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angina' 81iC

    The Ethiopian Journal of Health Development is yx!T×ùÃ -@Â L?T m{ÿT

    published three times a year by the Department of Community Health, Addis Ababa University . The Ethiopian Journal The Journal is jointly sponsored by the Ethiopian of Health Development Public Health Association and the Addis Ababa

     University.

    Editor-in-Chief

    Derege Kebede All articles published in the Journal, including

    Associate Editor-in-Chief editorials, represent the opinion of the authors and

    Gabre-Emanuel Teka do not necessarily reflect the official policy of the Editorial Board Ethiopian Public Health Association, the Editorial

    Dawit Abebe Board of the Journal or the institution with which

    Gabremaskel Habtemariam the author is affiliated, unless this is clearly

    Hailu Yeneneh specified.

    Mehari Woldeab Address all correspondence to: The Ethiopian

    Tesfaye Bulto Journal of Health Development, Tikur Anbessa

    Tigest Ketsela Hospital, P.O. Box 32812, Addis Ababa, Ethiopia.

    Wondimagegnehu Alemu Telephone:+251 1 513628, or +251 1 157701,

    Zewdie Wolde-Gebriel FAX: +251 1517701.

    Publication officer Annual subscription rates: Ethiopia 30.00 Birr;

    Fisseha Eshetu outside Ethiopia 50.00 US Dollars. All prices Publication Assistant include postage. Checks should be payable to: Addis

    Simon Tekle-Haimanot Ababa University, with postal address: P.O.Box Secretary 32812, Addis Ababa, Ethiopia.

    Meskerem Bezuayehu Publication of this issue was financially supported

     by the Ethiopian Public Health Association (through

    a grant from the Canadian Public Health Ethiopian Public Health

    Association), the Ethiopian Science and Technology Association Commission (through a grant from SAREC) , and

     Addis Ababa University.

    Executive Committee

    Derege Kebede (Chairman)

    Chanyalew Kassa (Exec. secretary) EPHA mission statement

    Seyoum Taticheff

    Hailu Yeneneh The Ethiopian Public Health Association is a Wondimagegnehu Alemu national, independent and voluntary association of Desta Alamerew professionals working or interested in public health. Haregewoin Cherenet (Treasurer) Its mission is to constitute a special national resource Mesfin Kassaye (Auditor) that advocates for, and contributes to, the national

     effort of health promotion and disease prevention .

     Copyright Department of commu-

     nity Health, Addis Ababa University.

    The Journal contributes to EPHA's mission All rights reserved. This Journal, or

    through publishing of peer-reviewed original any parts thereof, may not be reprod-

    articles, reviews and correspondences on the broad uced in any manner without written

    field of health development. permission.

Style requirement for authors

    The Ethiopian journal of Health Development is a multi-disciplinary peer-reviewed publication concerned with all aspects of public health and preventive medicine. The language of the journal is English. Articles of national importance written in Amharic might be accepted for special issues. All dates in manuscripts s~1d be based on the Gregorian calendar, not on the Ethiopian calendar.

    Each manuscript will be assessed by at least two reviewers knowledgeable in the relevant subject. manuscripts that are accepted for publication become the property of the journal; rejected manuscripts will e

    returned to the author .

    The Editorial Board reserves the right of final acceptance, rejection and editorial correction of papers submitted. Priority and time of publication are governed by the Editorial Board's decision.

    If the text is on a wordprocessor, we request that a diskette, be sent once the paper has been accepted for publication. Twenty five reprints will be supplied free to'the senior author. Additional reprints may be ordered and paid for in advance.

    All manuscripts submitted to the journal must conform to the following requirements. These requirements are in accordance with the uniform requirements for manuscripts submitted to biomedical journals as published by the International Committee of Medical Journal Editors (Uniform requirements for manuscripts submitted to biomedical journals. N Engl J Med 1991; 324: 428-8).

    Submission of manuscripts All manuscripts should be submitted to the Editor-in- Chief of the journal. Mail the required. number of manuscript copies in a heavy paper envelope, enclosing the manuscript.copies and figures in cardboard, if necessary, to prevent bending of photographs during mail handling. Place hotographs

    and transparencies in a separate heavy paper envelope.

