Studies on Knowledge, Attitude, and Practice of Complementary Feeding
Complementary feeding is starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infant, therefore other foods are needed while continuing to breastfed12. Knowledge, attitude, and practice of parents towards complementary feeding is important role to make successfull complementary feeding process. WHO recommends to introduce complementary feeding at 6 months. Knowledge of timing to start complementary feeding was varied among some studies. In our study, parent’s knowledge of timely complementary feeding before intervention was 37.3% in control, 45.7% in group 1, and 41.2% in group 2. This number was found lower compared to other studies, such as in Pakistan (54%), Karachi (57.2%), and Ghana (60%).13 Another study in South Ethopia showed that 72.5% mothers of children aged 6–23 months knew the initiation time of complementary feeding, which is less when compared to study in South India in 2011 (77.5%).13,14 Aggarwal et al observed that only 17.5% mothers had started complementary feeding at recommnended time and in a study held in slums of Delhi observed 16.6% of parents had initiated feed at the right time. Those studies showed lower level of mothers knowledge of initiation complementary feeding time than our study. After intervention, our study showed that the knowledge of timing to start complementary feeding was increased from 41.2–55.9% in group 2 (seminar and workshop intervention). In a contrary, our study found that the mean of parent’s attitude of timely complementary feeding was good with 64.2% in control group, 75.7% in group 1, 73.5% in group 2 before intervention and 80.6% in control group, 87.1% in group 1, and 88.2% in group 2 after intervention.
The recommended feeding frequency form WHO is two to three times at 6–8 months and three to four times at 9–12 months, with once to twice additional meal per day. Study in Nigeria showed only half of the responden knew the correct frequency, however another study in Ghana showed that almost all of the responden knew the correct frequency. In a similar study in Allahabad, only 38.7% of children received proper complementary feeding. 14 Our study found that 55.2% in control, 48.6% in group 1, and 45.6% in group 2 parents have been given the correct meal frequency before intervention and 34.4% in control, 45.7% in group 1, and 45.6% in group 2 after intervention. This finding was similar with the study finding in slums areas of Bahir Dar City, Ethiopia (47%),15 India (48.6%)16 and Pakistan (62%)17
Besides minimum meal frequency, the adequacy of miconutrients and macronutrients are important. Complentary food should be varied and include adequate macronutrients and macronutrients. Micronutrient needs are high during the first 2 years of life due to rapid rate of growth and development.6,18 In our study, parent’s knowledge, attitude, and practice of adequate macronutrients and micronutirents in complementary food was poor before intervention. After intervention, parent’s attitude of adequate amount of macronutrient was raised into 25.4% in control, 21.4% in group 1, and 14.7% in group 2. However, this attitude was still in low level. Other study held in 2018 showed that 27.3% mothers were aware that adding oil enriches children’s porridge nutritionally and 31.8% of mothers knew that childrean’s meal should be balanced.19 Another study in Sri Lanka showed that oil had been introduced to 84.9% of infants by the end of 12 months.20 In our study, only 34.3% parents in control group, 30% in group 1, and 48.5% in group 2 had the correct knowledge of fat component in complementary feeding before intervention but increased by 55.2% in control group, 47.1% in group 1, and 79.4% in group 2 after intervention. A study conducted in Urganda reported that majority of children were given cereals in the last 24 hours. Only 0.5% mother gave meat and milk products. Cereal based foods alone are not sufficient.21 WHO recommended mother to feed their children with locally available foods which contain calories, proteins, mineral, and vitamins. Our study reported parent’s knowledge of source of protein was low to moderate before intervention (53.7% in control group, 25.7% in group 1, 32.4% in group 2). A increase knowledge of source of protein intake was noted after intervention (56.7%, 40%, and 44.1% in control, group 1, and group 2 respectively). The use of fortified complementary food may be necessary to ensure adequacy of nutrient intakes.12 Hasnain et al17 reported that 82% respondents of their study knew that homemade food is good, but only 42% were giving them home made food. Our study found that only 10.4% in control group, 11.4% in group 1, and 1.5% in group 2 knew that fortified food can be used as complementary food.
