Prevalence of Minimum Meal Frequency Practice and Its Associated Factors among Children Aged 6 to 23 Months in Ethiopia: A Systematic Review and Meta-analysis

Abstract

Background. Inappropriate complementary feeding practices are amongst the key causes of child undernutrition. It rises the risk of undernutrition, illness, and mortality among children. Objectives. This study was aimed to determine the pooled prevalence of MMF practice and associated factors among children aged 6 to 23 months in Ethiopia. Methods. The search was conducted by using the following electronic databases; PubMed/MEDLINE, HINARI, EMBASE, Google Scholar, Web of Science, Scopus, African journals, and Google for grey literature. The publication bias was determined by using a funnel plot and Egger’s test. The heterogeneity between the studies was checked by using I² statistic. The subgroup analysis was done by sample size, region, and year of publication. Result. A total of 20 studies with 12 656 study participants were included in the present systematic review and meta-analysis. The pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia was estimated to be 63.80% (95%CI: 56.59, 71.01). PNC visit (AOR = 1.90, 95%CI [1.31, 2.49]), wealth index (AOR = 2.11, 95%CI [1.42, 2.81]) and age of child (AOR = 5.75, 95%CI [4.25, 7.26]) were factors significantly associated with MMF among children aged 6 to 23 months. Conclusion. The findings showed that the pooled prevalence of MMF among children aged 6 to 23 months in Ethiopia was relatively low. PNC visit, wealth index and age of child were factors significantly associated with MMF among children aged 6 to 23 months. Therefore, community-based health education concerning the recommended MMF among children aged 6 to 23 months is required to take place.

Keywords

minimum meal frequency child systematic review meta-analysis Ethiopia

Background

A suitable nutrition is crucial for health and development of the children.¹ MMF is a proportion of breastfed and non-breastfed among children 6 to 23 months of age who receive solid, semi-solid, or soft foods but also comprising milk feeds for non-breastfed children the minimum number of times or more.² The homemade complementary foods are principally based on cereals and legumes in Ethiopia. The consumption of micronutrients like iron, zinc, and calcium from homemade complementary foods was very low.³ However, appropriate complementary feeding practice is vital for the growth and development of the children.⁴ The indicators which reflects diet quality for young children are required for programs and in some research contexts.⁵

Starting from 6 months of age, infants, and young children are at an augmented risk of malnutrition.⁶ Six to twenty-four months of age is the period of most serious time for the development of the infant.⁷ Whereas, a time from birth to 2 years of age would provide a chance for the promotion of health, growth, and behavioral development of children.⁸ Furthermore, women of child-bearing age, infants and young children are the principally nutritional susceptible periods of the life cycle.⁹ Maternal and child undernutrition is vastly widespread in low-and middle-income countries leading in the considerable rises in mortality and overall disease burden.¹⁰

Directly or indirectly, undernutrition is accounted for around 35% of deaths in children less than 5 years of age worldwide. It is also a principal cause of disability in children.¹ Unsuitable complementary feeding in infants and children may rise the risk of undernutrition, illness and mortality.¹¹ Even the suboptimal complementary feeding practices found to lead to a quick rise in the magnitude of stunting in young children from 6 months age.¹² This is because of that suboptimal feeding practices were found to be associated with malnutrition.¹³ Besides, inappropriate duration of announcing complementary food would deprive the infant for optimum nutrition. Whereas, this would cause for undernutrition, and augmented morbidity and mortality.¹⁴ It is the main challenge to attain an optimum Infant and young child feeding practices in developing and developed countries. Inappropriate infant and young child feeding practices attributed to about 40% deaths of under 2 years age worldwide.¹⁵

In developing countries, about 19.4% of children <5 years of age were underweight and 29.9% were stunted in the year 2011. Undernutrition leads to around one third of deaths in children <5 years of age.⁷ Whereas, a report of World Health Organization¹ showed that about 32% (186 million) of children under 5 years of age were stunted and 10% (55 million) were wasted in developing countries. Malnutrition is a main community health problem in developing countries. If household food insecurity is combined with poor child feeding patterns, it would lead to malnutrition.⁸ In Ethiopia, the poor nutritional status of children and women has been a critical problem for numerous years.¹⁶ To improve infant and young child feeding, designing of the effective programmes that consider the understanding of the local condition and an efficient process for prioritizing interventions are required.¹²

Undernutrition remains the public critical issues. So that, the present meta-analysis could be significant in providing the essential information. This is because gaining the evidence for the MMF and associated factors among children aged 6 to 23 months in Ethiopia could encourage the healthcare providers, stakeholders, policy makers and implementers, nutritionist and government to focus on the nutritional status of the children. Further, they could develop different strategies to prevent the morbidity and mortality associated with the inappropriate feeding practice of the children based on this evidence.

