Exercise-Based and Associated Factors Breastfeeding on HIV-Infected Mothers for Children Age 1-24 Months in Central Zone, Tigray, North Ethiopia, 2019.

Background: Breastfeeding exposed to HIV is a major factor in the spread of HIV, but breastfeeding alone poses a signi�cant risk to the baby's health because breastfeeding can reduce the impact of many infections and support some chronic diseases. Therefore, this study was aimed to assess exercise-based and associated factors breastfeeding on HIV-infected mothers for children age 1-24 months in the central zone, Tigray, north Ethiopia. Methods: A Facility-based Cross-Sectional study was conducted from March to April 2019. A systematic random sampling method was used to select study participants. Information was collected using a structured, pre-tested questionnaire. The data is coded, cleaned, copied and entered EPI-info 7 and �nally export to SPSS version 22.00 for analysis. Association between independent and dependent variables was �rst analyzed using binary logistic regression analyses. An alternative bivariate logistic regression analyzes of less than 0.2 were entered in multivariable logistic regression analysis. The statistical association between variance dependent and independent variables was measured using an OR, AOR, 95% CI, and a p-value less than 0.05.


Background
Breastfeeding exposed to HIV is a major factor in the spread of HIV, but breastfeeding alone poses a signi cant risk to the baby's health because breastfeeding can reduce the impact of many infections and support some chronic diseases and breastfeeding.Diet exercise is generally the best baby diet choice for all women (1).
Globally, over 10 million children under ve die each year and 40% of diseases under the age of two are associated with inappropriate breastfeeding, 34% of which occur in South Asia and 41% in sub-Saharan Africa (2).In addition to breastfeeding, 300,000 HIV infections occur annually, while at the same time the United Nation Children Emergency Fund (UNICEF) is not responsible for the deaths of 1.5 million children in one year, and the biggest burden of this infection, Sub-Saharan Africa (3).
In the rst year of the world, two-thirds of all deaths in the world often follow appropriate nutritional practices, especially due to unspeci ed breastfeeding activities (4).In the developing world, including Ethiopia, 3000-4000 infants per day die from diarrhea and respiratory infections associated with high levels of disease (5).
In Ethiopia, 321,000 children under ve years of age die from malnutrition, with 57% of death each being primarily prevented by breastfeedings, such as diarrhea and pneumonia.(6).About 40% of the world population, 47% in Africa, and 58% in Ethiopia, according to Ethiopian demographic and health survey (EDHS) 2016, have increased the number of children under 0-6 months.(7,8).Study show's in India 30.6% (9) southern Ethiopia, Mekelle and central zone Tigray show that attitude towards exclusive breastfeeding about 56.7%, 81.6% and 82.6% of HIV mothers had favorable attitudes towards EBF (10)(11)(12).
Recent study identi ed that predictor for attitude and practice exclusives breastfeeding among mothers living with HIV/AIDS were mother's occupation, residence, knowledge on EBF practice, ANC service, counseling on EBF practice during ANC visit, insu cient breast milk, husband imposition, mother's illness and both mother's and infant's illness, income, maternal choice of maternal-infant feeding practice and cultural (10-21) Therefore, this study was aimed at assessing attitude, practice and determinant factors affecting exclusives breastfeeding among mothers living with HIV/AIDS have children age 0-24 months in central zone Tigray.

