or unwillingness to participate in the study, the next house was selected until a participant was recruited; then the selection process continued. A total of 248 mother - child pairs were recruited from the eight wards selected in Badagry LGA- (31 mother – child pairs per ward).

Urban area

The households in each selected house were numbered and an eligible respondent was selected by balloting. In houses with no eligible respondent or unwillingness to participate in the study, the next house was selected until a participant was recruited; then the selection process continued. A total of 248 (mother - child pairs) were recruited from the eight wards selected in Surulere LGA- (31 mother – child pairs per ward).

3.9.2. Qualitative survey

Six FGD sessions were conducted in this study; three in the rural area and three in the urban area. The first session consisted of mothers with children aged 6-24 months; the second session consisted of fathers with children aged 6-24 months; and the third one consisted of health care workers in the communities. Selection of participants for these sessions was by purposive sampling in both communities. Health care workers were selected from the health facilities in each area. Health care workers had FGD sessions because they are an important source of information to mothers at clinics and home visits. Thus, their level of knowledge and practices were assessed; in order to know the information being passed to the mothers.

Mothers and fathers with children aged 6-24 months were selected from Badagry and

Surulere LGA. Though purposively, one participant (Father, mother, health care worker) was selected from each of the eight selected wards used for the quantitative aspect of the study.

Consent for participation in the FGD was sought from eligible mothers, fathers and health care workers. The telephone numbers of consenting individuals were taken to send reminders to them about the sessions. When there was a refusal to give consent to participate, the consent of another eligible person was sought. A total of 48 individuals participated: that is eight participants for each session.

3.10. Study instruments

a) A semi structured interviewer administered questionnaire was used. (Appendix III)

This was developed by adaptation of two tools- Knowledge tests on complementary feeding and feeding during illness and an infant and young child feeding index which was constructed by Ruel and Menon using seven data sets from the Demographic and Health Surveys (DHS) for five Latin American countries. It has been used in Ghana and other studies.27, 32, 145

The questionnaire has four sections A-D. Section A addressed socio demographic characteristics of parents. Household and child characteristics were also assessed. Section B assessed the knowledge of mothers on child feeding and consists of 25 questions with Yes, No and Don’t know options. Questions tested the caregiver’s knowledge on timing of introduction of breastfeeding, use of pre-lacteal feeds, duration of exclusive breast feeding, complementary feeding frequency, caregiver’s attitude to refusal of feeds and feeding during illness.

Section C measured the mothers feeding practice majorly by using an infant and young child feeding index. This index has five main components which assessed: breastfeeding

(mother currently breastfeeding or not); bottle use (mother used bottles in the last 24 hours or not);the preceding 24 hour dietary diversity (number of food groups the child received in the last 24 hours);frequency of feeding (number of solids and semisolid foods (including snacks) eaten in the previous 24 hours); and a seven day food group frequency (number of days the child received selected food groups in the last seven days).The index is made age specific for ages 6-8 months, 9-11 months and 12-23 months. The total score ranges from zero to nine (0-

9) for all age groups.

Section D assessed the anthropometric nutritional status of children by measuring the weight and height and determining if they are appropriate for age, stunted, wasted or underweight. Anthropometric measurements of the eligible children were taken with the use of a digital paediatric scale - ADE M 112600 (GmbH & Co, Germany) with a precision of 5g.

The weight of the children was taken in light clothing, no shoes, no diapers, not holding anything (including toys). Recumbent length was taken using a length mat - ADE M Z10027-1

(GmbH & Co, Germany) with a precision of 5mm. The length was measured in the recumbent position, head touching the bar at one end, knees held down with feet touching the other end.

Every day, before data-collection, the instruments were standardised by measuring the weight and length of objects with known measures.

The questionnaire was pretested in 50 mother- child pairs (10% of the calculated sample size) that were selected from Ikorodu and Ikeja LGAs, representing rural and urban areas respectively. These are not included in the study. This is to ensure the validity and reliability of the instruments. It gave an idea of the ease of administration of the instrument.

The instrument was translated to local language and back translated (APPENDIX IV); and the pre-tested instrument was analysed and corrected.

The content validity of section A of the instruments was assessed by careful vetting of its items by the lecturers in the Department and their suggestions were incorporated into the final copy of the section.

b) The FGD interview guide contained questions that addressed the knowledge of mothers on breastfeeding and complementary feeding; their challenges with complementary feeding and their practices with respect to feeding their children Factors that affect their knowledge and practices were also sought for. (Appendix V)

Electronic weighing scales, length boards, a tape recorder, and note pads were used for data collection.

3.11. Conduct of the study

The study was carried out by the researcher with the help of nine research assistants (6 females, three males) who were trained to assist in the administration of the questionnaires.

The research assistants worked in sequence: one after the other on the field. They all had SSCE certificates; five were Community health officers while four were health volunteers in Badagry and Surulere; all had good communication skills and were proficient in English, Yoruba, and pidgin languages. The assistants used in the rural area also had proficiency in egun language

(the local language of badagry). Training of the research assistants on the sampling methods,

69 administration of the questionnaire and taking of weight and height measurements of children aged 6-24 months using the instruments was done prior to data collection. The training lasted about 4 hours each for two days in each study site. The first day was classroom training and the second day was a practical class on the field. First, there was an explanation of the purpose of the study, obtaining consent for the study, method of selection of houses, households and participants; a review of the questionnaire was done in both English and Yoruba languages; and modes of taking measurements using the instruments were shown. Each of the assistants rehearsed the questionnaire by role playing until all had had a chance. Field exercises were carried out on eligible mothers and children (not included in the study). The proficiency of the interviewers was verified through role-play and all collected data was checked by the researcher. Questions were answered and clarifications made after the sessions. Each research assistant collected data from two wards each (except for Badagry Olorunda where each of the two wards was taken by one research assistant each.) they worked in sequence starting from

Badagry.

Using a table of random numbers after numbering all the streets in each ward, the researcher selected 6 streets each from the selected wards. The research assistants were shown how to select the houses, households and participants. They had close supervision and were guided on the field and all the data collected was reviewed on the field by the researcher (one assistant was on the field per time with the researcher). The questionnaires used were in

English and Yoruba languages (by back translation).

Six focus group discussion sessions (Three in each Badagry and three in Surulere -one group for mothers, one for fathers and one for health care workers) were conducted in English and Yoruba Languages. In Badagry, the sessions were held in Ajara PHC while in Surulere, they were held in Akerele PHC. Informed consent was taken after explaining the nature and purpose of the session to the participants and they appended their signature on the attendance

70 sheet for each group. The recorder was shown to the participants and the purpose was explained to them. Discussants sat around a table where eye contact could be achieved and they were assigned numbers by which they were addressed and they were allowed to express their opinions freely. Each of the sessions consisted of eight participants, a moderator, a tape recorder / note taker. The moderator facilitated the discussions and a note taker took notes and documented the non – verbal cues and group dynamics during the sessions. She also helped with the recorder. Each session lasted about an hour and each participant was given transport fare at the end of the sessions. The FGD sessions were conducted in order to complement the findings from the questionnaires. Each group consisted of mothers / fathers / health care workers living in the communities with children between six and 24 months. Consent was sought from the participants before each session.

3.12. Data analyses

3.12.1. Qualitative data

At the end of each FGD session, the moderator and recorder got the recordings transcribed verbatim and reconciled with the notes. The transcripts were scrutinized and tabulated into the groups (following the themes) to facilitate comparison and interpretation. Similar responses were group-coded. A structured code book was established and structured text units were coded systematically. Quotes were used to illustrate the opinions expressed by the participants.

3.12.2. Quantitative data

Data collected was analysed using Statistical Package for Social Sciences (SPSS) version 22; percentages of socio-demographic characteristics of families, level of knowledge of mothers, level of practice of mothers and nutritional status of children were determined; means and standard deviation of ages were also determined. Chi square and t-Test were used to compare

71 the associations and differences between the variables in the rural and urban areas. Charts were drawn using Microsoft office excel (2007) and Z scores were derived using the World Health

Organisation Anthro software version 3.2.2. Multinomial and logistic regression was done to determine predictor variables among those that were significant on bivariate analysis.

Confidence interval was set at 95% and statistical tests were considered significant at p values less than 0.05 (p<0.05).

3.12.3. Social class scoring

The socioeconomic classification developed by Ogunlesi in 2008 that grouped socioeconomic status into five classes (I-V) was used in this study. In that classification, Education (E - category) and occupation (O -category) are divided into five categories based on the charts.

Social class scoring Parents’ highest level of education Categories SCORE PhD, Masters E-category 1 I

Bachelors, HND E-category 2 II

OND, NCE, Technical education E-category 3 III

SSCE, JSCE, Grade 2 teaching certificate E-category 4 IV

Primary, No formal education E-category 5 V

Parents’ occupation SCORE Professionals, High scale trading O-category 1 I

Senior government employee O-category 2 II

High scale farming, Middle scale trading, Clergy, Junior O-category 3 III government employee, Teachers, Technicians, Retirees, Clergy.

Artisans, Sentries, Security agents O-category 4 IV

Labourers, Messengers, Students, Apprentices, Peasant farmers, O-category 5 V Unemployed

It was derived by scoring the occupation and highest level of education attained each by the father and mother, and finding the mean of the four scores. The mean score derived (rounded to the nearest whole number is the socioeconomic class assigned to the child.). This classification breaks social class into classes I-V and is a modification of Oyedeji’s which was published 29 years ago.146 This scoring was modified in order to truly reflect socioeconomic status as it did 29 years ago.

3.12.4. Knowledge test scoring

The knowledge of mothers was scored using the 25 questions in section B of the questionnaire.

Each correct answer was scored 1 mark. Answers to all questions were required and the total score over 25 is converted to percentage (over 100%) and graded as follows:

0-49% - Poor knowledge

50-74% - Fair knowledge

75-100% - Good knowledge147

3.12.5. Infant and young child feeding index (ICFI) - the scoring

The responses of the mother to the questions in section C of the questionnaire were used to determine the practice score. These included the variables required for the child feeding index as follows: breastfeeding, bottle-feeding, 24-hour feeding frequency, 24-hour dietary diversity, and seven-day food-group frequency.27 The children were divided into age-groups 6-8 months,

9-11 months, and 12-23 months at the time of interview.

