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Dietary Knowledge, Complementary Feeding Practices and Nutrition
Status of Children 6–23 Months Old in Siaya County, Kenya
Ayoma Kambona Oscar
1*
, Moses Mogesi
1
, Peter Chege
2
1
Department of Human Nutrition and Dietetics, Kabarak University
2
Department of Food, Nutrition and Dietetics, School of Health Sciences, Kenyatta University
*Corresponding Author
DOI: https://dx.doi.org/10.51244/IJRSI.2025.1210000165
Received: 12 October 2025; Accepted: 20 October 2025; Published: 13 November 2025
ABSTRACT
Malnutrition remains a critical public health challenge in Kenya, particularly among children aged 6–23 months
during the complementary feeding period. Siaya County reports stunting rates (19.2%) exceeding the national
average (18.2%), with Alego Usonga Sub-County contributing 42% of the total county malnutrition cases,
indicating urgent need for evidence-based interventions. The aim of the study was to assess dietary knowledge,
complementary feeding practices, and nutritional status among children aged 6-23 months in Siaya County,
Kenya. Three specific objectives target caregiver knowledge assessment, practice determination, and nutritional
status evaluation with associated predictors. An explanatory sequential mixed-methods design was employed,
collecting cross-sectional data from 282 caregiver-child pairs through semi-structured questionnaires and focus
group discussions. Anthropometric measurements were analyzed using ENA for SMART (2015) software and
compared against WHO growth standards. Statistical analysis was conducted using SPSS Version 26, with chi-
square tests examining associations and logistic regression identifying predictors at p<0.05 significance level.
The study found that while 70.2% of caregivers initiated complementary foods at the recommended age (6-8
months), significant practice gaps persisted: only 36.5% achieved minimum dietary diversity (MDD), 5.0 % met
minimum meal frequency (MMF), and 4.6% achieved minimum acceptable diet (MAD). Malnutrition
prevalence included stunting (29.08%), underweight (13.1%), and wasting (4.96%). Girls experienced
significantly higher stunting rates than boys (36.55% vs 21.17%, p<0.05). Maternal education level showed
significant association with MDD achievement (p=0.03), while male sex significantly increased odds of wasting
(OR=13.4, p=0.013) and stunting (OR=2.15, p=0.005). Early solid food introduction at 4-6 months substantially
increased stunting risk (OR=2.42-4.66, p<0.05). Despite adequate knowledge of feeding timing, caregivers
demonstrated poor implementation of dietary diversity and meal frequency practices. Interventions on
complementary feeding need to prioritize maternal education, address gender-specific feeding vulnerabilities,
and strengthen community-based nutrition programs.
Keywords: Complementary feeding; Malnutrition; Dietary diversity; Nutritional status; Children 6-23 months;
Stunting; Predictors.
INTRODUCTION
Malnutrition among children aged 6–23 months represents a critical global health challenge, with approximately
22.3% of children under five having stunted growth worldwide (WHO, 2021). Sub-Saharan Africa bears a
disproportionate burden, contributing 43% of global malnutrition cases (Bain et a., 2013). In Kenya, while some
progress has been made with national stunting rates at 18.2% regional disparities persist, particularly in Siaya
County where stunting rates reach 19.2% (KNBS & ICF, 2023).
The 6–23-month period represents a critical window for child development, coinciding with the introduction of
complementary foods alongside continued breastfeeding (PAHO, 2020). This transition period markedly impacts
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long-term health outcomes, with inappropriate feeding practices contributing to growth faltering, developmental
delays, and increased mortality risk (Stein et al., 2020; Victora et al., 2021)
Current evidence reveals substantial gaps in optimal complementary feeding practices globally. Worldwide,
approximately half of all children are not provided the minimum meal frequency(Tebeje et al., 2024) , 29.4%
achieve minimum dietary diversity, and just 16% receive a minimum acceptable diet (World Health
Organization, 2021). These challenges are particularly pronounced in Eastern and Southern Africa, where dietary
diversity remains critically low, with only 21% of children achieving minimum standards (Victora et al., 2021).
