Dietary Diversity among School Children: A Cross-Sectional Study of Conflict-Affecting Communities in Southern Ethiopia

doi:10.21203/rs.3.rs-4699375/v1

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Research Article

Dietary Diversity among School Children: A Cross-Sectional Study of Conflict-Affecting Communities in Southern Ethiopia

https://doi.org/10.21203/rs.3.rs-4699375/v1

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Background: More than 815 million estimated people in the worldwide suffer from poverty or family problems with unable to access enough food and related factor like malnutrition. Developing a healthy and balanced dietary pattern is essential for school children because their habits in this period may last for a long time. The ability of communities to address the basic cause of chronic malnutrition is reduced when conflict stops farming and destroys livelihoods

Objective: The aim of this study was to assess the levels of dietary diversity practices and associated factors among school children in conflict affecting communities in southern Ethiopia.

Method and materials: A community-based cross-sectional study was conducted among 616 schoolchildren aged 6 to 12 years with their caregivers using a multistage sampling method. The data were collected by using a structured questionnaire containing ten food gloves for minimum dietary diversity for women and other parts. The data were collected and entered into Epi-data version 4.6.0.2 and exported to STATA software version 14 for analysis. Adequate dietary diversity was defined as the consumption of at least five food groups. Both bivariate and multivariate logistic regression analyses were performed. A p value less than 0.05 on multivariate logistic regression indicated a statistically significant association.

Results: The overall response rate of this study was 98.5%. The mean dietary diversity score of the studies was 1.41±0.02, and the prevalence of inadequate dietary diversity among the school children in this study was 59.4% (95% CI, 55.17-62.9937). In this study, schoolchildren with no near-health care facility (AOR = 1.95, 95% CI; 1.35-2.82), a family size greater than five (AOR= 1.44, 95% CI; 1.01-2.050), and the absence of a family home garden (AOR= 1.55, CI: 0.35-1.83) were significantly associated with low dietary diversity in preschool children.

Conclusion: The dietary diversity of school children in the study area was below average. A lack of proximity to a health care facility, a family size greater than five, and an absence of a family home garden were determinants of inadequate dietary diversity.

Dietary diversity practice

factor associated

schoolchildren

conflict affecting community

More than 815 million people worldwide suffer from poverty or family problems because they are unable to access enough food and related factors, such as malnutrition (1). However, malnutrition, including protein energy malnutrition and micronutrient deficiencies, is more common than the recommended daily energy intake (2). It is the leading risk factor for illness and death in children and affects more than 100 million young children globally (3).

School age is a censorious period in which the dietary patterns of children are applicable. It is an age category in which indicators of diversified diet intake are momentous (1). The development of a healthy and balanced diet is essential for school children because their habits may persist for a long time (4). They are the most vulnerable to poor nutrition for many reasons, including low dietary intake, food insecurity within the household, infectious diseases, and health care (5). A less-recommended diet decreases the health and physical growth of school children and negatively affects their cognitive and social skills and academic performance (6–8). Epidemiologically, micronutrient deficiencies are rare among school-age children and have a highly desolating effect. A study reported that approximately 79.5% of children had more than one micronutrient deficiency, while approximately 40% had one micronutrient deficiency, including zinc, vitamin A, and others (2). Additionally, a national study indicated that 44% of school children have anemia and vitamin A deficiency (9).

Despite being the African continent’s oldest sovereign state, Ethiopia has grown accustomed to conflict (10). People become uneasy when there are changes in leadership because of the political upheaval and instability that usually follow. The suggestion that Ethiopia’s history has been marked by war and conflict would not be overdone (11). In recent years, there have been violent confrontations that have forced people from their homes due to resurgent hostilities between nonstate armed groups and regional security forces over resource competition and land disputes in most regions, including southern Ethiopia (12). The ability of households and communities to address the fundamental cause of chronic malnutrition is reduced when conflict stops farming and destroys livelihoods (13, 14). Food assistance to populations at risk of malnutrition may be impeded by intermittent conflict (14, 15).

