Proper infant and young child feeding practice within the first two years of life is crucial for optimal child growth, development, better health, and preventing chronic degenerative disease [
Optimal complementary food is explained by fulfilling minimum dietary diversity, meal frequency, and an acceptable diet. Minimum dietary diversity refers to the proportion of children aged 6–23 months who received, on a preceding day, at least four or more varieties of foods from the seven standard food groups recommended by the WHO, without imposing a minimum intake restriction [
Greater than two-thirds of malnutrition-related child deaths are associated with inadequate dietary feeding practices during the first two years of life. In developing countries, only a quarter of children met the required minimum dietary diversity [
Globally, there are efforts to improve the nutritional status of children by implementing different programs like the zero hunger draft [
Currently, the Ethiopian government also set targets to improve the nutritional status of children through the National Nutrition Program (NNP-II) [
There are no documented studies on the dietary diversity feeding and associated factors among children aged 6–23 months in Northeast Ethiopia. Therefore, this study aimed to assess child dietary diversity score and associated factors among children aged 6–23 months in Golina district, Northeast Ethiopia.
A community-based cross-sectional study was conducted in Golina district from February 15 to March 30, 2017. The district is found in the pastoralist region of Afar regional state, located 691 km northeast of Addis Ababa, the capital city of Ethiopia, and 220 km northwest of Samara, the capital city of the region. According to the projection of the 2007 census, the total population of the district was estimated to be 56,929; of which 5,727 were under-five children [
The minimum sample size for each specific objective was separately calculated using a single population proportion formula (Table
Sample size calculation to assess the level of CDDS with the assumption of 95% CI, 5% margin of error, and 5% none response allowance.
Percentage of minimum child dietary diversity score (%) | Reference no. | Minimum final sample size |
---|---|---|
10.6 | [ | 153 |
68.4 | [ | 347 |
18.8 | [ | 247 |
12.6 | [ | 177 |
30.4 | [ | 342 |
Sample size calculation to identify factors associated with CDDS using Epi Info (double population proportion formula).
Variables | CI (%) | Power (%) | Ratio (unexposed to exposed) | Outcome in the unexposed group (%) | Outcome in the exposed group (%) | No response obtained (%) | Sample size |
---|---|---|---|---|---|---|---|
Maternal education [ | 95 | 80 | 4.56 | 8.4 | 25.6 | 5 | 268 |
Index child age [ | 95 | 80 | 1.15 | 6.8 | 18.3 | 5 | 307 |
Finally, the required size was taken as 347, since this was found as the largest from all calculated sample sizes (Tables
Data were collected using a semistructured questionnaire via face-to-face interviews with mothers of children aged 6–23 months. The questionnaire was prepared in English and translated into the local language and retranslated back to English to check the consistency. The Food and Agriculture Organization (FAO) meal frequency questionnaire was used to determine the weekly food group consumption of the children [
Pretesting was done on 10% of the calculated sample size in nonselected kebeles, and then the necessary modification was done. Anthropometric measurements, such as the mother’s height and weight, were performed following WHO standard procedures. The mother’s weight was measured using UNICEF electronic weighing scales. The weighing scales were calibrated and standardized using a 5 kg standard weight, every morning before the actual measurements. The children’s age was determined using written official documents like vaccination cards. For those who had no written evidence of birthdate, a preprepared local calendar was used by cross-checking with the other family members. The children’s vaccination status was assessed by card, BCG scar, and mother recalled.
Four data collectors and two supervisors, who were fluent in the local language, were employed. Two days of training, on the study tool and anthropometric measurement procedures, were given for data collectors and supervisors. When households found having two or more eligible children, one of them was selected randomly via the lottery method.
