|Year : 2017 | Volume
| Issue : 2 | Page : 60-66
Integrated nutritional intervention among mothers of under-five children in two rural communities of Kaduna State, Nigeria: Its effects on maternal practice of exclusive breast feeding and children's nutritional status
MO Onoja-Alexander1, SH Idris2, AA Gobir2, AD Onoja3, C. J. C. Igboanusi1, AA Olorukoba1, AA Aliyu2, CL Ejembi2
1 Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Kaduna, Nigeria
3 Wellcare Initiative, Nassarawa, Kano, Nigeria
|Date of Web Publication||30-Apr-2018|
Dr. M O Onoja-Alexander
Department of Community Medicine Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: The World Health Organization recommends that infants should be exclusively breastfed to achieve optimal growth, development, and health. Nonexclusive breastfeeding (EBF) causes infant malnutrition which is widespread in most developing countries and accounts for 11% of global disease burden. The aim of the study was to determine the effect of integrated nutritional intervention on maternal knowledge, practice of exclusive breastfeeding, and nutritional status of under-five children in two rural communities of Kaduna State, Nigeria. Materials and Methods: The study employed a quasi-experimental design, carried out between November 2014 and June 2015 with baseline, intervention, and postintervention phases in two rural communities of Kaduna State, Nigeria (Dangaiya (Sabon Gari Local Government Area [LGA] and Kufena [Zaria LGA] communities). The intervention was conducted among 167 mother/child pairs independently selected from the study and control areas through a multistage sampling technique. Data were collected using interviewer-administered questionnaire at baseline and 6 months after intervention from both communities. Weights and heights/length of recruited children were measured. Data were analyzed using SPSS statistics software version 20.0. (IBM). Results: The result indicated that malnutrition exists among under-five children in the study area. Postintervention, mothers of the children in the study community had better knowledge of EBF (P = 0.001), duration of EBF (P = 0.001), and recommended total breastfeeding duration (P = 0.001). The change in the malnutrition status of the children was not statistically significant (P > 0.05). Conclusion: In this study, nutritional education of mothers only had positive impact on their level of knowledge of EBF but not on their practice; therefore, there is a need for the Kaduna State Ministry of Health and Local Government Authorities to put in place prolonged (>4 weeks) integrated nutritional interventions with emphasis on correct exclusive breastfeeding practices to improve the level of malnutrition in the state.
Keywords: Exclusive breastfeeding, mothers, Nigeria, nutritional intervention, nutritional status, under-fives
|How to cite this article:|
Onoja-Alexander M O, Idris S H, Gobir A A, Onoja A D, Igboanusi C, Olorukoba A A, Aliyu A A, Ejembi C L. Integrated nutritional intervention among mothers of under-five children in two rural communities of Kaduna State, Nigeria: Its effects on maternal practice of exclusive breast feeding and children's nutritional status. Arch Med Surg 2017;2:60-6
|How to cite this URL:|
Onoja-Alexander M O, Idris S H, Gobir A A, Onoja A D, Igboanusi C, Olorukoba A A, Aliyu A A, Ejembi C L. Integrated nutritional intervention among mothers of under-five children in two rural communities of Kaduna State, Nigeria: Its effects on maternal practice of exclusive breast feeding and children's nutritional status. Arch Med Surg [serial online] 2017 [cited 2019 Dec 15];2:60-6. Available from: http://www.archms.org/text.asp?2017/2/2/60/231634
| Introduction|| |
The world Health Organization and other global authorities recommend that infants should be exclusively breastfed to achieve optimal growth, development, and health., However, the prevalence of exclusive breastfeeding (EBF) still remains low. Studies have shown that non-EBF is an important cause of infant malnutrition and other morbidities,, especially in developing countries.
Malnutrition accounts for 11% of the global burden of disease, leading to long-term poor health and disability and poor educational and developmental outcomes. Worldwide, by 2010, it was found that about 104 million children under 5 years of age were underweight and 171 million stunted. At the same time, it was found that about 43 million children under five were overweight or obese. About 90% of stunted children live in 36 countries and children under 2 years of age are most affected by undernutrition. Nearly 20 million children under five suffer from severe acute malnutrition, and it contributes to one million child deaths every year. The order of magnitude of this estimate suggests that severe malnutrition in children is a life-threatening condition requiring urgent treatment and is an important public health problem.
