https://doi.org/10.

1186/s12889-018-5531-5

RESEARCH ARTICLE Open

Access

Assessment of the knowledge and

attitude of infants’ mothers from Bushehr
(Iran) on food security using
anthropometric indicators in 2016: a
cross-sectional study
Sedigheh Yeganeh1, Niloofar Motamed2, Saeid NajafpourBoushehri3 and Maryam Ravanipour4,5*

Abstract
Background: Among the main elements of food security, in terms of food usage, are knowledge and
attitude. These are particularly important during the initial two years of a child’s life. The present study
was conducted in 2016 and aimed to assess the knowledge and attitude of infants’ mothers from Bushehr
(Iran) towards food security using anthropometric indicators.
Methods: The present cross-sectional, descriptive-analytical study was performed on 400 mothers of children
aged 1-2 years in Bushehr, Iran. Data were collected using a 20-item knowledge questionnaire (CVR = 0.95, CVI =
0.95, and reliability 0.7), a 26-item attitude questionnaire (CVI = 0.94, CVR = 0.91, and reliability 0.76), and a
16-item Radimer/ Cornell questionnaire, which were completed by all mothers. Anthropometric indicators
of children, including height-for-age, weight-for-age, and weight-for-height were also measured in
accordance with the z-score benchmark of the World Health Organization.
Results: A positive and significant relationship was found between knowledge and attitude (r = 0.26, P =
0.0001) as well as between knowledge and household food security (r = 0.11, P = 0.02) in
complementary feeding.
Approximately 26% of the studied children fell under the risk category of overweight to obese. A
significant relationship was found between inadequate knowledge of the mothers and height-for-age (OR =
4.87, P = 0.001) and weight-for-height (OR = 2.33, P = 0.04) indices, as well as between the negative
attitude of the mothers and weight-for-height index (OR = 2.91, P = 0.03).
Conclusions: The knowledge of food security purely relates to the dimension of the household food
security of a family and not to the individual/child level of food security. It seems that the knowledge of a
mother, as a positive factor, does not support child’s food security when the severity of household insecurity
triggers the child’s hunger and food inaccessibility. Also, inappropriate knowledge and negative attitude towards
food security were associated with an increased risk of obesity. Increased weight, in addition to being
affected by the knowledge and attitude of the mothers, is probably also influenced by the incorrect
conduct of the mothers. Further investigation on this topic is recommended.
Keywords: Anthropometry, Complementary feeding, Food security, Obesity, Stunting, Iran

* Correspondence: ravanipour@bpums.ac.ir; ravanipour@gmail.com;

http://www.linkedin.com/in/maryam-ravanipour-79330976
4
The Persian Gulf Tropical Medicine Research Centre, The Persian
Gulf Biomedical Sciences Research Institute, Bushehr University of
Medical Sciences, Bushehr, Iran
5
Department of Nursing, School of Nursing and Midwifery, Bushehr
University of Medical Sciences, Rishehr Street, PO Box 7518759577,
Bushehr, Iran
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution
4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Yeganeh et al. BMC Public Health (2018) Page 2 of
18:621