Review Questions

What is the pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia?

What are the factors associated with the MMF practice among children aged 6 to 23 months in Ethiopia?

Methods

Study Setting

The present study was conducted in Ethiopia. Ethiopia is found in the Horn of Africa with a total area of 1 100 000 km². In the world, it is the 13th most populous country, whereas, the 2nd most populous in Africa. The national capital and largest city is called Addis Ababa.¹⁷

Search Strategies

The search was conducted by the using the following electronic databases; PubMed/MEDLINE, HINARI, EMBASE, Google Scholar, Web of Science, Scopus, African journals, and Google for grey literature. Overall, all electronic search methods were used to find the relevant studies accordingly. The search was done by using the following keywords; “Acceptable diet,” “complementary feeding,” “Minimum Meal Frequency,” “Associated Factors,” “determinant factors,” “Factors,” “Children 6 to 23 months,” and “Ethiopia.” During this, “AND” and “OR” Boolean operators were employed to integrate the keywords.

Eligibility Criteria

Inclusion Criteria

Study setting: All studies conducted in Ethiopia.

Population: Children aged 6 to 23 months.

Publication status: All published and unpublished articles were considered.

Language: English

Study design: Observational studies (cross-sectional studies) were employed.

Publication date: articles published until April 18, 2021 were included.

Exclusion Criteria

Articles with poor quality and articles in which the outcome variable was not clearly defined and measured were excluded from the meta-analysis.

Outcome of Interest

In the present systematic review and meta-analysis, primary outcome was the prevalence of MMF practice among children aged 6 to 23 months, which was reported within the original articles. Likewise, the secondary outcome was factors associated with the MMF practice among children aged 6 to 23 months which was reported within the original studies.

Data Extraction

All studies obtained from all databases were exported to Endnote version 8 software and the duplicates were removed. Finally, all studies were exported to Microsoft Excel spreadsheet. The Titles and abstracts of studies retrieved using the search strategy and those from additional sources were screened to identify studies that satisfy the inclusion criteria. Then studies that satisfy the inclusion criteria by title or abstract screening were undergo full text review for eligibility and data extraction. The Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) flowchart was used for the stepwise inclusion and exclusion of the articles. The first author, publication year, regions, study area, sample size, prevalence and 95%CI for factors were included in to the data extraction format.

Quality Assessment

The Newcastle–Ottawa Scale (NOS) quality assessment criteria were used to include the studies. The quality of each study was assessed by using modified NOS for cross-sectional studies. It has 10 points in 3 domains of modified NOS components for observational studies. So that, the studies which were scored ≥5 out of 10 points were included in the final analysis.¹⁸

Data Processing and Analysis

Random effect model was employed to estimate the pooled prevalence of MMF practice among children aged 6 to 23 months. The analysis was conducted by using STATA version 11 statistical software after extraction of the articles in Microsoft Excel spreadsheet format were completed. The heterogeneity among the included studies was assessed by using Cochrane Q-test and I² statistics. The publication bias was measured by using Egger’s test. Subgroup analysis was done based on the region, category of publication year and sample size category. Finally, the forest plot format was used to display the pooled prevalence with 95%Cl.

Reporting the Results

In the present systematic review and meta-analysis, the results were reported based on the PRISMA 2009 checklist.¹⁹ Furthermore, tables, figures and narrative summaries were used to report the findings.

Result

A total of 643 articles were identified through the search strategies. They were retrieved from PubMed/MEDLINE, HINARI, EMBASE, Google Scholar, Web of Science, Scopus, African journals, and Google for grey literature. Out of 643, 336 articles were excluded due to duplication. Of the remaining 307 articles, 281 articles were excluded after reviewing of the titles and abstracts because of they were not related. Then, 26 full-text articles were assessed for eligibility based on the pre-setted criteria and 6 articles were excluded with a reason. Lastly, 20 articles were met the eligibility criteria and included in to the meta-analysis (Figure 1).

Figure 1.

PRISMA flowchart diagram of the study selection for systematic review and meta-analysis on the prevalence of MMF practice and its associated factors among children aged 6 to 23 months in Ethiopia.

Features of the Included Studies

Among the studies published up to April 18/2021 in Ethiopia, 20 studies were included into the present systematic review and meta-analysis. The study design of all these studies were a cross-sectional. The smallest sample size was 200, while the largest was 1034. The smallest prevalence of MMF practice among children aged 6 to 23 months in Ethiopia was 33%, while the largest was 94.5%. Further, 12 656 study participants were involved to determine the pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia (Table 1).

