Mothers’ Knowledge And Attitude Towards Infant And Young Child Feeding Practices In Shashemene City, Oromia- Ethiopia 2020

The scheme youngsters are fed has a huge impact on their development. Poor breastfeeding and infant feeding practices have a negative impact on children's health and nutritional status. Purpose: The study's aim was to analyze mothers’ knowledge, attitudes, and practices (KAP) regarding supplemental feeding of children aged 6–23 months in Shashamene City, Oromia Ethiopia. Methods : A community based cross-sectional study was conducted from January 1-january 28 using a two-stage sampling procès to chose 536 women with children aged 6 to 23 months for the study. The Statistical Package for the Social Sciences (SPSS) software were used to analyze the data. The characteristics related with complementary feeding (CF) practice were identied using logistic regression, and statistical signicance was determined at p-value of less than 0.05. Results: This study found that complementary food was rst introduced at the age of 6 months, 353 (68.4 %) and 167 (32.1 %) at greater and Less than 6 months age with bottle feeding (AOR: 0.27, 95 % CI: (0.13, 0.55)). Sources of information about the advantages of breast milk (AOR:4.3495 % CI (1.96,9.60)), minimum dietary diversity (AOR:2.21,95 % CI(1.01,4.85)), knowledge about iron-rich foods (AOR:0.029,95 % CI (0.04,0.21)), knowledge about iodine-rich foods (AOR:0.022,95 % CI (0.03,0.16)) were discovered to be independent predictors of mother’s knowledge on appropriate infant feeding Conclusion: Mothers' knowledge about the timing of CF practices is low in this study. Botte feeding, sources of information about the benets of breast Milk, a minimum dietary diversity, knowledge about infant and young child feeding were the indépendant factors that signicantly associated with mother's knowledge of appropriate infant and Young Child feeding practices.

Results: This study found that complementary food was rst introduced at the age of 6 months, 353 (68.4 %) and 167 (32.1 %) at greater and Less than 6 months age with bottle feeding (AOR: 0.27, 95 % CI: (0.13, 0.55)). Sources of information about the advantages of breast milk (AOR:4.3495 % CI (1.96,9.60)), minimum dietary diversity (AOR:2.21,95 % CI(1.01,4.85)), knowledge about iron-rich foods (AOR:0.029,95 % CI (0.04,0.21)), knowledge about iodine-rich foods (AOR:0.022,95 % CI (0.03,0.16)) were discovered to be independent predictors of mother's knowledge on appropriate infant feeding Conclusion: Mothers' knowledge about the timing of CF practices is low in this study. Botte feeding, sources of information about the bene ts of breast Milk, a minimum dietary diversity, knowledge about infant and young child feeding were the indépendant factors that signi cantly associated with mother's knowledge of appropriate infant and Young Child feeding practices.

Background
Children are particularly vulnerable to malnutrition in developing countries due to inadequate dietary intakes, a lack of appropriate care, and inequitable food distribution within households [1,2]. Appropriate feeding practices are critical for improving nutritional status and ensuring child survival. Inadequate feeding practices are often linked to 2/3 rd of the 10.9 million deaths among children under the age of ve worldwide [3,4]. CF is the gradual introduction of solid and semisolid foods into an infant's diet when breast milk alone is insu cient to meet the infant's nutritional needs. The age range for CF is considered to be 6 to 24 months, despite the fact that breastfeeding may continue for up to 2 years [3].
To monitor and guide infant and young child feeding practices, the World Health Organization (WHO) developed eight core and seven optional indicators [5,6]. Ethiopia, one of the Sub-Saharan African countries with a high level of malnutrition, launched a national strategy for infant and young child feeding in 2004 to improve children's nutritional status [7]. The WHO recommends using a combination of indicators to assess the level of appropriate CF, but most studies on complementary practices have used a single indicator with a narrow age range, failing to adequately quantify the level and determinants of appropriate complementary feeding practices (ACFP) [5,6]. Mothers' knowledge of appropriate CF has a greater impact on children's nutritional status than a lack of food; identifying gaps in feeding practices aids in the planning of interventions to improve feeding practices [7,8].
According to a study conducted in Nagele Arise, the rate of appropriate CF was 9.5 %. [9]. Infant feeding practices are changing over time and place as a result of modernization, changing lifestyles, and increased urbanization. Scarcity of information on appropriate CF on Infant Young Child Feeding (IYCF) in Ethiopia, calls for a study setting to explain the level of appropriate CF about IYCF and associated factors. Besides this, study serves as a baseline for future research. Yet, it had never been assessed in Shashemene city as a result; the study was designed to analyze mothers' KAP on Infant Young Child Feeding (IYCF) in study area. The ndings will aid in the promotion of appropriate CF.

