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Paediatrics
Original research
Maternal and household factors affecting the dietary diversity of preschool children in eastern Ethiopia: a cross-sectional study
  1. Aklilu Abrham Roba1,2,
  2. Öznur Başdaş3,
  3. Alexandra Brewis4,
  4. Kedir Teji Roba1
  1. 1Haramaya University College of Health and Medical Sciences, Harar, Ethiopia
  2. 2Institute of Health Science, Erciyes University, Kayseri, Turkey
  3. 3Faculty of Health Science, Erciyes University, Kayseri, Turkey
  4. 4School of Human Evolution and Social Change, Arizona State University, Tempe, Arizona, USA
  1. Correspondence to Aklilu Abrham Roba; akliltimnathserah{at}gmail.com

Abstract

Objective Investigate the association between the dietary diversity of preschool children and proximate factors including household food insecurity, maternal food choice, preferences, khat use, and levels of depressive symptoms.

Design Cross-sectional survey of randomly selected households.

Setting Haramaya Health and Demographic Surveillance site in Eastern Ethiopia, predominantly smallholder farming households.

Participants 678 preschool children (24–59 months) and their mothers.

Methods The key outcome, the adequacy of dietary diversity of preschool children, was calculated using a 24-hour parental dietary recall. Binary logistic regression was then used to identify maternal and household factors associated with dietary adequacy versus inadequacy.

Results The majority (80.53%) of surveyed children had low dietary diversity (mean Dietary Diversity (MDD)) score of 3.06±1.70 on a 7-point scale). Approximately 80% of households exhibited food insecurity. Households with greater food security (adjusted OR (AOR)=1.96, 95% CI 1.19 to 3.23), healthier maternal food choice (AOR=2.19, 95% CI 1.12 to 4.31) and broader maternal food preferences (AOR=4.95, 95% CI 1.11 to 21.95) were all associated with higher dietary diversity of their preschool children (p≤0.05). Other covariates associated with adequate child dietary diversity included improved household drinking water sources (AOR=1.84, 95% CI 1.16 to 2.92) and family planning use (AOR=1.69, 95% CI 1.00 to 2.86). Despite predictions, however, maternal depression and khat consumption were not identified as factors.

Conclusions The dietary diversity of preschool children is extremely low—a pattern observed in both food-secure and food-insecure households. Key factors include maternal selection of food for convenience and ease, preferences that do not include animal protein or healthier food choices, and lack of access to improved drinking water sources. Interventions around maternal food choice and preferences could improve preschool children’s nutritional health.

  • NUTRITION & DIETETICS
  • PUBLIC HEALTH
  • Community-Based Participatory Research
  • Community child health
  • Cross-Sectional Studies

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The data supporting this study’s findings are available upon submitting a reasonable request to the corresponding author.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-080616

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • Post hoc power analysis revealed the study’s power to be over 99%, ensuring that the sample size was sufficient for meaningful associations.

    • Children’s dietary diversity was determined using a parental 24-hour dietary recall, which can reduce accuracy due to recall bias.

    • Cause and effect relationships could not be established between dietary diversity and the predictor variables due to the cross-sectional design.

    Introduction

    One in three people worldwide is affected by some form of malnutrition.1 Although the causes of malnutrition are complex and multifaceted, dietary choices are important for optimal growth, health and development,2 especially for children.3 Dietary adequacy in children requires that they are not only given access to various foods from different food groups, but that they also agree to consume these foods to satisfy their energy, macronutrient and micronutrient demands.4 Evidence suggests that a child’s eating behaviour is strongly influenced by the parent and eating structure in the home.5 In many cases—including in Eastern Ethiopia—parents can have almost complete control over a child’s meals. This can affect a young child’s food choices, preferences and acceptance.6 7 Mothers often make many of the core dietary decisions for their child or children. Maternal diet is one of the best predictors of a child’s diet. This has led to many nutritional interventions focusing on the quality of the mother’s diet in order to promote healthy diets among preschool children.8 Additionally, increasing the nutritional knowledge of a caregiver also increases the dietary diversity of preschool children.9 10

    Parental feeding practices in early childhood are building blocks for eating behaviour throughout their life span.11–13 Preschool-aged children’s exposure to—and willingness to eat—diverse and healthy foods form the basis of dietary habits that persist throughout adulthood and affect lifelong nutritional well-being.14 Growth and development faltering predominantly occur during preschool age due to insufficient dietary intake and its complex interaction with immune function and frequency of infections. This can have lifelong implications.15 In addition, children at preschool age defined with excess adiposity (‘overweight’) have a higher risk of being obese at school age and throughout the rest of their life.16

