Original Research••

Hygienic complementary feeding practice and its associated factors among mothers having children aged 6–23 months in Antsokia Gemza district, Ethiopia: a cross-sectional survey

Abstract

Objective To assess the magnitude of parental hygienic complementary feeding practices (PHCFPs) and their associated factors among mothers with children aged 6–23 months in Antsokia Gemza district, Ethiopia, in 2022.

Methodology A community-based cross-sectional study was conducted in Antsokia Gemza district, North Shoa, Ethiopia, from 25 June to 22 July 2022. A systematic random sampling technique was applied to select study participants. A total of 391 respondents participated in the study. All mothers (biological mothers, grandmothers, sisters and others) taking responsibility for caring for a child of age 6–23 months were included in the study. Data were collected by using interviewer-administrated questionnaires. Data were entered into Epi-Data V.3.1 and exported to SPSS V.25 for data cleaning and further analysis. Bivariable and multivariable binary logistic regression were employed to identify predictor variables of hygienic practice in complementary feeding with a p value <0.25 entered into the multivariable logistic regression model. Independent variables with a 95% CI and p values <0.05 in multivariable logistic regression were considered statistically significant.

Result The magnitude of good parental hygienic practice during complementary feeding of their children aged 6–23 months was 45.3%, with a 95% CI (40.2%–50%). Maternal age of 34–41 years (adjusted odd ratio (AOR): 2.75, 95% CI (1.16–6.53)), secondary school educated mothers (AOR: 8.2, 95% CI (3.26–20.97)), daily laborer mothers (AOR: 0.22, 95% CI (0.06–0.83)), access to pipe water (AOR: 7.1, 95% CI (3.98–12.66)), access to media (AOR: 2.8, 95% CI (1.4–5.7)), and having a positive attitude (AOR: 8.6, 95% CI (2.43–31.0)) were significant predictors of maternal hygienic complementary feeding practice .

Conclusions The magnitude of good maternal hygienic complementary feeding practice was low. Hence, the district health office, education office, communication office and water and energy office should work hard jointly on maternal education, pipe water supply, awareness creation and information dissemination.

What is already known on this topic

  • The magnitude of parental hygienic complementary feeding practice (PHCFP) and its associated factors among mothers having children aged 6–23 months are known in other parts of Ethiopia, but nothing is known in the North Eastern Amhara region of Ethiopia.

What this study adds

  • The result of this study provides community-level data from a North Eastern Amhara region in Ethiopia on the magnitude of HCFP and its associated factors among mothers having children aged 6–23 months and helps elucidate factors associated with it that might be unique to the study setting.

How this study might affect research, practice or policy

  • The results of this study will help healthcare professionals create awareness and disseminate information about hygienic complementary feeding practice (HCFP) in order to improve HCFPs. The study also helps the leadership of the health system, programme managers and policymakers establish national guidelines and allocate budgets. It is important to conduct continuous research by considering a larger sample size and different methods in the future in order to identify additional predictors of maternal HCFP.

Introduction

Malnutrition outcomes (wasting, stunting and underweight) and under-five mortality have all been linked to globally improper and unsanitary complementary feeding practices. Previous research has demonstrated that introducing complementary foods (CFs) to infants and young children (IYC) at the right time lowers the risk of malnutrition, infectious disease in children and death.1

The WHO and UNICEF advise breastfeeding infants until they are at least 2 years old, at which point they should start eating safely.2 The WHO also advises against initiating CFs too early or too late. IYC are at a higher risk of developing diarrhoeal disease and, as a result, malnutrition due to their early exposure to microbial pathogens and unsafe and potentially contaminated supplemental foods and fluids.3 4

Due to their extensive nutritional needs for growth and development, IYC are particularly susceptible to malnutrition. Improving the quality and safety of supplemental foods has been identified as one of the most cost-effective measures for improving health and lowering food-borne morbidity and mortality in young children.5

Unsafe food would be food that was contaminated by micro-organisms and the environment and was therefore unfit for human consumption.6 Insufficient and less nutrient-dense meals, limited access to food, and ignorance of the proper methods for preparing, storing and feeding a CF are just a few of the gaps in the practice of effective and safe supplemental feeding.7 Although there is inadequate food safety in low-income settings for populations of all ages, various research indicates that diarrhoeal disease occurrences in children are significantly greater than they have ever been after weaning.1 7 8

