Prevalence of Malnutrition and Associated Factors among Under-Five Children in Pastoral Communities of Afar Regional State, Northeast Ethiopia: A Community-Based Cross-Sectional Study

Background. Malnutrition among children remains one of the most important causes of morbidity and mortality in the world. In Ethiopia, malnutrition is one of the most serious public health problem and the biggest in the world. This study aimed to assess the prevalence of malnutrition and associated factors among under-five children in pastoral communities of Afar Regional state, Northeast Ethiopia. Methods. A community-based cross-sectional study was conducted on 840 children aged 6-59 months from March 01-25, 2017. A multistage cluster sampling method was used to select the study participants. A structured questionnaire was used and anthropometric measurements were taken to collect data. EPI Data 3.1 and SPSS version 20.0 were used for data entry and analysis, respectively. Bivariate and multivariable logistic regression analysis was used to identify the factors associated with malnutrition. The statistical significance was declared at p value < 0.05 with 95% confidence intervals in the final model. Result. The study found the prevalence of wasting, stunting, and underweight was 16.2% (95% CI: 13.8-18.8%), 43.1% (95% CI: 39.8-46.5%), and 24.8% (95% CI: 21.9-27.8%), respectively. Family size (AOR = 2.72, 95% CI: 1.62-4.55), prelacteal feeding (AOR = 3.81, 95% CI: 1.79-5.42), and diarrhoea in the past two weeks (AOR = 4.57, 95% CI: 2.56-8.16) were associated with wasting. And sex of child (AOR = 1.98, 95% CI: 1.46-2.72), age of child ((12-23 months: AOR = 3.44, 95% CI: 2.24-5.29); (24-35 months: AOR = 3.58, 95% CI: 2.25-5.69); and (36-59 months: AOR = 4.42, 95% CI: 2.79-6.94)), and immunization status of child (AOR = 3.34, 95% CI: 1.31-4.81) were predictors for stunting. Moreover, mother's education (AOR = 4.06, 95% CI: 2.01-8.19), sex of child (AOR = 1.83, 95% CI: 1.29-2.94), prelacteal feeding (AOR = 2.81, 95% CI: 1.64-3.72), and immunization status of child (AOR = 3.17, 95% CI: 2.14-4.99) were significantly associated with underweight. Conclusions. This study indicated that child malnutrition was high among under-five children. Family size of five and above, receiving prelacteal feeding, and diarrhoea in the past two weeks were positively associated with wasting. Male child, increasing age of child, and not fully immunized child were positive predictors for increasing stunting. Maternal illiteracy, male child, prelacteal feeding, and not fully immunized child were factors affecting underweight. Promoting use of family planning, preventing diarrhoeal diseases, and vaccinating children integrated with the access of nutrition education programs are vital interventions to improve nutritional status of the children. The study was conducted in Dubti district located at a distance of 850 km from the capital, Addis Ababa, and 80 km from the regional capital, Semera, in Northeast direction of Ethiopia. The district has 13 kebeles (the smallest administrative units). The total population of the district was estimated to be 65,314, of which 34,870 and 30,444 are males and females, respectively, as projected from the 2007 census of the district [29]. Most of the pastoral community's income depends on animal breeding. The district has two public health centers, ten health posts, and two private clinics providing health services. The most common childhood illnesses in the district are malnutrition, diarrhoeal diseases, malaria, pneumonia, and measles [28]. A community-based cross-sectional study was conducted from March 01–25, 2017 in the district to assess the prevalence and associated factors with malnutrition among under-five children in Dubti district, Afar Regional State, Northeast Ethiopia, through door-to-door visits. Each child had 6–59 months of age and his/her mother/care giver was chosen by systematic random sampling method and involved in the study. All children aged 6–59 months old, and their mothers were the target for the study, whereas the study population consisted of a sample of all households with 6–59 months old children who were residing in the randomly selected kebeles. Those study participants who were residents of the study area for less than 6 months, children's mother who was seriously ill and difficulty to communicate, and children with physical deformities that hinder height measurements at the time of data collection were excluded from the study. Sample size was determined based on a single proportion population formula using z2 × p × q/d2 considering the following assumptions: 95% confidence level, estimated proportion (P) of wasting (19.5%), stunting (50.2%), and underweight (40.2%) taken from the previous EDHS report for Afar Regional State [22] and margin of error of 5%. Accordingly, the calculated sample size for prevalence of stunting was relatively largest (n = 384) and was taken as the sample size for this study. Considering design effect of 2% and 10% nonresponse rates, the final sample size was 844. A multistage cluster sampling method was used to enroll the study participants from the pastoral communities. First, six out of the thirteen kebeles were selected by lottery method. Next, the total number of 6–59 months old children in the selected kebeles was taken from the respective households using the registration at health posts. Then, the calculated sample size (844) was proportionally allocated to the selected kebeles based on the total number of households with 6–59 months children in each kebele. Finally, participants were selected using systematic random sampling technique after identifying the first household randomly and proceeded to the second participant based on the Kth interval. Whenever there were two or more 6–59 months old children, the youngest child was selected to avoid recall bias. The questionnaire was developed from the Ethiopian Demographic and Health Survey (EDHS) [22] and other relevant literatures based on the study objectives. The questionnaire was translated in to the local language, Afaraff, for data collection. The questionnaire consisted of socioeconomic and demographic factors, child feeding and caring practices, maternal health factors, environmental health related characteristics, and anthropometrics measurements. A structured-interviewer-administered questionnaire in a face-to-face manner was used to collect the data from mothers of children 6–59 months of age. Six health-extension workers for data and two BSc nurse supervisors who are fluent speakers of