Poor dietary diversity, wealth status and use of un-iodized salt are associated with goiter among school children: a cross-sectional study in Ethiopia

BMC Public Health, Volume 17, No. 1, Year 2017

Ukuhunyushwa

Background: Globally, more than two billion people are at risk of iodine deficiency disorders, 32% of which are school children. Iodine deficiency has been recognized as a severe public health concern in Ethiopia, however little is known about the problem. Therefore, this study aimed to assess the prevalence of goiter and associated factors among school children (6 to 12 years) in Dabat District, northwest Ethiopia. Methods: A school-based cross-sectional study was conducted from February 21 to March 31, 2016. A total of 735 school children were included in the study. A stratified multistage sampling followed by systematic sampling technique was employed to select the study participants. Thyroid physical examination was done and classified according to the World Health Organization recommendations as grade 0, grade 1, and grade 2. The level of salt iodine content was determined using the rapid field test kit. The value 0 parts per million (PPM), <15 PPM and ≥15 PPM with the corresponding color chart on the rapid test kit were used to classify the level of iodine in the sampled salt. A multivariable logistic regression analysis was employed to identify factors associated with goiter. Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was calculated to show the strength of association. In multivariable analysis, variables with a P-value of <0.05 were considered statistically significant. Results: In this community, the overall prevalence of goiter was 29.1% [95% CI: 25.9, 32.6], in which about 22.4 and 6.7% had goiter grade 1 and grade 2, respectively. The age of children (AOR = 1.13; 95% CI: 1.01, 1.26), being housewife mother (AOR = 1.49; 95% CI: 1.08, 2.15), use of unprotected well water source for drinking (AOR = 6.25; 95% CI: 2.50, 15.66), medium household wealth status (AOR = 1.78; 95% CI: 1.18, 2.92), use of inadequately iodized salt (AOR = 2.79; 95% CI: 1.86, 4.19), poor dietary diversity score of the child (AOR = 1.92;95% CI: 1.06, 3.48) and medium maternal knowledge (AOR = 0.65; 95% CI: 0.42, 0.94) were significantly associated with goiter. Conclusions: The prevalence of goiter is higher in Dabat District, which confirmed a moderate public health problem. Therefore, regular monitoring of household salt iodine content, improving access to safe water, promoting the importance of diversified food for children is recommended to address the higher burden of iodine deficiency. A school-based cross-sectional study was conducted from February 21 to March 31, 2016, in Dabat District, northwest Ethiopia. The district is found 821 km from Addis Ababa, the capital city of Ethiopia. The district has 26 rural and four urban Kebeles (smallest administrative unit in Ethiopia). The altitude of the district ranges from 1000 to 2500 m above the sea level. The total population of 175,737 lives in the district. Cereals, such as maize, sorghum, wheat, and barley are the main staple crops cultivated in the district. The district has six health centers and 31 health posts. There are 82 schools in the district, 79 of which are primary schools. The Health and Demographic Surveillance System (HDSS) site was also located in Dabat District. The HDSS site has been running since 1996 and hosted by the University of Gondar. The surveillance site covers thirteen kebeles (four urban and nine rural kebeles) selected by considering different ecological zones (high land, middle land and lowland). All children aged 6–12 years who lived in HDSS site and attended primary school during the study period were eligible for the study. The sample size was calculated using Epi-info version 2.3 by using the following assumptions; the prevalence of goiter among school-aged children was 37.6% [28], 95% level of confidence and 5% margin of error. Finally, the sample size of 757 was obtained by considering 5% non-response rate and a design effect of 2. A multistage stratified sampling followed by systematic random sampling technique was employed to reach the study participants. Initially, schools were stratified into urban and rural. Of the total twenty-four primary schools in the HDSS site, five (one urban and four rural) schools with a total of 3429 students were selected using the lottery method. Number of students included in each school were proportionate-to-population size. Finally, a systematic sampling technique was employed to select the study subjects. Physical examination was done for the selected child, after that using the child’s name, parent’s name and address, household visit was made by data collectors to gather the socio-demographic, the household utilization of iodized salt and dietary habit related characteristics of the child and the parents. Women who were majorly involved in food preparation of the household were selected as a respondent. A structured interviewer-administered questionnaire was used to collect data. The questionnaire was first prepared in English and was translated into