Understanding the Knowledge, Attitudes, and Practices of Mothers/Caretakers Regarding Complementary Feeding in Children Aged 6 Months to 2 Years Attending the Pediatrics Outpatient Department at Ishaka Adventist Hospital
Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda
This research aimed to evaluate the knowledge, attitudes, and practices among mothers caring for children aged 6 months to 2 years regarding Complementary Feeding (CF). Conducted over a one-month period from October to November 2020, this descriptive cross-sectional study engaged 206 Mothers/caretakers attending Ishaka Adventist Hospital OPD for various child health concerns, including immunization and growth monitoring. Participants were selected randomly based on their arrival order at the hospital during the study period. Data collection involved researcher-administered questionnaires for illiterate participants and self-administered questionnaires for literate individuals after obtaining consent. Participants’ comprehension and execution of complementary feeding practices were assessed through their responses. Data entry and analysis utilized EPI-DATA and STATA 17 software. Univariate analysis determined frequency, mean, mode, and percentage of participant responses, while bivariate analysis explored the relationship between knowledge and attitude, and between knowledge and practices among mothers/caretakers at Ishaka Adventist Hospital’s pediatric OPD. Findings revealed that only 4% of participants were knowledgeable about the frequency of both Complementary Feeding (CF) and Breastfeeding (BF) for infants and the ideal diet composition. However, 63% were aware of the appropriate ages to initiate CF and stop BF, along with the consequences of delayed CF initiation. Although 85.5% commenced CF at the recommended age of six months, merely 4.3% provided adequate quantity and quality of complementary feeds to their infants. The study discovered statistically significant associations between proper/poor CF practices and respondents’ age, education level, socio-economic status, and number of children in the household. Despite varied practices, participants generally exhibited positive and supportive attitudes toward CF.
Keywords: Breast milk, Malnutrition, Immunization, Complementary Feeding, Babies.
The whole life and health of an individual can be influenced by breastfeeding at birth and throughout the early years of a child. It is common knowledge that breastfeeding is important for optimal infant feeding. Breast milk alone can be used for feeding babies in the first six months of life, but from then on, complementary feeding is necessary [1-3]. The nutritional adequacy of complementary food is essential for the prevention of infant morbidity and mortality, including malnutrition and overweight. Malnutrition is one of the most widespread conditions affecting human health, especially during infancy and immune-compromised conditions [4, 5]. The ‘germ’ of malnutrition attacks a fetus in the intra-uterine life due to a lack of sufficient antenatal care on the part of the mother. The condition deteriorates further when after birth the infant is deprived of exclusive breastfeeding or the initiation of complementary food is delayed. Complementary food should be started after the age of 6 months and should contain energy-rich semi–solid food . Malnutrition makes a child susceptible to infections and delays recovery, thus increasing mortality and morbidity [7, 8]. The rapid growth of a baby during the first year of life and specifically the first 6 months postpartum requires an adequate supply of nutrients to cope with the rapid buildup of body muscle and other tissues. This critical transition period is associated with a dramatic increase in malnutrition among infants. The 24-hour dietary assessment revealed that children consumed mainly a thin porridge prepared from maize flour as a complementary food. Carbohydrates contributed the most energy (on average 69%), followed by fats (18.6%) and protein (on average 12.1%) . WHO and UNICEF recommend exclusive breastfeeding for the first 6 months of life starting within an hour after birth, followed by appropriate and adequate complementary breastfeeding for the first 2 years of life as an economical and safe means of protecting children from infection and providing them with an ideal source of nutrients . Almost half of the children below 6 months of age were exclusively breastfed (49 percent) . More children living in rural areas (50 percent) were exclusively breastfed than in urban areas (44 percent). At 6 – 9 months of age 42 per cent of children were breastfed and received timely complementary feeding. By 12 – 15 months, 74 percent of children were still being breastfed and by 20 – 23 months, 53 percent continued breastfeeding, with males breastfeeding longer than females .
