Study area, period and design
The study was conducted in pastoral community of Dawe Kachen district found in East Bale zone, Oromia Region, Southeast Ethiopia. Dawe Kachen district is located 582 km distance from Addis Ababa in Southeast direction. The district has 15 kebeles (all are rural kebeles) with the total population of 44,879(21,991 females and 22,888, male), and 6,732 children under age. The District has three health centers namely Mio health center, Sofumar health center and Hargedeb health center, 15 health posts, 4 primary clinics, 2 Drug stores, according to Dawe Kachen district health office report of 2021,(2014 Ethiopian Fiscal year) (14). All the three health centers in Dawe Kachen district give the community based acute malnutrition management services (CMAM). The study was conducted from May-June, 2022. Institutional-based unmatched case–control study design was employed
Population
All children 6–59 months of age living in the Dawe Kachen district with a mother/caregiver were the source population and all randomly selected children 6–59 months of age with a mother/caregiver pair were the study population.
Eligibility Criteria
Inclusion criteria
Selection of cases: - Children 6–59 months of age with mother/caregiver who were diagnosed and had acute malnutrition by fulfilling the WHO’s criteria for acute malnutrition, and had one of the followings MUAC < 12.5cm, Weight-for- height Z-score (WHZ) <-2SD, and/or Bilateral nutritional origin pitting edema were selected as cases.
Selection of controls
Controls were children 6–59 months of age with mother/caregiver who were without acute malnutrition that is, WFH ≥-2SD, MUAC of ≥ 12.5cm, and without bilateral pitting edema of nutritional origin and were selected from the same health facilities from which cases were selected.
Exclusion criteria
Children with evidence of chronic health problems like TB, HIV, cirrhosis of liver, protein losing enteropathy, and edema due to congestive heart failure and mother/caregiver who were unable to communicate or were seriously ill and unable to provide information were excluded from the study.
Sample size determination
The sample size was calculated using the two-population proportion formula and using the EPI INFO version 7.2.5.0 statistical software with the assumption of confidence level 95% (Z𝛼/2 = 1.96), power 80% (Z = 0.84), case-to-control ratio 2:1. Where P1 is the proportion of cases exposed and P2 is the proportion of controls exposed. Proportion of having family size ≥ 5 among the cases 0.753 and 0.572 among the controls (15). The calculated sample size with the maximum sample for this study was 294, after adding 10% expected non-response rate final, sample size obtained was 98 cases and 196 Controls.
Sampling procedures
All three public health facilities found in the district were included in the study, and private health facilities were not included because they do not provide Community Management of Acute Malnutrition (CMAM) services. The sample was allocated to the three public health facilities according to the number of acutely malnourished children.
The total number of acutely malnourished children aged 6–59 months and who were followed up before the study were 204 (Mio Health Centers, 72 patients; Sofumar Health Centers, 84 patients; and Hargedeb Health Centers, 49 patients). Finally, the sample was allocated as follows:
For the Mio Health Centers: (72/204) *98 = 35 patients and 70 controls. For the Sofumar Health Centers: (83/204) *98 = 39 patients and 78 controls. For Hargedeb Health Centers: (49/204) *98 = 24 patients and 48 controls. Finally, the study subjects (for cases) were drawn from each health facility using a systematic random sampling technique with a skipping interval (k = 2) (K is the sample fraction; N/n = 204/98 = 2). N = 204 is the total number of patients registered and on follow-up at health facilities before the study. Once an acutely malnourished child aged 6–59 months was selected as a case and his/her mother/caretaker was interviewed, the first two no acutely malnourished children aged 6–59 months were selected as controls, and their mothers/caretakers were interviewed. The numerator is the average monthly attendants of children aged 6–59 months in public health facilities
Data collection procedures (tools, techniques and personnel)
The data were collected using an interviewer-administered questionnaire to obtain information from the child’s mother/caregiver to address the socioeconomic status, demographic status, child feeding and caring practices, wealth index, dietary diversity of the child and household food insecurity status of the respondents. The questionnaire was prepared in the English language and then translated to Afan Oromo and back to English to check its consistency. Mothers/caretakers were interviewed using the questionnaire for approximately 25–30 minutes. A total of 6 data collectors who had community management of acute malnutrition training and 3 supervisors were recruited and trained for 2 days, mainly focusing on anthropometric measurement techniques and on how to administer and record the questionnaire. The data collectors were closely supervised by the three trained supervisors and by the investigator.
