Abstract

Background

Child malnutrition is a public health concern in developing countries including Ghana. Ensuring a child鈥檚 minimum meal frequency is met is critical for preventing malnutrition and improving nutrient intake. However, minimum meal frequency and its context-specific determinants among children in the Kumbungu District of Ghana are yet to be investigated. This study therefore examined minimum meal frequency and its determinants among children aged 6 to 23 months in Kumbungu District, Ghana.

Methods

An analytical cross-sectional study design was used and involved 395 mother-child pairs selected through systematic random sampling. A semi- structured questionnaire was used to obtain respondents鈥� socio-demographic characteristics, maternal nutritional knowledge and feeding practices and anthropometric information of children. Multivariate binary logistic regression analysis was used to determine the determinants of minimum meal frequency.

Results

Of the 395 children studied, about 51.4% of them were females, with about 25.8% and 74.2% of them aged 6鈥�8 months and 9鈥�23 months respectively. About 72.4% of the children met the minimum meal frequency. Children aged 9鈥�23 months were 3.48 times more likely to meet the minimum meal frequency as compared to children aged 6鈥�8 months [Adjusted odds ratio (AOR): 3.48, 95% CI: 1. 33-9.03, p鈥�=鈥�0.011]. Moreover, children who met the minimum dietary diversity were 46.32 times more likely to achieve the minimum meal frequency as compared to those who did not meet the minimum dietary diversity [AOR: 46.32, 95% CI: 17.78-120.64, p鈥�&濒迟;鈥�0.001闭.

Conclusions

The proportion of children who received minimum meal frequency was high. Child age and minimum dietary diversity were significant determinants of minimum meal frequency. To achieve optimal minimum meal frequency for all children, mothers should be encouraged to practice age appropriate meal frequency, particularly, those with children aged 6鈥�8 months as well as feed their children diversified diets.

Background

Child undernutrition, especially stunting is a public health concern globally. Globally in 2022, 148.1听million (23.3%), 45听million (6.8%) and 37听million (5.6%) children under five years were stunted, wasted and underweight respectively [1]. The majority of these malnourished children reside in developing countries including Ghana [2]. The rates of stunting, wasting and underweight among under-five children are 18.0%, 6.0% and 12.0% respectively in Ghana [3]. In the Kumbungu District, the malnutrition prevalence exceeds that of the National prevalence, as stunting, wasting and underweight rates stand at 21.9%, 19.9% and 20.8% respectively in the District [4]. These malnutrition cases largely occur between the ages of 6鈥�23 months because of rapid growth and increased risk of infection among children during this period [5]. It is estimated that, nearly 70% of the stunting cases occur in this age range [5]. Malnutrition results in morbidity, mortality, delayed mental and motor development in children [6]. Nearly half of child deaths is attributed to malnutrition [7].

The primary cause of undernutrition among children aged 6鈥�23 months is inadequate nutrient intake resulting mainly from sub-optimal complementary feeding practices, particularly inappropriate minimum meal frequency [8, 9]. Minimum meal frequency measures the percentage of breastfed and non-breastfed children aged 6 to 23 months who had solid, semisolid, or soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the preceding day [10]. Feeding meals frequently as recommended increases a child鈥檚 overall energy and micronutrient intake, thereby preventing growth faltering and malnutrition [9]. Hence, minimum meal frequency is a major determinant of malnutrition among children aged 6 to 23 months [11]. However, only a few children are fed the minimum number of meals per day [12]. It is estimated that more than half of children aged 6 to 23 months do not receive the minimum number of meals for their age per day [12]. According to the Ghana Demographic Health survey, 45% of children aged between 6 and 23 months in Ghana receive the minimum number of meals per day in Ghana [13]. In Northern Ghana, 57.3% of children aged between 6 and 23 month receive the minimum number of meals per day [14]. Age of child, mother鈥檚 educational status, breastfeeding status, postnatal visits and birth order of index child are some of the determinants of minimum meal frequency identified in other settings [11, 15, 16].