Area and subjects
The study was conducted in Shashemene city from January 1-28 in 2020. Shashemene is the most densely populated town with diversi ed ethnic groups of the population. It is located 250 km from Fin ne, the capital city of Ethiopia. Climatically, Shashemene city falls into subtropical climatic zones: The Population of Shashemene city is estimated to be 272193: 50.4% male and 49.6% are female in 2019 Children aged 6-23 months of age constituted 4.8 % of the population i .e.13065 as to Shashemene health o ce report. Regarding Study Design and Population, a community-based cross-sectional study was conducted in Shashemene city, Oromia, Ethiopia. All mothers with children aged 6-23 months who lived in Shashemene city by 2020 were considered the source population, whereas mothers with children aged 6-23 months who lived in selected households during the study period and lived in the study area for more than 6 months were considered as the study population.

Sample Size determination
The sample size was determined by a single population proportion formula taking the proportion of ACFP 11.4% from the previous study [10]. The following assumptions were used; margin of error=4%, Zα =1.96, and design effect =2. 243 samples were obtained with consideration of 10% contingency to nonresponders a total of 536 mothers sampled.
Sampling procedure A two-stage sampling technique was used to select the study subjects. Four sub-cities were randomly selected using a simple random sampling method from 8 sub-cities. The total population in 4 selected sub-cities: Buchanan, Arada, Alelu, and Awasho were 36877, 34529, 31734, and 36370 respectively (139510) of which 6697 was children 6-23 months of age. The calculated sample 536 was allocated equally among the selected 4 sub-city i.e. 134 mothers having children 6-23 months. To get the individual sample units or subjects at the household level a documented list of all target groups of the sub-city was used from the health post to acquire a list of the target group.
The rst individual was identi ed by lottery method and every K th mother with eligible children were picked from 4 sub-city using systematic random sampling thus a child was selected in each sub-city and his/her mother was interviewed accordingly. From each household, one eligible child with mother at the time of the survey was selected, incase >2 eligible children found the younger was taken and the process had been continuing until next K th in the same direction. If the mother was absent on the date of data collection she was substituted by the next mother from the same sub-city after one revisit was made.

Data collection procedures
Six diploma holder data collectors and two BSc. holder supervisors were participated to collect the data from mothers who had children aged 6-23 months by using a face-to-face interview during a home-tohome visit with semi structured questionnaire. The questionnaire comprised of data on background characteristics of mother and youngsters, maternal health practice, and child feeding practices. For data quality control, the questionnaire was rst developed in English and translated to the local language, Afan Oromo, and then back-translated to English by two people, who have good command in both languages for consistency. The training was given to data collectors and supervisors for 2 days and the questionnaire was pre-tested in 5% of mothers, in the study area, which is not included in the actual study to assess the content and approach of the questionnaire and a necessary correction was made. All questionnaires were checked daily for completeness accuracy and cleaned before analysis.

