Barriers to utilize nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia: An exploratory study

PLoS ONE, Volume 16, No. 4 April, Year 2021

Interpretation

Background While lactation is a physiological process requiring high energy demand to fulfill the nutrient requirements of the mother and the breastfeeding child, many factors affecting maternal nutrient intake can lead to nutritional deficits. Previous studies in Ethiopia have reported the prevalence of maternal and child undernutrition and related complications. However, qualitative studies exploring potential barriers to utilizing available nutrition interventions are limited. This study, therefore, sought to qualitatively explore barriers hindering the uptake of nutrition services among lactating mothers from rural communities in Tigray, northern Ethiopia. Methods We conducted 6 in-depth interviews, 70 key informant interviews, and 13 focus group discussions among purposively selected community groups, experts, and lactating mothers between November- 2017 and January- 2018. Audio records of all interviews and focus group discussions were transcribed verbatim (word-to-word) and translated into English. Then, translated data were analyzed thematically using qualitative data analysis software Atlas ti-version 7.4. Results The participants in this study perceived that lactating mothers in their study area are not properly utilizing available and recommended nutrition interventions, and as a result, their nutrient intake was reported as inadequate. Participants identified inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services and poor access to water, sanitation and hygiene as major barriers hindering the uptake of nutrition interventions by lactating women in Tigray, northern Ethiopia. Conclusion The uptake of nutrition intervention services was low among lactating mothers and was hindered by multiple socio-cultural and health service related factors requiring problem-specific interventions at community, health facility, and administrative levels to improve the nutritional status of lactating mothers in the study area. This study was conducted in five woredas in the Tigray region, northern Ethiopia between November- 2017 and January- 2018. Tigray is the northernmost region of Ethiopia. The population of Tigray is estimated to be about 5,541,736 (CSA projection for 2019). About 80% of the population lives in rural areas. The region is administratively divided into seven zones, 52 districts, and 763 kebeles, the smallest administrative division. Currently, there are 2 referral hospitals, 14 general and 24 primary hospitals, 226 health centers, and 740 health posts. Details of the study design were reported elsewhere [18]. In brief, three food-insecure woredas (Ofla, Samre Seharti, and Tanqua Abergele) and two food-secure woredas (Laelay Maichew, Medebay Zana) were purposively selected for this study. Then two kebeles, the smallest administrative unit of about 5000 people, were selected from each woreda. Therefore, the study was conducted in 10 kebeles in the region. An exploratory qualitative study design was utilized in this study. Taking into consideration the principle of maximum variation, participants were purposively selected from different community groups and areas of expertise with the help of kebele leaders and health extension workers. For in-depth interviews (IDI), lactating mothers were selected; for key informants interviews (KII), participants from different community groups such as religious leaders, women development groups (WDG), kebele leaders, health extension workers (HEWs), agriculture extension workers (AEWs), and experts from various nutrition-sensitive and nutrition-specific sectors such as agriculture, nutrition, education, water, health, youth and sports services, and women’s affairs were selected. Lactating mothers, WDG, and women of reproductive age were selected for focus group discussions (FGD). Qualitative data for this study were explored from KIIs, IDIs, and FGDs. While KIIs and IDIs were carried out to explore people’s opinions towards potential barriers to accessing nutrition interventions during lactation in the studied communities, FGDs were conducted to investigate people’s interactions regarding the research objective and to triangulate the findings of the study from the perspectives of different community groups and experts. After consulting experts from different disciplines such as public health, nutrition, agriculture, and food sciences and reviewing the literature, interview and discussion guides were developed to facilitate the KIIs, IDIs, and FGDs. The guides mainly covered the types of nutrition interventions available and barriers to the uptake of the available interventions in the study area. The guides were developed in English, translated into the local language for the study area, and back-translated to ensure consistency. They were also pre-tested before the actual data collection was carried out, and comments identified during the pre-test were used to modify the tools. The pilot test was conducted in Ofla district; one FGD for each FGD category and one IDI each for district-level experts were conducted. KIIs, IDIs, and FGDs were facilitated by MSc/MPH holders with previous experience in qualitative data collection (with one note taker and one facilitator). While KIIs and IDIs were conducted in locations preferred by participants, FGDs were carried out either in a health post or community development center where the discussion could be held with minimal destructions. While the average time of KII and IDI was 45 minutes, FGDs took 70 to 90 minutes. All KIIs, IDIs, and FGDs were audio-recorded. Investigators listened to the audiotaped FGDs, KIIs, and IDI data several times to familiarize themselves with the data. All KII, IDI, and FGD audio records were transcribed verbatim and translated into English. Then, translated transcripts were imported into Atlas ti-version 7.4 qualitative data analysis software for coding. Following the principles of thematic analysis set out by Braun and Clarke, investigators applied line-by-line coding to inductively explore the potential barriers to accessing nutrition interventions during lactation in the studied communities. Following coding, identified codes were grouped based on similarities and differences to form categories. Finally, themes were identified. Participants’ quotes were reported directly as they were spoken, without editing the grammar, to avoid any loss of meanings. Member checks and prolonged engagement with participants were done to strengthen the credibility of the accounts. Data collectors, supervisors, and investigators spent a prolonged time in field work to facilitate sustained engagement with the study participants. For the member checks, participants who were willing to stay following each focus group discussion were asked to listen to the sound recordings and asked if they agreed with what had been said. Research assistants and investigators also conducted peer debriefing during data collection on a daily basis. To ensure the reliability of the data, data from FGD and IDI were triangulated. Coding was done by at least two investigators, and differences in coding were resolved via discussion. Transparency was maintained by recording each step taken from the start of the project until reporting the research findings. Researchers sought to set aside their assumptions, perceptions, and values, and prior knowledge to reduce bias during the collection, coding, and interpretation of data. The study was approved by the ethical review committee of the College of Health Sciences, Mekelle University, and permission to conduct the study was also obtained from Tigray Regional Health Bureau. Before conducting data collection, participants were informed about the purpose of the study, their right to participate and refuse at any stage of the study, and confidentiality. Consequently, verbal consent was sought from each participant. Verbal consent was audiotaped after information about the study was provided to study participants.

