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Dietary diversity and associated factors among lactating women in Ethiopia:

Cross sectional study

Article in International Journal of Africa Nursing Sciences · June 2022

DOI: 10.1016/j.ijans.2022.100450

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 International Journal of Africa Nursing Sciences 17 (2022) 100450

Contents lists available at ScienceDirect

International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Dietary diversity and associated factors among lactating women in

Ethiopia: Cross sectional study
Wondwosen Molla a, *, Nebiyu Mengistu b, Derebe Madoro b, Dawit Getachew Assefa d,
Eden Dagnachew Zeleke c, Ruth Tilahun a, Yesuneh Bayisa e, Meiraf Daniel Meshesha e,
Getnet Melaku Ayele a, Robel Hussen Kabthyme f, Asrat Alemu a, Mesfin Abebe Eshetu a,
Seid Shumye b, Mengistu Lodebo Funga g, Aneleay Cherinet Eritero a, Saron Aregawi f,
Tilahun Wodaynew h, Temesgen Muche f, Aregahegn Wudneh a
a
Dilla University, Department of Midwifery, Dilla, Ethiopia
b
Dilla University, Department of Psychiatry, Dilla, Ethiopia
c
Department of Midwifery, Bule Hora University, Bule Hora, Ethiopia
d
Department of Nursing, Dilla University, Dilla, Ethiopia
e
School of Medicine, Dilla University, Dilla, Ethiopia
f
School of Public Health, Dilla University, Dilla, Ethiopia
g
Department of Midwifery, Hossana College of Health Science, Hossana, Ethiopia
h
School of Nursing, Jimma University, Bule Hora, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Lactating women are more vulnerable to malnutrition due to increased physiological demands, the
Dietary diversity lactogenesis process, consuming an undiversified monotonous diet, and increased nutrient needs during lacta­
Minimum dietary diversity score tion. However, meeting minimum standards of dietary diversity for lactating mothers is a challenge in many
Ethiopia
developing countries, including Ethiopia. As a result, the purpose of this study was to evaluate dietary diversity
and associated factors among breastfeeding mothers.
Method: A community-based cross-sectional study was conducted. A multistage sampling technique was used to
get a total of 665 lactating mothers from their kebeles. Face-to-face interviews with a structured questionnaire
were used to collect data. Data was entered into Epidata version 3.1 and exported to the Statistical Package for
the Social Sciences version 23.0 for analysis. Bivariate and multivariable logistic regression models were used to
identify the important predictors of maternal dietary diversity. Variables having p < 0.25 in bivariate analysis
were fitted to multivariate analysis. The odds ratio, P-value < 0.05, and 95% CI were computed to show the
association of variables.
Result: A total of 665 lactating women participated, with a response rate of 96.2%. Only 163 (24.5 %) mothers
satisfied the minimal dietary diversity criteria. Mothers’ dietary diversity was significantly associated with their
education status [AOR 5.173 (2.132–12.552)], head of household [AOR 3.822 (2.290–6.378)], family size [AOR
5.358 (2.838–10.116)], and meal frequency [AOR 3.379 (1.789–6.380).
Conclusion: One in every four mothers met the dietary diversity standard. Concerned bodies should consider
ensuring large-scale interventions that focus on the identified factors to improve dietary diversity practices.

Abbreviations: ANC, Antenatal care; AOR, Adjusted odds ratio; CI, Confidence Interval; COR, Crude odds ratio; DD, Dietary diversity; DHS, Demographic and
Health Survey; EDHS, Ethiopian Demographic and Health Survey; FANTA, Food and Nutrition Technical Assistance project; FAO, Food and Agriculture Organization
of the United Nations; HFIAS, Household Food Insecurity Access Scale; HH, Household; IYCF, Infant and young child feeding; MDD-M, Minimum dietary diversity of
mothers; NGO, Non Governmental Organization; PNC, Postnatal care; PPS, Probability proportional to size; SNNPR, South Nations Nationalities and Peoples Region;
SPSS, Statistical Package for the Social Sciences; SRS, Simple random sampling; UNICEF, United Nations Children’s (Emergency) Fund; USA, United States of
America; USAID, United States Agency for International Development; VIF, variance inflation factor; WHO, World Health Organization.
* Corresponding author.
E-mail addresses: wondwosenm@du.edu.et (W. Molla), robelk@du.edu.et (R.H. Kabthyme).

