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Original Article

Food and Nutrition Bulletin

ª The Author(s) 2019
Effect of Nutrition Article reuse guidelines:
Education on Knowledge, DOI: 10.1177/0379572119840214

Complementary Feeding,
and Hygiene Practices
of Mothers With Moderate
Acutely Malnourished
Children in Uganda

Richard B. Kajjura, BSc, MSc, PhD1,2 ,

Frederick J. Veldman, BSc, BSc (Hons), MSc, PhD3,
and Susanna M. Kassier, BSc, BSc (Hons), MSc, PhD2

Background: Inappropriate infant and young child complementary feeding practices related to a lack
of maternal knowledge contributes to an increased risk of malnutrition, morbidity, and mortality.
There is a lack of data regarding the effect of nutrition education on maternal knowledge, feeding, and
hygiene practices as part of a supplementary feeding intervention targeting infants and young children
with moderate acute malnutrition in low-income countries like Uganda.
Objective: To determine whether nutrition education improves knowledge, feeding, and hygiene
practices of mothers with infants and young children diagnosed with moderate acute malnutrition.
Methods: A cross-sequential study using a pretest–posttest design included 204 mother–infant pairs
conveniently sampled across 24 randomly selected clusters. Weekly nutrition education sessions were
embedded in a supplementary porridge intervention for 3 months. Mean scores and proportions for
knowledge, feeding, and hygiene practices were determined at baseline and end line. The difference
between mean scores at the 2 time points were calculated with the paired t test analysis, while the
proportions between baseline and end line were calculated using a z test analysis.
Results: Mean scores for knowledge, dietary diversity, and meal frequency were higher at end line
compared to baseline (P < .001). Handwashing did not improve significantly (P ¼ .183), while boiling
water to enhance water quality improved (P < .001).

School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
School of Agricultural, Earth & Environmental Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa
School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa

Corresponding Author:
Richard B. Kajjura, School of Public Health, College of Health Sciences, Makerere University, Mulago, Kampala 7062, Uganda.
2 Food and Nutrition Bulletin XX(X)

Conclusion: Nutrition education in conjunction with a supplementary feeding intervention targeting

infants and young children with moderate acute malnutrition improved meal frequency, dietary
diversity, and water quality.

nutrition education, knowledge, complementary feeding practices, dietary diversity, meal frequency,
hygiene practices, moderate acute malnutrition

Introduction knowledge.2-6 Seemingly, the changes implemen-

ted by mothers as a result of nutrition education
Globally, undernutrition contributes to an esti-
have not been adequately documented in low-
mated 60% of under-5 mortality.1 In developing income settings. Therefore, the aim of this study
countries, approximately one-third of infant and was to determine the effect of nutrition education
young child (IYC) deaths are associated with on nutrition knowledge, complementary feeding,
underlying causes of undernutrition,2 with an and hygiene practices as part of the management
estimated two-thirds being due to inappropriate strategy of IYC aged 6 to 18 months diagnosed
complementary feeding practices. 3,4 In sub- with MAM based on the Health Belief Model
Saharan Africa, IYC between 6 and 23 months constructs in Uganda.
with moderate acute malnutrition (MAM) are
more vulnerable to inadequate food intake due
to inappropriate feeding and hygiene practices, Methods
as it can result in high morbidity and mortality Study Design
rates.5 Childhood infections, such as diarrhea and
poor feeding practices including low meal fre- A cross-sequential approach employing a pretest–
quency and a lack of dietary diversity, contribute posttest design was used to determine knowledge,
to delayed recovery from MAM.6,7 However, feeding, and hygiene practices among breastfeed-
good hygiene practices, especially handwashing ing mothers of IYC diagnosed with MAM who
with soap, reduce the risk of diarrhea by 23%.8 received nutrition education for a period of
3 months while receiving a supplementary por-
Nutrition education on appropriate feeding and
ridge for their IYC. Seven to 9 mother-IYC pairs
hygiene practices that target mothers of IYC has
were conveniently sampled from 24 randomly
been reported to significantly improve knowl-
selected clusters. In 12 of the clusters, mothers
edge, nutritional status, and minimize disease
fed their IYC with a malted sorghum–based por-
when combined with the provision of supplemen-
ridge (MSBP), a novel supplementary porridge
tary foods in the management of MAM.2,6
formulated as part of the overarching cluster ran-
Optimal feeding and hygiene practices, there-
domized controlled trial of which nutrition edu-
fore, have the potential to prevent growth falter-
cation was a component, while in the remaining
ing among breastfed IYC with MAM. 7,9
12 clusters IYC were fed with a corn soy–based
However, it has been reported that supplementary
supplementary porridge (CSBþ) serving as a
feeding interventions either lack or provide inad- control.
equate nutrition education.5 Further, where nutri-
tion education was conducted in low-income
countries, there is a paucity of data documenting Study Setting
the impact thereof on mothers’ knowledge This study was embedded in a community-based
regarding IYC complementary feeding and cluster randomized controlled trial that deter-
hygiene practices.2,5,6 It is possible that the nutri- mined the effect of MSBP versus CSBþ supple-
tion education given to mothers could be inade- mentation, in conjunction with nutrition education
quate to facilitate an improvement in their of breastfeeding mothers, on IYC with MAM
Kajjura et al 3

