Impact of the Productive SafetyNet Program on the minimum acceptable diet in the rural community of South Gondar Zone, Northwest Ethiopia

Background

Even though Ethiopia has achieved success in various areas related to the millennium development goals (Horton and Lo, 2013), it currently faces significant challenges with regard to poverty and food insecurity due to high population growth (World Bank, 2015) and poor economic growth (Alderman, 2010; IFAD, 2016). Due to chronic food insecurity and low agricultural productivity, the Productive SafetyNet Program (PSNP) was implemented in Ethiopia in 2005 to tackle this problem. After 4 years, PSNP+ was introduced to include additional small income-generating activities among households to increase household income (Devereux et al., 2006; Gilligan et al., 2009; Berhane et al., 2012).

Despite the implementation of various interventions, food insecurity and hunger continue to be rampant and critical issues in Ethiopia, which have a significant impact on children's overall health [Devereux, 2000; CSA, 2011, 2014; Central Statistical Agency (Ethiopia) ICF International, 2016]. One of the main contributing factors to these issues is the inadequate intake of a variety of foods due to insufficient quantities and frequencies, particularly in the Amhara regional state [Central Statistical Agency (Ethiopia) ICF International, 2011, 2014]. Overall, food insecurity has an impact on educational attainment and attendance in Ethiopia (Belachew et al., 2011). The ultimate goal of PNSP is to ensure households build on-farm and off-farm activities to have a variety of procurement strategies for food and cash (Drinkwater and McEwan, 1992).

Livelihoods will be secured when households have secure ownership or access to resources and income-earning activities. It helps to reserve and build an asset, offset risks, ease shocks, and meet contingencies (Chambers, 1989; Frankenberger and McCaston, 1998) to mitigate the vulnerability risk of a household to income, food, health, and nutritional insecurity, which directly or indirectly affect the consumption behaviors of the families.

The Phase 4 PSNPs were launched in Ethiopia to achieve the goal of “enhancing resilience to shocks and livelihoods, improving food security and nutrition, for rural households vulnerable to food insecurity.” Thus, the PSNP's contribution to this goal was assessed through program impact assessments by using the percentage of infants aged 6 to 23 months who receive a minimum acceptable diet, household dietary diversity, the average value of asset holdings, and the number of different income sources. For this study, we intended to use the minimum acceptable diet among infants aged 6–23 months as an indicator of the impact assessment (MoALR, 2014).

In Ethiopia, the magnitude of the Minimum Acceptable Diet (MAD) is the lowest, which ranges from 4.2 to 13.3% (Abeshu et al., 2016; Gizaw and Tesfaye, 2019; Mulat et al., 2019; Tassew et al., 2019). The levels of the Minimum Dietary Diversity Score (MDDS) and Minimum Meal Frequency (MMF) are 45 and 33%, respectively, which are high as compared to the findings of the study in North Showa (Gizaw and Tesfaye, 2019). This might be due to household food insecurity, which mainly affects low-income populations, particularly in developing economies undergoing the demographic transition; hence, low socioeconomic status leads to poor diet, food insecurity, and ill health among infants (FAO, 2003; Popkin, 2004; Conforti NWCCNTP, 2014). In addition, demographic and other maternal and child-related predictors affect children's MAD through dietary diversity and meal frequency (Laraia et al., 2006). As mentioned above, even though there are studies on the general population and each independent indicator of MAD, there are none on PSNP beneficiaries on this topic. Thus, this study aimed to assess the impact of PSNP on a minimum acceptable diet of infants aged 6–23 months in the selected rural community of South Gondar Zone, Northwest Ethiopia.

Materials and methods

Study design, period, and setting

The data were collected through a community-based cross-sectional study design from 1 December 2017 to 30 January 2017. Then, we compared these data based on the household's Productive SafetyNet enrollment status.

If the number of woredas (districts) in South Gondar with PSNP was five (Libo Kemkem, Simada, Lay Gayint, Tach Gayint, and Ebnat), the data were collected at the rural kebeles of Libo Kemkem and Simada woredas in South Gondar Zone, Northwest Ethiopia. The topography of these woredas (districts) belongs to highlands with plain and mountainous features, and both woredas (districts) are found at 1,800 m above the sea level (SWEPLAUO, 2020; WEPLAUO, 2020).

If these people are chronically food insecure, agricultural cultivation includes maize, barley, and millet, which are the main food crops, while rice and chickpeas are the main cash crops. The total number of households with the Productive SafetyNet program in Libo Kemekem and Simada woredas was more than 9,000, participating either in public works or direct support. At the time of data collection, nearly 4,500 infants aged 6–23 months were found in these woredas.

