RESEARCH PROPOSAL

KENYA MEDICAL TRAINING COLLEGE

FACULTY OF INFORMATION TECHNOLOGY & MEDICAL EDUCATION
DEPARTMENT OF HEALTH RECORDS & INFORMATION

A STUDY ON FACTORS INFLUENCING EARLY WEANING PRACTICES AMONG

MOTHERS OF HIV EXPOSED INFANTS AT KISUMU COUNTY REFERRAL
HOSPITAL

BY

CLARICE ANYANGO ODHIAMBO

D/UPHRIFT/18051/278

A PROPOSAL SUBMITTED FOR APPROVAL TO UNDERTAKE RESEARCH IN PARTIAL

FULFILMENT FOR THE AWARD OF DIPLOMA OF HEALTH RECORDS &
INFORMATION TECHNOLOGY

SEPTEMBER 2018
DECLARATION

This proposal is my original work and has not been presented in any other institution for a
similar award.

Clarice Anyango Odhiambo

Signature…………………… Date ………………………..

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APPROVAL

The undersigned certify that they have read and approved this proposal to undertake research
entitled: “A study on factors influencing early infant weaning practices among mothers of HIV
exposed infants at Kisumu county referral hospital”

INTERNAL SUPPERVISOR

NAME: Ms. Cherop Kemboi

DISEGNATION: Masters in Nutrition

SIGNATURE:

DATE:

EXTERNAL SUPPERVISOR

NAME: Mr. Vitalis Sewe

DESIGNATION: Dip/BSc. HRIM; Master Project M&E

SIGNATURE:

DATE:

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DEDICATION

I’m dedicating this report to my lecturer Mr. Otwori, Ms. Cherop Kemboi, Mr. Sewe, Mr. Okaya
and my family members for the support they offered to me during my research period.

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ACKNOWLEDGEMENT

First and foremost, I magnify my Almighty God for granting me good health and strength
throughout my study period. I would like to extend my appreciation to everyone who made this
study possible, my heartfelt gratitude to my supervisors Ms. Cherop Florence Kemboi, Mr.
Vitalis Sewe and finally Mr. Okaya Bethwel for their outstanding academic advice, valuable
comments, challenges and encouragements which were basic in shaping and producing this
dissertation .I commend and thank them for the tireless expert opinion and a unique guidance
during this research proposal to report completion. I am grateful to my lecturer Mr. Otwori for
his sincere encouragement and allowing me to proceed with my research proposal. In addition I
would also acknowledge my beloved guidance Mrs. Silvyia Adhiambo Otieno, brother Antony
Odhiambo and Wickliffe Samo for their wisdom, supported, encouragement and prayers
throughout their lives. I also thank for their moral, spiritual and physical support and continuous
encouragement throughout my studies to be my source of inspiration. A special word of thanks
goes to my lovely friend Pauline Adhallah for her presences, encouragements and prayers. She
was tolerant and understanding for my absence at school during my studies. I warmly
acknowledge her. My God bless her and protect her brainwave to reach her life goal.

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Table of Contents
DECLARATION ........................................................................................................................................... i
APPROVAL ................................................................................................................................................. ii
DEDICATION ............................................................................................................................................. iii
ACKNOWLEDGEMENT ........................................................................................................................... iv
LIST OF FIGURES .................................................................................................................................... vii
LIST OF ABBREVIATION ...................................................................................................................... viii
DEFINITION OF TERMS. ......................................................................................................................... ix
CHAPTER ONE: INTRODUCTION ......................................................................................................... 10
1.1 Background to the Study ................................................................................................................... 10
1.2 Problem Statement ............................................................................................................................ 11
1.3 Justification ....................................................................................................................................... 12
1.4 Broad Objectives ............................................................................................................................... 13
1.4.1 Specific Objectives .................................................................................................................... 13
1.5 Research Questions ........................................................................................................................... 13
1.6 Study Limitations .............................................................................................................................. 13
1.7 Delimitation ...................................................................................................................................... 13
1.8 Significance of the Study .................................................................................................................. 14
1.9 Conceptual framework. ..................................................................................................................... 14
CHAPTER TWO: LITERATURE REVIEW ............................................................................................. 15
2.1 Introduction ....................................................................................................................................... 15
2.2 Overview of HIV & Aids Epidemic ................................................................................................. 15
2.3 PMTCT Programme.......................................................................................................................... 16
2.4 Maternal Knowledge on PMTCT of HIV ......................................................................................... 16
2.4.1 The mothers’ understanding of information to exclusively breastfeeding ................................. 16
2.5 HIV & Aids and Infant Feeding Practices ........................................................................................ 17
2.5.1 Breastfeeding and HIV/Aids ...................................................................................................... 18
2.5.2 Breastfeeding ............................................................................................................................. 18
2.5.3 Wet Nursing ............................................................................................................................... 19
2.5.4 Replacement Feeding ................................................................................................................. 20