Table 1.

Characteristics of the Studies Included in the Systematic Review and Meta-Analysis on the Prevalence of MMF Practice and Its Associated Factors among Children Aged 6 to 23 Months in Ethiopia.

S. No.	Authors	Region	Study setting	Study design	Sample size	Prevalence
1	Beyene et al²⁰	Amhara	Community	Cross-sectional	920	50.4
2	Kassa et al²¹	Oromia	Community	Cross-sectional	611	67.3
3	Mekonnen et al²²	SNNPR	Community	Cross-sectional	611	68.9
4	Mulat et al²³	Amhara	Community	Cross-sectional	502	63
5	Wagri et al²⁴	Afar	Community	Cross-sectional	364	69.2
6	Belew et al²⁵	Amhara	Community	Cross-sectional	1034	72.2
7	Gessese et al²⁶	Amhara	Community	Cross -sectional	543	60.6
8	Tegegne et al²⁷	Oromia	Community	Cross-sectional	801	68.4
9	Wuneh et al²⁸	Afar	Community	Cross-sectional	804	43.8
10	G/Tsadik²⁹	Sidama	Community	Cross-sectional	816	57.6
11	Bersisa³⁰	Oromia	Community	Cross-sectional	336	88.3
12	Areja et al³¹	SNNPR	Community	Cross-sectional	546	94.5
13	Asfaw et al³²	SNNPR	Community	Cross-sectional	671	61
14	Ferede et al³³	Amhara	Community	Cross-sectional	593	60
15	Birhanu et al³⁴	Sidama	Community	Cross-sectional	637	53.2
16	Brhane et al³⁵	Tigray	Community	Cross-sectional	949	68
17	Derebe et al³⁶	SNNPR	Community	Cross-sectional	733	56.5
18	Fanta and Cherie³⁷	Oromia	Community	Cross-sectional	323	51.4
19	Feleke and Mulaw³⁸	SNNPR	Community	Cross-sectional	662	87.2
20	Gizaw and Tesfaye³⁹	Oromia	Community	Cross-sectional	200	33

Heterogeneity and Publication Bias

The heterogeneity and publication bias of the studies included in the meta-analysis were assessed. After doing this, the result indicated that there is a significant heterogeneity among studies (I² = 98.9%, P = .000). The publication bias was determined by using Egger’s tests. According to the result, it was not statistically significant (P = .077). Besides, the funnel plot shows the symmetrical distribution of the included articles, this suggests there is no evidence for publication bias for this meta-analysis (Figure 2).

Figure 2.

Funnel plot with 95% confidence limits of the pooled prevalence of MMF practice among children aged 6 to 23 Months in Ethiopia.

Sensitivity Analysis

Sensitivity analyses using the random effects model revealed that no single study influenced the overall prevalence of MMF practice among children aged 6 to 23 months (Figure 3).

Figure 3.

The result of sensitivity analysis of 20 studies conducted on MMF practice among children aged 6 to 23 months in Ethiopia.

Prevalence of Minimum Meal Frequency

This meta-analysis was used the random effect model to estimate the pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia, which was 63.80% (95%CI: 56.59, 71.01). The level of heterogeneity was (I² = 98.9%: P = .000) (Figure 4).

Figure 4.

Forest plot of pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia.

Subgroup Analysis

Due to the presence of a significant level of heterogeneity among the included studies, subgroup analysis was required to be conducted. During this, sub-group analysis was deployed using region, publication year, and sample size to determine the pooled prevalence of MMF practice to identify the sources of heterogeneity. Accordingly, the pooled prevalence of MMF practice was 61.24% in Amhara region, 61.68% in Oromia region, 73.62% in SNNPR, 56.50% in Afar region, and 55.40% in Sidama region. Whereas, 60.48% for sample size ≤500 and 64.54 for sample size >500. Furthermore, it was 66.77 for studies published ≤2017 year and 61.24% for the studies published after 2017 year (Table 2).

Table 2.

Subgroup Prevalence of MMF Practice among Children Aged 6 to 23 Months in Ethiopia.

