Hygienic practice during complementary feeding and its associated factors among mothers/caregivers of children aged 6–24 months in Wolaita Sodo town,southern Ethiopia

Abstract

Introduction:

Complementary feeding is an important stage in a child’s development as it provides the necessary nutrients for optimal growth and development. However, improper handling, storage, and preparation of complementary foods can result in contamination by microorganisms, leading to foodborne illnesses and malnutrition. Therefore, this study aimed to determine hygienic practices during complementary feeding and associated factors among mothers of children aged 6–24 months in Wolaita Sodo town, southern Ethiopia.

Methods:

A community-based, cross-sectional study was undertaken among mothers/caregivers of children aged 6–24 months from December 1–30, 2022. A total of 602 participants were recruited using a simple random sampling procedure. The hygienic practice of complementary feeding was assessed based on a related seven items questionnaire (Cronbach’s alpha 0.72). Data were entered into Epi-data version 4.6 and analyzed using Statistical Package for Social Science version 26. Multivariable binary logistic regression was used to identify the statistically significant factors associated with proper hygienic practice of complementary feeding. Variables with a p-value of <0.05 in the multivariable logistic regression analysis model were considered statistically significant.

Results:

The study indicated that 42.0%, (95% confidence interval (CI): 38, 45.8) of the mothers/caregivers of children aged 6–24 months had proper hygienic practices during complementary feeding. Mothers who could read and write (adjusted odd ratio (AOR): 3.36, 95% CI (1.53, 7.41)) and those who had completed primary school (AOR: 1.7, 95% CI (1.02, 2.85)), media exposure (AOR: 3.38, 95% CI (2.1, 5.4)), and attitude toward hygienic practice (AOR: 3.29, 95% CI (2.2, 4.91)) were independent predictors of hygiene practices during complementary feeding.

Conclusion:

This study found that the prevalence of hygiene practices during complementary feeding was relatively low. Being educated, access to media, and positive attitudes toward hygienic practices were predicting factors. As a result, strengthening training and counseling services for mothers regarding complementary feeding and processing is recommended.

Keywords

Complementary feeding hygienic practice children aged 6–24 months Ethiopia

Introduction

Complementary feeding is the process of starting an additional meal of liquids when an infant’s need for energy and nutrients exceeds that of breast milk at 6 months of age. The 2 years following the end of exclusive breastfeeding are crucial windows for a child’s growth and development.^1,2 Although beginning at 6 months, breastfeeding should be combined with safe, age-appropriate solid, semisolid, and soft foods that should be stored and prepared hygienically and fed with clean hands.^2,3

Poor complementary food hygiene may contribute to diarrheal diseases among infants and small children in developing countries, which in turn contributes to a large proportion of infectious diseases worldwide.³ Inappropriate feeding practices can also cause malnutrition in young children. Children who lack proper nutrition are more likely to develop infections, grow poorly, and die almost six times more often.¹ Approximately 600 million foodborne diseases are diagnosed worldwide annually, resulting in 420,000 deaths. Under-5-year-olds account for 30% of foodborne deaths. More than 420,000 people die each year from such diseases, including 125,000 children under five.⁴

Infectious diseases caused by enteric pathogens associated with preventable foodborne bacteria remain a major global health threat for children under the age of 2. Furthermore, dietary contamination causes diarrheal diseases that cause 230,000 deaths every year.⁵ Poor food hygiene practices contribute to 70% of diarrhea episodes in developing countries, with 88% of childhood deaths.^5,6 The process of feeding complementary foods is directly related to malnutrition. This is estimated to be the underlying cause of 45% of all deaths in children fewer than 5 years of age 41% of these deaths occurred in sub-Saharan Africa and 34% in South Asia.^7–9

The transmission of food-borne diseases among children is aggravated by unsafe food-handling practices by mothers/caregivers. Approximately, 10%–20% of food-borne disease outbreaks are caused by a mother’s unclean food preparation practices.¹⁰ The current prevalence of adequate complementary food (CF) introduction in Ethiopia is 13%, according to the 2019 mini Demographic and Health Survey. Similarly, preventable bacterial pathogens causing diseases caused 43% of infant mortalities.⁷

