Background: Prior studies reported controversial results about the association between intestinal parasitic infections and childhood under-nutrition. We investigated the association of intestinal parasitic infections with under-nutrition among children aged 6-59 months in Boricha Woreda, Southern Ethiopia. Methods: This community-based prospective cross-sectional study was carried out from January 1-30, 2019 among 622 children aged 6-59 months. A two-stage stratified sampling procedure was used. Data were collected using a structured, face-to-face interviewer-administered questionnaire and standard anthropometric measurements. The stool specimens were collected using standard technique and examined for the existence and species of intestinal parasites using direct wet mount, Kato Katz and staining technique. We have entered data using Epi Data 3.1 and WHO Anthro software and all analyses were conducted using SPSS version 20. The descriptive analyses were done to find descriptive measures for the socio-demographic and other important variables. Multivariable logistic regression analysis was used to identify factors associated with under-nutrition. Adjusted odds ratios (AORs) with a 95% confidence interval (CI) were computed to assess the presence and strength of associations. Results: The total prevalence of intestinal parasitic infection was 48.7% (95% CI, 44.77-52.62). Approximately one-fourth (22%) of the children were infected with moderate intensity infections. Prevalence of stunting, underweight, wasting were 39.3, 24 and 11.6%, respectively. The prevalence of stunting among children infected with the intestinal parasite (59.4%) was significantly higher than the prevalence in non-infected children (20.6%) (p < 0.001). The absence of sanitation facility, living in medium and large family size, lack of shoes wearing practice, consuming raw vegetables and fruits were positively associated with intestinal parasitic infections. The presence of intestinal parasitic infections was positively associated with stunting (AOR = 2.18, 95% CI: 1.36-3.50) but not with wasting (AOR = 0.58, 95% CI: 0.3-1.13) and underweight (AOR: 0.92, 95% CI = 0.55-1.54). Conclusions: Under-nutrition and intestinal parasitic infections were serious public health concerns. Consolidating the prevailing water, sanitation and hygiene packages and routine deworming of children aged 6-59 months may aid to decrease the burden of both stunting and intestinal parasitic infection in children. Also, improving modern contraceptive methods utilization to reduce family size is recommended.
The study was conducted in Boricha Woreda of Sidama regional state, Southern Ethiopia. The Woreda is located 305 km from Addis Ababa, the capital of the country. It is also 32 km from Hawassa, the capital of Sidama regional state. Based on the central statistical agency report of Ethiopia, the population of the Woreda was projected to be 450, 260 (4.16% urban and 93.84% rural). Of these, 13.94% were children in the age group of 6–59 months. The Woreda has consisted of 04 urban and 39 rural Kebeles. The elevation of the Woreda extends between 1501 to 2265 m above sea level and categorized into dual agro-ecological regions. The Lowlands share for 65% of the inhabitants while Midlands share for the left 35% of the residents. Based on the time of year, temperature differs from 15 to 35 °C and the average rainfall is 900 mm per year. The highest rainy period is ranged in early June and late October. The physical health service coverage of the Woreda was 90%. The Woreda has merely 1-government primary hospital, 10 health centres, 39 health post and 8 private clinics. The most common type of toilet facility in both urban and rural households was a pit latrine without a slab or open pit [13]. Farming is the major source of income-generating activity. The main crops grown in the area are enset (false banana), barely, khat, broad beans, cereals, and coffee. Unimproved drinking water source, poor hygienic condition and frequent drought in the Woreda results in a high burden of the under-nutrition and intestinal parasites [23]. Poor hygiene-related diseases, like acute watery diarrhoea and intestinal parasites, are among the leading causes of childhood morbidity and mortality [13]. This community-based prospective cross-sectional study was conducted from January 1–30, 2019. The source and study population were all children in the age group of 6–59 months with their caregivers and all systematically selected children in the age group of 6–59 months with caregivers who resided in the Woreda for 6 months, respectively. The children whose parents/caregivers resided less than 6 months in the Woreda, children who had serious diseases, and treated last 1 month before the survey for any illness were excluded from the study. The adequate sample size was estimated using a single population proportion formula in Epi Info TM 7 statistical package with the inputs of the proportion (p) of intestinal parasites (52.3%) was received from a previous study [24], 95% confidence level and 5% margin of error. As a two-stage sampling method was utilized to select the study children, a design effect of 1.5 was accounted, and a 10% compensation for non-response rate was considered. Thus, the final calculated sample size was 634. A two-stage stratified sampling method was utilized to select representative study participants of this study. Firstly, we utilized a simple random sampling method to select representative kebeles from the Woreda. Secondly, we have utilized a systematic sampling method to select the study subjects. In Woreda, there are 43 Kebeles and eight kebeles were selected by using a simple random sampling method. Households (HHs) with 6–59 months aged children were distinguished by the house-to-house census and sampling frame which comprised of lists of HH in the selected kebeles was prepared. The total number of children aged 6–59 months who were eligible for the study were 8482 in the selected kebeles. Initially, the total sample size was allocated to the kebeles proportional to their population size. The calculated sample interval (K = N/n) was determined to be 14. Finally, the study children were selected using a systematic sampling strategy with a sampling interval of 14. The first child was selected by using a simple random sampling technique. Then, consecutive children were selected at a regular interval of the 14th HH until the needed sample size obtained. If a child was lacking from the HH for three sequential visits and there were no other alternatives, the next adjacent child was included. One child was included by using simple random sampling method when a twin or more than one child age group between 6 and 59 months found in the selected HHs. All children were provided with a unique identifier to be recognized during the stool examination and anthropometric measurements. The outcome variables were nutritional status and intestinal parasitic infection. The independent variables were socio-demographic variables such as age, sex, religion, ethnicity, family