Maternal behavioural determinants and livestock ownership are associated with animal source food consumption among young children during fasting in rural Ethiopia

Maternal and Child Nutrition, Volume 15, No. 2, Year 2019

Interpretação

Religious fasting often involves abstention from animal source foods (ASFs). Although children are exempt, their diets are influenced by the widespread fasting practices. This study investigated the factors influencing ASF consumption among young children during the Lent fasting period in western Amhara, Ethiopia. We used baseline survey data from households with children 6–23 months of age (n = 2,646). We conducted regression analysis to examine the maternal and household factors associated with ASF consumption and path analysis to examine the direct and indirect effects of maternal knowledge, beliefs, social norms, and livestock ownership on ASF consumption. Only 24% of children consumed any ASF in the previous day—18% dairy products, 5% eggs, and 2% flesh foods. Mothers with high knowledge, beliefs, and social norms about feeding children ASFs during fasting had higher odds (odds ratio: 1.3–1.4) of children who consumed them. Compared with households with no ASFs, those with ASFs available were 4.8 times more likely to have children who consumed them. Most of the association between knowledge, beliefs and social norms, and ASF consumption was explained by pathways operating through ASF availability (approximately 9, 12, and 8 pp higher availability, respectively), which in turn were associated with higher consumption. Cow ownership was directly and indirectly associated with ASF consumption, whereas having chickens was indirectly associated with consumption via the availability pathway. Our findings corroborate the importance of maternal behavioural determinants related to feeding ASFs to children during fasting on ASF consumption via household availability and the positive influence of livestock ownership. Study data were drawn from the baseline household survey conducted as part of the programme evaluation of Alive & Thrive (A&T) Phase II (2015–2017) in Ethiopia. A&T is an initiative to save lives, prevent illness, and contribute to healthy growth and development through improving infant and young child feeding (IYCF) practices. In Phase I (2009–2014), A&T operated in Bangladesh, Ethiopia, and Vietnam, reaching millions of children less than 2 years of age through large‐scale social and behaviour change communication interventions and achieving considerable gains in IYCF practices (Kim et al., 2016; Menon, Nguyen, Saha, Khaled, Kennedy, et al., 2016a; Menon, Nguyen, Saha, Khaled, Sanghvi, et al., 2016b; Rawat et al., 2017). The focus of Phase II in Ethiopia is to operationalize the Government of Ethiopia’s National Nutrition Plan in one region, Amhara, to improve breastfeeding and complementary feeding practices using a multiple sector approach. The baseline survey was carried out in March and April 2015, during the Lent fasting period, in 20 woredas (districts) belonging to three western zones of Amhara region (Awi, North Gondor, and West Gojjam) that do not participate in the Productive Safety Net Programme (national cash and food transfer programme targeted to chronically food‐insecure households; Government of the Federal Democratic Republic of Ethiopia, 2004). Within each of the 20 survey woredas, four enumeration areas (EAs—a geographical unit consisting of 150–200 households) were randomly selected, to yield a total of 80 EAs. At each EA, households from a listing of all eligible households were randomly selected to meet the estimated sample sizes for the impact evaluation. A total of 2,646 households with children 6–23 months of age participated in the survey. Given that 96.1% of our sample were Orthodox Christian, we restricted our sample to this group only. Data on ASF consumption were available for 2,536 mother–child pairs. All mothers of the study children were provided with information about the study at recruitment, and verbal informed consent was obtained from all participants. Data were collected via face‐to‐face interviews using a structured questionnaire. Ethical approval was obtained from the Institutional Review Boards of Addis Continental Institute of Public Health in Ethiopia and the International Food Policy Research Institute in Washington, D.C., USA. Child feeding practices were assessed by asking mothers about all liquids and solid and semisolid foods consumed by their children during the previous day. Dietary data for children 6–23 months of age were categorized into seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, and cheese); flesh foods (meat, fish, poultry, and liver/organ meats); eggs; vitamin‐A‐rich fruits and vegetables; and other fruits and vegetables. The main outcome variable was consumption of ASF (yes/no), which was defined as consumption of any of the following three food groups: dairy, flesh foods, and eggs in the past 24 hr. We also constructed five complementary feeding indicators on the basis of the WHO recommendations (WHO, 2010) including (a) minimum dietary diversity (received foods from 4 or more food groups), (b) minimum meal frequency as appropriate for age, (c) minimum acceptable diet (achieved the minimum dietary diversity and age‐appropriate minimum meal frequency), (d) consumption of iron‐rich foods, and (e) timely introduction of solid, semisolid, or soft foods (introduced to these foods when infants were 6–8 months of age). Because nearly all children were breastfed, we did not stratify the sample on breastfeeding status. We measured several potential behavioural determinants—maternal knowledge, beliefs, and perceived social norms (Glanz, Rimer, & Viswanath, 2008). Knowledge questions about ASF were drawn from a broader set of IYCF knowledge questions validated in a previous study (Menon, Ruel, Arimond, & Ferrus, 2003), whereas questions related to beliefs and social norms were developed specifically for this study on the basis of formative research findings (Alive & Thrive, 2016). Maternal knowledge about ASF was assessed on the basis of mothers’ responses to questions related to knowledge on timely introduction of different ASFs, frequency of feeding children ASFs, and benefits of ASFs to young children for growth and brain development (Table S1). Each correct answer was given a score of 1, yielding a total knowledge score of 10 (range 0–10). Maternal beliefs about ASF feeding during fasting was assessed on the basis of levels of agreement to statements about whether children should be fed eggs, milk, and meat during and outside the Lent fasting period. Each item was measured using a 5‐point Likert scale in which women responded with the degree to which they agreed or disagreed with the two statements (Table S1), yielding an overall score of 10 (range 2–10). Overall score (range 2–10) for perceived social norms about ASF feeding during fasting was created on the basis of the levels of agreement to two statements: (a) Most people who are important to me approve of me feeding eggs, milk, and meat to my child during Lent fasting and (b) most women who have young children like me feed their children eggs, milk, and meat during Lent fasting (Table S1). The scores for knowledge, beliefs, and social norms were used as continuous and categorical (using median cut‐off) independent variables. Because both methods showed similar results, we present the findings using the median as the cut‐off levels to compare those who have high scores with low scores in the behavioural determinants. Household availability of ASF was based on observation of whether there were any eggs, milk, or meat available in the house for feeding children by interviewers at the time of the survey. Mothers were also asked if the household owns any of the three types of livestock animals—chickens, cows, and goats or sheep. Selection of covariates were guided by previous literature on determinants of dietary patterns or diversity in low‐ and middle‐income countries (Mayen, Marques‐vidal, Paccaud, Bovet, & Stringhini, 2014) and in Ethiopia (Workicho et al., 2016). Variables that may be associated with child consumption of ASF were measured at child (age and sex), mother (age, education, and occupation), and household levels (food security and socioeconomic status [SES]). Household food security was measured using the Food and Nutrition Technical Assistance/United States Agency for International Development Household Food Insecurity Access Scale (Coates, Swindale, & Bilinsky, 2007). Household SES was created by principal components analysis using a set of items related to house and land ownership, housing quality (house construction materials), household assets (different types of durable goods and productive assets not including livestock previously mentioned), and access to utilities (water, electricity, gas, and sanitation services). The first component derived from component scores was used to divide household SES into tertiles (Vyas & Kumaranayake, 2006). Descriptive analyses were used to examine the characteristics of the study sample and complementary feeding practices including ASF consumption. Bivariate associations between predictor variables and ASF consumption were examined using chi‐square tests and unadjusted logistic regression models. Path analysis using the structural equation modelling command in Stata was conducted to examine the potential mediating effect of ASF availability on the relationship between maternal knowledge, beliefs, social norms, and livestock ownership on ASF consumption. Path analysis allows us to simultaneously estimate all regression equations identified in a model and quantify the direct and indirect effects of different independent variables on ASF consumption. The indirect effect on ASF consumption was calculated as the product of the two path coefficients: (a) between maternal behavioural factors/livestock ownership and ASF availability and (b) between ASF availability and ASF consumption. All models were adjusted for child, mother, and household covariates and geographical clustering at the EA level (Kline, 2011). The proportion of mothers reporting ASF consumption among children was within 0.2–0.8, so linear regression was used rather than logistic regression because results are essentially the same within this range (Cox & Snell, 1989; Hellevik, 2009). All the results were considered significant at P < 0.05. Data analysis was performed using Stata version 13.

