Dangura and Gebremedhin BMC Pediatrics (2017) 17:6

DOI 10.1186/s12887-016-0764-x

RESEARCH ARTICLE Open Access

Dietary diversity and associated factors

among children 6-23 months of age in
Gorche district, Southern Ethiopia:
Cross-sectional study
Dalecha Dangura1* and Samson Gebremedhin2

Abstract
Background: Dietary diversity (DD) is useful indicator of dietary quality and nutrient adequacy. In developing
countries limited evidence is available regarding predictors of DD during the critical complementary feeding period.
The purpose of the study is to assess DD and predictors among children 6–23 months of age in rural Gorche
district, Southern Ethiopia.
Method: A community based cross-sectional study was conducted among 417 children aged 6–23 months in
Gorche district. The children were selected using a stratified two-stage cluster sampling technique. DD in the
preceding day of the survey was assessed using the standard 7-food group score without imposing a minimum
intake restriction. Factors associated with DD were identified by modeling dietary diversity score (DDS) using linear
regression analysis.
Results: Only 10.6% (95% CI: 7.6–13.6) of the children had the minimum recommended DD (≥4 food groups). In
children born to literate fathers, the DD was increased by 0.26 as compared to their counterparts (p = 0.026). Children
from households that grow vegetables and own livestock, the DDS was significantly increased by 0.32 (p = 0.032) and
0.51 (p = 0.001). As the age of the child increases by a month, the DD also increased by 0.04 (p = 0.001). Mothers that
received Infant and Young Child Feeding (IYCF) education during their post-natal care, the DDS was increased by 0.21
(p = 0.037). Unit increase in maternal knowledge on IYCF was associated with 0.41 rise in DDS (p = 0.001). Other factors
that showed positive association were: mother’s participation in cooking demonstration, exposure to IYCF
information on the mass media and husband involvement in IYCF.
Conclusion: Nutrition education, promotion of husbands’ involvement in IYCF and implementation of
nutrition sensitive agriculture can significantly enhance DD of children.
Keywords: Dietary diversity, Infant and young child feeding, Nutrition education, Husband involvement

Background malnutrition include, but not limited to, poverty, adverse

In 2013, globally an estimated 6.3 million children under climatic conditions, natural resource degradation, fragile
the age of 5 years died, 2.9 million of them in the Sub- and poorly accessible health care services and existence
Saharan Africa (SSA) region. In 2030 about 60% of all of socio-cultural misconceptions [3].
child deaths will be expected to occur in the region [1]. In Ethiopia, over the past 15 years notable decline in
Worldwide, nearly half (45%) of all child deaths are child under-nutrition had been witnessed. Stunting was
linked to malnutrition and the figure might even be reduced by more than 30% and underweight was slashed
higher in Africa [2]. In SSA underlying causes of by 40% [4]. Yet, childhood malnutrition still remains a
major public health challenge. As of 2014, 9, 25 and 40%
* Correspondence: dalecha2dangura@gmail.com of children under the age of 5 years were wasted, un-
1
Sidama Zone Health Department, Hawassa, Ethiopia derweight and stunted, respectively [4]. National level
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Dangura and Gebremedhin BMC Pediatrics (2017) 17:6 Page 2 of 7