AI Digest

Study Justification:

This study aimed to explore the barriers hindering the utilization of nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia. While previous studies have reported the prevalence of maternal and child undernutrition in Ethiopia, there is a lack of qualitative research on the barriers to accessing available nutrition interventions. This study fills that gap by providing insights into the factors that hinder the uptake of nutrition services among lactating mothers.

Highlights:

– The study found that lactating mothers in the study area were not properly utilizing available and recommended nutrition interventions, leading to inadequate nutrient intake.
– The major barriers identified include inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services, and poor access to water, sanitation, and hygiene.
– The study highlights the need for problem-specific interventions at the community, health facility, and administrative levels to improve the nutritional status of lactating mothers in the study area.

Recommendations:

– Improve accessibility and availability of nutritious foods for lactating mothers in rural communities.
– Promote appropriate feeding practices and provide education on the importance of nutrition during lactation.
– Address cultural and religious influences that may hinder the uptake of nutrition interventions.
– Integrate nutrition interventions with agricultural programs to ensure food security and promote diverse diets.
– Strengthen health services to provide adequate support and guidance to lactating mothers.
– Improve access to clean water, sanitation, and hygiene facilities to enhance nutrition outcomes.

Key Role Players:

– Community leaders and organizations
– Health extension workers
– Religious leaders
– Women development groups
– Agriculture extension workers
– Experts from nutrition-sensitive and nutrition-specific sectors
– Health facility staff
– Administrative authorities

Cost Items for Planning:

– Training and capacity building for key role players
– Awareness campaigns and educational materials
– Infrastructure development for improved water, sanitation, and hygiene facilities
– Support for agricultural programs and diversification of food production
– Health service strengthening, including staffing and equipment
– Monitoring and evaluation activities to assess the impact of interventions
Please note that the cost items provided are general categories and not actual cost estimates. Actual budget planning would require a detailed assessment of specific needs and resources available in the study area.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is clearly described, including the methods used for data collection and analysis. The study conducted in-depth interviews, key informant interviews, and focus group discussions, which provide a comprehensive understanding of the barriers to utilizing nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia. The study also includes a description of the study area and population, which adds context to the findings. However, the abstract does not provide specific details about the number of participants or the criteria used for participant selection. Additionally, while the abstract mentions that the study was approved by an ethical review committee and obtained permission from the regional health bureau, it does not provide information on how informed consent was obtained from participants. To improve the evidence, the abstract should include more specific details about the participant sample and the informed consent process.

Abstract

This study was conducted in five woredas in the Tigray region, northern Ethiopia between November- 2017 and January- 2018. Tigray is the northernmost region of Ethiopia. The population of Tigray is estimated to be about 5,541,736 (CSA projection for 2019). About 80% of the population lives in rural areas. The region is administratively divided into seven zones, 52 districts, and 763 kebeles, the smallest administrative division. Currently, there are 2 referral hospitals, 14 general and 24 primary hospitals, 226 health centers, and 740 health posts. Details of the study design were reported elsewhere [18]. In brief, three food-insecure woredas (Ofla, Samre Seharti, and Tanqua Abergele) and two food-secure woredas (Laelay Maichew, Medebay Zana) were purposively selected for this study. Then two kebeles, the smallest administrative unit of about 5000 people, were selected from each woreda. Therefore, the study was conducted in 10 kebeles in the region. An exploratory qualitative study design was utilized in this study. Taking into consideration the principle of maximum variation, participants were purposively selected from different community groups and areas of expertise with the help