    Manuscripts must be accompanied by a covering letter signed by all authors. This must include (a) information on prior or duplicate publication or submission elsewhere of any part of the work as defined earlier in the document: (b) a statement of financial or other relationships that might lead to a conflict of interest; (c) a statement that the manuscript has been read and approved by all authors, that the requirements for authorship as previously stated in this document have been met, and furthermore, that each coauthor believes that the manuscript represents honest work; and (d) the name, address, and telephone number of the

    corresponding author, who is responsible for communicating with the other authors about revisions d final approval of the proofs. The letter should give y additional information that may be helpful to the Editor-in-Chief, such as the type of article the manuscript represents and whether the author(s) will be willing to meet the cost of reproducing colour illustrations. The manuscript must be accompanied by copies of any permission to reproduce published material to the illustrations or report sensitive personal information of identifiable persons, or to name persons for their contributions.

Prior and duplicate publication

    The Journal will not consider for publication a paper on work that has already been reported in a published paper or is described in a paper submitted or accepted for publication else where. This policy does not usually preclude consideration of a complete report that follows publication of a preliminary report, usually in the form of an abstract. Nor does it prevent consideration of paper that has been presented at a scientific meeting if not published in full in a proceedings in similar publication. Press reports of the meeting will not usually be considered as breaches of this rule, but such reports should not be amplified by additional data or copies of tables and illustrations. When submitting a paper an author should always make a full statement to the editor about all submissions and previous reports that might be regarded as prior or dupl icate publ ication of the same or very similar work. Copies of such material should be included with the submitted paper to help the editor decide how to deal with the matter .

    Multiple publication-that is, the publication more than once of the same study, irrespective of whether the wording is the same-is not acceptable. Secondary publication in another language is one possible justification, provided the following conditions are met.

    (1) The Editorial Board of the Journal is fully informed and approves the secondary publication; the editor concerned with secondary publication should have a photocopy, reprint, or manuscript of the primary ersion. (2) The priority of the primary publication is respected by a publication interval of at least two weeks.

    (3) The paper for secondary publication is written for a different group of readers and is not simply a translated version of the primary paper; an abbreviated version will often be sufficient.

    (4) The secondary version reflects faithfully the data and interpretations of the primary version. (5) A footnote on the title page of the secondary version informs readers, peers, and documenting agencies that the paper was edited, and is being published, for a national audience in parallel with a primary version based on the same data and interpretation. A suitable footnote might read as follows: "This article is based on a study first reported in (title of journal, with full reference)".

    Multiple publication other than as defined above is not acceptable to the Journal. If authors violate this rule they may expect appropriate editorial action to be taken. Preliminary release, usually to public media, of scientific information described in a paper that has been accepted but not yet published is a violation of the policy of the journal. In exceptional cases, and only by arrangement with the Editor-in-Chief, preliminary release of data may be acceptable-for example, to warn the public of health hazards.

Preparation of manuscript

    Type the manuscript on white bond paper, 216 x 279 mm (1/2 x 11 in.) or 150 A4 (212 x 297 mm), with margins of at least 25 mm (1 in.). Type only on one side of the paper. Use double spacing throughout, including title page, abstract, text, acknowledgments, references, table, legends for illustrations. Begin each of the following sections on separate pages: title page, abstract And key words, text, acknowledgments, references, individual tables, and legends. Number pages consecutively, beginning with the title page. Type the page number in the upper or lower right-hand corner of each page.

Title page

    To ensure anonymity in the peer review process, authors should supply identifying information on the title page of the original only; the title page for the two reviewers copies should list only the title. On the original, the title page should carry (a) the title of the article, which should be concise but informative; (b) first name, middle initial and last name of each author; with highest academic degree(s) and institutional affiliation; (c) name of department(s) and institutions(s) to which the work should be attributed; (d) disclaimers, if any; (e) name and address of author responsible for cqrrespondence about the manuscript; (I) name and address of author to whom requests for reprints should be addressed or statement that reprints will not be available from the author; (g) sources(s) of support in the form of grants, equipment, drugs, or all of these; and (h) a short running head or foot line of no more than 40 characters (count letters and spaces) placed at the foot of the title page and identified.

Authorship

    All persons designated as authors should quality for authorship. The order of authorship should be a joint decision of the coauthors. Each author should have participated sufficiently in the work to take public responsibility for the content.

