Assessment of wasting and associated factors among under five children of Wukro town, Tigray regional, North Ethiopia: a cross sectional study

Introduction Globally, 50 million children under 5 were wasted; of which 16 million were severely wasted. A severely wasted child is at a nine times higher risk of dying. To prevent this problem, it is necessary to determine the magnitude and factors associated with childhood wasting. In Ethiopia specifically Wukro town, Tigray regional state there is no clear information regarding under five wasting. Therefore, the study assessed the prevalence and associated factors of wasting among under five children in Wukro town, North Ethiopia. Objective: to assess the prevalence of wasting and associated factors among under five children of Wukro town, Tigray, North Ethiopia, 2017/2018. Methods Community based cross-sectional study design with a single population proportion formula was used with a total sample size of 400 children. Wukro town has three kebele, two kebelle were included in the study through simple random sampling method. There was proportional allocation of subjects to each kebelle and final study subject was selected using systematic method. In case there were more than one child in the household one child was selected randomly. The data were collected by face to face interview and measuring of weight and height after the instrument was pre-tested. The anthropometric results were entered in to Emergency nutritional assessment (ENA) to calculate Z-Score. The collected data and result of Z-score were entered in to Statistical package for social science (SPSS) version 20. Finally, results were presented in texts, graphs and tables. Results A total of 394 under five children were participated in this study, which gave a response rate of 98.5%. The respondents were females 222 (56.3%) and 106(26.95%) were in the age group of 12-23 month. The overall prevalence of wasting was 28 (7.2%). Out of this 14 (3.6%) were wasted and 14 (3.6%) were severely wasted. Under five children those, whose family does not live together were 3.086 times more likely to be wasted compared to under five children those, whose family live together (P=.038, OR=3.086, & 95% CI= (1.061, 8.970). Under five children those, whose mother did not taken family planning were 2.530 times more likely to be wasted compared to under five children those, whose mother take family planning (P=.038, OR=2.530, & 95% CI= (1.054, 6.074)). Conclusion Significant numbers of mothers were not taken extra food during pregnancy and lactation. There was significant prevalence of wasting of under five children in the study area. Living condition of family and usage of family planning were associated with increased risk of wasting.


Introduction
Nutrition is the provision of adequate energy and nutrients to the cells to perform their physiological function (of growth, reproduction, defense, and repair, etc) [1]. Malnutrition refers both to under nutrition and over nutrition, but the focus here is to under nutrition.
Under-nutrition causes 175 deaths per 1000 children in low income countries compared to high income countries 6/1000 deaths. The nutritional status of women and children is particularly important, because it is through women and their off-spring that the pernicious effects of malnutrition are propagated to future generations. A malnourished mother is likely to give birth to a low birth-weight (LBW) baby susceptible to disease and premature death, which further undermines the economic development of the family and society, and continues the cycle of poverty and malnutrition. Malnutrition commonly affects all groups in a community, but infants and young children are the most vulnerable because of their high nutritional requirements for growth and development [2,3]. Malnutrition due to primary lack of food and interplay of infections is known as primary malnutrition, which is responsible for most of the 112 million children suffering from moderate malnutrition in the developing world.
Malnutrition occurring as a result of chronic diseases such as chronic kidney, liver or heart disease is known as secondary malnutrition.
Although lack of food and repeated infections including diarrhea and pneumonia are the immediate, precipitating causes of malnutrition, the root causes are political in nature interlaced with issues of social and gender inequity particularly of income and education [4]. Causes of under nutrition that are being debated currently include growth faltering, low birth weight, maternal under nutrition, deficiencies of specific nutrients, diarrhoea, HIV infection and other infectious diseases, inadequate infant and child feeding practices, female time constraints, limited household income, limited agricultural production, food insecurity, environmental degradation, and urbanization.
Optimal nutritional status results when children have access to affordable, diverse, nutrient-rich food; appropriate maternal and child-care practices; adequate health services; and a healthy environment including safe water, sanitation and good hygiene practices. These factors directly influence nutrient intake and the presence of disease. The interaction between under nutrition and infection creates a potentially lethal cycle of worsening illness and deteriorating nutritional status. Food, health and care are affected by social, economic and political factors [5,6].
Globally in 2011, 52 million children under 5 years were wasted. The highest wasting prevalence is in South Asia, where approximately one in six children (16%) is wasted. In sub-Saharan Africa, nearly 1 in 10 children under the age of 5 (9%) were wasted. The number of wasted children in sub-Saharan Africa as a proportion of the world's total has increased over the same period of time. While a significant number of the world's 52 million wasted children live in countries where cyclical food insecurity and protracted crises exacerbate their vulnerability, the majority reside in countries not affected by emergencies [6]. Children who suffered from under nutrition are more likely to achieve lower educational levels than healthy children. The low education levels attained, often makes them less qualified for work, thus reducing their income-earning potential for non-manual work [7]. In 2014, the global wasting rate was 7.5%, approximately 1 out of every 13 children. Globally, 50 million children under 5 were wasted, of which 16 million were severely wasted [8]. The nutritional status of children is a reflection of their overall health. Under nutrition in childhood, is one of the main burdens of the health system and also affects the economic and socio-cultural status of society. Poverty and malnutrition play a crucial role in increasing morbidity and mortality, impairing cognitive development in children, and increasing common childhood infections. Acute malnutrition affects more than 50 million under-five children, causing 8% of child deaths globally each year. It is caused by poor maternal nutrition before and during pregnancy, inappropriate infant feeding practices, and repeated episodes of infections. A high percentage of illiterate mothers, limited access to safe drinking water, and poor hygiene and sanitation have also contributed to under nutrition and child morbidity in the country.
Growing evidence suggests that 80% of childhood disease is related directly or indirectly to unsafe drinking water, inadequate sanitation and hygiene practices [9]. Under nutrition are clearly a major contributing factor to child mortality, disease and disability. A severely wasted child is at a nine times higher risk of dying. Brain and nervous system development begins early in pregnancy and is largely complete by the time the child reaches the age of 2 years. The timing, severity and duration of nutritional deficiencies during this period affect brain development in different ways. An estimated one third of deaths among children under age 5 are attributed to under nutrition.
Under nutrition puts children at far greater risk of death and severe illness due to common childhood infections [6]. According to Ethiopian mini demographic and health survey, 2014, overall, 9% of Ethiopian children were wasted, and 3% are severely wasted. This coupled with inadequate feeding practices, may contribute to faltering nutritional status [10]. In particular, special attention should be given to the first 1,000 days, from the start of pregnancy to two years of age, pregnant and lactating women, women of reproductive age, and adolescent girls, by promoting and supporting adequate care and feeding practices, including exclusive breast feeding during the first six months, and continued breastfeeding until two years of age and beyond with appropriate complementary feeding [11]. In Wukro town, there is no clear information regarding the magnitude and factors that contribute to under five malnutrition. Therefore, the main aim of this paper was to assess the prevalence and associated factors of wasting among under five children and recommend necessary intervention methods to Tigray regional health bureau, Woreda Health Bureau and health care providers of the area. Likewise, the result of this study will be used as baseline information to Federal, regional and Woreda Health Office and professionals and local managers to prepare prevention method of wasting for the community, provide baseline information to researchers for further study in the area, supply important information for program managers and policy makers, provide pertinent information for curriculum designers to make necessary amendment and guide governmental and nongovernmental health organizations to focus and train health care providers.

