i SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA AN EXPLORATORY STUDY OF MARKET WOMEN’S KNOWLEDGE ON INFANT AND YOUNG CHILD FEEDING PRACTICES IN ASHIEDU KETEKE SUB-METROPOLIS OF THE GREATER ACCRA REGION GHANA BY ONWUKA ONYINYECHI CONFIDENCE (10553015) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2016 i DECLARATION I, Onwuka Onyinyechi Confidence, hereby declare that, apart from references made to other people’s work and duly acknowledge, this Dissertation is the result of the original work done by me under supervision. I further declare that this document has not been presented anywhere else for the award of any degree. Onwuka Onyinyechi Confidence …………………….. …………………. (Student) Signature Date Dr. Alfred E. Yawson …………………….. …………………. (Supervisor) Signature Date ii DEDICATION This work is dedicated to God Almighty for his compassions and provisions to me throughout my stay in Ghana. Also to My parents and my little sisters for their support in this academic journey. iii ACKNOWLEDGEMENT This work was possible by the unfailing grace and direction from the almighty God. I wish, therefore, to first and foremost thank the almighty God for making this work a success. I wish to register my profound appreciation to my academic supervisor, Dr. Alfred Yawson of School of Public Health, College of Health Sciences, University of Ghana for his generous supervision, and encouragement throughout this work. My profound gratitude goes to my beloved parents, Chief Ezekwesiri and Mrs. Regina Onwuka and my lovely brother Prince Ekene Onwuka for how far they have brought me in this life. I would like to sincerely appreciate my kid sisters, Precious Chinweolu Onwuka and Chiamaka Onwuka for their prayers and support throughout my stay in Ghana. My sincere appreciation also goes to the head of department of the Population Family and Reproductive Health, Prof Augustine Ankomah and Dr Rueben Esena for their fatherly love shown me throughout my period of study in School of Public Health. Also I wish to express my deep regard to my beloved sister Chinenye Afonne for her efforts towards the success of this project. I am extremely grateful to the respondents who participated in this study. My prayer is that the almighty God will continue to bless and uplift you all in Jesus name. iv LIST OF ABBREVIATIONS GDHS - Ghana Demographic and Health sSurvey GHS - Ghana Health Service HIV- Human Immunodeficiency Virus IYC- Infant and young child IYCF- Infant and young child feeding. UNICEF- United Nations Children’s Fund. USAID- United State Agency for International Development WHO- World Health Organization v DEFINITION OF TERMS Complementary feeding: this is known as the act of introducing extra food apart from breast milk to the infant for their healthy growth Complementary foods- the solid, semi-solid or liquid foods that are added to infant food starting from the age of 6 months of life for adequate nutritional support. Infant and young child- According to WHO and UNICEM, they are known as a children from the age of 0-2 years of life. Knowledge and awareness- This is what the respondents know about the type of contraceptives, how they work and how they are used. Market Women- market women in this study refers to women who are involved in table top selling or petty traders and hawkers in Makola market. Mother’s nutrition- This is known as the nutritional requirements of a reproductive age mother that enables proper and rich vitamins that is needed by the infants from the mother during breastfeeding for the support of child’s growth. Religion- This is the belief systems of the respondents Reproductive age women-Women aged between 15-49 years Responsive feeding – This is a close interactive period between mother and child during breastfeeding or complementary feeding. vi TABLE OF CONTENT Content Page DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................iii LIST OF ABBREVIATIONS....................................................................................................... iv DEFINITION OF TERMS ............................................................................................................ v TABLE OF CONTENT ................................................................................................................ vi LIST OF TABLES ........................................................................................................................ ix LIST OF FIGURES ........................................................................................................................ x ABSTRACT................................................................................................................................... xi CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background ........................................................................................................................... 1 1.2. Problem statement ............................................................................................................... 2 1.3. Justification .......................................................................................................................... 4 1.4. Research Questions ............................................................................................................. 4 1.5 Study Objectives................................................................................................................... 4 1.5.1. General Objective ......................................................................................................... 4 1.5.2. Specific Objectives ....................................................................................................... 4 CHAPTER TWO ............................................................................................................................ 6 LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK............................................ 6 2.0. Introduction.......................................................................................................................... 6 2.1 Conceptual Framework ........................................................................................................ 7 2.2. Breast feeding and its Benefits to children under two years ............................................ 8 2.3. Mother’s nutrition ............................................................................................................. 10 2.4. Complementary foods ....................................................................................................... 10 2.5. Complementary feeding .................................................................................................... 12 2.6. Infant and young child feeding (IYCF) practices ............................................................ 13 2.7. Four star diet (Balanced diet) ........................................................................................... 14 CHAPTER THREE ...................................................................................................................... 16 METHODS ................................................................................................................................... 16 3.1 Introduction......................................................................................................................... 16 3.2 Study area ........................................................................................................................... 16 3.3 study design ........................................................................................................................ 17 3.4 Variables ............................................................................................................................. 17 3.4.1 Dependent variable ...................................................................................................... 17 3.4.2 Independent variable ................................................................................................... 17 vii 3.5 Sampling ............................................................................................................................. 17 3.5.1 Study population .......................................................................................................... 17 3.5.2 Inclusion criteria .......................................................................................................... 17 3.5.3 Exclusion criteria ......................................................................................................... 18 3.5.4 Sample size calculation ............................................................................................... 18 3.5.5 Sampling procedure ..................................................................................................... 19 3.6 Data collection/ tools and techniques ................................................................................ 20 3.7 Ethical Considerations ....................................................................................................... 20 3.8 Quality Control ................................................................................................................... 21 3.9 Data Processing and Analysis............................................................................................ 21 3.10. Strength of the study ....................................................................................................... 21 CHAPTER FOUR ........................................................................................................................ 22 RESULTS ..................................................................................................................................... 22 4.1 Introduction......................................................................................................................... 22 4.2 Demographic characteristics of respondents .................................................................... 22 4.2.1 Background Information ............................................................................................. 22 4.2.2 Market activities of respondents .................................................................................... 22 4.3 Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) .......... 26 4.3.1. Factors affecting knowledge of recommended Infant and Young Child Feeding Practice (IYCF) ..................................................................................................................... 29 4.3.2. Logistic regression analysis on factors associated with knowledge of Infant and Young Child Feeding (IYCF) Practice ................................................................................ 