Dietary diversity and associated factors among children aged 6–23 months in Sinan Woreda, Northwest Ethiopia: a cross-sectional study

Globally, malnutrition affects social and economic development of a country. It is one of the commonest causes of under-five mortality, accounting for 45% of the 5.9 million deaths of under-five children in 2015 [1]. Those who survived from chronic malnutrition were suffering from wasting, irreversible physical and mental development [2–7]. Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. The first two years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall [3].

The Sustainable Development Goals (SDGs) aimed to ensure healthy lives and promote well-being for all children. The SDG 3 target 3.2 aimed to end preventable deaths of newborns and under five year children by 2030 [8]. 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].

Improvement in human nutrition can be achieved through dietary diversity. Dietary diversity scores of the individuals reflect nutrient adequacy. Hence, nutrient adequacy of the diet consumed by the individuals depends on the individual dietary diversity score [10, 11]. World Health Organization (WHO) has designed a diet quality indicator to assess child feeding practices among children 6–23 months old. Diversified diet helps children to have appropriate nutrients needed for adequate growth and development [12, 13].

World health organization recommends children to consume foods among the seven food groups [(1). Grains, roots and tubers; (2). Legumes and nuts; (3). Dairy products; (4). Flesh foods (meats/fish/poultry); (5). Eggs; (6). Vitamin A-rich fruits and vegetables; and (7). Other fruits and vegetables] [14]. Infant and Young child feeding (IYCF) practices recommend that breastfed children aged 6–23 months must fed four or more other food groups daily. Non-breastfed children should feed milk or milk products, in addition to four or more food groups [15]. Despite of the importance of diversified food for children aged 6–23 months, only less than a fourth of them globally get diversified food and had recommended meal frequency that are appropriate for their age [3].

Only 4% of breastfed children in Ethiopia have received diversified diet [15]. In Southwest Ethiopia, about 39% of the children were categorized in the low Dietary Diversity Score [16]. The national prevalence of under-five stunting in Ethiopia is 44% and it is 52% in Amhara [15].

Globally, studies show that different socio-demographic and economic characteristics of mothers/care takers and children are associated with dietary diversity for children aged less than two years [14, 17–24]. Place of residence, age of the child, maternal education, birth order, wealth index and number of children less than five years old in the household were some of the factors which determine minimum dietary diversity [11, 25].

The ministry of health of Ethiopia has targeted to improve nutritional practices for children of 6–23 months age. The first 23 months are critical period of opportunity for health and development of children. However, there is still low dietary diversity practice in children age 6–23 months according to 2011 Ethiopian Demographic and Health Survey (EDHS) report [15, 26]. There are no documented studies on the dietary diversity feeding and its associated factors among children aged 6–23 months in Sinan Woreda. This study aimed to identify the magnitude of low dietary diversity among children aged 6–23 months and associated factors.

Of the total 740 sampled mothers/care takers who had children 6–23 months, 736 of them participated in the study with the response rate of 99%.

Dietary diversity and type of diversified food items

Children who fed four or more food items within 24 h preceding data collection were 13%. Of children included in the study, 74(10%), 379(52%) and 189(26%) consumed from one, two and three food items were respectively. The mean (±SD) dietary diversity score (DDS) was 2.45(±0.95). The dominant food groups consumed were grains (99%) followed by legumes (83%) (Fig. 1).

This study assessed the factors associated with dietary diversity for children aged 6–23 months in Sinan Woreda. It identified that only 12.8% of the children received four or more food groups with in the 24 h preceding the survey. It is consistent with the findings from the studies done in Dangila 12.6% [28] and Tigiray 17.8% [30] districts of Ethiopia, India 13% [19] and Uganda 17.8% [31]. However, the finding is higher than the EDHS 2011 report [15] and lower than the studies done in India 27.4%, Tobago 48.23%, Cambodia 44%, Kenya 39.2%, 27.7%, Kamba district of Ethiopia 23.3% [22, 26, 29, 31–33]. The difference might occur due to time of study, socio-economic difference and geographical variation. 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 coasty are sold from the house instead of feeding their child. In addition, due to low feeding practices, animal source foods commonly used during holidays and ceremony other than usual.