Variable	Category	Included studies	Prevalence with 95%CI	I² (%)	P-value
Region	Amhara	5	61.24 (51.92, 70.56)	96.2	.000
	Oromia	5	61.68 (49.90, 73.46)	98.6	.000
	SNNPR	5	73.62 (58.38, 88.86)	99.3	.000
	Afar	2	56.50 (31.61, 81.39)	98.6	.000
	Sidama	2	55.40 (51.09, 59.71)	64.4	.094
	Tigray	1	68.00 (67.90, 68.10)	-	-
Publication year	≤2017	9	66.77 (56.69, 76.85)	99.1	.000
Publication year	>2017	11	61.24 (51.60, 70.87)	98.7	.000
Sample size	≤500	4	60.48 (38.88, 82.07)	98.9	.000
Sample size	>500	16	64.54 (57.07, 72.01)	99.0	.000

Associated Factors

According to the present meta-analysis, postnatal care (PNC) visit, wealth index and the age of children were factors significantly associated with MMF practice among children aged 6 to 23 months in Ethiopia.

PNC Visit

Based on the pooled effects of 2 cross-sectional studies,^25,28 mothers who had PNC visit were 1.90 times more likely to provide the recommended MMF for children aged 6 to 23 months (AOR = 1.90, 95%CI [1.31, 2.49], I² = 0.0%, P = .596) than mothers who had no PNC visits (Figure 5).

Figure 5.

The overall pooled odds ratio of the association between PNC visit and the MMF practice among children aged 6 to 23 months in Ethiopia.

Wealth Index

Based on the pooled effects of 2 cross-sectional studies,^25,32 rich family were 2.11 times more likely to provide the recommended MMF for children aged 6 to 23 months than poor family (AOR = 2.11, 95%CI [1.42, 2.81], I² = 0.0%, P = .493) (Figure 6).

Figure 6.

The overall pooled odds ratio of the association between wealth index and the MMF practice among children aged 6 to 23 months in Ethiopia.

Age of Child

Based on the pooled effects of the 3 cross-sectional studies,^20,25,28 children aged 18 to 23 months were 5.75 more likely to receive the recommended MMF than children aged 6 to 11 months (AOR = 5.75, 95%CI [4.25, 7.26], I² = 25.5%, P = .261) (Figure 7).

Figure 7.

The overall pooled odds ratio of the association between age of child and the MMF practice among children aged 6 to 23 months in Ethiopia.

Discussion

Among children <2 years of age, inappropriate feeding practice rises the risk of undernutrition, illness, and mortality. Understanding the level of MMF practice among children aged 6 to 23 months in Ethiopia would help in policy making and implementing, developing the significant strategies to prevent undernutrition and the associated morbidity and mortality among these children. So that, the present systematic review and meta-analysis was aimed to determine the pooled prevalence of MMF practice and associated factors among children aged 6 to 23 months in Ethiopia. Finally, the present systematic review and meta-analysis revealed that the pooled prevalence of MMF practice among children aged 6 to 23 months in Ethiopia was estimated to be 63.80% (95%CI: 56.59, 71.01).

This finding was lower when compared with the study conducted in China (75.1%),⁴⁰ Tanzania (82%),⁴¹ Rwanda (83%),⁴² Benin (75.4%),⁴³ Pakistan (84.7%),⁴⁴ Mongolia (92.1%),⁴⁵ Nepal (76.6%),⁴⁶ Sri Lanka (88%),⁴⁷ Bangladesh (81.06%),⁴⁸ Mosul city (79.1%)⁴⁹ and Kenya (88.3%).⁵⁰ The variation might be due to the difference in the tools used, awareness of undernutrition-related morbidity and mortality, sociodemographic characteristics of the study population and child nutritional management policy. Furthermore, active involvement of stakeholders, health professionals, and the government on the child nutrition could bring the variation. This finding was consistent with the study conducted in Ghana (57.3%).⁵¹ However, this finding was higher than the study conducted in metropolitan city (52%),⁵² Nigeria (33.6%),⁵³ India (41.5%),⁵⁴ Burkina Faso (24.37%),⁵⁵ Uttar Pradesh (50.9%),⁵⁶ Iran (42.7%),⁵⁷ Indonesia (53.0%).⁵⁸ The possible justification could be that the difference in the sociodemographic characteristics of the study population.

The subgroup analysis in the present systematic review and meta-analysis showed that the pooled prevalence of MMF practice was lowest in Sidama region 55.40% (95%CI: 51.09, 59.71) and highest in SNNPR region 73.62% (95%CI: 58.38, 88.86). It was lower for sample size ≤500 60.48% (95%CI: 38.88, 82.07) and higher for the sample size >500 64.54% (95% CI: 57.07, 72.01). Furthermore, it was higher for the studies published ≤2017 year 66.77% (95%CI: 56.69, 76.85) and lower for the studies published after 2017 year 61.24% (95% CI: 51.60, 70.87).

