Factors associated with Malnutrition among Children in Rural Terai of Eastern Nepal Mr. Pramod Singh Gharti Chhetri Dissertation submitted in partial fulfillment of the requirement for the award of the degree of Masters of Public Health. Achutha Menon Centre for Health Science Studies (AMCHSS) Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) Thiruvananthapuram Kerala (India) October 2005
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Factors associated with Malnutrition among Children
in Rural Terai of Eastern Nepal
Mr. Pramod Singh Gharti Chhetri
Dissertation submitted in partial fulfillment of the requirement
for the award of the degree of Masters of Public Health.
Achutha Menon Centre for Health Science Studies (AMCHSS)
Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST)
Thiruvananthapuram Kerala (India) October 2005
DECLARATION
I hereby certify that the work embodied in this dissertation titled “Factors
associated with malnutrition among children in rural Terai of Eastern
Nepal” is the result of original research and has not been submitted for the
award of any degree in any other University or Institution.
Mr. Pramod Singh Gharti Chhetri
Place: Thiruvananthapuram,
Date: 28th October 2005
CERTIFICATE
Certified that this dissertation titled, “Factors associated with malnutrition
among children in rural Terai of Eastern Nepal” is a record of original
research work undertaken by Mr. Pramod Singh Gharti Chhetri in partial
fulfillment of the requirements for the award of the Master of Public Health
degree under my guidance and supervision.
Guide
Dr. Manju Nair R
Scientist C
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram – 695 011
Kerala, India
Acknowledgements
First and foremost, I must admit that it was a privilege to do my dissertation under the
able guidance and supervision of my respected teacher Dr. Manju Nair, Achutha Menon
Center for Health Science Studies, Thiruvananthapuram, Kerala. I am thankful to her for
her keen interest and supervision, without which this dissertation would not have taken its
present form.
I would like to thank the Director, Prof K Mohandas and the Registrar, Sree Chitra
Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala for
their continuous support and encouragement throughout the course.
I am grateful to Dr. K R Thankapan, Dr. P S Sarma, Dr. T K Sundari Ravindran, Dr.
Mala Ramanathan, Dr. D V Varatharajan, Dr. Biju Soman and Mr. Sundar Jayasingh,
AMCHSS, for their continuous support and help.
I am thankful to the Vice Chancellor of BP Koirala Institute of Health Sciences, Dharan,
Nepal, Prof. Dr. Loke Bikram Thapa for giving me the opportunity to undertake the
Master of Public Health course. I am also thankful to WHO, Nepal for providing me the
fellowship to take up this course. I am also grateful to UNICEF, Biratnagar for providing
me with the digital weighing scale for the field study.
I am also thankful to Dr. F James Levinson, Associate professor, TUFTS University,
USA, Dr. Grubesic Ruth, Assistant Professor, Texas Woman's University, USA and Dr.
Lance Brennan, Flinders University, Australia, for their help by providing with valuable
literature.
My sincere thanks also go to Ms. Ram Kumari Chaudhai, Mr. Bikram Chaudhari and Ms.
Lalita Chaudhari for their sincere efforts in data collection.
My heartfelt thanks to my wife Rina for her help during data collection and data entry
and support throughout the course.
Last but not the least my genuine thanks to all the respondents and people of my study
area who cooperated with me during this study.
I have held many things in my hands, and I have lost them all; but whatever I have placed
in God’s hands, I still possess. Thank you, GOD.
CONTENTS 1. Introduction 1
2. Review of Literature 2-14
2.1 Definition of malnutrition
2.2 Measurements of malnutrition
2.3 Global burden
2.4 Factors associated with malnutrition
2.4 Rationale for the study
3. Methodology 15-19
3.1 Objectives of the study
3.2 Study setting
3.3 Study design
3.4 Sample size
3.5 Sample selection
3.6 Methods of data collection
3.7 Ethical considerations
3.8 Data analysis
3.9 Conceptual framework
4. Results 20-44
4.1 Sample characteristics
4.2 Prevalence of malnutrition
4.3 Factors associated with malnutrition
4.4 Multivariate analysis
5. Discussion 45-49
6. Conclusion 50
7. Policy implications 51
8. References
Annexures
Factors associated with Malnutrition among Children in Rural Terai of Eastern Nepal
Abstract The World Health Organisation (WHO) estimates reveal that more than half of all child
deaths are associated with malnutrition in the developing countries. It is responsible not
only for mortality among children but also seriously affects the health of millions of
survivors making them vulnerable to infections and other illnesses. More than fifty
percent of the worlds’ malnourished children are in the developing countries especially
South Asia. Nepal has an under five mortality rate of 91 per 1000 live births and a high
prevalence of malnutrition.
Objective: To study the prevalence and factors associated with malnutrition among
children aged 6 – 36 months in the rural area of Sunsari district, Terai , Eastern Nepal.
Study design and methods: A community based cross sectional descriptive study. The
data were collected from mothers of 443 children from Sunsari district of Eastern Nepal.
Multistage cluster sampling was used to select the samples. Anthropometric
measurements were made using the digital weighing scale, infantmeter and a portable
measuring board and interviews using pre tested interview schedule.
Results: 53.3 percent of the children were underweight; about 30% had wasting about
36.6% had stunting. There was no significant difference in the prevalence among male
and female children. Malnutrition was more among the older age groups, significant
relation with maternal education, mother’s age at marriage, socioeconomic status,
paternal education, feeding practices and the presence of toilet facility. Multivariate
analysis showed that children in households of low SES are twice at risk of being
underweight compared t o those from higher levels of SES.(OR=2.04, C.I 0.99-4.22).
1
1. INTRODUCTION
The World Health Organisation (WHO) estimates reveal that malnutrition is associated
with about half of the 10.7 million child deaths among under-five children occurring each
year in the developing world. It is estimated that about thirty percent of all the world’s
children under five years accounting to about 150 million children are malnourished in
terms of weight for age.16 It is estimated that the majority of them live in Asia and
especially Southern Asia and the risk of being underweight is about 1.5 times higher in
Asia than in Africa.6 It is responsible not only for the mortality among children but also
seriously affects the health of millions of survivors predisposing them to infections and
other illnesses. The effects of childhood malnutrition leads to physical and psychological
sequelae, continue through adulthood, cause intergenerational impact, loss of human
potential leading to loss of social productivity.