Epidemiological evidence shows that food plays a more significant role in the spread of germs that cause diarrhoea than drinking water. This is because food provides a medium for exponential bacterial growth, whereas bacterial pathogens in water may survive for a while but will not significantly increase in the absence of other nutrients.9 It is possible that supplemental foods would become contaminated with pathogenic bacteria, which would have detrimental clinical effects such as diarrhoea and malnutrition, as well as subclinical disorders such as environmental enteropathy.9 10

The WHO estimated in 2015 that diarrhoea caused by contaminated supplementary foods accounts for 125 000 deaths annually, or 30% of all deaths worldwide, among children under the age of five. The burden is unequally distributed around the globe, with the biggest burdens per population being in Africa, Southeast Asia and the Eastern Mediterranean.10

In Ethiopia, malnutrition continues to be one of the major causes of newborn and child mortality, accounting for 57% of these deaths. Although rates of stunting and underweight have declined over the past few decades, they are still significant, with 21% of children under the age of five and 37% of neonates being stunted. Stunting prevalence typically rises consistently with age, from 22% in infants aged 6–8 months to 44% in children aged 48–59 months. The high rates of baby undernutrition are caused by a lack of nutritional variety, a lack of awareness about food safety and unclean infant feeding methods.11 ,12

About 88% of children who die in impoverished nations do so due to insufficient sanitation, contaminated water and poor personal hygiene. According to estimates, poor WASH practices may be to blame for 50% of children who are undernourished.13 The first step in preventing and controlling food borne diseases in children aged 6–23 months in Ethiopia is understanding the risk of unclean activities during supplemental feeding. However, Ethiopia frequently faces implementation challenges.14

Despite all these, evidence on the hygienic practices of mothers during complementary feeding is only limited. As far as our knowledge, we did not get even a single study done in the North Eastern Amhara region of Ethiopia. Many studies focus on dietary diversity and the age of weaning. The purpose of this study was to assess the magnitude of parental hygienic complementary feeding practice (PHCFP) and its associated factors among lactating mothers having children aged 6–23 months in order to address the aforementioned gap in the area.

Methods and materials

Study setting and period

The study was conducted in the Antsokia Gemza district. It is found in the North Shewa Zone, Amhara region, Ethiopia, around 362 km away from Addis Ababa. The district comprises 12 kebeles, 1 urban and 11 rural, with an estimated total population of 63 533, of which 15% live in urban and 85% live in rural kebeles. There are 2246 lactating mothers in the district used as the source population, from which 402 respondents were taken as the study population. This research was conducted from 25 June to 25 July 2022.

Study design

A community-based cross-sectional study design was conducted.

Population

Source population

All mothers (caregivers) having children aged 6–23 months in Antsokia Gemza district, North Shewa, Ethiopia.

Study population

All mothers/caregivers in the selected kebeles with children of age 6–23 months in each kebele available at home during the data collection period.

Eligibility criteria

Inclusion criteria

All mothers (biological mothers, grandmothers, sisters and others) taking responsibility for caring for a child of age 6–23 months were included in the study.

Exclusion criteria

Those who are mentally ill (impaired) mothers and those who have hearing impairments were not included in this study, even though they have a child in the age category. Those guest lactating mothers for the study area (who came temporarily from other regions and districts and stayed for less than 6 months in the study period) were not included in this study.

Sample size calculation

We calculate the sample size for two objectives.

For the first objective

The sample size was calculated using a single population proportion formula using the assumption by taking proportion from a cross-sectional study done at Bahir Dar Zuria district Ethiopia,13 proportion of respondents with good hygienic practice during complementary feeding (p=38.9%), level of confidence=95%, zα/2=1.96 and margin of error(d)=0.05.

Sample size (n)=(zα/2)2 p(1–P)/d2

n=(1.96)2 (0.389) (1–0.389)/(0.05)2

n=365.22.

For the second objective

After considering the sample size for the second objective, which is identifying factors associated with the maternal hygienic practice of complementary feeding, it was found that the sample size in the first objective was 402, which is larger than the second (114 or 104) (table 1), hence it was used in the study.