The present systematic review and meta-analysis revealed that mothers who had PNC visit was 1.90 times more likely to provide the recommended MMF for children aged 6 to 23 months (AOR = 1.90, 95%CI [1.31, 2.49]) than mothers who had no PNC visits. In fact, during the PNC visit, the mother would be advised by the health profession on duty about her child nutrition, telling her that the inappropriate child feeding would lead to the morbidity and mortality. This would improve the knowledge of the mother concerning to her child nutrition. Knowing this, the mother would provide the meal as per recommendation.

The rich family was 2.11 times more likely to provide the recommended MMF for children aged 6 to 23 months than poor family (AOR = 2.11, 95%CI [1.42, 2.81]). This was supported by the conducted in India.⁵⁴ The possible justification could be that since there is no problem with the availability of the food, the mother would provide the meal to her child. Even if she is not fully aware about the recommended MMF, there could be the chance of giving the food to her child because of the accessibility of the food. Likewise, children aged 18 to 23 months were 5.75 more likely to receive the recommended MMF than children aged 6 to 11 months (AOR = 5.75, 95%CI [4.25, 7.26]). This was supported by the study conducted in Bangladesh, Indonesia and Malawi.^48,58,59 This was also supported by the study conducted in Ghana, the increase in the child’s age (18-23 months) was positively associated (β = 1.387, P < .01) with achieving the needed MMF.⁶⁰

Conclusion

The present systematic review and meta-analysis showed that the pooled prevalence of MMF among children aged 6 to 23 months in Ethiopia was relatively low. PNC visit, wealth index and age of child were factors significantly associated with MMF among children aged 6 to 23 months. These findings could encourage the healthcare providers, stakeholders, policy makers and implementers, nutritionist, and government to focus on the nutritional status of the children. Further, they could develop different strategies to prevent the morbidity and mortality associated with the inappropriate feeding practice of the children based on this evidence. Finally, based on these findings, the author recommends that community-based health education concerning the recommended MMF among children aged 6 to 23 months is required to take place.

Limitation of the Study

The present meta-analysis was not accomplished without the limitations. It was difficult to consider some of the associated factors with MMF among children aged 6 to 23 months because of they were not measured consistently across various studies. Therefore, these should be considered in the future studies. Besides, future studies are needed to be conducted to identify factors associated with MMF among children aged 6 to 23 months.

Footnotes

Author Contributions

Addisu Dabi Wake contributed to the conception of the study, data analysis, drafting or revising the article, gave final approval of the version to be published, and agrees to be accountable for all aspects of the work.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Addisu Dabi Wake

Data Sharing Statement

The data used to support the findings of this study are on the hands of the corresponding author.

References

World Health Organization. Indicators for assessing infant and young child feeding practices, Part 3 Country profiles. 2010. Accessed April 25, 2021. http://apps.who.int/iris/bitstream/handle/10665/44368/9789241599757_eng.pdf?ua=1

World Health Organization. Indicators for assessing infant and young child feeding practices: part 1: Indicators for assessing infant and young child feeding practices Part 1 definitions conclusions of a consensus meeting held 6–8 November 2007 in Washington, DC. Accessed April 25, 2021. http://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf?sequence=1

Abeshu

Lelisa

Geleta

Complementary feeding: review of recommendations, feeding practices, and adequacy of homemade complementary food preparations in developing countries – lessons from Ethiopia. Front Nutr. 2016;3:41. doi:10.3389/fnut.2016.00041

Aemro

Mesele

Birhanu

Atenafu

Dietary diversity and meal frequency practices among infant and young children aged 6–23 months in Ethiopia: a secondary analysis of Ethiopian demographic and health survey 2011. J Nutr Metab. 2013;2013:1-8. doi:10.1155/2013/782931

Arimond

Ruel

MT.

Dietary diversity is associated with child nutritional status: evidence from 11 demographic and health surveys. J Nutr. 2004;134:2579-2585. doi:10.1093/jn/134.10.2579

Rao

Swathi

Unnikrishnan

Hegde

Study of complementary feeding practices among mothers of children aged six months to two years – a study from coastal south India. Australas Med J. 2011;4:252-257. doi:10.4066/AMJ.2011.607

Lassi

Das

Zahid

Imdad

Bhutta

ZA.

Impact of education and provision of complementary feeding on growth and morbidity in children less than 2 years of age in developing countries: a systematic review. BMC Public Health. 2013;13 Suppl 3:S13. doi:10.1186/1471-2458-13-S3-S13

Tessema

Belachew

Ersino

Feeding patterns and stunting during early childhood in rural communities of Sidama, South Ethiopia. Pan Afr Med J. 2013;14:75. doi:10.11604/pamj.2013.14.75.1630

Lartey

Maternal and child nutrition in Sub-Saharan Africa: challenges and interventions. Proc Nutr Soc. 2008;67:105-108. doi:10.1017/S0029665108006083

10.

