A qualitative exploration of behavioral factors affecting mothers of malnourished children under 5 years old in Kiribati

Study design and setting

A qualitative study design was conducted for almost 8 weeks from 21^st of December 2015 to 12^th of February 2016, to determine the level of mother’s KAP on breastfeeding, weaning, dietary and immunization on South Tarawa (capital island of Kiribati). Tarawa is the capital island of Kiribati and is divided into two parts, North and South Tarawa, with South Tarawa being the only part of Kiribati considered ‘urban’. The focus group discussion (FGD) method was used which allowed participants to discuss problems in a group setting and allowed more detailed responses.

The FGD was held at nine different public health clinics on South Tarawa during working hours, as ‘saturation’ was reached after nine FGDs, meaning there was no new information or emerging themes¹⁹.

Study population: inclusion and exclusion criteria

The inclusion criteria were all women with children under 5 years old who were identified as being malnourished and were admitted to the Pediatric wards of selected public health clinics within the period of 1^st January to 31^st May 2015. The study participants had to be Kiribati citizens (self-identified) and their children’s names must be registered under the public health clinics. The exclusion criteria were mothers who didn’t meet the study inclusion criteria and were not willing to participate in the FGD, mothers or children who were not residents on South Tarawa and mothers with children aged more than 5 years old. Critical stage children that were admitted to the Pediatric ward were also not included.

Sampling, sample size and data collection tools

A non-probability purposive sampling method was used to recruit participants for nine FGDs. Each group contained 3 to 4 participants, with a total sample size of 35 participating mothers.

A semi-structured open ended questionnaire was used in this study whereby there were two open-ended questions allocated for each of the factors (breastfeeding, complementary feeding, dietary practice and immunization). Prior to collecting the data, the questionnaire was validated using two group discussions, during child health care visits. The participants who met the inclusion criteria were selected and given the questionnaire to answer to ensure the questions were understandable and readable for face validity. Content validity was also used whereby three academic experts (assistant professors and lecturers at the Public Health at Fiji National University) assessed the construction in question and checked whether the responses by the person answering the questions were affected by other factors. Once done, their comments were revised accordingly and a new version of the questionnaire was then distributed among the participants.

Data collection process

Mothers that were interested to participate in the study then signed a consent form to proceed with the discussion. The places and time of the discussions were chosen by the researcher that was convenient to the participants. All participants sat together in a private room in each public health clinic, in a circle, so the main researcher could have equal access with the voice recording. The researcher, who had previous experiences in conducting FGDs, and was bilingual, was present and available to translate the questions from English to Kiribati language for participants to have a clear understanding of the questions raised during discussion. The discussions were in the local language (Kiribati) and both audio recording and note taking were used.

The discussion began informally with the greetings and personal instructions from the researcher. When all participants were settled and ready to start, the researcher led the discussion by starting with a question for each topic on breastfeeding, complementary feeding, dietary practice and immunization. The participants in each group mingled well with each other so they communicated freely with one another. Each FGD had an average duration of 60 minutes. All conversations during the FGDs were conducted in Kiribati language so that participants were able to talk freely without any restrictions in expressing their opinions.

Semi-structured questionnaire

Questions were as follows:

Breastfeeding:

1.   What are your perceptions on breastfeeding?

2.   What problems you faced while breastfeeding and how did you overcome it?

Weaning:

1.   How do you know it is right to start weaning and how do you approach it?

2.   What foods do you give your baby when weaning, home-made foods or store-bought foods and why?

Diet:

1.   What are the obstacles you (mothers) you face in making recommended diet for your children?

2.   As your baby gets older what do you think will be the key things that you will be concerned about diet wise?

Immunization:

1.   What are your perceptions on immunization? Why are children immunized?

2.   What are obstacles to immunizing your children and why?

Data management and analysis

The researcher transcribed all digital recordings of the focus groups in Kiribati language, then translated these transcripts into English language. Transcripts and field notes were compared to ensure that no information was misinterpreted or omitted.

