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Despite concerted global efforts made towards infant-survival, infant death lingers as a huge problem in developing countries. Environmental and personal-level factors ranging from inadequacies of healthcare providers to poor support from family members and poor practices by nursing mothers are assumed to have accounted for this situation. This study aimed at considering predictors of infant-survival practices among mothers whose infants attend paediatric clinics in Ijebu-ode, Ogun state, Nigeria.

A cross-sectional survey design was adopted. Data was collected from three hundred and eighty-six nursing mothers attending paediatric clinics who were selected through stratified sampling technique. Self-administered questionnaires consisting of 38-items on demographic data, health-literacy counsels and instructions received, social-support received, self-efficacy to adhere to infant-survival instructions, and infant-survival practices were developed for data collection. Responses from participants were transformed into rating scales for each variable. Linear regression analysis was conducted to give statistical responses to the research questions and hypotheses. Decision rules for test of hypotheses were set at 5% level of significance.

Participants had a mean age of 29.79±5.84years. Majority (81.6%) were married while 15.5%, 1.8%, 0.5% and 0.5% were single, separated widowed and divorced respectively. Self-employed participants were 58.0%, 18.9% of them worked with either private organisations or were civil servants while 14.8% were unemployed. Among participants were 65.3% Christians, 31.6% Muslims and 3.1% traditional believers. Although, 10.6% were Igbos, 3.1% were Hausas and 3.4% belonged to other ethnic groups, participants were predominantly Yorubas (83.90%). Also, 42.5% of them had attained tertiary education, 42.5% had attained secondary education, 9.6% had only primary education while 5.4% were uneducated. One-third of respondents (33.4%) had more than two children, 34.5% had two children and 32.1% had one child. It was also revealed that 11.90% of participants had lost one or more infants at one point in time before the survey was conducted. Participants had mean scores of 11.41±3.91 on level of health-literacy counsels received which was measured on a 19-point rating scale, 10.61± 3.67 on social-support received measured on a 17-point rating scale, 16.61±4.56 on self-efficacy which was measured on a 24-point rating scale, and 16.53±4.71 on self-reported infant-survival practices measured on a 21-point rating scale. The study found a significant relationshipbetween health-literacy and infant-survival practices (R=0.320; R2=0.102; P˂0.05), and between social-support received and infant-survival practices (R=0.401; R2=0.161; P˂0.05). Self-efficacy to adhere to infant-survival instructions was the major predictor variable of self-reported infant-survival practices (R=4.66; R2=0.217; P˂0.05).

The study concluded that participants had average levels of health-literacy, social-support, self-efficacy and infant-survival practices. It suggests that efforts be made by health care providers to instruct pregnant women and strengthen them on activities required for the survival of their infants. Family members of nursing mothers should also be informed about the benefits of giving support to them.

Keywords: Health-Literacy, Social-Support, Self-Efficacy, Infant-Survival Practices and

Nursing mothers

Word Count: 454


Content                                                                                                                                 Page

Title Page                                                                                                                              i

Certification                                                                                                                          ii

Dedication                                                                                                                            iii

Acknowledgements                                                                                                              iv

Abstract                                                                                                                                v

Table of Contents                                                                                                                 vi

List of Tables                                                                                                                        ix

List of Figures                                                                                                                      x


1.1     Background to the Study                                                                                           1

1.2     Statement of the Problem                                                                                           3

1.3     Objective of the study                                                                                                            4

1.4     Research Questions                                                                                                     4

1.5     Justification for the Study                                                                                          5

1.6     Hypotheses                                                                                                                 6

1.7     Operational definition of terms                                                                                  6



2.0     Introduction                                                                                                                8

2.1     Epidemiology of infectious diseases among infants                                                   8

2.2     Global programs to ameliorate infant-survival                                                            10

2.3     Psycho-behavioural issues involved in infant mortality                                              10

2.4     Health-Literacy as a predictor of infant-survival practices                                         12

2.5     Social-Support as a predictor of infant-survival practices                                          14

2.6     Self-Efficacy as a predictor of infant-survival practices                                            16

2.7     The Multi-Level dimension for infant-survival                                                           18

2.8     Conceptual Model                                                                                                      19



