Study area and period
Boset district is found 125 kilometers east of Addis Ababa (the capital city of Ethiopia). There are 42 kebeles (the lowest administrative unit in Ethiopia) of which 37 are rural and 5 are urban kebeles. According to the Boset District Health Office in September 2021, the total population of the district was about 220,326 with 45,909 households. Of the total population, 12,583 were children less than two years of age.
Study Design and Population
A community-based cross-sectional study was conducted from January 1st to February 28th, 2022.
Source Population
All lactating mothers of children aged 6–24 months living in Boset District.
Study population
The study populations were Mothers with children aged 6–24 months, living in selected Kebele’s during the study period.
Inclusion and exclusion criteria
Inclusion criteria
Mothers residing in the selected kebeles of the study area for more than 6 months were included.
Exclusion criteria
Mothers who were unable to speak due to illness, mothers of children who had feeding problems, and mothers who were not biological were all excluded from the study.
Sample size determination and sampling procedures
Sample size determination
Single population proportion formula was used to calculate the sample size for the level of practices of key messages using the following assumption: Proportion (P) of 45.4% from a previous study on optimal breastfeeding [15], the expected margin of error (d) of 5%, and a 95% confidence level.
$$n=\frac{0.454\left(1-0.454\right){\left(1.96\right)}^{2}}{{0.05}^{2}}\approx 381$$
The sample size for the second specific objective was determined using the StatCalc algorithm in Epi Info version 7, with the following assumptions: 80% power, 95% confidence intervals, and the independent components of Practice of key messages for optimal breastfeeding as shown below.
Factors | CI (%) | Power (%) | Adjusted Odds Ratio | % in the unexposed group | % in the Exposed group | Sample size | 10% Non- response rate | Final sample size | Refs. |
ANC follow-up | 95 | 80 | 0.1 | 36.5% | 45.1% | 69 | 8 | 77 | 17 |
Counseling on optimal breastfeeding during PNC | 95 | 80 | 4.9 | 55.5% | 35.9% | 128 | 14 | 142 | 17 |
Employed mothers | 95 | 80 | 0.28 | 70.8%) | 29.2% | 266 | 30 | 296 | 18 |
Finally, adding a 10% non-response rate to the largest sample size, the total sample size required becomes 423.
Sampling procedures and technique
The kebeles in the district were stratified into urban and rural. Two kebeles from the urban and eleven from the rural were selected using a simple random sampling technique. The sampling frame was prepared from the lists of households (HHs) with mothers of a child between 6–24 months from the family folder registration book obtained from health posts in each kebele. The study participants were allocated proportionally to each kebele and selected by using a systematic random sampling technique for every unit of the 10th household. A lottery method was used to select one mother from the households where more than one mother was available and the youngest child was selected where more than two under two years of children were found in the household.
Study variables
Dependent variable
Practice of key messages for optimal breastfeeding (Yes/No)
Independent Variables
Socio-demographic characteristics
age of mother, residence, ethnicity, marital status, educational status of the mother, mother’s occupation, husband's education
Obstetrics characteristics
antenatal care (ANC) follow-up, birth interval, mode of delivery, number of ANC follow up, place of delivery, postnatal care(PNC) visit, counseling during PNC, number of previous pregnancies,
Child characteristics
sex of the child, age of the child
Personal factors
knowledge of optimal breastfeeding, attitude towards optimal breastfeeding
Operational definitions
Practicing key messages for optimal breastfeeding
The practice is considered “Yes” if the mother’s score is greater than the mean value obtained from the eight ENAs key messages for optimal breastfeeding, and 'No ' if below the average value [19–21].
Correct positioning
comprises the mother relaxed and comfortable, the mother sitting straight and well-supported back, trunk facing forward and lap flat, the baby's neck straight or bent slightly back and body straight, the baby’s body turned toward the mother, the baby’s body close to mother body and facing breast, and the baby’s whole body supported[22].
Correct attachment
criteria for correct attachment of the infant's mouth to the breast incorporate chin touching the breast, mouth wide and open, lower lip turned outward, and more areola seen above the baby’s mouth[22].
Knowledge about optimal breastfeeding
Knowledge was assessed by 9 items based on WHO-recommended breastfeeding practices and those mothers who had answered and scored above the mean for the knowledge-related questions were considered as having good knowledge[23].
Attitude
Those mothers who answered positively and scored above the mean of the attitude-related questions[23].
Early initiation of breastfeeding
Is defined as putting the neonate on the mother’s breast
to suckle within one hour of birth as reported by the mother/caretaker of the child[24].
Exclusive breastfeeding
No other liquids or solids are given even water-with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals, or medicines until the children reach six months[25].
Complementary feeding
Starting foods and liquids along with breast milk at six months when breast milk is no longer sufficient to meet the nutritional requirements of children[26].
Data collection procedures and instruments
The data collection tool was adapted from the WHO/UNICEF global strategy on infant and young child feeding practices[5]. Data were collected by a face-to-face interview using a pre-tested semi-structured questionnaire. Mothers were asked to provide information about their socio-demographic characteristics, obstetric characteristics, child characteristics, knowledge of optimal breastfeeding, attitude towards optimal breastfeeding, and optimal breastfeeding practice questions. The data were collected by five nurses, with two public health officers serving as supervisors.
Data quality control
The data collection tool was translated into a regional official language (Afaan Oromoo) and then translated back to English by a proficient translator to ensure consistency and accuracy. Two days of training were given to data collectors and supervisors on data collection tools. The questionnaires were pretested on 5% of the calculated sample size on non-selected kebele and a correction was made accordingly. Strict supervision was implemented during the data collection process.
Data processing and analysis
The collected data were entered into Epi info version 7 and subsequently exported to Statistical Package for Social Sciences (SPSS) Version 25 for cleaning and analysis. Eight ENA key messages were used in the calculation of the composite indicator score. The participant received one point for each correct ENA key message and was given 1 point when they responded correctly (conducted recommended practice) and 0 points when they responded incorrectly (conducted non-recommended practice). The Shapiro-Wilk test was used to check the normality assumptions for continuous variables. Descriptive statistics were employed to explain the study population and to display summary data in the form of tables and graphs. Binary logistic regression was used to model the association between the independent and the outcome variables. Those variables with a p-value less than 0.25 at bivariate analysis were included in the multivariable binary logistic regression model to determine the independent predictors of practices of key messages for optimal breastfeeding for children. Adjusted Odds Ratio (AOR) with a 95% confidence interval was used to estimate the strength of the association and a P-value less than 0.05 was used to decide the significance of the association. Data were verified for multi-collinearity using variance inflation factor (VIF) and Hosmer and Lemeshow test was used to test model goodness of fit.