studies indicated nearly half of preschool children (44%) single population proportion formula with the following
[5] and more than one-third of children 6–71 months specifications: 95% confidence level, 14.4% expected
(38%) have anemia and vitamin A deficiency [6]. prevalence of acceptable DD [17], 5% margin of error,
Complementary feeding is a critical period in which design effect of 2 and 10% contingency to account for
malnutrition starts to develop in many infants, contrib- possible non-response. The adequacy of the sample size
uting significantly to the high burden of malnutrition in for identifying correlates of DD was evaluated using
pre-school children [7]. In many developing countries Gpower software [18].
complementary feeding practices are frequently ill-timed,
unsafe and lack the desirable amount, feeding frequency Sampling procedure
and nutrient density for optimal child growth and devel- The study followed stratified two-stage cluster sam-
opment [8]. Globally, ensuring optimal complementary pling procedure. Initially the available 21 rural kebeles
feeding can avert a substantial proportion of childhood were stratified into two groups – midlands and high-
deaths [9]. lands – based on their predominating agro-ecological
Dietary diversity (DD), the number of food groups characteristics. From the available four and seventeen
consumed over a reference period [10], is a useful in- kebeles from the two strata, two and six kebeles were
dicator of dietary quality, nutrient adequacy and nu- selected respectively using simple random sampling
tritional status of children [11–13]. In the context of technique. Then, in each of the selected kebele,
infant and young child feeding (IYCF), minimum DD – exhaustive listing of eligible children was made and
proportion of children 6–23 months of age who received independent sampling frame was developed. Ultim-
foods from four or more out of seven standard groups in ately children were selected using systematic random
the preceding day– is as an imperative indicator [14]. sampling procedure. The sample size of the study was
However, in many low income countries meeting mini- proportionally distributed to the kebeles according to
mum the DD standard has been a major challenge. Sum- their population size.
mary of many Demographic and Health Surveys (DHS)
conducted in developing countries witnessed that only a Data collection
quarter of children met the requirement [15]. The figure Data were collected from the mothers/caregivers of the
is as low as 5% in Ethiopia [5]. selected children using structured questionnaire prepared
Accordingly, the purpose of the current study is to in the local language. The English version of the question-
assess dietary diversity and associated factors among naire is attached as a supplementary file (Additional
children aged 6–23 months in Gorche district, Southern file 1). Socio-demographic questions were adopted
Ethiopia. from the standard DHS questionnaire [5]. Minimum
acceptable DD was defined as taking four or more
Methods food groups in the preceding day of the survey out of
Study setting the seven standard food groups recommended by the
The study was conducted in Gorche, one of the districts WHO [19] without imposing a minimum intake re-
of Sidama Zone, Southern Ethiopia. According to the striction. Dietary diversity score (DDS) was computed
2007 national census, the district has a population size by summing the number of unique food groups the
of 139,780 of which 98% dwell in rural areas [16]. The child received in the preceding day of the survey.
livelihood of the population is reliant on subsistent Household food security was measured and classified
mixed farming and the area is vulnerable to food as recommended by the Food and Nutrition Technical
insecurity. Major crops grown in the district are enset Assistance (FANTA) Guideline [20].
(Enset ventricosum), barely and broad beans. Agro- Husbands were considered to be involved in IYCF
ecologically, the district is divided into midlands (20%) when they perform at least two of the following four
and highlands (80%). Administratively, Gorche is orga- activities: (1) buying/bringing nutritious foods (egg, milk
nized in 22 kebeles. A kebele is the smallest administrative and meat) to feed the child, (2) giving money to his wife
unit in Ethiopia with an approximate 1,000 households. to purchase nutritious foods specifically to the baby, (3)
checking whether his child is getting adequate amount
Study design of food or not, and (4) discussing with his wife about the
A community based cross-sectional quantitative study type of food that should be provided to the child.
with both descriptive and analytic elements was used. Mothers were considered to be knowledgeable on IYCF
when they know at least two from following four pa-
Sample Size rameters: timely initiation of complementary food,
The study was designed to include 417 children 6–23 dietary diversity, duration of breast feeding and timely
months of age. The sample size was estimated using initiation of family food.
Dangura and Gebremedhin BMC Pediatrics (2017) 17:6 Page 3 of 7

