Exploring dietary perception, beliefs and practices among pregnant adolescents, their husbands and healthcare providers in West Arsi, Central Ethiopia: a phenomenological study

Abstract

Background

The two most physically active stages of life, pregnancy and adolescence, put the pregnant adolescent under a lot of stress. Adolescence is a crucial era in women’s nutrition that is frequently overlooked.

Objective

This study aimed to explore dietary perceptions, beliefs and practices among pregnant Adolescents in West Arsi, Central Ethiopia.

Design

A qualitative method, specifically, a phenomenological research design, was carried out from February to March 2023.

Settings

This study was conducted in the West Arsi zone, Oromia, Ethiopia, in four randomly selected districts.

Participants

Thirty participants, 12 pregnant adolescents, 8 husbands of pregnant adolescents and 10 healthcare providers were purposefully selected and participated.

Methods

In-depth and key informant interviews were conducted. To create relevant codes, subthemes and themes, ATLAS.ti V.7.1 software was used. An inductive qualitative data analysis approach was used. The results were presented using respondents’ clear verbatim and thematic analysis.

Results

The findings were organised into four major themes: (1) low nutritional awareness, (2) poor dietary practice, (3) barriers to good dietary practice and (4) facilitators for good dietary practice. A low perceived severity (one’s belief of the seriousness) of undernutrition and low perceived benefits (one’s belief of the benefits) of balanced nutrition have been reported. A monotonous diet (one type food usually cereal based), no change in dietary practices during pregnancy, and low intake of animal food sources (meat, egg and milk) were found under dietary practices. One of the most striking findings to emerge from this study is the Alliance for Development (AFD), the former Women Development Army, which can be a great facilitator of good dietary practice. Husbands’ involvement in nutrition education and specific nutrition training for healthcare providers are the other facilitators identified in this study. The lack of nutrition education, misconceptions and economic problems are barriers to dietary practices.

Conclusion

This study found a low nutritional awareness and poor dietary practices. Further experimental studies are recommended to assess whether AFD is capable of delivering effective nutrition interventions that improve dietary practice of pregnant.

Strengths and limitations of this study.

• The strength of this study was, the fact that every person who was invited to participate in an interview did so (100% response rate).

• The limitations of this study were that in-depth insights may not be generalisable to other sociocultural contexts or to the national level because they are based on viewpoints and actual lived experiences in a particular geographic area.

• Nuanced information could be lost throughout the translation and transcription process.

Introduction

Adolescent pregnancy is defined as the occurrence of pregnancy among girls aged 10–19.¹ Pregnancy undernutrition is defined by a maternal nutritional status in which nutrient reserves and macronutrient/micronutrient consumption are below what is required to ensure the best outcomes for the mother, the fetus and the infant.² Adolescent pregnancy is a high-risk condition which potentially results in adverse pregnancy outcomes.¹ Undernutrition during and before pregnancy has been associated with a number of maternal, fetal and neonatal complications such as low-birth weight (LBW), intrauterine growth restriction (IUGR), anaemia, neonatal death and maternal death.^{2 3} It is now widely accepted that prenatal malnutrition influences the development of non-communicable diseases like cardiovascular disease, hypertension, diabetes, delayed developments and retardations in later life.^{4 5}

The two most physically active stages of life, pregnancy and adolescence, place the body under high stress.^{5 6} The increased energy and food needs of the mother and fetus during pregnancy makes proper eating more important. The two most significant modifiable factors affecting maternal and fetal outcomes are nutritional intake and weight gain during pregnancy.^{7 8} Pregnant adolescent nutrition issues are related to three Sustainable Development Goals (SDGs): SGD-2 zero hunger, SDG-3 good health and well-being, and SDG-5 Gender Equality.⁹

According to a review paper on pregnancy nutrition, pregnant women in underdeveloped nations do not receive sufficient nutritional education. There is very little evidence that midwives are giving adequate health and nutrition education to expectant mothers on nutrition.^{10 11} Females are said to be more interested in their health during pregnancy and are more concerned with nutritional education; however, this time is becoming a missed opportunity.¹²

