Dietary diversity has been a challenge in developing countries, especially in rural communities. In countries where resources are limited, lack of access to adequate and diversified diet has been identified as one of the severe problems among poor populations [
Dietary diversity (DD) is one of the proxy indicators for measuring dietary adequacy among individuals [
Ethiopia is one of the low-income countries with the highest levels of lactating mothers’ malnutrition in sub-Saharan Africa [
A community-based cross-sectional study design was employed in Lay Gayint District, South Gondar Administrative Zone, Amhara National Regional State. The district has 31 kebeles located 237 km from the region capital Bahir Dar. The district has a total population of 206,499 (male: 104,401 and female: 102,098) and 12,984 lactating mothers who have under two children. Out of the total population, 22,825 (11%) are urban dwellers, whereas 183,674 (88.95%) live in rural areas (CSA, 2007) [
The study population was lactating mothers who have children of two and less than two years in the selected smallest administrative units. The sample size is determined using single population proportion formula with the following assumptions: 56.4% of proportion of lactating mothers who have inadequate dietary diversity [
The systematic random sampling technique was used to select lactating mothers. Accordingly, the number of lactating mothers from the sampled kebele was selected in an (
Dietary diversity score is the sum of nine food groups eaten in the previous 24 hours. Women dietary diversity uses the following nine food groups: starchy staples, dark green leafy vegetables, vitamin A-rich vegetables and fruits, organ meat, flesh meat and fish, eggs, dairy, legumes, and nuts [
Household food insecurity was measured using a Household Food Insecurity Access Scale (HFIAS) adapted from household food insecurity scales that were previously validated for use in developing countries. It is the measure of the degree of food insecurity in the household in the past 4 weeks (30 days). It consists of two types of related questions. The first question type is called an occurrence question. There are nine occurrence questions that ask whether a specific condition associated with the experience of food insecurity ever occurred during the previous 4 weeks (30 days). Each severity question is followed by a frequency of occurrence question, which asks how often a reported condition occurred during the previous 4 weeks. There are three response options representing a range of frequencies (1 = rarely; 2 = sometimes; 3 = often). Finally, individuals were classified as food secure if the individuals responded “no” to all of the items and insecure if the individuals responded “yes” to at least one of the nine items [
The questionnaires had been pretested in Lay Gayint District at Sali rural kebele to check on the length, content, question wording, and language. This allows modifications on the questionnaires by correcting mistakes and inclusion of foods that may have been missed out or elimination of foods that may not be applicable in the community. Ambiguous questions were corrected to ensure clarity of the required information and then to enhance reliability. Furthermore, in order to control the quality of the data; correction and modification were done based on the gap identified during interview. Grade 12 and diploma holders were recruited as data collectors and supervised by clinical nurses. Training was given on the aim of the research, content of the questionnaire, and how to conduct interview and supervise to increase their performance in field activities. The collected data were checked every day by supervisors, and the authors checked the completeness and consistency.
Data were entered and analyzed using by SPSS version 21. Proportions and summary statistics were performed and bivariable and multivariable logistic regressions were used to determine the predictors of adequate dietary diversity. The variables that were found with
Ethical clearance was obtained from institutional review board of Bahir Dar University. Permission letter was obtained from the concerned bodies of the district and kebele administrations through a formal letter. The nature of the study was fully explained to the study participants to obtain their oral consent, and confidentiality of the information was ensured through not writing and recording the name of respondents, interviewing them privately. Study participants were also informed that they had a full right not to participate in the study and could withdraw any time.
