Open Journal of Epidemiology, 2019, 9, 15-26

http://www.scirp.org/journal/ojepi
ISSN Online: 2165-7467
ISSN Print: 2165-7459

The Determinants of Anthropometric Deficits

in Children under Five Years Old in Tete
Province Mozambique Using Hierarchy
Approach

Jonas B. Daniel1*, Elisabete Pinto2, Valterlinda de Oliveira Queiroz1, Ana Marlucia de Oliveira1

School of Nutrition, Federal University of Bahia, Salvador, Brazil

1

Center of Health Sciences, Federal University of Recôncavo of Bahia, Santo António de Jesus, Brazil
2

How to cite this paper: Daniel, J.B., Pinto, Abstract

E., Queiroz, V. de O. and de Oliveira, A.M.
(2019) The Determinants of Anthropome- Introduction: The malnutrition in children under 5 years is a serious public
tric Deficits in Children under Five Years health problem in the developing countries such as Mozambique. The stunt-
Old in Tete Province Mozambique Using ing can affect cognitive and physical development and compromise the
Hierarchy Approach. Open Journal of
school performance. Method: A cross sectional study was carried out which
Epidemiology, 9, 15-26.
https://doi.org/10.4236/ojepi.2019.91002 used the secondary data from a survey conducted by National Health Insti-
tute of Mozambique, in districts of Angonia, Tsangano, Magoe and Changara
Received: October 23, 2018 in Tete Province, Mozambique. The polynomial regression model and the
Accepted: December 26, 2018
hierarchical approach were used to examine the association between social
Published: December 29, 2018
economic factors and malnutrition in children measured by stunting (low
Copyright © 2019 by authors and height for age) and underweight (low weight for age). Results: The preva-
Scientific Research Publishing Inc. lence of moderate and severe stunting was 39.8%, and prevalence of moderate
This work is licensed under the Creative and severe underweight was 19.6%. In the basic level, the households that
Commons Attribution International
License (CC BY 4.0).
had 1 durable goods possession were associated to 1.46 times greater than the
http://creativecommons.org/licenses/by/4.0/ mild underweight, OR = 1.46 (C.I. 95% 1.02 - 2.11). In the intermediate lev-
Open Access el, lack of latrine increased 2.01 times greater than the moderate and severe
underweight in children, OR = 2.01 (C.I. 95% 1.09 - 3.70); In the immediate
level, the child deworming had 1.91 times greater than the moderate and se-
vere stunting, OR = 1.91 (C.I.95% 1.04 - 3.52) and children who did not
breastfeed had 2.42 times greater than the moderate and severe stunting, OR
= 2.42 (C.I. 1.49 - 3.43). Conclusion: In the countries where the weak health
system and the inadequate children food are frequent, the prevalence of un-
dernutrition in children remains very high.

Keywords
Child, Underweight, Stunting, Hierarchy Approach, Tete, Mozambique

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J. B. Daniel et al.

1. Introduction
Malnutrition is a public health problem in developing countries. It affects more
than one third of children and is directly associated with morbidity and mortali-
ty in children under 05 years old in the world [1]. The underweight (low weight
for age) and stunting (low height for age) are declining worldwide from 1990 to
2010, while the prevalence of underweight and stunting decreased from 24.8% to
16.2% and 39.9% to 24.8% respectively [2]. In the African continent, especially
in north of Africa the prevalence of underweight in children under five years
decreased from 30% to 18.4% [2]. In Sub-Saharan Africa it decreased from
48.2% to 38.7% [2]. For Mozambique, in 2011 the prevalence of underweight in
children under five was 15.0% and the stunting was estimated to be 42.3% [3].
Research carried out in 2011, Tete Province with representative sample of child-
ren under five years, showed the prevalence of stunting was 42% (Mozambique,
Demographic and Health inquiry, 2011) [3]. Factors such as biologics and pa-
thologics are also recognized as etiological factors of undernutrition [4]. Results
of studies conducted in many regions of the world, such as India in 2014,
showed that malnutrition in children under 5 years is associated with food inse-
curity, inappropriate feeding practices and diseases [5]. These determinants are
also observed in Mozambique among the most socially and economically vul-
nerable groups [6]. Currently, Mozambique has systematic information on
anthropometric status in childhood [7]. Result of study conducted in 2014 by
Cruz et al., in rural area of Tete Province showed that the prevalence of stunting
was 36.2% in children under five years old [8]. In Mozambique, studies of the
association between socioeconomic determinants and anthropometric status in
children are scarce. The objective of this study was to estimate the prevalence of
undernutrition in children under five years old and examine the socioeconomic
factors, according to the basic intermediate and immediate levels of hierarchy in
the districts of Angonia, Tsangano, Magoe and Changara in the Province of
Tete, Mozambique.