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 2.5.5 Complementary Feeding ............................................................................................................ 20
2.5.6 Partial Breastfeeding .................................................................................................................. 21
2.5.7 Infant Feeding Knowledge, Intention and Perception among Pregnant Women ....................... 21
2.6 Socio-Cultural and Economic Factors Influencing Infant Weaning ................................................. 21
2.6.1 CULTURAL BELIEFS AND NORMS ..................................................................................... 22
2.6.2 BAD OMEN (CURSE) AND EVIL EYE (If not breastfeed in public)..................................... 23
2.6.3 BREASTS SAG AND “BOYS ARE NOT BREASTFED THE SAME AS GIRLS” ............... 24
2.6.4 RELIGIOUS .............................................................................................................................. 24
2.7 Summary and Conclusions................................................................................................................ 25
CHAPTER THREE: RESEARCH METHODOLOGY.............................................................................. 26
3.1 Study Area ........................................................................................................................................ 26
3.2 Study Design ..................................................................................................................................... 26
3.3 Study Variables ................................................................................................................................. 26
3.3.1 Dependent Variable.................................................................................................................... 26
3.3.2 Independent Variable ................................................................................................................. 26
3.4 Inclusion/ Exclusion Criteria ............................................................................................................ 26
3.4.1 Inclusion Criteria........................................................................................................................ 26
3.4.2 Exclusion Criteria ...................................................................................................................... 27
3.5 Study Population ............................................................................................................................... 27
3.6 Sampling Methodology ............................................................................................................... 27
3.6.1 Sampling Procedure ................................................................................................................... 27
3.6.2 Sample Size Determination ........................................................................................................ 27
3.7 Data Collection Tool ......................................................................................................................... 28
3.8 Data Collection, Analysis and Presentation ...................................................................................... 28
REFERENCES ........................................................................................................................................... 29
APPENDICES ............................................................................................................................................ 33
Appendix 1: Interview Schedule ............................................................................................................. 33
Appendix 2: Work Plan .......................................................................................................................... 40
Appendix 3: Study Budget ...................................................................................................................... 41

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LIST OF FIGURES

Figure 1: Conceptual framework on infant feeding practices ..................................................................... 14

Figure 2: Social cultural beliefs and practices around breastfeeding.......................................................... 23

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LIST OF ABBREVIATION

AFASS Acceptable Feasible Affordable Sustainable and Safes

ARV Antiretroviral
DHS District Health Survey
HIV&AIDS Human Immunodeficiency Virus/Acquire Immunodeficiency Syndrome.
KAIS Kenya Aid Indicator Survey
WRA Women of Reproductive Age
WHO World Health Organization
PMTCT Prevention of Mother to Child Transmission
MCH Mather Child Health
MTCT Mother to Child Transmission
SANDH South Africa National Demographic Health
ZDHS Zambia Demographic Health Survey
MOH Ministry of Health
GPAF Glaser Paediatric Aids Foundation
FAO Food and Agriculture Organization
UNICEF United Nation Children Education Fund
KNBS Kenya National Bureau of Statistics
KEMRI Kenya medical research institute
KDHS Kenya Demographic Health Survey
UNHSP United Nation Human Settlement Programme
GNR General National Report
UNFPA United Nations Populations Fund
MOH ZAMBIA Ministry Of Health Zambia
NASCOP National Aids and STD Control Programme

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DEFINITION OF TERMS.

HIV EXPOSED INFANT: Is a child less than 18 months born to HIV positive mother.

HIV: Human Immunodefiency Virus.

WEANING: Gradual replacement of breast milk with complementary feeds

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 CHAPTER ONE: INTRODUCTION

This chapter provides background information on overview of the study topic. It also provides
details on statement of the problem, justification, research questions, hypothesis, objectives,
significance and anticipated outputs and limitations and delimitations of the study. Each section
is elaborate on the framework within which the study will be conducted.

1.1 Background to the Study

Infant feeding is critical in the first year of life and a key determinant of child survival and
development. Breastfeeding is a universal socio-culturally acceptable, nutritious way to feed an
infant and provides immunity (UNAIDS, 2009). However, research indicates that breast milk
contributes about 15% risk of HIV transmission from an infected mother to the child (Kilewo,
C., et al., (2009) especially when mixed feeding is practiced before weaning. HIV prevalence in
Kisumu County is 15.3% according to the Kenya AIDS indicator Survey 2017. It is estimated
that 35% of under-five mortality is due to HIV and AIDS (UNAIDS, 2018).

Prevention of mother-to-child transmission (PMTCT) of HIV is an important intervention in the

prevention and control of HIV and AIDS to reduce child mortality and increase the rate of child
survival. Mother-to-child transmission (MTCT) of HIV interventions requires more than
provision of drugs and commodities. Systems must be strengthened and communities need to be
prepared for this program. Therefore, commitment to providing a range of core MTCT
interventions is required to reduce the incidence of MTCT of HIV.

This requires a complete package of health care including maternity and family planning services
with increased antenatal care, voluntary counselling and testing (VCT) for HIV, possible use of
antiretroviral drugs and use of safe alternatives to the infected mother’s breast milk Nagata et al.,
and Cohen, C. R. (2012)

A culturally acceptable, low cost approach to infant feeding is essential to prevent breast milk
HIV transmission. In countries not affected by HIV, improving infant feeding can reduce
mortality by up to 19%. The impact could be greater in HIV affected populations if interventions
that reduce HIV transmission through breast feeding could be successfully linked to strategies
that improve infant feeding practices. However, this is confounded by complexity of identifying
most appropriate infant feeding practices that fits household and social circumstances of

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mothers. World Health Organization (2010) recommends that in light of the effectiveness of
ARVs, HIV infected mothers should continue breast feeding the infant until twelve months of
age. This capitalizes on the maximum benefit of breast feeding to improve the infant’s chances
of survival while reducing the risk of HIV transmission. The guideline also recommends to
national health authorities to promote a single infant feeding practice as a standard of care. The
information about other practices should be made available. This calls on governments and
donors to increase commitment to and resources for improving infant feeding practices in HIV
affected populations. The investment should be targeted to effectively prevent infants becoming
infected with HIV through breast feeding, improve HIV free-survival of infants and achieve
international developments goals, such as Millennium Development Goals (MDGs) and those set
by United Nations General Assembly Special Session on HIV and AIDS (UNGASS).

This study intends to explore the social, cultural and economic factors that influenced infant
feeding practices. Recommendations for possible interventions to reduce MTCT of HIV via
breast milk will be provided at the end of this study.

