Indian Journal of Public Health

: 2021  |  Volume : 65  |  Issue : 3  |  Page : 218--225

Exploration of dietary diversity and its associated factors among infant and young children in Rural Tamil Nadu – A mixed-method study

Kalaiselvi Selvaraj1, Tovia Stephen2, S Princy Priyadharshini3, Nikita Radhakrishnan3, Mohamed Ashic3,  
1 Assistant Professor, Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
2 Department of Community Medicine, Senior Resident, Puducherry, India
3 Intern, Puducherry, India

Correspondence Address:
Kalaiselvi Selvaraj
Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra


Background: A child receiving an acceptable diet is expected to reach the optimal anthropometric measures. More than 60% of dietary requirement has to be met through complimentary diet. Objectives: This aimed to estimate the prevalence of dietary diversity and to assess factors associated with it from caregivers' perceptions by quantitative and qualitative participatory techniques. Methods: A mixed-method study comprising community-based cross-sectional quantitative and participatory rural appraisal qualitative components was conducted in 25 villages from the field practice area of medical institute in South India during 2017. Caregivers of eligible children 6–23 months from villages were interviewed regarding various food groups consumed in the last 24 h using a validated checklist. Association of demographic-, child, and mother-related characteristics with inappropriate dietary diversity was identified using multivariate negative log-binomial model. Results: Of the 603 eligible children, 75.1% had inappropriate dietary diversity. Although inappropriate dietary diversity prevailed across all categories, mothers with less than primary education (adjusted prevalence ratio [PR]: 1.26) children <1 year (adjusted PR: 1.29) and not on current breastfeeding (adjusted PR: 1.15) had significantly more inappropriate diversity. Restraining and motivating forces for dietary diversity were initially recorded from free listing and subjected to force-field analysis. Ignorance, lack of literacy, affordability issues, nuclear family pattern, and influence of junk foods are restraining forces. Conclusion: Inappropriate dietary diversity among 6–23 months children in the rural block of Tamil Nadu, South India, is extensive (75%). Current Child development programs should focus to address these issues based on these identified contextual factors.

How to cite this article:
Selvaraj K, Stephen T, Priyadharshini S P, Radhakrishnan N, Ashic M. Exploration of dietary diversity and its associated factors among infant and young children in Rural Tamil Nadu – A mixed-method study.Indian J Public Health 2021;65:218-225

How to cite this URL:
Selvaraj K, Stephen T, Priyadharshini S P, Radhakrishnan N, Ashic M. Exploration of dietary diversity and its associated factors among infant and young children in Rural Tamil Nadu – A mixed-method study. Indian J Public Health [serial online] 2021 [cited 2021 Dec 2 ];65:218-225
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Full Text


The initial 1000 days in the life span of children are considered to be a critical window determining the nutritional status of children. Stunting which is established before 2 years is largely irreversible.[1],[2] Globally, 150.8 million and 50.5 million children were found to be stunted and wasted respectively. India alone is contributing to 30.9% of stunted children (46.6 million) and 50.5% of wasted children (25.5 million) in the world.[3] As a part of the global nutritional target, India envisages to achieve a 40% reduction in the rate of stunting.[4]

A child receiving an acceptable diet is expected to reach the optimal anthropometric measures. Consuming various food groups in adequate quantity by the infant and young children plays a pivotal role in their cognition, growth, and development.[5],[6],[7],[8],[9]

The deterioration in growth starts at 6 months of age and peaks at 2 years of age.[10],[11] Inappropriate complementary feeding practices are stated to be one of the commonest reasons for malnutrition among young children.[5],[12] After 6 months, 200 kcal, 300 kcal, and 550 kcal of energy among children 6–11, 12–18, and 19–23 months have to be provided through complementary feeding as breast milk alone cannot meet the requirements. Similarly, after 6 months, 87% of iron, 67% of calcium, and 75% of zinc requirements have to be met through complementary foods alone.[13] Dietary diversity is positively linked to micronutrient availability among children.[14],[15],[16],[17]

The access to dietary diversity closely reflects the extent to which the child is receiving an acceptable diet.[18],[19] Dietary diversity is recognized as one of the simplest reliable indicators to assess dietary adequacy among infants and young children. Dietary diversity is being defined as the sum of food groups, consumed irrespective of the quantity consumed in the previous 24 h.[20]

Often, cultural practices and food taboos prevailing in the community hamper the dietary diversity among caregivers.[21],[22] Further, socioeconomic factors, maternal occupation, literacy, and number of family members also can affect the dietary diversity.[23],[24],[25],[26] Most of the developing countries have the minimum dietary diversity in the range of 12%–40%. All National Health Survey including the recent National Family Health Survey (NFHS-4) has reported the dietary diversity to be as low as 35% and the trend of dietary diversity is declining further.[27],[28],[29]

There are ample evidences on prevailing infant and young child feeding (IYCF) practices and nutritional status of the children including the national surveys. However, the proximal and distal determinants on dietary diversity are largely unexplored, especially in the Indian context. The routine quantitative surveys do not elicit all factors associated with dietary diversity. Any effort which aims to change the practice toward improved dietary diversity would require more understanding on forces determining the dietary diversity.

