Knowledge, attitude and practice on diet and physical activity among mothers with young children

17 Pages·2017·1.34 MB·English

RESEARCHARTICLE
Knowledge, attitude and practice on diet and
physical activity among mothers with young
children in the Jhaukhel-Duwakot Health
Demographic Surveillance Site, Nepal
NataliaOli1,2*,AbhinavVaidya2,KatjaPahkala3,4,GabrieleEiben5,6,AlexandraKrettek1,6,7
1 DepartmentofInternalMedicineandClinicalNutrition,InstituteofMedicine,SahlgrenskaAcademyat
UniversityofGothenburg,Gothenburg,Sweden,2 DepartmentofCommunityMedicine,KathmanduMedical
a1111111111
College,Kathmandu,Nepal,3 PaavoNurmiCentre,DepartmentofHealthandPhysicalActivity,Universityof
a1111111111
Turku,Turku,Finland,4 ResearchCentreofAppliedandPreventiveCardiovascularMedicine,Universityof
a1111111111
Turku,Turku,Finland,5 DepartmentofPublicHealthandCommunityMedicine,UniversityofGothenburg,
a1111111111 Gothenburg,Sweden,6 DepartmentofBiomedicineandPublicHealth,SchoolofHealthandEducation,
a1111111111 UniversityofSko¨vde,Sko¨vde,Sweden,7 DepartmentofCommunityMedicine,FacultyofHealthSciences,
UiTTheArcticUniversityofNorway,Tromsø,Norway
*[email protected]
OPENACCESS
Abstract
Citation:OliN,VaidyaA,PahkalaK,EibenG,
KrettekA(2018)Knowledge,attitudeandpractice
Theprevalenceofcardiovasculardiseasesisincreasinginlowandmiddle-incomecoun-
ondietandphysicalactivityamongmotherswith
tries;Nepal’spopulationshowsahighprevalenceofbehavioralriskfactors.Ourcross-sec-
youngchildrenintheJhaukhel-DuwakotHealth
DemographicSurveillanceSite,Nepal.PLoSONE tionalstudyintheJhaukhel-DuwakotHealthDemographicSurveillanceSite(JD-HDSS),
13(7):e0200329.https://doi.org/10.1371/journal. locatednearthecapitalKathmandu,exploredknowledge,attitude,andpractice(KAP)of
pone.0200329
motherswithyoungchildrenregardingdietandphysicalactivityandmothers’perceptionof
Editor:IratxePuebla,PublicLibraryofScience, theirchildren’sattitudeandbehaviortowardthesameissues.Thepurposeofourstudywas
UNITEDKINGDOM
toassessneedsofthemothersconcerningcardiovascularhealthingeneralandmorespe-
Received:April10,2017 cificallyregardingdietandphysicalactivity,andtoestablishabaselineforfutureintervention
Accepted:June25,2018 inthecommunitybycomparingtwovillagesofJD-HDSS.InAugust–November2014,nine
trainedenumeratorsinterviewedallmothersofchildrenaged1–7years(N=962).We
Published:July9,2018
scoredresponsesondietaryandphysicalactivityKAP,thencategorizedthescoresbased
Copyright:©2018Olietal.Thisisanopenaccess
onthepercentageobtainedoutofthemaximumpossiblescoresinto“poor,”“fair,”and
articledistributedunderthetermsoftheCreative
CommonsAttributionLicense,whichpermits “good.”MorehighlyeducatedmothersscoredhigherforKAP(allp<0.001);thechildren’s
unrestricteduse,distribution,andreproductionin behaviorscorereflectedtheirmother’seducationlevel(p=0.007).Mostrespondentswere
anymedium,providedtheoriginalauthorand
unfamiliarwiththeconceptofhealthyandunhealthyfood.Overall,57%ofrespondentsin
sourcearecredited.