1.2 Problem Statement

Kenya HIV County Profile Report 2016 estimated that about 19.7% children were infected with
HIV in 2015, therefore, showing over 100% increase from 2013 which implies that more efforts
are needed in order to reduce MTCT of HIV. The report in addition showed HIV prevalence
among women in Kisumu County was 21.2%. Inadequate breastfeeding practices and early
introduction of complementary foods may contribute to cases of malnourished children. KDHS
(2014) indicates that the number of children receiving ART declined by 9% while ART coverage
increased by 32%in 2015 compare to 2013. Consequently, WHO, (2010), recommends that in
high of the effectiveness of ARVS, HIV infected mothers should continue breastfeeding the
infants until 24 months of age and therefore capitalized on the maximum beliefs of breastfeeding
to improve mothers chances of survival while reducing the risks of HIV transmission. Victoria et
al., (2008), on early nutritional deficits cause long term impairment in growth and health
therefore causes impairments intellectual performance.

Mothers who were unclear about weaning practices and under what circumstances weaning
might be appropriate in the event that sores developed on the breasts of the mother, this

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potentially alter their capacity to exclusive breastfeed and as a consequence, abrupt weaning
from exclusive breastfeeding was planned or initiated (Hazemba et at., 2016). However, the
HCWs need to be fully oriented to PMTCT interventions, be equipped with appropriate
communication skills, spend time with mothers focusing on individual needs, and help them to
make a genuinely informed-decision to practice exclusively breastfeeding. In Kenya,
increasingly more women, including breastfeeding mothers are joining the labour force and
where they work for long hours. This also leads to implications of high prevalence of
malnutrition in childhood hence, a threat to social and economic development.

Despite the established benefits of optimal breastfeeding, about 60% of infants in developing
countries are not exclusively breastfed for six months (Lauer et al., 2003). The Global strategy
for infant and Young Child Feeding further emphasizes on the need for those involved in
promoting breastfeeding to understand the Socio-cultural and environmental circumstances
around breastfeeding World Health Organization. (2007).

1.3 Justification

The aim of this study is to assess factors influencing early infant weaning practices among
mothers of HIV exposed infant at Kisumu County Referral Hospital. This is because mixed
feeding increases risks of infant death and morbidity, including diarrhoea, respiratory infections
and mother to child HIV transmission and re-infection still remains an obstacle to the reduction
of early infant weaning burden. A report by Kenya HIV county profile 2016 indicate that in
Kisumu women have a higher HIV prevalence of 21% and children on care is 88% on ART and
of 52% are virally suppressed therefore needs more improvement to achieve the unmet gaps. The
effects of various demographic and economic factors, national and international policies,
commercial pressure, family, medical and cultural, attitudes.

Although WHO recommendation on EBF has been in effect for more than two decades majority
of women do not comply with it. This discrepancy necessitate need to explore factors that hinder
women to practice EBF.

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1.4 Broad Objectives

To assess factors influencing early infant weaning practices among mothers of HIV exposed
infants at Kisumu County Referral Hospital.

1.4.1 Specific Objectives

1. To determine maternal knowledge on mother to child transmission of HIV among

mothers of HEI at Kisumu County Referral Hospital.
2. To explore infant feeding practices among mothers of HEI at Kisumu County Referral
Hospital.
3. To determine socio-cultural and economic factors influencing infants weaning practices
among mothers of HEI at Kisumu County Referral Hospital.

1.5 Research Questions

1. What are the levels of maternal knowledge on prevention of mother to child transmission
of HIV among mothers of HIE at Kisumu County Referral Hospital?
2. What are infant feeding practices among mothers of HEI female clients receiving HIV at
Kisumu County Referral Hospital?
3. What are the socio-cultural and economic factors influencing infants weaning practices
among mothers of HEI at Kisumu County Referral Hospital?

1.6 Study Limitations

 The study will not include HIV negative infants therefore result may not be generalized
to the entire population of mothers with infant age 18 months.
 The study will not include mothers who do not attend child welfare clinics.

1.7 Delimitation

 Data collection will only be one month.

 Data collection will be carried out only at Kisumu County Referral Hospital.
 Data collection will not be limited to mothers of HEI aged 18 months and below.

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1.8 Significance of the Study

1. Findings of this study will contribute to Millennium Development Goal # 6 which seeks
to combat HIV/AIDS, malaria and other disease. This will in turn reduce the socio-
economic burden currently experienced at national, community and household level.
2. The findings from this study should be evidence-based information to guide project
managers on targeted project planning. This will ensure prudent allocation of resources
based on need.
3. To researchers, the findings contributed to new knowledge in the field of learning and
professional development
4. The government, churches and NGOs may also use the information obtained from the
study to design educational materials & programs for MTCT prevention.

1.9 Conceptual framework.

Infant Feeding practices of HIV positive Mother

Proximate

Determinants Maternal Choices Opportunities to support the choices

Information on infant feeding, physical

Intermediate and social support during pregnancy,
child birth & post-partum.
Determinants

 Familial, medical and cultural attitudes and norms

Underlying  Demographic and economic factors
 Commercial pressures
Causes
 National and International policies

Source: Adapted from Lutter C.K (2000).

Figure 1: Conceptual framework on infant feeding practices

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 CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

The literature review is discussed in various sections aligned to the study objectives and also
conducted using a variety of sources, the sources use were direct internet searches, pub med,
difference search engines, publications and relevant books. Most literature will be derived from
developed countries and only a few were derived within the continent and locally. The
discussion of literature focused on factors influencing early infant weaning practices among
mothers of HIV expose infants, globally, regionally, nationally and current practice among
women of reproductive age both in the communities, and in the hospitals. The purpose of this
review will be done to confirm findings from related studies regarding early infant weaning
practices among mothers of HIV expose infants from different countries therefore, provides
basic for comparative analysis.

