2.1. Study designand period
This study was based on a descriptive cross-sectional study, conducted between January to April 2020.
2.2 Study setting
This study was conducted in MDH; it is a public hospital with a secondary level of care located in the Masaka neighborhood, in the capital city of Kigali, MDH is one public district hospital in Kicukiro district, it is a fresh brand hospital built. They offer specialized medical services and general medical services. The inhabitants who get served there fall between 380,000 and 400,000.
2.3. Study participants
Participants were selected based on a convenience non-random collection. A convenience non-random collection sampling technique approach was used where all mothers who were seen in the hospital during the period of data collection were enrolled if inclusion criteria were met.
All mothers attending the following departments, neonatology, maternity wards, immunization, obstetrics, and gynecology outpatient clinic for pregnant, women coming for antenatal visits in the hospital were all considered during data collection after being given the consent of the study. Those who had at least one child aged 6 months or younger at the time of the study were included.
2.4. Sample Size and Sampling Technique
We have used a single population proportion formula by taking a proportion of prevalence of EBF of the previous study, 68.6% and we used a 95% confidence interval. To adjust the non-response rate of study participants, we were added 10% of the sample size. Sample size determination using the Fischers formula:
Henced the total sample size required for this study with a 10% continuity correction was 364.
where 𝑎 is the level of significance which can be obtained as 1 − confidence interval, 𝑃 is a proportion of prevalence EBF, which is equal to 68.6, D is the maximum acceptable difference (margin of error) which is equal to 5%, and 𝑍𝑎/2 is the value under the standard normal table for the given value of confidence level which is equal to 1.96.
2.5. Data collection procedure and techniques
Data were collected during the study period via face-to-face interviews with women on a randomly selected working weekday. The researchers approached the mothers who visited MDH and those who accepted to participate in the study were interviewed until the final sample number was reached. The interviews were performed in the waiting rooms of the hospital using a questionnaire. Also, the interviews lasted 10 minutes on average and privacy were maintained during the interviewing period. This was done to maximize the chances of the participants feeling comfortable and able to answer the questionnaire. Before starting the interview, the researchers described the survey topic and the organization of the questionnaire to the participants and assured them that the interview was completely anonymous, and that the data collected would be saved private, and that the written informed consent was collected. Besides, the research team explained to the women that they could stop the interview at any time without penalty, the participation was voluntary, and that no payment would be given.
The questionnaire was organized into five sections: Section A: sociodemographic data, Section B: data on exclusive breastfeeding knowledge, Section C: Data on the attitude of respondents towards EBF, Section D: data on the practice of respondents towards EBF, and Section E: Reasons of not exclusive breastfeeding and information on breastfeeding practices.
Structured and semi-structured questionnaires were used for the data collection in the form of a closed-ended (multiple choice) question style. The items included in the questionnaire were chosen based on previously published investigations of a validated standardized questionnaire, the questionnaire used in the present [17, 19-22], or because they were considered interesting, or modified to meet our objectives of the study by the research team. The questionnaire will include a set of questions organized under five main sections was aimed at gathering information from mothers about exclusive breastfeeding. Section A of the questionnaire included a set of variables that targeted information about mothers social and demographic characteristics namely age, nationality, religion, marital status, educational status, partner’s level of education, occupation, residence, parity, gravidity, antenatal care follow-up, type of birth, gestational age, child’s body weight at birth, place of birth, and rooming-in.
Besides, there were 20 items to measure the knowledge of the participants about exclusive breastfeeding. Three possible responses for each item (Yes, No, and I don’t know). Correct responses were scored as one, and zero for other options. By summing up all the awarded points, the overall score was determined for each respondent and these were translated to percentages. Each respondent will be given an information grade based on his total percentage score. All mothers who score >70% in the knowledge test were considered to have good knowledge and those scoring <70% were considered as having poor knowledge according to FAO guidelines. .
Maternal attitudes towards EBF were determined by responses to 12 questions. Correct responses were scored as one, and zero for other options. The total score for each respondent was calculated by summing up all the awarded marks, and these were converted to percentages. The attitude score was calculated. Attitudes were measured with questions that required “Agree”, “Neutral” or “Disagree” responses. The total score for each respondent was calculated by summing up all the awarded marks, and these were converted to percentages. All mothers who scored >70% in the attitude test will be considered to have a positive attitude and those scoring <70% will be considered to a negative attitude.
Informed consent forms were attached to all questionnaire for the participants to read and sign if they were willing to participate in the study. Questionnaires and informed consent forms were drafted in Kinyarwanda. A pilot study was conducted after ethical approval was allowed to assess the questionnaire’s comprehensibility, and modifications were accordingly made. The pilot sample met this study’s inclusion, and exclusion criteria, and the pilot sample size was 36.
2.8. Data quality control
Three enumerators (data collectors) with a minimum of a Diploma in Health or Nutrition qualification were recruited from those residing in the study area, and who speak Kinyarwanda (the local language) fluently. The enumerators also had previous experience in survey data collection. The enumerators underwent 2 days of training to cover the following: the explanation of the study objectives, interview techniques, and research ethics.
2.9. Data analysis and presentation
The data was checked, cleaned, and coded, and analyzed using SPSS version 16.0. All data were analyzed using descriptive statistics of the frequencies and percentages for categorical variables. Cross tabulation and chi-square tests were used to determine univariate associations. To determine factors associated with the practice of EBF, multiple logistic regression was executed. The dependent variable of the logistic model was EBF practice. Only variables that were significantly associated with the practice of EBF in the cross-tabulation analysis were included in the logistic regression model. The findings are presented as odds ratios and their respective confidence intervals at 95 %. The p-value < 0.05 was considered statistically significant in all analyses.