# Minimum Meal Frequency Practice and Its Associated Factors among Children Aged 6–23 Months in Amibara District, North East Ethiopia

Authors: Mohammed Wagris; Anwar Seid; Molla Kahssay; Osman Ahmed
Journal: Journal of Environmental and Public Health
 (2019)

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## Abstract

Background. Minimum meal frequency, a proxy indicator for a child’s energy requirements, examines the number of times children received foods other than breast milk. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and increased morbidity and mortality. In Ethiopia, only 45% of children had fed with an age-appropriate minimum meal frequency. Objective. The study was aimed to assess the minimal meal frequency practice, and its associated factors among children aged 6–23 months in Amibara district, North East Ethiopia. Methods. A community-based cross-sectional study was conducted from May 07–May 23, 2018. Systematic random sampling technique was applied to select 367 children aged 6–23 months. The univariable and multivariable binary logistic regression analyses model was used to identify potential predictors of meeting minimum meal frequency. All variables with P values <0.25 in the univariable analysis were taken to multivariable analysis, and variables at P values <0.05 were considered as statistically significant. Results. The study revealed a prevalence of minimum meal frequency 69.2% (95% CI: 0.64–0.74). Timely initiation of breastfeeding (AOR = 2.2, 95% CI (1.17, 4.18)), current breastfeeding status (AOR = 7.5, 95% CI (3.95, 14.4)), meeting minimum dietary diversity (AOR = 3.7, 95% CI (1.85, 7.44)), and household hunger scale (AOR = 5.3, 95% CI (1.5, 12.5)) were some of the significant predictors to achieve minimum meal frequency. Conclusion. The prevalence of minimum meal frequency practice is low in the study area. Current breastfeeding status, timely initiation of breastfeeding, no/little household hunger scale, and meeting minimum dietary diversity were found as significant predictors for minimum meal frequency practice. Mothers having children aged 6–23 months should be aware and practice appropriate infant and young child feeding practices including timely initiation of breastfeeding, breastfeeding till the child celebrate his/her second birthday, recommended meal frequency, and dietary diversity practice. In addition, households should be assessed and strengthened for food security.


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## Body

## 1. Background

Adequate nutrition during birth to two years of age is a critical window period for the promotion of optimal growth, health, and behavioral development [1]. Around the age of 6 months, an infant's need for energy and nutrients increase. Hence, starting complementary foods are necessary to meet the infant's energy and nutrient requirements. Complementary foods should be introduced at 6 months of age and must be given appropriately, unless, infant's growth may falter [2].Inappropriate feeding practices are the most risk of malnutrition, illness, and mortality in both infants and young children less than 24 months of age, and more than two-thirds of children deaths related to malnutrition are associated with inappropriate feeding practices during the first 24 months of life [3].Over 50 million children under age five are wasted, and in low-income countries, one in every three children suffers from stunted growth; in reality, many children never reach this age, and the effects of poor nutrition and stunting continue throughout life, contributing to poor school performance, reduced productivity, and impaired intellectual and social development [4]. The level of malnutrition is high in Ethiopia [5].Minimum meal frequency, a proxy for a child’s energy requirements, examines the number of times children received foods other than breast milk. The minimum number is specific to the age and breastfeeding status of the child. Breastfed children are considered to be consuming minimum meal frequency if they receive solid, semisolid, or soft foods at least twice a day for infants of age 6–8 months and at least three times a day for children of age 9–23 months. Nonbreastfed children aged 6–23 months are considered to be fed with a minimum meal frequency if they receive solid, semisolid, or soft foods at least four times a day [6].Globally, only a few children are receiving nutritionally sufficient and diversified foods; in many countries, less than one fourth of infants aged 6–23 months meet the criteria for dietary diversity and feeding frequency [7]. The prevalence of minimum meal frequency practice among children aged 6–23 months in Ethiopia is very low, i.e., 45% [6]. There are limited studies regarding minimum meal frequency practice in pastoral community, and so far no similar study was done in the study area; hence, this study aimed to assess the prevalence of minimum meal frequency practice and its associated factors in Amibara district, Afar region, North East Ethiopia.


