Prevalence and socio-demographic factors associated with undernutrition among HIV-positive women of reproductive age in Mahama refugee camp, Rwanda

Abstract

Background

Despite the distribution of food rations, the existence of feeding programs, and the provision of free medical care, malnutrition and morbidity continue to pose a threat to women and children, who are the most nutritionally susceptible groups, especially during emergencies. When people consume less energy and nutrients than they require to maintain their health, it is called undernutrition. Undernutrition is still a major public health issue in many low- and middle-income countries, including Rwanda, despite significant advancements. Women and children are the most nutritionally susceptible groups, especially during emergencies. In Ethiopia, 38% of children are stunted, and 27% of nursing mothers are underweight or malnourished. However, during emergencies, such as war, the problem of undernutrition gets worse. Therefore, this study sought to determine the prevalence and the sociodemographic factors associated with undernutrition in HIV-infected women of reproductive age in Mahama refugee camp, Rwanda.

Methods

This was a cross-sectional study of 170 women selected by a simple random sampling technique using Yemane’s formula. A structured interviewer-administered questionnaire was used to elicit data. Undernutrition, the main study outcome, was assessed using BMI and MUAC. Data analysis was done using IBM SPSS version 25 and presented as charts and tables. P < 0.05 was taken as statistically significant.

Results

Most women fell in the age bracket of 40–49 years, most were Christians, and the majority were married, according to our study. In addition, a 25% prevalence of undernutrition, 74.7% of no thinness and 3.5% of severe thinness was revealed. Most women were unemployed and stayed in a household of less than 5 persons. Majority of the women earned below the poverty income line, and most utilized several loan shark schemes. Further analysis stated that only women with non-formal and primary levels of education were 3 times more at odds to be undernourished (p < 0.001, aOR: 3.06, CI: 1.32–7.10).

Conclusions

Out of the sampled women, 25% were undernourished, and 3.5% had severe thinness. The sociodemographic predictor of undernutrition among HIV-infected women of reproductive age at the refugee camp was non-formal and primary levels of education. Therefore, the authors recommend that public-private partnerships introduce a basic schooling system at the camp that promotes health education, promotion and skills.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28094-6.

Introduction

HIV infection is a global public health emergency, especially in areas where undernutrition is a major problem [1]. Approximately 25 million of the 38 million HIV-positive individuals worldwide live in Sub-Saharan Africa (SSA). Here, the number of undernourished individuals increased from 181 million in 2010 to 222 million in 2016, accounting for over 30% of the global undernutrition crisis [2]. Undernutrition is the condition in which people routinely consume less food than what is necessary to meet their body’s needs for energy to be healthy. HIV-positive individuals often struggle with this issue [3]. HIV and food insecurity pose serious challenges to Sub-Saharan Africa, where 57% of the affected population are adult women between the ages of 15 and 49 years; protein-energy undernutrition is particularly common in this demographic [4]. Research has shown a connection between undernutrition and the Human Immunodeficiency Virus (HIV), both of which can progressively weaken the immune system [5].

Among people living with HIV/AIDS (PLWHA), SSA has the greatest rate of undernutrition globally [6]. In addition, studies conducted in various regions of Sub-Saharan Africa yielded the following results: 19.5% in Tanzania [6], 13.8% in Ghana [7], 10.28% in Uganda [8], 43.3% in Nigeria [9], 19.2% in Senegal [10], and 10% in Zimbabwe [11]. Furthermore, distinct figures were reported in Ethiopia based on different regions: 12.3% [12], 42.3% [13], 18.2% [14], and 34.0% [15].

The 1951 Geneva Convention defines a Refugee as “any individual who, due to a well-founded fear of persecution based on race, religion, nationality, membership in a particular social group, or political opinion, is outside their country of nationality and is unable or, due to such fear, unwilling to return.” Therefore, the United Nations establishes that there is an increased risk of food insecurity and subsequent malnutrition in refugee groups [16], especially those living in camp settlements. Due to a lack of land to produce enough food to sustain themselves and a lack of money for food purchases, refugees experience food insecurity and consume unhealthy diets [17]. Nevertheless, these vulnerabilities are exacerbated in refugee households if there is an HIV infection in the family.

