Comprehensive Research Proposal

Assessment of Knowledge and Practice of Maternal Nutrition and Associated Factors Among Pregnant
Women Attending Antenatal Care in Jinka General Hospital, Southern Ethiopia, 2026

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Table of Contents

1. Introduction

2. Statement of the Problem

3. Significance of the Study

4. Literature Review

5. Objectives

6. Research Methodology

7. Ethical Considerations

8. Dissemination Plan

9. References

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1. Introduction

1.1 Background of the Study

Maternal nutrition during pregnancy exerts a significant influence on both maternal and foetal health, as
well as long-term child development . Nutritional requirements increase during pregnancy to maintain
maternal metabolism and tissue accretion while supporting foetal growth and development.
Unbalanced diets, poor dietary intakes, or deficiencies in key nutrients can adversely affect pregnancy
outcomes and neonatal health, leading to an increased risk of preeclampsia, gestational diabetes, and
excessive gestational weight gain in the mother, as well as preterm birth, low birth weight, and an
increased risk of developing chronic diseases in adulthood in the child .

Globally, maternal malnutrition remains a significant public health challenge despite international
efforts. The World Health Organization's Third Global Nutrition Target aims to reduce the proportion of
infants born with low birth weight by 30% by the year 2025 . However, rates of preterm birth and low
birth weight have remained static over the past decade, with an estimated 11.9 million infants born
preterm and 23.4 million born small-for-gestational-age in 2020, approximately 90% of these in low-
income and middle-income countries .

In sub-Saharan Africa, including Ethiopia, the burden of maternal malnutrition is particularly severe.
Approximately 57% of pregnant women in sub-Saharan Africa are anaemic, representing one of the
highest prevalence rates globally . Maternal undernutrition is prevalent in Ethiopia, where 23% of
reproductive-age women are underweight, and an estimated 69% of women of reproductive age have
micronutrient deficiencies . The Ethiopia Demographic and Health Survey indicates that 41% of pregnant
women are anaemic, with 20% moderately anaemic, 18% mildly anaemic, and 3% severely anaemic .

The first 1000 days of life, from conception to a child's second birthday, represent a critical window of
opportunity for nutrition interventions. Poor nutrition during this period can result in developmental
delays, stunted growth, cognitive impairments, and a higher risk of chronic diseases later in life .
Pregnancy is considered a "teachable moment"—a naturally occurring life transition that motivates
individuals to spontaneously adopt risk-reducing health behaviours . Therefore, improving nutrition
knowledge during this phase presents an important opportunity to establish healthy behaviours in
mothers that can be maintained throughout life and have beneficial consequences for their offspring.

1.2 The Ethiopian Context

Ethiopia has one of the highest rates of micronutrient deficiencies globally, making maternal
malnutrition a serious public health concern . Despite substantial achievements in maternal health
programmes over the past decade, maternal undernutrition continues to be a major public health
challenge. Maternal and child mortality rates remain high, with 412 maternal deaths per 100,000 live
births and 67 child deaths per 1,000 live births . These figures are closely associated with the high
prevalence of undernutrition among pregnant women in Ethiopia, which ranges from 14.4% to 47.9% .

The government of Ethiopia recommends nutrition counselling throughout pregnancy for better
consumption of diversified diets, as improving maternal nutrition is vital for the prevention of maternal
and child mortality and morbidity . The National Nutrition Strategy of Ethiopia, adopted in 2008,
recommends one additional meal per day to support healthy pregnancy . Iron-folic acid
supplementation, as part of routine antenatal care services, is the main strategy for preventing maternal
mortality due to anaemia .

However, recent evidence reveals striking gaps in the quality of care for undernutrition during
pregnancy in Ethiopia. A longitudinal eCohort study found that during the first antenatal care contact,
only 12% of women were screened for acute malnutrition, and only 11% of women with acute
malnutrition ever received supplemental food during their pregnancy . While 89% of women with
anaemia were given or prescribed iron and folic acid supplements at some point during pregnancy, only
32% took them throughout the entire pregnancy . Furthermore, less than 11% of pregnant women take
iron-folic acid supplements for the recommended period of 90 days or more .

1.3 The Knowledge-Attitude-Practice Gap

The Knowledge, Attitude, and Practice (KAP) model emphasises the role of nutrition knowledge as a key
factor in driving behavioural change, improving food choices, and fostering healthy dietary habits. The
model suggests that knowledge positively influences an individual's attitude, which in turn shapes
practices and behaviours . Nutrition knowledge serves as a fundamental component, acting as the initial
step toward developing positive attitudes and ultimately adopting healthier dietary behaviours.

