Introduction

Adequate nutrition contributes to the health and development of an individual. Maternal and child health can improve through proper nutrition alongside a safe environment during pregnancy and delivery.^1,2 Adequate nutrition, either directly or indirectly, lessens the risk of chronic diseases and improve excellent academic attainment among children.³ Dietary diversity (DD) and the number of animal source foods (ASF) consume by an individual are the two generally accepted measures for dietary quality.⁴ A diverse diet determines nutrient adequacy because no one food item can meet the nutritional requirement of an individual.⁵

Twelve food groups determine adequate dietary diversity score. These food groups provide the nutrients essential for life and growth. Are also known as ‘everyday foods.’ Each of the food groups provides a range of nutrients, and all have a role in helping the body function. In particular, vegetables, legumes and fruit protect against illness and are essential to a healthy diet. A balanced diet includes a variety of foods from each food group. It offers a range of different tastes and textures. It is important to choose most of the foods we eat each day from these food groups. For example, nutrients and vitamins and other food groups such as fruits, animal source foods, grains and vegetables require in their right amount for proper growth and development.⁵

Dietary determinants could contribute to a heightened risk of diseases, particularly chronic ones. However, adequate advice on nutrition can improve dietary diversity, thereby reduced in excessive intake of salt, fat, and refined sugars which are considered unhealthy in a large quantity.⁶ Households whose diets are monotonous on starchy foods that lack vital micronutrients are subscribing to malnutrition and its burden and deficiencies in micronutrients.⁷ Besides, diets of most pre-school children in Sub-Saharan African countries are mainly concentrated on starchy foods, fewer vegetables, fresh fruits and limited or no animal source foods.⁵

Dietary diversity is measured either at the individual or household level. Usually, it is measured by summing the number of food groups, not individual food items consumed. It is also a measure of access to food at the household level (example ability of households to obtain expensive food groups). Besides, it reflects dietary quality at the individual level. Mainly the micronutrient adequacy of the diet. The reference period of dietary diversity varies, but 24 hours recall period mostly used.⁸

Inadequate diet quality or diversity is an essential determinant of malnutrition, precisely, micronutrient deficiencies.⁹ Reduced dietary diversity is associated with food insecurity which affects the nutritional status of low-income households.¹⁰ Household food insecurity leads to underweight, wasting and stunting among children.¹¹ Micronutrient malnutrition is considered as a global health threat, especially among underdeveloped and developing countries. Among these countries, intake of foods concentrated mainly on starchy based grains(monotonous diets) in most cases lacks in diversity.¹² Women, especially those pregnant and children deemed vulnerable to malnutrition because they have high nutrient demand.^3,13-15 Therefore, a diet composed of different foods groups recognised as necessary in assuring sufficient nutrient intake among these vulnerable groups. Dietary diversity is essential in promoting nutrient intake. ⁴ At the same time establishing its determinants factors is indispensable and can help in policy formulation, which would eventually improve nutrient intake. ³ Studies have shown that an increase in dietary diversity is associated with socioeconomic status and household food security.¹⁶ In low-income countries, suboptimal dietary practices were due to either from limited access to the food supply or inadequate knowledge of the importance to obtain good diet quality.¹⁷

Although dietary diversity is imperative and is well recognised in The Gambia, however, limited studies conducted to determine the dietary diversity status of households and its related determinants, especially in the rural areas of The Gambia. Therefore, this current study aimed to assess household dietary diversity status and its associated factors in Central River Region South, The Gambia. This study would unquestionably contribute to the information essential for an evidence-based intervention programme to improve the dietary diversity status of households in Central River Region South.

