ABSTRACT
Exclusive breastfeeding (EBF) practice have been a serious public health concern, not only in Nigeria but in the world at large. It have severally been reported that there is low practice and awareness of EBF in Nigeria. I evaluated the variation in the level of knowledge of exclusive breastfeeding between mothers in Yola and those in Fufure IDP camp as well as their perceptions towards its practice. I also assessed the most effective medium of awareness for the knowledge of exclusive breastfeeding among the respondents. I used a targeted study design and convenience sampling method, which is a non-probability sampling technique. My total sample size was 220. The results showed that respondents have high degree of awareness of EBF (90.9%) and thus most of them practice it (70.4%). Clinical sessions appeared to be the most effective source of promoting EBF awareness as most of the respondents (60.1%) learned about it there. Finally, the result of this study have contradicted many other relevant studies because it revealed that there is so much knowledge and awareness of EBF among mothers in Adamawa state. Although, there is already a
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great deal of awareness of EBF in Adamawa state that are developed by the state health care units through antenatal and postnatal sessions, media would also be a great medium to promote EBF awareness in the state.
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TABLE OF CONTENTS
CERTIFICATION …………………………………………………………………………………………. ii
READER’S APPROVAL ………………………………………………………………………………. iii
DEDICATION ……………………………………………………………………………………………… iv
ACKNOWLEDGEMENTS …………………………………………………………………………….. v
ABSTRACT ………………………………………………………………………………………………… vii
LIST OF TABLES …………………………………………………………………………………………. x
LIST OF FIGURES ……………………………………………………………………………………… xi
CHAPTER ONE …………………………………………………………………………………………. 1
INTRODUCTION ………………………………………………………………………………………… 1
Malnutrition …………………………………………………………………………………………………. 2
Breastfeeding ………………………………………………………………………………………………… 5
Exclusive breastfeeding ………………………………………………………………………………….. 7
Early initiation of EBF …………………………………………………………………………………. 12
Baby-friendly hospital initiative …………………………………………………………………….. 13
HYPOTHESES …………………………………………………………………………………………… 15
AIMS & OBJECTIVES ……………………………………………………………………………….. 15
CHAPTER TWO ………………………………………………………………………………………. 17
MATERIALS & METHODS ……………………………………………………………………….. 17
CHAPTER THREE …………………………………………………………………………………… 20
RESULTS ………………………………………………………………………………………………….. 20
CHAPTER FOUR ………………………………………………………………………………………. 27
DISCUSSION …………………………………………………………………………………………….. 27
CHAPTER FIVE ……………………………………………………………………………………….. 35
CONCLUSION …………………………………………………………………………………………… 35
APPENDIX I ……………………………………………………………………………………………….. 36
APPENDIX II ……………………………………………………………………………………………… 41
APPENDIX II ……………………………………………………………………………………………… 42
REFERENCES ……………………………………………………………………………………………. 44
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LIST OF TABLES
Table 1: Plain water is the liquid that is given to infants in the first four months of life even much more than breast milk ………………………………………………………………….. 11
Table 2: Health workers are the primary reason why mothers give their infants glucose water and other PLFs ……………………………………………………………………………………. 11
Table 3: This table has shown that respondents of this study largely learnt EBF for antenatal sessions at the clinics ………………………………………………………………………. 24
Table 4: Of the respondent in this study, most believed that clinical sessions were the best place in which to promote EBF awareness. ………………………………………………. 24
Table 5: of the respondents in this study, most of those that support and have EBF knowledge are from Fofure IDP camp. However, the result was insignificant (2 = 1.04, df = 2, p = 0.59) ……………………………………………………………………………………. 25
Table 6: The result below was significant (2 = 5.8, df = 1, p = 0.01) and it has showed that knowledge of EBF have significant influence over supporting its practice ……. 25
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LIST OF FIGURES
Figure 1: Malnourished African children ………………………………………………………….. 2
Figure 2: Stunting prevalence is highest in sub-Saharan Africa and south Asia. Map shows percentage of children under age 5 who are moderately or severely stunted … 3
Figure 3: Children with different types of Undernutrition Malnutrition looks. Wasted children usually look very thin and tall. Stunted children look shorter than there age and wasted/stunted children look both shorter and thinner than their age has showed that knowledge of EBF have significant influence over supporting its practice ……… 4
Figure 4: Map of Nigeria showing the location of Adamawa State in the northeastern region. ………………………………………………………………………………………………………… 17
Figure 5: The frequency of the respondent’s children that died at different age category. Children that died below the age of one are much higher ……………………. 20
Figure 6: The level of education among the study respondents and the graph is showing that most of the respondents obtained primary school level education ………………… 21
Figure 7. Most respondents were skill-based workers or housewives. …………………. 22
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CHAPTER ONE
INTRODUCTION
Given the high prevalence of malnutrition in Africa, Exclusive Breastfeeding (EBF) offers a fool proof method to deter stunted growth and development in the African subcontinent. Malnutrition has been identified to be the direct cause of about 300,000 deaths every year and indirectly the cause of about half the deaths among young children in Africa (Müller et.al, 2005). Hence, the need for exclusive breastfeeding as the first stage of nutrition is the as a way to prevent malnutrition.
