PREVALENCEOFACUTE MALNUTRITION ANDASSOCIATED FACTORS AMONG CHILDREN UNDER FIVE YEARS OF AGE IN RURAL KEBELES OF SHASHEMENE WOREDA WEST ARSI ZONE, OROMIA REGIONAL STATE, ETHIOPIA, 2018

Background: Acute malnutrition is a devastating public health problem. Globally about, 52 million under-five years old were wasted. One-third of these children live in Africa and Ethiopia is the seventh country among the ten top countries in which wasting is concentrated and currently 10% of under-five children are wasted. Although Ethiopia is implementing different nutritional interventions, but the prevalence of wasting is increasing and there is no scientific study done previously in the study area. So this study aimed to assess the prevalence of Acute Malnutrition and associated factors among children under five years in Rural Kebeles of Shashemene District, West Arsi Zone, Oromia Regional State, Ethiopia, 2018. METHOD: A community based cross-sectional study design with multi stage sampling technique was conducted from July 1-30/2018 on a total of 457Mothers/caretakers of under-five children were interviewed using structured questionnaire and anthropometric measurements of the children were taken using standard procedures. Epi info version 7 was used for data entry and cleaning and SPSS version 21 was used for analysis bivariate and multivariate logistic regression were used to determine the association between dependent and independent variables. World Health Organization (WHO) Anthro software was used to convert nutritional data indices. The had decision children with diarrheal disease in the last two weeks were independent determinants of acute malnutrition. So the Woreda Health office and Health Extension Workers should consider empowering women, awareness and accessible antenatal care services, hygiene and sanitation to reduce acute malnutrition. The study was carried out in Shashemene woreda which is found in West Arsi Zone of Oromia Regional state, study was conducted from July 1 to 30 2018. The district is located at 250 Km far from Addis Ababa; the capital city of Ethiopia. Administratively the woreda is divided in to 38 rural administrative kebeles with 265,109 total populations with males to females ratio 1:1.02 living with 55,231 households and the under-five children are 43,557 projected from the 2007 national population census(15). The climatic condition of a woreda is 51.4% kola, 27% Weina Dega and 21.6 % Dega. Its altitude ranges between 1,500 to 2,300 meters above sea-level.


INTRODUCTION
Malnutrition is lack of right kinds of food and nutrients needed by the body for appropriate growth and development. It includes under nutrition and over nutrition. Stunting, wasting, and underweight are classified as among Anthropometric indicators commonly used to measure malnutrition in a population of under five children (1).Acute Malnutrition is classified into severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the degree of wasting and the presence of oedema (2).
The Sustainable Development Goals (SDGs) states that by "2030 end preventable under-five deaths by reducing under 5 mortality to at least as low as 25 per 1,000 live births." However in 2015 about 480,000 under five children continue to die every month globally. A large percentage of these deaths were caused by preventable diseases. Moreover, under nutrition remains a major cause of disability and mortality, ranked as the top cause of global burden of disease. Besides it is underlying causes of deaths in 53% children under-five years. Of total under five deaths contributed by under nutrition, acute malnutrition is responsible for more than 28% (3) and around one million children under the age of five die every year from severe acute malnutrition (4).Globally, about 52 million under-five years old were wasted and among this around 32%(16million) were severely wasted (5,6). And One-third of these children live in Africa Especially In Sub-Saharan Africa, Approximately 9% of children have moderate acute malnutrition and about 2% of children have Sever Acute Malnutrition (4) In line with the above report; the 2016 Ethiopian Demographic and Health Survey (EDHS) revealed that there has been improvement in the nutritional status of children. The percentage of stunting slightly fell from 40% in 2014 to 38 % in 2016.Similarly the percentage of underweight children declined from 25% to 24 %, but the prevalence of wasting is increased from 9% to 10%.
Furthermore the prevalence of wasting is different from region to region for instance In Oromia regional state, the percentage of children who were wasted is 10.6% and in Somali regional state was 22.7% (7).
The study conducted at Christ specialist Hospital, Ogui, Enuu, Nigeria and The two stage sampling procedure to collect cross-sectional survey at Kombolcha District of Eastern Harerghe zone, Oromia Regional state, Ethiopia shows that the prevalence of acute malnutrition (wasting) were 14.8% and 11.2% respectively (8)(9)(10) There are multi-factorial causes of malnutrition among under five children according to Study conducted in Dara district of Sidama zone describes that wasting and underweight were extremely high among children of low land society. Altitude was the determinant factor for wasting and underweight and house hold income was major determinant of acute malnutrition (11).Nested case control study done in Eastern rural Ethiopia result shows acute under nutrition among the cohort of children, was associated with poor and middle households socio-economic positions, individually made decision strategy on the treatment/care of the sick child, paternal education (12) In line with the above the study conducted at Gondar University hospital to identify the risk factors of acute malnutrition were the socioeconomic factors that were associated with severe acute malnutrition were maternal illiteracy, paternal illiteracy, monthly family income of less than 50 USD and large family size with the number of children greater than three (13).Matched case control study done in Shashogo woreda to determine risk factors of SAM socioeconomic factors that were associated with acute malnutrition were lack of maternal autonomy in decision making (AOR=4.13,95%CI,1.34-11.47) (14) Acute malnutrition is a problem of public health importance that disproportionately affects every region, including Ethiopia. Although Ethiopia is implementing different nutritional interventions but the prevalence of wasting is still increasing, and there is no scientific study done previously in the study area. the government in general and the District Health office need to have scientific bases on prevalence and possible determinants of wasting for which this study will supply valuable information. In additions, this study can help different stakeholders by paving the way to effective intervention in halting the morbidity and mortality associated with acute malnutrition.Therefore, improved understanding on prevalence and determinants of wasting locally helps the intervention to shoot the target and to design an effective strategy.

