Determinants Of Acute Malnutrition Among Under-Five Years Children In Illela Local Government Sokoto State, Nigeria

Project and Seminar Material for Public Health

Abstract

Malnutrition is one of the major causes of mortality and morbidity among under-five children in Sub Saharan Africa. To understand the determinants of malnutrition among under –five children, a study was conducted in Arabaand kalmalo districts of Illela l/g to Understand the determinants in these districts

Majority of the children were aged 37-59 months 54(51.9%) and followed by those aged 13-36 months 44 (42.3%) respectively the average age of the children in months is 37 with a standard deviation of 6.4 months. Half of the children 52 (50%) were of birth order 1-2 with a few in the birth order of 3-4 being 26 (25%) and 5 or more order 26 (25%) respectively. Most of the children were of birth intervals equal or less than two years 46 (44.2%). There were also quite a large number of children born in the birth interval of 3-4 years 43 (41.3%)

More than half of the under-five children in the study were females 53 (51%) and on the other hand 51 (49.0%) were males Based on the age of the mother at birth, majority of the children had their mothers aged 30-39 years 42 (44.4%) while quite a significant proportion was also from children whose mothers at birth were aged 20-29 years 34 (32.7%). Few of the children were from mothers aged less than 20 years 16 (15.4%) and 40-49 years 12 (11.5%) at birth respectively.

In conclusion, it is worthy to note that the study is essential in pointing out the particular age-groups among under five children as well as the occupations that contribute to malnutrition in the districts of Araba and kalmalo. Based on the findings, the study recommends exclusive breast feeding and proper complementary feeding especially among those aged less than three years. Special arrangement could also be put in place to have children of mothers engaged in cultivation brought regularly for breastfeeding.

Chapter One

Introduction

1.1 Background to the study

The World Health Organization (2013) estimates that thereare 178 million children that are malnourished across the globe, and at any given moment, 20 million are suffering from the most severe form of malnutrition. Malnutrition contributes to between 3.5 and 5 million annual deaths among under-five children. UNICEF estimates that there are nearly 195 million children suffering from malnutrition across the globe. In 1997, the World Health Organization had observed that 60% of the deaths occurring among all the underfive children in developing countries were attributed to malnutrition (Murray and Lopez., 1997). Most of the damage caused by malnutrition occurs in children before they reach their second birthday, in the time when the quality of a child’s diet has a profound impact on his or her physical and mental development.

It has been estimated by the global burden of disease study that under-five malnutrition alone has caused approximately half (15.9%) of the global loss of Disability Adjusted Life Years (DALYs) that is the sum of years of life lost from premature mortality years lived with disability adjusted for severity (Faruqueet al., 2008). This consequently affects the intelligence level of children, their behavior and school performance. The impaired mental development is taken as the most serious long-term handicap associated with underfive malnutrition.

Malnutrition among under-five children is one of the most important public health problems in developing countries especially Sub-Saharan Africa (Gulati, 2010) and about 35% of under-five deaths in the world are associated with malnutrition. An estimated 230 million under-five children are believed to be chronically malnourished in developing countries.

Similarly, about 54% of under-five deaths are believed to be associated with malnutrition in developing countries. In Sub-Saharan Africa, 41% of under-five children are malnourished and deaths from malnutrition are increasing on daily basis in the region. Malnutrition continues to be a significant public health problem throughout the low income countries, particularly in Sub-Saharan Africa and South Asia (Kimokoti and Hamer, 2008).

In Uganda, malnutrition remains a serious health and welfare problem affecting the under-five children to whom it contributes significantly to mortality and morbidity. According to Uganda Demographic and Health Survey of 2006, nearly four in ten Ugandan children under-five years of age (38 percent) are stunted (short for their age), six percent are wasted (thin for their height), and sixteen percent are underweight (UBOS &Macro International Inc, 2007).