The total score will be further categorised into three groups:

0-3 – Poor practice,

4-6 – Fair practice,

≥7 – Good practice.

Infant and Young Child Feeding Index (ICFI) – Scoring

Description of the scoring system to construct infant- and child-feeding index

Variable 6-8 months 9-11 months 12-23 months

Breast feeding Yes=2 Yes=2 Yes=1 No=0 No=0 No=0

Bottle feeding Yes=0 Yes=0 Yes=0 No=1 No=1 No=1

Dietary diversity None of the food None of the food- None or one of the food- (past 24 hours) groups=0 groups=0 groups=0 One food-group=1 One to two food- Two or three food-groups=1 Two or more food- groups=1 Four or more food-groups=2 groups=2 Three or more food -groups=2

Food group 0 (no foods in 0 or 1=0 0 through 3=0 frequency (past 7 days) previous week)=0 2 through 4=1 4 through 6=1 1 or 2=1 5 or higher=2 7 or higher=2 3 or higher=2

Feeding frequency Not at all=0 Not at all=0 Not at all or once=0 Once=1 Once or twice=1 Twice=1 Twice or more=2 Thrice or more=2 Thrice=2 Four times or more=3

Total score – 0/9 0/9 0/9 minimum/maximum

To assess breast feeding, the mother was asked if the child was currently being breastfed. Children in the 6-8 month and 9-11 month groups were scored +2 if yes and 0 if no

74 and children in the 12-23 month age group were scored +1 if yes and 0 if no. Bottle feeding was scored 0 if it was used in the last 24 hours and +1 if it was not used in all the age groups.

For dietary diversity, information was collected on the foods from different food- groups that were fed to the child during the last 24 hours of the interview. Then the number of food-groups given to the child were summed up. Seven food-groups that were used for this purpose are: (a) dairy and its products, ( milk, yoghurt, cheese) (b)carbohydrate-rich foods,(grains, cereals, tubers, ) (c) animal protein (meat/fish/eggs),(d) vegetable protein ( beans, soya beans, nuts) (e) oil/fat, (f) vitamin A-rich fruits and vegetables,(carrots, mangoes, pawpaw, ) and (g) other fruits/vegetables/juice. Based on the number of food-groups given, an age-specific score ranging from 0 to 2 was assigned. In the 6-8 moth age group, a child that received none of the food groups in the last 24 hours scored 0, if child was given once he scored +1 and a score of +2 was assigned to any child in that age group that received two or more of the food groups in the 24 hours preceding the interview. For the 9-11 month group, a child was scored 0 for none of the food groups, +1 for one to two food groups and +2 for three or more food groups. Children in the 12-23 month age group were scored 0 where none or one of the food groups is received in the last 24 hours, +1 if two or three is received and +2 where the child was fed four or more food groups in the preceding 24 hours.

To determine the food-group frequency in the last seven days preceding the survey, the same food groups were used. Questions were asked about the number of days during the previous one week (7 days) of the interview that the child was given a food item from each of the food-groups. A score ranging from 0 to 2 were assigned for each food group. Where a food-group was not consumed in the last seven days, the score 0 was assigned, if consumed on

1-3 days, the score +1 was assigned and if consumed on 4 days or more, the score +2. All the scores for different food-groups were summed to have a total score ranging from 0 to 14. A new score of 0-2 was assigned based on this total score, and this is age dependent. A child in

75 the 6-8 month group was scored 0 if he had none of the food groups, +1 if he scored one to two and +2 if he had three or more at the last stage. A score of 0 was assigned to child in the 9-11 month age group if he had none to one in the last stage, +1 if he had two through four and +2 if he had five or more. The child in the 12-23 month category was assigned a score of 0 if he had zero through three in the last stage, +1 if he had four through six and +2 if he had seven or more in the last stage.

The feeding frequency was determined based on the number of times the child was fed a complementary feed in the last 24 hours preceding the interview and it is scored as follows: in the 6-8 month age group, no feed at all was scored 0, one meal was scored +1 and a score of +2 was assigned where the infant is fed a complementary feed two or more times. An infant in the 9-11 month group that was not fed a complementary feed was assigned a score of

0, if fed once or twice, a score of +1 and a score of +2 where he was fed a complementary feed three or more times in the last 24 hours. The children in the 12-23 month age group were assigned scores based on the number of times they are fed complementary feeds as follows: 0 for children fed zero to once; +1 for children fed twice; +2 for children fed three times and +3 for children fed four or more times. For each age-group, the ICFI score ranged from 0 to 9.

3.12.6. Nutritional status of children

The nutritional status was determined by comparing the Z score with the WHO growth standards Z scores (WHO –MGRS 2006). Children with Z scores that were less than -2 were considered malnourished and further characterized as follows:

Wasted—low weight for height with Z scores less than −2;

Underweight—low weight for age with Z scores less than −2;

Stunted—low height for age with Z scores less than −2.

3.13. Ethical considerations

Ethical clearance was obtained from the Health Research and Ethics Committee of the

Lagos State University Teaching Hospital. Permission to conduct the study was obtained from the Chairman and Medical Officers of Health of the LGAs before commencement of the study.

The purpose and nature of the study was communicated to the respondents; informed, written consent was obtained from them prior to participation in the study; and anonymity of respondents was maintained by non-use of identifiers and personal information. They were also informed that they could decide not to participate or opt out at any time.

3.14. Limitations of the study.

The information from the mothers was based on their recall and the time lag (for older children) may have made recall more challenging. Thus, to reduce these potential biases, short term dietary recall (24 hours and 7 days) were required. Also, most practices measured were current practices. In addition, pictures of food groups were displayed for mothers to identify.

To reduce error with the measurements; the instruments were standardized daily.

Mothers may have moved from one practice to another and then moved back to the previous one and due to the cross sectional nature of this study, the practice being assessed as being associated with the nutritional status of the children is the current practice. The effect of current practices will not show on the child due to this study design. Children may also have been offered foods by others without the mother’s knowledge and she would not be able to account for it while being interviewed. Due to the cosmopolitan nature of Lagos, the results from this study may not be generalizable to all the rural and urban areas of Nigeria.

Chapter Four

RESULTS

Four hundred and ninety six respondents with children aged 6-24 months were recruited in Badagry (rural) and Surulere (urban) LGAs of Lagos state (248 mother-child pairs from each LGA). All the selected respondents were mothers. Six sessions of Focus Group

Discussions, three in each study site (one each among mothers, fathers and health care workers) held in the rural and urban areas. A total of 48 individuals (mothers, fathers and health care workers) participated in the six sessions.

Table 1: Demographic characteristics of respondents in the rural and urban areas. Characteristic Rural Area Urban Area Test statistic P value

n=248(%) n=248 (%) Mother’s age (years) 15-34 212 (85.5) 184 (74.2) 35-54 36 (14.5) 64 (25.8) t-Test = -4.566 Mean (SD) 28.9 (5.53) 31.2 (5.50) df = 494 <0.001*

Marital status Married 241 (97.2) 245 (98.8) X2 = 2.967 Single 7 (2.8) 3 (1.2) df = 1 0.459!

Type of marriage Monogamous 207 (86.6) 230 (94.7) X2 = 9.200 Polygamous 32 (13.4) 13 (5.3) df = 1 0.002*

Religion Christianity 168 (67.7) 170 (68.5) X2 = 2.012 Islam and other 80 (32.3) 78 (31.5) df = 1 0.572!

*Statistically significant p value. ! Exact p value used.

Table 1 shows that 212 (85.5%) mothers in the rural area were 34 years and younger when compared with 184 (74.2%) mothers in the urban area. The mean age of mothers in the rural area was significantly lower (28.9±5.53 years) than that of mothers in the urban area

(31.2±5.50 years; p <0.001). Monogamous marriages were more prevalent in both areas; however, polygamy was twice as common [32 (13.2%)] in the rural area than the urban area

[13 (5.3%)]. Most of the respondents in both study areas that is 241 (97.2%) in the rural and

245 (98.8%) in the urban were ever married. Christianity was the most prevalent religion in both areas as it was practised by 168 (67.7%) respondents in the rural area and 170 (68.5%) respondents in the urban area.

Table 2: Socio-economic characteristics of respondents in the rural and urban areas. Characteristic Rural Area Urban Area Test statistic P value n=248 (%) n=248 (%) Mother’s education (E) E-Category 1 2 (0.8) 7 (2.8) E-Category 2 27 (10.9) 10 (4.0) E-Category 3 13 (5.2) 74 (29.8) E-Category 4 92 (37.1) 116 (46.8) X2 = 90.509 E-Category 5 114 (46.0) 41 (16.5) df = 4 < 0.001* Father’s education (E) E-Category 1 10 (4.0) 4 (1.6) E-Category 2 28 (11.3) 15 (6.0) E-Category 3 18 (7.3) 78 (31.5) E-Category 4 114 (46.0) 138 (55.6) X2 = 92.716 E-Category 5 78 (31.5) 13 (5.2) df = 4 < 0.001* Mother’s occupation (O) O-Category 1 1 (0.4) 5 (2.0) O-Category 2 4 (1.6) 10 (4.0) O-Category 3 132 (53.2) 148 (59.7) O-Category 4 76 (30.6) 48 (19.4) X2 = 12.531 O-Category 5 35 (14.1) 37 (14.9) df = 4 0.014* Father’s occupation (O) O-Category 1 7 (2.8) 14 (5.6) O-Category 2 10 (4.0) 13 (5.2) O-Category 3 100 (40.3) 119 (48.0) O-Category 4 112 (45.2) 99 (39.9) X2 = 16.810 O-Category 5 19 (7.7) 3 (1.2) df = 4 0.002* Social class Class I (Upper Upper) 1 (0.4) 0 (0.0) Class II (Lower Upper) 10 (4.0) 16 (6.5) Class III (Middle) 36 (14.5) 66 (26.6) Class IV (Upper Lower) 160 (64.5) 159 (64.1) X2 =35.295 Class V (Lower Lower) 41 (16.5) 7 (2.8) df = 4 < 0.001* Mother’s monthly income (N) < 20000 178 (71.8) 101 (40.7) >20001 70 (28.2) 147 (59.3) Mean (SD) 22,790 (47,720) 29,840 (26,310) t-Test=-2.037 df =494 0.042* *Statistically significant p value. ! Exact p value used.