A total of 408 lactating women were included in the study. Most of the lactating women (72.8%) were in the age group of 15–30 years old. Above half of the lactating women (57%) were unable to read and write. Most of the lactating women were married (92%). Greater than half of the lactating women (65%) had four to six family sizes (Table
Sociodemographic characteristics of lactating mothers in Lay Gayint District (
Variables | Frequency | % |
---|---|---|
Age of lactating mothers (years) | ||
15–30 | 297 | 73 |
31–40 | 98 | 24 |
>40 | 13 | 3 |
Age of children (month) | ||
0–6 | 99 | 24 |
9–12 | 143 | 35 |
>12 | 166 | 41 |
Lactating mothers’ educational status | ||
Unable to read and write | 232 | 57 |
Able to read and write (informal education) | 37 | 9 |
Grade 1–6 | 53 | 14 |
Grade 7–10 | 75 | 18 |
>Grade 10 | 11 | 2 |
Marital status of lactating women | ||
Married | 374 | 92 |
Divorce | 18 | 4 |
Single | 11 | 3 |
Widowed | 5 | 1 |
Husband education | ||
Unable to read and write | 146 | 36 |
Able to read and write (informal education) | 122 | 35 |
Grade 1–6 | 37 | 9 |
Grade 7–10 | 68 | 17 |
>Grade 10 | 12 | 3 |
Family size | ||
1–3 | 88 | 21 |
4–6 | 264 | 65 |
>6 | 56 | 14 |
Most of the lactating women (85%) had own production for their food source as well as possessed farm lands (88%). Lactating women had low home gardening practice (19.4%) while pulse production was found to be better compared to practice of home gardening (44.9%). Three-fourth of the lactating women reported that they possessed big animals while half of them were found to possess small animals. Furthermore, a quarter of the lactating women had additional income generating activities. Regarding access to information and communication, half of the lactating women had a mobile phone.
From the total lactating women, 66% faced shortages of time to prepare food. And among them, 20%, 51%, and 49% lactating women gave care for members of the family, did extra outdoor activities (such as shopping, fetching water, and collecting firewood), and did farming activities in the field, respectively. Concerning the working hour, 65.7% of lactating women reported that they had worked 9 to 12 hours per day. Because of being busy, 38% of the participants reported that they spend time without food. Concerning fetching water, 14.5% of lactating mothers reported that they have spent more than 60 minutes to fetch water (Table
Work burden of lactating mothers (
Lactating women activities | Frequency | Percent |
---|---|---|
Give care for members of the family | ||
Yes | 81 | 20 |
No | 327 | 80 |
Time shortage to prepare food | ||
Yes | 176 | 43 |
No | 232 | 57 |
Extra outdoor activities | ||
Yes | 271 | 66 |
No | 137 | 34 |
Field/farm work | ||
Yes | 208 | 49 |
No | 200 | 51 |
Presence of assistant to cook food | ||
Yes | 70 | 17.4 |
No | 338 | 82.6 |
Presence of supporter to fetch water | ||
Yes | 169 | 41.4 |
No | 239 | 58.6 |
Working hour per day | ||
≤8 hours | 109 | 26.7 |
9 to 12 | 268 | 65.7 |
>12 | 31 | 7.6 |
Time spent without eating food due to being busy | ||
Yes | 155 | 38 |
No | 253 | 62 |
Time spent to fetch water | ||
<5 and 5 minute | 41 | 10 |
6 to 30 minute | 271 | 66.4 |
31–60 minute | 37 | 9.1 |
>60 minute | 59 | 14.5 |
Time spent for queuing to fetch water | ||
0–15 minute | 107 | 26.5 |
16–45 minute | 46 | 12 |
45–120 minute | 103 | 25.5 |
>120 minute | 142 | 36 |
Three hundred fifty-two (86%), 383 (94%), and 318 (78%) of the participants reported that they used antenatal care, postnatal care, and delivered at health center, respectively. 190 (51%) of the participants reported that there is illness within two weeks. From HFIAS, 58% of the respondents reported they worried about food; 63% of them faced lack of preferred food; 64% of them had limited access to a variety of foods; and 29% of them were forced to eat unpreferred food due to lack of resources.
