Optimal Dietary Diversity and its Associated Factors among Children Aged 6–23 Months in Bale Zone, Southeast Ethiopia: aCommunity Based Cross-Sectional Study

Background: Almost all nutritional related problems are preventable by implementing infant and child feeding strategies. The first two years of life are particularly important to reverse the nutritional problems by achieving dietary diversity feeding.This study assessed optimum dietary diversity and its associated factors among 6–23 months old children in Robe town, southeast Ethiopia. Methods: Community based cross sectional study design with simple random sampling was employed to include 517 children 6-23 months of age paired with their mothers in Robe town. Data were collected using pre-tested and structured questionnaire. Data were entered into EpiData version 3.1 and analysis was performed using SPSS version 20. Descriptive analysis was done for appropriate variables. Multivariate logistic regression analyses were used to identify factors associated with optimal dietary diversity practices among children aged 6-23 months. Results: Five hundred eight samples were included in the analysis making response rate of 98%. The optimal dietary diversity practice in the study area was 23%. The dominant food groups consumed by children aged 6-23 months in the study area were Grain, roots and tubers and Dairy products. Exposure to media (AOR=3.99, 95 % CI, 1.97:7.77), secondary and above maternal education (AOR=3.21, 95% CI, 1.05:9.85), and maternal knowledge about diet diversification (AOR=8.5, 95% CI, 4.95:14.58) were found positive significant predictors of optimal dietary diversity practice in the study area. Conclusion: This study concluded that optimum dietary diversity among children aged 6–23 months in the study area is low. Exposure to media and maternal education, maternal knowledge on dietary diversification were found as positive predictors of optimal dietary diversity practice for the children aged 6-23 months. So, inclusion of child nutrition programs different mass medias in the country and encouraging women education would contribute for better dietary diversity of these children.

Introduction Suboptimal infant and young child feeding practice is highly prevalent in low and middle-income countries, contributing to irreversible outcomes of nutritional problems, children mortality and overall disease burden [1][2][3].
Globally, out of 10.9 million under5-year deaths that occur, malnutrition is directly or indirectly responsible for 60% of death. More than 3.4 million under5-year children die each year due to inappropriate feeding practices. Of which, two-thirds of these deaths are associated with inappropriate feeding practices during the first 2 years of life [4].
Dietary diversity is a proxy for adequate micronutrient density of foods [5]. Appropriate dietary diversity feeding for Infant and young child during the first two years of life improves child growth and development, reduces morbidities, mortalities, and risks of other chronic diseases. However, only less than a fourth of children aged 6-23 months get recommended diversified diet globally [6].
World health organization recommend that children aged 6-23 month should consume foods among the seven food groups that includes: Grains, roots and tubers; Legumes and nuts; Dairy products; Flesh foods (meats/fish/poultry); Eggs; Vitamin A-rich fruits and vegetables; and other fruits and vegetables. In addition to breast feed, child must feed four and above and non-breast feed child should feed milk and milk products in addition to the United Nations has emphasized that implementations to achieve the SDGs should acknowledge the nutrition priorities in which all of the SDGs have relations with nutrition. Improvements in human nutrition represent both a maker and a marker of sustainable development [9].
In an effort to accelerate the reduction of undernutrition, the Government of Ethiopia developed the National Nutrition Strategy and the National Nutrition Programmes (NNP) [10,11]. Several additional initiatives also embody the government's commitment for improved nutrition. The Seqota Declaration (2015-2030) aims to eliminate all forms of malnutrition among children under age 2 by 2030 [12].
Despite these efforts to increase dietary diversity feeding practice in Ethiopia, the problem is still high. According to Ethiopia Demographic and Health Survey report only 7% of children age 6-23 months meet the minimum acceptable dietary standards and only 14% of children had an adequately diverse diet [13]. This indicates that still low dietary diversity practice in children age 6-23 months. Hence, this study aimed to identify the magnitude of optimum dietary diversity and its associated factors among children aged 6-23 months at the study area.

