Factors associated with Malnutrition among Children

in Rural Terai of Eastern Nepal

Mr. Pramod Singh Gharti Chhetri

Dissertation submitted in partial fulfillment of the requirement

for the award of the degree of Masters of Public Health.

Achutha Menon Centre for Health Science Studies (AMCHSS)

Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST)

Thiruvananthapuram Kerala (India) October 2005

DECLARATION

I hereby certify that the work embodied in this dissertation titled “Factors

associated with malnutrition among children in rural Terai of Eastern

Nepal” is the result of original research and has not been submitted for the

award of any degree in any other University or Institution.

Mr. Pramod Singh Gharti Chhetri

Place: Thiruvananthapuram,

Date: 28th October 2005

CERTIFICATE

Certified that this dissertation titled, “Factors associated with malnutrition

among children in rural Terai of Eastern Nepal” is a record of original

research work undertaken by Mr. Pramod Singh Gharti Chhetri in partial

fulfillment of the requirements for the award of the Master of Public Health

degree under my guidance and supervision.

Guide

Dr. Manju Nair R

Scientist C

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram – 695 011

Kerala, India

Acknowledgements

First and foremost, I must admit that it was a privilege to do my dissertation under the

able guidance and supervision of my respected teacher Dr. Manju Nair, Achutha Menon

Center for Health Science Studies, Thiruvananthapuram, Kerala. I am thankful to her for

her keen interest and supervision, without which this dissertation would not have taken its

present form.

I would like to thank the Director, Prof K Mohandas and the Registrar, Sree Chitra

Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala for

their continuous support and encouragement throughout the course.

I am grateful to Dr. K R Thankapan, Dr. P S Sarma, Dr. T K Sundari Ravindran, Dr.

Mala Ramanathan, Dr. D V Varatharajan, Dr. Biju Soman and Mr. Sundar Jayasingh,

AMCHSS, for their continuous support and help.

I am thankful to the Vice Chancellor of BP Koirala Institute of Health Sciences, Dharan,

Nepal, Prof. Dr. Loke Bikram Thapa for giving me the opportunity to undertake the

Master of Public Health course. I am also thankful to WHO, Nepal for providing me the

fellowship to take up this course. I am also grateful to UNICEF, Biratnagar for providing

me with the digital weighing scale for the field study.

I am also thankful to Dr. F James Levinson, Associate professor, TUFTS University,

USA, Dr. Grubesic Ruth, Assistant Professor, Texas Woman's University, USA and Dr.

Lance Brennan, Flinders University, Australia, for their help by providing with valuable

literature.

My sincere thanks also go to Ms. Ram Kumari Chaudhai, Mr. Bikram Chaudhari and Ms.

Lalita Chaudhari for their sincere efforts in data collection.

My heartfelt thanks to my wife Rina for her help during data collection and data entry

and support throughout the course.

Last but not the least my genuine thanks to all the respondents and people of my study

area who cooperated with me during this study.

I have held many things in my hands, and I have lost them all; but whatever I have placed

in God’s hands, I still possess. Thank you, GOD.

CONTENTS 1. Introduction 1

2. Review of Literature 2-14

2.1 Definition of malnutrition

2.2 Measurements of malnutrition

2.3 Global burden

2.4 Factors associated with malnutrition

2.4 Rationale for the study

3. Methodology 15-19

3.1 Objectives of the study

3.2 Study setting

3.3 Study design

3.4 Sample size

3.5 Sample selection

3.6 Methods of data collection

3.7 Ethical considerations

3.8 Data analysis

3.9 Conceptual framework

4. Results 20-44

4.1 Sample characteristics

4.2 Prevalence of malnutrition

4.3 Factors associated with malnutrition

4.4 Multivariate analysis

5. Discussion 45-49

6. Conclusion 50

7. Policy implications 51

8. References

Annexures

Factors associated with Malnutrition among Children in Rural Terai of Eastern Nepal

Abstract The World Health Organisation (WHO) estimates reveal that more than half of all child

deaths are associated with malnutrition in the developing countries. It is responsible not

only for mortality among children but also seriously affects the health of millions of

survivors making them vulnerable to infections and other illnesses. More than fifty

percent of the worlds’ malnourished children are in the developing countries especially

South Asia. Nepal has an under five mortality rate of 91 per 1000 live births and a high

prevalence of malnutrition.

Objective: To study the prevalence and factors associated with malnutrition among

children aged 6 – 36 months in the rural area of Sunsari district, Terai , Eastern Nepal.

Study design and methods: A community based cross sectional descriptive study. The

data were collected from mothers of 443 children from Sunsari district of Eastern Nepal.

Multistage cluster sampling was used to select the samples. Anthropometric

measurements were made using the digital weighing scale, infantmeter and a portable

measuring board and interviews using pre tested interview schedule.

Results: 53.3 percent of the children were underweight; about 30% had wasting about

36.6% had stunting. There was no significant difference in the prevalence among male

and female children. Malnutrition was more among the older age groups, significant

relation with maternal education, mother’s age at marriage, socioeconomic status,

paternal education, feeding practices and the presence of toilet facility. Multivariate

analysis showed that children in households of low SES are twice at risk of being

underweight compared t o those from higher levels of SES.(OR=2.04, C.I 0.99-4.22).

1

1. INTRODUCTION

The World Health Organisation (WHO) estimates reveal that malnutrition is associated

with about half of the 10.7 million child deaths among under-five children occurring each

year in the developing world. It is estimated that about thirty percent of all the world’s

children under five years accounting to about 150 million children are malnourished in

terms of weight for age.16 It is estimated that the majority of them live in Asia and

especially Southern Asia and the risk of being underweight is about 1.5 times higher in

Asia than in Africa.6 It is responsible not only for the mortality among children but also

seriously affects the health of millions of survivors predisposing them to infections and

other illnesses. The effects of childhood malnutrition leads to physical and psychological

sequelae, continue through adulthood, cause intergenerational impact, loss of human

potential leading to loss of social productivity.

The huge disparity in the prevalence of malnutrition across geographical areas and

countries and within populations is due to the fact that it is deeply rooted in poverty and

underprivileged social environment rather than biomedical causes. However during the past

two decades global trends have shown progress, with the prevalence rates of underweight

falling from around 38 percent in the eighties to around 25 percent presently.16The

millennium development goal for child mortality aims to reduce by two thirds the under

five mortality rate between 2000 and 2015 and in the developing countries tackling

malnutrition is the biggest challenge in achieving the goal

2

2. REVIEW OF LITERATURE

A review of literature was done to assess the burden of the problem, the measurement of

malnutrition and the factors associated with child malnutrition from available national and

international studies, reports and other published material.

2.1 Definition of Malnutrition

The simple meaning of malnutrition is a condition of improper nutrition which includes

both under nutrition and malnutrition. Malnutrition as mentioned in this study refers to the

state of under nutrition.

Malnutrition is defined as “a pathological state resulting from a relative or absolute

deficiency or excess of one or more essential nutrients”. 5 “Malnutrition or undesirable

physical or disease conditions related to nutrition can be caused by eating too little, too

much or an unbalanced diet that does not contain all nutrients necessary for good

nutritional status”. 3

In developing countries, malnutrition mostly refers to under weight, wasting or stunting in

the child. The child can be under weight for his age and height as well. The height of the

child may be affected if the malnutrition continues for a long time. This will cause short

stature or stunting in the child. If the malnutrition or under nutrition remains for a short

period of time, the child will be under weight or wasted and if it persists for a longer period

then it will cause the child stunting. 2

Anthropometric measurement is done to assess the nutritional status of children. When

deficits are found in one or more than one anthropometric indices, this is known as

‘malnutrition’. This may not be the result of only nutrient or energy deficit.

3

2.2 Measurement of malnutrition

Anthropometric measurement is done to assess the nutritional status of children. When

deficits are found in one or more than one anthropometric indices, this is known as

‘malnutrition’. This may not be the result of only nutrient or energy deficit. The following

measures are done in anthropometric measurement:

Weight for age: This measurement is used to determine whether the child is normal, over

weight or under weight. This basically shows the dimension of the body in relation to the

age of a person. It is affected by the height (height for age) and weight (weight for height)

of a person. If there is no more wasting among the children in the community, the height

for age and weight for age will give the similar type of information. Both of them will

replicate the long-term affect of malnutrition. The term ‘underweight’ is commonly used

for low weight for age. 5

Weight for height: This measurement shows the body weight in relation to the height of

an individual. The advantage of this measurement is that it is not necessary to know the

child’s age. However, it cannot be substituted for the weight for age. Because these indices

have different meanings, we can’t use them interchangeably though they may have similar

determinants.

The term wasting is used for low weight for height. The term wasting is used commonly

and widely for the current severe weight loss because of delicate hunger or illness. 5

Height for age: This is a linear growth measurement of a child. Length and stature are

used for the height for age based on the way of measurement. If there is shortfall on height

for age, it designates continuing growing insufficiency of health or nutrition.

4

The commonly used term for low height for age is stunting. Stunting suggests that

there was inadequate health and or nutrition for a long period of time. There is worldwide

variation of low height for age that ranges from 5% to 65% in less developed countries.

If any of the above-mentioned indices are below two standard deviations (<-2SD) of the

median value of sex specific NCHS reference data, a child will be regarded as

malnourished. If the indices are below three standard deviations (<-3SD), it is considered

as severe malnutrition.5

Mid Upper Arm Circumference (MUAC): The MUAC is measured on the left arm at the

mid point of elbow and the shoulder. A measuring tape is placed around the relaxed arm. A

single cut off value (12.5 or 13.0 cm) can be used for the children less than 5 years of age. 5

Head Circumference: Head circumference is a measurement of the child while sitting on

the lap of mother or care taker. Any object on the hair is removed while measuring. The

measuring tape is placed just above the eyebrows and positioned posteriorly. 5

Methods of measurements for malnutrition

Weight: One of the ways to weigh baby/ child is by using the UNICEF electronic scale

(Item No. 014015). In this method, mother and child will have to be weighed concurrently.

The child should wear minimal clothing. We should ask the mother to minimize the

clothing of the child. The sun should not over heat the weighing machine. The machine

should be placed on an even surface and can be read properly. The mother stands on the

scale with her baby and the weight is recorded to one decimal placement (e.g. 63.7 kg.).

Someone nearby then holds the child and the mother stands on the scale again without

child. The mother’s weight is recorded (e.g. 55.2). The difference is then determined (63.7-

55.2 = 8.5 kg.). 18

5

The other way of weighing a baby/ child is using a spring scale. , a 25kg scale. This is

hooked to a near by pole or tree or held by two people. The weighing pant is removed from

the lower hook of the scale and the child is placed in the weighing pants with the least

clothes possible. The pants should hang freely from the hook. The scale should be

calibrated everyday with a known 10kg weight.17

Height: There are basically two ways of measuring the height of the children based on the

age of child. The children aged two years and above are measured standing up. The

children aged less than 2 years are measured lying down. If there is problem to identify the

age should be decided based on the height. If the children are more than 85 centimeters are

measured standing up and the children who are less than equal to 85 centimeters are

measured lying down.

The measuring board for the children aged 2 years and above is placed where there is

enough room for movement. While taking the measurement, the head, shoulders, buttocks,

knees and heels of the child should touch the board.

