University of Ghana http://ugspace.ug.edu.gh RC607. A26 T57 bite C.l G374862 University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH CO LLEG E OF H EA LTH SCIENCES UNIVERSITY OF GHANA INFANT AND YOUNG CHILD FEEDING PRACTICES AMONG HIV POSITIVE MOTHERS IN MANYA KROBO DISTRICT, EASTERN REGION, GHANA. BY EM M ANUEL KWAKU-AFAWU TO FO A TSI This dissertation is submitted to the School of Public Health, University of Ghana, Legon in partial fulfillment of the requirement for the award of Master of Public Health Degree. March, 2005. University of Ghana http://ugspace.ug.edu.gh Declaration I hereby declare that with exceptions of specific quotations and ideas attributed to specific sources, this study is an original work and it has not been presented to this or any other university. Signed. V Emmanuel K.A. Tofoatsi Date,:S)± l°S Supervisor Dr. Henrietta Odoi-Agyarko Date. m l i University of Ghana http://ugspace.ug.edu.gh Dedicated To My dear Wife, Kafui, my life-long partner. University of Ghana http://ugspace.ug.edu.gh Acknowledgement I wish to extend my gratitude to the immediate past UNFPA Representative of Ghana, Mr. Moses Mukasa, for the fatherly advice and support that made my participation in the MPH course possible. My thanks go to all staff of UNFPA Country office, Accra, for willingly shouldering the extra responsibilities, which my engagement as a student-worker naturally placed on them. My sincerest appreciation goes to my supervisors, Dr. Henrietta Odoi-Agyarko, and Dr. F. K. Wurapa for their great support, advice and patience through out my field attachment and the course of my research work. My warm commendations go to my dedicated research team, made up of Ms. Vyda Hervi, Ms. Millicent Nartey, Ms. Dorothy Kweku, and Mr. Lawrence Awatay for their dedication to duty and patience throughout that fieldwork. I wish to thank the Manya Krobo District Director and the management and staff of Atua Government and hospitals for their kind support during the period of data collection. My special thanks go to Mrs. Justine Adeniran and Ms. Beatrice Tetteh of Atua Government Hospital and St. Martins Hospital for their hard work in mobilizing the respondents of this study. My gratitude goes to Mr. Addo of the Disease Control Unit, Korle Bu, for his assistant with the data analysis. I wish to register my deepest appreciation and gratitude to my dear wife, Kafui, and children for their sacrifice and support during the course of my study. Emmanuel K. A. Tofoatsi March, 2005. University of Ghana http://ugspace.ug.edu.gh Abstract This study was aimed at providing comprehensive information on infant and young child feeding practices adopted by HIV positive mothers participating in the nation’s pilot PMTCT programme in the Manya Krobo District, Eastern Region of Ghana. It also drew comparisons with the same feeding practices among mothers of unknown HIV status. Secondly, the study provided information on the relationships between infant and young child feeding practices and selected background factors of both sero-positive mothers and mothers o f unknown sero-status in the project area. All available and accessible HIV positive mothers with children aged 0-23 months and participating in the PMTCT programmes and mothers o f unknown HIV status with children 0-23 months attending child welfare clinics in the two major hospitals were the study targets. The sample comprised of all qualified HTV positive mothers participating in PMTCT programme (49 out of the 100 registered). In addition, mothers of unknown HIV status (100) were purposely sampled as they attended child welfare clinics. Data was collected using structured questionnaires to interview the respondents at child welfare clinics. In addition, in-depth interviews were conducted among service providers and HIV positive mothers. The data was analyzed using EPI Info data analysis package. The first level of analysis used simple frequency tables and column charts to describe the nature and type of infant and young child feeding practices and compared University of Ghana http://ugspace.ug.edu.gh and contrasted such practices among mothers of unknown HIV status and positive mothers. The second level o f analysis similarly used simple frequency tables and column charts to examine the relationships between selected background characteristics of respondents and their infant and young child feeding practices. The findings on the demographic and socio-economic background of the respondents showed that both positive mothers and mothers of unknown HIV status fell within the ages of 18 to 40 years. However, while 19% o f mothers o f unknown HIV status were teenage mothers, none o f the positive mothers were in their teens. Furthermore, a higher proportion (91%) of mothers o f unknown HIV status constituted town dwellers than HTV positive mothers (80%). Respondents who were natives (born in their places of current residence) or had stayed in their places of residence for more than five years made up the majority (48-54%) among both HIV positive mothers and mothers of unknown HIV status. The percentage of respondents with any level o f education was higher (92%) among mothers o f unknown HTV status than among positive mothers (71%). While 24% o f mothers o f unknown HIV status said they could read a letter or newspaper without difficulty, only 10 percent of HIV positive respondents said they were capable o f doing so. While about 90% of mothers of unknown HTV status listened to radio daily, 74% of positive mothers did so. A higher percentage (75%) o f mothers o f unknown HIV status claimed to be in stable marriages than positive mothers (60%) who claimed so. University of Ghana http://ugspace.ug.edu.gh The major findings related to the type/nature o f infant and young child feeding practices adopted by the two categories of respondents showed that all (100%) children o f mothers o f unknown HIV status were ever breastfed while 86% o f children o f positive mothers were ever breastfed. While 60% o f HTV positive mothers initiated breastfeeding immediately (within one hour after birth) only 37% of mothers of unknown HIV status did so. The proportion o f infants fed using feeding bottle with nipple was as high as 15% among HIV positive mothers but only 1.3% among mothers o f unknown HIV status. Furthermore, the study found that the proportion of mothers using iodized salt in the preparation o f child food was generally low irrespective ofHTV status with only 40% and 35% of mothers of unknown HTV status and positive mothers respectively making use of the salt. Over 90% of children of HIV positive mothers received Vitamin A while only 57% of the children of mothers of unknown HIV status did so. The complementary feeding adopted for more than 75% of all children of both positive mothers and mothers of unknown HTV status did not contain commonly available, affordable and easy to use nutritious food items such as vitamin A-rich oranges and other fruits, yellow vegetables and dark green vegetables. Certain factors were found to have influenced infant and young child feeding. The percentage of mothers who ever breastfed was high (75% to 100%) in stable and unstable relationships among both mothers of unknown HTV status and positive mothers. However, greater proportions of mothers in stable relationships (100% and 93% among mothers of unknown HIV status and positive mothers respectively) had ever breastfed University of Ghana http://ugspace.ug.edu.gh than women in unstable relationships (95% and 75% among mothers of unknown HIV status and positive mothers respectively). The use o f iodized salt among mothers of unknown HIV status and positive mothers tended to be higher in those mothers in stable relationship. Among mothers in stable relationships, positive mothers used less iodized salt (38%) than mothers of unknown status (42%). A greater percentage of mothers in unstable relationships (84% and 75% among mothers of unknown HTV status and positive mothers respectively) initiated breastfeeding immediately (within an hour after delivery} than those mothers in stable relationships irrespective of HTV status (70% and 60% among mothers of unknown HIV status and positive mothers respectively). The percentage of all mothers who ever breastfeed their current babies’ increased with age to a peak within either 20-24 age group (for mothers of unknown HTV status) or 25-29 age group (for HTV positive mothers) and from hence decreased progressively with age. The study made recommendations towards improving infant and young child feeding practices in the study area. These related to improving community mobilization and advocacy, strengthening social support for stable marriages, conduct o f ethnographic studies to support evidence based policies and programmes, and income generating activities for mothers. Other recommendations related to the improvement of girl child education, capacity building for health workers, male involvement, repackaging and launching of national BCC campaigns on critical maternal and child health issues* vn University of Ghana http://ugspace.ug.edu.gh Definitions of Terms In 1991, the World Health Organization convened an informal meeting to establish definitions and indicators for assessing breastfeeding practices in household surveys. The main purpose of promoting the use of the indicators was to have a common set of measures to assess practices and monitor the progress o f breastfeeding promotion programmes. Several of the following definitions are taken from this document; others are taken from the documents entitled “International Code of Marketing o f Breast-milk Substitutes”, “Breastfeeding Counseling: a training course” and “HIV and Infant Feeding: guidelines for decision makers” Breastfeeding The child has received breast milk (direct from the breast or expressed). Breastfeeding practices may be further described according to timing and frequency. In terms o f timing, breastfeeding may be described as on-demand (by the child) or on schedule (determined by a schedule or work/separation demands o f the mother). Exclusive breastfeeding The infant has received only breast milk from his/her mother or a wet nurse, or expressed breast milk and no other liquids, or solids with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicines. A child may be exclusively University of Ghana http://ugspace.ug.edu.gh breastfed with expressed human milk from his mother, a breast milk donor or from a milk bank. Predominant breastfeeding The infant’s predominant source o f nourishment has been breast milk. However the infant may also have received water or water-based drinks (sweetened or flavoured water, teas, infusions, etc.); fruit juice; Oral Rehydration Salts (ORS); drop and syrup forms of vitamins, minerals, and medicines; and folk fluids (in limited quantities). With the exception of fruit juice and sugar-water, no food-based fluid is allowed under this definition. Breast milk substitute Any food being marketed or otherwise presented as partial or total replacement from breast-milk, whether or not suitable for that purpose. Complementary feeding Any food, whether manufactured or locally prepared, suitable as a complement to breast milk or to infant formula, when either become insufficient to satisfy the nutritional requirements of the infant. Such food is commonly called “weaning food” or “breast-milk supplement” University of Ghana http://ugspace.ug.edu.gh Partial breastfeeding Means giving a baby some breastfeeds, and some artificial feeds, either milk or cereal, or other food. Replacement feeding Means the process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients the child needs. During the first six months this should be with a suitable breast-milk substitute — commercial formula, or home-prepared formula with micronutrient supplements. After six months it should preferably be with a suitable breast-milk substitute, and complementary foods made from appropriately prepared and nutrient-enriched family foods, given three times a day. If suitable breast-milk substitutes are not available, appropriately prepared family foods should be further enriched and given five times a day. University of Ghana http://ugspace.ug.edu.gh Acronyms ANC Ante Natal Clinic BCC Behavioural Change Communication BF Breast feeding DHMT District Health Management Team EPI Expanded Programme of Immunization FGD Focus Group Discussion FM Frequency Modulation FHI Family Health International GES Ghana Education Service GHS Ghana Health Service HIV/AIDS Human Immune Deficiency Virus/Acquired Immune Deficiency Syndrome IDI In-depth Interview IYCF Infant and Young Child Feeding Practices MOE ‘ Ministry of Education MOH Ministry of Health MTCT Mother-to-child Transmission NMIMR Noguchi Memorial Institute of Medical Research ORS Oral Rehydration Salt PI Principal Investigator PMTCT Prevention of Mother-to-child Transmission RA Research Assistant UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children Fund VCT Voluntary Counseling and Testing WHO World Health Organization. WIFA Women in Fertile Age University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS TITLE PAGE PAG Declaration i Dedication ii Acknowledgement iii Abstract iv Definition of Terms viii Acronyms xi Table o f Contents xii List of Tables xvi List of Figures xviii CHAPTER 1: 1.0 Introduction 1 1.2 Problem Statement 3 1.3 Rationale o f the Study 6 1.4 Study Area 7 CHAPTER 2: 2.0 Literature Review 11 CHAPTER 3: 3.0 Obj ectives of the Study 18 3.1.1 General Obj ective 18 3.2.1 Specific Obj ectives 18 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Variables 18 3.4 Background Factors 20 CHAPTER 4: 4.0 Methodology 21 4.1.1 Study Design 21 4.1.2 Data Collection Techniques and Tools 21 4.1.2.1 Sampling 21 4.1.2.2 Determination of Sample Size 22 4.1.2.3 Sampling Procedure 23 4.1.2.4 Data Collection Tools 24 4.1.2.5 Data Collection 24 4.1.2.6 Data Analysis 25 4.1.2.7 Ethical Considerations 25 4.1.2.8 Weaknesses o f the Study 26 CHAPTER 5 5.0 Findings 28 5.1 Introduction 28 5.1.1 Age 28 5.1.2 HIV Status 29 5.1.3 Residential Area 29 5.1.4 Duration ofResidence 30 5.1.5 Education 30 5.1.6 Highest Educational Attainment 31 xiii University of Ghana http://ugspace.ug.edu.gh 5.1.7 Ability to Read and Understand a Letter or Newspaper? 31 5.1.8 Radio Listening Habit 32 5.1.9 Television 32 5.1.10 Religion 33 5.1.11 Ethnicity 34 5.1.12 Occupation 3 5 5.1.13 Income Levels 36 5.1. 