Nutritional Knowledge, Practices, Nutritional Status and The Associated Factors Among HIV Positive Mothers on Antiretroviral Therapy: Evidence From Cross Sectional Survey in Abay Choman Health Centers, Western Ethiopia

Abstract

Background: Lack of nutritional knowledge, inadequate nutritional practice and under nutrition in HIV positive mothers contribute to accelerate the progression of HIV/AIDS.

Methods: An institutional based cross-sectional study was conducted on nutritional knowledge, practice and status among 394 HIV positive mothers by systematic sampling techniques in Abay Choman health centers from February 2019 to August 2019. Structured and pre-tested questionnaires were used to collect data and analysis was done using SPSS for windows version 22.0. Binary and multiple logistic regressions were computed to identify the presence of association at p<0.05. 

Results: This study revealed that more than half (58.9%) and (54.1%) of participants had good nutritional knowledge and practice, respectively. The prevalence of underweight, normal weight and overweight of the respondents were 31.2%, 59.1% and 9.7%, respectively. Age of mothers (AOR=2.1, 95% CI: 1.01, 4.6), marital status (AOR=4.26, 95% CI: 1.23, 14.81), educational level (AOR=3.57, 95%CI: 1.99, 6.43) and average monthly income (AOR=1.69, 95% CI: 1.03, 2.79) were significantly associated with level of nutritional knowledge during multivariate analysis. Educational level (AOR=3.83, 95%CI: 2.06, 7.13), family size (AOR=0.43, 95% CI: 0.23, 0.82), average monthly income (AOR=2.14, 95% CI: 1.10, 4.17) and mothers’ occupation (AOR=0.40, 95%CI: 0.22, 0.71) were significantly associated with the level of nutritional practice. Furthermore, marital status (AOR=0.34, 95% CI: 0.13, 0.86), educational level (AOR=0.54, 95% CI: 0.29, 0.99), average monthly income (AOR=0.44, 95% CI: 0.23, 0.85) and mothers’ occupation (AOR=1.86, 95%CI: 1.06, 3.26) were significantly associated with nutritional status.

Conclusions: The level of nutritional knowledge and practice of respondents was poor and their under nutrition was higher. This is associated to educational level, average monthly income, mothers’ occupation and marital status of the respondents. Therefore, health centers should have to work in the above gaps of nutritional knowledge and practice of HIV positive mothers through awareness creation in study area.

Keywords

Antiretroviral therapy; HIV positive mothers; Nutritional knowledge; Nutritional practice nutritional status

Abbreviations

ART: Antiretroviral Therapy; HIV: Human Immunodeficiency Virus; AIDS: Acquired immunodeficiency Syndrome; BMI: Body Mass index; AOR: Adjusted Odd Ratio; COR: Crude Odd Ratio; SS: Statistical Packages for Social Sciences, ETB: Ethiopian Birr.

Introduction

Human Immune deficiency Virus (HIV) infection and Acquired Immune Deficiency Syndrome (AIDS) has become one of the world’s most serious health and development challenges. Approximately 35 million people are living with HIV/AIDS through the world [1]. HIV can be spread through blood, semen, vaginal secretions, and breast milk [2]. For people infected by HIV, adequate nutrition is necessary to dwells as far as possible [3].

Malnutrition and HIV are related and aggravate one another in a vicious cycle [4]. Antiretroviral Therapy (ART) is an essential component of care for people living with HIV/AIDS and nutritional assessment and counseling are an integral part of all HIV treatment programs [5]. Adequate nutrition complements and effects of antiretroviral therapies, maintains body weight and improves the performance of the immune system already compromised by the infections [6].

Inadequate nutritional knowledge and practice among people with HIV infection lead to improper management of disease and lower immunological status as well as it accelerates the progression of HIV/AIDS related disease [7].

Among the infected countries, Sub Saharan Africa remains the most affected region by hosting 70% of the global disease burden. From these, nearly 60% of people living with HIV in sub-Sahara Africa are women of reproductive age. Ethiopia is one of the most affected countries by HIV/AIDS pandemic. Malnutrition is one of the main health problems facing women and children in Ethiopia and also the countries remains as the second highest rate of malnutrition in Sub-Saharan Africa [8].

