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Background: Under-nutrition is a global problem and one of the most serious public health issues. Globally, 156 million under-five children were stunted, and 50 million were wasted in 2016. Malnutrition among preschool-age children is caused by low socioeconomic status, food insecurity, poor feeding practices, and infectious diseases. This intervention aimed to evaluate the effect of nutrition education delivered through trained health professionals in improving the nutritional status of preschool -aged children. Methods: A quasi-experimental design among 588 preschool –aged children was used. A multistage sampling technique followed by a systematic random sampling technique was used to identify caregivers with preschool-aged children. Structured questionnaires were used to collect data. The baseline difference in demographic and socioeconomic characteristics between the two groups was examined using a chi-square test and an independent sample t-test was used to determine the mean difference in under-nutrition between the intervention and control groups. Generalized estimating equations (GEE) were used to determine the change in the difference in outcome between the intervention and control groups as well as the association of predictors with under-nutrition in children. The Adjusted odds ratio (AOR) with the corresponding 95% confidence intervals was reported to show the strength of the association. Variables with a p-value of less than 0.05 were considered statistically significant in multivariable analysis. Results: In this study, the nutritional status of preschool age children was significantly associated with nutrition education intervention [AOR = 0.566, 95% CI: (0.347, 0.923)], place of delivery [AOR = 0.724, 95% CI: (0.551, 0.951)], ARI in the last 2 weeks [AOR = 1.823, 95% CI: (1.226, 2.710)], source of drinking water [AOR = 0.624, 95% CI: (0.484, 0.805)] and household food security [AOR = 1.311, 95% CI: (1.030, 1.669)]. Conclusions: Findings of this study showed that nutrition education can effectively reduce the magnitude of under-nutrition among preschool children. Under-nutrition was e significantly associated with nutritional education, place of delivery, ARI in the last 2 weeks, source of drinking water, and food security. Therefore, both government and non-government should consider the impacts of nutrition education to alleviate under-nutrition and improve the health status of preschool-age children.
Ilu Abba Bor is a zone in the Oromia regional state, 600 km from the country’s capital, Addis Ababa. The Zone is divided into 14 districts, one administrative town, and 13 rural districts, with a total population of 934,783 people, including 153,585 children under the age of five and 100,209 children aged two to five years. It stretches from 70 27 ‘40 “N to 90 02’ 10” N latitude and 340 52′12 “E to 410 34’55” longitude in the western part of the country. The climate is divided into three main zones: temperate, humid, rainy, and dry arid. Rainfall occurs twice a year which ranges from 2400 mm to 100 mm. in most highland areas of Ilu Abba Bora, the highest mean annual temperature ranges from 26 °C to 10.6 °C. A quasi-experimental design with pre-test-post-test and control groups was used from May 15, 2019 to February 15, 2020 to assess the effectiveness of community-based nutritional education on nutritional status among preschool-aged children in 22 rural kebeles. The sample size was calculated using a G-Power model with the following assumptions: 52.5% expected prevalence of stunting among children aged 24 to 59 months, 2.07 odds ratio of acute respiratory tract infection [15], 80% power, and a 5% margin of error. Then, a design effect of 2 and a 15% non-response rate were taken into consideration and the final sample size was 588 (Fig. 1). shows a flow diagram of the research process A multi stage sampling technique followed by systematic random sampling technique was used to identify caregivers with preschool aged children. In the first stage, four districts were chosen purposively from the 14 districts. Due to their similarity in terms of access to health care, water, and other services, two neighboring districts from the selected districts were chosen as intervention and the other two adjacent districts as control groups to prevent information contamination. Then, at random, two districts were allocated to the intervention group and the other two districts to the control group. Eleven kebeles (Ethiopia’s smallest administrative units) were chosen at random from each community. Following the selection of kebeles, pre-school aged children (2–5 years) were identified and registered in each chosen kebele. Households with children aged 2 to 5 years were given a code, which was used as a sampling frame. Following the registration of preschool-aged children, a proportional allocation was carried out, and a sample was drawn from both the intervention and control groups using a systematic random sampling technique. If the caregivers/households had more than one child, one was selected at random using the lottery