Study setting, design, and period
The study was carried out in Shashemene woreda which is found in West Arsi Zone of Oromia Regional state, study was conducted from July 1 to 30 2018. The district is located at 250 Km far from Addis Ababa; the capital city of Ethiopia. Administratively the woreda is divided in to 38 rural administrative kebeles with 265,109 total populations with males to females ratio 1:1.02 living with 55,231 households and the under-five children are 43,557 projected from the 2007 national population census (15). The climatic condition of a woreda is 51.4% kola, 27% Weina Dega and 21.6 % Dega. Its altitude ranges between 1,500 to 2,300 meters above sea-level.
Regarding health infrastructures there are 8 health centers, 3private clinics and 38 health posts.
Majority of populations were engaged in agricultural activities in the woreda and the main crops/products being Maize, Teff, and Sorghum, fruits and vegetables and animal husbandry.

Source Population
All children under five years of age in the selected kebeles were source population.

Study population
Those children under-five years of age who lived in the selected Households were the study population.

Eligibility criteria
Those children below five years of age who lived in the selected households were included However Physically disabled and critically ill children who were in the age of below five years; since it is difficult to take anthropometric measurement were excluded from the study.

Sample size determination and sampling procedures
Sample size was determined using single population proportion formula. The sample size of the study was determined into the consideration of 95% confidence interval, 5% margine of error, and 23.6% prevalence of acute malnutrition from previous study done in Hawassa zuria district, Southern Ethiopia (16). After including 10% of non-response rate and since study group was stratified twice (multistage) the design effect was taken to be 1.5 finally 457individuals were included in the study.
For sampling procedures Initially, from the 38 kebeles in Shashemene woreda, 11 kebeles (30%) were selected using simple random sampling (lottery method).Each kebeles were given code (01-38) and these number were written on a small pieces of paper, all of them were put in a box, and then the box was shaken vigorously to ensure randomization, then 11-papers were taken out of the box and the numbers were recorded.
The total sample size was distributed to each kebeles proportionally to their population size. Then a random direction was employed from the center of the kebele to select the households with underfive children in the selected kebeles. A maximum of one child aged younger than 5 years was included randomly in each selected households.

