Prevalence of Acute Malnutrition and Associated Factors among Children aged 6–59 months in South Wollo Zone, East Amhara, Northeast Ethiopia: a Community-based cross-sectional study

Abstract

Objective

The aim of this study is to determine the prevalence of acute malnutrition and associated factors in South Wollo zone, East Amhara, Northeast Ethiopia.

Design

A community-based cross-sectional study was conducted among 504 children aged 6–59 months who were selected by using a multistage sampling technique. The mid-upper-arm-circumference and Z-scores for weight-for-height were used to determine the nutritional status of the participants. A semi-structured interview questionnaire was used to collect the data. Then data was entered into EpiData V.3.1 and exported to SPSS software V.25 for analysis. Binary logistic regression was used to identify factors associated with acute malnutrition and variables with p value<0.05 were declared as statistically significant.

Setting

The study was conducted in South Wollo zone, Northeast Ethiopia from 1 August 2020 to 30 September 2020.

Participants

Children aged 6–59 months with their mothers were the study subjects.

Results

The prevalence of acute malnutrition among children aged 6–59 months was 31.0%. Child aged 6–11 months (adjusted OR (AOR)=3.92; 95% CI: 1.74 to 8.82), illiterate mothers (AOR=3.01; 95% CI: 1.92 to 7.01), single mother (AOR=3.06; 95% CI: 1.32 to 7.07), lack of latrine (AOR=2.39; 95% CI: 1.12 to 5.11), diarrhoea (AOR=4.18; 95% CI: 2.02 to 8.65), respiratory tract infection (AOR=2.31; 95% CI: 1.08 to 4.94), family size (≥5) (AOR=3.29; 95% CI: 1.53 to 7.09) and cessation of breast feeding before 2 years (AOR=3.79; 95% CI: 1.71 to 8.23) were the independent predictors of acute malnutrition.

Conclusion

Acute malnutrition is highly prevalent in the study area which is more than the national figure. Thus, improving maternal education, access to the latrine, improved breastfeeding practice, improved family planning usage and early detection and treatment of diarrhoea and respiratory tract infections will enhance children’s nutritional status. In addition, nutritional diversity education needs to be strengthened.

Strengths and limitations of this study.

• Trained BSc nurse professionals were involved in data collection and anthropometric measurement process with strict follow up.

• We used WHO standard malnutrition screening tools to assess the prevalence of acute malnutrition.

• In addition, we used WHO Anthro 2010 software to calculate weight for height indicator.

• Only anthropometric measurement methods like mid-upper-arm-circumference and weight-for-height are used to investigate acute malnutrition; clinically wasted infants with symptoms such as pitting oedema, and other signs may not be included.

Introduction

Malnutrition is a major contributor of child mortality in the world particularly in developing countries.¹ Globally, there are over 50 million wasted children under the age of 5 years, with nearly 17 million being severely wasted.² More than half of all child deaths were directly or indirectly related to malnutrition and the majority of the deaths occur within the first year of life.³

Acute malnutrition is a serious public health problem in Africa, where prevalence rates range from 7.0% to 35.1%.^{1 4} Studies revealed that malnourished children face a number of physical and cognitive problems throughout their lives as a result of macronutrient and micronutrient deficiencies. Poor cognitive development in children, particularly in the first thousand days of life increases the risk of poor neurological development, poor academic performance, early school dropout and low-skilled employment.⁴

The most frequently cited causes of malnutrition by various scholars included maternal illiteracy,^{5 6} low maternal age,⁷ large family size,^{8 9} low socioeconomic or low family monthly income,^8–10 child diarrhoea,^{8 11} early initiation of complementary feeding^11–13 and shorter birth intervals.¹³

In collaboration with UNICEF and the World Bank, Ethiopia has created a number of measures to lower malnutrition to 4% by 2025. These include the Seqota Declaration Road Map and Innovative Phase Plan, 2015; the Food and Nutrition Policy of Ethiopia, 2018; the National Food and Nutrition Strategy; the Food and Nutrition Council and Agency Establishment Proclamation; and the Community-Based Nutrition Programme.¹⁴ In addition, increasing nutrition advocacy, communication and social mobilisation were actively used to promote healthy private and public behaviour related to nutrition and to better the understanding of nutrition concerns among policymakers and the general public. However, the aforementioned method has not led to a progressive decline in acute malnutrition.¹⁴ As a result, the primary goal of this study is to investigate the prevalence of acute malnutrition and associated factors among children aged 6–59 months in South Wollo zone, East Amhara, Northeast Ethiopia.

