Magnitude and factors associated with Availability of Adequately Iodized Salt at Households of Pregnant Mothers in Wonago district, south Ethiopia


 Background

Salt iodization is the most cost-effective, safe and sustainable strategy to eliminate iodine deficiency disorders. It is especially damaging during pregnancy and in early child hood. Adding iodine to salt provides protection from brain damage due to iodine deficiency for whole populations. However, little was known about the availability of adequately iodized salt in South Ethiopia. The aim of this study was to assess prevalence and factors associated with availability of adequately iodized salt at the households of pregnant mothers in Wonago District, South Ethiopia, 2018.
Methods

Community-based cross-sectional study was conducted from May 14-29, 2018 in Wonago district. Using a stratified two stage random sampling technique, a total of 604 pregnant mothers were included in the study. The level of salt iodine content was determined using the rapid field test kit, considering a value of <15 parts per million (PPM) and ≥15 PPM with the corresponding color chart on the rapid test kit for classification. Multivariable logistic regression model was fitted to identify factors associated with the availability of adequately iodized salt. Adjusted Odds Ratio (AOR) with the corresponding 95% Confidence Interval (CI) was calculated to show the strength of association.
Result

Availability of adequately iodized salt at households of pregnant mothers was 19.9%. House hold head, husband education, average monthly household income and time of salt addition during cooking were independently associated with adequately iodized salt availability. Accordingly, participatory male headed households [AOR=2.1(95%CI 1.08, 3.96)], women with an average monthly household income of ≥ 817 ETB [AOR=7.3(95%CI 3.03, 17.70)] and those who added salt late or after cooking during food preparation [AOR=2.17(1.08, 4.38)] were more likely to utilize adequately iodized salt. Conversely, women whose husband had no formal education were less likely [AOR=0.33(95%CI 0.11, 0.88)] to utilize iodized salt.
Conclusion

Compared to the recommended standard, use of adequately iodized salt among pregnant women is very low. Paternal conditions and household income level are key predictors of use of adequately iodized salt.


Introduction
Iodine de ciency is the world's single greatest cause of preventable mental retardation. It is especially damaging during the early stages of pregnancy and in early child hood. 1 Iodine de ciency disorders (IDD) include stillbirths, abortions, and congenital anomalies; endemic cretinism characterized most commonly by mental de ciency, deaf, mutism, and lessor degrees of neurological defect related to fetal iodine de ciency; impaired mental function in children and adults with goiter associated with subnormal concentrations of circulating thyroxin . 2,8 Even mild de ciency can cause a signi cant loss of learning ability -about 13.5 intelligence quotient (IQ) points at population level. 3 In addition to infringing on the rights of children, iodine de ciency results in a loss of economic productivity. 4 Prevention of the detrimental effects of inadequate intake of-iodine is of immense importance to global development. It could be the most important achievable international health goal of the decade, exceeding even the impact of global eradication of smallpox in the 1970s. 5 The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommended universal salt iodization since 1993 to end IDDs and their complications.
Globally, close to 2 billion populations (35.2% of world population) is at risk of iodine de ciency, while one-third lives in areas where natural sources of iodine are low. At least 350 million Africans are at risk of iodine de ciency and its complication. 6 Universal salt iodization (USI) is recommended as the most cost-effective, safe and sustainable strategy to eliminate iodine de ciency disorders (IDDs). However, only75% of the household's worldwide use iodized salt. This USI coverage is considered as a dramatic increment compared to the 1990 report, 10%. 7 Yet iodine de ciency remains a considerable challenge worldwide after decades of efforts to address the problem. 8 In terms of the region, an optimal iodized salt utilization (90%) is reported in East Asia and Paci c countries. In sub-Saharan Africa, 64% of households are using iodized salt, nevertheless the level of utilization widely varies from 10 to 90% in different countries. For instance, utilization of iodized salt is less than 10% in Sudan, Mauritania, Guinea-Bissau, and Gambia, whereas, in Burundi, Kenya, Nigeria, Tunisia, Uganda, and Zimbabwe, it is more than 90%. 9 To ensure the nutritional health of pregnant women with respect to iodine status, a World Health Organization (WHO) Technical Consultation in 2007 proposed increasing the recommendations for iodine intake of pregnant. The iodine content of household salt should be at least 32 and 51 ppm during early and late pregnancy, respectively. These levels are far above the 15 ppm currently considered to be adequate salt iodine content at the household level. Pregnant women may remain iodine insu cient due to the increased demands for iodine during pregnancy even when other members of a household have achieved iodine adequacy. 8, 10,18,19 In Ethiopia, availability of adequately iodized salt shows a gradual improvement, 4% in 2000 to 15% in 2011, 23% in 2014 and 26% in 2016. Disparities in level of utilization are detected with residence and regions. The rural and urban house hold availability of adequately iodized salt is 30.6% and 23.8%. South Nation Nationalities Peoples Region (SNNPR) is the lowest by adequately iodized salt availability in the country only 13.7%. 11 Ethiopia is a salt producing state, endorsed mandatory salt iodization program and is working with partners, United Nations Children's Fund (UNICEF),Global Alliance for Improved Nutrition (GAIN) and Micronutrient Initiatives, to reach utilization of iodized salt>90% thereby to mitigate iodine de ciency. 12 But, still only 23.2% of the households use adequately iodized salt. In addition, iodine de ciency remains the major public health problem among pregnant women and school children. 13 There were no studies regarding availability and factors associated with adequately iodizeds in Wonago District. Therefore, this study aimed to determine magnitude and factors associated with availability of adequately iodized salt at households of pregnant mothers in Wonago district, South Ethiopia.

