Adolescent Maternal Nutrition and Health in Uganda: Voices from the Community

Abstract

INTRODUCTION: Over one quarter of adolescent girls in rural Uganda and more than one fifth of them in the Busoga region of Eastern Uganda experience pregnancy and childbirth. These young mothers have disproportionately high rates of poverty, food insecurity, social isolation and poor health, and lack adequate access to health care and employment. Improvement of adolescent maternal/child nutrition and health may be compromised by a number of barriers faced by young mothers. Challenges met by stakeholders who could support adolescent maternal/child health may also complicate issues. Community-level action is a key strategy to reverse the cycle of oppression for these girls and their offspring. There is scanty literature about studies that have focused on needs and barriers of teenage mothers, opportunities available in the community, challenges faced by service providers, and stakeholder recommendations and avenues of capacity building in rural Eastern Uganda with a goal of understanding influences on adolescent maternal/child nutrition and health. Moreover, the application of the social cognitive theory and ideas borrowed from the social ecological framework to this issue helps to emphasize the individual and environmental (social/economic/physical/nutrition/health service) factors that interact to influence the behaviors of young mothers. Since an aim of the research is ultimately to guide community-level intervention, it was important to understand context from the perspectives of a range of stakeholders of adolescent maternal/child nutrition and health relevant to the geographic setting of rural Jinja district. This study could help to inform further research and may help in forming feasible and acceptable community-based interventions towards enhancing adolescent maternal/child nutrition and health. OBJECTIVES AND METHODS: This qualitative research examined, from the perspectives of a range of community-level stakeholders, the needs, barriers, opportunities, challenges, recommendations and areas of capacity building for improved adolescent maternal/child nutrition and health. The research was conducted in the rural Budondo sub-county of Jinja district, Uganda. Based on constructs of the social cognitive theory (SCT), in depth individual interviews were conducted among 101 purposively sampled respondents recruited from parishes surrounding 6 public health centers of the study area. The study participants included: pregnant adolescent mothers (n=11); lactating young mothers with infants of 0-6 months (n=8); lactating mothers of infant 7-12 months (n=6); mothers of young mothers (n=6) and grandmothers of young mothers (n=5). Other interviewees were: midwives (n=7); traditional birth attendants (n=3); village health team members (n=5); doctors (n=4); teachers (n=5); head teachers (n=11); agriculture officers (n=3); religious leaders (n=3); village political leaders (n=6); staff members of non-governmental organizations in the study area (n=5); and sub-county and district area administrators (n=13). Interview recordings were transcribed word for word and then translated into English. Codes were created from the transcribed interviews based on the constructs of the SCT model (individual factors; environmental factors [including social, economic, physical, nutritional and health service environments] and, as relevant, behavioral factors) and a priori themes of the study objectives. Using Atlas-ti 7.5.4 phrases in each transcript were linked to the created codes which were networked towards the main theme of adolescent maternal/child nutrition and health. RESULTS: Needs reported by the study include schooling and home-based employment at the individual level; belonging and encouragement at the social level; jobs and money to purchase basic needs at the economic level; and shelter, beddings and clothing at the physical level. Other needs included: food for young mothers and their infants at the nutrition level; and medical supplies, health home visits and training in good newborn care practices at the health service level. Barriers identified were: young mothers’ lack of knowledge in income generation and food preparation skills and confidence to handle new responsibilities or stay in school at the individual level; harsh treatment and stigmatization by family members and medical staff at the social level: and, at the economic level: young mothers’ lack of experience in income generation, lack of academic job qualifications and/or capital/fees for self-employment, heavy responsibilities of motherhood, lack of markets, and government programs such as the National Agricultural Advisory Services (NAADS) which support adults and men with agricultural items, like seeds for planting or animals for rearing, but not girls. At the physical level, barriers included long distances and slippery roads to the health centers or training programs, failure to inherit land by girls (unlike boy children), and restriction from sharing houses with their parents as, culturally, young mothers are taken to become in-laws belonging to the families of the boys/men they had sex with. At the nutrition level: infants did not benefit from exclusive breastfeeding (EBF) due to a range of maternal factors including, in some cases, negative attitudes towards breastfeeding, insufficient breastmilk, return to school, or breastfeeding problems; and at health service level barriers included: late reporting of medical personnel, long waiting lines, absence of medicines, failure to receive delivery materials, absence of tailored medical attention, and poor health communications. Opportunities identified at the individual level were the positive attitudes of some young mothers towards: taking-up health advice and practices, laboring for a pay and keeping their pregnancies to term. At the social level, some parents and community members were kind and caring, and provided emotional support. At the economic level: some family and community support in transferring income generation skills to young mothers was identified. Similarly, at the physical level: provision of land and shelter by family and community members was sometimes reported. At the nutrition level: provision of food by families, and training and support in maternal/child feeding were assets. At the health service level, medical care and availability of health-related staff were reported for some health centers. These cases could be held up as examples. Challenges raised by stakeholders that could block the identified opportunities included: at the individual (stakeholder) level: demotivation due to serving with a low/no pay and negative attitudes of community members, and inadequate training in adolescent maternal care; at the social level: lack of an organization supporting young mothers; and at economic level: uncertainty regarding how to use available resources to better serve young mothers and how to enhance the quality of agriculture and handcrafted products to be competitive for desired market prices. At the physical level, challenges included use of the available land by families to better their own lives rather than their daughter’s, finding ways to provide for more proximal services, e.g., equipping village health team members (VHTs) with protective materials