https://doi.org/10.1016/j.ijans.2022.100450
Received 3 October 2021; Received in revised form 11 June 2022; Accepted 18 June 2022
Available online 21 June 2022
2214-1391/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
W. Molla et al.
1. Introduction
Every individual should consume an adequate diet in terms of
quantity and diversity throughout their life to preserve health, to allow
for proper physical and mental development, and to avoid and reduce
mortality and morbidity (Kominiarek & Rajan, 2016, Shrivastava,
Shrivastava, & Ramasamy, 2016,World Health Organization, 2003).
Carbohydrates, lipids, proteins, vitamins, minerals, as well as water and
dietary fiber, are all necessary nutrients that must be obtained from
dietary sources (Fanzo, 2015,Naeem & Ugur, 2019,Nasir et al., 2015).
This diverse macro-and micronutrient can be found in a number of meals
and food groups, ensuring adequate nutritional consumption (Jevtić
et al., 2015, Shrivastava, Shrivastava, & Ramasamy, 2013,USAID,
2012). Variety foods contain a wide range of nutrients; in fact, except for
breast milk, no single food contains all the elements required for good
health (Fanzo, 2015,Ruel, 2003).
Dietary diversity is defined by World Health Organization and Food
and Agriculture Organization, as the sum of food categories taken by an
individual in a limited time capable of ensuring an appropriate intake of
vital nutrients important for health and well-being, particularly in
developing countries (Kennedy, Ballard, & Dop, 2010,Ruel, 2003). In­
dividuals’ physical and mental development might suffer as a result of a
lack of variety in their food, as well as their vulnerability or worsening of
the disease, mental retardation, blindness, and general loss in produc­
tivity and potential. According to available scientific evidence, the main
cause of malnutrition is a lack of diverse foods (Kemunto, 2013,Nun­
nery, Labban, & Dharod, 2018,Oduniyi & Tekana, 2020).
Currently, dietary diversity is becoming more popular due to its
perceived importance for health and nutrition (Belew, Ali, Abebe, &
Dachew, 2017); individuals who consume more diverse meals are
considered more likely to meet their nutrient demands (Ghosh, 2020).
Dietary diversity is one of the primary factors used by the World Health
Organization to determine nutritional adequacy (World Health Orga­
nization, 2009). However, during the Seqota Declaration, Ethiopia’s
national nutrition program was announced to pay special emphasis to
the importance of nutrition during pregnancy, lactation, and the first
years of a child’s life to break the cycle of undernutrition (Ayele, Zegeye,
& Nisbett, 2020).
Malnutrition is a frequent public health problem in both children and
adults, involving both overnutrition (overweight, obesity) and under­
nutrition (underweight, wasting, stunting). Today, approximately 821.6
million people worldwide are suffering from moderate-to-severe acute
malnutrition, with an estimated 118 million more people battling hun­
ger in 2020 than in 2019 (Dukhi, 2020,World Health Organization,
2020). The majority of 418 million and 282 million people live in Asia
and Africa, respectively, with 24.1% of them living in Sub-Saharan Af­
rica, which includes Ethiopia (Micha et al., 2020).
Malnutrition-related mortality and morbidity have not altered
appreciably over the last 30 years (Baumgartner, 2017). According to
the World Health Organization, over 5.4 million people die each year as
a result of malnutrition, with 2.7 million deaths occurring in sub-
Saharan African countries such as Ethiopia. Malnutrition has been
found as a significant contributor to maternal mortality and morbidity.
Malnutrition claims the lives of about 3.5 million women worldwide
each year, with developing nations accounting for more than half of
these deaths. Malnutrition kills 20% of African women, with Sub-
Saharan African nations, particularly Ethiopia, accounting for the ma­
jority of the 2.7 million deaths (World Health Organization, 2019).
Lactating women in developing countries including Ethiopia, are the
most nutritionally vulnerable population due to higher physiological
demands, an undiversified diet, and increased nutrient requirements
during breastfeeding (Marangoni et al., 2016,USAID, 2012). It has been
shown that malnutrition develops as a result of a suboptimal diet that
includes insufficient calorie and nutrient intake mixed with a hard
