Complimentary feeding practices amongst tribal and non-tribal population of Assam

INTRODUCTION

First 1000 days of life, period between woman's pregnancy (270 days in-utero, childbirth till second birthday, identified as the best opportunity for establishing optimum growth and development.[1] WHO/ UNICEF have emphasized importance of optimal Infant and young child feeding (IYCF) practices from birth to 2 years of age also known as “critical window”.[2] Optimal IYCF practices and its impact on health and economy is often underestimated in comparison to disease specific interventions and advances in technologies and pharmaceuticals at all levels.[3] Despite strong evidence on benefit of IYCF, inappropriate IYCF practices have been widely documented in low-and middle-income countries. Some study done in other part of World showed Mothers' knowledge on infant and young child feeding recommendation was very low while nutrition during this period, cornerstone for building a generation of healthy, highly intellectual and productive nation.[4,5] WHO has recommended timely initiation of complementary feeding at 6 months with continued breastfeeding.[6] Optimal IYCF practices is the most cost effective intervention capable of delivering universal health coverage with best nutrition to the most vulnerable population irrespective of economic condition, can significantly increase effectiveness of immunization, can avert most common causes of infant and under5 mortality, can prevent future development of chronic diseases such as obesity and related co-morbidities and prevent breast and ovarian cancers, depression among women.[7,8]

The status of complementary feeding in India is very poor with total children age 6-23 months receiving an adequate diet standing at 9.6 %. The state of Assam is still poorer than India at 8.9%. The interventions in IYCF have shown results through increased percentage of breast feeding but the complementary feeding part was neglected. Therefore, this study was undertaken to assess the complimentary feeding practices in Assam and to compare the difference in knowledge and practice of complimentary feeding amongst tribal and non-tribal population of Assam.

MATERIAL & METHODS

A community based cross-sectional observational study was conducted in one tribal and another non tribal dominated block of Assam by stratified Random Sampling. Study population were mothers or primary care givers of children aged between 6-12 months.

RESULTS

A total of 560 children (6-12 months) participated in the study with a response rate of 93% (560/600). Proportion wise allocation was 296 tribal and 264(53% vs 47%) non tribal children were enrolled in the study. The average income of the studied population was INR 14,105 (8120 vs 11970 amongst tribal and non-tribal population). According to BG Prasad socioeconomic classification majority (44%) were in class I in tribal population, while in non-tribal majority (35%) were in class II. Boy child outnumber girl child (53 vs 47) and 29% children aged between 6-8 months while 71% were between 9-12 months of age with an average age of 10 months (±2 months). Average age of mothers at the time of marriage was 22 years of which 16.3% got married before 18 years of age. Average age of mother at first pregnancy was 22 years of which 27.7% were adolescent pregnancy. Majority of study participants were Hindu by religion 96.2(%). Type of family was nuclear in 42% (39.5% vs 44.7%), while 58% (60.5% vs 55.3%) hailing from joint family. Average size of family is same (6) in both tribal and non-tribal community. Majority of children were of first order 56% (55.4% vs 56.8%), followed by second order 36% (34.5% vs 37.5), while only 8% were third order or above (7.1 % vs 4.5%).

Mean age of start of complimentary feeding was 7 months (7months vs 6months). Age of initiation of complimentary feeding was at 6 month was seen in 36.9% (40.2% in tribal vs 32.7% in non-tribal) population, while majority did delay initiation 60.6% (57.9% in tribal vs 64.1% in nontribal) population. Majority of non-tribal population (69.5%) do ceremonial start of complimentary feeding while 55.1% tribal do ceremonial start, while 38.2% do not do any ceremonial start (44.9% vs 30.5%) which is significantly different in both the groups (p=0.001). Majority of babies received biscuit 51.2% as complimentary food (49.2% in tribal and 53.4% in nontribal population (p=0.649). While nutritionally superior, cheap, locally available, culturally acceptable Khichri (rice, cereal, vegetables) was seen in 48% cases. Uses of commercial product, like Cerelac was high in non-tribal (7.1% tribal vs 19.3% in non-tribal, p=0.000). Rice gruel was another most commonly used complimentary food in both the groups (41.7% in tribal vs 41.3% in non-tribal, p=0.927). Similarly, banana which is very commonly available in both the locality used as complimentary food in 44.9% in tribal and 30.5% amongst non-tribal community (p=0.084). Majority do separate cooking of complimentary food for the child (66.2%) which is significantly higher in non-tribal compared to tribal (54.7% in tribal and 79.4% in non-tribal (p=000). Though majority of mother/ care giver wash their hands before feeding their child (89.1%) (86.2% in tribal vs 92.4% in non-tribal), while 10.9% still not practice hand washing (13.8% in tribal vs 7.6% in non-tribal), which is significantly different in both the groups (p=0.006). Tasting of food before offering to child was practiced by majority (79.5%) mother which is higher in tribal compared to non-tribal population (83.5% vs 74.9%), while 20.5% do not taste the food i.e., 16.5% in tribal vs 25.1% in non-tribal population, which is significantly different (p=0.021). Active feeding was seen in 82.2% (80.7% in tribal vs 83.9% in non-tribal, p=0.37). Feeding was done by using spoon in 60.8%, which is significantly higher amongst non-tribal (53.9% vs 68.6%, p=0.001). Source of water for preparation of complimentary food and consumption was tube well (92%) in most of the cases (99.2% vs 83.9%, p=0.000). [Table 1]