14 Respondents Living with Children 36 5.1.15 Stability o f Marriage 37 5.1.16 Summary 37 5.2.0 Description o f Infant Feeding Practices Currently Adopted by Mothers 38 5.2.1 Introduction 38 5.2.2 Children Ever Breastfed 39 5.2.3 Initiation of Breastfeeding 40 5.2.4 Infant Fed with Colostrum from Breast 41 5.2.5 Use o f Prelacteal Feed 41 5.2.6 Type o f Prelacteal Feed 42 5.2.7 Current Breastfeeding 43 5.2.8 Duration ofBreastfeeding 44 5.2.9 Water and Liquid Food 45 5.2.10 Use o f Feeding Bottle with Nipple 46 5.2.11 Complementary Feeding 47 5.2.12 Animal Source Foods - Meat, Eggs and Dairy 47 xiv University of Ghana http://ugspace.ug.edu.gh 5.2.13 The Use o f Vitamin A-Rich Foods 48 5.2.14 Use of Iodized Salt 49 5.2.15 Vitamin A 50 5.3.0 Factors Influencing the Choice of Infant and Young Child Feeding 51 5.3.1 Marital Relation and Ever Breastfed 51 5.3.2 Stability o f Marital Relations and Use of Iodized Salt 52 5.3.3 Stability of Marital Relation and Vitamin A 52 5.3.4 Marital Stability and Initiation of Breastfeeding 53 5.3.5 Age o f M other and Ever Breast Feeding 54 5.3.6 Age and Initiation o f Breast Feeding. 55 5.3.7 Age Distribution o f Mothers Whose Babies Received Vitamin A 55 5.3.8 The Influence of Level o f Education Attained, Ability to Read 56 5.3.9 Findings ofln-depth Interviews 57 CHAPTER 6 6.0 Discussion O f Findings 61 6.1 Findings on Background characteristics 61 6.2 Findings on Infant Feeding Practices 62 6.3 Factors influencing the choice of Infant and Young Child Feeding 66 6.4 Recommendations 70 6.5 Areas of Future Research 72 Reference '74 Appendix I: Key Findings Appendix II: Questionnaire xv University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES TABLE PAGE 1.1.1 Population Distribution by Sub-districts 8 5.1 Age Distribution of Respondents 28 5.1.3 Residential Area 29 5.1.4 Duration of Residence 30 5.1.5 School Attendance 30 5.1.6 Highest Level o f School Attended 31 5.1.7 Ability to Read and Understand a Letter or a Newspaper 31 5.1.8 Distribution o f Mothers According to Radio Listening Habits 32 5.1.9 Distribution of Mothers According to TV Viewing Habits 32 5.1.10 Religion 33 5.1.11 Ethnic Groups 34 5.1.12 Occupation 3 5 5.1.13 Monthly Income Levels 3 6 5.1.14 Distribution of Sons and Daughters Living with Respondents 36 5.1.15 Distribution of Respondents in Stable Marriages 37 5.2.4 Distribution of Mothers Who Gave Colostrum 41 from their Breast to Baby within Three Days after Birth 5.2.5 Use o f Prelacteal Feed 41 5.2.7 Distribution of Mothers Currently Breastfeeding 43 5.2.9 Percentage o f Mothers Who Gave Selected Liquid 45 to Baby Yesterday xvi University of Ghana http://ugspace.ug.edu.gh 5.2.14 Distribution o f Mothers Who Used Iodized Salt In Preparing Children’s Food 49 5 .2.15 Distribution of Mothers Whose Children Received Vitamin A Dose during Last Six Months 50 5.3.1 Distribution o f Mothers Who Ever Breastfed According to Stability o f Marital Relationship 51 5.3.2 Distribution o f Mothers Using Iodized Salt According to Stability of Marital Relationship 52 5.3.3 Distribution of Mothers Whose Children Received Vitamin A According to Stability of Marital Relationship 52 5.3.4 Distribution of Mothers According to the Time o f Initiation o f Breastfeeding and the Stability o f their Marital Relationships 53 5 3.5 Percentage Distribution of Mothers Who Ever Breastfed Their Current Babies According to Age of Mother 54 5.3.6 Age Distribution o f Mothers Who Initiated Breastfeeding Within an Hour o f Delivery 55 5.3.7 Age Distribution o f Mothers Whose Babies Received Vitamin A 56 xvn University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES FIGURE PAGE 1.1.4 Map of Eastern Region 8 5.2.2 Percentage of Children Ever Breastfed 38 5.2.3 Initiation of Breastfeeding after Delivery 39 5.2.0 Food Given to Baby During First Three Days Before Feeding With Breast Milk 41 5.2.8 Distribution o f Mothers According to Duration O f Breastfeeding 43 5.2.10 Percentage of Child Fed with Feeding Bottle and Nipple Yesterday. 45 5.2.11 Distribution of Mothers Feeding Children with 46 Various Complementary Foods 5.2.12 Percentage of Child Fed Animal Source Foods 48 5.2.13 Percentage o f Children Fed Vitamin A- Rich Foods 49 xviii University of Ghana http://ugspace.ug.edu.gh Chapter 1 1.0 Introduction 1.1.1 Background Over the years, most African countries have been unable to produce enough food and nutrition to meet their peoples’ basic needs for health, growth and development. The advent of HTV/A IDS has clearly made the situation more challenging. Africa has become the global epicenter of HTV/AIDS. Though the continent habours only 10 percent o f the world’s population, it accounts for as much as 70 percent of adults and children living with HIV/AIDS world-wide (29.4 million out o f 42 million). In the same vein, Africa is home to 75 percent of the number of children estimated to be living with HIV/AIDS (2.4 million of 3.2 million), 82 percent ofHTV/AIDS-related deaths in children (500,000 out o f 610,000) and 87.5 percent o f children newly infected with HIV (700,000 out o f 800,000) (UNAIDS, 2002). HIV/AIDS affect all sectors of national economy and it is rapidly eroding the development potential o f the continent. As a result, the continent finds it even more difficult to ensure food security, education and other basic services. Women in Africa, especially young women, are disproportionately affected by HTV/AIDS. Data suggest that about 55 percent o f all new infections in Africa occur among women (UNAIDS, 2002). Coupled with high birthrates, the high disease burden in women in Africa has contributed to large numbers of infants infected on the continent. Infant and child mortality rates are therefore rapidly increasing due to pediatric HTV-related deaths (Connolly et al., 1 University of Ghana http://ugspace.ug.edu.gh 1998). In Zimbabwe, for example infant mortality is expected to have increased from 30 to 60 per 1000 live births between 1990 and 1996. In addition, the child mortality rate rose from 8 to 20 per 1000 live births in the same period. (UNAIDS, 1999). The gains made in child survival measures such as breastfeeding, immunization, and oral rehydration therapy are therefore being rapidly reversed by the HIV/AIDS pandemic in Africa. In Ghana, the median HTV prevalence among adults is 3.4 percent (GHS 2002). The cumulative total reported cases of AIDS were 72,010 (June 2003, 30% estimated level of reporting). The National Aids Control Programme (NACP) reported that the number of HIV infections in Ghana is approximately. 550,000 (NACP, 2001). Women bear a greater share of the disease burden with the female/male ratio changing from a high o f 6:1 in 1987 to 2:1 in 2002. Furthermore, the HIV prevalence among commercial sex workers in Accra- Tema and Kumasi stand at 75.8 percent and 82 percent respectively (NACP, 2002). In spite o f the relatively low prevalence of HIV in Ghana (3.4%) as compared to the high rates in Southern Africa (20-30 percent), the danger signs for accelerated growth are apparent. For example, since 2000, the HIV prevalence rate has been on the increase, growing from 2.3 percent in that year to 3.4 percent in 2002. Furthermore, the number of sentinel sites with a prevalence of more than 5 percent in Ghana has grown from two to six between 1996 and 2002 (MOH, 2002). It is also noteworthy that these six high prevalence sites are spread all over the country. The discovery of HTV in human breast marked a renewed assault on infantputrition and health particularly in Africa. Breastfeeding is an important traditional practice in Africa and an important source of nutrition for infants in their first years of life. Breastfeeding, therefore, remains one of the most effective strategies to improve the health and survival of 2 University of Ghana http://ugspace.ug.edu.gh both mother and child. It provides psychological and child spacing benefits to infants and mothers, and reduces infant and child morbidity and mortality by protecting children from diarrhoeal diseases, pneumonia, and other infections. Unfortunately, between 10 and 20 percent of HIV-infected mothers will pass the virus to their babies through extended breastfeeding (Le Roy et al., 1998). In resource- constrained countries as those in Africa, the challenge is how to effectively protect infants from mother-to- child transmission of HTV while at the same time ensuring that effective measures are put in place to promote, protect and support breastfeeding. 1.2 Problem Statement The first case of HTV was recorded in Ghana in 1986. With the passing years Ghana’s immediate neighbours such as Togo and La Cote d’Ivoire have attained relatively higher HTV prevalence rates. In Ghana, the disease burden continues to increase and the number o f surveillance sites with rates higher than 5 percent has increased. The regional prevalence varies from 2 percent in the Northern region to 7.9 in the Eastern Region. The median adult HTV prevalence has been estimated at 3.4% (2002). MTCT is an important mode o f infection of HIV in Ghana besides sex and blood, accounting for 12-15 per cent of infections (NACP, 2001). In view of the growing importance of mother-to-child transmission (MTCT) o f HIV on the African continent and the need to ensure an expanded and comprehensiveoiational response to the HTV/AIDS disease in Ghana, The Ghana Health Service initiated a pilot project for the Prevention o f Mother-to-child Transmission (PMTCT) o f HTV. The project 3 University of Ghana http://ugspace.ug.edu.gh is based in the Atua Hospital and Saint Martins de Pores Catholic Hospital in the Manya Krobo District, one of the highest sero-prevalence districts in the country (6.6% in 2002). The aim of the project was to reduce MTCT o f HIV and improve health services provision and psychological support for mothers and children. The objectives of the PMTCT programme include to “advise HIV-infected mothers on the appropriate alternatives to breastfeeding” (MOH, 2003). After 20 months of implementation, the Ministry of Health (MOH) took a decision to expand the programme. As a result, a review o f the pilot project was commissioned in August 2003 with the view of drawing lessons from the pilot in order to inform the scale- up process. The August 2003 Rapid Assessment made the following key findings on the infant feeding situation on the project: 1. There is a conducive environment for the implementation o f the infant feeding strategy. The policy on Breastfeeding is in place as well as the implementation guidelines. The Code o f Marketing of Breast Milk Substitutes is implemented at national level with regulations. 2. Infant feeding practices remain an issue. The rate of exclusive breastfeeding in the Manya Krobo District s not known. In addition little is known about what happens after 6 months to the women who have been exclusively breastfeeding 3. There was no clarity about the duration of exclusive breastfeeding for HTV-jnfected women. Some were advised to feed for 3 months and others for 6months. 4. 5% o f HIV infected women opt not to breastfeed. With the weak follow-up of women in the home and the high level of stigmatization attached to artificial 4 University of Ghana http://ugspace.ug.edu.gh feeding, it is not sure if all the implications o f providing infant formula have been taken into consideration. The above findings raise a number of research questions relating to infant and young child feeding practices in the project area among which are the following: 1. What factors influence choice of and maintenance of feeding options among mothers? What role does stigmatization play? 2. How far is exclusive breastfeeding practice affected within the context of HIV/AIDS? 3. What is the nature and timing of infant and young child feeding practices adopted by HIV-infected mothers in the project area? 4. What is the level of adherence to infant and young child feeding standards being promoted among positive mothers to ensure the prevention o f M TCT of HIV? 5. What gaps should health workers address in their effort to support appropriate feeding practices promotive of the health and survival o f both babies and mothers? In the light of its findings, the August 2002 PMTCT Rapid Assessment had recommended, among others, that "an operational research on infant practices is urgently needed in order to inform programming around infant and young child feeding.” This recommendation therefore constitutes the key marching orders of the proposed study. By the second quarter of 2004, this information gap expressed in the above-cited recommendation still existed among officials of the Ministry of Health (including, those in the Reproductive and Child Health Unit and the National AIDS/STDs Control Programme), UNICEF, WHO, UNFPA UNAIDS, NMIMR and FHI. 5 University of Ghana http://ugspace.ug.edu.gh The research problem is therefore a highly relevant one, meant to fill an urgent information gap in programming and o f high policy relevance to government, relevant development partners, the project communities and the general public. 1.3 Rationale of the Study. The proposed study will provide comprehensive information on infant and young child feeding practices being adopted by HIV-positive mothers in the project area. In addition, the study will cover the socio-economic and demographic factors that influence the choice and maintenance o f feeding practices by a sero-positive mother. The results and findings of the proposed study will assist policy makers, programme managers and other stakeholders in the following areas: • Provide adequate information on the factors relevant to the choice and maintenance of feeding options among positive mothers as inputs for the design, and provision of evidence-based feeding strategies within PMTCT programmes. • Provide information on extent of breastfeeding among positive mothers as a basis for the protection of breastfeeding in both positive and negative mothers. • Support adequate monitoring and evaluation of the level o f adoption of infant and young child feeding standards being promoted among positive mothers to ensure the prevention ofM TCT of HTV. • Identify the gaps in the quality of counseling and support that the health worker currently provide and provide guidance on the nature of information and support that will make mothers’ choice of feeding practice as safe as possible. Health worker will have available relevant information that they can translate into 6 University of Ghana http://ugspace.ug.edu.gh knowledge that the mother can use to make the best infant and young child feeding decisions. • To provide inputs that will strengthen the PMTCT policy and enhance the implementation of the programme in the study district and the newly installed programmes nation-wide through the clearing of existing uncertainties. 