The Nigerian Demographic Health Survey (NDHS).conducted in 2008 showed that the nutritional situation in Nigeria was 14% wasting, 23% underweight, and 41% stunting. Underweight levels increased when compared with the 2003 NDHS. Twenty four out thirt¬¬y-six state (67%) had more than 2% severe Acute Malnutrition(SAM) level and 19 out 36(53%) had level of Global Acute Malnutrition (GAM) above 10%. The state most affected are in the north-east and north west zone of Nigeria, particularly the Sahel Regionbordering Niger and Chad with stunting level above 50% and wasting levels above 20%.

The Uganda food and nutrition policy focuses on nutrition and childhood development as one of the goals with an aim of improving child health especially among those under-five years.

This policy is being formulated to address nutrition priority problems with assistance from international and local agencies like UNICEF, Save the Children, Plan International and TASO. The 2004/2005 Uganda food and nutrition policy reform focuses on policies and guidelines on anaemia, breastfeeding, HIV/AIDS and a number of other nutrition related disorders prevalent in the country (MoH and MAAIF, 2005).

The Ugandan government has put in place tremendous efforts in reducing the prevalence of malnutrition in the country through effective nutrition programs which act directly on feeding practices. However, the yield would be more significant if the government acted through factors that affect under-five child malnutrition. In addition, addressing the plight of women by strategically targeting their economic, education, and health status can improve nutrition at household level since women are the principle providers and care givers of children at this level.

1.2 Problem Statement

Effective nutrition is one of the most important health determinants among citizens of any country including Nigeria. However, malnutrition remains a big threat to almost all regions of the country, highly in the Sahel region particularly north-west and north east zone in Nigeria.

Some children under-five years in Nigeria have shown signs of growth failure, irritability, swelling of body parts, thin gray-blond hair, diarrhoea, as well as poor hygienic conditions according to Ministry of Health (MoH and MAAIF, 2005). These children do not gain corresponding body weight which leads to premature deaths later in life because vital organs are never fully developed during childhood. Malnourished children have lowered resistance to infection and therefore more likely to die from ailments like diarrhoea and acute respiratory infections (Nguyen and Kam., 2008).

Data from the previous five Uganda Demographic and Health Surveys (2011, 2006, 2001,1995, 1989) show that the nutrition indicators have not improved much over the past 15 years and some indicators have even shown a worsening trend (UBOS and ICF International Inc., 2012). For example the UDHS 2006 reported that 16% of children under-five in Uganda are underweight, 38% are stunted and 6.1% are wasted (UBOS & Macro International Inc, 2007).

An operation framework for nutrition in terms of child survival strategies was developed by the Government of Uganda in 2009. Additionally, the Government also launched the Uganda Vision 2040 and National Development Plan (2010-2015) that focuses also on nutritional wellbeing of children. The government has other several initiatives aiming at reducing under-five malnutrition especially the food and nutrition policy 2003 as well as the implementation of the global Millennium Development Goals (GoU, 2013; GoU, 2010).

Given the fact that a lot of studies on the determinants of malnutrition among under five children have been conducted in the developing countries, there is need to examine if the same factors are responsible for malnutrition among children under five years in the districts of Araba and kalmalo hence forming the research gap.

1.3 Main Objective

The major objective of the study was to assess the determinants of malnutrition among under-five children in Araba and kalmalo districts in Illela local govt.

1.4 Specific Objectives

The study addresses the following specific objectives;

To ascertain the relationship between child factors and malnutrition of children under-five years.
To ascertain the relationship between maternal factors and malnutrition among children under-five years.

1.5 Hypotheses

The hypotheses to assess the determinants of malnutrition among under-five children are presented below;

There is no relationship between sex of a child and malnutrition among under-five children
There is no association between age of the child and malnutrition among under-five children
Birth Order of child and malnutrition among under five children are independent
There is no relationship between child birth interval and malnutrition among under five children
There is no relationship between mothers’ age at birth and malnutrition among under-five children
Maternal education level and malnutrition among under-five children are independent
There is no association between maternal occupation malnutrition among under-five children
There is no relationship between marital status of the mother and malnutrition among under-five children.

