Prevalence of malnutrition and its associated factors among under five children at debretabor town north-west ethiopia

Background: An estimated of 230 million under-fi ve children are believed to be chronically malnourished in developing countries Similarly, about 54% of deaths among children of this age group are believed to be associated with malnutrition in developing countries. In Sub-Saharan Africa, 41% of under-fi ve children are malnourished and deaths from malnutrition are increasing on daily basis in the region. Malnutrition continues to be a major public health problem in developing countries. It is the most important risk factor for the burden of disease causing about 300, 000 deaths per year directly and indirectly responsible for more than half of all deaths in children. So to minimize these direct or indirect causes of death additional investigation is needed since there is shortage of evidences. Objective: To assess prevalence of malnutrition among children of age 6-59 months in Debre Tabor town, North-West Ethiopia in December 2019 . Methods: A community based cross sectional study was conducted. The study area is Debre Tabour Town which is located North-West of Ethiopia, and is 97Km away from Bahir Dar. The sample size of the study was 277. Data were collected using structured questionnaire and anthropometric measurements. After the completion of data collection; editing, coding and cleaning was carried out. The data was analyzed manually. Different frequency tables, graphs and descriptive summaries were used to describe the study variables. Chi-square test and 95% CI were computed to measure the presence of the association between the outcome and the explanatory variables. P-value <0.05 was considered as a statistical signifi cant. Result: The prevalence of stunting, underweight and wasting was 23.2%, 11.9%, 7.6% respectively. About 1.8% of the children had acute malnutrition. Variables like family size, income, maternal and paternal educational status, diarrhea, health status during pregnancy, ANC visit were highly signifi cant (associated) with chronic malnutrition (stunting) at P-value <0.005. Conclusion and recommendation: Based on the fi ndings of this study we can conclude that; child malnutrition is still high in the study area even though it is lower than the national and regional EDHS 2016 national report. I recommend that nutritional education should be given by health extension workers to improve feeding and hygiene practice at HH level. There should be safe and adequate water supply, Immunization to overcome malnutrition in long term. Research Article Prevalence of malnutrition and its associated factors among under fi ve children at debretabor town north-west ethiopia Hwot Yisak* and Amien Ewunetei Debretabor University, College of Health and Medical Science, P.O. Box 272, Debre Tabor, Ethiopia Received: 17 September, 2020 Accepted: 26 September, 2020 Published: 30 September, 2020 *Corresponding author: Hwot Yisak, Debretabor University, College of Health and Medical Science, PO. Box 272, Debre Tabor, Ethiopia, E-mail: https://www.peertechz.com


Background
Insuffi cient supply of protein, carbohydrates and fat, the next major cause of protein-energy malnutrition is severe and chronic infections -particularly those producing diarrhea, but also other diseases such as helminthic infections. The underlying mechanisms include decreased food intake because of anorexia, decreased nutrient absorption, increased metabolic requirements and direct nutrient losses. Malnutrition is a condition that results from eating a diet in which nutrients are either not enough or too much such that the diet causes health problem it may involve calories, protein, carbohydrate, vitamins or minerals. Malnutrition continues to be a major public health problem in developing countries [1]. It is the most important risk factor for the burden of disease causing about 300, 000 deaths per year directly and indirectly responsible for more than half of all deaths in children [2].
Much of the burden of deaths resulting from malnutrition, estimated to be over half of childhood deaths in developing countries, can be attributed to just mild and moderate malnutrition, varying from 45% for deaths due to measles to 61% for deaths due to diarrhea [3]. It's estimated that 53 % of deaths among pre-school children in the developing world are due to the underlying effects of malnutrition on diseases such as measles, pneumonia, and diarrhea.
In Ethiopia, child malnutrition rate is one of the most serious public health problem and the highest in the world [4]. High malnutrition rates in the country pose a signifi cant obstacle to achieving better child health outcomes. Underweight and stunting rates among young children are the highest in sub-Saharan Africa [5,6] Malnutrition in Ethiopia, in the form of stunting, underweight and wasting were identifi ed as 38%, 24% and 10 % and. Amhara National region state 46 %, 28.4% and 9.8%, respectively in children under fi ve. A community based cross-sectional survey conducted West Gojam zone revealed that 49.2 % children were found to be under-weight ,43.2 % of the children under age fi ve were suffering from chronic malnutrition and 14.8 % acutely malnourished [6 7].
The cross sectional survey conducted rural communities of Tigray region also revealed that, the levels of stunting, under weight and wasting were 42.7%, 38.3% and 13.4%, respectively [8]. A cross sectional study conducted in Aynalem village in Tigray region, the overall prevalence of stunting, underweight and wasting were 45.7%,43.1% and 7.1% ,respectively [8,9].