    Authorship credit should be based only on substantial contributions to (a) conception and design, or analysis and interpretation of data; and to (b) drafting the article or revision it critically for important intellectual content; and on

    (c) final approval of the version to be published. conditions (a), (b), and (c) must all be met. Participation solely in the acquisition of funding or the collection of data does not justify authorship. General supervision of the research group is also not sufficient for authorship. Any part of an article critical to its main conclusions must be the responsibility of at least one author. A paper with corporate (collective) authorship must specify the key persons responsible for the article; others contributing to the work should be recognized separately (see Acknowledgments).

Abstract and key words

    The Second page should carry and abstract (of no more than 300 words). The abstract should state the purposes of the study or investigation, basic procedures (selection of study subjects or laboratory animal, observational and analytical methods), main findings (give specific data and their statistical significance, if possible), and the principal conclusion. Emphasize new and important aspect of the study of observations. Below the abstract provide, and identify as such 3 to 10 key words or short phrases that will assist indexers in

    cross-indexing the article and may be published with the abstract. Use terms from the medical subject headings (MeSH) list of Index Medicus; if suitable MESH terms are not yet available for recently introduced terms, present terms may be used.

Text

    The text of observational and experimental articles should be divided into sections with the headings: Introduction, Methods, Results, and Discussion. Long articles may need subheadings within some sections to

    clarify their content, especially the Results and Discussion sections. Other types of articles such as case reports, reviews, and editorials can have other formats.

Introduction

    State the purpose of the article. Summarize the rationale for the study or observation. Give only strictly pertinent references, and do not review the subject extensively. Do not include data or conclusions form the work being reported.

Methods

    Describe your selection of the observational or experimental subjects (patients or laboratory animals, including controls) clearly. Identify the methods, apparatus (manufacturer's name and address in parentheses), and procedures in sufficient detail to allow other workers to reproduce the results. Give references to established methods, including statistical methods (see below); provide references and brief descriptions or methods that have been published but are not well known. Describe new or substantially modified methods, give reasons for using them, and evaluate their limitations. Identify precisely all drugs and chemicals used including generic names(s), dose(s), and route(s) of administration.

Ethics

    When reporting experiments on human subjects indicate whether the procedure followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) or with the Helsinki Declaration of 1975, as revised in 1983. Do not use patients' names, initials or hospital numbers. When reporting experiments on animals indicate whether the institution's or the national Research Council's guide for, or any national law on, the care and use of laboratory animals was followed.

Statistics

    Describe statistical methods with enough detail to enable a knowledgeable reader with access 10 the original data to verify the reported results. When possible, quantify findings and present them with appropriate indicators of measurement error or uncertainty (such as confidence intervals). Avoid sole reliance on statistical hypothesis testing, such as the use of P values, which fails to convey important quantitative information. Discuss eligibility of experimental subjects.

    Give details about randomization. Describe the methods for and success of any blinding of observations. Report treatment complications. Give numbers of observations. Report losses to observation (such as dropouts from a clinical trial). References for study design and statistical methods should be to standard works (with pages stated) when possible rather than to papers in general-use computer programs used. Put general descriptions of methods in the Methods section. When data are summarized in the Results section specify the statistical methods used to analyze them. Restrict tables and figures to those needed to explain the argument of the paper and to assess its support. Use graphs as an alternative to table with many entries; do not duplicate data in graphs and tables. Avoid nontechnical uses of technical terms in statistics, such as "random" (which implies and randomizing device), "normal," "significant," "correlations," and "sample."

    Results

    Present your results in logical sequence in the text, tables, and illustrations. Do not repeat in the text all the data in the table on illustrations; emphasize or summarize only important observations.

Discussion

    Emphasize the new and important aspects of the study and the conclusions that follow from them. Do not repeat in detail data or other material given in the Introduction or the Results section. Include in the Discussion section the implications of the findings and their limitations, including implications for future research. Relate the observations to other relevant studies. link the conclusions with the goals of the study but avoid unqualified statements claiming priority and alluding to work that has not been completed. State new hypotheses when warranted, but clearly label them as such. Recommendations, when appropriate, may be included.

Acknowledgments

    Following the discussions, and on a separate page, one or more statements should specify (a) contributions that need acknowledging but do not justify authorship, such as general support by a departmental chairman; (b) acknowledgments of technical help; (b) acknowledgments of technical help; (c) acknowledgments of financial and material support, specifying the nature of the support; (d) financial relationships that may pose a conflict of interest. Persons who have contributed intellectually to the paper but whose contributions do not justify authorship may be named and their function or contribution described-for example, "scientific adviser", "critical review of study proposal", "data collection" or "participation in clinical trial". Such persons must have given their permission to be named. Authors are responsible for obtaining written permission from persons acknowledged by name, because readers may infer their endorsement of the data and conclusion.

