Determinants of the low practice, knowledge and attitude of exclusive breastfeeding in four health centres of the Talangaï Health District, Congo

Objectives The objective of the study is to assess the determinants of the low practice, knowledge and attitudes of breastfeeding mothers in the Talangaï district of Congo. Study design An analytical knowledge, attitudes and practice (KAP) study about EBF in mothers of children aged 0-6 months was conducted. Methods A KAP analytical study was carried out from December 3, 2017, to July 15, 2018, based on the four health centers of the Talangaï health district in Congo Brazzaville. Using formula from Wayne W. Daniel, 357 mothers were included. The practice of EBF was determined based on a 24-h recall. The main variables studied were the socio-demographic characteristics of the mothers and their knowledge, attitudes and practices regarding EBF based on WHO recommendations. A logistic regression analysis was performed, and the odds ratio was calculated with a 95% condence interval. Results The mean age was 26.8 years (± 5.9 years). Mothers with 2-3 children represented 42.6% of the sample. The prevalence of EBF among infants 0–6 months old was 33.9%. Mothers' knowledge, attitudes and practices were unsatisfactory (78.4%), favourable (79.5%) and bad (67.2%), respectively. Factors associated with satisfactory knowledge were being a public ocial [OR: 3.18 (1.39-7.28)] and/or multiparous [OR: 2.25 (1.23-4.11)]. Mothers who had satisfactory knowledge had a higher rating of having good practices on EBF. Conclusions Factors related to good knowledge among mothers are multiparity, age and being a civil servant. Promoters’ EBF must target mothers in all sectors of activity and even in the community by sensitizing them on the subject.


Introduction
Exclusive breastfeeding (EBF) consists of feeding one's infant exclusively with secretions produced by the mother's mammary glands (breast milk) until the age of six months. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that mothers start breastfeeding from the rst hour after birth [1][2][3][4][5] . Thereafter, mothers should continue to feed their babies with breast milk alone (including expressed milk or use of a wet nurse) for at least the rst six months of life before diet diversti cation, thus contributing to the reduction of malnutrition, one of the main causes of death of children under 5 years of age 6,8,9 . Exclusive breastfeeding allows for the possibility for infants to receive oral rehydration solutions, vitamins, minerals, and prescribed medications. Scienti c studies carried out by the WHO and UNICEF have proven that the risk of developing breast cancer is reduced by 6% in a breastfeeding woman 3,10,11 . The increase in breastfeeding rates could save the lives of 820,000 children annually and prevent 20,000 maternal deaths from cancer 8 . In low-and middleincome countries, infants who received foods and uids other than breast milk before six months of age had a 2.8 times higher risk of dying than those who were exclusively breastfed 6,9 . Many African mothers breastfeed their babies beyond one year, but EBF for up to six months is still not widely practiced 7 . Approximately 22% of infant deaths could be avoided if mothers practiced EBF 3,12 . Its bene ts are numerous, of which the following can be enumerated: rich nutritional content, psycho/emotional bonding attributes, anti-infective properties and harmonious growth with optimal cognitive development of infants 3,13 . According to the WHO, only 38% of children aged 0 to 6 months are exclusively breastfed in 194 countries 3 . In sub-Saharan Africa, the percentage of EBF is estimated at 31% and varies from country to country 3,[13][14][15] . There are multiple factors responsible for this decline [15][16]  The target population consisted of mothers of children aged 0 to 6 months who had attended the vaccination services of four health centers in the Talangai health district.
A probabilty sampling approach was used. The sample size was calculated using Daniel Wayne W. formula 18 n = z²s²/ e², where n = the required sample size, z = the standard deviation at a con dence level of 95 % (1.96), s = the estimated standard deviation of 0.36 ; and e = desired level of precision of 0.05. After calculation, the minimum sample size for mothers interviewed was approximately 200. A 20% attrition was anticipated; hence, the nal adjusted sample size was approximately 369 mothers. The rst mother to be interviewed was selected by a simple random sampling technique using a random number table to select a number between 1 and the sampling interval of 2. The number chosen at random (1 or 2) represented the rst mother sampled. The next respondent was selected by adding the sampling interval to the selected number. This procedure was used to select the rest of the mothers to be interviewed over the course of the day. Mothers were sampled in the lobby while waiting to be attended to. The same procedure was carried out over the following days until the required sample size was attained. Since women come to the health centre by appointment only, we considered all women who came for consultation during the day by following the selection procedure.

