FEEDING AND WEANING PRACTICES AMONG MOTHERS OF UNDER-FIVE CHILDREN IN SELECTED PRIMARY HEALTH CARE CENTRES IN ADO-EKITI, EKITI, NIGERIA Oluwaseyi Akpor, Tunrayo Oluwadare, Omotola Taiwo, Bukola Aladenika, Oghenerobor Akpor

An appropriate diet is necessary in the growth and health status of children especially in the first two years of life. This study determined the feeding and weaning practices among mothers of children below the age of five years in two selected Primary Healthcare Centres in Ado-Ekiti, Ekiti State, Nigeria. The study design was descriptive and cross sectional using an interviewer-administered questionnaire, 200 mothers who were purposely selected participated in the study. Statistical Package for Social Sciences was used for data analysis. Findings from the study revealed that the main practice of feeding of infants was breastfeeding, the majority of the mothers started to wean their children at about 6 – 7 months. Also, the major type of weaning practiced by mothers was abrupt weaning, majority of the mothers had good knowledge of feeding and weaning including how beneficial exclusive breastfeeding is, though it is just a few of them that practice exclusive breastfeeding. Therefore, complementary feeding education that will involve the use of various media most especially the primary health facilities is paramount for optimal health of infants. Also teaching should focus on the type of weaning and mothers should be educated on the consequences of abruptly weaning a child.


INTRODUCTION
Weaning is the process of gradually introducing an infant to adult foods while gradually withdrawing breast milk. The child is not abruptly taken off breast milk, the process of weaning should be started after the age of 6 months and natural weaning happens as the infant starts to accept increasing amounts and different variety of complementary feedings although still breastfeeding on request (Mohammed, 2014;Ogunsuyi, 2016). Weaning is traditionally described as withdrawal from breast feeding i.e. when breast feeding is gradually replaced by semisolid food. The shift from exclusive breastfeeding to family foods is referred to as complementary feeding and complementary feeding is defined by World Health Organization (WHO) as the addition of energy as well as non-energy containing fluids, non-human milk and semisolids or solids to children's diet which covers the time from 6 months to 18 -24 months of age (WHO, 2002; Chaudhry and Humayun, 2007).
The weaning period, which usually corresponds with the eruption of the child's major dentition implies that the child is ready to chew (Aliyu et al., 2019). The weaning period is a very susceptible period, since it is the point in which malnutrition set offs in many infants. Infants are predisposed to malnutrition as a result of poor quality of weaning foods, improper feeding and weaning practices, which can also predispose the infants to growth retardation, infectious diseases and high mortality rate (Rahul, Mohd and Rakesh, 2014; Mohammed, 2014).
It is indicated that poor infant feeding and their consequences are one of the world's major problems and a serious obstacle to social and economic development. During the first two years of life, poor feeding practices and weaning practices have both instant and long-standing consequences. Inappropriate feeding of infants has long been observed in our society to be one of the global problems responsible for about one-third of the cases of malnutrition worldwide (Anoshirike et al., 2014). According to Mohammed (2014) about ten million children below the age of 5 years old die annually and more than half of the deaths occur because of malnutrition.
In Nigeria, complementary foods are usually semi-solids and they differ in homes but most homes use maize based cereal (Aliyu et al., 2019). Due to introduction of westernized food and other factors like the advertising tactics taken up by most food and beverage companies and the readily preparation of most of these foods, these factors may influence the feeding practices like reducing the age of initiation of complementary feeding and early cessation of breastfeeding. Due to the high prevalence rate of malnutrition, there will be a burden on the economic development because huge amount of money will be spent towards treating these children (Aliyu et al., 2019). Among preventive measures that would reduce the excess mortality for children under the age of five years, good quality complementary feeding, proper breastfeeding and complementary feeding practices have been listed as part and about 19% of this death can be prevented (Kavitha, Nadhiya and Parimalavalli, 2014). Improved breastfeeding practices and reduction of artificial feeding is reported to save an estimated 1.5 million children a year (Bhanderi and Choudhary, 2011). This study therefore investigated the feeding and weaning practices among mothers of under five children in selected Primary Health Centres in Ado-Ekiti Local Government Area of Ekiti State, Nigeria.
The theoretical framework for this study is the Health Belief Model (HBM), which is a psychological model that endeavours to describe and forecast human behaviours (Janz and Becker, 1984). The HBM is an intrapersonal theory used in health promotion to design intervention and prevention programs, it is based on personal beliefs or perceptions about a disease and the schemes available to diminish its occurrence. The model proposes that people's viewpoints about health problems, perceived benefits of action and barriers to action, and self-efficacy enlightens commitment or lack of commitment in health promoting behaviour. A motivation, or cue to action must be present in order to set off the health-promoting behavior ( Figure  1).
For the purpose of this study five concepts of the Health Belief Model are used. This study is based on the feeding and the weaning practices of mothers of under-five children; it involves the practices adopted by mothers to feed their children, the timing of feeding and weaning, and also the food used. Therefore, these concepts will explain how the theory is related to the study. The Health Belief Model is a framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the prime drive. For example, inappropriate feeding and weaning has many negative health consequences, and the desire to avoid the consequences can be used to motivate mothers into practicing safe and appropriate feeding and weaning.
Perceived severity is described as the severity an individual attach to a disease which can be as a result of the beliefs a person has about the complications that can arise as a result of the disease or its outcome on his or her health, in this case on the child's health. The main component of infant feeding is breast feeding; studies have shown that infants who are not exclusively breastfed develop some long-term medical consequences. If mothers understand the degree of health challenges that may occur due to inappropriate infant feeding and weaning, it is likely they will change for the benefit of the health of their child.
After understanding the severity of the illness that may likely occur i.e. malnutrition, mothers tend to engage in health promotion and illness prevention. And for those that are already affected they tend to find solutions before it is too late.
Perceived benefits involve one's opinion of how useful an action is in reducing the risks of developing a disease. In relation to this study, the perceived benefits include, benefits of breast-feeding, benefits of other options of infant feeding and of weaning, for example, it is advantageous to give thick porridge to infants above 6 months because they provide a lot of energy to the infant. Also, if a mother knows the benefit of breastfeeding for both her and her child, she is more likely to practice it. Most women do not practice the appropriate infant feeding and weaning because they are ignorant of the health risks associated, therefore, adequate enlightenment will go a long way in helping them.
Perceived barriers are the perceived obstacles that prevent an individual from taking a particular health action. It is a way of an individual assessing the barriers that will prevent him or her from adopting the new lifestyle.
There are so many obstacles encountered by women during the period of breast feeding that prevents the practice of exclusive breast feeding such as husband refusal, painful nipple, infants' refusal to suck and career. These obstacles might prevent the woman from achieving the new lifestyle, encountering difficulties with breastfeeding may cause a woman to wean her child off breast milk earlier than recommended or expected. Poverty is also a major obstacle to good weaning practices as it affects the quality and quantity of food fed to infants. Other barriers in relation to this study include, lack of education, tradition and lack of social support.
Cues to action is always essential for commitment in health promoting activities; it indicates one's willingness to assess a health facility. People who are at risk of a disease, after seeing public display on the condition tend to remember they have appointment with a medical practitioner, alarms, and reminders can also be used to keep to date. Psychological cues such as pain also serves as a reminder. The cues to action in this study include health education and counseling by the nurse. The nurse acts as a teacher, counselor and communicator to the woman which helps to promote the performance of health related behaviours such as the practice of exclusive breastfeeding.