JD-HDSShad“good”knowledge,44.6%had“good”attitude,andmost(90%)had“poor”
DataAvailabilityStatement:Dataarefromthe
practice.Weobservednosignificantdifferencesbetweenthevillagesregardingmothers’
Knowledge,AttitudeandPracticeonDietand
PhysicalActivityamongNepaleseMotherswith knowledgeandattitudeorchildren’sbehavior.PracticescoreofmothersinJhaukhelwas
YoungChildrenstudyandarewithinthepaperand higherthanthoseinDuwakotregardingdietandphysicalactivity(p<0.001).Mothers’per-
itsSupportingInformationfiles.
ceivedbarriersforimprovinglifestylewerehighcostofhealthyfood,tastepreferenceof
Funding:Thestudywasfundedbythefollowing otherfamilymembers,andlackofknowledgeregardinghealthyfood.Barriersforphysical
grants:WilhelmandMartinaLundgrenFoundation,
activitywerelackofleisuretime,absenceofparksandplaygrounds,busycaringforchildren
grant2016-1179;theSwedishResearchCouncil,
andoldpeople,feelinglazy,andembarrassedtobephysicallyactiveinfrontofothers.Our
grant2016-05682;ArvidandKarinLundahl
Foundation,grant2016-12-01. findingssuggestthatahealtheducationinterventionpromotingahealthylifestylefor
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Competinginterests:Theauthorshavedeclared mothersandchildrenmightimproveKAPandalsoimprovecardiovascularhealth.To
thatnocompetinginterestsexist. addressmothers’gapbetweenknowledgeandpractice,afutureinterventionshouldcon-
siderperceivedbarriers.
Introduction
Noncommunicablediseases(NCDs),particularlycardiovasculardiseases(CVDs),arethelead-
ingcauseofmortalityandmorbidityworldwide.Alarmingly,theirprevalenceisincreasing
drasticallyinlow-andmiddle-incomecountries[1].InNepal,alow-incomecountry,thehigh
burdenofNCDsaccountfor60%ofalldeaths;halfofthemcontributedtoCVDs[2].Nepal’s
highprevalenceofbehavioralriskfactorscontributestotheincreasingfrequencyofCVDs[3].
Toaddressthisissue,in2010weestablishedaHealthDemographicSurveillanceSite
(HDSS)intwoneighboringvillages,DuwakotandJhaukhel,intheBhaktapurdistrictnear
Nepal’scapitalcityKathmandu.StudiesconductedintheJhaukhel-DuwakotHDSS
(JD-HDSS)demonstratedahighprevalenceofCVDriskfactorsinbothcommunities[4–6].
LowphysicalactivityandunhealthydietarecommoninJD-HDSS:morethanone-thirdof
respondentsareinactive[4]andmostdonotconsumefiveservingsoffruitsandvegetables
perday,asrecommendedbytheWorldHealthOrganization[6].Similartootherlow-income
countries,Nepalfacesanutritionaltransitionasitshiftsfromatraditionaldiet(i.e.,highfiber,
vegetables,andlow-fat)tothewesternhigh-energydensediet.Thisadoptionofawesterndiet
[7]isaccompaniedbyashifttowardssedentaryworkandleisuretime[8,9].Thisdevelopment
istroublesome,asitiswellestablishedthatdietandphysicalactivitycontributetotheetiology
ofCVDsandlifestylemodificationisanimportantcornerstoneforCVDprevention[10].
CVDsarerootedinchildhood—mothers’healthstatusandenvironmentduringpregnancy
andchildren’senvironmentafterbirthinfluencecardiovascularhealthinadulthood[11,12].
Severalfactorsaffecttheearly-lifeenvironment;e.g.,afamily’sfoodenvironmentisformedby
parentalknowledgeaboutnutrition,parents’feedingpracticesandcookingskills,accessibility
andavailabilityoffood,andchildren’sindividualcharacteristics[13,14].Goodnutritional
knowledgeofparentsandparentalsupportforphysicalactivityassociatewithahealthierlife-
styleinchildren[15].InNepal,mothersareprimarilyresponsibleforcreatingtheirchildren’s
environmentandlifestyle,whichmayaffectchildrenthroughoutlife[16,17].Hence,directing
lifestyleinterventionstowardsmothersaskeypersonsintheNepalesecontextmayhelp
improvetheirchildren’slifestyle.Subsequently,mothersmaytherebycontributetothepri-
mordialpreventionofNCDs.
Werecentlyconductedfocusgroupdiscussionstoexploremothers’perceptionsoftheir
children’sdietandphysicalactivityintheJD-HDSS[18].Irrespectiveofmothers’educational
level,allparticipantsshowedlowhealthliteracyregardingdietandphysicalactivity.Moreover,
participantsbelievedthatitwasimpossibletocontroltheirchildren’seatinghabitsandscreen
time[18].Giventheseresults,weundertookthecurrentstudytoinvestigateindetailtheover-
allknowledge,attitude,andpractice(KAP)ofmotherswithyoungchildrenregardingdietand
physicalactivity,andmothers’perceptionregardingtheirchildren’sattitudeandbehavior
towarddietandphysicalactivity.Wealsoaimedtocomparemothers’KAPandchildren’s
behaviorbetweenDuwakotandJhaukhel.Suchneedsassessmentidentifiespotentialgapsin
mothers’KAPandchildren’sbehaviorandiscrucialforplanningafuturecommunity
intervention.