According to studies, the Mai-Aini refugee camp in Northern Ethiopia has a high prevalence rate of acute malnutrition (33.4%) among children under five [18]; another research study in Ethiopia reveals a prevalence of 28.6% among children aged 6–59 months [19]. Compared to females, men were more prone to becoming underweight and wasting away. Maternal BMI, getting pre-lactating meals, and consuming extra food at least once a week during pregnancy were all linked to one type of malnutrition [18]. Furthermore, a Somalian study revealed a moderate public health concern with a prevalence of undernutrition of 24.9% [20]. Research indicates that anaemia is quite prevalent in both women and children at the Zaatari refugee camp in Syria (44.8% and 48.4%, respectively) [21].

Uganda accommodates over 1.5 million refugees, primarily from South Sudan, the Democratic Republic of Congo, Burundi, and Rwanda, residing in 31 open rural settlements integrated into host communities [22, 23]. These refugees share markets, schools, and Ministry of Health facilities with neighbouring villages. In Uganda’s settlements, primary care facilities operated by the Ministry of Health and the UN High Commissioner for Refugees (UNHCR), in collaboration with partner non-governmental organizations, provide complementary antiretroviral medication (ART) [24, 25]. Despite this, the HIV prevalence in the refugee settlements of Uganda is within 5–6%; Kyaka II refugee settlement has a 5.8%, and Nakivale records 5.5%, which is slightly higher than the national prevalence of 4.9% [25–27]. These data underscore the heightened vulnerability of refugees and the urgent need for targeted HIV and nutrition interventions. Studies have also shown that there is a poor level of access to and use of HIV and AIDS services among these refugees [17, 28, 29]. According to the UNICEF conceptual framework on malnutrition, sociodemographic factors are one of the major enabling determinants of maternal and child nutrition status [30, 31]. In addition, a North Korea study [32] revealed that sex, age and time of arrival were significant factors for undernutrition.

In Rwanda, the general population aged 15 to 49 years has an HIV prevalence of 3.0% [33]; however, the prevalence is higher in women (3.7%) than in men (2.3%) [33]. According to the Gender Assessment, women and girls account for about 60% of HIV-positive adults, indicating that they are disproportionately affected [33]. In almost every age group, the prevalence of HIV is higher among women and girls than among their male counterparts [33, 34]. The gender gap is especially noticeable in the youth when young women between the ages of 18 and 19 years have a tenfold higher risk of contracting HIV than young men in the same age range [34, 35]. Compared to their male counterparts, young women in the 20–24 age range are five times more likely to contract HIV [33]. Even though men report greater rates of early sexual debut, girls contract the virus earlier than boys [36].

In addition, 49% of Congolese refugee women in Rwanda camps attest to the fact that they have been victims of sexual, emotional, or physical abuse [34]. Furthermore, reports on the rapid assessment of sexually transmitted diseases/infections (STDs) among Rwandan refugees show that there was low sexual activity when the camps were first established; however, after it was founded, more than 50% of antenatal care (ANC) attendees had agents that caused vaginitis such as bacterial vaginosis (BV), trichomonas vaginalis(TV) and candida albicans (CA), and 3% had Neisseria gonorrhoeae (NG) infections. Finally, 4% of the refugees had active syphilis. 2.6% and 6.1%, respectively, of the male outpatients had urethritis and serological syphilis; 2.9% of the community’s male members had urethritis, of which most of the cases were asymptomatic infections [35].

Studies on refugees in Rwanda and Tanzania revealed a relationship between poor nutritional status and age and sex [36]. Therefore, the study aimed to determine the prevalence and socio-demographic factors of undernutrition among HIV-positive women of reproductive age in Mahama refugee camp, Rwanda.