The huge disparity in the prevalence of malnutrition across geographical areas and
countries and within populations is due to the fact that it is deeply rooted in poverty and
underprivileged social environment rather than biomedical causes. However during the past
two decades global trends have shown progress, with the prevalence rates of underweight
falling from around 38 percent in the eighties to around 25 percent presently.16The
millennium development goal for child mortality aims to reduce by two thirds the under
five mortality rate between 2000 and 2015 and in the developing countries tackling
malnutrition is the biggest challenge in achieving the goal
2
2. REVIEW OF LITERATURE
A review of literature was done to assess the burden of the problem, the measurement of
malnutrition and the factors associated with child malnutrition from available national and
international studies, reports and other published material.
2.1 Definition of Malnutrition
The simple meaning of malnutrition is a condition of improper nutrition which includes
both under nutrition and malnutrition. Malnutrition as mentioned in this study refers to the
state of under nutrition.
Malnutrition is defined as “a pathological state resulting from a relative or absolute
deficiency or excess of one or more essential nutrients”. 5 “Malnutrition or undesirable
physical or disease conditions related to nutrition can be caused by eating too little, too
much or an unbalanced diet that does not contain all nutrients necessary for good
nutritional status”. 3
In developing countries, malnutrition mostly refers to under weight, wasting or stunting in
the child. The child can be under weight for his age and height as well. The height of the
child may be affected if the malnutrition continues for a long time. This will cause short
stature or stunting in the child. If the malnutrition or under nutrition remains for a short
period of time, the child will be under weight or wasted and if it persists for a longer period
then it will cause the child stunting. 2
Anthropometric measurement is done to assess the nutritional status of children. When
deficits are found in one or more than one anthropometric indices, this is known as
‘malnutrition’. This may not be the result of only nutrient or energy deficit.
3
2.2 Measurement of malnutrition
Anthropometric measurement is done to assess the nutritional status of children. When
deficits are found in one or more than one anthropometric indices, this is known as
‘malnutrition’. This may not be the result of only nutrient or energy deficit. The following
measures are done in anthropometric measurement:
Weight for age: This measurement is used to determine whether the child is normal, over
weight or under weight. This basically shows the dimension of the body in relation to the
age of a person. It is affected by the height (height for age) and weight (weight for height)
of a person. If there is no more wasting among the children in the community, the height
for age and weight for age will give the similar type of information. Both of them will
replicate the long-term affect of malnutrition. The term ‘underweight’ is commonly used
for low weight for age. 5
Weight for height: This measurement shows the body weight in relation to the height of
an individual. The advantage of this measurement is that it is not necessary to know the
child’s age. However, it cannot be substituted for the weight for age. Because these indices
have different meanings, we can’t use them interchangeably though they may have similar
determinants.
The term wasting is used for low weight for height. The term wasting is used commonly
and widely for the current severe weight loss because of delicate hunger or illness. 5
Height for age: This is a linear growth measurement of a child. Length and stature are
used for the height for age based on the way of measurement. If there is shortfall on height
for age, it designates continuing growing insufficiency of health or nutrition.
4
The commonly used term for low height for age is stunting. Stunting suggests that
there was inadequate health and or nutrition for a long period of time. There is worldwide
variation of low height for age that ranges from 5% to 65% in less developed countries.
If any of the above-mentioned indices are below two standard deviations (<-2SD) of the
median value of sex specific NCHS reference data, a child will be regarded as
malnourished. If the indices are below three standard deviations (<-3SD), it is considered
as severe malnutrition.5
Mid Upper Arm Circumference (MUAC): The MUAC is measured on the left arm at the
mid point of elbow and the shoulder. A measuring tape is placed around the relaxed arm. A
single cut off value (12.5 or 13.0 cm) can be used for the children less than 5 years of age. 5
Head Circumference: Head circumference is a measurement of the child while sitting on
the lap of mother or care taker. Any object on the hair is removed while measuring. The
measuring tape is placed just above the eyebrows and positioned posteriorly. 5
Methods of measurements for malnutrition
Weight: One of the ways to weigh baby/ child is by using the UNICEF electronic scale
(Item No. 014015). In this method, mother and child will have to be weighed concurrently.
The child should wear minimal clothing. We should ask the mother to minimize the
clothing of the child. The sun should not over heat the weighing machine. The machine
should be placed on an even surface and can be read properly. The mother stands on the
scale with her baby and the weight is recorded to one decimal placement (e.g. 63.7 kg.).
Someone nearby then holds the child and the mother stands on the scale again without
child. The mother’s weight is recorded (e.g. 55.2). The difference is then determined (63.7-
55.2 = 8.5 kg.). 18
5
The other way of weighing a baby/ child is using a spring scale. , a 25kg scale. This is
hooked to a near by pole or tree or held by two people. The weighing pant is removed from
the lower hook of the scale and the child is placed in the weighing pants with the least
clothes possible. The pants should hang freely from the hook. The scale should be
calibrated everyday with a known 10kg weight.17
Height: There are basically two ways of measuring the height of the children based on the
age of child. The children aged two years and above are measured standing up. The
children aged less than 2 years are measured lying down. If there is problem to identify the
age should be decided based on the height. If the children are more than 85 centimeters are
measured standing up and the children who are less than equal to 85 centimeters are
measured lying down.
The measuring board for the children aged 2 years and above is placed where there is
enough room for movement. While taking the measurement, the head, shoulders, buttocks,
knees and heels of the child should touch the board.
