This study assessed infant and young child feeding practices in three communities in Ghana. It found that 75% of children aged 6-8 months did not meet minimum dietary diversity requirements. Nearly half of households did not treat water before drinking, with water sources including boreholes, wells, rivers and streams. Stunting prevalence was 22.6%, with the average length-for-age z-score being below normal. The study highlights inadequate complementary feeding and lack of water treatment as issues negatively impacting child nutrition in these communities.

1. ASSESSMENT OF INFANT AND YOUNG CHILD FEEDING IN THREE
COMMUNITIES IN THE UPPER MANYA KROBO DISTRICT
University of Ghana and Iowa State University
June 26, 2016
Authors: Asare H, Ayande RE, Becker J,
Dzivenu P, Johnson W, Jorgenson T, Kokoro S,
Ludemann M, Oberkor O, Renz M, Smith S, Wilson B

2. i
TABLE OF CONTENTS
1.0 INTRODUCTION.............................................................................................................. 1
1.1 AIM/OBJECTIVES........................................................................................................... 1
2.0 BACKGROUND OF STUDY AREA............................................................................... 2
3.0 METHODS......................................................................................................................... 3
4.0 RESULTS ........................................................................................................................... 4
5.0 DISCUSSION................................................................................................................... 11
6.0 RECOMMENDATIONS................................................................................................. 12
7.0 REFERENCES................................................................................................................. 13
APPENDIX.................................................................................................................................. 15
APPENDIX I ............................................................................................................................... 15
APPENDIX II.............................................................................................................................. 15
LIST OF TABLES
TABLE 1: SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS ............ 4
TABLE 2: DEMOGRAPHIC CHARACTERISTICS OF CHILDREN ................................. 5
TABLE 3: DIETARY DIVERSITY SCORES ACROSS DIFFERENT AGE GROUPS ...... 7
TABLE 4: FEEDING FREQUENCY ACROSS AGE GROUPS OF CHILDREN ............... 8
TABLE 5: DISTRIBUTION OF BOTTLE FEEDING ACROSS AGE GROUPS ................ 8
LIST OF FIGURES
FIGURE 1: PERCENTAGE OF INFANTS AND TIME LAPSE FOR INITIATION OF
BREASTFEEDING ...................................................................................................................... 5
FIGURE 2: EARLY INITIATION OF BREASTFEEDING (BF) PERCENTAGES
AMONG CHILDREN 0-59 MONTHS....................................................................................... 6
FIGURE 3: CONTINUED BREASTFEEDING AFTER 12 MONTHS OF AGE ................. 6
FIGURE 4: PERCENTAGE OF CHILDREN 0-23 MONTHS WHO MET DIETARY
DIVERSITY (DD) CRITERIA.................................................................................................... 7
FIGURE 5: WATER SOURCES FOR HOUSEHOLD OF CHILDREN ASESSED IN
SURVEY........................................................................................................................................ 9
FIGURE 6: WATER TREATMENT METHODS USED......................................................... 9
FIGURE 7: AVERAGE Z-SCORES FOR WHZ, WHZ AND BMI FOR AGE................... 10

3. 1
1.0 INTRODUCTION
The World Health Organization (WHO) recommends exclusive breastfeeding for infants 0-6
months old and introduction of safe complementary foods after six months with continued
breastfeeding until 24 months of age (WHO, 2008). To assess and monitor infant and young
child feeding practices, a set of core indicators including exclusive breastfeeding, introduction of
complementary foods, dietary diversity, education of mothers, and water sanitation (Appendix I)
have been used extensively by researchers. In low-income and middle-income countries, only
37% of children younger than six months of age are exclusively breastfed (Victoria, et al., 2016).
According to WHO (2010), dietary diversity is an indicator for adequate intake of micronutrient-
dense foods. The Academy of Nutrition and Dietetics (AND) stated in their position paper on
nutrition security in developing nations that the main cause of micronutrient deficiencies is due
to lack of dietary diversity (Nordin, Boyle, & Kemmer, 2013). Maternal education is also a
factor that influences child health (Quansah, et al, 2016; Dickson, 2016). Further, WHO (2012)
states that lack of education for women is a risk factor for child malnutrition including
underweight, wasting, stunting and overweight. In addition to problems associated with food
intake in developing areas, AND states that food insecurity often includes poor sanitation
(Nordin, Boyle, & Kemmer, 2013). The Center for Disease Control and Prevention (CDC) states
that diarrheal diseases are the cause of 4% of deaths in Ghana. Diarrheal diseases are often
caused by unsanitary water consumption and lack of water treatment facilities and methods
(Keusch, et al, 2016).
1.1 AIM/OBJECTIVES
The aim of the study was to assess the feeding practices of infants and young children aged 0-60
months in selected communities in the Upper Manya Krobo District. The specific objectives
were:
1. To determine the prevalence of malnutrition using weight for height, weight for age and
weight for height z-scores; WHZ, WAZ, HAZ (see Appendix II) among children 0-60 months.
2. To assess the initiation of breastfeeding, the introduction of complementary foods, and the
dietary diversity of children in the selected communities.
3. To assess drinking water sources and water treatment practices in the communities.

