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 min. 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 . 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 of 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 h. 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 h (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 h 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 a food from at least four of the seven food groups in the last 24 h [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.
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.