1

INFLUENCE OF SOCIO-ECONOMIC FACTORS ON NUTRITIONAL STATUS OF CHILDREN IN A RURAL COMMUNITY OF OSUN STATE, NIGERIA

*Senbanjo IO (FWACP), **Adeodu OO (FWACP), ***Adejuyigbe EA (FMCPaed) * Senior registrar, Department of Paediatrics & Child Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. ** Associate professor, Department of Paediatrics & Child Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. *** Senior lecturer, Department of Paediatrics & Child Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria

2 ABSTRACT Protein energy malnutrition (PEM) remains a major public health problem in Nigeria to such extent that it is the second most common cause of childhood morbidity and mortality. This was a questionnaire-based, cross sectional survey which relied on anthropometry to assess the nutritional status of children aged one year to five years. It was conducted using the multistage cluster sampling technique in Ifewara, a rural community in Osun State, about 200 kilometers from Lagos, Nigeria in order to determine the prevalence and types of malnutrition and the associated socio-economic determinants in the population. A total of 420 children were recruited from 344 households. By the modified Wellcome Classification, the prevalence of PEM was 20.5 percent, and using the World Health Organization/ National Centre for Health Statistics (WHO/ NCHS) cut off points, the prevalence rates of underweight, wasting and stunting were 23.1 percent, 9 percent and 26.7 percent respectively. One hundred and twelve (26.7 percent) children had borderline malnutrition. However, severe forms of PEM were not common. Only 4 (1 percent) children had marasmus while there were no cases of kwashiorkor or marasmic-kwashiorkor. Of the 348 mothers, 336 (96.6 %) had secondary education at best while 12 (3.4 %) had post secondary. The prevalence rate of underweight children was three times as high in the former as in the later group. Also, children of mothers who were not educated beyond secondary school level had one and a half to two times the prevalence rate of stunting. On the other hand, children of mothers with post secondary education were apparently more often affected by wasting than those with less educated mothers. However, no statistically significant difference was found in

3 all these comparisons (2 = 2.38, p = 0.667; 2 = 1.9, p = 0.754 and 2 = 2.38, p = 0.666 respectively). Of the 344 fathers, 25 (7.3 %) were educated beyond secondary school level. The others (92.7 %) had at least secondary school education at best. There was a subtle inverse relationship between fathers educational qualification and prevalence of underweight but the differences were not statistically significant (p = 0.568). There was no consistent trend in the pattern of wasting or stunting with respect to paternal educational level. Low maternal income and overcrowding were associated with higher prevalence of wasting (2 = 4.63, p = 0.031 and 2 = 4.79, p = 0.029 respectively). No association was found between the source of drinking water or social class and malnutrition. It is concluded from this study that PEM is a major childhood public health hazard in Ifewara and the local government authorities need to plan and implement effective child health promotion. However, the prevalence of PEM in Ifewara is low when compared with reports from other parts of Nigeria and this has been ascribed to the availability of social amenities and access to basic medical care provided by a comprehensive health centre and a Non Governmental Organization. To this end, it is recommended that governments should support and collaborate with Non Governmental Agencies in the provision of health care needs to the people. Empowerment of mothers with the aim of augmenting family income and parental education on the need to limit family size may also be key measures in reducing the incidence and expectedly mitigate the effect of PEM among the children of this rural community.

4 INTRODUCTION Malnutrition has for a long time been recognized as a consequence of poverty since most of the worlds malnourished children live in the developing nations of Asia, Africa and Latin America where those mostly affected are from low income families.1 It is conceivable that most of the resources of these developing countries are spent servicing external debts at the expense of health and other social welfare services. The heavy depletion of state funds by corrupt political leaders as well as the ravaging effects of wars and strife result in economic instability and low purchasing power of the currencies.2 This translates to low standard of living of the people.2 Therefore, this study, aimed at determining the current nutritional status of underfive children in a rural Nigerian community and the socio economic determinants can be used to canvass for nutrition surveillance and appropriate nutritional intervention programme particularly in a times of depressed economy.