Sample size determination

The first study included a total of 769 participants. Of these, data from 442 infants aged 6–23 months were retrieved for this study after removing incomplete data and data from infants under the age of 23 months.

Eligibility criteria

We included data of all children aged 6 to 23 months of complete dietary diversity and meal frequency variables; if either of them were incomplete, we excluded them from this study.

Patient and public involvement

During this study, no patients or members of the general public were involved in the development of the research question, data collection, or analysis.

Sampling procedure

During the primary data collection, a multistage sampling method was employed by allocating the calculated sample size to each designated Kebeles of selected woredas, and the data were collected at the household level. Then, the refined data were analyzed.

Data collection methods and tools

During the primary data collection phase, the pretested Amharic version questionnaire was employed after being translated from the English language, which consists of socioeconomic and consumption-related variables. The dietary intake and minimum meal frequency data were collected using seven food groups through a 24-h dietary recall. Ten BSc nurse enumerators collected the data.

Data quality

Prior to the original data collection, a pretest was conducted on 5% of the total sample size. The data collectors received 1 day of training with a pretest, and the questionnaire was administered in Amharic (the local language). During the primary data collection period, regular communication was maintained to discuss the progress and any issues that arose. The collected data were checked for completeness and consistency by the investigators and supervisors. All data collectors were recruited outside the study area to minimize bias.

Term definitions

➢ Households with PNSPs: These households are identified as chronically food insecure and are currently a part of cash transfer or asset-building programs.

➢ Households without PNSPs: These households are not identified as chronically food insecure because they graduated from PNSPs and are not currently part of cash transfer or asset-building programs.

➢ Kebele: It is the smallest administrative division or village in Ethiopia.

➢ Minimum dietary diversity: It is the proportion of infants aged 6–23 months who received ≥4 food groups from the seven through a 24-h dietary recall; it is categorized as inadequate if dietary diversity has ≤ 4 food groups and good if the individual dietary diversity has ≥5 food groups according to FAO.

➢ Minimum meal frequency: It is the proportion of breastfed and non-breastfed infants aged 6–23 months who received solid, semisolid, or soft foods (also including milk for non-breastfed infants). Minimum meal frequency was defined as at least two times for breastfed infants aged 6–8 months, at least three times for breastfed infants aged 9–23 months, and at least two feedings of milk products for non-breastfed infants during the previous 24 h.

➢ Minimum Acceptable diet: Proportion of infants aged 6–23 months who receive a minimum acceptable diet (both minimum dietary diversity and minimum meal frequency) during the previous 24 h.

Data processing and analysis

These secondary data were imported from SPSS into the Stata file version. The data were then cleaned, categorized, and tabulated using Stata 16.0/MP software for Windows. The wealth index data were gathered by utilizing household assets such as land, materials, and utilities (electricity and water sources). After checking the assumptions, the index was built using principal component analysis (PCA). The outcome was ranked into five categories: poorest, poorer, middle, richer, and richest.

Finally, both descriptive and analytical analyses of variables were employed. In addition, univariable and multivariable binary logistic analyses were used to evaluate the independent and multiple effects of each variable on the dependent variable. In the univariable binary logistic regression analysis, a p-value of ≤ 0.25 was employed to select candidate variables for multivariable analysis.

Furthermore, the co-linearity between variables was determined using variance inflation factors (VIF). A p-value of ≤ 0.05 was used to declare statistical significance during multivariable analysis. For each odd ratio (ORs; adjusted and crude), the 95% CI was computed. During the final analysis, the model's fitness was checked (p-value ≥0.05).

Results

Sociodemographic characteristics

The average age (±SD) of infants was 14.04 (±4.59) months. Moreover, nearly one-third of the children were found between the ages of 11 and 23 months. The mean age ± SD of the mother/caregiver was 29.40 ± 5.29 years. The majority of the mothers/caregivers (173 [39.14%]) were found between the ages of 25 and 29 years. All of them were Orthodox by religion. The mean ± SD of family size among participants was 4.54 ± 1.51. Here, nearly three-fourths (328 or 74.21%) of the households were not enrolled in the Productive SafetyNet Program during data collection (either because they graduated from the program or were not enrolled initially) (Table 1).

TABLE 1

Table 1. Socioeconomic characteristics of the mother/caregiver of infants aged 6–23 months in South Gondar Zone, Northwest Ethiopia, 2017 (n = 442).