the local language (Amharic) and back translated to English to maintain consistency by two BSc holder English teachers who are also native speakers of Amharic language. Pretest was done on five percent of the sample out of the study area. Two days training on techniques of interview, salt iodine content determination and thyroid physical examinationwas given for data collectors and supervisors. A total of nine data collectors (two health officers, an environmental health professional, and six permanent data collectors of the HDSS site) and three supervisors (two public health experts and a medical doctor) were involved in the study. Accordingly, the thyroid physical examination was undertaken by two Health Officers under the supervision of a medical doctor. Determination of salt iodine content was done by the trained environmental health professional. Daily supervision and feedback were carried out by the investigators and supervisors during the entire data collection period. The presence of goiter was assessed by the trained Health Officers with strict adherence to the standard procedures stipulated by the World Health Organization. Accordingly, goiter was defined as grade 0 if no palpable mass in the neck was detected, grade 1 if there was a mass in the neck consistent with palpable enlarged thyroid, but not visible when the neck was in the normal position, whereas grade 2 was a swelling in the neck that was visible when the neck is in a normal position and is consistent with an enlarged thyroid when the neck is palpated (palpable and visible). Lastly, the child was deemed as having goiter when he/she had goiter of grade 1 or 2 [29]. A tablespoon of salt was collected from each household and the MBI international Rapid Test Kit (RTK) was used to determine the level of salt iodine content [16, 27, 29]. The small cup in the kit was filled with salt and made the cup surface flat. Two drops of test solution from white ampule were added to the surface of the salt by piercing the white ampoule with a pin and gently squeezing the ampule. The salt iodine content was determined within one minute by comparing the color developed on the salt with the color chart. The value 0 Parts per Million (PPM), <15 PPM and ≥15 PPM with the corresponding color chart on the rapid test kit were used to classify the level of iodine in the sampled salt. If no color appears, after 1 min, five drops of the recheck solution from red ampule was added to a fresh salt sample and followed by two drops of test solution on the same salt sample. Then, a comparison was done with the color chart indicators for salt iodine content [29]. Determination of dietary diversity score (DDS) of the child was started by asking the mother to list all food consumed by the child in the previous 24 h preceding the survey. Then reported food items were classified into nine food groups, as starchy staples; dark green leafy vegetables; vitamin A rich fruits and vegetables; other fruits and vegetables; organ meat; flesh meat and fish; and egg [30]. Considering four food groups as the minimum acceptable dietary diversity, a child with a DDS of less than four was classified as having poor dietary diversity; otherwise, it was deemed to have good dietary diversity [30]. Household’s wealth index, adopted from EDHS 2011 [31], was determined using Principal Component Analysis (PCA) by considering the household assets, such as quantity of cereal products, type of house, livestock and agricultural land ownership. First, variables were coded between 0 and 1. Then variables entered and analyzed using PCA, and those variables having a communality value of greater than 0.5 were used to produce factor scores. Finally, the factor scores were summed and ranked into tertiles as poor, medium and rich. Similarly, the knowledge of mothers towards iodized salt use was computed by using nine knowledge item questions, adopted by reviewing different literatures [7, 16, 28], including the health benefit of iodized salt, disorders resulted from ID, food sources of iodine, appropriate place for salt storage, time to add salt during food preparation, salt storage material and existence of law prohibiting selling of non-iodized salt in Ethiopia. Accordingly, the factor scores were summed and ranked into poor, medium and high. The collected data were checked and entered into Epi-info version 7 and exported to SPSS version 20 statistical software for analysis. Descriptive statics were carried out and the result was presented using text, tables and graph. A binary logistic regression model was fitted to identify factors associated with goiter. Variables with a p-value less than <0.2 in the bivariable analysis and those which frequently showed significant association with goiter in the previous studies were fitted into the multivariable logistic regression analysis and backward LR method was employed. Both Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with the corresponding 95% Confidence Interval (CI) were calculated to show the strength of association. In multivariable analysis, variables with a p-value of <0.05 were considered as statistically significant.