The dominant food groups given to the children were grains, tubers and roots (98.8%) and legume (83.2%).This is comparable with the results from the studies done in Ethiopia [26, 28], and South Africa [34]. Feeding of flesh, egg, dairy products, vitamin rich fruits and vegetables and other fruits was low. This was in line with the studies done in Ethiopia [16, 26, 28], Central America [34], and Kenya [20]. The possible reason might be due to the unavailability of these food sources at household level; in which cereals, grains and tubers are the commonest products in the study area. People commonly consume those food items they cultivated and accessed from the market in low cost [35, 36].

The likelihood of feeding children with optimum dietary diversity was more among mothers who had media sources like radio and television (TV). Similar findings have been reported by the previous studies done in Northwest Ethiopia [28] and India [19]. We can understand from this result that availability of media sources at household might help the mothers getting information on recommended child feeding options [36].

Mothers who had available cow’s milk at household level were more likely to feed diversified food group than those who had not. Presence of accessible animal source foods at households helped women to feed their children with dairy products [36]. Similar result has been reported by the study conducted in southern Ethiopia Kemba district [26]. The possible reason might be the household that have cow’s milk, feed their child milk and milk products in addition to usual diet. Those mothers who were participating in decision making at household were more likely practicing optimal dietary diversity feeding to their children. The study done in Northwest part of Ethiopia had also revealed that feeding of optimum dietary diversity to their children is more among mothers who had involved in household decision making [28].

Among health utilization factors, those women who delivered their last child at health institutions were more likely to feed their children with diversified food. Similarly, those mothers who received postnatal care were more likely to feed their children with diversified food. This was in line with the study done in southern Ethiopia that showed the odds of feeding of diversified food was higher among mothers who received institutional delivery and postnatal follow up [26]. A study done in East African Regions [14] also revealed those hospital-based births shown to have a positive relationship with complementary food diversity. Health professionals might provide health education and counseling on dietary diversity when they deliver at health institutions and during postnatal care follow up visits [37]. Those who delivered their last child with assisted mode of delivery were more likely to feed diversified diet to their child than those who had spontaneous vaginal delivery. Mothers who gave birth through assisted mode of delivery might have prolonged stay at health institutions and get the opportunity to receive health education on infant and child feeding by senior providers [37].

Surprisingly, mothers residing relatively far from the health centers had higher odds of feeding their child with diversified diet. The possible reason might be due to frequent visit by health extension workers (HEWs). In rural Ethiopia, HEWs are working at health posts relatively far to health centers but closest to the community. They are responsible to provide health care services summarized into 16 packages at household level in the community [38, 39]. In addition, currently most of the child health activities are carried out at health post in Ethiopia. Children, whose meal frequency was four and more times per day, had higher odds of dietary diversity, This finding was in line with the study conducted in East African regions [14].

Optimum dietary diversity among children aged 6–23 months in Sinan Woreda is low. Availability of media sources, availability of cow’s milk in the household, delivered at health institutions, assisted delivery, postnatal care, relatively far distance to reach to nearby health centers and feeding frequency four and above times/day was significant factors associated with optimal dietary diversity feeding of children aged 6–23 months. Infant and young child feeding practice according to the guideline should be implemented at community level and Mothers should be educated about how to prepare the diversified diet from locale available food groups for complimentary after 6 months. This study concluded that women involvement at household decision making improves dietary diversity of children. Ensuring maternal health service utilization can contribute for better dietary diversity of children aged 6–23 months. The government should strengthen the maternal health service utilization by expanding institutional delivery service, PNC service and counseling on child feeding. Information and advertising about IYCF are disseminated to grass-root level. Large scale an interventional based research has to be conducted.