1

PHARMA
HEALTH
SCIENCE

PREVALENCE AND CONTRIBUTING FACTOR TO MALNUTRITION AMONG

UNDER FIVE CHILDREN, ATTENDING PUBLIC HEALTH FACILITIES, WOLAITA

ZONE, SOUTHERN ETHIOPIA 2017 E.C.

Comprehensive Nursing 2017 Graduate Batch (Group Two).

Submitted to; Pharma health science college of Public Health and Nursing science,

Department of Comprehensive Nursing.

Advisor`s: Mr. Wosenseged Abera

(MSc PH)

Mr. Aschalew December, 2017

Mulugeta (Bsc PH) Wolayita, Ethiopia.
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 Group member`s, their Id number and roll.

Table 1. Group member, Id number and roll.

S.N Group member`s name Id No Roll

1. ABERASH BUSHO 401636 Member

2. DEREGE SHIBIRU 401728 Writer

3. EDIGET MEKONEN 401632 Casher

4. ELSA TADELE 401754 Member

5. EYOB TAMIRAT 401675 Leader

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 Acronyms and abbreviations.

Anti-Natal Care Pharma Health Science College Wolaiyta Sodo

(ANC), - 14 - Campus
Anti-retroviral Therapy (P/H/S/C/W/S/C), - 19 -
(ART), - 11 - Prevention of Mother-to-Child Transmission
(PMTCT), - 11 -
Bacille Calmette Guerin Probablity Value
(BCG), - 19 - (P-value), - 6 -
Body Mass Index Protable Document Format
(BMI), - 18 - (pdf), - 19 -
Protein Energy Malnutrition
Chi-square (PEM), - 5 -
(X2), - 6 -
Community-based Management of Acute Ready to Use Therapeutic Food
Malnutrition (RUTF), - 9 -
(CMAM), - 9 -
Confidence Interval Screening Tool of Assessment of Malnutrition in
(CI), - 6 - Pediatrics
(STAMP), - 17 -
Geneme Health Center Sever Acute Malnutrition
(G/H/C), - 11 - (SAM), - 9 -
Global Lidership Inotiatove of Malnutrition Statistical Packege for Social Sciences
(GLIM), - 18 - (SPSS), - 19 -
Gudimo Koysha Health Center Supplemental Feeding
(G/K/H/C), - 11 - (SF), - 8 -

Health Extension Workers Voluntary Counsling and Testing

(HEWs), - 14 - (VCT), - 11 -

Intrauterine Growth Restriction (IUGR), - 8 - Wadu Health Center

(W/H/C), - 11 -
Maternal and Child Health Wolaiyta Sodo University Comprehensive
(MCH), - 11 - Specialized Hospital
(WSUCSH), - 10 -
Out Patient Department World Health Organization
(OPD), - 16 - (WHO), - 20 -
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Contents

 GROUP MEMBER`S, THEIR ID NUMBER AND ROLL....................................................................................................... II

 ACRONYMS AND ABBREVIATIONS............................................................................................................................ III
 LIST OF TABLE..................................................................................................................................................... VI
 LIST OF FIGURE.................................................................................................................................................. VII

CHAPTER ONE................................................................................................................................................. - 1 -

INTRODUCTION............................................................................................................................................... - 1 -

I. BACKGROUND.................................................................................................................................................- 1 -
II. STATEMENT OF PROBLEM..................................................................................................................................- 2 -
III. SIGNIFICANCE OF STUDY...............................................................................................................................- 4 -
BASIC RESEARCH QUESTIONS......................................................................................................................................- 5 -

CHAPTER TWO................................................................................................................................................ - 6 -

LITERATURE REVIEW....................................................................................................................................... - 6 -

A. SOCIOECONOMIC FACTORS................................................................................................................................- 6 -
B. DEMOGRAPHIC FACTORS...................................................................................................................................- 7 -
C. CULTURAL FACTORS.........................................................................................................................................- 8 -

CHAPTER THREE............................................................................................................................................ - 10 -

OBJECTIVES................................................................................................................................................... - 10 -

I. GENERAL OBJECTIVE.......................................................................................................................................- 10 -
II. SPECIFIC OBJECTIVES......................................................................................................................................- 10 -

CHAPTERFOUR.............................................................................................................................................. - 11 -

METHODOLOGY............................................................................................................................................ - 11 -

I. Study area and period..........................................................................................................................- 11 -

II. Study design.........................................................................................................................................- 12 -
IV. Sample population...........................................................................................................................- 12 -
V. Study population...................................................................................................................................- 12 -
VI. Sample size determination...............................................................................................................- 12 -
VII. Sampling technique and procedure..................................................................................................- 14 -
VIII. Inclusion and exclusion criteria.........................................................................................................- 16 -
IX. Measurement...................................................................................................................................- 16 -
X. Data Collection Tools............................................................................................................................- 17 -
XI. Data Collection Procedure....................................................................................................................- 17 -
XII. Data Processing and Analyzing........................................................................................................- 19 -
XIII. Ethical Consideration........................................................................................................................- 19 -
XIV. Quality Control Measures.................................................................................................................- 20 -
XV. Disseminations Plan.........................................................................................................................- 20 -
XVI. Term`s and Operational Definition...................................................................................................- 20 -
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CHAPTER FIVE................................................................................................................................................. - 3 -

RESULT........................................................................................................................................................... - 3 -

CHAPTER SIX................................................................................................................................................... - 8 -

DISCUSSION.................................................................................................................................................... - 8 -

CHAPTER SEVEN............................................................................................................................................ - 15 -

WORK PLAN.................................................................................................................................................. - 15 -

CHAPTER....................................................................................................................................................... - 16 -

BUDGET........................................................................................................................................................ - 16 -

REFERENCES.................................................................................................................................................. - 17 -

ANNEX.......................................................................................................................................................... - 19 -
 QUESTIONNAIRES..........................................................................................................................................- 19 -
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 List of table.

Table 1. Group member, Id number and roll................................................................................................................ii

Table 3. Parameters and their scoring system.........................................................................................................- 1 -

Table 4. Socio demographic and economic characters of respondent.....................................................................- 3 -

Table 5. Nutritional status of under-five children by their care taker......................................................................- 6 -

Table 6. Time schedule..........................................................................................................................................- 15 -

Table 7. Budget schedule.......................................................................................................................................- 16 -

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 List of figure.