4. 2
2.0 BACKGROUND OF STUDY AREA
The Upper Manya Krobo (UMK) District is located in the Eastern Region of Ghana. The district
is made up of six sub-districts with 198 communities. Asesewa is a sub-district and is the
district’s capital with an estimated population of 9,840 in 2016, determined by the Asesewa
Government Hospital. The Asesewa Government Hospital and Asesewa Community Health
Planning and Services are the local health facilities (Gabriel, 2016).
According to the Housing and Population Census of 2010, the district is nearly 90% rural and
96.3% of households is involved in crop farming. This was confirmed by a focus group
discussion held by the Nutrition Research and Training Centre (NRTC) team on June 15, 2016.
Community members reported that they cultivate maize, cassava, beans, tomato, mango, yam,
pepper, okro and groundnuts. Farmers also raise animals to sell and consume on special
occasions. In addition to farming, chickens are the most popular animal reared in the district.
Main sources of water in the district are borehole, river/stream, public tap and pipe borne water;
about 40% of households drink water from boreholes (Ghana Statistical Service, 2014).
Upper respiratory infections, diarrhea and intestinal worms were among the top ten causes for
outpatient department visits within the district in 2015. That same year, pneumonia was
determined to be the leading cause of mortality. Regarding breastfeeding rates in the UMK
district in 2015, 70% initiated breastfeeding within the first one hour after delivery, and 64%
were exclusively breastfeeding at discharge. There has been drastic decrease in malnutrition
rates, with only 1.1% malnutrition rate in 2015 compared to 12.8% in 2010 (GABRIEL , 2016).
In the last national survey, wasting (low weight-for-length) prevalence reached almost one-third
(29%) of infants 6-8 months; 40% of children 18-23 months were stunted (low length-for-age).
The UMK district registers the highest rates of anemia (74%) and stunting among infants and
young children (38%) in the country (Ghana Statistical Service, 2014).

5. 3
3.0 METHODS
A cross-sectional study was performed in the Aboasa and Akohia communities in the UMK
District. Before data collection, focus group discussions were conducted in both communities to
gain an understanding of the study area. Young children and infants between the ages of 0-60
months were eligible for the assessment; 93 children were recruited. A previously validated
Infant Young Child Feeding Questionnaire (IYCF) was used. Questionnaires were pretested for
12 children at the Asesewa Child Welfare Clinic. The questionnaire included information on
socio-demographic circumstances, an infant and young child feeding module, liquids and
medicines consumed, a 24-hour food recall, food groups, fortified foods and drinking water.
To assess the weight of the child an electronic scale, able to measure to a precision of 0.1kg
(maximum 100 kg), was used. Children were naked or in underwear while being weighed and
measured. If a child was able to stand, the scale was tarred and the child stepped onto the scale
facing forward with arms at sides and feet shoulder width apart. For infants that could not stand,
mothers were asked to step on the scale, the scale was tarred and then child was handed to the
mother. Weight was then recorded. A stadiometer was used to measure height for children above
two years whereas an infantometer was used to collect recumbent length for children less than
two years. If a child over two was measured using the infantometer because of an inability to
stand on the stadiometer, 0.7 cm was subtracted from the recumbent length to convert to height.
To measure mid-upper arm circumference (MUAC) for infants above six months, a children’s
MUAC measuring tape was used. The mid-point between the acromion process and the tip of the
elbow of the left arm was determined using a non-elastic tape and marked with a marker, and
circumference taken at this point. The MUAC tape was color coded with red indicating severe
malnutrition (11.5 cm and below), yellow indicating moderate/at risk (11.5-12.5 cm) and green
indicating normal nutrition (12.5 cm and above). All measurements were taken in duplicate and
the mean completed was used in analysis.
Data entry was done in Microsoft Access. WHO Anthro was used to determine WHZ, WAZ and
WLZ (Appendix II) from anthropometric data. Statistical Package for Social Sciences (SPSS)
15.0 was used for analyses.