    Technical help should be acknowledged in a paragraph separate from those acknowledging other contributions.

References

    Number references consecutively in the order in which they are first mentioned in the text. Identify references in text, tables, and legends by Arabic numerals in parentheses. References cited only in tables or in legends to figures should

    be numbered in accordance with a sequence established by the first identification in the text of the particular table or illustration. Use the style of the examples below, which are based with slight modifications on the formats used by the U.S. National library of Medicine in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus. Consult list of Journals

    Indexed in Index Medicus, published annually as a separate publication by the library and as a list in the January issue of Index Medicus. Try to avoid using abstracts as references: "unpublished observations" and "personal communications" may not be used as references, although references to written, not oral, communications may be inserted (in parentheses) in the text. Include among the references papers accepted but not yet published; designate the journal and add "In press." Information from manuscripts submitted but not yet accepted should be cited in the text as "unpublished observations' (in parentheses).

The references must be verified by the author(s) against the original documents.

    Ethiopian names should not be referenced differently from other names. For example, Almaz Abate should be referenced as Abate A.

    Examples of correct forms of references are given below.

    Articles in journals

    (1) Standard journal article

    (list all authors, but if the number exceeds six give six followed by et al.)

    You CH, lee KY, Chey RY, Menguy R. Electrog- astrographic study of patients with unexplained nausea, bloating and vomiting. Gastroenterology 1980 Aug; 79(2):311-4.

    As an option, if a journal carries continuous pagination throughout a volume, the month and issue number may be omitted. You CH, lee KY, Chey RY, Menguy R. Electrog-astrographic study of patients with unexplained nausea, bloating and vomiting. Gastroenterology 1980;79:311- 4.

(2) Organization as author

    The Royal Marsden Hospital Bone-Marrow Transplantation Team. Failure of syngeneic bone-marrow graft without preconditioning in post-hepatitis marrow aplasia. Lancet 1977;2:742-4.

    (3) No author given Coffee drinking and cancer of the pancreas [editorial]. BMJ 1981;283:628. (4) Article in a foreign language Massone L. Borghi S, Pestarino A, Piccini R, Gambini C. Localizations palmaires purpuriques de la dermatite herperiforme. Ann Dermatol Venereol1987; 114:1S45- 7.

    (5) Volume with supplement

    Magni F. Rossoni G. Berti F. BN-52021 protects guinea- pig from heart anaphylaxis. Pharmacol Res Commun 1988;20 Suppl 5:75-8.

    (6) Issue with supplement

    Gardos G, Cole JO. Haskell D, Marby D, Paine SS, Moore P, The natural history of tardive dyskinesia, J Clin Psychopharmacol 1988;8(4 Suppl):31 S-37S.

    (7) Volume with part Hanly C. Metaphysics and innateness: a psychoanalytic perspective. Int J Psychoanal 1988:69(Pt 3):389-99.

    (8) Issue with part Edwards L, Mcyskens F, Levine N, Effect of oral isotretinoin on dysplastic nevi, J Am Acad Dermatol 1989; 20(2 Pt 1 ):257-60.

    (9) Issue with no volume Baumeister M. Origins and control of sterotyped movements. Monogr Am Assue Ment Defic 1978;(3):353-84.

    (10) No issue or volume

    Danoek K. Skiining in and through the history of medicine. Nord Medicinhist Arsb 1982:86-100. (11) Pagination in Roman numerals

    Ronne V. Ansvarsfull. Blodtransfusion till fel patient. Vardfacket 1989:13:xxvi-xxvii.

    (12) Type of article indicated as needed

    Sprago PM, Manners JM. DDAVP and open heart surgery [letter] Anaesthesia 1989;44:363-4.

    Fuhrman SA, Joiner KA. Binding of the third component of complement C3 by Toxoplasma gondii [abstract]. Clin Res 1987:35:475A.

    (13) Article containing retraction

    Shishido A. Retraction notice: Effect of platinum compounds on murine lymphocyte mitogenesis (Retraction of Alsabti EA, Ghalib ON, Salem MP In: Jpn J Med Sci Bioi 1979;32:53-65). Jpn J Med Sci Bioi 1980;33:235-7. (14) Article retracted

    Aisabti EA, Ghalib ON, Salem MH. Effect of platinum compounds on murine lymphocyte mitogenesis [Retracted by Shishido A. In:Jpn Med Sci Bioi 1980;33:235-7). Jpn J Med Sci Bioi 1979;32:53-65.