3.1     Research Design                                                                                                         22

3.2     Population                                                                                                                   22

3.3     Sample size and sampling Technique                                                                          23

3.4     Study variables and test of Null Hypotheses                                                             24

Content                                                                                                                                 Page

3.5     Instrument for data collection                                                                                                26

3.6     Validity and reliability of the instrument                                                                   26

3.7     Method of Data Collection                                                                                         27

3.8     Ethical Considerations                                                                                                27

3.9     Method of Data Analysis                                                                                           28



                                DISCUSSION OF FINDINGS

4.0     Introduction                                                                                                                29

4.1     Demographic characteristics of the participants                                                         29

4.2     Health-Literacy instructions and counsels communicated to                                     32        participants at paediatric clinics about infant care and survival

4.3     Social-Support received by participants                                                                     36

  • Self-efficacy of participants to adhere to infant-survival instructions received 38
  • Self-reported Infant-Survival Practices among the participants 41
  • Answers to research questions 1 to 4 44
    • Level of Health-Literacy instructions and counsels received by participants 44
    • Level of Social-support received by participants 44
    • Level of Self-efficacy of participants 44
    • Level of Self-Reported Infant-Survival Practices of participants 44
  • Answers to research hypotheses (Regression analysis and associations 46

between independent variables and the dependent variable in the study)

4.8     Correlation among variables in the study                                                                   49

4.9     Analysis of means in demographic characteristics of respondents                             51

in relation to variables in the study

  • Analysis of means across the health centres 51
  • Analysis of means across ages of respondents 51

4.9.3    Analysis of means across marital status of respondents                                           52

4.9.4    Analysis of means across occupational status of respondents                                  52

4.9.5    Analysis of means across religious affiliation of respondents                                  52

4.9.6    Analysis of means across ethnicities of respondents                                                54

4.9.7    Analysis of means across educational attainment of respondents                            54

4.9.8    Analysis of means across number of children respondents had alive                       54

4.9.9    Analysis of means across number of infants respondents had ever lost                   55


Content                                                                                                                                 Page



5.1       Summary                                                                                                                   57

5.2       Conclusion                                                                                                                62

5.3       Recommendations                                                                                                    62

5.4       Limitation of the Study                                                                                            63

REFERENCES                                                                                       64

APPENDICES                                                                                                               72


Table                                                                                                                                       Page

4.1       Frequencies and percentages of demographic characteristics                         31

4.2       Frequencies and percentages on health-literacy instructions                                      34

4.3       Frequencies and percentages on social-support received                                            37

4.4       Frequencies and percentages on self-efficacy of respondents                                    39

4.5       Frequencies and percentages on infant-survival practices                                          42

4.6       Summary of means of variables in the instrument                                                      45

4.7       Associations between independent variables and dependent variable                       47

4.9.5    Analysis of means across religious affiliations of participants                                   53

4.9.9    Analysis of means across number of infants respondents had ever lost                     56


Figure                                                                                                                            Page

1       Application of the PRECEDE Framework                                                         21

2       Associations between dependent and independent variables                             48

3       Correlation among variables in the study                                                            5



1.1  Background to the Study

Global deaths among infants recorded for a period of four years from 2012 to 2015 showed a marginal improvement towards achieving the target for the Millennium Development Goal-four with records of 35 to 32 deaths out of 1,000 live births (United Nations Inter-Agency Group, 2015). In spite of efforts made towards infant-survival all over the world, recent data on infant mortality shows a rate of 56 deaths for every 1,000 births in regions in Africa. This is in contrast to other regions such as East-Asia with 14 deaths per 1,000 live births and the Middle East with 20 deaths for every 1,000 live births (Bado & Appunni, 2015).