Data were then analyzed manually, by the author, to discover inter-rater coding dependability. After the first review of the data, a categorizing method was developed by using thematic analysis based on the study objectives. Then the researcher identified themes and sub-themes developed from the data analysis and lastly produced a final thematic index to code the data. The researcher listened to the recordings and read the written notes numerous times to understand the participants’ views and ideas they expressed through their own words. Data were then interpreted and conclusions were drawn based on coding summaries and contextual field notes provided by direct quotes from participants. Codes were then grouped into themes which can be defined as repeated features or patterns.

Ethical considerations

The ethical approval for this study was received from the Kiribati Ministry of Health after the research proposal was approved by Fiji National University’s College Health Research Ethics Committee (CHREC).

Socio-demographic characteristic of the participants

The majority of the women in the study were aged 19–32 years, followed by 26–32 years. Most of the participants had attended high school (67.1%) and the majority of them were living in a family with 5–9 people (46.3%). More than two thirds of participants (85%) were married and 31.7% of mothers had only 1 child.

Seven main themes were identified: knowledge, behaviors, perceived severity, perceived benefit to action, perceived barriers, cues to action and cultural related issues.

1. Knowledge

Knowledge and understanding from experiences is another way to carry out things in our daily lives. When mothers were asked about when was the right time to start complementary feeding, only two groups mentioned that complementary feeding should be started when the child is refusing to breastfeed.

Four different groups were not sure about the right age to start complementary feeding. One mother from one group said that 1 year old is the right age to start complementary feeding, whereas others said it was 2 years old, 3 years old and 4 years old.

Mothers provided different ranges of knowledge when asked about their perception on breastfeeding. Most of the groups (6 groups) stated that breastfeeding will prevent disease to their child and make the child healthier (5 groups). One participant said that during antenatal and postnatal clinic, she always got advised by the nurses about the importance of breastfeeding;

When mothers were asked about their perception on immunization, a few of the groups (4 groups) stated that immunization was free of charge. One participant mentioned that immunization is important to her child and it is a service that is provided so you do not have to spend money on it:

Mothers had different knowledge when asked about the key things on diet when their child becomes older. Most of the groups (7 groups) reported that more solid food and a balanced diet should be introduced when their child is older. They are more knowledgeable on the types of food to give their children because they were given a pamphlet during the child health clinic to guide them with feeding their child and from their past experiences from previous children. One mother pointed out that nurses play a major role in assisting mothers to know how to provide the proper food to their children:

2. Behaviors

Many of the FDGs reported that forgetfulness was continuously the reason for not immunizing their children on schedule. This was because they were not concerned about the effect of not being immunized would have on the children. They thought it was alright to miss their child’s vaccines and when they remember next time they will go and attend immunization clinic.

Mothers had different behaviors when asked about breastfeeding. Most groups (5 groups) stated when they were faced with breast milk insufficiency the only option is to give formula milk straight away. One participant claims that because she does not want her child to get hungry and cry she had no choice but to give formula milk.

In regards to immunization, most of the mothers (7 groups) had poor behaviors in getting their child immunized with forgetfulness as one of their obstacles in fulfilling a good immunization record. One participant admitted that forgetfulness is a common excuse they will provide for not attending to their child immunization.

3. Perceived severity of health issue (malnutrition)

When mothers responded to a question on what obstacles they faced in immunizing their children, most of the focus groups (5 groups) stated that mothers worried that their child will get a fever after receiving an immunization. One mother explained that they do not want to take their child for immunization because they feel sorry for their child and they do not want to stay up and cool sponge the child when he/she gets a fever:

4. Perceived benefits of action

Out of the nine FGDs, most groups (6 groups) believed that breastfeeding prevented disease in the child. Most mothers continue to breastfeed their children because they are advised during antenatal and postnatal clinics that breastfeeding is important for their children because it will protect them from infectious diseases. They had the knowledge that breastfeeding is critical, especially during their child’s young age. In one group, the mother shared her experience and compared her situation with one of her siblings that did not breastfeed her children.

