Original Article

Food and Nutrition Bulletin

1-10
ª The Author(s) 2019
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Education on Knowledge, DOI: 10.1177/0379572119840214
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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

Abstract
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).

1
School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
2
School of Agricultural, Earth & Environmental Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa
3
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.
Email: rkajura@musph.ac.ug
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.
Keywords
nutrition education, knowledge, complementary feeding practices, dietary diversity, meal frequency,
hygiene practices, moderate acute malnutrition
Introduction
Globally, undernutrition contributes to an esti-
mated 60% of under-5 mortality.1 In developing
countries, approximately one-third of infant and
young child (IYC) deaths are associated with
underlying causes of undernutrition,2 with an
estimated two-thirds being due to inappropriate
complementary feeding practices. 3,4 In sub-
Saharan Africa, IYC between 6 and 23 months
with moderate acute malnutrition (MAM) are
more vulnerable to inadequate food intake due
to inappropriate feeding and hygiene practices,
as it can result in high morbidity and mortality
rates.5 Childhood infections, such as diarrhea and
poor feeding practices including low meal fre-
quency and a lack of dietary diversity, contribute
to delayed recovery from MAM.6,7 However,
good hygiene practices, especially handwashing
with soap, reduce the risk of diarrhea by 23%.8
Nutrition education on appropriate feeding and
hygiene practices that target mothers of IYC has
been reported to significantly improve knowl-
edge, nutritional status, and minimize disease
when combined with the provision of supplemen-
tary foods in the management of MAM.2,6
Optimal feeding and hygiene practices, there-
fore, have the potential to prevent growth falter-
ing among breastfed IYC with MAM. 7,9
However, it has been reported that supplementary
feeding interventions either lack or provide inad-
equate nutrition education.5 Further, where nutri-
tion education was conducted in low-income
countries, there is a paucity of data documenting
the impact thereof on mothers’ knowledge
regarding IYC complementary feeding and
hygiene practices.2,5,6 It is possible that the nutri-
tion education given to mothers could be inade-
quate to facilitate an improvement in their
knowledge.2-6 Seemingly, the changes implemen-
ted by mothers as a result of nutrition education
have not been adequately documented in low-
income settings. Therefore, the aim of this study
was to determine the effect of nutrition education
on nutrition knowledge, complementary feeding,
and hygiene practices as part of the management
strategy of IYC aged 6 to 18 months diagnosed
with MAM based on the Health Belief Model
constructs in Uganda.
Methods
Study Design
A cross-sequential approach employing a pretest–
posttest design was used to determine knowledge,
feeding, and hygiene practices among breastfeed-
ing mothers of IYC diagnosed with MAM who
received nutrition education for a period of
3 months while receiving a supplementary por-
ridge for their IYC. Seven to 9 mother-IYC pairs
were conveniently sampled from 24 randomly
selected clusters. In 12 of the clusters, mothers
fed their IYC with a malted sorghum–based por-
ridge (MSBP), a novel supplementary porridge
formulated as part of the overarching cluster ran-
domized controlled trial of which nutrition edu-
cation was a component, while in the remaining
12 clusters IYC were fed with a corn soy–based
supplementary porridge (CSBþ) serving as a
control.
Study Setting
This study was embedded in a community-based
cluster randomized controlled trial that deter-
mined the effect of MSBP versus CSBþ supple-
mentation, in conjunction with nutrition education
of breastfeeding mothers, on IYC with MAM
Kajjura et al
feeding and hygiene practices. Study participants
resided in 4 subcounties of a rural district of Arua
in West Nile, North Western Uganda. The region
is characterized by a high prevalence of wasting
(13.6%) among IYC.10
Participant Recruitment
Two-hundred and four (N ¼ 204) mothers of IYC
aged between 6 and 18 months were recruited to
participate in either the MBSP or CSBþ supple-
mentation arm of the study. Each supplementa-
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
8 to 10 mother-IYC pairs recruited per cluster. A
week after enrollment, participants were
approached and recruited to participate in the
nutrition education study.
Nutrition Education
The nutrition education intervention was imple-
mented based on the premise of the Health Belief
Model,11 to improve maternal complementary
feeding and hygiene practices. It was believed
that when mothers acquire knowledge through
nutrition education, it will be internalized to
result in behavioral change.12,13 The nutrition
education was conducted in Lugbarati, the local
language spoken by 2 health workers who served
as research assistants on a weekly basis for a
period of 3 months. The contents of the education
sessions with a duration of up to 60 minutes
included information on appropriate feeding and
optimal hygiene practices, using a standardized
counseling card.14 Face-to-face group education
and discussion sessions in addition to practical
demonstrations regarding the preparation of the
supplementary porridges were used throughout
the nutrition education intervention. Key mes-
sages conveyed included breastfeeding before
giving the IYC the supplementary porridge or
other household foods. In addition, active feeding
practices such as feeding the IYC 3 times a day
were encouraged, as well as feeding an appropri-
ate amount of supplementary porridge of an
appropriate consistency to ensure an optimal
energy and nutrient intake. Regular handwashing
3