## 2. Methods

### 2.1. Study Area

This study was conducted in Amibara woreda. Amibara is one of the 32 woredas in Afar regional state. The woreda has bordered on the north by Gewani woreda, on the northwest by Hari Rasu (Samuroobi Galalu woreda) Administrative zone, on the south by awash fentiale woreda, on the east by Ethiopian Somali region, on the southeast by Oromia region, and on the west by Dulecha woreda.The Woreda is found 279 kms away from Addis Ababa capital city of Ethiopia and 360 kms away from Samara administrative town of Afar regional state. Currently, Amibara woreda has 19 kebelle (the smallest administrative unit in Ethiopia next to district) from this 15 are rural, and the rest 4 kebelles are urban kebelles.According to 2009, in the annual report of Amibara district, it had a total population of 81,811 of whom 44,178 were men and 37,633 were women, and of them, 8262 and 2, 455 were estimated to be children aged 6–59 months and children aged 6–23 months, respectively.The district population has pastoral and agropastoral community. The livelihood of the people in the community is irrigation and rain-fed crop production combined with livestock rearing. Cotton- and irrigation-based crop production was mainly practiced in the district. There are one hospital, four health centers, and twenty functional health posts in the district.


### 2.2. Study Design and Period

A community based cross-sectional study was conducted from May 7 to May 23, 2018.


### 2.3. Eligibility Criteria

All mothers having children aged 6–23 months were included in the study. Mothers having children aged 6–23 months, who were not able to respond the interviews due to illness, were excluded from the study.


### 2.4. Sample Size Determination

Sample size was calculated using a formula for a single population proportion considering 95% confidence level, 80% power, 5% margin of error, 68.4% maximum variability (prevalence of minimum meal frequency from a research conducted in South East Ethiopia [8]), and 10% nonresponse. The sample size was 333, and after adding 10% nonresponse rate, the final sample size was 367.(1)n=Zα/22∗P∗1−Pd2,n=1.962∗0.684∗0.3160.052=333.Upon adding 10% nonresponse rate ((333∗10%) + 333), the final sample size was 367.


### 2.5. Sampling Procedure

Simple random sampling technique was used to select six rural and two urban kebelles. Population proportion to size was used to estimate the number of samples from each kebelle. Finally, systematic random sampling technique was applied to select the study participants after a total of 1034 infants, and young children aged 6–23 months were obtained.


### 2.6. Data Collection Tools

The data collection tools were adopted from EDHS 2016 questionnaire with some modification and questionnaire assessing meal frequency and was adopted from WHO standardized questionnaire for infant and young child feeding (IYCF) practices.


### 2.7. Data Collection Procedure

Primarily questionnaire was formulated in English language. The English version questionnaire was translated to local language which is Afar’af language and then translated back to English to check for consistency. Eight data collectors and two supervisors were recruited to handle the overall data collection process.


### 2.8. Operational Definitions of Terms

#### 2.8.1. Minimum Meal Frequency

For the proportion of breastfed and nonbreastfed children who are 6–23 months of age and who receive solid, semisolid, or soft foods (but also including milk feeds for nonbreastfed children), the minimum is defined as: 2 times for breastfed infants aged 6–8 months, 3 times for breastfed children aged 9–23 months, and 4 times for nonbreastfed children aged 6–23 months [9].


#### 2.8.2. Minimum Dietary Diversity Score

It is the proportion of children who are 6–23 months of age and who receive foods from 4 or more food groups [9].


### 2.9. Data Quality Control

A local language (Afar’af) was used to collect the data. Data collectors were local language speakers. Pretest was done in 10% of the total samples. Pretest was done in nonselected kebelles of the woreda. Two days training was given for the data collectors and supervisors. Routine daily checkup was done by supervisors and principal investigator in data collection period.


### 2.10. Data Processing and Analysis

After the end of data collection, data were checked for completeness, entered in to Epi-data version 3.1 for cleaning and transported to SPSS version 20 for analysis. Descriptive analysis was used to see frequency and percentages of the characteristics. Binary logistic regression was used to assess significant predictors of the outcome variable. Variables havingP value <0.25 in univariable binary logistic regression were taken to multivariable binary logistic regression to control the confounding effect. Finally, odds Ratio (OR) and 95% confidence intervals (CI) were used to express the final mode, and statistical significance was declared at P value ≤0.05.


### 2.11. Ethical Consideration

Ethical clearance was obtained from Samara University Ethical Review Committee. Letter of support was obtained from the Afar Regional Health Bureau, Amibara woreda health office. Informed oral consent was also obtained from study participants.


