SAINT PAUL HOSPITAL MILLENNIUM MEDICAL COLLEGE
RESEARCH
PROPOSAL
ON
DETERMINING
FACTORS
AFFECTING NUTRITIONAL STATUS OF CHILDREN AMONG
6-59 MONTHS OF AGE ADMITTED TO PEDIATRIC WARD AND
EMERGENCY WARD IN THE MONTH OF APRIL 2020.
PREPARED BY: MOTUMA TOLU (INTERN).
ADVISORS: MR. TEMESGEN GELETA.
DR. TEMESGEN (PEDIATRIC CARDIOLOGIST).
A STUDENT RESEARCH PROPOSAL TO BE SUBMITTED TO THE
DEPARTMENT
OF
PUBLIC
HEALTH
,SPHMMC,
IN
PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF MEDICINE
FEBRUARY, 2020
ADDIS ABABA
SAINT PAUL HOSPITAL MILLENNIUM MEDICAL COLLEGE
RESEARCH
PROPOSAL
ON
DETERMINING
FACTORS
AFFECTING NUTRITIONAL STATUS OF CHILDREN AMONG
6-59 MONTHS OF AGE ADMITTED TO PEDIATRIC WARD AND
EMERGENCY WARD IN THE MONTH OF APRIL 2020.
PREPARED BY: MOTUMA TOLU (INTERN)
ADVISORS: MR. TEMESGEN GELETA
DR. TEMESGEN (PEDIATRIC CARDIOLOGIST)
A STUDENT RESEARCH PROPOSAL TO BE SUBMITTED TO THE
DEPARTMENT
OF
PUBLIC
HEALTH,
SPHMMC,
IN
PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF MEDICINE
FEBRUARY, 2020
ADDIS ABABA
ii
Acknowledgement
I am grateful to the almighty GOD and also would like to thank my advisors Mr. Temesgen and
Dr Temesgen for their help in the development of this research proposal. My thanks also extend
to those all who cooperated with me in preparing this research proposal. Finally I would also like
to acknowledge all staff members of the Saint Paul hospital millennium medical college library
for-all their contribution to my proposal.
i
Summary
Background: Childhood malnutrition is a silent emergency and complex problem with far
reaching consequence and is frequently part of a vicious cycle that includes poverty and disease.
Child under nutrition remains neglected issue and major public health problem in many countries
and continues to hamper children’s physical growth and mental development. The factors that lead
to it are varied and inter connected. The aim of this study is to determine factors affecting the
nutritional status of children among 6-59 months old admitted to Saint Paul pediatric and
emergency ward in the months of April, 2020.
Objectives: The Primary target is to determine factors affecting nutritional status of children
among 6-59 months of ages admitted to pediatric ward and emergency ward in the month of April
2020 and in the meantime to create the awareness regarding how the nutrition of children should
be.
Method: A hospital based prospective cross-sectional study design with both descriptive and
analytical components will be conducted, which will be including the use of intervieweradministered questionnaire to determine the factors affecting the nutritional status of 6-59 months
old children admitted to saint Paul hospital pediatric ward in the months of April 2020.Each filled
questionnaire will be assigned unique code and will be entered into computer by using SPSS
version 20 for analysis
Work plan and budget required: This research will be completed over a period of seven
months and will probably be covered with a budget plan of 1879 birr.
ii
Acronym and abbreviation
SDG
Sustainable development goal
HIV/AIDS
Human immune virus/ acquired immune deficiency syndrome
DNA
deoxyribonucleic acid
MUAC
Mid-upper arm circumference
WHO
World health organization
PEM
Protein Energy Malnutrition
NCHS
National Centre for Health Statistics
SD
Standard deviation
H/A
Height-for-age
W/A
Weight-for-age
W/H
Weight-for-height
UNICEF
United nation children’s emergency fund
SPSS
Software Package for Social Science
IMCI
Integrated management of childhood illness
SAM
Severe acute malnutrition
GEMS
Global Enteric Multicenter Study
iii
Table of Contents
Acknowledgement ......................................................................................................................................... i
Summary ....................................................................................................................................................... ii
Acronym and abbreviation ........................................................................................................................... iii
1.
Introduction ........................................................................................................................................... 1
1.1.
Background ................................................................................................................................... 1
1.2.
Statement of the problem .............................................................................................................. 3
2.
Literature review ................................................................................................................................... 6
2.1.
3.
Factors affecting nutritional status of children.............................................................................. 8
2.1.1.
Disease and child malnutrition .............................................................................................. 8
2.1.2.
Influence of feeding practices and dietary intake on child nutrition ..................................... 9
2.1.3.
Levels of care and malnutrition ............................................................................................ 9
2.1.4.
Influence of household environment on childhood malnutrition ........................................ 10
2.1.5.
Influence of health services on nutritional status of children.............................................. 10
2.1.6.
Individual characteristics and child malnutrition ................................................................ 10
2.1.7.
Influence of household access to resource on nutritional status of children ....................... 11
Objectives ........................................................................................................................................... 12
3.1.
General objectives ....................................................................................................................... 12
3.2.
Specific objectives ...................................................................................................................... 12
4.
Method and material ........................................................................................................................... 12
4.1.
Study area.................................................................................................................................... 12
4.2.
Study design and Study period.................................................................................................... 12
4.3.
Source population ....................................................................................................................... 13
4.4.
Study population ......................................................................................................................... 13
4.4.1.
Inclusion criteria ................................................................................................................. 13
4.4.2.
Exclusion criteria ................................................................................................................ 13
4.5.
Sampling method and sample size determination ....................................................................... 13
4.6.
Data collection method ............................................................................................................... 14
4.7.
Measurement ............................................................................................................................... 14
4.8.
Data processing and analysis ...................................................................................................... 16
4.9.
Variables ......................................................................................................................................... 16
4.9.1.
Dependent variables ................................................................................................................ 16
4.9.2.
Independent variables ............................................................................................................. 16
iv
4.10.
Operational definition ................................................................................................................. 17
5.
Ethical consideration ........................................................................................................................... 17
6.