2.2 Overview of HIV & Aids Epidemic

HIV&AIDS has caused a severe and generalized epidemic and reversed trends gain in child
survival (UNAIDS, 2010). In Kenya HIV prevalence is 6.3% (UNAIDS, 2012) compared to
Kisumu county 51% (Kenya HIV county profile, 2016). This is about to fall the nation average.
HIV prevalence among women of reproductive ages in Kisumu county hospital is 21.2% Kenya
HIV county profile 2016 hence the need for PMTCT services. More than 100 children are newly
infected with HIV daily. MTCT accounting for 96% of HIV transmission in children during
pregnancy, labour, birth or breastfeeding (UNAIDS2, 010). Breastfeeding beyond 24 months
increases infection by between 25-45% Zhang, H., and Wood, C. (2010). Every hour about 30
children die as a result of aids (UNAID, 2010) MTCT of HIV interventions requires more than
provision of drugs and communities prepared for these programs therefore commitment to
provide arrange of core MTCT interventions is required to reduce the incidence of MTCT of
HIV.

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2.3 PMTCT Programme

Guideline on use of ART for treating and preventing HIV infection in Kenya 2016 recommends
that HIV positive mothers should be given information on the government guidance on
breastfeeding in the context of HIV and counselled on benefits and challenges of breastfeeding
(NASCOP, 2016).It required that breastfeeding should only stop once a nutritionally adequate
and safe diet without breast milk can be provided and supported for all and especially for those
categorize as food insecure (NASCOP, 2016)

2.4 Maternal Knowledge on PMTCT of HIV

Maternal knowledge in this context referred to extent to which mothers understood and defined
HIV &AIDS, modes of transmission and prevention of HIV from mother to child. The general
belief was that any HIV infected mothers would automatically infect her baby in the womb and
that is not preventable. HIV positive mothers breastfeed their babies because they do not know
their HIV sera status of pregnancy or early enough. Many of them prefer cow milk as an
alternative feed because it is acceptable ,affordable and feasible and can be sustainable However,
in the general population majority lactating women breastfed their babies .Wet nursing for
instance was practiced by elderly women who have reached menopause to feed orphaned babies,
young and middle age women are reluctant to use wet nursing formula feeding is recognized as a
feeding option but not widely practiced because it is expensive and may also expire before use.
Goat milk, expressed breast milk is rarely used. The ideal of expressed milk sounded strange to
them since it was not normal milk of a human, expressing breast cannot produce enough milk to
satisfy the baby and may make breasts painful

2.4.1 The mothers’ understanding of information to exclusively breastfeeding

The aim of promotion of exclusive breastfeeding is to improve child survival for HIV –exposed
babies. Mothers appeared to be understood that ARVS they were taking reduced the risks of
MTCT of HIV though breast milk and hence recognized its benefits for the exposed babies.
(Hazambe et al, 2017)

The risk that a woman with HIV will transmit the risks to her infants can be reduced in a number
of ways, prophylaxis with ARVs during pregnancy and breastfeeding, caesarean section delivery,

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and following infant feeding practices. By providing care, treatment and support for mothers
with HIV and their infants helps to ensure the mothers health and to protect the child health and
development (Elizabeth, 2010).

Family planning provides couples with HIV an opportunity to prevent unintended pregnancies
and to avoid having children who are infected with HIV. Strengthening family planning
programs for all women who are still do not know their status and need family planning. (GPAF,
2012)

2.5 HIV & Aids and Infant Feeding Practices

The preparation for the health and survival of the infants were serious with studies showing
much higher mortality rate due to diarrhoea, malnutrition and other diseases in non-breastfed
children .The (2010 ) ,recommendations are based on evidence of positive outcomes for HIV free
survival through provision of ARVS to breastfed HIV exposed infants .Thus the focus is now
firmly on ensuring HIV free survival, not just on preventing transmission .According to UN,
(2010) guidelines provide much clearer pathway toward the goals. Infant feeding practices vary
with individuals in difference communities. The comparative preferences are dependent on social
cultural and economic factors. This include maternal willingness and freedom to choose
preferred method, level of maternal knowledge of infant feeding, physical and social support
provided during pregnancy, childbirth and past partum experiences. This factor is in turn
influenced by familial medical, cultural attitudes and norms, demographic, economic conditions,
commercial pressures and national policies. Thus, promote optimal breastfeeding and
complementary feeding practices, intervention should target individual mothers and the context
in which they live. Safe infant feeding practices remain an integral part prevention of mother to
child transmission of HIV (PMTCT).The WHO, (2010 )guidelines on infant feeding in the
context of HIV infection recommend that infant feeding practices should support the greatest
likelihood of infant HIV free survival ,while also protecting against non-HIV morbidity and
mortality(WHO, 2010).The current recommendation is for women with HIV to breastfeed for up
to 12 months with provision of infant and maternal ARVs (ANDH, 2015)

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2.5.1 Breastfeeding and HIV/Aids

It is scientific fact that a child born to a HIV positive mothers may be HIV negative. However,
the child may acquire the virus from the mother through the breast milk. The most likely way
that this may happen is when a child’s gut lining is bruised. Bruising of the child’s gut happens
when it is given solid foods at an early age since the foods erode some of the protective
membranes along the gastrointestinal tract. On the other hand, a mother who is positive should
be counselled during her visit to the antenatal clinic at the PMTCT station. She should be
advised to choose between either the baby on breast milk exclusively for four months (then stop
the breast milk and substitute it with other milk (animal) and solid foods), or to feed the baby on
formula feeds or milk .therefore, mothers who is HIV positive should never mix-feed the baby
i.e. give breast milk and solid foods at the same time (Peter Ngatia, 2015).

