Dietary diversity (DD) has long been recognized by nutritionists as a key element of high quality diets. Increasing the variety of foods across and within food groups is recommended in most dietary guidelines internationally [1,2].

Insufficient quantities and inadequate quality of complementary foods, poor child feeding practices, and high rates of infections have a detrimental effect on health and growth in children less than 2 years of age. Even with optimum breastfeeding, children will become stunted if they do not receive sufficient dietary diversity and meal frequency after 6 months of age [3,4].

The transition period from exclusive breastfeeding to two years is a critical window for optimal growth and development of the child. During this period, appropriate, safe, adequately nourished and frequent feeding is essential [5].

For vulnerable infants and young children, the problem is particularly critical because they need energy and nutrient dense foods to grow and develop both physically, mentally and to live a healthy life [6]. An estimated 6% of under-five deaths can be prevented by ensuring optimal complementary feeding among which dietary diversity and meal frequency are the most important ones, significantly contributing to the realization of Millennium Development Goal 4 [7,8].

Meeting minimum standards of dietary quality is a challenge in many developing country settings including Ethiopia, especially in areas where household food security is poor, and it has often not been given enough emphasis. Children may not be fed frequently enough during the day, or the quality of the food may be inadequate [9-12].

In developing countries where the main concern is dietary deficit, nutrient adequacy alone is often used to refer to dietary quality. However, quantifying intake of nutrients is often expensive, time consuming and associated with methodological challenges. Dietary diversity is frequently assessed by the use of simple tools such as diversity scores, i.e., the number of food groups consumed over a reference period. These scores are promising measurement tools in industrialized as well as developing countries, and several studies indicate that they are good proxies of overall dietary quality [13-15].

Recently there has been lack of evidence regarding dietary diversity status and determinant factors in Kamba community therefore this study was conducted to that directs policy makers to draw appropriate intervention measures to improve and flourish the health of future generation.

Study setting and source population

This community based cross sectional study was conducted on 579 mothers who had young child from 6 to 23 months in Southern parts of Ethiopia in Kamba Woreda in 2014. Kamba Woreda is one of the administrative Woreda in Gamo Gofa Zone, South Ethiopia 100 kms away from Zonal town Arba Minch and 505 Kms from Addis Ababa. From the total population around 44,000 are women in reproductive age group. The local communities are largely depending on subsistence agriculture economy. The health institution distribution in the Woreda is 39 health posts and 9 health centers providing health services including maternal and child health care [16-18].

Inclusion and exclusion criteria

Mothers/care givers who have young children from 6 to 23 months who live in the selected Keble for at list 6 months were included in the study and those who had mental illnesses interfering the interview were not considered in study.

Sample size determination

The sample size was determined by using single population proportion formula by the following assumption for prevalence of minimum dietary diversity feeding practice 17.8% in among mothers having children 6-23 months-of-age in Northern Ethiopia [19], desired precision (d) =4% and 95% confidence level.

The final sample size was calculated by taking 1.5 design effect and 10% none response rate which is 579.

Sampling methods and procedures

From all small Keble (smallest administrative unit) in the Woreda, eight Kebles were selected by using lottery method. Then the number of study participants was allocated for each Keble based on proportional to population size allocation method by using community based demographic and health related information registration prepared by health extension workers as the sampling frame. Preliminary survey was conducted first to identify the target households which have young child from 6 to 23 months. Finally infant-mother pairs were selected from each Keble by using simple random sampling methods after giving code for each house hold which have young child from 6 to 23 month and house to house interview was under taken [20].

Data collection procedure

Data was collected from mothers/care givers who have one child in age 6 to 23 months from each household by direct interviewing. Pre tested and structured questioner was used to collect data on socio demographic characteristics and maternal characteristics. First dietary diversity score tools was adapted from WHO infant young child feeding gridline which contains seven food items (groups) for young child dietary diversity from 6 to 23 months [17]. Data on dietary diversity was collected by allowing mothers freely to recall the type of food items feed their child within 24 hours. Then the data collector’s records the child dietary diversity with the help of seven food items [17,18].

Data quality control

First the questioner was prepared in English and translated to Amharic and pre tested on 5% of mothers before actual data collection outside the selected kebeles; correction and modification was done based on the gap identified during interview. Sixteen Grade 12 completed female students were recruited as data collectors and supervised by 4 clinical nurses. Two day training was given on the aim of the research, content of the questionnaire, and how to conduct interview for data collectors and supervisor to increase their performance in field activities. The Collected data was checked every day by supervisors and principal investigator for its completeness and consistency.