The measuring board is placed on hard flat ground to measure the height of the children

aged below 2 years. The child should be lying flat at the center of the board. We should

place the head of the child against the base of the board and place our hand on the child’s

knees and press them gently against the board. 18

2.3 Global burden

It is estimated that there are about 208 million stunted children, around 49 million children

who are wasted and approximately 168 million underweight children in terms of their age

in the world. 37 The World Health Organization (1995) estimates that more than half of the

children’s deaths in developing countries are associated with malnutrition. It is estimated

6

that half of all children in South Asia are malnourished. Of the 12 million children death in

developing countries, 55 percent were related to malnutrition. 38 Among the South Asian

Association for Regional Cooperation (SAARC) countries according to UNICEF

Bangladesh has the highest (47.8%) prevalence of under weight among children followed

by Nepal (47.1%) and India (47%). Bhutan has the lowest (18.7%) among the SAARC

countries. The prevalence of stunting is highest in Nepal (54.1%) followed by India

(45.8%) and Bangladesh (44.8%). The lowest prevalence is in Sri Lanka (17%). Pakistan

has no data. The prevalence of wasting is highest in Maldives (16.8%) followed by India

(15.5%) and Sri Lanka (15%). Bhutan has got the lowest prevalence (2.6%) of wasting.

Bhutan seems to be in a better position in terms of child malnutrition in SAARC countries.

In 1975, 50 percent of the children aged 6 to 48 months were stunted in Nepal. In 1998,

47.1 percent children aged 6 to 59 months were under weight. Of these 12 percent were

severely malnourished. In the same period 54.1 percent children were stunted and of these

22.1 percent were severe. Children with wasting were 6.7 percent and out of this 0.5

percent were severely wasted. 16

2.4 Factors causing child malnutrition

There are multiple factors associated with childhood malnutrition and these are often

interrelated. One simply cannot say that these are the cause of childhood malnutrition

because it is a complex phenomenon. However, the major factors associated with

childhood malnutrition as mentioned are poverty, educational level of mother, faulty

feeding practices, vitamin A status, low status of women, birth order, unsafe drinking

water, mother’s occupation, diarrhea etc. 6, 7

7

Poverty:Poverty is an established cause of malnutrition. Malnutrition is highly prevalent in

the places where the people are struggling with severe poverty. The World development

Report shows that the countries with low GNP per capita have a high prevalence of under

weight children. According to a study in Indonesia malnutrition can be a practical indicator

of poverty. Sunutar Setboonsarng in his/ her report on ‘Child Malnutrition as a Poverty

Indicator: An Evaluation in the Context of Different Development Interventions in

Indonesia mentioned, “The evaluation shows that child malnutrition as poverty indicator to

assess the fulfillment of socio-economic development goals and targets is conceptually

sound and is more practical”. 4

The World Bank Economic Review39 also mentions that the higher the per capita income

the lower the malnutrition. Based on a cross-country and household study, it is concluded

that malnutrition can be reduced with sustainable economic growth. 4 There is an

assumption that income plays an important role for the underlying factors of malnutrition.

The underlying factors e.g. education; safe drinking water, health services etc. can be raised

with the increment in per capita income. 7 A study done in Rural Punjab found the

economic growth as a prominent factor for reducing the child malnutrition. 24

Education of Mother: The education of mothers has several positive effects on care of

children in comparison to mother with no education. The educated mother utilizes the

health care facility, discusses more about the illness of the child with health care provider

and follows the instructions about feeding and caring practices given by the health workers.

They also take benefit of guidance and information of health workers. They are more likely

to keep their environment clean. 7,9,10 One study in Indonesia shows that mother’s

education plays a strong role to protect child malnutrition. 13 It is found that the educated

8

mothers have less stunted children. 21,23 A study in Malawi also supports the role of mother

for better child nutrition to some extent. 10

In a survey done in Nepal it was found that the children with literate mothers have less risk

and severity of diarrhea. However it also says that it is likely to be associated features

rather than the literacy itself. 11 In another survey done in Nepal has found the negative

relationship between mother’s education and child mortality that is higher the mother’s

education, lower the child mortality. 21

Feeding Practices: The risk of childhood malnutrition increases with not feeding

colostrums. The non-use (throwing) of colostrums varies among the different ethnic groups

of Nepal. However, it mainly prevails among the ethnic groups of Terai. 11 Faulty feeding

practices like late initiation of breast feeding, starting artificial feeding before 6 months and

early and late start of complementary foods causes malnutrition. 12,27 It was found in Egypt

that early initiation of breast-feeding to the infants was associated with lower rate of

diarrhea episodes (episode per child per year) than those of late initiated breast-feeding (6.4

vs 9). A study in Uttar Pardesh and Karnataka of India shows that putting the baby to breast

within 24 hours after birth does not reduce stunting. Nevertheless, stunting and severe

stunting can be reduced if the baby is exclusively breast-fed for 4-6 months and mother

does not squeeze the colostrums from her breast. The child older than 6 months of age

needs to be given supplementation for reducing the stunting. 28 The children below one

year of age who was no longer exclusively breast-fed were found more malnourished. 13

This statement is also supported by the studies in Jamaica and Malawi. 10,14 A study in

Uganda shows that the children who never consumed breast milk had higher incidence of

underweight. The same study indicates that breast-feeding until 18 months decreases the

9

risk of stunting in contrast to those who were fed only in early infancy. However, breast-

feeding from 18 months to 24 months increases the risk of stunting approximately seven

fold. If it is continued to more than 24 months decreases the threat of stunting. 23 The

association of breast feeding and stunting may be because of reverse causality. A child

might not be stunted because of breastfeeding but s/he might have more breastfeeding

because of her/his poor health condition. Thus, children’s health should be considered

while evaluating the association between breast-feeding and child malnutrition. 28 A study

in Malawi found that giving complementary food to the baby at or after 4 months was

associated with better nutritional status in children. 10 A study in Andhra, India also shows

that late weaning had a negative impact on child nutrition. 19 A study in Nepal illustrates

that the risk of wasting increases if a child is fed less frequently (less than 6 times a day). 11

However, a study in Kerala states that the variables related to child feeding practices were

not significantly associated with underweight. 26 In Nepal healthy foods such as green leafy

vegetables are considered as low-status food and are not fed to the children even though it

is accessible and meat is not eaten either because of religious reason or it is prohibitively

expensive. 25

Vitamin A: A study done in Nepal found that the children taking Vitamin ‘A’ supplements

twice a year regularly had better health outcomes for malnutrition, diarrhea and acute

respiratory infection than those who did not take one capsule or took only one time.

Consumption of Vitamin ‘A’ rich food alone was not enough to protect the children from

malnutrition, diarrhea and ARI. 25

Women’s Status: A woman having lower status will have less opportunity to interact with

others and less freedom for independent behavior. It will restrict her to gain the knowledge

10

and lose self-esteem. A woman’s status in society will determine her physical and mental

health and her autonomy and control over household resources. If a woman has weak

physical and mental health, she will not be able to give quality care to her children. If a

woman is poorly fed or has poor nutrition during her childhood, adolescent and pregnancy,

her child is more likely to be low birth weight and affect subsequent growth. If a woman

has relatively less status compared to men this will restrict her to act for her own and her

child’s interest. 7,15 A study report from Uttar Pradesh and Karnataka, India did not reveal

the strong relationship between women’s autonomy and stunting. 28

South Asia has better per capita GNP, better education and safe drinking water in

comparison to Sub Saharan Africa. However, child malnutrition is higher in South Asia

than in Sub Saharan Africa. India is trying to eliminate child malnutrition from the country

since last 20 years but has not been able to get that much success. The reason given is low

women’s status. Professor Ramalingaswami, Dr. Urban Jonsson and Dr. Jon Rohde named

it as “The Asian enigma”. They pointed out that the low status of women in South Asia

accounts for the high rate of child malnutrition in comparison to Sub Saharan Africa.15

According to a study conducted in Nepal it was found that there was increased risk of child

malnutrition with frequent abuse to the mother. 11 According to a meta-analysis, 30 infant

mortality is higher in males than females; however, child mortality is higher among

females than males. Roughly half of the studies did not find any significant gender effect

on child malnutrition but about half of them showed that male children are less well

nourished than female children. 30 The data of rural Punjab of India also supports the

relationship between gender and child malnutrition. In 1971 the prevalence of child

malnutrition among male children was 32% and for female it was 54.2%. In 2001 it was

11

11% for male and 17.4% for female24. A study in Bangladesh also has made public that

female children are more vulnerable to be severely malnourished in comparison to male

children. The female had a 44% higher risk of being malnourished than male children. The

possible reason might be the discrimination against female children for food and health

care. 31

Birth Order According to the study done in Uganda, there is no role of birth order in

stunting and underweight among children. 23 A study in Jamaica kept up the evidence that

birth order is not significantly associated with underweight of children. 14 However, a study

done in Nepal shows a relationship between birth order and child malnutrition. 11 It shows

that higher the birth order, the higher the stunting and underweight21. This statement is

supported by another study in Indonesia. It also adds that first-born children have

advantage over later born children. 13 Nevertheless, on the contrary a study in Ethiopia

revealed that first birth order children were found to be at more risk for stunting than the

children of higher birth order. 27

Source of Water: Clean water is prerequisite factor for preventing child malnutrition.

Contaminated water lead to diarrhea and diarrhea in turn lead to malnutrition, even if the

food supply is sufficient. 30 Clean water reduces the infant and child mortality.

A study in Malawi established that private tap followed by public tap is linked with better

child nutrition. Poor water supply especially the unprotected wells were found negative

impact on child nutrition. 10 A study in Uganda supports the evidence of Malawi that the

children having unprotected water were found more underweight. Nevertheless, it had no

consequence on stunting. 23 Studies done in Rural Punjab of India, and Ethiopia also

12

revealed that one of the factors for the improvement in child malnutrition was improvement

in safe drinking water. 24,27

Mother’s Occupation: Studies done in Uganda and Ethiopia found no association

between mother’s occupation and child nutrition. 23,27. According to a study in Indonesia,

non-working mothers had better nourished children than that of working mothers. The

mothers working in the informal sector were found to have the highest risk factor for child

malnutrition. 13 The working mothers are able to earn money to fulfill the necessity of their

own and of their children but it’s opportunity cost will be higher because they will not be

able to give their time to look after the children. 7

Diarrhea: Diarrhea has negative affect on child nutrition. 10,11,28 A study in Jamaica also

was found that there was an association between diarrhea and underweight. 14 A higher

episode of diarrhea was found to be short term and long-term affect on malnutrition in

Andhra Pardesh, India. 19

Birth Interval: In a study in Malawi an association was found between birth interval and

child malnutrition. A child born 4 years after his preceding sibling was found to be better

weight for age than first born child or child born within four years. 10 A study in Ethiopia

also revealed that there was significant risk for the children of lower preceding birth

interval. 27 An Indian study reveals significant association between mortality risk and

preceding birth interval. Short birth intervals (<18months) were found to be more risk for

child mortality. 32

Parity and No of Children Below 5 Years: A study in Jamaica shows that there is no

effect of parity, and number of children less than 5 years of age on child malnutrition. 14

13

Caste/ ethnicity: In a study in Andhra Pardesh, caste was not found to be a determinant

factor for current malnutrition but was a significantly determinant factor for past

malnutrition. 19 In contrast a study in Dhanusha (Sah) 34 shows that there is no significant

relationship between caste/ ethnicity and child malnutrition. However, the prevalence

underweight and stunting is higher for Dalits.