workload. A child has higher nutritional needs than an adult, even
though they have had breast feeding. Mothers possibly require at least
2
International Journal of Africa Nursing Sciences 17 (2022) 100450
two additional meals per day due to the fact that the nutrients present in
this milk come from the diet of the mother or from her nutrient reserves
for their breastfeeding baby. When these needs are not met, mothers
may suffer from malnutrition, especially from micronutrient deficiencies
(FAO, 2016,Haileslassie, Mulugeta, & Girma, 2013).
The problem of malnutrition has a double burden for lactating
women that has a negative impact on the quality of breast milk,
compromising their child’s nutritional status, delaying neonatal phys­
ical growth and motor development, lower intellectual quotient (IQ),
childhood health problems (Allen, 2012,Jones, Berkley, & Warner,
2010), and it affects the quality of maternal life during the postnatal
period; it increases the risk of infection, anemia, visual impairment, and
goiter (Oluwole, Agboola, Onyibe, & Adeyoju, 2016) and has lifelong
impacts adversely on the health of the mother (USAID, 2012).
Many studies have found that the most prevalent immediate causes
of maternal malnutrition include insufficient food consumption, low
nutritional quality of diet, recurrent illnesses, and short interpregnancy
intervals (Belew et al., 2017,Ghosh, 2020). In Sub-Saharan Africa, the
burden of nutritional deficiency among women remains high (Baum­
gartner, 2017,Global Nutrition Report, 2016). Due to insufficient food
intake, limited diet diversity, and changing lifestyles, 22% of Ethiopian
women are thin and 8% are obese (Ethiopia & Macro, 2016).
Dietary diversification is one of the most effective nutritional ther­
apies for preventing and correcting lactating women’s nutritional
vulnerability, particularly during the first two years after giving birth
(Kominiarek & Rajan, 2016,Wambach & Spencer, 2019). However,
meeting minimum standards of dietary diversity is a major challenge in
many developing countries, including Ethiopia, where it is as low as 7%
(Demographic, 2016). According to the previous studies, socioeconomic
status, marital status, agricultural practices, ethnic and cultural beliefs,
husband’s occupation, occupation of mothers, women’s empowerment,
household food security, poverty, disparities in households, husband’s
educational status, media exposure, mother’s age, and family size all
have a significant relationship with dietary diversity (Beyene, Worku, &
Wassie, 2015,Disha, Tharaney, Abebe, Alayon, & Winnard, 2015,Kang
et al., 2019).
Therefore, this study was aimed at evaluating dietary diversity and
associated factors among lactating women in Ethiopia, which may be
useful for communities, governmental and non-governmental organi­
zations, program managers, and stakeholders in identifying specific
strategies to improve the nutrition status of women, particularly
lactating women. It plays a major role in reducing maternal
mortality and morbidity.
2. Methods
2.1. Design, location, and period of study
A community-based cross-sectional study was conducted in Gedeo
Zone, Ethiopia, from September 2020 to January 2021. The Gedeo zone
is located in southern Ethiopia, 360 km from Addis Abeba, with the
administrative centre in Dilla town. The zone is bounded by Sidama in
the south, Abaya in the north, H/Mariam in the east, and Kericha in the
west. The Gedeo zone is composed of six Woredas and two city admin­
istrations (Bule, Gedeb, Wonago, Kochere, and Dilla Zuria), as well as
two administrative towns (Dilla and Yirgachefe), and has a total popu­
lation of 1,086,768 people (532,516 males and 554,225 females) and an
area of 1,210.89 square kilometres. The estimated number of
reproductive-age women (15–49) is 278,008; the estimated number of
deliveries is 8730; and the skilled delivery rate is 57.43%. There is one
referral hospital, three district hospitals, 38 health centers, and 146
health posts in the study area. Besides nine nongovernmental organi­
zations (NGOs) providing health services for the community, there are
private health facilities including low-level clinics, medium-level clinics,
drug stores, and pharmacies. This study included all mothers who were
currently breastfeeding, had children aged 6 months and under, and had
W. Molla et al. International Journal of Africa Nursing Sciences 17 (2022) 100450

