Acute undernutrition (Wasting) and Associated Factors among Children
aged 6-23 Months in Kemba Woreda, Southern Ethiopia: A community based
Background: wasting is a major health problem in developing countries. Wasting (low in weight- for- age of < -2 Z -score) is
affecting significant number of children in the world and responsible for loss of many child lives particularly in Asian and sub-Saharan
countries. Identifying potential factors and forecasting appropriate intervention strategies plays vital role in declining child mortality.
To assess acute undernutrition (wasting) and associated factors among Children aged 6-23 Months in Kemba Woreda, Southern
Community based cross-sectional study was carried out among 562 mothers who have young child from 6-23 months in 2014/15 in
Kemba Woreda by using pre tested and structured questioners. Multivariate analyses were conducted by SPSS version 20.
The prevalence of wasting was found to be 21% with 95% CI (17.2-23.9). In multiple logistic regressions, boys[AOR: 1.8; 95%
CI(1.17-2.81)],maternal age > 30years [AOR: 2.60; 95% CI(1.07-6.35)], mothers who have no formal education [AOR: 2.76; 95%
CI(1.63-4.69)], mothers who work as daily workers [AOR: 3.06; 95% CI(1.03-9.12)] and have Private work activity(merchant,
farmers) [AOR: 2.39; 95% CI(1.61-3.53)],mothers who have no antenatal and post natal follow up [AOR: 2.33; 95% CI(1.45-3.74)],
[AOR: 1.82; 95%CI(1.02-3.25)] respectively, non-exclusive breastfed children [AOR: 2.18; 95% CI(1.20-3.99)] and media exposure
of the mother[AOR: 1.99;95% CI(1.19-3.32)] were identified as significant independent predictors of childhood acute under-nutrition.
However, medical illness of children and immunization status were not associated with wasting.
Conclusion and Recommendation :
A great proportion of children were affected by acute nutritional insult. Significant numbers of factors were found to be having
statistical association with wasting. An organized effort should be made at all levels to increase maternal awareness and strengthening
on practice of exclusive breastfeeding, proper antenatal and post natal care provision to solve the high level of acute under-nutrition
wasting, children, Kemba, South Ethiopia
Undernutrition results most commonly from limited quality or
quantity of food, suboptimal feeding practices, and high rates of
infectious diseases. It is found in the form of either wasting, which
is usually considered to be a short-term (i.e., acute) response to
inadequate intake or an infectious disease episode, or stunting
that is considered to be a longer-term response to a sustained poor
dietary intake or repeated illnesses.
Worldwide, of the 80 countries with available data, 23 have levels
of wasting (i.e., weight-for-height below –2SD) greater than 10 per
cent. 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. In these countries factors
such as frequent incidence of infectious diseases, inadequate caring
capacity and social and cultural practices are the major factors
that need to be addressed to reduce wasting. Moderate and severe
wasting represents an acute form of undernutrition, and children
who suffer from it face a markedly increased risk of death. More
than 29 million children under 5, an estimated 5 per cent, suffered
from severe wasting[2, 3].
Undernutrition puts children at far greater risk of death and severe
illness due to common child-hood infections, such as pneumonia,
diarrhea, malaria, HIV and AIDS and measles. A child who is
severely under-weight is nearly 10 times more likely to die of
diarrhea than a child who is not. Moreover, undernutrition not
only weakens the immune system, putting children at higher risk
of more severe, frequent and prolonged bouts of illness and it may
further worsen the child’s nutritional status at a time of greater
nutritional needs but also decrease mental development and
cognitive achievement. This interaction between undernutrition
and infection creates a potentially lethal cycle of worsening illness
and deteriorating nutritional status. Critical nutrition interventions
that break this cycle include promoting optimal breastfeeding
practices, encouraging micronutrient supplementation and
reducing the incidence of low birth weight.
Ethiopia is the seventh wasting burden country from the ten most
affected countries. The nationwide magnitude of wasting is almost
10 %[3, 4]. Some studies conducted in different parts Ethiopia shows
that significant numbers of children are suffering from wasting ([5,
6]. In contrast Ethiopia is one the nation known by implementing
both nutrition specific and nutrition sensitive intervention
strategies of infant and child feeding guideline developed by
WHO in 2004 Due to the high prevalence of inappropriate child
feeding practices and the importance of exclusive breastfeeding.
Since then, varying levels of interventions, giving due emphasis to
key messages on complementary feeding, were being given both
at health institution and community level to meet the Millennium
Development Goals’ (MDGs).Nonetheless, these efforts were not
based on organized evidence on the level of existing practices .