feeding and hygiene practices. Study participants to prevent IYC diarrhea was also promoted, as
resided in 4 subcounties of a rural district of Arua was the use of previously boiled water for drink-
in West Nile, North Western Uganda. The region ing. The promotions of other appropriate IYC
is characterized by a high prevalence of wasting food preparation techniques that are known to
(13.6%) among IYC.10 prevent disease were also included. Before intro-
ducing a new topic, a review of content previ-
ously covered and an overview of previous
Participant Recruitment group discussions were held to obtain feedback
Two-hundred and four (N ¼ 204) mothers of IYC from mothers and discuss what was learnt during
aged between 6 and 18 months were recruited to the previous session, as well as how this informa-
participate in either the MBSP or CSBþ supple- tion was being implemented at the participant’s
mentation arm of the study. Each supplementa- home.
tion arm consisted of 12 clusters that were
randomly allocated to either a treatment or con-
trol group in a ratio of 1:1. A cluster consisted of
Data Collection and Measurement
8 to 10 mother-IYC pairs recruited per cluster. A Face-to-face interviews were conducted with
week after enrollment, participants were mothers after they signed an informed consent
approached and recruited to participate in the form in the local language at their nutrition edu-
nutrition education study. cation sites. Pretest and posttest data were col-
lected using a semi-structured questionnaire that
was administered by the same trained research
Nutrition Education assistant to avoid personal intervariability15 and
The nutrition education intervention was imple- ensure validity. The Ugandan Demographic and
mented based on the premise of the Health Belief Health Survey (2016) questionnaire was adapted
Model,11 to improve maternal complementary for the purpose of this study.10 Participant socio-
feeding and hygiene practices. It was believed demographic data were collected after expert
that when mothers acquire knowledge through input was gained on the questionnaire developed
nutrition education, it will be internalized to for the purpose of this study. The questions in the
result in behavioral change.12,13 The nutrition guidelines for assessing nutrition-related knowl-
education was conducted in Lugbarati, the local edge were adapted and modified after expert
language spoken by 2 health workers who served input to facilitate data collection regarding moth-
as research assistants on a weekly basis for a er’s feeding and hygiene practices.16 The moth-
period of 3 months. The contents of the education er’s knowledge scores for either feeding practices
sessions with a duration of up to 60 minutes or hygiene practices were a sum of the correct
included information on appropriate feeding and responses out of a total score of 8. A score of 1
optimal hygiene practices, using a standardized to 3 was classified as poor knowledge, while a
counseling card.14 Face-to-face group education score of 4 to 8 was classified as a high knowledge
and discussion sessions in addition to practical for either complementary feeding practices (diet-
demonstrations regarding the preparation of the ary diversity and meal frequency) or hygiene
supplementary porridges were used throughout practices (water quality and food safety).
the nutrition education intervention. Key mes- A 24-hour recall was used to determine the
sages conveyed included breastfeeding before dietary diversity score of IYC. The minimum
giving the IYC the supplementary porridge or dietary diversity score was determined with ref-
other household foods. In addition, active feeding erence to the World Health Organization 7 rec-
practices such as feeding the IYC 3 times a day ommended food groups.14 Each of the 7 food
were encouraged, as well as feeding an appropri- groups was allocated a score of 1. However,
ate amount of supplementary porridge of an breast milk was not allocated a score.17 The diet-
appropriate consistency to ensure an optimal ary diversity scores were recorded as adequate for
energy and nutrient intake. Regular handwashing IYC who consumed 4 or more food groups.17,18
4 Food and Nutrition Bulletin XX(X)

