Exploring the Determinants of Infant Feeding Practice among Mothers Living with HIV in Addis Ababa, Ethiopia Pubblico
Mikulich, Meridith (Spring 2025)
Abstract
Background: Mother-to-child transmission (MTCT) of HIV remains a critical public health issue in Ethiopia, particularly in urban areas like Addis Ababa. The World Health Organization (WHO) and Ethiopian national guidelines recommend exclusive breastfeeding (EBF) for the first six months of life, combined with maternal antiretroviral therapy (ART), to minimize the risk of HIV transmission while promoting infant health. However, adherence to these guidelines is influenced by complex sociocultural and behavioral factors, and many women struggle to EBF for 6 months. This mixed methods study, guided by the Theory of Planned Behavior (TPB), aimed to assess the factors influencing EBF intentions and practices among HIV-positive mothers in Addis Ababa between birth and four months postpartum.
Methods: First, qualitative elicitation interviews with HIV-positive mothers were conducted to identify salient behavioral, normative, and control beliefs regarding EBF. The results then informed the development of a quantitative, theory-driven instrument, which was then validated through pre-testing, and demonstrated adequate reliability and construct validity, effectively measuring key TPB constructs of attitude (ATT), subjective norms (SN), and perceived behavioral control (PBC). Next, a prospective cohort study was conducted with 161 HIV-positive pregnant women, enrolled from 29 health facilities in Addis Ababa. The questionnaire was administered between 36 weeks gestational age and time of birth, and follow-up data was collected at four months postpartum.
Results: At baseline, 96.9% of participants intended to EBF, while 2.5% intended to mixed feed, and 0.6% were undecided. However, follow-up data revealed that only 71.4% adhered to EBF at four months. Bivariate and multivariate analysis identified religion, early antenatal care initiation, and the number of antenatal care visits as factors significantly associated with EBF. Longitudinal analyses revealed that several indirect TPB measures evolved over the postpartum period and were associated with infant feeding practice, notably beliefs about EBF convenience, spousal support for EBF, breastmilk adequacy, and dependency on other caregivers.
Conclusions: These findings highlight the need for targeted and individualized interventions that address barriers to EBF. The validated TPB-based instrument offers a valuable tool for future research and intervention design aimed at improving infant feeding practices among HIV-positive mothers in Ethiopia and similar settings.
Table of Contents
Chapter 1: Introduction ............................................................................................................... 1
Background & Statement of the Problem ................................................................................... 1
Mother-to-child Transmission of HIV .................................................................................... 1
HIV and Infant Feeding in the Global Context....................................................................... 2
MTCT of HIV and Infant Feeding in Ethiopia ....................................................................... 5
Theoretical Framework ............................................................................................................... 7
Chapter 2: Infant feeding intention and practices among women living with HIV in Sub- Saharan Africa: A Systematic Review ....................................................................................... 13
Background ............................................................................................................................... 13 Purpose...................................................................................................................................... 14
Research Questions ................................................................................................................... 15 Methods..................................................................................................................................... 15
Inclusion and Exclusion Criteria........................................................................................... 16
Search Strategy ..................................................................................................................... 17
Screening and Data Extraction.............................................................................................. 17
Results....................................................................................................................................... 17
Study Selection ..................................................................................................................... 17
Geographic Representation ................................................................................................... 18
Research Question 1: What proportion of mothers living with HIV in sub-Saharan Africa make the decision to exclusively breastfeed for 6 months, as opposed to replacement feeding (e.g. formula feeding) or mixed feeding? ................................................................ 18
Research Question 2: What proportion of mothers living with HIV in sub-Saharan Africa who choose to exclusively breastfeed for 6 months are successful in accomplishing this behavior?............................................................................................................................... 19
Research Question 3: Among those who do not continue breastfeeding until 6 months, at what time point do they discontinue this behavior?.............................................................. 22
Research Question 4: What personal and/or environmental factors significantly predict or are associated with exclusive breastfeeding decision-making and/or practice? ................... 22
Research Question 5: What gaps and/or challenges towards understanding infant feeding practices among mothers living with HIV currently exist in the literature? ......................... 27
Conclusion ................................................................................................................................ 31
Chapter 3: Development and Validation of a Theory-Based Tool for Examining Infant Feeding Practices Among Mothers living with HIV in Addis Ababa, Ethiopia .................... 47
Background ............................................................................................................................... 47
Infant Feeding Practices and HIV ......................................................................................... 47
Infant Feeding Practices among Mothers living with HIV in Sub-Saharan Africa .............. 48
Theoretical Framework Application ..................................................................................... 49
Ethical Approval ....................................................................................................................... 51
Study Setting and Target Population......................................................................................... 51
Phase I: Qualitative Research ................................................................................................... 52 Methods................................................................................................................................. 52 Results................................................................................................................................... 55
Phase II: Pre-testing of Quantitative Tool................................................................................. 56 Methods................................................................................................................................. 56 Results................................................................................................................................... 57
Discussion ................................................................................................................................. 62
Chapter 4: Applying the Theory of Planned Behavior to Infant Feeding Practices among Mothers Living with HIV in Addis Ababa, Ethiopia ............................................................... 77
Background ............................................................................................................................... 77 Methods..................................................................................................................................... 79
Design and Sample Size........................................................................................................ 79
Participants and Recruitment ................................................................................................ 80
Instruments & Measures ....................................................................................................... 81
Data Analysis ........................................................................................................................ 81 Results....................................................................................................................................... 82
Baseline Characteristics ........................................................................................................ 82
Follow-Up Characteristics and Infant Feeding Behaviors.................................................... 84
Associations of Baseline Characteristics and Infant Feeding Practice at 4 months PP ........ 85
Analysis of Changes from Baseline to Follow Up................................................................ 87
Discussion ................................................................................................................................. 90
Chapter 5: Integrative Summary ............................................................................................ 102
Summary & Key Findings ...................................................................................................... 102
Strengths & Limitations .......................................................................................................... 104
Clinical and Public Health Programming Implications .......................................................... 105
Future Research ...................................................................................................................... 107
Conclusion .............................................................................................................................. 108
References .................................................................................................................................. 109
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