Determinants of Severe Acute Malnutrition Among 6-59 Months’ Children at Dubti Referral Hospital, Afar Agro-Pastoralist Region North Eastern Ethiopia, 2018


 Background: Severe acute malnutrition(SAM) is one of the major public health problems in developing countries including Ethiopia specifically in Afar having an overwhelming consequence on the survives of several children under five-years of age. This study intends to identify the determinants of SAM among 6-59 months of children at Dubti referral hospital, Afar Regional State, EthiopiaMethods: An institution-based unmatched case-control study was conducted in Dubti referral Hospital from March 1 to May 15, 2018. The sample size was calculated using Epi-InfoTM version 7.2.2.6 Statistical software. Using cases-control (1:2), the total sample size was 297(cases 99, controls 196). A systematic random sampling technique was used, data were collected using interviewer-administered structured questionnaire, entered in Epi-info TM, and analyzed using SPSS 21 version using binary logistic regression, with P < 0.05 considered significant. Result: The response rate was 100 % (297), mean age of the cases and controls was 14.8 months (SD ± 7.9) and 26.9 months (SD ± 15.9), respectively. Of the participants, 58.58% were male, 85.4% were Muslim, and 65.65% were of Afar ethnicity. SAM was significantly associated with children aged 6-11 months and 12-23 months adjusted odds ratio (AOR)=4.3, 95%CI 3.64-6.73, 11.2, 95% CI 7.89-14.5), respectively. Rural residences (AOR=2.8, 95% CI 2.62-5.73), and low monthly family income (<$30) (AOR=3.8, 95% CI 2.97-4.87) were independent predictors of SAM. This study revealed low ANC visits (32.2%), low exclusive breastfeeding practices (34.9%), and low vaccination coverage (29.6%). Conclusion: Children aged 12-23 months, rural dwellers, and low monthly family income (<$30) were identified as independent predictors of SAM. This study revealed low ANC visits, low exclusive breastfeeding practice, and low immunization coverage. Hence, cooperative efforts are needed to increase promotion of enhanced child caring practices specifically, child and maternal feeding practices, and ANC follow up and vaccination practice.


Introduction
Child severe acute malnutrition(SAM) remains to be an important public health problem in an unindustrialized nation-state. Globally, there were 165 million stunted, 99 million underweight, and 51 million severe acute malnutrition children by year 2012. It kills 3.1 million under-ve children every year [1][2]. Under-ve children are the most susceptible age group for malnutrition [3]. Malnutrition at the early stages of life can increase risk infections, morbidity, and mortality, together with decreased mental and cognitive development. The effect of child malnutrition is long-lasting and goes beyond childhood [4]. For example, malnutrition throughout a timely age loses learning attainment and work productivity and increases the possibility of protracted diseases in advanced stages [1,2,5].
Malnutrition is the major cause of illness and death among under-ve children in Ethiopia [6]. The rate of malnutrition among under-ve children in the country is among the highest in the world and Sub-Saharan Africa [7]. Moreover, malnutrition is the underlying cause for three-fth of child deaths in the country [1,8].
According to the 2014 Ethiopian Mini Demographic and Health Survey (EMDHS) report, 42%, 26.7%, and 9% of under-ve children were stunted, underweight, and wasted, respectively, [1]. The problem is even worse in rural areas. For instance, the prevalence of underweight and stunting among rural children was 27% and 42% compared with only 13% and 24% among urban children, respectively, [1,5].
The planning of an appropriate intervention requires knowledge of the extent and underlying causes of the problem. To this end, very few studies have been conducted regarding childhood malnutrition in rural Ethiopia [1]. All of them were small-scale surveys limited to particular regions of the country [1,8]. Later, they did not provide a complete representation of the magnitude of the problem at the nation-state level.
Moreover, these studies used the conventional indicators of nutritional status to measure the prevalence of malnutrition in under-ve children [1]. However, a number of studies have pointed out that the use of conventional indicators provides only the categorization of children into the general categories of malnutrition and does not determine the inclusive occurrence of malnutrition related to several catastrophes. Accordingly, these indicators underestimate the occurrence of malnutrition due to the possible similarity of children into various types of anthropometric catastrophe [1]. Therefore, in this study, we used a recently developed and relatively robust alternative indicator of malnutrition, the composite index of anthropometric failure (CIAF) to determine the risk factors of malnutrition among under-ve children in Dubti Hospital, Afar region, Ethiopia.

Methods And Materials
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 ve 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 fty-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 fty-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.

Inclusion criteria
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.

Exclusion criteria
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 ow. 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-Info TM version 7.2.2.6 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 % con dence interval and power 80%. So the cases were 99, controls were 198, and the total sample size was 297.

Sampling technique
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 2 nd 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 [5]. The adapted questionnaire was once modi ed 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 brie ngs of the study objectives, methods of selecting the study participants, a thorough review of the questionnaire, interviewing techniques, direction as to how to ll 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 nalizing 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 midpoint. 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 speci cally in the suitable lling 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 signi cant changes were made at the beginning of the results. Data collectors were combined throughout data collection to con rm 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-t was used to check for model tness. Variables that showed a relationship with the independent variable in the bivariate analysis with p value <0.05 were entered into the nal multivariable logistic regression to control for possible confounders. Adjusted odds ratio (AOR) along with 95 % con dence interval was estimated to calculate the strength of the association, and a P value < 0.05 was measured to declare the statistical signi cance in the multivariable analysis in this study.

Ethics approval
Before engaging in this study, all participants gave verbal informed consent. The research was approved by the Scienti c Review Committee and the Ethical Review Committee of Samara University. Con dentiality has been ensured, and no personal details are reported in this paper.

Results
The response rate was 100% (99 cases and 198 controls) were participated. The mean age of the cases and controls was 14.8 months (SD ± 7.9) and 26.9 months (SD ± 15.9), respectively. Of the cases and controls, 56 (32.2) and 118 (68) (Table 3).  According to multivariate statistical analysis, age of the children, sex of the children, current residence of the children, and monthly income of the family of children were statistically associated with acute malnutrition independent of other factors. Based on this multivariate statistical analysis result, children 6-11 months and 12-23 months were 4 times and 11 times, severe acute malnourished than children 24-59 months, AOR with CI 4.3(3.64-6.73), and 11.2(7.89-14.5), respectively. On the subject of their current residence, children in rural residences were 3 times more severely acute malnourished than urban dwellers (AOR = 2.8, 95% CI 2.62-5.73). Concerning monthly income of the family, those who had less than 30-dollar per month were 4 times more severe acute malnourished than the family those who had more than 30-dollar per month (AOR = 3.809, 95% CI 2.97-4.87) ( Table 5).

Discussion
Children age was one of the determinants of severe acute malnutrition. Children aged 6-11 months and 12-23 months were 4 and 11 times more likely to be severely acute malnourished than those aged 24-59 months, respectively. This study is similar to a study done in India 12 to 23 months of children with severe acute malnutrition than the older one [9]. This result is also related to a study conducted in 2014 in The difference might be the time gap of years and geographical differences.

Conclusion
Children aged 12-23 months, rural dwellers, and low monthly family income (<$30) were identi ed as independent predictors of SAM. This study revealed low ANC visits, low exclusive breastfeeding practice, and low immunization coverage. Hence, cooperative efforts are needed to increase promotion of enhanced child caring practices speci cally, child and maternal feeding practices, and ANC follow up and vaccination practice.
Abbreviations AIDS Acquired Immunode ciency Syndrome