1.4 Study Area 1.4.1 Introduction The Manya Krobo District is one of the fifteen (15) districts in the Eastern Region. The district lies at the south-eastern part of the Eastern Region between latitudes 6-05 S and 6­ 30 N and longitudes 0-08 E and 0-20 W. The Kwahu North and the Fanteakwa districts bound the district on the northeast and northwest sides respectively. On the east, the district is bound by the Asougyaman District and on the west by the Fanteakwa and Yilo Krobo districts. The Volta, the largest man-made lake in the world, is found in the east beyond the Asougyaman district. The North Tongu District lies to the South of the district. The total surface area is one thousand, four hundred and seventy-six square kilometers (1,476 sq. km.). The Manya Krobo is composed of two divisions, namely Upper Manya and Lower Manya with Asesewa and Odumase Krobo as their respective capitals. It covers fifty-four (54) electoral areas, one hundred and sixty-five (165) unit committees and three-hundred and seventy-one (371) communities. The district capital, Odumase, is situated eighty (80) kilometers from Accra, the national capital. 7 University of Ghana http://ugspace.ug.edu.gh 1.4.1 MAP OF EASTERN REGION University of Ghana http://ugspace.ug.edu.gh 1.4.2 Population The Manya Krobo District has an estimated population of 1608731 and an annual growth rate of 1.4%. There are six sub-districts in the district as follows: Odumase, Kpong-Akuse (Lower Manya) and Asesewa, Otrokpe Anyaboni, and Sekesua (Upper Manya). Table 1.1.1: Population Distribution by Sub-districts Sub-district Estimated Population Percentage share of Population Odumase 37,966 23.6 Kpong-Akuse 25,740 16.0 Asesewa 33,783 21.0 Otrokpe 15,283 9.5 Anyaboni 23,327 14.5 Sekesua 24,774 15.4 Total 160,873 100 The estimated population of children less than 24 months is 9,652 (6%), that of women in fertile ages, 15-44 years (WIFA) is 37,001 (23%) while expected pregnancies and births stand at 4826 (3%) each. 1 Projected from data of the 2000 Population and Housing Census o f Ghana. 9 University of Ghana http://ugspace.ug.edu.gh The main ethnic groups in the district are the Krobo and Ewe making up 70.5% and 18.2% respectively of the total population. Christians are in the majority forming 76.4% of the population while Moslems and Traditional believers form 17.5% and 6.1% respectively. 1.4.3 Household Characteristics The average household size in the district is 7.5. This is higher than both the regional and national averages of 4.6 and 5.1 respectively. The large household size is a reflection of the influence o f the extended family ties in the social structure. Women head 40% of the households in the urban areas of the district. 1.4.4 Health facilities The district is served by three hospitals. Two of these hospitals, the Atua and the Saint Martins hospitals host the pilot PMTCT project in Ghana started in December 2001. The district is one o f the UNICEF Sentinel districts in the country and therefore runs the Bamako Initiative Programme (based at the Atua Government Hospital), which is the bedrock of the cash and carry system of the hospital. 10 University of Ghana http://ugspace.ug.edu.gh Chapter 2 2.0 Literature Review Over the past three decades, considerable improvements have been made in child health through the adoption o f strategies to reduce child mortality and promote family health (World Development Report, 1993). Promotion of breastfeeding easily stands out as one o f these strategies. Breastfeeding contributes to reduced child mortality by providing optimum nutrition, by protecting against common childhood infections, and by its child spacing effects (American Academy of Pediatrics, 1997; Golding et al., 1997; Victora et al., 1987; Monteiro etal., 1990; De Soysa et al., 1991). However, HTV in children threatens to reverse these steady gains made through wide scale implementation of child survival programmes. This sad realization dawned on the world in the mid 1980s when HIV was cultured from breast milk in HIV-infected mothers, and cases were reported of breastfed infants sero converting during the postpartum period (Preble & Piwoz, 1998). Since then it has been established through several studies that breastfeeding by an HIV-positive mother increases the risk of HTV transmission to her infant (UNICEF/UNAIDSAVHO, 1998). HIV and AIDS have seriously affected women of reproductive age in sub-Saharan Africa. Since HIV infection in children is directly linked to that in mothers, over 90 per cent of paedriatic HTV infections are maternally acquired. In spite o f the rapid advances made all over the world in scientific understanding of mother-to child transmission (MTCT) of HIV (also known as vertical transmission) over the last decade, the number o f children falling prey to the virus still continues to grow. In 11 University of Ghana http://ugspace.ug.edu.gh 2002, a total o f 3.2mn children were estimated to be living with HTV/AIDS worldwide with 2.4mn of them from Sub-Saharan Africa. In the same year, 800,000 children were newly infected with HTV with 700,000 o f them from Sub-Saharan Africa. Out of the estimated 610,000 children who died from HIV AIDS in 2002, 500,000 were from Sub-Saharan Africa (UNAIDS, 2002). In general, therefore, 90% of these HIV-positive infants live in Sub:Saharan Africa where health services are already overburdened with other diseases and the governments could only afford only a few dollars per individual per year for health services. (Gilks etal.,1997) In Ghana, cumulated total reported cases of AIDS were 72,010 (June 2003, 30% estimated level of reporting). The National Aids Control Programme (NACP), Ghana, reported that the number of HIV infections in Ghana is approx. 550,000 (NACP, 2001). The median adult HTV prevalence is 3.4% (2002). M TCT is an important mode of infection of HIV in Ghana besides sex and blood accounting for 12-15per cent (NACP, 2001). 2.1 Impact of HTV on infants and children HIV is contributing to the fuelling of infant and child mortality in most Sub- Saharan African countries. In countries with a high prevalence of HIV, about 4% o f all infants can be expected to become infected through breastfeeding. In South Africa, for example, this means that more than 30,000 infants may be infected through breastfeeding each year. In Zambia and Zimbabwe, where the prevalence in pregnant women is above 20 percent in urban areas, the infant mortality rate is 25 per cent higher than it would have been in the absence of AIDS. Under-five mortality has increased by over 70 per cent in 12 University of Ghana http://ugspace.ug.edu.gh Botswana and Zimbabwe. (Staneki & Way, 1996). This situation sounds a clarion call for the establishing of the safest feeding methods for infants of HIV-infected mothers. The UNAIDS and WHO had reported that between 25 and 40 per cent of HTV- infected children die before their fifth birth date (UNAIDSAVHO, 1998). Other studies have established that HTV is already contributing significantly to increased childhood mortality. (Ryder et al., 1194; Nesheim etal., 1994). Although HTV transmission through breastfeeding is only partially to blame for this increase, infant and young child feeding in the context o f HTV is an important public health issue, particularly in high HTV prevalence countries. (UNICEF/UNAIDS/WHO, 1998). 2.2 Evidence of Breast-milk Transmission of HIV Since the close of the 1980s, several studies indicate clear evidence of HTV transmission through breastfeeding among seropositive mothers. Many studies estimated the risk of HTV transmission through breastfeeding by comparing overall vertical transmission rates among formula-fed and breastfed infant. (Ryder et al., 1991; Hutto et al., 1991; Gabiano et al., 1992). Using this approach, findings revealed that the risk of HIV transmission attributable to breastfeeding varies greatly from 0 to 46 per cent. In a clinical study conducted in Nairobi, Kenya, it was found that formula feeding using cup reduced post-natal HTV transmission by 44 per cent. (Nduati etal., 2000). Additional evidence from prospective studies also indicate that among infants born to HTV-positive mothers, those who are breastfed are more likely to be infected than those who are formula-fed. This has been proven true even after allowing for all other factors known to be associated with mother-to-child transmission of HTV (European Collaborative Study, 1992; Tovo et al., 1998) Generally, higher rates of mother-to-child transmission of HTV are observed where 13 University of Ghana http://ugspace.ug.edu.gh most infants are breastfed rather than where fewer infants are breastfed. However, other reasons for variations in transmission rates such as maternal nutrition status, stage of HTV disease and possible differences in transmission of HTV subtypes cannot be excluded. Meta analysis of studies conducted estimated a transmission rate of 14 per cent from mothers who are seropositive at the time o f delivery and 29 per cent from others who had primary infection during the postpartum period. (Dunn et al., 1992). Some studies suggest that the risk of vertical transmission is greatly enhanced with the adoption of early mixed feeding (breast milk plus other foods and juices) than exclusive breastfeeding (Tess et al., 1998). Coutsoudis et al in a Durban study showed, that at three months, MTCT in children exclusively breast fed (14.6 per cent) was significantly lower than those given mixed feeding (24.1 per cent). Moreover, exclusive breastfeeding did not seem to increase the risk of MTCT over formula feeding. This effect appeared to be sustained to 18 months despite continuous breastfeeding. The mechanism for this reduction in risk is not clear but may be associated with early mixed feeding causing mucosa inflammation, facilitating transmission of HIV (Coutsoudis etal., 1999). Recent studies from 1995 onwards focused more on the role of breastfeeding in mother-to-child transmission. These studies estimate the effects o f breastfeeding on the risk of late postnatal HIV transmission. Studies in Cote d’Ivoire (Ekpini et al., 1997) and the former Zaire (Bertolli et al., 1996) conclude that breastfed infants of HTV - 1 -infected mothers who escape early infection remain at risk of HTV transmission after six months (4 per cent in Zaire; 12 per cent in Cote d ’Ivoire). In Cote d ’Ivoire, the risk increased to 20 per cent among infants who were breastfed for at least twelve months. Current information available is insufficient to estimate the exact association between duration of breastfeeding 14 University of Ghana http://ugspace.ug.edu.gh and the risk of transmission o f HTV to infants and babies. However, there is strong evidence supporting the conclusion that there is a gradual and continuous increase in transmission risk as long as the child is breastfed (Taha et al., 1998, Leroy et al., 1998). In this regard several researches and mathematical modelers suggest that early weaning should be explored as a possible intervention to reduce HTV transmission through breastfeeding. 2.3 Timing of HIV transmission during breastfeeding Transmission of HTV through breastfeeding can take place at any point during the period of breastfeeding. The persistence of maternal antibodies and the presence of a window period’ during which infection is undetected using currently available technology, make it impossible to determine if an infant has been infected during delivery or during breastfeeding in the period following birth. Therefore, when seropositive women breastfeed their infants, it is not possible to differentiate transmission attributable to delivery and that resulting from breastfeeding from birth. (Newell, 1998; M andelbrote et al., 1996; Datta et al., 1994). A study conducted in Nairobi, Kenya evaluated the probability of breast milk transmission of HIV-1 per day of breastfeeding and per liter o f breast milk ingested. Mother/infant pairs were followed for two years with periodic collection of breastfeeding infoimation. It was found that breast milk infectivity appeared to be constant-per liter ingested over time, indicting volume of milk ingested and length o f exposure are both important factors in breast milk transmission o f HIV-1 (Richard et al., 2000). 15 University of Ghana http://ugspace.ug.edu.gh Several studies conducted on the risk associated with non-breast feeding fail to differentiate between voluntary and involuntary weaning as a result o f pre-existing maternal/infant illness. This has the tendency o f overestimating the risk associated with formula feeding. However, the 1995 Uganda Demographic and Health Survey helped to clarify this issue. In the survey 4,000 mothers with live borne infants were asked about breastfeeding and whether weaning was "voluntary’ (i.e. as a result o f age of child or work demands) or involuntary (i.e. preceding maternal/infant mortality). Voluntary weaning was associated with lower mortality rates. This strongly suggests that voluntary feeding should be used as the benchmark in assessing the risks and benefits o f formula feeding by HIV positive mothers (Gray et al., WeOrC496). In spite of several years o f promotion of exclusive breastfeeding in Africa, compliance faces a number of constraints. A prospective study of infant feeding practices in rural Kwazulu Natal was conducted to understand the constraints to exclusive breastfeeding. Of 113 mothers o f live borne babies, 39 per cent o f mothers intended to breastfeed to 6 weeks of age and 16 per cent to 12 weeks o f age. In practice, 53 out o f 113 mothers supplemented breast milk within 48 hours o f life. By 6 weeks o f age, only 5 per cent (3/52) of infants had been exclusively breastfed since birth. Additional feeds were introduced due to unsatisfied baby (59 per cent) or perceived insufficient breast milk (13 per cent). The study also found out that although more than half the women intended to return to work or school in the first six months after delivery this was a minor reason for supplementation (Bland et al., WeOrC497) It is important for programme planning purposes to clarify the attitude of mothers concerning infant and young child feeding within the context o f HIV/AIDS. Among 300 16 University of Ghana http://ugspace.ug.edu.gh women who ever breastfed and were attending clinics in Bobo Dioulasso, the mean duration of breastfeeding was 20 months while 187 of them had never bottle-fed infants. Among them, 75 per cent said they would accept a wet nurse if they were HTV positive, the most suitable person being their own sisters. Furthermore, 70 per cent o f the mothers would agree to be wet nurses to babies bome to a HTV positive mother and 65 per cent would use a milk extraction device to feed that baby. (Nacro et al., W ePpCl 318). 17 University of Ghana http://ugspace.ug.edu.gh Chapter 3 3.0 Objectives of the Study 3.1.1 General Objective Describe the types of infant and young child feeding practices currently adopted by HIV positive mothers and mothers of unknown HIV status in the Manya Krobo District, Eastern Region, Ghana. 