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Materialsandmethods
Studysetting
Wedesignedacross-sectionalanalyticalstudytoexploreandcompareJD-HDSSrespondents’
KAPondietandphysicalactivity,andmothers’perceptionregardingtheiryoungchildren’s
attitudeandbehaviortowarddietandphysicalactivity.JD-HDSSislocatednearNepal’scapi-
talcityKathmandu.ItcomprisesthetwoneighboringandurbanizingvillagesDuwakotand
Jhaukhelthathavesimilargeo-ecological,ethnic,andculturalcharacteristics[19].Thevillages
haveacombinedpopulationof16,918people(8,516maleand8,402female)in3,505house-
holds[19,20].
Studyparticipants
FromtheJD-HDSS2012database,wecreatedalistofallmotherswithatleastonechildaged
1–7yearsandintendedtoenrollallofthesemothersintoourstudy.Motherswithhearingor
mentaldisordersaswellasmotherswithmentallyillchildrenorchildrenwhosehealthcondi-
tionrequiredspecialdietandphysicalregimewereexcludedfromthestudy.Alleligiblemoth-
erswhowerewillingtoparticipatewereincludedinthestudy.
Weidentifiedandcontacted1,062eligiblemothersinthestudyarea.Theresponseratewas
93.5%inDuwakotand91.8%inJhaukhel.Altogether,962mothers(90.6%)completedforms
thatwereusedforanalysis.Amongthem,904(94%)reportedtheirmonthlyhousehold
income.
Tools
Wedevelopedastructuredquestionnairebasedonpreviouspublications[21–23].Wetailored
thequestionnairetothelocalcontextanddiscussedwithinourresearchgroup.Weincluded
questionsonrespondents’demographiccharacteristics(e.g.,age,education,occupation,type
offamily,etc.)aswellastheoccupationandeducationstatusoftheirhusbands.Thissection
alsocontainedquestionsaboutchildren(e.g.,age,sex,schoolgrade,andprimarycaretaker).
ThemainquestionnairecontainedthreesectionsthatfocusedonKAP.Eachsectionincluded
questionsaboutdietandphysicalactivity.BasedontheGlobalPhysicalActivityQuestionnaire
(GPAQ),wedescribedphysicalactivityforrespondentsduringwork(includinghousework),
traveltoandfromplaces,andleisuretime[24].Pictureswithexamplesofcommonphysical
activitiesinthecommunitywereshowntomotherstofurtherclarifythequestions.
Theknowledgesectioncoveredrespondents’knowledgeofhealthyandunhealthydietsand
physicalactivityandtheireffectsoncardiovascularhealth.Questionsaimedtoexploreknowl-
edgeofhealthydiet(e.g.,“Whatdoyouconsidertobeahealthydietaryhabitforyou?”)ina
multipleresponseformatwithoptionssuchas“eatinghygienicfoodirrespectiveofconten-
t,”“eatinglesssugar/sugaryfoods,”“eatingsmallerportionsbutmorefrequently,”“usingless
fatincooking,”and“consumingmorefruitsandvegetables.”Furthermore,thequestionspro-
videdsomeexamplesoffooditems(freshsalad,deep-friedvegetables,sweetenedsoftdrinks,
fruits,chips,etc.)andaskedrespondentstoclassifythemashealthyorunhealthy.Theques-
tionnairealsomentioneddifferentdiseases(e.g.,leprosy,heartdiseases,malaria,diabetes,
HIV/AIDS,etc.)andaskedmothersiftheyassociateddevelopmentoftheseconditionswith
consumptionofunhealthyfood.Theknowledgesectionalsocontainedopen-endedquestion
(e.g.,“Whatisjunkfood?”).Wementionedfoodcomponents(i.e.,sugar,salt,grains,fat,and
fruitsandvegetables)andaskedrespondentstodefinetheamount(high,low,ornotimpor-
tant)appropriatetoahealthydiet.Thesectionaboutknowledgeofphysicalactivityaskedan
open-endedquestion:“Whatistheroleofphysicalactivityforourhealth?”Anotherquestion
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
includeddifferentstatements(e.g.,“physicalactivityisbadfortheheart,improvesmental
health,causesdepressionandfrustration,”etc.)andaskedrespondentstoeitheragreeordis-
agreewiththestatements.
