Effect of Behaviour Change Communication on Iodised Salt Utilization and Median Urine Iodine Concentration among Children Growth Age 6 -59 Months in Central Highland of Ethiopia: Cluster Randomized Control Trial

The most daunting challenge to control Iodine Deficiency Disorder (IDD) in Ethiopia
is accessing iodised salt with adequate quantity of iodine. Fundamentally, measuring
Median Urine Iodine Concentration (MUIC) is good surrogate marker of the amount of
iodine found in plasma thyroxine. There was no study in Ethiopia that evaluated whether
education on the iodized salt at household levels improves iodine status.


Introduction
Iodine deficiency is the primary cause of preventable brain damage and growth retardation in children during the first few years of their [1]. Nearly thirty per cent of the world's population lives in areas with iodine deficiency [Iodine Global Network, www.
World Health organization (WHO) recommended that the deficiency of iodine corrected by increasing iodine intake through fortified table salt which required four major components of implementing strategies. Among these strategies are correction of iodine deficiency, surveillance including monitoring and evaluation, educate the public to qualify iodise salt utilization and intersectoral collaboration and advocacy and communication to mobilize public health authorities are frontline for the Control of IDD through the world [3].
Iodised salt intervention impact indicator principally median urinary iodine level is recommended in younger children population.
Most studies attempted to measure the prevalence of IDD based on goitre rate in school-age children at sever development stage of iodine deficiency. Additionally, these studies frequently focused to clinical signs of iodine deficiency after it becomes irreversible stage of disorder. In many parts of the world, children's diets contain insufficient micronutrients and deficiencies are widespread because of consuming a less or lack of diverse nutrient-dense foods [4].
Due to iodine deficiency, mental impairment and physical damage among children prevalent [5]. After more than two decades of implementing iodized salt as an intervention modality in Ethiopia, the problem of iodine deficiency is still prevalent. There was not an any longitudinal study that determined the effect of behaviour change communication promoting the proper use of iodised salt on prevention and control of IDD. This study started by quantifying iodine found in table salt at household level and assessed women's knowledge and attitude concerning prevention of IDD at the same time [6]. Currently, there is a tremendous change in implementation of universal iodised salt intervention in Ethiopia [6,7]. Given the fact that the government is making all efforts to avail iodized salt to the population, we hypothesised that the iodine deficiency disorder is related to the improper use of iodized salt at the household level. In this study we set out to determine the effect of behavioural modification of women through self-monitoring, behavioural contracts and goal setting for safely and adequately utilization of iodised salt in the households on iodine status of children 6-59 months.

Study Area and Period
The study was conducted from February 2018 to April 2019 (for 15 months) in Central highland of Ethiopia which includes area with altitude ranging from 2100 to 3000 found near to Arsi Bale plateau and the neighbouring of Chilalo Mountain. This includes, Tiyo, Limuna Bilalo, Digeluna Tijo ditricts and Asella Town that are found in a highland ecological zone. Historical annual rainfall ranges from 2200 -2350 mm [8]. This study focused on the highland area as its surface layer exposed is likely to lose iodine through erosion and leaching [9]. Community based Cluster Randomized Control Trial (CRCT) design was used. Sixteen kebeles were selected from Highland Districts of Arsi Zone and randomly assigned either to intervention group or control group. All children age 6 -59 months and their pair mothers/caregivers found in districts Central Highland of Ethiopia were considered as the source population while children age 6 to 59 months old and their pair mothers/caregivers selected for this study form selected districts found in Central Highland of Ethiopia were considered as study population.
A total sample size of 829 mother child pair (415 intervention and 415 control were determined using Gpower 3.0 software with assuming a power of 95%, precision of 5%, effect size of 0.125 and ration of intervention to conrol of one. Multistage sampling method was applied to allocate intervention and control clusters randomly.
First, sixteen kebeles were randomly assigned to either intervention or control cluster using Emergency Nutritional Assessment

Laboratory Procedure for Iodine Determination from Mid Urine
MUIC were analysed with ammonium persulfate methods in Ethiopian Public Health Institute laboratory.
The following steps used for analysing median urine iodine concentration.

1.
In first, for each specimen, shaking was done to suspend sediment.

2.
from each urine sample 250μl was pipetted into a 13 x 100 mm test tube. Pipette was used for each iodine standard and then water was added as needed to make a final volume of 250μl. Duplicate iodine standards and a set of internal urine standards were included in each assay.