SUBJECTS AND METHODS The study was carried out in Ifewara, a rural community located in Atakunmosa West Local Government Area, of Osun State, south-western Nigeria. Ifewara with the estimated population of 3, 927 and household count of 1,849 is located 18 kilometers from Osu, the headquarters of the local government area, 36 kilometers from Osogbo, the capital of Osun State and 200 kilomaters from Lagos, a former federal capital city. 3, 4 The multistage cluster and random sampling techniques were used to select households and subjects. All under-five children in the entire households of the selected houses were studied. For the purpose of this study, the housing system was classified into flats or self contained apartments and individual rooms. A flat/self contained apartment refers to residence whereby a family is able to carry out some of its major functions without sharing with another family while individual room refers to sleeping room. In each household, information was obtained on demographic, socio-economic and environmental characteristics and the families were assigned a socio-economic class using the method recommended by Oyedeji.5 The anthropometric parameters of every child were recorded and each child was clinically examined for gross evidences of malnutrition. Standardization checks on the tools for anthropometric measurements were done periodically. Children with evidences of chronic diseases were excluded. Malnutrition was diagnosed clinically using the modified Wellcome System of Classification.6 The National Centre for Health Statistics/World Health Organization (NCHS/WHO) guidelines and cut off points
7, 8, 9, 10

were also used to determine the

degree of stunting, underweight and wasting. Underweight, wasting and stunting were

6 diagnosed when the Weight-for-Age (WA), Weight-for-Height (WH) and Height-for-Age (HA) were equal to minus two Standard Deviation (-2 SD) or below the mean of this reference international standards respectively.7 Using the Mid Arm Circumference (MAC), the subjects with values less than 12.5cm, between 12.5cm and 13.5cm and above 13.5cm were deemed to have severe malnutrition, borderline malnutrition and normal nutritional status respectively as suggested by Shakir.10 Data analysis was done using the Epi info 2002 and the SPSS for windows version 11 softwares.11,
12

Personal and family data were separately analyzed to avoid data

duplication. Proportions and rates were compared using the Pearson Chi squared (2) test. p values less than 0.05 were accepted as statistically significant.

7 RESULTS Demography A total of 420 children were studied from 344 households consisting of 348 mothers and 344 fathers. The mean age of the study population was 35.4 + 14 months. There were 218 (51.9 %) females and 202 (48.1 %) males giving a female: male ratio of 1.1: 1. The means ( SD) of the weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and weight-for-height Z-scores (WHZ) were -1.25 + 1.36, - 1.30 + 1.30 and 0.402 + 1.12 respectively. The prevalence of underweight, wasting and stunting are 23.1 %, 9.0 % and 26.7 % respectively (Table II). Socioeconomic Characteristics of Parents and Nutritional Status Tables III and IV shows the level of education of the parents in relation to the nutritional status of their children. Of the 348 mothers, 336 (96.6 %) had secondary education at best while 12 (3.4 %) had post secondary education. Underweight and stunting were more common among the former than the latter while wasting was found more among the latter. These differences, however, lack statistical significance. Of the 344 fathers, 319 (92.7%) had at most secondary education while 25 (7.3 %) were educated beyond secondary school level. There was no consistent trend in the pattern of wasting or stunting with respect to paternal educational level but there was a non- significant relationship between fathers educational qualification and prevalence of underweight. The earning power of fathers and mothers are as shown in Tables V and VI. One hundred and ninety-nine (57.8 %) fathers earned more than ten thousand naira per month compared to 178 (51.1 %) mothers. The nutritional status of children of fathers that