Methods and materials

Study design, period and setting

A community-based cross-sectional study was conducted in five districts of South Wollo zone, Amhara regional state, Northeast Ethiopia, from 1 August 2020 to 30 September 2020. These five (Legambo, Delanta, Ambassel, Dessie Zuria and Kutaber) districts have 137 kebeles, of which 41 kebeles were selected in this study.

Study participants and sampling procedure

Children aged 6–59 months with their mother in the defined areas were included in the study. However, children who showed indicators of a serious disease were excluded in the study. From a total of 20 districts, 5 districts (Legambo, Delanta, Ambassel, Dessie Zuria and Kutaber) were chosen by lottery method. In each designated district, 30% of kebeles were chosen. Each kebele’s health extension workers provided the number of households along with their home number. A single population proportion formula was used to calculate the sample size by using the assumptions prevalence (p) of 18.2% which was taken from the study done in Dabat district,¹⁵ a 95% CI, and a 5% margin of error (d). It was decided to employ a multistage sampling method. As a result, the authors have used a design effect of 2 and using a 10% none response rate, the final sample size was 504.

Operational definition

Acute malnutrition

Acute malnutrition is indicated by weight-for-height/length less than −2 SD and by a mid-upper-arm-circumference (MUAC) less than 12.5 cm.

Patient and public involvement

No patient involved in the study design.

Data collection tools and procedures

A semi-structured tool that was adopted from the Ethiopian Public Health Institution from Ethiopia Demographic and Health Survey 2016 was used to gather the data.¹⁶ The tool addresses the maternal and child socio-demographic parameters, environmental healthcare and nutritional determinants. The English version questionnaire was translated into Amharic and then back into English for checking its consistency. The pretest was carried out on 5% of the sample size at a different location, and the results were used for tool amendment. Mothers and children were asked before data collection to ensure their informed consent and assent, respectively.

Weight

UNISCALE was used to take measurements by removing heavy clothing and standing barefoot; calibrating the weight scale at 0; and double-checking the weight. For children under the age of 2, the mother and child were weighed together and the mother’s weight was subtracted to get the child’s weight. The mother informed us of the child’s age.

Height

The following measurements were obtained: length for children under the age of 2 years was taken with an infant metre, height for children beyond the age of 2 years was measured with a stand metre, shoes were removed and hair was compressed.

The selected districts have 137 kebeles of which 41 kebeles were selected by simple lottery method. Proportional sample size allocation was obtained in each kebeles based on their population size. A total of 504 mother–child paired samples were selected from selected kebeles. Then a systematic random sampling method was conducted to select households based on each house number. When the selected households have no child aged 6–59 months, we jumped to the next household and extended the interval. The selected household child, aged 6–59 months, could not be obtained during the data collection; hence the data was returned the next day. When a family had more than one child, only one was chosen by lottery.

The data collectors and supervisors were chosen based on their acquaintance with the study area, ability to communicate in the local language and willingness to engage in the research and then trained them about study objectives. In this study 10 BSc nurse data collectors and 5 supervisors were appointed to measure anthropometric and data collection simultaneously.

At the time of data collection, the completeness and consistency of each respondent’s questionnaire were verified. Participants’ data was handled with extreme caution and confidentiality.

Data processing and analysis

The data was cleaned, coded and entered using EpiData V.3.1 before being sent to SPSS software V.25.0 for analysis. An anthropometric measurement was carried out by both weight-for-height/length Z-score (WHZ) and MUAC. Weight for height/length was calculated by the WHO Anthro 2010. To describe the study population in relation to key factors, descriptive statistics were used. The association between factors associated with the occurrence of acute malnutrition was determined using OR. All variables with a p value<0.25 significant correlations in the bivariable analysis were included in the final multivariable model. Then variables in the multiple regression models with p values<0.05 are known as independent variables.

Results

Maternal socio-demographic characteristics

There were 504 mothers interviewed in total, with a 100% response rate. The respondents (mothers) were between the ages of 15 and 49 years; with a mean age of 28.72 years (±5.029 SD years). The majority of the 272 (54.0%) mothers were between the ages of 20 and 29 years, while 32 (6.3%) mothers were under the age of 20 years. Among 504, 474 (94%) mothers were married and 438 (86.9%) mothers have formal education. In terms of employment status; 420 (83.3%) of the mothers were housewives, whereas 84 (16.7%) mothers were government employees (table 1).

Table 1.

