Undernutrition and associated factors among urban children aged 24–59 months in Northwest Ethiopia: a community based cross sectional study

A community based cross-sectional study was conducted among children aged between 24 and 59 months in Aykel Town from January to February 2017. Aykel Town is located in Chilga district, Northwest Ethiopia about 780 km away from the capital city of Ethiopia, Addis Ababa. There are two kebeles (the smallest administrative unit in Ethiopia) in the Town and each kebele has four villages. The Town has one hospital, one health center and two urban health posts. It has a total of 4246 households and total population of 30,201 among which 16,498 (54.6%) are females. Of the total population, 1768 (6%) are preschool children. The people in this area are engaged in different activities such as farming, trade, civil servant, carpentering, and construction. They also produce cereals, legumes and spices and root crops, and keep animals, including goats, sheep and cattle [14].

All children aged 24–59 months with their mothers/caregivers in Aykel Town were the study population. All randomly selected children aged 24–59 months with their mothers/caregivers who lived in the Town for at least 6 months were included in to the study. Children who were seriously ill, with diarrhoea and /or malaria, and whose mothers’/care givers were unable to communicate were excluded from the study.

The minimum sample size was determined by using single population proportion formula. The prevalence of undernutrition in the specific age group (24–59 months) was used to calculate the sample size. The prevalence of stunting, wasting and underweight were 57, 16 and 25%, respectively [15]. Considering 95% confidence interval and 5% margin of error, the largest sample size was taken after sample size was calculated for the three indicators of under nutrition. The prevalence of stunting provided the largest sample size. Finally, a sample size of 416 was obtained after considering a 10% non-response rate.

Regarding the sampling procedure, both kebeles of the Aykel Town were included in the study. There were 4246 households in the two kebeles. The total number of households (1768) with children aged 24–59 months was obtained from the Health Extension Workers housing registration. Then households were sampled from each kebele based on proportional allocation. Finally, a systematic random sampling technique was used to select households with eligible children. The first household was selected by lottery method from the first four households by spinning a pen at the center of the Town. Where impossible to get preschool aged children, the next house was considered for the study. When there were more two or more children in the household, one of them was selected by lottery method.

Interviewer-administered questionnaire was used to collect data on socio-demographic and other relevant child and mothers/caregivers related information. To maintain its consistency, the questionnaire was first prepared in English and translated into Amharic, the local language of the study area, and then back translated to English. Six data collectors and two supervisors were involved in the data collection process. Two days training has been given for both data collectors and supervisors on areas related to anthropometric measurements and interview techniques. The questionnaire was pre-tested on 5% of the total sample size outside of Aykel Town. Based on the results of the pre-test, the acceptability and applicability of the procedures and tools were assessed. Necessary revisions were made on the questionnaire.

Early initiation of breastfeeding: Children who received breast milk within 1 h of birth [16]

Exclusive breastfeeding: Children who received breast milk exclusively up to 6^th months of life [16].

Continued breastfeeding at 1 year: Children 12–15 months of age who continued breast feeding after the age 1 year [16]

Introduction of solid, semi-solid or soft foods: Children who received solid, semi-solid or soft foods during the age of 6–8 months [16]

Minimum dietary diversity: Children 6–23 months of age who received foods from 4 or more food groups in the past 24 h [16]

Minimum meal frequency: Children from 6 to 23 months of age who received solid, semi-solid, or soft foods (including milk feeds for non-breastfed children) for at least three times per day in the past 24 h [16]

Continued breastfeeding at 2 years: Children 20–23 months of age who continued breast feeding after his/her 23 months of age [16]

Duration of breastfeeding: Median duration of breastfeeding among children less than 36 months of age [16]

Under-nutrition: Refers to a state/condition/ resulting from deficiency of one or more essential nutrients and manifested by stunting, wasting and underweight [17]

Stunting: Wasting: Underweight: Refer to a low height for age, weight for height and weight for age, respectively. The child was classified as stunted, wasted and underweight if his/her z score was less than −2SD; otherwise, he/she was considered as well-nourished (≥ − 2 Z score), based on international median of WHO reference value, taking sex into consideration [17].

Weight was measured with light cloths and no shoes by using beam balance in kilogram to the nearest of 0.1 kg. A vertical measuring board was used to measure the height of children. The child stands up on the board barefooted; have hands putting loosely with feet parallel to the body, and heels, buttocks, shoulders calve and back of the head touching the board. Child’s head was held straight comfortably with the lower border of the orbit of the eye being in the same horizontal plane as the external canal of the ear. The head piece of the measuring board was then moved gently, touching the hair and making contact with the top of the head. Height was read to the nearest 0.1 cm [17].

To determine the minimum dietary diversity score (DDS) of the child, the mother was asked to list all food items consumed by the child in the previous 24 h ahead of data collection. Then, the listed food items were grouped in to seven food groups. Namely grains, roots and tubers, legumes and nuts; Dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry and liver/organ meats); Eggs, Vitamin-A rich fruits and vegetables and Other fruits and vegetables. Considering the four food groups as the minimum acceptable dietary diversity, a child with a DDS of less than four was classified as poor dietary diversity [18].

