Show simple item record

dc.contributor.authorFadnes, Lars Thoreeng
dc.date.accessioned2011-06-06T09:35:39Z
dc.date.available2011-06-06T09:35:39Z
dc.date.issued2011-06-03eng
dc.identifier.isbn978-82-308-1768-1 (print version)eng
dc.identifier.urihttp://hdl.handle.net/1956/4785
dc.description.abstractBackground: Despite gradual improvements in child survival, around 8 million children die globally every year before the age of 5 years. Infant feeding practices including breastfeeding vary considerably between settings, and health counselling both in the public health services and community based interventions has been suggested to be important to improve the feeding practices. Breastfeeding promotion in particular, is regarded as one of the most effective interventions to improve child health, and has been proposed to reduce under-5-mortality by 8%. Few studies have assessed the health outcomes after infancy of promotion of exclusive breastfeeding. Methods: This thesis utilises both quantitative and qualitative data, and also combine them in a mixed methods approach. The quantitative data includes two cross-sectional surveys and a follow-up assessment of a trial. The cross-sectional surveys collected information on infant feeding practices among children below 1 and 2 years of age. One of the surveys focused primarily on HIV-positive mothers while the other was a community-based survey conducted in the general population. A 2-years follow-up of the community-based cluster-randomised PROMISE-EBF intervention trial, promoting exclusive breastfeeding for 6 months with peer counsellors, was used to assess growth outcomes (ClinicalTrials.gov no. NCT00397150). Anthropometric analyses are presented from five interview visits that were conducted in the age range from birth up to 2 years of age. To get a deeper understanding of the feeding practices and perceived challenges both in the general population and among people living with HIV, 15 focus group discussions were conducted. To assess health counselling within the health facilities, 18 key informant interviews were conducted with health workers from both the public health facilities and non-governmental organisations working with HIV. All the studies were conducted in Mbale District in Eastern Uganda between 2003 and 2008 and involved around 1850 participants. Results: From the surveys, it was shown that HIV-positive mothers breastfed their children for a shorter duration than the general population. Among the HIV-positive mothers, the breastfeeding duration was particularly short among those with higher education, with a median of 3 months (95% confidence interval [CI] 0–10.2), compared to a median of 18 months among mothers with no education (95% CI 15.0–21.0). Similarly, the poorest HIV-positive mothers also breastfed for a longer duration than the less poor. The main reasons to stop breastfeeding among HIV-positive mothers were advice from health workers, general illness and the HIV-diagnosis. The qualitative studies made it clear that infant feeding counselling in health facilities was often improvised, and many health workers had not been re-trained on infant feeding since their professional training. Poverty among the mothers was seen as one of the main challenges for many of the health workers, and many mothers struggled with the feasibility of infant feeding recommendations. Several health workers tended to give one-sided and simplistic messages, which seemed to cause confusion in a number of cases. Other challenges that were reported were inadequate facilities and lack of sufficient health workers. Concerns related to disclosure of HIV-status among health clients also served as a barrier to good infant feeding practices. In the intervention trial promoting exclusive breastfeeding for six months, the children of mothers having received peer counselling tended to have lower weight-for-length, length-for-age and weight-for-age z-scores compared to the control arm. This was seen in nearly all the time points. The situation was most severe for length-for-age (LAZ), which had a considerable left-shifted distribution. Stunting (LAZ<-2) was more common in the intervention arm than in the control arm. At the 2 year visit, 139 (45%) of the children were stunted in the intervention arm compared to 109 (37%) in the control arm, with an odds ratio of 1.7 (95% CI 1.1–2.4). Conclusion: Both mothers and health workers experienced numerous challenges related to infant feeding. This was often related to poverty and insufficient health resources. There were also several challenges related to infant feeding among HIV-positive mothers. The breastfeeding duration was shorter among HIV-positive mothers than in the general population, particularly among the most educated and least poor. In the intervention trial promoting exclusive breastfeeding for 6 months with peercounsellors, there were no growth advantages in the intervention during the first 2 years of follow-up. For several aspects, the children in the intervention arm performed worse than children in the control arm. It is time to reconsider how infant feeding support and health counselling best can be delivered.en_US
