Mothers’ knowledge and attitudes regarding child feeding recommendations, complementary feeding practices and determinants of adequate diet

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However, evidence shows children from developing countries do not meet the core indicators for appropriate complementary feeding. We evaluated mothers’ knowledge and attitudes regarding child feeding recommendations and the determinants of adequate diet among children aged 6-23 months. Methods: This cross-sectional study included 200 children aged 6-23 months and their mothers/care givers recruited during the child welfare clinics of two health facilities in Ghana. Data was collected using a structured questionnaire. Multivariate logistic regression was used to assess determinants of adequate diet. Results: Sixty-eight percent of the mothers knew the recommended duration of continued breastfeeding, 56.5% how to ensure dietary diversity and enrich their children’s diets and 94% (n=188) had positive attitude towards recommended infant and young child feeding practices. Majority of the mothers (92%, n=183) practiced continued breastfeeding, 10.5% of the children met minimum diet diversity score, 39.5% minimum meal frequency and 8.5% received minimum adequate diet. Determinants of receipt of minimum adequate diet were: having high knowledge in child feeding recommendations (100% vs. 0.0; p<0.001) and child’s father reportedly earning adequate income to cater for the family (AOR = 12.1 (1.32 – 109.72; p = 0.027). Conclusion: Motherss knowledge levels regarding infant and young child feeding recommendations had notable deficiencies although they generally had a positive attitude towards child feeding recommendations. Knowledge regarding infant and young child feeding recommendations as well as the child’s father having adequate income were important determinants of adequate diet. Nutrition education should emphasize on improving mothers’ nutrition knowledge regarding infant and young child feeding recommendations and supporting mothers to overcome barriers to feed their children with adequate diets. Nutrition & Dietetics Knowledge attitudes child feeding practices Kpandai Ghana Figures Figure 1 Background Child malnutrition is a global emergency affecting every country in the world [1]. Globally, 151 children aged 0-59 months are stunted; 51 million wasted and 38.3 million have excess weight [1]. In sub-Saharan Africa, 39% of children are stunted; 28% wasted and 24% overweight [2]. According to the 2014 Ghana Demographic and Health Survey (GDHS), 19% of Ghanaian children are stunted, 5% wasted, 11% underweight and about 3% are overweight [3]. The Northern Region of Ghana has the highest prevalence of stunting affecting 33% of children aged under 5 years. A number of underlying factors could be contributing to the rising prevalence of malnutrition in children including poor access to health care, inadequate caring and feeding practices and poor sanitation [4]. Among these, appropriate complementary feeding is very paramount and has been shown to improve nutrition status of children. According to the WHO there are eight core indicators of that can be used to assess and guide the feeding practices of young children including 1) early initiation of breastfeeding; (2) exclusive breastfeeding under six months; (3) continued breastfeeding for one year; (4) the introduction of solid, semi-solid or soft foods; (5) minimum dietary diversity; (6) minimum meal frequency; (7) minimum acceptable diet; and (8) consumption of iron rich or iron fortified foods [5, 6]. Appropriate complementary feeding refers to the timely introduction of solid, semi-solid or soft foods, minimum meal frequency, minimum adequate diet and minimum dietary diversity ([5-7]. It has been linked to optimal nutrition in infant and young children as it ensures their growth, health and development to attain their full potential. It’s been shown to reduce child morbidity and mortality thereby increasing child survival and protection [8, 9]. No wonder the WHO recommends that nutritionally adequate and safe complementary feeding should start from age 6 months with continued breastfeeding up to 2 years of age or beyond [8, 9].Evidence shows that appropriate complementary feeding rates in developing countries are less desirable and majority of infants and young children do not meet the minimum indicators for appropriate complementary feeding [10, 11]. Only 13% of Ghanaian children aged 6-23 months are fed a minimum acceptable diet [3]. Among a sample of 778 children aged 6-23 months from Northern Ghana, Saaka et al [7] found 57.3% of the children meeting the minimum meal frequency, 35.3% minimum dietary diversity score and 25% had minimum acceptable diet. In Nigeria, Udoh et al [12]found 31.5% of a sample of 330 children aged 6-23 months from Cross River State meeting minimum diet diversity, 36.5% minimum meal frequency and 7.3% received an acceptable diet. A community-based cross-sectional study among a sample of 506 children from North West Ethiopia found only 63% of the children receiving minimum meal frequency, 9.8% for minimum diet diversity and only 8.6% received the minimum acceptable diet [13]. A number of factors have been noted for the less optimal rates of appropriate complementary feeding including maternal education, income levels, antenatal attendance, spouse employment status, quality of institutional healthcare delivery, women empowerment in decision making, and among others [7, 13-15]. Notable among these factors is the mothers’ knowledge and attitudes regarding child feeding recommendations. There is evidence that high knowledge is associated with improved complementary feeding practices among mothers [15-17]. A few studies have investigated adequate diet and its determinants among infant and young children in Ghana. In our search of the literature we only came across three studies [7, 17, 18] that have investigated the core indicators of complementary feeding such as meal frequency, diet diversity, minimum adequate diet and their determinants among children aged 6-23 months. The Saaka et al [7] study that was conducted in Northern Ghana assessed the three indicators of appropriate complementary feeding but did not assess the knowledge and attitude of the mothers regarding infant and young child feeding recommendations. Gyampoh et al [17] investigated mothers knowledge regarding recommended infant and young child recommendations and its association with complementary feeding practices but did not assess the mothers/care givers’ attitude towards complementary feeding practices and was also conducted in Accra, which differ socio-economically from Northern Ghana. Frempong and Annim [18] investigated dietary diversity and malnutrition in children using the Ghana Multiple Indicator Cluster Survey for 2011 but did not assess the other indicators of complementary feeding such as meal frequency and acceptable diet. Thus, there is limited data regarding the knowledge and attitudes of mothers on infant and young child feeding recommendations and how these are associated with complementary feeding practices in Northern Ghana and particularly the Kpandai District. An understanding of the determinants of poor complementary feeding practices within a given context is a necessary step that should be taken to inform the design, planning and implementation of effective and sustainable interventions to improve the nutrition needs of children aged 6-23 months. The current study thus aims to evaluate the knowledge and attitudes of mothers regarding infant and young child feeding recommendations, complementary feeding practices and the determinants of adequate diet among children aged 6-23 months in the Kpandai district of the Northern Region of Ghana. Methods Study setting, design and participants This cross-sectional study was conducted during the Child Welfare Clinics (CWCs) of the Kpandai District and the Evangelical Church of Ghana (ECG) Hospitals in Kpandai. Kpandai is the district capital of the Kpandai district. It is located at the South-Eastern Corner of the Northern Region of Ghana. It is bordered to the North by Nanumba South district, East Gonja to the West, Krachi West district to the South-West and Nkwanta North district to the East. The district is largely rural. Agriculture is the main occupation of the majority of inhabitants and has maize, sorghum, millet and yam as staple foods. These are usually harvested from October through December, during which time child care may not be optimal as these rural mothers may lack time due to the harvest. The participants of the study included mothers /care givers with children aged 6-23 months who visited the CWCs of the ECG and Kpandai District Hospitals for growth monitoring and promotion (GMP) services. Mothers/care givers with infants aged 6–23 months of age and were willing to participate were eligible for inclusion. Mothers/care givers with children below 6 months, those with children older than 24 months, those that were sick and those not willing to participate were excluded from the study. Recruitment and data collection procedures Purposive sampling procedure was used to recruit participants. Recruitment and data collection procedures were done by the first (KAB) and second authors (EKC). The hospitals were visited during the study period on days that were scheduled to provide GMP services to mothers/care givers and their children. The mother-child pairs were approached while they waited to receive their GMP service and consent to participate was sought for. Those who agreed to participate were taken through the consent processes, explaining to them the benefits of participating in the study. Voluntary participation was encouraged. Verbal informed consent was obtained from those who could not read nor write in English and written informed consent obtained from those who could read and write in English. In a secluded area at the centre, a paper-based questionnaire was administered face-to face in the local dialect to the mothers who agreed and consented to participate in the study. The questionnaire was completed within 10-20 minutes. All data collection procedures, methods and informed consent procedures were approved by the Tamale Teaching Hospital Ethical Review Committee. Data collection tools All data was collected using a questionnaire (Additional file 1). The items of the questionnaire were adapted from the Food and Agriculture Organization questionnaires for assessing knowledge, attitudes and practices concerning nutrition and feeding of infants and young children [19]. Components of nutrition knowledge that was assessed were: duration of continued breastfeeding, age of start of complementary feeding, reasons for giving complementary feeds and ways of making complementary feeds more nutritious. The knowledge scale had 7 items and consisted of both open-ended questions and multiple-choice questions. Each question was scored 1 for a correct answer. Total scores were generated for each participant and computed out of 100%. Components of the attitude towards infant and young child feeding recommendations that was assessed were: confidence in preparing meals, giving a variety of meals, feeding frequency and possible barriers associated with them. The attitude scale had 7 items that were answered on a 3- point-Likert scale. Two forms of the 3-point Likert scale were used depending on whether the item was assessing perceived barriers or perceived benefits. For perceived barriers the responses were: 1- not difficult, 2- So-so and 3-Difficult. For perceived barriers: 1-Not good, 2-not sure and 3-Good. In order to ensure higher scores denoted positive attitude, items for the perceived barriers were reversed score (i.e. 1=3, 2=2, 3 = 1). Total