Ethiopia ranks among the top three countries in Eastern and Southern Africa in terms magnitude of child marriage. The vast majority of young women who married in childhood gave birth during adolescence; Ethiopia is home for about 15 million newly married children, of these 6 million were married before 15 years of age.^{13 14}

Studies on the local environment, West Arsi, showed that 79% had pregnancy diets that were insufficiently diverse and 12% of the pregnant avoided at least one type of food (such as yoghurt, banana, legumes, honey) for one or more reasons,¹⁵ another study also showed that only 25.4% of pregnant mothers consumed adequate dietary diversity diet,¹⁶ moreover 34% magnitude of undernutrition was revealed among pregnant adolescents in West Arsi.¹⁷ There are good efforts from government through national nutrition strategies,¹⁸ food policy,¹⁹ and there are antenatal care (ANC) services and nutrition education from health facilities, however few proportions (27%) of pregnant adolescents receive ANC services.²⁰

Teenage pregnancy,²¹ unintended pregnancies³ and poor nutrition,^{3 21} are few of the factors that continue to have a heavy toll on morbidity and mortality among Ethiopian adolescents,²¹ pregnant adolescents are a vulnerable group of the population and there are problems related with dietary behaviours and beliefs during pregnancy in Ethiopia; however, maternal nutrition counselling provided to pregnant mothers is inadequate and neglected by most stakeholders.²² Adolescence is a crucial period in women’s nutrition that is frequently overlooked; therefore, this study aimed to explore the dietary perceptions, beliefs and practices of pregnant adolescents in West Arsi, Central Ethiopia.

Material and methods

Study setting and design

This study was conducted in the West Arsi zone, Oromia, 250 km from Addis Ababa, the capital city of Ethiopia. A qualitative method, specifically, a phenomenological research design, was developed. A qualitative design was considered appropriate for obtaining a profound comprehension of community perceptions of the issues of interest.²³ The study aimed to deeply investigate and explore nuances related to the dietary perception, beliefs and practices among pregnant adolescents; therefore a qualitative study was used and, a phenomenological design is chosen to capture the lived experiences of participants. The study period was from 4 February to 29 March 2023.

Study population

Study participants were pregnant adolescents aged between 15 and 19 years, husbands of pregnant adolescents and healthcare providers (midwives, nurses, health officers, health extension workers and masters of public health holders who had rich experience (four or more years)) in the West Arsi zone, Central Ethiopia.

Inclusion criteria included 10–19 years old pregnant, husbands of the pregnant adolescent, willingness to participate in the study, providing informed consent; and healthcare provider working on maternal nutrition for at least 4 years. Exclusion criteria included unable to continue participating in the study at any stage of the study.

Study population and enrolment

We recruited pregnant adolescents, husbands and healthcare professionals from several districts in order to have a good representation of participants. We chose participants from the district’s rural and urban geographic areas, based on maximum variation in age and educational level, so that they would have a diverse variety of perceptions. Data were collected through unstructured interviews.

Sample size and sampling technique

The point of concept saturation, which is information saturation and redundancy that comes to the discussion point, determines the number of participants and serves as a guide for the sampling and data collection process.^24–26 Thirty participants, comprising 12 pregnant adolescents, 10 healthcare providers and 8 husbands of pregnant adolescents were selected for this study. No participant refused to participate or dropped out.

Data collection methods

Data were gathered using a purposive sampling technique that considered the perceptions, knowledge and comprehension of key informants and pregnant adolescents. Respondents were deemed pertinent to the study based on their familiarity. Data were gathered face to face using key informant interviews (KIIs) and in-depth interviews (IDIs) (online supplemental file) in the local language (Afaan Oromo and Amharic). Interview guide was pretested. Both the pregnant adolescents’ house and the public health institution hosted the interviews. Data were gathered through audiotaping interviews. The average duration of the interview was 45 min. Field notes were included in the interviews. Digital recordings of the interviews were conducted with interviewees’ consent. An experienced member of the research team transcribed and translated the recordings into English for the analysis. The accuracy of the translation was reviewed by the second author. To determine the true value of the data; two coders participated in the coding, categorisation, analysis and interpretations. Rapport building was conducted and all possible attempts were made to make each interviewee feel as comfortable as possible. The interviewer was the first author; he is a PhD student and nutritionist who has qualitative research training and experience in the research area.