The nutritional knowledge, practice and status of HIV positive mothers on antiretroviral therapy is not well known and to the best of our knowledge, there was no conducted studies on nutritional knowledge, practice and status of HIV positive mothers in the district. Therefore, this study was aimed to assess the nutritional knowledge, practice and status of HIV positive mothers with ages of 15-49 years attending antiretroviral therapy in Abay Choman district health centers, western Ethiopia.

Methodology

Study design and period

An institutional based cross-sectional study design was conducted to assess nutritional knowledge, practice and status of HIV positive mothers, age 15-49 years attending ART. The study was conducted from February 2019 to August 2019.

Study area

Abay Choman district is located 295 km to the west of Addis Ababa in Horo Guduru wollega Zone and Fincha is the capital town of the district which is 48 km away from zonal town, Shambu. It is known for having sugar factory and source of electricity. This district has 5 health centers. According to the 2007 national census report, the total population of this district was estimated to be 48,316 (24,972 males and 23,344 females), out of which 9,440 or 19.54% of its population were urban dwellers.

Source of population

All HIV positive mothers, age 15-49 years live in Abay Choman district and those who were attending health centers ART clinic.

Inclusion and exclusion criteria: All HIV positive mothers in the age group of 15-49 years old are included while, HIV positive mothers who were seriously ill, have hearing impairment, non-voluntary and pregnant mothers were excluded. 

Sample size determination

The required sample size for this particular study was calculated using single population proportion formula, Where, n=is required sample sizes; Zα/2=1.96, d=Margin of error=5% (0.05); p=prevalence of under nutrition among women with HIV/AIDS (42.3 %) in Humera Hospital [9]. And q=(1-p)=(1-0.423)=0.577. Therefore, then after adding 5% of non-respondent rate, the final sample size was 394.

Sampling procedure

The sampling method used was systematic random sampling in which, the first study subject was selected using lottery method and then by systematic random sampling technique every 2^th was selected from the entire sampling frame of 1092 HIV positive mothers to compose 394 as sample size.

Data collection procedure

Data collection technique was conducted using structured questionnaire and these questionnaires were developed in English language and then translated into a local language (Afan Oromo) and back into English to ensure consistency. An intensive training was given for data collectors and supervisors on the purpose of the study, data collection method and ethics of the study.

Assessment of nutritional knowledge and practice

Data on nutritional knowledge and practice was collected using a structured questionnaire from HIV positive mothers, age 15-49 years who attends ART in the study area.

Anthropometric measurement

The weight and height of the participants were measured after interview. Weight measured by using beam balance with light clothes, without shoes and read nearest to 0.5 kg. The height of respondents was measured using stand meter with bare foot and looks straight in horizontal plain. During this measurement the back of the head, shoulders, buttocks and the heels touch the vertical stand and read nearest to 0.5 cm. Then, the Body Mass Index (BMI) was calculated by using weight in kilograms divided by the square of height in meters (kg/m²).

Data quality control

To assure the quality of data, the English version of the questionnaire was carefully translated into Afan Oromo and back to English by language translators in order to check for validity [10]. The first questionnaires pre-tested on 5% of HIV positive mothers before actual data collection.

Statistical analysis

The collected data was first checked for completeness, coded and entered into the computer using SPSS version 22 statistical software. Bivariate and multiple logistic regressions were computed to measure association between dependent variable and independent at p-value<0.05.

Results

Socio-demographic characteristics of the respondents

About 394 HIV positive mothers were sampled for this study with response rate of hundred percent (100%). One third 133 (33.8%) of respondents were in the age group of 31-40 years and more than half 213(54.0%) of them were married. With regard to residence, more than half 237(60.2%) of respondents live in urban area [11]. In connection to average monthly income in ethio-birr, more than half 204 (51.8%) of participants were earned ≤ 1000 birr (Table 1).

Table 1. Frequency distribution of socio-demographic characteristics of respondents (n=394).

As described in Table 1 above, with regard to religion, the majority 245 (62.2%) of respondents were protestant. More than one quarter 123 (31.2%) of the participants were governmental employee. In connection to their husband occupation, 135 (34.2%), 104 (26.4%), 102 (25.9%) and 53 (13.5%) of them were governmental employees, daily laborers, farmers and merchants, respectively. more than three fourth 335 (85.0%) of respondents were Oromo ethnic group.