The measuring board is placed on hard flat ground to measure the height of the children
aged below 2 years. The child should be lying flat at the center of the board. We should
place the head of the child against the base of the board and place our hand on the child’s
knees and press them gently against the board. 18
2.3 Global burden
It is estimated that there are about 208 million stunted children, around 49 million children
who are wasted and approximately 168 million underweight children in terms of their age
in the world. 37 The World Health Organization (1995) estimates that more than half of the
children’s deaths in developing countries are associated with malnutrition. It is estimated
6
that half of all children in South Asia are malnourished. Of the 12 million children death in
developing countries, 55 percent were related to malnutrition. 38 Among the South Asian
Association for Regional Cooperation (SAARC) countries according to UNICEF
Bangladesh has the highest (47.8%) prevalence of under weight among children followed
by Nepal (47.1%) and India (47%). Bhutan has the lowest (18.7%) among the SAARC
countries. The prevalence of stunting is highest in Nepal (54.1%) followed by India
(45.8%) and Bangladesh (44.8%). The lowest prevalence is in Sri Lanka (17%). Pakistan
has no data. The prevalence of wasting is highest in Maldives (16.8%) followed by India
(15.5%) and Sri Lanka (15%). Bhutan has got the lowest prevalence (2.6%) of wasting.
Bhutan seems to be in a better position in terms of child malnutrition in SAARC countries.
In 1975, 50 percent of the children aged 6 to 48 months were stunted in Nepal. In 1998,
47.1 percent children aged 6 to 59 months were under weight. Of these 12 percent were
severely malnourished. In the same period 54.1 percent children were stunted and of these
22.1 percent were severe. Children with wasting were 6.7 percent and out of this 0.5
percent were severely wasted. 16
2.4 Factors causing child malnutrition
There are multiple factors associated with childhood malnutrition and these are often
interrelated. One simply cannot say that these are the cause of childhood malnutrition
because it is a complex phenomenon. However, the major factors associated with
childhood malnutrition as mentioned are poverty, educational level of mother, faulty
feeding practices, vitamin A status, low status of women, birth order, unsafe drinking
water, mother’s occupation, diarrhea etc. 6, 7
7
Poverty:Poverty is an established cause of malnutrition. Malnutrition is highly prevalent in
the places where the people are struggling with severe poverty. The World development
Report shows that the countries with low GNP per capita have a high prevalence of under
weight children. According to a study in Indonesia malnutrition can be a practical indicator
of poverty. Sunutar Setboonsarng in his/ her report on ‘Child Malnutrition as a Poverty
Indicator: An Evaluation in the Context of Different Development Interventions in
Indonesia mentioned, “The evaluation shows that child malnutrition as poverty indicator to
assess the fulfillment of socio-economic development goals and targets is conceptually
sound and is more practical”. 4
The World Bank Economic Review39 also mentions that the higher the per capita income
the lower the malnutrition. Based on a cross-country and household study, it is concluded
that malnutrition can be reduced with sustainable economic growth. 4 There is an
assumption that income plays an important role for the underlying factors of malnutrition.
The underlying factors e.g. education; safe drinking water, health services etc. can be raised
with the increment in per capita income. 7 A study done in Rural Punjab found the
economic growth as a prominent factor for reducing the child malnutrition. 24
Education of Mother: The education of mothers has several positive effects on care of
children in comparison to mother with no education. The educated mother utilizes the
health care facility, discusses more about the illness of the child with health care provider
and follows the instructions about feeding and caring practices given by the health workers.
They also take benefit of guidance and information of health workers. They are more likely
to keep their environment clean. 7,9,10 One study in Indonesia shows that mother’s
education plays a strong role to protect child malnutrition. 13 It is found that the educated
8
mothers have less stunted children. 21,23 A study in Malawi also supports the role of mother
for better child nutrition to some extent. 10
In a survey done in Nepal it was found that the children with literate mothers have less risk
and severity of diarrhea. However it also says that it is likely to be associated features
rather than the literacy itself. 11 In another survey done in Nepal has found the negative
relationship between mother’s education and child mortality that is higher the mother’s
education, lower the child mortality. 21
Feeding Practices: The risk of childhood malnutrition increases with not feeding
colostrums. The non-use (throwing) of colostrums varies among the different ethnic groups
of Nepal. However, it mainly prevails among the ethnic groups of Terai. 11 Faulty feeding
practices like late initiation of breast feeding, starting artificial feeding before 6 months and
early and late start of complementary foods causes malnutrition. 12,27 It was found in Egypt
that early initiation of breast-feeding to the infants was associated with lower rate of
diarrhea episodes (episode per child per year) than those of late initiated breast-feeding (6.4
vs 9). A study in Uttar Pardesh and Karnataka of India shows that putting the baby to breast
within 24 hours after birth does not reduce stunting. Nevertheless, stunting and severe
stunting can be reduced if the baby is exclusively breast-fed for 4-6 months and mother
does not squeeze the colostrums from her breast. The child older than 6 months of age
needs to be given supplementation for reducing the stunting. 28 The children below one
year of age who was no longer exclusively breast-fed were found more malnourished. 13
This statement is also supported by the studies in Jamaica and Malawi. 10,14 A study in
Uganda shows that the children who never consumed breast milk had higher incidence of
underweight. The same study indicates that breast-feeding until 18 months decreases the
9
risk of stunting in contrast to those who were fed only in early infancy. However, breast-
feeding from 18 months to 24 months increases the risk of stunting approximately seven
fold. If it is continued to more than 24 months decreases the threat of stunting. 23 The
association of breast feeding and stunting may be because of reverse causality. A child
might not be stunted because of breastfeeding but s/he might have more breastfeeding
because of her/his poor health condition. Thus, children’s health should be considered
while evaluating the association between breast-feeding and child malnutrition. 28 A study
in Malawi found that giving complementary food to the baby at or after 4 months was
associated with better nutritional status in children. 10 A study in Andhra, India also shows
that late weaning had a negative impact on child nutrition. 19 A study in Nepal illustrates
that the risk of wasting increases if a child is fed less frequently (less than 6 times a day). 11
However, a study in Kerala states that the variables related to child feeding practices were
not significantly associated with underweight. 26 In Nepal healthy foods such as green leafy
vegetables are considered as low-status food and are not fed to the children even though it
is accessible and meat is not eaten either because of religious reason or it is prohibitively
expensive. 25
Vitamin A: A study done in Nepal found that the children taking Vitamin ‘A’ supplements
twice a year regularly had better health outcomes for malnutrition, diarrhea and acute
respiratory infection than those who did not take one capsule or took only one time.
