Inappropriate supplementary feeding techniques put children under the age of two in danger of malnutrition, illness, and death. However, only a few children receive nutritionally appropriate and diversified diets. It is noteworthy that achieving minimum dietary diversity plays a pivotal role in the attainment of Sustainable Development Goals. However, the double burden of malnutrition poses a significant threat to achieving these goals.

A health facility-based cross-sectional study was conducted from April to July 2021. A multi-stage sampling technique was used to sample 422 study participants. Data were collected with a paper-based questionnaire, coded and entered into Epi-Data version 3.1. Data extraction was carried out in Excel Sheet for cleaning and then later exported into STATA for analysis. The dependent variable explored in the study was MDD. The independent variables considered in our estimation include; mothers’ age (years), educational level, marital status, ethnicity, occupational status, religion, place of residence, sex of the child, age of the child (in months), and complementary feeding practices.

Out of the 422 participants, the majority of them 343 (81.0%) had good dietary practices. The prevalence of MDD among the children was 17.1%. On the other hand, educational level [aOR = 3.16 (95% CI: 0.75–13.29), p = 0.001] and ethnicity [aOR = 24.72 (1.43–15.64), p = 0.011] were statistically associated with children’s high MDD.

The study concludes that while MDD was low among the children studied, breastfeeding was common but gaps existed in providing essential food groups, with significant influences from maternal education and ethnicity. The study highlights the need for targeted interventions to enhance dietary practices for children aged 6–23 months. Specifically, the study emphasized scaling up comprehensive public awareness campaigns to raise awareness about the importance of dietary diversity for child health and development.

The golden period in the first 1000 days of life is between the ages of 6–23 months [1] This period is referred to as a critical window because it promotes the optimal growth and development of the child [2]. However, the nutritional status of children in this critical period is strongly influenced by their feeding patterns, which in turn has an impact on their survival [3]. The World Health Organization (WHO) has developed recommendations for Infant and Young Child Feeding (IYCF) practices for children aged 6–23 months, including Minimum Dietary Diversity (MDD) as one of the seventeen indicators [4]. According to the revised WHO/UNICEF 2021 guidelines, to achieve minimum dietary diversity, children must have consumed foods and beverages from at least 5 out of 8 of the food groups during the previous day. These eight food groups include: breast milk, grains, roots, tubers and plantains, pulses (beans, peas, lentils), nuts and seeds, dairy products (milk, infant formula, yogurt, cheese), flesh foods (meat, fish, poultry, organ meats), eggs, vitamin-A rich fruits and vegetables and other fruits and vegetables [4].

Globally, only a few children receive nutritionally appropriate and diversified diets. In many countries, fewer than one-fourth of infants aged 6–23 months meet the nutritional diversity and feeding frequency standards [5]. Inappropriate supplementary feeding techniques put children under the age of two in danger of malnutrition, illness, and death [6]. It is noteworthy that achieving MDD plays a pivotal role in the attainment of Sustainable Development Goals (SDG) (2, 3, and 4, 7). However, the double burden of malnutrition as demonstrated by nutritional deficiencies (related to higher risk of infectious diseases) and overweight/obesity (associated with increased risk for non-communicable diseases) has been a stumbling block to meeting these goals [7, 8].

Research has shown that children who do not meet the MDD in their regular diets face a heightened risk of stunting, being underweight, anemia, increased susceptibility to infections, and severe illnesses [9]. To counter this, a study has established that the nutritional status of children can be enhanced by consuming a diverse range of foods in accordance with WHO recommendations [10]. However, only one in four children aged 6–23 months in low- and middle-income countries meet the WHO guidelines for MDD [11].

Achieving MDD for children under five in sub-Saharan Africa (SSA) remains a significant challenge, primarily due to widespread poverty [11]. A study conducted in Ghana found that only 35.3% of children aged 6–23 months met MDD [12]. While poverty plays a central role in achieving MDD, it is crucial to explore other contextual factors that contribute to this menace in order to streamline appropriate and context specific interventions. Several studies across different regions have identified factors influencing MDD, including maternal education [13, 14], the age of the child in months [15,16,17], child’s sex [18], mothers’ socioeconomic status [13, 19] mothers’ education status [20, 21], and place of residence [22]. Despite these findings, there is limited evidence specific to the Volta Region of Ghana. This study sought to address this gap by assessing MDD and its associated factors among children aged 6–23 months in the Hohoe Municipality of the Volta Region, Ghana.

