ABSTRACT
Complementary feeding is the greatest contributor to health and nutrition status of infants and young children. Malnutrition remains one of the greatest concerns in Sub- Saharan Africa region. In Kenya, national findings show inappropriate complementary feeding practices. Out-patient therapeutic programmes (OTPs) have been established to address severe acute malnutrition (SAM) among children 6-59 months of age. There are 6 OTP centres in Kamukunji sub-county in, Nairobi County. There is limited information on the knowledge, attitude and practices on complementary feeding among the caregivers of the children admitted into OTP centres. The main purpose of this study was to determine the knowledge, attitudes and practices (KAP) on complementary feeding among care-givers of children 6-23 months of age admitted into OTP centres in Kamukunji sub-County. The study adopted a cross-sectional analytical design. An exhaustive sample of 200 caregivers from four OTP centres in Kamukunji sub-county participated in the study. Data was collected from the caregivers using structured researcher-administered questionnaires and focus group discussion (FGD) guide, and from OTP programme staff using Key Informants Interview (KII) guide. Data was analysed using SPSS software (version 22). A p-value of <0.05 was used as the criterion for statistical significance. Caregivers’ mean score for knowledge on CF for children with normal nutrition status was 6.11± 2.33, out of a total score of 12, while for feeding children with Severe Acute Malnutrition (SAM) was 8.7± 2.63 out of a total score of 10. Eighty-eight percent (88%) knew the guidelines on how to give Ready-to-use therapeutic food (RUTF) to a child with SAM, 78% knew the time of introduction to complementary feeding, 100% knew that a child should be breastfed before administering the RUTF and 21% knew that breastfeeding should be increased and additional nutritious food given to a child during illness. For attitudes, the mean score was 24.1±11.73 out of 85 and 79.7% had a positive attitude towards the high nutritive value and the potential of RUTF to cure SAM, 67.5% had a positive attitude towards continued breastfeeding, and 61% had a positive attitude towards the recommended daily dietary intake for of RUTF. Almost all the caregivers (98.5%) introduced their children to complementary feeding at 6 months of age. Seventy-three percent of the children ate the recommended amount of RUTF per day. Maternal time constraints, low socio- economic status, and leakage of RUTF at the household through sharing were major barriers to optimal feeding for children with SAM. Lack of commitment in attending MIYCN education sessions was a major reason for low knowledge on complementary feeding for children with normal nutrition status. It is recommended that the Ministry of Health scale up Behaviour Change Communication (BCC) interventions for care- givers of children 6-23 months of age with a focus on complementary feeding knowledge, attitudes and practices specifically dietary diversity. The study findings may be utilized by the Ministry of Health at National, County and Sub county levels and the agencies dealing with child survival to establish strategies focusing on enhancing infants and young child nutrition among severely malnourished children through appropriate feeding. The findings also provide valuable information on the research efforts to rehabilitate children with SAM.
CHAPTER ONE: INTRODUCTION
Background to the study
Infants and young children 6-23 months of age are within the vital window of opportunity for foundational growth and development and hence they need good nutrition to achieve this requirement (WHO 2008a). During this stage, sub-optimal nutrition greatly compromises childhood developmental milestones and may cause permanent nutritional and health complications in future. These include cognitive, physical and physiological complications (WHO, 2008a). Indicators to complementary feeding practices include timely introduction of solid, semi-solid and soft foods at 6 months of age, with increasing amount and frequency. Minimum meal frequency is defined as: two times foor breastfed infants 6–8 months; three times for breastfed children 9–23 months; and four times for non-breastfed children 6–23 months. The practices also include dietary diversity (comprising of at least 5 out of 8 food groups). The food groups include breast milk, grains, roots and tubers, legumes and nuts, dairy products, flesh foods (meat, fish, organ meats and poultry), eggs, vitamin-A rich fruits and vegetables and other fruits and vegetables) (WHO/UNICEF, 2017). The breast milk during this period provides half of the infant’s energy (Victora et al., 2008).
Children born in urban informal settlements in Kenya are often at risk of sub-optimal breastfeeding and complementary feeding practices thus increasing their risk of mortality and delayed psycho-motor development (Concern Worldwide, 2014). Additionally, compromised sanitation within the settlements exposes infants and young children further to higher risks of infectious diseases, thus strengthening the vicious cycle of malnutrition (Korir, 2013). Limited resources and unsustainable
household income are prevailing circumstances in these settings and this reduces the caregivers’ food purchasing power, thus limiting their ability to diversify the child’s diet (Kimani-Murage et al., 2011).
Half the number of children’s death worldwide is as a result of malnutrition. Three million children die annually from under-nutrition. In 2017, UNICEF analysis showed that 51 million children 0-59 months of age suffered from wasting, of which 16 million were severely wasted, these translating to 7.4% and 2.4% respectively. Of the 51 million children, 25% were from Sub-Saharan Africa (UNICEF, 2017). In Kenya, 61% of children 0-5 months of age are exclusively breastfed, 26% of children under five years of age are stunted and 4% are wasted (Kenya National Burea of Statistics, 2015). More than 420,000 children suffer acute malnutrition in Kenya, of which 73,000 are severely malnourished (Save the Children, 2017). The highest prevalence of acute malnutrition is in Arid and Semi-arid Lands (ASAL) areas, urban informal settlements and areas with high prevalence of HIV and AIDS such as Homa-bay (26.0%), Siaya (23.7%), Kisumu (19.3%) and Migori (14.7%) (Kenya Aids Strategic Forum, 2018). Between January and May 2017, 42,579 children were treated for severe acute malnutrition from ASAL, Urban informal settlements, and refugee camps. In 2017, SAM rate in Kenya was at 7% while that of MAM was at 25.4% (UNICEF, 2017).
