Underweight and Its Associated Factors Among Children 6–59 Months of Age in Debre Tabor Town, Amhara Region of Ethiopia, 2019: A Community-Based Cross-Sectional Study

Introduction

Even-thought malnutrition is a double burden now time being, under-nutrition among under-5 year children is a common public health problem and it is one of the main reasons for the death of children in developing countries.^1–3 Globally, there are 165 million stunted, 99 million underweighted, and 51 million wasted children.^2–5

Demographic health survey of Pakistan (2012–2013) report confirmed that 29.4% of under-five children were underweight, on the other hand, mothers’ educational level, and child-size at birth were found the significant factors for being underweight.⁶

As a systematic review done in Sub-Saharan Africa (SSA) the overall (pooled) prevalence of underweight was not reported. However, low mother’s education, increasing child’s age, sex of child (male), wealth index (poor household), mother’s age (<20 years), source of drinking water, birth size (small), diarrheal morbidity, and low father’s education were the most significant factors for the occurrence of under-nutrition in the stated area.⁷

Weight-for-age is an overall indicator of a population’s nutritional health because children can be underweight for their age when they are stunted, wasted, or both. Therefore, weight-for-age is a composite index of weight-for-height and height-for-age and thus does not differentiate between acute malnutrition and chronic malnutrition.⁸

A community-based cross-sectional study was conducted in Ethiopia among children age 6–59 months and the result revealed that 15.8% of the child were underweight, adjacent to this maternal Education, family size, and diarrheal morbidity were the leading factors of children for the existence of under-weight.⁹

National demographic health survey of Ethiopia (EDHS 2016) report showed that 24% of all children were underweight, but good education level and household wealth can reduce the percentage of underweight of children in their life extent.⁸

As a study conducted in Gida Ayana and Aris Oromia, Ethiopia, the overall prevalence of underweight among children age 6–59 months was 19.2% and 49.2%, respectively. Besides, sex of child (male), numbers of children in the family (>one), breastfeeding, and diarrhea were showed a significant association for the direction of the survival of the problem.^10,11

As the study allowed in an-other area of Oromia at Bishoftu town, the study revealed that 22.6% of children were underweight. However, the age of the child and numbers of the visit by health extension visits were determinant factors since, as the age of a child increases the risk of being underweight to be not increased.¹²

Materials and Methods

Study Area and Setting

This study was conducted at Debre Tabor town, Amhara regional state of Ethiopia. Debre Tabor town is the capital city of the South Gondar zone and has 6 kebeles with 36,285 households. The town had 84,382 general population, of them 19,898 was in a reproductive age (15–49) group, and from the total population 10,868 were children from age 6–59 months.

Study Design and Data Source

A community-based cross-sectional study was conducted among children age 6–59 months in randomly selected kebeles at Debre Tabor town and available during the data collection period were the study population.

Sample Size Determination and Sample Size Calculation

The sample size for this study was calculated using single population proportion formula considering the following assumption: according to a study done in Aris, Oromiya Ethiopia the prevalence of underweight among children age from 6 to 59 months was 49%. Based on this assumption the sample size was calculated as follow:

Where: n= the required sample size, z= standard score corresponding to 95% CI, p= prevalence of parental traditional medicine use for children, q= 1-p and d= the margin of error 5%. Therefore, 384*1.5=576 and 10% of none response rate 58 and total sample size are 634.

Sampling Procedure and Technique

Six kebeles were considered as a cluster and 50% of the clusters (three clusters) were selected randomly. To gate study participants for data collection, systematic random sampling technique was used. For households that had more than one eligible child, a lottery method was considered to select one child for the study.

Dependent Variable

• Underweight (below −2 SD) children age from 6 to 59 months

Independent Variables

• Socio-economic and Demographic variables (age, educational level, marital status, family wealth, and family size)
• Maternal Characteristics (ANC visits, family planning use, age at first birth, place of delivery)
• Childs’ Characteristics (sex of the child, birth order)

Operational Definition

Underweight

A child is defined as underweight if the weight-for-age Z-score is found to be below −2 SD of the median of the WHO standard curve.

Data Collection Tools and Procedures

Measurements

Anthropometric measurement was done. Child weight was measured by an electronic digital weight scale for children who were comfortable to be measured alone, but children who were unable to be measured alone; we were used mother-child weight combined measurement, and then the mother’s weight was measured to calculate the child’s weight through subtraction.