6. 4
4.0 RESULTS
TABLE 1: SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
PARAMETER FREQUENCY(n) PERCENTAGE (%)
Age of mothers (years)
Less than 18 6 6.5
19-29 48 51.6
30-49 28 30.1
50-69 1 1.1
Don't know 10 10.8
TOTAL 93 100
Mothers Highest Education
Never Attended school 22 23.7
Primary/Elementary 31 33.3
Junior High 38 40.9
Senior High 2 2.2
TOTAL 93 100
Mothers Marital Status
Married 22 23.7
Single 15 16.1
Separated/divorced 5 5.4
Widowed 3 3.2
Cohabitant 48 51.6
TOTAL 93 100
Mothers Occupation
Farmer 44 47.3
Trader 29 31.2
Dressmaker 9 9.7
Hairdresser 5 5.4
Other 6 6.5
TOTAL 93 100
Parity
Primiparous 22 23.7
Multiparous
2-4 children 44 47.3
5-7 children 22 23.7
8-10 children 5 5.4
TOTAL 93 100
n=Number of Respondents

7. 5
TABLE 2: DEMOGRAPHIC CHARACTERISTICS OF CHILDREN
PARAMETER FREQUENCY (n) PERCENTAGE (%)
Sex of Child
Male 53 57
Female 40 43
TOTAL 93 100
Age of Child (completed months)
0-24 45 48.4
25-48 37 39.8
48-59 11 11.8
TOTAL 93 100
Malnutrition Indices
Underweight (WAZ<-2SD)
Stunting (HAZ<-2SD)
11
21
11.8
22.6
Wasting (BAZ<-2SD) 6 6.5
Mean age of children= (27.4±16.8) months
MUAC for children was significantly higher than 11.5 (Mean MUAC=14.9±1.2cm
p=<0.001)
Number of overweight children= 0
FIGURE 1: PERCENTAGE OF INFANTS AND TIME LAPSE FOR INITIATION OF
BREASTFEEDING
48
56
60
14
49
37
44
25
71
38
15
0
15 14 12
0
10
20
30
40
50
60
70
80
90
100
Immediately Within First Hour Hours Days
Baby to Breast Total
percentageofchildren
Age of children in months 0 to 24 months Age of children in months 25 to 48 months
Age of children in months 49 to 59 months Age of children in months 49 to 59 months

8. 6
FIGURE 2: EARLY INITIATION OF BREASTFEEDING (BF) PERCENTAGES
AMONG CHILDREN 0-59 MONTHS
FIGURE 3: CONTINUED BREASTFEEDING AFTER 12 MONTHS OF AGE
71% 71.40%
63%
0%
20%
40%
60%
80%
100%
0-24 months 25-48 months 49-59 months
Percentage of Children with BF Initiation Within
the First 1 Hour 0-59 Months
0-24 months
25-48 months
49-59 months
100%
18.20%
12-15 20-24
0%
20%
40%
60%
80%
100%
120%
Age of children
Continued Breastfeeding After 1 Year

9. 7
TABLE 3: DIETARY DIVERSITY SCORES ACROSS DIFFERENT AGE GROUPS
Age for dietary
diversity
*n minimum maximum mean SD1
6-8 8 0 4 2.00 1.604
9-11 4 3 5 4.25 0.957
12-23 19 0 6 4.32 1.701
24-25 19 2 6 4.26 1.098
36-60 35 3 6 4.37 0.808
*n= Number of children 1
SD=Standard deviation
FIGURE 4: PERCENTAGE OF CHILDREN 0-23 MONTHS WHO MET DIETARY
DIVERSITY (DD) CRITERIA
32%
68%
Children Under 24 Months Who Met Dietary
Diversity Criteria
Children who did not meet DD Children who met DD

