Description of the study setting, design and period.
This study was conducted in Lemo district of Hadiya zone. Hadiya zone is one of the major zones found in Southern Nation Nationalities and Peoples Regional States (SNNPR) of Ethiopia. Hadiya Zone is most intensively cultivated and densely populated areas of Ethiopia. Enset based mixed crop-livestock production is the main agricultural production system. Lemo district is located at a distance of 230 km in North East from Addis Ababa, the capital city of Ethiopia and 187 km from Hawassa, the capital city of SNNPR region.
According to CSA 2017/2018 report, major population (97.3%) of Lemo district was rural residents. There are a total of 35 Kebeles most of which (33) are rural and 2 Kebeles are urban. There are 7 health centers and 35 health posts in the districts. There were 65 health extension workers which work in health posts. Farming comprises the major (65.5%) populations’ livelihood. This is a community based cross sectional study was conducted in Lemo district of Hadiya Zone from March to April 2021.
Source population
Children of age category of 24 to 59 months in Lemo district were the target population in this study. Furthermore, children whose age group were from 24-59 months and randomly selected and presented during data collection period were the study population in this study. Mothers /Caregivers/ pairs whose children were in the age group from 24-59 months agreed to participate in the study were included in this study. Mothers who were unable to give full response and critically ill during data collection period were excluded from the study.
Sampling and sample size determination
The sample size for this study was determined using single population proportion formula with the following assumptions: Prevalence of stunting (52.1%) in of Saesie Tsaeda-Emba District, Tigray, North Ethiopia [15], 95% confidence level, 5% margin of error. Hence, the sample size was computed using standard Cochran formula, n = z2pq/d2. Then, plugging values in the formula, a total sample of 384 were found. By considering a non-response rate of 10%, the final sample size was calculated to result 422.
Based on the report of figure 1, this study was done throughout the rural Kebeles in Lemo district.
Based on the report of figure 1, multistage sampling (two stages) was applied to Kebeles (Sub-districts). In the first stage, one urban Kebele and 10 rural Kebeles were selected with lottery method. In the second stage, households were selected using systematic random sampling technique. A sampling frame of registered children was identified from health posts and family folder. It consists of lists of 24-59 months children in the Kebele health post. Each household for this study was identified using systematic random sampling. The first household was identified using lottery methods and then subsequent households were selected using Systematic random sampling every sample at Kth (N/n). The households selected for this study which contain children’s of age 24-59 months were proportionally allocated in each Kebele. A representative sample of 422 households was selected (See figure 1).
Measurement
According to the report of figure 2, the dependent variable of this study is the status of stunting among children. Stunting is determined by measuring the height and age of the child and compares the height for age score of children with the WHO standardized score. The independent includes the socio-demographic characteristics, children characteristics, parent characteristics and Environmental risk factors. Figure 1 of this study indicates the influence of socio-economic status of the family, parent characteristics and environment variables on childhood stunting status. The child height was measured using measuring board. The vertical and horizontal measuring board reading reaches a maximum of 175cm and capable of measuring to 0.1cm. The child was measured accurately as much as possible with bare foot, standing in perfect erection position to touch the measuring board by most part of the body. Two readings were recorded and the computed average was used in the analysis. Length was measured as by making the child lie flat on the length board. The sliding piece is placed at the edge of the bare feet as the head touches the other end of the measuring device. Then two readings were taken and the average was computed. Weight was measured by using an easily portable weighing scale, graduated by 0.1 kg, was used. The scale was adjusted before weighing every child by setting it to zero. Two readings were taken for each child and the average was recorded on the questionnaire (See figure 2).
Operational definitions
Food insecurity: Is a state or a condition in which people experienced limited or uncertain physical and economic access to safe, sufficient and nutritious food to meet their dietary needs or food preferences [16].
Food security: A situation when all people at all times have both physical and economic access to safe, sufficient and nutritious food to meet their dietary needs or food preferences for a productive, healthy and active life [16, 17].
Stunting /chronic malnutrition/: Reflects long term cumulative effects of inadequate nutrition and health. Shortness in height refers to low height-for-age that may reflect either normal variation in growth or a deficit in growth. It is defined as low height-for-age at< -2 SD of the median value of the NCHS/WHO international growth reference [18].
Data collection tools and procedure
A structured and interviewer-administered questionnaire was used to collect socio-demographic variables of mothers and child characteristics. Furthermore, anthropometric measurements were taken to determine the nutritional measurement outcome: Weight, Height and Childs age was taken to investigate the nutritional status of the children. The questionnaire was first prepared by English then translated to Hadyiyissa and back to English to keep its consistency. Interview was conducted in the local language (Hadyiyissa) for easy understanding. Also, anthropometric measurements such as Weight, Height and Childs age was taken to assess the nutritional status of the children. Children were examined to find signs of malnutrition (stunted, wasted or underweight) with the help of seven BSC nurses which had previous experience in measuring child malnutrition outside of the study area. The Growth standard anthropometric measurement procedure was performed according to World Health Organization recommendation[19]. The children’s age was determined with interrogation and confirm through probing. The age of the children was collected from the health posts family folder as well as mother or caregiver of the children. Weight was recorded in kilograms by using standard calibrate machine. During measuring weight each subject was asked to bare footed and to remove heavy cloths. Weight was measured to the nearest 0.1kg. Weighing scale was calibrated to zero before taking every measurement; Measuring of height, subjects was positioned to stand on the platform, bare footed with their head upright, looking straight forward by using standard height measuring scale. Height was measured to the nearest 0.1 cm.
Data quality control
A pretest was performed on 5% of households that were not included in the actual samples of the study. Data collectors and supervisors were trained for three days to improve the quality of data. Training was given about the aim of the study, sampling procedure and data collection technique. Questionnaire was pretested on 5% of households that were not included in the actual samples of the study. At the end of each day, the completeness of the questionnaires was checked by the principal investigator.
Data analysis
Data were cleaned, coded and entered using Epi-info7 software. Then, it was exported to Statistical Package for Social Sciences (SPSS) software version 24 for analysis. WHO anthro program version 3.2.2 software was used to generate nutrition indexes and export to SPSS. Before the actual logistic regression analysis, necessary assumption of logistic regression analysis was checked. The World Health Organization (WHO) growth reference was used to report anthropometric result; Individual anthropometric data was compared with reference values on a graph using sex and age specific the z-score classification system.
The nutritional status indicators, weight-for-Height (WHZ), Height-for-age (HAZ) and weight-for-age (WAZ) were compared with the reference data from World Health Organization standards. Children below-2 standard deviations (-2SD) of the WHO median for WHZ, HAZ, and WAZ were considered as wasted, stunted or underweight respectively. A cut-off of below-2 standard deviations (-2SD) of the WHO median for HAZ was considered. Frequencies and cross tabulations were used to check for missed values and variables. Descriptive analysis was made using percentage, mean, standard deviations for variables included in the study. Variables with a P-value < 0.25 were taken as a candidate variable for the multivariable logistic analysis. Multivariate logistic-regressions were used to adjust for possible confounding variables. Adjusted odds ratio with 95% CI and P-value < 0.05 was computed to assess the strength and significant level of the association. Finally, Hosmer-Lemeshow goodness of test was used to check the model fitness.