scores were generated for each participant and computed out 100%. Complementary feeding practices were assessed based on the mother/care givers recall of foods consumed by the child. Key components that were assessed according to the WHO guidelines were continued breastfeeding, meal frequency and diet diversity. Regarding meal frequency, mothers/care givers were asked to indicate the number of times the child ate in the past 24 hours. Mothers were asked to indicate whether the child was still breastfeeding (Yes/No response). Concerning dietary diversity, a list of food items from six food groups were provided and mothers were asked to indicate whether the child had taken any of the foods within a respective food group. This was obtained by summing the number of unique food groups consumed in the last 24 hours (FAO, 2011). For instance, if a child was reported to have eaten at least one of the foods listed in a particular food group, the participant was scored 1 for that food group. The food groups were: grains, roots and tubers; dairy products; vitamin A rich foods; flesh foods; eggs; fruits and vegetables; and legumes and nuts. Mothers responses to these questions were used to generate complementary feeding indicators minimum meal frequency, minimum diet diversity score and minimum adequate diet. Following the WHO/UNICEF guidelines, a child was considered to have met the minimum meal frequency if in the last 24 hours he/she received the minimum frequency for appropriate complementary feeding (i.e. 6-8 months = 2 times; 9-11 months = 3 times, 12-23 months≥ 3 times; non-breastfed child = 4 times) [5, 6]. According to the WHO/UNICEF and as adopted in this study, minimum dietary diversity refers to the proportion of children aged 6-23 months who received at least food from at least four of the seven food groups in the last 24 hours [5, 6]. A child was considered to have met minimum acceptable diet if he/she had met both minimum meal frequency and minimum dietary diversity. Thus, minimum acceptable diet was the proportion of children aged 6-23 months who met both minimum meal frequency and minimum dietary diversity. Socio-demographic characteristics such as child’s age, mothers’ level of education, marital status, religion, mother’s employment status, and child’s father having adequate income (This was assessed by the question: Do you think your child’s father or husband earns adequate income to cater for the family: Yes/No.) were also evaluated using the questionnaire. The questionnaire was piloted on a sample of 20 mother-child pairs and the issues that were identified were used to revise the questionnaire to allow for easy understanding and comprehensibility among the participants. In addition, a multidisciplinary team comprising a nutritionist, paediatrician, public health specialist and a behavioural scientist evaluated the final version of the questionnaire for content validity (i.e. relevance, completeness, clarity, and meaningfulness). Suggested revisions were made and the final version approved for data collection. The data from the pilot evaluation were not included into the analysis for the current study. Statistical analysis We analysed the data using the Statistical Package for the Social Sciences (SPSS) software. Descriptive statistics of mean, standard deviation and frequencies were used to describe the data. The dependent variable was minimum adequate diet which was classified into those who met the criteria (Yes) and those who did not meet (No). Independent variables were child’s age (6-11 months vrs. ≥ 12 months), mothers age (< 30 years, ≥ 30 years), mother’s level of education (No formal education, High, Low), mothers employment status (Employed, Not employed), Child’s father having adequate income (Yes/No), marital status of mother (Married, Single), and religion (Christianity, Islamic, Traditionalist). To evaluate determinants of adequate diet the following analytical approaches were used: univariate and multivariate tests. The Univariate tests adopted were Chi-square test and Fisher’s exact test. Fixer’s exact test was used for responses that were less than 10 participants. To identify factors associated with minimum adequate diet while adjusting for confounders, multivariate logistic regression (a priori selection) was conducted. A p-value of less than 0.05 was considered significant. Results In all, 215 mother/care giver-child pairs were approached in which 200 agreed and consented to participate in the study. Table 1 shows the demographic characteristics of the mothers’/care givers and their children. The mean (SD) age of the mothers/care givers was 27 (5.12) years. Majority of the mothers/care givers were married (96%), 49.0% had no formal education and 77.0% were Christians. The mean (SD) age of the children was 12 (5.15) months and the majority were males (56.5%). Table 1: General and social demographic characteristics of the mothers /care givers Variable Frequency Percentage Age < 30 years 150 75 ≥ 30 years 50 15 Marital status Married 192 96.0 Not married 8 4.0 Educational level No education 98 49.0 Low level education 41 20.5 High level education 61 30.5 Religion Christianity 154 77.0 Muslim 38 19.0 Traditionalist 8 4.0 Employment Status of the mother Employed 146 73.0 Unemployed 54 27.0 Child’s father earns adequate income for family upkeep Yes 129 64.5 No 71 35.5 Knowledge regarding infant and young child feeding recommendations Table 2 shows mother’s/care giver’s knowledge in infant and young child feeding recommendations. Sixty-eight percent of the mothers/care givers knew the recommended duration of continued breastfeeding. Regarding the recommended age at which a baby should be given complementary foods, 72% rightly said after 6 months. Eighty-four percent of the mothers/care givers knew the right consistency of meal, to be given to children, but only 27.5 % were able to give the reason for consistency of meal by reporting that thick porridge is more nutritious because it is prepared with different types of foods or ingredients (food diversity). Eighty-one percent of mothers/care givers had knowledge on ways of encouraging young children to eat. In all, the mothers had a mean (SD) knowledge score of 58.0 (28.45) %. Based on the scores, 52.0% (n=103) of the mothers/care givers had high level of knowledge. Table 2: Proportion of mothers’/care givers’ who had knowledge in infant and young child feeding recommendations Variable Frequency (%) Correctly answered recommended duration of continued breastfeeding 137 (68.5%) Correctly answered age of start of complementary foods 144 (72.0%) Gave good reasons for giving complementary foods at 6months 11 (5.5%) Correctly knew how to ensure consistency of meal 168 (84.0%) Gave good reasons why consistency of meal of meal is necessary 55 (27.5%) Correctly knew how to ensure dietary diversity and ways of enriching porridge 113 (56.5%) Knew responsive feeding 163 (81.5%) Mean (SD) knowledge score (%) 58(28.45%) Classification of knowledge scores High (>70%) 104(52.0%) Low 96(48.0%) Mothers’ attitudes towards infant and young child feeding recommendations Table 3 shows the mothers’ attitudes towards infant and young child feeding recommendations. Ninety-three percent (n=185) of the mothers expressed confidence in preparing food for their children and 51% expressed difficulty in giving different types of food to child. Inadequate finance and inadequate nutritional knowledge were the reasons giving by mothers/care givers for their difficulty. Ninety-three percent knew the perceived benefits of continuing breastfeeding beyond 6 months, with 7.5% expressing difficulty in executing this citing time and work constraints as contributing reasons. Based on the attitude scores, 94% (n=188) had positive attitude towards recommended infant and young child feeding recommendations. Table 3: Mothers’ attitudes towards infant and young child feeding recommendations Variable Frequency (%) Feels confident in preparing food for child 185(92.5%) Perceives that giving different types of food is beneficial to child 179(89.5%) Has difficulty giving different types of food to child 103(51.5%) Perceives that feeding child several times each day is beneficial 171(85.5%) Has difficulty feeding child several times a day 96(48.0%) Perceives that its beneficial to continue breastfeeding beyond 6 months 198(99.0%) Has difficulty continuing to breastfeeding beyond 6 months 15(7.5%) Mean (SD) attitude score 87.3(12.18%) Attitude classification Positive (> 70%) 188(94.0%) Less Positive 12(6.0%) Child complementary feeding practices Regarding, the consumption of at least one unique food item in the last 24 hours from the food groups evaluated,, 16.5% (n=33) gave food to their children from the legumes and nuts group; 68.0%(n=136) grains, roots and tubers; 13.5% (n=39) dairy products; 27.0% (n=54) flesh foods; 14.5% (n=29) eggs; 20.5% (n=41) vitamin A rich foods; and 5.0% (n=10) fruits and vegetables. A greater proportion of the mothers (92%, n=183) were currently breastfeeding; 10.5% (n=21) of the children met minimum diet diversity score; 39.5% (n=79) met minimum meal frequency and 8.5% (n=17) met minimum acceptable diet. Determinants of minimum adequate diet Table 4 shows the univariate and multivariate determinants of minimum adequate diet. Significant determinants of adequate diet were mothers/care givers having high knowledge in child feeding recommendations; and the father of the child reportedly earning adequate income for the upkeep of the family. Table 4: Univariate and multivariate determinants of minimum adequate diet for complementary feeding Variable Univariate Multivariate Met minimum adequate diet Yes (n= 17) No (n= 183) p-value B AOR (95% CI) p-value < 30 years 15(88.2%) 135(73.8%) 0.249 -1.43 0.2(0.44 – 1.29) 0.097 Married 1(5.9%) 7(3.8%) 0.515 -1.30 0.3(0.02 – 3.99) 0.343 Child’s mother has high level of education 8(47.1%) 53(29.0%) 0.166 0.19 1.22 (0.32 – 4.67) 0.778 Child’s mother is employed 14(82.4%) 131(71.6%) 0.41 0.46 1.6(0.32 – 7.84) 0.574 Child’s father earns enough 16(94.2%) 113(61.7%) 0.007 2.49 12.1(1.32 – 109.72) 0.027 High knowledge level 17(100%) 87(47.5%) <0.001 NA NA NA Positive attitude 17(100%) 171(93.4%) 0.604 NA NA NA 6-11 months old 12(70.6%) 88(48.1%) 0.097 -0.30 0.7(0.21 – 2.56) 0.633 Male 7(41.2%) 105(57.4%) 0.213 -0.39 0.7 (0.06 – 8.29) 0.762 Currently breastfeeding 16(94.1%) 168(91.8%) 1.000 -0.62 0.5(0.06 – 5.08) 0.588 NA = not applicable. All children who met the minimum adequate diet had parents who had high knowledge level and positive attitude. Discussion In this study we investigated mothers’ knowledge and attitudes regarding infant and young child feeding recommendations. In addition, we investigated complementary feeding practices and the determinants of adequate diet among children aged 6-24 months. An important finding of this study was that a greater proportion of the mothers/caregivers (92%) were practicing continued breastfeeding indicative of meeting the infant and young child feeding recommendation for mothers/caregivers to continue to breastfeed as well as giving complementary foods after 6 months. Our finding is similar to the 97.6% reported by Saaka et al [7] among a sample of children aged 6-23 months from Northern Ghana. Another important finding of this study was that 39.5% of the children met the minimum meal frequency, 10.5% minimum diet diversity score and 8.5% were fed minimum adequate diet. This is one of the lowest rates of infant and young child feeding practices in Ghana and other developing countries. In a study that consisted of a sample of 778 children aged 6-23 months from three northern regions of Ghana, Saaka et al [7] found 57.3%, 35.6% and 24.9% of the children meeting minimum meal frequency, minimum diet diversity and