Adequately Iodized Salt Utilization and Associated Factors among Households in Tach Armachio District, Northwest Ethiopia: A Community-Based Cross-Sectional Study

Background For the synthesis of thyroid hormones, iodine is a crucial trace element. Iodine deficiency disorders affect all groups particularly: pregnant, young women and children. Iodine deficiency disorder has been recognized as a serious public health issue in Ethiopia. Therefore, this study planned to assess iodized salt utilization and associated factors at the household level. Methods A community-based cross-sectional study was conducted from January 25 to February 24, 2019, in Tach Armachio district, Northwest Ethiopia. A single population proportion formula was used to calculate the sample size and a total of 555 households were sampled. A multistage sampling technique was conducted to select the household. An iodometric titration method was performed. A structured, pretested, and face-to-face interview questionnaire was used to collect data; then, it was entered in Epi Info 7 and exported to SPSS version 25 for analysis. Bivariable and multivariable analyses were done to identify predictor variables. A 95% confidence interval and adjusted odd ratio were reported. P values less than 0.05 were considered statistically significant in the multivariable analysis. Results This study showed that iodized salt was adequately utilized by 61.1% (CI = 57%–65%) of households. Good knowledge of iodine deficiency disorder (AOR = 2.25, 95% CI = (1.44, 3.50)), keeping salt in the kitchen house away from fire (AOR = 5.09, 95% CI = (3.25, 7.98)), buying packed salt [AOR = 1.89, 95% CI = (1.12, 3.19)), keeping salt in a covered container (AOR = 2.18, 95% CI = (1.24, 3.81)), and exposing salt to sunlight (AOR = 0.39, 95% CI = (0.23, 0.65)) were significantly associated. Conclusion In the district, adequately iodized salt utilization was low. Therefore, it is necessary to enforce the current law for merchants to sell iodized packed salt and teach the community how to handle it.


Introduction
Iodine is a crucial element for the synthesis of thyroid hormone (TH). is hormone is involved in the body's growth, development, reproduction, and metabolic process control [1]. Iodine deficiency disorders (IDDs) occur when the human body does not receive the recommended amount of iodine on a daily basis. IDDs can result in mental impairment, endemic goiter, hypothyroidism, reproductive failure, and dwarfism [2][3][4]. Salt iodization is the most cost-effective, widely used, and low-cost public health intervention for delivering the required amount of iodine to the general population [2,4].
In 2017, less than 10 percent of the global population of the general population lived in countries categorized as iodine deficiency [5]. IDDs affect people of all ages, but young children, women of reproductive age, pregnant women, and lactating women are the most vulnerable [4]. IDDs remain a public health concern [6]. Previous studies in South Asia [7][8][9][10] and Sub-Saharan Africa [7,[11][12][13][14] have found that iodized salt is in short supply at the household (HH) level. In Ethiopia, pocket-area studies revealed that a large number of HHs used insufficiently iodized salt when compared to the universal standard [15][16][17][18][19][20]. However, according to the 2016 Ethiopian Demographic Health Survey, 89 percent of HHs used enough iodized salt [21]. e use of packed salt, not exposing salt to sunlight, storing salt in dry areas, shorter storage time, adding salt late after cooking, good knowledge of iodized salt and IDDs, and socioeconomic status are all factors that influence the availability of adequately iodized salt [7,[22][23][24][25][26]. Previously, a rapid test kit was used to assess iodine content qualitatively, but it was unreliable (low specificity) [27]. e iodometric titration method (IDTM) is the best and most preferred method. is method is reliable and is used to determine the amount of iodine in salt [28][29][30].
A good strategy for preventing IDDs is to ensure that the iodine content in salt is safe and sufficient at the HH level [29,31]. It is necessary to pay attention to how such iodine salt should be stored. According to literatus because of the volatile of iodine, it will be lost due to high humidity and boiling during cooking. Even if the effect is small, light or dry heat causes iodine to be lost from the salt [32][33][34]. ere is an inconsistency of findings in Ethiopia, and no studies have been done using the titration method in the current study area. Furthermore, the study area has a high prevalence of goiter, implying that iodized salt utilization will be poor [35,36]. erefore, this study used gold standard IDTM to assess the prevalence of adequately iodized salt usage and associated factors at the HH level in Tachar Amchio district, Northwest Ethiopia.