## 2.1. Study Area

This study was conducted in Amibara woreda. Amibara is one of the 32 woredas in Afar regional state. The woreda has bordered on the north by Gewani woreda, on the northwest by Hari Rasu (Samuroobi Galalu woreda) Administrative zone, on the south by awash fentiale woreda, on the east by Ethiopian Somali region, on the southeast by Oromia region, and on the west by Dulecha woreda.The Woreda is found 279 kms away from Addis Ababa capital city of Ethiopia and 360 kms away from Samara administrative town of Afar regional state. Currently, Amibara woreda has 19 kebelle (the smallest administrative unit in Ethiopia next to district) from this 15 are rural, and the rest 4 kebelles are urban kebelles.According to 2009, in the annual report of Amibara district, it had a total population of 81,811 of whom 44,178 were men and 37,633 were women, and of them, 8262 and 2, 455 were estimated to be children aged 6–59 months and children aged 6–23 months, respectively.The district population has pastoral and agropastoral community. The livelihood of the people in the community is irrigation and rain-fed crop production combined with livestock rearing. Cotton- and irrigation-based crop production was mainly practiced in the district. There are one hospital, four health centers, and twenty functional health posts in the district.


## 2.2. Study Design and Period

A community based cross-sectional study was conducted from May 7 to May 23, 2018.


## 2.3. Eligibility Criteria

All mothers having children aged 6–23 months were included in the study. Mothers having children aged 6–23 months, who were not able to respond the interviews due to illness, were excluded from the study.


## 2.4. Sample Size Determination

Sample size was calculated using a formula for a single population proportion considering 95% confidence level, 80% power, 5% margin of error, 68.4% maximum variability (prevalence of minimum meal frequency from a research conducted in South East Ethiopia [8]), and 10% nonresponse. The sample size was 333, and after adding 10% nonresponse rate, the final sample size was 367.(1)n=Zα/22∗P∗1−Pd2,n=1.962∗0.684∗0.3160.052=333.Upon adding 10% nonresponse rate ((333∗10%) + 333), the final sample size was 367.


## 2.5. Sampling Procedure

Simple random sampling technique was used to select six rural and two urban kebelles. Population proportion to size was used to estimate the number of samples from each kebelle. Finally, systematic random sampling technique was applied to select the study participants after a total of 1034 infants, and young children aged 6–23 months were obtained.


## 2.6. Data Collection Tools

The data collection tools were adopted from EDHS 2016 questionnaire with some modification and questionnaire assessing meal frequency and was adopted from WHO standardized questionnaire for infant and young child feeding (IYCF) practices.


## 2.7. Data Collection Procedure

Primarily questionnaire was formulated in English language. The English version questionnaire was translated to local language which is Afar’af language and then translated back to English to check for consistency. Eight data collectors and two supervisors were recruited to handle the overall data collection process.


## 2.8. Operational Definitions of Terms

### 2.8.1. Minimum Meal Frequency

For the proportion of breastfed and nonbreastfed children who are 6–23 months of age and who receive solid, semisolid, or soft foods (but also including milk feeds for nonbreastfed children), the minimum is defined as: 2 times for breastfed infants aged 6–8 months, 3 times for breastfed children aged 9–23 months, and 4 times for nonbreastfed children aged 6–23 months [9].


### 2.8.2. Minimum Dietary Diversity Score

It is the proportion of children who are 6–23 months of age and who receive foods from 4 or more food groups [9].


## 2.8.1. Minimum Meal Frequency

For the proportion of breastfed and nonbreastfed children who are 6–23 months of age and who receive solid, semisolid, or soft foods (but also including milk feeds for nonbreastfed children), the minimum is defined as: 2 times for breastfed infants aged 6–8 months, 3 times for breastfed children aged 9–23 months, and 4 times for nonbreastfed children aged 6–23 months [9].


## 2.8.2. Minimum Dietary Diversity Score

It is the proportion of children who are 6–23 months of age and who receive foods from 4 or more food groups [9].


## 2.9. Data Quality Control

A local language (Afar’af) was used to collect the data. Data collectors were local language speakers. Pretest was done in 10% of the total samples. Pretest was done in nonselected kebelles of the woreda. Two days training was given for the data collectors and supervisors. Routine daily checkup was done by supervisors and principal investigator in data collection period.


## 2.10. Data Processing and Analysis

After the end of data collection, data were checked for completeness, entered in to Epi-data version 3.1 for cleaning and transported to SPSS version 20 for analysis. Descriptive analysis was used to see frequency and percentages of the characteristics. Binary logistic regression was used to assess significant predictors of the outcome variable. Variables havingP value <0.25 in univariable binary logistic regression were taken to multivariable binary logistic regression to control the confounding effect. Finally, odds Ratio (OR) and 95% confidence intervals (CI) were used to express the final mode, and statistical significance was declared at P value ≤0.05.


## 2.11. Ethical Consideration

Ethical clearance was obtained from Samara University Ethical Review Committee. Letter of support was obtained from the Afar Regional Health Bureau, Amibara woreda health office. Informed oral consent was also obtained from study participants.


