Gizaw et al.

Italian Journal of Pediatrics (2018) 44:21

DOI 10.1186/s13052-018-0457-1

RESEARCH Open Access

Acute malnutrition among children aged

6–59 months of the nomadic population in
Hadaleala district, Afar region, northeast
Ethiopia
Zemichael Gizaw1*, Wondwoson Woldu2 and Bikes Destaw Bitew1

Abstract
Background: Acute malnutrition to be a major health burden in the world, particularly in the developing world.
Acute malnutrition is associated with more than one third of the global disease burden for children. Malnourished
children are physically, emotionally and intellectually less productive and suffer more from chronic illnesses and
disabilities. The nature, magnitude and determinants of acute malnutrition are determined among the general
populations; however, there is a lack of evidence in the nomadic communities.
Methods: A cross-sectional study was conducted to assess the magnitude and factors associated with acute
malnutrition among children aged 6–59 months in Hadaleala district, Afar Region. A total of 591 under-five
children were included in this study, and subjects were recruited by the multistage cluster sampling
technique. Data were collected by a pre-tested questionnaire and a simple anthropometric index so called
mid-upper arm circumference (MUAC). The multivariable binary logistic regression analysis was used to
identify factors associated with acute malnutrition on the basis of adjusted odds ratio (AOR) with 95%
confidence interval (CI) and p < 0.05.
Results: The prevalence of acute malnutrition was 11.8% (95% CI = 9.3, 14.8%). The highest prevalence (50%)
of acute malnutrition occurred among children aged between 12.0–23.0 months. Childhood acute malnutrition was
associated with the presence of two (AOR = 2.49, p < 0.05) and three (AOR = 12.87, p < 0.001) children in each
household, unprotected drinking water sources (AOR = 3.78, p < 0.05), absence of the latrine (AOR = 5.24, p < 0.05),
hand washing with soap (AOR = 0.21, p < 0.05), childhood diarrheal disease (AOR = 2.72, p < 0.05), and child vaccination
(AOR = 0.15, p < 0.001).
Conclusion: The prevalence of acute malnutrition among children aged 6-59 months was was higher than the
national prevalence. The number of children in each household, drinking water sources, latrine availability,
hand washing practice before food preparation and child feeding, childhood diarrheal disease, and child
vaccination were identified as factors affecting the childhood acute malnutrition in the nomadic community.
Protecting drinking water sources from possible contaminants, improving hand washing practices, utilization
of latrine, preventing diarrheal diseases and vaccinating children integrated with the access of nutrition
education is important to improve nutrition of children of the nomadic people.
Keywords: Acute malnutrition, Children aged 6–59 months, Nomads, Afar region, Ethiopia

* Correspondence: [email protected]
1
Department of Environmental and Occupational Health and Safety,
University of Gondar, Gondar, Ethiopia
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 2 of 10

Background Ababa, the capital city of Ethiopia. It has an area of

Under nutrition continues to be a major health burden 1272 km2 divided into 11 rural kebeles (the smallest ad-
in the world, particularly in the developing world [1–3]. ministrative units in Ethiopia) with a total population of
Globally, children with moderate and severe acute under 42,845 as projected for the year 2015. It has 7516 house-
nutrition are approximately 60 million and 13 million holds with an average household size of 5.7 persons per
respectively [1, 2]. Under nutrition is globally the most house. Under-five children account for 10.1% (4328) of
important risk factor for illness and death, with hun- the total population. As the population lives in a very
dreds of millions of young children particularly affected scattered manner, the average population density is 14
[4, 5]. It is associated with more than one third of the persons/km2. Furthermore, the economy of the district is
global disease burden for children [6]. Between 8 to 11 based on livestock and crop production [48].
million under-five children die each year globally [2, 7],
and more than 35% of these deaths are attributed to Sample size determination
under nutrition [3]. The sample size was determined using the single population
Under nutrition among children is a critical problem. Its proportion formula by considering the following assump-
effects are long lasting [1, 8]. Under nourished children tions: p = 10.0% (prevalence of malnutrition among children
are physically, emotionally and intellectually less product- aged 6–59 months in Bule Hora district, South Ethiopia
ive and suffer more from chronic illnesses and disabilities [49]), 95% confidence interval, and a 4% margin of error (d),
[9–12]. Malnutrition affects child performance, health,