Methodology

Research design

In this study, we employed a cross-sectional design to determine the prevalence of undernutrition and identify the sociodemographic factors that may influence it among HIV-positive reproductive-age women in Mahama refugee camp.

Study setting

Mahama refugee camp, located in Rwanda’s Eastern Province (Kirehe District), was established in 2015 on 160 hectares of land and today hosts over 650,000 refugees, predominantly from Burundi and the Democratic Republic of the Congo. More than half (51%) of its residents are women and children, and despite various supports from international bodies (UNHCR, WFP), food insecurity remains a pressing challenge. Two health centres in the camp provide integrated HIV and nutrition services [36].

Study population

Our study targeted HIV-positive women of reproductive age (15–49 years).

Inclusion criteria

All women of reproductive age who had been tested HIV-positive from the clinic registers for at least a year and have lived in the camp for at least a year.

Exclusion criteria

This research excluded individuals with serious physical or mental impairments that would make it impossible to take accurate anthropometric measurements or give their informed permission. This complies with WHO guidelines for nutritional surveys.

Sample size determination

The Mahama I and Mahama II medicalized health centres, part of the Mahama refugee camp, served as the sites for this cross-sectional study. The registry books and records of the health institutions show that in the year 2023, 294 registered childbearing women living with HIV received nutrition services. The study was open to all registered HIV-positive women of reproductive age who consume blended food that has been fortified. Yamane’s (1973) [37] method for a specific, constrained population was used to calculate the overall sample size, which came out to be 170 women of reproductive age living with HIV.

Where: ‘n’ represents the intended sample size.

‘N’ represents the entire population or sample frame (294).

‘d’ represents the margin of error set at 5% [38, 39].

Sampling strategies and procedures

Respondents were chosen through a probability sampling technique, specifically simple random sampling. A total of 170 participants were obtained from a sampling frame of 294 HIV-positive women of reproductive age. Each participant had an equal probability of being chosen after utilizing a computer-generated simple random sampling procedure with MS-Excel, where 170 data represented “Yes”, and 124 represented “No”. The sample finally consisted of 170 HIV-positive women of reproductive age and 124 who were not.

Data collection methods

The questionnaire was modified from the Demographic and Health Survey (DHS) women’s questionnaire and the validated FANTA/WFP nutrition assessment questionnaire. To assure accuracy, the tool was first translated into Kinyarwanda and then back-translated. Fifteen eligible women who were not included in the final sample participated in a pretest; their responses resulted in slight phrasing changes. The sociodemographic items’ internal consistency demonstrated an adequate level of reliability with a Cronbach’s alpha of 0.78. Data enumerators were trained for two weeks before being allowed to conduct in-person interviews using the questionnaire [40–42]. Furthermore, data were collected from a proportion of 34 pregnant/exclusively breastfeeding women and 136 non-pregnant/lactating women. The data collection equipment was calibrated [43, 44] daily before setting up for the next day. Data was collected from the 8th to the 28th of December 2023. However, approval for the study was obtained on the 29th of November 2023 for a year; this enabled the data collection tools to be pretested. Anthropometric measurements of HIV-positive women of reproductive age were measured and recorded.

Data analysis

Data was analysed using descriptive statistics, which included frequencies and percentages. Undernutrition of respondents was the main outcome of this research, and this was determined by calculating the Body Mass Index (BMI) for non-pregnant and lactating women above six months and the Mid Upper Arm Circumference (MUAC) for pregnant women and those still exclusively breastfeeding. WHO reference standard was used to classify the nutrition status of individuals through BMI and MUAC cut-offs; those with a BMI below 18.5 kg/m2 and a MUAC below 23 cm were considered undernourished.

A chi-square test with binary logistic regression analysis was used to identify the socio-demographic factors associated with undernutrition. Variables with a significant level of less than or equal to 5% were considered significant.