the local languages (Afaraff) including the principal investigator were involved in the data collection process. Prior to the interview, verbal informed consent was obtained from all participants after explaining about the objective of the study, and it was confirmed that the information will be kept confidential. Anthropometric measurements such as weight and height of children were taken using the standard anthropometric measurement procedures outlined in the measurement guide prepared by the Food and Nutrition Technical Assistance (FANTA) project in 2007 [30]. Body weight was measured using a weighing scale in light clothing with no jackets or coats, shoes, and additional clothing to the nearest 0.1 kg on a new calibrated portable scale. Height of children was measured using a portable stadiometer with no shoes; the shoulders, buttocks, and the heels touched the vertical stand with the head in Frankfurt's position to the nearest 0.1 cm. For children with 6–23 months of age, recumbent length and for children 24–59 months of age, standing height to the nearest 0.1 cm were measured. MUAC was measured by marking midway between shoulder tip and the elbow tip on the vertical axis of the upper arm with the arm bent at right angle and between the lateral and medial surface of the left arm [30, 31]. Age of each child was also collected from the mother and counter-checked using vaccination cards or other forms of informal recording. All anthropometric measurements were taken twice, and the average of the two measurements was calculated and recorded. The 2006 WHO Anthro 3.2.1 software was used to convert weight, height, and age of child (months) into height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) Z-scores to assess malnutrition taking sex in to consideration. Anthropometric classifications were based on global standards: <−3 SD, <−2 SD, and ≥−2 SD. Children with HAZ, WAZ, and WHZ below −2 SD of the median of reference population were considered as stunted, underweight and wasted, respectively. Children with HAZ, WAZ, and WHZ below −3 SD were also considered as severely stunted, wasted, and underweight, respectively. Moreover, these variables were considered as the dependent variables during statistical analysis. The dichotomous variables stunting, underweight, and wasting were defined as 1 = for stunted and 0 = for not stunted, 1 = for underweight and 0 = for not underweight, and 1 = for wasted and 0 = for not wasted, respectively [16, 32]. Child feeding practices such as exclusive breastfeeding (EBF) were understood as feeding a child only breast milk without anything else for the first six months of life, with the exception of medicines for therapeutic purpose [33]. A 24-hour recall method (from sun rise to sun rise) was used to assess dietary diversity practices. This was based on the mother's recall of foods given to her child in the previous 24 hours prior to the interview date. Then, minimum dietary diversity was estimated using information collected from the 24-hour dietary recall. Minimum dietary diversity was fulfilled if a child had received food from four or more food groups from the seven WHO food groups in the last 24 hours preceding the survey [34]. The seven food groups used included were grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, and cheese); flesh foods (meat, fish, poultry, and liver/organ meats); eggs; vitamin-A rich fruits and vegetables; and other fruits and vegetables. Moreover, minimum meal frequency was fulfilled if breastfed child with the of age 6–8 months and 9–59 months received a minimum of two or three meals with one to two snacks and three or four meals with one to two snacks per day, respectively [33, 34]. Food security status of the households was determined based on nine standard Household Food Insecurity Access Scale (HFIAS) questions that were developed for this purpose by Food and Nutrition Technical Assistance (FANTA). The respondents were asked about the amount and variety of meal eaten and the occurrence of food shortage for the household members, causing them not to eat the whole day or eat at night only, in the past four weeks before the survey. Then, food-secure households were coded “1” and food-insecure ones “0” for further analysis [35, 36]. Child immunization status of children (full, partial, or never) was also checked by observing the immunization card, and if not available, mothers were asked to recall it. BCG vaccination was checked by observing scar on right (also left) arm. To ensure data quality, the English version questionnaire was translated into the local language Afaraff and then back to English to maintain its consistency. Pretest was conducted on 42 subjects (5% of the sample) in kebeles not in the study for necessary modification. Two-day training was given to the data collectors and supervisors before the actual date of data collection. Continuous supervision was done by the supervisors and principal investigator on daily bases. Data entry and analysis was done using EPI data 3.1 and SPSS version 20.0, respectively. Anthropometric indices were calculated using the 2006 WHO Anthro 3.2.1 Software. Descriptive analysis was used to describe the percentages and frequency of sociodemographic characteristics and other relevant variables in the study. Bivariate and multivariable logistic regression analysis was used to identify the factors associated with child malnutrition. Both crude and adjusted odds ratios together with their corresponding 95% confidence intervals were computed to see the strength of association between the outcome and independent variables. All independent variables that were associated with the outcome variables (wasting, stunting, and underweight) in bivariate analysis (with p value < 0.20) were included in the final multivariable logistic analysis. A p value of < 0.05 was considered to declare the result as statistically significant. The Hosmer–Lemeshow test was performed for model fitness in the final model, and p value > 0.05 was considered a good fit. The result was presented in text, tables, and graphs based on the types of data. Ethical clearance was obtained from the College of Health Sciences of Samara University, Research and Ethical Review Committee (RERC). Then, officials at different levels in the study area were communicated through letters from Afar National Regional Health Bureau. Letters of permission were obtained from district administrative and health offices. Verbal informed consent was obtained from each participant prior to the interview after explaining the purpose of the study.