Immunization:Immunization (polio and DPT) has no association with chronic

malnutrition but has significant affect on current nutrition status as per a study in Andhra

Pardesh. 19 Nevertheless a study done in Rural Punjab has advocated the coverage of

immunization as one of the factors for improvement in nutrition. 24

Age: It was observed in an Ethiopian study that there was significant high risk of stunting

among the children aged 12 to 23 months in comparison to 6 to 11 months age group. 27 A

study in Dhanusha district of Nepal also has revealed that higher age children are at more

risk of underweight and stunting. 34 The most vulnerable age group for malnutrition is

under 15 years. However, most victims of malnutrition are children under the age of 5

years. It is because the growth rate is so fast among the children in their first 5 years of age.

Inadequate nutrition adversely affects the growth and development of children. 2

2.4 Rationale for the study

Nepal has a big burden of child malnutrition. The under-five mortality rates are still high at

119 per 1000 live births in Terai which is higher than that of Hilly region 93 per 1000 live

births. 21 As Nepal is a multi cultural country, the cultural practices of one area are different

from other areas. According to the Nepal Demographic Health Survey, 2001, only 20.2%

of mothers breastfed their babies within one hour of birth and only 45.2% mothers within

one day of birth21. The Parda system (covering the face by cloth in front of adult males

14

other than husband and siblings) is very much prevalent in Nepal, which reflects the lower

status of the women. The percentage of underweight children is higher in Terai than that of

Hill and Mountain and wasting is even higher than underweight but stunting is little less in

Terai in comparison to Hill and Mountain area. 21 However, in a study it is shown that

being malnourished for children in Terai is 2.36 times higher. 11 Nepal has a high under

five mortality rate and malnutrition levels and needs to be addressed to eliminate the child

deaths and morbidity. This study is proposed to help to know the trend of child

malnutrition in eastern Terai of Nepal and find the factors associated with child

malnutrition. It will inform policy making and program management in community based

programs on reduction of malnutrition and promotion of child health.

15

3. METHODOLOGY

3.1 Objectives of the study

1) To study the prevalence of malnutrition among children aged 6-36 months in

Sunsari District of Eastern Nepal

2) To study the factors associated with malnutrition in the population

3.2 Study design

A descriptive cross sectional community based survey

3.3 Study setting

The study was done in the rural areas of Sunsari district of Eastern Terai , Nepal in four

randomly selected Village development Committee areas.

3.4 Sample size

The formula n = 4pq/d2 was used to calculate the sample size for a cross sectional survey

where p = prevalence, q=1-p and d the desired precision. Based on prevalence of under

weight children of 47%21, for 95 % confidence interval with ± 10% and a design effect of

2, minimum sample size was calculated as 400 that is 200 each from male and female

children. However, total 443 children were finally included in the study.

3.5 Sample selection procedures

Multi stage cluster sampling method was used to collect the data. There are 49 Village

Development Committees in Sunsari District. Total 4 VDCs were selected randomly from

49 VDCs of this district and 4 wards out of 9 wards were selected from each selected VDC

using random sampling method. The selected ward was considered as a cluster. Thus there

were total 16 clusters. From each cluster 18 to 35 samples (aged 6 –36 months children)

were taken. All the eligible children were taken as sample from a selected family. The

16

children were selected from every alternate household. As and when there were more than

one family having the child of eligible age in a household, one of the families would

selected randomly on the spot. The selected household was excluded if there was no

eligible child. The selected child also was excluded from the sample if the mother was not

present. However, 2 –3 more visits were done in appropriate time e.g., the researchers

visited to the household in lunchtime if the mother had gone to field. They come to their

home for lunch for about 3 hours.

3.6 Data collection techniques

Structured Interview schedule were prepared and individual interviews done with mothers.

The schedule was pre tested before using it for data collection. For anthropometry the

UNICEF Electronic Scale (SECA 890) was used to measure the weight of children and

mothers. The machine gives only the weight of child after weighing the mother first and

then mother with baby. An infantometer was used to measure the height of the children

below the age of 25 months. A stature meter (a wooden rod with centimeter) was used for

more than 24 months of children and mothers to measure their height.

Variables

The following predictor (independent) and outcome (dependent) variables were studied.

Predictor variables

• Demographic variables (age and, sex)

• Socio-economic variables (using an index made of the type of house, presence of

livestock, durable goods , toilet, lighting, fuel for cooking , source of drinking water

etc which was used in the National family Health Survey)

• Sanitation (presence of toilet)

17

• Mother’s care during pregnancy (Antenatal check up, food, illness etc.)

• Safe delivery (place of birth, birth attendants etc.)

• Feeding practices (Breast feeding, weaning etc.)

• Immunization (BCG, DPT/polio, measles, vitamin A)

• Illness (common cold, fever, diarrhea etc.)

• Health care facilities

Dependent/ outcome variables

• Underweight (weight for age)

Weight-for-age below -2 SD from the National Centre for Health Statistics/WHO reference median value. (NCHS/WHO)

• Wasting (weight for height)

Weight-for-height below -2 SD from the NCHS/WHO reference median value

• Stunting (height for age)

Height-for-age below -2 SD from the NCHS/WHO reference median value. (NCHS/WHO)

3.7 Ethical considerations

The study objective and procedure was reviewed and cleared by the Institutional Ethical

Committee (IEC) of the Sree Chitra Tirunal Institute for Medical Sciences and Technology.

The local leaders were informed about the study. An informed verbal consent was taken

from the mother of the child, who was the respondent of the survey. She/ he was informed

that there was no direct benefit for them from this study but there might be benefit in the

long run if any organizations (governmental or non-governmental) initiate a child nutrition

program based on result of the study. The respondents were informed of the objectives of

the study at the beginning of the interview and were also informed that she could withdraw

18

from the study at any time. All data were entered the identity of the individual respondents

were masked.

3.8 Data collection and analysis

Three female enumerators who were high school graduate and above were hired to conduct

the interview with mothers and to measure the height and weight of mothers and children

and one male person hired to carry the instruments All the enumerators were given

intensive training for 3 days. The researcher himself was involved in data collection

specially the anthropometric measurements. The time period of data collection was about

one and half months from June to August 2005.

Data were entered in Excel and was analyzed using SPSS and Epi nut of the Epi info

program. Univariate and bivariate analysis was done and Chi square test done for

comparing proportions was used to test for associations.

Multiple regression analysis was done to determine the independence of associations

observed in the bivariate analysis by controlling for potential confounders.

19

3.9 Figure I. Conceptual framework for empirical analysis of the study

Child’s nutritional status

Child’s Dietary intake

Child’s health status

Feeding practices

Care of mother and Child

Health environment and services

-Breast-feeding practices -Weaning practices

-ANC of mother -Nutrition during pregnancy -Autonomy --Immunization

-Health care facility -Safe water supply - Sanitation

P O V E R T Y

Socio-cultural environment Economic status

Environment

Basic determinants

Immediate determinants

Source6: Adapted from Smith LC, Haddad L. 2000

20

4. RESULTS

The survey was carried out in the four selected Village Development Committees (VDCs),

Hansposa, Khanar, Babiya and Tanmuna in Sunsari district from June to August 2005

among 443 children below the age of 36 months. The sample was almost uniformly spread

across the four VDCs; 121 from Hansposa, 117 from Babiya, 103 and 102 from Khanar

and Tanmuna respectively.

4.1 Sample characteristics

The total sample consisted of 443 children below the age of 36 months. Out of total (443)

study population, 249 (56.2%), were males and 194 (43.8%) were females.

4.1.1 Age and sex distribution The sample of 443 children is almost uniformly spread among the age groups. The mean

age of the children was 20.21 months; 20.18 among male children and 20.24 among girl

children.

Table.1. Age and sex distribution of the study population Age in months Male Female Total 6 - 11 58 (23.3) 47(24.2) 105 (23.7) 12 - 23 93 (37.3) 72(37.1) 165 (37.2) 24 - 36 98 (39.4) 75(38.7) 173 (39.1} Total 249 194 443 (100)

*Figures in bracket indicates percentages

4.1.2 Socio demographic characteristics

Almost all the children (93 percent) belonged to Hindu households and about one third of

the study populations were from Dalit families. Socio economic status of the study

population was assessed by a standard of living index and nearly 44 percent of the

population belonged to low socio economic status. Toilet facility was not present in 85

percent of the households

21

Table.2. Socio demographic characteristics Variable Frequency Percent

Ethnicity Dalits 145 32.7 Non-Dalits 298 67.3

Religion Hindu 416 93.3 Islam 24 5.4 Buddhist 2 0.5 Christian 1 0.2

Type of house Kachha 366 82.6 Semi Pucca 67 15.1 Pucca 10 2.3

Toilet facility Pit 65 14.7 No toilet 378 85.3

Separate Kitchen Yes 336 75.8 No 107 24.2

Source of cooking fuel Firewood/ cow dung 424 95.7 Electricity/ bio gas 16 3.6 Kerosene 3 0.7

Socio economic status Low 194 43.8 Medium 155 35.0 High 94 21.2

4.1.3 Socio demographic characteristics of parents Almost all the mothers (91.5 percent) were in the age group between 20-34 years. More

than half of the fathers were in the age group 25- 34 and about a quarter less than twenty-

five years. Less than one fifth of the mothers had attended any form of formal education.

50 percent of them were illiterate and about a third could only just read and write but had

attended no formal education. Fathers of the children had better educational status than

their mothers. Almost fifty percent of the fathers had attended school. More than 85 percent

22

of the fathers were either employed in waged labour or farming and the rest in other jobs

like clerks/sales/services etc.

The mean at marriage of mothers was 17.84 years and ranging from 12 to 26 years. Nearly

half of the mothers had married at less than 18 years - the legal age for marriage.

Table.3. Socio demographic characteristics of parents Variable Frequency (n=443) Percent

Age of mother 15 – 19 years 15 3.4 20 – 24 years 210 47.4 25 – 29 years 142 32.1 30 – 34 years 53 12.0 35 – 39 years 17 3.8 40 - 44 years 6 1.4

Education of mother Illiterate 206 46.5 Literate (can read and write only) 138 31.2 Primary and some secondary 73 16.5 SLC and above 26 5.9

Mother’s occupation No wage earning work 419 94.6 Wage earning work outside home 24 5.4

Age of father < 25 years 104 23.5 25 - 29 years 139 31.4 30 - 34 years 124 28.0 35+ years 76 17.2

Education of father Illiterate 126 28.4 Literate (can read and write only) 105 23.7 Primary 50 11.3 Some secondary 90 20.3 SLC and above 72 16.3

Occupation of father Labour 304 68.6 Agriculture 76 17.2 Clerical/ sales/ services 63 14.3

Mother’s age at marriage 12 - 17 years 209 47.2 18 - 20 years 185 41.8 21 - 26 years 49 11.0

23

4.2 Antenatal care (ANC) and maternal factors during pregnancy More than 85 percent of the mothers had antenatal care visits during their pregnancy and 15

percent of the mothers had no antenatal care visits.21 All the women who had received

antenatal care had received the same from a health professional (doctor,nurse, auxillary

nurse midwife,health assistant, auxillary health worker, maternal and child health worker,

village health worker) The national average for Nepal for is near 50 percent for antenatal

care seeking and 28 percent from a health professional. Only 8.1 percent women had any

illness during their pregnancy. About 38 percent of women reported taking less than

normal quantity of food during pregnancy.