Questionsintheattitudesectionexploredmothers’attitudetowardtheirownandtheir
children’sdietandphysicalactivity.Inaddition,weexaminedmothers’perceptionoftheir
children’sattitudetowardfoodandphysicalactivity.Weused5-pointLikertscaleformostof
theattitudequestions.Weprovideddifferentstatementsondietandphysicalactivityand
askedmotherstochoosebetween“stronglyagree,”“agree,”“neutral”,“disagree,”“stronglydis-
agree”.Thefoodquestionsincludedstatementssuchas“healthyfoodisnottasty;”“healthy
foodisenjoyable;”“healthyfoodisforsickpeople;”“ifsomeonedoesenoughexercise,canhe/
sheeatwhatevertheylike;”“itisgoodtobuysoftdrinksforthechildrenbecausetheyare
healthy;”“ifyouloveyourchild,youshouldpleasehim/herbybuyingfavoritesweets,”etc.We
alsoused“yes/no”questionswhenmentionedspecificfooditemsandaskedrespondents’for
theiropinionaboutthetasteofthosefoods.Additionally,weaskedrespondents’perceptionof
theirownknowledgeabouthealthydietandphysicalactivityandtheirabilitytoidentifytheir
mainsourcesforhealth-relatedinformation.Examplesofquestionsregardingrespondents’
attitudetowardtheirchildren’sdietandphysicalactivityinclude:“Whatdoyouthinkaffects
yourchild’sfoodchoice?”“Doyouwanttochangeyourchild’sfoodpattern?Ifyes,how?”
(open-endedquestion).“Howwouldyourateyourchild’sphysicalactivitystatus?”Wealso
askedrespondentsaboutperceivedbarriersthatpreventthemandtheirchildrenfromeatinga
morehealthydietandbeingmorephysicallyactive(“yes/no”questions).
Similarly,questionsrelatedtopracticeexploredmothers’ownpracticeandpracticetoward
theirchildrenregardingdietandphysicalactivity.Wealsoaskedhowrespondentsperceived
theirchildren’sdietaryandphysicalactivitybehavior.Questionsexploredtheavailabilityof
junkfoodandsoftdrinksatrespondents’home,typesoffoodgiventochildrenathome,and
mothers’reactionwhenchildrendemandjunkfoodwhileshopping.Weadoptedthesection
aboutmothers’physicalactivitypracticefromtheGPAQ[24].Thissectionaimedtoexplore
howmuchtimeperdayandhowmanydaysperweekmothersperformedvigorousactivities
atwork(e.g.,liftingheavyloads)andduringleisuretime(e.g.,runningorotherintensive
sportsactivities).Likewise,questionsexploredmothers’moderatephysicalactivityatwork
(e.g.,carryinglightloads,housework)andleisuretime(e.g.,dancing).Traveltimequestions
exploredifmotherswalkedorcycledcontinuouslyforatleast10minutestoreachwork,mar-
ket,etc.
Questionsaboutchildren’sdiet-relatedbehavioraimedtoinquirethemothersonhowtheir
childspendpocketmoney,thetypeoffoodchildrenconsumeassnacksandduringmain
meals,favoritefooditemsanddrinks,howoftenchildrenconsumesoftdrinksorprepackaged
juices,andchildren’seatinghabitswhilewatchingtelevision.Questionsthatexploredchil-
dren’sphysicalactivityincluded:“Howlongdoesthechildwalktoschool?”“Howlongdoes
he/shespendtimedoinghomework?”“Doeshe/shespendtimeplayingoutside?”Wealso
askedquestionsaboutchildren’sscreentime.
Tovalidateourquestionnaire,wetranslateditfromEnglishintoNepalilanguageandback-
translatedtoEnglish.Wedidpre-testingofthequestionnaireinChangunarayan,aneighbor-
ingandsocio-culturallysimilarvillage.Ourpre-testingincluded85motherswithchildren
aged1–7years,whichisabout9%ofthetotalnumberofeligiblemothersinthestudysite[25].