When they were asked about their perception on immunization and why their child is immunized, all nine FGDs mentioned that immunization is preventing disease to young children. However, mothers had problems getting the child to their appointment for immunization because they were too lazy to walk to the health clinic. They are expecting the nurse to visit them at home to give immunization injections. One of the mothers in a group explained that they continue to immunize their child because they know the importance and benefits of it to their children.

In responding to the question about their perception on breastfeeding, four focus groups said that breastfeeding is convenient and enhances the child’s learning ability. They explained that breast milk, food for their baby, is always available at any time, and they do not have to do much work to prepare it for their child. Mothers also mentioned that breastfeeding enhances the child’s learning ability, as it is good for the child’s brain. They understand that a breastfed child is more intelligent in school compared to someone that was not breastfed. One participant stated that when she goes somewhere with her baby she does not have to worry about taking a lot of things as breast milk is always available and convenient:

5. Perceived barriers to action

Among the nine FGDs it was found that there were barriers to action, such as one’s belief in the physical and psychological costs of the advised behavior. When mothers were asked about problems they faced while breastfeeding many groups reported that they were having problems with breast milk insufficiency. One participant said that she is not getting enough breast milk when she breastfed her child and she got advice from the nurse to start giving formula milk while continuing with breastfeeding.

Two focus groups reported that breast abscess, the child refusing, and no breast milk were problems they faced while breastfeeding. One participant mentioned that she had a breast abscess in one breast and she knew that she was not giving as much breast milk to her child as when she was giving both breasts to feed her child.

Most of the mothers (6 groups) mentioned that breast milk insufficiency is another barrier they are facing with breastfeeding. One participant from two different groups stated that they did not have breast milk at all after delivery and they felt bad for their child because she was always crying.

Mothers are facing obstacles to immunizing their children. A few of the groups indicated that these obstacles included a family problem, loss of their child immunization card and moving to a new place. They stated that when they are fighting or arguing with their husband it affects everything and they are not prioritizing what is best for their child. Another view is that when they lose their immunization card, they are scared to attend immunization clinic as the nurse will scold them for losing an important card so they stay home. When mothers move to a new place and they are not sure where to take their child for immunizations, they miss taking them for immunization.

The public health nurses’ poor attitude contributed a lot to the barriers for mothers to attend immunization clinics. Two different responses from mothers said that once they miss their child immunization they will not go again. This happens because nurses are not welcoming or encouraging mothers to attend a regular immunization clinic. One participant said that nurses should be politer when talking to mothers because they are causing mothers to be reluctant about getting their child’s immunizations.

6. Cues to action

One participant had stated she missed taking her child for immunization because of advice from other people, especially old people. She was told that there is no point of getting immunizations because the other generations did not receive any immunization and they are still healthy and surviving till now.

In responding to a question about “what are the obstacles they are facing in making a recommended diet for their children?” most groups (5 groups) stated that they cannot give proper food to their children because of peer group advice. Most mothers said that rumors from other mothers in the community affected the way we feed our children. One participant said they were advised to control the food you give to your child while they are young because when they grow up it is hard to control them.

7. Culture-related issues

According to the mothers’ FGD, five groups stated that children should be given complementary foods when the mother is pregnant again or if the child is having diarrhea after breastfeeding. It is common that when the mother is pregnant the grandmother makes sure the child is not breastfed again. One of the mothers shared her experience with her child when she got pregnant again.

Another issue with culture is that people are living in extended families and the appropriate food that should be given to young children was affected by it. When asked about “obstacles faced in making a recommended diet for their children”, three focus groups described that they cannot give special food to their young children because there are so many people living in one home. One of the respondents claimed that they feel sorry for their young children because it is not fair for them to be treated the same way as adults.

Underlying data

As the transcripts of the interviews encompass identifiable information and therefore the data are not openly provided. Limited de-identified transcripts of the interviews performed with the mothers (in Kiribati and English) are available on request from the corresponding author (masoud.m@fnu.ac.fj).