Household Food Insecurity, Underweight Status, and Associated Characteristics among Women of Reproductive Age Group in Assayita District, Afar Regional State, Ethiopia

Background. Poor nutritional status of women has been a serious problem in Ethiopia. Rural women are more likely to be undernourished than urban women. Afar region is the most likely to be undernourished (43.5%). Despite the humanitarian and food aid, food insecurity and maternal underweight are very high in the region. Household food insecurity is not adequately studied in Afar region. The aim of this study was to assess the prevalence of household food insecurity and underweight status and its association among reproductive age women. Method. The study was conducted in Assayita district in June 2015. Community-based cross-sectional study design was used among nonpregnant women. Household data was collected using structured questionnaire. Multistage cluster sampling procedure was applied. Two pastoral and two agropastoral Kebeles have been selected by simple random sampling. Systematic random sampling was used to select respondents. The total sample size was 549 households. Household Food Insecurity Access Scale (HFIAS) and anthropometric data were used to determine food insecurity and underweight, respectively. Multivariate regression models were used to measure associations. Results. Prevalence of HFIAS was 70.4 with a mean of 7.0 (3.6 ± SD); 26.1%, 30.20%, and 14.1% were mild, moderate, and severe food insecurity, respectively. Underweight prevalence (BMI < 18.5) was 41.1% with prevalence of mild, moderate, and severe underweight being 34.5%, 3.9%, and 2.7%, respectively. Age, parity, and having >2 children below five years of age were statistically associated with household food insecurity and maternal underweight. Conclusion. Household food insecurity and maternal underweight were very high. Age, parity, and having ≥2 children below five years of age were associated with household food insecurity. Maternal underweight was associated with maternal age, marital status, parity, number of children below 5 years, household food insecurity, and vocation of the respondents. The study was conducted in June 2015 in Assayita zone, Afar regional state, which is located 650 km away from Addis Ababa, the capital of Ethiopia. Based on the 2007 Census Result of the Central Statistical Agency of Ethiopia (CSAE), the total population of Afar region was 1,411,092, consisting of 786,338 men and 624,754 women. Rural inhabitants constitute 1,222,369 (86.6%) of the total population. 67.3% of inhabitants fall into the lowest wealth quintile; adult literacy for men is 27% and it is 15.6% for women [18]. Assayita is one of the largest districts which has thirteen Kebeles; of which two are urban, six are pastoral, and five are agropastoral Kebeles. Total population of the district was 47,210. Of the total population, 31,162 (66%) live in rural areas and the rest, 16,048 (34%), live in urban areas [18]. The district has four clinics, three health posts, and one health center [19]. A community-based cross-sectional study design was applied and the source population was all households with reproductive age women, while study population was households of randomly selected agropastoral and pastoral community (Figure 1). Households with at least one reproductive age woman were included. However, if more than one eligible woman was available in one household, the one who is responsible for family care and/or is head was considered for this study. Percentage of households in each category of food security for agropastoral and pastoral households, Assayita district, June 2015 (n = 490). Sample size was computed using single population proportion formula assuming a marginal error of 5% and 95% confidence interval. During sample size determination, prevalence of undernourished women and national prevalence for food insecurity were taken into consideration and the prevalence that yields the maximum sample size was taken as final sample. Besides this, 35% undernourished prevalence rate from national food insecurity survey [17] with 5% nonresponse rate and design effect of 1.5 gives us a maximum sample size of 549. The sample was distributed across the selected Kebeles proportional to their household size. With regard to sampling procedures, first multistage stratified sampling procedure was deployed to get a representative data. Two pastoral and two agropastoral Kebeles were selected using simple random sampling. Systematic random sampling was used to identify respondents and probability proportionate to size (PPS) technique was applied. Data was collected through interviews and anthropometric measurements. During interview, structured questionnaire consisted of socioeconomic and demographic characteristics and frequency of 24-hour dietary recall and household food insecurity measurements were used. The questionnaire was initially prepared in English and then translated into Amharic. Six experienced data collectors who had Diploma certificate in health and were able to speak the local language fluently collected the data. Meanwhile, two supervisors from the district health office were involved in supervising the overall data collection process. Household Food Insecurity Access Scale (HFIAS) was used to create a continuous numeric food insecurity “score,” which can then be compared to established cut-points to categorize the level of food insecurity experienced by the household. Nine-item questionnaire with three domains of food insecurity, anxiety/uncertainty about the household food supply, insufficient quality of food (including variety and food preferences), and insufficient food intake and its physical consequences, was used. The participants’ responses indicate a frequency of occurrence of the following: never, rarely (1 to 2 times), sometimes (3 to 10 times), and often (>10 times) for each of the questions over the previous 30 days. This was then used to calculate HFIAS scores. HFIAS scores range from 0 to 27, with a higher score indicating greater food insecurity [20]. The last three questions of the HFIAS were used to calculate the Household Hunger Scale (HHS). The three questions inquired about whether participants “had no food in the house,” “went to sleep hungry,” or “lacked food for 24 hrs.” The household score recodes the responses to each frequency-of-occurrence question from three frequency categories (“rarely,” “sometimes,” and “often”) into two frequency categories (“rarely or sometimes” and “often”). Each household will have score between 0 and 6. These values are then used to generate the household indicators which in turn are categorized into little to no hunger (0-1) in the household, moderate hunger (2-3) in the household, and severe hunger (4–6) in the household [21]. Data on household dietary diversity was collected using a 24-hour recall method and information was entered into the Household Dietary Diversity Score (HDDS) sheet. The HDDS captures dietary diversity in a normal 24-hour period by the household as a whole and not a single member. Food consumed outside the home which was not prepared in the home was not included. A set of 12 food groups were used to guide the scoring as per the food items consumed, with 1 being the minimum score and 12 being the maximum score [22]. To determine the impact of household food insecurity on nutritional status of reproductive age women’s weight, height measurements were taken from all study subjects. Weight was measured to the nearest 0.5 kg using a weight measurements scale. Height was measured to the nearest centimeters also using tap meter; the scales were calibrated after each session of measurements. Malnutrition in women was assessed using the body mass index (BMI), which is defined as a woman’s weight in kilograms divided by the square of her height in meters (BMI = kg/m2). A BMI below 18.5 among nonpregnant, nonlactating women indicates chronic energy deficiency or undernutrition. When BMI is above 25, women are considered overweight [6]. Underweight prevalence (BMI < 18.5 kg/m2) was further categorized by WHO standards for mild (BMI: 18.5–17 kg/m2), moderate (BMI: 16.99–16.00 kg/m2), and severe (BMI: < 16 kg/m2) underweight [23]. Household food insecurity status and underweight status among women of reproductive age were considered as dependent variables, whereas sociodemographic characters, height, weight, and BMI were our independent variables. To ensure quality of data, structured questionnaire was employed to attain the required information after getting written and verbal consent from the respondents. The data collectors and supervisors were trained on objectives of study sampling procedures, techniques of interviews, and data handling. The questionnaire was pretested in a community similar to the study population and the necessary modification was made. The supervisors and principal investigator were closely following the day-to-day data collection process and ensured completeness and consistency of questionnaire administered each day. Statistical software was used to analyze data. The data was entered using Epi Info version 7 and analysis was done using Statistical Package for Social Sciences (SPPS version 21). Descriptive statistics were tabulated to describe the characteristics of households in each level of food security, as well as the nutritional outcomes associated with food security. For variables expressed as percentages or proportions, chi-square test was used to assess differences between food security classifications. Multiple binary logistic regression models were used to quantify the association between household food security and nutritional outcomes among reproductive age women. Ethical clearance was obtained from ethical review committee of College of Health Sciences, Addis Ababa University. An official letter was also obtained from Afar Regional Health Bureau and district health office. Similarly, written consent was obtained from interviewee before proceeding to data collection. All information that was obtained from the individual was treated confidentially. In this study, underweight was defined as BMI < 18.5 kg/m2; normal weight was defined as BMI ≥ 18.5 and <25 kg/m2 [23]. Food-secure household was defined as the household that experiences none of the food insecurity (access) conditions or just experiences worry but rarely. Mildly food-insecure household is defined as the household that sometimes or often worries about not having enough food and/or is unable to eat preferred foods and/or eats a more monotonous diet than desired and/or some foods considered undesirable but only rarely but it does not cut back on quantity and does not experience any of three most severe conditions. Moderately food-insecure household is considered so if it sacrifices quality more frequently by eating a monotonous diet or undesirable foods sometimes or often and/or has started to cut back on quantity by reducing the size of meals or number of meals rarely or sometimes. But it does not experience any of the three most severe conditions. Severely food-insecure household is the household that is forced to cut back on meal size or number of meals often and/or experiences any of the three most severe conditions (running out of food, going to bed hungry, or going a whole day and night without eating), even as infrequently as rarely this is assumed as. Dietary diversity is the number of different foods or food groups consumed over 24-hour period.