Ecology of Food and Nutrition

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Application of the Health Belief Model to Teach

Complementary Feeding Messages in Ethiopia

Befikadu Tariku, Susan J. Whiting, Demmelash Mulualem & Pragya Singh

To cite this article: Befikadu Tariku, Susan J. Whiting, Demmelash Mulualem & Pragya Singh
(2015) Application of the Health Belief Model to Teach Complementary Feeding Messages in
Ethiopia, Ecology of Food and Nutrition, 54:5, 572-582, DOI: 10.1080/03670244.2015.1049344

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Ecology of Food and Nutrition, 54:572–582, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0367-0244 print/1543-5237 online
DOI: 10.1080/03670244.2015.1049344

Application of the Health Belief Model to Teach

Complementary Feeding Messages in Ethiopia

BEFIKADU TARIKU
College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia

SUSAN J. WHITING
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada

DEMMELASH MULUALEM and PRAGYA SINGH

School of Nutrition, Food Sciences and Technology, Hawassa University, Awassa, Ethiopia

In Ethiopia many women do not practice appropriate comple-

mentary feeding (CF). The Health Belief Model (HBM) asserts that
change in behavior is determined after consideration of severity,
benefit, and barriers to change. This study examined the effec-
tiveness of 3 months of HBM-based education compared to the
traditional (didactic) method on CF practices of mothers, with no
education as control, using three randomized groups. One hun-
dred sixty-six mother-infant (6–18 months) pairs were recruited. At
baseline and after intervention, knowledge, perceptions, and prac-
tices about CF and related areas were determined. It was only diet
diversity that increased significantly in the HBM group (from 3.05
± 0.94 food groups to 3.79 ± 0.82, p < .05) while the other two
groups had no change. Improvements in food groups were most
noticeable as legumes & nuts (from 35.6% use to 83.9% in HBM
group). Thus, nutrition education about diet diversity improvement
needs to be conducted promotes behavior change.

KEYWORDS behavior, breast-feeding, dietary diversity

Infants and young children are vulnerable to malnutrition because of

their high nutritional requirements for growth and development (Blösssner
et al. 2005). They are particularly vulnerable during the transition period

Address correspondence to Susan Whiting, PhD, College of Pharmacy and Nutrition,

University of Saskatchewan, 110 Science Pl., Saskatoon, S7N5C9, Canada. E-mail: susan.
whiting@usask.ca

572
 Health Belief Model and Complimentary Feeding in Ethiopia 573

when complementary feeding begins, at six months (WHO-UNICEF 2003).

Widespread malnutrition hampers children’s growth and development, open-
ing the door to those diseases that are the biggest killers of children under
five years of age. Further, malnutrition is associated with high mortality rates
of children under 5 years of age (Black et al. 2013). In Ethiopia, among
children under 5 years of age there is a high prevalence of underweight,
stunting, and wasting of 44%, 28%, and 10%, respectively (Central Statistical
Agency 2012).
Appropriate complementary feeding practice includes different compo-
nents. The first is that introduction of complementary food should occur
when the energy and nutrient needs of the infant exceed what is provided
through exclusive breastfeeding. The second is that the food should provide
sufficient energy, protein, and micronutrient to meet the growing child’s
nutrition need. The third is hygiene, an important consideration during
preparation, storing and feeding, and the fourth is to have a responsive feed-
ing approach (WHO-UNICEF 2003).Nutrition education is needed to convey
these messages, but not all modes of education are successful in having
impact (Bhutta et al. 2013). In 2012, health extension workers (HEW) in
Ethiopia were using a traditional education approach that was didactic.
The underlying concept of the health belief model (HBM) is that health
behavior is determined by personal belief or perception about a disease or
health problem and strategies available to decrease its occurrence. Personal
perception is influenced by a range of intrapersonal factors affecting health
behavior (Hayden 2009). HBM stipulates that the willingness of people to
take a health-related action depends upon their attitudes and beliefs about
the threat posed by a health problem (susceptibility, severity); benefits of
avoiding the threat (benefits); and factors influencing the decision to act (bar-
riers, cues to action, and self-efficacy). These concepts include the following:
perceived susceptibility (i.e., the belief about the chance of experiencing a
risk or getting a condition or disease); perceived seriousness or severity (i.e.,
the belief about how serious a condition and its sequelae are); perceived
benefits (i.e., belief in efficacy of the advised action to reduce risk or seri-
ousness of impact); perceived barriers (i.e., the belief about the tangible and
psychological costs of the advised action); cues to action (i.e., strategies to
activate “readiness”); and self-efficacy (i.e., confidence in one’s ability to take
action) (Hayden, 2009; Champion and Skinner 2008).
We hypothesized that for improving complementary feeding practices,
it is important that the community members perceive undernutrition as an
important health concern in order to motivate implementation of behav-
ior change (IYCN Project, 2011), using the HBM that is a fitting approach.
Therefore, this study examined the effectiveness of HBM-based approach
compared to the Traditional approach and a Control group in promoting
appropriate feeding practices of the mothers on intake of infants and children
as well as related practices.
574 B. Tariku et al.

