144 Factors Associated With Underweight and Stunting Among Children in Rural Terai of Eastern Nepal

7/28/2019 144 Factors Associated With Underweight and Stunting Among Children in Rural Terai of Eastern Nepal

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144

Asia-Pacific Journal of

Public Health

Volume 21 Number 2

April 2009 144-152

2009 APJPH

10.1177/1010539509332063

http://aph.sagepub.comhosted at

http://online.sagepub.com

Factors Associated With

Underweight and StuntingAmong Children in RuralTerai of Eastern Nepal

G. C. Pramod Singh, MA, MPH, Manju Nair, MBBS, MPH,Ruth B. Grubesic, DrPH, and Frederick A. Connell, MD, MPH

Malnutrition continues to affect a large proportion of children in the developing world. The

authors undertook this study to identify biologic, socioeconomic, and health care factors associ-

ated with underweight and stunting in young children in an the eastern Tarai (plains) district of

Nepal. Data were collected via questionnaires from mothers of 443 children aged 6 to 36 months

in Sunsari district. Multistage cluster sampling was used to select villages and children.

Anthropometric measurements were made on both children and their mothers. Logistic regres-

sion was used to measure the independent (adjusted) effect of risk and protective factors on the

odds of underweight or stunting. More than half (53.3%) of the children were found to be under-

weight (5

years was strongly protective. These results suggest that underweight and stunting are the result

of a nexus of biological, socioeconomic, and health care factors.

Keywords: malnutrition; children less than 3 years; underweight; stunting; Nepal

The World Health Organization estimates reveal that malnutrition is associated withabout half of the 10.7 million child deaths among children less than 5 years occurringeach year in the developing world.1 According to the 2001 Nepal Demographic and

Health Survey, the prevalence of underweight (defined as weight for age


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Underweight and Stunting Among Children in Nepal /Singh et al 145

of the worlds children less than 5 years of age were underweight and 33% were stunted. 3The majority of underweight and stunted children live in Asia, especially Southern Asia, andthe risk of being underweight is about 1.5 times higher in Asia than in Africa.4 Malnutritionis responsible not only for mortality among children but also seriously affects the health ofsurvivors predisposing them to infections and other illnesses. The effects of childhood mal-

nutrition lead to physical and psychological sequelae continuing through adulthood, causeintergenerational effects, and loss of human potential, leading to loss of social productivity.5

Malnutrition is deeply rooted in poverty and underprivileged social environments inaddition to being caused by biomedical reasons. During the past 2 decades, global trendshave shown progress, with the prevalence rates of underweight children falling from around27% in the 1990s to around 22% in 2000.6 The United Nations Millennium DevelopmentGoal for child mortality aims to reduce by two thirds the mortality rate in children less than5 years between 2000 and 2015, and in developing countries, tackling malnutrition is thebiggest challenge in achieving this goal.7

This cross-sectional study, conducted in eastern Nepal, attempted to identify risk factorsassociated for underweight and stunting in children. Specifically, the objectives of this studywere the following:

1. To measure the prevalence of underweight and stunting in a representative sample of rural Nepalichildren under 3 years of age living in Sunsari district

2. Measure the association of biological factors, socioeconomic and demographic factors, and nutri-tional interventions on underweight and stunting

3. Assess whether use of 2 nutritional programs was associated with a reduction in underweight andstunting

MethodologyMultistage cluster sampling method was used to select subjects of this study. Four villagedevelopment committees (VDCs) were selected randomly from the 49 VDCs in this district,and 4 wards out of 9 wards were selected from each VDC using a random sampling method.The selected ward was considered as a cluster. Thus, there were a total of 16 clusters in thesample. A minimum sample size of 400 children was based on an expected prevalence of48%1 of underweight children in this district. Within each cluster, children less than 3 yearsof age were selected from every alternate household, and all eligible children in each familywere included. If there was more than one family having a child of eligible age in a house-hold, one of the families was selected randomly on the spot for inclusion in the study. Theselected household was excluded if there was no eligible child. The children in a householdwere excluded from the sample if the mother was not present. A total of 443 children wereincluded in the study.