Socio-demographic characteristics of 6–59 months aged children mothers in South Wollo zone, Northeast Ethiopia, 2020

Variables	Category	Frequency	Per cent
Age of mother (years)	<20	32	6.3
	20–29	274	54.4
	30–39	178	35.3
	40–49	20	4.0
Marital status	Married	422	83.7
	Single	82	16.3
Educational status	Literate	438	86.9
	Illiterate	66	13.1
Employment status	House wife	420	83.3
	Government employee	84	16.7
Family monthly income	<1254 ETB	388	77.0
	≥1254 ETB	116	23.0

ETB, Ethiopian birr; single, single and separated and widowed.

Child socio-demographic characteristics

The mean age of the children was 25 months with an SD of ±12 months. Majority, 240 (47.6%), of the children were between the age of 24 and 59 months. Two hundred and sixty-six (52.8%) children were girls. A month before the interview 88 (17.5%) and 80 (15.9%) of the children were affected by diarrhoea and respiratory tract infection (RTI), respectively. The majority of mothers, 402 (79.8%), began breast feeding as soon as their child was delivered. However, 51 (20.2%) mothers provided prelactation food or water to their child before they started breast feeding (table 2).

Table 2.

Characteristics of children 6–59 months age in South Wollo zone, Northeast Ethiopia, 2020

Variables	Category	Frequency	Per cent
Age of the child (months)	6 to <11 months	88	17.5
	12 to 23 months	176	34.9
	24 to 59 months	240	47.6
Sex	Male	238	47.2
	Female	266	52.8
Birth interval of the child	<2 years	290	57.5
	≥2 years	214	42.5
Family size per house	<5	346	68.7
	≥5	158	31.3
Number of under 5-year children per household	<2	364	72.2
	≥2	140	27.8
Took vitamin A	Yes	400	79.4
	No	104	20.6
Immunised based on child age	Yes	460	91.3
	No	44	8.7
Diarrhoeal diseases	Yes	88	17.5
	No	416	82.5
Respiratory tract infection	Yes	80	15.9
	No	424	84.1
Child fed by whom	Caregivers	84	16.7
	Mothers	420	83.3
Complementary feeds started	<6 months	84	16.7
	≥6 month	420	83.3
Cessation of breast feeding	<2 years	58	11.5
	≥2 years	446	88.5
Feeding per day	<6 times	154	30.6
	≥6 times	350	69.4
Feeds before breast feeding	Yes	64	12.7
	No	440	87.3
Types of feeds before breast feeding	Water only	24	4.8
	Glucose	36	7.1
	Butter	42	8.3
	Only breast feeding	402	79.8

Environmental and maternal obstetrics health-related characteristics

The two main sources of drinking water for households were 170 (33.7%) protected springs and 334 (66.3%) public taps. In terms of toilet facilities, 398 (79%) of houses had latrines, which were most usually used, and virtually all households washed their hands after using the toilet. According to study participants, agriculture is the primary source of food. During pregnancy, 466 (92.5%) of mothers went to a health facility for antenatal care (ANC) service. Among those surveyed, 410 (61.5%) and 22 (4.4%) had visited ANC for the fourth and first times, respectively (table 3).

Table 3.

Environmental and maternal obstetrics health-related characteristics of children aged 6–59 months in South Wollo zone, Northeast Ethiopia, 2020

Variables	Category	Frequency	Per cent
Availability of latrine	Yes	408	80.6
	No	98	19.4
Food source of parents	Farmer	422	83.7
	Donated	82	16.3
Water source of the mother	Public tap	334	66.3
	Protected spring	170	33.7
Has antenatal care	Yes	466	92.5
	No	38	7.5
Mothers had number of antenatal care	First visit	22	4.4
	Second visit	14	2.8
	Third visit	120	23.8
	Fourth visit	310	61.5

Acute malnutrition of the children aged 6–59 months

The overall prevalence of acute malnutrition among children aged 6–59 months was 31.0% (95% CI: 27.0% to 35.1%). Acute malnutrition by MUAC and WHZ-score is displayed by figure 1 below.

Figure 1.

Acute malnutrition of children aged 6–59 months in the South Wollo zone of Ethiopia, based on MUAC and Z-score, in 2020. The extent of acute malnutrition evaluated by mid-upper-arm-circumference (MUAC), Z-scores for weight-for-height-score and children falling under both MUAC<12.5 cm and Z-score less than –2 SD is shown in the graph above.

