University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVF.RSITY OF GHANA DETERMINANTS OF MALNUTRITION IN cmLDREN UNDER FIVE AT EFFUTU MUNICIPALITY BY VIVIAN TACKlE (10598910) THIS DISSERTATION IS SUBMITTED TO UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH DEGREE JULY 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Vivian TadGe, hereby declare that with the exception of references to other people's work which have been duly acknowledged, this work is the result of my own original research with guidance from my supervisor. I further affIrm that this work has never been submitted to any other University, in part or whole for any Degree or other purpose. ....... ~............. .. .... !P./fP/ll. ........ . VIVIAN TACKlE DATE (STUDENT) ACADEMIC SUPERVISOR'S DECLARATION I hereby declare that the preparation and presentation of the project work was supervised in accordance with the guidelines on supervision of dissertation laid down by this University. '::j!f!fiL------ DR. ERNEST MAYA DATE (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to the Almighty God, children under five years and parents in the Effutu Municipality. I also dedicate it to my my able supervisor, Dr. Ernest Maya and his family for their commitment, guidance and support. Not forgetting my dear husband Mr. Eric Essel, my children, Nhyria, Adorn, and Ayeyi Essel and my brothers and sisters for their prayer support, counseling, and their ever ready support in my life. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT The end of everything is surely better than its beginning. I am highly indebted with thanks to a number of people, who have helped in making this project a possible. I thank the Almighty God for the strength He has given me, even until this fmal day. My profound gratitude goes to my supervisor, Dr. Ernest Maya, whose his love, guidance and unflinching support has made this project a reality. I am equally grateful to all Lecturers of the Population, Family and Reproductive Health Department of the School of Public Health for their contributions, corrections and suggestions during the preparation of this work. Finally, special thanks goes to my lovely family, who supported me financially, emotionally and spiritually and to all colleagues and friends who also encouraged me through thick and thin. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background-Malnutrition is an underlying factor in many diseases for both children and adults and is particularly prevalent in developing countries, where it affects one out of every three preschool-age children. Under nutrition (malnourished) a form of malnutrition has been a worldwide problem which is being tackled in various ways and is usually prevalent among children in developing economies. One of the appropriate measures to support the fight against malnutrition in general and undernutrition specifically is to know the nutritional status and conditions of the population so that appropriate measures can be taken to address them. Objective- The study sought to find out the proportion of children under five years who were malnourished and examined what socio-economic, household practices, child health care seeking practices and cultural beliefs and practices are associated with the most prevalent form of undernutrition Metbodology-A community based researcb was conducted to assess the nutritional status of children under five years in Effutu municipality for a total of 350 children. With the use of a structured questionnaire, data on children and care givers was collected. Data was entered into Microsoft Excel 2010. WHO Anthro software version 3.2.2.1 was used in determining the z-scores and SPSS software version 20 was used to perform univariate, bivariate and logistic regression analysis. A P<0.05 was deemed statistically significant. Results-Out of the 350 children under five, the most prevalent undernutrition case is stunting (59%) and the least malnutrition case was wasting (19%). Stunting was most prevalent among children in the age group of 12-23 months (35.5%). Occupation of Mother and Household income were socio-economic factors that were found to be iv University of Ghana http://ugspace.ug.edu.gh significantly associated with stunting at 95% significant level. What is done when the child is sick was the only child health care seeking factor associated with stunting at 95% significant level. The number of times child feeds daily is the only-house hold practice that is associated with stunting at 5% significant level. None of the cultural practices and believe system had any significant association with stunting. With regards to the socio- economic factors, Children whose parents who are self-employed are about twice likely to be stunted than those who are unemployed (OR=2.18; 95% CI, 1.14 - 3.246). Those who earn more than GhclOOO are about two and halftimes more likely to be stunted than those who earn less than GhclOO (OR=2.672; 95% CI, 2.198 - 47.145). Those who consult traditionalist when their child is sick are less likely to stunted than those who visit the hospital when the child is sick by a multiplicative factor of 0.355 (OR= 0.355; 95% cr, 0.098 - 0.612). Conclusion- The study showed that of the economic factors, mother's occupation and household income was significantly associated with their child being stunted. The fmdings of the study also showed of the house hold practices, the number of times a child feeds in a day was significantly associated with their child being stunted. Child health care practices and stunting, also showed no significant relationship. Which was not the same as in the case of cultural beliefs and practices and stunting among children under five years. University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT DECLARATION .................................................................... !. ........................................... 1 ACADEMIC SUPERVISOR'S DECLARATION .............................................................. 1 DEDICATION ........................................................................ :. .......................................... II ACKNOWLEDGEMENT ................................................................................................. 111 ABSTRACT............................ .. ................................................................................... IV TABLE OF CONTENT ..................................................................................................... VI LIST OF TABLES ............................................................................................................. IX LIST OF FIGURES ............................................................................................................. X LIST OF ABBREVIATIONS ............................................................................................ XI DEFINITION OF TERMS ................................................................................................ XII CHAPTER ONE ................................................................................................................. 1 INTRODUCTION .............................................................................................................. 1 1.1 Background ................................ .............. ... ....... ...... .................. ............................... 1 1.2 Problem Statement .................................................................................................... 4 1.3 Conceptual Frantework ............................................................................................. 5 1.4 Justification ............................................................................................................... 6 1.5 General Objectives..... . ...................................................................................... 8 1.5.1 Specific objectives .................................................................................................. 8 1.6 Research Questions ................................................................................................... 9 CHAPTER TWO .............................................................................................................. 10 LITERATURE REVIEW .................................................................................................. 10 2.1 Introduction ............................................................................................................ 10 2.2. Concept of Malnutrition ......................................................................................... 10 2.3 Prevalence of malnutrition ...................................................................................... 12 2.4 Type of malnutrition ................................................................................................ 15 2.5 Measuring malnutrition in children under five years ....... ri ..................................... 16 2.5.1 Biochemical assessment ....................................................................................... 17 2.5.2 Dietary assessment ............................................................................................... 17 2.5.3 Clinical assessment .............................................................................................. 17 2.5.4 Anthropometry ..................................................................................................... 18 2.6 Determinants of Malnutrition in under fives ........................................................... 19 2.7 Socioeconomic Factors and Undernutrition ........................................................... 22 2.8 Household practices and Undernutrition ............................................................... 24 2.9 Maternal and Child Health Practices and Undernutrition ...................................... 25 2.10 Child Welfare Services and Malnutrition .......................................................... 29 vi University of Ghana http://ugspace.ug.edu.gh 2.11 Cultural Practices and Undernutrition ............................ :.·. .•.....•............................ 30 CHAPTER THREE ................................................................. :.. ........................................ 32 rrE~'E';.~ .. :::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::::: ~~ 3.2.1 Geography/Background of the ArealEffutu Municipal Assembly ....................... 32 ~~:~E~§;:7~S~:::.:: .. :::::: ... ::.: .. ::::::::::::::::::::::::::::.:::::::::::::. .. :~~ 3.2.5 Environmental Health and Sanitation Facilities ................................................... 35 ~:~:ig~~~~=::::::::::;;;;;;::;;:;::::;:.;;;;;;;:;:;::;:;:::;::;.;.;.;;:;;;::;;;;:;::::::::j! 3.5 Data Collection TechniquelMethod and Tools ....................................................... 38 3.5.1 Anthropometric Technique .................................................................................. 38 3.5.2 Questionnaire ....................................................................................................... 40 3.6 Quality Control ........................................................................................................ 40 3.7 Variables .................................................................................................................. 41 3.7.1 Dependent Variable .............................................................................................. 41 3.7.2 Independent Variable ........................................................................................... 41 3.8 Pre-Testing / Pilot Study ......................................................................................... 41 3.9 Data management and analysis ............................................................................... 