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HARAMAYA UNIVERSITY

SCHOOL OF GRADUATE STUDIES

MAGNITUDE OF RELAPSE AFTER CURE FOR SEVERE ACUTE

MALNUTRITION AND ASSOCIATED FACTORS AMONG CHILDREN OF 6-

59 MONTH IN KURFA CHELE DISTRICT, EASTERN ETHIOPIA, CROSS-

SECTIONAL STUDY DESIGN.

MPH THESIS

HINSARMU AMANO (BSc)

COLLEGE: HEALTH AND MEDICAL SCIENCES

SCHOOL: PUBLIC HEALTH

PROGRAM: PUBLIC HEALTH NUTRITION

MAJOR ADVISOR: DR.KEDIR TEJI (PhD, ASSOCIATE PROFESSOR)

CO-ADVISOR: DR.TARIKU DINGATE (PhD, ASSISTANT PROFESSOR)

NOVEMBER, 2021

HARAMAYA UNIVERSITY

HARAR, ETHIOPIA

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Magnitude of Relapse after cure for Severe Acute Malnutrition And Associated

Factors Among Children Of 6-59 Month In Kurfa Chele District, Eastern

Ethiopia, Cross-Sectional Study Design.

A Thesis Submitted to the School of Public Health School of Graduate Studies

of Haramaya University.

In Partial Fulfillment of the Requirements for the Degree of

Master of Public Health Nutrition

Hinsarmu Amano (BSC.)

Major Advisor: Dr. Kedir Teji (PhD, Associate Professor)

Co-Advisor: Dr.Tariku Dingate (PhD, Assistant Professor)

November, 2021

Haramaya University,

Harar, Ethiopia

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APPROVAL SHEET

HARAMAYA UNIVERSITY

POST GRADUATE PROGRAM DIRECTORATE

I hereby certify that I have read and evaluated this Thesis entitled magnitude of relapse after cure

for severe acute malnutrition and associated factors among children of 6-59 month in kurfa chele

district, Eastern Ethiopia, prepared under my guidance by Hinsarmu Amano. I recommend that

it be submitted as fulfilling the thesis requirement.

Dr. Kedir Teji (PhD) _______________ _______________

Major Advisor Signature Date

Dr.Tariku Dingate (PhD) _______________ _______________

Co-Advisor Signature Date

As a member of the Board of Examiners of the MPH Thesis Open Defense Examination, I certify

that I have read and evaluated the Thesis prepared by Hinsarmu Amano and examined the

candidate. I recommend that the Thesis be accepted as fulfilling the Thesis requirements for the

degree of Master of Public Health in Public Health Nutrition.

____________________________ _______________ ________________

Chair Person Signature Date

____________________________ _______________ ________________

Internal Examiner Signature Date

____________________________ _______________ ________________

External Examiner Signature Date

Final approval and acceptance of the Thesis is contingent upon the submission of its final copy to

the Council of Graduate Studies (CGS) through the Candidate’s Department or School Graduate

Committee (DGC or SGC).

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STATEMENT OF THE AUTHOR

By my signature below, I declare and affirm that this Thesis is my own work. I have followed all

ethical and technical principles of scholarship in the preparation, data collection, data analysis, and

compilation of this Thesis. Any scholarly matter that is included in the Thesis has been given

recognition through citation.

This Thesis is submitted in partial fulfillment of the requirements for MPH degree at the Haramaya

University. The Thesis is deposited in the Haramaya University Library and is made available to

borrowers under the rules of the Library. I solemnly declare that this Thesis has not been submitted

to any other institution anywhere for the award of academic degree, diploma, or certificate.

Brief quotations from this may be made without special permission provided that accurate and

complete acknowledgement of the source is made. Requests for permission for extended

quotations from or reproduction of this thesis in whole or in part may be granted by the Head of

the School when in his or her judgments the proposed use of the material is in the interest of

scholarship. In all other instances, however, permission must be obtained from the author of the

thesis.

Name: Hinsarmu Amano Erkiso

Signature:

Date: 28/9/2021.

School: Public Health.

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BIOGRAPHICAL SKETCH

The author was born in 1992 in Asella, Oromia Regional State, Ethiopia. I completed my

Elementary School in Abosara Alko Elementary School. I attended my Secondary at Golja and

Preparatory school in Asella. After completion of Preparatory School, I joined Madda Walabu

University in 2012. At Madda Walabu University I studied Generic Nursing and got my BSc

degree in General Nursing in June 2015. After graduation I were employed in Oromia regional

state on October, 2016 and served in Kurfa Chelle woreda at kurfa health center till now. In June

2019, I joined Haramaya University Post Graduate Program Directorate.

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ACKNOWLEDGMENTS

First of all my endless thanks is to my almighty God for his unmeasurable gift. Next to that I would

like to extend my great gratitude to Haramaya University, College of Health and Medical Sciences

for their providing this great chance for me to write this thesis research.

My deepest gratitude also goes to my advisors Dr. Kedir Teji Roba (PhD, Associate professor) and

Dr.Tariku Dingate (PhD, Assistant professor) for their unreserved continuous guidance, support

and showing direction during writing this thesis. Again I want to acknowledge data collectors and

supervisors.

Lastly, I would also like to give my special thanks for my house maker Engineer Muhabbaza

Muhammed for uncreditable assistance and Kurfa challe Health Bureau for providing me major

and important data are helpful during this thesis research development.

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TABLE OF CONTENTS

CONTENTS PAGE

APPROVAL SHEET .................................................................................................................................. II

STATEMENT OF THE AUTHOR .......................................................................................................... III

BIOGRAPHICAL SKETCH .................................................................................................................... IV

ACKNOWLEDGMENTS .......................................................................................................................... V

TABLE OF CONTENTS .......................................................................................................................... VI

LIST OF TABLES ..................................................................................................................................... IX

LIST OF FIGURES .................................................................................................................................... X

ACRONOYMS/ABBREVIATIONS ........................................................................................................ XI

ABSTRACT ............................................................................................................................................... XII

1. INTRODUCTION ............................................................................................................................... 1

1.1. Background ................................................................................................................................. 1

1.2. Statement of the problem ........................................................................................................... 3

1.3. Significance of the study ............................................................................................................. 6

1.4. Objective of the study ................................................................................................................. 6

2. LITERATURE REVIEW................................................................................................................... 8

2.1. Magnitude of relapse after cure for severe acute malnutrition .............................................. 8

2.2. Associated factors of relapse after cure for severe acute malnutrition. ................................. 9

2.2.1. Anthropometric factors associated with SAM ............................................................................ 9

2.2.2. Illness history of admitted child with severe acute malnutrition. ............................................. 10

2.2.3. Socio-economic status of Households ...................................................................................... 12

2.2.4. Nutritional education/counseling. ............................................................................................. 13

2.3. Conceptual Framework. ........................................................................................................... 14

3. METHODS AND MATERIALS ..................................................................................................... 16

3.1. Study area and period .............................................................................................................. 16

3.2. Study design ............................................................................................................................... 16

3.3. Source population ..................................................................................................................... 16

3.4. Study population ....................................................................................................................... 16

3.5. Inclusion and Exclusion creteria. ............................................................................................ 17

3.5.1. Inclusion criteria ................................................................................................................. 17

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3.5.2. Exclusion criteria ................................................................................................................ 17

3.6. Sample size determination........................................................................................................ 17

3.7. Sampling procedure and technique ......................................................................................... 18

3.8. Data collections Methods .......................................................................................................... 20

3.8.1 Data Collection Tools/Instruments ............................................................................................ 20

3.8.2. Data Collectors .......................................................................................................................... 20

3.8.3. Data Collection Procedure ........................................................................................................ 20

3.9. Study variables .......................................................................................................................... 21

3.9.1. Dependent variable ............................................................................................................. 21

3.9.2. Independent variables ......................................................................................................... 21

3.10. Data Quality Control ............................................................................................................ 21

3.11. Operational Definitions ........................................................................................................ 22

3.12. Data processing and analysis ............................................................................................... 24

3.13. Ethical Considerations .......................................................................................................... 24

4. RESULTS .......................................................................................................................................... 26

4.1. Socio demographic characteristics of care givers .................................................................. 26

4.2. Environmental Characteristics of study participants. ........................................................... 27

4.3. Nutritional Characteristics of children aged 6-59 months With Diagnosis Severe Acute

Malnutrition. ......................................................................................................................................... 27

4.3.1. Household’s food consumption frequency of the study participants .................................. 28

4.4. Household food security status Among Caregivers of Children with Severe Acute

Malnutrition. ......................................................................................................................................... 29

4.5. Child Feeding Practice among children treated for Severe Acute Malnutrition. ............... 31

4.6. Magnitude of relapse among study participants .................................................................... 32

4.7. Factors associated with relapse among children cured for severe acute malnutrition. ...... 33

4.7.1. Results of bivariable analysis .............................................................................................. 33

4.7.2. Results of multivariable analysis ........................................................................................ 34

5. DISCUSSION .................................................................................................................................... 36

5.1. Strength and limitation of study ................................................................................................... 37

6. CONCLUSION AND RECOMMENDATION .............................................................................. 39

6.1. Conclusion ................................................................................................................................. 39

6.2. Recommendation ....................................................................................................................... 39

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7. REFERENCES .................................................................................................................................. 40

8. APPENDICES ................................................................................................................................... 45

8.1. English version of Participant Information Sheet & Informed voluntary Consent Form . 45

8.2. Afan Oromo Version Participant Information Sheet & Informed voluntary Consent Form

46

8.3. English version of Questionnaire for Participant Interview ................................................. 48

8.4. Afan Oromo Version of Data Collection Instrument. ............................................................ 55

8.5. Principal Investigator Curriculum Vitae (CV) ...................................................................... 62

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LIST OF TABLES

Table 1: Objective two sample size calculation for relapse to severe acute malnutrition children

population of Kurfa Chele district, Eastern Ethiopia, 2021………………18

Table 2: Socio-demographic and socio-economic characteristics of care givers of admitted

children to severe acute malnutrition Kurfa Chelle district………………26

Table 3: Environmental and Socio-Economic Characteristics of 6-59 Months Children Kurfa

Chelle District………………………………….…………………………27

Table 4: Nutritional status of the children 6-59 months during admission among severe acute

malnutrition 6-59 months children in Kurfa Chelle District………………28

Table 5: Household food insecurity access scale associated with relapse to severe acute

malnutrition at Kurfa Chelle districts …………………………………….30

Table 6: Child feeding practice variables associated with relapse to severe acute malnutrition at

Kurfa Chelle District …………….…………….…………………………31

Table 7: Factors associated with relapse to severe acute malnutrition in bivariate logistic

regression analysis in Kurfa Chele district, 2021 ………………………………..33

Table 8: Factors associated with relapse to severe acute malnutrition in multivariate analysis in

Kurfa Chele district, 2021 …………………………….…………………………35

Table 9: English version of Questionnaire for Participant Interview…………….…..49

Table 10: Afan Oromo Version of Data Collection Instrument ……………………..56

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LIST OF FIGURES

Figure 1. Conceptual Framework of associated factors after cure of severe acute

malnutrition……... 15

Figure 2. Sample size determination of relapse after cure for severe acute malnutrition and

associated factors kurfa chele woreda, Eastern Ethiopia, 2021…...19

Figure 3. Household food consumption frequency of kurfa Chelle District Eastern Ethiopia,

2021. ……………………………………29

Figure 4. Household food insecurity access scale associated with relapse to severe acute

malnutrition at Kurfa Chelle district 2021 ….………………………. 29

Figure 5. The overall magnitude of relapse for severe acute malnutrition among children of 6-59

months children at Kurfa Chelle district……….………… 32

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ACRONOYMS/ABBREVIATIONS

BF……………………………………..Body Fat

BMI……………………………………Body Mass Index

BSc…………………………………….Bachelor Science

CI……………………………………...Confidence Interval

COR…………………………………...Crude Odds Ratio

DF……………………………………...Degree of Freedom

ETB………………………………….....Ethiopian Birr

FANTA……………………………..….Food and Nutrition Technical Assistance

FMOH……………………………….....Federal Ministry Of Health

HC……………………………………...Health Center

HHFS…………………………………..House Hold Food Security

HIT…………………………………….Health Information Technician

HP……………………….……………..Health Post

IRR………….........................................Incidence of Relative Risk

IHRERC……………………………….Institutional Health Research Ethics Review Committee

M & E………………………………... Monitoring and Evaluation

MUAC………………………………...Mid-Upper Arm Circumference

NNP………………………………..….National Nutritional Program

NRR……………………………...……Non Response Rate

OR…………………………………….Odds Ratio

OPD…………………………………...Outpatient Department

ORHB…………………………...…… Oromia Regional Health Bureau

P……………………………………….P-value

PI ……………………………………...Principal Investigation

PR…………………………………….. Prevalence Rate

RR…………………..…………………Relative Risk.