resided in the Gedeo zone for at least 6 months. All women who suffered Table 1
a newborn or child loss, as well as those who were very severely ill Socio-demographic characteristic of respondent in Gedeo zone, SNNPR,
during the study period, and households that had a special ceremony on Ethiopia, 2021.
the day prior to data collection were excluded from the study. Variable Category Frequency Percent

Age of mothers >=30 110 16.5

2.2. Sample size determination and sampling technique 25–29 315 47.4
20–24 133 20.0
The sample size was calculated using the single population propor­ <20 107 16.1
Marital status Single 59 8.9
tion formula (n = (Z/2)2p (1p)/d2) with 0.05 margin of error at the 95%
Married 499 75.0
confidence level (CI). 50% was used as a proportion of DD by consid­ Widowed 42 6.3
ering the fact that the proportion closest to 50% gives the largest sample Divorced 65 9.8
size (Suri, 2018). The sample size was then multiplied by 1.5 to account Ethnicity Gedeo 368 55.3
for the design effect, and for a possible nonresponse rate during the Amhara 85 12.8
Oromo 133 20.0
study, the sample size was increased by 20% to: n = 691. Other* 79 11.9
A multistage sampling technique was used to conduct this study. Out Religion Protestant 304 45.7
of the 6 districts that make up the Zone, three districts are selected by Orthodox 219 32.9
using simple random sampling techniques (lottery method). Namely, Muslim 107 16.1
Other 35 5.3
Yirgacheffie district (39 kebeles), Wonago district (29 kebeles), and
Educational status Formal education 84 12.6
Dilla Zuria (9 kebeles). From a total of 69 kebeles (the smallest admin­ Cannot read and 375 56.4
istrative unit) in the selected districts, eleven out of 39, ten out of 29, write
and three out of nine kebeles were selected by using lottery methods Read and write 206 31.0
from Yirgacheffie district, Wonago district, and Dilla Zuria district, Occupation Governmental 30 4.5
employer
respectively. Then the census was conducted to identify the number of Student 27 4.1
lactating women who were breastfeeding for their children under the Housewife 412 62.0
age of 6 months and below that was available in the selected kebeles. Merchant 88 13.2
Based on the census, a total of 3146 women were identified. Of those, Daily laborer 108 16.2
Family size 314 62.1
1493 were in the Yirgacheffie district, 1056 were in the Wonago district, >=4
<4 351 52.8
and 597 were in Dilla Zuria (9 kebeles). A simple random sampling Primary source of obtaining Buying from market 422 66.5
technique was used to get a total of 691 women out of 3146 women who food Farming 223 33.5
were identified and registered during the census. Households were Head of house hold (mother) Yes 272 40.9
sampling units for this study, and the final sample size was allocated No 393 59.1
Antenatal clinic visits Yes 621 93.4
proportionally to each kebele based on the number of women. There­ No 44 6.6
fore, 328 mothers from Yirgacheffie district, 232 from Wonago district, Postnatal care Yes 590 88.7
and 131 from Dilla Zuria district were allocated to participate in the No 75 11.3
study. Then the study households were selected from each kebele Place of delivery Institution 633 95.2
Home 32 4.8
through a simple random sampling technique by using a computer-
Household wealth Poor 220 33.1