METHODS
Design
The study was conducted from April to July 2012, in Dore Bafano dis-
trict, a district of the Sidama Zone in the Southern Nations, Nationalities,
and People’s Region (SNNPR) of Ethiopia. It is a rural area located 20 km
from Hawassa, the capital city of SNNPR. There are 23 administrative units
(Kebeles) in the district. The total population of the district was 143,566.
From this, 8,184 were children from 6 to 24 months old.
The design of this study was a cluster-randomized trial with the assign-
ment of Kebeles by matching. Of the 21 rural Kebeles (two urban Kebeles
were excluded), one group were chosen from seven matched groups
(each matched groups had three Kebeles). The criteria for matching the
Kebeles included an equal number of households which had been trained
in the Health Extension Package of Ethiopia, as well as similar water
supply, weather condition and crop production. Kebeles chosen were non-
neighboring, to reduce the information contamination among groups. Using
the lottery method, one group of matched Kebeles was selected to comprise
each study group: one allocated to the HBM intervention (Jara Gelelcha),
one to the Traditional education (Udo Wotate), and the third one as Control
(Doyo Chale); again allocated to the intervention group by lottery method.
Within each Kebele, 180 households with children 6–18 months of age were
selected by a systematic sampling method. Inclusion criteria including being
resident in the Kebele and likely to be resident for the entire 3-month
intervention period. The child must have been breastfed during the pre-
intervention (baseline) data collection period. Exclusion criteria included:
children without a mother and those with serious congenital anomalies.

Procedures
The method of the data collection was interviewing using questionnaires
for mothers about feeding practice of the infants and children. The compo-
nents of the questionnaire were socio-demographic, complementary feeding
practices. Health belief model constructs were tested using a questionnaire
with the following areas covered: Perception of the mothers about malnutri-
tion (5 questions); Perception of the severity of malnutrition (2 questions);
Perceived barriers to practice appropriate complementary feeding (5 ques-
tions); Perceived benefit of practice appropriate complementary feeding
(6 questions); Self efficacy of the mothers to implement complementary
feeding messages (10 questions). Respondents were asked to evaluate health
belief model constructs on a 5-point Likert scale, from 1 (strongly disagree) to
5 (strongly agree). Complementary feeding practices were measured by the
following indicators: meal frequency; the proportion of infants and young
 Health Belief Model and Complimentary Feeding in Ethiopia 575