Figure A. Stratifying the study area........................................................................................................................- 16 -

Figure B. Z-score results by age of under-five OPD at WHC, GHC and GKHC...........................................................- 5 -

Figure C: Z-score results by age of under-five OPD at WHC, GHC and GKHC...........................................................- 5 -
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CHAPTER ONE.

Introduction.

I. Background.

Malnutrition is a state of nutrition in which a deficiency or an excess of energy, protein,

and other nutrients which cause measurable adverse effects on tissue body form for function and

clinical outcome. A magnitude of malnutrition has been shown through various studies that

children and women are the primary victims of malnutrition who suffer the most lasting

consequences. It is closely related to nutrition security (WHO, 2009).

Under nutrition, which is focus of this study, conversely has been estimated to be an

underlying cause for around half of all child deaths worldwide. It has different types of

measurements. Due to this fact, malnutrition continues to be a significant public health and

development concern not only in developing country but also in the world (Health, 2019).

Then child malnutrition still remains a public health problem mostly in developing

countries including Ethiopia. Deficiencies of both macro- and micronutrients impair the immune

system, with well-documented consequences. The most immediate consequence of under

nutrition is premature death (Hospital, 2016 GC) (Guideline, 2022).

The most frequently suggested causes of malnutrition are: poverty, low parental education,

lack of sanitation, low food intake, diarrhea and other infections, poor feeding practices, family

size, short birth intervals, maternal time availability, child rearing practices and seasonality.
 9

There are also economic, social, and cultural causes of malnutrition which underscore the close

link between malnutrition (Nutrition, 2021).

Children are most vulnerable to malnutrition in developing countries because of low

dietary intakes, lack of appropriate care, and inequitable distribution of food within the

household. (WHO, 2009).

II. Statement of problem.

Malnutrition is a serious problem because it causing the deaths of 3.5 million children

under 5 years old per- year in the world, as well as it is at third level in the world of the disease

burden in this age group.

In 2022, an estimated 149 million children under the age of 5 years were suffering from

stunting, while 37 million were living with overweight or obesity. Nearly half of deaths among

children under 5 years of age are linked to undernutrition. These mostly occur in low- and

middle-income countries (Ethiopia, 2024).

The global estimates conclude that stunting, severe wasting, and IUGR jointly contributes

to 2.2 million deaths of children<5 year of age. This accounts for 35% of all child mortality

globally, under nutrition have substantial consequences for survivors and their families by

requiring them to spend additional resources on health care and by affecting the productivity of

malnourished persons. There is substantial evidence that early child malnutrition is detrimental

to productivity in adulthood (WHO, 2009) (Ethiopia, 2024)

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Even though globally, childhood malnutrition declined relatively during the year 1990’s;

its prevalence in Africa actually increased even during 1990’. More than 25% under five children

in the developing world are malnourished which accounts about 143 million children.

Malnourished children often suffer the loss of precious mental capacities. They fall ill more

often. If they survive, they may grow up with lasting mental or physical disabilities

(Programme/United, 2007)

There are an estimated 3 million malnutrition is by far the largest contributor to child

mortality globally, cure present in 45% of all cases .Underweight births & IUGR are responsible

about 2.2 million children deaths annually in the world. Deficiencies in vitamin A or zinc cause 1

million deaths each year (Policy, 2019) (WHO, 2009)

This human suffering and waste happen because of illness much of it preventable; because

breastfeeding is stopped too early; because children are nutritional needs are not sufficiently

understood; because long-entrenched prejudices imprison women and children in poverty (Policy,

2019).

In Ethiopia, child malnutrition is one of the most serious public health problem and the

highest in the world. Nationally about 40% stunted, 25% underweight and 9% children were

wasted. Among all under-five children, the weighted analysis indicated that 2.14% children were

overweight/obese (Ethiopia, 2024; Policy, 2019).

In the wolaita zone the results of the current study showed that the prevalence of wasting

and underweight were 11.1% and 14.0%, respectively. Wasting was significantly associated with
 11

male gender, diarrheal morbidity and early initiation of complementary feeding. (Efrata Girma

Samson Kastro Dake, 2018)

The prevalence of wasting and underweight among under-five children is common in the

study area. Diarrheal morbidity was associated with both wasting and underweight. Inappropriate

child care, low socio economic status, cultural food taboos and illiterate parent are those from the

most encountered risk factor to the phenomena. Interventions targeting prevention of diarrheal

morbidity through hygienic practices and creating awareness on infant feeding practices need to

be implemented in the study area. (Efrata Girma Samson Kastro Dake, 2018)

III. Significance of study.

In Ethiopia, malnutrition is the underlying causes for over 58% of all under five deaths.

The country is one of the most exposed and least developed countries in the world where the

malnutrition cases highly rooted. Malnutrition is one of the major public health problems of the

country (Guideline, 2022; Nutrition, 2021).

Even if the factors for malnutrition occurrence are many, most of them are which we can

prevent or modified by public health intervention. Knowledge of the prevalence of malnutrition

and its determinants in a given country help so as appropriate intervention

The study of malnutrition, especially in developing countries, will remain important for a

long time to come. This is because vulnerable communities, families, and/or individuals therein

are likely to be adversely affected, with consequences of morbidity and mortality.

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Malnutrition, which is often overlooked by clinicians, is common and has wide-ranging

effects on physiological function. It is associated with increased rates of morbidity and mortality

in hospital patients and significantly increases healthcare costs. (Nutrition, 2021)

In summary this study is expected to enrich knowledge and provide information to health

centers and the community involvement for the existence of child malnutrition. Hence, this helps

them to plan how to minimize the prevalence, underlying cause and basic factor of nutritional

problems in children under five years.

Also the study enrich recognition to the faculty to assess their institutional vision, mission

and goal. Hence, the study also very significant to the group member by exploring the theoretical

knowledge to the practice with having some basic experience.

Basic research questions.

The study were mainly focused to answer on the following basic research question;

 The magnitude of malnutrition among in the study area

 The factor that contribute to the problem

 What possible intervention of actions to be taken by health centers to minimize these

identified contributing factors

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CHAPTER TWO

Literature review.