Table 4. ANC and other conditions of mother factors during pregnancy Variable Frequency Percent

Antenatal care visits Yes 377 85.1 No 66 14.9

No. of ANC visits None 66 14.9 1 – 2 75 16.9 3 – 4 210 47.4 5+ 92 20.8

Stage of pregnancy at first ANC visit No ANC 66 14.9 < 4 142 32.1 4 – 5 173 39.1 6 - 9 62 14.0

Type of service provider Doctor 108 24.4 Nurse/ MCHW 198 44.7 HA/ AHW 71 16.0 Not visited for ANC 66 14.9

Any illnesses during pregnancy Yes 36 8.1 No 407 91.9

Food intake during pregnancy < Normal 167 37.7 Normal 125 28.2 > Normal 151 34.1

24

4.3 Details regarding delivery Almost seventy percent of the deliveries took place at home and the rest at hospital. More

than fifty percent of the women were being delivered by dais or relatives in spite of the

high coverage of antenatal care by health professionals. Twenty eight percent of the

mothers interviewed reported some kind of complication during delivery

Since details regarding birth weight was not available, mothers were asked about their

perception of the size of the baby at birth as normal, small and big which was done by

NFHS II in India. 21.3 percent of the mothers reported that at birth their babies were

smaller than normal in size.

Table 5. Characteristics of delivery of baby

Variable Frequency Percent Place of birth

Home 304 68.6 Hospital 139 31.4

Delivery assistance Doctor 51 11.5 Nurse 89 20.1 TBA (Trained Birth Attendant) 64 14.4 Dai / relatives 239 54.0

Size of baby1 Big 149 33.7 Medium 199 45.0 Small 94 21.3

Complications during delivery Yes 123 27.8 No 320 72.2 1according to mother’s perceptions 4.4 Feeding practices

Breast feeding was initiated in the first hour of birth only by less than fifty percent of the

mothers. Among those who did not, a quarter of them started breast feeding 2 to 24 hours

after birth and some 3 days after. The breast milk substitutes used among those who were

25

not initiated into breast feeding within one hour after birth were goat’s milk, cow’s milk,

milk of other women or for some, nothing.

Table 6. Characteristics of feeding practices Variable Frequency Percent

Initiation of breast feeding Within one hour 190 42.9 2 – 24 hours 123 27.8 2 – 3 days 108 24.4 After 3 days 22 5.0

Breast milk substitutes Goat/ cow milk 105 23.7 Other women’s breast 42 9.5 Nothing 106 23.9 Fed within one hour 190 42.9

Duration of exclusive breast feeding < 4 months 16 3.6 4 – 5 months 47 10.6 6 months 175 39.5 7 – 9 months 110 24.8 10 – 12 months 76 17.2 13 – 24 months 19 4.3

Bottle feeding Yes 26 5.9 No 417 94.1

Initiation of weaning n= 410 6th month and below 63 15.4 7 – 11 months 268 65.4 12 and above 79 19.3

Frequency of complementary food < 4 times 184 44.9 4 – 5 times 197 48.0 6 – 9 times 29 7.1

Nutritional supplementary programme Yes 23 5.2 No 420 94.8 Fifty percent of the mothers exclusively breast fed their children for 4-6 months. However

it is a matter of concern that babies are exclusively breastfed for more than six months

since delay in the introduction of solid foods or weaning would also predispose children to

under nutrition. About one in five mothers’ exclusively breast fed their babies for ten

26

months and more. There were very few (3.6 percent) who exclusively breast-fed their

children for less than 4 months. Bottle feeding was reported by only 6 percent of mothers

Regarding weaning practices, around fifteen percent of children were introduced to solid or

semisolid food during 0-6 months of age. WHO recommends the introduction of solid or

semisolid food to infants at around the age of 6 months. Around 65 percent were weaned

after 6 months and below one year and about one in five at one year of age and above. Only

five percent had coverage of some nutritional supplementary programme.

4.5 Immunization coverage

Immunisation coverage in the study population was good with almost 100 percent coverage

with BCG and around 80 and above for DPT/Polio and Measles. Vitamin ‘A’ was given to

almost all the children.

Table 7 Immunisation coverage Variable Frequency Percent

BCG Yes 433 97.7 No 10 2.3

DPT/ Polio No dose / incomplete dose 75 16.9 Complete dose 368 83.1

Measles Yes 310 79.7 No 79 20.3 4.6 Infections and Illnesses

The common cold was found to be more common (37.2 percent) followed by fever (35.4

percent) in the two weeks preceding the survey, among the children. Around 13 percent of

children were found to be suffering from diarrhea. 6.3 percent of the children had to be

required admission in the hospital in last 6 months preceding the survey.

27

Table 8. Morbidity of children Variable Frequency Percent

Diarrhea in last 2 weeks Yes 57 12.9 No 386 87.1

Fever in last 2 weeks Yes 157 35.4 No 286 64.6

Common cold in last 2 weeks Yes 165 37.2 No 278 62.8

Hospitalisation in last 6 months Yes 28 6.3 No 415 93.7 4.7 Health care facility – availability and access Almost three fourth of the population had a health facility within 1 to 2 kilometers. The

distance ranged from one to four kilometers. Almost all of them people could reach their

nearest health facility within fifteen minutes to half an hour. Very few (2.5 percent) needed

more than half an hour to an hour to reach their nearest health facility.

For the majority (60.9 percent) their nearest health facility was sub-health post. Private

clinic was the nearest health facility for a little more than one fourth of the population.

More than two third of people had transport facility to reach the nearest health facility.

Close to fifty percent of the populations depend on private clinic for their treatment.

Around one fourth used the hospital for their treatment and one fourth the health post or

sub-health post for their treatment.

Around 85 percent could reach the health facility they usually consult within half an hour.

15.4 percent of them need more than half an hour to reach their health facility they usually

visit for treatment.

28

More than fifty percent had outreach clinic facility in their village. More than 80 percent

respondents reported that health workers had visited their house. About 25 percent of the

respondents also reported that the health workers gave health information

Table 9. Health care facilities Variable Frequency Percent

Distance to nearest health facility < 1 KM 38 8.6 1 – 2 KM 325 73.4 2.1 – 4 KM 80 18.1

Time to reach to nearest health facility < 16 Minutes 207 46.7 16 – 30 Minutes 225 50.8 31 – 60 Minutes 11 2.5

Type of the nearest health facility Sub-health post 270 60.9 Hospital 50 11.3 Private clinic 123 27.8

Transport to nearest health facility Yes 305 68.8 No 138 31.2

Type of health facility usually used Sub-health post and health post 111 25.0 Hospital 124 28.0 Private clinic 208 47.0

Time to reach to health facility usually used < 16 Minutes 151 34.0 16 – 30 Minutes 224 50.6 >30 Minutes 68 15.4

Admission facility at the health facility usually used Yes 163 36.8 No 280 63.2

Presence of out reach clinic Yes 228 51.5 No 215 48.5

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4.10 Prevalence of child malnutrition

The prevalence of underweight was 53.3 percent, wasting 29.8 percent and stunting 36.6

percent in the study population

Table 10. Distribution of child malnutrition Below –3 SD Below – 2 SD Total Weight for age (underweight) 75(16.9) 161 (36.3) 236 (53.3) Weight for height (wasting) 24 (5.4) 108 (24.4) 132 (29.8)

Height for age (stunting) 55 (12.4) 107 (24.2) 162 (36.6) 4.11 Socio demographic characteristics and malnutrition 4.11.1Age and child malnutrition

There was increasing prevalence of underweight and stunting among the older age groups

of children compared to the lower age groups. The difference in the prevalence in the 12-

23 months and above is much more than the younger group. The difference was not

however significant in the case of wasting.

Table 11. Age and child malnutrition Age Weight for age (under weight) P value

Below- 3 SD Below – 2SD Total 6 - 11 10 (9.5) 27 (25.7) 37 (35.2) 0.000 12 - 23 26 (15.8) 69 (41.8) 95 (57.6) 24 - 36 39 (22.5) 65 (37.6) 104 (60.1)

Weight for height (wasting) 6 - 11 5 (4.8) 23 (21.9) 28 (26.7) 0.148 12 - 23 12 (7.3) 49 (29.7) 61 (37.0) 24 - 36 7 (4.0) 36 (20.8) 43 (24.8)

Height for age (stunting) 6 - 11 6 (5.7) 18 (17.1) 24 (22.8) 0.010 12 - 23 23 (13.9) 48 (29.1) 71 (43.0) 24 - 36 26 (15.0) 41 (23.7) 67 (38.7)

30

4.11.2 Sex and child malnutrition There were no more differences for underweight, wasting and stunting between male and

female children. Both sexes were equally affected. The differences in the prevalence was

not statistically significant for underweight, wasting and stunting.

Table 12 Sex and child malnutrition

Sex and malnutrition P value Sex Weight for age (under weight)

Below- 3 SD Below – 2SD Total Male 44 (17.7) 86 (34.5) 130 (52.2) 0.660

Female 31 (16.0) 75 (38.7) 106 (54.7) Weight for height (wasting)

Male 17 (6.8) 60 (24.1) 77 (30.9) 0.332 Female 7 (3.6) 48 (24.7) 55 (28.3)

Height for age (stunting) Male 36 (14.5) 59 (23.7) 95 (38.2) 0.335

Female 19 (9.8) 48 (24.7) 67 (34.5) 4.11.3 Ethnicity and child malnutrition

The ethnic groups were divided into two groups that were Dalits and Non-Dalits. Children

belonging to Dalit families were much more affected by malnutrition. The prevalence of

underweight among Dalit children (63 percent) was higher than that among Non-Dalits (49

percent). There was a statistically significant higher prevalence in the case of underweight

and stunting among Dalit children.

Table 13 Ethnicity and child malnutrition Ethnicity Weight for age (under weight)

Below- 3 SD Below – 2SD Total P value Dalit 35 (24.1) 56 (38.6) 91 (62.7) 0.004

Non Dalit 40 (13.4) 105 (35.2) 145 (48.6) Weight for height (wasting)

Dalit 11 (7.6) 36 (24.8) 47 (32.4) 0.350 Non Dalit 13 (4.4) 72 (24.2) 85 (28.6)

Height for age (stunting) Dalit 22 (15.2) 43 (29.7) 65 (44.9) 0.042

Non Dalit 33 (11.1) 64 (21.5) 97 (32.6)

31

4.11.4 Socio economic status and malnutrition There was a significant difference in the prevalence of underweight and stunting between

the low, middle and high SES groups in the study population. The prevalence of under

weight and stunting is significantly higher in the lower socioeconomic groups and the

difference is statistically significant.

The prevalence of stunting was also higher among the lower SES group. The relationship

the prevalence of stunting and socioeconomic status is also statistically significant.