Factors of acute malnutrition

Children aged 6–11 months were approximately four times more likely to be acutely malnourished (adjusted OR (AOR)=3.92; 95% CI: 1.74 to 8.82) than children of other age categories. Children with a mother who did not have a formal education were roughly three times more likely to be acutely malnourished (AOR=3.01; 95% CI: 1.92 to 7.01) than children with a mother who had a formal education. When compared with children with a married mother, those with a single mother had three times higher risk of being acutely malnourished (AOR=3.06; 95% CI: 1.32 to 7.07). Children whose mothers did not have access to a latrine were more than two times more likely to be acutely malnourished than children whose mothers did have (AOR=2.39; 95% CI: 1.12 to 5.11). Children who had diarrhoea within the previous 30 days had four times higher risk of being acutely malnourished than those who had not (AOR=4.18; 95% CI: 2.02 to 8.65). A child’s likelihood of being acutely malnourished increased by 2.3 times if they had an RTI for the last 30 days (AOR=2.31; 95% CI: 1.08 to 4.94). Children who live in a large family (≥5 people) were three times more likely to be acutely malnourished than those who live in a small family size (AOR=3.29; 95% CI: 1.53 to 7.09). Acute malnutrition was nearly four times as common in children who stopped nursing before age 2 compared with those who did so at age 2 or later (AOR=3.79; 95% CI: 1.71 to 8.23) (table 4).

Table 4.

Associated factor of acute malnutrition among children aged 6–59 month in South Wollo zone, Northeast Ethiopia, 2020

Variables	Acute malnutrition (wasting)		COR (95% CI)	AOR (95% CI)
	Yes	No
Age of the child in months
6–11	28	60	5.76 (2.98 to 11.11)	3.92 (1.74 to 8.82)*
12–23	14	162	1.07 (0.52 to 2.21)	1.31 (0.57 to 3.01)
24–59	18	222	1	1
Marital status of the mother
Single	20	62	3.08 (1.69 to 5.61)	3.06 (1.32 to 7.07)*
Married	40	382	1	1
Educational status of the mother
Illiterate	20	46	4.33 (2.33 to 8.02)	3.01 (1.29 to 7.01)*
Literate	40	398	1	1
Maternal employment status
Government employee	22	62	3.57 (1.98 to 6.43)	2.90 (0.82 to 4.07)
Housewife	38	382	1	1
Had latrine
No	26	72	3.95 (2.24 to 6.98)	2.39 (1.12 to 5.11)*
Yes	34	372	1	1
Family water source
Protected spring	22	141	1.86 (1.49 to 2.51)	0.83 (0.39 to 1.79)
Public tap	38	296	1	1
Family food source
Donation	18	76	2.08 (1.13 to 3.80)	1.52 (0.67 to 3.45)
Farming	42	368	1	1
Cessation of breast feeding
<2 years	24	34	8.04 (4.31 to 15.00	3.76 (1.71 to 8.23)*
≥2 years	36	410	1	1
Birth interval
<2 years	36	254	2.12 (1.641 to 3.94)	0.56 (0.27 to 1.13)
≥2 years	24	190	1	1
Family size
≥5	28	130	2.11 (1.22 to 3.65)	3.29 (1.53 to 7.09)*
<5	32	314	1	1
The child had diarrhoea
Yes	36	52	3.96 (2.22 to 7.07)	4.18 (2.02 to 8.65)*
No	24	346	1	1
The child had RTI
Yes	18	62	2.64 (1.43 to 4.88)	2.31 (1.08 to 4.94)
No	42	382	1	1

*P value<0.05, respiratory tract infection (RTI), single, divorced+widowed+unmarried.

AOR, adjusted OR; COR, crude OR.

Discussion

This study revealed that 31.0% of children aged 6–59 months have acute malnutrition. This finding is lower than the study in Somalia region, Ethiopia 42.3%,⁴ a study in Gambella region, Ethiopia 37.1%¹⁷ and another study in Khyber Pakhtunkhwa, Pakistan (46%).¹⁸ The reason could be implementation of the Health Extension Program enhances the community’s feeding programmes of children that might lower the prevalence of acute malnutrition among children.

However, the finding is higher than study in Dabat district, Amhara region (18.2%),⁷ a study in Tahtay Adiyabo Woreda, Tigray region (17.8%),⁹ a study in Bure town, Amhara region (11.1%),⁸ a study in Lalibela town, Amhara region (8.9%),¹⁹ a study in Debre Tabor town, Amhara region (7.6%),²⁰ a study in Gursum district, Somali region (21.2%)²¹ and the national report in Ethiopia 7%.⁹ Different definitions of acute malnutrition could be the cause of the discrepancies between the current study and the earlier investigations. In contrast to other research, which solely used either MUAC or WHZ-score approach to define acute malnutrition, the current study measures acute malnutrition by both MUAC and WHZ-score values of <12.5 cm and less than –2 SD, respectively.