2. Methodology
2.1. Study Design
This was a cross-sectional study based on secondary data from the research on
malnourished children carried out by National Institute of Health in 2012
(IAFNUT-2012) in the districts of Angonia, Tsangano, Magoe and Changara, in
the province of Tete-Mozambique.

2.2. Sampling
The sample of this study is representative survey on malnourished children car-
ried out in selected districts of Tete Province. To select the participants, 12
communities from each district was selected; and then 48 communities in four
districts, 1248 households were selected in four districts. The households with at
least one child 0 - 59 months was randomly selected, only 583 children were in-

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 J. B. Daniel et al.

cluded in this study.

The sample size was calculated based on the prevalence of stunting estimated
in 43% in Mozambique. It was previously established by UNICEF [9]. To calcu-
late this sample size was taken in account the effect of study design in 4%. Ac-
cording to the World Health Organization (WHO), all records from the anth-
ropometric status contain Z scores values <−5 and >+5 to weight for age and
<−5 and >+3 to height for age should be excluded for statistical analysis [10].

2.3. Ethical Approval

The study proposal was submitted to the ethics committee for the human health
studies from the National Institute of Health Mozambique and it was approved.
Before the start of the study, all participants who agreed to participate in the
study, signed the free consent and informed form.

2.4. Data Collection

Data were collected between1 September and 30 October by four trained teams.
The information was provided by the mother or the child’s caregiver and rec-
orded in two questionnaires, one for the household and another for the mothers
and children.
Children were weighed in SECA brand scales with capacity of 25 kg and ± 100
g precision calibrated after every 2 weighings. Height was measured by a stadi-
ometer (SECA) and the length of those of up to 2 years was measured with in-
fantometer, followed the technical recommendations for the anthropometric
measurement [11].

2.5. Allocation and Definition of Variables

In this study the socioeconomic and demographic variables of children and
mothers was allocated in three hierarchy levels: basic, intermediate and imme-
diate. The basic level is the economic factors of households, in the intermediate
level are allocated the mothers and household sanitary conditions variables and
in the immediate level, the children demographic characteristics and morbidity.
In this study, the hierarchy model was adapted from the Unicef [15].
Outcome variables
This study adopted two outcome variables, weight for age (WAZ) z score and
height for age (HAZ) z score classified according to the reference values of the
World Health Organization criteria [12]. These variables were categorized into
three levels: state of eutrophic (reference = 0) [Z score +4.99 to −1.0]; mild defi-
cit: 1) [Z score −1.01 SD to −2.0 SD]; moderate deficit (2) [Z score −2.01 SD to
<−3.01 SD]; 2) and severe deficit; 3) Z score < −3.00 SD and more.
Independent variables
Basic level: Possession of goods index (medium and tertil); Possession of do-
mestic animals (tertil); type of water at home (potable water = 0; non potable
water = 1); the household own land (Yes = 0, No = 1); Intermediate Level (age

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J. B. Daniel et al.

of mother 16 to 22 = 1; 23 to 34 = 0; ≥35 = 2); Maternal education level (Sec-

ondary = 0; Primary = 1; unlettered = 2); household had a latrine (Yes = 0, No =
1); type of latrine (Improved latrine = 0; unimproved latrine = 1; no latrine = 2);
sharing a latrine with other households (Yes = 1, No = 0); Immediate level:
children’s sex (M = 0, F = 1); age in months (0 - 6 = 0; 6.1 - 11.9 = 1; 12 - 23.9 =
2, 24 - 59 = 3); birth weight (>=2500 g = 0; <2500 g = 1); Morbidity and treat-
ment cough Yes = 1, No = 0; child had diarrhea 15 days before the interview Yes
= 1, No = 0; child was deworming against helminths (Yes = 0; No = 1); Diet Ex-
clusive breastfeed 0 to 6 months = 0; complementary feed = 1; mixed breastfeed
artificial and maternal milk = 2; and the family food = 3 [13]. The evaluation of
the child’s food consumption was based on qualitative survey of food intake 24
hours prior to the interview.