Feeding practices during infancy are critical for the growth, development, and health of a child and of importance for the early prevention of chronic degenerative diseases [12, 13]. Anemia and its related complications are the most prevailing effects of undernutrition in both adults and children [14-16]. It has been estimated that exclusive breastfeeding (BF) for the first 6 months of life could reduce infant deaths by 13% and optimal complementary feeding practice could reduce 6% of all under 5 deaths . As of 2018, 2.2 million (29 percent) of Ugandan children under the age of five are stunted, meaning they are too short for their age. About 850,000 (11 percent) of Ugandan children under the age of five are underweight and a further 300,000 (4 percent) are too thin for their height. The severity of a child’s stunting directly relates to their degree of cognitive impairments. Adults who were malnourished as children often have lower educational attainment and earn decreased wages. These adults have a reduced likelihood of escaping poverty. Current population-based estimates of age-related patterns of complementary feeding are few and generally of poor quality. In Uganda, the scant information available suggests that there is inappropriate timing of introduction and frequency of complementary feeding and that the nutrient content of traditional complementary recipes is inadequate. This study, therefore, seeks to assess the knowledge, attitude, and practices of mothers/caretakers about complementary feeding in children aged 6 months to 2 years visiting the pediatrics outpatient department of Ishaka Adventist Hospital.
The study revealed that the knowledge of mothers/caretakers regarding CF of infants was extremely limited with only 5% (10/206) being knowledgeable. This is consistent with a study by Nankumbi and Muliira , on CF showing a low level of CF knowledge, in Uganda. A similar study in an urban local government in Lagos, Southwest Nigeria to determine the CF knowledge, practices, minimum dietary diversity, acceptable diversity, and acceptable diet among mothers showed that the knowledge of CF was low 14.9% which is higher compared to this study  similar to the reports from Lahore in Pakistan 24% and Kenya 33.5% . Reports from countries in Africa have also corroborated this low level of knowledge with even lower figures compared to the study . This applied to an overwhelming majority who didn’t know how frequently in a day should an infant breastfeed after initiating CF, how often a day should an infant be given complementary feeds, and what the diet of an infant, plus a significant minority who didn‘t know when to stop BF when to introduce/initiate CF and effects of its delayed initiation, and those who didn‘t know what would be appropriate to use when administering complementary feeds to the infant. This was apparent for both the educated and those who had NOT attained any level of formal education though relatively worse for the latter. This very low level of knowledge of mothers/caretakers regarding CF can be justified by three reasons; (1) lack of experience about CF of infants by study respondents due to study respondents’ young age and the number of children they had i.e. (24.3% were 18-25 years old, 56% were 26-30 years old) and 46% of study respondents had less than three children respectively. (2) Lack of accessible, reliable, and consumer-friendly information regarding CF as 33% of study respondents reported getting insight into CF from family members/friends/neighbors and 4% reported getting information about CF from media, and the reliability of both these sources can’t be ascertained. (3) No or low level of education i.e. 22.3% had not attained any level of education, 12.1% had attained a primary level of education and 41.3% had attained a secondary level of education. The findings from the study suggested some synergies between the level of education and level of knowledge regarding CF as those with the highest knowledge score were some nurses and some teachers. The same synergism was expressed between knowledge level about CF and positive/negative attitudes towards the same. The vast majority of the respondents 88.3% (182/206) indicated that they knew the term complementary feeding, however, their practices exhibited otherwise reflecting they were not conversant with what it entails. Most respondents reported getting information about CF from health workers, this has an implication of reliable information relative to those who were faced with sourcing information about CF from friends/neighbors/relatives and/or media whose origins and reliability could not be ascertained. Generally, respondents’ attitudes toward CF were overwhelmingly positive and supportive and it was so for both those who had attained some level of education and those who had not, however, in spite of such positive inferences, it was apparent that a significant minority had negative attitudes which were shaped partly by lack of knowledge as previously indicated. Lack of knowledge about complementary feeding was a significant factor influencing the responses of some study participants. For example, some respondents 56% (116/206) perceived processed packaged foods as being more nutritious than locally available foods whereas others confessed not knowing if they are or not. This was consistent with a study by Chambers et al.  on British and French lactating mothers which revealed that British mothers had a perception that only foods with high nutrient content should be given to the child whereas the French mothers thought that pleasure and taste development are of primary importance during CF. Others perceived it right to stop breastfeeding the infant as soon as that infant can eat other foods, with a misconception that those infants can no longer nutritionally benefit from breast milk. Of some study respondents, 10% (20/206) thought infants should only eat solids and/or semisolids after developing teeth, thinking it would choke the baby and it’s difficult for the baby to digest. This was similar to findings in a study in a rural area in Nigeria by Ogunlesi  which reported that 75% of lactating mothers