31 4.4 Infant and Young Child Feeding Practices and perceptions ............................................ 33 4.4.1 Respondents’ preference and choice of formula feeding .......................................... 38 4.4.2 Factors affecting Infant and Young Child Feeding Practices and perceptions ........ 40 4.4.2.1 Logistic regression analysis on factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions ................................................................ 42 4.5 Assessment of IYCF practices based on WHO/UNICEF indicators .............................. 43 4.5.1 Factors associated with respondents’ preference of formula foods over local foods. ..................................................................................................................................... 46 4.5.2 Factors influencing early initialization of breastfeeding........................................... 48 CHAPTER FIVE .......................................................................................................................... 51 DISCUSSION ............................................................................................................................... 51 5.0 Discussion ........................................................................................................................... 51 5.1 Demographic characteristics of respondents .................................................................... 51 5.2 Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) .......... 52 5.3 Factors affecting knowledge of recommended Infant and Young Child Feeding Practice (IYCF) ....................................................................................................................................... 53 5.4 Infant and Young Child Feeding Practices and perceptions of the respondents ............ 55 5.5 Assessment of IYCF practices based on WHO/UNICEF indicators .............................. 56 5.6 Respondents’ preference and choice of formula feeding ................................................. 57 viii CHAPTER SIX............................................................................................................................. 58 CONCLUSION AND RECOMMENDATION ......................................................................... 58 6.1. Conclusion ......................................................................................................................... 58 6.2. Recommendations ............................................................................................................. 59 6.3 Limitations to the study ..................................................................................................... 60 REFERENCES ............................................................................................................................. 61 APPENDICES .............................................................................................................................. 64 Appendix 1. Questionnaire on Market Women’s Level of Knowledge on Infant and Young Child Feeding Practice ............................................................................................................. 64 Appendix 2: Consent form for market women’s knowledge on infant and young child feeding practices. ...................................................................................................................... 71 ix LIST OF TABLES Table 4.2.1: Background information on market women in the survey .................................... 24 Table 4.2.2: Market Activities among respondent in the selected markets............................... 25 Table 4.3.1.1: Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) ................................................................................................................................. 27 Table 4.3.1.2: Factors associated with respondents’ knowledge on knowledge of recommended Infant and Young Child Feeding (IYCF) Practice................................................ 30 Table 4.3.1.3: Logistic regression analysis on factors associated with respondents’ knowledge of recommended Infant and Young Child Feeding (IYCF) Practice .................. 32 Table 4.4.1.1: Infant and Young Child Feeding Practices and perceptions among the market women ..................................................................................................................... 35 Table 4.4.1.2: various food stuffs used by respondents to prepare food for their children ...... 37 Table 4.4.2.1: Respondents’ preference and choice of formula feeding ................................... 39 Table 4.4.3.1: Factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions ....................................................................................................... 41 Table 4.4.3.2: Logistic regression analysis on factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions .................................................. 43 Table 4.5.1: Assessment of IYCF practices based on WHO/UNICEF indicators .................... 44 Table 4.5.2.1: Factors influencing preference of Formula food over local foods by respondents ................................................................................................................................. 47 Table 4.5.3.1: Factors influencing early initial of breastfeeding ............................................... 49 x LIST OF FIGURES Figure 2.1: Conceptual Framework of market women’s knowledge on infant and young child feeding (IYCF) practice ........................................................................................... 8 Figure 3.1: Map Showing Ashiedu Keteke Sub Metropolis. ..................................................... 16 Figure 4.4.1.1: Age of children at time of cessation of breastfeeding by mother..................... 34 Figure 4.4.1.2: Age of children at time of introduction of solid food (for children ≥ 6 months) ................................................................................................................................. 34 Figure 4.4.1.3: Classification of the food stuffs used by respondents to prepare their children’s food, based on the 4-star diet groups ..................................................................... 37 xi ABSTRACT Market Women’s Knowledge on Infant and Young Child Feeding Practices in Ashiedu Keteke of the Greater Accra Region, Ghana. Infant and young child feeding is an important area to improve child survival and promote healthy growth and development as recommended by the WHO/UNICEF. Malnutrition remains the leading cause of child morbidity and mortality among children under five years of age particularly in sub-Saharan Africa. Amidst the many efforts over the years to curb the malnutrition menace in Ghana, current statistics reveal that working mothers like market women resort to all forms of inappropriate feeding practices which eventually leads to malnutrition in their children. This study was therefore designed to explore market women’s knowledge on Infant and Young Child Feeding Practices in Makola market, Ashiedu Keteke, Accra. Objective: The main aim of this study is to assess the level of knowledge of market women with children 0-23 months on Infant and Young Child Feeding (IYCF) practices in Makola, Ashiedu Keteke sub-Metropolis. Methods: An exploratory cross-sectional study involving 300 mothers with children between the ages of 0-23 months consecutively enrolled in the study. The study excluded those who do not bring their children to the market. Structured questionnaire was pretested to enable modification. Findings: Only 148 (49.3%) initiated breast feeding within the first hour of delivery. In all, 121 (40.3%) introduced solid or semi-solid food to their children before 6 months. More than half 245 (81.7%) did not know responsive feeding. About 175 (58.3%) did not know the risk of not practicing the recommended IYCF and 177 (59.3%) did not wash their children’s hands before feeding them. Among the women, attending to their customers was a priority for almost half (47%) of them. Conclusion: Knowledge and practice of respondents on recommended IYCF was poor. Educational level, child’s age and market area were found to be significantly associated with respondents’ knowledge and practice levels. There is need to intensify awareness and education of recommended IYCF among mothers, especially market women and other busy mothers. Health facilities need to increase health education among mothers during antenatal and post-natal visits to ensure good health for Ghanaian children. 1 CHAPTER ONE INTRODUCTION 1.1 Background An infant is a young child between the age of one month and 12 months and a young child is a child from birth up to two years of age (Laghari et al., 2015). Infant and young child feeding practices includes exclusive breastfeeding, timely and appropriate introduction of complementary feeding to children at six completed months of age, and continued breastfeeding alongside with other foods until two years of age and beyond. This is an essential part of infant and young child proper growth and health (Cassells, Magarey, Daniels, & Mallan, 2014). Proactive interventions and mothers education, staff and caregivers attitude are necessary to protect and support sustainable infant and young child feeding practices (Musa, Musa, Ali, & Musa, 2014). Appropriate infant and young child feeding practice helps to minimize the possibility of micro-nutrient deficit through exclusive breast feeding at the first six months of life followed by the introduction of essential vitamin rich foods (Sint, Lovich, Hammond, Kim, Melillo, Lu, Ching, Marcy, Rollins,Koumans & Heap, 2014). However, inadequate support to infant feeding has been established as one of the main causes of malnutrition among children. Poor nutrition increases the risk of illness, and is responsible, directly or indirectly, for one third of deaths among children under the age of five years old (WHO, 2008). Inappropriate feeding practices such as poor hygiene, unhealthy preparation of locally available foods and where appropriate, use of fortified blended foods exposes infants and young children to danger thereby causing disease, infections and illnesses that could lead to child mortality (Kandala, Madungu, Emina, Nzita, 2 & Cappuccio, 2011). Every infant and young child has the right to good nutrition according to the convention on the right of children. Early nutritional deficiency are linked to long term impairment in growth and health, and malnutrition during the first two years of life results in stunting leading to adult height several centimeters shorter than his or her potential height (WHO ,UNICEF 2009). Malnutrition is a leading cause of morbidity and mortality among children under five years of age around the globe. Malnutrition affects both physical growth and cognitive development of children under five years (Laghari et al., 2015). This leads to reduction in reproductive and physical work capacity, hence a direct impact on health, performance and survival of the infants and young children. It is estimated that about 150 million children under five years of age are underweight and over 20 million are severely malnourished (Katepa-bwalya, Mukonka, Kankasa, Masaninga, & Babaniyi, 2015). In sub-Saharan Africa, about 47 million children under 5 years of age are stunted (Musa et al., 2014) and (de Onis, Blössner, & Borghi, 2012). However, available Statistics indicate the trends of child mortality that occurred between 2008 and 2014 were severe in urban areas than in rural areas (Tullus, 2015). However, improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level. 