3.2.1 Specific Objectives 1. Provide the demographic and socio-economic information on HTV positive mothers participating in the PMTCT programme and mothers of unknown HIV status in the Manya Krobo District 2. Describe the nature/types of infant feeding practices currently adopted by HIV positive mothers and mothers of unknown HIV status in the study district. 3. Describe the factors influencing the choice o f infant feeding practices among HIV positive mothers and mothers of unknown HIV status 4. Make recommendations relevant to the improvement of infant and young child feeding programme planning and implementation. 3.3 Study Variables The main variables will be the major categories of infant and young child feeding practices. These will comprise the following: 1. Exclusive breastfeeding 2. Exclusive Formula Feeding or Replacement Feeding 3. Mixed Feeding 18 University of Ghana http://ugspace.ug.edu.gh 4. Complementary Feeding 5. Food Group Diversity A number of indicators were used in differentiating between and describing the various types of feeding practices. The WHO Guiding Principles 2003 and the guidelines contained in the PMTCT Training Manual of the Ministry of Health, Ghana, provided the framework for the selection of indicators. Some of these indicators are as follows: Indicators (MOH: PMTCT Manual for Health Workers, 2001) 1. Duration o f exclusive breastfeeding 1. 0-5 months: Exclusive breastfeeding yesterday. 2. Initiation o f Breast feeding 2. Percentage of children put to • breast within an Hour o f Birth. 3. Use of Food Groups in complementary Feed 3. Percentage of Children fed from various Food Groups. 4. Meal frequency 4. 6-23 months: Minimum age- appropriate frequency o f feeding 5. Nutrient content o f complementary foods. 5. 6-23 months; high dietary diversity i.e. number of food sources. 19 University of Ghana http://ugspace.ug.edu.gh 3.4 Background Factors The following background factors of mothers were considered during the study and the influence o f a selected number o f them on the choice o f infant and young child feeding among sero-positive and negative mothers were described: 1. Age 2. Place and Duration of Residence 3. Education 4. Marital Stability 5. Income 6. Media Habits 7. Occupation 8. Religion 9. M other’s perception o f stigma. 20 University of Ghana http://ugspace.ug.edu.gh Chapter 4 4.0 Methodology. 4.1.1 Study Design. The study was originally conceived as a cross-sectional descriptive one dealing with only HIV positive mothers. However, due to the exigencies met during the data collection phase, as expected and documented in the project proposal, the study was changed to a comparative cross-sectional study by including mothers ofunknow n HTV status. The study, therefore, described the types of infant and young child practices among HTV positive mothers and analysed the demographic and the socio-economic factors influencing choice of infant and young child feeding practices among HTV positive mothers. Comparisons were made on these issues among mothers of unknown sero-status 4.1.2 Data Collection Techniques and Tools 4.1.2.1 Sampling The study unit was an HIV positive mother with infant(s) (under two years) who was currently participating in the Manya Krobo District PM TCT programme. The study population was all HTV positive mothers with infants and participating in the Manya Krobo District PMTCT programme based at either the Atua or the St. Martins Hospitals. The comparative study unit was a mother o f unknown HIV staus with infant(s) under two years that attended child welfare clinic in one of the two major hospitals. 21 University of Ghana http://ugspace.ug.edu.gh 4.1.2.2 Determination of Sample Size The following considerations that derived from targets attained during the course of implementation of the pilot PMTCT in the Manya Krobo District guided the determination of the sample size: By the end o f July 2003, a total of 5,370 new ante natal registrants were recorded; 2822 (53%) had VCT; 339 (12%) tested for positive; more than 50% o f HIV positive mothers attending ANC did not come back for supervised deliveiy. (MOH, 2003) In effect, the proportion o f HTV positive pregnant women who availed themselves o f the PMTCT programme out of all pregnant women opting for VCT was less than 6%. The sample of HIV positive mothers was therefore calculated as follows: n = p (100 - p) = 6 (100 - 6) = 90.24 e2 2.52 n = sample size p = 6% (Proportion of HTV positive mothers participating in the PMTCT programme) e = standard error =2.5 95% precision required ( Varkervisser et al.,1991) 22 University of Ghana http://ugspace.ug.edu.gh The last review o f the available data (in both Atua and St. Martins hospitals), prior to the commencement of this study in March 2004, put the actual number o f positive mothers participating in the PMTCT at just around 100. All the 100 registered positive mothers were therefore target by the study. As stated in the study proposal though 90 was the determined sample size, the actual number of positive women recruited for the study was determined by those who were available, accessible and willing to participate at the time the study took off. These turned out to be forty-nine (49). These included some who were traced to the community and interviewed after they failed to turn up in the clinic as scheduled. Some of the positive mothers who were part o f the PMTCT programme in the district had moved out o f the district, and could not be traced. After 49 of the positive women were interviewed a long drawn out search and waiting could not produce any more new such respondents. After consultations with the Supervisor, the PI re-oriented the design to include mothers of unknown HIV status with children less than two years and attending welfare clinics in the two hospitals in the study area. Their number was pegged at double (100) that o f the positive mothers (49) earlier obtained. 4.1.2.3 Sampling Procedure Since HIV positive mothers participating in the PM TCT programme were already just about 100, all of them were targeted. The counselors (health workere) in the two hospitals were requested to invite to the hospitals on the usual child welfare clinic days the HIV positive mothers for interview. On the other hand, the mothers of unknown status 23 University of Ghana http://ugspace.ug.edu.gh were purposively sampled up to the desired number as they attended child welfare clinics in both hospitals 4.1.2.4 Data Collection Tools Initial in-depth interviews (IDI) of selected positive mothers and care providers were conducted using In-depth Interview Guides. These initial interviews provided the necessary information for the revision of the main structured questionnaire to include culturally relevant and locality specific issues, format or approaches. Structured interviews questionnaires were then used to conduct structured interviews of both positive and negative mothers. 4.1.2.5 Data Collection Selection and training o f Research Assistants - Five qualified Research Assistants (RA) were initially recruited and trained by the Resident who was the Principal Investigator (PI). The PI supervised all the processes. All the RAs were fluent in Krobo, the local vernacular and one or two other Ghanaian languages. The training of RAs consisted of building and improving knowledge and skills in survey data collection and IDI. Skills needed for building rapport and securing the confidence of respondents were discussed and practiced. In addition, various ways and means to ensure confidentiality and non-disclosure of the sero-status of respondents were also treated. The IDI guides and questionnaires were translated from English to the vernacular and back into English for use during the training, pretest and actual field study. 24 University of Ghana http://ugspace.ug.edu.gh The training took a total o f three days. The third was devoted to pre-testing o f the questionnaires. After pretesting of the questionnaires, the necessary adjustments and corrections occasioned by the pretesting were made. Respondents were met during the usual child welfare days. The respective counselors specifically invited the positive mothers while the negative mothers were interviewed as they attended their usual child welfare clinics. After each day’s work, the PI checked each completed questionnaire manually for completeness and consistency. The non pre-coded questions were then coded and independently double entered into EPI Info by PI and a Statistician. 4.1.2.6 Data Analysis A number of methods were adopted in the analysis of the data. Frequency tables and bar charts were used to show the distribution of HTV positive and mothers of unknown HTV status adopting each feeding practice. In addition, cross tabulations of selected socio­ economic and demographic factors o f mothers and kind o f feeding practice were produced. Cross tabulations of the number of children using each feeding option were produced. 4.1.2.7 Ethical Considerations The PI and RAs took steps to obtain the approval of all stakeholders involved or were one way or the other affected by the study both at the institutional, community and the personal levels. The permission of the School of Public Health, Legon, the Manya Krobo District Health Management Team (DHMT) and traditional and relevant community leaders was 25 University of Ghana http://ugspace.ug.edu.gh obtained. In addition, the informed consent o f the respondents and their spouses were obtained. The selection of scheduled welfare clinic days for the conduct o f interviews was purposely decided in order to help ensure that the sero status of the respondents was not disclosed. Absolute confidentiality was maintained and interviews were conducted in side rooms to ensure privacy. The design o f the structured interview instrument prevented any disclosure of sero- status. The structured interview questionnaire, which was essentially on infant and young child feeding practices, has absolutely nothing directly referring to HIV/AIDS and does not mention the term. Therefore, during structured interviews, which were conducted for the generality of respondents, there was no risk o f disclosure of sero-status o f the respondent even if some one were to be listening in. Snack was provided to respondents after the interviews and returned transport fares were reimbursed. 4.1.2.8 Weaknesses of the Study In spite o f the apparent strengths of this study, there were a couple of factors, which might affected the quality of the study. In the first place, the PI did not understand nor speak Krobo, the vernacular of the project area in which the bulk of the respondents were interviewed. Though the RAs spoke the Krobo language fluently and were well trained, the PI was not in absolute control of the interview process. It was, however, hoped that the rigorous supervision of the PI during the data collection phase and the daily review of completed questionnaires, had prevented any serious errors. 26 University of Ghana http://ugspace.ug.edu.gh Secondly, the low numbers of the HIV positive mothers that were accessible to the study, might have affected the strength o f data analysis. However the challenge o f low samples was more than adequately met when the decision was taken to turn the study into a comparative one by including mothers of unknown HTV status o f the same background. Indeed, this decision had introduced a new dimension into the study and shed more light on the issues of infant and young child feeding that the original focus on HTV positive mothers would not have accomplished. 27 University of Ghana http://ugspace.ug.edu.gh Chapter 5 5.0 Findings 5.1. Introduction This chapter examines the background characteristics o f respondents (nursing mothers). These characteristics are important because they will be used to analyse the feeding practices o f respondents. The background characteristics examined in this chapter are age, HIV status, place o f residence, duration o f residence, education and grade. Other background characteristics are ability to read, listening to radio and watching TV. The rest are religion, ethnicity, occupation, income levels, number o f children and marital status. 5.1.1 Age Age is an important determinant of behaviour particularly in the area of reproductive and child health practices. Table 5.1.1 shows the age distribution o f all respondents. Table 5.1: Age distribution of Respondents. 1 Mothers of |Age Unknown Status HIV Positive Mothers My I (Years) : I Freq Percent Freq iPercent 115-19 16 119 0 !0 ;!20-24 29 :|34.6 12 I26.7 jj 125-29 24 28.6 14 m . .............................i 130-34 7 8.3 11 124.4 j35-39 8 }9.5 7 115.6 < 2 £a>30 23.125- Q_ 20 10 L 7.7 0 Vitamin A Fruits Dark green Orange Veg. Type of Food Among the vitamin A-rich food sources, palm oil and palm nut foods are most popular among both positive and mothers of unknown status. However, while as much as 65 percent o f children of mothers of unknown HIV status are given food from palm oil sources only 31 percent o f children o f positive mothers receive such food. Readily available and affordable fruits such as oranges, pawpaw and mangoes feature very little in complementary foods for children of all mothers. While oranges are fed to only 23s percent of children o f positive mothers, only 10 percent of children o f mothers o f unknown status take oranges. The performance related to the other fruits is even poorer with less than 10 percent o f all children taking them. Interestingly, common and cheap dark leafy vegetables, 48 University of Ghana http://ugspace.ug.edu.gh such as kotonmire, bokoboko and alefu, do not feature in the food o f 75pecent o f children of women irrespective o f sero-status. 5.2.14 Use of Iodized Salt Table 5.2.14: Distribution o f Mothers Who Used Iodized Salt in Preparing Children’s Food. Mothers of Used Iodized Unknown Status Positive Mothers Total Salt Freq. Percent Freq. Percent Freq. Percent Yes 36 40.9 17 34.7 53 38.7 No 56 59.1 32 65.3 84 61.3 Total 88 100 49 100 137 100 The table shows that the use of iodized salt in preparing children’s food is low among all mtfthers with 60-65 percent o f all children not receiving iodized salt. However, the use o f iodized salt is higher (41 percent) among mothers o f unknown HTV status than among HIV positive mothers (35 percent). 49 University of Ghana http://ugspace.ug.edu.gh 5.2.15 Vitamin A Table 5.2.15: Distribution o f Mothers Whose Children Received Vitamin A Dose within Last Six Months. Mothers of Received Unknown Status Positive Mothers Total Vit. A Freq. Percent Freq. Percent Freq. Percent Yes 50 56.8 45 91.8 95 69.4 No 33 37.5 4 8.2 37 27.0 Don’t Know 5 5.7 0 0 5 3.6 Total 88 100 49 100 137 100 In general the table shows that the administration o f Vitamin A to children is quite high among all mothers (69%). However, performance is clearly higher among children of HTV positive mothers. As much as 92 percent of children of HTV positive mothers receive Vitamin A as compared to 57 percent o f children of mothers o f unknown HTV status. It should be noted that as much as 43 percent of children of mothers o f unknown HTV status do not received vitamin A as against 8 percent of children o f positive mothers. 