Table 1
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Sample size determination using Epi-Info software

Sampling technique and sampling procedures

Systematic random sampling was applied to select study participants. The total number of lactating mothers who live in the Antsokia Gemza district was 2246, which was obtained by referring to the kebele health postregistration book or record prior to data collection. All 12 kebeles found in the Antsokia Gemza district were included in the study. The size of households consisting of eligible populations to be selected from each kebele was determined proportionally based on the size of the study units found in each kebele. The sampling interval (kth unit) was obtained by dividing the lactating mothers (2246) by the total sample size (402), and it was approximately 5. The first participant was randomly chosen for the survey by the lottery method, and then every five participants were recruited for the study. If more than one eligible mother is found in a household, one is chosen by a lottery method to take part in the study.

Data collection and measurements

Data were collected using an interviewer-administered, structured questionnaire. Three clinical nurses with advanced training collected the data. The questionnaire was derived from prior research and adjusted for this study’s environment.15 16 Questionnaires were categorised into sociodemographic characteristics, environmental factors, maternal health-related factors, maternal knowledge of CF hygiene, maternal attitudes towards CF hygiene and maternal practice on CF hygiene (online supplemental file 1).

Maternal knowledge on hygienic complementary feeding

Respondents were asked eight questions related to their knowledge of hygiene during CF preparation and feeding. Respondents who scored <70% of their responses were considered to have inadequate knowledge of the hygiene of CF, while those who scored greater than or equal to 70% were considered to have adequate knowledge of hygienic complementary feeding.17

Maternal attitude towards hygienic complementary feeding

Respondents were asked nine questions related to their attitude towards hygienic complementary feeding; those who scored greater than or equal to 70% were considered to have a positive attitude, while those who scored less than 70% were considered to have a negative attitude towards hygienic complementary feeding.17

Maternal practice on hygienic complementary feeding

Respondents were asked ten questions related to their complementary feeding hygienic practices; those who scored greater than or equal to 75% were considered to have good hygienic practice during complementary feeding, while those who scored less than 75% were considered to have poor practice during complementary feeding.13

Data quality assurance

The 1 day training was given to both supervisors and data collectors. The pretest was conducted on 5% of the sample size in Gshe Rabel District before the actual data collection period. A necessary correction was made based on the results of the pretest data. The questionnaire was prepared in English, translated into the local language (Amharic), and translated back to English by another translator to check consistency. Strict supervision was done by supervisors, and the overall quality of the data collection was also monitored by the principal investigator. The collected data were checked for completeness and consistency before starting, processing and analysing the data.

Data management and analysis

Once the raw data were collected, questionnaires were checked for completeness and consistency, and questionnaires with gross gaps of incompleteness were rejected and excluded from the study. Data were then entered into Epi-Data V.3.1. The data were then coded and cleaned, and finally, they were exported to SPSS V.20 software for analysis. Descriptive statistics were done to describe the study variables. Each independent variable was assessed for statistically significant association with the dependent variable in bivariate analysis at a 95% confidence level and a p value of less than 0.20.

Those variables whose p values were less than 0.2518 during bivariable analysis were fitted into the final multiple logistic regression model to adjust for potential confounders. In the final model, a p value <0.05 was considered statistically significant. The goodness of fit of the final model was checked using the Hosmer and Lemeshow test of goodness of fit with a p value >0.05. Significant independent variables were declared at a 95% confidence level, and a p value of <0.05 OR was used to observe the strength of the association between the dependent variable and each significant independent variable. Finally, results were presented using frequencies, proportions figure and tables.

Patient and public involvement

None.

Results

Sociodemographic characteristics of respondents

A total of 391 mothers with children aged 6–23 months participated in this study, with a response rate of 97.3%. The mean age of the respondents was 29.3 years. 317 (81.1%) of the respondents were rural dwellers. 324 (82.8%) of the respondents can at least read and write. 280 (71.6%) of the respondents were married. 249 (63.6%) work as housewives. 204 (52.2%) households have had a family size of 2–4 persons, and 172 (43.9%) households have had a family size of 5–7 persons (table 2).

Table 2
|
Sociodemographic characteristics of mothers having children of age 6–23 months in Antsokia Gemza district, North Shewa, Ethiopia, July 2022 (n=391)

Nearly three-fourths (74.1%) of households have an estimated monthly income of 2000–4000 ETB, and 86 (21.9%) households have an estimated monthly income of less than 2000 ETB. Out of 391 respondents, 283 (72.4%) of them have had access to media (television and/or radio) (table 2).