Malnutrition during childhood is as a result of a wide range of factors, most of which

relate to unsatisfactory food intake or severe and repeated infections, or a combinations of the

two (Nutrition, 2017).

The most frequently suggested causes of malnutrition are: poverty, low parental

education, lack of sanitation, low food intake, diarrhea and other infections, poor feeding

practices, family size, short birth intervals, maternal time availability, child rearing practices and

seasonality. There are also economic, social, and cultural causes of malnutrition which

underscore the close link between malnutrition (Hospital, 2016 GC; Nutrition, 2017)

The majority of studies on child nutritional status have described prevalence of

malnutrition among under-five children and analyzed socioeconomic, demographic and cultural

factors associated with child malnutrition.

A. Socioeconomic factors.

Poverty amplifies the risk of, and risks from, malnutrition. People who are poor are more

likely to be affected by different forms of malnutrition. Also, malnutrition increases health care

costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty

and ill-health. (Bekele A, 2024)

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Poorer children are not only more exposed to risks such as unhealthy sanitary conditions

or pollution, but also more likely to have lower resistance to illness – in part due to the links

between the immune system and nutrition, or suboptimal foetal development leading to low birth

weights (Hospital, 2016 GC; Efrata Girma Samson Kastro Dake, 2018).

The greatest risk of under nutrition occurs during pregnancy and in the first 2 years of

life, the effects of this early damage on health, brain development, intelligence, educability, and

productivity are potentially irreversible. Deficiencies of both macro- and micronutrients impair

the immune system, with well-documented consequences. The most immediate consequence of

under nutrition is premature death (Hospital, 2016 GC)

B. Demographic factors.

Child’s gender, age, birth size, preceding birth order, anemia status, maternal education,

work status, body weight, household wealth status, number of bedrooms were among

individual/household predictors of malnutrition.

On the community level, being from community with high wealth index, distance to

nearest health facilities is no big problem. Regional variations and gender inequality index were

the state level predictors of malnutrition among under five children (Mathewos Alemu

Gebremichael, 2019).

The global estimates conclude that stunting, severe wasting, and IUGR jointly contributes

to 2.2 million deaths of children <5 year of age. This accounts for 35% of all child mortality

globally, under nutrition have substantial consequences for survivors and their families by
 15

requiring them to spend additional resources on health care and by affecting the productivity of

malnourished persons. There is substantial evidence that early child malnutrition is detrimental

to productivity in adulthood (Efrata Girma Samson Kastro Dake, 2018)

C. Cultural factors.

Food taboos and misconceptions about food use contribute to the high levels of

undernutrition. In fact, it plays a significant role in determining the diets of pregnant and

lactating women, infants and young children (Nutrition, 2017; Mathewos Alemu Gebremichael,

2019)

Their understanding of food taboos, food taboos they knew restrictions during pregnancy

and breastfeeding (women); foods that they ate especially during pregnancy and lactation for

good health of the child, foods young children cannot eat according to cultural beliefs and foods

not eaten during illness according to cultural beliefs.

Malnutrition is a state of nutrition in which a deficiency or an excess of energy, protein,

and other nutrients which cause measurable adverse effects on tissue /body form for function and

clinical outcome. There are an estimated 3 million malnutrition is by far the largest contributor to

child mortality globally, cure present in 45% of all cases. Underweight births & Intrauterine

Growth Restriction (IUGR) are responsible about 2.2 million children deaths annually in the

world. Deficiencies in vitamin A or zinc cause 1 million deaths each year (Nutrition, 2021).

Children are most vulnerable to malnutrition in developing countries because of low

dietary intakes, lack of appropriate care, and inadequate distribution of food within the
 16

households. Malnutrition remains one of the most common causes of morbidity & mortality

among children throughout the world. (WHO, 2009)

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CHAPTER THREE

Objectives.

I. General objective.

 To assess the prevalence and factors contributing to malnutrition among under

five children attending public health center facilities in, wolayita zone, southern Ethiopia 2017

E.C.

II. Specific objectives.

 To assess the prevalence of malnutrition among under five children.

 To identify the contributing factors for malnutrition among under five.

 To compare the magnitude of malnutrition among the health facilities.

 To recommend possible measure of intervention to be taken by health centers and the

community.


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CHAPTERFOUR.

Methodology.

I. Study area and period.

Study was conducted in wolaita zone, city public health facilities of G/H/C, W/H/C and

G/K/H/C. G/H/C, W/H/C and G/K/H/C are among the city public health care facilities of

Wolaita Zone, South Ethiopia Region and with target population of 7150.

Wolaita zone is one of 6 zone in Southern Ethiopia Region and also the regional capital

located in the northern part of the region at 338 km distance from Addis Ababa. Soddo Town is

the capital city of wolaita zone and located in 6048`-6053`N latitude, 37044`-37046`E longitude,

at the altitude of 1500-2500m with an area of 82.1 km2.

The town is structured in 3 sub- cities and 11 administrative kebeles. There are 2 hospitals

(specialized), 10 health centers, 11 health posts & more than 21 private health institutions

providing health services in the town. G/H/C, S/C/H/C and G/K/H/C are among 10 health

centers. They give services for the community such as promotive, curative, preventive,

admission services and referral management.

There are out patient department, MCH, delivery service, ART clinic service, VCT, , and

other public health services were offered to the community 7 days in the week and 24 hour of

service.
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The community earn their livelihood being employed in the civil services, non-government

organizations, trading, small-scale industries (woodwork, metalwork) and other petty businesses,

the main staple food of the population is teff and maize. The climate is stable, the dry temperate

heat makes the climate simply ''delicious'. The main spoken language in the community was

“WOLYTATTUWA”

The survey was conducted from December 04 – December 24/2017 E.C.

II. Study design.

A facility based cross-sectional study design was used to assess the prevalence and

associated factor of malnutrition among under-five children.

III. Source population.

All under-five children who live in wolayita zone, G/H/C, W/H/C and G/K/H/C catchment

area.

IV. Sample population.

All under five children, that came to visit G/H/C, W/H/C and G/K/H/C in the need of

different health services.

V. Study population.

All randomly selected under-five children paired with their mothers/care giver.

