Minimum acceptable diet and associated factors among children aged 6–23 months in Ethiopia

Introduction: The health and growth of children less than two years of age can be affected by the poor quality of complementary foods and poor feeding practices even with optimal breastfeeding. In Ethiopia, empirical evidence on the minimum acceptable diet and its associated factors is limited. Therefore, this study was aimed to assess the level of minimum acceptable diet and its associated factors among children aged 6–23 months in Addis Ababa Ethiopia. Methods: An institution-based Cross-sectional study was conducted among a total of 575 mother-child pairs. A simple random sampling technique was used to recruit participants. For infant and young child feeding practices, the data collection tools were adapted from world health organizations’ standardized questionnaire which is developed in 2007. Data entry and analysis were performed using EPI data version 3.1 and SPSS version 20 respectively. Bivariable and multivariable logistic regression analyses were performed to determine predictor variables. Statistical significance was declared at p-value < 0.05. Result: In this study, the level of minimum acceptable diet was found to be 74.6%. About 90.6 and 80.2% of the children received minimum meal frequency and dietary diversity respectively. Having a husband secondary and above educational level [AOR = 4.789(95%CI:1.917–11.967)], being a housewife [AOR = 0.351(95% CI: 0.150–0.819)], having a history of more than three postnatal follow-ups [AOR = 2.616(95%CI:1.120–6.111], Having mothers age between 25 and 34 years [AOR = 2.051(95%CI:1.267–3.320)], being male child [AOR = 1.585(95%CI:1.052–2.388)] and having children age between 18 and 23 months [AOR = 3.026(95%CI:1.786–5.128)] were some of the factors significantly associated with a minimum acceptable diet. Conclusion: In this study, the minimum acceptable diet among children aged 6–23 months was significantly associated with the educational status of the husband, mother’s occupation, history of postnatal follow-up, age of the mother, sex of the child, and age of the child. Thus, attention should be given to educating the father, empowering mothers to have a job, promoting gender equality of feeding, and counseling on the benefit of postnatal care visits. In addition, the ministry of health should work on educating and advocating the benefit of feeding the recommended minimum acceptable diet to break the intergenerational cycle of malnutrition. An institution-based cross-sectional study was conducted from June 01 to June 30, 2019, in the city of Addis Ababa Ethiopia. The city comprises 10 sub-cities (Kifle Ketemas). Yeka sub-city, Bole sub-city, and Arada sub-city were three of the ten sub-cities with a total population of 454,850, 406,059, and 279,020 respectively. The expected number of children aged 6–23 months was 21,872 (8719 from yeka sub-city, 7796 from Bole sub-city and 5357 from Arada sub-city). Yeka sub-city had 14 districts and 15 health centers and one governmental hospital, Bole sub-city had 10 health centers and 15 districts and Arada sub-city had 9 health centers and 10 districts (Addis Ababa city administration health bureau of 2011 E. C data). All children aged 6–23 months who came for the expanded program on immunization (EPI) at the government health facility in Addis Ababa, Ethiopia were the source population whereas those children aged 6–23 months and came to the Expanded Program on Immunization (EPI) during the data collection period at the selected governmental health centers were taken as the study population. All children aged 6–23 months with a permanent residence of the mother (lived for at least six months) who came for the Expanded Program on Immunization (EPI) only. Children aged 6–23 months whose mothers had (permanent residents) in the study area during data collection. While those children aged 6–23 months with known medical or surgical problems were excluded. Minimum dietary diversity: was taken as an achieved if the children were received four or more food groups from of the seven food groups such as grains, roots and tubers; legumes and nuts; dairy products (milk, yogurt); Flesh foods (meat, fish, poultry, and liver/organ meats); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables [19–21]. Minimum meal frequency: The children who received solid, semisolid, or soft foods is taken as minimal meal frequency and was measured when the infant feeds twice for breastfed infants 6–8 months, three times for breastfed children 9–23.9 months, and four times for non-breastfed children 6–23 months [19, 21]. Minimum acceptable diet: For breastfed children, it is achieved if the child meets both the MDD and MMF criteria. For non- breastfeed children, the child has to receive at least four food groups excluding dairy products, two milk feeds, and MMF [19]. Satisfactory exposure to media: If Women aged 15–49 years read a newspaper or magazine or listen to the radio, or watched television at least once a week [15]. Household income: consists of all receipts whether monetary or in-kind (goods and services) that are received by the