2
and survival [13, 14]. In the long term, early nutritional zα =2 pð1−pÞ ð1:96Þ2 0:1ð1−0:1Þ
deficits are linked to impairments of intellectual perform- n¼ 2 ¼ ¼ 217
d 0:042
ance; work capacity, reproductive outcomes and overall
health during adolescence and adulthood [14–18]. The Considering the design effect of 2 and 10% non response
immediate consequences of poor nutrition during the rate, the final sample size was 478 mother-child pair.
early years include significant morbidity and mortality and
delayed mental and motor developments. Malnutrition at Sampling procedure
the early stages of life can lower child resistance to The multistage cluster sampling technique was used to se-
infections [19]. Moreover, the potential negative impact of lect study participants from the nomadic population. The
child malnutrition goes beyond the individual, affecting clusters were villages with defined geographical boundar-
society and future generations [20, 21]. ies. Out of a total of 11 kebeles, 6 were selected by the
In Ethiopia, under nutrition among children is still a com- simple random sampling technique. The 6 selected
mon problem. Ethiopia is one of the countries with very kebeles were clustered into 39 villages, and 17 villages
high burden of under nutrition. In the country, under nutri- were selected by the systematic random sampling tech-
tion is the underlying cause of 57% of child deaths [22–25]. nique. All the households (591) found in the selected 17
Under nutrition among children depends on complex in- villages with children aged 6–59 months were included in
teractions of various factors, like socio-demographic [24–30], the study. For households which had more than one child
drinking water quality [26, 28, 29, 31–35], hygiene of each, the younger one was selected for the study.
complementary foods [24, 28], environmental sanitation
[26, 31, 32, 36–38], child co-morbidities [19, 39–44], and Data collection tools and procedures
child vaccination [45–47]. Though, the nature, magnitude A structured questionnaire and anthropometric meas-
and determinants of under nutrition are determined urement were used to collect data. The questionnaire
among the general populations, there is lack of evidence was pre-tested out of the study area in a community
in the nomadic communities. This cross-sectional study which had similar characteristics prior to the actual data
was therefore conducted to assess the magnitude and fac- collection. Eight diploma graduate nurses and two envir-
tors associated with acute malnutrition among children onmental health officers who were fluent enough in both
aged 6–59 months in Hadaleala district, Afar Region, Amharic and Afarigna (local languages) and working in
northeast Ethiopia. the district were involved in the data collection process.
Training was given for the data collectors and supervi-
Methods sors. The data collectors visited all households in the
Study design and settings selected clusters. When the data collectors found the
A community - based cross-sectional study was con- target groups during the visits, they interviewed the
ducted among the nomadic populations in Hadaleala mothers about the variables and measured the circum-
district, Afar Region, northeast Ethiopia in May, 2015. ference of the upper arm of the child. Finally, the
Hadaleala district is located at 341 km southwest of the collected data were checked and corrected by the data
regional capital, Semera, and 268 km north of Addis collectors immediately after finalizing the questionnaire.
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 3 of 10