The Operational Study Definition

Dietary Diversity Score

The number of food groups consumed by households out of the twelve (12) food groups. These food groups included; cereals, fish and seafood, root and tubers, pulses/legumes/nuts, vegetables, milk and milk products, fruits, oil/fats, meat, poultry or offal, sugar/honey, eggs and different foods (tea).³

High Dietary Diversity

Consumption of seven or more food groups of the 12 food groups used in this study.³

Medium Dietary Diversity

Consumption of four to six food groups of the 12 food groups used in this study.³

Low Dietary Diversity

Consumption of three or fewer food groups of the 12 food groups used in this study.³

Methodology 

Study Location

This study was carried out in the Central River Region South, The Gambia. It is situated about 200 km from the south of the capital of The Gambia, Banjul. The region largely depends on agriculture chiefly on cereal grains crop production for a living. The principal varieties of crops produced in this area are groundnut, cassava, maize, bean, millet, sorghum, and rice. The region has two different seasons, dry and wet seasons. The data was collected during the lean season, where households might be experiencing food shortages.

Study Design, Duration and Participants

A cross-sectional study was conducted from August to November 2018 in Central River Region South, The Gambia. All households with women responsible for preparing meals for the households were selected as the study participants.

Calculation of Sample and Size Sampling Method

The sample size of this study was calculated using a single population proportion formula based on the assumptions: Prevalence of food insecurity in the Gambia (11%) Comprehensive Food Security Vulnerability Analysis.¹⁸ absolute precision (5%), confidence interval (95%), a design effect of 2 and with non- response rate of 10%. The final calculated sample size was 334 households. All households with women responsible for preparing meals for the households were selected randomly to participate in the study. Ten villages from 11 districts were selected by simple random sampling method. Lastly, the sample was allocated to each village proportionally and a systematic random sampling method was used to select households. The exclusion criteria were women who cannot speak (difficulty in speaking or deaf).

Dietary Assessment

This study used the Food and Nutrition Technical Assistance (FANTA) Household Dietary Diversity Score Questionnaire version 2006. The questionnaire was administered to women responsible for preparing meals in the households. Twelve (12) enumerators conduct the data collection under the supervision of supervisors. Dietary diversity status was measured at the household level. The questionnaire comprises 12 food groups, which cover almost every food consume in The Gambia. Also, the survey asks a single question regarding any food group household consumed. A simple count of each food group consumed by any of the household members during the previous 24 hours before the study was calculated to determine dietary diversity scores for each food group.

Ethical Approval

This study obtained approval from Universiti Sains Malaysia (USM) with protocol code JEPeM/18050260 and The Gambia Government/Jointly Medical Research Council(MRC) Ethics Committee with protocol code SCC1605V2.1. The participants were briefed about the objective of the study before they signed the written consent form. All the data collectors and principal investigator assured the participants the confidentiality of the information, and the households were coded by numbers rather than family names. Other possible ethical concerns were also discussed before the interview.

Data Quality Assurance

Before the start of the survey, all data collectors and two supervisors underwent two days of orientation training on ethics and standard of data collection procedures, validity, and reliability of the collected data. The first day of the training covered practical theories demonstration on different areas of data collection, which include assessment of sociodemographic and economic characteristics and dietary diversity status. About 5% (17 households) from two districts that were not part of the study were selected to pre-test the questionnaire. Strict supervision was conducted during the data collection. Data completeness was verified daily. Data were also cleaned and double-checked before entry into (SPSS) Statistical Package for Social Science version 24 for analysis.

Statistical Analyses

Dietary diversity categories were expressed using the 12 food groups in this study. Low dietary diversity category (less than three food groups), medium diversity category (four to six food groups) and high diversity category (seven than more food groups). ³  The dietary diversity scores were category dichotomised as “0” not attaining minimum dietary diversity and “1” for achieving minimum diversity.

Data was entered into (SPSS) version 24, cleaned before the analysis. A descriptive statistic was used to describe the study participants. Crude Odds Ratios (COR) were estimated using binary logistic regression at a 95% confidence level to assess the strength of association between dietary diversity (dependent variable) and the independent variables. All the variables with a P-value of <0.25 in the univariate logistic were considered and fitted in the multivariable logistic regression (Adjusted Odds Ratio: AOR). Results with a P-value < 0.05 were considered statistically significant as a predictor of low dietary diversity status.

Result

The overall sample size was 334 households that participated in this study. The mean age of the respondents 28.04 (SD5.88) years. About 92.0% of the households headed by males and 8.1% headed by females. A large number of respondents, 97.3%, were married, and about 42.8% of households have seven and above family members and the mean household size was 7.96 (SD5.05).