Inclusion and exclusion criteria
We included biological mothers with at least one child alive during the period of our study who gave their verbal consent. We excluded mothers of infants who were unable to respond to our study questions, as well as infant caretakers. In total, we considered 369 women, of which 12 (3.3%) were excluded.

Variables
Variables relating to socio-demographic characteristics (age, level of education, profession, marital status and parity), knowledge, attitude and practice on EBF were collected.

Data analysis
We recruited and trained undergraduate sociology students as investigators. The questionnaire was pretested in the Moungali health district, after which corrections were made to remove any inconsistencies. Data were collected using a structured questionnaire by direct interviews with mothers. The questionnaires were prepared and administered in Lingala (local langage) and in French for those who wished to do so. The data on the knowledge, attitude and practice of mothers were assessed with maximum possible scores of 19, 4 and 6 points, respectively. Each proposition under the knowledge, attitude and practice sections was scored and cumulated to obtain the total score of participants for each of the three variables of interest (knowledge, attitude and practice). The rating of the level of knowledge and attitude was modeled based on Bruno De Finetti 19 and Likert's method 20, respectively. As for the level of practice, it has been structured to mirror certain works on the quanti cation of levels of practice in previous KAP studies 21 . To assess the interaction between knowledge, attitude and practice, we strati ed the level of knowledge, attitude and practice into two modalities, namely, for knowledge: unsatisfactory and satisfactory [0-8 points; 9 to 19 points]; for attitudes: unfavorable and favorable [0-2 points; 3-4 points] and for practices: bad and good [0-2 points; 3 to 6 points], respectively. EBF practice was determined on the basis of a 24-hour recall. Data were analyzed using Epi-Info 7.2.2.2.6 software. Absolute and relative frequencies as well as parameters of central tendency (mean) for a normal distribution and dispersion (standard deviation) were calculated for our qualitative and quantitative variables, respectively.
A simple logistic regression was used to establish the relationship between knowledge and sociodemographic characteristics (age, marital status, educational level, profession and number of children). The Chi-square and Wald tests were used as well as the odds ratio with their 95% con dence interval at the 5% threshold. Multiple logistic regression was used to establish the relationship between attitudes and knowledge and practices with knowledge and attitudes. Multivariable logistic regression analyses with backward elimination stepwise selection with p < 0.20 were used to identify baseline explication that predicts practices or attitudes of mothers.

Ethical considerations
Ethical clearance and research authorization were obtained for this study. Informed consent was written and submitted to mothers who had read before agreeing to participate in this study. The ethics committee of the Inter-State Centre for Higher Education in Public Health in Central Africa (CIESPAC) approved the study, and the ethical clearance was number C005/ CSERC/CIESPAC/2018. Further permission was obtained from the Ministry of Health of the Republic of Congo and the hospital under study.

Sociodemographic characteristics of participants
A total of 357 mothers were interviewed. The average age was 26.8 years (± 5.9 years). Single mothers constituted the majority of sampled participants, 333 women, 93.3%. Many mothers (257/357) were in secondary school. The majority of participants were students (112/357) and traders (129/357) ( Table 1).     (Table 6). The mean age of the participants was 26.8 (± 5.9) years. Some authors did work on the same subject as us. In these studies, the average age ranged from 26 to 30 years old 13,14,22,23 . This narrow variation in the average age reported could be explained by the fact that, like our study, these studies were carried out in other African countries (Cameroon, Tanzania, Tunisia and Mali).