Work plan............................................................................................................................................ 18
7.
Cost breakdown .................................................................................................................................. 19
8.
References ........................................................................................................................................... 20
9.
Annexes I ............................................................................................................................................ 22
v
1. Introduction
1.1.
Background
Children are one of the most important population groups in the world and their health is a matter
of fundamental importance. Malnutrition is considered as one of death causes among them,
especially those under five years old. In this regard, proper nutrition is a prerequisite for good
health. Children’s Nutrition is directly or indirectly linked to the Sustainable Development Goals
(SDG) and it is critical in the overall development of individuals and the national large. On the
other hand, malnutrition remains a major public health problem and is responsible for one-third of
all infant and child mortality especially in third world countries. Protein calorie malnutrition is a
widespread nutritional disease in developing countries. Under-five children are notoriously fraught
with the risk of malnutrition. Malnutrition is the consumption of dietary nutrient either
insufficiently or exclusively. In most countries, it is often observed that child mortality arises from
the synergistic impact of effect of under-nutrition and infection. Children who are severely
malnourished are susceptible to impaired cognitive growth and development which consequently
affect them later in life as they grow older. Long-term malnutrition among children under five
years of age results from poor dietary intake which can adversely lead to dysfunction of the
physical and mental health. The burden of malnutrition commonly occurs within the African
especially in sub-Saharan and Asian countries of the world. High rates of child mortality in SubSaharan Africa results from factors such as low intake of calories, high rates of HIV/AIDS,
political instability, poor implementation of government policies, conflicts among groups, etc[1].
A balance between high energy and nutrient content required for growth and development of
infants and children in conjunction with regular physical exercise. Therefore, childhood nutrition
should be made up of natural, fresh sources of energy and nutrients. The requirements for
micronutrients and macronutrients are highly needed during infancy and early childhood than at
any other stage of development, which are triggered by rapid cell division that occurs during
growth which requires nutrients, proteins and energy in DNA synthesis and metabolism of calories,
protein and fat. Inadequate nutrition during the first two years of life may lead to childhood
morbidity and mortality, as well as inadequate brain development. Children living in most
1
developing countries are introduced directly to the regular household diet made of cereal or starchy
root crops which is a major cause for the high incidence of child malnutrition, morbidity and
mortality [1, 2].
Periodic growth monitoring of children is an important indicator of the health and nutritional
wellbeing of the pediatric age population. The three main indicators used to define and asses under
nutrition are underweight, stunting and wasting. In which each parameter represents different
histories of nutritional insult to the child during different time of period. This occurs primarily in
the first 2–3 years of life. Child under nutrition remains a major public health problem in many
countries and continues to hamper children’s physical growth and mental development. The
leading childhood diseases are diarrhea, respiratory infections, measles, tuberculosis and etc. It is
known that a child may get affected several times in a year; that is incidence increases with the
aggravation of a state of malnutrition leading the underlying cause of morbidity and mortality in
pediatric age groups [3].
Although malnutrition in pediatrics is of concern in low resource settings, this state is also of major
worry for hospitalized children in developed as well as in-transition countries. However, causes
for malnutrition differ in the two environments. Independently of the income setting, malnutrition
is multifactorial. Whereas malnutrition in low-income countries is often, but not solely, attributable
to limited access to food and/or medical care, it is often triggered by disease in in-transition
countries. In comparison to adults, children are particularly vulnerable to malnutrition, having a
lower caloric reserve and higher nutritional requirements per unit of body weight, to account for
growth. When factoring in the impact of disease or illness that contributes to increased nutrient
requirements, malnutrition may, on long-term, impact the growth and cognitive development
trajectory. It follows that early identification of malnourished children or children who are
potentially at risk for malnutrition is key to preventing debilitating sequels [4].
Malnutrition is common in pediatric inpatients, and nutritional status often deteriorates in the
hospital. Although the prevalence of hospital malnutrition is high, this condition is ignored and
consequently, not treated. The first step to fight malnutrition knows how to identify patients at
greater risk of this condition. Based on its etiology, malnutrition is classified as primary, caused
by environmental and behavioral factors associated with low nutrient intake and secondary, caused
by one or more diseases that promote nutritional imbalance. Disease or trauma-related malnutrition
2
stems from different mechanisms like low nutrient intake, higher nutritional requirements, higher
losses, and changes in food use. In developed countries malnutrition results mainly from diseases,
and it may be worsened by frequent hospital stays and the need to undergo diagnostic tests. Primary
malnutrition occurs mostly in developing countries. Although primary malnutrition decreased
considerably in the last three decades, its prevalence remains high and disease-related malnutrition
and hospital malnutrition also occur. Malnutrition is common in pediatric inpatients as their
nutritional status often deteriorates during hospital stay. Even though the prevalence of hospital
malnutrition is high, child healthcare professionals ignore this condition time and again, and
consequently, leave it untreated [5].
Many factors contribute to the high frequency of hospital malnutrition. Some factors are inherent
to the patient, such as age, nutritional status at disease onset, medical and obstetric history, and
social status. Other factors are related to hospital stay, such as procedures that require fasting, diet
acceptance, time to achieve full diet, diet efficacy, the disease itself, and disease severity. Hospital
malnutrition present in the first 72 hours of hospital stay stems partially or totally from patient
inherent causes. If malnutrition occurs after the first 72 hours of hospital stay, it is more strongly
related to low nutrient intake. Age is an important risk factor for malnutrition as the risk of losing
weight increases with decreasing age. Children of breastfeeding age require higher calorie intake
per kilogram of body weight than older children and adolescents, so they are at greater risk of
malnutrition during hospital stay. Prevalence of undernutrition in developing countries, though on
the declining trend, is still a cause for alarm in morbidity and mortality [5, 6].
1.2. Statement of the problem
Malnutrition is one of the diseases of public health importance globally as it’s responsible for the
death of over 41% (2.3 million) of children with in age group of 6 to 24 months living in the
developing countries (7). In 2017 UNICEF/WHO/World bank group joint child malnutrition
estimated stunting affected estimated 22.9% or 154.8 million children under five years globally.
