EFFECT OF NUTRITION EDUCATION VIDEOS ON MOTHERS’

KNOWLEDGE AND PRACTICES ON COMPLEMENTARY FEEDING OF

CHILDREN 6-23 MONTHS, NAIROBI CITY COUNTY, KENYA.

ROBINSON NYARIBO MOCHONI (Bsc. FND)

REG. NO. H60/25987/2013

A RESEARCH THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF
SCIENCE (FOOD, NUTRITION AND DIETETICS) IN THE SCHOOL OF
PUBLIC HEALTH AND APPLIED HUMAN SCIENCES OF KENYATTA
UNIVERSITY

NOVEMBER 2020
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DECLARATION
This thesis is my original work and has not been presented for a degree in any other

university or any other award.

Signature ........................................ Date .....................................................

Robinson Nyaribo Mochoni – Reg. No. H60/25987/2013

SUPERVISORS:

We confirm that the work reported in this thesis was carried out by the candidate under

our supervision:

Signature Date ……………………………….

Prof. Judith Kimiywe (Ph.D.)

Department of Foods, Nutrition and Dietetics
Kenyatta University

Signature Date ……………………………..

Prof. Marja Mutanen (Ph.D.)

Department of Food and Nutrition Sciences
University of Helsinki, Finland
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DEDICATION

To my dear wife Jeniffer, My brother Jonnes, my sister Abigail, My parents; Juditth

Nyamoita Mochoni and Mr. Henry Mochoni Otuke, my daughter Ariella Kemunto

Nyaribo, my supervisors and all my friends for their great support in this work.
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ACKNOWLEDGEMENT

I thank God for giving me the strength, sustenance and grace in my studies. I thank my

supervisors, Prof. Judith Kimiywe of Kenyatta University and Prof. Marja Mutanen of

the University of Helsinki, Finland for their professional and expertise guidance and

tireless efforts to assist me in the course of my study.

I appreciate Prof. Marja Mutanen and her team for allowing me to be part of Glocal

project where I got data to support my study, and Kennedy Abonyo for his assistance

in data analysis.

Sincere gratitude goes to Mathare North Health Center, Baba Dogo Health Center,

Korogocho Health Center and Kahawa West Health centers’ staff members and their

administration for granting me the permission to conduct this study in their institutions.

My appreciation goes to my respondents, mothers of children aged 6-23 months who

participated in the study, without whom the study could not have been successful. I am

also grateful to the research assistants who were much instrumental during the data

collection and cleaning. I am very grateful to my colleagues, my wife, my parents,

siblings and friends for their encouragement, love and support during my studies.
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TABLE OF CONTENTS
DECLARATION..........................................................................................................ii
DEDICATION............................................................................................................ iii
ACKNOWLEDGEMENT .......................................................................................... iv
LIST OF TABLES ...................................................................................................... ix
LIST OF FIGURES ..................................................................................................... x
LIST OF ABBREVIATIONS AND ACCRONYMS ............................................... xi
DEFINITION OF TERMS........................................................................................xii
OPERATIONAL DEFINITION OF TERMS ....................................................... xiii
ABSTRACT ............................................................................................................... xiv
CHAPTER ONE: INTRODUCTION ........................................................................ 1
1.1 Background of the study ...................................................................................... 1
1.2 Problem statement with justification .................................................................... 4
1.3 Purpose of the study ............................................................................................. 5
1.4 Objectives of the study ......................................................................................... 6
1.5 Research hypotheses ............................................................................................ 6
1.6 Significance of this study ..................................................................................... 6
1.7 Delimitation of this study ..................................................................................... 7
1.8 Limitation of this study ........................................................................................ 7
1.9 Assumption of this study ...................................................................................... 7
1.10 Conceptual framework ....................................................................................... 8
CHAPTER TWO: LITERATURE REVIEW ......................................................... 10
2.1 Factors associated with complementary feeding ........................................... 10
2.1.1 Socio-Demographic Characteristics and Complementary Feeding ............. 10
2.1.2 Socio-Economic Characteristics and Complementary feeding ................... 11
2.1.3 Water, Sanitation and Hygiene and Complementary Feeding .................... 12
2.2.0 Maternal Knowledge and Complementary Feeding .................................. 13
2.2.1 Understanding the Role of Appropriate Infant Feeding for their Growth ... 13
2.2.2 Initiation of Complementary Feeding.......................................................... 14
2.2.3 Complementary Foods and Dietary Diversity ............................................. 16
2.2.4 Complementary Feeding and Meal frequency............................................. 17
2.2.5 Complementary Feeding and Minimum Acceptable Diet ........................... 19
2.2.6 Complementary feeding frequency with continued breastfeeding .............. 20
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2.2.7 Maternal Practice and Complementary Feeding ......................................... 22

2.2.8 Handling, Preparation and storage of complementary foods ...................... 22
2.2.9 Feeding during and after illness................................................................... 23
2.3 Effect of nutrition education video lessons on knowledge, attitude and
practices of mothers on complementary feeding. ................................................ 25
2.4 Summary of literature review ......................................................................... 26
CHAPTER THREE: RESEARCH METHODOLOGY ........................................ 28
3.1 Research design ................................................................................................ 28
3.2 Research variables............................................................................................ 28
3.2.1 Dependent variable ...................................................................................... 28
3.2.2 Independent variable.................................................................................... 28
3.2.3 Extraneous variables .................................................................................... 28
3.2.4 Intervening Variable .................................................................................... 28
3.3 Study location ................................................................................................... 29
3.4 Target population ............................................................................................. 29
3.4.1 Inclusion criteria .......................................................................................... 30
3.4.2 Exclusion criteria ......................................................................................... 30
3.5 Intervention procedures .................................................................................. 30
3.5.1 Brief background of the project ................................................................... 30
3.5.2 Procedures of video projection .................................................................... 31
3.5.3 Nutrition messages of the videos ................................................................. 31
3.6.0 Sampling procedures..................................................................................... 32
3.6.1 Sample size determination ........................................................................... 32
3.6.2 Sampling technique ..................................................................................... 34
3.7 Research team................................................................................................... 35
3.7.1 Recruitment of research assistants ............................................................... 35
3.7.2 Training of research team ............................................................................ 35
3.8 Research instruments ....................................................................................... 35
3.8.1 Questionnaires ............................................................................................. 35
3.8.2 Pre-testing of data collection tools and study procedures ........................... 36
3.8.3 Validity ........................................................................................................ 36
3.8.4 Reliability .................................................................................................... 36
3.9 Data collection procedures .............................................................................. 37
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3.10 Data analysis, and presentation .................................................................... 38

3.11 Ethical and Logistical considerations ........................................................... 39
CHAPTER FOUR: RESULTS ................................................................................. 40
4.1 Demographic and socio-economic features of the participants ................... 40
4.1.1 Introduction ................................................................................................. 40
4.1.2: Socio-demographic characteristics of the study households ...................... 40
4.1.3: Socio-demographic characteristics of the mothers/caregivers ................... 41
4.1.4: Socio-economic and household features of the respondent ....................... 43
4.1.5 Infants and children’s profile ....................................................................... 45
4.2: Knowledge level of mothers and caregivers on complementary feeding ... 46
4.2.1. Maternal knowledge on complementary feeding ....................................... 46
4.2.2 Information on Infant feeding and its source............................................... 46
4.2.3 Mothers/caregivers’ knowledge level on duration, frequency and amount of
food infants and young children are fed .................................................................. 48
4.2.4 Mothers/caregiver’s knowledge on feeding infants and children during
illness .................................................................................................................... 50
4.3 Mothers/caregiver’s complementary feeding practices ................................ 51
4.3.1 Initiating and sustaining breastfeeding practices ......................................... 51
4.3.2 Mothers/caregivers’ WASH practices on complementary feeding ............. 54
4.3.3 Mothers/Caregivers’ feeding practices of ill children ................................. 56
4.3.4 Dietary diversity .......................................................................................... 57
4.4 Effect of nutrition education videos on knowledge and practices on
complementary feeding among mothers of children aged 6 to 23 months in the
two groups ............................................................................................................... 59
CHAPTER FIVE: DISCUSSION ............................................................................. 61
5.1 Demographic and socio-economic characteristics of children and their
caregivers ................................................................................................................ 61
5.2 Mothers/Caregivers’ knowledge on complementary feeding ....................... 63
5.2.1 Information on Infant feeding and its source............................................... 63
5.2.2 Knowledge on Breastfeeding....................................................................... 64
5.2.3 Knowledge on Complementary feeding ...................................................... 65
5.3 Mothers/caregivers’ complementary feeding practices ................................ 66
5.3.1 Initiating and sustaining breastfeeding practices ......................................... 66
5.3.2 Mothers/caregivers’ WASH practices on complementary feeding ............. 67
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5.3.3 Respondents’ practices on feeding during illness........................................ 68

5.3.3.1 Amount of food given to ill children .................................................... 68
5.3.3.2 Amount of food given to children after recovery ................................. 68
5.3.4 Complementary feeding practices ............................................................... 69
5.3.4.1 Introduction of solid, semi-solid and soft foods ................................... 69
5.3.4.2 Minimum Dietary Diversity .................................................................. 69
5.3.4.3 Minimum Meal Frequency ................................................................... 71
5.3.4.4 Minimum Acceptable Diet .................................................................... 71
CHAPTER SIX: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
...................................................................................................................................... 73
6.1 Introduction ........................................................................................................ 73
6.2 Summary of the findings .................................................................................... 73
6.2 Conclusion.......................................................................................................... 77
6.3 Recommendations .............................................................................................. 78
6.3.1 Practice ........................................................................................................ 78
6.3.2 Policy ........................................................................................................... 79
6.3.3 Research....................................................................................................... 79
REFERENCES ........................................................................................................... 80
APPENDICES ............................................................................................................ 90
Appendix A: Summary of data analysis per objective. ............................................ 90
Appendix B: Informed Consent and Introduction Form .......................................... 91
Appendix C: Questionnaire ...................................................................................... 94
Appendix D: Research Approval from Kenyatta University Graduate School ..... 104
Appendix E: Approval from Kenyatta University Ethical Review Committee ..... 105
Appendix F: Research Permit by National Commission for Science, Technology and
Innovation .................................................................................................................. 107
Appendix G: Research Authorization from National Commission for Science,
Technology and Innovation .................................................................................... 108
Appendix H: Ethical Clearance from AMREF ...................................................... 109
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LIST OF TABLES
Table 1: Table of different amounts of food, frequencies, and texture at different ages

of children…………………………..........…...….…………………….…….24

Table 2: Table summary of nutrition education video messages projected ………… 32

Table 4.1: Distribution of participants by household head ………………...….…….41

Table 4.2 Respondent’s socio-demographic characteristics.………………….……. 42

Table 4.3: Respondents’ socio-economic and household characteristics …….….…44

Table 4.4: Source of mother’s/respondents’ information on infant feeding.…....……47

Table 4.5: Respondent’s knowledge on complementary feeding ……………….......49

Table 4.6: Feeding infants and children at recovery….………………………………51

Table 4.7: Initiation of complementary feeding and sustaining breastfeeding ..……..53

Table 4.8: Water, sanitation and hygiene practices by respondents …………….….. 55

Table 4.9: Feeding infants and children during illness ………………………...…… 57

Table 4.10: Minimum meal frequency, dietary diversity and knowledge scores…… 60
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LIST OF FIGURES
Figure 1.1 A conceptual framework of KAP design instrument …..……….….………8

Figure 3.1: Flow chart on the sampling procedure ………….………………………..34

Figure 4.1: Distribution of infant and children’s ages in both groups …..……………45

Figure 4.2: Comparison of hand washing practices in both groups …..……..……… 56

Figure 4.3: Food distribution and consumption Patterns by children …...…..……… 58

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LIST OF ABBREVIATIONS AND ACCRONYMS

APHRC African Population and Health Research Centre

CHW Community Health Workers

FAO Food and Agriculture Organization

IYCF Infant and Young Child Feeding

IYCFP Infant and Young Child Feeding Practices

KDHS Kenya Demographic and Health Survey

KNBS Kenya National Bureau of Statistics

LBW Low Birth Weight

MCN Maternal and Child Nutrition

MCH Maternal and Child Health

MIYCN Maternal Infant and Young Child Nutrition

SDG Sustainable Development Goals

UNICEF United Nations Children’s Fund

WASH Water Sanitation and Hygiene

WHO World Health Organization

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DEFINITION OF TERMS

Complementary feeding- A period during which other foods or liquids are provided

along with breast milk (WHO, 2006b)

Complementary foods – any non-breast milk foods or nutritive liquids that are given

to young children during the period of complementary feeding (WHO, 2006b)

Introduction of solid, semi-solid or soft foods; - proportion of infants 6-8 months of

age who receive solid, semi-solid or soft foods during the previous day (WHO, 2006b)

Maternal knowledge: - Mother’s know-how, information, acuities, and familiarity

with complementary feeding built on the guiding principle of complementary feeding

that is for the breastfed child. (WHO, 2006a)

Minimum acceptable diet – the proportion of lowest dietary diversity attained at the

minimum mealtime frequency during the preceding day (WHO, 2007)

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OPERATIONAL DEFINITION OF TERMS

Adequacy of complementary food- In this study it refers to the capacity of

complementary food to offer satisfactory energy, micronutrients, and protein.

Complementary feeding: For this study, it was the process commencing when breast

milk isn’t sufficient to encounter the nutritive needs of infants and thus other foods, and

liquids are ushered in to the infant, accompanying breast milk at 6 months and above.

Complementary feeding practices: - Here, it encompassed habitual intake of semi-

solid, solid foods, fruits, and vegetables plus foods rich in iron, least dietary diversity,

lowest meal frequency, and all foods done for children aged 6-23 months

Complementary food – In this study it referred to any semi-solid, solid or soft food,

either manufactured or locally made as a complement to the breast milk.

Knowledge; – in this study it referred to the information, skills, awareness or

familiarity gained on complementary feeding for the children of 6-23 months old.

Nutrition Education - It referred to amalgamation of stratagems designed to expedite

voluntary espousal of food selections and other comportments for good health.

Nutrition education videos; - In this study it referred to short clips with various themes

on nutrition matters aimed at influencing and enhancing good health and well-being.

Practices; – In this study it referred to actual application, use or way of putting into

action the activities which are in line with complementary feeding for good health.

Responsive feeding; – Referred to understanding the baby’s language in meal time.