This result was consistent with research conducted in Hawassa Zuria, South Ethiopia (28.2%)⁹ and in Nigeria (35.1%).²² The possible explanations might be due to the use of similar study design and the presence of similar socioeconomic characteristics between study populations. A similarity with the later study could also be due to applying a similar definition for acute malnutrition to both MUAC and WHZ-score.

A significant number of children within age group 6–11 months have been acutely malnourished in this study which was similar to a study conducted in India.²³ The reason for this could be that, this age is the time of complementary feeding commencement. However, parents may not provide enough food to their child to meet their child’s needs.

Children who had RTI in the last 30 days were at a higher risk of acute malnutrition. This is supported by a study conducted in Bure town, west Gojjam zone Ethiopia.⁸ This could be children who are affected by RTI (tuberculosis) were most likely to experience poor appetite which in turn leads to acute malnutrition.

Children who had diarrhoea 30 days prior to the study have a higher risk of developing acute malnutrition than those who did not have. This is in line with a study in Gursum district, Somali region,²¹ a study in Gambella region, Ethiopia,¹⁷ a study in Lalibela town, Amhara region,¹⁹ a study in Hawassa Zuria, South Ethiopia⁹ and a study in Jimma, Oromia, Ethiopia.²⁴ This might be explained by the fact that the children who suffered from diarrhoea were most likely to experience poor appetite which in turn leads to malnutrition.¹

Moreover children born from illiterate mothers are more likely to suffer from acute malnutrition. The finding was comparable to a study in India,^{25 26} a study in Somali region²¹ and a study in Gambella region, Ethiopia.¹⁷ This could be explained by the fact that educated mothers know more about their children’s health and nutrition. They can use health services more effectively, give better care and practice better hygiene than illiterate people.

Children whose mothers did not have access to a latrine had a higher risk of acute malnutrition. The finding was similar with a study in Pakistan,¹⁸ a study in rural Ethiopia²⁷ and a study in Afar Ethiopia.²⁸ The reason could be absence of a toilet in the house encourages open defecation and diarrhoeal illnesses. Open defecation and its associated poor environmental hygiene²⁹ and diarrhoeal illnesses ultimately cause acute malnutrition.³⁰

Acute malnutrition has been observed in children living with single mothers. The reason could be attributed to single mothers not having time or finances to properly care for their infants or they might lack knowledge of child nutrition.³¹ Additionally, children living with a large family (≥5) were at a higher risk for acute malnutrition. The finding is in line with a study in the Afar region,⁵ study in Gursum, Somali region²¹ and another study in Gambella region, Ethiopia.¹⁷ This is explained by the fact that a large family consumes a lot of food and parents might not be able to satisfy nutritional requirements for their child.

Acute malnutrition was significantly higher in children who ceased breast feeding before 2 years of age. The finding is similar with the study in Congo³² and a study in Nigeria.²² This might be due to the fact that breast milk is an important source of minerals and energy for children between the ages of 6 and 23 months.³³ As a result, children who stopped breast feeding before reaching 2 years of age will not be able to meet their energy need, which in turn leads to acute malnutrition.

Strength and limitations

This is a community-based study which truly quantified the magnitude (representative) of acute malnutrition of the South Wollo zone. However, since it is a cross-sectional study it does not show the incidence of the causal relationship. It also used only MUAC and weight-for-height to investigate acute malnutrition; clinically wasted infants with symptoms such as pitting oedema, and other signs may not be included.

Conclusion

Acute malnutrition was highly prevalent in the study area which is more than the national figure. Contributing factors found in this study were; maternal educational status, presence of latrine, child diarrhoea, child age, child RTI, family size and cessation of breast feeding. Thus, to reduce this problem the local government and other concerned bodies should improve maternal education, improve family planning usage and construct a common latrine. In addition, local health extension workers should provide health education to bring community behavioural change for better child feeding and caring practices to prevent and control common childhood illness.

Data availability statement

Upon a reasonabe request the data will be obtained from the crossponding author.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by Wollo University institutional review board (IRB) PCHN/IRB-38/2020. Participants gave informed consent to participate in the study before taking part.