Nutritional knowledge of respondents in the study area

More than two third 263 (66.8%) of respondents had knowledge about fish as source of protein and nearly two third 258 (65.5%) of them had information about protein rich food builds and repair body tissues [12]. More than two third 276 (70.0%) of the respondents had knowledge about carbohydrate and lipids as energy providers. This study also showed that, more than three fourth 301 (76.4%) of participants knew the importance of balanced diet as preventing infection (Table 2).

Table 2. Frequency distribution of nutritional knowledge of respondents in study area (n=394).

The majority 300 (76.1%) of respondents knew about benefit of dietary diversity to HIV positive patients. Respondents had knowledge about water as nutrients, fruit and vegetable rich in vitamins and mineral, the importance of banana as control of diarrhea in HIV patients 57.1%, 62.7% and 30.5%, respectively. Regarding the overall level of nutritional knowledge, more than half 232 (58.9%) of the respondents had good nutritional knowledge while 162 (41.1%) of them had poor nutritional knowledge in the study area [13].

Nutritional practice of respondents in the study area

More than two third 274 (69.5%) of participants ate breakfast every day and 208 (52.8%) of them had accepted as preparing balanced meal is a time consume. Nearest to three fourth 282 (71.6%) of respondents were wash fruit and vegetables before consumption in the study area. The majority 326 (82.7%) of the respondents were took ART after a meal (Table 3).

Table 3. Frequency distribution of nutritional practice of respondents in study area (n=394)

More than half 200(50.8%) of participants did not eat food during period of illness. The majority 337 (85.5%) of respondents were washed their hand and utensils before and after preparation of food. In this study, more than half 213 (54.1%) and 181 (45.9%) of participants had good and poor nutritional practice, respectively.

Nutritional status of respondents in the study area

The prevalence of overall under nutrition (BMI<18.5kg/m²) in this study was 31.2%. The mean BMI of respondents was 20.48 kg/m² with standard deviation (SD ± 3.2). The finding revealed that more than half 233 (59.1%) and 38 (9.7%) of the respondents had normal weight (18.5-24.9 kg/m²) and overweight (25-29.9 kg/m²), respectively in the study area (Figure 1).

Factors associated with nutritional knowledge of respondents

In binary logistic regression: age of mothers, marital status, educational level, average monthly income and mothers’ occupation were significantly associated with level of nutritional knowledge of respondents in the study area [14]. However, in multivariate analysis after controlling the possible variables: age of mothers, marital status, educational level and average monthly income were identified as important predictors of nutritional knowledge among the study participants. Age of participant was one of the factors associated with nutritional knowledge in the study area. Accordingly, study participants whose age groups 41_49 year were 2.16 times more likely knowledgeable than respondents whose age groups 15_20 year (AOR=2.16, 95%CI: 1.01, 4.65). The odds of nutritional knowledge was 4.26 times higher among HIV positive mothers were married compared to who were single mothers (AOR=4.26, 95%CI: 1.23, 14.81) (Table 4).

Table 4. Factors associated with nutritional knowledge of respondents in study area (n=394).

Educational status of HIV positive mother was significantly associated with nutritional knowledge in this study area. The respondents who completed primary school were 3.57 times more likely knowledgeable compared to those who hadn’t formal education. Participants who earned average monthly income between 1001_2000 birr were 1.69 times more likely knowledgeable about nutrition than those who had earned ≤ 1000 birr in study area.

Factors associated with nutritional practice of respondents

In this study educational level, family size, average monthly income and mothers’ occupation had significant association with nutritional practice of respondents in both bivariate and multivariate analysis. Respondents who completed primary school were 3.83 times more likely to nutritional practice as compared to those who hadn’t formal education. In addition, in a multivariate analysis participants who had ≤ 3 family sizes were 57% more likely to nutritional practice than those who had 4_6 family size (Table 5).

Table 5. Factors associated with nutritional practice of respondents in study area (n=394).

The participants who earned average monthly income between 1001-2000 and ≥ 2001 increases the odds level of nutritional practice by 1.84(AOR=1.84, 95% CI: 1.09, 3.03) and 2.14 (AOR=2.14, 95% CI: 1.10, 4.17), respectively were associated to nutritional practice in the study area. The respondents whose occupational status was daily laborers were 60% less likely associated to nutritional practice than those who were housewife only by occupation (AOR=0.40, 95% CI: 0.22, 0.71).