VI. Sample size determination.

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The sample size were calculated by group member`s. The required sample size of the study

were calculated by considering the prevalence of malnutrition in wolayita zone, 25.1% (0.25)

(Efrata Girma Samson Kastro Dake, 2018)

With 95% confidence interval and using proportion of 25.1% (0.25) and marginal error of

5% the required sample size for population more than 10,000 will be determined by the formula:

N = (zα/2)2 P (1-p) 2

d2

Where n= minimum sample size required

P = prevalence of malnutrition = 0.25

Zα/2 = the standard normal variable with 95% CI at (1-α) % confidence level and α is

mostly 5% =1.96

d = the standard error = 0.05

ni = zα/22 P (1-p)

d2

ni= (1.96)2 0.25(1-0.25)

(0.05)2

ni= 288
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Calculated sample size = 288

Since the source population is 7150 which is less than 10,000, so it needs finite population

correction formula.

n = nₒ/ (1+ (nₒ/N))

Where n=adjusted sample size

no = initial sample size

N=total population of under five children which is 7150.

‘’NF=278 where adding 10% non-respondent rate 305.8 ≈ 306.

Then totally 306 sample size was used.

VII. Sampling technique and procedure.

Stratified random sampling technique was used and the health facilities are grouped

under three strata (A, B and C) and proportional allocation method was used to assure a

representative sample of key subgroups.

The formula for proportional allocation method is:

ni = (n * Ni) / N
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Where:

ni; is the sample size for the nth stratum

N; is total population

n; is total sample size to be selected

Ni; is total population of each strata

Strata 1. W/H/C = (306*2380)/7150 = 102

Strata 2. G/H/C = (306*2085)/7150 = 89

Strata 3. G/K/H/C = (306*2685)/7150 = 115

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Figure A. Stratifying the study area.

VIII. Inclusion and exclusion criteria.

 Inclusion criteria

 All children under five years of age, who came to visit the OPD at study area.

 Willing subjects (whose mother/care taker who gave orally expressed consent

were a part of the study).

 Exclusion criteria.

 Children those were critically ill and need`s emergent medical intervention,

and difficult for measurement.

IX. Measurement.

 Dependent Variable

 Undernutrition.

 Independent Variables
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 Determinant of malnutrition.

 Parental factors; Occupation, Educational status, sex of child

 Environmental factor; Housing, Water source

 Nutritional factors; Breast feeding, decreased food intake, Complementary

feeding

 Health factor; Illness of the child, Immunization status

 Socio-economic factor; monthly income, household wealth index

X. Data Collection Tools

 STAMP (Mod)

 Semi-structured questionnaire

 Z-score model.

Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP Mod)-

modified is derived from a screening tool developed for use in hospitalized children that was

modified for use outpatient department.

XI. Data Collection Procedure.

Interview was conducted with mothers/care takers of the children to fill the questionnaire.

Structured questionnaire interviewer administered were used which was adapted from different

literatures in English to enable the comparability of the finding and was translated into

“Wolaytattuwa” language orally during interview for field work purpose and back to English for
 25

checking language consistency. It consists of socio-economic, demographic, child

characteristics, child caring practices, and environmental health condition and other.

Weight was measured with minimum clothing and no shoes using a beam balance in

kilogram to the nearest of 0.1 digits. Weighing scales was calibrated with known weight object

regularly.

The ace scales indicators were checked against zero reading after weighing every child

and Oedema was checked and noted on data sheet because children with edema were severely

malnourished.

In order to determine the presence of edema, normal thumb pressure was applied to the

two feet for three seconds whether a shallow print or pint remains on both feet when the thumb is

lifted.

Weight loss, reduced BMI, and reduced muscle mass were categorized as phenotypic

criteria, and reduced food intake and disease burden as etiologic criteria. For the diagnosis of

malnutrition, GLIM recommends that the combination of at least one phenotypic criterion and

one etiologic criterion is required.

The selection of threshold values for the consensus diagnostic criteria was guided by

review of existing approaches used in assessment as was the selection of threshold values for

severity grading described in table.

To identify reduced food intake, disease burden mothers was asked about any occurrence

of illness during the past two weeks. Enumerators investigate to confirm nature of illness based
 26

on operational case definition and also ask to identify occurrence of measles in the past one year.

Vaccination status of children was checked by observing immunization card and if not

available mothers was asked to recall it. BCG vaccination was checked by observing scar on

right (also left) arm scar.

XII. Data Processing and Analyzing.

Collected data were sorted in accordance to their collected date and quality control was

made in each day after data collection, the collected data was processed by SPSS software and,

data entry and verification was also made by computer. After assuring the completeness of

processed data, the analysis was made, to quantitative data by using simple frequency table,

charts & pdf, and qualitative data will be presented by pdf.

XIII. Ethical Consideration.

The survey were conducted after the approval of the research proposal by advisor`s (Mr

Aschlew M, Mr Wosenseged A) and PHSCSC nursing department office, ethical clearance

committee. Official letter from PHSCWSC was offered to the study area health facilities and the

general information regard to the survey was explained to the health facilities

curator/representative after introduction/greeting and after the sanction the written formal assent

was assigned with the health facilities curator/representative.

Written assent letter was showed to the each mother/care taker (if, unable to read the

assent was orally translated to the main language). Permission and verbal consents was also
 27

obtained from each respondent. General information were explained and confidentiality was

assured before conducting data collection process.

XIV. Quality Control Measures.

The collected data was checked for its completeness, accuracy, clarity, and consistency

every day by group member.

XV. Disseminations Plan.

The finding of the survey was disseminated to the facilities. And also submitted to

PHSCWSC of public health and nursing sciences, department of nursing.

