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The impact of nutrition education on child feeding practices among low-income urban Indian mothers

Mamta Agarwal and Shobha A. Udipi

Feeding practices during childhood are of critical importance to growth and development of children, especially during the preschool years. Numerous studies in India [1-5] have documented that breastfeeding remains the major source of nutrients during infancy and into the second year of life, and that the introduction of solid foods is often delayed up to 12 or even 18 months of age. Such weaning practices are responsible for inadequate food intake of toddlers and, along with superimposed infections, lead to poor nutritional status of children [6].

One way to improve and ensure the well-being of children is to improve the family's knowledge regarding nutrition and health and to modify their practices. In India there are many programmes that provide food and nutrient supplements as well as health and nutrition education, including the Integrated Child Development Services (ICDS) of the Government of India and others run by various voluntary agencies.

Most programmes attempt to monitor immunization, morbidity, mortality, growth, and other parameters of health. However, few reports are available in the literature regarding the evaluation of nutrition education and its impact on current infant- and child-feeding practices by mothers in India. Therefore, the present study was undertaken to examine the influence of nutrition education in (1) an ICDS block located in an urban slum and (2) a nutrition-education programme run by a voluntary agency.

Experimental design and subjects

The aim of the study was to determine whether the nutrition-education content of two programmes influenced the child-feeding practices of 100 mothers (50 from each programme) from urban families of poor socio-economic status. These mothers were compared with two groups of 50 mothers each who lived in the same areas and were from the same socioeconomic stratum but who had never received nutrition education. Selected socio-economic characteristics for the four groups are presented in tables 1 and 2.

Programmes in two slum areas were selected; one was an ICDS block in north Bombay, and the other was a nutrition-education programme conducted by a voluntary agency, the Sophia Rotary Medical Center (SRMC), in south Bombay. Although the services offered by both programmes were similar, the mode of delivery differed substantially, especially for nutrition and health education. Therefore, the results of the survey for these two programmes are reported separately.

Information regarding the services and details of nutrition and health education were obtained by interviewing supervisors and the health-education personnel involved in the programmes. Information regarding feeding practices for children from birth to three years old was collected by interviewing the mothers. Also, the mothers were asked about dietary and feeding practices during common childhood ailments.

Differences among the groups for specific parameters were tested for statistical significance using the chi-square test [7].

Results and discussion

Programme services and nutrition education

Services rendered to beneficiaries in the two programmes are presented in table 3.

Nutrition education

The person principally responsible for nutrition education in the ICDS programme was the anganwadi (local service centre) worker, who was literate and was not a local person. In addition to imparting nutrition education to mothers, her responsibilities included the maintenance of growth charts and records of immunization, preschool education, and literacy classes for women. One anganwadi worker was responsible for a population of approximately 1,000. Nutrition education was imparted primarily through home visits, but talks and demonstrations were also conducted. The anganwadi workers are trained for a period of two weeks at the time of recruitment and then for a period of approximately two weeks after about three years. Training sessions are conducted by various agencies, usually academic institutions recommended by the National Institute of Public Cooperation and Child Development of the Government of India. For the training, a prescribed syllabus is followed for the topics listed in table 3. The syllabus and content of education imparted by the anganwadi workers is centrally formulated on an all-India basis.

TABLE 1. Average per capita monthly income and number of rooms per family in the study and control groups

a. Mean ± SD.

TABLE 2. Type of house, sanitary facilities, and mothers' literacy levels in the study and control groups (percentages)

TABLE 3. Services provided to beneficiaries in the ICDS and SRMC programmes

+ indicates services provided;
- indicates services not provided.

The principal functionaries in the SRMC programme were illiterate women who had themselves once been beneficiaries of the programme. There were two health educators, who had received nutrition education as beneficiaries for a period of two years before being made health educators. They were living in the same slum as were the mothers. One health educator was responsible for 25 women. The health educators were trained and supervised on an ongoing basis by a qualified social worker, who had been trained as a nutrition educator as part of a programme conducted by the Catholic Relief Services.