I-AI Digest

Study Justification:

– Iodine deficiency is a global public health concern, affecting over two billion people, including 32% of school children.
– Ethiopia is also facing a significant iodine deficiency problem, but there is limited information about the prevalence and associated factors.
– This study aimed to assess the prevalence of goiter (an indicator of iodine deficiency) and identify factors associated with goiter among school children in Dabat District, northwest Ethiopia.

Study Highlights:

– The study was conducted from February 21 to March 31, 2016, in Dabat District, northwest Ethiopia.
– A total of 735 school children aged 6 to 12 years were included in the study.
– The prevalence of goiter in the community was found to be 29.1%.
– Factors significantly associated with goiter included the age of children, being a housewife mother, use of unprotected well water source for drinking, medium household wealth status, use of inadequately iodized salt, poor dietary diversity score of the child, and medium maternal knowledge.
– The study confirmed that goiter is a moderate public health problem in Dabat District.

Recommendations for Lay Reader and Policy Maker:

– Regular monitoring of household salt iodine content is recommended to ensure adequate iodization.
– Improving access to safe water sources is crucial to reduce the risk of iodine deficiency.
– Promoting the importance of diversified food for children is recommended to address the higher burden of iodine deficiency.

Key Role Players:

– Health officers: Conducting thyroid physical examination and data collection.
– Environmental health professional: Determining salt iodine content.
– Data collectors: Gathering socio-demographic and dietary habit data.
– Supervisors: Overseeing data collection and providing feedback.
– Investigators: Providing overall guidance and supervision.

Cost Items for Planning Recommendations:

– Training costs for data collectors and supervisors.
– Transportation costs for data collectors and supervisors.
– Salt iodine test kits.
– Administrative costs for data management and analysis.
– Communication and dissemination costs for sharing study findings.
– Monitoring and evaluation costs for assessing the impact of interventions.
Please note that the provided cost items are general suggestions and may vary depending on the specific context and resources available.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is rated 8 because it provides a detailed description of the study design, sample size calculation, data collection methods, and statistical analysis. The study used a stratified multistage sampling technique and employed a structured questionnaire to collect data. The prevalence of goiter and associated factors were assessed using a multivariable logistic regression analysis. The study also provided adjusted odds ratios and 95% confidence intervals to show the strength of association. However, to improve the evidence, it would be helpful to include information on the response rate and any potential limitations of the study, such as selection bias or measurement error.