Consumption of Vitamin ‘A’ rich food alone was not enough to protect the children from
malnutrition, diarrhea and ARI. 25
Women’s Status: A woman having lower status will have less opportunity to interact with
others and less freedom for independent behavior. It will restrict her to gain the knowledge
10
and lose self-esteem. A woman’s status in society will determine her physical and mental
health and her autonomy and control over household resources. If a woman has weak
physical and mental health, she will not be able to give quality care to her children. If a
woman is poorly fed or has poor nutrition during her childhood, adolescent and pregnancy,
her child is more likely to be low birth weight and affect subsequent growth. If a woman
has relatively less status compared to men this will restrict her to act for her own and her
child’s interest. 7,15 A study report from Uttar Pradesh and Karnataka, India did not reveal
the strong relationship between women’s autonomy and stunting. 28
South Asia has better per capita GNP, better education and safe drinking water in
comparison to Sub Saharan Africa. However, child malnutrition is higher in South Asia
than in Sub Saharan Africa. India is trying to eliminate child malnutrition from the country
since last 20 years but has not been able to get that much success. The reason given is low
women’s status. Professor Ramalingaswami, Dr. Urban Jonsson and Dr. Jon Rohde named
it as “The Asian enigma”. They pointed out that the low status of women in South Asia
accounts for the high rate of child malnutrition in comparison to Sub Saharan Africa.15
According to a study conducted in Nepal it was found that there was increased risk of child
malnutrition with frequent abuse to the mother. 11 According to a meta-analysis, 30 infant
mortality is higher in males than females; however, child mortality is higher among
females than males. Roughly half of the studies did not find any significant gender effect
on child malnutrition but about half of them showed that male children are less well
nourished than female children. 30 The data of rural Punjab of India also supports the
relationship between gender and child malnutrition. In 1971 the prevalence of child
malnutrition among male children was 32% and for female it was 54.2%. In 2001 it was
11
11% for male and 17.4% for female24. A study in Bangladesh also has made public that
female children are more vulnerable to be severely malnourished in comparison to male
children. The female had a 44% higher risk of being malnourished than male children. The
possible reason might be the discrimination against female children for food and health
care. 31
Birth Order According to the study done in Uganda, there is no role of birth order in
stunting and underweight among children. 23 A study in Jamaica kept up the evidence that
birth order is not significantly associated with underweight of children. 14 However, a study
done in Nepal shows a relationship between birth order and child malnutrition. 11 It shows
that higher the birth order, the higher the stunting and underweight21. This statement is
supported by another study in Indonesia. It also adds that first-born children have
advantage over later born children. 13 Nevertheless, on the contrary a study in Ethiopia
revealed that first birth order children were found to be at more risk for stunting than the
children of higher birth order. 27
Source of Water: Clean water is prerequisite factor for preventing child malnutrition.
Contaminated water lead to diarrhea and diarrhea in turn lead to malnutrition, even if the
food supply is sufficient. 30 Clean water reduces the infant and child mortality.
A study in Malawi established that private tap followed by public tap is linked with better
child nutrition. Poor water supply especially the unprotected wells were found negative
impact on child nutrition. 10 A study in Uganda supports the evidence of Malawi that the
children having unprotected water were found more underweight. Nevertheless, it had no
consequence on stunting. 23 Studies done in Rural Punjab of India, and Ethiopia also
12
revealed that one of the factors for the improvement in child malnutrition was improvement
in safe drinking water. 24,27
Mother’s Occupation: Studies done in Uganda and Ethiopia found no association
between mother’s occupation and child nutrition. 23,27. According to a study in Indonesia,
non-working mothers had better nourished children than that of working mothers. The
mothers working in the informal sector were found to have the highest risk factor for child
malnutrition. 13 The working mothers are able to earn money to fulfill the necessity of their
own and of their children but it’s opportunity cost will be higher because they will not be
able to give their time to look after the children. 7
Diarrhea: Diarrhea has negative affect on child nutrition. 10,11,28 A study in Jamaica also
was found that there was an association between diarrhea and underweight. 14 A higher
episode of diarrhea was found to be short term and long-term affect on malnutrition in
Andhra Pardesh, India. 19
Birth Interval: In a study in Malawi an association was found between birth interval and
child malnutrition. A child born 4 years after his preceding sibling was found to be better
weight for age than first born child or child born within four years. 10 A study in Ethiopia
also revealed that there was significant risk for the children of lower preceding birth
interval. 27 An Indian study reveals significant association between mortality risk and
preceding birth interval. Short birth intervals (<18months) were found to be more risk for
child mortality. 32
Parity and No of Children Below 5 Years: A study in Jamaica shows that there is no
effect of parity, and number of children less than 5 years of age on child malnutrition. 14
13
Caste/ ethnicity: In a study in Andhra Pardesh, caste was not found to be a determinant
factor for current malnutrition but was a significantly determinant factor for past
malnutrition. 19 In contrast a study in Dhanusha (Sah) 34 shows that there is no significant
relationship between caste/ ethnicity and child malnutrition. However, the prevalence
underweight and stunting is higher for Dalits.
Immunization:Immunization (polio and DPT) has no association with chronic
malnutrition but has significant affect on current nutrition status as per a study in Andhra
Pardesh. 19 Nevertheless a study done in Rural Punjab has advocated the coverage of
immunization as one of the factors for improvement in nutrition. 24
Age: It was observed in an Ethiopian study that there was significant high risk of stunting
among the children aged 12 to 23 months in comparison to 6 to 11 months age group. 27 A
study in Dhanusha district of Nepal also has revealed that higher age children are at more
risk of underweight and stunting. 34 The most vulnerable age group for malnutrition is
under 15 years. However, most victims of malnutrition are children under the age of 5
years. It is because the growth rate is so fast among the children in their first 5 years of age.