Videos; - In this study it referred to recordings of moving visual images made digitally

with various themes

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ABSTRACT

Optimal feeding of infants depend not solely on what they are fed but also how, when,
where and by whom. Inappropriate feeding practices can cause negative consequences
on the growth, development and a child’s life or survival in future. Data from a number
of countries show that there are lots of efforts to improve child nutrition, but still, there
are significant gaps in complementary feeding. In slum areas, there is an indication of
little success of complementary feeding practices due to limited knowledge and
negative attitudes towards the practice. The purpose of conducting this study was to
explore the effect of using nutrition education videos on the maternal knowledge,
attitudes, and practices on complementary feeding of children 6-23 months of age
attending selected Maternal Child Health facilities in Ruaraka Sub-County, Nairobi
City County Kenya. The study adopted post intervention Cross-sectional analytical
design with control. The study involved an intervention group that watched the short
nutrition video clips on complementary feeding and a control group that did not watch
the videos from a different locality but shared similar characteristics with the
intervention group. The sample size of 80 Mothers from control and 118 mothers from
intervention who had children aged 6-23 months participated in this study. A
researcher-administered questionnaire was expended to collect data which was
afterwards analyzed using SPSS version 21. T-test was wrought to compare
dissimilarities in continuous data amongst the two study groups on the socio-
demographic characteristics, knowledge, attitudes, and practices on complementary
feeding, and percentages were done to test for the effect realized on the study variables.
P value of < 0.05 was expended as the standard for statistical significance.
Most households (83.6% for the control and 92.4% for the intervention) were headed
by males. The mean age of the mothers was 25.3 years (24.8 years for control and 25.9
for intervention group). Most mothers were married (83.8% from control and 89.0%
from the intervention group), Christians (95.0% from control and 99.2% from
intervention), housewives (67.5% from control and 67.8% from the intervention), and
had primary school education (38.0% from the control and 54% from the intervention)
as their highest education level. There was significantly higher proportion of mothers
in the intervention (100%) than in control (51.3%) who had the correct knowledge on
exclusive breastfeeding (P=0.041). Similarly, the most mothers from intervention had
good knowledge on age of initiating complementary feeding (100%) while control
(96.3%) with P=0.021, feeding children from at least 4 food groups (30.0% for control
group and 95.5% for intervention group) with a significant difference in these groups
group (P=0.006). There was also a significant difference on knowledge mean scores
between the control and intervention (P=0.001). A significant difference was found
between intervention and control groups on complementary feeding for children aged
6-23 months (P=0.021) where mother in intervention area had better performance than
the control. Mothers who were in the intervention area had better nutrition knowledge,
and practices as compared to their counterpart, control group. Nutrition messages in the
nutrition videos on Infant and Young Child Feeding Practices were easily understood
by the mothers/caregivers as they watched then in the health facilities thus bring about
behavior change. The use of videos on nutrition education can be of great significance
in reducing knowledge gaps among the mothers and caregivers. The findings can be
used by the Ministry of Health and other stakeholders to guide them in targeting during
their intervention programs. A similar study in the rural set up is highly recommended
for scaling out to communities at risk of poor nutrition indicators.
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CHAPTER ONE: INTRODUCTION

1.1 Background of the study

The triple burden malnutrition is presently persistent in developing countries and

accelerated by poor quality of diets which children are fed (UNICEF, 2019) with under-

nutrition being the major problem with 820 million people undernourished (FAO, 2019

and WFP, 2012). It confers negative consequences on individuals and Populations since it

causes increased health costs, reduced productivity, lagged economic development and

continuous cycle of ill-health and poverty (WHO, 2018). Under-nutrition contributes to

almost half (45%) of all the <5 deaths today (WHO, 2018; UNICEF, 2018). Though the

numbers of undernourished people have fallen from 815 million to 777 million people, still

this is unacceptable since still around 52 million children < 5 years are affected by wasting

(FAO, 2017). Appropriate nutrition is vital for desired growth, and development in children

(Bhutta et al., 2013). Insufficient amounts and eminence of complementary foods coupled

with inappropriate feeding practices increase the rate of infection thus making children

who haven’t attained 2 years of age much susceptible to stunting (White et al., 2017). There

exists inadequate knowledge, inappropriate feeding practices, food insecurity and less

attention to children <5 years due to inadequate advocacy and campaigns (KNBS & ICF

macro, 2015)

Global under-nutrition 820 people are under-nourished with over 22% children < 5 years

still stunted and over 50 million wasted (FAO, 2019). Child undernutrition has been

prevalent in countries with low and middle-incomes thus remaining pervasive and

consequently damaging conditions (Black et al., 2017). Around 2 billion children suffer
 2

from micronutrient deficiencies due to inadequate diet affecting their growth and brain

development, school performance later in life (UNICEF, 2019). Wasting is still a challenge

in the world today whereby 7.3% of children are wasted with 2.4% severely wasted

(UNICEF/WHO/World Bank, 2019). The initial 1000 days of life of children prove to be

a precarious moment for optimal child growth, and development (WHO, 2018). Optimal

feeding of infants depends on what the progenies are fed, how they are fed, when, where,

and who feeds them (UNICEF, 2019). This has not been achieved because there is a need

for more communication platforms which could be used to capacity built the caregivers

and mothers (Obare et al., 2012)

In Africa, particularly in the sub-Saharan region, child under-nutrition remains high with a

drastic decline in nutrition status during the period of complementary feeding (Black et al.,

2013). These rates have brought about increased disease burden hence high mortality levels

(Danaei et al., 2016). The lack of adequate knowledge thus inappropriate infant feeding

practices prove to be major contributor to increased morbidity and mortality among infants

which have also led to increased rates of stunting (White et al., 2017). The interventions

should focus at the period of window of opportunity so as to prevent morbidity and

mortality rates thus avert any long-term harm which may befall infants and young children

(Fabrizio et al., 2014)

In Kenya stunting is at 26% with a proportion of 8% of severe stunting for children aged

18-23 months with Nairobi city county rating at 18% (KNBS & ICF macro, 2015).

Wasting is at 7% for children 6-11 months old in age and underweight at 11% (KNBS &
 3

ICF macro, 2015). Infant mortality is 39% and under-nutrition is 13.67% (KNBS & ICF

macro, 2015). Studies from the informal settlement areas of Nairobi show that for children

under five, 46% are stunted, 11% underweight and 2.5% wasted (Kimani-Murage et al.,

2015). Inadequate knowledge and practice on appropriate breastfeeding plus poor

complementary feeding prove to be the foremost causes of under-nutrition in children

(Olatona et al., 2017). Therefore, there is need for more interventions to enhance

knowledge gain on proper complementary feeding practices which involves; timely

initiation of weaning foods at the age of six months alongside breastfeeding till the age of

2 years, right feeding frequency within a particular age and consuming diverse foods

(Manikam et al., 2017).

To attain optimal complementary feeding, there is a need of establishing education system

to focus on mothers (Ledoux et al., 2016) to change their knowledge, attitudes, and

practices. The existing interventions to address KAP of mothers who have children below

2 years include; face to face nutrition counseling, use of printed posters that are put on the

wall for the mothers to read, use of mother and child clinic booklet and health talks as the

mothers sit awaiting to be served at the maternal and child health clinics. Despite the

interventions, the stunting rates are still high and more interventions are needed to support

the existing ones (Kimani-Murage et al., 2015).

Video learning enhances mastery skills and recall/remembrance which improves an

individual’s knowledge (Ledoux et al., 2016). The use of nutrition education videos in

locally understood language on complementary feeding is likely to be an appropriate

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educational tool for the illiterate mothers attending clinics in these health facilities. They

will serve as a channel of communication which will increase the frequency of contact with

information while increasing memory as more senses (audio-visual) are put in play. These

videos can also be watched elsewhere if they are transferred to a portable device.

1.2 Problem statement with justification

Nutrition is the key factor determining morbidity, and mortality patterns in primary years

of life (UNICEF, 2019). High levels of under-nutrition have been documented in emerging

countries especially Sub-Saharan Africa which has detrimental implications to child

survival (Kimani‐Murage et al., 2015). Adequate breastfeeding and complementary

feeding combined with good hygiene and sanitation will enhance Infant and Young Child’s

survival (De Onis & Branca, 2016). Poor awareness on adequate nutrition is a key factor

behind unfavorable practices that cause under-nutrition (Mahmood et al., 2012). For

instance, in Kenya 51% of children who are still breastfeed up to 20-23 months, and only

21% consume appropriate complementary diet (KNBS & ICF macro, 2015).

Despite the interventions in place, appropriate complementary feeding has not been

achieved (Ledoux et al., 2013). Some of the interventions to improve complementary

feeding that have been put in place in Kenya include; national operation guidelines for

health workers, policy for Maternal Infant and Young Child Nutrition and information in

mother and child clinic booklet for the mothers to read and gain knowledge on

complementary feeding. There is still a challenge of optimal communication of the

messages in these documents to the mothers to improve their knowledge (Ledoux et al.,
 5

2013; UNICEF, 2019). Children from mothers who had no education have 10% higher

chances of malnutrition like wasting (KNBS & ICF macro, 2015).

Additionally, the high turn up at the Maternal Child Health clinics may not allow for

adequate time for face to face education by the health care workers who are more often

overwhelmed by the numbers of the patients whom they attend to per day. Complementary

feeding practices are still poor since only 21% of children are fed appropriately (KNBS &

ICF macro, 2015) despite all the interventions in place. Consequently, this has led to poor

health, growth and development among children which if not addressed, will contribute to

high morbidity and mortality rates, and low performance in future. This will pose a

challenge to the achievement of SDG 3 and SDG 4 which aims at; warranting healthy living

and enhancing good fortune of all people in all years and safeguarding inclusive, equitable

and excellent education which promote life-time learning chances for all respectively.

Therefore, there is need for introduction of additional interventions that can improve

Knowledge Attitude and Practices in complementary feeding practices for mothers with

children aged 6-23 months that would be suitable to those with low education level in

languages easily understood by high coverage.

1.3 Purpose of the study

The purpose of this study was to determine the effect of using nutrition education videos

on the mother’s knowledge, attitude and practices on complementary feeding of children

aged 6-23 months attending the selected MCH clinics in Ruaraka Sub-County.
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1.4 Objectives of the study

1. To establish the socio-economic and demographic characteristics of mothers with

children aged 6-23 months who were attending selected MCH clinics, in

intervention and control health facilities, in Ruaraka Sub-county.

2. To assess the knowledge levels of mothers on complementary feeding of children

aged 6-23 months attending selected MCH clinics intervention and control health

facilities, in Ruaraka Sub-county.

3. To establish the practices of mothers on complementary feeding of children aged

6-23 months attending selected MCH clinics, at both the intervention and control

health facilities, in Ruaraka Sub- county.

4. To determine the effect of the nutrition education videos on mothers’ knowledge

and practices on complementary feeding of children 6-23 months attending selected

MCH clinics in Ruaraka Sub-county.

1.5 Research hypotheses

Ho1: There is no significant difference in socio-demographic characteristics of mothers with

children 6-23 months of age between the intervention and control health facilities.

Ho2: There is no significant difference in knowledge on complimentary feeding of children

6-23 months between mothers in intervention and control health facilities.

H03: There is no significant difference in complementary feeding practices of children 6-23

months between mothers in intervention and control health facilities.

1.6 Significance of this study

It is projected that these results will provide the Ministry of Health and other stakeholders

with information to guide interventions that can be put in place to enrich mother and young
 7

child feeding (MYCF) practices. The findings will be useful to nutrition care providers in

similar settings in that the model can be used to complement counseling cards for educating

the mothers on young child nutrition. The findings will equally add to the field of

knowledge on nutrition education intervention programs concerning maternal, infant, and

young child nutrition (MIYCN) for enhanced knowledge, attitude and practices on young

child feeding by care givers.

1.7 Delimitation of this study

This was conducted in selected MCH clinics in the informal settlement of Ruaraka Sub-

county only. Therefore, these results can be generalized only to other areas with same

characteristics.

1.8 Limitation of this study

This being a post intervention cross-sectional study with control, the findings are not

compared to any baseline data hence the effect of the videos may not be measured with

certainty.

1.9 Assumption of this study

It was anticipated that the socio-economic and socio-demographic features in both the

control and intervention study groups could remain the same throughout the study. This

was affirmed after the analysis since it was noted that the characteristics did not change. In

this study design, the control group is assumed to be like the baseline whose data was

compared with the one from the intervention group then compared to establish if there was

any difference between the two groups. The difference in knowledge and practices realized

is attributed to the intervention.

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1.10 Conceptual framework

Bennett’s hierarchy model (1976) has been used to evaluate the extension and success of a

project. The framework is sequential and has various steps such as inputs/participation,

reaction, knowledge, skills and opinions. The aim of the hierarchy is to show the

consequence realized upon something when an external agent is exerted on it.

The effect hierarchy model has been used in evaluating the basic principles for impact and

it was also applied in this study. Before the assessment, key indicators were identified for

this study which were; knowledge, practices and the effect which could be realized if they

are measured and analyzed as explained in the data analysis section (Bennett’s 1976). The

effect is attributed to the influence of the intervention i.e. the use of nutrition education

videos on complementary feeding (Figure 1).

Intervening Variable Extraneous Variable and Independent Variable

dependent Variable
Socio-economic and
Socio-demographic
characteristics
Nutrition education
video messages on Improved maternal
complementary practices on
feeding complementary feeding

Maternal knowledge of
complementary feeding

Figure 1. A conceptual framework of KAP design instrument showing how nutrition

education video messages can influence the mother’s knowledge, attitudes and practices
on complementary feeding.
Source: Adopted and modified from Bennett’s change hierarchy model (Bennett’s 1976).
 9

From the above conceptual framework, the study aimed at evaluating the effect of the

intervention, use of nutrition education videos to change the maternal knowledge, attitudes

and practices on complementary feeding for children aged 6-23 months through the

nutrition education messages projected by the video clips in the televisions which were

installed in the selected Health facilities. The dependent variable was maternal knowledge

and attitude, extraneous variable being the mothers’ or caregivers’ socio-economic and

socio-demographic characteristics. Complementary feeding practices was the independent

variable.

The findings of the link and interactions between the above variables is clearly explained

and expounded in the results section of this study. There are various components which

build or comprise of the variables mentioned above bringing out clearly the gaps existing

in each component as shown in the following chapter of literature review.

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CHAPTER TWO: LITERATURE REVIEW

2.1 Factors associated with complementary feeding

2.1.1 Socio-Demographic Characteristics and Complementary Feeding

Complementary feeding is influenced by; - the mothers’ education level especially the ones

with little education are more likely to introduce complementary foods too early

(Wijndaele et al.,2009). High literacy among mothers is directly proportional to timely

initiation of complementary foods for nurslings, and young children (Rao, 2011). Gebru

(2007) established that the employed mommies are more likely to start complementary

foods prior to 6 months unlike the unemployed ones. The inappropriate practice of

complementary feeding among this population is due to inadequate information which is

mostly brought by inadequate method of communication (Mucheru et al., 2016). Studies

have shown that behavior change communication targeting especially young, single and

illiterate mothers or caregivers in the developing countries will reduce morbidity and

mortality rates in a great way (Olatona et al., 2017).

Most mothers in households which have poor feeding practices tend to be associated with

large family size (Jansen et al., 2015) which is mostly attributed to inadequate knowledge

on child spacing in developing countries (Fabrizio et al., 2014). Married mothers tend to

have positive attitudes consequently practice on complementary feeding compared to their

counterparts because of the support they get from their partners (Kimani-Murage et al.,

2011). The informal settlements have a majority of young mothers who are inexperienced

in child feeding due to inadequate information and poor attitude which results to improper

practice of Infant and Young child feeding practices (Bahl et al., 2009). Therefore, there is
 11

a need of establishing another method of communicating messages on Infant and Young

Child Feeding to these mothers as Haider et al. (2010) shows that it can improve the

knowledge and practice which is also an indication of an improved attitude.

In Kenya, according to Kimani-Murage et al. (2011) who did a research in Nairobi informal

settlements to establish the determinants of child feeding practices found that unmarried

women practiced too early initiation of complementary foods than their married

counterparts. According to Roy (2009), urban slum children below 6 months were initiated

to complementary foods owing to apparently insufficient breast milk by their mothers. This

concurred with the study which was done in Kibera slums in Nairobi, Kenya.

2.1.2 Socio-Economic Characteristics and Complementary feeding

According to Mucheru et al. (2016), maternal education, employment/unemployment and

occupation directly relate to complementary feeding. This concurred with the studies which

were done nationally in Kenya that showed that educated mothers had better child feeding

practices compared to the illiterate (KNBS & ICF macro, 2015). There is low or high

adherence to good feeding practices of Infant and Young children among mothers

depending on the occupation of the household head, the mother and how the family income

is handled in matters of good in a household (Engebretsen et al., 2007).

Many households in the informal settlements do not allocated income for food due to

inadequate knowledge, unemployment among the majority and large families (Mututho,

2012; Korir, 2013; Kimani-murage 2015 and Black et al., 2013). Therefore, to improve the

complementary feeding practices, there is a need of coming up with an educational

 12

intervention (Bhandari et al., 2004) to supplement the existing methods geared towards

improving the maternal knowledge and attitudes for better practices.

2.1.3 Water, Sanitation and Hygiene and Complementary Feeding

Water is an important element in the body of children (UNICEF, 2019) since they are

mostly prone to childhood infections which manifest high fevers leading to dehydration

(WHO, 2019). Mothers who continue breastfeeding after 6 months, their children had far

much better weight for height standard deviation than their counterpart (Srivastava, 2006;

Magarey et al., 2015). Cultural practices have been a great hindrance to proper water,

sanitation and hygiene practices and this can be made better through proper communication

with an aim of improving the maternal knowledge and probably practice on complementary

feeding (Fabrizio et al., 2014).

In the informal settlements, studies show that there is a need of additional methods which

can be used in complementary feeding messaging to improve the knowledge of mothers

and other members of the community in a simplest manner they can understand (Abuya et

al., 2012). Inadequate observation of hygiene and sanitation in the introduction of

complementary feeding due to inadequate knowledge has led to increased undernutrition

especially stunting in the developing countries (Danaei et al., 2016). Therefore, well

packaged messages on water, sanitation and hygiene should be put in place for a successful

complementary feeding since according to Magarey et al. (2015), the mode of handling the

Infant and Young Children will be greatly influenced by the knowledge borne by the

mothers or the caregivers.

