The Association between Nutritional Knowledge, Socio-Economic Status of Caregivers and Stunting of Children Under 5 Years in Kwale County of Kenya: A BaselineSurvey

Research Article

Austin J Nutr Metab. 2021; 8(2): 1105.

The Association between Nutritional Knowledge, Socio-Economic Status of Caregivers and Stunting of Children Under 5 Years in Kwale County of Kenya: A Baseline Survey

Wanjihia VW1*, Chepkirui F2, Hitachi M3, Muniu E1, Nyandieka L1, Ndemwa P1, Wekesa N4, Changoma J5, Kiplamai F2, Karama M6 and Kaneko S3

1Kenya Medical Research Institute-Centre for Public Health Research, Kenya

2Kenyatta University, Kenya

3Nagasaki University, Japan

4Kemri Graduate School, Kenya

5Nuitm-Kemri Project, Kenya

6UMMA University, Kenya

*Corresponding author: Violet Wanjihia, Kenya Medical Research Institute-Centre for Public Health Research, Nairobi, Kenya

Received: February 09, 2021; Accepted: March 16, 2021; Published: March 23, 2021


Background: In Low and Middle Income Countries (LMIC), including Kenya, undernutrition has been the most significant contributor to child morbidity and mortality. Knowledge and practices of mothers/caregivers have been identified as a key sustainable factor for consideration in determining the nutritional status of children. The study aim was to determine how caregiver knowledge and socio-economic status will impact on nutritional status of children under 5 years.

Methods: This study was conducted in Kwale County, Kenya to assess at baseline maternal and child parameters. Seven hundred pairs; children and their primary caregivers were sampled at baseline.

Results: A total of 681 households comprised of caregiver and index child pair, participated in the survey from the sampled 700. Knowledge scores of food functions, breastfeeding and complementary feeding were combined to assess caregivers nutritional knowledge with a maximum score of 24. The median score was 11 (IQR: 9 – 12) and ranged from 0 to 24. Those with scores of 12 and above (50% plus) were 230 (33.2%). Stunting was 29.8% and the level of under-weight was 16.4%.

No significant association was found between nutritional knowledge of the caregivers and nutitional indicators of children under 5 years but there was significant differences (P= 0.002.) in the Knowledge score of caregivers between the five wealth quintiles.

Conclusion: Most of the caregivers did not have any nutritional knowledge which was assessed as knowledge of food groups and sources and functions of different foods as well as knowledge in breastfeeding and complementary feeding.

Keywords: Stunting; Nutritional knowledge; Caregivers


In the Sustainable Development Goals (SDGs) which replaced the Millennium Development Goals (MDGs) the importance of reduction of child mortality and enhancement of child health and nutrition has been captured in goal 3 [1]. In developing countries, undernutrition has been the most significant contributor towards child morbidity and mortality [2]. It has been reported to be the underlying cause of about 35% of the disease burden in children under 5 years [3].

Kenya has been ranked among 34 countries suffering the highest burden of child malnutrition globally [4]. In Kenya, 26% of children under 5 years have been reported as stunted, and 11% underweight. Kwale county, in the coastal region of Kenya, is above the national average for stunting, at 29.7% [5]. In order to reverse this trend, it has been suggested that proper interventions should be based on bottomup approaches where local communities and caregivers are sensitized on child nutrition based on the local culture and context [6].

Enhancing the knowledge and practices of mothers/caregivers has been identified as a key sustainable factor for consideration in improving the nutritional status of children [7].

Appropriate feeding of young infants and children under 5 years has been identified among the key interventions necessary to reduce under 5 mortality and this cannot be achieved without enhancement of caregiver knowledge and practices [8].

In a study on advice on breastfeeding for first-time mothers in rural coastal Kenya, it was found that the majority of the key advisers are relatives rather than trained health workers [9]. A study in Uganda also reported that women face numerous challenges to their freedom to make decisions and married women reported that their husbands make the primary decisions about their health care and household purchases [10]. Constrained decision-making among women was described to limit women’s caregiving capabilities for nutrition [11].