Study Design and Setting
Community based cross-sectional study was conducted in Bale zone, robe town of south east Ethiopia, located at about 430 kilometers from the capital, Addis Ababa. Bale highland (in which the town located) is highly suitable for agriculture and is known for potential production of wheat and barley in Ethiopia. According to Robe Town Health of report of 2017, the town has a total of three kebeles and has 67,124 total populations, from which total of children 6-23 months of age are estimated to be 2,873. A study was conducted from March 28 to April 30 2017.

Sample Size Determination
Sample size was determined by using OpenEpi, Version 3. The assumption made includes: the proportion of children practiced minimum dietary diversity, 12.6%, 95% level of confidence and margin of error 3% to get a sample size of 470 [14]. After considering 10 % for non-response rate the sample size was increased to 517. 0

Sampling Procedure
The study town, Robe town has three main kebeles: Baha Biftu, Oda Robe and Café Donsa. Based on the town health office data of 2017, there were 2873 households having children 6-23 months of age during the study period. Of these, 543 households were from Baha Biftu kebele, 990 were from Oda Robe and 1339 households were from Café Donsa. Based on these data, the determined sample size was proportionally allocated to each three kebeles. Sampling frame was constructed based on community-based health information system of family folder in health posts. Lists of all mothers having children age 6-23 months with Community Health Information System (CHIS) number in selected kebeles were used to select the respondents through computer generated methods of random sampling. When the mother/caregiver is not available at the time of data collection, another one-timerevisitwas made on the next day and were replaced by the next household having a child of 6-23 months of age if absent on this visit.

Data Collection Tool and Procedures
Dietary diversity score tool was adapted from the World health organization IYCF guideline [15]. Questions regarding maternal and child demographic characteristics was adapted from Ethiopia Demographic Health Survey [13]. Questionnaire was first prepared in English and translated into Afaan Oromo, which later on, were translated into English for consistency check. Finally, Afaan Oromo version questionnaire was used to collect data. Data were collected by ten diploma holder health extension workers. Data on dietary diversity were collected through face to face interviewing of mothers having children aged 6-23 months by allowing them freely to recall the type of food items they feed to their child/children within the last 24 hours. One-day training was given for data collectors on the questionnaire and data collection procedures. Three supervisors were assigned and checked completeness of the questionnaire daily with principal investigators and data collectors.

Study Variables
Dietary diversity (dichotomized as optimal /suboptimal) was dependent variable and the Independent variables include Parental level variables including maternal age, maternal education, maternal knowledge, maternal occupation, and marital status of the mother, place of delivery, religion, paternal education and paternal occupation. Child level variables were age of the child, sex, birth order of index child, growth monitoring follow-up and breast-feeding status. Household level variables included were exposure to media, number of under-five aged children, family size, and monthly income, type of latrine and source of drinking water.

Optimal Dietary Diversity:
Dietary diversity was defined as optimal if children (aged 6-23 months) received foods from at least four of seven food groups (1) Grains, roots, and tubers, (2) Legumes and nuts, (3) Dairy products, (4) Flesh foods, (5) Eggs, (6) Vitamin-A rich fruits and vegetables, (7) Other fruits and vegetables, within the preceding 24 h of interview and Sub-optimal dietary diversity is if children of age group were receiving three foods or fewer within 24 h [7].

Results
Of the total 517 sampled mothers'/care takers who had children 6-23 months, 508 of them participated in the study with the response rate of 98%.

Socio-Demographic Characteristics of Mothers
One hundred ninety-nine (39.2%) of respondents were in the age group 25-29 years, 337 (66.3%) were Muslim religion followers and 470 (92.5%) were Oromo in ethnic group. Concerning the educational status of the mothers, 61 (12%) had no formal education, 245(48.2%) were completed primary education 202(39.8%) were completed secondary education and above. Forty-five (9%) of fathers of children had no formal education, and 180 (35.4%) of them were daily laborers Table 1.