Operational de nitions
Timely introduction of CF: The proportion of children 6-23 months that were introduced to solid and semisolid foods at 6 months of age [5, 6].
Minimum dietary diversity is that the proportion of youngsters 6-23 months aged who receive foods from 4 or more food groups with the food groups consisting; (I) grains, roots, and tubers; (II) legumes and nuts; (III) dairy products; (IV) esh foods; (V) eggs; (VI) vitamin A-rich fruits and vegetables; and (vii) other fruits and vegetables the prior day of the study [5,6].
Minimum meal frequency is that the proportion of breastfed and non-breastfed children 6-23 months aged , who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum number of times or more during the previous day. The minimum is de ned as 2 times for breastfed infants 6-8 months, 3 times for breastfed children 9-23 months, 4 times for nonbreastfed children 6-23 months [5, 6].
A minimum acceptable diet is the proportion of children 6-23 months of age who receive both minimum meal frequency and minimum dietary diversity during the previous day of study. ACFP: -de ned appropriate when they meet all the four indicators timely introduction, minimum meal frequency, and minimum dietary diversity and MAD while it is considered inappropriate when it fails to ful ll even a single indicator [5,6].
Knowledge and attitude about ACFP were measured among respondents using 10 items [(1). ever breastfeed your child? (2). Time of initiation of rst breast milk? (3) How long you gave Breast Milk to the baby? (4) Having information on CF; (5). Know the advantage of iron-rich food? (6). know the bene t of Iodized salt? (7). Frequency of feeding solid, semisolid, or soft food (8) sources information about the advantage of breast feeding? (9). sources information about commercially prepared complementary food (10). How to prepare complementary foods] And 4 items [1 it is important to help my child when she eats, 2. It is important to feed my child to eat slowly and patiently, 3. It is important to encourage my child to eat and 4.I talk to my child during feeding by looking straight in the eyes] respectively. Therefore, mothers responded ''Yes'' was given a value of ''1,'' while those said ''No'' were given ''0'' and summed up.
Those mothers scored mean or more were considered as having knowledgeable, whereas those scored below mean value was characterized as not knowledgeable similarly procedure was followed for attitude those who scored mean or more value were considered as having a good attitude, whereas those scored below mean value were categorized as poor attitude on ACFP.
Inclusion and exclusion criteria All mother-child pairs age 6-23 months living in Shashamene city were taken as source population. Whereas mothers -child pairs aged 6-23 months living in the selected household during the study period and lived in the study area for ≥6 months as well presented during the study period were included as study population while those resided in the study area for <6 months were excluded from the study subjects.

Independent and dependent variables
The outcome variable for this study was the magnitude of knowledge, attitude, and practices (KAP) regarding CF and its components. The independent variables were maternal, child, and household characteristics. Brie y, the description of the variables was as follows: Socio-demographic characteristics (age, sex, type of family size, monthly income), Partner education level, household wealth index, food insecurity, occupation, residence, knowledge, and attitude of mothers, Obstetric history :( Pregnancy History, ANC, PNC, delivery mode and Place of delivery, birth space and no of Parity) were the independent variables.

Statistical analysis
Data were coded and entered into Epi-info 3.5.1 statistical software and analysis was made by using statistical package for social science (SPSS) version 25. Descriptive statistics such as frequencies, proportions, means, and standard deviation are used to describe data. Bivariate analysis was made to see the relation of each independent variable with the dependent variable. Finally, independent variables associated during bivariate analysis with P-value <0.25 were entered into multivariable logistic regression analysis used to determine the strength of association between independent and dependent variables. Odds ratios along with 95% CI were reported and the statistical signi cance was declared at the p-value < 0.05. A multivariate Logistic regression model was used to control confounders.

Study Result
Socio-demographic Characteristics of Study Subjects.
The study included 520 mother-child pairs with a perfect response rate of 100 %. Mothers' mean age was 24.81 SD (+0.87) years. More than half of the study participants were between the ages of 25 and 34.
14.8 % of households do not have a job. 481 (92.5 %) of the total study subjects were married, and 325 (62.5 %) were Muslim. More than half of the respondents 333 (64 %) belonged to the Oromo ethnic group, 89 (17.1 %) is Amahara, and the rest is wolayita, Tigre, and other, accounting for 47 (9%), 11 (2.1%), and 40 (7.6%) respectively. Three hundred twenty-seven (62.9 %) of the households have a family size of 4-6 members, 101(19.4) have 1-3 household members, and the rest have more than seven family members (table1).   In contrary, the discouraging practices were 31 (6%) mothers start CF earlier, breast fed continuation was not as recommended at 1 & 2 years / I.e. not satisfactory but by far better than that of Kosovo [12]. The other discouraging practice was bottle with nipple feeding which accounts for about 86%. Over all, the mothers' good knowledge and positive attitude about appropriate IYCF practice were 319 (61.3%) and 313 (74%) among 6-23moths age old children in the study area.

