Household dietary diversity and associated factors among residents of finote selam town, north west Ethiopia: a cross sectional study

Background Monotonous low quality diets are the norm in resource-limited environments across the globe. Dietary diversity is a challenge for rural communities in developing countries. Their diets are based on starchy staples with inadequate animal products, fresh fruits and vegetables. Methods A community based cross sectional study was conducted from August 22–30, 2015 at Finote Selam Town. Systematic random sampling technique was used to select 400 households. Data were collected using pretested and semi-structured questionnaire. Both bivariate and multivariate logistic regression analyses were carried out to identify factors associated with household dietary diversity. Results The prevalence of low, medium and high dietary diversity scores were 11.8, 67.2 and 21% respectively. Family head (Men headed) [AOR = 4.75 (2.22, 10.16)], frequency of eating [AOR = 6.06 (2.82, 13.06)] and shortage of water for cooking [AOR = 5.69 (1.39, 23.27)] were significantly associated with household dietary diversity. Conclusions In this study the prevalence of adequate household diversity was 88.2%. Family head, frequency of eating and shortage of water for cooking were significant factors for household dietary diversity. Empowering women, increasing frequency of eating among family members and avoiding shortage of water for cooking were recommended to sustain and improve household dietary diversity.


Background
Monotonous low quality diets are the norm in resourcelimited environments across the globe. Risks for a range of micronutrient deficiencies are high when grain or tuber-based staple foods dominate and diets lack vegetables, fruits and animal-source foods. Dietary diversity is widely recognized as a key dimension of diet quality. Evidences from developed countries showed that dietary diversity is strongly associated with nutrient adequacy [1].
Dietary diversity which is defined as an increase in the variety of foods within and across food groups capable of ensuring adequate intake of essential nutrients that can promote good health, physical as well as mental development [2]. The more food groups included in daily diet the greater the likelihood of meeting nutrient requirements because all nutrients can't be found within a single food item [3].
In developing countries, dietary diversity is a challenge for rural communities. Their diets are based on starchy staples with inadequate animal products, fresh fruits and vegetables. 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 that resulted various forms of nutritional problems [4]. Chronic energy deficiency, inadequate energy intake and micronutrient deficiencies are among the top priority nutritional problems that affect women of reproductive age [5].
In areas where household food security is poor, meeting minimum standards of dietary quality is another challenge in many developing country settings and it has often not given enough emphasis [6]. Now, developing countries are burdened with the 'triple burden of malnutrition' encompasses the three dimensions of under nutrition (wasting, stunting & underweight), micronutrient deficiencies and over nutrition. Food security policies should focus not only on calorie intake but also consumption of a diversified diet. Consumption of a diversified diet promotes the intake of different nutrients and thus prevents many diseases. Reduction in dietary diversity will lead to an increase in the proportion of malnourished people [7].
Ethiopia Socioeconomic Survey (ESS) -2013/14 reported that cereals (rice, sorghum, barley, wheat) are the most consumed food items with 90% of all households reporting consumption of at least one of these items in any form in six of the last 7 days on average [8]. In Ethiopia, 60 and 40% of households had low and medium diet diversity scores [9]. A non-diversified diet can have negative consequences on individuals' health, well-being and development, mainly by reducing physical capacities as well as resistance to infection. In addition, cognitive development, reproductive and even social capacities may also be impaired [10]. Therefore, the aim of this study was to assess household dietary diversity and associated factors among residents of Finote Selam Town.

Study setting and participants
A community based cross sectional study was conducted from August 22-30/2015 in Finote Selam Town which is located at a distance of 380 Km North-West of Addis Ababa. The town has approximately 39585 total population and 5248 households. The study populations were permanent residents of Finote Selam Town from August 22-30/2015.
The sample size was calculated by using a single population proportion formula with the following considerations; prevalence of consuming diversified diet (60.4%) from previous research conducted in Addis Ababa [11], 95% confidence level, 5% margin of error and a 5% non response rate. A total of 403 households were selected using a systematic random sampling technique from a list of all households of the town.

Measurements
Interviewer administered questionnaire was used to collect data from respondents. First, the English version of the questionnaire was prepared, translated to Amharic and then back to English by language translators in order to check for consistency.
The respondents were asked to recall all foods eaten and beverages taken in the previous twenty-four hours prior to the interview. A scale of twelve food groups was used in assessing the dietary diversity of the respondents. A single point was given to each of the food groups consumed over the reference period giving a maximum sum total dietary diversity score of 12 points for each household.
For data collection eight diploma nurses and for supervision two Bachelor of Science nurses were recruited and trained for one day before data collection started.