Out of the total lactating mothers of Lay Gayint District, 163 (40%), 1724 (30%), 62 (15.19%), 29 (7%), and 16 (4%) of the respondents reported that they were eating small portions, they were skipping meals, their households ran out of food, they went to sleep hungry, and they remained 24 hours without food, respectively. Regarding the food security status of lactating mothers, 286 (70%) of lactating mothers are food insecure. Out of the total lactating mothers, 261 (64%) of the participants reported that they had consumed three meals per day within the past 7 days. The mean meal frequency of lactating mothers was three (+SD 0.64).
Nearly all women (99.5%) consumed starchy staples, and 90.7% of them consumed pulses and 94.6% of them did not have any green leaf vegetation in previous 24 hours. More than two-third of the participants (71.1%) reported that they did not have fruits and vegetables within 24 hours, and 62% of the participants indicated that they had fat and oil within 24 hours (Table
Dietary diversity frequency of lactating mothers (
Food group consumed within the previous 24 h | Frequency | Percent | |
---|---|---|---|
Carbohydrates and starch | Yes | 406 | 99.5 |
No | 2 | 05 | |
Green leafy vegetable | No | 386 | 94.6 |
Yes | 22 | 5.4 | |
Sources of vitamin A | No | 387 | 94.9 |
Yes | 21 | 5.1 | |
Fruits and vegetables | No | 290 | 71.1 |
Yes | 118 | 28.9 | |
Fat and oil | No | 156 | 38 |
Yes | 252 | 62 | |
Meat and fish | No | 378 | 92.6 |
Yes | 30 | 7.4 | |
Egg | No | 379 | 92.9 |
Yes | 29 | 7.1 | |
Pulse | No | 38 | 9.3 |
Yes | 370 | 90.7 | |
Dairy products | No | 383 | 94 |
Yes | 25 | 6 | |
Dietary diversity (DD) | Low | 268 | 65.7 |
Medium | 123 | 30.1 | |
High | 17 | 4.2 |
Lactating women who possessed a mobile phone were 2.3 times more likely (OR: 2.3; 95% CI: 1.15–4.54) to have a diversified diet compared to those who did not have the mobile phone. Lactating women who practiced home gardening were four times more likely (OR: 4.1; 95% CI: 1.70–9.86) to have a diversified diet than those who did not practice. Lactating women who produced pulses were 4.8 times more likely (OR: 4.8; 95% CI: 2.50–9.32) to diversify their diet compared to those who did not. Lactating women who delivered in health center were 4.7 times more likely (OR: 4.7; 95% CI: 1.79–12.25)) to have diversified diet compared to their counterparts. Lactating women who had food secured households were 2.4 times more likely (OR: 2.4; 95% CI: 1.24–4.62) to have diversified diet compared to those who have food insecure household. Lactating women who had above three meals per day within the previous seven days were 11 times more likely (OR: 11.1; 95% CI: 2.73–45.24) to have diversified diet compared to those who had below three meals per day within the previous seven days. Lactating women who had a practice of income generating activities were four times more likely (OR: 4.0; 95% CI: 2–8.33)) to have diversified diet compared to those who did not practice income generating activities (Table
Bivariable and multivariable associations of factors with dietary diversity among lactating mothers in Lay Gayint District, South Gondar Zone, Ethiopia, March 2018.
Variables | Dietary diversity | COR (95% C.I.) | AOR (95% C.I.) | |
---|---|---|---|---|
Adequate | Inadequate | |||
Mobile phone | ||||
Yes | 103 | 104 | 4.6 (2.945, 7.272) | 2.29 (1.152–4.546) |
No | 165 | 36 | 1 | 1 |
Home gardening | ||||
Yes | 18 | 61 | 10.7 (5.98, 19.22) | 4.1 (1.707–9.866) |
No | 250 | 79 | 1 | |
Pulses production | ||||
Yes | 78 | 105 | 7.3 (4.592, 11.629) | 4.8 (2.508–9.325) |
No | 105 | 35 | ||
Income generating activities | ||||
Yes | 50 | 85 | 6.35 (4.23, 10.019) | 4 (2–8.331) |
No | 218 | 57 | ||
Delivered in health center | ||||
Yes | 191 | 127 | 3.94 (2, 7.388) | 4.7 (1.799–12.250) |
No | 77 | 13 | ||
Household food insecurity status | ||||
Food secured | 50 | 72 | 4.6 (2.938, 7.254) | 2.4 (1.245–4.620) |
Food insecure | 218 | 68 | 1 | 1 |
Meal frequency | ||||
Below 3 meals | 66 | 5 | 1 | 1 |
3 meals | 190 | 71 | 4.9 (1.909, 12.743) | 2.5 (0.746–8.458) |
>3 meals | 15 | 61 | 70.4 (23.470, 211.170) | 11.12 (2.735–45.243) |
Adequate dietary diversity includes both medium and high dietary diversity categories; inadequate dietary diversity includes low dietary diversity.