Table 2 shows that more urban mothers [207 (83.4%)] had completed post-primary education

(E-Categories 1-4) when compared with 134 (54%) rural mothers who had. Similarly, more urban fathers [235 (94.8%)] had completed post-primary education than rural fathers [170

(68.6%)]. O-Categories 3 and 4 occupations were the most prevalent in both groups and among the fathers and mothers; however, more fathers and mothers in the urban than rural areas were in the O-Categories 1 and 2. In spite of the fact that the majority in both study sites were in social class IV [160 (64.5%) in the rural area and 159 (64.1%) in the urban]; only 7 (2.8%) urban respondents were in class V when compared with 41 (16.5%) rural respondents who were. In addition, more urban respondents 66 (26.6%) than rural respondents 36 (14.5%) were in class III (p<0.001). Most of the mothers in the rural area 178 (71.8%) earned N20,000 and less monthly while 101 (40.7%) of urban mothers earned less than N20,000 monthly. There was a significant difference in the mean of monthly income of mothers in both areas (p =

0.042) with urban mothers having a higher mean. All the socio-economic characteristics of respondents were significantly associated with their residence (p<0.05): having more years of education, higher categories of occupation, and more income was associated with mothers and fathers in the urban area than the rural area.

Table 3: Household characteristics in the rural and urban areas. Characteristic Rural Urban Test statistic P value n =248 (%) n =248 (%) Family size < 4 152 (61.3) 151 (60.9) 5-6 79 (31.9) 82 (33.1) > 7 17 (6.9) 15 (6.0) Mean (SD) 4.4 (1.35) 4.4 (1.44) t-Test = 0.194 df =494 0.847 Number of rooms the family Lives in < 2 211 (85.1) 217 (87.5) 3-4 34 (13.7) 29 (11.7) > 5 3 (1.2) 2 (0.8) Mean (SD) 1.75(0.87) 1.92 (0.77) t-Test = -2.293 df =494 0.022*

House ownership Family 117 (47.2) 22 (8.9) Rented apartment 131 (52.8) 224 (90.3) Squatter settlement 0 (0.0) 2 (0.8) X2 = 91.291 df = 2 < 0.001*!

Connected to public power supply Yes 213 (85.9) 247 (99.6) No 35 (14.1) 1 (0.4) X2 = 34.624 df = 1 < 0.001*

Method of disposal of faeces Water closet 81 (32.7) 218 (87.9) Pit latrine 96 (38.7) 24 (9.7) Dumping in the bush /water 71 (28.6) 6 (2.4) X2 = 160.843 df = 2 < 0.001*!

Source of water Borehole 190 (76.6) 87 (35.1) Well 47 (19.0) 63 (25.4) Government supply 11 (4.4) 95 (38.3) Others 0 (0.0) 3 (1.2) X2 = 110.193 df = 3 < 0.001*! *Statistically significant p value. ! Exact p value used.

Table 3 shows that 152 (61.3%) mothers in the rural area and 151 (60.9%) mothers in the urban area had a family size of ≤ 4. The majority [211 (85.1%) in the rural] and 217 (87.5%) in the urban) live in two rooms or less. Almost half [117 (47.2%)] of rural respondents live in a family owned apartment while only 22 (8.9%) urban respondents did. Almost all [224 (90.3%)] urban respondents and about half [131 (52.8%)] of rural respondents lived in rented apartments. Almost all the houses in the urban area [247 (99.6%)] are connected to public power supply while 213 (85.9%) houses in the rural area are connected. While only a third of households in the rural area use the water closet to dispose their faeces, pit latrine was the most common and was used by 96 (38.7%) households. However, the water closet was the most commonly used method among urban respondents [218 (87.9%)] and the pit latrine was used by only 24 (9.7%) urban respondents. Boreholes were the most common source of water in the rural area [190 (76.6%)]; however, it was used by only 87 (35.1%) urban families. There was no statistically significant difference in the family size in both areas; however, statistically significant differences (p<0.001) were shown in the other household characteristics.

Table 4: Maternal characteristics in the rural and urban areas. Characteristic Rural Area Urban Area Test statistic P value n =248 (%) n =248 (%) Mother’s total live births < 4 233 (94.0) 236 (95.2) 5-6 14 (5.6) 10 (4.0) >7 1 (0.4) 2 (0.8) Mean (SD) 2.5 (1.2) 2.4 (1.2) t-Test = 1.116 df =494 0.265

Mother’s living children < 2 151 (60.9) 150 (60.5) 3-4 83 (33.5) 86 (34.7) > 5 14 (5.6) 12 (4.8) Mean (SD) 2.4 (1.2) 2.4 (1.1) t-Test = 0.230 df =494 0.818

Table 4 shows that 233 (94.0%) mothers in the rural area and 236 (95.2%) mothers in the urban area had ≤ 4 total live births; and about the same number had ≤4 total living children. There were no statistically significant differences in the mothers’ total number of live births and total living children in the rural and urban areas (p>0.05).

Table 5: Child characteristics in rural and urban areas. Characteristic Rural Area Urban Area Test statistic P value

n =248 (%) n =248 (%) Age (months) 6-8 50 (20.2) 87 (35.1) 9-11 54 (21.8) 56 (22.6) 12-24 144 (58.1) 105 (42.3) Mean (SD) 13.3 (5.1) 11.5 (4.7) t-Test = 4.171 df = 494 <0.001*

Gender Male 125 (50.4) 116 (46.8) Female 123 (49.6) 132 (53.2) X2 = 0.654 df = 1 0.419

Birth order < 2 148 (59.7) 155 (62.5) 3-4 86 (34.7) 83 (33.5) > 5 14 (5.6) 10 (4.0) Mean (SD) 2.4 (1.2) 2.3 (1.2) t-Test = 1.229 df =494 0.220

*Statistically significant p value.

Table 5 shows that children aged 12-24months were the most prevalent among respondents in both areas: 144 (58.1%) in the rural area and 105 (42.3%) in the urban area. Male and female children were almost equally distributed in both groups and 148 (59.7%) children in the rural area and 155 (62.5%) children in the urban area were first or second children. There were no statistically significant differences in the gender and birth order of children in the rural and urban areas (p>0.05): however, age group distribution had a statistically significant difference

(p < 0.001) between the two areas.

Table 6a: Mothers with correct knowledge on breastfeeding in the rural and urban areas. Knowledge Area Rural Urban Test statistic Breastfeeding (is/should be) n=248 (%) n=248 (%) X2 (Df = 1) P value Commenced in the 1st hour 175 (70.6) 207 (83.5) 11.663 0.001*

Commenced after first stool 198 (79.8) 222 (89.5) 8.95 0.003*

Includes giving colostrum 219 (88.3) 236 (95.2) 7.684 0.006*

Colostrum is nutritious 221 (89.1) 235 (94.8) 5.330 0.021*

Excludes pre-lacteal herbs 216 (87.1) 232 (93.5) 5.905 0.015*

Excludes pre-lacteal water 193 (77.8) 145 (58.5) 21.399 <0.001* Bonds mother/child 232 (93.5) 246 (99.2) 11.299 0.001*

Prevents certain diseases 230 (92.7) 241 (97.2) 5.097 0.024*

Cost effective 196 (79.0) 202 (81.5) 0.458 0.499

Duration > 3 months 229 (92.3) 146 (58.9) 75.305 < 0.001*

Not exclusive for one year 223 (89.9) 171 (69.0) 33.373 < 0.001*

Is enough for the 1st 6 months 223 (89.9) 128 (51.6) 87.954 < 0.001*

Not be stopped once eating 219 (88.3) 219 (88.3) 0.00 1.000 *Statistically significant p value.

Table 6a shows that more urban mothers [207 (83.5%)] than rural mothers [175 (70.6%); p =

0.001] knew that breastfeeding should be commenced within the first hour of birth. In the urban area, 236 (95.2%) mothers knew that colostrum should be given to a newborn while 219

(88.3%) mothers in the rural area did (p = 0.006). Almost all urban mothers [246 (99.2%)] knew that breast feeding bonds the mother and child while 232 (93.5%) rural mothers knew (p

= 0.001). More mothers in the rural area [193 (77.8%)] than the urban area [145 (58.5%)] knew that a newborn should not be given water before commencement of breastfeeding (<0.001).

More rural mothers [223 (89.9%)] also knew that breast milk alone is enough for the first 6 months of life when compared with 128 (51.6%) urban mothers who did. More mothers in the rural area correctly answered questions on breastfeeding duration than mothers in the urban area. More mothers in the urban area had the correct responses to all the other questions except for the question on discontinuing breastfeeding once other feeds are established where an equal number of mothers had the correct response. The same number of mothers in both areas [219

(88.3%)] knew that breastfeeding should not be discontinued in children older than 6 months even after complementary feeding is established.

SUMMARY OF FGD.

Knowledge on breastfeeding

a) The best food for the baby

All the rural and urban respondents said that breast milk and colostrum are best for the baby.

“The mother’s breast milk is best for the baby before 6 months”. – Rural mother

“It is very very good.” – Rural father

“Our mothers told us to discard it. They did not know better.” - Rural health worker

“Breast milk is best.” – Urban mother

“The baby should get breast milk.” – Urban father

“Breast milk is best for the newborn.” – Urban health worker

b) Exclusive breastfeeding

In the rural and urban communities, all the respondents knew that exclusive breastfeeding is giving a child breast milk for six months. Some of the respondents said it included addition of water and drugs.

“Giving the baby breast milk and paracetamol.” - Urban mother

“Giving the baby breast milk with water. There is no need to give your baby paracetamol except the baby is sick or when the baby gets vaccinated. I can count the number of times my baby has taken paracetamol and multivitamins and he is very healthy.” - Urban mother

“It is giving the baby ordinary breast milk without any other thing till age 6 months but I think

6 months is too long” – Rural mother

“It is giving no other food, herbs or drinks to a newborn till 6 months of age.” - Urban health worker.