3.
One ml 1.0 M ammonium persulfate was added to each test tube.

4.
All test tubes were heated for 60 minutes at 100 OC.

5.
Each test tube was cooled to room temperature.

8.
Each test tube contained treated specimen was allowed to sit at room temperature. 9. Exactly after 30 minutes, ceric ammonium sulphate was added to the first tube and its absorbance was read at 420 nm.

9.
Successive tubes were read at the same interval of adding the ceric ammonium sulphate.

MUIC Laboratory Result Remarks
Cut-off value for iodine adequacy was indicated with the ref- erence of WOH, MUIC 100μg/L and higher substantially adequate.

Anthropometric Measurements
Children's height and weight (Wt) were measured according to standard procedures recommended by WHO. Weight was measured using hanging spring balance for children age < 2 years and digital scale for children 2 years and above without shoes and with light cloths. Besides, height was measured bare foot using a a stadiometer for children in age group 24 months and above. For children less than 24 months, recumbent length board was used for and each child rested in relaxed manner parallel to the long axis of the board and measurement was taken using two trained data collectors. Weight reading and height reading take to the nearest 0.1 kg and 0.1 cm, respectively. Average reading of two independently observers were used for the final analyses [11,12].

Data Processing and Analysis
At the first step, data entering children's height (Ht), weight (Wt), age and sex were entered using Emergency Nutrition Assessment (ENA) software to determine children nutritional status.
These variables were converted into HAZ and Wt for Ht (WHZ) for individual study subjects. HAZ > -2 Z-score standard deviation (ZSD) predicts as normal growth status and HFA < −2 ZSD evidenced that child's growth was stunted. In addition, weight for height Z score (WHZ) was also generated to determine wasting among [11,12].

Results
At baseline 812 (98.9%) were participated, but 715 (87.1%) of study subjects pursued their intervention in the endlien survey.  At baseline survey, the prevalence of iodine deficiency (MUIC<100 μg/L) among children who participated in this study was higher (12.4%) among intervention than control group (11.2%). The prevalence among children who participated in this study at baseline was (11.8 % [7] and thus, the baseline finding was higher compared to endpoint survey (6.15%), which was almost by half percent of ID decreased among study subjects. The prevalence of iodine deficiency among control group at endpoint survey did not change (11.20 %) from the baseline finding.
But, among intervention group during endline survey declined by more than 75% which was 3.0%. Therefore, near to 94% of children participated in the study had met their need of iodide nutrient,

Discussion
This study demonstrated improvement in the proportion of children who met the requirement in their requirement of iodine [6]. The proportion of children age 6-59 months who had adequate iodine nutrient (MUIC > 100 μg/L) improved from 88.2% at baseline assessment [7] to 94% at the endline survey. In this study, end line survey showed that there was low proportion (6.1%) of iodine deficient children compared to baseline survey [11.8%] [7]. The entire prevalence (6.1%) of iodine deficiency was very high compared to the study finding among Korean preschool children that reported a proportion of 3.9 % [14]. The content of iodine found in table salt was quantified using titration method and this enabled the determination of the fact that households in this study area are consuming sufficiently iodized salt and met their requirement of iodine per person per day [6]. Consequently, in the baseline survey MUIC laboratory analysis reported that most children included in the survey had adequate iodine nutrient [7]. These the above inter-related findings are evidences that high content of iodine found in iodised salt is significantly associated with MUIC in children.

Acknowledgement
We would like to express their gratitude to Jimma University for financial support. They extend their special gratitude to Arsi Zone, health department, districts and kebeles administrative officers and all health Extension Workers for their assistance and cooperation at the time of data collection and accompanying field work and assisting the our one year and three month intervention program.
Furthermore, we would also like to express their deep appreciation towards Ethiopian Public health institute food and nutrition laboratory officers for their technical work in their laboratory.

Ethical approval
Ethical approval was obtained from the Ethical Review Committee of the institutional Review Board (IRB) Institute of Health, Jimma University. A formal letter was written to the eight district Health offices and Health Extension Workers for permission and support until the intervention program completed. The study participants were clearly informed that their participation was voluntary, and they were free to participate in the study, or refuse at any time and for any reason without any penalty. Informed consent for their paired children and for them consent protocol was approved by the Ethical Review Committee.