Concordance of Mother-Child (6-23 Months) Dietary Diversity and Its Associated Factors in Kucha District, Gamo Zone, Southern Ethiopia: A Community-Based Cross-Sectional Study

Meeting minimum standards of dietary quality in mothers and children is a challenge in many developing countries including Ethiopia. Emerging evidence suggests that maternal and child dietary diversity is associated, but little is known about the associated factors of concordance of mother-child dietary diversity in Ethiopia and none is documented in the study area. This study examines the concordance between mother-child (6-23 months) dyads dietary diversity and the associated factors in Kucha District, Gamo Zone, Southern Ethiopia. A community-based cross-sectional study was conducted among 791 mother-child (6-23 months) pairs from 11 selected kebeles on March 6 to April 13, 2017. Multistage cluster sampling technique was used to select the study subjects. The sampling frame was obtained from the family folder of health posts in each kebele. The mother-child pairs were selected by the simple random sampling method. The 7 food groups of the World Health Organization (WHO) for children and the 10 food groups of FANTA/FAO 2016 for mothers were used to analyze the dietary diversity. Cohen’s kappa statistics was calculated to see the strength of concordance. The multivariable logistic regression model was fitted to determine factors affecting mother-child dietary diversity concordance. A good concordance was noted between mother-child dietary diversity scores (Kappa = 0.43). Only 56 (7.1%) mothers were negative deviants, and 133 (16.8%) mothers were positive deviants in dietary diversity consumption. Rural residence (AOR = 3.49; 95% CI: 1.90-6.41), having no formal education (AOR = 1.8; 95% CI: 1.08-3.05), not owning milking cow (AOR = 1.7; 95% CI: 1.10-2.56), children with low dietary diversity (AOR = 8.23; 95% CI: 5.17-13.08), and mothers with low dietary diversity (AOR = 0.46; 95% CI: 0.29-0.74) were found to be factors associated with mother-child dietary diversity concordance. An increase in the percentage of children reaching the minimum dietary diversity was greater with a successive increase in maternal dietary diversity. Despite interesting similarities between mothers and children dietary consumption, more than three-quarters of concordants did not achieve the recommended dietary diversity score (were low concordants). Interventions targeting on rural women’s access to high school education, home-based milking cow rearing, and promoting nutrition-sensitive agriculture to meet the dietary requirements of mothers and children in a sustainable manner and public health efforts to improve child nutrition may be strengthened by promoting maternal dietary diversity due to its potential effect on the entire family. The study was conducted in Kucha District located 450 km away from the country’s capital, Addis Ababa, and 215 km from the regional capital, Hawassa. The district is located in Gamo Zone in the Southern Nations, Nationalities, and Peoples’ Region (SNNPR) and contains a total of 35 (32 rural, 3 urban) administrative subdistricts (kebeles). According to the Kucha District Health Office estimate, the district has a total population of 189,233 in 2017 and of which mothers 15–49 years were 37,544 (19.8%) and 6,642 (3.5%) were children (6–23 months). The district has eight health centers, thirty-nine health posts, one preparatory school, eight high schools, and fifty-one second-cycle and eighteen first-cycle primary schools [29]. A community-based cross-sectional study was conducted from March to April, 2017, among mother-child pairs (both breastfeeding or not with children aged 6–23 months) who were permanent residents of the district and able to provide information (free of mental illness and communication difficulties). The sample size was determined by using the single population proportion formula with the assumptions of 95% confidence level, estimated proportion of discordance in mother-child DD of 50%, 5% margin of error, and the minimum sample size (no) of 384. Since the source population was 6642 that is less than 10,000, we have reduced the sample to 362 by using the finite population correction formula. By considering (10%) nonresponse rate and a design effect of 2, the final sample size was 796. From the total 35 kebeles of the district, eleven kebeles were selected using simple random sampling/SRS/lottery method. To identify mother-child (6–23 months) pairs from the selected kebeles, the family folder (registry book of all families with their children) within the health post was used. Using these registered data as a sampling frame in each kebele, the required number of samples was determined for each kebele with consideration of size of mother-child pairs in each kebele. The required numbers of women interviewed in each kebele were selected randomly from the sampling frame using the “select random samples” command in the Statistical Package for Social Sciences (SPSS) software. In case of twins, one of the twins was randomly selected. When two or more children in the specified age range were present in one HH, the last child with his/her mother was selected. Data were collected by ten nurses who were recruited as data collectors and supervised by two BSc nurses. Mothers were asked to respond on the diet they fed their children and their own feeding in the past 24 hours and their sociodemographic characteristics. They were asked to recall all foods and beverages the child fed during the past 24 hours, both within and outside the home. A semistructured pretested questionnaire was used to collect data on variables pertaining to sociodemographic characteristics as well as dietary, health care practices, and other related variables of mothers and their children (6–23 months old). The questionnaire was first developed in English, translated to the local language Gamotho, and then back translated to English by an independent translator for consistency. Minimum dietary diversity of children: proportion of children 6–23 months of age who receive foods from ≥4 food groups during the previous day considered adequate and <4 food groups is considered inadequate (low) from the seven defined food groups the previous day and night. A cutoff point of 4 was used to assess the adequacy of a child's DDS; hence, a child with DDS ≥ 