Supervisors daily checked the completeness, quality, and interquartile range was 25-35 years. Almost all, 577
consistency of information collected. (97.6%) of the mothers were married at the time of data
collection. The great majority, 514 (87.0%) of mothers
Measurement of outcome variable were illiterate. Almost all, 559 (94.6%) of the mothers
Childhood malnutrition, the primary outcome variable were housewives by occupation. Five hundred thirty –
of this study, is determined by a simple anthropometric seven (90.9%) mothers were Afar by ethnicity. More
index the so called mid-upper arm circumference than half, 339 (57.4%) of the households had more than
(MUAC). Nutritional status of children was take as acute five family members. Three hundred eighty – two
malnutrition if MUAC value is lower than 125 mm [50]. (64.6%) households were economically poor. Two hun-
Childhood diarrheal disease, one of the predictor vari- dred twenty – nine (38.7%) of the children were aged
ables is defined as having three or more loose or watery above 35 months. The median age of children was
stools in 24 h [51, 52]. Household economic status, 28 months and the interquartile range (IQR) was 16-
which was the other predictor variable was calculated by 40 months. More than half, 338 (57.2%) of the house-
using tropical livestock unit (TLU). Tropical livestock holds had only one child aged 6-59 months, and 317
unit was determined by multiplying the number of spe- (53.6%) of the children were male (Table 1).
cific species with the TLU conversion factor assigned to
that specific species. Camels, cattle, sheep, goats, horses, Drinking water and hygiene of complementary foods
mules, asses, and chickens were common in the study Three hundred fifty – four (59.9%) households collected
area. Generally, TLU was determined as (1.0*Number of drinking water from unimproved sources and the greater
camels) + (0.8*Number of horses) + (0.7* Number of majority, 522 (88.3%) of the water sources were seasonal.
mules) + (0.7*Number of cattle) + (0.5*Number of asses) Very few, 20 (3.4%) households treated drinking water at
+ (0.1*Number of sheep) + (0.1*Number of goats) home. Cow or goat milk was the commonest, 337
+ (0.01*Number of chickens). Household economic sta- (57.0%) complementary food for the children. Three
tus was determined by comparing the TLU scores with hundred thirty – three (56.3%) households served un-
the standard score. A below 5 TLU score indicated that cooked foods for the children, and the greater majority,
the household was poor. A TLU score of 5 to 12.99 551 (93.2%) of the households used unclean utensils to
showed the household was medium in economic status, serve foods. Three – forth, 447 (75.6%) of the house-
and rich households scored 13 and above TLU [53]. holds fed the children soon after the food is prepared,
and the overwhelming majority, 539 (91.2%) used left-
Data management and statistical analysis over foods. Three hundred twenty - four (54.8%)
Data were entered using the EPI-INFO version 3.5.3 stat- mothers washed hands with only water (Table 2).
istical package and exported to SPSS version 20 for further
analysis. Cross tabulation was used to describe socioeco- Personal hygiene and environmental sanitation
nomic, environmental sanitation, health, and nutritional Nearly one – tenth, 56 (9.5%) of the mothers had good
characteristics of children. Categorical data were pre- personal hygiene. More than threefold, 483 (81.7%), and
sented as frequency counts or percentages and compared 490 (82.9%) of the households practiced open defecation
using the Pearson chi-square. Continuous data were sum- and indiscriminate solid waste disposal respectively. The
marized as mean or median with ± standard deviation and living environment of 464 (78.5%) households was poor
interquartile range. The univariable binary logistic regres- condition, and vector infestation was observed among
sion analysis was used to choose variables for the multi- 483 (81.7%) households. Three hundred thirty (55.8%)
variable binary logistic regression analysis, and variables households had only one room, and very few, 91 (15.4%)
which had less than 0.2 p – values by the univariable ana- households had cemented or plastered floor (Table 3).
lysis were then analyzed by the multivariable binary logis-
tic regression for controlling the possible effects of Health condition of mothers and children
confounders, and finally, variables which had significant Sixty (10.2%) mothers and 172 (29.1%) children had
association were identified on the basis of adjusted odds diarrheal disease in the 2 week period prior to the sur-
ratio (AOR) with 95% CI and p < 0.05. vey. A majority, 416 (70.4%) of the mothers didn’t know
the causes of diarrhea. Three hundred twenty – seven
Results (55.3%) and 377 (63.8%) mothers didn’t know that flies
Socio-demographic information and child excreta can cause diarrheal diseases, respect-
A total of 591 mothers - child pair participated in this ively. The great majority, 477 (80.7%) of the children had
study with a 100% response rate. More than half, 311 ever been vaccinated. However, significant number or
(52.6%) of the mothers were aged 25-34 years. The me- proportion, 254 (43.0%) and 418 (70.7%) of the children
dian age of the mothers was 30 years, and the had no measles and rotavirus vaccination respectively.
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 4 of 10