1.2. Problem statement Essential and adequate nutrition during infancy and early childhood is very important to ensure growth and health development of children to their ample potential (Laghari et al., 2015). Insufficient nutrition raises the risk of illness. In 2006, about 9.5 million deaths occurred in children less than 5 years of age due to malnutrition (WHO, Black et al., 2008). 3 It is estimated that, 218 million Africans suffer from chronic hunger and malnutrition. Additionally, an estimated 43% of pre-school children in Africa are deficient of vitamin A – a micronutrient needed for healthy growth (Ghana FAO., 2015). Ghana is one of the countries that give high priority to the attainment of the sustainable millennium development goals. Child mortality reduction is one of the goals of the declaration to lessen the burden of death on the Ghanaian population. According to the GDHS 2014 report, Greater Accra region recorded an estimated number of 47 deaths per 1000 live births among children and 37 deaths per 1000 live births among the infants due to malnutrition (GDHS, 2014). More so, in Ghana, available statistics indicate that 12,000 children die every year of under- weight related ailments due to malnutrition (GHS, 2012). The statistics also indicate that under- nutrition contributes to about half of all child deaths beyond early infancy, whilst one out of every thirteen children in Ghana die before their fifth birthday – mostly as a result of under- nutrition. Though many interventions have been implemented over the years to curb the malnutrition menace in Ghana, the above outlined statistics showed that working mothers like market women resort to all forms of inappropriate feeding practices which eventually leads to malnutrition in their children. One of such is formula feeding which most mothers with children under two years resort to (Zhang et al., 2015). Much has not been done to assess busy working mothers like market women’s knowledge on infant and young child feeding practices and factors associated with mother’s preference for formula feeding rather than breastfeeding. There is also the need to assess how mothers manage their businesses with appropriate and timely child care practices. 4 1.3. Justification Reduction of child mortality can be reached only when nutrition in early childhood and IYCF specifically are highly prioritized among busy mothers including market women. Significant reduction in child mortality can only be achieved by preventing child malnutrition in the early lives of newborns (Addo et al., 2001). It is against this background that this study seeks to assess market women’s knowledge on recommended infant and young child feeding practices and the factors that influence their preference of formula feeding to breastfeeding. The study will also contribute to literature on infant feeding practices among very busy everyday working women. It will help policy makers identify unfavorable gaps in child nutrition and subsequently develop good public health interventions to improve child survival. 1.4. Research Questions • What is the level of knowledge of market women about recommended IYCF? • How do market women manage their daily activities and child care practices? • What proportion of market women initiate timely and adequate complementary feeding practices? • What factors influence mothers’ preference of formula feeding to breast feeding? 1.5 Study Objectives 1.5.1. General Objective To assess the level of knowledge of market women with children 0-23 months on infant and young child feeding practices in the Ashiedu Keteke sub-Metropolis. 1.5.2. Specific Objectives • To assess the level of knowledge of mothers on recommended infant and young child feeding practices 5 • To identify the proportion of mothers initiating adequate and timely recommended IYCF. • To determine the factors that influence mothers’ choice of formula feeding. • To assess the IYCF practice of the mother’s based on WHO/UNICEF global indicators for monitoring IYCF 6 CHAPTER TWO LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 2.0. Introduction This chapter seeks to review literature on the optimal infant and young child feeding practices, subsequently, it is expected to explore literature on the knowledge of infant and young child feeding practices amongst market women, and to access their ability to handle their business, time management, and adequate feeding practice, as well as their attitude towards complementary feeding and exclusive breast feeding considering their busy schedule. Malnutrition impacts on human performance, health and survival have been the reason of extensive research for many years, several studies have showed that undernutrition affects physical growth, morbidity , mortality , cognitive development ,reproduction and as well the capacity to work physically and effectively (UNICEF, 2006). One of the underlying factors that is most responsible for diverse illness and diseases in both children and adults is malnutrition, which contributes immensely to the incompetencyadjusted years of life globally (Ingram et al., 2015). However, undernourishment is specifically prevalent in developing countries, thereby one out of every three preschool-age children is affected (Durão et al., 2015). Moreover, an accurately nourished child is a child that has a connection to sufficient supply of food, proper care and health (UNICEF, 2006). Children who have such degree of care and attention tends to have weight and normal height measurements that is similar with the accepted normal distribution of heights (H) and weights (W) of healthy children who are of the same age group and gender (WHO, 2009). 7 However, factors that contribute to malnutrition in children and infants are in diverse forms, and the primary determinants have been reviewed by several writers and researchers with association to substandard food consumption and severe repeated infections, or a combination of both (Musa et al., 2014). The nutritional status and the total health of a child are subjects to be assessed against malnutrition as factors that could be attributed to poor practice of maternal to child care, and health care, furthermore, these very factors negatively impact children heath, growth, thereby leading to uncountable child mortality worldwide (Kandala et al., 2011). 2.1 Conceptual Framework The frame work (Figure 1.) is showing the interrelationship between the factors that can influence WHO recommended IYCF practice among market women with children between the ages of 0-23 months who are regularly in the market with their mothers. Maternal factors can be considered as a major factor in proper feeding practice e.g. age, level of education marital status can affect mother’s choice on choosing the type of infant food, and adequate feeding practice. More so, child-related factors affect proper practice of IYCF. A child nutritional status and health conditions at birth may contribute to the mother’s choice or preference of feeding practice to adopt thereby resulting to less adherence to the recommended practice by the mother, and market environment can also contribute in the reduction of adequate time that the mother can dedicate for proper feeding of the child. However, the mothers knowledge also contributes immensely because, the mothers awareness of the consequences of poor feeding will encourage her to adhere to recommended feeding practice despite the cost. 8 Figure 2.1: Conceptual Framework of market women’s knowledge on infant and young child feeding (IYCF) practice 2.2. Breast feeding and its Benefits to children under two years Breast feeding is a possible way of providing ideal food for the healthy growth and development of infants, and also an integral part of the reproductive process with important implications for the health of mothers. As a global public health recommendation, infants should be breastfed exclusively for the first six months of life to achieve optimal growth development and health (UNICEF, 2013). MOTHERS FACTORS – EDUCATIONAL LEVEL, MARITAL STATUS, AGE, RELIGION FEEDINIG PRACTICES - EXCLUSIVE BREASFEEDING, 0 - 6 MONTHS. ADEQUATE COMPLEMENTARY FEEDING FROM 6 - MONTHS 23 ENVIRONMENTAL FACTORS - MARKET ACTIVITIES, MOTHER SUPPORT GROUP CHILDS FACTORS – MALNOURISHED, SICK CHILD, PREMATURE BABY KNOWLEDGE ON IYCF PLACE OF DELIVERY, FAMILY SIZE, 9 Exclusive breastfeeding is the situation where an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines (WHO, 2008). Breast feeding confers short term and long term benefits and helps to protect children against variety of acute and chronic disorders. Exclusive breast feeding is of more importance than partial breast feeding. According researchers in early studies, it was recorded that in 1984, a study reviewed discovered the risk of death from diarrhea of partially breastfed infants 0-6 months of age was 8.6 times the risk for exclusively breastfed children, Among those children that received no breast milk the risk was 25 times that of those who were exclusively breastfed (UNICEF, 2007). The WHO evidence in 2007, on long term impacts of breast feeding recorded that exclusive breast feeding of 4 or more months is capable of protecting an infant from single and recurrent episodes of otitis media. However, in Africa today poverty among lactating mothers remains an underlining cause of improper breast feeding which woefully retards the growth of most developing children in return. Furthermore, early breastfeeding is associated with fewer nighttime feeding problems. Early skin-to-skin contact between mother and baby improves breastfeeding outcomes, increases cardio-respiratory stability and decreases infant crying. Breastfeeding aids general health, growth and development in the infant. There is a significantly risk increase of acute and chronic infection and diseases among infants who are not breastfed properly, lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection and necrotizing enterocolitis. Exclusive Breastfeeding may defend against unexpected infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma, allergic diseases, and digestive diseases and may enhance cognitive development (GHS, 2015). 