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Background: There are compelling theoretical and empirical reasons that link household food insecurity to mental distress in the setting where both problems are common. However, little is known about their association during pregnancy in Ethiopia. Methods: A cross-sectional study was conducted to examine the association of household food insecurity with mental distress during pregnancy. Six hundred and forty-two pregnant women were recruited from 11 health centers and one hospital. Probability proportional to size (PPS) and consecutive sampling techniques were employed to recruit study subjects until the desired sample size was obtained. The Self Reporting Questionnaire (SRQ-20) was used to measure mental distress and a 9-item Household Food Insecurity Access Scale was used to measure food security status. Descriptive and inferential statistics were computed accordingly. Multivariate logistic regression was used to estimate the effect of food insecurity on mental distress. Results: Fifty eight of the respondents (9 %) were moderately food insecure and 144 of the respondents (22.4 %) had mental distress. Food insecurity was also associated with mental distress. Pregnant women living in food insecure households were 4 times more likely to have mental distress than their counterparts (COR = 3.77, 95 % CI: 2.17, 6.55). After controlling for confounders, a multivariate logistic regression model supported a link between food insecurity and mental distress (AOR = 4.15, 95 % CI: 1.67, 10.32). Conclusion: The study found a significant association between food insecurity and mental distress. However, the mechanism by which food insecurity is associated with mental distress is not clear. Further investigation is therefore needed to understand either how food insecurity during pregnancy leads to mental distress or weather mental distress is a contributing factor in the development of food insecurity.
A facility-based cross-sectional study was conducted in Jimma Zone, one of the 20 administrative zones in Oromia Regional State, southwest Ethiopia. According to the Central Statistical Authority [38] 2.7 million people live in Jimma Zone on an area of 15,569 km2 with a population density of 159.69 persons per km2. Of these, 1.23 million are women. An estimated 31,050 women become pregnant every year and antenatal care coverage in the zone is 64.3 percent. There are three hospitals and 84 primary health centers in Jimma zone where pregnant mothers can receive antenatal care services. There are 12 public health facilities affiliated with Jimma university within the radius of 70 km for community based education program, research and services. Between the months of June and August 2013, a total of 2,987 pregnant women were on antenatal care (ANC) follow up at the 12 health facilities selected for this study [39]. A single population proportion formula was used to estimate 660 pregnant women to be included in the sample. Assumptions for calculating the sample size were the degree of confidence interval (95 %; Z1-α/2 = 1.96), the estimated magnitude of mental distress among pregnant women (P = 50 %), a 4 % degree of precision, and a non-response rate of 10 %. A total of 11 health centers and one hospital were selected to sample the study subjects. These facilities were chosen purposefully based on their previous affiliation with the Jimma University Community Based Education Training Program (CBTP). Probability proportional to size sampling (PPS) techniques was employed to assign the number of pregnant women to be interviewed from each selected health center and hospital. All pregnant women coming for ANC services during the data collection period were taken as the source population for the study. Finally, a consecutive sampling technique was used to identify the study subjects from each of the health facilities until the desired sample size was obtained. Seriously ill pregnant women were excluded from the study and referred to the respective hospital. The instruments used for data collection were adapted from earlier studies and WHO guidelines [30, 40–48] and translated from English into the two most commonly spoken languages in the study setting (Afan Oromo and Amharic) by two fluent linguists (from the university Language and Literature Department). Each translation was then translated back by another person (linguists from the English Department) to ensure its consistency. Before the actual survey, the final translated questionnaires were pre tested on 5 % of the sample at two different health institutions (one urban and the other rural) so that coherence, wording, sequencing and consistencies of all questions were amended accordingly. The result of this pretest was not included in the main analyses. Two days of intensive training on how to approaches the clients, interview techniques, ethical consideration and how to refer any mothers that needed help. Finally, exit interviews were conducted by trained data collectors at each of the 12 health facilities immediately after the mothers had received their ANC services. Field supervisors and the research team supervised the data collection process. Supervisors also checked the consistency of data before submission to the data manager. Ethical clearance was obtained from the Jimma University (JU) ethical review board. The participants were asked for their oral consent after the purpose of the study was clearly communicated. Confidentiality was ensured for each study participants. Mental distress was measured using The Self Reporting Questionnaire (SRQ-20). The SRQ-20 is a screening instrument developed by the World Health Organization (WHO) to assess the level of symptoms of overall mental distress one month preceding the survey [42]. Scores range from 0 to 20, with higher scores representing more severe mental distress. The SRQ has been used in several previous studies exploring the relationship between maternal psychological wellbeing and infant health [42, 46]. In developing countries, cutoff scores of ≥6, 7, 8, 4 and 10 have been used for identifying cases of mental distress [40, 42, 46, 48]. However, in this study we report the proportion of women scoring SRQ ≥7 or greater to indicate mental distress. The SRQ-20 has been validated in Ethiopia for measuring mental distress among rural pregnant women and the recommended cutoff points greater or equal to 7 have specificity of 62 % and sensitivity of 68.4 % [40]. If the scoring was <7, we coded “0” for no mental distress and if it was greater or equals to 7, we coded “1” to indicate presence of mental distress. Household food insecurity access was measured using items from the validated Household Food Insecurity Access Scale (HFIAS) that was specifically developed for use in developing countries [41, 43–45]. The HFIAS consists of 9 items specific to an experience of food insecurity occurring within the previous four weeks. Each respondent indicated whether they had encountered the following due to lack of food or money to buy food in the last one month: (1) worried about running out of food, (2) lack of preferred food, (3) the respondent or another adult had limited access to a variety of foods due to a lack of resources (4) forced to eat un preferred food due to lack of resources, (5) eating smaller portions, (6) skipping meals, (7) the household ran out of food, (8) going to sleep hungry, and (9) going 24 hours without food. Endorsed items are then clarified with reported estimates of the frequency of food insecurity (rarely, sometimes, and often). Scores range from 0 to 27 where higher scores reflect more severe food insecurity and lower scores represent less food insecurity. To determine the status of food insecurity the average HFIAS score (dividing the sum of Household score by number of household in the sample) was computed and then household food insecurity access prevalence (HFIAP) categories (food secure, mild, moderately and severely food insecure) was generated. But, since none of the mothers reported mild and severely food insecure households, HFIAP was only categorized in to two conditions [44]. The data were entered, cleaned, and analyzed using STATA version 12 for Microsoft Windows. Descriptive statistics, bivariate and multivariate logistic regression analyses were computed to examine the relationship between the explanatory variables and mental distress. Assuming a linear relationship between independent and dependent variables, the binary form of the dependent variable was coded as “1” for mental distress and “0” for not distressed. First binary logistic regression analyses were conducted between each and separate explanatory variables with the outcome of our interest (mental distress) (Model I) and reported using crude Odds Ratios. Finally, all significant variables(P < 0.05) during the bivariate analyses were chosen for multivariate logistic regression modeling using forward selection method to explore the association of food insecurity with mental distress by controlling for other confounding variables such as age, occupation, monthly income, and ownership of agricultural land (Model II). Adjusted odds ratios (AOR) and their 95 % confidence intervals (CI) were presented as indicators of strength of association. A p-value of 0.05 or less was used to determine the cut-off points for statistical significance.
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