The early first years of a child’s life is the most vital and delicate period of development. It is the stage at which a healthy child goes through rapid development, psychologically and physically. A child at this stage needs good nutrition for his or her physical, mental, and immune system development. Moreover, it is at this stage that the comprehension and sensation potentials of a child begin to develop, as well as the base of intellectual, social, and emotional competencies of the child (Michaelsen et al, 2003). Sadly, due to the level of poverty in sub-Saharan Africa, most children at this stage in the region are prone to poor nutrition (Bain et al., 2013).
Poor nutrition, or malnutrition, results in growth abnormality and easy contraction of infectious diseases due to a weak immune system that is caused by the disease. It also causes problems such as deficiency in learning, lack of development of social skills, behavioral abnormality, and defects in educational achievement (Michaelsen et al., 2003).
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MALNUTRITION
Figure 1: Malnourished African Children. (Credit: Bilkis Ogunnubi, 2016)
Malnutrition is defined as the lack of enough, too much, or unbalanced energy and/or nutrients in a person’s diet (WHO, 2017). There are three types of malnutrition: undernutrition, micronutrient related malnutrition, and overweight/obesity (WHO, 2017).
Undernutrition is the deficiency or lack of energy and nutrients in the body which results in stunted growth, wasting, or underweight. Wasting is having severe low weigh for height of the body. It indicates lack of enough food or reoccurrence of diarrhea (WHO, 2017). Stunted growth is having low height for the age of a person. It indicates persistent undernutrition and it is often related to deficiency in maternal health, recurrent illness or poor feeding during infancy.
Stunting deprives children from attaining their deserved physical size. Studies have shown that stunting is prevalent in sub-Saharan Africa and Asia.
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Figure 2: Stunting prevalence is highest in sub-Saharan Africa and south Asia. Map shows percentage of children under age 5 who are moderately or severely stunted (credit: UNICEF Global Nutrition Database, 2012).
About 25 percent of children in the world are stunted, and most of them are from sub-Saharan Africa. This region is reported to have about 38 percent world’s reported incidence of stunted growth (UNICEF, 2016). However, the Multiple Indicator Cluster Survey (MICS) and Demographic and Health Survey (DHS) reported that the nutrition status of Nigeria’s children had been gradually improving over the past few decades, reducing from 41 percent in 2008 to 36 percent in 2011(DHS, 2013). The target of WHO is to reduce or eliminate the percentage of the stunted growth cases to 3.9 percent by 2025 (UN, 2012).
On the other hand, underweight is having low weight for the age of a person or child and it can be caused by wasting, stunting or both of the diseases (WHO, 2017).
The figure below shows the physical characteristics of children with undernutrition malnutrition looks like. It has the image of how a normal child is expected to look like and as well how children with the diseases look like.