minimum acceptable diet respectively. In rural Madagascar, Rakotonirainy et al [20] found 50% of a sample of 1824 children aged 6-23 months meeting the minimum acceptable diet. Among a sample of children from South West Ethiopia, Edris et al found 38% of the children attaining minimum diet diversity score [21]. The findings of this study are however comparable to the 8.6% of children aged 6-23 months meeting minimum acceptable diet reported among children from a rural area in North West Ethiopia [13] and the 36.7% and 7.3% rates of minimum meal frequency and minimum adequate diet respectively reported among children from the Cross-River State of Nigeria [12]. Our findings also compare favourably with the 12% of Ghanaian children meeting minimum adequate diet as reported in the 2017/2018 Multiple Indicator Cluster Survey report for Ghana [22]. Notwithstanding the differences in the prevalence rates between the current study and those of the other studies from other parts of sub-Sharan Africa, the rates of the minimum meal frequency and minimum diet diversity, minimum adequate diet and the minimum adequate diet are woefully low depicting the preponderance of poor infant and young child feeding practices in sub-Sharan Africa. It can be very difficult for mothers from poor societies such as those in Kpandai, Ghana to be able to feed their children diverse diets and the recommended number of times as they may have low income levels to be able to secure food to meet these recommendations [12]. We found in this study that about half of the mothers had adequate knowledge regarding infant and young child feeding practices, although two notable knowledge deficits were identified. Firstly, we found that, about a quarter of the mothers did not know the recommended duration for continued breastfeeding notwithstanding our finding that a greater majority of the mothers practiced continued breastfeeding. Secondly, 28% did not also know when to start appropriate complementary feeding, although all the children were receiving complementary feeding. These knowledge deficits may have negative consequences as mothers may start complementary feeding too early and may also stop continued breastfeeding before the recommended period which may not auger well for the growth and development of the child. There is thus the need for healthcare providers to emphasize these recommendations during routine nutrition education sessions of the growth monitoring promotion sessions during child welfare clinics. Although the attitude of the mothers towards infant and young child feeding practices were positive it is important to note two important difficulties that were expressed by the majority of the mothers. We found in this study that about 52% of the mothers perceived difficulty in giving their children different types of food, although about 90% perceived this practice to be beneficial to the child. Also, a greater majority of the mothers perceived that it was beneficial to feed their children several times a day, meanwhile almost half of them perceived difficulty in doing so. Given that attitude may be a predictor of practice, these difficulties might have contributed to the low level of dietary diversity and meal frequency reported in this study. Poor income levels can also be responsible for mothers to have less desirable attitudes towards child feeding recommendations as majority of them cited lack of income as reason for having difficulty in feeding children with diverse diets and the recommended frequencies. Individualized counselling could be provided by healthcare providers during child welfare clinics in order to identify the individual challenges and difficulties of mothers/care givers. During these sessions, mothers/care givers could be encouraged to meet the recommendations and also supported on how to overcome some of the difficulties. Less than 30% of the children took food from both plant and animal sources of protein such as legumes and nuts, fleshy foods, dairy products and eggs. Also, the proportion of children who took Vitamin A sources of food was also low and less encouraging. These findings could be due to participants inadequate knowledge on diet diversity and consistency of diets as we found in this study that 43.5% of the mothers did not know how to diversify and enrich the diets of their children and another 72% did not know the reason why they should ensure the consistency of the diets of their children. These assertions were confirmed by our finding in this study that high level of knowledge was significantly associated with children being fed a minimum adequate diet. This finding thus demonstrate that knowledge is necessary to improving infant and young child feeding practices and justifies the need for health providers to continue to provide nutrition education to mothers during routine child welfare clinics. Another important finding was that children whose fathers reportedly earned adequate income were several times more likely to be fed minimum adequate diet compared to their counterparts whose fathers did not earn high. This finding compares favourably with those of the 2017/2018 multiple cluster Survey report for Ghana in which minimum adequate diet and diet diversity were highest among the richest than among the poorest [22]. Obviously, fathers are the economic heads of most homes in northern Ghana and as a result are responsible for providing for the needs of the family including food. Thus, if the father earns enough income it is likely to result in the acquisition of foods to meet the complementary feeding needs of the child. There is thus the need to come out with interventions that will create nutrition awareness among fathers to enable them recognise the important role complementary feeding plays in the health and development of their children. Fathers should be encouraged to attend child welfare clinics with their spouses and be included into the nutrition education and counselling sessions. This study is not without limitations. Its cross-sectional nature makes it difficult to establish causality. The use of a single study setting may affect the generalisability of the findings to other settings. Social desirability and recall bias may be present due to the use of a self-report instrument that required participants to recall. Notwithstanding this the study has important strengths. The findings add to the current literature regarding infant and young child feeding practices thereby increasing our understanding of the rates of infant and young child feeding practices and the associated factors. The findings provide avenues that will inform the design of interventions to improve infant and young child feeding practices in the study setting and other parts of Ghana. Conclusion Mothers had notable knowledge and attitude gaps that could be addressed through nutrition education during the monthly child welfare clinics. Mother’s knowledge regarding infant and young child feeding recommendations as well as child’s father having adequate income were important determinants of the consumption of adequate diet by the children. The findings demonstrate the need for healthcare providers to continue to provide nutrition education during child welfare clinics. Abbreviations CWC: Child Welfare Clinic ECG: Evangelical Church of Ghana FAO: Food and Agriculture Organization GDHS: Ghana Demographic and Health Survey (GDHS), GMP: Growth monitoring and promotion SD: Standard deviation UNICEF: United Nations Children’s Fund WHO: World Health Organisation Declarations Ethics approval and consent to participate All data collection procedures, methods and informed consent procedures were approved by the Tamale Teaching Hospital Ethical Review Committee. Verbal informed consent was obtained from those who could not read nor write in English and written informed consent obtained from those who could read and write in English. The data was handled anonymously and confidentially. Consent for publication Not applicable Availability of data and material Data is available upon request from the corresponding author Competing interests The authors declare that they have no competing interests Funding Not applicable Authors’ contribution KBA & ECK conceived the study, collected data, performed data analyses and drafted the manuscript, VM designed the study, interpreted the data and critically revised the manuscript; AA, MAA & CKK jointly undertook critical revision of the manuscript. All authors approved the manuscript for publication. Acknowledgement Authors wish to thank the authorities of the Kpandai District Hospital and the Evangelical Church of Ghana (ECG) Hospital in Kpandai for granting them permission into the facilities to conduct the study. Authors’ information 1 Department of Community Health and Family Medicine School of Medicine and Health Sciences University for Development Studies O. Box TL 1883 Tamale, Ghana 2 Department of Paediatrics and Child Health School of Medicine and Health Sciences University for Development Studies O. Box TL 1883 Tamale, Ghana 3 Department of Health Policy Planning and Management School of Public Health University of Health and Allied Sciences Ho-Ghana 4 Department of Nutritional Sciences School of Allied Health Sciences University for Development Studies O. Box TL 1883 Tamale, Ghana 5 Department of Health Professions Education and Innovative Learning School of Medicine and Health Sciences University for Development Studies O. Box TL 1883 Tamale, Ghana References Development Initiatives: 2018 Global Nutrition Report: Shining a light to spur action on nutrition . In: Development Initiatives. Edited by Initiatives D. Bristol, UK: Development Initiatives; 2018. UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: Levels and trends in child malnutrition . In . Edited by Group UWWB. UNICEF: UNICEF; 2019. 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Frempong RB, Annim SKJH: Dietary diversity and child malnutrition in Ghana . 2017, 3 (5):e00298. Marías Y, Glasauer P: Guidelines for assessing nutrition-related knowledge, attitudes and practices : Food and Agriculture Organization of the United Nations (FAO); 2014. Rakotonirainy NH, Razafindratovo V, Remonja CR, Rasoloarijaona R, Piola P, Raharintsoa C, Randremanana RVJPo: Dietary diversity of 6-to 59-month-old children in rural areas of Moramanga and Morondava districts, Madagascar . 2018, 13 (7). Edris M, Atnafu N, Abota TJP, Research H: Determinants of dietary diversity score among children age between 6–23 months in Bench Maji Zone, Southwest Ethiopia . 