10 2.3. Mother’s nutrition Adequate nutrition intake has important benefits for both women and their children. Children who are well breastfed gain a lot of micronutrients supplements received by the mother during and after pregnancy, especially vitamin A which is mostly needed for the children’s nutrient stability. More so, iron supplement of women during pregnancy has the ability to protect the mother and the infant against anemia, since anemia is considered as a major cause of maternal and perinatal mortality worldwide. Nutritional imbalance in pregnancy is a major treat to the fetus and could leads to unfavorable birth outcome such as premature or low birth weight delivery. Ultimately, iodine deficit is associated with diverse of advance pregnancy events, including abortion, fetal brain damage, congenital malformation, stillbirth and prenatal death. Insufficient dietary intake as well as diseases is said to be the major cause of malnutrition in human, the WHO standards confirmed that there is an important intimate link between the nutritional status of the mother and that of the child, therefore to achieve improved infant and young child feeding begins with ensuring the health and nutritional status of the women throughout all the stages of life. During pregnancy and lactation, women’s nutrient requirements increase to cater for the fetus. During this period, women therefore tend to use their nutrient reserves for energy if their increased nutrient is not catered for and subsequently become malnourished due to inadequate nutrient intake which could result to low birth and still birth (Sagawa, 2010). 2.4. Complementary foods Increase food consistency and variety is essential for the provision of enough and required nutrients for the growth and sustainable development of a child throughout infancy and to the adulthood, to support the nutrients infant gained from the mother through the breast milk. 11 Complementary foods is the nutrient rich food that is given to an infant after the baby has reached the first 6 months of age. Nutrition is an essential, unlimited and acknowledged part of a child’s right no matter the age, for the pleasure of attainable standard of health. Children possess the right to adequate nutrition and access to safe and nutritious food and these are important requirements for fulfilling a child’s right and need to accomplish the highest standard of health. This process begins from when breast milk is no longer enough to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk even though breastfeeding may continue (USAID/ WHO/ UNICEF, 2008). Starting from the age of 6 months, when an infant's need for energy and nutrients exceeds what is provided by the mother, supplements like complementary food becomes necessary to fill the energy and nutrient gap in the children (Dewey and Adu-Afarwuah, 2008). The period of 6-23 months is the time of peak incidence of growth and health faltering, deficiencies in micronutrients and risk of infectious illnesses, therefore the need for the introduction of appropriate complementary foods is important at this age to prevent an infant growth from being faltered, However, infants with exceptional difficult situations such as preterm or low birth weight infants, severely malnourished children and emergency situations, additional food source like complementary food can be applied especially an infants born to infected HIV mothers (UNICEF and WHO, 2009). There is the need for safe and sufficient nutrients in Complementary foods for infants in order to meet the demand of the young child's energy and nutrient requirements (WHO, 2009). Studies has shown that complementary foods that can provide the adequate nutrients to meet the infant needs for sustainable energy and nutrients is the local type of supplemented foods 12 especially for the first trial of complementary food such as tick portage, animal source of foods (e.g., meat, fish, chicken, liver, eggs, milk and milk products). All these are to be introduced at 6 months of age. The introduction of vitamin A, rich fruits and vegetable such as (mango, papaya, passion fruits, dark-green leaves, carrots, yellow sweet potato pumpkin and other fruits and vegetables such as banana, pineapple, avocado, watermelon, tomatoes, eggplant and cabbage, including locally-used wild fruits and other plants, legumes (beans lentils etc.), grains such as maize, wheat, rice, millet, potatoes and many other complementary foods that can enhance the growth of infants and encourage healthy state of their health as well as support to building a strong immunity against infectious disease and infant mortality due to malnutrition(UNICEF, 2013). However, the introduction of complementary fluids and foods before six months and inability to dedicate quality time for infant and young child feeding is reportedly common in this era, particularly among working mothers and those with higher levels of education (Madsen, 2010). Moreover in a recent research it was discovered that about 13.5% of infants had received complementary foods before 3 months and 83.5% before 6 months (Patterns, 2013). Early introduction of Foods such as cow’s milk, eggs and honey may increase the risk of allergies and food poisoning in young infants leading to diarrhea, vomiting, and exposure to morbidity and treat to infant’s poor life (Gardner, Green, & Gardner, 2015). 2.5. Complementary feeding Infant and young child feeding practice also put emphasis on complementary feeding practices and foods or diets of children under two years of age. The knowledge, attitudes, practices and social norms of infant and young child feeding and its related practices among mothers is very important (UNICEF, 2011). Infants at six months need additional foods aside the breast milk to grow healthy. Therefore, to meet their evolutional requirements, infants should receive 13 nutritionally adequate and safe complementary foods while breast feeding continues for up to two years of age or beyond. The recommended feeding practices at this stage of the child’s life is very important since the breast milk only is not sufficient for the growing child’s nutrient needs. It is therefore imperative for mothers to follow the recommended complementary feeding practices. At six month, the child needs two to three meals plus frequent breastfeeds a day. A child from 6 to 9 months needs the same frequency as a child at six months in addition to one to two snacks per day while a child from 12 to 24 months needs more, three to four meals plus breastfeeds including one to two snacks (UNICEF, 2013). Children under two years of age need more time to feed, therefore mothers should be patient and encourage their children to eat more. Most children under this age often refuse to eat due to the introduction of new foods aside breast milk. It also recommended that mothers should not force-feed their children (UNICEF, 2013). 2.6. Infant and young child feeding (IYCF) practices Infant and young child nutrition is a vital component in human life.Infant and young child feeding is a basic care for early childhood development. Poor physical development, cognitive impairment and repeated infections normally occur as a result of poor feeding practice (UNICEF, 2011). Infant and young child feeding aims to revitalize efforts to promote, protect and support appropriate infant and young child feeding practice among mothers, caregivers and family members. Breast milk is the first food for the new-born (Mcdaniel & Pisani, 2012). Even in resource poor settings, improved feeding practices can lead to improved intakes of energy and nutrients, leading to better nutritional status (Hausman, 2008). 14 According to previous researchers, adequate and good practice of infant and young child feeding is a key stone of a child proper development in life, it is also a building block for an infant and young child IQ development (Gardner et al., 2015). A well fed child is a child according to UNICEF and WHO recommendation, with sufficient nutrient and energy needed for the growth and healthy state of the entire body. Early infant with poor feeding practice is prone to suffer from low immunity, morbidity and mortality (WHO, 2009). Over the past decades, the evidence of biological requirements for appropriate nutrition, recommended feeding practices and factors impeding appropriate feeding has grown steadily, Moreover, much has been learned about interventions that are effective in promoting improved feeding (Gardner et al., 2015). For example, recent studies in Bangladesh, Brazil and Mexico have demonstrated the impact of counselling, in communities and health services, to improve feeding practices, food intake and growth (Addo et al., 2001). Globally, an awareness for a Strategic Infant and Young Child Feeding practices has been dually emphasised on, with the aims to revitalize efforts and positive response and cooperation from the mothers and caregivers to promote, protect and support appropriate infant and young child feeding. It builds upon past initiatives, in particular the Incentive Declaration and the Baby-friendly Hospital initiative and addresses the needs of all children including those living in difficult circumstances, such as infants of mothers living with HIV, low-birth-weight infants and infants in emergency situations (Sint et al, 2014) 2.7. Four star diet (Balanced diet) A four star diet is a new method of food preparation, with a guarantee that individual meals are balanced and contain foods from all the food groups. According to UNICEF recommendation, this method/technique is proposed mostly for infant and young child feeding as well as infant and maternal nutrition (during pregnancy and lactation). However, this is 15 mostly used in developing countries where literacy and adherence to preparing balanced diet is relatively low. Various food groups that made up the four star diet are staples, legumes, vitamin and proteins (UNICEF Manual, 2010). Staples 1 star * These are different categories of food stuffs that made up of one star diet, ability to include at least one of the following in each meal to provide adequate amounts of carbohydrates. They include: grains such as maize, wheat, rice, millet and sorghum and roots and tubers such as cassava and potatoes. Legumes 2 Star ** These are foods stuffs that provides adequate nutrient needed by the body, these are Legume rich foods such as beans, lentils, peas, groundnuts and seeds such as sesame. Vitamin a-rich fruits and vegetables 3 Star *** According to UNICEF, vitamin rich food are needed to improve growth and organ development in children and during pregnancy, they include fruits and vegetables such as mango, papaya, passion fruit, oranges dark-green leaves, carrots, carrots, yellow sweet potato and pumpkin and other fruits and vegetables such banana, pineapple, avocado, watermelon, tomatoes, eggplant and cabbage. Animal source-source foods 4 Star **** Animal source foods are recommended by UNICEF for enrichment of foods given to the infant and young children, pregnant and lactating mothers for good protein. Example of animal foods such as meat, chicken, fish, liver, eggs and dairy products (UNICEF Manual, 2010). 