Minimum dietary diversity and its associated factors among children of 6–23 months in rural Ethiopia 2023  – Nature.com 23:12 

Scientific Reports volume 15, Article number: 9709 (2025)

Abstract

Dietary diversity is a useful proxy indicator of diet quality and nutrient adequacy, which plays an important role in children’s growth and development. Meeting the standard of dietary diversity remains a challenge in developing countries. In Ethiopia, including the study area, there is limited evidence on dietary diversity and associated factors in children aged 6–23 months. Minimum dietary diversity and its associated factors among children of 6–23 months. A Community -based cross-sectional study design was conducted from April 11, 2023 to May 20, 2023 among 597 study participants. Nutrition counseling was measured through various metrics such as attendance rates, client satisfaction and feedback, the number of sessions per month or year, and the duration of each session. Face-to-face interviews were conducted by structured questionnaire, and the data were entered into Epi-data version 3.1 software. Later, IBM SPSS version 27 was used to perform bivariate and multivariate logistic regression analyses. To check for multicollinearity, the variance inflation factors (VIF) were used. The Hosmer–Lemeshow goodness of fit test was used to assess model fitness. Adjusted odds ratios and their 95% confidence intervals were used to identify statistically significant factors at P values 0.05. The results showed that the prevalence of acceptable dietary diversity was 35.5% [95% CI 31.5, 39.7]. The study also found that factors such as equal decision-making power (AOR: 2.46, 95% CI (1, 24, 4.9)), participation in cooking demonstrations (AOR = 1.61, 95% CI (1.10, 2.363), attendance at ANC follow-ups (AOR = 5.027, 95% CI (2.02, 12.46)), have nutrition counseling (AOR = 2.450, 95% CI (1.32), 4.54), food secured family (AOR = 2.7, 95% CI (1.8, 4.06), and child growth and development-monitoring behavior (AOR = 1.8, 95% CI 1.24, 2.6) were significantly associated with unacceptable dietary diversity. The study found that factors such as equal decision-making power, participation in cooking demonstrations, ANC follow-ups, nutrition counseling, food security, and monitoring child growth significantly influence dietary diversity. It recommends implementing strategies to promote dietary diversity and health for children aged 6–23 months, providing nutritional information to lactating mothers, and empowering mothers to alleviate food insecurity through home gardening.

Introduction

Dietary diversity is the sum of the food groups consumed by a person in a 24-h period1, The Dietary Diversity Score (DDS) was calculated by summing the number of food groups eaten daily and averaging it over the three days2. The mean DDS for the 3 days is called the minimum adequacy score for diet variety. According to the United Nations International Children’s Fund (UNICEF) and the World Health Organization (WHO), the following eight food groups are used to declare DDS: 1. breast milk; 2. Grains, roots, tubers and plantains; 3. Legumes (beans, peas, lentils), nuts and seeds; 4. Dairy products (milk, baby food, yogurt, cheese); 5. Meaty foods (meat, fish, poultry, offal); 6. Eggs; 7. Fruits and vegetables rich in vitamin A; and 8 other fruits and vegetables3.

Diet diversity is an indicator of nutritional adequacy, which plays an important role in children’s growth and development4. The inability to maintain this optimal varied diet, defined by UNICEF and WHO as minimum dietary diversity, as a percentage of children aged 6 to 23 months who had consumed food and drink from at least five of eight defined food groups the previous day, is categorized according to its severity into the child food poverty category as follows: Severe child food poverty: when children under 5 years of age consumed food from zero, one or two of eight defined food groups the previous day, and moderate food child poverty when children under the age of 5 consume food from three food groups or four out of eight defined food groups the previous day5.

The first 1,000 days of life, from the first day of pregnancy to the 24th month of the child, is a crucial time window for a child’s health and development, as rapid physical development takes place. Children during this period are more susceptible to infection, have heightened sensitivity to biological programs, and are completely dependent on others for nutrition, care, and social interactions6,7. The proportion of children who eat a minimally varied diet is almost twice as high in urban areas 39% as in rural areas 23%. Over the past decade, disparities in food distribution and dietary diversity between children living in poorer and wealthier households have not narrowed8. The double burden of malnutrition is a global challenge. Micronutrient deficiencies are associated with high levels of over- and under nutrition. It is estimated that 46% of children aged 6 to 23 months suffer from anemia caused by an inadequate and varied diet9,10.