42 3.10 Ethical Consideration! Issues ................................................................................ 43 CHAPTER FOUR ............................................................................................................ 44 RESULTS ........................................................................................................................ 44 4.0 Introduction ............................................................................................................. 44 4.1 Characteristics and socio-demographic information of Children under five years. 45 4.2 General malnutrition levels of children under five years ........................................ 46 4.2.1 Nutritional status of under-five according to weight-of-age ................................ 47 4.2.2 Nutritional status of under-five according to height-of-age ................................. 48 4.2.3 Nutritional status of under-five according to weight-of-height ........................... 49 4.2.3 Stunting status of children under-five according to their age .............................. 50 4.3 Association of socio-economic factors with stunting ............................................. 51 4.4: Association of Child health seeking practices with stunting ................................. 53 4.5 Association of Household practices with stunting .................................................. 56 4.6 Association of cultural practices and beliefs factors with stunting ......................... 59 4.7 Socio-Economic factors associated with stunting among children under five years: ........................................................................................ ··· .. · .. ·. ..... ·. . ···· .. ·. ..................... 61 vii University of Ghana http://ugspace.ug.edu.gh 4.8: Child health seeking factors associated with stunting among children under five years: .......................................................................................•..................................... 63 4.9: Household practices factors associated with stunting among children under five years: ............................................................................................................................. 65 CHAPTER FIVE ............................................................................................................... 68 DISCUSSION ................................................................................................................... 68 5.1 Introduction ............................................................................................................. 68 5.2 Discussion of main findings .................................................................................... 68 5.2.1 General outcome of malnutrition status of children under five ........................... 68 5.2.2 Socioeconomic Factors and Undernutrition ......................................................... 70 5.2.3 Household practices and Undernutrition .............................................................. 72 5.2.4 Child Healthcare Seeking Factors ........................................................................ 73 5.2.5 Cultural Practices and Undernutrition .................................................................. 74 CHAPTER SIX ................................................................................................................. 77 CONCLUSION AND RECOMMENDA nONS .............................................................. 77 6.1 Conclusion ............................................................................................................... 77 6.2 Recommendations ................................................................................................... 78 6.2.1 Policy Related Recommendations ........................................................................ 78 6.2.2 Practice related recommendations ........................................................................ 80 6.2.3 Further Research recommendation ....................................................................... 80 REFERENCES ....................................................................................................•............ 81 APPENDIX A: CONSENT FORM ...................................................................................... 91 APPENDIX B: QUESTIONNAIRE ....................................................................................... 93 APPENDIX C: ASSENT FORM ........................................................................................... 99 APPENDIX D: ETHICAL CLEARANCE FORM ................................................................... 100 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Distribution of the 17 electoral areas in the Effutu Municipality ................................. 33 Table 4.4: Bivariate analysis of stun~g status and children under-Jive in Effutu municipality: Child health seeking practices ....................................................................................................... S3 Table 4.5: Bivariate analysis of stunting status and children under- five in Effutu municipality: household practices factors ...................................................... , ........ , ............................................ S6 Table 4.6: Bivariate analysis of stunting status and children under- five in Effutu municipality: cultural practices and beliefs factors .............................................................................................. S9 Table 4.7 : Associations between selected exposure variables and Stunting: Socio-economic factors ............................................................................................................................................ 62 Table 4.8: Associations between selected exposure variables and Stunting: Child health seeking practices ......................................................................................................................................... 64 Table 4 9: Associations between selected exposure variables and Stunting: household practices66 IX University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Fl'8Illework .................................................................................................... 5 Figure 2: Nutritional status of under-five according to weight-of-age .......................................... 47 Figure 3: Nutritional status of under-five according to height-of-age (Stunting) .......................... 48 Figure 4: Nutritional status of under-five according to weight-of-height (Wasting) ..................... 49 Figure 5: Stunting status of children under-five according to their age ......................................... 50 University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ANC Ante Natal Clinic CI Confidence Interval DHS Demographic Health Survey ESPEN European Society for Clinical Nutrition Metabolism FAD Food and Agricultural Organization GSS Ghana Statistical Service HIV/AIDS Human Immune Virus/Acquire Immune Deficiency Syndrome IQ Intelligent Quotient NCHS National Center for Health Statistics PEM Protein Energy Malnutrition SES Socioeconomic Status SD Standard Deviation SDG Sustainable Development Goals UNICEF United Nations International Children Education Fund UNDP United Nations Development Programme USAID United States Agency International Development WMHD Winneba Municipal Health Directorate WAZ Weight for Age Z - score WHO World Health Organization xi University of Ghana http://ugspace.ug.edu.gh DEFI~ITION OF TERMS Anthropometry Measurement of body parts Child welfare clinics Integrated services that are provided to all children from birth to 5 years of age, with the purpose of monitoring their nutritional Child under 5 years A child under the age of 5 years refers to a young human being whose age ranges from 6 to 59 months from his date of birth Malnutrition Undernutrition and overnutrition. Overnutrition Overconsumption of nutrients and food to the point at which health is adversely affected developing develop into child. Parent Biological mother or the guardian of the under-five participant Undernutrition Stunting (low height for age), wasting (low weight for height), underweight (low weight for age) xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background For a healthy early childhood, adequate nutrition is essential to ensure proper organ fonnation and function, healthy growth, neurological and cognitive development and a strong immune system. For a good human development and economic growth, well- nourished populations who can think critically, learn new skills and contribute to their communities. Child malnutrition has impact on cognitive functions and is a contributor to poverty by impeding individuals' ability to lead productive lives (Hoseini, Moghadam, Saeidi, & Rezaei, 2013). Children's full physical and mental potentials can be prevented by malnutrition; prolonged malnourishment in children is known to result in: lower intellectual quotient (lQ), delay in their physical growth and motor development, deficient social skills and greater behavioural problems (Food and Agriculture Organization (FA O), 2016; Black, Morris & Jennifer, 2003). Children less than five years worldwide are known to be vulnerable and susceptible in many respects, especially on matters on health (FA O, 2016). Nutritional deficiencies and malnutrition generally affect children more than any other group (F AO, 2016). This trend is not unique to any particular nation; poor nutrition occurs in developing and developed nations, however, it is prevalent in some nations than others. As revealed in the WHO's report, developing countries has, of all the children under five years of age, 27% being underweight and this accounted for approximately 3.4 million deaths in year 2000 (World Health Organization (WHO), 2002). Malnutrition in children alone accounts to about 60 percent of mortality of children under-five in Sub-Saharan University of Ghana http://ugspace.ug.edu.gh Africa (SSA) countries (KandaIa, Emina, Nzita & Cappuccio, 2009).Unstable countries which have different kinds of conflicts, are fragile and vulnerable and have the highest numbers of malnutrition. (Kandala et aI., 2009). Countries that are like that need more interventions and actions to reduce malnutrition. Continuous malnutrition causes stunting and is very destructive to a child and has an effect on the family largely. This is because severely malnourish children can have impaired learning and psychological problems, which to a can be a source of worry to their parents (Hoseini et ai., 2013; Kandala et aI., 2009). Malnutrition contributes to the weakening ofa child's health, ability to learn, and later on livelihood and ability to have healthy children (World Vision Finland, 2013.) The Millennium Development Goal I (Target 2) aimed that between 1990 and 2015, the prevalence of underweight among children under five years, which is used as the measure of the proportion of people who suffer from hunger, is halved (Musa, Musa, Ali, & Musa, 2014). Despite various interventions, the burden of under-nutrition among under-five children has not changed much (Musa et aI., 2014). Undernutrition of children is a significant global health problem that contributes to childhood morbidity; suboptimal adult work capacity, mortality, harmed intellectual development and the risk of adulthood diseases. Children between the ages of 6 and 24 months are the most vulnerable to undernutrition (Health across the life span, 2012.). According to Kandala et al. (2009) malnutrition has been the cause of death for hundreds of thousands of children over the past 12 years. One key to meeting many other SDG targets is tackling malnutrition. Good nutrition is a signal the