The women who attended formal education were 30.8%. Regarding the livelihood, among women, 4.5 % were employed, and 76.3% of households had a monthly income of 1837.50 Gambian Dalasis (GMD) / USD59, while 23.7% gain monthly income of GMD ≥1837.51 /USD59. For the spouse, 31.7% had a formal education, and 15% of them were employed. For households reporting ownership of assets ranged from mobile phone 77.5%, TV 18%, Radio 79%, bicycle 70.6%, refrigerator 10.2%, electricity 19.5% , farmland 52.7% and livestock 77.2% (Table 1).

Table 1: Characteristics participants in Central River Region South, The Gambia.

Table 2 presents the consumption of each food group in the households. More than 90% of households consumed cereals-based grains 24 hours before the survey. About 53.6% of households consumed peas, beans, lentils, or nuts; 47.9 % of households consumed sugar or honey, and 46.7% consumed dried fish or fresh or shellfish. Besides, 47.0% of households consumed food made with oil, fat, or butter. In comparison, 45.8% of households consumed roots or tubers, 38.0% of households consumed milk or other milk products, cheese, yoghurt, 24.6% of households consumed vegetables, 12.3% of households consumed fruits, 11.7% of households consumed meat or poultry or offal, whereas 15.0% of households consumed miscellaneous foods (tea and coffee) and 6.0% of households consumed eggs. n = Number, SD = Standard deviation. 1 USD = GMD 49. The poverty line is less than Dalasis is 1,837.50 =(1.25 USD),GMD= Gambia Dalasis 

Table 2: Consumption of individual food group by households recorded in the previous 24 hours.

 *Responses of more than one option of food groups

Households Dietary Diversity Status

Table 3 presents households dietary diversity score. The mean dietary diversity score was 4.36 (SD 2.28). Averagely, households consumed four (4) food groups before 24-hours recall period. The vast majority of households 201(60.2%) were found in low diversified state (consumed ≤three food groups), 85 (25.4.%) of households are in the medium dietary category (consumed 4–6 food groups), and 48 (14.4%) of households are in the high dietary category (consumed 7-12 food groups).

Table 3: Dietary Diversity status of households in Central River Region South, Gambia.

Predictors of Household Dietary Diversity

Table 4 displays univariate and multiple logistic analysis of associated factors of dietary diversity of households. During univariate analysis, no education among women, lack of unemployment and education among spouses, monthly income of less than 1,387.50 Gambian Dalasis (GMD), ownership of farmland and livestock, lack of financial assistance, not practising home gardening and lack of market access were the predictors of low dietary diversity. During multiple logistic analyses, monthly household income below 1,387.50 GMD, not practising home gardening, lack of ownership of farmland, lack of education among women and lack of employment among spouses were the significant associated factors of low household dietary diversity.

Table 4: Univariate and multivariable logistic regression analyses of factors associated with household dietary diversity.

AOR^a = Adjusted Odds Ratio, COR^b = Crude Odds Ratio, CI= Confidence Interval, ^* Statistically significant at P<0.25, ^b Statistically significant at P <0.05.

Discussion

This study evaluated the household dietary diversity status and its determinants in Central River Region South, The Gambia. The mean score of dietary diversity was 4.36(SD2.28). On average, four (4) food groups were consumed by households 24-hours before the study was conducted. There were 60.2 %, 25.4% and 14.4% of households in low, medium and high, dietary diversity status respectively. The finding from this study agreed with similar studies conducted in Bangladesh, Vietnam and Ethiopia, by Nguyen et al. ¹⁹ Low dietary diversity among breastfeeding mothers was also reported in Ethiopia.¹³ Similar findings also reported in six Nigerian states.²⁰ The similarities among these studies were the same tool used to assess the dietary diversity status of households. The high rate of low dietary diversity could be related to the food insecurity situation of households in the study area. Since dietary diversity is a surrogate measure of food security and food-insecure households ate a diet less diverse than food-secure households. ²¹ The study also showed more than 90.0% and 53.6 % of households had consumed cereals, seeds and nuts, respectively. This finding could be explained that, in The Gambia, agriculture is the primary source of cereals, which are often available in the local communities where households can have access to it, such as rice and sorghum. This finding supported by other studies in Africa.^22,23, whereas both rice and sorghum are stapled foods for most African countries which are readily available at the local markets. Conversely, households were low diversified in fruits, eggs, milk and milk products, vegetables and meat or poultry or offal (12.3%, 6.0%, 38.0, 24.6 %, 11.7%), respectively. This finding supported by similar findings reported in Bangladesh, Vietnam, Ethiopia by Nguyen et al.²⁴ and in Kenya.²⁵