AI Digest

Study Justification:

This study aimed to investigate the factors influencing animal source food (ASF) consumption among young children during the Lent fasting period in rural Ethiopia. The study is important because religious fasting practices often involve abstaining from ASFs, which can impact the diets of children. Understanding the determinants of ASF consumption during fasting can help inform interventions to improve the nutritional status of young children in these communities.

Highlights:

– Only 24% of children consumed any ASF in the previous day, with dairy products being the most commonly consumed (18%).
– Maternal knowledge, beliefs, and social norms about feeding children ASFs during fasting were associated with higher odds of children consuming them.
– Households with ASFs available were 4.8 times more likely to have children who consumed them.
– Maternal knowledge, beliefs, and social norms influenced ASF consumption through the pathway of ASF availability.
– Livestock ownership, particularly cows, was directly and indirectly associated with ASF consumption.

Recommendations:

Based on the findings of this study, the following recommendations can be made:

1. Promote maternal knowledge, beliefs, and social norms about the importance of feeding children ASFs during fasting.
2. Improve household availability of ASFs through interventions such as promoting livestock ownership and ensuring access to dairy products, eggs, and flesh foods.
3. Strengthen nutrition education programs targeting mothers and caregivers to increase awareness of the benefits of ASF consumption for young children during fasting.

Key Role Players:

1. Government agencies responsible for nutrition and child health programs.
2. Non-governmental organizations working in the field of nutrition and child development.
3. Community leaders and religious leaders who can promote the importance of ASF consumption during fasting.
4. Health workers and community health volunteers who can provide education and support to mothers and caregivers.

Cost Items for Planning Recommendations:

1. Development and dissemination of educational materials on the benefits of ASF consumption during fasting.
2. Training programs for health workers and community health volunteers on nutrition education.
3. Livestock support programs to promote livestock ownership among households.
4. Infrastructure development to improve access to dairy products, eggs, and flesh foods in rural areas.
5. Monitoring and evaluation activities to assess the impact of interventions on ASF consumption.
Please note that the cost items provided are general suggestions and may vary depending on the specific context and resources available.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides detailed information about the study design, data collection methods, and statistical analysis. However, it does not mention the specific results or findings of the study. To improve the evidence, the abstract could include a summary of the key findings and their implications.

