Knowledge, attitudes, beliefs and behaviour of mothers of young children related to healthy eating

422 Pages·2017·13.85 MB·English

Knowledge, attitudes, beliefs and behaviour of mothers of young
children related to healthy eating: Comparing rural and urban
perspectives in Nepal

A thesis submitted in partial fulfilment of the requirements of
Bournemouth University for the degree of
Doctor of Philosophy

Jib R. Acharya

Faculty of Health and Social Sciences
Bournemouth University

November 2017
COPYRIGHT STATEMENT
The copy of the thesis is supplied on the condition that anyone who wants to consult or seek help with
this dissertation in any regard has no right to copy, reproduce, or imitate any part of this report without
the consent of the author.
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DEDICATION

This work is dedicated to my father Lt. Shri Lok Prasad Acharya, I had lost him in my early childhood
and my father-in-law Lt. Shri Ganesh Prasad Chaulagain whom I lost during this study. Moreover, I
would like to dedicate this study to all the undernourished children of Kaski District of Nepal.

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ABSTRACT
Knowledge, attitudes, beliefs, and behaviour of mothers of young children related to healthy eating:
Comparing rural and urban perspectives in Nepal.
Jib R. Acharya
Introduction
Mothers’ misconception of a healthy diet is one of the major causes of nutritional problems in
preschool-aged children in Nepal and these beliefs and attitudes can result in the inappropriate feeding
of young children. There is growing research on this topic in Nepal but very little from a public health
perspective. This thesis has been designed to cover gaps in this understanding, especially mothers’
decision-making around feeding their children and is based on a general public health/behavioural
change model conceptualised by Marks et al., (2001).
Aim
The aim of this thesis was to compare food knowledge, beliefs, attitudes and behaviour related to
feeding preschool-aged children in rural and urban Nepalese mothers.
Objectives
The objectives were to:
i. assess the knowledge, attitudes, and beliefs about nutritious food amongst mothers.
ii. identify major barriers that are associated with existing cultures, religions and ethnic
divisions; including public opinions for recommending healthy food for preschool-aged
children.
iii. assess health-seeking behaviour for rural and urban children of low socio-economic status.
iv. determine factors that affect the availability of food locally.
v. measure the mothers’ knowledge of and attitudes towards health promotion and food
security.
vi. evaluate the health-seeking behaviours for undernourished children and the reasons why.
vii. seek mothers’ suggestions for a better nutritional environment.
viii. evaluate the perceptions about healthy diet amongst the stakeholders, such as policy
people, health professionals (low level to mid-level), pharmacists and spiritual healers.
Methods:
This research used a mixed-methods approach in two different locations in Nepal, including a
quantitative survey and qualitative focus group discussions. The questionnaire comprised open-ended
and structured questions on knowledge, beliefs, and attitudes about nutritious food, child-feeding
patterns, food recommendations, major barriers, food insecurity, and health-seeking behaviours. A
descriptive data analysis approach was used to analyse the quantitative data by using SPSS version
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21.0. The qualitative focus groups aimed to collect in-depth information around attitudes and beliefs
and data were thematically analysed.
Results:
A total of 524 mothers completed the questionnaire. All had children aged 36 – 60 months and were
no longer breastfeeding at the time, from rural (n=228) and urban (n=296) localities. In addition, 50
key informants participated in seven focus groups. The findings revealed that 66% of children were
being fed by mothers and only 5% by fathers. The major barriers to recommending nutritious foods
perceived by mothers included: lack of knowledge (19%); high prices (45%); and cultural influences
or beliefs (13%). Almost 12% of mothers never fed colostrum to their children and 34% were unable
to identify nutritious food when shopping at grocery stores, whilst 19% lacked food at home. Nearly
57% of children had been taken at least once to a spiritual healer for treatment and 16% more than
once. The focus group analysis suggested that important factors associated with knowledge, attitudes,
and beliefs about a healthy diet are: poverty, education level, strong cultural beliefs, family size,
household income, time, and a growing preference for fast food.
Conclusions:
Levels of knowledge on what types of food are nutritious were low in both urban and rural mothers
and their attitudes and views appear to be poorly-informed. Mothers from both rural and urban
communities had great faith in spiritual healers. This study suggests that a public health approach is
needed to address nutrition problems associated with behaviour and revealed major barriers to
maternal knowledge, which were associated with poverty, resources, mothers’ education level, and
climate change. Diversified and conflicting views were also found to be a major barrier preventing
mothers from making better decisions. Thus, special attention should be paid at the practitioner and
policy-maker level on appropriate interventions and approaches, based on changing these cultural
beliefs and behaviours, to help reduce undernutrition in poor communities.
Keywords:
Malnutrition; knowledge, attitudes, beliefs, food; nutrition, poverty; health, South Asia.

