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Objective To assess the prevalence of food insecurity (FI) and its predictors among lactating mothers in Ataye District, North Shoa Zone, Central Ethiopia. Design A community-based cross-sectional study design was used. Setting Two urban and four rural randomly selected kebeles of the Ataye District in Ethiopia. Participants Out of 635 participants, 612 lactating mothers aged 15-49 years participated from February to April 2018. Mothers who lived for at least 6 months and above in the district were included, and mothers who were not able to respond to an interview were excluded. A single lactating mother per household was included. Lactating mothers in the households were selected using a cluster sampling technique. The number of lactating mothers found in each kebele was taken from family folder documentation. Primary outcome The prevalence and predictors of food insecurity. Results The prevalence of FI among lactating mothers was 36.8%. No formal education (adjusted OR (AOR) =1.82, 95% CI 1.13 to 2.92), no income-generating activities (AOR=3.39, 95% CI 2.05 to 5.64), no home gardening practice (AOR=5.65, 95% CI 3.51 to 9.08), alcohol use by husbands (AOR=2.02, 95% CI 1.25 to 3.24), low minimum dietary diversity score (AOR=2.94, 95% CI 1.88 to 4.57), less than three frequencies of meals (AOR=3.97, 95% CI 1.65 to 9.54) and three meals only per day (AOR=1.86, 95% CI 1.08 to 3.17) were significant predictors of FI of mothers. Conclusion The prevalence of FI was high in the study area. No formal education, no income-generating activities, no home gardening practice, alcohol use by husbands, low minimum dietary diversity score, fewer than three frequencies of meals and three meals only per day were independent predictors of FI. Therefore, increasing home gardening, decreasing alcohol intake, increasing dietary diversity and performing income-generating activities are highly recommended to reduce FI.
This study was conducted in Ataye District, which is 270 km away from Addis Ababa (the capital city of Ethiopia) and 140 km from Debre Berhan town (the Zonal Town of North Shoa) in central part of Ethiopia. From the 2007 national census projection, the total population of Ataye District was 110 493, and the current population was estimated to be 170 425. The district has 30 kebeles, which is the lowest administrative unit in Ethiopia (Ataye District Report, 2017). This study was conducted in two urban and four rural randomly selected kebeles in the district. A community-based cross-sectional study design was used to determine the prevalence and predictors of FI from February to April 2018. During the study period, the source populations of the study were all lactating mothers aged 15–49 years. A clear description of the study title, purpose, procedure, duration, possible risks and benefits of the study were explained to each study participant. Then written informed consent was obtained from each respondent before starting the interview. Regarding the eligibility criteria, mothers aged 15–49 years who lived for at least 6 months and above in the district were included. On the other hand, mothers who were unable to respond to an interview, were severely sick and did not volunteer to respond to the questionnaire were excluded from this study. The required sample size for this study was determined and calculated using a single population proportions formula with the following assumptions: proportion of FI among lactating mothers 50% (0.5), Za/2 with 95% confidence level to be 1.96, margin of error to be 0.05, non-response to be 10%, and a design effect of 1.5. Accordingly, the final calculated sample size of the study was 635. Regarding the sampling procedures, considering kebeles as clusters, lactating mothers in the households were selected by the cluster sampling technique. The Ataye District has 30 kebeles (6 urban and 24 rural). However, the kebeles were selected using a simple random sampling method. Based on the residence of mothers, these kebeles/clusters were classified into urban and rural areas. The sample size was allocated proportionally according to the population size of the selected urban and rural kebeles. The number of lactating mothers found in each kebele was taken from a family folder, which is documented by the health extension workers with respect to their household. Through house-to-house visits, all lactating mothers in randomly selected clusters were included in the study. In the absence of eligible mothers during the time of visit, a revisit was arranged a minimum of three times and finally, if they were not present, were considered non-respondents. The study data collection instruments were developed by reviewing different kinds of literature using search engines such as PubMed, Google Scholar, Hinari and The Lancet series. A structured interviewer-administered questionnaire was used to collect the data through Amharic language (local language), which was translated from the English language. The data collectors of this study were six female grade 10 graduated students who were fluent speakers in the local language. The data collectors underwent a community-based face-to-face interview using a structured and pretested questionnaire in Amharic. The lactating mothers were informed about the details of the research during the interview period. Two health professionals who have bachelor dgree from Ataye District Hospital and Health Center were recruited for the supervision of the data collection procedure. The variables of this study were grouped as sociodemographic variables, health service utilisation related variables, and food source and feeding practice of mother-related variables. The sociodemographic variables were place of residence, maternal age, marital status, maternal educational status, family size, number of children under 5 years of age, maternal occupation, religion, ethnicity and sex of the household head. The health service utilisation related variables were ANC visit, place of delivery, postnatal care visit and maternal history of illness. The food source and feeding practice of mothers’ related variables were inadequate dietary intake, nutrition knowledge, sources of food, home gardening practice, alcohol intake by husbands and income-generating activities. Household FI was measured with the Household Food Insecurity Access Scale (HFIAS), a structured, standardised and validated tool developed mainly by Food and Nutrition Technical Assistance (FANTA), to classify households as food secure or not.1 28 The scale is a valid tool for measuring household FI among both rural and urban areas of Ethiopia with Cronbach’s α values of 0.76 for round 1 and 0.73 for