Timely Initiation of Complementary Feeding and Associated Factors among Mothers of Children Aged 6–24 Months in Dessie Referral Hospital, Northeast Ethiopia, 2019

Background Timely, appropriate, safe, adequate, and frequent feeding is essential during the transition period for optimal growth and development as well as vulnerability of the child. The age of initiation of complementary feeding needs to be strongly addressed. Thus, the aim of this study was to determine timely initiation of complementary feeding and associated factors among mothers of children aged 6–24 months in Dessie Referral Hospital. Methods Institutional-based cross-sectional study was conducted among 280 mothers of children aged 6–24 months. A systematic random sampling technique was employed for selection of study participants by considering the 1st comer as a starting point and then at every 5th interval till the sample size was saturated at exit time. Data were collected using pretested and validated structured interviewer-administered questionnaire. Data were entered to Epi data version 3.1 and exported to SPSS version 20.0 software for analysis. Descriptive statistics and binary logistic regression model were used. Results Overall response rate was 98.2%. Among 275 mothers with children aged 6–24 months, 36 (13.1%), 179 (65.1%), and 60 (21.8%) mothers started giving complementary feeding for their children early (before six months), timely (at six months), and late (after six months), respectively. Mothers' educational status of grade 9–12 and college and above [AOR = 3.03; 95% CI (1.13–8.14), and AOR = 3.74; 95% CI (1.19–11.70), respectively], getting counsel [AOR = 2.83; 95% CI (1.54–5.21)], and poor knowledge [AOR = 0.37; 95% CI (0.19–0.72)] were found to be independent predictors. Conclusions Prevalence of timely initiation of complementary feeding was high as compared to the national prevalence. Mothers' educational status, getting counsel about complementary feeding, and knowledge were factors associated with timely initiation of complementary feeding. Therefore, awareness creation, counseling, and health education should be done on society by concerned bodies to improve timely introduction of complementary feeding level more than this result.


Introduction
Complementary feeding is the process of starting foods and liquids along with breast milk when breast milk is no longer sufficient to meet nutritional requirements of children [1]. Appropriate, safe, adequately nourished, and frequent feeding is essential during the transition period from child's birth to 2 years of age since this period is a critical window for optimal growth and development as well as vulnerability of the child [2]. e World Health Organization (WHO) recommends that complementary feeding should be commenced at the age of 6 months, and the frequency of nonmilk feeding should gradually increase until 24 months. But most mothers do not start complementary feeding at appropriate time [3][4][5][6]. Children are at increased risk of malnutrition starting from six months because breast milk alone is not sufficient to give the required nutrient contents [7].
Optimal complementary feeding is associated with some concerns like what food should be given to the child and how and when it should be given. e age of initiation of complementary feeding needs to be strongly addressed due to the risk of food intolerance, stunning, and malnutrition that do not confer any growth advantage [8,9]. A complementary feeding practice is mostly inappropriate, which seems to be strongly associated with lack of proper knowledge among mothers regarding complementary feeding initiation time. Emphasis should be given to educate mothers about breastfeeding and initiation of complementary feeding practices during immunization [10].
Evidences show that inappropriate timing of complementary feeding practices remain as major public health problem from global to national level even if it is declared that it should be initiated at 6 months' of age. is inappropriate timing of complementary feeding could result in child illness and suboptimal growth and development, and also it causes 45% child death [11,12]. Out of 715 mothers with children, 5% of them introduced solid food for their children before 4 months of age, 14% were not started at 5.5 months of age, while 81% were introduced in between 4 and 5.5 months age [13].
Many factors can affect timely initiation of complementary feeding practice such as mother's postnatal checkup, urban residence, family size, occupation of mother, having antenatal care follow-up, believed time of initiation of complementary feeding, place of delivery, and family monthly income [14][15][16][17]. Failure to give a great attention to timely initiation of complementary feeding puts the children at risk for malnutrition. Malnutrition has been responsible, directly or indirectly 10.9 million deaths annually among children under five due to lack of timely initiation of complementary feeding [18,19]. Despite its serious socioeconomic and health impact on children and community, it is not well studied in Ethiopia specifically in the study area. erefore, this study was aimed to assess timely initiation of complementary feeding and associated factors among mothers of children aged 6-24 months in Dessie Referral Hospital.