Each mother was interviewed, from August to September 2005, using a pretestedquestionnaire that included items about demographic characteristics of the mother, father,and child; obstetric history (eg, number of previous pregnancies, birth order of each child);antenatal care; diet, drug use, alcohol use, and smoking during pregnancy; feeding practices(eg, length of exclusive breast-feeding); birth spacing; childs use of health services (eg,immunizations, vitamin A, nutritional programs); and family religion and caste. Religion wasclassified as either Hindu or other. Caste is an important source of identity in Nepal. Castes

were classified either as Dalits, who inhabit the lowest rung in the Hindu caste hierarchy,or All Others, including non-Hindus.


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In addition, the questionnaire obtained information to standard of living using astandard of living index. This index is computed based on inventory of 30 household assets,such as toilet facilities, ownership of various durable goods, housing type. Each of the 39assets are scored, with scores of 0 to 14 indicating a low, 15 to 24 indicating a medium, and25 to 67 indicating a high standard of living.8

Anthropometry was conducted at the same time as the interviews, using the UNICEFelectronic scale (SECA 890) to measure the weight of children. An infantometer was usedto measure the height of the children up to age 24 months. A stature meter (a wooden rodwith centimeter markings) was used for children more than 24 months of age. Three femaleenumerators who were at least high school graduates were hired to conduct the interviewwith mothers and to measure the height and weight of children. They were trainedtheoretically and practically on how to interview mothers and how to measure weights andheights. Underweight was defined as a weight for age less than 2 SDs from the NationalCentre for Health Statistics/World Health Organization reference median value9; similarly,stunting was defined as a height for age less than 2 SDs of the reference median value.

In addition, the mothers weight and height was measured, and body mass index (BMI)was computed using the usual formula: BMI = weight (kg)/height2 (m).

We conducted bivariate analyses to examine the association of potential risk or protectivefactors with the 2 outcomes (underweight and stunting) using 2 tests to determine thestatistical significance of these associations. Multiple logistic regression was then used toassess the strength of risk/protective factors that were found to be important in the bivariateanalyses, controlling for potential confounding. SPSS, version 15, was used for the statisticalanalyses.

Ethical Considerations

The consent form was read to the mother, and verbal consent was obtained for participationin the study. The ethics committee of Sree Chitra Tirunal Institute for Medical Sciences andTechnology, Thiruvananthapuram, India, reviewed the protocol and gave approval for thestudy.

Results

Table 1 describes the demographic characteristics of the study group. Fifty-six percent ofthe study children were male. Approximately one fourth was 6 to 12 months of age at the

time of the survey. The vast majority of families were Hindu (94%), and one third was ofDalit caste. Only 21% of families had a high standard of living score, whereas 44% hadscores in the low range. Although almost half of the mothers married before the age of 18,95% were 18 years or more at the time of the birth of the index child. Almost half of themothers had less than 6 years of schooling, compared with 40% of the fathers. Only 5% ofthe mothers worked outside the home. Fathers were employed predominantly (86%) in agri-culture or as laborers. Mothers BMI values ranged from 13.3 to 29.6; the median BMI ofmothers was 19.1.

Antenatal care was begun in the first trimester for approximately one third ofpregnancies; however, almost 15% of pregnancies had no prenatal care visits (Table 2). More

than a third of subjects (38%) were firstborn. Only 9% of the subjects were born within 24months of the birth of the previous child. Among the mothers of subjects more than 24months of age, 15% had another birth within 24 months of the birth of the index child.Approximately one third of the mothers reported eating more than usual during the index


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pregnancy, and 21% said that the index child appeared small at birth. More than 80% ofthe children had received 3 or more doses of polio and DPT vaccines. Among children more

than 1 year of age, 56% had received 3 or more vitamin A treatments. Exclusive breast-feeding for less than 6 months occurred in 14% of the children more than the age of 1 year,and 31% were exclusively breast-fed for 9 months or more.