These children are surrounded by major problems such as less cognitive function and hence
learning difficulties, psychosocial barriers, physical problems and most importantly their ability to
withstand infectious disease is low and their risk of developing chronic disease is high. Africa and
Asia are the most affected in the world. In 2016 more than half of all stunted children under five
years of age (56%) lived in Asia and more than one third (38%) lived in Africa [8].
3
Malnutrition is common in pediatric inpatients, and nutritional status often deteriorates in the
hospital. Although the prevalence of hospital malnutrition is high, this condition is ignored and
consequently, not treated. The first step to fight malnutrition knows how to identify patients at
greater risk of this condition. In developed countries the prevalence of acute and chronic
malnutrition on hospital admission varies from 6.1% to 19% and 8.7% to 12.8%, respectively.
Despite all the scientific knowledge, the prevalence of malnutrition in the last 10 years has not
decreased [5].
Children who suffered from undernutrition problem are at increased risk for repeated infection and
are more likely to die from diarrhea, pneumonia, and measles and undernutrition by itself had
impact on socioeconomic status of the future adult [9]. In addition to an increased frequency of
infectious disease, severe acute malnutrition can be a direct cause of death. It can also increase the
case fatality rates in children suffering from common childhood illnesses like diarrhea and
pneumonia. Though on a decreasing trend, undernutrition is a still a major health problem in Asia
and also in Africa especially sub Saharan region. Children with malnutrition are at significantly
higher risk of more severe disease and suffer significantly more acute and long-term morbidity
and mortality when infected [10].
Children with malnutrition appear to be at substantially higher risk of diarrhea, with both higher
incidence and increased severity reported in malnourished children. Children with SAM are more
likely to present to health care with at least one integrated management of childhood illness (IMCI)
danger sign and may be more likely to have a bacterial pathogen identified as a potential causative
agent of their diarrhea than undernourished children. In addition, as demonstrated in a study of
1146 children admitted to hospital with moderate-severe diarrhea in Western Kenya (2005–2007),
among children with severe acute malnutrition, risk of death following an episode of diarrhea was
four times higher than better nourished children. The community-based Global Enteric Multicenter
Study (GEMS) also enrolled 9439
children with moderate-to-severe diarrhea and
control children without diarrhea in seven countries in Africa and Asia. Diarrhea case status was
associated with stunting (chronic malnutrition leading to linear growth failure) [9, 10].
Similarly, malnutrition is not only associated with an increased risk of pneumonia episodes, but
increased
severity
and
case
fatality.
Development
of
an
inpatient
pediatrics
pneumonia mortality risk score (RISC) in Malawi (n = 16 475) identified severe malnutrition as
4
having similar predictive value to hypoxemia and coma. In Kenya, among 4187 children admitted
to hospital with severe pneumonia, 25% were severely malnourished, again a strong risk factor for
inpatient death alongside signs of disease severity. A subset of children was followed after
discharge from hospital; 37% of deaths occurred after discharge. Malnutrition, young age, HIV
status and prolonged hospital admission were associated with post discharge mortality, whilst
pneumonia severity indicators were not, suggesting that an episode of severe pneumonia is a
marker of background risk [9.10].
5
2. Literature review
Under nutrition is the outcome of insufficient food intake and recurrent infectious diseases. The
baseline levels of under nutrition remain so high that Ethiopia still needs to continue substantial
investment in nutrition. Therefore, with the aim of nutritional assessment and to identify
determining factors of nutritional status among children of 6-59 months of age, the study will be
done in Saint Paul hospital pediatric ward and emergency ward.
According to one study done focusing on the Nutritional Assessment of under Five Children
Attending Pediatric Clinic in a Tertiary Care Hospital in the Capital of Nepal had reported that
among a total of 424 children included in the study, There were 2.1% severely stunted, 6.4%
severely wasted and 4.7% severely underweight[6].
There was also another study on the prevalence of undernutrition among under five children
attending pediatric tertiary care hospital in northeast of India in which 6183 under five children
are included in the study with in a time period of three months revealed that the overall prevalence
of underweight, stunting and wasting was found to be 19.7%, 35.5% and 8.5% respectively. Of
these, 9.0%, 19.7%and 3.4% children were found to be severely underweight, stunted and wasted
respectively with male predilection [7].
Hospital based cross sectional study done in Tanzania Buganda medical Centre revealed that
Severe malnutrition was found in 178(24.7 %) children and among these 97 (54.5 %) had
marasmus [11].There is strong relationship between malnutrition in children and factors such as
time of initiation of complementary feeding, socio demographic indices such as maternal
education, number of children in the home and parental social status [12].
There is a descriptive and retrospective cross-sectional hospital based study that was carried out
for over ten years in Cameroon. The most frequent symptoms on admission were: wasting (58.1%)
and fever (53.6%). Respiratory tract infections were the most common comorbidities and were
presenting 45 patients (25.1%), followed by malaria in 15.1% of cases. Dehydration was the most
frequent complication, with an occurrence of 29.6% [13].
The factors leading to undernutrition are multidimensional, complex and interrelated. The united
nation children’s fund conceptual framework of childhood malnutrition shows causes of
6
malnutrition as being classified into three main categories: basic, underlying and immediate causes
(figure 1) (14).
Figure 1.1. Conceptual framework of determinants of child undernutrition
The basic causes deal with the society as a whole that is it is structures and processes. These
includes social, economic and political factors. The underlying causes deal with factors in the
household and community. The immediate causes are on the level of the individual. Factors at one
level contribute to the other levels.
The consequences of malnutrition in children under 5 years are many and affect multiple areas of
their lives. They can be irreversible and devastating especially if undernutrition occurs in the first
1000 days of life, that is, during pregnancy and the first two years of life. During this period a child
has high nutritional demands due to rapid growth, is totally dependent on others to meet their
7
nutritional needs and has increased susceptibility to infection. The consequences of undernutrition
can be divided into short term and long term consequences. Short term consequences include
reduced immune competence, lethargy, delayed milestones and mortality. Long term consequence
include poor school performance, reduced productivity in adulthood, shorter adult height, reduced
cognitive ability and metabolic diseases [15].
