Study area, design, and period
The study was conducted at the Dubti referral hospital, which was found in the awsa zone. The awsa zone is one of the five administrative zones of the Afar national regional state and is located north east to 594 km of Addis Ababa. It has an estimated population of 55,519 as projected from the 2007/2008 census. An institution-based unmatched case-control study was conducted from March 1 to May 15, 2018.
Source and study population
Children aged six up to fifty-nine months who were attending Dubti referral hospitals for different health care concerns throughout the study period were the source population. Randomly selected children aged six up to fifty-nine months were the study population. Those children who had severe acute malnutrition Mid-Upper Arm Circumference (MUAC) <11.5 cm, if there was edema for cases and who had no malnutrition a MUAC ≥ 12.5 cm, there was no edema) for controls with their corresponding mothers’/care takers, respectively.
Children aged 6–59 months who visited or were admitted to the hospitals and who had severe acute malnutrition (MUAC <11.5 cm or with bilateral pitting edema of nutrition origin), with their caretakers/mothers who gave informed consent were recruited into the study as cases. Controls included children aged 6–59 months, and attending to the hospitals (MUAC ≥ 12.5, without bilateral pitting edema of nutritional origin) with their mothers/caretakers, who gave informed consent.
Children who had physical deformities (children born without hands due to congenital deformities, wounded, and burned hands) that make anthropometric measurements inconvenient were excluded from the study.
Selection of cases
Children aged 6–59 months who were admitted during the data collection period were allocated to hospital depending on the previous month’s severe acute malnourished children flow. Cases were children with a diagnosis of severe acute malnutrition with MUAC of <11.5 cm or bilateral pitting edema of nutritional origin.
Selection of controls
Controls were children without malnutrition a MUAC of ≥ 12.5 cm, without bilateral pitting edema of nutritional origin, and were selected from the same hospital from which cases were selected.
Sample size determination
The sample size was calculated using Statcalc of application of Epi-InfoTM version 18.104.22.168 Statistical software. Using one to two ratios (1:2) of cases to controls, percentage of controls exposed 70% and cases exposed 85% and odds ratio 2.42 in Dubti district with an assumption of 95 % confidence interval and power 80%. So the cases were 99, controls were 198, and the total sample size was 297.
Only one referral hospital found in the Afar region was included, and 98 children who were severely acute malnourished and 196 well-nourished admitted/visited to the hospitals for other health care issues were selected. Children aged 6–59 months with severe acute malnutrition were allocated to the hospital depending on the average previous month’s severe acutely malnourished children admission to the Hospitals.
From previous months on average, 112 children with cases of severe acute malnutrition were reported, and during the three months, there were 412 children with cases of severe acute malnutrition at Dubti hospital. Depending up on this, 98 cases and 196 controls were selected from the Dubti referral Hospital and a systematic random sampling technique was used to select each 2nd child from 412 children. The controls were selected as quickly as cases were selected from the same hospital.
Data collection instruments and procedures
Data were collected using a pre-tested, structured, and interviewer and anthropometric measurements (particularly MUAC) administered questionnaire adapted from the Ethiopian Demographic and Health Survey . The adapted questionnaire was once modified and contextualized to suit the local situation and the research objective. The questionnaire was initially prepared in English and then translated into Afar’af and back to English to check for uniformity. The Afar’af model of the questionnaire was used to collect the data. Data were collected through two diploma nurses. The data collectors were trained for one day through the principal investigator on the study tool, consent procedure, how to interview and data collection method. The training included briefings of the study objectives, methods of selecting the study participants, a thorough review of the questionnaire, interviewing techniques, direction as to how to fill the structured questionnaire, and how to make certain high-quality data collection. At the end of the theoretical training, participants of the training were taken to areas where they could practice administering the questionnaire and taking anthropometric measurements. Inter- and intra-observer variations were monitored, especially for anthropometric measurements. This pre-testing also served to evaluate the study tool, estimate the average time to administer a questionnaire, and made corrections and additions before finalizing the instrument for actual the study. Once a case was found and his or her caregivers interviewed, two controls meeting the criteria were selected and their caregivers interviewed. To discover the retrospective morbidity of children, mothers were asked about any occurrence of sickness in the course of the previous two weeks.
Variables of the study
MUAC was measured with a standard MUAC tape on the upper left arm. After locating the mid-point for dimension between the end of the shoulder (acromion) and the tip of the elbow (olecranon), this point was then marked. The arm was then made to hang freely, and MUAC was measured at the marked mid-point. Sociodemographic variables, economic status, maternal characteristics, child characteristics and caring practices, health-related characteristics, and community factors were considered as independent variables.
Data quality control
The data collectors and supervisors were trained for one day and standardized specifically in the suitable filling of questionnaire, and the practice of the measurement system the armband/tape in order to decrease inter and intra-observer errors. Data quality was measured through piloting a pretest on 5 % of the samples in Aysaita Hospital before the real study, and significant changes were made at the beginning of the results. Data collectors were combined throughout data collection to confirm the quality of the data. Data collection was supervised by the primary investigator. Each questionnaire was managed and revised for completeness and logical consistency. The comprehensiveness of the questionnaire was also checked before data entry. Anthropometric measurement (MUAC) of children used to be executed via trained data collectors the use of standard procedures.
Data processing and analysis
The data were checked for comprehensiveness, coded, and entered into a computer using SPSS for Windows version 21 and then corrected, prepared, managed, and analyzed. Descriptive analysis was used to describe the percentages and number of distributions of the respondents via socio-demographic features and other appropriate variables in the study. In order to consider the relationship of independent variables with severe acute malnutrition, both bivariate and multivariate analyses were used. Bivariate analysis was done on the independent variables, and their proportions and crude odds ratio were calculated compared to the outcome variable to ascertain the factors that were related with child severe acute malnutrition. Hosmer-Lemeshow goodness-of-fit was used to check for model fitness. Variables that showed a relationship with the independent variable in the bivariate analysis with p value <0.05 were entered into the final multivariable logistic regression to control for possible confounders. Adjusted odds ratio (AOR) along with 95 % confidence interval was estimated to calculate the strength of the association, and a P value < 0.05 was measured to declare the statistical significance in the multivariable analysis in this study.
Before engaging in this study, all participants gave verbal informed consent. The research was approved by the Scientific Review Committee and the Ethical Review Committee of Samara University. Confidentiality has been ensured, and no personal details are reported in this paper.