Methods
Community based cross-sectional study design was conducted from

Definition of terms
Wasting: nutritional deficient state of recent onset related to sudden food deprivation or mal-absorption utilization of nutrients which results weight loss, weight-for-height below -2SD from the NCHS/WHO median value. Severe wastage was diagnosed if it was below -3 SD [13].

Anthropometric measurement
Height/length measurement: body length of children age up to 23 months was measured without shoes and the heights were read to the nearest 0.1 cm by using a horizontal wooden length board with movable headpiece and the infant in recumbent position. However, height of children 24 months and above was measured using a vertical wooden height board by placing the child on the measuring board, and child standing upright in the middle of board. The child's head, shoulders, buttocks, knees and heels touching the board.
Weight measurement: weight was measured by electronic digital weight scale with minimum/lightly/clothing and no shoes. Calibration was done before weighing every child by setting it to zero. In case of children age below two years, the scale was allowed weighing of very young children through an automatic mother-child adjustment that was eliminated the mother's weight while she standing on the scale with her baby.
Methods of data analysis: data was checked for completeness and any incomplete information was excluded from entry. Anthropometric result was entered in to ENA (emergency nutritional assessment) to calculate Z-Score. The collected data and result of Z-score were entered in to SPSS version 20.0. Simple frequencies were run to see the overall distribution of the study subject with the variables under study. Level of interaction of independent variables (multicollinearity) was assessed through VIF and was found absence of interaction of independent variables. Multi-variable logistic regression analysis was run to identify the independent predictors of wasting of under five children. Adjusted odds ratio with 95% confidence interval was used to ascertain the association between dependent and independent variables. The level of significance was taken at α <0.05. Finally, result was presented in texts, and tables. Ethical clearance and approval was obtained from college of medicine and health science, Adigrat University. Official cooperation letter was written from Adigrat University research and community service directorate to Tigray regional health bureau. Then Tigray regional health bureau sent written cooperation letter to Wukro town administration health office.
Official letter was obtained from Wukro town health office to each selected kebele. After explaining about the purpose, and the possible benefit of the study; written permission was obtained from each respondents. Confidentiality of the respondent was maintained throughout the study.