Inadequate nutrition adversely affects the growth and development of children. 2
2.4 Rationale for the study
Nepal has a big burden of child malnutrition. The under-five mortality rates are still high at
119 per 1000 live births in Terai which is higher than that of Hilly region 93 per 1000 live
births. 21 As Nepal is a multi cultural country, the cultural practices of one area are different
from other areas. According to the Nepal Demographic Health Survey, 2001, only 20.2%
of mothers breastfed their babies within one hour of birth and only 45.2% mothers within
one day of birth21. The Parda system (covering the face by cloth in front of adult males
14
other than husband and siblings) is very much prevalent in Nepal, which reflects the lower
status of the women. The percentage of underweight children is higher in Terai than that of
Hill and Mountain and wasting is even higher than underweight but stunting is little less in
Terai in comparison to Hill and Mountain area. 21 However, in a study it is shown that
being malnourished for children in Terai is 2.36 times higher. 11 Nepal has a high under
five mortality rate and malnutrition levels and needs to be addressed to eliminate the child
deaths and morbidity. This study is proposed to help to know the trend of child
malnutrition in eastern Terai of Nepal and find the factors associated with child
malnutrition. It will inform policy making and program management in community based
programs on reduction of malnutrition and promotion of child health.
15
3. METHODOLOGY
3.1 Objectives of the study
1) To study the prevalence of malnutrition among children aged 6-36 months in
Sunsari District of Eastern Nepal
2) To study the factors associated with malnutrition in the population
3.2 Study design
A descriptive cross sectional community based survey
3.3 Study setting
The study was done in the rural areas of Sunsari district of Eastern Terai , Nepal in four
randomly selected Village development Committee areas.
3.4 Sample size
The formula n = 4pq/d2 was used to calculate the sample size for a cross sectional survey
where p = prevalence, q=1-p and d the desired precision. Based on prevalence of under
weight children of 47%21, for 95 % confidence interval with ± 10% and a design effect of
2, minimum sample size was calculated as 400 that is 200 each from male and female
children. However, total 443 children were finally included in the study.
3.5 Sample selection procedures
Multi stage cluster sampling method was used to collect the data. There are 49 Village
Development Committees in Sunsari District. Total 4 VDCs were selected randomly from
49 VDCs of this district and 4 wards out of 9 wards were selected from each selected VDC
using random sampling method. The selected ward was considered as a cluster. Thus there
were total 16 clusters. From each cluster 18 to 35 samples (aged 6 –36 months children)
were taken. All the eligible children were taken as sample from a selected family. The
16
children were selected from every alternate household. As and when there were more than
one family having the child of eligible age in a household, one of the families would
selected randomly on the spot. The selected household was excluded if there was no
eligible child. The selected child also was excluded from the sample if the mother was not
present. However, 2 –3 more visits were done in appropriate time e.g., the researchers
visited to the household in lunchtime if the mother had gone to field. They come to their
home for lunch for about 3 hours.
3.6 Data collection techniques
Structured Interview schedule were prepared and individual interviews done with mothers.
The schedule was pre tested before using it for data collection. For anthropometry the
UNICEF Electronic Scale (SECA 890) was used to measure the weight of children and
mothers. The machine gives only the weight of child after weighing the mother first and
then mother with baby. An infantometer was used to measure the height of the children
below the age of 25 months. A stature meter (a wooden rod with centimeter) was used for
more than 24 months of children and mothers to measure their height.
Variables
The following predictor (independent) and outcome (dependent) variables were studied.
Predictor variables
• Demographic variables (age and, sex)
• Socio-economic variables (using an index made of the type of house, presence of
livestock, durable goods , toilet, lighting, fuel for cooking , source of drinking water
etc which was used in the National family Health Survey)
• Sanitation (presence of toilet)
17
• Mother’s care during pregnancy (Antenatal check up, food, illness etc.)
• Safe delivery (place of birth, birth attendants etc.)
• Immunization (BCG, DPT/polio, measles, vitamin A)
• Illness (common cold, fever, diarrhea etc.)
• Health care facilities
Dependent/ outcome variables
• Underweight (weight for age)
Weight-for-age below -2 SD from the National Centre for Health Statistics/WHO reference median value. (NCHS/WHO)
• Wasting (weight for height)
Weight-for-height below -2 SD from the NCHS/WHO reference median value
• Stunting (height for age)
Height-for-age below -2 SD from the NCHS/WHO reference median value. (NCHS/WHO)
3.7 Ethical considerations
The study objective and procedure was reviewed and cleared by the Institutional Ethical
Committee (IEC) of the Sree Chitra Tirunal Institute for Medical Sciences and Technology.
The local leaders were informed about the study. An informed verbal consent was taken
from the mother of the child, who was the respondent of the survey. She/ he was informed
that there was no direct benefit for them from this study but there might be benefit in the
long run if any organizations (governmental or non-governmental) initiate a child nutrition
program based on result of the study. The respondents were informed of the objectives of
the study at the beginning of the interview and were also informed that she could withdraw
18
from the study at any time. All data were entered the identity of the individual respondents
were masked.
3.8 Data collection and analysis
Three female enumerators who were high school graduate and above were hired to conduct
the interview with mothers and to measure the height and weight of mothers and children
and one male person hired to carry the instruments All the enumerators were given
intensive training for 3 days. The researcher himself was involved in data collection
specially the anthropometric measurements. The time period of data collection was about
one and half months from June to August 2005.
Data were entered in Excel and was analyzed using SPSS and Epi nut of the Epi info
program. Univariate and bivariate analysis was done and Chi square test done for
comparing proportions was used to test for associations.
Multiple regression analysis was done to determine the independence of associations
observed in the bivariate analysis by controlling for potential confounders.
