Household Food Insecurity, Coping Strategies and Adolescent Girls’ Dietary Diversity Status in Hossana Town, Ethiopia.

Background Globally there are 1.8 billion adolescents, comprised of 10-19 years old, represent approximately 20% of the world’s population. In Ethiopia this group represents 20-26% of general population. Despite the fact that this period is a window of opportunity to break intergenerational cycle of malnutrition, macro and micronutrient deficiencies are among leading health problems in this vulnerable age groups. Moreover, there is scarcity of data on the status of dietary diversity in this segments of the population. Methods a community based cross sectional study design was employed from May 21-June 20, 2019. Pre-tested structured questionnaire was used for data collection using cluster sampling technique to approach 451 households with adolescent girls. Data was entered in to Epi-Data version 3.1 then exported to SPSS version 23 for analysis. Descriptive and logistic regression analysis were performed. Adjusted Odd Ratios (AOR), along with corresponding 95% confidence interval (CI) were used and the level of statistical significance was declared at a p-value of <0.05. Results a total of 434 households with adolescent girls were involved in the study. We found that 41.7% of households were food insecure, only 57.8%, (C.I.53.5-62.2) of adolescent girls consumed diversified diet, with the mean DDS of 5.38 (SD=1.75). After adjusting for potential confounders, occupational status of the adolescents’ father, (AOR= 0.56, 95% C.I. 0.32-0.99 and AOR=0.26, 95% C.I. 0.17-0.47), exposure to televised media (AOR=3.36, 95% C.I. =1.55-7. 3) and household food security status (AOR=5.09, 95% C.I. =3.2-8.08) were significant predictors of dietary diversity among adolescent girls. Conclusion Significant portion of households were food insecure; practicing ranges

of coping strategies which further compromised dietary diversity of adolescent girls.
Poor dietary diversity adversely affects micronutrient reserves of to-be a-mother girls; the vicious cycles of malnutrition continues its far fetching effect. Given that adolescence is the second period in life with rapid growth and development, improving dietary status of this sensitive segments of the population are to be an agenda of all concerned bodies.

Background
Globally there are 1.8 billion adolescents, comprised of 10-19 years old, represent approximately 20 % of the world's population. Of which 90% live in low and middleincome countries (LMICs). In Ethiopia, these group represents 20-26 % of the population (1)(2)(3). Adolescence is the period of most rapid growth second to childhood (4); characterized by rapid transition to adulthood marked by physical and biological growth and development. For instance 50, 20 and 50% of adult weight, height, and skeletal mass are gained in this period; hence optimal nutrition is critical during this period (5)(6)(7)(8). Additionally, it is a period of critical window of opportunity to intervene an intergenerational cycle of malnutrition (3). Addressing the nutrition needs of adolescents girls could be an important step in breaking the vicious cycle of intergenerational malnutrition, chronic diseases, and poverty (9,10).
However; adolescents from developing countries are susceptible to nutritional deficiencies due to early childhood nutritional insults (11) and adverse environmental conditions including food insecurity which could impact on their development and wellbeing (5).
Dietary diversity score (DDS), a proxy for adequate micronutrient density of foods (12), defined as a number of individual food groups consumed over a given period of time. Along with food variety and consumption of animal source foods, dietary diversity is an indicator commonly used to assess intake and quality of diet at the household or individual level. In addition, DDS is a measure of food security, nutrition information, early warning system and target of intervention at global or national level (6,13). It has been propagated as a health-beneficial component of dietary behavior, and complements the concept of exploratory dietary patterns. In LMICs, dietary diversification has been examined, primarily concerning malnutritionrelated health outcomes (14).
The overall nutritional quality of the diet is improved with diverse diet. Therefore, diversity in the diet is important to meet the requirements for energy and other essential micronutrients especially for those who are in the risk of nutrition deficiencies (15). Dietary diversity is a predictors of the observed under-nutrition (16).
Despite considerable efforts to decrease its prevalence, the health and nutritional status of adolescents has seen limited improvement over the past 50 years (8,17).
It is estimated that micronutrient deficiency is a global public health problem affecting two billion people worldwide (10,18), of which 500 million are women in their reproductive age (19). Although diet related health problem affects both sexes and all age groups, it is a major public health problem among women (20) especially among adolescent girls (21). It can result in diminished physical growth, cognitive and motor development, poor performance in school and productivity, and affect reproduction (21,22). Considering the burden of sub-optimal dietary intake, promotion of adequate dietary diversity becomes one of the global concerns (6).
In recognition of its health consequences, in 2012, the 65th World Health Assembly endorsed a 50% reduction in the burden of micronutrient deficiency in women of reproductive age by 2025, from 2011 levels. Ethiopia has also been striving to curve the high burden of micronutrient deficiencies through implementing national nutritional programs and strategies. However, the initiatives have been targeting only pregnant women and children aged 6-59 months; under-representing adolescent girls. Additionally, status of dietary diversity is not investigated in this vulnerable age segments of the population. size of the adolescent girls for each "Mender". Afterwards; required numbers of clusters (Mender) were assigned to kebeles by ENA software using probability proportional to population size (PPS) method. In this method, larger settlements have a higher chance of being selected as clusters compared to smaller settlements because the probability of selection is proportional to population size of the settlement. Once again using computer generated random number specific clusters corresponding to each kebeles were assigned. Finally, all households (HHs) from identified clusters with adolescent girls were selected for data collection.

