Utilization of Growth Monitoring and Promotion Services and Undernutrition of Children less than two years of Age in Northern Ghana

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Aminu, Emmanuel Bekyieriya, Martin N. Adokiya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1722413/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jun, 2023 Read the published version in BMC Nutrition → Version 1 posted 10 You are reading this latest preprint version Abstract Background Child malnutrition is a major public health problem and an important indicator of child’s health. Adequate nutrition is critical for a child’s growth and development. Growth monitoring and promotion (GMP) services is a nutrition intervention aimed at improving the nutritional status of children. We assessed the utilization of growth monitoring and promotion services and nutritional status of children less than two years in northern Ghana. Methods The study was a descriptive cross-sectional survey that involved face-to-face interviews among 266 mothers with children < 2 years of age attending child welfare clinics (CWC) as well as some anthropometric measurements. Data were entered and analyzed using Statistical Package for Social Science software, version 20. The nutritional status of children was classified as underweight (weight-for-age z score < -2 standard deviations), stunted (length-for-age Z score < − 2) and wasted (weight-for-length z score < -2) while utilization of GMP services was based on attendance to CWC and ability to interpret to different growth curves. Results The prevalence of child undernutrition shows that, 18.6% were underweight, 14.7% were stunted and 7.9% were wasted. About 60% of the mothers accessed GMP services regularly. The main reason for irregular access to GMP services was due to travel out (68.0%). Less than half of the mothers were able to interpret the children’s growth curve correctly: falling growth curve (36.8%), flattening growth curve (35.7%) and rising growth curve (27.4%). In combining children < 6 and 6–23 months of age. Only one-third (33.1%) of mothers practiced appropriate infant and young child feeding. Conclusion We found that, the level of undernutrition was high, child feeding practices was poor and maternal utilization of GMP services was low in the study area. Similarly, ability to interpret the child’s growth curve appropriately was a challenge among women. Thus, attention is needed to improve knowledge and utilization of GMP services and to address breastfeeding and complementary feeding challenges. Maternal child GMP feeding practice undernutrition Ghana Introduction Malnutrition remains the world’s most serious health problem and major contributor to child mortality [ 1 ]. Child malnutrition is responsible for > 50.0% of all childhood deaths [ 2 ]. Globally, it is estimated that, 25.6% of children 40% in many developing countries [ 3 ]. Also, it is estimated that, 43.0% of children < 5 years in developing countries are prone to falling short of their life potentials due to poor nutritional situations they faced in their early formative years [ 4 ]. The inadequacy of growth is high among children < 24 months of age [ 5 ]. The period from birth until two years of age is considered a critical stage for maximum nutrition care to enhance optimum growth. This is the basis for global initiatives toward child care [ 6 ]. Child malnutrition is an important public health problem in Ghana. According to 2014 Ghana Demographic and Health Survey (GDHS) report, 19% of children < 5 years of age were stunted, 11% were underweight and 5% were wasted. In northern Ghana, 33.1% of children were stunted, 20.1% were underweight and 6.3% were wasted. Similarly, stunting was between 8.0% and 21.9%, underweight was between 4.2% and 14.6% and wasting was between 6.9% and 10.6% among children less than 2 years of age in Ghana [ 7 ]. Growth monitoring (GM) is the measurement that best defines the children’s health and nutritional status. It provides a measurement on the quality of life of the entire population [ 8 ]. The growth pattern of a child is determined by comparing his/her growth indices with that of a reference child of the same age and sex [ 8 ]. In Ghana, GMP services are implemented at the community level through the primary health care system in order to improve child nutritional status. GMP is a prevention activity comprised child GM linked with promotion that increases awareness about child growth; improves caring practices and increases demand for other services. It also serves as the core activity in an integrated child health and nutrition program [ 9 ]. Globally, growth chart is used as a tool to monitor child’s growth and determine the nutritional status of children. GM uses weight-for-age, weight-for-height and height-for-age as indicators to determine the nutritional status of children. The growth monitoring outcomes are complemented with targeted counseling for children with special needs [ 10 ]. The GM also provides opportunity for intercommunication between health workers and caregivers concerning the wellbeing of their children [ 11 ]. In Ghana, children are routinely weighed on a monthly basis. Regular monitoring of growth helps in early detection of danger warning signs and conditions that affect growth [ 12 ]. Despite several efforts to reduce child malnutrition through GMP services in Ghana, prevalence of malnutrition remains high among child < 5 years, particularly in northern Ghana [ 7 ]. Few studies have been conducted to determine the utilization of GMP services and prevalence of undernutrition in Ghana. Thus, the objective of this study was to assess the utilization of growth monitoring and promotion services and nutritional status of children less than two years of age in northern Ghana. Materials And Methods Study design and setting We employed a cross-sectional descriptive design to collect data from mothers with children less than two years of age. The study was conducted in the Tamale Metropolis of Northern Region, Ghana. There are six (6) Metropolis in Ghana and the Tamale Metropolis is the only one in the north of the country. Currently, the north of Ghana is composed of five (5) regions namely: Upper East, Upper West, Northern, North-East and Savannah Regions. The Metropolis is located in the central part of the Northern Region with Tamale as the capital. It has an estimated land size of 646.90180 square kilometre and a population of 233,252 [ 13 ]. According to the database of the District Health Information Management System, 64,641 women are in their reproductive age and 10,769 children are less than two years of age. Health services in the Metropolis are provided by public and private health facilities in four (4) demarcated sub-metropolis [ 13 ]. We used the formula by Cochran (1963) to calculate the sample size for mother-child pairs for the study. We used the highest prevalence of underweight (14.6%) among children less than two years in Ghana [ 7 ] and the study population was 10,769 children. In using a 95% confidence interval (CI), 5% margin of error and a 1.4 design effect (DE), a sample size of 270 respondents was calculated. Study participants and sampling The target population were women of childbearing age (15–49 years) with children < 2 years of age. The main criteria for inclusion of households were: 1) a mother who has a child less than two years of age; 2) a mother who was present at the time of the survey; 3) child of singleton birth, 4) no obvious signs of illness and 5) a mother who consented to participate in the study. The children chosen were within the critical stage of the first 1,000 days of a child’s life. The list of qualified mothers was received from the study health facilities. The study participants were chosen using a simple random sampling method within each health facility. This sampling method allowed every member of the population to have an equal chance of being selected. Overall, 266 interviews were conducted ( Table 1 ) comprising of 122 mothers with children aged from < 6 months and 144 women with children aged between 6–23 months. Table 1 Mothers attending child welfare clinics (CWC) in Tamale Metropolis Name of health facility CWC attendance Weighted sample size Reproductive and Child Health 2721 89 Builpela 2049 67 Vittin 1984 64 Nyohini 1432 46 Total 8186 266 Data collection tool and procedure The mothers were interviewed using a structured questionnaire which covered socio-demographic characteristics (education, occupation, parity, age, ethnicity, and marital status), child characteristics (age and sex) and utilization of GMP services. In addition, child GM information was extracted from maternal and child health record book using observation checklist. Anthropometric instruments were used to measure weight and height of individual children according to World Health Organization (WHO) guidelines [ 14 ]. We used Beurer digital scale to measure the weights and recorded to the nearest 0.1kg. All weight measurements were taken in duplicate and the averages recorded. A locally manufactured infantometer with a fixed headboard and