A theory-based nutrition education intervention to enhance complementary feeding practices among young children in Southern Ethiopia

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Purpose. The purpose of this study was two-fold: 1) to assess the nutritional status of children; their complementary feeding practices; household food insecurity; mothers’ knowledge and attitudes towards complementary feeding practices; and water, sanitation and hygiene practices; and 2) to design and implement a nutrition education intervention (NEI) to improve child feeding practices and related nutritional status by improving mothers’ knowledge, attitudes, and practices (KAP) of complementary feeding for children aged 6 to 23 months in the Sidama and Oromia regions of Ethiopia. Methods. This study used cluster-randomized trial design with an intervention and a control group. Pairs of mothers and their children aged six to 23 months from six villages located in Arsi Negele, Wondo Genet, and Dale districts were recruited and randomly assigned into the intervention (IG, n = 99) or control group (CG, n = 91). The NEI was was guided by the Social Cognitive Theory. The NEI curriculum spanned a period of six weeks, with a weekly three-hour session. Each session was designed to provide a lecture on the week’s topic, a discussion using counseling cards, a cooking demonstration, and key messages. The control group did not receive any intervention. Data was collected pre- and post-intervention using the knowledge, attitudes and practices towards complementary feeding questionnaire and anthropometric measurements. Household food insecurity; water, sanitation, and hygiene practices; and demographic characteristics were assessed only at baseline. Linear and generalized mixed models were used to assess the effectiveness of the NEI. Linear and logistic regressions were performed to assess associations between variables at baseline and post-intervention. Results: A quarter (25.8%) of children were stunted, 13.7% were underweight, and 6.8% were wasted. Most (87.4%) children achieved the recommended minimum meal frequency (MMF), while only 27.4% achieved the minimum dietary diversity (MDD) and 26.8% the minimum acceptable diet (MAD). Majority (80%) of households were food insecure, with 40% of households reporting severe food insecurity. At baseline, half (50%) of mothers demonstrated poor levels of knowledge on complementary feeding practices. Mothers that lacked formal education and that lived in moderate and severely food insecure households had a reduced probability of achieving children’s MDD (p < .05) and MAD (p < .05). Mothers with low-income levels were less likely to achieve children’s MAD (p = .014). At post-intervention, the IG significantly increased its knowledge scores compared to the CG (3.47 ± 1.28 vs. 0.57 ± 1.41, p = .004). Similarly, the IG had a significantly greater increase in the proportion of children that achieved the MDD (p = .003) and MAD (p < .001) than the control group. Post-intervention results demonstrated a significant reduction of stunting in the IG than those in the CG (p = .035). Conclusion: A high prevalence of child undernutrition, food insecurity, and suboptimal complementary feeding practices remains in the region. In addition, this study demonstrated that theory-based NEIs that use low-literacy strategies are effective in improving complementary feeding knowledge and practices, and the nutritional status of children. Future NEIs that focus on the improvement of complementary feeding practices in Ethiopia should implement low-literacy strategies such as the use of plain language, applying the teach-back method, integrating activities that are based in observational learning, and providing an intensive training for nutrition educators.

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Child Undernutrition, Nutrition Education, Young Child Feeding Practices, Food Security, Social Cognitive Theory