Despite the high prevalence rate of child malnutrition, particularly stunting (21.9%), in the Kumbungu District of Ghana [4], minimum meal frequency, a crucial determinant of nutrient intake and nutritional status of children [9], is yet to be assessed, along with its context-specific determinants in the District. Identifying the context-specific determinants of minimum meal frequency in the Kumbungu District is crucial in developing effective interventions to reduce child malnutrition as a variety of local factors and individual needs will be considered in devising these interventions. This study therefore assessed minimum meal frequency and its determinants among children aged 6鈥�23 months in the Kumbungu District.

Methods

Study design, setting, population and sampling

An analytical cross-sectional design was employed in the study. The study was carried out in 5 randomly selected communities (Dulzugu, Zugu, Kumbungu-Kukuo, Zugu-Yipelgu and Satani comminities) in the Kumbungu District, Ghana. The study population comprised of children aged 6鈥�23 months in the Kumbungu district. Information on children was elicited from their respective caregivers/mothers. Simple random sampling and systematic random sampling techniques were used to select the study communities and households of participants respectively. Regarding selection of communities, all communities in the district were identified and allocated specific numbers on pieces of paper, which were then placed in a basin, mixed, and selected one at a time with replacement until the desired number of communities was gotten. In each community, the households were chosen using systematic random sampling, by starting at a random point and then choosing every household at regular interval. To obtain the interval, the total number of households was divided by the sample size. The sample size for each of the selected communities was obtained using the population proportion to size method. If there were two or more eligible participants in a household, simple random sampling technique was used to select one participant to partake in the study. Eligible participants were mothers/caregivers with children aged 6鈥�23 months who consented to participate in the study. Participants who were mentally handicapped or critically ill were excluded from the study. Population proportion to size was employed to determine how many samples came from each community.

Sample size

The sample size was calculated using the formula [17]:

$$\mathrm N=\frac{z^2p(1-p)}{{M.E}^2}\;$$

N is the sample size, z is confidence interval (95%) which gives a critical value of 1.96, P is the estimated prevalence of an attribute present in the population. A minimum meal frequency prevalence of 57.3% [14] in Northern Ghana was used. M.E (margin of error) is the desired level of precision (5%=0.05).

$$\:\mathrm N=\frac{\left(1.96\right)^20.573\left(1-0.573\right)}{\left(0.05\right)^2}=376$$

A provision of 5% was made for incomplete questionnaires and non-response. Hence, the sample size used for the study was 395.

Variables and their measurement

The dependent variable of the study was minimum meal frequency. The independent variables were maternal characteristics (age, marital status, household monthly income, educational level, employment status, religion, birth interval, place of delivery, antenatal care visits, post-natal care visits, breastfeeding status, timely initiation of breastfeeding, exclusive breastfeeding and nutritional knowledge) and child characteristics (age, sex, co-morbidity status, nutritional status and minimum dietary diversity). The independent (exposure) variables for the study were selected based on literature review.

Regarding data collection, a pre-tested semi-structured questionnaire was used to document participants鈥� information on socio-demographic characteristics (age, gender, marital status, household monthly income, ethnicity, religion, parity of mother, birth interval), clinical factors (place of delivery, antenatal care visits and post-natal care visits) and child feeding practices. The pre-testing of the questionnaire was conducted by administering the questionnaires to 40 mothers/caregivers (10% of sample size) with children aged 6 to 23 months in the study area, which aided in refining the questions for better understanding by the participants. These participants did not partake in the study.

Maternal knowledge on infant and young child feeding practices was assessed with a questionnaire used in a previous similar study [11]. The knowledge questionnaire consists of ten yes-or-no questions in statement form: (1) Heard about importance of feeding diversified foods to a 6鈥�23 month child, (2) Complementary feeding should start at 6 months of child age, (3) A 6鈥�23 month child should eat five or more food groups in a day, (4) Giving meat is advisable for 6鈥�23 month child, (5) One cause of childhood malnutrition is not having diversified foods, (6) Didn鈥檛 feel hungry doesn鈥檛 mean that the nutritional need of a child is fulfilled, (7) One cause of childhood malnutrition is not starting complementary feeding at 6 months of child age, (8) Feeding only animal products is not enough/adequate for 6鈥�23 month child, (9) A 6鈥�23 month child should be fed organ meat, like liver, kidney and (10) A 6鈥�23 month child should be fed egg. Each correct answer (yes) was assigned 1 point, while any wrong answer was assigned 0. Mothers who got a score of 7 and above, out of the ten knowledge questions were deemed to have high level of knowledge [11]. Mothers who scored 6 and below, out of the ten knowledge questions were classified as having low level of knowledge [11].

