Meal frequency and associated factors among children 6-23 months in Tahtay michew district, northern Ethiopia, 2018

Background The term meal frequency is used to describe the adequacy of complementary feedings among children. In the absence of adequate meal frequency young children are susceptible to malnutrition like stunting, wasting, micronutrient deciencies and associated morbidity and mortality. More half of Ethiopian children did not receive age appropriate minimum meal frequency. Therefore, the aim of this study is to determine minimum meal frequency and associated factors among children 6–23 months in Tahtay Michew district, Northern Ethiopia. Methods A community based cross sectional study was conducted among systematically selected 981 mothers with index children 6–23 month. An interviewer- administered structured questionnaire was used to collect data. 24 hours dietary recalls was used to determine minimum meal frequency. Crude and Adjusted Odds Ratio with the corresponding 95% condence interval were computed. In the multivariable analysis, variables with less than 0.05 P-value were considered statistically signicant.


Introduction Background
Minimum meal frequency is a proxy indicator of the adequacy of complementary foods among children [1]. The World Health organization (WHO) recommend that children should get the age appropriate minimum meal frequency that is two or more times for breastfed infants 6 to 8.9 months of age, three or more times for breastfed children 9 to 23.9 months, and four times for non-breastfed children 6 to 23.9 months [2].
Inappropriate feeding practices are important risk factors for malnutrition and associated morbidity and mortality among infants and young children, and more than two-thirds of children deaths related to malnutrition are associated with inappropriate feeding practices during the rst 24 months of life [3]. In addition poor nutrition in the early life is associated with irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased offspring birth weight [4].
In many countries in the world less than one fourth of children 6-23 months of age meet the criteria for meal frequency and dietary diversity [5], and case is more sever in Africa especially in sub-Saharan countries [6]. In case of Ethiopia despite many efforts were done to improve minimum meal frequency, a signi cant number of Ethiopian children did not receive age appropriate minimum meal frequency [7][8][9].
Despite the fact that adequate meal frequency in the early life is very important for healthy growth and development of children; little is known about meal frequency and factors associated with it and so far no similar study was done in the study area. Therefore the aim is to determine minimum meal frequency and factors associated with minimum meal frequency.

Methods And Materials
Study design and setting A community based cross sectional study was conducted from January, 22, 2018 to February, 30, 2018.
The study was conducted in Tahaty Michew district found in central zone of Tigray Regional State one of the nine regional states in Ethiopia located at a distance of 1041 km from Addis Ababa (the capital city of Ethiopia). The weather condition of the district is semi highland. Maize, teff and sorghum are the staple cereals in the district and more than 95% of the population is living with farming activities. Tahtay Michew district has 17 kebele (the smallest administration unit in Ethiopia) administrations.

Sample size determination and sampling technique
The sample size was calculated by using the single population proportion formula. Therefore, the total sample size was calculated with assumption of 95% con dence level, 4% margin of error, prevalence of minimum meal frequency 45% [7], design effect of 1.5 and non response rate of 10% of 1.65%. Finally the sample size was 981.
Out of seventeen kebeles found in the district eight kebeles was included in the study using lottery method. The number of study participant was allocated for each Kebele based on proportional to population size allocation methods by using community based demographic and Health related information registration prepared by Health Extension workers as a sampling frame. Rapid census was conducted 07 days before the actual data collection on the kebeles rst to identify the target House hold.
Finally child-mother pairs was selected from each Kebele by using systematic random sampling technique after giving code for each house hold which has child from 6 months to 23 months.
Measurement and data collection procedure Data was collected from mothers who have at least one child in age 6-23 months from each household by direct interviewing. Those who have more than one child in age range of 6 to-23 month one child were selected randomly by lottery method. A pre-tested structured questionnaire adapted from different literatures [6][7][8][9][10][11][12][13][14][15][16][17] was used to collect data. The questionnaire was prepared in English e and translated in to Tigriga the (local language). Later on, it was translated back to English to check its consistency. The Tigrigna version of questionnaire was used to collect the data. Eight data collectors and two supervisors who are speakers of the local language were recruited during the data collection period.
Minimum meal frequency of the child was determined by asking the mother (care taker) how many times the child took solid, semi-solid, or soft foods in the 24 h preceding the survey. Accordingly, two or more times for breastfed infants 6 to 8.9 months of age, three or more times for breastfed children 9 to 23.9 months, and four times for non-breastfed children 6 to 23.9 months were considered as the children received the minimum meal frequency [2]. Wealth index was determined using Principal Component Analysis (PCA) by considering household assets, such as quantity of cereal products, house, livestock and agricultural land ownership [10].
Knowledge on complementary feeding of the mother was determined by asking questions related on complementary feeding and meal frequency. A mother or care taker answers above mean for the knowledge related questions was considered as knowledgeable [10]. Maternal social capital was assessed using six questions related social capital. A mother or care taker answers above mean for the social capital related questions was considered as having good social capital [8].

