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Research Proposal
Research Proposal
DECEMBER 2021
DECLARATION
This Research proposal is my original work and has not been presented for a degree in any other
University.
1) Signature Date
Height for age: is an indicator of nutrition status that gives information on the nutritional
situation in the past and indicates whether a person suffers from chronic malnutrition.
Weight for height: is a nutritional indicator that gives information on the present nutritional
status and indicates whether a child suffers from acute malnutrition. The weight of a child is
taken and compared against the weight of a standard child of the same height.
Recommended breastfeeding practice: is the breastfeeding pattern that ensure optima; growth,
development and health of infants. It include exclusive breastfeeding for the first six months, the
(WHO/UNICEF, 2003).
Exclusive breastfeeding: is the feeding of the infants with breast milk only.
Breastfeeding: is the action of feeding a baby with milk from the breast.
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ABSTRACT
Child health is a prime concern to any country. Poor child health has a far reaching consequence
on the future of a developing country. Malnutrition is the leading causes of morbidity among
cases of stunting and wasting. Infants residing in urban settlements are at a greater risk of
malnutrition due the vulnerabilities offered by their biophysical, demographic and socioeconomic
breastfeeding and pre lacteal feeds within one hour after birth are also key contributors to
morbidity and mortality among infants. The duration of breastfeeding below the recommended
duration will leave the infant vulnerable to disease. This study focused on breastfeeding practices
and morbidity among children aged 0-24 months in Kahawa Soweto. A descriptive cross sectional
survey was carried out. The study tools included an open-ended questionnaire, which focused on
demographic characteristics of the mothers and their families and morbidity status among the
This study showed that majority of the householdheads were men (94.3%). Out of those household
heads, (51.9%) were employed. Majority of the mothers and caregivers were below the age of 30
and among them, 69.8% were housewives. Only 5.7% of the mothers` were employed. 53.8% of
the children were breastfed before one hour after birth. 53.8% of the mothers’ did not practice pre
lacteal feeding. Bottle feeding was slightly common in the area with 42.5% of the mothers’
practicing it. During the time of the study, 78.3% of the infants were still being breastfed. Only
24.5% of the mothers’ expressed breast milk. Majority of the mothers’ knew that a child should
be breastfed on demand (74.5%). A large number of the mothers’ obtained information about
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breastfeeding from clinics in the area. 70.8% of the mothers knew that colostrum should be given
to a child.
43.4% of the children were moderately wasted while 34.91% were underweight. 59.4% of the
children had a history of previous illness. In a period of 14 days, 24.5% of the targeted population
had been ill. Common cases were; fever, cough, meningitis and jaundice.
Majority of the mothers had knowledge on the recommended breastfeeding practices. Exclusive
breastfeeding was not practiced fully as there were cases of inappropriate breastfeeding practices.
From the study, there should be an emphasis on the benefits of breastfeeding, expression of breast
milk and its benefits and breastfeeding and other feeding options for infants older 6 months. There
is also the need to encourage women to be employed and guidance of first time mothers’.