8 earned more than ten thousand naira per month and those that earned less than ten thousand naira per month was similar. While underweight and stunting were common in both groups of mothers, wasting was more significantly associated with mothers who earn less than ten thousand naira. (2 = 4.63, p = 0.031). None of the children studied belonged to the social class I. In classes II, III, IV and V were 3 (0.87 %), 86 (25 %), 245 (71.2 %) and 10 (2.91 %) children respectively. There was no significant relationship between the prevalence of underweight (p = 0.826), wasting (p = 0.537) and stunting (0.484) and the social classes to which the parents belonged (Figure 1). Housing and Nutritional Status Fourteen (4.1 %) households occupied flats and self contained apartments, 35 (10.2 %) lived in houses with at least 4 rooms, 38 (11 %) lived in houses with 3 rooms, 154 (44.8 %) occupied 2 rooms and 103 (29.9 %) families occupied only one room each (Table VII). The nutritional status as measured by the degree of underweight, wasting and stunting showed a correlation with the types of houses occupied although without statistical significant. Underweight (2 = 5.93, p = 0.313), wasting (2 = 3.57, p = 0.614) and stunting (2 = 4.78, p = 0.443). Two hundred and fifty-three (73.5 %) children lived in rooms with less than four people while 91 (26.5 %) lived in rooms with more than 4 people (Table VIII). There was a significantly higher prevalence of wasting among children with more than four occupants per room (2 = 4.79, p = 0.029). The prevalence rates of underweight and stunting were comparable in the two groups ((2 = 0.76, p = 0.385 and 2 = 0.027, p = 0.868 respectively).

9 Source of Drinking Water and Nutritional Status The major sources of water supply were stream 256 (74.4 %), well 55 (16 %) and rain water 11(3.2 %). Twenty-two (6.4 %) households used packaged water either in satchets or bottles. None of the households used pipe borne water (Table IX). There was no significant relationship between the prevalence of underweight (p = 0.568), wasting (p = 0.575 and stunting (p = 0.37) and their sources of water supply.

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DISCUSSION Most of the parents in this rural Nigerian community had at least primary education in contrast to the literacy level of 56 % and 72 % reported in 2000 for female and male Nigerians respectively.7 There exist a direct relationship between educational qualification of mothers and the nutritional status of their wards similar to previous reports 13-15 It is expected that the more educated a mother is, the more likely she is to be receptive to developmental initiatives such as the Childhood Survival Strategies. This has the resultant effect of improved family nutrition and less risk of childhood malnutrition. 16 The majority of the mothers in Ifewara were traders while the fathers were mainly farmers. This is as expected of a rural Nigerian community. Therefore, the lack of relationship between parental occupation and the nutritional status of children may be attributed to the fact that most of families belonged to about the same socioeconomic class. Although many factors are involved in the development of PEM, it is believed that poverty at the family level is the principal cause of childhood malnutrition. The average monthly income of fathers in this study is higher than the national minimum monthly payable wage of ten thousand naira (about seventy dollars). The empirical position is that a womans earnings will more likely be spent on family feeding than the husbands income. This is contrary to the belief that the earning power of father rather than that of the mother determines the finances of the family and is directly related to the nutritional status of children.17 The implication of this finding is that if empowered economically,

11 women could supplement the finances of the households and help in reducing the prevalence of PEM. The provision of adequate and proper housing is essential for the normal growth and development of a child. In Nigeria, the population growth rate is very high (2.88%) compared with that of the developed world where population growth rate is almost static at 0.6%.18 The high population growth rate leads to overcrowding if adequate number of housing is not provided for the citizens. The consequence of overcrowding is the spread of diseases like Acute Respiratory Infection (ARI) and diarrhoea which are known causes of malnutrition. The lack of any relationship between the type of housing and the prevalence of malnutrition in this study may reflect the generally poor construction standard of most of the houses since the socioeconomic status of the families is not significantly different. However, the association of wasting with the number of occupants of a room is similar to the finding in Lagos where it was ascribed to rapid urbanization.13 Malnutrition may also be associated with overcrowding not just because of the transmission of infections but also because food sharing may be unfavorable to the younger ones. The provision of adequate, safe and clean water is a component of Primary Health Care. Today, only a few Nigerians have access to this. In rural Nigeria, only 49 % of the population use improved quality potable water compared with 78 % for the urban.18 The situation is not different in Ifewara where the major source of drinkable water is the stream as the entire community has no pipe borne water supply. The apparent lack of association between source of water and poor childhood nutrition in this study may be ascribed to the probability that the children in this community have developed antibodies