However, little information is available on factors associated with
wasting, or acute malnutrition. In this study, we tried to determine
the extents of factors that could lead to acute undernutrition in
children. Therefore, the aim of this study was to have detailed
and concrete data that fill these gaps and would add a value that
directs policy makers to draw appropriate intervention measures to
improve and flourish the health of future generation.
Methods and Materials
Study Setting and Source population
This community based cross-sectional study was carried out in
2014/15 on 562 mothers who has young child from 6 months to
23 months of age in Kemba Woreda located in Southern parts
of Ethiopia. The Southern Nations Nationalities and People’s
Regional State (SNNPRS) consists of 13 zones and 104 woredas.
The region has an estimated 15,042,531 (20.4% of the national
estimate) people. Close to 90% of the population are estimated to
be rural inhabitants, while 1,545,710 or 10.3% are urban. Kemba
woreda is one of the administrative woreda in Gamo Gofa Zone,
South Ethiopia 100 kms away from Zonal town Arba Minch. From
the total population around 44,000 are women in reproductive
age group. The Health institution distribution in the woreda is
39 health posts and 9 health centers providing health services
including maternal and child health care.
Inclusion and Exclusion criteria:
Mothers/care givers who have young children from 6 to 23 months of age who live in the selected Keble for at least 6 months
were included in the study and those who had mental illnesses
interfering the interview were not considered in study.
Sample size determination and Sampling Technique :
The sample size was determined by using single population proportion formula by the following assumption for prevalence
of wasting (P) as 13% in Gambella region, 4% as degree of precision and with 95% of confidence interval
The final sample size was calculated by taking 2 as design effect and 5% none response rate which is 569. The sample size for the second objective was also calculated by using Epi-info version 7
for cross sectional study by taking in to account of different factors
affecting the level of wasting from previous studies but the results
were less than the sample size obtained above and finally the maximum(n=569) was taken.
Sampling Procedure :
From 39 small Keble in the woreda six Kebele was selected by
using lottery method. Then the number of study participant was
allocated for each Kebele based on proportional to size allocation
methods by using community based demographic and health related information registration prepared by Health Extension
workers as the sampling frame. Rapid censuses were conducted
first to identify the target house hold. Finally infant-mother pairs
were selected from each Keble by using systematic sampling
technique after giving code for each household which has young
child from six to 23 months (figure1).
Data collection method, measurement and quality control
Data were collected from Mothers/care givers who have one
child in age 6 to 23 months from each household by direct
interviewing. Pre-tested structured questionnaire adapted from
different literature was used to collect socio-demographic and others variables. First the questionnaire s was prepared in English
and translated to Amharic and pre tested on 5% of mothers before
actual data collection outside the selected kebeles; correction
and modification was done based on the gap identified during
interview. Six grade 12 completed students were recruited as data
collectors and supervised by 3 Nurses. Three day training was
given on the aim of the research, content of the questionnaire, and
how to conduct interview for data collectors and supervisor to
increase their performance in field activities. The Collected data
were checked every day by supervisors and principal investigator
for its completeness and consistency.
Anthropometric measurements were also taken after making
proper adjustment or standardization of instruments. The weight
of each child was taken by using digital scale wearing light
cloth, checking the calibration using 2kg rod during each instant
of weight measuring and the measurement was approximated to
the nearest 10g. Sliding board was used to measure the length of
children in recumbent position by two data collectors and taken to
the nearest 1mm[8, 9]. The data collectors were trained efficiently on how to take the anthropometric measurements.
Data analysis and Management
Data was coded and entered in to Epi-Info version 3.5.1 and exported
to SPSS Version 20 for analysis. Exploratory data analysis was
done to check missing values, potential outliers and the normality
distribution for those continuous variables. The presence of multicollinearity
also was checked and effort was made to incorporate
different models to cross check. Anthropometric index (WHZ)
was analyzed by using WHO Anthro software version 3.2.2 and
categorized as wasted if WHZ <-2 Z score and as normal if WHZ
>-2 Z score. Extreme outlier of <-5 Z score of WFL was omitted
from the analysis. Descriptive Frequencies were calculated to
describe the study population in relation to relevant variables.
Bivariate logistic regression analysis was calculated to assess the
crude association between dependent and independent variables.
Finally Variables which shows association in bivariate logistic
regression analysis and have P-value less than 0.25 entered in
to Multivariate logistic regression model, to identify significant
independent predictors of wasting and to control the possible effect
of confounding. Significant factors were considered at P-value less
Ethical consideration :
Ethical clearance was obtained from Research ethics committee
(REC) of Addis continental institute of Public Health. Permission
letter was obtained from Kemba Woreda Health office. Verbal
informed consent from each study participant was obtained after
clear explanation about the purpose of the study. All the study
participants were reassured that only anonymous data were taken.
They were given the chance to ask anything about the study and
made free to refuse or stop the interview at any moment they want
if that was their choice.