Black

Allen

Bhutta

, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-260. doi:10.1016/S0140-6736(07)61690-0

11.

Joshi

Agho

Dibley

Senarath

Tiwari

Determinants of inappropriate complementary feeding practices in young children in Nepal: secondary data analysis of Demographic and Health Survey 2006. Matern Child Nutr. 2011;8 Suppl 1:45-59. doi:10.1111/j.1740-8709.2011.00384.x

12.

Daelmans

Ferguson

Lutter

, et al. Designing appropriate complementary feeding recommendations: tools for programmatic action. Matern Child Nutr. 2013; 9:116-130. doi:10.1111/mcn.12083

13.

Tette

EMA

Sifah

Tete-Donkor

Nuro-Ameyaw

Nartey

. Feeding practices and malnutrition at the Princess Marie Louise Children’s hospital, Accra: what has changed after 80 years? BMC Nutr. 2016;2:42. doi:10.1186/s40795-016-0082-6

14.

Hazir

Senarath

Agho

, et al. Determinants of inappropriate timing of introducing solid, semi-solid or soft food to infants in Pakistan: secondary data analysis of Demographic and Health Survey 2006–2007. Matern Child Nutr. 2012;8:78-88. doi:10.1111/j.1740-8709.2011.00383.x

15.

Kahssay

Ebrahim

Seid

Woldu

Reddy

Infant and young child feeding practices and associated factors among children aged 0-23 months in Assayita district afar region Ethiopia. J Food Nutr Sci. 2019;7:96. doi:10.11648/j.jfns.20190706.13

16.

Central Stastical Agency. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia. 2012:452. Accessed April 23, 2021. https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf

17.

Wikipedia. Ethiopia. Wikipedia. 2021. Accessed April 23, 2021. https://en.wikipedia.org/w/index.php?title=Ethiopia&oldid=1019429668

18.

Modesti

Reboldi

Cappuccio

, et al. Panethnic differences in blood pressure in Europe: a systematic review and meta-analysis. PLoS One. 2016;11:e0147601. doi:10.1371/journal.pone.0147601

19.

Moher

Liberati

Tetzlaff

Altman

DG.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006-1012. doi:10.1016/j.jclinepi.2009.06.005

20.

Beyene

Worku

Wassie

MM.

Dietary diversity, meal frequency and associated factors among infant and young children in Northwest Ethiopia: a cross- sectional study. BMC Public Health. 2015;15:1007. doi:10.1186/s12889-015-2333-x

21.

Kassa

Meshesha

Haji

Ebrahim

Appropriate complementary feeding practices and associated factors among mothers of children age 6–23 months in Southern Ethiopia, 2015. BMC Pediatr. 2016;16:1-10.

22.

Mekonnen

Workie

Yimer

Mersha

WF.

Meal frequency and dietary diversity feeding practices among children 6-23 months of age in Wolaita Sodo town, Southern Ethiopia. J Health Popul Nutr. 2017;36:18. doi:10.1186/s41043-017-0097-x

23.

Mulat

Alem

Woyraw

Temesgen

Uptake of minimum acceptable diet among children aged 6-23 months in orthodox religion followers during fasting season in rural area, DEMBECHA, north West Ethiopia. BMC Nutr. 2019;5:1-10.

24.

Wagris

Seid

Kahssay

Ahmed

Minimum meal frequency practice and its associated factors among children aged 6–23 months in Amibara district, North East Ethiopia. J Environ Public Health. 2019;2019:8240864.

25.

Belew

Ali

Abebe

Dachew

BA.

Dietary diversity and meal frequency among infant and young children: a community based study. Ital J Pediatr. 2017;43:1-10.

26.

Gessese

Bolka

Abajobir

Tegabu

The practice of complementary feeding and associated factors among mothers of children 6-23 months of age in Enemay district, Northwest Ethiopia. Nutr Food Sci. 2014;44:230-240.

27.

Tegegne

Sileshi

Benti

Teshome

Woldie

Factors associated with minimal meal frequency and dietary diversity practices among infants and young children in the predominantly agrarian society of Bale zone, Southeast Ethiopia: a community based cross sectional study. Arch Public Health. 2017;75:1-11.

28.

Wuneh

Ahmed

Bezabih

Reddy

PS.

Dietary diversity and meal frequency practices among children aged 6-23 months in agro pastoral communities in Afar region, Ethiopia: a cross-sectional study. Ecol Food Nutr. 2019;58:575-596.

29.