3. Statistical Analysis
Data was analyzed using STATA software version 12:0. The polynomial regres-
sion an extension of logistic regression was used the outcome variables were ca-
tegorized in more than two levels [14]. The hierarchical approach was adopted
to identify the determinants of the underweight and stunting. Two models were
adjusted, one for each anthropometric indicator. The predictor variables were al-
located according to the hierarchy block in basic, intermediate and immediate lev-
el, adapted from the UNICEF [15]. The OR (odds ration) was used to examine the
association between the socioeconomic factors and malnutrition in children.
Initially there was the univariate polynomial regression analysis taking into
account all predictor variables allocated to each hierarchy block and variables
with p values lower than 20% were included in the multivariate model. All asso-
ciations with p value less than 0.05 in each hierarchy level of multivariate analy-
sis were included in the final model. The value of p (0.05) and the confidence
interval (CI) of 95% were adopted to accept the investigated associations in the
final model.

4. Results
4.1. Basic Level
In this study, the anthropometric and socioeconomic characteristics of children
are shown in Table 1. The prevalence of underweight (z-score < −2) was 13.9%
and (z-score < −3) was 5.7%. The overall prevalence of underweight was 19.6%.
The prevalence of stunting (z-score < −2) was 24.2% and (z-score < −3) 15.6%.
The overall prevalence of stunting was 39.8% (Table 1).
Half of households, 53.3% (Table 1) that had (0 or 1) durable goods were as-
sociated with underweight and stunting .The risk of malnutrition was signifi-
cantly higher among children that had 1 or had not any durable goods in the
household. Children who had 1 durable goods in a household were 1.46 times
greater to be underweight OR = 1.46 95% CI (1.01 - 2.11). In the households that
had 1 durable goods, the prevalence of stunting in moderate and severe forms

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 J. B. Daniel et al.

Table 1. Anthropometric and socio economic characteristics of children and their fami-
lies in the districts of Angonia, Tsangano, Magoe and Changara in the Province of Tete in
Mozambique, in 2012.

Anthropometric state N %

Weight for age (WAZ) (583)

Eutrofic 290 49.7

Mild 179 30.7

Moderate 81 13.9

Severe 33 5.7

Height for age (HAZ) (583)

Eutrofic 145 24.9

Mild 206 35.3

Moderate 141 24.2

Severe 91 15.6

Basic level

Durable goods in the household index (medium) (583)

0 to 1 311 53.3

2 to 8 272 46.7

Household own land (583) 513 88

Household without own land 70 12

Possess of domestic animals (tertil)

0 to 1 animal 162 27.8

2 animals 185 31.7

≥3 animals 236 40.5

Water at home (583)

Safe water (Potable water) 288 41.8

Non drinkable water 355 60.9

Intermediate level N %

Mother’s age (years) (583)

16 to 22 166 28.5

23 to 34 319 54.7

≥35 98 16.8

The household has a latrine (583)

Yes 342 59.4

No 234 40.1

Sharing a latrine with other families (583)

Yes 112 19.2

No 471 80.8

Mother’s education level (583)

Secondary 68 10.8

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J. B. Daniel et al.

Continued

Primary 331 56.8

Unlettered 189 32.4

Immediate level N %

Child’s age (months) (583)

0 - 24 398 68.3

24.1 - 59 185 31.7

Child’s Sex (583)

Male 287 49.2

Female 296 50.8

Weight at birth (583)

≥2500 g 508 87.1

<2500 g 75 12.9
Child had cough* (583)
Yes 225 38.6
No 358 61.4
Child was deworming against helminthes* (583)
Yes 190 32.6
No 393 67.4
Child had diarrhea 15 days before the interview (583)
Yes 176 30.2

No 407 69.8

Children feeding (583)

Exclusive breastfeed 34 5.8

Complementary breastfeed 229 39.3

Mixed breastfeed (maternal and artificial milk) 89 15.2

Family food 231 39.7

was OR = 5.00 (95% CI 2.16 - 6.99).Children that had 1 durable goods in the
households were increased 5 times the risk to be stunting when compare with
children with 3 to 8 durables goods (reference) (Table 2).
The households with (2 goods) (2nd tertile) the stunting was OR = 3.12 (95%
CI 1.40 - 7.00) in moderate and severe when compared with the households
which had 3 to 8 goods (reference) (Table 2). Children lived in the household
with 2 durables goods were 3 times greater to be moderate and severe stunting.
The results of this study, showed that children who lived in the households
without own land to agriculture practices were associated with mild underweight
OR = 1.98 (CI95% 1.02 - 3.82) (Table 2). The households with high economic
and social vulnerability have children at risk to have malnutrition. Children of
household had not the land to agriculture practices, were 98% risk to have un-
derweight.