Table 14 SES and child malnutrition

Standard of living

Weight for age (under weight) P value Below- 3 SD Below – 2SD Total

Low 41 (21.1) 82 (42.3) 123 (63.4) 0.000 Medium 26 (16.8) 53 (34.2) 79 (51.0)

High 8 (8.5) 26 (27.7) 34 (36.2) Weight for height (wasting)

Low 12 (6.2) 48 (24.7) 60 (31.9) 0.864 Medium 8 (5.2) 40 (25.8) 48 (31.0)

High 4 (4.3) 20 (21.3) 24 (25.6) Height for age (stunting)

Low 27 (13.9) 61 (31.4) 88 (45.3) 0.006 Medium 16 (10.3) 33 (21.3) 49 (31.6)

High 12 (12.8) 13 (13.8) 25 (26.6) 4.12 Parental characteristics and child malnutrition 4.12.1 Age at marriage of mother and child malnutrition The mother who got married between 12 – 17 years had more underweight children

compared to those who got married between the age of 18 – 20 and 21 – 26 years. This

relationship was statistically significant.

32

Table 15 Age at marriage of mother and malnutrition

Age Weight for age (under weight) P value Below - 2 SD Total

12 – 17 122 (58.4) 122 (58.4) 0.021 18 – 20 96 (51.9) 96 (51.9) 21 - 26 18 (36.7) 18 (36.7)

4.12.2 Mother’s education and child malnutrition

The prevalence of underweight is almost double among children of illiterate mothers than

those of the children of the mothers with some formal education. Underweight children

among illiterate mothers are significantly more than those among literate and more

educated women.

The relationship was also no statistically significant with wasting.

There was a similar significant association between education of mother and stunting of

children. The result of the analysis show that the lower the level of education of mother,

higher was the prevalence of stunting among their children.

Table 16. Education of mother and child malnutrition Education Weight for age (under weight) P value

Below- 3 SD Below – 2SD Total Illiterate 51 (24.8) 79 (38.3) 130 (63.1) 0.000

Literate only 14 (10.1) 59 (42.8) 63 (52.9) Some formal edu. 10 (10.1) 23 (23.2) 33 (33.3)

Weight for height (wasting) Illiterate 15 (7.3) 55 (26.7) 70 (34.0) 0.184

Literate1 only 3 (2.2) 33 (23.9) 36 (26.1) Some formal edu. 6 (6.1) 20 (20.2) 26 (26.3)

Height for age (stunting) Illiterate 32 (15.5) 64 (31.1) 96 (46.6) 0.001

Literate only 15 (10.9) 29 (21.0) 44 (31.9) Some formal edu. 8 (8.1) 14 (14.1) 22 (22.2)

1can read and write only (no formal education)

33

4.12.3 Father’s education and child malnutrition

The prevalence of underweight was more among children of illiterate fathers than the

children of fathers who are literate of some form of formal education. The fathers having

lower level of education had more underweight children. The relationship between father’s

education and underweight was statistically significant.

Wasting did not show any significant difference between the groups.

The relationship between stunting of children and education of father was also statistically

significant. The lower educated fathers had more children who had stunting than the better

educated.

Table 17 Education of father and child malnutrition Education of mother and child malnutrition

Education Weight for age (under weight) P value Below- 3 SD Below – 2SD Total

Illiterate 32 (25.4) 54 (42.9) 86 (68.3) 0.000 Literate only 20 (19.0) 35 (33.3) 55 (52.3)

Primary and some secondary

20 (14.3) 49 (35.0) 69 (49.3)

SLC and above 3 (4.2) 23 (31.9) 26 (36.1) Weight for height (wasting)

Illiterate 10 (7.9) 30 (23.8) 40 (31.7) 0.112 (Not valid) Literate only 9 (8.6) 19 (18.1) 28 (26.7)

Primary and some secondary

4 (2.9) 38 (27.1) 42 (30.0)

SLC and above 1 (1.4) 21 (29.2) 22 (30.6) Height for age (stunting)

Illiterate 21 (16.7) 40 (31.7) 61 (48.4) 0.001 Literate only 18 (17.1) 23 (21.9) 41 (39.0)

Primary and some secondary

12 (8.6) 36 (25.7) 48 (34.3)

SLC and above 4 (5.6) 8 (11.1) 12 (16.7)

4.13 Place of birth and child malnutrition The place of birth or safe delivery of the children had a significant effect on underweight

and stunting. The children born at home had significantly higher prevalence of underweight

34

and stunting compared to those born at hospital. However, the relationship was not

statistically significant with wasting.

Table.18 Place of birth and child malnutrition

Ethnicity and child malnutrition Place Weight for age (under weight) P value

Below- 3 SD Below – 2SD Total Home 60 (19.7) 112 (36.8) 172 (56.5) 0.004

Hospital 15 (10.8) 49 (35.3) 64 (46.1) Weight for height (wasting)

Home 17 (5.6) 78 (25.7) 95 (31.3) 0.350 Hospital 7 (5.0) 30 (21.6) 37 (26.6)

Height for age (stunting) Home 43 (14.1) 82 (27.0) 125 (41.1) 0.042

Hospital 12 (8.6) 25 (18.0) 37 (26.6) 4.14 Type of provider at delivery and malnutrition The type of provider at delivery and underweight was very significantly associated with

each other. The prevalence was lower among those attended by health professionals who

were professionally more trained. This could be a proxy indicator of the health seeking

practices, socio behavioral factors and also may be due to permeation of information

regarding health from the providers.

Table 19 Type of provider at delivery and malnutrition

Type of provider

Weight for age (under weight) P value Below- 3 SD Below – 2SD Total

Doctor 2 (3.9) 14 (27.5) 16 (31.4) 0.009 Nurse 13 (14.6) 35 (39.3) 48 (53.9) TBA 9 (14.1) 22 (34.4) 31 (48.5)

Dai/ Relatives 51 (21.3) 90 (37.7) 141 (59.0) 4.15 Size of baby at birth and malnutrition

Since the number of institutional deliveries and even antenatal care is poor in the

community there were no options to find the birth weight of the baby. Instead the mothers

35

were asked about their perception of the baby’s size at birth as whether normal, big or

small as a proxy indicator of birth weight.

The size of the baby at birth according to the mother’s perception was strongly associated

with the presence of malnutrition. The prevalence of underweight was significantly higher

among small sized babies than normal and big sized babies. Stunting was also associated

with the size with smaller the size of birth, the prevalence of stunting. The relationship was

statistically significant.

Table 20 Size of baby1 and malnutrition Size of baby1 Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total Small 26 (27.7) 38 (40.4) 64 (68.1) 0.000

Medium 28 (14.1) 80 (40.2) 108 (54.3) Big 21 (14.1) 42 (28.2) 63 (42.3)

Weight for height (wasting) Small 7 (7.4) 27 (28.7) 34 (36.1) 0.628

Medium 9 (4.5) 46 (23.1) 55 (27.6) Big 8 (5.4) 35 (23.5) 43 (28.9)

Height for age (stunting) Small 16 (17.0) 31 (33.8) 47 (50.8) 0.013

Medium 21 (10.6) 50 (25.1) 71 (35.7) Big 18 (12.1) 25 (16.8) 43 (28.9)

1according to mother’s perception 4.16 Birth order and child malnutrition

The prevalence of underweight among the higher birth orders was significantly higher than

those among the lower birth orders. The first and the second born were found to have much

lower prevalence compared to the third & fourth and above

36

Table 21 Birth order and malnutrition Order Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total First 23 (13.9) 55 (33.1) 78 (47.0) 0.004

Second 15 (11.5) 49 (37.4) 64 (48.9) Third 17 (20.5) 34 (41.0) 51 (61.5)

Fourth+ 20 (31.7) 23 (36.5) 43 (68.2) Weight for height (wasting)

First 7 (4.2) 42 (25.3) 49 (29.5) * Second 4 (3.1) 30 (22.9) 34 (26.0)

Third 7 (8.4) 22 (26.5) 29 (34.9) Fourth+ 6 (9.5) 14 (22.2) 20 (31.7)

Height for age (stunting) First 19 (11.4) 32 (19.3) 51 (30.7) 0.034

Second 13 (9.9) 34 (26.0) 47 (35.9) Third 8 (9.6) 24 (28.9) 32 (38.5)

Fourth+ 15 (23.8) 17 (27.0) 32 (50.8) * Statistical test not done due to insufficient numbers 4.17 Duration of exclusive breast-feeding and child malnutrition The prevalence of underweight was significantly higher in children who were exclusively

breast fed for greater periods. The relationship was not however significant for wasting and

stunting.

Table 22 Duration of exclusive breast feeding and malnutrition

Duration Weight for age (under weight) P value Below - 3 SD Below - 2 SD Total

Up to 6 months 31 (13.0) 85 (35.7) 116 (48.7) 0.001 7 – 9 months 16 (14.5) 38 (34.5) 54 (49.0) 10+ months 28 (29.5) 38 (40.0) 66 (69.5)

Weight for height (wasting) Up to 6 months 12 (5.0) 53 (22.3) 65 (27.3) 0.689 7 – 9 months 7 (6.4) 27 (24.5) 34 (30.9) 10+ months 5 (5.3) 28 (29.5) 33 (34.8)

Height for age (stunting) Up to 6 months 33 (13.9) 48 (20.2) 81 (34.1) 0.063 7 – 9 months 8 (7.3) 29 (26.4) 37 (33.7) 10+ months 14 (14.7) 30 (31.6) 44 (46.3)

37

4.18 Immunization and child malnutrition

The immmunisation status among the study population was good. The prevalence of

underweight among completely vaccinated children was significantly lesser than those who

had no or incomplete vaccination.

Table.23 Immunization and malnutrition Immunization Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total No/ Incomplete 20 (26.7) 27 (36.0) 47 (62.7) 0.034

Complete 55 (14.9) 134 (36.4) 189 (51.3) Weight for height (wasting)

No/ Incomplete 10 (13.3) 15 (20.0) 25 (33.3) * Complete 14 (3.8) 93 (25.3) 107 (29.1)

Height for age (stunting) No/ Incomplete 10 (13.3) 25 (33.3) 35 (46.6) 0.097

Complete 45 (12.2) 82 (22.3) 127 (34.5) * Statistical test not done due to insufficient numbers 4.19 Infections and Illnesses 4.19.1 Fever and child malnutrition

Higher prevalence of underweight and stunting was associated with having fever in last 2

weeks preceding the survey. The prevalence was higher among those who had fever than

those who had no fever in the previous two weeks. The relationship was statistically

significant.

Table 24. Fever in the last 2 weeks and malnutrition Fever Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total Yes 36 (22.9) 59 (37.6) 95 (60.5) 0.018 No 39 (13.6) 102 (35.7) 141 (49.3)

Weight for height (wasting) Yes 11 (7.0) 37 (23.6) 48 (30.6) * No 13 (4.5) 71 (24.8) 84 (29.3)

Height for age (stunting) Yes 21 (13.4) 48 (30.6) 69 (44.0) 0.040 No 34 (11.9) 59 (20.6) 93 (32.5)

* Statistical test not done due to insufficient numbers

38

4.19.2 Diarrhea and child malnutrition

History of diarrhea was not found to be associated with underweight and wasting but with

stunting. The prevalence was higher for those who had history of diarrhea in the 2 weeks

preceding the survey than those who did not.