Data analysis

Before coding, 10 (30%) of the transcripts (six IDIs and four KIIs) were cross-checked with audio recordings to guarantee accuracy and consistency. In accordance with the methodology recommended by Braun and Clarke,²⁷ data analysis was assisted by ATLAS.ti V.7.1 software; the data were examined to condense the informational contents of the verbatim transcriptions of all interview recordings. Data collection and analysis were simultaneously performed. Field notes were combined with interview transcripts to provide a comprehensive dataset for analysis. Based on the research questions, the data were classified into categories and themes were created using these categories. Themes emerged from the data, not predefined.

Variations in the themes, categories and subcategories were recorded after comparing the results. The implementation of an audit trial indicated that the researcher’s sources were meticulously recorded and disseminated to subject-matter experts. The researcher took meticulous notes, recorded actions and stored the data in an easy-to-access format. A thorough description of the research procedure and outcomes preserves the transferability of the findings.

Trustworthiness

The reliability and authenticity standards established by Schwandt et al²⁸ were adhered to. The researcher used triangulation and sustained engagement as criteria. By investing extra time in the data collection process during key informants and in-depth interviews to build rapport, the researcher ensured sustained involvement.

The researchers used reflexivity during the analysis to prevent bias based on personal experiences with the topic being studied.²⁹ To avoid bias and data misinterpretation, the researcher spent time with nutrition specialists and Dilla and Jimma University staff members, who had experience with qualitative research.

Patient and public involvement

Patients or the general public were not actively involved in the design of this study. The study’s objectives were disclosed to and approved by the study’s participants, Jimma University, and the zonal and district health offices. Additionally, we intended to communicate the results to the West Arsi zonal and relevant district health offices.

Results

Characteristics of study participants

Half of the participants were from rural areas. The healthcare providers included midwives, nurses, health extension workers, health officers and master of public health (MPH) holders (table 1).

Table 1.

Sociodemographic characteristics of study participants, West Arsi, Central Ethiopia, 2023 (n=30)

Variable	Frequency	Per cent
‍Pregnant adolescent
‍Residence
‍Urban	6	50
‍Rural	6	50
Occupation
‍Student	4	33.3
‍Housewife	4	33.3
‍Merchant	4	33.3
‍Education status
‍ No formal education	3	33.3
‍Elementary	3	33.3
‍High school	3	33.3
‍ College	3	33.3
‍Marital status
Married	7	58.3
‍ Single	4	33.3
‍ Divorced	1	8.3
‍Pregnancy experience
‍Pregnant for the first time	4	50
‍2nd pregnancy	4	50
‍Husbands of pregnant adolescent
‍Residence
Urban	4	50
‍ Rural	4	50
‍Occupation
Government employee	4	50
‍ Farmer	2	25
‍ Merchant	2	25
Education
‍ No formal education	2	25
‍ Elementary	2	25
‍High school	2	25
‍College	2	25
‍Healthcare providers
‍Sex
Female	5	50
‍ Male	5	50
‍Age
18–30	3	30
‍ 31–45	3	30
‍≥46	4	40
‍Profession
Midwife	2	20
‍Nurse	2	20
‍ MPH	2	20
‍Health officer	2	20
‍HEW	2	20
‍Position/responsibility/work place
‍ Health centre manager	2	20
‍ MPH/zonal health office	1	10
‍MPH/district health office	2	20
‍ ANC/care provider	3	30
‍Health extension worker	2	20
‍Working years less than or equal to 4	1	10
‍5–8 years	4	40
More than 8 years	5	50

ANC, antenatal care; HEW, health extension worker; MPH, masters of public health.