Households with a low monthly income of ≤1387.50 GMD were 4.57 times higher odds to be low diversified as compared to households with a higher income of ≥1837.51 GMD per month. This finding agreed with a study done by Thorne-Lyman et al. ²⁶ In Bangladesh, the economic status of the households was associated with low dietary diversity status. ²⁶ This finding could be explained that households with low income adversely affected their food preference, in terms of quantity and quality of different food groups consumed. Household food insecurity could affect the dietary diversity of households. A household may lack adequate income to access food to improve their dietary diversity status. Low household dietary diversity in this study could also be associated with food insecurity. If households depend highly on cereals without other food groups such as animal source food, fruits and vegetables might lead to micronutrient deficits. ²⁷

Literature has shown that better socioeconomic status linked to a higher diet diversity score of households in developing countries.²⁸ An increase in household income would also increase household dietary diversity status by consuming different food groups.²⁹ Households that reported not engaging home gardening were found low dietary diversified. Households not practising home gardening were 1.43 more likely to experience low diversified when compared to households with home gardening. Finding from this study concurred with a study carried out in Ethiopia.²⁵ This finding demonstrated that home gardening could adequately improve the intake of vegetables. Home gardening offers a way of consuming a range of foods that may not be available in the market by growing fruit, vegetables and other crops. Home gardens also provide convenient access to fresh plants and animals source foods in rural as well as urban areas.³⁰ This finding could be explained that households with gardens could use food produce from the gardens to diversify daily food intake of vegetables. Besides, households can also sell parts of the vegetables and get additional income to purchase other food items for the household.²⁵

Our study also showed that spouses that were not employed were 2.50 times expected to experience low dietary diversity status as compared to spouses employed. This study finding agreed with a finding reported in South Africa.³¹ This finding could be explained that spouses that were not employed might have experienced inadequate income in households, which could decrease their odds of accessing adequate foods to improve their dietary diversity status. Besides, it could also be associated with the low purchasing power of spouses. Either employed or not spouses depend on employment as a source of household income. Women that were not educated were 1.67 times a higher chance of attaining low dietary diversity. Comparable conclusions on the influence of women’s educational status on low dietary diversity were reported in Bangladesh, South Africa and Kenya.^14,26,31 This finding could be explained that women without education might not get the necessary information on appropriate food preparation, feeding practices, nutrient content in foods and nutritious food choices. Higher education among women could be served as a source of employment opportunities for income generation. Women are known to play an essential role in the household economy. They are more likely to prioritise the household budget on food, health services and childcare as compare to their male counterpart. Therefore, women’s incomes or income managed by women can lead to increased dietary diversity in the household.

Moreover, households without access to farmland were 2.18 times high odds to achieve low dietary status as opposed to households with ownership of farmland. A similar finding reported elsewhere example, Bangladesh, where households with farmland said to have improved dietary diversity status of women positively. ³² The finding could be explained that households with farmland could grow more foods to supplement other food items obtained through purchases.

Strength and Limitation

The household dietary diversity questionnaire was able to identify households with low and high dietary diversity status. The study provided baseline data on household dietary diversity status, which has not been available in the study area. Seasonal variation affects the availability of food that could lead to low dietary diversity status of households. The data were collected during the rainy season when households usually experience food shortages. Household dietary diversity data were collected only at one recall period, which could be subjected to under-reporting. Only women in the household answered the questionnaire on behalf of all household members, which determine the household dietary diversity status for the entire household. However, since all the respondents were women, they had a good knowledge of the situation in the household.