A recent systematic review and meta-analysis of dietary knowledge, attitude, and practice among
pregnant mothers in Ethiopia revealed concerning findings: the pooled good dietary knowledge was
48.0%, favourable attitude was 47.0%, and good practice was only 34.0% . This demonstrates a
significant gap between knowledge and practice, indicating that knowledge alone does not
automatically translate into appropriate dietary behaviours. The same review identified multiple factors
influencing dietary practice, including urban residency, food security, nutrition information, family
support, perceived severity of malnutrition, and positive perception of dietary benefit .
1.4 Study Setting

Jinka General Hospital is located in Jinka town, the administrative centre of the South Omo Zone in the
Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia. The South Omo Zone is
characterised by diverse ethnic groups, varying agro-ecological zones, and unique cultural practices that
influence dietary habits and nutritional status. Despite the presence of Jinka General Hospital as a
referral facility serving a large catchment population, there is limited evidence regarding the knowledge
and practice of maternal nutrition among pregnant women attending antenatal care in this setting.
Understanding the local context, including cultural beliefs, food taboos, and health-seeking behaviours,
is essential for designing effective nutrition interventions tailored to the specific needs of this
population.

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2. Statement of the Problem

Maternal malnutrition remains a persistent public health challenge in Ethiopia despite decades of
national and international efforts. The consequences are severe: maternal undernutrition contributes to
increased risk of spontaneous preterm birth, low birth weight, and small-for-gestational-age infants .
These adverse birth outcomes are associated with higher risks of neonatal mortality, impaired growth
and neurodevelopment, and chronic disease in adulthood . The World Health Assembly target of
reducing low birth weight by 30% by 2025 appears increasingly unlikely to be achieved in Ethiopia given
current trends.

The problem is multi-faceted. First, despite national guidelines recommending nutrition counselling
throughout pregnancy, coverage and quality remain inadequate. While 62% of pregnant women receive
at least one antenatal care visit, the quality and extent of nutrition counselling received is unknown .
Second, even when women receive nutrition information, the translation into practice is poor. The
national evidence shows that while 48% of pregnant women have good dietary knowledge, only 34%
demonstrate good dietary practices . This knowledge-practice gap represents a critical failure point in
nutrition interventions.
Third, specific gaps in screening and management of maternal malnutrition persist. A recent Ethiopian
eCohort study revealed that only 12% of women are screened for acute malnutrition at their first
antenatal care contact, only 4% of women with acute malnutrition receive weight monitoring according
to national guidelines, and only 11% ever receive supplemental food during pregnancy . Among women
with anaemia, only 23% receive the recommended number of blood tests, and despite 89% being
prescribed iron-folic acid supplements, only 32% adhere to supplementation throughout pregnancy .

Fourth, contextual factors influencing maternal nutrition knowledge and practice in specific regions of
Ethiopia remain poorly understood. The South Omo Zone, where Jinka General Hospital is located,
presents unique characteristics including ethnic diversity, food insecurity, limited infrastructure, and
cultural practices that may influence dietary behaviours during pregnancy. No published studies have
specifically examined maternal nutrition knowledge and practice among pregnant women attending
antenatal care in this setting.

Fifth, the year 2026 represents a critical juncture for assessing progress towards national and
international nutrition targets. Understanding the current status of maternal nutrition knowledge and
practice, and identifying factors associated with optimal practices, is essential for informing future
interventions and policy decisions.

Therefore, this study aims to answer the following research questions:

1. What is the level of knowledge regarding maternal nutrition among pregnant women attending
antenatal care at Jinka General Hospital in 2026?

2. What are the dietary practices of pregnant women attending antenatal care at Jinka General Hospital,
including dietary diversity, meal frequency, and adherence to iron-folic acid supplementation?

3. What socio-demographic, obstetric, and health system factors are associated with maternal nutrition
knowledge and practice in this population?

4. What is the relationship between nutrition knowledge, attitude, and practice among pregnant women
in this setting?

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3. Significance of the Study

3.1 Contribution to Scientific Knowledge

This study will generate empirical evidence on the current status of maternal nutrition knowledge and
practice in a previously under-researched population in southern Ethiopia. The findings will contribute
to the growing body of literature on maternal nutrition in Ethiopia and provide region-specific data that
can be compared with national estimates. Understanding the knowledge-practice gap in this context will
inform theoretical frameworks linking knowledge, attitude, and behaviour change.

3.2 Policy and Programme Implications

The findings will provide evidence-based information to guide the development of targeted nutrition
interventions for pregnant women in Jinka and the surrounding South Omo Zone. Specific policy
contributions include:

· Informing antenatal care guidelines: Evidence on specific knowledge gaps and practice deficiencies will
help refine nutrition counselling messages delivered during antenatal care visits.

· Supporting resource allocation: Identifying the most significant factors associated with poor nutrition
practices will enable efficient targeting of limited resources to address the most critical barriers.

· Enhancing screening and management protocols: Findings related to screening coverage and follow-up
care will inform quality improvement initiatives at Jinka General Hospital.

· Contributing to national monitoring: As Ethiopia works towards the 2025 global nutrition targets, this
study will provide timely data on progress in a representative population.

3.3 Community Benefits

The study will indirectly benefit participants through increased awareness of maternal nutrition during
data collection. Community engagement activities associated with the research may enhance knowledge
dissemination. Long-term, the findings will support the development of culturally appropriate nutrition
education materials and interventions tailored to the specific needs and beliefs of communities in the
South Omo Zone.