    One widely validated way to assess early childhood nutritional adequacy is by evaluating children’s dietary diversity.3 15 17 18 Adequate dietary diversity (ADD) for preschool children equates consuming four or more of the following food groups per day: grains, roots and tubers; legumes and nuts, dairy products (eg, milk, yoghurt and cheese), flesh foods (eg, meat, fish, poultry and liver/organ meats), eggs, vitamin-A rich fruits and vegetables, and other fruits and vegetables.19 Children with low dietary diversity (LDD) exhibit stunting and wasting and are often underweight indicating this method has validity.20 In conjunction with physical health, preschool children with higher dietary diversity scores also have better mental health, lower hyperactivity/inattention, fewer peer relationship problems and more prosocial behaviour.21

    Many children—especially in low-income countries—consume diets that rely on monotonous carbohydrate staples with little to no animal products, or few fresh fruits and vegetables.10 The situation is also worsened by household food insecurity, low socioeconomic status, lack of access to clean drinking water, inadequate sanitation, child disease exposure, access to healthcare, large family size, less maternal educational level and rural environment.22–26

    Maternal food choice is also determined by several factors including individual behaviour (e.g., traditions, beliefs and nutrition awareness), food environment, food supply system (e.g., agricultural production, storage, transportation, marketing and processing) and purchasing power.27 Individuals are more likely to have a healthy and diversified diet when they are more concerned about the absence of contaminants, local production, health and innovation, and less concerned about price.28 In Ethiopia, cultural food traditions can promote the consumption of cereal-based diets, followed by meat, eggs and other animal-source foods, and cause an aversion to fruits and vegetables among adults.29 Little is known, however, about the effect of mothers' food choices and preferences on the dietary diversity of preschool children. A better understanding of the factors that affect dietary diversity is essential for improving the dietary intake of preschool children. Therefore, this study aimed to establish the association between preschool children’s dietary diversity and household food insecurity and to test how this is additionally explained by maternal food choice and preferences in Haramaya, Eastern Ethiopia.

    Methods

    Study area

    This cross-sectional study is based on data we collected using the Haramaya Health and Demographic Surveillance System (HDSS). The HDSS was established by Haramaya University in 2018 to be a comprehensive and sustainable data source for monitoring population health and demographic events in the Haramaya district of the East Hararghe Zone in the Oromia region of Eastern Ethiopia. The study area encompasses 17,461 households with a total population of 99,898 (51,259 male and 48,639 female), of whom 23.86% were women of reproductive age, with the latter and their children being the focus of this study.30

    Population and sample size

    A cross-sectional quantitative survey was conducted in Haramaya HDSS from July–September 2019 and included 4583 households. A total of 678 households were included for the present study and consisted of preschool children and their mothers. Inclusion criteria for the children were those who were aged 24–59 months and living with their mother. If there was more than one preschool child in the household, we selected the younger one for inclusion. To determine the power of the study, a post hoc power analysis was conducted using GPower V.3.1.9.4 software.31 The analysis used an alpha level of 0.05, a sample size of 678 and a two-tailed distribution. The OR for various factors, such as the minimum dietary diversity (MDD) of preschool children and household food insecurity (1.96), the mother’s choice of food based on easiness to prepare/convenience (2.43), the mother’s choice of food based on health and safety (2.19), and the mother’s preference for animal source food (4.95), resulted in a power of 0.99.

    Data collection and measurements

    Sociodemographic information about the mother and child was collected using questions from previously implemented HDSS Questionnaires. The dependent variable for this study was whether the child met a basic standard of dietary diversity for their age.

    The MDD of preschool children was determined by maternal reports, calculating the previous 24 hours food consumption to categorise the children’s dietary diversity as ADD (four or more) or LDD (less than four) from seven food groups.32 33 The score increased by one point if the child consumed an item at least once from a unique food group within 24 hours according to their dietary record.34 These seven food groups included: (1) Grains, roots and tubers; (2) Legumes and nuts; (3) Dairy products (eg, milk, yoghurt and cheese); (4) Flesh foods (eg, meat, fish, poultry and liver/organ meats); (5) Eggs; (6) Vitamin-A rich fruits and vegetables; and (7) Other fruits and vegetables.19 The definition of MDD has recently been updated by the WHO and UNICEF, substituting ‘≥ 4 out of 7 food groups’ (MDD-7FG) with ‘≥ 5 out of 8 food groups’ (MDD-8FG) by including breast milk as an eighth food group.35 However, as our study participants were not breast feeding, we used the MDD-7FG definition of ‘≥ 4 out of 7 food groups’.