Kenya's situation reflects both progress and persistent challenges. The country outperforms regional averages in
continued breastfeeding (75%) and timely food introduction (80%), with better MDD (36%) and MAD (22%)
rates than neighboring countries (UNICEF, 2020). However, half of Kenyan children still fail to meet MMF
standards, and 29% consume no vegetables or fruits (UNICEF, 2020).. These disparities are particularly
concerning in high-burden areas like Siaya County, which reports higher stunting (19% against national 18%)
and alarming malnutrition concentrations (with 42% reporting from Alego Usonga of all malnutrition cases in
Siaya County) (KNBS & ICF, 2023).
Evidence shows that caregiver knowledge significantly influences feeding practices Abeshu et al. (2022), yet
the relationship between knowledge, actual practices, and nutritional outcomes remains unclear. While
nutritional awareness is important, socio-economic factors, including household income, food insecurity, and
cultural and traditional beliefs for instance gendered feeding practices, often determine feeding behaviors more
than knowledge alone (Anyati et al., 2025; Cheruiyot, 2024; Khamis et al., 2019; Semahegn et al., 2014). For
instance, in rural Kenya, only 34% of caregivers with high knowledge adhered to dietary diversity guidelines
due to economic constraints (Kimani-Murage et al., 2021).
MATERIALS AND METHODS
Study Design
This study applied the explanatory sequential mixed-methods design..
Study Area
The study was conducted in Siaya County, Western Kenya, bordering Lake Victoria. The study was specifically
conducted in two Community Health Units (CHUs) - Hono and Bar Agulu in Alego Usonga Sub-County. Alego
Usonga Sub-County was purposively selected due to its high malnutrition burden, accounting for up to 42% of
all malnutrition cases screened within Siaya County according to the County Department of Health Services
(2023).
Population and Sampling
The study population included caregiver-child pairs with children aged 6-23 months residing in the selected
CHUs, covering 22 villages with 2,773 documented households and serving approximately 20,700 people with
a target group of 435 eligible children (MOH Kenya, DHIS2 2024)
Sample Size
The sample size was determined using Fisher's formula (1998), calculating a minimum required sample of 238
participants based on a stunting prevalence of 19.2% and a 95% confidence level. To account for potential non-
response and incomplete data, an adjustment factor of 18.8% was applied, resulting in a final sample size of 282
participants. This specific non-response rate was derived from study-specific considerations, including the
sensitivity of topics related to infant feeding practices and nutritional assessment, anticipated participant attrition
during multi-stage data collection (dietary recall, anthropometric measurements, and knowledge assessments),
and historical non-response patterns observed in similar community-based nutritional surveys conducted in
comparable settings (Emon, 2024).
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Inclusion and Exclusion criteria
Primary caregivers of children aged 6-23 months providing written informed consent were included in the study.
Children with developmental delays or disabilities, caregivers who declined consent, and children with medical
conditions requiring specialized nutritional management were excluded from the study.
Study variables
The primary variables included dietary knowledge across four WHO domains: (1) minimum dietary diversity,
(2) minimum meal frequency, (3) minimum acceptable diet, and (4) consumption of iron-rich or iron-fortified
foods, in complementary feeding practices, and nutritional status using WHO growth standards. Secondary
variables included demographic and socioeconomic factors.
Data Collection Tools and Procedures
Quantitative data was collected using KoBoCollect/Toolbox (2023). [Cited: 21 October 2025].
https://www.kobotoolbox.org/ on Android tablets with pre-tested semi-structured questionnaires capturing
demographic, socioeconomic, feeding practices, and caregiver knowledge data. Anthropometric measurements
were taken using SECA 334 digital scales, length mats, and WHO-standardized MUAC tapes. Qualitative data
was collected through focus group discussions with 8-12 participants using WHO-aligned guides until thematic
saturation (Guest et al., 2006) .
Definition of terms
Dietary knowledge defined as understanding of food variety and their importance and timely introduction of
complementary feeding.
Complementary feeding defined as Giving foods to children 6-23 months old to complement breast-milk when
it is unable to supply the child’s essential nourishment anymore.
Minimum Acceptable Diet- children 6-23 months old who attained both the MDD and MMF through
consumption of five or more food groups used in this study.
Minimum meal frequency proportion of children aged 6-23 months who received the minimum number of
daily meals
Minimum diet diversity: Children aged 6-23 months who ate a diverse diet from 5 or more of the identified
food groups.
Nutrition status- the state of children’s health determined by nutrients intakes.