✓ The prevalence of approximately 25% of overweight and obesity understand how to feed children [17, 18]. There are
in 1-2 years old infants from Bushehr. vari- ous methods to examine feeding status (e.g.
✓ Increased risks of stunting and obesity in infants due to
inadequate knowledge of food security by the mothers. clinical, bio- chemical, dietary, etc.) [19] among which
✓ Increased risks of obesity in infants due to the negative anthropometry is the preferred method [20].
attitude towards food security by the mothers.
✓ Application of the role of household food insecurity knowledge Anthropometric method is the determination of an
to correct food insecurity and prevent child nutritional harm. individual’s physical size and its relation to the
standards, which indicates growth and de-
velopment [21]. By recording the size of a child, one can
determine his/her progress and feeding, individually moni-
tor the health and feeding status of the child, and deter-
Background mine the feeding status of the population [22]. A
The effect of nutrition and food security on human nationwide survey on the development of children in Iran
health, particularly during the early years of childhood, (1998) showed that a large percentage of children in the
is evident [1]. The initial 2 years of life are the most im- country suffer from growth decline. It began from the age
portant contributor to the growth and development of a of 6 months (due to inappropriate feeding pattern and
child. Food insecurity during this period is the source of habits), reached its peak at 18 months (due to inadequate
many chronic diseases during adulthood [2, 3]. In 2015, health care and the feeding knowledge of mothers), and
one out of every 6 American children experienced food then the child effortlessly regained the lost weight [23].
insecurity [4]. Food insecurity among the Iranian chil- The present study was conducted in 2016 and aimed to
dren is reported as high as 67% [5]. assess the knowledge and attitude of infants’ mothers
Feeding during the initial 2 years of life is termed com- from Bushehr (Iran) on food security using
plementary feeding [6] and is associated with many fac- anthropometric indicators.
tors such as the knowledge and attitude of a mother [7].
Mothers play an important role since they are generally Method
responsible for providing and allocating food to the fam- The present cross-sectional, descriptive-analytic study
ily [8]. Aside from financial capacity, as one of the com- was conducted during 2016 in Bushehr, Iran. The study
ponents of food security, studies have shown that children included mothers from Bushehr (Iran) having a child aged
are better fed if their mothers have a sufficient knowledge 1-2 years. The selection criterion was mothers who
of feeding methods [9]. Hence, an appropri- ate attitude referred to the Comprehensive Health Service Centers in
leads to a coherent feeding habit and behav- ior [10]. A Bushehr for routine care and received early instructions
study by Gholizadeh et al. (2017) on rural households in related to complementary feeding. The sample size was
Kermanshah (Iran) indicated feeding knowledge as one of estimated based on n = Z 21-α/2P(1-P)/d2 formula in
the main causes affecting food inse- curity. They accordance with previous studies in the field of
suggested that improving the feeding know- ledge of knowledge and practice [24] and food security in Iran
households is a way to improve household food security [25]. As part of the sampling process, all Comprehensive
[11]. On the other hand, at the household level, food Health Service Centers (n = 10) in the city of Bushehr
security has different components and the amount of were visited. After counting the eligible mothers of
food being purchased and consumed is a major elem- ent each center, a sample size was randomly considered for
[12]. One of the main components of providing food each center. Following 3 months of sampling, the highest
security - in terms of utilization - is knowledge, culture, and lowest number of samples associated with each
and literacy. It allows the family members to easily base center was 64 and 21, respectively. The inclusion
the choice of food on what they like (de- sirability), what criteria were non-diagnostic neurological disorders and
they can afford (affordability), and what they need chronic musculoskeletal diseases of the mother, birth
(adequacy) [8, 13, 14]. It is note- worthy to mention weight of the child > 2.5 kg and < 4 kg, starting
that a study in three southern provinces of Iran, complementary feeding after 6 months of age, a child
including Bushehr, indicated the lack of knowledge as a with no acute and chronic gastrointestinal dis- eases, or
major issue in improving nu- trition [15]. other chronic diseases affecting feeding based on the
Food insecurity (i.e. inadequate feeding in complemen- physician opinion.
tary feeding [16]), is one of the most undesirable forms of The data were collected using the demographic infor-
child neglect and, if prolonged, will have a direct effect on mation form, knowledge questionnaire, attitude ques-
the weight and height of a child [1]. Indirect means (e.g. tionnaire, Radimer/Cornell questionnaire for food
determining the extent of food insecurity, recognizing defi- security, and anthropometric indicators of the child. A
ciencies, and providing appropriate nutrition status assess- dedicated demographic information form comprising 23
ment) are the preferred and most desirable methods to questions, designed according to the demographic vari-