Table 1. Underweight and Stunting in Relation to Demographic Characteristics of Infants,Mothers and Fathers

Percentage Percentage 2 Percentage 2

n of Study Group Underweight P Value Stunted P Value

Total 443 100% 53.3 NA 36.6 NA

Childs sex

Male 249 56.2 52.3 NS 38.2 NS

Female 194 43.8 54.6 34.5

Childs age

6-12 Months 105 23.7 35.2


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More than 53% of the children were underweight and 36.6% were stunted, defined asless then 2 SDs between the reference median weight or height for age. Severe underweightor stunting (24 months old)

Within 24 months 25 14.5 64.0 NS 48.0 NS

After 24 months 148 85.5 59.5 37.2

Diet during pregnancy

Did not eat more than usual 292 65.9 57.5 .012 38.7 NS

Ate more than usual 151 34.1 45.0 32.5

Babys size at birth

Appeared small 94 21.2 68.1 .001 50.0 .002Did not appear small 349 78.8 49.3 33.0

Exclusive breast-feeding

(children 12

months and more)

0-5 Months 48 14.2 58.3 .038 37.5 NS

6-8 Months 187 55.3 53.5 39.0

9 Months or more 103 30.5 68.9 45.6

DPT/polio


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when less than 18 years of age, father working in agriculture or as a laborer, and lowmaternal BMI (Table 1). With the exception of mothers age at marriage and BMI, these

same characteristics were also significantly associated with stunting.Earlier and more frequent antenatal care were associated with a lower likelihood of both

underweight and stunting, as was being firstborn. Children whose mothers reported beingsmall at birth were significantly more likely to be underweight and stunted, whereasmothers who reported eating more than usual during pregnancy were less likely to havean underweight child. Infants who were exclusively breast-fed either less than 6 months ormore than 8 months were more likely to be underweight. Both vitamin A supplementationand participation in a nutritional assistance program were associated with a lower likelihoodof being underweight. Birth intervals, either before or after the birth of the index child, werenot related to either underweight or stunting in this study group.

Because it was likely that many of the factors found to be associated with eitherunderweight or stunting were interrelated, we used multivariate logistic regression tosimultaneously adjust for their potentially confounding effects. In creating the logisticregression modes, we excluded (a) variables that were not associated with the outcomes inbivariate analyses (eg, infant sex), (b) variables that were not associated with the outcomesafter adjusting for standard of living (eg, ethnicity/caste, fathers education, and others), or(c) variables that were not logically causal (eg, immunization). We also did not include thevariables describing mothers assessment of infants size at birth or her recollection theamount of food eaten during pregnancy, as these were likely to be inaccurate due to recallbias. Therefore, 7 variables were included in the multiple logistic regression analyses: childs

age (entered as the natural log of the age in months), mothers education (0-5 vs 6+ years),vitamin A treatment (3+ vs


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Discussion

This study found very high rates of both underweight and stunting; these rates were similar to,but higher than, those that have been measured for Nepal as a whole.2 We found that biologic,socioeconomic, and health care factors were all associated with underweight or stunting.

Biologic Factors

Similar to earlier reports,2,8,10-12 children more than 12 months of age were more likely to beunderweight and stunted than younger children. It is likely that nursing during early life isprotective and that undernutrition becomes more likely as the child becomes moredependent for caloric intake on foods that have to be grown or bought. Interestingly,

although either short (9 months) duration of exclusive breast-feedingwas found to be weakly associated with underweight in bivariate analyses, we found thatduration of breast-feeding was not significantly related to underweight after adjusting forother factors.

Birth order of the baby had an effect on underweight, as shown in previous studies.2,8,13,14The higher the birth order, the higher the prevalence of underweight and stunting. Repeatedpregnancies drain the mothers health and also further impoverish the family. A higher birthorder and more surviving children reflect repeated pregnancies and possibly less care for theindividual children.