Studies have revealed that malnutrition is a leading problem that adversely affects a large number of school-age children. The mean estimated prevalence of stunting and thinness was 27.11% and 37%, respectively (16–18). Both higher and inadequate dietary diversity (DD) are significantly related to different nutritional indicators, such as age and weight (9, 19). DD is regarded as a basic and appropriate indicator to guarantee that children have access to locally grown foods that will safely meet their energy and nutritional needs (20, 21). A higher intake of a diversified diet indicates a lower risk of developing micronutrient deficiencies (2). The Food and Agriculture Organization (FAO) developed a validated seven DD score for younger children that can be scored out of seven. However, the dietary habits of older children, especially those of school-aged children, are scaled based on the DD score of ten food groups because these age groups/older children/are different and completely depend on dietary sources of energy other than breast milk (9).

Studies have shown that there is limited dietary intake of a variety of food groups, especially animal source foods (22, 23). In different parts of the country, malnutrition is common among school-aged individuals and remains a major public health problem for school-aged children (16–18). The World Health Organization (WHO) has reported that one in every two preschool-aged children suffers from covered hunger (24). Although some studies have assessed the dietary diversity of schoolchildren in different countries, including Ethiopia (19, 25, 26), they have focused on the general dietary diversity of schoolchildren in communities, but none have specifically explored the dietary diversity level of schoolchildren in conflict-affected communities. Therefore, this study assessed the dietary adequacy level and factors associated with dietary diversity among school children in conflicts affecting communities in southern Ethiopia.

Study area, period, and design

A community-based cross-sectional study was conducted from 16th June to 23rd July 2023 in Konso zones, southern region of Ethiopia. The Konso Zone is one of the 12 zones in the southern region of Ethiopia. The Konso Zone is divided into five districts (K. zuriya, Kena, Koleme, Karat city administration and Segen Zuriya) with an estimated total population of 359,998 and a total of 43 Kebeles. It is situated 595 km away from the capital city of Ethiopia, Addis Ababa. Konso shares a boreder with the northwest Alle zone’s Burji zone in the east, the northeastern Amaro zone’s Gardula zone in the north, the ARI zone in the southwest, and the Borena zone of Oromia in the south (27). Mixed farming, or the production of both crops and animals, is the primary source of household income in many districts. The main cabbage tree in the area is Moringa stenopetala, also known as Shelaqta’an in Konso. Fresh green leaves are used in everyday meals as a vegetable that is cooked and consumed, and they can also be sold for cash in the neighborhood market. This area in Ethiopia is impacted by intercommunal conflict (28).

Population, Sample Size Calculation, and Sampling procedure

All school-age children paired with their parents or caregivers in conflicts affecting the community of southern Ethiopia were the source population, and all school-age children were systematically selected from randomly sampled households with their parents or caregivers in the selected Keble. Only households with at least one school-age child aged between 6 and 12 years of age with their parent/caregiver’s pair were included in this study. Study participants who were sick during the previous week and who had a special ceremony on the day before data collection and who were children who were new to that area were excluded from the study.

The sample size was calculated based on the single population formula by Epi-data version 4.6.0.2 considering the following assumptions: P (proportion of dietary diversity practice among school-age children) = 58.3% of the studies conducted with school children in the Gurage Zone, Ethiopia (25); margin of error (d) = 5%; confidence level = 95%; n= (Za/2)²p (1-p)/d²; n = sample size = 373; and a multiplier design effect of 1.5 = 560. After considering a 10% nonresponse rate, the final sample size was 616.

Analogously, related studies (29, 30) have employed this methodology. Using a multistage simple random sampling technique, districts and kebeles within the study area were chosen. Four of the five districts—three rural districts and one district with an intentionally chosen karate city administration—were included in the study. Twelve kebeles (three in each) were chosen from these districts using a basic random sampling number. Next, in the chosen kebeles, every household was registered as a sampling frame. Ultimately, the sample size was distributed proportionally among the designated kebeles in the respective districts, and the respondents were selected through a computer-generated basic random sampling procedure.

Study variables

The dietary diversity score (DDS) was used as the outcome variable in this study. The independent variables were sociodemographic characteristics (age, maternal status, maternal and paternal education status, maternal and paternal occupational status, child sex, birth order, resident, family size, household head, household hanger scale), environmental characteristics (water source, type of water treatment, availability of latrine, hand washing practice), comorbidity of children (chronic disease conditions, acute illness for the last two weeks), and access-related characteristics (animal in household of their family, own farm land, media, home garden, access to fruit/vegetables, presence of a near market, and access to healthcare services). In this study, the household hanger scale was categorized into three levels based on the FANTA recommendation (21, 31).