Results

Descriptive analysis

Most of the women were between the ages of 40 and 49 years (57.7%), while a few fell in the range of 15–19 years (1.2%). With regards to Religion, the majority were Christians 95.9%; in addition, the majority were married (47.6%), while the minority were single (8.8%). Over half of the respondents had primary education (51.8%), and a few had secondary/post-secondary education (16.4%). Women whose household numbers were less than 5 were the majority (72.9%); more women earned a sum of less than 50,000 Rwf per month (69.5%), and a few earned above 100,000 Rwf (2.9%). Finally, respondents who utilized loan app schemes were more in number (62.4%), and a few stated that they patronized them sometimes (9.4%) Table 1.

Table 1.

Background characteristics of the study respondents

Variable	N = 170	%
Age (years)
15–19	2	1.2
20–29	22	12.9
30–39	48	28.2
40–49	98	57.7
Religion
Christian	163	95.9
Muslim	7	4.1
Marital Status
Single	15	8.8
Married	81	47.6
Divorced	30	17.6
Widow	44	26.0
Educational level
Non-formal	54	31.8
Primary	88	51.8
Secondary	28	16.4
Occupation
Employed	13	7.6
Unemployed	157	92.4
Household number
Less than 5	124	72.9
Above 5	46	27.1
Monthly income (Rwf)
≤ 50,000	118	69.5
51,000-100,000	47	27.6
Above 100,000	5	2.9
Loan shark (imigwazo)
No	48	28.2
Sometimes	16	9.4
Yes	106	62.4

Prevalence of undernutrition among respondents

The figure shows the prevalence of undernutrition of reproductive aged women living with HIV in Mahama refugee camp of Rwanda. It further reveals a prevalence of 25% of undernutrition, and 75% recorded no thinness, Fig. 1.

Fig. 1.

Prevalence of undernutrition among HIV-positive women of reproductive age in Mahama refugee camp

Nutrition status (BMI) of respondents

The figure shows the nutritional status of reproductive-aged women living with HIV in Mahama refugee camp of Rwanda. In addition, 75% of the respondents recorded " no thinness “, 16.5% showed “mild thinness”, 5% showed “moderate thinness”, and 3.5% showed “severe thinness”, Fig. 2.

Fig. 2.

Body Mass Index (BMI) nutritional status of HIV-positive women of reproductive age in Mahama refugee camp

Bivariate and regression analysis

Further analysis revealed that none of the variables was statistically significant or influenced undernutrition among the respondents at the bivariate level; however, after controlling for confounders [45, 46], the binary logistic regression analysis revealed that the educational level of the respondents influenced undernutrition (p < 0.001, aOR: 3.06, CI: 1.32–7.097). This might imply that respondents with non-formal and primary levels of education were 3 times more at odds to be undernourished than any other educational level, Table 2.

Table 2.

Sociodemographic factors influencing undernutrition

Variables	Undernutrition						95% CI
	Yes (%)	No (%)	χ²	P-value	Sig	aOR	Lower	Upper
Age (years)			1.427	0.699	0.995	1.027	0.371	2.842
15–19	0 (0.0)	2 (100.0)
20–29	4 (18.2)	18 (81.8)
30–39	13 (27.1)	35 (72.9)
40–49	26 (26.5)	72 (73.5)
Religion			0.041	0.839	0.884	0.875	0.146	5.245
Christian	41 (25.2)	122 74.8)
Muslim	2 (28.6)	5 (71.4)
Marital Status			4.625	0.201	0.106	0.225	0.037	1.372
Single	5 (33.3)	10 (66.7)
Married	15 (18.5)	66 (81.5)
Divorced	11 (36.7)	19 (63.3)
Widow	12 (27.3)	32 (72.7)
Educational level			2.894	0.235	0.001	3.06	1.32	7.10
Non-formal	17 (31.5)	37 (68.5)
Primary	22 (25.0)	66 (75.0)
Secondary and above	4 (14.3)	24 (85.7)
Occupation			2.308	0.129	0.203	4.151	0.464	37.145
Employed	1 (7.7)	12 (92.3)
Unemployed	42 (26.8)	115 73.2)
Household number			1.095	0.295	0.998	3.003	0.000	1.323
≤ 5	34 (27.4)	90 (72.6)
> 5	9 (19.6)	37 (80.4)
Monthly income (Rwf)			2.550	0.279	0.615	0.655	0.126	3.410
≤ 50,000	34 (28.8)	84 (71.2)
51,000–100,000	8 (17.0)	39 (83.0)
100,000+	1(20.0)	4 (80.0)
Loan shark			1.769	0.413	0.377	0.662	0.266	1.651
No	14 (29.2)	34 (70.8)
Sometimes	2 (12.5)	14 (87.5)
Yes	27 (25.5)	79 (74.5)

