proposal uog hanan v2
TRANSCRIPT
JOINT MPH PROGRAMSUNIVERSITY OF GONDAR AND
ADDIS CONTINENTAL INSTITUTE OF PUBLIC HEALTH
Name of Investigator Hanan Ali Mohammed
Full title of the ResearchProject Knowledge and practice of caregivers on
complementary feeding for under two year children
in Sebeta Hawas Woreda, Oromia Region,
Ethiopia.
Study Area Sebeta Hawas woreda,Oromia Region,Ethiopia
Total Cost of the Project
Source of Funding Self-Funding
Address of Investigator Tel:
Cell Phone: +251 915 211065
Fax:
P.O.Box:
Email:[email protected]
Name of Advisor Professor Yemane Berhane
Table of Contents
Summary..........................................................................................................................3
Introduction......................................................................................................................4
Literature Review.............................................................................................................6
Objectives......................................................................................................................10
Methods.........................................................................................................................10
Study Setting..............................................................................................................10
Study Design..............................................................................................................10
Sampling Procedures.................................................................................................11
Data Collection Procedures........................................................................................11
Operational Definitions...............................................................................................11
Data Management......................................................................................................12
Data Analysis Procedures:.........................................................................................12
Ethical consideration..................................................................................................12
Dissemination of Results............................................................................................12
Work plan.......................................................................................................................13
Estimate cost of the research.........................................................................................14
References.....................................................................................................................15
Assurance of principal investigator.................................................................................16
Annexes.........................................................................................................................17
Questionnaire and Interview Guide............................................................................17
Amharic Consent Form...............................................................................................18
English Consent Form................................................................................................19
Summary
Complementary feeding is the process starting when breast milk alone or infant formula
alone is no longer sufficient to meet the nutritional requirements of an infant and when
other foods and liquids along with breast milk or a breast milk substitute are needed.
The age range for complementary feeding is generally 6-24 months. Poor nutrition or
complementary feeding results not only from a lack of food but also from inappropriate
feeding practices where the timing, quality and quantity of foods given to infants and
young children are often inadequate(national infant and child feeding guideline). Poor
breastfeeding and complementary feeding practices, coupled with high rates of
infectious diseases, are the principal proximate causes of malnutrition during the first
two years of life(23).
Malnutrition is the largest risk factor in the world for disability and premature mortality
among young children, especially in developing countries and Ethiopia is categorized
among them.
Since the first two years of life are critical stages for a child’s growth and development.
Any damage caused by nutritional deficiencies during this period could lead to impaired
cognitive development, compromised educational achievement and low economic
productivity and It is much more difficult to reverse the effect of malnutrition on stunting,
and some of the functional deficits may be permanent, it is important to explore the
practice and determinants of complementary feeding in this specific study are.
The general objective of the study is to explore knowledge and practice of
complementary feeding among caregivers of under two year children in Sebeta-Hawas
woreda, Oromia region, Ethiopia.
The study design will be qualitative study, using phenomenology study design and data
will be collected by conducting in-depth interview with caregivers of under two children
that will be chosen using purposive sampling method. After transcribing and translating
the analysis will be done using open code software. The thesis will take the course of
eleven months with 23,280.00 birr budget.
Introduction
The greatest decline in nutritional status of children is seen between the ages of six
months and two years of life. This is a critical nutritional window for children, in which
they should be transitioning from exclusive breastfeeding to receiving complementary
foods in addition to continued adequate intake of breast milk. The four principals of
complementary feeding defined by WHO are that complementary feeding be:
Adequate in terms of the energy and nutrient needs of the child;
Introduced at the appropriate age and not replace but rather augment intake from
breast milk
Safe from environmental and biological contamination
Provided in a manner and style which is consistent with the child’s appetite and
that feeding frequency and feeding methods are age-appropriate
These four principals for complementary feeding are frequently not met, due to a variety
of factors, including but not limited to, poor utilization of locally available nutrient-dense
foods, time constraints related to meal preparation, poor and inadequate water and food
storage options and lack of knowledge and time for age-appropriate feeding by
caregivers. The result is often complementary foods with inadequate energy and
micronutrient density and also with risk of contamination introduced during preparation
and/or storage. These factors then contribute to the overall burden of malnutrition and
illness experienced amongst infants and young children.