Scientific hypothesis
Hypotheis 1: There is no significant relationship between respondents' level of education with feeding and weaning practices.
Hypothesis 2: There is significant relationship between respondents' age with feeding and weaning practices.

MATERIAL AND METHODOLOGY Study design and setting
The study design was descriptive and cross sectional. Purposive sampling technique was used to select two Primary Health Care centres in Ado-Ekiti Local Government Area of Ekiti State, Nigeria. To maintain anonymity, the PHC were referred to as 'PHC A' and 'PHC B'.
The 'PHC A' is made up of a waiting room, examination room, labour ward and an admission ward. The services rendered in the Centre include antenatal services, delivery, circumcision, family planning, treatment of childhood diseases and immunization services. It is operated by four registered nurses and fifteen community health extension workers (CHEWS) with an average patient patronage of 744 per month.
The settings for 'PHC B' was similar to PHC A with five registered nurses and fifteen CHEWS. Services rendered in the clinic include, family planning, antenatal clinic, delivery, circumcision, treatment of childhood diseases, infant growth monitoring and immunization services. It has an average monthly patient patronage of 132.
Study population, sampling technique and sample size. The target population for this study comprised of women in the selected PHC centres whose confinement was not more than five years to avoid recall bias. Inclusion criteria included attending one of the selected PHC centres, have children below the age of five years who are being fed (bottle feeding or breastfeeding) or weaned. Potential participants had to be willing to participate in the study.
Purposive sampling technique was used to select 238 mothers that participated in the study while only 200 mothers returned fully completed questionnaire. The sample size was calculated, using the Fischer's formula for descriptive study. Although the calculated sample size of 217 and obtained, deliberate over-sampling was done to the tune of 10% (21.7) to make up for incomplete responses. Therefore, a sample size of 238 was used but only 200 questionnaires were fully completed.