Index child-related characteristics

The average ± SD of the birth interval between the two-consecutive infants from the index was 3.33 ± 1.66 years. The majority of index infants have been breastfed (427 or 96.61%). In this study, three-fourths of the mothers/caregivers started complementary foods at the age of 6 months for their child. Still, the rate of institutional delivery is very low (68 [15.38%]). Approximately 6% (25) of the mother gives extra food/beverages after delivery instead of colostrum (Table 2).

TABLE 2

Table 2. Obstetrics-related characteristics of the mother for infants aged 6–23 months in South Gondar Zone, Northwest Ethiopia, 2017 (n = 442).

Level of a minimum acceptable diet among children

The mean (±SD) minimum dietary diversity score (MDDS) was 5.38 ± 1.04. The overall MDDS and minimum meal frequency (MMF) magnitudes were 79.86 (95% CI: 75.82, 83.50) and 82.58% (95% CI: 78.71, 86.00), respectively. The consumption of vitamin-A-rich fruits and vegetables was found to be zero, which could be due to a lack of awareness about these types of food, difficulty accessing them, or the belief that other fruits and vegetables provide sufficient quantity of vitamin A. The magnitude of the minimum acceptable diet (MAD) score was 66.52% (95% CI: 61.90, 70.90) (Table 3).

TABLE 3

Table 3. Level of a minimum acceptable diet intake percentage by 6–23-month-old infants in South Gondar Zone, Northwest Ethiopia, 2017 (n = 442).

The highest proportion of adequate diet diversity scores (261 [59.05%]) was from households that either graduated from PSNP or that were not enrolled in this program. Besides, the level of an adequate minimum acceptable diet score among the current PSNP users was low (79 [26.87%]) among all adequate MAD scores (Table 4).

TABLE 4

Table 4. Children's practice of the minimum acceptable dietary intake parameter with Productive SafetyNet enrolment status in the South Gondar Zone, Northwest Ethiopia, 2017 (n = 442).

Factors associated with a minimum acceptable diet among children

During the independent assessment, all other factors were assumed to be constant; being a part of a PSNP household was not associated with a minimum acceptable diet during factor assessment. In addition to this, we assessed the combined effect of the other variables, which were assessed by doing univariable and multivariable binary logistic regression models. In the univariable binary logistic regression analysis, caregiver/maternal, marital status, the age of the child, family size, the educational status of the father, the occupational status of the father, breastfeeding, extra food before 6 months, wealth index, and the place of delivery were the significant variables.

Finally, in multivariable binary logistic regression, marital status, the educational status of the father, child age, and places of delivery were the associated factors for the uptake of a minimum acceptable diet among infants aged 6–23 months (Table 5).

TABLE 5

Table 5. Factors associated with MAD uptake among infants aged 6–23 months in South Gondar Zone, Northwest Ethiopia, 2017 (n = 442).

Here, infants of single women were 3.98 times (AOR = 3.98, 95% CI: 1.39, 11.40) more likely to have/receive MAD as compared to infants of married women. Infants aged 11–23 months were 2.82 times (AOR = 2.82, 95% CI: 1.78, 4.47) more likely to have/receive MAD. In addition, while we compared children's fathers who could not read and write, children's fathers who could read and write were 44% less likely (AOR = 0.56, 95% CI: 0.35, 0.89) to receive an inadequate minimum acceptable diet. In addition, infants born in health institutions were 3.14 times (AOR = 3.14, 95% CI: 1.47, 6.73) more likely to have MAD. Furthermore, infants from the wealthiest families are 73% (AOR = 0.27, 95% CI: 0.12, 0.64) less likely to have an insufficient MAD intake than their peers.

Discussion

Despite enormous intervention by stakeholders, in Ethiopia, chronic food insecurity and undernutrition remain significant public health problems that affect the nutritional status of infants (Central Statistical Agency (Ethiopia) ICF International, 2014; Haile et al., 2016). In Ethiopia, PSNP was implemented to prevent existing household asset reduction and increase consumption by poorer/poorest household members. Being a part of this program may help to avoid the risk of food self-insufficiency or acute shortage and to build assets. Socioeconomic status is a necessary factor for optimal health (Fotso and Kuate-Defo, 2005; Gwatkin et al., 2007), which is determined using the wealth status or possession score from selected household items (Houweling et al., 2003; Mohsena et al., 2010), which influences the proportion of a minimum dietary diversity, meal frequency, and minimum acceptable diet directly or indirectly.