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INTRODUCTION
1.1 BACKGROUND.
Breast milk is the global standard meal for optimal infant nutrition and health. It’s a natural
resource that has a major impact on child health, growth and development. Breastfeeding
promotion is a key in newborn and child survival. Optimal breastfeeding practices include
exclusive breastfeeding (breast milk with no other foods or liquids) for the first six months of
life, followed by breast milk and complementary foods (solid or semi-solid foods) from about six
months of age on, and continued breastfeeding for up to at least two years of age at beyond,
complimentary feeding after six months with continued breastfeeding for up to 24 months or
beyond according to WHO. Sub-optimal breastfeeding results in over 800000 deaths of under 5
children annually including 250000 due to morbidity. Morbidity is defined as the rate of disease
in a population. Studies by UNICEF in low income countries and middle income countries
indicate increased rates of morbidity among infants due to the practice of suboptimal
breastfeeding practices. . For example, a study by Kerac (2011)using data from Demographic and
Health Surveys indicated that among 21 developing countries, prevalence of wasting for children
under 6 months may be as high as 34%. .In Kenya, high levels of undernutrition has been
documented. At the national level, 35% of children under 5 years are stunted, 16% are
underweight, and 7% are wasted (Kenya National Bureau of Statistics & ICF Macro 2009).The
problem of under nutrition is even worse in urban poor settings with stunting prevalence of over
Lack of support and inadequate knowledge on recommended breastfeeding practices affect the
breastfeeding practices and the required breastfeeding duration rates (WHO 2017). Poor care
practices during the first 1000 days of life have been widely documented in the Low-and Middle
Income Countries (LMICs). For example, about 40% of infants in LMICs are exclusively
breastfed for the first 6 months (Lauer 2004).In Kenya, a third of children living in urban
settlements(slums) are exclusively breastfed for the first 6 months while about 40% of children in
Kenya aged 6–23 months are fed according to IYCN guidelines (World Health Organization
2005). According to KDHS 2014, just over 60% infants were breastfed before one hour after
birth in the whole country. However in urban poor settings in Kenya, poor infant feeding
practices have been identified. While close to 40% of the infants are not breastfed within 1 h
following delivery, 15% stop breastfeeding by the end of 1 year (Kiman - Murage. 2011). High
levels of malnutrition have been documented among urban settlements with a stunting
prevalence of 40% ( Abuya 2012) due to poor infant feeding practices among other potential
causes such as poor water and environmental sanitation and access to health services (African
Population and Health Research Center 2002a,b; Kimani-Murage & Ngindu 2007).The factors
that are associated with suboptimal breastfeeding and complementary feeding practices include
maternal characteristics such as age, marital status, occupation and education level; antenatal and
maternity health care seeking; health education and socio-economic status; and the child’s
characteristics including birth weight (Setegn 2012).In addition, social-cultural factors including
food insecurity, lack of knowledge or competence, socio-cultural myths and health status of the
mother are also related to sub-optimal breastfeeding practices. These factors lead to
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undernutrition which may be short term effect or a long term effect on child’s health and
survival. They are also associated with increased morbidity (World Health Organization 2009).
The urban settlements have poor housing, no basic infrastructure such as potable water and waste
disposal, and are characterized by high levels of violence and insecurity, unemployment and
poor health indicators (Fotso 2012). Being malnourished leaves an infant susceptible to Acute
respiratory infection, fever and diarrhea. According to KDHS 2014, diarrhea caused by use of
contaminated water and improper practices in food preparation, causes dehydration which leads
To determine breastfeeding practices and morbidity among children aged 0-24 months in
Kahawa Soweto
1. Does the social-demographic factors of the mothers relate to morbidity among the
children?
2. Are the mothers or the caregivers well informed on the recommended breastfeeding
practices?
Breast milk is produced by mammary glands of a human female to feed child. It’s the primary
source of nutrition for newborns before they are able to eat and digest other foods. Breastfeeding
offers health benefits to mother and child even after infancy. Few examples of importance of
are involved in increase in head size in early infancy reflecting an increase in brain
volume during a critical period in development and is related to higher cognitive function
later in life (Bredow M ;The influence of head growth in fetal life, in-fancy and childhood
2. It provides cold and flu resistance. Immunoglobulin A found in breast milk is important
because it coats and seals the infant’s respiratory and intestinal tract to prevent germs
from entering his/her body and his/her bloodstream. The IgA antibodies protect the
infant from a variety of illnesses including those caused by bacteria, viruses, fungi, and
3. Presence of Leukocytes which primarily provide active immunity and promote the
4. It also reduces the risk of developing psychological disorders. Breast milk contains health
promoting anaerobic bacteria including bacteriodes. These individual species aid in early
Universally, there is no commercial formula that can equal breast milk. Breast milk has
appropriate amounts of carbohydrates, protein, and fat. In addition, it provides vitamins, minerals
digestive enzymes and hormones. It also contains antibodies and lymphocytes from the mother
that help the baby resist infections (Le-Doare, K. M. 2015. Human breast milk: A review on its
composition and bioactivity). The immune function of breast milk is individualized as the mother
through her touching and taking care of the baby, comes into contact with pathogens that
colonize the baby and as a consequence her body makes the appropriate antibodies and immune
cells.