SPSS……………………………….…. Statistical Package for Social Science

UNICEF…………………………….…United Nation Children Fund

WHO…………………………………..World Health Organization

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ABSTRACT

Background: The relapse of severe acute malnutrition is one of the problems encountered in

managing of children with severe acute malnutrition. The proportion of children who relapsed after

severe acute malnutrition treatment varied greatly from 0% to 37% across varying lengths of time

following discharge. The evidence surrounding post-discharge outcomes after initial recovery

from severe acute malnutrition are limited but tends to highlight poor health and nutrition

outcomes, including relapse.

Objective: To identify magnitude of relapse after cure for severe acute malnutrition and

associated factors among children of 6-59 month in Kurfa Chele District, Eastern Ethiopia.

Methods: A community based cross-sectional study were collected among 6-59 months children

after discharge from Outpatient treatment program and stabilization center for severe acute

malnutrition in the Kurfa Chele District, Eastern Ethiopia. Primary data were collected from

mothers/ care givers/ after cases were identified from health management information system

report and outpatient or stabilization center registration. The Nutritional Assessment tools of

household food insecurity access scale, Dietary diversity score and food consumption score were

used to identify household food security status. The collected data were double entered into

EpiData Version 3.02 statistical software and exported to the SPSS Version 22 statistical package

for analysis. The odd ratio was reported with 95% confidence intervals (CI) was used to measure

the strength of association with a level of statistical significance was declared at p-value less or

equal to 0.05.

Results: Out of 223 study participants 11.36%, 95% CI: (4.50%, 29.06%), among children

recovered and relapsed in the past one year. On multivariable logistic regression, having edema on

admission [(OR=10.02; 95% CI: (1.6 - 61.8)], household water source from spring [(OR=15.9; CI

(2.2 - 18.3)] and children living in food insecure household [(OR=1.85; 95% CI (1.23, 2.80)

identified as factors of relapse after cure from severe acute malnutrition.

Conclusion: The magnitude of relapse after cure for severe acute malnutrition is 11.36% within

one year of post discharge. More than one in ten children were cured from severe acute

malnutrition but relapse within one year of post discharge. Detail assessment, and targeted

counselling and follow up is need especially on children admission and discharge with edema and

from household with food insecurity.

Key words: Relapse, severe acute malnutrition, wasting.

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1. INTRODUCTION

1.1. Background

There are four broad sub-forms of undernutrition including: - wasting, stunting, underweight, and

deficiencies in vitamins and minerals. Undernutrition makes children vulnerable to disease and

death. Low weight-for-height is known as wasting and usually indicates recent and severe weight

loss, due to inadequate intake food to eat or due infectious disease, such as diarrhoea, which causes

weight loss. A young child who is moderately or severely wasted has an increased risk of death,

but treatment is possible (Somassè et al., 2016).

Low height-for-age is known as stunting. It is the result of chronic or recurrent undernutrition,

usually associated with poor socioeconomic conditions, poor maternal health and nutrition,

frequent illness, and/or inappropriate infant and young child feeding and care in early life. Stunting

holds children back from reaching their physical and cognitive potential(Global Nutrition report,

2020). Stunting refers to a child who is too short for his or her age:-these children can suffer severe

lifelong irreversible physical and cognitive damage associated with the stunted growth: - the

devastating effects can extend to next generation. Some children suffer from more than one form

of malnutrition – such as stunting, overweight or wasting(Dale et al., 2018a).

Malnutrition in all forms has become the leading cause of ill health and death, and the rapid rise

of diet-related NCDs is putting strain on the health systems. Yet, most people cannot access or

afford quality nutritious food for prevention or treatment. Worldwide, only about one-quarter of

the 16.6 million children under 5 years of age with severe acute malnutrition received treatment in

2017, this highlights the urgent need to address this unacceptable burden.

Although nutrition actions are highly cost-effective and able to reduce healthcare spending in the

long term, they represent only a small of the national health budgets. These strategies are largely

focused on undernutrition and rarely delivered by skilled nutrition professionals. At the same time,

health records and checks are not optimized to screen, monitor and treat malnutrition, such as

through assessments of diet quality and food security(Dale et al., 2018b). One in 9 people – 820

million worldwide – are hungry or undernourished, with numbers rising since 2015, especially in

Africa, West Asia and Latin America. Around 113 million people across 53 countries experience

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acute hunger, as a result of conflict and food insecurity, climate shocks and economic

turbulence(UNICEF, WHO and World Bank, 2020)

The latest data reveals some progress towards select 2025 global nutrition targets, including

maternal, infant and young child nutrition (MIYCN) targets, and diet-related NCD targets.

However, overall, progress towards global nutrition targets is far too slow or non-existent.

Malnutrition is persisting at unacceptably high levels, with marked differences between countries,

within countries and by population characteristics (WHO, 2020).

The mortality rate among children with SAM is 5–20 times higher than among well-nourished

children. Globally about 1 million children die every year from SAM and in Ethiopia about 57%

of all under-five deaths are related to malnutrition, of which three-quarters are related to mild to

moderate malnutrition. It is also estimated that about 70% of all childhood mortality in developing

countries is due to five major conditions, and for these, malnutrition increases the likelihood of

mortality up to 56%.

Ten high-impact, nutrition-specific interventions have been identified that, if taken as a package

up to 90 percent coverage, could reduce wasting by 60 percent. Among these important

interventions is the management of SAM and MAM (Abitew et al., 2020)

Children with uncomplicated SAM (WHZ below -3 SD cut-off and/or with MUAC cut-off 11.5

cm and/or with bilateral edema) and MAM (WHZ between −2 and −3 or mid-upper arm

circumference (MUAC) between 11.5 and 12.5 centimeters) may be treated in the community

setting with special therapeutic foods without requiring admission to a health facility, referred to

as Community based Management of Acute Malnutrition program(Somassè et al., 2016).

Around 17 million children worldwide suffer from severe acute malnutrition (SAM), defined as

having a weight‐for‐height z‐score (WHZ) less than −3 SD or a mid‐upper arm circumference

(MUAC) less than 115 mm (United Nations Children's Fund, World Health Organization, & World

Bank Group, 2017).

Unfortunately estimates reveal that worldwide numbers of children who suffer from acute

malnutrition have decreased very little (only 11% over the past 20 years), particularly with the

progress made in reducing other malnutrition indicators, such as stunting (Annan, Webb, & Brown,

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2014). Moreover, the immediate consequences of SAM are life threatening, as a child with SAM

is approximately nine times more likely to die than a non‐malnourished child (Stobaugh et al.,

2019)

1.2.Statement of the problem

The relapse of SAM is one of the problems encountered in managing of children with severe acute

malnutrition. The proportion of children who relapsed after SAM treatment varied greatly from

0% to 37% across varying lengths of time following discharge. The lack of a standard definition

of relapse limited comparability even among the few studies that have quantified post‐discharge

relapse (Stobaugh et al., 2019).

The international normative guidance does not endorse the possibility that SAM treatment

programs restrict admission to children with MUAC < 115 mm or nutritional edema (Guesdon et

al., 2021a), this proposal has been increasingly promoted and applied(Bliss et al., 2018)

Evidence on SAM relapse is sparse with a high variation in estimates because of contextual and

methodological differences(Stobaugh et al., 2018) This makes it difficult to understand the

persistent risk of a SAM episode after initial recovery from the CMAM programme, and the

associated risk factors. Another critical gap in the literature is the absence of comparison groups,

making it difficult to determine the excess risk for SAM associated with a recent SAM episode.

Additionally, to our knowledge, only one study explored the issue of relapse in Nigeria and did

not include a control group (Stobaugh et al., 2018). To fill this gap in the literature, the ongoing

risk was evaluated by measuring the 12‐month incidence rate of relapse among children discharge

as cured from the OTP services of the CMAM programme. Our objective was to identify factors

that are associated with the risk of relapse.

As opposed to its consequences on targeting and assessing eligibility to treatment, which has been

described by rogers (Rogers et al., 2015), the impacts on discharge have not been analyzed.

However, in programs abandoning the assessment of WHZ, MUAC ≥ 125 mm is used as the only

restrictive criterion to consider children as cured, irrespective of the WHZ deficits that may be

present upon admission. This practice is expected to discharge many children as cured with

remaining WHZ deficits (Guesdon et al., 2021a) and may affect treatment effectiveness to an

unknown extent.

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Post-treatment outcomes follow-up in children discharged as cured with variable levels of

anthropometric deficits is instrumental to filling current evidence gaps about the adequacy of

existing international recommendation and the extent to which different types of anthropometric

deficits at discharge, including WHZ deficits, influence the risk of relapse (Guesdon et al., 2021a).

In Nepal, severely acutely malnourished children are managed and treated as per the national

guideline on Integrated Management of Acute Malnutrition (Guesdon et al., 2021a) According to

this guidance, all internationally agreed-upon case definitions of SAM (low MUAC or low WHZ

or nutritional edema) are eligible for treatment, yet discharge criteria are less stringent than WHO

standards: they mainly consist in the observation of a MUAC > 115 mm after a minimum treatment

duration of 6 weeks.

Many children may thus be discharged from SAM treatment while still presenting anthropometric

deficits (Guesdon et al., 2021b). The resulting risks have never been assessed. In particular we do

not know if (or to what extent) this may predispose to relapse or if instead, the child recovery

process would continue after treatment cessation.

The literature strongly suggests that CMAM programmes are effective in achieving ‘nutritional

recovery in a timely manner’(Lenters, Wazny and Bhutta, 2016), However, to maximize impact,

programmes working to treat SAM should improve long‐term outcomes of survivors by

minimizing relapse, defined as a new episode of SAM after discharge, persistent excess morbidity

and mortality.

A systematic review by (Stobaugh et al., 2019) shows that the evidence surrounding post-

discharge outcomes after initial recovery from SAM are limited but tends to highlight poor health

and nutrition outcomes, including relapse.

Although most of the research conducted around SAM addresses the causes, short‐term

consequences, and treatment methods for achieving immediate recovery, little is known about

children’s overall health and nutrition following discharge. A small body of evidence is emerging

from the few studies that followed children after treatment for SAM, demonstrating poor post‐

discharge outcomes after initial recovery including mortality, morbidity, and functional

implication (Stobaugh et al., 2019a).

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The development of a standard definition of relapse is needed for programme implementers and

researchers. This research gap allowed for assessment of programme quality regarding relapse and

a better understanding of the associated factors of or contribution of relapse to the local and global

burden of SAM. Some studies from India, Mali and Bangladesh have investigated the factors

specifically associated with relapse of severe acute malnutrition after been discharged recovered,

in Ethiopia children are discharged from the program based on the percent of weight gained or

weight for height > 70%.

The CMAM program has been reported to be effective in access and key performance indicators

(recovery, default, and death rates). In some research findings, the recovery rate has been reported

to be above the Sphere Handbook(Sphere-handbook, 2018))minimum standard of >75% , but the

relapse rate of acute malnutrition after discharge as recovered is high. This has been noted as in

Bangladesh 9% SAM (Banerjee C., et al. 2016), 10% SAM (Chang C. Y., et al., 2013) , and in

Southern Ethiopia 34.6% SAM (Tadesse et al., 2018).

The magnitude of acute malnutrition nationally and in the Oromia region was 10% (CSA, 2016).

The extent of undernutrition and subsequent health consequences are essential, as children

suffering from acute malnutrition have weakened immunity and face an increased risk of death,

mainly when wasting is severe (UNICEF, et al. 2019).