This study tried to determine the predictors of dietary diversity among lactating mothers in Lay Gayint District, Amhara National Regional State, Ethiopia. The prevalence of inadequate dietary diversity was 65.7% in this study. This is a very alarming proportion that could show most of the lactating mothers and their children are at risk of malnutrition. A study conducted in Aksum town showed that about 56% lactating mothers had low dietary diversity [
Large proportions of the lactating women in the study area seem to have good access to carbohydrates and fats and oils. However, only little proportion could access protein (meat, fish, egg, and dairy products) and vitamin sources within 24 hours. This can be strong evidence that the study population is exposed to malnutrition in terms of protein. This finding is almost consistent with the finding of other similar studies conducted in various developing countries [
The most important predictors of dietary diversity were meal frequency, pulses production, institutional delivery, home gardening, and income generating activity. Thus, immediate interventions may be needed towards alleviating low dietary diversity by encouraging the society to regularly practice the above factors. This study showed that mothers lactating more than three times per day are 11.12 times more likely to diversify their diet. Similarly, a study conducted in Aksum reported a strong association between meal frequency and dietary diversity [
Lactating mothers who produced pulses were 4.8 times more likely to diversify their diet. Pulses are main crops to fulfill protein energy requirement in the world. Of course, those who did not produce pulses always eat by buying the pulses by compromising other food items. In a study conducted in Alamata area, pulses production was not associated with dietary diversity [
Lactating mothers who delivered in health center were 4.7 times more likely to diversify their diet. This result agrees with EDHS [
Lactating mothers who practiced home gardening were 4 times more likely to have a diversified diet. This is consistent with studies conducted in Aksum [
Lactating mothers who had a practice of income generating activity were 4.45 times more likely to diversify their diet compared to those who did not practice IGA. Studies conducted in rural Burkina Faso [
However, the study conducted in Aksum town [
Lactating mothers who had a mobile phone were 2.2 times more likely to have a diversified diet compared to their counterparts. Same results were reported by previous study conducted in South Gondar [
Meal frequency, home gardening practices, pulses production, delivery at health center, practice of income generating activity, food insecurity, and mobile phone usage had significant association with dietary diversity. Therefore, concerned bodies should design multidimensional livelihood and health service programs to alleviate inadequate dietary diversity.
Antenatal care
Bureau of Finance and Economic Development
Dietary diversity score
Dietary diversity
Food and Nutrition Technical Assistance II Project
Food and Agriculture Organization of the United Nations
Food frequency questionnaire
Food security and nutrition policy
Government of Ethiopia
Individual dietary diversity score
International Food Policy Research Institute
Ethiopia Demographic and Health Survey
Ethiopia National Bureau of Statistics
Millennium development goals
Postnatal care
United Nations International Children’s Emergency Fund
Household Food Insecurity Access Scale
Women of reproductive age
World Health Organization
World Food Program.
The datasets supporting the conclusions of this article are included within the article.
The authors declare that they have no conflicts of interest.
NF and EA conceived the study, developed the study method, analyzed the data, and drafted and revised the manuscript. All authors read and approved the final manuscript.
Our appreciation goes to the local community participants, data collectors, supervisors, heads of health facilities, and all staff members for their unlimited support and provision of the required information.