Foodborne sickness also has serious short- and long-term health effects, such as bloodstream infections, reactive arthritis, convulsions, kidney failure, and even death.² Hence, complementary food requires the appropriate preparation, administration, and storage of supplemental foods under proper parental supervision, which may reduce the risk of food contamination.^9,11 For example, if proper hygiene habits are practiced along with the availability of water and sanitation, the average number of deaths due to diarrheal diseases can be reduced by 65%.⁸ The major risk factors for poor hygienic practices according to previous studies are low level of awareness on susceptibility, risk of infection, poor food handling, and unclean surroundings.^9,11

Complementary foods should be prepared with appropriate hygiene, and caregivers must possess adequate nutritional knowledge and apply it to the preparation of complementary foods.¹² Evidence demonstrated that children’s morbidity and mortality can be reduced significantly by improving food hygiene practices during complementary feeding. However, hygiene practices during complementary feeding have not been well addressed, particularly in the study area. Therefore, this study aimed to assess the hygiene practices during complementary feeding and associated factors among mothers/caregivers of children aged 6–23 months in Wolaita Sodo town, southern Ethiopia.

Methods

Study area, study period, and study design

A community-based cross-sectional study was conducted among mothers of children aged 6–23 months in Wolaita Sodo town from December 1 to 30/2022. Wolaita Sodo town is the capital city of Wolaita zone, which is located in the southern nation nationalities people regional state of Ethiopia. It is approximately 320 km from Addis Ababa, the capital of Ethiopia. Based on Sodo town health office report of 2020 the overall population of the town is estimated to be 244,813 of whom 49.1% are male and 51.9% are female, and the number of households in the town is 49,963. Based on the town health office report of 2020, the health system of the town consists of one teaching and referral hospital, one general hospital, three health centers, 25 health posts, 12 private clinics, and 15 private drug stores.

Source population and study population

All mothers/caregivers of children aged 6–23 months who reside in Wolaita Sodo town were used as the source population. On the other hand, all randomly selected mothers/caregivers with children aged 6–23 months were taken as the study population.

Inclusion and exclusion criteria

All mothers/caregivers who had children aged 6–23 months in the study period were included in the study. Mothers/caregivers who are unable to respond, and seriously ill during the data collection period were excluded from the study.

Sample size determination

The required sample size was computed using Epi info Version 7 statistical software developed by centors for disease control and prevention in Atlanta, Georgia(US). The following assumptions were considered: a confidence level of 95%, marginal error of 5%, design effect = 1.5, and prevalence of good hygienic practice during complementary food preparation from the previous study as 39.6%.¹³ Based on this assumption, the required sample size was 551. Finally, considering a 10% non-response rate, the required sample size was 602.

Sampling technique and procedure

A multistage sampling technique was used to recruit the study participants. There are 25 kebeles in Wolaita Sodo town; of which seven kebeles (the smallest administrative units in a given district in Ethiopia) were selected using simple random sampling. The total sample was allocated proportionally to each kebele based on the number of mothers of children aged 6–24 months in each kebele and the list of mothers of children aged 6–24 months from respective health posts was used as the sampling frame. Finally, study participants were selected using a simple random sampling technique after the required sample size was proportionally allocated to each kebele.

Data collection tools and procedures

Data were collected using a pretested structured interviewer-administered questionnaire developed based on a review of the related literature.^9,11–18 The questionnaire contained items on sociodemographic and economic factors, environmental and housing condition-related factors, awareness and attitude-related characteristics, and hygienic complementary food preparation-related factors.¹³ The tool was initially created in English, translated into Amharic, and then translated back into English to ensure consistency. Three BSc nurses and one Master of Public Health (MPH)-level healthcare worker were hired and trained as data collectors and supervisors, respectively.

Operational definition

Hygiene practices during complementary feeding were measured using a seven-item questionnaire Cronbach’s alpha (0.72). A three-point scale was used to evaluate the responses: always = 2, sometimes = 1, and never = 0. In light of this, the mean of the responses was computed. Participants who scored ⩾50% and above on the practice measuring items about hygiene during complementary feeding were labeled as having good hygienic practice and the score of <50% as poor hygienic practice.⁵

Seven attitude questions about hygienic practice during complementary feeding were presented to the respondents. Each question contained a 5-point Likert-type scale (1 = strongly agree, 2 = agree, 3 = not applicable/undecided, 4 = strongly disagree, 5 = strongly disagree). The replies were composited after being divided into two categories: positive attitude and negative attitude. Additionally, study participants were considered to have a positive attitude if they received mean or higher scores on the attitude questions.