The number of times the IYC consumed solid, Ethical Considerations

semisolid, or soft foods (other than liquids) within
Ethical approval to conduct this study was
24 hours was determined using meal frequency
obtained from the Biomedical Research Ethics
Committee (BE218/18) of the University of
KwaZulu-Natal South Africa, the Higher
Data Quality Degrees, Research and Ethics Committee (REC/
11353/394) of the School of Public Health,
The survey questionnaire was translated into the
Makerere University Uganda, and the Uganda
local language (Lugbarati) and back-translated
National Council of Science and Technology
into English in order to ensure content validity.
(SS4705). Informed consent forms were signed
Four research assistants used for data collection
by participants who were literate, while illiterate
were trained in appropriate questionnaire admin-
participants made a thumbprint on the informed
istration techniques prior to data collection. Two
consent form prior to participation in the study.
experienced research assistant responsible for
All participants were guaranteed confidentiality
conducting nutrition education were trained on
and anonymity as they were assigned a coded
appropriate IYC feeding practices, water quality,
number for identification purposes.
food preparation, and food hygiene messages. A
pilot study was conducted among 24 breastfeed-
ing mothers in an area with characteristics similar
to the study area to pretest the survey instruments Results
prior to commencement of data collection. Where
inconsistencies were found, questions were Sociodemographic Characteristics
adjusted by paraphrasing prior to commencement The majority of mothers (84.3%) were younger
of data collection. Face-to-face interviews were than 35 years, while 70.1% had a primary school
conducted in Lugbarati, the local language spo- education. Thirty-one (15.1%) had no formal edu-
ken by mothers and trained research assistants. cation. In addition, 21.1% were underweight
The response to each questionnaire was reviewed (body mass index less than 18.5 kg/m2).
for completeness and consistency before leaving
the field. After data collection, all questions were
coded and cleaned before double data entry was
Baseline Characteristics
performed to ensure accuracy. Mothers’ knowl- There was no significant difference in IYC feed-
edge and feeding practices regarding meal fre- ing and hygiene practices between the propor-
quency, dietary diversity, and hygiene practices tions of participants who were in the MSBP
were analyzed as mean scores and proportions at group compared to those in the CSBþ group.
baseline and end line (3 months). Nearly one-fifth (19.1%) of mothers reported that
they practiced appropriate IYC feeding practices,
whereas 16.2% had adequate knowledge regard-
Data Analysis ing food safety and water quality practices.
Stata/SE 15.0 statistical software was used to
generate descriptive statistics. Baseline and end
Mean Knowledge Scores Regarding Feeding
line data were analyzed and presented as propor-
tions and mean scores. The z test was used to
and Hygiene Practices
compare mothers’ knowledge proportions regard- There was a significant difference between moth-
ing water quality, IYC feeding, and hygiene prac- ers’ mean knowledge score regarding IYC feed-
tices between the MSBP and CSBþ groups. The ing and hygiene practices at 3 months end line
paired t test was used to compare feeding and compared to baseline, irrespective of the supple-
hygiene practice mean knowledge scores between mentary porridge received, with a significant dif-
baseline and end line data. A P value of  0.5 was ference (P < .001) between mothers’ mean
considered statistically significant. knowledge score regarding complementary
Kajjura et al 5