Traditionally, this practice has not been common in Africa since most lactating mothers and
children were always together. Most women stay at home and cared for the family .However,
today, several mothers have to work and are only a month or two for maternity leave. After this
period, they have to learn to express breast milk for the sake of the baby .the same is important
for a mother who is HIV positive and chooses to breast feed exclusively but has to leave the baby
for more than six hours .expressing the breast milk is a simple technique that a mother van be
thought .in addition, the importance of maintenance of hygiene for mother, baby, expressed milk
and utensils should be emphasized to prevent contamination that may lead to diarrhoea. The milk
should be stored in a closed container, in a cool place in the house away from direct sunlight.
They should be fed the expressed breast milk using cup and spoon and not a bottle. Therefore,
health care workers should take to educate the mothers on these practices as they go a long way
in minimizing childhood illnesses, related complications and deaths arising from malnutrition,
infections and other diseases (Peter Ngatia, 2015).

2.5.2 Breastfeeding

Breastfeeding is the normal way and breast milk is all the baby needs for the first six months of
life (Burgress A, 2009) Without intervention, about 35% of HIV positive pregnant women will
pass on the infection to their babies during pregnancy, delivery and postnatal through
breastfeeding without preventive interventions about 10-20 per cent of infants born to infected

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mothers will contact the virus through breast milk if breastfed for 2 years (WHO, 2010).They
further recommends mothers safety breastfeed exclusively for 6 months and continuous
breastfeeding until 12 months alongside complimentary feeding after 6 months provided that
they or their infant received ARVS drugs during the breast feeding period. Exclusive
breastfeeding is where an infant receives only breast milk and no other liquids or solids, not even
water, with the exception of drops or syrup consisting vitamins minerals supplements or
medicines (Burgress A, 2009).This has been shown to give infants the best chance to be
protected from HIV transmission in settings where breastfeeding is the best option .This also
show that complementary foods introduced to infant less than 6 months of age damages the
already delicate and permeable gut wall of the infants and allows the virus to penetrate easily
(UNAIDS, 2010), therefore many health and UNICEF providers recommended exclusive
breastfeeding for about 6 months.

It is recommended that mothers who are HIV negative or are of unknown status should be
encouraged and supported to exclusively breastfeed for 6 months and continue breastfeeding
with appropriate complimentary feeding at 6 months for a period of 24 months and beyond
however, all HIV positive mothers should be encouraged and supported to exclusively breastfeed
for the first 6 months of life, introducing appropriate complimentary foods at six months and
continue breastfeeding up to at least 12 months of the infant life and preferably up to 24 months
(NASCOP, 2016) while mothers whose infants are HIV infected should exclusively breastfeed
their infants for the first 6 months of life, introducing appropriate complimentary food at 6
months ,and continue breastfeeding 24 months and beyond (NASCOP, 2016)

2.5.3 Wet Nursing

Wet-nursing is where an infant is breastfed by a woman other than his or her mother. Wet
nursing may be considered in communities where this option is accepted. The wet nurse must
understand and agree for implications of HIV counselling and testing HTC, as she will need HIV
testing before wet nursing and 6 – 8 weeks after starting. In addition, she should be counselled
about HIV infection during breastfeeding. There is an evidence where the overall prevalence and
evidence of HIV is low, and HIV has thus not spread to significant levels in any of sub
populations, HTC of a potential wet nurse is still indicated. If in these circumstances no HTC is,

19
the available potential wet nurse should undergo a HIV risk assessment as a minimum
requirement (WHO, 2010).

2.5.4 Replacement Feeding

Replacement feeding is also referred artificial feeding. It is used in the context of HIV to
describe feeding infants who are receiving no breast milk with a diet that provides the nutrients
infants need until the age at which they can be fully fed on family foods .During the first 6
months , replacement feeding should be with a suitable breast milk substitute , which definition
includes infants formula .Infant formula is a breast milk substitute formulated industrially that
should be in accordance with applicable codex alimentations standard Joint, F. A. O., WHO
Expert Committee on Food Additives, & World Health Organization. (2012)

2.5.5 Complementary Feeding

Infant feeding means giving other foods in addition to breast milk. It should start when the baby
is age 6 months and continue until the child is eating only or mainly, family foods; usually
between the ages of 2 and 3 years. This is a disadvantage on breastfeeding for HIV positive
mothers. The first 1000 days from conception to 2 years of is the time when nutrition is critically
important. Exclusive breastfeeding can protect children malnutrition until the age of 6 months.
But after this, from 6 and 24 months, they are at risk because this is when their main source of
nutrient gradually changes from breast milk to family foods and exposure to germs in foods and
in the environment increases. The is also the time of rapid growth and development and therefore
of high nutrient needs particularly between the ages of 6 and 11 months. Children’s needs for
some micronutrients, such as iron are exceptionally high, compared to their energy needs.
Therefore, as children are unable to eat large amounts, complementary food should have a high
density of nutrients especially micronutrients (FAO, 2011).

Complementary feeding may damages the lining of the baby’s stomach and intestines and thus
makes it easier for HIV in breast milk to infect the baby (UNICEF, 2010).Mixed feeding before
6 months is not recommended because it carries a higher risk than exclusive breastfeeding
(WHO, 2010), before this period the baby’s stomach and intestinal lining is not fully developed
and control with stand solid food

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2.5.6 Partial Breastfeeding

A breastfeeding baby who is given other liquids or artificial feeds suckles less. The results in the
mother producing less breast milk and the baby getting fewer essential nutrients and immune
factors. Bottle feeding may reduce effective suckling and breast milk production. Partial breast
feeding before 6 months of age increases the risk of transmission of human immunodeficiency
virus HIV infection from the mother to the baby. However, if the mother is HIV negative, partial
breastfeeding is better than not breastfeeding at all (WHO, 2010).