Minimum child dietary diversity (MCDD): when a child gets at least 4 from the 7 WHO recommended food groups, regardless of the portion size and meal frequency [ Minimum meal frequency (MMF): calculated by grouping child age into two (6–8 months and 9–23 months). The acceptable MMF of children aged 6–8 months is considered as two or more times per 24 hours while for children aged 9–23 months it is three or more times [ Minimum acceptable diet (MAD): the percentage of breastfed children 6–23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day, and nonbreastfed children 6–23 months of age who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day [
Data were edited, cleaned, coded, and entered into EPI Data 4.2 and exported to SPSS version 22 for analysis. Characteristics of study participants were summarized using descriptive statistics. Multivariable logistic regression was used to identify independent predictors of childhood dietary diversity. The strength of association was measured through the odds ratio at a 95% confidence interval. Predictor variables with the
Multicollinearity was checked using standard error as a cutoff of 2, but no variables were found. The percentage of the model accurately classified was 70.7%, with Hosmer and Lemeshow goodness-of-fit test
A total of 345 study participants were included, with a 97% response rate. Nearly 264 (76.5%) were lived in rural areas, and 284 (82.3%) were of Afar ethnicity. Almost quarters (254 (73.6%)) of mothers had not attended formal education. More than half (180 (52.2%)) of children were female (Table
Socioeconomic and demographic characteristics of study participants by the minimum dietary diversity score of children, in Golina district, Northeast Ethiopia, 2017 (
Variable | Category | Total, | Minimum child dietary diversity score (MCDDS) | ||
---|---|---|---|---|---|
Meet, | Not meet, | ||||
Maternal religion | Muslim | 315 (91.3) | 106 (87.6) | 209 (93.3) | 0.073 |
Others | 30 (8.7) | 15 (12.4) | 15 (6.7) | ||
Maternal ethnicity | Afar | 284 (82.3) | 92 (76) | 192 (85.7) | 0.024 |
Others | 61 (17.7) | 26 (24) | 32 (14.3) | ||
Maternal age | 15–24 | 95 (27.5) | 39 (32.2) | 56 (25.0) | 0.338 |
25–34 | 195 (56.5) | 65 (53.7) | 130 (58.0) | ||
≥35 | 55 (16) | 17 (14.1) | 38 (17.0) | ||
Maternal education status | No formal education | 254 (73.6) | 74 (62.2) | 180 (80.4) | <0.0001 |
Primary | 35 (10.1) | 16 (13.2) | 19 (8.5) | ||
Secondary and above | 56 (16.3) | 31 (25.6) | 25 (11.1) | ||
Maternal occupation | Government employee | 41 (11.9) | 24 (19.8) | 17 (7.6) | <0.0001 |
Pastoralist | 216 (62.6) | 65 (53.7) | 151 (67.4) | ||
Housewife | 62 (18) | 17 (14.0) | 45 (20.1) | ||
Others | 26 (7.5) | 15 (12.3) | 11 (4.9) | ||
Maternal residence | Urban | 81 (23.5) | 52 (23.2) | 29 (24) | 0.875 |
Rural | 264 (76.5) | 172 (76.8) | 92 (76) | ||
Index child sex | Male | 165 (47.8) | 48 (39.7) | 117 (52.2) | 0.026 |
Female | 180 (52.2) | 73 (60.3) | 107 (47.8) | ||
Index child age | 6–8 months | 53 (15.4) | 26 (21.5) | 27 (12.1) | 0.025 |
9–11 months | 77 (22.3) | 20 (16.5) | 57 (25.4) | ||
12–23 months | 215 (62.3) | 75 (62.0) | 140 (62.5) | ||
Maternal age (in completed years) | Mean ± SD | 27.97 ± 5.43 | |||
Family size | Mean ± SD | 5.81 ± 2.13 | |||
Index child age (in completed month) | Mean ± SD | 13.76 ± 4.57 |
More than half (202 (58.5%)) of mothers were not attended ANC, and 267 (76.8%) of them were given birth at home (Table
Maternal healthcare and nutritional status characteristics by the minimum dietary diversity score of children, in Golina district, Northeast Ethiopia, 2017 (
Variables | Category | Total, | MCDDS | ||
---|---|---|---|---|---|
Meet, | Not meet, | ||||
Maternal ANC follow-up | Yes | 143 (41.5) | 43 (35.5) | 100 (44.6) | 0.101 |
No | 202 (58.5) | 78 (64.5) | 124 (55.4) | ||
Birth place | Home | 267 (76.8) | 93 (76.9) | 174 (77.7) | 0.862 |
Health institution | 78 (23.2) | 28 (23.1) | 50 (22.3) | ||
Nutrition counseling and health education | Yes | 82 (23.8) | 34 (28.1) | 48 (21.4) | 0.165 |
No | 263 (76.2) | 87 (71.9) | 176 (78.6) | ||
Maternal BMI (kg/m2) | <18.5 | 73 (21.2) | 19 (15.7) | 54 (24.1) | 0.012 |
18.5–24.9 | 32 (9.3) | 6 (5.0) | 26 (11.6) | ||
≥25 | 240 (69.5) | 96 (79.3) | 144 (64.3) |
Nearly two-thirds (115 (33.3%)) of children were not exclusively breastfed for the first six months of age. About 67 (19.4%) of children have met the minimum acceptable diet (Table
Child healthcare and feeding-related characteristics by the minimum dietary diversity score of children, in Golina district, Northeast Ethiopia (
Variables | Category | Total, | MCDDS | ||
---|---|---|---|---|---|
Meet, | Not meet, | ||||
Exclusive breastfeeding for the first six months | Yes | 115 (33.3) | 50 (41.3) | 65 (29) | 0.021 |
No | 230 (66.7) | 71 (58.7) | 159 (71) | ||
Food taboo for children | Yes | 14 (4.1) | 2 (1.7) | 12 (5.4) | 0.096 |
No | 331 (95.9) | 119 (98.3) | 212 (94.6) | ||
Minimum meal frequency (MMF) | Meet | 185 (53.6) | 67 (55.4) | 118 (52.7) | 0.632 |
Not meet | 160 (46.4) | 54 (44.6) | 106 (47.3) | ||
Minimum acceptable diet (MAD) | Meet | 67 (19.4) | 67 (55.4) | 0 (0) | <0.0001 |
Not meet | 278 (80.6) | 54 (44.6) | 224 (100) | ||
Immunization status of the child (at least one type) | Yes | 170 (49.3) | 62 (51.3) | 108 (48.2) | 0.592 |
No | 175 (50.7) | 59 (47.7) | 116 (51.8) | ||
Birth order of the child | ≤3 | 174 (50.4) | 71 (58.7) | 103 (46) | 0.047 |
4–5 | 93 (22.6) | 24 (19.8) | 69 (30.8) | ||
≥6 | 78 (27) | 26 (21.5) | 52 (23.2) |
All of the children consumed cereals for one week before the survey. But only 35.9% of them consumed flesh foods. Children meeting the dietary diversity score was 35.1% (Figure
Percentage of children, who consumed the seven food groups one week before the survey, in Golina district, Northeast Ethiopia, 2017.