In Nairobi, the Global Acute Malnutrition (GAM) rate stood at 4.6% in May 2017. The SAM rate was at 0.1% while MAM rate was at 4.5%. The GAM rate for the Nairobi informal settlements combined was at 4.6%, which was equal to the entire county’s GAM rate. Kamukunji sub-county had the highest prevalence of wasting and
severe wasting at 9.6% and 1.9% respectively, which was far above the global and national rates (Concern Worldwide, 2017).
The United Children’s Fund (UNICEF) organization developed a programme focusing on integrated management for acute malnutrition, which entails the use of therapeutic nutrition supplements adapted to the progressive treatment and management of acute malnutrition (UNICEF, 2012). This was operationalized in 2009 in Kenya. Out-patient Therapeutic Programme (OTP) centres were established to provide treatment and nutritional rehabilitation services for severely acute malnourished children 6-59 months of age without complications (Concern Worldwide, 2011). The children are treated with a specified number of take-home Ready-Use Therapeutic Food (RUTF) issued according to their body weight, along with specialized routine medication. This RUTF is an energy-dense, micronutrient- rich fortified paste, mixed with peanut paste, oil, sugar and dry milk products, procedurally used to manage and rehabilitate severe acute malnourished children. These children are reviewed on a weekly basis at the facility where they receive their weekly re-fills of RUTF, and are followed-up at community level until they recover from acute malnutrition. The OTP centres are located within the residence of the children in order to reach as many children with SAM as possible (Concern Worldwide, 2012). Kamukunji subcounty has six OTP centres namely; Bahati, Majengo, Eastleigh, Biafra, SOS and Moi Forces. The first five centres are surrounded by a dense population of people, with low socio-economic status, dwelling in informal settlements. Children in these informal settlements are at great risk of malnutrition (Korir, 2013). This study was motivated by the many cases of severe acute malnutrition (SAM) among children in Kamukunji sub-County, being
area with the highest caseloads of acute malnutrition of all other informal settlements in Nairobi (MOH, 2017).
Despite various strategies implemented by the Ministry of Health and implementing partners in the management of acute malnutrition and sensitization on Maternal, Infant and Young Child Nutrition (MIYCN) at facility and community level, malnutrition rates still remain high in Nairobi, with Kamukunji having the highest caseloads among urban informal settlements (MOH, 2017). In a coverage survey by Concern Worldwide, the study established that only 47% of children with SAM were admitted to OTP, and one of the barriers was that most of the mothers (whose children were not admitted) did not attribute malnutrition to sub-optimal complementary feeding (Concern Worldwide, 2017). This may be an indicator that insufficient knowledge and inappropriate attitude of caregivers towards complementary feeding practices is a barrier to access and utilization of OTP services for treatment of acute malnutrition (Agozie et al., 2012). It is against this background that this study was conducted. A search through available literature did not reveal any information on caregivers’ knowledge, attitudes and practices on feeding a child with severe acute malnutrition.
Problem statement
Complementary feeding contributes the greatest percentage to the outcomes of a child’s growth (Victora et al., 2010). Poor complementary feeding practices still remain a significant challenge in Kenya, with one of the greatest challenges being insufficient knowledge and unfavourable attitudes towards complementary feeding among caregivers in the urban informal settlements. This is despite the fact that the
Ministry of Health and other stakeholders have implemented strategies promoting optimal infant and young child feeding, (Kimani-Murage et al., 2011). A study on complementary feeding practices in Nairobi informal settlements found that 62.6% of the children 6-23 months of age attained the minimum dietary diversity, 54.8% attained the minimum acceptable diet, 69.6% attained the minimum meal frequency while 75.9% got timely introduction to complementary feeding (Concern Worldwide, 2014). Another study in Korogocho on complementary feeding for children 6-23 months of age showed that 83.0% attained minimum meal frequency, 17.9% attained minimum dietary diversity while 15.4% attained the minimum acceptable diet (Korir, 2013). In Kahawa West studies showed that 79.0% of children 6-23months of age attained minimum dietary diversity while 79.5% attained minimum acceptable diet (Kimwele & Ochola, 2017). These were all below the recommended threshold of 80% attainment for each category (Concern Worldwide, 2014).
Available data on nutrition situation in Nairobi showed the minimum meal frequency, minimum dietary diversity and minimum acceptable diet for only specific informal settlements but not for the entire Nairobi County (MOH, 2017). Nationally, 21% of children consume the minimum acceptable diet at 6-23 months of age (KNBS, 2015). Worldwide, only a third of breastfed infants 6-23 months of age meet the criteria for dietary diversity and feeding frequencies appropriate for their age (WHO, 2013). Studies in Nairobi informal settlements show poor complementary feeding practices among the caregivers. A study conducted in Korogocho (Korir, 2013), reported that 15.4% of the children got minimum acceptable diet, despite a higher knowledge score on dietary diversity among the mothers. The prevalence of children with SAM in Nairobi by February 2017 was 74% of the total SAM children in Kenyan urban centres, with the highest caseloads being in the Nairobi informal settlements.
Kamukunji sub-county, largely characterised by people living in informal settlements with compromised sanitation, had the highest prevalence of wasting at 9.6%. (MOH, 2017). The risk of death is 5-20 times higher among children with SAM compared to that of well-nourished children (WHO, 2013).