Methods
A facility-based cross-sectional study was conducted from March to April 2019, at Central zone Tigray regional state of Ethiopia.The central zone is 1024km from Ethio -capital, Addis Ababa, 240 km from the capital city of Tigray.The central zone was divided into 12weredas, of which 631,972 were female and 613,251 were males.The total number of people living with HIV was 4841, the reproductive-age women who are HIV positive were 2028 and HIV positive mothers who have an infant less than or equal to 24 months were 485.There were 72 health centers (20 of them have ART service), 6 primary hospitals, 3general hospitals, and 1 referral hospital.
All HIV positive mothers with children younger than or equal 24 months were recruited as a study group within the designated public health facility's central zone.All HIV-positive mothers who gave birth within 24months before the study were included, excluded, had no mental illness or had several mental illnesses during data collection.
Considering 82% of exclusive breastfeeding rate for children under six months of age (21), 95% con dence level, 5% tolerable margin of error, 5% unresponsive, a total sample of 239 were considered.to test the consistency of sample size, Epi-info was considered to be the only breastfeeding practice considering the relevant aspect of the observation.It was larger than the EPi-info by comparing a sample size based on a population.Therefore, the largest sample size of 239 was determined.
Considering all public health institutions in the Tigray region of the Central Zone, the sample size visited all public health institution s based on the number of children under or equal the age of 24 months who were HIV positive mother, round up.Participants in the study were selected for each of the 2 HIV-infected mothers of a randomized random sampling method, equal to 24 months.Attitude and practice Exclusive Brest feeding was considered as the dependent variable.Sociodemographic and Reproductive characteristics, knowledge exclusive breastfeeding, Institutional and source of information related factors were considered as the independent variable.
Good practice of exclusive breastfeeding -mothers answer (score > 60%) on the overall practice question (17).
Keble: A small administrative unite consisting of 20.000 population.
The information was collected using the questionnaire and a structured questionnaire from a variety of similar research (15, 17, 19) if there was a change in the context of the study.Face-to-face breastfeeding alone was tested during a panel discussion with 12 women and one of the women in questionnaire accuracy and translation quality questionnaire.A few questions for language transparency and information were reviewed and the questionnaire was completed for the study.The applicant includes a source of social and demographic, reproductive history, institutional and informational sources.
Five health care professionals and two supervisors were recruited from the health center and trained for one day.Supervisors follow a daily data collection process and communicate with investigators every day to check the consistency of the data.
The data is coded, cleaned, copied and entered EPI-info 7 and nally export to SPSS version 22.00 for analysis.A simple descriptive summary was made.Table, diagrams, descriptions, charts, and graphs were used to produce the result of the analyzed data.After that, you can combine the lters into the corresponding catalogs using a chi-square test variable with small cell size.An alternative bivariate logistic regression analyzes of less than 0.2 were entered in multivariable logistic regression analysis.
Appropriate tness testing done well more than 0.2 predicted variants and a multiple-choice test between Hosmer and Lemeshow test P-value to assess model performance.The statistical association between various independent variables was measured using an OR, AOR, 95% CI, and a p-value less than 0.05.

Socio-demographic characteristics of mothers
A total of 239 HIV positive mothers participated in a response rate of 100%.Out of the total participated mothers, 175(73.5%)were with an age range of 25-35 years.The majority of the participants 177(73.8%)were married (Table 1).

Health institutions related factors and source of information
Three fourth of the respondents (75.8%) reported that they had to get information about EBF from health professionals.Among them, 97.9% of these respondents had availability of health care facilities in your area.(Table 2).

Reproductive characteristics of mothers
The majority of the respondent's 74.4% mother's age at marriage was 18-24 years.Among them, 54.2% of mothers their child age from 6 months up to 12 months.From total respondents, about 95.8 % attended ANC follow and about 76.6 % were from 3-4 ANC follow up (Table 3).

Knowledge of EBF among HIV positive mothers
In our study majority respondents, 93.7% heard about exclusive breastfeeding, among this 92.4% knew the importance of exclusive breastfeeding for child health.About knowledge on EBF HIV positive mother, 88.2% of the respondents know HIV seropositive mother can breastfeed, 90.8% know foods or uids recommended to under 6-month child is only breast milk and about 35.6% know times baby breastfeeding per day were from 8-10 times (Table 4).

The attitude of EBF among HIV positive mothers
In our study more than three fourth respondents, 78.6% believed that breast milk was free from any contamination; among this 86.6%believe that EBF is better than arti cial feeding.80.9% of HIV seropositive mothers strongly recommended breastfeeding, and 10% of participants believe that is important to eat food six months ago.Of the total respondent, 83.6% had a positive attitude about EBF for up to six months.(Table 5).