The aim of the study was to assess MDD and its associated factors among children aged 6–23 months. A health facility-based cross-sectional study was carried out from April to July 2021. The study was conducted in the Hohoe Municipality of the Volta Region, Ghana. The Municipality is one of the twenty-six [26] districts in the Volta Region. The city of Hohoe, of which the district was named, serves as the capital and the administrative or local government center. The study was conducted in the Hohoe Municipal Hospital now the Volta Regional Hospital and the Lolobi Health Center at the Maternal and Child Health (MCH) clinic, specifically the Postnatal Care (PNC) Unit.

The source populations included all mothers of children aged 6–23 months who were residents of the Hohoe Municipality and had come for immunization (Expanded Program on Immunization-EPI) at the Maternal and Child Health (MCH) clinic, at the major health facilities of the two sub-districts randomly selected. Sampled mothers of children between the ages of 6–23 months, who met the inclusion criteria constituted the study population of the study.

Mothers with children aged 6–23 months who were residents of the Hohoe municipality and had given their informed consent to participate in the study were included. Additionally, the mothers should come for EPI at the MCH to be recruited to participate. However, non-resident mothers, mothers seriously ill on the day of data collection, and non-consenting mothers were excluded from the study. Mothers who did not come purposely for EPI at the MCH were also excluded.

The sample size for this study was calculated using a single proportion population formula by Cochran (Eq. 1), (1997);

Parameters in the formula include;

n = Sample size to be determined

z = Z-score (95% confidence interval)

P = a proportion of 50% was used because no previous study had been conducted in the study area to provide an informed estimate.

d = precision or margin of error (0.05)

The reliability coefficient used was 1.96 since the confidence interval is 95%.

Hence, sample size, 𝑛 = 384.16. Adjusting for an anticipated 10% non-response rate, an approximate minimum total of 422 mothers who met the inclusion criteria were included in this study.

A multistage sampling technique was used to select the participants for the study. The first stage employed a simple random sampling to select two (2) sub-districts from the seven (7) sub-districts in the Hohoe municipality (Lottery method). From the two sub-districts (Hohoe-sub and Lolobi) randomly selected, data was collected at their various major health facilities (Hohoe Municipal Hospital now the Volta Regional Hospital and Lolobi Health Center). In the second stage, for each health facility, the sample size was allocated proportionally to the total number of children aged 6–23 months who came for immunization at the MCH clinic; during the period from 2nd April to 24th July 2021. Finally, mothers who met the inclusion were randomly selected until the whole sample size was exhausted.

Data were collected with a paper-based questionnaire by using a 24-hour recall method. This allowed the mothers to recall the type of food items they fed their children within the previous 24 h. The questionnaire was designed in the official language (English) but the questions were explained in both English and the local dialects (Ewe, and Akan) without changing the context. This was to give the participants a better understanding. The questionnaire was in sections A, B, C and D. The section A contained items used to collect socio-demographic information of the participants. The section B of the questionnaire included questions that measured participants’ dietary practices. The questions were adopted from the WHO indicators for assessing IYCF practices [4]. Sections C and D assessed the dietary diversity using a 24-hour dietary recall. In determining the overall MDD among the children, children who had eaten from at least 5 food groups of the 8 MDD food groups within the past 24 h were classified as having “high minimum dietary diversity” and children who ate from less than 5 food groups of the 8 MDD food groups were classified to have “low minimum dietary diversity” [23, 24].

Dependent variable

The dependent variable of the current study was MDD. Children were regarded to have met MDD if they obtained at least five food groups from the eight WHO’s standard food categories without a minimum intake limitation during the reference period. On the other hand, children who received less than five food groups from the recommended eight groups of food categories were considered to have not met MDD [4].

Independent variables

Ten (10) independent variables were considered in our estimation. The independent variables of the study included factors such as mothers’ age (years), educational level, marital status, ethnicity, occupational status, religion, place of residence, sex of the child, age of the child (in months), and complementary feeding practices.

