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  • Research note
  • Open Access

Knowledge and practice of iodized salt utilization among reproductive women in Addis Ababa City

  • 1,
  • 2 and
  • 3Email author
BMC Research Notes201811:734

https://doi.org/10.1186/s13104-018-3847-y

  • Received: 31 August 2018
  • Accepted: 11 October 2018
  • Published:

Abstract

Objective

The objective of this study was to assess knowledge and practice of iodized salt utilization among reproductive women in Addis Ababa city. A cross-sectional study was carried out on 549 households. A sample district was designated by using the simple random sampling techniques. Data were collected by a face-to-face interview and household salt was tested to check whether its practice was good. p < 0.2 in the bivariate logistic regression was entered into the multivariable logistic regression, and p < 0.05 was considered as significantly associated.

Results

Mothers who had good knowledge and practice of iodized salt were 78% (95% CI 74.9, 81.2) and 76.3% (95% CI 72.7, 79.8), respectively. Monthly household income (AOR = 2.97; 95% CI 1.20, 7.37) was associated with knowledge of iodized salt of respondents. Similarly, educational status (AOR = 2.45; 95% CL 2.10, 6.43) of respondents was significantly associated with the practice of iodized salt. This study indicated that increasing the level of knowledge and practice of iodized salt was good. Monthly household income and educational status were associated with knowledge and practices of iodized salt of respondents. Hence, improving mothers’ education is a highly recommended strategy for addressing public health problems of iodine deficiency.

Keywords

  • Knowledge
  • Practice
  • Iodized salt
  • Reproductive age
  • Ethiopia

Introduction

Iodine is an essential dietary nutrient for the thyroid hormones that regulate the growth and development of humans and animals. It plays an important role in controlling body metabolic rate, growth and development of body structures by producing the thyroid hormone [1, 2]. According to the World Health Organization (WHO), adults need about 120 μg of iodine per day to prevent iodine deficiency disorders (IDD) [3].

Poor intake of iodine is the major public health problem of women in the reproductive age pregnant and lactating women are particularly the most susceptible to iodine deficiencies which expose them to getting irreversible mentally impaired babies [2]. It is also documented that it causes abortions, stillbirths, congenital abnormalities, cretinism, goiter and impaired mental function as well as squinting, hypothyroidism, and stunting [4, 5]. Moreover, it impedes learning capacity, women’s health, the quality of life of communities, and the economic productivity of nations [4].

Globally, 38% of the world’s population lives with insufficient iodine [6]. Africa with its 9321.1 million deficient people bears the most burden of the region [7]. In Ethiopia, 35 million people are at risk of iodine deficiency, and the 50,000 annual prenatal deaths are related to this problem [8]. As a result, universal salt iodization (USI) is recommended as the most cost-effective, safe and sustainable strategy to eliminate IDDs [9]. Fortunately, 76% of households are consuming adequate iodized salt globally [10].

Regional coverages of iodized salt vary from 90% in Asia and the Pacific region to 40–60% in Sub-saharan Africa [10]. The level of utilization also varies from 10 to 90% in different countries. For instance, the utilization of iodized salt is less than 10% in Sudan, Mauritania, Guinea-Bissau, and Gambia, whereas Burundi, Kenya, Nigeria, Tunisia, Uganda, and Zimbabwe have achieved the USI target [7].

In Ethiopia, the practice of adequate iodized salt use showed a marked increase from 15% in 2011 to 89% in 2016 [11, 12]. Inconsistencies of the practice are detected among dwellings and economic status. As an illustration, iodized salt utilization is the highest in Tigray (55.2%) and Somali (49.4%) and the lowest in Gambela (9.5%), SNNPR (13.7%), and Amhara regions (15%) [13]. As a result, 10.8–36% [14, 15] of women aged 15–49 years have been affected by goiter.

The Government of Ethiopia revitalized and launched universal salt iodization initiatives and planned strategies for the achievement of a virtual elimination of iodine deficiency disorders through achieving universal salt iodization [16, 17]. However, still, only 26% of the households are using adequate iodized salt [14]. In fact, IDD stays the major public health problem among all segments of the population [14, 18]. Besides, there is limited information on knowledge and practice of iodized salt use in Addis Ababa. Therefore, this study aimed to assess the knowledge and practice of iodized salt utilization among reproductive women in the city.