The magnitudes of the overall minimum dietary diversity score, minimum meal frequency, and overall minimum acceptable diet were 79.86, 82.58, and 66.52%, respectively. In this study, the proportion of MAD is higher than that shown in the research conducted in Ethiopia, which ranges from 4.2 to 13.3% (Abeshu et al., 2016; Gizaw and Tesfaye, 2019; Mulat et al., 2019; Tassew et al., 2019). Similarly, the magnitude of MDDS and MMF is also high when we compared it with the study findings in North Showa, Ethiopia, which are 45 and 33%, respectively (Gizaw and Tesfaye, 2019). The possible reasons may be due to the difference in the data collection period and residential differences, household socioeconomic status, cultural differences, child feeding knowledge of the mother, existing interventions by stakeholders, and dietary habits.

Here, infants of single women were 3.98 times more likely to have/receive MAD when we compared them to infants of married women. This could be because single women might have a high decision-making capacity (Mulat et al., 2019), a small family size, and increased care.

Infants aged 11–23 months were 2.82 times more likely to have/receive MAD, which is consistent with EDHS data analysis findings (Tassew et al., 2019). The study findings are similar in Ghana and Uganda (Ng et al., 2012; Na et al., 2018). However, according to the study findings in Wolita Sodo, Ethiopia (Mekonnen et al., 2017), infants age and infants receiving MAD are inversely related. The possible cause might be the change in mothers'/caregivers' knowledge, behavior, and meal frequency due to the diminishing breast milk production. In addition, as infants grow and develop, their bodies may demand more nutrients, leading to an increase in food cravings.

When compared to infants whose fathers could not read or write, those whose fathers could read and write were 44% less likely to receive a minimum acceptable diet. The result of this study is invariant with the research done in Oromia, Ethiopia (Mulat et al., 2019), Enemay District, Northwest Ethiopia (Gessese et al., 2014) and is consistent with EDHS data analysis findings (Tassew et al., 2019). Additionally, it is a strong predictor similarly in South Asia, Bangladesh, and Nepal (Kabir et al., 2012; Senarath and Dibley, 2012; Khanal et al., 2013). The possible reason might be the link between educational status, income, exposure to mass media, and knowledge about healthy dietary habits.

Furthermore, infants born in hospitals were 3.14 times more likely to have MAD than those born at home. The study finding is similar to the study conducted in Oromia, Ethiopia (Mulat et al., 2019). This might be due to appropriate counseling by healthcare providers on proper IYCF practices, their importance, and their effect on optimal health.

Furthermore, infants from the wealthiest families are 73% less likely to have insufficient MAD than their peers. This finding is consistent with other studies that showed that infants in high-income households consume a more diverse diet than those in low-income households (Gessese et al., 2014; Solomon et al., 2017). This could be due to household purchasing power for a variety of foods. Similarly, a high income may be associated with a higher level of education, which may increase knowledge about proper child feeding.

Limitations of the study

One of the limitations of this study is that it could not link MAD to specific causes; it was difficult to establish a possible causality, and it was unable to include knowledge, attitude, and practice of caregivers/mothers related to infant and young child feeding (IYCF) due to the nature of the data (secondary data), and recall-related problems. Finally, the IYCF program indicators were not a part of this study.

Conclusions

Nearly two-thirds of the infants had/received a minimum acceptable diet. Moreover, households' Productive SafetyNet status has no statistical impact, and the proportion of the minimum acceptable diet was low in the study area. There were program phases or stages implemented in the past before phase 4 (productive SafetyNet program) was launched. So, this is the comparison of phase 4 (the current) with the past (phase 3 and before it). Here, marital status, the educational status of the father, the child's age, and the place of delivery were the associated factors for the uptake of a minimum acceptable diet among infants aged 6–23 months.

Based on this, stakeholders should have to strengthen the PSNPs through the integration of current nutrition and other health-related strategies/programs to increase MAD uptake. Moreover, health professionals shall have to provide health and nutrition education and counseling based on the child's age, the father's educational status, the marital status of the woman or caregiver, and the place of delivery through other child and reproductive healthcare services.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by Ethical Review Committee of Debre Tabor University. The patients/participants provided their written informed consent to participate in this study.

Author contributions

ME and AG made the draft of the proposal for data collection. ME, AG, BK, DT, ST, and YS contributed to the acquisition and analysis of data and to the interpretation or discussion, the results of the manuscript, the analysis, interpretation, discussion and results, and revised the manuscript. All the authors read and approved the final manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Abbreviations

AOR, adjusted odds ratio; COR, crude odds ratio; HEWs, health extension workers; MAD, minimum acceptable diet; MDDS, minimum dietary diversity score; MMF, minimum meal frequency; PSNP, Productive SafetyNet program; SD, standard deviation; WEPLAUO: Libo Kemekem Word Environmental Protection, Land Administration; SWEPLAUO: Simada Worda Environmental Protection, Land Administration and Use Office; WHO, World Health Organization.

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