3.4 Academic Significance

This research will serve as baseline data for future interventional studies aiming to improve maternal
nutrition in the region. It will also provide a methodological framework for similar assessments in other
underserved areas of Ethiopia. For the researcher, this study fulfils academic requirements and
contributes to building local research capacity.

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4. Literature Review

4.1 Conceptual Framework: The Knowledge, Attitude, and Practice (KAP) Model

The Knowledge, Attitude, and Practice (KAP) model provides the theoretical foundation for
understanding the relationship between nutrition knowledge and dietary behaviours during pregnancy.
The model posits that knowledge serves as a fundamental component, acting as the initial step toward
developing positive attitudes and ultimately adopting healthier dietary behaviours . Nutrition knowledge
encompasses understanding dietary guidelines, nutrient functions, and the principles of healthy eating,
providing the foundation for making informed dietary choices.

Social Cognitive Theory complements the KAP model by highlighting that nutrition knowledge not only
informs individuals about what to eat but also strengthens self-efficacy, beliefs, and skills necessary to
make and sustain healthy dietary decisions . Several studies have demonstrated the role of nutrition
knowledge in determining dietary intake and how inadequate nutrition knowledge may act as a barrier
to the adoption of healthy behaviours .

4.2 Burden of Maternal Malnutrition in Ethiopia

Maternal undernutrition in Ethiopia represents a significant public health challenge with wide-ranging
consequences. A recent study in the Gamo Zone of southern Ethiopia found that 31.97% of pregnant
women were suffering from undernutrition . This is consistent with national estimates showing the
prevalence of undernutrition among pregnant women ranging from 14.4% to 47.9% across different
regions .

Anaemia affects nearly one-third of the world's population, with women in low- and middle-income
countries most affected . In Ethiopia, 41% of pregnant women are anaemic, of which 20% are
moderately anaemic, 18% mildly anaemic, and 3% severely anaemic . Anaemia is associated with
adverse reproductive outcomes including preterm birth, low birth weight, impaired child development,
and reduced productivity in adults .

The consequences extend beyond pregnancy. Small vulnerable newborns (preterm and/or small-for-
gestational-age) have a higher risk of neonatal mortality, contribute to half of all neonatal deaths, and
carry increased risk of impaired growth, neurodevelopment, and adult chronic disease . These newborns
comprise 99.5% of low birth weight infants .

4.3 Knowledge of Maternal Nutrition Among Pregnant Women

A systematic review and meta-analysis of dietary knowledge among pregnant mothers in Ethiopia,
encompassing multiple studies up to 2024, found that the pooled good dietary knowledge was 48.0%
(95% CI: 39.0%–57.0%) . This indicates that approximately half of pregnant women in Ethiopia lack
adequate knowledge about proper nutrition during pregnancy.

Nutrition knowledge among pregnant women encompasses several domains, including understanding of
increased nutritional requirements during pregnancy, knowledge of specific nutrients (iron, folic acid,
calcium, iodine), awareness of food sources of key nutrients, and understanding of food safety concerns
during pregnancy . A validated nutrition knowledge questionnaire developed for pregnant populations
typically covers topics such as recommended weight gain, food safety concerns, intake frequencies of
food groups, and recommended intake and food sources of critical nutrients .

Factors associated with nutrition knowledge include educational attainment, exposure to mass media,
antenatal care attendance, and prior nutrition education . Socio-demographic variables and
gynaecological issues significantly influence dietary knowledge .
4.4 Attitudes Towards Maternal Nutrition

Favourable attitude towards maternal nutrition among pregnant women in Ethiopia is 47.0% (95% CI:
38.0%–55.0%) . Attitude encompasses beliefs about the importance of nutrition during pregnancy,
perceived benefits of good dietary practices, perceived severity of malnutrition, and confidence in one's
ability to follow dietary recommendations.

The Health Belief Model has been effectively used to understand and influence attitudes towards
nutrition during pregnancy. A community-based quasi-experimental study in southern Ethiopia
demonstrated that nutrition education using the Health Belief Model significantly improved maternal
attitude towards iron-folic acid supplementation, with significant changes in the proportion of women
with favourable attitudes following the intervention .

Knowledge and attitude have bidirectional relationships, each influencing and being influenced by the
other . Positive attitudes towards nutrition are associated with greater likelihood of seeking nutrition
information and adopting recommended dietary practices.

4.5 Dietary Practices During Pregnancy

Dietary practice represents the actual eating behaviours of pregnant women, including dietary diversity,
meal frequency, and adherence to supplementation recommendations. The pooled good dietary
practice among pregnant women in Ethiopia is only 34.0% (95% CI: 28.0%–40.0%) , substantially lower
than both knowledge and attitude levels, confirming a significant knowledge-practice gap.