10. 8
TABLE 4: FEEDING FREQUENCY ACROSS AGE GROUPS OF CHILDREN
Age Category
(completed months)
*n Minimum Maximum Mean SD1
6-8 8 0 3 1.25 1.165
9-11 4 0 3 2.25 1.5
12-23 19 0 3 2.32 1.057
24-35 19 1 4 2.74 0.733
36-60 35 0 5 3.23 0.808
*n= Number of children 1
SD=Standard deviation
TABLE 5: DISTRIBUTION OF BOTTLE FEEDING ACROSS AGE GROUPS
Age
(completed months)
*n Percentage (%)
0-5 0 0
6-11 1 3.23
12-23 1 3.23
Total 2 6.46
*n=number of children

11. 9
FIGURE 5: WATER SOURCES FOR HOUSEHOLD OF CHILDREN ASESSED IN
SURVEY
FIGURE 6: WATER TREATMENT METHODS USED
51%
2%
17%
2%
28%
Distribution of Water Sources Among
Community Members
borehole
rain water
river/stream
bottled water
well water
45%
13%
42%
Water Treatment Methods Used by
Caregivers
none
boil
filter

12. 10
FIGURE 7: AVERAGE Z-SCORES FOR WHZ, WHZ AND BMI FOR AGE
-1.8
-1.6
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
0-5 6-11 12-23 24-35 36-47 48-60
PercentageSD
Age in Months
Mean Z Score
WAZ
LAZ
BMI for Age

13. 11
5.0 DISCUSSION
The study revealed several significant problems including: minimum dietary diversity for
complementary feedings for ages 6-8 months, lack of water treatment methods before drinking,
and stunting.
The majority of the age groups met the score for dietary diversity. However, 75% of children 6-8
months did not meet the minimum requirement of four food groups. Grains were the most
commonly consumed, whereas fruits, legumes, meat and dairy were the least consumed.
Although Caloric needs may be met, low dietary diversity may lead to inadequate consumption
of micronutrients, contributing to increased risk for disease and poor growth (Dickson, 2016).
Boreholes and wells were the most common sources of water. The percentage of people that did
not treat their water was 45.2%, and 41.9% filtered drinking water with a cloth. Filtering alone
removes debris but does not treat for bacteria and other contaminants. Previous research done by
the NRTC found that 83.1% of the community did not use any water treatment methods, which is
congruent with the findings of this study (Arthur et al, 2013). The high rates of hospital
admissions related to diarrhea that were found in the UMK District may be related to untreated
water.
The anthropometric data revealed that 22.6% of children in the study were stunted. Poor
introduction of diverse foods correlates to increased rates of stunting. Mid-upper arm
circumference (MUAC), weight for height and weight for age were within the normal range. The
NRTC team’s 2013 study revealed that there was significant stunting, wasting, and underweight
children in the community (Arthur et al, 2013); however, the 2014 study done by the NRTC only
noted significant stunting in children (Ababio et al, 2014). The decrease in the rate of
malnutrition can likely be related to increased interventions in the UMK District like maternal
education at the child welfare clinic among others.

14. 12
6.0 RECOMMENDATIONS
The results showed a need for education for both water treatment and dietary diversity for
children ages 6-8 months. The following statements address these findings:
1. Intake of unsafe food (NB- 3.1) related to potential food and nutrition related knowledge
deficit as evidenced by community explanation of using untreated open well system.
2. Undesirable food choices (NB-1.7) related to potential food and nutrition related
knowledge deficit as evidenced by children 6-8 months of age having a mean dietary
diversity of 2 of the 7 recommended food groups.
Using the above diagnosis, the introduction of more food groups during complementary feeding
by increasing meat and dairy but more especially eggs, legumes and nuts which are readily
available to community members and are affordable is recommended. Planned interventions
included education on increasing diet diversity in children 6-8 months of age and proper water
treatment methods. To make these interventions interesting and interactive, skits were used to
educate through entertainment and community members were engaged through questioning as a
monitoring and evaluation tool to measure impact of the intervention.