In Kenya, mothers also receive health advice from health workers at clinics during antenatal and maternity services, but for a majority of the mothers/caregivers, this may be hampered by poor transport links to the facility [12]. Home-based follow up visits by Community Health Volunteers (CHVs) trained in nutritional counselling and peer support groups for mothers are two promising approaches that have been identified for not only improving mothers’ breastfeeding self-efficacy and confidence but also for improving nutritional wellbeing of children [13].

Personalised home-based nutritional counselling and support of mothers/caregivers has been hypothesized to lead to higher knowledge and self-efficacy in adhering to breastfeeding guidelines and other feeding practices for children under 5 years [14]. Caregiver attitudes and practices have been highly correlated with the nutritional status of children under 5 years [15]. In a study conducted in Mexico City, in a community based randomized study, it was found that repeated contact with peer counsellors was highly associated with exclusive breastfeeding and the duration of breastfeeding [16].

It has been reported that children under 5 years in low-income countries are not fed with a diversity of diets and are also not frequently fed according to the guidelines for Infant and Young Child Feeding (IYCF) practices. Analysis carried out of countries with a high burden of undernutrition reported less than 40% of children in 16 of 22 sub-Saharan African countries were fed a “minimally diverse diet” [17].

Lack of caregiver knowledge about healthy complementary feeding practices was found to present a major barrier to adequate child feeding [18]. Caregivers with limited literacy skills are also less likely to feed their children according to recommended Infant and Young Child Feeding (IYCF) practices [19].

Apart from caregiver knowledge, caregiver socio-economic status is also a factor in enhancing child nutrition [20]. In Socio-economic status, wealth index is used to rank households into quintiles. The value of using the wealth index is important in contexts where reliable income and expenditure data is absent. In surveys, wealth index is chosen because of the impact that wealth or financial status has on household health. Researchers can identify the impact of wealth status on health outcomes within a community [21].

The aim of this study was to determine how an intervention to improve caregiver knowledge, attitude and practices through nutritional counseling, including exclusive breastfeeding promotion, complementary feeding using locally available options and peer support, will impact on nutritional status, morbidity and mortality of children under 5 years, at endline. This study reports the knowledge and socio-economic status of the caregivers in both the control and the intervention arms before the intervention was implemented.

Materials and Methods

Study design

This was a baseline study based on a prospective cohort comparative study which was conducted in Kwale County to determine caregiver knowledge, socio-economic status and Child nutrition status before the intervention was carried out. The study participants were a sample nested in the Health and Demographic Surveillance System (HDSS) program that was implemented in the area by the Kenya Medical Research Institute in collaboration with Nagasaki University [22].

Study populations and sampling procedures

681 children under five years and their caregivers were recruited randomly from a list of individual households with children under five years. Out of the 700 sampled pairs, only data for 681 pairs was complete.

Study site

In the HDSS area there was a population of 65,000 living by December 2017 in about 12,000 households. The area has 4 locations which include Mwaluphamba, Kinango, Ndumbule and part of Puma which is north of Kinango town. This study covered the areas of Dumbule and Miatsani under the HDSS program.

Sample size considerations

The sample size was based on a two-arm prospective interventional study whose baseline survey results are presented in this paper.

For the prospective study, the primary outcome was infant growth velocity which was estimated by using proportion of infants experiencing growth faltering as assessed by stunting levels. From KDHS 2014 for children aged under 5 years, the stunting level countrywide was 26%. If we assume the control represents the current situation and the estimate of growth faltering (stunting) among infants is the same as that reported by KDHS 2014 of 26%, then it can be hypothesized that counseling will reduce growth faltering by 10%. A sample size of 289 per group was sufficient to detect a 10% difference in growth faltering between the control and intervention groups (a = 0.05, β = 0.10). To cater for loss to follow up, the sample size was adjusted upwards by 20% giving a final sample size of 350 per group; control and intervention groups. (700 total child/caregiver pairs).

Assessment of Caregiver Knowledge

In the first section as indicated in Table 1, caregivers were asked about knowledge of food groups and the sources of different functions of food. Knowledge of foods was assessed by giving a score of 1 to each correct responses on food groups and specific food types for each food group with a maximum score of 12.