The effect of UNIMMAP multiple micronutrient supplements versus iron-folic acid and placebo in anemia reduction among women of reproductive age in Kebribeyah Woreda, Somali Regional State, Ethiopia: a study protocol for a community-based individual RCT.

BACKGROUND: Women of reproductive age (WRA) in developing countries are often at risk of micronutrient deficiencies due to inadequate intakes and excessive losses. OBJECTIVE: The purpose of this trial is to assess the effectiveness of United Nations International Multiple Micronutrient Antenatal Preparation-Multiple Micronutrient Supplements (UNIMMAP-MMS) versus iron-folic acid (IFA) among WRA in reducing anemia. METHODS: Three parallel groups of WRA will participate in a community-based, individually randomized, double-blinded, placebo-controlled superiority trial. After consent, the sample of 375 mildly or moderately anemic women based on hemoglobin by Hemocue will be randomly assigned across two interventions and one control arm. Trial participants in intervention arms will receive UNIMMAP-MMS or IFA while those in the control arm will receive placebos twice a week for 17 weeks. The primary outcome will be a change in mean hemoglobin (Hb) concentrations. Outcome assessors and study participants will be blinded to the type of supplements and study arm. DISCUSSION: The World Health Organization (WHO) added UNIMMAP-MMS to its essential medicine lists in 2021 but recommended rigorous study. Several factors in addition to inadequate intakes of iron and folic acid contribute to the high prevalence of anemia among WRA in the Somali region. The findings of this study will provide evidence on the effect of UNIMMAP-MMS and IFA on Hb concentrations and anemia prevalence among anemic WRA. TRIAL REGISTRATION: ClinicalTrials.gov NCT05682261. Registered on January 12, 2023.

Dietary patterns in relation with nutritional outcomes and associated factors among adolescents: implications for context-specific dietary intervention for the Agrarian Community, Northwest Ethiopia.

Introduction: Dietary pattern analysis allows us to characterize the dietary intakes of individuals rather than nutrient intake data and strongly predicts disease risks. The relationship between food intake and adolescents' nutritional health is not well understood yet. Therefore, this study aimed to generate evidence for context-specific dietary intervention for adolescents. Objective: This study aimed to determine dietary patterns and their relationship with nutritional outcomes and identify the contributing factors among adolescents in the Agrarian Community of Northwest Ethiopia. Methods: A cross-sectional survey was conducted among 622 randomly selected adolescents. Dietary data were collected over a 1-week recall period using the Food Frequency Questionnaire (FFQ). After testing the basic assumptions, an exploratory factor analysis was conducted to determine the dietary patterns. Anthropometric data on weight and height were collected to determine the nutritional status using WHO Anthroplus 2010 software. A chi-square test was conducted to evaluate the effect of different dietary patterns on nutritional outcomes. A multivariable binary logistic regression model was used to identify factors affecting the dietary patterns of adolescents. Result: Three types of dietary patterns, namely, traditional, mixed, and animal-source foods with traditional alcoholic beverage consumption were identified. These dietary patterns explain 58.64% of the variance in adolescent diet in the study setting. The burden of stunting was 15.12% vs. 11.21, 19.40% vs. 6.94, and 8.36% vs.17.97% among adolescents with lower traditional, mixed, and higher animal sources with alcoholic dietary pattern consumption habits, respectively (value of p <0.05). Adolescents who resided in low-land agroecology (AOR = 2.44; 95% CL: 1.24, 4.81) and had access to animal-source foods (AOR = 1.64; 95% CI: 1.04, 2.60) were associated with lower consumption of traditional dietary patterns. Similarly, adolescents who resided in low-land (AOR = 1.80; 95% CI: 1.18, 2.74) had formal education (AOR = 2.38; 95% CI: 1.35, 4.19) and had poor nutrition knowledge (AOR = 2.83; 95% CL: 1.55, 5.19) were associated with lower consumption of mixed dietary patterns. Moreover, adolescents residing in the high-land (AOR = 2.50; 95% CI: 1.37, 4.56) and being female (AOR =1.87; 95% CI: 1.27, 2.74) were significant factors associated with lower consumption of animal-sourced foods with traditional alcoholic beverage consumption patterns. Conclusion: Multidimensional modifiable factors were explored that could be targeted for public health interventions for the identified dietary patterns. Integrated and multifaceted dietary intervention approaches are needed to promote healthy diets and discourage the consumption of unhealthy diets to reduce undernutrition in the study area and similar settings.