12 to the various organisms contaminating the water they consume thereby leading to reduction in their susceptibility to water borne diseases like diarrhoea which could predispose to malnutrition. The findings in this study have confirmed many issues about the risk factors for childhood malnutrition which have been known for decades. It is remarkable that almost halfway into the 21st century, the same factors still abound. This calls the impact of the various intervention programmes used in this wise in the past to question and demands a reverberated approach. Women empowerment promises improved family finances, better food security and better childhood nutrition. This is worth trying in the developing world.

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REFERENCES 1. UNICEF. Malnutrition: causes, consequences and solution. The state of the worlds children 1998. 2. Osibogun A. The epidemiology of undernutrition. In: Osibogun A (Ed) A handbook of public health nutrition for developing countries Miral press first edition, 1998: 13-30. 3. Microsoft Encarta Reference Library Software. Microsoft Corporation, 2002.

4. National Population Commission. Final result of 1991 population census of Nigeria. 5. Oyedeji GA. Socioeconomic and cultural background of hospitalized children in Ilesa. Nig J Paediatr 1985; 12 (4): 111 117. 6. Hendrickse RG. Protein energy malnutrition. In: Hendrickse RG, Barr DGD, Mathews TS (Eds.) Paediatrics in the tropics. Blackwell scientific publications first edition, 1991: 119-131. 7. UNICEF. The state of the world children 2003. 8. Binns CW. Assessment of growth and nutritional status. J Food Nutr. 1985; 42(3):119-125. 9. WHO. Use and interpretation of anthropometric indicators of nutritional status. Bull World Health Organ.1986; 64: 929-941. 10. World Health Organisation (1998). Management of severe malnutrition; a manual for physician and other senior health workers. 11. WHO/Centers for Disease Control and Prevention. Epi Info 2002. 12. SPSS for windows. Release 11.0.0 SPSS Inc Standard Version 2001.

14 13. Abidoye RO, Ihebuzor NN. Assessment of nutritional status using anthropometric methods on 1-4 year old children in an urban ghetto in Lagos, Nigeria. Nutr Health 2001; 15(1): 29-39. 14. Abidoye RO, Sikabofori. A study of the prevalence of protein energy malnutrition among 0-5 years in rural Benue state, Nigeria. Nutr Health 2000; 13(4):235-47. 15. Esimai OA, Ojofeitimi EO, Oyebowale OM. Sociocultural practices influencing under five nutritional status in an urban community in Osun State, Nigeria. Nutr Health 2001; 15(1): 41-46. 16. UNICEF. Female education. The state of the world children 2000. 17. Ighogboja SI. Some factors contributing to protein energy malnutrition in the middle belt of Nigeria. East Afr Med J 1992; 69(10): 566-71. 18. Rao S, Kanade AN. Prolonged breast feeding and malnutrition among rural Indian children below 3 years of age. Eur J Clin Nutr. 1992; 46 (3): 187 195.

15 TABLES

Table I: Epidemiological features of the 420 children study.