Operational definitions
Household: One or more people who live in the same dwelling and also share at meals or living accommodation, and may consist of a single family or some other grouping of people. Household dietary diversity: Refers to the number of food groups consumed by household members over a 24-hour period. Low household dietary diversity score: When households consumed less than or equal to three food groups within 24 h before the survey [6]. Medium household dietary diversity score: When households consumed four to six food groups within 24 h before the survey [6]. High household dietary diversity score: When households consumed seven or more food groups within 24 h before the survey [6] Adequate household dietary diversity: When households consumed at least four or above food groups within 24 h before the survey. Inadequate household dietary diversity: When households consumed less than four food groups within 24 h before the survey.

Data processing and analysis
Data were checked for completeness and entered (double entry) into Epi data version 3.1. Data were cleaned and coded using Epi data and transferred to SPSS version 20 for analysis. Descriptive statistics were used to characterize respondents using different variables of interest. First, bivariate logistic regression analysis was undertaken for each explanatory variable with the outcome variable (household dietary diversity). Variables with a p-value ≤ 0.2 on bivariate logistic regression analysis were included in the multivariate logistic regression analysis. Statistical significance was determined using odds ratio with a 95% confidence interval. Statistical significance was declared if p-value was < 0.05.

Ethical consideration
Ethical clearance was obtained from Debre Markos University College of medicine and Health Sciences ethical review committee and permission also obtained from Finote Selam district health office as well as each kebele administration units. Informed verbal consent was obtained from the study participants and the objective of the study was explained to them. Those who were not volunter to participate are not enforced to respond.
Confidentiality and privacy of collected information ensured at all levels.
Almost all (99%) of respondents consumed cereal food groups and half (50.5%) of them also consumed vegetables (Table 4).

Factors associated with household dietary diversity
Hosmer-Lemeshow goodness-of-fit test (p = 0.144) was used to assess the fitness of the model. During the bivariate logistic regression analysis; head of the family, frequency of eating per 24 h, water shortage for cooking, ownership of farming land and household food insecurity access score were significantly associated with household dietary diversity.
During the multivariate logistic regression analysis; head of the family, frequency of eating per 24 h and water shortage for cooking were significantly associated with household dietary diversity. But, ownership of farming land and household food insecurity access score

Discussion
This community based cross-sectional study assessed household dietary diversity and associated factors in Amhara region, West Gojjam zone, Finote Selam town in 2015. The major goal of dietary diversity is to promote households to consume diversified diets rather than consuming monotonous diets throughout 24 h. The results of this study showed that low, medium and high household dietary diversity scores in Finote Selam town were found to be 11.8, 67.2 and 21% respectively.   Head of the family is among various socio-demographic factors that shows significant association with household dietary diversity in this study. The odds of having adequate household dietary diversity is 4.75 times higher among men headed families compared to women headed. This has similarities with study findings from Amatole and Nyandeni districts, South Africa [14], Mirab Abaya wereda, Southern Ethiopia [13], rural households in West Bengal, India [16], Sri Lanka [17] and Ethiopia [18]. This could be due to male headed households have more money at their disposal hence the higher dietary diversity.
Frequency of eating per 24 h is another dietary factor that has a significant association with household dietary diversity. The odds of having adequate household dietary diversity is 6.06 times higher among households who consumed food three times & above compared to households who consumed food two times. This could be explained by the fact that increasing frequency of consuming food items is one of the strategies to increase dietary diversity of households.
Availability of water for cooking is one of the prerequisites for ensuring adequate household dietary diversity. No shortage of water for cooking is significantly associated with household dietary diversity in this study. The odds of having adequate household dietary diversity is 5.69 times higher among households who didn't have water shortage for cooking compared to households who had water shortage. This could be due to the fact that clean water is important for washing, preparing and cooking our food items.
The limitations of this study are relying on 24 h dietary recall which doesn't show the usual dietary practice of household members and affected by religious festivals.

Conclusions
In this study the magnitude of adequate household diversity was 88.2%. Family head, frequency of eating and shortage of water for cooking were significant factors for household dietary diversity. Empowerment of women, increasing frequency of eating among family members and avoiding shortage of water for cooking were recommended to sustain and improve household dietary diversity.