Unveiling the Factors Behind Delayed Introduction of Complementary Feeding and its Impact on Infant Nutrition: A Case Study in Peshawar, Pakistan

feeding practices, particularly in initiating CF late, remains prevalent in developing regions. Objective: To examine the reasons for delayed CF in Peshawar, as well as its impact on infant health. Methods: A Retrospective case-control study was conducted with 800 mothers at the Hyderabad Medical Complex (HMC) vaccination center in Peshawar between July and October, 2022. Infants aged 6-12 months were categorized based on timely or late CF introduction. Late initiation of CF de�ned as, introduction of CF beyond 30 weeks. Regression analysis was employed to scrutinize parental background and psychological elements in the study. Results: Results of Multivariate logistic regression revealed that house hold income, maternal education level, low Antenatal Care (ANC) visits, maternal belief about CF and maternal drug addiction were signi�cant (p<0.05) factors that responsible for late starting of CF. Particularly late initiation of CF poorly effects Infant nutrition status. Conclusions: This study highlights the requirements for targeted population to advance CF practices in Peshawar. Such intervention promises to improve child health in the region, emphasizing the importance of proactive measures to address this concern.

Practicing of CF remain largely unexplored, hampering our understanding of factors that contribute to improper practices such as late initiation of CF.This research aims to ll this gap and identify the factors responsible for late starting of CF.Additionally, the ndings of this research can be used at the community-level interventions to promote child health by practicing adequate CF.Crosscultural assessments with researches from developed nations can improve the study's in uence and applicability, possibly leading to successful approaches tailored to the local context.The main objective of this study is identifying the factors responsible for late initiation of CF among infants and understanding the association between late initiation of CF and infant nutritional status.These results can deliver valued indication making policies to indorse timely CF in Peshawar.Given the need for custom interventions to suit different population's needs, there is no xed set of constituents for effective CF interventions [17].

M E T H O D S
This study was conducted in the vaccination Center of Hayatabad Medical Complex, Peshawar in a time setting of July to October 2022.This study received ethical approval from the University of Agriculture, Human Nutrition department on 18th April 2022.Present research collected data from mothers of infants', aged 6 to 12 months.Data collection was started when approval is accepted from hospital administration.Current study has retrospective case control design, collected information from 800 infants' mothers, divided into two groups on the base of CF initiation time.The determination of the sample size was achieved using Cochran's formula, a method that considers various factors to ascertain the necessary sample size for a desired level of accuracy.The formula utilized was: n = (Z^2 * p * q) / (e^2), where 'n' represents the required sample size, 'p' s i g n i e s t h e ex p e c te d p r eva l e n c e of t i m e l y complementary feeding (assumed as 0.50), ' q' denotes the rate of late complementary feeding (also assumed as 0.50), ' e' represents the level of precision (set at 0.05), and 'Z' is the statistical value corresponding to a 95% con dence level (which is 1.96).With these inputs, the calculated sample size was determined to be 384.The study entailed a retrospective case-control analysis utilizing data collected from the mothers of 800 infants, categorized into two groups: the standard group (consisting of infants adhering to timely complementary feeding) and the target group (comprising infants practicing late complementary feeding).

Target group
A total of 988 mothers of infants were assessed after obtaining their consent, with 452 in the control group and 536 in the target group.
In the control group, 52 mothers of infants were excluded, and in the target group, 136 mothers of infants were excluded because their husbands didn't accompany them.This resulted in an incomplete questionnaire for the current study, which includes two specific questions for infants' fathers.
Additionally, various reasons, like the infants' mothers leaving the questionnaires incomplete, contributed to this situation.In this research, data were collected from a cohort of 800 mothers with infants.These mothers acted as the primary respondents during the data collection phase.Structured interviews were conducted using a questionnaire, initially crafted in English and later translated into Urdu.Upon obtaining consent, mothers were provided with hard copies of the questionnaire.Face-to-face interviews were employed in cases where mothers had limited education, ensuring comprehensive data collection.Data collection ceased upon reaching responses from all 800 participants, achieving a 100% response rate.Trained interviewers assisted mothers in completing the questionnaires, which aimed to capture details regarding the timing of introducing complementary foods.Additionally, fathers were asked two questions regarding the timing of complementary feeding and any history of drug addiction.
Questionnaires were also administered to fathers, either self-completed or via face-to-face interviews for those with limited education.Following questionnaire completion, anthropometric data for infants were collected, measuring weight with a Salter scale and length with a recumbent scale, recorded in grams and centimeters, respectively.Z-scores were then calculated using Anthro-plus software, providing a standardized assessment of infants' nutritional status.The survey encompassed various inquiries into parental, infant, and familial dynamics, including demographic background, psychosocial factors affecting mothers, and maternal drug addiction beliefs.Prior to full-scale implementation, a pilot study with 15 mothers was conducted to re ne the questionnaire design, revealing an average completion time of 20 minutes.It's worth noting that pilot study participants were excluded from the nal sample.To streamline data analysis, SPSS version 21.0 software was utilized for conducting pertinent statistical tests.The data presented in tables 1 and 2 underwent chi-square analysis to facilitate their presentation, evaluation, and the observation of discrepancies among different variables.
Table 1 displays the demographic factors of the interviewed infants' parents.Chi-square analysis was employed to assess the association between various factors of the timely and late complementary feeding groups.Seven factors were evaluated, namely father's education, income level, maternal education, maternal age, parity, availability of counselling facility for complementary feeding, and antenatal care (ANC) visits during the last pregnancy.All factors, except parity, exhibited signi cant differences between the timely and late complementary feeding groups.