believed that giving complementary foods to infants would cause illnesses, choking and trouble with digestion to the infants; this is higher than that of the current study probably this can be because the current study was a hospital-based study and the respondents are likely to have had right information regarding that subject from health providers at the facility. Others expressed reluctance to feed infants on demand believing that infants should eat meals prepared for the household at scheduled time only and this can be attributed to misleading and/or unreliable information regarding CF practices from unreliable sources e.g. un-informed or misinformed friends/relatives/neighbours. Generally, the CF practices of study respondents were very poor (4.3%) but relatively worse among mothers who had attained no or only primary level of education and those from poor households (earning <25,000/- to 100,000/-). Similarly, Ethiopia DHS, shows the prevalence of appropriate CF practices among children aged 6-23months was very low (4.8%), and in another study to assess for the appropriate CF practices and associated factors among mothers of children aged 6-23months in south Ethiopia, it was found out that only 9.5% of mothers practiced appropriate CF . This is higher compared to this current study. The poor CF practices in this current study can be explained by low socio-economic statuses for most respondents which leave them incapable of providing varieties of complementary feeds to their infants plus a low level of knowledge of mothers regarding CF due to low or no education level and the unreliable sources of insights into CF. The majority of the respondents 72% (148/206) were still breastfeeding their infants; a large number who were non-working mothers were breastfeeding their children according to the child’s demand while others were breastfeeding their children two to three times a day. This is consistent with a study assessing breastfeeding practices in Iran by Olang et al. , which showed that children of non-working and educated mothers were more likely to feed their children appropriately. This is because non-working mothers (housewives) always have ample quality time with their infants therefore capable of timely BF unlike their working counterparts. Similarly, educated mothers are more likely to comprehend rightful information given to them from appropriate sources e.g. health facilities and this shall properly guide their BF and CF practices, unlike their un-educated counterparts. A significant minority 28% (58/206) had stopped breastfeeding; most of them reported having stopped when the infant was 9-12 months of age, followed by those who had stopped when the infant was between 12-18 months of age and the least respondents reported having stopped breastfeeding when the infant was 6-9 months old. Among the reasons for this were; mothers not having time for their children because of busy schedules at work, mothers not having enough breast milk and the child refusing breast milk. The majority of the respondents 74% (152/206) had introduced CF and most of them had introduced it when the infants were six months old and above while a few had introduced it when the infant was below 6 months of age. This is consistent with the findings in a study by Akhtar et al.  in slums of Dhaka city which showed that although CF is started early by some mothers, the majority started at 6months, as 64% of mothers started CF at 6-7months while only 19.2% started CF between 4 to 5months. This is lower compared to the current study. In this current study, most mothers were introduced to CF at the recommended age of six months and this can be attributed to most of them having received and comprehended the right information about CF from health facilities. A significant minority 26% (54/206) had not introduced CF when infants were 6 months old. This is similar to a study in northern Uganda, a study to assess current practices, challenges and opportunities of CF in Kitgum and Pader districts, where 54% of mothers were not in a position to practice recommended IYCF practices . This was higher than that of the current study. In this current study some mothers had not introduced CF due to their child refusing complementary feeds, some mothers believed they had a lot of breast milk and that it was sufficient to meet their infant’s nutritional demands while others thought at six months their babies were still too young to enroll on CF. The majority of respondents 53%(109/206) reported majorly feeding their infants on Bushera porridge and this is reflected in another studies [29, 30]. In contrast, a study in South Africa revealed that 7 out of 10 lactating mothers’ believed that starch-rich foods (excluding maize porridge) or fat should not be given to small children because it was considered unsuitable to them .
In this study majority of respondents’ level of knowledge about CF was very low (5%), their attitudes toward CF were highly positive and supportive and their CF practices were generally poor (4.3%).
Ishaka Adventist Hospital in conjunction with other stakeholders should address the high-profile concern of knowledge gaps revealed by the study to aid mothers/caretakers in embracing proper CF practices since at the heart of proper CF practices lies accessible, credible and audience-friendly information provided by trained and appropriately qualified health professionals through proper channels to its intended consumers/users, the following should be done: Establish a CF awareness campaign for the general population at health facilities and through mass media. Form peer-support programs where young mothers/caretakers can get reliable and credible information from informed peer educators at the health facilities or mass media.
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CITE AS: Akankwatsa Sandrah (2023). Understanding the Knowledge, Attitudes, and Practices of Mothers/Caretakers Regarding Complementary Feeding in Children Aged 6 Months to 2 Years Attending the Pediatrics Outpatient Department at Ishaka Adventist Hospital. INOSR Experimental Sciences 12(2):42-67. https://doi.org/10.59298/INOSRES/2023/2.4.1000