dc.description.abstractTil tross for en gradvis reduksjon i dødsfall blant barn, dør hver år 8 millioner barn før de fyller 5 år. Ernæring og amming regnes som en av de viktigste faktorene for god barnehelse. Samtidig er det stor variasjon i hvordan amming og ernæring av barn foregår i ulike deler av verden. Helseundervisning er viktig for barnehelse, men det er i liten grad kjent hvordan dette har fungert i Uganda. Det har også blitt foreslått at tiltak som fremmer fullamming fram til 6 måneders alder kan bedre ammemønstre og redusere barnedødelighet med 8 prosent. Det har ikke blitt bekreftet at dette stemmer, og at barn vokser tilstrekkelig godt når fullamming fremmes fram til 6 måneder. Denne avhandlingen vil evaluere ernæringspraksis blant småbarn i Uganda, helseundervisning i helsevesenet, og effekten på barnevekst av en studie som har fremmet fullamming. Denne avhandlingen benytter både kvalitative og kvantitative forskningsmetoder. Dette inkluderer to tverrsnittsstudier som har sett nærmere på amme- og ernæringspraksis hos små barn i både den generelle befolkning og blant barna til mødre med HIV. Det har også det blitt gjennomført fokusgruppeintervjuer blant tilsvarende grupper, samt nøkkelinformantintervjuer blant helsepersonell. I tillegg er det gjort en toårsoppfølging av barn som har deltatt i en studie hvor fullamming har blitt fremmet fram til 6 måneders alder. Barnas høyde og lengdevekst har blitt brukt til å evaluere effekten av forsøket. Alle studiene ble gjennomført i Mbale i den østlige delen av Uganda mellom 2003 og 2008, og involverte rundt 1850 studiedeltakere. De kvalitative studiene viste at helseundervisning i helsevesenet ofte var improvisert og at helsearbeiderne hadde tallrike utfordringer. Dette inkluderte mangel på helsearbeidere, tilstrekkelig utstyr og lokaler, samt sjeldne oppfriskningskurs, og store utfordringer med å støtte og gi råd til en befolkning med høy grad av fattigdom. Den utstrakte fattigdommen gjorde det i mange tilfeller vanskelig å få et godt og variert kosthold. Noe som gjorde dette spesielt vanskelig var at retningslinjene som var aktuelle da studiene ble gjennomført i for liten grad tok hensyn til den stedsspesifikke sitasjonen, de økonomiske faktorene og kulturen. En del helsearbeidere hadde også vanskeligheter med å balansere det å forenkle viktige budskap og samtidig gi et budskap som var tilstrekkelig nyansert til ikke å skape forvirring. Resultatene viste også at mødre med HIV ammet kortere enn befolkningen for øvrig – særlig blant de minst fattige med høyest utdanning. Hovedårsakene til at mødre med HIV sluttet å amme var råd fra helsearbeidere, sykdom og HIV-diagnosen. En bekymring blant flere mødre med HIV var det at enkelte av de tidligere anbefalingene, og da særlig det å gi morsmelkserstatning fra tidlig alder, var forbundet med å bli ansett som HIV-positiv i lokalsamfunnet. Dette kunne by på store utfordringer for enkelte. Det viste seg også at forsøket med å benytte mor-til-mor rådgivere for å fremme fullamming fram til 6 måneders alder ikke hadde positiv effekt på barnas vekst – verken i løpet av de første 6 månedene eller ved 2 års alder. Nærmere halvparten av barna til mødrene som fikk mor-til-mor rådgivning hadde svært lav høyde for alderen. Blant barna til mødrene som ikke fikk helserådgivning var over en tredel av barna svært lav høyde for alderen. Avhandlingen viser at det er helt sentralt at retningslinjer tar den stedsspesifikke situasjonen og kulturen i betraktning. Samtidig er det på tide å revurdere hvordan man kan fremme ernæring blant barn på en best mulig måte.en_US
dc.language.isoengeng
dc.publisherThe University of Bergeneng
dc.relation.haspartPaper I: BMC Pediatrics 9(2), Fadnes, L. T.; Engebretsen, I. M. S; Wamani, H.; Wangisi, J.; Tumwine, J. K.; Tylleskär, T., Need to optimise infant feeding counselling: A cross-sectional survey among HIV-positive mothers in Eastern Uganda. Copyright 2009 Fadnes et al; licensee BioMed Central. Reproduced with permission. Published version. The published version is also available at: <a href="http://dx.doi.org/10.1186/1471-2431-9-2" target="_blank">http://dx.doi.org/10.1186/1471-2431-9-2</a>eng
dc.relation.haspartPaper II: BMC Public Health 9(124), Fadnes, L. T.; Engebretsen, I. M. S; Wamani, H.; Semiyaga, N. B.; Tylleskär, T.; Tumwine, J. K., Infant feeding among HIV-positive mothers and the general population mothers: comparison of two cross-sectional surveys in Eastern Uganda. Copyright 2009 Fadnes et al; licensee BioMed Central. Reproduced with permission. Published version. The published version is also available at: <a href="http://dx.doi.org/10.1186/1471-2458-9-124" target="_blank">http://dx.doi.org/10.1186/1471-2458-9-124</a>eng
dc.relation.haspartPaper III: BMC Health Services Research 10(260), Fadnes, L. T.; Engebretsen, I. M. S; Moland, K. M.; Nankunda, J.; Tumwine, J. K.; Tylleskär, T., Infant feeding counselling in Uganda in a changing environment with focus on the general population and HIV-positive mothers - a mixed method approach. Copyright 2010 Fadnes et al; licensee BioMed Central. Reproduced with permission. Published version. The published version is also available at: <a href="http://dx.doi.org/10.1186/1472-6963-10-260" target="_blank"> http://dx.doi.org/10.1186/1472-6963-10-260</a>eng
dc.relation.haspartPaper IV: Fadnes, L. T.; Nankabirwa, V.; Engebretsen, I. M. S.; Sommerfelt, H.; Lombard, C.; Swanevelder, S.; Van den Broeck, J.; Tylleskär, T.; Tumwine, J. K. for the PROMISE-EBF Study Group, Growth outcomes at 2 years from a cluster-randomised controlled trial promoting exclusive breastfeeding for six months in Uganda. Full text will be available in BORA when published.eng
dc.titleCounselling, child growth and feeding of children in Uganda in the era of HIV. Contexts and consequenceseng
dc.typeDoctoral thesiseng
dc.subject.nsiVDP::Medical disciplines: 700::Health sciences: 800::Nutrition: 811eng
dc.subject.nsiVDP::Medical disciplines: 700::Health sciences: 800::Community medicine, Social medicine: 801eng
dc.rights.holderCopyright the author. All rights reserved
dc.rights.holderThe authoreng
dcterms.hasParthttp://dx.doi.org/10.1186/1471-2431-9-2
dcterms.hasParthttp://dx.doi.org/10.1186/1471-2458-9-124
dcterms.hasParthttp://dx.doi.org/10.1186/1472-6963-10-260


Files in this item

Thumbnail

This item appears in the following Collection(s)

Show simple item record