Environmental and maternal health characteristics

From a total of 391 respondents, 204 (52.2%) of the respondents have their own pipe water supply, 329 (84.1%) of the respondents have their own private latrine, 371 (94.8%) of the respondents have had prenatal care attendance in their index child and 100 (25.5%) of the respondents were sick in the past 1 month time during data collection (table 3).

Table 3
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Environmental and maternal health characteristics of mothers having children of age 6–23 months in Antsokia Gemza district, North Shewa, Ethiopia, July 2022 (n=391)

Maternal knowledge on hygienic complementary feeding

Among the 391 respondents, 301 (76.9%) had good knowledge about hygienic complementary feeding (table 4).

Table 4
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Maternal knowledge of hygienic complementary feeding of mothers having children of age 6–23 months in Antsokia Gemza district, North Shewa, Ethiopia, July 2022 (n=391)

Maternal attitude towards hygienic complementary feeding

Among 391 respondents, 342 (87.4%) had a positive attitude towards hygienic complementary feeding (table 5).

Table 5
|
Maternal attitude towards hygienic complementary feeding of lactating mothers having children of age 6–23 months in Antsokia Gemza district, North Shewa, Ethiopia, July 2022 (n=391)

Maternal hygienic practice during complementary feeding

Respondents were asked 10 questions using interviews and observation about their hygienic complementary feeding practice (HCFP). Those respondents who scored ≥75% were considered to have good practice during complementary feeding. Among 391 respondents, 177 (45.3%), 95% CI 40.2–50.4 had good hygienic practices during complementary feeding of their children aged 6–23 months.

Factors associated with HCFP

In bivariate logistic regression, having good maternal knowledge, maternal sickness in the past 1 month, being secondary educated mothers, being diploma and above graduates, being housewives, maternal age of 34–41 years, access to pipe water, positive maternal attitude and having maternal exposure to media were candidate variables for the multivariable logistic regression analysis.

A multivariable logistic regression analysis was carried out to evaluate the combined effect of multiple associated factors, adjusting for confounding variables. The result revealed that maternal age of 34–41 years, being high school educated mothers, being housewives’ mothers, having access to pipe water, having maternal exposure to media, and having a maternal positive attitude showed statistically significant association with maternal HCFP among lactating mothers who had children aged 6–23 months (table 6).

Table 6
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Bivariable and multivariable logistic regression analysis output of associated factors with maternal hygienic complementary feeding practice in Antsokia Gemza district, North Shewa, Ethiopia, July 2022

Accordingly, those mothers who are 34–41 years old have almost three times (adjusted OR (AOR): 2.75, 95% CI 1.16–6.53) higher odds of practicing good HCFPs than those mothers who are 18–25 years old (table 6).

Those mothers who can read and write are nearly three times (AOR: 2.5, 95% CI 1.0–6.0) more likely to practice hygienic complementary feeding than those mothers who have no formal education. Those mothers who completed high school are eight times (AOR: 8.27, 95% CI 3.2–20.9) more likely to practice hygienic complementary feeding than those mothers who do not have formal education. Those mothers who are diploma graduates and above are 24 times (AOR: 24.1, 95% CI 6.7%–85.9%) more likely to practice hygienic complementary feeding than those mothers who do not have formal education (table 6).

Those mothers who are daily workers are 78% less likely to have good hygienic complementary feeding practice than those mothers who work as housewives (AOR: 0.22, 95% CI 0.06–0.83) (table 6).

Those mothers who have access to pipe water are seven times (AOR: 7.1, 95% CI 3.98–12.66) more likely to practice hygienic complementary feeding compared with those mothers who do not have access to pipe water (table 6).

Those mothers who have access to media (television and/or radio) have three times (AOR: 2.84, 95% CI 1.40–5.75) higher odds of practicing hygienic complementary feeding than those mothers who do not have access to media (table 6).

Those respondents who have a positive attitude have nearly nine times (AOR: 8.69, 95% CI 2.43–31.04) higher odds of practicing hygienic complementary feeding than mothers who have a negative attitude (table 6).

Discussion

The magnitude of HCFPs in this study was 45.3%, 95% CI 40.2–50.4, which is higher than the percentage (38.9%) reported by studies in the Tegede district study in Tigray Ethiopia (33.6%),14 Debre Tabor town study in Ethiopia (37.2%)19 and Bahir Dar Zuria district study in North West Ethiopia.13 This could be as a result of the gap in time between these studies and the current study as well as the involvement of various NGOs, such as World Vision Ethiopia, in the study area who worked hard to build schools and health facilities in both urban and rural kebeles, which might give mothers the chance to learn about and gain experience with HCFPs.

