Spatial distribution of inadequate meal frequency and its associated factors among children aged 6–23 months in Ethiopia: Multilevel and spatial analysis
Authors: Tesfie Tigabu Kidie , Endalew Bekalu , Birhanu Molla Yigzaw , Haimanot Aysheshim Belaineh , Mneneh Anteneh Lamesgen , Mengie Muluye Gebrie , Mazengia Elyas Melaku , Simegn Mulat Belay , Agimas Muluken Chanie , Derseh Nebiyu Mekonnen , Argaw Girum Shibeshi , Tilahun Werkneh Melkie 
Published: July 2024

Introduction
More than two-third of global child death is occurred due to inappropriate feeding practice that happened during early childhood period. Evidence on meal frequency status among infant and young children at national level can be used to design appropriate interventions to improve the recommended feeding frequency. Therefore, this study was aimed to explore the spatial distribution and identify associated factors of inadequate meal frequency among children aged 6–23 months in Ethiopia.

Methods
Secondary data analysis was conducted using the 2019 mini Ethiopian Demographic and Health Survey data. A total weighted sample of 1,532 children aged 6–23 months were included. To identify significant factors associated with of inadequate meal frequency, multilevel binary logistic regression model was fitted. Variables with p-value < 0.25 from the bi-variable model were exported to multivariable analysis. In the multivariable model, variables with p-value < 0.05 were declared as significantly associated factors and adjusted odds ratio (AOR) with its 95% confidence interval were reported. Multilevel models were compared using deviance and log-likelihood. Spatial analysis tools were utilized to visualize the distribution of inadequate meal frequency. Bernoulli model was fitted using SaTScan V.9.6 to identify most likely clusters and ArcGIS V.10.8 was used to map the hotspot areas. Ordinary least square and geographic weighted regression models were used and compared using information criteria and adjusted-R2. Local coefficients of factors associated with hotspots of inadequate meal frequency were mapped.

Results
The prevalence of inadequate meal frequency was 47.03% (95% CI: 44.54%, 49.53%) in Ethiopia. Age of the child, sex of the household head, timely initiation of breastfeeding, current breastfeeding status, number of antenatal care visit, maternal education, and region were significantly associated with inadequate meal frequency. The spatial distribution of inadequate meal frequency was showed significant variation across Ethiopia (Global Moran’s I = 0.164, p-value <0.001). A total of 38 significant clusters were detected through SaTScan analysis, from these the 22 primary clusters were located in Somali and Harari.

Conclusion and recommendation
The prevalence of inadequate meal frequency was high in Ethiopia and had significant clustering patter. Significant hotspot clusters were located in Somali, northern Afar, Harari, Amhara, Gambela, and eastern South nation nationalities and peoples’ region. Therefore, public health interventions which enhance breastfeeding practice, optimal number of antenatal care visits, educational empowerments should target hotspot areas to decrease inadequate meal frequency practice.