children consuming a variety of food group for the previous 24 hours; and
dietary diversity score (number of food groups consumed based on 7 food
groups) (Moursi et al. 2008). Female data collectors who had completed high
school were recruited from each Kebele to collect dietary data. Training was
given to the data collectors for three days on the data collection methods
and pre-test was done for one day. After the intervention, the data collector
got refresher training for one day to collect the post-intervention data.
For each intervention, health workers were recruited to provide the
messages. For the health belief model messages, local community health vol-
unteers were recruited. These were women from the local community who
were fluent in Amharic and Sidamigna, and training was given by us. The
traditional method (TM) of nutrition education was given by health extension
workers who were already assigned by the government to conduct health
and health related activities in these districts. However, for the purposes of
our study, both sets of workers were provided with an honorarium equal to a
regular HEW salary. The HEW provided complementary feeding messages of
Essential Nutritional Action that were explained along with the causes of mal-
nutrition. The effect of malnutrition on the health of the child was discussed
during the home visiting. Then the educators encouraged the mothers to use
this knowledge to take the right steps to complementary feeding practice
and to prevent and safeguard their own child from malnutrition.
For the HBM group, the intervention was the same knowledge as for
the TM group but based on HBM constructs, by incorporating the percep-
tions of the susceptibility of the child for malnutrition; and the severity of
malnutrition the child exhibited. The benefits of appropriate complementary
feeding practice and self-efficacy to prepare the appropriate complementary
feeding (e.g., use and selection of local available food groups; method of
preparation appropriate for the child’s age, etc.) was emphasized through
discussion with the mothers. Perceived barriers (e.g., concerns related to
use some food groups as a component for the complementary foods, forced
feeding as major alternative to feed the child, etc.) to practice appropriate
complementary feeding practice were identified by discussion with the moth-
ers. Based on the information obtained from the mother about the barriers to
practice appropriate complementary feeding, information was given to them
to make adjustments. To increase self-efficacy, for example, the community
health volunteers visited the mothers in their homes and showed how to
prepare the complementary food. Overall, teaching was more personalized
and more active rather than the one-way messages of the TM. The commu-
nity health volunteers assigned to HBM group obtained training to relate the
HBM with the complementary feeding messages.
For the Control group, routine activities by health extension workers
of the Kebeles and others who were performing nutrition and other health
related activities were performed as in the intervention Kebeles, except no
specific nutritional education was given by community health volunteers.
576 B. Tariku et al.

In both intervention groups, the nutritional education (in both HBM and TM)
was given every 2-week by home visits. In addition, they had the mothers
meet as a group at least two times during the intervention period to discuss
feeding practice issues.

Statistical Analysis
Sample size was determined based on the difference between two means
of dietary diversity that had been previously published for similar areas in
Ethiopia (Kebebu et al. 2013). Using a level of confidence of .05 and power
of 80% the required sample size was 36.85 households. With the consid-
eration of 10% dropout rate, it was around 40 for one group. With further
consideration of 1.5 design effect, the sample size of the study was 60 house-
holds per group. The collected data was coded and analyzed using SPSS for
Windows (version 20.0). All continuous variables were checked for normality
using the Kolmogorov–Smirnov test and those not normally distributed data
were transformed. The significance level was set at p < .05. Descriptive statis-
tics were calculated for all relevant variables. Chi-square and Fisher Exact
tests were applied to analyze categorized variable. The differences among
the means between groups were determined by ANOVA and Kruskal-Wallis
test. Student’s t tests and McNemar’s test were conducted to see the differ-
ences between the pre and post- intervention values. Bonferroni correction
was utilized to determine significance in the follow up. Cronbach’s alpha
was used to calculate the reliability coefficient for subscale of health belief
model constructs.

Ethics
Ethical approval was taken from Hawassa University, College of Medicine
and Health Sciences Ethical Review Board. Informed written consent was
provided by all the mothers.

RESULTS

The response rate at post-intervention data collection was 92.2% (n = 166).