“Giving the baby breast milk alone for the first 9 months. Water should not be added until about 7 months. I am Ijebu. We don’t give water.”-Urban Father

“It is giving a newborn baby breast milk alone for the first 6 months of life. No water, no drug”- Rural father

“Giving the baby breast milk, water and multivitamins for 6 months. It has to be with multivitamins. I have never heard that we breast feed without water or multivitamins. The baby must take multivitamins” - Urban mother

“Let us be sincere with ourselves. Breastfeeding the baby without water will make the baby have problems with pooping. The mother then needs to take a lot of fluids so that the baby will not have constipation”. - Urban mother

“It is giving the baby breast milk and water with paracetamol also”. – Rural health worker

c) Adequacy of breast milk.

Differing opinions were expressed with respect to the adequacy of breast milk. Health care workers in both areas said that breast milk is enough for both thirst and nutrients. The view of a rural mother is that it does not have enough nutrients for the boys till six months.

Thirst was the reason given by an urban mother for the early introduction of other feeds.

“It depends on the nature of the baby. For a baby boy, breast milk alone is not enough I stay two hours breastfeeding my baby. I was trying to push him to 4 months before adding but he did not agree. I had to add.” - Rural mother

“I believe the 6 months is based on research and it is supposed to be enough but from my personal experience and what I have seen around, it is not advisable. Children that are exclusively breastfed do not accept other feeds on time and that is challenging. I had to add water and local meals at 5 months. So my child eats well now. I did not allow my baby to wait till 6 months.” – Rural father

“My first baby did not get any other thing till 6 months and he is very healthy- no illness”. -

Urban mother

“He may not be ill but you will notice the way he drank water the first time you offered it – like you have been starving him. The way this small boy is, once he sees a sachet of water, he jumps at it and opens his mouth. They get really thirsty.” – Urban mother

“Breast milk alone is enough. It has enough water to quench thirst.” - Rural health worker

“It is enough and it is protective. The baby may get thirsty but the water in breast milk is enough.” - Urban health worker

Table 6b: Mothers with correct knowledge on complementary feeding in the rural and urban areas. Knowledge area Rural Urban Test P value n=248 (%) n=248 (%) statistic Complementary feeding (Df = 1) (is / should ) X2 Not commence at 4 months 174 (70.2) 213 (85.9) 17.884 < 0.001*

Not wait to cut first tooth 213 (85.9) 231 (93.1) 6.960 0.008*

Not wait for crawling 211 (85.1) 209 (84.3) 0.062 0.803

2-3 meals plus breast milk 205 (82.7) 231 (93.1) 12.817 < 0.001* daily for 6-8 month old.

3-5 meals plus breast milk 182 (73.4) 221 (89.1) 20.129 < 0.001* daily for 9-24 month old.

Meats and legumes help 236 (95.2) 245 (98.8) 5.568 0.018* growth

More than one egg a week 101 (40.7) 198 (79.8) 79.230 < 0.001*

Excludes force feeding 165 (66.5) 173 (69.8) 0.594 0.441

< 2 years should own plates 214 (86.3) 218 (87.9) 0.287 0.592

Actively encourage to eat 200 (80.6) 174 (70.2) 7.348 0.007*

Family/community support 130 (52.4) 66 (26.6) 34.551 < 0.001*

Not waiting to feed a sick 181 (73.0) 200 (80.6) 4.087 0.043* child.

*Statistically significant p value.

Table 6b shows that more urban mothers [213 (85.9%)] than rural mothers [174 (70.2%)] knew that complementary feeding should not be commenced at four months (p<0.001). Similarly, more urban mothers [231 (93.1%)] than rural mothers [213 (85.9%)] knew that the baby need not cut its first tooth before introduction of complementary feeds (p= 0.008). More of the mothers in the urban area [231 (93.1%)] than the rural area [205 (82.7%)] knew the recommended 2-3 meals in addition to breast milk for a 6-8 month old (p<0.001). More of the mothers in the urban area [221 (89.1%)] than the rural area [182 (73.4%)] knew the recommended 3-5 meals in addition to breast milk for a 9-24 month old (p<0.001). More mothers in the urban area [198 (79.8%)] knew a child could be given more than an egg per week while about half that number [101 (40.7%)] knew in the rural area. About two thirds in both study sites knew that a child should not be force fed (p = 0.441). The majority in both study sites [214 (86.3%); 218 (87.9%)] knew that children less than two years should have their own plates. This was not statistically significant (p = 0.592). Two hundred mothers in the rural area (80.6%) knew that children should be encouraged to eat while fewer mothers [174

(70.2%)] in the urban area knew. A little over half of the mothers in the rural area [130

(52.4%)] knew that they need the support of the family and the community to feed their babies while only about a quarter of mothers in the urban area [66 (26.6%)] knew (<0.001).

SUMMARY OF FGD

Knowledge on complementary feeding

a) Complementary feeding

Many of the respondents knew that complementary feeding is the introduction of feeds at 6 months however, some of the respondents did not know. Some of the respondents did not agree with the duration in spite of their correct knowledge of the time of introduction.

“Complementary feeding is adding infant formula before a child turns 6 months. I think breast milk alone is not enough till 6 months. People say exclusive breast feeding should extend till 6 months but for children of nowadays, breast milk is not enough till 6 months. The baby will not be alright on breast milk alone. One needs to shuffle with formula- at least according to me”

- Rural mother

‘’Complementary feeding can be given from between 3-4 months. Money is a factor. It makes a parent introduce other meals earlier- parents may not be able to start infant formula because they need to purchase it every three days. – Rural father

“Complementary feeding depends on your perspectives and your beliefs. I think breastfeeding is western culture. I believe in the traditional way. My baby should only take breast milk for 1 month then he should start taking pap with palm oil and other meals. Complementary feeding can start at any age and it is with local meals and pap.” – Urban father

“Complementary feeding starts at 6 months and combines normal adult semi-solid meals with breast milk. It is supplementing breast milk with other nutrients. By 6 months, breast milk will not be enough and they need other foods to sustain them.” - Urban health worker.

“I will say it is adding food from about 4 months of age because some children lose weight before 6 months.”- Urban health worker

“Complementary feeding is adding another meal apart from breast milk and water. It is what you start to feed the baby with after 6 months.”- Urban mother

“Complementary feeding is adding cereals or staple home meals to breast milk from 6 months of age. By 6 months, breast milk alone is not enough. Complementary feeds have to be appropriate and adequate enough to supplement the breast milk. And a mother needs to be mindful of the way she prepares it and the quantity she gives her baby.”- Rural health worker

“It is the process of introducing cereals, semi- solids and solids to babies from 6 months of age to help them to be active. At 6 months, breast milk alone will not be enough. This will help the baby to grow and helps relieve the mother of some stress because babies suck breast milk less when they start complementary feeds.”- Rural health worker

b) Age of introduction of complementary feeds.

The majority of respondents particularly in the urban area think feeds should be added at an earlier age than 6 months. Health care workers in the urban centre also did not think that a mother should wait till 6 months before introducing feeds. Gender differences stating that boys eat more were raised also in the rural area.

“I don’t think a mother should wait till 6 months - especially with boys. Girls and boys are not the same. Boys take more food so no exclusive breastfeeding”. – Rural mother

“To leave a baby till 6 months on only breast milk without water without anything else will make the baby lose weight. Some babies lose weight before that 6 months. As the baby turns 4 months, one can start to add other meals so that the baby will not lose weight.” - Rural mother

“Due to the economy, I will say three months is fine. Some three month old babies fight for food like the 7 month old. So from 3 months, we should introduce other feeds.” – Rural father

It should be six months for me. Because the 6 months was based on research and it should not be changed. I introduce at 5 months but the baby was rejecting the food most of the time. So we majorly breastfed for 6 months; and my baby doesn’t get sick because of this. Even if the baby takes other feeds early, it is still good to give breast milk predominantly (>80%) for 6 months.

– Rural father

According to the nurses and doctors, the time is 6 months but I don’t agree. In my opinion, it should be 3 months. Once you wait until they are 6 months old, they refuse those meals when they are offered. – Urban father

Children start to show interest from about 2 months- we should let them taste food from that time. My baby started to show interest about then and so I started other feeds gradually but I stabilised them at about 5 months. – Urban health worker

Before we were instructed to advise mothers on Exclusive breastfeeding from 6 months, we were introducing feeds at 4 months. Children ate better then – even they take breast milk better. I will say the semi-solids should be introduced at 4 months. – Urban health worker

“Feeds should be added after 6 months except the mother is ill. This is the reason why a baby can be given other meals earlier.”- Rural health worker

“A mother can add feeds at 3 months.” – Urban mother

c) Acceptable foods for babies

Respondents generally volunteered infant formula and staple home meals as the most acceptable feeds to give babies. However, health workers in the urban centres recommended

95 infant formula, cereals and mixed gruels to start with. In the rural centre, the issue of cost of cereals came up and that was a determinant of what they fed their babies.

“You can give your baby milk, semo or amala and ewedu, crayfish and egg custard.” - Rural mother

“Peeled beans and egg custard are book matters as far as I am concerned. My wife doesn’t have the time to peel beans and cook a quarter of a cup per time; out of which the baby will take a spoon and we will store the rest in the fridge where it will start to lose taste; they didn’t work for me. My children take amala and ewedu or okro; and titus fish is a good way out.

Infant formula was offered at 7 months but the baby didn’t take it either. My wife makes a mix of 11 foods (fish, crayfish and grains); lightly roasted ground and made into a soft pap. We mix that with infant formula and my baby loves that a lot.”- Rural father.

Some mothers do not have much money so soft semo with ewedu and crayfish. Many families cannot afford the cereals. They are costly. One can also give pap, peeled beans with tomatoes.

- Rural health worker

“Plantain or potatoes with butter. Whatever one eats, one can give but one should avoid giving eba.”- Urban mother

“Cereals and mashed potatoes with eggs.”- Urban father

“Cereals, amala and ewedu and pap. They can’t digest noodles well yet.”- Urban health worker

d) Foods to be avoided in babies

Carbohydrates like yam and cassava based foods such as garri, eba and fufu came up as the most mentioned foods not to give children. Allergies and taboos were also reasons for

96 which certain foods should be avoided. However, in the rural area, issues of availability came up as reasons why any food can be fed to the baby.