ables required in the research, was developed. The
Yeganeh et al. BMC Public Health (2018) Page 3 of
18:621

design and psychometric measurement of knowledge that the scoring of the negative questions was
and attitude questionnaires on food security, accord- inverted (I do not know and true = 0, wrong = 1).
ing to food access and usage were done based on the
Waltz method (2010) [26]. This was carried out in The 16-item Radimer/Cornell questionnaire was used to
four stages: measure food security [29]. Each item included three
choices (not true, sometimes true, and most often true)
1- Definition of food security and complementary and measured in three segments: household, individual,
feeding of children based on several literature and infant (child) food security within the recent year. If
reviews. the respondent marks all items as not true, the food secur-
2- Design of the questionnaire items according to the ity of household will be at the household level. A house-
three areas of food security (availability, access, hold with food insecurity should positively (sometimes
and utilization) as well as national and international true, and most often true) answer to one or more ques-
studies. The knowledge questionnaire had 20 items tions (items 1-8) and negatively (not true) answer to other
with 3-point Likert scale (right, wrong, I do not items (9-16). The respondent should mark items 9-13 as
know) and the attitude questionnaire had 26 items not true in terms of food security at the individual level.
with 5-point Likert scale (from totally agree to Note that items 14-16 measure child’s food insecurity.
totally disagree). Therefore, the answer “not true” means food security of
3- Determination of the face and content validity of the child whereas positive answer means food insecurity
both questionnaires. The face validity of both and hunger of the child. Internal consistency of the ques-
knowledge and attitude questionnaires was tionnaire was 0.89, 0.82, and 0.79 for food security of the
measured by 10 mothers across all educational household, individual, and child, respectively [30]. The re-
groups. Finally, the coefficient of face validity for liability of the questionnaire was again measured and the
all questions was higher than 1.5. The content Cronbach’s alpha was 0.92 in 30 qualified Iranian samples.
validity of questionnaires was measured by 12 Anthropometric indicators of weight, height, and weight-
individuals (specialized in the fields of nutrition, for-height (WFH)were measured in accordance with the
social medicine, nursing, and public health z-score benchmark of the World Health Organization.
education) using the Lawshe table. In content Weight-for-age index (WFA) was divided into three
estimation, knowledge was scaled by CVR = 0.95 groups of underweight (− 3 ≤ z-score < − 2), normal (− 2
and CVI = 0.95, respectively. Moreover, attitude ≤ z-score ≤ + 1), and overweight (above + 1). The height-
was scaled by CVI = 0.94 and CVR = 0.91, for-age (HFA) was divided into four groups of severe
respectively. short height (less than − 3 z-score), short
4- The reliability of the questionnaire was measured
by Cronbach’s alpha coefficient. The conditions
used for the coefficient in a sample of 30 height (− 3 ≤< z- − 2), normal (− 2 ≤ z-score ≤ + 3),
score
mothers for the knowledge and attitude sections and tall (higher than + 3). The weight-for-height index
were 0.7 and 0.76, respectively. It should be (WFH) was divided into 5 groups of lean (less than − 2),
noted that the knowledge and attitude normal (− 2 ≤ z-score ≤ + 1), overweight (+ 1 < z-score ≤
questionnaires had 2 and 4 negative items, + 2), weight gain (+ 2 < z-score ≤ + 3), and obese (> +
respectively. The knowledge and attitude 3). The weight of the children was measured using a
questionnaires were scored according to previous meas- uring scale with weighing precision of 5 g and
studies (KAP) [27] and FAO guideline for feeding control weights of 50, 100, and 1000 g. The
knowledge, attitude, and performance [28]. measurement was carried out daily in sleeping or sitting
Mothers who correctly answered 70% (14 out of position after hav- ing removed the excess clothes. The
20 scores) and more of the knowledge questions height was also measured in sleeping or standing height
were considered to have the desired knowledge. position using a fabric meter with a precision of 0.1 cm.
Mothers who answered < 70% of the questions The shoes, socks, and other accessories of the child
correctly were considered to have inadequate or were removed before the measurement. The body of
undesired knowledge (I do not know and false = the child was then held in position and the moving
0, I know = 1). In the case of attitude piece was attached to the child’s foot. If the child did
questionnaire, mothers who answered 70% of the not stretch, the height was measured in the standing
questions as agree or totally agree (18 out of 26 position and 0.7 cm was added to determine the height
scores) were considered to have a positive or [31].
desired attitude. Mothers who received scores
less than 18 were considered to have a negative Ethical considerations
and/or undesired attitude (I totally disagree and For the purpose of sampling, following the introduction
no idea = 0, I totally agree and agree = 1). Note of the research, the goals and duties of the participants
Yeganeh et al. BMC Public Health (2018) Page 4 of
18:621
during the study were clarified. The confidentiality of
Yeganeh et al. BMC Public Health (2018) Page 4 of
18:621