With regards to minimum meal frequency, each mother was made to recall the number of times child ate solid, semisolid, or soft foods (plus milk feeds for non-breastfed children) during the entire previous day [10, 11]. Minimum meal frequency was set at 鈮モ��2 times for breastfed children aged 6 to 8 months, 鈮モ��3 times for breastfed children aged 9 to 23 months, and 鈮モ��4 times for non-breastfed children aged 6 to 23 months [10, 11].

Dietary diversity score (DDS) of participants was also assessed using a 24-hour dietary recall, which was repeated in 20.0% of random sub-sample for usual intake [18,19,20,21,22]. The respondents were asked to recall all foods eaten and beverages taken by children in the previous twenty-four hours prior to the interview. The DDS was assessed by assigning a score of 1 to each food group consumed and a score of 0 to each food group not consumed in a 24-hour period prior to the survey and a sum total of all scores was computed. The 8 food groups recommended by WHO/UNICEF [23] were considered in this study: Breast milk; grains, roots and tubers; legumes, nuts and seeds; dairy products; flesh foods, eggs; vitamin A-rich fruits and vegetables and other fruits and vegetables. Consequently, the minimum possible DDS score was 0 (no food group consumed) and the maximum possible DDS score was 8 (all food groups consumed). Using dietary diversity score of 5 (minimum dietary diversity score) as cut-off point, a child was defined as having 鈥減oor dietary diversity鈥� if he/she consumed less than 5 food groups while having 鈥済ood dietary diversity鈥� if he/she consumed 5 or more food groups [23].

Additionally, child undernutrition was assessed using WHO Child Growth Standards [24]. Length (m) of child was measured without shoes using an infantometer (Seca 417, Germany). The infantometer was positioned horizontally on a flat and even surface. The child was placed flat on it with the feet together, knees straightened, heels and buttocks touching the infantometer, shoulders relaxed, arms extended alongside their body, and shoulder blades in contact with the infantometer prior to the length measurement. Weight (kg) of child was measured without clothing using an electronic weighing scale (Seca 874, Germany). The scale was first calibrated with a known weight and placed on a hard, flat, even surface prior to the weight measurement. The caregiver was first made to stand on the scale without shoes and the scale was tarred. While standing still on the tarred scale, the undressed child was then handed over to mother and the weight recorded as weight of child. Both length and weight of child were measured twice and an average calculated. The child鈥檚 age, sex, weight and length were used to calculate Z-scores for the following growth indicators: weight-for-height (wasting), weight-for-age (underweight) and height-for-age (stunting). Z-scores less than 鈭掆��2 to 鈭掆��3 standard deviations (SDs) indicated moderate wasting, moderate underweight and moderate stunting whiles Z-scores less than 鈭掆��3 SDs indicated severe wasting, severe underweight and severe stunting [24]. Z-scores 鈮� 鈭�2 indicated the absence of wasting, stunting and underweight.

Statistical analysis

Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 21 and WHO Anthro software. Bivariate analysis was ran using Chi-square/Fisher exact test. The independent variables with p鈥�<鈥�0.25 [25] in the bivariate analysis were considered for multivariate logistic regression analysis to remove confounders. Hosmer-Lemeshow test was used to test for goodness-of-fit of the adjusted model. Percentages and cross tabulations were used to show participants鈥� responses. Responses were presented in tables. P鈥�<鈥�0.05 was considered significant at two tailed tests.