In Nigeria, malnutrition is an underlying factor in >50% of childhood mortalities. According to the Nigerian National Demographic Health Survey of 2013, 37% of children under five are stunted and 21% are severely stunted based on the height-for-age index of the US National Centre for Health Statistics reference population. The national survey in 2013 also showed that 39% of boys and 35% of under-five girls are moderately or severely malnourished, based on the weight-for-age index.
Growth failures during intrauterine life and poor nutrition in the first 2 years of life have critical consequences throughout the life course. Improvement of EBF practices along with continued breastfeeding for up to 2 years or beyond could save annually the lives of 1.5 million children under 5 years of age. Appropriate breastfeeding and complementary feeding practices not only play a significant role in improving the health and nutrition of young children but also they confer significant long-term benefits during adolescence and adulthood.
Studies have shown that the burden of undernutrition is due to failed infant feeding,, and there are demonstrable evidence that nutrition education can improve dietary intake and child growth. The evidence shows that programs promoting infant complementary feeding can improve children's weight and reverse growth retardation. However, it is in developing countries that the challenge of providing nutrition education is often the greatest.
Community-level interventions for nutrition education have also been shown to improve prevalence of undernutrition, infant feeding practices, growth, and health  in developing countries, even in resource-limited settings. Mothers or caregivers living in resource-challenged environment and rural communities of Nigeria can benefit from nutritional education intervention where they can acquire new knowledge and good feeding practices on infant and young children feeding technique that support normal growth. The aim of the study was to determine the effect of integrated nutritional intervention on maternal knowledge and practice of EBF and the nutritional status of the children among mothers of under-five children in two rural communities of Kaduna State.
| Materials and Methods|| |
The study was carried out from November 2014 to June 2015 in two rural communities in Kaduna State, North West Nigeria: the two communities were Dangaiya and Kufena. Based on 2006 census, the estimated population of the communities at the time of study was 2349 and 2236, respectively (NPC, 2006). The study was a quasi-experimental study which consisted of three stages – (i) preintervention stage, (ii) intervention stage, and (iii) postintervention stage among mother/caregiver/child pairs (0–59 months). Sample size was calculated using the sample size formula for comparison of independent proportions at significance level (α) of 5% and at a power of (1− β) 80%.
Multistage sampling technique was employed for the study. Stage 1 involved the selection of one political ward from the two Local Government Areas (LGAs). This was done by balloting. Stage 2 was the section of two communities in the selected wards by toss of coin. Dangaiya in Sabon Gari LGA was chosen as the intervention community and Kufena in Zaria LGA as the control community. Stage 3 was selection of households in the selected communities. The list of all households was obtained with the aid of primary health-care identification number. Moreover, Stage 4 was section of mother–child pair in the selected households by systematic sampling technique.
In the preintervention phase, data collection was conducted by a team of six trained research assistants who were fluent in the local language (Hausa). Baseline data were collected over 3 days in the study and control communities separately. A pretested, semi-structured interviewer-administered questionnaire was used to collect data from mothers/caregivers on sociodemographics, knowledge, attitude, and practices related to infant and young child nutrition. The questionnaire was adapted from the NDHS Guideline for infant nutrition. Anthropometric measurements of each child were also taken. The questionnaire was pretested in Milgoma village in Giwa LGA.
The nutritional status of the children was determined at baseline (preintervention) by estimating the Z-score values derived from their anthropometric measurement using the WHO growth reference chart. Children were weighed using electronic weighing scale (personal type; model seca 840). A purposely designed measuring board was used for measuring the length (height) of children in supine position.
In the intervention phase, the nutrition intervention was carried out over a period of 4 weeks using four nutritional education modules in the study community. The modules were adapted from the infant and young child feeding practices (IYCFP) guidelines. Group nutritional counseling sessions and demonstration of EBF were held fortnightly for mothers at the study community using the purposely designed IEC materials which focused on the concept of EBF, its benefits, its duration, and correct method of practicing it. Some of the IEC materials in form of leaflets were also given to mothers to take home. Home visit was conducted monthly to each pair at the study community.