There were 54 (90%), 56 (93.3%), and 56 (93.3%) infants and young children
with their mothers who fully participated in the study in the TM group, the
HBM group, and the Control group, respectively. Of households, 14 were
lost to follow-up; 5 households later refused to participate in the nutrition
education and after a repeated attempt, a further 9 were not at their home
during the post-intervention data collection. Of 166 infants and young chil-
dren, 76 (45.8%) were boys, and there was no significant difference among
 Health Belief Model and Complimentary Feeding in Ethiopia 577

groups on the distribution of sex (p = .69). In addition, there were no sig-

nificant differences (p = .66) among the groups on the mean (SD) age in
months. The mean (SD) age of the infants and young children in months of
traditional method, health belief model, and control groups were 11.8 (3.9),
12.0 (4.1), and 11.4 (3.8), respectively, at baseline and there was no signif-
icant difference among groups on their mean age (p = .66). Characteristics
of the mothers and households are given in Table 1. Groups were similar in
these respects.
Before the intervention, 1 (1.9%), 6 (10%), and 0 mothers practiced
some bottle feeding; and during post-intervention, these were 0, 1 (1.8%),
and 2 (3.6%) in the TM, HBM, and Control groups, respectively. At baseline,
all of the infants were being breastfed. After intervention, two mothers in
HBM group stopped breastfeeding before the child reached 24 month of
age. There was a significant increase in meal frequency from pre- to post-
intervention survey (p < .05) for the HBM group and Control group, but not
the TM group.
Using Cronbach’s alpha, the reliability coefficient for subscale was cal-
culated. Pre-intervention Cronbach’s alpha for the perceived susceptibility,
perceived severity, perceived benefits, perceived barriers and perceived
efficacy subscales were 0.74, 0.72, 0.90, 0.70, and 0.51, respectively. Post-
intervention’s Cronbach’s alpha for the perceived susceptibility, perceived
severity, perceived benefits, perceived barriers and perceived efficacy sub-
scales were 0.64, 0.78, 0.87, 0.83, and 0.78, respectively. Table 2 shows
the change in constructs of the health belief model, namely: Susceptibility,

TABLE 1 Mothers’ Occupation and Educational Level and Family Size of the Participating
Households at Baseline among Two Methods of Nutrition Education and Controls

Intervention groups∗

TM HBM Control Total

Characteristics (n = 54) (n = 56) (n = 56) (n = 166)

Occupation of mother (%)

None 9.3 1.8 8.9 6.6
Farmer 31.5 96.4 67.9 65.7
Petty trading 40.7 1.8 23.2 21.7
Other 18.5 0 0 6.0
Mothers’ educational level (%)
None 33.3 30.4 51.8 38.6
Read/write 0 0 10.7 3.6
Grade 1–4 37 35.7 25 32.5
Grade 5–8 25.9 25 10.7 20.5
Grade 9–12 3.7 8.9 1.8 4.8
Family size
Mean ± SD 4.8 ± 1.6 4.8 ± 1.6 5.0 ± 2.0 4.9 ± 1.8
Note. TM = Traditional method; HBM = Health belief model.
∗
There were no significant differences between groups.
578 B. Tariku et al.

TABLE 2 The Constructs of the Health Belief Model Measured for Study Mothers in a Nutrition
Education Intervention Comprising Traditional Method of Nutrition Education, Health Belief
Model of Nutrition Education, and No Intervention

Mean score (SE)

HBM
Intervention construct Pre-intervention Post-intervention p

TM Susceptibility 3.62 (0.94) 3.98 (0.67) .0045

Severity 2.82 (1.28) 2.83 (1.11) .484
Benefit 2.35 (1.12) 2.96 (1.12) <.001
Barrier 3.64 (1.07) 3.73 (0.84) .31
Efficacy 1.63 (0.32) 1.69 (.47) .2145
HBM Susceptibility 2.78 (0.67) 4.03 (0.31) <.001
Severity 2.93 (0.64) 3.54 (0.71) .0325
Benefit 2.03 (0.60) 2.30 (0.50) .0125
Barrier 3.62 (0.60) 3.09 (1.03) .0015
Efficacy 1.83 (0.41) 2.28 (0.37) <.001
Control Susceptibility 3.10 (0.74) 3.34 (0.73) .0595
Severity 1.28 (0.37) 1.31 (0.51) .337
Benefit 1.19 (0.25) 1.35 (0.46) .0015
Barrier 4.06 (0.59) 4.00 (0.47) .2695
Efficacy 1.80 (0.18) 1.91 (0.16) .001
Note. Values are out of a possible score of 5 (highest). Pre and post-intervention changes tested using
paired t-test. TM = Traditional method; HBM = Health belief model; Control = No intervention.