RESULTS
Demographics and socio-economics characteristics
The study encompassed 282 caregiver-child pairs, with biological mothers constituting the overwhelming
majority of primary caregivers at 92.55%, while biological fathers and other relatives or grandparents
represented 2.84% and 4.61% respectively. The child population showed balanced gender distribution with
51.42% female and 48.58% male participants, though age distribution favored older children, with 54.96% aged
13-23 months compared to 45.0% aged 6-12 months. (Table 1).
Caregiver demographics revealed a predominantly young population, with nearly 39.7% aged 14-24 years
representing the largest cohort. The majority of the respondents were married (78.0%) On educational attainment
42.9% had secondary education, 42.2% had primary education (, while vocational training, university degrees,
and no formal education were 11.0%, 2.1%, and 1.8% respectively. In Occupations, 27.0%, were waged laborers,
while were (25.2% were housewives,20.2% were unemployed. (Petty traders and agricultural; laborers were
18.8%, and 8.9% respectively.
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Table 1: Demographic and Socioeconomic Characteristics of Caregivers (n=282)
Characteristic
Category
Frequency (n)
Percent (%)
Relationship to Child
Biological mother
261
92.6
Biological father
8
2.8
Others (relatives, Grandparents)
13
4.6
Child’s Gender
Male
137
48.6
Female
145
51.4
Age Distribution (Child)
6-12 months
127
45.0
13-23
155
55.0
Marital Status
Married
220
78.0
Single
62
22.0
Age Distribution (caregiver)
14-24 years
112
39.7
25-30 years
91
32.3
31-70 years
79
28.0
Occupation
Agricultural labour
25
8.9
Housewife
71
25.2
Waged labour
76
27.0
Petty trade
53
18.8
Unemployed
57
20.2
Education Level
No education
5
1.78
Primary school
119
42.2
Secondary school
121
42.9
University degree
6
2.1
Vocational college
31
11.0
Dietary Knowledge
This dietary knowledge assessment reveals a complex knowledge profile with distinct strengths and weaknesses
among participants. The study found that most of the respondents had a high knowledge on l hygiene and feeding
practices, with over 90% correctly identifying basic food safety protocols like handwashing, appropriate food
types such as fruits and vegetables, and the mother's primary feeding role. Knowledge of continued breastfeeding
recommendations was high (84%),
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However, caregivers show more moderate competencies in areas requiring practical application (58%). While
most understand protein introduction timing and food variety importance, fewer grasp how caregiver preferences
and economic constraints create real-world feeding barriers. Most concerning in this study are the knowledge
gaps in culturally-sensitive areas, where only 67% understand traditional beliefs' influence on feeding practices
and just 57% knew appropriate family pot feeding timing. This pattern suggests participants possess strong
theoretical foundations but struggle with contextual integration, indicating that nutrition education programs
may need better cultural adaptation and practical implementation guidelines.
Knowledge assessment using Bloom’s Taxonomy
Very High knowledge
High knowledge
Moderate knowledge
Figure 1: Knowledge Assessment based on Bloom's Taxonomy,
Complementary Feeding Practices
This study reveals a gap between the timely initiation of complementary feeding and its nutritional adequacy.
While 70.2% of the children were introduced to complementary foods at 6-8 months and 77.3% continued
breastfeeding-the quality and frequency of meals are deficient. Only 5% of children received the minimum
number of daily meals (MMF), and 36.5% consumed a minimum diverse diet (MDD) from five or more food
groups. On the other hand, only 4.6% achieved a minimum acceptable diet (MAD).
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Figure 2: Compliance gaps with feeding frequency and acceptable diet standards
Food consumption pattern: 24-hour recall
Dietary patterns were heavily reliant on staples like grains (93.3%), with critically low consumption of nutrient-
rich eggs (36.5%) and dairy (10.6%). This demonstrates that while caregivers understand when to start feeding,
profound challenges exist in providing frequent, diverse, and nutrient-dense meals, explaining the high rates of
malnutrition in this population.
Food consumption pattern: 24-hour recall
Figure 3: Food consumption pattern: 24-hour recall
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Nutritional Status by Child Sex.