to prevent IYC diarrhea was also promoted, as
was the use of previously boiled water for drink-
ing. The promotions of other appropriate IYC
food preparation techniques that are known to
prevent disease were also included. Before intro-
ducing a new topic, a review of content previ-
ously covered and an overview of previous
group discussions were held to obtain feedback
from mothers and discuss what was learnt during
the previous session, as well as how this informa-
tion was being implemented at the participant’s
home.
Data Collection and Measurement
Face-to-face interviews were conducted with
mothers after they signed an informed consent
form in the local language at their nutrition edu-
cation sites. Pretest and posttest data were col-
lected using a semi-structured questionnaire that
was administered by the same trained research
assistant to avoid personal intervariability15 and
ensure validity. The Ugandan Demographic and
Health Survey (2016) questionnaire was adapted
for the purpose of this study.10 Participant socio-
demographic data were collected after expert
input was gained on the questionnaire developed
for the purpose of this study. The questions in the
guidelines for assessing nutrition-related knowl-
edge were adapted and modified after expert
input to facilitate data collection regarding moth-
er’s feeding and hygiene practices.16 The moth-
er’s knowledge scores for either feeding practices
or hygiene practices were a sum of the correct
responses out of a total score of 8. A score of 1
to 3 was classified as poor knowledge, while a
score of 4 to 8 was classified as a high knowledge
for either complementary feeding practices (diet-
ary diversity and meal frequency) or hygiene
practices (water quality and food safety).
A 24-hour recall was used to determine the
dietary diversity score of IYC. The minimum
dietary diversity score was determined with ref-
erence to the World Health Organization 7 rec-
ommended food groups.14 Each of the 7 food
groups was allocated a score of 1. However,
breast milk was not allocated a score.17 The diet-
ary diversity scores were recorded as adequate for
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,
semisolid, or soft foods (other than liquids) within
24 hours was determined using meal frequency
questions.17
Data Quality
The survey questionnaire was translated into the
local language (Lugbarati) and back-translated
into English in order to ensure content validity.
Four research assistants used for data collection
were trained in appropriate questionnaire admin-
istration techniques prior to data collection. Two
experienced research assistant responsible for
conducting nutrition education were trained on
appropriate IYC feeding practices, water quality,
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
prior to commencement of data collection. Where
inconsistencies were found, questions were
adjusted by paraphrasing prior to commencement
of data collection. Face-to-face interviews were
conducted in Lugbarati, the local language spo-
ken by mothers and trained research assistants.
The response to each questionnaire was reviewed
for completeness and consistency before leaving
the field. After data collection, all questions were
coded and cleaned before double data entry was
performed to ensure accuracy. Mothers’ knowl-
edge and feeding practices regarding meal fre-
quency, dietary diversity, and hygiene practices
were analyzed as mean scores and proportions at
baseline and end line (3 months).
Data Analysis
Stata/SE 15.0 statistical software was used to
generate descriptive statistics. Baseline and end
line data were analyzed and presented as propor-
tions and mean scores. The z test was used to
compare mothers’ knowledge proportions regard-
ing water quality, IYC feeding, and hygiene prac-
tices between the MSBP and CSBþ groups. The
paired t test was used to compare feeding and
hygiene practice mean knowledge scores between
baseline and end line data. A P value of  0.5 was
considered statistically significant.
Ethical Considerations
Ethical approval to conduct this study was
obtained from the Biomedical Research Ethics
Committee (BE218/18) of the University of
KwaZulu-Natal South Africa, the Higher
Degrees, Research and Ethics Committee (REC/
11353/394) of the School of Public Health,
Makerere University Uganda, and the Uganda
National Council of Science and Technology
(SS4705). Informed consent forms were signed
by participants who were literate, while illiterate
participants made a thumbprint on the informed
consent form prior to participation in the study.
All participants were guaranteed confidentiality
and anonymity as they were assigned a coded
number for identification purposes.
Results
Sociodemographic Characteristics
The majority of mothers (84.3%) were younger
than 35 years, while 70.1% had a primary school
education. Thirty-one (15.1%) had no formal edu-
cation. In addition, 21.1% were underweight
(body mass index less than 18.5 kg/m2).
Baseline Characteristics
There was no significant difference in IYC feed-
ing and hygiene practices between the propor-
tions of participants who were in the MSBP
group compared to those in the CSBþ group.
Nearly one-fifth (19.1%) of mothers reported that
they practiced appropriate IYC feeding practices,
whereas 16.2% had adequate knowledge regard-
ing food safety and water quality practices.
Mean Knowledge Scores Regarding Feeding
and Hygiene Practices
There was a significant difference between moth-
ers’ mean knowledge score regarding IYC feed-
ing and hygiene practices at 3 months end line
compared to baseline, irrespective of the supple-
mentary porridge received, with a significant dif-
ference (P < .001) between mothers’ mean
knowledge score regarding complementary
Kajjura et al 5

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

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.
a
Mean score out of 8.
b
Paired t test.
c
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC
consumption.