Dietary Diversity: A study in the Gamo Zone of southern Ethiopia found that 76.96% of pregnant women
had acceptable food consumption scores, while 14.89% had borderline scores and 8.15% had poor
scores . Factors associated with acceptable food consumption scores included urban residence, higher
economic status, planned pregnancy, exposure to mass media, having a vegetable garden, attending
health facilities for antenatal care, and consuming food four or more times per day . Additionally,
acceptable food consumption scores increased by 2%, 3%, and 4% for every one-unit increase in BMI,
mid-upper arm circumference, and gestational age, respectively .
Iron-Folic Acid Supplementation: Despite iron-folic acid supplementation being the main intervention
strategy for reducing anaemia in pregnant women, compliance remains extremely low. According to the
Ethiopia Demographic and Health Survey, less than 11% of pregnant women take iron-folic acid
supplements for the recommended period of 90 days or more, approximately 12% take 60-89 pills, more
than one-third (35.7%) take fewer than 60 pills, and around 42.2% do not take any iron tablets during
their most recent pregnancy .

Factors contributing to non-adherence include socio-economic factors, poor knowledge, negative

attitudes, low antenatal care utilisation, and perceived side effects of iron-folic acid pills .

4.6 Factors Associated with Maternal Nutrition Knowledge and Practice

Multiple factors influence maternal nutrition knowledge and practice at different levels:

Socio-demographic Factors:

· Residence: Urban residency is strongly associated with better dietary practice (OR = 6.68, 95% CI: 2.49–
10.87)

· Education: Women with secondary education are more likely to adhere to iron-folic acid
supplementation

· Wealth: Higher economic status is associated with acceptable food consumption scores

· Food security: Food-secure households demonstrate better dietary practices (OR = 3.51, 95% CI: 1.02–
5.99)

Knowledge and Information Factors:

· Nutrition knowledge: Good knowledge is strongly associated with better practice (OR = 4.53, 95% CI:
3.22–5.74)

· Nutrition information: Access to nutrition information improves practice (OR = 3.07, 95% CI: 1.13–5.02)
· Mass media exposure: Women exposed to mass media have higher acceptable food consumption
scores

Psychosocial Factors:

· Attitude: Favourable attitude is associated with better practice (OR = 2.32, 95% CI: 1.34–3.30)

· Perceived severity: Recognition of malnutrition severity improves practice (OR = 2.07, 95% CI: 1.82–
2.31)

· Perceived benefit: Positive perception of dietary benefit improves practice (OR = 2.19, 95% CI: 1.56–
2.82)

Family and Social Support:

· Family support: Family support improves dietary practice (OR = 2.14, 95% CI: 1.43–2.85)

· Decision-making autonomy: Women's involvement in household decisions affects nutrition practices

Health System Factors:

· Antenatal care attendance: Attending health facilities for antenatal care is associated with better food
consumption scores

· Timing of first ANC visit: Women who receive or are prescribed iron-folic acid supplements during the
first antenatal care contact are more likely to adhere to supplementation

· Screening and management: Gaps in screening for malnutrition and follow-up care negatively impact
nutrition outcomes

4.7 Nutrition Interventions and Their Effectiveness

Several intervention studies have demonstrated the potential to improve maternal nutrition knowledge
and practice in Ethiopia.

Nutrition Education Interventions: A community-based quasi-experimental study in southern Ethiopia

implemented six nutrition education sessions using the Health Belief Model. The intervention
significantly improved maternal knowledge towards iron-folic acid supplementation, with intervention
group levels increasing by 35 percentage points. The odds of being knowledgeable at the endpoint in the
intervention group were 2.6 times higher than at baseline .

Dietary Diversity Interventions: A systematic review and meta-analysis of nutrition interventions on

dietary diversity among pregnant women in Ethiopia found a pooled difference-in-difference percentage
effect of 35.63% (95% CI: 6.87%, 64.39%) and a mean effect of 0.78 (95% CI: 0.38, 1.18) . Interventions
lasting five months or more showed higher effects (44.70%) compared to shorter interventions
(29.61%) .

Integrated Nutrition and Infection Packages: The Enhancing Nutrition and Antenatal Infection Treatment
(ENAT) study in Amhara tested enhanced nutrition packages including iron-folic acid, iodised salt, and
targeted micronutrient-fortified balanced energy protein supplementation for undernourished women.
While the intervention did not significantly affect birth weight or length, the combined delivery of both
nutrition and infection intervention packages reduced the risk of stillbirth compared to routine care .

4.8 Research Gap

Despite the growing body of literature on maternal nutrition in Ethiopia, significant gaps remain. Most
studies have been conducted in northern and central Ethiopia, with limited representation from the
southern regions. The South Omo Zone, characterised by unique ethnic diversity, food insecurity, and
cultural practices, has not been adequately studied. Jinka General Hospital serves a large catchment
population, yet no published research has assessed maternal nutrition knowledge and practice among
pregnant women attending antenatal care in this facility.

Furthermore, existing studies have predominantly focused on either knowledge or practice in isolation,
rather than comprehensively examining the relationships between knowledge, attitude, and practice
within the same population. Understanding these relationships is essential for designing effective
interventions that address the specific barriers to behaviour change in this context.
This study aims to fill these gaps by providing comprehensive evidence on maternal nutrition
knowledge, attitude, and practice among pregnant women attending antenatal care at Jinka General
Hospital in 2026, and identifying factors associated with optimal nutrition practices in this under-
researched population.