Results
Participants' socio-demographic characteristics: a total of 394 under five children were participated in this study, which gave a response rate of 98.5%. The respondents were females 222 (56.3%) and 106  (Table 1).
Two hundred two (51.3%) of the children's gestational age were <37 Almost all households 393 (99.7%) were used common pit waste disposal method and 392 (99.5%) participants wash hands before preparing food ( Table 3). The overall prevalence of wasting was 28 (7.2%). Out of this 14 (3.6%) were wasted and 14 (3.6%) were severely wasted. Before bivariate and multivariate analysis multicollinearity diagnosis was assessed and absence of multicollinearity was satisfied. In bivariate analysis Mothers educational status, whether family live together, and whether mothers take family planning were associated with wasting. Variables which have P-value less than or equal to 0.25 in bivariate analysis were selected as a candidate for multivariate analysis. The multivariable result showed that child's age, mothers education level, whether child still taking breast feeding, mother take extra food during pregnancy, and number of ANC follow up were not statistically associated with wasting of under five children but whether family live together, and mother's take family planning were significantly associated with wasting. That is Under five children those, whose family does not live together were 3.086 times more likely to be wasted compared to under five children those, whose family live together ( Under five children those, whose mother did not taken family planning were 2.530 times more likely to be wasted compared to under five children those, whose mother take family planning (

Discussion
The study result showed that 376(95.4%) of under five children were initiated breast feeding within one hour of delivery, 1 (0.3%) of child had received prelactal feeding, 94% received exclusive breast feeding Provera 633 (77.2%) was used by majority of the mothers [11]. The difference might be due to difference in time duration and sociodemographic characteristics. The study result showed that the prevalence of wasting was 14 (3.6%) and 14 (3.6%) were severely wasted. Males were more wasted than females (18.6%, 12.6%) respectively). Only 1 (0.3%) of children was received prelactal feeding, and 94% of children were received exclusive breast feeding for 6 month. This result is comparatively different except the prevalence with the study conducted in Nzego district rural Tanzania which shows the prevalence of wasting was 6.5%. Girls were more wasted than boys (8.8% vs. 4.4%). About one third of children (33.5%) were given prelactal feeds. Only 22.9% of mothers practice exclusive breast feeding at least in the first three months of child's life [14]. This difference could be due to sociocultural difference of the two study area.
This study result is comparatively lower than the study conducted in Sudan Khartoum, that's the prevalence of sever wasting was 7.3%.
Severe wasting was 11% among males while it was 4% among females [15]. This difference could be due to difference in sociodemographic characteristics and study period. The study result was also comparatively similar with study result of EDHS 2014 that indicates that, 9% of Ethiopian children were wasted, and 3% were severely wasted. Male children are slightly more likely to be wasted (10%) than female children (7%) [10]. This similarity could be due to similarity in socio-demographic characteristics. This study indicated that 76(19.3%) participant mothers gave their first birth before the age of 18 years. One hundred eleven (28.2%) and 26(6.6%) were not received extra food during pregnancy and lactation respectively.
Under five children those, whose family does not live together were 3.086 times more likely to be wasted compared to under five children those, whose family live together (  1.061, 8.970)). Under five children those, whose mother did not taken family planning were 2.530 times more likely to be wasted compared to under five children those, whose mother take family planning. (P=.038, OR=2.530, & 95% CI= (1.054, 6.074)).
This study is relatively lower than the study done in Dollo Ado district, Somali region Ethiopia, 385(71.2%) of mothers gave first birth when they were younger than 18 years of age. Among those who had experienced at least one pregnancy, 392(72.5%) no extra food was taken from the usual time during pregnancy and lactation. Mother's education and prevalence of wasting were inversely related. Children who had ARI in the preceding two weeks of the survey were 1.96 times higher risk of being wasted compared to those who are not suffered with ARI(AOR=1.96 95% CI=1.20,3.18).
The odds of being wasted was 1.69 times higher among male children than female children (AOR=1.69 95% CI=1.16, 2.45). The risk of being wasted was 1.55 times higher among mother of children who consumed extra food during pregnancy than those mother of children who had not consumed extra food during pregnancy (AOR=1.55 95% CI=1.06, 2.26) [16]. This difference might be due to difference on socio-demographic characteristics of the study participants and living condition of the participants. Based on this study, almost all 393(99.7%) of children were delivered at health facilities but 1(0.3%) were delivered at home but 89(22.6%) of children were experienced diarrhea in the last 2 weeks of data collection, 55(14%) had What is known about this topic  The prevalence of wasting in rural Tanzania was 6.5%. Girls were more wasted than boys (8.8% vs. 4.4%);  The prevalence of sever wasting in Sudan Khartoum, was 7.3%. Severe wasting was 11% among males while it was 4% among females;  According to mini EDHS 2014, 9% of Ethiopian children were wasted and 3% were severely wasted. Male children are slightly more likely to be wasted (10%) than female children.

What this study adds
 The prevalence of wasting in rural Tanzania was 6.5%. Girls were more wasted than boys (8.8% vs. 4.4%);  The prevalence of sever wasting in Sudan Khartoum, was 7.3%. Severe wasting was 11% among males while it was 4% among females;  According to mini EDHS 2014, 9% of Ethiopian children were wasted and 3% were severely wasted. Male children are slightly more likely to be wasted (10%) than female children.