of kebele leaders and health extension workers. For in-depth interviews (IDI), lactating mothers were selected; for key informants interviews (KII), participants from different community groups such as religious leaders, women development groups (WDG), kebele leaders, health extension workers (HEWs), agriculture extension workers (AEWs), and experts from various nutrition-sensitive and nutrition-specific sectors such as agriculture, nutrition, education, water, health, youth and sports services, and women’s affairs were selected. Lactating mothers, WDG, and women of reproductive age were selected for focus group discussions (FGD). Qualitative data for this study were explored from KIIs, IDIs, and FGDs. While KIIs and IDIs were carried out to explore people’s opinions towards potential barriers to accessing nutrition interventions during lactation in the studied communities, FGDs were conducted to investigate people’s interactions regarding the research objective and to triangulate the findings of the study from the perspectives of different community groups and experts. After consulting experts from different disciplines such as public health, nutrition, agriculture, and food sciences and reviewing the literature, interview and discussion guides were developed to facilitate the KIIs, IDIs, and FGDs. The guides mainly covered the types of nutrition interventions available and barriers to the uptake of the available interventions in the study area. The guides were developed in English, translated into the local language for the study area, and back-translated to ensure consistency. They were also pre-tested before the actual data collection was carried out, and comments identified during the pre-test were used to modify the tools. The pilot test was conducted in Ofla district; one FGD for each FGD category and one IDI each for district-level experts were conducted. KIIs, IDIs, and FGDs were facilitated by MSc/MPH holders with previous experience in qualitative data collection (with one note taker and one facilitator). While KIIs and IDIs were conducted in locations preferred by participants, FGDs were carried out either in a health post or community development center where the discussion could be held with minimal destructions. While the average time of KII and IDI was 45 minutes, FGDs took 70 to 90 minutes. All KIIs, IDIs, and FGDs were audio-recorded. Investigators listened to the audiotaped FGDs, KIIs, and IDI data several times to familiarize themselves with the data. All KII, IDI, and FGD audio records were transcribed verbatim and translated into English. Then, translated transcripts were imported into Atlas ti-version 7.4 qualitative data analysis software for coding. Following the principles of thematic analysis set out by Braun and Clarke, investigators applied line-by-line coding to inductively explore the potential barriers to accessing nutrition interventions during lactation in the studied communities. Following coding, identified codes were grouped based on similarities and differences to form categories. Finally, themes were identified. Participants’ quotes were reported directly as they were spoken, without editing the grammar, to avoid any loss of meanings. Member checks and prolonged engagement with participants were done to strengthen the credibility of the accounts. Data collectors, supervisors, and investigators spent a prolonged time in field work to facilitate sustained engagement with the study participants. For the member checks, participants who were willing to stay following each focus group discussion were asked to listen to the sound recordings and asked if they agreed with what had been said. Research assistants and investigators also conducted peer debriefing during data collection on a daily basis. To ensure the reliability of the data, data from FGD and IDI were triangulated. Coding was done by at least two investigators, and differences in coding were resolved via discussion. Transparency was maintained by recording each step taken from the start of the project until reporting the research findings. Researchers sought to set aside their assumptions, perceptions, and values, and prior knowledge to reduce bias during the collection, coding, and interpretation of data. The study was approved by the ethical review committee of the College of Health Sciences, Mekelle University, and permission to conduct the study was also obtained from Tigray Regional Health Bureau. Before conducting data collection, participants were informed about the purpose of the study, their right to participate and refuse at any stage of the study, and confidentiality. Consequently, verbal consent was sought from each participant. Verbal consent was audiotaped after information about the study was provided to study participants.