2018, 3 (3):10. Ghana Statistical Service (GSS): Multiple Indicator Cluster Survey (MICS 2017/18), Survey Findings Report . In . Edited by GSS. Accra: GSS; 2018. Supplementary Files QuestionnaireBMCNutrition.docx Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2020 Read the published version in BMC Nutrition → Version 3 posted Submission checks completed at journal 31 Oct, 2020 Editorial decision: Accept 26 Oct, 2020 You are reading this latest preprint version Show more versions 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-25288","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":4180305,"identity":"4aaaffcb-3217-4b86-9a02-39693e203f8a","order_by":0,"name":"Kingsley B Appiah","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kingsley","middleName":"B","lastName":"Appiah","suffix":""},{"id":4180306,"identity":"a2bf1c17-5003-4061-bab7-73d15f11dba4","order_by":1,"name":"Ernest K Cheyuo","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ernest","middleName":"K","lastName":"Cheyuo","suffix":""},{"id":4180307,"identity":"6b69aacd-7f76-4a5d-a501-c5a83cd029a1","order_by":2,"name":"Abdul-Mumin Alhassan","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abdul-Mumin","middleName":"","lastName":"Alhassan","suffix":""},{"id":4180308,"identity":"960b3a87-28bf-4ba9-b122-3ccf920488aa","order_by":3,"name":"Martin A Ayanore","email":"","orcid":"","institution":"University of Health and Allied Sciences Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martin","middleName":"A","lastName":"Ayanore","suffix":""},{"id":4180309,"identity":"20302b28-6db8-4207-889f-8185ae6d6f3e","order_by":4,"name":"Clement K Kubuga","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Clement","middleName":"K","lastName":"Kubuga","suffix":""},{"id":4180310,"identity":"423b957a-e4b6-4a10-a368-010cced8a4be","order_by":5,"name":"VICTOR MOGRE","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYPACGwaGA0CKB4gNiNSSRrqWwyRoMbh2+PDriorziX3nDzA+eNvGYLedoJbbaWmWZ87cTpx5I4HZcG4bQ/LOBgJaJGfnmBk2tt1O3HCDgU2aF6jF4ABRWv6dS9xw/gD7b6K08EvnGD9sbDiQuOFAAhszUIsdEVrS0hgbjiUbz7yR2Cw555xEAkEtbNLJhz821NjJ9p0/fPDDmzIbe4JaQLokIDRjA5CQSGwgrIOB+QMyz54IHaNgFIyCUTDCAAABq0Yk10LFogAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0230-5783","institution":"University for Development Studies","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"VICTOR","middleName":"","lastName":"MOGRE","suffix":""}],"badges":[],"createdAt":"2020-04-24 11:33:23","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-25288/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-25288/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40795-020-00393-0","type":"published","date":"2020-12-01T15:02:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3412938,"identity":"b49f45ae-4bdd-4158-b713-984f3146a70e","added_by":"auto","created_at":"2020-11-05 22:15:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82550,"visible":true,"origin":"","legend":"Child feeding practices as reported by the mothers/care givers","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-25288/v3/53e1c85ae8bb9823169ffd8a.jpg"},{"id":13612357,"identity":"de1bb54c-78cf-41fe-bcdf-02265e67655d","added_by":"auto","created_at":"2021-09-17 06:32:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":915969,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-25288/v3/35d7bacf-a2da-4c91-8cf1-f7bcaecdd237.pdf"},{"id":3412937,"identity":"18aaeaca-bf0c-4112-9da6-a056a75ac551","added_by":"auto","created_at":"2020-11-05 22:15:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":485650,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireBMCNutrition.docx","url":"https://assets-eu.researchsquare.com/files/rs-25288/v3/a926c42d68c83ff6aaba68ed.docx"}],"financialInterests":"","formattedTitle":"Mothers’ knowledge and attitudes regarding child feeding recommendations, complementary feeding practices and determinants of adequate diet","fulltext":[{"header":"Background","content":"\u003cp\u003eChild malnutrition is a global emergency affecting every country in the world [1]. Globally, 151 children aged 0-59 months are stunted; 51 million wasted and 38.3 million have excess weight [1]. In sub-Saharan Africa, 39% of children are stunted; 28% wasted and 24% overweight [2]. According to the 2014 Ghana Demographic and Health Survey (GDHS), 19% of Ghanaian children are stunted, 5% wasted, 11% underweight and about 3% are overweight [3]. The Northern Region of Ghana has the highest prevalence of stunting affecting 33% of children aged under 5 years.\u003c/p\u003e\n\u003cp\u003eA number of underlying factors could be contributing to the rising prevalence of malnutrition in children including poor access to health care, inadequate caring and feeding practices and poor sanitation [4]. Among these, appropriate complementary feeding is very paramount and has been shown to improve nutrition status of children. According to the WHO there are eight core indicators of that can be used to assess and guide the feeding practices of young children including 1) early initiation of breastfeeding; (2) exclusive breastfeeding under six months; (3) continued breastfeeding for one year; (4) the introduction of solid, semi-solid or soft foods; (5) minimum dietary diversity; (6) minimum meal frequency; (7) minimum acceptable diet; and (8) consumption of iron rich or iron fortified foods \u0026nbsp;[5, 6].\u0026nbsp; Appropriate complementary feeding refers to the timely introduction of solid, semi-solid or soft foods, minimum meal frequency, minimum adequate diet and minimum dietary diversity ([5-7]. It has been linked to optimal nutrition in infant and young children as it ensures their growth, health and development to attain their full potential. It\u0026rsquo;s been shown to reduce child morbidity and mortality thereby increasing child survival and protection [8, 9]. No wonder the WHO recommends that nutritionally adequate and safe complementary feeding should start from age 6 months with continued breastfeeding up to 2 years of age or beyond [8, 9].Evidence shows that\u0026nbsp; appropriate complementary feeding rates in developing countries are less desirable and majority of infants and young children do not meet the minimum indicators for appropriate complementary feeding [10, 11]. Only 13% of Ghanaian children aged 6-23 months are fed a minimum acceptable diet [3]. Among a sample of 778 children aged 6-23 months from Northern Ghana, Saaka et al [7] found 57.3% of the children meeting the minimum meal frequency, 35.3% minimum dietary diversity score and 25% had minimum acceptable diet. In Nigeria, Udoh et al [12]found 31.5% of a sample of 330 children aged 6-23 months from Cross River State meeting minimum diet diversity, 36.5% minimum meal frequency and 7.3% received an acceptable diet. A community-based cross-sectional study among a sample of 506 children from North West Ethiopia found only 63% of the children receiving minimum meal frequency, 9.8% for minimum diet diversity and only 8.6% received the minimum acceptable diet [13].\u003c/p\u003e\n\u003cp\u003eA number of factors have been noted for the less optimal rates of appropriate complementary feeding including maternal education, income levels, antenatal attendance, spouse employment status, quality of institutional healthcare delivery, women empowerment in decision making, and among others [7, 13-15]. Notable among these factors is the mothers\u0026rsquo; knowledge and attitudes regarding child feeding recommendations. There is evidence that high knowledge is associated with improved complementary feeding practices among mothers [15-17].\u003c/p\u003e\n\u003cp\u003eA few studies have investigated adequate diet and its determinants among infant and young children in Ghana. In our search of the literature we only came across three studies [7, 17, 18] that have investigated the core indicators of complementary feeding such as meal frequency, diet diversity, minimum adequate diet and their determinants among children aged 6-23 months. The Saaka et al [7] study that was conducted in Northern Ghana assessed the three indicators of appropriate complementary feeding but did not assess the knowledge and attitude of the mothers regarding infant and young child feeding recommendations. Gyampoh et al [17] investigated mothers knowledge regarding recommended infant and young child recommendations and its association with complementary feeding practices but did not assess the mothers/care givers\u0026rsquo; attitude towards complementary feeding practices and was also conducted in Accra, which differ socio-economically from Northern Ghana. Frempong and Annim [18] investigated dietary diversity and malnutrition in children using the Ghana Multiple Indicator Cluster Survey for 2011 but did not assess the other indicators of complementary feeding such as meal frequency and acceptable diet. Thus, there is limited data regarding the knowledge and attitudes of mothers on infant and young child feeding recommendations and how these are associated with complementary feeding practices in Northern Ghana and particularly the Kpandai District.\u003c/p\u003e\n\u003cp\u003eAn understanding of the determinants of poor complementary feeding practices within a given context is a necessary step that should be taken to inform the design, planning and implementation of effective and sustainable interventions to improve the nutrition needs of children aged 6-23 months. The current study thus aims to evaluate the knowledge and attitudes of mothers regarding infant and young child feeding recommendations, complementary feeding practices and the determinants of adequate diet among children aged 6-23 months in the Kpandai district of the Northern Region of Ghana.\u003c/p\u003e\n"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting, design and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted during the Child Welfare Clinics (CWCs) of the Kpandai District and the Evangelical Church of Ghana (ECG) Hospitals in Kpandai. Kpandai is the district capital of the Kpandai district. It is located at the South-Eastern Corner of the Northern Region of Ghana. It is bordered to the North by Nanumba South district, East Gonja to the West, Krachi West district to the South-West and Nkwanta North district to the East. The district is largely rural. Agriculture is the main occupation of the majority of inhabitants and has maize, sorghum, millet and yam as staple foods. These are usually harvested from October through December, during which time child care may not be optimal as these rural mothers may lack time due to the harvest. The participants of the study included mothers /care givers with children aged 6-23 months who visited the CWCs of the ECG and Kpandai District Hospitals for growth monitoring and promotion (GMP) services. Mothers/care givers with infants aged 6\u0026ndash;23 months of age and were willing to participate were eligible for inclusion. Mothers/care givers with children below 6 months, those with children older than 24 months, those that were sick and those not willing to participate were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and data collection procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling procedure was used to recruit participants. Recruitment and data collection procedures were done by the first (KAB) and second authors (EKC). The hospitals were visited during the study period on days that were scheduled to provide GMP services to mothers/care givers and their children. The mother-child pairs were approached while they waited to receive their GMP service and consent to participate was sought for. Those who agreed to participate were taken through the consent processes, explaining to them the benefits of participating in the study. Voluntary participation was encouraged. Verbal informed consent was obtained from those who could not read nor write in English and written informed consent obtained from those who could read and write in English. In a secluded area at the centre, a paper-based questionnaire was administered face-to face in the local dialect to the mothers who agreed and consented to participate in the study. The questionnaire was completed within 10-20 minutes. All data collection procedures, methods and informed consent procedures were approved by the Tamale Teaching Hospital Ethical Review Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data was collected using a questionnaire (Additional file 1). The items of the questionnaire were adapted from the Food and Agriculture Organization questionnaires for assessing knowledge, attitudes and practices concerning nutrition and feeding of infants and young children [19]. Components of nutrition knowledge that was assessed were: duration of continued breastfeeding, age of start of complementary feeding, reasons for giving complementary feeds and ways of making complementary feeds more nutritious.