Operational Definitions
Acute Malnutrition (Wasting): -a child's weight for height measurement is less than -2SD or bilateral pitting oedema.
Bilateral pitting oedema: bilateral pitting oedema also known as edematous malnutrition is assign of SAM. It is defined by bilateral pitting edema of the feet and verified when thumb pressure applied on top of both feet for three seconds leaves a pit (indentation) in the foot after the thumb is lifted. It is an abnormal infiltration and excess accumulation of serous fluid in connective tissue.
This type of edema, beginning in the lower is most commonly nutritional in origin. Critically ill: a child who has chronic disease like severe pneumonia, TB, CHF, DM and HIV/AIDS Anthropometrics: Measurement of the human body E.g. weight and height.
Dietary diversity score: is the sum of total number of food groups consumed over 24 hours before the data collection Health care seeking behavior: health care seeking behavior by the caregiver of the child within 24 hours of the onset of symptoms.
Immunization status: either vaccinated or not, If possible looking at vaccination card or asking the mother (caregiver).
Morbidly status of the childmorbidity status in the last 2 weeks before the study period (fever, cough, diarrhea)

Illiteracy: an able to read and write
Complementary foods: are foods which are required by the child, after six months of age, in addition to sustained breastfeeding

Data collection tools and procedures
For face to face interview were conducted using pre-tested and standardized questionnaire with questions adopted and modified from Different literature reviews, were used to collect data.
Trained data collectors were assigned to all kebeles to collect the data from sample population.
Informed verbal consent was obtained from all participants and the information from participants was kept confidential, Vaccination status of the children was assessed looking at vaccination card or asking the mother (caretaker).
Anthropometric data were collected through measurement of length/height and weight of all children. Salter hanging spring scale with graduations of 0.1 kg and a capacity for 25 kg were used for measuring the weight of the children aged 0-23 month and beam scale for children over 24 months of age were used for measuring weight with minimum clothing and no shoes to the nearest 0.1 kg. Recumbent length measurement was taken for children under two years of age while for children above two years stature was measured in a standing position in centimeters to the nearest of 0.1 cm Oedema of the feet was diagnosed if a bilateral depression (pitting) remained after the pressure was released.
Child dietary diversity score were calculated by summing a total of 7 food groups [1) Grains, roots and tubers; 2) Vitamin A rich fruits and vegetables; 3) Dairy product; 4) Flesh foods (meat, fish, poultry and liver or organ meat); 5) Other fruits and vegetables; 6) Egg; 7) Legumes and nuts; consumed over reference period (24 hours before the data collection). For example, if one child eats from each food group, his/her DDS were 7

Data quality assurance
The questionnaire was translated into local languages, Afan Oromo, for the field work and back to English to check its consistency by three health workers who are fluent speakers Afan Oromo and English. Besides, it was pre-tested in Shalla Woreda in 5% of the sample size. Twelve diploma nurses for data collection and Four BSc nurses for supervision were trained for Two days. The training was cover on the questionnaire, and the importance of disclosing the possible benefits and purpose of the study to the study participants before the starting data collection. The data collection was supervised by the principal investigator. Every questionnaire were supervised and reviewed for completeness and logical consistency. The completeness of the questionnaire was also checked before data entry. Validation of instruments, and measurements and random auditing were done on a daily basis. Double data entry would be used to ensure data quality.

Data processing and analysis
EPI info version 7software was used for data entry and cleaning and then the data were exported to SPSS Version 21 for further processing and analysis. World Health Organization (WHO) Anthro software were used to convert nutritional data indices from anthropometric measurement into Z-scores. Binary logistic regression model were used to compute the association between each independent variables and dependent variables. Independent variables that show association with outcome during bivariate analysis at P value less than 0.25 were included in multivariate analysis to control for potential confounders. Descriptive analysis were used to describe the percentages and number of distributions of the respondents by socio demographic characteristics and other relevant variables in the study.
Hosmer-Lemshow goodness-of-fit were used to test for the model fitness and forward step-wise (likelihood ratio) method were also conducted. Adjusted odds ratio (AOR) along with 95 % confidence interval were estimated to assess the strength of the association and a P value <0.05 were considered to declare the statistical significance in the multivariable analysis in this study.

Characteristics of the study Participants
A total of 457 under five children were participated in the study with a response rate of 100%. As Out of the respondents, 314(68.71%) had average and less than five family size, while 143(31.29%) of households have more than five.
The mean age of the children was 25 months with SD of ±15.72.

