Knowledge , Attitude and Practices ( KAP ) of Mothers toward Infant and Young Child Feeding in Primary Health Care ( PHC ) Centers , Erbil City

Background and objectives: Improving infant and young child feeding practices in children birth–23 months of age is therefore critical to improved nutrition, health, development of children and, ultimately and impact child survival. The main objective is to: Assess knowledge, attitude and practices of mothers concerning infant and young child feeding, and to use the results as baseline for nutritional intervention programs in the future. Subjects and methods: A survey study was carried out in (13) Primary Health Care centers in Erbil city to assess knowledge, attitude and practices of mothers concerning infant and young child feeding, and to use the results as a baseline for nutritional intervention programs in the future in a period from ٢ of January 2008 to 30 of September 2009. Purposive (non probability) sample of 1000 (mother-child pairs) were selected . Results: The results of present study shows that the mothers have efficient practices and attitudes toward breast , formula and complementary feeding. Infant and young child feeding indicators concerning early initiation and exclusive breastfeeding were poor , among mothers attending PHC centers in Erbil. Conclusion and Recommendation: Majority of surveyed infant and young child’s feeding pattern was mixture feeding, or mixture and complementary feeding . And the feeding indicators were low among mothers in Erbil city, the investigators decided to construct an educational health program to be implemented by nurses in Primary Health Care centers in Erbil city for improving mothers knowledge, attitudes and practices of infant and young child feeding. The study recommended to revitalizing and expanding the Baby-friendly Hospital Initiative and Establishing of breastfeeding intervention programs for protection, promotion, and support of breastfeeding.


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child feeding, and to use the results as a baseline for nutritional intervention programs in the future in a period from ٢ nd of January 2008 to 30 th of September 2009.Official permission were obtained from the Ministry of Health -Directorate of Health-Erbil.Purposive (non probability) sample of 1000 (mother-child pairs) were selected and the criteria of the sample are: 1. Mother lives in Erbil city and attends Primary Health Centers (PHC) for routine follow up of their infant and young child.2. Infant age (birth -<2years), full term normal healthy (free from diseases and congenital malformation), non twins with birth weight of 2500 gm or greater and youngest child in the family.A questionnaire format with (85) items structured after studies and review of literatures, used in data collection consist of four parts.Part 1 A list of (18) items covered Sociodemographic variables that included:-Phase 1: child's age, gender; Phase 2: mother's {age, education, occupation, income, obstetrical history (Para, gravid, abortion, and dead children),information of mother previous children (type of delivery, place of delivery, type of feeding during the 1 st 6 months)}; Phase 3: father's (education, occupation, income ), number of family members and number of rooms in the house and type of child feeding .Part 2 A list of ( 14) items testing mothers knowledge regarding infant and young child feeding (Breastfeeding, Formula feeding, Complementary feeds) .Part 3 A list of ( 14) close ends questions that evaluated mother's attitude toward infant feeding (Breastfeeding, Formula feeding, Complementary feeds) .Part 4A list of (39) close end question covered mother's practices concerning infant and young child feeding (Breastfeeding, Formula feeding, Complementary feeds), and mother's source of information.After obtaining the questionnaire's validity and reliability, data were collected by interviewing the mothers' face to face by investigator and a team from 4 interviewers (who have Bachelor in nursing science and work as clinical instructors in pediatric and fundamental nursing units of Nursing College) at child growth monitoring unit in primary health .The KAP of mother's toward IYCF questionnaire items were rated and scored according to the following patterns: a) Two point type scale is used for rating the knowledge and practices.b ) The three point type Likert scale is used for rating the mothers attitudes .Data of the study were ordinal according to two level scale for mothers knowledge and practices which were scored as (1, 0) for true ,false respectively ,and three levels scale for mothers attitudes as(1, 2, 3) for agree , neutral ,disagree levels respectively.The cut off point was: 50 for the both mother's knowledge and practices, and 66.66 for mother's attitudes.The Statistical Package for Social Sciences software (SPSS, version 15) was used for data processing and statistical analysis.Table (1) shows the socio-demographic information related to mother, father and their family's property, most of mother were from age groups (20-24), (25-29) and (30-34) years old.Highest percentage of mothers were illiterate (28%), (17%) of them can read and write and (25%) were primary school graduates.Distribution of mother with respect to their Work most of mothers (84.6%) were not working (housewives).Concerning mothers obstetrical history the highest percent (46.4%) of mothers who attended PHC centers had only one child.The highest percentage of fathers (26.8%) were primary school graduates group, concerning father occupational statuses most of them (63.1%) were working in low professional jobs, and (66.4%) of employed mothers think that they had insufficient incomes.Distribution of families with respect to property indicates that the (38.1%) of the families live in houses shared with aonther family, (32.9%) live in rented house and (29%) owns houses.Regarding their family type clarifies that (56.6%) of the families were nuclear family, (43%) were extended families and (6%) were other type of families.(18.9%) of families consisted of < 4 members, (30.6%) of families consisted from 4 -5 members, 279 (27.9%) of families consisted from 6-8 family member and (22.6%) of families consisted from > 9 family members .