Operational definition

The dietary diversity score was defined as the total count of different food groups irrespective of the amount consumed by children in the 24-hour period preceding the survey. A tool adopted from the Food and Nutrition Technical Assistance (FANTA) with a ten-food group minimum diet for women (MDD-W) with the previous 24-hour dietary recall was used to assess the variety of food consumed (21, 31).

School age

children aged 6 to 12 years were included (25).

Data collection tools

The data were collected via face-to-face interviews using pretested questionnaires adapted from related literature (4, 6, 19, 22, 23, 25, 26, 30). It is collected from children and caregivers by allowing them to freely recall the type of food items they feed to their child or children within the last 24 hours. The data were collected from the child and their caregiver on a day where the days of the interview and the previous consecutive days were not holidays, special days such as the marriage ceremony birth date or others. When there are unusual holidays or others ascertained from the respondent, that respondent was not included in the survey, as it can overestimate dietary diversity. The questionnaire was prepared in English, translated to the local language and checked for consistency by translating it back to English by those who were well-oriented with the stated languages.

Adequate dietary diversity was defined as the consumption of at least five food groups in 24 of the ten contextualized food groups (31). The data collected from the primary caregivers and the gathered data were recorded. The response option of “yes” was scored as one point if at least one food item in each food group was consumed by the child, whereas food groups were not consumed at all, with a response option of “no”, and zero (0) points were given.

Data quality control

The data collectors were trained before the data collection for two days on how to ask questions and code answers. Close supervision was provided by the investigators and the assigned supervisors. Any quest related to clarity, ambiguity, incompleteness, or misunderstanding was resolved on the day following the next day. Pretests were performed on 5% of the sample, and necessary amendments were made accordingly. All finalized data collection forms were checked for completeness and clarity before and during data management, storage and analysis. The data were collected from the child and their caregiver on days where the days of the interview and the previous consecutive days were not holidays, special days such as the marriage ceremony birth date or others. When there are unusual holidays or others ascertained from the respondent, that respondent was not included in the survey, as it can overestimate dietary diversity.

Data processing and analysis

The data were entered into Epi-data version 4.6.0.2 and exported to STATA software version 14 for analysis. Binary logistic regression was performed to examine the association of each independent variable with the outcome variable. Variables with p values < 0.25 in the bivariate analysis were selected and included in the final multivariate logistic regression analysis. Variables with a p value < 0.05 in the multivariate analysis were considered to be significantly associated with the independent variable. Model fitness was assessed using Hosmer and Lemeshow’s test, with a P value greater than 0.05 indicating a fitted regression model.

Ethical reviews

The institutional review board of the College of Health Science and Medicine, Wolaita Sodo University approved the ethical statement. The study was conducted following the relevant guidelines, regulation, and principles of the Helsinki Declaration. Furthermore, official permission letter was obtained from the Konso Zone Health Department and the respective woreda health offices. Also Verbal and written informed consent was obtained from the respondents after they explained the purpose and objective of the study. The confidentiality of the participants in the study was considered.

Patients and public involvement

Patients and the public were not involved in the design of the study, the conduct of the study or the dissemination of the findings.

Sociodemographic characteristics of the respondents

The overall response rate of this study was 98.5%. Almost all households (91.1%) were led by fathers, and nearly half (45.9%) of the heads of household were aged 20–29 years. A significant percentage of mothers (72.3%) were housewives, and approximately 58.3% had no formal education. Additionally, a significant number (62.4%) of fathers were farmers, and approximately 255 (42.0%) of fathers had completed primary school. More than half of the school children (325, 53.5%) were male. Although the mean (standard deviation) age of the school children was 9.1 ± 0.34, nearly two-thirds of the 370 (60.1%) school children were aged less than 6–8 years. The birth order of more than one-third of the 246 (40.5%) children was intermediate. The majority of the 530 (87.3%) study participants were living in rural areas (Table 1).