Study setting and design
A community-based cross-sectional quantitative study method was applied from May 14-29/2018 in Wonago district. The study was carried out in six randomly selected kebeles of Wonago district which is located 13km from Dilla (administrator city of Gedeo zone) and 377km from Addis Ababa (capital city of Ethiopia).The district has 152,609(female=76,686 and male=75,923) population and households 31,145.
Wonago district has 21 kebeles (the smallest administration unit in Ethiopia). 14 Study population Households with pregnant mother who were apparently healthy during the study period were included in the study and severely ill to respond or with di culty in speech or listening were excluded. The sample size of 604 households of pregnant women was determined by using formula for estimating single population proportion and with the following assumptions to obtain the optimum sample size: P = proportion of households with adequately iodized salt 39% , 15 Z =reliability coe cient= 1.96, d = 5% margin of error and, design effect (DE) = 1.5, non-response rate = 10% Data collection instruments and procedure A structured interviewer-administered questionnaire was used to collect survey data. The questionnaire was developed by the investigator after reviewing literatures They were initially prepared in English then translated in to the local language (Amharic and Gedeo-fa) and nally, back translated to English to maintain consistency. A total of six data collectors (six diploma nurses) and one supervisor (BSc nurse) were recruited for the study. Daily supervision and feedback was carried out by the investigator and supervisors during the entire data collection period. A table spoon of salt was taken from each house hold and iodine Rapid Test Kit (MBI-International) was used to determine the level of salt iodine content.
The small cup in the kit was lled with salt, and made the cup surface at. Two drops of test solution from white ampoule were added to the surface of the salt by piercing the white ampoule with a pin and gently squeezing the ampoule.
The iodine content in the salt was determined within one minute by comparing the color change on the salt with the color chart. The value parts per million (PPM), <15 PPM and ≥15 PPM with the corresponding color chart on the rapid test kit was used to classify the level of iodine in the sampled salt.
If no color appears (after 1 min), 5 drops of the recheck solution from red ampoule were added to a fresh salt sample and followed by 2 drops of test solution on the same salt sample. A comparison was done with the color chart indicators for salt iodine content. Finally, Availability of adequately iodized salt was considered when the household sampled salt had ≥ 15 ppm iodized salt. Otherwise, it was classi ed to inadequately iodized or non-iodized salt. 12,19 Data Processing and Analysis Each questionnaire was checked for completeness and consistency by supervisors. Data was exported from epi-data version 3.1 to SPSS version 20.0 for analysis. It was summarized with tables and gures. To identify factors associated with availability of adequately iodized salt, each variable was assessed independently whether a predictor of availability of adequately iodized salt or not. First, variables were tested using bivariate analysis. Variables which were associated in bivariate analysis were tested in the nal multivariate analysis to see their association with availability of adequately iodized salt.

Socio-economic and demographic characteristics
Majority of the respondents 310(52.7%) were in the age group of 25-34 years and their mean (SD±5.40) age was 26.7 years. 514(87.4%) were from rural area .More than three-fourth (77.7%) households were headed by men (husbands). Majority of the respondents (54.4%) had family size greater than ve.
Slightly less than half or 286 (48.6%) had not formal education, but three-fourth (74.5%) of husbands of these women had at least some form of formal education. More than ninety ve in hundred (96.30%) respondents were housewife (

Discussion
The study aimed to assess the availability and predictors of using adequately iodized salt among pregnant women in one of the rural cash crop (coffee) producing areas of Ethiopia. Accordingly, results showed that utilization of adequately iodized salt among pregnant women was very low. There were several maternal, paternal and household factors identi ed as key predictors of use or non-use of products. In this study, Households whose head were both husband and wife (participatory) was signi cantly associated with adequately iodized salt utilization. The possible explanation could be free ow of ideas between the partners exposed to information and commonness. Besides, husband education was signi cantly associated with adequately iodized salt utilization. This might be due to education and household discussion in uences nutritional knowledge. This nding was similar with a study conducted referral Hospital especially for public health department, for their effort and ongoing coordination for the effectiveness of this study.
Authors' contributions MA involved in the design, selection of articles, statistical analysis and manuscript writing.TAZ and ATA also involved in analysis and manuscript preparing and editing. All authors read and approved the nal draft of the manuscript.

Disclosure
The author reports no con icts of interest in this work.

Additional Files
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.