This study contained 21 primary documents, coded into 386 codes, 14 subthemes and 4 themes. The identified themes included (1) low nutritional awareness, (2) poor dietary practice, (3) barriers to good dietary practices and (4) facilitators of good dietary practices (table 2).

Table 2.

The summary of main theme and subthemes

S. No.	Main themes	Subtheme
1	Low nutritional awareness	Vulnerability of pregnant adolescent Perceived severity of undernutrition Perceived benefits of balanced nutrition
2	Poor dietary practice	Dietary change during pregnancy Monotonous diet Animal source food consumption
3	Barriers to good dietary practice	Poor nutrition awareness Nutrition education is overlooked Conflicting advice/misconceptions Lack of adequate nutrition education Economic problems
4	Facilitators for good dietary practice	AFD (Alliance for Development), formerly known as: Women Development Army Husband involvement in nutrition education Specific nutrition training to health professionals

Theme 1: low nutritional awareness of pregnant adolescent

The level of awareness among pregnant adolescents showed a diverse picture, with some general knowledge about nutrition and the need for increased frequency and amount of food during pregnancy. However, there was no detailed information about the significance of nutrition in pregnancy, and most participants had a low level of perceived benefit and severity of undernutrition, although many considered themselves susceptible to undernutrition.

Low perceived benefits of balanced nutrition

Disease prevention, energy provision, and growth and development are some benefits mentioned by some of the participants. Healthcare providers have reported that the benefits of balanced nutrition have been underestimated. Most pregnant adolescents and their husbands are unsure about the nutritional information they replay when interviewed, and most of the time, they provide general answers. For example, one interviewee stated,

… Ummmm … Balanced food is good … It is my first pregnancy; I do not know much about the benefits of balanced nutrition … I do not know what good feeding changes I should make in pregnancy … [18 years old pregnant, student]

Many adolescents remain silent for a long time and respond little information; for many of them, everything was new.

Health expert at zonal level indicated that:

… Pregnant adolescents are immature, they require more advice … they have very low awareness of the benefits of balanced nutrition and severity of problems which come from lack of it, they are vulnerable to many unfavorable pregnancy outcomes … [nurses, 14 years experience]

Low perceived severity of undernutrition

Most pregnant adolescent and husband participants did not state the level of severity of problems arising from undernutrition. Several healthcare providers have reported that pregnant adolescents do not fully understand the consequences of undernutrition. One healthcare provider commented on the use of a warning approach for health education at funeral ceremonies (incorporating brief health and nutrition message to prevent death of others), at homes and health facilities, in addition to learning from the positive deviance approach (model mothers). Regarding this issue, one interviewee said,

… Undernutrition is bad however, more dangerous is to have large baby which can result death of mother during delivery, our body weight will also be increased and we lose our current shape after birth, many mothers lose their former shape after delivery … [19 years old pregnant, housewife]

However, it is worth noting that one interviewee had an extraordinary understanding.

… What always comes to my mind is what my husband told me … he told me that an unhealthy small baby, death of child, death of mother, anemia can happen if there is poor nutrition … [19 years old, college student]

Vulnerability of pregnant adolescent

Although the levels differed, the majority of pregnant adolescents did not explain the nutritional vulnerability of pregnant adolescents. Most husbands consider pregnant adolescents similar to pregnant women. One husband quoted traditional quote: ‘We cannot say “Dist” [Traditional pot made of mud in Ethiopia] and females are small, they can handle everything!’, to explain his idea that pregnant adolescents are no longer vulnerable, they are capable of managing their pregnancies. Healthcare providers commented that pregnant adolescents had a low understanding of vulnerability to undernutrition. For example, a care provider stated that:

… Many pregnant adolescents are depressed and less interested for adequate food intake, some worry not to lose their current shape, very few know the high vulnerability they have for undernutrition [midwife, 9 years experience]

One husband reflecting his idea on this issue said that:

… My wife is leading the same lifestyle as before pregnancy, I have seen that she never understood how vulnerable she is to different health problems … [32 years, government worker]

Theme 2: poor dietary practices

Dietary change during pregnancy

Regarding quantity and variety of food, both key informants and in-depth interview participants knew that a pregnant adolescent must eat additional food to protect the health of both the child and mother; however, in practice, what is reported showed a low intake of animal source food, same food daily, low fruits and vegetables from most of the study participants. One husband reported the following.