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Figure 3: Children with different types of Undernutrition Malnutrition looks. Wasted children usually look very thin and tall. Stunted children look shorter than there age and wasted/stunted children look both shorter and thinner than their age (Credit: Bradly et. al, 2009)
Micronutrient related malnutrition is defined as having insufficient vitamins or minerals in the body. Micronutrients such as iodine, vitamin A, zinc, iron and calcium are crucial substances that the body uses to produce enzymes and hormones for growth and development (WHO, 2017). Thus, lack of these nutrients in the body stops the body from proper growth and causes diseases such as scurvy (deficiency of vitamin C) and rickets (deficiency of vitamin D).
Overweight/obesity is defined as having weight that is heavier than is healthy for the height of the body. An overweight or obese child has excess fat accumulated in his or her body and this leads to cardiovascular diseases and type II diabetes amongst other diseases. However, there is a slight difference between overweight and obesity and this can be determined only by measuring the body mass index (BMI). The BMI is generally used for adults; it is a number that is calculated to find a person’s weight with his or her length and height. When plotted in a graph, it is commonly used as a
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growth indicator against a child’s age. BMI is calculated by dividing the weight in kilograms by the squared height in meters, i.e. Weight (kg) / Height2 (m) (WHO, 2008).
Despite the rapid economic development and concerted efforts to curb malnutrition among infants and mothers, little or no progress has been observed in the developing countries (Gillespie et al., 2003). However, the first stage of ensuring a child’s good nutrition is the ability of the child to be well breastfed. Breastfeeding is the feeding of babies and young children from a woman’s breast, which gives the child the maximum benefits of breast milk (Tyndall et al., 2016). Breast milk is milk that is highly nutritious, which helps a child maintain healthy growth.
BREASTFEEDING
Breastfeeding is the first stage and the most effective level of primary nutrition. Breastfeeding improves the four aspects of health: mental, spiritual, physical, and social (Bonomi et al, 2000). It not only improves infants’ health, but it is also beneficial to the mother. It delays the menstrual cycle of a mother, which protects her from early pregnancy (Tyndall et al., 2016).
Early breastfeeding of an infant helps in improving the child’s psychological and physical health, as well as improving the child’s immune system (National Resources Defense Council, 2001). The benefits of breastfeeding are numerous. The human milk glycans contain oligosaccharide, which helps in the formation of natural immunological mechanism. This helps to protect children against infectious diseases (Lamberti et al, 2011). Breast milk also helps decrease the level of contact with
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contaminated foods and drinks that might result in the contraction of diseases. However, in order for an infant to get maximum benefits of breast milk, the mother must have an adequate diet. Malnutrition in mothers increases the level of risks that a mother would face during pregnancy and delivery. Such risks include high level of and maternal infant mortality and morbidity, insufficient provision of breast milk, and premature birth (Ransom and Elder, 2003).
The use of contaminated water can lead to serious infections and gastrointestinal diseases. It has been reported that drinking water is the primary cause of microbial pathogens in developing countries. Additionally, gastrointestinal diseases are also more frequent in the countries due to lack of intervention strategies and under-nutrition (Ashbolt, 2004). It has also been reported that poor water quality, hygiene and sanitation account for the death of a1.7 million people worldwide and it is mainly through diarrhea (Ashbolt, 2004). However, nine out of each death is among chi1dren and a1most a11 the death incidence happens in deve1oping countries (Ashbolt, 2004).
In Nigeria, 5.5 percent of reproductive women are malnourished, while about 2.5 percent of them are extremely malnourished. As a result of the high level of poverty in the northeastern part of Nigeria, the highest percentage of the malnourished women are from the northeastern region of the country, whereas the southeastern region has the lowest percentage of the malnourished women (DHS, 2013).
Due to the extreme importance of breastfeeding to both a mother and her baby, WHO recommends that children are breastfed from the first hour of life to at least six
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months without introducing any supplement, not even water; this is a practice called exclusive breastfeeding (WHO, 2012).
EXCLUSIVE BREASTFEEDING
According to the World Health Organization (2001), “Exclusive breastfeeding is defined as the exclusive breastfeeding of infants for the first six months of life without the introduction of any food supplement, not even water, apart from Oral Rehydration Solutions (ORS) drops or syrup that may be required for medication.” Exclusive breastfeeding (EBF) has reduced child mortality by eliminating or reducing the incidences of gastrointestinal diseases (Huffman & Combest, 1990; Young et al., 2011), ear infections, and respiratory diseases amongst children that were breastfed exclusively up to six months (Tyndall et al, 2016). It also speeds up maternal weight loss and delays the return of the menstrual cycle (WHO, 2011).