Food diversity recognized as a key of high quality diets.WHO guideline recommend that child should eat meatt, poultry, fish, or eggs as often as possible. Vitamin A rich fruits andvegetables also should be eaten daily. In our study, food diversity among parents attitude was low (20.9% in control group, 28.6% in group 1, and 26.5% in group 2) before intervention. The percentage increased after intervention but still in low level (29.9% in control gorup, 30% in group 1, and 41.2% in group 2). Another study showed that majority of the children had eaten food from grain, tubers, roots like porridge, rice, bread, and cassavas. The study also found that consumption of iron rich foods was low, because animal protein are most likely out of financial reach for the majority participants. According to study in Sri Lanka, animal product protein intake was very low, fish and eggs were consumed by 25% and 18% of infants. However, the other study in one area in Sri Lanka, Galle reported that inroduction rates of fish and eggs were high, 75% and 63%. Consumption rates of pro vitamin A rich food (carrot and pumpkin) were also high (97% and 90%).20 Senarath et al22 reported the variation of food was increased as the age of the child increased (40.1% in 6–8 month age group and 82.5% in 18–23 month age group).
Safe preparation and storage of complementary feeding are also play important role. Washing parents’ and children’s hands before eating is recommended by WHO. In our study, practices of hand washing with water and soap was moderate before intervention (50.7%, 60%, and 45.6% in control, group 1, and group 2 respectively). A increase in parent’s attitude was notable in control and group 2 after intervention. Mihreite23 also found the same result that majority of mothers in their study had high knowledge on hand hygiene practices; washing hands before preparing food (44.5%) and treating of water used for preparing food for a child (46.4%). Madhu et al21 reported from 200 partisipants in their study, 96% clean hands and utensils before feeding, 66% wash hands of children before feeding, and 61% boiling of drinking water.
Responsive feeding is one of complementary feeding practice principle recommended by WHO, including sensitive to children hunger and satiety cues, feed slowly and patiently, experiment with different food combination, taste, texture, minimize distractions during meal time, and talk to children during feeding. Inappropriate feeding practices are an important role of stunting. Parents are unaware of the importance of responsive feeding.24 Less than half of mothers reported the need for responsive feeding of complementary food to ensure optimal intakes (45.5%).19 In our study, parent’s knowledge of recommended feeding duration was poor, 58.2% in control group, 71.4% in group 1, and 66.2% in group 2 didn’t know the recommended feeding duration. The percentage was decreased after intervention, which is the knoweldge of recommended feeding duration was increased. This findings were followed by poor responsive feeding practice in all groups, only 29.9% in control group, 51.4% in group 1, and 29.4% in group 2 practiced responsive feeding before intervention.
Continuing breastfeeding until two years of age or beyond make an important contribution to maximize child’s growth, because of its energy and essential fatty acids content. Breast milk also provides substantial amount of micronutrient.24 In this study, parent’s attitude of continuing breastfeeding before intervention were 44.8% in control group, 52.9% in group 1, and 50% in group 2 respectively. Parent’s attitude was increased in all group to 58.2% in control group, 61.4% in group 1, and 72.1% in group 2. This finding in lower that other study in Ethiopia, about 92% and 94% of mothers have continued to breastfeed their children at age one and two respectively.15 The majority of women participated in that study were housewives which increases the likelihood of continuing to breastfeed.15 Meanwhile, our study found that parents had continued breastfed in 79.1% (control), 78.6% (group 1), and 86.9% (group 2) before intervention.
Factors Affecting Complementary Feeding Knowledge, Attitude, and Practice
Our study found no correlation between mother’s age, mother’s education, and household income with parent’s knowledge, attitude, and practice of complementary feeding (p > 0.05) (Additional File 1). Nonetheless, some similar studies reported different findings with our study.