Instrument and data collection
A semi-structured interviewer-administered questionnaire was used for data collection. The research instrument was developed by checking previous articles done on weaning and feeding practices and deducing questions from most of them. The questionnaire was divided into four sections, sections A and B contained the demographic data and the feeding practices applied by the participants, respectively. Section C assessed the weaning practices and foods used in weaning off the children, while Section D assessed the knowledge of mothers on feeding and weaning. The questionnaire was written in English language and participants were informed about the purpose of the study. Furthermore, pre-testing of the questionnaire was carried out using five participants that had similar characteristics with the study population but the findings were not included in the final data. Mothers of children below the age of five were asked to participate in the study during their visit to the health care centres for ante-natal and post-natal services (booking, immunization) or family planning. Data was collected from March to April 2017. Guidelines for completion of the questionnaire was explained to the participants, questionnaires were collected and collated.

Ethical consideration
Before the commencement of the study, the research proposal was submitted to the Research and Ethics Committee of Afe Babalola University, Ado-Ekiti (ABUAD) for reviewed and permission to conduct the study was given. Likewise, an official letter was written to the two selected PHC centres and permission letters were obtained from the facility managers. Prior to data collection, each participant's right was explained and inform consent were obtained. The participants were assured that information provided will not be used against them, no remuneration was offered and they were informed of the opportunity to withdraw at any stage of the research.

Statistic analysis
Data analysis was done with the aid of Statistical Package for Social Sciences (SPSS) version 20 and Microsoft Office Excel (2016) to generate figures and graphs. Descriptive statistics such as frequencies, percentages, mean were presented on tables, or charts.

RESULTS AND DISCUSSION Socio-demographic characteristics of participants
With respect to the socio-demographic characteristics of participants, of the 200 participants, 50.5% of them were between the ages of 31 -40. A total of 70.5% of the mothers were married. The vast majority (48.0%) of the mothers have 2 children, with only 1.0% of them having six children. Over 40% of the mothers had at least secondary school education (Table 1).

Feeding practices of participants
As shown in Table 2, more than half of the respondents (59.5%) fed their infants at least 6 times a day, 88.0% of the mothers breastfed their children and 63.0% did not give their children anything to drink other than breast milk in the first 3 days after delivery. Of the 37.0% of mothers who gave their infants anything other than breast milk in the first 3 days after delivery, more than half (54.1%) gave their baby glucose water.
Most mothers (60.0%) gave their children only breast milk and the minority. Almost half (42.0%) of the mothers fed their children with only breast milk till when they were 5 -6 months, and 61.0% of the children were satisfied with only breast milk in the first 6 months. .0 months, also vast majority (81.0%) of the mothers practice night feeding and close to one-third (38.9%) of the night feeding was on demand.

Weaning practices of the participants
As revealed in the study, more than one-third (39.5%) of mothers weaned their child within the age range of 6 -7 months which is also the same age most of the mothers stopped breastfeeding their children. Close to half (44.0%) of the participants weaned their children because they had reached the weaning age, while 44.0% weaned their child off breast milk abruptly. Pap and milk (64.0%) were the food used the most by mothers during the period of weaning (Table 3).
The use of bitter substance (39.0%) was used by mothers the most as a method to take their child off breastmilk. More than half (57.5%) of the mothers gave their weaning food with a spoon and cup. A high percentage (70.0%) of the children was not selective of weaning food, 71.0% of the mothers responded that the weaning method affected the baby's weight. Majority (88.5%) of the mothers did not take drugs when they were pregnant (Table 3).

Knowledge on feeding and weaning practices
As shown in Table 4, about half (51%) of the mothers obtained their knowledge on feeding and weaning of their infants from health care workers and 82% of the mothers were familiar with the right meaning of exclusive breastfeeding (Table 4).
Almost half (51%) of the participants indicated that their knowledge on breast feeding was shown to have come from health workers (Figure 2). Generally, a vast majority (70%) of the participants were observed to have ideal knowledge of breastfeeding and weaning (Figure 3).
The majority of mothers in the study breastfed their children for at least six times daily, and breastfeeding was given for about six months in total.

Figure 2
Participants' source of information on feeding and weaning.