Exploring barriers to diversified dietary feeding habits among adolescents in the agrarian community, North West Ethiopia.

Introduction: Adolescence is a critical and neglected age group of the population in any form of nutritional intervention. A comprehensive study that assesses barriers that influence their diversified feeding habit is not well investigated in qualitative approaches. Therefore, this study was conducted to fill this gap by providing evidence on exploring barriers to diversified feeding habits of adolescents in the agrarian community, North West Ethiopia. Objective: The aim of the study was to explore barriers to diversified feeding habits of adolescents in the agrarian community, North West Ethiopia. Methods: A phenomenological qualitative study design was conducted among adolescents in the age group of 10-19 years, and adults in the age range of 25 to 64 years (representatives of farmers, agricultural, health, and education sectors). We conducted 24 in-depth interviews (12- adolescents, 4-health, 2- agricultural extension, 3-education, and 3-farmer representative) among purposively selected community groups. In-depth interview guides and observation checklist were utilized for data collection. The audio-recorded qualitative data were transcribed word by word into English. Finally, the translated data were exported to ATLAS ti version 7.1 software for thematic analysis based on inductive content analysis. All coded quotations, including memos written throughout the coding process, were then analyzed to identify themes inductively. Results: Dietary habit of adolescents in the study area was predominantly plant-based cereals with low protein, vitamins, and mineral contents. Adolescents have limited consumption of fruits, vegetables, and animal source foods. Adolescents with these feeding habits had suboptimal intake of micronutrients and proteins, which are crucial for their rapid growth stage. Individual-level barriers, family-level influence, dietary tradition of community, agricultural practice (poor agroforestry practice of the community, and poor agricultural practice to produce year-round diverse food items), and week multi-sectorial collaboration for nutritional intervention all influenced adolescent dietary habits. Conclusion: Multiple layers of barriers influenced the diverse dietary habits of adolescents in the study setting. These multiple and interconnected influences ranged from individual level to multi-sectorial collaboration. Nutritional interventions should be implemented at the individual, family, agricultural, and multi-sectorial levels to improve adolescents' diverse dietary habits.

Low breastmilk vitamin A concentration is prevalent in rural Ethiopia.

BACKGROUND: There is scant information on the breastmilk vitamin A (BMVA) concentration of lactating women in developing countries, partly due to lack of methods applicable in-field. OBJECTIVE: To assess BMVA concentrations of samples collected from lactating women of children aged 6-23 months, in Mecha district, Ethiopia. SUBJECTS/METHODS: Data on socio-demographic and anthropometric characteristics were collected from randomly selected lactating women (n = 104). Breast milk samples were collected and vitamin A concentrations were analyzed using HPLC and iCheck FLUORO then the two measurements were compared. RESULTS: The prevalence of underweight (BMI < 18.5 kg/m2) among lactating women was 17%. Seventy six percent of the BMVA values were <1.05 µmol/l and 81% were <8 µg/g fat. The mean BMVA concentration accounted to 41% of the estimated average value for mothers in developing countries. The BMVA values from HPLC and iCheck were correlated (r = 0.59, p = < 0.001), but it was not strong. CONCLUSIONS: The result indicates the low vitamin A status of the lactating women and their children. It further indicates that intake assessments should not use average BMVA composition. The possibility of using iCheck for monitoring interventions designed to improve vitamin A status of lactating women with low BMVA requires further investigation.

Simulated effects of home fortification of complementary foods with micronutrient powders on risk of inadequate and excessive intakes in West Gojjam, Ethiopia.