Main text

Methods

Community based cross-sectional study design was conducted to assess Knowledge and Practice on iodized salt among reproductive age group women in Yeka Sub City Addis Ababa. Addis Ababa is a Capital City of Ethiopia. The City has 10 boroughs named sub-Cities and 99 districts. Yeka is one of the 10 sub cities of Addis Ababa, with the total population of a 413, 175. The sub-City has 13 districts [19].

All the women in the reproductive age in Addis Ababa were used as the source of the population this study. The sample size was calculated by using a single proportion formula through by judging the following assumptions; 29.6% as prevalence of salt practice [11], 95% confidence level, and 4% degree of precision. Finally, the sample size of 550 was obtained by considering 10% non-response rate. A multistage stratified sampling technique followed by systematic sampling technique was employed to select study participants. Four districts were selected by lottery method among 13 districts in Yeka sub-city. Then, the total sample size was allocated proportionally to each selected district. Finally, Households were selected using systematic random sampling technique.

Structured interviewed and observation technique was used to collect data. The questionnaire was first prepared in English and then translated into Amharic. The questionnaire was developed by through by different literature review, other similar studies and EDHS [11, 2022]. Two day training was given for data collectors and supervisors who have extensive experience in data collection about the methods of interview and observation. A total of 6 clinical nurses as data collector and 2 public health experts as supervisor were recruited for the study. During the data collection, close supervision was done by the principal investigator and supervisors.

The knowledge of the respondents towards iodized salt use were computed by using eight knowledge item questions accordingly, participants who respond correctly to knowledge questions and score median and above the median value considered as good knowledge whereas, respondents respond below median value were supposed as poor knowledge. Practice of iodized salt was summarized by applying four practice questions, as a result, participants who respond correctly answered practice question score median and above the median value considered as good practice whereas, respondents respond below median value were supposed as poor practice of iodized salt. Concerning media exposure women who read a newspaper or magazine or listen to the radio, or watched television at least once per month were considered having satisfactory media exposure and salt iodine content estimation was done by using a rapid test kit (RTK). The colour of the test sample is compared with the standard colour chart for calculating the salt iodine content. Finally, salt with ≥ 15 PPM was categorized as adequately iodized salt, whereas < 15 PPM was considered non-iodized salt.

All returned questionnaire were checked for completeness and consistency of responses manually. The data were entered using Epi-info version 3.5.4. Analysis associations between dependent and independent variables was assessed by using binary logistic regression and variables with p value < 0.2 entered into multiple logistic regression with 95% Confidence Intervals. Corresponding p value of < 0.05 was considered as statistically significant at 95% of confidence interval.

Result

Nearly half (45.5%) of the respondents were in the age group of 36–49 years; two-thirds (62.7%) were married and 25.5% of the respondents had university degrees. About 35.8% were employed, while 25.3% of the households earned a monthly income of less than ETB 1500. The majority (69.9%) of the husbands were employed of whom 10.2% were unable to read and write. A huge proportion (88.3%) of the respondents indicated that they had heard about iodized salt. Radio and television were the major media for 73.3% of the information about the importance of iodized salt and iodine-deficiency diseases. They said that a legal frame which prohibits the production, trade, and sales of non-iodized salt is in place in Ethiopia. Nearly two-thirds (60.8%) of the respondents added salt at the end of cooking. The majority (88.9%) of the respondents stored their salt in closed containers. Some (33.5%) participants consumed salt with an iodine level of ≥ 15 ppm (Table 1).
Table 1

Reproductive age women and their husbands Socio-demographic characteristics in Yeka sub-city, Addis Ababa, March 2015

Variable

Frequency

Percent (%)