Data management and analysis
After all returned questionnaire was checked for completeness and consistency, data was data were coded and entered in to EPI INFO version 7 and then, exported to STATA-12 statistical software. During descriptive analysis, continuous variables were summarized using mean and standard deviation while categorical variables were summarized using percentages. The effect of each variable on meal frequency was assessed using bi-variable logistic regression model. Before inclusion of predictors to multivariable logistic regression analysis, ful llment of model assumption was checked using Homers-lemeshow test. Multi co-linearity was checked using Variance In ation Factors (VIF). Those variables with P ≤ 0.1 in bivariable logistic regression model were entered spontaneously in multivariable logistic regression model to measure the effect of each category of each variable on meal frequency. Variables with P < 0.05 in multivariable logistic regression analysis were considered as the factor associated with meal frequency.
Measure of association was calculated using adjusted odds ratio (AOR) with 95% con dence interval.

Results
Socio-demographic and socio-economic characteristics of study participants Out of 954 mothers participated in the study; 949 of the participants gave complete response with the response rate of 96.7%. The mean age [± SD] of the children was 13.7 ± 4.59 months. The mean age [± SD] of the mother was 29.74 ± 6.66 years.

Factors associated with minimum meal frequency
In the bi-variable logistic regression analysis eight variable namely number of wealth index, ANC follow up, place of delivery, growth monitoring follow up, health extension worker home visit, mothers knowledge on child feeding, satisfactory media exposure and mothers social capital in the last 12 months were signi cantly associated with minimum meal frequency at 95% CL and p value ≤ 0.1. In the multivariable logistic regression analysis only three variables namely wealth index, growth monitoring follow up and mothers' knowledge were signi cantly associated with minimum meal frequency at P-value < 0.05 and 95% con dence level.
Speci cally children belonging to rich wealth status families were1.69 time (AOR = 1.69, 95% CI = 1.09, 2.61) more likely to receive the recommended minimum meal frequency, compared to poor wealth status families. Mothers who toke their index child to growth monitoring follow-ups were 1.98 times (AOR = 1.98, 95% CI = 1.41, 2.79) more likely to provide minimum meal frequency compared to their counterparts. Mothers who had good knowledge on childe feeding were 2.15 times (AOR = 2.15, 95% CI = 1.51, 3.04) more likely to provide minimum meal frequency compared to mothers who had poor knowledge on child feeding [ Table 3]. The proportion of children who received meal frequency was in line with ndings from southern Ethiopia [17] and Arsei negele [8]. However, the nding is slightly lower from the ndings from northwestern Ethiopia [10]. The difference could be explained by signi cant proportion of mothers (42.1%) in this study lacks the necessary knowledge about child complementary feeding.
The nding is also higher from ndings from North West Ethiopia [9], from secondary analysis EDHS 2016 [7], western Ethiopia [18] and Nigeria [19].The difference might be due to the fact that the EDHS were nationwide survey on a larger sample. In addition, the EDHS were conducted on culturally different population, which may inhibit child feeding practices while, the current study was conducted on almost culturally homogenous population with similar feeding practices.
Children belonging to rich wealth status family were1.69 times more likely to receive the recommended minimum meal frequency compared to poor wealth status families. supportive ndings were found from study conducted in Dangila town [9], north west Ethiopia [10], Ethiopia [11] ,east Africa region [6] and Haiti [12]. This may due to the fact that rich wealth status families are more likely to be food secure and have the capacity to purchase different consumables goods for their families.
Growth monitoring follow-ups was one of the determinant factors for meal frequency. Mothers who toke their index child to growth monitoring follow-ups were 1.98 times more likely to provide minimum meal frequency compared to their counterparts. Supportive ndings were reported from studies in northwest Ethiopia [10] and Nepal [20]. This could be explained by growth monitoring and promotions are supported by individual counseling and community conversations which are likely to enhance the understanding of mothers about how many they should feed their children.

Conclusion And Recommendation
The proportion of children who received the recommended meal frequency was found low as measured by WHO indicators. Wealth index, growth monitoring follow up and mother's knowledge about child feeding were independent determinants of minimum meal frequency.
Therefore, policy makers (government) should do to improve the wealth status of families. Health professionals and health extension workers needs to support mothers to have the right knowledge on child feeding practice by providing timely and appropriate counseling during PNC and growth monitoring follow ups.
Abbreviations ANC: Antenatal Care Funding Not applicable Contributions EB conceived the idea in mind, involved in proposal development, supervised data collection, and participated in data analysis and interpretation of the data. TG, TH and GA assisted in the design of the study, proposal writing, data analysis, and interpretation of the study. All authors were responsible for data collection, initial analysis and drafting of manuscript. All authors reviewed and approved the nal manuscript.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Minimummealfrequencywithmininumdata.dta