Optimal Dietary Diversity and its Associated Factors among Children Aged 6-23 Months in Bale Zone, Southeast Ethiopia: aCommunity Based Cross-Sectional Study
Copyright: © 2020 Tefera T.B, et al.

Household Level Characteristics
Regarding households of the study participants, 293 (57.7%) of households had only one under five children and 261 (51.4%) of households had five and above total family sizes. Almost all mothers involve on decision of the type of the food to provide for their child at household level and 153 (30%) of total mothers did not have media exposure.

Child Level Characteristics
From the total children included 353(69.5%) were in the age group 12-23 months. Four hundred seventy-two (92.9%) children were born at health institutions (hospital or health center). The majority of children 446 (87.8%) conducted growth monitoring follow up Table 2

Water and Sanitation Characteristics of Households
Two hundred thirty-eight (47%) households use an improved latrine type, which include pit latrines with slab; ventilated improved pit latrines and other improved type of latrines (pour flush toilets discharge into septic tank). However, more than half, 53% of households use an unimproved type of latrine. The most common type of unimproved toilet facility is a pit latrine without slabs, used by 52% of households of the study participants.
The principal sources of drinking water for the households were improved source. Four hundred twenty-four (83.5%) of households were using piped water and fewer households 2 (0.4%) were using unimproved source of drinking water.

Minimum Dietary Diversity Practice
According to mothers' report of what their child had consumed in the preceding 24 hours of the day of the data collection, the mean dietary diversity score out of the seven food groups were 2.89 with SD of 1.17. The study revealed that 118 (23%) of infants and young children consumed the required minimum number of food groups (≥4 food groups). The rest 390 (77%) of infants and young children in the study area practiced below the minimum recommended dietary diversity for children 6-23 months of age Figure 1.

Factors Associated with Dietary Diversity Among Children Aged 6-23 Months
Among variables evaluated in bivariate and multivariable logistic regression analysis child age, mothers' education, media exposure, fathers' occupational status and knowledge of mothers on food diversification were the only variables which have shown statistically significant and independent association with minimum dietary diversity practices. The analysis indicated that

Optimal Dietary Diversity and its Associated Factors among Children Aged 6-23 Months in Bale Zone, Southeast Ethiopia: aCommunity Based Cross-Sectional Study
Copyright: © 2020 Tefera T.B, et al. children aged 12-23 months were more likely to fed minimum dietary diversity compared with children who were aged 6-11 months (AOR=2.99, 95% CI, 1.65:5.42). This study also indicated children of mothers having secondary and above education level were more likely to be fed diversified food. It showed that the odds of feeding their baby minimum dietary diversity among mothers whose education level was secondary or above were nearly 3 times higher than those mothers who have no formal education (AOR=3.21, 95% CI, 1.05:9.85).
Mothers who were exposed to media frequently had higher odds of feeding their children diversified diet than those mothers who had not attended to the media (AOR=3.99, 95 % CI, 1.97:7.77). The study showed that mothers 15-24 years of age were more likely to feed their child diversified food than older mothers. Children whose mothers aged 30 or above years were 56% less likely to meet minimum dietary diversity score than children whose mothers were aged 15-24 years (AOR=0.44, 95% CI, 0.22:0.87). Mothers who have knowledge about food diversification showed significant association to their habit of dietary diversity feeding practice. Children whose mothers were knowledgeable about food diversification had 8.5 times higher odds of minimum dietary diversity practice as compared to children whose mothers haven't specific knowledge on food diversification (AOR=8.5, 95% CI, 4.95:14.58) Table 3.
Children whose fathers were daily laborers showed low practice of minimum dietary diversity as compared to children whose fathers were merchants. Children whose father's occupation was merchants were 2 times more likely to get diversified diet than children whose fathers were daily laborers (AOR=2.27, 95% CI, 1.19:4.33) Table 4.

