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 TO 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 1 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. 2 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. 3 CERTIFICATION BY THE HEAD OF DEPARTMENT 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 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. 4 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. 5 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. 6 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. 7 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 8 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 9 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 10 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 11 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.