Inappropriate complementary feeding results in malnutrition and Malnutrition is the
greatest determinant in the world for morbidity and premature mortality among young
children, especially in developing countries, with its 2 constituents of protein–energy
malnutrition and micronutrient deficiencies, continues to be a major health burden in the
world.
Ethiopia is categorized as one of the highest infant and child mortality rates country in
the world. According to 2011 Ethiopian Demographic Health Survey (EDHS), infant
mortality rate is 59 per 1000 live births and under five mortality rates is 88 per 1000 live
births. Even if the EDHS 2011 report showed progressive improvement in nutritional
status of children, the prevalence of wasting remained constant and the prevalence of
stunting and underweight decreased, 44 % and 29% respectively.
A study done in china indicated that educational intervention can improve caregivers
feeding practice and child dietary intake, however there was small knowledge about
how to deal with deep-rooted cultures, traditions and heterogeneity of the country (4).
Infant and child feeding practices are major determinants of malnutrition. A very large
proportion of women do not practice appropriate complementary feeding (CF) behavior
for their children and there are also serious problems in the timing of complementary
food introduction, with a large majority of infants introduced to such foods too early or
too late.
In Ethiopia only 4 percent of youngest children with the age range of 6-23 months living
with their mothers are fed in accordance with Infant and young child feeding (IYCF)
practices (2). Among breastfed children age 6-23 months, 4 percent receive foods from
at least four food groups, while 48 percent are fed the minimum number of times or
more. In total, 4 percent of breastfed children are given foods from four or more groups
and also are fed at least the minimum number of times per day.
Ethiopia is a large country with diverse ethnic groups and cultures from region to region
which is reflected by different food habits and traditional practices. To ensure
appropriate complementary feeding it is mandatory to better understand various IYCF
practices at community levels as well as the factors which influence child feeding
practices and the barriers, facilitators, people that can influence change for optimal
IYCF practices. Understanding the whole components of complementary feeding in this
specific study area has the same goal with the above concept.
Literature Review
Complementary feeding consists of exclusive breastfeeding up to 6 months, withbreast
feeding lasting up to 2 years or longer in combination with the introduction of balanced
complementary feeding (17).The appropriate CF must include a balanced composition of
foods containing an adequate amount of macro and micronutrients (with special
attention to iron, zinc, calcium, vitamin A, vitamin C and folic acid), contamination-free
(biologic, chemical or physical) food, which can be easily digested and accepted, at
reasonable cost and prepared (17) using food usually consumed by the family.
UNICEF and WHO also recommend the introduction of solid food to infants around age
6 months because by that age breast milk alone is no longer adequate to maintain a
child’s optimal growth. In the transition to introducing the child to the family diet, in
addition to breastfeeding, children age six months and older should be fed small
quantities of solid and semi-solid foods frequently throughout the day(2).
The first two years of life are critical stages for a child’s growth and development. This
critical transition period is associated with a dramatic increase in malnutrition among
infants 19. And any damage caused by nutritional deficiencies during this period could
lead to wasting, stunting, underweight, impaired cognitive development, compromised
educational achievement and low economic productivity (2 and 3).
Different Studies done in different countries indicated inappropriate complementary
feeding result in stunting, wasting, underweight, poor cognitive development, Anemia,
vitamin A deficiency, Iodine deficiency, zinc deficiency, pneumonia, diarrhea,
cardiovascular disorders, obesity, type 2diabetes and to the worst will cause Death (1-25).
Globally less than half of infants are exclusively breastfed up to four months, and many
not receive appropriate complementary foods starting at 6 months (24).Poor breast
feeding and complementary feeding practices have been widely documented in the
developing countries. Only about 39% of infants in the developing Countries and 25% in
Africa are exclusively breast fed for the first six months (3).