Household wealth status was measured based on com- Table 1 Socio-demographic characteristics of the respondents
posite variables including ownership of selected household and study children in Gorche district, Southern Ethiopia, 2015
assets, size of agricultural land, quantity of livestock, Variables (n = 417) Frequency Percentage
materials used for housing construction and ownership of Head of the household
improved toilet and water sources. Male 411 98.6
Female 6 1.4
Data analysis
Mother’s age (year)
The data were entered into Epi-info 2007 software and stat-
istical analysis was performed using SPSS version 20. Below 25 102 24.5
Household wealth index was computed using Principal 25 and above 315 75.5
Component Analysis. Factors associated with DD were Child’s age (months)
identified by modeling DDS using multivariate linear re- 6–8 58 13.9
gression model. The association between each independent
9–11 61 14.6
and dependent variable was initially assessed in simple (i.e.
12–23 298 71.5
bivariate) regression model; then, variables that showed sig-
nificant association were considered for multivariate model. Child sex
The independent variables were modeled in two – distal Male 218 52.3
and proximal – regression models. All socio-demographic Female 199 47.7
characteristics and variables related agricultural production Father’s education
and exposure to IYCF education were considered as distal
Illiterate 294 70.5
variables; whereas, maternal knowledge and husband’s
Literate 117 28.1
involvement in IYCF were taken as proximal factors.
Assumptions of the regression model (linearity, absence of Mother’s education
multicollinearity, normality and homoscedasticity of error Illiterate 340 81.5
terms) were checked as described elsewhere and they were Literate 77 18.5
found to be satisfied [21]. Model fitness assessed using Father’s occupation
adjusted r-squared value. Outputs of the analysis were
Farmer 398 95.4
provided in unstandardized regression coefficients.
Merchant 93 22.3

Ethical consideration Others 9 2.2

Ethical clearance was secured from the Institutional Review Mother’s occupation
Board (IRB) of Hawassa University, College of Medicine and Farmer/house wife 385 92.3
Health Sciences. Data were collected after taking informed Merchant 55 13.2
consent from the primary caregivers of the study subjects.
Others 3 0.7
Marital status
Results
Socio-demographic characteristics Married/living together 411 98.6
From 417 infants and young children included in the Widowed 6 1.4
study, 52.3% were males. The mean (±SD) age of the Family size
children was 15.3 (±5.6) months. The mean (±SD) Less than five 154 36.9
household size of the study participants was 5.3 (±1.8)
Five or more 263 63.1
persons. More than half (54.0%) of households had two
Number of children under the age of five
or more under five children. The majority (98.6%) of the
children were sampled from male-headed households. One 192 46.0
Nearly all (92.3%) of the mothers were housewives and Two or more 225 54.0
81.5% had no formal education (Table 1).
food secured; whereas, the remaining 2.9, 50.1 and
Household agricultural production and status of 30.2% had mild, moderate and severe food insecurity,
household food security respectively (Table 2).
The mean (±SD) household agricultural land size of the
households included in the study was 1.4 (±0.5) hectares. Level of dietary diversity
Four-in-five (80.6%) households were involved in live- The mean (±SD) DDS calculated out of the standard
stock production. The assessment of household food seven food groups was 2.0 (±1.0) and only 10.6% (95%
security showed that only 16.8% of the families were CI: 7.6-13.6) of the children had acceptable DD in the
Dangura and Gebremedhin BMC Pediatrics (2017) 17:6 Page 4 of 7