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5. Objectives

5.1 General Objective

To assess the knowledge and practice of maternal nutrition and associated factors among pregnant
women attending antenatal care at Jinka General Hospital, Southern Ethiopia, in 2026.

5.2 Specific Objectives

1. To assess the level of knowledge regarding maternal nutrition among pregnant women attending
antenatal care at Jinka General Hospital, 2026.

2. To determine the dietary practices of pregnant women attending antenatal care at Jinka General
Hospital, including dietary diversity, meal frequency, and adherence to iron-folic acid supplementation.

3. To assess the attitudes towards maternal nutrition among pregnant women attending antenatal care
at Jinka General Hospital.

4. To identify socio-demographic, obstetric, and health system factors associated with maternal
nutrition knowledge and practice.

5. To examine the relationship between nutrition knowledge, attitude, and practice among pregnant
women in the study population.

6. To determine the proportion of pregnant women with adequate dietary diversity based on the
Minimum Dietary Diversity for Women (MDD-W) indicator.
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6. Research Methodology

6.1 Study Area and Period

The study will be conducted at Jinka General Hospital, located in Jinka town, the administrative centre of
the South Omo Zone in the Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia.
Jinka is approximately 750 kilometres south of Addis Ababa. The South Omo Zone is known for its ethnic
diversity, hosting numerous indigenous communities including the Ari, Bena, Hammer, Karo, Mursi, and
Nyangatom peoples. The zone is characterised by varied agro-ecological zones, from highlands to
lowlands, with mixed farming and pastoralist livelihoods.

Jinka General Hospital serves as a referral facility for the entire South Omo Zone, providing
comprehensive health services including antenatal care, delivery services, postnatal care, and
specialized outpatient departments. The hospital's antenatal care clinic operates daily and attracts
pregnant women from Jinka town and surrounding rural districts.

The study will be conducted from January to March 2026.

6.2 Study Design

A facility-based cross-sectional study design will be employed. This design is appropriate for assessing
the prevalence of knowledge and practice and identifying associated factors at a single point in time.

6.3 Population
Source Population: All pregnant women living in the catchment area of Jinka General Hospital, South
Omo Zone.

Study Population: All pregnant women attending antenatal care at Jinka General Hospital during the
data collection period.

Inclusion Criteria:

· Pregnant women of any gestational age

· Attending antenatal care at Jinka General Hospital during the study period

· Aged 18 years and above

· Permanent residents of the study area (planned to stay until delivery)

· Willing to participate in the study

Exclusion Criteria:

· Pregnant women who are critically ill or unable to communicate at the time of data collection

· Women with known medical conditions that require special dietary management (diabetes mellitus,
hypertension, renal disease) as these may confound nutrition practices

· Women who have participated in similar studies within the past six months

6.4 Sample Size Determination

The sample size will be determined using the single population proportion formula, considering the
following assumptions:
· Proportion of good dietary practice among pregnant women (p) = 34.0% (based on a recent systematic
review and meta-analysis in Ethiopia )

· Margin of error (d) = 5%

· Confidence level = 95% (Zα/2 = 1.96)

· Design effect = 1.5 (to account for potential clustering)

· Non-response rate = 10%

n = \frac{(Z_{\alpha/2})^2 \times p(1-p)}{d^2} \times \text{Design effect}

n = \frac{(1.96)^2 \times 0.34(0.66)}{(0.05)^2} \times 1.5

n = \frac{3.8416 \times 0.2244}{0.0025} \times 1.5

n = \frac{0.862}{0.0025} \times 1.5 = 344.8 \times 1.5 = 517.2

Adding 10% for non-response: 517.2 × 1.1 = 568.9

Therefore, the final sample size will be 570 pregnant women.

6.5 Sampling Technique and Procedure

A systematic random sampling technique will be employed to select study participants. The following
procedure will be followed:

1. Determine the sampling frame: The total number of pregnant women attending antenatal care at
Jinka General Hospital during the study period will be estimated based on previous months' attendance
records. Assuming an average of 25 antenatal care attendees per day over 60 working days, the
estimated total population (N) will be approximately 1,500.

2. Calculate the sampling interval (k): k = N/n = 1500/570 = 2.63 ≈ 3. Therefore, every 3rd pregnant
woman attending antenatal care will be selected.

3. Determine the starting point: The first participant will be selected randomly from the first three
antenatal care attendees on the first day of data collection using a lottery method.

4. Recruitment process: On each data collection day, all pregnant women attending antenatal care will
be registered in order of arrival. The sampling interval will be applied to select participants. If a selected
woman declines participation or does not meet inclusion criteria, the next eligible woman will be
recruited.

5. Daily sample allocation: The total sample will be distributed proportionally across the data collection
period to ensure representation of women attending on different days.

6.6 Data Collection Instrument

A structured, interviewer-administered questionnaire will be developed based on extensive literature

review and adapted from validated tools used in previous studies . The questionnaire will be prepared in
English and translated into the local languages (Amharic and Ari, the predominant languages in the area)
and then back-translated to ensure consistency.