realization of people's rights to food and health. The reflection of Inequalities in the world is narrowed by good nutrition. Without it, it becomes difficult for people to University of Ghana http://ugspace.ug.edu.gh achieve their full potential. An improvement in the nutrition of people helps generates broad based economic growth, break the intergenerational cycle of poverty and leads to a host of benefits for countries, communities, families and individuals (Musa et aI., 2014). The foundation of human development and scaffolding needed to ensure it reaches full potential is provided by good nutrition. In short, good nutrition, is an essential driver of sustainable development. Malnutrition takes many forms in children: children who do not grow properly, those who suffer because of imbalanced diet, and those who are suffer from nutrition-related non- communicable diseases or are obese (Cederholm et al, 2015). Almost half of all countries encounter mUltiple serious burdens of malnutrition such as micronutrient deficiency, poor child growth, and adult overweight ( Cederholm et ai, 2015). In many cases, parents are not aware of the fact that the diet of their children should be changeable and that the importance of breast feeding should be fully understood (Cederholm et ai, 2015). Mothers suffering from malnutrition give birth to malnourished children (UNICEF, 2012). The breast milk is the best way to ensure the proper intake of food during the first few months after birth; the child is protected with adequate body nutrients that help to strength the immunity of the child (WHO, 2009). About 1.5 million lives in a year can be saved by breastfeeding (FAO, 2016). It is important that a child has diverse diet after breastfeeding. In many cases the unawareness of parents about healthy diet is the reason for malnutrition in children and not scarcity of food (WHO, 2009). Studies have shown that various factors account for malnutrition. According to FAO (2016) factors like extreme poverty, high mortality, high incidence of childhood diseases and poor infrastructure account for malnourished. Knowing specific determinant that account for University of Ghana http://ugspace.ug.edu.gh malnutrition. goes a long way in tackling the prevalence of mafnutrition in Ghana, which is a major motivation for this study. 1.2 Problem Statement Malnutrition has been a worldwide problem which has been addressed by various interventions but has not yielded much results. Malnutrition continues to be a killer for millions of children daily (FAO, 2016). Worldwide, approximately 165 million children under five years old are suffering from stunting, 52 million are experiencing wasting syndrome (hereafter referred to as wasting) and 101 million are underweight(Das, Salam, & Bhutta, 2016). One underlying factor in many diseases in children and adults such as hypertension and diabetes is malnutrition (Tette, Sifah, & Nartey, 2015) and in developing countries where it is particularly prevalent, it affects one out of every 3 preschool-age children. (UNICEF, 2011) In Ghana, malnutrition remains a challenge among children under five. According to the Ghana Statistical Service (GSS) (2010) children, under five accounts for 15% of the population and Demographic and Health Survey (DHS) (2014) report indicates that 19% of children under five are stunted, 5% severely stunted, 11% underweight, indicating chronic malnutrition. The central region where Efutu municipality is located has 34% of children under five stunted (DHS, 2014). Report available at the Winneba Municipal Health Directorate (WMHD) indicates that the municipality recorded 6000 cases of malnutrition in children under five between 2010 and 2015 (WMHD, 2016). This is relatively high for a fishing 4 University of Ghana http://ugspace.ug.edu.gh community since FAO report indicates that where there is abundance of protein, nutrition is relatively low (FAO Fisheries and Aquaculture, 2014). Several other factors may exist which contributes to malnourishment in such communities. There is however limited literature explaining this phenomenon. It has therefore become imperative to investigate the factors that might have accounted for this high prevalence of malnutrition in the municipality. 1.3 Conceptual Framework Malnutrition r Cultural Inadequate Maternal and Household practices and household food Child Health practices behaviour security practices Socio Economic Status Adopted From UNICEF 1998 Figure I: Conceptual Framework 5 University of Ghana http://ugspace.ug.edu.gh The conceptual frame work (figure 1) explains that malnutrition is influenced by several factors and a factor influences the other. Factors such as maternal socioeconomic status, maternal health seeking behaviour, cultural practices and household practices or determinants influence malnutrition. Socio-economic status, household size, parents knowledge on malnutrition, breastfeeding practices, number of meals taken by child per 24 hours, parent employment status, the marital status of parents and the number of children under five in a household. It is also influenced maternal and child health seeking practices (ANC attendance, child birth weight, HIV status of mother during pregnancy, immunization status, place of delivery of child and vitamin A supplementation), household practices (unsafe hygienic practices, poor sanitation, and inadequate access to quality water supply) may lead to unhealthy environment causing diseases. These diseases can lead to inadequate nutritional intake in the child causing malnutrition. Maternal socio economic status will also influence household food security which will determine dietary intake of the child causing malnutrition. On the other hand, cultural practices and believes( food taboos, customary systems of food sharing within the family, cultural attitudes towards various foods, food preparation methods and child rearing practices) may be influenced by maternal socio economic status and will influence the maternal health seeking behaviour causing malnutrition. 1.4 Justification Globally, especially in the developing countries, government agencies and researchers are working extensively to improve nutritional status among human being with special attention on children under five. High child mortality has malnutrition as major contributor 6 University of Ghana http://ugspace.ug.edu.gh which various countries and communities are trying hard to\feduce in other to produce '8 healthy population and to achieve goal 3 of the Sustainable Development Goals (SDG). Children are one of a country's greatest assets, hence providing optimum health to children in tenns of social, physical and intellectual development should therefore be a priority to everyone, There are several causes of malnutrition which are preventable in communities, hence results from research related to investigating the determinant of malnutrition can be very helpful in tackling malnutrition, The Efutu municipality is a fishing area and hence there is abundance of proteins. It is believed that malnourished children usually suffer from poor diet particularly in vitamins and proteins. It is therefore worth investigating what other factors could be causing malnutrition amongst a fishing community with abundance of proteins. This would help identify other tactors that affects malnourishment apart from the diet of children. The work would help expose other important factors that affects under-five malnutrition apart from food the children consume. This could help public health experts to consider other areas of tackling under-five malnutrition in Ghana and give them a holistic approach in dealing with the issue of malnutrition. Th\! findings of the study would infonn better planning, management and prevention of malnutrition (undernutrition) generally, and specifically to children less than five years to health experts and health policy advocators. It would unearth specific detenninants of the high cases of under-five malnutrition in the municipality and enable the WMHD and health related Non-Governmental Organizations (NGOs) to develop interventions to reduce malnutrition in the Effutu Municipality. 7 University of Ghana http://ugspace.ug.edu.gh The results of these finding would provide empirical evidence of how socio-economic factors, cultural factors, household practices and child healthcare seeking practices affects malnutrition of children under-five years. This can be used as literature for further research and filling some literature gaps in identifying causes of malnutrition of under-five especially in Ghana. 1.5 General Objectives Malnutrition defines both overnutrition and undernutrition but the focus of the study will be to assess the prevalence of undernutrition and the factors that determine the most prevalent form of undernutrition in children under five years in the Effutu Municipality. 1.5.1 Specific objectives I. To determine the association between socio-economic status and the most prevalent form of undernutrition in children under five years in the Efutu municipality . 2. To determine how household practices influence the most prevalent fonn of undernutrition in children less than five years in the Efutu municipality. 3. To determine how maternal and child healthcare practices influence the most prevalent form ofundemutrition in children under five in the Efutu municipality 4. To determine cultural beliefs and practices associated with the most prevalent form of undernutrition among children under five years in the Efutu municipality 8 University of Ghana http://ugspace.ug.edu.gh 1.6 Research Questions I. What is the relationship between socio- economic status and the most prevalent fonn of undernutrition in children under five years in the Effutu municipality? 2. How do household practices associate with the most prevalent form of undernutrition in children under five in the municipality? 3. How does maternal and child healthcare practices influence the most prevalent fonn of undernutrition in children under five the municipality? 4. What cultural beliefs and practices are associated with the most prevalent form of undernutrition among children under five years in the municipality? 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction The growth of children is recognized internationally as an essential public health indicator use to monitor health and nutritional status of populations (WHO, 2009). There is more frequent occurances of severe diarrhea and prone to many infectious diseases like meningitis, pneumonia and malaria for children who suffer from growth retardation due to poor diet. (WHO, 2009). The prevalence of malnutrition, which includes the determinants of malnutrition is a major source of problem for most countries in sub Saharan Africa (USAID. 2007; WHO, 2009), of which Ghana is not excluded. This study seeks to discover specific determinants of malnutrition in the Effutu Municipality. This chapter includes the review of important concepts and literature. 