After relapse following treatment of severe acute malnutrition (SAM), relapse is poorly defined

and scarcely measured across programs and research. The data across studies are not comparable

due to different treatment protocols, various follow‐up periods, and inconsistent reporting of

relapse as a point prevalence (not cumulative), cumulative prevalence, and incidence rate (Abitew

et al., 2020). Although relapse of SAM is one of the problems encountered in the managing of

children with severe acute malnutrition.

A retrospective study of CMAM in Ethiopia suggests that, the relapse rate is 22% due to Low

admission MUAC criteria and % weight gain as discharge criteria may explain higher relapse

rates(Stobaugh et al., 2019a). Ethiopia Programme evaluation CMAM with relapse rate1%, 1.3%,

1.8% in 2007, 2008, and 2009, respectively shows that no established follow‐ up procedure; all

relapses were defined as self‐ referring readmissions. Likely an underestimation of true

relapse(Stobaugh et al., 2019a)

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However, study done in south Ethiopia was limited to factor identification of relapse such that

important factors were not studied such as antibiotics, vaccination status, access to health services,

standard of living, food security, provision of colostrum, Vitamin A supplementation, and distance

from water sources and access to clean water that may affect relapse to SAM or was limited to

factor identification associated factors not documented so far in the study area as well as in Oromia.

Unfortunately, in Ethiopia there is only one case control study on acute malnutrition (Abitew et

al., 2020) and one cohort study on severe acute malnutrition (Abera et al., 2021). So, this study is

aimed to identify magnitude and associated factors in the kurfa Chele District.

1.3. Significance of the study

The intention is to highlight evidence gaps, provide a basis for hypothesis generation and guide

researchers, practitioners and policymakers on key considerations for the collection of research

and operational data in different contexts, thereby improving our understanding of risk factors for

and prevention of relapse.

One of the most immediate outcomes that needs to be understood and addressed is relapse to SAM.

To find appropriate, scalable solutions to tackle relapse, overall burden of relapse in different

contexts, and need to be identified and a better understanding of potential risk factors and

consequences associated with relapse.

The objectives of most treatment programs for severe acute malnutrition (SAM) in children

focuses primary on initial recovery, which leaves post‐discharge outcomes, such as relapse, poorly

understood and undefined. The program designers, coordinators, community and researchers will

benefits from this study Therefore due to these study gaps magnitude of relapse and associated

factors after cure for SAM treatment was investigated in this study area.

1.4. Objective of the study

To identify magnitude of relapse after cure for severe acute malnutrition and associated factors

among children aged 6-59 month in kurfa chele district, Eastern Ethiopia.

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1.4.1. Specific Objective

To calculate magnitude of relapse after cure for severe acute malnutrition among children

aged of 6-59 months in kurfa chele district.

To identify factors associated with relapse after cure for severe acute malnutrition among

children aged of 6-59 months in kurfa Chelle district.

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2. LITERATURE REVIEW

2.1. Magnitude of relapse after cure for severe acute malnutrition

Relapse tended to occur more frequently during the first 6 months following discharge. For

example, a 2016 study in India that followed children on a quarterly basis for 18 months after

discharge found that children were more likely to relapse in the first 3 months (9.1%) versus 6

months (2.9%), 9 months (2.1%), 12 months (2.8%), and 18 months 0%(Stobaugh et al., 2019a).

In Niger, those who defaulted during treatment had 7.1 times higher risk of death and were more

likely to relapse at 3 months than those who were discharged as recovered(Adegoke et al., 2021)

Study in India observed relapse as high as 52% of children who defaulted from SAM treatment.

Including defaulters in the definition of relapse likely inflates the proportion of relapse due to the

inability to determine whether those defaulters ever reached a state of recovery (and thus truly

“relapsed” back to being malnourished again) or remained malnourished throughout the time after

leaving the treatment programme to the follow‐up point. The latter case is not a true relapse, rather

a prolonged case of unresolved acute malnutrition( Pati et al., 2018)

A facility based longitudinal prospective cohort study in India with relapse rate 4.9% total (8%,

3%, and 5% for 0–6, 7–24, 25–59 months, respectively) that Suggested better integration between

Prospective cohort study of India on CMAM admitted with WHZ < -3 or oedema prevalence of

relapse rate of 37.4% to SAM, 48% to MAM (42.4% local diet, 40.7% conventional RUTF, 29.2%

local RUTF) RUTF resulted in lower relapse rates than fortified home‐based diet (Bhandai 2017).

facility‐based and community‐based treatment to reduce relapse( Guesdon et al., 2021).

Ethiopia Programme evaluation CMAM with relapse rate1%, 1.3%, 1.8% in 2007, 2008, and 2009,

respectively shows that no established follow‐ up procedure; all relapses were defined as self‐

referring readmissions. Likely an underestimation of true relapse(Stobaugh et al., 2019a)

A 2015 longitudinal study in Ethiopia demonstrated the probability of experiencing a new episode

of acute malnutrition (AM) was 26% and 7.5% for 6 and 12 months, respectively (Abitew et al.,

2020). When including both MAM and SAM in the definition of relapse, the proportion of relapse

increases dramatically, from 38% to 86% at 3 months in India (Guesdon et al., 2021a).

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30% to 80% over 3.5 months in Ethiopia (Stobaugh, 2017), 13% to 41% over 6 months in the

Democratic Republic of Congo (Grellety et al., 2017) , and 15% to 44% over 12 months in

Ethiopia(Stobaugh et al., 2019a) for relapse to SAM and AM, respectively. From most studies,

only one study included a true control group of non‐malnourished counterparts for which to

compare excess relapse (Stobaugh et al., 2019a). This 2015 longitudinal study in Ethiopia followed

children after SAM treatment as well as matched non wasted community controls for 1 year and

found 15% relapse in-group yet 1.2% of the control children became severely malnourished in the

same time period. The incidence rate was 1.27 and 0.09 per 100 person‐months for post‐SAM and

controls, respectively post‐SAM and controls, respectively(Stobaugh et al., 2019a).

The difference between reporting relapse as point prevalence and cumulative incidence is seen in

the 2015 Ethiopian study where both indicators were calculated. In this study, reported relapse is

1% as a point prevalence at 12 months post‐discharge (meaning only 1% of children was in a state

of relapse at the time of 12 months post‐discharge) and yet relapse is 15% cumulative incidence

over the course of the entire 12 months (Simachew, Zerfu and Alemu, 2020).

2.2. Associated factors of relapse after cure for severe acute malnutrition.

2.2.1. Anthropometric factors associated with SAM

Consistently, studies and programme evaluations reported that children who defaulted or were

discharged prior to reaching recommended anthropometric discharge criteria had higher risk for

relapse, Including defaulters in the definition of relapse likely inflates the proportion of relapse

due to the inability to determine whether those defaulters ever reached a state of recovery (and

thus truly “relapsed” back to being malnourished again) or remained malnourished throughout the

time after leaving the treatment programme to the follow‐up point. The latter case is not a true

relapse, rather a prolonged case of unresolved acute malnutrition (Stobaugh et al., 2019a)

The strongest, most consistent risk factor associated with relapse was having lower anthropometric

measurements upon admission to and discharge from treatment of SAM(Somassè et al., 2016).

Prospective cohort study of CMAM at Malawi with relapse rate of 1.9%, MUAC deemed an

appropriate discharge criterion; due to early detection of SAM may reduce relapse. Cure rate for

initial treatment programme was low (63%) due to early discharge. Children in SFP during follow‐

up period (Adegoke et al., 2021).

10 | P a g e

As longitudinal cohort study done in Burkina Faso indicate that children with MUAC < 11cm with

edema or WHZ>- with relapse rate of 11% severe acute malnutrition; due to high lost to follow-

up 34%, which may be lead to under estimation of relapse; it may be due to MUAC upon discharge

below 12.5cm, no oil or fat consumption, and incomplete vaccination(Somassè et al., 2016).

The relapse of SAM is one of the problems encountered in the management of children with severe

acute malnutrition. Children with SAM are admitted to health posts using MUAC < 11.5cm and

get treated with ready to use therapeutic food and other treatments indicated in the protocol for a

period of 8 weeks(FDRE, 2019). Children with the lowest MUAC at admission showed a

significant gain in MUAC but not weight, and children with the lowest weight-for-height/length

(WHZ) showed a significant gain in weight but not MUAC and response to treatment was largest

for children with the lowest anthropometric status at admission in either measurement modality by

WHZ or MUAC (Simachew, Zerfu and Alemu, 2020).

A retrospective study of CMAM in Ethiopia suggests that, the relapse rate is 22% due to Low

admission MUAC criteria and % weight gain as discharge criteria may explain higher relapse

rates(Stobaugh et al., 2019a).

2.2.2. Illness history of admitted child with severe acute malnutrition.

Illness was observed at the time of relapse in eight studies(Ashraf et al., 2012). Several authors

suggested that children who are discharged as recovered from SAM treatment based on

anthropometrics alone may not have experienced full immunologic recovery, leaving them

susceptible to infection and subsequent relapse. Although rarely measured, micronutrient

deficiencies were not associated with relapse( Abitew et al., 2020).

Based on secondary data analysis the database of children from a CMAM programme in Dowa,

Malawi contained 1,361 records with a mean follow‐up period of 15 months (range 1–32 months)..

Loss to follow‐up and/or survivor bias, may be underestimating the relapse rate, especially among

those who defaulted from treatment. There was no significant difference in odds ratio of relapse at

6 nor 12 months when regressed against age at admission, sex, oedema at admission, diarrhoea at

admission, fever at admission, cough at admission, MUAC at admission, mother not alive, father

not alive, attendance to supplementary feeding program, or MUAC at discharge, respectively.

11 | P a g e

A cross‐sectional study at Malawi on CMAM, admitted by WHM < 70% MUAC < 110 mm

oedema and discharge criteria of WHM ≥ 80% followed for 15.6 months (median length) 3, 12

months, prevalence of relapse rate 3% (35.7% for HIV+ and 2% for HIV-) and Recommend more

RUTF for HIV+ children, continued feeding for HIV+ children, and link CMAM model with HIV

treatment( Adegoke et al., 2021).

Prospective cohort study of SAM in India, which is relapse rate 9.1%, 2.9%, 2.1%, 2.8%, and 0%

at 3, 6, 9, 12, and 18 months, respectively associations with relapse include: seasonality, use of

health services, lower standard of living, less time outside the programme, low HAZ at time of

discharge(Chaw et al., 2018).

A retrospective study of Haiti of CMAM for each year of 2009–2013, only 56% cured at discharge

with Low cure rate at discharge reflects programme quality, which likely impacts relapse

rates(Cuneo et al., 2017).

Prospective cohort study of India on CMAM providing locally made therapeutic food for 90 days

severely underweight with relapse rate 3% SAM and 11% severely underweight higher relapse

rates to underweight may be due to stunting following SAM(Jansen et al., 2021).A study of

prospective cohort at Banglidash on SAM Day care, with relapse rate 17.8% Observed persistent

stunting, high prevalence of illness in first 3 months, study experienced high drop‐out rate (Ashraf

et al., 2012).

A study of Nigeria Coverage survey on CMAM with admission creteria of WHZ < -3 or MUAC

< 115 mm or oedema and discharged of MUAC ≥ 125 mm and with relapse rate 25% mothers

were asked if child had previously been admitted and discharged, Observed high prevalence of

illness at time of relapse; rates rely of caregivers' report of prior treatment( Adegoke et al., 2021).

As longitudinal prospective cohort study done in Ethiopia after recover they relapsed to SAM by

35% and 38% to MAM, followed after discharge for about 2-6 weeks it may be due to Many

children discharged prior to anthropometric recovery; proportion of children readmitted was

significantly higher among children with most severe degree of wasting on admission( Kabalo and

Seifu, 2017).

12 | P a g e

2.2.3. Socio-economic status of Households

Poor linear growth and stunting were also consistently observed post‐discharge(Somassè et al.,

2016). Data are mixed regarding significant associations between relapse and household‐level

factors, such as socio‐economic status, feeding practices, and sanitary living conditions(Stobaugh

et al., 2018). Results are inconclusive regarding the effect of seasonality and food security on

relapse( Pati et al., 2018).Unconditional cash transfers during and following the treatment of SAM

led to a decrease in relapse rates(Grellety et al., 2017).