Study Area.
Dessie Referral Hospital is the only referral hospital in Wollo Province serving for about 7 million people including the neighboring regions. e hospital was established around 1840s. It covers 200 hectares of land and has 400 beds. Dessie is a major city administration in South Wollo Zone located 401 km away from Addis Ababa, the capital city of Ethiopia and 480 km from Bahir Dar, the capital city of Amhara regional state.

2.2.
Study Design, Period, and Population. Institutional-based cross-sectional study was conducted from March 17 to April 17, 2019, among mothers of children aged 6-24 months. All eligible mothers with children aged 6-24 months in the study areas were included in the study where as those who were unable to communicate and critically ill at the time of data collection were excluded from the study.

Sample Size Determination and Sampling Techniques.
e sample size was determined through StatCalc function of Epi Info version 7 software for each objective with the assumptions of 95% confidence interval, 5% marginal error, 80% power, unexposed to exposed ratio, percent outcome in unexposed group, and adjusted odds ratio of each major factors from the previous study [17], and the maximum calculated sample size was taken. erefore, the maximum sample size from the Epi Info version 7 StatCalc software calculations was 280 mothers of children aged 6-24 months including nonresponse rate.
ere were 1300 registered children with age of 6 to 24 months attending in Dessie Referral Hospital. e medical record numbers (MRN) of the children were used as a sampling frame. e sampling technique was systematic random sampling using the formula N ÷ n to calculate the K value: 1300 ÷ 280 � 5. So, mothers of children aged 6-24 months were selected by considering the 1st comers as a starting point and then at every 5 th interval till the sample size was saturated at exit time.

Data Collection and Quality
Control. Data were collected through validated, structured, and pretested intervieweradministered questionnaire which was adapted from different reviewed literatures [4,5,15,[20][21][22] with some modifications by researchers. Five parts with sociodemography (14 questions), knowledge-related question (12 questions), obstetrics and gynecological-related question (9 questions), maternal reproductive history and health service utilization-related question (12 questions), and practicerelated question (14 questions) (in total 61 items) were utilized for the study. e internal reliability with Cronbach's alpha values for knowledge and practice questions was 0.612 and 0.884, respectively. In order to determine the level of mothers' knowledge and practice regarding timely initiation of complementary feeding, we used mean as a cut point. Good knowledge and practice means those study participants who scored above or equal to the mean value of knowledge and practice questions, respectively. Eleven graduate nurses, eight as data collectors and three as supervisors, were recruited and trained for 2 days. To assure data quality, primarily, the questions were prepared in English and translated to Amharic, which is a local language and then retranslated back to English by bilingual experts to ensure its consistency. Principal investigators and supervisors made spot-checking and reviewing questionnaires completeness.

Data Management and Analysis.
e collected data were checked visually for its completeness, and the responses were coded and entered into Epi data version 3.1 statistical package. en, data were exported to SPSS version 20 for analysis. During the process of analysis, descriptive statistics were used to provide an overall and coherent presentation and description of the data. Variables with 95% confidence interval and P value less than or equal to 0.2 during the bivariate analysis were entered to multivariate logistic regression analysis to see the relative effect of confounding variables and interaction of variables. Odd ratio with 95% CI was performed on variables to determine the strength of association of variables. P value less than 0.05 was taken as the cut off value to be significant.

Results
Out of the total 280 sampled mothers with children aged 6-24 months in Dessie Referral Hospital, 275 of them were included in the study giving a response rate of 98.2%. e age of mothers of the study children ranged from 17 to 37 years with the mean ± SD of 27.44 ± 4.488 years in which most of the respondents fall within the ranges of 25-29 years age group (129 (47.0%)). Majority of the respondents had orthodox religion (132 (48.0%)), Amhara ethnicity (242 (88%)), and 4-6 family size (134 (47.8%)). As to the educational status of children' mother, 115 (41.9%) had educational status of grade 9 and above (Table 1).

Knowledge on Timely Initiation of Complementary
Feeding. Out of the total 275 mothers with children 6-24 months of age, 263 (95.6%) knew the importance of complementary feeding and the suitability of fruits and vegetables as complementary food was 246 (89.5%). Most of mothers with children aged 6-24 months (214 (77.8%)) confirmed that complementary food should be introduced at 6 months even though all did not practice it properly due to different factors. Around 108 (39.3%) mothers did not know that adding oil to child's porridge is advisable, and 246 (89.5%) mothers knew fruits and vegetables are suitable complementary foods.