In 1990, the Millennium Development Goal-four was initiated as part of the eight millennium goals with the aim of reducing child and infant mortality by two-thirds between 1990 and 2015 (Adegboye, Kotze, Adegboye, 2014; Diallo, Meda, Sommerfelt, Traore, Cousens & Tylleskar, 2012). Reports have given the global percentage reduction in infant and child mortality to be 53% over the 15-year goal which was aimed at 75% reduction (Murray, Wang, Fullman, Lopez & Murray, 2015). Also, in 2015, countries in Sub-Saharan Africa recorded an achievement of 52% of the 75% target and remain major contributors to the global mortality burden of infants (Adedini, Odimegwu, Imasiku, Ononokpono & Ibisomi, 2015). This shows that the goal was not attained. Recent data on infant mortality in Nigeria shows a prevalence of 69 deaths per 1,000 live births which has ranked the country as one of the top ten nations in infant mortality (Ezeh, Agho, Dibley, Hall & Page, 2015).

Infant death lingers as a huge problem in developing countries (Fehling, Nelson, Ahn, Eckardt, Tiernan, Purcell et al, 2013). In June 2012, more than 80 countries represented by government officials, partners from private sectors, civil societies, and religious organizations gathered for the Child-Survival Call to Action. The forum was convened by the governments of Ethiopia, India, and the United States, in collaboration with the United Nations Children’s Fund (UNICEF) and challenged the world to lessen infant and child mortality to 20 or lesser deaths per 1,000 live births in every country by 2035 (Koffi, Mleme, Nsona, Banda, Amouzou & Kalter, 2015). Beyond the challenges of establishing infant-survival in developing countries are underlying reasons why these conditionscontinue to constitute the challenge (Chatterjee & Paily, 2011) and these are the essential issues of concern.

A vast number of studies have identified certain factors that put infants at risk of mortality. Infections, vaccine-preventable diseases, nutritional inadequacies, sanitation challenges and health status of the mother during pregnancy have been documented (Cheraghi, Poorolajal, Hazavehi & Rezapur-Shahkolai, 2014; Jarso, Workicho & Alemseged, 2015). Other factors contributory to infant mortality from investigations include poor antenatal planning of mothers, poor service provision by healthcare service providers, inadequate birthing practices of care-givers and poor health-information dissemination to mothers of infants (Atulomah & Atulomah, 2015). If these factors are not critically attended to, infant mortality will continue to be an issue without lasting solutions (Joshi, Sharma & Teijlingen, 2013).

Some of the requirements of mothers include skill-building in preparation for enhancing the survival of their infants, getting skills that will strengthen them to take their infants for immunisation (Oyo-Ita, Wiysonge, Oringanje, Nwachukwu, Oduwole & Meremikwu, 2016), practicing exclusive breastfeeding, imbibing positive sanitary habits and preventing cases of diarrhoea and malaria (Fadnes, Engebretsen, Moland, Nankunda, Tumwine & Tylleskär, 2010). These should be essential components of health-literacy instructions communicatedto mothers of infants during antenatal care sessions.

Also, behaviour-change in mothers of infants to enhance their self-efficacy in ensuring that they carry-out activities that will ascertain the survival of their infants will be as a result of comprehensible health-instructions (Elder, Pequegnat, Ahmed, Bachman, Bullock, Carlo et al, 2014). Furthermore, programs with innovative approaches to engage key influencers such as fathers and other family members around the mother to provide positive social-support for her could be more successful in changing her behaviour to improve maternal and infant care (Altrena, Martin, Egondi, Bingham and Thuita,2016).

Infants are a group of individuals who have neither control over themselves nor the power to cater or care for themselves. They are delicate subgroup of a population. Their survival is a fundamental pointer to the level of maternal and child health, therefore, investigating their well-being is an investment for the development of any nation (Sathiyasusuman & Hamisi, 2012).