a movable footboard was used to measure the recumbent length of children. The length was recorded to the last completed 1.0cm. In addition, all recumbent length measurements were taken in duplicate and the averages recorded. The interviews were conducted privately by two final year students pursuing Bachelor of Science in Nursing at the University for Development Studies, Tamale. The interviews were conducted in Dagbani and English languages. The study tools were pretested in a health facility. The study was conducted during January - February, 2018. Data processing and analysis On daily basis, the data were checked for completeness and accuracy. Data were entered and analyzed using the Statistical Package for Social Science software for Windows, version 20. Descriptive statistics were performed covering prevalence of undernutrition, utilization of GMP services, breastfeeding and complementary feeding practices. Knowledge of recommended infant feeding practices were scored [ 15 ]. Data on CWC attendance was obtained from the maternal and child health record book. Comprehension of the growth curve and knowledge of GMP activities was determined was determined through the interviews. Feeding practices of children < 6 months of age were estimated using the WHO child feeding recommendation [ 15 ]. We assessed whether the child was fed breastmilk or infant formula/semi-solid/solid foods in a 24-hour recall. A score of zero (0) was given for each wrong practice and score of one (1) for a correct practice. Mothers were interviewed on recommended breastfeeding practices that ensures that the children received good supply of breastmilk. Practices were then divided into “adequate” and “inadequate” along the median. Children 6–23 months of age, dietary diversity, feeding frequency and current breastfeeding status were used to create a feeding practice score. Using the WHO guidelines [ 15 ], seven food groups: 1) grains, roots and tubers; 2) legumes and nuts; 3) dairy products; 4) flesh foods; 5) Eggs, 6) vitamin A fruits and vegetables and 7) other fruits and vegetables and were used to assess dietary diversity score. A score of one (1) was given for a food group fed and zero (0) for a food group not fed based on the guidelines [ 15 ]. A child with a score of at least four (4) was classified to have a diverse diet. A child fed the recommended minimum feeding frequency was given a score of one (1) for adequate feeding frequency and a child who fed less than the minimum frequency was given a score of zero (0). A breastfed child received a score of one (1) while a non-breastfed child was given a score of zero (0). The total practice score was then determined by adding scores from all the variables. Child anthropometric data are expressed by age and sex appropriate z-scores for weight-for-age (WAZ), weight-for-height/length(WHZ) and height-for-age (HAZ). The children were grouped into normal z-scores for all indicators ≥-2 standard deviation, underweight (WAZ <-2 score), wasting (WHZ <-2 score) and stunting (HAZ <-2 score). The child nutritional status was then classified into normal as against underweight stunted or wasted [ 16 ]. Results Demographic characteristics In total, 266 mothers with children less than 2 years were enrolled. Analysis show that 85% of the participants were between 18 and 34 years of age. More than half (57.5%) of the participants had either no education (45.9%) or only primary education (11.6%). Nearly all (94.7%) of the mothers were married. About half (42.8%) of the mothers were traders. More than half (61.3%) of the women were classified as coming from low wealth households and more than half (56.0%) had either 1–2 children. Less than half (46.0%) of the children were < 6 months of age. More than half (53.8%) of the children were males (Table 2 ). Table 2 Socio-demographic characteristics of mothers with children < 2 years (n = 266) Characteristics of respondents Frequency Percentage (%) Age of mother (years) <18 2 0.8 18–34 226 85.0 ≥ 35 38 14.2 Mothers’ educational level No education 122 45.9 Primary 31 11.6 Secondary 81 30.5 Tertiary 32 12.0 Marital status of mothers Single 14 5.3 Married 252 94.7 Mothers’ occupation Unemployed 103 38.7 Trader 144 42.8 Artisan 14 5.3 Salary workers 35 13.2 Ethnicity of mothers Dagomba 224 84.2 Gonja/Mamprusi/Akan 11 4.2 Moshi/Bimoba 29 11.6 Level of household wealth Low 163 61.3 High 103 38.7 Parity 1–2 149 56.0 3–4 83 31.2 5+ 34 12.8 Age of child (months) < 6 122 46.0 6–11 94 35.3 12–23 50 18.7 Sex of children Male 143 53.8 Female 123 46.2 Utilization of GMP Services About three-fifths (59.8%) of the mothers were accessing regular monthly GMP services at the CWC (Table 3 ). Traveling of mothers (68.0%) was the main reason for irregular GMP attendance. The analysis showed that about one-third of mothers were able to interpret falling (36.8%) and flattening (35.7%) growth curves while a little above one-quarter (27.4%) interpreted rising growth curve correctly. The main action taken by mothers was taking child to hospital (33.8% for falling growth curve and 29.3% for flattening growth curve). Meanwhile, about two-fifths (42.2%) of mothers did not know how to response if the child’s growth curve was falling, 46.2% when the growth curve was flattening or 42.1% when the growth curve was rising. Table 3 Utilization of GMP Services (n = 266) Variable Frequency Percentage (%) Monthly GMP attendance Regular attendance 159 59.8 Irregular 107 40.2 Barriers to GMP attendance Travelled 181 68.0 Work 51 19.2 Others 34 12.8 Ability to interpret falling growth curve Yes 98 36.8 No 168 63.2 Ability to interpret flattening growth curve Yes 95 35.7 No 171 64.3 Ability to interpret rising growth curve Yes 73 27.4 No 193 72.6 Response during growth curve falling Improve feeding 57 21.4 Take child to hospital 90 33.8 Seek nutritional care 7 2.6 Don’t know 112 42.2 Response during growth curve flattening Improve feeding 11 4.1 Take child to hospital 78 29.3 Give more breastmilk 54 20.3 Don’t know 123 46.2 Response during growth curve rising Continued breastfeeding and improved care 154 57.9 Don’t know 112 42.1 Nutritional Status of children less than two years of age attending CWC services The nutritional status of children was classified as: underweight, stunting and wasting as summarized based on the WHO classification. Based on the anthropometric measurements, 18.6% of the children were underweight, 14.7% were stunted and 7.9% were wasted (Table 4 ). Table 4 Nutritional status of children < 2 years (n = 266) Variable Frequency Percentage (%) Weight-for-age z score Normal 217 81.6 Underweight 49 18.4 Height/length-for-age z score Normal 227 85.3 Stunted 39 14.7 Weight for length z score Normal 245 92.1 wasted 21 7.9 Maternal knowledge, exclusive breastfeeding and complementary feeding practices In total 122 of the children were less than 6 months of age and analysis showed that 72.1% of these children were exclusively breastfed (Table 5 ). About one-third (33.6%) of these children were breastfed at least eight (8) times. Fewer mothers (5.7%) used at least two (≥ 2) hunger cues to identify hunger among children less than 6 months of age. The majority of children (91.0%) were either breastfed only in the day or in the night. Less than half (46.7%) of the mothers used weightlessness of the breast to determine emptiness and the need to change to the other breast during breastfeeding. The analysis also showed less than one-third (30.3%) of mothers used at least four (4) key signs to demonstrate proper positioning during breastfeeding. Nearly two-thirds (60.7%) of the children < 6 months of age had already received first water. Less than one-fifth (18.0%) of the mothers practiced exclusive breastfeeding for children < 6 months of age in the study area. In total, 144 children were between 6 and 23 months of age. About two-thirds (67.4%) of these children were receiving complementary foods (Table 5 ). The analysis showed that 86.1% of the children were fed at least two (2) times a day on complementary foods. More than two-thirds (70.8%) of the children 6–23 months of age received complementary foods at six (6) months and 66.7% received first water before six months of age. Few children (11.8%) received minimum dietary diversity (≥ 4 food groups). That is, they consumed at least four (4) food groups in a 24-hour recall. Less than half (44.4%) of the mothers with children 6–23 months of age practiced adequate complementary feeding. Overall, about one-third (33.1%) of mothers practiced appropriate/good infant and young child feeding (IYCF) among children < 2 years of age in the Tamale Metropolis. Table 5 Maternal knowledge, exclusive breastfeeding and complementary feeding practices Recommended exclusively breastfeeding practices (n = 122) Variable Frequency Percentage (%) exclusive breastfeeding Yes 88 72.1 No 34 27.9 Number of times child is breastfed in a day ≥ 8 times 41 33.6 < 8 times 81 66.4 Hunger cue used to identify hunger in child ≥ 2 cues 7 5.7 < 2 cues 115 94.3 Time of day child is breastfed Both day and night 11 9.0 Only day/night 111 91.0 Empty one breast at a time during feeding