19
3.9 Figure I. Conceptual framework for empirical analysis of the study
Child’s nutritional status
Child’s Dietary intake
Child’s health status
Feeding practices
Care of mother and Child
Health environment and services
-Breast-feeding practices -Weaning practices
-ANC of mother -Nutrition during pregnancy -Autonomy --Immunization
-Health care facility -Safe water supply - Sanitation
P O V E R T Y
Socio-cultural environment Economic status
Environment
Basic determinants
Immediate determinants
Source6: Adapted from Smith LC, Haddad L. 2000
20
4. RESULTS
The survey was carried out in the four selected Village Development Committees (VDCs),
Hansposa, Khanar, Babiya and Tanmuna in Sunsari district from June to August 2005
among 443 children below the age of 36 months. The sample was almost uniformly spread
across the four VDCs; 121 from Hansposa, 117 from Babiya, 103 and 102 from Khanar
and Tanmuna respectively.
4.1 Sample characteristics
The total sample consisted of 443 children below the age of 36 months. Out of total (443)
study population, 249 (56.2%), were males and 194 (43.8%) were females.
4.1.1 Age and sex distribution The sample of 443 children is almost uniformly spread among the age groups. The mean
age of the children was 20.21 months; 20.18 among male children and 20.24 among girl
children.
Table.1. Age and sex distribution of the study population Age in months Male Female Total 6 - 11 58 (23.3) 47(24.2) 105 (23.7) 12 - 23 93 (37.3) 72(37.1) 165 (37.2) 24 - 36 98 (39.4) 75(38.7) 173 (39.1} Total 249 194 443 (100)
*Figures in bracket indicates percentages
4.1.2 Socio demographic characteristics
Almost all the children (93 percent) belonged to Hindu households and about one third of
the study populations were from Dalit families. Socio economic status of the study
population was assessed by a standard of living index and nearly 44 percent of the
population belonged to low socio economic status. Toilet facility was not present in 85
percent of the households
21
Table.2. Socio demographic characteristics Variable Frequency Percent
Ethnicity Dalits 145 32.7 Non-Dalits 298 67.3
Religion Hindu 416 93.3 Islam 24 5.4 Buddhist 2 0.5 Christian 1 0.2
Type of house Kachha 366 82.6 Semi Pucca 67 15.1 Pucca 10 2.3
Toilet facility Pit 65 14.7 No toilet 378 85.3
Separate Kitchen Yes 336 75.8 No 107 24.2
Source of cooking fuel Firewood/ cow dung 424 95.7 Electricity/ bio gas 16 3.6 Kerosene 3 0.7
Socio economic status Low 194 43.8 Medium 155 35.0 High 94 21.2
4.1.3 Socio demographic characteristics of parents Almost all the mothers (91.5 percent) were in the age group between 20-34 years. More
than half of the fathers were in the age group 25- 34 and about a quarter less than twenty-
five years. Less than one fifth of the mothers had attended any form of formal education.
50 percent of them were illiterate and about a third could only just read and write but had
attended no formal education. Fathers of the children had better educational status than
their mothers. Almost fifty percent of the fathers had attended school. More than 85 percent
22
of the fathers were either employed in waged labour or farming and the rest in other jobs
like clerks/sales/services etc.
The mean at marriage of mothers was 17.84 years and ranging from 12 to 26 years. Nearly
half of the mothers had married at less than 18 years - the legal age for marriage.
Table.3. Socio demographic characteristics of parents Variable Frequency (n=443) Percent
Age of mother 15 – 19 years 15 3.4 20 – 24 years 210 47.4 25 – 29 years 142 32.1 30 – 34 years 53 12.0 35 – 39 years 17 3.8 40 - 44 years 6 1.4
Education of mother Illiterate 206 46.5 Literate (can read and write only) 138 31.2 Primary and some secondary 73 16.5 SLC and above 26 5.9
Mother’s occupation No wage earning work 419 94.6 Wage earning work outside home 24 5.4
Age of father < 25 years 104 23.5 25 - 29 years 139 31.4 30 - 34 years 124 28.0 35+ years 76 17.2
Education of father Illiterate 126 28.4 Literate (can read and write only) 105 23.7 Primary 50 11.3 Some secondary 90 20.3 SLC and above 72 16.3
Occupation of father Labour 304 68.6 Agriculture 76 17.2 Clerical/ sales/ services 63 14.3
Mother’s age at marriage 12 - 17 years 209 47.2 18 - 20 years 185 41.8 21 - 26 years 49 11.0
23
4.2 Antenatal care (ANC) and maternal factors during pregnancy More than 85 percent of the mothers had antenatal care visits during their pregnancy and 15
percent of the mothers had no antenatal care visits.21 All the women who had received
antenatal care had received the same from a health professional (doctor,nurse, auxillary
nurse midwife,health assistant, auxillary health worker, maternal and child health worker,
village health worker) The national average for Nepal for is near 50 percent for antenatal
care seeking and 28 percent from a health professional. Only 8.1 percent women had any
illness during their pregnancy. About 38 percent of women reported taking less than
normal quantity of food during pregnancy.
Table 4. ANC and other conditions of mother factors during pregnancy Variable Frequency Percent
Measles Yes 310 79.7 No 79 20.3 4.6 Infections and Illnesses
The common cold was found to be more common (37.2 percent) followed by fever (35.4
percent) in the two weeks preceding the survey, among the children. Around 13 percent of
children were found to be suffering from diarrhea. 6.3 percent of the children had to be
required admission in the hospital in last 6 months preceding the survey.
27
Table 8. Morbidity of children Variable Frequency Percent
Diarrhea in last 2 weeks Yes 57 12.9 No 386 87.1
Fever in last 2 weeks Yes 157 35.4 No 286 64.6
Common cold in last 2 weeks Yes 165 37.2 No 278 62.8
Hospitalisation in last 6 months Yes 28 6.3 No 415 93.7 4.7 Health care facility – availability and access Almost three fourth of the population had a health facility within 1 to 2 kilometers. The
distance ranged from one to four kilometers. Almost all of them people could reach their
nearest health facility within fifteen minutes to half an hour. Very few (2.5 percent) needed
more than half an hour to an hour to reach their nearest health facility.