Basedonthepretestingresults,wemadenecessarychangesinthequestionnairetomakeit
clearerfortherespondents.Furthermore,wealsocheckedthequestionnaireforinternalcon-
sistency(Cronbach’salpha=0.7).
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Datacollection
Ourcriteriaforrecruitmentofenumeratorsfordatacollectionwerefemalesfromthelocal
communitieswitheducationlevelcompletedgrade10andpreviousexperienceindatacollec-
tion.Weinterviewedtheapplicants,andindeferencetothetraditionalandculturalaspectsof
Nepalesesociety,recruitedninefemaleenumerators.Tosupervisethedatacollectionprocess,
werecruitedthreeBachelorofPublicHealthgraduateswithpreviousexperienceinfieldwork.
NOandAVconducted3-daytrainingforthefieldsupervisors.NO,AVandfieldsupervisors
conducted6daystraining(5hourseachday)ondatacollectionfortheenumerators.Theenu-
meratorsconducteddoor-to-doorvisitstoallofthelistedmothersbetweenSeptember-
November2014andinterviewedeligiblemothers,usingthequestionnaire.Inhouseholdscon-
tainingmorethanoneeligiblemother,enumeratorsappliedalotterymethodtoselectone
interviewee.Enumeratorscontactedmotherswhowerenotathomeduringthehousehold
visitbyphoneandmetthemlateraccordingtothemothers’convenience.
Dataanalysis
TrainedoperatorsinitiallyentereddataintoEpidata3.1software.Next,wetransferredand
analyzedthedatausingSPSS,version22.0.Wescoredknowledgequestionsas1and0forcor-
rectandincorrectanswers,respectively.Forexample,forthemultipleoptionquestion“What
doyouconsidertobeahealthydietaryhabitforyou?”,the‘yes’responsetotheoption“eating
hygienicfoodirrespectiveofcontent”scored0,whereasthe‘yes’responsetotheoption“eating
lesssugar/sugaryfoods”scored1.Furthermore,iftherespondentconsideredchips,deep-fried
vegetables,sugar-sweetenedcarbonateddrinksashealthyfood,shewasgiven0scoresforeach
ofthesefooditemsand1scoreiftheythoughtofthemtobeunhealthy.Incaseofopenended
questionssuchas“Whatisjunkfood?”,wegavescore1forcorrectanswerand0forincorrect
orfor“don’tknow”answer.
Wescoredattitudequestionsfrom1to5(fromstronglydisagreetostronglyagree),giving
maximumscoresforapositiveattitudeabouthealthydietandphysicalactivity[26].Inthe
practicesectionrelatedtomothers’physicalactivity,weconvertedresponsestometabolic
equivalenttotask(MET)–minutes/weekaccordingtotheGPAQAnalysisGuide[24].Wefur-
thercategorizedmothers’physicalactivityashigh,moderate,orlowdependingontheirtotal
MET–minutes/week.Motherswithhighphysicalactivityreceived2points,comparedto1
pointformoderatephysicalactivityand0pointsformotherswithlowphysicalactivity.Fur-
thermore,motherswhoweresedentaryfor3hoursperdayreceived0points,comparedto1
pointformotherswhosatlessthan3hoursperday.
Wealsoscoredchildren’sbehavior.Infamilieswithmorethanonechildaged1–7,we
selectedtheoldestchildfordataanalysis.Forexample,questionsaboutfooditemschildren
usuallyatehadtheoptionsof“often”,“sometimes,“seldom,”and“never”.Answer“often”for
healthyfoodsuchasegg,milk,riceandvegetableswasgivenscore3,whereas“sometimes”,
“seldom”and“never”scored2,1and0,respectively.Incaseofunhealthyfooditemssuchas
sweets,instantnoodles,chips,scores0,1,2and3weregivenfor“often”,sometimes”,“seldom”
and“never”respectively.Childrenwithpositiveornegativedietaryandphysicalbehavior
received1or0points,respectively.Multipleoptionquestionswithyes/noanswersuchas
“Whatisyourchild’favoritedrink?”weregiven1scoreforhealthyitemssuchaswater,fresh
juice.Childrenwhoprefersugar-sweetenedcarbonateddrinks,packedjuicegot0score.Chil-
drenwhoplayedoutsidemorethan3hoursperdayreceived5scores,whilethosewhoplayed
for2–3hours,1–2hours,30min-1hour,lessthan30minutes,andwhoarenotplayingscored
4,3,2,1and0,respectively.Similarly,screeningtimewasscored:lowestscore(i.e.0)formore
than3hoursperdayandhighestscore(i.e.5)forthosewhospendlessthan30minutes.