Results

Socio-demographic characteristics

The mean age of the mothers/caregivers was 28.9鈥壜扁��5.4 years, with the minimum and maximum ages of 17 and 60 years respectively. A little more than half (55.7%) of the mothers had no formal education. Also, a little more than half (52.9%) of mothers were self-employed. Regarding monthly household income, mothers earning less than GH然500 formed the majority (96.5%). It was also observed that nearly (99.7%) all of the mothers were Muslims. Moreover, almost all (99.5%) of them were married. Concerning the children, 25.8% and 74.2% of them were aged 6鈥�8 months and 9鈥�23 months respectively. Also, about 51.4% of children were females. Table听1 depicts the socio-demographic characteristics of the respondents.

Table 1 Socio-demographic characteristics of respondents

Maternal dietary knowledge and practices and child nutritional and co-morbidity status

The study revealed that about 83.0% of the mothers/caregivers had high level of knowledge on infant and young child feeding practices. Nearly all (96.7%) the children were breastfeeding during the study. Also, about two-third (68.8%) of the children were breastfed within the first hour after birth. Approximately 72.4% of the children met the minimum meal frequency, with about 24.9%, 18.7% and 25.3% being stunted, wasted and underweight respectively. Almost a third (32.7%) of the children experienced illness two weeks prior to the study (Table听2).

Table 2 Maternal dietary knowledge and practices, child nutritional status and child co-morbidity status

Maternal health care services utilization

More than half (61.3%) of the mothers delivered at the hospital. Also, all the mothers went for ANC visits with majority (96.7%) of them going for more than 4 visits. About 98.5% of the mothers went for a postnatal care visit (Table听3).

Table 3 Maternal health care services utilization

Factors associated with minimum meal frequency

A bivariate analysis was performed to the determine factors associated with minimum meal frequency. Factors with P value鈥�<鈥�0.25 were considered for multivariate logistic regression to determine the independent predictors of minimum meal frequency. Maternal age, child age, timely initiation of breastfeeding, current breastfeeding status, exclusive breastfeeding, minimum dietary diversity, maternal knowledge on infant and young child feeding practices, child history of illness and nutritional status (underweight and stunting) were the factors considered for multivariate logistic regression (P鈥�<鈥�0.25) (Table听4).

Table 4 Bivariate analysis of factors associated with minimum meal frequency (MMF)

Determinants of minimum meal frequency

In the multivariate binary logistic regression analysis, child age and minimum dietary diversity were identified as predictors of minimum meal frequency. Children aged 9鈥�23 months were 3.4 times more likely to meet the minimum meal frequency as compared to children aged 6鈥�8 months [Adjusted odds ratio (AOR): 3.48, 95.0% CI: 1. 338鈥夆垝鈥�9.030, p鈥�=鈥�0.011]. Moreover, children who met the minimum dietary diversity were 46.3 times more likely to achieve the minimum meal frequency as compared to those who did not meet minimum dietary diversity [AOR: 46.316, 95.0% CI: 17.784鈥�120.641, p鈥�<鈥�0.001] (Table听5).

Table 5 Multivariate analysis for determinants of minimum meal frequency

Discussion

Throughout the developing world, including Ghana, child malnutrition continues to rank among the most persistent public health issues. Minimum meal frequency has been shown to be a significant predictor of child nutritional status. However, the practice and influencers of minimum meal frequency among children aged 6鈥�23 months are currently unknown in the Kumbungu District. Hence, the purpose of this study was to fill the above gap.

It was revealed in the current study that 72.4% of children met the minimum meal frequency, which is comparable to the prevalence of 72.2%, 69.2%, 68.9% and 68.4% reported by Belew et al. [26], Wagris et al. [11], Mekonnen et al. [27] and Tegegne et al. [28]. in Ethiopia. However, the prevalence is higher compared to the study conducted in Northern Ghana, where a prevalence of 57.3% was reported [14]. The disparity in results may be attributed to the large sample size and different sampling procedure employed in the preceding local study [29]. It is essential to also note that the prevalence stated in the prior local study was an average figure for Northern Ghana, indicating that other districts in Northern Ghana may have higher prevalences, hence the result of the current study. The time gap between the studies could be another reason [28], as the preceding local study was undertaken 7 years ago.