2.2. Concept of Malnutrition Literally, the term malnutrition refers to "bad nutrition" thus it integrates either 'too much' nutrition and under-nutrition. In relations to trends of malnutrition globally, developing countries including Ghana is more prevalent in the later. Malnutrition is defined as excess, deficiencies or imbalances in intake of protein, energy and other nutrients. This is the effect of being unable to meet the nutritional needs continually over a period of time. Child malnutrition continues to be one of the most 10 University of Ghana http://ugspace.ug.edu.gh dreaded health problems. Several studies have been conducted and are still being conducted, all in an attempt to solve the problem of malnutrition. Despite of all these efforts, each year, 4.6 million children under-five die due to malnutrition (WHO, 2009). The European Society of Clinical Nutrition and Metabolism (ESPEN) (2015), which is an European nutritional organization, explains that malnutrition resulting from diseaSe, ageing or extreme hunger can be dermed as "a state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat-free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease·'. According to the Swedish National Board of Health and Welfare, (2011) this particular nutrition deficiency as "a condition where a deficiency of energy, protein, and other nutrients causes measurable adverse effects on body composition, function or of a person's clinical outcome" The cognitive function of children is impacted by child malnutrition and contributes to poverty since it impedes individuals' ability to lead productive lives. Estimates show that malnutrition causes death of one out of three of children less than five years. (Liu et aI, 2012; Black et ai, 2008). Nutrition has increasingly been regarded as a very important contributor to social and economic development. The reduction of young child and infant malnutrition is necessary in achieving the Sustainable Development Goals- especially those regarding good health and wellbeing (SDG 3). Considering the impact early childhood nutrition can have on cognitive development and health, putting measures in place or optimal nutrition would also go a long way to aid in achieving (SDG 1) that is related to no poverty and also promote empowerment of women and gender equality, 11 University of Ghana http://ugspace.ug.edu.gh combact HNIAIDS and improve maternal health and. (UNICEF, WHO, & World Bank, 2012). 2.3 Prevalence of malnutrition Over the years different rate of malnutrition rates have been recorded, showing variations even in countries in the same region. In a study on children between 6 and 59 months old in Bam, Iran, prevalence of medium and acute underweight, medium and acute stunting; and medium and acute wasting were 15.2%, 8.9010, and 5.6% respectively (Yarparvar, Omidvar, Golestan, & Kalantari, 2006). According to the study carried out on under two-year old children in Golestan, Iran province prevalence of slight to acute underweight, slight to acute wasting and slight to acute stunting were 21.4%, 16.5%, and 31.4% respectively(Kabir, Keshtkar & Lashkar, 2006). In a study on 25-36 months old children under the care of Kerman, Iran rural health houses prevalence of underweight, wasting, and shortness was worked out 16.1%, 7.2%, and 15.6% respectively (Alavi-naien, Keyghobadi, Djazayery & Djazayery, 2003). Deshmukh, Dongre, Gupta and Garg (2007) carried out a study on 1497 children under six in the health-care center of Anganwadi in 2007 to investigate malnutrition on the basis of NCHS concluded that 53% of the children were underweight while 15% suffered from acute underweight. A similar study carried out in Aydin in Turkey, also had similar 12 University of Ghana http://ugspace.ug.edu.gh conclusions. The study by Ergin, Okyay, Atasoylu and Beser, (2007) shows that the prevalence of underweight was 4.8%, wasting as 8.2%, and nutritive stunting was 10.9%. In Bangladesh a study perfonned on malnutrition for children under-five revealed high numbers of underweight and delayed growth with 40% and 42% of under-five children being underweighted and stunted respectively (Siddiqi, Haque, & Goni, 2011). In another Asian country, Mongolia, a study conducted to investigate under- five children the nutritional status emphasised that, the numbers are no different, with underweight, wasting and emaciated children being 4.7%, 1.7%, and 15.6% respectively which is relatively lower than those of Bangladesh (Otgonjargal, Woodruff, Batjargal, Gereljargal, & Davaalkham, 2012). Another study carried out in south Asia, Belahara, and Dhankuta districts in Nepal on the prevalence of stunting, wasting and underweight also showed varying results, it concluded the prevalence of wasting ,stunting and underweight were 11 %, 37% , 27%, respectively (Gurung & Sapkota, 2010). A study that was done in a rural area of Nigeria by Senbanjo, Adeodu and Adejuyigbe, (2007) found that prevalence of underweight was 23.1%, wasting 9%, and that of nutritional stunting 26.7%. A study which was carried out in osun state in Nigeria, particularly a rural area, on the effect socio-economic factors can have on nutritional status of children concluded that the prevalence rates of stunting wasting, and underweight were 9 %, 26.7%, and 23.1 % respectively. Also in a similar study also carried out in Nigeria, on determinants and prevalence of malnutrition among Farming Households in Kwara State, Nigeria focusing on children under five, shows that 22.0%, 14.2% and 23.6%, of the sample popUlation were underweight, wasted and stunted respectively (Babatunde, 13 University of Ghana http://ugspace.ug.edu.gh Olagunju, Fakayode, & Sola-Ojo, 20 II). Another study in a different African country also showed varying prevalence rate. Bloss, Wainaina and Bailey (2010) carried out a study in Kenya on the predictors and prevalence of stunting, wasting and underweight among children who are 5 years and below. The study investigated the nutritional level, as it were, and health of children aged less than 5years and below by assessing children in three villages in western Kenya District of Siaya. The study was cross-sectional, and focusing on 175 children and 121 adults in July 2002, the result showed the prevalence as 30 percent for underweight, 47 percent for stunted, and 7 percent were wasted. The study also showed there was a higher likelihood of being underweight for children who had early child introduction. Children who are two years were had a higher risk of being stunted and underweight. Those who were not living with their biological parents had a higher likelihood of becoming stunted whiles those who had had all their vaccinations were protected against becoming stunted in growth. In the rural area of Kenya, a research that was conducted on pre-school children in western Kenya rural areas which showed that the number of underweight, wasting and stunting children were 20%, 4% and 30%, respectively (Kwena, et ai, 2003). In Southern Sudan, another African country, the prevalence of acute malnutrition of children less than five showed that approximately of every five children, one of them (22%) suffers from severe or moderate acute malnutrition (wasting). A similar conclusion was also recorded in another parts of Sudan and also concluded with similar results, There was high prevalence of malnutrition among children under five. About 35% suffered from either mild or 14 University of Ghana http://ugspace.ug.edu.gh moderate malnutrition and 27.5% were severely malnourished (USAID, 2007; Ola et aI., 2011) Mengistu, Alemu and Destaw (2013) carried a study with the aim of assessing the malnutrition prevalence and associated factors among under-five children. The scope was the Hidabu Abote district, North shewa, Oromia. A cross sectional community study was adopted by sampling 820 children aged 6-59 months in September, 2012. Anthropometric measurements and structured questionnaires were used. The result showed that 30.9%, 47.6% and 16.7% of children were underweight, stunted and wasted respectively. With stunting, the main associated factors discovered were child age, children who received butter as pre-lacteal feeding, family monthly income and family planning. Children who lived in households were found to be associated with Underweight. Wasting was associated with treatment of water in House Hold. 2.4 Type of malnutrition According to the WHO (2006), wasting, stunting and underweight are the commonly used comprehensive types of malnutrition by weight of height, height of age and weight of age indexes respectively. Growth retardation or chronic protein-energy malnutrition (PEM) which is also known as stunting is deficiency for protein and calories available to the tissues of the body. It is also the persistent and recurrent ill-health or inadequate intake of food over a long period of time. It should be noted that height-for-age index (stunting) has lower sensitivity to 15 University of Ghana http://ugspace.ug.edu.gh temporary food shortages, hence stunting regarded as the most reliable indicator (UNDP, 2007). Stunting is as a result of poor nutritional history, and it can be as result of dietary habits, such as long term intake of insufficient protein and energy. It can also be due to recurrent infection, poor feeding practices and low income. (Bruce, 2001). Wasting is also known as acute protein-energy malnutrition. It occurs when during the period immediately before a survey one fails to receive adequate nutrition as a result of recent episodes of diarrhoea or illness and acute food shortage. Wasting shows current or acute malnutrition which is as a result of inability of a person to gain weight or losing some of the gained weight. (Bruce, 2001). Being Underweight is part of Stunting and Wasting, hence it can either be due to sustained or acute malnutrition or even PEM. Stunting, wasting and underweight were defined as height-for-age, weight-for-height and weight-for- age of 2SD or more below respectively for the corresponding median of the reference popUlation; while severe stunting and severe wasting was defined as 3SD or more below the same median, respectively. 2.5 Measuring malnutrition in children under five years Assessment of nutritional status attempts to give an interpretation of what the body lacks, has in right amounts, or has in excess. It helps in the identification of people with nutritional deficiencies (malnourished or with malnutrition) and the type of deficiencies they have as well as obesity. Nutrition status can be determined by either one of the following method analysed below or a combination of them. Every nutritional assessment requires one or more of these for better interpretations since no single method provides an adequate assessment of nutritional 16 University of Ghana http://ugspace.ug.edu.gh status. They include anthropometry, biochemical analysis, clinical assessment, and dietary assessment (Maqbool et al., 2008). However, the best way to assess nutri.tion~l status is by combing all four methods; anthropometry, biochemical, clinical and dietary methods (Wasantwisut et al., 2007). These indicators help to measure long tenn nutritional imbalance and malnutrition. 2.S.1 Biochemical assessment Biochemical assessment is used to measure the nutrients in the body. It involves collection oflaboratory samples to assess nutritional status (various nutrients). Samples such as blood and urine are taken from the individual and the levels of biological markers in the body are assessed. These makers are used to detennine levels of nutrients in the body «Maqbool et al.,2008). 2.5.2 Dietary assessment Dietary assessment is used to measure dietary intake and feeding ability. It can be used to assess both nutrient and food intake. Methods use includes individual dietary assessments, food frequency questionnaires, household survey methods, and simple food list. It provides information about the amount, and quality of food consumed and also eating patterns and behaviours of the family (Maqbool et al., 2008). 2.5.3 Clinical assessment This method unearths the signs of malnutrition on the body of the individual. These signs can be seen by close observation of the individual. According to Maqbool et al. (2008), it 17 University of Ghana http://ugspace.ug.edu.gh involves the close examination of the physical body such as skin, hair and teeth. It is used to identify evidence of specific nutritional deficiencies. Clinical assessments require little expertise. 