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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 73-81

Magnitude of underweight and its associated factors among children aged 6–59 months visiting health center in Nefas Silk Lafto Sub City, Addis Ababa, Ethiopia


1 Department of Maternal, Child Health and Nutrition, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
2 Department of Nutrition, Sante Medical College, Addis Ababa, Ethiopia
3 Department of Hygiene and Environmental Health, Ethiopian Ministry of Health, Addis Ababa, Ethiopia

Date of Submission05-Jan-2021
Date of Decision08-Feb-2021
Date of Acceptance29-Mar-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Mr. Ziyad Ahmed Abdo
Department of Hygiene and Environmental Health, Ethiopian Ministry of Health, Addis Ababa
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_3_21

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  Abstract 


INTRODUCTION: Millions of children in low-income countries suffer from malnutrition, which continues to be the most important public health problem in developing countries. Although the proportion of underweight has declined in Addis Ababa, it remains a leading cause of illness and death in children <5 years. Therefore, this study aims to close the knowledge gap by assessing the prevalence and factors related to underweight among children aged 6–59 months who visit the health centers in Nefas Silk Lafto Sub City, Addis Ababa, Ethiopia.
MATERIALS AND METHODS: An institutional-based, quantitative cross-sectional design was used to conduct the study. Systematic sampling system was applied to select 422 study participants. The data were collected via interview using a structured questionnaire. Weight of children was taken according to the recommended standard procedures. WHO Anthro software was used to convert anthropometric measurements into Z-scores. Bivariate and multivariable logistic regressions were employed to identify the predictor variables. Statistical significance was considered at P < 0.05 with adjusted odds ratio (AOR) calculated at 95% confidence interval (CI).
RESULTS: The overall underweight prevalence among under-five children was 9.9% with 95% CI (7.2–12.8). Participants from low household income (AOR = 1.6; 95% CI 1.4–1.97), children having a history of diarrhea (AOR = 14.7; 95% CI: 3.7–23.3), children who were frequently ill (AOR = 12.7; CI = 1.02–15.1), children who were not frequently breastfed (AOR = 9.3; CI = 1.6–12.9), children who were given prelacteal foods at birth (AOR = 11.7; CI = 2.2–13.9), and children from family which used public toilet (AOR = 5.4; CI = 1.05–6.5) were more likely to be underweight than their respective counterparts.
CONCLUSIONS AND RECOMMENDATION: Prevalence of underweight was 9.9% is even better than the nation. Strengthening behavior change activities, enable mothers to avoid giving prelacteal foods and increase the frequency of breastfeeding should be in place to prevent diarrhea and promoting environmental cleanness are recommended.

Keywords: Associated factor, Ethiopia, food insecurity, malnutrition, underweight


How to cite this article:
Girma F, Demessie T, Abdo ZA. Magnitude of underweight and its associated factors among children aged 6–59 months visiting health center in Nefas Silk Lafto Sub City, Addis Ababa, Ethiopia. BLDE Univ J Health Sci 2022;7:73-81

How to cite this URL:
Girma F, Demessie T, Abdo ZA. Magnitude of underweight and its associated factors among children aged 6–59 months visiting health center in Nefas Silk Lafto Sub City, Addis Ababa, Ethiopia. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 16];7:73-81. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/73/348269



All forms of malnutrition are a global burden affecting almost every country in the world, presenting significant public health risks and huge economic costs.[1] It is one of the important causes of death in the world, which led to one-third of the deaths in young children.[2] It is the cause of 2.6 million deaths each year. Today, 1 in 4 children in the world is suffering from stunted due to malnutrition; this number is higher with 1 in 3 children suffering from malnutrition in developing countries, especially in Africa.[2],[3] It is the most important risk factor for the burden of disease causing about 300,000 deaths annually directly and indirectly accountable for more than half of all deaths in children.[2],[4] Millions of children living in low-income countries suffering from malnutrition, which remains a main public health problem.[5]

Despite significant global progress in reducing infant mortality since 1990, under nutrition remains one of the most common causes of infant morbidity and mortality worldwide.[6] Under-five children death fell from 12.7 million in 1990 to 5.9 million in 2015. The global mortality rate for children under-five fell by 53% from 91 deaths per 1000 live births in 1990 to 43% in 2015.[7],[8] It has been directly or indirectly responsible for 60% of the 10.9 million deaths that occur each year in children <5 years of age.[9] More than two-thirds of these deaths are associated with poor nutritional practices that occur in the 1st year of life.[10]