16 CHAPTER THREE METHODS 3.1 Introduction This chapter presents the pattern of research methods that was adopted in this study. This involves the type of study design, study area, study population, variables, sample size, technique and method, data collection method and tools and ethical consideration. 3.2 Study area Ashiedu keteke (Figure 2.) is one of the thirteen sub metros in the Accra metropolitan assembly or sub metropolis. Ashiedu Keteke serves as economic and administrative hub of the Accra Metropolitan Assembly. It is also a centre of a wide range of nightclubs, restaurants, and hotels. The central business district of Accra contains the city's main banks and department stores, and an area known as the Ministries, where Ghana's government administration is concentrated. Economic activities in Accra include the financial and agricultural sectors, Atlantic fishing, and the manufacture of processed food, lumber, plywood, textiles, clothing, and chemicals. Figure 3.1: Map Showing Ashiedu Keteke Sub Metropolis. https://en.wikipedia.org/wiki/Central_business_district https://en.wikipedia.org/wiki/Central_business_district https://en.wikipedia.org/wiki/Plywood 17 3.3 study design An exploratory Cross-sectional study with stratified sampling methods, was adopted to determine the knowledge on IYCF practice among market women in Ashiedu Keteke, Accra Metropolis in the Greater Accra Region, Ghana. This study was designed to involve Makola market women with children between the ages of 0 - 23 months. 3.4 Variables 3.4.1 Dependent variable Feeding practice (example: exclusive breast feeding/complementary feeding) 3.4.2 Independent variable Mother’s factors: age, marital status, level of education, Religion, Environmental factors, Market activities, Mother support group, Childs factors, Malnourished child, Sick child, Premature birth and knowledge. 3.5 Sampling 3.5.1 Study population The study subjects included market women with children between the ages of 0 -23 months who trade in Makola market. 3.5.2 Inclusion criteria The study population included any child/infant • Market women with children between the ages of 0- 23 months • Table top sellers, hawkers, carriers, shops and store owners and open wares in the market, • Women who bring their children to the market • Women who provided written or verbal informed consent 18 3.5.3 Exclusion criteria The study population excluded any child or infant: • Who was not within the ages of 0 to 23 months. • Whose mother does not transact business in the study area • Whose mother/caregiver declined written or verbal consent. 3.5.4 Sample size calculation Sample size was calculated using the Leslie Kish formula (Cochran, 1977). Using n = Z2p (1-p) d2 Where n = desired sample size Z = the standard normal deviation, set at α = 0.05 based on a 95% confidence level P = estimated proportion of infants and young children who received recommended complementary feeding, which is 22.7 % (227) according to recent surveys (GDHS, 2014). d = the allowable margin of error = 0.05 Thus n = (1.96)2 (0.227*0.778) = 271 children (0.05)2 19 Adjusting for non-response rate of 10% (considering the nature of the market activities and how busy the respondents could be and loss of questionnaire), the final sample size was calculated to be; Where N = n × 100 100 – r And n = initial sample size r = non response rate (10%) Thus N = 271 × 100 = 300 100 – 10 3.5.5 Sampling procedure A two staged sampling procedure was employed. Stratified sampling method was used to demarcate the market into zones 1, 2, 3, and 4. However, names of the market areas were used to denote each zone. The Kantamanto area was zone 1, Okaishie area represented zone 3, Lome market was labelled as zone 3, while Rawlings Park and the post office area was labelled as zone 4. In each zone, 75 market mothers with infants and young children was recruited consecutively i.e. any market mother encountered in the zone with an infant and young child who was consents to participate was interviewed. This procedure was employed in each zone until the required total sample size of 300 market mothers with infants and young children was obtained for the study. 20 3.6 Data collection/ tools and techniques A face- to- face interview using a well-structured questionnaire adopted from UNICEF was used to collect data from respondents. Before administering the questionnaire, Pre-testing of questionnaire was done at Madina market using market women with children 0-23 months to enable modification and corrections of the procedure. The following concerns were also evaluated during the pretesting: • Reliability of questionnaire. • Average time needed to administer questionnaire. • Sequence of questions and their clarity. • Evaluating the success of training of research assistance. Data were collected from market women with children who took their children to the market, the market was also divided into different zones to enable the true picture of the intended study and avoid bias. Data on IYCF practice, knowledge and proper child care was also obtained from the women. Background information such as age, sex, and marital status, level of education, child’s age and religion was captured as well. Three hundred market women with children between the ages of 0 -23 months were interview using a well-structured questionnaire. 3.7 Ethical Considerations Approval for this study was sought from the Ethical Review Board of Ghana Health Service. In addition, research participants which formed the sample of the study were given details of the study which includes spelling out of the nature and importance of the study before they were selected. Each participant provided informed consent 21 3.8 Quality Control For reliable findings, quality control measures were adopted during the data collection process. Research assistants were trained to administer questionnaire. Data entry was done by research assistants, which required daily supervision by the researcher. Also, the researcher checked all the questionnaires administered to ensure accuracy, and necessary editing before entry. 3.9 Data Processing and Analysis Data collected from the study area was analysed with a computer software. The software used for the data entry was Epi data version 3.1 and SPSS version 22. Descriptive measures (frequency, proportion and mean± standard deviation were used to describe the data and these were represented by tables and graphs. Associations between independent and dependent variables were tested for significance, applying chi square method, and logistic regression to measure existing associations. 3.10. Strength of the study Three research assistants were trained prior to the data collection to assist in data gathering. This helped to minimize stress and ensured quality data collection. The questionnaires of the study were interviewer administered and this enable the researcher and the trained three research assistants to read and translate each question to the respondents. This ensured that all questions were appropriately answered without missing answers. The questions were also couched in simple sentences which were easy to explain to the understanding of respondents. Data cleaning was done before analysis was undertaken to guarantee accuracy of results. 22 CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents findings of the study on market women’s knowledge on infant and young child feeding practices in Ashiedu Keteke sub-metropolis of the Greater Accra region. The results of this study are presented in five major sections: • Demographic characteristics of respondents • Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) • Infant and Young Child Feeding Practices and perceptions • Assessment of IYCF practices based on WHO/UNICEF indicators. 4.2 Demographic characteristics of respondents 4.2.1 Background Information The demographic characteristics of respondents is shown in Table 4.1 below. Mean age of the respondents was 29.2 ± 6.8 years while 153 (51.3%) of the children being males. Very few 14 (4.7%) respondents had ≥ 5 number of children. When asked about place of delivery, a large proportion (81.0%) of the respondents said they delivered their children in a health facility. Educationally, about 88 (29%) of the respondent had no formal education, (83.7%) were married. Christianity and Islamic religion were the two major religions practiced by the respondents. 4.2.2 Market activities of respondents Respondents were equally selected 75 (25.0%) from each of the four market areas and about 127 (42.3%) of the respondents traded in an open space or outside a building while 84 (28.0%) were either hawkers or carriers (these help customers carry their stuff around). Majority of the respondents came to market at least 4 times per week and many 252 (84.0 %) admitted that they brought their children to the market always. out of these, 246 (97.6%) 23 indicated that they and only 57 (22.6%) fed their children at least 3 times in a day. When asked about how many times they usually feed their children in the market, different responses were given including once 13 (4.4%), twice 65 (22.0%) seven (2.4%) indicated that they only breastfed their children and did so as often as possible. Among the respondents who said they only breastfed their children, 3 (43.0%) of the children were more than 6 months. The respondents were also asked how they manage their business with feeding their children on a typical busy day, a greater number 139 (47.0%) admitted that attending to their customers is of prior importance, other response given is shown in Figure 4.2.1 below. Table 4.2.2 summarizes the market activities of the respondents. 