Study Design, Area, and Period.
Tach Aramchio district is found in the Central Gondar Zone, Amhara region, Northwest Ethiopia. It is located 790 kilometers north of Addis Ababa and 63 kilometers south of Gondar Town. According to the 2011 Finance and Economic Development Bureau projections, the district had a total of 37,139 households and 162,354 people. e administration is divided into 32 kebeles (the smallest administrative unit of Ethiopia). e elevation ranges from 900 to 1200 meters above sea level. ere is one district hospital, nine health centers, and 39 health posts. A community-based crosssectional study was conducted from January 25 to February 24, 2019. e sample size was determined using a single population proportion formula. It accounts for a 33.2% prevalence [15], 95% confidence level (CI), 5% margin of error, and 1.5 design effect. It also included a 10% nonresponse rate, resulting in a sample size of 563 households. A multistage sampling procedure was used. Eight of the 32 kebeles were chosen by lottery in the first stage (one from the urban area and the other from the rural area). Second, an HH was chosen using a systematic sampling method, with every 15 th HH included in the study sample.

Data Collection Tools and Measurement.
A structured, pretested, and face-to-face interview questionnaire was used to collect data. e questionnaire included sociodemographic questions, as well as questions about iodized salt and IDD knowledge (study participants who answered correctly 50% of nine questions about iodized salt and IDD knowledge were considered to have good knowledge, while those who scored below 50% were considered to have poor knowledge) [22], salt storage condition, and practice variables for handling. Four welltrained health extension workers collected the data.

Laboratory Procedures.
To determine salt iodine content, IDTM was done. A 50 g mixed (homogenized) salt sample was taken from each systematically selected household, using a moisture-free, clean, and airtight plastic container. e sample was labeled and coded with the date of sampling, source of salt, and batch number. Each sample was analyzed in triplicate, and the average sample concentration was used to calculate the iodine concentration. e IDTM uses reagents like sulphuric acid, potassium iodate, and potassium iodide as principal reagents, standardized sodium thiosulphates (as titrant), and starch solution as an indicator. e titration results were converted to iodine concentrations and then classified based on their iodine content. e outcome variable, adequately iodized salt utilization measured as parts per million (ppm) < 15 was considered as inadequately iodined, while ≥15 ppm is considered as adequately iodized [30]. e test was carried out in an Ethiopian public health institution's laboratory.

Data Processing and
Analysis. Data quality is maintained by ensuring that data is complete and consistent. It was entered into the Epidemiological Information (Epi Info) software version 7.1 and then transferred to Statistical Package for Social Sciences (SPSS) version 16 for analysis. e following calculations were made: mean, standard deviation, percentage, confidence interval, and odds ratio (OR). A principal component analysis was used to determine wealth status. Wealth is a latent variable which cannot measure directly using a single question. ere were 15 questions dealing with productive assets, nonproductive assets, and household utilities. We used a factor reduction analysis. Our first step was that variables have been reclassified; we assign categories values with 0 and 1. en, we check coefficients, KMO, Bartlett's test of sphericity, and eigenvalues. Finally, we rank the wealth index after ascending and created the quintiles as poor, medium, and rich. Bivariable logistic regression was used to see if there was a significant relationship between the dependent and independent variables. Variables with P values of 0.2 were included in the multivariable analysis during the bivariable analysis. A multivariable analysis was done to control a possible confounding effect of independent variables. In the multivariable analysis, a variable with a P value of less than 0.05 was considered statistically significant. e Hosmer and Lemeshow goodness of fit test for the model was also checked and it had a P value of 0.15. Multicollinearity among independent variables was checked using the Variance Inflation Factor (VIF) which indicates that there is no multicollinearity because all variables have VIF < 7 and tolerance greater than 0.1.

Result
A total of 555 households were involved in the study and eight HHs declined to participate which made the response rate 98.57%. e average age of respondents was 33.36 years with standard deviation ± 9.08. Almost half of the respondents 270 (48.6%) were between the ages of 34 and 44. e majority of the study participants (n � 459; 82.7%) were females by sex, and 317 (57.1%) were housewives by their occupation. Five hundred twenty-two (94.1%) of the respondents were Orthodox Christians.
Regarding marital status, 442 people (79.6%) were married. Nearly half of the study subjects' 263 participants (47.4%) could read and write. ree hundred and seventyfour (67.4%) of the HHS have less than five members. In family wealth status, 206 (37.1%) were classified as middle income (Table 1).