50 University of Ghana http://ugspace.ug.edu.gh 5.3.0 Factors Influencing the Choice of Infant and Young Child Feeding. This section discusses the possible relationship between selected background factors o f mothers and their choice of infant and young child feeding practices. 5.3.1 Marital Relation and Ever Breastfed 5.3.1: Distribution of Mothers Who Ever Breastfed According To Stability Of Marital Relationships. Ever Mothers of Unknown Positive Mothers Breastfed/ Status Marriage Ever Breastfed Ever Breastfed Stability Freq. Total % Freq. Total % Yes 64 64 100 27 29 93.1 No 20 21 95.2 15 20 75.0 Total ‘ 84 85 98.8 42 49 85.7 From the table above, the percentage of mothers who ever breastfed is high in stable and unstable relationships among both mothers of unknown HIV status and positive mothers. However, greater proportions of mothers in stable relationships have ever breastfed than women in unstable relationships irrespective of sero-status. Among HTV positive mothers, those in stable marriages have a much higher ever breastfed rate (93%) than those in unstable relationships (75%). The difference in ever breastfed rates among mothers of unknown status living in stable and unstable relations is not as large as among the positive mothers. This does not, however, provide sufficient basis for any conclusions about the relationship between marital stability and ever breastfeeding among mothers of a particular sero-status. This is because the influences on mothers of significant others towards ever breastfeeding and the choice of positive mothers not to breastfeed could mask the effect that a stable marital relationship might make. 51 University of Ghana http://ugspace.ug.edu.gh 5.3.2: Stability of Relationship Marital and Use of Iodized Salt Table 5.3.2: Distribution O f Mothers Using Iodized Salt According To Stability O f Marital Relationship. Use o f Mothers ofUnknown Iodized Status Positive Mothers Salt/ Use of Iodized Salt Use of Iodized Salt Marriage Stability Freq. Total % Freq. Total % Yes 27 64 42.2 11 29 37.9 No 8 21 38.1 6 20 30.0 Total 35 85 41.2 17 49 67.9 From the table, it could be seen that use of Iodized salt among all mothers irrespective o f sero-status tend to be higher in those mothers in stable relationship. Among mothers in stable relationships, positive mothers use less iodized salt (38%) than mothers of unknown status (42%) 5.3.3 Stability of Marital Relation and Vitamin A Table 5.3.3: Distribution of Mothers Whose Children Received Vitamin A According To Stability of Marital Relationship. Vit. A Mothers ofUnknown Status Positive Mothersuse / Mairiage Vitamin A use Vitamin A use Stability Freq. Total % Freq. Total % Yes 37 64 57.8 27 29 93.1 No 12 21 57.1 18 20 90.0 Total 49 85 57.6 45 49 91.8 The table shows that a slightly higher percentage of children of all mothers in stable relationships irrespective of sero-status, received Vitamin A in the last six months before 52 University of Ghana http://ugspace.ug.edu.gh the study than children of mothers in unstable relationships. As shown earlier, greater percentage o f children of positive mothers received vitamin A irrespective o f stability of the relationship their mothers were in. 5.3.4 Marital Stability and Initiation of Breastfeeding Table 5.3.4 Table 18: Distribution of Mothers According To the Time Breastfeeding Is Initiated After Delivery and the Stability of their Marital Relationships____________ Time of Mothers of Unknown Status Positive Mothers Breastfeeding Initiation / Within I hr Within I hr Marriage Freq. Total % Freq Total %. Stability Stable 37 53 70 9 15 60 Unstable 27 32 84.4 18 24 75 Total . 64 85 75.3 27 39 69.2 From the table, initiation o f breastfeeding within 1 hour is quite high among all mothers irrespective o f sero-status and for both stable and unstable relationships. However, a greater percentage mothers in unstable relationships initiate breastfeeding within an hour than those mothers in stable relationships. On the whole, among all mothers, mothers of unknown status have the greater propensity to put their baby to the breast immediately after birth than positive mothers. This might be due to the fact that more positive mothers are opting not to breastfeed in order to prevent transmitting the virus to their babies. 53 University of Ghana http://ugspace.ug.edu.gh 5.3.5 Age of Mother and Ever Breast Feeding Table 5 3.5: Percentage Distribution of Mothers Who Ever Breastfed Their current babies According to Age of mother. Age of Mothers ofUnknown Positive Mothers Total Mother Status (Y ears)/Ever Breastfeed Freq. Percentage Freq. Percentage Freq. Percentage 15-19 15 18.1 0 0 15 12.3 20-24 29 34.9 11 28.1 40 32.8 25-29 24 29.0 13 33.3 37 30.3 30-34 7 8.4 8 20.5 15 12.3 35-39 8 9.6 6 15.4 14 11.5 40+ 0 0 1 2.7 1 0.8 . Total 83 100 39 100 122 100 The percentage of all mothers who ever breastfeed their current babies’ increases with age to a peak within either 20-24 or 25-29 age groups and from hence decrease progressively with age. While the highest percentage of mothers o f unknown status who ever breastfeed is within a younger age group (the 20-24 age group), the highest percentage of positive mothers who ever breastfed is within an older age group (25-29 age group). 54 University of Ghana http://ugspace.ug.edu.gh 5.3.6 Age and Initiation of Breast Feeding. Table 5.3.6: Age Distribution ofM others Who Initiated Breastfeeding within an Hour Of Delivery. Age of Mothers ofUnknown Positive Mothers Total mother Status (Years) Freq. Percentage Freq. Percentage Freq. Percentage 15-19 10 18.5 0 0 10 15.0 20-24 20 37.0 6 46.1 26 38.7 25-29 14 26.0 4 30.8 18 26.9 30-34 3 5.5 2 15.4 5 7.5 35-39 7 13.0 1 7.7 8 11.9 40+ 0 0.0 0 0 0 0 Total 54 100 13 100 67 100 Among all mothers, the immediate initiation of breastfeeding after delivery is highest in the 20-24 age group (37-46 percent) and reduces progressively with age of mother. In general, immediate initiation o f breastfeeding is more popular among younger mothers than among the older mothers. 5.3.7 Age Distribution ofMothers Whose Babies Received Vitamin A Table 5.3.7 Age Distribution ofM others Whose Babies Received Vitamin A Age of Mothers ofUnknown Positive Mothers Total mother Status (Years) Freq. Percentage Freq. Percentage Freq. Percentage 15-19 14 28.0 2 4.8 16 17.4 20-24 16 32.0 9 21.4 25 27.2 25-29 13 26.0 14 33.3 27 29.3 30-34 3 6.0 9 21.4 12 13.0 35-39 4 8.0 7 16.7 11 40+ 0 0 1 2.4 1 1.1 . . Total 50 100 42 100 92 100 From the table it is observed that for all mothers the percentage of children receiving vitamin A increases with age of mother to a point and declines progressively. - 55 University of Ghana http://ugspace.ug.edu.gh While among mothers of unknown HTV status the highest percentage o f babies receiving vitamin A belong to mothers o f 20-24 age group, in HTV positive mothers it occurs in the 25-29 age group. Teenage and older mothers (30 years and above) are therefore more likely to default in ensuring that their babies received the vitamin A. 5.3.8 The Influence of Level of Education Attained, Ability to Read Newspaper, Radio and TV on Child Feeding Practices. The influence of education on infant and young child feeding practices is also a mixed one. Among mothers of unknown HIV status, the immediate initiation of breast­ feeding after delivery is highest amongst primary school attendants whilst among positive mothers the practice is highest amongst JSS/Middle attendance. However, in relation to the use o f iodized salt, SSS (the highest level of education among respondents) attendants register the highest rates among both positive mothers and mothers o f unknown HTV status. The same goes for mothers who ensure that their children receive vitamin A. The mixed influence o f education may partly be explained by the low number of respondents among SSS attendants. Therefore, the full effects of education could probably be ascertained in a larger study. The same mixed influences have been indicated in connection with newspaper, radio and TV on one hand and selected feeding practices on the other. For e.g. while the highest proportion of mothers of unknown HIV status who ever breastfed say they do notjisten to radio daily, among positive mothers the highest proportion o f mothers who ever breastfed say they listen to radio daily. In addition, the highest proportions of both mothers of unknown HTV status and positive mothers who initiated breast-feeding immediately after 56 University of Ghana http://ugspace.ug.edu.gh birth are among mothers who say they do not listen to radio daily. For iodized salt, the highest proportions of users among mothers of unknown HIV status are those who listen to radio daily but among positive mothers, the highest users say they do not listen to radio daily. The highest proportions of mothers irrespective o f HTV status who ensured that their children received vitamin A are among mothers who say they do not listen to radio regularly. This goes for the influence of television among mothers who have ever breastfed, which indicated a negative relationship. On the other hand, a positive relationship between weekly viewing of television and use of iodized salt among mothers irrespective of HTV status. While the administration of vitamin A is highest among mothers of unknown HTV status who say they watch television weekly, the same is true among HIV positive mothers who say they-do not watch television weekly. 5.3.9 Findings of In-Depth Interview of Selected HIV Positive Mothers All the HIV positive mothers with infant between 0-5 months who were interviewed about their infant feeding practices said they were either practising exclusively breastfeeding from 3 up to 6 months or using baby formula feeds. When asked about why they chose the particular infant feeding practice, all o f them answered that they had tested positive and as a result of counseling received had opted for their chosen infant feeding practice. Many o f the mothers who were adopting exclusive breastfeeding said they chose that option because they did not have the money to sustain the purchase of formula food. When asked whether they used any other liquid or solid food in addition to either breastfeeding or formula feeding, all the respondents interviewed replied that they were 57 University of Ghana http://ugspace.ug.edu.gh adopting either exclusive formula feeding or exclusive breastfeeding. They explained the negative consequences o f mixed feeding on the health o f the infant as diarrhoea and transmission of HTV to the child and said they were avoiding mix feeding to prevent these consequences. On the difficulties experienced in connection with their chosen infant feeding practice, the mothers adopting infant formula feeding all replied that the major difficulty was with getting money to buy the infant formula. When asked about whether they had disclosed their sero-status to any one, two- thirds o f the positive mothers interviewed said they did not. The reasons given by those who did not disclose their status was either that their husbands were drunks and would beat them and /or-throw them out of the marital homes if they knew the truth about their sero- status. The mothers who disclosed their sero-status did so to their husbands or parents, particularly mothers or both. Still some disclosed their positive status to a sister or some close female friend. When asked about what support they were receiving from those they had revealed their status to, many o f the mothers said their husbands and or their mothers were assisting in either buying the infant formula or were regularly reminding them of the feeding times and formula mixing methods. Others said their mothers were very sympathetic and provided emotional and moral support. When asked whether they experienced any form of discrimination from the people to whom they disclosed their status, all the mothers replied in the negative. Some added, “We are a family, we are very close” Others replied, “my family is very loving” 58 University of Ghana http://ugspace.ug.edu.gh A few mothers revealed that their husbands do not believe that they (the mothers) are positive even after showing them the test result. One mother said her husband was still living in denial because she was not sick. When asked further whether this disbelieving husband adopted any safe sex practice such as condom use, the mother in question said he did not. When asked about whether they had any regrets about having disclosed their sero­ positive status, almost all o f the mothers (who did disclose their status) said they had no regrets. They thought it was necessary to disclose their status to very close relatives so that when their health status begun to deteriorate as the AIDS set in they would have ready assistance. On whether they would advice others to disclose their status to their close relatives, the answer was conditional; that is, they would advise disclosure depending on the nature of the relationship those others had with their relations. When asked about whether they adopt any particular strategies or mechanisms to prevent others from knowing their sero-status, some o f the women said they tell people they have breast problems. Others said they usually apply medication to their breasts to deceive people. Still others said they did not care if people knew their status or not and that their greatest worry was about how to ensure that the child did not have the HIV. One mother who had a caesarian operation and was separated from her baby for some time said she used to tell people she was not breastfeeding because after the period of separation from the baby, she just opted for formula feeding upon being united with her baby. Some mothers said they did not adopt any special strategies but behaved normally. 