\u003c/p\u003e\n\u003cp\u003eThe knowledge scale had 7 items and consisted of both open-ended questions and multiple-choice questions. Each question was scored 1 for a correct answer. Total scores were generated for each participant and computed out of 100%. Components of the attitude towards infant and young child feeding recommendations that was assessed were: confidence in preparing meals, giving a variety of meals, feeding frequency and possible barriers associated with them.\u003c/p\u003e\n\u003cp\u003eThe attitude scale had 7 items that were answered on a 3- point-Likert scale. Two forms of the 3-point Likert scale were used depending on whether the item was assessing perceived barriers or perceived benefits. For perceived barriers the responses were: 1- not difficult, 2- So-so and 3-Difficult. For perceived barriers: 1-Not good, 2-not sure and 3-Good. In order to ensure higher scores denoted positive attitude, items for the perceived barriers were reversed score (i.e. 1=3, 2=2, 3 = 1). Total scores were generated for each participant and computed out 100%.\u003c/p\u003e\n\u003cp\u003eComplementary feeding practices were assessed based on the mother/care givers recall of foods consumed by the child. Key components that were assessed according to the WHO guidelines were continued breastfeeding, meal frequency and diet diversity. Regarding meal frequency, mothers/care givers were asked to indicate the number of times the child ate in the past 24 hours. Mothers were asked to indicate whether the child was still breastfeeding (Yes/No response).\u003c/p\u003e\n\u003cp\u003eConcerning dietary diversity, a list of food items from six food groups were provided and mothers were asked to indicate whether the child had taken any of the foods within a respective food group. This was obtained by summing the number of unique food groups consumed in the last 24 hours (FAO, 2011). For instance, if a child was reported to have eaten at least one of the foods listed in a particular food group, the participant was scored 1 for that food group. The food groups were: grains, roots and tubers; dairy products; vitamin A rich foods; flesh foods; eggs; fruits and vegetables; and legumes and nuts. Mothers responses to these questions were used to generate complementary feeding indicators minimum meal frequency, minimum diet diversity score and minimum adequate diet.\u003c/p\u003e\n\u003cp\u003eFollowing the WHO/UNICEF guidelines, a child was considered to have met the minimum meal frequency if in the last 24 hours he/she received the minimum frequency for appropriate complementary feeding (i.e. 6-8 months = 2 times; 9-11 months = 3 times, 12-23 months\u0026ge; 3 times; non-breastfed child = 4 times) [5, 6]. According to the WHO/UNICEF and as adopted in this study, minimum dietary diversity refers to the proportion of children aged 6-23 months who received at least food from at least four of the seven food groups in the last 24 hours [5, 6].\u003c/p\u003e\n\u003cp\u003eA child was considered to have met minimum acceptable diet if he/she had met both minimum meal frequency and minimum dietary diversity. Thus, minimum acceptable diet was the proportion of children aged 6-23 months who met both minimum meal frequency and minimum dietary diversity. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocio-demographic characteristics such as child\u0026rsquo;s age, mothers\u0026rsquo; level of education, marital status, religion, mother\u0026rsquo;s employment status, and child\u0026rsquo;s father having adequate income (This was assessed by the question: Do you think your child\u0026rsquo;s father or husband earns adequate income to cater for the family: Yes/No.) were also evaluated using the questionnaire. The questionnaire was piloted on a sample of 20 mother-child pairs and the issues that were identified were used to revise the questionnaire to allow for easy understanding and comprehensibility among the participants. In addition, a multidisciplinary team comprising a nutritionist, paediatrician, public health specialist and a behavioural scientist evaluated the final version of the questionnaire for content validity (i.e. relevance, completeness, clarity, and meaningfulness). Suggested revisions were made and the final version approved for data collection. The data from the pilot evaluation were not included into the analysis for the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analysed the data using the Statistical Package for the Social Sciences (SPSS) software. Descriptive statistics of mean, standard deviation and frequencies were used to describe the data.\u003c/p\u003e\n\u003cp\u003eThe dependent variable was minimum adequate diet which was classified into those who met the criteria (Yes) and those who did not meet (No). Independent variables were child\u0026rsquo;s age (6-11 months vrs. \u0026ge; 12 months), mothers age (\u0026lt; 30 years, \u0026ge; 30 years), mother\u0026rsquo;s level of education (No formal education, High, Low), mothers employment status (Employed, Not employed), Child\u0026rsquo;s father \u0026nbsp;having adequate income (Yes/No), marital status of mother (Married, Single), and religion (Christianity, Islamic, Traditionalist). To evaluate determinants of adequate diet the following analytical approaches were used: univariate and multivariate tests. The Univariate tests adopted were Chi-square test and Fisher\u0026rsquo;s exact test. Fixer\u0026rsquo;s exact test was used for responses that were less than 10 participants. To identify factors associated with minimum adequate diet while adjusting for confounders, multivariate logistic regression (a priori selection) was conducted. A p-value of less than 0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn all, 215 mother/care giver-child pairs were approached in which 200 agreed and consented to participate in the study. Table 1 shows the demographic characteristics of the mothers\u0026rsquo;/care givers and their children. The mean (SD) age of the mothers/care givers was 27 (5.12) years. Majority of the mothers/care givers were married (96%), 49.0% had no formal education and 77.0% were Christians. The mean (SD) age of the children was 12 (5.15) months and the majority were males (56.5%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: General and social demographic characteristics of the mothers /care givers\u003c/p\u003e\n\u003ctable border=\"1\" width=\"564\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003eFrequency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003ePercentage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003e\u0026lt; 30 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e75\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003e\u0026ge; 30 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eMarital status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e96.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eNot married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e4.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eEducational level\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eNo education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e49.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eLow level education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e20.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eHigh level education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e30.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eReligion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eChristianity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e154\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e77.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eMuslim\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e19.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eTraditionalist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e4.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eEmployment Status of the mother\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eEmployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e146\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e73.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eUnemployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e27.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eChild\u0026rsquo;s father earns adequate income for family upkeep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e129\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e64.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"224\"\u003e\n\u003cp\u003e\u0026nbsp;No\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"143\"\u003e\n\u003cp\u003e71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"196\"\u003e\n\u003cp\u003e35.5\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\u003eKnowledge regarding infant and young child feeding recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows mother\u0026rsquo;s/care giver\u0026rsquo;s knowledge in infant and young child feeding recommendations. Sixty-eight percent of the mothers/care givers knew the recommended duration of continued breastfeeding. Regarding the recommended age at which a baby should be given complementary foods, 72% rightly said after 6 months. Eighty-four percent of the mothers/care givers knew the right consistency of meal, to be given to children, but only 27.5 % were able to give the reason for consistency of meal by reporting that thick porridge is more nutritious because it is prepared with different types of foods or ingredients (food diversity). Eighty-one percent of mothers/care givers had knowledge on ways of encouraging young children to eat. In all, the mothers had a mean (SD) knowledge score of 58.0 (28.45) %. Based on the scores, 52.0% (n=103) of the mothers/care givers had high level of knowledge.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Proportion of mothers\u0026rsquo;/care givers\u0026rsquo; who had knowledge in infant and young child feeding recommendations\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eFrequency (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eCorrectly answered recommended duration of continued breastfeeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e137 (68.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eCorrectly answered age of start of complementary foods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e144 (72.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eGave good reasons for giving complementary foods at 6months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e11 (5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eCorrectly knew how to ensure consistency of meal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e168 (84.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eGave good reasons why consistency of meal of meal is necessary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e55 (27.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eCorrectly knew how to ensure dietary diversity and ways of enriching porridge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e113 (56.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eKnew responsive feeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e163 (81.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eMean (SD) knowledge score (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e58(28.45%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eClassification of knowledge scores\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eHigh (\u0026gt;70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e104(52.