Reference category: undernourished

The non-formal and primary educational levels of the respondents were significantly associated with undernutrition (p<0.001)

Discussion

Prevalence and sociodemographic factors of undernutrition

The findings from this research on the prevalence of undernutrition revealed that 25% of women at the refugee camp were undernourished; mild thinness was 16.5%, moderate thinness was 5.3%, and severe thinness was 3.5%. This was in contrast with the results from Syrian refugee women in Jordan, which stated a prevalence of 49.2% [47]; and displaced lactating mothers in Northern Ethiopia, which revealed a higher prevalence of 54.8% [48]. However, this research prevalence aligns with data in regions of Ethiopia, such as in Arba Minch districts, a prevalence of 17.4% was recorded [49], Moyale district 17.7% [50], Angecha district 21.2% [51], Dessie town 21% [52], Sidama region 25.9% [53], Dega Damot district 21.8% [54], and Afar region 33.3% [55]. The difference in results could be because of dynamics in the economic and sociodemographic characteristics of the respondent. The lower prevalence in this research study might be attributed to Governmental, humanitarian and international support for refugee camps in the Country.

This research study revealed that the educational level of mothers at the refugee camp had a significant association with undernutrition. It showed that mothers with no formal or primary education were three (3) times more at odds to be undernourished than those with any other educational level. These findings align with a study in Somalia [56], which revealed that women who had low educational levels (non-formal) were more likely to be undernourished and give birth to Low-Birth-Weight babies; this was also consistent with a systematic review of studies in low and middle-income countries [57]. In addition, findings from Afghan [58] and Rohingya [59] refugee camps revealed that children whose mothers had low educational levels were found to be more at odds of being underweight. These differences in statistics can be attributed to cultural and environmental factors. In this research study setting, non-governmental organizations play a vital role in conducting health education and promotion at various refugee campsites on the burden of diseases caused by undernutrition. Therefore, maternal education has a significant effect on the nutritional status of mothers and children in any setting [60].

The maternal age of our respondents showed no significant predictor of undernutrition. This finding contrasts with several studies from Ethiopia [48, 61, 62], Rohingya [59] and Uganda [63], which revealed maternal age as a significant predictor of undernutrition. Furthermore, several studies from Somalia, Malaysia and Thailand show that teenage mothers are at a high risk of undernutrition [56, 64–66]. These differences in significance may be attributed to our sample being focused on only reproductive-aged women living with HIV. However, it still underscores the fact that maternal age has a role to play in preventing undernutrition in refugee camps.

Religion mostly serves as a stand-in for societal food rules, cultural eating customs, and systemic socioeconomic marginalization. Our findings revealed no significant association between religion and undernutrition. This was similar to a study in Cameroon [67], which revealed no association with religion. However, an Ethiopian study [68] showed that Muslim women were associated with undernutrition. Thus, its independent effect in multivariate models is inconsistent and context-dependent; religion may predict undernutrition in bivariate correlations.