generated random number starting from kebele one from a random Middle 223 33.5
start point after developing the sampling frame having a list of in­ Rich 222 33.4
dividuals’ house numbers which were given during the census. When
two or more eligible mothers with their children were found in one
household, only one was interviewed by using the lottery method. diplomas or above in the health profession. The data was gathered
through face-to-face interviews with a pretested structured question­
2.3. Study variables and operational definitions of terms naire at women’s homes, outdoor living areas, and open and closed quiet
places without anyone other than lactating women in the community,
The dietary diversity of lactating women was the dependent variable and lasted 30–40 min.
of this study. In contrast, socio-demographic and economic factors such To maintain the quality of the data, the standard questionnaire was
as maternal age, educational level, occupation, status in household, adapted from the FANTA/FAO.
residence, household wealth, family size, chicken rearing, milking, The questionnaire was divided into six sections; socio-demographic
cows, vegetable gardening; health care related factors such as ANC, characteristics, maternal-related characteristics, child-related charac­
PNC, delivery site, dietary advice; morbidity related factors such as diet teristics, meal frequency, diet and food access related factors, Household
and food access; household food insecurity and primary source of food food insecurity assessment, and 24-hour recall dietary diversity assess­
were the independent variables of this study. ment. The questionnaire was developed in English, then translated to
Amharic and Gedeo-Uffa languages, and finally back-translated to En­
• The minimum dietary diversity of women (MDD-W) was measured glish by independent translators for consistency. The data collectors and
according to the FANTA/FAO 2016 MDD-W guideline. supervisors were trained for 3 days on the aims of the research, the
• The MDD-W is a dichotomous indicator of whether or not lactating content of the questionnaire, and how to conduct an interview to in­
women have consumed at least five out of ten food groups the pre­ crease their performance in the activities.
vious day and night. A pretest was performed on 10% of the total participants in Gongua,
• Lactating women with a dietary diversity score of five or more (>5) a town near the study area. During the pretest, the questionnaire was
were classified as meeting minimal dietary diversity, while those assessed for its clarity, readability, comprehensiveness, accuracy, and
with a dietary diversity score of less than five were classified as not optimal time for completing the interview. The optimal time to complete
meeting dietary diversity (Belew et al., 2017). the interview and the readability of the items were updated and revised
based on the results of the pretest. Cronbach’s alpha was used to assess
2.4. Data collection methods and quality assurance: the item’s internal consistency and reliability. The value of Cronbach’s
alpha was within the normal range of values (0.86).
Data was collected by 10 data collectors and 5 supervisors who had Data was collected on all days of the week since people may eat