Factors associated with nutritional status of respondents

In this study marital status, educational level, average monthly income and mothers' occupation had significant association with nutritional status of respondents (p<0.05) in both bivariate and multivariate analysis. Participants who were single mothers were 66% more likely exposed to malnourished as compared to those who were married (AOR=0.34, 95%CI: 0.13, 0.86). The result of study revealed that uneducated HIV positive mothers’ were about 46% more likely under nutrition than those who completed primary school (AOR=0.54, 95%CI: 0.29, 0.99) (Table 6).

Table 6: Factors associated with nutritional status of respondents in study area (n=394)

Participants who earned average monthly income ≤ 1000 birr were 66% more likely exposed to malnourished than those who had earned ≥ 2001 birr (AOR=0.44, 95% CI: 0.23, 0.85) in the study area. Finding of this study showed that respondents with daily laborers by occupation were 1.86 times more likely exposed to undernourished than those who were house wife only (AOR=1.86, 95% CI: 1.06, 3.26).

Correlation between nutritional Knowledge, practice and status of respondents

The Pearson correlation between nutritional knowledge, practice and status of HIV positive mothers is shows in Table 7. Bivariate analysis showed that level of nutritional knowledge scores had significantly positive correlations with nutritional practice (r=0.420, p=0.001) while it had negative correlation with body mass index (r= -0.224, p=0.001) of respondents.

Table 7: Pearson’s correlation between nutritional Knowledge, practice and status

However, the level of nutritional practice of respondents had negatively correlated with nutritional status in the study area (r= -0.403, p=0.001).

Discussion

The study showed that 58.9% and 41.1% of respondents had good and poor nutritional knowledge, respectively. This finding is comparatively lower than the study conducted in Uganda, which shows that 88% of the women living with HIV/AIDS had good nutritional knowledge, whereas 70.9% of them had adequate nutritional knowledge among people living with HIV in Ghana [15] and the study conducted in Manzini, Swaziland demonstrated that, 67% had good nutritional knowledge among pregnant and Lactating Women living with HIV/AIDS [16,17].

In addition, the result of the study relatively higher than the study conducted in Bahir Dar Felege Hiwot Referral Hospital and shows that, 21.7% had good nutritional knowledge among adults on ART and Southwest Nigeria and shows that, 23.5% had good nutritional knowledge in women living with HIV/AIDS [18] . The difference of the results might be because of educational level, health service and awareness about the importance of nutrition. The respondents whose age groups 41-49 year were 2.16 times more likely knowledgeable than respondents whose age groups 15-20 year. This finding is supported by the study conducted in Nigeria which shows that there is significant relation between age of women and knowledge level. Women with HIV/AIDS age greater than 40 years had more nutritional knowledge than the youngest women.

The odd of nutritional knowledge was 4.26 times higher among HIV positive mothers who were married compared to single mothers. The result of this study is similar with the study conducted in Nigerial, married women were 78.7% more likely to had nutritional knowledge than unmarried women living with HIV/AIDS. The respondents who completed primary school were 3.57 times more likely knowledgeable compared to those who hadn’t formal education. This finding is supported by the study conducted in Lagos, southwest Nigeria.

The participants who earned average monthly income between 1001-2000 birr were 1.69 times more likely knowledgeable about nutrition than those who had earned ≤ 1000 Ethiopian birr ETB) in study area. This study is supported by research conducted in India and shows that monthly income payment has an important role in getting the formal education. Therefore, the women from higher income group usually possess radio and television in which they are accessible to the education.

The result of the study revealed that more than half 54.1% and 45.9% of respondents had good and poor nutritional practice. This finding is comparatively lower than the study conducted in Lagos, Southwest Nigeria which shows that 65.1% of women living with HIV/AIDS have good nutritional practice. In addition, this finding is higher than the study conducted in Bahir Dar city and Manzini, Swaziland which shows that, 30.4% and 51% of respondents with HIV/AIDS have good nutritional practice.