Table 1. Mean Knowledge Scores Regarding Appropriate IYC Feeding and Hygiene Practices at Baseline Versus 3

MSBP Group, n ¼ 104 CSBþ Group, n ¼ 100

Mean Scorea (SD) Mean Score (SD)

Knowledge Parameter, N ¼ 204 Baseline End line P Valueb Baseline End line P Valueb

Feeding practices
Meal frequency 2.21 (0.84) 2.82 (0.90) <.001 2.10 (0.94) 2.83 (0.82) <.001
Dietary diversity 3.76 (2.35) 5.63 (2.13) <.001 3.76 (2.19) 6.14 (2.08) <.001
Hygiene practices
Food safety and water qualityc 2.13 (0.66) 3.31 (1.29) <.001 2.08 (0.73) 3.52 (1.20) <.001
Abbreviations: CSBþ, corn soy–based supplementary porridge; IYC, infant and young child; MSBP, malted sorghum–based
porridge; SD, standard deviation.
Mean score out of 8.
Paired t test.
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC

Table 2. Comparison of the Proportions of Feeding and Hygiene Practices at 3 Months.

Practice Parameters, N ¼ 204 Baseline, n (%) Three months, (%) P Valuea

Feeding practices
Fed 3 meals a day 83 (40.7) 180 (88.2) <.001
Fed 4 food groups a day 27 (13.2) 169 (82.8) <.001
Met minimum acceptable diet 12 (5.9) 151 (74.2) <.001
Hygiene practices
Food safety and/or water qualityb 36 (36.7) 184 (90.2) <.001
Handwashing with water and soap 16 (7.8) 24 (11.8) <.183
Abbreviation: IYC, Infant and young child.
z test.
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC

feeding and hygiene practices at 3 months when significantly between mothers in the CSBþ group
compared to baseline and end line (Table 1). compared to those in the MSBP group at 3-month
follow-up. However, the practice of making
water and food safe for consumption differed sig-
Feeding and Hygiene Practice Proportions nificantly between MSBP mothers compared to
their CSBþ counterparts at baseline. The remain-
As shown in Table 2, appropriate IYC feeding der of other IYC feeding and hygiene practices
and hygiene practice proportions differed signif- did not differ between groups at end line.
icantly at 3 months when compared to baseline
(P < .001) for all variables, except for handwash-
ing. The IYC dietary diversity score at 3 months
improved 6-fold when compared to baseline. In
addition, there was a significant difference This is the first known study that investigated
between baseline and 3-month dietary diversity feeding practices and measures of hygiene fol-
scores (P < .001). The z test results reported in lowing nutrition education in the management
Table 3 indicated that the IYC feeding practice of of IYC with MAM in Uganda. Following nutri-
feeding 3 or more meals per day differed tion education for a period of 3 months, an
6 Food and Nutrition Bulletin XX(X)

Table 3. IYC Feeding and Hygiene Practices Between Baseline and 3-Month Follow-Up by Supplementary

Baseline by Groups, n (%) Three Months by Groups, n (%)


Parameter, N ¼ 204 n ¼ 104 n ¼ 100 P Valuea n ¼ 104 n ¼ 100 P Valuea

Daily feeding practices

Fed 3 meals 43 (41.4) 40 (40.0) .845 87 (83.7) 93 (93.0) .038
Fed 4 food groups 9 (8.7) 18 (18.0) .049 81 (77.9) 88 (88.0) .055
Hygiene practices
Handwashing with water and soap 9 (8.7) 7 (7.0) .660 9 (8.7) 15 (15.0) .160
Food safety and/or water qualityb 24 (23.1) 12 (12.0) .038 86 (82.7) 87 (87.0) .294
Abbreviations: CSBþ, corn soy–based supplementary porridge; IYC, infant and young child; MSBP, malted sorghum–based
z test.
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC

improvement in IYC complementary feeding and Change in Mother’s Knowledge

hygiene practices that differed significantly from
The majority of mothers had a primary school
baseline values was observed. However, hand-
education or no formal education, suggesting that
washing, in both the MSBP and CSBþ supple-
they could have experienced difficulty in compre-
mentation groups, did not significantly improve
hending available nutrition education messages.
after the 3-month intervention period.
Results from this study indicated that at the end of
the intervention period, mothers’ knowledge
regarding IYC feeding practices differed signifi-
Sociodemographic and Baseline cantly from baseline. The latter is consistent with
Characteristics results documented in Kenya, where it was
The majority of participating mothers were reported that nutrition education regarding appro-
younger than 35 years, similar to the findings of priate IYC feeding practices contributed to an
the 2016 Ugandan Demographic and Health Sur- improvement in mothers’ knowledge.20 It is pos-
vey.10 Mothers’ level of education was also com- sible that the significant change in mother’s
parable to national statistics. 10 As a lack of knowledge at 3-month follow-up could have been
knowledge among mothers of IYC with MAM ascribed to the targeted nutrition education mes-
hinders appropriate complementary feeding prac- sages provided in their mother tongue.
tices, this finding provides evidence that the pro- In addition, nutrition education improved
vision of nutrition education to mothers of IYC mothers’ knowledge regarding meal frequency
with MAM could improve their complementary and the variety of food groups that are appropriate
feeding practices.2 In addition, IYC who were for IYC. This suggests that an improvement in
being fed the minimum acceptable diet (MAD) mother’s knowledge about appropriate IYC feed-
at baseline was 5.9% compared to the national ing practices could contribute to improved food
average of 14.0%.10 This finding could be related intake among their offspring,5 with a concomitant
to the fact that IYC with MAM seldom receive a improvement in IYC nutritional status.21,22 How-
diverse diet and are often fed less frequently than ever, despite targeted nutrition education mes-
their healthy counterparts. However, results of sages, not all mothers showed an improvement
the current study compare favorably with that of in knowledge after the 3-month intervention
a study conducted in Ethiopia among IYC aged 6 period. It is possible that the implementation of
to 23 months with a reported MAD of 10.8%.19 newly acquired knowledge regarding appropriate
Kajjura et al 7