 13

Substantial evidence have shown that behavior change can be achieved to better up water,

sanitation, and hygiene practices in various households through using a good channel of

passing information (Fabrizio et al., 2014). An intervention using video education to

promote appropriate feeding practices by Bhandari, (2004) showed an improvement in

physical growth of infants. Similar studies done by Madise (1991) in Botswana found that

children initiated to complementary feeding at the age of 4 months or younger experienced

more than 11 episodes of diarrhea compared to those exclusively breastfed for 6 months

before introduction of complementary foods.

2.2.0 Maternal Knowledge and Complementary Feeding

2.2.1 Understanding the Role of Appropriate Infant Feeding for their Growth
The most desirable global goal is to reduce infant and young child malnutrition through

appropriate infant feeding (Olatona et al., 2017). Estimates show that the worldwide load

of malnutrition for the under-fives is 149 million children being stunted, 146 million

underweight and 49 million children wasted (WHO, 2018; Mukuria et al., 2016). Linear

growth for all healthful children in the world since birth till 5 years have similar features

worldwide (Aguayo, 2017).

According to the causal matrix of under-nutrition (UNICEF, 2014) the major underlying

factor of malnutrition is the care given to infants and young children. Childhood nutrition

deficiencies in the early age of children leading to impaired growth is not only detrimental

in academic abilities of children but also diminished capacity of earning in future (Fabrizio

et al., 2014). One of the key care practices that has a significant consequence in a child’s

growth, and development is complementary feeding (Aguayo, 2017). There should be

 14

sustained breastfeeding alongside complementary feeding up to 2 years for children since

it is very important for their growth and development (Olatona et al., 2017).

Appropriate practice of complementary feeding could avert up to 6% of child’s mortality

per year (White et al., 2017). Mothers and care givers from poor resource settings have

been noted to have inappropriate infant feeding practices (Dewey, 2016) due to inadequate

knowledge which has affected the growth, and development of infant, and young children

who come from those areas. Thus, there is much need of improving maternal knowledge

on the complementary feeding in order to realize good health and nutrition outcomes

among infant and young children (Yohannes et al., 2018). Additional methods and

approaches can be used to relay information thus equip the mothers and caregivers with

adequate knowledge on complementary feeding.

2.2.2 Initiation of Complementary Feeding

Globally, infant, and young child feeding guidelines commend that there be timely

initiation of diverse complementary foods to bridge the nutrient gap that is created as a

child grows (WHO, 2018). Timely initiation of complementary foods is vital for better

growth, and development in infants (Manikam et al., 2017). Introduction of complementary

foods before the required time is hazardous to children and can make them very much

susceptible to diseases (White et al., 2017). Unfortunately, most mothers introduce

complementary foods early compared to those who introduce late due to inadequate

knowledge (Yohannes et al., 2018).

 15

Improved complementary feeding habits forecast better rectilinear growth results for

children especially before attaining the age of 2 years (Aguayo, 2017). This should begin

at 6 months of infants and go alongside with breastfeeding (Williams et al., 2016). Most

studies done in different African countries such as in Uganda (Engebretsen et al., 2007),

Ethiopia (Agedew & Demissie, 2014), South Africa (Mamabolo et al., 2004) and Kenya

(KNBS & ICF macro, 2009) report that majority of the children are initiated into

complementary feeding before attaining the age of 6 months. Gebru (2007) indicated that

children are given complementary foods at 4 months old since most mothers and caregivers

lack adequate knowledge.

Poor transition from exclusive breastfeeding to complementary feeding has been associated

with high risk of children not realizing their full potentiality in future life due to high

mortality rates (Manikam et al., 2017). Globally, only 64.5% of infants who are aged 6-8

months are fed with solid, soft, and semisolid foods according to WHO recommendations

(White et al., 2017) which also indicate little consumption of a balanced diet since children

from most households’ are fed on the staple foods.

In informal settlements like in Nairobi, 63.1% of infants are fed on complementary foods

earlier before attaining the age of 6 months because of inadequate knowledge and low

education levels among the mothers or caregivers (Muchina, 2010). This implies that

infants are exposed to gastrointestinal complications in tender age leading to diarrhea,

impaired nutrition status and increased morbidity and mortality rates (KDHS, 2014). There

have been many interventions to improve complementary feeding among infants and young
 16

children but nothing much has changed (Aguayo, 2017); still there exist gaps on knowledge

thus influencing practice negatively.

Therefore, from the studies shown above there is a need to enrich the existing methods of

complementary feeding messaging with other methods which are simpler and context

based to capacity built the mothers and caregivers on complementary feeding.

2.2.3 Complementary Foods and Dietary Diversity

There should be diversification of complementary foods (Williams et al., 2016) when

feeding infants and young children. This maintains micro-nutrient and macronutrient

adequacy within the frame of complementary foods (Nankumbi et al., 2012). Keen

observation of dietary diversity leads to reduced risks of underweight, stunting, and

wasting among children (Bhutta et al., 2013).

It has been found that the level of maternal education has a great influence on

complementary feeding practices (Manikam et al., 2017). The period between birth to age

2 years is marked with much nutrient deficiencies which interferes with the child’s optimal

growth and development (KDHS, 2014). Between the age of 6-9 months rarely do infants

meet minimum dietary diversity but between 9 to 23 months they perform above average

(Olatona et al., 2017). Therefore, it’s important for the mothers and caregivers to utilize

postnatal care to gain appropriate knowledge which can lead to improved complementary

feeding practices (Yohannes et al., 2018).

 17

Children 6-23 months should feed from 4 food groups minimally out of the 7 commended

foods (WHO, 2018) for proper growth and development. These food groups entail the

following: Grains, roots and tubers, legumes and nuts, dairy products, flesh foods, eggs,

Vitamin A-rich fruits and vegetables and other fruits and vegetables. A study done in

Mongolio found that most children consumed < 2 food groups (Lander et al., 2005). In

some areas like Mwingi district, Eastern Kenya, about 60% of children consumed starchy

staples and oils (Macharia et al., 2010) both of which are associated with mothers and care

givers having inadequate knowledge on child feeding.

Therefore, there is a need for additional awareness creation methods for instance the use

of audio-visual methods, Information Education and Communication materials or any

other method which is targeting behavior change for betterment of dietary diversity during

complementary feeding among mothers and caregivers.

2.2.4 Complementary Feeding and Meal frequency

Lowest possible meal frequency is the fraction of progenies aged 6 to 23 months old who

take soft, semisolid, and solid foods (but comprising milk foods/products also for non-

breastfed children) in the minimum number of times recommended by WHO (WHO,

2008). This is clearly shown that the number of times an infant, and young child is to be

fed depends on the age of the child: 2 times for the age of 6-8 months for the breastfed

infants, 3 times for 9-23 months for the breastfed children and 4 times for those children

who are between 6 to 23 months old (WHO, 2008). These meals comprise of main foods

given to children and also the snacks (other than frivolous amounts).
 18

Studies done in Brazil, Romulus-Nieuwelink et al. (2011), among breastfed infants aged 8

months showed that children were fed well and met the recommended lowest possible meal

frequency of 3 times each day. This study was also in agreement with the other one which

was done in Burkina Faso, Sawadogo et al. (2011) which focused on examining the time

of initiation of complementary food, and the dietary diversity which found out that infants

received 2 meals each day at 9 months and 3 meals each day for those who were 12 months

old of age.

In Kenya, children are not fully fed in the needed number of times more especially in the

poor resource setting areas (KDHS, 2014). It was clearly found that children from mothers

who had no education had greater chances of wasting, precisely 10%, than those whose

mothers had received some education (KDHS, 2014). Equipping mothers and caregivers

with specific information and messages like meal frequency requirements for the infants

and young children may improve complementary feeding practices (Yohannes et al., 2018).

Therefore, from the findings discussed above, this calls for raising awareness to mothers

and caregivers to improve their maternal knowledge and practice on meal frequencies

which are appropriate for the infants and young children so as to curb the rising rates of

malnutrition among infants and young children (Manikam et al., 2017)

 19

2.2.5 Complementary Feeding and Minimum Acceptable Diet

There exists a positive relationship between complementary feeding and the nutrition

wellbeing of children (Kimwele, 2014). Unattained lowest possible acceptable diet is a

predictor of wasting for children aged 6 to 23 months of age (Korir, 2013). Studies show

that the shift of food consumption by humans from traditional foods to fast foods like soft

drinks, and cookies has also made the feeding practices for children to change (Caetano et

al., 2010).

There might be consumption and meeting of minimum acceptable diet but on the other

hand consuming less healthy foods in large amounts (Korir, 2013). There is poor

consumption of minimally acceptable diet especially in the low-income earners like in the

slum areas because of low purchasing power by its residents (White et al., 2017).

In Kenya, only 2 in ten children (21%) aged 6 to 23 months are fed correctly and meets the

lowest possible acceptable diet (KNBS & ICF macro, 2015). There is better meeting of the

minimum required diet between the ages 12 to 17 months, 24%, and worst is between 6-8

months which indicate 17% of children who are fed with minimum acceptable diet (KNBS

& ICF macro, 2015). These findings agree with the study which was done in Indonesia by

Ahmad et al. (2018) which also found out that minimum acceptable diet was below

average, 40% among the mothers with children aged 6 to 23 months.

Therefore, to curb the suboptimal complementary feeding which consequently affect the

minimum acceptable diet among children aged 6-23 months, there is great need of
 20

equipping and enlightening child bearing mothers with appropriate messages on how to

feed children so as to heighten infant and young child feeding practices and meet minimum

acceptable diet (Ahmad et al., 2018; Yohannes et al., 2018)

2.2.6 Complementary feeding frequency with continued breastfeeding

There should be promotion and support of foods for age-appropriate so as to make the

practice of complementary feeding successful (Aguayo, 2017). The way children are

transited to complementary foods and the feeding experience they encounter isn’t only

crucial for their immediate survival, growth, and development but also for their potentiality

in future life (White et al., 2017). Most mothers and caregivers have inadequate knowledge

thus low knowledge on carrying out the transition process to complementary feeding and

that is why there is still high rates of malnutrition among children who are Under Five

years (Bhutta et al., 2013).

Complementary foods should be given in various frequencies depending on the age of

children: 2 times for those children who are breastfed and aged 6-8 months, 3 times for

breastfed children with ages 9-23 months and for the children aged 9-23 months and are

not breastfed, should be fed at least 4 times (WHO, 2010). Though meeting the nutritional

needs through appropriate complementary feeding in a poor resource setting is a challenge,

due to knowledge inadequacies which in turn impact negatively on practice, leading to high

malnutrition rates and hindrance to proper development in early childhood (Dewey, 2016),

much advocacy can be done to boost the mothers’ and caregivers’ knowledge hence
 21

influencing their practice (Aguayo, 2017). This could lead to behavior change and reduced

child morbidity and mortality rates.

In Kenya, the national data shows that the percentages; 72.5%, 65.0%, 60.7% and 57.7%

of children are fed the lowest possible recommended times or more for 6-8, 9-11, 12-17

and 18-23 ages respectively (KNBS & ICF macro, 2010). The period between birth and 2

years is marked with much nutrient deficiencies which interferes with the child’s optimal

growth and development (Fabrizio et al., 2014). This occurs as a result of poor practices

on complementary feeding among the caregivers and mothers because of inadequate

knowledge on complementary feeding. Along the complementary foods, infants, and

young children are to be breastfed till the age of at least 2 years (Ricci & Caffarelli, 2016).

The need for more advocacies among mothers to elevate their knowledge is needed which

will in turn enable them feed their infants and young children as expected to attain better

growth and development (Aguayo, 2017).

If good methods are used to campaign against malnutrition, there will be a great change in

people’s way of life leading to better nutrition among children (Fabrizio et al., 2014).

Insufficient amounts coupled with poor quality of complementary foods and inappropriate

feeding practices threatens children’s health, and nutrition (Bhutta et al., 2013). As a child

grows, there is an increased need of nutrients by the body for full growth and development

(Sayed & Schönfeldt, 2018). This knowledge need to be shared with the mothers and

caregivers so as to enable them practice appropriate infant and young child feeding

practices.
 22

2.2.7 Maternal Practice and Complementary Feeding

Even though there have been much efforts to promote good practices on complementary

feeding, there has been low uptake (Mutiso et al., 2018). It is a common practice for early

introduction of complementary foods among the infants (Sayed & Schönfeldt, 2018). In

Kenya, the percentage of children breastfeeding up to 20 to 23 months old is 51%. It is

further shown that 21% of progenies of age 6 to 23 months old consume appropriate diet

(KNBS & ICF macro, 2015).

Therefore, there is need for increasing awareness on continuous breastfeeding with

appropriate complementary feeding to enhance the nutrition status of children. Studies

illustrate that improved infant, and child care activities are likely to reduce deaths of under-

fives by 19 % in those countries which have high mortality rates (Agedew & Demissie

2014).

2.2.8 Handling, Preparation and storage of complementary foods

Globally, the objective of preventing and controlling diseases also targets on improving

how food is prepared and stored more especially for the infants and young children (Quick

et al., 2015). Inadequate knowledge and poor attitude coupled with cultural practices have

contributed to great hindrance to complementary feeding in some communities especially

in developing countries more especially on food preparation and storage (Fabrizio et al.,

2014). To alleviate such challenges, there is a need of nutrition education so as to provide

relevant knowledge that can empower mothers and caregivers to enhance behavior change
 23

(White et al., 2017). Safe preparation, storage, and serving of complementary food for the

infants, and young children is as important as the food itself (Manikam et al., 2017).

The caregiver should wash her or his hands before preparing food and feeding the infants

and young children. Food should be stored under good hygienic conditions and served

immediately after preparation (WHO, 2012). Mostly, complementary foods at the initiation

point to the infants are of low energy, and micronutrients, unhygienic prepared, and stored

leading to exposure of children to infections that lead to diarrhea, thus resulting to growth

faltering. Educating mothers and caregivers on appropriate preparation and storage of

complementary foods should be major areas to train and educate mothers (Savalia et al.,

2013) so as to achieve the required behavior change.

2.2.9 Feeding during and after illness

Children should continue breastfeeding more and be fed during illness and giving them

extra food after the illness (UNICEF, 2014). The infant should be well fed with fluids at

this period because of exposure to much dehydration due to increased fever. In these fluids,

water should take a large portion since it is neutral (Gessese et al., 2014) and can efficiently

restore the lost water that might have been experienced. Most mothers and caregivers in

the informal settlements do not feed their children adequately during illness due to

inadequate knowledge on feeding the under 5 years’ children during illness (White et al.,

2017)
 24

The amounts of foods per meal, the age, texture and frequency can be summarized as in

the table below:

Table 1: Different amounts of food, frequencies and texture at different ages of children.

Age Texture Frequency Amounts of

food per meal
6 Infant to be started with Should be fed 2 times a day Should be
Months small amounts and with frequent breast milk given 2
consistencies and tablespoon and
increase as the child increase as the
grows older child grows
7-8 The infant should be Should be fed 3 times a day Should be
months started with thick porridge with a snack and frequent given 2-3
& well mashed family breast milk depending on his spoonful per
foods. or her appetite. feed with
gradual
Snacks can be given too (1-2) increment to
half 250ml cup
9-11 Should be given finely This should be 3 meals on top Give ¾ cup of
months chopped foods that the of the breast milk dependent of food per meal
baby can pick the appetite of the baby of family food
1 snacks can be given
12-23 The child should be given 3 meals should be given on top 1 cup (250ml)
months the family food and if of breastfeeding depending on cup should be
need be, it can be chopped the appetite of the child. given.
or mashed. 2 snacks can be given

Table 1: Adopted from WHO (2008), Infant and Young Child Feeding Counseling Guide
 25

2.3 Effect of nutrition education video lessons on knowledge, attitude and practices of

mothers on complementary feeding.