Age of the respondents

 15–25

76

13.8

 26–35

223

40.7

 36–49

250

45.5

Religious of the respondents

 Orthodox

372

67.8

 Protestant

86

15.7

 Muslim

79

14.4

 Catholic

11

2.0

 Other

1

0.2

Ethnicity of the respondents

 Amhara

240

43.7

 Oromo

151

27.5

 Gurage

85

15.5

 Tigire

56

10.2

 Other

17

3.1

Marital status

 Married

344

62.7

 Unmarried

205

37.3

Educational status of the mother

72

13.1

 Unable to read and write

49

8.9

 Read and write

23

4.2

 Primary education

137

25

 Secondary education

156

28.4

 Vocational Diploma

44

8.0

 Degree and above

140

25.5

Respondents occupational

 Own business

138

25.1

 House wife

128

23.3

 Private employee

101

18.4

 Government employee

79

14.4

 Unemployed

40

7.3

 Daily laborer

38

6.9

 Other

25

4.6

Household monthly income (ETB)a

 < 1500

239

25.3

 1501–2800

139

25.3

 2801–5000

164

29.9

 > 5000

107

19.5

Age of the husband (n = 352)

 23–35

104

29.5

 36–50

176

50.0

 > 50

72

20.5

Religion of the husband (n = 352)

 Orthodox

229

65.1

 Muslim

57

16.2

 Protestant

49

13.9

 Catholic

14

4.0

 Other

1

0.4

Husband educational status (n = 352)

 Unable to read and write

32

9.1

 Read and write

4

1.1

 Primary education

37

10.5

 Secondary education

100

28.4

 Vocational diploma

27

7.7

 University degree

152

43.2

Husband occupation

 Private employee

136

38.6

 Government employee

90

25.6

 Own business

76

21.6

 Non-governmental organization

20

5.7

 Daily laborer

18

5.1

 Other

12

3.4

Have you heard about iodized salt

 Yes

485

88.3

 No

64

11.7

The source of information about iodized salt

 Radio, television

402

73.2

 Printed material

68

12.4

 Friends/neighbors

26

4.7

 Health workers

20

3.7

 Others

2

0.4

Have you heard the effects of iodine deficiency on human

 Yes

436

79.4

 No

113

20.6

Iodized salt should be handled in the store and household with great care than non-iodized

 Yes

86

15.7

 No

463

84.3

What are the advantage of using iodized salt?

 Better test

24

4.4

 Better digestion

3

0.5

 Makeup for iodine in the human body (prevent IDD such as goiter, abortion)

401

73

 I don’t know

99

18

 Other

22

4

What is the consequence of Iodine deficiency?

 Goiter

420

76.5

 Cretinism/mental retardation in children

118

21.5

 Abortion/still birth/miscarriage

96

17.5

Regular consumption of iodized salt can remove iodine deficiency in the body?

 Yes

408

74.3

 No

141

25.7

Health risk of unborn baby if there is lack of iodine in the diet of pregnant women?

 Risk of being mentally impaired

170

31

 Risk of being physically impaired

68

12.4

 I don’t know

270

49.5

 Other

39

7.1

Group of population should receive much iodine than other

 Children

220

40.1

 Pregnant women

179

32.6

 All people need same amount

195

35.5

 I don’t know

92

16

 Other

4

0.7

Is there legal frame exist in Ethiopia which prohibit production, trade and sales of non-iodized salt?

 Yes

70

12.8

 No

246

44.8

 I don’t know

233

42.4

Does iodine in the salt affect its test?

 Yes

75

13.7

 No

329

59.9

 I don’t know

145

26.4

In what place should iodized salt be kept

 Dry place

235

42.8

 With no direct sunlight contact

71

12.9

 In closed container

358

65.3

 It doesn’t need special place

31

5.6

 I don’t know

  

Timing of adding salt during food cooking process

 At the beginning

45

8.4

 In the middle

168

30.8

 At the end

334

60.8

Where do you usually store your salt

 In an open package

25

4.6

 In container without lid

36

6.5

 In container with closed lid

488

88.9

Iodine test result

 Not iodized (0 ppm)

160

29.1

 Inadequate iodine in the salt (< 15 ppm)

200

36.4

 Adequate iodine in the salt (> 15 ppm)

184

33.5

 No salt at home

5

0.9

Place where salt is store

 Exposed to sun light

4

0.7

 Near to fire in the kitchen

7

1.3

 Far from sun light and fire

536

97.6

 Other

2

0.4

aIndicate One US Dollar = 27.00 Ethiopian Birr (ETB)

The overall prevalence of knowledge and practice of iodized salt use among women in reproductive age in Addis Ababa was 78% (95% CI 74.9, 81.2) and 76.3% (95% CI 72.7, 79.8), respectively.