Being an orphan was associated with five times greater odds of relapse at 12 months' post‐

discharge (95% CI [1.7, 12.4], P = 0.003),(Kerac et al., 2014). A facility based prospective cohort

study in Bangladesh with relapse rate 1% suggest that all study participants lived <10 km of the

health facility; access to healthcare services may explain low relapse rates(UNICEF, WHO and

World Bank, 2020).

A retrospective study in Madasgascar with relapse rate 1% states that Being younger, higher

admission WHZ, and use of chlorine water treatment increased likelihood of maintaining recovery;

when children were lost to follow‐up, data on other children who had participated in the

programme were used (Magnin et al., 2017).

Study of Guinea Bissau of facility based prospective cohort indicate that 1% of Children treated

for SAM had better outcomes than those who had not been treated with SAM before response to

prior study saying treatment was a waste. One cross‐ sectional survey at 18 months follow‐up is

likely to miss relapses that take place closer to the time of discharge( Colombatti et al., 2008)

A prospective cohort study in DRC(6 months after admission) children relapsed to SAM by 11%

and to MAM by 44% ) an implementation an unconditional cash transfer in combination with

CMAM led to significantly lower relapse, time of follow‐up after discharge varied between

participants(Grellety et al., 2017).

Retrospective secondary data analysis of CMAM of Gambia relapse rate 6% (7.1% and 3.8% for

MUAC and WHZ discharge) indicate that No statistical difference in relapse rates between

discharges criteria using MUAC versus WHZ; no established follow‐up procedure; all relapses

13 | P a g e

were defined as self‐referring readmissions. Likely an underestimation of true relapse (Burrell

2017).

A study of Malawi prospective cohort CMAM versus facility‐based with relapse rate 6.9% (6.2%

and 10.6% for home‐RUTF and inpatient) for home‐RUTF and inpatient receiving home‐based

RUTF is associated with lower risk of relapse (Kerac et al., 2014).

Prospective cohort study shows that children return to SAM followed for 12 months 15% to SAM

in post SAM ,1% in health controls post SAM children had higher risk for Acute malnutrition than

controls; due to MUAC,HAZ,food security, and IYCF associated with relapse; discharge using %

weight gain may increase relapse rate (Abitew et al., 2020).

2.2.4. Nutritional education/counseling.

A facility based cross-sectional study in Senegal prevalence relapse rate 10.1%, Suggests return to

an unfavourable environment and poor adoption of nutrition counselling messages explain high

relapse rates(Stobaugh et al., 2019a).

A facility based Study done in Sudan on program evaluation of CMAM indicate that 0% Report

was written using programme monitoring data and does not include much detail regarding follow-

up procedure or duration(Stobaugh et al., 2019a). A facility based prospective cohort study at

Tanzania on SAM treatment 13% relapse us a result of they used outdated treatment

protocols(Shams et al., 2012).

As study done in Kenya on facility based programme monitoring and evaluation on CMAM

relapse to inpatient 6.1%, outpatient 3.2% due to health workers stated that sharing RUTF

negatively affects relapse( Desormeaux, 2015). Study of Niger state that facility based prospective

cohort followed for 3-18 months and treatment given to they by outdated treatment protocol, high

mortality and default rate during treatment and no follow up occurred between discharge and 3

months( Niger Health Survey, 2018).

As the study done in south Ethiopia, having nutritional edema during the first admission increased

incidence rate ratio of relapse for SAM by 2.205 times (IRR = 2.21, 95% CI: 1.303–3.732).

Similarly, being in the age groups of 6–11 months increased the incidence rate ratio of relapse for

14 | P a g e

SAM by 4.7 times compared to the age group of 48–60 months (IRR = 4.74,95% CI:1.79–12.53)

due to quality of care and poor counseling (Abera, Deselegn, and Tefera 2021).

2.3. Conceptual Framework.

The systematic review on relapse to severe acute malnutrition (Stobaugh et al 2019). Found that

children discharged before reaching WHO recommended discharge criteria tended to have higher

risks of post-treatment severe acute malnutrition, representing ongoing episodes of or regressions

to SAM after partial recovery. Furthermore, worse anthropometric measurements at admission and

discharge were most consistently found to be associated with increased risk of post-treatment

SAM. Some studies reported illness among children at time of relapse, suggesting that children

discharged on the basis of anthropometric criteria may have remained immunologically susceptible

to infection (Chevalier et al., 1998). There were mixed results regarding household-level factors,

such as socio-economic status, feeding practices and sanitary living conditions, as well as seasonal

patterns of food security and infectious diseases.

However, studies commonly did not differentiate between factors associated with incidence of

severe acute malnutrition and those specifically associated with relapse, and reoccurrence to severe

acute malnutrition after exit from treatment, with widespread confusion between causality and

association.

Relapse after cure for SAM or after exit from treatment occurs within a broader socio-economic

and ecological environment with contextual factors acting at different levels (relating to the

individual, household, community, and broader political and economic structures) (Figure 1).

These factors may be present before, during and/or after treatment for SAM and may be the same

factors causing severe wasting in the first place while also contributing to relapse, or reoccurrence

after treatment.

The relative importance of these factors differs across settings, and studies have linked risk of

relapse to factors such as age and gender (Abitew, Yalew, Bezabih, & Bazzano, 2020; Adegoke et

al., 2020; Chang et al., 2012; Stobaugh et al., 2018), HIV status (Bahwere et al., 2008; Chang et

al., 2012), vaccination status (Somassè, Dramaix, Bahwere, & Donnen, 2016), diet and feeding

practices (Abitew, Yalew, Bezabih, & Bazzano, 2020; Somassè, Dramaix, Bahwere, & Donnen,

15 | P a g e

2016), household handwashing practices and distance to water sources (Abitew, Yalew, Bezabih,

& Bazzano, 2020), seasonality and food security (Abitew, Yalew, Bezabih, & Bazzano, 2020;

Burza et al., 2016; Chang et al., 2012; Grellety et al., 2017; Stobaugh et al., 2018), and

environmental shocks (Adegoke et al., 2020). These contextual factors have broad influence on

access to treatment, type of exit from treatment (e.g., by affecting risks of defaulting),

characteristics before and at entry into and exit from treatment, and risk of developing relapse after

exiting treatment.

In this studies, we aim to address the need for theoretical guidance by providing a framework for

post-treatment SAM to facilitate conceptualize evidence around relapse.

Figure 1: Conceptual framework magnitude and associated factors of relapse after cure for

severe acute malnutrition of kurfa chele district 2021.

16 | P a g e

3. METHODS AND MATERIALS

3.1. Study area and period

A community based cross-sectional study was conducted from 01/07/2021-30/07/2021 in Kurfa

Chele district, East Hararghe, Oromia national regional state, Eastern Ethiopia, located

approximate geographical coordinates of Latitude: 9° 09' 60.00" N Longitude: 41° 44' 59.99" E.

Kurfa Chele is a woreda in the Oromia Region of Ethiopia. It is named after its administrative

center, Kurfa Chele. Part of the Misraq (East) Hararghe Zone, Kurfa Chele is bordered on the south

by Girawa, on the west by Bedeno, on the northwest by Kersa, and on the northeast by Haro Maya.

The altitude of this woreda ranges from 1400 to 3400 meters above sea level; Gara Muleta, and

Gebiba are amongst the highest points. Rivers include the Dawe, Gefra Gelana and Gefra.

A survey of the land in Kurfa Chele (released in 1995/96) shows that 23.3% is arable or cultivable,

1.4% pasture, 14.7% forest, and the remaining 60.6% is considered built-up, degraded or otherwise

unusable. Khat and vegetables are important cash crops at a distance of 540 km in the East of

Addis Ababa. Regarding to the population of the town the total population of the town is estimated

to be about 84496 of which 43196 are females and 41300 are males. Out of this total population,

the number of 6-59 month population estimated to be about 12674 of which is 6337 are males and

6337 are females. The district have 18 rural and two urban kebeles and also 18 health post and 4

health center (Kurfa Chele district physical and socioeconomic profile, 2021).

3.2. Study design

A community based cross-sectional study design was used.

3.3. Source population

Children aged 6-59 months discharged from June 30/ 2019 to June30/2020 as recovered from

OTP/SC and their mothers/care givers in Kurfa Chele district.

3.4. Study population

All randomly selected children aged 6-59 months following discharge from June 30/ 2019 to

June30/2020 as recovered from OTP and their mothers/care givers in the selected kebeles of Kurfa

Chele district.

https://en.wikipedia.org/wiki/Districts_of_Ethiopia

https://en.wikipedia.org/wiki/Oromia_Region

https://en.wikipedia.org/wiki/Ethiopia

https://en.wikipedia.org/w/index.php?title=Kurfa_Chele&action=edit&redlink=1

https://en.wikipedia.org/wiki/Misraq_Hararghe_Zone

https://en.wikipedia.org/wiki/Girawa_(woreda)

https://en.wikipedia.org/wiki/Bedeno_(woreda)

https://en.wikipedia.org/wiki/Kersa_(Hararge)

https://en.wikipedia.org/wiki/Haro_Maya_(woreda)

https://en.wikipedia.org/wiki/Forestry_in_Ethiopia

https://en.wikipedia.org/wiki/Khat

17 | P a g e

3.5. Inclusion and Exclusion creteria.

3.5.1. Inclusion criteria

Children whom aged 6 to 59 months old were discharged as recovered from OTP July 30/2019 to

June 30/2020 and their mothers / care givers/ during the time of study were included.

3.5.2. Exclusion criteria

Children mothers/care givers who could not responded to the interview during data collection due

to illnesses were excluded from the study.

3.6. Sample size determination.

For objective 1: The prevalence of relapse of severe acute malnutrition in children The sample size

was calculated using single population proportion formula considering expected recovery rate

from stabilization center 46% from Sekota hospital the similar study (Kebede., 2015) at 0.05 level

of significance, 0.05 marginal error at 95% level of confidence and calculated as below and finally

10 % non-response rate was added.

Where:

n= minimum sample size required for study

p= estimated prevalence from literature 46% (.46)

Z α/2 = critical value at 95% confidence level of certainty (1.96).

d= margin of error 5% (0.05).

Thus, n is calculated as:

𝑛 =( 𝑍𝑎

2⁄ )2 𝑝(1−𝑝)

𝑑2

n = (1.96)2(0.096) (0.904)/ (0.05)2= 381.

After 10% non-response rate was added to the sample size the final sample size obtained was 419.

For objective 2: Factors associated with relapse to severe acute malnutrition among children of 6-

59 months.

18 | P a g e

The sample size for factors associated with relapse to severe acute malnutrition was calculated for

some factors obtained from different literature by using the statistical calculation of EPI INFO

statistical software version 7.2 with the following assumptions: power 80%, 95% confidence level

and ratio of unexposed to exposed 1.5.

After the sample sizes were calculated for the first and second objectives for different factors, due

to total case admitted in the woreda 223 the all SAM cases included in the study.

Table 1: Objective two sample size calculation for relapse to severe acute malnutrition children

population of Kurfa Chele district, Eastern Ethiopia, 2021.

Variables Proportion relapse among

children cured from SAM

Sample size

computed

Computed

sample size

+(10%)NR

Reference

Exposed Unexposed

Oedema Oedematous

(20%)

Non-

oedematous(10)

203

223 (Guesdon et

al., 2021a)

Frequency of

BF/day

<8(6.3%) 8-12(18.3%) 105 116 (Abitew et

al., 2020)

MUAC MUAC < 125

mm (41.7%)

MUAC ≥ 125

(mm 27.8%)

65 72 (Abera et

al., 2021)

3.7. Sampling procedure and technique

For this study, all Kurfa Chele Kebeles (20) were included in the study. Simple random sampling

technique was used based on the case load of each kebele from registration book. So to earn final

sample from each kebele by proportional allocation for each kebeles then the final sample size

n=223 children as follows: The total sample size was proportionally allocated for all selected health

facilities providing OTP in the study area based on the number of children with SAM admitted to

OTP services in each facilities.

19 | P a g e

Figure 2: Sample size determination of relapse after cure for severe acute malnutrition and

associated factors kurfa chele woreda, Eastern Ethiopia, 2021.