Abstract

A school-based cross-sectional study was conducted from February 21 to March 31, 2016, in Dabat District, northwest Ethiopia. The district is found 821 km from Addis Ababa, the capital city of Ethiopia. The district has 26 rural and four urban Kebeles (smallest administrative unit in Ethiopia). The altitude of the district ranges from 1000 to 2500 m above the sea level. The total population of 175,737 lives in the district. Cereals, such as maize, sorghum, wheat, and barley are the main staple crops cultivated in the district. The district has six health centers and 31 health posts. There are 82 schools in the district, 79 of which are primary schools. The Health and Demographic Surveillance System (HDSS) site was also located in Dabat District. The HDSS site has been running since 1996 and hosted by the University of Gondar. The surveillance site covers thirteen kebeles (four urban and nine rural kebeles) selected by considering different ecological zones (high land, middle land and lowland). All children aged 6–12 years who lived in HDSS site and attended primary school during the study period were eligible for the study. The sample size was calculated using Epi-info version 2.3 by using the following assumptions; the prevalence of goiter among school-aged children was 37.6% [28], 95% level of confidence and 5% margin of error. Finally, the sample size of 757 was obtained by considering 5% non-response rate and a design effect of 2. A multistage stratified sampling followed by systematic random sampling technique was employed to reach the study participants. Initially, schools were stratified into urban and rural. Of the total twenty-four primary schools in the HDSS site, five (one urban and four rural) schools with a total of 3429 students were selected using the lottery method. Number of students included in each school were proportionate-to-population size. Finally, a systematic sampling technique was employed to select the study subjects. Physical examination was done for the selected child, after that using the child’s name, parent’s name and address, household visit was made by data collectors to gather the socio-demographic, the household utilization of iodized salt and dietary habit related characteristics of the child and the parents. Women who were majorly involved in food preparation of the household were selected as a respondent. A structured interviewer-administered questionnaire was used to collect data. The questionnaire was first prepared in English and was translated into the local language (Amharic) and back translated to English to maintain consistency by two BSc holder English teachers who are also native speakers of Amharic language. Pretest was done on five percent of the sample out of the study area. Two days training on techniques of interview, salt iodine content determination and thyroid physical examinationwas given for data collectors and supervisors. A total of nine data collectors (two health officers, an environmental health professional, and six permanent data collectors of the HDSS site) and three supervisors (two public health experts and a medical doctor) were involved in the study. Accordingly, the thyroid physical examination was undertaken by two Health Officers under the supervision of a medical doctor. Determination of salt iodine content was done by the trained environmental health professional. Daily supervision and feedback were carried out by the investigators and supervisors during the entire data collection period. The presence of goiter was assessed by the trained Health Officers with strict adherence to the standard procedures stipulated by the World Health Organization. Accordingly, goiter was defined as grade 0 if no palpable mass in the neck was detected, grade 1 if there was a mass in the neck consistent with palpable enlarged thyroid, but not visible when the neck was in the normal position, whereas grade 2 was a swelling in the neck that was visible when the neck is in a normal position and is consistent with an enlarged thyroid when the neck is palpated (palpable and visible). Lastly, the child was deemed as having goiter when he/she had goiter of grade 1 or 2 [29]. A tablespoon of salt was collected from each household and the MBI international Rapid Test Kit (RTK) was used to determine the level of salt iodine content [16, 27, 29]. The small cup in the kit was filled with salt and made the cup surface flat. Two drops of test solution from white ampule were added to the surface of the salt by piercing the white ampoule with a pin and gently squeezing the ampule. The salt iodine content was determined within one minute by comparing the color developed on the salt with the color chart. The value 0 Parts per Million (PPM), <15 PPM and ≥15 PPM with the corresponding color chart on the rapid test kit were used to classify the level of iodine in the sampled salt. If no color appears, after 1 min, five drops of the recheck solution from red ampule was added to a fresh salt sample and followed by two drops of test solution on the same salt sample. Then, a comparison was done with the color chart indicators for salt iodine content [29]. Determination of dietary diversity score (DDS) of the child was started by asking the mother to list all food consumed by the child in the previous 24 h preceding the survey. Then reported food items were classified into nine food groups, as starchy staples; dark green leafy vegetables; vitamin A rich fruits and vegetables; other fruits and vegetables; organ meat; flesh meat and fish; and egg [30]. Considering four food groups as the minimum acceptable dietary diversity, a child with a DDS of less than four was classified as having poor dietary diversity; otherwise, it was deemed to have good dietary diversity [30]. Household’s wealth index, adopted from EDHS 2011 [31], was determined using Principal Component Analysis (PCA) by considering the household assets, such as quantity of cereal products, type of house, livestock and agricultural land ownership. First, variables were coded between 0 and 1. Then variables entered and analyzed using PCA, and those variables having a communality value of greater than 0.5 were used to produce factor scores. Finally, the factor scores were summed and ranked into tertiles as poor, medium and rich. Similarly, the knowledge of mothers towards iodized salt use was computed by using nine knowledge item questions, adopted by reviewing different literatures [7, 16, 28], including the health benefit of iodized salt, disorders resulted from ID, food sources of iodine, appropriate place for salt storage, time to add salt during food preparation, salt storage material and existence of law prohibiting selling of non-iodized salt in Ethiopia. Accordingly, the factor scores were summed and ranked into poor, medium and high. The collected data were checked and entered into Epi-info version 7 and exported to SPSS version 20 statistical software for analysis. Descriptive statics were carried out and the result was presented using text, tables and graph. A binary logistic regression model was fitted to identify factors associated with goiter. Variables with a p-value less than <0.2 in the bivariable analysis and those which frequently showed significant association with goiter in the previous studies were fitted into the multivariable logistic regression analysis and backward LR method was employed. Both Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with the corresponding 95% Confidence Interval (CI) were calculated to show the strength of association. In multivariable analysis, variables with a p-value of <0.05 were considered as statistically significant.

Izinto zokwakha

N/A

Emisha

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and resources related to maternal health, including prenatal care, nutrition, and postnatal care. These apps can be easily accessible to pregnant women and new mothers, providing them with guidance and support.

2. Telemedicine: Implement telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone calls. This can help overcome geographical barriers and ensure that women receive timely and appropriate care.

3. Community Health Workers: Train and deploy community health workers who can provide basic maternal health services, education, and support in underserved areas. These workers can conduct prenatal visits, provide health education, and refer women to higher-level healthcare facilities when necessary.

4. Maternal Health Vouchers: Introduce voucher programs that provide pregnant women with access to essential maternal health services, such as antenatal care, delivery, and postnatal care. These vouchers can be distributed to women in need, enabling them to seek care from accredited healthcare providers.

5. Mobile Clinics: Establish mobile clinics that travel to remote and underserved areas to provide maternal health services. These clinics can offer prenatal check-ups, vaccinations, and health education, bringing healthcare closer to women who have limited access to healthcare facilities.

6. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about the importance of maternal health and the available services. These campaigns can be conducted through various channels, such as radio, television, community meetings, and social media.