… My wife does not eat as required because she often focus on caring and sharing foods to other little children in our large family, she had also vomiting and nausea which made her hate different food … [34 years, daily labourer]

One pregnant adolescent said,

… I did not notice it even, … yes I did not eat more, it is almost the same as before pregnancy, I eat the routine foods I used to eat. [19 years old pregnant]

While a minority mentioned that they had changed their dietary practices, all participants reported the same feeding style. One participant, a college student, reported a very good dietary change in both amount and frequency of feeding.

… after the pregnancy I started eating four-five times per day, Due to the pregnancy I am forced to take more food and more rest, … [18 years old pregnant, merchant]

Monotonous diet

Several participants reported that they had the same type of food daily, usually cereal-based, and were made of potato or cabbage with bread. Healthcare providers mentioned Chuko [made from barley and butter] and chechebisa [made from any cereal and butter], which are the dietary staples and traditional local diet in West Arsi; however, only a few families afford them. Many participants considered it luxury to consume balanced foods. For example, one pregnant adolescent said:

… I continued eating same types of foods; I eat “Injera with Shiro wot” [Ethiopian traditional food made of cereal and grain] always. Nothing changed my feeding style. [19 years old pregnant adolescent, grade 5 dropout]

A small number of respondents indicated that they take variety of foods, for example one interviewee said:

… I eat different types of foods and more fluids; I started eating fruits. [19 years old pregnant, college student]

Animal source food conception

Most participants reported fewer intakes of animal-source foods because they were too expensive. Healthcare providers mentioned that animal source foods (ASF) are calorie-dense foods, and their essentiality vis-à-vis plant-based foods lies in their content of high-quality proteins and micronutrients, such as iron, vitamin B12, vitamin A and zinc. Of the food groups that determine the optimal dietary diversity, three (meat, eggs and dairy) are ASFs. One interviewee stated,

“… Egg, meat and fish are the most expensive, I never afford that on regular bases, let alone meat, tomato is sold 70 birr per kg [showing depressed face] ….” Participants were reluctant to discuss this issue. [18 years old pregnant, grade 4 dropout]

Furthermore, another participant said that:

… I eat what I get I did not give special attention for meat and egg, I eat these on holly days only …] [19 years old pregnant, grade 6 drop out]

Theme 3: barriers to good dietary practice

Poor nutrition awareness

Majority of the healthcare professionals interviewed indicated that poor nutrition awareness or lack of nutrition literacy is a key reason for poor dietary practice. For example, one health professional said:

… I think the role of nutrition is underestimated, many do not know how harmful and impactful it Is to have undernutrition. let alone the immature young pregnant, the educated adults have poor nutrition awareness … [38 years old, MPH]

This view was echoed by another informant who stated that:

… Nutrition education is over looked, let alone the nutrition literacy of the pregnant, the health care provider’s nutrition awareness is not satisfactory, they need specific nutrition trainings; having low knowledge they cannot teach and bring change. More advocacies for nutrition are needed. [midwife with 9 years of experience]

Nutrition education is overlooked

Several healthcare provider participants reported that nutrition still did not receive the attention it deserved. One senior professional with ten years of experience indicated the following:

… compared with other health services, the attention given to nutrition is low, although nutrition interventions are included under ANC/ ante natal care, … due to excess activities on ANC guideline, usually some services including nutrition are overlooked; this should be avoided, we should invest our time and energy on nutrition, it is rewarding investment … [nurse, health office]

One interviewee also commented that:

… Nutrition course for health and medicine students should be given in more credit hour, currently it is 2 credit hour and I do not think it is adequate to equip students with all necessary knowledge and skills. [nurse, 12 years experience]