The collected data were coded and entered into Epi-Data version 3.1. Data extraction was carried out in an Excel Sheet for cleaning and then later exported into STATA V.16.0 (Stata Corp. 2019. Stata Statistical Software: Release 16. College Station, TX: Stata Corp LLC.) for analysis. To ensure the quality of the data extracted, double entry was done in Epi-Data to address discrepancies which may have occurred during extraction. A confidence interval of 95% was used in Pearson’s Chi-Square test. Normality tests were done to ensure that all the quantitative data were normally distributed. Descriptive statistical analysis, which included frequency, mean, standard deviation (SD) and percentages, was used to characterize the data. Findings were presented in tables and graphs. A bivariate logistic regression analysis was then performed to examine the association between each independent and dependent variable. Variables that showed significant associations based on the assumptions were considered for multivariate logistic regression. Finally, in multivariate logistic regression, significant variables were identified at a p-value < 0.05.

MDD was calculated using the WHO/UNICEF formulae (Eq. 2);

In determining the overall MDD among the children, children who had eaten from at least 5 food groups of the 8 MDD food groups within the past 24 h were classified as having “high minimum dietary diversity” and children who ate from less than 5 food groups of the 8 MDD food groups were classified to have “low minimum dietary diversity” [23, 24].

The overall complementary feeding practices was categorized into three groups: thus “poor complementary feeding practices”, “average complementary feeding practices”, and “good complementary feeding practices”. These categories were determined based on the summation of the responses to the questions; “have you introduced any food part from breast milk to your child?”, “is your still child breastfeeding?”, and “Did your child receive any food apart from milk yesterday?”. The summation of the responses to the question was scored over 3 points. Mothers who scored 1 out of the 3 points were categorized under “poor complementary feeding practices”. Similarly, mothers who scored 2 out of 3 and 3 out of 3 were categorized as “average complementary feeding practices” and “good complementary feeding practices” respectively.

In assessing the socio-demographic information of the respondents, age of mother, age of child, and size of household were collected as continuous variables and categorized into (≤ 24 years, 25–29 years and ≥ 30 years), (6–11 months, 12–17 months, and 18–23 months) and [1,3,4,5,6,7,8,9,10,11,12,13,14,15 and 16,17,18,19,20] respectively. Educational level, marital status, ethnicity, occupational status, religion, place of residence, and sex of current child were collected as categorical variables.

In this study, a total of 422 mothers were interviewed. The ages of the mothers were categorized into mothers aged 24 years and below, 25–29 years, and 30 or more years. Out of the 422 mothers, the majority of them 153 (36.3%) were 30 or more years. A large proportion 177 (41.9%) of them indicated to have had JHS as their highest level of education and most 257 (60.9%) of the mothers belonged to the Ewe ethnic group. A large proportion 272 (64.5%) of the mothers were self-employed and a significant majority 293 (69.4%) were Christians. Furthermore, prominent 322 (76.3%) among them were married. The majority 113 (26.8%) of the mothers were residents of Zongo. In addition to the 422 mothers who participated in the study, the child of each of the mothers was considered in the study. Of these 422 children, 239 (56.6%) were males and 209 (49.5%) of the children were 6–11 months old (Table 1).

The table below presented the type of minimum dietary diversity foods mothers fed their children. To determine the MDD among the children, mothers were asked to briefly recall the eight MDD food groups from which their child had eaten in the past 24 h. The majority 374 (88.6%) of the mothers agreed to have given their children breastmilk in the last 24 h against 48 mothers (11.4%) who did not. It was reported that 295 (69.9%) of the mothers did not give their children an egg in the previous 24 h. A large proportion 250 (59.2%) of the respondents gave their children either grain, root or tubers in the last 24 h. Mothers who indicated to have given their children legumes and nuts were about 94 (22.3%) and a comparative majority of them gave their children flesh food thus; 267 (63.3%). Predominant among the mothers indicated to have not given their children any dairy product, vitamin-A-rich fruits or vegetables, and any other fruit or vegetable thus 339 (80.3%), 387 (91.7%), and 274 (64.9%) respectively (Table 2).

The prevalence of MDD in children was calculated using the formulae;

Thus: Prevalence of MDD (Eq. 2) \(\frac{72}{422} \times 100\%\) [4].