Health and nutrition education was given to the mothers in the SRMC programme in class once a fortnight by the health workers, and this was followed up by routine home visits by the health educator and the social worker. Sessions included the use of films and other audio-visual aids, demonstrations, and competitions-e.g. a healthy baby contest, a cleanest house contest, etc. Maintenance of records and growth charts was done by the social worker.

In both programmes, nutrition and health education covered the following topics: the importance of breast-feeding, supplementary and weaning foods, balanced diet, diet during pregnancy and lactation, immunization, sanitation and hygiene, including safe water for drinking, and oral rehydration therapy.

The SRMC trainers had continuous support and ongoing informal training conducted by the nutrition educator. In the ICDS programme, the anganwadi worker normally functions under a supervisor who also has been trained for a specific period. In addition, there is a medical officer attached to the anganwadi. Thus in both programmes the health educators had a trained individual who could advise them whenever necessary.

The frequency of contact with the mothers and consequently reinforcement of teaching was greater in the SRMC programme than in the ICDS programme. Oral rehydration therapy was not given as much emphasis in the SRMC programme as in the ICDS programme. In both. the health workers felt that children who were beneficiaries of the projects were healthier than others who were not. They also reported that mothers' response to advice regarding the nutrition and health care of their children was usually good.

The Impact of nutrition and health education on the mothers

A greater percentage of the mothers who received nutrition education from the SRMC programme (80% ) reported that they treated drinking water. The most common method of treatment they used was boiling, while approximately 20% of them filtered the water through a cloth. However, approximately 70%-80% of the mothers in the ICDS programme and the two control groups did not treat drinking water at all. The percentage of mothers who did not treat drinking water was not found to differ significantly among the three latter group when the chi-square test was applied. Most of the mothers who treated drinking water did so in order to remove germs and dirt. Those who did not treat drinking water attributed this to lack of time and fuel.

Cleanliness of the home and good personal hygiene of the mothers and their children were observed more frequently among the SRMC-programme beneficiaries than in the other three groups (table 4). This may have been because sanitation and hygiene was emphasized more in the SRMC programme and was not sufficiently emphasized in the ICDS programme.

TABLE 4. Personal hygiene and sanitation among the nutrition-education beneficiaries and controls (percentages of mothers)

Chi-square values:

ICDS vs. non-ICDS, x² = 15.699; P < .001.
SRMC vs. non-SRMC,x² = 24.299; P < .001.
ICDS vs. SRMC, x² = 47.989; P < .001.

Child-feeding practices

Most mother in all four groups (64%-71%) began breast-feeding on the third day after delivery. Approximately 15%-30% initiated breast-feeding on the second day, and only a small percentage (5%-10%) started on the day of delivery itself. A significantly larger percentage of mothers who received nutrition education (18%, p<.01) fed colostrum to their infants than of those who did not receive any education (5%). The various reasons given by the mothers for not feeding colostrum and their responses are summarized in table 5.

The duration of breast-feeding in all four groups was observed to be similar to that reported by other investigators [1; 3; 4]. Approximately 50% of the mothers in all the groups breast-fed until their infants reached 18-24 months of age, and 10%-20% continued breast-feeding beyond this age.

TABLE 5. Reasons given by mothers for not feeding colostrum to neonates (percentages)

Almost all the mothers felt that mothers' milk was the best source of nourishment, gave strength to the child, etc. However, 8%-12% of the mothers in the control groups reported that they breast-fed their infants because it was customary. In the SRMC and ICDS programmes, 56% and 37% of the mothers stopped breast-feeding because of a subsequent pregnancy. Approximately 11%-25% of the mothers in these two groups cited other reasons for stopping breast-feeding-e.g. insufficient milk, work, or that the child had begun consuming solids. In comparison, approximately 26%-43% of the mothers who were not in the nutrition-education programmes stopped breast-feeding because they felt that they had insufficient milk, and a similar percentage ceased breastfeeding because of pregnancy.