The weight measurement was recorded to the nearest 0.1 kg. The data were collected using a semi-structured interviewer-administered questionnaire. Either fathers or mothers of the children were interviewed but the priority was given to mothers because mothers are believed to be closer to their children than fathers.

When the mother would not available the father was interviewed and if not the guardian was interviewed. Semi-structured interviewer-administered questionnaires were adapted from previous researches done on similar topics and WHO stepwise surveillance (WHO STEPS) for child malnutrition. However, wealth status related questionnaire was adopted from EDHS (Ethiopian Demographic Health Survey, 2016). Pre-test (5% of the sample size) was done in non-selected clusters. The questionnaire was translated into Amharic, the national language of Ethiopia, and back-translated to English for its consistency.

The questionnaire had consisted of four parts (socio-demographic, maternal, child health-related characteristics), and wealth status of the family. The data was collected by three Diploma Nurses. The supervision was made by three master holder nurses. Before the data collection, one-day training was given to data collectors and supervisors.

Data Processing and Analysis

World Health Organization (WHO) Antro-version 3.2.2 software was used to generate the Z-score value of weight-for-age (WAZ) to compute underweight or to assess the nutritional status of the children by using the age of the child, sex of the child, the weight of the child and ID of the child. Principal component analysis (PCA) was used to compute family wealth status by fulfilling the assumptions of factor analysis, KMO value, and communality.

The data were cleaned, coded, and, entered into Epi info version 7.2.0.1 and transferred to SPSS version 20.0 for analysis. Descriptive and inferential statistics were used for presenting and analyzing the data, respectively. Descriptive statistics like frequency and percentage were done to summarize the data. And inferential statistics like odds ratio, binary logistic regression, and multiple logistic regression were used to determine the association between the dependent variable and different independent factors. Statistical significant variables (p <0.2) in the binary logistic regression analysis were entered for multivariable analysis and P-value less than 0.05 was considered as significant at 95% CI. Hosmer and Lemeshow goodness of fit test was checked.

Ethical Consideration

Ethical clearance was obtained from the school of the nursing ethical review committee on behalf of the University of Gondar review board. The verbal informed consent was acceptable and approved by Ethical review board on the behalf of the University of Gondar, and that this study was conducted under the declaration of Helsinki. A permission letter was obtained from the Debre Tabor town department of health. Participants were informed about voluntarism and that they can withdraw at any time of the study if they want not to respond. For those who were a volunteer to participate, verbal consents were obtained from the parent/legal guardian/for the children involved before the study begin. At the end of the interview, participants were informed about underweight and associated potential effects.

Results

Socio-Demographic Factors of the Study Participants

From a total of 634 proposed participants, 608 participants with a 95.9% response rate were included in the analysis. Among the total participants, 554 (91.1%) were married in their marital status and a half and above 55.9% were mothers have no formal education level.

Of the total participants of mothers, near to half, 54.4% had less than four antenatal care visits, and most of the mothers (97.2%) were gave birth in the health institutions. Almost half and above sex of the child were male (52.2%), and most of (93.4%) the participants were had less than or equal to four birth order in their family health-care status (Table 1)

Table 1 Characteristics of Participants for Underweight Among Children Age from 6 to 59 Months in Debre Tabor Town Amhara Region of Ethiopia, 2019

Underweight Among Children Age from 6 to 59 Months in Debre Tabor Town Amhara Region of Ethiopia

From the total participants of the survey age from 6 to 59 months of children, 17.4% (95% CI 14.5%-20.6%) were found underweight (Figure 1)

Figure 1 Prevalence of underweight among children age from 6–59 months in Debre Tabor town Amhara Region of Ethiopia, 2019.

Factors Associated with Underweight Among Children Age from 6 to 59 Months in Debre Tabor Town Amhara Region of Ethiopia

Bivariable and multivariable logistic regression analysis were used to determine factors affecting the weight of children age from 6 to 59 months. The bivariable analysis showed that birth order, sex of the child, age of the mother at first birth, marital status of the participant, mothers’ educational level, fathers’ educational level, place of delivery, family planning use, and wealth of the family were associated with parental traditional medicine use for children considering p-value≤0.2. For adjusting potential confounders those variables which were significant at bivariable analysis were entered into multivariable logistic regression. The result revealed that the sex of the child, fathers’ educational level, and wealth status of the family were significantly associated with underweight for children age 6–59 months. However, the remaining listed above variables were not significant at p-value≤0.05 (Table 2).