Severity, Benefit, Barrier, and Efficacy. These were moderate to low at

baseline in all groups. After the intervention, all of these improved in
the HBM group, while in the TM group, susceptibility and benefit sig-
nificantly improved, and in the Control group, susceptibility and efficacy
improved.
Practices concerning continued breastfeeding duration and frequency,
improved during intervention but there was not effect of intervention meth-
ods. Similarly, meal frequency and hygiene improved, but with no effect of
intervention method. The minimum and maximum of the meal frequency
were 2 and 5 at baseline survey and 3 and 5 at post-intervention survey,
respectively. The Kruskal-Wallis test for comparison of meal frequency of
infants and young children indicates that there was statistically significant
difference in meal frequency between Kebeles at pre-intervention survey,
H(2) = 23.5, p < .001; and post-intervention survey, H(2) = 54.8, p <
.001. Mann-Whitney test was used to follow up this finding by applying
Bonferroni correction and showed that the difference in the meal frequency
was significant between the HBM Kebele and other two Kebeles (with TM
Kebeles, U = 1,042, p = .002 and with Control Kebeles; U = 759, p < .001).
The post-intervention Mann-Whitney test again showed that significant dif-
ferences were seen between HBM Kebele and Traditional model (U = 449,
p < .001); and the HBM and Control (U = 706, p < .001) Kebeles; how-
ever, there was no significant difference between the Traditional model and
 Health Belief Model and Complimentary Feeding in Ethiopia 579

Control Kebele both during pre-intervention (U = 1,154, p = .066) and post-

intervention (U = 1,327, p = .197) survey. For example, regarding to the
hand washing practice, the proportion of mothers who would wash their
hands after intervention significantly increased for all Kebeles compared to
pre-intervention, but no significant differences were found in the proportion
of hand washing practices. For the use of soap to wash their child’s hand,
there were significant difference between TM and Control Kebeles (p = .005);
and HBM and Control Kebeles (p = .001).
There was a significant difference in diet diversity of infants and young
children, defined11 as eating at least four food groups (Table 3). At baseline,
children in the TM group were consuming the most of the food groups.
In the post-intervention, a greater proportion of children in the HBM group
had more diet diversity than either of the other two groups, which were
not different from each other. Only the HBM based group had a signifi-
cant increase in mean dietary diversity score (p < .001) at post-intervention
compared to baseline.
Almost all infants and young children consumed foods containing
grains, roots, and tubers during both pre- and post-intervention periods.
Vitamin-A rich fruits and vegetables and eggs were much less commonly
consumed, and flesh foods had close to zero usage. There were no sig-
nificant differences between the pre- and post-intervention survey in the
consumption of most of these foods groups. There was a significant differ-
ence in proportion of intake of legumes and nuts food group between pre-
and post-intervention (35.7% vs. 83.9% respectively) (p < .001). Based on
the separate consideration of food groups for the infants and young chil-
dren, significant improvement in consumption was seen only in HBM based
group (p < .001), for legumes and nuts.

TABLE 3 Diet Diversity Score (DDS) and Proportion of Infants and Young Children Who Meet
DDS of Four or More Food Groups in Pre-intervention and Post-intervention of Traditional
Method of Nutrition Education, Health Belief Model of Nutrition Education, or No Intervention

DDS DDS ≥ 4 food groups

Intervention Groups Mean SD % n

Pre-intervention TM 2.43 0.92 13.0 47

HBM 3.05 0.94∗ 37.5 35∗
Control 3.00 0.98 34.0 35
Post-intervention TM 2.69 0.86 20.4 43
HBM 3.79 0.82∗ 67.9 18∗
Control 3.21 0.77 33.9 73
Note. Values given as mean and standard deviation (SD). TM = Traditional method; HBM = Health belief
model; Control = No intervention.
∗
Means sharing symbol are different from each other, p < .05.
580 B. Tariku et al.