The strongest determinants of good child nutrition are education and nutritional knowledge

(Abuya et al., 2012). Caregivers lack up-to-date knowledge on optimal feeding especially

infant and young children during complementary period (Mukuria et al., 2016). According

to Kumar et al. (2006), Inadequate knowledge on the appropriate complementary feeding

is an important risk aspect for stunting, wasting and underweight. When mothers and

caregivers keenly observe dietary timely initiation, dietary diversity, good meal regularity

and lowest possible acceptable diet, there will be decreased risks of underweight, stunting,

and wasting (White et al., 2017).

Therefore, there is a need of more nutrition education approaches to enhance behavior

change (White et al., 2017). Behavior change interventions have been used largely and

noted to have a vital role in improving complementary feeding practices thus leading to

improved children’s growth and development (Fabrizio et al., 2014). The target of nutrition

education is to change the behavior and perceptions (Welch & Sheridan, 2000).

Social cognitive theory is very much useful in this aspect since it depicts a person’s self-

efficacy and the expected outcome (Bandura, 2004). The use of video education to modify

health behaviors is the best than many other education forms (Tuong et al., 2014). It has

also been noted that the use of videos as a method of education serves as cost-effective

where people can just observe what other people have acted (Sirota & Hamez, 2013). To
 26

a great extent, educational videos have been found to be the most effective tool in changing

maternal knowledge and practices on complementary feeding (Scheimann et al., 2010).

2.4 Summary of literature review

This chapter gives the review of the literature which are on line with the study objectives

that lead to the realization of the main purpose of the whole study which is to establish the

effect of using nutrition education videos to improve maternal and caregiver’s knowledge

on complementary foods in Ruaraka sub-county, Nairobi city county. Appropriate

complementary feeding practices can bring a great change by impacting positively on

maternal and caregiver’s attitude and practices on complementary feeding for the children

under 5 years.

Mothers need to learn, understand and prevent the problem of nutritional inadequacy of

complementary foods quality-wise and quantity-wise which is the major crisis in the

developing countries today. Even though there are a number of strategies put in place to

improve complementary feeding in Kenya, complementary feeding practice is still very

poor with many children receiving complementary foods very early below the

recommended, 6 months, by WHO. A review of the literature has revealed that there is

little achievement in sharing information on complementary feeding practices to mothers

with children 6-23 and particularly in Kenya. There is little literature on the use of nutrition

education videos on capacity building the mothers and caregivers on complementary

feeding in Kenya.
 27

Therefore, this study addresses the maternal and caregivers’ knowledge, attitude gaps

which will also affect their practice on complementary feeding of children Under 5 years

in the informal settlements of Ruaraka sub-county in Nairobi City county. The findings of

the study will complement other ongoing interventions to ensure optimum complementary

feeding that will improve child health and nutrition status.

 28

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Research design

Post intervention cross-sectional analytical design with control was employed in the study.

This is applicable for comparison of any two groups, with intervention group and control

group, under conditions in which the two groups are of similar characteristics such that any

change in the intervention group is attributed to the effect of the intervention. For this study,

the control group was taken as baseline then compared with the intervention group

(Kothari, 2004). In the study, information about the mothers’ and caregivers’ knowledge

on complementary feeding was assessed both in intervention and control group and then

compared to establish any difference that could be realized.

3.2 Research variables

3.2.1 Dependent variable

In this study, the dependent variable was maternal knowledge on complementary feeding.

The analysis was done as shown in Appendix A

3.2.2 Independent variable

The independent variable was complementary feeding practices. The analysis was done as

shown in Appendix A

3.2.3 Extraneous variables

The extraneous variable in the study was the socio-demographic and economic features of

the study population. The analysis was done as shown in Appendix A

3.2.4 Intervening Variable

The intervening variable for this study was the nutrition education video clips which were

projected in the selected intervention health facilities

 29

3.3 Study location

This research was conducted in Mathare slums in Ruaraka sub-county, Nairobi City

County. This informal settlement had an approximate population of 180, 000 people

(KNBS, 2009). The study focused the 4selected Health Centers. The two intervention

health centers which were; Mathare North Health Center and Baba Dogo Health Center.

The other two which were the control health centers were Korogocho and Kahawa West

Health centers. The health centers were selected based on the high numbers of their

catchment populations compared to other health centers which were near them. The two

control health facilities were selected outside the area of intervention so as to avoid

proximity that could lead to cross contamination. From the baseline data, both intervention

and control groups had similar characteristics. This area was picked because previous

studies had shown that most infants and young children were probably exposed to

inappropriate complementary feeding due to sub-optimal living conditions (Kimwele

2014; Korir, 2013; Kimani-Murage et al., 2011 & Mutua et al., 2007).

3.4 Target population

The study targeted mothers of children 6-23 months of age who sought health services

from Mathare North, Baba-dogo, Korogocho and Kahawa West health centers. Mathare

North and Baba Dogo health centers were having short clips of nutrition messages which

they watched at least 4 months prior to the study. After the intervention period had expired,

same questionnaire was administered to both the intervention and the control group to get

the information on complementary feeding and related issues for children aged 6-23

months.
 30

3.4.1 Inclusion criteria

The study interviewed mothers of children 6-23 months of age who attended the selected

health facilities for at least 4 months preceding the study. This was ensured by having the

mothers being recruited and listed in a booklet which was kept in the MCH. Consent to

participate was sought from the participants before taking part in the study.

3.4.2 Exclusion criteria

The eligible mothers who declined to consent were not included in the study. Additionally,

the study was to exclude mothers and caregivers who had hearing and sight impairments.

Though they were not there in this study.

3.5 Intervention procedures

3.5.1 Brief background of the project

GloCal (Global issues in loCal context) was a nutrition and health project of the University

of Helsinki, Finland. In Kenya, collaboration with MOH and UNICEF Kenya was done to

produce a set GloCal videos used in this project. The GloCal project aimed at improving

mother’s knowledge, attitude and practices on maternal nutrition, breastfeeding and

complementary feeding through the use of simple videos and animations. These short

attractive videos were tested by the Ministry of Health in Kenya before they were used in

the intervention Health facilities. The short attractive video clips contained messages in

form of short stories which were based on real life situations. The content was in line with

WHO recommendations, Kenya National Maternal, Infant and Young Child strategy 2012-

2017 and the Maternal, Infant and Young Child Nutrition Policy. These narrations could

be in any language, but for this project Swahili language was adopted because it is
 31

commonly used in Nairobi more especially in the slum area (study area). The intervention

described in this report was carried out in collaboration with the University of Helsinki and

Kenyatta University. This project was anticipated to contribute to the achievement of the

Kenya Country Specific Health Action Plans in Vision 2030 and Sustainable Development

Goals (SDGs).

3.5.2 Procedures of video projection

The videos were shown for 6 months on the TV screens at two intervention centers of the

study area which were; - Mathare North Health Center and Babadogo Health Center.

During the intervention period mothers would watch the videos while waiting to be served.

In addition, they were able to participate in health talks organized twice a week at the

facility. At the end of the intervention period - 6 months, KAP survey was carried out both

in the intervention centers and the control centers. For this study, there was a little

difference from the usual KAP surveys since it focused on comparing if there was any

effect on knowledge and practices in the intervention group as compared to the control

group. Control health facilities had all other programs offered by the MOH except the

videos, but was assessed on same KAP as the intervention.

3.5.3 Nutrition messages of the videos

The videos that were projected had a variety of nutrition messages. They had education

lessons on nutrition during pregnancy, breastfeeding, and complementary feeding. They

also had messages on water, sanitation and hygiene.

 32

For this study, Table 2 shows a summary of the messages that were projected which were

in line with the WHO recommended complementary feeding practices.

Table 2: Summary of Nutrition Education video messages projected at the MCH clinics

on complementary feeding practices.

No. Age Topic Key points

(Months)
1 6-8 Texture Starts with soft foods (Mashed)
Frequency 2-3 meals per day
Support The child is entirely supported in eating by the
caregiver
Breastfeeding Should be breastfeed before meal
2 9-11 Texture Slightly solid foods (cubes)
Frequency 3-4 meals per day
Support Supported by the mother though tries to pick the
Breastfeeding food
Should continue breastfeeding
3. 12-23 Texture Family food; whole foods and can be chewed
Frequency 3-4 meals per day
Support Supports him/herself though needs to be monitored
Breastfeeding Should continue breastfeeding
4. 6-23 Dietary The child should consume food from 4 or more out
diversity of the 7 food groups to be termed as acceptable
5. 6-23 Other The food should be cooked and stored in a clean
Practices environment
Hygiene & The child should continue breastfeeding and eating
sanitation Should also be given much fluids
Illnesses The child should be encouraged to eat

3.6.0 Sampling procedures

3.6.1 Sample size determination

The sample size for this study was 200 mother-child pairs who had 6-23 months old

children. This was calculated using a formula by Yamane (1967). These were the ones who

were to be interviewed – sample size. This is calculated as:

 33

n = N
1 + N (e)²

= 400
1 + 400 (0.05)²

= 200 Mothers with children 6-23 months

Where: N = Estimated population (being served – 400 Mothers)

n = Sample size

e = Level of precision (0.05)

From the above scheme, four health facilities with high catchment population in the sub-

county were selected for this study. Two of them were control facilities and the other two

were intervention. Both control and intervention health centers were selected based on: the

findings and recommendations from previous research (Korir 2013; Kimwele 2014 &

Kimani-Murage 2011). Each health facility’s number of respondents was arrived at

proportionately to the catchment population; the number of people each health facility

serves. Mothers who had children aged 6 to 23 months and selected from these health

facilities were not the same because each health facility had different target as per their

catchment population. The eligible mothers were randomly and systematically selected

from the sample frame made at the health facilities by the Glocal project and then a

questionnaire administered to them.

 34

3.6.2 Sampling technique

Nairobi slums
Purposive
(Ruaraka Sub-County)
sampling

2 Health centers (Intervention) 2 Health centers (Control) Purposive

sampling

Babadogo Mathare Kahawa Korogocho

Purposive
Health North West Health Health
sampling
center Health center center
center

Systematic
60 mothers 50 mothers 30 mothers random
60 mothers
sampling

Total number of mothers = 200 sample size

Figure 3.1: Flow chart on the sampling procedure

Ruaraka Sub-county in Nairobi City County was purposively selected as opposed to other

sub-counties with slums because of the recommendations from previous studies conducted

there on complementary feeding. The health centers were also purposively selected

because from the studies, there was a clear observation that the area had high malnutrition

levels thus recommendations made for more studies to be done. These health facilities in

the sub-county also serve proportionately higher population in their catchment areas

compared to other health facilities in the sub-county.

 35

Mothers who had children 6 to 23 months old were recruited in these health facilities and

their records kept in the MCH. This list formed a sample frame that was used for the study

in the intervention group. In the control group, mothers of children aged 6 – 23 months

were identified, a sample frame developed then a sampling interval was calculated. The

first respondent was randomly selected and the rest of the respondents were systematically

selected from the sample frame in the health facilities until the sample size was realized.

3.7 Research team

3.7.1 Recruitment of research assistants

Four Research assistants were recruited each with at least a Bachelor’s degree in Foods,

nutrition and dietetics as minimum education qualification. They were verified by

presenting valid documents.

3.7.2 Training of research team

There was a 3 days training for those who participated in data collection process. They

were taken through the research questionnaire analyzing each question for clarity. Role

play was used to illustrate consistency in asking questions and recording of the responses.

They were oriented with the survey procedures including observance of ethical issues. The

research assistants also participated in the pre-testing of the questionnaire.

3.8 Research instruments

3.8.1 Questionnaires

A researcher administered questionnaire (Appendix C) was used to seek information on

socio-economic, demographic characteristics of the mothers with children aged 6-23

 36

months. It was based on the World Health Organization’s recommendations. The

questionnaire was successfully standardized and validated. It was administered in the

health facilities where it sought information from the mothers and caregivers on; what they

knew about complementary feeding; time of initiation, what to start with, change of

frequency, dietary diversity and the amounts of food at different ages, hygiene and

sanitation and how to feed a child during illness. Each mother or caregiver was interviewed

separately in a separate room to ensure that each one gave her feedback and not copying.

3.8.2 Pre-testing of data collection tools and study procedures

The questionnaire’s content, length, wording and language was pre-tested using 10 mothers

where the pre-testing of the nutrition education videos was also done at Kasarani Health

center with similar characteristics and in same sub county as the study sites. Mothers with

children who were 6-23 months of age were sampled and interviewed. This helped to

evaluate the questionnaire for feasibility and efficiency in collecting data to answer to the

study objectives and also test the flow of the study procedures.

3.8.3 Validity

The content validity of the research tool was analyzed, cleaned and its quality checked.

The questions were reviewed by a team of nutrition connoisseurs (my supervisors) so as to

make sure that the questions besought the intended information (WHO, 2016).

3.8.4 Reliability

The data or information was collected in two phases (with a span of one week between the

interviews). Then a comparison between the respondents was made and any adjustments

needed in the tool were done. Test-retest method was employed to test for reliability of the
 37

questionnaire. The tool yielded after comparison a reliability coefficient of 0.85 (0.80-0.99;

95% CI). This was considered adequate since it’s above 0.70 as recommended by Murphy

and Davidshofer (2005).

3.9 Data collection procedures

The research was conducted in health facilities for mothers/caregivers with children 6-23

months. These mothers/caregivers were grouped into 3 depending on the age of their

children; (i.e. 6 to 8 months, 9 to 11 months and 12 to 23 months). The research assistants

who had been trained and gone through the questionnaire met the mothers and caregivers

at the health facilities. They explained to them the objectives of the study and requested for

their consent so as to participate in the study. Those who consented were interviewed on

complementary feeding and any related influencer so as to establish any change in their

knowledge, and practices which could be attributed to the influence of nutrition education

videos for the mothers and caregivers from the intervention group.

A sample was prepared, listed down and then given respective codes thus enhancing

confidentiality. Similarly, in control health facilities eligible mothers and caregivers were

identified, sample frame prepared and given various codes to enhance confidentiality. The

respondents either put their thumb prints or signed the consent forms after which the

questionnaire (Appendix C) was administered to them. Quantitative data was collected on

the Socio-economic and socio-demographic characteristics of the participants. The

questionnaire also sought information from mothers on complementary feeding under the

following areas; - time of initiation, texture of foods at different age groups, amount of

food, hygiene, dietary diversity and meal frequency.

 38

3.10 Data analysis, and presentation

The quantitative data that was collected was cleaned, entered, and analyzed using SPSS

version 21. Descriptive statistics such as percentages and means were used to describe

demographic, socio-economic, maternal knowledge and complementary feeding practices.

T-tests were used to compare the difference between the control and intervention and Pivot

Tables drawn so as to depict a graphical view, make comparisons and summarize data in a

quick and easy manner. The effect of using nutrition education videos on the maternal

knowledge, and practices was also determined.

Measurement of knowledge levels

A set of 10 questions on knowledge (on the duration of Breastfeeding, frequency of

complementary feeding, amount of food, food groups and feeding of a recovering child)

from the questionnaire were administered to the mothers and caregivers with children 6-23

months in both the control and intervention health facilities. All the responses were

analyzed with means brought forth for comparison. Statistical test was done using T-test.

Measurement of practices

The mothers/caregivers’ complementary feeding practices (on breastfeeding, length of

EBF, sustained breastfeeding, giving any other liquid, the type of porridge, dietary

diversity, water treatment, disposal of child’s fecal matter and feeding the child during

illness) was determined. Using the 24-hour recall, the respondents gave information on

their children’s food consumption patterns. This helped in calculating the dietary diversity

from the 7 food groups for children. A score which was >4 was acceptable while below
 39

this was considered as low. Food frequencies were also determined by comparing with the

WHO’s standard (WHO, 2008) depending on the age of the child.

The data was analyzed at a statistical significance of P<0.05. Each objective with different

types of data was analyzed using different references/ standards so as to come up with the

conclusion of the outcome as shown in appendix A. Data has also been presented in figures,

bar graphs and tables.

3.11 Ethical and Logistical considerations

Research clearance was obtained from Graduate School, Kenyatta University. The Ethical

Clearance from Kenyan ethical committee AMREF had been obtained for the core GloCal

project. An Ethical clearance was also obtained from Kenyatta University Ethical Review

Committee. A research permit to conduct the research was also sought from National

Commission for Science, Technology and Innovation. Consent from the area

administration and the health facilities was sought too. Consent from the respondents was

also sought assuring them of concealment, and informed them that the information

provided would only be used for research purposes. They would benefit from viewing the

information on nutrition education videos projected at the intervention facilities

 40

CHAPTER FOUR: RESULTS

4.1 Demographic and socio-economic features of the participants

4.1.1 Introduction

The comparison in this study was done between the control group and intervention group

at the end line (at the end of the intervention) since the baseline data was not available. The

design allows for taking the control to be likened to baseline then compare the outcomes

from the intervention unit to establish the effect achieved.