the information, including names and personal issues of Table 1 Demographic indicators in a sample of 400
the participants was stated. A written informed consent households with children aged 1-2 years
(e.g. subject to an active and optional presence, op- Variable Frequency %
tional withdrawal in case of unwillingness to continue Mother’s job* Housewife 324 81
with the research, no liability due to damages caused Employed Employee 73 18.3
by the research, and no reimbursement of personal
Housewifery 47 11.8
expenses) was signed by the participants. The study
Self- 1 3
was supported by the Research Council of Bushehr employed
University of Medical Sciences and approved under
Mother’s education Illiterate 5 1.3
the grant number 2015.5624 and the Research Ethics
Primary education 18 4.5
Committee (code: IR.BPUMS.REC.2016.9) of Bushehr
University of Medical Sciences. The mothers who Under diploma 40 10
completed the questionnaires were awarded a comple- Diploma 164 41
mentary feeding manual containing food security is- Bachelor and higher 173 43.3
sues, complementary feeding, and correct answers to Father’s education Illiterate 2 0.5
the questions.
Primary education 29 7.3
Under diploma 51 12.8
Data analysis
The data were analyzed using the SPSS software, version Diploma 153 38.3
18.0. Descriptive statistics including average, mean, and Bachelor and higher 165 41.3
standard deviation was used for demographic and an- Father’s job Employee 172 43
thropometric indicators. Spearman test was used to de- Worker 33 8.3
termine the relationship between knowledge, attitude,
Self-employed 192 48
and food security questionnaires. Chi-square test and
Unemployed 2 0.5
multinomial regression analysis were used to determine
the relationship between anthropometric index and food Income < 5 million IRR 49 12.2
security. Fisher’s exact number and logistic regression 5-10 million IRR 133 33.3
were used to determine the relationship between the an- 10-20 million IRR 160 40
thropometric indicators with knowledge and attitude at 20 million IRR 58 14.5
a significant level of 0.05 and OR with 95% CI.
Type of house Owner 218 54.5
Rented 151 37.8
Results
A total of 400 mothers entered the study. Their mean Living with other family 30 7.5
members
age was 29.53 ± 4.92 years, housewife (81%), employed
(19%), high school diploma (41%), university degree Marital status Married 395 98.8
(43.3%), married (98%), and 98% were not covered by Divorced 1 0.3
any support organization. The mean age of the chil- Widow 2 0.5
dren was 16.44 ± 3.96 months and mean birth weight Living apart 2 0.5
was 3.2 ± 0.43 kg (Table 1). Under coverage of Yes 8 2
In terms of knowledge, 74 (18.5%) mothers had un- supportive organ
No 392 98
desired knowledge of food security in complementary
feeding and 326 (81.5%) had the desired knowledge. Child sex Girl 215 53.8
Based on the results on attitude, 42 (10.5%) mothers had Boy 185 46.3
a negative attitude towards food security and 358 (89. Number of children 1 165 41.3
5%) had a positive attitude. Based on the Radimer/Cor- 2 173 43.3
nell questionnaire, the rate of food insecurity of the 3 54 13.5
household, individual, and child levels was 51.5, 22.3, and
4 6 1.5
11.3%, respectively (results not shown in a table).
5 1 0.3
Spearman correlation coefficient showed a significant
positive relationship between knowledge and attitude 6 1 0.3
(r = 0.26, P = 0.0001) and between knowledge and
household food security (r = 0.11, P = 0.02) (Table 2). 26% were overweight to obese, and only 2.5% had weight
In relation to anthropometric indicators, the results loss. The mean weight of the children was 10.47 ± 1.
showed that 71.5% of the children had normal weight, 66 kg (min: 7.50 kg, max: 18.91 kg). In measuring the
Yeganeh et al. BMC Public Health (2018) Page 5 of
18:621

