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Fasting period and fasting status affect the feeding practices and nutritional status of Ethiopian Orthodox mothers. Even if children are exempted from fasting, some mothers do not prepare their food from animal sources as it could contaminate utensils for cooking family foods. Therefore, the objective of this study was to assess feeding practices and undernutrition in 6–23-months old children whose mothers are Ethiopian Orthodox religion followers during lent fasting and non-fasting periods in rural Tigray, Northern Ethiopia, and to identify associated factors. A community-based longitudinal study was carried out in Ethiopian Orthodox lent fasting and non-fasting periods. Using a multi-stage systematic random sampling technique, 567 and 522 children aged 6–23 months old participated in the fasting and non-fasting assessments, respectively. Statistical analyses were done using logistic regression, an independent sample t-test, Wilcoxon signed-rank (WSRT) and McNemar’s tests. The prevalences of stunting, underweight and wasting were 31.6–33.7%, 11.7–15.7% and 4.4–4.8%, respectively. The weight-for-height (WHZ) and height-for-age (HAZ) values for children of fasting mothers were significantly lower (p < 0.05) compared to those of non-fasting mothers. Likewise, the median weight-for-age (WAZ) and diet diversity score (DDS) of children of fasting mothers were also significantly higher in non-fasting than in fasting periods. A small proportion of children (2.3–6.7%) met the minimum acceptable diet (MAD) in the study population, but these measures were significantly increased (p < 0.001) in the children of non-fasting mothers. Mother’s fasting during lactation period of the indexed child was amongst the independent factors common in child stunting, underweight and wasting. Nutritional status and feeding practices of 6–23-month-old children are affected by maternal fasting during the fasting period. Therefore, without involvement of religious institutions in the existing nutritional activities, reduction of undernutrition would not be successful and sustainable.
A longitudinal community-based survey was conducted in lent fasting (15 February–15 April 2017) and non-fasting (1–30 May 2017) periods in rural Genta Afeshum woreda (the third-level administrative division in Ethiopia), in rural Tigray, Ethiopia. The district is one of the hot spot areas of food insecurity and has a total population of 99,112 and 19 health posts to serve the community. Almost all people in the woreda belong to the ethnic group of Tigray and are followers of Ethiopian Orthodox Christianity. For this study, the sample size was calculated using a single population proportion formula and considering the prevalence of stunting (57.1%) elsewhere in Tigray region [12], 95% of confidence interval for true prevalence and a relative precision (d) of 5%. The total population of children aged between 6–23 months old in the district was 4906, so that the finite source population size correction formula was used. Additionally, a 1.5 design effect and 10% non-response rate was used in the calculated sample size so as to get the final sample size of 575. To obtain representative samples, multi-stage systematic random sampling was used. First, of the three woredas where the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ, Bonn, Germany) are implementing a nutrition sensitive agriculture (NSA) project in Ethiopia, Genta Afeshum was randomly selected. Then, seven kebeles (smallest administrative unit in Ethiopia) were selected randomly out of the twenty kebeles residing in the woreda. Children who were aged between 6–23 months, apparently healthy and breastfeeding during the study periods, were included, whereas children who were twins and whose mothers were not permanent residents of the study area during the study period were excluded from the study. Based on these, the list of children was prepared by the health extension workers in the selected kebeles, and finally the samples were selected using systematic random sampling methods. Trained and experienced data collectors who are fluent in Tigrigna, Amharic and English languages were recruited. First, the questionnaire was prepared by the principal investigator, considering the information needed for the study, translated to the local language Tigrigna by a professional translator and pre-tested for its appropriateness. Using this, information on socio-demographic and economic characteristics, maternal and child characteristics, water, sanitation and health (WASH) and feeding practices was collected. The household food insecurity information was also collected using a household food insecurity access scale (HFIAS) standard questionnaire developed by Food and Nutrition Technical Assistance Project (FANTA) [13]. The weight of children was measured using a calibrated portable digital scale (Seca 770, Hanover, Germany) working with powered battery and measured to the nearest 0.1 kg. Likewise, the length of children was measured in a lying position with a wooden board to the nearest 0.1 cm. During weight and length measurements, the mothers were advised to remove their child’s clothes and shoes until the child had only light clothes to minimize the weight and to get actual length, respectively. Duplicate measurements (length and weight) were carried out following standard procedures. Minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) of the children were computed from the two 24-h recall data points collected preceding the survey. Ethical approval was obtained from the institutional review board of the College of Health Sciences at Hawassa University and Tigray region Health Bureau in Ethiopia and Ethics Commission, Landesärztekammer Baden-Württemberg, Germany. Permission was also obtained from the Genta Afeshum woreda Health Office in the Tigray Province of Ethiopia. Additionally, the purpose of the study and the confidentiality of the information to be collected were explained to the mothers, and their agreement to participate with their indexed child in the study was documented by signing the informed consent. Each participating mother was also told that whenever the mothers felt they wanted to discontinue the participation with their child, withdrawal from the study was possible. Before submitting the data, variable coding was conducted in SPSS for window version 20 (IBM Corporation, Armonk, NY, USA). Following this, the data were entered, cleaned and analyzed. First, frequency and crosstab were conducted to check completeness of data and to present the results in descriptive statistics (frequency and percent). In our case, the diet diversity score was calculated as the summation of the number of food groups consumed for each of the two days, and averaged. Seven food groups were created, which included: grains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Likewise, meal frequency was computed as sum of the number of solid, semi-solid, or soft foods eaten by the child within 24-h for each of the two days, and averaged. A child who ate an average of at least four food groups in their meals of the two days fulfilled MDD. In breastfed children, the MMF was two times if aged 6–8 months and three times for 9–23 months. If a child fulfilled both the criteria for MDD and MMF, then he/she was considered as having met MAD. The nutritional status (stunting, underweight and wasting) was identified using length-for-age, weight-for-age, and weight-for-height Z scores and compared with WHO reference data. For this, the height, weight, age and sex data of the children were entered in WHO Anthro software version 3.2.2 (World Health Organization, Geneva, Switzerland). A child who was below -2 standard deviations (-2SD) for HAZ, WHZ or WAZ was considered as stunted, wasted or underweight, respectively. First, potential predicting variables for the outcome variables (stunting, underweight and wasting) were assessed from previous studies and included in bivariate analysis, and those with p-value < 0.25 were selected for multivariate logistic regression. Then, multi-collinearity was checked between the candidate variables separately for the three outcome variables using a variance inflation factor (VIF), and all were less than 10. Then, the candidate variables were entered in a multivariate logistic regression model with the stepwise forward Wald method. A p-value < 0.05 was used to declare the variables as predictors of the outcome variables. Hosmer and Lemeshow test and C-statistics (Area under the curve (AUC)) were used for model tests and were verified. Normality of continuous data was checked using the Kolmogorov-Smirnov test. An independent sample t-test was used to identify the difference between the children of fasting and non-fasting mothers’ WAZ, WHZ and WAZ score values during the lent fasting period. Non-normally distributed data were analyzed using the Wilcoxon signed-rank test, whereas dichotomous data were analyzed by McNemar’s test to identify the difference between children of fasting and non-fasting mothers’ sub-groups dietary patterns between fasting and non-fasting periods.
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