“Yes, there are. A baby should not eat eba, fufu, garri and rice. One should limit carbohydrates. Children should get more proteins. But there is a way we were taught in clinic that one can cook the carbohydrate and add proteins and it will be good for the baby but only after one year.” - Rural mother

“Human beings generally do not have food taboos. Only foods they react to should be avoided.

A two year old can take any food. Growing up, I was not told to avoid any meals. Even by education. Any child can eat anything except the child refuses. Even when the child has diarrhoea, it may be due to hygiene not a reaction” – Rural father

“Fufu should be avoided because it is too hard but whatever food the mother has will be fed to the baby. God will save the child.” – Rural health worker

“A child can eat yam when it is boiled but roasted yam and fufu should be avoided.” – Urban mother

“Yes. Foods like Eba and fufu should be avoided.” Urban father

“Yes. Dry yam and unpeeled beans should be avoided.” – Urban health worker

e) Source of information on child feeding

Family tradition is still being upheld amongst mothers and fathers in the rural and urban centres; however, some mothers in both areas also check the internet to update their information while health workers in both areas get information from trainings and books.

“I get my information from experienced mothers and grandmothers. Some of the information that we are given in the clinics are not appropriate for the baby. For example, I tried to give

97 my baby egg custard and he refused, but when I took to the advice of my mother in-law at home, the local meals they told me to give works well. So I just packed aside the information from the hospital and concentrate on the things they tell us at home and it is always best. What they say always works.” - Rural mother

“From healthcare workers and internet but I prefer the internet. Many mothers give advice. I just say thank you and continue with what I was doing.” – Urban mother

“I get information from my parents and the hospital. But when there is a conflict, I follow my family 60% of the time. My parents say that any child that is formula fed will become an animal – on those grounds, I disagree with the health worker and follow my parents”. – Urban father

“My parents, relatives and surroundings are the primary sources but these information need to be modified.”- Rural father

“I was lectured in school, heard at training and read in books. I also read online.” – Rural health worker

“I get my information from nutrition companies and the internet. I also learn from seminars.”

– Urban health worker

Figure I shows knowledge grade of mothers on child feeding in both communities.

Figure I show that the majority of mothers in the rural area [183 (74%)] and the urban area

[197 (79%)] had good knowledge with more mothers in the urban than the rural area having good knowledge. However, about 2% (6 mothers in the rural and 4 mothers in the urban) had poor knowledge.

The mean knowledge score was 20.10 ±3.42 in the rural area and 20.20 ±2.61 in the urban area. There was no statistically significant difference (p=0.734) between the level of knowledge on child feeding in the rural and urban areas.

Table 7: Association between demographic characteristics and the level of knowledge of respondents on child feeding. Characteristic Rural area Urban area Poor Fair Good Test P value Poor Fair Good Test P value n (%) n (%) n (%) statistic n (%) n (%) n (%) statistic Mother’s age (years) 15-34 4 (1.9) 48 (22.6) 160 (75.5) 4 (2.2) 36 (19.6) 144 (78.3) 35-54 2 (5.6) 11 (30.6) 23 (63.9) X2= 16.646 0 (0.0) 11 (17.2) 53 (82.8) X2 = 4.059 df = 2 0.021*! df = 2 0.576!

Marital status Married 5 (2.1) 59 (24.5) 177 (73.4) 4 (1.6) 46 (18.8) 195 (79.6) Single 1 (14.3) 0 (0.0) 6 (85.7) X2 = 6.782 0 (0.0) 1 (33.3) 2 (66.7) X2 = 0.957 df = 4 0.152! df = 6 1.0!

Type of marriage Monogamous 3 (1.4) 50 (24.2) 154 (74.4) 3 (1.3) 41 (17.8) 186 (80.9) Polygamous 2 (6.3) 9 (28.1) 21 (65.6) X2 = 3.521 1 (7.7) 5 (38.5) 7 (53.8) X2 = 6.949 df = 2 0.182! df = 2 0.029*!

Religion Christianity 5 (3.0) 43 (25.6) 120 (71.4) 2 (1.2) 29 (17.1) 139 (81.8) Islam and other 1 (1.3) 16 (20.0) 63 (78.8) X2 = 2.793 2 (2.6) 18 (23.1) 58 (74.4) X2 = 2.029 df = 4 0.431! df = 4 0.374!

*Exact p value used.

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Table 7 shows that in both areas, more than three quarters of younger mothers aged 15-34 years had good knowledge. More mothers aged 35-54 years in the urban area [53 (82.8%)] had good knowledge when compared with those who did [23 (63.9%)] in the rural area. The majority of mothers with good knowledge were 34 years and younger in the rural area [160

(87.4%)] and the urban area [144 (73.1%)]. A statistically significant association between maternal age and the level of knowledge on child feeding (p=0.021) was shown in the rural area. The majority of mothers who had good knowledge in both areas were in monogamous marriages. However, the proportion was higher in the urban area [186 (80.9%)]. A statistically significant association was shown between the type of marriage and the level of knowledge on child feeding in the urban area (p=0.029).

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Table 8: Association between family characteristics and the level of knowledge of respondents on child feeding. Characteristic Rural area Urban Area Poor Fair Good Test P value Poor Fair Good Test P value n (%) n (%) n (%) statistic n (%) n (%) n (%) statistic Mother’s children < 2 5 (3.3) 30 (19.9) 116 (76.8) 3 (2.0) 32 (21.3) 115 (76.7) 3-4 1 (1.2) 25 (30.1) 57 (68.7) 0 (0.0) 15 (17.4) 71 (82.6) > 5 0 (0.0) 4 (28.6) 10 (71.4) X2 = 4.343 1 (8.3) 0 (0.0) 11 (91.7) X2 = 8.190 df = 4 0.331! df = 4 0.079

Age (months) 6-8 1 (2.0) 8 (16.0) 41 (82.0) 2 (2.3) 14 (16.1) 71 (81.6) 9-11 0 (0.0) 17 (31.5) 37 (68.5) 1 (1.8) 11 (19.6) 44 (78.6) 12-24 5 (3.5) 34 (23.6) 105 (72.9) X2 = 5.298 1 (1.0) 22 (21.0) 82 (78.1) X2 = 1.240 df = 4 0.249! df = 4 0.891!

Child’s gender Male 3 (2.4) 25 (20.0) 97 (77.6) 0 (0.0) 26 (22.4) 90 (77.6) Female 3 (2.4) 34 (27.6) 86 (69.9) X2 = 2.018 4 (3.0) 21 (15.9) 107 (81.1) X2 = 4.987 df = 2 0.393! df = 2 0.078!

Family size < 4 4 (2.6) 30 (19.7) 118 (77.6) 3 (2.0) 30 (19.9) 118 (78.1) 5-6 1 (1.3) 25 (31.6) 53 (67.1) 0 (0.0) 16 (19.5) 66 (80.5) > 7 1 (5.9) 4 (23.5) 12 (70.6) X2 = 5.213 1 (6.7) 1 (6.7) 13 (86.7) X2 = 5.245 df = 4 0.247! df = 4 0.230!

!Exact p value used.

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Table 8 shows that the majority of mothers in both study sites have good knowledge. More mothers of children aged 6-8 months in the rural [41 (82%)] and urban areas [71 (81.6%)] had good knowledge. These were however not statistically significant in both study areas. In the rural area, more mothers of male children [97 (77.6%)] had good knowledge when compared with the urban area [90 (77.6%)]. Fewer mothers of female children in the rural area [86

(69.9%)] than mothers of female children [107(81.1%)] in the urban area had good knowledge.

No statistically significant association was found between family characteristics and level of knowledge of respondents.

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Table 9: Association between socioeconomic characteristics and the level of knowledge of respondents on child feeding. Characteristic Rural area Urban area Poor Fair Good Test P value Poor Fair Good Test P value n (%) n (%) n (%) statistic n (%) n (%) n (%) statistic Mother’s education E-Category 1 0 (0.0) 0 (0.0) 2 (100.0) 0 (0.0) 2 (28.6) 5 (71.4) E-Category 2 0 (0.0) 2 (7.4) 25 (92.6) 1 (10.0) 4 (40.0) 5 (50.0) E-Category 3 0 (0.0) 0 (0.0) 13 (100.0) 1 (1.4) 18 (24.3) 55 (74.3) E-Category 4 3 (3.3) 21 (22.8) 68 (73.9) X2 = 14.543 0 (0.0) 13 (11.2) 103 (88.8) X2 = 20.265 E-Category 5 3 (2.6) 36 (31.6) 75 (65.8) df = 8 0.095! 2 (4.9) 10 (24.4) 29 (70.7) df = 8 0.021*!

Father’s education E-Category 1 0 (0.0) 1 (10.0) 9 (90.0) 0 (0.0) 1 (25.0) 3 (75.0) E-Category 2 1 (3.6) 3 (10.7) 24 (85.7) 1 (6.7) 7 (46.7) 7 (46.7) E-Category 3 0 (0.0) 1 (5.6) 17 (94.4) 1 (1.3) 17 (21.8) 60 (76.9) E-Category 4 4 (3.5) 33 (28.9) 77 (67.5) X2 = 11.312 1 (0.7) 17 (12.3) 120 (87.0) X2 =22.605 E-Category 5 1 (1.3) 21 (26.9) 56 (71.8) df = 8 0.175! 1 (7.7) 5 (38.5) 7 (53.8) df = 8 0.021*!

Mother’s occupation O-Category 1 0 (0.0) 0 (0.0) 1 (100.0) 1 (20.0) 4 (80.0) 0 (0.0) O-Category 2 0 (0.0) 0 (0.0) 4 (100.0) 0 (0.0) 3 (30.0) 7 (70.0) O-Category 3 1 (0.8) 32 (24.2) 99 (75.0) 3 (2.0) 25 (16.9) 120 (81.1) O-Category 4 1 (1.3) 24 (31.6) 51 (67.1) X2 = 21.433 0 (0.0) 12 (25.0) 36 (75.0) X2 = 31.176 O-Category 5 4(11.4) 3 (8.6) 28 (80.0) df = 8 0.031*! 0 (0.0) 3 (8.1) 34 (91.9) df = 8 0.003*!