    (15) Article containing comment

    Piccoli A, Bossani A. Early steroid therapy in 19A neuropathy: still an open question [comment]. Nephron 1989;51 :289-91. Comment on: Nephron 1988;48:12-7.

    (16) Article commented on Kobayashi V, Fujii K, Hiki V, Tateno S, Kurokawa A, Kamiyama M. Steroid therapy in 19A nephropathy: a retrospective study in heavy proteinuric cases [see comments]. Nephron 1988;48:12-7 Comment in: Nephron 1989;51:289-91.

    (17) Article with published erratum

    Schofield A. The CAGE Questionnaire and psychological health [published erratum appears in Br I Addict 1989;84:7;01). Br I Addict 1988:83; 761-4. Books and Other Monographs

    (18) Personal authors Colson IH, Armour WI. Sports injuries and their treatment. 2nd rev. ed. london: S. Paul, 1986. (19) Editor(s), compiler as author

    Diener HC, Wilkinson M, editors. Drug-induced headache. New York: Springer Verlag, 1988.

    (20) Organization as author and publisher

    Virginia law Foundation. The medical and legal implications of AIDS. Charlottesville: The Foundation, 1987. (21) Chapters in book

    Weinstein L. Swartz MN. Pathologic properties of invading microorganisms. In: Sodeman WA Ir, Sodeman WA, editors. Pathologic physiology:mechanisms of disease. Philadelphia: Saunders, 1974:457-72.

(22) Conference proceedings

    Vivian Vl. editor. Child abuse and neglect: a medical community response Proceedings of the First AMA National Conference on Child Abuse and Neglect; 1984 Mar 30-31; Chicago. Chicago: American Medical Association, 1985. (23) Conference paper

    Harley NH. Comparing radon daughter dosimetric and risk models. In: Gammage RB. Kaye SV, editors. Indoor air and human health. Proceedings of the Seventh life Sciences Symposium; 1984 Oct 29-31; Knoxville (TN). Chelsea (MU; lewis, 1985:69-78.

    (24) Scientific and technical report

    Akutsu T. Total heart replacement device. Bethesda (MD): National Institutes on Health, National Heart and lung Institute; 1974 Apr. Report No.:NIH-NHLI-69-2185-4.

    (25) Dissertation

    Youssef NM. School adjustment of children with congenital heart disease [dissertation]. Pitsburgh(PA): Univ. of Pittsburgh, 1988.

    (26) Patent

    Harred IF, Knight AR, Mclntyre IS. inventors. Dow Chemical Company, assignee, Epoxidation process, US pat net 3, 654,317. 1972 Apr 4. Other Published Material

    27 Newspaper article

    Rensberger B, Specter B. CFCs may be destroyed by natural process. The Washington Post 1989 Aug 7; Sect. 1 :2(col.5).

    (28) Audiovisual

    AIDS epidemic:the physiciar)'s role [videorecording]. Cleveland (OH): Academy df Medicine of Cleveland, 1987.

    (29) Computer file

    Repal system [computer program]. Ms-DOs version. Edwardsvill(Ks): Medi Sun, 1988.

    (30) Legal material

    Toxic Substances Control Act: Hearing on s. 776 Before the subeomm on the Environment of the Senate Comm. on Commerce. 94th Cong. 1 st sess. 343 (1975).

    (31) Map

    Scotland [Topographic map]. Washington: National Geographic Society (US), 1981.

    (32) Book of the Bible

    Ruth 3:1 18 The Holy Bible. Authorized King James version. New York: Oxford Univ. Press, 1972. (33) Dictionary and similar references

    Ectasis Dorland's illustrated medical dictionary. 27th ed. Philadelphia: saunders, 1988:527. (34) Classical material

    The Winter's Tale act 5. Scene 1, lines 13-66. The complete works of William Shakespeare. London: Rex, 1973. Unpublished material

    (35) In press

    Lillywhite HB. Donald JA. Puhnonany blood flow regulation in an aquatic snake, Science. In press.

Tables

    Type each table double-spaced on a separate sheet. Do not submit tables as photographs. Number tables consecutively in the order of their first citation in the text and supply a brief title for each. Give each column a short or abbreviated heading. Place explanatory matter in footnotes, not in the heading. Explain in footnotes all nonstandard abbreviations that are used in each table. Number footnotes consecutively in the order in which they appear in the table.