G/Tsadik A. Infant and Young Child Feeding Practice in Predominantly Food Insecure Communitites of Hawassa Zuria Woreda in Sidama Zone, SNNPR, Ethiopia. Thesis. Addis Abeba Universty; 2010. Accessed April 18, 2021. http://etd.aau.edu.et/handle/123456789/1958

30.

Bersisa

AB.

Current level and determinants of optimal complementary feeding practices among lactating mothers of children in ambo town, Oromia, Ethiopia. 2019;73. Accessed April 21, 2021. http://etd.aau.edu.et/bitstream/handle/123456789/23095/ASSEFA%20BELAY.pdf?sequence=1&isAllowed=y

31.

Areja

Yohannes

Yohannis

Determinants of appropriate complementary feeding practice among mothers having children 6-23 months of age in rural Damot sore district, Southern Ethiopia; a community based cross sectional study. BMC Nutr. 2017;3:82. doi:10.1186/s40795-017-0202-y

32.

Asfaw

Wondafrash

Optimal Complementary Feeding Practice and Associatedfactors among Mothers in west Badewacho District, Hadiya Zone, SNNPR, Ethiopia. PhD Thesis. Jimma University; 2017. Accessed April 20, 2021. https://repository.ju.edu.et/bitstream/handle/123456789/3641/arega%20asfaw%20final%20thesis%20attached.pdf?sequence=1

33.

Ferede belete

Bikes

, gebregyorgis Gebremichael T. Appropriate Complementary Feeding Practice and Associated Factors among Mothers with Children Age 6-23 Months in Faggeta-Lekoma District, Northwest Ethiopia: Community-Based Cross-Sectional Study. ResearchSquere; 2019. doi:10.21203/rs.2.12833/v2

34.

Birhanu

Abegaz

Fikre

Magnitude and factors associated with optimal complementary feeding practices among children aged 6-23 months in Bensa District, Sidama Zone, South Ethiopia. Ethiop J Health Sci. 2019; 29:153-164. doi:10.4314/ejhs.v29i2.2

35.

Brhane

Grum

Abraha

Aregawi

Meal frequency and associated factors among children 6-23 months in Tahtay Michew district, northern Ethiopia, 2018. preprint. In Review; 2020. doi:10.21203/rs.3.rs-70779/v1

36.

Derebe

Lolemo

Samson

KD.

Appropriate complementary feeding practice among mothers of 6-23 months old children in Kedida Gamela district, south Ethiopia: a community based cross-sectional study. Int J Nutr Metab. 2019;11:19-26. doi:10.5897/IJNAM2019.0252

37.

Fanta

Cherie

HA.

Magnitude and determinants of appropriate complementary feeding practice among mothers of children age 6-23 months in Western Ethiopia. PLoS One. 2020;15:1-11. doi:10.1371/journal.pone.0244277

38.

Feleke

Mulaw

GF.

Minimum acceptable diet and its predictors among children aged 6-23 months in Mareka District, Southern Ethiopia: community based cross-sectional study. Int J Child Health Nutr. 2020;9:202-211. Accessed April 19, 2021 https://www.lifescienceglobal.com/pms/index.php/ijchn/article/view/6918

39.

Gizaw

Tesfaye

Minimum acceptable diet and factor associated with it among infant and young children age 6-23 months in North Shoa, Oromia Region, Ethiopia. Int J Homeopathy Nat Med. 2019;5:1. doi:10.11648/j.ijhnm.20190501.11

40.

Liao

Huang

Liao

Huang

Appropriate complementary feeding practices and associated factors among caregivers of children age 6-23 months in Rural Areas of Hunan Province, China: a community-based cross-sectional study. preprint. In Review; 2020. doi:10.21203/rs.3.rs-98306/v1

41.

Manzione

Kriser

Gamboa

, et al. Maternal employment status and minimum meal frequency in children 6-23 months in Tanzania. Int J Environ Res Public Health. 2019;16:1-10. doi:10.3390/ijerph16071137

42.

Umwali

. Influence of Maternal Nutrition Knowledge on Infant and Young Child Feeding Practices and Nutrition Status of Children in Musanze District, Rwanda. Thesis. University of Nairobi; 2020. Accessed April 22, 2021. http://erepository.uonbi.ac.ke/handle/11295/154143

43.

Bodjrènou

FSU

Hounkpatin

Termote

Dato

Savy

. Determining factors associated with breastfeeding and complementary feeding practices in rural Southern Benin. Food Sci Nutr. 2021;9:135-44. doi:10.1002/fsn3.1971

44.

Ariff

Saddiq

Khalid

, et al. Determinants of infant and young complementary feeding practices among children 6–23 months of age in urban Pakistan: a multicenter longitudinal study. BMC Nutr. 2020;6:75. doi:10.1186/s40795-020-00401-3

45.