Father’s occupation O-Category 1 0 (0.0) 1 (14.3) 6 (85.7) 0 (0.0) 5 (35.7) 9 (64.3) O-Category 2 0 (0.0) 0 (0.0) 10 (100.0) 0 (0.0) 4 (30.8) 9 (69.2) O-Category 3 3 (3.0) 23 (23.0) 74 (74.0) 1 (0.8) 21 (17.6) 97 (81.5) O-Category 4 2 (1.8) 30 (26.8) 80 (71.4) X2 = 5.741 3 (3.0) 17 (17.2) 79 (79.8) X2 = 6.833 O-Category 5 1 (5.3) 5 (26.3) 13 (68.4) df = 8 0.654! 0 (0.0) 0 (0.0) 3 (100.0) df = 8 0.466

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Characteristic Rural area Urban area

Poor Fair Good Test P value Poor Fair Good Test P value n (%) n (%) n (%) statistic n (%) n (%) n (%) statistic Social class Class I 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) Class II 0 (0.0) 0 (0.0) 10 (100.0) 1 (6.3) 8 (50.0) 7 (43.8) Class III 0 (0.0) 4 (11.1) 32 (88.9) 1 (1.5) 14 (21.2) 51 (77.3) Class IV 4 (2.5) 46 (28.7) 110 (68.8) X2 = 11.617 2 (1.3) 23 (14.5) 134 (84.3) X2 = 15.851 Class V 2 (4.9) 9 (22.0) 30 (73.2) df = 8 0.130! 0 (0.0) 2 (28.6) 5 (71.4) df = 6 0.028*!

Monthly income < 20000 5 (2.8) 45 (25.3) 128 (71.9) 2 (2.0) 19 (18.8) 80 (79.2) >20001 1 (1.4) 14 (20.0) 55 (78.6) X2 = 1.287 2 (1.4) 28 (19.0) 117 (79.6) X2 = 0.145 df = 2 0.589! df = 2 1.000!

*Statistically significant p value. !Exact p value used.

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Table 9 shows that all mothers in the occupation categories 1 [1 (100%)] and 2 [4 (100%)] had good knowledge in the rural area (p= 0.031); while in the urban area, no mother in occupation category 1; and 7 (70%) mothers in the occupation category 2 had good knowledge (p= 0.003).

Social class was not found to be associated with the level of knowledge of respondents in the rural area (p>0.05) however in the urban, it was associated with knowledge as more mothers in social class IV had good knowledge (p=0.028). In the urban area, there was a statistically significant association between the level of knowledge of mothers and the mother’s and father’s education (p=0.021).

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Table 10a: Multinomial regression of factors associated with fair knowledge of respondents on child feeding. Predictor variable p Odd’s ratio 95% confidence interval Rural area Mother’s age (years) 15-24 0.509 3.3 0.09 120.35 25-34 0.159 15.7 0.34 720.26 35-44 0.595 2.8 0.06 126.90 Mother’s occupation O-Category 1 - 3.6 3.64 3.64 O-Category 2 1.000 7.8 0.00 - O-Category 3 0.009 38.5 2.47 599.47 O-Category 4 0.026 19.2 1.41 260.26 Urban area Type of marriage Monogamous 0.987 32.65×10 5 0.000 - Mother’s education E-Category 1 0.998 1.73×10 10 0.000 - E-Category 2 0.993 1.60×10 10 0.000 - E-Category 3 0.988 10.21×10 4 0.000 - E-Category 4 0.984 1.62×10 10 0.000 - Father’s education E-Category 1 1.000 3.09 0.000 - E-Category 2 0.998 7.63×10 -7 0.000 - E-Category 3 0.988 1.10×10 -6 0.000 - E-Category 4 0.988 1.60×10 -6 0.000 - Mother’s occupation O-Category 1 0.990 4.35×10 -24 0.000 - O-Category 2 0.997 3.01×10 -6 0.000 - O-Category 3 0.987 3.68×10 -12 0.000 - O-Category 4 0.999 3.45 0.000 - Social class Class II 1.000 18.94 0.000 - Class III 0.988 6.16×10 -6 0.000 - Class IV 0.174 0.17 0.014 2.17 The reference category is: Poor Knowledge.

Being a mother in occupation categories 3 (High scale farming, Middle scale trading, Clergy, junior government employee, Teachers, Technicians, Retirees, Clergy) and 4 (Artisans,

Sentries, Security agents) was found to be a predictor of fair knowledge. The odds that a mother in occupation category three will have fair knowledge is twice the odds that a mother in category 4 will and it is five times and ten times the odds that mothers in occupation categories

2 and 1 respectively will have fair knowledge.

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Table 10b: Multinomial regression of factors associated with good knowledge of respondents on child feeding. Predictor variable P value Odd’s ratio 95% confidence interval Rural area Mother’s age (years) 15-24 0.083 24.7 0.66 927.49 25-34 0.016 123.0 2.47 6122.80 35-44 0.166 15.5 0.32 745.10 Mother’s occupation O-Category 1 - 68.98×106 68.98×10 6 68.98×10 6 O-Category 2 0.999 16.38×10 7 0.0 - O-Category 3 0.047 13.3 1.04 170.02 O-Category 4 0.237 4.2 0.39 44.58 Urban area Type of marriage Monogamous 0.986 71.93×10 5 0.000 - Mother’s education E-Category 1 0.997 1.55×10 11 0.000 - E-Category 2 0.993 7.71×10 10 0.000 - E-Category 3 0.998 11.12×10 4 0.000 - E-Category 4 0.984 3.48×10 10 0.000 - Father’s education E-Category 1 0.998 5.92×10 14 0.000 - E-Category 2 1.000 4.30 0.000 - E-Category 3 0.989 2.42×10 -6 0.000 - E-Category 4 0.989 4.54×10 -6 0.000 - Mother’s occupation O-Category 1 0.987 2.07×10 -39 0.000 - O-Category 2 0.997 1.39×10 -6 0.000 - O-Category 3 0.987 1.47×10 -12 0.000 - O-Category 4 1.000 0.839 0.000 - Social class Class II 0.998 6.811×10 -7 0.000 - Class III 0.988 5.50×10 -6 0.000 - Class IV - 0.210 0.210 0.21 The reference category is: Poor Knowledge.

Being a mother in the 25-34 age group is a predictor of good knowledge. The odds of a mother in that age group having good knowledge are five and eight times the odds in mothers in the

15-24years and 35-44 years age group. Being a mother in occupation category 3 was also a predictor of good knowledge. In the urban area, no predictor factors were found for fair and good knowledge.

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Table 11: Breastfeeding practices of respondents in rural and urban areas. Practice Rural Area Urban Area Test statistic P value N=248 (%) N=248 (%) Given colostrum 231 (93.1) 240 (96.8) X2 = 3.412 df = 1 0.065

Given pre-lacteal feeds 24 (9.7) 35 (14.1 X2 = 2.328 df = 1 0.127 Pre-lacteal feeds received Plain Water 5 (20.8) 28 (80.0) Glucose Water 10 (41.7) 2 (5.7) Infant Formula 8 (33.3) 1 (2.9) X2 = 27.514 Other pre-lacteal feeds 1 (4.2) 4 (11.4) df = 3 < 0.001*!

Exclusively breastfed 215 (86.7) 200 (80.6) X2 = 3.320 df = 1 0.068 Duration of Exclusive breastfeeding 0-3 months 0 16 4-6 months 150 138 7-12 months 64 43 X2 = 21.107 13-15 months 1 3 df = 3 0.001*!

Bottle feeding 70 (28.2) 43 (17.3) X2 = 8.355 df = 1 0.004*

Age breastfeeding stopped < 4 months 1 (1.4) 2 (2.0) 6-8 months 3 (4.3) 28 (27.7) 9-11 months 3 (4.3) 11 (10.9) 12-24 months 62 (90.0) 60 (59.4) t- Test = 4.849 Mean (SD) months 14 (3.6) 11 (3.7) df = 168 <0.001*

Currently breastfeeding 179 (72.2) 147 (59.3) X2 = 9.165 df = 1 0.002* Reasons for stopping breastfeeding Child’s age 33 (47.8) 62 (61.4) Child refused breast milk 6 (8.7) 15 (14.9) Child refused other meals 11 (15.9) 11 (10.9) Mother tired 2 (2.9) 3 (3.0) Mother ill 5 (7.2) 0 (0.0) Mother’s job 2 (2.9) 6 (5.9) Mother pregnant 7 (10.1) 2 (2.0) X2 =17.484 Other reasons 3 (4.3) 2 (2.0) df = 7 0.011*!

*Statistically significant p value. ! Exact p value used.

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Table 11 shows that the majority of babies (93.1% in the rural and 96.8% in the urban) were given colostrum while only 9.7% in the rural and 14.1% in the urban were given pre-lacteal feeds. More babies in the rural area [215 (86.7%)] than the urban area [200 (80.6%)] were exclusively breastfed. There were no statistically significant differences (p>0.05) between the rural and urban areas with respect to the proportions that gave colostrum, gave pre-lacteal feeds and exclusively breastfed their babies. Statistically significant differences were found between the groups with respect to the type of pre-lacteal feeds offered: the majority of babies that were given pre-lacteal feeds in the urban area (80%) were given plain water while in the rural area,

41.7% and 33.3% of babies were given glucose water and infant formula respectively. More rural babies [70 (28.2%)] were bottle fed when compared with their urban counterparts [43

(17.3%)]. This difference was statistically significant (p=0.004). In the rural area, more children [179 (72.2%)] were currently being breastfed than the urban area [147 (59.3%)]. This was statistically significant with a p value of 0.002. Among those who had stopped breastfeeding, 90% stopped after 12 months in the rural area while 59.4% of children in the urban area stopped after 12 months with a statistically significant difference at a p value <

0.001. The mean ages that breastfeeding was stopped were 14±3.6 months (rural) and 11±3.7 months (urban) with a statistically significant p of <0.001. With respect to the reasons given for stopping breastfeeding, the child being of age was the most commonly given reason in the rural

(47.8%) and the urban (61.4%) areas, the child’s refusal of feeds (15.9%), mother’s pregnancy

(10.1%), and illness (7.2%) were other reasons in the rural area while refusal of breast milk and other feeds (25.8%); and mother’s job (5.9%) were the other reasons given in the urban area. A statistically significant difference (p=0.011) in the reasons why breastfeeding was stopped was shown.