Data from UNICEF, WHO and the World Bank Group on the extent and trends of under nutrition in 2020 shows that more than half (54%) of all underdeveloped children under the age of five lived in Asia, while 40% lived in Africa, 69% of wasted children were found in Asia, 27% lived in Africa, while 45% of obese children lived in Asia and 24% in Africa. However, diet-related factors alone are responsible for about 45% of deaths in children aged 6 to 23 months11.

According to the 2019 Ethiopia Population and Health Survey (EDHS) report, 37% of children under the age of 5 are stunted or underdeveloped, 7% are emaciated (thin for their height), 21% are underweight, and 2% are overweight. Almost all children born by age 2 (96%) were breastfed at some point. Minimum diet: Only 11% of the children aged 6 to 23 months received an acceptable minimum diet in the 24-h recall, 14 percent of the children had a sufficiently varied of diet12.

In Ethiopia, there have been numerous studies related to these findings. However, as we know, Ethiopia is a large nation with diverse socioeconomic cultures. This study is needed to identify the factors affecting this issue, which may vary from region to region.

Ethiopian government recognizes that children should be offered a varied of diet and follows the release of the Sequota Declaration and health extension program to End Child Malnutrition13,14. However, due to various factors, like the Sequota Declaration, while ongoing, has yet to demonstrate its impact. Additionally, the health extension program exhibits numerous gaps. It ambitiously includes 16 packages within a single program, with nutrition being one of the components. However, this breadth makes it challenging to focus on and address each aspect thoroughly due to the program’s expansive scope. The other significant gap in the Ethiopian health extension program is the training duration for health workers. They receive only one year of training, covering both theoretical and practical aspects of all packages, which is insufficient for comprehensively understanding such a complex program. Consequently, children’s dietary diversity remains a public health concern at the national level in Ethiopia, therefore:

This study aims to identifying the factors that influencing minimum dietary diversity among children aged 6–23 months in rural Ethiopia, and also the study provides valuable insights that can inform targeted interventions to prevent malnutrition and micronutrient deficiencies.

Methods and materials

Study area, design and period

A community-based cross-sectional study design was from April 11, 2023 to May 20, 2023, in Giedi Bench district, rural south west Ethiopia. This district bordered by North Bench district to the north, Shay Bench district to the east, Sheko district to the west, and South Bench district to the south. The estimation population in this area is 46,843, of which 22,156 were males and 24,687 were females and the total estimation number of children under two years were 2469. Major food crops in this area include maize, godere (taro root), and enset, while sorghum, teff, wheat, and barley are grown in significant quantities. Although cattle, sheep and poultry are produced in limited quantities, meat and milk are highly valued. Cash crops include fruits (bananas, pineapples, oranges) and spices (e.g. coriander and ginger); Honey is also an important local source. However, coffee is the most important source of income.

Source population and study population

The source population were all children aged 6 to 23 months live with their mothers/caregivers in the rural south west Ethiopia and the study population consisted of all infants aged 6 to 23 months live with mothers or caregivers enrolled in the study from the study area.

Eligibility criteria

Sample size determination

Sample size was determined by using single and double population proportion formula and the largest sample size was taken.

A single population proportion was used the following assumption P= 42.3%15,

Z = 95% confidence level 1.96, d = 0.05,

N= (1.96)2 (0.423) (1-0.423) / (0.05)2 = 375, including 10% of non–response rates and 1.5 design effect. N= 620.

Also double population proportion formula was used the following assumption Two-sided confidence level of 95%; Power of 80; 0.5 margins of error; and 10% of contingency non-response rate by using Epi Info Version 7 statistical software. See Table 1.Table 1 Sample size calculation using different variables associated with acceptable DDs in rural, Ethiopia, 2023.

Full size table

Finally 620 was taken the sample size for this study which were the largest sample to get representative study population.

Sampling procedure and techniques

Giedi Bench district was randomly selected from the south west Ethiopia Regine and three rural kebeles (the small administrative unit of Ethiopia), namely Taste, Giedi Bench and Berehan Shay, were randomly selected. For each Keble, the sample size was assigned proportionally to the total number (432, 879 and 404 respectively) of children aged 6 to 23 months living in the study area. Households with at least one child (aged 6 to 23 months) were identified and coded and sample frames were formed. If there are more than children of the same age in the selected households (children aged 6 to 23 months) one was selected by lottery method.

Finally, study participants were identified from each selected Keble using a systematic random sampling method. The first respondent is selected using the lottery method, and subsequent respondents are determined using the sampling interval (k = 3).

Operational definition

Data collection tools and procedures

Data was collected by 10 health professionals (BSc nurse) and supervised by two (BSc public health officers) individuals.

