Minimum dietary diversity and associated factors among lactating mothers in Ataye District, North Shoa Zone, central Ethiopia: A community-based cross-sectional study

Background. Low dietary diversity superimposed with poor-quality monotonous diets is a major problem that often results in undernutrition, mainly micronutrient deficiencies. However, there is limited evidence on minimum dietary diversity and associated factors among lactating mothers in resource-poor settings, including the study area. Therefore, the objective of the study is to assess the prevalence of minimum dietary diversity and associated factors among lactating mothers in Ataye District, Ethiopia. Methods. A community-based cross-sectional study design was used among 652 lactating mothers aged 15-49 years from January 25 to April 30, 2018. Dietary diversity was measured by the minimum dietary diversity indicator for women (MDD-W) using the 24-hour dietary recall method. Data were entered into EpiData version 4.2.0.0 and exported to the statistical package for social science (SPSS) version 24 for analysis using the logistic regression model. Results. The prevalence of minimum dietary diversity among lactating mothers was 48.8% (95% CI: (44.7%, 52.9%). Having formal education ((AOR = 2.16, 95% CL: (1.14, 4.09)), a final say on household purchases ((AOR = 5.39, 95% CI: (2.34, 12.42)), home gardening practices ((AOR = 2.67, 95% CI: (1.49, 4.81)), a history of illness ((AOR = 0.47, 95% CI: (0.26, 0.85)), good knowledge of nutrition ((AOR = 5.11, 95% CI: (2.68, 9.78)), being from food-secure households ((AOR = 2.96, 95% CI: (1.45, 6.07)), and medium ((AOR = 5.94, 95% CI: (2.82, 12.87)) and rich wealth indices ((AOR = 3.55, 95% CI: (1.76, 7.13)) were significantly associated with minimum dietary diversity. Conclusion. The prevalence of minimum dietary diversity among lactating mothers was low in the study area. It was significantly associated with mothers having a formal education, final say on the household purchase, home garden, good knowledge of nutrition, history of illness, food-secure households, and belonging to medium and rich household wealth indices. Therefore, efforts should be made to improve the mother’s decision-making autonomy, nutrition knowledge, household food security, and wealth status.