The questionnaire will comprise the following sections:

Section A: Socio-demographic Characteristics

· Age, marital status, religion, ethnicity

· Educational level (woman and partner)

· Occupation (woman and partner)

· Monthly household income

· Family size
· Residence (urban/rural)

· Access to mass media (radio, television, mobile phone)

Section B: Obstetric and Reproductive Health Characteristics

· Gestational age

· Parity and gravidity

· Number of antenatal care visits (including current)

· Pregnancy planned or unplanned

· History of adverse pregnancy outcomes (low birth weight, preterm birth, stillbirth)

· Previous nutrition counselling during pregnancy

· History of anaemia in current or previous pregnancies

Section C: Nutrition Knowledge Assessment

This section will assess knowledge across multiple domains, adapted from validated questionnaires :

· Knowledge of increased nutritional requirements during pregnancy (5 items)

· Knowledge of specific nutrients and their food sources (10 items covering iron, folic acid, calcium,
protein, vitamin A)

· Knowledge of foods to avoid or limit during pregnancy (5 items)

· Knowledge of consequences of poor nutrition during pregnancy (5 items)

Each correct answer will receive 1 point, with total knowledge scores ranging from 0 to 25. Knowledge
will be categorised as "good" if the score is above the mean/median, or using a predetermined cut-off
point (e.g., ≥70% correct).
Section D: Attitudes Towards Maternal Nutrition

Attitudes will be assessed using a 5-point Likert scale (strongly agree to strongly disagree) across 15
statements covering:

· Perceived importance of nutrition during pregnancy

· Perceived benefits of good dietary practices

· Perceived severity of maternal malnutrition

· Perceived barriers to healthy eating

· Self-efficacy in following dietary recommendations

Attitude scores will be summed and categorised as "favourable" if the score is above the mean/median.

Section E: Dietary Practices Assessment

Dietary Diversity: The Minimum Dietary Diversity for Women (MDD-W) indicator will be used to assess
dietary diversity. Women will be asked to recall all foods and beverages consumed in the previous 24
hours. Foods will be categorised into the following 10 food groups:

1. Grains, white roots and tubers, and plantains

2. Pulses (beans, peas, lentils)

3. Nuts and seeds

4. Dairy products

5. Meat, poultry, and fish

6. Eggs

7. Dark green leafy vegetables

8. Other vitamin A-rich fruits and vegetables

9. Other vegetables

10. Other fruits

Women consuming at least five of the ten food groups will be classified as having adequate dietary
diversity .

Meal Frequency: Women will be asked about the number of meals and snacks consumed in the previous
24 hours and typically during pregnancy.

Iron-Folic Acid Supplementation: Adherence will be assessed by asking women about:

· Receipt of iron-folic acid supplements during current pregnancy

· Number of supplements taken

· Duration of supplementation

· Reasons for non-adherence (if applicable)

Food Consumption Score: A simplified food consumption score will be calculated based on frequency of
consumption of different food groups over the past seven days .

Section F: Health System and Service Factors

· Timing of first antenatal care visit

· Number of antenatal care visits attended

· Receipt of nutrition counselling during antenatal care

· Screening for malnutrition (MUAC measurement, weight monitoring)

· Receipt of nutritional supplements

Section G: Anthropometric Measurements

· Mid-upper arm circumference (MUAC): Measured using non-stretchable tape at the midpoint of the
non-dominant upper arm. MUAC < 23 cm indicates acute malnutrition .

· Weight: Measured using calibrated electronic scale.

· Height: Measured using stadiometer for first-time attendees with available baseline data.

· Haemoglobin: If recent measurement is available in antenatal care records, anaemia status (Hb < 11
g/dL) will be recorded .

6.7 Data Quality Assurance

Questionnaire Development and Pre-testing: The questionnaire will be developed based on validated
tools from previous studies. A pre-test will be conducted on 5% of the sample size (29 women) at a
nearby health centre not included in the main study. Necessary modifications will be made based on
pre-test findings.

Training of Data Collectors: Four trained data collectors (health professionals with experience in
maternal health) and two supervisors will be recruited. Training will cover:

· Study objectives and methodology

· Interview techniques

· Ethical considerations and informed consent

· Anthropometric measurement techniques

· Handling of difficult situations

· Data recording and confidentiality

Standardisation of Measurements: Data collectors will be trained and standardised in anthropometric

measurements. Inter-rater reliability will be assessed during training.
Supervision: Supervisors will conduct daily checks of completed questionnaires for completeness and
consistency. Any issues will be addressed immediately with data collectors.

Data Entry and Cleaning: Data will be double-entered to minimise errors. Range and consistency checks
will be performed before analysis.

6.8 Data Processing and Analysis

Data Entry: Data will be entered into EpiData version 3.1 or a similar programme with built-in quality
control features.

Statistical Analysis: Analysis will be conducted using SPSS version 26 or STATA version 17.