2.5.4 Anthropometry A very useful tool for monitoring nutritional assessment and growth is Anthropometry. It has been used for a long time to diagnose and grade malnutrition (Duggan, 2010). Duggan (2010) describes it as a simple tool for nutritional assessment of individuals because of its objectivity and relatively low technology required in its usage. Anthropometric measurements is well known and widely used indicators for nutritional status in a community. Anthropometric measurement involves taking body measurements such as height,weight, Mid-Upper Arm circumference and comparing them to the WHO growth standards (Duggan, 20 I 0). These body measurements are used to formulate indicators that give some infonnation on children nutritional status. There are three main anthropometric Indices used in children nutritional status assessment. They are weight-for-height, height- for age and weight -for-age. Height-for-age: This malnutrition index gives an indication of linear growth retardation. A height-of-age index which is below minus two standard deviations (-2SD) from the median of the reference population, are regarded as being short for their age (stunted). If a child falls below three standard deviations (-3SD) from the reference popUlation median, he/she are considered severely stunted. Factors such as inadequate nutrition over a long period of time or recurrent or chronic illness can cause stunting in children. It reflects chronic malnutrition (malnutrition over a long period of time) which is due to prolonged inadequate nutrient intake (GSS, 2011). Height-forage, therefore shows the outcome of 18 University of Ghana http://ugspace.ug.edu.gh under nutrition over a sustained period, and does not really change with the season of data. Weight-for-age: This assesses the weight of a child for his age and is a measure of long and short term malnutrition (Prentice et al., 2008).Children whose weight-for-height measures are below minus two standard deviations (-2SD) from the median of reference popUlation are considered underweight for their age while those with measures below minus three standard deviation (-3SD) from the reference popUlation are severely underweight (GSS, 2011). Weight-for-height: This is a measure of body mass (weight) in relation to body length. Below minus two standard deviations (-2SD) from the median of the reference population, a child is considered too thin for their height (wasted). Those children with measures below minus three (-3SD) from the reference popUlation are considered severely wasted which is a measure of acute malnutrition (malnutrition of a short period of time) that is recent nutritional deficiency (Prentice et ai., 2008). This indicator highlights significant changes associated with the availability of food or disease prevalence (GSS, 2011). 2.6 Determinants of Malnutrition in under fives Malnutrition in children is determined by mUltiple and interrelated factors. Food related factors are just one aspect of the mUltiple determinants of malnutrition (lram& Butt, 2006). it is difficult to point to a particular causes of malnutrition, since there are various determinant, and most of them are intertwine with each other and are hierarchically related, however, the most common of these determinants are poor diet and disease which are also 19 University of Ghana http://ugspace.ug.edu.gh influenced by other factors, like; household food security, maternal! child caring practices and access to health services and healthy environment (Muller & Krawinkel, 2005). These factors in turn are also influenced by the basic socio-economic and political conditions (Muller & Krawinkel, 2005). Studies have shown that malnutrition is usually related to food security, care practises, and the health environment at the household level, which are also influenced by the socioeconomic and demographic situation of households, communities and public health policies (Moradi & Klasen, 2000; Caputo, Roraita, Klasen & Pigeot, 2003). Factors like acute deprivation ofliving facilities, recent droughts, poverty, and unfavourable nutrition of children have been discovered to be factors that account for the prevalence of malnutrition (Alavi-naien, Keyghobadi, Djazayery & Djazayery, 2003; Jafarinia, Faraz, Akhoundzadeh, & Gahgaei, 2003; Nojomi, Kafashi, & Najmabadi, 2003). Over the years various studies have found, illiteracy and low education of parents having an mlluence on the malnutrition of children, and it is established that this leads to varying malnutrition prevalence (Jafarinia, Faraz, Akhoundzadeh & Gahgaei, 2003; Yarparvar, Omidvar, Golestan & Kalantari, 2006; Deshmukh, Dongre, Gupta & Garg, 2007; Senbanjo, Adeodu & Adejuyigbe, 2007; AI-Hashem, 2008). Higher knowledge ofliterate parents and higher income of families with higher education as compared to illiterate ones regarding children's nutrition accounts for varying rate of prevalence (Yarparvar et aI., 2006; Deshmukh et aI., 2007; Senbanjo et aI., 2007; AI-Hashem, 2008). Higher income results in higher probability of accessing quality health care, education, and nutritional facilities which leads to lower malnutrition, basically knowledge with enough income can improve the nutritional status of a family (Jafarinia et aI., 2003; Yarparvar et aI., 2006; Dcshmukh et aI., 2007; Senbanjo et aI., 2007; AI-Hashem, 2008). 20 University of Ghana http://ugspace.ug.edu.gh According to (Ahmed, Elkhalifa & Elnasikh, 2011), factors like poor sanitary conditions and inadequate food intake increases the prevalence of malnutrition. Ahmed et a1. (20 II ), shows that Mother's education was found to be the strongest factor associated with malnutrition among the children under 5 years of age. A research carried out on malnutrition among under five children in Bangladesh revealed that household economic status, mother's educational status, father's educational status, mother's antenatal visit (s), mother's age at birth and mother's BMI are the most significant factor/determinants of child's malnutrition (Siddiqi., Haque & Goni, 2011) A study focusing specifically on the influence of socio-economic factors on nutritional status, looked at rural children in a Osun state community in Nigeria, revealed that mothers whose education is below secondary had their children having one and half to two times the rate of prevalence of stunting. Those mothers who had post-secondary education had their children more often affected by wasting compared to those mothers who were less educated. Paternal education level did not have a consistent pattern or trend with wasting or stunting. High prevalence of wasting had associated low maternal income and overcrowding. The source of drinking water and or social class had no association with malnutrition (Gurung & Sapkota, 2010). Malnutrition was significantly associated with education and body mass index of mother, gender, age of child, access to clean water, calorie intake of the households and presence of toilet in the households by a study that was conducted on the prevalence and 21 University of Ghana http://ugspace.ug.edu.gh detenninants of malnutrition among Under-five Children in Kwara State, Nigeria on Farming Households (Babatunde, Olagunju, Fakayode, & Sola-Ojo, 2011). In a similar study at Beta-Israel, it was revealed that under-five malnutrition was mainly contributed by factors such as child's age, sex of the child, diarrhoea episode, duration of breastfeeding, deprivation of colostrums, pre-lacteal feeds, age of introduction of complementary feeding and method of feeding, type of food, (Asres & Eidelman, 2011). 2.7 Socioeconomic Factors and Undernutrition Globally, undernutrition in children is highly prevalent and remains a big challenge. According to estimates by the United Nations Food and Agriculture Organization (FAO), 11.11% of world populations were suffering from chronic undernourishment in 2012-2014 (FAO, 2014). Children are the most visible victims of undernutrition. United Nations Children's Fund (UNICEF) reports that 25% and 8% of under-five year old children were estimated to be stunted and wasted respectively with an estimated 6·3 million live born children worldwide dying before age 5 years, in 2013 because of undernutrition (UNICEF et aI., 2014b). This shows that almost half of all deaths in children under 5 can be attributable to under nutrition. According to Ethiopian demographic and health survey (DHS) report, nationally 40%, 25% and 9010 of children under age five were stunted, underweight and wasted respectively in 2014 (CSA, 2014) with the prevalence of overweight or obese children not being more than 3%. This high prevalence of under-nutrition of children exerts impacts economically and socially on the country. Various studies in different or the same countries may come out with different results over the importance of the determinants behind children's nutrition. Their estimates may differ 22 University of Ghana http://ugspace.ug.edu.gh depending on various variables including the type of the data and the methodology. In Ethiopia, studies by Tesfaye (2009) and Alemu et al. (201:1) found out that household wealth or income is an important determinant of child nutritional and health status. A study conducted by Kamiya (2011) in Lao using multilevel mixed linear model to estimate a health production function showed that educational attainment of mothers do not exert any positive impact on childhood nutrition (height-for age, weight-for -age and weight-for height) In a study by Mostafa (2011) in Bangladesh and employing data from the 2007 Bangladesh Demographic and Health Survey, a Cross-sectional and multinomial logistic regression analyses was done on moderate and severe stunting over normal among the children looking at how socio-demographic variables affect them. Findings showed of all the children used in the study, over two-fifths of the children were stunted, of which 15.1% were severely stunted and 26.3% were moderately stunted. Multivariate multinomial logistic regression analysis revealed that children of a thinner mother had significantly increased risk of severe stunting and moderate stunting over normal. Child's age region, father's education, birth order of children, toilet facilities and wealth index were also important determinants of children's nutritional status. Maternal age at birth has been associated with malnutrition among under-five year old children. It was found out in Bangladesh that children whose mothers were less than 20 years at the time of their birth were 1.22 times more likely to be stunted, wasted and underweight compared to children whose mothers were 20 years and above at birth their birth (Nure., Nuruzzaman and Goni, 201 I). 23 University of Ghana http://ugspace.ug.edu.gh 2.8 Household practices aud Undernutrition A study was conducted by Babatunde, Olagunju, Fakayode, and Sola-Ojo,(2011) to examined the prevalence and determinants ofmalnutritionl27 among under-five children in Kwara State, Nigeria. Results revealed from descriptive and regression analyses used to analyze anthropometries that 23.6%, 22.0% and 14.2% oft he sample children were stunted, underweight and wasted respectively. In addition, regression analysis showed that the significant detenninants of malnutrition included gender and age of child, education and body mass index of mother, calorie intake of the households, access to clean water and presence of toilet facility in the households in addition to mother's variables (education and nutrition. Again, the results showed that children from richer households were less malnourished than those from poorer households which underscores the importance of household income in child nutritional status. Furthennore, a study conducted on malnutrition among under five childrenin Bangladesh revealed that household economic status, mother"seducation, father"s education, mother"s antenatal visit,mother"s ageat birth and mother"s 8MI are the most significant factor/detenninants of child"s malnutrition Siddiqi ,Haque Goni (20 II ).Low maternal income and overcrowding were associated with higher prevalence of wasting. Low maternal income and overcrowding were associated with higher prevalence of wasting. However, no association was found between the source of drinking water or social class and malnutrition. Sapkota ,Gurung (2008). 