Early initiation of breast feeding (EIBF) was 79.3% amongst studied population (81.1% vs. 77.3%, p=0.267). Minimum meal frequency (MMF) was on 60.5% (42.3% vs 81.1%) while minimum dietary diversity (MDD) 44.4% (43.7% vs 45.3%) and minimum acceptable diet MAD was very low 29.1% (20.5% vs 38.9%). [Figure 1]

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FIGURE 1:

IYCF INDICATORS FOR COMPLIMENTARY FEEDING AMONGST STUDIED POPULATION

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Regarding antenatal check-up, universally the mothers got ANC (99.7% in tribal vs 100% in non-tribal) population. Similarly place of delivery was hospital in majority (50.2% vs 46%, p=0.082). Type of delivery normal in 75% amongst tribal vs 53% non-tribal population, while 25% tribal mothers had LSCS compared to 47% amongst non-tribal which is significantly higher (p=0.000). Most of the children got breast feeding 99.7% in tribal vs 98.9% amongst non - tribal population, only 0.7% tribal and 1.1% non-tribal population had never given breast feeding. Early initiation of breast feeding was found in 81.1% amongst tribal population compared to 77.3% amongst non-tribal population (p=0.267). Commonest reasons for late initiation of breast feeding were, LSCS in majority (61.2%; 71.4% amongst tribal and 51.7% amongst non-tribal) of the studied population. Colostrum was given in majority (44.6% vs 44.5%) which is significantly different (p=0.001). Common reasons for discarding colostrum were elder's advice in majority (36.1% vs 9.8%). On demand breast feeding was given in majority (84.5% vs 94.3%), while night feeding was given by most of the mothers (99.7% vs 98.1%), which is considered as a good IYCF practice. [Table 2]

This study revealed some interesting things about anthropometric data. The proportion of normal weight is significantly (p=0.003) higher in tribal community (90.5%) than the non-tribal community (81.1). underweight was seen in 5.7% cases (3% vs 8.7%). Stunting and wasting is lower in tribal community (7.4% vs 16.7% and 1.4% vs 3.4%). [Table 3] [Figure 2]

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FIGURE 2:

NUTRITIONAL STATUS OF CHILDREN IN TRIBAL AND NON-TRIBAL COMMUNITY

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A total of 37 service providers i.e., AWW were assessed, 22 serving in tribal area and 15 service in non-tribal area. Though majority (94.6%) know that exclusive breast feeding should be given up to 6 months which is known to 54.5% AWW serving in tribal area while in AWWs working in non-tribal area it was known to all. Appropriate age of initiation of complimentary feeding was as 6 months was known to almost all (90.9% for tribal vs 100% for non-tribal). Importance of formula feeding was still perceived by 24.3% (31.8% in tribal vs 13.3% in non-tribal, p=0.198) population. Importance of components of complimentary feeding practices was again variable in both the group though statistically significant difference does not exist. Overall, 70 % know about quantity, 81.1% know about quality, 64.9% know about frequency, 59.5% know about diversity while only 43.2% know about consistency which is again lower amongst AWWs working in non-tribal area (54.5% vs 26.7%, p=0.093). [Table 4]

Kitchen garden was present in 52.9% of the studied households, which is significantly high in tribal compared to non-tribal population (64.9% vs 39.4%, p=0.000). But the type of kitchen is seasonal in most of the cases (92.9%; 93.2% vs 92.3%). Majority uses kitchen garden produce for their own consumption (85.8%; 87% vs 83.7%), but only 45.9% (46.9% amongst tribal vs 44.2% non-tribal) used their kitchen garden produce for preparation of complimentary food. Fish pond was found in 24.1% household (23% in tribal vs 25.4% in non-tribal), while 29.6% (45.6% tribal vs 13.4% non-tribal) use fish from their own pond for feeding child as complimentary feeding. Majority produce fish 87.4% (89.7% tribal vs 85.1% non-tribal) for their own consumption. [Table 5]

Live stock was present in 80.7% households (85.5% tribal vs 75.4% non-tribal, p=0.003), which is significantly higher amongst tribal. Hen/chicken was the commonest live stock (52.9%; 52.8% in tribal vs 40.2%, p=0.000), followed by duck (45.4%; 46.6% tribal vs 43.7% non-tribal, p=0.536), Cow for milk production in 73% (74.7% tribal vs 70.7% non-tribal, p=0.36) and pig (pork) 39.8% (56.5% tribal vs 18.6%, p=0.000), which is significantly higher tribal population. Of the live-stock present 36.5% uses for their own consumption (26.5% tribal vs 49.2% non-tribal; p=0.000), which is significantly higher amongst non-tribal population. Only 33.6% of livestock produced were used for preparation of complimentary feeding (33.6%; 61.3% tribal vs 72.9%; p=0.01), which significantly higher amongst non-tribal population. [Table 5]