2.5.7 Infant Feeding Knowledge, Intention and Perception among Pregnant Women

Pregnant women with HIV had better overall knowledge on safe infant feeding practices, scoring
a mean two points higher than pregnant women without HIV, population less than 0.001. This
difference related both to better knowledge about infant feeding in the context of HIV and to
general infant feeding practices. Women without HIV scored poorly on question relating to
definition and duration to exclusive breastfeeding and formula feeding, and also on questions
related to antiretroviral prophylaxis for HIV exposed infant (Mnyani et al., 2017)

Differences were observed in overall knowledge between postpartum women with and without
HIV women with HIV had a higher score on knowledge of safe infant feeding practices in the
context of HIV infection, while the knowledge scores on general infant feeding were familiar far
both groups (Mnyani et al., 2017).

2.6 Socio-Cultural and Economic Factors Influencing Infant Weaning

There is wide knowledge on the benefits of exclusive breastfeeding and the association it has
with physical and intellectual development .Babies who are exclusively breastfed were said to be
very intelligent, strong, with better health compared to those who are not .A young mother for
instance believed that children who are exclusively breastfed perform well and go to the best
school in the country “.If breastfed for six months they become very clever (whistles)” (Wanjohi
et al., 2017). Despite the knowledge on the benefits of exclusive breastfeeding their children
were noted .These include the perception that same mothers do not have adequate breast milk to
practice exclusive breastfeeding for six months, that breastfeeding exclusively or for six months
causes for difficulties in initiating complementary foods;” some children are used to breast milk

21
that they refuse other foods at 6 months’…to make them eat, you have to stop breastfeeding
“(FGD with older mothers – viwandani). Also, breast milk alone is insufficient to support
optimal growth of babies perceived to be either too big,” some children are born heavy in terms
of weight …and they don’t get full on breast milk. You give other foods like porridge even
before one month.” (FGD, older mothers – Korogocho).

2.6.1 CULTURAL BELIEFS AND NORMS

Cultural beliefs and norms have powerful influence on human nutrition (David Napier et al.,
2014; Bandyopadhyay, 2009) and have been identified as among the determinants of
breastfeeding practices (Rollins et al., 2016). Although myths, misconception and cultural beliefs
have highlighted as among the hurdles to optimal breastfeeding and infant feeding in Kenya,
there is a death of evidence on the specific cultural beliefs and practices on breastfeeding,
especially in the urban slums where poor breastfeeding practices are rampant

22
 SOCIAL-CULTURAL BELIEFS AND PRACTICES AROUND BREASTFEEDING

Sociocultural
Socio-cultural beliefs and
practices that do
beliefs and
not align with the
practices align WHO
with the WHO recommendations
recommendation

Exclusive breastfeeding is Children are always hungry at

beneficial, but there are birth
exceptions
Curse if you breastfeed in some
Evil eye if you breastfeed in circumstances
public
Breasts will sag
It’s a religious
Boys are not breastfed the same
recommendation
as girls

Breastfeeding for long duration

is counter productive
Source: Wanjohi et al, international breastfeeding journal (2017)

Figure 2: Social cultural beliefs and practices around breastfeeding

2.6.2 BAD OMEN (CURSE) AND EVIL EYE (If not breastfeed in public)

It is strongly believed in some ethnic groups, especially the Lou and Luhya ethnic groups, that a
mother’s milk becomes unclean if she involved in extramarital relationships with men who are
not the baby’s father. It is considered a bad omen or curse “chira”if the mother continues
breastfed while engaging in such relations, which could lead to death of the baby. As a result
some mothers cannot continue breastfeeding if they engaged in this relations unless some
cleansing ritual are done. This however does not directly associate breastfeeding with marital

23
faithfulness or non-breastfeeding promiscuity in the general community. Further, breastfeeding
women have to undergo cultural cleansing rituals “manyasi” after having confrontations with
community members or their spouse before they are allowed to resume breastfeeding is
recommended .This is common among Luo and Luhya ethnic groups (Wanjohi et al.,
2017).Some women fear breastfeeding in public as they could be watched by people in the
community who are believed to have an ‘evil eyes ‘(malevolent glare which is believed to be a
curse associated with witchcraft).They fear that if a person with ‘evil eye ‘look at them while
breastfeeding , breast milk will dry up or the mother will develop breast sore .This may prompt
some mothers to avoid breastfeeding or start bottle feeding ,especially when attending public
gathering or generally being in public (Wanjohi et al ., 2017).

2.6.3 BREASTS SAG AND “BOYS ARE NOT BREASTFED THE SAME AS GIRLS”

A community belief among young mothers in the community is that breastfeeding for a long
duration will make their breasts sag and render them unattractive. For these reasons young
mothers stop breastfeeding their children as early as possible to prevent their breasts from
sagging. (Wanjohi et al., 2017). The duration of breastfeeding is said to be shorter in boys than
girls in some communities, due to a common belief that boys breastfeed a lot and weaken the
mother. ‘Mother with male children complain that the children really breastfeed often , so they
cannot be allowed for maybe a year and a half or less .The female girl is advantaged because
they may breastfeed longer up to maybe three years , a male child may even make the mother
feel dizzy after sucking ‘(FGD with older mothers – Korogocho).As a consequence there is a
tendency of earlier introduction of foods and shorter breastfeeding duration in boys than girls.
Boys breastfeed a lot (laughter) so they are stopped when still young (FGD, older mothers –
Viwandani).

2.6.4 RELIGIOUS

Islamic was said to recommend breastfeeding for an exact number of years which is equated to
sharing one’s wealth with their children. This issue emerged from mothers and further
investigated by Muslims religious leaders in the community. For this reason, mothers from this
religious breastfed their children for at least two years. However, the Quran seems more lenient
on the breastfeeding recommendation than how people presented the case as the decision about

24
breastfeeding and the time of weaning is expected to be a mutual decision to both parents, in
consideration of what is best for their family as depicted by the Quran verse.