While underweight prevalence is decreasing, increases in the under-five population in the least developed Countries counteracts this trend and results in stagnation in the proportion of the underweight burden.[11],[12],[13] Child malnutrition in Ethiopia is one of the most serious public health problems.[14] According to the Ethiopian Demographic Health Survey (EDHS) 2016 in Ethiopia, 29% of children under the age of 5 years are underweight and 7% are severely underweight.[11] The proportion of children who are underweight depends on the age group.[15] These 48–59-month-old infants can be exposed to infections and contagious diseases when exposed to the environment.[11]

To solve this problem, research must focus on identifying causes of malnutrition. Some studies have identified potential limiting factors. Short-term effects include nutrient loss, morbidity, long-term effects, disorders, reduced productivity and death, inadequate food intake, ill health, inadequate childcare, home food insecurity, environmental health, and socioeconomic, demographic, political, and other environmental factors.[2],[3],[16],[17],[18],[19],[20]

The problem of malnutrition in Ethiopia is relatively well documented, but its specific determinants are not well understood. To reduce malnutrition, we need to understand its causes. Although the current research does not rely much on small studies focusing on specific regions of the country, there is also disagreement about the relative importance of factors affecting nutritional status. This issue has great political importance among national and international policymakers, as well as academic interest. Therefore, it is important to better understand what influences malnutrition and their differences between regions. Without this information, it is not possible to develop an effective political strategy to tackle this problem. Therefore, this research was intended to identify the prevalence of underweight and its associated factors of among children aged 6–59 months attended health centers in Nefas Silk Lafto Sub City.


  Materials and Methods Top


Study design and settings

A facility-based cross-sectional study design was used to assess the levels and associated factors of underweight among children aged 6–59 months visiting health centers in Nefas silk Lafto Sub City in Addis Ababa. The data collection was carried out from June 1 to 30, 2019, in Addis Ababa, Nefas Silk Lafto Sub City, Health Centers. The total population of the Sub City is around 396,486 of which 10,552 are under-five children as projected from the 2009 census.[11] This Sub City has 13 Woredas and 10 health centers and also 158 middle and higher private clinics, but there is no government hospital.[21]

Population and eligibility criteria

All children who were visiting health centers in Nefas Silk Lafto Sub City for any reason constituted the source of population for the study. All selected children among those who were of age 6–59 months who visiting the health centers for any reason during the study period. All child–mother pairs who were visited health centers in Nefas Silk Lafto Sub City for any reason during data collection period were included in the study. Children who were severely ill and with unwilling parents and care taker were not excluded.

Sample size and sampling strategy

By using simple proportion formula, the sample size was calculated. The required sample size for the study was calculated by using single population proportion formula with the following assumptions: 95% confidence level, 5% margin of error, and 49.2% prevalence of underweight from the previous study in Shashemene Referral Hospital.[22]



Based on this information, the sample size calculated was 384. Finally, including 10% nonresponse rate, the total sample size of the study was found to be 422.

To get sample size, systematic sampling was used to get sample size from the health center. First, district 3 health center was selected using purposive sampling system from Heath Centers found in Nifas Silk Lafto Sub City. The number of under-five children who attended the under-five clinics in the previous six months was determined from records to constitute sampling frame, which was 7297 with a monthly average attendance of 1216. Then, the monthly attendance was divided by total sample size of 422 to get the sampling interval, which were about 3. Therefore, every third child–mother pair was included in the study. The first child–mother pair was selected randomly from the first three child–mother pairs. Thereafter, every third child–mother pair was taken until the total sample size was attained.

Study variables

  • Dependent variable: Underweight among children aged 6–59 months
  • Independent variables: Inadequate dietary intake (feeding frequency, 24-h recall), disease (morbidity of children [in the last 2 weeks], frequency and health-seeking practice), food insecurity (dietary diversity, availability, accessibility, utilization, and sustainability of consumed food in the household), inadequate child feeding and healthcare (initiation of breastfeeding, exclusive breastfeeding, feeding whole colostrum, pre-lacteal feeding, complementary feeding), lack of health service and unhealthy environment (immunization, Vitamin A supplementation, antenatal care, health-seeking practice, clean water supply, environmental sanitation, and toilet facility), and socioeconomic and demographic factors (sex and age of child, age of mother, education and occupation of the parent, family size, employment, income).