Resumo

Study data were drawn from the baseline household survey conducted as part of the programme evaluation of Alive & Thrive (A&T) Phase II (2015–2017) in Ethiopia. A&T is an initiative to save lives, prevent illness, and contribute to healthy growth and development through improving infant and young child feeding (IYCF) practices. In Phase I (2009–2014), A&T operated in Bangladesh, Ethiopia, and Vietnam, reaching millions of children less than 2 years of age through large‐scale social and behaviour change communication interventions and achieving considerable gains in IYCF practices (Kim et al., 2016; Menon, Nguyen, Saha, Khaled, Kennedy, et al., 2016a; Menon, Nguyen, Saha, Khaled, Sanghvi, et al., 2016b; Rawat et al., 2017). The focus of Phase II in Ethiopia is to operationalize the Government of Ethiopia’s National Nutrition Plan in one region, Amhara, to improve breastfeeding and complementary feeding practices using a multiple sector approach. The baseline survey was carried out in March and April 2015, during the Lent fasting period, in 20 woredas (districts) belonging to three western zones of Amhara region (Awi, North Gondor, and West Gojjam) that do not participate in the Productive Safety Net Programme (national cash and food transfer programme targeted to chronically food‐insecure households; Government of the Federal Democratic Republic of Ethiopia, 2004). Within each of the 20 survey woredas, four enumeration areas (EAs—a geographical unit consisting of 150–200 households) were randomly selected, to yield a total of 80 EAs. At each EA, households from a listing of all eligible households were randomly selected to meet the estimated sample sizes for the impact evaluation. A total of 2,646 households with children 6–23 months of age participated in the survey. Given that 96.1% of our sample were Orthodox Christian, we restricted our sample to this group only. Data on ASF consumption were available for 2,536 mother–child pairs. All mothers of the study children were provided with information about the study at recruitment, and verbal informed consent was obtained from all participants. Data were collected via face‐to‐face interviews using a structured questionnaire. Ethical approval was obtained from the Institutional Review Boards of Addis Continental Institute of Public Health in Ethiopia and the International Food Policy Research Institute in Washington, D.C., USA. Child feeding practices were assessed by asking mothers about all liquids and solid and semisolid foods consumed by their children during the previous day. Dietary data for children 6–23 months of age were categorized into seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, and cheese); flesh foods (meat, fish, poultry, and liver/organ meats); eggs; vitamin‐A‐rich fruits and vegetables; and other fruits and vegetables. The main outcome variable was consumption of ASF (yes/no), which was defined as consumption of any of the following three food groups: dairy, flesh foods, and eggs in the past 24 hr. We also constructed five complementary feeding indicators on the basis of the WHO recommendations (WHO, 2010) including (a) minimum dietary diversity (received foods from 4 or more food groups), (b) minimum meal frequency as appropriate for age, (c) minimum acceptable diet (achieved the minimum dietary diversity and age‐appropriate minimum meal frequency), (d) consumption of iron‐rich foods, and (e) timely introduction of solid, semisolid, or soft foods (introduced to these foods when infants were 6–8 months of age). Because nearly all children were breastfed, we did not stratify the sample on breastfeeding status. We measured several potential behavioural determinants—maternal knowledge, beliefs, and perceived social norms (Glanz, Rimer, & Viswanath, 2008). Knowledge questions about ASF were drawn from a broader set of IYCF knowledge questions validated in a previous study (Menon, Ruel, Arimond, & Ferrus, 2003), whereas questions related to beliefs and social norms were developed specifically for this study on the basis of formative research findings (Alive & Thrive, 2016). Maternal knowledge about ASF was assessed on the basis of mothers’ responses to questions related to knowledge on timely introduction of different ASFs, frequency of feeding children ASFs, and benefits of ASFs to young children for growth and brain development (Table S1). Each correct answer was given a score of 1, yielding a total knowledge score of 10 (range 0–10). Maternal beliefs about ASF feeding during fasting was assessed on the basis of levels of agreement to statements about whether children should be fed eggs, milk, and meat during and outside the Lent fasting period. Each item was measured using a 5‐point Likert scale in which women responded with the degree to which they agreed or disagreed with the two statements (Table S1), yielding an overall score of 10 (range 2–10). Overall score (range 2–10) for perceived social norms about ASF feeding during fasting was created on the basis of the levels of agreement to two statements: (a) Most people who are important to me approve of me feeding eggs, milk, and meat to my child during Lent fasting and (b) most women who have young children like me feed their children eggs, milk, and meat during Lent fasting (Table S1). The scores for knowledge, beliefs, and social norms were used as continuous and categorical (using median cut‐off) independent variables. Because both methods showed similar results, we present the findings using the median as the cut‐off levels to compare those who have high scores with low scores in the behavioural determinants. Household availability of ASF was based on observation of whether there were any eggs, milk, or meat available in the house for feeding children by interviewers at the time of the survey. Mothers were also asked if the household owns any of the three types of livestock animals—chickens, cows, and goats or sheep. Selection of covariates were guided by previous literature on determinants of dietary patterns or diversity in low‐ and middle‐income countries (Mayen, Marques‐vidal, Paccaud, Bovet, & Stringhini, 2014) and in Ethiopia (Workicho et al., 2016). Variables that may be associated with child consumption of ASF were measured at child (age and sex), mother (age, education, and occupation), and household levels (food security and socioeconomic status [SES]). Household food security was measured using the Food and Nutrition Technical Assistance/United States Agency for International Development Household Food Insecurity Access Scale (Coates, Swindale, & Bilinsky, 2007). Household SES was created by principal components analysis using a set of items related to house and land ownership, housing quality (house construction materials), household assets (different types of durable goods and productive assets not including livestock previously mentioned), and access to utilities (water, electricity, gas, and sanitation services). The first component derived from component scores was used to divide household SES into tertiles (Vyas & Kumaranayake, 2006). Descriptive analyses were used to examine the characteristics of the study sample and complementary feeding practices including ASF consumption. Bivariate associations between predictor variables and ASF consumption were examined using chi‐square tests and unadjusted logistic regression models. Path analysis using the structural equation modelling command in Stata was conducted to examine the potential mediating effect of ASF availability on the relationship between maternal knowledge, beliefs, social norms, and livestock ownership on ASF consumption. Path analysis allows us to simultaneously estimate all regression equations identified in a model and quantify the direct and indirect effects of different independent variables on ASF consumption. The indirect effect on ASF consumption was calculated as the product of the two path coefficients: (a) between maternal behavioural factors/livestock ownership and ASF availability and (b) between ASF availability and ASF consumption. All models were adjusted for child, mother, and household covariates and geographical clustering at the EA level (Kline, 2011). The proportion of mothers reporting ASF consumption among children was within 0.2–0.8, so linear regression was used rather than logistic regression because results are essentially the same within this range (Cox & Snell, 1989; Hellevik, 2009). All the results were considered significant at P < 0.05. Data analysis was performed using Stata version 13.

Materiais

https://efashare.b-cdn.net/materials/976d682b41f58606acda4ed165444929b72a327f5ded2c92592471433a29315a/MCN-15-e12695-s001.docx

Inovações

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women and new mothers with information and resources related to maternal health, including nutrition, breastfeeding, and child feeding practices. These apps can also send reminders for prenatal and postnatal appointments, provide access to telemedicine consultations, and offer support through chat or helpline services.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women and new mothers in rural areas. These workers can conduct home visits, offer counseling on maternal health practices, and connect women to healthcare facilities for prenatal and postnatal care.

3. Telemedicine Services: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone consultations. This can help address the lack of healthcare providers in rural areas and improve access to timely and quality maternal healthcare.

4. Maternal Health Vouchers: Implement voucher programs that provide pregnant women with financial assistance to access maternal healthcare services, including prenatal care, delivery, and postnatal care. These vouchers can be distributed through community health workers or local healthcare facilities.

5. Maternal Health Clinics: Set up dedicated maternal health clinics in rural areas, equipped with trained healthcare providers and necessary medical equipment. These clinics can offer comprehensive prenatal and postnatal care services, including regular check-ups, vaccinations, and counseling on maternal and child health practices.

6. Maternal Health Education Campaigns: Conduct targeted education campaigns to raise awareness about the importance of maternal health and promote healthy behaviors during pregnancy and postpartum. These campaigns can use various media channels, such as radio, television, and community gatherings, to reach a wide audience.

7. Improved Transportation Infrastructure: Invest in improving transportation infrastructure in rural areas to ensure that pregnant women have access to healthcare facilities for prenatal and postnatal care. This can include building roads, providing transportation subsidies, or implementing mobile clinics to reach remote areas.

8. Maternal Health Insurance: Introduce or expand maternal health insurance schemes to provide financial protection for pregnant women and cover the costs of prenatal, delivery, and postnatal care. This can help reduce the financial barriers to accessing maternal healthcare services.

9. Maternal Health Monitoring Systems: Develop and implement digital health systems that enable the monitoring of maternal health indicators, such as prenatal visits, vaccinations, and postnatal check-ups. These systems can help identify gaps in care and ensure timely interventions for at-risk women.

10. Partnerships and Collaboration: Foster partnerships and collaboration between government agencies, non-governmental organizations, healthcare providers, and community organizations to collectively address the challenges of improving access to maternal health. This can involve sharing resources, expertise, and best practices to maximize impact and reach more women in need.

AI Innovations Description

Based on the description provided, the study identified several factors that can be used to develop recommendations for improving access to maternal health. These recommendations include:

1. Increase maternal knowledge: Educating mothers about the importance of consuming animal source foods (ASFs) during fasting periods can help improve access to maternal health. Providing information on the benefits of ASFs for growth and brain development of young children can encourage mothers to include these foods in their children’s diets.

2. Address maternal beliefs and social norms: Promoting positive beliefs and social norms around feeding children ASFs during fasting can help improve access to maternal health. Encouraging mothers to believe that it is acceptable and beneficial to feed eggs, milk, and meat to their children during fasting can lead to increased consumption of ASFs.

3. Improve household availability of ASFs: Ensuring that households have access to eggs, milk, and meat can increase consumption of ASFs among young children. Strategies to improve availability may include promoting livestock ownership, such as cows and chickens, which are directly associated with ASF consumption.

4. Enhance complementary feeding practices: Promoting minimum dietary diversity, minimum meal frequency, and consumption of iron-rich foods can contribute to improved access to maternal health. Providing guidance and support to mothers on appropriate complementary feeding practices can help ensure that children receive a balanced and nutritious diet.

5. Collaborate with existing programs: Partnering with initiatives like Alive & Thrive, which focuses on improving infant and young child feeding practices, can help integrate efforts to improve access to maternal health. Leveraging existing programs and resources can lead to more effective and sustainable interventions.

It is important to note that these recommendations are based on the specific findings of the study conducted in rural Ethiopia. When implementing interventions to improve access to maternal health, it is crucial to consider the local context and adapt the recommendations accordingly.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Develop and implement targeted educational campaigns to increase maternal knowledge about the importance of maternal health and the available healthcare services. This can include information about prenatal care, nutrition, and the benefits of seeking timely medical assistance during pregnancy.

2. Improve healthcare infrastructure: Invest in improving healthcare facilities, especially in rural areas where access to maternal health services may be limited. This can involve building or upgrading healthcare centers, ensuring the availability of essential medical equipment and supplies, and training healthcare providers to deliver quality maternal healthcare.

3. Strengthen community-based care: Establish and support community-based programs that provide maternal health services, such as antenatal care, postnatal care, and family planning. These programs can be implemented through trained community health workers who can provide basic healthcare services and referrals to higher-level facilities when needed.

4. Enhance transportation services: Improve transportation infrastructure and services to ensure that pregnant women can easily access healthcare facilities. This can include providing affordable transportation options, such as ambulances or community transport systems, and addressing geographical barriers by improving road networks or implementing telemedicine services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define indicators: Identify key indicators that measure access to maternal health, such as the number of women receiving prenatal care, the percentage of births attended by skilled healthcare providers, or the availability of emergency obstetric care.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area. This can involve conducting surveys, interviews, or reviewing existing data sources.

3. Implement interventions: Implement the recommended interventions in the target area. This can be done through partnerships with local healthcare providers, community organizations, and government agencies.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can involve regular data collection through surveys, interviews, or health facility records.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on the selected indicators. This can be done using statistical methods, such as regression analysis or trend analysis.

6. Compare results: Compare the results with the baseline data to determine the extent of improvement in access to maternal health. This can help identify the effectiveness of the interventions and areas that may require further attention.

7. Adjust and refine interventions: Based on the analysis of the data, make adjustments and refinements to the interventions as needed. This can involve scaling up successful interventions, addressing any identified challenges or barriers, and continuously improving the strategies to enhance access to maternal health.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health and make evidence-based decisions for further improvements.

Autores & Coautores

Statistics:

Citations: 16

Authors: 7

Identifiers:

DOI: 10.1111/mcn.12695

ISSN: 17408695

Research Areas:

Community Interventions, Disparities, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Exploratory Study

Study Approach:

Quantitative

Participants Gender:

Female

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