Table 2 The relationship between food security and maternal knowledge and attitude in complementary feeding
Variable Knowledge Attitude Individual food security Child hunger
r P r P r P r P
Attitude 0.26 0.0001 – – – – – –
Individual food security 0.05 0.25 0.05 0.29 – – – –
Child hunger 0.03 0.49 −0.19 0.70 0.66 0.0001 – –
Household food insecurity 0.11 0.02 0.05 0.29 0.50 0.0001 0.34 0.0001

height-for-age index, only three children had severe short The multinomial regression between the food security
height and 93.5% had a height within the normal range and anthropometric index showed that the odds of
(80.16 ± 4.92). In terms of weight-for-height index, weight gain in food secure households was 0.6 times
72.75% had a weight for normal height and the higher than the food insecure households (OR = 0.61, P
remaining 27.25% (i.e. about a quarter of the children = 0.03). Also, the odds of weight gain in children
aged 1-2 years) fell under the risk category of overweight without hunger (food secure) was 0.4 times higher than
to obese (Table 3). that of children with starvation (OR = 0.4, P = 0.04)
The logistic regression between knowledge and (Table 5).
weight- for-height index showed that the risk of obesity
in chil- dren whose mothers did not have adequate Discussion
knowledge was twice as high as those being lean and Based on the findings of the present study, the majority
having a normal weight (OR = 2.33, P = 0.04). Also, of the mothers had the desired knowledge and positive
the risk of short height in children whose mothers did attitude towards food security in complementary feed-
not have adequate knowledge of food security was ing. This could be the result of preliminary instructions
more than 4 times in comparison with the normal given at all Comprehensive Health Service Centers be-
height (OR = 4.87, P = 0. 001). The risk of obesity in fore and during complementary feeding. The knowledge
children whose mothers had a negative attitude of food security was purely related to the dimension of
towards food security was more than 2 times in household food security of a family and not to the indi-
comparison with the normal weight (OR = 2.91, P = vidual/child level of food security. As an interpretation,
0.03). No relationship was found between other it can be argued that knowledge is as effective as con-
anthropometric indicators to both knowledge and trolling food insecurity that has not involved the child.
attitude (Table 4). Moreover, it seems that parents were prepared to pre-
vent food insecurity of their children even by self-
sacrifice (e.g. hunger). Resorting to food security know-
Table 3 Z-score for the height-for-age (HFA), weight-for- ledge, they attempted alternative foods and tried to re-
age (WFA), and weight-for-height (WFH) of the children aged 1- solve all other issues affecting the health of their
2 years (n = 400)
children. However, it seems that the knowledge of a
Anthropometric Indicators Frequency (%) mother, as a positive factor, does not support child’s food
WFA security when the severity of household insecurity trig-
Underweight 10 2.5 gers a child’s hunger and food accessibility. Household
Normal 286 71.5 support at this stage, either by managing food crises or
Overweight 104 26 resorting to food aid, could be an appropriate solution
to improve the situation.
HFA
A study conducted in India by Jain et al. [32] reported
Sever stunting 3 0.8
that the knowledge of mothers regarding breastfeeding
Stunting 15 3.8 and complementary feeding was at an acceptable level of
Normal 374 93.5 83%. In addition, a study conducted in Boroujerd (Iran)
Tall 8 2 reported that the knowledge of mothers regarding com-
WFH plementary feeding was 61% and satisfactory [24]. A
Wasting 3 0.75
study conducted in Ethiopia by Abeshu et al. [33] re-
ported an appropriate maternal knowledge of food se-
Normal 291 72.75
curity in supplemental nutrition.
Risk of overweight 78 19.5 The results of the present study indicated a positive at-
Overweight 17 4.25 titude towards food security in complementary feeding
Obese 11 2.75 by the mothers. A study conducted in Indonesia by
Suparmi et al. [34] reported 50% positive feeding attitude
Yeganeh et al. BMC Public Health (2018) Page 6 of
18:621

Table 4 Logistic regression analysis between mother’s insufficient knowledge and negative attitude with child (1-2
years) anthropometric indicators (n = 400)
Anthropometric indicators Knowledge (insufficient) Attitude (negative)
OR” CI● P-value OR CI P-value
a
WFH
< + 2 Z-scored 1 1
≥ + 2 Z-scoree 2.33 1.01-5.41 0.04 2.91 1.09-7.71 0.03
b
HFA
< −2 Z-scoref 4.87 1.86-12.75 0.001 0.56 0.15-2.05 0.38
≥ −2 Z-scoreg 1 1
WFAc
≤ + 1 Z-scoreh 1 1
i
> + 1 Z-score 0.81 0.45-1.48 0.51 1.49 0.75-2.95 0.25
a
Weight-for-height
b
Height-for-age
c
Weight-for-age
d
Wasted, normal, risk overweight
e
Overweight and obese
f
Stunting
g
Normal and tall
h
Underweight and normal
i
Overweight
OR”: Odds ratio
CI●: Confidence interval (95%)