EBF practice among HIV-positive mothers
Most, 214(89.5%) of mothers feed their last baby on the mother's breast.The majority of the participants reported that 194(90.6%) of mothers started breastfeeding immediately within one hour after birth.102(42.5%) of all breastfeeding was 8-10 times a day.Most mothers reported 74.6% of explicit breastfeeding exercises for your baby up to six months, 20.8% of respondents had 6 to 12 months and 1.3% of mothers over 12 months.It was 86.2% of all positive experiences.(Table 6).

Factors associated with the attitude of EBF among HIV positive mothers
In bivariate analysis, maternal educational status, mothers who had Information on the term of EBF, types of health care facility available, age at rst birth and numbers of postnatal care visits were signi cant association with exclusive breastfeeding attitude among HIV positive mothers.In multivariate analysis, mothers who had information on the term of EBF and age at rst birth had signi cantly associated with an attitude of HIV positive mothers on EBF (AOR: p<0.05).HIV positive mothers who had Information on the term of EBF 2.57 more likely favorable attitude than mothers who had no information on the term of EBF (AOR,2.57,95%CI: 1.03-6.4).HIV positive mothers whose age at rst birth 24 and above were 0.247 times less likely had favorable attitude than HIV positive mothers whose age at rst birth were 18-24 years (AOR.247,95% : (.106-.578).(Table7)

Factors associated with the practice of EBF among HIV positive mothers
In bivariate analysis, maternal educational level, number of gravidities, number of ANC visits, types of health care facility available and Income had a signi cant association with exclusive breastfeeding practice among HIV positive mothers and those candidate variables for multivariate logistic regression.In a multivariate analytical number of ANC visit only had a signi cant association with exclusive breastfeeding practice among HIV positive mothers, mothers were 3-4 numbers of ANC visit had 3 times more likely practice on exclusive breastfeeding than mothers were ANC visits' less than or equal 2 ( AOR; 2.981,95%CI;1.113-7.983).(Table 8).

Discussions
This study was a case study of cognitive functioning and corresponding breastfeeding status among HIV-infected mothers who participated in PMTCT and ART services in selected health education of the central zone, Tigray, Ethiopia.In this study, two hundred ve (85.4) of the HIV infected mother reported the mother had a positive attitude towards the EBF experience.This source study conduct in Botswana 56.3% (13), is higher than a study.This may be the single most effective and effective treatment for children under six months of age.This nding is higher than another study conducted in southern Ethiopia (56.7% ) and central zone Tigray 82.6% respectively.This difference may be due to health services and health education(17,21).
In this study, the mother, who had information about EBF status and age at rst birth, had played a signi cant role in the attitudes toward EBF on the HIV positive mothers.HIV positive mothers who have had information on the term of EBF three times more likely favorable attitude than mothers who had no information on the term of EBF.This may be due to poor information or poor advice on dietary options for children under six months.HIV positive mothers whose age at rst birth 24 and above was 24% times less likely had favorable attitude than HIV positive mothers whose age at rst birth were 18-24 years.This may be due to poor advice on the risk of HIV transmission to your baby and breastfeeding alone.
In this study, two hundred six (86.2) of HIV positive mothers had good practice towards EBF practice.This nding is higher than the study conducted in India 30.6% (9), Tanzania ilala municipality dares salaam46% (22), Botswana 20% (13), western Nigeria 61% (14) and in Burkina Faso, 52.5%(15) of HIV positive mothers were practice exclusively breastfed to their children.This discrepancy might be due to socio-demographic characteristics and the availability of health services.
In this study, about 85 % of HIV positive mothers initiated breastfeeding within the recommended rst hour of birth.this result was higher than the study conducted in Oromia regional 69.3% and Southern Ethiopia shows that 51.5% initiated breastfeeding within the recommended rst hour of birth(20,17).
In this study, HIV positive mothers practiced complementary feeding at 6 months of life were 53.3 % .thisnding is lower than the study done in Southern Ethiopia that 77.2 % mothers practiced complementary feeding at 6 months of life (17).
This study also found out that 86.7 % of HIV positive mothers were practiced exclusive breastfeeding This nding was higher than from a study done in Bahir Dar 75.2% and west Oromia 72% practiced exclusive breastfeeding(17, 20).However, this study nding is lower the study done Gondar town 89.5% and Mekelle town, 90 % of HIV positive mothers had practiced exclusive breastfeeding (11,18).In this nding number of ANC visits had a signi cant association with exclusive breastfeeding practice among HIV positive mothers, mothers were 3-4 numbers of ANC visits had 37% more likely practice on exclusive breastfeeding than mothers were ANC visits' less than or equal 2. This may be to increasing contact with the health care provider and to provide information on breastfeeding practices, particularly in EBF practice.