Ku

rfa C

hel

e W

ore

da

Ch

ild

ren

ad

mit

ted

wit

h S

AM

at

ku

rfa c

hel

e d

istr

ict

n=

33

0

sdd

Orde

(8)

Arrele Guda

(13)

Arrele Tika

(10)

Kurfa Chelle Health Center

Goro

Garbii (8)

8)

Gudina

Muldhata(25)

Adu

Bate (9)

Jiruu

Baldhin(17)

S777 (17 )

Kurfa

(6)

SAM cases

Proportionally for calculating sample

4 6 12 8 7 12 7 10

Dawe Health Center

Dawe

(10)

Rasa Jannata

(25)

Hula

Jannata(19)

19)

Caffe

Anani (25)

Jiru Gammachu

(40)

6 16 14 16 20

Dire Gudina Health Center

Bili

Baldhina (8)

Ija Kacu

(15)

Dire Gudina

(35)

Afran Qallo

(12)

Alam

Durom (30)

7 12 25 20 7

Darmashek

(8)

SAM cases

Dhaqqaba

(8)

SAM cases

9

5

Proportionally for calculating sample

Tota

l S

am

ple

siz

e=223

Sa

Proportional allocation for calculating sample size

20 | P a g e

3.8. Data collections Methods

3.8.1 Data Collection Tools/Instruments

The data collection tools used consisted of a checklist, questionnaire and primary data were

collected from the respondents by the interview. The checklist was prepared using the stabilization

Centre/outpatient therapeutic program (SC/OTP) multi-chart and registration logbook which are

utilized throughout the country such as EDHS 2016 (Central Statistical Agency of Ethiopia , 2016).

3.8.2. Data Collectors

Twenty health extension workers were collected data. Four public health officers supervised and

coordinated data collectors. A two day training regarding the objective of the study, data collection

tools and interview methods were given by the principal investigator.

3.8.3. Data Collection Procedure

To identify and trace the discharged recovered children, the number admitted cases from the

woreda HMIS report and the names of children and the address (Ganda) were identified from their

respective heath post and health center registration book for the sampling frame. In addition, the

questionnaire used for this study was adapted from validated locally used questionnaires in

nutrition research and survey reports. For example questions and potential responses regarding

socio-demographic/economic, housing conditions, child feeding/caring and related items were

developed from the Ethiopian Demographic and Health Survey reports(CSA, 2016).

In addition, the questions to assess household (HH) food security status were taken from a

validated questionnaire developed by Food and Nutrition Technical Assistant (FANTA) project

(Coates, Swindale and Bilinsky, 2007), For further validation, prior to data collection, the

questionnaires were pre-tested on 5% of actual respondents in another health facility ( Girawa

health Post) outside of the study area to check for understandability and clarity, and appropriate

corrections were made based on the pre-test finding. The questionnaire was prepared in English

and then translated to the local language (Afan Oromo) and back to English to check the

consistency. Mothers or primary caretakers were interviewed using the questionnaire which took

approximately 35–45 minutes.

21 | P a g e

The data collection took place from June 01/06/2021 to 30/06/2021. A total of 20 data collectors

who had SAM management training and relevant previous experience in data collection were

recruited and trained for 2 days, with training content mainly focusing on objective of the study

and on how to administer the questionnaire. The data collectors were closely supervised by the 4

trained public health offer (HO) and by the principal investigator. The data were collected from

the participants by using a structured questionnaire that contains a socio-demographic and

socioeconomic characteristic, health and life style factors, HFIAS factors and food consumption

scores.

The Household food security status (HFSS) of participants were measured by using the FANTA.

HFIAS score is a continuous measure of the degree of food insecurity (access) in the household in

the past four weeks (30 days). The tool is constructed from nine consecutive food insecurity

occurrence experience and frequency of occurrence questions with three possible answers, and a

total of 27 scores. Then, HFSS was categorized as; “Food secure” (when a household scored ≤ 1)

and “Food in secured” (when a household scored greater than or equal to 2) (Coates, Swindale

and Bilinsky, 2007).

3.9. Study variables

3.9.1. Dependent variable

Relapse to severe acute undernutrition (yes/no).

3.9.2. Independent variables

The independent variable included in this study were, RUTF sharing, edema during admission,

history of BF, illness history, age of the child, type of treatment, Place of first treatment, MUAC

at discharge, practiced GMP, Household food insecurity, Dietary diversity, Household food consumption

score (FCS), family meal environment, parity, parent led feeding, persuasive feeding, Child feces disposal,

hand washing practice, parent education agricultural land, HH own livestock, distance to water source,

source of water, toilet of facility, fuel for cooking, number of rooms, agricultural land and electricity

3.10. Data Quality Control

Four public health officers (HO) were supervise data collectors daily to ensure whether the data

collectors were filling the questionnaire correctly or not and completeness of the collected data.

22 | P a g e

Any missing data was be confirmed before the start of the next day interviews by the data

collectors. The supervisors followed the activities daily to ensure the completeness of the

questionnaires. The supervisors were responsible for the overall data collection processes.

Twenty health extension workers who trained in ICCM and SAM management, collected the data

after having two days of training on the neutrality of interviewers, responsibilities of the data

collector, how to measure study subjects and how to calibrate tools and rights of respondents. Pre-

test up to 5% of the sample were conducted on one kebeles that is not included (Girawa woreda)

in 20 selected kebeles to check the consistency, length, content, question wording and language

understandability of the question before the actual data collection time.

The data collectors were closely supervised by the 4 trained public Health Offer (HO) and by the

principal investigator. The data were collected from the participants by using a structured

questionnaire that contains a socio-demographic and socioeconomic characteristic, health and life

style factors, HFIAS factors and food consumption scores.

The data collected for the pre-test was not be included in the data analysis. Probing words was be

used at the time of interviewing for questions that may be difficult to respond directly forward and

the English version of the questionnaire was be translated to local language for the purpose of

understandability and retranslated to English after the data has been collected for analysis of the

data. One health information technician (HIT) were recruited as a data clerk for data entering and

checking. Double data entry in to EpiData for the questionnaire was performed to realize

consistency in data entry and separately entered data was checked to correct mismatches.

3.11. Operational Definitions

Relapse: Relapse (D): Cured within the past 3 months and now meets the admission criteria for

SC or OTP (FDREMH, 2019)

A respondent was be categorized as having good hand washing practice if they reported washing

hands at 3 or more of the recommended critical times/points (before eating, before preparing food,

after defecation, and after cleaning child’s bottom)(UNICEF,2020).

23 | P a g e

A household was be considered to have improved drinking water if the source was either from

a pipe, protected spring, protected well and/or boiled water. A respondent was considered as

currently on family planning if she reported using any family planning methods currently to avoid

pregnancy or extend the interval between birth (Creanga et al., 2011)

Household food insecurity status was be determined using the 9 item Household Food Insecurity

Access Scale (HFIA) question. and Prior to assigning the food insecurity category (access), each

frequency of occurrence responses was coded as 0 for all cases where the answer to the

corresponding occurrence question was “no” and then the four food security categories were

computed and created sequentially as recommended by FANTA(Coates, Swindale and Bilinsky,

2007). Finally, the HFIA category 1 was considered as food secure and the remaining as food

insecure.

Wasting: A child with severe wasting has lost fat and muscle and has a “skin and bones”

appearance1. Another term used for this condition is non-edematous malnutrition (Marasmus”) or

less than -2 z score.

Severe acute malnutrition; It is diagnosed by weight for- height below -3 SD of the WHO

standards, by a MUAC < 11.5 cm and by Clinical sign having bilateral edema (WHO, 2020)

Kwashiorkor or edematous malnutrition; is also form of severe under nutrition, the child’s

muscles were wasted, but wasting may not be apparent due to generalized edema or swelling from

excess fluid in the tissues(FDRE, 2019).

Criteria for discharging children from treatment; weight-for-height/length is ≥–2 Z-scores

and they have had no oedema for at least 2 weeks(FDRE, 2019).

Recovered; Patient that has reached the discharge criteria (FDRE, 2019).

Defaulter; children who were absent treatment for two consecutive sessions (FDRE, 2019)

Cured: Weight-for-height/length Z-score is ≥ –2 SD, and child has had no oedema for at least 2

weeks; OR MUAC is ≥ 125 mm and child has had no oedema for at least 2 weeks (FDRE

MH.2019).

24 | P a g e

3.12. Data processing and analysis

Data were entered using EpiData Version 3.02 and exported to SPSS Version 22 for data analysis.

Univariable analysis was used to determine frequencies of variables. Cross-tab was done to

identify the relationship between relapse to SAM and not relapse to SAM individuals with

independent associated factors. Food consumption score was recoded to same variables by using

standard 7-day food frequency data and grouped all the food items into specific food groups and

sum all the consumption frequencies of food items of the same group, and recode the value of each

group above 7 as 7. Multiplied the value obtained for each food group by its weight and created

new weighted food group scores and sum the weighed food group scores, thus creating the food

consumption score (FCS). Then, categorized by using the appropriate thresholds, recoded the

variable food consumption score, from a continuous variable to a categorical variable as poor,

borderline and acceptable food consumption score (WHO, 2020)

Bivariable logistic regression analysis was done to see the association between the dependent

variable and each independent variable. All covariates that were significant at p-value < 0.25 in

the bivariable analysis were taken to multivariable analysis to control for all possible confounding

variables. Multi-colinearity effect was checked to see the linear correlation among the independent

variables by using Variance inflation factor. Model fitness was checked by using Hosmer-

Lemeshow goodness of fit test (p-value= 0.372). Odd ratio (OR) along with 95% interval was

estimated to measure the strength of the association. Level of statistical significance was declared

at p-value less or equal to 0.05.

3.13. Ethical Considerations

Ethical clearance were obtained from the institutional health research ethics review committee

(IHRERC) of the college of health and medical sciences, Haramaya University. A written

permission letter was obtained from East Hararghe Zonal Health Office to Kurfa Chele Health

office was write Letters to each kebeles HC and HP for their cooperation. For all study participants'

information were given about the study before the data collection on its possible risk, benefit,

confidentiality, privacy, its voluntary activity, right of with-drawl, and the time the questionnaire

was take and then informed, voluntary, written and signed consent was obtained from each

participant before beginning any interview. Personal identification were not be written on the

25 | P a g e

questionnaire and all information that were obtained from them to keep confidentiality of the study

participants. A safety measure of COVID 19 was maintained for the data collectors by providing

face mask, sanitizer and sanitizer were sprayed for the respondents as well for children.

26 | P a g e

4. RESULTS

4.1. Socio demographic characteristics of care givers

Out of 223 children who were attempted to enroll, 220 study participants agreed to participate in

the study giving a response rate of 98.7%. Two hundred fourteen (97.3%) of the study participants

care givers were females, and their age ranged from 16-66 years with mean (±SD) age of 37.15 (±

8.753) years. Regarding educational level 101 (45.1%) of the care givers were unable to read and

write. 217 (98.2%) of the study participants care givers ate food with the family. Two hundred

eleven (95.5%) of the study participants were Khat chewers and the majority (90.4%) of them

chewe daily. Almost all 216 (98.2 %) of the study participants did not consume alcohol and the

majority 212 (92.36.7%) of them did not smoke cigarettes. More than half, 174 (79 %), consume

meals only once per a day (Table 2).

Table 2: Socio-demographic and economic characteristics of study participants Kurfa Chelle

district, Eastern Ethiopia 2021(n=223).

Characteristics Category Frequency Percentage (%)

Sex of care giver Male 6 2.7

Female 214 97.3

Age of care giver

(15-30) 32 14.3

(30-45) 136 61

(>45) 52 23.3

Marital status of care giver

Single 7 3.2

Married 203 91.9

Divorced/ Separated 5 2.3

Widowed 5 2.3

Religion Islamic 218 98.6

Christian 2 .9

Educational level

Illiterate 101 45.7

Elementary 97 43.9

5-10 grade 14 6.3

College and above 8 3.6

Occupation

Employed 5 2.3

Farmer 7 3.2

Retired 2 .9

Housewife family 205 92.8

Depend on family 1 0.5

Monthly income <500 217 98.2

500-1000 1 0.5

27 | P a g e

>1000 2 0.9

Family size

(1-4) 50 22.7

(5-13) 170 77.3

Eat with family or not Alone 3 1.4

With family 217 98.2

Drink alcohol Yes 5 2.3

No 215 97.3

Smoking cigarette No 220 99.5

Chew chat Yes 211 95.5

No 9 4.1

4.2. Environmental Characteristics of study participants.

In this study, the relapse case count was conducted for severe acute malnutrition in kurfa Chelle

woreda, in 18 health posts among 220 children with severe acute malnutrition in the last one year

before the survey. From the total case counts from the records 109(49.8%) were females and

111(50.2%) were males. The mean (SD) age of the children in this study was 20.10±8.127 months.

