Cross-sectional study of predictors of infant nutrition knowledge among new mothers in Iraq

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Short research communication

Aseel Muayad Salih^1,2, Tarik Ziyad Tarik Shwaish³, Elaf Mohammed Saleh² and Wefak Hasan Abdulraheem Alkawaz²

¹Arab Board of Health Specializations, Iraq. ²Basra Health Directorate, Basra, Iraq. ³Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy (Correspondence to Tarik Shwaish: This email address is being protected from spambots. You need JavaScript enabled to view it.)

Abstract

Background: Despite recent improvements, infant and young child feeding (IYCF) remains a challenge in Basra, Iraq.

Aim: To describe the predictors of IYCF knowledge among new mothers in Basra City, Iraq.

Methods: This cross-sectional study collected data on infant nutrition knowledge from 400 new mothers attending 12 primary health care centres in Basra, Iraq, between February and June 2023. Jamovi version 2.3 was used for statistical analyses. Predictive analysis was performed with univariable and multivariable ordinal logistic regression, and the results were reported as crude and adjusted odds ratios with 95% confidence interval. P < 0.05 was considered significant.

Results: Most (60%) of the women interviewed were younger than 19 years, married (98%), living in an extended family setting (93%), and in the lowest income level (76%). Age ≤19 was a significant predictor of knowledge about breastfeeding, formula feeding, complementary feeding, water and supplements, and food allergies (adjusted odds ratio range 2.24–5.30). Unemployment and low education status predicted lower knowledge about breastfeeding, complementary feeding, water and supplements, and food allergies, but neither unemployment nor low education status predicted lower knowledge about formula feeding. Receiving information from doctors or healthcare workers and social media or the internet was associated with better maternal IYCF knowledge while receiving information from family and friends predicted poorer knowledge about food allergy and water and supplements.

Conclusion: IYCF education in Basra should be improved, with particular attention to healthcare worker-mediated and social media- and family systems-based approaches. Priority should be given to the less educated, younger and unemployed women and those in the lower income group.

Keywords: infant nutrition, infant feeding, breastfeeding, formula feeding, complementary feeding, water and supplements, food allergies, Basra, Iraq

Citation: Salih AM, Shwaish TZT, Saleh EM, Alkawaz WHA. Cross-sectional study of predictors of infant nutrition knowledge among new mothers in Iraq. East Mediterr Health J. 2024;30(9):641–649. https://doi.org/10.26719/2024.30.9.641.

Received: 06/01/2024; Accepted: 18/07/2024

Copyright © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Background

The promotion of infant and young child feeding (IYCF) education and baby-friendly hospitals by the Iraqi Ministry of Health in the past decade has been associated with a significant increase in exclusive breastfeeding rates nationwide (1,2). However, despite these improvements and the prioritization of maternal education in the Iraqi national nutrition strategy and the national development plan, IYCF practices in Iraq remain inconsistent with global recommendations (1,3-5).

Basra, the third most populous Iraqi governorate seems to have a persistent IYCF problem. During 2011–2018, when national exclusive breastfeeding rates increased from 19.6% to 25.6%, exclusive breastfeeding rate in Basra remained low (15.8–16.0%). The governorate has the second lowest exclusive and predominant breastfeeding rates for children under 6 months in the country (6,7). To design effective IYCF education strategies and identify women at risk of lower knowledge, understanding the factors influencing maternal knowledge is imperative (8-10). However, such data is not available because the national surveys only assess practice and not knowledge (6,7).

This study, therefore, aimed to assess the socioeconomic and information-source predictors of IYCF knowledge among new mothers in Basra City. The IYCF areas considered were breastfeeding, formula feeding, complementary feeding, water and supplements, and food allergies. To the best of our knowledge, this is the first study using a regression model to assess the predictors of maternal IYCF knowledge in Iraq.

Methods

This cross-sectional study was conducted in 12 primary health care centres (PHCs) in Basra from February to June 2023. Data was collected using a questionnaire administered by a trained medical doctor. The questionnaire contained 33 close-ended questions covering 5 areas: breastfeeding (10), formula feeding (6), complementary feeding (10), water and supplements (5), and food allergy (2). Each close-ended question was followed by an open-ended question to verify respondents’ knowledge (e.g. “Do you know the signs of baby satiety?” was followed by “What are they?”). A lack of, or incorrect knowledge was assigned zero point, correct answers were assigned 1 point, and extra points (maximum 10 extra points) were awarded if mothers mentioned specific details in their response to 3 open-ended questions on breastfeeding and 1 open-ended question on food allergy (maximum 3 extra points). The area-specific knowledge score (points obtained/points obtainable x 100%) was used to define good (80–100%), satisfactory (50–79.9%) and poor ( 0.7) before administration.