Conflicting advice/ misconceptions

Healthcare providers reported that there are contradictory advice that some people give for example, after health professionals advised pregnant to eat more amount of food and iron folic acid supplementation, when they go to the community some people say ‘more food and iron will make the baby fatty and you will face problems in delivery’. For many participants, conflicting advice or misconceptions were observed to be barriers to dietary practice. For example, one interviewee argued,

… One older mother advised me that I am too young and I have to take care about intake of food, if I eat much, the baby will be large and I will face problems on delivery. [19 years old pregnant, grade 4 dropout]

For some interviewed health professionals, conflicting advice or misconceptions were concerning. For example, one midwife reported that:

… although food taboo is not that much problem in this society, very few say that cabbage and some fruits like banana should not be eaten during pregnancy … [midwife, 7 years experience]

Lack of nutrition education

While one healthcare provider mentioned that the nutrition education being given was adequate, all agreed that there was very little nutrition education. One participant stated the following.

… To bring behavioral change the nutrition education should be given at list 3 times with different methods and materials taking adequate time in detail, we do not have policy problem but implementation and monitoring, becomes a problem … I can say the nutrition education is inadequate … [MPH, 11 years experience]

The majority of pregnant adolescents expressed a desire for more nutritional information, and they reported that they did not receive nutrition education and advice; some received it, but they mentioned it was little. For example, one interviewee stated,

… No one gave me nutrition advice, although they check my blood pressure and my weight, I want to know more about how my nutrition should be, to care for the baby and myself …. [18 years old pregnant, housewife]

Economic problems

Some felt that low economy was a key challenge against healthy dietary practice, while others considered it to be just one barrier among several pregnant women. For example, one healthcare provider interviewee argued,

… Yes, shortage of money is a key barrier however, our problems are not only that, lack of knowledge, and lack of hard work culture is a problem, Ethiopia is resourceful country … [public health officer, 13 years experience]

One pregnant adolescent indicated that:

… My food intake is limited by the money we get; my husband is a farmer and we have small land and sessional incomes … [19 years old pregnant, housewife]

Another pregnant adolescent added:

… Price of food is almost increasing weekly, we are forced to limit our food, every food is expensive, we have lots of other expenses which are must like house rent fee and transport … [19 years old pregnant, college student]

Theme 4: facilitators of good dietary practice

Alliance for Development

Alliance for Development (AFD), earlier known as the Health Development Army, was suggested by a number of healthcare providers as a great facilitator for nutrition interventions, including nutrition education. One healthcare provider interviewee argued,

AFDs can be used for different nutritional interventions, including nutrition education; if we select active and experienced AFDs and give them intensive training, they can create a huge impact, they are very close to pregnant they can teach at pregnant mother forum, home to home, and we can use them at health facilities too. [public health, 11 years experience]

Another senior health expert added:

… AFDs gained knowledge and experience by closely working with health extension workers, they have good appetite for work, they can closely follow and support mothers, AFD structure should be strengthened, if we teach them well and make them part of the health system it is great … [MPH, 12 years experience]

One pregnant adolescent said that:

… Our women development army leader is very active, she follows us, she advises us, she teach us to take iron tablets, to use iodine salt and to have regular checkups, she is knowledgeable and caring. [19 years old, housewife]

The network diagram (figure 1: Barriers and facilitators of dietary knowledge and practice) shows barriers and facilitators in improving dietary knowledge and practices in pregnant women.

Figure 1.

Network diagram showing barriers and facilitators of dietary knowledge and practice among pregnant adolescents, West Arsi, Central Ethiopia, 2023. The figure helps to conceptualise the data under barriers and facilitators theme by connecting sets of related codes and quotations; it also shows the type of relationship among the codes. It was generated by ATLAS.ti software; == lines show is associated with, [] lines show it is part of, => lines show it is cause of, < > lines show it is contradicts. AFD, Alliance for Development; ANC, antenatal care; HCP, healthcare provider; HEW, health extension worker.