For the majority (60.9 percent) their nearest health facility was sub-health post. Private
clinic was the nearest health facility for a little more than one fourth of the population.
More than two third of people had transport facility to reach the nearest health facility.
Close to fifty percent of the populations depend on private clinic for their treatment.
Around one fourth used the hospital for their treatment and one fourth the health post or
sub-health post for their treatment.
Around 85 percent could reach the health facility they usually consult within half an hour.
15.4 percent of them need more than half an hour to reach their health facility they usually
visit for treatment.
28
More than fifty percent had outreach clinic facility in their village. More than 80 percent
respondents reported that health workers had visited their house. About 25 percent of the
respondents also reported that the health workers gave health information
Table 9. Health care facilities Variable Frequency Percent
Distance to nearest health facility < 1 KM 38 8.6 1 – 2 KM 325 73.4 2.1 – 4 KM 80 18.1
Time to reach to nearest health facility < 16 Minutes 207 46.7 16 – 30 Minutes 225 50.8 31 – 60 Minutes 11 2.5
Type of the nearest health facility Sub-health post 270 60.9 Hospital 50 11.3 Private clinic 123 27.8
Transport to nearest health facility Yes 305 68.8 No 138 31.2
Type of health facility usually used Sub-health post and health post 111 25.0 Hospital 124 28.0 Private clinic 208 47.0
Time to reach to health facility usually used < 16 Minutes 151 34.0 16 – 30 Minutes 224 50.6 >30 Minutes 68 15.4
Admission facility at the health facility usually used Yes 163 36.8 No 280 63.2
Presence of out reach clinic Yes 228 51.5 No 215 48.5
29
4.10 Prevalence of child malnutrition
The prevalence of underweight was 53.3 percent, wasting 29.8 percent and stunting 36.6
percent in the study population
Table 10. Distribution of child malnutrition Below –3 SD Below – 2 SD Total Weight for age (underweight) 75(16.9) 161 (36.3) 236 (53.3) Weight for height (wasting) 24 (5.4) 108 (24.4) 132 (29.8)
Height for age (stunting) 55 (12.4) 107 (24.2) 162 (36.6) 4.11 Socio demographic characteristics and malnutrition 4.11.1Age and child malnutrition
There was increasing prevalence of underweight and stunting among the older age groups
of children compared to the lower age groups. The difference in the prevalence in the 12-
23 months and above is much more than the younger group. The difference was not
however significant in the case of wasting.
Table 11. Age and child malnutrition Age Weight for age (under weight) P value
High 12 (12.8) 13 (13.8) 25 (26.6) 4.12 Parental characteristics and child malnutrition 4.12.1 Age at marriage of mother and child malnutrition The mother who got married between 12 – 17 years had more underweight children
compared to those who got married between the age of 18 – 20 and 21 – 26 years. This
relationship was statistically significant.
32
Table 15 Age at marriage of mother and malnutrition
Age Weight for age (under weight) P value Below - 2 SD Total
Height for age (stunting) Home 43 (14.1) 82 (27.0) 125 (41.1) 0.042
Hospital 12 (8.6) 25 (18.0) 37 (26.6) 4.14 Type of provider at delivery and malnutrition The type of provider at delivery and underweight was very significantly associated with
each other. The prevalence was lower among those attended by health professionals who
were professionally more trained. This could be a proxy indicator of the health seeking
practices, socio behavioral factors and also may be due to permeation of information
regarding health from the providers.
Table 19 Type of provider at delivery and malnutrition
Type of provider
Weight for age (under weight) P value Below- 3 SD Below – 2SD Total
Height for age (stunting) First 19 (11.4) 32 (19.3) 51 (30.7) 0.034
Second 13 (9.9) 34 (26.0) 47 (35.9) Third 8 (9.6) 24 (28.9) 32 (38.5)
Fourth+ 15 (23.8) 17 (27.0) 32 (50.8) * Statistical test not done due to insufficient numbers 4.17 Duration of exclusive breast-feeding and child malnutrition The prevalence of underweight was significantly higher in children who were exclusively
breast fed for greater periods. The relationship was not however significant for wasting and
stunting.
Table 22 Duration of exclusive breast feeding and malnutrition
Duration Weight for age (under weight) P value Below - 3 SD Below - 2 SD Total
Height for age (stunting) No/ Incomplete 10 (13.3) 25 (33.3) 35 (46.6) 0.097
Complete 45 (12.2) 82 (22.3) 127 (34.5) * Statistical test not done due to insufficient numbers 4.19 Infections and Illnesses 4.19.1 Fever and child malnutrition
Higher prevalence of underweight and stunting was associated with having fever in last 2
weeks preceding the survey. The prevalence was higher among those who had fever than
those who had no fever in the previous two weeks. The relationship was statistically
significant.
Table 24. Fever in the last 2 weeks and malnutrition Fever Weight for age (under weight) P value
Weight for height (wasting) Yes 8 (5.0) 35 (21.7) 43 (26.7) 0.560 No 16 (5.7) 73 (25.9) 89 (31.6)
Height for age (stunting) Yes 16 (9.9) 30 (18.6) 46 (28.5) 0.030 No 39 (13.8) 77 (27.3) 116 (41.1)
4.22 Health care facility and child malnutrition 4.22.1 Type of nearest health facility and child malnutrition No significant relationship was found between type of nearest health facility and child
malnutrition. The prevalence of underweight was slightly higher for those who had health
post or sub-health post as nearest health facility. There was no basic difference between
40
them who had hospital and private clinic as nearest health facility. Wasting was slightly
lower for those who had hospital as a nearest health facility. Stunting was almost same for
all in terms of the types of nearest health facility.