Data collection tools and procedures
Questionnaire was adapted from the Ethiopian Demographic and Health Survey 2016 (EDHS,2016) and WHO/FAO guideline (24). Structured Amharic version questionnaire was administered to assess socio-economic and demographic factors. Household food security status was determined using the household food insecurity access scale (HFIAS) developed by Food and Nutrition Technical Assistance (FANTA) (25).
We have used 24-H dietary recall in the preceding day to assess dietary diversity score among adolescents. Groups of foods were prepared from FANTA/FAO and further categorized into ten food groups. Dietary diversity score was created as a summary measure using consumption of 5 or more food groups as adequate (6) otherwise it is inadequate so that to apply logistic regression model.

Data quality management
To assure the quality of data, data collectors supervisors were trained for two days on the clarity of tools and overall data collection procedures. Structured questionnaire was prepared in English, then translated to Amharic and back translated to English by bilingual experts in order to check consistency. Pre-test was done on 5% of sample size and this was not included in actual data. Cronbach's alpha was computed to assess the internal consistency; hence possible modification to the tool was considered based on pre-test result. Data collection was carried out by trained diploma nurses under supervision. All collected data were returned to PIs and checked and cleaned for consistency and completeness; discussion was made on daily bases. When food insecurity exists at HH level, shifting to less expensive and poor qulity food (73.5%), reducing on non-food expenditures (53%), reducing the amount of consumed meal (41%) and cutting the number of meals (40%) were among the major coping stratagies used by the household. Almost all of the participants (97.5%) consumed grains, white roots and tubers, and plantains followed by pulses (87.6%) and dark green leafy vegetables (77.2%). The least consumed diets were nuts (22%) and meat, poultry and fish (22.4%) ( Table 2). In bivariate analysis ten potential covariates were identified for multivariable logistic regression model; age of adolescent girls, living with both parents, educational status of mother, educational status of father, maternal occupation, paternal occupation, adolescents listening to radio, adolescents watching television, HHs wealth index and HHs food security status identified at a p-value <0.25.

Predictors of dietary diversity status
Potential covariates identified in bivariate analyses were entered into multivariable logistic regression model using backward removal method to adjust for potential confounders in predicting the outcome.

Discussion
The Sustainable Development Goals (SDGs) call for efforts to eliminate world hunger and malnutrition in its all forms by 2030, and ensure the access of all people to nutritious and abundant food. But there is a problem of access to it making close to 800 million chronically hungry despite sufficient food production in the world (27,28).
In spite of global initiatives and sufficient food production, our study reported that around 42% of HHs were food insecure. This is in line with reported 37.2-44.4% HHs food insecurity in the country (29,30); however the status of food insecurity is much higher than reported 14% (3), and lower when compared to 75% of Birhane et al (31) and 80.5% of Kenya (32). These inconsistencies could be explained by the socioeconomic and methodological differences. In the context of food insecurity, we found that HHs use different coping strategies to deal with difficulties. This is supported by findings from qualitative and quantitative studies (28,(31)(32)(33).
Our study witnessed that substantially less than two third of adolescent girls consumed diversified diet. This intake is lower than reports from some parts of the country which documented 63.3-75.5% of adolescent had adequate dietary diversity (6,29,34), but it is higher than studies in Gurage Zone (23). The possible explanation for this variation could be due to use of different cut-off to declare consumption of diversified diet in the population.
After controlling the confounding effects of others, occupational status of adolescent's father, adolescent's exposure to televised information, and household food security status predicted dietary diversity status among adolescent girls. This study identified that adolescent girls whose father are merchant and of other occupation are less likely to consume diversified diet in comparison to their counterparts from employed father. This could be explained by the fact that lack of time to stay at home due to busy working schedules (35); as a result, minimal care is expected. In other way, men can contribute towards improving household nutrition security by reducing consumption of food away from the home (36).
Moreover, male involvement in affaires of family care including nutrition is found to be determinant (37).
In this study it was found that adolescent girls who watch television at least once a week are more likely to consume diversified diet. This may be best explained as television media have more favorable associations with recommended levels of lifestyle behaviors (38). Adherence to a healthy dietary recommendation is increased with greater exposure to the information delivered by different mass media (39). As a result, individuals with access to health promoting information are supposed to have better nutritional knowledge that could be translated to practice.
The current study identified that HHs food security status determines dietary diversity of adolescent girls in the study setup. This is in line with other studies which reported that likelihood of having adequate dietary diversity were higher among adolescents from food secured HHs; food insecurity predisposes people to relay on an undiversified diet (13,40), ranges of coping strategies as evident in this study.
In contrary to the hypothesis, surprisingly parental education (23)

Declarations
Ethics approval and consent to participate The study was approved by ethical Review Board of Hossana college of health science. All the study participants were informed about the purpose of the study and oral consent was obtained before interview. For age less than 18 years, ascent was prepared. Respondents were informed that they have the right to refuse or terminate the interview and the information provided by each respondent was kept confidential.

Consent for publication
Not applicable for this section.

Availability of data and materials
The datasets used during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests. has no effect on the scientific procedure of this paper.
Authors' contributions BB involved in design, conduct, analysis, interpretation and drafting the manuscript; LP involved in the in design, analysis, interpretation and revise the manuscript. BBF, AE and RD involved in design, analysis and interpretation. ML revised and edited the manuscript for the final submission. All authors read and approved the final manuscript.    Figure 1 Household coping strategies in response to food insecurity in Hossana Town, 2019.