Women living on a monthly household income greater than ETB 5000 had 2.97 times better knowledge on iodized salt use [AOR: 2. 97; 95% CI (1.20, 7.37)] compared to those who lived on a monthly income of less than ETB1500 (Table 2). Women who had college and above educational status were 2.45 (2.10, 6.43) times more likely to use iodized salt compared to mothers unable to read and write. Similarly, the odds of having earning a monthly household income greater than ETB 5000 were 3.66 times [AOR: 3.66; 95% CI (1.78, 8.03)] higher among respondents who had good practice of iodized salt use compared to their counterparts (Table 3).
Table 2

Bivariate and multivariable logistic regression output showing that factors associated with knowledge of iodized salt among women at reproductive age, in Yeka Sub-city Addis Ababa, March 2015

Variables

Knowledge

Crude Odds Ratio with 95% CI

Adjusted Odds Ratio with 95% CI

Good

Poor

Respondents educational status

 Unable to read and write

33 (67.3)

16 (32.7)

1

1

 Read and write

19 (82.6)

4 (17.4)

2.30 (0.67,7.90)

2.44 (0.68,8.68)

 Primary education

84 (61.3)

53 (38.7)

0.77 (0.39,1.53)

0.76 (0.37,1.55)

 Secondary education

128 (82.1)

28 (17.9)

2.22 (1.08,4.57)

2.02 (0.92,4.44)

 Degree and above

164 (89.1)

20 (10.9)

3.98 (1.87,8.47)

2.72 (1.05,7.03)

Occupations of the respondents

 Government employee

69 (87.3)

10 (12.7)

1.08 (0.34,3.41)

1.21 (0.35,4.13)

 Private employee

87 (86.1)

14 (13.9)

0.97 (0.32,2.91)

1.64 (0.51,5.27)

 Own business

101 (73.2)

37 (26.8)

0.43 (0.16,1.18)

1.02 (0.33,3.14)

 House wife

88 (68.8)

40 (31.2)

0.34 (0.13,0.95)

0.97 (0.30,3.06)

 Unemployed

27 (77.1)

8 (22.9)

0.53 (0.15,1.80)

1.01 (0.47,2.10)

 Daily laborer

24 (77.4)

7 (22.6)

0.54 (0.15,1.90)

1.19 (0.32.4.51)

 Others

32 (86.5)

5 (13.5)

1

1

Household monthly income

 < 1500

98 (70.5)

41 (29.5)

1

1

 1500–2800

100 (71.9)

39 (28.1)

1.07 (0.64,1.80)

0.85 (0.48,1.49)

 2801–5000

131 (79.9)

33 (20.1)

1.67 (0.98,2.82)

0.97 (0.54,1.83)

 > 5000

99 (92.5)

8 (7.5)

5.18 (2.31,11.61)

2.97 (1.20,7.37)*

Marital status

 Not married

164 (80)

41 (20)

1

1

 Married

264 (76.7)

80 (23.3)

2.59 (0.81,8.32)

0.86 (0.53,1.40)

Media exposure

 Poor

7 (58.3)

5 (41.7)

1

1

 Good

421 (78.4)

116 (21.6)

1.21 (0.79,1.85)

1.15 (0.33,3.94)

* Indicate significant at p value less than 0.05 in multivariable logistic analysis

Table 3

Bivariate and multivariable logistic regression output showing that factors associated with practice of iodized salt among women at reproductive age, in Yeka Sub-city Addis Ababa, March 2015

Variables

Practice

Crude Odds Ratio with 95% CI

Adjusted Odds Ratio with 95% CI

Good

Poor

Respondents educational status

 Unable to read and write

19 (38.8)