Husband involvement in nutrition education

Health professionals agree that if husbands are given health and nutrition education and made part of the solution, they can help a lot. For example, one participant said,

… My husband is well educated and he reads every day … he always explains for me about balanced food, use of food for me and the child, he reminds me of iron tablets, although he is not a health professional; he reads for the sake of my health, his support is great … [19 years old, college student]

However, many pregnant adolescents reported that their husbands were extremely busy or extravagant. Healthcare providers commented that the use of male involvement would bring about change because many decisions in the house are made by males.

Specific nutrition trainings

Health professional participants stated that the government had already provided a number of trainings; however, they stated that specific nutrition training, such as nutrition education and nutrition for pregnant adolescents, is required. For example:

There is a huge gap in nutrition awareness among healthcare providers, which is why they underestimate it; therefore, in-depth specific nutrition training and advocacy are needed. [MPH, 11 years experience]

Another respondent added that:

… NBCC (Nutrition behavioral change communication) interventions trainings are required to equip all responsible care providers with the skills required for behavioral change interventions … [midwife, 9 years experience]

Discussion

The results of this study showed that pregnant adolescents have low nutritional awareness and poor dietary practices. Little attention given to nutrition, lack of nutrition awareness, lack of adequate nutrition education, conflicting advice and economic problems are barriers to dietary practices; and AFD, Husbands’ involvement in nutrition education and specific nutrition training for healthcare providers are facilitators for good dietary practice during pregnancy.

Although healthcare providers provide nutrition education, they are very shallow and small, due to shortage of time and this could be a reason for the low awareness of nutrition among participants in this study, this was consistent with other qualitative studies.^{8 11} Low awareness can lead to poor dietary practices, which, at this age and during pregnancy, have a wide range of consequences. Pregnant adolescents who have the potential for growth and development may stop growing, and may give birth to an LBW baby; stillbirth and prematurity can still occur. Similarly, children are also vulnerable to non-communicable chronic diseases later in life.^{30 31}

Community-level structures, such as the AFD, should be properly used and involved in behaviour change communication interventions. If the nutrition education is only brief and general, it cannot change behaviour; it should be given at least three times with different teaching materials and methods as different literatures recommended.^{32 33}

Pregnant adolescents had poor dietary practices, perhaps because the most relevant public health finding was this poor feeding practice revealed by a monotonous diet, no dietary change during pregnancy, and very low animal source food conception. Animal source food conception is affected by religious fasting and income of the household, this finding is similar with other studies.^{7 11}

In addition to the substantial role of maternal nutrient reserves, it is the outcome of dietary changes during the pregnancy period, which has the most significant effects on birth outcome and nutrition status.³⁴ Inadequate dietary intake during pregnancy increases the risk of short-term and long-term consequences such as IUGR, LBW, preterm birth, and prenatal and infant mortality and morbidity. It has also been associated with metabolic consequences,³⁵ resulting in poor growth and development, and affects the quality of life.³⁶ We need to identify the most feasible dietary interventions, including behavioural change communication interventions for pregnant adolescents, aimed at preventing adverse neonatal and infant outcomes.³⁷

There are similarities between some of the barriers to good dietary practice expressed by healthcare providers in this study and those described by Abas et al on Barriers to Optimal Maternal Nutrition in the Somali Region, Eastern Ethiopia.³⁸ Poor nutritional perception and misconceptions were similar. While previous research has focused on pregnant women, these results demonstrate that pregnant adolescents have more barriers. For the great majority, it is their first pregnancy, and they have very little awareness and are easily vulnerable to wrong advice from misconceptions in the community. They believed that it would be easier to deliver only smaller babies. Pregnant adolescents did not realise that smaller babies might not be able to cope and might become distressed. The short-term and long-term harmful effects of LBW should be considered for pregnant adolescents based on behavioural change communication models.

There is a good policy environment for food and nutrition in Ethiopia, to mention some; the food and nutrition policy of Ethiopia, national nutrition programme, national nutrition strategy, food security strategy, productive safety net programme, Seqota declaration, food based dietary guideline,^{39 40} however, these should be translated and practiced properly to improve dietary practice; the policies, plans and programmes must be implemented, and a robust monitoring and evaluation system is required. Some segments of the population, such as pregnant adolescents, still require special attention. The SDG recommends,⁴¹ to support adolescents through different skill development programmes and adolescent pregnancy prevention programmes, using reproductive and sexual health education.

