Hygienic Practice during Complementary Feeding and Associated Factors among Mothers of Children Aged 6–24 Months in Bahir Dar Zuria District, Northwest Ethiopia, 2019

Department of Environmental Health and Hygiene, Bonn Universiy Hospital, Bonn, Germany Deprtmenet of Public Health, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia Deprtmenet of Biomedical Sciences (Medical Biochemistry), College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia Deprtmenet of Environmental Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia Deprtmenet of Biomedical Sciences (Medical Physiology), College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia


Introduction
Complementary feeding is the process that starts when breast milk alone is no longer sufficient to meet the nutritional requirements of infants and therefore food is needed, along with breast milk. Complementary foods in resource-poor settings can result in diets that are microbiologically unsafe, which can lead to the risk of exposure to food-borne pathogens [1]. Microbiologically contaminated food is particularly harmful for children aged <2, who have immature immune systems and are vulnerable to infections with enteric pathogens [2].
Poor food hygiene practice is one of the major contributors to childhood diarrhea up to 70% of diarrhea episodes in developing countries [3]. Poor sanitation, unsafe water supplies, and poor personal hygiene are responsible for 88% of childhood deaths [4]. Recent evidence indicated that weaning foods prepared in unhygienic conditions can be highly contaminated by pathogens and are a major cause of diarrhea and associated malnutrition [5]. It has been estimated that 50% of child under nutrition may be attributable to poor WASH practices [6]. Children are particularly vulnerable to infections at the weaning period, and poor complementary food hygiene practice and subsequent diarrhea may contribute to stunting [7].
Contamination of complementary foods is very common in developing countries due to contaminated water, poor personal hygiene, inadequate cleaning of eating utensils and inappropriate storage of foods after preparation [8], inadequate knowledge of safe food handling, poor environmental sanitation, and inadequate social amenities such as toilets, kitchen, and poor sewage systems [9]. Appropriate complementary feeding (CF) is an important determinant for the achievement of healthy growth and survival of young children in their early years of life. It has a potential to prevent 6% of all under-five deaths, particularly in the developing world [10]. Improving home handwashing practices remains one of the central challenges for the public health in the 21st century. Each year, over 5 million children in developing countries die from either diarrhea or acute respiratory infections [11].Globally handwashing with soap at key times is as low as 2 to 35% [12]. An average of 65% of death caused by diarrheal diseases could be reduced if good hygiene practice accompanies with the provision of water and sanitation [13].
A Vietnam study revealed that 36.8%, 29%, and 43.2% of mothers always washed their hand with soap, after using toilet, before eating, and before feeding, respectively [14]. Another study conducted in Bangladesh illustrated that 17% of mothers did not wash their hands after defecation and 26% of mothers did not properly clean their hands and utensils before feeding [12]. e study performed in Northwest Ethiopia showed that mothers who received weaning advice tend to practice appropriate weaning than those who did not receive [15]. Another study conducted in rural Bangladesh found the presence of water and soap at the handwashing place, mother's education level, availability of water, and soap near to the toilet to be significantly associated with handwashing practices [16].
A similar study conducted in Bangladesh showed that latrine ownership, availability of handwashing materials such as ash or soap, and water availability near to latrine were associated with handwashing practice [17]. A study in India reported 59.4% of the participants used water and soap for cleaning their hands and 37% of them washed their hands with water and soap after defecation [18].
Improving food hygiene practices play a great role in child growth and development. Previous studies were focused on the time of weaning and the frequency and consistency of complementary feeding; however, hygienic practice during complementary feeding was not addressed. erefore, the present study was aimed to assess the hygiene practice and associated factors during complementary feeding among mothers of children aged 6-24 months in Bahir Dar Zuria District, Northwest Ethiopia.

Study Area and Period.
A community-based cross sectional study was conducted from March 20 to April 20, 2019, in Bahir Dar Zuria District, Northwest Ethiopia. e district is located at the distance of 564 km from the capital city Addis Ababa. ere are 36 kebeles with a total population of 200,000. e district has 9 health centers and 36 health posts.