    Identify statistical measures of variations such as standard deviation and standard error of the mean. Do not use internal horizontal and vertical rules. Be sure that each table is cited in the text. If you use data from another published or unpublished source obtain permission and acknowledge fully. The use of too many tables in relation to the length of the text may produce difficulties in the layout of pages. Only one table per 1000 words of text is acceptable. The Editor-in-Chief, on accepting a paper, may recommend that additional tables containing important backup data to extensive to

    publish be deposited with an archival service or made available by the authors. In that event an appropriate statement will be added to the text. Submit such tables for consideration with the paper.

Illustrations

    Submit the required number of complete sets of figures. Figures should be professionally drawn and photographed; freehand or typewritten lettering is unacceptable. Instead of original drawings, and other material send sharp, glossy black-and-white photographic prints, usually 127x173 mm (5 x 7 in), but no larger than 203x254 mm (8x10 in.). letters, numbers, and symbols should be clear and even throughout and of sufficient size that when reduced for publication each item will still be legible. Titles and detailed explanations belong in the legends for illustrations, not on the illustrations themselves.

    Each figure should have a label pasted on its back. indicating the number of the figure, author's name, and top of the figure. Do not write on the back of figures or scratch or mark them by using paper clips. Do not bend figures or mount them on cardboard. Photomicrographs must have internal scale marker. Symbols, arrows, or letters used in the photomicrographs should contrast with background. If Photographs of persons are used, either the subjects must not be identifiable or their pictures must be accompanied by written permission to use the photograph.

    Figures should be numbered consecutively according to the order in which they have been first cited in the text. If a figure has been published acknowledge the original source and submit written permission from the copyright holder to reproduce the material. Permission is required irrespective of authorship or publisher, except for document's in the public domain. Coloured illustrations will be reproduced at the author's expense.

legends for Illustrations

    Type legends for illustrations double-spaced, starting on a separate page, with Arabic numerals corresponding to the illustrations. When symbols, arrows, numbers, or letters are used to identify parts of the illustrations, identify and explain each one clearly in the legend. Explain the internal scale and identify method of staining in photomicrographs.

Units of measurement

    Measurements of length, height, weight, and volume should be reported in metric units (meter, kilogram, or litre) or their decimal multiples.

    Temperatures should be given in degrees Celsius. Blood pressures should be given in millimetres of mercury. All hematolgic and clinical-chemistry measurements should be reported in the metric system in terms of the International System of Units (SI). Editors may request that alternative or non-SI units be added by the authors before publication.

Abbreviations and symbols

    Use only standard abbreviations. Avoid abbreviations in the title and abstract. The full term for which an abbreviation stands should precede its first use in the text unless it is a standard unit of measurement.

Original article

    Breastfeeding In Addis Ababa, Ethiopia: Results of a focus group study

     121Tigest Ketsela , Derege Kebede , Channyalew Belachew and Hanna Neka- Tibeb

    Abstract: A large shift has been observed from breastfeeding to bottle feeding in the urban areas of developing countries. Non-optimal breastfeeding patterns are contributing to the diarrhoeal diseases and malnutrition problems in such areas. To examine the existent of non-optimal breastfeeding, to identify the segment of the population in which these practices exist, and to ultimately carry out well targeted interventions, a situation analysis study on the breastfeeding patterns of infants was undertaken in the capital city of Ethiopia, Addis Ababa. In-depth interviews and focus group discussion were used in this study. The in-depth interviews revealed out that there was no policy 9! the Ministry of Health concerning breastfeeding and supplementation and there was a delay in the rooming-in of babies delivered at health facilities during evening and night hours. Newborns were also given non-nutritive fluids in the first three days of life. Working mothers were allowed to have a 45-day paid maternity leave. The focus group discussions undertaken wi!h mothers and grandmothers revealed that most newborns were given water just after birth. Itwas generally found out that women from low socio-economic status (SES) had negative attitude while those from middle and high socio-economic status and grandmothers had positive attitude towards breastfeeding regardless of their ethnicity. Recommendations are made based on the results obtained in the study. [Ethiop. J. Health Dev. 1996;10(3):133-143]

Introduction

    several studies indicate that infants not breastfed have an increased incidence of diarrhoeal, respiratory and skin infections compared to those breastfed. In Lima, Peru, for example, the incidence rates of diarrhoeal diseases in those for whom breast-feeding had been discontinued were 15-48% higher than those of the breast fed infants (1). Though initiation of breastfeeding is universal in most developing countries, cessation of breastfeeding and early supplementation have been observed in a substantial proportion (2,3).

