PROPER UTILIZATION OF IODIZED SALT AND ASSOCIATED FACTORS AMONG RURAL COMMUNITY OF HETOSA DISTRICT, OROMIA REGIONAL STATE, SOUTH EAST ETHIOPIA

Introduction Iodine is considered to be one of the most essential micronutrients for the normal physical and mental development of human beings. However, little is known about households’ use of iodized salt and associated factors. Objectives This study was to assess the proper utilization of iodized salt at the household level and associated factors in Hetosa District, Southeast Ethiopia, 2019. Methods A Community-based cross-sectional study was conducted from August 20 up to September 15/2019 in rural Hetosa District, Arsi Zone, and east-south Ethiopia. A total of 603 households were selected using a systematic random sampling technique. Data were collected employing structured and pre-tested questionnaires by face -to -face interview technique. The use of iodized salt at the household level was tested with the iodine rapid test kit. The data were checked, coded and entered into Epi Info Version 7 and export to SPSS version 21 for analysis. Result A total of 596 participants were included in this study. The availability of adequately iodized salt was 61.1%. The proportion of proper utilization of iodized salt at the household level was 38.4%.Formal Educational (AOR=1.688, 95%CI (1.002, 2.846)),Practice of iodized salt use (AOR= 3.352, 95%CI (2.160, 5.202)), Knowledge on use of iodized salt (AOR=2.320, 95%CI (1.437, 3.745)) and level of iodine content in salt (AOR= 1.668, 95%CI (1.071, 2.597)) were statistically significant to utilization of iodized salt. Conclusion Proper utilization of iodized salt remains very low, which was 38.4% in the district and does not meet the national goal. Educational status, level of iodized salt, good knowledge and good practice were significantly associated factors with proper utilization of adequately iodized salt in this study.


Background
Iodine is an essential micronutrient. The human demand for iodine is a hundred and fifty mcg/ day.Iodine is a trace element sparsely distributed over the surface of the earth. About 90% of this comes from food while 10% from water. It is essential for the synthesis of the thyroid hormone, which is necessary for human growth and development (1). Iodine is present in the body in a minute amount, mainly in the thyroid gland. Its confirmed role is in the synthesis of thyroid hormone (2).
Iodine is an essential dietary nutrient that helps the body to manufacture thyroxin, the hormone that regulates normal growth and development. The quantity of iodine required by an individual is minute, being 150-200μg per day or a teaspoonful during a lifetime (4). Iodine is considered to be one of the most vital micronutrients for the standard physical and mental changing of anthropological existences. The erosion of soil and deforestation is considered to be the reasons for the decrease of the iodine level in hilly and mountainous areas (5).Universal salt iodization (USI) is globally accepted as the most cost-effective public health strategy to prevent iodine deficiency (6).This strengthening salt iodization programs and improving monitoring is a crucial step to eradicate the problem (7).
Many studies evidenced that iodine deficiency disorders contribute to the increment of morbidity and mortality of infants and neonates. It also reduces the quality of life, national productivity and 13.5 points of the intelligent quotient (IQ) (22). If iodine deficiency continued as a problem by 2012-2025 about 12 million children would be born from iodinedeficient mothers; these children would have some point of permanent brain damage (with a decrease in IQ). Economic productivity losses related to iodine deficiency during 2012-2025 is US$5 billion (5).
The prevalence of IDD based on the total goiter rates (visible and palpate) is the highest in the Eastern Mediterranean region 32%, followed by Africa 20%, European 15% and Southeast Asia 12%. However, it is important to recognize that these clinical signs are superficially in severe cases and subclinical deficiency, which is also associated with a range of intellectual and behavioral deficits, affects many more individuals. Nearly one -third of the world's population (2.3 billion is considered to be at risk of iodine deficiency, which a large proportion live in Southeast Asia (22).
According to World Health Organization (WHO),United Nation International Child Fund(UNICEF) and International Council for Control of Iodine Deficiency Disorder (ICCIDD) the daily recommended dietary allowance (RDA) is 90, 120, 150, 200 mcg of iodine for preschool children, school children, adults, and pregnant and lactating women respectively (10).
Ethiopian Public Health Institute 2016 survey reported that national iodized salt utilization coverage was 89.2%.However,only about 26% of the surveyed households had salt that was adequately iodized salt (at>15ppm) (13).The National goal of iodization utilization coverage of Ethiopia 95% (14).
It is estimated that almost half of Ethiopia's 80 million population faces iodine deficiency disorder (IDD), raising alarm in the Horn of Africa nation (23).In Ethiopia, one out of each a thousand may be a hypothyroidism and concerning 50,000 prenatal deaths were occurring annually because of iodine deficiency disorders, twenty sixth of the overall population have a goiter and 62% of the population is at risk of IDD according to the national survey made by the previous Ethiopian Nutrition Institute (24).
Study conducted in Chole district arsi zone south east Ethiopia,among school children revealed that the prevalence of goiter was 36.6% (25).A study conducted on the Utilization of Iodized Salt at Household Level in Zuway Dugda district revealed that , only 25.6% nof the respondents properly utilized iodized salt (26). Therefore,eventhough iodine deficiency is the major public health problems and the cause of morbidity and mortality, but very little is known about households' use of iodized salt and associated factors in Ethiopian context and why this study was conducted.