Weightless breast 57 46.7 Not weightless 65 53.3 Proper positioning during breastfeeding Adequate (4 key signs) 37 30.3 Inadequate (< 4 key signs) 85 69.7 Age child received first water < 6 months 74 60.7 ≥ 6 months 48 39.3 Overall exclusive breastfeeding practices Adequate 22 18.0 Inadequate 100 82.0 Recommended complementary feeding practices (n = 144) Child eating in addition to breastmilk Yes 97 67.4 No 47 32.6 Number of times child was fed Adequate (≥ 2) 124 86.1 Inadequate ( < 6 Months 42 29.2 Number of food groups child was fed Adequate (≥ 4) 17 11.8 Inadequate (< 4) 127 88.2 Age child received first water < 6 months 96 66.7 ≥ 6 months 48 33.3 Overall complementary feeding Adequate 64 44.4 Inadequate 80 55.6 IYCF practices (EBF/CF) Good 88 33.1 Poor 178 66.9 Discussion We sought to assess the utilization of growth monitoring and promotion services and nutritional status of children < 2 years of age in northern Ghana. Nearly all (99.2%) mothers were older than 18 years of age (99.2%). In urban communities, women delay marriages until at least 18 years of age. About six out of every ten mothers (57.5%) had either no formal education or only primary education level while about one-tenth (12.0%) of mothers had tertiary level education. The findings of the current study confirm similar conclusions that northern Ghana has low levels of literate population compared to the southern part of the country. In Ghana, the five northern regions (formerly three regions) are the least developed with low level of literate population. We found that 95.0% of the mothers were married. The high level of married mothers in this study is likely due to geographical area and the cultural/religious values. In Muslim majority communities, marriage is considered an important cultural value [ 17 ]. Thus, females are expected to be married before they start to have children. This finding is in consistent with the GDHS 2014 and Population and Housing Census, 2010 reports [ 7 ]. About half (48.1%) of the mothers were traders/artisans. In Muslim dominated communities, petty trade is major activity for women. Often, the extreme poor in such populations are engaged in artisan activities for income generation. We found that about 5.3% of the mothers engaged in artisan activities. This finding is similar to previous study which found about low respondents engaged in artisan activities as source of income. At least three out of every five (61.3%) mothers were classified as living in households with low wealth status. The northern part of Ghana is the least developed with less economic activities. However, as the only Metropolis in northern Ghana, the level of low wealth status was surprisingly high. This may be explained due to the low level of education attained by the mothers. As one progresses in terms of education, the level of productivity and livelihood equally increases. However, in the current study only 42.5% of mothers attained secondary or tertiary level education. This corresponds with the level of low wealth status. We found that more than half (56.0%) of the mothers had 1 or 2 children. This is very important for child growth and development. This is less than the findings in the GDHS 2014 where more than half of the women in northern region had more than 2 children. We found that majority of the children were males (53.8%). Other studies found similar patterns where males are in the majority [ 17 ]. However, there are a couple of studies which rather found that females were in the majority [ 18 ]. We sought to assess the utilization of growth monitoring and promotion (GMP) services as well as nutritional status of children less than two years of age attending child welfare clinics (CWC). The effective utilization of GMP services is critical to child nutritional status. The focus of GMP services is to affect family-level decision making on child feeding. For health workers, it provides an opportunity to assess child health status and offer counseling on healthy feeding, whereas for mothers, they acquire knowledge about the growth of their children and how to improve on it [ 9 , 19 ]. The study assessed the relationship between utilization of GMP services and child nutritional status. Nutritional status was determined using weight-for-age Z scores for underweight, height-for-age Z score for stunted growth and weight-for-height Z scores for wasting. In the current study, underweight was 18.4%, stunting was 14.7% and wasting was 7.9%. The 2014 Ghana Demographic and Health Survey found 20.1% of children under five years to be underweight, 33.1% stunted and 6.3% wasted in northern region [ 7 ]. The nutritional status of children in the study area is generally poor. There have been similar revelations about poor nutritional status in developing countries from various studies across the world [ 20 ]. Black et al., (2008) found in their study that, developing countries bear the highest burden of under-nutrition in spite of the advancement made in nutrition worldwide [ 21 ]. Reasons for these findings are not clear but we think that, inadequate infant feeding practices coupled with infections could be a contributory factor. Unlike the Southern sector in Ghana, northern region is one of the poorest regions in the country with a single but short rainy season. This generally affects household food security and dietary diversity particularly in the dry season. It also affects farming, household income and food supply. This overall contributes to the nutritional situation revealed by this study. In assessing the utilization of GMP services, the child’s health record card was used to record information on how regular mothers utilized the available services. Those who never defaulted in any of their monthly appointments were referred to as “regular attendants”, but those who have ever defaulted were classified as “not regular attendants”. The results found that, about 60% were regular attendants. Studies conducted in Kwazulu Natal and Uganda found that 67% and 59% of mothers were regular attendants [ 22 ]. However, this finding is higher than a previous study conducted by Feleke et al . 2017 who reported that the utilization rate of GMP services was only 16.9% in Ethiopia [ 23 ]. The current finding may suggest a well-implemented intervention in Ghana compare to Ethiopia. The findings also revealed that, over 97% of respondents expressed their intention to continue seeking GMP services because of its importance. The intention to continue seeking GMP services did not reflect the regular attendance rate. This could be attributed to service utilization challenges such as unavailability of services at the time of need, inadequate information on next visit, busy schedules of mothers and natural barriers such as rain. Feeding practices of children < 6 months of age were estimated using the WHO child feeding recommendation [ 15 ]. We assessed whether the children received only breastmilk or infant formula/semi-solid/solid foods in a 24-hour recall. Overall, less than one-fifth (18.0%) of the mothers practiced exclusive breastfeeding for children < 6 months of age in the study area. This is less than the results of the GDHS, 2014, where 28.9% of caregivers interviewed were practicing exclusive breastfeeding [ 7 ]. Similarly, some studies in the advanced countries have also noted a reduced prevalence rate of the practice of optimal exclusive breastfeeding [ 24 ]. Regarding children, 6–23 months of age, dietary diversity, feeding frequency and current breastfeeding status were used to create a feeding practice score in line with the WHO guidelines [ 15 ]. Overall, less than half (44.4%) of the mothers with children 6–23 months of age practiced adequate complementary feeding. Similar findings have been reported in other studies [ 24 ]. This is an indication that majority of children 6–23 months are underfed. This kind of practice makes them more vulnerable to undernutrition. However, improvement in complementary feeding practices have been observed in areas where health workers offer age appropriate nutrition counseling specific to the family environment [ 25 ]. In combining children < 6 and 6–23 months of age, only one-third (33.1%) of mothers practiced appropriate infant and young child feeding (IYCF) among children < 2 years of age in the Tamale Metropolis. This result may have influenced the undernutrition indicators observed in this study − 18.4% underweight, 14.7% stunted and 7.9% wasted. Limitations Of Study The study has some limitations. Data for this study were collected one time and thus a probable change in child nutritional status in relation to attendance over time may have been missed. However, we believe that the findings reflect the prevailing situation among the participants in the study site. Conclusion We found that, the level of undernutrition was high, child feeding practices was poor and maternal utilization of GMP services was low in the study area. Similarly, ability to interpret the child’s growth curve appropriately was a challenge among women. Thus, attention is needed to improve knowledge and utilization of GMP services and to address breastfeeding and complementary feeding challenges. Declarations Ethical approval An introductory letter and ethical approval was received from the ethics committee of School of Public Health, University for Development Studies, Tamale, Ghana. In addition, permission letter was obtained upon a written request and explanation of the protocol, methods and questionnaires from the Tamale Metropolitan Health Directorate. At the individual level, the protocol, methods and approach was explained in English or Dagomba (main local language) and an informed consent was obtained from each respondent of 18 years of age and above before the interview was conducted. Among the few teenagers, informed consent was obtained through their husbands (those married) or parents (those unmarried) and legal guardians (with no education) was provided. Respondents were informed that participating was voluntary and it was their right to stop at any time. They were also informed of data confidentiality by not using any personal identifiers. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable Availability of dataset The dataset analyzed during the current study are available from the corresponding author on request. Competing interests The authors declare that they have no competing interests Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions MNA and DM conceptualized and designed the protocol. MNA supervised the implementation of the study. MNA and DM conducted the study and performed analysis. BB and EB drafted the manuscript. MNA, BB and EB edited the manuscript. All authors read and approved the final manuscript. Acknowledgments The authors are grateful to all heads of households who gave the researchers the permission to interview respondents and the individual respondents for their consent for this study. 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Lancet (London, England) 2008; 371 (9608), 243–60. https://doi.org/10.1016/S0140-6736(07)61690-0 Faber M, Phungula MA, Kvalsvig JD Benadé AJ. Acceptability of community-based growth monitoring in a rural village in South Africa. Food and Nutrition Bulletin 2003; 24(4), 350–359. https://doi.org/10.1177/156482650302400405 Feleke FW, Adole A.A, Bezabih AM. Utilization of growth monitoring and promotion services and associated factors among under two years of age children in Southern Ethiopia. PLOS ONE 2017; 12 (5), e0177502. https://doi.org/10.1371/journal.pone.0177502 Al-Sahab, B., Lanes, A., Feldman, M., & Tamim, H. Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey. BMC Pediatrics 2010; 10 , 20. https://doi.org/10.1186/1471-2431-10-20 Pelto, G. H., Santos, I., Gonçalves, H., Victora, C., Martines, J., & Habicht, J.-P. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. The Journal of Nutritio n 2004; 134 (2), 357–62. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14747672 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Jun, 2023 Read the published version in BMC Nutrition → Version 1 posted Editorial decision: Major revision 07 Sep, 2022 Reviews received at journal 05 Sep, 2022 Reviews received at journal 17 Jul, 2022 Reviewers agreed at journal 23 Jun, 2022 Reviewers agreed at journal 20 Jun, 2022 Reviewers invited by journal 20 Jun, 2022 Editor assigned by journal 20 Jun, 2022 Editor invited by journal 06 Jun, 2022 Submission checks completed at journal 06 Jun, 2022 First submitted to journal 03 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1722413","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":111442183,"identity":"ad6d977e-6724-4001-897a-788e45ba2cf9","order_by":0,"name":"Benjamin Baguune","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYHACNhAhJ8HeAKQOgNiMjQeI0WIswXMArEUCqKWBKC2JMyQSYFqgluEC8hE5Zg8+7jjMOHPm24cPfpyxqdNtPwy0pcYmGpcWwxs55oYzzxxmlpZONzbsuZEmYXYmEajlWFpuAy4tM3LMpHnbDrPJSaexSTN8OCxhdgCohbHhMH4tf9sO88hJHgNp+S9hdv4hfi3yEkAtjG2HJaQl2IBabhyQMLtBwBYDnmflhr1t6QaSPWnMhj1nkiW33QDakoDHL/Ltydse/Gyzrp9x/Bjjgx/H7PjNzqc/fPChxga3LQfAVDOacAIO5WBbIGbV4VEyCkbBKBgFIx4AAK1xYlOSMKBgAAAAAElFTkSuQmCC","orcid":"","institution":"Ministry of Health","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Baguune","suffix":""},{"id":111442186,"identity":"b4140808-bc66-484f-869d-a75b8c1ad157","order_by":1,"name":"Dramani M. Aminu","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dramani","middleName":"M.","lastName":"Aminu","suffix":""},{"id":111442192,"identity":"38b6c8d3-da3d-41d0-9e02-b77a02731dab","order_by":2,"name":"Emmanuel Bekyieriya","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Bekyieriya","suffix":""},{"id":111442196,"identity":"7cfd34ea-3bef-4642-a53d-2a87786af046","order_by":3,"name":"Martin N. Adokiya","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martin","middleName":"N.","lastName":"Adokiya","suffix":""}],"badges":[],"createdAt":"2022-06-03 10:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1722413/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1722413/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40795-023-00729-6","type":"published","date":"2023-06-22T21:17:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44733046,"identity":"fd349c57-599b-45bd-ae23-3ba349d0f31e","added_by":"auto","created_at":"2023-10-16 22:03:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":649637,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1722413/v1/c7724e2f-55a8-4783-9332-acfb55ac5c65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilization of Growth Monitoring and Promotion Services and Undernutrition of Children less than two years of Age in Northern Ghana","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalnutrition remains the world\u0026rsquo;s most serious health problem and major contributor to child mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Child malnutrition is responsible for \u0026gt;\u0026thinsp;50.0% of all childhood deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, it is estimated that, 25.6% of children\u0026thinsp;\u0026lt;\u0026thinsp;5 years of age are stunted with prevalence rates\u0026thinsp;\u0026gt;\u0026thinsp;40% in many developing countries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Also, it is estimated that, 43.0% of children\u0026thinsp;\u0026lt;\u0026thinsp;5 years in developing countries are prone to falling short of their life potentials due to poor nutritional situations they faced in their early formative years [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The inadequacy of growth is high among children\u0026thinsp;\u0026lt;\u0026thinsp;24 months of age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The period from birth until two years of age is considered a critical stage for maximum nutrition care to enhance optimum growth. This is the basis for global initiatives toward child care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Child malnutrition is an important public health problem in Ghana. According to 2014 Ghana Demographic and Health Survey (GDHS) report, 19% of children\u0026thinsp;\u0026lt;\u0026thinsp;5 years of age were stunted, 11% were underweight and 5% were wasted. In northern Ghana, 33.1% of children were stunted, 20.1% were underweight and 6.3% were wasted. Similarly, stunting was between 8.0% and 21.9%, underweight was between 4.2% and 14.6% and wasting was between 6.9% and 10.6% among children less than 2 years of age in Ghana [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGrowth monitoring (GM) is the measurement that best defines the children\u0026rsquo;s health and nutritional status. It provides a measurement on the quality of life of the entire population [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The growth pattern of a child is determined by comparing his/her growth indices with that of a reference child of the same age and sex [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Ghana, GMP services are implemented at the community level through the primary health care system in order to improve child nutritional status. GMP is a prevention activity comprised child GM linked with promotion that increases awareness about child growth; improves caring practices and increases demand for other services. It also serves as the core activity in an integrated child health and nutrition program [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Globally, growth chart is used as a tool to monitor child\u0026rsquo;s growth and determine the nutritional status of children. GM uses weight-for-age, weight-for-height and height-for-age as indicators to determine the nutritional status of children. The growth monitoring outcomes are complemented with targeted counseling for children with special needs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The GM also provides opportunity for intercommunication between health workers and caregivers concerning the wellbeing of their children [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In Ghana, children are routinely weighed on a monthly basis. Regular monitoring of growth helps in early detection of danger warning signs and conditions that affect growth [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite several efforts to reduce child malnutrition through GMP services in Ghana, prevalence of malnutrition remains high among child\u0026thinsp;\u0026lt;\u0026thinsp;5 years, particularly in northern Ghana [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Few studies have been conducted to determine the utilization of GMP services and prevalence of undernutrition in Ghana. Thus, the objective of this study was to assess the utilization of growth monitoring and promotion services and nutritional status of children less than two years of age in northern Ghana.