Child Caring Practice
All of the children's mothers have been breast feed their child. Among these 320(70.02%) of children had breast feeding that was initiated within one hour after birth and 90(19.69%) of children took pre Lacteal feeding.
From the total children 281(61.49%) of children's mother were exclusively breast feed their child for the first six months.
About 323(74.08%) of the children started complementary feeding in addition to breast feeding at the age of 6 months while 111(25.46%) of the children were started complementary feeding in addition to breast feeding at the age less than six months.
Regarding method s of feeding majority of the children who were started complementary feeding 240(55.04%) were used by spoon while 147(33.72%) and 49(11.24%) were used by bottle and cup respectively. among these 315(72.25%) of children were consumed diversified food groups less than 4 within 24 hours while 121(27.75%) of children were consumed diversified food groups greater than or equal to 4 within 24 hours.

Factors associated with acute malnutrition (Wasting)
In Bivariate Analysis, Parental education, Maternal autonomy in decision making, Squeezed out and throw colostrum, ANC visit, History of Diarrhea in the last two weeks, History of febrile disease in the last two weeks, Age of Mather at first birth, place of birth, Maternal education and pre Lacteal feeding were the variables that showed an association with the outcome variable at the bivariate analysis with P value < 0.25 were entered into the final multivariable logistic regression to control potential confounders.
Then after using standard multiple logistic regression to assess the impacts of candidate variable on acute malnutrition four independent variables namely, Mothers who had no power in decision making, squeezed out and throw colostrum's, Mothers who had no ANC visit, child's history of Diarrhea in the last two weeks were independent determinants of acute malnutrition.
Maternal ANC visit were significant determinant for Acute malnutrition, children whose mother were not on ANC visit were 2 times more likely to be Acute malnourished than those children whose mothers were on ANC visits(AOR=2.26,95%CI 1.14-4.46). The odds of developing wasting was 2 times higher among children whose mother has not autonomous in decision making than those whose mother has autonomous in decision making(AOR=2.42,95%CI 1.42-4.12).
Morbidity status of the child by diarrheal disease in the last 2 weeks preceding the survey were also seen one of the determinant of the acute malnutrition in under five children. Acute malnutrition was 2 times less likely to occur in children who had no diarrhea before 2 weeks than those children who had diarrhea within two weeks (AOR=2.07, 95%CI 1.19-3.59). Although children who had fever in the last two weeks preceding the survey shows significant association in bi variable analysis, no association was observed between children who had fever in the last two weeks preceding the survey and wasting in multivariable analysis.
Similarly children whose mothers had squeeze out of colostrums were 2 times more likely to be wasted than under five children whose mothers had no squeeze out colostrums(AOR=1.99,95%CI 1.07-3.71).