The study population was selected using 2-stage clustering method involving systematic random sampling of PHCs and simple random sampling of women. There are 39 PHCs in Basra City, divided across 3 geographically defined health sectors. In this study, 4 PHCs were selected from each health sector, making a total of 12 PHCs. Inclusion criteria for the women were either current first pregnancy or first delivery within 1 year. Women who did not consent to participate or whose children were on a medically prescribed diet were excluded. A sample size of 384 was estimated using the Steven Thompson equation [z 1.96, d 0.05, p (proportion of the population with good or adequate knowledge) = 0.5].

Jamovi version 2.3 was used for statistical analyses (12). Predictive analysis was performed using univariable and multivariable ordinal logistic regression. The dependent variable was the knowledge level per area and the independent variables were the sociodemographic variables and information sources. The multivariable models for sociodemographic predictors and information sources were built separately using a stepwise backward elimination method, to avoid over-adjustment (entry threshold: P < 0.5) (13). Results were reported as crude and adjusted odds ratios (COR and AOR) with a 95% confidence interval (CI). P < 0.05 was considered statistically significant. Reference levels for non-binary sociodemographic variables were adopted from the national household survey report (1). When more than 1 reference level was present in the report, the level achieving the lowest Akaike information criterion in the multivariable sociodemographic model was selected (14,15).

The study was approved by the Scientific Council of the Arab Board of Health Specializations and the Research Committee of the Basra Health Directorate (Decision 360/01/02/2023). Participants were informed about the purpose of the study, and they gave oral consent before the interviews.

Results

The overall study population was 400, and 32–35 women were interviewed in each PHC. Most of them were younger than 19 years (60%), married (98%), living in an extended family setting (93%), and were in the lowest income group (76%) (Table 1).

Family and friends, social media and internet, and doctors and healthcare workers were the most reported information sources; 89.0%, 24.3%, and 19.0%, respectively. Table 2 presents the distribution of correct answers, knowledge levels and sources of information about IYCF.

In the multivariable sociodemographic model (Table 3), unemployment was the predictor associated with the highest odds for lower knowledge about breastfeeding [AOR (95% CI) = 4.55 (2.06, 10.28)], complementary feeding [AOR (95% CI) = 6.52 (2.70, 17.67)], water and supplements [AOR (95% CI) = 4.55 (2.06, 10.28)], and food allergy [AOR (95% CI) = 6.49 (3.22, 13.38)]. In contrast, employment did not predict lower knowledge of formula feeding, which was better predicted by age below 19 years [AOR (95% CI) = 2.46 (1.60, 3.81)] and lower family income [AOR (95% CI) = 2.63 (1.47, 5.00)]. Age ≤19 was a significant predictor of knowledge in all areas [AOR (95% CI) range = 2.24 (1.44, 3.35)–5.30 (2.82, 10.64)].

In the multivariable information source model, better knowledge levels in all areas were predicted by information from social media and internet [AOR (95% CI) range = 3.18 (1.37, 8.48)–57.58 (25.86, 138.50)] and doctors and healthcare workers [AOR (95% CI) range = 2.92 (1.38, 6.17)–10.13 (2.62, 67.38)]. In contrast, information from friends and family predicted lower knowledge of water and supplements [AOR (95% CI) = 0.320 (0.143, 0.699)] and food allergy [AOR (95% CI) = 0.33 (0.15, 0.70)].

Discussion

In this study, we found age ≤ 19, housewife status, education below secondary school, income < IQD 500 000 (about US$ 381.56) per month, and living in extended family setting as independent socioeconomic risk factors for low IYCF knowledge among women in Basra. Receiving information from social media, internet, doctors, and healthcare workers predicted better knowledge of all IYCF areas. Conversely, receiving information from friends and family independently predicted lower knowledge of water and supplements and food allergy.

Women aged ≤ 19 were more likely to have lower knowledge of all IYCF areas, while income level predicted lower knowledge of breastfeeding, complementary feeding, and formula feeding. These findings agree with studies conducted in Indonesia and Gambia, which showed age and income level as significant predictors of IYCF knowledge (16,17). In contrast, age but not income level was found to be a significant predictor of knowledge levels in Ethiopia and Poland (18,19). This study showed that education below secondary school and unemployment independently predicted lower knowledge of all areas except formula feeding, in agreement with a study in Indonesia (16). In contrast, studies from Ethiopia and South Africa showed that education but not employment predicted maternal knowledge (18,20). These findings suggest that the predictors of maternal IYCF knowledge are highly context-variable.