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Wecombinedrelevantscorestocalculatefourcompositescores:threeformothers’KAP
andoneforchildren’sbehavior.Furthermore,wecategorizedmothers’KAPscoresintothree
categoriesbasedonthepercentageofthemaximumpossiblescores:“poor”(0%-50%),“fair”
(51%-75%),or“good”(76%-100%).Similarly,wecategorizedchildren’sbehaviorscoresinto
“poor”,“fair”orgood”categories.Themaximumpossiblescoresformothers’knowledge,atti-
tude,andpracticewere73,192,and17,respectively.Themaximumscoreforchildren’sbehav-
iorwas110.WeperformedKruskal–Wallistesttodeterminetherelationshipbetween
respondents’KAPanddemographicvariablessuchasage,religion,ethnicity,averagemonthly
householdincome,mothers’education,andoccupation.Weappliedthesametesttoinvesti-
gateapossibleassociationofchildren’sbehaviorscoreswithmothers’levelofeducation,occu-
pationandhouseholdincome.
AlldatawerecheckedfornormaldistributionusingShapiro-Wilktest.Sincedatawerenot-
normallydistributed,wecalculatedmedianandinterquartilerange(IQR)forKAPscores
regardingdietandphysicalactivity.KAPscoresfromDuwakotandJhaukhelvillageswere
comparedusingMann–WhitneyUtest.WealsoappliedChi-squaredtesttocomparecatego-
riesofKAPscoresbetweenthevillages.P<0.05wasconsideredsignificant.
Ethicalconsideration
TheNepalHealthResearchCouncilgrantedethicalpermissionforthisstudy(No.150/2014).
Wealsoconsultedwithlocalleadersandhealthandadministrativeauthoritiesinbothvillages,
whograntedtheirapproval.Trainedenumeratorssolicitedinformedverbalconsentfromthe
eligiblemothers.Thiswasdoneasmanymothersinourstudywereilliterateandwerethere-
foreunabletoprovidewrittenconsent.Moreimportantly,evenliteraterespondentshesitated
signingdocumentsbecauseofculturalinhibitions,whichifchallenged,couldbeevencounter-
productivefortheirparticipation.Allrespondentswereinformedthattheywerefreetoleave
thestudyatanytime.Privacyandconfidentialitywasmaintainedduringallinterviews.No
externalobserverswerepresentduringdatacollection.Filledquestionnaireswerekeptinthe
JD-HDSSofficeandalldatawereaccessibleonlytotheresearchteam.
Results
Demographiccharacteristics
Table1showsthedemographiccharacteristicsofrespondents(673motherswithchildren
aged1–7yearsinDuwakotand289inJhaukhel).Respondents’medianage(IQR)29(6)and
28(6)years,respectively,andtheiragedistribution,educationalstatus,andreligionofthe
respondentsweresimilarinbothvillages.However,thevillagesdifferedregardingmothers’
ethnicity,occupation,averagemonthlyincomeofthehousehold,andtypeoffamily(p<0.05).
One-quarterofthemothers(22.8%)hadnotcompletedprimaryschool(<5grades).Although
Newar,HillBrahmins,andChhetriweretheprevalentethnicgroupsinbothcommunities,
Chhetrisweremorecommon(35.4%)inDuwakotandNewarsweremorecommon(39.8%)
inJhaukhel.Almost60%oftherespondentsinDuwakotlivedinnuclearfamilies,whereas
about60%ofmothersinJhaukhellivedinextendedfamilies.Mostrespondents(73.3%)in
bothvillageswerehousewives.Furthermore,themonthlyhouseholdincomeofmostrespon-
dents(71.7%)was<20,000Nepaleserupees(NPR).MorehouseholdsinJhaukhelthanDuwa-
kot(32.7%vs.23%,respectively)hadamonthlyincomeof<10,000NPR.Inmostfamilies
(89%),themotherwastheprimarycaregiveroftheirchildren.
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Table1. ComparisonofDuwakotandJhaukhelvillagesaccordingtodemographicvariables.