Statistical analysis

After data collection, data were entered into Epi-Data version 4.6, and exported to Statistical Package for Social Science version 26 for analysis. A descriptive summary of the statistics was performed to describe the frequency distribution, proportion, measures of central tendency, and dispersion. Binary logistic regression was performed to determine the crude relationship of each independent variable with hygienic practice during complementary feeding and to select candidate variables for the multivariable logistic regression analysis model. Variables with a p-value < 0.25 in the bi-variable logistic regression analysis were entered into multivariable logistic regression. To check the fitness of the regression model, the Hosmer and Lemeshow test was performed, and the model was fit at a p-value of 0.095. Finally, significant factors were identified based on a 95% confidence level with adjusted odds ratio (AOR) and p-value < 0.05 and the results were presented using texts, frequency tables, and graphs.

Results

Sociodemographic characteristics

A total of 602 mothers/caregivers participated in this study with a response rate of 100%. The mean (±standard deviation) age was 31.51 years (±3.48), with minimum and maximum ages of 19 and 45 years, respectively. Regarding the educational level of the study participants, 114 (18.9) cannot read and write; and 175 (29.0 %) had an educational status of secondary or above. The majority of the respondents, 494 (82.1%) were housewives. Regarding the educational level of the husbands, 185 (32.7) had primary education. Over two-thirds of husbands, 220 (38.9) were farmers and 133 (23.5) were government-employed. About 234 (37.6%) of the family had more than three families in the household (Table 1).

Table 1.

Sociodemographic characteristics of participants and their husbands among mothers of children aged 6–23 mothers/caregivers in Wolaita Sodo town, southern Ethiopia, 2022.

Variables	Category	Frequency (%)
Woman’s age	19–24	26 (4.3)
	25–29	149 (24.8)
	30–34	319 (53.0)
	⩾35	108 (17.9)
Marital status of mother’s	Married	565 (93.8)
	Divorced	16 (2.7)
	Widowed	21 (3.5)
Educational status respondents	Cannot read and write	114 (18.9)
	Can read and write	86 (14.3)
	Primary	227 (37.7)
	Secondary and above	175 (29.0)
Occupation of respondents	Housewife	494 (82.1)
	Farmer	27 (4.5)
	Merchant	71 (11.8)
	Employee	10 (1.6)
Husband’s education	Cannot read and write	60 (10.6)
	Can read and write	172 (30.4)
	Primary	185 (32.7)
	Secondary and above	148 (26.3)
Husband’s occupation	Farmer	220 (38.9)
	Merchant	157 (27.8)
	Employ	133 (23.5)
	Daily laborer	55 (9.7)
Monthly income	<1000 Ethiopian Birr	208 (34.6)
Monthly income	⩾1000 Ethiopian Birr	394 (65.4)
Number of families	<5 family	368 (61.1)
Number of families	⩾5 family	234 (38.9)

Environmental and housing conditions

The majority, 540 (89.7%) of the respondents had their own latrines, out of which only 33 (4.3%) respondents had hand washing facilities on nearby toilets, and 570 (94.7%) respondents did not have solid disposal pits available at home. More than three-fourths, 459 (76.2%) respondents have access to media either TV or radio (Table 2).

Table 2.

Environmental and housing condition among mothers of children aged 6–23 months in Wolaita Sodo town, southern Ethiopia, 2022.

Variables	Category	Frequency (%)
Have a separate kitchen facility	Yes	424 (70.4)
Have a separate kitchen facility	No	178 (29.6)
Latrine available at home	Yes	540 (89.7)
Latrine available at home	No	62 (10.3)
Hand washing facility near the toilet	Yes	40 (6.6)
Hand washing facility near the toilet	No	562 (93.4)
Have a solid disposal pit available nearby	Yes	32 (5.3)
Have a solid disposal pit available nearby	No	570 (94.7)
Separate cattle living room	Yes	196 (86.3)
Separate cattle living room	No	31 (13.7)
Have access to media (TV or radio)	Yes	459 (76.2)
Have access to media (TV or radio)	No	143 (23.8)

Hygienic practice during complementary feeding

The study revealed that good hygienic practice during complementary feeding among mothers/caregivers of children aged 6–24 months was 253 (42.0%) (95% confidence interval (CI): 38, 45.8). Of the total respondents, the majority, 537 (89.2%) washes their hands before feeding their children and about 508 (84.4%) served food immediately after preparation. More than one-third 208 (34.6%) of the respondents used hot water to clean food utensils and only used soap or ash to wash food utensils. Concerning attitude toward hygienic practice, 379 (63.0%) participants had a positive attitude (Table 3).