Bivariate and Multivariable Analyses
Factors related to mother's knowledge of infant feeding of children aged 6-23 months were identi ed: A Variables with P.Values less than 0.25 in bivariate analyses were re-entered into a multivariate logistic regression to account for potential confounders. There was no correlation between maternal age, family size, household income and knowledge of mother on infant feeding in this study.
Knowledge of mothers with higher levels of education was reported higher on infant and young child feeding compared with those mothers who had completed secondary education or no schooling (AOR= 2.26(1.08-4.71)).* After adjusting for maternal education and other potential confounders, 'working mother' (mothers 'occupation) regardless of type of occupation remained as a signi cant association factor for IYCF practices compared with Homemaker. The odd of being Knowledge able about IYCF practices among mothers who had occupation (AOR: 2.94, 95%, CI, (1.53-5.64)) *** were higher than that of mothers who did not had occupation (Table 4). Abbreviations: CI-con dence interval, COR-Crude odd ration, AOR-Adjusted odd ratio, P. vale ≤0.05*, P. value <.001*** The ndings revealed that, of the total entered variables, Bottle feeding, Initiation of CF at 6 months, and TV, radio, reading, and health professionals are all good places to get information about the bene ts of breast milk. Minimal dietary diversity was attained.
Maternal knowledge about IYCF practices was One of the predictor variables that statistically signi cant.
The odd of Introduction of solid, semi-solid or soft foods for children from knowledgeable mothers was 4.31times higher when compared with children of mothers with no knowledge (AOR: 4.3195%,CI:(2.92-6.36))*** Knowledge of iron-rich foods and Knowledge of iodine-rich foods are factors signi cantly associated with Knowledge of mother on appropriate infant feeding, whereas the rest variables were not associated after controlling for potential confounders, despite being associated in bivariate analyses. Approximately 73% of bottle-feeding mothers were unaware of proper infant feeding (AOR = 0.27, 95% CI: (0.13, 0.55)). The start of CF at 6 months was found to be statistically signi cantly related to the mother's knowledge of appropriate infant feeding. Mothers who began CF at 6 months were approximately six times more likely to be knowledgeable about appropriate infant feeding (AOR = 6.21, 95 % CI: (2.97,13.0)).
Sources of information about the bene ts of breast milk and mothers who met the minimum dietary diversity had four and two times more knowledge on appropriate infant feeding practice, respectively (AOR= 4.34,95 % (1.96,9.60)), (AOR=2.21,95 % CI,(1.01, 4.85)). After controlling for potential confounders, our ndings showed that mothers who did not know about proper infant feeding were 97.1 % and 97.8 % less likely to give iron and iodine-rich food, respectively (AOR= 0.029,95 % CI,(0.04,0.21), AOR=0.022,95 % CI,(0.03,0.16) ( Table 5). This might be due to difference in time, socio culture version. In current study a large majority 496 (94.6%) of mothers knew and imitate breast milk within one hour of delivery as recommended by WHO this is in fact very good practices that is helpful for successful lactation and weaning practices. Breast feeding was continued till 1 and 2 years by 89.9 % and 93.1 % of mothers respectively this is encourage able practice which was supported by study done in Karachi Hospital [14] in which the initiation of breastfeeding soon after birth was very common.
Bottle feeding, start of CF, Sources of information on the Bene ts of Breast Milk, mother Knowledge of iron-rich foods and mother knowledge of iodine-rich foods were signi cant factors associated with mother knowledge of infant feeding among children aged 6-23 months. Children from low-income families were also found to be at a signi cantly higher risk of receiving inappropriate CF.
The study's ndings revealed that mothers who knew about infant feeding had practice 73 % (AOR: 0.27 95 % CI (0.13, 0.55) less bottle-feeding than those who did not. This nding is supported by a study conducted in Adudabi, which found that mothers with less knowledge about infant feeding practice formula feed before 6 months, complaining of decreased milk production and the baby appearing hungry or unsatis ed after feeding [15].
Bottle feeding with a nipple the day preceding the survey that was during the day or night after birth nearly account for 86% in this study area which was discouraging practice. This is supported by another study conducted in Jigjiga with the highest percentage of mothers (90.9 %) thought as bottle feeding was a better option for feeding non-breastfed children and for medical problems [16].
This suggests that mothers who are unfamiliar with appropriate infant feeding prefer bottle-feeding to breastfeeding for a variety of reasons, including even who received advice from a healthcare provider about the importance of breastfeeding during antenatal and postnatal visits, having been counseled about the appropriate breast feeding Practice at any time, and having previous breast feeding practices experience. At six months, mothers who know infant feeding initiate CF 6.2 times more than mothers who do not know infant feeding (AOR:6.21 95 % CI: (2.97,13.0)). This nding is similar to a study done in India by which found that 52 % of children started complementary food at the age of 6 months, and another study done in Jigjiga, Ethiopia, which found that 90 % of children's mothers started CF at 6 months, but only 27.3 % of the mothers were aware that adding ghee or oil enriches children's diet [8,16].
These similarities may be explained by the fact that these two regions have similar cultures and receive health education on exclusive breastfeeding and appropriate CF from health extension workers. Sources of information such as mass media (TV, Radio) and health professionals are four times more signi cant (AOR: 4.34 95 % CI (1.96,9.60)) for mother's knowledge on infant feeding about the bene ts of breast milk. This discovery is the result of a well-supported study conducted in Bahir Dar [17].Reported Mothers who had access to a radio were 1.7 times more likely to have adequate knowledge than their counterparts who did not have access to a radio. In contrast to the previous study, conducted in India [8] found that the primary source of knowledge about complementary food items was family (52%), followed by healthcare professionals, electronic media, and relatives. This disparity could be attributed to differences in socioeconomic, cultural, and technological access in each country.
Mothers' knowledge of dietary diversity and child feeding was signi cantly associated with their child's infant feeding practice (AOR: 2.2195 % CI (1.01, 4.85)). Furthermore, this study con rmed that mothers' knowledge of dietary diversity and child feeding practices in uence appropriate dietary diversity feeding practice. Mothers who knew a lot about dietary diversity and child feeding practices were more likely to feed their children a variety of foods than their counterparts. This nding is consistent with the ndings of a study conducted in Addis Ababa, Ethiopia [18]. And a study in Adea woreda found that mothers who were not knowledgeable about dietary diversity were 70% less likely to practice good dietary diversity for their 6-23-month-old children than their counterparts [18,19].
This demonstrates a better understanding of the various food items and their bene ts, which assists the mother in implementing appropriate child feeding practices. Mothers who were unaware of the bene ts of iron-rich foods were 97 % less effective in infant feeding practice than mothers who were aware of the bene ts of iron-rich foods (AOR: 022,95 % CI) (0.03,0.16)). Furthermore, a study conducted in Bahir Dar revealed that mothers' knowledge of Infant young CF practice, particularly on the frequency and type of complementary food, the need for iron-rich foods, and additional foods during illness, was very low [17].
This could imply that mothers who have access to micronutrients are less likely to practices CF.
Other independent predictors were maternal education and mothers' occupation that showed a stronger association with child feeding practices. In short the higher the level of maternal education the better the IYCF practice. This supported by previous evidence from study done in Sri lank that shown maternal education and mothers' occupation were a strong predictor of child Nutrition [20,21].This is possibly due to that educated ,and employed mothers have high chance of having information on child care as well they get better access to improved health services and economy. This implies women education and empowering have great role in improving IYCF practices.