DISCUSSION
In this study, the prevalence of wasting is 19.91% at 95%CI and Maternal autonomy in decision making, squeezed out and throw colostrums, ANC visit, History of Diarrhea in the last two weeks, shows significant association with wasting.
This study showed that prevalence of wasting is 19.91% at 95%CI.The result of this study revealed that, the prevalence of wasting were higher as compared with a community cross sectional study conducted in Bule Hora District, South Ethiopia, Hidabu Abote, North shewa, Oromia regional state and Damot Gale, South Ethiopia (13.4%16.7%, 9%,) (17,18).This difference might be due to study period, study area, sample size and the inclusion of children under the age of six months. In this study, data were collected in July when most rural areas have shortage of food; this could probably one of the reasons for high prevalence of wasting in the area. Although present study result showed that the prevalence of wasting were high in the district in comparison with the regional and national prevalence reported by EDHS 2016 (10.6%,11%) (15). The discrepancy might be due to sample size compared to that of national data and although it signifies acute malnutrition problem is probably due to illness like diarrheal morbidity and due to most of the time the district were affected by drought.
Even though the prevalence of wasting were high in this district but nearly similar with the study conducted in Hawassa Zuria District, Southern Ethiopia (23.6%) (16). This similarity may be due to socioeconomic, study design and sample size.
But the prevalence of acute malnutrition is low in this district when compared to a community based cross-sectional study conducted in 2012, the magnitude and factors associated with malnutrition in children 6-59 months of age in a pastoral community of Dolo Ado district, Somali region, Ethiopia shows that the prevalence of acute malnutrition (wasting) was 42.3% (17). This is may be due to Dolo Ado District were affected by drought and the community were pastoralist.
Similarly, the prevalence of wasting is low when compared to the study conducted at Christ specialist Hospital, Ogui, Enuu, Nigeria, about 25% of children were wasted However the prevalence were low when compared to the study conducted in University of Nairobi shows that the prevalence of Wasting were 14.8% (9,10). This difference was might be due to the study design, socio demographic characteristics and exclusion of under-six months of children.
Maternal ANC visit were significant determinant for Acute malnutrition, children whose mother had no ANC visit were 2 times more likely to be Acute malnourished than those children whose mother has ANC visits, which is consistent with a community based cross sectional studies conducted on the prevalence of malnutrition and associated factors in children aged 6-59 months among rural dwellers of Damot Gale district, south Ethiopia shows children whose mothers attended ANC(AOR=0.18,95%CI,0.07-0.45) were less likely for acute malnutrition and the studies conducted in Shone District, Hadiya Zone, SNNPR(AOR=0.51,95%CI, 0.27-0.96) showed that children whose mother have antenatal care follow up is less with acute malnutrition of the children (19). Since the overall aim of antenatal care is to produce a healthy mother and baby at the end of pregnancy, taking antenatal visits may help the mother and child to have better health and knowledge of child caring practice.
Autonomy of mothers in decision making were significantly associated with wasting of under-five children. Children whose mothers were not autonomous in decision making were two times more likely wasted than those children whose mothers were autonomous in decision making.  (13,14).Such decision might also require women's autonomy to participate in decision making process of the household equally with their husband. Now adays the policy of government also supports the empowering women, women education and increasing influentially of women has significant impact for the health of the family and community.
Recurrent infection has been associated with malnutrition, especially the child with diarrhea preceding 2 weeks before the onset of acute malnutrition is significantly associated with wasting of the children. This can be due excessive loss of fluids and electrolytes, loss of appetite, lack of absorption of food in the intestine due to high motility of the intestine during diarrhea episodes. . On the other hand, the present study does not show significant association between morbidity status of the child with fever and acute malnutrition. This is inconsistent with the similar studies conducted in Gondar university and Oromia public hospitals (12,20).This might be due to the district is a known malarious area and the homogeneousness of febrile disease of cases.
In the current study, there is no significant difference in children who have not exclusive breastfeeding and those children who have exclusive breast feeding. This is inconsistent with the other studies conducted in East rural Ethiopia and Oromia public hospitals (20,21). This might be due to increased good awareness in breast feeding currently from the community. Exclusive breastfeeding is recommended because breast milk is containing necessary nutrients in the first few months of life. In addition, the mother's antibodies in breast milk provide the infant with immunity to disease. Early supplementation exposes infants to pathogens and thus increases their risk of infection, especially diarrheal disease and it decreases infants' intake of breast milk and therefore suckling, which in turn reduces breast milk production (22). These might be due to study design, socio economic characteristics, and exclusion of under-six months of children, study period and sample size (10).

CONCLUSION AND RECOMMENDATION
According to this study, the prevalence rate of wasting among under-five children in the district were high. children's whose mother had no ANC visit, no autonomy in decision making, squeezed out and throw colostrums and children who had diarrheal disease in the last two weeks were more likely to develop wasting.
The Woreda health office should create awareness and accessible antenatal care services through community health workers and women's developmental army to improve child care practice. The Woreda Health Office should focus on the intervention targeting the community for promotion of hygiene and sanitation as well as designing an intervention which increases mother's awareness related to causes of diarrheal disease and how to manage their children to make nutritional interventions more effective. The Health Extension Workers should strength pregnant and Lactating women's conference to make nutritional interventions more effective. Woreda administrative office and Woreda Health Office should encourage anyone who interested interventional work on women empowerment to participate in decision making through strengthening girls and women's participation in decision making.

Limitation
The findings may be prone to recall bias during data collection time as some of the variables need a recall to situations happened before the actual data collection time (example DDS, frequency of

Declarations Ethics approval and consent to participate
Ethical clearance were obtained from the Institutional Review Board at the College Health Sciences of Arsi University. In addition, Permission letter was obtained from the Shashemene district Health office before field activities started and verbal consents were obtained from the parents/caretakers of the study subjects after explaining the study objective and procedures.

Funding
The study was not funded by any organizations.

Availability of data and materials
The datasets created and analyzed during the study will be made available to organizations and individuals by the first author based on fair request.