Education is one of important determinants of children’s growth and development, such as association between parents’ education level and appropriate infant feeding. Mother’s education plays a significant role on proper infant feeding after a comparative study involving five Asian countries.22 However, Seram et al25 found no correlation between parents education and knowledge on complementary feeding. The result was in line with other study in rural Bangladesh that maternal education was not associated with timing of introduction of complementary food based on study in rural Bangladesh. Maternal knowledge or education may not be the foremost driever of child complementary feeding practice.19 Seranath et al22 in their study observed a linear correlation between meal frequency and maternal education, but it was not associated with others complementary feeding indicator i.e timely introduction of complementary feeding, food diversity, and minimal acceptable diet. Compared with mothers with higher levels of education, those who had completed secondary education or had not attended any level of education reported a higher risk for low diversity (OR 1.97 and 1.48).22 This result is in acordance to study in Kenya which found that level of education and knowledge of forbidden foods had a positive correlation.26
Economic status play role in fulfilling household resource including component of complementary food. Poverty was one of factor for inappropriate complementary feeding practice. Study in Wollow found that rich households had improved complementary feeding practice due to dietary diversity.27 Several studies also reported that the low income was a major constraining factor to food security. It may have contributed to inability to achieve minimum meal frequency and meal diversity.27,28 The study showed that diets of infant and young children in low income countries are iron, zinc, and B6 deficiency.24 This finding was confirmed by other study in Sri Lanka, the result showed that dietary diversity gradually declined with lower income.22
Study in Wanogo District, South Ethiopia in 2017 showed that culture plays a major role in feeding practices. Feeding culture in community is not in favor of recommended feeding guideline and was responsible for increasing the odds of inappropriate complementary feeding practice by 2.4%. Most of participant in that study revealed that elders especially husbands was priority during feeding practice and the leftover was served for the child.27 Another study held in China found that mother introduced complementary food before six months, most offent at three months. They believed that there were some benefits to introduce Chinese traditional food earlier, included strengthening bone development, children learning to swallow food, prolonged satiety, accelerated growth, and improved digestive system.26 Similar to that studies, study in Lubao, Kenya reported that most of parents gave porridge to their child as early as the first month because they explained that porridge was good to make their child strong. The result of this study reported that culture was the reason of 54% parents to forbid their child to consume some foods. This study also reported that various diet restrictions and food taboos affected to infant feeding. A common taboo in the area were not fed children with eggs as they believe that eggs made speech delay. Some parts of meats especially organ meats also could not be eaten by children or women because it just served to men and some local belief to feed their children a small amount of ashes along with burning fish to help soothe the baby to sleep.26
Impact of Educational Interventions for Improving Parent’s KAP on complementary feeding
Although having a similar general aim compared to other researches, our study strived to show a different parameter on the effectiveness of educational interventions in form of seminar and workshop by measuring the immediate change of parent’s KAP in four weeks interval. It could be observed that the implementation of seminar have promoted a positive result in parent’s practice, although it might not be in significant improvement. Furthermore, better improvements are also shown by the implementation of seminar and workshop, in which it encourages increased scores in parent’s attitudes and practices.
The inadequate improvement in parent’s knowledge observed in both first and second intervention groups raise an inquiry on the reason that might explain this drawback. It might be argued that this could be due to parent’s education level that mostly (> 60%) are at low level (less than 9 years education time) and the short interval to the second assessment. Improvements found in the first and second intervention groups might be appeared as the results of direct replication from the given intervention. Furthermore, a study by Shi et al. in China which gathered their second follow-up data at 6 months successfully showed that the intervention group had a significant improvement in parent’s complementary feeding practices.29 However, in this study, the intervention was slightly different with ours in which home visits were performed as an additional approach to the combination of group training, demonstration, and booklet administration.
In the implementation of the intervention, the involvement of the local health workers along with the community cadres and leaders are important to assure a successful intervention for the community. We managed to collaborate with the local primary health cares in the villages. However, several aspects could still be improved, such as implementing additional interpersonal session with the participants by having an individual counseling and home visit. This method was implemented by Hotz and Gibson in Malawi and resulted in improved knowledge ad behavior on food seection and preparation of parents.30 Other study by Shi et al also noted that the involvement of family members mainly husband and parents-in-law are also essential to create a supportive environment for the improvement of parents in complementary feeding.29 This study showed a significant result in parent’s practice and also in children’s anthropometry such as in increased weight gain and length.
As blinding was not performed in this study, this research is prone to selection bias performed by trainers in the interventions. We have attempted to minimise the bias by having a training for all the trainers prior to the interventions in order to give a standardised and similar intervention for both the intervention groups. We were also unable to perform an individual consultation, assess any cultural concerns, and home-visit with the participants, and this might play a role on consolidating participant’s knowledge on the new given information. Furthermore, we only included one parent for every children, thus other family members that might have influence on the parents such as husband and mother-in-law were not enclosed in the intervention. We also noted that a longer interval follow-up, such as three and six months, should be incorporated in the study design to capture the longer change in parent’s KAP.