30 (61.2)

1

1

 Read and write

12 (52.2)

11 (47.8)

0.04 (0.02,0.11)

1.18 (0.38,3.64)

 Primary education

86 (62.8)

51 (37.2)

0.08 (0.03,0.22)

2.06 (0.98,4.32)

 Secondary education

131 (84)

25 (16)

0.12 (0.05,0.25)

2.10 (1.24,5.6)

 Technical/vocational

40 (90.9)

4 (9.1)

0.36 (0.16,0.80)

2.14 (1.55,5.43)

 Degree and above

101 (93.6)

9 (6.4)

0.69 (0.20,2.35)

2.45 (2.10, 6.43)*

Occupations of the respondents

 Government employee

75 (94.9)

4 (5.1)

2.93 (0.74,11.63)

2.85 (0.64,12.76)

 Private employee

83 (82.2)

18 (17.8)

0.72 (0.25,2.10)

1.07 (0.32,3.57)

 Own business

98 (71)

40 (29)

0.35 (0.14,1.05)

1.08 (0.31,3.51)

 House wife

95 (74.2)

33 (25.8)

0.45 (0.16,1.25)

1.41 (0.41,4.79)

 Unemployed

31 (88.6)

4 (11.4)

1.21 (0.30,4.93)

3.53 (0.75,16.07)

 Daily laborer

5 (16.1)

26 (83.9)

0.03 (0.08,0.12)

0.56 (0.25,1.51)

 Others

32 (86.5)

5 (13.5)

1

 

Household monthly income

 < 1500

84 (60.4)

55 (39.6)

1

1

 1500–2800

94 (67.6)

45 (32.4)

1.37 (0.84,2.24)

0.98 (0.50,1.60)

 2801–5000

138 (84.1)

26 (15.9)

3.48 (2.03,5.96)

1.69 (0.87,3.27)

 > 5000

103 (96.3)

4 (3.7)

2.57 (1.50,7.23)

3.66 (1.78,8.03)*

Marital status

 Not married

146 (71.2)

59 (28.8)

1

1

 Married

273 (79.4)

71 (20.6)

1.55 (1.04,2.32)

1.30 (0.77,2.18)

Media exposure

 Poor

5 (41.7)

7 (58.3)

1

1

 Good

414 (77.1)

123 (22.9)

4.71 (1.47,15.11)

1.52 (0.44,5.27)

Knowledge

 Poor

81 (66.9)

40 (33.1)

1

1

 Good

338 (79)

90 (21)

1.86 (1.19,2.890)

1.27 (0.75,2.14)

* Indicate significant at p value less than 0.05 in multivariable logistic analysis

Discussion

It is apparent that the use of iodized salt by individuals and households is the major approach in the control of IDDs globally [2325]. Thus, strengthening salt iodization programs and improving monitoring is a crucial step to eradicate the problem [22, 26, 27]. This study found that 78% of the respondents had good knowledge of iodized salt use. The finding was higher than the 26% reported from Tehran [22]. The variation might be due to the nature of study settings in that woman from slum areas and poor communities were included in the Tehran study. Clearly, slum areas are characterized by poor infrastructure and inadequate communication channels compared to Addis Ababa, the setting of our study, where the respondents had ample opportunities to increase their knowledge through promotions of iodized salt on the media. In fact, promotions on the media increase public awareness and alert that all salt producers and traders duly iodize their salt which is essential for achieving the USI goal [18, 28]. Our finding was slightly lower than 90.4% reported in Ghana [5]. This might be due to the accessibility of different media nearby for the target group in the study area.

Regarding the practice of iodized salt use of reproductive women, this finding is also higher than the 14% noted in Tehran [22]. The difference could be due to the fact that our study was used to ascertain the outcome by using two cut-off points, whereas the Tehran study considered three classifications as to determine outcome variable.