## 3. Results

### 3.1. Sociodemographic Characteristics of Study Subjects

A total of 364 mother-child pairs with a response rate of 99.18% were included in the analysis. The mean age of mothers was26.4±5.40 years. More than half of study subjects were of age 20–34 years. Regarding educational status, about 44% of mothers were unable to read and write. 47.8 and 44.5 percent of the households are 3-4 and above 5 family members. Of the total study subjects, 297 (81.6%) were married, 255 (70.1%) were Muslim by religion. More than half of the respondents were Afar ethnic group, and two hundred forty eight (68.1%) were rural inhabitants (Table 1).Table 1
Sociodemographic and economic characteristics of study subjects in Amibara district, North East Ethiopia, 2018 (n = 364).
Variable
Category
Frequency
%
Age of the child (in months)
6–8
60
16.5
9–23
304
83.5
Sex of the child
Male
194
53.3
Female
170
46.7
Birth order of the child
1st
117
32.1
2nd-3rd
162
44.5
≥4th
85
23.4
Maternal age (in years)
<20 years
52
14.3
20–34 years
283
77.7
>34
29
8.0
Religion
Muslim
255
70.1
Orthodox
77
21.2
Protestant
30
8.2
Other
2
0.5
Maternal marital status
Married
297
81.6
Single
10
2.7
Divorced
42
11.5
Widowed
15
4.1
Household family size
2
28
7.7
3–4
174
47.8
≥5
162
44.5
Average HH monthly income
<1000
106
29.1
≥1000
258
70.9


### 3.2. Knowledge of Mothers on Infant and Young Child Feeding

Regarding the knowledge of mothers about child feeding, ten knowledge questions were provided. Participants who scored seven and above, 299 (82.1%) were considered as knowledgeable. Among 364 study participants interviewed, 315 (86.5%) of the mothers had heard of feeding diversified food to their children. Majority of the mothers (87.4%) knew that complementary foods should be introduced at six months of child age. With regard to dietary diversity, 321 (88.2%) mothers confirmed that a child should consume at least four types of food groups. 293 (80.5%) the mothers stated that even if a child did not feel hungry, it does not mean that his/her nutritional requirement is fulfilled. 283 (77.7%) of the mothers/caregivers recognized that giving only animal source food is not adequate for child growth and development (Table2).Table 2
Knowledge of mothers on infant and young child feeding among children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Knowledge variables
Frequency
%
Heard about importance of feeding diversified foods to a 6–23-month child
315
86.5
Complementary feeding should start at 6 months of child age
318
87.4
A 6–23-month child should eat four or more food groups
313
86
Giving meat is advisable for a 6–23- month child
283
77.7
One cause of childhood malnutrition is not having diversified foods
321
88.2
Did not feel hungry does not mean that the nutritional need of a child is fulfilled
293
80.5
One cause of childhood malnutrition is not starting complementary feeding at 6 months of child age
317
87.1
Feeding only animal products is not enough/adequate for a 6–23-month child
313
86
A 6–23- month child should feed organ meat, such as liver and kidney
237
65.1
A 6–23-month child should feed an egg
301
82.7
Overall knowledge score
Good knowledge
299
82.1
Poor knowledge
65
17.9


### 3.3. Dietary Practice of Study Subjects

Two hundred and sixty two (72%) children were breastfeeding during the interview. All study subjects had ever breastfed their children, and 239 (65.7%) had initiated breastfeeding within the first one hour of birth, but the rest one-third 34.3% mothers had started breastfeeding after one hour of birth. Around 138 (37.9%) had practiced prelacteal feeding and out of this, 35.5%, 32.6%, and 29.7% were given water, butter, and milk, respectively. Nearly one-third (29.9%) of children experienced illness 2 weeks prior to the survey (Table3).Table 3
Breastfeeding and meal frequency practice among children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Characteristics
Category
Frequency
Percentage
Prelacteal feeding
Yes
138
37.9
No
226
62.1
Currently breastfeeding
Yes
262
72
No
102
28
Child history of illness in the past 2 weeks
Yes
109
29.9
No
255
70.1
Timely initiation of breastfeeding
Yes
239
65.7
No
125
34.3
Minimum meal frequency 6–8 months and currently breastfeeding meal >2 times
Yes
53
91.4
No
5
8.6
Minimum meal frequency 9–23 months and currently breastfeeding meal >3 times
Yes
164
80.4
No
40
19.6
Minimum meal frequency 6–23 months and currently not breastfeeding meal >4 times
Yes
35
34.3
No
67
65.7
Overall minimum meal frequency (number of minimum meals for their age)
Yes
252
69
No
112
31