2.1.
Factors affecting nutritional status of children
According to the UNICEF conceptual framework (figure 1), the factors leading to malnutrition
can be discussed under the following titles.
1. Immediate causes:
1.1.Inadequate dietary intake
1.2.Disease
2. Underlying causes:
2.1.Inadequate feeding practices-breastfeeding, complementary feeding
2.2.Inadequate care-health seeking behavior, hygiene practices
2.3.Household environment- type of house, access to clean water, sanitation, Urban/rural,
family size
2.4.Inadequate health services: immunization rates, distance to health facilities
3. Basic causes
3.1.Household access to resources: land ownership and utilization, education, employment,
income.
2.1.1. Disease and child malnutrition
Of the most common immediate causes of death in children under 5 years of age malnutrition
contributes to a significant extent. The interaction between nutrition and infection is cyclic and
closely linked. For instance one study revealed that there is strong association between acute
malnutrition and diarrheal disease with ODD RATIO 3.94 indicating fourfold risk of acute
malnutrition among children who had diarrhea as compared to those without it. In general
Malnutrition could also come as a result of loss of appetite, and this may be common among
terminally ill people such as HIV/AIDS, cancer and failed organ patients, kwashiorkor people and
elderly people [10].
8
Figure 2. Interactions between malnutrition and infection
Several studies have shown an association between a child suffering an illness and the presence of
malnutrition [3, 5, 7, 9, 10, and 15].
2.1.2. Influence of feeding practices and dietary intake on child nutrition
Correct feeding practices are an integral to a child’s nutritional status and general well-being.
These feeding practices include practicing exclusive breastfeeding, early initiation of
breastfeeding, and avoidance of pre lacteal feeds, appropriate complementary feeding and
practicing responsive feeding [16].
Different studies have shown negative, positive and no correlation between breastfeeding practices
and the presence of malnutrition. In developing nations, children not exclusively breast fed for 6
months are more likely to have severe malnutrition. There has also been a correlation found
between late initiation of breastfeeding and malnutrition [17, 18]. Some study also found that
there is an association between giving pre lacteal feeds and malnutrition. Bottle feeding has also
been associated with the presence of malnutrition [18, 19]
2.1.3. Levels of care and malnutrition
Inadequate care also contributes to the development of malnutrition. Indicator that can be used to
reflect this include health seeking behavior and hygiene practices. A delay between a child falling
sick and being presented to a healthy facility was found to be significantly associated with
malnutrition with cases taking a mean of 2.1 days to present to hospital and controls taking a mean
of 1.9 days [18]. Poor hand washing practices of both mother and child which include not washing
9
hands before meals and after defecation have also been associated with the risk of developing child
malnutrition [17, 18]
2.1.4. Influence of household environment on childhood malnutrition
The household environment is also a contributor to the development of childhood malnutrition.
Studies have shown a correlation between the type of building materials used for the home and
child malnutrition. Living in a temporary house was associated with severe malnutrition even
though the correlation was less pronounced when income was taken into account [24]. The risk of
developing SAM was increased when no method of water purification is used with 15% of cases
and 5% of controls not using any method of water purification. There was also an association
between stunting and underweight and the type of sewage disposal system with the strongest being
in those without toilet and in the same study an association was also found between absence of
latrine and malnutrition with 22.1% of cases and 11.9% of controls lacking access to a latrine.
Living in a rural area increases the risk of developing malnutrition [17, 18]. Child living in a
female headed household were more likely to have al, three forms of under nutrition. The order of
birth has been found to be associated with wasting and being underweight with children of lower
order of birth being the ones more affected. This may be due to the mother shifting attention to the
newest child [22].
2.1.5. Influence of health services on nutritional status of children
Having inadequate health services contributes to the development of child malnutrition. The
indicators that can be used to assess this are distance to a health facility, time taken to reach a
health facility and immunization rates among children. The lack of age appropriate vaccination
was found to be associated with the risk of having SAM with 26% of cases and 9% of controls
lacking age appropriate vaccination [18].
2.1.6. Individual characteristics and child malnutrition
Some individual characteristics have also been found to be associated with childhood malnutrition.
Some study revealed that 58.3% of male children had protein energy malnutrition (PEM) while
PEM was found in 44.6% of female children. The age at which malnutrition is most likely to occur
is 6 to 24 months, which is most likely due to the introduction of inappropriate complementary
feeds [21]. The order of birth has been found to be associated with wasting and being underweight
with children of lower order of birth being the ones more affected, which is due to the mother
10
shifting attention ti the newest child. Several studies have indicated that young maternal age is
associated with high prevalence of malnutrition, while children of older women are less likely to
suffer from malnutrition [24]. Maternal age is also found to be correlated with child’s malnutrition
in which same study found higher maternal age to be protective against under nutrition [22].
2.1.7. Influence of household access to resource on nutritional status of
children
It is general knowledge that malnutrition is a condition that is associated with poverty since it
comes with hunger and lack of food at the right quantity and quality.
Family income has been found to have a strong association with nutritional status with the
prevalence of stunting, underweight and wasting being approximately 7, 4 and 2 times higher
respectively among children from the poorest than among those from the wealthiest homes
[20].One study also indicate that children from illiterate mothers were about two times more likely
to be acutely malnourished as compared to their counterparts from literate mothers. This could be
due to the higher education level of the mothers, the better perception and estimation of
malnutrition in their children [22].
Generally children 6-59 months of age are more vulnerable to malnutrition. The risk of
malnutrition is increasing with decreasing in socio-economic development. Factors that are
contributing to malnutrition vary from country to country. Identifying the under lying causes of
malnutrition in a particular locality is important approach to solve the nutritional problem.
11
3. Objectives
3.1.
General objectives
To determine factors affecting nutritional status of children among 6-59 months of ages admitted
to pediatric ward and emergency ward in the month of April 2020.
3.2.
Specific objectives
1. To determine nutritional status of children among 6-59 months of ages admitted to Saint Paul
hospital pediatric ward and emergency ward in the month of April 2020.