household or by individual members of the household at annual or more frequent intervals, but exclude windfall gains and other such irregular and typically one-time receipts [22]. Household food security: households who experience none of the food insecurity (access) conditions, or just experience worry, but (one or two times in the last 4 weeks) are labeled as “Food secured” [23, 24]. Household food insecure: in the ability of households to access sufficient food at all time to lead to an active healthy life (includes all stage of food insecurity; mild, moderate and severe) without eating), even as infrequently as rarely (one or two times in the last 4 weeks) [25]. Maternal decision making: if the mother has the right to decide on the amount of food type of food and the right to buy food for the baby, then the mother is said to be involved in the decision making. However, if she doesn’t involve in any of the above criteria, then the mother is said to be not involved in the decision-making. Timely introduction of complementary feeding: the Introduction of solid, semi-solid, or soft foods, minimum meal frequency, minimum dietary diversity, and consumption of iron-rich or iron-fortified foods and started at six months of age [21, 26]. Appropriate:-if the mother responds correctly to all four indicators (timely introduction of complementary feeding, MMF, MDD, and MAD). Inappropriate:-among the four indicators if at least one indicator was not fulfilled [27]. The minimum sample size was determined using a single and the double population proportion formula for the first and the second objectives respectively and was calculated using Epi Info™ version 7 stat calc. The final required sample size (large sample from the two objectives) for this particular study was obtained using the second objective and it was 575 [10]. Out of 10 sub-cities in the city, 30% of them (3 sub-cities such as Yeka, Bole and Arada) were selected by lottery method. From each sub-city 30% of their health centers (HC) were again selected by lottery method (from yeka 5 HC, from Bole 3 HC and Arada 2 HC). The eligible total number of children aged 6–23 months from each sub-city were selected using population size to proportional allocation based on their medical record number as sampling frame (Fig. 1). simple sketch map for sampling procedure of the study for minimum acceptable diet A structured and pre-tested interviewer-administered questionnaire was prepared by reviewing relevant works of different literature. Primary data on the practice of minimum acceptable diet, minimum dietary diversity by 24 h method, minimum meal frequency, and related factors were collected from mothers or caregivers who had a child aged 6–23 months by using the 24-h recall method. Five experienced well-trained and experienced clinical nurses and two senior public health officers were recruited and trained for data collection and supervision, respectively. The data collection tool regarding the various factors is adapted from EDHS 2016 and different literature with some modifications to fit with the local context. Moreover, the tool on dietary diversity meal frequency was adapted from the WHO standardized questionnaire for IYCF practices [21]. To ensure quality, the questionnaire was translated into the local language by experts. Finally, before data collection, it was re-translated back to English to verify consistency. Before starting the actual data collection, one day of extensive training was given for the data collectors and supervisors. A pre-test for appropriateness and feasibility of the tool was conducted and all necessary modifications and amendments were done accordingly. The tool was used with a reliability test or Cronbach’s alpha correlation coefficient of greater than or equal to 0.7 for inter-item consistency. The completeness and accuracy of questionnaires were checked daily before leaving the data collection site for immediate action. After data collection before analysis, all collected data were checked for completeness. Double data entry (data were entered by two people independently) was performed to check the consistency or reduce data entry error. The collected data were coded, cleaned, edited, and entered into Epidata version 3.1 and exported to SPSS version 20.0 for statistical analysis. The presence of an association between explanatory and outcome variables was ascertained using binary logistic regression analysis. The goodness of fit was tested by the log-likelihood ratio (LR). To control all possible confounders all variables with P < 0.25 in the bivariate analysis were included in the final model of multivariable analysis. To see the correlation between independent variables multi-collinearity test was carried out by using collinearity statistics. Values with the standard error > 2 were dropped from the analysis. In a multivariable model adjusted odds ratio determined with a 95% confidence level was used to assess the strength of association. In this study P-value < 0.05 was deemed to declare statistical significance. Then, the finding was presented by using simple frequencies, summary measures, tables, texts, and figures.