Study design and setting
This cross-sectional study was conducted from December 2018 to July 2019 in the Nanumba South district of the Northern Region of Ghana. The Nanumba South District is located about 211km Southeast of the Northern Regional Capital, Tamale. The district lies within Latitudes 8.50 and 9.00 North and longitudes 0.5o east and 0.5o West of the Greenwich Meridian. It has Wulensi as the administrative capital. According to the 2010 Ghana Population and Housing census, the district has a total population of 114,173 inhabitants at an annual growth rate of 2.9%. The sub-categorical operational populations for 2017 were 4,567 for children aged 0-11 months; 4,567 for children aged 12-23 months; and 13,472 for children aged 24-59 months. The district has four (4) health centres and eleven (11) functional Community-Based Health Planning and Services (CHPS) compounds across all of its four sub-districts to cater for the health needs of the people living in 137 communities. The average distance to a health facility in the district is about 8km. Antenatal and child welfare services are organized across 128 static and outreach points where GMP services are provided.
Study participants, sample size determination and recruitment procedures
The participants of this study were mothers with their children aged 0-59 months attending monthly child welfare clinics at all the four health centres and one CHPS zone selected from each of the sub-district by way of the lottery method. Using Cochran’s formula n = Z2pq /e2 where n is the sample size, e is the desired level of precision (margin of error), p is the (estimated) proportion of the population which has the attribute in question (GMP utilization rate) or the degree of variability, q is 1-p and Z is the abscissa of the normal curve that cuts off an area at the tails, a sample size of 405 was obtained. A 5% non-response rate was computed to yield a final sample size of 425. Using data from the child welfare attendance in the selected health facilities, proportionate random sampling was done to obtain the 425 mother-child participants for the study. Participants were recruited at the health facility level during monthly GMP sessions until the quota allocated for the facility was met. Before commencing data collection, written permission was obtained from the health authority at the district, sub-district and facility levels. Each time, a selected health facility was visited, the study rationale and procedure were explained to all clients who attended the welfare clinics and only those who agreed and provided informed consent were included into the study. Voluntary participation was encouraged throughout the study. Each participant was free to decline at any point of the study without condition. Access and provision of child welfare services to those who agreed to participate in our study as well as those who declined was without any discrimination. Ethical approval was granted by the Ethical Review Committee of the Tamale Teaching Hospital in Ghana.
Data collection methods
A semi-structured questionnaire was used to collect data. The questionnaire consisted of three sections. Section one evaluated the socio-demographic characteristics of both the mother and the child (i.e., child’s age, child’s gender, mothers’ level of education, income level, marital status, employment status). Child’s age was recorded in months and was obtained by recording the date of birth from the Child Welfare Book. Mothers were asked to indicate their current level of formal education received: No formal education, primary, Junior high school, Senior High School, and Tertiary. The age of the mother was assessed asking the question: How old are you? Income level was evaluated by asking mothers to estimate how much they earned monthly. Mothers were asked to indicate whether they were single, married, cohabiting, widowed or divorced. Employment status was assessed by the asking the question: Which of the following sectors are you currently working: Formal sector, private sector, farmer, trader, and housewife. Section two consisted of both closed and open-ended items that assessed mothers’ knowledge regarding: the purpose of GMP, recommended frequency of attendance of GMP sessions and the use and interpretation of growth charts. The items were derived from previous studies. Participants were given a score of 1 for every correct answer. A total score was generated and computed 100%. Section three assessed the level of GMP utilisation by asking the mother and cross-checking in the child health record book the number of times mothers visited the GMP sessions with their children, and the number of times they missed GMP sessions. Utilization was then determined by the number of visits to the GMP session as per the recommendation in the Child Health Record booklet, which requires monthly visits from aged 0 to 23 months, and a visit at every four months from aged 24 to 59 months (Ghana Health Service, n.d.). To ensure comprehensibility, the questionnaire was pretested among 20 participants selected from a non-participating community within the area having similar characteristics. This allowed for further clarification and modification of some of the items of the question. In addition, the questionnaire was evaluated for content validity by a team of nutritionists, behavioural sciences and public health specialists. Since most of the participants could not read nor write in English, participants were interviewed in their local dialect where necessary. All participants were interviewed in privacy in a secluded area of the facility to ensure confidentiality. All methods were carried out in accordance with relevant guidelines and regulations.
Statistical analysis
Data was entered onto Microsoft Excel 2010 and analysed using the Statistical Package for the Social Sciences (SPSS) software, version 20. Descriptive statistics of mean and standard deviation was used to describe continuous variables whilst frequencies and percentages were used to describe categorical variables and presented as frequencies and charts. Following the Food and Agriculture Organisation nutrition-related knowledge thresholds for a nutrition intervention in which a knowledge score ≤ 70 % shows an urgent need for a nutrition intervention, all mothers who scored > 70 % in the knowledge test were classified as having high level of knowledge and those scoring ≤ 70 % were classified as having a low level of knowledge [15, 16]. Quotes from open-ended knowledge questions were used to support the correct answers provided by the mothers. Chi-square test and Fisher’s exact test were used to determine the association among categorical variables where appropriate (i.e., utilisation of GMP with socio-demographic characteristics and levels of knowledge). To identify factors associated with the utilisation of GMP, multivariate logistic regression (a priori selection) was conducted. For the purposes of the analysis the age of the children was categorised into 0-11 months, 12-23 months and 24 – 59 months; monthly income levels. Level of education was categorised into no formal education, low and high levels of education in which senior high school and tertiary levels of education were combined to yield “High level of education” and Primary and Junior High School levels were combined to yield “Low level of education “. Mothers/care givers’ age was categorised into: < 30 years and ≥ 30 years. Based a median income level of GHC 60, mother’s monthly income level was placed into two categories: ≤ GHC60 (US$ 11) and > GHC 60. Regarding employment status, responses to formal sector, private sector, traders and farmers were categorised into ‘employed’ and those who reported as being housewives was categorised into ‘unemployed’. A p-value of less than 0.05 was considered significant in all comparative analysis.