Study area and period

The study was conducted from March 15 to April 15, 2020, in Legambo district, South Wollo area, northern Ethiopia. The district is located in the Amhara region of the South Wollo area. it is located on the beautiful highlands of southern Wollo at an altitude of about 3000 m above sea level and is located 100 km from Dessie (the capital of the south Wollo area), 430 km from Bahir Dar (the capital of the Amhara region) and 501 km from Addis Ababa (the capital of Ethiopia). The district has 33 health posts, 9 health centers, 1 hospital, 78 health extension workers. The total district population was 281,974 with 147,160 men and 134,748 women while the total number of children aged 0 months to 23 months was 10,172 in 2017, which was projected from the Woreda administrative office. [20].

Study design

A community-based unpaired case-control study design was used.

Eligibility criteria

All mother-child couples aged 0 to 23 months residing in Legambo district during the study period were included in the study. While children aged 0-23 months with chronic illnesses and those on treatment such as tuberculosis, HIV were excluded from the study.

Determination of sample size

The sample size was calculated using Epi Info version considering the following assumptions:, power of 80%, case / control ratio of 1: 3, design effect of 1.5 and non-response of 10% [12]. The final sample size was 363 (91 cases and 272 controls).

Sampling procedures

A multistage sampling technique was used to select study participants. Out of 34 kebeles in the district, 7 kebeles were selected by lot. The list of mother-child couples aged 0 to 23 months and their house numbers for each kebele were obtained from the health extension workers. House-to-house enumerations were carried out to identify cases and witnesses and children aged 0-23 months were identified and recorded sequentially and had an identification number as case and control. And then the total sample size was allocated proportionally to each kebele. Finally, cases and controls were selected by a simple random sampling technique.

Operational definitions

Case: A child’s participation in GMP services at least once for 0 months, at least twice for 1 to 3 months, at least five times for 4 to 11 months, and at least four times a year for 12 to 23 months.

Control: a child who had not participated in GMP services at least once for 0 months, at least twice for 1 to 3 months, at least five times for 4 to 11 months and at least four times a year for 12 to 23 month.

Good knowledge: is defined as a score greater than 7 out of the total of ten knowledge questions [13].

Bad knowledge: is defined as having a score less than 7 were considered to have low knowledge [13].

Unfavorable attitude: is defined as a score

A favorable attitude: is defined as a score ≥ 75% [13].

Data collection tools and procedures

Data were collected using a structured questionnaire administered by the interviewer. The questionnaire includes socio-demographic, economic, health care, behavioral and characteristics related to the mother / caregiver and adapted from previous studies [12, 13, 16, 21, 22] and collected by two nurse clinicians and three trained midwives and three well-trained and experienced supervisory health workers.

The antenatal visit was assessed on the basis of the minimum recommended visits (yes; for having had four or more visits and no; for less than four visits). And, PNC was also assessed based on the recommended minimum visits (yes; for having had at least one visit in the postpartum period and no; for no visit at all). The immunization status of the children was checked by observing the immunization card and if it was not available, mothers / caregivers were asked to recall it. BCG vaccination was verified by observing a scar on the right arm (also left). The household wealth index was determined using Principal Component Analysis (PCA) taking into account latrines, water source, household assets, livestock and agricultural land adopted at from EDHS 2016. [10]. Responses for all variables were classified into two scores. The highest score was coded 1 and the lowest score was coded 0. The PCA assumptions were checked to perform the wealth index score. In the PCA to determine the number of components that would be retained, the criterion of eigenvalue one was used and variables with a common value greater than 0.5 were used to produce factor scores. Finally, the score of each household on the first main component was used to create the wealth score. Finally, wealth score tertiaries were created to classify households into poor, middle and rich.

Distance to health facility determined by distance (time taken to reach health facility from mother’s home to nearest health facility). The distance to the health facility was classified as less than 1 hr and greater than 1 hr to reach the nearest health facility [23]. Mothers’ knowledge of using GMP services was assessed using ten knowledge questions. Each question has two answers (yes = 1 or 0 = no). The total score ranges from 0 to 10. A score greater than 7 was classified as good knowledge and less than 7 was classified as poor knowledge. [13]. The mother’s attitude towards the GMP service was assessed by 12 attitude questions using Likert scale measures (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree). The total score ranges from 12 to 60. A score ≥ 75% was classified as a favorable attitude and a score

Data quality assurance

The questionnaire was translated into Amharic and retranslated into English to ensure consistency. The questionnaire was pre-tested in 5% of the population sampled in the unselected kebeles before the actual data collection. Data collectors and supervisors were trained for 2 days. The test-retest reliability of the research instrument was established during the pretest. The reliability of the retest was established by examining the consistency of the pretest responses. Spot checks and corrections were made for incomplete questionnaires by the supervisor. The overall data collection process was controlled by the principal investigator.

Data processing and analysis

The data were coded and entered into Epi info version 7 and exported to SPSS version 23 for analysis. Descriptive statistics were calculated and presented using tables, figures and graphs. The quality of the fitness model was assessed using the Hosmer and Lemeshow test. Multicollinearity between the independent variables has been verified. A bivariate logistic regression was performed and the variables with pP-value


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