59 University of Ghana http://ugspace.ug.edu.gh Those using infant formula planned to shift to supplementary feeding from 4-5 months because of difficulty in buying the infant formula. When asked about their experiences upon first learning o f their positive test result, all the positive mothers said it was difficult at first but with counseling they had accepted their status and were taking steps to maintain their health and that o f their babies. One mother said she had contemplated abortion at first but upon receiving counseling on PMTCT she decided to have the baby. Finally when asked about what assistance they would require in order to sustain their chosen infant and young child feeding practices, many of the mothers said they needed money to add to their trading capital to continue their trade and earn regular incomes to sustain them. From these interviews one would get the impression that the issue of stigma was not a very straightforward one. Though cases of stigmatization o f sero-positive people especially mothers did not seem to be a daily experience in the area, the mothers were very sensitive and took steps to prevent others from knowing their status including even spouses and close relatives. However, the fear of stigmatization did not seem to be critical in determining the choice and maintenance of infant and young child feeding practices among HIV positive mothers. 60 University of Ghana http://ugspace.ug.edu.gh Chapter 6. 6.0 Discussion of Findings/Conclusions/ Implications 6.1 Findings on Background characteristics The homogenous socio-demographic and cultural backgrounds of respondents are of strategic importance. Traditional and religious leaders have enormous influence in such social settings and could be of great assistant in policy change, advocacy, and behavioral change communication. Programme managers dealing with child nutrition within the context of HTV/ADDS in the project area and similar settings all over the country need to work closely with the chiefs, queen mothers, religious leaders etc to bring about the desired changes in infant and young child nutrition. Strong community mobilization and advocacy will help reduce stigma, break the silence surrounding HIV/AIDS and improve social support (including that of males) to women during and after the antenatal period. In addition, one would want to believe that the common socio-cultural norms, attitudes and practices might provide certain information that may be useful for the development o f appropriate policies, advocacy, BCC programmes and messages on child nutrition. This calls for an in-depth ethnographic study through close collaboration between credible research institutions, health providers, local government administrators and the community leaders and members. The combination of high level of poverty and low education among the respondents is frightening, to say the least, and poses the greatest obstacle ever to controlling the pandemic. This should attract relevant policy and programme interventions. This is because poverty and ignorance are at the root of many social development problems particularly 61 University of Ghana http://ugspace.ug.edu.gh those related to health behavior including HIV/AIDS risks. The HIV pandemic, for example, has at its root the twin evils o f poverty and illiteracy. Poverty drives many women toward unhealthy sexual practices, which leads to HTV and other sexually transmitted diseases. Also, poor mothers are unable to support, on sustainable basis, the recommended infant and young child feeding practices due to inability to afford the needed foods. Effective and sustainable programmes on improving income generation particularly among women and enhancing girl child education will help deal with these root causes of risky health behaviour. 6.2 Findings on Infant Feeding Practices It is encouraging to note that breastfeeding is highly popular among women irrespective of HIV status as shown by the high ever breastfed (86%) and currently breastfeeding levels (93% among mothers o f unknown HIV status). This ensures that mothers and children are able to take advantage of the benefits of breastfeeding as documented in the literature review. (Golding et.al., 1997, American Academy of Pediatricians., 1997). As we commend the health providers and relevant partners in the study area for this achievement, there is the need to reinforce and strengthen this commendable practice through intensifying health education. The high performance o f HTV positive mothers in putting their babies to the breast immediately after birth is one reflection of the good results that intensive attention from health providers and educators could yield. It is probable that the reason why positive mothers performed better than their mothers of unknown HIV status on this parameter (60% against 37%) may be because positive mothers received greater attention through 62 University of Ghana http://ugspace.ug.edu.gh PMTCT and the related supervised deliveries that they entail. This gives an indication that supervised deliveries bring added advantages to the mother and child, which may not be available within the context o f non-supervised deliveries. The high proportions (10%) of both mothers o f unknown HTV status and positive mothers who do not give their infants colostrum from their breast within the first three days after delivery and the high use of other fluids and/or solids for feeding infants in the first few days after delivery (prelacteal feeds) (15% children o f all mothers) are threats to reaping the full benefits of breastfeeding by mother and child in the project area. Many mothers may be adopting these practices out of ignorance believing that the colostrum is dirty and also that the baby needs water to survive. As contained in the literature review, breast milk contains the most natural, affordable and best way of feeding an infant. It contains all the nutrients and water, in the right proportions, needed by the infant from birth to 6 months of age. Health workers, therefore, need to intensify their education and focus on messages highlighting the antiviral/antibacterial benefits of mothers’ colostrum and the fact that the breast milk contains enough water for the needs of the child. This is important within the context of HIV especially. The literature review has documented studies with findings that prove that the risk of vertical transmission is greatly enhanced with the adoption o f early mixed feeding (use of breast milk with other foods and juices) (Coutsoudis et al., 1999) Mixed feeding increases the risk of mother to child transmission o f the virua^through increase diarrhoea, mucosa inflammation, and other illnesses. 63 University of Ghana http://ugspace.ug.edu.gh O f all prelacteal feeds, the administration of traditional medicines to infants within three days of delivery is the most disturbing. All health workers and community leaders should emphasize messages on the harmful effects of administering herbal medicines. The high rate of breast feeding for at least six months among both positive and mothers o f unknown HTV status (63% and 72%) is commendable and a major factor in the promotion of infant health. However, the high proportions of HTV positive mothers (36%) that continues to breastfeed for six to nine months and beyond is clearly in contravention of the recommended practice. As captured in the literature review, studies have shown that prolong breast-feeding particularly beyond six months among HIV positive mothers increases the risk of mother to child o f the-HIV. (Taha et al., 1998; Leroy et al., 1998). The MOH guidelines on breastfeeding within the context of HIV are appropriate and only need to be strictly followed in educating mothers. .The high levels o f use o f feeding bottle and nipple among HIV positive mothers (15%) have also been indicated by the findings. This practice is risky as it introduces pathogens into children. Within the high poverty settings of the study area and Africa in general, the use of feeding bottle and nipple is particularly not advisable since the mothers are incapable of providing the fuel for adequate sterilization the bottles on a sustainable basis and providing the quality of water needed to safely sustain the use of bottle.-feeding. It is noted that this practice sometimes results from the blind adoption of what is considered “fashionable” among mothers, especially the low educated ones. Considerable education had been done in Ghana on this issue but this finding suggests that health workers and 64 University of Ghana http://ugspace.ug.edu.gh Of all prelacteal feeds, the administration of traditional medicines to infants within three days of delivery is the most disturbing. All health workers and community leaders should emphasize messages on the harmful effects of administering herbal medicines. The high rate of breast feeding for at least six months among both positive and mothers of unknown HIV status (63% and 72%) is commendable and a major factor in the promotion of infant health. However, the high proportions of HIV positive mothers (36%) that continues to breastfeed for six to nine months and beyond is clearly in contravention of the recommended practice. As captured in the literature review, studies have shown that prolong breast-feeding particularly beyond six months among HIV positive mothers increases the risk o f mother to child o f the-HTV. (Taha et al., 1998; Leroy et al., 1998). The MOH guidelines on breastfeeding within the context o f HTV are appropriate and only need to be strictly followed in educating mothers. The high levels of use of feeding bottle and nipple among HTV positive mothers (15%) have also been indicated by the findings. This practice is risky as it introduces pathogens into children. Within the high poverty settings of the study area and Africa in general, the use of feeding bottle and nipple is particularly not advisable since the mothers are incapable of providing the fuel for adequate sterilization the bottles on a sustainable basis and providing the quality of water needed to safely sustain the use o f bottle.-feeding. It is noted that this practice sometimes results from the blind adoption of what is considered “fashionable” among mothers, especially the low educated ones. Considerable education had been done in Ghana on this issue but this finding suggests that health workers and 64 University of Ghana http://ugspace.ug.edu.gh other development workers need to go back to the drawing board in order to reverse the situation. The study also indicated that HIV positive mothers are clearly ahead of mothers of unknown HIV status in adopting the right combination of food groups in the preparation of complementary feeding to ensure high diversity o f nutrients in infant and young child feeding. However, what is surprising is the low use o f readily available, affordable and highly nutritious food items by all women irrespective o f sero-status. This includes oranges, sweet potatoes, vitamin A-rich dark green leafy vegetables (Kontomire, bokoboko, alefu etc) and other fruits. It should be noted that the project area is one o f the leading districts in the production o f mangoes and plantations of the fruit are springing up rapidly. It is therefore, clear that this lapse cannot be explained away as a result o f poverty. It may be clearly an issue of lack of sufficient education on the issue of the benefits o f food diversity during childhood and or the blind extension to young children of traditional adult foods in oblivion of the special needs of children. In spite o f the high level of education in public campaign on the use of iodized salt, the findings show 60% and 65% percent of mothers o f unknown HTV status and HTV positively mothers respectively do not use iodized salt in preparing food. As indicated in the literature, it has been proven that iodine deficiency is a major cause o f several childhood illnesses including mental deficiencies and learning disabilities. To be a^vakened to the fact that as many as 60 to 65% of Ghanaian children are denied this simple, lowcost, and user-friendly technology with a huge health dividend should receive more attention than it is currently given by public health programmes. There is the need to focus more 65 University of Ghana http://ugspace.ug.edu.gh attention on educating mothers and the general public on the benefits o f iodized salt for children and adults. Findings on vitamin A supplementation for children also show that positive mothers are performing highly as opposed to mothers of unknown HTV status (92% as against 57%). The attention should in this case be on children of mothers ofunknown HTV status to ensure that the over 40% of children of mothers of unknown HIV status that today go without this essential service in the project area are captured. 6.3 Factors influencing the choice of Infant and Young Child feeding The positive influence of stable marital relationship on several feeding practices among women has been indicated by the findings. This is clearly shown in relation to the high rate of ever breastfed children o f mothers in stable relationship, the high adoption of high diversity food by positive mothers in stable relationship and the high adoption of iodized salt by women in stable relationships. However, the influence o f stable marital relationships is not clearly shown in the number of children who receive vitamin A. The very high levels o f marital instability (30% and 40% for mothers of unknown HIV status and positive mothers respectively) found among respondents should therefore be a matter for serious policy and programme interventions. This is because besides the positive effects of marital stability on child nutrition and health, all mothers, particularly sero-positive ones, derive immense benefits if they have supportive husbands. This includes support in sustaining recommended infant feeding practices, adherence to ART and other drugs and the breaking of silence and stigma. This issue of high marital instability, therefore, requires research, policy and programme interventions. A comprehensive ethnographic research 66 University of Ghana http://ugspace.ug.edu.gh should be conducted in collaboration with all stakeholders (community leaders and members, policy makers and programme managers) to provide evidence-based information and recommendations for policy and programme interventions. The findings show an interesting phenomenon related to women who have ever breastfed. While the highest proportion of ever breastfed mothers of unknown HTV status lies within a younger age group (20 - 24 years), the highest proportion of ever breastfed positive mothers are older (20 - 29 years). This may be difficult to explain. However, it looks like generally, HTV positive women may be older on the average than mothers of unknown HIV status due to the nature and progress of HIV and AIDS. The influence o f age of mother on breast-feeding practices also varies and no specific conclusion could be made in relation to the influence of age. For example, whilst mothers within the ages o f (20 - 24 years) have the highest proportions of all mothers who initiated breast-feeding immediately after birth. This is not so in relation to the administration of vitamin A to their babies. Whereas the highest proportion of mothers of unknown HTV status who ensured the administration of vitamin A to their babies lies between 20 - 24 years age group, among positive mothers, the highest proportions lies within 20 - 29 years age group. One trend that seems to be established concerning age, however, is that the younger and the older reproductive ages (of 15 - 19 years and 30+ years respectively), are worse off in the adoption o f good feeding practice than those within the middle reproductive ages of 20 - 29 years. This, therefore, points to the-fact that education should focus on the younger and older ages of mothers as special target audiences for the improvement of child nutrition practices. 