Most interviewees in our study showed poor knowledge of breastfeeding (64.5%), complementary feeding (70%), water and supplements (57.7%), and food allergy (74.3%), while only 10.7% showed poor knowledge of formula feeding. Maternal knowledge levels varied considerably per question and these knowledge gaps will be relevant when planning targeted IYCF information and education in Basra (8). In the breastfeeding area, for instance, 69.3% of women knew they should feed their baby on demand, while only 15.5% knew the appropriate time to switch sides when breastfeeding, which may be important for mothers not producing enough milk (21). In one study in Erbil, Iraq, adult milk scarcity was the most reported maternal barrier to exclusive breastfeeding (22).

In this study, the most reported source of knowledge was friends and family, similar to findings in Egypt, Jordan, Lebanon, State of Palestine, Sudan, and the Iraqi governorates of Erbil, Najaf and Anbar (23–26). Our finding that friends and family predicted lower IYCF knowledge is consistent with findings from key informant interviews in Egypt, Jordan, Lebanon, State of Palestine, and Sudan that mothers who lacked knowledge about IYCF relied on their mothers and mothers-in-law, who themselves were thought to lack the knowledge (25). Household members other than the mother are known to have strong influence on IYCF practices among women living in extended family settings (27), and our study found that extended family living (93%) was an independent predictor of lower breastfeeding knowledge.

In the past, efforts by the Iraqi Ministry of Health to improve IYCF knowledge have focused on healthcare worker training, television advertisements and flyer distribution (1). Our results showed that information from doctors or healthcare workers and social media or the internet independently predicted better knowledge of all areas, while traditional media predicted better knowledge of water and supplements only. Evidence from metanalyses shows that mediation by doctors and healthcare workers increases the effectiveness of IYCF education (28). In one study from Baghdad, Iraq, education by doctors and healthcare workers accounted for the awareness about exclusive breastfeeding among 87.5% of women (29). In contrast, there is little evidence on the use of internet-based media for IYCF education, most studies focus on non-internet-based mass media (30,31). During the COVID-19 pandemic, however, UNICEF suggested using social media for IYCF promotion, and studies in Indonesia and Sri Lanka showed that social media-based IYCF education campaigns improved maternal IYCF knowledge (32,33). This study therefore contributes to a growing body of evidence on the impact of social media on IYCF knowledge.

Strengths and limitations of the study

The limitations of this study include its exclusively urban setting and cross-sectional design, which limit the interpretations of causality. We did not consider unhealthy feeding practices (e.g. use of sweetened beverage drinks). The inclusion of first-time mothers only eliminated bias related to maternal experience and birth order, but limited interpretation of the results to new mothers and children under 12 months of age. Studies from Africa, Asia, and Europe have shown that birth order and child age are positively correlated with maternal IYCF knowledge (18,19,34). Despite reaching statistical significance, the uncertainty intervals of some information sources were wide. Larger studies may therefore be required to quantify the effect of information sources as predictors of maternal IYCF knowledge.

The strengths of the study include the range of areas assessed using a structured interview and the inclusion of all mothers registered in the PHCs rather than only those documented in the antenatal register. All the predictors included in the sociodemographic model (except income level) are readily available in the medical records of all PHC users, thus facilitating the use of our results to identify mothers at risk for lower knowledge (35).

There is a need to improve IYCF education in Basra, with particular attention to healthcare worker-mediated and social media- and family systems-based approaches. Priority should be given to the less educated, younger and unemployed women and those in the lower-income group.

Étude transversale des facteurs prédictifs des connaissances en matière de nutrition infantile chez les nouvelles mères en Iraq

Résumé

Contexte : Malgré de récentes améliorations, l’alimentation du nourrisson et du jeune enfant demeure un défi à Bassora en Iraq.

Objectif : Décrire les facteurs prédictifs des connaissances en matière d’alimentation du nourrisson et du jeune enfant chez les nouvelles mères à Bassora (Iraq).

Méthodes : La présente étude transversale a permis de recueillir des données sur les connaissances en matière de nutrition infantile auprès de 400 nouvelles mères dans 12 centres de soins de santé primaires à Bassora (Iraq) entre février et juin 2023. La version 2.3 du logiciel Jamovi a été utilisée pour l’analyse statistique. Une analyse prédictive a été réalisée avec une régression logistique ordinale univariable et multivariable, et les résultats ont été présentés sous forme de odds ratios bruts et ajustés avec un intervalle de confiance à 95 %. Un p inférieur à 0,05 était considéré comme significatif.

