Undernutrition and Its Correlates among Children of 3–9 Years of Age Residing in Slum Areas of Bhubaneswar, India

Undernutrition among children is a major public health concern worldwide, more prevalent in Asia and Africa. It manifests itself in various forms such as wasting or stunting or underweight and retards physical and mental development, increases susceptibility to infection, and reduces educational attainment and productivity. The present study was undertaken to assess the level of wasting, stunting, and underweight and determine its associates among slum children of 3–9 years of age, residing in Bhubaneswar city, India. After obtaining informed consent, a total of 249 children from 249 households were studied and their parents/guardians were interviewed to collect all relevant information. 23.3%, 57.4%, and 45.4% of children were found to have wasting, stunting, and underweight, respectively. Variables like birth order of child, period of initiation of breastfeeding and mother's education were found to be strong predictors of wasting, whereas toilet facility in household and practice of drinking water storage were significantly associated with stunting among slum children as revealed in multiple regression analysis. Thus, a multipronged approach is needed such as giving priority to improve education for slum community especially for women, creating awareness regarding benefits of early initiation of breastfeeding, small family size, and proper storage of drinking water, and providing toilet facility in slum households which could improve the nutritional status of slum children.


Introduction
Nutrition has been recognized as a basic pillar for social and economic development. Adequate nutrition is necessary in early childhood to ensure healthy growth, proper functioning of organs, strong immune system, and neurological and cognitive development [1]. Undernutrition is a leading contributor to infant, child, and maternal morbidity and mortality playing a role in about half of all child deaths [1,2]. Undernutrition directly affects many aspects of children's development such as retarding physical and mental development, increasing susceptibility to infections like sepsis, diarrhoea, pneumonia, and so forth, and further enhancing the probability of undernutrition [2,3]. It also undermines education attainment and productivity, thereby affecting the economic growth. The prevalence of underweight children in India is among the highest in the world and is nearly double that of sub-Saharan Africa [4]. Undernutrition manifests itself in different forms in children such as wasting (indicator 2 The Scientific World Journal are always at a high risk of developing health and nutritional problems [7]. Although numerous studies have been done in different states of India to assess the nutritional status of children, there are very limited studies involving children both in preschool age and in school age group, especially in Odisha, one of the high prevalence states of India. Thus, the present study was undertaken to ascertain the level of different forms of undernutrition such as wasting, stunting, and underweight and determine its associates among slum children of 3-9 years residing in Bhubaneswar city, Odisha.

Methodology
The present cross-sectional study was carried out in urban slums of Bhubaneswar, Odisha, India, involving children of age group (3-9 years) during the year 2013-2014. The sample size of 190 was calculated assuming the prevalence of undernutrition as 45% [8], precision of 10% at 95% confidence interval, with a design effect of 2. Multistage cluster random sampling technique was adopted to select the study population.
Bhubaneswar city has been divided into 5 geographical zones such as North, East, Central, West, and South, out of which 3 were selected randomly. From each zone, one ward was randomly chosen and then all the notified slums in the selected wards were considered for the study purpose. Overall, 6 slums were considered as study clusters. It was decided to include 40 households from each of the selected slum areas for the study purpose. In each household, only one child aged between 3 and 9 years having no known health disorder was randomly chosen as study subject. However, a total of 249 children of 3-9 years of age were included in the study. Their anthropometric measurements such as height and weight were taken by the investigators and trained field workers. A predesigned and pretested schedule was used to elicit relevant information regarding sociodemographic and individual characteristics like age, sex, education and occupation of parents, per capita monthly income, type of family, mother's age at the time of birth of the child, birth order, and exclusive breastfeeding, and environmental information such as overcrowding, toilet facility, and drinking water storage.
Ethical approval was obtained from the Institutional Ethics Committee of Kalinga Institute of Medical Sciences, Bhubaneswar. For participation of the study subjects, parents/guardians were informed about the study objectives and verbal consent was obtained prior to inclusion in the study.
Weight and height measurements were made following standard operating procedures. Weight was measured to the nearest 0.5 kg in a standard weighing (bathroom) scale (model number PL8019, NOVA BS 1120/00). Weighing scale was calibrated every time before a new measurement was taken. Children were asked to stand still over the centre of the scale with minimal clothing and without footwear and hold their head up and face forward, arms hanging freely by the sides of the body, with palms facing the thigh. Height was measured to the nearest 0.1 cm with nonstretchable tape (TR-13-60 Tailor's tape) which was fixed to a vertical smooth wall and the subject was asked to stand erect without footwear on a firm/level surface with his/her back against the wall, feet parallel, and hands hanging by the sides. Each measurement was done twice and the average of the two readings was recorded. Anthropometric data were analysed using WHO AnthroPlus version 1.0.4 software for assessing the growth of the children. The children were classified using the following categories.
(1) Wasting (acute undernutrition) is defined as a low weight for height. Children with scores (WHZ) < −2 are considered as wasted and those with WHZ < −3 are severely wasted. (2) Stunting (chronic undernutrition) is defined as a low height for age. Children with scores (HAZ) < −2 are considered as stunted and those with HAZ < −3 are severely stunted. (3) Underweight (mixed acute and chronic undernutrition) is defined as a low weight for age. Children with scores (WAZ) < −2 are considered as underweight and those with WAZ < −3 are severely underweight. (4) Thinness (measure of body fat) is defined as a low body mass index. Children with scores (BMIZ) < −2 are considered as thin and those with BMI < −3 are severely thin.
All the data were compiled and analysed using Statistical Package for Social Sciences (SPSS) software version 16.0 and appropriate statistical tests were applied. " " value <0.05 was considered as statistically significant. Univariate as well as multivariate analyses were carried out to test associations between various individual and sociodemographic characteristics and nutritional status of children. The variables found to have " " value <0.25 in univariate analysis were entered into logistic regression model. As multistage sampling technique was used for data collection, sample weights were calculated and taken into consideration during the data analysis in order to get more valid results.