Knowledge of IDD, Storage Condition, and Utilization Practice of Iodized Salt at Households.
e prevalence of adequately iodized salt is found in 61.1% (95% CI 57-65) of the study participants, which is >15 ppm. e median iodine content of the sampled salt was 18.03 ppm, with an interquartile range of 11.66 ppm to 28.34 ppm. e amount of salt in the 15-40 ppm range was 42.2%.
Respondents with good knowledge of IDDs and iodized salt were 312 (56.2%). e majority of study participants (n � 417; 75.1%) walked less than an hour to buy salt, and two-thirds (77.5%) did so once a week. Households that purchased it from a retail store and in packed form numbered 312 (56.2%) and 432 (77.8%), respectively.
Almost all of the 545 (98.2%) HHs stored their salt in a dry place. Of these, 467 (84.1%) kept their salt away from sunlight ( Table 2).

Discussion
According to the WHO and International Council for Control of Iodine Deficiency Disorders (ICCIDD) standard, the elimination of IDD will be possible if more than 90% of the households utilized adequately iodized salt [37]. e current study revealed that 61.1% of households had adequately iodized salt (>15 ppm), falling short of the universal salt iodization (USI) target of 90% coverage. is result was lower than those found in studies from Saudi [37], Bangladesh [26], Nepal [38], and Dessie town, Ethiopia [19]. It was, however, higher than the studies of Morocco [39], Sudan [16], and four studies from Ethiopia [17][18][19]21]. It is in line with research conducted in Ethiopia's Asella town [40], Dera district [41], and Wondo Genet town [20]. e possible reason for this difference includes the use of IDTM to measure iodine content in the current study, difference in the study population, governments' commitment to enforcing legislation, and regulations on the iodization of salt, distribution, and retail. Ethiopian Food and Drug Authority issued a directive in 2011 to prohibit the distribution and retail of noniodized salt. If the directive is violated, the trade license will be temporarily suspended for one to six months, and in the worst case, the license will be permanently revoked [42].
In this study, the odds of having adequately iodized salt in a household was higher among participants who had good knowledge of IDD and iodized salt utilization than poor knowledge. is finding is supported by the studies in Ghana [23], Bensa woreda [43], Laelay Maychew [23], and Dabat [15], Ethiopia. ese could be respondents (households) who are already aware and can easily put their knowledge into practice by purchasing iodized salt.
Households who keep their salt away from the fire in the kitchen were more likely to have adequate iodized salt compared to those that kept their salt near the fire. is could result from heat-induced alteration or depletion of iodine as it is volatile by nature. As a result, the respondents who had placed salt away from the fire and protected it from the heat in the kitchen had adequately iodized salt [44].
HHs who used packaged salt were more likely to have adequate iodized salt than those who used bulk salt. is finding is supported by the studies done in Bensa woreda [43], Gondar town [22], and Dabat [23]. is may have been packing material that protected the salt from exposure to sunlight and kept it from moisture.
Households that used salt stored in covered containers were positively associated with adequately iodized salt. Salt placed in a covered container was 1.92 times more likely to have adequately iodized salt than salt stored in open containers, and this study is consistent with the studies in Dera and Lalo Assabi district, Ethiopia [41,45]. e iodine content of the salt may be maintained or retained in the covered container. Also, a covered container prevents salt from being exposed to light and keeps it dry.
At the HH level, exposing salt to sunlight was found to be inversely related to adequate iodized salt utilization. is finding is consistent with research from Wolita [18], Goba town [46], Dera district [45], and Gondar town [22],  Ethiopia. is could be the result of sunlight (heat) slowly evaporating the iodine content (volatile nature of iodine content) from the HH's use of iodized salt.

Limitations of the Study.
e study's limitation was that the use of iodized salt in retail stores was not measured, and the labeling time was not checked. e impact of clusters  Journal of Nutrition and Metabolism 5 between urban and rural areas is not being considered. In responding to handling practices, this study was not free of social desirability bias.

Conclusion and Recommendation
In the district, the proportion of people who use enough iodized salt in their homes is still low. e location of storage, the type of salt purchased, whether the salt was stored in a covered container, and whether the salt was exposed to sunlight have all been identified as significant predictors. As a result, it is necessary to enforce the existing law prohibiting traders from selling unpacked iodized salt and educate the public about how to use iodized salt in the kitchen. Data Availability e data are available upon request made to the corresponding author via email.

Ethical Approval
Ethical clearance was obtained from the Ethical Review Board of the Institute of Public Health, University of Gondar.

Consent
After getting permission from the district to proceed with the study, informed written consent was granted from each study participant. Anyone who was not willing to take part in the study was excluded. Finally, the study did not disclose any information which shows personal identity to assure confidentiality.
Disclosure e authors declare that they have no conflicts of interest.

Conflicts of Interest
e authors declare that they have no conflicts of interest.