24 University of Ghana http://ugspace.ug.edu.gh A study by Hussin,(201O) on the detenninants of malnutrition among children in rural Kelantanin Malaysia,the results demonstrated that environinental construct comprising factors that included total household income, total expenditure, number of rooms in the house as well as socioeconomic status had a significant effect on malnutrition. Neither do biological or behavioural constructs had significant effects on malnutrition. 2.9 Maternal and Child Health Practices and Undernutrition Antenatal care refers to the care rendered to a pregnant woman from conception to the beginning of labor. Ideally, the midwife provides an individualized care to the woman and her family by providing guidelines to the woman to enable her make choices about her care that are well-informed. (Fraser, Brockert & Ward, 2006). According to Tjukurpa (2008) antenatal care is also intended to improve the health of the pregnant woman and her baby, since it allows for continuous monitoring of the pregnancy so that any problems can be seen and corrected promptly. The primary objective of antenatal care is to interact with pregnant women, identify and manage known and potential risks and complications. WHO (2014) proposed new essential ANC interventions (Focused Antenatal Care). This aims to provide at least over four visits of antenatal care at specified intervals, for healthy mothers with no underlying complications. This new model of the ANC was defined by WHO based on four goal-oriented visits. The maximum number of ANC visits for areas where there are limited resource depends on effectiveness, costs and other barriers to ANC availability. The focused antenatal care (FANC) was implemented to solve some of the barriers associated with the old system, such as ignorance, long waiting time, repetition of 2S University of Ghana http://ugspace.ug.edu.gh topics in group counseling and clients seen by different providers. The benefits of FA NC include: early recognition and correction of complications; promotion of health and reduce disease prevalence; detection of known medical problems of mothers; and also improving preparedness for birth and readiness for complications. (WHO, 2014). This new sphere to ANC is more geared towards quality of care, not the quantity. With regards to women with normal pregnancies, the recommendation is four antenatal visits. The main aim of the FA NC is to aid women go through pregnancy without problems through: identification of pre-existing health conditions; early recognition and correction of complications; promotion of health and lessen disease prevalence; early detection of known medical problems of mothers; and also improving preparedness for birth and readiness for complications (WHO, 2014). The schedule of activities and visits of the FANC include the following: First visit up to 16 weeks: confirmation of pregnancy and EDD, classify women for basic ANC, four visits or more. Screen for STIs, anemia, preventive measures, as well as treatment. Schedule a birth and emergency plan. Counseling on danger signs and how to promote health and prevent diseases. Second visit 24-28 weeks: assess maternal and fetal health and exclude PIH and anemia. Give preventive measures such as IT, SP, iron, and folate. Review and modify birth and emergency schedule I needed. Third visit 32 weeks: Assess maternal and fetal well-being; exclude PIH, anemia, and multiple pregnancies. Give preventive measures such as IT, SP, iron, and folate. Review and modify birth and emergency plan. Counsel the client on your fmdings. 26 University of Ghana http://ugspace.ug.edu.gh Fourth visit 36-38 weeks: assessment of maternal and, fetal well-being, exclude PIH, anemia, multiple pregnancy and malpresentation. Give preventive measUres. Review and modify birth and emergency plan with the client and relative where possible. Advice and counsel client on your findings (WHO, 2014). How far antenatal care covers in a particular setting indicates the accessibility and utilization of care during pregnancy. It reveals the number or proportion of women who receive care at least once during pregnancy annually. ANC coverage has reduced smoothly from 98.2% in2011 through 92.2% in 2012 to 90.8% in 2013and 87% in 2014 (GSS, 2015). As the ANC coverage decrease there is likelihood that the health status of the pregnant women and their unborn babies will be reduce. This is due to the fact that the pregnant women who are not attending the ANC will not have information about their nutritional requirements and the drugs they need to take improve their nutritional status to support the growth of the fetus in their uterus. This could lead to increase in the prevalence of malnutrition among children under five in the country. In accordance with this, GHS (2015) reported that the prevalence of severe underweight among children between 0-11 months increased from 0.01 to 1.9 in 2010 and 2014 respectively. Statistics on ANC coverage in 2014 showed that, although there have been sustained decrease over the last three years, pregnant women making at least four visits to the hospital spiked over the same period as shown in figures I and 3 respectively. This is important because it shows that more pregnant women's concerns, at least the basic ones, were met; such as Intermittent Preventive Treatment of malaria in pregnancy, Prevention of Mother- to Child Transmission of HIV and nutrition counseling among others (GSS, 2015). 27 University of Ghana http://ugspace.ug.edu.gh The National Reproductive Health Policy stipulates that pregnant women who have no complications should make not less than four visits to the antenatal clinic. The ratio of pregnant women who actually made the required visits within the year (2015), increased from 72.7% in 2013 to 76%. Generally, most clients, are not able to make the four visits because of late registration; since this limits accessibility to all the needed antenatal interventions (GSS, 2015). Starting antenatal care early as well as close monitoring of clients is important for early detection and correction of anaemia since it is known to increase the risk of pre-term labour, low birth weight and perinatal death. The overall prevalence of anaemia among pregnant women increased from 25.8% in 2010 to 31.8% in 2014 and anaemia at 36 weeks, 24.2% in 2010 to 26.8% in 2014 (GSS, 2015). Daily oral iron supplementation, at a 60 to 120 mg dosage is given to correct most of mild-to moderate anaemia. During antenatal care service. pregnant women are counselled to eat nutritious diet and iron supplements are also given to improve their nutritional status and hemoglobin level. The level of mothers nutritional status have great influence on the health of the fetus in the uterus which also determine the growth pattern of the child after delivery (11,13,14). According to Brantuo et al. (2009), Ghana Health Service (2008) and Bryce, Coitinho, Damton-Hill. Pelletier, and Pinstrup-Andersen (2008) nutritional counseling at health facilities is a major intervention to improve the health status of the mother and the child. Women who have inadequate antenatal and postnatal visits are more likely to have malnourished children (Tette, Sifah & Nartey, 2015). 28 University of Ghana http://ugspace.ug.edu.gh 2.10 Child Welfare Services and Malnutrition Child welfare clinic (CWC) is a place where children under school going age are sent for examination and for their growth and development to be monitored and to be vaccinated. It is also a place where babies and malnourished children are given health care. Child welfare clinics focuses on all families with children in issues related to child health. These clinics enable the child grow and develop well and also maintain their health. A child welfare clinic helps families to understand that healthy ways of life are important for a child from the early years. A child welfare clinic also provides guidelines to families in making good health choices. The activities that carried out at the CWC are registration, weighing, immunization, examination of children from head to toe, counseling of mothers, treatment of minor ailml!nt, referrals, health education talks, distribution of nutrients, family planning and other reproductive health services, nutritional rehabilitation and report writing. These activities help in early identification of childhood conditions such as malnutrition and appropriate interventions given (GSS, 2015). According to GSS (2015) trend in CWC has remained consistent over the years for all age ranges. Children 0-11 months continue to record the highest proportion of registrants, and this has been linked to the fact that the majority of vaccinations, immunizations and supplementations are given within this age range. However, the proportion of children registered at child welfare clinics reduced by almost 50% for the 12-23 months age range, and is lowest for children 24- 59 months as shown in figure 50. These low proportions 29 University of Ghana http://ugspace.ug.edu.gh result from drop outs in attending child welfare clinics after completing vaccinations (GSS, 2015). Immunization is the strategy used to eliminate vaccine preventable diseases. In a study conducted by Samaru, Alamu, Atawodi and Edokpayi (2011) at Ahmadu Bello University revealed that rates of childhood immunization and vitamin supplementation were 92-97% and analysis of anthropometric data indicates that most of the infants have a moderate weight and height for their age. From the findings, the children were adequately immunized against many vaccine preventable diseases (92-97%). In the findings 95% of the infants have been given vitamin A and the care givers know the consequences oflack of vitamin A which mean there is adequate intake of micronutrient. Anthropometric data is used for the assessment of nutritional status of children below five years. According to Samaru et al (2011) the anthropometric data shows that the male infant status has a normal weight of 52.10% and normal length 43.50%. The female nutritional status has a normal weight of 64.70% and normal length of47.00%. 2.11 Cultural Practices and Undernutrition Cultural practices are vital in communities and they influence dietary practices globally. This influence can be on men, women and children but children under five are the most vulnerable groups who sutTer undernutrition among these people (Cohen 2009; Sucher & Kittler, 2007). In a study by Johnson et al,(2011) it came out that there is a relationship between culture and dietary habits of people despite where they fmd themselves. These intend influences 30 University of Ghana http://ugspace.ug.edu.gh what they consume and what they don't consume. Various studies have also indicated that cultural beliefs be an indicator of people see as important diets, less important diets as well as bad diets that should not be eaten ( Kittler, Sucher & Nelms,2011) and people will consume what they consider as valuable or important. Another studies conducted by Lyana and Manimbulu (2014), and Trefry, Parkins and Cundill (2014), highlights the fact that diets adopted by individuals are influenced by culture and consequently the their household food security status. This can therefore have consequences on their health and nutritional status whether young or old. Traditional practices usually impede seeking early treatment and are dangerous to health. It account for the great majority of mortality. Among the major reasons for the infants' mortality rate and children being 10-15 times as high in the developed world is due to the lack of good medical care and malnutrition specifically undernutrition. Accordingly in Turkey, 17.6% children aged 0-5 groups are undernourished and 24% undernourished to the extent that they will need treatment in various health facilities and they are underweight. These reflect that there are several problems in the nutritional practices with regards infants in the country. The data indicates that 97% of infants are breastfed for just a while; 54% of them usually start to be breastfed within the frrst hour after birth while 16% of them are never breastfed in the first 24 hours. Unfortunately, mothers who don't breastfeed, especially in rural areas, are regarded as evil mothers. (Giil E & Ergiin, 2013). 