The BMI of the mother was strongly related to underweight in the bivariate analyses and toboth underweight and stunting in the multiple logistic regression analyses, suggesting perhapsthat the nutritional status of the mother, especially when she is pregnant, may affect thesubsequent growth of her children. It is also possible, however, that unmeasured factors (inaddition to the familys standard of living, which was controlled for in the multivariate analyses)may be causally related to both maternal and child nutritional status.

We found no relationship, however, between various measures of birth spacing andeither underweight or stunting. Nor was the nutritional status of children in this studysignificantly different according to gender. Other studies in Nepal and India 2,8,10 show thatthe prevalence of malnutrition was similar in both the genders in this age group.

Socioeconomic FactorsAs found in many previous reports,15-17 this study demonstrates the significant relationshipbetween socioeconomic status and child malnutrition. The standard of living score was

Table 4. Logistic Regression Model for Stunting

95% CI for OR

OR Lower Upper Significance

Childs age (continuous as ln[months]) 8.80 2.62 29.52


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strongly related to underweight and stunting in both the bivariate and the multipleregression analyses.

Children from Dalit families were found to have significantly higher malnutrition rateswhen compared with other children. Sah,10 in his study in Dhanusha, did not find asignificant relationship between ethnicity and child malnutrition, but the prevalence was

higher for Dalits than non-Dalits. The National Family Health Survey, India,8

revealed thatthe children belonging to schedule castes, tribal groups, and other backward classes werefound to have relatively higher prevalence of child malnutrition. It is important to point out,however, that the effect of caste was minimal and not statistically significant when standardof living was controlled for, suggesting that the major nutritional disadvantage of lower castestatus is due to poverty. Like many previous studies,2,12,13,18-22 this study found that highereducational attainment of both mothers and fathers were strongly protective in relation tounderweight and stunting. Fathers education, however, was not significant after controllingfor standard of living. It is important to emphasize that mothers educational level wasstrongly protective for both underweight and stunting, even after controlling for otherimportant variables in the multiple regression analyses. This effect may be due to the factthat an educated mother has more opportunities to be informed of, and be aware, of healthcare, better nutrition, and child development when compared with uneducated mothers.

It is noteworthy that the use of vitamin A treatments (OR = 0.37) and participation ina nutritional program (OR = 0.33) was strongly protective for underweight, even aftercontrolling for other important factors such as mothers education, standard of living, andchilds age. This finding suggests that health care programs can and do make a difference inthe nutritional status of poor, rural children.

This study was restricted to a single district in eastern Nepal and may not be generalizableto other populations. Data on risk and protective factors were mostly obtained fromquestionnaires, and it is not known how much recall bias or other threats to validity may

affect the accuracy of these data. For this reason, we did not use mothers assessment of theamount she ate during pregnancy or the size of the child at birth in the logistic regressionmodels. Finally, the statistical analysis did not take the cluster sampling methodology intoaccount when calculating P values and confidence intervals. If we had adjusted the analysesfor clustering, it is likely that some of the weaker results would not be significant at the .05level.

These results suggest that underweight and stunting are the result of a nexus of bio-logical, socioeconomic, and health care factors. In addition to programs that offer directnutritional support or supplementation, efforts to improve the nutritional status of poorchildren should consider interventions that can improve the overall health of mothers;

advance socioeconomic status, especially income and maternal education; and limit thenumber of pregnancies. Policies and strategies have to be long term and strategic at theindividual, community, and country levels:

Improving the status of women through primary and secondary education, including nonfor-mal skill training to increase economic independence.

Providing health information packages aimed at popularizing better locally available nutri-tious food, supplementary feeding programs for children aged less than 5 years through anetwork of child care centers.

Supporting behavior change interventions designed to address locally relevant child care,maternal care, and hygiene practices developed with an understanding of the local culture

and practices.


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144 Factors Associated With Underweight and Stunting Among Children in Rural Terai of Eastern Nepal