method. Following the completion of the baseline data collection, nutrition education was implemented for a total of 9 months in all intervention groups. A nutrition education package was developed using family dietary guidelines [16] and other relevant nutritional education intervention modules and topics were adopted and modified as local situations from literature [17, 18] for community-based nutrition intervention as well as using the findings of a base line survey. It is easy, interactive, and user-friendly for all trained professionals, health extension workers, and caregivers/mothers to use in implementing nutrition interventions for mothers/caregivers of preschool-aged children at the community level. The Nutrition educational package consists of three educational modules and a number of supporting educational materials. The education modules addressed three main aspects: healthy diet awareness, nutrition, and hygiene, with a total of ten topics, namely: Enjoying a variety of foods, Feeding toddlers and preschoolers aged 2 to 5 years; Make starchy foods the base of the majority of your meals. Consuming a variety of vegetables and fruits on a daily basis, regularly consume dry beans, split peas, lentils, and soya. Chicken, fish, meat, milk, or eggs can be eaten daily; Use salt sparingly. Consume fat sparingly. Use food and drinks containing sugar sparingly and not between meals; this keeps food safe and clean. The caregivers/mothers gathered in a school, health postl, or health center that was convenient for them and comfortable for the group. Nutrition education was provided to eleven kebele caregivers/mothers by trained health professionals. One trained health professional and one health extension worker were assigned to each kebele, implying that health extension workers acted as assistants and facilitators. Over the course of five months, ten sessions were held every two weeks for approximately 30–45 min, with two sessions held in the seventh month as a refresher. The topic of the day was introduced to the group of caregivers on the day of the presentation. Following that, specific questions about the topic were asked to assess prior knowledge and encourage discussion. The caregivers were evaluated at the end of the session to see how well they understood the information. The communication mechanism is determined by the context, cultural preferences, and the way in which individuals normally receive and obtain information. A set of educational materials, including group discussions, lectures, role-plays, active participation, and demonstrations, was used to teach mothers knowledge and skills about child feeding. The group discussion method was used more in this study because it is an excellent way to encourage interaction between group members and it allows for more participation. Monitoring activities and process evaluation were used to improve and track compliance with the intervention. The principal investigator and supervisors visited each household to monitor the implementation of the intervention and discuss the activities with the mothers/caregivers. The principal investigator made many visits to the field. Investigators and supervisors have met on a regular basis to review the project’s progress and discuss any necessary changes. The goal of the process evaluation was to document the intervention’s implementation process in order to see if the activities were carried out as planned, determine the degree to which the intervention reached children and mothers/caregivers; evaluate the extent to which the intervention reached children and mothers/caregivers; determine the extent to which intervention components are exposed to target children and caregivers; investigate contextual factors that may influence intervention effectiveness, and provide information that can help in the interpretation of outcome indicators and also be used to monitor the attendance of mothers/caregivers during nutritional education sessions. A baseline analysis of 569 caregivers or mothers with preschool-aged children was conducted at the time of enrollment. Trained data collectors used a structured interviewer questionnaire to interview all caregivers/mothers at the start and end of the study. The questionnaire was written in English first, then translated into the local language (Afan Oromo), and finally back to English to ensure consistency and quality of the data. A pre-test of the questionnaire was conducted outside the study area on 5% of the total samples to determine the acceptability and applicability of the tools and procedures before the real data collection. Over the course of three days, all data collectors and supervisors received extensive training. To avoid within-examiner error, all anthropometric measurements were taken by investigators, supervisors, and data collectors. Before the measurement, the weight scale was set to zero and placed on a level surface. The age of the child was calculated using the child’s date of birth and the date of the interview. Where the exact date of birth was not registered or unknown, the caregiver was asked to guess based on local events. By