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"468\"\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e96(48.0%)\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\u003eMothers\u0026rsquo; attitudes towards infant and young child feeding recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows the mothers\u0026rsquo; attitudes towards infant and young child feeding recommendations. Ninety-three percent (n=185) of the mothers expressed confidence in preparing food for their children and 51% expressed difficulty in giving different types of food to child. Inadequate finance and inadequate nutritional knowledge were the reasons giving by mothers/care givers for their difficulty. Ninety-three percent knew the perceived benefits of continuing breastfeeding beyond 6 months, with 7.5% expressing difficulty in executing this citing time and work constraints as contributing reasons. Based on the attitude scores, 94% (n=188) had positive attitude towards recommended infant and young child feeding recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Mothers\u0026rsquo; attitudes towards infant and young child feeding recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eFeels confident in preparing food for child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e185(92.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003ePerceives that giving different types of food is beneficial to child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e179(89.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eHas difficulty giving different types of food to child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e103(51.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003ePerceives that feeding child several times each day is beneficial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e171(85.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eHas difficulty feeding child several times a day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e96(48.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003ePerceives that its beneficial to continue breastfeeding beyond 6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e198(99.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eHas difficulty continuing to breastfeeding beyond 6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e15(7.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eMean (SD) attitude score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e87.3(12.18%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003e\u003cstrong\u003eAttitude classification\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003ePositive (\u0026gt; 70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e188(94.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"445\"\u003e\n\u003cp\u003eLess Positive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e12(6.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild complementary feeding practices \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding, the consumption of at least one unique food item in the last 24 hours from the food groups evaluated,, 16.5% (n=33) gave food to their children from the legumes and nuts group; 68.0%(n=136) grains, roots and tubers; 13.5% (n=39) dairy products; 27.0% (n=54) flesh foods; 14.5% (n=29) eggs; 20.5% (n=41) vitamin A rich foods; and 5.0% (n=10) fruits and vegetables. \u0026nbsp;A greater proportion of the mothers (92%, n=183) were currently breastfeeding; 10.5% (n=21) of the children met minimum diet diversity score; 39.5% (n=79) met minimum meal frequency and 8.5% (n=17) met minimum acceptable diet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeterminants of minimum adequate diet\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 shows the univariate and multivariate determinants of minimum adequate diet. Significant determinants of adequate diet were mothers/care givers having high knowledge in child feeding recommendations; and the father of the child reportedly earning adequate income for the upkeep of the family.\u003c/p\u003e\n\u003cp\u003eTable 4: Univariate and multivariate determinants of minimum adequate diet for complementary feeding\u003c/p\u003e\n\u003ctable border=\"1\" width=\"654\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"150\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"246\"\u003e\n\u003cp\u003e\u003cstrong\u003eUnivariate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" rowspan=\"2\" width=\"258\"\u003e\n\u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"246\"\u003e\n\u003cp\u003e\u003cstrong\u003eMet minimum adequate diet\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n= 17)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(n= 183)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e\u003cstrong\u003eAOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003e\u0026lt; 30 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e15(88.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e135(73.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.249\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-1.43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e0.2(0.44 \u0026ndash; 1.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.097\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e1(5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e7(3.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.515\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-1.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e0.3(0.02 \u0026ndash; 3.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.343\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eChild\u0026rsquo;s mother has high level of education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e8(47.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e53(29.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.166\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.22 (0.32 \u0026ndash; 4.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.778\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eChild\u0026rsquo;s mother is employed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e14(82.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e131(71.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.6(0.32 \u0026ndash; 7.84)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.574\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eChild\u0026rsquo;s father earns enough\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e16(94.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e113(61.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e12.1(1.32 \u0026ndash; 109.72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.027\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eHigh knowledge level\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e17(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e87(47.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003ePositive attitude\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e17(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e171(93.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.604\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003e6-11 months old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e12(70.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e88(48.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.097\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-0.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e0.7(0.21 \u0026ndash; 2.56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.633\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e7(41.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e105(57.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.213\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e0.7 (0.06 \u0026ndash; 8.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.762\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eCurrently breastfeeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e16(94.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e168(91.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e0.5(0.06 \u0026ndash; 5.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.588\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNA = not applicable. All children who met the minimum adequate diet had parents who had high knowledge level and positive attitude.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we investigated mothers\u0026rsquo; knowledge and attitudes regarding infant and young child feeding recommendations. In addition, we investigated complementary feeding practices and the determinants of adequate diet among children aged 6-24 months.\u003c/p\u003e\n\u003cp\u003eAn important finding of this study was that a greater proportion of the mothers/caregivers (92%) were practicing continued breastfeeding indicative of meeting the infant and young child feeding recommendation for mothers/caregivers to continue to breastfeed as well as giving complementary foods after 6 months. Our finding is similar to the 97.6% reported by Saaka et al [7] among a sample of children aged 6-23 months from Northern Ghana.\u003c/p\u003e\n\u003cp\u003eAnother important finding of this study was that 39.5% of the children met the minimum meal frequency, 10.5% minimum diet diversity score and 8.5% were fed minimum adequate diet. This is one of the lowest rates of infant and young child feeding practices in Ghana and other developing countries. In a study that consisted of a sample of 778 children aged 6-23 months from three northern regions of Ghana, Saaka et al [7] found 57.3%, 35.6% and 24.9% of the children meeting minimum meal frequency, minimum diet diversity and minimum acceptable diet respectively. In rural Madagascar, Rakotonirainy et al [20] found 50% of a sample of 1824 children aged 6-23 months meeting the minimum acceptable diet. Among a sample of children from South West Ethiopia, Edris et al found 38% of the children attaining minimum diet diversity score [21]. The findings of this study are however comparable to the 8.6% of children aged 6-23 months meeting minimum acceptable diet reported among children from a rural area in North West Ethiopia [13] and the 36.7% and 7.3% rates of minimum meal frequency and minimum adequate diet respectively reported among children from the Cross-River State of Nigeria [12]. Our findings also compare favourably with the 12% of Ghanaian children meeting minimum adequate diet as reported in the 2017/2018 Multiple Indicator Cluster Survey report for Ghana [22]. Notwithstanding the differences in the prevalence rates between the current study and those of the other studies from other parts of sub-Sharan Africa, the rates of the minimum meal frequency and minimum diet diversity, minimum adequate diet and the minimum adequate diet are woefully low depicting the preponderance of poor infant and young child feeding practices in sub-Sharan Africa. It can be very difficult for mothers from poor societies such as those in Kpandai, Ghana to be able to feed their children diverse diets and the recommended number of times as they may have low income levels to be able to secure food to meet these recommendations [12].\u003c/p\u003e\n\u003cp\u003eWe found in this study that about half of the mothers had adequate knowledge regarding infant and young child feeding practices, although two notable knowledge deficits were identified. Firstly, we found that, about a quarter of the mothers did not know the recommended duration for continued breastfeeding notwithstanding our finding that a greater majority of the mothers practiced continued breastfeeding. Secondly, 28% did not also know when to start appropriate complementary feeding, although all the children were receiving complementary feeding. These knowledge deficits may have negative consequences as mothers may start complementary feeding too early and may also stop continued breastfeeding before the recommended period which may not auger well for the growth and development of the child. There is thus the need for healthcare providers to emphasize these recommendations during routine nutrition education sessions of the growth monitoring promotion sessions during child welfare clinics.