From 2006 to 2010, on average, only 37 percent of mothers globally practiced exclusive breastfeeding (UN, 2012). Also, only 17% of mothers practiced EBF in Nigria. By 2025, WHO’s target is to have countries increase the rate of exclusive breastfeeding up to fifty percent of the general population (UN, 2012).
WHO suggests that all children are required to be exclusively breastfed for the first six months of age and at least for the first four months of life (WHO, 2012). In 2001, the effects of exclusive breastfeeding for 6 months vs. 3-4 months were studied in order to find out the difference between EBF for 6 months and months less than 6. The research resulted in endorsement for supporting and encouragement of exclusive breastfeeding up to six months of age. This is because the study found out that
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children that are exclusively breastfed turned out to be more healthy and energetic (Lamberti et al., 2011). The study also found that morbidity and mortality are also related to partial exclusive breastfeeding (WHO, 2001).
In countries with high levels of infectious diseases, it is recommended that a child should be breastfed for two years (WHO, 2011). This is because children in the regions are vulnerable to infectious diseases due to the unhealthy conditions of the environment they live in, but if the children are breastfed up to two years, the risk of them contaminating disease is lower. WHO also recommends that every country should support and promote breastfeeding by achieving the four targets that are outlined in the Innocenti Declaration. The four targets are having a national coordinator of breastfeeding, practicing the Baby-Friendly Hospital Initiative, initiating the international code of marketing breast milk and a law to protect breastfeeding mothers (UNICEF,1990). Innocenti Declaration was produced and adopted by participants at the WHO/UNICEF policymakers’ meeting on breastfeeding in the 1990s, which is a global initiative, co-sponsored by the US Agency for International Development (A.I.D) (UNICEF, 1990).
Exclusive breastfeeding between the first day to six months is a key child survival support (Lamberti et al., 2011). Children who are breastfed for 2 years of age have a lower risk of diarrheal infections and death (Lamberti et al., 2011). However, despite the extreme importance of the practice of breastfeeding or specifically exclusive breastfeeding, the percentage of this practice is very low all over the world and most especially in the developing nations (Lamberti et al., 2011). Forty seven to fifty seven percent of babies who are less than two months and 25-31 percent of babies
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who are between 2-5 months in developing countries are exclusively breastfed, whereas all other babies that are above 6 months of age receive any kind of food supplement apart from breast milk (Black et al., 2008).
Factors such as culture, beliefs and perceptions, and lack of awareness are influencing or hindering the practice of EBF. Religious beliefs are one of the factors that hinder most people from practicing exclusive breastfeeding. Muslim and Hindu followers are an example of societies that, despite possibly having knowledge of the importance of exclusive breastfeeding, still consider feeding their babies honey, dates, and zamzam (a spiritual water that is believed to be from mekkah) (Chagan, Fayyaz, & Aamir, 2016).
Prelacteal feeds (PLF) are one of the major factors that hinder mothers from exclusively breastfeeding their babies. PLFs are food supplements that are administered to babies at the early hour of birth as a result of religious beliefs, cultural traditions, or lack of breast milk from the mothers’ breast at the early hours of birth (Chagan et al., 2016). In the Pakistan Muslim societies, for example, the tradition of administering PLF is called tahneek, which is the process of introducing a softened date to a baby before taking the first breast milk. This practice is done by a respected member of a family, and it is believed that the child will be raised to have the same character as the family member (Chagan et al., 2016). Other reasons for PLF among these societies include purification of the tummy, lessening of aches, making excretion easier for the baby, and provision of moisture to the mouth of the baby before the arrival of milk (Chagan et al., 2016).
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Studies have shown the harmful effects of practices of PLFs hamper the early initiation of breastfeeding (Fidler & Costello, 1995). As such, these practices are harmful to infants unless they are medically prescribed by a doctor (Hossain et al.., 1995).