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( a ) Rotation converged in 9 iterations.Rotation Method: Varimax with Kaiser Normalization.Extraction Method: Principal Component Analysis.Table (4) indicates that the nine factor of child feeding have been created to construct a concepts for the first time for mothers KAP of infant and young child feeding the concepts are (Natural feeding) for knowledge, and practices correlation; (Artificial Feeding) for knowledge and Attitude correlation; (Natural feeding )for practices correlation; and Artificial Feeding Attitudes.Table (5) shows that (41.6%) of mothers received information concerning breast feeding or complementary feeding from physician, (41.9%) of mothers received information from physician in the private clinic ,(17.2%) of mothers received information concerning breast feeding or complementary feeding from nurse ,(54.7%) of mothers received information from nurse in the PHC centers and (36.1%) of mothers receive information from their mothers or mothers in law.Information presents in Table (6) depicts the high significant correlation among mothers Knowledge ,Attitudes and practices.Discussion: Majority of the children attending PHC centers were less than 10 months old which is the age when child receive routine vaccinations (figure 1).Female to male ratio in this study was 1.1: 1 .Table (1) Majority of mothers were between (20-34) years old which is expected as the reproductive age in between (25-35) years .Mothers from age group from (30-34) year were more knowledgeable about child feeding, had better attitudes toward infant and young child feeding, while mothers ages had high-significant relation with mothers practices of infant and young child feeding this is in contrast to what found by Baisch et al who conducted a ٨ study to assess breastfeeding attitudes, and he founded that there is no differences in attitudes by age (9) .
The type of child's feeding might be affected by the socioeconomic status of the family including the education level, occupation and monthly income of mother and father, in this study.The highest percentages of mothers were housewives, and the working mothers were not satisfied with their monthly income (Table 1).Mothers occupation had high significant relation with mothers knowledge but non significant relation with mothers attitudes and practices .While Earland stated that Maternal employment does influence infant feeding practices and consequently may have repercussions on future health.Mother's low educational level makes them unable to understand the existent educational information in posters and magazines and they need direct health education from health facilities (10) .
About quarter of the mothers stopped breastfeeding , more than half of them stopped before 3months of child age which is contrary to the WHO's recommendations of infant feeding in 2003 (11).Al-Jassir et al Conducted a study in Saudia Arabia ,they found that 76.1% had introduced bottle-feeding by 3 months (48.3% cited insufficient milk as the reason for introducing the bottle ) (12).Also in current study (Table 2) showed that the main reason for early weaning which was insufficient mother's milk which is also confirmed by Al-Abdalli and Abdul Ameer et al they found that nearly 35% believed that breast milk was not enough for their infants (13,14).The rotated component matrix consists from 9 factors , according to their eigenvalues.A new concept developed for first time as we know regarding KAP of infant and young child feeding the concepts suggested as (Natural feeding) for knowledge, Attitude and practices correlation; (Artificial Feeding) for knowledge and Attitude correlation and again (Natural feeding) for practices (Table 3).As majority of mothers were started breastfeeding but for mother's lack of confidence they supplemented breastfeeding with other foods and gradually the breastmilk supply decrease and child stopped breastfeeding and turn to artificial feeding in the same time early starting of complementary food introduction(Table 4) .The present study finding regarding mothers delay in initiation of breastfeeding (Table 5) is in agreement with findings of MICS in 2006 (5) which indicated that only (31%) of mothers in Iraq started breastfeeding within one hour of birth, and The same thing concerning continued breastfeeding were found by Khassawneh (15) which revealed that two thirds of Jordanian women were breastfeeding for more than one year.while continued breastfeeding at 1 year was good, minimum meal frequency rate was poor, ever breast feed was good among mothers in Erbil city.We can say that early breastfeeding initiation and exclusive breastfeeding were poor, while continued breastfeeding at 1 year was good, minimum meal frequency rate was poor, ever breast feed was good among mothers in Erbil city ( Table 6).

Conclusion :
The results of servy study conclued that most of mothers were illiterate or primary school graduate; housewives ; fathers were low professional workers and majority of mothers and fathers were unsatisfied with their monthly income, and don't own houses, more than half of mothers were a member of nuclear family.Majority of surveyed infant and young child's feeding pattern was mixture feeding, or mixture and complementary feeding.

Table ( 2) Causes of Breastfeeding Stopping
This Table shows that of mothers 222 (23.4%) of breastfed mothers stopped breast feeding before 24months of child age from them:-(7.2%)were stopped for having nipple or breast problem, (35.1%) were stopped for having insufficient milk, (29.7%) for child refusal, (9 %) for mother's health problem, (8.1%) of mother's dislike breastfeeding and (5.4%) of them for having pregnancy.

Table ( 3): Simple Correlation Coefficients between the main three criteria ( Breast , Formula , Complementary ) feeding for the Assessment of Mothers ( KAP )Toward Infant and Young Child Feeding
Table(3): presents the correlation matrix for testing the relationship among mother's knowledge, attitude and practices through three feeding criteria, and indicates presence of significant relation between KBF and (ABF,AFF,PBF,PFF)