31 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Study Design The study was a cross-sectional study to assess the determinants of undernutrition in the Effutu Municipality. 3.2 Study Area 3.2.1 Geography/Background oftbe ArealEffutu Municipal Assembly The Effutu Municipal Assembly is one of the 216 Administrative Districts in Ghana and one of the 20 districts in the Central Region. Currently, the Municipality has been divided into four sub-areas called sub-Municipalities with 17 Electoral areas; they are as shown in the table below; The land area of the Municipality is 64 square kilometers. It is bounded on the North by Gomoa East, on the South by the Gulf of Guinea, on the East by Gomoa East and on the West by Gomoa West. Winneba with a population of 40,017 is the only urban settlement. Other big settlements in the Municipality are Sankor, Gyangyenadze, Nsuekyir, Ateitu, Osubonpanyin and Woarabeba. All the Sub- districts were used for the study. 32 University of Ghana http://ugspace.ug.edu.gh Table 3.1: Distribution oftbe 17 electoral areas in tbe Effutu Municipality Sub district Electoral Areas No. I Essuekyir/Gyahadze EssuekyirGyahadze - - - - 2 Kojo Beedu 1. KojoBeedu North North/Low Cost 2. Low Cost 3 Winneba East 1. KojoBeedu South 2. Abasraba North/Zongo, DonkunyamuiObrawogum, 3. Dwoma, 4. SankorlDon Bosco 5. OsakamIF etteh 4 Winneba West 1. Abasraba South 2. DomeabralPolice Training Depot 3. DomeabraOtutuase i 4. Penkye : 5. AlataKokwado 6. Ponkoekyir 7. Eyipey 8. Mburabamu 9. Ndaama Source: Effutu Munici! fJ at Assemb ly 33 University of Ghana http://ugspace.ug.edu.gh 3.2.2 Geographical Features and Climate The municipality is basically a low lying area drained by a few rivers and streams, notably Ayensu and Ntarkufa. A few lagoons are also found along the coast, the biggest being Muni lagoon. near Winneba and into which flows river Ntarkufa. The area experiences 2 rainfall seasons. The main season occurs from April to July and the minor one from September to November. The periods from December to March and August to early September are always dry. Temperatures are generally mild, ranging between 24°C and 28°C the coastline is usually very windy. The vegetation is predominantly savannah. 3.2.3 Population The Municipality has a total popUlation of 82,470 for the year 2016. The population was projected from the 2010 popUlation census with a growth rate is 3.2% per annum (GSS, 2010). The Municipality has 12 Health institutions. These are two government hospitals, one health centre, four CHPS zones, two private hospitals, one Quasi-Government Clinic, one CHAG hospital and one private maternity home (Bethel Maternity Home). The Winneba municipal hospital serves as the referral center for all the other health facilities and surrounding health facilities. 34 University of Ghana http://ugspace.ug.edu.gh 3.2.4 Economic Activities Agriculture Economic activities in the area are dominated by agriculture, with farming falling slightly behind fishing. The main staple food crops cultivated are cassava, maize and vegetables. Winneba is the only marketing centre Industries A few small scale industries abound in the municipality. These include Ekern Art Pottery, Mbroh Ceramics, Winneba Oil Mills, Saw Mills, a salt Factory, Poultry Farms, Livestock rearing (cattle, pigs, sheep and goats) and a Chemical Factory. 3.2.5 Social Infrastructure Water Majority of the people living within the area have access to pipe borne water. Other sources of drinking water include bore holes, wells and rivers/stream. 3.2.5 Environmental Health and Sanitation Facilities The mission of the Environmental Health sanitation unit of the municipality is to promote and protect public health by ensuring the provision of basic requirements for a healthy and pleasant physical environment in collaboration with other stakeholders 3.3 Study Population The study population for this study were children between the ages of 6-59 months and their caregivers in Effutu Municipality. 3S University of Ghana http://ugspace.ug.edu.gh 3.4 Sampling 3.4.1 Sample Size Sample size estimation gotten was done from the target population .T he fonnula for estimating the sample size is n=Z2pq/d2 (Charan & Biswas, 2013) n = Sample size Z = 1.96, that is the value of Z corresponding to the 95% confidence level p = 0.35 (35%) malnutrition prevalence rate of children under 5 years of 35% q = I-p (1-0.35=0.65) d = 0.05 (5% error margin) DHS (2014) report indicated that 19% of children under five are stunted, 5% severely stunted. II % underweight The P. is the estimate of malnutrition among the target population according to GDHS (2014) 19% stunted, 5% severely stunted, and 11% underweight = 35% n = 1.962 x 0.35 (0.65)/0.052 n = 3.8416 x 0.2275= 0.873964/0.0025 n = 349.5856 n=350 The sample size for the study will be 350. 36 University of Ghana http://ugspace.ug.edu.gh 3.4.2 Sampling Method Simple random sampling The community is divided into four sub-districts namely Essuekyir, Gyahadze, Kojo- Beedu north-Low Cost, South East Winneba and south west Winneba respectively. A simple random sampling was used to select two communities from each sub-district. The data was collected from all the four sub-districts. The communities were numbered. The numbers were written on a piece of paper. Each paper was folded and put in a box. The researcher picked from the box. Any number that was picked, the community with that number was selected. Choosing the households was done by modified random walk. Respondents were chosen based on the population of the chosen communities. 3.4.3 Modified random walk The conununities do not have a proper housing list therefore, the modified random walk was used to select the households from housing units. According to Manu (2011), the modified random walk can be used in the absence of a proper housing list. In doing the modified random walk, key land marks in the community such as churches, private and public schools, the mosque, the CHPS compound, the information centre and the community taxi rank were listed. One of the landmarks was randomly selected and the first house closest to the landmark was chosen as the first house from which subjects were selected. 37 University of Ghana http://ugspace.ug.edu.gh Dwelling place units were used for identification of households. Dwelling place refer to a specific area occupied by a particular household and therefore need not necessarily be the same as a house (GSS, 2010). Children under-five years were identified by asking the residents of the chosen communities. All children aged 6-59 months from the different households who were eligible to be part of the study were used. If in a household, where mothers have more than one child less than five years; one of the children was randomly selected to be part of the study. 3.5 Data CoUection Technique/Method and Tools 3.5.1 Anthropometric Technique Anthropometric measures (weight and height) were all taken and recorded on the questionnaires. All children were in only underwear or light clothing during measurements. The measurements were taken using WHO standard procedure. Each measurement was taken by a field skilled worker. The scales were checked for accuracy by before taken to the field. Length measurement: Recumbent length was taken for children below 24 months. It was measured with the infantometer. The child was placed on the infantometer gently with hislher head against the head board. The child's head was positioned firmly in place by cupping the ears. It was ensured that the vertical line formed from the ear canal to the lower border of the eye socket the child was at right angle to the horizontal board. This is referred to as the Frankfort vertical plane. While another fieldworker ensured that the child's trunk was straight and flat on the board. The foot board was pushed gradually to the feet of the 38 University of Ghana http://ugspace.ug.edu.gh child with the left hand whiles the right was used to hold the legs together in place. The length was recorded on the questionnaire. Height was taken for children the rest of the children (above 24 months) with a stadiometer. The child was asked to stand on the footboard with the back of the head against the back board. This was to ensure that the back of their head, shoulder blade, back, buttocks calf and their heel touched the back board of the stadiometer. The head was positioned such that the horizontal line connecting the upper ear opening and lower edge socket of the eye ball run parallel to the base board. This is the formation of the Frankfort horizontal plane. The child's tummy was pushed in gently to help the child to stand straight and the head board pressed ftrmly on the top of the head. The reading was then taken and recorded on the questionnaire. Standing height and length were recorded to the nearest O.lcm. Weight measurement: For children below 24 months, their mothers were made to stand on the scale without footwear and all heavy objects she was holding or adorned taken from her. The scale was then tarred and the child handed to the mother on the scale for the weight of the child to be taken. For children above 24 months, they stood by themselves on the scale and their feet positioned slightly apart. They were instructed to stand still and the reading taken and recorded on the questionnaire. Weight measurements were taken to the nearest O.lkg 39 University of Ghana http://ugspace.ug.edu.gh 3.5.2 Questionnaire A questionnaire constructed by the researcher was used to collect the data from the respondents. The questionnaire consisted of a list of items related to the topic, research questions and the objectives of the study. 3.6 Quality Control To ensure quality outcome of the study the following were done: I. Research assistants with the adequate knowledge in data collection for nutrition surveys were recruited and trained for the study. 2. Data collection tools were critically analyzed with my supervisor and remove all errors and ambiguity. 3. The questionnaire was studied carefully with my supervisor to eliminate ambiguous items. 4. The data was collected and analyzed by the researcher, research assistant, trained data analyst and data entry personnel. 5. Data that was collected on daily basis was assessed to ensure that all information had been properly collected and the questionnaires properly filled. 6. Data cleaning and analysis was done with SPSS 20software. 7. Each questionnaire after entry was separated and an indication made on it. 40 University of Ghana http://ugspace.ug.edu.gh 3.7 Variables 3.7.1 Dependent Variable The dependent variable used in the in the study of undernutrition status of children between the ages of 6-59 months in the community was stunting. 