### 3.4. Minimum Meal Frequency Practice

The overall minimum meal frequency was practiced in 69.2% (95% CI: 0.64, 0.74%) of the participants. To compute minimum meal frequency, infants were categorized into currently breastfeeding (72%) and currently nonbreastfeeding (28%). Age categorization of infants was also used to compute minimum meal frequency. Based on that, 53 (91.4%) and 164 (80.4%) of currently breastfeeding infants aged 6–8 months 9–23 months met the minimum meal frequency, respectively. Regarding nonbreastfeeding infants 24 hrs prior to this survey, only 35 (34.3%) met minimum meal frequency (Table3).


### 3.5. Maternal Health Care Utilization Characteristics of Study Subjects

Regarding health service utilization, 40% of the study subjects had antenatal care visit for more than three times, and 64.6.% of the study subjects had postnatal care visit. About 223 (76.4%) and 206 (87.7%) of mothers received nutrition counseling on infant and young child feeding practices by health professionals during their antenatal and postnatal visit, respectively. Around seventy percent of mothers gave birth at health institutions (Table4).Table 4
Maternal health care utilization characteristics of mothers having children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Variable
Category
Frequency
%
Parity of mother
1
113
31
2–4
194
53.3
≥5
57
15.7
History of antenatal care visit
Yes
292
80.2
No
72
19.8
Frequency of antenatal care visit (n = 292)
1st visit
3
0.8
2-3 visit
142
39
≥4
147
40.4
Counseling on infant and young child feeding during ANC visit (n = 292)
Yes
223
76.4
No
69
23.6
Postnatal care service visit
Yes
235
64.6
No
129
35.4
Counseling on infant and young child feeding during PNC visit (n = 235)
Yes
206
87.7
No
29
12.3
Place of delivery
Home
108
29.7
Health institution
256
70.3


### 3.6. Factors Associated with Minimal Meal Frequency Practice

In univariable binary logistic regression, residence, place of delivery, antenatal care visit, postnatal care visit, maternal education, timely initiation of breastfeeding, current breastfeeding status, source of food, household hunger scale, meat minimum dietary diversity, family size, and media exposure were some of the determinant factors (withP value <0.25) for meeting minimum meal frequency. Those variables having the P value of <0.25 in univariable analysis were taken to multivariable binary logistic regression analysis. In multivariable binary logistic regression analysis, those variables with P value <0.05 were considered significant predictors to meet minimum meal frequency. Therefore, timely initiation of breastfeeding, current breastfeeding status, meeting minimum dietary diversity, and household hunger scale were some of the predictor variables with P value <0.05. Respondents who had experienced timely initiation of breastfeeding were 2 times more likely to meet minimum meal frequency comparing with their counterparts, AOR = 2.2, 95% CI (1.17, 4.18). Currently, breastfeeding children were 7.5 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 7.5, 95% CI (3.95, 14.4). Children who had met minimum dietary diversity score were 3.7 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 3.7, 95% CI (1.85, 7.44). Children from household with no and little household hunger scale were 5 times more likely to achieve minimum meal frequency comparing with children from households with moderate-to-severe hunger scale, AOR = 5.3, 95% CI (1.5, 12.5) (Table 5).Table 5
Binary logistic regression analysis for determinants of meeting minimum meal frequency among children aged 6–23 months in Amibara district, North East Ethiopia, Ethiopia, 2018 (n = 364).
Variables
Meet minimum meal frequency
COR (95% CI)
AOR (95% CI)
Yes
No
Residence
Urban
86
30
1.42 (0.87, 2.32)
0.69 (0.33, 1.41)
Rural
166
82
1
1
Place of delivery
Home
63
45
1
1
Health institution
189
67
2 (1.26, 3.23)∗
1.35 (0.55, 3.32)
ANC service visit
Yes
211
81
1.97 (1.12, 3.34)∗
1.8 (0.69, 4.7)
No
41
31
1
1
PNC service visit
Yes
173
62
1.77 (1.12, 2.79)∗
1.5 (0.65, 3.7)
No
79
50
1
1
HH hunger scale
Little to no hunger
247
93
10.1 (3.67, 17.4)∗
5.3 (1.5, 12.5)∗
Severe to moderate hunger
5
19
1
1
Early initiation of breastfeeding
Yes
195
44
5.29 (3.27, 8.5)∗
2.2 (1.17, 4.18)∗
No
57
68
1
1
Media exposure
Yes
168
52
2.3 (1.47, 3.64)∗
1.32 (0.65, 2.65)
No
84
60
1
1
Currently breastfeeding
Yes
217
45
9.23 (5.49, 15.5)
7.5 (3.95, 14.4)∗
No
35
67
1
1
Source of food
Own production
15
7
4 (1.36, 11.9)∗
4.61 (0.95, 13.4)
Purchase
221
75
5.53 (2.85, 10.7)∗
1.94 (0.76, 4.95)
Food aid
16
30
1
1
MDDS
Yes
141
95
4.4 (2.48, 7.8)∗
3.71 (1.85, 7.44)∗
No
111
17
1
1
Note:∗P value <0.05; COR: crude odds ratio; AOR: adjusted odds ratio.