24 Table 4.2.1: Background information on market women in the survey Variables Frequency Percentage Respondent’s age (in years) 15-19 10 3.3 20-29 144 48.0 30-39 126 42.0 40 and above 20 6.6 Mean ± SD 29.2 ± 6.8 Age of child (in months) 0-5 17 5.7 6-11 89 29.7 12.17 98 32.7 18-23 96 32.0 Mean ± SD 2.9 ± 0.9 Educational status No formal education 88 29.3 Junior Secondary 123 41.0 Senior Secondary 62 20.7 Vocational 9 3.0 Tertiary 18 6.0 Religion Christianity 174 58.0 Islamic 125 41.7 African Traditional Religion 1 0.3 Marital status Never married 33 11.0 Married 251 83.7 Divorced/ separated/ Widowed 16 5.3 Place of delivery Home 44 14.7 Traditional birth attendant 13 4.3 Health facility 243 81.0 Number of children 1-4 children 286 95.3 5 or greater than 5 children 14 4.7 25 Sex of child Male 154 51.3 Female 146 48.7 Table 4.2.2: Market Activities among respondent in the selected markets Variable Frequency Percentage Market area Kantomanto Okaishie Lome Rawllings park Market space/structure Enclosure/Within a building 75 75 75 75 89 25.0 25.0 25.0 25.0 29.7 Open space/outside a building 127 42.3 Hawkers and carriers 84 28.0 Days spent in the market in a week? 1-3 21 7.0 4-6 224 74.7 Everyday 55 18.3 Bringing of child to market? Always 252 84.0 Sometimes 44 14.7 Never 4 1.3 Number of times child is fed in the market on a normal day? (n=296) Once 13 4.4 Twice 65 22.0 Thrice 145 49.0 At least four times 66 22.3 I only breastfeed, and do so as often as possible 7 2.4 Managing business and child feeding on busy market days Attending to my customers is priority Feeding my child is more important 139 108 47.0 36.5 I come with a relation who helps me 44 14.9 My fellow market women do assist me 5 1.7 26 Figure 4.2.2 Responses given by respondents on how they balance busy market schedule and feeding their children 4.3 Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) A large proportion (70.3%) of respondents claimed they know what colostrum is. However, about 63.3% of respondents actually gave it to their baby others discarded it. With respect to practicing recommended IYCF, 204 (68.0%) could not correctly mention the risk of not practicing recommended IYCF. More than half (59.0%) of respondents stated that it is not necessary washing a child’s (6-9 months) hands with water. Respondents were also asked if they had ever heard of responsive feeding, only 55 (18.3%) gave a positive response, out of these, 11 (20.0%) associated it with feeding on demand, 7 (12.8%) admitted they did not know, however 37 (67.3%) indicated it was feeding on schedule. When asked about the 4 star food/diet, a larger proportion (62.0%) indicated that they did not know what it meant. An 18-point score was designed to assess the knowledge of IYCF among respondents, Respondents were graded based on their responses to 10 knowledge questions in the questionnaire, 7 of the questions were given 1 mark each for correct response, while 2 questions which required multiple response were given 4 marks each, and another similar one given 3 marks, giving a total of 18 marks. In summary, Knowledge of IYCF appears poor among many of the respondents. Table 4.3.1.1 reveals further information. ATTENDING TO MY CUSTOMERS IS PRIORITY FEEDING MY CHILD IS MORE IMPORTANT I COME WITH A RELATION WHO HELPS ME MY FELLOW MARKET WOMEN DO ASSIST ME 47 .0 36.5 14.9 1.7 27 Table 4.3.1.1: Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) Variables Percentage Frequency Knowledge of colostrum Yes 211 70.3 No 89 29.7 Use of first yellowish milk at delivery Gave it to my baby 190 63.3 Discarded it 110 36.7 Infants from 6-9 months and eating of food from animal sources Yes 149 49.7 No 151 50.3 Knowledge of risk of not practicing recommended IYCF Yes 125 41.7 No 175 58.3 Consequences of not practicing recommended IYCF* (n=125) Anaemia 3 2.4 Brain loss 1 0.8 Cholera 7 5.6 Cold 1 0.8 Cough 1 0.8 Death 1 0.8 Diarrhoea 16 12.8 Fever 3 2.4 Kwashiokor 38 30.4 Loss of weight 25 20.0 Malaria 12 9.6 Malnutrition Obesity 3 1 2.4 0.8 Rashes Stomach pain/ulcer 1 6 0.8 4.8 Stunted growth 36 28.8 Weakness 5 4.0 Knowledge of daily minimum feeding frequency for children based on age group 6- 9 months (n = 68) 3.6 ± 1.2 9-12 months (n = 99) 3.4 ± 1.3 28 12-18 months (n = 65) 3.7 ± 0.9 18-23 months (n = 68) Not Necessary to wash 6-9 month old child’s hand though not self-fed? 3.4 ± 0.8 Yes 177 59.0 No 123 41.0 Knowledge texture of food for a 6-9 month old child Very light 51 17.0 Light 163 54.3 Thick 39 13.0 Very thick 47 15.7 Recommended food for Child at 6 month? Light porridge or kooko 214 71.3 Thick porridge or kooko 86 28.7 Hygiene practices associated with IYCF known* Wash hands before feeding my child 267 89.0 Giving child a warm food 182 60.7 Using/washing clean plates/cups/spoons 173 57.7 I do not know 10 3.3 Washing breast before breastfeeding 1 0.3 Ever heard of responsive feeding Yes 55 18.3 No 245 81.7 Briefly describe responsive feeding (n=55) Feeding on schedule 37 67.3 Feeding on demand 11 20.0 Whenever child is crying 4 7.3 29 I don’t know 3 5.5 Knowledge of the 4 star food/diet Yes 114 38.0 No 186 62.0 Groups that make up the 4 star diet Protein 108 36.0 Vitamin 100 33.3 Mineral 80 26.7 Fats 79 26.3 Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) Very Poor (0-4) 49 16.3 Poor (5-9) 171 57.0 Good Knowledge (10-18) 80 26.7 Mean Knowledge score 7.5 ± 3.1 Note: Multiple response included* 4.3.1. Factors affecting knowledge of recommended Infant and Young Child Feeding Practice (IYCF) The knowledge of respondents according to socio-demographic characteristics and market activities is shown in Table 4.3.1.2. There was significant association between respondents’ Knowledge level and their educational status, age group, religion, market area, market structure, place of child’s delivery, frequency of days in the market and frequency of times that the child is brought to market at p < 0.05. No significant relationship existed between knowledge level and marital status, age of child, sex of child and number of children at p > 0.05. 30 Table 4.3.1.2: Factors associated with respondents’ knowledge on knowledge of recommended Infant and Young Child Feeding (IYCF) Practice Variables Knowledge category Poor Good X2 P value Educational status Any formal education No formal education 137 (64.6) 83 (94.3) 75 (35.4) 5 (5.7) 28.04 0.001 Age group 15-24 years ≥ 25 years 70 (85.4) 150 (68.8) 12 (14.6) 68 (31.2) 8.36 0.004 Religion Christianity Islamic 111 (63.8) 109 (87.2) 63 (36.2) 16 (12.8) 20.50 0.000 Marital status Currently married Not currently married 186 (74.1) 34 (69.4) 65 (25.9) 15 (30.6) 0.466 0.495 Market area Kantomanto Okaishie Lome market Rawllings park 57 (76.0) 48 (64.0) 49 (65.3) 66 (88.0) 18 (24.0) 27 (36.0) 26 (34.7) 9 (12.0) 14.32 0.003 Market space/structure Enclosure/ within a building Open space/outside a building Hawkers/carriers 56 (62.9) 87 (68.5) 77 (91.7) 33 (37.1) 40 (31.5) 7 (8.3) 20.89 0.000 Age of child 0-5 months 6-11 months 12-17 months 18-23 months 11 (64.7) 63 (70.8) 76 (77.6) 70 (72.9) 6 (35.3) 26 (29.2) 22 (22.4) 26 (27.1) 1.84 0.606 Sex of child Male Female 115 (74.7) 105 (71.9) 39 (25.3) 41 (28.1) 0.29 0.589 Number of children 209 (73.1) 11 (71.4) 77 (26.9) 3 (21.4) 0.21 0.650 Place of delivery Home Traditional Birth Attendant Health facility 41 (93.2) 11 (84.6) 168 (69.1) 3 (6.8) 2 (15.4) 75 (30.9) 11.90 0.003 31 Market attendance in a week 1-3 times 4-6 times Everyday 11 (52.4) 163 (72.8) 46 (83.6) 10 (47.6) 61 (27.2) 9 (16.4) 8.74 0.021 Number of times child is brought to market in a week Always Sometimes 192 (76.2) 24 (54.5) 60 (23.8) 20 (45.5) 8.89 0.003 4.3.2. Logistic regression analysis on factors associated with knowledge of Infant and Young Child Feeding (IYCF) Practice A logistic regression was run on all the statistically significant factors associated with respondents’ knowledge of recommended Infant and Young Child Feeding (IYCF) Practice. Respondents with no formal education were 6.7 times (OR = 0.15, p = 0.001) the odds of having good knowledge compared to those with any formal education. Similarly respondents who trade in Okaishie were about 5 times (OR = 5.14, p = 0.001) the odds of having good knowledge of recommended IYCF practices. Other factors such as mother’s age group, religion, market structure, place of delivery, frequency of days to market in a week had no significant association with knowledge of recommended IYCF practices. 32 Table 4.3.1.3: Logistic regression analysis on factors associated with respondents’ knowledge of recommended Infant and Young Child Feeding (IYCF) Practice Educational status Any formal education (Reference) No formal education 0.001 0.150 0.051 0.441 Mother’s age group 15-24 years ≥ 25 years (Reference) 0.139 0.548 0.247 1.215 Religion Christians (Reference) Muslims 0.362 1.406 0.675 2.928 Market area Kantomanto Okaishie Lome market Rawllings park (Reference) 0.115 0.001 0.974 2.194 5.135 5.218 0.826 1.956 1.980 5.829 13.478 13.753 Market structure Enclosure/ within a building (Reference) Open space/outside a building Hawkers/carriers 0.082 0.082 0.545 0.391 0.135 0.275 1.128 1.081 Place of delivery Home Traditional Birth Attendant Health facility (Reference) 0.238 0.375 0.450 0.383 0.119 0.046 1.698 3.186 How often do you go to market in a week? 1-3 times (Reference) 4-6 times Everyday 0.180 0.166 0.435 0.358 0.129 0.084 1.468 1.530 How often do you bring your child to the market? Always (Reference) Sometimes 0.138 1.874 0.818 4.294 Variable P value OR 95 %CI Lower Upper 33 4.4 Infant and Young Child Feeding Practices and perceptions More than half (63.0%) of the respondents admitted not washing their child’s hand during the last meal given. Two respondents (0.7%) indicated that their children were never breastfed while 64 (21.3%) admitted that they were no longer breastfeeding their children; among the respondents no longer breastfed their children, 4 (6.3%) and 5 (7.8%) stopped breastfeeding when their children were 0-5 months and ≥ 23 months respectively, Figure 4.4.1.1 is pictorial representation of this information. Respondents were also asked about how long it took them before breast feeding their children for the first time after delivery, only about (49.3%) indicated that they breastfed within first hour of delivery. When asked about what their children were given before breastfeeding for the first time, some admitted that they gave milk (3.7%), plain/ripe water (15.3%), and infant formula (10.7%). Only 126 (42.0%) of the respondents confirmed that they first gave solid or semi-solid food to their children at 6 months, while 121 (40.3%) fed their children with solid or semi-solid food before 6 months, out of the latter, 90 (74.4%) said that they had insufficient breast milk while about 27 (22.3%) added that it was because of their business. This is represented in Figure 4.4.1.2 below. For the assessment of respondent’s practices and perception, 16 (5.3%) respondents whose IYCF practice could have been influenced by congenital abnormalities, complications or death of mother at delivery, were omitted to ensure an unbiased evaluation. A 6-point scale comprising six purposely selected questions with 1 mark for each correct answer was used. Majority of the respondents (73.6%) had very poor perceptions/practice of the IYCF recommended practices. Table 4.4.1.1 reveals further information. Table 4.4.1.2 is a summary of the various food stuffs normally used by respondents to prepare food for their children; Similarly Figure 4.4.1.3 is a pie chart showing the distribution of the food stuffs used according to the WHO/UNICEF recommended 4 star foods for children. 