In this background, this study was conducted to estimate the prevalence of dietary diversity among children aged 6–23 months and to assess factors associated with dietary diversity obtained through caregivers' perceptions collected from both quantitative and qualitative participatory rural appraisal (PRA) techniques.

 Materials and Methods

Study design

This was a community-based explanatory mixed-method study where initially quantitative survey was conducted among primary caregivers of young infants and qualitative approach was followed as one of the PRA techniques, namely force-field analysis. Findings of the quantitative survey were used to prepare the field guide for conducting force-field analysis and explanations were sought for the findings of the quantitative survey. Force-field analysis is a diagrammatic representation of factors for and against the event influencing at that moment and captured through qualitative interviews.[30],[31],[32]

Study setting and study period

This study was conducted in 25 villages located around the rural health training center of academic medical institute in Tamil Nadu, India. In this block, more than 47% of people are involved in agricultural occupation and have access to Integrated Child Development Services (ICDS) within 1–2 km from their residence.

A quantitative survey was conducted during January 2017 and the force-field analysis was carried out during April 2017.

Study population

This study included children who completed 6 months of age and <2 years regardless of their supplementary feeding status during the survey period. For this purpose, a line list of children who were born from January 01, 2015, to December 31, 2016, was obtained from the Community Health Information Management System maintained in the rural health center. It was also cross-verified with enumeration registers of ICDS.

Data collection: Tools and techniques

Quantitative part

All eligible children were identified from the line list and those households were contacted by trained medical undergraduates. Without any further sampling, all children completed at least 6 months of age were included during the field survey. Using the pretested proforma, data related to sociodemographic characteristics, birth details were collected from the primary caregiver. Caregivers were specifically asked about the food items consumed by the child on the previous 24 h. These food items were marked in the structured checklist as prescribed by the World Health Organisation tool for measurement indicators.[20] Anthropometric measurements such as length/height and weight were measured as per the standard procedures.[33]

Dietary diversity is being defined as consumption of at least four groups of food regardless of their quantity on the previous day from the following identified food groups, namely (1) grains, roots, and tubers, (2) legumes and nuts, (3) Vitamin A-rich fruits and vegetables, (4) other vegetables and fruits, (5) flesh foods (meat, poultry, fish, and organ meat), (6) egg and egg products, and (7) dairy products (milk, yogurt, and cheese).[20]

Qualitative part

Mothers and caregivers of infants and young children are called to participate in one of the PRA techniques, namely free listing and force-field analysis. During the quantitative survey on IYCF practices, vocal and willing to participate mothers or caregivers were identified. As ICDS workers are involved in conducting the mother support meeting to impart nutritional education, those who are willing to participate in the exercise were also invited. They were informed on the previous day regarding their role of participation in this exercise, venue and timings also shared during this contact. All food groups, namely cereals, pulses, Vitamin A-rich and other fruits, vegetables and green leaves, roots and tubers, meat, chicken, egg, and milk and milk-related products were displayed with clear labels. Mothers were instructed to see all these food groups kept on the display. All groups of foods were chosen based on the local relevance.

Free listing: A total of 11 women assembled for participation in one of the identified facilities of ICDS (Anganwadi) centers. Of 11, six are mothers of young children; five of them were Anganwadi workers. All women were briefed regarding what is meant by dietary diversity. They were informed regarding results of quantitative survey followed by requested to free list the reasons for enabling and deterrent factors against dietary diversity in their community in the provided piece of chart. Each woman wrote several reasons for and against dietary diversity. For one of the illiterate women, to document the reasons, a dictator was provided. Later, all reasons facilitating dietary diversity were made in one comprehensive list. Similarly, reasons for unable to following the dietary diversity were also compiled as one list.

Data management and analysis


Data were entered in EpiData (version 3.1) and analyzed using EpiData analysis software (v and STATA 14 (StataCorp, College Station, Texas). Sociodemographics such as gender, birth details, parental factors, breastfeeding status, supplementary feeding started or not, and food items consumed by the child are summarized as frequencies and percentages. Of the several groups of foods, if the child had consumed at least four groups of foods on the previous day, it was considered as dietary diversity present. Prevalence of dietary diversity is presented as percentages with a 95% confidence interval (CI). To avoid overestimating the risk by odds ratio for highly prevalent conditions like dietary diversity, it was preferred to present an adjusted prevalence ratio (PR) using negative log-binomial regression with the Poisson family. Factors identified with P value of 0.2 or less were further subjected to Poisson model with log link.[34] Measures of association with dietary diversity were reported as adjusted PR with 95% CI.