Of the 422 children, 72 (17.1%) of them had “high minimum dietary diversity” as compared to the 350 (82.9%) others who had “low minimum dietary diversity score”.

Therefore, the prevalence of MDD among children aged 6–23 months was 17.1% (see Fig. 1).

Minimum dietary diversity among children 6-23 months

Full size image

Regarding the dietary practices of the mothers as presented in Table 3 below, they were assessed based on a series of questions asked. Of all the 422 mothers, more than ninety per cent 410 (97.2%) of them agreed to have introduced other foods apart from breastmilk to the child whereas almost all 421 (99.76%) of them indicated to have started this practice when the child was 6-11months old. The majority 377 (89.3%) of the mothers said they still breastfeed their children and almost all 387 (91.71%) of them said they will stop breastfeeding their children when they are 18–23 months old. The most common complementary food introduced by the mothers was porridge 275 (65.2%) and a large portion 303 (71.8%) of them indicated they introduced complementary foods because their child was 6 months old. Furthermore, mothers who agreed to have given their children any food apart from breastmilk the previous day were 391 (92.7%).

The figure below shows the overall complementary feeding practices of the respondents. Among the 422 mothers, 9 (2.0%) of the mothers had poor complementary feeding practices, 70 (17.7%) had average complementary feeding practices and the majority 343 (80.3%) had good complementary feeding practices (see Fig. 2).

Complementary feeding practices among mothers

Full size image

In the pursuit of promoting optimal maternal and child health, our study not only delves into the dietary practices of mothers but also identifies noteworthy best practices that emerged from our findings. By spotlighting these practices, we aim to provide valuable insights for caregivers, health professionals, and policymakers.

A key finding of our study emphasized the importance of introducing complementary foods gradually. From our study, a large proportion of mothers (71.8%) initiated complementary feeding when their child reached 6 months. Emphasizing the importance of timely initiation aligns with established guidelines promoting the introduction of complementary foods alongside continued breastfeeding at this stage. Based on the experiences of the majority of participating mothers, initiating this practice between the 6th and 11th months proved prevalent. This approach aligns with global recommendations for optimal infant nutrition [25]. The study also highlighted the majority of mothers (89.3%) who continue breastfeeding. This practice aligns with established health guidelines advocating for sustained breastfeeding [26].

Low-cost recipes that emerged from the study included local grains, local vegetables, legumes and nuts. Mothers with poor economic backgrounds can leverage these recipes to provide diversified diets for their children.

In an association test using Pearson’s Chi-square, the educational level of mothers, their ethnicity, their occupation and their complementary feeding practices were found to be significantly associated with children’s MDD with χ2/p-value of 14.0396/0.007, 14.7567/0.005, 7.5546/0.050 and 0.1753/0.006 respectively.

Furthermore, a bivariate analysis using logistic regression was performed. It was found that there was a significant association between the educational level of mothers and MDD among children [cOR = 3.12 (95% CI: 1.57–6.19), p = 0.001]. However, when other characteristics were adjusted for in a multivariate analysis, it was further revealed that children whose mothers had obtained tertiary education were 3 times more likely to have acquired a high MDD thus consuming 4 or more food items from the 7 MDD food groups compared to the children of mothers with a low level of education [aOR = 3.16 (95% CI: 0.75–13.29), p = 0.001]. The study also found a significant association between Ethnicity and MDD [cOR = 4.69 (95% CI: 1.55–14.19), p = 0.006]. The odds of a child whose mother belongs to another ethnic groups (Krobo, Kusasi) obtaining a high MDD was 25 times more likely compared to mothers that belong to Ewe, Akan, Guan or Ga-Adamgbe ethnic groups [aOR = 24.72 (1.43–15.64), p = 0.011].

Similarly, mothers’ occupations were also significantly associated with their child’s MDD. The probability of a child obtaining a high MDD by mothers who were government-employed was 2 times more likely as compared to mothers who are not government workers [cOR = 2.18 (95% CI: 1.15–4.11), p = 0.017]. However, after adjusting for all other characteristics in a multivariate regression, mothers’ occupation was no more significantly associated with high MDD. Furthermore, children whose mothers scored average dietary practices [cOR = 0.72 (95% CI: 0.13–3.92), p = 0.008] were significantly less likely to have obtained a high MDD score compared to their counterparts. However, after adjusting for all other co-variates, complementary feeding practices was no longer significantly associated with high MDD (Table 4).