Complementary Feeding Practice.
e prevalence of timely initiation of complementary feeding among mother with children aged 6-24 months in Dessie Referral Hospital was 65.1% with 95% CI (59.3%-70.5%). Out of the total mothers, 123 (44.7%) of them started breastfeeding for their children at the time of less than one hour after giving birth. Most of mothers started giving complementary food for their children at the age of six months 179 (65.1%). Most mothers (70 (25%)) fed semisolid (porridge) food for their children when they started complementary feeding.

Bivariable and Multivariable Analyses.
Bivariable analysis showed significant associations between timely initiation of complementary feeding and age of mother, educational status of mother, wealth index, family size including the current child, growth monitoring follow-up, getting complementary feeding counsel, and knowledge on CF.
In multivariable logistic regression, only educational status of women, complementary feeding counseling, and knowledge on CF keep their significance association with timely initiation of complementary feeding. erefore, a multivariable analysis model revealed that mothers having educational status of grade 9-12 and college and above were almost 3 and 4 times more likely to initiate complementary feeding timely than illiterate mothers [AOR � ; 3.03; 95% CI (1.13-8.14), P � 0.028] and [AOR � 3.74; 95% CI (1.19-11.70), P � 0.024], respectively. Similarly, those mothers who got counseling about timely initiation of complementary feeding were almost 3 times more likely to initiate complementary feeding timely than those who did not get [AOR � 2.83; 95% CI (1.54-5.21), P � 0.001]. e likelihood of initiating complementary feeding timely by mothers with 6-24 months aged children having poor knowledge was almost 63% [AOR � 0.37; 95% CI (0.19-0.72), P � 0.004] lower as compared to those mothers having good knowledge on CF ( Table 2).

Discussion
In this study, the prevalence of timely initiation of complementary feeding among children in 6-24 months of age in Dessie Referral Hospital was 65.1% with 95% CI (59.3%-70.5%), which was in line with studies conducted in public health facilities found in Mekelle Town, Northern Ethiopia (62.8%) [4], and Lalibela (63%) [16]. is study finding was higher than the national prevalence (51%) [23], result from study in India (42.1%) [24], Nigeria (41%) [5], Nepal (57%) [6], and Sidama Zone Southern Ethiopia (42%) [7]. is difference might be due to sociodemographic character difference, wealth status difference, and activeness of the society. It was also low compared with study in Sodo Town, Southern Ethiopia (71.2%) [17]. is discrepancy might be due to difference in sample size, awareness of the society, and study time.
Educational status of mothers was significantly associated with timely initiation of complementary feeding; mothers having educational status of grade 9 and above were more likely to initiate complementary feeding timely than illiterate mothers. is might be due to an increment of awareness as educational status increases.
is finding contradicted with studies in Nigeria [5] and Harar [25] that stated parental education was not associated with timely initiation of complementary feeding. e possible reason might be due to societal background difference and educational environment difference. And it also was consistent with study in India [24], Saudi Arabia [26], Sidama Zone, Southern Ethiopia [7], and Wollega [22], which revealed mothers who had education status of illiterate and primary school were less likely to initiate complementary feeding timely as compared to those mothers who had the educational status of high school and above.
Mothers who had got counseling about complementary feeding were more likely to initiate complementary feeding timely as compared with who had not got. is was similar with studies in Nepal [6], Sodo Town [27], and Bangladesh [28]. e possible reason might be due to the reality that person can be changed by their awareness if they get education and counseling. Journal of Nutrition and Metabolism e likelihood of initiating complementary feeding timely by mothers having poor knowledge was lower as compared to those mothers having good knowledge. ese results were supported by study findings in Nepal [10], Pakistan [20], and Harar [25]. is may be because timely initiation of complementary feeding needs a critical knowledge on the adequacy, component, duration, and time at which it should be started; if mothers' knowledge is poor, it is difficult to initiate proper CF timely.

Conclusion
e present study showed that timely initiation of complementary feeding among children with 6-24 months of age in Dessie Referral Hospital was higher than the critical point of the national prevalence that is good. Mothers' educational level, counseling about complementary feeding, and knowledge on timely initiation of CF were found to be statistically significant with timely initiation of complementary feeding. So it is recommended that there should be awareness creation on society by counseling and giving health education to boom their knowledge and practice of timely initiation of complementary feeding. Data Availability e datasets of this study are available from the corresponding author on reasonable request.

Ethical Approval
Ethical clearance was obtained from Wollo University, Medicine and Health Sciences College, Research and Community Service (RCS) office.