DISCUSSION

WHO recommended infant and young child feeding practices in term of IYCF 8 core indicators and 6 optional indicators along with their socio-demographic, maternal, child and other characteristics. The present study revealed that early initiation of breastfeeding within 1 hour of birth was 79.3% which is better than the national (41.8%) and Assam (49.2%) average reported in NFHS 5(2019-21).[10] Among the study population, timely introduction of solid and semi solid food was seen in 36.9% at 6 months children, early introduction was 2.5% at less than 6 months of age and delayed introduction was 60.6%. As per the WHO cut-off for rating, the present percentage stood within the range 60-79% denoted as ‘Fair’ practice in the community. Children of 6 to 8 months who received both solid and semi solid food along with breastmilk was 75% which was higher than the state report -51.7% (rural-51.2%, urban-57.6%) as well as national report-45.9% (rural 43.9%, urban-52.0%) of NFHS-5. [10] The energy needs from complementary foods also differs between infants who are breastfed and non-breastfed; for which guidelines for complementary feeding were made separately pertaining to their needs. However in both, responsive feeding and safe preparation of these complementary foods were vital components of the guideline.[2] WHO has recommended continued breastfeeding up to 2 years or beyond along with age appropriate introduction of hygienic complementary food as complimentary breastfeeding. [7] It ensures at least the benefits of breast milk irrespective of families’ ability to provide diverse range of complementary food especially among those living with limited access to safe water and Children of 12-23 months of age can still receive 35-40% of their total energy needs form breast milk. Breast milk continues to be a key source of energy and essential fatty acids because of its relatively high fat content compared to most complementary foods. Its fat content was assumed to be critical for utilization of pro-vitamin A carotenoids in predominantly plant-based diets such as in India with an evident vegetarian population. [2]

It was observed that about 37.74% of children 6 to 12 months received minimum dietary diversity which is comparatively higher than findings reported for urban informal settlement of Mumbai by Bentley et al. [11] Istiyaq Ahmad, in their cross-sectional survey conducted in Aligarh in 2017 reported 42.6% (95% CI = 37.4%-48.1%) of children receiving minimum dietary diversity. [12] The children receiving minimum acceptable diet in this study was about 24.7%. This finding is contrary to the NFHS-5 (2019-2021) reports, where minimum acceptable diet is higher among non-breastfed children (12.7%) compared to breastfed (11.1%) [10]

Lack of knowledge among the mothers and primary care givers about the minimum number of meals and types of food groups requirement at that age was evident in our study. It also reveals lack of counselling on all aspects of complementary feeding to the community. The study reveals that most of the mothers received counselling on exclusive breastfeeding but very few had knowledge about the complementary feeding as well as early initiation of breastfeeding.

Consumption of iron-rich or iron fortified foods, i.e. number of children consuming flesh foods and green leafy vegetables was low 25.6% and 45.7% among the children though availability of kitchen garden is encouraging in number but majority were seasonal and utilization of kitchen garden produce for preparation of complimentary food was less. The NFHS-4 report for country's average consumption of flesh foods among the same age-group was also 24%. The similar study conducted by Aguayo, et al in Maharashtra reported lower percentage of 12.1% for IYCF i.e., indicator 8. [13]. The study revealed that children ever breastfed was almost universal (99.30%), During the survey only 58% of 6-12 months children continued to receive breast milk.

Knowledge level of AWWs was found to be poor amongst the studied service providers.

Capacity building of the AWWs at the community level with necessary knowledge and skills to promote the recommended IYCF guidelines would improve the IYCF practices at the community level. Mothers/ caregivers attending facilities like Anganwadi centre (AWC) need to be educated/ counselled on different issues related to breast feeding and complementary feeding. Village health and nutrition day (VHND) celebration at AWCs may be utilized as a plate form for imparting knowledge related to complimentary feeding for the community. The scope of behaviour change communication (BCC) in nutrition has expanded rapidly in recent years, fuelled by the growing recognition that social and behavioural change interventions are fundamental to achieving the nutrition-related goals. Behaviour change communication (BCC) is a key component of infant and young child feeding (IYCF) programmes in low-resource countries. [14]

CONCLUSION

Health education and demonstration of recommended complementary diet with locally available homemade ingredient with knowledge while disseminating knowledge that home-made foods are no inferior to artificial feeding may enhance mothers’ self-confidence and independence concerning infant feeding.

The findings show that the main barriers to the use of appropriate infant and young child-feeding practices fall under four themes: caregiver's knowledge about breastfeeding, caregiver's knowledge about complimentary feeding, influence of culture custodians on the caregivers, and patterns and burden of other responsibilities the caregivers have in the household.[15] The information regarding complimentary feeding practices was collected by interviewing the mothers/ primary care givers of the under 2 children -quality of such information might have been influenced by recall bias. Appropriately designed in-depth research studies should be undertaken to understand the social and behavioural determinants and other aspects of improper IYCF practices.

AUTHORS CONTRIBUTION

TGM: Concept, Design, Manuscript editing. PR: Manuscript editing. MB: Study implementation. SB: Data Analysis