3.7.2 Independent Variable Economic Factors (Type of community, occupation of mother, occupation of father, household income and highest level of education for mother) Maternal and Child health Practices ( Number of ante natal care received during pregnancy, how often the child gets sick, frequent disease the child suffers from, what support is given to child when sick) Household Practices (Duration for exclusive breastfeeding, number of times the child feeds in a day. main source of drinking water, How food is preferred to be served, how refuse is stored, toilet facility available) Cultural practices (what types of foods the child is allowed to eat, what type of foods the child is not allowed to eat, why children are not allowed to eat some food and presence or absence of taboo foods). 3.8 Pre-Testing I Pilot Study The structured questionnaire and anthropometric instruments were pretested at Apam, a town close to Winneba. The tools were fine-tuned before going to the field for final study. 41 University of Ghana http://ugspace.ug.edu.gh 3.9 Data management and analysis Of all 350 sampled people, 350 was obtained. Data was then entered into ,SPSS 20 and cleaned by running frequencies of all the variables to check for incorrect entries. This was double checked with the raw data and the needed corrections done. Incomplete entries were traced back to the respondents for correction. Data was subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS) version 20 and WHO Anthro Software version 3.2.1. Data collected on demographic characteristics were presented in tables as frequencies and percentages. Percentages were calculated from the frequency of responses for the items and put into tables. For the anthropometric data obtained, the Height-for-age, (HlA), Weight-for-age (W/A) and Weight-for-Height (WIH) of the subjects was compared to the WHO child growth standards (WHO, 2006) The general prevalence of malnutrition was assessed by the Z score so that those who fall below -2 Z score for height of age, weight of height and weight of age were classified as stunted, wasted and underweight. Those who fall above +2 Z-scores for weight of age were classified as overweight. Association between undernutrition and selected characteristics was limited to the most prevalent undernutrition, specifically stunting using chi -square test at 95% significant level. The study employed logistic regression to assess the statistical association between stunting of children under five years and those variables that were significant in the bivariate analysis at 95% significant levels. Crude and adjusted odds ratios, and p-values were obtained and statistical significance determined at 95% confidence intervals (CI). 42 University of Ghana http://ugspace.ug.edu.gh 3.10 Ethical Consideration! Issues Approval was obtained from Ghana Health Service (GHS) I;:thical Review Committee. Initial consultations was done with the Municipal Director of Health Services, Municipal Chief Executive, community leaders and assembly men of the selected suburbs, and management at the hospital and letter followed up to conflI1llli the study. Written infonned consent was obtained from mothers or guardians of the children, and consent was sort from the mothers or guardians before the children were used for the study. Explanation of the study to the participants was done in a language they understand to gain their maximum cooperation. Purpose and objective of the study was explained to the participants. They will were also informed that there will be no financial or material reward for participating, except that their participation will genemte knowledge for taking measures to prevent undernutrition in the municipality and the country at large. Again, they were told that participation is voluntary and as such they could withdmw at any time if they feel like and without any consequences to them. For anonymity, codes were given to participants instead of their names. During data. collection, all materials related to the study was Locked up in a safe location. 43 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the analysis of the data obtained from the research and their interpretations. Out of the total of 350 sample size, 350 responded to the questionnaire. Data from these 350 respondents were analysed and compared on measures relating to economic factors, child health seeking practices, household practices and cultural practices and believes of undernutrition of children under five years. The work is organised into sections, the first section considered the demographic information of the sample used for the study. The second section considered the general prevalence of malnutrition of children under five years in Effutu municipality. The third section looks at relationship between socio- economic factors and the stunting status of children. The section that followed considered how household practices associate with stunting in children. The next section looked at how child health seeking practices associates stunting in children. The section that follows looks at how cultural beliefs and practices associate with stunting. The final section considered the extent to which those socio-economic factors, child health seeking practices, house hold practices and cultural practices that have significant association with stunting affects stunting. 44 University of Ghana http://ugspace.ug.edu.gh 4.1 Cbaracteristics and socio-demograpbic information of Children under five years Table 4.1: Cbaracteristics and socio-demographic information of Children under five years Options Frequency(N=350) Percent Age of Child (Months) 0-5 12 3.4 6-11 76 21.7 12-23 114 32.6 24-35 60 17.1 35-47 50 14.3 48-59 38 10.9 Sex ofCbild Female 172 49.1 Male 178 50.9 Age of Mother less than 20 years 89 25.4 20-34 202 57.7 35-49Yrs 59 16.9 Religion of Mother Christian 237 67.7 Muslim 105 30 Traditionalist 8 2.3 Marital Status of Mother Single 124 35.4 Married 121 Separated 34.6 19 5.4 Divorced 2 Widowed 0.6 5 Cohabiting 1.4 79 22.6 Number of Children by Motber I Child 116 2 Children 33.15 87 3 Children 24.9 66 4 Children 18.9 69 19.7 More Than 4 Children 12 Type of Community 3.5 Urban 110 Rural 31.4 240 76.7 45 University of Ghana http://ugspace.ug.edu.gh Table 4.1 above shows the demographic characteristics oflchildren used in the study.· Majority (32.6%) of the children were within the ages of 12 t023 months followed by those who were within the ages of6 to 11 months. Majority of the children were males (50.9%). Majority (57.7%) of the mothers were within the age range of20 to 34. The least (16.9%) were those in the ages within the ages of 35 to 49years and 48 years. Majority of the respondents were Christians (67.7%) whiles 30% were Muslims. With regards to the marital status of the parents of children used in the study, majority (35.4%) of them were Single followed by those who were married (34.6%). With regards to the number of children that the mother of the children used in the study have, had about a third (33.2%) having only a child. The least (3.5%) were those who had more than four children. Considering the geographic location of the parents as either living in a rural or urban area showed that most (67.7%) of the parents of the children examined lived in rural areas. 4.2 General malnutrition levels of children under five years This sections looks at the various malnutrition status of the children used in the study. 46 University of Ghana http://ugspace.ug.edu.gh 4.2.1 Nutritional status of under-five according to weight-for-age • Underweight • Normal • Overweight Figure 2: Nutritional status of under-five according to weight-for-age The weight-for-age nutritional status had majority of the children used in the study being normal (64%). Those who were underweight formed 20%. 47 University of Ghana http://ugspace.ug.edu.gh 4.2.2 Nutritional status of under-five according to height-for-age • Stunted • Normal Figure 3: Nutritional status of under-five according to height-for-age (Stunting) The height-for-age nutritional status had majority of the children used in the study being stunted (59%). 48 University of Ghana http://ugspace.ug.edu.gh 4.2.3 Nutritional status of under-five according to weight-for-height _ Wasted _ Normal Figure 4: Nutritional status of under-five according to weight-for-height (Wasting) The weight-for-height nutritional status had majority of the children being normal (81%) and 19% of them being wasted. Of all the undernutrition status, that is weight-for-height, height-for-age and weight-for- height, the one with the highest proportion of children being malnourished is stunting making it the most prevalent hence the study concentrated on stunting. 49 University of Ghana http://ugspace.ug.edu.gh 4.2.3 Stunting status of children under-five according to their age 80 73,35.3% c 70 Q/ :E 57,21..5.26 :c 60 u '0 50 ~ .tl 40 34,~.4'JIj E z:::: I 30 I 18! 8.7~_ _ 20 15-,7.2% 10,4.8% 10 o - -0-5- -I I 6-11 12-23 24-35 35·47 48·59 Age Groups (in Months) Figure 5: Stunting status of children under-five according to their age Children who were between the age group of 12-23 months were most prevalent with stunting (35.5%). Followed by those who were within the ages of 6-11 months. The Least age group with stunting were those who were up to five months old. so University of Ghana http://ugspace.ug.edu.gh 4.3 Association of socio-economic factors with stunting '. Table 4.1 Bivariate analysis of stunting status and children under- five in E(futu municipality: Socio-Economic factors Outcome (n=350) Characteristics Normal Stunted (%) (%2 Chi-Sguare P-Value Occupation of Mother 4.897 0.038* Unemployed 61(68.5) 28(31.5) Self Employed 144(56.3) 112(43.8) CivillPublic Servant 2(40) 3(60) Occupation of Father 1.122 0.571 19(48.7) Unemployed 20(51.3) 181(60.1) 120(39.9) Self Employed CivillPublic Servant 6(60) 4(40) Household Income per month 12.619 0.013** Less than 100 95(62.1) 58(37.9) 100 to 200 59(59.6) 40(40.4) 201 to 500 34(63) 20(37) 501 to 1000 17(56.7) 13(43.3) Above 1000 2(14.3) 12(85.7) Educational Levels 6.263 0.18 Tertiary 8(40) 12(60) Secondary 30(53.6) 26(46.4) Junior High School 6(85.7) 1(14.3) Primary 112(60.5) 73(39.5) No FonnaI Education 51(62.2) 31(37.8) *P-value significant at 0.05, **P-value significant at 0.01 With regards to the socio-economic factors of undernutrition, unemployed mothers were found have more (68.5%) stunted children than nonnal. Children of self-employed mothers were more stunted (56.3%) than nonnal. Children of mothers who were public or civil servants were more stunted that nonnal (60%). There is a significant difference between children who are stunted and nonnal with respect to the occupation of their mothers at P<0.05. Sl University of Ghana http://ugspace.ug.edu.gh With regards to the occupation of the father, children of unemployed father were more (51.3%) stunted than normal. Those children whose fathers were self-employed were more (60.1%) stunted than nonnal. Those whose fathers were in the civil or public service had their children being more (60%) stunted than normal. There is no significant difference between children who are stunted and normal with respect to the occupation oft heir fathers. Children who lived in households that earn less than GhlOO, between GhclOO and Ghc200, between Ghc 201 and Ghc 500 and between Ghc 501 and Ghc lOOO were more stunted than nonnal with 62.1%,59.6%,63% and 56.7% respectively. Those children who lived in households that earn more than Ghc I 000, were more normal than stunted (85.7%). There is a significant difference between children who were stunted and normal with respect to the income levels of the household they live in at P<0.05. Children of mothers who had no fonnal education, primary, junior or secondary were more stunted than nonnal with 62.2%, 60.5%, 85.7% and 53.6% respectively. Those who had tertiary education however had more (60%) normal children than stunted. There is a no significant difference between children who were stunted and normal with respect to the level of education of the mother at P