XVI. Term`s and Operational Definition.

Definite nutritional implications: - any chronic GI condition that adversely impacts

food assimilation or absorption and, the consequence of how a child eat/feed on their health

(according to the WHO appropriate child nutrition), occurrence of illness and chronic disease.

i. Bowel failure, intractable diarrhea vii. Major surgery

ii. Burns and major trauma viii. Multiple food allergies/intolerances

iii. Crohn's disease ix. Oncology on active treatment

iv. Cystic fibrosis x. Renal disease/failure

v. Dysphagia xi. Inborn errors of metabolism

vi. Liver disease

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Possible nutritional implications: - potential health effect.

i. Behavioural eating problems vi. Minor surgery

ii. Cleft lip and palate vii. Neuromuscular conditions

iii. Coeliac disease viii. Psychiatric disorders

iv. Diabetes ix. Respiratory syncytial virus (RSV)

v. Gastro-oesophageal reflux x. Single food allergy/intolerance

No nutritional implication.

i. Day case surgery iv. Medications

ii. Investigations
v. Poor water, sanitation, and
iii. Social and cultural norms
hygiene

Recently decreased or poor nutritional intake: - unusual behavioral experience by child.

i. A lack of appetite or interest in food iv. Loss of fat, muscle mass, and body

or drink tissue

ii. Tiredness and irritability v. Frequently getting sick and taking

iii. Always feeling cold longer to recover

vi. Longer healing time for wounds

No change in eating patterns and good nutritional intake: - child who score 0 in all the above

parameters.

Table 2. Parameters and their scoring system.

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Step 1 - Diagnosis

Does the child have a diagnosis that has any nutritional implications? Score

A Definite nutritional implications 3

B Possible nutritional implications 2

C No nutritional implications 0

Step 2 - Nutritional Intake

What is the child's nutritional intake? Score

D No nutritional intake 3

E Recently decreased or poor nutritional intake 2

F No change in eating patterns and good nutritional intake 0

Step 3 - Weight and Height

Use the centile quick reference tables to determine the child's measurements Score

G > 3 centile spaces/≥3 columns apart (or weight < 2nd centile) 3

H > 2 centile spaces/= 2 columns apart 1

I 0 to 1 centile spaces/columns apart 0

Each component is scored from 1-3 with the total score reflecting the risk of

undernutrition. A score of 1 to 3 indicates medium risk and a score > 4 indicates high risk.

Score 3 for presence of ≥3 parameters, 2 for presence of ≤2 parameters and 0 for none.
 30

CHAPTER FIVE

Result.

A total of 280 children 0 - 59 month of age and their mothers/care takers, participated in

the study, providing 91.5% response rate. Out of these (78.9%) of the willing subject were

mothers. The largest proportion (47.2%) of the children were in the age range of 13-35 months,

68 (24.4%) were in the group of 36-59 months, (19.5%) was in the age 6-12months, and (8.9%)

were in the age of <6months. The 52.8% were females.

Majority of the house hold 54.5% had 2-3 under five children while 45.5% household had

single under-five children. The majority of mothers were married 89.2%, protestant religion

followers 54.2%. Most mothers 75% were Wolayita in ethnicity. The mean age group of the

mothers was 25-35 years (table 4).

About 21.1% of mothers were illiterate and the rest 79% were literate, and only 11.3% of

the fathers are illiterate

Trade was the most frequent occupation (35%) among the mothers and the least

proportion of them 8.9% were private job. The biggest 15.3% of the fathers were government

employers followed by farmers 12.5%. The mean family size was 5. The greater portion of

respondent (78.9 %) had a monthly income between 500-1000 (table 4).

Table 3. Socio demographic and economic characters of respondent.

SN Category Category Number Percentage

 31

1 Ethnicity Wolayita 210 75

Gurage 30 10.7
Gamo gofa 35 12.5
Amahara 5 1.7
2 Religion Protestant 152 54.2
Orthodox 98 35
Muslim 20 7.1
Catholic 10 3.5
4 Marital status Married 250 89.2
Widowed 7 2.5
Divorced 20 7.1
Single 3 1
5 Family size 2-5 205 73.2
>-5 75 26.7
6 Sex of child Male 123 47.1
Female 148 52.8
7 Age of child in month <6 24 8.5
6-12 54 19.2
13-35 134 47.8
36-59 68 24.4
8 No of <5 year children 1 56 20
2-3 224 80
9 Maternal level of education Illiterate 26 9.2
1-8 14 5
9-12 88 31.4
Above 93 33.2
10 Paternal level of education Illiterate 0 0
1-8 10 3.5
9-12 15 5.3
Above 34 12.1
11 Maternal occupation House wife 77 62.6
Farmer 0 0
Merchant 98 35
Employee 20 16.2
Private gob 11 3.9
12 Paternal occupation Gov’t 43 35
Employee 32 25.9
Farmer 35 12.5
Merchant 11 8.9
Private gob 11 8.9
Daily laborer 0 0
13 Monthly income 500 26 9.2
500-10000 221 78.9
>10000 33 11.7
 32

From the total 280 respondents 28(10%) are stunting, 11(3.9%) are wasting, 6(2.1%) are

under weight. The largest (54.8%) prevalence of PEM was found in GKHC. The prevalence of

PEM was 31(11%) and out of this, prevalence of stunting, wasting and underweight were 90.3%,

35.5 % and 19.4% respectively, and 29% 12.9%, 3.2% are kwashiorkor, marasmic ,and

marasmic-kwash respectively.

Figure B. Z-score results by age of under-five OPD at WHC, GHC and GKHC.

Figure C: Z-score results by age of under-five OPD at WHC, GHC and GKHC.
 33

Table 4. Nutritional status of under-five children by their care taker.

Nutritional status X2 P-value CI

PEM Normal
No % No %
1 Male 15 5.35 130 46.4 5.7 0.1 1.11
Female 16 5.71 119 42.5
2 Decreased 30 5.04 0.025 1.58
appetite
Yes 21 7.5 175
No 10 3.5 85
Months 5.04 0.025 2.58
13-36 10 3.5 71 25.3
37-59 9 3.2 96 34.2
3 Immunized 1 5.89 <0.005 1.7
Not 14 5 3
Partial 3 1 12
Fully 0

4 SF 6.7 6.81 <0.0005 2.36

Before 6 mo 12 4.2 19
After 6 mo 19 6.7 14
5 Edema 97.1 4.56 0.03 1.56
Grade + 10 3.5 18
Grade ++,+++ 3 1 29

6 Measle 72.8 20.25 <0.0005 4.64

Positive 25 8.9 6
Negative 6 2.1 12
7 Diarrhea 37.5 12.05 <0.0005 4.44
Yes 28 10.3 3
No 3 1 11
8 Fever 8.9 15.5 <0.0005 5.16
Yes 6 2.1 25
No 25 8.9 5

9 Weight loss 7.5 26.34 <0.0005 0.04

Yes 10 3.5 21
No 21 7.5 15
10 EBF 28.9 0.15 0.1 3.11
6 mo 10 3.5 81
>6 mo 7 2.5 74
<6 mo 14 5 21
 34

Income 15.2 84.8 0.006 3 3

<500 ETB 16 5.7 44
500 – 1000 ETB 10 3.5 14
>1000 ETB 5 1.7 24
Illiterate 27 9.6 13 14.1 85.9 10 81
Literate 4 1.4 79

Family size 4.56 0.03 2.5

2-5 5 1.7 50 54.3
>5 26 9.2 42 45.7
 35

CHAPTER SIX

Discussion.
In Ethiopia and other developing countries as well as to the study area, malnutrition

among children is a major health problem. Nationally, 40 percent of children under age five are

stunted, 9 percent of Ethiopian children are wasted, and 25 percent of children under age five are

under weight (Ethiopia, 2024).

