Magnitude of Child Food Insecurity, Its Association with Child Immunization and Huosehold wealth Status, and Coping Strategies In Dabat Demographic and Surveillance System North West Ethiopia

Background The magnitude of food insecurity in Ethiopia ranges from 38.7% to 82.3% among the general population. Children under the age of five years were more prone to food insecurity and its serious consequences like anemia, low bone density, frequent episodes of common cold, stomachache, poor educational performance, and dental carries in developing countries like Ethiopia. However, there is no any research finding that documented the magnitude of child food insecurity, coping strategies, and associated factors in the study area. Therefore, the aim of this study was estimating the magnitude of child food insecurity, major coping strategies, and factors associated with child food insecurity in the study area. Methods A community-based cross-sectional survey has been conducted in Dabat demographic and health surveillance site among 7152 mothers/caretakers of children under the age of five years. Data were collected by experienced data collectors working for the demographic and health surveillance site, and the collected data were entered into EpiData template and then transported to Stata 14 software for data cleaning and analysis. The ordinal logistic regression model was fitted to identify predictors for child food insecurity. Results About 21.42% of children under the age of five years were food insecure in Dabat district of whom 57.8%, 38.6%, and 3.6% had experienced mild, moderate, and severe levels of child food insecurity, respectively. All most all 1391 (92%) of the mothers/caretakers of food insecure children had practiced food insecurity coping strategies. More than half (57%) of mothers/caretakers reduces the size of child meal as insecurity coping strategy. Child food insecurity was associated with household wealth status, parent's education status, and maternal and child health service utilization and child feeding practices. Conclusion A large segment of under-five children had experienced food insecurity in Dabat district, and the major coping strategy for child food insecurity was reducing meal size. Therefore, working on household wealth improvement and expansion of basic health services would improve child food security.


Background
Food security is a concept that existed when all people at all times have physical and economic access to safe and sufficient food [1,2]. Assuring food security for mankind is among the priority agendas of leaders around the world. United Nations sustainable development goal (SGD) has two targets dedicated for assurance of food security [2]. Despite these efforts globally, the prevalence of food insecurity was 9.3% in 2016 [3]. In Africa, it was a serious public 2. Methods and Materials 2.1. Study Area. The study was conducted at Dabat Demographic and Health Surveillance System (HDSS) site. The HDSS covers 13 kebeles divided into 83 clusters. The altitude of the district ranges from 1000 meters to 2500 meters above sea level, and the weather condition is divided into highland, midland, and lowland climatic conditions. Dabat town, the capital of the district, is located 821 km from Addis Ababa and 75 km from Gondar town to the north. Dabat district has six health centers, three health stations, and thirty-one health posts that provide health services to the community. The total population of the district was estimated to be 158,250 of whom about 70,611 were the population of the HDSS with the sex ratio of nearly 1 : 1. In the HDSS, there are 7,918 children under the age of five years [20].

Study Design and Population.
The community-based cross-sectional study design was carried out among rural and urban households with under-five children from April to December 2016. Mothers/caretakers of under-five children available during the study period were participants for this study. In the absence of mothers/caretakers of under-five children during visit day, other senior household members beyond 18 years were interviewed after consenting.

Data Collection Tool and Data Collection Procedure.
A pretested interviewer-administered structured questionnaire was used to collect data on sociodemographic, and maternal and child health service utilization. To assess the level of child food security, we use FANTA III food insecurity access measurement scale version 3. A five-day training was provided for data collectors and supervisors. A pretest was conducted in the rural and urban kebeles of Dabat district which are not included in the HDSS, and necessary modification of the tool was made according to the inputs of the pretest. Data were collected by 15 experienced data collectors and supervised by supervisors working for Dabat HDSS.

Data Processing and Analysis.
To avoid data entry errors related to the translation of the responses, collected data were entered into EpiData template prepared in Amharic language that have similar content with the data collection tool. Five experienced data entry clerks were recruited for the data entry, and the overall data entry process was supervised by a data manager working at the HDSS site. Entered data were transported to STATA version 14.1 for data cleaning and analysis. The correlation of a dependent variable with each independent variable was assessed by Pearson's chi-square test before fitting univariate and multivariate ordinal logistic regression models. All variables with significant Pearson's chi-square test were considered for univariate ordinal logistic regression model, and variables significant at the univariate ordinal logistic regression model were fitted into the multivariate ordinal logistic regression model to identify predictors for child food insecurity. Proportional cumulative odds ratio assumption was checked by significant Pearson's chisquare before the attempt to interpret the final model.    (Table 3).

The Magnitude and Copying Strategies of Child Food
Insecurity in Dabat HDSS. In the study area, 1512 (21.42%) of the children were food insecure of whom about 57.8%, 38.6% and 3.6% of the children had experienced mild, moderate, and severe level of food insecurity, respectively. All   International Journal of Pediatrics most all 1391 (92%) of the mothers/caretakers of food insecure children had practiced copying strategies. More than half (57%) of them skips child meal time as child food insecurity strategy (Figures 1 and 2).