Data collection tools and procedure

The data were collected by using structured pretested questionnaires, prepared after reviewing different relevant kinds of literature. Household food insecurity status was measured using Food and Nutrition Technical Assistance (FANTA) Household Food Insecurity Access Scale (HFIAS) tool. Weight was measured with minimum clothing and taking off shoes, using calibrated portable scale (UNICEF electronic scale) to the nearest 0.1 kg. Each measurement was taken two times by different data collectors. If there was a difference in readings, the average of the two readings was taken. Standardization of weight measurements was done to minimize the intra- and inter-observer variations, and instruments were calibrated by known weight within certain period of time.

The questionnaire was first prepared in English and translated into Amharic and then back to English by different translator to check correctness and consistency of translation. Data were collected and supervised by healthcare professionals. For data quality control purpose, the data collectors were trained before the data collection and supervised during the data collection period. The questionnaire was pretested in 5% of the calculated sample size in public health center, which was not included in the study before the actual data collection. Principal investigator and supervisors made spot-checking and reviewing the completed questionnaires to ensure completeness and consistency of the information collected. Those incomplete questionnaires were omitted from the analysis.

Operational definition

Malnutrition is the condition that results from eating a diet in which nutrients are either low or are too much. Underweight is weight for age < –2 standard deviations (SD) of the WHO Child Growth Standards median. Anthropometry is the measurement tool used to assess the nutritional status of individuals at different age level and body size and composition.

Data management and analysis

Data were cleaned, coded, and entered into Epidata software version 3.1 and then exported to SPSS, version 22 for further analysis. Anthropometric data were exported to WHO Anthro software to convert anthropometric measurements into Z-scores. Child Dietary Diversity Score (DDS) were calculated based on different food groups recommended by the FANTA guideline and using WHO guidelines for measuring household food security and individual dietary diversity. DDS is the sum of food groups eaten by the child over last 24 h. In HFIAS measurement, each of the respondents was asked within a recall period of 4 weeks. The respondent was first asked an occurrence question, that is, whether the condition in the question happened at all in the past 4 weeks (yes or no). If the respondent answers “yes” to an occurrence question, a frequency-of-occurrence question was asked to determine whether the condition happened rarely (once or twice), sometimes (three to ten times), or often (more than ten times) in the past 4 weeks. Descriptive statistics, percentages, and mean were carried out. Hence, bivariate logistic regression was performed to identify variable that associates with dependent variables. Accordingly, variables with P < 0.2 during bivariate analysis were included in multiple logistic regression to identify factors associated with underweight among children aged 6–59 months by controlling potential confounding variables. Statistical significance was considered at P < 0.2 to see the determinant factors with adjusted odds ratio calculated at 95% confidence interval.

Ethical consideration

Ethical clearance was obtained from Santé Medical College. A formal letter obtained from Addis Ababa Health Bureau was submitted to health center included in the study. The purpose of the study was well explained to the study participants and informed consent was obtained. Participation was totally voluntarily.


  Results Top


Demographic and socioeconomic characteristics of respondents

A total of 422 households having at least one child aged 6–59 months were included in the survey. Data for 17 children were incomplete; thus, the study was conducted based on 405 mother/child pairs with a response rate of 96%. Two hundred and fifty-four (62.9%) mothers belong to the age group of 25–34 years. The mean family size was 4.3 (±1.4). Maternal education levels show that approximately 133 (32.9%) and 128 (31.7%) mothers have attained secondary and primary levels, respectively. The majority of the respondents (54.7%) were homemakers. Most of the father of the children (315, 82.5%) were employed in government and private organizations. Regarding household income, most of the households earned (161, 39.8%) less than or equal to 2500 birr. 209 (51.5%) children were male and 48.5% were female. About 44.2% of children were in the age range of 6–17 months [Table 1].
Table 1: Demographic and socioeconomic characteristics of parents and children in Nefas Silk Lafeto Sub City Health Center, Addis Ababa, Ethiopia

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Dietary diversity

Most of the children ate cereals (92.1%), vegetables (78%), and legumes/pulses (51.4%). Small proportion of children ate fruits (23.7%) and meat, egg, and fish (25.7%). According to FANTA categorization, 260 (64.2%) children did not consumed the recommended levels of diversified foods [Table 2].
Table 2: Dietary diversity intake of children aged 6-59 months in Nefas Silk lafeto Sub City Health Center, Addis Ababa, Ethiopia

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Frequency of common childhood disease and health-seeking practice of children