## 3.1. Sociodemographic Characteristics of Study Subjects

A total of 364 mother-child pairs with a response rate of 99.18% were included in the analysis. The mean age of mothers was26.4±5.40 years. More than half of study subjects were of age 20–34 years. Regarding educational status, about 44% of mothers were unable to read and write. 47.8 and 44.5 percent of the households are 3-4 and above 5 family members. Of the total study subjects, 297 (81.6%) were married, 255 (70.1%) were Muslim by religion. More than half of the respondents were Afar ethnic group, and two hundred forty eight (68.1%) were rural inhabitants (Table 1).Table 1
Sociodemographic and economic characteristics of study subjects in Amibara district, North East Ethiopia, 2018 (n = 364).
Variable
Category
Frequency
%
Age of the child (in months)
6–8
60
16.5
9–23
304
83.5
Sex of the child
Male
194
53.3
Female
170
46.7
Birth order of the child
1st
117
32.1
2nd-3rd
162
44.5
≥4th
85
23.4
Maternal age (in years)
<20 years
52
14.3
20–34 years
283
77.7
>34
29
8.0
Religion
Muslim
255
70.1
Orthodox
77
21.2
Protestant
30
8.2
Other
2
0.5
Maternal marital status
Married
297
81.6
Single
10
2.7
Divorced
42
11.5
Widowed
15
4.1
Household family size
2
28
7.7
3–4
174
47.8
≥5
162
44.5
Average HH monthly income
<1000
106
29.1
≥1000
258
70.9


## 3.2. Knowledge of Mothers on Infant and Young Child Feeding

Regarding the knowledge of mothers about child feeding, ten knowledge questions were provided. Participants who scored seven and above, 299 (82.1%) were considered as knowledgeable. Among 364 study participants interviewed, 315 (86.5%) of the mothers had heard of feeding diversified food to their children. Majority of the mothers (87.4%) knew that complementary foods should be introduced at six months of child age. With regard to dietary diversity, 321 (88.2%) mothers confirmed that a child should consume at least four types of food groups. 293 (80.5%) the mothers stated that even if a child did not feel hungry, it does not mean that his/her nutritional requirement is fulfilled. 283 (77.7%) of the mothers/caregivers recognized that giving only animal source food is not adequate for child growth and development (Table2).Table 2
Knowledge of mothers on infant and young child feeding among children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Knowledge variables
Frequency
%
Heard about importance of feeding diversified foods to a 6–23-month child
315
86.5
Complementary feeding should start at 6 months of child age
318
87.4
A 6–23-month child should eat four or more food groups
313
86
Giving meat is advisable for a 6–23- month child
283
77.7
One cause of childhood malnutrition is not having diversified foods
321
88.2
Did not feel hungry does not mean that the nutritional need of a child is fulfilled
293
80.5
One cause of childhood malnutrition is not starting complementary feeding at 6 months of child age
317
87.1
Feeding only animal products is not enough/adequate for a 6–23-month child
313
86
A 6–23- month child should feed organ meat, such as liver and kidney
237
65.1
A 6–23-month child should feed an egg
301
82.7
Overall knowledge score
Good knowledge
299
82.1
Poor knowledge
65
17.9