Conclusion

The dietary diversity status of households in the study area was very poor. Factors such as monthly income less than 1387.500 GMD, not having home gardening, spouses’ employment status, ownership of farmland and women’s educational status were significantly associated with low household dietary diversity status. The government should improve job opportunities and strengthening education, particularly among women, to improve household dietary diversity. Home-gardening practices should be encouraging at the community level to enhance household food security, especially dietary diversity in their food consumption. Land should be accessible to farmers to grow more foods, which may increase dietary diversity. More studies are recommended on dietary diversity in different seasons of the year to better understand the actual dietary diversity status of households in the study area.

Acknowledgement

Appreciation goes to the Islamic Development Bank (IDB) for the award of Master of Science scholarship programme. We thank all participants and their family members for their support and co-operation throughout this study. The authors also express their appreciation to the Regional health authorities in Central River Region Health Directorate and the community health nurses for their continual support.

Funding Source

Technical and logistics support by the Regional Health Directorate Central River Region, Mr. Lamin BS Jarju and Mr. Fabakary Bass of National Malaria Control Programme and National Nutrition Agency of The Gambia Respectively. Financial support has been received from the Islamic Development Bank (IDB) for the present study.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Reference

1. Black RE, Victora CG, Walker SP, . Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet. 2013;382(9890):427-451.
   CrossRef
2. Bukania ZN, Mwangi M, Karanja RM, . Food insecurity and not dietary diversity is a predictor of nutrition status in children within semiarid agro-ecological zones in Eastern Kenya. Journal of Nutrition and Metabolism. 2014;2014.
   CrossRef
3. Kennedy G, Ballard T, Dop MC. Guidelines for measuring household and individual dietary diversity. Food and Agriculture Organization of the United Nations; 2011.
4. Musaiger AO, Takruri HR, Hassan AS, Abu-Tarboush H. Food-based dietary guidelines for the Arab Gulf countries. Journal of Nutrition and Metabolism. 2012;2012.
   CrossRef
5. Ekesa B, Blomme G, Garming H. Dietary diversity and nutritional status of pre-school children from Musa-dependent households in Gitega (Burundi) and Butembo (Democratic Republic of Congo). African Journal of Food, Agriculture, Nutrition and Development. 2011;11(4).
   CrossRef
6. Kennedy G, Fanou-Fogny N, Seghieri C, Brouwer ID. Dietary diversity as a measure of the micronutrient adequacy of women’s diets: results from Bamako, Mali site. 2009.
7. Allen LH. To what extent can food-based approaches improve micronutrient status? Asia Pacific Journal of Clinical Nutrition. 2008;17.
8. Food and Agriculture Organization F. Guidelines for measuring household and individual dietary diversity. Food and Agriculture Organization of the United Nations, Rome, Italy. 2011.
9. Mayén A-L, Marques-Vidal P, Paccaud F, Bovet P, Stringhini S. Socioeconomic determinants of dietary patterns in low-and middle-income countries: a systematic review–. The American Journal of Clinical Nutrition. 2014;100(6):1520-1531.
   CrossRef
10. Ahmed U, Ying L, Bashir M, Abid M, Elahi E, Iqbal M. Access to output market by small farmers: The case of Punjab, Pakistan. Journal of Animal and Plant Sciences. 2016;26(3):2016.
11. Agbadi P, Urke HB, Mittelmark MB. Household food security and adequacy of child diet in the food insecure region north in Ghana. PloS One. 2017;12(5).
    CrossRef
12. Desta M, Akibu M, Tadese M, Tesfaye M. Dietary Diversity and Associated Factors among Pregnant Women Attending Antenatal Clinic in Shashemane, Oromia, Central Ethiopia: A Cross-Sectional Study. Journal of Nutrition and Metabolism. 2019;2019.
    CrossRef