Table 1 Socioeconomic information of households (n = 591) Table 2 Drinking water and hygiene of complementary
in Hadaleala district, Afar region, northeast Ethiopia, April to foods of households in Hadaleala district, Afar region,
May, 2015 northeast Ethiopia, April to May, 2015
Variables Frequency Percentage Environmental variables Frequency Percentage
Age of mothers in years Drinking water sources
15–24 131 22.2 Improved 237 40.1
25–34 311 52.6 Unimproved 354 59.9
≥ 35 149 25.2 Seasonality of water sources
Marital status of mothers Permanent 69 11.7
Currently married 577 97.6 Temporarily 522 88.3
Currently not married 14 2.4 Home based water treatment
Educational level of mothers Yes 20 3.4
No formal education 514 87.0 No 571 96.6
Formal education 77 13.0 Types of complementary foods for the children
Occupational status of mothers Cow or goat milk 337 57.0
Housewife 559 94.6 Adults’ food 133 22.5
Employed 32 5.4 Gruel 112 19.0
Ethnic group of mothers Infant formula/Powder milk 9 1.5
Afar 537 90.9 Using unclean utensils to serve foods
Oromo 44 7.4 Yes 551 93.2
Amhara 10 1.7 No 40 6.8
Family size Serving uncooked food for the children
≤ 5. 252 42.6 Yes 333 56.3
>5 339 57.4 No 258 43.7
Household economic status Feeding children soon after food prepared
Poor 382 64.6 Yes 447 75.6
Medium 209 35.4 No 144 24.4
Age group of children Children ate leftover foods
6.0–11.0 72 12.2 Yes 539 91.2
12.0–23.0 152 25.7 No 52 8.8
24.0–35.0 138 23.4 How do you wash your hand
> 35.0 229 38.7 With plain water 324 54.8
Sex of children With soap 267 45.2
Male 317 53.6
Female 274 46.4
Number of children (95% CI = 9.3, 14.8%). Female children were more mal-
One 338 57.2 nourished than males. Out of 70 malnourished children,
42 (60%) females and 28 (40%) males were malnourished
Two 218 36.9
respectively. The highest prevalence of acute malnutri-
Three 35 5.9
tion occurred among children aged 12-23 months, which
accounted 35 (50%) (Fig. 1).
Four hundred eighty- eight (82.6%) of the children re-
ceived vitamin A supplementation (Table 4). Factors associated with nutritional status
Table 5 presents the results of the binary logistic
Nutritional status regression analysis on socioeconomic, water and hy-
The MUAC value of 70 children was below 125 mm. giene of complementary foods, personal hygiene and
Therefore, the prevalence of acute malnutrition among environmental sanitation, and health related variables.
children aged 6 - 59 months in the nomadic population Childhood acute malnutrition was statistically associ-
of Hadaleala district, Afar Region was found to be 11.8% ated with the number of children in the household.
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 5 of 10