However, in rural Egypt, PFL use was found to be higher among mothers who attended clinics and obtained modern training (Hossain et al., 1995). This may be because health care professionals suggested the introduction of glucose water and formula milk to the infants for the prevention of hypoglycemia (low blood sugar levels), and this is done in many parts of the world (Fidler & Costello, 1995). Additionally, some doctors promote the practice of PLF to prevent or treat dehydration and newborn jaundice. However, professionals argue that introducing PLF to avoid disease or dehydration is not sound advice because babies do not need PLFs, as breast milk is fully sufficient for them (Isenalumhe & Oviawe, 1987). Insufficient breast milk production by the mothers is, however, one valid reason for PLF practice (Hossain et al., 1992).
In Nigeria, late commencement of breastfeeding is frequently practiced and is associated with PLF practices (Cunningham el at., 1991). Almost all mothers (99.8 percent) in southern Nigeria give water to their neonates from the early hour of birth, and 75.2 percent of them give their neonates glucose water (Nwankwo & Brieger, 2012). However, the influence of health workers, family members, culture, and personal interests were the major reasons for the introduction of prelacteal foods to the neonates in the region. Health workers were mainly responsible for recommending glucose water, whereas grandmothers often recommended herbal tea.
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Giving babies plain water is mostly due to the belief that the neonates are thirsty (Nwankwo & Brieger, 2012).
The table below shows the percentage of liquids that are given to infants in the south and the level of whom the administer it to the infant at each stage of life.
Table 1: Plain water is the liquid that is given to infants in the first four months of life even much more than breastmilk.
Point/period in time (per cent giving)
Type of fluid At birth first week 1-4 months
Breast milk 86.9% 100.0 100.0
Plain water 99.8% 100.0 100.0
Glucose water 75.2% 71.5% 37.2%
Agbo (herbal tea) 3.6% 47.2% 97.3%
Data source: Brief report journals credit
The table below shows the types of prelacteal liquids that are given to children and the people that recommend each type of liquid.
Table2: Health workers are the primary reason why mothers give their infants glucose water and other PLFs
Types of fluids recommended (percent)
People who recommend breast milk plain water glucose water Agbo (herb tea)
Health workers 71.5% 80.8% 93.7% 3.1%
Grandmother 1.0% 0.5% 0.6% 50.5%
Culture 5.3% 3.9% 0.0% 12.3%
Husband 0.2% 0.2% 0.6% 10.2%
Data source: Brief report journals credit: file:///C:/Users/hp%20dm4/Downloads/480109.pdf
Moreover, most of the mothers who were involved in the study did not have the knowledge of exclusive breastfeeding; only 45 percent of the mothers had ever heard of exclusive breastfeeding. Their sources of EBF knowledge were mostly from primary health care workers, their mothers or mothers-in-law, friends, husbands, and
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radio/television campaigns. Primary health care workers are the primary recommenders of EBF. About 94.7 percent of mothers heard about the practice of EBF from them. The media is the less effective way of informing the mothers about EBF because mothers that respond to the study who heard about EBF on the radio were very few. Additionally, the mothers who knew of other mothers practicing EBF were only 7.5 percent of the total mothers (Nwankwo & Brieger, 2012).
More than half the women involved in the study understood EBF to be of good effect to their children, whereas most who heard about it for the first time felt it was a bad idea–believing that children who undergo EBF would not grow well and would be unhealthy. They believed even if a child were be exclusively breastfed, the child must also be given agbo (herbal tea) for protection from diseases (Nwankwo & Brieger, 2012).
EARLY INITIATION OF EBF
The introduction of prelacteal feeds is the reason breastfeeding is not initiated at the early hour of birth. This practice deprives a lot of babies of the most important nutrient in breast milk, known as the colostrum. Colostrum is the first breast milk that is produced immediately after giving birth and it lasts for about two to four days of the perinatal lactation period (Godhia & Patel, 2013). It is thicker than the normal breast milk, and contains many nutrients, including protein, growth factors, immunoglobulin, vitamin K (Kries et al., 1987). Colostrum has twice the nutrients that normal breast milk has (Tyndall et al., 2016). Many mothers in Adamawa State, northeastern Nigeria, consider colostrum as stale milk and hence avoid giving it to their children (Tyndall et al., 2016). Another factor hindering the practice of EBF in
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this region was that mothers believe the weather of the region makes EBF inappropriate for their children because the children will become dehydrated (Tyndall et al., 2016). Adamawa State is a tropical dry land region with average annual temperatures of 35 degrees Celsius and maximum temperatures of 41 degrees Celsius between February and May (Bidinger, 1990).