In view of the observations regarding delayed initiation of breast-feeding, mothers were questioned about prelacteal feeding. Most of the mothers had delivered in nearby municipal hospitals. These subjects reported that their infants were fed glucose water. Also, some of the SRMC-programme mothers reported that diluted cow's or buffalo's milk was used for prelacteal feeding by the hospital staff. Sixteen per cent of the ICDS-programme and 36% of those in the non-lCDS control group fed their infants honey and castor oil. Most of these mothers were found to be Muslims. Between 7% and 15% of the mothers reported using water alone, sugar and water, or milk and water for prelacteal feeding! while 8%-9% gave nothing at all until the second or third day after birth. Even in the case of those infants who were fed, only small amounts-usually 1-2 teaspoonfuls-were given two or three times in a 24-hour period.

These findings are of concern, especially, since the neonatal period is critical for infant survival. The custom of abstinence from feeding colostrum and supplying inadequate or no nourishment to the infant would undoubtedly impose a stress on the vulnerable child. It is essential, therefore, to emphasize the importance and use of colostrum for infant health in programmes run by the government and voluntary agencies. Furthermore, this prelacteal feeding, with the concomitant denial of colostrum, could be a potential source of infection for the vulnerable infant. Agarwal [8] has reported that in Varanasi, India, potential pathogens such as E. cold were present in a substantial percentage of the utensils, foods, nipples, etc. used for feeding infants, as well as in the mothers' fingernails.

Approximately 60% of the mothers in all four groups used other milk in addition to breast milk from the time the child was three to four months old. Of these, half the mothers used bottles, whereas the other half used cups or katoris and spoons. The bottles were sterilized by 60% of the mothers in the ICDS programme and 80% of those in the SRMC programme, while mothers who were not beneficiaries of either programme cleaned the bottles with either plain or lukewarm water. These findings clearly showed that mothers did adopt good hygienic practices when they were well reinforced. However, the practice of using cow's or buffalo's milk to supplement and in some cases to substitute for breast milk is a matter of concern. In most cases, the reason for the introduction of these milks was an insufficiency of breast milk.

In a more recent study conducted in this department (unpublished data), it has been observed that mothers dilute the cow's or buffalo's milk because they feel that it is too concentrated and therefore difficult for the infant to digest. Further, the dilution is sometimes quite a lot, so that the infant receives less nutrients. Often this is compounded by unhygienic practices associated with bottle-feeding. Also, since the mother may gradually reduce the number of breast feedings, the passive immunity conferred on the child by mother's milk would decrease. Thus, all these factors in combination would lead in infection and ultimately malnutrition. It is vital, therefore, that the necessity of breastfeeding for the first four to six months of the child's life should be given greater emphasis in nutrition education programmes.

Supplementary feeding practices

Nutrition education seemed to greatly influence the introduction of supplementary foods into infants' diets by mothers (table 6). A large percentage of the SRMC-programme mothers (76%) introduced other milk and solid foods in addition to the breast milk to their children at three to five months of age; in contrast, however, only 12% of the ICDS-programme mothers introduced supplementary foods by that age. In both programmes, it was suggested to the mothers that some supplementary foods should be given to the infant at five to six months, while it was stressed that breast-feeding should be continued.

Women who did not belong to either programme initiated weaning only after eight months (88% of the non-SRMC-programme control group and 66% of the non-lCDS-programme group). The remainder of the mothers introduced supplementary foods after 12 months, with 6% doing so when their children were more than two years old. Most mothers in the two programmes mentioned that they had been influenced by the health or anganwadi workers, while in the non-programme groups those mentioned as influential persons were usually mothers or relatives.