Descriptive Analysis: Frequencies and percentages for categorical variables; means and standard
deviations (or medians and interquartile ranges) for continuous variables. Results will be presented
using tables, figures, and narrative summaries.

Knowledge and Practice Scoring:

· Knowledge scores will be calculated and presented as mean ± SD. Women scoring above the mean will
be classified as having "good knowledge."

· Practice will be assessed through dietary diversity (adequate if ≥5 food groups) and iron-folic acid
adherence (adequate if ≥90 days of supplementation).

· Attitude scores will be summed and dichotomised at the mean.

Bivariate Analysis: Binary logistic regression will be used to examine associations between each
independent variable and the outcome variables (knowledge and practice). Variables with p-value < 0.25
in bivariate analysis will be candidates for multivariable analysis.
Multivariable Analysis: Multiple logistic regression will be employed to identify independent factors
associated with nutrition knowledge and practice, controlling for potential confounders. Adjusted odds
ratios with 95% confidence intervals will be reported. Statistical significance will be declared at p < 0.05.

Model Fit: Hosmer-Lemeshow goodness-of-fit test will be used to assess model fit.

Relationship Analysis: Correlation analysis (Pearson or Spearman) will examine the relationship between
knowledge, attitude, and practice scores.

6.9 Variables

Dependent Variables:

· Level of nutrition knowledge (good/poor)

· Dietary practice (adequate dietary diversity/not adequate)

· Adherence to iron-folic acid supplementation (adherent/non-adherent)

Independent Variables:

· Socio-demographic: age, education, occupation, income, residence, marital status, family size,
ethnicity, religion

· Obstetric: gestational age, parity, number of ANC visits, pregnancy plan, history of adverse outcomes

· Health system: timing of first ANC, receipt of nutrition counselling, screening for malnutrition

· Psychosocial: attitude scores, perceived barriers, social support

· Economic: household food security, wealth quintile

· Media exposure: access to radio, television, mobile phones

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7. Ethical Considerations

7.1 Ethical Approval

Ethical clearance will be obtained from the Institutional Review Board (IRB) of the relevant academic
institution. A formal letter of permission will be secured from the South Omo Zone Health Department
and the administration of Jinka General Hospital.

7.2 Informed Consent

Information Provision: All potential participants will receive clear, comprehensive information about the
study purpose, procedures, potential risks and benefits, and their rights. Information will be provided in
a language they understand (Amharic or Ari) at an appropriate literacy level.

Voluntary Participation: It will be emphasised that participation is entirely voluntary, that declining
participation will not affect their access to antenatal care services or any other benefits, and that they
may withdraw at any time without penalty.

Documentation: Written informed consent will be obtained from all participants. For participants unable
to read or write, the consent information will be read to them in the presence of a impartial witness,
and thumbprint signatures will be accepted.

7.3 Confidentiality
All data will be collected anonymously or with codes rather than personal identifiers. Questionnaires will
be stored in locked cabinets accessible only to the research team. Electronic data will be password-
protected. No individual identifiers will be included in any publications or presentations.

7.4 Privacy

Interviews will be conducted in private settings within the antenatal care clinic to ensure confidentiality
and comfort of participants.

7.5 Potential Risks and Benefits

Risks: The study presents minimal risk to participants. Potential risks include mild discomfort or
embarrassment when answering personal questions about diet and health. Participants may experience
fatigue during the interview.

Risk Mitigation: Interviewers will be trained to be sensitive and non-judgemental. Participants will be
informed that they may skip any question they are uncomfortable answering. Breaks will be offered if
needed.

Benefits: While there are no direct individual benefits, participants will receive information about
maternal nutrition following the interview. Any participant identified with malnutrition or anaemia will
be referred to the antenatal care provider for appropriate management.

7.6 Referral and Linkages

Women identified with acute malnutrition (MUAC < 23 cm) or anaemia (if haemoglobin results available)
will be referred to the antenatal care clinic for further assessment and management according to
national guidelines. The research team will facilitate this referral and ensure linkage with appropriate
services.
7.7 Community Engagement

Prior to data collection, meetings will be held with community leaders and health extension workers to
explain the study purpose and procedures, address concerns, and seek community support.

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8. Dissemination Plan

The findings of this study will be disseminated through multiple channels to ensure reach to relevant
stakeholders:

Academic Dissemination:

· Submission of manuscript(s) to peer-reviewed journals for publication

· Presentation at national and international conferences on maternal nutrition and public health

· Deposit in institutional repositories for access by other researchers

Policy and Programme Dissemination:

· Preparation of a policy brief for the South Omo Zone Health Department and SNNPR Regional Health
Bureau

· Presentation of findings to health managers and antenatal care providers at Jinka General Hospital

· Sharing results with the Federal Ministry of Health through appropriate channels

Community Dissemination:
· Feedback meetings with community leaders and health extension workers

· Preparation of simplified summaries in local languages for community consumption

· Use of local radio stations to share key findings with the broader community

Stakeholder Engagement:

· Sharing findings with non-governmental organisations working on maternal and child nutrition in the
region

· Collaboration with the Ethiopian Public Health Institute for integration into national nutrition
surveillance

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9. References

1. Bayked EM, Yimer EM, Gelaw T, Mohammed AS, Mekonen NA. Dietary knowledge, attitude, practice,
and associated factors among pregnant mothers in Ethiopia: a systematic review and meta-analysis.
Front Public Health. 2024;12:1393764.