The results related to child morbidity indicate that 119 (29.4%) had cough, 103 (25.4%) had fever, and 57 (14.1%) had diarrhea in 2 weeks before the survey. Among the children, 138 (34.1%) came to health center due to illness, 100 (24.8%) came for vaccination, while 61 (15.1%) came (62.9%) of sick children not refused feeding but their parent feed as usual [Table 3].
Table 3: Common child hood disease and health seeking practice of children aged 6-59 months in Nefas Silk Lafeto Sub City Health Center, Addis Ababa, Ethiopia

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Household food insecurity status

Around 44.4% of the respondents said that they were worried about food shortages over the last 4 weeks; 70.6% reported inability to eat the preferred food; 83.2% reported to have eaten limited variety of food; 55.6% ate food that they really do not want to eat and were unable to eat the preferred variety of food due to lack of adequate resource; 79.3% reported that their household members have eaten smaller amount of food; 67.7% missed the number of meals per day; 19.3% reported that they have no food of any kind to eat; 10.6% reported sleeping without eating food; and 10.4% reported to have spent the day and night without eating any food. From the total household included in the survey, more than three-fourths of households (370, 91.4%) experienced some degree of food insecurity in the 1 month preceding the survey. Among these households, 34 (8.4%) experienced mild food insecurity, 244 (60.3%) experienced moderate food insecurity, and 92 (22.7%) experienced severe food insecurity [Table 4].
Table 4: Household food insecurity of children aged 6-59 months in Nefas Silk Lafeto Sub City Health Center, Addis Ababa, Ethiopia

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Child feeding and caring practice of children

According to children included in the study, 66.5% of the children received breast milk within 1 h after birth, 276 (68.3%) were exclusively breast fed for 6 months, 391 (97.3%) received colostrum, and about 225 (57.1%) of children less than 8 times per day breast feed. 129 (31.9%) started complementary feeding below the age of 6 months, and 212 (52.3%) of the children had practiced bottle feeding. Concerning immunization, majority (74.3%) of the children received immunization and 344 (84.9%) and received Vitamin A supplement [Table 5].
Table 5: Child feeding and caring practice of children aged 6-59 months in Nefas Silk Lafeto Sub City Health center, Addis Ababa, Ethiopia

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Characteristics of health service and environment issue

The vast majority (399, 98.5%) of mothers visited health facilities for antenatal care (ANC) during pregnancy. Regarding the use of family planning, 268 (66.5%) mothers used family planning, and out of these, 103 (36.6%) mothers used injectable contraceptives. Almost all (401, 99%) of the mothers delivered in the health institutions. Regarding water treatment, 239 (59%) of the respondents were not using treated water [Table 6].
Table 6: Health service and environment issues of children aged 6-9 months in Nefas Silk Lafeto Sub City Health Center, Addis Ababa, Ethiopia

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Prevalence of underweight among children aged 6–59 months

The overall prevalence of underweight among under-five children was 9.9% with 95% CI (7.2–12.8). Accordingly, 4.7% were moderately underweight and 5.2% were severely underweight [Figure 1].
Figure 1: Prevalence of under-weight of children aged 6–59months in Nefas Silk Lafeto Sub-City health Center, Addis Ababa Ethiopia

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Factors associated with underweight of children aged 6–59 months

Bivariate and multivariable analysis were conducted to see the association of one independent variable with the dependent variable. Variables with P < 0.2 during the bivariate analysis were included in the multivariate logistic regression analysis to see the association of independent variables with underweight among children aged 6–59 months by controlling confounding variables. After computing multivariate analysis, household income, diarrhea in the last 2 weeks, the frequency of illness per year, prelacteal feeding, frequency of breastfeeding, and toilet facility remained significantly associated with underweight among children aged 6–59 months after controlling for the confounding variables in the regression model [Table 7].
Table 7: Logistics regression of factors associated with underweight of children aged 6-59 months in Nefas silk Lafeto Sub City Woreda 3 Health Center, Addis Ababa, Ethiopia

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  Discussion Top


This study investigated the prevalence of underweight and associated factors among children aged 6–59 months in health centers in Nifas Silk Lafto Sub City. In this study, the overall prevalence of underweight was 9.9%, of which 4.7% and 5.2% were under moderate and severe weight, respectively. According to the EDHS 2016 report, the prevalence of overall underweight in Addis Ababa is 5.3% (5% moderate underweight and 0.3% severe underweight). Compared to this, the results obtained in this study are slightly higher. However, compared to several other studies, the rate of underweight observed in this study is much lower. For example, the rate of underweight observed in this study is significantly lower than the underweight prevalence rate reported in the study done in Shashemene Hospital (49.2%).[22] The huge discrepancy might be due to the difference in the study setting, methods, and tools used.

