Optimal Complementary Feeding Practices Among Caregivers and Their Children Aged 6-23 Months in Kisoro District, Uganda

Abstract

Background: There is a wide number of risk factors for stunting and one that is most often corroborated by studies is complementary feeding practices. There was a need to ascertain the prevalence of and factors that lend to caregivers meeting requirements for the optimal complementary feeding practices in Kisoro district, a district with high stunting rates.

Methodology: A cross-sectional analytical study that used secondary data obtained from the USAID/Uganda’s Integrated Community, Agriculture, and Nutrition (ICAN) Activity. Multi-stage sampling on the data was done to select entries for 384 caregivers of children aged 6-23 months in Kisoro district. The data was first proffered in Excel sheets and analysed using SPSS version 20. Multivariable logistic regressions were conducted to determine independent factors, at the 3 levels of the SEM, associated with optimal complementary feeding practices.

Findings: The prevalence of introduction to solid, semi-solid or soft foods was the highest at 95.06%, and the prevalence for Minimum Dietary Diversity (MDD) and Minimum Acceptable Diet (MAD) was very low at 4.43%.

At the settings level, type of occupation (AOR = 21.206; CI = 2.032 - 221.256; p=0.011) and community groups (AOR = 0. 426; CI = 0.219 - 0.828; p=0.012) were found to be statistically significant for association with minimum meal frequency.

At the interpersonal level, household size (number of household members) (AOR = 0.346; CI = 0.128 - 0.936; p=0.037) was statistically significant for association with minimum dietary diversity amd minimum acceptable diet. Also, marital status was found to be  statistically significant for association with continued breastfeeding (AOR = 13.245; CI = 1.763 - 100.248; p=0.012).

At the intrapersonal level, age was associated with timely introduction of complementary foods (AOR = 1.731; CI = 1.040 - 2.883; p=0.035). While age was associated with minimum meal frequency (AOR = 2.208; CI = 1.097 - 4.445; p=0.026).

Conclusion: The study findings revealed that the prevalence of MAD and MDD was very low in Kisoro district putting these children at a very high risk to become stunted. 

Introduction

Stunting, a sub-form of malnutrition, which is responsible for 14% of global childhood deaths also heavily debilitates cognitive growth and physical capabilities, leaving the future of a person less gainful than it would otherwise have been [1, 2]. There are a wide number of risk factors for stunting and one that is most often corroborated by studies is complementary feeding practices [2, 3]. In many countries across the world, few children receive nutritionally adequate and safe complementary foods; and less than a quarter of the population of infants 6–23 months of age meet the criteria of the Minimum Acceptable Diet (MAD) appropriate for their age [4]. These reports of inappropriate and inadequate complementary feeding practices feed into the current 21.9% of stunted children that are in the world [5].

In Uganda, Infant and Young Child Feeding (IYCF) and thus complementary feeding is guided by the Policy Guidelines on Infant and Young Child Feeding. The recommendations from discussions at several technical consultations and documents on complementary feeding produced by the World Health Organisation and UNICEF were used to develop the guidelines[6]. The guidelines described complementary feeding as providing other foods (solid or semi-solid) to the infant, in addition to breastfeeding or replacement feeding, to fulfil the nutritional needs of the baby from the age of 6 months [6]. Herein replacement feeding referred to feeding a child not receiving breast milk on a sufficient diet until a time when the child is fully fed on family foods [6]. The guidelines further elaborated on the practices by recommending: introduction of complementary foods at the age of 6 months; continued breastfeeding until 2 years of age and beyond; feeding on various nutritious, locally available foods; feed liquid/soft, semi-solid foods using clean cups and spoons; disuse of cups with spouts, bottles or teats; preparing food with the right consistency (thickness) and nutrient density (especially energy and micronutrients); feeding as frequently as is consistent with the child’s age; practising active feeding; practising high standards of hygiene when handling the child’s food; feeding the child more frequently when sick with extra fluids; and maintaining sanitation and food/water safety [6, 7].