The respondents who completed primary school were 3.83 times more likely to nutritional practice as compared to those who hadn’t formal education. This finding was supported by the study conducted in Jinja district, Eastern Uganda and shows that nutritional education and good nutritional practice was found to have positive correlation. The participants who earned average monthly income between 1001-2000 and ≥ 2001 increases the odds level of nutritional practice by 1.84, respectively were factors associated to nutritional practice in the study area.

The prevalence of overall undernourished (BMI<18.5 kg/m²) in this study was 31.2% which is comparatively lower than the study conducted in Tigray region, Humera hospital 42.3% of women under nutrition [19], but it is higher than the previous study, the magnitude of under nutrition in Jimma university is 27.2%, in Bahir Dar is 21.1%, in Dilla university referral hospital is 12.3% and in Nekemte referral hospital and Health Centers is 27%. This discrepancy might be because of the present study that focused only on mothers which could increase the prevalence of under nutrition. Since body mass index is affected by sex, age and muscle mass.

Participants who were single mothers were 66% more likely exposed to malnourished as compared to those who were married. Never-married women belong to households with relatively poor economic status, which may also make it more difficult to obtain sufficient food [20]. Uneducated respondents were about 46% more likely under nutrition than those who completed primary school. Dietary intake plays a critical role in maintaining optimal nutrition status and PLWHA may be unable to choose and eat a varied diet if they do not possess adequate nutrition knowledge [21].

The respondents who earned average monthly income ≤ 1000 birr were 66% more likely exposed to malnourished than those who had earned ≥ 2001 birr. This finding is supported by the study conducted in Nekemte Referral Hospital and Health Centers, showed that the household economic status is positively associated with maternal nutrition status, which is a prerequisite for access to adequate dietary intake and improved nutritional status for members of maternal nutritional status [22].

The participants with daily laborers by occupation were 1.86 times more likely exposed to undernourished than those who were house wife only. The higher risks of developing malnutrition in unemployed people with HIV/AID were greater than the employment subject [18]. Nutritional knowledge had positive correlation with nutritional practice in this study area. Respondents who had more nutritional knowledge were more likely exposed to nutritional practice and again the more practice had the more resistant to disease. However, nutritional knowledge may not obviously translate into a nutritional practice. Hence, there is need to consider the broader social, cultural and economic factors.

Conclusions

This study revealed that, 41.1% of respondents had poor nutritional knowledge in study area. Age of mothers, marital status, educational level and average monthly income were associated factors with nutritional knowledge. In this study 45.9% of the respondents had poor nutritional practice. Educational level, family size, average monthly income and mothers’ occupation were associated factors with nutritional practice. The overall prevalence of under nutrition (BMI<18.5kg/m²) was 31.2%. Educational level, average monthly income, mothers’ occupation and marital status were associated factors with nutritional status. It is concluded that the level of nutritional knowledge and practice of respondents in this study was poor and under nutrition was higher. This is associated to educational level, average monthly income, mothers’ occupation and marital status of the respondents in study area. The health centers should have to work to fill the above gaps of nutritional knowledge and practice of HIV positive mothers through awareness creation.

Limitations of the Study

In this study, an institutional based single population proportion cross-sectional study design was used that limits the relevance of the risk factor analysis to the entire population of HIV positive mothers on ART.

Acknowledgement

The authors would like to extend their gratitude to the participants, data collectors, Wollega University and Abay Choman health centers.

Funding

No funding was obtained for this study.

Availability of Data and Materials

All the required data will be available upon request.

Ethics Approval and Consent to Participate

Ethical clearance was obtained from Wollega University Research Ethics Review Committee. The permission and supportive letter was obtained from Abay choman district informing the respective health centers. Verbal informed consent was obtained from each respondent after briefly explaining the purpose, and benefit of the study. Confidentiality was maintained by avoiding personal identifiers and keeping the data locked..

Competing Interests

The authors declare that they have no competing interests.

Consent for Publication

Not applicable

Authors' Contributions

HFG conceived the study, developed the title, coordinated the data collection activity, carried out the statistical analysis and reviewing the manuscript. FK participated in the design of the study, tool development, data collection supervision, statistical analysis and drafting the manuscript. MD reviewing and preparing the final manuscript and facilitated the publication process. All authors read and approved the final manuscript.