Statement of the problem
Malnutrition is the result of complex interactions between food consumption and the overall status of health and health care practices. Numerous socioeconomic and cultural factors infl uence patterns of child feeding and nutritional status of women and children [4,5].
Appropriate and adequate feeding is a pre-requisite to good nutritional status in any given time of human life because consumption of nutritionally inadequate diet leads to malnutrition [6,7]. Proper nutrition in the early years of life is usually determined by feeding practice, which includes the methods and frequency of feeding, degree of stimulation and interaction with parents [8,9]. Traditional feeding practices( No special emphasis on feeding of children)are those practices that are directly related to the nutritional and dietary aspects of feeding. Ethiopia is a large country with cultural diversifi cation refl ected by different feeding habits and traditional feeding practices [10,11]. Malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. It has been responsible, directly or indirectly, for 60% of the 10.9 million deaths annually among children under fi ve ages [12,13].
But, there is no information available on the stated problem in Debre Tabor town since the national data obtained from demographic health survey may not represent the study area and the data is generated every fi ve years. This study, therefore, aimed at assessing prevalence of malnutrition in Debre Tabor town town, North-west Ethiopia. Among Children age 6-59 Months. Despite the fact that the government of Ethiopia health sector has increased its efforts to enhance good nutritional practices, child malnutrition is still among the highest in the world. Malnutrition is one of the main health problems in Amhara National Regional State as well as to the study area. Determining the prevalence for malnutrition among children age 6-59 months will assist the health system and other concerned stakeholders to plan appropriate and effi cient nutrition intervention. There is no recent study done and documented to this specifi c topic in the area. The result of this study, which specifi es the prevalence of child malnutrition with these various causes, can serve as reference in priority setting, designing effective nutritional programs to address the problem and its consequences Methodology Study area and study period: The study was conducted in As 2007 CSA population projected the town has a total population of 81,644 with female population 40,414 and male population 41,230 and the wereda has 18,987 total households and it has a total of 1007, 0-59months of children.

Study design:
A community based, cross-sectional study was conducted.

Source population
All children 6-59 months of age living in Debre Tabor town.

Study population
All sampled/selected children of age 6-59 months who were available during the data collection period in the town.

Inclusion (eligibility) criteria
Children who are 6-59 months of ages selected for the study.

Exclusion criteria
Children who were seriously ill were excluded.
Disabled children were also be excluded.

Sample size determination
Total of 276 children who are aged from 6-59 month were assessed in the study.

Sampling procedure
Systematic random sampling technique was used to assess Prevalence of malnutrition in child at Debre Tabor town. if there is refusal or if there is no child in the selected HH , the next HH will consider for the study. Randomly select by lottery method the fi rst house to be 3.
Where impossible to get them or if there is refusal, the next HH was consider for the study. In households with more than one children of age between 6-59 months, one child was selected randomly.

Data collection instruments/tools
A structured questionnaire was used to obtain sociodemographic information, environmental related factors and dietary habit, and Malnutrition. The questionnaire was developed in English and then was translate into Amharic language during the interview to obtain correct data since the local language is Amharic. The data collectors were regularly supervised by the principal investigator for proper data collection.

Data processing and analysis
Data was assessed, should be cleaned and edited using tally sheet for independent variable frequencies, percentage, mean, range and proportion were calculated and presented using tables and fi gures. The associations of independent and outcome variables were tested. Chi-square test and 95% CI was computed to measure the presence of the association between the outcome and the explanatory variables. P-value <0.05 was considered as a statistical signifi cant.

Data quality control
To ensure quality of data, pre-test for the data collection tools was done on Health centers Findings and experiences from the pre-test was utilized in modifying the data collection tool. 6 Data collectors were trained by the principal investigator.
Supervision was done during data collection. The collected data were checked for completeness and clarity by supervisors and principal investigators on daily basis. Diarrhea: A child with loose stools for three or more times in a day and a sign of dehydration

Study variables
Family size: refers total number of people living in a house during the study period.
Fever: A child with elevated body temperature than usual Income: It is periodical monthly earning from one's business, lands, work, investment etc Malnutrition: refers to under nutrition or defi ciency in protein-energy nutrition.
Measles: A child with fever, generalized rash and conjunctivitis (red eyes) Stunting: H/A that is less than the international median NCHS reference value by more than two standard deviations, below -3SD is severe stunting.
Underweight: W/A that is less than two SD below the international median NCHS reference value.
Wasting: W/H less than the international median NCHS reference value by more than two SD.