Parameters 1. Age (months) 12-23 24-35 36-47 48-60 2. Sex Male Female 3. Religion Christianity Islam 4. Ethnic groups Yoruba Non-Yoruba

No of children 105 94 120 101

Percentage 25 22.4 28.6 24

202 218

48.1 51.9

290 54

84.3 15.7

289 55

84 16

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Table II: Nutritional status of the study population using the Weight-for-Age Zscore (WAZ), Height-for-age Z- scores (HAZ) and Weight-for-Height Zscore

Nutritional status Normal (> - 2.00 SD) Malnourished (- 2.00 to - 2.99 SD) Severely Malnourished (-3.00 SD and above)

WAZ 323 (76.9) 65 (15.5) 32 (7.6)

HAZ 308 (73.3) 78 (18.6) 34 (8.1)

WHZ 382 (91.0) 29 (6.9) 9 (2.1)

Total

420 (100.0)

420(100.0)

420(100.0)

Key: Figures in parenthesis are percentages of the total in the respective column.

17 Table III: Nutritional status in relation to level of education of mothers. Nutritional status Educational status No formal education WAZ WHZ HAZ Primary WAZ WHZ HAZ Secondary WAZ WHZ HAZ Post Secondary WAZ WHZ HAZ 11 (91.7) 10 ( 83.3) 10 (83.3) 1 (8.3) 2 (16.7) 2 (16.7) 12 (100) 138 (75.8) 168 (92.3) 129 (70.9) 44 (24.2) 14 (7.7) 53 (29.1) 182 (100) 96 (75.6) 113 (89) 97 (76.4) 31 (24.4) 14 (11) 30 (23.6) 127 (100) 20 (74.1) 24 (88.9) 19 (70.4) 7 (25.9) 3 (11.1) 8 (28.6) 27 (100) > - 2 SD - 2 SD and below Total

Key: Figures in parenthesis are percentages of the total in the respective row. WAZ 2 = 2.38, (df) = 3, p = 0.667.

WHZ - 2 = 2.38, (df) = 3, p = 0.666. HAZ 2 = 1.9, (df) = 3, p = 0.754.

18 Table IV: Nutritional status in relation to level of education of fathers Nutritional status Educational status No formal education WAZ WHZ HAZ Primary WAZ WHZ HAZ Secondary WAZ WHZ HAZ Post Secondary WAZ WHZ HAZ 21 (84) 23 (92) 19 (76) 4 (16) 2 (8.0) 6 (24.0) 25 (100) 158 (76.7) 186 (90.3) 154 (74.8) 48 (23.3) 20 (9.7) 52 (21.2) 206 (100) 63 (73.3) 79 (91.9) 57 (66.3) 23 (26.7) 7 (8.1) 29 (33.7) 86 (100) 19 (70.4) 23 (85.2) 21 (77.8) 8 (29.6) 4 (14.8) 6 (22.2) 27 (100) > - 2 SD - 2 SD and below Total

Key: Figures in parenthesis are percentages of the total in the respective row. WAZ 2 = 2.94, (df) = 3, p = 0.568.

WHZ - 2 = 1.88, (df) = 3, p = 0.757. HAZ 2 = 2.87, (df) = 3, p = 0.579.

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Table V: Nutritional status in relation to fathers monthly income.

Nutritional status Monthly income (Naira) < Ten thousand WAZ WHZ HAZ > Ten thousand WAZ WHZ HAZ 151 (75.9) 184 (92.5) 143 (71.9) 48 (24.1) 15 (7.5) 56 (28.1) 199 (100) 110 (75.9) 127 (87.6) 108 (74.5) 35 (24.1) 18 (12.4) 37 (25.5) 145 (100) > - 2 SD - 2 SD and below Total

Key: Figures in parenthesis are percentages of the total in the respective row.

WAZ -

2 = 0.0, (df) = 1, p = 0.997.

WHZ - 2 = 2.3, (df) = 1, p = 0.129. HAZ 2 = 0.29, (df) = 1, p = 0.589.

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Table VI: Nutritional status in relation to mothers monthly income.

Nutritional status Monthly income (Naira) < Ten thousand WAZ WHZ HAZ > Ten thousand WAZ WHZ HAZ 137 (77) 167 (93.8) 127 (71.3) 41 (23.0) 11 (6.2) 51 (28.7) 178 (100) 128 (75.3) 148 (87.1) 128 (75.3) 42 (24.7) 22 (12.9) 42 (24.7) 170 (100) > - 2 SD - 2 SD and below Total

Key: Figures in parenthesis are percentages of the total in the respective row.

