Study design and setting
A community based cross-sectional study was conducted in Dera Woreda, South Gonder Zone from December 1/2018 to January 1/2019.Dera Woreda is located 600 km from Addis Ababa in Northwest and 40 km from Bahir Dar in Northeast. The estimated population of the Woreda in 2017/18 is about 154,886. The estimated number of the under-five year children is22, 567. The total number of estimated children aged 6–59 months were19282. Quantitative data were collected from mothers who have a child age 6–59 months.
All participants were allowed to ask questions throughout data collection and could refuse to answer questions or stop the interview at any moment.
Sample size determination and sampling procedure
The sample size was determined using a single population proportion formula.
[28], where, p represents the proportion of children who took the Vitamin A Deficiency, which was 8.6% taken from the study done in Dembia [20].. To get the optimum sample size, 5% margin of error (d) was considered with 95% confidence interval.
We added 10% for the non-response rate and multiplied by 2 because of design effect. Then the final sample size was 267.
Of the 39 administrative Kebeles in Dera Woreda, nine were selected randomly by lottery method. Among those kebele 20–30% of the population proportional allocation was done to select the desired samples from each selected Kebele. The sampling frame, based on a community-based health information system of the family folder in health posts, was constructed. Lists of all mothers having children age 6–59 months with Community Health Information System (CHIS) number in selected kebeles were used to select the respondents. Finally, we used a computer-generated random sampling to select the desired sample from the sampled frame of each selected kebele. other-child pair having a child aged 6 to 59 months who has a mental problem, critically ill were excluded.
Data collection procedure and measurements
Questionnaires were first prepared in English and translated into Amharic Version, which later back-translated into English. Amharic version questionnaires were used to collect data. A structured questionnaire was used to collect data on socio-demographic characteristics, maternal and child characteristics, and a Pre-test was done on 5% of the samples, two weeks before the actual data collection at FegeraWoreda. Data on Vitamin A deficiency were collected through face to face interviewing and with direct observation of children eyes of children age 6–59 months.
Assessment of dietary diversity and Quasi-food frequency
Food consumption studies can provide important information at an earlier stage before the clinical manifestation has appeared. To determine the food consumption of the children twenty-four-hour recall method was used. One single twenty–hour-hour recall was collected for every participant and dietary diversity was calculated. Determination of dietary diversity score (DDS) was done by asking the mother/caregiver to list all foods consumed by the child in the previous 24 hours preceding the survey. In the case of a mixed dish, mothers were asked to list the ingredients of the food items. Then reported food items were classified into seven food groups like grains, legumes, vitamin A-rich fruits and vegetables, other fruits and vegetables, egg, dairy products (milk, yogurt, and cheese), and meat. Considering four food groups as the minimum acceptable dietary diversity, a child with a dietary diversity score (DDS) of less than four was classified as having poor dietary diversity; otherwise, they were considered to have good dietary diversity [21].
Assessment of vitamin A deficiency
A detailed ophthalmic examination was carried out by clinical optometrists was used to assess the clinical signs of vitamin-A deficiency, such as Bitot’s spot, Conjunctival xerosis, corneal xerosis, corneal ulceration, and corneal scar. However, during data collection time the history of night blindness was confirmed by asking mothers about her childs using the local word for night blindness “dafint” or “chicken eye”. Information on whether a child faced any difficulty while playing or in identifying objects in dim light, especially at sunset, was gathered.
Six data collectors (2 clinical optometrists & 4 clinical nurses) and two supervisors (public health officers) were participating in the data collection process. One day training was provided to data collectors and supervisors about how to collect the data and how to ask the investigators.
The Dependent variable of this study is Vitamin A deficiency and Independent variables are Socio-demographic and economic characteristics, Health utilization and Child factors
Operational definition
Optimal dietary diversity: Dietary diversity was defined as optimal if children (aged 6–59 months) received foods from at least four of seven food groups(1) Grains, roots, and tubers, (2) Legumes and nuts, (3) Dairy products, (4) Flesh foods, (5) Eggs, (6) Vitamin-A rich fruits and vegetables, (7) Other fruits and vegetables, within the preceding 24 hours of the interview.
Sub-optimal dietary diversity: Suboptimal dietary diversity:-If a child aged 6–59 months receives foods from three or below three food groups from seven food groups [22]
VAD: - if a child has a history of night blindness and during the physical examination if the child has one signs of vitamin A deficiency, such as Bitot’s spot, Conjunctival xerosis, corneal xerosis, corneal ulceration, and corneal scar.
The terms ‘Women and mothers’ are used interchangeably in this study.
Statistical analysis
Data were entered into EpiData version 3.1 with double entry for verification. The analysis was performed using SPSS version 20.0. Descriptive data presented by using Frequency and cross-tabulation. Both the bivariate and multivariable logistic regression analyses were used to assess the association between dependent and independent variables. Independent variables that showed P < 0.2 at 95% CI in the bivariate logistic regression analysis were included in the multivariable logistic regression model. P < 0.05, with 95% CI, was considered to declare the variables significantly associated with the dependent variable.