67 University of Ghana http://ugspace.ug.edu.gh The influence of education on infant and young child feeding practices is also a mixed one. Among mothers o f unknown HTV status, the immediate initiation of breast­ feeding after delivery is highest among primary school attendants whilst among positive mothers the practice is highest amongst JSS/Middle attendance. However, in relation to the use o f iodized salt, SSS (the highest level o f education among respondents) attendants register the highest rates between both positive and mothers o f unknown HIV status. The same goes for mothers who ensure that their children receive vitamin A. The mixed influence o f education may partly be explained by the low number of respondents among SSS attendants. In view of the widely documented beneficial effects o f education, particularly o f females, on various health practices, one need to take these mixed influences of education -on child feeding practices with some caution. A larger study is probably required to ascertain the real levels o f influence (and nature o f relationship) of education and related background factors of mothers on infant and young child feeding. The same mixed influences/relationships have been indicated in connection with newspaper; radio and TV on one hand and selected feeding practices on the other. For example, while the highest proportion of mothers o f unknown HIV status who ever breastfed say they do not listen to radio daily, among positive mothers the highest proportion o f mothers who ever breastfed say they listen to radio daily. In addition, the highest proportions o f both mothers of unknown HTV status and positive mothers who initiated breast-feeding immediately after birth are among mothers who say they do not listen to radio daily. For iodized salt, the highest proportions o f users among mothers o f unknown HTV status are those who listen to radio daily but among positive mothers, the highest users say they do not listen to radio daily. The highest proportions of mothers 68 University of Ghana http://ugspace.ug.edu.gh irrespective of HIV status who ensured that their children received vitamin A are among mothers who say they do not listen to radio regularly. This same negative relationship exists between ever breastfeeding levels and weekly viewing o f TV among mothers irrespective o f mothers’ HIV status. On the other hand, there is a positive relationship between weekly viewing o f television and use of iodized salt among mothers irrespective o f HTV status. While the administration o f vitamin- A is highest among mothers of unknown HIV status who say they watch television weekly, the same is true among HIV positive mothers who say they do not watch television weekly. Despite these mixed relationships and influences between the media habits and young child feeding practices o f mothers, the strategic role o f the mass media, particularly radio and TV in the context of high illiteracy and ignorance, cannot simply be ignored. Media habits o f mothers and their effects on the choice o f feeding practices and other health related behaviours of mothers need a more focused attention in the future. 69 University of Ghana http://ugspace.ug.edu.gh 6.4 Recommendations In view of the findings, several recommendations need to be made towards improving infant and young child feeding among mothers particularly HIV positive mothers in the study area in particular and Ghana in general. These recommendations are as follows: 1) The PMTCT Programme Managers in the study area and elsewhere in the country should take advantage o f the large influence of traditional and religious leaders in the communities by mobilizing them to undertake an effective community mobilization and advocacy-programme. This would create stronger social support basis and enabling environment for the successful implementation of the PM TCT and related child nutrition programmes. 2) Traditional/community leaders and religious leaders should redouble efforts at promoting faithfulness and stability in marriages as a means of building congenial family environment to support the health and education o f family members particularly children. 3) Health Programme Managers and policy makers, particularly in the district assembly levels, should work together in commissioning credible research institutions to conduct ethnographic studies among communities being targeted for PM TCT and child^utntion programmes in order to come out with relevant information on cultural norms, beliefs, attitudes and practices that may inform policy making, evidence-based programming and message development in PMTCT and child nutrition activities. 70 University of Ghana http://ugspace.ug.edu.gh 4) In collaboration with appropriate governmental organizations and non-governmental and community based organizations, District Assemblies should spearhead efforts to put in place realistic and sustainable programmes on improving income generation particularly among women so as to tackle the health related impact o f extreme poverty. 5) All stakeholders (Ministry of Education/GES, District Assemblies, community leaders and parents) should increase their efforts in improving girl-child education since educated mothers are better placed to adopt healthier child-feeding practices. These efforts should focus on increasing enrolment and retention o f girls in school and ensuring high results. In spite o f the huge resource requirements in support o f this recommendation, the benefits and multiplier effects o f female education in all aspects o f maternal and child health and entire human development should be incentive enough to give the issue the needed priority. 6) The MOH/GHS and other health service providers in the country should pool their efforts to ensure increase in the rate of supervised deliveries and other emergency obstetric care for mothers to ensure that mother and child have the best services. 7) Efforts should be made by DHMT to intensify in-service training for health providers to be able to ensure high quality services and information to their clients particularly those within the PMTCT programme. 8) The GHS should make more efforts to provide counselors on the PMTCT programme the necessary logistics and motivation to ensure consistent clients follow-up and more efficiency and effectiveness in their work with PMTCT clients. 9) The GHS, particularly the public health outfits at the district level should undertake periodic BCC campaigns targeted at males and mothers to ensure maternal and child 71 University of Ghana http://ugspace.ug.edu.gh health practices, particularly those dealing with child nutrition within the context of HTV/AIDS, are improved and general social support to mothers is enhanced. 10) Key national campaign issues such as campaign on the use o f iodized salt, vitamin A supplementation for children, breast feeding, and the use o f feeding bottle and nipple, etc should be repackaged and re-launched to ensure stronger results and prevent loss of programme gains made over the last five years or so. This will require action and from the MOH/GHS, relevant industry, MOE/GES, and the mass media establishments. The FM and other community radios should be mobilized as key partners. 6.5 Areas of Future Research This study has opened up several new research possibilities that may be pursued by the PI or any other interested scholar, granting the availability o f needed resources. The issues are as follows: 1. The replication of this study to investigate on a more comprehensive bases the infant and young child feeding among mothers in all districts where the PMTCT programme is being taken to scale nationwide. This will help establish baseline information and data for monitoring and evaluation of the new PMTCT programmes throughout the country. 2. A more comprehensive study to investigate the possible relationships that might exist between infant feeding and young child practice? among either positive or negative and/ or all mothers one hand, and the health outcomes of their children. 72 University of Ghana http://ugspace.ug.edu.gh 3. A comprehensive study on the influence o f mothers’ education and other selected background factors and mothers’ child nutrition practices. 4. A study on how the media habits o f mothers affect their infant and young child feeding practices. 73 University of Ghana http://ugspace.ug.edu.gh References 1. Bertolli J., St Louis M.E., Simonds R. J., et al. 1996. Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population Kinshasa, Zaire. J Infect Dis 174(4:722-6. 2. Bland R.M. et al., Longitudinal infant feeding study: constraints to exclusive breastfeeding. WeOrC497. 3. Coutsoudis A, Pillay K, Spooner E et al. For the South African Vitamin A Study Group. Influence of infant feeding patterns on early mother-to-child transmission o f HIV-1 in Durban, South Africa: a cohort study. Lancet 1999:354;471-476. 4. Dalta P, Embree JE, Keiss JK, et al. Mother - to -ch ild transmission of human immunodeficiency virus 1: report from the Nairobi study. Journal o f Infection 1994: 170:1134-1140 5. De Soyza I, Rea M, Martines J, Why promote breastfeeding in diarrhoeal disease control programmes? Health Policy and Planning. 1991:6(4):371-379. 6. Dunn DT, Newell ML, Ades AE, Peckham C. Risk of human immunodeficiency virus type I transmission through breastfeeding. Lancet 1992; 340:585-588 7. Early Human Development. 1997:49 Supl. S143 -S15 5. 8. Ekpini E. R., Wiktor SZ, Satten G. A., et al.1997. Late postnatal mother-to-child transmission ofHIV-I in Abidjan. Cote d ’Ivoire. Lancet 349:1054-59. 9. European Collaborative Study. Caesarean section and the risk of transmission of HTV-I infection. La 1994:343:1464-1467 10. Gabiano C, Tova P-A, Martino, et al. m other-to-child transmission of human immunodeficiency virus type I: Risk of infection and correlates of transmission. Paediatrics 1992:90:369-374. 11. Ghana Health Service (MOH), Ghana HTV Sentinel Survey 2002, March 2002. Acts Commercial Ltd. 12. Gilks CF, Katabira E, De Cock KM. The challenge of providing effective'care of HIV/AIDS in Africa. AIDS 1997: 11 suppl B S99-S106) 13. Golding J, Emmett P M Rogers IS, Breastfeeding and infant mortality 74 University of Ghana http://ugspace.ug.edu.gh 14. Hutto C, Wade PP, Shenghan L, et al. A hospital-based prospective study of perinatal infection with human immunodeficiency virus type I. Journal o f Pediatrics 1991:118:347-53 15. Gray R et al., Child Mortality Associated with the failure to breastfeed and voluntary and involuntary weaning; An assessment of the risks and benefits of breastfeeding by HTV-infected mothers WeOrC496. 16. Leroy V, Newell ML, Debis F. International multicentre pooled analysis of late postnatal mother-to-child transmission ofHIV infection. Lancet 1998:352:597-600 17. Mandelbrot L, Mayaux MJ, Bongain A, et al. Obstetric factors and mother-to-child transmission o f I type I: the French perinatal cohorts. Am J Osbtet Gynecol 1996:175:661-667 18. MOH. A report of a rapid assessment of prevention of mother-to-child transmission ofHTV pilot programme in Manya Krobo District, Ghana, 2001-2003. August 2003. (a draft report) 19. Monteiro C A Can infant mortality be reduced by promoting breastfeeding? Evidence from Sao Paulo City. Health Policy and Planning 1990:5:23-29 20. Nesheim SR, Lindsay M, Sawyer MK, et al. A prospective population-based study ofHTV perinatal transmission. AIDS 1994:8:1293-1298. 21. Newell ML, Mechanisms and timing of mother-to-child trasmission of HIV-I. AIDS 1998:12:831-837. 22. Preble E A Piwoz EG. HTV and infant feeding: a chronology of research and policy advances and their implications for programs. Washington, DC: Academy for Educational Development, 1998. 23. Richard B et al., Breast milk infectivity of HIV-1 infected Mothers. WeOrC492, abstract in Reproductive Matters Vol. 8 NO. 16 Nov. 2000. 24. Rudiger P, www.bmj.com, 18 Jul 2000. 25. Ryder RW, Manzila T, Baende E, et al. Evidence from Zaire that breastfeeding by HIV seropositive mother is not a major route for perinatal HTV-I transmission but does decrease morbidity. AIDS 1991:5:709-714. 26. Ryder RW, Nsuami M, Nsa W, et al. Mortality in HIV-I seropositive women, their spouses, and their newborn children during 36 months of follow-up in Kinshasa, Zaire. AIDS 1994:8:667-672. ’ 75 University of Ghana http://ugspace.ug.edu.gh 27. Staneki K. A, Way, P O. The Demographic Impact o f HIV/AIDS: Perspectives from the World Population Profile. 1996 International Programme Centre, Population Division, U.S. Bureau o f the Census Washington DC 20233). 28. Taha T, Miotti P, Kumwenda N, et al. HIV infection due to breastfeeding in a cohort o f babies not infected at enrolment. XII international Conference on AIDS. Geneva. July 1998 Abstract 23270. 29. Tovo PA, De Martino, Caramia G, et al. Epidemiology, clinical features, and prognostic factor paediatric HIV infection. Lancet 1988:ii: 1043-1046. 30. Tess B H, Rodrigues L C, Newell ML et al. Infant feeding and risk of mother-to- child transmission o f HIV-1 in Sao Paulo state, Brazil. Sao Paulo collaborative study for the Vertical Transmission of HTV. Journal o f Acquired Immune Deficiency Syndrome 1998:19(2); 189-194. 31. UNAIDS, Report of the Global HIV/AIDS Epidemic. Geneva: UN AIDS, 1998 32. UNAIDS, Report o f the Global HTV/AIDS Epidemic. Geneva: UNAJDS, June 2002 . 33. UNICEF/UNAIDS/WHO, HIV and Infant Feeding: A review of HIV transmission through breastfeeding. WHO/FRH/NUTCHD/98.3 1998a. 34. Varkevisser, CM, Pathmanthan, I. Browniee, A. Designing and Conducting Health Systems Research Projects. Volume 2 Part 1., Proposal Development and Fieldwork. Ottawa: International Development Research Centre 1991. 35. Victora CG, Vaughan JP, Lonbardi C, Fuchs SM, Gigante LP, Smith PG, Nobre LC, Teixeira AMB, 36. Moreira LB, Barros, FC. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. The Lancet 1987(ii):319-322. 37. World Development Report: Investing in health. World Development Report, Oxford University Press 1993 76 University of Ghana http://ugspace.ug.edu.gh Appendix 1 SUMMARY OF KEY FINDINGS Key Findings Findings Mothers of Unknown HIV Status Positive Mothers 1. Children Currently Breastfed 93.0% 44.0% (0-23 months) 2. Children Ever Breastfed 99.9% 85.7% (0-23 months) 3. Initiation of Breastfeeding Immediately after birth. 