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Table 12: Complementary feeding practices of respondents in rural and urban areas. Practice Rural Urban Test statistic P value n =248 (%) n =248 (%) Age at first complementary feed < 4 months 12 (4.8) 50 (20.2) 4-5 months 16 (6.5) 21 (8.5) 6-8 months 196 (79.0) 163 (65.7) 9-11 months 11 (4.4) 9 (3.6) 12-24 months 13 (5.2) 5 (2.0) Mean (SD) 6.4 (2.1) 5.6 (2.3) t Test = 3.995 df = 494 < 0.001*

Complementary feeds received Cereals 77 (31.0) 44 (17.7) Milk 25 (10.1) 56 (22.6) Pap alone 22 (8.9) 79 (31.9) Pap and Milk 32 (12.9) 43 (17.3) Staples and Noodles 84 (33.9) 26 (10.5) Drinks 8 (3.2) 0 (0.0) X2 = 93.228 df = 5 < 0.001*

24 hour meal frequency recall ≤3 meals 166 (66.9) 121 (48.8) >3 meals 82 (33.1) 127 (51.2) Mean (SD) 3 (1.1) 4 (1.4) tTest= -5.593 df = 494 < 0.001*

Action -when child refuses feeds Leave the child 35 (14.1) 66 (26.6) Force feed the child 41 (16.5) 55 (22.2) Offer child favourite food 65 (26.2) 26 (10.5) Encourage/pet child 83 (33.5) 40 (16.1) Not applicable, child eats 24 (9.7) 61 (24.6) X2 = 59.409 df = 4 < 0.001*

*Statistically significant p value.

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Table 12 shows that more mothers in the rural [196 (79.0%)] than the urban [163 (65.7%)] introduced complementary feeds between the 6th and 8th month; and the mean age of introduction of complementary feeds was higher in the rural (6.4±2.1) than the urban area

(5.6±2.3; p <0.001). More mothers in the urban area [50 (20.2%)] introduced feeds before 4 months when compared with the rural area where only 12 (4.8%) mothers introduced feeds before 4 months. More than half of mothers in the urban area [ 127 (51.2%)] offered their children more than 3 meals asides breast milk in the preceding 24 hours while a third of rural mothers [ 82 (33.1)] did. The majority of mothers in the rural area [166 (66.9%)] offered their children ≤3 meals. The mean number of meals offered were lower in the rural area (3±1.1) than in the urban (4±1.4; p <0.001). More than a quarter of urban mothers [66 (26.6%)] leave their children when they refuse to eat while in the rural area, 35 (14.1%) children are left when they refuse to eat. More urban children are force-fed [55 (22.2%)] when they refused feeds when compared with 41 (16.5%) rural children who get force-fed when feeds were refused. More rural mothers offered other meals [65 (26.2%)] than urban mothers [26 (10.5%)] and more rural mothers encouraged the child to eat [ 83 (33.5%)] when feeds were refused than urban mothers [40 (16.1%)]. There were statistically significant differences (p<0.001) in the complementary feeding practices of the mothers in the rural and urban area.

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SUMMARY OF FGD.

Challenges of complementary feeding

a) T he challenges of CF and factors that affect CF.

All the fathers, mothers, and health workers; at both study sites chorused that complementary feeding is very challenging. The specific challenges that they had varied from the time spent in cooking the food separate from the general pot, the need to pay extra attention to hygiene, the need to personally feed the baby, to the cost of the meals and the fact that the babies do not get to eat substantial quantities. The type of work that the mother does was said to be a key determinant of the level of the challenge.

Power outage and seasonal variations of food crops were said to be the things in the environment that make feeding a baby challenging. Also, lack of help was a major concern for the women. Family tradition was a factor that was strongly identified in the rural area.

However, low income, a mother’s occupation and a lack of education were the factors raised during the urban sessions.

“The challenges that I face are that no matter what I am doing, once my baby starts to cry, I don’t have a choice but to abandon the work I am doing and face the baby for hours. I have to rush through my activities and meals to personally attend to my baby”. – Rural mother

“The challenges will depend on the work a woman is engaged in. As an employee, it is very challenging in fact; your boss can sack you. But if you run your own business, it is not very challenging you have time to yourself to feed your baby”. - Rural mother

“My challenge is that I need to prepare the baby’s food separately. After preparing other people’s food, I start for my baby. It takes extra time, money, dirty pots and plates- it is tiring.”

– Rural mother

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Financial challenges affect feeding- it affects all of us. We give what we have. - Rural father

“The problem is that when I have finished preparing the adults’ food, I have to start step two: cooking my baby’s food afresh. Even for the same things that we eat, I cook the baby’s own separately and it takes more time. Then I need to personally feed the baby I need to monitor the feeding due to hygiene. It stresses me.” - Urban mother

“It is challenging because it is not like breastfeeding that is readily available. One needs to cook it. It is time consuming and it is not economical”. - Urban health worker

“The meals are not economical because one needs to buy them all the time. One also needs to pay attention to hygiene and that is not easy- people can’t be allowed to help because they may feed wrongly.”- Urban health worker

“The stress comes from the refusal of the food by the baby- one doesn’t try once and stop. One needs to keep trying foods and wasting food.” - Urban health worker

“It is very challenging. Children are used to breast milk. Initially, they refuse other feeds. My first baby refused everything I made, in spite of the stress I went through. Later he accepted pap but only by force-feeding. I lie him down and I force-feed him. We do it so neatly and he didn’t have any problem with it. He never accepts it from a spoon or a bottle. He is still that way till today.” – Rural health worker

“I don’t have someone to help me. There is no one to help relieve me of my duties. If I had help, I will cook the food and leave the feeding of the baby to someone else. But it is just me suffering. My husband is hardly around and I don’t have a sister that can stay with me.” -

Rural mother

“Power outage affects it. It makes feeding the baby at night challenging – not everyone has generators and not everyone can fuel it all the time.”- Urban father

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“Food scarcity due to seasonal variations affects child feeding. We don’t always get what we want and when we change their meals, it affects them.” - Urban father

“Our tradition affects it. Our parents always remind us that they were born before us. They want us to feed our children the way they fed us. They want us to give our babies who are being exclusively breastfed water because they say the babies are thirsty. The traditional beliefs are still engrained in them so we get to fight a lot. Our mothers especially push us.” –

Rural father

“My husband’s family tradition affected me. When I had my baby, I had to take cold pap and water only for 9 days I could not take tea. That is my husband’s family culture does not permit a new mother to eat. Despite the fact that I am a health worker, I had to do that. If I knew, I wouldn’t have married them. My baby kept crying because I was not lactating. I had to give him infant formula in those 9 days.” – Rural health worker

“I don’t have a challenge with respect to money. But my education affects my baby. I leave him early in the morning to go to school. Only God knows what happens to him there- I don’t know whether they feed him well or not”. - Urban mother

“Income greatly affects it. All hands are not equal. I give what is available. Some mothers don’t give any special meals because they don’t have the means. Power also affects it. What you buy cannot be stored. The environment also affects it because there are some foods you cannot find in some areas” - Urban health worker

“A working mother has that challenge because of time. They don’t want to prepare meals.

They want to bottle everything up and feed the baby and give ready-made food. They don’t have time to spoon-feed.” – Urban health worker

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b) Family / community support

With respect to roles, there was a tilt in the direction of mothers who felt the real job is in baby care and their husbands were uninvolved. However; many said that the mother is responsible for the duties and fathers for the finances. In the urban site, the fathers expressed more involvement in child care than the fathers in the rural site. They said that the in-laws that come to help were said to not really be of help particularly in the urban communities where more of the mothers go to work and need people to help.

“Both parents though the fathers are only involved by asking about the baby. When my husband is at work, he calls to ask if I have fed his baby. When he gets back, he is not actively involved. In fact, when the baby is crying or playing, my husband calls me to feed the baby.”-

Rural health worker

“There is no issue with that. We all know our roles. Money alone cannot raise the child – the mother needs to go to work. It is both of them.”– Rural father

“It is the mother’s responsibility. She cooks, feeds, breastfeeds, washes clothes, rocks the baby.

It is her time that is being spent.” - Urban father

“When my mother in-law is around, she doesn’t even play with my child. I do everything. It is very stressful”. - Urban mother

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“When my mother is around, In fact, I can sleep for ‘42’ hours a day – she does all the work.

But when my mother in-law is, I work round the clock- I don’t get any help at all – she says she is here to eat the fruit of her labour and not to work.”- Urban mother

“My wife tells me to carry my baby when the baby cries at night. She tells me not to kill her because she has worked all day. We both raise them – I don’t just get money; I work at home also.”- Urban health worker

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Table 13: Twenty four hour dietary diversity recall in the rural and urban areas. Food Type Rural area Urban area Test statistic P value n =248(%) n=248 (%) X2 Df =1 Dairy products 209 (84.3) 211 (85.1) 0.062 0.803

Carbohydrate rich food 243 (98.0) 238 (96.0) 1.719 0.190

Animal protein 204 (82.3) 210 (84.7) 0.526 0.468

Plant protein 124 (50.0) 141 (56.9) 2.342 0.126

Oil/Fat 185 (74.6) 167 (67.3) 3.170 0.075

Vitamin A rich fruits/vegetables 89 (35.9) 106 (42.7) 2.442 0.118

Other fruits 157 (63.3) 149 (60.1) 0.546 0.460

Table 13 shows that in the 24 hours preceding the survey, more rural children were fed carbohydrate rich foods [243 (98.0%)], oil and fat [185 (74.6%)], and other fruits [157 (63.3)] than urban children where carbohydrate rich foods were offered to 238 (96.0%) children, oil and fat was given to 167 (67.3%), and other fruits were given to 149 (60.1%) children. More children in the urban area were offered dairy products [211 (85.1%)], animal protein [210

(84.7%)], plant protein [141 (56.9%)] and vitamin A rich fruits and vegetables [106 (42.7%)] than in the rural area where dairy products were given to 209 (84.3%) children, animal protein given to 204 (82.3%) children, plant protein given to 124 (50.0%) and vitamin A rich fruits and vegetables given to 89 (35.9%). The majority of children in both areas were offered foods from all the groups except for the vitamin A rich fruits and vegetables group. These differences were not statistically significant.