for their work. At the nutrition level, challenges included determining how to improve the skills in food preparation for mothers when faced with a lack of food and trained facilitators, and at health service level, meeting medical needs with poor access to medical supplies, poor working conditions and understaffing. Recommendations given by stakeholders included: individual level: sensitization of family and community members to support young mothers, and motivation of community members with pay; social level: community collective responsibility and policing for better health services, special schooling for young mothers, supervision of medical staff, presidential directive to fathers of babies who fail to assume financial responsibility, and use of suggestion boxes at health centers. At the economic level: employment creation, improved facilitation in agriculture, payment of service providers, putting up vocational institutes, and prioritizing the health sector within the national budget were recommended. At the physical level: building medical staff houses and operating theatres, provision of medical equipment, and supporting local health-related personnel with protective gear and delivery materials, were suggested. Further recommendations included, at the nutrition level, use of tailored nutrition education videos and expanding food preparation facilities, while at the health service level: adequate, timely and informed supply of medicines and medical supplies, employing more medical staff, having a designated space or health center for young mothers, and use of tailored health education videos. Capacity building avenues that were suggested included: at the individual level: training health personnel to meet the needs of young mothers, training young mothers and VHTs in income generation skills and use of adult VHTS by future organizations that could support young mothers; at the social level: training teachers and community workers to counsel parents; and at the economic level: teacher training to, in turn, train youth on handcraft skills while VHTs could train and monitor projects of young mothers. Other areas of capacity building included: at the physical level: training of local health-related personnel on use of anthropometry equipment to support better monitoring of maternal and child growth; at the nutrition level: training community workers in nutrition and food preparation to better support their training of mothers, and at the health service level: training of community workers, like VHTs, in the unique maternal/child health needs of adolescents and monitoring, and licensing traditional birth attendants (whose could be revised by the World Health Organization). DISCUSSION: The study revealed perceptions of diverse stakeholders that call for improved well-being of adolescent mothers and their infants at the individual and environment level in rural Uganda. By understanding the needs, barriers and supports of young mothers, challenges of service providers and suggested solutions, it may be possible to consider opportunities to shift behavior or overcome obstacles. Lessons from strategies used by a number of organizations in the study area or other districts in rural Uganda could be taken up for improved adolescent maternal/child nutrition and health. At the individual level, counselling, sensitization, and peer groups could be used to encourage, support and strengthen positive attitudes and practices of young mothers. For example, since young mothers were involved in family agriculture and home-based employment, personal projects in the same could be possible, while, staying in school could also be possible for mothers who were interested in schooling. At the social level, information sharing, counselling and sensitizing families, local community members, district administrators, civil society organizations and policy makers, could shift collective support for young mothers at home, schools, and health centers, as demonstrated elsewhere [Leerlooijer et al., 2014]. At the economic level, partnering with non-governmental organizations and government programs in the area could help in providing skill training, and grants, in the form of money or resources, to support income generation by young mothers. The said programs could also support train-the trainer opportunities for educators and other community workers. Use of agriculture for income generation is an ideal opportunity in the region as young mothers are involved in agriculture, since, on the gender level, women and girls are the major agriculture labor force in Africa. At the physical level, lessons learned from other studies could help to improve the well-being of young mothers through avenues such as family joint land ownership or and lobbying for infrastructure improvement and support to service providers such as medical staff, VHTs, and TBAs. At the nutritional level, production of food through crop growing and bird/animal rearing, in addition to adolescent maternal child nutrition education is important as suggested by several studies [Nabugoomu et al., 2015a; Nabugoomu et al., 2015b; Nabugoomu & Hanning, 2015; Shefner-Rogers 2014, Berti et al’, 2010]. Nutrition education by VHTs who are the community-based workers could also be explored as an opportunity suggested by other studies [Stanback et al., 2007; Tylleskär et al., 2011; Kirkwood et al., 2013; Penfold et al., 2014; Flax et al., 2014]. This opportunity would be possible as some of the VHTs were willing to use their homes for training of young mothers in practical food preparation skills. At the health service level, district and national authorities could be lobbied, so as to aid in the training of medical staff in adolescent friendly services, and taking and recording of measurements of young mothers and translating these measurements in a manner that can be understood by the young mothers. Lobbying to facilitate home visits by health-related personnel could also be helpful. Training of VHTs and TBAs in maternal/child health education and health monitoring by organizations such as World Vision [Ononge et al., 2016] could also help since VHTs and TBAs were trusted by community members. For example, these service providers could be used as agents of change for gender and cultural biases. This study involved a large, diverse sample of participants and hence captured a broad range of views. Conducting interviews in homes or places of work helped to make use of observations and extra information from non-participants for triangulation of information. In addition, observations at health centers were triangulated with views of stakeholders. CONCLUSION: Using the SCT, this study identified a range of needs and barriers faced by adolescent mothers in rural Uganda making them vulnerable to poor maternal/child health. Participants also identified opportunities that could support young mothers, challenges of service providers, and gave feasible steps to addressing the needs, barriers and challenges by building on available opportunities to enhance health and well-being. This research underpins the importance of research at the community level and the inclusion of knowledge users and decision makers in the process. Findings of this study may help to direct future community-based interventions for improvement of adolescent maternal/child nutrition and health.