Results
Overall, 249 slum children of age group between 3 and 9 years were surveyed. Majority of the study subjects were girls (68.3%) and the rest were boys (31.7%). Mean age with standard deviation (SD) of girls and boys was 5.07 ± 1.6 years and 5.75 ± 2.07 years, respectively. The mean height (with SD) of the girls was 100.3 ± 11.5 cm, whereas that of boys was 103.1 ± 12.8 cm. The mean weight (with SD) of the girls was 15.0 ± 3.5 kg, whereas that of boys was 15.7 ± 4.33 kg. The anthropometric measurements such as height and weight were found to be more in boys than in girls in all the age groups. Table 1 shows the nutritional status among slum children. Out of 249 children, 58 (23.3%), 143 (57.4%), 113 (45.4%), and 57 (22.9%) were wasted/severely wasted, stunted/severely stunted, underweight/severely underweight, and thin/very thin, respectively. Overall, 65.5% of slum children were found to have undernutrition.
Univariate analysis showing association between wasting and various individual and sociodemographic characteristics is given in Table 2. The prevalence of wasting was found to be more in children in higher age category and more boys had wasting than girls, though these differences are statistically insignificant. More children with birth order ≥2 were suffering from wasting as compared to children having first birth order, which is statistically significant ( = 0.010). Higher proportions of wasted children were observed in mothers having lower education and vice versa. Hence, higher maternal education appeared to be associated with better child nutrition ( = 0.056). Almost similar pattern of child's nutrition was found with father's education. Further, households where the practice of storing drinking water was satisfactory had less number of wasted children (13.9%) as compared to 27.6% children in households with unsatisfactory practice of drinking water storage. This difference is statistically significant ( = 0.016). Other factors such as period of initiation of breastfeeding, mother's age at birth of child, type of family, per capita monthly income, presence of overcrowding, and toilet facility in household were not found to be significantly associated with wasting among slum children.
All the variables found to have " " value <0.25 in the univariate analysis were entered into logistic regression model (Table 3). When controlling for other variables, practice of drinking water storage lost its significance. However, birth order of child, period of initiation of breastfeeding, and mother's education came out as strong independent predictors of wasting in slum children. Table 4 depicts the association between stunting among slum children and various individual and sociodemographic characteristics. In contrast to wasting, the prevalence of stunting was more among children of lower age. However more boys (63.3%) were found to be stunted than their counterparts (54.7%). The mother's age at child's birth appeared to be significant risk factor for stunting in children as more children (71.4%) born to younger mothers (≤20 years of age) had stunting compared to children born to older women ( = 0.015). Households having toilet facilities had significantly less number of stunted children (52.4%) as compared to 67.9% children in households without toilet facilities ( = 0.019). It was also observed that the practice of storing drinking water satisfactorily in the households had a significant positive impact on the child nutrition ( = 0.007) as more (63.5%) children were having stunting in households where practice of drinking water storage was unsatisfactory compared to less (44.3%) number of children in households having satisfactory storage of drinking water. Other factors such as birth order of the child, period of initiation of breastfeeding, parents' education, type of family, per capita monthly income, and overcrowding were not found to significantly affect the status of stunting among slum children.
All the variables found to have < 0.25 in the univariate analysis were entered into logistic regression model (Table 5). Variables like toilet facility and practice of drinking water storage in household came out as strong predictors of stunting among slum children, whereas mother's age at birth of child lost its significance.