Discussion
In this study, 21.42% of children were food insecure and major coping strategies considered by mothers/caretakers childern under the age of five years were skipping of child meal time, borrowing money, selling of household asset, and money or food aid. All of child food insecurity coping strategies identified by this study have a potential to worsen food security; and was supported by the findings of a study among Kenyan urban poor community [21].
In our study, children from households with low wealth status were 2.26 (1.86-2.57) times and from households with medium wealth status were 1.57 (1.30-1.90) times more likely to experience mild, moderate, or severe levels of child food insecurity compared with those children who are from household with high wealth status. The more likelihood of experiencing different levels of child food insecurity by children from low and medium household wealth statuses was supported by the findings of the studies carried out in Bangladesh and Ethiopia [22][23][24][25]. This more likelihood of experiencing of different levels of child food insecurity with low and medium household wealth status might be explained by the fact households with low and medium wealth statuses might not be easily able to assure availability, accessibility, and sustainability of food for children in the household.
Illiteracy of heads of the household was strongly associated with the more likelihood of experiencing different levels of child food insecurity in this study. Children from households with heads who were unable to read and write were 1.54 (1.07-2.21) times, and those with heads only able to read and write were 1.60 (1.11-2.30) times, respectively, more likely to experience different levels of child food insecurity compared with those children from households with heads who completed secondary school education. This more likelihood of experiencing different levels of child food insecurity with the illiteracy of head of the household was supported by the findings of studies from Ethiopia conducted in households by considering children as members of the household [25][26][27]. This significant association between child food insecurity and illiteracy of heads of the household might be explained in the fact that illiterate heads of the household might not have better economic opportunity since being educated heads of the household is important to maintain children food security. The findings of this study had confirmed the above claim where children from households headed by those who achieve college and above educational level were 88% (47-97%) less to experience food insecurity than children from households headed by those who achieve secondary school only. Not receiving vaccination and child illness were associated with experiencing child food insecurity. Children who does not receive BGC

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International Journal of Pediatrics security as evidenced by studies in South Africa and southwest and south Ethiopia [28][29][30]. Similarly, child illness and home treatment were factors associated with different levels of child food insecurity. Children with illness in two weeks of the survey were 1.32 (1. 16-1.49) and those received home treatment for the illness were 2.74 (1.75-4.28) times more likely to experience mild, moderate, or severe child food insecurity in this study compared with children who had no illness with two weeks of the survey. This strong association between childhood illness and home treatment with child food insecurity could probably be explained by the fact that those children with health problems and who get treated in home might have good outcome of the phenomenon that negatively affects food security as evidenced by household food insecurity studies in America, Canada, Malaysia, and Ethiopia [18,[31][32][33]. Furthermore, feeding practice, feeding style, and birth order of the children were also associated with experiencing different levels of child food insecurity in this study. Children with a history of late breast feeding initiation were 1.47 (1.17-1.85) times, those who do not receive colostrum were 2.40 (1.82-3.17) times, those with a history of prelacteal feeding were 2.40 (1.82-3.17) times, those who have had exclusive breast feeding for more than six months were 1.90 (1.04-3.50) times, and those who were introduced with the supplementary food before six months were 2.36 (1.10-5.07) times more likely to experience different levels of child food insecurity than their counterparts. It was supported by the evidences of studies conducted in America and Ethiopia [18,31]. On the other hand, children who had three meals per day were 33% (14-47%) less likely to experience child food insecurity in this study compared with their counterparts. When we look at child feeding style, children who were fed with adults and older children were 1.64 (1.32-2.06) and 2.40 (1.90-3.02) times more likely to experience different levels of child food insecurity than their counterparts. This

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International Journal of Pediatrics more likelihood of child food insecurity with feeding style may probably be due to the inability of younger children to compete with adults and older children and resulted in child food insecurity.
Children at the fourth birth order and fifth birth order were 1.40 (1.12-1.75) times and 1.28 (1.05-1.55) times more likely to experience mild, moderate, and severe levels of child food insecurity compared with children with the first birth order. This may be explained by the fact that children at the highest birth order would probably not receive care directly from their mothers as evidenced by the findings of this study where children who receive care from grandparents and other family members were 2.35 (1.53-3.59) times more likely to experience food insecurity. If grandparents or other family members provide child care due to maternal illness, it has direct effect on the worsening of child food insecurity as evidenced by the findings of different studies [19,34].

Conclusion and Recommendation
A large segment of under-five children were experiencing mild, moderate, and severe levels of food insecurity associated with poor wealth of the household, illiteracy of the head of household, child immunization, and child feeding practices were positively associated with child food insecurity. The parents of children had practiced food insecurity copying strategies that could be probable risks for child malnutrition. Therefore, improvement of household wealth, education of the head of the household, and expansion of maternal and child health services would improve child food security.

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Additional Points
Limitation of the Study. Data was collected only from the mothers/caretakers, where involvement of both parents may better supplement the evidence. Strength of the Study. For the assessment of mothers/caretakers' food preference, the study considers the relatively large sample size and advanced statistical model.

Ethical Approval
Ethical clearance was obtained from Institutional Ethical Review Board (IRB) of University of Gondar with the reference no R.NO.O/V/P/RCS/05/1220/2016. The interviewers explain the objective, benefit, and risk of the study before getting the consent from the parents of study participants. In addition, data collectors were instructed to assure the rights of the respondents to refuse or withdraw from the interview at any time without any form of prejudice. Children with under nutrition (midupper arm circumference ðMUACÞ = 11:5 cm or below), anemia, and intestinal parasitosis were referred to the nearest health facilities, and health/nutritional education was also given to parents/caretakers by data collectors and supervisors. Confidentiality of the information was maintained by coding of all personal or household identifiers.

Consent
Consent for data collection and publication has been approved by Institutional Ethical Review Board (IRB) of University of Gondar, and participants were informed about publication.

Conflicts of Interest
We declare that we do not have competing interest.