34 Figure 4.4.1.1: Age of children at time of cessation of breastfeeding by mother Figure 4.4.1.2: Age of children at time of introduction of solid food (for children ≥ 6 months) 0-5 months 6-12 months 13-21 months 23 months 4.7 % 23.4 % 64.1 % 7.8 % 38.5 44.5 12.7 3.2 1.1 Before 6 months At 6 months 7 months and above Yet to start solid food Cannot remember 35 Table 4.4.1.1: Infant and Young Child Feeding Practices and perceptions among the market women Variables Frequency Percentage Washing of child’s hands for the last meal given** Yes 111 37.0 No 189 63.0 Children still breastfeeding** Yes 234 78.0 No 64 21.3 Never breastfed 2 0.7 Age at which child stopped taking breast milk (n=64) 0-5 months 4 6.3 6-12 months 15 23.4 13-21 months 40 62.5 23 months 5 7.8 Milk feeding frequency before 6 months (n=2) Five or more times a day 2 100.0 Time taken to breast feed child for the first time** Within first hour of delivery 148 49.3 2-23 hours after delivery 93 31.0 Next day or More than 24 hours 55 18.3 Do not remember 2 0.7 Never breastfed 2 0.7 Food given to child before breastfeeding ** Nothing Plain water Infant formula Gripe water Milk(other than breast milk) Cannot remember Never breastfed 199 34 32 12 11 10 2 66.3 11.3 10.7 4.0 3.7 3.3 0.7 Age of child when solid/semi solid food was given for the first time Before 6months 121 40.3 At six months 126 42.0 36 Seven to 9 months 15 5.0 After nine months 21 7.0 Yet to start 14 4.7 Cannot remember 3 1.0 Reasons for feeding child with solid food before six months (n=121)* Because of my business 27 22.3 Insufficient breast milk 90 74.4 Child was not satisfied with breast milk only 8 6.6 Congenital abnormality 2 1.7 child rejected breast milk 2 1.7 Mothers illness 1 0.8 Because of mothers death 1 0.8 Because I had twins 1 0.8 Still bottle feeding? ** Yes 185 61.7 No 115 38.3 Correct daily minimum feeding frequency of solid/semi solid foods for a child aged 6-9 months? ** Once only 9 3.0 2-3mealwithfrequencybreastseeds 259 86.3 2-3mealsplusbreastfeeds and 1-2 snack 23 7.7 At least 4 times 9 3.0 Practice/perception of recommended Infant and Young Child Feeding Practice (IYCF) Poor practice/perceptions (0-3) 209 73.6 Good practice/perceptions (4-6) 75 26.4 Mean practice score 2.8 ± 1.3 Note: Multiple response included*, Six questions selected for Practice/perceptions assessment** 37 Table 4.4.1.2: various food stuffs used by respondents to prepare food for their children Food stuff Frequency Percentage Maize 247 82.3 Soyabean 233 77.7 Fishpowder 147 49.0 Groundnut 49 16.3 Vegetables (Cabbage, carrot, garden egg, tomatoes, Nkontomire, okro) 34 11.3 Rice 34 11.3 Millet 17 5.7 I don’t cook 8 2.7 Eggs 7 2.3 Cassava 3 1.0 Fruits 3 1.0 Meat 3 1.0 Yam 3 1.0 Cocoyam 1 0.3 Plantain 1 0.3 Grounded shrimp 1 0.3 Dawadawa 1 0.3 Figure 4.4.1.3: Classification of the food stuffs used by respondents to prepare their children’s food, based on the 4-star diet groups 39 % 36 % 20 % 5 % Group 1 (Grains, Roots and Legumes) Group 2 (Legumes and Nuts) Group 3 (Animal source foods) 38 4.4.1 Respondents’ preference and choice of formula feeding Majority 208 (69.3%) of the respondents mentioned “Cerelac” as their most preferred formula food. However many 219 (73.0%) admitted that they did not prefer formula foods to local food, main reasons given were it is expensive 112 (51.1%), local foods are more healthy 63 (28.8%) and more. For the few (25.3%) who indicated preference of formula food over other foods, about 59 (77.6%) of them said their children liked formula food more than other foods. When asked about advantages of using infant feeding formula, some 32 (42.1%) affirmed that it was easy to prepare and saved time, while others 31 (40.8%) indicated that it boosted their children’s growth. They were also asked about other things that influenced their preference for formula feeding, one-half 38 (50.0%) stated that they did not like to expose their breasts in the public and about one-quarter 19 (25.0%) said it was because of their business. Respondents associated, high costs 45 (59.2%), diarrhea 25 (32.9%), obesity 9 (11.8%) excess sugar 32 (42.1%) with major disadvantages of using feeding formula. More on this information is revealed in Table 4.4.2.1 below. 39 Table 4.4.2.1: Respondents’ preference and choice of formula feeding Variable Frequency Percentage Formula food given to child apart from breast milk and family foods Cerelac I don’t use formula feed Lactogen SMA NAN 208 76 56 14 11 69.3 25.3 18.6 4.7 3.7 Do you prefer formula foods to local food? No Yes Still breastfeeding only Why (n=219)* 219 76 5 73.0 25.3 1.7 It is expensive 112 51.1 Local foods are more healthy 63 28.8 My child prefers local foods 46 21.0 They cause serious health issues like cancer, kidney problem etc 3 0.5 Reasons for preference* (n=76) My child’s likes it more than other foods 59 77.6 They are cheap 16 21.5 I use it as supplement 6 7.9 Frequency of formula feeding in a day (n=76) Once 17 22.4 Twice 40 52.6 Thrice 8 10.5 Four times 8 10.5 Five times or more 3 3.9 Advantages of using infant feeding formula (n=76) Easy to prepare and saves time 32 42.1 Boosts my child’s growth 31 40.8 Makes my child strong/full of strength 6 7.9 It is more nutritious 6 7.9 Used as supplementary food 1 1.3 Other things that will make you opt for formulae feeding*(n=76) I don’t like exposing my breast in public 38 50.0 Because of my business 19 25.0 Insufficient flow of breast milk 8 10.5 40 Nothing else 7 9.2 I want to maintain shape of my breast 6 7.9 Child’s illness 5 6.6 Mother’s illness 4 5.3 Child’s preference 3 3.9 Diet diversity 1 1.3 Multiple birth 1 1.3 Disadvantage of using feeding formula*(n=76) Costs/It is expensive 45 59.2 Causes diarrhea 25 32.9 Causes obesity/overweight 9 11.8 Contains excess sugar 32 42.1 I don’t think there is any disadvantage 12 15.8 I don’t know 2 2.6 Note: Multiple response included*, 4.4.2 Factors affecting Infant and Young Child Feeding Practices and perceptions There were significant relationship between the IYCF practices and perceptions of the respondents and their educational status, knowledge level, age of child, frequency of going to market in a week, and frequency of times child is taken to market (p < 0.05). Table 4.4.3.1 summarizes this information. 41 Table 4.4.3.1: Factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions Variables Practice category Poor Good X2 P value Educational status Any formal education No formal education 136 (68.0) 83 (94.3) 64 (32.0) 5 (5.7) 10.89 0.001 Age group 15-24 years ≥ 25 years 63 (81.8) 146 (70.5) 14 (18.2) 61 (29.5) 3.68 0.055 Religion Christianity Islamic 115 (70.6) 94 (77.7) 48 (29.4) 29 (22.3) 1.82 0.177 Marital status Currently married Not currently married 172 (72.3) 37 (80.4) 66 (27.7) 9 (19.6) 1.32 0.250 Knowledge level Poor Good 165 (79.3) 44 (57.9) 43 (20.7) 32 (42.1) 13.12 0.000 Market area Kantomanto Okaishie Lome market Rawllings park 59 (83.1) 51 (69.9) 47 (70.1) 52 (71.2) 12 (16.9) 22 (30.1) 20 (29.9) 21 (28.8) 4.44 0.218 Market space/structure Enclosure/ within a building Open space/outside a building Hawkers/carriers 60 (72.3) 86 (72.3) 63 (76.8) 23 (27.7) 33 (27.7) 19 (23.2) 0.622 0.733 Age of child 0-5 months 6-11 months 12-17 months 18-23 months 12 (75.0) 56 (65.1) 65 (69.9) 76 (85.4) 4 (25.0) 30 (34.9) 28 (30.1) 13 (14.6) 10.68 0.017 Sex of child Male Female 102 (72.3) 107 (74.8) 39 (27.7) 36 (25.2) 0.23 0.635 Number of children 199 (73.7) 71 (26.3) 0.04 0.851 10 (71.4) 4 (28.6) Place of delivery Home Traditional Birth Attendant Health facility 33 (84.6) 9 (69.2) 167 (72.0) 6 (15.4) 4 (30.8) 65 (28.0) 2.88 0.238 42 How often do you go to market in a week? 1-3 times 4-6 times Everyday 9 (47.4) 158 (74.2) 42 (80.8) 10 (52.6) 55 (25.8) 10 (19.2) 8.14 0.017 How often do you bring your child to the market? (n=252) Always Sometimes 181 (76.1) 25 (58.1) 57 (23.9) 18 (41.9) 5.97 0.015 4.4.2.1 Logistic regression analysis on factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions Results from the logistic analysis revealed that educated respondents were 2.6 times the odds of having good IYCF practice compared to those with no formal education (OR = 0.375, p = 0.012); also Respondents with children aged 6-11 months and 12-17 months were 4 times the odds (OR = 4,092, p = 0.001); and 2.7 times the odds (OR = 2.787, p = 0.012) respectively, to having good practice compared to respondents with children aged 0-5 months. However, all other factors as shown in the table below were not significant (p > 0.05). 43 Table 4.4.3.2: Logistic regression analysis on factors associated with respondents’ Infant and Young Child Feeding Practices and perceptions Variable P value OR 95%CI Lower Upper Educational status Any formal education (Reference) No formal education 0.012 0.375 0.175 0.804 Knowledge category Poor Good (Reference) 0.046 0.525 0.279 0.988 Age of child 0-5 months (Reference) 6-11 months 12-17 months 18-23 months 0.001 0.012 0.585 4.092 2.787 1.465 1.796 1.250 0.372 9.325 6.213 5.766 How often do you go to market in a week? 1-3 times (Reference) 4-6 times Everyday 0.175 0.219 0.459 0.438 0.149 0.117 1.415 1.636 How often do you bring your child to the market? Always (Reference) Sometimes 0.068 2.208 0.942 5.175 4.5 Assessment of IYCF practices based on WHO/UNICEF indicators The IYCF practices of the respondents were assessed based on the 15 WHO/UNICEF global indicators for IYCF. A little below half, of the respondents (49.3%) initiated breastfeeding within one hour of birth and among 17 (5.6%) of children aged 0-5 months, only 5 (29.4%) were exclusively breast fed. Only 17 (6.0%) of children aged 6-23 months satisfied the required dietary diversity for their age group. Also bottle feeding was a common practice among 61.7% of the respondents. Table 4.5.1 shows the calculation, values and percentage estimates for each indicator. However the data for this survey was not collected based on information collected for previous day. For indicators 12, 13 and 15, no data was computed as the data available from this study was not sufficient to compute the variables. 