Table 1

Sociodemographic characteristics of respondents in conflict-affecting communities in the southern region of Ethiopia, 2023.
Variables(n = 607)	Category	Dietary diversity practice (%)		p value
Variables(n = 607)	Category	Inadequate	Adequate	p value
Head of household	Fathers	327(59.1)	226(40.9)	0.986
Head of household	Caregivers	32(59.3)	22(40.7)	0.986
Age category of head of household (Year)	15–19	25(67.6)	12(32.4)	0.720
	20–29	16157.7)	118(42.3)
	30–39	133(59.4)	91(40.6)
	40+	40(59.7)	27(40.3)
Occupational status mother	Housewife	277(62.5)	166(37.5)	< 0.001
	Government Employee/NGO	5(17.9)	23(82.1)
	Merchant	61(57.5)	45(42.5)
	Farmer	16(53.3)	14(46.7)
Educational status mother	No formal education	226(63.8)	128(36.2)	< 0.001
	Primary school	103(63.2)	60(36.8)
	Secondary school	28(50.9)	27(49.1)
	College and above	2(5.7)	33(94.3)
Occupation of father	Farmer	240(63.3)	139(36.7)	< 0.001
	Merchants	95(60.5)	62(39.5)
	Government/NGO employee	24(33.8)	47(66.2)
Educational status of father	No formal education	145(62.8)	86(37.2)	< 0.001
	Primary school	165(64.7)	90(35.3)
	Secondary school	38(43.2)	50(56.8)
	College and above	11(33.3)	22(66.7)
Sex of children	Male	200(61.5)	125(38.5)	0.197
Sex of children	Female	159(56.4)	123(43.6)	0.197
Age category of children (year)	6–8	220(59.5)	150(40.5)	0.868
Age category of children (year)	9–12	134(58.8)	94(41.2)	0.868
Birth order of children	First	104(53.9)	89(46.1)	0.154
	Middle	155(63.1)	91(36.9)
	Last	100(59.5)	68(40.5)
Number of school child in household	One	167(56.4)	129(43.6)	0.222
	Two	154(63.4)	89(36.6)
	Three	38(55.9)	30(44.1)
Residence	Rural	332(62.6)	198(37.4)	< 0.001*
Residence	Urban	27(33.4)	54(66.6)	< 0.001*
Number of family size	≤ 5	194(66.4)	98(33.6)	< 0.001*
Number of family size	> 5	165(52.4)	150(47.6)	< 0.001*

Environmental characteristics of the respondents

Approximately 241 (39.7%) of the school children used communal water. The majority (505, 83.1%) had access to water near their residence area, and more than one-third (33.9%) of the respondents did not use any type of water treatment. Greater than two-thirds (77.3%) of the respondents had a toilet. Overall, 454 (74.8%) practiced hand washing either before or after eating or before or after food processing (Table 2).

Table 2

Environmental characteristics of respondents in conflict affecting communities in the southern region of Ethiopia, 2023.
Variables(n = 607)	Category	Dietary diversity practice (%)		p value
Variables(n = 607)	Category	inadequate	Adequate	p value
Water source	Protected water	46(54.8)	38(45.2)	0.763
	River water	40(63.3)	23(36.5)
	Unprotected water	25(55.6)	20(44.4)
	Pond	30(58.8)	21(41.2)
	Communal	149(61.8)	92(38.2)
	Pipe	69(67.6)	23(32.3)
Distance of water	Near	293(58.1)	212(41.9)	0.210
Distance of water	Far	66(64.7)	36(35.3)	0.210
Treatment of water	Agar	115(58.7)	81(41.3)	0.973
	Boling	48(58.5)	34(41.5)
	Never	196(59.6)	133(40.4)
Latrine availability	Yes	271(57.8)	198(42.2)	0.209
Latrine availability	No	88(63.8)	50(36.2)	0.209
Hand washing practice	Yes	262(57.7)	192(42.3)	0.216
Hand washing practice	No	97(63.4)	56(36.6)	0.216
Hand washing before meal	Yes	275(60.2)	182(39.8)	0.367
Hand washing before meal	No	84(56.0)	66(44.0)	0.367
Hand washing after meal	Yes	277(60.6)	180(39.4)	0.199
Hand washing after meal	No	82(54.6)	68(45.4)	0.199
Hand washing after toilet	Yes	276(60.4)	181(39.6)	0.274
Hand washing after toilet	No	83(55.3)	67(44.7)	0.274
Hand washing before food processing	Yes	272(59.4)	186(40.6)	0.829
Hand washing before food processing	No	87(58.4)	62(41.6)	0.829
Hand washing before food processing	Yes	273(60.0)	182(40.0)	0.458
Hand washing before food processing	No	86(56.6)	66(43.4)	0.458

Comorbid conditions of the school children

Of the total respondents, 96 (23.6%) had chronic diseases. Overall, 78 (18.8%) of the school-aged children had fever 2 weeks before the data collection. Of these, 25 (32.1%) had related diarrheal disease, and 24 (30.7%) had upper respiratory tract infections (Table 3).