Breast milk is produced under the influence of the hormones prolactin and oxytocin. The initial
milk to be produced after giving birth is referred to as colostrum. Its high in immunoglobulin. Its
responsible for protecting the newborn until its own immune system is functioning properly
(Blumberg, R. S. (2016). How colonization by microbiota in early life shapes the immune
system). According to Becker GE “Methods of milk expression for lactating women”, a greater
volume of milk is expressed while listening to relaxing audio during breastfeeding, along with
warming and massaging of the breast prior to and during feeding. A greater volume is expressed
can also be attributed to instances where the mother starts to pumping milk sooner, even if the
According to WHO, breastfeeding is an unequalled way of providing ideal food for the healthy
growth and development of infants. To enable mothers to establish and sustain exclusive
Exclusive breastfeeding- refers to the type of infant feeding in which the infant only
receives breastmilk without any additional food or drink not even water.
Breastfeeding on demand – that is as often as the child wants, day and night
Breastmilk promotes sensory and cognitive development, and protects the infant against
infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common
childhood illnesses such as diarrhea or pneumonia, and helps for a quicker recovery during
illness. Breastfeeding contributes to the health and well-being of mothers; it helps to space
children, reduces the risk of ovarian cancer and breast cancer, increases family and national
resources is a secure way of feeding and is safe for environment. While breastfeeding is a natural
act, it’s also a learned behavior. An extensive body of research of WHO and UNICEF, it
demonstrated that mothers and other caregivers requires require active support for establishing
and sustaining appropriate breastfeeding practices. However, various social and structural
recommendations for breastfeeding in urban settlement. There is high level of poverty, poor
livelihood and poor living conditions. This is due to unemployment, alcoholism and undefined
living arrangements (Muindi K., Elung’ata P. (2011) Monitoring of health and demographic
outcomes in poor urban settlements). Others include: poor social and professional support, poor
Complementary foods are often of lesser nutritional quality than breast milk. In addition, they are
often given in insufficient amounts and, if given too early or too frequently, they displace breast
milk (WHO 2002 COPLEMENTARY FEEDING). Gastric capacity limits the amount of food
that a young child can consume during each meal. Repeated infections reduce appetite and
increase the risk of inadequate intakes. Infants and young children need a caring adult or other
responsible person who not only selects and offers appropriate foods but assists and encourages
them to consume these foods in sufficient quantity. Global recommendations for appropriate
feeding of infants and young children are: Breastfeeding should start early, within one hour after
birth. Breastfeeding should be exclusive for six months. Appropriate complementary feeding
should start from the age of six months with continued breastfeeding up to two years or beyond.
1. Timely – meaning that foods are introduced when the need for energy and nutrients exceeds
2. Adequate – meaning that foods provide sufficient energy, protein, and micro nutrients to meet
3. Safe – meaning that foods are hygienically stored and prepared, and fed with clean hands
4. Properly fed – meaning that foods are given consistent with a child’s signals of appetite and
satiety,
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Socio-economic status shows individuals living standards, life style and all over development
and progress. The education, occupation are the most important elements in the study of socio-
economic status of population. Besides these elements age, caste are also taken into
consideration. Slum is considered unhygienic place for human settlements. It’s the human
settlement in divert condition or situation (UNHABITAT 2003; Slums of the world). The urban
settlements have poor housing, no basic infrastructure such as potable water and waste disposal,
and are characterized by high levels of violence and insecurity, unemployment and poor health
indicators (African Population and Health Research Center Fotso 2009) It’s the adjustment with
nature and compromise with life’s needs for survival in worst conditions. This happens due to
poverty affecting the people who reside in the area. Hence the population is backward socially
and economically. Poverty affects the health, nutrition, education, birth and death ratio. Due to
poverty economic status is lower, so education level is low, unskilled or low skills, so the socio-
economic status of people in the slum is low. Some of this houses are headed by Women. They
are lower educated unskilled, have poor economic condition so they perform the work as per
Human settlement is a term used to refer to slums as they are known in Brazil, Egypt, Turkey
and Kenya. These human settlements have local native words like favelas or kijiji. The United
Nations Expert Group characterizes human settlements as a place with inadequate access to clean
and safe water, low level of sanitation, poor structural quality of housing, a congested location,
there is high rate of unemployment and high rate of communicable diseases. According to KDHS
2014, for child survival, health and development there is need to focus on a healthy start of life.