3
W. Molla et al.
Dietary diversity score of mothers
24.5
75.5
meet MDD-W unmeet MDD-W
Fig. 1. Dietary diversity scores of mothers at Gedeo zone, Ethiopia 2020.
differently on different days of the week. All interviews were conducted
at the residences of the study participants. Vacant or closed houses
during the day of the visit were revisited two more times to maintain the
required sample size. The collected data was checked every day by the
supervisor and principal investigator for its completeness and consis­
tency. All questionnaires were kept under lock and key for security and
confidentiality of the obtained information.
2.5. Data analysis
Data was checked for completeness, edited, coded, and entered into
Epi Data version 3.1 and exported to SPSS version 23.0 statistical soft­
ware for analysis. Descriptive statistics such as frequency and percent­
age were used and presented using text, charts, and tables. Bivariate
analysis was done and all explanatory variables that had a P-value of
<0.25 were included in the multivariable analysis. Multi-variable
analysis was employed to determine an independent determinant
CONSUMPTION OF FOOD GROUPS
55.30%
40.20%
36.50%
32.90%
20.30%
Fig. 2. Consumption of foods group by mothers at Gedeo zone, Ethiopia 2020.
4
International Journal of Africa Nursing Sciences 17 (2022) 100450
factor among explanatory variables with an adjusted odds ratio (AOR),
95% confidence interval, and a P-value less than or equal to 0.05 were
used to decide if there was a statistically significant association with the
outcome variables. Model fitness was assessed by using the Hosmer and
Lemeshow test. Multicollinearity was checked by the variance inflation
factor (VIF) and the tolerance test. The result of the VIF was <2, while
the tolerance test was greater than 0.1.
3. Result
Socio demographic characteristics of respondents.
A total of 665 mothers participated in the study, giving a response
rate of 96.2%. The majority of the 368 (55.3 percent) were Gedeo, while
304 (45.7 percent) were protestant. Furthermore, the majority of 499
(75%) of the respondents were married; 412 (62%) were housewives;
and 375 (56.4%) could not read or write, as indicated in Table 1.
3.1. Dietary diversity of mothers
From the total of 665 respondents, only 24.5% (163) of mothers
received a minimum of dietary diversity per 24 h before data collection,
see Fig. 1.
3.2. Consumption of food groups
Regarding the consumption of foods by mothers based on ten food
groups, the most commonly consumed foods were cereals, 602 (90.5%),
followed by dark green leafy vegetables (497, 74.7%), and other fruits
(483, 72.6%), while the least consumed food groups by the mothers
were organ meats, which was 135 (20.3%), see Fig. 2.
3.3. Determinants of dietary diversity among mothers
In the bivariate logistic regression analysis, occupation, age, marital
status, education status, number of family/children, being head of the
household, primary source of food, meal frequency, and ANC follow-up
were associated with the dietary diversity of mothers. Whereas in the
multivariable logistic regression analysis, education status, number of
family/children, meal frequency, and occupation were significantly
90.50%
74.70%
72.60%
71.40%
56.80%
W. Molla et al. International Journal of Africa Nursing Sciences 17 (2022) 100450

Table 2
Bivariate and Multivariable Analysis on factors associated with dietary diversity among lactating mothers in Gedeo zone, Ethiopia, 2021.
Variables Dietary Diversity COR (95% CI) AOR (95% CI) P value

>MDDS <MDDS

Educational status
Cannot read and write 55 320 1 1
read and write 57 149 2.226 (1.465–3.382) ** 5.173 (2.132–12.552) 0.001
Formal education 51 33 8.992 (5.329–15.171) ** 2.864 (1.156–7.094) 0.003
Age of respondent
< 20 33 74 4.459 (2.068–9.619) **
20–24 58 75 7.733 (3.709–16.125) **
25–29 62 253 2.451 (1.209–4.969) *
>=30 10 100 1
Head of house hold (mother)
Yes 107 165 3.833 (2.642–5.560) 3.822 (2.290–6.378) 0.002
No 56 337 1 1
Occupation
Housewife 79 333 1
Student 2 25 0.337 (0.078–1.454)
Governmental employer 11 19 2.440 (1.116–5.334)*
Daily laborer 10 98 0.430 (0.215–0.862)*
Merchant 61 27 9.523 (5.689–15.941)**
Marital status
Married 122 377 1
Single 5 54 0.286 (0.112–0.732)**
Divorced 16 49 1.009 (0.554–1.839)
Widowed 20 22 2.809 (1.483–5.323)**
Number of family
<4 119 232 3.147 (3.732–7.293)** 5.358 (2.838–10.116) 0.001
>=4 44 270 1 1
Primary source of food
Farming 112 330 1.145 (0.784–1.672)**
Buying from market 51 172 1
Meal frequency
<=2 times 64 124 1 1
>2 times 99 378 2.171 (1.356–2.865)* 3.379 (1.789–6.380) 0.002
ANC
Yes 158 463 2.662 (1.031–6.871)*
No 5 39 1