A community-based cross-sectional study was conducted from January 25 to April 30, 2018, in Ataye District. Ataye is located 270 km away from Addis Ababa, the capital city of Ethiopia. The District has 30 kebeles (lowest administrative unit in Ethiopia), seven health centers, 24 health posts, and one district hospital. The common agricultural practices in the district are teff, wheat, sorghum, barley, maize, peas, and beans. Cabbage, potato, pumpkin, tomato, onion, carrots, and lettuce are the most common vegetables, and orange, papaya, banana, and mango are the most common fruits. Lactating mothers, aged 15–49 years, who lived for, at least, six months and above in the district during the study period were included in the study, while mothers who were not able to respond to an interview and who had an unusual dietary intake in the previous 24 hours, such as feasts and celebrations, were excluded from the study. The sample size was estimated using two approaches based on the objectives of the study. To determine the prevalence of minimum dietary diversity, a single population proportions formula was used with the following assumptions: the proportion of maternal dietary diversity among lactating mothers was 43.6% [18], and Za/2 had a 95% confidence level of 1.96, a margin of error of 0.05, a nonresponse of 10%, and a design effect of 1.5. Accordingly, the calculated sample was 624. On the other hand, to assess the predictors of minimum dietary diversity using a double proportion formula considering different predictors significantly associated with the outcome variable, such as educational status, occupational status, and meal frequency were used. During calculation, assumptions such as a two-sided confidence level of 95%, a margin of error of 5% and power of 80%, a 1 : 1 proportion of exposed to unexposed ratio, a respective odds ratio for each factor, a nonresponse of 10%, and a design effect of 1.5 were considered using Epi Info 7 software program, and then, the calculated sample size was 647. The latter sample size was considered to increase the power of the study. However, the total number of mothers in the selected kebeles was 652. Thus, due to the nature of the cluster sampling method, all mothers were included in the selected cluster using a cluster sampling technique considering kebeles as clusters. This study was conducted in the two urban kebeles and four rural kebeles in the district. The numbers of lactating mothers found in each kebele were taken from a family folder documented by the Health Extension Workers (HEWs) with respect to their household. After that, all lactating mothers in randomly selected clusters were included in the study through the house-to-house visit. A structured interviewer-administered questionnaire was first prepared in English and was translated to Amharic (the language spoken in the study area) for data collection and then translated back to English by an independent language expert to ensure its consistency. Six grade-ten graduated students who were female and fluent speakers in the local language were recruited to participate in data collection. Two-degree health professionals were recruited for the supervision of the data collection procedure. The data collectors underwent a community-based face-to-face interview using a structured and pretested Amharic questionnaire. The mothers were interviewed (on average 30 minutes) in a private setting inside their own house. In this study, the outcome variable (minimum dietary diversity) was measured by minimum dietary diversity for a woman (MDD-W), which is a dichotomous indicator/tool that has been developed by the FAO. A total of 16 food groups were considered in this study (i.e., cereals, white tubers and roots, vitamin A-rich vegetables and tubers, dark green-leafy vegetables, other vegetables, vitamin A-rich fruits, other fruits, organ meat, flesh meat, eggs, fish and seafood, legumes, seeds and nuts, milk and milk products, oils and fats, sweets, spices, condiments, and beverages). These food groups were further regrouped into ten food groups (i.e., all starchy staples, pulses (beans, peas, and lentils), nuts and seeds, all dairy, flesh foods (including organ meat), eggs, vitamin A-rich dark green-leafy vegetables, other vitamin A-rich vegetables and fruits, other vegetables, and other fruits) during analysis [3, 4]. The Minimum Dietary Diversity Score (MDDS) was calculated for each lactating mother during the previous 24 hours to classify mother’s dietary diversity as adequate (≥5 food groups) or not adequate (<5 food groups) from ten food groups. Then, the outcome variable was coded as a minimum dietary diversity score ≥5 food groups as “1” and a minimum dietary diversity score <5 food groups as “0” for logistic regression analysis. Household food insecurity was measured with the Household Food Insecurity Access Scale (HFIAS), a structured, standardized, and validated tool that was developed mainly by the FANTA, to classify households as food secure or not [22, 23]. A scale is to be a valid tool in measuring household food insecurity among both rural and urban areas of Ethiopia with Cronbach's alpha values of 0.76 for round 1 and 0.73 for round 2 [24]. In this study, nine standard Household Food Insecurity Access Scale (HFIAS) questions adapted from FANTA were computed. All “Yes” responses were coded “1” and “No” responses were coded “0,” and the responses were summed to obtain the household food insecurity status. The HFI status, which had a high internal consistency (Cronbach's alpha = 0.927), was further dichotomized as “food-secure” and “food-insecure” households which coded as “1” and as “0,” respectively, during analysis. Furthermore, the household wealth index was analyzed using principal component analysis (PCA) by using approximately 20 locally available household assets considering the assumptions. The knowledge of mothers about nutrition was computed based on six questions using a mean score. The questions include awareness of mothers about nutrition, dietary diversity practice, taking varieties of food groups, types of varieties of food groups, definitions of the term nutrition and malnutrition, causes of malnutrition, and consequences of malnutrition. Mothers who scored above the mean cutoff point were considered to have good knowledge and coded as “1,” whereas those who scored below this cutoff point were considered to have poor knowledge and coded as “0” during analysis. The adapted and further developed English language questionnaire was translated and contextualized into the Amharic language by an Amharic language speaker who has attained a Master of Arts in the Amharic language. It was translated back to the English language by a person who attained a Master of Arts in the English language, and comparison was made on the consistency of the two versions. Data were collected using the translated and pretested Amharic version structured questionnaire. The questionnaire was modified further after a pretest was conducted. During data collection, the interviewers informed mothers about all the details of the research. Mothers were encouraged to feel free during the interview. The interviewers informed about the confidentiality of the responses and that no information would be shared with anybody besides the researcher. After this, women who were willing to participate and signed the informed consent document were interviewed. The ethical approval letter was obtained from Haramaya University, College of Health and Medical Science Institutional Health Research Ethics Review Committee (IHRERC). The approval letter was dated 15 January 2018 and numbered Ref C/AC/R/D/897/18. Before informed consent was obtained, a clear description of the study title, purpose, procedure, duration, possible risks, and benefits of the study was given for each study participant. Their rights during the interview were guaranteed. Then, written and signed informed consent was obtained from each respondent before starting the interview. Questionnaire code numbers were used to maintain the confidentiality of information gathered from each study participant throughout the study. On both theoretical and practical aspect, two days of training was given for the six female grade-ten graduated students and the two supervisors. The training was focused on interview technique, ethical issues, rights of the participants, reading through all the questions and understanding them, and ways of decreasing under/overreporting and maintaining confidentiality. Three weeks before the actual data collection, the questionnaire was pretested outside to the selected kebele on 5% of the total sample size to ensure the validity of the tool. After the pretest was performed, all the necessary adjustments were made. To minimize bias, interviews were conducted in an area with adequate confidentiality, privacy, and without the involvement of any other person other than the respondent. On-site supervision was carried out during the whole period of data collected daily by the supervisors and principal investigators. At the end of each day, questionnaires were reviewed and cross checked for completeness, accuracy, and consistency by the supervisor and principal investigator, and in the end, corrective measures were taken. All the interviewed questionnaires were checked visually by the principal investigator. Data were coded, entered, and cleaned using EpiData version 4.2.0.0 software. Double data entry was performed by two data clerks to cross check the data for completeness before analysis. The entered data were exported and analyzed with Statistical Package for Social Science (SPSS) version 24 software. Simple descriptive statistics, such as simple frequency distribution, measures of central tendency, measures of variability, and percentages, were performed to describe the demographic, socioeconomic, and maternal-related characteristics of the respondents. Then, the information was presented using tables and figures. The continuous variables were tested for normal distribution using a histogram, Q-Q plot, and some statistical tests such as Kolmogorov–Smirnov and Shapiro–Wilk tests. Bivariable analysis and crude odds ratio along with a 95% confidence interval (CI) were used to see the association between each independent variable and the outcome variable by using binary logistic regression. Independent variables with a p value of ≤0.25 were included in the multivariable analysis to control for confounding factors. Multicollinearity was checked to see the linear correlation among the independent variables by using standard error (SE). Variables with a standard error of ≥2 were dropped from the multivariable analysis. The fitness of the model was tested by Hosmer–Lemeshow's goodness-of-fit test model coefficient with an enter method, which was found to be insignificant with a large p value (P=0.374), and the Omnibus tests were significant (P=0.0001). The adjusted odds ratio along with 95% CI was estimated to identify the factors associated with dietary diversity using multivariable logistic regression analysis. All tests were two sided, and the level of statistical significance was declared at a p value less than 0.05.

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