WAZ -

2 = 0.13. (df) = 1, p = 0.714.

WHZ - 2 = 4.63, (df) = 1, p = 0.031. HAZ 2 = 0.69, (df) = 1, p = 0.406.

21 Table VII: Nutritional status in relation to type of house Nutritional status Type of House One room Underweight Wasting Stunting 2 rooms Underweight Wasting Stunting 3 rooms Underweight Wasting Stunting > 4 rooms Underweight Wasting Stunting Flat Underweight Wasting Stunting 12 (85.7) 14 (100) 13 (92.9) 2 (14.3) - (0) 1 (7.1) 14 (100) 29 (82.9) 33 (94.3) 28 (80) 6 (17.1) 2 (5.7) 7 (20) 35 (100) 32 (84.2) 35 (92.1) 28 (73.7) 6 (15.8) 3 (7.9) 10 26.3) 38(100) 115 (74.7) 131 (189) 111 (72.1) 39 (25.3) 17 (11) 43 (27.9) 154 (100) 73 (70.9) 92 (89.3) 71 (68.9) 30 (29.1) 11 (10.7) 32 (31.1) 103(100) > - 2 SD -2 SD and below Total

Key: Figures in parenthesis are percentages of the total in the respective row. WAZ - 2 = 5.93, (df) = 4, p = 0.313. WHZ - 2 = 3.57, (df) = 4, p = 0.614. HAZ - 2 = 4.78, (df) = 4, p = 0.443.

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Table VIII: Nutritional status and number of persons living in a room

Number of person

Nutritional status > - 2 SD -2 SD and below Total

Less than 4 Underweight Wasting Stunting More than 4 Underweight Wasting Stunting 66 (72.5) 77 (84F.6) 67 (73.6) 25 (27.5) 14 (15.4) 24(26.4) 91 (100) 195 (77.1) 234 (92.5) 184 (72.71) 58(22.9) 19 (7.5) 69 (27.3) 253 (100)

Key: Figures in parenthesis are percentages of the total in the respective row. WAZ - 2 = 0.76, (df) = 1, p = 0.385 WHZ - 2 = 4.79, (df) = 1, p = 0.029 HAZ 2 = 0.027, (df) = 1, p = 0.868.

23 Table IX: Nutrition status in relation to source of drinking water.

Source of Water Well WAZ WHZ HAZ Rain Water WAZ WHZ HAZ Stream WAZ WHZ HAZ Others WAZ WHZ HAZ

Nutritional status > - 2 SD -2 SD and below 43 (78.2) 48 (87.3) 43 (78.2) 12 (21.8) 7 (12.7) 12 (21.8)

Total 55 (100)

10 (90.9) 11 (100) 9 (81.8)

1 (9.1) - (0.0) 2 (18.2)

11 (100)

192 (75) 231 (90.2) 180 (70.3)

64 (25.0) 25 (9.8) 76 (29.7)

256 (100)

16 (72.7) 21 (95.5) 19 (84.4)

6 (27.3) 1 (4.5) 3 (13.6)

22 (100)

Key: Figures in parenthesis are percentages of the total in the respective row. WAZ 2 = 2.94, (df) = 4, p = 0.568.

WHZ - 2 = 3.26, (df) = 4, p = 0.575. HAZ 2 = 4.28, (df) = 4, p = 0.37.

24

25

20 Prevalence (%)

15

10

0 1 2 3 Social class
Underweight
Wasting
Stunting

Figure 1: Nutritional status of Children in relation to social class of parents.

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Correspondence to: Dr. Senbanjo I.O, Department of Paediatrics & Child Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. E-mail: senbanjo001@yahoo.com