2.7 Summary and Conclusions.

Significant programmatic experience and research evidence regarding HIV and infant feeding
have accumulated since WHO's recommendations on infant feeding in the context of HIV were
last revised in 2006. In particular, evidence has been reported that antiretroviral (ARV)
interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce
the risk of postnatal transmission of HIV through breastfeeding. This evidence has major
implications for how women living with HIV might feed their infants, and how health workers
should counsel these mothers. Together, breastfeeding and ARV intervention have the potential
to significantly improve infants' chances of surviving while remaining HIV uninfected.

While the 2010 recommendations are generally consistent with the previous guidance, they
recognize the important impact of ARVs during the breastfeeding period, and recommend that
national authorities in each country decide which infant feeding practice, i.e. breastfeeding with
an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be
promoted and supported by their Maternal and Child Health services. This differs from the
previous recommendations in which health workers were expected to individually counsel all
HIV-infected mothers about the various infant feeding options, and it was then for mothers to
decide between them.

Where national authorities promote breastfeeding and ARVs, mothers known to be HIV-infected
are now recommended to breastfeed their infants until at least 12 months of age. The
recommendation that replacement feeding should not be used unless it is acceptable, feasible,
affordable, sustainable and safe (AFASS) remains, but the acronym is replaced by more
common, everyday language and terms. Recognizing that ARVs will not be rolled out
everywhere immediately, guidance is given on what to do in their absence.

25
 CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Study Area

Kisumu County Referral Hospital has been in existence for more than 100 years, having been
established in the early 1900s to cater for the health needs of the workers at the port town of
Kisumu. Since then it has grown to become the referral hospital serving more than 100 district
and sub district hospitals in more than 10 counties in the Western Kenya Region. Its main
mandate is to provide curative, preventive, promotive and rehabilitative health services

3.2 Study Design

Cross-Sectional descriptive survey method will be used to collect information required for the
study on factor influencing early weaning practices among female clients of reproductive age
receiving care and treatments at HIV clinic at Kisumu County Hospital.

3.3 Study Variables

3.3.1 Dependent Variable

Factors influencing early infant weaning practices among mothers of HIV exposed infants at
Kisumu County Referral Hospital.

3.3.2 Independent Variable

1. Maternal knowledge on MTCT of HIV among female clients receiving care and treatment.
2. Maternal choice on infant feeding practices.
3. Factors influencing infant weaning practices e.g. age, level of education, employment and
marital status.

3.4 Inclusion/ Exclusion Criteria

3.4.1 Inclusion Criteria

All HIV positive mothers of HEI 18 months and below who are receiving their care and
treatment at KCH during the time of data collection.

26
3.4.2 Exclusion Criteria

1. HIV positive mothers of HEI 18 months and below who never breastfed their infants at all.
2. HIV positive mothers of HEI 18 months and below who declines to participate in the study or
who are unable to participate in the study due to any reason.

3.5 Study Population

Mothers of HIV exposed infants aged 18 months and below who are receiving their HIV care
and treatment at KCH at the time of data collection

3.6 Sampling Methodology

3.6.1 Sampling Procedure

Simple random sampling technique will be used to select the respondents for the study since this
technique gives each person has an equal chance of being selected in the sample, where is
discourage biasness. List of female clients of reproductive age with infants 18 months and below
will be obtained from the hospital. Each potential participant clinic number will be written on a
small piece of papers from which the researcher will pick at random with her eyes closed until
the desired sample is obtained. The researcher will then interview those women whose number
has been picked.

3.6.2 Sample Size Determination

Sample size was determined using the following formula (Fishers 1998):
Z2 pq
𝑛=
d2

Where N=Desire sample when population is above 10000

Z = Confidential interval usually (0.05)
P = Proportion in target population estimated to have a particular characteristic
Q = Target population estimated to have characteristics not being measured (q = 1 –p)
In this case - of the respondents are expected to be interviewed at KCH, therefore, (q = 1 – p) .
1.962 ×0.8364×0.9140
Therefore: 𝑛 =
0.052

n=117.8

27
In 2016 Kisumu County Referral Hospital had a total of 275 HIV Exposed Infants with a
monthly average of about 23 infants visiting the facility.
Since the population is less than 10,000, Fisher’s formula will be used to adjust the sample:
NF = n
1 +n
N
Where;
nf =Required sample size
N = Estimate number of target population
n= Constant
Therefore,
117.78
1+ 117.78
275
Sample size will be 82 mothers of HIV Exposed Infants

3.7 Data Collection Tool

A structured Interview Schedule with both open and closed ended questions will be used to
obtain data from sampled mothers of HEI at KCH during the duration of data collection

3.8 Data Collection, Analysis and Presentation

Data collection is expected to last for about one month. Data will be collected through face to
face interviews between the investigator herself and mothers of HEI until the desired sample size
is attained. Both quantitative and qualitative data will be collected regarding various factors
influencing early infant weaning practices among mothers of HEI.

After data collection, data entry will be done on an MS Excel sheet. Quantitative data will be
described using descriptive statistical analysis techniques: Measures of Central Tendency and
Measures of Dispersion. Data analysis will be done using SPSS version 12.0. Data will be
presentation on charts, tables, graphs and in narratives.

3.9 Ethical Considerations

Letter of clearance to conduct the study will be obtained from KMTC Rera campus. Additional
clearance will be obtained from KCH Administration. Detailed description of the purpose of the

28
study and verbal consent will be obtained from sampled participants before starting an
embarking on data collection.