A total of 198 respondents took part in the study, out of which, 40.4% were from the

control group and 59.6% from the intervention group. Therefore, it is notable to conclude

that most of the participants in the study were from the intervention group. The difference

exists as shown due to the differences in the admissions and coverages of these health

facilities within their catchment areas. The intervention health facilities had a wider

catchment population as compared to the health facilities in the control area.

4.1.2: Socio-demographic characteristics of the study households

As the study targeted mothers/caregivers from each selected household, some of them

coupled up as heads of those households. The study established that most households from

the control group were headed by males (83.6%) as compared to the female headed ones

(16.4%). Similarly, from the intervention group, high proportion of the households were

also headed by males (92.4%) and just a few (7.6%) were female headed as shown (Table

4.1).
 41

Therefore, in consolidation of the groups, majority (88.0%) of the households were headed

by males, which represented more than half of the total participants.

Table 4.1: Distribution of participants by household head

Category Sex of household head Total

Male; (n=176) Female; (n=22) (N=198)
(%) (%) (%)
Control Group 83.6 16.4 100
Intervention Group 92.4 7.6 100

Average 88 12 100

4.1.3: Socio-demographic characteristics of the mothers/caregivers

It was found out from the study that most mothers/caregivers; 83.8% from control group

and 89.0% from intervention group were married. In a similar manner, a higher proportion

of the participants, 95% from the control group and 99.2% of the intervention group were

Christians as shown (Table 4.2). Majority of the participants, 45.0% from the control group

and 39.8% from the intervention group, reported primary education as their highest level

of education. Furthermost, 93.8% respondents from the control group and 96.6% from the

intervention groups were breastfeeding their children during the time of study. From the

study, the youngest respondent was 17 years old while the oldest respondent was 40 years

old. The mean age for these mothers in complete years was 25.3 years; representing

24.8+4.3 from the control group and 25.9+4.4 from the intervention group.
 42

Table 4.2: Respondents’ socio-demographic characteristics

Characteristic Control group Intervention t-test

(N=80) group(N=118) P
n % n %
Marital status
Married 67 83.8 105 89.0 0.065
Single 1 1.3 3 2.5
Divorced 1 1.3 1 0.8
Separated - - 2 1.7
Widowed 11 13.8 7 5.9

Religion
Christian 76 95.0 117 99.2 0.086
Muslim 3 3.7 1 0.8
Hindu 1 1.3 - -
Physiological status
Pregnant 1 1.3 4 3.4 0.098
Lactating 75 93.8 114 96.6
Pregnant and lactating 1 1.3 - -
Not lactating 3 3.8 - -

Education Level
Below Primary 7 8.8 6 5.1 0.077
Primary 38 47.5 54 45.8
Secondary/High School 28 35.0 40 33.8
College/Pre-university/Uni. 7 8.7 18 15.3
Average Age 24.8+4.3 25.9 + 0.064
Mean age (both groups) 25.3 Years 4.4
Significant at < 0.05

Table 4.2 establishes the demographic characteristics of mothers who had children 6 to 23

months old and were attending MCH clinics in both the control health facilities and the

intervention health facilities. There was no significance difference in demographic and

economic characteristics of mothers with children aged 6 to 23 months between the control

health center and the intervention health center.

 43

Therefore, we fail to reject the null hypothesis which states that there is no significant

difference in socio-demographic characteristics of mothers with children aged 6-23 months

between the intervention and control groups.

4.1.4: Socio-economic and household features of the respondent

The study established that a half of the households, 50.0% from control group and 42.3%

from intervention group had 3 members as the household size whereby there was at least

one child who was under five years and specifically under 2 years of age. The

preponderance of households (50.0% for the control group and 43.2% for the intervention

group) reported that casual labor was the main source of livelihood for the household head.

Similarly, most mothers, 67.5% from the control group and 67.8% from the intervention

groups, were found to be housewives for the married mothers.

In the allocation of finances for food in households, the study established that majority of

the households (38.7% from the control group and 44.1% from the intervention group) did

not have specific amounts allocated for food (46.3% from the control group and 69.5%

from the intervention group), having husbands as the decision makers on how family

income should be spent. The study further revealed that in most households (88.7% from

the control group and 89.0% in the intervention groups) mothers were the main decision

makers on what foods to be cooked in the households (Table 4.3)

 44

Table 4.3: Respondents’ socio-economic and household characteristics

Characteristic Control Intervention t-test:

group (N=80) group (N=118) P
Household Size n % n %
2 People 3 3.8 1 0.8
3 People 40 50.0 51 43.2 0.045
4 People 23 28.7 42 35.6
5 People 8 10.0 16 13.6
6 People and above 6 7.5 8 6.8
Children U5 Years in a HH
1 Child 5 6.3 78 66.1 0.036
2 Children 55 68.7 39 33.1
3 Children 20 25.0 1 0.8
Occupation of HH head
Formal Employment 21 26.3 46 39.0
Self Employed 19 23.7 21 17.8
Casual Labor 40 50.0 51 43.2 0.059
Occupation of the Mother
Formal Employment 7 8.7 12 10.2
Self Employed 19 23.8 26 22.0
Housewife 54 67.5 80 67.8 0.085
Money allocated for food
Largest % of HH income 4 5.0 9 7.6
Smallest % of HH income 17 21.3 18 15.3
Half of HH income 28 35.0 39 33.0
No specific allocation 31 38.7 52 44.1 0.068
Decisions on use of family income
Husband 37 46.3 82 69.5 0.092
Wife/mother 16 20.0 28 23.7
None 27 33.7 8 6.8
Decision on food to cook
Husband 5 6.3 8 6.8
Wife/mother 71 88.7 105 89.0 0.074
Children - - 2 1.7
All (Parents and Children) 4 5.0 3 2.5
Significant at <0.05

The established socio-economic characteristics of the mother-child pairs for children aged

6-23 months showed that there was no significant difference between the control and the

intervention groups in the study.

 45

4.1.5 Infants and children’s profile

The highest proportion of children observed was 12 – 23 months across the study groups

(48.75% in the control and 46.60% in the intervention group) with no significance

difference (P = 0.064). The lowest proportion (26.30% from control and 25.25% from the

intervention) had children aged 6 to 8 months, as shown in Figure 4.1

There was a higher number of children aged between 12 to 23 Months in the study because

of the following; - most children had turned 12 months and above after the 6 months of

watching the nutrition education videos and most children in that age period are active and

most likely susceptible to diseases making them have high health seeking behaviors.

Age Distribution of Infants and Children

60.00%
48.75% 46.60%
50.00%

40.00%
Percentage

30.00% 25.25% 26.30% 26.0% 27.10%

20.00%

10.00%

0.00%
6 to 8 9 to 11 12 to 23
Age group of the child

Control Intervention

Figure 4.1: Distribution of infant and children’s ages in control and intervention groups
 46

4.2: Knowledge level of mothers and caregivers on complementary feeding

4.2.1. Maternal knowledge on complementary feeding

To assess the respondents’ knowledge on infant and young child feeding, the participants

were asked questions including on when it was appropriate to breast feed a child. The study

also tended to establish the source of information the mothers had on complementary

feeding of children aged 6-23 months.

The mother’s knowledge on exclusive breastfeeding, complementary feeding and the age

at which children should be introduced to solid food was also sought. The study wanted to

find out if mothers had received nutrition knowledge, changed attitude and practices on

complementary feeding from nutrition education videos they had watched. The proportion

of parents involved were assessed on the question of how long exclusive breastfeeding

should be done, how many times a mother should breastfeed and when to introduce

complementary/ semi-solid foods.

4.2.2 Information on Infant feeding and its source

More than a half of mothers (58.7%) from the control group and a high proportion (96.6%)

from the intervention group) reported to have received information on complementary

feeding. There was a significant difference between intervention and control respondent’s

knowledge on information about feeding (P=0.043).

About a half of mothers/caregivers (52.5%) from the control group had received

information on complementary feeding of infants and young children from their

mother/mother-in-laws compared to the majority of mothers (85.3%) from the intervention

 47

group who reported to have received information from the nutrition education videos as

shown in Table 4.4 but others indicated that they acquired information from their parents

and their mother-in-laws (52.5% from the control group and 0.9% from the intervention

group). A higher proportion, 62.5% from the control group and 90.1% from the

intervention group reported to have felt that they still needed a variety of information. They

had a desire to be given more information touching on lifestyle diseases. They added that

if more lessons on current chronic diseases like Diabetes, HIV/AIDS among others could

be included for public awareness could be of great help to the community and a greater

impact could be realized.

Table 4.4: Source of mother/caregiver’s information on infant and young child feeding

Control Intervention Total t-test

Knowledge on child feeding, source of group % group % % P
information and if in need of variety
Value
n=80 n=118 n=198
No. of Mothers 0.043
Yes 58.7 96.6 77.7
who received
information on
complementary
feeding
Mother/mother-in-law 52.5 0.9 26.7 0.065
Source of Neighbor/friend 7.3 0.2 3.8
information Day care center 7.2 0.3 3.8
received Health Worker 33.0 13.3 23.1
Education videos 0 85.3 42.6
No. of mothers 0.087
still in need of
more
Yes 62.5 90.1 44.4
information at
the time of data
collection
Significant at < 0.05
 48

4.2.3 Mothers/caregivers’ knowledge level on duration, frequency and amount of food

infants and young children are fed
About a half of mothers (51.3%) from the control group and all mothers (100%) from the

intervention group reported to have known the correct length of time a mother should

exclusively breastfeed a child (Table 4.5). On prevalence of how many times a mother

should breastfeed a child after 6 months, most mothers (35% from the control group and

60.2% from the intervention group) proved to be having the correct knowledge on the

recommended frequency for child feeding. The majority of participants across the groups

in this study (41% from the control group and 50% from the intervention group) were found

practicing breastfeeding alongside complementary feeding up to a period of 24 months.

Preponderance of mothers and caregivers, 46.3%, in the control group indicated that a child

should be fed from 2 to 3 food groups per day while majority in the intervention, 95.5%

reported that a child should be fed from at least 4 food groups a day. There was a significant

difference between the two group; control and intervention groups (P=0.042). The study

also sought the knowledge of mothers on the age of introduction of complementary feeding

to the infants. A higher proportion from both groups (96.3% from the control group and

100% from the intervention group) reported the introduction to be after 6 months. There

was also a significance difference between the two groups (P=0.021). On the consistency

of the infant and young children’s porridge, a high proportion from the control group,

63.7% knew that they should feed their infants and young children with thin porridge while

majority from the intervention, 82.7% knew that infants and young children are fed with

thick porridge exhibiting a significant difference between the control and intervention

groups (P=0.032)
 49

Table 4.5: Respondent’s knowledge on complementary feeding

Control
Intervention Total
Knowledge on the duration, group
group n=118 n=198 t-test
frequency and amount of food a n=80
P
child should be fed Percentage Percentage Percentage
(%) (%) (%)
Length of 5 months 33.7 0 16.8 0.041
exclusive 6 months 51.3 100 75.7
breastfeeding 3 months and below 15 0 7.5
Frequency of One time 15 0 7.5 0.064
breastfeeding a Thrice 45 39.8 42.4
child after 6
On demand 35 60.2 47.6
months
Length of 6-12 months 20 14.5 17.3 0.048
breastfeeding 12-18 months 38.5 35.5 37.0
before
complete 24 months 41 50.0 45.7
cessation
Decision Baby’s mother 96.3 97.5 96.5 0.024
maker on what Baby’s father 1.2 2.5 1.8
to feed the
Baby’s grandmother 3.5 0 1.7
child
Type of Thin 63.7 17.3 40.5 0.032
porridge best
Thick 36.3 82.7 59.5
for babies
Age of After 3 months 3.7 0 1.9 0.021
introduction of
complementary After 6 months 96.3 100 99.1
foods
Minimum 1-2 groups 23.7 0 11.9 0.042
number of food
groups to feed 2-3 groups 46.3 4.5 25.4
a child per day 4 and above groups 30 95.5 62.7
Significant at <0.05
 50

Therefore, having established a higher knowledge gain in the intervention as opposed to

the control group with significant differences as shown in the table 4.5, we reject the null

hypothesis that there is no significant difference in knowledge on complementary feeding

of children 6-23 months between mothers in control and intervention group.

4.2.4 Mothers/caregiver’s knowledge on feeding infants and children during illness

Questions on whether mothers or caregivers knew the amount of milk and meals to feed

children during illness were administered in the study population. WHO recommends that

normal breastfeeding should continue whether the child is ill or not and even the sick child

to be breastfed more.

The study revealed that most mothers, 52.5%, from the control group knew that children

are given same amount of food after recovery while 39.8% from the intervention group

knew that they are given more. Few mothers or caregivers, 1.25% from the control group

knew that the child should be given less amount of food because of the mother’s decision

while 4.2% from the intervention reported that the child should be given less because they

did not want the food may be because of poor appetite as shown in Table 4. 6. Generally,

there was no significant difference in the mothers’ availability to the baby during the day

in relation to illness (P=0.152).

 51

Table 4.6: Feeding infants and children at recovery

Control Intervention
Mothers/caregivers’ knowledge on feeding group Total t:P
group
children at recovery Value
n (%) n (%) n (%)
Less, because the child 0.118
5 4.2 4.6
did not want it
Amount of food Less, because mother’s
given to the 1.25 0 0.6
decision
child after More 22.5 59.8 41.2
recovery
The same 52.5 30.5 41.5
Does not know 18.75 5.5 12.1
Always/most days (6 0.152
1.2 0.9 1.0
days/week),
How often the Often/many days (4-5
6.3 5.1 5.7
mother/caregiver days/week),
away from the Sometimes/a few days (2-
6.2 3.4 4.8
baby 3days/week),
Never/few days (0-1
86.3 90.6 88.5
days/week)
P>0.05 and n is presented in form of percentages

4.3 Mothers/caregiver’s complementary feeding practices

4.3.1 Initiating and sustaining breastfeeding practices

The study intended to establish if mothers or caregivers were putting into practice the

knowledge they had on complementary feeding of children aged 6 to 23 months. A couple

of questions were asked to assess when the breastfeeding was initiated after birth, its

sustenance and complementary feeding practices.

The study established that majority of mothers across the groups (98.8% from the control

group and 99.2% from the intervention group) had breastfed their children exhibiting a

significant difference between the two group (P=0.021). The study further revealed that a

higher proportion across the groups breastfed their children within 1 hour of birth (63.8%
 52

from the control group and 87.1% from the intervention group) equally with a significant

difference between the groups (P=0.048). It was also found out that most mothers in both

groups did not give anything to the infants to drink in the first 3 days (81.7% from the

control group and 94.9% from the intervention group) with a significant difference among

the groups (P=0.01)

The study discovered that a high proportion of mothers and caregivers from both the groups

fed their children with colostrum within the first 3 days (79.5% from the control group and

95.8% from the intervention group) and also bringing out a significant difference among

the two groups (P=0.046). From the onset of complementary feeding most mothers and

caregivers in in the control group (73.7%)initiated their children with thin porridge as

opposed to majority in intervention group who started off their children with thick porridge

(93.8%) as a complementary food thus establishing a significant difference between the

groups (P=0.022) as shown in table 4.7

Generally, the study found out a difference that was statistically significant between the

two groups thus the null hypothesis which states that there’s no significant difference in

complementary feeding practices of children aged 6 to 23 months between mothers in

control and intervention health facilities was not rejected.