of the mothers. According to Behroozeh et al. [35], atti- family member. Such religious tendency is even applied
tude is among the factors affecting food security that during the holy month of Ramadan when they prepare
should be addressed. They argued that the attitude to- special food for distribution to the public [37].
wards the effect of food on health and the notion of food The present study showed a positive and direct rela-
enjoyment relate to food security. Vereecken et al. [36] tionship between knowledge and attitude of the
also concluded that positive feeding attitude of a mother mothers. It indicates that increased knowledge of a
is one of the main principles of feeding adequacy of chil- mother would, in turn, improve her attitude. Since
dren. In addition, feeding habits, the cost of food, health, attitude is the most important factor determining
and religious beliefs have been an effective framework feeding behavior [28], the behavior of the mothers in
for people in Bushehr to store and consume food. Even Bushehr would improve by increasing their knowledge
among poor and less educated people, there was a ten- and aligning their attitude. However, this is inconsistent
dency towards food diversification (red meat, chicken, with the findings of Suparmi et al. [34] who indicated
fish, shrimps, and grain) as a source of protein. They that there was no rela- tionship between knowledge and
consider food diversification as an important contributor attitude.
to health and enforce it even at the cost of distaste by a In relation to the weight-for-height index, the alarming
prevalence of weight gain (from overweight

Table 5 Multinomial regression analysis between food security and anthropometric indicators of insecure to secure (n =
400)
Anthropometric Household food security Individual food security Child hunger
indicators OR CI P OR CI P OR CI P
WFAa
Normal 1 1 1
Overweight 0.61 0.38-0.96 0.03 0.91 0.52-1.57 0.74 0.40 0.16-0.97 0.04
Underweight 1.25 0.34-4.52 0.73 0.85 0.17-4.10 0.84 0.72 0.89-5.88 0.76
WFHb
Normal 1 1 1
Risk of overweight 0.68 0.41-1.13 0.14 0.62 0.31-1.21 0.16 0.45 0.17-1.20 0.11
Overweight and obese 1.02 0.47-2.23 0.94 1.89 0.83-4.30 0.12 0.51 0.11-2.24 0.37
a
Weight-for-age
b
Weight-for-height
Yeganeh et al. BMC Public Health (2018) Page 7 of
18:621

to obese) was about 26.6% (i.e. a quarter of the sam- mothers with poor knowledge use non-nutrient foods
ple population). Compared to other studies, Poh et al. that are only high in calories. Consequently, while a
[38] reported 21.6% overweight and obesity in child may not feel hungry or craving is suppressed, such
Malaysia. Rahmani et al. (2014) reported that obesity non-nutrient foods do not meet the needs of a child in
among the Iranian individuals under 18 years of age terms of nutrition. Contrary to our expectations, the
was only at 6.1% [39]. Increased weight and obesity high prevalence of overweight and obesity in infants sug-
in the early years of life can increase the risk of de- gests that the knowledge and attitude of the mothers to-
veloping metabolic and cardiovascular diseases during wards issues related to malnutrition and underweight
adulthood. It also adversely affects the self-confidence seem to have increased due to prior instructions. Studies
of a child. The cohort study by Ostovar et al. on eld- conducted in the past 10 years in Iran indicated a
erly in Busheh (Iran) highlighted the high prevalence decrease in the prevalence of malnutrition in Iranian
of the tendency for cardiovascular diseases and meta- children. The trend for underweight during 1995 to
bolic syndrome [40]. In the present study, inappropri- 2004 showed an improved nutritional status of children
ate knowledge and negative attitude towards food under 5 years of age in Iran [47]. However, it is unlikely
security were associated with an increased risk of that issues related to weight gain and obesity have been
obesity. A study conducted in Turkey by Yabancı et considered since some Iranian parents perceive slight
al. [41] showed that the higher the knowledge of the overweight as desirable [48].
mothers, the more normal the children index will be.
Heslot [42] concluded that despite the fact that Ira- nians Conclusion
do not suffer from hunger, the community moves The present research, among the few studies conducted in
towards obesity due to the changes in feeding patterns. It Iran, assessed the knowledge and attitude of mothers towards
seems that increased weight, in addition to being food security in complementary feeding. Localized knowledge
affected by the knowledge and attitude of the and attitude questionnaires were used to measure food secur-
mothers, is likely to be the result of inappropriate conduct ity and examine anthropometric indicators of children in
of the mothers despite their adequate know- ledge (e.g. complementary feeding. It was shown that the majority of the
consuming non-nutrient supplements, snacks, high- participants had the desired knowledge and positive attitude
calorie foods with the main meal, irregu- lar use of towards food security in complementary feeding. In the face
supplements beside breast milk, artificial juice drinks, of various levels of food insecurity (household, individual, and
and reduced physical exercise and child mobility due to child), there is a need for alternative approaches. In food se-
local climate). Further investigation regarding the above is cure families, increased food security could be achieved by in-
recommended. creasing the level of knowledge on nutrition. However,
A study conducted in Damavand (Iran) by Salarkia et nutritional packages and family support (economic) will re-
al. also stated that despite their adequate knowledge, duce food insecurity in food insecure families. This topic re-
mothers had inappropriate conduct regarding food se- quires further investigation. Besides, various observations (e.g.
curity in complementary feeding [16]. In a study by the alarming prevalence of weight gain in infants, the relation-
Dhurandhar, obesity was considered as an indication of ship between inadequate knowledge and negative attitude to-
food insecurity [43]. Based on the results of the present wards food security combined with an increased risk of
study, another related index to knowledge was the weight- obesity, and the short stature of infants) indicated the need to
for-height for which the risk in short height in children of determine other factors associated with food insecurity, in-
mothers with inadequate knowledge was high. Shorter cluding the conduct by the mothers in complementary feed-
height is an important indicator for exam- ining the ing. In addition, due to the low number of lean infants, we
feeding status of a child. Note that unlike weight, height combined the lean with normal-weight infants in order to es-
is not rapidly adjusted and it takes a lon- ger time. In a timate logistic regression. Therefore, a case-control study is
study on 1257 primary school children in Hamadan recommended to address this limitation.
(2012), the level of education and knowledge of the
Abbreviations
mothers was considered as one of the causes asso- ciated CVI: Content validity index; CVR: Content validity ratio; HFA: Height-for-age;
with reduced short height [44]. In a study con- ducted in WFA: Weight-for-age; WFH: Weight-for-height
Ghana by Saaka [45], a significant relationship was found
between the height-for-age index and the knowledge of Acknowledgments
The present manuscript is extracted from the Master’s thesis by S.
the mothers. Abuya et al. also considered the education of Yeganeh, the Faculty of Nursing and Midwifery, Bushehr University of
a mother as one of the most important indicators of the Medical Sciences, Bushehr, Iran. The study was approved in 2015 and
financially sponsored by the Deputy of Research of Bushehr
height-for-age index of a child [46]. Based on the
University of Medical Sciences. We would like to express our
relationship between inadequate know- ledge and obesity gratitude and appreciation to the respective authorities, the
and short height, it is concluded that participating mothers, and the staff of Bushehr Health Service Centres.
Yeganeh et al. BMC Public Health (2018) Page 8 of
18:621

