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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 PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 1/17 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. PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 2/17 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 PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 3/17 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). PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 4/17 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. PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 5/17 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. PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 6/17 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. PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 7/17 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). PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 9/17 Knowledge,attitudeandpracticeondietandphysicalactivityamongNepalesemotherswithyoungchildren PLOSONE|https://doi.org/10.1371/journal.pone.0200329 July9,2018 10/17

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mothers with young children regarding diet and physical activity and scored responses on dietary and physical activity KAP, then categorized the
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