13. Nguyen PH, Avula R, Ruel MT, . Maternal and Child Dietary Diversity Are Associated in Bangladesh, Vietnam, and Ethiopia. The Journal of Nutrition. 2013;143(7):1176-1183.
    CrossRef
14. Rashid DA, Smith LC, Rahman T. Determinants of dietary quality: evidence from Bangladesh. World Development. 2011;39(12):2221-2231.
    CrossRef
15. Rosas LG, Harley K, Fernald LC, . Dietary associations of household food insecurity among children of Mexican descent: results of a binational study. Journal of the American Dietetic Association. 2009;109(12):2001-2009.
    CrossRef
16. Food and Agriculture Organization of the United Nations. Guidelines for Measuring Household and Individual Dietary Diversity. Rome, Italy, 2013.
17. Belachew T, Lindstrom D, Gebremariam A, . Food insecurity, food-based coping strategies and suboptimal dietary practices of adolescents in Jimma zone Southwest Ethiopia. PloS One. 2013;8(3):e57643.
    CrossRef
18. Comprehensive Food Security and Vulnerability Analysis (CFSVA), Gambia. 2013.
19. Hien NN, Hoa NN. Nutritional status and determinants of malnutrition in children under three years of age in Nghean, Vietnam. Pak J Nutr. 2009;8(7):958-964.
    CrossRef
20. Ajani S. An assessment of dietary diversity in six Nigerian States. African Journal of Biomedical Research. 2010;13(3):161-167.
21. Faber M, Wenhold FA, Laurie SM. Dietary diversity and vegetable and fruit consumption of households in a resource-poor peri-urban South Africa community differ by food security status. Ecology of Food and Nutrition. 2017;56(1):62-80.
    CrossRef
22. Herrador Z, Perez-Formigo J, Sordo L, . Low dietary diversity and intake of animal source foods among school-aged children in libo kemkem and fogera districts, Ethiopia. PloS One. 2015;10(7).
    CrossRef
23. Keding GB, Msuya JM, Maass BL, Krawinkel MB. Relating dietary diversity and food variety scores to vegetable production and socio-economic status of women in rural Tanzania. Food Security. 2012;4(1):129-140.
    CrossRef
24. Nguyen PH, Avula R, Ruel MT, . Maternal and child dietary diversity are associated in Bangladesh, Vietnam, and Ethiopia. The Journal of Nutrition. 2013;143(7):1176-1183.
    CrossRef
25. Knueppel D, Demment M, Kaiser L. Validation of the household food insecurity access scale in rural Tanzania. Public Health Nutrition. 2010;13(3):360-367.
    CrossRef
26. Ongosi AN, Gericke G, Mbuthia E, Oelofse A. Food variety, dietary diversity and perceived hunger among lactating women (0-6 months postpartum) in a low socio-economic area in Nairobi, Kenya. African Journal of Food, Agriculture, Nutrition and Development. 2014;14(2).
27. Arimond M, Wiesmann D, Becquey E, . Simple food group diversity indicators predict micronutrient adequacy of women’s diets in 5 diverse, resource-poor settings. The Journal of Nutrition. 2010;140(11):2059S-2069S.
    CrossRef
28. Becquey E, Martin-Prevel Y, Traissac P, Dembélé B, Bambara A, Delpeuch F. The household food insecurity access scale and an index-member dietary diversity score contribute valid and complementary information on household food insecurity in an urban West-African setting. The Journal of Nutrition. 2010;140(12):2233-2240.
    CrossRef
29. Ogundari K. Determinants of food-poverty states and the demand for dietary diversity in Nigeria. Paper presented at: 2013 AAAE Fourth International Conference, September 22-25, 2013, Hammamet, Tunisia2013.
30. Cabalda AB, Rayco-Solon P, Solon JAA, Solon FS. Home gardening is associated with Filipino preschool children’s dietary diversity. Journal of the American Dietetic Association. 2011;111(5):711-715.
    CrossRef
31. Taruvinga A, Muchenje V, Mushunje A. Determinants of rural household dietary diversity: The case of Amatole and Nyandeni districts, South Africa. Int J Dev Sustainability. 2013;2(4):2233-2247.
32. Harris-Fry H, Azad K, Kuddus A, . Socioeconomic determinants of household food security and women’s dietary diversity in rural Bangladesh: a cross-sectional study. Journal of Health, Population and Nutrition. 2015;33(1):2.
    CrossRef