2. To identify the demographic, socioeconomic, nutritional, child care, household and individual
factors affecting nutritional status child’s among 6-59 months of ages admitted to Saint Paul
hospital pediatric ward and emergency ward in the month of April 2020.
4. Method and material
4.1.
Study area
Saint Paul hospital was established in 1947 around mercato presently known as regional bus
terminal. The hospital was shifted in the current place in 1969 and the building was erected with
the help of the German evangelical church. As a source of medical care for economically under
privileged population, almost 75% of the patients receive medical services free of charge. Saint
Paul currently examines an average of 800 patients as an emergency and outpatient daily by using
over 20 departments. Among those pediatric department is one of them and established in 1999
started work as an outpatient with one pediatrician and two general practitioners and nurses. Later
on in 2002 pediatric inpatient department initiated with 39 beds. Currently pediatric ward was
transferred to the new maternal and child health building, which provides over 100 bed for
pediatric ward. This study will be carried out in Saint Paul hospital pediatric ward.
4.2.
Study design and Study period
The study will utilize a hospital based prospective cross-sectional study design with both
descriptive and analytical components. It will be conducted in the month of April 2020.
12
4.3.
Source population
Source population will be under five children admitted to pediatric ward and emergency ward in
the month of April 2020.
4.4.
Study population
The study population will be all children among 6-59 months of age in the selected area. Those
Children will be included in the study according to the following inclusion criteria.
4.4.1.
Inclusion criteria
Children among 6-59 months of age admitted to pediatric ward and emergency ward in the month
of April in 2020.
4.4.2.
Exclusion criteria
i.
Chronically sick and grossly deformed child.
ii.
Age less than 6 months
iii.
Those children admitted in previous month and still there.
iv.
Those children with congenital problems
4.5.
Sampling method and sample size determination
According to a systematic review and meta-analysis of eighteen studies on nutritional status of
under five children in Ethiopia done in the last ten years, the prevalence of stunting, underweight
and wasting was found to be 42.0%, 33.0 %and 15.0% respectively [25].
To determine the required data, representative sample size will be determined using the formula
of sample size determination for our target population based on the following assumptions:
• The prevalence of stunting, underweight and wasting was found to be 42.0%, 33.0 % and
15.0% respectively. So taking the P value the maximum value (p=42%).
• Margin of error 6.25%
• Confidence level 96%
• Contingency for non-response rate 10%
By using the sample size determination formula
no= (1.96*1.96) *0.42(1-0.42)/0.0625*0.0625=240
no= 240 population
no= 240+10 % (non-response rate) = 264
13
Accordingly, the sample size required for this study will be 240; adding 10% for non-response rate
the total sample size required will be 264.
Now the total average patient served within a month is 500(finite population size=N). By using
this average finite patient number we can calculate the sample size that represents this finite
average patient within a month since our study period is one month by using finite population
correction formula.
………where
n is the new sample size
n0 is already calculated sample size
N is the finite population size
Therefore the new sample size would be 173 Childs
4.6.
Data collection method
Data will be collected using structured questionnaire which has three parts (socio demographic
parts, household belongings and anthropometric measurement’s which are going to be measured
by the principal investigator during the face to face interview with participant’s mother or care
takers. The questionnaire initially will be prepared in English and translated in to local language
then retranslated to English to check consistency. The data will be collected by the principal
investigator.
4.7.
Measurement
Anthropometric measurements (weight, height, and mid upper arm circumference) will be done
for included children into the study. All anthropometric measurements will be taken by the
principal investigator and will be documented. Weight will measured in kilogram to the nearest
0.1 Kg. due to difficulty of obtaining Salter hanging scale for children 6 to 23 months, beam weight
scale will be used for all study population for measuring weight. Instruments will be checked
against a standard weight for its accuracy daily. Calibration of the indicator against zero reading
will be checked following weighting every child. Length will be taken with length board if it is
available for those children less than two years of age, while height will be taken with height board
14
if it is available for children two and above years in centimeter. Length and height will be measured
to the nearest 1cm. Left mid-upper arm circumference will be measured to the nearest 1 mm.
Weight, height and MUAC measurements will be taken three times for every child and the average
will be documented for analysis.
Growth assessment is the single measurement that best defines the health and nutritional status of
children, because disturbances in health and nutrition, regardless of their etiology, invariably affect
child growth. It also provides an indirect measurement of the quality of life in an entire population
(26).
To measure malnutrition, you may use biochemical or laboratory methods, dietary history and
clinical including anthropometry and physical examination. The first two methods are expensive
and need qualified health personnel to use and impose difficulty to assess children where facilities
weren’t available. The last method especially anthropometric measurements are best suited for
developing countries because they are non-invasive, relatively inexpensive and relatively easy to
do. The anthropometric measurements while being relatively simple do require adequate training
and standardization of technique. In-order to distinguish the phase and degree of protein-energy
malnutrition (PEM), weight-for-height can be considered as a measure of the degree of acute under
nutrition or wasting. While height-for-age reflects the level of malnutrition in the past, that is,
impairment of physical development, stunting. Weight-for-age and the mid-upper arm
circumference measurements (MUAC) have been extensively used to monitor early child growth
in many developing country situations. The use of mid upper arm circumference as an indicator
for detection of protein energy malnutrition in routine health check-up is supported by its low
costs, simple technology, and an acceptable degree of correlation with weight-for age(26, 27).
The three basic outcomes variables to define childhood undernutrition are stunting, underweight
and wasting.
1. Stunting: A child more than two standard deviations below the median (<-2 SD) of the WHO
reference population in terms of height-for-age was considered stunted [18].
2. Underweight: A child more than two standard deviations below the median (<-2 SD) of the
WHO reference population in terms of weight-for-age was considered underweight [18].
15
3. Wasting: A child more than two standard deviations below the median (<-2 SD) of the WHO
reference population in terms of weight-for-height was considered wasted [18].
4.8.
Data processing and analysis
Following data entry and clearing, analysis will be done using scientific calculator and SPSS version
20 statistical software. Editing and clearing data will be done together with computer assistance.
Frequency distribution will be investigated and unusually extreme values will be checked. Cross
tabulations of related variables will be examined and unexpected results also will be checked.
4.9.
Variables
4.9.1. Dependent variables
In this study the dependent variables will be the nutritional status of 6-59 months old children.
This nutritional status would be measured by the nutritional indicator. Those includes weight-forheight, weight-for-age, height-for-age and mid upper arm circumference which are going to be
compared with reference data from WHO growth chart. Children below -2 SD of the standard
deviation on WHO growth chart for weight-for-age, height-for-age and weight-for-height were
considered under-weight, stunted or wasted, respectively. Values of the indicators below -2 SD of
the standard deviation will be considered to represent moderate under nutrition, while values below
-3 SD will be considered to indicate severe malnutrition [27].
4.9.2. Independent variables
Child age, child sex, religion, ethnicity, family size, parental age, marital status, parental
occupation, maternal knowledge, number of under five children, antenatal care, place of delivery,
time of initiation of breast feeding, duration of exclusive breast feeding, duration of breast feeding,
time of initiation of complementary feeding, type of complementary food, method of
complementary feeding and number of meals per day, type of birth(singleton or multiple), birth
order of the child will be assessed.
16
4.10. Operational definition
Family size: - The total number of people lives in a house during the study period.
Literacy: - Ability to read and write.
Quintal: - A units of weight measurement which is about equal to 100 Kg.
Parent: - Biological father and mother.
Diarrhea: - Three or more loose stools over a period of 24 hours.
Supplemental Diet: - Any kind of food items (liquid or solid-form) other than breast milk.
Standard NCHS references and WHO growth curve:Z-score: - values used by NCHS, defined as SD score.
Wasting: - having <80% weight/height or Z-score <-2SD.
Stunting: - having <90% height/age or Z-score <-2 SD.
Under-Wt: - having <80% weight/age or Z-score <-2SD.
Income: - It is periodical monthly (total annual) receipts from one's business, lands, work,
investment, etc. Monthly Income of the family was estimated by converting what they have and
got in a year to cash form and dividing to twelve months.
Nutritional status:- nutritional indicator value less than -2 SD according to WHO growth chart.
5. Ethical consideration
Ethical clearance will be obtained from Saint Paul hospital Faculty of public health. During the data
collection, the purpose and objective of the study will be explained and verbal consent will be taken from
each respondent. Confidentiality of the information will be assured, freedom will be given to the
respondents to skip any question during interview process and dignity of the
Individuals will be highly respected. Results of this study will be provided to public health department
in Saint Paul hospital.
17
6. Work plan
The work plan for the research starting from the initial is scheduled as follows.
1
RESPONSIIBILITY
June 15-19,2020
June 3,2020
May 20,2020-May 30
April 22,2020-May 20, 2020
January 29,2020-april 22, 2020
January 29,2020
January 15, 2020-january 28, 2020
December 18,2019
Activities
December 18,2019-january 15,2020
Time frame (months) 2020 G.C
Overview of Proposal development
2
First Draft Proposal development
3
Final Proposal development
4
Overview of data collection Meeting
with advisors
5
Questionnaire
development,
data
Principal investigator
meeting with advisors
collection and data analysis
6
Development of First draft report
7
Development of Final report
8
Submit final report
9
Thesis Defense
18
7. Cost breakdown
Item
Unit
measurement
of
Quantity
Cost
per
unit Birr
Total in ETB
Tape meter
Number
2
10
20
paper
Ream
3
110
330
Questionnaire print
Per page
4-6
1
6
Questionnaire
Per questionnaire
173
6
1038
Final paper print
Per page
100-120
1
120
Pen
Number
4
5
20
Pencil
Number
2
2
4
sharpener
Number
2
2
4
Eraser
Number
2
2
4
Note book
Number
2
10
20
photocopy
Sub Total
1566
20% contingency
313
Total
1879 ETB
19
8. References
1. R. E. Kalu, k. D. Etim. Factors associated with malnutrition among underfive children in
developing countries: a review. Global journal of pure and applied sciences vol. 24, 2018:
69-74.
2. Yirgu Fekadu1, Addisalem Mesfin1, Demewoz Haile2 and Barbara J. Stoecker. Factors
associated with nutritional status of infants and young children in Somali Region, Ethiopia:
a cross- sectional study. BMC Public Health (2015) 15:846.
3. Shreyash J. Gandhi, Jayantkumar Patel, Sujit B. Parmar. Assessment of nutritional status
of children attending paediatric outpatient department at a tertiary care hospital.
GJMEDPH 2015; Vol. 4, issue 4.
4. Andrea McCarthy, Edgard Delvin, Valerie Marcil, Veronique Belanger, Valerie Marchand,
Dana Boctor, Mohsin Rashid, Angela Noble, Bridget Davidson, Veronique Groleau,
Schohraya Spahis, Claude Roy and Emile Levy. Prevalence of Malnutrition in Pediatric
Hospitals in Developed and In-Transition Countries: The Impact of Hospital Practices;
MDPI; Nutrients 2019, 11, 236; doi:10.3390/nu11020236
5. Gouveia MAC and Silva GAP. Hospital Malnutrition in Pediatric Patients: A Review. Ann
Nutr Disord & Ther. 2017; 4(2): 1042.
6. Chhetri UD, Sayami S, Mainali P. Nutritional assessment of under five children attending
pediatric clinic in a tertiary care hospital in the capital of Nepal. Journal of Lumbini
Medical College. 2017; 5(2):49-53.
7. Sourabh Duwarah11, Samiran Bisai1, Himesh Barman. Prevalence of Undernutrition
among Preschool Children under Five Attending Pediatric OPD in a Tertiary Care Hospital
of Northeastern India. Int J Pediatr: April 2015:Vol.3, N.2-2.
8. UNICEF-WHO-The World Bank. Levels and trends in child malnutrition, joint child
malnutrition estimates, key findings of the 2017 edition. 2017;available from:
https://data.unicef.org/wp-content/uploads/2017/06/JME-2017_brochure_june-25.pdf
9. Walson, Judd L. Berkley, James A. The impact of malnutrition on childhood
infections. Current Opinion in Infectious Diseases: June 2018 - Volume 31 -Issue 3 - p
231-236.
10. https://www.researchgate.net/publication/269181112_Severe_acute_malnutrition_and_in
fection
20
11. Maimuna M. Ahmed1, Adolfine Hokororo1, Benson R. Kidenya, Rogatus Kabyemera and
Erasmus Kamugisha.
Prevalence of undernutrition and risk factors of severe
undernutrition among children admitted to Bugando Medical Centre in Mwanza, Tanzania.
BMC Nutrition (2016).
12. https://www.researchgate.net/publication/285720476_Factors_influencing_the_pattern_o
f_malnutrition_among_acutely_ill_children_presenting_in_a_tertiary_hospital_in_Nigeri
a/
13. Andreas Chiabi, Berthe Malangue, Seraphin Nguefack, Félicitée Nguefack Dongmo,
Florence Fru, Virginie Takou, Fru Angwafo. The clinical spectrum of severe acute
malnutrition in children in Cameroon: a hospital-based study in Yaounde, Cameroon.
Transl Pediatr 2017; 6(1):32-39.
14. UNICEF, others. Improving child nutrition. The achievable imperative for global progress.
2014. N Y U N child fund google Sch [Internet]. [cited 2017 jan 5]; available from:
http://scholar.google.com/scholar?cluster=4378516511084728395&hl=en&oi=scholar
15. UNICEF. Undernutrition consequences popup [Internet]. [Cited 2017 Jun 5]. Available
from:
https:///www.unicef.org/progressforchildren
/
2006n4/undernutritionconsequences.html
16. PAHO, WHO. Guiding principles for complementary feeding of the breastfed child. 2003.
17. Ayana AB, Hailemariam TW, Melke AS. Determinant of acute malnutrition among
children aged 6-59 months in public hospital, oromia region, west Ethiopia: a case control
study. BMY nutrition 2015; 1:34.
18. Ambadekar NN, Zodpey SP. Risk factor for severe acute malnutrition in under five
children: a case control study in a rural part of India. Public health. Jan 2017. 136-143.
19. Mishra K, Kumar P, Basu S, Rai K, Aneja S. risk factors for severe acute malnutrition in
children below 5 year of age in India: A case control study. Indian J Pediatric. 2014 Aug.
1; 81(8):762-765.
20. Wong HJ, Moy FM, Nair S. Risk factor of malnutrition among preschool children in
Terengganu, Malaysia: a case control study. BMC public health 2014; 14:785.
21. PAHO, WHO. Guiding principles for the non-breastfed child 6-24 months of age. 2005.
22. Fentaw R, Bogale A, Abebaw D. prevalence of child malnutrition in agro pastoral
households in Afar regional state of Ethiopia. Nutr res pract. 2013 April; 7(2):122-131.
21
23. Maimuna M. Ahmed, Adolfine Hokororo1, Benson R. Kidenya, Rogatus Kabyemera1 and
Erasmus Kamugisha. Prevalence of undernutrition and risk factors of severe undernutrition
among children admitted to Bugando Medical Centre in Mwanza, Tanzania. BMC
nutrition. 2016
24. N. mwangi. Factors associated with severe acute malnutrition in children 6-59 months at
EMBU level v hospital. 2018.
25. Ahmed Abdulahi, Shahabeddin Rezaei, Kourosh Djafarian, Sakineh Shabbidar. Nutritional
Status of Under Five Children in Ethiopia: A Systematic Review and Meta-Analysis.
Ethiopia: JHealth Sci 2017; 27(1):175. doi: http://dx.doi.org/10.4314/ejhs.v27i2.10
26. Maria I. Toulson, Davisson Correia. Nutrition screening vs Nutrition Assessment: What’s
the Difference? Nutr Clin Pract. 2018;33:62–72
27. Who guideline on the management of severe acute malnutrition in infants and young
children: 2016
9. Annexes I
DATA COLLECTING QUESTIONNAIRE.
22
Questionnaire identification number……………
This questionnaire is prepared for collecting information for the study of determining factors
affecting nutritional status of children 6-59 months old admitted to pediatric ward in the months
of April 2020 conducted at Saint Paul hospital pediatric ward.
Greetings!
My name is ______________________. I am a final year medical student at Saint Paul hospital
millennium medical college. Currently I am undertaking a research on a topic entitled as
determining factors affecting nutritional status of children 6-59 months old admitted to Saint Paul
pediatric ward in the months of April 2020 and you are being asked for a little of
your time to fill the questionnaire’s . It will be costing you not more than 15 to 20 minutes. There
is no possible risk associated with participating in this study except you will be asked some time
of yours to fill the questionnaires. The primary objective of this study is determining those factors
affecting nutritional status of your child and if possible to intervene those factors. In the meantime
it is also targeted to creation of awareness for the care takers on how the nutrition of children
should be. While answering those questions, your name will not be written on this form and will
never be used with any information you tell me. You don't have to answer any questions that you
don't want to answer, either you can skip it or may end this interview at any time you want to.
However, your honest answers to these questions will help us to better understand what factors
affect the nutritional status of those children. I would greatly appreciate your help in responding
to these questionnaires.
If you have questions regarding this study, or would like to be informed of the results after its
completion, please feel free to contact the principal investigator with the following address.
Principal investigator name: - Dr Motuma Tolu
Phone number: - +251946610390
Email address: - motumatolu@gmail.com
Would you be willing to participate?
1. Yes 2. No
A. Socioeconomic and house belongings status
1. Family size A. <3 B. 4-6 C. >7
2. Number of children 6 to 59 months of age --------23
3. Parental age:I.
Age of the father:- A. 18-25 B. 26-30 C. 31-35 D. 36-40 E. 41-45 F. 46-50 G. Above 51yr
II.
Age of the mother:- A. 18-25 B. 26-30 C. 31-35 D. 36-40 E. 41-45
4. Education level:I.
Father A. Illiterate Read and write B. Formal education if so specify………
II.