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.
a
z test.
b
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC
consumption.

feeding and hygiene practices at 3 months when
compared to baseline and end line (Table 1).
Feeding and Hygiene Practice Proportions
As shown in Table 2, appropriate IYC feeding
and hygiene practice proportions differed signif-
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
between baseline and 3-month dietary diversity
scores (P < .001). The z test results reported in
Table 3 indicated that the IYC feeding practice of
feeding 3 or more meals per day differed
significantly between mothers in the CSBþ group
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-
nificantly between MSBP mothers compared to
their CSBþ counterparts at baseline. The remain-
der of other IYC feeding and hygiene practices
did not differ between groups at end line.
Discussion
This is the first known study that investigated
feeding practices and measures of hygiene fol-
lowing nutrition education in the management
of IYC with MAM in Uganda. Following nutri-
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
Groups.

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

MSBP, CSBþ, MSBP, CSBþ,

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
porridge.
a
z test.
b
Safe food preparation and feeding practices including boiling water for drinking and food preparation to render it safe for IYC
consumption.

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

hygiene practices that differed significantly from
baseline values was observed. However, hand-
washing, in both the MSBP and CSBþ supple-
mentation groups, did not significantly improve
after the 3-month intervention period.
Sociodemographic and Baseline
Characteristics
The majority of participating mothers were
younger than 35 years, similar to the findings of
the 2016 Ugandan Demographic and Health Sur-
vey.10 Mothers’ level of education was also com-
parable to national statistics. 10 As a lack of
knowledge among mothers of IYC with MAM
hinders appropriate complementary feeding prac-
tices, this finding provides evidence that the pro-
vision of nutrition education to mothers of IYC
with MAM could improve their complementary
feeding practices.2 In addition, IYC who were
being fed the minimum acceptable diet (MAD)
at baseline was 5.9% compared to the national
average of 14.0%.10 This finding could be related
to the fact that IYC with MAM seldom receive a
diverse diet and are often fed less frequently than
their healthy counterparts. However, results of
the current study compare favorably with that of
a study conducted in Ethiopia among IYC aged 6
to 23 months with a reported MAD of 10.8%.19
The majority of mothers had a primary school
education or no formal education, suggesting that
they could have experienced difficulty in compre-
hending available nutrition education messages.
Results from this study indicated that at the end of
the intervention period, mothers’ knowledge
regarding IYC feeding practices differed signifi-
cantly from baseline. The latter is consistent with
results documented in Kenya, where it was
reported that nutrition education regarding appro-
priate IYC feeding practices contributed to an
improvement in mothers’ knowledge.20 It is pos-
sible that the significant change in mother’s
knowledge at 3-month follow-up could have been
ascribed to the targeted nutrition education mes-
sages provided in their mother tongue.
In addition, nutrition education improved
mothers’ knowledge regarding meal frequency
and the variety of food groups that are appropriate
for IYC. This suggests that an improvement in
mother’s knowledge about appropriate IYC feed-
ing practices could contribute to improved food
intake among their offspring,5 with a concomitant
improvement in IYC nutritional status.21,22 How-
ever, despite targeted nutrition education mes-
sages, not all mothers showed an improvement
in knowledge after the 3-month intervention
period. It is possible that the implementation of
newly acquired knowledge regarding appropriate
Kajjura et al
IYC feeding practices could have been compro-
mised by household socioeconomic factors,
including mother’s level of education.23
Change in Mothers’ Feeding Practices
Complementary feeding practices of mothers,
especially in terms of dietary diversity and meal
frequency, significantly improved at follow-up
compared to baseline (P < .001). This illustrates
that a nutrition education intervention with a dura-
tion of 3 months is able to improve complementary
feeding practices of mothers with IYC diagnosed
with MAM as part of the management process.24
Findings of this study concur with those of a meta-
analysis2 that illustrated how nutrition education
could be beneficial to IYC complementary feeding
practices. Results of this study also compare favor-
ably with those documented in Peru that indicated
how a nutrition education intervention promoting
appropriate complementary feeding practices in
IYC could promote growth22 and improve IYC
feeding practices for the management of MAM.2,20
This view is supported by an investigation of the
factors associated with complementary feeding
practices in Uganda that reported how mothers,
when given nutrition education, are able to
improve their IYC feeding practices.25
The improvement in mothers’ knowledge and
practices regarding dietary diversity as a result of
nutrition education documented in this study has
the ability to enhance the nutritional status of IYC
with MAM.26 Study findings also compare favor-
ably with that of a study conducted in Ethiopia