1.2  Statement of the Problem

About 353,000 births are reported to occur daily around the world, yet, infants are exposed to the risk of mortality as these births occur (Ayele, Zewotir & Mwambi, 2016). One main challenge in attaining the target reduction in infant death is that most infant health programs do not get to the mothers through tangible programs (Lassi, Middleton, Crowther & Bhutta, 2015).

Few studies have recognised components leading to lack of infant care and poor survival of infants. Issues involving the personal-level predisposition of mothers stem from factors such as health-literacy instructions and counsels communicated to mothers at antenatal sessions. Most of these counsels have either not been strategically delivered to mothers or have not been adequately delivered to them in ways by which they are empowered, encouraged and willing to ensure the survival of their infants (Lu & Johnson, 2014; Owor, Matovu, Murokora, Wanyenze & Waiswa, 2010; Rosato, Lewycka, Mwansambo, Kazembe, Phiri & Chapota, 2014).

Also, environmental-level factors have posed a challenge in ensuring infant-survival. Such deficienciescome from lack of social-support from family members and significant others in the lives of nursing mothers. Nursing mothers should receive reinforcements in terms of encouragements to carry-out instructions received for infant care, positive advises and assistancefrom those around them in order to enable them carry-out activities that will strengthen the survival chances of their infants (Fry-Bowers, Maliski, Lewis, Connell & DiMatteo, 2014).

Mothers should receive health instructions and counsels during preconception and antenatal periods, and support in the many ways they will require assistance in order to practice skills that will prolong the lives of infants (Berglund & Lindmark, 2016; McInnes, Hoddinott, Britten, Darwent & Craig, 2013). If they are not adequately equipped with skills regarding what to do during the period preceding delivery, after delivery and how to respond to emerging situations that threaten the lives of their infants, they will be weak in ensuring the survival of their infants.It will therefore be of immense benefit to investigate into how these personal and environmental-level factors can collectively be predictors of infant-survival practices among mothers.The aim of this study was to consider the predictors of infant-survival practices among mothers whose infants attend paediatric clinics in Ijebu-ode, Ogun state, Nigeria.

1.3  Objective of the Study

The main objective of this study is to assess factors associated with self-reported infant-survival practices among mothers with infants attending paediatric clinics in Ijebu-Ode, Ogun state, Nigeria. The specific objectives are to:

  1. assess the level of personal-level predisposing factors (health-literacy and demographic characteristics)of the respondents;
  2. measure the level of environmental-level reinforcing factors in terms of social-support received by respondents from significant others in ensuring infant-survival;
  3. assess the level of personal-level enabling factors in terms of self-efficacy to adhere to infant-survival instructions received among respondents;
  4. measure the level of self-reported infant-survival practices among respondents;
  5. determine if there is a relationship between personal-level predisposing factors (health-literacy and demographic characteristics) and self-reported infant-survival practices among respondents;
  6. determine if there is a relationship between environmental-level reinforcing factors in terms of social-support received by respondents and their self-reported infant-survival practices;
  7. determine if there will be an association between personal-level enabling factors in terms of self-efficacy to adhere to infant-survival instructions received and self-reported infant-survival practices among the respondents and
  8. identify which of these personal and environmental-level factors will predict infant-survival practices most significantly among the respondents.

1.4  Research Questions

The questions for this research are as follows:

  1. What is the level of personal-level predisposing factors (health-literacy and demographic characteristics)of the respondents?
  2. What is the level of environmental-level reinforcing factors in terms of social-support received by respondents from significant others in ensuring infant-survival?
  3. What is the level of personal-level enabling factors in terms ofself-efficacy toadhere to infant-survivalinstructions received among respondents?
  4. What is the level of self-reported infant-survival practices among respondents?
  5. Is there a relationship between the personal-level predisposing factors (health-literacy and demographic characteristics) and self-reported infant-survival practices among respondents?
  6. Is there a relationship betweenenvironmental-level reinforcing factors in terms of social-support received byrespondents and their self-reported infant-survival practices?
  7. Will there be an association between personal-level enabling factors in terms of self-efficacy to adhere to infant-survival instructions received andself-reported infant-survival practices among respondents?
  8. Which of these personal and environmental-level factorswill predictself-reported infant-survival practices most significantly among respondents?

