Uptake of minimum acceptable diet among children aged 6–23 months in orthodox religion followers during fasting season in rural area, DEMBECHA, north West Ethiopia

Inappropriate feeding practice of Infants and young child leads to malnutrition, this exposes the children to under nutrition, increasing morbidity and mortality, and chronic stunting that will be continuing to next generations [1–3]. By improving the quality and frequency of complementary feeding practice it is possible to improve health, reducing morbidity and mortality of young children [4]. Nearly one third of children deaths could be prevented by appropriate complementary feeding practices [5, 6]. Early initiation of breastfeeding, exclusive breastfeeding, implementing complementary feeding, consumption of diversified diet, adequate meal frequency, and consumption of iron fortified foods are core indicators for monitoring feeding practices of infants and children. Minimum Acceptable diet defined by WHO as is the proportion of children 6–23 months of age who receive a minimum acceptable diet (both minimum dietary diversity and the minimum meal frequency) during the previous 24 h [6, 7].

In developing countries including Ethiopia, feeding infants and children with diversified diet is practiced inappropriately. In Africa less than one-third and one-half of children aged between 6 and 23 months met the minimum criteria for dietary diversity and meal frequency, respectively. That is why the prevalence of stunting in African countries increases threefold during the first 2 years of life [8].

Burden of stunting is high in Amhara region and children in rural are more vulnerable for stunting than urban children [9, 10]. Minimum dietary diversity practice is low in Amhara region than national i.e., 2% of children in Amhara region got minimum dietary diversity. Children of Orthodox mother were 40% less likely to receive minimum dietary diversity than non-Orthodox children [11]. In our country, especially in rural area, there is poor practice in children feeding [9, 12].

Around 50- 7 % of death in under-five children in Ethiopia is accounted by inappropriate complementary feeding practices [4]. Malnutrition below 2 years of age leads children to become vulnerable to growth retardation, delayed mental development, micronutrient deficiencies, and common childhood illnesses and death. [13]. Culture has effect on practice of dietary diversity, meal frequency and minimum acceptable diet.

According to Ethiopian demographic health survey data analysis, consumption of animal source by orthodox religion followers children were less than other religion follower families [11].

Both minimum dietary diversity and meal frequency practices were affected by age of a child, birth order of index child, religion, and media exposure of mother. Minimum dietary diversity separately affected by educational level of a mother, residence and home gardening activity while mother’s involvement in household decision making and postnatal visit have significant association with minimum meal frequency [11, 12, 14–20].

Minimum acceptable diet indicator is used for assessing infant and young child feeding practices and it is a composite indicator comprises minimum dietary diversity and minimum meal frequency indicators and to measure both quality and quantity of nutrients [5, 7]. A cross- sectional study conducted in primary health care facility in 2015 to assess magnitude of minimum acceptable diet in Indonesia found that 66.6% of infants and young children aged 6–23 months consume minimum diversified diet [21]. A community- based cross-sectional study conducted in 2016 among rural resident in Nigerian Infant and Young Children (IYC) showed that 31.5% infants consumed the minimum dietary diversity. [22].

Another community-based cross-sectional study conducted in southern part of Ethiopia (Arsi Zone) in 2015 showed that only18.8% of children aged between 6 and 23 months consumed four or more food groups to meet the minimum dietary diversity criteria [23]. A health institution based cross sectional-study conducted in Addis Ababa in 2016 showed that 59.9% of the children aged 6–23 months meet the minimum requirement of diversified diet [15].

A cross-sectional study done to assess dietary diversity and meal frequency feeding practice in wailayita sodo town in 2015 showed that only 27.3% of infants and young children consumed diversified diet [24]. Studies conducted in different parts of Amhara region, North West Ethiopia, showed that low practice of feeding children with diversified diet [12, 25]. Study conducted in Northwest Ethiopia in 2016 to assess weaning practice and associated factors in Feres Bete town indicate that about 43.9% of infants and young children met minimum diversified diet [26].

Community- based cross -sectional study conducted in Northwest Ethiopia in 2015 to assess dietary diversity, meal frequency and associated factors among IYC showed that around 50.4% of children received minimum meal frequency [12]. The same study conducted in wolaita Sodo town in 2015 showed that 68.9% of IYC met the minimum meal frequency effect [24].

A healthy care facility based cross-sectional study conducted in Indonesia in 2015 to determine minimum acceptable diet showed that only 47.7% of children met the minimum acceptable diet. [21]. A result from analysis of 10 Sub Saharan countries’ demographic and health surveys between 2010 and 2013 revealed that 18% of children aged 6–23 months met minimum acceptable diet. The surveys’ analysis also suggested that women’s empowerment enhance practice of infant and young children MAD. Greater overall empowerment of women was consistently and positively associated with multiple IYCF practices in Mali, Rwanda and Sierra Leone, but negative relationships were found in Benin and Niger. Null or mixed results were observed in the remaining countries [27].

Nutrition education has a great role to improve food security and this enhance to improve nutritional status of children using diversified diet feeding for children [16, 28]. Mother education is one determinant factor affecting practice of feeding diversified food. Children born from mothers who were well educated and had a secondary level education or higher education had feeding with diversified foods [12, 15]. Media exposure and income level have positive association with dietary diversity practice. This showed that media exposure has increased the chance infant and young child to feed with diversified food [12]. Children in houses of having high level of income had consumed highly diversified diet than those living in a house of low income level [15, 25].

Involvement of mothers in household decision found to be another determinant factor affecting practice of minimum meal frequency [12, 18]. As a result children aged 6–23 months will not consume recommended minimum acceptable diet in fasting season. As indicted above variety of studies was conducted and come up with different results of minimum acceptable diet. But none of them considers fasting season in orthodox religion followers.