 53

Table 4.7: Initiation of complementary feeding and sustaining breastfeeding

Mothers/caregivers’ initiation Control Intervention Total t:P
Complementary Feeding and group n=80 group n=118 N=198 value
sustenance of Breastfeeding
practices n (%) n (%) n (%)
Proportion of
children ever Yes 98.8 99.2 99.0 0.026
Breastfed
Less than 1 hour 63.8 87.1 75.5 0.048
How soon after
More than 24Hrs 8.7 4.9 6.8
birth children
2 Days 15 8.0 19
were breastfed
3 Days and above 13.8 0 6.9
Less 3 months 17. 0 0 8.5 0.021
Length of time
4 months 12.0 0 6.0
you exclusively
5 months 30.2 4.0 17.1
breastfed
6 months 40.8 96.0 68.4
Proportion of Yes 79.5 95.8 87.7 0.046
children Fed
with the fluid
from breast for
first 3 days
Type of Thin 73.7 6.2 40.0 0.022
porridge the
baby is fed with Thick 26.3 93.8 60.0
Given anything Plain water 18.3 5.9 10.1 0.01
to drink save the Sugar water or
0 0.9 0.5
breastmilk in the glucose water
first 3days Not given 81.7 94.9 89.4
Proportion of 0.003
children who are
Yes 95 100 97.9
Still
breastfeeding
No 1.3 2.5 2.0 0.207
Proportion of
Yes, it’s easy 7.5 3.4 5.1
mothers who
Yes, gives baby
will sustain 37.5 38.1 37.9
nutrients
breastfeeding
Yes, helps baby
after initiation 22.5 28.0 25.8
develop
of CFs till 2
Yes, protects baby
years 31.2 28.0 29.6
against disease
No. of food 1-2 groups 21.7 0 10.9 0.042
groups the child 2-3 groups 44.7 3.8 24.3
is fed from daily 4 & above groups 33.6 96.2 64.7
Significant at <0.05, values reported as percentages of the n
 54

4.3.2 Mothers/caregivers’ WASH practices on complementary feeding

The study also probed for information on water, sanitation and hygiene practices which

could enhance complementary feeding. This is one of the components which influence

nutrition status and mostly carried out among households. Participants were asked

questions on the safety of water they used, source of their drinking water, how they treat it

making it safe for drinking, their access to a toilet facility, their disposal of children’s waste

and the 5 critical moments of handwashing.

A high proportion of mothers and caregivers across the study groups (97.5% from the

control group and 98.3% from the intervention group) used tap water as their main source

of drinking water while few (1.3%) from the control group used water from the river and

few (1.7%) in the intervention group used borehole water as their source main source of

drinking water. To ensure that drinking water is safe, the study established that most

mothers and caregivers across the groups boiled it (control group, 52.2% and intervention

group, 47.5%) and few mothers did nothing for drinking water in both groups (control

group, 20% and intervention group, 11%). There was no significant difference between the

two groups (P=0.052).

In matters of hygiene, most mothers and caregivers in both the groups (98.7% in the control

and 100% from the intervention) had access to toilet facilities and hygienic disposal of

children waste (100%) while just a few (1.3%) from the control group were unable to access

toilet facilities. Since majority of mothers had access to toilet facilities, both groups

deposited the child’s fecal matter immediately (100% from the control group and 100%
 55

from the intervention group) with no significant difference between the two groups

(P=0.055).

Table 4.8: Water, sanitation and hygiene practices by respondents

Control Intervention Total t-test

Components of WASH group N=80 group N=118 N= 198 P
n (%) n (%) n (%)
Main River 1.3 0 0.5
source of Tap water 97.5 98.3 98.0 0.024
drinking Borehole 0 1.7 1.0
water Tanker 1.2 0 0.5
Treatment Boiling 52.5 49.2 50.8 0.052
done to
Use chemicals 27.50 39.8 33.7
water
before Nothing 20 11.0 15.5
drinking
Access to Yes 98.7 100 99.5 0.074
toilet
facility No 1.3 0 0.5
Type of Traditional pit latrine 38.7 11.0 22.2 0.048
toilet Ventilated improved
17.5 10.2 13.1
facility latrine
used Flush toilet 42.5 78.8 64.2
Disposal Disposed 0.055
of child's immediately and 80 (100) 118 (100) 198 (100)
feces hygienically
After visiting toilet 18.0 20.0 19 0.033
When to Before feeding baby 23.5 25.3 24.4
wash Before eating 25. 27.0 26
hands
(multiple Before prepare food 17.3 20.2 18.8
answers Change baby diapers 4.2 7.5 5.8
possible) When think hands
12.0 0 6
are dirty
Significant at <0.05

As shown in figure 4.2, there were multiple responses and variations in responses on

critical times of hand washing. Mothers and caregivers washed their hands on different
 56

circumstances with a majority in both cases before eating (25% from the control group and

27% from the intervention group). It was also evident from the study that few (12%)

mothers and caregivers from the control group washed their hands only when they thought

they were dirty. There was a difference which was scientifically significant between the

two groups (P=0.033).

CO M PARISO N BETWEEN CO NTRO L AND

INTERVENTIO N O N TIM ES F O R H AND WASH ING
25.30%

control Intervention
23.50%

27%
25%

20.20%
17.30%
20%
18%
PERCENTAGE

12%
7.50%
4.20%

0%
AFTER BEFORE BEFORE BEFORE CHANG ING WHEN
VISIT ING FEEDING EAT ING PREPARING THE BABY'S T HINK
T O ILET THE BABY FOOD DIAPERS HANDS ARE
DIRT Y
FIVE CRITICAL MOMENTS OF HANDWASHING

Figure 4.2: Comparison of hand washing practices between control and intervention

groups.

4.3.3 Mothers/Caregivers’ feeding practices of ill children

The study also desired to establish how mothers and caregivers were managing infants and

young children while they were sick. They question needed them to share their experience

on how they managed their children when he or she was sick in the last time.
 57

The preponderance of mothers and caregivers across the study groups were found to have

fed their children with less amount of breast milk because the child did not want it (50%

from the control group and 72% from the intervention group) while few from both groups

did not breastfeed because of the mothers’ or caregivers’ decision (1.2% for the control

group and 0.9% from the intervention group). there was also a significant difference

between the two groups (P= 0.002) as seen in Table 4.9

Table 4.9: Feeding infants and children during illness

Control Intervention
Mother/caregiver’s knowledge on the group Total t:P
group
amount of milk and food to give ill children Value
n (%) n (%) n (%)
Less, because the child 0.002
50.0 72.0 40.4
did not want it,
Less, because mother’s
1.2 0.9 1.0
Amount of decision
breast milk More 15 17.0 16.2
offered to the The same 21.3 7.6 13.1
child last when Child never breastfed or
8.7 2.5 5.1
he/she was ill child not
Breastfeeding before last
1.3 0 0.5
illness,
Child has never been sick 2.5 0 1.0
P>0.05 and n is presented in form of percentages

4.3.4 Dietary diversity

In establishing dietary diversity, mothers and caregivers were required to remember the

foods the child consumed in the last 24 hours. This could help to establish if the child was

fed from different food groups (7 food groups as recommended by WHO). This also

covered the number of times the child ate food, snacks or took drinks, over the last 24

hours.
 58

Mothers and caregivers were asked to mention without quantifying the type of food their

children had eaten in the previous 24 hours and clustered to compare with the groups

recommended by WHO. Most mothers and caregivers from control group fed their

children from flesh foods (56.2%), followed by other fruits and vegetables (53.8%) and

grains, roots and tubers (51.2%) while majority of mothers and caregivers fed their children

from other fruits and vegetables (92.2%) followed by grains, roots and tubers (84.1%) then

eggs (82.7%) as illustrated in figure 4.3.

FOOD DISTRIBUTION AND CONSUMPTION PATTERNS BY

CONTROL AND INTERVENTION GROUPS IN THE 24 HOURS

92.2%
Control Yes Control No Intervention Yes Intervention No
84.1%

82.7%
78.0%

77.8%

76.3%
69.3%

65.0%
60.0%

56.2%

53.8%
52.5%
51.2%

51.0%
49.0%
48.8%

47.5%

46.2%
43.8%
PERCENTAGES

40.0%

35.0%
30.7%

23.7%
22.2%
22.0%

17.3%
15.9%

7.8%
GRAINS, LEGUMES DAIRY FLESH EGGS VIT-A RICH OTHER
ROOTS AND AND NUTS PRODUCTS FOODS FRUIT & FRUITS AND
TUBERS VEGATABLES VEGETABLES
FOOD GROUP CONSUMED

Figure 4.3: Food distribution and consumption patterns by children based on the 24 hour

dietary recall

On food diversity and nutrient sources, for example source of vitamin A; it was reported

that most respondents from the intervention readily gave their children vitamin A-rich

foods.
 59

In probing further, the respondents from the intervention site confirmed that their behavior

and practice changed after they had watched the nutrition education videos at the health

facility. They further affirmed that they could now feed their children with eggs, legumes

and meat and meat organs; with much efforts made to reduce the habit of giving children

sweets, cookies and candies. This difference is clearly ascertained in the figure 4.3. There

was a significant difference in dietary diversity between the groups, (P=0.006).

4.4 Effect of nutrition education videos on knowledge and practices on

complementary feeding among mothers of children aged 6 to 23 months in the two

groups

To establish if there was any influence or effect that was noted in the intervention group,

there was a need to calculate the knowledge score, minimum meal frequency, and

minimum dietary diversity score for the two groups to enhance comparison as shown in

Table 4.10. It was found out that there was a significant difference in knowledge between

the control and intervention group.

The study found a difference in minimum meal frequencies between the two groups

(control which had a mean of 2.58+1.2 and the intervention group had a mean of 2.72+1.12)

`though the difference was not significant, (P=0.524). Secondly, for dietary diversity there

was a significant difference between the groups (mean for control 3.731+1.55 while

5.191+4.62 was the mean for the intervention group) with a difference which was

statistically significant (P=0.006). Thirdly, for the knowledge score, there was also a

difference between intervention whose mean was 9.842+1.05 and control group whose

mean was 8.110+1.78 with a significant difference (P= 0.001).

 60

Table 4.10: Minimum Meal frequency, Dietary diversity and Knowledge scores

Study group N Mean SD t:P value

Minimum meal frequency Control 78 2.58 1.2 0.524

Intervention 118 2.72 1.12
Dietary diversity score Control 78 3.73 1.55 0.006
Intervention 118 5.19 4.62
Knowledge score Control 78 8.11 1.78 0.001
Intervention 118 9.84 1.05
Significant at <0.05
 61

CHAPTER FIVE: DISCUSSION

5.1 Demographic and socio-economic characteristics of children and their caregivers

The current study found out that the majority of the households were headed by males in

both the control and intervention groups in which most of them were the bread winners.

They also had small household sizes. These findings were in agreement with the studies

done in Kibera informal settlement, Mucheru et al. (2016) and similar to the study which

was done in Korogocho informal settlement on determinants of complementary feeding

practices Korir (2013). This could mean that most household decisions could be highly

influenced by the fathers as opposed to the mothers. It also meant that they could

adequately care for their households because they had manageable numbers.

This study established that most caregivers were married in both groups and nearly all of

them were Christians. This conformed with the study done in Kibera slum which is also an

informal settlement (Mucheru et al., 2016). Therefore, this can strongly affirm that the

responsibility of upbringing of children in households is a collective responsibility since

both parents are there. Education is a major tool which can empower women and influence

them to appropriate care of their children (Paudel & Giri, 2014). Findings from this study

pointed out that the majority of mothers in both the groups had primary school education

as their highest level of education. They are in line with the studies done in Kasarani

informal settlement in Molo, Mututho (2012) and that which was done in Viwandani

informal settlement (Kimani-Murage et al., 2011). This is significant to note as it affirms

that the populations which are being compared are similar in characteristics thus any
 62

change which can be realized in their knowledge and practice can be comfortably

associated with the change agent.

Most household heads were casual laborers as their main source of family income, whereas

most mothers were housewives and lactating. This study was similar with the studies done

in areas with similar characteristics, Viwandani, Molo and Kibera, (Kimani-Murage et al.,

2011; Mututho, 2012; Kamau 2016; Ochola, 2008 & Adere, 2006). This means that the

mothers most probably depended on their husbands for provision of food plus other

household necessities. At the same time, most mothers being housewives must have been

contributed by their low levels of education, primary level, as this came out strongly which

could not gain them an employment. This was also backed up by a study done in South

Ethiopia on predictors of inappropriate complementary feeding practices (Berhanu et al.,

2019) and another one done in Lagos on complementary feeding knowledge, practices and

dietary diversity in urban community (Olatona et. al., 2017).

The current study observed that most households did not have specific amount allocated

for food in with husbands being the main decision makers of how the family income should

be used, and most mothers being main decision makers of what foods to be cooked in the

household. This study conforms to the study which was done in Kahawa West Public

Health Center (Kimwele, 2014) and the one done in Korogocho (Korir, 2013). It is also in

tandem with the study which was done in Bangladesh (Owais et. al., 2019). This implies

that the households purely depended on whatever the household head could get and plan

for it once received. They did not have any prior budget which is also similar to the study
 63

which was done in Lagos (Olatona et. al., 2017). But the mothers could have a chance to

decide what to cook for the family. This meant that having good knowledge could easily

enable them opt to cook appropriate recipes for their children and families at large.

There was proportionate participation of mothers with children 6-23 months in the study

area due to different caseloads handled by each health center and the catchment population

it serves. Notably, from both groups the number of mothers with children of ages between

12 to 23 months were higher than the other age cohorts.

5.2 Mothers/Caregivers’ knowledge on complementary feeding

5.2.1 Information on Infant feeding and its source

Information acquired through any source is power and can bring about great behavior

change leading to better practices in the community (Paudel & Giri, 2014). This study also

looked into the source of information on complementary feeding among the mothers. Most

respondents had received information on complementary feeding; - in intervention group,

the information had been acquired from multiple sources but prominently from the

nutrition education videos. Others had stated to have received from health care provider

but upon probing further, their neighbors and friends and from the mother and mother-in-

laws. It was discovered particularly from the intervention group that the information from

the nutrition education videos projected were being emphasized by the Health care

providers during the health talks and consultations in the health centers.
 64

Whereas the control group had also received information on complementary feeding, it was

observed outstandingly that the information was given by the mother/mother-.in-laws.

These findings show similarities with the studies which were done in southwest Nigeria

(Agunbiade and Ogunleye 2012) and that which was done in china (Zhang et al., 2009)

which showed great roles of mother-in-laws in child feeding. Though the study which was

done in Bangladesh (Paul et al., 2015) found out that the mother-in-laws had low role in

child feeding practices. The source of information and the content are vital for the proper

practice of complementary feeding (Mucheru et al., 2016). It is important to trace the

source of any information since it authenticates it and make it reliable as it bears evidence

of professionalism and experience.

5.2.2 Knowledge on Breastfeeding

On pursuit to establish the mother/caregiver’s knowledge on complementary feeding, the

study also intended to know their understanding on breastfeeding from initiation until

complete cessation. It was found that majority of the respondents had breastfed their

children with correct time of initiation. This corresponded to the studies which have been

in Kenya (Kimani-Murage et al., 2011; KNBS & ICF Macro, 2010; Ochola, 2008 and

Kamau, 2016).

This study agrees with Dewey (2016), Olatona et al. (2017) and Yohannes et al. (2018) on

length of time for exclusive breastfeeding, frequency, sustained till 24 months, food groups

and the consistency. Though there was better knowledge in the intervention than the control

group. The better knowledge in the intervention group might have been brought by the
 65

nutrition education videos which were being aired in the health facilities within these

regions.

5.2.3 Knowledge on Complementary feeding

Complementary feeding is significant for children after 6 months as it bridges the gap that

is left breastfeeding alone (KNBS & ICF Macro, 2010). Too early or too late introduction

of complementary foods is enough to lead to nutrition deficiencies among children (Saleh

et al., 2014). This therefore is a good reason practice appropriate complementary feeding

because it can highly reduce infant morbidity and mortality (Sayed & Schönfeldt, 2018).

Breastfeeding till 2 years elapses and even beyond has a greater role in enhancing proper

growth and development among children (Illif et al., 2005; Bahl et al., 2009 and Venneman

et al., 2009). There was a higher number of mothers who had appropriate knowledge on

sustained breastfeeding till 2 years in intervention group than the control group. This

difference is strongly attributed to the nutrition education videos. The mothers had watched

them, learnt and put the knowledge into practice. This is similar to the findings of the study

which was done in Houston, USA on influence video games on nutrition of young people

(Ledoux et al., 2016) and Allen and Smith (2012) which observed that video education has

great effect on cognitive performance and behavior change.