A structured and pre-tested questionnaire was used to collect the required information by face to face interviewing mother/ caregivers and measuring the anthropometric measurement of children aged between 6–23 months.

The questionnaire covers children’s socio-demographic characteristics, economic status, use of child and maternal health services, agricultural output, and household food security status.

Data on the date of birth of children was obtained from written evidence on birth certificates or immunization cards. If these documents were not available, information provided by mothers or caregivers was used. This data was then cross-checked with the family folder.

Household food security status nine questions that quantify occurrence and frequency. It is measured using nine questions representing increasing degrees of severity and nine frequency-of-occurrence questionnaire asking about changes in diet or food consumption behavior that households have made in the past 30 days due to limited resources. Participants received a score between 0 and 27 based on their answers to nine questions and the number of times they occurred over the past 30 days. A lower HFIAS score indicates better access to food and lower household food insecurity, while a high HFIAS score indicates a lack of food access and lack of food insecurity, adapted from previous literatures and FANTA20.

The Minimum Dietary Diversity (MDD) status of children was assessed based on the proportion of children consuming fewer than five food groups versus those consuming five or more out of eight food groups. This was categorized into two dietary intake groups: less than five food groups and five or more food groups, coded as zero and one, respectively. Children who consumed fewer than five major food groups were considered to suboptimal dietary variety 5. Household wealth was assessed using the Household Wealth Index, which considered the variety and quantity of household goods, from hens to oxen, as well as housing characteristics such as flooring material, latrine facilities, drinking water sources, and the home environment. We then used principal component analysis to calculate a composite score. Finally, households were ranked by their scores and divided into three wealth categories: poor, middle, and rich 12.

Data quality control

To assure data quality the following measure were taken: the questionnaire was prepared in English and then translated into Amharic by language expert and then back into English to check for consistency by the individual who was blind to the original version.

Before data collection began, a pre-test was performed on 5% the sample size in not selected kebele.

Data collectors and supervisors were trained for one day and half on the method of data collection, ethical issues and the purpose of the study, and every step is tracked and monitored; the completeness of the questionnaire was checked on site and during data entry and the data collected are verified and entered using Epi-Data software version 3.1.

Every effort is made to improve mothers’ recall skills, and face-to-face interviews are conducted in a separate, private area to avoid social desirability and memory bias.

Data processing and analysis

The collected data was reviewed daily for completeness. Following that, every completed questionnaire was given a unique code, interred into EPI-DATA, and exported to IBM SPSS version 27 for analysis.

Descriptive analysis was used to investigate the socioeconomic characteristics of the respondents, and the findings were reported in frequency tables.

The outcome variable was recoded as either “unacceptable” or “acceptable dietary diversity”. Those with acceptable dietary diversities were coded “1”, whereas those with unacceptable dietary diversities were marked “0”.

We created the family wealth index data using the principal component analysis approach and then computed the composite score. Finally, the household wealth quintiles were determined by assigning a household score to each household, rating each household in the community based on their score, and dividing the distribution into three equal categories: poor, middle, and rich.

The household Food Insecurity Access Scale was used to determine if a household was food insecure or not.

The Dietary Diversity score (DDs) status of children aged 6–23 months was assessed by comparing the proportion of children who fed fewer than five main food categories to those who fed five or more major food groups out of eight food groups. Children who were fed less than five of the major food categories were considered to have suboptimal dietary variety.

The multicollinearity effect was assessed using the IVF. Only non-collinear variables were used in binary logistic regression to determine the potential relationship between each independent and dependent variable. Factors having a P-value ≤ 0.25 in bivariate analyses were selected for additional analyses using multiple logistic regressions to account all possible confounders and find factors substantially linked with the outcome variable. The study’s model fitness was assessed using the Hosmer–Lemeshow goodness of fit test (0.06). The study found statistically significant associations with adjusted odds ratios (AOR) and 95% confidence intervals (CI) at P values ≤ 0.05.

Ethical considerations

This study adhered to the principles outlined in the Declaration of Helsinki. Ethical clearance was obtained from the Mizan-Tepi University Institutional Health Research Ethics Review Committee (IHRERC) IRB 032/23. Additionally, a permission letter was acquired from Mizan-Tepi University and submitted to the regional health office. Voluntary written informed consent and signed informed consent was obtained from each child’s mother or caregiver after a thorough explanation of the study’s purpose, procedures, duration, and potential risks and benefits the current study.