Table.25 Diarrhea (2 wks preceding survey) and malnutrition Diarrhea Height for age (Stunting) P value

Below - 3 SD Below - 2 SD Total Yes 13 (22.8) 11 (19.3) 24 (42.1) 0.036 No 42 (10.9) 96 (24.9) 138 (35.8)

4.20 Sanitation and child malnutrition The prevalence of under weight and stunting was found to be much higher among the

children from households which did not have toilet facility compared to those who had

toilet facility. The relationship was statistically significant. However, no relationship was

established between wasting and presence or absence of toilet in the household.

Table. 26 Presence of toilet and malnutrition Toilet Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total Pit 4 (6.2) 17 (26.2) 21 (32.4) 0.001 No 71 (18.8) 144 (38.1) 215 (56.9)

Weight for height (wasting) Pit 3 (4.6) 15 (23.1) 18 (27.7)

* No 21 (5.6) 93 (24.6) 114 (30.2) Height for age (stunting)

Pit 6 (9.2) 8 (12.3) 14 (21.5) 0.021 No 49 (13.0) 99 (26.2) 148 (39.0)

* Statistical test not done due to insufficient numbers 4.21 Exposure to media and malnutrition 4.21.1 Ownership of radio and child malnutrition

Ownership of radio as a medium of communication also had a significant association with

malnutrition. The prevalence of underweight and stunting were significantly lower in

39

households owning a radio. It could be a proxy indicator of exposure to health information

or also may be due to better social status and better practices

Table 27. Ownership of radio and malnutrition Ownership Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total Yes 30 (13.6) 69 (31.2) 99 (44.8) 0.002 No 45 (20.3) 92 (41.4) 137 (61.7)

Weight for height (wasting) Yes 12 (5.4) 57 (25.8) 69 (31.4) 0.783 No 12 (5.4) 51 (23.0) 63 (28.4)

Height for age (stunting) Yes 25 (11.3) 37 (16.7) 62 (28.0) 0.000 No 30 (13.5) 70 (31.5) 100 (45.0)

4.21.2 Ownership of television and malnutrition: The households who owned television had statistically significant lower prevalence of

underweight and wasting. The relationship was however not significant with wasting.

Table 28 Ownership of television and malnutrition Ownership Weight for age (under weight) P value

Below - 3 SD Below - 2 SD Total Yes 21 (13.0) 47 (29.2) 68 (42.2) 0.000 No 54 (19.1) 114 (40.4) 168 (59.5)

Weight for height (wasting) Yes 8 (5.0) 35 (21.7) 43 (26.7) 0.560 No 16 (5.7) 73 (25.9) 89 (31.6)

Height for age (stunting) Yes 16 (9.9) 30 (18.6) 46 (28.5) 0.030 No 39 (13.8) 77 (27.3) 116 (41.1)

4.22 Health care facility and child malnutrition 4.22.1 Type of nearest health facility and child malnutrition No significant relationship was found between type of nearest health facility and child

malnutrition. The prevalence of underweight was slightly higher for those who had health

post or sub-health post as nearest health facility. There was no basic difference between

40

them who had hospital and private clinic as nearest health facility. Wasting was slightly

lower for those who had hospital as a nearest health facility. Stunting was almost same for

all in terms of the types of nearest health facility.

Table 29. Type of nearest health facility and malnutrition

Type Weight for age (under weight) Below - 2 SD Total P value

Health post. Sub-health post

151 (55.9) 151 (55.9) 0.372

Hospital 25 (50.0) 25 (50.0) Private clinic 60 (48.8) 60 (48.8)

Weight for height (wasting) Health post.

Sub-health post 89 (33.0) 89 (33.0) 0.162

Hospital 14 (28.0) 14 (28.0) Private clinic 29 (23.6) 29 (23.6)

Height for age (stunting) Health post.

Sub-health post 100 (37.0) 100 (37.0) 0.920

Hospital 17 (34.0) 17 (34.0) Private clinic 45 (36.6) 45 (36.6)

4.22.2 Time to reach nearest health facility and child malnutrition

The time to reach to the nearest health facility had no significant relationship with child

malnutrition. The prevalence of underweight was almost same for all. Wasting was slightly

lower for those who could reach to the nearest health facility in least time (< 16 minutes).

Stunting was slightly less for those who need more time to reach to the nearest health

facility. It might be because most of them reach within half an hour. There were only 11

households who need more than half an hour to reach to the nearest health facility.

41

Table 30 Time taken to reach nearest health facility and malnutrition Time Weight for age (under weight)

Below - 2 SD Total P value < 16 minutes 112 (54.1) 112 (54.1) 0.905

16 – 25 minutes 50 (53.8) 50 (53.8) 26 – 60 minutes 74 (51.7) 74 (51.7)

Weight for height (wasting) < 16 minutes 57 (27.5) 57 (27.5) 0.617

16 – 25 minutes 30 (32.3) 30 (32.3) 26 – 60 minutes 45 (31.5) 45 (31.5)

Height for age (stunting) < 16 minutes 78 (37.7) 78 (37.7) 0.654

16 – 25 minutes 36 (38.7) 36 (38.7) 26 – 60 minutes 48 (33.6) 48 (33.6)

4.22.3 Type of health care facility usually visited and malnutrition

There was no significant association between child malnutrition and the type of health care

facility that were usually consulted.

Table 31. Type of frequently used health facility and malnutrition

Type Weight for age (under weight) P value Below - 3 SD Below – 2 SD Total

Health post/ Sub-health

post

23 (20.7) 42 (37.8) 65 (58.5) 0.150

Hospital 21 (16.9) 52 (41.9) 73 (58.8) Private clinic 31 (14.9) 67 (32.2) 98 (47.1)

Weight for height (wasting) Health post/ Sub-health

post

7 (6.3) 26 (23.4) 33 (29.7) 0.757

Hospital 5 (4.0) 35 (28.2) 40 (32.2) Private clinic 12 (5.8) 47 (22.6) 59 (28.4)

Height for age (stunting) Health post/ Sub-health

post

13 (11.7) 22 (19.8) 35 (31.5) 0.300

Hospital 20 (16.1) 34 (27.4) 54 (43.5) Private clinic 22 (10.6) 51 (24.5) 73 (35.1)

42

4.22.4 Time taken to reach the commonly used health facility Mothers were asked about the time it took them to reach the health facility where they

commonly seek care. It was to assess indirectly whether access to health facility in terms of

distance and time affects health care seeking for children and whether it has any association

with the malnutrition. It was however seen that there was no significant relationship.

Table. 32. Time taken to reach the commonly used health facility and malnutrition Time Weight for age (under weight)

Below - 2 SD Total P value < 16 minutes 80 (53.0) 80 (53.0) 0.430 16 – 30 minutes 115 (51.3) 115 (51.3) 31+ minutes 41 (60.3) 41 (60.3) Weight for height (wasting) < 16 minutes 38 (25.2) 38 (25.2) 0.198 16 – 30 minutes 69 (30.8) 69 (30.8) 31+ minutes 25 (36.8) 25 (36.8) Height for age (stunting) < 16 minutes 54 (35.8) 54 (35.8) 0.475 16 – 30 minutes 87 (38.8) 87 (38.8) 31+ minutes 21 (30.9) 21 (30.9)

4.23 Multivariate analysis

To determine the extent of influence of various correlates on underweight and stunting,

multiple regression analysis was done. The independent variables with which the

dependant variable exhibited significant associations during bivariate analysis were

considered for regression analysis.

Correlates of underweight

The odds of under weight were more with lower education of fathers. Children born to

illiterate fathers have more chance (OR=1.65, C.I 0.74 –3.70) for being underweight.

43

Children who live in low standard of living have twice the chance of being under weight

compared to children with higher standard of living. Under weight was also associated

with age of the child. Children in households without toilets were 1.35 times at more risk

than those living in households with toilet for being underweight.

Table 33: Correlates of under weight: Results of multiple regression analysis Variables p

Value Odds ratio C.I

Age of baby (in months)

6-9 0.000 0.25 0.13-0.49 10-12 0.810 1.08 0.52-2.13 13-24 0.502 1.15 0.7-1.86

25-36 (R ) 1.000 Education of

father

Illiterate 0.223 1.65 0.74 –3.70 Literate 0.934 1.03 0.48-2.19 Primary 0.850 1.08 0.48-2.45

Secondary 0.528 1.25 0.63-2.50 SLC and above

(R ) 1.00

Birth Order 1 0.143 0.35 0.08-1.42

2-3 0.257 0.45 0.11-1.79 4-5 0.754 0.79 0.17-3.47

6+ (R ) 1.00 Standard of living index

Low 0.05 2.04 0.99-4.22 Medium 0.22 1.47 0.79-2.74 High (R ) 1.00

Toilet facility Yes (R ) 0.178 1.00 0.90-3.52 No 1.35

R: Reference category

Note: Some variables that were considered in the model were dropped subsequently

44

Correlates of Stunting

Table Correlates of Stunting: Results of multiple regression analysis Variables p

Value Odds ratio C.I

Age of baby (in months)

6-9 0.014 0.41 0.20-0.83 10-12 0.882 0.95 0.48-1.87 13-24 0.420 1.22 0.75-1.96

25-36 (R) 1.000 Birth Order

1 0.387 1.74 0.49-6.18 2-3 0.236 2.12 0.61-7.31 4-5 0.039 4.05 1.07-15.28

6+ (R) 1.00 Mother’s edn

Illiterate 0.118 2.38 0.80-7.04 Literate 0.627 1.32 0.43-3.98 Primary 0.556 1.53 0.36-6.35

Secondary 0.836 0.88 0.26-2.95 SLC and above

(R )

R Reference category Note: Some variables that were considered in the model were dropped subsequently

Children born to mothers who are illiterate are more than twice at risk of being stunted,

compared to those born to women with higher education. Children of birth order 4 and 5

showed higher chance of being stunt compared to children in the birth order of 6 and

above.

45

5. DISCUSSION

Discussion The study findings suggest that the prevalence of underweight, wasting and stunting in

children between six and thirty six months of Sunsari district is 53.3, 29.8 and 36.6 percent

respectively.

When analysis was done to find the possible factors associated with malnutrition, it was

clearly seen that malnutrition increased with increase in age of the child. Older children

were found to be more underweight and stunted compared to the younger children. This is

similar to other studies, which have reported more malnutrition among the older children.21

It confirmed the earlier reports (NDHS, 21 Sah, 34 NFHS-II, 35 Andhra Pardesh, 19 Ethopia,

27) that the prevalence of malnutrition was higher among 13 – 36 months aged children.

The nutritional status of the female children was not significantly different from

males in this study. Other studies in Nepal and India (NDHS,21NFHS II35 Sah,34) that the

prevalence of malnutrition was similar to both the sexes males and females in this age

group.

Children from Dalit families were found to have significantly higher malnutrition

rates compared to other children. It is probably due to the general social backwardness in

education, resources, social mobility and opportunities that the prevalence of underweight

and stunting was quite higher for Dalits compare to Non-Dalits. Sah 34 in his study in

Dhanusha did not find significant relationship between ethnicity and child malnutrition but

the prevalence was higher for Dalits than Non-Dalits. National Family Health Survey, India

(NFHS-2), revealed that the children belonging to schedule caste, tribal groups and other

46

backward classes were found to have relatively higher prevalence of child malnutrition

than forward groups.