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the attitude of the mothers towards infant and young child feeding practices were positive it is important to note two important difficulties that were expressed by the majority of the mothers. We found in this study that about 52% of the mothers perceived difficulty in giving their children different types of food, although about 90% perceived this practice to be beneficial to the child. Also, a greater majority of the mothers perceived that it was beneficial to feed their children several times a day, meanwhile almost half of them perceived difficulty in doing so. Given that attitude may be a predictor of practice, these difficulties might have contributed to the low level of dietary diversity and meal frequency reported in this study. Poor income levels can also be responsible for mothers to have less desirable attitudes towards child feeding recommendations as majority of them cited lack of income as reason for having difficulty in feeding children with diverse diets and the recommended frequencies. Individualized counselling could be provided by healthcare providers during child welfare clinics in order to identify the individual challenges and difficulties of mothers/care givers. During these sessions, mothers/care givers could be encouraged to meet the recommendations and also supported on how to overcome some of the difficulties. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLess than 30% of the children took food from both plant and animal sources of protein such as legumes and nuts, fleshy foods, dairy products and eggs. Also, the proportion of children who took Vitamin A sources of food was also low and less encouraging. These findings could be due to participants inadequate knowledge on diet diversity and\u0026nbsp; consistency of diets as we found in this study that 43.5% of the mothers did not know how to diversify and enrich the diets of their children and another 72% did not know the reason why they should ensure the consistency of the diets of their children. These assertions were confirmed by our finding in this study that high level of knowledge was significantly associated with children being fed a minimum adequate diet. This finding thus demonstrate that knowledge is necessary to improving infant and young child feeding practices and justifies the need for health providers to continue to provide nutrition education to mothers during routine child welfare clinics.\u003c/p\u003e\n\u003cp\u003eAnother important finding was that children whose fathers reportedly earned adequate income were several times more likely to be fed minimum adequate diet compared to their counterparts whose fathers did not earn high. This finding compares favourably with those of the 2017/2018 multiple cluster Survey report for Ghana in which minimum adequate diet and diet diversity were highest among the richest than among the poorest [22]. Obviously, fathers are the economic heads of most homes in northern Ghana and as a result are responsible for providing for the needs of the family including food. Thus, if the father earns enough income it is likely to result in the acquisition of foods to meet the complementary feeding needs of the child. There is thus the need to come out with interventions that will create nutrition awareness among fathers to enable them recognise the important role complementary feeding plays in the health and development of their children. Fathers should be encouraged to attend child welfare clinics with their spouses and be included into the nutrition education and counselling sessions.\u003c/p\u003e\n\u003cp\u003eThis study is not without limitations. Its cross-sectional nature makes it difficult to establish causality. The use of a single study setting may affect the generalisability of the findings to other settings. Social desirability and recall bias may be present due to the use of a self-report instrument that required participants to recall. Notwithstanding this the study has important strengths. The findings add to the current literature regarding infant and young child feeding practices thereby increasing our understanding of the rates of infant and young child feeding practices and the associated factors. The findings provide avenues that will inform the design of interventions to improve infant and young child feeding practices in the study setting and other parts of Ghana.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMothers had notable knowledge and attitude gaps that could be addressed through nutrition education during the monthly child welfare clinics. Mother\u0026rsquo;s knowledge regarding infant and young child feeding recommendations as well as child\u0026rsquo;s father having adequate income were important determinants of the consumption of adequate diet by the children. The findings demonstrate the need for healthcare providers to continue to provide nutrition education during child welfare clinics.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCWC: Child Welfare Clinic\u003c/p\u003e\n\u003cp\u003eECG: Evangelical Church of Ghana\u003c/p\u003e\n\u003cp\u003eFAO: Food and Agriculture Organization\u003c/p\u003e\n\u003cp\u003eGDHS: Ghana Demographic and Health Survey (GDHS),\u003c/p\u003e\n\u003cp\u003eGMP: Growth monitoring and promotion\u003c/p\u003e\n\u003cp\u003eSD: Standard deviation\u003c/p\u003e\n\u003cp\u003eUNICEF: United Nations Children\u0026rsquo;s Fund\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data collection procedures, methods and informed consent procedures were approved by the Tamale Teaching Hospital Ethical Review Committee. Verbal informed consent was obtained from those who could not read nor write in English and written informed consent obtained from those who could read and write in English. The data was handled anonymously and confidentially.\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 data and material \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available upon request from the corresponding author\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\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKBA \u0026amp; ECK conceived the study, collected data, performed data analyses and drafted the manuscript, VM designed the study, interpreted the data and critically revised the manuscript; AA, MAA \u0026amp; CKK jointly undertook critical revision of the manuscript. All authors approved the manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors wish to thank the authorities of the Kpandai District Hospital and the Evangelical Church of Ghana (ECG) Hospital in Kpandai for granting them permission into the facilities to conduct the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Community Health and Family Medicine\u003c/p\u003e\n\u003cp\u003eSchool of Medicine and Health Sciences\u003c/p\u003e\n\u003cp\u003eUniversity for Development Studies\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eO. Box TL 1883\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTamale, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Paediatrics and Child Health\u003c/p\u003e\n\u003cp\u003eSchool of Medicine and Health Sciences\u003c/p\u003e\n\u003cp\u003eUniversity for Development Studies\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eO. Box TL 1883\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTamale, Ghana\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e Department of Health Policy Planning and Management\u003c/p\u003e\n\u003cp\u003eSchool of Public Health\u003c/p\u003e\n\u003cp\u003eUniversity of Health and Allied Sciences\u003c/p\u003e\n\u003cp\u003eHo-Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eDepartment of Nutritional Sciences\u003c/p\u003e\n\u003cp\u003eSchool of Allied Health Sciences\u003c/p\u003e\n\u003cp\u003eUniversity for Development Studies\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eO. Box TL 1883\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTamale, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eDepartment of Health Professions Education and Innovative Learning\u003c/p\u003e\n\u003cp\u003eSchool of Medicine and Health Sciences\u003c/p\u003e\n\u003cp\u003eUniversity for Development Studies\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eO. Box TL 1883\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTamale, Ghana\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDevelopment Initiatives: \u003cstrong\u003e2018 Global Nutrition Report: Shining a light to spur action on nutrition\u003c/strong\u003e. In: \u003cem\u003eDevelopment Initiatives.\u003c/em\u003e Edited by Initiatives D. Bristol, UK: Development Initiatives; 2018.\u003c/li\u003e\n\u003cli\u003eUNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: \u003cstrong\u003eLevels and trends in child malnutrition\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Edited by Group UWWB. UNICEF: UNICEF; 2019.\u003c/li\u003e\n\u003cli\u003eGhana Statistical Service (GSS) GHSG, and ICF International,: \u003cstrong\u003eGhana Demographic and Health Survey 2014\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Edited by GSS G, and ICF International. Rockville, Maryland, USA: GSS, GHS, and ICF International; 2015.\u003c/li\u003e\n\u003cli\u003eBranca F, Grummer-Strawn L, Borghi E, Bl\u0026ouml;ssner M, Onis Md: \u003cstrong\u003eExtension of the WHO maternal, infant and young child nutrition targets to 2030\u003c/strong\u003e. \u003cem\u003eSCN News \u003c/em\u003e2015(No.41):55-58.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization: \u003cstrong\u003eIndicators for assessing infant and young child feeding practices: part 2: measurement\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Geneva; 2010.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization: \u003cstrong\u003eIndicators for assessing infant and young child feeding practices: part 1: definitions: conclusions of a consensus meeting held 6-8 November 2007 in Washington DC, USA\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Edited by Organization WH. Geneva; 2008.\u003c/li\u003e\n\u003cli\u003eSaaka M, Larbi A, Mutaru S, Hoeschle-Zeledon IJBN: \u003cstrong\u003eMagnitude and factors associated with appropriate complementary feeding among children 6\u0026ndash;23 months in northern Ghana\u003c/strong\u003e. 2016, \u003cstrong\u003e2\u003c/strong\u003e(1):2.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization: \u003cstrong\u003eGlobal strategy for infant and young child feeding\u003c/strong\u003e. Geneva: World Health Organization; 2003.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization: \u003cstrong\u003eInfant and young child feeding: model chapter for textbooks for medical students and allied health professionals\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Edited by Organization WH. Geneva; 2009.\u003c/li\u003e\n\u003cli\u003eWhite JM, B\u0026eacute;gin F, Kumapley R, Murray C, Krasevec JJM, nutrition c: \u003cstrong\u003eComplementary feeding practices: Current global and regional estimates\u003c/strong\u003e. 2017, \u003cstrong\u003e13\u003c/strong\u003e:e12505.\u003c/li\u003e\n\u003cli\u003eAbeshu MA, Lelisa A, Geleta BJFin: \u003cstrong\u003eComplementary feeding: review of recommendations, feeding practices, and adequacy of homemade complementary food preparations in developing countries\u0026ndash;lessons from Ethiopia\u003c/strong\u003e. 2016, \u003cstrong\u003e3\u003c/strong\u003e:41.\u003c/li\u003e\n\u003cli\u003eUdoh EE, Amodu OKJS: \u003cstrong\u003eComplementary feeding practices among mothers and nutritional status of infants in Akpabuyo Area, Cross River State Nigeria\u003c/strong\u003e. 2016, \u003cstrong\u003e5\u003c/strong\u003e(1):2073.