Table 3.

Hygienic practice during complementary feeding among mothers/caregivers of children aged 6–23 months in Wolaita Sodo town, southern Ethiopia, 2022.

Variables	Category	Frequency (%)
Washing hands before feeding children	Yes	537 (89.2)
Washing hands before feeding children	No	65 (10.8)
Serving food immediately after preparation	Yes	508 (84.4)
Serving food immediately after preparation	No	94 (15.6)
Using clean cups and bowls when feeding children	Yes	510 (84.7)
Using clean cups and bowls when feeding children	No	92 (15.3)
Use of hot water for cleaning food utensils	Yes	208 (34.6)
Use of hot water for cleaning food utensils	No	494 (65.4)
Use soap or ash for washing food utensils	Yes	423 (70.3)
Use soap or ash for washing food utensils	No	179 (29.7)
Covering cooked food	Yes	511 (84.9)
Covering cooked food	No	70 (11.6)
Attitudes toward hygienic practices during complementary feeding	Positive	379 (63.0)
	Negative	223 (37.0)
Food hygienic practice training	Yes	132 (21.9)
Food hygienic practice training	No	470 (78.1)
Hygienic practice during complementary feeding	Good	253 (42.0)
Hygienic practice during complementary feeding	Poor	349 (58.0)

Factors associated with the hygienic practice of complementary feeding

In multivariable logistic regression analysis, the educational status of respondents, access to media, and attitude toward hygienic practice were significantly associated with good hygienic practice during complementary feeding practice. The good hygienic practice was 3.36 times more likely among women who could read and write (AOR: 3.36, 95% CI (1.53, 7.41)) and 1.7 times more likely among those who had completed primary school (AOR: 1.7, 95% CI (1.02, 2.85)) as compared to who could not read and write.

Mothers/caregivers of children aged 6–24 months who had access to media were three times more likely to have good hygienic practice during complementary feeding practice than those who had not (AOR: 3.38, 95% CI (2.1, 5.4)). The odds of good hygienic practice during complementary feeding practice were 3.29 times higher among mothers/caregivers with a positive attitude toward hygienic practice as compared to those who had negative attitudes (AOR: 3.29, 95% CI (2.2, 4.91)) (Table 4).

Table 4.

Bivariable and multivariable logistic regression model on factors associated with hygienic practice during complementary among mothers/caregivers of children aged 6–23 months in Wolaita Sodo town, southern Ethiopia, 2022.

Variable	Hygienic practice		COR (95% CI)	AOR (95% CI)
Variable	Good (%)	Poor (%)	COR (95% CI)	AOR (95% CI)
Age of mothers
<30 years	106 (44.5%)	118 (54.5%)	1.43 (1.03, 2.0)	1.49 (0.95, 2.33)
⩾30 years	147 (37.9%)	231 (62.1%)	1	1
Educational status
Cannot read and write	33 (28.9%)	81 (71.1%)	1	1
Can read and write	43 (50%)	43 (50%)	2.4 (1.36, 4.4)**	3.36 (1.53, 7.41)**
Primary education	96 (42.3%)	131 (57.7%)	1.8 (1.13, 2.9)*	1.7 (1.02, 2.85)*
Secondary and above	81 (46.3%)	94 (53.7%)	2.11 (1.86, 3.4)**	1.13 (0.32, 3.94)
Occupation of respondents
Housewife	192 (38.9%)	302 (61.1%)	1	1
Farmer	18 (66.7%)	9 (33.3%)	3.15 (1.4, 7.2)	0.46 (0.04, 5.37)
Merchant	34 (47.9%)	37 (52.1%)	1.45 (0.95, 3.34)	0.55 (0.046, 6.76)
Employee	9 (90%)	1 (10%)	14.15 (2.0, 22.3)*	0.53 (0.024, 2.7)
Family income per month
<1000	78 (37.5%)	130 (62.5%)	0.75 (0.53, 1.06)	1.03 (0.65, 1.61)
⩾1000	175 (44.4%)	219 (55.6%)	1
Number of families in the households
<5	162 (41.6%)	217 (58.4%)	1.1 (0.79, 1.53)	1.02 (0.65, 1.62)
⩾5	91 (39.3%)	132 (60.7%)	1	1
Latrine available at home
Yes	229 (42.4%)	311 (57.6%)	1.17 (0.68, 1.99)	1.39 (0.76, 2.55)
No	24 (38.7%)	38 (61.3 %)	1	1
Media exposure
Yes	221 (48.1%)	238 (51.9%)	3.22 (2.1, 4.89)**	3.38 (2.1, 5.4)**
No	32 (22.4%)	111 (77.6 %)	1	1
Attitude toward a hygienic practice
Positive	200 (51.5%)	179 (48.5%)	3.58 (2.5, 5.2)**	3.54 (2.4, 5.26)**
Negative	53 (27.7%)	170 (77.3%)	1	1