Materials

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health in the context of lactating mothers in rural communities of Tigray, northern Ethiopia:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide lactating mothers with information on nutrition interventions, feeding practices, and health services. This could help overcome barriers related to accessibility and availability of information.

2. Community-Based Nutrition Programs: Implement community-based programs that involve local leaders, health extension workers, and women development groups to raise awareness about the importance of nutrition interventions during lactation. These programs could provide education, counseling, and support to lactating mothers in their own communities.

3. Integration of Services: Improve the integration of nutrition services with existing health services, such as antenatal care and postnatal care. This could ensure that lactating mothers receive comprehensive care and support for their nutritional needs.

4. Infrastructure Development: Address barriers related to water, sanitation, and hygiene by improving access to clean water sources, sanitation facilities, and hygiene education in rural communities. This could help improve the overall health and well-being of lactating mothers.

5. Empowerment of Women: Promote women’s empowerment through education and economic opportunities. This could help address cultural and religious influences that may hinder the uptake of nutrition interventions by lactating mothers.

6. Strengthening Health Systems: Enhance the capacity of health facilities, including referral hospitals, general hospitals, health centers, and health posts, to provide quality maternal health services. This could involve training healthcare providers, improving infrastructure, and ensuring the availability of essential supplies and equipment.

7. Collaboration and Partnerships: Foster collaboration and partnerships between different sectors, including agriculture, nutrition, education, water, health, youth and sports services, and women’s affairs. This could facilitate a multi-sectoral approach to addressing the barriers and improving access to maternal health services.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and contextualized to the specific needs and resources of the rural communities in Tigray, northern Ethiopia.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health in rural communities of Tigray, northern Ethiopia is to address the barriers identified in the study. These barriers include inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services, and poor access to water, sanitation, and hygiene.

To address these barriers, the following innovations can be developed:

1. Improve accessibility and availability of foods: Implement strategies to increase the availability of nutritious foods in rural communities, such as promoting home gardening and supporting local agricultural production. This can be done through training and providing resources to families to grow their own fruits, vegetables, and other nutritious crops.

2. Promote appropriate feeding practices: Conduct community-based education programs to raise awareness about the importance of proper nutrition during lactation and provide guidance on optimal feeding practices for lactating mothers. This can include promoting exclusive breastfeeding, introducing complementary foods at the appropriate time, and ensuring a diverse and balanced diet.