In the postintervention phase, 6 months after the intervention, postintervention data were collected on the mothers' knowledge and practice EBF and the anthropometric (height and weight) measurements of under-five children of both the study and control groups using the same procedures and instruments as those for the preintervention phase for evaluation. The same training intervention given to the study group was administered to the control group after collection of end line data for ethical reasons.
Data were analyzed using SPSS package version 20.0 (SPSS Inc., Chicago, IL, USA 2012) computer software. Qualitative data were summarized using frequencies, percentages, measures of central tendency (means), and dispersion (standard deviations) and presented as tables and charts. Bivariate analysis was done using Chi-square test., with the P = 0.05 set as statistical significance. Undernutrition was classified using the Z-score values; the three indices used to assess the nutritional status of children were (i) weight-for-age Z-score, which measures underweight, (ii) weight-for-height Z-score, which measures wasting, and (iii) height-for-age Z-score, which measures stunting. A child was classified to be undernourished if the Z-score value is <−2 and children with Z-score value >−2 were classified as normal.
Questions on knowledge carried a score of 1 point for correct answer, and incorrect or “don't know” responses were scored zero; maximum score was 24 points. Scores above 12 points (>50%) were regarded as good while those below 12 (<50%) were regarded as poor.
Ethical clearance for the study was obtained from the Ethics and Scientific Committee of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Permission was also sought from the local government and the ward and village heads. An informed written consent was sought from the participants before conducting any interview. The same intervention was applied in the control community 3 months after the study to address the ethical issue of withholding an established beneficial effect of the intervention.
| Results|| |
Of the 167 mother/child pairs (children aged 0–59 month) recruited for the study, 163 (97.6%) and 164 (98.2%) were successfully followed up for 6 months in the intervention and control communities, respectively, because four children died in the study community while two died and one relocated in the control community. The mean age of mothers in the study and control communities was 25 ± 7.4 years and 27 ± 7.5 years, respectively. There was a significant statistical association when the two communities were compared in terms of mother's educational status, occupation, and marriage type at P ≤ 0.05 [Table 1].
|Table 1: Sociodemographic characteristics of respondents by study status|
Click here to view
[Table 2] shows the ages and sex of the children. The highest percentage of the children was found to be between 12 and 23 months in both communities.
|Table 2: Demographic characteristics of respondents' children (aged 0-59 months)|
Click here to view
[Table 3] shows the prevalence of the nutritional indices of children from the study and control communities. For the study community, the prevalence of underweight, wasting, and stunting was the same before and after intervention; there was no statistically significant difference (P > 0.05) in all cases. Results showed that 65% of children had normal nutritional status in the study community and 71.9% in the control community.
|Table 3: Nutritional status of children from both study and control communities|
Click here to view
[Table 4] shows that respondents from the study community demonstrated better knowledge of IYCFP recommendations compared to the control community after the intervention. This included better knowledge of EBF (P< 0.05), duration of EBF (P ≤ 0.05), and recommended total breastfeeding duration (P< 0.05). All these indicators improved significantly as a result of the intervention (P ≤ 0.05) in the study community compared to the control community. In the study group, the percentage of respondents with adequate knowledge increased from 49.1% at baseline to 72.3% at end line, the percentage change was 23.4% for the study group, and this was statistically significant (P ≤ 0.05). In the control group, there was no statistically significant difference between percentage of respondent's adequate knowledge at baseline and end line (P > 0.05).
[Table 5] shows that majority of mothers in both communities did not breastfeed their babies within the 1st h of delivery, as recommended by the WHO/UNICEF. The practice of giving early supplementary liquids was also frequently found in both communities. At baseline, only 32.3% of mothers in the study community exclusively breastfed their children during the first 6 months of their lives and this dropped to 24.7% postintervention. On a similar note, in the control community, it dropped from baseline rate of 35.5%–26.8% postintervention. These changes were not statistically significant (P = 0.13 and 0.33, respectively). Majority of mothers in both communities gave prelacteal feeds. No statistically significant difference (P > 0.05) was obtained in bottle-feeding and other feeding practices of respondents from the study and control community.
| Discussion|| |
The major finding from this study at baseline showed that 32.3% of the mothers from the study community and 35.5% in the control community reported that they exclusively breastfed their infants in the first 6 months and knew the benefits of breastfeeding in terms of child survival, and all mothers from the two communities could state at least two advantages of EBF. The reported practice of EBF is higher than the national average of 13.0%, but similar to a study in two rural communities of south west of Nigeria, the EBF rate was 68.1% and also similarly a study in the north west zone with the rate of 54.3% for EBF.