Variables Duwakot,N(%) Jhaukhel,N(%) Total,N(%) Pvaluea
Age(years)
19–25 161(23.9) 62(21.5) 223(23.2) 0.681
26–35 459(68.2) 205(70.9) 664(69.0)
36–48 53(7.9) 22(7.6) 75(7.8)
Education
<5grade 163(22.4) 56(19.4) 219(22.8)
5–10grade 330(49) 135(46.7) 465(48.3) 0.052
>10grade 180(26.7) 98(33.9) 278(28.9)
Religion
Hindu 615(91.4) 268(92.7) 883(91.8)
Buddhism 33(4.9) 10(3.5) 43(4.5) 0.611
Othersb 25(3.7) 11(3.8) 36(3.7)
Ethnicity
Newar 157(23.3) 115(39.8) 272(28.3)
HillBrahmins 136(20.2) 86(29.8) 222(23.1)
Chhetri 238(35.4) 41(14.2) 279(29) <0.001
Hillethniccastec 73(10.8) 31(10.7) 104(10.8)
Othersd 69(10.3) 16(5.5) 85(8.8)
Familystructure
Nuclear 398(59.1) 121(41.9) 519(54.0) <0.001
Extended 275(40.9) 168(58.1) 443(46.0)
Mothers’mainoccupation
Agriculture 28(4.2) 3(1.0) 31(3.2)
Office 23(3.4) 9(3.1) 32(3.3)
Labor 50(7.4) 15(5.2) 65(6.8) 0.045
Self-employed 83(12.3) 46(15.9) 129(13.4)
Housewife 489(72.7) 216(74.7) 705(73.3)
Averagemonthlyhouseholdincome(NPR)e,f
<10,000 146(23) 88(32.7) 234(25.9)
10,000–19,999 301(47.4) 113(42) 414(45.8)
20,000–29,999 93(14.6) 42(15.6) 135(14.9) 0.016
30,000–39,999 42(6.6) 11(4.1) 53(5.9)
>40,000 53(8.3) 15(5.6) 68(7.9)
Total 673 289 962
ClassificationofethnicgroupsisbasedontheNationalCentralBureauofStatistics[27].
aObtainedfromaχ2test.
bOtherreligionincludesChristianityandIslam.
cHillethniccastesincludeTamang,Dalit,Thakuri,Magar,andRai.
dOtherethnicityincludesLama,Sherpa,Madeshi,Gurung,Tharu.
eNRs=Nepaleserupees(1USD=NRs106,approximately)
fTotalnumberofrespondentsforaveragemonthlyhouseholdincome=904(635inDuwakotand269inJhaukhel)
https://doi.org/10.1371/journal.pone.0200329.t001
Mothers’KAPscores
Whenwecategorizedrespondents’scoresinto“poor,”“fair,”and“good”groups,wefound
that57%hadgoodknowledge,45%hadgoodattitude,andmost(90%)hadpoorpractice.
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Wefurtheranalyzedthedistributionofmothers’practiceaccordingtotheirknowledgecat-
egories(Fig1).Allmothersfellintoeither“poor”or“fair”categories(i.e.,noonewasinthe
“good”category).Thepercentageofmotherswithfairpracticewashigheramongmothers
with“good”knowledge(14.6%),comparedtomotherswith“fair”(4.4%)or“poor”knowledge
(0.0%).
Associationofmothers’KAPscoreswithdemographicvariables
Mothersaged26-35yearshadhighermedianknowledge(p<0.001),attitude(p=0.037),and
practice(p<0.001)scorescomparedtoyoungerorolderwomen.KAPscoresregardingdiet
andphysicalactivityincreasedwithlevelofeducation(Fig2).
Respondents’knowledgeandattitudescoresincreaseduptoahouseholdincomeofNPR
20,000–29,999permonth(p<0.001)andleveledoffthereafter.Mothers’practicescoresdid
notchangewithincreasinghouseholdincome(p<0.14).
Wealsoexaminedwhetherrespondents’KAPscoreslinkedwiththeirreligionandethnic
origin.HillBrahminwomenhadhigherKAPscoresregardingdietandphysicalactivity,fol-
lowedbyChhetrisandNewars(p<0.001).Furthermore,Hindumothersscoredhigherthan
Buddhistmothersandotherreligions(p<0.001).Additionally,motherswhoworkedaslabor-
ersorintheagriculturalsectorhadlowerknowledgeandattitudescorescomparedtoother
occupations(p<0.001).Motherswhoworkedinofficesorwereself-employedscoredhigher
onpracticethanmotherswhowerehousewivesorwhoworkedaslaborersorintheagricul-
turalsector(p<0.001).Regardingfamilystructure,mothersinextendedfamilieshadhigher
KAPscoresthanthoseinnuclearfamilies(p<0.001forknowledge,p<0.001forattitude,and
p=0.033forpractice).