From total households 191(86.8%) households, used water from piped and dug well and

29(13.18%) from spring water.

Table 3: Environmental Characteristics of study participants of Children Kurfa Chelle District,

Eastern Ethiopia, 2021(n = 223).

Variables Frequency Percent

Sex of child Male 111 50.2

Female 109 49.8

Age of child 6-11 30 13.6

12-23 101 45.7

24-35 84 38.0

36-47 3 1.4

48-60 2 .9

Type of admission New admission 195 86.7

Re admission 25 11.36

Main source drinking

water

Piped water 158 71.5

Dug well 33 14.9

Water from spring 29 13.1

Water source not

available in 24 hrs.

In own dwelling 15 6.8

In own yard/plot 15 6.8

Elsewhere…….specify 190 86.0

4.3. Nutritional Characteristics of children aged 6-59 months With Diagnosis

Severe Acute Malnutrition.

Regarding the types of admissions, from 223 children with SAM, 195(86.7%) were new

admissions and 25(11.36%) were relapse cases. From the total admissions for SAM, 195 (88.2)

28 | P a g e

were non-edematous and diagnosed as marasmic cases, while 19(8.6%) were edematous and

diagnosed as kwashiorkor, the rest were diagnosed as marasmic kwashiorkor. The mean (± SD)

days of stay on treatment after admission were 56 days (±10.038) days. Regarding the treatment

outcome of admitted children 194 (87.8%) were cured, 1(.5%) Defaulter, 1(.5%) non-response and

24(10.9%) transfer out (Table 4).

Table 4: Nutrition related characteristics of children aged 6-59 months with diagnosis severe

acute malnutrition in Kurfa Chelle District, Eastern Ethiopia 2021(n = 223).

Nutrition related characteristics of children diagnosed with SAM Number Percent

Presence of edema during first

admission

Yes 57 25.8

No 163 73.8

Diagnosis during admission Non-edematous 195 88.2

Edematous 19 8.6

Marasmus-kwashiorkor 6 2.7

Treatment outcomes Cured 194 87.8

Defaulter 1 0.5

Non-response 1 0.5

Transfer out 24 10.9

MUAC of children at termination

of treatment(cm)

<11.5cm 5 2.3

11.5-12.5cm 29 13.1

>12.5cm 186 84.2

4.3.1. Household’s food consumption frequency of the study participants

Al most all (91.9%) of study participants consumed food from cereals and grains daily the seven

days prior to data collection period. None of the study participants ate meat and eggs on a daily

basis and very few (1.2%) consumed meat and eggs seven times per week the week preceeding

the data collection period (Figure 3).

29 | P a g e

Figure 3: Household food consumption frequency of kurfa Chelle District

Eastern Ethiopia 2021(n=223).

4.4. Household food security status Among Caregivers of Children with

Severe Acute Malnutrition.

Out of 220 households about 197(89%) were food insecure and 24(10.9%) food secure in terms

of HFIAS ranked from 0-27 points (Figure 4).

Figure 4: Household food security status among caregivers of children with severe acute

malnutrition in Kurfa Chelle district, Eastern Ethiopia, 2021(n = 223).

34.2

54.8

1.4

58.4

98.8

15.1

55.7

27.3

0.4

3.1

0

0

0.4

0.4

0.4

5.4

0.4

25.1

6.7

4.5

0.4

9.4

5.4

61.9

65

15.7

91.9

36.3

0.4

75.1

38.5

5.4

Oil, fats/butter

Sugar/Honey

Cereal and grain

Milk

Meats

Fruits

Vegetables

Pulses

Frequency (%)

Fo

od

gro

up

s

Household Food Consumption Frequency

Never eat Eat 1-2x/wk Eat 3-6x/wk Eat all days

66.50%

22.20%

10.90%

Food security

sever food secure moderate food secure food secure

30 | P a g e

Table 5: Household food insecurity access scale among caregivers of children with severe acute

malnutrition in Kurfa Chelle District, 2021(n=223).

Variables Frequency Percent

Have no enough food Yes Rarely 162 72.6

Sometimes 25 11.2

Often 9 4.0

No 24 10.9

Lack of resource Yes Rarely 135 60.5

Sometimes 24 10.8

Often 8 3.6

No 53 24

Limited variety of food to eat Yes Rarely 133 59.6

Sometimes 12 5.4

Often 12 5.4

No 63 28.6

Eat some food Yes Rarely 101 45.3

Sometimes 31 13.9

Often 3 1.3

No 85 38.6

Have smaller meal to eat Yes Rarely 112 50.2

Sometimes 11 4.9

Often 6 2.7

No 91 41.4

Eating smaller meal Yes Rarely 73 32.7

Sometimes 16 7.2

Often 10 4.5

No 121 55

Have no food to eat Yes Rarely 69 30.9

Sometimes 19 8.5

Often 8 3.6

No 124 56.4

Go to sleep at hungry Yes Rarely 65 29.1

Sometimes 12 5.4

Often 6 2.7

No 137 62.3

Without eating any thing Yes Rarely 39 17.5

Sometimes 10 4.5

Often 4 1.8

No 167 75.9

31 | P a g e

4.5. Child Feeding Practice among children treated for Severe Acute

Malnutrition.

Out of 223 admitted with severe acute malnutrition 34 (15.5%) were fed milk (f-100 and f-75,

143(64.1%) received deworming tablets, 36(16.14) were treated at the stabilization centre and

187(85) were at the outpatient treatment program.

Table 6: Child feeding practice variables associated with relapse to severe acute malnutrition at

Kurfa Chelle District, Eastern Ethiopia 30/10/2019-30/10/2020 (n = 223)

Variable Frequency Percent

Shared plumpnut Yes 84 38.0

No 136 61.5

Baby transferred SSF Yes 48 21.7

No 172 77.8

Baby finished plumpnut Yes 63 28.5

No 157 71.0

Baby finished plumpy sum Yes 72 32.6

No 148 67.0

Baby received antibiotics Yes 175 79.2

No 45 20.4

Colostrum given Yes 210 95.0

No 10 4.5

Prelacteal feeding

Yes 211 95.5

No 9 4.1

Currently breast feeding Yes 163 73.8

No 57 25.8

Frequency of bf 8-12 times 190 86.0

Less than 8 times 6 2.7

Prepare food sepately for the child 8-12 times 195 88.2

Less than 8 times 25 11.3

Trained for preparation child diet Yes 163 73.8

No 57 25.8

Wash hands while preparing food Yes 181 81.2

No 39 17.5

Child feces disposal Yes 179 80.3

No 41 18.4

duration category 2.00 15 6.7

3.00 204 91.5

deworming tablet Yes 143 64.1

No 77 34.5

vitamin a supplementation Yes 186 83.4

No 34 15.2

vaccinated for measle Yes 173 77.6

No 47 21.1

illness history Yes 204 91.5

No 16 7.2

32 | P a g e

practiced GMP Yes 151 67.7

No 69 30.9

diagnosis during admission

Non-edematous 195 87.4

Edematous 19 8.5

Marasmus-kwashiorkor 6 2.7

muac of children at discharge

<11.5cm 17 7.6

11.5-12.5cm 17 7.6

>12.5cm 186 83.4

where the treatment of first admission HC 35 15.9

HP 185 84

child first treatment at sc or otp OTP 183 83.2

SC 37 16.8

currently on treatment Yes 11 4.9

No 209 93.7

Current MUAC

<11.5cm 1 0.4

11.5-12.5cm 90 40.4

>12.5cm 128 57.4

child good appetite Yes 216 96.9

No 4 1.8

number of under five children within

households

1-2 5 2.2

2-6 122 54.7

3 93 41.7

4.6. Magnitude of relapse among study participants

The overall magnitude of relapse in the past one year among children of 6-59 months children at

kurfa Chelle district was 11.36 % (4.50, 29.06) Figure 5.

Figure 5: The overall magnitude of relapse among children of 6-59 months children at kurfa

Chelle district 2021(n=223).

88.64%

11.36%

Relapse of SAM

No Yes

33 | P a g e

4.7. Factors associated with relapse among children cured for severe acute

malnutrition.

4.7.1. Results of bivariable analysis

Variables were checked whether the factors associated with after cure of treatment to severe acute

malnutrition using bivariate logistic regression model and a total of 11 variables with P value <0.25

were identified, they were entered in to the multivariate regression model to control for

confounding. Seven variables retained their statistical significance when entered in to the final

regression model. All covariates that were significant at p-value < 0.25 in the bivariable analysis

were taken to multivariable analysis to control for all possible confounding variables. Multi-

colinearity effect was checked to see the linear correlation among the independent variables using

variance inflation factor. Model fitness was checked by using Hosmer-Lemeshow goodness of fit

test (p-value= 0.372). In addition, multicollinearity was checked using the variance inflation

factors (VIF) values of variables and found in the below 5 indicating no multicollinearity.

In bivariable logistic regression analysis, factors such as being male child [(OR=4.13; 95% CI:

(1.45, 11.4)], aged 6-11 months [(OR=1.14; 95% CI: (.06, 20.02)] and using sources water from

spring [(OR=58.1; 95% CI: (17.9, 188.2)] having edema on admissions [(OR=17.08; 95%CI:

(6.02, 48.5)] being having a low MUAC at discharge[(OR=28.8; 95% CI: (8.5, 96.9)] and living

in food insecure household (OR= 1.8; 95% CI: were (1.39 -2.35) variables positively associated

with SAM relapse at p-value < 0.25(Table 7.)

Table 7: Results of bivariable analyses on factors associated with relapse to severe acute

malnutrition in Kurfa Chele district, Oromia, Eastern Ethiopia, 2021(n = 223)

Variable Category Relapse P value OR (95%CI)

Yes (%) No (%)

Sex of child

Male 14 96 .006 4.13 (1.45 11.4)

Female 5 99

6-11 16 14 .927 1.14(.06 20.02)

12-23 7 98 .023 .03(.002 .6)

24-35 9 79 .064 .06(.003 1.17)

36-47 15 5 .999

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Age of child in

months

48-60 9 41 .000

Source of drinking

water

Piped water 5 153 .000

Dug well 15 32 .968 .96 (.11 8.5)

Water from spring 19 10 .000 58.1 (17.9 188.2)

MUAC at discharge

<11.5cm 9 8 .000 8 (8.5 12)

11.5-12.5cm 9 8 .000 .5 (.52 12)

>12.5cm 7 179 .000

Edema at admission Yes 20 37 .000 17.08 (6.02 48.5)

No 5 158

HFIAS Insecure 19 7 .000 1.8(1.39 2.35)

Secure 5 21

FCS Poor 22 174 .000 20.17(7.2-32.8)

Moderate adequate 16 26 .188 .24(.030-2)

Adequate 10 15 .000 1.00

Own live stock Yes 6 188

No 19 7 .000 8 (2 - 7.03)

Deworming tablet Yes 8 135 .000 4.78 (1.95 11.68)

No 17 60

Practiced GMP Yes 7 144 .000 7.3 (2.9 18.39)

No 18 51

HH using kerosene No 18 115

Yes 7 80 .22 .56(.22 1.4)

4.7.2. Results of multivariable analysis

In multivariable logistic regression analysis, children ages in 6-11 months, Edema on admission,

drinking water from spring, living in food insecure households were the factors that had a

statistically significant association with relapse to severe acute malnutrition at p-value <0.05.

Having edema on admission was 10.02 times more likely to have a relapse when compared to

those who were non-edematous [(OR=10.02;95% CI: (1.6 - 61.8)] Children drinking water from

spring were 15.9 times more likely to relapse to severe acute malnutrition when compared with

children drinking piped water [(OR=15.9 ;CI:(2.2 - 114.3)]. Children living in food insecure

household were 1.85 times more likely to relapse to severe acute malnutrition when compared to

those food secured households [(OR=1.85; 95%C (1.23, 2.80) [OR=4.37; 95% CI: (1.60, 11.93)],

(Table 8).