CI: confidence interval, COR: Crude Odds Ratio, ANC: Antenatal Care, 1 – reference variable, * – significant at P < 0.01, ** – significant at P < 0.05, MDDS – Minimum
dietary diversity score.

associated with the dietary diversity of mothers.
Mothers who had had formal education were 5.1 times more likely to
consume the recommended minimum dietary diversity than those who
couldn’t read and writeAOR 5.173(2.132–12.552)].
The odds of consuming the recommended minimum dietary diversity
among mothers from households headed by themselves were 3.8 times
more likely compared to mothers from households headed by their
husbands [AOR3.822 (2.290–6.378)].
Regarding meal frequency, thus, those who had three or more meal
frequencies per day were 3.3 times more likely to consume the recom­
mended minimum dietary diversity than those who had under three
meal frequencies per day [AOR 3.379 (1.789–6.380)]. Furthermore,
mothers with fewer than four children were 5.3 times more likely than
those with four or more children to consume the recommended mini­
mum dietary diversity [AOR 5.358 (2.838–10.116)], as indicated in
Table 2.
4. Discussion
This study has investigated the dietary diversity and associated fac­
tors among lactating mothers in Gedeo zone, SNNPR, Ethiopia. The
World Health Organization and Food and Agriculture Organization of
the United Nations recommended a new minimum dietary diversity for
women, consisting of ten food groups and a dichotomous indicator to
show minimum dietary diversity when consuming at least five of the ten
food groups. However, in this study, only 24.5% (163) of the lactating
mothers were consuming a minimal dietary diversity in the 24 h pre­
ceding the survey. This is slightly similar to the studies conducted in
South Africa where (25%) of the lactating mothers were consuming a
minimal dietary diversity (Taruvinga, Muchenje, & Mushunje, 2013)
and Ethiopia where (25%) of the lactating mothers were consuming
minimal dietary diversity (Desta, Akibu, Tadese, & Tesfaye, 2019). The
findings of this study are much lower than the study conducted in
Dhaka, Bangladesh where about 58% of lactating mothers consumed a
diet with minimal diversity (Arimond, Torheim, Wiesmann, & Joseph,
2008). The study conducted in southern part of Benin (more than 50%)
(Bellon, Ntandou-Bouzitou, & Caracciolo, 2016), East Gojjam Zone
Northwest Ethiopia (45%) (Demilew, Alene, & Belachew, 2020) and
Angecha district, Southern Ethiopia (47.8%) (Meretie, 2020) are also
higher than the present study.
On the other hand, the result of this study is higher than previous
studies conducted in Vietnam (17%) (Nguyen et al., 2013) and Gondar
Zone Northwest Ethiopia (16.2%) (Aserese et al., 2020). This discrep­
ancy and similarity might be due to the difference in socioeconomic
status, sample size, seasonal variability, and study setting. Since, in the
area of the current study, coffee is the predominant product, followed by
fruit and vegetables. This might have its own contribution to the low
consummation of the minimal requirement of dietary diversity. In
addition to that, this discrepancy might be due to differences in dietary
diversity measurement tools; the current study was conducted by using
the new WHO recommended indicator of ten food groups, while some
studies were conducted by using nine food groups’ indicators.
In this study, mothers who had three meals or more were 3.3 times
more likely to consume the recommended minimum dietary diversity
compared with those who had fewer than three meals per day [AOR,
3.379 (1.789–6.380)]. The findings of the present study are similar to
the findings of other studies conducted in the Raya Azebo Zone in
Ethiopia (Jemal & Awol, 2019). However, the findings of the study done