3. Address cultural and religious influences: Work with community leaders, religious leaders, and influential individuals to promote the importance of maternal nutrition and overcome cultural and religious barriers that may hinder the uptake of nutrition interventions. This can be done through community dialogues, workshops, and awareness campaigns that highlight the benefits of maternal nutrition for both the mother and the child.

4. Integrate nutrition interventions with agricultural programs: Collaborate with agricultural extension workers to incorporate nutrition-sensitive practices into existing agricultural programs. This can include promoting the cultivation of nutrient-rich crops, providing training on post-harvest handling and storage to preserve the nutritional value of foods, and linking farmers with markets to improve access to nutritious foods.

5. Strengthen health services: Improve the availability and quality of health services for lactating mothers, including antenatal and postnatal care, nutrition counseling, and access to essential supplements and micronutrients. This can be achieved by training healthcare providers, ensuring the availability of necessary resources and equipment, and strengthening the referral system to ensure timely and appropriate care.

6. Enhance water, sanitation, and hygiene (WASH) infrastructure: Address the barriers related to poor access to water, sanitation, and hygiene by improving WASH infrastructure in rural communities. This can include constructing and maintaining clean water sources, promoting proper sanitation practices, and providing hygiene education to prevent waterborne diseases and improve overall health.

By implementing these innovations, it is expected that access to maternal health and nutrition interventions will be improved in rural communities of Tigray, northern Ethiopia, leading to better health outcomes for lactating mothers and their children.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Increase accessibility and availability of nutritious foods: Implement strategies to improve the availability and accessibility of nutrient-rich foods in rural communities, such as promoting local agricultural production, establishing community gardens, and improving transportation infrastructure to ensure the timely delivery of food supplies.

2. Enhance feeding practices: Develop educational programs and support systems to promote optimal feeding practices among lactating mothers, including exclusive breastfeeding, complementary feeding, and proper nutrition education.

3. Address cultural and religious influences: Collaborate with community leaders, religious institutions, and cultural influencers to raise awareness about the importance of maternal nutrition and overcome cultural and religious barriers that may hinder the uptake of nutrition interventions.

4. Strengthen health services: Improve the quality and accessibility of health services by increasing the number of trained healthcare providers, ensuring the availability of essential maternal health supplies, and implementing community-based health programs that specifically target lactating mothers.

5. Improve water, sanitation, and hygiene (WASH) facilities: Enhance access to clean water, sanitation facilities, and hygiene education in rural communities to reduce the risk of infections and improve overall maternal health outcomes.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather information on the current status of maternal health access, including data on nutrition interventions utilization, barriers, and demographic characteristics of the target population.

2. Define indicators: Identify specific indicators that will be used to measure the impact of the recommendations, such as the percentage increase in utilization of nutrition interventions, changes in feeding practices, or improvements in maternal nutritional status.

3. Develop a simulation model: Create a mathematical or computational model that incorporates the identified recommendations and their potential impact on the defined indicators. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and cultural and socio-economic factors.

4. Input data and assumptions: Input relevant data into the simulation model, including information on the target population, baseline indicators, and assumptions about the effectiveness of the recommendations. These assumptions may be based on existing evidence, expert opinions, or pilot studies.

5. Run simulations: Use the simulation model to run multiple scenarios, varying the parameters related to the recommendations. This will allow for the estimation of the potential impact of each recommendation on the defined indicators.

6. Analyze results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. Compare the outcomes of different scenarios to identify the most effective strategies.

7. Validate and refine the model: Validate the simulation model by comparing its predictions with real-world data or conducting further studies to assess the actual impact of implementing the recommendations. Refine the model based on the findings to improve its accuracy and reliability.

8. Communicate findings: Present the simulation results and their implications to relevant stakeholders, including policymakers, healthcare providers, and community members. Use the findings to advocate for the implementation of the recommended strategies and inform decision-making processes.

It is important to note that the methodology described above is a general framework and can be adapted and customized based on the specific context and available resources.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1371/journal.pone.0250696

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Qualitative

Participants Gender:

Female