Résultats : La plupart des femmes interrogées (60 %) étaient âgées de moins de 19 ans, 98 % étaient mariées, 93 % vivaient dans un cadre familial élargi et 76 % se situaient dans le niveau de revenu le plus faible. Le fait d’être âgées de 19 ans ou moins était un facteur prédictif significatif de connaissances concernant l’allaitement maternel, les préparations pour nourrissons, l’alimentation complémentaire, l’eau et les suppléments, ainsi que les allergies alimentaires [ORa 2,24 – 5,30]. Le chômage et le faible niveau d’éducation étaient des facteurs prédictifs d’un niveau de connaissances plus bas sur l’allaitement maternel, l’alimentation complémentaire, l’eau et les suppléments, et les allergies alimentaires, mais aucun de ces deux paramètres ne prédisait une moindre connaissance concernant les préparations pour nourrissons. Le fait de recevoir des informations de la part de médecins ou d’agents de santé et via les médias sociaux ou Internet était associé à une meilleure connaissance de l’alimentation du nourrisson et du jeune enfant par les mères, tandis que l’obtention d’informations par la famille et les amis laissait entrevoir une connaissance insuffisante sur les allergies alimentaires, l’eau et les suppléments.

Conclusion : L’éducation à la nutrition infantile à Bassora devrait être améliorée, et une attention particulière doit être accordée aux approches médiatisées par les agents de santé, aux médias sociaux et aux systèmes familiaux. Il est nécessaire de privilégier les femmes plus jeunes, sans emploi et dont le niveau d’éducation et de revenu sont plus faibles.

دراسة مقطعية لمُنبئات مستوى المعرفة بتغذية الرضَّع بين الأمهات الجدد في العراق

أسيل مؤيد صالح، طارق زياد طارق شويّش، إيلاف محمد صالح، وفاق حسن عبد الرحيم الكواز

الخلاصة

الخلفية: على الرغم من التحسينات الأخيرة، لا تزال تغذية الرضَّع والصغار تمثل تحديًا في مدينة البصرة بالعراق.

الأهداف: هدفت هذه الدراسة الى وصف المُنبِئات لمستوى المعرفة بتغذية الرضَّع والصغار بين الأمهات الجدد في مدينة البصرة بالعراق.

طرق البحث: جمعت هذه الدراسة المقطعية بيانات عن مستوى المعرفة بتغذية الرضَّع من 400 أُم جديدة يترددن على 12 مركزا للرعاية الصحية الأولية في مدينة البصرة بالعراق، في المدة من فبراير/ شباط إلى يونيو/ حزيران 2023. واستُخدم الإصدار 2.3 من برنامج Jamovi لإجراء التحليلات الإحصائية. كما أُجري تحليل تنبؤي باستخدام انحدار لوجستي تتابعي أحادي المتغيرات ومتعدد المتغيرات، فوَرَدت النتائج في صورة نسب أرجحيةٍ أولية ومصحَّحة بفاصل ثقة نسبته %95. كما عُدت قيمة الاحتمال الأقل من 0.05 ذات دلالة إحصائية.

النتائج: كانت معظم النساء (%60) اللاتي أُجريَت معهن مقابلات أصغر من 19 سنة، ومتزوجات (%98)، ويعشن ضمن عائلة كبيرة (%93)، وينتمين إلى أدنى مستوى للدخل (%76). كان بلوغ سن الأم 19 سنة أو أقل مُنبئًا ذا دلالة إحصائية بمعرفتها بالرضاعة الطبيعية، والتغذية ببدائل لبن الأم، والتغذية التكميلية، والمياه والمكملات الغذائية، والحساسية من الأغذية [نطاق نسبة الأرجحية المُصحَّحة (بفاصل ثقة %95) يتراوح من 2.24 (1.44، 3.35) إلى 5.30 (2.82، 10.64)]. كما كانت البطالة وانخفاض مستوى التعليم مُنبئين بانخفاض المعرفة بالرضاعة الطبيعية، والتغذية التكميلية، والمياه والمكملات الغذائية، والحساسية من الأغذية، لكن لا البطالة ولا انخفاض مستوى التعليم كانا مُنبئين بانخفاض المعرفة بالتغذية ببدائل لبن الأم. وتبيَّن أيضًا أن تلقِّي المعلومات من الأطباء أو العاملين في مجال الرعاية الصحية ومن وسائل التواصل الاجتماعي أو الإنترنت مرتبط بتحسن معرفة الأمهات بتغذية الرضَّع والصغار، أمَّا تلقِّي المعلومات من العائلة والأصدقاء فكان مُنبئًا بضعف نسبي في المعرفة بالحساسية من الأغذية وبالمياه والمكملات الغذائية.

الاستنتاجات: ينبغي رفع مستوى التثقيف بتغذية الرضَّع والصغار في البصرة، مع إيلاء اهتمام خاص إلى النُّهج القائمة على العاملين في مجال الرعاية الصحية وعلى وسائل التواصل الاجتماعي وعلى النُّظم العائلية. وينبغي كذلك إيلاء الأولوية إلى النساء الأدنى تعليمًا والأصغر سنًّا والعاطلات عن العمل والمنتميات إلى فئة الدخل المنخفض.

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