5
W. Molla et al.
in Pakistan revealed that there is no association between dietary di­
versity score and meal frequency (Ali, Thaver, & Khan, 2014). The
possible justification for this difference and similarity might be due to
their economic status. Dietary diversity has been found to be strongly
related to a family’s income and socioeconomic status. Individuals with
a higher socioeconomic status consumed higher quality food diversity
than those with a lower socioeconomic status. However, the opportunity
of having more than two meals may give the chance of consuming
different categories of meals.
According to this study, the educational status of mothers had a
statistically significant association with dietary diversity. Mothers who
had formal education were 5.1 times more likely to be consuming the
recommended minimum dietary diversity than those who couldn’t read
and write [AOR 5.173 (2.132–12.552)). The findings of this study are in
line with the studies conducted in Ethiopia at Shashemane, Kenya,
Tanzania, and Ghana (Amugsi, Lartey, Kimani-Murage, & Mberu, 2016,
Desta et al., 2019,Kiboi, Kimiywe, & Chege, 2017,Ochieng, Afari-Sefa,
Lukumay, & Dubois, 2017). A possible explanation is that those with
formal education have a better chance of receiving nutritional infor­
mation and are capable of understanding educational messages deliv­
ered through various media outlets. As a result, as the educational level
increases, the level of consumer and adequate dietary diversity also
increases.
In this study, the head of the family was one of several socio-
demographic factors that had a significant association with the
mother’s dietary diversity. The odds of consuming the recommended
minimum dietary diversity among mothers from households headed by
themselves were 3.8 times more likely compared to mothers from
households headed by their husbands [AOR3.822 (2.290–6.378)]. This
might be due to women’s who are the head of households have a chance
to prepare and avail different foods based on their interest. However, the
finding of this study is contradicted with the studies conducted in
Ethiopia (Haidar & Kogi-Makau, 2009) and Kenya (Gitagia et al., 2019),
they revealed that consuming of the recommended minimum dietary
diversity among mothers in male-headed households was better than in
female-headed households.
5. Limitations of the study
The major limitation of this study was its cross-sectional design,
which does not allow cause-effect relationships. It may not also accu­
rately reflect the lactating mother’s past food conception experience,
since it considers only 24-hour feeding.
6. Conclusions and recommendations
Only one out of four mothers received a minimum dietary diversity
in the study area. In this study, education status, number of families,
meal frequency, and occupation were significantly associated with Di­
etary Diversity of mothers. The Ministry of Women and Woreda Women
and Child office should promote mother education to improve mothers’
knowledge and increase the level of dietary diversity practices. Gov­
ernment media should promote and educate the community about the
benefits of dietary diversity. It should also promote women’s socioeco­
nomic empowerment in order to increase mothers’ culinary diversity
practices. Furthermore, mothers targeted health education programs
that focused on the nutritional values of locally available foods and
nutritious foods that are required for their own health. Further study has
to be conducted in the area to determine the adequacy of nutrient intake
and nutritional status.
7. Ethics approval and consent to participate
Ethical approval and clearance were obtained from the Dilla Uni­
versity College of Medicine and Health Science Institutional Review
Board (IRB), with the ethics approval number 0143/20-04. Official
6
International Journal of Africa Nursing Sciences 17 (2022) 100450
letters have been sent and submitted to all respective health de­
partments. Permission was also obtained from the appropriate author­
ities. Prior to data collection, all participants provided written informed
consent following a brief explanation of the study’s purpose and ob­
jectives; for participants who were unable to read or write, informed
consent was obtained from their legal guardian or legally authorized
representative. Participants’ involvement in the study was totally
voluntary basis, and those who were unwilling to participate in the study
or who wished to discontinue their participation at any time were
informed that they could do so without restriction. Confidentiality was
maintained throughout the study by avoiding using the participants’
names in the questionnaire. Participants were assured on data collected
anonymous and individual findings would not be reported or shared
publicly (published reports only refer to aggregate data). For ­
security reasons, the collected data was kept under lock and key and
used only for the purposes of the study.
Funding
This study was not funded by any grant. There have been no re­
imbursements, fees, funding, nor salary from any organization that de­
pends on or influence the results and publication of this study.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
We are thankful to the study participants for giving their fruitful time
to participate in this study and for their unlimited support throughout
the data collection.
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