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CONTENTS
COPYRIGHT STATEMENT ........................................................................................................... ii
DEDICATION ............................................................................................................................ iii
ABSTRACT ............................................................................................................................... iv
CONTENTS ............................................................................................................................... vi
LIST OF TABLES ....................................................................................................................... xv
LIST OF TEXTBOXES ................................................................................................................ xvi
ACKNOWLEDGEMENTS ......................................................................................................... xvii
DECLARATIONS OF AUTHORSHIP............................................................................................ xix
LIST OF ABBREVIATIONS ......................................................................................................... xx
DEFINITIONS/TERMINOLOGY ................................................................................................xxiv
CHAPTER ONE: INTRODUCTION ................................................................................................. 1
1.1 Introduction .............................................................................................................................................................. 1
1.2 Malnutrition.............................................................................................................................................................. 1
1.3 Importance of nutrition .......................................................................................................................................... 3
1.4 Global scenario of malnutrition ............................................................................................................................ 4
1.4.1 Children stunting ............................................................................................................................................. 5
1.4.2 Wasting and severe wasting ......................................................................................................................... 5
1.4.3 Underweight .................................................................................................................................................... 5
1.5 Global hunger scenario ........................................................................................................................................... 6
1.6 Malnutrition and its consequences ...................................................................................................................... 7
1.7 Magnitude of malnutrition..................................................................................................................................... 8
1.7.1 Malnutrition in the Nepalese context............................................................................................................... 9
1.7.2 Nepal: demographic outline........................................................................................................................ 10
1.7.3 The socioeconomic situation in Nepal....................................................................................................... 11
1.7.4 The prevalence of poverty in Nepal........................................................................................................... 12
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1.8 The socio-cultural scenario in Nepal .................................................................................................................. 15
1.8.1 The religion scenario in Nepal..................................................................................................................... 16
1.8.2 Food practices and taboo’s related issues in Nepal................................................................................ 17
1.8.3 Caste systems in Nepal................................................................................................................................. 18
1.8.4 Status of women in Nepal ........................................................................................................................... 19
1.9 Nepal: major determinants of malnutrition...................................................................................................... 20
1.9.1 Healthcare services ....................................................................................................................................... 20
1.9.2 Knowledge, attitudes and beliefs about nutritious food in Nepal ....................................................... 22
1.9.3 Infant and child feeding practices in Nepal .............................................................................................. 24
1.9.4 Agriculture and food security in Nepal...................................................................................................... 25
1.9.5 Climate change and effects in Nepal ......................................................................................................... 26
1.9.6 Internal conflict and political instability in Nepal.................................................................................... 27
1.10 Researcher’s interest .......................................................................................................................................... 27
1.11 Brief outline of the researcher’s background................................................................................................. 28
1.12 Overview of the thesis structure ...................................................................................................................... 30
1.13 Chapter summary ................................................................................................................................................ 32
CHAPTER TWO: LITERATURE REVIEW....................................................................................... 33
2.1 Introduction ............................................................................................................................................................ 33
2.2 Strategy of literature search ................................................................................................................................ 33
2.3 Overview of undernutrition ................................................................................................................................. 36
2.4 The life cycle of poor nutrition ............................................................................................................................ 36
2.5 Consequences of undernutrition ........................................................................................................................ 37
2.6 Current global situation of undernutrition........................................................................................................ 38
2.6.1 Stunting ........................................................................................................................................................... 39
2.6.2 Underweight .................................................................................................................................................. 40
2.6.3 Wasting ........................................................................................................................................................... 40
2.7 The global development plans and undernutrition ......................................................................................... 40
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2.7.1 Millennium Development Goals (MDGs) .................................................................................................. 41
2.7.2 Global targets 2025....................................................................................................................................... 43
2.7.3 SUN movement.............................................................................................................................................. 43
2.8 Undernutrition as an issue in the regional context ......................................................................................... 44
2.9 Undernutrition in the context of Nepal ............................................................................................................. 45
2.9.1 Major determinants of undernutrition in Nepal ..................................................................................... 49
2.9.2 Nepal: hunger scenario ................................................................................................................................ 50
2.9.3 Socio-cultural situation in Nepal ................................................................................................................ 53
2.9.4 Socio-cultural influences in child nutrition ............................................................................................... 55
2.9.5 Health situation/facilities of Nepal ............................................................................................................ 56
2.9.6 Health status of mothers ............................................................................................................................. 59
2.9.7 Poverty ............................................................................................................................................................ 61
2.9.8 Diseases and infections ................................................................................................................................ 63
2.9.9 Knowledge, attitudes, and beliefs about healthy food ......................................................................... 65
2.9.10 Energy intake ............................................................................................................................................... 67