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However this turns to be a challenge in the human settlements. The socioeconomic differences
have an impact on infant and child mortality. A study by the UN also shows that children in
Nairobi slums are two and half times more likely to die before their fifth birthday due to the
existence of young mothers who have little knowledge on the recommended breastfeeding
practices and can hardly afford to feed their children, Few resources and poor sanitation is a
challenge during the initiation of complimentary feeding. This leaves a risk of contracting a
disease due to lack of clean water which is also expensive in these type of areas
There exists a need to work on morbidity of children in human settlements to aid in the reduction
of mortality of children to help to reduce the negative effect on the development of the country
Morbidity is defined as the rate of disease among a population. A large global disease burden is
attributed to sub-optimal breastfeeding practices accounting for 77% and 85% of the under- five
deaths and disability-adjusted life years (DALYs), respectively (Black, 2008). According to
(Black 2008), sub-optimal breastfeeding, especially non- exclusive breastfeeding in the first six
months of life, results in 1.4 million deaths and 10% of disease burden among children younger
than five years. In developing countries, sub-optimal breastfeeding practices during the first
months of life are an important risk factor for infant and childhood mortality, especially resulting
from diarrhea and acute respiratory infection (WHO 2011). Kenya is rated among 22 countries in
Africa with poor infant and young child feeding (IYCF) practices with a resultant high burden of
under nutrition among the under-fives (UNICEF 2011).The latest Kenya Demographic and
Health Survey (KDHS) showed that nutritional status of children under five in Kenya is poor
with 26% stunted, 4% wasted and 11% underweight. Cases of diseases among infants include:
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1. Acute respiratory infection (ARI) which is a leading cause of childhood morbidity and
mortality throughout the world (Pan American Health Organization (PAHO) and World
2. Fever which is a major symptom of malaria and other acute infections in children.
3. Diarrhoea causes dehydration among infants which is a major cause of morbidity and
.High levels of malnutrition have been documented in low-income countries despite many global
strategies, declarations and policies aimed at combating it (World Health Organization 2007)
Wasting, including severe wasting with implications on child survival, is also prevalent in low-
income countries. For example, a study by Keral.(2011) using data from Demographic and
Health Surveys indicated that among 21 developing countries, prevalence of wasting for children
under 6 months may be as high as 34%.In Kenya, high levels of undernutrition have been
documented. At the national level, 35% of children under 5 years are stunted, 16% are
underweight, and 7% are wasted (Kenya National Bureau of Statistics & ICF Macro 2009).The
problem of undernutrition is even worse in urban poor settings with stunting prevalence of over
40% (Olack 2011). .The global strategy on infant and young child nutrition (IYCN) highlights
the notion that inadequate knowledge about proper foods and feeding practices is often a more
Organization2003). While close to 40% of the infants are not breastfed within 1 h following
delivery, only 2% are exclusively breastfed for the first 6 months, and 15% stop breastfeeding by
the end of 1 year (Kimani-Murage 2011).As a possible consequence of poor infant feeding
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practices high levels of malnutrition have been documented among urban poor residents with
stunting prevalence of over 40% (Abuya 2012). Stunting reflects a failure to reach linear growth
potential. Stunting is a key indicator for chronic malnutrition. Globally between 171 million and
314 children are classified as stunted (WHO database on child growth and malnutrition). 90%
CHAPTER 3: METHODOLOGY
3.1 STUDY DESIGN
This study will be conducted in Kahawa Soweto, an informal settlement found in Nairobi
constituency. The study area is located in between the Kenyatta university hospital and Kahawa
The study targets mothers’ and children of 0-24 months of age attending public outpatient health
center in Kahawa Soweto and lactating mothers in the area. The estimated targeted population in
3.4 SAMPLING
The Fischer’s formula will be used for sample size for sample size calculation (Lwanga,
N=Z2*pq / d2
q= 1-p (children under optimal breastfeeding practices and not affected by morbidity)
Structured questionnaires will be used for data collection in the area. The questionnaire comprise
a section assessing the social economic status of the caregivers and a section of morbidity that
will be used to assess the morbidity status of the infants in the area. It also comprises of a section
that will assess the level of breastfeeding practices and the level of knowledge on the
The data will be collected and entered in statistical package for social sciences (SPSSv16) for
analysis purposes. Data from open-ended questions will be pre-coded before entry. Various
forms of presentations will be used i.e. frequency’s, frequency tables, percentages, graphs
The study will be carried out in a public health setting hence the findings are void of the users of