Result

Socio-demographic characteristics of the study participants

A total of 597 study participant had involved in the current study with a response rate of 96%. From the total involved in the current study about 97.3% of mother or care giver were married, 51.8% of study participants had fewer than 5 family members and The majority of respondents (532 (89.1%)) have one child within 6–23 months. See Table 2.Table 2 Socio-demographic characteristics of study participants in rural, Ethiopia, 2023.

Full size table

Household wealth and food security status

The study’s findings highlight a significant prevalence of food insecurity, with 63% of participants not having reliable access to a sufficient quantity of affordable, nutritious food. Additionally, a substantial portion, 33%, were identified as having the lowest household wealth. See Table 3.Table 3 Household Wealth and Food Security Status of study participants in rural, Ethiopia, 2023.

Full size table

Child’s and maternal health seeking behavior

In the study area, approximately 55.8% of children aged between 6 to 23 months received full immunization, and nearly 98.7% of mothers had attended antenatal care (ANC) follow-up sessions during their most recent pregnancy. See Table 4.Table 4 Children and maternal health seeking behavior in rural, Ethiopia, 2023.

Full size table

Children aged between 6–23 months feeding practice

Among the study participants, an overwhelming majority (99.8%) of children aged 6 to 23 months initiated breastfeeding within the first hour after birth. However, only a small fraction (4.9%) continued breastfeeding until they reached two years of age. See Table 5.Table 5 Children aged between 6–23 months feeding practice in rural, Ethiopia, 2023.

Full size table

Dietary diversity score of children aged between 6–23 months

The overall prevalence of minimal acceptable dietary diversity (more than 5 food groups) among the study participants was 35.5% (95% CI: 31.5–39.7) during the previous 24 h of the survey. The food groups most consumed by children aged between 6–23 months were vitamin A-rich foods (65%), other fruits and vegetables (60%), followed by grains and roots (58.6%). The least consumed food group by study participants were flesh foods. See Fig. 1

figure 1
Fig. 1

Factors associated with children aged between 6–23 months dietary diversity score

In multiple logistic regression, the variables significantly associated with unacceptable minimum dietary variety among children aged 6–23 months were identified at a p-value of 0.05: equal decision-making power, participation in cooking demonstrations, attendance at ANC follow-ups, nutrition counseling, food security status, and child growth and development-monitoring behavior.

In the current study, equal decision-making power was positively associated with adequate minimum dietary diversity in children aged between 6–23 months. Those children whose fathers and mothers made decisions together on major productive assets were 2.42 times more likely to have acceptable minimum dietary diversity than those whose parents did not make decisions together (AOR 2.42, 95% CI: 1.22, 4.70). Similarly, children who benefited from mother/caregiver participation in cooking demonstrations were 1.54 times more likely to achieve minimum acceptable dietary diversity compared to their counterparts (AOR 1.54, 95% CI: 1.06, 2.25).

Attendance at ANC follow-ups also showed an association in the present study. Children aged between 6–23 months whose mothers attended ANC follow-ups during the last pregnancy were 6.38 times more likely to be protected from poor dietary diversity compared to their counterparts (AOR 6.38, 95% CI: 2.6, 15.4). Similarly, nutrition counseling was positively associated with acceptable dietary diversity in children aged between 6–23 months. Children whose mothers or caregivers received nutrition counseling were 2.25 times more likely to achieve acceptable minimum dietary diversity than those whose mothers or caregivers did not receive nutrition counseling (AOR 2.25, 95% CI: 1.22, 4.16).

Household food security status also showed a significant association with minimum acceptable dietary diversity in children aged between 6–23 months. Children from food-secure households were 2.7 times more likely to have minimum acceptable dietary diversity compared with children from food-insecure households (AOR 2.7, 95% CI: 1.9, 4.06). Similarly, monitoring child growth and development also showed an association in the current study. Children from families that followed or monitored the growth and development of their children were 1.9 times more likely to achieve minimum acceptable dietary diversity compared to their counterparts (AOR 1.9, 95% CI 1.34, 2.85). See Table 6.Table 6 Both Bivariate and multivariable logistic regression analysis of factors associated with acceptable dietary diversity in children aged 6 to 23 months in south Ethiopia, 2023.

Full size table

Discussion

This study was conducted to determine the prevalence of good dietary diversity score and its associated factors among children aged between 6–36 months. The result of the current study indict that the overall prevalence of good diet diversity score among children aged 6 to 23 months was 35.5 ± 4% (95% CI 31.5, 39.7). This finding indicate that the prevalence of good dietary diversity score is very low in the study area.