    According to the MDD of women (MDD-W) guidelines, there are 10 food groups: (1) Grains, roots and tubers; (2) Pulses; (3) Nuts and seeds; (4) Dairy; (5) Meat, poultry and fish; (6) Eggs; (7) Dark green leafy vegetables; (8) Other vitamin A-rich fruits and vegetables; (9) Other vegetables; and (10) Other fruits.36 Women who consumed at least 5 or more of the 10 possible food groups were classified as having ADD. In contrast, those who consumed less than five were classified as having a LDD.36

    Key explanatory variables of interest were household food security status (i.e., food-secure, mildly insecure, moderately insecure and severely insecure) and binary (yes/no) characterisations of mothers’ food preferences in relation to health and safety, preference for animal-source foods and food choice by easiness to prepare/convenience. Other binary variables considered in modelling included availability of safer and more accessible drinking water (protected/piped vs unprotected), child wasting status, and if the mother is using family planning methods, khat usage (a culturally significant chewed stimulant grown by many households in the area), and displays higher levels of depressive symptoms.

    Household food insecurity status was calculated from the Household Food Insecurity Access Scale (HFIAS) nine-item questionnaire (maximum score of 27 and minimum score of 0). Households were grouped into four categories: food-secure, mildly food-insecure, moderately food-insecure and severely food-insecure. Categories of food insecurity (access) were determined according to HFIAS Indicator Guide, V.3.37

    A seven-item list assessed maternal food choice determinants. These included the nutritional/health value, household preference (eg, mood and taste), produced at home, marketing/advertising, easiness of preparing the food/convenience, and health and safety. The food preference scale included 10 items and used a 5-point Likert Scale where participants could rate their preference from 1 (lowest) to 5 (highest). The responses were categorised as positive [4/5] or negative/neutral [1-3]. Mothers who expressed these positive preferences were classified as having a positive preference for the item, while all other responses were considered negative or neutral. The scale demonstrated strong internal consistency, as indicated by a Cronbach’s alpha value of 0.92.

    Trained health professionals assessed children’s anthropometric measurements. Height and weight were measured twice, and the average was used. Weight was measured to the nearest 10 grams using a digital infant balance, and height was measured to the nearest 1 mm using a rigid height board. Wasting was defined as weight-for-height z-scores (WHZ)−2 SD below the mean of the reference population. Stunting was defined as height-for-age z-scores (HAZ)−2 SD below the mean of the reference population. Underweight was defined as weight-for-age z-scores (WAZ) −2 SD below the mean of the reference population.38 A child was defined as concurrently wasted and stunted (WaSt) based on these same measures.39

    The Patient Health Questionnaire [PHQ] was used to measure and grade symptoms of maternal depression.38 Using the depression diagnostic status suggested by the author of the scale, the level of depression symptomology was classified as follows: minimal (score of 0–4), mild (5–9), moderate (10–14), moderately severe (15–19) and severe.20–27 40 It was further dichotomised into having some depression symptoms (5–27) and having few or none depression symptoms (0–4).41

    Statistical analysis

    The normality of continuous variables was determined using the Shapiro-Wilk test. Outlier detection was made by visual inspection of histograms and box plots. Descriptive statistics were used to present the frequency and median with the first and third quartiles. Using WHO ANTHRO software (V.3.2.2, WHO, Geneva, Switzerland), WAZ, HAZ and WHZ were standardised into anthropometric indices with z-scores.38 Bivariate and multivariate logistic regression analyses were carried out to examine the associations between MDD of preschool children with household food insecurity, maternal food choice and preferences controlling for other variables. An adjusted OR (AOR) (with 95% CI) was used to determine the strength of the association in models adjusting for food insecurity, source of drinking water, wasting, mother’s food choice and preferences, maternal family planning utilisation, maternal depression status and maternal khat chewing. Statistical significance was determined using a value of p<0.05. Analysis was conducted using Stata V.14.2.