Table 2 Household agricultural production and status of media, during Postnatal Care (PNC) visit and through
household food security in Gorche district, Southern having discussion with Health Extension Workers
Ethiopia, 2015 (HEWs), mother’s participated in food cooking demon-
Variables and categories (n =417) Frequency Percentage stration, husband involvement in IYCF and maternal
Proportion of households that: knowledge on IYCF.
Grow Enset 410 98.3 According to the final multivariate regression models,
Grow cereals 337 80.8
in children having literate fathers, the DD was increased
by 0.26 as compared to their counterparts (p = 0.026).
Own livestock 336 80.6
Whereas, children from households that grow fruits and
Grow fruits and vegetables 333 79.9 vegetables and own livestock, the DDS was increased by
Grow cash crops 289 69.3 0.32 (p = 0.032) and 0.51 (p = 0.001) as compared to their
Grow legumes 202 48.4 counterparts and, respectively. As the age of the child
Household food security status increases by a month, the DD also increased by 0.04
Food secured 70 16.8
(p = 0.001). Children born from mothers that received
IYCF message during PNC, the DDS was increased by
Mildly food insecure 12 2.9
0.21 (p = 0.037). Unit increase in maternal knowledge on
Moderately food insecure 209 50.1 IYCF was associated with 0.41 rise in DDS (p = 0.001).
Severely food insecure 126 30.2 Other factors that were positively associated with the out-
come variable were mothers participated in food demon-
preceding day of the survey. About three-fourth (78%) of stration, exposure to IYCF information on the mass media
the children received solid, semi-solid, or soft foods of and husband involvement in IYCF (Table 3).
the minimum recommended frequencies, as defined in
the WHO guideline [14]. Only 8.4% of the children had Discussion
met the minimum acceptable diet standard – having the The study found only one-tenth of children received
minimum DD and the minimum meal frequency during adequately diversified food while a higher proportion
the previous day. (78%) had optimal feeding frequency. Consequently, frac-
The majority (87.5%) of mothers reported that their tion of children that received the minimum acceptable
children consumed complementary foods prepared from diet – a combined indictor on the basis of feeding fre-
starchy staple foods including grains, roots and tubers in quency and diversity – remained exceedingly low (< 10%).
the reference period. Only a quarter (24.2%) received This signifies that most children failed to satisfy the mini-
foods made from legumes and pulses. Vitamin A rich mum acceptable diet requirement largely due to sub-
and other fruits and vegetables were consumed by 7.2 optimal DD. Other studies conducted in Ethiopia supports
and 39.1% of the children, respectively. Regarding animal the current studies [5, 22]. According to DHS 2011, 48%
source foods, more than half (60.7%) received dairy and of children had the acceptable meal frequency; nonethe-
dairy products excluding breast milk (85.4%); neverthe- less, proportions that met the minimum DD (4.3%) and
less, eggs (11.0%) and meat (2.6%) were less frequently acceptable diet (4.0%), were remarkably low [5]. The find-
consumed. ing also shows, the district is lagging behind the national
target that envisions to raise proportion of children with
Factors associated with dietary diversity acceptable diet to 20% by 2015 [23].
A total of 20 variables were considered for the bivariate The study concluded only 10.6% of children had the
analysis. The following variables did not show significant minimum DD and local complementary foods are
association hence they were not considered for the mainly prepared from starchy staple foods. Furthermore,
multivariate analysis: child’s sex, mother’s and father’s nutrient dense animal source foods like eggs and flesh
occupation, household wealth index, sex of the head of foods are infrequently offered to children. Other studies
the household, land size, the number of under five from Ethiopia came up with parallel findings [17, 22, 24].
children in the household, birth order and women in- A study conducted in 2011 in a nearby Borcha district
volvement in Income Generating Activities (IGA). found that only 14% of children had met the minimum
Fifteen variables met the inclusion criteria and hence DD and only 3 and 2% of children respectively received
included in the multivariate model. The variables were; flesh foods and eggs [17]. A summary of surveys con-
mother’s age, child’s age, father’s and mother’s educa- ducted in Southern Ethiopia concluded that in six of the
tional status, the size of the households, agro-ecology of nine surveys included, proportions of children with opti-
the kebele, cultivation of fruits and vegetables, pro- mal DD were less than 25% [25].
duction of legumes and nuts, ownership of livestock, Husband’s educational status and their direct involve-
mother’s exposure to IYCF information on the mass ment in IYCF showed positive association with DD of
Dangura and Gebremedhin BMC Pediatrics (2017) 17:6 Page 5 of 7