Force-field analysis – Following the free listing, all mothers and caregivers were informed to arrange the reasons in terms of its contribution to dietary diversity. To facilitate this, circular charts (Chapati diagram/Venn diagram) were provided in various sizes.[35] The most important reasons were displayed based on chart size in a graded manner. Ranking of reasons for poor dietary diversity was made based on the consensus among the group. Factors from free listing were also further explored with Smith value using anthropic software. A similar approach was followed to rank the free listed factors facilitating dietary diversity. Furthermore, each named factor has been further explored the extent to which they were perceived as addressable by these women. At the end, groups were briefed regarding the summary results of this force-field analysis.



A total of 803 children were born during the reference period. Out of 783 children surveyed, 180 were <6 months of age. Hence, they were excluded from the assessment of dietary diversity.

Majority of the under − 2 years children informants were mothers (92%). About, 54.6% of the participated children were males. Majority of the mothers (85.5%) were unemployed and 8.3% of them involved in agricultural occupation with remuneration. About one-fourth of children (41.6%) had birth weight >3 kg. More than one-third of the children had low birth weight (38.7%). Majority of children had born in government hospitals (88.2%). The average median household income was Rs. 9221 (133.14$). Around 87.4% of children were of first or second birth order.

Of the 603 children assessed for dietary diversity, only 25% (95% CI: 21.6%–28.5%) had an appropriate diversified diet. Cereals (92.9%), animal milk (63.6%), and pulses (53.6%) were the most common food given to children for complementary feeding. Next to cereals and pulses, eggs (23.3%) were consumed by a large number of children. Consumption of green leaves (4.8%) and green vegetables (2.8%) was found to be in the least quantity.

In the multivariate negative log-binomial model, the child not meeting minimum dietary diversity was considered as a dependent variable and income quartile, literacy of mother, current breastfeeding status, and age of the child were considered as independent variables in the final model as this model yielded the least possible log-likelihood and AIC values. Across all attributes of children in terms of sex, birth weight, birth order, and place of birth, more than three-fourth (75.1%) had consumed less than four food groups (inappropriate dietary diversity) in their diet. In specific, children less than 12 months had 29% more poor dietary diversity compared to children of 18 months–2 years old (adjusted PR: 1.29 [95% CI: 1.11–1.51] P = 0.001). Children who were currently not on breastfeeding had 15% more inappropriate dietary diversity compared to children who were on breastfeeding (adjusted PR: 1.15 [95% CI: 1.03–1.29] P = 0.001) [Table 1].{Table 1}

Similar to child-related factors, family pattern (nuclear/joint family), income status of the family, and mother-related factors also showed three-fourth of the children to receive inappropriate diversified diet [Table 2]. Children of mothers educated less than primary education had 26% more poor dietary diversity compared to children of mothers educated more than primary education (adjusted PR: 1.26 [95% CI: 1.08–1.48] P = 0.003). There is no significant difference in nutritional status (as measured by weight for age z score, height/length for age z score estimated using WHO Anthro plus software) observed among children who did not receive appropriate diversified diet compared to those who receive diversified diet [Table 2].{Table 2}


Free listing for and against the optimal following of dietary diversity exercise was attended by 11 women from rural backgrounds. This exercise lasted for 15 min. Discussion within the group to attain consensus regarding the ranking of reasons for force-field analysis extended to a further 20 min of duration.

Perceived barriers for inappropriate dietary diversity and facilitating factors for appropriate diversity captured through PRA techniques are given in [Figure 1]. Perception regarding to what extent these factors were felt as addressable is depicted in [Figure 2].{Figure 1}{Figure 2}


The current study from one of the rural blocks in Tamilnadu, India, had shown the low prevalence of minimum dietary diversity (25%) among infants and young children. The recent NFHS-4 survey from India and states of Tamilnadu had estimated 22.3% and 57.6% dietary diversity in the rural area, respectively.[27],[28] The study by Khan et al. from Delhi had reported the rate of minimum dietary diversity to be 32.6%.[36] The global prevalence of dietary diversity among young children is 29.3%.[4] Thus, the prevalence estimated in the current study is similar to other study estimates. However, “Rapid Survey On Children: by UNICEF for India reported the dietary diversity in rural India as 19.6%.[29]