Table 3 Personal hygiene and environmental sanitation of Table 4 Health conditions of mothers and children in Hadaleala
households in Hadaleala district, Afar region, northeast Ethiopia, district, Afar region, northeast Ethiopia, April to May, 2015
April to May, 2015 Health related information Frequency Percentage
Environmental variables Frequency Percentages Two week history of maternal diarrhea
Personal hygiene of mothers Yes 60 10.2
Poor 535 90.5 No 531 89.8
Good 56 9.5 Childhood diarrhea
Latrine availability Yes 172 29.1
Yes 108 18.3 No 419 70.9
No 483 81.7 Mothers know the causes of diarrheal disease
Solid waste management Yes 175 29.6
Controlled 101 17.1 No 416 70.4
Open field 490 82.9 Mothers know flies transmit diarrheal disease
Environmental sanitation Yes 264 44.7
Poor 464 78.5 No 327 55.3
Good 127 21.5 Mothers know excreta of children can cause disease
Infestation of insects Yes 214 36.2
Yes 483 81.7 No 377 63.8
No 108 18.3 Child ever been vaccinated
Number of rooms Yes 477 80.7
One 330 55.8 No 114 19.3
Two 231 39.1 Measles vaccination
Three 30 5.1 Yes 337 57.0
Housing floor material No 254 43.0
Earth/sand 500 84.6 Rota virus vaccination
Cemented 91 15.4 Yes 173 29.3
No 418 70.7
Acute malnutrition was 2.49 times more likely to be Vitamin A supplementation
higher among households with two children compared Yes 488 82.6
with households with only one child [AOR = 2.49, 95% CI
No 103 17.4
= (1.06, 5.85)]. Similarly, the likelihood of acute malnutri-
tion was also 12.87 times higher among households with
three children compared with households who had one
child [AOR = 12.87, 95% CI = (4.04, 41.00)]. diarrhea and vaccination. Childhood acute malnutrition
Acute malnutrition among children aged 6 - 59 months was 2.72 times more likely to be higher among children
was associated with drinking water sources, availability of who had diarrheal disease [AOR = 2.72, 95% CI = (1.15,
latrine, and hand washing practices. It was 3.78 times 6.40)]. This study indicated that child vaccination has a
more likely to be higher among households that collected protective effect on childhood acute malnutrition.
drinking water from unprotected sources [AOR = 3.78, Children who ever been vaccinated were 85% less
95% CI = (1.07, 13.34)]. The likelihood of childhood acute likely to be malnourished, compared with their coun-
malnutrition was 5.24 times to be higher among house- terparts [AOR = 0.15, 95% CI = (0.07, 0.31)].
holds who had no latrine compared with their counter-
parts [AOR = 5.24, 95% CI = (1.19, 23.19)]. Children Discussion
whose mothers washed their hands before food prepar- The prevalence of acute malnutrition among children
ation and feeding with soap were less likely to be malnour- aged 6-59 months was 11.8% (95% CI = 9.3, 14.8%).
ished. Hand washing with soap before food preparation Childhood acute malnutrition was statistically associated
and child feeding can prevent childhood acute malnutri- with the number of children in each household, drinking
tion by 79% [AOR = 0.21, 95% CI = (0.05, 0.81)]. water sources, latrine availability, hand washing practice
Childhood acute malnutrition was also statistically asso- before food preparation and child feeding, childhood
ciated with the health status of children, like childhood diarrheal disease, and child vaccination. The prevalence
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 6 of 10

13.0% 14.0%

6 - 11 months

12 - 23 months
23.0%
24-35 months

>35 months

50.0%

Fig. 1 Prevalence of acute malnutrition with respect to age of children in Hadaleala district, Afar region, northeast Ethiopia, April to May, 2015

of acute malnutrition reported by this study is slightly that children who frequently affected by infections have
higher than the national prevalence of acute malnutrion mal-absorption of important nutrients [60–63].
(9%) [54] and findings of various studies conducted in This study indicated that acute malnutrition was associ-
Ethiopia like Bule Hora district, South Ethiopia, 10% ated with child hood diarrheal diseases. Children who had
[49] and it was also just two-fold higher than the preva- diarrheal disease were more likely to be acutely malnour-
lence reported in Aleta Chucko and Aleta Wondo dis- ished as compared with their counter parts. This finding
tricts, Sidama Zone, South Ethiopia, 5.6% [55]. Whereas, was supported by the findings of other similar studies [24,
the magnitude of acute malnutrition reported by this 28, 33, 36, 38, 64–66]. This may be due to the fact that
study was lower than the findings of studies conducted diarrheal disease due to poor hygiene and lack of sanita-
in Pagak district, South Sudan, 16.7% [56]. The differ- tion induces a gut disorder called environmental enterop-
ence in prevalence might be attributed to the difference athy (EE) characterized by blunted intestinal villi,
in the socio- demographic, environmental, and behav- increased intestinal permeability; fat and carbohydrate
ioral characteristics of households and the nomadic na- mal-absorption, and increased protein needs [67] that di-
ture of the population. verts energy from growth towards an ongoing fight against
This study showed that families who had two or above subclinical infection [68–71]. EE is a major cause of post-
children aged 6-59 months were more likely to have natal stunting and wasting [71–77].
childhood acute malnutrition than those who had only Child vaccination was also the other statistically associ-
one child. This probably attributed to less balanced diet ated variable with childhood acute malnutrition. Children
intake and accessibility of child healthcare decreased who ever vaccinated were less likely to be malnourished
with more number of children per household, especially compared with their counterparts. This finding is supported
in low income families [33, 34, 57, 58]. by the findings of other similar studies [36, 45–47, 78]. This
In this study, it was found that acute malnutrition can be justified as vaccinated children are less likely to be
was associated with unprotected drinking water frequently infected with vaccine preventable diseases such
sources, open defecation, and poor hand washing as diarrhea and respiratory infections, which are known in
practices of mothers. Different studies also reported depleting nutrients from the body [45, 79, 80].
that acute malnutrition was associated with drinking Finally, this paper determined acute malnutrition using
water sources [26, 28, 29, 31–35], availability of MUAC measurement. It didn’t measure weight and
latrine [26, 31, 32, 36–38] and hand washing practices height to determine global malnutrition. This paper also
[36, 59]. This may be so because poor water, hygiene didn’t consider the effect of food security and access to
and sanitation condition increase the risk of diversified foods on childhood malnutrition. Moreover,
infections. Infections affect nutrient absorption and com- the paper didn’t investigate demand side issues and sup-
promised nutritional status of children. Evidences show ply side issues of systems failures with respect to poverty
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 7 of 10