Late N (%)
Table 2 presents the psychosocial beliefs of the interviewed infants' parents.Chi-square analysis was employed to determine the signi cant differences between timely and late introduction of complementary feeding groups across various factors.Signi cant associations were found between timely and late complementary feeding groups concerning two factors related to mothers' beliefs about complementary feeding: the appropriate timing and drug addiction.Regarding factors related to fathers of infants, assessed through chisquare analysis, questions included the appropriate age for complementary feeding and drug addiction.Only one factor, namely the appropriate timing of complementary feeding, exhibited a signi cant difference between the timely and late complementary feeding groups.

Fathers' Psychosocial Belief
Table 3 shows the effect of complementary feeding timing on the nutritional status of the infants.children in the late group, who have a z-score below -2, mostly commenced complementary feeding after 34 weeks.Table 4 shows Pearson correlation analysis that reveals a clear trend: as the age of complementary feeding increases, the nutritional status of children decreases, In this study, Table 3 was utilized to present the results of a correlation analysis conducted between the introduction of complementary feeding at various ages and the prevailing nutritional status of children.The analysis revealed a statistically signi cant negative correlation (Pearson Correlation = -0.427,p < 0.001) between the delayed initiation of complementary feeding and the nutritional status of children.These ndings are consistent with a prior study conducted Nigeria, which similarly concluded that a delayed introduction of complementary feeding is a signi cant contributing factor to the development of poor nutritional status in children [19].The data presented in Table 3 also elucidate the distribution of children across different Z-Score categories in relation to both timely and late complementary feeding practices.
This study highlights the negative affect of late starting of CF on infant nutritional status, great ratio of infants falls into the <-2 Z-Score category, When CF is initiated than suggested time frame.Data shown in table 3 reveals that 22% of infants started CF at age of 7 months (30 weeks), 69% started at age of 31 and 38 weeks and 9% were introduced to CF between 39 and 48 weeks.This data illustrated that a large number of infants introduced to CF, deviated from WHO CF guidelines.Similar results are also identi ed in studies conducted across Asia, that identi ed that more than half of infants introduced to CF after recommended time across the regions [20][21][22].Current study recognized six factors that are signi cantly (p<0.05)associated with late introduction of CF.Particularly, income level and low maternal education level is interconnected factors manipulating the appropriate timing of CF, various studies in Pakistan and India supported these ndings that infants in low-income families has more chances of introducing to CF in lateral stage [20,21].Similarly, studies in Nepal and Islamabad, Pakistan shows a negative association between low maternal education and trends of late initiation of CF [22,20].These ndings parallel with previous studies in many circumstances, highlighting the critical need to report these factors to advance infants nutrition.Furthermore, this study identi ed a noteworthy correlation between breast feeding facility at health center and less than four ANC visits.The delay of CF beyond recommended time due to fewer ANC are also reported in the study conducted in India, that revealed, ANC visits is a contributing factor to start CF beyond the recommended time [21].Similarly, studies in Ethiopia, additionally highlights the absence of breastfeeding counseling at health center is an important factor, play roles in initiating timely CF [23].Educating mothers about breast feeding and indorsing ANC visits having essential role in minimizing late practices of CF.

D I S C U S S I O N
potentially leading to malnutrition.

Figure 1 :
Figure 1: Flowchart of the Study

PJHS VOL. 5 Issue. 3 March 2024
Data collection involved obtaining consent from t h e m o t h e r s a n d a d m i n i s te r i n g c l o s e d -e n d

Table 3 :
Impact of Timing of Complementary Feeding on Nutritional Status of Infants (N=800)

Table 4 :
Correlation between Complementary Age and Current Nutritional Status

Table 5 :
Factors Associated with the Late Initiation of Complementary FeedingThis study identi ed the correlation between delayed introduction of CF and infant nutritional status.Infants has low nutritional status, if introducing CF beyond the recommended time.Factors like income level and low maternal education contributing to delay introduction of CF.Maternal drug addiction and social inactivity also effect CF time in a negative way.Addressing late initiation of CF needs a wide-ranging approach that considers maternal knowledge, socio-economic aspects and social welfare.These ndings are appropriate for policymakers, healthcare professionals, and communities, offering map to improve child nutrition and health.