Early initiation of breastfeeding fosters bonding between mother and child. From this study, 13.8% of mothers in the study community and 28.1% in the control community initiated breastfeeding within 1 h of birth. This finding is lower than the national average  but similar to the finding of studies in the same region.,
The practices of giving prelacteal feeds, discarding of colostrum, bottle feeding, and giving other foods or fluid to infants in the first 6 months of life such as plain water, pap, and adult diet were found also in both communities. This finding is similar to the finding of other studies.,
In most rural settings in developing countries, breastfeeding is often prolonged. The NDHS 2013 reported that two-thirds of children aged 20–23 months have discontinued breastfeeding. In this study, majority of the mothers stopped breastfeeding their children before the age of 24 months, and the two main reasons for breastfeeding cessation are when the mother thinks that child is of age and when a mother becomes pregnant. This is similar to the finding of Anigo et al. and the finding of Inayati et al. in Nisa Island.
Other findings from this study show that the prevalence of malnutrition in both communities among the under-five children was high. This may be precipitated by many factors such as unfavorable breastfeeding practices, poor complementary feeding and health-seeking practices, low education levels, and the general low socioeconomic status as see in this study. The prevalence of stunting was 65.5%, underweight 32.3%, and wasting 8.4% among the children in study community and stunting was 71.9%, underweight 31.7%, and wasting 8.4% in the control community. The finding of this study is similar to a study done in Zaria, Northern Nigeria, by Sabitu et al. where they found that 77%, 7%, and 61% of the 67 children were stunted, wasted, and underweight. The findings of this study are relatively higher compared to the findings from the NDHS 2013 for the north west zone in which the prevalence of stunting was 53.0%, wasting 20.6%, and underweight 23.1%.
At baseline, one-quarter of the mothers had correct knowledge on IYCFP; this is similar to the finding of Sabitu et al. in the same north west region. This finding is different from the finding of a similar study carried in South West Nigeria where most mothers had good nutritional knowledge. This might be as result of repeated nutritional education in the south west compared to the north west.
There was remarkable improvement in knowledge and practices of mothers in the intervention community compared to the control community after the intervention. This finding is similar to other studies., The proportion of mothers who had correct knowledge of the EBF rose to 59.5% in the study community; the overall knowledge on all the questions on breastfeeding increased to 72.3% postintervention. This may be due to repeated counseling sessions at the different centers and during the home visits. The finding from this study is similar to finding of Sule et al.
More mothers exclusively breastfed and breastfeed longer in the intervention community.
However, there was no statistically significant change in the malnutrition status (underweight, wasting, and stunting) of the children postintervention. The finding from this study is similar to the finding of Sule et al. In contrast, a similar study done in Peru found that children in the intervention group after 18 months had improved nutritional status compared to the control group. Another study done by Sabitu et al. in a rural community in Zaria showed that there was a significant reduction in the proportion of stunting, wasting, and underweight children. The difference in this study may be partly explained by the basic fact that the duration of observation and evaluation of the outcome of the intervention was 6 months as compared to other studies where the duration of the intervention was found to be longer. For example, stunting requires a longer time to change; therefore, this type of study with a longer period of follow-up will provide more valuable information.
| Conclusion|| |
From the study, nutritional education of mothers had a positive impact on the knowledge of EBF after the intervention and limited improvement in feeding practices. To improve maternal EBF knowledge, practice, and reduce the level of malnutrition among under-fives, the Kaduna State Ministry of Health and Local Government Authorities should put in place prolonged (>4 weeks) integrated nutritional interventions with emphasis on correct exclusive breastfeeding practices.