TABLE 6. Age of introduction of supplementary foods into infants' diets (percentages)

Commercial cereals were rarely used, and the first foods commonly given were rice and dal. Most of the SRMC-programme mothers introduced fruits, fruit juices, vegetables, and eggs by 12 months of age. In the ICDS programme, however, few mothers (15%-20%) introduced any other foods besides rice and dal. Eighty-five per cent of the mothers in both programmes reported that their children should be able to eat the food prepared for the family by one year of age. However, 30% of the mothers in the non-ICDS programme control group felt that the appropriate age for participation in family meals should be two years. In most families in the low socioeconomic strata, food is not prepared separately for the young child. Often the preparations are spicy, and hence mothers may delay the introduction of these foods into their infants' diets. This may explain the response obtained from non-beneficiary mothers who delayed weaning as well as felt that a child could consume the family diets by around two years of age.

Feeding practices during illness

The mothers were asked about the type and frequency of illnesses among their children during the month preceding the survey. The incidence of illness was observed to be greater in children of the mothers who did not receive any nutrition education; almost all their children included in the study had one or more ailments. In contrast, 52% of the SRMC-programme mothers and 22% of the ICDS-programme mothers reported that their children had no ailments of any kind. In all four groups, the ailments commonly reported by the mothers were coughs, colds, runny noses, diarrhoea, and vomiting. Most of the mothers in all four groups reported that they did not know the causes of these health problems. At least one-fourth of the mothers used home remedies for coughs, colds, and fever. However, in case of diarrhoea and vomiting, the mothers did not mention the use of any home remedies and took the child to a doctor. Fourteen to sixteen per cent of the mothers did not breast-feed during vomiting and diarrhoea. Also 17%-18% of the ICDS-programme mothers restricted water to their children during illnesses. In contrast, all the SRMC-programme mothers gave water to their children during an illness. Thus it appears that the use of water, especially during vomiting and diarrhoea, was not receiving adequate emphasis in the ICDS programme.

Conclusions

The results of the present study indicate that the SRMC- sponsored nutrition-education program me has been more successful than the ICDS programme in changing attitudes and practices concerning children's health and nutrition. This could be attributed to a motivated team of social and voluntary health workers who continuously reinforced messages imparted during class sessions. Since the health workers had been beneficiaries of the programme, personal experience could be responsible for their motivation to some extent. Also, the ratio of beneficiaries to health workers was 25:1. The ICDS anganwadi worker had many other demands on her time and so was perhaps unable to meet the mothers often enough to reinforce desirable practices of child care. This is especially possible in view of one anganwadi worker's having to cover a population of 1,000. which may represent approximately 150 mothers (assuming an average family size of five members).

The data in this study show that nutrition education can positively effect changes in the attitudes and practices of mothers and is an extremely valuable tool in alleviating the malnutrition which may occur as a result of delayed weaning. However, in view of the widespread occurrence of xerophthalmia and other single-nutrient deficiencies, these two programmes did not give sufficient emphasis to the inclusion of protective foods such as fruits and leafy vegetables in the infants' diets. However, it is essential to have personnel who are motivated and, as far as possible, who understand the beneficiaries' problems and can identify with them, as in the SRMC programme, and also to keep the ratio of beneficiaries to health workers within manageable limits.

References

1. Indian Council of Medical Research. Studies on weaning and supplementary food in six different regions of the country. ICMR Technical Report Series. New Delhi, 1977:27.

2. Mehta MJ, Pawar RJ, Betkevra TN. Infant feeding practices in Surat city. Ind Pediatr 1982:9:290-93.

3. Banik D. Breast feeding and weaning practices of preschool children in urban communities in Delhi. Ind Pediatr 1976;2:569-72.

4. Kalra A, Kalra K, Dayal RS. Breast feeding practices in different residential economic and educational groups. Ind Pediatr 1982;19:419-25.

5. World Health Organization. Contemporary patterns of breast feeding. Report on the WHO collaborative study on breast feeding. Geneva: WHO, 1981.

6. Ebrahim J. Nutrition in mother and child health. London: Macmillan, 1983:7-10,86-87.

7. Winer BJ. Statistical principles in experimental design. 2nd ed. New York: McGraw-Hill, 1971.

8. Agarwal DK. Infant feeding practices and environmental hazards during weaning. Baroda J Nutr 1982;9:185-89.

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