In our study from the total 280 respondents 28(10%) are stunting, 11(3.9%) are wasting,

6(2.1%) are underweight, this implies that though stunting and underweight finding in our study

are smaller, the prevalence of wasting was the same as that of the national level (table 5).

Factors associated with stunting

The results from the Z-score method showed that educational status, SF, disease

occurrence and age of the child were significantly associated with stunting. The odds of stunting

were 2.90 and 1.98 times more likely among children whose mothers were from GKHC and

GHC, respectively, compared to those who were from WHC. The likelihood of stunting was 3.79

times more likely among children in the age group of 13–36 months compared to those who were

less than 12 months.

Factors associated with wasting

The results from Z-score method showed that disease occurrence, household wealth

index, and maternal/paternal educational status were significantly associated with wasting. Our
 36

study shows that wasting was more common among children whose mothers were from GKHC

and GHC compared to those who were from WHC. The risk of wasting was 0.47 times less

likely for children who are from the >1000 monthly income and educational status >9 and above,

compared to those who are from the 500 monthly income and educational status <9.

The findings of this study revealed that PEM was 31(11%) and out of this prevalence of

stunting, wasting and underweight were 90.3%, 35.5 % and 19.4% respectively, and 29% 12.9%,

3.2% are kwashiorkor, marasmic ,and marasmic-kwash respectively, but comparing with the

report of similar study which is done at WSUCSH, it is much better. And out of the total (16%),

prevalence of stunting, wasting and under-weight were 90.3%, 35.5 % and 19.4% respectively,

and 29% 12.9%, 3.2% are kwashiorkor, marasmic, and marasmic-kwash respectively (table 5).

Factors associated with PEM.

In fact, low socioeconomic status can result in problems with nutritional status of

children that could come from low intake of a balanced diet, irregular diet intake, low health care

coverage (Nutrition, 2021).

In this study, GKHC was found to be significantly associated with stunting. This could be

due to the socio-economic status, residence, and feeding style variations.

Even though health workers provide RUTF as a treatment for SAM children, their

caregivers use it also for meeting broader food and economic needs of the household

endangering the effectiveness of CMAM program. In chronically food insecure contexts,

 37

interventions that also address economic and food needs of entire household are essential to

ensure successful treatment of SAM children. This may need a shift to view SAM as a symptom

of broader problems affecting a family rather than a disease in an individual child (Health, 2019).

Although the prevalence of wasting and underweight are better than the similar study

report in WSUCSH, the prevalence of stunting remains higher which needs the attention of all

concerned bodies (Hospital, 2016 GC).

The result of this study indicates that the prevalence of PEM among children aged 13-36

month was 3.5%. The possible reason for this was 70.7% of the mothers stop breast fed at the

age of less than or equal 2 years old and probably some mothers start to induce complementary

foods too late, Surprisingly 4.8% of mothers introduce it to their children after 12 months

celebration. And this age group is also susceptible for diarrheal disease, intestinal parasites and

others acute infections as well.

Breast feeding is norm in Ethiopia; nearly all the children in both group were breast fed.

The national survey indicates that 96% of children under age of five are breast fed (14). The

finding of this study indicates the prevalence of PEM was 11% (x2=5.7, P= 0.1)

The majority (11.3%) of children who were presented with diarrheal disease were being

PEM children’s from diarrhea were 14 times more likely to have risk of PEM. Even though other

disease is associated to malnutrition, diarrhea is the leading cause of morbidity and mortality in

children. There is reciprocal relationship with diarrhea leading to malnutrition and malnutrition

predisposing to diarrhea.
 38

Diarrhea kills over one million children every year through dehydration and malnutrition

(WHO, 2009). The prevalence of PEM of the non-immunized was 5% and they are more at risk

of being PEM than those who are immunized for their age. The reason for immunized children

become malnourished was probably, if other factors were existed

Economic status of the household can directly indicates the level of household food

security is positively associated with PEM. The prevalence of PEM in children from households

having monthly income less than 500 birr were 5.7 and they more at risk of being PEM than

those children from household having monthly income 500 – 1000 and >1000. Household

economic status can affect children’s nutritional status through its association with adequate

dietary intake, use of health service, improved water resource and sanitation facilities. Similar

result was reported in sub-Saharan African countries.

Maternal education has positive effect on nutritional status of the children. The result of

this study shows the prevalence of PEM in children’s from illiterate mothers were 9.6% and

children’s from illiterate mothers more likely to have risk of PEM than those from literate

mothers.

In general, women’s education affects the knowledge and attitude of parents which in

turn affect their fertility behavior, their use of health service and their access to information

(Mathewos Alemu Gebremichael, 2019). Hence, considering the importance of women’s

education for the improvement of children’s nutritional status as crucial, more deliberate effort

by local government administrator and educational personnel is needed to improve educational

opportunities for female children as long term strategy (Efrata Girma Samson Kastro Dake,

2018).
 39

The prevalence of PEM in children who were from total family size greater than 5 was

9.2%. A larger family size was also associated with PEM (x2 =4.56, p=0.03). The effect of large

family size with overcrowding and inadequate spacing has been implicated as a risk factor for

severe malnutrition in different studies as well (Hospital, 2016 GC)

Strengths and limitations of the study

The study used national data collected from different nations and this, can be considered

strength of the study. Due to the cross-section design of the study, it is difficult to establish a

temporal association between under-nutrition and other independent variables. Besides, recall

bias can occur when reporting the age of the child.