Discussion
This study assessed the magnitude of Optimum dietary diversity and its associated factors for children aged 6-23 months in Robe town of southeast Ethiopia. The magnitude of optimum dietary diversity in this study area was found 23% that is low. The possible reasons for low dietary diversity practices in the study area could be low practice giving complimentary feeds after six months and the habit of the family (i.e. Preparing the family food together, no food preparation for children alone). Also, low affordability of foods that is not available at home and those foods that are costly are sold from the house instead of feeding their child.
This finding is comparable with the findings from the studies done in Kamba district of Ethiopia 23.3%, Amhara region 17% districts of Ethiopia, and Haramaya town of Oromia region 25.2 % [17][18][19]. However, higher than findings from the studies done Dejen District of North West Ethiopia (13.6%), in Dangila of Northwest Ethiopia 12.6%, Gorche district of southern Ethiopia

Optimal Dietary Diversity and its Associated Factors among Children Aged 6-23 Months in Bale Zone, Southeast Ethiopia: aCommunity Based Cross-Sectional Study
Copyright: © 2020 Tefera T.B, et al.  [20][21][22][23][24][25]. Geographical variation, study time, sample size and socio-economic differences might be the possible justification for the similarities and difference of optimum dietary diversity practice for children aged 6-23 months of age.
The current study found that 95% of mothers responded that their children were consumed foods prepared from grains, roots and tubers. This finding comes similar with study conducted in Southern part of Ethiopia [26]. This implies that, most infants and young children could get foods consist mainly of carbohydrates, which provide energy, but lacks enough protein, iron and Zink [27]. In the current study child age, mothers' education, media exposure, fathers' occupational status and knowledge of mothers on food diversification were significantly associated with dietary diversity practices. Children aged above one year were about three times more likely to consume a minimum dietary diversity compared with infants aged 6-11 months. This finding was similar with studies previously conducted in Dangila town of Northwest Ethiopia and Gorche district [21,22]. This might be due to the fact that most of the mother's start introduction of complementary food with milk only; because of their awareness that intestine of the younger child has poor ability to digest solid, semisolid and soft foods.
Mothers who had been exposed to different media like television and radio at least once a week or all time frequently were more likely to provide their children with adequate dietary diversity compared to those who have not exposed to the media at all. This finding is similar with study done in Dangila town and study done by Disha et, alusing EDHS 2011 and 2015 [21,28]. The possible reason could be the dissemination of child nutrition related information through medias in national radio and television have positive influence on mothers feeding practice, due to the fact that their nutritional knowledge could increase through regular exposure.
The study identified that 66% of mothers aged above 30 years were less likely to feed their child diversified food than their counterparts. It was similar with finding of the analysis of EDHS study that showed older women were giving their children less diverse diets [29]. The possible reason for this variation might be the difference in study setting and sociocultural difference.
Maternal knowledge on food diversification showed strong positive associations to their habit of dietary diversity feeding practice which is consistent with the finding of study conducted in Adea district of Oromia region, which showed mothers who were knowledgeable on dietary diversity were about eight times more likely to feed dietary diversity as compared with their counterparts [30]. The possible explanation for this finding is that, even if families can afford and different food varieties are available from the local markets, the awareness of mothers on the nutritional value of different variety of foods is a crucial factor to purchase it regularly for their children. The main problem identified in the current study is that, mothers list foods of the same group as different function (nutritional value) for children's health. The majority of mothers perceived that products of cereals which are the same food group such as pasta, rice and macaroni as different sources of nutrient for their children.

Conclusion
Optimum dietary diversity among children aged 6-23 months at the study area is low. A large proportion of mothers are feeding their children only from grain, roots and tubers or from dairy products due to their limited knowledge on diet diversification. Maternal education and availability/exposure to mass media were found as a positive predictor of optimum dietary diversity practice in the study area indicating the importance of maternal education on improvement of infant and young child feeding. So, Infant and young child feeding practice should be implemented according to the guideline at community level and Mothers should be educated about how to prepare the diversified diet from locale available food groups.