We acknowledge ABUTH Zaria for all the support toward this work. We also acknowledge all the respondents who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Exclusive Breastfeeding. Available from: http://www.who.int
. [Last accessed on 2015 Dec 12].
World Health Organization, United Nations Children's Fund. The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (Spedale degli Innocenti), Florence, Italy; 1990. Available from: http://www.unicef.org/programme/breastfeeding/innocenti/htm
. [Last accessed on 2015 Jul 06].
Li R, Darling N, Maurice E, Barker L, Grummer-Strawn LM. Breastfeeding rates in the United States by characteristics of the child, mother, or family: The 2002 National Immunization Survey. Pediatrics 2005;115:31-7.
Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics 2001;108:E67.
Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet JP, et al.
Infant growth and health outcomes associated with 3 compared with 6 months of exclusive breastfeeding. Am J Clin Nutr 2003;78:291-5.
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al.
Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008;371:243-60.
Community-Based Management of Severe Acute Malnutrition: A Joint Statement by the World Health Organization, the World Food Program, the United Nations System Standing Committee on Nutrition, the United Nations Children's Fund. Geneva: World Health Organization; 2007.
Prudhon C, Briend A, Weise Prinzo Z, Daelmans BM, Mason JB. Food and Nutrition Bulletin: WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children. Tokyo: International Nutrition Foundation; 2006.
National Population Commission (NPC) [Nigeria] and ICF International. Nigeria Demographic and Health Survey. Abuja, Nigeria, and Rockville, Maryland, USA: NPC ICF International; 2013. p. 196-209.
Grantham M, McGregor SM. The effect of malnutrition in mental development. Protein-energy malnutrition. London, Edward Arnold, London; 1992. p. 340-60.
World Health Organisation. Infant and Young Children Feeding: Report of a Regional Consultative Meeting, Sulaya, Thailand. Geneva: World Health Organisation (WHO); 2001.
Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: Revisiting implications for interventions. Pediatrics 2010;125:473-80.
Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK; Infant feeding study group. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: A cluster randomised controlled trial. Lancet 2003;361:1418-23.
Brown LV, Zeitlin MF, Peterson KE, Chowdhury AM, Rogers BL, Weld LH, et al.
Evaluation of the impact of weaning food messages on infant feeding practices and child growth in rural Bangladesh. Am J Clin Nutr 1992;56:994-1003.
Taofeek I. Research Methodology and Dissertation Writing for Health & Applied Professionals. 1st
ed. Nigeria: Cress Global Link Limited Abuja; 2009. p. 70-5.
UNICEF Training Aids the Community Infant and Young Child Feeding Counselling Package. September, 2012. p. 1-52.
Sule SS, Onayade AA, Abiona TC, Fatusi AO, Ojofeitimi EO, Esimai OA, et al.
Impact of nutritional education on nutritional status of under-five children in two rural communities of South-West Nigeria. Niger Postgrad Med J 2009;16:115-25.
Anigo KM, Ameh DA, Ibrahim S, Danbauchi S. Infant feeding practices and nutritional status of children in North Western Nigeria. Asian J Clin Nutr 2009;1:12-22.
Sabitu K, Iliyasu Z, Hassan SS, Mande AT. Evaluation of a community level nutrition information system for action in a rural community of Zaria, Northern. Niger Ann Afr Med 2004;3:120-5.
Tagoe-Darko E, Mukuria A, Paula D. Water, Koko and Apetite, Complementary Feeding Practices in Kumasi. Ghana, Maryland: ORC Macro Calverton; 2003.
Inayati DA, Scherbaum V, Purwestri RC, Hormann E, Wirawan NN, Suryantan J, et al.
Infant feeding practices among mildly wasted children: A retrospective study on Nias Island, Indonesia. Int Breastfeed J 2012;7:3.
Malekafzali H, Abdollahi Z, Mafi A, Naghavi M. Community-based nutritional intervention for reducing malnutrition among children under 5 years of age in the Islamic Republic of Iran. East Mediterr Health J 2000;6:238-45.
Guldan GS, Fan HC, Ma X, Ni ZZ, Xiang X, Tang MZ. Culturally appropriate nutrition education improves infant feeding and growth in rural Sichuan, China. J Nutr 2000;130:1204-11.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]