    Patient and public involvement

    None

    Results

    Child characteristics and nutritional status

    A total of 678 preschool children and their mothers were included in this study (see table 1). The median age of the preschoolers was 36 months, with 25th and 75th percentiles of 24 months and 48 months, respectively. A slightly higher number of boys (53.54%) were included in the study than girls (46.46%). The prevalence of indicators of malnutrition was WaSt (4.87%), wasting (7.08%), stunting (52.06%), underweight (25.66%) and overweight (4.13%)

    View this table:
    Table 1

    Sociodemographic characteristics and nutritional status of preschool children in Haramaya, Ethiopia (n=678)

    Maternal and household characteristics

    Around a third (33.33%) of households used improved water sources for drinking. Only 99 mothers (14.60%) used any form of family planning method, 272 (40.12%) smoked, 517 (76.25%) chewed khat, and 306 (59.41%) smoked and chewed khat. Only 90 (13.27%) women achieved the MDD Score (table 2).

    View this table:
    Table 2

    Maternal and household characteristics in Haramaya, Ethiopia (n=678)

    Dietary diversity of preschool children and the mother

    The majority of preschool children (546, 80.53%) and 588 (86.73%) mothers were classified as LDD, indicating that they consumed a limited variety of food groups. Only a small proportion of preschoolers (n=132 (19.47%)) and mothers (90, 13.27%) met the MDD (figure 1). The ean Dietary Diversity Score was 3.06±1.70. A majority (90.12 %) of the children consumed foods made from grains, while eggs were the least consumed (3.98%).

    Figure 1
    Figure 1

    Proportions of food group consumption in the last 24 hours among preschool children in Haramaya, Eastern Ethiopia.

    In line with the child’s dietary diversity, the dietary diversity of their mothers was also impoverished and is provided in online supplemental figure 1. Specifically, 20.64% of the children consumed only one food group, 16.08% consumed two food groups, 20.35% consumed three food groups, 23.45% consumed four food groups, 12.39% consumed five food groups, 5.16% consumed six food groups and 1.92% consumed seven food groups within the past 24 hours (online supplemental table 1).

    Food insecurity

    Most (78.46%) of the households had some form of food insecurity, with 10.47% of the households having mild food insecurity, 23.16% experiencing moderate food insecurity, 44.84% having severe food insecurity and 21.53% being food-secure (see online supplemental figure 2).

    In our study, the MDD of preschool children was met by 30.82% and 16.35% households among food-secure and food-insecure households, respectively (see online supplemental figure 3).

    Maternal depressional status

    A total of 370 (54.57%) mothers had minimal depressive symptoms, 77 (11.36%) experienced mild depressive symptoms, 70 (10.32%) had moderate depressive symptoms, 51 (7.52%) had moderately severe depressive symptoms and, lastly, 110 (16.22%) experienced severe depressive symptoms. In summary, 45.43% of mothers had notable depressive symptoms (i.e., excluding minimal depressive symptoms).

    Maternal food choice

    Most of the mothers in the study (82.01%) chose foods based on the health and safety of the food and prepared food at home (81.56%), while the price of the food had the most negligible variable in the food choice (70.21%) (online supplemental figure 4)

    Maternal food preferences

    Even though there was no significant difference in food preferences among mothers in the study area, an unexpectedly high percentage of mothers (13.57%) had negative or neutral preferences towards animal source foods (figure 2). This percentage is surpassed only by those who prefer sugar-sweetened foods and chips/crisps (19.76%).

    Figure 2
    Figure 2

    Maternal food preferences in households with preschool children in Haramaya, Eastern Ethiopia.

    Predictors of MDD of preschool children

    The predictors of MDD of preschool children include household food insecurity, source of drinking water, wasting, maternal food choice, maternal food preference and mother receiving family planning methods.

    The odds of ADD among preschool children were twice (AOR=1.96, 95% CI 1.19 to 3.23) as high among food-secure households when compared with severely food-insecure families. Similarly, preschool children from homes with access to piped/protected water sources for drinking was also twice (AOR=1.84, 95% CI 1.16 to 2.92) as high in achieving ADD than those who drank from unprotected sources. Lastly, the odds of ADD were three times (AOR=2.93, 95% CI 1.01 to 8.46) higher among non-wasted preschool children than their counterparts.

    This study predicted the effect of maternal food choice on preschool child dietary diversity (table 3). Preschool children from mothers whose food choices were not solely by easiness to prepare/convenience were 2.43 times (AOR=2.43, 95% CI 1.43 to 4.12) more likely to have ADD compared with their counterparts. On the other hand, children belonging to mothers whose food choice was based on the health and safety of the food were twice (AOR=2.19, 95% CI 1.12 to 4.31) as likely to have adequately diversified foods compared with their counterparts. In the same fashion, mothers who preferred foods that include animal sources were five times (AOR=4.95, 95% CI 1.11 to 21.95) more likely to feed their children adequate diversified foods than those who avoided it. Lastly, children whose mothers used family planning methods were 1.69 (AOR=1.69, 95% CI 1.00 to 2.86) times more likely to have diversified foods than children whose mothers did not use any family planning methods.