37.0% 60.0% 4. Prelacteal Feeds Rate (Percentage of infants who were fed with liquids or solids in the first few days after delivery prior to breastfeeding) 15.0% 11.0% 4. Percentage of Children Breastfed for at least six months. 72.0% 63.0% 5. Percentage of Children Breastfed for 6-9 months and beyond 23.3% 37.0% 6. Percentage of Children fed using Feeding Bottle with Nipple 1.3% 15.0% 7. Percentage of Children whose Mothers Use iodized salt in food preparation 40.0% 35.0% Percentage of Children who had Vitamin A 57.0% 92.0% 1 University of Ghana http://ugspace.ug.edu.gh 9. Frequency of Feeding. 95.0% 100% (Percentage of Children who were fed 2 or more times yesterday during the day and night) 10. Use of animal source foods (Meat, Poultry, Fish) 45.0% 15.4% Percentage of Children 6-23 months Fed from animal sources 11. Percentage of Children 6-23months who had food from Egg sources 25.0% 46.2% 12. Percentage of Children 6-23months who had food containing Dairy Products 5.0% 7.7% 13. Percentage of Children who Had food from Vitamin A-rich orange / Yellow Vegetables 10.0% 23.1% 14. Percentage of Children fed with other Vitamin A Fruits 5.0% 7.7% 15. Percentage of Children fed with Dark Green Vegetables 25.0% 23.1% 16. Percentage of Children fed from Palm Oil / Nut sources 65.0% 30.8% 2 University of Ghana http://ugspace.ug.edu.gh Appendix 2 BREASTFEEDING AND INFANT CH ILD FEED IN G (A) RESEARCH ASSISTANT FIELD EDITOR OFFICE KEYED EDITOR BY NAME NAME DATE DATE NO. QUESTIONS AND FILTERS CODING CATEGORIES 100 RECORD THE TIME HOUR...................................................................... MINUTES............................................................... 102 First I would like to ask some questions NAME OF PLACE OF about you and your household. Where do RESIDENCE..................................... you currently live? CITY......................................................................1 TOWN...................................................................2 VILLAGE.............................................................3 103 How long have you been living YEARS............................................................. continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? ALWAYS (SINCE BIRTH)..........................95 IF LESS THAN ONE YEAR ENTER VISITOR........................................................... 96 ‘00 ’ 104 In what month and year were you bom? MONTH............................................................. DON’T KNOW M ONTH................................ YEAR................................................................19 DON’T KNOW YEAR..................................98 105 How old were you at your last birthday? AGE IN COMPLETE YEARS......................... COMPARE AND CORRECT 104 AND/OR 105 IF INCONSISTENT. 106 Have you ever attended school? YES.............................................. 1 NO....................................................................... 2 l University of Ghana http://ugspace.ug.edu.gh 107 What is the highest level o f school you PRIMARY................ .1 attended: Primary, Middle/JSS, Secondary/SSS, or higher? MIDDLE/JSS............ .2 SECONDARY/SSS. ..3 HIGHER.. ..4 108 What is the highest grade you completed GRADE. at that level? 109 Can you read and understand a letter or EASILY........................ newspaper easily, with difficulty, or not at all? WITH DIFFICULTY.. NOT AT ALL............. 110 Do you usually read a newspaper or YES. magazine at least once a week? NO.. I l l Do you usually listen to a radio every day? YES.. NO... 112 Do you usually watch television at least YES.. once a week? NO... 113 What is your religion? CATHOLIC.................. ..01 ANGLICAN.................. .02 METHODIST............... ..03 PRESBYTERIAN....... .0 4 PENTECOSTAL ....... .0 5 OTHER CHRISTIAN.. ...06 MOSLEM.................... ...07 TRADITIONALIST... .08 NO RELIGION............ . .0 9 OTHER 96 (SPECIFY) 2 University of Ghana http://ugspace.ug.edu.gh 114 To which ethnic group do you belong? ASANTE........................................................ 01 AKWAPIN.........................................................02 FANTE................................................................03 OTHER AKAN.................................................04 GA/ADANGBE................................................. 05 EW E.................................................................... 06 GUAN................................................................. 07 MOLE-DAGBANI.............................................08 GRUSSI................................................................09 GRUMA...............................................................10 HAUSA................................................................11 OTHER_________________________________ 96 _________________(SPECITY)_____________________ 115 What is your occupation, that is, what kind STATE of work do you mainly do? 116 How much do you usually earn for this Less th an 0 1 0 0 ,0 0 0 ....................................................1 work PER MONTH? PROBE: Is this by the day,by the 0 1 0 0 .0 0 0 - 0 4 9 9 ,9 9 9 ............................................... 2 month, or by the Month? 0500.000 -099 9 ,9 9 9 ...........................................3 0 1 m n - 0 4 .9 m n ..............................................................4 0 5 m n + ...............................................................................5 OTHERS______________________________ 9 9 9 9 9 9 6 ________________ (SPECIFY)______________________ 117 Do you have any sons or daughters whom YES......................................................................1 you have given birth to who are living with you? N O ....................................................................... 2 118 How many sons live with you? SONS AT HOME................................................ And how many daughters live with you? DAUGHTERS AT HOME............................... IF NONE, RECORD ‘00 ’.____________ 3 University of Ghana http://ugspace.ug.edu.gh 119 Do you have any sons or daughters whom SONS ELSEWHERE....................................... you have given birth to who are alive but do not live with you? DAUGHTERS ESLESWHERE..................... IF NONE, RECORD ‘00 ’ 120 Have you ever given birth to a boy or girl YES..................................................................... 1 who was bom alive but later died? NO........................................................................2 IF NO, PROBE: Any baby who cried or showed signs of life but survived only a few hours or days? 121 How many boys have died? BOYS DEAD.................................................. And how many girls have died? GIRLS DEAD................................................. IF NONE, RECORD ‘0 0 ’ 122 SUM ANSWERES TO M l9, M20, M22, TOTAL............................................................ AND ENTER TOTAL 123 Just to make sure that I have this right: you have had" in TOTAL children during your life. Is that correct? YES NO PROBE AND CORRECT M19-M23 4 University of Ghana http://ugspace.ug.edu.gh BREASTFEEDING AND INFANT/CHILD NUTRITION (B) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 124. MONTH ................................ In what year and month and year was your last child bom? YEAR.......................... 125 SEX OF CHILD MALE = 1 FEMALE - 2 Y e s ....................................................................1 126 Did you ever breastfeed (NAME)? N o ......................................................................2 133 127 How long after birth did you first put IMMEDIATELY WITHIN FIRST HOUR AFTER (NAME) to the breast? B IRTH ...............................................................1 AFTER THE FIRST H O U R........................ 0 D O N ’T REM EM BER/DON’T K NO W .... 8 During the first three days after Y ES......................................................................I 128 delivery, did you give (NAME) the liquid that came out from your N O .........................................................................0 breasts? D O N ’T K NOW ..................................................8 YES.......................................................................I During the first three days after delivery, did you give (NAME) N O .........................................................................0 131129 anything else to eat or drink before feeding him/her breastmilk? D O N ’T KNOW ................................................. 8 131 130 What did you give (NAME)? MILK (OTHER THAN BREASTM ILK)... A Anything else? PLAIN W ATER..................................................B W ATER W ITH SUGAR AND OR/SALT. . C DO NOT READ THE LIST FRUIT JUICE...................................................... D RECORD ALL MENTIONED BY TEA/INFUSIONS...............................................E CIRCLING LETTER FOR EACH ONE MENTIONED LIQUID OR SEMI-LIQUID TRADITIONAL M EDICINE.......................... F INFANT FORM ULA........................................ G OTHER (SPECIFY) ............ X Are you currently breastfeeding Y ES.........................................................................1 „ 133131 (NAME)? N O ...........................................................................0 132 For how long did you breastfeed (NAME)? M ON TH S.............................................................. IF LESS THAN ONE MONTH RECORD ‘00’ MONTHS. 5 University of Ghana http://ugspace.ug.edu.gh 133 Now I would like to ask you about the types of liquids (NAME) drank yesterday during the day and at night. Did (NAME) drink any of the following liquids yesterday during the day or at night? READ THE LIST OF LIQUIDS (A THROUGH H, STARTING WITH “BREASTMILK”). PLACE A CHECK MARK IN THE BOX IF CHILD DRANK LIQUID IN QUESTION A Breastmilk? A............................. B Plain water? B................................................................. C Commercially produced infant C.............................................................. formula? D Any other milk such as tinned, powdered, or fresh animal milk? D.............................................................. E Fruit juice? E.............................................................. F Coffee or tea F.............................................................. G Any other liquids such as sugar G.............................................................. water, minerals, light soup. H Liquid or semi-liquid traditional H...................................................... medicine? 134 Did (NAME) drink anything from a YES.....................................................1 bottle with a nipple yesterday or last night? NO........................................................0 DON’T KNOW....................................8 ^ 135 Now I would like to ask you about the type of foods (NAME) ate yesterday during the day and at night. Did (NAME) eat any o f the following foods yesterday during the day or at night? READ THE LIST OF FOODS. CHECK MARK IN THE BOX IF CHILD ATE THE FOOD IN QUESTION 6 University of Ghana http://ugspace.ug.edu.gh A Any foods made from grain (for example, A........ made with millet, sorghum, maize, rice, wheat, or other local grains. B B............. Orange-flesh squash, carrots, or yellow /orange- fleshed sweet potatoes? C Any other food made from roots or tubers (for C................ example potatoes, yams, cassava, coco yam or other local roots/tubers)? D D............... Any dark green leafy vegetables (for example cassava leaves, beans leaves, kotomire, alefu, spinach, pepper leaves, or other dark green leaves)? E E........................................ Ripe mango, ripe pawpaw (or other local vitamin A-rich fruits)? F Any other fruit and vegetables (for example, F ......................................... pear, pineapple, bananas, avocadoes, tomatoes, onions, apples, oranges, others)? G Any beef, pork, lamb, goat, rabbit (or wild G .......................................... game meat such as antelope/deer) H H.......................................... Any chicken, duck, or other birds (for example, pigeon, guinea hen, others)? I I........................................... Any fresh or dried fish, or shellfish? J Any eggs? J ........................................... K K......................................... Any foods made from beans or lentils (for example, made with cowpeas, beans, red beans, black beans, soyabeans, bambara beans or others)? L L.......................................... Any groundnuts/peanuts, or any other nuts? M M ..........................................Any cheese or yogurt? N N .......................................... Any food made with oil, fat, or butter? 0 Organ meats (for example liver, kidney, 0 .......................................... others) P P........................................... Snails, other small protein food Q Foods made with red palm oil, palm nut, palm Q.............................................. nut pulp soup 136 How many times did (NAM E) eat solid, semi­ NUMBER OF TIMES.........................solid, or soft foods other than liquids 7 University of Ghana http://ugspace.ug.edu.gh yesterday during the day and at night? IF CAREGIVER ANSW ERS SEVEN OR DON’T KNOW... 8 M ORE TIMES R EC O RD “7” ADAPT THIS Q U ESTIO N TO USE LOCAL W ORDS FOR TH E SEMI-SOLID FOODS THAT ARE GIVEN. INCLUDE M ASHED OF PUREED FOOD, ALONG WITH PORRIDGES PAPS, THICK GRUELS, STEWS ETC, SOLID FOODS- FO R EXAM PLE, FAMILY FOODS, BANANAS, MANGOES, POTATOES, BREAD- SHOULD ALSO BE INCLUDED. W E WANT TO FIND OUT HOW MANY TIMES THE CHILD ATE EN O U G H TO B E FULL.SMALL SNACKS AND SMALL FEEDS SUCH AS ONE OR TW O BITES OF M O T H ER ’S OR SISTER’S FOOD SHOULD N OT BE COUNED LIQUIDS DO N O T COUNT FOR THIS QUESTIONS. D O NOT INCLUDE THIN SOUPS OR BOTH, W ATERY GRUELS, OR ANY •O T H E R LIQUID. USE PROBING QUESTIONS TO HELP THE RESTPONDENT REMEMBER ALL THE TIMES THE CHILD ATE YESTERDAY. 137 What type o f salt do you use for cooking? FORTIFIED................................................... 1 CAN SHOW SAM PLE TO M OTHER NOT FORTIFIED........................................ 0 138 Did (NAME) receive a vitamin A dose like this during the last 6 Y ES.................................................................I months? N O ....................................................................0 D O N ’T KNOW .............................................8 Adapted from Arimond M. Ruel M.T. Generating Indicators o f Appropriate Feeding o f Children 6 through 23 Months from the KPC 2000+ 2003. food and nutrition Technical Assistance Project (FANTA) Washington DC 8