Inappropriate supplementary feeding techniques put children under the age of two in danger of malnutrition, illness, and death [6]. To avert the dire consequences this might have on young children, the WHO has developed recommendations for Infant and Young Child Feeding practices for children aged 6–23 months, including MDD as one of the core indicators [4]. In our study, we assessed the MDD and associated factors among children aged 6–23 months in the Hohoe Municipality, in the Volta Region of Ghana. The finding from the study revealed that only 17.1% (72 children) had achieved minimal dietary diversity within 24 h preceding the study. This proportion contrasts with earlier studies in India and Ethiopia [5, 15, 16, 27], as well as Burkina Faso [28], where higher percentages were reported. However, in comparison to studies in Pakistan [29], India [30], (Sri Lanka, Nepal, and Bangladesh) [16], Ethiopia [5], Nigeria [31], Tanzania [32], and Ghana [12, 33], the current study’s findings indicate a relatively lower prevalence of MDD. The observed variations in MDD rates among children could be attributed to a complex interplay of cultural, socioeconomic, geographical, and healthcare-related factors, as well as differences in data collection methods across the different studies in these regions.

Our study revealed that a substantial majority of mothers, specifically 374 (88.6%), reported providing breast milk to their children within the past 24 h. Conversely, the consumption of eggs in the previous 24 h was reported by only 127 (30.1%) mothers. Notably, a significant proportion of 250 (59.2%) mothers offered their children foods such as grains, roots, or tubers within the same timeframe. In comparison, a study carried out in Ethiopia documented a comparatively elevated percentage [34]. The difference in feeding practices among mothers can be attributed to a combination of cultural, economic, knowledge-based, and contextual factors that could plausibly shape dietary choices for their children contributing to the observed variations in these populations.

The study also reported a low consumption of Vitamin-A-rich vegetables and fruits 387 (91.7%) among children aged 6–23 months. This could potentially be attributed to the prohibitively high cost, rendering them inaccessible to individuals residing in economically challenged households in Ghana. Additionally, caregivers might lack the necessary knowledge to effectively incorporate these essential dietary components into meals, highlighting the need for educational interventions, as emphasized in a study by [35]. When contrasted with earlier studies conducted in Central America [36], Uttar Pradesh [37], Ethiopia [38], and Ghana [33], the pattern of diminished consumption of vegetables and fruits remained consistent.

An additional finding from this study revealed that a substantial majority 343 (80.3%) of mothers exhibited a good dietary practice for their children. In comparison to earlier research, this particular finding outperformed the results of a study conducted in Ethiopia [34]. The disparity observed between the two different regions can be attributed to cultural and dietary distinctions, varying economic conditions, differences in nutritional awareness and education, government policies, food availability, sample characteristics, as well as methodological variations.

According to our study, the educational level of mothers had a significant association with MDD in children [aOR = 3.16 (95% CI: 0.75–13.29), p = 0.001]. This aligns with similar findings from research conducted in Uttar Pradesh [37], Nepal [39], Sri Lanka [40], and Ethiopia [5, 16]. This correlation can be explained by the fact that mothers with higher education levels often have better access to information about nutrition and child care, enabling them to make informed decisions about their children’s diets [41]. Additionally, higher education may enhance mothers’ ability to understand the nutritional needs of their infants and incorporate a wider variety of foods into their diets. Educated mothers are more likely to engage in health-seeking behaviors and adhere to recommended feeding practices, contributing to the observed positive outcomes in MDD [42]. The consistency of these findings across the different regions and cultures underscores the universal importance of maternal education in fostering optimal infant feeding practices and ultimately promoting child health and development.