Table 3 Bivariate and multivariate linear regression analyses on the factors associated with dietary diversity among children 6–23
months of age in Gorche District, Southern Ethiopia, 2015
Outputs of the analysis
Variables and coding Bivariate Multivariate
βa P value βa P value
Distal factors
Mother age in years (18–44) -0.02 0.038* -0.013 0.301
Father education (0 = illiterate, 1 = literate) 0.38 0.001* 0.26 0.026*
Mother education (0 = illiterate, 1 = literate) 0.24 0.049* -0.09 0.533
Size of the household (3–12) -0.03 0.289 -0.02 0.696
Agro-ecology (0 = Dega, 1 = Woyinadega) -0.29 0.005* 0.10 0.459
Grow fruits and vegetables (0 = No, 1 = Yes) 0.39 0.001* 0.32 0.032*
Grow legumes (0 = No, 1 = Yes) 0.25 0.009* 0.09 0.373
Own livestock (0 = No, 1 = Yes) 0.60 0.001* 0.51 0.001*
Received IYCF information on mass media in the last 1 month (0 = No, 1 = Yes) 0.38 0.001* 0.29 0.004*
Received IYCF information from HEWs in the last 1 month (0 = No, 1 = Yes) 0.26 0.016* 0.17 0.086
Participated in cooking demonstration in the last 6 months (0 = No, 1 = Yes) 0.25 0.009* 0.23 0.010*
Child age in months (6–23) 0.05 0.001* 0.04 0.001*
Received IYCF information during PNC visit (0 = No, 1 = Yes) 0.34 0.001* 0.21 0.037*
Proximate factors
Husbands involvement in IYCF (0 = No, 1 = Yes) 0.23 0.018* 0.20 0.037*
Maternal knowledge (0–4) 0.44 0.001* 0.41 0.001*
a
Unstandardized regression coefficient
* Significant at P value of 0.05

children. Limited number of literatures empirically eval- considered as a credible source of health and nutri-
uates the role of husbands in IYCF practice. An unpub- tion information hence such messages are likely to be
lished study conducted in South Wollo Zone, North adopted.
Ethiopia concluded that children living in households Mothers who took part in cooking demonstrations were
where husbands are directly involve in IYCF have a more likely to provide diversified complementary food to
significant 13.7% rise in DDS. A qualitative study in their children. A study from Peru concluded the same
Gambia reported that husbands have a major influence findings [31]. A mixed study conducted in Ethiopia
on infant feeding practice including the timing for initi- witnessed the role of cooking demonstrations in enhan-
ating complementary foods [26]. cing the IYCF practice of rural women [32]. The finding is
In this study it was observed that production of consistent to the understanding that cooking demonstra-
fruits and vegetables and ownership of livestock is tion particularly benefits resource poor rural communities
associated with significant rise in DDS. The finding with limited formal education by providing hands-on
indicates implementation of nutrition sensitive agri- learning experiences based on available recipes.
culture might be imperative for improvement diversity Unexpectedly, the study found no association between
of children’s diet. A study conducted in South Africa DD and, maternal education and household wealth
supports the current study [27]. A study in Philippines index. This can be due to various reasons. Regarding
concluded preschool children from households with maternal education, the study was conducted in pre-
gardens had higher DDS as compared with their dominately uneducated community where less than 20%
counterparts [28]. of mothers were literates. Most of the literate mothers
Exposure to IYCF messages on the mass media showed were also likely to have very brief exposure to formal
significant association with DD. Other studies also education. Consequently, comparison of the DDS be-
availed consistent evidence. A secondary data analysis tween literate and illiterate mothers may not be sensitive
of Ethiopian DHS and another study from Northwest enough to show the real merits of maternal education.
Ethiopia supports the study [22, 29]. A study in India The null association with household wealth status can
also identified media exposure as a significant de- be due to the methodological weakness of wealth index.
terminant of IYCF practice [30]. Media is usually As wealth index is a relative, not absolute scale, it may
Dangura and Gebremedhin BMC Pediatrics (2017) 17:6 Page 6 of 7

not have a discriminatory power in setting, like the study Ethics approval and consent to participate
area, where wealth is relatively homogenous. The data were collected after taking ethical clearance from the Institutional
Review Board (IRB) of Hawassa University, College of Medicine and Health
The following limitation should be noted while inter- Sciences. Written informed consent for participation in the study was taken
preting the findings of the study. The DD was assessed from the primary caregivers of the children.
on the basis of a single day recall hence it may not pre-
Author details
cisely show the usual dietary behavior of the community. 1
Sidama Zone Health Department, Hawassa, Ethiopia. 2Hawassa University,
Maternal knowledge and husbands’ involvement in IYCF School of Public and Environmental Health, Hawassa, Ethiopia.
were measured via non-standard scales hence misclassi-
Received: 10 January 2016 Accepted: 20 December 2016
fication errors cannot be excluded. Further, measure-
ment of husbands’ involvement in IYCF can be liable to
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