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 J. B. Daniel et al.

Table 2. Adjusted OR for associations between exposure variables and anthropometric status, according weight to age and height
for age, Tete Mozambique, in 2012.

Weight for Age (WAZ) Height for Age (HAZ)

Moderate and Moderate and

Variables Mild deficit Mild déficit
severe deficit severe deficit

OR p-value CI 95% OR p-value CI 95% OR p value CI 95% OR p value CI 95%

Basic level

Durable goods in the

household index (medium)

2 to 8 goods (above medium) 1 1

0 to 1 goods (below medium) 1.46 0.037 1.02 - 2.11 1.30 0.219 0.85 - 1.99

Durable goods in the

household index (Tertile)

1st Tertile (3 to 8 goods) 1

2 Tertile (2 goods)
nd
2.71 0.013 1.23 - 5.96 3.12 0.006 1.40 - 7.00
3 Tertile (0 or 1 good)
rd
1.81 0.180 0.76 - 4.31 5.00 <0.001 2.16 - 6.99
The household owns land
Yes 1
No 1.98 0.04 1.02 - 3.83 0.55 0.29 0.18 - 1.69
Intermediate level
Latrine type
Improved latrine 1 1
Non improve latrine 1.17 0.52 0.71 - 1.91 1.42 0.25 0.77 - 2.59 1.89 0.12 0.83 - 4.25 2.17 0.044 1.02 - 4.61
No latrine 1.15 0.58 0.69 - 1.90 2.01 0.02 1.09 - 3.70 2.21 0.06 0.96 - 5.07 1.78 0.149 0.01 - 3.88

The household shared

latrine with families
No 1
Yes 1.63 0.06 0.97 - 2.72 1.88 0.03 1.03 - 3.42
Maternal education level
Secondary
1 1
(8th grade to 12th grade)
Primary (1st grade to 7th grade) 2.38 0.02 1.11 - 5.10 0.72 0.39 0.34 - 1.51
Illiterate 1.96 0.09 0.88 - 4.35 1.18 0.65 0.55 - 2.53
Immediate level
The child was deworming*
No 1 1
Yes 0.94 0.79 0.61 - 1.45 1.91 0.02 1.07 - 3.40
The child had cough*
No 1 1
Yes 1.29 0.22 0.85 - 1.95 2.42 <0.01 1.49 - 3.93
The child took breastfeed**
Yes 1 1
No 1.16 0.06 0.61 - 2.20 1.91 0.04 1.04 - 3.52

*15 days before the interview; **the interview date.

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J. B. Daniel et al.

4.2. Intermediate Level

In the intermediate level, 19.2% of the households shared the same latrine, in the
communities (Table 1). This study shown that children that lived in the house-
holds without latrine increased in 2.01 times greater OR = 2.01 95% (CI 1.09 -
3.70) in moderate and severe underweight and unimproved latrine OR = 2.17
95% (CI 1.02 - 4.61) increased in 2.17 times greater the moderate and severe
stunting when compared with those that had the improved latrine (Table 2).
In this study, mothers with primary educational was associated with mild un-
derweight in children OR = 2.38 95% (CI: 1.11 - 5.10). Children of mothers with
primary school had 2.38 times greater to be mild underweight when compared
with children of mothers with secondary or high school (reference) Table 2.

4.3. Immediate Level

This study showed that the children up to 2 years who were in breastfeeding
adequately had a protective effect of breastfeeding, especially for the children
living in the better conditions, when compared to those that had not in breast-
feeding OR 1.91 95% (CI 1.04 - 3.52). Children did not breastfeeding were 91%
times greater to be moderate and severe stunting when compared with those
breastfeed.