A study done in Ethiopia indicated the adolescent’s attitude and expectations deviate
from international feeding guideline(24). According to Ethiopian demographic and health
report only 4 percent of youngest children 6-23 months living with their mothers are fed
in accordance with Infant and young child feeding (IYCF) practices (2). Among breastfed
children age 6-23 months, 4 percent receive foods from at least four food groups, while
48 percent are fed the minimum number of times or more. In total, 4 percent of
breastfed children are given foods from four or more groups and also are fed at least
the minimum number of times per day (2).
Inappropriate complementary feeding is a multi-causal problem as reported by different
studies and it can be grossly categorized as perceived and actual causes. Initiation of
complementary feeding before six month of age has been the major cause(1-4, 6-8, 12,17, and
21-24)and in contrary late introduction of complementaryfoods was also seen (7,10,21, and 22),
with low protein, fat and vitamin intake (2,7,8,9,15, and 17).
A study done in India, Lebanon and Tanzania showed that the frequency of feeding
cereal based foods were high (7, 8, 9, and 14) and bottle feeding has been the malpractice
reported(10, 12, 17, and 23). In addition, low food diversity and frequency (7 and 18),inadequate
micronutrient intake (17 and 22), early introduction of manufactured milk (17),inappropriate
intake of macronutrients (17) and too frequent feeding(25) was the causes seen.
The above causes of inappropriate complementary feeding associated with the cultural
and perceived beliefs like colostrum is dirty milk and will make the child sick (13), breast
milk is not adequate for infants below six month of age or there is no breast milk (1-4, 8,12,17,
and 23) and it does not contain water(12 and 23). Pre-lacteal feeding is perceived to avoid
abdominal pain and soften gastrointestinal tract (10) and the infant is thought to be old
enough to eat adult food. Mothers belief breast milk could turn bad if there is new
pregnancy or HIV and they introduce early complementary feeding by fear of dying
before the child is used to other food than breast milk.
Various factors associated with inappropriate complementary feeding have been
identified in various settings this include maternal factors, socio-economic factors,
demographic factors, access to maternal health service and male child’s sex. Low
maternal education level or illiteracy is one of the many most studies reported (2,3,7,13,15,16,
17,18, and 22). A study done in Kenya showed mothers with at least secondary level
education had 10% lower hazards of early introducing foodsbefore 6 months of age (3)
but in a study done in Lebanon mothers who were employed were 1.78 times more
likely to introduce solid foods at < age 4 months(8).
Paternal illiteracy was also indicated in a case control study done in Ethiopia. A study
done in Kenya showed, mothers who were previously in union and those never in union
had close to 3 and 2 fold higher hazards of stopping breastfeeding before the age of 12
months respectively compared to mothers in union(3). Inadequate knowledge about
appropriate foods and feeding practices is often a greater determinant of malnutrition
than actual lack of food (10), but in a study done in rural Bangladesh house hold food
security was associated with better infant and young child feeding and with the type of
complementary foods given(6). Mothers who were employed, and having short maternal
leave with lack of adequate time is also one of the determinants, in addition maternal
rural residency with poor maternal health and nutritional status is also indicated, in a
cross sectional study done in Lebanon mothers who exclusively breast fed for six month
were born in a rural than in an urban region 57.1% versus 30.0%(8). Women who are
overweight before becoming pregnant are less likely to initiate breastfeeding than are
women with a normal BMI(23). Low media exposure and high parity are also indicated (7,10,15, and 23).
Complementary feeding practice is a process that lasts for almost eighteen months so
this process can be better described by providing a comprehensive and holistic
understanding of the caregivers social setting in which the research is conducted and by
looking in to the views, norms, values and lived practices of the caregivers on
complementary feeding, to fulfill all the aim of this study qualitative research is superior
than quantitative research method.
Ethiopia is a large country with different cultures which is reflected by different food
habits from one place to other place. Most of the pertinent information from the literature
review focused on the initiation of breastfeeding and complementary feeding practices
in different countries and in a general sense, thus more detailed information is needed
to fully understand the practices of complementary feeding in these specific study
areas.
Objectives
General Objective
To describe and explore the practice of complementary feeding among care givers of
under two children in Sebeta-Hawas Woreda,Oromia Region, Ethiopia.
Specific objectives
1. To describe the current practice of complementary feeding for under two
children.