Table 2 Bivariate and Multivariable Logistic Regression Analyses for Underweight Among Children Age from 6 to 59 Months in Debre Tabor Town Amhara Region of Ethiopia, 2019

Fathers who have primary education levels were 2.13 times more likely to have underweight children than those who have secondary and above education levels [AOR: 2.13; 95% CI: 1.19–3.80]. Similarly, parents who have poor wealth status in their family 2.2 times more likely to have underweight child than those who have rich wealth status in their family [AOR: 2.2 (1.21–4.09)]. However, on the sex of child being male were 1.8 times more likely to become underweight than female [AOR: 1.8 (1.14–2.85)].

Discussion

Under-nutrition is a lack of proper nutrition, caused by not having enough food in the body, and expressed by non-specific nutritional problems like underweight.¹

In this cross-sectional study, the prevalence of underweight among children age from 6 to 59 months was 17.4% (95% CI: 14.5–20.6%). It was higher when compares to a study done at Sodo, Ethiopia 14%,¹³ East Gojjam, Ethiopia from model house-holds 10%,¹⁴ and at Khyber Paktunkuwa 11.4%,¹⁵ Vietnam 8.4%.¹⁶ The possible reasons might be the number of mother to child for the participation in the study, and the period of the study.

On the other hand, this study was in line with the study done at Wonsho, Ethiopia 20.5%,¹⁷ Takusa Ethiopia 19.5%,¹⁸ Gidayana Ethiopia 19.2%,¹⁰ Howassa town Ethiopia 15.8%,⁹ and at the pooled prevalence of Sub-Saharan Africa 16.3%.¹⁹ However, this study was lower as evaluated to the study done at Bula-Hora, Ethiopia 29.2%,²⁰ Dollo-Ado Somalia Ethiopia 47.7%,²¹ Afar Ethiopia 33.7%,²² a previous study of Ethiopia 25%,²³ Lalibela Ethiopia 25.6%,²⁴ Ethiopia (EDHS 2016) 24%,²⁵ Bishofitu Ethiopia 22.6%,¹² Tahtay Tigray Ethiopia 37.4%,²⁶ EDHS-Tigray 23.9%,²⁷ Shashemena Ethiopia 49.2%,¹¹ Mai-Aini Eritrean refugee camp 33.4%,²⁸ Khartoum Sudan 35%,²⁹ Tigray region 33%,³⁰ East Gojjam Ethiopia from non-model house-holds 52.5%,¹⁴ Nigeria,³¹ Pakistan 29.4%,⁶ Belahara VDC of Dhankuta district 27%,³² and Bangladesh 33%.³³

The possible reasons might be due to different study periods in between the studies, and most studies were nationwide while this study was specific to one town.

In the present study fathers’ educational level was one of the predictors of underweight among children age 6–59 months. Fathers who have primary and below the level of education were 2 times more likely to have underweight children than those fathers’ who have secondary and above level of education in their educational status. The result is supported by the research done in Tigray region Ethiopia,²⁷ Bangladesh,³³ Khyber Pakhtunkhwa.¹⁵

An-other predictor of underweight for children age from 6 to 59 months was the sex of the child. Male children were 1.8 times more likely to have under-weight nutritional status than those female children. This finding is supported by a study done in EDHS Ethiopia (2016).²⁵

Tigray region Ethiopia,²⁷ Oromia region Ethiopia,¹⁰ Bula Hora Ethiopia,²⁰ Somalia region Ethiopia,²¹ South Ethiopia,¹⁷ sub-Saharan Africa,⁷ Machakos country.³⁴

Wealth status in the family has great importance for the occurrence of mal-nutrition typical under nutrition for children in developing countries. In this study families who have poor wealth status 2 times more likely to have under-weighted children than those families who have rich wealth status. Because, children who have poor family wealth status lack adequate nutrition’s in their house-hold, and this leads to a nutritional imbalance between demand and supply. This finding is supported by the study done in Tigray region Ethiopia,²⁷ Sub-Saharan Africa,⁷ Bangladesh.³³

Limitations of the Study

The present study has some limitations. It was focused on children characteristics rather than environmental factors, and also the study is cross-sectional it does not show a cause-effect relationship between underweight and associated factors.

Conclusion

Among under nutrition of children age 6–59 months underweight is still a significant public health problem. Significantly associated factors with underweight for children age from 6 to 59 months were the father’s educational level, sex of the child (male), and wealth status of the family.

These findings have great importance for different stokeholds that have responsibilities on the reduction of under-nutrition typically underweight, besides this, it is important for policymakers for nutrition and nutrition-related intervention programs.