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec3\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWe employed a cross-sectional descriptive design to collect data from mothers with children less than two years of age. The study was conducted in the Tamale Metropolis of Northern Region, Ghana. There are six (6) Metropolis in Ghana and the Tamale Metropolis is the only one in the north of the country. Currently, the north of Ghana is composed of five (5) regions namely: Upper East, Upper West, Northern, North-East and Savannah Regions. The Metropolis is located in the central part of the Northern Region with Tamale as the capital. It has an estimated land size of 646.90180 square kilometre and a population of 233,252 [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. According to the database of the District Health Information Management System, 64,641 women are in their reproductive age and 10,769 children are less than two years of age. Health services in the Metropolis are provided by public and private health facilities in four (4) demarcated sub-metropolis [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. We used the formula by Cochran (1963) to calculate the sample size for mother-child pairs for the study. We used the highest prevalence of underweight (14.6%) among children less than two years in Ghana [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e] and the study population was 10,769 children. In using a 95% confidence interval (CI), 5% margin of error and a 1.4 design effect (DE), a sample size of 270 respondents was calculated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population were women of childbearing age (15\u0026ndash;49 years) with children\u0026thinsp;\u0026lt;\u0026thinsp;2 years of age. The main criteria for inclusion of households were: 1) a mother who has a child less than two years of age; 2) a mother who was present at the time of the survey; 3) child of singleton birth, 4) no obvious signs of illness and 5) a mother who consented to participate in the study. The children chosen were within the critical stage of the first 1,000 days of a child\u0026rsquo;s life. The list of qualified mothers was received from the study health facilities. The study participants were chosen using a simple random sampling method within each health facility. This sampling method allowed every member of the population to have an equal chance of being selected. Overall, 266 interviews were conducted \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e comprising of 122 mothers with children aged from \u0026lt;\u0026thinsp;6 months and 144 women with children aged between 6\u0026ndash;23 months.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMothers attending child welfare clinics (CWC) in Tamale Metropolis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eName of health facility\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCWC attendance\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWeighted sample size\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReproductive and Child Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2721\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBuilpela\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVittin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNyohini\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e8186\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e266\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eData collection tool and procedure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe mothers were interviewed using a structured questionnaire which covered socio-demographic characteristics (education, occupation, parity, age, ethnicity, and marital status), child characteristics (age and sex) and utilization of GMP services. In addition, child GM information was extracted from maternal and child health record book using observation checklist. Anthropometric instruments were used to measure weight and height of individual children according to World Health Organization (WHO) guidelines [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. We used Beurer digital scale to measure the weights and recorded to the nearest 0.1kg. All weight measurements were taken in duplicate and the averages recorded. A locally manufactured infantometer with a fixed headboard and a movable footboard was used to measure the recumbent length of children. The length was recorded to the last completed 1.0cm. In addition, all recumbent length measurements were taken in duplicate and the averages recorded. The interviews were conducted privately by two final year students pursuing Bachelor of Science in Nursing at the University for Development Studies, Tamale. The interviews were conducted in Dagbani and English languages. The study tools were pretested in a health facility. The study was conducted during January - February, 2018.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData processing and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn daily basis, the data were checked for completeness and accuracy. Data were entered and analyzed using the Statistical Package for Social Science software for Windows, version 20. Descriptive statistics were performed covering prevalence of undernutrition, utilization of GMP services, breastfeeding and complementary feeding practices. Knowledge of recommended infant feeding practices were scored [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Data on CWC attendance was obtained from the maternal and child health record book. Comprehension of the growth curve and knowledge of GMP activities was determined was determined through the interviews.\u003c/p\u003e\n\u003cp\u003eFeeding practices of children\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age were estimated using the WHO child feeding recommendation [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. We assessed whether the child was fed breastmilk or infant formula/semi-solid/solid foods in a 24-hour recall. A score of zero (0) was given for each wrong practice and score of one (1) for a correct practice. Mothers were interviewed on recommended breastfeeding practices that ensures that the children received good supply of breastmilk. Practices were then divided into \u0026ldquo;adequate\u0026rdquo; and \u0026ldquo;inadequate\u0026rdquo; along the median.\u003c/p\u003e\n\u003cp\u003eChildren 6\u0026ndash;23 months of age, dietary diversity, feeding frequency and current breastfeeding status were used to create a feeding practice score. Using the WHO guidelines [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], seven food groups: 1) grains, roots and tubers; 2) legumes and nuts; 3) dairy products; 4) flesh foods; 5) Eggs, 6) vitamin A fruits and vegetables and 7) other fruits and vegetables and were used to assess dietary diversity score. A score of one (1) was given for a food group fed and zero (0) for a food group not fed based on the guidelines [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. A child with a score of at least four (4) was classified to have a diverse diet. A child fed the recommended minimum feeding frequency was given a score of one (1) for adequate feeding frequency and a child who fed less than the minimum frequency was given a score of zero (0). A breastfed child received a score of one (1) while a non-breastfed child was given a score of zero (0). The total practice score was then determined by adding scores from all the variables.