The purpose of the study was to determine the infant feeding practices and nutrition status of HIV-exposed infants 0–5 months of age attending the paediatric clinic in a mission hospital in Bomet County.
Study design, setting and period
The study adopted a cross-sectional design with mixed methods (quantitative and qualitative approaches) in data collection and analysis. The study was conducted at a referral mission hospital in Bomet County. The hospital has several clinics, including one for Maternal and Child Health, where the Paediatric clinic is based. Services offered at the paediatric clinic include: growth monitoring, immunization and treatment of various childhood illnesses, as well as HIV- related care for women and children [13]. Bomet is a rural County located in the former Rift Valley Province of Kenya with a population of 730,129 as per 2009 national census [14]. The main economic activities in the county include farming for subsistence and cash, tourism and sports [14].
Data was collected for 3 months between November 2015 and January 2016.
Study participants
The target population was pairs of mothers/caregivers and infants between 0–5 months of age born by mothers living with HIV (HIV-exposed) who were attending the paediatric clinic in the mission hospital. The mission hospital had registered 127 HIV-exposed infants 0–5 months of age during the study period. Infants born with very low birth weight (less than 1500 g) as recorded in the Maternal and Child Health booklet as well as mothers/caregivers who declined to participate were excluded from the study.
Sample size and sampling techniques
The calculated sample size was 112, based on the exclusive breastfeeding rates of 35 % and a sampling frame of 127 HIV-exposed infants 0–5 months of age in the county, at the time of the study. A further 10 % was added to cater for non-response. Comprehensive sampling was then adopted in which all eligible mother/ caregiver-infant pairs were recruited (121). This is because the calculated sample size and the sampling frame were almost equal in number.
Every consecutive mother/caregiver with a HIV-exposed infant 0–5 months of age who consented to participate in the study was recruited once to avoid duplication of data collected. One hundred and twenty seven mothers/caregivers were eligible for the study, 121 consented while 6 declined, and therefore, 121 mothers/caregivers were recruited to participate in the study. Out of the 121 questionnaires, 118 were analysed as 3 infants had very low birth weight and thus their questionnaires were not included in the analysis. The response rate was therefore, 97.5 %.
Additionally, 11 key informants were interviewed. Key informants were purposively selected; all nutritionist, nurses, clinicians and adherence counsellors who provided services to the mothers living with HIV at the mission hospital’s paediatric clinic. They were purposively selected because they were knowledgeable of the context specific information for mothers living with HIV registered at the health facility. For the FGDs, participants were selected using simple random sampling based on their reported mode of feeding. Two groups of 10 and 9 mothers/caregivers each were selected from those who had exclusively breastfed, 8 were selected among those who had practiced exclusive replacement feeding and 8 among those who had mixed fed.
Data collection instruments and procedures
A validated and pre-tested researcher-administered questionnaire, a Focus Group Discussion guide and a Key Informant Interviews guide were used for data collection. The questionnaire had three sections. Section A was used for recording the anthropometric data of the infant, while Section B elicited information on socio-economic characteristics of the mothers/caregivers (education, occupation and income), demographic characteristics of the mothers/caregivers (age, marital status, religion, ethnicity, parity), infant characteristics (age and sex) and infant illness in the previous 2 weeks. Questions in the Kenya Demographic Health Survey questionnaire were adopted for this section. Section C comprised of the generic Infant and Young Child Feeding questionnaire by CARE USA (2010) [15] which applies the WHO indicators for Infant and Young Child Feeding. It elicited information on the feeding practices of the infants in the previous 24 h which enabled classification into exclusive breastfeeding, exclusive replacement feeding and mixed feeding. Three questions were further adopted from the World Health Organisation’s indicators for assessing Infant and Young Child Feeding Practices questionnaire and added to elicit information on: time of breastfeeding initiation after birth and baby’s first feed after birth (breast milk or pre-lacteal) [16]. The questionnaire was translated to Kipsigis, the native language in Bomet County, to cater for mothers/caregivers who did not understand English.
The questionnaires were researcher-administered during face to face interviews conducted with mothers/ caregivers. A total of four focus group discussions were also conducted with mothers/caregivers and the number of participants per group was 8, 8, 9 and 10 respectively. The areas that were covered in the discussions included the mothers/caregivers infant feeding experiences, health services they received and challenges they faced in their choice of infant feeding. The key informant interviews were conducted with 3 nutritionists, 4 nurses, 2 clinical officers and 2 adherence counsellors who provide services to HIV-exposed infants 0–5 months of age at the paediatric clinic. The discussions and interviews were audio tape recorded. To determine the nutrition status, anthropometric rmeasurements of weight and length were taken using the WHO recommended instruments and procedures [17].
Data analysis
Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) version 22. Infant’s nutrition status was analysed using ENA for Smart software version 2011 and then exported to SPSS. Nutrition status was assessed based on the WHO 2006 growth standards Z-score cut offs for length-for-age, weight-for-age, and weight-for-length z-scores [17]. Infant feeding practices were analysed based on the WHO and Ministry of Health recommendations for HIV-exposed infants 0–5 months of age, and were classified as exclusive breastfeeding, exclusive replacement feeding and mixed feeding. The analysis on infant feeding was categorised into mode of feeding in the previous 24 h and mode of feeding since birth. The modes of feeding were defined as: Exclusive breastfeeding when infant received only breast milk and no other liquids or solids except drops or syrups consisting of vitamins, minerals, or medicines; Exclusive replacement feeding when infant received nothing else except a suitable breast milk substitutes in the form of commercial infant formula; and Mixed feeding when infant received breast milk and any other food or liquid including water, non-human milk and formula. For the mode of feeding since birth, infants who had received pre-lacteals and/ or post-lacteals were classified as mixed feeding regardless of the feeding mode in the previous 24 h. Statistical significance was set at p < 0.05.
For qualitative data, content analysis was conducted for the Focus Group Discussions and Key Informant Interviews. The discussions and the interviews were transcribed verbatim and translated into English by the researchers. They were then read through several times by the researchers and the information from the FGDs categorized into sub-themes: experiences the mothers/caregivers had on feeding practice chosen; challenges faced; and suggestions for feeding practices of HIV-exposed infants. The information categories obtained in the focus group discussion analysis were used to organize the information in each key informant interview according to the informant category: nutritionist, nurses, adherence counsellors and clinical officers. Illustrative quotations were also selected from the discussions and interviews.
Logistical and ethical considerations
Ethical clearance was sought from Kenyatta University Ethical Review Committee PKU/381/E33 and Tenwek Institution Research Committee. A research permit was obtained from the National Commission for Science, Technology and Innovation. Informed voluntary consent was sought from the mothers/caregivers and healthcare workers in form of signatures or thumb-print. Participants’ privacy and confidentiality has been ensured by the use of codes rather than names.