Table 29. Type of nearest health facility and malnutrition
Type Weight for age (under weight) Below - 2 SD Total P value
Study on Factors Associated with Malnutrition Among Children in
Rural Terai of Eastern Nepal
Consent Form I am Mr. Pramod Singh Gharti Chhetri an employee of B.P.Koirala Institute of Health
Sciences, Dharan, Nepal studying for Masters in Public Health at the Achutha Menon
center for Health Science Studies, Trivandrum, Kerala, India. I am doing a community
based research study to find the prevalence and factors associated with malnutrition
among children aged 6-36 months in Terai. You will not have any direct benefit now
from this research but you can be benefited in long run if any governmental or
nongovernmental organization started any program on nutrition based on the report of
this research. As a part of the study I would like to ask you some information regarding
your child, feeding practices, diet etc. I would also like to measure her/ his weight, height
and mid arm circumference as a part of assessing her/ his nutritional status. The
information collected will be kept confidential and used for research purposes only. You
can refuse to answer any of the questions that you don’t want to. You can opt out of the
interview at any time without fear or harm. If you are willing to participate, kindly give
me your consent.
Willing to take part in the research
Yes / No
Interviewer: ____________ Date ____________
Witness: _______________
Background information
House ownership (a) Yes_______ (b) No__________
Type of Family (a) Nuclear____ (b)Extended___ ( c ) Joint______
Type of House (a) Kachha_____ (b)Semi Pucca__ ( c ) Pucca_____
Type of toilet (a) Flush_____ (b) Pit______ ( c ) No_______
Agricultural land holding Acre____ Bigha____ Kathha__ Dhur__ No__
Irrigated land holding Acre____ Bigha____ Kathha__ Dhur__ No__
Source of lighting (a) Electricity_________ (b) Kerosene/Gas/Oil____
( c) Others (specify)___________
Main fuel for cooking (a) Electricity/ Liquid petroleum/ Gas/ Bio gas_________
(b) Coal/ Charcoal/ Kerosene_______
( c ) Wood/ Cow dung____ (d) Others (Specify)____
Source of drinking water Private (a) Pipe_ (b) Hand Pump___ ( c ) Well___
Public (a) Pipe_ (b) Hand Pump__ ( c ) Well___
Others (specify)_________
Separate room for cooking (a) Yes________ (b) No___________
Ownership of Livestock (a) Yes________ (b) No___________
Ownership of durable
goods
(a) Car______ (b) Tractor____ ( c )Motorcycle_
(d) Telephone__ (e) Refrigerator_ (f) Color TV___
(g) Bicycle____ (h) B/W TV____ (i) Water pump_
(j) Bullock cart_ (k) Thresher___ (l) Mattress___
(m) Pressure Cooker_____ (n) Chair___________
(o) Cot/bed____ (p) Table___ (q) Clock Watch___
(r) Elect. Fan__ (s) Radio___ (t) Sewing Machine___
Socio-demographic information of the mother of index child Age (in completed years) Religion Caste/ ethnicity Education Age at marriage (in completed years) Occupation (Whether wage earning inside/outside)
Inside Outside
Socio-demographic information of the father of index child
Age (completed) Education Occupation
ANC/Illness during pregnancy of Mother (of index child)
Antenatal care Yes No Number of ANC visits Time of first ANC visit ANC Examined by Illness diagnosed during pregnancy Yes (specify) No Any illness for which medication is taken Yes (specify) No
Diet/ life style during pregnancy
Food (a) Normal (b)>Normal ( c ) < Normal Food avoided (name) Smoking (a) Yes (b) No Alcohol (a) Yes (b) No
Information of Index child
Age in months (completed) Sex (a) Male (b) Female Place of birth (a) Home (b) Hospital ( c ) Others (specify) Birth Attendant (a) Doctor (b) Nurse (b) TBA ( c) Dai (d) Relative Complication Yes No Birth order How old was the older child when this baby was born
How old was the child when the next baby was born
Perceived birth size (by mother) (a) Big (b) Medium ( c ) Small No of siblings below 5 years of age Primary care taker Mother’s age at index child birth
Status/ autonomy of mother In a family, there are certain activities on which, either the husband or the wife makes decisions alone. In addition, sometimes decisions may be made through discussions with the spouse, making final decisions together, or someone else in the household may make the decision. Who in your family usually has the final say in the following decisions? * Your own health care Making large household purchases, e.g. TV Making household purchases for daily needs
Visits to family, friends, or relatives What food should be cooked every day What to do if a family member becomes sick Whether you should work outside the home Whether or not to use family planning in the future Adopted from the Mullany Britta C, Hindin Michelle J, Becker Stan, 2005*
Feeding Practices:
Breast feeding Initiation after birth (a) Within one hour (b) Within 24 hours ( c ) Within 3 days (d) After 3 days If not within 1 hour, what was fed (a) Goat milk (b) Cow milk ( c ) Other women’s
milk (d) Others (specify)
Exclusive breast feeding (in months) Bottle feeding Yes No
Weaning Time of initiation of supplementary feeding / weaning (in months)
Type of foods No of meals per day (24 hours) Any nutritional supplementation prog
Immunization and illness Immunization BCG DPT1/Polio DPT2 /Polio DPT3/Polio Measles Vitamin “A” Diarrhea in last 2 weeks Yes No Fever in last 2 weeks Yes No Cold in last 2 weeks Yes No Any severe illness for which admission was required during last 6 months
Yes No
Any illness for which treatment was taken in last 6 months
Yes No
How many times child was admitted for any treatment in last one year?
Health facility
Nearest health facility (distance) (km) Type of health facility (nearest) (a) Sub health post (b) Health post ( c ) Hospital (d) Primary health C. (e) Private Clinic (f) Others (specify Transport facility Yes No
Tentative time to reach the facility Health facility to go normally for treatment
(a) Sub health post (b) Health post ( c ) Hospital (d) Private clinic
(e) Others (specify) In patient facility Yes No Transport facility Yes No Tentative time to reach Home visit of health workers Yes No Out reach clinic of health workers Yes No Any health education about Maternal and Child Health by health workers during home visit or out reach clinic
Yes No
Anthropometric measurement of child
Height (cm) Weight (kg) Mid arm circumference (cm) Head circumference (cm) Anthropometric measurement of mother Height (cm) Weight (kg)