The nutrition survey covered five programme districts of Northern Ghana comprising the Northern Region (NR), Upper East Region (UER) and Upper West Region (UWR). The five districts where International Institute of Tropical Agriculture (IITA) project is currently operating are Nadowli, Wa West, Tolon, Savelugu and Kassena-Nankana.
Majority of the people in the study area have agriculture as their main occupation while some are involved in trading. The main staple foods including maize, sorghum, millet and yam are usually harvested from October through December. Although the food security situation is usually good during the harvesting time, child care tends to suffer because of lack of time on the part of rural mothers. A high proportion of rural women work daily away from home, and therefore frequently face challenges to the care of children.
The rainfall pattern is unimodal and the period is usually short and lasts from May to August, followed by a long dry season (September – April) with dry harmattan winds.
Survey design, population and sampling
This paper is based on re-analysis of data which was collected in a base-line cross-sectional survey in November 2013. The overall aim of the community based cross-sectional study was to collect information on knowledge and practices related to infant and young child feeding (IYCF) practices which will serve as a baseline for future comparison after the implementation of IITA sponsored nutrition project.
A sample size of 288 was required to ensure that the estimated prevalence of the main outcome variable was within plus or minus 5 % of the true prevalence at 95 % confidence level. Assuming a correction factor of 2 (the “design effect”) for cluster sampling, the sample size was increased to 576. A non response rate of 5 % and other unexpected events (e.g., damaged/incomplete questionnaire) was factored in the sample size determination and so the sample size is adjusted to 600 for 25 intervention communities that were already selected. The same number of children was selected from comparison communities using probability proportionate to size (PPS).
The basic primary sampling unit was the household and these were selected using a two-stage cluster sampling technique. PPS was used to select the comparison communities in adjacent districts given the lack of a comprehensive sampling frame and the geographic distribution of the population. Each comparison district was considered a stratum, from which clusters were selected based on stratified probability proportional to population size (PPS) sampling. The sampling frame of communities for each district was constructed using projected population figures based on 2010 Ghana population census. The Emergency Nutrition Assessment (ENA) software was used to randomly select the required number of clusters.
In each selected cluster, a complete list of all households was compiled, and systematic random sampling was used to select eligible households.
Data were collected using face-to-face interview during house-to-house visit from mothers who had 6–36 months age children using structured questionnaire. The mother of the child or other caretaker provided information on the child’s age, gender, morbidity in the past week and child feeding practices. Information on the household’s composition, household wealth index (socio-economic), crop and poultry/livestock production practices and child anthropometry indicators were also collected.
Independent and dependent variables
The main outcome variable for this study was the prevalence of appropriate complementary feeding and its components. The independent variables were maternal, child and household characteristics. A brief description of main independent and dependent variables is as follows:
Assessment of infant and young child feeding (IYCF) practices
Infant and young child feeding indicators including minimum meal frequency, minimum dietary diversity and minimum acceptable diet were estimated by recall of food and liquid consumption during the previous day of the survey as per WHO/UNICEF guidelines .
A child was judged to have taken ‘adequate number of meals if he/she received the minimum frequency for appropriate complementary feeding (that is, 2 times for 6–8 months and 3 times for 9–11 months, 3 times for children aged 12–23 months) in last 24 h. For non breast feeding children, the minimum meal frequency was 4. Adequacy of meal frequency was ranked by assigning a score of 1.
The WHO defined minimum dietary diversity as the proportion of children aged 6–23 months who received foods from at least four out of seven food groups [8, 9]. The 7 foods groups used for calculation of WHO minimum dietary diversity indicator are:
(i) grains, roots and tubers; (ii) legumes and nuts; (iii) dairy products; (iv) flesh foods; (v) eggs; (vi) vitamin A rich fruits and vegetables; and (vii) other fruits and vegetables.
From the dietary diversity score, the minimum dietary diversity indicator was constructed using the WHO recommended cut-off point with a value of “1” if the child had consumed four or more groups of foods and “0” if less. Minimum dietary diversity is the proportion of children who ate at least 4 or more varieties of foods from the seven food groups in a 24 h time period [8, 9]. Minimum acceptable diet is a composite indicator of minimum dietary diversity and minimum meal frequency. Breastfed children who meets both the minimum diversity and the minimum meal frequency are considered to have met the WHO recommended minimum acceptable diet.
Previous studies have described complementary feeding practices using single indicators but a combination of indicators is needed to better explain the role of complementary feeding practices in child growth. To adequately quantify appropriate complementary feeding, we used a composite indicator comprising three of the WHO core IYCF indicators that relate closely to complementary feeding. These are timely introduction of solid, semi-solid or soft foods at 6 months, minimum meal frequency, and minimum dietary diversity. In this study, a child was classified as having received appropriate complementary feeding if the child met all the following three criteria:
Complementary feeding commenced at 6th month of birth
Minimum dietary diversity score was at least 4
Minimum meal frequency was adequate for age of child
Complementary feeding was inappropriate if any of the three criteria was not fulfilled
For the present study, we defined positive deviant children as having both height - for -age Z-score (HAZ) and weight – for height Z-score (WHZ) ≥ −2 (best nutritional status). A negative deviant child was defined as having both HAZ and WHZ < −2. Median deviant child was defined as having either HAZ or WHZ < −2.
Statistical data analyses
Both bivariate and multivariate analyses were done to identify the determinants of appropriate feeding practices and minimum dietary diversity (MDD). Firstly, bivariate analyses for all the various risk factors were performed using X2 tests. Child, maternal and household characteristics that were significantly associated with the outcome variable were included in the logistic regression (LR) models. Multiple logistic regression analyses using appropriate measures to account for the complex survey design were applied to examine the associations between dependent variable (that is, appropriate complementary feeding) and potential predictors. Stepwise backward LR was used for multiple logistic regressions. Odds ratio with 95 % confidence interval to ascertain association between independent and dependent variable was used.
The study protocol was approved by the Ethical Committee of the School of Allied Health Sciences, University for Development Studies. Community leaders in the study communities were briefed about the study and permission sought to proceed. Informed consent was also obtained verbally after needed information and explanation. Participation was voluntary and each woman signed (or provided a thumb print if she was illiterate) a statement of an informed consent after which she was interviewed.