15. 13
7.0 REFERENCES
Abibo, BK., Bauermeister K., Carboo, J., et al. (2014). Nutrition assessment and intervention in
three rural communities of Asesewa sub-district in the Upper Manya Krobo district in
Ghana.
Arthur, E., Davis, C., Innocent, B., (2013). Assessing the nutrition status of children under 5
years in selected rural communities in Manya Krobo District.
Center for Disease Control and Prevention. (2016). CDC Global Health - Ghana.
http://www.cdc.gov/globalhealth/countries/ghana/
Dickson, A.A.. (2016). Women’s participation in household decision-making and higher dietary
diversity: findings from nationally representative data from Ghana. Journal of Health,
Population and Nutrition, 35(16).
Gabriel , L. (2016, June 9). HEALTH INFORMATION OF UPPER MANYA KROBO
DISTRICT. GHANA HEALTH SERVICE UPPER MANYA KROBO DISTRICT. Asesewa.
Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. (2014).
Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS,
and ICF International.
Ghana Statistical Service. (2014). Population and Housing Census 2010, Upper Manya Krobo
District. District Analytical Report. Rockville, Maryland: GSS, GHS, and ICF
International.
Keusch, GT. et al. (2016) Diarrheal Diseases. Reproductive, Maternal, Newborn, and Child
Health: Disease Control Priorities, 2(3).
Nordin, S., Boyle, M., & Kemmer, T. (2013). Position of the Academy of Nutrition and
Dietetics: Nutrition Security in Developing Nations: Sustainable Food, Water, and
Health. Journal of the Academy of Nutrition and Dietetics, 113(4), 581-595.
Quansah, E. (2016). Social Factors Influencing Child Health in Ghana. PLOS ONE PLOS ONE,
11(1).
Victoria, C., Bahl, R., Barros, A., França, G. , et al. (2016). Breastfeeding in the 21st century:
Epidemiology, Mechanisms and Lifelong effect. Lancet, 387, 475-90.
WHO. (2008). Indicators for assessing infant and young child feeding practices. Part 1,
Definitions. Washington DC: WHO.

16. 14
WHO. (2010). Indicators for Assessing infant and young child feeding practices. Washington
DC: WHO.
WHO. (2012). Nutrition Landscape Information System Country Profile: Ghana. Retrieved June
2, 2016, from The World Health Organization:
http://apps.who.int/nutrition/landscape/report.aspx?iso=gha

17. 15
APPENDIX
APPENDIX I
WHO Core Indicators and indicator definitions (9 out of 15 relevant to current study)
1. Early initiation of breastfeeding: Proportion of children born in the last 24 months who were
put to the breast within one hour of birth.
2. Exclusive breastfeeding under 6 months: Proportion of infants 0–5 months of age who are
fed exclusively with breast milk.
3. Continued breastfeeding at 1 year: Proportion of children 12–15 months of age who are
fed breast milk.
4. Introduction of solid, semi-solid or soft foods: Proportion of infants 6–8 months of age who
receive solid, semi-solid or soft foods
5. Minimum dietary diversity: Proportion of children 6–23 months of age who receive foods
from 4 or more food groups.
6. Minimum meal frequency: Proportion of breastfed and non-breastfed children 6–23 months
of age, who receive solid, semi-solid, or soft foods (but also including milk feeds for non-
breastfed children) the minimum number of times or more.
7. Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who are
fed breast milk.
8. Bottle feeding: Proportion of children 0–23 months of age who are fed with a bottle.
9. Duration of breastfeeding: Median duration of breastfeeding among children less than 36
months of age; the age in months when 50% of children 0–35 months did not receive breast milk
during the previous day.
APPENDIX II
WAZ: Weight for age z-score; deviation of infant weight for age from median weight for age on
WHO standard growth charts. Indicator for underweight (WAZ <-2SD)
HAZ: Height for age z-score; deviation of infant height for age from median weight for age on
WHO standard growth charts. Indicator for stunting (HAZ<-2SD)
WHZ: weight for height z-score; deviation of infant weight for height from median weight for
height on WHO standard growth charts. Indicator for wasting (WHZ<-2SD)