Table 3

Comorbidity conditions of schoolchildren in conflict affecting communities in the South Region, Ethiopia, in 2023.
Variables	Category	Dietary diversity practice (%)		p value
Variables	Category	Inadequate	Adequate	p value
Chronic disease	Yes	56(58.3)	40(41.7)	0.860
Chronic disease	No	303(59.3)	208(40.7)	0.860
Acute illness last two weeks	Yes	56(69.1)	25(30.9)	0049
Acute illness last two weeks	No	303(57.6)	223(42.4)	0049
Types of illness	Diarrheal	19(82.6)	4(17.4)	0.434
	Acute upper tract infection	16(66.7)	8(33.3)
	Acute febrile diseases	16(59.3)	11(40.7)
	Other specify	4(66.7)	2(33.2)

Access-related characteristics of the respondents

The majority, 527 (86.8%), had animals in the household of their family, and a significant number of households, 424 (69.8%), had their own farmland. The majority, 524 (86.3%), of their households had access to any type of media. Greater than one-third of the participants (469, 77.3%) had home gardens, and nearly two-thirds (386, 63.6%) had access to fruits/vegetables. Approximately 357 (58.8%) of the respondents were near the market, and nearly half (323, 53.2%) had access to healthcare services; nearly half (144, 44.6%) of the respondents had access to health care facilities for < 30 minutes (Table 4).

Table 4

Access-related characteristics of school-aged children in conflict-affecting communities in the South Region, Ethiopia, in 2023
Variables(n = 607)	Category	Dietary diversity practice (%)		p- value
Variables(n = 607)	Category	inadequate	Adequate	p- value
Presence of animal in household	Yes	331(62.8)	196(33.2)	< 0.001*
Presence of animal in household	No	28(35.0)	52(65.0)	< 0.001*
List of animals	Chicken only	22(55.0)	18(45.0)	0.010
	Chicken, and sheep/goat	36(59.1)	25(40.9)
	Cow, and sheep/goat	66(73.3)	22(26.7)
	Chicken, and cow	54(73.9)	19(26.1)
	chicken, cow, and sheep/goat	102(55.4)	82(44.6)
	Chicken, cow, sheep/goat	51(62.9)	30(37.1)
Presence of farm land	Yes	267(63.0)	157(37.0)	0.003
Presence of farm land	No	92(50.3)	91(49.7)	0.003
Harvest list	Sorghum only	7(46.7)	8(53.4)	0.821
	Sorghum and bean	17(54.8)	14(45.2)
	Sorghum, barely	23(60.5)	15(39.5)
	Sorghum potatoes	26(63.4)	15(36.6)
	Sorghum, bean and barley	85(65.9)	44(34.1)
	Sorghum, bean, and potatoes	48(59.3)	33(40.7)
	Sorghum, barley ,and potatoes	23(63.9)	13(36.1)
	Sorghum, bean, barley, and potatoes	98(64.1)	55(35.9)
Presence of any media	Yes	305(58.2)	219(41.8)	0.238
Presence of any media	No	54(65.1)	29(34.9)	0.238
List of media exist	Radio only	203(57.2)	132(42.8)	0.003
	Radio, and Phone	66(66.0)	34(34.0)
	TV, and Radio	25(30.1)	58(69.9)
	TV, and phone	9(25.0)	27(75.0)
	Radio, TV, and phone	2(50.0)	2(50.0)
Presence of Home garden	Yes	297(63.3)	172(36.7)	< 0.001*
Presence of Home garden	No	62(31.0)	138(69.0)	< 0.001*
List of Home garden product	Moringa only	56(71.8)	22(28.2)	0.094
	Cabbage only	58(55.2)	47(44.8)
	Moringa and cabbage	64(71.2)	26(28.8)
	Cabbage, and hurt	21(58.3)	15(41.7)
	Moringa, and hurt	35(60.3)	53(39.7)
	Moringa, hurt, and cabbage	63(58.3)	45(41.7)
Access to fruit and vegetables	Yes	246(63.7)	140(36.3)	0.002
Access to fruit and vegetables	No	113(51.1)	108(48.9)	0.002
Presence of near market	Yes	231(64.7)	126(5.3)	0.001
Presence of near market	No	128(51.2)	122(48.8)	0.001
Length of market (kilometer)	< 1	54(50.9)	52(49.1)	0.538
	1–2	50(47.6)	55(52.4)
	> 2	21(58.3)	15(41.7)
Presence of near health care	Yes	222(68.7)	101(31.3)	< 0.001
Presence of near health care	No	137(48.2)	147(51.8)	< 0.001
Time to reach health care from home	< 30 minutes	64(44.5)	80(55.5)	0.341
	30 minutes-1 hours	57(50.0)	57(50.0)
	> 1 hours	16(47.1)	18(52.9)
TV: Television