Funding Received: 15 September 2017 Accepted: 1 May 2018

This work was supported by the Research Council of Bushehr
University of Medical Sciences (grant number: 2015.5624). The
Research Council of Bushehr University of Medical Sciences had no
role in the conduct of the study, data analysis or interpretation, writing References
the manuscript, or decision to submit for publication. 1. Pushpa KS, Rani DJ. Nutritional profile of children (0-5years) in the
service villages of Gandhigram rural institute. Curr Res Nutr Food Sci.
2015;3(1) https://doi.org/10.12944/CRNFSJ.3.1.09.
Availability of data and materials
2. Black R, Singhal A, Uauy R. International nutrition: achieving
The datasets used and/or analysed during the current study are
millennium goals and beyond. Nestlé Nutr Inst Workshop Ser.
available from the corresponding author upon reasonable request.
2014;78:111–20. Nestec Ltd. Vevey/S. Karger AG Basel, ©
3. Bottino CJ, Rhodes ET, Kreatsoulas C, Cox JE, Fleegler EW. Food
Authors’ contributions insecurity screening in pediatric primary care: can offering referrals
The contribution of the authors to the research were: Research design by help identify families in need? Academic pediatrics. 2017;17(5):497-
SY, NM, SN-B, MR; data collection by SY; research execution by SY, NM, 503.
MR; data analysis by NM; draft manuscript by SY; documentation by SY, NM, 4. Feeding America. http://www.feedingamerica.org/research/map-the-meal-
SN-B, MR; and primary responsible for the final content by MR. All gap/2015/2015-mapthemealgapexec-summary.pdf. 2015.
authors have read and approved the final manuscript. 5. Behzadifar M, Behzadifar M, Abdi S, Salmani MA, Ghoreishinia G, Falahi
E, et al. Prevalence of food insecurity in Iran: a systematic review and
meta- analysis. Arch Iran Med. 2016;19(4):288.
Authors’ information 6. Yue A, Marsh L, Zhou H, Medina A, Luo R, Shi Y, et al. Nutritional
Sedigheh Yeganeh: Master of Science in Paediatric Nursing from the deficiencies, the absence of information and caregiver
Department of Nursing, School of Nursing and Midwifery, Bushehr University shortcomings: a qualitative analysis of infant feeding practices in
of Medical Sciences, Bushehr, Iran. Her thesis is on “Assessing the rural China. PLoS One. 2016;11(4):e0153385.
Knowledge, Attitude, and Practice of Mothers with the Approach to 7. Dumaguing NV, Ignacio JLC, Naupal RT, Apostol NES, Ilagan JR,
Finding the Rate and Causes of Food Insecurity in Bushehr Children from Talavera MTM. Knowledge, attitude, and Practices of complementary
the Viewpoints of Medical Sciences and Public Health.” feeding by Mothersin the BayaniJuan Southville 7 Resettlement Village
Niloofar Motamed: Associate Professor of Community Medicine in Calauan, Laguna, Philippines. J Hum Ecol. 2011;1(1):58-9.
(MD/MPH) at Bushehr University of Medical Sciences, Bushehr, Iran. Her 8. Seyedhamzeh S, Damari B. The conceptual model of food and
work focuses specifically on promoting population health and the role nutrition security in Iran. Community Dent Health. 2017;4(3):228–37.
and contribution of the health system. Children as a vulnerable group 9. Mutisya M, Ngware MW, Kabiru CW, Kandala N-b. The effect of
are the focus of her research. education on household food security in two informal urban
Saeid NajafpourBoushehri: Assistant Professor of Nutritional Sciences settlements in Kenya: a longitudinal analysis. Food Security.
(Ph.D.) at the Department of Nutrition, School of Health and Nutrition, 2016;8(4):743–56.
Bushehr University of Medical Sciences, Bushehr, Iran. He has a 10. Paknahad Z, Sharifirad GR, Yazdani M, Hoseini SM. Effect of nutrition
food security fellowship and his work focuses specifically on education on nutritional knowledge and attitude among adolescent
promoting food hygiene. girls (Isfahan_ Iran). Health Syst Res. 2010;6(1):73–7.
During the past five years he has been the Head of Food Control 11. Gholizadeh H, Motlagh ZR, Badsar M, Shams A. Culture and nutrition
Laboratory and the Deputy of Food and Drug at Bushehr University of knowledge, and their relationship with food insecurity among rural
Medical Sciences. Maryam Ravanipour: Associate Professor of Nursing at households in Kermanshah County, Iran. J Rural Res. 2017;8(1):52–
Bushehr University of Medical Sciences; the Persian Gulf Tropical 65.
Medicine Research Centre, and the Persian Gulf Biomedical Sciences 12. FANTA project. https://www.fantaproject.org/focus-areas/food-security.
Research Institute (Bushehr, Iran). Her work focuses specifically on nursing Accessed 07 May 2018.
care and empowering the patients and their family, especially those with 13. Ghasemi H. Food and nutrition security and future challenges in the
chronic diseases. country. first Conference on Agriculture and the National
Developmentaccess in: http://www.ensani.ir/storage/Files/20101213180438-
94163.pdf (text is persian):1022-50.
Ethics approval and consent to participate 14. Sumarti T, Adiwibowo S, Vitayala A. The Power of Women’s
The study was approved by the Research Ethics Committee (code: Knowledge in Food Security at the Rural Families in Indonesia (The
IR.BPUMS.REC.2016.9) of Bushehr University of Medical Sciences, Bushehr, Case in South Sumatera). 2014;4(7):308-13.
Iran. A written informed consent was obtained from all participants. 15. Farivar F, Heshmat R, Azemati B, Abbaszadeh Ahranjani S, Keshtkar
A, Sheykholeslam R, et al. Understanding knowledge about, general
attitudes toward and practice of nutrition behavior in the Iranian
Competing interests
population. Iran J Epidemiol. 2009;5(2):11–8.
The authors declare that they have no competing interests.
16. Salarkia N, Amini M, Abdollahi M, Eshrati B, Neyestani TR. Mothers’ views
on food security and complementary feeding: a qualitative study in urban
Iran. Nutr Food Sci Res. 2014;1(2):35–42.
Publisher’s Note 17. Rineh HN, Salarkia N. Height and weight of less than 5-year-old
Springer Nature remains neutral with regard to jurisdictional claims children, Tonekabon, 2000-01. J Babol Univ Med Sci. 2004;6(1):55–
in published maps and institutional affiliations. 9.
18. Corkins KG, Teague EE. Pediatric nutrition assessment. Nutr Clin Pract.
Author details 2017; 32(1):40–51.
1
Department of Nursing, School of Nursing and Midwifery, Bushehr 19. Suskind RM, Varma RN. Assessment of nutritional status of children.
