Study area and period
The study was carried out in Wolaita Soddo town, which is an administrative town in the Wolaita zone in southern Ethiopia. The town is situated 152 km southeast of Hawassa, the regional center of the Southern Nations, Nationalities, and Peoples Region, and 327 km south of Addis Ababa. There was one teaching and referral hospital, one private hospital, three health centers, and thirteen private clinics in the town. The three study health centers offer services for adult outpatients, chronic disease clinics, reproductive health services or youth-friendly services, laboratory services, and pharmacy services, as well as pediatric and maternity health care [under five OPD, immunization, family planning, and delivery]. The teaching and referral hospital serves as a referral hospital in the Wolaita Zone, offering outpatient and inpatient services as well as pediatric, adult, and neonatal intensive care units, adult medical and surgical wards, and pharmacy and laboratory services. The study was conducted from June to July, 2021.
Study design
An institution based cross-sectional study design was employed.
Source population
All children aged 6 to 59 months who received health services in public health facilities in Wolaita Soddo town.
Study population
Children aged 6 to 59 months who attended maternal and child health services and fulfilled the inclusion criteria.
Inclusion and exclusion criteria
Inclusion criteria
All children aged 6 to 59 months who attended maternal and child health services during the data collection period, as well as children accompanied by their mother, father, or caregiver.
Exclusion criteria
Children who were critically ill, with known chronic diseases like DM and chronic heart diseases, and mothers or caregivers who were ill.
Sample size and sampling technique
The sample size was calculated using a single population proportion with the following assumptions: the prevalence of a minimum dietary diversity, 59.9% from Addis Ababa ( [15] and a 95% confidence level with a 5% margin of error. Accordingly, the calculated sample size, with the consideration of a 10% non-response rate, was 406. This size was chosen as the final sample size because it gives a better sample size than the other calculated sample sizes.
Sampling technique and procedures
First, all the public health facilities in the town were selected for the study. Then, the computed sample size was proportionally allocated to the town’s health facilities based on the average monthly flow of the children. Finally, study participants were selected using a computer-generated simple random sampling method as shown in Fig. 1.
Schematic presentation of sampling procedure of the study, 2021
Data collection instruments and procedures
A pre-tested, interviewer-administered questionnaire was used to collect data from mothers, fathers, and child caretakers. Data collection tool was prepared after reviewing related literature [15,16,17,18]. The minimum dietary diversity of the children was assessed using a standardized dietary assessment tool [6]. The Food and Nutrition Technical Assistance (FANTA) Household Food Insecurity Access Scale Measurement Tool was used to assess the food security of households [25]. The questionnaire was translated into Amharic and the local language (Wolaittato) for fieldwork purposes and then translated back into the English language to check its consistency. The questionnaire contains four parts: socio-demographic characteristics of the children; utilization of child and maternal health services; household food security; and dietary diversity. The minimum of dietary diversity was assessed by asking the mothers or fathers or caretakers whether the child consumed food from the seven food groups on the previous day of the survey. The data were collected by ten trained nurses and supervised by four supervisors.
Study variables
Dependent variable
Minimum dietary diversity among under-five children.
Independent variable
Socio-demographic characteristics
Parental occupation, education, family size, household income, food security, and family decision-making on household expenditures.
Child characteristics and maternal health service utilization
Age, sex, birth interval, and birth order, recurrent illnesses, antenatal care (ANC), post-natal care (PNC), immunization status, place of delivery, and health education on child feeding.
Operational definitions
Minimum dietary diversity
The proportion of children aged 6 to 59 months who consumed at least four food groups out of the seven referenced food groups during the previous day of the study [6]. The seven food groups are: (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.
Food security
The state of having sufficient food at all times to meet dietary needs for a productive and healthy life [25].
Data quality management
Training was given for the supervisors and data collectors on the purpose of the study, the techniques of data collection, and data recording. A pre-test was conducted on 5% of the total sample size outside of the study area (Boditi primary hospital). Based on the result of the pre-test, necessary modifications and corrections were made. The supervisors and investigators followed the data collection process on a daily basis. To ensure the quality of the data, each questionnaire was checked for consistency and completeness.
Data processing and analysis
The data were entered into EpiData version 4.6, cleaned, and analyzed by SPSS version 26. The 4 scores of food security, i.e., “food secure,” “mild food insecurity,” “moderately food insecure,” and “severely food insecure,” were dichotomized into “food secure” and “food insecure.” The results of the study were presented in text, tables, and graphs. A bivariate analysis was done to select the variables for a multivariate analysis. A multivariable logistic regression analysis was performed on the variables with a P-value < 0.25. Before adjusting in the multivariable analysis, the variables candidates for the multivariable analysis were checked for multi-collinearity using the variance inflation factor which ranged from [1.1—1.87]. A multivariable logistic regression analysis was done to identify the independent predictors of the minimum dietary diversity. The Hosmer-Lemes show test was used to assess the model’s fitness [0.124]. P-values < 0.05 were considered statistically significant, and an adjusted odds ratio (AOR) with a 95% confidence interval was used to measure the degree of association.
Ethical approval and consent to participate
Ethical clearance was obtained from the institutional review board at Addis Ababa University, the College of Health Sciences, and the School of Nursing and Midwifery with protocol number 70/21/SNM and meeting number: 01/2013EC. Written informed consent was obtained from the parents or legal guardians of the children, and the confidentiality of the information was maintained throughout the study. All methods and procedures utilized in this study were in conformity with the Declaration of Helsinki.
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