subtracting the child’s date of birth from the date of data collection, the child’s age was calculated. Each questionnaire was monitored and double-checked by a principal investigator and professional supervisors for completeness, irregularities, inconsistencies, and out-of-the-ordinary responses, making immediate corrections as needed. During data entry, computer frequencies were used to check for missing variables, outliers, and other errors. The dietary diversity score was assessed using the repeated 24-h dietary recall method, which was taken three, times (two weekdays and one weekend). Every day of the week was described, including fasting and feasting days. The children’s caregivers were asked to remember everything their children ate or drank during the 24-h period of study. The individual dietary diversity score (DDS) of the study respondents was calculated according to the FAO guidelines [19]. Dietary diversity was calculated as the sum of scores in each of the seven food groups, with a scale of 0 to 7. The minimum dietary diversity (MDD) indicator was calculated using at least four of the seven food groups mentioned below: (1) staples (cereals/grains, roots, and tubers); (2) dairy products; (3) animal/flesh foods; (4) legumes and nuts; (5) vitamin A-rich fruits and vegetables; (6) eggs and (7) other fruits and vegetables [19]. The Ethiopia Demographic and Health Survey factors were used to create the Household Wealth Index, which is focused on household ownership of fixed assets, services, housing characteristics, and other factors [20]. Standard anthropometric procedures were used to measure the children’s height and weight [21]. The children’s heights were measured using a portable stadiometer. All of the children were told to take off their shoes and stand erect, with their heels, knees, buttocks, shoulders, and heads in contact with the stadiometer’s wall and their eyes straight ahead (Frankfurt plane) so that their line of sight was perpendicular to their bodies. The height was measured to the nearest 0.1 cm. A portable digital scale was used to measure the weight (Seca, Germany Model). The weight was registered to the nearest 0.1 kg. It was regularly calibrated against a known weight. During the training, a standardization exercise was conducted to capture technical measurement errors before the actual anthropometric data collection (TEM). The children wore light clothes and removed their shoes for the procedure. Height for age Z-scores (HAZ), weight for height Z-scores (WHZ), and weight for age Z-scores (WAZ) were calculated using an anthropometric calculator. Moderately stunted, wasted, and underweight children had Z-scores of − 3 to − 2 SD in HAZ, WHZ, and WAZ [22]. The composite index of anthropometric failure was used to calculate the overall prevalence of under-nutrition in pre-school children (CIAF). The Nandy et al. model was used to divide CIAF into seven (7) groups. Group A (no failure), group B (waste only), group C (waste and underweight), group D (stunting, wasting, and underweight), group E (stunting and underweight), group F stunting only), and group Y (underweight only) (Tables 1), [23]. classification of composite index of anthropometric failure (CIAF)* *adapted from Nandy et al., 2005 Data was checked, cleaned, coded and entered into Epi-data 3.1 version and then it was exported to SPSS (version 21.0) for further analysis. The baseline difference in demographic and socio-economic characteristics between the two groups was examined using a chi-square test. A t-test was used to determine the mean difference in under-nutrition between the intervention and control groups. Generalized estimating equations (GEE) with a binary logistic function and exchangeable correlation structure, were used to determine the change in the difference in outcome between the intervention and control groups as well as the association of predictors with under-nutrition in children. Accordingly, the bi-variable GEE for socio- demographic and economic factors, water and hygiene habits, maternal and child health, and child feeding habits factors for child under-nutrition were fitted. All variables in the bivariable with a p-value of 0.25 were fitted into a multivariable GEE. Time and treatment interaction were used to determine the intervention’s effectiveness. The Adjusted odds ratio (AOR) with the corresponding 95% confidence intervals was reported to show the strength of the association. All analyses were conducted with the goal of considering the (ITT) concept. Variables with a p-value of less than 0.05 were considered statistically significant in multivariable analysis. For anthropometric data analysis, anthropometric indices were calculated by WHO Anthro software 3.2.2 using WHO child growth references. The z-scores of (< −2SD) were calculated to determine HAZ, WHZ and WAZ category of stunting, wasting and underweight, respectively. Finally, CIAF was computed from the above three anthropometric indices. Any child who has one of the six different types of anthropometric measurements is classified as having CIAF.
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