2. To explore the factors influencing the practice of complementary feeding for
under two year old children.
Methods
Study Setting
Thestudy will be conducted in Sebeta Hawas woreda, Oromia region, Ethiopia. The
woreda is located 25 Km from Addis Ababa. Sebeta Hawas is one of the Woredas in
Oromia Region of Ethiopia, part of the Oromia special zone surrounding Addis Ababa.
The altitude of the woreda ranges from 1700 meters above sea level to about 3385
meters. According to the Woreda Agricultural and rural Development office, 87.2% of
the land is devoted to agriculture, 4.2% is pastoral, 2.9% is forest, 1.86% is reserved for
industrial establishment, 1.68 is covered by lakes and other bodies of water, and built-
up land covers 1.28%. According to 2007 national census report the total population
is133,746 consisting of 68,908 male and 64,838 female.
According to the Ethiopian Federal Ministry of Agriculture Sebeta Hawas woreda is one
of the flood‐prone woredas in Oromiaregion (25).
Picture 1: Sebeta Hawas Woreda
Study Design
The study will be qualitative research using phenomenological study design.
Phenomenological study design is helpful in identifying caregivers held view of
complementary feeding, their practice and factors influencing their practice from the
actual caregivers.
Sampling Procedures
Since this study aims to get as much information as possible about complementary
feeding, studying information-rich subjects is superior method of all, so the sampling
procedure will be purposive sampling method. From mothers or caregivers who have a
child or children less or equal to two years of age, eight mothers or caregivers will be
chosen. From the mothers the sampling will include purposefully caregivers, of which
two of them will be educated or employed, with the minimum of secondary school, one
with primary level education or illiterate, one housewife, one employed, one living in
slum area, one single mother and one married caregiver or who is in union.
Data Collection Procedures
One team of three individual will be established, one of them will be the investigator who
will do five of the interviews, and the rest will do the remaining. The interviewers will
use the pretested data collection tools.
All the data collectors are fluent speakers of Amharic, female and undergraduate
degree holders in health related study.
The data collection will begin in October and the actual interview time depends on the
appropriate time for the caregivers and the interview will be done by going home to
home or any place the caregivers are residing.
To assure the quality the data, open-ended questioner will be based on established
protocols already used and tested in infant feeding programs. This will be adopted from
the ProPan Manual: Process for the Promotion of Child Feeding, developed by the Pan
American Health Organization (PAHO). And will be modified with the study population.
The data collectors will be trained for half day with the data gathering procedure and
after the interviewer finished each interview he or she will write a short note about the
important finding in the interview.
Operational Definitions
Should be done…
Data Management
Should be done…
Data Analysis Procedures:
The data collection and analysis will be done simultaneously. The audiotaped data with
the notes taken during the interview will be transcribed in the interview language and
will be translated to English and cleaned, then will be entered to open code software
and it will be coded.After coding is finalized, inductive approach will be used to identify
new insight or new knowledge about complementary feeding. The data reporting will be
using quotes from the original date to give the study more credibility and to create direct
link with the data.
Ethical consideration
Ethical clearance will be sought from Addis continental institute of public health.
Participants of the study will be given complete information about the objective of the
study and their benefits/risks and only following their consent they will participate in the
interview. The consent forms will be translated into local languages (the language
spoken in the selected Woreda).
Most of the data collection will take place at home, so caregivers will be free to talk in
detail. No subjects or caregiver will be identified in any data set and report. Access to
research documents and data will be strictly limited to the researcher. Access to
documents and data stored electronically will also be protected by a password. Hard
copies of research documents and data will be stored in locked place with access
limited to the researcher only. Data will be stored for 2 years, at which time it will be
destroyed.
Dissemination of Results
Should be done…
Work plan
S.no Description Date Due
1 Proposal finalization October 5, 2012
2 Ethical review October 5-26, 2012
3 Study tool development. October 5-26, 2012
4 Training October 5-26, 2012
5 Pre-testing October 5-26, 2012
6 Field work: data collection October 27, 2012
7 Supervision December 3, 2012
8 Data management: entry, cleaning December 4-7, 2012
9 Data Analysis January 7, 2013
10 Draft Thesis December 28, 2013
11 Final Thesis April 19, 2013
12 Defense May 2013
13 Finalizing Thesis
Estimate cost of the research
SN Budget/cost item Unit Justification Unit cost ETB Total ETB1 Data collectors (4) Person-days Service fee;
4 data collectors X 4 days
1000 per day 16,000.00
2 Data Collection Kit Kit or Package (set)
Folder + notebook, etc.