Conclusion
The study found that HIV positive mothers attending health care facilities in the central zone, the Tigray region had a favorable attitude but practiced on EBF is still low.Factor such as Information on the term of EBF and age at rst birth was associated with attitude toward EBF and the Number of ANC visits was associated with practice on EBF.Therefore, train health professionals especially health extension workers to raise awareness education, enhance information, regarding EBF and strength counseling in ANC service is better to improve the HIV positive mother level of attitude and practice to EBF.

Declarations
Ethics approval and consent to participant Ethical clearance was obtained from the Institutional Review Committee (IRC), College of Medicine and Health Sciences, University of Aksum.Permission letter was received from those administrative bodies of the Central Tigray Health Department and each health facility's verbal and written consent was obtained from all participants after they informed on the purpose of the study.

Table 1 :
Thio E, Yonaba C, Ouédraogo S, Meda N, Dahourou DL, et al.Prevention and care of pediatric HIV infection in Ouagadougou, Burkina Faso: knowledge, attitudes, and practices of the caregivers.BMC pediatrics.2016;16(1):33. 1 .Jepkogei KW.Determinants of adherence to exclusive breastfeeding among HIV positive mothers attending child welfare clinic at Pumwani maternity hospital, Nairobi County, Kenya.Nairobi: Mekonnen HS, Siyoum TM.Assessment of Knowledge, Attitude, and Practice of HIV Positive Mothers on Antiretroviral Treatment towards Infant Feeding in Gondar Town Health Institutions, North West Ethiopia, 2017.International Journal of Pediatrics.2019.Socio-demographic characteristics of HIV positive mothers on EBF in a public health facility central zone, Tigray, Ethiopia, 2019.Table2: Health Institutions related factors and source of information on EBF among HIV positive mothers in public health facility central zone, Tigray, Ethiopia 2019.
20. Bekere A, Garoma W, Beyene F. Exclusive Breastfeeding Knowledge of HIV Positive mothers and Associated Factors in Selected Health Institution of West Oromia, Ethiopia.Universal Journal of Food and Nutrition Science.2014;2(3):37-44.21.Hiwot, A.G., Silassie, K.H., Mirutse, G.M. and Alem Desta, H.A., 2014.Infant feeding practice of HIV positive mothers and its determinants in public health institutions in the central zone, Tigray Region, Northern Ethiopia.International Journal of Pharma Sciences and Research (IJPSR).22.Saka FJ.Factors in uencing exclusive breastfeeding among HIV positive mothers at Ilala Municipality Dar es Salaam: the Muhimbili University of Health and Allied Sciences; 2012.Tables

Table 3
Reproductive characteristics of HIV positive mothers on EBF in public health facility central zone, Tigray, Ethiopia 2019.

Table 4 :
Knowledge of HIV positive mothers on EBF in public health facility central zone, Tigray, Ethiopia 2019

Table 5 :
Attitude of HIV positive mothers on EBF in public health facility central zone,

Table 6 :
Practice of HIV positive mothers on EBF in public health facility central zone, Tigray, Ethiopia 2019.

Table 7 :
Factors associated attitude of HIV positive mothers on EBF in a public health facility in the central zone, Tigray, Ethiopia 2019.

Table 8 :
Factors practice of HIV positive mothers on in a public health facility in the central zone, Tigray, Ethiopia 2019.