44 Table 4.5.1: Assessment of IYCF practices based on WHO/UNICEF indicators 1. Early initiation of Children born in the last 24 months who were 148/300 49.3 breastfeeding put to the breast within one hour of birth x 100 Children born in the last 24 months 2. Exclusive Infants 0–5 months of age who receive 5/17 29.4 breastfeeding only breast milk x 100 under 6 months Infants 0–5 months of age 3. Continued Children 12–15 months of age who receive 75/80 93.8 breastfeeding at 1 breast milk x 100 year Children 12–15 months of age 4. Introduction of Infants 6–8 months of age who receive 39/46 84.8 solid, semi-solid solid, semi-solid or soft foods x 100 Breastfed children 9–23 months of age or soft foods Infants 6–8 months of age 5. Minimum dietary diversity Children 6–23 months of age who received foods from ≥4 food groups x 100 Children 6–23 months of age 17/283 6.0 6. Minimum meal frequency Breastfed children 6–8 months of age who receive solid, semi-solid or soft foods or milk feeds at least 2 times x 100 Breastfed children 6–8 months of age Breastfed children 9-23 months of age who receive solid, semi-solid or soft foods or milk feeds at least 3 times x 100 Breastfed children 9-23 months of age 46/46 220/235 100.0 93.6 7. Minimum acceptable diet Breastfed children 6–8 months of age who receive at least the minimum dietary diversity and the minimum meal frequency x 100 Breastfed children 6–8 months of age 3/46 6.5 Breastfed children 9–23 months of age who 14/235 6.0 receive at least the minimum dietary diversity and the minimum meal frequency x 100 Indicator Calculation Value Percentage 45 frequency non - breastfed children 8. Consumption of Children 6–23 months of age who receive 272/283 96.1 iron-rich or iron- an iron-rich food or a food that was fortified foods specially designed for infants and young children and was fortified with iron, or a food that was fortified in the home with a product that included iron x 100 Children 6–23 months of age 9. Children ever Children born in the last 24 months 280/300 93.3 breastfed who were ever breastfed x 100 for age who received at least 2 milk feedings x 100 Non-breastfed children 6–23 months of age Children born in the last 24 months 10. Continued breastfeeding at 2 years Children 20–23 months of age who receive breast milk x 100 Children 20–23 months of age 18/51 35.3 11. Age-appropriate breastfeeding Children 6–23 months of age who Received breast milk, as well as solid, semi-solid or soft foods x 100 Children 6–23 months of age 209/283 73.9 12. Predominant breastfeeding under 6 months Infants 0–5 months of age who received breast milk as the predominant source of nourishment x 100 Infants 0–5 months of age Not applicable 13. Duration of breastfeeding when 50% of children 0–35 Months did not receive breast milk. x 100 Not applicable 14. Bottle feeding Children 0–23 months of age who were fed with a bottle x 100 Children 0–23 months of age 185/300 61.7 15. Milk feeding Non-breastfed children 6–23 months of Not applicable 46 4.5.1 Factors associated with respondents’ preference of formula foods over local foods. This study also considered possible factors that could have influenced respondents’ preference of formula foods over local foods. There was no significant relationship between the socio- demographic, family and market- related characteristics and the respondents’ preference of formula foods over local foods. Table 4.5.2.1 below is a representation of the analysis. 47 Table 4.5.2.1: Factors influencing preference of Formula food over local foods by respondents Variables Do you prefer formula foods to local food? Educational status Any formal education No formal education Age group 15-24 years ≥ 25 years Religion Christianity Islamic Marital status Currently married Not currently married Market area Kantomanto Okaishie Lome market Rawllings park Market space/structure Enclosure/ within a building Open space/outside a building Hawkers/carriers Yes 56 (26.9) 20 (23.0) 21 (25.3) 55 (25.9) 51 (29.5) 24 (19.8) 65 (26.4) 11 (22.4) 16 (21.6) 17 (23.0) 16 (21.6) 27 (37.0) 19 (21.8) 34 (27.0) 23 (28.0) No 152 (73.1) 67 (77.0) 62 (74.7) 157 (74.1) 122 (70.5) 97 (80.2) 181 (73.6) 38 (77.6) 58 (78.4) 57 (77.0) 58 (78.4) 46 (63.0) 68 (78.2) 92 (73.0) 59 (72.0) X2 0.50 0.01 3.49 0.34 6.44 1.02 P value 0.48 0.91 0.06 0.56 0.09 0.6 Age of child 0-5 months 6-11 months 12-17 months 18-23 months 3 (21.4) 30 (34.5) 18 (18.4) 25 (26.0) 11 (78.6) 57 (65.5) 80 (81.6) 71 (74.0) 6.40 0.09 Sex of child Male Female 38 (25.3) 38 (26.2) 112 (74.7) 107 (73.8) 0.03 0.86 Number of children 71 (25.3) 210 (74.7) 0.76 0.383 5 (35.7) 9 (64.3) 48 Place of delivery Home Traditional Birth Attendant Health facility 12 (27.3) 5 (38.5) 59 (24.8) 32 (72.7) 8 (61.5) 179 (75.2) 1.27 0.531 How often do you go to market in a week? 1-3 times 4-6 times Everyday 6 (28.6) 56 (25.6) 14 (25.5) 15 (71.4) 163 (74.4) 41 (74.5) 0.09 0.954 How often do you bring your child to the market? (n=252) Always Sometimes 65 (26.3) 9 (20.5) 182 (73.7) 35 (79.5) 0.68 0.41 Knowledge category Poor Good 57 (26.3) 19 (24.4) 160 (73.7) 59 (75.6) 0.11 0.74 Practice category Poor Good 56 (27.3) 17 (23.0) 149 (72.7) 57 (77.0) 0.53 0.47 4.5.2 Factors influencing early initialization of breastfeeding The association between respondents’ socio-demographic, family, market- related characteristics and whether they initialized breastfeeding early or late, was tested. Of all the factors tested, no statistical difference was found among the various categories. Table 4.5.3.1 gives a summary of the test. 49 Table 4.5.3.1: Factors influencing early initial of breastfeeding Variables Initiation category Early Late ꭓ2 p value Educational status Any formal education No formal education 109 (51.4) 39 (44.3) 103 (48.6) 49 (55.7) 1.25 0.263 Age group 15-24 years ≥ 25 years 41 (49.4) 107 (49.3) 42 (50.6) 68 (50.7) 0.00 0.989 Religion Christianity Islamic 90 (51.7) 57 (45.6) 84 (48.3) 68 (54.4) 1.09 0.296 Marital status Currently married Not currently married 124 (49.4) 24 (49.0) 127 (50.6) 25 (51.0) 0.003 0.957 Market area Kantomanto Okaishie Lome market Rawllings park 37 (49.3) 34 (45.3) 42 (56.0) 35 (46.7) 38 (50.7) 41 (54.7) 33 (44.0) 40 (53.3) 2.027 0.567 Market space/structure Enclosure/ within a building Open space/outside a building Hawkers/carriers 38 (42.7) 68 (53.5) 42 (50.0) 51 (57.3) 59 (46.5) 42 (50.0) 2.484 0.289 Age of child 0-5 months 6-11 months 12-17 months 18-23 months 7 (41.2) 42 (47.2) 50 (51.0) 49 (51.0) 10 (58.8) 47 (52.8) 48 (49.0) 47 (49.0) 0.84 0.840 Sex of child Male Female 74 (48.1) 74 (50.7) 80 (51.9) 72 (49.3) 0.21 0.648 Place of delivery Home Traditional Birth Attendant Health facility 17 (38.6) 9 (69.2) 122 (50.2) 27 (61.4) 4 (30.8) 121 (49.8) 4.15 0.126 How often do you go to market in a week? 1-3 times 4-6 times Everyday 13 (61.9) 104 (46.4) 31 (56.4) 8 (38.1) 120(53.6) 24 (43.6) 3.17 0.205 How often do you bring your child to the market? (n=252) Always Sometimes 117 (46.4) 30 (68.2) 135 (53.6) 14 (31.8) 7.09 0.008 Knowledge category Poor 106 114 (51.8) 0.438 0.508 50 Good (48.2) 42 (52.5) 38 (47.5) Practice category Poor Good 75 (35.9) 70 (93.3) 134 (64.1) 5 (6.7) 72.89 0.000 51 CHAPTER FIVE DISCUSSION 5.0 Discussion This study showed the result of an exploratory study of market women’s knowledge on infant and young child feeding practices in Ashiedu Keteke sub-metropolis of the greater Accra region Ghana. Amongst the findings, represented include demographic characteristics of the respondents, knowledge of the recommended infants and young child feeding practice (IYCF) , perception and practice of infant and young child feeding. Correspondingly, assessment of IYCF practices based on WHO/UNICEF indicators and factors that influence choices of IYCF practice among the respondents were explored. 5.1 Demographic characteristics of respondents Findings from this study reveal a preponderance of mothers aged 20-39 years. This follows similar age group distribution as reported in similar studies in England (Durham Region, 2016) and Ethiopia (Abera et al., 2013). Also a greater percentage of the respondents in this study were educated. This is in line with the report from England (Durham Region, 2016) this indicates a laudable advancement in the education of the female gender in the region. Also in this study, more than three quarter delivered their children in health facilities than at home or with traditional birth attendants. A similar finding in China (Wu et al., 2014) also showed a high rate (98.7%) of women who utilized the health facility for delivery. Almost all the respondents brought their children to market every day. This is common practice as also observed in a recent study among market women in Enugu State of Nigeria (Ene-obong et al., 2016). Thus majority of children born to these respondents mostly spend the period of their infancy and early developmental period in the market, suggesting nonresponsive feeding practices which will be detrimental to the overall growth and development of the children. 52 Hence, public health intervention and proper education is needed to address this situation, particularly among market women. In the same way, close to half of respondents admitted that, on a very busy day, attending to their customers is more important than their children’s feeding and care. Thus feeding of infants and children is no doubt affected by their busyness and perceived priorities and in the long run the child will be denied the benefits associated with responsive feeding such as developing healthy eating behavior and optimal skill for self-regulation and self-control of food intake (Harbron, Booley, Najaar , 2013). 5.2 Knowledge of recommended Infant and Young Child Feeding Practice (IYCF) A large majority of the respondents have poor knowledge of the recommended IYCF. This compares well with the study carried out in two districts of Zambia by (Katepa-bwalya et al., 2015) where poor knowledge of IYCF were found among a large proportion of women involved. Although a greater percentage of the women reported to have given the first milk (colostrum) to their child just at birth, their ignorance about the colostrum should not be ignored. Mothers should be made to understand the health benefit of colostrum to their newborns and also encouraged to inform their peers who are not otherwise knowledgeable. More than half of the respondents admitted that it is not necessary to wash a child of 6 -9 months old hands before feeding since they are fed by their mothers or caregiver, this draws attention to the need for health education and promotion and improved behavioral change communication