Data analysis and management

Data was coded and entered in to EPI Info version 3.5.1 and exported to SPSS Version 20 for analysis. Missing values checked by conducting simple frequency analysis. Exploratory data analysis was done to check missing values, potential outliers and the normality distribution for those continuous variables. The presence of multi-collinearity also was checked and effort was made to incorporate different models to cross check. Frequencies and cross tabulation were calculated to describe the study population in relation to relevant variables. Binary logistic regression analysis was conducted to assess the crude association between dependent and independent variables. Finally Independent variables which show association in binary logistic regression analysis and those which have P-value less than 0.25 entered in to multivariate logistic regression model, to identify significant factors associated with outcome variables.

Finally significant factors were identified based on AOR include with 95% confidence level which did not include none value and P-value less than 0.05 [21-24].

Data was kept in the form of file in secure place where no one access except the investigator, confidentiality was insured by not recording names or any personal identifiers.

Operational definition and definition of terms

Minimum dietary diversity: Proportion of children 6-23 months of age who receive foods from four or more food groups during the previous day considered as adequate and three and below is considered as inadequate (low). The seven food groups used for tabulation of this indicator were: grains, legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, chicken and liver/organ meats); eggs; vitamin A rich fruits and vegetables; and other fruits and vegetables consumption of any amount and quality of foods from each food group was sufficient to ‘count’ [16-18].

Complementary feeding: is the period (between 6-2 years) during which foods or liquids are provided along with continued breastfeeding [16-18].

Growth monitoring practices-it is routine activity performed by health professional at health facility and Community level to screen nutritional status in fewer than five children [17].

The proposal was submitted to the Research ethics committee (REC) of Addis continental institute of Public Health. Ethical clearance was obtained from Addis continental institute of Public Health. Permission letter was obtained from Kamba Woreda Health office. Verbal informed consent from each study participant was obtained after clear explanation about the purpose of the study. All the study participants were reassured that they would be anonymous. Names or any personal identifiers were not recorded. Respondents were clearly told about the study and the variety of information needed from them. They were given the chance to ask anything about the study and made free to refuse or stop the interview at any moment they want if that was their choice [25].

Socio-demographic characteristics of mothers and young child

Among mother interviewees having young child-266 were male (47.3%), and 296 were female (52.7%). The mean age of young child was 13.75 months ± 5.95 (SD). One third of respondents had no formal education and half of them were government workers and student in there occupational status (Table 1).

Table 1: Socio-demographic Characteristics of mothers, who had infant aged from 6 to 23 months, who live in Kamba Woreda, 2014

Prevalence of dietary diversity and type of diversified food items in Kamba Woreda, South Ethiopia

Among mothers who took part in the study, i.e. 131 (23.3%) fed their child ≥4 food items and the rest 431 (76.7%) fed ≤3 food items within 24 hours preceding the survey based on WHO young child feeding guide line indictors on dietary diversity. The dominant food items were grain and legumes. Low feeding practice was observed on animal source food like eggs and meat which is 17.3% and 2% respectively (Figure 1). Among mothers who fed their child minimum dietary diversity (≥ food groups) 33.59% were in age group 9-12 months (Figure 2) [26].

Figure 1: Kameba Woreda smallest administrative unit.

Figure 2: Dietary diversity feeding practices of mothers for their young child in Kamba Woreda Southern Ethiopia in 2014.

As study revealed that mother had relatively good practice dietary diversity feeding practice in age group of 6 to 8 months and decrease in age group above 9 months (Figure 3).

Figure 3: Dietary diversity feeding pattern of mothers by age group for their young child in Kamba Woreda Southern Ethiopia in 2014

Factors associated with dietary diversity feeding practices

After conducting multivariate analysis of delivery venue, those who gave birth at health facility Adjusted odd ratio (AOR) 4.45 (2.08-9.54), Growth monitoring practice in health facility AOR 2.28 (1.33-3.89), those who had access to cow milk AOR 2.01 (1.19-3.37) and those who work in home as housewives AOR 2.50 (1.23-4.93) were significant identified factors for minimum dietary diversity feeding practice (Table 2) [27].