Study area
The study was carried out in Hetosa district one of the 26 districts found in Arsi Zone. Hetosa district is located in Arsi zone in Oromia Regional State, about 160 Kilometers Southeast from Addis Ababa of Ethiopia. The area lies between 08° 08'N-08°13' E latitude and 39° 14' N -39° 23' E longitude with an elevation range from1500-4170meters above sea level and characterized by mid subtropical temperature ranging from 5 C°-28 C°. According to the District Health Office 2019 report, there are four Primary Health Care Unit which includes four health centers and 23 health posts. The potential health coverage by health center 62.7% in 2019(55).

Study design and period
The community-based cross-section study design was carried out at household level among a rural community of Hetosa District, Southeast Ethiopia. The study was carried out from August 20 up to September 15/2019.

Source population
The source populations were all households who live in Hetosa District

Study population
Households were systematically selected in the selected Kebele of the Hetosa District to be part of the study.

Inclusion criteria:
The study was conducted among adult aged 18 years and above those who involved in food item purchasing and preparation/cooking and live the area for more than 6 months.

Exclusion Criteria:
The household head/food preparation had seriously sick that makes communication difficult to get the necessary information

Sampling procedure
In this study multi-stage sampling method was used, by considering Hetosa district, which consists of twenty-three Kebele. Kebele were selected using simple random sampling from the total 23 rural administrative areas (Kebele) of the district, from those Kebele 30% (7 Kebele).The calculated sample size (603 households) were proportionately allotted to every elect Kebele supported its size of households. Then a systematic random sampling technique was used to identify the study households from each selected Kebele.
The first house was chosen at randomly by lottery method. This house became the starting point or first house to sampling frame. Where there was more than one eligible individual in selected households, a lottery method was used to pick one of them. Where there were 4 or more eligible households in a house selected, two households was drawn at random and only one eligible person (household head) a lottery method was used to pick one of them. Where no eligible household was found in a selected house, the next house closest to the previously selected one was selected. This procedure was repeated until the required number of respondents was obtained. When the interviewer refused to involve in the study, the household was taken as nonresponse.

Data collection procedures (instruments, personnel, measurements)
Data were collected using a structured questionnaire and rapid iodine test kit by face-to-face interview with four diploma nurse and Supervised by 2 BSC Nurse. The standard structured questionnaire which was modified for this study was used for recording the responses by the interviewee. The questionnaire was adapted in English and then translated to Afan Oromo and finally, it was retranslated in to English by another language translator for checking consistency.
The questionnaires were used to collect data on socio-economic characteristics, Behavioral factors, and environmental factors associated with utilization of iodized salt.
For the data collector training was given for one day, focusing on communication and technical issues on how to collect data, interview technique and recording how to test the salt for adequately iodized and supervisors was trained on how to supervise the data collectors by the investigator. Questions was analyzed and reported before actual data collection on similar kebelesbut not included in the study subject for completeness, consistency, and timeliness. Data collection was started with a brief introduction and after consent for participants obtained and then questionnaire completed by face to face interview, in the language of respondent and salt tested.Supervisors were checking questionnaire and contact at least 50% of the respondents to verify that the correct procedures had been followed in data collection and testing for iodized salt.
Salt test kit -To assess the availability of adequately iodized salt at household, the interviewer asks every sample household to provide a teaspoon of salt used for food preparation and fill

Data quality assurance
Questionnaire was checked and screened for completeness and consistency. Omission, error, completeness was checked. Data were cleaned, edited and coded before entry. Data processing was done before analysis. The prepared questionnaire was pretested prior to the actual data collection on 30 participants. Checking on the spot and double data entry on EPI INFO-7 was done to ensure the completeness and consistency of the information collected.