Therefore this study is needed to assess practice of minimum acceptable diet and to identify associated factors. Although the study area is the area where variety of foods is available, there is no study conducted in Dembecha district on practice of minimum acceptable diet.

. The study revealed that about 8.6% of children received minimum acceptable diet. This result is lower than findings of studies conducted in southern and northern part of Ethiopia which was 12.3 and 12.0%, respectively [23, 29, 30]. But the above mentioned studies determined minimum acceptable diet practice when they studied minimum dietary diversity and minimum meal frequency practiced without consideration of fasting. The difference might be due to high non educated mothers were included in this study but higher number of participants of the above three studies were educated. Difference in data collection period and the above studies include different religion followers who were not in fasting. Finding of this study is compatible with results i.e.,7.3 and 7% obtained from studies conducted in Nigeria and Ethiopian Demographic and health survey respectively [9, 22].

There is no study conducted to show the association between practice of minimum acceptable diet and associated factors in Ethiopia even if the practice was determined when minimum dietary diversity and minimum meal frequency were assessed. Therefore it is not possible to compare factors associated with minimum acceptable diet practice in this study with other study findings. Mother educational status was significantly associated with minimum acceptable diet. According to this study children born from mother who had education were 56% more likely to receive minimum acceptable diet when compared with children born from non-educated mother(AOR = 0.44,95%CI:0.23, 0.86). This showed that education enables mothers/caregivers to know benefits of practice of dietary diversity and feeding frequency and minimum acceptable diet practice in infants and young children aged between 6 and 23 months was adequate.

This study found that birth order of the index child is one of the predictors of practice of minimum acceptable diet. Children born in first order (AOR = 0.36, 95%CI: 0.16, 0.58), and second to fourth order (AOR = 0.28, 95%CI: 0.14, 0.54) were 64 and 72% less likely to receive minimum acceptable diet when compared with children born in above fourth order respectively. As parity of mother’s increases, there is high exposure to practice and information on diversified diet preparation and feeding frequency that enables children to meet minimum acceptable diet. Another important factor significantly associated with minimum acceptable diet during fasting season was mothers’ participation in household decision making. Children born from mothers involved in household decision making were 78% more likely to receive minimum acceptable diet when compared with children of mothers who were not involved in decision making(AOR = 0.22. 95%CI: 0.1,0.48). involvements of mothers in decision making in the household enables mothers to access money for purchasing foods which increases availability of some foods like egg and fruits and vegetables in the household. Then children would meet minimum acceptable diet. Delivery in health facility found to be significant associated with practice of minimum acceptable diet. Children born in health facility were 5 times more likely to receive minimum acceptable diet than who were born at home (AOR = 5.13, 95%CI: 1.26, 20.8). Mother counseling on child feeding after delivery in health facility increases knowledge of mother on dietary diversity and feeding frequency.

Other factor associated with minimum acceptable diet feeding practice was previous knowledge on feeding frequency based on age. Children whose mothers or caregiver’s did not have knowledge on feeding frequency (AOR = 0.3, 95%CI: 0.16, 0.58) were 70% less likely to receive minimum acceptable diet when compared to children of mothers who had knowledge of feeding frequency. This indicate that knowing feeding frequency based on child age leads the mother/ care givers to give diet timely throughout all seasons.

Presence of family member who fed animal source foods found to be significantly associated with practice of minimum acceptable diet. Children lived with family member who consumed animal source foods were 5 times more likely received minimum acceptable diet than those children who were living in houses with no family member who could consume animal source foods(AOR = 5.64, 95% CI: 2.8, 11.37). This showed that animal source foods might be prepared and its availability would be increased if consumer of this food group was present in the house. This would enable the child to consume animal source foods and this increases the number of food groups the child could fed.

Only 9.8% of children received minimum dietary diversity which is lower than results of similar study conducted in North West Ethiopia [31]. The difference might be due to participants’ residential difference. Studies conducted in southern part of Ethiopia that is 23.3% of children received foods from four and above food groups [14]. The difference might be due to high purchasing capacity and greater than 60% of mothers of the children were protestant religion followers who are not participated in fasting season. Due to this reason the practice of dietary diversity is high in the above study. Other study conducted in North West Ethiopia showed that 12.6% of children received minimum dietary diversity feeding which is greater than the result of this study [12]. The difference is due to educational status difference. About 58% of mothers had education in the above study, but 46% of mothers included in this study were educated. The result of this study showed that the practice of dietary diversity is higher than result of study conducted in other area of North West Ethiopia which was 8.5% [25]. The difference might be due to recent expansion of nutritional programs working in child nutrition that enables improvement in dietary diversity in rural area. In this study 63.5% of children fulfill the WHO minimum meal frequency criteria in 24 h. The result is lower than results of two studies conducted in southern part of Ethiopia with results of 67.3 and 68.9% respectively [23, 24]. The difference might be due to difference in religion status of mothers of children. But the result is higher than result of studies conducted in Ethiopia with result of 50.5%, and in North West Ethiopia with a result of 50.4% [12, 29]. The difference in results might be due to presence of low attention for child feeding in previous year.

Minimum acceptable die practice in infants and young children aged between 6 and 23 months is low. Educational status of mother, involvement of mother in decision making, First birth order of index child, second to fourth birth order of index child, knowledge on feeding frequency were factors negatively associated with minimum acceptable diet. Delivery in health facility, and presence of family member who fed animal source foods during fasting were positively associated with minimum acceptable diet. Strengthening mothers’ education on acceptable child feed practice and working with religion leaders to increase knowledge of mother on child feed practice during fasting season. Conduct study with strong study design in wide area to determine minimum acceptable diet and factor associated with minimum acceptable diet practice.