2.9.11 Socio-economic factors.............................................................................................................................. 70
2.9.12 Beliefs about undernutrition in Nepal .................................................................................................... 71
2.9.13 Beliefs about healthy food in Nepal ........................................................................................................ 72
2.9.14 Breastfeeding............................................................................................................................................... 74
2.9.15 Natural calamities including change of climate..................................................................................... 76
2.9.16 Geographical location: Rural and Urban................................................................................................. 78
2.9.17 Theoretical models ..................................................................................................................................... 79
2.10 Barriers to recommending healthy food ......................................................................................................... 82
2.11 Chapter summary ................................................................................................................................................ 83
2.12 Rationales for study ............................................................................................................................................ 84
2.13 Aim of the study................................................................................................................................................... 86
2.13.1 Objectives..................................................................................................................................................... 86
2.13.2 Research questions..................................................................................................................................... 87
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CHAPTER THREE: METHODOLOGY AND METHODS ................................................................... 88
3.1 Introduction ............................................................................................................................................................ 88
3.2 Methodology .......................................................................................................................................................... 88
3.3 Mixed-methods ...................................................................................................................................................... 90
3.3.1 Strengths of mixed-methods research ...................................................................................................... 93
3.3.2 Limitations of mixed-methods research ................................................................................................... 93
3.4 Locality ..................................................................................................................................................................... 94
3.4.1 Definitions of urban and rural..................................................................................................................... 94
3.4.2 Study location ................................................................................................................................................ 95
3.5 Research design ..................................................................................................................................................... 95
3.6 Methods .................................................................................................................................................................. 98
3.6.1 Quantitative ................................................................................................................................................... 98
3.6.1.1 Survey questionnaire ........................................................................................................................... 98
3.6.1.2 Sampling................................................................................................................................................. 99
3.6.1.3 Sampling frame ...................................................................................................................................100
3.6.1.4 Sampling process ................................................................................................................................101
3.6.1.5 Study period ........................................................................................................................................101
3.6.1.6 Research instrument (tools) .............................................................................................................102
3.6.1.7 Selection, recruitment, and training ...............................................................................................102
3.6.1.8 Data collection ....................................................................................................................................103
3.6.1.10 Descriptions of data collection forms..........................................................................................104
3.6.1.11 Data collection process ...................................................................................................................106
3.6.1.11.1 Logistical considerations ........................................................................................................106
3.6.1.11.2 Field schedule and management..........................................................................................107
3.6.1.11.4 Data collection schedule ........................................................................................................107
3.6.1.12 Pre-testing and piloting...................................................................................................................108
3.6.1.12.1 Pre-testing/piloting of survey questionnaire & FGD schedule........................................109
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3.6.1.12.2 Recruitment for pilot study for survey questionnaire and FGD ......................................110
3.6.1.12.3 Findings of the pilot study......................................................................................................111
3.6.1.12.4 Outcomes of FGD pilot ...........................................................................................................111
3.6.1.12.6 Conclusion of pilot study........................................................................................................112
3.6.1.13 Quantitative data analysis ..............................................................................................................113
3.6.1.13.1 Data analysis processes ..........................................................................................................113
3.6.1.13.2 Validity and reliability .............................................................................................................114
3.6.1.13.3 Potential bias............................................................................................................................115
3.6.2 Qualitative approach ..................................................................................................................................115
3.6.2.1 Introduction.........................................................................................................................................115
3.6.2.2 Focus group sampling method and sample size ...........................................................................116
3.6.2.3 Data collection process (qualitative)...............................................................................................117
3.6.2.4 Qualitative data record .....................................................................................................................118
3.6.2.5 Data handling ......................................................................................................................................119
3.6.2.6 Data analysis........................................................................................................................................120
3.6.2.7 Generalizability and transferability .................................................................................................123
3.6.2.8 Conformability ....................................................................................................................................123
3.6.2.9 Credibility .............................................................................................................................................124
3.6.2.10 Dependability....................................................................................................................................124
3.7 Ethical considerations .........................................................................................................................................125
3.8 Chapter summary ................................................................................................................................................126
CHAPTER FOUR: QUANTITATIVE RESULTS ...............................................................................127
4.1. Introduction .........................................................................................................................................................127
4.2. Overall outcomes of quantitative method.....................................................................................................127
4.2.1. Socio-demographic information of respondents (mothers) ..............................................................128
4.2.2 Socio-economic status of respondents ...................................................................................................130
4.2.3. Responsibility for taking care and feeding of the child .......................................................................132
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