Knowledge and associated factors on exclusive breastfeeding among HIV positive mothers who have children age 0-24 months in Central Zone, Tigray, North Ethiopia, 2019


 Background: Although breastfeeding is widely practiced in many African countries, studies have shown that lack of knowledge, pressure, and cultural beliefs play a significant role in the success of exclusive breastfeeding for six months. Therefore, this study was aimed to assess knowledge and determinant factors affecting exclusives breastfeeding among mothers living with HIV/AIDS have children age 0-24 months in central zone Tigray. Methods: A Facility-based Cross-Sectional study was carried out on April 23 to May 10, 2017. A systemic random sampling method was used to select study participants. Information was collected using a structured, pre-tested questionnaire. The data were entered into Epi info 7 and imported to SPSS version 22. Summary statistics and logistic regression analysis were performed using SPSS version 22. Those variables having a P-value of less than 0.2 in the bivariable analysis were fitted in multivariable analysis.AOR with 95% CI and P-value<0.05 were used during multivariable analysis to identify the factors associated with the knowledge of exclusive breastfeeding. Result: In this study, the overall knowledge of exclusive breastfeeding was 88.4%. Monthly income (AOR: 5.57, 95% CI: (1.176-26.38)) and age at first birth (AOR: 0.339, 95% CI, (0.133-0.863) were significantly associated with knowledge of HIV positive mothers towards exclusive breastfeeding. Conclusion: HIV positive mothers attending health care facilities in the central zone, Tigray region knowledge of the mothers was good but still now needs the effort to achieve the goal of exclusives breastfeeding. HIV positive mothers with risk factor income and Age need strict follow up to increase knowledge on exclusives breastfeeding. Keywords: Knowledge, Exclusive breastfeeding, HIV positive Mothers.

carries significant health risk to infant because breastfeeding is vital to the health of children, reducing the impact of many infectious diseases and preventing some chronic disease and support breastfeeding practice as the best infant feeding choice for all women in general (2).
Globally, more than 10 million children under the age of five die each year and about 40% of under two years of deaths are associated with inappropriate breastfeeding practices, 34% of these deaths occur in South Asia and 41% in sub-Saharan Africa (3).In addition to this, breastfeeding brings about 300,000 HIV infection per year while at the same time, United Nation Children Emergency Fund(UNICEF) in the world estimated that not breastfeeding is responsible for 1.5 million children death per year and largest burden of this infection and death occur in sub-Saharan Africa (4). About two-thirds of deaths occurring worldwide during the first year of life children are often regarding appropriate feeding practice, especially due to poor exclusive breastfeeding practices (5). In the developing world including Ethiopia, every day 3000-4000 infants die from diarrhea and respiratory infection associated with inadequate breastfeeding practice in combination with a high level of disease (6).
In general in developing, country lack of exclusive breastfeeding attributes 45% of neonatal infectious death,30% diarrheal death and 18 of acute respiratory death. Exclusive breastfeeding can significantly reduce the burden of under-five death in Africa especially SSA (7,8). In Ethiopia, about 321,000 under-five children die each year by malnutrition from the total of death about 57% of death primarily through the exacerbation of other major causes, such as diarrhea and pneumonia death from which can be significantly prevented by exclusive breastfeeding (9).
Factors associated with knowledge of EBF among HIV positive mothers in west Oromia were, educational level, occupation, mode of delivery had statistically significant with knowledge of HIV positive mothers on EBF (p < 0.05). HIV positive mothers whose educational level were about 11.5 times more likely had knowledge about EBF than the other educational level, mothers whose occupation merchant was less likely had knowledge about EBF than mothers with another type of occupation (15). Therefore, this study was aimed at assessing knowledge and determinant factors affecting exclusives breastfeeding among mothers living with HIV/AIDS have children age 0-24 months in central zone Tigray.

Study setting
A facility-based cross-sectional study was conducted from March to April 2019, at Central zone Tigray There were 72 health centers (20 of them have ART service), 6 primary hospitals, 3general hospitals, and 1 referral hospital.

Participants
All HIV positive mothers having infants less than or equal 24 month years visit in the selected public health facility central zone were taken as the study population. All HIV positive mothers who gave birth within 24 months before the study period are included, while mothers who unable to communicate, who were not mentally competent or who had any psychiatric disorders and critically ill during data collection were excluded.