Socio-demographic characteristics of the mothers and young
A total of 562 women having young child aged 6 to 23 months were
interviewed in the study from 569 sampled mothers with 98.77%
response rate. The mean age of children were 13.82 months ±
5.85 (SD) and 53% were found in age range from 6 months to 1
years and 273(48.6%) were male and 289(51.4%) were female.
About one third (30.8%) of respondents were having no formal
educational and about half (46.1%) of them were farmers and
merchants in their occupational statues (Table 1).
Prevalence of acute under nutrition
From 562 interviewed mothers-child pair 21%; 95% CI (17.2-
23.9) of children had global acute malnutrition of which 24.4%;
95% CI (19.2-29.6.) were boys and 17.1%; 95%CI (12.8-21.4)
were girls, 13.7%; 95% CI (10.8-16.6) were moderately wasted
and boys were more affected than girls, 17.6%; 95% CI (13.0-
22.2) boys and 10.2%; 95% CI (6.8-13.7) girls had moderate acute
malnutrition. The prevalence of severe wasting was 6.8%; 95% CI (4.7- 8.9) In this case boys were more vulnerable than girls; of
boys and of girls were severely malnourished. Mean ± SD of WHZ was -0.44±2.52 (fig.2).
Factors associated with acute under nutrition
After conducting Multivariate logistic regression analysis, boys
[AOR: 1.8; 95% CI(1.17-2.81)], age of mothers those in age
group >=30 years [AOR: 2.60; 95% CI(1.07-6.35)], education
level those who have no formal education [AOR: 2.76; 95%
CI(1.63-4.69)], occupational of mothers those who worked as daily
workers [AOR: 3.06; 95% CI(1.03-9.12)]and Private work activity(merchant,
farmers) [AOR: 2.39;95% CI(1.61-3.53)], media
exposure of the mother[AOR: 1.99;95% CI(1.19-3.32)],children
who did not exclusively breastfed [AOR: 2.18; 95% CI(1.20-3.99)
and mothers who had no antenatal and post natal care follow up
[AOR: 2.33; 95% CI(1.45-3.74)], [AOR: 1.82; 95%CI(1.02-3.25)]
respectively were significantly associated with acute undernutrition.
On the other hand, age of the child, residence, place of delivery,
timely introduction of complementary feeding; dietary diversity
score and immunization status of children were not identified as
predictors of wasting (Table2).
Result of this study showed that the level of acute under-nutrition
or wasting (i.e. WHZ<-2SD) was 21%; 95% CI (17.2-23.9)
and found that males (24.4%); 95% CI (19.2-29.6.) were more
vulnerable population group than females (17.1%) 95%CI (12.8-
21.4). The overall prevalence of wasting in this study is much
higher than the national prevalence of Ethiopia (10%), SNNPR
(9.7%), Nepal (16%), among orphaned children in Gondar (9.9%)
[4, 9, 10]respective, but nearly similar finding were observed
in study conducted in north west Ethiopia(17.7%) and report of
regional prevalence of wasting in Afar(19.5%) and Somali(22.2%)
from EDHS[4, 11]. The discrepancies may be due to variation in
data collection period and the target populations in this study are
those children whose nutritional need and feeding practice are relied by their mothers or caregivers. They are prone to nutritional
deprivation. Practices of suboptimal breast feeding, untimely
inappropriate introduction of complementary feeding may take
higher contribution of why the prevalence of wasting is higher in
The main contributing factors for child wasting or acute
undernutrition were being male, maternal age >30 years, maternal
educational status and occupational status, post natal follow up
exclusively breast fed children, maternal media exposure and
having antenatal and post natal care follow up. Children born from
mothers whose age >30 years were nearly 3 times more likely
to wasted than those who born from younger mothers. The odds
of wasted children in non-exclusively breast fed children was 2
times higher as compared to children who exclusively breastfed.
Similarly, children born from mothers with no formal education
were almost three times more likely to be undernourished than
children born from mothers who have secondary and above
education level. This finding is consistent with finding[9, 12-
14],it shows that improved maternal education enhances mothers
knowledge ,attitudes and practice towards benefits of exclusive
breast feeding practice, and they are the primary responsible body
to improve and maintaining better nutritional status of children.
In addition, children born from mother who work as daily workers
and merchant; and children from mothers who have no post natal
care follow up were more likely to be wasted as compared to their
counterparts. The findings are almost go in line with findings from
north west Ethiopia and Nigeria[9, 13].
Strength and weakness of the study :
The study has strong generalization power as compared with others
study conducted with relatively small sample size and institutional
based. Recall bias may be introduced even if it was minimized by
probing mothers to report by association with different life events
may not remember events occurred in the past, and possibility of
interviewer bias and misreporting of events were the potential
limitation. And the study was also fail to address variables like
dietary inadequacy at individual level or portion size estimation,
household income status and house hold food security which may
have affect our measure of interest.