size, wealth status, maternal or paternal education status, occupation status, marital status and media availability and accessibility; environmental factors such as the source of drinking water, types of sanitation facility, availability of solid waste disposal site, types of house and numbers of separate rooms; health-seeking behaviour such as personal hygiene practices, the technique of water treatment, handwashing practices, playing with soil, practice of eating raw fruits and vegetables and shoes wearing status; health service availability; dietary diversity score of the children and HH food insecurity status. The data collection was run by 8 diploma nurses, 2 laboratory technicians and 8 community health worker data collectors. Two health officers carefully supervised the data collection procedure. Dietary diversity of the children was evaluated using the children’s Dietary Diversity Score tool (questions) of the Food and Agriculture Organization (FAO). The parents/caregivers were asked whether the children ate from seven standard food groups in the preceding day of the survey without putting the smallest consumption limits. Finally, dietary diversity score (DDS) was calculated out of the total score of seven and classified into inadequate or low ( 4) [25]. The mid-upper arm circumference (MUAC) was measured following standard methods. MUAC indicators less than 11 cm indicates Severe Acute Malnutrition (SAM), between 11 and 12.5 cm indicates Moderate Acute Malnutrition (MAM), between 12.5–13.5 cm indicates mild malnutrition and above 13.5 cm indicates that the child is well nourished [1]. Food insecurity status was assessed by asking parents/caregivers from nine occurrences and frequency question of food insecurity. Based on the household food insecurity access prevalence (HFIAP) indicator, the households were categorized into four levels of household food insecurity (access): foods secure, mild, moderately and severely food insecure. Households are categorized as increasingly food insecure as they respond affirmatively to more severe conditions and/or experience those conditions more frequently [26]. All parents/caregivers were instructed by health extension workers (HEWs) to bring their children to the health posts. First, the parents/caregivers were told to bring about small fresh stool specimen of the child on the spot. In the process of stool examination, a simple and standard microscope (40X) known as Olympus was used. The stool samples were observed microscopically for the existence of eggs, trophozoites or cysts by using the direct wet mount, Kato Katz and staining technique to diagnose potential intestinal parasites. Infection intensity was estimated by averaging eggs per gram (epg) of faeces on both slides [27]. Finally, two laboratory technicians read each prepared slides, both of them blind for recheck purpose. The anthropometric data of children were collected by using the measurement of age, height/length and weight. Height was measured using a measuring board and weight was measured using a SECA scale by appropriately trained nurses. Data collection was conducted in a stepwise manner in each kebele in their respective schedule. The weight of each child was taken with minimal clothing, without shoes, and with empty pockets. Measurement of height was done without shoes; to the nearest 0.1 cm. The raw anthropometric data of the studied children were converted to nutritional indicators using WHO Anthro Software (WFH) or Z-score by considering sex. Direct microscopic evidence of one or more parasites. Means HFA is below − 2 SD of the reference population while below − 3 SD indicates severe stunting. Means WFA is below − 2 SD of the reference population while below − 3 SD indicates severe underweight. Means WFH is below − 2 SD of the reference population while below − 3 SD indicates severe wasting. Is defined as an overall number of family members existing in the HH. Family size is categorized as small when it is 8. The data were collected using a structured, face-to-face interviewer-administered questionnaire and standard anthropometric measurements (Supplementary file 1). Initially, the study tool (questionnaire) was prepared in English language. Then, it was converted into Sidamic language. Lastly, it was retranslated back to English to retain its accuracy and consistency. The evaluation was conducted to consider the consistency and accuracy of the two types of study tool. The pre-test was conducted on 5% of samples in kebeles other than actual study area. At that time, any inconsistency and non-accuracy were adjusted so. The data of the pretest analysis was not used for the final sample of our study. The training was provided for data collectors and supervisors by the principal investigators for 2 days. The training was aimed at the study objective, methods and data collection procedure. Moreover, regular checkup for incompleteness, non-accuracy and inconsistency of the data were made daily. Data were entered into Epi Data 3.1 and WHO Anthro software and analyzed using SPSS version 20. All needed variables recording and calculations were carried out earlier to the major analysis. The descriptive analyses were done to find descriptive measures for the socio-demographic and other important variables. The chi-square(X2) test was utilized to describe the association between independent and dependent variables. A cross-tabulation was utilized to assess the main assumption of chi-square. Sensitivity analysis was carried out to consider the influence of missing data by using multiple imputation methods. Principal Component Analysis (PCA) was conducted in the calculation of the wealth index. Wealth index was computed as a composite indicator of living standard based on 25 variables associated to possession of carefully chosen household assets, the scale of agricultural land, number of livestock, supplies utilized for house building, and ownership of improved water and sanitation facilities. The analysis generated a summary score that explained 65.1% of the variability of the data and the score was finally ranked into five categories such as lowest, second-lowest, middle, second-highest and highest. Bi-variable and multivariable binary logistic regression analyses were used to identify factors of under-nutrition. The bi-variable logistic regression analysis started with unadjusted analysis in which every possible factor was evaluated independently for its relationship with under-nutrition. The variables with p-values 0.1 and variance inflation factor (VIF) was < 10 which indicates no evidence of multicollinearity. The fitness of the binary logistic regression model was also assessed in the model using the Hosmer-Lemeshow statistic (0.85). The existence and strength of association among independent variables and under-nutrition were evaluated using adjusted odds ratios (AORs) with a 95% CIs. A statistically significant association was confirmed when the 95% CI of the (AORs) did not contain 1.
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