The prevalence of the current study is slightly higher than the finding of study conducted in Gedeo zone21, and east Gojjam, North West Ethiopia22. The possible reason might be the time when the research were conducted. Mean that the study were conducted before 4 years and three years respectively. And another explanation might be behavioral characteristics of households and socio cultural condition.

In the present study, equitable decision-making power was found to be positively correlated with adequate minimum dietary diversity among children aged 6 to 23 months. Specifically, children whose parents jointly made decisions regarding major productive assets were more likely to achieve acceptable minimum dietary diversity compared to those whose parents did not collaborate in decision-making. This finding is consistent with results from studies conducted in other regions23,24,25,26. The possible explanation are equal decision-making power between women and their husbands can lead to enhanced influence over household nutrition choices, potentially resulting in improved dietary diversity for their children. Furthermore, women’s empowerment may grant them greater access to resources, thereby elevating the quality and variety of food accessible to children27.

Attendance at ANC follow-ups and nutrition counseling during the last pregnancy was also showed positively associated with children adequate dietary diversity. Children aged between 6–23 months from mothers’ who attending ANC follow ups and had nutrition counseling during the last pregnancy were more likely to had good dietary diversity as compared whit their counterpart. This finding is in line with study conducted in Nepal28. A possible explanation is that mothers who attend antenatal care (ANC) follow-up appointments receive extensive information and education about proper nutrition during pregnancy and the significance of dietary diversity for their children’s health. This knowledge likely motivates them to provide their children with a more varied diet, thereby enhancing their nutritional diversity.

Food security status also positively associated with adequate dietary diversity of children aged between 6–23 months in the present study. Children who from household food secure were more likely to had adequate dietary diversity than children who from household food insecure. This is similar with other study conducted in different area29,30,31,32. Children from food-secure families are more likely to have a diverse diet because their parents have constant access to a wide range of foods. This promotes a more appropriate intake of key nutrients. On the other hand, families with food insecurity may struggle to procure enough food, let alone a varied selection of foods, resulting in low dietary diversity and associated nutritional deficiencies.

Monitoring child growth and development is also associated with adequate dietary diversity among children aged 6 to 23 months. Children who receive regular monitoring from their mothers or guardians regarding their growth and development are more likely to have a diverse diet compared to their peers. This finding aligns with results from other studies27,33. This might be due to parental participation frequently involves nutrition advice, which can lead to healthier eating choices and a wider range of foods ingested.

This study has both strengths and limitations. One of its key strengths is providing valuable insights into the nutritional status of young children in a specific rural setting. It focuses on a critical age group 6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23months, which is essential for child development. The study employs a community-based cross-sectional design and structured interviews, ensuring comprehensive data collection and relevance to local contexts. However, the study’s limitations include potential recall bias from caregivers during interviews and the cross-sectional nature, which limits the ability to establish causality. Additionally, the findings may not be generalizable to other regions or urban settings in Ethiopia..

Conclusions

The findings of this study showed that equal decision-making power, participation in cooking demonstrations, attendance at ANC follow-ups, nutrition counseling, food security status, and child growth and development monitoring behavior were significantly associated with dietary diversity. Based on the findings of the study, the following recommendations are made. First, strategies and programs targeted towards promoting dietary diversity and good health among children aged between 6–23 months should be implemented at all levels, including promoting ANC follow-ups. Second, lactating mothers should be adequately provided with nutritional information for their children aged between 6–23 months.

Third, mothers should be empowered to alleviate household food insecurity by leveraging their premises for gardening diversified and nutritious vegetables.

Data availability

The dataset used and/or analysed during the current study available from the corresponding author on reasonable request.

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Funding

No funding received for the current study.

Author information

Authors and Affiliations

  1. School of Public Health, College of Health and Medical Sciences, Mizan-Tepi University, Mizan-Aman, EthiopiaTeshale Darebo, Rahel Dereje & Dinaol Abdissa Fufa

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Teshale Darebo, Rahel Dereje, Dinaol Abdissa Fufa: Conceived and designed the experiments; performed the experiments; analyzed and interpreted the data; contributed analysis tools or data; wrote the paper.

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Correspondence to Teshale Darebo or Dinaol Abdissa Fufa.

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Darebo, T., Dereje, R. & Fufa, D.A. Minimum dietary diversity and its associated factors among children of 6–23 months in rural Ethiopia 2023. Sci Rep 15, 9709 (2025). https://doi.org/10.1038/s41598-025-87320-0

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