The study found that the children of low-income family respondents were less likely to be underweight than high-income children. This result differs from the result of a study conducted in the town of Lalibela.[23] This may an indication for a double burden in developing country.

In this study, children who had diarrhea in the past 2 weeks preceding the survey were more at risk of being underweight. This result is consistent with the findings of several other studies such as studies done in Haramaya,[24] Bule Hora,[25] Badawacho district,[26] Machakel Woreda.[14] This is expected because diarrhea leads to malnutrition due to nutrient loss, reduced nutrient absorption, increased nutritional demand, and reduced appetite. The contribution of acute diarrhea and infections in children with developmental delay has long been recognized. For example, studies show that, in rural Malawi, diarrheal disease may be responsible for up to 80% of childhood growth retardation in rural Malawi.[27]

Children who became ill more often (more than six times a year) were more likely to be underweight than children who fell ill less often. The results are consistent with the results of studies conducted in Mashkir and Lida in Northwestern Ethiopia. Numerous studies have also shown that childhood illness has a negative impact on child development.[14] Childhood illness affects nutrient intake, absorption, and utilization which determine the nutritional status of children. Infections play an important role in malnutrition as they lead to increased energy demand and expenditure, leading to nutrient loss during vomiting, diarrhea, dyspepsia, malabsorption, loss of appetite and metabolism disorders.[14]

The findings of this study indicated that children who were breastfed less than eight times a day are more likely to be underweight than children who were breastfed eight times and more, which is consistent with the findings of the study done in Machakel Woreda, Northwest Ethiopia. The findings are also in line with the findings of studies done in Bangladesh, which reported that inadequate breastfeeding among others (early supplementation of infant formula or cow's milk, bottle feeding and early introduction of semi-solid complementary foods) was the important risk factor of malnutrition.[14],[28]

The finding of this study indicated that children who were given prelacteal feeds within the first 3 days of life were more likely to be underweight than children who were not given prelactal feeds. This finding is in agreement with the findings of the studies done in Hidabu Abote, Badawacho district, and Shashemen Referral Hospital and other studies.[22] The practice of giving pre-lacteal feeds is discouraged because it limits the infant's desire to suckle. This puts the baby at risk for infections, especially gastrointestinal infections.[12] The increased risk of being underweight in babies receiving immediate dairy products may be due to adverse effects on breastfeeding. If babies are not breastfed well, they are more susceptible to malnutrition. Moreover, prelacteal feeds are known to interfere with early attachment of the child to the breast.[26]

The survey found that the children of interviewees who used a public toilet were more likely to be underweight than children who used a private toilet. This result is similar to the results of a survey in Malawi and Bangladesh and other results study.[28] These studies have shown that the presence of a private toilet is an important factor affecting a child's nutritional status. This makes perfect sense in the sense that unclean public toilets often cause diarrhea and other illnesses, which are the main causes of malnutrition.

Strengths and limitations of the study

Due to the nature of the design of the cross-sectional study, causality cannot be established. Respondents who answer questions about the past events may have a potential recall bias. Since the study was conducted at a certain time of the year, it was unable to cope with the possibility of seasonal changes in nutritional status and related factors. The prompt feedback on the nutritional status of the children as well as delivering relevant advice/counseling for the care takers during interview can be considered as one of the strength of the study.


  Conclusions and Recommendation Top


Prevalence of underweight among children 6–59 months of age was high in the health center in Nefas silk Lafto Sub City compared to Addis Ababa prevalence rates. Underweight was significantly associated with household income, diarrheal disease, frequency of illness, frequency of breast feeding, prelacteal feeding practice, and using public toilets in the studied area. Encourage the community to increase their household income through some other entrepreneur activities and give them financial literacy that helps to generate their own income. Encourage and enable mothers (counseling and educating during ANC and postnatal care visits or during any contacts with health workers) to breastfeed their children frequently (greater than eight times per day). Prelacteal feeding habits need to be tackled by promoting awareness regarding the risks of prelacteal feeding as well as enabling mothers to initiate breastfeeding within 1 h after delivery. Strengthened awareness creation by health workers at any contacts is important. Health sector must strength its efforts to promote appropriate breastfeeding practices which discourage pre-lacteal feeding practices. Regular deworming, Vitamin A supplementation, and all anthropometric measurements for all children should be strengthened to detect underweight early. Research is needed to identify more variables that may determine the nutritional status of children in the study area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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