    The changes in the types of supplements used and in breastfeeding duration are analogous to the changes observed in industrialized countries from the mid 19th century and many of the associated factors are similar: urbanization, female participation in labour force, increased availability of processed milk and their promotion both by companies and health sectors and regimentation of breastfeeding (4).

    With the decline in breastfeeding, there is a shift to bottle feeding which could be hazardous in that the bottle or the content can be contaminated and/or the baby gets inadequate supplement as a result of over dilution (5) which is the case in most developing countries. These predispose young infants and children to diarrhoea and/or

    malnutrition.

    In Ethiopia, like in other developing countries, diarrhoea is a major contributor of morbidity and mortality in young infants and children as demonstrated by diarrhoeal diseases morbidity, mortality and treatment surveys conducted between 1983-89, by the National

_________________________ 1From the National CDD Program, Ministry of Health, Addis Ababa, Ethiopia, 2the Dept. of Community Health, Faculty of Medicine Addis

    Ababa University, and 3the Ethiopian Health and Nutrition Research Institute, p .0. Box 1242, Addis Ababa, Ethiopia

    Control of Diarrhoeal Diseases Programme in Ethiopia (14). Specially in urban areas, it seems that non-optimal breastfeeding patterns are contributing to the diarrhoeal diseases problem. It is, therefore, essential to examined the existence of non-optimal breastfeeding and to identify the segment of the population in which these practices exist so that well targeted interventions could be undertaken.

    Different studies have been conducted in different parts of Ethiopia to study breastfeeding patterns. In a study of socio- cultural factors related to breastfeeding in Jimma (a town in south-western part of Ethiopia) (6) where 79% of the women claimed to have initiated breastfeeding in 12 hours time after delivery, duration of exclusive breastfeeding was found to be 45.6% in infants less than three months of age and 43.1%, 4.7% and 6.6% in those who were 4-6, 7-9 and 10 or more months of age, respectively.

    The three rounds of the Rural Nutrition Survey (7) found that 93.9%, 93.3% and 94.6% of children less than two years of age were breastfeeding in the rural areas of 12 surveyed regions. Almost 88% of the children less than one year of age were also found to be getting supplementary diets at the time of the survey. In a nation-wide study which looked into the first two years of infant feeding (2), economically advantaged and educated families (Group A), poor and usually poorly educated families (Group C) and families in rural areas (Group R) were studied. One of the places where the urban groups were studied was Addis Ababa. Ninety one percent, 97% and 100% of Groups A, C and R had breastfed the index child, respectively. The most common reason for not breastfeeding was found to be insufficient milk irrespective of the child's age.

    Prevalence of breastfeeding was food to fall. steeply with increasing child age and was well maintained in urban poor and rural groups of mothers. In another study (8), three different Ethiopian Communities representing different economic and cultural situations were studied. In the studied children who have completely ceased breastfeeding the highest duration of breast-feeding (19 months or more) was found in Tigray (Northern part of Ethiopia) and no infant with breastfeeding duration of less than seven months was found in this community .

    Tigray Region is a highly traditional community in Ethiopia and the authors accounted its high breastfeeding prevalence for its extremely meagre resource preventing mothers from adopting new things. In Sidamo (Southern Ethiopia), on the other hand, 32% of the children were breastfed for 19 months or more and 38% for 7-12 months. Sidamo is a cash crop area and the society is described as " open" which can " afford" to be more open because of the availability of resources. Arssi (Southern Ethiopia) children were breastfed for less than three months in 15% of the studied subjects, 27% were fed for 4-6 months and 47% for 7-12 months with only 11% fed longer than one year .People of the studied village in Arssi were found to be cattle people, with cow's milk given a very big importance in child-feeding and, hence, early weaning was the norm. Paradoxically enough, males were found to be breastfed longer than females because of "their need for energy to become good herdsmen" .The most frequent reason given for early weaning was "...otherwise the mother will not have children. ." .Hence, the ever increasing morbidity and mortality in the area was found to increase the need for more children further strengthening the picture of early weaning. Other reasons given for weaning included "cow milk better than human milk", and "child hurts the mother if he breast feeds any longer". A study undertaken in a rural community in the south western part of the country (9) found that 86% , 69% and 31% of infants 0-2 months, 2.1-4 months and 4.1-6 months, respectively, were given breast milk alone. It is obvious from these studies that different practices exist in the country in regards to breastfeeding. It was, therefore, deemed necessary to assess breastfeeding practices and the factors contributing to these practices in Addis Ababa where a large number of people with different socio- economic and ethnic mix reside.