Population and Eligibility
Criteria. All lactating mothers who reside in the district were the source population while lactating mothers with children aged 6-24 months old and who were present during the data collection period were the study population. All mothers with children aged 6-24 months were included, while mothers who were seriously ill and unable to hear were excluded from the study.

Sample Size Determination and Sampling Technique.
e sample size was determined using the single population proportion formula with the following assumptions: 95% CI, margin of error (D � 0.05), and proportion of hygienic practice about 50% since the prior researches did not mention the level of hygienic practice of mothers during complementary feeding. Considering the design effect of 1.5 and 5% nonresponse rate, the final sample size was 604. e multistage sampling technique was used to get the study participants. In Bahir Dar Zuria District, there are a total of 36 kebeles. Among these, ten kebeles were selected randomly. e sample size was proportionally allocated to each selected kebeles based on the size of the population in the kebeles.
e list of study participants by their name and residence was found from health posts and the health centers. After this, six villages were selected in each selected kebeles (a total of 60 villages), and all mothers with children aged 6-24 months were included in the study, and the data were collected.

Data Collection
Procedure. An interviewer-administered semistructured questionnaire was used to assess the hygienic practice of mothers during complementary feeding. e data were collected by ten health extension workers under the supervision of investigators (supervisors). e data were checked for any incompleteness and coding error and then entered into Epi Data version 3.1 software, and finally, it was exported to SPSS software for analysis.

Operational Definition.
Good hygienic practice was defined as a score of ≥75%, and poor hygienic practice as a score of <75% [12].

Data Analysis.
Descriptive statistics such as frequencies, proportions, and numerical summary measures were used. e data were analyzed using statistical package SPSS version 21 software. Bivariable and multivariable logistic regression analyses were done, and the results were presented by using tables. e P value less than 0.2 in the bivariable regression was considered as eligible for the multivariable logistic regression analysis. Statistically significant association was measured by using the adjusted odds ratio (AOR) with 95% confidence interval, and p value <0.05 was considered as statistically significant.

Data Quality
Management. Data quality was ensured through training of data collectors, close supervision, prompt feedback, and review of each of the completed questionnaires daily. One-day training was given for data collectors about the administration of each question and ethical principles before starting the data collection. Daily supervision was done by the supervisors to check the completeness and reliability of the data. e principal investigator was also checking the data consistency and completeness during data collection, data entry, and analysis.

Ethical Consideration.
e study was conducted after getting the ethical approval from the institutional review board of Bahir Dar University, informed consent was obtained from mothers having children aged 6-24 months, and the confidentiality of the information taken from the study participants was maintained.

Sociodemographic Characteristics of the Respondents.
A total of 604 study participants were interviewed. e mean age of the respondents (mothers) was 28.3 ± sd 4.4. e majority (593 (98.2%)) of the respondents were orthodox, and 601 (99.5%) of the respondents were Amhara in their ethnicity. 342 (56.6%) of mothers were unable to read and write, and 338 (56%) mothers were house wives as illustrated in Table 1 In the present study, 46.2% of the respondents had handwashing facility after toileting, and among those, 33.2% of the respondents' used soap or ash with water at the handwashing facility. 27.8% of the respondents used water treatment solution (Wuha Agar) whereas 45.5% of the respondents did not use any water treatment method ( Table 2).

Factors Associated with Hygienic Practice of the Respondents during Complementary
Feeding. Factors associated with hygienic practice during complementary feeding were described by using bivariable and multivariable logistic regression in Table 3. Hygienic practice during complementary feeding was significantly associated with the residence of the respondents.
Mothers who live in the urban area were 5-folds (AOR: 5.42, 95% CL:1.94-15.2) more likely to practice hygienic preparation of complementary food as compared with those who live in rural. Respondents who were accessed to media such as television or radio were 9-folds (AOR: 8.8, 95% CL: 3.8-20.3) more likely to carry out hygienic practice during complementary feeding than respondents who were not accessed to media, and those respondents who had private latrine were 4-folds (AOR: 4.11, 95% CL: 1.90-8.49) more likely to perform good hygienic practice during complementary feeding, as compared with their counterparts.  Respondents who had positive attitude towards hygienic complementary feeding were 4-folds (AOR: 4.01, 95% CL: 1.9-8.5) more likely to follow hygienic practice while complementary feeding than those who had negative attitude towards hygienic complementary feeding. Respondents who had handwashing facility after toilet visit were 7-folds (AOR: 6.75, 95% CL: 3.16-14.41) more likely to follow good hygienic practice during complementary feeding as compared with those respondents who had n o handwashing facility in their doorstep (Table 3).