Conclusion And Recommendation
The ndings evaluated among mothers with children under the age of two years show that mothers have signi cant and appropriate knowledge, attitude, and practice regarding early initiation of breastfeeding, exclusive breastfeeding, initiation of appropriate complementary feeding, as well as the preference for preparing home-based complementary feeding that focuses on MDD and MAD. Besides, the study reveals that mothers' knowledge and attitude about IYCF feeding during illnesses were the very is limited. The practices and attitude of mothers' about Bottle feeding was high though it was discouraging practice / feeding which was the primary cause of child under/malnutrition. Bottle feeding, sources of information about the bene ts of breast milk, a minimum of dietary diversity and, MAD, knowledge about iron-rich foods, and knowledge about iodine-rich foods were the independent factors that were signi cantly associated with mother knowledge about appropriate infant feeding practices.

Recommendation
It was stated in previous studies as 2/3 of child death was attributed to inappropriate complementary feeding, in this study knowledge was low. So, to scale up these successful interventions to levels that would make an impact. Health Bureau, NGOs and other development sectors should give special attention to: Educational/ counseling intervention on bene ts of breast feeding, CF, and dietary diversity for mothers and /or caregivers are essential for improving IYCF practices, particularly for mothers with younger children about, time, variety, quantity and frequency of food and discourage bottle-feeding practices to reduce malnutrition HCWs should encourage the women to attend more ANC as well as give attention to mothers during counseling on Infant and young child feeding practices /nutrition /educational interventions to improve complementary feeding practices and brings positive attitude about IYCF practices To come up with the real gure large scale follow-up study will be proposed for the researcher collectors and study participants for the support they provided us throughout the whole process of the data collection period.
Funding: The authors stated No speci c funding for this work.
Availability of data and material: Data are available without restriction in the body of manuscript.