IYC feeding practices could have been compro- (11.8%) was lower than the mean of 14% for the
mised by household socioeconomic factors, African continent, despite being within the esti-
including mother’s level of education.23 mated prevalence of 9% to 24% for Uganda.8
These results show that a targeted nutrition edu-
cation intervention with a duration of 3 months was
Change in Mothers’ Feeding Practices not adequate to bring about a significant change in
Complementary feeding practices of mothers, handwashing practice among mothers of IYC with
especially in terms of dietary diversity and meal MAM. This finding suggests that nutrition educa-
frequency, significantly improved at follow-up tion alone may not be sufficient to change personal
compared to baseline (P < .001). This illustrates hygiene habits in rural low-income settings. It is
that a nutrition education intervention with a dura- possible that mothers’ existing handwashing prac-
tion of 3 months is able to improve complementary tices were too entrenched or that water was not
feeding practices of mothers with IYC diagnosed freely available, a variable which was not deter-
with MAM as part of the management process.24 mined in this study.8 Alternatively, mothers could
Findings of this study concur with those of a meta- have been reluctant to change handwashing
analysis2 that illustrated how nutrition education behavior, as it was not appealing or not a sustainable
could be beneficial to IYC complementary feeding behavior as a result of living under conditions where
practices. Results of this study also compare favor- handwashing was not a social norm, or they were not
ably with those documented in Peru that indicated washing hands with soap for quite some time.27
how a nutrition education intervention promoting The results of this study compare favorably with
appropriate complementary feeding practices in that which was documented in Bangladesh, where a
IYC could promote growth22 and improve IYC gap between knowledge and practice still prevails
feeding practices for the management of MAM.2,20 when it comes to handwashing practices.27 Hence,
This view is supported by an investigation of the continuous motivating activities are required to
factors associated with complementary feeding improve handwashing practice with soap.27 Despite
practices in Uganda that reported how mothers, the health benefit of reducing the prevalence of
when given nutrition education, are able to diarrheal diseases, a systematic review on global
improve their IYC feeding practices.25 handwashing practices8 concludes that handwash-
The improvement in mothers’ knowledge and ing with soap after contact with excreta is poorly
practices regarding dietary diversity as a result of practiced. Due to a lack of awareness regarding its
nutrition education documented in this study has importance,8 it is possible that a 3-month interven-
the ability to enhance the nutritional status of IYC tion is insufficient in bringing about significant
with MAM.26 Study findings also compare favor- change regarding handwashing habits among
ably with that of a study conducted in Ethiopia mothers of IYC diagnosed with MAM.
where it was reported that bimonthly nutrition In contrast, the practice of safe food preparation
education for a period of 6 months improves IYC techniques and feeding practices, including boiling
dietary diversity practices,5 as well as a study water for drinking and food preparation, to render
conducted in Peru where an improvement in IYC it safe for IYC consumption differed significantly
dietary diversity as a result of an 18-month nutri- between baseline and 3-month follow-up (P <
tion education intervention was documented.22 .001). It is, therefore, possible that the nutrition
education intervention could have improved the
mother’s attitude28 toward appropriate food pre-
Change in Mothers’ Hygiene Practices paration techniques and boiling water, which is
No significant difference was found between vital in the management of IYC with MAM.
mothers’ hygiene practices in terms of handwash-
ing with soap after contact with excreta, and
before feeding IYC after the intervention period
when compared to baseline (P ¼ .183). The pre- There could have been some form of social desir-
valence of handwashing at 3-month follow-up ability bias when it came to the evaluation of
8 Food and Nutrition Bulletin XX(X)

dietary diversity, as it is possible that mothers Authors’ Note

could have given information which they thought Richard Kajjura designed the study, performed data
was appropriate, yet they did not implement this collection and management, conducted the statistical
knowledge and/or beliefs.18 However, this phe- analysis, interpreted the results, and drafted the manu-
nomenon was addressed by building rapport with script. Susanna Kassier and Frederick Veldman revised
mothers and probing them to remember food the study design, assisted with the interpretation of
items such as snacks given to IYC between main results, and revised the draft manuscript. All authors
meals, in addition to special meals and mixed read and approved the final manuscript. This research
received no specific grant from any funding agency in
dishes consumed within 24 hours prior the data
the public, commercial, or not-for-profit sectors other
collection. In addition, it should be noted that the
than the PhD Fellowship, from PowerFour Interna-
positive effect of nutrition education on mothers tional, Inc, USA.
of IYC with MAM was not compared to that of a
control group of mothers with IYC with MAM for Acknowledgments
ethical reasons. However, the study documented The authors are grateful to the mothers who partici-
a high proportion of mothers with improved pated in the intervention, as well as the research assis-
knowledge regarding hygiene and feeding prac- tants who collected the data. Dr Hedwig Acham of
tices, despite the fact that this change cannot be Makerere University and Dr Lindie Ncube of Sefako
attributed to the nutrition education intervention Makgatho Health Sciences University are acknowl-
in isolation. edged for the scientific assistance.

Declaration of Conflicting Interests

Conclusion The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
Infant and young child feeding practices in terms cation of this article.
of dietary diversity, meal frequency, and hygiene
practices through handwashing with soap, and Funding
making food and water safe for consumption sig-
The author(s) received no financial support for the
nificantly improved at 3-month follow-up (post- research, authorship, and/or publication of this article:
intervention) compared to baseline. Thus,
targeted nutrition education with a duration of 3 ORCID iD
months has the ability to change knowledge and
Richard B. Kajjura
practices of mothers with IYC diagnosed with 1763-1258
MAM when combined with a supplementary
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