2. Enhancing Nutrition and Antenatal Infection Treatment (ENAT) Study Group. The impact of enhancing
nutrition and antenatal infection treatment on birth outcomes in Amhara, Ethiopia: a pragmatic
factorial, cluster-randomised clinical effectiveness study. BMJ Glob Health. 2025;10(6):e016264.

3. Development and Validation of the Italian Pregnancy Nutrition Knowledge Questionnaire (ItPreNKQ):
A Nutrition Knowledge Questionnaire for Pregnant Italian Women. Nutrients. 2025;17(5):901.

4. Clarke-Deelder E, Getachew T, Taddele T, Tollera G, Wright K, Bekele D, et al. Screening, prevention,

and management of maternal acute malnutrition and anemia in Ethiopia: evidence from a longitudinal
eCohort study. medRxiv. 2025. [Preprint].

5. Belay MA, et al. Effect of Nutrition Interventions on the Dietary Diversity Status Among Pregnant
Women in Ethiopia: Systematic Review and Meta-Analysis. Food Sci Nutr. 2025;13(12):e71231.

6. Reshid M, Anato A. Community-based nutrition education and counselling provided during pregnancy:
effects on knowledge and attitude towards iron-folic acid supplementation. J Nutr Sci. 2024;13:eXX.
7. Emory University. Healthy Baby Healthy Mother Toolkit. [Link] [Internet]. Bethesda (MD):
National Library of Medicine (US). 2024 Mar 24. Identifier NCT06594419. Available from:
[Link]

8. Fikadu T, Tamiru D, Ademe BW. Food consumption score and the Nexus of maternal nutritional status
among pregnant women in Gamo Zone, South Ethiopia. Front Nutr. 2025;12:1498599.

9. PREG-NFS-Q: Development, face and content validation of an instrument to measure maternal

nutrition and food safety knowledge in pregnancy. Eur J Midwifery. 2025;9(Supplement 1):A104.

10. Clarke-Deelder E, Getachew T, Taddele T, Tollera G, Wright K, Bekele D, et al. Screening, prevention,
and management of maternal acute malnutrition and anemia in Ethiopia: evidence from a longitudinal
eCohort study. QuEST Network; 2025. Available from:
[Link]
malnutrition-and-anemia-in-ethiopia-evidence-from-a-longitudinal-ecohort-study

11. Azene AG, Aragaw AM, Wubetie HT, Wassie GT, Tsegaye GW, Derebe MA, Mitiku HD. Dietary
diversity among pregnant women and associated factors in Ethiopia: Systematic review and meta-
analysis. PLoS One. 2021;16(6):e0251906.

12. Beressa G, Whiting SJ, Belachew T. Effect of nutrition education integrating the health belief model
and theory of planned behavior on dietary diversity of pregnant women in Southeast Ethiopia: a cluster
randomized controlled trial. Nutr J. 2024;23(1):3.

13. Tsegaye D, Tamiru D, Belachew T. Theory-based nutrition education intervention through male
involvement improves the dietary diversity practice and nutritional status of pregnant women in rural
Illu Aba Bor Zone, Southwest Ethiopia: A quasi-experimental study. Matern Child Nutr.
2022;18(3):e13350.

14. Bayissa ZB, Girma TN, Alamirew JA, Fite RO, Alemu K, Taddesse L, et al. Dietary diversity and
associated factors among pregnant women in Ethiopia: a systematic review with meta-analysis. J Glob
Health. 2025;15:04286.

15. Ethiopian Public Health Institute. Ethiopia National Food Consumption Survey Report. Addis Ababa:
EPHI; 2023.

16. Federal Ministry of Health, Ethiopia. National Nutrition Strategy II. Addis Ababa: FMOH; 2021.

17. World Health Organization. WHO Antenatal Care Recommendations for a Positive Pregnancy
Experience. Geneva: WHO; 2016.

18. World Health Organization. Global Nutrition Targets 2025: Low Birth Weight Policy Brief. Geneva:
WHO; 2014.

19. United Nations Children's Fund (UNICEF), World Health Organization (WHO), International Bank for
Reconstruction and Development/The World Bank. Levels and Trends in Child Malnutrition:
UNICEF/WHO/The World Bank Group Joint Child Malnutrition Estimates: Key Findings of the 2023
Edition. New York: UNICEF; 2023.

20. Food and Agriculture Organization. Minimum Dietary Diversity for Women: A Guide for
Measurement. Rome: FAO; 2016.

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Appendices (to be developed separately):

· Appendix A: Informed Consent Form (English, Amharic, Ari)

· Appendix B: Structured Questionnaire (English, Amharic, Ari)

· Appendix C: Ethical Approval Letters

· Appendix D: Permission Letters from Health Facilities