## 3.3. Dietary Practice of Study Subjects

Two hundred and sixty two (72%) children were breastfeeding during the interview. All study subjects had ever breastfed their children, and 239 (65.7%) had initiated breastfeeding within the first one hour of birth, but the rest one-third 34.3% mothers had started breastfeeding after one hour of birth. Around 138 (37.9%) had practiced prelacteal feeding and out of this, 35.5%, 32.6%, and 29.7% were given water, butter, and milk, respectively. Nearly one-third (29.9%) of children experienced illness 2 weeks prior to the survey (Table3).Table 3
Breastfeeding and meal frequency practice among children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Characteristics
Category
Frequency
Percentage
Prelacteal feeding
Yes
138
37.9
No
226
62.1
Currently breastfeeding
Yes
262
72
No
102
28
Child history of illness in the past 2 weeks
Yes
109
29.9
No
255
70.1
Timely initiation of breastfeeding
Yes
239
65.7
No
125
34.3
Minimum meal frequency 6–8 months and currently breastfeeding meal >2 times
Yes
53
91.4
No
5
8.6
Minimum meal frequency 9–23 months and currently breastfeeding meal >3 times
Yes
164
80.4
No
40
19.6
Minimum meal frequency 6–23 months and currently not breastfeeding meal >4 times
Yes
35
34.3
No
67
65.7
Overall minimum meal frequency (number of minimum meals for their age)
Yes
252
69
No
112
31


## 3.4. Minimum Meal Frequency Practice

The overall minimum meal frequency was practiced in 69.2% (95% CI: 0.64, 0.74%) of the participants. To compute minimum meal frequency, infants were categorized into currently breastfeeding (72%) and currently nonbreastfeeding (28%). Age categorization of infants was also used to compute minimum meal frequency. Based on that, 53 (91.4%) and 164 (80.4%) of currently breastfeeding infants aged 6–8 months 9–23 months met the minimum meal frequency, respectively. Regarding nonbreastfeeding infants 24 hrs prior to this survey, only 35 (34.3%) met minimum meal frequency (Table3).


## 3.5. Maternal Health Care Utilization Characteristics of Study Subjects

Regarding health service utilization, 40% of the study subjects had antenatal care visit for more than three times, and 64.6.% of the study subjects had postnatal care visit. About 223 (76.4%) and 206 (87.7%) of mothers received nutrition counseling on infant and young child feeding practices by health professionals during their antenatal and postnatal visit, respectively. Around seventy percent of mothers gave birth at health institutions (Table4).Table 4
Maternal health care utilization characteristics of mothers having children aged 6–23 months in Amibara district, North East Ethiopia, 2018 (n = 364).
Variable
Category
Frequency
%
Parity of mother
1
113
31
2–4
194
53.3
≥5
57
15.7
History of antenatal care visit
Yes
292
80.2
No
72
19.8
Frequency of antenatal care visit (n = 292)
1st visit
3
0.8
2-3 visit
142
39
≥4
147
40.4
Counseling on infant and young child feeding during ANC visit (n = 292)
Yes
223
76.4
No
69
23.6
Postnatal care service visit
Yes
235
64.6
No
129
35.4
Counseling on infant and young child feeding during PNC visit (n = 235)
Yes
206
87.7
No
29
12.3
Place of delivery
Home
108
29.7
Health institution
256
70.3


## 3.6. Factors Associated with Minimal Meal Frequency Practice

In univariable binary logistic regression, residence, place of delivery, antenatal care visit, postnatal care visit, maternal education, timely initiation of breastfeeding, current breastfeeding status, source of food, household hunger scale, meat minimum dietary diversity, family size, and media exposure were some of the determinant factors (withP value <0.25) for meeting minimum meal frequency. Those variables having the P value of <0.25 in univariable analysis were taken to multivariable binary logistic regression analysis. In multivariable binary logistic regression analysis, those variables with P value <0.05 were considered significant predictors to meet minimum meal frequency. Therefore, timely initiation of breastfeeding, current breastfeeding status, meeting minimum dietary diversity, and household hunger scale were some of the predictor variables with P value <0.05. Respondents who had experienced timely initiation of breastfeeding were 2 times more likely to meet minimum meal frequency comparing with their counterparts, AOR = 2.2, 95% CI (1.17, 4.18). Currently, breastfeeding children were 7.5 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 7.5, 95% CI (3.95, 14.4). Children who had met minimum dietary diversity score were 3.7 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 3.7, 95% CI (1.85, 7.44). Children from household with no and little household hunger scale were 5 times more likely to achieve minimum meal frequency comparing with children from households with moderate-to-severe hunger scale, AOR = 5.3, 95% CI (1.5, 12.5) (Table 5).Table 5
Binary logistic regression analysis for determinants of meeting minimum meal frequency among children aged 6–23 months in Amibara district, North East Ethiopia, Ethiopia, 2018 (n = 364).
Variables
Meet minimum meal frequency
COR (95% CI)
AOR (95% CI)
Yes
No
Residence
Urban
86
30
1.42 (0.87, 2.32)
0.69 (0.33, 1.41)
Rural
166
82
1
1
Place of delivery
Home
63
45
1
1
Health institution
189
67
2 (1.26, 3.23)∗
1.35 (0.55, 3.32)
ANC service visit
Yes
211
81
1.97 (1.12, 3.34)∗
1.8 (0.69, 4.7)
No
41
31
1
1
PNC service visit
Yes
173
62
1.77 (1.12, 2.79)∗
1.5 (0.65, 3.7)
No
79
50
1
1
HH hunger scale
Little to no hunger
247
93
10.1 (3.67, 17.4)∗
5.3 (1.5, 12.5)∗
Severe to moderate hunger
5
19
1
1
Early initiation of breastfeeding
Yes
195
44
5.29 (3.27, 8.5)∗
2.2 (1.17, 4.18)∗
No
57
68
1
1
Media exposure
Yes
168
52
2.3 (1.47, 3.64)∗
1.32 (0.65, 2.65)
No
84
60
1
1
Currently breastfeeding
Yes
217
45
9.23 (5.49, 15.5)
7.5 (3.95, 14.4)∗
No
35
67
1
1
Source of food
Own production
15
7
4 (1.36, 11.9)∗
4.61 (0.95, 13.4)
Purchase
221
75
5.53 (2.85, 10.7)∗
1.94 (0.76, 4.95)
Food aid
16
30
1
1
MDDS
Yes
141
95
4.4 (2.48, 7.8)∗
3.71 (1.85, 7.44)∗
No
111
17
1
1
Note:∗P value <0.05; COR: crude odds ratio; AOR: adjusted odds ratio.