1.6 Scope of the Study

The study considered children below five years living in Araba and kalmalo District. This is because children under-five years are normally the most at risk of malnutrition within households and communities in Illela.

1.7 Conceptual Frame Work

Figure 1.1 shows the conceptual framework on the determinants of malnutrition among under-five children inIllela taking a case study of Araba and kalmalodistricts.

In developing countries and particularly in Sub-Saharan Africa, under-five child malnutrition is normally determined by a large number of factors to the extent that it sometimes becomes difficult to predict the risk factors (Victoria et al., 1997). Such factors act through a number of interrelated proximate determinants to bring about under five malnutrition that is stunting, underweight and wasting. The demographic (child factors) and socio-economic factors (maternal factors) such as age of child, birth order, mothers age at birth, mothers education level, marital status as well as maternal occupation work through proximate variables like the Duration of breast feeding, sanitation and mother’s health seeking behaviors to determine Under five malnutrition.

Figure 1.1: Conceptual Framework showing the determinants of malnutrition among under-five Children

1.8 Significance of the Study

The study provides information that could be used for nutritional surveillance and targeting programmes that would focus more on populations at risk particularly the under-five children. The study also makes important contribution to future research by contributing to the existing literature particularly on nutrition among under-five children. The study further avails information that could be used in policy planning and implementation particularly in vulnerable groups.

1.9 Structure of the Dissertation

This dissertation is divided into five chapters which include; the introduction, literature review, research methodology, presentation of findings, summary of findings, conclusion and recommendations.

Chapter one provides the background to the study, problem statement, study objectives, hypotheses, scope of the study, conceptual framework and significance of the study.
Chapter two presents reviewed literature on the determinants of malnutrition among under-five children.
Chapter three presents the methodology used in the study including measurements of anthropometric measures and limitations.
Chapter four presents study results and interpretations.
Chapter five is the last chapter and it presents summary of results, conclusion, study recommendations and areas for further research.

Chapter Five

Discussion, Summary, Conclusions and Recommendations

5.1 Discussion

Based on the findings from this study, more than half of the under-five children in the study were females (51%) and majority were aged 37-59 months (54.8%) and followed by those aged 13-36 months (42.3%) respectively. Half of the children (50%) were of birth order 1-2 with a few in the birth order of 3-4 (25%) and 5 or more order (25%) respectively. Most of the children were of birth intervals equal or less than two years (44.2%). There were also quite a large number of children born in the birth interval of 3-4 years (41.3%). The delivery of majority of children within a birth interval of two years implies that child feeding brings about weaning off breast milk early to give room for the mother to take care of a possible new pregnancy. Based on the above results, it is not by surprise that malnutrition of children under-five years has persisted in Araba and Kalmalo districts since short breast feeding intervals subjects the child to early weaning.

On the age of the mother at birth, majority of the children had their mothers aged 30-39 years (44.4%) while quite a significant proportion was also from children whose mothers at birth were aged 20-29 years (32.7%). Few of the children were from mothers aged less than 20 years (15.4%) and 40-49 years (11.5%) at birth respectively.
The percentage distribution of under-five children according to the education level of the mother indicates that majority of the mothers had received primary level education (73.1%) and quite a few had never been to school (15.4%). Findings further reveal that only 11.5% of the children had mothers with secondary education and above. The level of education could impact on child care as many of the mothers may lack the basic skills and knowledge to look after their children by offering nutritious feeding. Many of such mothers still believe in traditional way of feeding and would ignore the recommended child feeding and health practices that encourages exclusive breast feeding for up to at least six months as well as provision of nutrition supplements and balanced diet.

The distribution of under-five children according to the marital status of their mother indicates that majority of the children were born to mothers who were married/cohabiting (66.3%). Quite a big number of the under five children were born to never married/separated mothers (33.7%). There was quite a high number of children born to single mothers which could have serious implications on under-five child malnutrition since the kind of care that the child receives from the single parent may be compromised compared to those with both parents who will always give their children undivided attention and care. Besides single mothers may not have advantage of receiving financial support from the father of the child especially in proper feeding. The cultural practices of our people could also be a major factor in this regard.