References

1. Youngleson MS, et al. Improving a mother to child HIV transmission programme through health system redesign: Quality improvement, protocol adjustment and resource addition. PloS one. 2010; 5:e13891.
2. Chartier MC. HIV/AIDS and human rights promoting human rights through the ILO Code of Practice on HIV/AIDS and the world of work (No. 994827203402676). International Labour Organization. 2002.
3. Shikuma CM, et al. HIV-associated wasting in the era of highly active antiretroviral therapy: a syndrome of residual HIV infection in monocytes and macrophages? Clin Infect Dis. 2005; 40: 1846-1848.
4. Oketch JA, et al. Too little, too late: Comparison of nutritional status and quality of life of nutrition care and support recipient and non-recipients among HIV-positive adults in KwaZulu-Natal, South Africa. Health policy. 2011; 99: 267-276.
5. Tsai AC, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Social science & medicine. 2012; 74.
6. Banwat ME. An assessment of the nutritional knowledge, practice and status of adult HIV/AIDS patients attending an ART centre in Jos, north central Nigeria. Health Care Curr Rev. 2013; 1-5.
7. Bartlett JG. Introduction: Integrating nutrition therapy into medical management of Human Immunodeficiency Virus. 2003.
8. Bekele S. Analysis on the quality of age and sex data collected in the two population and housing censuses of Ethiopia. SINET: Ethiop J Sci 2006; 29: 123-132.
9. Hadgu TH, et al. Undernutrition among HIV positive women in Humera hospital, Tigray, Ethiopia, 2013: antiretroviral therapy alone is not enough, cross sectional study. BMC public health, 2013; 13: 1-10.
10. Bukusuba J, et al. Nutritional Knowledge, attitudes and practices of Women living with HIV in Eastern Uganda. J Health Popul Nutr. 2010; 28:182-188.
11. Nti CA, et al. Nutrition knowledge, diet quality and nutritional status of people living with HIV (PLHIV) in Ghana. Public Health Nutr. 2012; 2: 219-227.
12. Sakhile KS, et al. Nutritional knowledge, attitude, and practices among pregnant and lactating women living with hiv in the manzini region of swaziland. Health Popul Nutr. 2014: 32:261-269.
13. Mengie GM, et al. Nutritional knowledge, dietary practice and associated factors among adults on antiretroviral therapy in Felege Hiwot referral hospital, Northwest Ethiopia. BMC nutrition, 2018; 4:1-8.
14. Ezechi L, et al. Nutritional knowledge, attitude and practices of women living with HIV/AIDS in lagos Southwest, Nigeria. Malays J Nutr. 2016; 22: 23-32.
15. Ravindra K. Knowledge of rural women regarding nutrition practices in bikaner district of Rajasthan, India. Int j curr microbiol appl. 2018; 7: 2319-7706.
16. Melese S, et al. Under nutrition and its predictors among people living with HIV/AIDS attending antiretroviral therapy clinic in Jimma. University specialized Hospital. Int J Nutr Metab. 2017; 9:67-74.
17. Molla D, et al. Nutritional status and associated factors among adult HIV/AIDS clients in Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia. J Public Health. 2013; 1: 24-31.

    [Crossref] [ Google Scholar]

18. Solomon H, et al. Malnutrition: Prevalence and Its associated factors in PLWHA, in Dilla University Hospital. Arch Public Health. 2013; 71:13.
19. Kenea MA, et al. Assessment of adult nutritional status and associated factors among ART users in Nekemte referral hospital and health center, east Wollega zone, Ethiopia. Food Sci Nutr. 2015; 3: 56.

    [Crossref] [ Google Scholar]

20. Medhin G, et al. Prevalence and predictors of undernutrition among infants aged six and twelve months in Butajira, Ethiopia: the P-MaMiE Birth Cohort. BMC Public Health. 2010; 10: 1-15.

    [Crossref] [ Google Scholar]

21. Meyer SA. Measuring the potential for malnutrition in people with the human immunodeficiency virus. Florida Dietetic Association, Palm Beach, FL. 1994; 847-54.
22. Hundera TD, et al. Nutritional status and associated factors among lactating mothers in Nekemte Referral Hospital and Health Centers, Ethiopia. Int J Nutr Food Sceince. 2015; 4: 216-22.