On the subject of consistency and food groups this study had similar findings with the

studies which were done by WHO (2010), White et al., (2017), Williams et al., (2016) and

Agedew and Demissie (2014) which found out that infants should be given thick liquid

(porridge) when initiating complementary feeding and be fed from at least 4 food groups.
 66

The intervention group in this study also exhibited better knowledge as opposed to the

control. This was because of the nutrition education videos which were shown in the health

facilities and the questions responded to by the health care workers during the health talks.

to the control.

5.3 Mothers/caregivers’ complementary feeding practices

5.3.1 Initiating and sustaining breastfeeding practices

These findings agree with other studies which had been done by Korir (2013), Mucheru et

al., (2016) and Agunbiade and Ogunleye (2012) which found out that most children were

breastfed within the 1 hour of birth, and the infants were not given anything to infants to

drink in the first 3 days. There was a higher practice in the intervention group than the

control group and this is associated with the use of videos which were projected in the

health facilities in the intervention centers.

Colostrum is very essential for child’s growth, and development especially cognitive and

immune aspects (Armstrong et al., 2014). There was a significant difference in mothers

who gave their children colostrum between the two groups. More mothers in the

intervention group gave their infants colostrum than those in control. This can be alluded

to the nutrition education videos which the mothers and caregivers were exposed to in the

intervention group. These findings agree with the studies which were done by Graziose et

al. (2018) and Lloyd & Robertson (2012). which found out that mass media is effective in

nutrition education for the infant and young child feeding.

 67

5.3.2 Mothers/caregivers’ WASH practices on complementary feeding

Majority of the respondents used tap water as their main source of drinking water. These

findings were in consistent with the study which was done in Korogocho on the

contributing factors to complementary feeding (Korir, 2013) and that which was done in

Nepal on the factors associated with breastfeeding practices (Paudel & Giri, 2014).

Treating water is effective for quality improvement in the household level (KNBS & ICF

Macro, 2010). There was a higher response from intervention on the number of respondents

who boiled water for drinking as the safest means of treating water before drinking parallel

to the control group. These results were in agreement with the study which was done on

infant feeding mode Butte et al. (2000) and Young Child feeding practices Christina &

Lartey (2007).

Most of the respondents in both cases reported to have had access to flush toilet facilities

and hygienically disposed their children’s wastes. This concurred with the study which was

done in Molo in an informal settlement (Mututho, 2012). There were multiple differences

in responses to the critical moments of hand washing. Majority reported to have washed

their hands at different circumstances. A greater difference was seen in higher number of

respondents in the control who felt they could only wash their hands when they thought

they were dirty. This can be accredited to the dissimilarity in knowledge and consequently

practices amongst the control and the intervention groups. Therefore, the difference can be

strongly said to have been brought about by the lack of nutrition education videos in the

control health centers as opposed to intervention centers.

 68

5.3.3 Respondents’ practices on feeding during illness

5.3.3.1 Amount of food given to ill children

Children under 2 years of age have their immune system not fully developed and this makes

them prone to childhood illnesses (Mutua et al., 2007). During illness, there is also

tendency of losing appetite, but it is recommended that there should be a continued

consumption of foods as recommended so as to maintain nutrient balance and enhance

recovery (Brown, 2001). Majority of the mothers in this study reported that when their

children had been ill a within a month prior the study and they ate less food because of loss

of appetite. There was though a significant difference between the intervention and control

group. This is in agreement with the recommendation of World Health Organization

(WHO, 2008).

5.3.3.2 Amount of food given to children after recovery

When infants and young children are infected by illnesses, they become weak and

vulnerable Therefore, there is a need of greater intake of nutrients by a recovering child so

as to make up for lost nutrients (Mututho, 2012). From this study, it was found out that the

intervention group reported of increasing the amount of food while from the control

reported of maintaining the same quantity of food for recovering children. The findings

from intervention group were similar to those which were found in a study which was done

in Kahawa West Public health center (Kimwele, 2014) and those of control differed from

those the study which was done in Korogocho (Korir, 2013). The difference in knowledge

and practice between the intervention and the control is most likely attributed to the

projection of the nutrition education videos which might have influenced behavior change.
 69

5.3.4 Complementary feeding practices

5.3.4.1 Introduction of solid, semi-solid and soft foods

Late introduction to semi-solid and solid foods may cause stunted growth and lead to

malnutrition among children (Olatona et al., 2017). The findings of this study showed that

majority of the participants introduced complementary foods after 180 days. This was in

tandem with the recommendation given by UNICEF (UNICEF, 2014).

There was a significant difference between the control and intervention group in that from

the intervention group, no mother or caregiver who introduced the complementary foods

before 6 months were complete as required while in the control group, there were some

who introduced complementary foods more significantly after 3 months. This is strongly

attributed to the nutrition education videos which had been placed at the health centers in

the intervention site that had taught the mothers and caregivers leading to improved

knowledge and consequently the practice. This was in agreement with the study which was

done in Bangladesh using Television to improve breastfeeding in infancy (Haider et al.,

2010).

5.3.4.2 Minimum Dietary Diversity

Any complementary food is considered appropriate when it has a balanced composition of

macro and micro nutrients (KNBS & Macro, 2010) with special attention to vitamin A,

zinc, folate, iron, and calcium. These nutrients are vital more especially in the first 2 years

of a child’s life for better future growth and development (Roy et al., 2009). Scientific
 70

studies have also indicated that appropriate dietary diversity is closely linked with

improved nutrition status of children (Arimond & Ruel, 2002).

For food diversity and nutrient sources, this study found out that majority of the

respondents from both groups fed their children foods from grains, roots and tubers more

especially in form of porridge. From the study, it was noted that majority of the mothers

from intervention knew and gave their children thick porridge as opposed to the majority

of mothers who gave their children thin porridge. Thick porridge is the best for starting up

children on complementary feeding. This study was in tandem with the study that was done

to establish the influence of videos in modifying the health behavior (Tuong & Armstrong,

2014). The wide difference that is noted in the intervention from that of the control is

attributed to the nutrition education videos which they watched.

They also fed their children on dark green vegetables, eggs, pumpkin and legumes.

Generally, there was good consumption of balanced diet across the groups but across the

food groups, intervention group showed a better consumption than the control group.

Consumption of vitamin A rich food sources stood out to be best consumed in the

intervention than control. These findings conformed to the study which was conducted

among the immigrant Latin mothers (Scheinmann et al., 2010). The better performance by

the respondents from the intervention group might have been attributed to the nutrition

education videos which were being projected and explained by the health workers in the

health facilities. It was found that out of the 7 food groups for complementary foods for

children between 6 to 23 months, the caregivers from the intervention group had better
 71

practice than those in the control group. There was a significant difference between the

intervention group whose mean was 5.191+4.624 and the control group, 3.731+1.548.

5.3.4.3 Minimum Meal Frequency

As children aged 6-23 months grow, their energy requirements, though with limited

stomach capacity hinders their ability to achieve nutrient needs more especially if few

meals are given each day (Islam et al., 2008). Frequent meals are vital for children to

receive enough energy (WHO, 2014). Minimum meal frequency should be; - 2 times for

children who are breastfed, (6-8 Months), 3 times for children 9-23 months and are

breastfed and 4 times for those children who are non-breastfed between 9-23 months

(UNICEF, 2014 & WHO, 2008). In this study, over a half of the mothers in both

intervention and control groups knew the meal frequency for children after 9 months and

are breastfeeding. This was in agreement with the findings of the study which was done at

Kahawa West Public Health Center (Kimwele, 2014). It was found that there was a

difference in the meal frequencies which were given to children between the intervention

group and the control group though was not significant. The intervention group had a mean

of 2.72+1.115 and the control group 2.58+1.2.

5.3.4.4 Minimum Acceptable Diet

In Kenya, there is low achievement of minimum acceptable diet (KDHS, 2014). From this

study, majority of children from intervention attained minimum acceptable diet as

compared to control group. The difference between the two groups was contributed by

nutrition education videos which were projected in the intervention sites. The low

attainment is similar findings realized in the study which was done in Korogocho (Korir,
 72

2013). The minimum acceptable diet is achieved when a child consumes food from varied

sources with recommended meal frequencies.

The low adherence to recommended feeding practices for this study can be attributed to

the low level of education, unemployment for most women and also obtaining food through

buying. These findings were similar to the findings which were reported in Kibera informal

settlement in Nairobi (Mucheru, 2016). Both groups had similar socio-economic features

though had different practice outcomes. This might be clearly attributed to the use of the

nutrition education videos which influenced participants in the intervention sites both in

their knowledge, attitude and practice. In a study done of a project termed as video-

mediated staff development for establishing educational partnership (Welch & Sheridan,

2000 and Kay, 2012) showed similar findings. Out of the 12 knowledge questions which

the caregivers were asked, there was a difference between intervention group whose mean

was 9.842+1.045 and control group whose mean was 8.110+1.778.

 73

CHAPTER SIX: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

6.1 Introduction

This was a post-intervention cross-sectional analytical study whose main purpose was to

determine the effect of using nutrition education videos on the mother’s knowledge,

attitude and practices on complementary feeding of children aged 6-23 months attending

the selected MCH clinics in Ruaraka Sub-county, Nairobi City County.

6.2 Summary of the findings

The preponderance of the households was headed by males (83.6% from the control group

and 92.4% from the intervention group). Most respondents were middle aged mothers

(25.32 years), married (83.8% for the control and 89.0% for the intervention group),

Christians (95.0% from the control and 99.2% from the intervention group), lactating

(93.8% from the control and 96.6% from intervention group) and had primary school

education as their highest level of education (47.5% from the control group and 45.8%

from the intervention group). It was also observed that majority of the mothers were

housewives (67.5% from the control and 67.8% from the intervention group) with no

employment thus depended on their husbands as the main provider for family needs who

majority were casual laborers (50.0% from the control and 43.2% from the intervention

group). It was also noted that majority of the households never allocated specific amounts

for food (38.7% from control and 44.1% from the intervention group) with their husbands

being the sole decision makers on how family income should be used (46.3% from control

and 69.5% from intervention group) and wives decide on which foods to be cooked (88.7%

from control and 89.0% from the intervention group).

 74

Mothers from the intervention group were more likely aware of on child feeding (P=0.043)

and appreciated the information. Though there was no significant difference on the need of

more education on child feeding, the intervention group a higher interest ownership and

possession of information (90.1%) as compared to the control group (62.5%) in that they

felt they needed to be enlightened more and more. It was also established that mothers from

the intervention group had a good understanding of the number of food groups from which

a child is supposed to be fed from each day which gave out a significant difference

(P=0.042). Even though the study found out that there was a higher proportion of mothers

who knew the right age of introducing complementary foods (96.3% from the control group

and 100% from the intervention group) there was a significant difference between the two

groups (P=0.021).

In handling sick children, only few mothers from both the groups (1.25% from the

intervention group and 4.2% from the intervention group) did not know how to feed them

according to the WHO guidelines but majority had a good knowledge on this. Therefore,

there no significant difference between the two groups (P=0.152).

The study also found out that as both groups reported to have breastfed their children as

stipulated by the WHO guideline, there was a significant difference (P=0.021) with a higher

proportion from the intervention group (87.1%) breastfeeding within the 1st one hour of

birth enabling their children to get colostrum which is vital for the child as compared to the

control group (63.8%) thus exhibiting a significant difference between the two groups
 75

(P=0.048). This study also showed that the two groups also adhered to the principle of not

giving the child any drink in the first 3 days apart from the breast milk though the

intervention group (94.9%) showed a better observation of this compared to the control

(81.7%) with a significant difference between the two groups (P=0.01).

Most mother (100% from intervention and 95.0% from the control group) were still

breastfeeding. In terms of complementary feeding and food diversity, the study found a

significant difference between the two groups (P=0.042) whereby mothers from the

intervention group fed their children from at least 4 food groups minimum attainment of

minimum acceptable diet while majority of mothers from the control group fed their

children from 2-3 food groups. Even though the two groups exhibited a good understanding

and practice of the consistency of the baby’s foods, there intervention group had a good

practice in that they gave their children thick porridge (93.8%) while most mothers from

the control group fed their children with thin porridge (73.7%) thus showing a significant

difference between the two groups (P=0.022).

In terms of water sanitation and hygiene, most mothers (97.5% from the control and 98.0%

from the intervention group) preferred using tap water as their main source of drinking

water. The bigger number of these mothers and the caregivers boiled water for drinking as

the main way of treatment. It was also observed that the two groups accessed toils with

flush toilets being the most common ones. Though they disposed their children’s fecal

matters immediately, there was a significant difference in the critical moments of

handwashing between the two groups (P=0.033).

 76

In feeding sick children, it was found that most mothers (50% from the control group and

72% from the intervention group) fed their children with less food because the sick children

did not want to eat though there was a significant difference between these two groups

(P=0.002).

Overall, the study established a difference between the control and intervention groups on

minimum meal frequencies though not significant (2.58+1.2 mean score for the control

group and 2.272+1.12 mean for the intervention group). The two groups exhibited

differences which were statistically significant on both dietary diversity (P=0.006) and

knowledge mean scores (P=0.001) indicating that the intervention group had better

knowledge and practice on foods to be used during initiation of complementary feeding.

Generally, from the study it can be noted that intervention group had better knowledge and

practice compared to the intervention group on matters of complementary feeding. The

difference can be strongly alluded to the nutrition education videos which were projected

in the health facilities which were in the intervention centers. The effect of nutrition

education videos was realized as the knowledge of mothers and caregivers improved in the

intervention centers as opposed to the control centers.

Therefore, in line with the hypotheses that had been set, the following are the summaries

of the findings; -

Ho1: There is no significant difference in socio-demographic characteristics of mothers

with children 6-23 months of age between the intervention and control groups; fail to reject
 77

Ho2: There is no significant difference in Knowledge on complimentary feeding of children

6-23 months between mothers in intervention and control groups; rejected

H03: There is no significant difference in complementary feeding practices of children 6-

23 months between mothers in intervention and control groups; rejected

6.2 Conclusion

The study population is composed of middle-age mothers who have low levels of education

and socio-economic status. Most households are headed by the fathers who couple as the

bread winners as their wives being housewives. Mothers depend on their husbands in

providing for the family and main decision makers on how to use family income.

Generally, there is great knowledge and practice on complementary feeding exhibited

especially by those who were exposed to nutrition education videos. They are much

enlightened by the videos and put whatever they learn into action. This is a clear evidence

that if the audio visual messaging can be embraced in the facilities, many patients will have

improved knowledge on various aspects of health. The differences realized mostly between

the intervention and the control group can be bridged if the nutrition education videos can

be aired in all the health facilities for the patients to view and learn in all aspects of health

as they wait to be attended to by clinicians.

Though there is a significant difference between the mothers in the intervention and control

groups, most mothers from both groups received, embraced and appreciated the

information they were given and even desire to be given more and more. Through the use
 78

of education videos, the workload in the health facilities are lighted for the health workers

more especially in the health facilities which have high caseloads.

Complementary feeding practices are more appropriate in the intervention group than in

the control group in terms of introduction of solid, semi-solid and soft foods for children

aged 6-8 months, and minimum meal frequency for the children. Dietary diversity is better

in the intervention group than the control group though not high as it could have been

expected may be because of the low-income levels of the mothers and caregivers of these

children; which might have affected their purchasing power of a variety of foods. There

are gaps noted in the feeding of sick children in both intervention and the control groups.

6.3 Recommendations

6.3.1 Practice

The Ministry of Health (Unit of nutrition and dietetics) to take up the use of nutrition

education videos and help in installing them in as many health facilities as possible as a

viable strategy of messaging/communication and support health facilities so as to educate

caregivers by complimenting the existing channels in use. This will enable them to

overcome challenges associated with maternal and child health in informal settlements.

Many messages can also be prepared and effectively passed within a short period of time

which could make it a cost-effective strategy in the long term.

 79

6.3.2 Policy

The Ministry of Health both at National and County level to come up with a Standard

Operation Procedures for the effective utilization of installed TV sets at the health facilities

for health and nutrition education. This will help in terms of accountability and durability.

Additionally, they should recommend that the language and content to be used in the video

clips should be contextualized so as to benefit the communities within the specified

catchment.