Household Food Security

Approximately 259 (42.3%) were secured with food access scales. In the past 4 weeks, 46.7% were worried about household food shortages, 48.6% could not eat the kinds of foods they preferred, 40.3% ate a limited variety of foods, 39.2% ate some foods that truly did not want to eat, 37.5% ate a smaller meal than you felt, 46.8% ate a fewer meal a day, 36.2% went to sleep at night hungry and 33.1% went a whole day and night eating nothing (Table 4).

Table 4

Household food insecurity of respondents in conflict affecting communities in the South Region, Ethiopia, 2023.
Variables(n = 607)	Category	Dietary diversity practice (%)		p value
Variables(n = 607)	Category	inadequate	Adequate	p value
worry that your household would not have enough (last 4 weeks)	Yes	166(58.9)	116(41.1)	< 0.877
	No	193(59.4)	132(40.6)	< 0.877
Not able to eat the kinds of foods they preferred (past 4 week)	Yes	175(59.3)	120(40.7)	0.931
	No	184(58.9)	128(41.1)	0.931
did you or any household member have to eat a limited varieties (past 4 week)	Yes	142(57.7)	104(42.3)	0.973
	No	217(60.1)	144(39.9)	0.973
household member have to eat some foods truly did not want to eat (past 4 week)	Yes	136(57.1)	102942.9)	0.421
	No	223(60.4)	146(39.6)	0.421
household member have to eat a smaller meal than you felt (past 4 week)	Yes	171(60.2)	113(39.8)	0.616
	No	188(58.2)	135(41.8)	0.616
household member have to eat a fewer meal a day (past 4 week)	Yes	133(60.2)	84(39.8)	0.216
	No	226(57.9)	164(42.1)	0.216
No food to eat of any kind in your household night(past 4 week)	Yes	227(58.6)	160(41.4)	0.746
	No	132(60.0)	88(40.0)	0.746
No food to eat of any kind in your household day-night(past 4 week)	Yes	120(59.7)	81(40.3)	0.274
	No	239(58.8)	167(41.2)	0.274
Overall household food insecurity	Yes	154(59.5)	105(40.5)	0.891
Overall household food insecurity	No	205(60.5)	134(39.5)	0.891

Dietary Diversity Practice

The mean dietary diversity score of the participants was 1.41 ± 0.02. The proportion of study participants with adequate dietary diversity in this study was 40.6% (95% CI, 37.0-44.8). Flesh food (9.9%) was the food group least consumed by the preschoolers, and cereals, roots and tubers (90.1%) were the most consumed food group by the school children (Figs. 1 and 2).

Factors affecting school children’s dietary diversity practices

All the independent variables were analyzed via logistic regression with the dependent variable of school children’s dietary diversity practices to analyze their associations. Nine variables were significantly associated with school dietary diversity according to binary logistic regression (p ≤ 0.2) and were entered into the multiple logistic regression analysis. There was a significant association between the following variables: educational level of the father, residence, number of family members, birth order, ease of access to health care, fruit/vegetable access, presence of a home garden, presence of an animal, and presence of a market resident area.