The findings also indicate that majority of the under-five children had their mothers who were peasant farmers (50%) as their occupation. Children whose mothers were doing business or civil servants were also significantly many (30.8%) as well as the pastoralists (13.4%). Followed by those whose mothers were doing business or self employed (17.3%). Most of the mothers who did business lived nearer to the trading centres in Araba and Kalmalo districts. There were also a few children whose mothers did handcrafts/artisans as their occupation (5.8%).
The immunization status of the under-five children that were involved in the study reveals that majority of the children (51.9%) were immunized up to date according to the Expanded Programme on Immunization Card (EPI Card), and this was confirmed by at least 32.7% of the mothers whose children were fully immunized. Similar results were obtained for the BacilleCalmette-Guerin (BCG) immunization where most of the children had BCG scars (46.2%) followed by 32.7% of the children that were immunized up to date. Non immunized children were few (only 3.9%) among the under-five children. BCG is a vaccine for tuberculosis (TB) disease recommended by the World Health Organization.

On vitamin A supplement administration, majority of the children received vitamin A supplement according to EPI card (54.8%) followed by those who were administered vitamin A as reported by their mothers (37.5 %). Only 7.6 % of the children had not received vitamin A supplementation. The high immunization and Vitamin A supplementation levels among the children is in line with the Nigeria Government’s policy through which mothers are regularly mobilized to take their children to health units for immunization. This programme is known as routing immunization (R. I).

Results indicate that stunting was the most common malnutrition problem (38.5%) among under five children in Araba and Kalmalo district. There was also quite a high prevalence of wasting and underweight among under five children given the fact that the sample of children was not very big. The findings are slightly higher than the national figures of stunting at 33%, and wasting at five percent. There is an almost similar proportion of children underweight with the national prevalence of 14% according to Nigeria Demographic and Health Survey (UBOS and ICF International Inc., 2012).

On the levels of malnutrition by district, results found from the in tables indicate that stunting was higher in Araba district than in Kalmalo. Similarly, child wasting and underweight were highest in Araba than in kalmalo district.
A comparison of stuntedness between males and females showed that slightly more females (39.6%) were stunted compared to 38.5% of the males. For wasting and underweight, females were equally more wasted and underweight respectively than their male counterparts. However there was no significant relationship between sex of child and malnutrition.

On the age of a child, there was a significant relationship between age of child and underweight(p=0.041**<0.05).There were few children underweight from 13-59 months(only five) unlike those aged 12 months and below as shown in table 4.5. Also children aged 12 months and below were more stunted and wasted than those older from 13-59 months.

For birth order, stunting was more among children of birth order 1-4 than those of order 5 and above. Children of birth order 3-4 were more wasted than those of birth order 1-2 or 5 and above

Similarly, underweight was highest among children of birth order 3-4. On the birth interval, stunting was highest among under five children with birth interval of 3-4 years than those of < 2 or even 5-6 years. For wasting, however, more children of birth interval <2 years were wasted. On underweight, only few cases of children with birth interval 4 years and below were underweight. There was however no significant relationship between birth interval and all the malnutrition indices that is stunting, wasting and underweight.

Results also indicate that there were more stunted children among mothers aged 30-39 years (56.5%) than those 20-29 years or even 40-49 years. There was however no significant relationship between age of mother at birth and stunting. However, there were more wasted children among mothers aged 20-29 years unlike other age groups. It is indicated that majority of underweight children were from mothers aged 40-49 years. There was no significant relationship between age of mother and malnutrition among under five children.

On mother’s level of education, most of the children had mother with primary and secondary+ education. Stunting was less among children of mothers with no formal education. There was no significant relationship between mother’s education level and malnutrition.

On the marital status, majority of the stunted children were from mothers who were married or cohabiting (44.6%). Similarly, there were more wasted and underweight children among married or cohabiting couples. There was however no significant relationship between marital status and malnutrition.

There was a significant relationship between mothers occupation and malnutrition (p=0.05).