Among all children, only 19.4% of them met the minimum acceptable diet (Figure
Percentage of infant and young child feeding practice among children aged 6–23 months in Golina district, Northeast Ethiopia (
Child dietary diversity score had no significant association with place of delivery, birth order, maternal residence, child immunization status, and food taboo (Table
Factors associated with child dietary diversity score in Northeast Ethiopia (
Variables/Category | Minimum CDDS | COR (95% CI) | AOR (95% CI) | |
---|---|---|---|---|
Meet (≥4) | Not Meet (≤3) | |||
Maternal education status | ||||
No formal education | 74 (61.16) | 180 (80.36) | 1 | 1 |
Attended primary | 16 (13.22) | 19 (8.48) | 2.048 (0.999–4.200) | 1.877 (0.807–4.370) |
Secondary and above | 31 (25.62) | 25 (11.16) | 3.016 (1.668–5.454) | 3.042 (1.312–7.052) |
Maternal BMI in (kg/m2) status | ||||
Normal | 19 (15.7) | 54 (24.11) | 1 | 1 |
Underweight | 6 (4.96) | 26 (11.61) | 0.528 (0.295–0.946) | 0.488 (0.259–0.918) |
Overweight | 96 (79.34) | 144 (64.28) | 0.346 (0.137–0. 873) | 0.319 (0.119–0.855) |
The variables entered into the model was maternal educational status, maternal marital status, maternal BMI status, number of under-five children at the household, nutrition counseling during antenatal care follow-up, household decision making power, livestock, index child sex, maternal ethnicity, family size, maternal age, child age, and religion.
In this study, children who met the minimum dietary diversity score were 35.1%, (95% CI: (30%–40%)). This figure is higher than that reported in studies done in Ethiopia such as Arsi Negele district (18.8%) [
This study revealed that maternal nutritional status (BMI) was associated with meeting the minimum dietary diversity score of children. This finding could be explained by the good nutritional status of the mother which might be due to her improved feeding practice, which could be a proxy for her child’s good feeding practice. This might be also influenced by decision making and media exposure [
Maternal education was found to be associated with meeting the child’s minimum dietary diversity score. This is in line with studies done in Ethiopia such as Dangilla [
In conclusion, maternal nutrition status and maternal education status were associated with child dietary diversity scores. This study revealed that children who met the minimum dietary diversity score were few. Therefore, increased emphasis on the importance of the education of girls (future mothers) and nutrition counseling for girls/women who received little education on ways to improve the family and child dietary feeding practice is needed.
Adjusted odds ratio
Bacillus Calmette–Guerin
Body mass index
Confidence interval
Child dietary diversity score
Ethiopian Demographic and Health Survey
Food and Agriculture Organization
Minimum dietary diversity score
Minimum meal frequency
Mid-upper arm circumference
Statistical Package for Social Science
United Nations Children’s Fund
World Health Organization.
The datasets analyzed during the current study are available from the corresponding author upon reasonable request.
Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Mekelle University (protocol approval: ERC-0936/2007). An official letter of support was obtained from Afar Regional Health Bureau, Golina district Health and Administrative Offices. The study objective was explained to parents. Privacy and confidentiality were ensured at all levels. Interview and anthropometric measurements were conducted in a private area and their name was not requested and recorded.
Informed written consent was obtained from study participants. Counseling and linkage to appropriate healthcare and support were given.
The authors declare that they have no conflicts of interest.
GFM conceived and designed the study, performed analysis, interpreted the data, and drafted the manuscript. FWF and SA were involved in the analysis and interpretation of the data and critically reviewed the manuscript. All authors read and approved the final manuscript.
The authors would like to express their deepest gratitude to Samara University for facilitating this study. Our appreciation also goes to supervisors, data collectors, and study participants.