Table 8: Results of multivariable analysis on factors associated with relapse to severe acute

malnutrition in multivariate analysis in Kurfa Chele district, Oromia, Eastern Ethiopia,

30/10/2019-30/10/2020 (n = 223).

35 | P a g e

Variables Β P AOR(95% CI) COR

Age of child in months 6-11 -4.088 .035 .017 (.000 - .743) .15(.000 - .57)

12-23 -5.200 .004 .006 (.000 - .184) .008(.000 - .251)

24-35 -3.449 .030 .032 (.001- .722) .035(.003- .008)

36-47 -22.309 .999

48-60 1.00 1

Edema at admission Yes 2.305 .013 10.02 (1.6 - 15) 10.3(1.5-17.2)

No 1.00 1

Source of drinking water Piped water 1. 1

Dug well -.389 .753 .67 (.06 - 7.605) .87(.05-8)

Water from

spring

2.771 .006 15.9 (2.2 - 18.3) 16(2.3-19)

Own livestock Yes

No 2 .25 8 (2 - 7.03) 5(2.1-8)

Deworming tablet Yes 3.2 .52 4.78 (1.95 -11.68) 3.5(1.3-13)

No

Practiced GMP Yes 3.57 .26 7.3 (2.9 -18.39) 7.4(2.3-19)

No

Household using

kerosene

Yes .56 .52 .56(.22- 1.4) .72(.45-1.5

No

Sex of the child Male .78 034 4.13 (1.45- 11.4) 3.5(1.3-13.5)

Female

HFIAS Insecure .617 .003 1.85(1.23-2.80) 2.(1.23-3.5)

Secure 1

FCS Poor 3.004 .000 20.17(7.2-32.8) 19(1.56-35)

Moderate

adequate

-1.411 .188 .24(.030-2) .25(.03-.32)

Adequate .000 1.00 1

36 | P a g e

5. DISCUSSION

Out of 223 study participants 11.36%, were relapse cases in the past year. On multivariable logistic

regression, having edema on admission , household water source from spring and children living

in food insecure household were significantly associated with relapse to severe acute malnutrition.

We found out that the proportion of relapse was 11.36%, 95% CI: 11.44 (4.50, 29.06) which is in

line with a study conducted in South Ethiopia which found 9.6% ( Abera, Deselegn and Fera

2021) and much higher than a study done in rural Malawi that revealed that children treated for

SAM and discharged in 8 weeks had a 7% relapse after treatment(Kerac et al., 2014). Similarly,

another prospective cohort studies in Bangladesh, among severely malnourished children indicate

that from those who were treated for severe malnutrition and discharged by weight for height but

not for MUAC; 7% required re admission to the nutrition program(Ashraf et al., 2012). This may

be because of different admission criteria, different study designs as well different socio economic

status.

Similarly, having edema on admission increased the risk of relapse by 10.02 times compared to

non-edematous children on admission which is much higher than study done in a south Ethiopia

which found a 2.25 times increase (Abera, Deselegn, and Tefera 2021) This may be related to

the fact that edematous children lose significant amount of lean body mass and have marginal

protein status reserves, requiring more time for recovery. Experimental studies on edema showed

that dietary treatment improved edema even before the albumin concentrations increase. The

edematous children, there was low plasma zinc concentrations which was associated with

nutritional edema and there was significant associated with a plasma zinc concentrations and

stunting, skin ulceration, and wasting(Abitew,2021).

However, as earlier weight losses there among severe acute malnourished children after

treatment there may be early discharge before cure for some micronutrients like zinc and this

may result in recurrence of SAM cases among under five children. When we come to discharge

criteria of edematous severe acute malnourished children as loss of edema but not weight gain;

however, no cut-off points for weight for the height after edema. This may be related to early

discharge from the program as weight is discharge criteria for SAM cases at the health post.

Edematous may give false weight gain as a result of nutritional edema. As nutritional oedema

37 | P a g e

affects the function of the glycocalyx are dependent upon sulphated proteoglycans which are and

other glycosaminoglycans and fundamentally related to a defect in sulphur metabolism which can

explain the clinical features of the condition ( Di Giovanni V, Bourdon C, and Wang DX 2021)

Household that use water from springs were 15.9 more likely to have SAM relapse than those from

households used water sources from piped water (15.9 (2.2 - 18.3) This finding may be because this

practice is likely to result in enteric infections and environmental enteropathy due to consuming

of unsafe water or liquids, this emphasizes the need to counsel families on prompt initiation and

exclusive breastfeeding while supporting changing norms, as well as provision of appropriate

counseling not to provide water due to risks associated decades (UNICEF, WHO and World Bank,

2020)

Those from household food insecure were 1.9 times more likely to have relapsed than children

food secure households 1.85(1.23-2.80) this is in line with a study done in north Ethiopia which

revealed 1.5 times. This is likely explained because Food insecurity can be linked to inadequate

intake of diversified foods and studies have reported consumption of low dietary diversity as being

associated with acute malnutrition. Other studies pointed to the role of low socioeconomic status

or monthly income in food insecurity, which directly or indirectly reduces the household

purchasing power, and thus, reduces access to food.

In the current study, children in food-insecure households were more acutely malnourished than

their counterparts, a finding supported by results of other recent studies, Low household

socioeconomic status could contribute to children being acutely malnourished which in turn may

lead household to feeding children less diversified diets( I Dodos J., et al. 2018). In the current

study, 1.1% of the respondents reported sharing therapeutic food with other children in the family

and 1.2% reported knowing other households which also did this. Sharing therapeutic food

increase the likelihood of relapse ( Pati et al., 2018).

5.1. Strength and limitation of study

The strengths of this study are that this study considered the household food security status which

was not considered by many studies with similar titles. In this study as much as possible we have

tried to cover 18 health posts and four health centers to minimize sampling error. As there is no

38 | P a g e

prior study on the relapse to severe acute malnutrition this study gives new insight for researchers

and program planners. The study is the first study among children successfully discharged

recovered from SAM in the study area to identify key associated factors registration (e.g.,

antibiotics, vitamin A, vaccination status, access to health services, standard of living, food

security, and access to clean water that may affect relapse to SAM) with post-discharge relapse of

acute malnutrition; such information will help program managers and nutrition focal persons to

address acute malnutrition.

The study could have the following limitations: due to cross-sectional study design it is only the

snap shoot it shows only the data collection period. Some information obtained for household food

consumption and household insecurity access scale might suffer from recall bias. Micronutrient

status was not assessed for study participants due to resource constraints. Food insecurity status

could be overestimated as the data collection time was in the summary season. As this study is

retrospective cohort and study design itself bring some limitation and it is better to support this

study with prospective cohort to know the sequential order of factors and to identify which factors

precedes as cause of relapse.

39 | P a g e

6. CONCLUSION AND RECOMMENDATION

6.1. Conclusion

More than one in ten children cured from SAM relapsed with SAM again within one year of

discharge from care. Having edema on admission and certain household characteristics were

associated with relapse of severe acute malnutrition. Therefore, detail assessment, and targeted

counselling and follow up is need especially for children admitted with edema and from household

with food insecurity. Therefore, the combination of improved WASH condition, as well as

improved anthropometrics from the time of SAM discharge, may have a significant impact on

reducing relapse rates after treatment of severe acute malnutrition.

6.2. Recommendation

For Kurfa Chelle district health office:

Close follow-up after discharged from severe acute malnutrition for screening

Strict monitoring for children admitted with edema after discharge

Detail assessment, targeted counselling and follow-up is need especially for children

admitted from households with food insecurity.

For East Hararghe zone health department:

Household food insecurity interventions through public Safety Net programs should be

strengthened.

For researchers:

To conduct further studies on relapse to severe acute malnutrition among children 6-59

months nutrition status assessment by changing study methodology with adding

biochemical parameters and to report the findings for all stakeholders for action.

40 | P a g e

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GRELLETY, E., EMMANUEL, B., PÉLAGIE, B., AMINA, M., GUSTAVE, L. 2017. ‘Effects of

unconditional cash transfers on the outcome of treatment for severe acute malnutrition

(SAM): A cluster-randomised trial in the Democratic Republic of the Congo’, BMC

Medicine, 15(1), pp. 1–19. doi: 10.1186/s12916-017-0848-y.

GUESDON, L., BENJAMIN, K., MANISHA, P., AMOD, B., TUSLI, C., EMILIE, N., et al.

2021a. ‘Anthropometry at discharge and risk of relapse in children treated for severe acute

malnutrition: a prospective cohort study in rural Nepal’, Nutrition Journal. doi:

10.1186/s12937-021-00684-7.

42 | P a g e

GUESDON, L., BENJAMIN, K., MANISHA, P., AMOD, B., TUSLI, C., EMILIE, N., et al.

2021b. ‘Anthropometry at discharge and risk of relapse in children treated for severe acute

malnutrition: a prospective cohort study in rural Nepal’, Nutrition Journal, 20(1), pp. 1–11.

doi: 10.1186/s12937-021-00684-7.

JANSEN, E., RUSSELL V., APPLETON, G., BYRNE J., DANIELS R., FOWLER A., et al. 2021.

‘The Feeding Practices and Structure Questionnaire: development and validation of age

appropriate versions for infants and toddlers’, International Journal of Behavioral Nutrition

and Physical Activity, 18(1), pp. 1–14. doi: 10.1186/s12966-021-01079-x.

KABALO,E., M. Y. & SEIFU, C. N. 2017. ‘Treatment outcomes of severe acute malnutrition in

children treated within Outpatient Therapeutic Program ( OTP ) at Wolaita Zone , Southern

Ethiopia : retrospective cross-sectional study’, pp. 1–8. doi: 10.1186/s41043-017-0083-3.

KAEWKIATTIKUN, K. 2017. Effects of immediate postpartum contraceptive counseling on

long-acting reversible contraceptive use in adolescents, Adolescent Health, Medicine and

Therapeutics. doi: 10.2147/ahmt.s148434.

KERAC, J., MARKO, B., JAMES, CH., GEORGE, B., PALUKU, T., ANDREW, C., et al. 2014.

‘Follow-up of post-discharge growth and mortality after treatment for severe acute

malnutrition (FuSAM study): A prospective cohort study’, PLoS ONE. doi:

10.1371/journal.pone.0096030.

LENTERS, L., WAZNY, K. AND BHUTTA, Z. 2016. ‘Management of Severe and Moderate

Acute Malnutrition in Children’, Disease Control Priorities, Third Edition (Volume 2):

Reproductive, Maternal, Newborn, and Child Health, pp. 205–223. doi: 10.1596/978-1-

4648-0348-2_ch11.

MAGNIN, Z., MARGOT, S., BEAT, V., RAJAOBELINA, J., EMILIEN, B., et al. 2017 ‘Most

children who took part in a comprehensive malnutrition programme in Madagascar reached

and maintained the recovery threshold’, Acta Paediatrica, International Journal of

Paediatrics, pp. 960–966. doi: 10.1111/apa.13796.

NUTRITION, G. A. For I. 2020. Global Nutrition Report, The Global Nutrition Report’s

43 | P a g e

Independent Expert Group.

PATI, N., SANGHAMITRA, M., SANDEEP, S., RAJESHWARI, P., SANDIPANA, S., SATYA,

N. et al. (2018) ‘Community Management of Acute Malnutrition (CMAM) in Odisha, India:

A Multi-Stakeholder Perspective’, Frontiers in Public Health. doi:

10.3389/fpubh.2018.00158.

ROGERS, A., ELEANOR, M., MARK, W., SAUL, A., JOSE, L. 2015. ‘Coverage of community-

based management of severe acute malnutrition programmes in twenty-one countries, 2012-

2013’, PLoS ONE. doi: 10.1371/journal.pone.0128666.

SHAMS, M., ZACHARIAH, Z., ENARSON, R., SATYANARAYANA, A., VAN DEN BERGH,

S., ALI, R., et al. 2012. ‘Severe malnutrition in children presenting to health facilities in an

urban slum in Bangladesh’, Public Health Action, 2(4), pp. 107–111. doi:

10.5588/pha.12.0039.