COR: crude odd ratio.

Statistical significance at p < 0.05.

Statistical significance at 0.001.

Discussion

Hygienic practices during complementary feeding have an extensive role in decreasing child morbidity and mortality related to inappropriate feeding practices. Thus, this study aimed to assess hygienic practices during complementary feeding and associated factors among mothers/caregivers of children aged 6–24 months in Wolaita Sodo town, southern Ethiopia. This study revealed that good hygienic practices during complementary feeding were 42.0%, 95% CI (38, 45.8). In addition, we identified factors associated with good hygienic practice during complementary feeding, higher educational status, access to media, and attitude toward hygienic practices.

Good hygienic practice during complementary feeding was 42%, 95% CI (38, 45.8), which was consistent with the results of a study conducted in Nigeria (36.5%),¹⁴ Thrissur district, Kerala India (45%),¹⁵ Bahir Dar (38.9%),¹⁶ and Harari region, eastern Ethiopia (39.6%).¹³ However, it was higher than the study conducted in Tsegede district of northern Gondar (33.3%), which had good hygienic practices during complementary feeding.¹⁷ Compared to the current study area, the Tsegede district includes both urban and rural mothers and caregivers. These mothers may have had limited access to information, water, and sanitation. Mothers and caregivers can improve their hygiene habits by providing better access to water and sanitation services.

In contrast, it was lower than the hygienic practice during complementary feeding reported in Abobo district southeastern Ethiopia (51%)¹⁸ and Bale Zone Oromia region Ethiopia (55%).¹⁰ This discrepancy may be due to the use of different methods to measure proper hygiene practices and to the fact that a previous study included model households with a higher likelihood of practicing proper hygiene practices during complementary food preparation. Our finding was also lower than those studies conducted in Malaysia (71.8%)¹⁹ and Seri Lanka (60%).²⁰ The difference across the studies could be explained by the socio-demographic features of the study participants, the study setting, the time gaps between the study periods, and the difference in data collection methods. And also it might be due to differences in access to water, healthcare facility, and level of education in the study population.

The educational status of respondents was another significantly associated factor for hygienic practice during complementary feeding. In this study, the good hygienic practice was 3.36 times more likely among mothers/caregivers women who could read and write and about two times more likely to those who had completed primary as compared to those who could not read and write. This finding was also confirmed by studies conducted in Harari region, eastern Ethiopia,¹³ Thrissur district, Kerala, India,¹⁵ where mothers/caregivers without formal education were less likely to follow proper hygiene practices when complementary feeding. This might have been a participant who had formal education and could use their baseline information to have effective hygiene practices during complementary feeding activities. They could successfully practice proper hygiene during complementary feeding activities by reading guidelines related to food hygiene and implementing professionally recommended practices.

However, being secondary and above were not predictors. There are several reasons why the primary educational level was found to significantly predict proper hygiene practices among mothers more than those who had a secondary educational level. One primary reason is that primary education often covers basic health and hygiene practices, including hand washing, food safety, and personal hygiene. This means that individuals with primary education are more likely to have a basic understanding of how to maintain proper hygiene. Additionally, primary education is often more accessible for individuals in low-income or rural areas, where access to healthcare and hygiene resources may be limited. As a result, individuals with primary education may have gained more practical experience with hygiene practices in their daily lives.

This study also found a positive relationship between access to media TV or radio and hygiene practices during complementary food preparation. Those who had access to media (TV or radio) were three times more likely to have good hygiene during complementary feeding than those who did not have access to media. This finding was supported by studies conducted in Bahir Dar Zuria, northwest Ethiopia¹⁶, and Bale zone Oromia region, Ethiopia.¹⁰ This finding was also supported by a systematic review from low- and middle-income countries on the effectiveness of mass media and nutrition education interventions for improving infant and young child feeding practices. This highlights the importance of the media in disseminating information and educating caregivers about complementary feeding practices.²¹ This could be because the media play a crucial role in disseminating information about complementary feeding practices that are essential for their implementation. Moreover, mothers/caregivers with access to the media are likely to be better informed and follow acceptable hygiene standards during complementary feeding. Thus, they practice targeted behaviors such as washing their hands when preparing complementary foods, taking care of their diet, and trimming their fingernails.