The in-depth interviews were carried out (a) to learn about the policy of the Ministry of Health (MOH)

    regarding breastfeeding and supplementation, (b) to understand hospital practices concerning feeding of infants and children and the existence of communication activities with regard to child feeding, and (c) to identify areas to be emphasized in the focus group discussions and to help us frame the focus group guides. The focus group discussions, on the other hand, were carried out with the objectives of (a) assessing participants' attitudes, perceptions and opinions on infant feeding with particular emphasis to breastfeeding,

    (b) attaining greater depth of understanding about choices of the different modes of feeding and to make a preliminary determination of the importance of ethnicity in breastfeeding behaviour .

Methods

    The components of the situation analysis were in-depth interview and focus group discussion.

1. In-depth Interview:

    A pretested questionnaire was used to interview concerned officials in the MOH and the Ministry of Labour and Social Affairs (MOLSA); obstetricians, midwives and matrons of the three major obstetric hospitals in Addis Ababa: Tikur Anbessa Hospital (TAH), Yekatit 12 Hospital (YI2H) and Ghandi Memorial Hospital (GMH). All the three are central referral and teaching hospitals. T AH is the biggest teaching hospital in the country .GMH is the biggest obstetric hospital and its yearly deliveries are estimated at more than 2500.

2. Focus Group Discussions:

    Eight focus group discussions were conducted from Sep., 1991 to January, 1992. The first group consisted of 10 women but, as it was felt that the group was too big to conduct an effective discussion, the subsequent groups sizes were reduced to 6-8 women. The groups were: two groups of low SES Amhara mothers, two groups of low SES Guragie mothers, one group of Amhara grandmothers, one group of low SES Tigre mothers, one group of low middle income Amhara working mothers and one group of high income Amhara working mothers. The discussions mainly focused upon Arnhara, Gurage and Tigre mothers, because these are the three major ethnic groups comprising of 50% , 17% and 15% of the population of Addis Ababa, respectively (CSO, 1988). Homogeneity within the groups was maintained regarding ethnicity, monthly income, age and presence of a child less than one year of age. Fathers of children less than one year of age were not included in the focus group discussions because of repeated failure to have them assembled resulting from their lack of interest in discussion about child feeding. Most of the approached fathers stated that they do not know or do not get involved much in child feeding, a task carried out entirely by mothers. A questionnaire was used to recruit the different groups of mothers from "Kebeles " (local government units).

    The questionnaire included presence of a child less than one year old, ethnicity of mother, age of mother, and monthly income. Two health workers went from house to house each day of the focus group discussions till they found 6-9 women fulfilling the criteria of age, ethnicity, monthly income and educational status set for the focus group discussion of the day. Mothers fulfilling the set criteria were informed that the discussions were about "child feeding" and were asked for their consent to participate. The discussions were conducted in Kebele offices except the ones for the working mothers which were conducted in a diarrhoea training unit.

    The discussions were chaired by the principal investigator who used pretested discussion guides. The discussion guides among the groups were similar dealing approximately with the same topics with only some changes addressing the respective groups. The discussion was recorded verbatim by two recorders, both health professionals.

    The recorders were not used for fear about the reactions of the mothers. The basic areas covered in each of the sessions were health of the youngest child; necessities at birth; first breastfeeding; supplementation; problems of breastfeeding; problems of the different modes of feeding; images of babies and mother; necessities for good health; factors making a child look unhealthy and feeding modes of poor and a well-to-do mothers. To elicit information on images of babies and mothers, a photo-sort projective technique was used. This was done in the following ways.

    1. Photographs of well nourished and malnourished children, below and over five months of age, were shown and respondents were asked what they think each child feeds on and why.

    2. Photographs of well-to-do mothers and poor mothers were shown and respondents were asked what they think each mother in the picture would feed her child who is less than one year old and why. After each discussion, transcription was done, verbatim findings under each of the above topics were summarized. After completion of all the eight focus group discussions a cross-group analysis was done under the above topics.

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