Children who achieved the minimum dietary diversity in the present study were 46 times more likely to meet the minimum meal frequency as compared to children who did not meet minimum dietary diversity. Similarly, a previous study in Ethiopia [11] indicated that children who meet minimal dietary diversity are more likely to attain minimum meal frequency than children who do not meet minimum dietary diversity. This results from the fact that families with access to a variety of foods are much more likely to give their children food often, as one key factor in achieving minimum meal frequency is food accessibility [11]. The finding of the present study underscores the need for integrated, age-appropriate nutrition interventions. Public health policies should focus on improving both dietary diversity and meal frequency, as they are crucial for ensuring optimal child development and preventing malnutrition. By promoting these factors through caregiver education, community-based interventions, and policy reforms, governments can significantly improve child health outcomes and reduce the long-term burden of malnutrition and related diseases.

Also, child age was significantly related with minimum meal frequency in the present study. When compared to children aged 6鈥�8 months, children aged 9鈥�23 months were 3.4 times more likely to meet the minimum meal frequency. Similarly, studies by Tegegne et al. [28], Beyene et al. [16], Aemro et al. [30], Wuneh et al. [31]. and Belew et al. [26] found that minimum meal frequency increases as age of child increases. This is likely to be due to the fact that children between the ages of 6鈥�8 months are typically breastfed, making it less vital for mothers and other caregivers to view frequent feedings of extra solid food as a priority [26]. Also, older children have the chance of consuming a family meal, increasing their meal frequency [28]. It may also be due to mothers鈥� perception that, the younger the child, the poor the capability of the child鈥檚 intestines to properly digest solid, semisolid, and soft meals [31]. The finding of the current research demonstrates that children aged 6鈥�8 months are considerably more at danger of becoming malnourished. Hence, practicing age appropriate meal frequency during this age period is recommended to lessen the risk of malnutrition and infections. The finding of the present study also highlights the need for age-specific approaches in public health nutrition policies. Tailoring interventions to address the specific needs of children at various developmental stages through nutrition education or targeted food assistance, can improve child health outcomes and reduce the risk of malnutrition and related diseases.

In the present study, maternal nutritional knowledge was not found to be significantly correlated with minimum meal frequency despite majority of mothers having high level of knowledge. Similarly, a study by Binamungu et al. [32] found no relationship between maternal nutrition knowledge and minimum meal frequency. This suggests that while knowledge about nutrition is important, it may not directly influence meal frequency in practice, possibly due to other factors like socio-economic conditions, cultural practices, or access to resources. Contrarily, a study by Unwali [33] reported a significant relationship between maternal nutrition knowledge and minimum meal frequency. These varying findings highlight the complexity of how knowledge translates into behavior, suggesting that more contextual factors need to be considered when interpreting the influence of nutritional knowledge on feeding practices.

This study was not without limitations. There is a likelihood of recall bias as the measurement of child feeding practices were based on memory, which may result in inaccuracies regarding the frequency or variety of meals. Also, there is a chance of social desirability bias as the responses were self-reported, which could influence participants to present their feeding practices in a more favorable way, leading to potential over-reporting of positive practices and underreporting of less desirable ones. Additionally, the study鈥檚 cross-sectional nature does not offer a solid foundation for determining causality since exposure and outcome were measured concurrently. Notwithstanding these limitations, the study provided the first insight into minimum meal frequency and its related characteristics among children aged 6 to 23 months in Kumbungu District. We recommend that longitudinal studies be conducted to determine the causal relationship between the independent and dependent variables.

Conclusion

The prevalence of minimum meal frequency was high in the study district. Child age and minimum dietary diversity were independent predictors of minimum meal frequency among children aged 6鈥�23 months in the Kumbungu District. Mothers should be encouraged to practice age appropriate meal frequency, particularly, those with children aged 6鈥�8 months as well as feed their children diversified diets to improve child health outcomes and reduce the risk of malnutrition and related diseases. By highlighting the impact of child age and dietary diversity on meal frequency and suggesting strategies for improving child feeding practices, this study contributes significantly to the existing body of knowledge on child nutrition in Ghana.