Socio-demographic
From the total 276 planned study subjects, complete response was obtained. As indicated in Table 1, male headed HHs were 91.3 percent and the rest 8.7 percent were female headed HHs.
From the study subjects 88 percent were married, 5.1 percent divorced, 4.0 percent were separated, 2.5 percent were widowed and 0.4 percent was single.
About 50.7 % of the HHs had a total family size of more than four while, 49.3% of the HHs had family size of less than or equals to four. About 62.3% of the HHs had one under fi ve year children, 33.7 percent of the HHs had two under fi ve year children and 4.0 percent had three under fi ve children.
Regarding to educational status of mothers and fathers respectively shows that 36.2% and 33.0 % were illiterate, From the total children, 65.2% were weighted at birth.

child caring practice
Breast feeding: All children had breast fed after birth, among these 76.1% were breast fed immediately(within an hour), 15.6% were breast fed b/n 1-23 hours and only 0.7% were breast fed after 24 hours.10.5% of children were exclusively breast fed for less than six months, 80.1% of the children for six months and the rest 9.4% were EBF for greater than six months About 6.5% of the respondents squeezed out(threw) the fi rst milk(colostrums) and 7.2% of mothers had given prelactational food for their newborn baby. The commonest type of food given was butter which was 90.9%.
From the total number of study subjects, 50% are still breast feeding. About 48.2% breast feed less than eight times in 24 hours, 48.9% from 8 up to 12 times and 2.9% above 12 times in 24 hours. Most of respondents used cup and spoon for feeding (64.5%) whereas 35.1% used bottle feeding and 93.5% of households, mothers were usually taking care of babies feeding.
All of the children visited health institution for treatment of illness Tables 6,7.
As shown above from chi square test (At p-value<0.05), Exclusive breast feeding and colostrums squeezed out are   signifi cantly associated with stunting whereas the person who is caring the child is not signifi cantly associated with stunting.

Maternal characteristics
As indicated in Table 4, Mothers who gave fi rst birth at their age less than 18 years were 15.9%, while 84.1% were in b/n 18-28 years. Most of the mothers (92.8%) had ANC follow up Among these mothers 97.1% had good health during pregnancy.
About 93.8% of mothers had knowledge about family planning, and 74.5 %of mothers had used FP in the past. But Currently only 46.4% of mothers are using FP. Among them 66.5% of mothers are using Depo-Provera, 16.7% are using Implanol, 13.5% are using Pills and only 3.3% are using IUCD [13][14][15].
Regarding Hand washing, All mothers wash their hands after latrine use, before preparing food, before serving food and after cleansing child feace. 98.9% of mothers used water and soap for washing and 1.1% of them used only water for washing.
About 70.7% of mothers thought that their child physical looks normal, 13.8% looks thin, 9.4% looks heavy, 5.8% looks tall and 0.4% looks small. From the total number of   respondents 87.3% of mothers thought that EBF is given for the fi rst 6 months, 5.4% thought EBF should be given for less than 6 months whereas 7.2% of them thought should be given for more than 6 months Figure 5, Tables 8-10.

Environmental health condition
Majority of the respondents were using pipe water(99.3%) as shown in Table 5
Even though the prevalence of child malnutrition of our fi nding is lower than the above different studies, socioeconomic status, study subject, study period, sample size and the like might different compared with this study.
As indicated from this study about 5(1.8%) children had bilateral pitting edema.
It signifi es acute nutritional problem due to illness and/or recent food shortage. High chronic malnutrition also signifi es children's failure to grow; impact on both physical and mental capacity.
Variables like family size, income, maternal and paternal educational status, diarrhea, health status during pregnancy, ANC visit were highly signifi cant (associated) with chronic malnutrition (stunting) at P-value <0.005.

Conclusion
Based on the fi ndings of this study we can conclude that; child malnutrition is still high in the study area even though it is lower than the national and regional EDHS 2016 national report.
According to investigation of independent variables with dependent variables in chi-square test, marital status, number of children under 5 years, family size, monthly income of the HH, maternal and paternal educational status, place of delivery, type of birth, immunization, diarrhea, edema, EBF, health status during pregnancy and ANC visit were signifi cantly associated with chronic malnutrition (stunting).

Strength and limitation
Strength Valid questionnaires used in other studies were adapted for this study.
Finishing of the study in short period of time.

Limitation
I had done association factors for only stunting due to shortage of time. I couldn't address underweight and wasting.
Since, stunting is long term indicator of child malnutrition (chronic malnutrition) I had selected it.