More stunted children were from peasant farmers as well as business/civil servants. In the same vein, wasting and underweight was common among peasant farmers and pastoralists.

The binary logistic regression model was fitted to examine the determinants of under-five child malnutrition. Results indicated that children aged 37-59 months were less likely to be underweight (OR=0.76) than their counterparts who were aged 12 months and below (reference category) in Araba and Kalmalo districts. In fact children aged 37-59months and child underweight were statistically significant since the p-value (p=0.03**<0.05) was less than the critical value of 0.05 at 95% confidence interval. The above findings agree with similar findings at national level that the proportion of underweight children is lowest among children 36-59 months old and highest among those 6-8 months old (UBOS and ICF International Inc., 2012). Similar findings have been observed by several scholars in Vietnam, India, Nigeria and Kenya (Nguyen and Kam., 2008; Sarmistha, 1999;

Babatunde, 2011 and Kabubo-Mariaraetal., 2006). The findings are however contrary to the study in Ethiopia that found out that underweight had a positive linear relationship with age of a child (Yimer, 2000).

Findings indicate that there is a significant relationship between woman’s occupation and stunting among under five children (p=0.05) in Araba and kalmalo districts. Children whose mothers were pastoralists (OR=0.12) were less likely to be stunted unlike their counterparts whose mothers were peasant farmers (reference category). Mothers engaged in pastoralism are believed to supplement the nutrition value of their children with cow milk and other milk products which consequently reduces the risk of stunting unlike the peasant farmers and business people. According to Salah and Nnyepi (2006), crop cultivators were more likely to have stunted children. Similarly, a study done in Vietnam found out that children from mothers who were crop cultivators had an increased risk of stunting because they rarely get time to care for their children hence end up leaving them under the care of elder siblings or inexperienced maids (Nguyen and Kam, 2008). In another study, it 42found out that some mothers especially peasant farmers in most cases fail to provide supplementary feeding to their children because they cannot afford (Olwedoetal., 2008)

5.2 Summary of Findings

The study found out that malnutrition is one of the major challenges affecting under-five children in Araba and kalmalo district. The common form of malnutrition included stunting, wasting and under weight. Children aged 39-59 months were less likely to be underweight than those aged less than twelve months. Stunting was majorly common among children of peasant farmers than those from pastoralist mothers or even those doing business.

5.3 Conclusion

Results from the analysis confirm that age of a child and maternal occupation are one of the most significant determinants of malnutrition in Araba and Kalmalo district. The study therefore underscores the age groups prone to malnutrition challenges as well as the particular occupations among women that could pose a risk of malnutrition to the under five children.. This then gives a focus to policymakers in the designing of strategies aimed at combating malnutrition among children below five years.

5.4 Recommendations

The study recommends exclusive breast feeding and proper supplementary feeding especially among children aged less than three years. In line with UNICEF and WHO recommendations, there is need for exclusive breast feeding during the first six months of life and thereafter semi-solid complementary foods are introduced up to at least two years or more. This will consequently reduce on the underweight children who are mostly aged less than three years in the districts of Araba and kalmalo districts. The study also recommends a special arrangement for mothers engaged in cultivation to have their children breastfed regularly by having their babies brought to the gardens at regular intervals. The mothers could also visit their babies at home regularly from their gardens to ensure that proper nutrition is given to their children. This may contribute to a reduction in stunting especially among children of peasant farmers who were found to have increased levels of malnutrition than the rest of the children with mothers of other occupations. There is need for a bigger study to be carried out in the district Araba and kalmalo covering more children to establish the determinants of under five malnutrition. Perhaps another study may establish significant determinants like education of mother, sex of child, birth order, birth interval, age of mother and marital status. These factors were found significant in the literature review despite the fact that they were insignificant in this study.

5.5 Areas for Further Studies

There is need for a comprehensive study on the impact of climatic variability on the malnutrition of under-five children in Nigeria. This is an environmental aspect that was not particularly studied at length yet it is an important phenomenon that has not been widely studied by several scholars.

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