4 persons X 75
300.00
3 Printing & Photocopy Paper
Ream Direct day to day use; 3 ream X 60 180.00
4 Photocopying service fee
pcs Quest./tools Pages 200.00
5 Translation of tools (English-Oromifa)
2,000.00
6 Tape recorder/battery set
Set 2 recorders with 2 tapes/10 battery
500X2 1,000.00
7 Lunch and Transport Allowance
Person-day/each
4 persons X 200 Birr X 4 days
3,200.00
8 Mobile card 4 persons X 100 Birr
400.00
Grand Total 23,280.00
References
1. Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding:
inappropriate practices in infants. Jornal de pediatria. 2010;86(3):196-201. Epub
2010/04/20.
2. Ethiopian Central Statistical Agency and ICF International, Ethiopia Demographic and
Health Survey, 2011, ORC Macro, Calverton, Maryland, USA, March 2012.
3. Wang X, Wang Y, Kang C. Feeding practices in105 counties of rural Chaina. Child Care
Health Dev 2005;31(4):417-23.
4. .Kimani-Murage EW, Madise NJ, Fotso JC, Kyobutungi C, Mutua MK, Gitau TM, et al.
Patterns and determinants of breastfeeding and complementary feeding practices in
urban informal settlements, Nairobi Kenya. BMC public health. 2011;11:396. Epub
2011/05/28.
5. Hadley C, Lindstrom D, Belachew T, Tessema F. Ethiopia Adolescents’ Attitudes and
Expectations Deviate from Current Infant and Young Child Feeding Recommendations.
J Adolesc Health. 2008;43(3):253–9.
6. Garg A, Chadha R. Index for measuring the quality of complementary feeding practices
in rural India. Journal of health, population, and nutrition. 2009;27(6):763-71. Epub
2010/01/27.
7. Amsalu S, Tigabu Z. Risk factors for severe acute malnutrition in children under the age
of five: A case-control study. EthiopJHealth Dev. 2008;22(1):1-95.
8. Wasser H, Bentley M, Borja J, Goldman BD, Thompson A, Slining M, et al. Infants
Perceived as “Fussy” Are More Likely to Receive Complementary Foods Before 4
Months. PEDIATRICS. 2011;127(2).
9. Medhin G, Hanlon C, Dewey M, Alem A, Tesfaye F, Worku B, et al. Prevalence and
predictors of undernutrition among infants aged six and twelve months in Butajira,
Ethiopia: The P-MaMiE Birth Cohort. BMC public health. 2010;10:27.
10. Batal M, Boulghourjan C, Akiki C. Complementary feeding pattern in a developing
country : a cross-sectional study across Lebanan. Eastern meditranian health
journal.2010; v 16 no 2.
11. Mamiro PS, Kolsteren P, Roberfroid D, Tatala S, Opsomer AS, Van Camp JH. Feeding
practices and factors contributing to wasting, stunting, and iron-deficiency anaemia
among 3-23-month old children in Kilosa district, rural Tanzania. Journal of health,
population, and nutrition. 2005;23(3):222-30.
12. Menon P. The crisis of poor complementary feeding in South Asia: where next? Maternal
& child nutrition. 2012;1:1-4.
13. Pelto GH, Armar-Klemesu M. Balancing nurturance, cost and time: complementary
feeding in Accra, Ghana. Maternal & child nutrition. 2011;7Suppl 3:66-81. Epub
2011/10/05.
14. . Worobey J, Lopez MI, Hoffman DJ. Maternal Behavior and Infant Weight Gain in the
First Year. J NutrEducBehav. 2009;41(3):169–75
15. Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding:
inappropriate practices in infants. Jornal de pediatria. 2010;86(3):196-201. Epub
2010/04/20.