FACTORS/FACILITIES THAT WILL PROMOTE EARLY EBF; BABY FRIENDLY HOSPITALS
In 1991, WHO and UNICEF instigated the Baby-Friendly Hospital Initiative (BFHI). The purpose of the initiative is to improve and protect breastfeeding practices. The initiative took all measures in ensuring that infants are exclusively and well breastfeed, with about 156 countries implementing the idea (WHO, 2009). The major target of this initiative is to develop hospitals where the staff will be well trained so as to train mothers how to breastfeed their children well. One such hospital in Ile-Ife, Nigeria, found that mothers who had the baby-friendly training breastfed their children in better ways than those who did not (Ojofeitimi et al., 2000). The initiative is meant to reach all mothers so that its aim will be achieved, but in Nigeria, the BFHI program is restricted to tertiary health care units and thus the program does not reach a large number of families (Ogunlesi, 2004).
Nigeria, with 15 percent level of EBF, is one of the countries with lowest rate of exclusive breastfeeding (UN, 2012). However, UNICEF has recently reported that the rate of exclusive breastfeeding is now 25 percent in Nigeria, which is still low because despite the increase over 5.4 million children are still not getting sufficient benefits of exclusive breastfeeding. In comparison to Ghana, Nigeria’s increase in
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the rate of exclusive breastfeeding is extremely slow. In 1994, Nigeria and Ghana were both at the rate of 7.4 percent EBF but by 2013, Ghana sped up to 63 percent while Nigeria has remained at 25 percent up to this year (2017) (UNICEF Nigeria, 2016).
Nigeria has the largest population of any African nation and a rapidly growing population with about 195,510,982 people (DHS, 2018). Considering the many benefits of EBF and its underuse in Nigeria, I investigated mothers’ knowledge and attitudes toward EBF in clinics in Yola-Jimeta, Adamawa State, northeastern Nigeria. I also evaluated the role of awareness programs on affecting attitudes and opinions toward exclusive breastfeeding. The findings of this study will be shared with the community, and recommendations will be made to health care facilities in Yola-Jimeta to increase outreach on exclusive breastfeeding.
The internally displaced people (IDP) are immigrants that are mostly from Maiduguri who migrated to Adamawa state as a result of the Boko Haram crisis. They are mostly Kanuri by tribe and they speak both Hausa and Kanuri language. Majority of the IDPs are Muslim women, young children and old men. There are 390 women in the camp in which 54 are and 252 are lactating. The total number of children in the camp is 759. Additionally, most of the IDPs are from Damboa, Gwoza, and Ngala local government of Maiduguri state.
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HYPOTHESES
NULL HYPOTHESIS: There will be no difference in the level of knowledge of EBF between mothers in Yola and those at Fofure IDP camp.
RESEARCH HYPOTHESIS: Mothers in Yola have higher level of knowledge of exclusive breastfeeding than mothers in Fofure IDP camp.
AIMS AND OBJECTIVES AIMS: To evaluate the variation in the level of knowledge of exclusive breastfeeding between mothers in Yola and those in Fufure IDP camp as well as their perceptions towards its practice. To evaluate the most effective medium of awareness for the knowledge of exclusive breastfeeding among mothers in Adamawa State.
OBJECTIVES: 1. To test mothers’ knowledge on exclusive breastfeeding. 2. To determine mothers’ opinions and attitudes toward exclusive breastfeeding. 3. To compare the variation in the level of knowledge of EBF between mothers in Yola and those at Fufore IDP camp. 4. To find the most effective medium of awareness of EBF towards the practice of EBF in Adamawa State.
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5. Based on my findings, to make recommendations to health care facilities within Yola and Fufure IDP to increase outreach on exclusive breastfeeding through the most effective medium that was found from the result of the research.
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