Mothers/caregivers with positive attitudes toward hygiene practice were more likely to have good hygiene practices during complementary feeding. In this study, the odds of good hygienic practice during complementary feeding practice were three times higher among mothers/caregivers with positive attitudes toward hygienic practice as compared to those who had negative attitudes. It was supported by findings in Nairobi Kenya,²² Bahir Dar Zuria,¹⁶ northwest Ethiopia, and Bale zone Oromia region Ethiopia,¹⁰ which revealed that mothers/caregivers with positive attitudes toward hygiene practice were more likely to engage in good hygiene during complementary feeding. A possible explanation for this might be due to the fact that having a positive attitude about the advantages and disadvantages of hygiene during complementary food preparation enables mothers/caregivers to engage in proper hygienic practice during complementary feeding.

Strengths and limitations of the study

The strength of this study is that we use a relatively large sample size as compared to other studies conducted on hygienic practices, which increases the precision of the result. Limitation of this study, as it was a cross-sectional it does not indicate cause and effect relationship. Moreover, this study was not supported by direct observations during the hygienic practice of complementary feeding. This data was collected through self-report of the respondents so that there could be recall bias.

Conclusion

This study found that the prevalence of hygienic practices during complementary feeding was relatively low. The higher educational status of respondents, access to media (TV/radio), and attitude toward hygienic practice were found as significant contributing factors for good hygienic practice during complementary feeding. Consequently, complementary food processing and preparation training and counseling should be provided to mothers and caregivers. In addition, to effectively reach the target population, policymakers, health professionals, and media organizations should work together to develop and communicate evidence-based messages. Media organizations should also try to foster a favorable social and cultural climate that supports wholesome complementary feeding practices for young children.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231195416 – Supplemental material for Hygienic practice during complementary feeding and its associated factors among mothers/caregivers of children aged 6–24 months in Wolaita Sodo town, southern Ethiopia

Supplemental material, sj-docx-1-smo-10.1177_20503121231195416 for Hygienic practice during complementary feeding and its associated factors among mothers/caregivers of children aged 6–24 months in Wolaita Sodo town, southern Ethiopia by Gizachew Ambaw Kassie, Natnael Atnafu Gebeyehu, Molalegn Mesele Gesese, Endeshaw Chekol Abebe, Misganaw Asmamaw Mengstie, Mohammed Abdu Seid, Wubet Alebachew Bayih, Sefineh Fenta Feleke, Natnael Amare Tesfa, Tadesse Asmamaw Dejenie, Berihun Bantie, Yenealem Solomon Kebede, Melkamu Aderajew Zemene, Anteneh Mengist Dessie, Denekew Tenaw Anley and Getachew Asmare Adella in SAGE Open Medicine

Footnotes

Acknowledgements

We thank Wolaita Sodo University for approval of ethical clearance. Then, we would like to thank all study participants who participated in this study for their commitment to responding to our interviews. Lastly, we are indebted to each department's health offices for their assistance and permission to undertake the research.

Author contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Ethical approval and consent to participants

An ethical clearance letter was obtained from Wolaita Sodo University, College of Health Sciences; School of Public Health Institutional Review Board (ref. no. CRCSD (15/02/2013). An official letter was received from the school of public health and submitted to the Sodo Town Health Office to get an official letter of permission for data collection. Furthermore, after a thorough discussion and explanations of the purpose, benefits, and possible risks of the study, written informed consent was secured from each study participant before enrolled to study. All relevant ethical principles under the Helsinki Declaration were followed and respected.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Gizachew Ambaw Kassie

Misganaw Asmamaw Mengstie

Mohammed Abdu Seid

Sefineh Fenta Feleke

Natnael Amare Tesfa

Anteneh Mengist Dessie

Denekew Tenaw Anley

Getachew Asmare Adella

Data sharing statement

All the minimal datasets used to reach the conclusions drawn in the manuscript are included within the manuscript.

Supplemental material

Supplemental material for this article is available online.

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