As reported in many previous reports, this study also revealed the significant

relationship between standard of living and child malnutrition. There was vast difference in

prevalence of underweight and stunting between the low SES and the higher SES group.

Wasting also was slightly low for high standard of living group.

The age at marriage of mother was found to be significantly associated with child

malnutrition. The prevalence was quite higher among the children belonging to the mother

who got married before 18 years of age. Because early marriage especially among females

is quite common, half of the mothers were married before reaching 18 years of age though

the legal age for marriage in Nepal for girls is 18. The women who got married earlier, may

be physically and mentally fit enough to handle the stress of a marriage, early child

bearing and child rearing and negotiate contraception or other matters relating to their

children with the husband or other relatives. It puts them at risk of repeated pregnancies

which puts their health and the health of their children at risk.

No significant relationship was established between the present age of mothers and child

malnutrition or the age at delivery of mothers and child malnutrition.

Like many previous studies, this study also showed significant relationship between

mother’s education and child malnutrition. This may be due to the fact that an educated

mother has more opportunities to be informed and be aware of aware about health care,

better nutrition, child development etc compared to an uneducated mother.

47

Educated fathers had significantly lower number of malnourished children

compared to less educated fathers. This could be due to the fact that they could be earning

more, are aware of general health and nutrition. It could be also due to the fact that they are

exposed to mass media and other opportunities, which has made their expectations of their

children much higher than those who are not educated. The prevalence of stunting was

almost three times higher among the children belonging to illiterate fathers compare to

children belonging to the fathers having SLC and above level of education.

Place of birth and type of assistance at delivery had significant association with

child malnutrition. The prevalence of underweight and stunting was higher among the

children born at home compared to those born at hospital. The prevalence of underweight

was higher among the children whose deliveries were conducted by Dai or relatives.

Though malnutrition may not be directly related to the place of delivery and the type of

provider it reflects the general health seeking behaviour and the awareness of the mothers

of safe motherhood and childcare that is causing the association. Also exposure to the

formal health system or providers would also help in gaining more health and childcare

related information.

Size of the babies at birth according to the mothers’ perception was considered

since information was not available about the actual birth weight and was found to be

significantly more malnourished than others. It was found that lower the size at birth higher

was the prevalence of underweight and stunting. Mother’s care especially during her pre

pregnancy period, her height and weight, weight gain during pregnancy, maternal illnesses

including hypertension can cause low birth weight. Low birth weight babies also need

48

special care and nutrition to make up for the deficit. In many socio economically poor

households and communities it does not happen and results in malnutrition.

Birth order of the baby has an affect on malnutrition as it was shown in previous

studies like NFHS-2 (India). 35 The first and second birth had almost the same experience

of being underweight. However there is significant difference in the prevalence of

underweight and stunting in the higher birth orders. Higher the birth order, higher was the

prevalence of stunting. Higher birth order and surviving children reflects repeated

pregnancies and probably less care for the individual children. Repeated and often

unplanned pregnancies drain on the mother’s health and also impoverish the family further.

All these might be the reasons that birth order has an affect on child malnutrition.

In children with exclusive breast-feeding for more than 6 months the prevalence of

underweight was very much higher for those children whose mothers exclusively breast-fed

up to 6 months. Exclusive breastfeeding even after nine months and one year could be due

to the belief that breast feeding is the best for children and not knowing that breast feeding

alone for more than 6 months would not be sufficient for the child and would cause

malnourishment. But no significant relationship was found between late weaning and child

malnutrition.

Immunization also had an affect on child malnutrition. The children who took

complete dose of DPT/polio were less affected by malnutrition. This could be due to the

fact that it indicates better health care seeking and awareness regarding general health.

Fever in the two weeks preceding the survey had significant affect on underweight and

stunting. The children having fever were had more prevalence of underweight and stunting.

49

This could be due to the fact that repeated infections causing fever brings down the

immunity and causes lack of appetite and cause malnourishment and it becomes a vicious

cycle.

Diarrhea in the two weeks preceding the survey had no affect on underweight and

wasting but was significantly associated with stunting. Some previous report e.g., Jamaica

14 mentioned that diarrhea was significantly associated with underweight what it could not

be found in this study.

Sanitation was significantly associated with child malnutrition. The households

having toilets had less prevalence of underweight and stunting. Most of the households in

this area didn’t have toilet facility. Even the economically sound households didn’t have

toilets in this area, which was affecting a lot in child nutrition. This reflects the need for not

only provision of toilets for the people who cannot afford them but also needs an

anthropological enquiry into their beliefs systems around the construction and use of toilets

within homes, which is not popular among well to do families.

Ownership of radio and ownership of television also had significant association

with child malnutrition. The children belonging to the households having radio and

television had less prevalence of underweight and stunting. It might be because they might

have listened to or watched the programs about maternal and child health care. There are

advertisements about maternal and child health in local languages in radio and television.

No significant relationship was found about the availability and type of health care facility

and child malnutrition. The district has a good infrastructural facilities including tertiary

medical college, primary health centres , health posts, one sub health posts for each VDC

and private practitioners and also a multi speciality hospital in the nearby district. The

50

physical availability and the accessibility to the health facilities therefore are not enough to

create healthier children in the country. Their social and economic constraints and their

realities may be limiting their use of these facilities. The reasons could be one of broader

social and economic disparities.

6. CONCLUSION

The conclusion of the study is that there is a high level of malnutrition among the children

between 6 months and 36 months in the rural Terai region. The factors underlying the

malnutrition include socio economic and cultural factors in the community. Children born

in household with low socioeconomic status, to mothers who were less educated and whose

fathers were less educated had more chances of being underweight and stunted compared to

others.

About half of the people had low standard of living. Sanitation seemed to be very poor

because most of the people had no toilet facility. Overall education level was poor and it

was even poorer for females. Hand pump was the source of drinking water for almost all

households. Immunization coverage seemed to be satisfactory. Most of the mothers had

gone for antenatal check up at least once during pregnancy. The availability of health care

facility seemed not to be a problem.

More than half of the children were underweight, more than one third were stunted and

about one third were wasted. Socio-economic factors were found to be the key factors of

child malnutrition. Mother’s condition like age at marriage and education had significant

relationship with child malnutrition. Sanitation and prolonged exclusive breast-feeding also

51

had strong relationship with malnutrition. Size of baby at birth also was one of the

important factors influencing child malnutrition.

7. RECOMMENDATIONS

The policy implications and the possible recommendations out of this study cannot be

short-term measures. Since the prevalence of under nutrition and stunting was associated

with factors like low socioeconomic status, lower literacy levels and absence of toilet the

policies and strategies have to be long term and strategic at the individual, community and

the country level.

• Improving the economic and food security especially of the poor and marginalised

through increased production, public distribution system, job security etc.

• Improve the status of women through primary and secondary education, non-formal

skill training to increase economic independence

• Health information packages aimed at popularizing better locally available

nutritious food, supplementary feeding programs for children under five through

network of child care centers like the anganwadis in India.

• Health workers were reported to be visiting rural households; they can be trained on

giving culturally sensitive health information sessions on nutrition and child health

among other topics.

• 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

REFERENCES

1. Jelliffe DB. The Assessment of the nutritional status of the community: WHO

monograph series no. 53, Geneva: WHO, 1966.

2. Morel AJ, Pereira BJC. Childhood Malnutrition [online]. 2005 [cited 2005

March 15]. Available from URL: http://www.medinet.lk/education-on-

dis/CHILDHOOD%20MALNUTRITION.htm

3. Latham MC. Human Nutrition in the Developing World, Food and Nutrition

Series - No. 29. [online]. 1997 [cited 2005 March 15]. Available from URL:

http://www.fao.org/documents/show_cdr.asp?url_file=/DOCREP/W0073e/w0073

e00.htm

4. Setboonsarng S. Child Malnutrition as a Poverty Indicator, An Evaluation in the

Context of Different Development Interventions in Indonesia [online]. 2005 [cited

2005 March 13]. Available from: URL:

http://www.adbi.org/files/2005.01.14.dp21.malnutrition.poverty.indonesia.pdf

5. World Health Organization. Physical Status: the use and interpretation of

anthropometry. Technical Report Series no. 854.WHO, Geneva, 1995.

6. Smith LC, Haddad L. Explaining Child Malnutrition in Developing Countries, A

Cross Country Analysis: International Food Policy Research Institute,

Washington DC [online]. 2000 [cited 2005 March 14]. Available from: URL:

http://www.ifpri.org/pubs/abstract/111/rr111.pdf

7. Smith LC, Haddad L. Overcoming Child Malnutrition in Developing Countries:

Past Achievements and Future Choices: Food, Agriculture and the Environment

Discussion Paper 30 [online]. 2000 [cited 2005 March 13]. Available from: URL:

http://www.ifpri.org/2020/dp/2020dp30.pdf

8. Haddad L, Alderman H., Appleton S, Song L, Yohannes Y. Reducing Child

Malnutrition: How Far Does Income Growth Take Us? The World Bank

Economic Review Vol. 17, No. 1. 107-131 [online]. 2001 [cited 2005 March 14].

Available from: URL:

http://www.nottingham.ac.uk/economics/credit/research/papers/cp.01.05.pdf

9. Borooah VK. The Role of Maternal Literacy in Reducing the Risk of Child

Malnutrition in India: University of Ulster and ICER [online]. 2002 [cited 2005

March 14]. Available from: URL: http://ideas.repec.org/p/icr/wpicer/31-

2002.html

10. Madise N.J, Mpoma M. Child Malnutrition and Feeding Practices in Malawi

[online]. 1992 [cited 2005 March 12]. Available from: URL:

http://www.unu.edu/unupress/food/V182e/ch13.htm

11. Early childhood feeding, nutrition and development [online]. 1997 [cited 2005

March 12]. Available from: URL:

http://www.cbs.gov.np/Surveys/NMIS%20cycles/4th_cycle.pdf

12. Faulty Feeding Practices and Malnutrition [online]. 2003 [cited 2005 March 7].

Available from: URL: www.bpni.org/cgi/faultyfeeding.asp?pr=yes

13. Waters H, Saadah F, Surbakti S, Heywood P. Weight-for-age malnutrition in

Indonesian children, 1992 – 1999. International Journal of Epidemiology 2004;

33: 589-595

14. Melville B, Williams M. Francis V, Lawrence O, Collins L. Determinants of

Child Malnutrition in Jamaica [online]. 1998 [cited 2005 March 7]. Available

from: URL: http://www.unu.edu/unupress/food/8F101e/8F101E08.htm

15. Despite efforts, why does child malnutrition persist in India? [online]. [cited

2005 March 16]. Available from: URL:

www.ifpri.org/media/BeijingPlus10/briefIndia.pdf

16. UNICEF. Global database on Child Malnutrition [online]. [cited 2005 March 18].

Available from: URL: http://www.childinfo.org/eddb/malnutrition/database3.htm

17. Taking Measurements [online]. [cited 2005 March 19]. Available from: URL:

http://www.fantaproject.org/downloads/pdfs/anthro_5.pdf

18. Learn More about Nutrition; Anthropometric measurement and indices [online].

[cited 2005 March 21]. Available from: URL:

http://www.refugeecamp.org/learnmore/nutrition/weight-for-height.htm

19. Yasoda Devi P, Geervani P. Determinants of Nutrition Status of Rural Pre-school

Children in Andhra Pardesh [online]. [cited 2005 March 23] Available from:

URL: http://www.unu.edu/unupress/food/8F154e/8F154E0c.htm

20. Clemens J., et al. Early Initiation of Breast Feeding and the Risk of Diarrhea in

Rural Egypt. Pediatrics [serial online] 1999 [cited 2005 March 16]; 104; 3-.