Home fortification of complementary foods (CFs) with multiple micronutrient powders (MNPs) is being scaled up in various countries, but little is known about the prevailing complementary feeding practices and the type and nutrient gaps to be filled with MNPs. The present study evaluated the complementary feeding practices of young children and simulated the risk of inadequate and excessive intakes associated with home fortification with MNPs. We have assessed the sociodemographic status, anthropometry, and complementary feeding practices of young children (N = 122) in Mecha district, rural Ethiopia. Using a 2-day, quantitative 24-hr recall, usual intakes of energy, protein, iron, zinc, and calcium were estimated. The risks of inadequate and excessive iron and zinc intakes with or without home fortification scenarios were assessed. The simulations considered intakes from CFs assuming average breast milk contributions and additional nutrients provided by the MNPs. Stunting was highly prevalent (50%) and was associated with a lower dietary diversity (P = .009) and nutrient intakes from the CFs. Median energy, zinc, and calcium intakes were below the estimated needs from CFs; protein needs were met. Median dietary iron intake appeared adequate, but 76%, 95% CI [68%, 84%], of children had inadequate intake (assuming low bioavailability), whereas another 8%, 95% CI: [3%, 13%], had excessive intakes. Simulation of daily and alternative day's fortification with MNP decreased the prevalence of inadequate iron and zinc intake but significantly increased the risk of excessive intakes that remained unacceptably high for iron (>2.5%). Untargeted MNP interventions may lead to excessive intakes, even in settings where poor complementary feeding practices are prevalent.

Child feeding style is associated with food intake and linear growth in rural Ethiopia.

BACKGROUND: Little is known about mother-child feeding interactions and how this is associated with food intake and linear growth. OBJECTIVE: To characterize mother-child feeding styles and investigate their associations with accepted mouthful and linear growth in west Gojam, rural Ethiopia. SUBJECTS/DESIGN: Two, in-home, meal observations of children aged 12-23 months (n = 100) were video-taped. The number of mouthful accepted was counted and the caregiver/child feeding styles were coded into positive/negative categories of self-feeding, responsive-feeding, active-feeding, social-behavior and distraction. Data on socio-demographic characteristics, child feeding practices, perception about child's overall appetite, and strategies adopted to overcome food refusal were collected through questionnaire-based interviews. Child and mothers' anthropometric measurements were also taken. RESULTS: Stunting was highly prevalent (48%) and the number of mouthful accepted was very low. Offering breastmilk and threatening to harm were the main strategies adopted to overcome food refusal. Although all forms of feeding style were present, active positive feeding style was dominant (90%) and was positively associated with mouthful accepted. Talking with non-feeding partner (64%), and domestic animals (24%) surrounding the feeding place were common distractions of feeding. Feeding was mostly terminated by caregivers (75%), often prematurely. Overall, caregivers of stunted children had poorer complementary- and breast-feeding practices and were less responsive to child's hunger and satiation cues (P < 0.05). Positive responsive feeding behaviors were associated with child's number of mouthful accepted (r = 0.27; P = 0.007) and stunting (r = 0.4; P < 0.001). CONCLUSION: Low complementary food intake in this setting is associated with caregivers' feeding style and stunting. Nutrition interventions that reinforce messages of optimal infant and young child feeding and integrate the promotion of responsive feeding behaviors are needed.

Health Extension Workers' Knowledge and Knowledge-Sharing Effectiveness of Optimal Infant and Young Child Feeding Are Associated With Mothers' Knowledge and Child Stunting in Rural Ethiopia.

BACKGROUND: Little is known about how the knowledge and the knowledge-sharing effectiveness (KSE) of health extension workers (HEWs) affect maternal knowledge of optimal infant and young child feeding (IYCF) and their child's nutritional status. OBJECTIVE: The objective of this study was to evaluate mothers' and HEWs' knowledge of key IYCF practices and to investigate whether mothers' knowledge and HEWs' KSE are associated with stunting in young children (aged 12-23 months). METHODS: This cross-sectional study used face-to-face interviews to assess the IYCF knowledge of HEWs (n = 96) and mothers of 12- to 23-month-old children (n = 122) in Mecha district, West Gojam, Ethiopia. The association between HEWs' KSE and children's length-for-age z scores (LAZ) was investigated. RESULTS: Stunting (50%), underweight (34%), and wasting (10%) were highly prevalent. Less than half (45%) of the mothers had access to nutrition education through the health extension program, but those who had, had better knowledge of IYCF practices and thus lower rates of stunting ( P < .001). However, key IYCF practices were not well understood by the HEWs and this affected their KSE. The gap in KSE was negatively associated with LAZ ( r = -.475, P < .001) and remained significant even after adjusting for maternal height, socioeconomic status, and maternal education ( r = -.423, P = .002). CONCLUSION: Health extension workers' KSE is associated with child stunting. Future training of HEWs would benefit from emphasis on not only the content of the IYCF messages but also the process of delivery while increasing their counseling skills.