Sample Size Determination
By taking into consideration 88.1% of knowledge exclusive breastfeeding among HIV positive mothers (12). 95% confidence level, 5% tolerable margin of error, possible non-response rate of 5%, a total sample of 239 was taken. To check for the adequacy of the sample size, Epi info was used by considering factors associated with knowledge exclusive breastfeeding. By comparing sample size based on a single population proportion formula and Epi-info, the sample size determined by the single population proportion was greater than that of the Epi-info. Therefore the largest sample size of 239 was taken.

Sampling Procedure
All public health facilities in the central zone Tigray region was considered then the sample size was allocated to each health facility proportionally based on their expected number of HIV positive mothers having infants less than or equal 24 months visited all public health facilities during the preceding month before data collection. The study participant was selected by a systematic random sampling method every 2 nd HIV positive mothers having infants ageless or equal to 24month.

Dependent Variables
Knowledge Exclusive Brest feeding

Independent Variables
Socio-demographic and Reproductive characteristics, Institutional and source of information related factor Operational Definition Good knowledge -mothers answer (Score>60% ) on the overall knowledge question (18).
Participants' knowledge was assessed by 13 questions in which each question had a group of 1-3 options. Those participants who answered more than8 questions correctly categorized as "Good knowledge" and those who scored less were categorized as "Poor knowledge" (18).

Data collection tools and techniques
Data was collected by using an interviewer-administered and structured questionnaire adapted from different similar research (15,18,19) with modification according to the context of the study area. To establish face validity and translation quality the questionnaire was tested on 12 women in exclusive breastfeeding outside the study area by data collectors and supervisors during training. A few questions, language clarity and information were revised and the questionnaire was finalized for the study. The questionnaire includes socio-demographic, Reproductive history, Institutional, and source of information related factors.

Data quality assurance and control
Five health professional data collectors and two supervisors were recruited from the Health Center and they were given training for one day. The supervisors followed the process of data collection daily, checked the data completeness consistency and communicate with principal investigators daily.

Data Processing and Analysis
Data were coded, cleaned, recorded and entered Epi info 7and finally export to SPSS version 22.00 for analysis. Simple descriptive summary statistics were done. Tables, statements, charts, and graphs were used to present the result of the analyzed data. Associations between independent and dependent variables were analyzed first using bivariate logistic regression analysis. Variables that had p<0.2 on bivariate analysis were entered multivariable logistic regression analysis. After checking using chi-square test variables with small cell size were merged into related categories.
Appropriate model diagnostics and goodness of fit tests were done. Multicollinearity was checked to test correlation among predictor variables and Hosmer and Lemeshow test P-value (>0.2) were conducted to see model fitness. The statistical association between the different independent variables about dependent was measured using OR, AOR, 95% CI and P-values <0.05 was considered statistically significant.

Socio-demographic characteristics of mothers
A total of 239 HIV positive mothers participated in a response rate of 100%. Out of the total participated mothers, 175(73.5%) were with an age range of 25-35 years. The majority of the participants 177(73.8%) were married (Table 1).   (Table 3).    (15,20). This might be due to differences in the sociodemographic characteristics of the respondent. According to this finding 170(70.8%) of respondents know the duration of newborn fed breast milk only and 128(53.3%) HIV positive mothers know starting age for complementary feeding is at six months. This study finding shows that almost similar to a study conducted in Addis Ababa, Ethiopia and Gondar Town (21,22). In this study monthly income and age at first, the birth was the major determinant factor affecting knowledge of the mothers towards EBF. This may indicate that those mothers who had a monthly income from 1000-15000 birr were 55% more likely to have good knowledge than participants' monthly income from greater than 1500birr towards EBF. This might be due to mothers who had middle income better information on the risk and benefit of exclusive breastfeeding. HIV positive mothers whose age at first birth 24 years and above were 33% times less likely knew HIV positive mothers whose age at first birth were 18-24 years. This might be due to mothers whose age at birth from18-24 were most of them had at school age secondary and higher education there is a share of information.

Conclusion
HIV positive mothers attending health care facilities in a central zone, Tigray region knowledge of the mothers was good but still now needs the effort to achieve the goal on EBF. HIV positive mothers with risk factor income and Age need strict follow up to increase knowledge on EBF.

Ethics approval and consent to participant
Ethical clearance was obtained from the Institutional Review Committee (IRC), College of Medicine and Health Sciences, University of Aksum. Permission letter was received from those administrative bodies of the Central Tigray Health Department and each health facility's verbal and written consent was obtained from all participants after they informed on the purpose of the study.

Consent for publication
Not applicable

Availability of data and materials
All relevant data are within the manuscript and its Supporting Information files.