Dietary diversity, meal frequency and associated factors among infant and young children in Northwest Ethiopia: a cross- sectional study

A total of 920 infants and young children aged 6 to 23 months along with their mothers were enrolled in the study, with a response rate of 99.5 %. For all parental characteristics see Table 1. Table 2 presents the distribution of the sample according to attributes of the child, household, community and health care characteristics. Among the children, 338 (36.7 %) were in the age category of 6–11 months The mean age of children was 14.21 ± 5.27(SD) months, and 90 % of children were breast fed at a time of data collection.

Table 3 indicates the types of food groups practiced by study subjects. Grains, roots and tubers were eaten by 80.2% of children. The present study found that only 12.6 % of children received the recommended dietary diversity, which is lower as compared with the DHS reports of developing countries from Africa, Asia, and Latin America [10]. This low dietary diversity coverage is also similar with different studies conducted in Ethiopia (10.8 %) [9], Democratic Republic of Congo (12 %), Burkina Faso (14 %), Mali (16 %), and India (15.2 %) [10, 11]. However, it is lower than findings from Nepal (34 %), East New Delhi (33 %), Bangladesh (41.9 %), Nepal (72 %), and Sri Lanka (71 %) [12, 13, 15‐17] (Fig. 1).

The difference could be due to lack of awareness about nutritional requirements for infants and young children, affordability to a food product and low purchasing power for food. This population has also different feeding habit with a tradition of cooking few verities of food for the family. Moreover, there appears to be a tendency to share food with siblings at home.

Proportion of children who received minimum meal frequency found to be 50.4 %. The practice is higher as compared to EDHS report (44.7 %) [9], Mali (25 %), Burkina Faso (31 %), Democratic Republic of Congo (30 %), Cameron (41 %) and India (42 %) [10, 11]. It is similar with studies conducted in New Delhi (49 %), Vietnam (48 %), Namibia (49 %) [10, 17]. But it is lower when compared with studies from Asia and Latin American countries like Nepal (82 %), Kathmandu (65 %), Bangladesh (81 %), Sri Lanka (88 %), and Peru (78 %) [10, 12, 13, 15, 16].

As we see the meal frequency practice is higher compared with same African countries this might be due to difference in feeding habits and had better production and purchasing power compared with others relatively. But much lower than Asian countries, this difference might be due to educational level, habit of feeding frequency, lack of knowledge about how many time solid, semisolid and soft food should be given for a child and even if had knowledge lack of affordability to enough food production and purchasing power.

The educational status of a mother, age of a child, birth order of index child, area of residence, home gardening and satisfactory media exposure of a mother were significantly associated with providing the minimum dietary diversity after controlling for other predictors in the model (Table 4).

The study found that children born from mothers who were well educated and had a secondary level education [AOR 2.52; 95 % CI (1.28, 4.93)] or higher education [AOR 4.23; 95 % CI (1.92, 9.33)] had greater odds of feeding diversified foods. A recent study done on comparison of five Asian countries on infant feeding reports that mother’s education is a significant determinant of appropriate diversified infant feeding [18, 19]. Sri Lanka had the highest proportion of children meeting the infant feeding guidelines for diversity; and this is linked to the higher education status of mothers and overall literacy [12]. Similar positive impact of education on diverse feeding practices is also reported in a previous studies in Nepal, Bangladesh, Indonesia, India including Ethiopia [9, 19]. This could be educated mothers are more likely to have information (media exposure), understand the education message, more likely to be engaged in the paid work and might have received lessons on child feeding in the curricula at school.

Another most important factor significantly associated with minimum dietary diversity was age of a child. Children aged 12–17 and 18–23 months had about two times higher odds [(AOR 2.05; 95 % CI (1.17–3.58) and (AOR 2.89; 95 % CI (1.69, 4.93)] of having minimum dietary diversity compared to children aged 6–11 months. This study is in line with studies conducted in Ethiopia, Indonesia, Nepal, and Sri Lanka [9, 12, 15, 19]. This indicated the relationship between different food groups by age group which implies that food groups decrease as the child age decreases. This might be due to late introduction of complimentary feeding and when they start complimentary feeding on time; they included only milk or cereal products like gruel. Other possibility could be mothers may perceive that younger the child, the poor ability of child’s intestine to digest solid, semisolid and soft foods. Besides, mothers may assume introducing a bulk of food would lead them to develop infections [20].

It was found that birth order of index child had significant association with dietary diversity. Children born in the second to fourth order [AOR 2.08; 95 % CI (1.24, 3.49)] and above fourth order [AOR 2.76; 95 % CI (1.26, 6.05)], respectively, had about two and three times higher odds of having the minimum dietary diversity compared with children who were born in first order. This result is contradictory to that of previous studies conducted on 2011 EDHS analysis [9]. This difference might be due to study area, sample size and time horizon. This study is conducted in more or less homogenous community with limited sample size; but the EDHS study included large population from different ethnic and regions with various culture, beliefs, and traditions such as a tendency to prioritizing the first child from his/her younger siblings. Another possible reason for this difference may be that as a mother’s parity increase, she gets experience on how to prepare and feed diversified diet to her child.