The data revealed a significant gender disparity in nutritional status, with female children experiencing
substantially higher rates of malnutrition across all measured indicators. Female children showed higher stunting
rates, with 36.56% affected (8.28% severe, 28.28% moderate) compared to 21.17% of males (3.65% severe,
17.52% moderate). Wasting patterns had similar trends, affecting 8.97% of females versus only 0.73% of males.
Underweight prevalence shows the most pronounced disparity, with 21.38% of female children affected
compared to just 4.38% of males. All differences achieve statistical significance (p<0.05), indicating systematic
gender-based nutritional inequities rather than random variation. These findings suggest possible differential
feeding practices, resource allocation, or care-seeking behaviors that systematically disadvantage female
children, highlighting the need for gender-sensitive nutritional interventions.
Table 2: Nutritional Status by Child Sex.
Stunting Status (%)
Wasting Status (%)
Underweight Status (%)
Severe
Moderate
Normal
Severe
Moderate
Normal
Severe
Moderate
Normal
8.28
28.28
63.45
3.45
5.52
91.03
0
21.38
78.62
3.65
17.52
78.83
0
0.73
99.27
0
4.38
94.89
0.015
0.004
<0.001
Associations Knowledge-Practice Relationships with Dietary Diversity Outcomes
The statistical analyses reveal critical determinants of child feeding practices and nutritional outcomes with clear
socioeconomic patterns. Caregiver education exhibits a striking dose-response relationship with minimum
dietary diversity (MDD) compliance, ranging from 20% among mothers with no formal education to 100%
among university graduates (p=0.03). This educational gradient is reinforced by significant associations between
food knowledge/preferences and MDD (p=0.03), while strong adherence to traditional beliefs negatively impacts
dietary diversity (p=0.018). Food affordability preferences significantly influence both MDD (p=0.038) and
minimum acceptable diet (MAD) (p=0.04), indicating that informed economic choices can lead to better
nutritional outcomes. Feeding frequency patterns demonstrate measurable impacts on nutritional status, with
higher meal frequency reducing wasting risk (p=0.048) and increased milk feeding frequency lowering stunting
(p=0.022) and underweight rates (p=0.031). Psycho-social factors emerge as the most significant predictor of
dietary diversity (p=0.006), while demographic factors showed no significant associations with feeding
outcomes.
Table 3: Associations Knowledge-Practice Relationships with Dietary Diversity Outcomes
Variable
Outcome Measure
p-value
Effect Size
(OR/β)
95% CI
Associations with
Dietary Diversity
Caregiver education
MDD
0.03
1.45
(1.04-2.03)
Food knowledge/preferences
MDD
0.03
1.38
(1.03-1.85)
Traditional beliefs impact
MDD
0.018
0.72
(0.55-0.94)
Food affordability preferences
MDD
0.038
1.32
(1.02-1.71)
Food affordability preferences
MAD
0.04
1.29
(1.01-1.65)
Psychosocial factors
MDD
0.006
1.58
(1.14-2.19)
Feeding Practices
and Nutritional
Status
Meal frequency
Wasting
0.048
0.78
(0.61-0.99)
Milk feeding frequency
Stunting
0.022
0.65
(0.45-0.94)
Milk feeding frequency
Underweight
0.031
0.71
(0.52-0.97)
Caregivers’
Education and
MDD Compliance
Education Level
MDD Compliance Rate
p-value
University degree
100.00%
0.030
Secondary school
65.29%
Primary school
63.03%
No education
20.00%
MDD: Minimum Meal Diversity
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Multivariable Analysis of Independent Risk Factors for Child Malnutrition
The multivariable analysis reveals complex gender-specific malnutrition patterns and critical timing effects for
complementary feeding (Table 4). Male children demonstrate paradoxical risk profiles. They show protection
against underweight (OR=0.63, 95% CI: 0.43-0.94) but face dramatically elevated wasting risk (OR=13.39, 95%
CI: 1.73-103.83) and more than doubled stunting risk (OR=2.15, 95% CI: 1.26-3.65) compared to females. This
suggests distinct nutritional vulnerabilities by gender requiring targeted interventions. Solid food introduction
timing emerges as a critical determinant of stunting, with delayed introduction showing dose-dependent risk
increases. Children receiving solids at 4-5 months have 2.4 times higher stunting odds (95% CI: 1.17-5.02)
compared to those introduced at 3-4 months, while those starting at 5-6 months face 4.7 times higher risk (95%
CI: 1.93-11.26). Notably, factors previously significant in univariate analyses-including caregiver knowledge,
psychosocial support, water boiling practices, and milk feeding frequency-lost significance in the multivariable
model, indicating that child sex and feeding timing are the primary independent predictors of malnutrition
outcomes.