round 2.29 With regard to the knowledge of nutrition, we used self-reported data asking mothers about their knowledge of nutrition. It was assessed and computed based on six questions. The questions included mothers’ awareness about nutrition, dietary diversity practice and taking varieties of food groups, definitions of the term varieties and types of varieties of food groups, definitions of the term nutrition and malnutrition, causes of malnutrition, and consequences of malnutrition. The previous history of illness of mothers’ was assessed by self-reporting asking them whether they faced any illness in the last time or not, whereas the current illness was assessed by self-reporting and measurements such as fever check and temperatures. To assess the antenatal visits (ANC), first the data collectors ask the mothers about their ANC follow-up as a self-reported to know the understanding level of mothers on their health service practice. To check its appropriateness, whether they attended or not, we cross-checked it from their family folder in their administrative kebeles. Mothers aged 15–49 years and having children 6–23 months old who were currently breast feeding their infant/child.30 Mothers who have experienced none of the FI (access) conditions or have just been worried, although rarely, during the past 4 weeks.6 Mothers who are unable at all times to access food sufficient to lead an active and healthy life (includes all stages of FI; mild, moderate and severe).6 Mothers who worry about not having enough food sometimes or often and/or are unable to eat preferred foods and/or eat a more monotonous diet than desired and/or some foods considered undesirable, but only rarely.6 Mothers who sacrifice quality more frequently, by eating a monotonous diet or undesirable foods sometimes or often, and/or have started to cut back on quantity by reducing the size of meals or number of meals, rarely or sometimes. However, they do not experience any of the three most severe conditions.6 Mothers who have been forced to cut back on the meal size or number of meals often and/or experience 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.6 The data collection instrument was translated back to English by independent language experts in both languages to ensure its consistency, and comparisons were made on the consistency of the two versions. Before the actual data collection, the questionnaire was pretested outside the selected kebeles on 5% of the total sample size to ensure the validity of the tool. After the pretest had been done, all the necessary adjustments were made. Some of the adjustments were modifications and improvements to the questions related to knowledge on nutrition, the approach of the data collectors and the ability to review the mothers. Then, the translated, pretested and structured Amharic version of the questionnaire was used to collect the data. Two days of training on theoretical and practical aspects was given to the six female grade 10 graduated students and the two supervisors. The focus areas of the training were interview techniques, ethical issues, rights of the participants, reading through all the questions and understanding them well, and ways of minimising under-reporting or over-reporting and maintaining confidentiality. Interviews were conducted without the involvement of any person other than the respondent in an area providing adequate confidentiality and privacy. The actual data collection was closely supervised by the principal investigator and the two supervisors. The collected data were cross-checked on each day of activity for consistency, missing data and completeness. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. The authors visually checked all the interview questionnaires before going in for analysis. EpiData V.4.2.0.0 software was used to code, enter and clean the data. To cross-check the data for completeness, double data entry was made by two data clerks. After doing this, the entered data were exported and analysed with Statistical Package for Social Science (SPSS) V.24 software for windows using IBM SPSS Statistics 24 Core System User’s Guide. To describe the demographic, socioeconomic and maternal-related characteristics of the respondents, simple descriptive statistics such as simple frequency distribution, measures of central tendency, measures of variability and percentages were performed. Tables and figures were used to present the information of respondents. The outcome variable (FI) was determined by computing nine standard HFIAS questions adapted from the FANTA project. The tool consists of nine questions that show frequency of occurrence and measures the severity of FI in the last 4 weeks in terms of Likert Scale question responses (0=never, 1=rarely (1 or 2 times), 2=sometimes (3–10 times), 3=often (>10 times)). The mothers were expected to answer these questions on behalf of all household members in their household. This tool was used to assess access to food for all household members at the time of data collection. To determine the cumulative score of FI among mothers, the nine items ranged from 0 to 27, and a higher score indicated that the household members experienced more FI. For analysis, all ‘Yes’ responses were coded in ‘1’ and ‘No’ responses were coded in ‘0’, and the responses were summed to obtain the household FI status. The HFI status, which had high internal consistency (Cronbach’s α=0.927), was further dichotomised as ‘food insecure’ and ‘food secure’ households, which were coded as ‘1’ and ‘0’, respectively, for analysis. Related to the analysis of knowledge of nutrition, using a mean score, mothers who scored above the mean cut-off point were considered to have good knowledge and coded as ‘1’, whereas those who scored below this cut-off point were considered to have poor knowledge and coded as ‘0’. To see the association between each independent variable and the outcome variable, the bivariate analysis and crude OR along with a 95% CI were used. In addition, independent variables with a value of p≤0.25 were included in the multivariate analysis to control for confounding factors. To see the linear correlation among the independent variables, multicollinearity was checked using SE. Variables with an SE of ≥2 were dropped from the multivariate analysis. The test coefficient of Hosmer-Lemeshow’s goodness-of-fit model was used to test the fitness of the model which was found to be insignificant with a large p value (p=0.860). To identify the predictors of FI, adjusted ORs (AORs) along with 95% CIs were estimated using multivariate logistic regression analysis. All tests were two-sided and the level of statistical significance was declared at a value of p<0.05.