Basic anthropometry was performed on children aged 6–59 months by measuring weight, height/length and MUAC based on the Guide to Anthropometry, a practical tool for program planners, managers, and implementers standardized procedures (2).
Weight: The weight of the child was taken by using an electronic weighing scale model EB9360 to the nearest 0.1 kg for accuracy. The study participants were weighed while wearing the lightest possible clothes and without shoes or bare feet.
Height/length: The height of the child was determined using a scale stadiometer/woodboard for 24-59-month-old children. The children were required to stand with their legs straight and with their heels and height measured while touching the back, arms on the sides, and relaxed shoulders, with their chin level to ground and looking straight ahead. A sliding board was used to measure the length of teeth less than 2 years (85 cm) in the recumbent position to the nearest 0.1 cm for accuracy by laying the child on a flat surface with the head positioned firmly against the fixed board and the eyes looking vertically.
Mid-Upper Arm Circumference (MUAC): The MUAC of the child was measured on the left arm halfway between the olecron and acromion processes using a colour-coded nonstrech tape metre to the nearest 0.1 cm for accuracy. Two different data collectors took anthropometric measurements, and average measurements were taken for analysis. The presence of edema was assessed by grasping both feet in the hands with the thumbs on the top of the fit and then pressing the thumbs gently for three seconds or a count of 101, 102, or 103 and then releasing the thumbs. Registration was made as “+” if an indent was detected on the feet, “++” if it was detected on the feet and legs, and “+++” if it included the hands and the face according to accepted standards.
The dietary diversity of the children was assessed by using a 24-hour recall method. The food security status of the household was collected by using standardized questionnaires developed by the Food and Nutrition Technical Support for Developing countries (FANTA) in 2007 (16)
Study Variables
Dependent variable
Children aged 6–59 years were acutely malnourished (children aged between 6–59 months whose WFH < 80% and/or whose MUAC was < 12.5 cm (MAM) and whose WFH < 70% and/or MUAC was < 11.5 cm (SAM) with or without bilateral pitting oedema (9)).
Independent Variables
Sociodemographic and Economic related factors
Age, educational status of mothers/husband, occupational status of mothers/husband, wealth index, Ethnicity, marital status, family size, religion, and Household food security status.
Child feeding and caring practices
information on child feeding, duration of child feeding, colostrum feeding, exclusive breast feeding and complementary feeding, IYCF counseling, and dietary diversity
Maternal and child health conditions
Immunization, diarrhea, fever, ANC and PNC follow up, height, weight, birth order
Sanitation and hygiene condition
sources of drinking water, latrine availability and hand washing practice of mother/caregiver.
Operational definitions
Acute malnutrition (Cases)
is defined as children between 6–59 months of age whose WFH < 80% and/or children whose MUAC is < 12.5 cm (MAM) and WFH < 70% and/or MUAC is < 11.5 cm (SAM) with or without bi-lateral pitting edema were considered as acutely malnourished(9).
No acute malnutrition (Controls)
is defined as children between 6–59 months of age Whose WFH ≥ 80% and/or MUAC ≥ 12.5cm and without pitting nutritional edema attending the selected health facilities.
Wasting (weight-for-height index)
Wasting refers to a lack of appropriate nutrition in the weeks leading up to the survey. It might be the result of insufficient food consumption or a recent sickness that caused weight loss and the development of malnutrition(9).
Describes current nutritional status; includes both MAM and SAM.
Moderate acute malnutrition
WFH < 80% and MUAC < 12.5 cm with or without edema.
Severe acute malnutrition
WFH < 70% and MUAC < 11.5 cm with or without edema (9, 17).
Household food security status (18).
Food secure
Household experiences none of the food insecurity conditions, or experiences worry, but rarely.
Food insecurity
When household worries about not having enough food sometimes or often and or experiences other food insecurity conditions.