In this study, schoolchildren who were not at a health care facility were 1.95 times more likely to have low dietary diversity than were their counterparts (AOR = 1.95, 95% CI; 1.35–2.82). Schoolchildren with family sizes greater than five were 1.44 times more likely to have low dietary diversity than their counterparts were (AOR = 1.44, 95% CI; 1.01–2.05). School children with no family home garden were 1.55 times more likely to have inadequate dietary diversity (AOR = 1.55, CI: (1.35–2.03)), which was significantly associated with inadequate dietary diversity in the study area (p value < 0.05) (Table 5).

Table 5

Bivariable and multivariable analysis of factors associated with school children in conflict affecting communities in the southern region of Ethiopia in 2023.
Variables	Category	Dietary diversity practice (%)		COR (95% CI)	AOR (95% CI)	p value
Variables	Category	Inadequate	Adequate	COR (95% CI)	AOR (95% CI)	p value
Educational level of father	No formal education Primary school Secondary school College and above	145(62.8)	86(37.2)	1(reference)	1(reference
		165(64.7)	90(35.3)	0.92(0.63–1.33)	0.78(0.53–1.15)	0.128
		38(43.2)	50(56.8)	2.21(1.34–3.65)	1.59(0.92–2.76)	0.100
		11(33.3)	22(66.7)	3.37(1.55–7.29)	1.07(0.39–2.94)	0.881
Residence	Rural Urban	332(13.6)	198(86.4)	0.29(0.17–0.47)	0.77(0.32–1.87)	0.573
Residence	Rural Urban	27(24.2)	54(75.8)	1(reference)	1(reference)
Number of family size	≤ 5 > 5	194(66.4)	98(33.6)	1 (reference)	1 (reference)
Number of family size	≤ 5 > 5	165(52.4)	150(47.6)	1.79(1.29–2.49)	1.44(1.01–2.05)	0.042*
Birth order of children	First Middle Last	104(53.9)	89(46.1)	1 (reference)	1(reference)
		155(63.1)	91(36.9)	0.68 (0.46–1.01)	0.71(0.47–1.08)	0.054
		100(59.5)	68(40.5)	0.79(0.52–1.21)	4.38(0.51–1.23)	0.281
Access to Fruit/vegetable	Yes No	246(63.7)	140(36.3)	0.59(0.42–0.83)	0.96(0.65–1.43)	0.875
Access to Fruit/vegetable	Yes No	113(51.1)	108(48.9)	1(reference)	1(reference)
Presence of home garden	Yes No	297(11.2)	172(88.8)	1(reference)	1(reference)
Presence of home garden	Yes No	62(18.2)	138(81.8)	2.11(1.44–3.11)	1.55(1.35–2.03)	0.043*
Presence of animal	Yes No	331(62.8)	196(33.2)	0.31(0.19–0.52)	0.80(0.35–1.83)	0.602
Presence of animal	Yes No	28(35.0)	52(65.0)	1(reference)	1(reference)
Presence of near market	Yes No	231(64.7)	126(5.3)	0.57(0.411–0.79)	0.90(0.61–1.33)	0.611
Presence of near market	Yes No	128(51.2)	122(48.8)	1(reference)	1(reference)
Presence of near health care	Yes No	222(68.7)	101(31.3)	1(reference)	1(reference)
Presence of near health care	Yes No	137(48.2)	147(51.8)	2.35(1.69–3.28)	1.95(1.35–2.82)	< 0.001

This community-based study assessed dietary diversity and its predictors among school-age children in the southern region of Ethiopia. The mean dietary diversity score of the study participants was 1.41 ± 0.02, and the prevalence of inadequate dietary diversity among the schoolchildren in this study was 59.4% (95% CI, 55.17–62.99). This percentage was lower than that reported in a previous study (32), which was 19.2%, and a study conducted in India showed that the mean diversity of food scores calculated using 24-hour diet recall data (FS24 hr) was 7 (33). The results of our study align with those of a study conducted in the Gurage Zone, southern Ethiopia (58.3%) (25). However, the results of this study were better than those of studies conducted in the EDHS (10.8%) (34), Merawi town, Amhara region, Ethiopia (8%) (35), Sinan districts (13%) (36), the Gonder Zone (16.2%) (37), the Mirab Abaya district in the southern region of Ethiopia (34.3%) (38) and the Wolayita Sodo region (43.2%) (39). Possible explanations for these variations could be the sociocultural, economic, and geographical differences between the study area and the referenced places. In addition, because a significant number of participants in the study area had animals in the household of their family, their own farmland and access to fruit/vegetables may have affected their dietary practices compared with those in other studies.