This study also indicated that children born from mothers who lived in urban areas were reported higher practice of minimum dietary diversity [AOR 2.09; 95 % CI (1.12, 3.93)] as compared to those children born from mothers who lived in rural areas. This is similar to study conducted in Indonesia [21]. The low practice of diet diversity in rural region may be due to lake of awareness regarding importance of dietary diversity in rural community compared to urban community, which has access to mass media. Another difference may be traditional beliefs and practices. During introducing complimentary food to infants in rural community, infants may develop diarrhea due to poor hygienic condition, but mothers could associate this problem with taking different food items and eventually she might not permit the child to taste unfamiliar foods. Those children with parents possessing home gardening had two times [AOR 2.03; 95 % CI (1.09–3.78)] higher odds of having the minimum dietary diversity as compared to children whose parents did not. This could indicate that parents with home gardening would grow vegetables and fruits and then they child would get additional options in his/her diet. This finding is supported by a study conducted in Southern Ethiopia [22].

Children whose mothers who had been exposed to media had a higher odds of having diversified diet [AOR 2.74; 95 % CI (1.52, 4.94)] than those children of mothers who had not been exposed to media. This is similar studies shown in Ethiopia, India, and Sri Lanka [9, 11, 12]. This might be pointing to the influence of the media on infant and young child feeding practices. This could have happened due to the promotions of child nutrition related media advertisement in national radio and television.

Age of a child, birth order of an index child, involvement of mother in decision making in the household, satisfactory media exposure of a mother and time of postnatal care visit were significantly associated with the recommended minimum meal frequency after controlling for other predictors in the model (Table 5).

The study showed that children with age group of 12–17 months [AOR 3.03; 95 % CI (2.14,4.27)] and 18–23 months [AOR 5.03; 95 % CI (3.52,7.18)] had higher odds of recieving the minimum frequency in their daily meal compared to children age group between 6-11months. This study also supported by studies conducted in Ethiopia, India, and Seri Lanka [9, 11, 12]. This might be occurred due to the fact that for the infants during 6–11 months, mothers did not introduce semi solid and soft food; they are simply fed on animal or canned milk along with breast milk. Unfortunately, however, the definition of minimum meal frequency, did not not consider breast milk while calculating minimum meal frequency for breast feed infants.

The study found that Children born in the second to fourth order [AOR 1.58; 95 % CI (1.13, 2.21)] and above fourth order [AOR 1.78; 95 % CI (1.07, 2.96)] were more likely to met the minimum meal frequency as compared with children who were born first order. This difference could be due to mothers who give birth for first time may have less knowledge than those of multi parity mothers. And also as mother’s parity increased mothers become experienced how to feed children frequently.

Involvement of mothers in household decision making found to be significantly associated with minimum meal frequency. Children from mothers involved in decision making in the house hold were 1.5 times[AOR 1.51; 95 % CI (1.05–2.17)] more likely to provide the recommended meal frequency as compared to the children from the mothers not involved in decision making in the household. This study also in line with study conducted in India [11]. The possible explanation for this difference may be, most of the time the responsibility of child feeding is on the shoulders of mother even if the source is from husbands in Ethiopian context [20]. So participation of mothers with their household issues, they can access household resources easily and contribute that mothers can fed the children more frequently.

Children born from mothers who were exposed to media, i.e., watched television, listened to radio and read newspapers or magazines every day or at least once a week has more likely to meet minimum meal frequency [AOR 2.62; 95 % CI (1.90–3.61)] than those children born from mothers who watched television, listened to radio and read newspapers or magazines less than once a week or not at all. This study is similar with other studies conducted in Ethiopia, Nepal, Seri Lanka and India [9, 11, 12, 14]. The reason behind for this could be currently there is a media promotion using radio and television that promote and show practice of IYCF. This may reflect broadly the power of mass media for improvement meal frequency practice.

Mothers who had attended PNC within 1–2 day after delivery [AOR 2.30; 95 % CI (1.27–4.15)] were more likely to provide recommended meal frequency than mothers who had no PNC visit. Nutritional counseling for mothers about frequent feeding during PNC is important continuum and Mothers who have attended PNC visits may be more informed, have greater access to services and may be from a well off family, and thus more likely to be able to afford and provide of foods more frequently to their children.

The study is not free of recall bias and social desirability bias. It may not also accurately reflect childrens’ past feeding experience since it considers only 24-hour feed. This study does not take account of the quality and amount of food provided.