DISCUSSION

Continued breast-feeding and complementary feeding practices are funda-

mental to children’s survival and development. Interest has been raised
regarding the first 1000 days, from conception to the second birthday
(Bhutta et al. 2013; Black et al. 2013). Continued, frequent breastfeeding
also protects a child’s health by reducing risk of morbidity and mortality in
disadvantaged populations. The mean breastfeeding frequency of this study
(12.8 times per 24 hour) exceeded the minimum recommended by the WHO,
of 8 times per day (WHO 2008). In our study, all groups improved prac-
tice, even the Control group, suggesting that the presence of investigators
measuring knowledge, perceptions, and practices may have been influen-
tial to improved knowledge, attitude and practices. For example, in China
an educational intervention study (Shi et al. 2009) showed that breastfeed-
ing practices did not differ between nutrition education intervention and
Control groups, suggesting this practice (or lack of practice) cannot be
altered through education (i.e., it may be that it is a practice that is well
understood and needs reminding rather than education).
Of note in our study, while there was an apparent increase in the mean
dietary diversity score in all groups post-intervention, only in the HBM group
was this significant. Improving dietary diversity was one of the objectives of
complementary feeding education. Using HBM, the barriers described by par-
ticipants to using animal source foods included cost and suitable preparation
methods. To allay cost concerns, HBM educations stressed use of legumes
and nuts as these foods improved protein quality of cereals through comple-
mentary amino acids. Our previous work has shown mothers are reluctant to
change from a simple cereal-based porridge until they have been shown the
child will accept (Kebebu et al. 2013). Further, cost of more nutritious foods is
an issue that may take convincing rather than mere educating, which may be
why the HBM worked for diet diversity but the TM did not. Thus only inform-
ing mothers of the need to change is not enough. In a 6-month recipe-based
intervention on adding broad beans to complementary foods in Ethiopia,
Negash and colleagues (2014) found improvements in diet diversity as well
as some significant changes in improved growth of children 6–24 months
old. In that study, the HBM was not used, however reinforcement of the
need for diet diversity was provided. As the HBM improves perceptions, the
improvement in diversity that was seen in our study as a significant increase
in use of legumes (pulses) and nuts, agrees with the findings of those authors
(Negash et al. 2014). Those families not following diversity recommendations
often chose not to do so (e.g., one mother said “the baby’s ability to start
speaking would be delayed”). After the intervention period, mothers still did
not give foods from the flesh food (meat) group, except one mother from the
HBM group. In a study in Peru, Penny and colleagues (2005) showed that
significantly more infants and young children in their education intervention
 Health Belief Model and Complimentary Feeding in Ethiopia 581

group received chicken liver, fish, or egg than did children in the Control
group; in that study, animal-source foods were specifically targeted, and the
intervention period (1 year) was much longer than this study.
In this study design, the strength was having three groups used to see
the effectiveness of using HBM to teach complementary feeding messages.
However, there are some limitations to our study design. The community
health volunteers had to be trained, while the health extension workers
were already teaching messages. To attain participants’ dietary information
we used recalls, a method which may not accurately assess usual intake.
The HBM constructs questions were developed by the investigators and not
tested for their validity beyond using statistical validity test. The numbers
of questions used for assessing the HBM constructs’ subscale were small
(e.g., two questions for assessing perceived severity). The timing of the study
did not take seasonality into account; the duration of the study was only
3 months, which is not long enough to see outcomes in relation to the
nutritional status. Thus, the study examined behavioral outcomes only.

CONCLUSIONS

In this study, an educational intervention based on the health belief model

improved the complementary feeding practice of diet diversity, which may
be the most difficult practice to achieve for mothers in situations of low
income. Other messages related to continued breast feeding practice and
meal frequency were improved in all groups, indicating that the traditional
method is sufficient to remind mothers of these practices. Even mothers in
the control group improved, suggesting that testing of knowledge, attitude,
and practices imparted some learning. This study demonstrated the need
for effective delivery of important nutrition education messages such as diet
diversity, and this deserves further study.

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