## 4. Discussion

The prevalence of children aged 6–23 months who received the recommended minimum meal frequency were 69% (95% CI: 0.64–0.74). The minimum meal frequency practice was nearly similar with the study conducted in Bale Zone, South West Ethiopia (68.4%) [8], but less than from Bangladesh (81%), Colombia (72%), Bolivia (74%), and Madagascar (76%), [10]. This difference might be due to the livelihood nature of the pastoral community and household food insecurity.The minimum meal frequency practice was higher than the finding from Ethiopian demographic and health survey (45%) [6], Dangila town northwest Ethiopia (50.4%) [11], Assella town South East Ethiopia (53.8%) [12], Egypt (58%) [10], Ghana (46%) [13], and northern Ghana (57.3%) [14]. This might be due to a difference in the study period, and sociodemographic characteristics of study population.Regarding factors associated with achieving minimum meal frequency, respondents who had experienced timely initiation of breastfeeding were 2 times more likely to meet minimum meal frequency comparing with their counterparts, AOR = 2.2, 95% CI (1.17, 4.18). This can be due to that mothers who had appropriate infant and young child feeding practice (timely initiation of breastfeeding) are more likely to continue such positive and appropriate practice including feeding their children with appropriate meal frequency. Besides, mothers who had a positive experience are thought to have a previous exposure of appropriate practices.Currently, breastfeeding children were 7.5 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 7.5, 95% CI (3.95, 14.4). This can be possibly because the meal frequency of breastfeeding children decreases comparing with those nonbreastfeeding children, and nonbreastfeeding children are requested to eat at least four meals per day, but there is at least one meal reduction in breastfeeding children to fulfill the criteria for achieving minimum meal frequency.Children who had met minimum dietary diversity score were 3.7 times more likely to achieve minimum meal frequency comparing with their counterparts, AOR = 3.7, 95% CI (1.85, 7.44). This is due to that households with the availability of diversified food are more likely to feed their children frequently. Availability of food is one core criterion to achieve minimum meal frequency.Children from household with no and little household hunger scale were 5 times more likely to achieve minimum meal frequency comparing with children from households with moderate-to-severe hunger scale, AOR = 5.3, 95% CI (1.5, 12.5). This might be due to low purchasing capacity of households for food items. If food is not available in households, it is too tough for the children to get a required number of meals.


## 5. Limitation of the Study

Due to the fact that the study was a cross-sectional study, describing cause and effect relationship of the exposure and outcome variables is difficult.


## 6. Conclusion

The prevalence of minimum meal frequency practice is low in the study area. Current breastfeeding status, timely initiation of breastfeeding, no/little household hunger scale, and meeting minimum dietary diversity were found as significant predictors for minimum meal frequency practice. Mothers having children aged 6–23 months should be aware and practice appropriate infant and young child feeding practices including timely initiation of breastfeeding, breastfeeding till the child celebrate his/her second birthday, recommended meal frequency, and recommended dietary diversity practice. In addition, households should be assessed and strengthened for food security.



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*Source: 8240864-2019-12-18.xml*