Another finding is that AFD is found to be a great opportunity to support pregnant adolescents, these results further support Health Extension Programme’s ‘philosophy’, which is based on the creation of more and more ‘model households’, or homes that accept a whole spectrum of healthy ideas, attitudes and behaviours as well as ‘responsibility’ or ‘ownership’ for their own health,⁴² AFD can build on the Health Extension Programme’s successes and help Ethiopia more quickly reduce the different forms of malnutrition. Pregnant adolescents are not easily accessible,⁴³ therefore; AFD makes a unique contribution to these segments of the population. Further studies are required to examine the effects of nutritional interventions delivered by AFD to determine whether they can be used in the healthcare system.

Results of a cluster-randomised programme Evaluation in Bangladesh showed; engagement of husbands in a maternal nutrition programme substantially contributed to greater intake of micronutrient supplements and dietary diversity during pregnancy⁴⁴ moreover, some literatures makes clear the significance of male partner support for enhancing maternal health-seeking behaviours and practices; such as studies from Kenya⁴⁵ and Peru⁴⁶ have similarly emphasised the significance of spousal support for enhancing pregnant women’s compliance with micronutrient supplementation.

It would be good to have husband forums that brought together local men and provided them with the chance to converse with one another on topics such as maternal nutrition and ways to support their wives. To support their pregnant partners, husbands can help out around the house, ensure there is enough food available, and encourage and prod their partners to eat well and get enough rest.

Poor nutritional perception was reported in this study, different studies in Ethiopia showed a nutrition knowledge gap among healthcare providers. For example, a study conducted in Hawassa City, Southern Ethiopia, revealed that only 55.5% of health professionals have adequate knowledge,⁴⁷ similar study conducted in Addis Ababa⁴⁸ revealed a 65.7% level of good nutrition knowledge. Moreover, a study conducted among medical doctors in Ghana reported low levels of nutrition literacy.⁴⁹ Healthcare providers should update their nutrition knowledge and the continuous professional development should incorporate adequate specific nutrition trainings to fill the nutrition knowledge gap among healthcare professionals.

Limitations of this study are; a national level or other sociocultural contexts may not be able to generalise in-depth insights because they are based on viewpoints and lived experiences in a particular geographic area; and the process of translating and transcribing could result in the loss of subtle information. It is beyond the scope of this study to determine nutrition knowledge level; future studies should take into account quantitative study to measure this.

Conclusion

This study found that there were poor dietary habits and low nutritional awareness. The obstacles are lack of nutrition education, contradicting advice and financial difficulties. Facilitators found were AFD, husband involvement in nutrition education, nutrition training and education. Unless the government focuses on enforcing policies and strong monitoring and evaluation, improvements in knowledge and dietary practices will not be attained. Further studies are recommended to assess whether AFD is capable of delivering effective nutrition interventions that improve dietary practice of pregnant.

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request from the first author.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and the ethical approval was obtained from the Jimma University IRB/ethics committees (reference number JUIH/IRB/194/22) and the Oromia Regional Health Office. Prior to providing informed consent, each study participant received a thorough description of the study’s title, goal, protocol and duration as well as the potential risks and benefits. Parents/ guardians provided informed consent for participants under the age of 18. Each teenager provided written and signed informed consent forms prior to any interviews or measurements. Participants were made aware of the publication of their anonymous comments. Informed consent was obtained from all participants prior to the commencement of the interviews. The researcher remained truthful of the academic and ethical requirements. Finally, the researcher kept field notes and the audio tape was recorded in a locked file cabinet in a safe place after the completion of the study. Moreover, the final research report was submitted and reviewed by members of the scientific community. Both assent from adolescents and consent from their husbands or parents were obtained. Finally, data destruction will be done as soon as the purpose of the research is served. No participant refused to participate; all completed the interview without any ethical problems.