CONCLUSION.

From this study what we concluded is that there was low prevalence of malnutrition.

Stunting 28% was dominant over the wasting 3.9% and underweight 2.1%.

The prevalence of PEM among under-five children among those attending under- five

OPD at GKHC was needs urgent intervention to save the lives. Malnutrition is continued to be a

substantial burden in under five age children in GKHC.

The finding of this study confirmed that demographic and socio-economic factors and

many other independent variables had significant association Such as; household economic

status, family size was affect children’s nutritional status through its direct association with

adequate dietary intake. Maternal educational status, immunization status, time of initiation of

complementary foods had a massive effect on the establishment of PEM.

 40

RECOMMENDATION.

To reduce childhood malnutrition due emphasis should be given in both community and

health sector sides.

For the community.

a) Child age specific attention should be given while feeding.

b) Availability of food alone was not sufficient to address the nutritional security of

children, as they need someone to feed them, teach and guide them, and take them to receive

healthcare whenever they become sick.

c) Late initiation of complementary feeding, and Pre-lacteal feeding to the child, were

common among the studied children, such habits need to be tackled by practicing appropriate

feeding.

d) Breast feeding after six months of age needs integration with appropriate

complementary feeding

For the health sector.

Community based nutrition program should be established to tackle the problem of

malnutrition at community level depending on the severity of malnutrition identified in this

study.

Nutrition education by health extension works should be strengthening to improving the

feeding practice of parents on appropriate children feeding.

 41

a) Encouraging and strengthening appropriate complementary feeding with breast feeding

child soon after six months of ages.

b) Health Extension Workers (HEWs) and other health professionals should take a part

on improving the knowledge and practices of parents through nutrition education on appropriate

feeding practice through community based nutrition program in the study area in order to

accelerate improvement in children’s nutritional status

c) Availability and accessibility of ANC services and institutional delivery to pregnant

women should be increased as a means to improve long term nutritional and survival status of

children.

d) Regular de worming service to children should be strengthened

Acknowledgment.

Firstly, we would like to forward our deepest gratitude to Pharma Health Science

College. We would like to express our heartfelt thanks to Mr. Aschalew Mulugeta (BSc, PH) and

Mr. Wosenseged Abera (MSc PH) for their constructive advice, feedback, comment and valuable

suggestions offered. We would like to acknowledge with gratitude all the individuals who

facilitated the implementation of study. We also extend our gratitude to all study participants for

their time and willingness to take part in the study.

 42

CHAPTER SEVEN.

Work plan.

Table 5. Time schedule.

SN Activity October October October Nove Novemb November January

15 - 17 18 - 20 21 - 30 mber er 6 - 12 29 - 1-7
1-5 December
30
1 Cover page
design
2 Reviewing
referencing
literature
3 Specific
objectives
4 Methodology
5 Work plan &
budget
6 Questionnaire
7 Submission of
proposal
8 Proposal
presentation
9 Data collection,
processing and
analyze
10 Documentation
11 Finalized research
finding
submission
 43

CHAPTER.

Budget.

Table 6. Budget schedule.

SN Item Unit Quantity Cost/unit Total/ETB

1 Food, water & - Launch & 100 1200

coffee/tea snacks

2 Umbrella - 3 300 900

3 Copying page 1 379 1895

questionnaire

4 Transport - - 1000

5 Pencil - 5 20

6 Paper Rim 50 - 25

7 Camera - 5 - -

8 Tally sheet/paper paper 1 50 25

9 Kilogram - 3

10 MUC tape - 3 150

11 Meter - 3 200

12 Computer writing Page 60 20 1200

13 Contingency 1083

14 Subtotal 5415
 44

References

• Samson Kastro Dake, •. E. T. B. •. H. A. T. •. T. M. B. •. B. N. A. &. •. F. B. S., 2018. BMC Research Notes.

[Online]

Available at: [Link]

[Accessed 3 november 2018].

Bekele A, T. M. M. P. o. m. a. i. a. f. a. u. f. i. h. i. o. S. E. a. c.-s. s., 2024. BMC Nutrition. [Online]

Available at: [Link]

[Accessed 02 January 2024].

Efrata Girma Samson Kastro Dake, •. E. T. B. •. H. A. T. •. T. M. B. •. B. N. A. &. •. F. B. S., 2018. BMC Research

Notes. [Online]

Available at: [Link]

[Accessed 3 september 2018].

Ethiopia, F. D. R. o., 2024. NIPN Ethiopia. [Online]

Available at: [Link]

[Accessed 7 November 2024].

Guideline, I. H. T., 2022. [Link]. [Online]

Available at: [Link]

[Accessed 8 december 2022].

Health, N. I. o., 2019. PMC. [Online]

Available at: [Link]

[Accessed 28 March 2019].

Hospital, W. s. u., 2016 GC. CORE. [Online]

Available at: [Link]

[Accessed 15 November 2016 GC].

 45

Mathewos Alemu Gebremichael, M. M. M. 2. S. H. 2. H. A. 2. A. A. 3. B. B. W., 2019. PubMed. [Online]

Available at: [Link]

[Accessed 12 agust 2019].

Nutrition, F. D. o. E. F. a., 2017. [Link]. [Online]

Available at: [Link]

[Accessed 17 July 2017].

Nutrition, H. p. a., 2021. Health update. [Online]

Available at: [Link]

[Accessed 23 July 2021].

Policy, F. a. N., 2019. NIPN. [Online]

Available at: [Link]

[Accessed 07 september 2019].

Programme/United, ©. W. H. O. F., 2007. Unicef. [Online]

Available at: [Link]

[Accessed 9 may 2007].

Program, T. D., 2017. The DSH pROGRAM. [Online]

Available at: [Link]

[Accessed 13 june 2017].

WHO, 1., 2009. World Health Organization & United Nations Children's Fund (UNICEF). [Online]

Available at: [Link]

[Accessed 01 jan 2009].

 46

Annex.

 Questionnaires.

Part one- Information to the respondent.

Good morning/afternoon?

We come from the Faculty of Health Sciences Nursing department of Pharma Health

Science College. We are currently conducting a survey of prevalence and its associated factor on

malnutrition in this health center and we have also written assent to conduct this study (show the

assent to the mother/care taker).

