Study setting, design and participants
This study was conducted in the North Wollo zone (Woldia, Kobo and Lalibela towns) of North Eastern Ethiopia during March 2015. North Wollo zone is one of the ten zones of the Amhara region, located 520 km north-east of Addis Ababa. Based on the 2007 census conducted by the Central Statistical Agency (CSA) of Ethiopia, this zone has a total population of 1,500,303 of whom 752,895 were men and 747,408 were women. There are 64 functional health centres and three hospitals in North Wollo zone. Woldia, Kobo and Lalibela towns have sixteen, five and four health extension workers respectively [North Wollo zone Health Department report, 2015: unpublished]. A quantitative community based cross-sectional study was employed. All mothers who had children less than 24 months of age were the source population of this study.
Sample size determination
The sample size was determined using a formula for the estimation of a single population proportion as follows [18]:
$$ n=D\left[\ \frac{{\left(Z\frac{\alpha }{2}\right)}^2\ P\left(1-P\right)}{d^2}\ \right] $$
Where n = required sample size, Z = critical value for normal distribution at 95 % confidence level (1.96), P = 50 %, d = 0.05 (5 % margin of error), D = 2 (design effect), and with an estimated non-response rate of 10 % produced a final sample size of 844.
Sampling procedure
Multi-stage sampling was employed to select the 844 study subjects. A pre-survey was conducted before the actual day of data collection to determine which households had the target mother-child pairs. 6,013 households contained the targeted mother-child pairs in the selected eight kebeles (the smallest administrative unit in Ethiopia). Kebeles of the towns were selected by simple random sampling (SRS). At the kebele level households were selected by systematic sampling method. According to the population proportion in the study areas; 420, 224 and 200 mothers were selected from Woldia, Kobo and Lalibela towns respectively. A starting point was identified based on the help of health extension workers.
Inclusion and exclusion criteria
From each household unit one eligible mother who had a biological child aged less than 24 months was selected. Non-biological mothers and mothers who were unable to communicate due to disability or any other health problem were excluded from the study.
Data collection procedure
Data were collected using a pre-tested, structured, interviewer-administered questionnaire adapted from the Ethiopian National Nutrition Survey questionnaire [16]. The adapted questionnaire was modified according to the research objective and the actual setup. The questionnaire was prepared first in English, translated into Amharic, and then back into English by fluent speakers of both languages to check its consistency. The data was collected by six diploma midwives and three Bachelor of Science degree holder midwives were recruited as supervisors. The data collectors and the supervisors were trained for three days (including practical work) by the principal investigator (Nigus Bililign).
Study variables
Dependent variable
Prelacteal feeding practices among mothers of children aged less than 24 months. Prelacteal feeding was defined as providing foods and/or drink other than human milk for the infant before breastfeeding was established [5].
Independent variables
The adapted questionnaire had three sections (both closed and open-ended questions). These were: socio-demographic characteristics (age, marital status, educational status, religion), maternal factors (antenatal care visit, parity, place of delivery) and child feeding practices (prelacteal feeding, colostrum feeding). The variable ‘Antenatal Care Visit’ was defined as receiving at least one visit of health facility during the associated pregnancy. The ‘Postnatal Care Visit’ variable was defined as receiving at least one visit within the six-week postpartum period. ‘Untrained traditional birth attendant’ was used to describe individuals who provided delivery services without having formal training in basic mother and child health care.
Data processing and statistical analysis
The data was checked for completeness and inconsistencies. It was also cleaned, coded and entered to the SPSS version 20.0 computer program. Univariate binary logistic regression analysis was performed to assess the association between each single independent variable and the dependent variable (prelacteal feeding yes/no). Multivariable logistic regression was performed to control the possible confounding factors. Variables with a p-value < 0.25 in the binary logistic regression analysis were used in the multivariable logistic analysis, with the same binary dependent variable (prelacteal feeding yes/no). The Hosmer-Lemeshow goodness-of-fit with enter procedure was used to test for model fitness. Adjusted Odds Ratios (AOR) with a 95 % confidence interval were estimated to assess the strength of associations and statistical significance was declared at a p-value <0.05.
Ethical considerations
The study was approved by the Institutional Research Review Board of Woldia University. An official letter was written from Woldia University to the Woldia, Kobo and Lalibela town Administration Offices. Then a permission and support letter was written to each selected Kebele. Informed verbal consent was received from the participants before the interview. The participants were also assured about the confidentiality of the information they provided.