1.5  Justification for the Study

To reduce infant mortality, previous investigations have recognized the need for effective behaviour-change interventions targeting mothers (Elder, Pequegnat, Ahmed, Bachman, Bullock, Carlo et al, 2014). Past studies have indicated that behaviour-change on the part of mothers is critical in averting infant death and improving child development (Fishbein, Bandura, Triandis, Kanfer, Becker, & Middlestadt, 1992; Sulzer-Azaroff & Mayer, 1992).

However, behaviour-change approaches should focus on improving information and comprehension of it towards mothers in order to enhance infant care (McInnes, Hoddinott, Britten, Darwent & Craig, 2013).

A number of studies have suggested that health-literacy, social-support and self-efficacy may play significant roles as personal and environmental-level predictors of infant-survival practices (Fry-Bowers, Maliski, Lewis, Connell & DiMatteo, 2014; Lars, Engebretsen, Moland, Nankunda, Tumwine & Tylleskär, 2010). However, these studies did not apply behaviour-change theories, hence, they did not provide the needed empirical evidence to support their claims. Most of these studies did not also link health-literacy, social-support and self-efficacy together as a combination of components that will improve and predict infant-survival practices of mothers.

In this study, an ecological model was adapted to assess the personal and environmental-level factors affecting infant-survival practices. The PRECEDE (Predisposing Reinforcing and Enabling Construct in Educational/Environmental Diagnosis and Evaluation) Model (Green, Kreuter, Deeds & Patridge, 1980) which suits the diagnosis of concern was used as the conceptual guide to give the study an ecological outlook. This study therefore investigated how health-literacy, social-support and self-efficacy serve as collective predictors of infant-survival. The outcomes derived will provide a conceptual understanding of determinants essential in predicting infant-survival practices among mothers in paediatric clinics. It may also lessen the rate of infant mortality in Ijebu-Ode, Ogun State to rational extent and will therefore be extensively beneficial in enhancing the health of infants in Nigeria as a nation.

1.6  Hypotheses

This study hypothesized the following:

  1. There will be a significant relationship between personal-level predisposing factors (health-literacy and demographic characteristics) and self-reported infant-survival practices among respondents.
  2. There will be a significant relationship between environmental-level reinforcing factors in terms of social-support received and self-reported infant-survival practices among respondents.
  3. There will be a significant association between personal-level enabling factors in terms of self-efficacy to adhere to infant-survival instructions received and self-reported infant-survival practices among the respondents.
  4. One of these personal and environmental-level factors will predict infant-survival practices most significantly among the respondents.
  • Operational Definition of Terms


Nutbeam (2008), describes health-literacy as the cognitive and social skills that determine the motivation and ability of individuals to gain access to, comprehend and use information in ways which promote and maintain health. In this study, it involved the possession of health counsels and instructions by mothers of infants and their ability to understand and carry-out these instructions for the survival of their infants as received by healthcare providers.


Social-support is the perception and certainty that one is cared for and can be measured as the availability of assistance or degree to which a person is included into a social network (Nausheen, 2009). Support can be emotional (encouragement or affection), informational (advice or instruction) tangible (financial assistance, running errands), and companionship (sense of belonging, presence of companions). In this study, social-support included emotional-support, informational-support, tangible-support and companionship from family members of nursing mothers.


Self-efficacy is an individual impression that focuses on a person’s absolute utilization of his or her cognitive skill to produce beneficial outcomes (Htay, 2010). For this study, self-efficacy was measured by self-responsibility, skills, abilities, self-determination, confidence and willingness of the mothers to adhere to infant-survival instructions and counsels.

Infant-Survival Practices

Infant-survival practices were described as actions to support the existence of infants to keep to them without disability, morbidity or anything that will lead to mortality beyond the age of infancy (zero to two years). It also the ability of the nursing mothers to carry-out practical actions regarding infant-survival.


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