Caregiver resources, household decision-making, and poverty susceptibility are all influenced by marital status. In addition, perhaps the most significant socioeconomic factor contributing to undernutrition in refugee and displacement contexts is monthly income. Although marital status is a bivariate predictor, in adjusted models it is frequently mediated by household structure and income. Nevertheless, our data revealed no significant association between marital status and monthly income with undernutrition. However, several studies in Nigeria [69], Lebanon [70], and Jordan [71] found a dominant predictor between marital status and income levels with undernutrition in humanitarian settings, especially in polygamous marriages. These context differences may be attributed to cultural variations among refugee camps and low variability in monthly income levels.

Occupation influences household purchasing capacity, availability of time for childcare, and access to a variety of food sources. In addition, the size of a home serves as a structural amplifier of nutritional risk; larger households distribute scarce food resources more sparsely, hence elevating the likelihood of child undernutrition. Despite these, our findings on occupation and household number revealed no significant link with undernutrition among our respondents. This finding does not align with results from Rohingya [59], Armenia [72] and sub-Saharan Africa [73], which revealed reduced odds of undernutrition associated with occupation. Furthermore, findings from Cameroon [67, 74] and Lebanon [70] revealed that large household size is a significant predictor of undernutrition. These variations in findings may be linked to sociodemographic and geographical differences, together with the high unemployment level among the refugees in Mahama camp.

Finally, in refugee nutritional research, loan schemes such as microfinance, savings organizations, and cash transfers represent an understudied but potentially influential variable. Yet, camp-specific nutrition multivariate models do not regularly assess them as a covariate. Our findings revealed no significant association between loan schemes and undernutrition. Evidence from related fields, however, is instructive: small loans enabled the creation of small businesses and the acquisition of assets required to reduce poverty, while savings-led microfinancing successfully raised household incomes among participating households in rural Lesotho [75], thereby amplifying consumption and access to basic needs. On the other hand, among displaced people, households with debt, children, and nursing mothers were more likely to experience food insecurity, indicating that predatory or poorly structured loan access may exacerbate rather than alleviate nutritional vulnerability [76].

Conclusion

The prevalence of undernutrition among reproductive-age women at the refugee camp was moderately low at 25%. Regarding thinness, 16.5% of mothers experienced mild, 5.3% moderate and 3.5% severe. Women with non-formal and primary levels of education were 3 times more at odds to be undernourished as compared to their counterparts in the camp.

Recommendations

Health education and health promotion should be continuously carried out at the refugee camp. In addition, a public-private partnership can establish a basic education programme with integrated health literacy.

Limitations of the study

Despite the strengths of this study, these stood as a limitation. Although the study employed a statistically adequate random sample of 170 participants, the cross-sectional study design that was employed cannot establish a causal relationship with the study’s outcome variable.

The objective of this study was focused mainly on the sociodemographic factors of the respondents; further research should be done on dietary diversity, duration of illness and other comorbidities.

Abbreviations

HIV

Human Immunodeficiency Virus

AIDS

Acquired Immunodeficiency Syndrome

SSA

Sub Saharan Africa

PLWHA

People Living with HIV/AIDS

BMI

Body Mass Index

MUAC

Mid-upper Arm Circumference

CMHS

College of Medicine and Health Sciences

IRB

Institutional Review Board

MINEMA

Ministry in Charge of Emergency Management

SPIU

Single Project Implementation Unit

Authors’ contributions

B.S, H.S, and E.N, conceptualized the research and data collection process; K.N, assisted in data analysis and interpretation; N.K supervised and was involved in the entirety of the process of the research.

Funding

The authors of this research study, received no funding to execute this research; thus, it was self-funded.

Data availability

All data are provided within the manuscript and the raw data available upon request.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from the University of Rwanda, College of Medicine and Health Sciences Institution Review Board (CMHS/IRB/539/2023). Further clearance was obtained from the Ministry in Charge of Emergency Management (MINEMA) with reference (1882/MINEMA/SPIU/22). The study participants were free to withdraw from the study at any time if they felt uncomfortable. Written informed consent was obtained from the parents/guardians/custodians for young women below the age of 18 years. The consent forms were kept private by the principal investigator. The researchers used numbers to identify the study participants and guarantee total confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.