Table 5 Factors affecting acute malnutrition among children aged between 6 and 59 months in Hadaleala district, Afar region,
northeast Ethiopia, April to May, 2015
Variables Acute malnutrition COR with 95% CI AOR with 95% CI
Yes No
Number of children
One 13 325 1
Two 35 183 4.78 (2.47, 9.27) 2.49 (1.06, 5.85)*
Three 22 13 42.31 (17.52, 102.18) 12.87 (4.04, 41.00)**
Family size
≤5 37 215 1
>5 33 306 0.63 (0.38, 1.03) 1.99 (0.95, 4.18)
Wealth status
Poor 58 324 2.94 (1.54, 5.61) 1.68 (0.72, 3.94)
Medium 12 197 1
Mothers’ occupation
House wife 63 496 0.45 (0.19, 1.09) 0.20 (0.04, 1.05)
Employee 7 25 1
Water sources
Protected 4 233 1
Unprotected 66 288 13.35 (4.80, 37.16) 3.78 (1.07, 13.34)*
Latrine availability
Yes 4 104 1
No 66 417 6.61 (2.04, 21.40) 5.24 (1.19, 23.19)*
Hand washing** *
With water only 66 258 1
With soap 4 263 0.06 (0.02, 0.17) 0.21 (0.05, 0.81)*
Children eat leftover foods
Yes 61 478 0.61 (0.28, 1.31) 0.68 (0.23, 2.01)
No 9 43 1
Childhood diarrhea
No 11 408 1
Yes 59 113 19.37 (9.85, 38.10) 2.72 (1.15, 6.40)*
Children ever vaccinated
Yes 19 458 0.05 (0.03, 0.09) 0.15 (0.07, 0.31)**
No 51 63 1
Solid waste management
Controlled 15 62 2.02 (1.08, 3.79) 1.89 (0.62, 5.75)
Uncontrolled 55 459 1
*Statistically significant at p < 0.05 | **statistically significant at p < 0.001 | ***before food preparation and child feeding

alleviation. The authors believed that other studies food preparation and child feeding, childhood diarrheal dis-
should be conducted to fill the above identified gaps. ease, and child vaccination were identified as factors affecting
the childhood acute malnutrition in the nomadic commu-
Conclusion nity. Protecting drinking water sources from possible con-
The prevalence of acute malnutrition among children aged taminants, improving hand washing practices, utilization of
6-59 months was higher than the national prevalence. The latrine, preventing diarrheal diseases and vaccinating children
number of children in each household, drinking water integrated with the access of nutrition education is important
sources, latrine availability, hand washing practice before to improve nutrition of children of the nomadic people.
Gizaw et al. Italian Journal of Pediatrics (2018) 44:21 Page 8 of 10

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