However, several studies have reported on the inadequacy in IYCF practices and consequently complementary feeding practices and advocate for the need to support populations, especially in low- and middle-income countries such as Uganda to adopt the recommended evidence-based guidelines when practising complementary feeding. These studies established that when complementary feeding practices were carried out appropriately per the global and national recommendations, then they were termed as appropriate or optimal but when they were inadequate, they were considered inappropriate or sub-optimal with terrible consequences to a child’s growth and future productivity [1, 5, 8–11].

Several studies revealed that proportions of children meeting requirements for optimal complementary feeding (CF) were generally low with minimum acceptable diet (MAD), minimum dietary diversity (MDD) and minimum meal frequency (MMF) in order of lowest to slightly higher across all the regions. Other indicators such as continued breastfeeding (CBF) at 1 year and introduction of solid semi-solid or soft foods (ISSSFs) showed higher proportions for children aged 6–23 months [5, 12–14]. The literature also revealed the prevalence of MDD in Kisoro district to be very low at 3.9% [15]. The prevalence of the other CF indicators was not revealed, however.

Various factors were documented to be associated with complementary feeding and this study concentrated on factors according to the SEM, at the settings, interpersonal and intrapersonal levels.

At the settings level, the literature explored locations or social contexts that were positively or negatively associated with complementary feeding practices (CFPs); the factors mentioned were the type of occupation of the caregiver [16–19]; rural vs urban areas [20–24]; ease of access to a health facility [25, 26]; type of community group [15, 27–29] and place of delivery [25, 30–32]. At the interpersonal level, the literature delved into relationships and household factors documented to be associated with CFPs which included family or household size [22, 23, 33, 34]; the number of children under five years of age [16, 35–37]; the number of household chores (workload effect) [22, 38–40]; the influence of interpersonal relationships with emphasis on the marriage partner (marital status) [16, 22, 30, 35, 41–44]; WASH situation of the household [16, 45, 46] and household wealth [16, 17, 20, 22, 24, 26, 34, 43, 47]. At the intrapersonal level, the literature examined biological characteristics and personal background factors of caregivers recognised as associated with CFPs which included the age of the caregiver [16, 17, 24, 43]; the education level of the caregiver [16, 17, 19, 25, 43, 48]; antenatal and postnatal visits [21, 25, 33, 34, 47, 49]; sex of the HH head [22, 34, 40]; age and sex of the child [17, 22, 43, 48, 50, 51]; and maternal parity [33, 42, 43].

However, to the best of our knowledge, none of the studies determined the prevalence of more than three OCFPs and the factors that lend to caregivers meeting requirements for the optimal complementary feeding practices in the Kisoro district. Cognizant of this empirical gap, this study, therefore, sought to determine the prevalence and factors associated with the optimal complementary feeding practices of caregivers and their children aged 6–23 months in Kisoro district. The findings gathered from this study will provide evidence for use by policymakers and organisations towards strengthening existing strategies tackling the malnutrition scourge, at least in the Kigezi region.

Methods

Optimal complementary feeding practices (OCFPs): This is the feeding of other foods and liquids to a breastfeeding child aged 6 to 23 months that meets the requirements for introduction to solid, semi-solid and soft foods, continued breastfeeding at 1-year, minimum dietary diversity, minimum meal frequency and minimum acceptable diet.

Minimum dietary diversity (MDD): This is defined and measured as the proportion of children aged 6–23 months who received foods from 4 or more food groups consisting of; grains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin-A rich fruits and vegetables; and other fruits and vegetables the previous day or 24 hours.

Minimum meal frequency (MMF): the proportion of breastfed children who receive solid, semi-solid or soft foods the minimum number of times or more; 2 times for infants 6–8 months and 3 times children 9–23 months.