5. Discussion
5.1. Basic Level
In this study, the prevalence of overall malnutrition (underweight was 50.3% and
stunting 75.1%), the prevalence of moderate and severe underweight was 19.6
this prevalence was lowest when compared with 36% of moderate and severe
prevalence of underweight reported by UNICEF in Madagascar [16]. This pre-
valence of underweight were similar that reported in Madagascar by Rakotoma-
nana et al., found the prevalence of stunting in children under 5 years was ex-
tremely high (48.5%) [17]. This results show that in developing countries, the
prevalence of malnutrition in children under five years is extremely high. In this
study, the prevalence of severe stunting is 15.6% although, in different finding
was reported by Nampossa et al. the prevalence of severe stunting among sick
children was 11% in Manhiça district, Mozambique [18]. Curiously the results
reported by Nampossa et al., were lowest than the one observed in this study
(15.6%).
In Mozambique, the prevalence of severe stunting in children under five years
remains high 19.7% [19]. In India, Buthia et al. reported the prevalence of
stunting was 48% in children under the age of five [20] These results shown that
the malnutrition in children under five years is a challenge in developing coun-
tries such as Mozambique.
In this study, half of households (53.3%) had (0 or 1) durable goods, this re-
sult is similar to reported by Babatundi et al., in Nigeria that revealed children
from richer households were less malnourished than those from poorer house-

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 J. B. Daniel et al.

holds [21]. This results shows that children from richest families were more
protected from undernutrition when compared with those children from the
household without durable goods.
The results of this study, revealed that children who lived in the households
without own land were associated with mild underweight OR = 1.98 CI95%
(1.02 - 3.82). Similar results were reported in other countries in few decades ago,
in Brazil when the prevalence of malnutrition was high, especially in the north
and northeast, children that households had not the own land were more mal-
nourished [22] [23]. These findings were observed in children that had failure of
liner growth in some African countries, like Kenya [24] and Ghana [25] in other
countries such as India [26] and Brazil [27], are some reports of anthropometric
deficits in children.
In Mozambique, the diets are monotonous and contains few micronutrients,
the food insecurity is frequently in rural areas. This conditions affects many
young children. If the government in coordination with Ministry of Health and
Ministry of Agriculture and Food Security provides food fortification with mul-
ti-micronutrients, food security in the households and balanced diet, will im-
prove the nutritional status of the children, especially in the rural areas.

5.2. Intermediate Level

In this study, 19.2% of the households shared the latrine with others families in
the communities, the same finding was observed in Siri Lanka [28]. This study
showed that children that lived in the households without latrine increased the
chance to be moderate and severe underweight and those who lived in house-
hold with unimproved latrine increased chance to be moderate and severe
stunting.
In Tete province share the latrine is less frequent. This study showed that
shared the latrine with other families was associated with moderate and severe
underweight in children OR = 1.88 (95% CI 1.03 - 3.42). Sharing the latrine with
other households is not good for health due to hygienic condition. So, a better
sanitary conditions prevent diseases such as diarrhoea, cholera and malnutrition.
These findings corroborate with reports of other studies carried out in the ru-
ral areas in Ethiopia [29]. In this sense, the Department for International Devel-
opment in UK [30] identified some intervention and actions to be taken in order
to promote hygiene and sanitation to improve the health in children.
In this study, children of mothers with primary school had 2.38 times greater
to be mild underweight. The maternal education is strongly associated with
children nutritional status the; results of other study that examined the
association between maternal education and nutrition status in children showed
the inverse correlation between the maternal education and children
malnutrition.
The results of study carried out in developing countries in Sub-Saharan Africa
(Malawi, Tanzania and Zimbabwe) examined the influence of the maternal

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J. B. Daniel et al.

educational and nutritional status of children, showed the inverse correlation.

The maternal education level is necessary to make a significant reduction in
children malnutrition is at least 9 years of schooling in Malawi, 5 years of
schooling in Tanzania and at least 8 years of schooling in Zimbabwe [31].
In Mozambique the influence of maternal education was reported, mothers
with secondary or high school used frequently the health services, improved the
health and hygiene practices when compared with those unschooled mothers
[32]. Similar results were reported in Ghana [33] and Pakistan [34]. In countries
that the low maternal education is frequent, the access of women to health
service is deficient.

5.3. Immediate Level

This study showed that the children that were deworming in the 2 weeks before
the interview, were associated with underweight and stunting. The association
between intestinal parasites and anthropometric deficit in children was reported
in the developing countries, such as Nigeria [35], Uganda [36] and Malaysia
[37].
This study reported that the cough was associated with moderate and severe
stunting OR = 2.42 (95% CI 1.49 - 3.93). The Government of Mozambique is
carrying out the multisectoral plan for chronic malnutrition reduction to pro-
mote the health and reduce the undernutrition in children.

6. Conclusion
The study shows that the malnourished children under the age of 5 are a serious
public health problem in the province of Tete, Mozambique. It is associated with
basic, intermediate and immediate factors. It is necessary to continue improve
the health, nutrition and food programs in the rural areas.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

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