The purpose of the study is to determine the prevalence and its associated factor of the

problems in your son/daughter and to solve them as best we can and to refer the problems

beyond our capabilities to various parties. You and your son/daughter is included in the survey

according to the research methodology.

There is no harm in participating in this study, also participation in this study does not

earn you any money. But by participating in this study, you will be making a significant

contribution to improving the health of your son/daughter.

So we would like to ask you some questions perform some procedures on your

son/daughter. Your truthful answer will contribute to the success of this study. The information

you provide will not be passed on to any third party except for the researcher and interviewer.

You have the full right not to participate or to withdraw yourself from the study at any time,

while we ask for your participation to be voluntary.

 47

Do you agree to participate in this survey?

1. Yes 2. No

If the participant answers "No", acknowledge and go ahead.

If yes, answer;

Participant: Signature .

Petitioner: Name_______________ Signature .

Part two- General information

Date: - Day . Month . Year .

Registered by: - .

Name of head of house hold: - .

1. Number of children 0 to 59 months of age .

2. Age of mother/care takers .

3. Education level of mother or care takers:-

A. 1 – 8 B. 9 – 12 C. Diploma and above E. illiterate

 48

4. Occupation:-A. Farmer B Merchant C. Daily laborer Civil-servant E. Others .

5. Ethnic A. Wolaitta B. Amhara C. Guraghe D. Tigre E. Other .

6. Marital status: - A. Married B. Single C. Widow D. Divorced

7. Religion: - A. Muslim B Orthodox C Protestant D. Catholic E. Other--

8. Family size A. <5 B. 6-10 C. >10

9. Water supply:-

A. pip bono B. pip in the yard. C. other

10. Estimated monthly income in Birr ETB.

A. <500 B. 500 - 1000 C. >1000

Part three- Questions directed to mother/care taker

1. Age at first marriage .

2 use of family planning 1 Yes 2 No

3. Number of children alive:-Male . Female .

4. Number of children total:-Male . Female .

5. Do you usually take your child to health institution when sick? 1. Yes [Link]

If not, where do you prefer to take? .

7. Do you now on breast feeding. 1. Yes 2. No

 49

If yes; how much you drink per day (any liquid rather than alcoholic content) (ml)

- How frequent have you eat per day times/day

8. Does a child have a history/event of recent trauma or burn? 1. Yes 2. No

9. Does a child have any a diagnosis of GI problem? 1. Yes 2. No

10. Does a child refuse to swallow or get difficult to feed? 1. Yes 2. No

11. Does a child had a history of recent surgery? 1. Yes 2. No

12. Does a child has any food allergies? 1. Yes 2. No

13. Does a child eagerly feed with each feeding frequency? 1. Yes 2. No

14. Does a child congenital anomalies (cleft lip and palate) Inspection

15. Does a child have a DM? 1. Yes 2. No

16. Do you agree with that feeding child in accordance to WHO and UNICEF appropriate

neonatal and child care practice? 1. Strongly agree 2. Disagree 3. Neutral

17. Does a child recently received PO medication? 1. Yes 2. No

18. Is the child now on breast feeding? 1. Yes 2. No

Do you give other food additional to the breast milk (additional food for not breast feeding now)

1. Yes 2. No

If yes, what kind of food

 50

A. Egg B. Fruit (orange, papaya, mangos, Avocado) C. porridge D. Mashed potatoes

E. cereal and legume mixes (shiro, kik) F. Mashed meat G. vegetables (green leafy,

carrots, mashed gommen)

19. How frequent do you give these food`s in one day?

A. One time in a day B. 2 - 3 times in a day C. 4 - 5 times in a day

20. Do you have a habit of giving snacks to your child 1. Yes 2. No

If yes, how frequent A. one`s in a day B. two times in a day C. more than two times in a day

21. Do you give cow milk to your child?

If yes, how frequent do you give the child cow milk per day.

A. with (as) breakfast B. with (as) launch C. with (as) dinner D. at all.

22. How much you give in each feeding?

A. 1 cup B. 2 cup`s C. 3 cup`s D. 4 cup`s E. more than 4 cup`s

23. Habit of utensils processing and antiseptic hand washing.

Do you protect the cleanness of the dishes? 1. Yes 2. No

If yes, how frequent? A. before and after each feeding B. after feeding only C. before feeding

only D. scarcely before feeding E. scarcely after feeding

24. Do you wash your hand when you are to feed your child? 1. Yes 2. No

If yes, tell me how you wash your hand? .

 51

Part four- For child of 0 to 59 months of age:-

Conducted by assessing, measuring and asking to the mother.

1. Age . Sex .

2. Anthropometric measurement:-

First Second Third time Average

Weight kg.

Height cm.

BMI kg/m2.

Is the child had edema?

If present; A. pitting B. non pitting

3. Immunization status:-

A. Not vaccinated B Partially vaccinated

C. Fully vaccinated D. Not known

4. History of illness in the last one week:-

Refuse to feed A. Yes B. No

Anorexia A. Yes B. No

Fever A. Yes B. No
 52

Diarrhea A. Yes B. No, if yes frequency of diarrhea

A. 1 episode B.2 episode C. 3-4 episode D. >-5

Vomiting A. Yes B. No

5. Severity of illness:-

Did the child stay in bed? A. Yes B. No

If yes, for how long? (In days).

Did the illness subside by itself? A. Yes B. No

If not, did you take him/her to health institution?

1. Yes 2. No

6. Do the child breast feed now? 1. Yes 2. No

If yes, when is breast feed given?

1. When child cry 2. According to time scheduled

3. According to mothers feeling 4. Other

7. at what age initiation of breast feeding started

A. immediately

B. after 1-24 hours C after a day

8. till what age is the child given EBM (in months)

 53

A.1-3 B. 4-5 C. 6. D.7-12

9. At what age is the child given supplemental feeding?

A. before 6 months B. At 6 month

C. 7 to 9 months D. 10 to 12 months

E. after 12 months

10. at this age, how frequent should the child eat?

A. Less than 3times B. 3-4 times C. 5-6 times

D. Greater than six times.

THANK YOU!!!

እናመስግናለን !!!

GALATETTES!!!