Household monthly income of the respondents was one of the factors associated with knowledge of iodized salt use of reproductive women. Accordingly, women belonging to greater than ETB 5000 monthly income were about three times more likely to have good knowledge of iodized salt compared to women belonging to less than ETB 1500 monthly household income group. This might be because women who lived on higher socioeconomic status had chances to purchase and use different electronic equipment which is important for enhancing nutrition education. In addition, house-to-house health visits by urban health workers improves knowledge of iodized salt utilization [29]. Besides, household income can be strongly associated with the type of salt used. That is, poorer households are much more likely to consume coarser salt owing to their low purchasing power [30].

The odds of practicing iodized salt were 2.45 times higher among reproductive age women who were university degree and above graduates compared to those who were unable to read and write. This finding is supported by those of studies done in Wolaita [31] and Arsi [28] zones. This might be due to the fact that higher levels of education provided better nutritional awareness about the benefits of iodine, increased awareness on the health benefits of iodine in diets, and raised the use of iodized salt. In addition, women who had the highest educational status had good employment opportunities which might be indicative of better socioeconomic status. This could relate to women who were better educated and had the ability of purchasing good quality food appropriate for salt iodization practice [30]. Moreover, mothers who were less educated and had less resources, had the least knowledge about the importance of iodized salt [20].

Finally, the probabilities of practicing iodized salt use were high among reproductive women who had higher monthly income compared to those who had low income. This finding was supported by researches elsewhere [24, 28]. Confirming the fact that better practices of iodized salt by women in the reproductive age has a relationship to the price of the salt. Women who earned better monthly household income have the ability of purchasing and utilizing iodized salts for high prices [32]. Similarly, household income might be strongly associated with the types of salt preference in that poorer households were much more likely to purchase coarser salts [30]. Furthermore, excess cost of iodized salt might be a barrier to preventing iodine deficiency because it forces people with low incomes not to buy and use the salt [29, 33]. Thus, most women may not able to use it due to its high cost [21].

In conclusion, this study showed that women had good levels of knowledge and practice of iodized salt use. Monthly household income and educational status are associated with the knowledge and practices of iodized salt of respondents. Hence, improving mothers’ education is an important strategy to address the public health problems of IDDs.

Limitation of the study

Rapid test kit show only color change which cannot tell the exact amount of iodine concentration in the salt but due to resource constraint gold standard iodine test couldn’t be use which show the exact concentration. This study didn’t triangulate with qualitative study.

Abbreviations

ACIPH: 

Addis Continental Institute of Public Health

AOR: 

Adjusted Odd Ratio

CI: 

confidence interval

COR: 

Crude Odd Ratio

IDD: 

iodine deficiency disorder

UNICEF: 

United Nations International Children’s Education Fund

USI: 

universal salt iodization

PPM: 

part per million

SPSS: 

Statically Package for Social Science

WHO: 

World Health Organization

Declarations

Authors’ contributions

MS conceived the study, developed the tool, coordinated the data collection activity, and carried out the statistical analysis. WW participated in the design of the study, tool development, and drafting the manuscript. AK participated in the design of the study and tool development, performed statistical analysis, and reviewed the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank all respondents for their willingness to participate in the study. They are also grateful to Yeka Sub-city administration for their cooperation and UNICEF Addis Ababa nutrition department, ACIPH and University of Gondar for material support.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Data will be available upon request from the corresponding authors.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethical approval was obtained from the ACIPH and University of Gondar Institutional Review Board. The purpose of the study was clearly explained to all concerned bodies. Informed verbal consent was obtained from parent/guardians before the interview for each participant after briefly explaining the purpose, risk, and benefit of the study subject less than 18 years old and oral assent obtained from study subjects. Confidentiality was maintained and assured by excluding their names from identification of the study subjects. The instruments and procedures were not cause any harm to the study subjects, the community, the data collectors and supervisor. Health education about the use of iodized salt and handling practices in the household were given to each participant after data collection.

Funding

No fund was obtained for this study.

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Authors’ Affiliations

(1)
Development and Research Institute, Addis Ababa, Ethiopia
(2)
Department of Environmental, Occupational Health and Safety, Institute of Public Health, University of Gondar, Gondar, Ethiopia
(3)
Department of Human Nutrition, Institute of Public Health, University of Gondar, Gondar, Ethiopia

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