Furthermore, our study found a correlation between ethnicity and high MDD [aOR = 24.72 (1.43–15.64), p = 0.011]. This finding aligns with a prior study conducted in Nepal, which demonstrated that children from (Dalit and Janajati) ethnic groups had a higher odds ratio of not meeting the MDD compared to those from the (Brahmin/Chhetri) ethnic group [43]. Similarly, another study in Nepal indicated that children from the (Brahmin/Chhetri) ethnic group were more likely to receive a variety of food groups compared to those from other caste/ethnic groups [39]. The reason for this correlation across these studies can be attributed to the distinct cultural and dietary practices among these ethnic groups, varying levels of access to nutritional resources, traditional knowledge of locally available nutritious foods, socioeconomic influences, differences in healthcare access and education, geographical availability of diverse foods, as well as the impact of public health interventions.

The Krobo and Kusasi ethnic groups in Ghana exhibit unique dietary practices rooted in their cultural and agricultural traditions, which contribute to their higher MDD. The Krobo people, primarily residing in the Eastern Region of Ghana, consume diverse diets that often include akple with nutrient-rich okra stew, kontomire stew made with cocoyam leaves and groundnuts, and yam or plantains paired with garden egg stew [44]. These dishes incorporate multiple food groups, including vegetables, legumes, and animal proteins. Similarly, the Kusasi people in the Upper East Region rely on locally available grains and legumes, featuring meals such as tuo zaafi served with green leafy soups like ayoyo or baobab leaves, zeem (a millet or sorghum porridge enriched with groundnuts or dairy), and bean or cowpea-based dishes. These diets are further enriched with occasional animal protein, such as goat or guinea fowl. Both groups benefit from agricultural practices that provide access to a variety of locally grown food items, cultural emphasis on diverse meals, and seasonal availability of indigenous crops, ensuring year-round nutritional balance. These factors collectively explain the higher dietary diversity observed among these ethnic groups as compared to the other ethnic groups on Ghana.

In conclusion, the study revealed that a minor proportion of children attained MDD in the last 24 h, indicating a relatively lower occurrence compared to certain other geographic areas. A significant majority of mothers in the current study demonstrated commendable dietary practices for their children. While breastfeeding was widespread, there were notable deficiencies in providing other essential food groups like eggs, vegetables, and fruits. Importantly, the educational background and ethnicity of mothers emerged as influential factors affecting children’s MDD.

The current study highlights the need for the integration of nutrition counselling and guidance within routine antenatal (ANC) and postnatal (PNC) care visits. This approach will ensure that mothers receive timely and accurate information on optimal feeding practices, starting from pregnancy through the early childhood years. The strong association between maternal education, ethnicity and children’s dietary diversity highlights the need for educational interventions targeting mothers, especially those with lower levels of education as well as culturally sensitive interventions. Comprehensive public awareness campaigns can raise awareness about the importance of dietary diversity for child health and development. These campaigns can leverage various communication channels, including mass media, social media, community events, and local networks, to reach caregivers and influence positive behavior change. These interventions can be integrated into existing maternal and child health services to reach a wider audience. The implications drawn from this study emphasize the need for multisectoral and context-specific approaches to improve infant and young child feeding practices. By addressing them we can work together to promote optimal nutrition for children aged 6–23 months, contributing to better health outcomes and overall well-being.

The strength of the study lies in the utilization of standardized data collection tool and the rigorous statistical analysis employed in the study. However, the study identified some limitations which must be acknowledged. The study’s reliance on maternal recall of dietary practices over the past 24 h introduces potential recall bias, as memory may not accurately capture all details, leading to underreporting or overestimation of certain food groups. Additionally, respondents may have provided answers that they perceived as socially desirable, potentially leading to an overestimation of positive feeding practices. Despite multivariate regression analysis, there may be unmeasured confounding factors not accounted for in the study that could influence the observed associations.

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PSA and SS conceived and designed the study. SS drafted the manuscript. Both authors read and approved the final manuscript.

Correspondence to Samuel Salu.

All methods were in accordance with the Declaration of Helsinki. The University of Health and Allied Sciences Research Ethics Committee (UHAS-REC) reviewed the study and approved it with a reference [ID:UHAS-REC A.12 [112] 20–21]. Permission was also obtained from the Hohoe Municipal Health Directorate before the commencement of the study. During data collection, permission was also sought from all the in-charges of the facilities where data was collected. The study did not directly involve the children therefore, written informed consent was obtained from all mothers before the administration of the questionnaire.

The authors declare no competing interests.

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