The study revealed that children from extended families were 1.44 times more likely to have a low DD level (AOR = 1.44, 95% CI; 1.01–2.05). A study carried out in the Gurage Zone in southern Ethiopia provided evidence in favor of this conclusion (25). The equitable distribution of food among household members according to their physiological needs is essential, as one strategy for mitigating global malnutrition is making food more accessible at home. Our research revealed that a sizable average family size exists because a significant proportion of households had two or more school-age children. Given that the total fertility rate in the country is approximately 4.6 (40), ensuring equitable food distribution within households is crucial for addressing marginalized and nutritionally vulnerable populations.

According to this study, there was a 1.95-fold increase in the probability of being close to a health care facility (AOR = 1.95, 95% CI; 1.35–2.82) for every schoolchildren with diverse diets. Our study revealed that access to health care services in Southwest Nigeria was a significant determinant of children’s dietary diversity, either positively or negatively, according to the study (41–43). This study also supports research from Nepal, which revealed that declining dietary diversity was significantly and negatively correlated with household spending and community infrastructure (hospital presence) (lowest versus highest household expenditure quintile, less developed (without hospital) versus more developed communities (23). It is evident that people’s intention to feed varied food to their children arises when the awareness and directive of an attitude allows the person to practice those particular health behaviors. Thus, enhancing the educational level of caregivers, particularly people responsible for primary care of the child coupled with conducive environments such as physical and economical access to food, is important (44). This may be because there are no access health settings and thus limited food options.

School children with no family home garden were 1.55 times more likely to have a diversified diet (AOR = 1.55, CI: (1.35–2.03)), which was significantly associated with a p value < 0.05 in the study area. This finding is consistent with an analogous study conducted in the South Gondar Zone, Northwest Ethiopia (30). A study carried out in Nepal also revealed that access to home gardens was positively correlated with high dietary diversity and negatively correlated with low dietary diversity and that home gardens have high levels of species diversity. Furthermore, research findings suggest that rural households with home gardens have a greater probability of transitioning from a medium dietary diversity status (45). There ought to be a wide range of food available in home gardens. A varied family diet is the result of the diversity of plants in the garden (46). Growing fruits, vegetables, and other crops at home allows you to have access to a wide range of food that might not be found in store. In both rural and urban locations, home gardens make it simple to obtain fresh vegetables and animal products (47). This could be because home gardeners have the ability to gather excess food from their farms to substitute for foods that are in short supply or nonexistent at home.

The dietary diversity of the school children in the study area was below average. A lack of proximity to a health care facility, a family size greater than five, and an absence of a family home garden were determinants of inadequate dietary diversity. A health extension platform should be used to raise awareness of the issue of inadequate dietary diversity in the area, and backyard vegetation should be improved. In addition to nutritional counseling for caregivers and the household as a whole, enhanced behavioral change programs should be implemented through community health agents, agricultural extension workers, and volunteers. This will help to improve and promote agricultural activities (farming variety of products) for the primary purpose of household consumption. To better understand the nutritional concerns facing schools and to develop or modify relevant polies and interventions that effectively encourage healthy diets in the study areas, more nationwide research is needed.

Data availability statement

The data will be available upon request from the corresponding author.

Conflict of interest statement

The authors declare no conflicts of interest.

Funding

The authors declare(s) that no financial support was received for the research, authorship, and/or publication of this article.

Author contributions

TY: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review and editing; BY: Conceptualization, Writing—original draft, Writing—review and editing; EJ: Software, Writing—original draft, Writing—review and editing; TU: Visualization, Writing—original draft, Writing—review and editing; EI: Writing—original draft, Writing—review and editing; AA: Supervision, Validation, Visualization, Writing—original draft, Writing—review and editing.

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Dietary Diversity among School Children: A Cross-Sectional Study of Conflict-Affecting Communities in Southern Ethiopia

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Background

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Study area, period, and design

Population, Sample Size Calculation, and Sampling procedure

Study variables

Operational definition

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Data quality control

Data processing and analysis

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Results

Sociodemographic characteristics of the respondents

Environmental characteristics of the respondents

Comorbid conditions of the school children

Access-related characteristics of the respondents

Household Food Security

Dietary Diversity Practice

Factors affecting school children’s dietary diversity practices

Discussion

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