Comparisonofmothers’KAPbetweenthevillagesofJD-HDSS
Median(IQR)scoresformothers’knowledgewere57(10)inDuwakotand57(9)inJhaukhel
(p=0.771).Median(IQR)scoresforattitudewere142(20)inDuwakotand143(18)inJhau-
khel(p=0.588).Furthermore,mothers’practicescoreswere7(2)and7(2)inDuwakotand
Jhaukhel,respectively(p<0.001).
WeobservednosignificantdifferencesbetweenDuwakotandJhaukhelinthecategoriesfor
mothers’knowledgeandattitudeandchildren’sbehavior(Table2).However,moremothers
inDuwakothad“poor”practicecomparedtothoseinJhaukhel(p=0.032).
Mothers’perceivedbarriersandsupportivefactorsforhealthydietand
physicalactivity
Respondentsindicatedthatthemostcommonbarriersforhealthydietincludedhighcostof
healthyfood(72%),difficultygivingupfavoritefood(70%),tastepreferenceofotherfamily
members(69%),lackofknowledgeregardinghealthyfood(68%),busylifestyle(63%),and
lackofcookingskillsforhealthyfood(61%).Similarly,barriersforincreasedphysicalactivity
werelackofleisuretime(84%),havingtocareforchildrenoroldpeople(82%),feelinglazy
(79%),absenceofparksandplaygrounds(76%),andembarrassedtodophysicalactivityin
frontofothers(66%).
Factorsthatmothersperceivedasimprovingtheirowndietandphysicalactivityincluded
betterinformationabouthealthyfood(92%),importanceofphysicalactivity(97%),dietary
advicefrommedicalpersonnel(92%),andadviceaboutphysicalactivity(94%).Moreover,
mothersalsoemphasizedtheimportanceofsupportfromrelativesandfriendsforhealthydiet
(87%)andphysicalactivity(93%).Theyalsothoughtthatavailabilityofplaygrounds(93%),
PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 8/17
Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
Fig1.Levelsofmothers’practicescoreaccordingtotheirknowledgescorecategories.KAPscoreswerecategorized
intothreecategoriesbasedonthepercentageofthemaximumpossiblescores:“poor”(0%-50%),“fair”(51%-75%),or
“good”(76%-100%).
https://doi.org/10.1371/journal.pone.0200329.g001
theirownillhealth(83%),andhealthydietandphysicalactivity(55%)canfacilitatepositive
behaviorchanges.
Children’sbehaviorscoresandtheirvariations
Thechildreninourstudyincluded444girls(46.2%)and518boys(53.8%).Median(IQR)
scoreforchildren’sbehavior,asperceivedbytheirmothers,was72(6).Themaximumpossible
scoreforchildren’sbehaviorregardingdietandphysicalactivitywas110.Onlyfourchildren
(0.4%)had“good”behavior,whilealmostallofthechildren(99.5%)had“fair”behaviorand
onechild(0.1%)had“poor”behaviorfordietandphysicalactivity.Wedidnotassessthechil-
dren’sknowledgeandattitudeaboutdietandphysicalactivity.
Associationofchildren’sbehaviorscoreswithmothers’demographic
variables
Thechildren’sdietscoresincreased(p<0.001),whereastheirphysicalactivityscoresdecreased
(p<0.001)withincreaseintheirmothers’levelofeducation(Fig3).Ontheotherhand,
monthlyhouseholdincomeandmothers’occupation(p=0.41andp=0.39,respectively)did
notassociatewithchildren’sbehavior.
Similartothemothers’KAPscores,children’sbehaviorscoreswerehigheramongHill
Brahmins,followedbyChhetrisandNewars(p<0.001).ChildrenofHindumothershad
higherbehaviorscores,followedbychildrenofmotherswithotherreligions(p=0.001).Like-
wise,children’sbehaviorscoreswerehigherinextendedfamiliesthaninnuclearfamilies
(p=0.042),andtheirbehaviorscoresweresimilarinmothersofdifferentagegroups
(p=0.943).
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Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren
PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 10/17