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APPENDICES

Appendix 1: Interview Schedule

A study on factors influencing early weaning practices among mothers of HIV expose infant at
Kisumu County Referral Hospital.

Dear respondents,

I am a student from Kenya medical training college, Rera, carrying out a research on factors
influencing early weaning practices among mothers of HIV expose infant in Kisumu County
Referral Hospital MCH

Clinic. I request you to participate in this study by completing this questionnaire confidentiality
of the given data will be highly assured. The information obtained will be strictly for learning
purposes.

The interview schedule to be completed by mothers and guidance’s with expose infant age 18
months and below attending MCH clinic in kisumu county referral hospital.

Interview schedule no.........................

Date.....................................................

Instructions

I. The information given shall be confidential

II. Do not write your name on the paper
III. All answers should be relevant to what has been asked
IV. Use a pencil to tick ( ) the most appropriate answer in the box alongside
V. All questions are compulsory
VI. Read the questions carefully before answering

DEMOGRAPHIC INFORMATION

1. How old are you?

33
  Blow 18
 18-24 years
 25-34 years
 35-45 years
 Above 45 years
2. What is your highest level of education?
 No formal education
 Primary school
 Secondary school
 College and above
3. What is your marital status?
 Married
 Single
 Divorced
 Widow
4. What is your Religion
 Catholic
 Protestant
 SDA Casual, 2=Farming, 3=Business, 4=Employed, 5=Others
 Pagan
 Others specify.....................
5. What is your family’s source of income?
 Casual
 Farming
 Business
 Employed
 Others Specify…………….
6. How many times have you given birth
 Once
 Twice and Above
7. How old is your baby?.......................(months)

34
8. Sex of your child?
 Male
 Female
9. Where did you deliver this child?
 Hospital /Health facility
 Home
 Traditional Birth Attendant
 Other specify..................................
10. What was the mode of delivery?
 Normal delivery
 Caesarean section
 Assisted delivery
11. How long do you take to breastfeed your child immediately after delivery?
 Less than 1 hour
 2-3 hour
 Days (mention)
12. Other than breast milk, did you give your baby any fluid before initiating breastfeeding?
 Yes
 No
13. If yes, what did you give your baby?
 Water
 Porridge
 Milk
 Medicine
 Others (specify)
14. Why did you give him/ her such fluid?
………....................................................................................................................................
................................................................................................................................................
15. When did you start introducing extra foods / drinks including water to your child?
 Below 1 month
 1 - 3 months

35
  4 - 5 months
 6 months
 More than 6 months
16. Why did you introduce extra food/ drinks at that time?
………………………………………………………………………………………………
……………………………………………………………………………….......................
17. How much do you eat per day when the baby is less than six months
 Less than 3/day
 At least 3 times/days
 More than 3/day
 On demand
18. What is the interval between the first child and the last born?
1
2
>3
 Other specify.................................................................................................................
19. Did you practice exclusive breast feeding to your child for first 6 months?
 Yes
 No [skip question 19]
20. If YES, who among these persons could have influenced your decision on feeding your
child? (choose all that apply)
 Husband/ spouse
 Mother/ father
 Mother/ father in law
 Health worker
 My own decision
 Others specify........................................................................................
 None
21. Do you believe breast milk is sufficient for the baby for the first six months of life?
 Yes [skip question 21]
 No

36
22. If NO, why do you believe it’s not sufficient?
……………………………………………………………………...........................
23. Do other relatives/ neighbours monitor and insist on your exclusive breastfeeding
practices?
 Yes
 No
24. If Yes, who supported you? (Mention)
………………………………………………………………………………………………
………………………………………………………………………………………………
25. Did you experience any breastfeeding problems?
Yes
No [skip question 25]
26. If Yes, what was the problem?
 Abscess
 Mastitis
 Sore/cracked nipples
 Others (specify) ………………………………………………..
27. Did you hear breastfeeding?
 Yes
 No
28. What did you hear about breastfeeding?
 Benefits of breastfeeding
 Positioning of the baby
 Exclusive breastfeeding
 Management of breast problem
 Expression of breast milk
 Others (specify) ………………………………………………..
29. At what time did you take to listen?
 <5 minutes
 5 - 10 minutes
 > 10 minutes

37
30. Where have heard about breastfeeding?
 Hospital/clinics
 Others (specify)......................
31. From where have you heard about breastfeeding and its importance?
 Healthcare provider
 Radio
 Newspaper
 Television
 Others (specify)..............................................................................................
32. What do you understand by the term exclusive breastfeeding?
……………………………………………………………………………...........
33. Do healthcare providers use to spend time to monitor your breast feeding practices?
 Yes
No
34. How many times per day should the baby be breastfed?
3-4
5–6
 When he/ she demands for it
 Others (specify)...............................................................................
35. What is the appropriate time to start complimentary foods?
 Less than one month
 1 -3 months
 4 -5 months
 6 months
36. What were reasons for not practice exclusively breast feeding?
 Going back to work
 Breast milk was not enough
 Maternal problem (specify).............................................................................
 Child problem (specify)...................................................................................

38
We have come to the end of this interview. I sincerely thank you for taking part in this
interview. Do you have any question or concern?

39
Appendix 2: Work Plan

Period/ Activities 2018 2019

May June - August Sept - December January -March April - May

1. Problem identification
2. Literature review
3. Proposal writing
4. Proposal submission
5. Data collection
6. Data analysis
7. Report writing
8. Report submission

40
Appendix 3: Study Budget

Description Quantity Rate Amount

Printing paper 1rim 100 100
Pens Sharp pointed bic 25 100
Pencils Hb 25 50
Rubber 1 1 10
Ruler Office ruler 30
Sharpener 1 1 25
Internet Safaricom Airtime 600
Flash disk Hp 8GB 1 1200
Transport 1000

41