Table 4: Multivariable Analysis - Predictors of Malnutrition
Factor
Underweight OR (95% CI)
Wasting OR (95% CI)
Stunting OR (95% CI)
Child Sex (Male vs Female)
0.63[0.43-0.94]
13.39 [1.73-103.83]
2.15 [1.26-3.65]
Solid Food Timing
4-5 months vs 3-4 months
1.06 [0.66-1.69]
0.92 [0.32-2.63]
2.42 [1.17-5.02]
5-6 months vs 3-4 months
0.95 [0.55-1.63]
1.18 [0.39-3.58]
4.66 [1.93-11.26]
≥6 months vs 3-4 months
1.61 [0.66-3.91]
1.42 [0.28-7.18]
1.89 [0.72-4.94]
Caregiver Knowledge
0.79 [0.49-1.26]
1.02 [0.42-2.48]
0.85 [0.53-1.37]
Psychosocial Support
0.96 [0.67-1.37]
0.81 [0.42-1.58]
1.12 [0.78-1.60]
DISCUSSION
The findings from this study reflect broader patterns observed across Sub-Saharan Africa, where the persistent
gap between nutritional knowledge and feeding practices continues to undermine child health outcomes despite
significant policy investments (Bolarinwa et al., 2022; Silva et al., 2023). This study's documentation of 95%
non-compliance with minimum meal frequency standards and 95.39% failure to achieve minimum acceptable
diet criteria mirrors regional challenges, where only two of twelve Sub-Saharan African countries with available
data are on track to achieve the 2025 global nutrition target of reducing stunting by 40% (Global Nutrition Report
2022). In Kenya specifically, while impressive gains have been made in exclusive breastfeeding rates, progress
in complementary feeding practices has lagged substantially, as evidenced by national statistics showing 18%
of children under five years remain stunted, (National Bureau of Statistics Nairobi, 2023). The Siaya findings
are particularly concerning when viewed against Kenya's recent progress in reducing acute malnutrition, where
approximately 847,000 children under five faced acute malnutrition in 2024, representing a 14.5% reduction
from 2023 levels (UNICEF Kenya Annual Report, 2024) This improvement in acute conditions makes the
persistent structural barriers to optimal complementary feeding in Siaya even more significant, suggesting that
while emergency interventions may be succeeding, fundamental feeding practice improvements remain difficult
to achieve.
The pronounced gender disparities observed in Siaya County, where female children experienced 36.55%
stunting rates compared to 21.17% in males, alongside 21.38% underweight prevalence versus 4.38% in males,
reflect deeply embedded cultural and structural inequities that extend beyond the immediate study area (Oranga
et,al., 2018; Birhanu et al., 2024). These patterns align with documented gender-based feeding practices across
western Kenya, where research has shown that mothers perceive nutrition problems as embedded within broader
gender and family relations, particularly in contexts of marital conflict, male labor migration, and household
impoverishment (And & Health Transition Review, 1991). The paradoxical finding that male children showed
protection against underweight but increased vulnerability to wasting and stunting suggests complex biological
and cultural interactions that require nuanced understanding ((Thurstans et al., 2022). Recent socioeconomic
disparity analyses from Kenya's demographic and health surveys spanning 2014-2022 have confirmed that
gender continues to play a significant role in child malnutrition patterns, with household income, parental
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education, dietary knowledge levels and access to healthcare creating differential impacts by sex (Sahiledengle
et al., 2023; Sunder Raj & Ahmad Sheikh, 2024).
However, the near-universal reliance on staple grains (93.3%) and critically low consumption of nutrient-rich
foods like eggs (36.5%) and dairy (10.6%) illustrates how economic constraints force families into nutritionally
inadequate dietary patterns. Recent analyses of household behavior and vulnerability to acute malnutrition in
Kenya have confirmed that differential household capacities to adapt to external shocks help explain why some
families remain more vulnerable despite similar knowledge levels, emphasizing that economic resilience rather
than nutritional awareness often determines feeding outcomes (Wanjohi et al., 2023).