4 was considered to have a high diet diversity (adequate diet) and otherwise DDS < 4 was considered a child with low diet diversity (inadequate diet) [30]. Minimum dietary diversity of women (MDD-W): a cutoff point of 5 food groups was used to assess the adequacy of a mother's DDS; hence, a mother with DDS ≥ 5 was considered to have a high dietary diversity (adequate diet) and otherwise DDS < 5 considered a mother with low diet diversity (inadequate diet) [16]. The proportion of mothers who reach this minimum in a population is used as a proxy indicator for higher micronutrient adequacy, one important dimension of diet quality [16, 31]. Household food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS) developed by FANTA, and food security status was classified into four categories: food secured, mild, moderate, and severely food insecure. It records household reactions and response to food access problems faced during a recall period of four weeks. It aims to capture the severity of food insecurity faced by households due to lack of or limited resources to access food. The respondent is first asked an occurrence question, that is, whether the condition in the question happened at all in the past four weeks (yes or no). If the respondent answers “yes” to an occurrence question, a frequency-of-occurrence question is asked to determine whether the condition happened rarely (once or twice), sometimes (three to ten times), or often (more than ten times) in the past four weeks [32]. Wealth index: to measure the wealth index, a wealth index measurement tool adapted from EDHS was used [33]. It was classified using terciles (low, medium, high). Concordance: agreement of dietary diversity in mother-child dyads. If the mothers eat ≥5 food groups from the ten food groups and her child eats ≥4 foods from the seven food groups (high concordant who achieved the recommended minimum dietary diversity), or when the mothers eat <5 food types from the ten food groups and her child eats <4 foods groups from the seven food groups (low concordant who did not achieve minimum dietary diversity) in the previous day (24 hours) of the survey was termed as mother-child dietary diversity concordance. Discordance: disagreement on dietary diversity consumption between mothers and children. Mothers >5 and children <4 food groups or mothers <5 food groups and children >4 food groups. Negative deviant: among the discordant mothers who ate ≥5 food groups from ten food groups of MDD-W (meeting high dietary diversity criteria of the FANTA and FAO) but who fed their children <4 food groups (not meeting minimum dietary diversity, WHO criteria). Positive deviant: among the discordant mothers who eat <5 food groups from ten food groups of MDD-W (low dietary diversity) but who fed their children ≥4 food groups (meeting the WHO criteria of minimum dietary diversity of children). High concordant: mothers/children who achieved the minimum dietary diversity and being concordant. Low concordant: mothers/children who did not achieve the minimum dietary diversity and being concordant. Dietary diversity level: considered high if the DDS is ≥4 in children and ≥5 in mothers; otherwise considered low. .The questionnaire was pretested on 5% of the sample of mother-child pairs in the Boreda district out of the study area, and the necessary changes were made to it before data collection. Two-day training was given on the aim of the research, content of the questionnaire, and the interview process for data collectors and supervisors to increase their performance in the activities. Data were collected on all days of the week since people may eat differently on different days of the week. The collected data were checked every day by supervisors and the principal investigator for its completeness and consistency. All the interviews were conducted at the residences of the study participants. Vacant or closed houses during the day of visit were revisited two times to maintain the required sample size. Probing technique was used in 24-hour dietary data to minimize recall bias. After checking the data for completeness and missing values, they were coded and entered using EpiData, version 3.1, cleaned and analyzed using SPSS statistical software version 20.0. Descriptive statistics for categorical variables was presented as frequency percent, and continuous variables were presented using mean ± SD and percentage and to examine the differences among low and high dietary diversity of mothers and children. Principal component analysis was done to set household wealth score; the score was ranked into terciles (low, middle, and high). The HFIAS score was calculated for each household food insecurity status by summing the codes for each frequency of occurrence of the condition questionnaire. The score for a household ranges from 0 to 27, with a maximum score of 27 indicating most food-insecure households and ranked into secure, mildly insecure, moderately insecure, and severely insecure. Finally, food insecurity was categorized as secure and insecure (mild, moderate, and severe). Bivariate analysis was done to examine the associations between the concordance of maternal-child dietary diversity and each of the independent variables independently. To identify the predictors of maternal-child dietary diversity concordance, variables that were significantly associated at P value (<0.25) in the bivariate analysis were entered into the multivariable logistic regression model. Those variables with P value < 0.05 in the multivariable analysis were declared as significant. Adjusted odds ratios (AOR) with 95% confidence level showed the strength of association between the predictors and the dependent variable. The Hosmer–Lemeshow test was checked for model fitness. Cohen's Kappa value was calculated to measure the strength of concordance between the dietary diversity score categories calculated for mothers and children. Ethical clearance was obtained from Institutional Research Review Board, Institute of Health, Jimma University. Written permission was obtained from the Gamo Zone (the then Gamo Gofa Zone) Health Department and Kucha District Health Office. During data collection, informed written consent was obtained from women who participated in the study. Confidentiality of mothers' and children's information was maintained during data collection, analysis, and interpretation.