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In Ethiopia, information is limited about energy and micronutrient intakes from complementary foods consumed by children in Productive Safety Net Program districts. Therefore, we assessed feeding practices and intakes of energy and selected micronutrients from complementary foods of children aged 6-23 months in a food insecure rural area of Ethiopia. Energy and micronutrient intakes were estimated from multiple-pass 24 h recall. Data were collected using a structured questionnaire. Only 1⋅9 % of children in the age range 6-8 months met recommended minimum dietary diversity of ≥5 food groups; this value slightly increased to 4 and 10⋅1 % in the older age groups (9-11 months and 12-23 months, respectively). Overwhelmingly, none of the children (9-11 months) did get the minimum acceptable diet (Children receiving minimum acceptable diet were 4 and 2⋅6 % in 6-8 months and 12-23 months, respectively). The overall prevalence of stunting was 34 % in younger children (6-8 months) and 51 % in older children aged 12-23 months. Median energy and selected micronutrient intakes from complementary foods were below corresponding WHO recommendations assuming average breast-milk amount and composition. The worst shortfalls were for vitamins A and C and for Ca. In contrast, median iron, protein and niacin intakes and densities were above the WHO recommendation. Caretakers and community leaders in the study setting need nutrition education on IYCF-related practices and on the importance of men’s involvement in IYCF. Ensuring the accessibility and affordability of animal source foods (ASFs), fruits and vegetables, and feasible complementary foods is critical to address the quality of complementary feedings. This can be achieved through promoting nutrition-sensitive agriculture such as poultry and home gardening in this setting.
The study was conducted in 10 kebeles (the smallest administrative unit in Ethiopia) of Meket district, north Wollo, Ethiopia from February to March 2020. The Meket district is one of the food insecure areas in north Wollo, and a majority of the households are dependent on transfer of food aid(8). As a result, the district is included in the Productive Safety Net Program (PSNP4). Presently, 69 649 households are enrolled in the PSNP4 program from Meket district. Stunting prevalence in the region (41⋅3 %) exceeds the national average (37 %) for children younger than 5 years(5). There are one primary hospital, seven governmental health centres and thirty-six health posts in the district. The inhabitants of the district mainly produce maize (Zea mays L.), millet (Pennisetum glaucum), pulses and teff (Eragrostis tef) as staple foods. Vegetables such as kale and potato are also grown. Traditional animal rearing such as cattle is common, mainly as a source of income. As part of a larger study that investigated maternal depression and child undernutrition(11), the sample size was calculated using power analysis to detect a medium effect size (0⋅5 sd difference with an α of 0⋅05 and a power of 0⋅8). The final sample size was estimated to be 232, after 1⋅5 for design effect and approximately 15 % for non-response rate. The determined sample size and data set were sufficient to characterise the mean energy intake of the three age groups with a 95 % confidence level of approximately ±30 kcal. Of the 27 kebeles in the district, 10 were randomly selected. A listing of PSNP4 households with infants and young children (6–23 months of age) who had lived at least 6 months in the selected kebeles were completed from the database that was compiled by the research team including local healthcare workers prior to actual data collection. The number of mother–child pairs to be selected was proportionally allocated to the 10 kebeles based on the total number of the households with 6–23-month-old children in each kebele. The study participants were then randomly selected from the sampling frame. In the rare cases, when several children in the same household fulfilled the inclusion criteria, one child was randomly selected. The inclusion criteria were being permanent residents for the mother–child pairs, the child being breast-fed and apparently healthy and household enrollment in PSNP4. Children with physical disabilities and severe illnesses were excluded. Basic socio-demographic characteristics of study participants were collected by face-to-face interviews using a pretested questionnaire that included sex of child, age (in months), maternal age, occupation, and educational status, marital status, family size, ownership of sanitary facility, source of water, and common child illness (cough, fever, nausea/vomiting, diarrhoea or acute respiratory infection) in the 2 weeks prior to the survey. Household food insecurity was evaluated using the Household Food Insecurity Access Scale(12). The households were categorised into four groups: food secure, mildly food insecure, moderately food insecure and severely food insecure. Finally, these were merged into two groups: food secure and food insecure (mildly, moderately and severely) households. Maternal exposure to child feeding promotion and related activities was collected using structured questions. Men’s involvement in IYCF was considered if they carried out at least one of the following supportive actions in the households: buying or providing money for the purchase of special foods for the baby (i.e. different from the usual household food); advising the mother to provide special food for the baby; keeping some milk or an egg for the baby instead of selling it in the market; preparing food for the baby; or helping the mother with some domestic duties while she cooked food or fed the baby(13). All anthropometric measurements were conducted by a supervisor (B. S.) and the principal investigator (A. A.) to eliminate inter-examiner variation. Recumbent length was measured to the nearest millimetre as recommended by WHO(14) using a portable adult/infant length/stature measuring board (Perspective Enterprises, Portage, MI, USA) and weight via an electronic scale (Seca 770, Seca Corporation, Hanover, MD, USA) to the nearest 0⋅1 kg. The mean Z-scores for length-for-age (LAZ), weight-for-age (WAZ) and weight-for-length (WLZ) were calculated from WHO multicentre growth reference data(15) using the WHO Anthro (v. 3.2.2) computer program. Stunting, wasting and underweight were defined by Z-scores for LAZ, WLZ and WAZ < −2 standard deviations (sd), respectively. Age of each child was determined from their immunisation card and/or local events calendar. Dietary intake was assessed using a multiple-pass interactive 24 h recall with the mother of each child in the home. The method used in this study was adapted and validated for use in developing countries(16). Each mother was asked to recall all foods and fluids consumed by a child in the previous 24 h including time, type of meal, ingredients used, amount of total dish and amount consumed. A day before intake was assessed (2 d before the recall), plates and cups were supplied to the mothers, who were instructed not to change the dietary pattern of the child on the recall day. A demonstration was given on how weighing of food would be conducted. Portion size of foods consumed was estimated by direct weighing of salted replicas of actual foods prepared locally. In order to adjust for individual day-to-day intake variation, Intake Monitoring Assessment and Planning Program software (IMAPP) was used (More details about the program and how to access it can be found at http://www.side.stat.iastate.edu/, http://www.side.stat.iastate.edu/.), a second day dietary intake recall was collected using the same procedures from a randomly selected subsample (n 35) on a different day of the week as recommended by the Institute of Medicine (IOM)(17). All days were equally represented for each age group to account for any day-of-the-week effects. Data collection was conducted by experienced data collectors who were recruited locally and trained in a classroom setting for 5 d followed by a field practice with a group comparable to that of the actual study. The data collectors’ training was mainly focused on how to ask detailed information on type, quantity and preparation method of each food consumed, including the detailed recipe. Each data collector was supplied with a digital food weighing scale (2000 g maximum weight: Model CS 2000; Ohaus Corporation, Parsippany, NJ, USA), and plates as well as cups which were distributed for mothers. For mixed dishes, the contribution of each ingredient to the total amount or volume (g or ml) consumed was estimated. The dietary data were entered in the ‘Census and Survey Processing System’ to convert food model weights to grams of food consumed and calculate individual energy and nutrient intakes (CSPro, https://www.census.gov/population/international/software). Ethiopian food composition tables (EFCTs) were used(18–20). The vitamin A activity from complementary foods was expressed as REs for comparison with the WHO recommendations(21). The median daily intakes for each age group were compared with the corresponding estimated energy and selected nutrient needs that should be obtained from complementary foods (any food other than breast-milk)(22–24), assuming average breast-milk amount and composition as suggested by Dewey and Brown(21) and WHO(7). Nutrient densities (amount per 100 kcal) were compared with desired values suggested by(6). Median dietary diversity scores were calculated based on eight food groups as described in WHO/UNICEF(2) and classified as low (1–2), medium (3–4) and high (≥5). All continuous variables were checked for normality using the Kolmogorov–Smirnov test. Breast-feeding and child dietary diversity indicators (i.e. dietary diversity, minimum number of time fed solids/semi-solids; minimum number of food groups; good IYCF practices) were calculated and presented as recommended by the IYCF guidelines published by WHO/UNICEF(2). Mean differences in anthropometric status across age group were compared using t-test, whereas the proportion of stunting, wasting and underweight were compared using χ2 test. Nutrient intakes (per day) and nutrient densities (per 100 kcal) were expressed as medians and interquartile range because of non-normal distributions of some nutrients. In all comparisons, differences were considered statistically significant when P < 0⋅05. Statistical analyses were performed using SPSS version 21. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Hawassa University Institutional Review Board (Ref. No. IRB/178/10). The purpose of the study was explained in a formal letter to district administration and then informed written consent was obtained from the Meket district health office. Prior to enrollment in the study, the purpose of the study was explained for mothers and written informed consent was obtained from mothers.
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