Janmohamed

Luvsanjamba

Norov

Batsaikhan

Jamiyan

Blankenship

JL.

Complementary feeding practices and associated factors among Mongolian children 6-23 months of age. Matern Child Nutr. 2020;16 Suppl 2:1-9. doi:10.1111/mcn.12838

46.

Khanal

Sauer

Zhao

Determinants of complementary feeding practices among Nepalese children aged 6–23 months: findings from demographic and health survey 2011. BMC Pediatr. 2013;13:131. doi:10.1186/1471-2431-13-131

47.

Senarath

Godakandage

SSP

Jayawickrama

Siriwardena

Dibley

MJ.

Determinants of inappropriate complementary feeding practices in young children in Sri Lanka: secondary data analysis of Demographic and Health Survey 2006–2007. Matern Child Nutr. 2012;8:60-77. doi:10.1111/j.1740-8709.2011.00375.x

48.

Kabir

Khanam

Agho

Mihrshahi

Dibley

Roy

SK.

Determinants of inappropriate complementary feeding practices in infant and young children in Bangladesh: secondary data analysis of Demographic Health Survey 2007. Matern Child Nutr. 2012;8:11-27. doi:10.1111/j.1740-8709.2011.00379.x

49.

AL-Waly

AL- Hafidh

N mustfa

. Assessment of complementary feeding practice in children 6-23 months of age in Mosul city. Mosul J Nurs. 2014;2:13-18. doi:10.33899/mjn.2019.162923

50.

Korir

JK.

Determinants of complementary feeding practices and nutritional status of children 6-23 months old in Korogocho slum, Nairobi county, Kenya. 2013:129. Accessed April 20, 2021. https://ir-library.ku.ac.ke/bitstream/handle/123456789/9419/Jacob%20Kipruto%20Korir.pdf;sequence=1

51.

Saaka

Larbi

Mutaru

Hoeschle-Zeledon

Magnitude and factors associated with appropriate complementary feeding among children 6-23 months in Northern Ghana. BMC Nutr. 2016;2:2. doi:10.1186/s40795-015-0037-3

52.

Kunhipurayil

Srivastav

Determinants of minimum acceptable diet among young children in an urban slum: a community-based study. Int J Community Med Public Health. 2021;8:638-643. doi:10.18203/2394-6040.ijcmph20210214

53.

Samuel

Ibidapo

EG.

Complementary feeding practices and associated factors among nursing mothers in Southwestern Nigeria. Int J Matern Child Health AIDS IJMA. 2020;9:223-231. doi:10.21106/ijma.363

54.

Patel

Pusdekar

Badhoniya

Borkar

Agho

Dibley

MJ.

Determinants of inappropriate complementary feeding practices in young children in India: secondary analysis of National Family Health Survey 2005-2006. Matern Child Nutr. 2012;8:28-44. doi:10.1111/j.1740-8709.2011.00385.x

55.

Paré

Dahourou

Kabore

, et al. Prevalence of wasting and associated factors among 6 to 23 months old children in the Sahel Region of Burkina Faso. Pan Afr Med J. 2019;34:164. doi:10.11604/pamj.2019.34.164.19886

56.

Ahmad

Khalique

Khalil

Urfi Maroof

Complementary feeding practices among children aged 6-23 months in Aligarh, Uttar Pradesh. J Fam Med Prim Care. 2017;6:386-391. doi:10.4103/jfmpc.jfmpc_281_16

57.

Kamran

Sharifirad

Nasiri

Soleymanifard

Savadpour

Akbar Haghighat

Determinants of complementary feeding practices among children aged 6-23: a community based study. Int J Pediatr. 2017;5:4551-4560. doi:10.22038/ijp.2016.7811

58.

Dibley

Agho

KE.

Complementary feeding indicators and determinants of poor feeding practices in Indonesia: a secondary analysis of 2007 Demographic and Health Survey data. Public Health Nutr. 2012;15:827-839. doi:10.1017/S1368980011002485

59.

Nkoka

Mhone

Ntenda

PAM

. Factors associated with complementary feeding practices among children aged 6-23 mo in Malawi: an analysis of the Demographic and Health Survey 2015-2016. Int Health. 2018;10:466-479. doi:10.1093/inthealth/ihy047

60.

Dadzie

. Women Empowerment and Frequency of Meal Intake among Children in Ghana. Research Squere. 2020;1-21. Accessed April 19, 2021. https://assets.researchsquare.com/files/rs-123025/v1/1d4052c5-714e-4b12-a3cd-fdd94cdcd04e.pdf