Table 2: Association between dietary diversity feeding practice and each explanatory variable (Crude and adjusted OR) among 6 to 23 months young child in Kamba Woreda, Southern Ethiopia in 2014. **Significant factors

This community based cross-sectional study identified the prevalence of dietary diversity feeding practice was 131 (23.3%) fed their child four or more varieties of foods and the rest 431 (76.7%) feed ≤3 food items from the seven food groups in 24 hour preceding the survey based on the WHO recommendation and indicators [26,28], the finding is higher than national prevalence which is 10.8% and relatively higher from recent study conducted in North Ethiopia Mekelle city which is 17.8% [29],and relatively lower than from finding from Nepalese (30.4%) [30].

The possible explanation for this variations in the prevalence of dietary diversity feeding practice have been observed and direct comparisons is difficult because of differences in methodology (the current study was conducted by primary data source and the previous were utilize secondary data source [10,25], study setting, study population dynamics, timing of the study, and related socioeconomic factors [29,31]. Even though Ethiopian Government implemented through health extension programs by adapting WHO infant and young child feeding practice guideline [27]; however the achievement is not satisfactory in dietary diversity feeding practice which is a core feeding practice for the wellbeing of a child [23,29]. The dominant dietary food items were grain (96.3%) and legumes (76.2%) this is consistent with study conducted in north Ethiopia, but low feeding practice is observed in diary and dairy products, meat, Vitamin A rich fruits and vegetables. The possible explanations might be misunderstanding of mothers young children could not be able to digest food like meat and egg; and majority of the mothers has low economic status which make unable to purchase and fed these relatively costly food sources items from the local market [32].

Among socio-demographic factors, mothers who worked as housewives at home have 2.5 more likely to fed diversified food as compared to those who work far from their house in field area. The possible explanation for this finding, mothers who worked off-residence had no sufficient time to prepare mixed and diversified food for their child [33].

Mothers who had access to cow milk fed diversified foods two times as compared to their counterpart. The possible explanation for this association mothers who have access to cow milk fed frequently their child and increase dietary diversity feeding practice specifically diary and dairy products.

Mothers who gave birth in health institution were 4.45 (2.08-9.54) and those who had Growth monitoring practice were 2.28 (1.33-3.89) more likely to fed diversified food as compared to their counterpart and correlate with study conducted in North Ethiopia, Sri Lanka and Tanzania. In general service utilization like growth monitoring, Post natal, Antenatal and institutional delivery enhance diversified feeding practice of mothers for their child because health professional give health education on importance of dietary diversity feeding practice during this service utilization [29,30,33].

Global infant and young child feeding practice guideline is being implemented in Ethiopia for more than a decade, but dietary diversity feeding practice of mothers was poor in current study setting. The dominant food groups were grain and legumes and low practice of animal source food like (eggs and meat) and vitamins reach sources food items (fruits and vegetables) feeding practice was observed.

This study was conducted as community based empirical research and believed to be representative for similar setting. It was undertaken by employing free recall ways of interviewing methods on dietary diversity to avoid or minimize recall bias. In contrary, the study did not consider the quantity of food variety consumed by a child consumed. Social desirable bias might be introduced even effort exerted to minimize by ensuring privacy matters. The nature of this study design was cross-sectional and it is difficult to establish cause-effect relationship.

For health professional

•Mothers should be properly educated on the appropriate combination of local staples for complementary food for children of six months and above through practical food. demonstration classes during post-natal period in health facility and at house hold level.

•Health professional should give focus to advice and counsel mothers on dietary diversity feeding practice.

For government public health sectors

•Appropriate behavioral change communicating (BCC) and attitude change communication (ACC) tools should be developing and disseminated to target audience though different media to educate the significance of dietary diversity feeding practice for young child in this critical window period.

•Government media should make advertising on dietary diversity feeding importance for a child growth and development.

For agricultural sectors

•The agricultural sectors should be support the family to grow home garden and rare animals to improve dietary diversity feeding practice.

For researchers

•Further study should be conducted to measure dietary adequacy by measuring (weighting) food consumed by a young child per 24 hours and anthropometry measurement to see dietary feeding on nutritional status.

Our deepest gratitude goes to Kamba Woreda Health office and kebeles leaders for their cooperation from the beginning till the end of data collection time. We also thank Arba Minch University for funding of our research work.

The authors declare that they have no conflict of interest.

EA: Initiated the research, wrote the research proposal, conducted the research, did data entry and analysis and wrote the manuscript. DM: Involved in the write up of methodology of proposal and research work.