6.3.3 Research

This study was done in the urban slums set up only. Another study can be conducted in the

rural set up to enable bring up any differences so as to enable scaling to wider populations

and also recommend appropriate intervention strategies for the different set ups.
 80

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APPENDICES

Appendix A: Summary of data analysis per objective.

DATA ANALYSIS

Objectives Type of data Method of Standards

analysis /Referenc
es
To establish the socio-economic and
demographic characteristics of mothers Frequencies,
with children aged 6-23 months attending Continuous Percentages KDHS
selected MCH clinics, both intervention and Categorical and mean 2014
control facilities, in Ruaraka Sub-county.
To assess the knowledge of mothers on
complementary feeding of children aged 6- Continuous Frequencies WHO
23 months attending selected MCH clinics, Categorical and 2010
both intervention and control facilities, in proportions
Ruaraka Sub-County
To determine the attitudes of mothers on
complementary feeding of children aged 6- Continuous Frequencies WHO
23 months attending selected MCH clinics, Categorical and 2010
both intervention and control facilities, in proportions
Ruaraka Sub- County.
To establish the practices of mothers on
complementary feeding of children aged 6- Continuous Frequencies WHO
23 months attending selected MCH clinics, Categorical and 2010
both intervention and control facilities, in proportions
Ruaraka Sub- County.
To establish the effect of nutrition education T-test
videos on mothers’ knowledge, attitudes Continuous
and practices (KAPs) on complementary Categorical
feeding of children 6-23 months attending
selected MCH clinics, both intervention and
control facilities,Ruaraka Sub-County.
 91

Appendix B: Informed Consent and Introduction Form

My name is ROBINSON NYARIBO MOCHONI. I am a masters’ student at Kenyatta

University from the school of Applied Human Sciences, Department of Food, Nutrition

and Dietetics. I am conducting a study on the Effect of Nutrition Education Videos on

Mothers’ Knowledge, Attitudes and Practices on Complementary Feeding of children aged

6-23 months, Ruaraka nairobi City County. The information will be used by the ministry

of Health and programmers for guiding interventions that can be put in place to enrich

mother and young child feeding (MYCF) practices.

Procedures to be followed

Participation in this study will be required that I will ask you questions after you had

watched the video records projected for 6 months on the knowledge, attitudes and practices

gained. I will record the information from you in a questionnaire.

You have the right to refuse participation in this study.

Please remember the participation is voluntary. You may ask questions related to the study

at any time.

You may refuse to respond to any questions and you may stop an interview at any time.

You may also stop being in the study at any time without any consequences to the service

you receive from this institution or any other organization now or in future.

Discomforts and risks

The study has no potential risks or injuries to the participants as no victimization, cohesion

or any other form of uncomfortable action administered to the participants.

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Benefits

The findings from this study will give the Ministry of Health and other stakeholders useful

information for guiding interventions that can be put in place to enrich mother and young

child feeding (MYCF) practices.

You will also benefit as a care provider in that you can use the model to complement

counseling cards for education on the infant and young child nutrition.

Rewards

You will not receive any form of payment or compensation if you agree to participate in

this study. Similarly you will not be charged any fee for your participation.

Confidentiality

There will be confidentiality in the information given. Your name will not be recorded on

the questionnaire. The questionnaires will be kept in a locked cabinet for safe keeping. All

the information you will give me will be kept private.

Contact Information

If you have any questions you may contact: 1. Prof. Judith Kimiywe 0722915459 or Prof.

Marja Mutanen ([email protected]) or the Kenyatta University Ethical Review

Committee Secretariat on [email protected].

[email protected], [email protected]
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Participant’s statement

The above information regarding my participation in the study is clear to me. I have been

given a chance to ask questions any my questions have been answered to my satisfaction.

My participation in this study is entirely voluntary. I understand that any records will be

kept private and that I can leave the study any time. I understand that I will still get the

same services whether I decide to leave the study or not and my decision will not change

the services that I will receive from the institution today or any other time.

Name of the participant: ___________________________________________________

Signature or thumbprint: Date:

____________________________ _____________________

Investigator’s statement

I, the undersigned, have explained to the volunteer in a language she/he understands, the

procedures to be followed in the study and the risks and benefits involved.

Name of Interviewer: ______________________________________________________

Signature or Thumbprint Date:

_____________________________ ________________________
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Appendix C: Questionnaire

COMPLEMENTARY FEEDING PRACTICES.

Administrative details

Questionnaire identity number……………. Name of the County

……..…….…………….

Date of interview…………………… Health Care Center …….….…………..

What group does the baby belong? (Months) 6-8 [ ] 9-11 [ ] 12-23 [ ]

Section A: Household demographic and socio-economic data

A1. Sex of household head 1. Male [ ] 2. Female [ ]

A2. Age of the mother…………………………. Years

A3.Marital status 1. Married [ ] 2. Single [ ]

3. Divorced [ ] 4. Separated [ ] 5. Widowed [ ]

A4. Are you currently;

a) Pregnant [ ]Months …………..

b) Lactating [ ]
c) Pregnant and lactating [ ]
d) Not lactating [ ]

A5 highest education level completed

1) Less than primary [ ]

2) Primary [ ]
3) Secondary/High school [ ]
4) College/pre-university/university [ ]
5) Post graduate degree [ ]

A6 Which religion do you belong to?

a) Christian [ ]
b) Muslim [ ]
c) Hindu [ ]
d) Other ………………..
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e) None [ ]

A 7 Occupation of household head (skip to A9 if the mother is the household head)

1. Employed [ ] 2. Self employed [ ]

3. Casual labour [ ]

Any other (specify) ………………………………………….

A8. Occupation of mother

1. Employed [ ] 2. Self employed [ ]

3. Housewife [ ]

Any other (specify) ………………………………………….

A9. Household size……………………….. people.

A10. How many children do you have……………..

A11. How many children are below 5 years of age……………..

A12. What is the main source of family income?

1. Formal employment [ ] 2.Casual labor [ ]

3. Business [ ]

Any other (specify) ………………………………………….

A13. How is food obtained in the family?

1. Farming [ ] 2. Buying [ ]

A14. Who has the primary responsibility of providing food for the household?

1. Father [ ] 2. Mother [ ] 3. Grandparent [ ]

4 Relatives [ ] 5. Any other (specify) ………………………………..

A15. How much money is allocated to food every month?

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1. Largest % of household income [ ] 2. Smallest % of household income [ ]

3. Half of household income [ ] 4. No specific allocation given [ ]

A16. Who usually decides how family income will be used?

1. Husband/Partner [ ] 2. Wife [ ]

A17. Who usually decides on what food to be cooked each day in the family?

1. Husband/partner [ ] 2. Wife [ ]

3. Children [ ]

4. Any other (specify)…………………………………..

Section B: Household water consumption, sanitation and hygiene

B1. What is your main source of drinking water?

1=River 2=Water tap 3=Borehole 4=Unprotected well 5=Protected well

6=Tanker 7=Other 8=Other………………

B2.Do you do anything to the water before drinking it?

(More than one response possible)

1=Boiling 2=Use traditional herbs 3=Use chemicals 4=Filters/Sieves

5=Decant 6=Nothing 7=Others (Specify)…………………

B3. Does your house hold have access to a toilet facility?

1=YES 2=NO

B4. If YES, What type of toilet facility?

1=Bucket 2=Traditional pit latrine 3=Ventilated improved pit latrine

4=Flush toilet

5=Other (specify)…………………………………

B5. If NO, where do you go/use? (Probe further)

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1=Bush 2=Open field 3=Near the river 4=Behind the house 5=Other
specify

B6. How are children’s fasces disposed? (OBSERVE)

1=Disposed off immediately and hygienically 2=Not disposed (scattered in the

compound) 3=Others (Specify)

B7. At what times do you wash your hands? (Multiple answers possible)

1=After defecation/visiting toilet 2=Before feeding the child 3=Before eating

4=Before preparing food 5=When I think they are dirty 6=When water is
available 7=Other (Specify)

Section C: Complementary feeding practices

C1. Did you ever breastfeed [Name]? [If No, go to C2.; If yes, go to C3.]

1.Yes [ ] 2. No [ ] 3= DNK

C2. If No, why?

1= No milk; 2= Did not want to breast feed 3=traditional beliefs (child will die)
4= other (Specify)

C3. If yes, how soon after birth did you put [Name] on the breast?

If less than an hour record 00; If less than 24 hours record number of Hours; If more
than 24 hours record number of Days; If mother does not know, record: 88

C4. During the first 3 days after delivery, did you give [Name] the fluid/liquid that came
from your breasts?

1= Yes

2= No,

3= DNK

C5. In the first 3 days after delivery, was [Name] given anything to drink other than
breast milk?

1= Plain water; 2= Sugar water or glucose water; 3= powdered milk or fresh milk; 4=
infant formula (Mamex, Nan), 5= Gripe water; 6= not given; 7= Other (specify)

C6. Are you still breastfeeding [Name]?

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1= Yes

2= No

C7. If no when was breastfeeding stopped?.............................months.

C8. Was [NAME] breastfed yesterday during the day or at night?

1. Yes [ ]

2. NO. [ ]

3. Don’t know [ ]

C9. Have you received information about feeding?

1. Yes [ ] 2. NO. [ ]

C10. From whom/where did you receive/have you received information from? (NAME)

1. Mother/mother-in-law [ ]
2. Father/ father-in-law [ ]
3. Other Relatives [ ]
4. House girl [ ]
5. Neighbor/friend [ ]
6. Day care center [ ]
7. Siblings [ ]
8. Health worker [ ]
9. Community health volunteer [ ]
10. Media [ ]
11. Glocal videos
12. Others (Name) …………………………….
C11. Do you feel you have received enough information about feeding?
a) Yes [ ]
b) No [ ]
C12. Who mainly decides what (NAME) should or should not eat?

i. Baby’s mother [ ]
ii. Baby’s father [ ]
iii. Baby’s grandmother [ ]
iv. House girl [ ]
v. Day care centers [ ]
vi. No one (self) [ ]
vii. Others (specify) [ ]
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C 13. Now I would like to ask you about liquids that [NAME] drank yesterday during the
day or at night, whether at home or outside the home from the time he/she woke up to the
time he/she went to bed.

Coding
Fluids categories(circle as
applicable)

Yes No DK
(1) (2) (3)

A Plain water

B Juice or juice drinks

C Soda

D Clear broth

E Milk such as tinned, powder or fresh animal milk

F Infant formula

G Any other liquid

H Yoghurt

N/B DK- Don’t Know

C14. Did [NAME] eat any solid, semi-solid, or soft foods yesterday during the day or at

night? ……If YES, proceed to C15.

C15. How many times did (NAME) eat solid, semi-solid or soft foods other than liquids

yesterday during the day or at night? 1. No of times………..98. Don’t know

C16. Please describe everything that (NAME) ate yesterday during the day or night,
whether at home or outside home.

a) Think about when (NAME) first woke up yesterday. Did (NAME) eat anything at
time?
If yes: please tell me averything (NAME) ate at that time. Probe:Anything else?
Until respondent says nothing else. If no, continue to question b.
b) what did (NAME) do after that? Did (NAME) eat anything at that time?
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If yes: please tell me averything (NAME) ate at that time. Probe:Anything else? Until the
respondent says nothing else.
Repeat question b) above until respondent says the child went to sleep until next day.
If respondent mentions mixed dishes like PORRIDGE, sauce or stew, probe:
c) What ingredients were in that (MIXED DISH)? Anything else? Until respondent says
nothing else.Select from the following:
Breakfast
Lunch
Dinner
Snack
Tick boxes for food groups that the child ate from at each meal.
Only include food groups that child ate more than a spoonful of:

No
Coding
Question and filters categories(circle
as applicable)

Yes No

A Any fortified baby food like cerelac

B Maize, rice, wheat, porridge, sorghum, break or other foods made

from grains
C Pumpkin, carrots, squash, or sweet potatoes that are yellow or
orange inside?
D White potatoes, white yams, cassava, or any other foods made
from roots?
E Any dark green vegetables?

F Ripe mangoes, papayas, pawpaw guava (yellow or orange on the

inside of fruit)
G Liver, kidney, heart, or other organ meats

H Any meat, such as beef, pork, lamb, goat, chicken, or duck

I Eggs

J Fresh or dried fish, shellfish, or seafood

K Any foods made from beans, peas, lentils, nuts, or seeds

L Cheese or other food made from milk?

M Any oil, fats, or butter, or foods made with any of these

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C17. At what age in Months should one introduce first solid/semi-solid food to
buy?Did the babydrink anything from a bottle with a nipple yesterday during the day or
night?

1. Number of the month…………….2. Don’t know [ ]

C18. In your opinion, is it important to continue breastfeeding when a child has started
eatingfoods, why? (Select first answer!)
a) No [ ]
b) Yes, it is easy [ ]
c) Yes, it gives baby nutrients [ ]
d) Yes, it helps baby develop [ ]
e) Yes, it protects baby against disease [ ]
f) Yes, Others [ ]
C19. What type of porridge is better for babies, liquid or thick?
i. Thin [ ]
ii. Thick [ ]
C20. How often should a baby be given food (meals and snacks) after 9 months?

1) 1 meal + snacks [ ]
2) 2 meals + snacks [ ]
3) 3-4 meals + snacks [ ]
4) More often [ ]
C21. What are the main food groups? (take answers that give only examples of foods from
these groups as correct) . POSSIBLE RESPONSE POSSIBLE
a) Cereals, roots and tubers [ ]
b) Milk and milk products [ ]
c) Fruits and vegetables [ ]
d) Fats [ ]
e) Meat [ ]
f) Fish and eggs [ ]
g) Pulses [ ]

Section D: Maternal knowledge on complementary feeding practices

D1. For how long should a mother exclusively breastfeed a child?
a) 0-2months [ ]
b) 2-3 months [ ]
c) 4 Months [ ]
d) 5 months [ ]
e) 6 Months [ ]
f) Don’t know [ ]
g) Other (specify)………………………………………………….
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D2. How many times should a mother breast feed a child after 6 months?
a) One time [ ]
b) Thrice [ ]
c) On demand [ ]
d) Don’t know [ ]
e) Other (specify) ………………………………………………….
D3. For how long should a mother breastfeed a child before ceasing completely?
a) 1-6 months [ ]
b) 6-12 months [ ]
c) 12-18 months [ ]
d) 24 months [ ]
e) More than 2 years [ ]
D4. At what age should semi-solid, solid and soft foods be introduced to the child?
a) After 3 months [ ]
b) After 6 months [ ]
c) Anytime [ ]
d) Don’t know [ ]
e) Other (specify) ………………………………………………….
D5. What is the minimum number of food groups your child should consume each day?
a) 1-2 groups [ ]
b) 2-4 groups [ ]
c) Above 4 [ ]
d) Don’t know [ ]
e) Other (specify) ………………………………………………….
D6. How many times should you feed your child on complementary food each day?
a) Once [ ]
b) Twice [ ]
c) Thrice [ ]
d) Four times [ ]
e) Don’t know [ ]
f) Other (specify) ………………………………………………….
Section E: Feeding the child during illness
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E1. The last time [NAME] was ill, did you offer less, more or thesame amount of breast
milk as when (NAME) is healthy?
a) Less, because the child did not want it, [ ]
b) Less, because mother’s decision, [ ]
c) More, [ ]
d) The same, [ ]
e) Child never breastfed or child not, [ ]
f) Breastfeeding before last illness, [ ]
g) Child has never been sick, [ ]
h) Does not know [ ]
E2. After the illness ended, did you offer less, more or the same After amount of food as
when [NAME] is healthy?
1) Less, because the child did not want it, [ ]
2) Less, because mother’s decision, [ ]
3) More, [ ]
4) The same, [ ]
5) Does not know, [ ]
E3. How often are you/ is the mother away from the baby for most of the day (more than

half a day)?

a) Always/most days (6 days/week), [ ]

b) Often/Many days (4-5 days/week), [ ]
c) Sometimes/A few days (2-3days/week), [ ]
d) Never/few days (0-1 days/week) [ ]
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APPENDIX D: Research Approval from Kenyatta University Graduate School

 105

APPENDIX E: Approval from Kenyatta University Ethical Review Committee

106
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Appendix F: Research Permit by National Commission for Science, Technology and

Innovation
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Appendix G: Research Authorization from National Commission for Science,

Technology and Innovation
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Appendix H: Ethical Clearance from AMREF