Introduction of solid, semi-solid or soft foods (ISSSFs): This indicator measured the timeliness of the introduction of complementary foods and it is defined as the proportion of children who had received solid, semi-solid or soft foods at 6–8 months of age.

Minimum Acceptable Diet (MAD): the proportion of children aged 6–23 months who consumed the minimum dietary diversity and minimum meal frequency in the previous 24 hours.

Setting: This is a location (workplaces, place of residence, closeness to a health facility) or social context (community groups) in which people carry out everyday activities that influence how they practice complementary feeding.

Community group: This is defined as five or more people who live in the same area and either work together to maximize economic opportunities from agriculture and non-agriculture-based livelihoods through connections to markets and financial services (livelihood group) or participate in activities such as nutrition education to reduce malnutrition in mothers, infants, young children, adolescents, and new-borns (MIYCAN group).

WASH (Water, Sanitation and Hygiene) Situation: Possession of a functional latrine and handwashing facility (with a cleansing agent and water) gauged as best, good, bad and terrible.

Caregiver

A parent (mother or father) or any other person that is directly involved in meeting the child’s needs (feeding, grooming etc) and lives within the household.

Results

Discussion

Of the 81 caregivers with children 6–8 months of age, 95.06% (77/81) introduced solid, semi-solid or soft foods in a timely fashion relatively higher than national prevalence which stood at 78.8% (Uganda Bureau of Statistics and ICF, 2018). However, similar findings were obtained by a study carried out in China amongst persons in rural settings where 95. 4% of the infants aged 6–8 months received solid, semi-solid or soft foods appropriately [55] which the study attributed to the caregivers having received nutrition education which they applied by introducing their children to foods at the right age.

Minimum Dietary Diversity was too low at 4.43% (17/384) for mothers of infants 6 to 23 months of age that met the standards for minimum dietary diversity. The proportion was significantly lower than that for Uganda at 30% [12]. The MDD was exceedingly low similar to that from other studies carried out after the COVID-19 pandemic traversed the globe. Kundu et al.[56] and Minja et al.[57] explained that MDD was heavily associated with the earning potential of HHs and in rural areas where most HHs earned low incomes, and in the presence of the pandemic that negatively impacted income earning, MDD was in turn very low. Amongst the food groups, grains, roots and tubers were consumed by the majority of the children (93.5%) while eggs were the least consumed at 6%. Similarly, a study carried out in Northern Uganda also found that cereals were more consumed compared to foods of animal origin which the people also attributed to cereals being cheaper to purchase and easier to access compared to foods of animal origin [3].

The study findings revealed that at the settings level, caregivers that gained income in other ventures such as begging, remittances and so on were more likely to meet the requirements for MMF for their children compared to caregivers working in the agricultural sector. Findings similar to those from studies carried out in Poland, Austria and Southern Benin which reported that parents or caregivers in particular mothers that were employed or heavily involved in income-generating activities were less likely to have their children meet the MMF requirements either due to early return to work and or not having more time with their children compared to their stay-at-home, unemployed or otherwise less engaged counterparts [22, 58].

In addition, caregivers that belonged to the livelihood group were less likely to achieve minimum meal frequency for their children compared to caregivers that belonged to the MIYCAN group. These findings were probably because caregivers in the livelihood group were more involved in income-generating activities which decreased the time offered to care for the children which hampered meeting requirements for MMF [22, 58]. In addition, caregivers in the MIYCAN groups received nutrition knowledge; a factor documented to favour optimal complementary feeding practices [17, 43].

At the interpersonal level, caregivers residing in HHs with 7 or more HH members were less likely to offer their children an acceptable and diverse diet compared to caregivers living with 6 or fewer HH members. Studies in Ethiopia, Australia, and Benin concluded that HHs with more than seven residents usually had sub-optimal CFPs because of the food insecurity brought on by income limitations; the low incomes can not ably support the large household sizes [22, 23, 33].