Discussion
Childhood undernutrition is a major public health problem in India especially in slums [9][10][11][12]. Starting with the positive aspect of results found in the present study, it was found that almost 90% of slum children were completely immunised till date, but the prevalence of undernutrition was still very high (65.5%). Taking different indicators of undernutrition into account, wasting (23.3%), stunting (57.4%), and underweight (45.4%), found in the children under study, is unacceptably high. Most studies worldwide have also reported high rates of undernutrition among slum children [8,[13][14][15][16]. The results of the present study are consistent with these findings.
Various studies have established the fact that boys are more likely to be stunted, wasted, and underweight than girls [17][18][19][20], which was also observed in the present study. In contrast, some other studies found no such association between gender and undernutrition [21][22][23].
Logistic regression analysis revealed the net effect of individual predictor on the dependent variable. It was observed that children of birth order of 3 or more were almost three times having wasting than children of first order. Children with higher birth order might get less attention and care compared to children of first order. Elkholy et al. revealed in their study that high means of wasting were found among the group of high birth order [24]. Association of undernutrition with high birth order has been shown by many studies [25][26][27][28]. The odds of having wasting rise 4.2 times in case of children whose mothers initiated breastfeeding after 24 hours of birth as compared to children who were breastfed within 1 hour of their birth. Early initiation of breastfeeding positively affects child's overall nutritional status [29,30]. Mother's education was found to have a strong independent effect on child's nutrition controlling the effects of other variables. Illiterate mothers and mothers with primary education were about thrice more likely to have wasted children as 4 The Scientific World Journal  Note: R = reference category, = regression coefficient (log odds ratio), and Exp( ) = odds ratio. Model fit statistics: pseudo-squares-Cox and Snell = 0.188, Nagelkerke = 0.283, and Mcfadden = 0.191; classification table reports that the overall expected model performance is 81.1%; that is, 81.1% of the cases can be expected to be classified correctly by the model. compared to mothers who had attained higher education (high school and above). It might be due to the reason that higher educated women can take independent decisions and have greater exposure to outside world and thus access to various resources which help them in securing proper nutrition of their children. They are more aware about proper nutrition, maintenance of hygiene, and various health issues as compared to uneducated or less educated women. Earlier studies have also documented the positive impact of mother's education on wasting [31][32][33].
Two independent predictors of stunting were also identified. Children residing in households without having toilet facility were 1.5 times more at risk of developing stunting as compared to children in households with toilet facility. This finding has been corroborated in other studies [34][35][36][37]. Unavailability of toilet facility in households would 6 The Scientific World Journal  showed in their study that children coming from homes with water and sanitation had a 17% greater chance of reversing stunting than those coming from homes without either facility [35]. Similar results have also been found in other studies [38,39]. The estimation in the study is not a good measure of causal association between independent variables and nutrition of children because of cross-sectional nature of the study.
There might be recall bias as some of the information was based on response of the study participants. In spite of these limitations, the study has certain important implications.

Conclusion and Recommendation
The present study was probably the first of its kind in Odisha to assess the nutritional status among the slum children both in preschool age and in primary school age group using WHO child growth standards. It is evident from the study that nutritional status of children shows a gloomy picture in slums of Odisha. Thus, utmost care and attention must be focused on these socioeconomically and disadvantaged children living in slums to attain the MDG goals. Sincere 8 The Scientific World Journal efforts must be undertaken to make a significant impact on child's nutrition with multipronged approach such as giving priority to education for slum community especially for women, creating awareness regarding benefits of factors like early initiation of breastfeeding, limiting family size, proper storage of drinking water, and so forth, and providing toilet facility in the household. Similar studies need to be carried out among slum children of different regions to find out whether there are any ethnic and regional variations in the prevalence of undernutrition and also operational research can be planned regarding deliverance of multipronged strategies to curb this public health menace.