Initiation of complementary feeding was measured as early initiation, timely initiation and lately initiation if the mother initiated complementary feeding to the index child before sixth month, at sixth month and after sixth months of age, respectively [16].

Appropriate hand washing practice is defined through 2 questions. The first question was as to when do mothers/caregivers wash their hands. The possible answers for this question were after defecation, after cleaning baby’s bottom, before food preparation, before eating, before feeding children (including breastfeeding). The second question was about how the mothers/caregivers wash their hands. The possible answers for this question were uses water, uses soap or ashes, washes both hands, rubs hands together at least three times, and dries hands hygienically by air-drying or using a clean cloth. A score of 9 points or more (out of a possible 10 points) qualifies a hand washing behavior as appropriate [19]. Wealth index of the household was constructed using household assets data via a principal component analysis to categorize the household wealth index in to lowest, middle, and highest.

Household food insecurity was measured using Household Food Insecurity Access Scale (HFIAS) measurement tools of FAO-FANTA. The HFIAS consists of 9 items specific to an experience of food insecurity occurring within the previous 4 weeks. Respondents were asked whether they had encountered the items because of lack of food or money to buy food in the last month. Each item was received either 1 for occurrence or 0 for non-occurrence. The frequency scores were ranged from 0 to 3, while 0 was the score for non-occurrence, 1 for rarely (once or twice in the past 4 week), 2 for sometimes (three to ten times in the past 4 weeks), and 3 for often (more than ten times in the past month), renamed as food secure, mildly food insecure, moderately food insecure, and severely food insecure, respectively [20].

Maximum efforts were made to maintain the quality of data. The measuring equipment was calibrated using a known weight material each day. At the end of every data collection day, each questionnaire was examined for its completeness and consistency by field supervisors and investigators and pertinent feedback was given to data collectors and supervisors.

Data was coded, cleaned, and entered in to Epi-Info version 3.5.3 and then exported to Statistical Package for Social Sciences (SPSS) version 20 for further analysis. Anthropometric measurements were converted into Z-sore values using WHO Anthro version 3.2.2 software for the indices; Height for- Age (HAZ), Weight-for-Height (WHZ) and Weight-for- Age (WAZ) taking sex into consideration using WHO 2006 standards. The child was classified as stunted, wasted and underweight if his/her z score was less than −2SD; otherwise, he/she was well-nourished (≥ − 2 Z score) [17]. Mean with standard deviation for continuous and proportion for categorical variables were calculated. Binary logistic regression model was used to identify factors associated with stunting, wasting and underweight. Variables which had a p-value of < 0.2 in the bivariable analysis were taken in to the multivariable analysis to control the possible effects of confounders. Adjusted odds ratio (AOR) with a 95% confidence interval (CI) was computed to assess the strength of the association. A p-value of < 0.05 was used to determine statistical significance in the multivariable analysis. The Hosmer and lemeshows goodness of fit-test was run to check the fitness of the final model for the three separate models.

Ethical clearance was obtained from Ethical Review Board of University of Gondar. An official permission letter was secured from Aykel Town administration health office. Participants were involved in the study on a voluntary basis after written consent, signed or verified by fingerprint was obtained. Parents/care givers of the children were informed about the study and written consent on behalf of the children were obtained from the parents. Privacy of the participants was protected and the information was kept confidential.

A total of 401 child-mother pairs were participated in the study, making a response rate of 96.4%. The mean (±SD) age of the children was 41.24 (±10.64) months, and the sex ratio of participants was almost equal (50.4, 49.6%). The majority of the mothers/care givers were married, 371(92.5%), and Orthodox Christians, 351(87.5%). More than half, 244 (60.3%), of the mother/care givers were housewives. Nearly one-third, 129 (32.2%), of the households had > 4 family size. Over three-fourth of the mothers, 324 (80.8%), and fathers, 305 (76%), were at least at their primary level of education (Table 1).

Almost all, 410 (99.8%), of the children were fully immunized. Eighty percent of the children were born at the health facility. Over three-fourth of the children, 323 (80.5%), had dietary diversity score less than four food groups. Majority, 354 (88.3%), of the mothers initiated breast feeding timely. Most of mothers didn’t practice pre-lacteal feeding, 341 (85%), but started complementary feeding at the 6^th month of age, 326 (81.3%) (Table 2).

Regarding household water source for domestic consumption, almost all, 398 (99.3%), of the participants reported that they used from protected source and were able to access water within 30 min walking distance. Most of the households had latrine, 397 (97.3%), and more than half of the respondents had good hand washing practice, 248 (61.8%) (Table 3).

Of the total children participated in the study, 28.4% were stunted, 10% wasted and 13.4% underweight. The prevalence of the mixed undernutrition was found to be 0.25% for both stunting and wasting, 8.23% for stunning and underweight, and 4.99% wasting and underweight.

This study has attempted to determine the magnitude and factors associated with undernutrition (stunting, wasting and underweight) among children aged 6–59 months in the urban community (Aykel Town), Northwest Ethiopia. However, it is without limitations. Firstly, the study did not include some information, like deworming, vitamin supplementation status, and nutritional status of mothers. Secondly, there might be a recall bias in responding for questions related to events happening in the past.