Conclusion and Recommendation
A striking figure was observed from the finding. Huge numbers
of children were suffering from wasting and can be conclude
that prone to various infections and found at greatest risk for
childhood mortality. Positive statistically significant associations
were identified between acute under-nutrition and exclusive
breast feeding, access to information sources, high academic
achievement, having occupation and attending antenatal and
postnatal care follow up. But, being boy and increased maternal
age were negatively associated with wasting. Nutrition education
should be highly integrated with other routine health service
provisions and especially essential nutrition action should effectively implemented at the grass root level because most of
the identified factors are delivered during the six critical contact
points as clearly stated from the guideline of IYCF. As a strong
recommendation, there should be program evaluation studies that
are specifically targeted to direct nutrition intervention towards the
management of acute malnutrition at the community level.
We would like to thank Arba Minch University for funding of
our research work. Our deepest gratitude goes to data collectors, kebeles leaders and Kemba woreda Health center manager for his cooperation starting from the beginning till the end of data collection time. Computing interest-The authors declare that they have no computing interest.
Authors’ contribution :
EA: Initiated the research, wrote the research proposal, conducted
the research, did data entry and analysis and wrote the manuscript.
AS: Involved in the write up of methodology of proposal and
AOR-Adjusted odd ratio, SAM-sever acute malnutrition, MUACMid-upper–arm
circumference, CI-confidence interval, SDstandard
deviation, TFU- Therapeutic feeding Unit, SNNPR- South nations and nationalities people’s region of Ethiopia, IYCF-infant
and young child feeding.
- Stephanie A. Richa rd, Robert E. Black, and R.H. Gilman
(2012) Wasting Is A ssociated with S tunting in Early Childhood.
The Journa l of Nutrit ion, 142 p. 1291-1296.
- United Nations Children’s Fund, W.H.W., The World Bank,
Levels & Trends in Child Malnutrition;UNICEF-WHO-The World Bank Joint Child Malnutrition Estimates 2012.
- UNICEF, IMPROVING CHILD NUTRITION;The achievable imperative for global progress. 2013.
- Macro, C.S.A.E.a.O.,(2011) Ethiopia Demographic and Health
Survey . Addis Ababa, Ethiopia and Calverton, Maryland,USA: Central Statistical Agency and ORC Macro.
- Motee A, D.R.D., Pugo-Gunsam P,and Rajesh Jeewon (2013) An Assessment of the Breastfeeding Practices and Infant Feeding
Pattern among Mothers in Mauritius. Journal of Nutrition and
- Kimani-Murage WE, M.J., Fotso C, Kyobutungi C, Mutua KM,Gitau MT (2011) Patterns and determinants of breastfeeding
and complementary feeding practices in urban informal settlement,
Nairobi Kenya. BMC Public Health.
- Health, F.M.o., (2004) National strategy for Infant and Young Child Feeding (IYCF). Ethiopia: Federal Ministry of Health, Family Health Department.
- WHO, WHO Multicenter Growth Reference Study Group WHO Child Growth Standards: Length/ height-for-age, weight-for-age, weight-forlength, weight-for-height and body mass index-for-age: Methods and development. Geneva, World Health WHO. 2006.
- Gultie, T., E. Sisay, and G. Sebsibie, (2014) Nutritional status and associated factors among orphan children below the age of five years in Gondar City, Ethiopia Journal of Food and Nutrition Sciences, 2(4): p. 179-184.
- Bhandari, T.R. and M. Chhetri, (2013) Nutritional Status of Under Five Year Children and Factors Associated in Kapilvastu District, Nepal. Journal of Nutritional Health & Food Science, 1: p. 6.
- Edris, M.,(2007) Assessment of nutritional status of preschool
children of Gumbrit, North West Ethiopia Ethiop.J.Health Dev.21(2): p. 125-129.
- Charmaine S, M.J., Dibley and Kingsley E.(2010)
Complementary feeding indicators and determinants of poor feeding practices in Indonesia: a secondary analysis of 2007,Demographic and Health Survey data. Public Health Nutrition:
- Akorede, Q.J., O.M. Abiola, (2013) and ASSESSMENT
OF NUTRITIONAL STATUS OF UNDER FIVE CHILDREN
IN AKURE SOUTH LOCAL GOVERNMENT, ONDO STATE,
NIGERIA IJRRAS, 14 (3)
- Egata, G., Y. Berhane, and A. Worku,(2014) Predictors of acute
u ndernutr it io n among children aged 6 to 36 months in east rural Ethiopia. BMC Pediatrics, 14: p. 91.