16. Fjeld E, Siziya S, Katepa-Bwalya M, Kankasa C, Moland KM, Tylleskär T. 'No sister, the
breast alone is not enough for my baby' a qualitative assessment of potentials and
barriers in the promotion of exclusive breastfeeding in southern Zambia. International
Breastfeeding Journal. 2008;3:26.
17. Oche MO, Umar AS, Ahmed H. Knowledge and practice of exclusive breastfeeding in
Kware, Nigeria. African health sciences. 2011;11(3):518-23. Epub 2012/01/26.
18. Shi L, Zhang J, Wang Y, Caulfield LE, Guyer B. Effectiveness of an educational
intervention on complementary feeding practices and growth in rural China: a cluster
randomised controlled trial. Public health nutrition. 2010;13(4):556-65. Epub 2009/08/27.
19. Sinhababu A, Mukhopadhyay DK, Panja TK, Saren AB, Mandal NK, Biswas AB. Infant-
and young child-feeding practices in Bankura district, West Bengal, India. Journal of
health, population, and nutrition. 2010;28(3):294-9. Epub 2010/07/20.
20. Ramji S. Impact of infant & young child feeding & caring practices on nutritional status &
health. The Indian journal of medical research. 2009;130(5):624-6. Epub 2010/01/22.
21. K Kuntal K, Edward, Dewan , Shams E. , Lars , and Kathleen M. Household Food
Security Is Associated with Infant Feeding Practices in Rural Bangladesh, J Nutr. 2008
July ; 138(7): 1383–1390.
22. Wondafrash M, Amsalu T, Woldie M. Feeding styles of caregivers of children 6-23
months of age in Derashe special district, Southern Ethiopia. BMC public health.
2012;12:235. Epub 2012/03/24.
23. WHO: http://www.paho.org/English/AD/FCH/NU/Guiding_Principles_CF.htm W.
GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING OF THE BREASTFED
CHILD. [Cited 2012 September 27].
24. Federal Ministry of Health, Family Health Department, Ethiopia. National Strategy for
Infant and Young Child Feeding. 2004.
25. Federal Ministry of Agriculture, Disaster Risk Management & Food Security Sector, Early
Warning and Response directorate, Ethiopia.Flood Alert. 2011.
Assurance of principal investigator
I the undersigned agree to accept all responsibilities for the scientific and ethical
conduct of the research project. I will provide timely progress report to my advisor and
seek the necessary advice and approval from my primary advisors in the course of the
research. I will communicate timely to my advisors all stakeholders involved in the study
including any source of funding for this research.
Name of the student: _______________________________________
Signature: _______________________________________________
Date: ___________________________________________________
Approval of the primary Advisor
Name of the primary advisor: _________________________________
Signature: _______________________________________________
Date: ____________________________________________________
Annexes
Questionnaire and Interview Guide
English Consent Form
Title of the Research:Knowledge and practice of caregivers on complementary feeding for under
two year children in Sebeta Hawas Woreda, Oromia Region, Ethiopia.
Principal Investigator:Hanan Ali
Purpose of the Study:
We are currently conducting an assessment of the knowledge and attitudes ofcaregivers on
complementary feeding. As part of this assessment we will collect information from mothers or
caregivers of under 2 children. The study will help us understand the knowledge and attitudes of
mothers towards complementary feeding.
Confidentiality:
The information you provide will not be shared with anyone by the assessment team. All results will
be combined and presented without any information that can be used to identify you.
Participation in the assessment:
Your participation in this study is completely voluntary. You can refuse to participate and if you do
participate you can stop the interview at any time and can decide not to allow us to use the
information you provide.
Benefits:
The study is unable to provide any financial benefit for participation.
Risk:
There are limited anticipated risks of participation in this study. If someone heard your answers, it is
possible that this could be a problem for you.
Consent:
Do you have any questions about the study and your participation in it? Are you willing to give us
permission to use your information for the assessment?
1. Yes 2. No
Signature of interviewee: ___________________ Date: ____________________
Signature of interviewer: ___________________ Date: ____________________
Amharic Consent Form
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