    View this table:
    Table 3

    Factors associated with minimum dietary diversity of preschool children in Haramaya, Ethiopia

    Discussion

    Dietary diversity was low in this sample. Only 19.47% of preschool children attained healthy dietary diversity in Haramaya, Ethiopia. This was lower compared with similar studies conducted in South-West Ethiopia (46.4%),14 Nigeria (59.80%),42 Thailand (79%)43 and Malawi (39% vs 28% in the intervention group compared control group according to a randomised controlled trial).24 The high percentage of LDD reflects poor nutrient adequacy in the diet of preschool children.44 The mean dietary diversity score (3.06) was also lower than that previously reported: 4.56±0.85 in Sri Lanka,3 4.11±0.03 in Zambia45 and 5.05 in Nigeria.9

    Consumption of animal-source foods by preschool children was low (22.27%) in this study and was below the average of 34.3% that has been recorded for the Horo Guduru Wolega zone.32 Proteins from animal sources (eg, meat, poultry, fish, eggs and dairy products) provide all nine essential amino acids and are called complete/ideal proteins.46

    Eggs are a significant potential sustainable nutritional source for children in Haramaya and similar smallholder farming settings. According to a study conducted in the USA, eggs ranked as the most cost-efficient food for delivering protein, choline and vitamin A, and it ranked as the second most cost-efficient food for vitamin E and third for vitamin D in children.47 Eggs provide essential fatty acids, proteins, choline, vitamins A and B12, selenium, and other critical nutrients at levels above or comparable to those found in other animal-source foods.48 49 For growing children, egg consumption can satisfy the nutritional demand and enhance brain development.50 While eggs are cheap, available and frequently consumed by young children in high-income and middle-income countries, they are expensive, scarce and rarely consumed by children in much of Africa and South Asia.51

    However, egg consumption among preschool children in Haramaya is meagre even when compared with Horo Guduru Wolega, Ethiopia (25.9%),32 and samples from Romania (46.5%)52 and Thailand (20%).43 Children’s egg consumption also notably varies across the world and the prevalence of egg consumption among African children is reported to be less than half that of most other regions, and it is a third of that in Latin America and the Caribbean.50 In our study area, less than 4% of children consumed eggs in the past 24 hours, a remarkably low prevalence given the potential availability of chickens to 35.25% households. Based on our general observations at the field site, we can identify likely reasons that eggs are not given to preschool children as a common food source. Some households might not be fully aware of the nutritional benefits of eggs, but others elect to sell them for pressing financial purposes, such as covering school fees or daily expenses.

    Some studies in literature reported effective results using behaviour change communication programmes to motivate households to increase egg production and consumption. In Nepal, an intervention that increased egg consumption of young children significantly reduced the prevalence of stunting and underweight.53 Similarly, a cluster randomised controlled trial in Nepal among preschool children is underway to increase egg consumption using short service messaging.54

    Vitamin-rich foods help with night vision, immunity, bone growth and reproduction, and epithelial integrity of the respiratory, urinary and gastrointestinal tracts.55 In the current study, 44.25% of preschool children consumed vitamin A-rich fruits in the past 24 hours. This percentage was better than the 25.9% found in the Horo Guduru Wolega zone.32 Nevertheless, to maximise preschoolers’ general health and well-being, efforts should be focused on encouraging consumption of fruit that is high in vitamin A. For this population group, improved nutritional outcomes could be attained through the application of focused interventions and increased awareness of the significance of including such foods in regular diets.

    In the studied households, food insecurity was widely experienced, and around four in five (78.46%) households had some food insecurity, with 44.84% experiencing severe food insecurity. Better dietary diversity of preschool children and greater household food security were significantly associated with food insecurity. This was in alignment with studies conducted in the Gaza strip, Palestine56 and Somalia.57 Food-insecure households may reduce the quality and quantity of foods to satisfy the current demand rather than the future benefits of cognitive development.48 58 However, even in food-secure households, around 70% of preschool children were still reported to have LDD. This was comparable with a study in Albuko district, North-East Ethiopia (30.2% in food-secure households and 27.1% in food-insecure households).23