7. Improved Infrastructure: Invest in improving healthcare infrastructure, including the construction and renovation of healthcare facilities, particularly in rural and underserved areas. This can help ensure that women have access to quality maternal health services.

8. Transportation Support: Provide transportation support for pregnant women who have difficulty accessing healthcare facilities. This can include arranging transportation services or subsidizing transportation costs to enable women to reach healthcare facilities for prenatal visits, delivery, and postnatal care.

9. Maternal Health Hotlines: Establish hotlines that pregnant women can call to seek advice, ask questions, and receive guidance on maternal health issues. Trained healthcare professionals can provide information and support over the phone, helping women make informed decisions about their health.

10. Partnerships and Collaboration: Foster partnerships and collaboration between government agencies, non-profit organizations, healthcare providers, and community leaders to collectively address the barriers to accessing maternal health services. This can lead to more comprehensive and sustainable solutions.

AI Innovations Description

Based on the study findings, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Regular monitoring of household salt iodine content: Implement a system to regularly monitor the iodine content of household salt. This can be done through the use of rapid test kits, similar to the method used in the study. By ensuring that households have access to adequately iodized salt, the risk of iodine deficiency and associated health problems, such as goiter, can be reduced.

2. Improving access to safe water: Promote and implement interventions to improve access to safe water sources, particularly for drinking purposes. This can include initiatives such as providing clean water sources, promoting water treatment methods, and educating communities on the importance of using safe water for drinking and food preparation. Access to safe water is crucial for maintaining good health and preventing waterborne diseases.

3. Promoting the importance of diversified food for children: Raise awareness among parents and caregivers about the importance of providing a diverse and balanced diet for children. This can be done through educational campaigns, workshops, and community outreach programs. Encourage the consumption of a variety of food groups, including starchy staples, fruits, vegetables, and protein sources, to ensure adequate nutrient intake for optimal maternal and child health.

By implementing these recommendations, it is possible to address the higher burden of iodine deficiency and improve access to maternal health in the community. Regular monitoring of salt iodine content, improving access to safe water, and promoting diversified food for children can contribute to reducing the prevalence of goiter and other iodine deficiency disorders, ultimately improving maternal and child health outcomes.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement comprehensive education programs to raise awareness about the importance of maternal health, including the risks and complications associated with pregnancy and childbirth. This can be done through community outreach programs, workshops, and educational campaigns.

2. Improve access to healthcare facilities: Ensure that pregnant women have easy access to healthcare facilities that provide prenatal care, skilled birth attendants, and emergency obstetric care. This can be achieved by establishing more healthcare facilities in rural areas, improving transportation infrastructure, and providing financial support for transportation costs.

3. Strengthen health systems: Invest in strengthening health systems by training healthcare providers, improving the availability of essential medicines and supplies, and implementing quality assurance mechanisms. This will help ensure that pregnant women receive high-quality care during pregnancy, childbirth, and postpartum.

4. Promote antenatal care: Encourage pregnant women to seek early and regular antenatal care by providing incentives such as free or subsidized services, flexible clinic hours, and community-based antenatal care programs. Antenatal care visits are crucial for monitoring the health of both the mother and the baby, and for identifying and managing any potential complications.

5. Address social and cultural barriers: Address social and cultural barriers that prevent pregnant women from seeking healthcare services. This can be done by engaging community leaders, religious leaders, and traditional birth attendants to promote the importance of maternal health and to dispel myths and misconceptions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. For example, indicators could include the percentage of pregnant women receiving antenatal care, the percentage of births attended by skilled birth attendants, and the maternal mortality rate.

2. Collect baseline data: Collect baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, and data analysis of existing health records.

3. Implement the recommendations: Implement the recommended interventions and strategies to improve access to maternal health. This may involve collaboration with local health authorities, NGOs, and community organizations.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the recommendations on the selected indicators. This can be done through regular data collection, analysis, and reporting. Adjustments can be made to the interventions based on the evaluation findings.

5. Compare results: Compare the post-intervention data with the baseline data to assess the impact of the recommendations. This can be done by calculating the percentage change in the selected indicators and conducting statistical analyses to determine the significance of the changes.

6. Disseminate findings: Share the findings of the impact assessment with relevant stakeholders, including policymakers, healthcare providers, and the community. This can help inform future decision-making and resource allocation to further improve access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and identify areas for further improvement.

Umbhali

Dima Health

Statistics:

Citations: 23

Identifiers:

DOI: 10.1186/s12889-016-3914-z

Research Areas:

Community Interventions, Disparities, Environmental, Food Security, Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: