Study Area, Design, and Period
A community-based cross-sectional study was conducted from March 01- 30, 2020, in Ambo town using a systematic sampling technique among children aged 6 to 59 months. Ambo town is the capital city of the West Shoa zone of Oromia regional state that was found 144 km to the west of Addis Ababa. The town has a total population of 96,521off which 4869 are children of under-five years old(14). There are 02 public hospitals, 02 health centers, 32 private clinics, and 10 pharmacies. The lively hood of the resident of the town was majorly relaid on the market and informal sectors. The town has six kebeles of which three kebeles (Hora Ayetu, Sankale Farisi, and Yaí Gada) were included in the study.
Source population: All children aged 6-59 months who were living in Ambo town were the source population.
Study population: All 6-59 months children residing in Ambo town were selected by systematic random sampling method.
Exclusion criteria
All children with the following parameters were excluded from the study.
- Those who are critically ill at the time of the study
- Those who did not volunteer to participate.
- Children whose family/caregivers were away from home during data collection for three consecutive visits were excluded from this study.
Study Variables, Sample Size, and Sampling Technique
Dependent variable: nutritional status measured as wasting, stunting, and underweight
Independent variables: Seven categories of determinant factors were assessed as independent variables;
Socio-economic and demographic variables: Head of HHs, marital status, ethnicity, religion, family size, income, education, occupation, ownership of livestock and farmland, crop production, and home garden
Child characteristics; Age, Sex, birth order, place of delivery, gestational age, types of birth, birth weight, and morbidity status
Child caring practices; breastfeeding status, dietary diversity score (DDS), hygiene, health care seeking, and immunization
Maternal characteristics; Age, number of children ever born, anti-natal care (ANC) visits, and autonomy in decision-making on major food purchases.
Environmental health conditions; safe water supply, sanitation, and housing condition.
The minimum sample size (n) required for this study is calculated using single population formula as follows,
Where:
Zα/2= is the standard normal score at confidence interval (CI) 95%=1.96
p= proportion of stunting in Haramaya district 36.07% (15)
d= is the margin of sampling error tolerated 5% =0.05.
ni =354
Since, the estimated population size is less than 10,000 (i,e there were only about 4869 children who are living in Ambo Town kebeles), using the following correction formula:
Where N= number of overall population. Size (4869)
nf final sample size
nf = 354 / (1+354/4869) =330 and considering 10% non response rate, a total of 363 children were included in this study.
Three kebeles were selected by lottery method and the final sample was proportionally allocated to the size of the participant in each selected kebeles. Finally, systematic sampling technique without a sampling frame was used to select the study participant. The data collector makes the Kebeles office the center of the kebeles and goes to the four directions of the kebeles. They contact any household and count the first house that they got children of 6 – 59 months as one. They continue the same procedure until they reach the k value for each kebeles. The first household with children of 6 – 59 months to be included in the study was selected by the lottery method from the first household to k for each kebeles. Then they interview the study participant in the household in every kth value for each kebeles. K values vary for each kebeles. If there are two or more children of 6 – 59 months in the same household, one of them was selected by lottery method.
Data Collection Tool, Process, and Quality Management
A structured pretested questionnaire was used to collect the required data through face-to-face interview and anthropometric measurement was made with children and their mothers. The tool was adopted from similar studies conducted in a different part of Ethiopia including the Ethiopian demographic and health survey (EDHS) (16-18) and some possible modification was made to the tool after to pretest to fit the local context. The questionnaire was translated to Afan Oromo by one of the senior lecturer at Ambo University who is a fluent speaker of English and Afan Oromo for the field purpose and back-translated to English by another lecturer to check for consistency.
All anthropometric data were collected according to Food and Nutrition Technical Assistance( FANTA) anthropometric guide 2018 (19).
Weight was measured to the nearest 0.1 kg using a calibrated portable electronic digital scale (Seca). For children younger than 2 years old, the “tared weight” procedure was used. Children older than two years/able to stand on a weight scale and mothers were measured with minimal close and without shoes. Weighing scales were calibrated with one liter water regularly, because it’s weight is known. The ace of scale indicator was checked against a zero reading for each measurment. Height/length was measured using a standardized measuring board to the nearest 0.1 cm. All anthropometric measurements were made two times and the average values were used for analysis. The child’s minimum dietary diversity score (MDDS) was measured using 24-hour dietary recall method.
Four public health graduating students were recruited and trained for four days on the tool, sampling technique, and obtaining informed verbal consent. The data collection was supervised by two field supervisors. The field supervisor and principal investigator checked the completeness, inconsistency, and inconvenience of data on the field and during summation.
Statistical analysis
Anthropometric data were converted to nutritional status indices using ENASMART software and imported to Package for Social Science SPSS version 21 for analysis. Before data analysis using SPSS version 21, all other data were cleaned, coded, and entered into the Epi data 3.1 version. Continuous variables were presented using mean with standard deviation. Frequencies and percentage were used to present categorical variable. After excluding variable with collinearity coefficients of > 0.8, variables with a p-value of < 0.25 on binary logistic regression were entered into backward multivariate logistic regression analysis with statistical significance at p-value < 0.05 to search for an independent determinants of all the indices of undernutrition.
The household food insecurity level was measured with the Food Insecurity Experience Scale (FIES), a structured, standardized, and validated tool globally(20).
Operational definition
Under five children: in this study under five children mean those children of 6 – 59 months.
Under nutrition: undernutrition was used to indicate wasting, underweight and stunting.
Access to improved drinking water: those who had access to tap water, drink boiled water, or treated water with wuha agar were categorized as having access to an improved water supply.
Appropriate breastfeeding: those who practice early initiation, exclusive breastfeeding for six months, Giving colostrum, feed breast milk at least eight times per day, and continue breastfeeding for two years for children older than two years and currently breastfeeding for children < 2 years (21).
Dietary diversity score: those who fed at least 4 food groups among 7 food groups over the last 24 hours before the interview were recorded as achieving good DDS and those who fed < 4 food groups were recorded as having poor DDS(21).
Underweight: Refers to weight for age z score below the -2 SD from the NCHS/WHO reference of the median of the standard curve(19).
Wasting: Nutritional deficient state of recent of weight fo height/length below-2SD from the NCHS/WHO median value (19).
Stunting: A child was defined as stunted if the height for age index was found to be below -2 SD of the median of the standard curve (19).
Food secure:→ with raw scores= 0-3 to the questions about food insecurity-related experiences
Moderate Food insecure:→ with raw scores= 4-6 questions about food insecurity-related experiences.
Severe food insecurity: with raw scores of 7-8 about food insecurity-related experiences(22).
Fully immunized: A child receiving all immunization recommended for his/her age according to recommended immunization for children in Ethiopia (23).
Partially immunized: A child that misses at least one of his/her immunization recommended for his/her age(23).
Not immunized: a child never took any immunization at all.
Ethical consideration
Ethical clearance was obtained from Ambo University, college of medicine and health science ethical review Committee with the reference number AU/PGC1035/2020 on 20 February 2020. Confidentiality was kept and informed verbal consent was obtained from each study participant after explaining the purpose of the study. Verbal informed consent was approved by the Ambo University college of medicine and health science ethical review Committee. This study was conducted following the ethical guidelines of the Helsinki Declaration.