The remarkable interplay between knowledge, structural barriers, and cultural beliefs identified in Siaya County
underscores the need for comprehensive, multisectoral interventions that move beyond traditional nutrition
education approaches(Reynolds et al., 2021). While recent government actions have accelerated progress in
some areas of infant and young child feeding, the persistent implementation gaps revealed in this study suggest
that current approaches inadequately address the intersection of poverty, cultural beliefs, and gender-based care
practices that fundamentally shape feeding behaviors (Kenya BFCI guidelines, 2016). Given that Kenya's
nutritional landscape presents a complex picture of progress amid persistent challenges. Despite improvements
in stunting rates (dropping from 26% in 2014 to 18% in 2022) and slight reductions in overweight (4% to 3%)
and underweight (11% to 10%) prevalence, the country reported 942,000 acute malnutrition cases in children
aged 6-59 months during the first half of 2022. Only 31% of children aged 6-23 months consume a minimum
acceptable diet, while 5% remain wasted(Kenya-Strategy-for-MIYCN-2023-2028; Kenya Demographic and
Health Survey (2022).
Kenya demonstrates relative strengths in continued breastfeeding (60%) and timely food introduction (87%),
outperforming regional averages. However, critical gaps persist: half of children fail to meet minimum meal
frequency standards, 29% consume no vegetables or fruits, and exclusive breastfeeding rates remain low at
57.8% in counties like Siaya. These disparities are particularly pronounced in high-burden areas
(UNICEF/WHO/World Bank group, 2023), with Siaya County reporting higher stunting rates (19.2%) and
concentrated malnutrition cases, notably 42% from Alego Usonga alone. Such patterns underscore the need for
integrated strategies addressing knowledge gaps, economic constraints, gender equity, and community support
systems through culturally-adapted programs recognizing structural determinants' primacy over individual
knowledge in shaping feeding practices.
CONCLUSION
This study highlights the persistent disconnect between caregivers’ nutritional knowledge and actual
complementary feeding practices (CFP). While caregivers exhibited sound awareness of appropriate feeding,
implementation was hindered by structural barriers such as poverty, food insecurity, and entrenched cultural
norms. These findings align with broader literature indicating that socio-economic conditions and gendered
caregiving traditions often exert more influence on feeding behaviors than knowledge alone. The study revealed
significant non-compliance with WHO feeding standards particularly low dietary diversity and inadequate meal
and milk frequency. Girls were disproportionately affected, exhibiting higher rates of stunting and wasting.
Interestingly, while boys were somewhat protected from underweight, they were still vulnerable to wasting and
stunting, underscoring the complex and inconsistent gender dynamics at play.
These findings affirm the need for multisectoral interventions that go beyond education to address systemic
issues such as household income, food access, and gender inequality. The evidence supports the case for
community-tailored nutrition strategies that incorporate social protection, access to quality foods, and behavior
change support. Addressing these structural determinants is essential for translating nutritional knowledge into
improved practices and outcomes. Sustainable progress in child nutrition must be grounded in integrated,
context-specific approaches responsive to local realities.
Abbreviations
CFP: Complementary Feeding Practices; CHU: Community Health Unit; MAD: Minimum Acceptable Diet;
MDD: Minimum Dietary Diversity; MMF: Minimum Meal Frequency; MIYCN: Maternal and Infant Young
Child Nutrition; MUAC: Mid-Upper Arm Circumference; OR: Odds Ratio; WHO: World Health Organization
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ACKNOWLEDGEMENTS
We acknowledge the study participants, Siaya County health officials, and community health volunteers.
Ethics approval and consent to participate
The study maintained strict adherence to international ethical standards, including the Helsinki Declaration
(2013), and secured comprehensive approvals from Kabarak University Ethics Review Committee (KUREC),
the National Commission for Science, Technology and Innovation (NACOSTI), Siaya County Health
Management Team (CHMT), and local administration. Participant protection was ensured through written
informed consent from all participants, with verbal explanations provided in the local Dholuo language to ensure
comprehension. The study applied voluntary participation with explicit withdrawal rights, while confidentiality
was maintained through anonymization codes. Rather than providing monetary incentives, the research offered
nutrition education as a community benefit, ensuring ethical reciprocity while avoiding potential coercion in
participant recruitment and engagement.
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