    Preschool children from households with access to piped/protected water sources for drinking were twice as likely to have ADD than those who drink from unprotected sources. This was compatible with studies conducted elsewhere.14 42 The time needed to obtain drinking water may be an opportunity cost for cooking/preparing diversified child food and was generally associated with reduced feeding frequency.59 Notably, during the transition from infancy to childhood, the personal demand for water increases.60

    Maternal food choice was confirmed here as a strong determinant of child dietary diversity. Maternal food choice is a complex interaction of personal, social, physical and macro-level environments.61 Food choices can also be determined by nutrition knowledge (food and nutrition literacy), establishing routines, food accessibility, price of food (affordability), food availability in the market, advertisement, convenience, health, and safety of the food, taste and sensory perception of food, seasonality of food items, and time for preparations.62–66 Therefore, interventions that target the mother’s food and nutrition literacy and increase access to affordable healthy foods may increase the dietary diversity of the preschool children/the mother. Children’s perceived modelling, dietary intentions, norms, liking and preference determine their eating behaviour and food choices, which are majorly influenced by maternal/family food choices.67 In this study, in line with the ideas discussed above, preschool children were more likely to have ADD when the mother’s food choice was based on health and safety but not on its easiness to prepare/convenience compared with their counterparts.

    In the current study, maternal food preference was associated with the dietary diversity of preschool children. For example, Haramaya mothers in this sample who prefer foods that include animal sources were five times more likely to feed their children adequate diversity than those who avoid it. This aligns with a study conducted in experimental models that the mother’s food preference and nutrition during pregnancy and lactation affect the offspring’s food preference and neural components.68 Foods disliked by mothers tended not to be offered to children.69 A child’s preferences depend on early exposure to family foods that contribute to shaping food preferences later.70 The transition from infancy to preschool increases the rejection of new foods (neophobia).71 Limited diversity of family diet or limited exposure of a child to diversified foods at early life limit food preferences and dietary diversities.72

    In this study, children whose mothers used family planning methods were approximately twice as likely to have diversified foods than their counterparts. This could be associated with such economically helpful factors as wider birth spaces, stable employment, better postnatal health, and providing women with more decision-making power, time and energy to prepare foods from diversified groups.73–76 Conversely, larger family size was typically associated with decreased childcare and LDD.77 However, only approximately 15% of the mothers used any form of family planning methods in the current study. This low prevalence of family planning utilisation agreed with a previous study of 18.4% in the study area in which knowledge of the family planning methods, husband approval, male involvement in decisions about family planning and desire for an additional child were identified factors.78 Thus, advancing family planning in this region is one potential means to improve child dietary health.

    We expected a negative association between maternal depression symtom level and child dietary diversity because depressed mothers may face challenges for providing care and diversified food to preschoolers. However, we found no correlation. This may be due to other family members—including grandparents or older siblings—providing additional care for a preschooler. More study on this specific point is warranted.

    The following limitations should be taken into consideration when interpreting the study. Our main limitation was the use of a 24-hour dietary recall to assess dietary diversity, as it is susceptible to recall bias, causing underestimation. Furthermore, cross-sectional study designs like the one used in this study cannot establish a causal relationship between dietary diversity and the predictors. Despite these shortcomings, this study is based on a large random sample, produced interesting findings and pointed out areas that need more investigation.

    Conclusion

    Children’s diets in the surveyed region are inadequately diverse by nutritional standards, and this inadequacy is embedded in the broader context of food and water insecurity and limited uptake of family planning. In this Haramaya sample, greater food insecurity, unimproved drinking water sources and non-use of family planning methods were the predictors of failure to meet the MDD of preschool children. Strategies that increase access, availability, and affordability for diversified foods—including animal-source foods for preschool children—and improve food and nutrition literacy of the mothers/parents are warranted. Water security and family planning strategies tailored to eastern Ethiopia’s cultural and religious differences should also assist in improving child nutritional diversity and thus health.

    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The data supporting this study’s findings are available upon submitting a reasonable request to the corresponding author.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Haramaya University Institutional Health Research and Ethics Review Committee (reference number IHREC/152/2018, 09 May 2018). Adult participants gave informed consent to participate for them and their child.

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    Footnotes

    • Contributors AAR, OB, and KTR contributed to the study design, implementation, and data collection. AB assisted with the funding and study design. KTR provided the necessary logistical support and contextual information for the study. AAR analysed the data and drafted the manuscript. OB, KTR, and AB commented on and edited the manuscript for intellectual content. All authors read and approved the manuscript. AAR is the author acting as guarantor for this manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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