Discussion
e present study showed that, out of 604 study participants, 303 (50.2%) participants had separate kitchens for children, and it was lower than that found in the study conducted in Mohoni town (86%) [19]. is difference could be due to the study setting, because the previous study was conducted the in urban community; as a result, they might have access to information related with hygiene practice and that might have helped them to have separate kitchens.  is study showed that only 56 (9.3%) and 54 (8.9%) of mothers always washed their hands with soap after toileting and before feeding the children, respectively, which is lower than those of the study conducted in Bangladesh, who reported 59.2% and 43.2% mothers always washed their hands with soap after toileting and before feeding, respectively [16].
In the present study, 145 (24%) and 123 (20.4%) of mothers always washed their hands with soap after toileting and before eating, respectively. is study finding is lower than that of the study conducted in Hanoi, Vietnam, which revealed that 36.8% and 29% mothers always washed their hands with soap after toileting and before eating, respectively [14]. e difference might be due to the difference in the study setting, and both studies (Vietnam and Bangladesh) were performed in the cities, so the study participants might be informed on the importance of hygienic practice and the health sector might be committed to wards' hygiene and sanitation activities in both countries.
is study reported that 9% of mothers washed their hands with water and soap at critical times, and this result was supported by the study conducted in Tanzania Longido District of Arusha, in which they reported 9.3% of mothers washed their hand with water and soap at critical times [20]. Additionally, this study finding was higher than that of the study conducted in Ghana, where only 2.3% of Ghanian mothers always washed their hands with water and soap at critical times [21]. is difference might have occurred due to the period the study was performed; a Ghana study was performed ten years ago, and the study participants might not have got adequate information related to good hygiene practices.
In the present study, 424 (70.2%) mother washed their hands only with water before feeding the child, which is lower than that of the study conducted in India, which reported more than 90% of the study participants washed their hands with water only before and meal [18]. e difference might be because of the difference in the study setting; the prior study was conducted in urban areas and also the development level of the country might have contributed to follow good hygiene practice properly. Hygienic practice during complementary feeding is affected by cultural factors, beliefs, and knowledge of parents on appropriate practices, safe preparation, and proper storage of complementary foods, which are the important determinants of proper CF practices [22]; as a result, the cultural practice and knowledge of mothers might have varied between the two countries, and this variation might have a great contribution on people's hygiene practice.
e present study illustrated that the perception or attitude of mothers was significantly associated with the hygienic practice of mothers during complementary feeding.
is study finding is supported by a study in Hanoi, Vietnam [14]. In this study, latrine ownership and access to media (TV or radio) were significantly associated with the hygienic practice in complementary feeding, and the result was also supported by a study performed in Bangladesh [17]. is could due to the fact that media play a great role in disseminating information necessary to implement appropriate complementary feeding.
In the present study, the availability of handwashing facility at doorstep after toilet visit was significantly associated with hygienic practice during complementary feeding, and this finding was supported by similar studies performed in the rural parts of Bangladesh [16].
e present study showed that the residence of the study participants was significantly associated with hygienic practice during complementary feeding. Respondents who were living in urban were 5-folds more likely to perform good hygienic practice as compared with those respondents who were living in the rural areas.

Limitations of the Study
is study was conducted at the community level, so the finding of the study could be a better representative of the source population. Despite this, social desirability bias and recall bias might be introduced while interviewing the study participants.

Conclusions
e present study showed that mothers had poor hygienic practice during complementary feeding. In this study, attitude, access to media, household private latrine ownership, presence of handwashing facility in their doorstep, and residence of the study participants were significantly associated with good hygienic practice of mothers during complementary feeding. It is recommended that the health sector shall work greatly on providing health education and training on the health consequence of poor hygienic practice during complementary feeding on their child.

Data Availability
All the relevant data used to support the study are included within the manuscript. Disclosure e funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.