In addition, caregivers who were not married were more likely to have continued breastfeeding their children by 1 year of age compared to caregivers that were married. This finding differed from what studies in Kenya and Southern Benin discovered where caregivers who were married were more likely to meet the requirements for OCFPs [22, 30]. However, Scott et al. [59] concluded that partners could be deterrents to continued breastfeeding and mothers that did not have partners would breastfeed longer because they had the time to dedicate to their children and also issues such as sagging breasts and losing the interest of your partner were not a worry [60] promoting longer durations of breastfeeding.

At the intrapersonal level, caregivers older than 29 years were more likely to introduce solid, semi-solid and soft foods timely to their children compared to caregivers that were 29 years or younger (AOR = 1.731; CI = 1.040–2.883; p = 0.035). Studies concluded that the age of a mother was a predictor for complementary feeding practices because older mothers were more experienced and knowledgeable in taking care of their children and so exhibited optimal complementary feeding practices, compared to their younger, less knowledgeable counterparts [17, 43].

Caregivers for children aged between 12–17 months were more likely to meet the MMF requirements for their children compared to caregivers with children in the 6–11 months age bracket. A study that had similar findings explained that children within this age bracket had likely settled into the pattern of the family meals which were the prescribed number of times a child that age should be fed lending to meeting the MMF requirements [50].

Recommendations

Increased advocacy by nutrition champions and organisations for augmented funding to the nutrition sector to support the direct implementation of the IYCF guidelines and Multisectoral Nutrition Action Plans. Mass media used to boost nutrition education. The government and policymakers must strengthen existing initiatives and develop new intervention measures to increase the socioeconomic position, education status, and occupational opportunities of the citizenry for better CFPs. More research in other regions of the country on factors associated with IYCF.

Conclusion

The study findings revealed that the prevalence of Minimum Acceptable Diet (MAD) and Minimum Dietary Diversity (MDD) was very low in Kisoro district putting these children at a very high risk to become stunted. At all levels of the SEM, there was at least a factor associated with OCFPs intimating the need for all sectors to work together to break down barriers preventing caregivers from meeting requirements for OCFPs as we forge forward to end malnutrition for all.

Abbreviations

ANC: Antenatal Care; AORs: Adjusted Odd Ratios; CBF: Continued breastfeeding; CORs: Crude Odd Ratios; HH: Household; ISSSFs: Introduction to Solid, Semi-solid and Soft Foods; IYCF: Infant and Young Child Feeding; MAD: Minimum Acceptable Diet; MDD: Minimum Dietary Diversity; MIYCAN: Maternal, Infant, Young Child, Adolescent and New-born; MMF: Minimum Meal Frequency; OCFPs: Optimal Complementary Feeding Practices; WHO: World Health Organisation

Declarations

Ethical Approval and Consent to Participate

The study did not require ethical approval because the data set used was freely available to the public domain upon request from the organisation from which it was obtained.

Permission to use data was requested from the USAID/Uganda’s Integrated Community, Agriculture, and Nutrition (ICAN) Activity by the student and received (see Additional File 1). Endorsement to carry out the study was also obtained from the university and an introductory letter was given that was presented to ICAN to receive the secondary data (see Additional File 2). Anonymity was ensured so that there was no re-identification of participants. Confidentiality of the information gathered was guaranteed; lastly, the researcher worked to maintain that the data used did not harm or distress the participants’ lives.

Consent for publication

Not applicable

Availability of data and materials

The dataset supporting the conclusions of this article is included as Additional File 3.

Competing interests

None to declare.

Funding

This study received no grants from any funding agency from the public, for-profit, or non-profit sectors.

Author’s Contribution

T.L.B. designed the study, conducted the analysis and wrote the manuscript. D.L.E. provided supervision for the development of the study design, data analysis and manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors are thankful to the staff of USAID/ICAN for availing of the data used in the study and to Dr Peterson Kato Kikomeko and Nassamula Brenda for their guidance in analysing the data.

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Supplemental Data

Additional files 1-3 are not available with this version