Data quality assurance
To assure the quality of data, both data collectors and supervisors were given two days training. Questionnaire was pretested on 5% of acutely malnourished and no acutely malnourished children at other nearby health center to check for its appropriateness such as typing error, missing questions by the investigator. Questionnaire was revised as needed. Supervisors to minimize information bias during data collection classified cases and controls. Data collectors were blinded to cases and controls. Data collectors were submitting the collected data on daily basis to supervisors. Each questionnaire was checked before data entry for completeness and consistency.
For dietary diversity, foods were categorized into seven food groups. List of locally available foods were adapted by interview of key informants and agriculture research experts near to study area. Childs Mother/caregiver was asked to recall the foods child consumed in the previous 24-hrs, and followed by probes to ascertain that no meal or snack were left out. A detailed list of all the ingredients of the dishes, snacks, or other foods consumed was generated to enable better classification of mixed dishes. Validation of instruments and measurements was done randomly on a daily basis. Weighing scale was calibrated using 2 kg Ringer lactate solution randomly on daily basis.
Data processing and analysis
The Questionnaires was checked manually for completeness and entered in to Epi data v4.6.0.4 and exported to SPSS version 24 for analysis. The data set was first checked to make sure it was free from outliers and collinearity issues. The dependent and the independent variables were categorized to facilitate the analysis Bivariate analysis was done to see an association between the outcome and independent variables. Those variables with a P-value < 0.25 in bivariate logistic analysis were entered into a final regression model. Multivariable logistic regression analysis using stepwise selection method was done to determine independent predictors of acute malnutrition among explanatory variables and strength of association was determined using odds ratio with 95% CIs. Model fitness was tested for goodness of fit using Hosmer-Lemeshow tests (p value = 0.5). Multicollinearity between independent variables was checked by variation inflation factor (VIF), and was < 10. The possible effect modifiers were tested by stratified analysis using Breslow Day test (Test for homogeneity of odds Ratio) at p-value < 0.05. Explanatory variables that were significant at p-value < 0.05 were considered as determinants for acute malnutrition. Adjusted odds ratio (AOR) with its 95% confidence interval (CI) was considered to see the association. Principal Component Analysis (PCA) was done for household wealth score, and the household wealth index was ranked in to tertile. The findings were presented using, tables, graph, and text.
Anthropometric data were analyzed using WHO Anthro software version 3.2.2. The validity of anthropometric z- scores were investigated using WHO protocol guidelines (2006), which provide standard deviation cut off points for anthropometric Z-scores as a data quality evaluation tool(45). Impossible z-scores data were removed if a child's HAZ is below − 6 or above + 6, WAZ is below − 6 or above + 5, WHZ is below − 5 or above + 5, or BMIZ is below − 5 or above + 5.
Dietary Diversity Score (DDS) was calculated from a single 24 hrs recall method and all the foods and the liquids consumed a day before the study was categorized in to 7food groups. Consuming a food item from any of the groups was assigned a score of 1and if no food is taken a score of 0 was given. Accordingly, a DDS of 7 points was computed by adding the values of all groups. The DDS was computed using the following seven dietary groups: cereals, roots, and tubers; legumes and nuts; dairy products; meat meals; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables, with one being the lowest and seven being the greatest score.
Household food security status was determined using the nine standard household food insecurity access scale (HFIAS) questions developed in 2007 by Food and Nutrition Technical Support for Developing countries (FANTA)(18). Prior to assigning the food insecurity access category, each frequency of occurrence question was coded as “0” for all cases where the answer to the corresponding was “no” and then the four food security categories were created sequentially as recommended by FANTA. Based on HFIAS, households were categorized as food secure, mild food insecure, moderate food insecure and severe food insecure. Finally, the HFIAS category one was considered as food secure and the remaining as food insecure.
Ethical considerations
The study protocol was approved and ethical approval letter is provided by the Ethical Review board of Salale University with reference number HSC/878/14. The study was performed in line with the World Medical Association Declaration of Helsinki on medical research. Informed verbal and written consents were obtained from every study subject before the data collection and. The entire information collected from the study participants was handled confidentially by omitting their identification.