University of Medical Sciences, Rishehr Street, PO Box 7518759577, Pediatr Rev. 1984;5(7):195–202.
Bushehr, Iran. 2Department of Community Medicine, School of Medicine, 20. Darvishi S, Hazhir MS, Reshadmanesh N, Shahsavari S. Evaluation of
Bushehr University of Medical Sciences, Moallem Street, PO Box malnutrition prevalence and its related factors in primary school students
7514763448, Bushehr, Iran. 3Department of Nutrition, School of Health and in Kurdistan Province. Sci J Kurdistan Univ Med Sci. 2009;14(2):78–87.
Nutrition, Bushehr University of Medical Sciences, Rishehr Street, PO Box 21. Mahan LK, Escott-Stump S. Krause's food & nutrition care process :
7518759577, Bushehr, Iran. 4 The Persian Gulf Tropical Medicine Research 2vol: offset. 2012:420-421.
Centre, The Persian Gulf Biomedical Sciences Research Institute, Bushehr 22. WorldVisionInternational. Measuring and promoting child growth
University of Medical Sciences, Bushehr, Iran. 5Department of Nursing, Facilitator’s manual. World Vision International, Global Health and WASH.
School of Nursing and Midwifery, Bushehr University of Medical Sciences, 2010;Version 2.
Rishehr Street, PO Box 7518759577, Bushehr, Iran. 23. Barak M, Amani F, Mirza Rahimi M, Abbasgholizadeh N, Hamid Kholgh
A R. Evaluating Mothers’ Knowledge about Infant Proper Nutrition in Hir
Health Center, 2001. J Ardabil Univ Med Sci. 2005;5(1):26-29.
Yeganeh et al. BMC Public Health (2018) Page 9 of
18:621
24. Soheili Azad AA, Yeghaneh Ghasemi L, Naserkhaki V. Knowledge and practice of women referred to health centers Boroujerd on
complementary feeding. 2. 2013;2(2):97–102.
25. Alimoradi Z, Kazemi F, Estaki T, Mirmiran P. Household food security in Iran: systematic review of Iranian articles. J Nurs Shahid Beheshti Univ
Med Sci. 2014;24(87):63–76.
26. Waltz CF, Strickland OL, Lenz ER. Measurement in nursing and Health Research. 4th ed. New York: Springer Publishing Company; 2010.
27. Soares LS, Almeida RCC, Cerqueira ES, Carvalho JS, Nunes IL.
Knowledge, attitudes and practices in food safety and the presence of coagulase-positive staphylococci on hands of food handlers in the
schools of Camaçari, Brazil. Food Control. 2012;27(1):206–13.
28. Marías Y, Glasauer P, Macias Y. Guidelines for assessing nutrition-related knowledge, attitudes and practices: Food and Agriculture
Organization of the United Nations (FAO) Publisher, Location of publication: Rome, Italy. 2014.
29. Radimer KL, Olson CM, Campbell CC. Development of indicators to assess hunger. J Nutr. 1990;120(Suppl 11):1544–8.
30. Zerafati_Shoae N, Omidvar N, Ghazi-Tabatabaie M, Houshiar_Rad A, Fallah H, Mehrabi Y. Is the adapted Radimer/Cornell questionnaire valid to
measure food insecurity of urban households in Tehran, Iran?. Public Health Nutrition. 2007;10(8):855-61.
31. Talachyan E, Bidari A, Barakati SH, Allahi AH, Lornezhad HR, et al. Comprehensive guide integrated care healthy children. Published by
Andishe Mandegar. Qom, Iran. 2015. ISBN:978-600-6782-15-7.
32. Jain S, Thapar RK, Gupta RK. Complete coverage and covering completely: breast feeding and complementary feeding: knowledge, attitude, and
practices of mothers. Med J Armed Forces India. 2017;
33. Abeshu MA, Adish A, Haki GD, Lelisa A, Geleta B. Assessment of Caregiver’s knowledge, complementary feeding practices, and adequacy of nutrient
intake from homemade foods for children of 6–23 months in food insecure Woredas of Wolayita zone, Ethiopia. Front Nutr. 2016;3:32.
34. Suparmi, Desanti OI, Cahyono B. The correlation between knowledge and attitude on food colorant uses of PKK mothers in Penggaron Lor
Village. Procedia Food Sci. 2015;3:156–61.
35. Behroozeh S, Shahvali M. Comparison of food security villagers with different attitude and nutritional culture in three zones of climate south of
Kerman Province. J Rural Res. 2016;7(3):454–69.
36. Vereecken C, Maes L. Young children’s dietary habits and associations with the mothers’ nutritional knowledge and attitudes. Appetite. 2010;
54(1):44–51.
37. Ravanipour M, Ravanipour M, Pouladi S, Vahedparast H, Yazdankhahfard M, Hajinejad F, et al. Culture of food preservation among Bushehrian people
in Iran. Pak J Nutr. 2009;8(8):1212–7.
38. Poh BK, Ng BK, Siti Haslinda MD, Nik Shanita S, Wong JE, Budin SB, et al. Nutritional status and dietary intakes of children aged 6 months to 12
years: findings of the nutrition survey of Malaysian children (SEANUTS Malaysia). Br J Nutr. 2013;110(Suppl 3):S21–35.
39. Rahmani A, Sayehmiri K, Asadollahi K, Sarokhani D, Islami F, Sarokhani M. Investigation of the prevalence of obesity in Iran: a systematic review and
meta-analysis study. Acta Medica Iranica. 2015;53(10):596–607.
40. Ostovar A, Nabipour I, Larijani B, Heshmat R, Darabi H, Vahdat K, Ravanipour M, Mehrdad N, Raeisi A, Heidari G. Bushehr elderly health (BEH) Programme,
phase I (cardiovascular system). BMJ Open. 2015;5(12):e009597.
41. Yabancı N, Kısaç İ, Karakuş SŞ. The effects of Mother’s nutritional knowledge on attitudes and behaviors of children about nutrition. Procedia Soc
Behav Sci. 2014;116:4477–81.
42. Heslot S. Iran’s Food Security. http://www.futuredirections.org.au/ publication/iran-s-food-security/2014. Accessed 07 May 2018.
43. Dhurandhar EJ. The food-insecurity obesity paradox: a resource scarcity hypothesis. Physiol Behav. 2016;162:88–92.
44. Davoodi M, Amini P, Vahidinia A. Evaluation of stunting prevalence and its association to parental education, socioeconomic status and
household size of first-grade students in Hamadan, 2012. Pajouhan Sci J. 2015;13(3):58–65.
45. Saaka M. Relationship between mothers’ nutritional knowledge in childcare practices and the growth of children living in impoverished rural
communities. J Health Popul Nutr. 2014;32(2):237–48.
46. Abuya BA, Ciera J, Kimani-Murage E. Effect of mother’s education on child’s nutritional status in the slums of Nairobi. BMC Pediatr. 2012;12:80.
47. Sheikholeslam R, Naghavi M, Abdollahi Z, Zarati M, Vaseghi S, Sadeghi Ghotbabadi F, et al. Current status and the 10 years trend in the
malnutrition indexes of children under 5 years in Iran. Iran J Epidemiol. 2008;4(1):21–8.
48. Akbari N, Forozandeh N, Delaram M, Rahimi M. Parent’s perception of obesity their 6-12 year old in obese child can parental education be
effective? Iran J Endocrinol Metab. 2006;8(3):241–8.