Data processing and analysis
Data were entered, cleaned and edited by using EPI-INFO Version -7 Statistical software and then data was exported to SPSS version 21 for analysis. Descriptive statistics of the collected data was done for most variables in the study using statistical measurements. Frequency

Ethical considerations
Ethical clearance was obtained from the ethical review board of Arsi University and the formal letter of support obtained from the Hetosa Woreda. Verbal consent was obtained from households head and study participants. The participants were allowed to consider their participation and given the opportunity to withdraw from the study at any point in the course of study when they were not comfortable with the study. Data collector presented questions for the respondent by their language. Name of the respondent was not including in the questionnaire and information of individual respondent was not being shared to ensure confidentiality. All the responses of the participants and the results obtained from each household were kept anonymous and confidential by using a coding system whereby no one should had access except the principal investigator. The study had no risk on the study subject and interview was conducted in a private area.

Socio demographic characteristics of respondent's
From 603 participants invited to participate in the study, 596 participants were included with a response rate of 98.8%. The mean age + standard deviation participants were 34 + 11.8 years.

Level
In a bivariable analysis, Age, family size, marital status, educational status, religion status , monthly income, type of house Iodine content level, knowledge, and practice were significantly associated with proper utilization of iodized salt selected as a candidate predictors for the multivariable model at P<0.25.
In multivariable analysis after controlling the possible confounders; among variable studied, in the bivariable analysis of the utilization of Iodized salt in this study, some variables show significant differences with a p-value less than 0.05. To avoid missing variables those were significant in another similar study p-value less than 0.05 was used as a cut point off for multivariable analysis 10 variables that were significant at p-value less than 0. 25 (Table 4).

Discussion
Proper utilization of iodized salt at household level is a critical point to achieve the intended intervention of iodine Fortification. Universal salt iodization (USI) is globally accepted as the most cost-effective public health strategy to prevent iodine deficiency (6). This strengthening salt iodization programs and improving monitoring is a crucial step to eradicate the problem (7).
Accordingly, the present study identified the overall level of proper Iodine utilization and factors associated with this proper utilization of iodine; namely, Educational status, level of iodine in salt, good knowledge, and good practices. Identifying the proper utilization of iodized salt was the final target to tackle IDDs and this means that iodized salt should be added after cooking finished in community and at households' level (14). Damot 88.8% in 2019 (29,37,40,41,45). This difference might be due to the study period, study area, information access, Knowledge of about iodized salt of respondents. This finding also Which is far lower than the Ethiopian Public Health Institute 2016 survey reported that national iodized salt utilization coverage was 89.2%((13).
Yet the current rate was considerably below the national goal of 95% of coverage (14).This discrepancy due to this study focus on local than the national level, the small size of area and study period. 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 (7,41). Therefore observed proper utilization of iodized salt in the study area was very low.
World Health Organization (WHO) recommended that at least 90% of households using adequately iodized salt which contains 15ppm or more at the household's level (11). Elimination of Iodide deficiency is possible if more than 90% of the households consume adequately iodized salt and must granted (33).  (32,41,44).This discrepancy might be due study period in case of Asella and Dessie.
In addition the discrepancy might be due Access of information, availability packed salt, study design and residence of the respondents (37,43). This finding ,Which is far from the WHO recommendation to eliminate Iodine Deficiency Disorder 90% (10) (40).This difference might be due to the fact that the present study period.
In addition to this, the difference in socio-demographic characters and participants might be affecting the proper utilization of iodized salt.The finding of this study odds lower than odds that studied in Mecha (3.8) (14,38,41,45,53).This discrepancy might be due to information access, study period and study setting. This may show the role of good knowledge on influencing demand and need of properly utilization of iodized salt.
Iodine stability is critical for the success of salt fortification (33).Poor storage of iodized salt also leads to loss of iodine in the salt (54). Iodine content will remain relatively constant if the salt, kept dry, cool and away from light (41).Good practice of iodized salt at household level was significantly increased .  (7). This discrepancy might be due to information access and setting area. This indicates that good practice of iodized salt at household level has positive relationship for the demand for iodized salt.

5.Conclusion
Proper utilization of iodized salt remains very low, which was 38.4% in the district and does not meet the national goal. Educational status, level of iodized salt, good knowledge and good practice were significantly associated factors with proper utilization of adequately iodized salt in this study.

6.Acknowledgment
We would like thank Arsi Universityto give this golden chance. Next, We would like to thank Arsi zone health department for the provision of Iodine test kits. Our appreciation also extends to Hetosa Health Office for providing necessary information and material support. We would like to thank data collectors and supervisors for taking their precious time to collect data. Finally, We would like to thank to participants of the study who have took their time to provide necessary information for my thesis development.