Knowledge, attitudes and practices of infants' mothers
Exclusive breastfeeding is practiced by 33% of women surveyed. This corroborates the results reported by UNICEF and some authors concerning the low prevalence of EBF in sub-Saharan Africa 3,13,14,22-25 . In our case, the lack of awareness among women could explain this low prevalence, even though we have not explored other underlying reasons for the low practice of EBF. In contrast, this prevalence is higher in Western countries, ranging from 57% to more than 70% [23][24][25][26][27] . In our case, the lack of awareness among women could explain this low prevalence, even though we have not explored the other deep reasons for the poor practice of EBF.
The level of knowledge of mothers on EBF is considered unsatisfactory at 78.43%. The main reason is the lack of information on this concept. Indeed, 147/357 mothers (48.08%) mentioned health services as the sole source of information, which sporadically sensitizes women on EBF. Otherwise, the participants' attitudes do not correlate with their practice of EBF.
In uence of sociodemographic characteristics on knowledge The factors linked to a better (satisfactory level) knowledge of EBF were being between 26 and 35 years old, being a civil servant and being multiparous. Kazaura's work in Tanzania has similar results to ours 14 . These results differ from those of Ihudiebube-Splendor et al. in Nigeria, who showed that neither age, marital status, nor profession were associated with a satisfactory level of knowledge of EBF 28 . This difference is explained by the fact that our study concerned all women, unlike Ihudiebube-Splendor, who worked only with primiparas. In addition, mothers who were civil servants have much more access to information on EBF by having sources of information other than health services such as the media. Compared to primiparas, multiparous women have had frequent contacts with health care personnel, who represent the major source of information on EBF.
In uence of knowledge on mothers' attitudes towards EBF Satisfactory levels of knowledge did not necessarily imply favorable attitudes towards EBF in our study. Some authors have been able to establish factors in uencing the favorable attitude towards EBF, namely, the age of the mother and her profession 29 . This difference could be explained by Noumbissi's theory, which stipulates, apart from the knowledge that people could have about any fact with regards to their adoption of a given behavior, other intermediate factors such as social values, viewpoints and beliefs are likely to explain the attitude of these people 30 .
In uence of mothers' knowledge and attitudes on the practice of EBF Multiple logistic regression analysis revealed that the level of knowledge of mothers in uences their practice on EBF. However, we have observed that regardless of whether participants' attitudes are favourable, they do not necessarily imply good EBF practices. This study did not discuss the reasons or hurdles to the non-practice of EBF, as discussed by several authors in sub-Saharan Africa or in developing countries 15,31,32,33,34,35,36 . There may be other hurdles obscurring the correlation between a favourable attitude and the practice of EBF. These obstacles are present when the mother has to make a decision, as underlined by Noumbissi's theory, stating that individuals' practices are sometimes in uenced by beliefs, viewpoints and society 30 .

Limitations of the study
The retrospective nature of some questions asked to mothers could induce a memory bias. Although the mothers' consent was obtained before the administration of the questionnaire, some of them were reluctant, which could lead to information bias. Finally, the study took place only in health structures and not in the community. When selecting our study population, we found that more than three-quarters of the participants were single women, i.e., 93.3%. The high proportion of single women resulting from our research work is explained by the fact that we de ned the single matrimonial status as all women not legally married with respect to the country's constitutional law to a man, any woman living without a husband and/or any woman having a cohabitation relationship with the man.

Conclusion
The results of our study show that mothers have unsatisfactory knowledge about exclusive breastfeeding. EBF was only practiced at 33.9% with an inadequate level (67.2%) because the mothers had an unsatisfactory level of knowledge on the subject. Factors associated with a satisfactory level of knowledge on EBF were being a civil servant and/or being multiparous. Factors associated with good EBF practice were educational level, occupation and parity. The level of attitude doesn't in uence the practice of mothers in relation to exclusive breastfeeding Intensive breastfeeding education for women of childbearing age in different locations could help achieve the goal set by the World Health Assembly's 2012, to achieve an EBF rate of 50% by 2025.
Ethical Approval and Consent to participate Authority to conduct the research was sought from the Inter-State Center for Higher Education in Public Health in Central Africa (CIESPAC), Brazzaville, Congo. Ethical clearance to conduct the study was sought from the Ethical Review Committee of the CIESPAC with reference number c005/CSERC/CIESPAC/2018 and permission to conduct the research from the Talangai Health District Direction. Participants were assured of con dentiality. All the participants were also assured that the information they gave would only be used for purposes of research and that ndings would be communicated to them. Informed written or thumb print consent was sought from the respondents who were selected to take part in the study. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. The datasets generated and/or analysed during the current study are not publicly available due to the promise made to mothers to keep the data con dential when they are questioned but are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests.

Fundings: None
Authors' contributions SHW designed the study, wrote the protocol and text and supervised the data analysis. MBOE and JSA participated in the drafting of the protocol, data analysis and text writing. FEYM participated in the revision of the manuscript. Finally, PMT coordinated the entire study. All authors have read and approved the manuscript.