\u003c/li\u003e\n\u003cli\u003eMulat E, Alem G, Woyraw W, Temesgen HJBN: \u003cstrong\u003eUptake of minimum acceptable diet among children aged 6\u0026ndash;23 months in orthodox religion followers during fasting season in rural area, DEMBECHA, north West Ethiopia\u003c/strong\u003e. 2019, \u003cstrong\u003e5\u003c/strong\u003e(1):18.\u003c/li\u003e\n\u003cli\u003eDhami MV, Ogbo FA, Osuagwu UL, Agho KEJBph: \u003cstrong\u003ePrevalence and factors associated with complementary feeding practices among children aged 6\u0026ndash;23 months in India: a regional analysis\u003c/strong\u003e. 2019, \u003cstrong\u003e19\u003c/strong\u003e(1):1034.\u003c/li\u003e\n\u003cli\u003eDemilew YMJBrn: \u003cstrong\u003eFactors associated with mothers\u0026rsquo; knowledge on infant and young child feeding recommendation in slum areas of Bahir Dar City, Ethiopia: cross sectional study\u003c/strong\u003e. 2017, \u003cstrong\u003e10\u003c/strong\u003e(1):191.\u003c/li\u003e\n\u003cli\u003eEgata G, Berhane Y, Worku AJIbj: \u003cstrong\u003ePredictors of non-exclusive breastfeeding at 6 months among rural mothers in east Ethiopia: a community-based analytical cross-sectional study\u003c/strong\u003e. 2013, \u003cstrong\u003e8\u003c/strong\u003e(1):8.\u003c/li\u003e\n\u003cli\u003eGyampoh S, Otoo GE, Aryeetey RNOJBp, childbirth: \u003cstrong\u003eChild feeding knowledge and practices among women participating in growth monitoring and promotion in Accra, Ghana\u003c/strong\u003e. 2014, \u003cstrong\u003e14\u003c/strong\u003e(1):180.\u003c/li\u003e\n\u003cli\u003eFrempong RB, Annim SKJH: \u003cstrong\u003eDietary diversity and child malnutrition in Ghana\u003c/strong\u003e. 2017, \u003cstrong\u003e3\u003c/strong\u003e(5):e00298.\u003c/li\u003e\n\u003cli\u003eMar\u0026iacute;as Y, Glasauer P: \u003cstrong\u003eGuidelines for assessing nutrition-related knowledge, attitudes and practices\u003c/strong\u003e: Food and Agriculture Organization of the United Nations (FAO); 2014.\u003c/li\u003e\n\u003cli\u003eRakotonirainy NH, Razafindratovo V, Remonja CR, Rasoloarijaona R, Piola P, Raharintsoa C, Randremanana RVJPo: \u003cstrong\u003eDietary diversity of 6-to 59-month-old children in rural areas of Moramanga and Morondava districts, Madagascar\u003c/strong\u003e. 2018, \u003cstrong\u003e13\u003c/strong\u003e(7).\u003c/li\u003e\n\u003cli\u003eEdris M, Atnafu N, Abota TJP, Research H: \u003cstrong\u003eDeterminants of dietary diversity score among children age between 6\u0026ndash;23 months in Bench Maji Zone, Southwest Ethiopia\u003c/strong\u003e. 2018, \u003cstrong\u003e3\u003c/strong\u003e(3):10.\u003c/li\u003e\n\u003cli\u003eGhana Statistical Service (GSS): \u003cstrong\u003eMultiple Indicator Cluster Survey (MICS 2017/18), Survey Findings Report\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e Edited by GSS. Accra: GSS; 2018.\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":"Knowledge, attitudes, child feeding practices, Kpandai, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-25288/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-25288/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Complementary feeding is critical for optimal nutrition in infant and young children as it ensures their growth, health and development to attain their full potential. However, evidence shows children from developing countries do not meet the core indicators for appropriate complementary feeding. We evaluated mothers’ knowledge and attitudes regarding child feeding recommendations and the determinants of adequate diet among children aged 6-23 months. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This cross-sectional study included 200 children aged 6-23 months and their mothers/care givers recruited during the child welfare clinics of two health facilities in Ghana. Data was collected using a structured questionnaire. Multivariate logistic regression was used to assess determinants of adequate diet. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eSixty-eight percent of the mothers knew the recommended duration of continued breastfeeding, 56.5% how to ensure dietary diversity and enrich their children’s diets and 94% (n=188) had positive attitude towards recommended infant and young child feeding practices. Majority of the mothers (92%, n=183) practiced continued breastfeeding, 10.5% of the children met minimum diet diversity score, 39.5% minimum meal frequency and 8.5% received minimum adequate diet. Determinants of receipt of minimum adequate diet were: having high knowledge in child feeding recommendations (100% vs. 0.0; p\u0026lt;0.001) and child’s father reportedly earning adequate income to cater for the family (AOR = 12.1 (1.32 – 109.72; p = 0.027). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Motherss knowledge levels regarding infant and young child feeding recommendations had notable deficiencies although they generally had a positive attitude towards child feeding recommendations. Knowledge regarding infant and young child feeding recommendations as well as the child’s father having adequate income were important determinants of adequate diet. Nutrition education should emphasize on improving mothers’ nutrition knowledge regarding infant and young child feeding recommendations and supporting mothers to overcome barriers to feed their children with adequate diets.\u003c/p\u003e","manuscriptTitle":"Mothers’ knowledge and attitudes regarding child feeding recommendations, complementary feeding practices and determinants of adequate diet","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-11-05 22:15:57","doi":"10.21203/rs.3.rs-25288/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-10-31T22:04:39+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-10-27T00:00:00+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}},{"code":2,"date":"2020-08-29 21:00:48","doi":"10.21203/rs.3.rs-25288/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-10-22T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-09-17T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the authors for providing detailed responses to each of my previous suggestions.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-27T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-26T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-20T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-19T12:00:00+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}},{"code":1,"date":"2020-05-07 22:44:55","doi":"10.21203/rs.3.rs-25288/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-07-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-01T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThis manuscript reports on a study which explores the knowledge and attitudes of mothers of infants and young children in Ghana around feeding children. It also explores maternal reports of their child's minimum meal frequency, minimum diet diversity, and minimum acceptable diet. The study aimed to \"evaluate the knowledge and attitudes of mothers regarding infant and young child feeding recommendations, child feeding practices and the determinants of adequate diet among children aged 6-23 months\" which is a worthwhile endeavour. The manuscript goes some way towards addressing this, but I have some concerns about some aspects.\n\n1. In the manuscript title, and elsewhere throughout the manuscript, it is suggested that this study is measuring mother's \"competence\" but none of the measures assess this, so the use of this term is slightly misleading. \n2. It is also not clear to what extent this study is measuring \"attitudes\" around feeding as three of the seven questions in Table 3 (the ones which start \"Has difficulty…\") are not tapping attitudes, but the presence/absence of a barrier. Thus, this construct does not seem to fully assess what it says it is (i.e. it's not only about attitudes).\n3. The results on lines 272-279 seem really interesting. I'd suggest that these are expanded, have their own clear aim (see below), and are more fully described and discussed. The mean values on line 276 would benefit from explaining so it is very clear what these values show and how they link to the percentages in lines 278-9.\n4. Table 4: it is not clear what the univariate or the multivariate determinants are (how are they different) but, more concerningly, I'm not sure that the analyses in Table 4 are that meaningful given the same size differences between the groups. Only 8.5% (n=17) met minimum adequate diet and these 17 are compared with the other 183. I'd suggest removing these analyses and this aim and, instead, focusing more on the dietary findings (see point above) which seem novel and informative.\n5. The manuscript would benefit from a really clear set of aims and hypotheses which are consistently presented and referred back to in the abstract, statistical analysis section, results, and the discussion. At present, it is sometimes hard to tell what each bit of analysis is aiming to determine.\n6. Relatedly, it would help to clearly define and stick with consistent terminology. Sometimes the authors talk about \"complementary feeding\", sometimes it is \"child feeding practices\", sometimes it's \"complementary feeding practices\". These all have different meanings in the feeding literature so choosing the most suitable term and using it throughout would help the reader.\n7. Page 5: the data collection tools section is really important but I found it lacking in detail and, as it was all in one paragraph, really hard to digest. Could the authors separate each component out into distinct paragraphs and then clearly and fully outline what each measure assesses and how it's scored? This is key for understanding the results.\n8. Line 202-3: \"food and liquid consumption\" is not \"child feeding practices\" - so it would be good if description could be amended.\n9. Results - it was unclear why certain factors were dichotomised and how demographic information had been captured (e.g., Table 1, age, education, father's earnings - what constitutes \"enough\"?). Could this be clarified and justified, perhaps in the expanded Method section?\n10. Table 2 - what does \"Knows responsive feeding\" mean? Could this be clarified and justified, perhaps in the expanded Method section?\n11. Table 3 - it might help to list the items which assess benefits and then those which assess the barriers.\n12. At the start of the Discussion, it would help the reader to remind them of the study aims.\n\nMore minor points:\n1. The manuscript was not formatted as per journal guidelines (e.g., around spacing) and was hard to read without any lines between, or indents at the start of, paragraphs.\n2. The abstract would benefit from a review as many of its points are not wholly clear or do not map onto the content of the manuscript. For example, there is nothing mentioned about the aim related to the children's dietary intake, the methods are very brief, some of the results are lacking context (e.g., line 66), and it's not clear which results have supported the first part of the conclusion \"Poor complementary feeding practices were common\".\n3. It would be good to define \"appropriate complementary feeding\" on its first use (line 102).\n4. Line 109, it states \"three main indicators\" but four are listed.\n5. Line 178: it states that \"Voluntary participation was encouraged\" but earlier on (line 166) it states that no coercion or intimidation was used. To what degree was participation \"encouraged\"?\n6. I don't think Figure 1 is needed.\n7. Line 322 - how is \"adequate knowledge\" determined?\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. 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