\u003c/p\u003e\n\u003cp\u003eChild anthropometric data are expressed by age and sex appropriate z-scores for weight-for-age (WAZ), weight-for-height/length(WHZ) and height-for-age (HAZ). The children were grouped into normal z-scores for all indicators \u0026ge;-2 standard deviation, underweight (WAZ \u0026lt;-2 score), wasting (WHZ \u0026lt;-2 score) and stunting (HAZ \u0026lt;-2 score). The child nutritional status was then classified into normal as against underweight stunted or wasted [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIn total, 266 mothers with children less than 2 years were enrolled. Analysis show that 85% of the participants were between 18 and 34 years of age. More than half (57.5%) of the participants had either no education (45.9%) or only primary education (11.6%). Nearly all (94.7%) of the mothers were married. About half (42.8%) of the mothers were traders. More than half (61.3%) of the women were classified as coming from low wealth households and more than half (56.0%) had either 1\u0026ndash;2 children. Less than half (46.0%) of the children were \u0026lt;\u0026thinsp;6 months of age. More than half (53.8%) of the children were males (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic characteristics of mothers with children\u0026thinsp;\u0026lt;\u0026thinsp;2 years (n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics of respondents\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge of mother (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge; 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMothers\u0026rsquo; educational level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status of mothers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMothers\u0026rsquo; occupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArtisan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSalary workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity of mothers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDagomba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGonja/Mamprusi/Akan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMoshi/Bimoba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of household wealth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge of child (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u0026ndash;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex of children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003cp\u003e\u003cstrong\u003eUtilization of GMP Services\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAbout three-fifths (59.8%) of the mothers were accessing regular monthly GMP services at the CWC (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Traveling of mothers (68.0%) was the main reason for irregular GMP attendance. The analysis showed that about one-third of mothers were able to interpret falling (36.8%) and flattening (35.7%) growth curves while a little above one-quarter (27.4%) interpreted rising growth curve correctly. The main action taken by mothers was taking child to hospital (33.8% for falling growth curve and 29.3% for flattening growth curve). Meanwhile, about two-fifths (42.2%) of mothers did not know how to response if the child\u0026rsquo;s growth curve was falling, 46.2% when the growth curve was flattening or 42.1% when the growth curve was rising.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUtilization of GMP Services (n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly GMP attendance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular attendance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIrregular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to GMP attendance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTravelled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbility to interpret falling growth curve\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbility to interpret flattening growth curve\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbility to interpret rising growth curve\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse during growth curve falling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImprove feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTake child to hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeek nutritional care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse during growth curve flattening\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImprove feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTake child to hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGive more breastmilk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse during growth curve rising\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinued breastfeeding and improved care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNutritional Status of children less than two years of age attending CWC services\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThe nutritional status of children was classified as: underweight, stunting and wasting as summarized based on the WHO classification. Based on the anthropometric measurements, 18.6% of the children were underweight, 14.7% were stunted and 7.9% were wasted (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNutritional status of children\u0026thinsp;\u0026lt;\u0026thinsp;2 years (n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight-for-age z score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeight/length-for-age z score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e85.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStunted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight for length z score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ewasted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal knowledge, exclusive breastfeeding and complementary feeding practices\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIn total 122 of the children were less than 6 months of age and analysis showed that 72.1% of these children were exclusively breastfed (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). About one-third (33.6%) of these children were breastfed at least eight (8) times. Fewer mothers (5.7%) used at least two (\u0026ge;\u0026thinsp;2) hunger cues to identify hunger among children less than 6 months of age. The majority of children (91.0%) were either breastfed only in the day or in the night. Less than half (46.7%) of the mothers used weightlessness of the breast to determine emptiness and the need to change to the other breast during breastfeeding. The analysis also showed less than one-third (30.3%) of mothers used at least four (4) key signs to demonstrate proper positioning during breastfeeding. Nearly two-thirds (60.7%) of the children\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age had already received first water. Less than one-fifth (18.0%) of the mothers practiced exclusive breastfeeding for children\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age in the study area.\u003c/p\u003e\n\u003cp\u003eIn total, 144 children were between 6 and 23 months of age. About two-thirds (67.4%) of these children were receiving complementary foods (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). The analysis showed that 86.1% of the children were fed at least two (2) times a day on complementary foods. More than two-thirds (70.8%) of the children 6\u0026ndash;23 months of age received complementary foods at six (6) months and 66.7% received first water before six months of age. Few children (11.8%) received minimum dietary diversity (\u0026ge;\u0026thinsp;4 food groups). That is, they consumed at least four (4) food groups in a 24-hour recall. Less than half (44.4%) of the mothers with children 6\u0026ndash;23 months of age practiced adequate complementary feeding. Overall, about one-third (33.1%) of mothers practiced appropriate/good infant and young child feeding (IYCF) among children\u0026thinsp;\u0026lt;\u0026thinsp;2 years of age in the Tamale Metropolis.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab5\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMaternal knowledge, exclusive breastfeeding and complementary feeding practices\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eRecommended exclusively breastfeeding practices (n\u0026thinsp;=\u0026thinsp;122)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eexclusive breastfeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of times child is breastfed in a day\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;8 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;8 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHunger cue used to identify hunger in child\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;2 cues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;2 cues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of day child is breastfed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth day and night\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOnly day/night\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmpty one breast at a time during feeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeightless breast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot weightless\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProper positioning during breastfeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdequate (4 key signs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate (\u0026lt;\u0026thinsp;4 key signs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge child received first water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall exclusive breastfeeding practices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommended complementary feeding practices (n\u0026thinsp;=\u0026thinsp;144)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild eating in addition to breastmilk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of times child was fed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdequate (\u0026ge;\u0026thinsp;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate (\u0026lt;\u0026thinsp;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge child received other foods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt; \u0026lt; 6 Months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of food groups child was fed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdequate (\u0026ge;\u0026thinsp;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate (\u0026lt;\u0026thinsp;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge child received first water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall complementary feeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIYCF practices (EBF/CF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe sought to assess the utilization of growth monitoring and promotion services and nutritional status of children\u0026thinsp;\u0026lt;\u0026thinsp;2 years of age in northern Ghana. Nearly all (99.2%) mothers were older than 18 years of age (99.2%). In urban communities, women delay marriages until at least 18 years of age. About six out of every ten mothers (57.5%) had either no formal education or only primary education level while about one-tenth (12.0%) of mothers had tertiary level education. The findings of the current study confirm similar conclusions that northern Ghana has low levels of literate population compared to the southern part of the country. In Ghana, the five northern regions (formerly three regions) are the least developed with low level of literate population. We found that 95.0% of the mothers were married. The high level of married mothers in this study is likely due to geographical area and the cultural/religious values. In Muslim majority communities, marriage is considered an important cultural value [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, females are expected to be married before they start to have children. This finding is in consistent with the GDHS 2014 and Population and Housing Census, 2010 reports [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. About half (48.1%) of the mothers were traders/artisans. In Muslim dominated communities, petty trade is major activity for women. Often, the extreme poor in such populations are engaged in artisan activities for income generation. We found that about 5.3% of the mothers engaged in artisan activities. This finding is similar to previous study which found about low respondents engaged in artisan activities as source of income. At least three out of every five (61.3%) mothers were classified as living in households with low wealth status. The northern part of Ghana is the least developed with less economic activities. However, as the only Metropolis in northern Ghana, the level of low wealth status was surprisingly high. This may be explained due to the low level of education attained by the mothers. As one progresses in terms of education, the level of productivity and livelihood equally increases. However, in the current study only 42.5% of mothers attained secondary or tertiary level education. This corresponds with the level of low wealth status. We found that more than half (56.0%) of the mothers had 1 or 2 children. This is very important for child growth and development. This is less than the findings in the GDHS 2014 where more than half of the women in northern region had more than 2 children. We found that majority of the children were males (53.8%). Other studies found similar patterns where males are in the majority [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, there are a couple of studies which rather found that females were in the majority [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe sought to assess the utilization of growth monitoring and promotion (GMP) services as well as nutritional status of children less than two years of age attending child welfare clinics (CWC). The effective utilization of GMP services is critical to child nutritional status. The focus of GMP services is to affect family-level decision making on child feeding. For health workers, it provides an opportunity to assess child health status and offer counseling on healthy feeding, whereas for mothers, they acquire knowledge about the growth of their children and how to improve on it [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The study assessed the relationship between utilization of GMP services and child nutritional status. Nutritional status was determined using weight-for-age Z scores for underweight, height-for-age Z score for stunted growth and weight-for-height Z scores for wasting. In the current study, underweight was 18.4%, stunting was 14.7% and wasting was 7.9%. The 2014 Ghana Demographic and Health Survey found 20.1% of children under five years to be underweight, 33.1% stunted and 6.3% wasted in northern region [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The nutritional status of children in the study area is generally poor. There have been similar revelations about poor nutritional status in developing countries from various studies across the world [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Black et al., (2008) found in their study that, developing countries bear the highest burden of under-nutrition in spite of the advancement made in nutrition worldwide [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Reasons for these findings are not clear but we think that, inadequate infant feeding practices coupled with infections could be a contributory factor. Unlike the Southern sector in Ghana, northern region is one of the poorest regions in the country with a single but short rainy season. This generally affects household food security and dietary diversity particularly in the dry season. It also affects farming, household income and food supply. This overall contributes to the nutritional situation revealed by this study. In assessing the utilization of GMP services, the child\u0026rsquo;s health record card was used to record information on how regular mothers utilized the available services. Those who never defaulted in any of their monthly appointments were referred to as \u0026ldquo;regular attendants\u0026rdquo;, but those who have ever defaulted were classified as \u0026ldquo;not regular attendants\u0026rdquo;. The results found that, about 60% were regular attendants. Studies conducted in Kwazulu Natal and Uganda found that 67% and 59% of mothers were regular attendants [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, this finding is higher than a previous study conducted by Feleke \u003cem\u003eet al\u003c/em\u003e. 2017 who reported that the utilization rate of GMP services was only 16.9% in Ethiopia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The current finding may suggest a well-implemented intervention in Ghana compare to Ethiopia. The findings also revealed that, over 97% of respondents expressed their intention to continue seeking GMP services because of its importance. The intention to continue seeking GMP services did not reflect the regular attendance rate. This could be attributed to service utilization challenges such as unavailability of services at the time of need, inadequate information on next visit, busy schedules of mothers and natural barriers such as rain.\u003c/p\u003e \u003cp\u003eFeeding practices of children\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age were estimated using the WHO child feeding recommendation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We assessed whether the children received only breastmilk or infant formula/semi-solid/solid foods in a 24-hour recall. Overall, less than one-fifth (18.0%) of the mothers practiced exclusive breastfeeding for children\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age in the study area. This is less than the results of the GDHS, 2014, where 28.9% of caregivers interviewed were practicing exclusive breastfeeding [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, some studies in the advanced countries have also noted a reduced prevalence rate of the practice of optimal exclusive breastfeeding [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Regarding children, 6\u0026ndash;23 months of age, dietary diversity, feeding frequency and current breastfeeding status were used to create a feeding practice score in line with the WHO guidelines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Overall, less than half (44.4%) of the mothers with children 6\u0026ndash;23 months of age practiced adequate complementary feeding. Similar findings have been reported in other studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This is an indication that majority of children 6\u0026ndash;23 months are underfed. This kind of practice makes them more vulnerable to undernutrition. However, improvement in complementary feeding practices have been observed in areas where health workers offer age appropriate nutrition counseling specific to the family environment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In combining children\u0026thinsp;\u0026lt;\u0026thinsp;6 and 6\u0026ndash;23 months of age, only one-third (33.1%) of mothers practiced appropriate infant and young child feeding (IYCF) among children\u0026thinsp;\u0026lt;\u0026thinsp;2 years of age in the Tamale Metropolis. This result may have influenced the undernutrition indicators observed in this study \u0026minus;\u0026thinsp;18.4% underweight, 14.7% stunted and 7.9% wasted.\u003c/p\u003e"},{"header":"Limitations Of Study","content":"\u003cp\u003eThe study has some limitations. Data for this study were collected one time and thus a probable change in child nutritional status in relation to attendance over time may have been missed. However, we believe that the findings reflect the prevailing situation among the participants in the study site.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe found that, the level of undernutrition was high, child feeding practices was poor and maternal utilization of GMP services was low in the study area. Similarly, ability to interpret the child\u0026rsquo;s growth curve appropriately was a challenge among women. Thus, attention is needed to improve knowledge and utilization of GMP services and to address breastfeeding and complementary feeding challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn introductory letter and ethical approval was received from the ethics committee of School of Public Health, University for Development Studies, Tamale, Ghana. In addition, permission letter was obtained upon a written request and explanation of the protocol, methods and questionnaires from the Tamale Metropolitan Health Directorate. At the individual level, the protocol, methods and approach was explained in English or Dagomba (main local language) and an informed consent was obtained from each respondent of 18 years of age and above before the interview was conducted. Among the few teenagers, informed consent was obtained through their husbands (those married) or parents (those unmarried) and legal guardians (with no education) was provided. Respondents were informed that participating was voluntary and it was their right to stop at any time. They were also informed of data confidentiality by not using any personal identifiers. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of dataset\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMNA and DM conceptualized and designed the protocol. MNA supervised the implementation of the study. MNA and DM conducted the study and performed analysis. BB and EB drafted the manuscript. MNA, BB and EB edited the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all heads of households who gave the researchers the permission to interview respondents and the individual respondents for their consent for this study. We would also like to acknowledge the contributions made by Ghana Health Service staff and the research assistants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Bank. Repositioning Nutrition as Central to Development; A Strategy for Large Scale Action. Washington DC, USA; 2006.\u003c/li\u003e\n \u003cli\u003eAsfaw M, Wondaferash M, Taha M, Dube L. 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Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2008; \u003cem\u003e371\u003c/em\u003e(9608), 243\u0026ndash;60.\u0026nbsp;\u003ca href=\"https://doi.org/10.1016/S0140-6736(07)61690-0\"\u003ehttps://doi.org/10.1016/S0140-6736(07)61690-0\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eFaber M, Phungula MA, Kvalsvig JD Benad\u0026eacute; AJ. Acceptability of community-based growth monitoring in a rural village in South Africa. \u003cem\u003eFood and Nutrition Bulletin\u003c/em\u003e 2003; 24(4), 350\u0026ndash;359. https://doi.org/10.1177/156482650302400405\u003c/li\u003e\n \u003cli\u003eFeleke FW, Adole A.A, Bezabih AM. Utilization of growth monitoring and promotion services and associated factors among under two years of age children in Southern Ethiopia. \u003cem\u003ePLOS ONE\u003c/em\u003e 2017; \u003cem\u003e12\u003c/em\u003e(5), e0177502. \u003ca href=\"https://doi.org/10.1371/journal.pone.0177502\"\u003ehttps://doi.org/10.1371/journal.pone.0177502\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eAl-Sahab, B., Lanes, A., Feldman, M., \u0026amp; Tamim, H. Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey. \u003cem\u003eBMC Pediatrics\u003c/em\u003e 2010; \u003cem\u003e10\u003c/em\u003e, 20. \u003ca href=\"https://doi.org/10.1186/1471-2431-10-20\"\u003ehttps://doi.org/10.1186/1471-2431-10-20\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003ePelto, G. H., Santos, I., Gon\u0026ccedil;alves, H., Victora, C., Martines, J., \u0026amp; Habicht, J.-P. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. \u003cem\u003eThe Journal of Nutritio\u003c/em\u003en 2004; \u003cem\u003e134\u003c/em\u003e(2), 357\u0026ndash;62. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14747672\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal, child, GMP, feeding practice, undernutrition, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-1722413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1722413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChild malnutrition is a major public health problem and an important indicator of child\u0026rsquo;s health. Adequate nutrition is critical for a child\u0026rsquo;s growth and development. Growth monitoring and promotion (GMP) services is a nutrition intervention aimed at improving the nutritional status of children. We assessed the utilization of growth monitoring and promotion services and nutritional status of children less than two years in northern Ghana.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was a descriptive cross-sectional survey that involved face-to-face interviews among 266 mothers with children\u0026thinsp;\u0026lt;\u0026thinsp;2 years of age attending child welfare clinics (CWC) as well as some anthropometric measurements. Data were entered and analyzed using Statistical Package for Social Science software, version 20. The nutritional status of children was classified as underweight (weight-for-age z score \u0026lt; -2 standard deviations), stunted (length-for-age Z score\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;2) and wasted (weight-for-length z score \u0026lt; -2) while utilization of GMP services was based on attendance to CWC and ability to interpret to different growth curves.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of child undernutrition shows that, 18.6% were underweight, 14.7% were stunted and 7.9% were wasted. About 60% of the mothers accessed GMP services regularly. The main reason for irregular access to GMP services was due to travel out (68.0%). Less than half of the mothers were able to interpret the children\u0026rsquo;s growth curve correctly: falling growth curve (36.8%), flattening growth curve (35.7%) and rising growth curve (27.4%). In combining children\u0026thinsp;\u0026lt;\u0026thinsp;6 and 6\u0026ndash;23 months of age. Only one-third (33.1%) of mothers practiced appropriate infant and young child feeding.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found that, the level of undernutrition was high, child feeding practices was poor and maternal utilization of GMP services was low in the study area. Similarly, ability to interpret the child\u0026rsquo;s growth curve appropriately was a challenge among women. Thus, attention is needed to improve knowledge and utilization of GMP services and to address breastfeeding and complementary feeding challenges.\u003c/p\u003e","manuscriptTitle":"Utilization of Growth Monitoring and Promotion Services and Undernutrition of Children less than two years of Age in Northern Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-08 16:55:38","doi":"10.21203/rs.3.rs-1722413/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-09-07T05:19:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-05T21:46:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-17T23:18:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b845a52c-4d38-47ce-ad07-c127c7906bf6","date":"2022-06-23T18:24:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"874a6858-e638-4880-a073-04eabf75d37d","date":"2022-06-20T22:02:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-20T15:22:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-06-20T15:20:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-06T12:46:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-06T12:42:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2022-06-03T10:57:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"74296cbb-520b-4a98-b002-0c535dd2b019","owner":[],"postedDate":"June 8th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T21:46:46+00:00","versionOfRecord":{"articleIdentity":"rs-1722413","link":"https://doi.org/10.1186/s40795-023-00729-6","journal":{"identity":"bmc-nutrition","isVorOnly":false,"title":"BMC Nutrition"},"publishedOn":"2023-06-22 21:17:53","publishedOnDateReadable":"June 22nd, 2023"},"versionCreatedAt":"2022-06-08 16:55:38","video":"","vorDoi":"10.1186/s40795-023-00729-6","vorDoiUrl":"https://doi.org/10.1186/s40795-023-00729-6","workflowStages":[]},"version":"v1","identity":"rs-1722413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1722413","identity":"rs-1722413","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}