Available from: URL:

http://www.pediatrics.org/cgi/content/full/104/1/e3

21. Nepal Demographic Health Survey, 2001: Chapter 10. p.171-193

22. Sangvi T. Reducing Severe and Moderate Malnutrition in Children [online]. [cited

2005 March 27] Available from: URL

http://www.basics.org/pdf/worldsummit/world/worldsummit-sec7.pdf

23. Kikafumda JK., Ann F. Walker AF., Collett D., Tumwine JK. Risk Factors for

Early Childhood Malnutrition in Uganda. Pediatrics [serial online] 1998 [cited

2005 March 27]; 102; 45-. Available from: URL:

http://www.pediatrics.org/cgi/content.full/102/4/e45

24. Levinson FJ et al. Morinda revisited: changes in nutritional well-being and

gender differences after 30 years of rapid economic growth in rural Punjab, India.

Food Nutr Bull. 2004 Sep;25(3):221-7.

25. Grubesic RB. Children aged 6 to 60 months in Nepal may require a vitamin A

supplement regardless of dietary intake from plant an animal food sources. Food

Nutr Bull. 2004 Sep;25(3):248-55.

26. Sanghvi U, Thankappan KR, Sarma PS, Sali N. Assessing potential risk factors

for child malnutrition in rural Kerala, India. J Trop Pediatr. 2001 Dec; 47(6): 350-

55.

27. Girma W, Genebo T. Determinants of Nutritional Status of Women and Children

in Ethiopia [online]. 2002 [cited 2005 April 16]. Available from: URL:

www.measuredhs.com/pubs/pdf/FA39/02-nutrition.pdf

28. Marquis GS, Habicht JP, Lanata CF, Black RE, Rasmussen KM. Association

of breastfeeding and stunting in Peruvian toddlers: an example of reverse

causality. Int J Epidemiol. 1997 Apr;26(2):349-56.

29. Bennan L, McDonald J, Shlomowitz R. Infant feeding practices and chronic child

malnutrition in the Indian states of Karnataka and Uttar Pradesh. Economics and

Human Biology 2 (2004) 139-158.

30. Chamarbagwala R, Ranger M, Waddington H, White H. The Determinants of

Child Health and Nutrition: A Meta_Analysis [online]. [cited 2005 April 21].

Available from: URL: http://www.wam.umd.edu/~ranger/home/papers/meta-

analysis.pdf

31. Chaudhari KK, Hanifi MA, Rasheed S, Bhuiya A.Gender inequality and severs

malnutrition among children in a remote rural area of Bangladesh. J Health Popul

Nutr 2000 Dec; 18(3): 123-130.

32. Whitworth A, Stephenson R. Birth spacing rivalry and child mortality in India.

Social Science and Medicine 2002; 55: 21017-21019.

33. District profile of Sunsari [online]. 2005 [cited 2005 Oct. 14]. Available from:

URL: http://npc.gov.np:8080/dprofile/distinfo.jsp?dist=71&chapter=1&topic=4

34. Sah N. Determinants of child malnutrition in Nepal, A case analysis from

Dhanusha, central Terai of Nepal [online]. 2005 [cited 2005 Sept. 25]. Available

from: URL: http://iussp2005.princeton.edu/download.aspx?submissionId=51628

35. National Family Health Survey 1998-1999. International Institute for Population

Sciences, Bombay, 2000.

36. Population Census 2001 [Monograph on CD-ROM]. National Planning

Commission, Central Bureau of Statistics, Nepal.

37. World Health Organization. Global Database on Child Growth and Malnutrition

[online]. 1997 [cited 2005 April 7]. Available from: URL:

http://whqlibdoc.who.int/hq/1997/WHO_NUT_97.4.pdf

38. UNICEF. The State of the World’s Children [online]. 1998 [cited 2005 May 5].

Available from: URL: http://www.unicef.org/sowc98/silent.htm

39. Reducing child malnutrition; How far does income growth take us?. Haddad L,

Alderman H, Appleton S, Song L, Yohame Y. World Bank.Econ Rev Vol

17;1,107-131

ANNEXURES

Abbreviations

WHO World Health Organization

AHW Auxiliary Health Worker

HA Health Assistant

MCHW Maternal and Child Health Worker

VDC Village Development Committee

VHW Village Health Worker

TBA Trained Birth Attendant

SAARC South Asian Association for Regional Cooperation

MUAC Mid Upper Arm Circumference

ARI Acute Respiratory Infection

GNP Gross National Product

SLC School Leaving Certificate

ANC Antenatal Care

SD Standard Deviation

SES Socio economic status

SLI Standard of living index

P Value Probability Value

BCG Bacillus Calmette Guerin vaccine

DPT Diphtheria, Pertussis and Tetanus vaccine

NFHS National Family Health Survey

NDHS National Demographic Health Survey

Interview Schedule No.: ______ VDC: _________ Household no. ______ Ward No.: __________

Study on Factors Associated with Malnutrition Among Children in

Rural Terai of Eastern Nepal

Consent Form I am Mr. Pramod Singh Gharti Chhetri an employee of B.P.Koirala Institute of Health

Sciences, Dharan, Nepal studying for Masters in Public Health at the Achutha Menon

center for Health Science Studies, Trivandrum, Kerala, India. I am doing a community

based research study to find the prevalence and factors associated with malnutrition

among children aged 6-36 months in Terai. You will not have any direct benefit now

from this research but you can be benefited in long run if any governmental or

nongovernmental organization started any program on nutrition based on the report of

this research. As a part of the study I would like to ask you some information regarding

your child, feeding practices, diet etc. I would also like to measure her/ his weight, height

and mid arm circumference as a part of assessing her/ his nutritional status. The

information collected will be kept confidential and used for research purposes only. You

can refuse to answer any of the questions that you don’t want to. You can opt out of the

interview at any time without fear or harm. If you are willing to participate, kindly give

me your consent.

Willing to take part in the research

Yes / No

Interviewer: ____________ Date ____________

Witness: _______________

Background information

House ownership (a) Yes_______ (b) No__________

Type of Family (a) Nuclear____ (b)Extended___ ( c ) Joint______

Type of House (a) Kachha_____ (b)Semi Pucca__ ( c ) Pucca_____

Type of toilet (a) Flush_____ (b) Pit______ ( c ) No_______

Agricultural land holding Acre____ Bigha____ Kathha__ Dhur__ No__

Irrigated land holding Acre____ Bigha____ Kathha__ Dhur__ No__

Source of lighting (a) Electricity_________ (b) Kerosene/Gas/Oil____

( c) Others (specify)___________

Main fuel for cooking (a) Electricity/ Liquid petroleum/ Gas/ Bio gas_________

(b) Coal/ Charcoal/ Kerosene_______

( c ) Wood/ Cow dung____ (d) Others (Specify)____

Source of drinking water Private (a) Pipe_ (b) Hand Pump___ ( c ) Well___

Public (a) Pipe_ (b) Hand Pump__ ( c ) Well___

Others (specify)_________

Separate room for cooking (a) Yes________ (b) No___________

Ownership of Livestock (a) Yes________ (b) No___________

Ownership of durable

goods

(a) Car______ (b) Tractor____ ( c )Motorcycle_

(d) Telephone__ (e) Refrigerator_ (f) Color TV___

(g) Bicycle____ (h) B/W TV____ (i) Water pump_

(j) Bullock cart_ (k) Thresher___ (l) Mattress___

(m) Pressure Cooker_____ (n) Chair___________

(o) Cot/bed____ (p) Table___ (q) Clock Watch___

(r) Elect. Fan__ (s) Radio___ (t) Sewing Machine___

Socio-demographic information of the mother of index child Age (in completed years) Religion Caste/ ethnicity Education Age at marriage (in completed years) Occupation (Whether wage earning inside/outside)

Inside Outside

Socio-demographic information of the father of index child

Age (completed) Education Occupation

ANC/Illness during pregnancy of Mother (of index child)

Antenatal care Yes No Number of ANC visits Time of first ANC visit ANC Examined by Illness diagnosed during pregnancy Yes (specify) No Any illness for which medication is taken Yes (specify) No

Diet/ life style during pregnancy

Food (a) Normal (b)>Normal ( c ) < Normal Food avoided (name) Smoking (a) Yes (b) No Alcohol (a) Yes (b) No

Information of Index child

Age in months (completed) Sex (a) Male (b) Female Place of birth (a) Home (b) Hospital ( c ) Others (specify) Birth Attendant (a) Doctor (b) Nurse (b) TBA ( c) Dai (d) Relative Complication Yes No Birth order How old was the older child when this baby was born

How old was the child when the next baby was born

Perceived birth size (by mother) (a) Big (b) Medium ( c ) Small No of siblings below 5 years of age Primary care taker Mother’s age at index child birth

Status/ autonomy of mother In a family, there are certain activities on which, either the husband or the wife makes decisions alone. In addition, sometimes decisions may be made through discussions with the spouse, making final decisions together, or someone else in the household may make the decision. Who in your family usually has the final say in the following decisions? * Your own health care Making large household purchases, e.g. TV Making household purchases for daily needs

Visits to family, friends, or relatives What food should be cooked every day What to do if a family member becomes sick Whether you should work outside the home Whether or not to use family planning in the future Adopted from the Mullany Britta C, Hindin Michelle J, Becker Stan, 2005*

Feeding Practices:

Breast feeding Initiation after birth (a) Within one hour (b) Within 24 hours ( c ) Within 3 days (d) After 3 days If not within 1 hour, what was fed (a) Goat milk (b) Cow milk ( c ) Other women’s

milk (d) Others (specify)

Exclusive breast feeding (in months) Bottle feeding Yes No

Weaning Time of initiation of supplementary feeding / weaning (in months)

Type of foods No of meals per day (24 hours) Any nutritional supplementation prog

Immunization and illness Immunization BCG DPT1/Polio DPT2 /Polio DPT3/Polio Measles Vitamin “A” Diarrhea in last 2 weeks Yes No Fever in last 2 weeks Yes No Cold in last 2 weeks Yes No Any severe illness for which admission was required during last 6 months

Yes No

Any illness for which treatment was taken in last 6 months

Yes No

How many times child was admitted for any treatment in last one year?

Health facility

Nearest health facility (distance) (km) Type of health facility (nearest) (a) Sub health post (b) Health post ( c ) Hospital (d) Primary health C. (e) Private Clinic (f) Others (specify Transport facility Yes No

Tentative time to reach the facility Health facility to go normally for treatment

(a) Sub health post (b) Health post ( c ) Hospital (d) Private clinic

(e) Others (specify) In patient facility Yes No Transport facility Yes No Tentative time to reach Home visit of health workers Yes No Out reach clinic of health workers Yes No Any health education about Maternal and Child Health by health workers during home visit or out reach clinic

Yes No

Anthropometric measurement of child

Height (cm) Weight (kg) Mid arm circumference (cm) Head circumference (cm) Anthropometric measurement of mother Height (cm) Weight (kg)