Mother A. Illiterate Read and write B. Formal education if so specify………
5. Occupation:I.
Father: - 1.Farmer 2.Merchant 3. Daily labour 4. Civil servant 5. Others
II.
Mother: - 1.Farmer 2. Merchant 3. Daily labour 4. Civil servant 5. Others
6. Ethnic (maternal):- 1. Oromo 2. Amhara 3. Tigire 4. Gurage 5. Hadia 6. Wolita 7. Silte 8.
Kembata 9. Other
7. Marital status:- 1.Married 2. Single 3.Widow 4. Separated
8. Religion:- A. Christian B. muslim C. other
9. Economic status:I.
Do you have domestic animal? 1. yes 2. No If yes, how many do you have of the
following? Cattle ----- (oxen ----) Sheep ---- Goat ---- Horse ----- Donkey ---- Mule ---Poultry ------ Camel----------Others --------II.
How many quintals do you harvest in a year? ----III.
Estimated monthly income in Birr? A. < or = 500 B. 501-1000 C. 1001-1500 D. 15012000 E. 2001-2500 F. 2501-3000 G. 3001-3500 H. 3501-4000 I. 4001-4500 J. 45015000 K. >5000
B. Questions directed to mother:10. Age at first marriage. A. <18 B. 19-24 C. 25-30 D. 31-36 E. >36
11. Age at first delivery. A. <18 B. 19-24 C. 25-30 D. 31-36 E. >36
12. Number of pregnancies A. <or= 2 B. 3-4
C. 5-6
D.7-8
E. 9-10 F. > or = 11
13. Number of children alive:-Male ---- Female ---- Death------I.
If there is death, specify the cause? A. Diarrhea B. cough C. fever and chills D. Accidents
E. other………..
II.
If there is abortion, how many times? ---------14. Do you think you spend more time with your children? A. yes B. No
I.
How long do you spend with your children per day in hours? A. <or= 4hours B. 4<x<or=8
C. 8<x<or=12
D. >12 hours. E. only weekends F.I have got no time
II.
Have
you
got
enough
time
to
prepare
food?
1.Yes 2.No
III.
Do you usually take your child to health institution when sick?
1.
Yes
2.No
If not, where do you prefer to take? -------15. How do you usually prepare food for children under five year of age?
I.
Together with adult food
II.
Separately for them
24
16. In which order is food served to the members of the household?
(First
=
1,
second
=
2,
third=3,
all
together
=
4)
Husband --- Husband and wife -- Children ----Mother and children ----- All together --c. For child of 6 to 59 months of age:17. Age _____ Sex _______
18. Birth order A. 1 B. 2 C. 3 D. 4 E. 5 F. 6 G. 7 H. 8 I. 9 J. 10 K. 11
19. General appearance:- 1. Normal 2. Deformed
20. Anthropometric
measurement:First time
Second time
Third time
Average
Weight in KG ------ ----- -----------------------------------------Height in CM ------ ----- - -----------------------------------------MUAC in CM ------ ----- - -----------------------------------------21. Immunization
status:A. Not vaccinated B. Partially vaccinated C. Fully vaccinated
D. Not known
22. Reason of admission (chart diagnosis):23. What was the chief complaint for current admission?
I.
Diarrhea
II.
Vomiting
III.
Diarrhea with vomiting
IV.
Diarrhea With blood
V. Shortness of breath
VI.
Fever with chills
VII.
Fever with rash
VIII.
Cough and difficulty in breathing
IX.
Difficulty to swallow
X. Refuse to feed
XI.
Other----------------------------24. Duration of hospital stay………...
25. Did the child exclusively breastfed? A. Yes B. No
if No, counsel on exclusive
breastfeeding
26. Do the child on breast feeding now? 1. Yes 2. No
If yes, when is breast feed
given?
A. When child cry
B. According to time
C. According to mothers feeling
D.
Other………………………
27. At
what
age
is
the
child
given
supplemental
feeding?
A. before 4 months B. 4 to 6 months C. 7 to 9 months D. 10 to 12 months E. After 12 months
28. What
was
the
first
supplementary
food
given
to
the
child?
A. Milk B. Genfo C. Soup D. Habish E. Mitin F. other……………..
29. If not breast feed, at which age discontinued breast feeding?
25
A. <3 months B. 4 to 6 months C.7 to 9 months D. 10 to 12 months E. 13 to 24 months F.
>24 months.
30. At
his
age,
how
frequent
should
the
child
eat
per
day?
A. Less than 3 times B. 3-4 times C. 5-6 times D. Greater than six times.
31. What
kind
of
food
did
you
feed
your
child
yesterday?
A. breast milk only B. breast milk and cow’s milk C. cow’s milk only D. cereals and legumes
E. meat and egg F. vegetables G. others.
32. How
frequent
do
you
feed
your
child
the
following
foods?
Daily
Weekly
Occasionally
Never
Injera
-------------------------------------------Dabo
-------------------------------------------Kita
-------------------------------------------Kolo
-------------------------------------------Nifro
-------------------------------------------Genfo
-------------------------------------------Kinche
-------------------------------------------Chechebsa
--------------------------------------------Shiro wot
---------------------------------------------Vege. wot
--------------------------------------------Meat wot
--------------------------------------------Milk
--------------------------------------------Meat
--------------------------------------------Ayib
--------------------------------------------Egg
--------------------------------------------Butter
--------------------------------------------Fish
--------------------------------------------Oil
--------------------------------------------Beverage
--------------------------------------------Tea
--------------------------------------------Coffee
---------------------------------------------
Thank
you,
I
If you have any question?
have
finished
the
interview.
ASSURANCE OF INVESTIGATOR
The undersigned agrees to accept responsibility for the scientific, ethical and technical conduct of
the research Project and for provision of required progress reports as per terms and conditions of
the Research and Publication Directorate or /and Department of Public Health of St Paul’s Hospital
Millennium Medical College.
26
Name of Student__________________________________
Date____________________
Signature_____________
Approval of Advisor(s)
Advisors name
Name: 1.____________________________
2.______________________________
Signature
_____________
______________
Date
__________
________
27