where it was reported that bimonthly nutrition
education for a period of 6 months improves IYC
dietary diversity practices,5 as well as a study
conducted in Peru where an improvement in IYC
dietary diversity as a result of an 18-month nutri-
tion education intervention was documented.22
Change in Mothers’ Hygiene Practices
No significant difference was found between
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-
valence of handwashing at 3-month follow-up
7
(11.8%) was lower than the mean of 14% for the
African continent, despite being within the esti-
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
not adequate to bring about a significant change in
handwashing practice among mothers of IYC with
MAM. This finding suggests that nutrition educa-
tion alone may not be sufficient to change personal
hygiene habits in rural low-income settings. It is
possible that mothers’ existing handwashing prac-
tices were too entrenched or that water was not
freely available, a variable which was not deter-
mined in this study.8 Alternatively, mothers could
have been reluctant to change handwashing
behavior, as it was not appealing or not a sustainable
behavior as a result of living under conditions where
handwashing was not a social norm, or they were not
washing hands with soap for quite some time.27
The results of this study compare favorably with
that which was documented in Bangladesh, where a
gap between knowledge and practice still prevails
when it comes to handwashing practices.27 Hence,
continuous motivating activities are required to
improve handwashing practice with soap.27 Despite
the health benefit of reducing the prevalence of
diarrheal diseases, a systematic review on global
handwashing practices8 concludes that handwash-
ing with soap after contact with excreta is poorly
practiced. Due to a lack of awareness regarding its
importance,8 it is possible that a 3-month interven-
tion is insufficient in bringing about significant
change regarding handwashing habits among
mothers of IYC diagnosed with MAM.
In contrast, the practice of safe food preparation
techniques and feeding practices, including boiling
water for drinking and food preparation, to render
it safe for IYC consumption differed significantly
between baseline and 3-month follow-up (P <
.001). It is, therefore, possible that the nutrition
education intervention could have improved the
mother’s attitude28 toward appropriate food pre-
paration techniques and boiling water, which is
vital in the management of IYC with MAM.
Limitations
There could have been some form of social desir-
ability bias when it came to the evaluation of
8 Food and Nutrition Bulletin XX(X)
dietary diversity, as it is possible that mothers
could have given information which they thought
was appropriate, yet they did not implement this
knowledge and/or beliefs.18 However, this phe-
nomenon was addressed by building rapport with
mothers and probing them to remember food
items such as snacks given to IYC between main
meals, in addition to special meals and mixed
dishes consumed within 24 hours prior the data
collection. In addition, it should be noted that the
positive effect of nutrition education on mothers
of IYC with MAM was not compared to that of a
control group of mothers with IYC with MAM for
ethical reasons. However, the study documented
a high proportion of mothers with improved
knowledge regarding hygiene and feeding prac-
tices, despite the fact that this change cannot be
attributed to the nutrition education intervention
in isolation.
Conclusion
Infant and young child feeding practices in terms
of dietary diversity, meal frequency, and hygiene
practices through handwashing with soap, and
making food and water safe for consumption sig-
nificantly improved at 3-month follow-up (post-
intervention) compared to baseline. Thus,
targeted nutrition education with a duration of 3
months has the ability to change knowledge and
practices of mothers with IYC diagnosed with
MAM when combined with a supplementary
feeding program.
Recommendation
Health workers should continue the promotion
of dietary diversity, increased meal frequency,
food safety, and improved water quality among
mothers to enhance the effectivity of supplemen-
tary foods given to IYC as part of the manage-
ment of MAM. However, an approach other than
the constructs of the Health Belief Model should
be considered to significantly improve hand-
washing practices among mothers. This is impor-
tant because a limitation of the Health Belief
Model is related to a lack of perceived benefit by
the mothers.23,29
Authors’ Note
Richard Kajjura designed the study, performed data
collection and management, conducted the statistical
analysis, interpreted the results, and drafted the manu-
script. Susanna Kassier and Frederick Veldman revised
the study design, assisted with the interpretation of
results, and revised the draft manuscript. All authors
read and approved the final manuscript. This research
received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors other
than the PhD Fellowship, from PowerFour Interna-
tional, Inc, USA.
Acknowledgments
The authors are grateful to the mothers who partici-
pated in the intervention, as well as the research assis-
tants who collected the data. Dr Hedwig Acham of
Makerere University and Dr Lindie Ncube of Sefako
Makgatho Health Sciences University are acknowl-
edged for the scientific assistance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article:
ORCID iD
Richard B. Kajjura https://orcid.org/0000-0003-
1763-1258
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