Participants´source of information on feeding and weaning
Adequate knowledge Moderate knowledge Poor knowledge  where only 30.1% and 6.8% of mothers practiced exclusive breastfeeding respectively. Despite the fact that breast feeding is known to be a highly recommended and beneficial way to feed infants as it provides psychological and health benefit to both the mother and the child. Globally there has been a common decline in the practice of breastfeeding both in terms of occurrence and interval in the past few decades (Berra, 2013).
The study further revealed that about 40.0% of the mothers in addition to breastfeeding included complementary foods for their children at 4 -6 months of age. This contrast with the results obtained from some studies conducted in South-West, South-South and North-West regions of Nigeria where 76.7%, 79.9% and 80.1% When breast milk is no longer adequate to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child (Kavitha, Nadhiya and Parimalavalli, 2014). Proper breastfeeding practices are effective ways for reducing childhood morbidity and mortality. While many mothers understand the significance of breastfeeding, others are less informed on the benefits of breastfeeding and weaning. Anoshirike et al. (2014) stated that, malnutrition in Nigerian infants is found to be as a result of inappropriate child feeding practices such as late introduction of complementary foods, small energy and nutrient density of foods offered, feeding in little quantity at meals, food limitations due to cultural beliefs, low birth-weight and high morbidity.

Hypothesis testing Hypothesis 1:
From the chi-square test (Table 6), the null hypothesis of no significant relationship between respondents' level of education and deeding and weaning practices is rejected. Consequently, the alternative hypothesis of a significant  relationship between respondents' level of education with feeding and weaning practice accepted (Table 5).

Hypothesis 2:
As shown in Table 2, there was no significant relationship between respondents' age and feeding and weaning practices, hence the null hypothesis of a significant relationship between respondents' age with feeding and weaning practices was rejected (Table 7 and  Table 8).
Adequate nutrition during infancy and early childhood is essential to ensure the development, health, and growth of children to their full potential. As stated by Mohammed (2014), gradual weaning period should be introduced first which allows the child to receive the benefits from breastfeeding while also consuming necessary nutrients from complementary foods. This is contracts with the result obtained in this study where about 45% of mothers abruptly weaned their children from breast milk. According to Razia and Naheed (2007), complete weaning can be introduced at about 2 -4 years of age, and this is the total withdrawal from breast milk. The findings of the study showed that 39.5% of the mothers weaned their children at about 6 -7 months and 45% of mothers weaned because they were of the opinion that the child is old enough. This is similar to the results obtained by Kikafunda, Walker and Tumwine (2003), Mohammed (2014), Olatona, Odozi and Amu (2014) and Ogunsuyi (2016), where 42%, 91.6%. 48.4% and 55.6% respectively started the weaning process between ages 4 -6 months. Feeding and weaning are important components for the physical and psychological well-being of a child. Feeding a child which involves breast feeding is a complex approach while weaning is a critical approach. According to Kavitha, Nadhiya and Parimalavalli (2014), displacement of breast milk and increased risks of infections such as diarrhoea which further contributes to weight loss and malnutrition can be as a result of untimely introduction of complementary feeds before the age of six months. Thus, it is important that weaning should be gradual and not done abruptly. In addition, the findings revealed that during weaning, homemade food, infant formula and family food were given to the infants by the mothers.
The present study revealed that the majority of participants had good knowledge (70%) on feeding and weaning of their infants, with most indicating their knowledge came from the information provided by health workers. Poor infant feeding and their consequences are one of the world's major problems and a serious obstacle to social and economic development, therefore adequate knowledge on the feeding and weaning practices of the children is very essential. Nurses can assess the knowledge of mothers attending post-natal clinic towards feeding and weaning, certain educational programmes can be conducted for the mothers based on the needs which will help improve the mother's knowledge regarding feeding and weaning. Since health care workers serve as a strong means of disseminating health information to the community; they too need to be abreast of information (Kambli, 2012).

CONCLUSION
This study assessed mother's feeding practices, their weaning practices and also their knowledge on the feeing and weaning practices. The findings from the result showed that the vast majority of the mothers have good knowledge about feeding and weaning of their infants.
The practices of mothers on the feeding of their children were good based on the fact that breastfeeding was the major practice by mothers and also the knowledge of mothers on feeding and weaning their children was good. Specifically, the results of this study provide a baseline data on the importance of establishing standard indigenous nutrition education programme for mothers of young children in Nigeria. Emphasis should be placed on including pregnant women and women of child bearing age as the target audience. This will facilitate the mothers understanding of nutrition which will in turn enhance the feeding practices and nutritional status of their children. There is need concerning health education program aimed at educating mothers on commencement of breastfeeding within one hour after birth, exclusive breastfeeding till six months of age and the value of night feed and the benefits of giving infants colostrum.