Across several child-related factors and maternal and sociodemographic factors, the inappropriate dietary diversity was found to be extensive (~75%). Poor literacy state of the mother and younger age of the children were extensively quoted as independent determinants in several studies from African countries, Nepal, and previous Indian studies including the current study.[24],[25],[26],[37],[38],[39],[40] This could be explained by higher literacy that is often linked with improved health literacy, more autonomy, and increased opportunities for economic security. Poor dietary diversity observed among children <1 year could be due to hesitancy, perceived intolerability, or allergy to the children by the caregivers. Findings from one of the tertiary care hospitals had elicited fear of vomiting, ignorance, indigestion, and lack of teeth as common reasons for the delayed introduction of complementary foods.[41] The increased dietary diversity as the age advances among children is reported by Patel et al. and other studies from the African context as well.[19],[24],[25],[38],[40]

In contrary to the expectations, the current study had poor dietary diversity prevailing more among nonbreastfed children.[38] This indicates that the complementary feeding is not necessarily practised from the diversified diet. Complementary feeding is dominated by feeding from mere cereals and pulses. Studies from other developing countries where starch-based staple foods are predominant and animal-based products and fruits are taken in the least proportions of children also could not meet the dietary diversity norms.[24],[37],[42]

The most common restraining force was lack of awareness/poor literacy followed by economic reasons. Affordability influencing the dietary diversity was reflected by the participating women in many ways quoting the food price, lesser income, Non affordability and single earning member in the family. Quantitative analysis of the current study also indicated the increasing diversity as the income quartile increased. However, the trend was not statistically significant.

During the force-field analysis, participating women had opined that preparing a diversified diet is often time consuming. Hence, women from nuclear families and working mothers could not meet the minimum dietary diversity of their children.

Apart from this, craving toward junk foods and processed foods and less attraction toward natural foods were also stated as main barriers. The impact of junk foods among infants and young children in compromising the quality of the diet, micronutrient adequacy, and overall development of the child was also reported in previous studies.[43],[44]

During force-field analysis participant shared that advice from health-care providers and neighbors as positive forces to follow minimum dietary diversity among young children. Few studies from the developing countries had attributed the increasing number of antenatal visits, exposure to postnatal visits, and previous exposure to counseling sessions with better dietary diversity.[24],[25],[38],[39],[40] These opportunistic visits could have increased the awareness of the mother.

This study has the following strengths. First, this is a mixed-method study where reasons for poor dietary diversity were identified from the quantitative survey as well as explored from the qualitative force-field analysis technique. Second, the response rate of 95% with major respondent being the mother is expected to have high reliability. This study also estimates dietary diversity in different children age groups (6–9, 9–11, 11–18, and 18–23 months) and current breastfeeding status which is often not available in representative surveys.

This study did not show any significantly improved anthropometric measures among children who received a diversified diet. Even some of the community-based behavior change intervention trials also have documented the failure to link better IYCF with better anthropometry.[45] As it was based on 24 h recall, it may not completely reflect the routine diet. Since the study was conducted during the months of winter, there could be food taboos related to the season. The cross-sectional data may not exactly reflect the long-term growth of the child.

Although the sample size was adequate to estimate the burden of inappropriate dietary diversity, it precludes the statistical significance to prove the several subgroups associated with it. The findings of the current study leave a scope for improving several programmatic concerns. The highly prevailing inappropriate dietary diversity directs the need for revitalizing the role of ICDS centers and imparting nutrition-related literacy during mother's meetings and immunization services. Food taboos and misconceptions should be clarified by the health-care providers. The mere regular utilization of supplementary nutrition itself could easily contribute 3–4 types of foods. Both quantitative and qualitative findings re-iterated the role of ignorance linked with poor dietary diversity, the existing opportunistic platforms such as village health nutrition days, nutrition week (Poshan Diwas), and antenatal and postnatal visits should be used effectively to disseminate the messages through participatory methods. Dietary diversity is often not assessed in routine day-to-day practice. This is one of the reliable indicators which can assess the quality of diet and easily identify the “at risk children” going for undernutrition. Using this Indicator, peripheral health workers can identify the faulty dietary practices at the earliest and able to reflect the change in dietary patterns followed by the family during their subsequent visits.


Minimum dietary diversity among 6–23 months children in the rural block of Tamil Nadu, India, is very low (25%). Although three-fourth children had poor dietary diversity across all categories, children <1 year, mothers with poor literacy, and currently not breastfed children were could not meet the minimum dietary diversity compared to others. Qualitative techniques applied in the form of force-field analysis had revealed that ignorance, lack of guidance and time, lack of affordability, and increasing trend toward junk foods as restraining forces and perceiving the diet quality with improved nutritional status and advice from health-care providers and neighbors were stated as motivating forces for better dietary diversity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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