The magnitude reported in studies conducted in Guto Gida district, Oromia region, Ethiopia (52.2%)20 and Lasta district, Amhara region, Ethiopia (56.5%)21 is smaller than the magnitude of the current study (45.3%). This may be the result of the socioeconomic differences between the respondents in the two studies, as 93.2% of respondents in the former study were housewives (had time to care for their children), compared with only 64.2% in the present study. Additionally, more respondents in the Lasta district study (78.5%) had access to the media than in the present study (72.4%). The current study was conducted nearly after a major devastating war season in the area; hence, it might affect maternal HCFPs in one way or another compared with the previous study area and season.

In this study, it was found that maternal age was a predictive variable of the use of hygienic supplemental feeding, with women aged 34–41 having a greater OR than mothers aged 18–25. Another study carried out in the Oromia region of Ethiopia’s Guto Gida area20 backed up this conclusion. This might be due to the fact that older women tend to have better life experiences than younger mothers when performing hygienic complementary feeding.

In this study, it was also discovered that the educational status of the mother was a predictive variable of HCFP, with mothers with a secondary school certificate or above having a higher likelihood of practicing HCF than mothers without any formal education. This discovery is consistent with research conducted in Bangladesh, Nepal, Southern Ethiopia, Asosa Town and Debarq Town.17 22–25 The reason for this association might be due to the fact that better-educated mothers will tend to have better access to different facilities and health-seeking behaviours than mothers with no formal education.

In this study, maternal occupational status was another predictor variable. Results from the Guto Gida and Lasta districts of Ethiopia21 24 showed that mothers who were housewives performed better than day workers and government employees. This might be due to the fact that housewife mothers might have more time to care for their children compared with daily workers and employed mothers.

In this study, access to piped water was shown to be another predictive variable, and it was discovered that mothers who had access to piped water performed better than mothers who did not. This could be due to the fact that water availability is one of the most important resources needed to maintain hygienic practices at home.

Another predictive variable in this study was media access, and it was discovered that women with media access practiced greater hygiene during supplemental feeding than mothers without access to the media. Numerous studies conducted in Bangladesh, Ethiopia’s Bahir Dar Zuria district and Bangladesh’s Lasta district corroborated this conclusion.13 21 25 This might be due to the fact that the media will play a great role in disseminating the information necessary to implement hygienic complementary feeding.

In this study, attitude was another predictive variable. Mothers who had a positive attitude were more likely to practice sanitary supplemental feeding than mothers who had a negative attitude. Other observations from the Ethiopian towns of Debarq and Bahir Dar Zuria provided support for this conclusion.13 23 This might be due to the fact that attitude (internal thinking) is the first requirement to perform HCFP.

This study found that if all the relevant organisations put serious effort into modifiable factors including the mother’s employment position, maternal educational status, maternal media exposure and clean water supply, more hygienic supplemental feeding practices may be attained. This will once again contribute to the development of young, adequately nourished children who are free from the effects of malnutrition, such as stunting, wasting, and adult-onset chronic disorders like diabetes mellitus and hypertension. They will become strong, capable adults as a result and contribute to society.

Limitations of the study

We tried to reach our sample size, but some of our participants refused to continue as participants after initial consent was taken, and we considered them as non-response rates. Recall bias and social desirability bias might be introduced during the interviewing of study participants. In order to avoid recall bias, we tried to look up personal records like antenatal care appointment cards and family planning appointment cards. In order to avoid social desirability bias, we used spot checks on some of the variables together with the structured questionnaires.

Conclusion

In this study, the magnitude of good maternal hygienic complementary feeding practice was low. Maternal age of 34–41 years, maternal educational status of high school completion, diploma graduation and above, being housewife mothers, access to pipe water, access to media and having a positive attitude were significantly associated variables with maternal hygienic complementary feeding practice. The district health office, the district education office, the district water and energy office, the district communication office, and other concerned government and non-government offices should work together on women’s education, pipe water supply, awareness creation and information dissemination about hygienic complementary feeding practice. Because of different setups and the continuously changing ideas and behaviours of people through time, it is important to conduct continuous research by considering a larger sample size and different methods in the future in order to identify additional predictors of maternal hygienic complementary feeding practice.

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