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Table 14: Seven day food group frequency recall in the rural and urban areas. Food Type Rural area Urban area Test statistic P value n =248 (%) n=248 (%) X2 Df = 1 Dairy products ≤3 days 57 (23.0) 64 (25.8) >3 days 191 (77.0) 184 (74.2) 0.536 0.765

Carbohydrate ≤3 days 22 (8.8) 17(6.9) >3 days 226 (91.1) 231 (93.1) 0.696 0.706

Animal protein ≤3 days 64 (25.8) 90 (36.3) >3 days 184 (74.2) 158 (63.7) 6.366 0.041*

Plant protein ≤3 days 168 (66.9) 127 (51.2) >3 days 82 (33.1) 121 (48.8) 13.187 < 0.001*

Oil/Fat ≤3 days 62 (25.0) 120 (48.4) >3 days 186 (75.0) 128 (51.6) 29.197 < 0.001*

Vitamin A rich fruits/vegetable ≤3 days 190 (76.6) 178 (71.8) >3 days 58 (23.4) 70 (28.2) 3.530 0.171

Other fruits ≤3 days 148(59.6) 132 (53.2) >3 days 100 (40.3) 116 (46.8) 2.099 0.350 *Statistically significant p value.

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Table 14 shows that about three quarters of mother in both areas offered their children dairy products on more than three days in the preceding seven days of the survey [191 (77% - rural) and 184 (74.2% urban)]. More urban mothers offered carbohydrates on more than three days

[231 (93.1%)] than rural mothers [226 (91.1%); p = 0.706]. More rural mothers offered their children animal protein on more than three days [184 (74.2%)] than urban mothers [158

(63.7%); p =0.041]. Almost half (48.8%) of urban mothers gave plant proteins on more than three days in the last seven days while only a third of rural mothers (33.1%) gave plant proteins on more than three days (p<0.001). Oil / fat was given on more than three days in the last seven days by three quarters of mothers in the rural area with about half of mothers in the urban area

(51.2%) giving it for more than three days in the last seven days. This difference was statistically significant (p <0.001).

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Table 15: Infant and young child feeding index and single practices scores in the rural and urban areas. Food Type Rural area Urban area Test P value n =248 (%) n = 248 (%) statistic

Dietary diversity score Low = 0 6 (2.4) 16 (6.5) Medium = 1 46 (18.5) 41 (16.5) High = 2 196 (79.0) 191 (77.0) X2 = 4.897 df = 2 0.086 Food group frequency score Low = 0 2 (0.8) 15 (6.0) Medium = 1 32 (12.9) 34 (13.7) High = 2 214 (86.3) 199 (80.2) X2 = 10.547 df = 2 0.005* Feeding frequency Low = 0 13 (5.2) 12 (4.8) Medium = 1 61 (24.6) 23 (9.3) High > 2 174 (70.2) 213 (85.9) X2 = 21.161 df = 2 < 0.001*

ICFI Score Minimum 2 1 Maximum 9 9 Mean (SD) 6.3 (1.6) 6.5 (1.9) t-Test = -1.273 df = 494 0.204 *Statistically significant p value. ! Exact p value used.

Table 15 shows that more rural mothers had high food group frequency scores [214 (86.3%)] than urban mothers [199 (80.2%); p =0.005]. However, more urban mothers [213 (85.9%)] had high feeding frequency scores than rural mothers [174 (70.2%); (p<0.001)]. A higher proportion of children in the rural area [196 (79.0%)] had high dietary diversity scores compared with 191 (77.0%) in the urban area, but the difference was not statistically significant (p =0.086). There was no statistically significant difference between the mean ICFI scores in spite of the higher mean in the urban area (6.5±1.9) than the rural area (6.3±1.6; p =

0.204).

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% 60 55 50 50 43 42 40

20 7 10 4

0 Urban Area Rural Area Poor Fair Good

Figure II: ICFI composite scores of mothers in the rural and urban areas Figure II shows the proportion of mothers in the rural and urban areas who had poor, fair and good practice. A statistically significant difference in the ICFI grade of the rural and urban areas (X2 =7.865, p=0.02) was shown. Half of the children in the urban area had a good

ICFI score while more than half of the children in the rural area (54.8%) had a fair ICFI score.

However, poor ICFI was shown in about twice as many urban children (6.9%) than rural children (3.6%).

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SUMMARY OF FGD.

Feeding practices

a) Age of introduction of feeds

The mothers in the rural site mostly waited till about 6 months to introduce other feeds. In the urban area, that was a bit different, the mothers fed earlier.

I initiated breastfeeding after 7 hours of delivery. I breastfed for 6 months and commenced such foods as semo and amala, wheat at 6 months. I waited till 6 months. - Rural mother

“During antenatal care, we were advised to clean our breast with olive oil. I did that and so my breast milk started to flow immediately and I started breastfeeding within 30 minutes of delivery.” – Rural mother

“From six to seven months is the right time to add other foods to breast milk.” – Rural father

“I started giving formula from birth because breast milk was not enough it was like water to her. And by 10 weeks, I introduced pap and she rushes that too – she sleeps well for a long time and I rest. I breast fed for 2 months only.” Urban mother

“I breastfed exclusively and give other feeds 4-5 times a day- I give him a variety of meals at different times. By one year, he started to ask for his food by carrying his plate” – Rural health worker

“My wife’s work made us start infant formula at 3 months. Other meals were added at 11 months.” – Urban father

“My wife decided to add pap between 4-6 months.” – Urban father

“My mother in-law was living with me and she started to feed my baby anything she ate from 5 months. So I just joined her.” - Urban health worker

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“I started to give other feeds at about 5 months because I notice breast milk was not enough and the weight was not increasing. By 4 months, the growth had slowed down.”- Urban health worker

“I added cereals at 5 months because of my job. I resumed from maternity leave at three months, managed for an additional two months but I couldn’t continue.” – Urban mother

b) Feeds commonly given

Staple home meals and mixed gruel made from many grains, nuts and fish were offered by the mothers in the rural area. In the urban area however, pre packaged cereals were mostly given because it was said to be less time consuming.

“After 6 months, I make the baby taste my soup. The baby’s reaction will determine when I will add other foods. I give Semo, beans, noodles. I alternate.” – Rural mother

My children don’t take other foods apart from pap. I offered pap at 6 months – we had to force-feed wit pap. Local solids were introduced after nine months. - Rural mother

“Grains which include maize, millet, guinea corn, soya beans, groundnut, fish and crayfish and other ingredients blended together make up my wife’s 11 food mix.”- Rural father

“It is my 8 item mixture. The reason why I give it is because that is what my mum fed me and my siblings with and I saw our baby pictures so I adopted it. My baby accepted it and it is helping him grow well.” Rural health worker

“I started adding cereals at 5 months because of my job.” – Urban mother

“We give cereals. We don’t have time.” - Urban health worker

“Cereals are first introduced. Staple home meals are added at 1 year because it is only then that they are mature enough to eat other things.”- Urban father

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c) Factors affecting choice of feeds

The factors that informed the choice of feeds in the rural study site were the income and purchasing power of the parents. In the urban, the reasons for their choice of feeds varied from tradition, to the mother’s job, the ease of preparation, the fact that the feeds were natural and soft, the baby’s acceptance of the feeds, and time. Health workers particularly emphasized time as their reason.

“My husband told me he didn’t have money for infant formula, so I have never given it to my child. I only give breast milk and local food. I have never purchased it.” – Rural mother

“I give my baby amala because it is light and soft.” – Urban mother

“The ease of preparation of pap and milk is my reason for the choice.” Urban mother

“It is because that is what he accepts and that is what we focus on.” Urban mother

“The local foods are preferred because they are natural and they don’t have preservatives.”

Urban mother

“I learnt from my upbringing that we introduce semo or amala at 9 months to one year. And that is what I practiced.” Urban father

“My wife’s work made us start infant formula at 3 months. Other meals were added at 11 months.” – Urban father

Time informed the choice. We don’t have the time- we are health workers. - Urban health worker 7

d) Frequency of feeding

The majority at both study sites said they feed their baby too many times to count.

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“I don’t know how many. It is too frequent. They breastfeed, eat solids; take snacks- I don’t count.” - Rural mother

“I am not usually at home. I get home at 5pm and my baby still eats up to twice before we go to bed. I don’t know what happens when I am away.”-Urban father

“It is when he cries. I don’t count the number - I use the feeding bottle.”- Urban mother

“We give complementary feeds on demand. When they complain, we feed. It is up to 6-8 times a day.” - Urban health worker

“We feed more than five times a day.” – Rural father

e) Factors affecting frequency of feeding

The baby’s cues were factors raised as being responsible for the frequency of feeds. Mothers’ work / school and availability were also brought up at the sessions in the urban area.

“Money doesn’t really affect the food a baby eats. It is the mother that does. The child eats with other members of the family and still takes snacks and breast milk.”- Rural mother

“My baby only accepts food occasionally. So it’s when he accepts it.” - Urban mother

“When my baby cries, I feed him. It is the cue he gives that determines the number of times he is fed.”- Rural father

“My baby doesn’t like food so it depends on if the baby accepts it”. Rural health worker

“Once I am home, I feed him well. But where I keep him, they feed him only once –well I leave one meal for him and I am not sure they feed him.” - Urban mother

“The demand of the baby determines the number of times. Being busy affects the number of times. Sometimes, we don’t have time and the baby cries.” Urban health worker

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f) Action taken when the child refuses to eat

Action taken when the child refuses to eat in the rural site include use of herbs, giving multivitamins, offering oth