SIMACHEW, Y., ZERFU, T. AND ALEMU, W. 2020. ‘<p>Treatment Outcomes and Predictors

of Recovery from Severe Acute Malnutrition Among Children Aged 6–59 Months

Attending an Outpatient Therapeutic Program in Wenago District, Southern Ethiopia</p>’,

Nutrition and Dietary Supplements, Volume 12, pp. 189–200. doi: 10.2147/nds.s245070.

SOMASSÈ, R., YASSINMÈ, D., MICHÈLE, B., PHILIPPE, M. 2016. ‘Relapses from acute

malnutrition and related factors in a community-based management programme in Burkina

Faso’, Maternal and Child Nutrition, 12(4), pp. 908–917. doi: 10.1111/mcn.12197.

STOBAUGH, T. 2017. ‘Relapse after treatment for moderate acute malnutrition : Risk factors and

interventions to prevent it Summary of presentation 1 based on published research 2’.

STOBAUGH, T., HEATHER, C., BEATRICE, L., WEBB, S., PATRICK, R., IRWIN T.,

CHRISSIE, M., et al. 2018. ‘Household-level factors associated with relapse following

discharge from treatment for moderate acute malnutrition’, British Journal of Nutrition,

119(9), pp. 1039–1046. doi: 10.1017/S0007114518000363.

44 | P a g e

STOBAUGH, T., HEATHER, C., AMY, M., MARIE, B., PALUKU, Z., NOËL, M., et al. 2019a.

‘Relapse after severe acute malnutrition: A systematic literature review and secondary data

analysis’, Maternal and Child Nutrition, 15(2), pp. 1–12. doi: 10.1111/mcn.12702.

STOBAUGH, T., HEATHER, C., AMY, M., MARIE, B., PALUKU, Z., NOËL, M., et al. 2019b.

‘Relapse after severe acute malnutrition: A systematic literature review and secondary data

analysis’, Maternal and Child Nutrition. doi: 10.1111/mcn.12702.

UNITED NATION CHILDREN FUND, WORLD HEALTH ORGANIZATION AND WORLD

BANK. 2020. ‘Levels and trends in child malnutrition: Key findings of the 2020 Edition of

the Joint Child Malnutrition Estimates.’, Geneva: WHO, 24(2), pp. 1–16.

45 | P a g e

8. APPENDICES

8.1. English version of Participant Information Sheet & Informed voluntary

Consent Form

My name is …………………………………..,I am working as data collector for the study being

conducted in this community by Hinsarmu Amano who is studying for his master’s degree at

Haramaya University, College of Health and Medical Sciences. I kindly request you to lend me

your attention to explain you about the study and being selected as the study participant.

Study title: To identify Relapse and associated factors after treatment of Severe Malnutrition

among children of 6-59 months in Kurfa Challe District, East Oromia, Eastern Ethiopia, from

July1/07/2021-30/07//2021. .

Aim of Study: The findings of the study helps Kurfa Chele health office to plan on relapse to

severe acute malnutrition after treatment. Moreover, the aim of this study is to write a thesis as a

requirement for the partial fulfillment of master’s program in Public Health Nutrition.

Procedure and duration: I was be interviewing you using a questionnaire to provide me a relevant

data that is helpful for the study. There are about 75 questions to answer when I was fill

the questionnaire by interviewing you. The interview was take about 30 to 45 minutes, so I kindly

request you to spare me this time for the interview.

Risks and benefits: The risk of being participating in this study is very minimal, but only taking

few minutes from your time. There was not be any direct payment for participating in this study.

Moreover, the finding from this research may reveal important information for the local health

planners and implementers.

Confidentiality: The information you was provide us was be confidential. There was be no

information that was identify you in particular. The finding of the study was be general to the study

community and was not reflect any thing particular of individual person or housing. The

questionnaire was be coded to exclude showing names and other specific identity. No reference

was be made in oral or written reports that could link participants to the research.

Rights: Participation of the study was be fully voluntary. You have the right to declare to

participate or not in this study. If you decide to participate, you have the right to withdraw from

the study at any time and this was not label for any loss of benefits which you otherwise entitled.

You do not answer any question that they do not want to answer.

46 | P a g e

Contact Address: If you have any question or inquires at any time about the study or

procedures, please contact with the following address: Principal investigator: Hinsarmu Amano

Erkiso Email:[email protected] Mobile phone: +251922294861. Haramaya University

College of Health and Medical Sciences Institutional Research Ethical Review Committee: Office

phone: 0254662011 P.O Box: 235, Harar.

Declaration of informed voluntary consent:

I have read/was read to me the participant information sheet. I have clearly understood the purpose

of the research, the procedures, the risks and benefits, issues of confidentiality, the rights of

participating, and contact address for any queries. I have the opportunity to ask questions for things

that may have been unclear. It was informed that I have the right to withdraw from the study at

any time or not to answer any question that I do not want Therefore, I declare my voluntary consent

to participate this study to be conducted with my initials (signature).

Name and Signature of the participant:____________________Date______________

Name & Signature of data collector: ____________________Date______________

8.2. Afan Oromo Version Participant Information Sheet & Informed

voluntary Consent Form

Afaan Oromootiin Walii galtee hirmaattota qorannichaa waliin geggeeffamu

Ani maqaan Koo………………………………………………………………..jedhama. Kanan

hojjedhu qorannoo (Research) Obbo Hinsarmuu Amaanoo barnoota isaanii digirii lammaffaaf

Yuunivarsitii Haramayaa, Koollejjii Fayyaa fi Meedikalaatti barataa jiraniif ragaa qorannoo

funaanudha. Kanaafis duraan dursee waa’ee qorannichaa fi maalif hirmaataa qorannichaa taatanii

akka filamtaniif waanan isiniif ibsuuf yaadaan akka na dhaggeeffattanii fi gaaffileen itti aansee

isin gaafadhuuf nuffii malee akka naaf deebiftaniif kabaja guddaa waliin isin gaafadha.

Mata Duree Qorannichaa

Sababoota hir’ina nyaataa cimaa irra deebiin qabaman Ijjollee batii 6 hanga 59 jirattota Aanaa

kurfaa calee Kan ta’ani dha.

Kaayyoo Qorannichaa

Jalqabarratti bu’aan qorannoo kanaa Kan fayyadu Waajjira Eegumsa fayyaa Aanaa kurfaa callee

kan gargaaru yoo ta’u, lammaffarratti kaayyoon qorannoo kanaa eebba barnoota digrii lammaffaa

geggeeffamaa jiruufi.

47 | P a g e

Adeemsaa fi Yeroo qorannichaa

Ani gaaffilee adda addaa waanan gaafadhuuf ragaa dhugaa irratti hundaa’eefii qorannichaaf

gargaaru akkan argadhuuf gaaffileen isin gaafadhuuf obsaa akka naaf deebistaniifi. Kanan isin

gaafachuuf deemu hanga gaaffii 40 yoo ta’u walii galatti hanga daqiiqaa 25-30 fudhata.

Miidhaa fi Faayidaa Qorannichaa

Qorannoo kana keessatti sababa hirmaattaniif faayidaan kallattiin isaanif kennamu hin jiru.

Akkasumas miidhaan isinirra gahus baay’ee xiqqaadha, kunis yeroo qabdan keessaa gara

daqiiqaa 30 naaf kennuun gaaffilee isin gaafadhuuf waan silaa hojjechuuf jettan adda kuttanii

deebii naaf kennuun yeroo gubdaniin alatti miidhaa isin irraan geessisu kan hin jirre dha. Garuu

bu’aan qorannoo kanaa namoota karoora baasaniif ragaa barbaachisaa ta’a.

Iccitii ragaalee

Iccitiin Ragaalee nuti isinirraa fudhannuu kan eeggamuudha. Ragaan kamuu addatti baasee waa’ee

keessan ibsu hin jiraatu. Gaaffileen gaafatamu lakkoofsa addaa kennammeefii waan jiruuf maqaan

keessan hin barbaachisu. Ragaan nama dhuunfaa qorannoo wajjiin addatti baasee

ibsu tokkollee hin jiraatu.

Mirga hirmaataa qorannichaa

Hirmaataa qorannoo kanaa ta’uun fedhii guutuun keessan qofa irratti kan hundaa’e

ta’a. Qorannicha irratti hirmaachuu dhiisuu mirga qabdu. Yoo hirmaachuuf murteessan, gaaffii fi

deebii Kennan yeroo barbaaddettanitti addaan kutuu dandeessu, kana jechuun faayidaan ala ta’a

jechuu miti. Gaaffii fi deebii keessatti gaaffii hin barbaadneef deebii kennuu diduu ni dandeessu.

Karaa ittiin qorataa qunnamtan

Yoo gaaffiis ta’ee komii jiraate yeroo barbaaddetti lakkoofsa bilbilaa armaan gadiin qaama

dhimmi ilaaluu qunnamuu dandeessa. Lakk. Bilbilaa: 0922294861 kan qorannicha geggeessuu fi

0254662011/ P.O. Box. 235, Harar---- Institutional Health Research Ethics Review Committee

(IHRERC). Haramaya Yuuniversiitiitti koree qorannoo fayyaa fi seera qabeessummaa isaa

hordofu.

Walii galtee hirmaattota qorannichaa waliin geggeeffamu

Ani waraqaa ragaa hirmaattota dubbisee/ naaf dubbifamee jira. Ifatti kaayyoo qorannichaa,

adeemsa, miidhaa fi bu’aa, iccitii, mirgaa fi lakkoofsa yeroo rakkoon uumamee fi gaaffiin jiraate

ittiin qunnamu argadheen jira. Carraa gaaffii naaf hin Galle yeroo kamittuu gaafachuu danda’uu fi

48 | P a g e

yeroon barbaaddetti qorannicha keessaa itti bahuu danda’u naaf kennamee jira. Kanaaf, ani walii

galtee qorannicha keessatti ittiin hirmaadhu mallattoo kootiin akka armaan gadiitti nan seena.

Maqaa fi Mallattoo hirmaataa/hirmaattuu_____________________Guyyaa____________.

Maqaa fi mallattoo ragaa funaanaa __________________Guyyaa____________

8.3. English version of Questionnaire for Participant Interview

Questionnaire ID _______________________

Name of data collector: ____________________ Signature___________ Date: _______

Name of supervisor: ______________________ Signature________ Date_______

Table 9: English version of Questionnaire for Participant Interview

49 | P a g e

PART 1: Socio-demographic and life style factors questionnaire

Code Variables/questions Response Skip to

100. Sex of care giver interviewed? 1) Male 2) Female

101. Age of care giver interviewed? 1) ___________years old.

102. Marital status of care giver interviewed? 1) Single 3) Divorced/ Separated

2) Married 4) Widowed

103. Which religion do you follow? 1) Islamic 2) Christian 3) Other (Specify)

104. What is your Educational level? 1) Illiterate 2) Elementary 3) 5-10 grade

4) College and above

105. What is your occupation? 1) Employed 2) Farmer 3) Retired

4) Housewife family 5) Dealer

6) depend on family 7) Other (Specify)

106. How much is your monthly income in ETB? 1.________ETB 2. Don’t know

107. What is your family size? ___________

108. Do you normally eat alone or with family? 1. Alone 2. With family

109. Do you drink alcohol? 1. Yes 2. No

110. Do you smoking cigarette? 1. Yes 2. No

111. CHEW chat 1. Yes 2. No

PART 2: Household Food Insecurity Access Scale questionnaire

112. In the past 4 weeks, did you worry that your

household would not have enough food?

0=No 1=Yes

If “no” skip to Q.113

112 a. How often did this happen? 1 = Rarely (once or twice in the past 4 weeks)

2 = Sometimes (3-10 times in the past 4 weeks)

3 = Often (> 10 times in the past 4 weeks).

113. In the past 4 weeks, were you or any household

member not able to eat the kinds of foods you

preferred because of a lack of resources?

0 = No 1=Yes If “no” skip to Q.114



3 = Often (> 10 times in the past 4 weeks).

114. In the past 4 weeks, did you or any household

member have to eat a limited variety of foods

due to a lack of resources?

0 = No 1 = Yes If “no” skip to Q.115



3 = Often (> 10 times in the past 4 weeks)


member have to eat some foods that you really

did not want to eat because of a lack of

resources to obtain other types of food?

0 = No 1 = Yes






member have to eat a smaller meal than you

felt you needed because there was not enough

food?

0 = No 1 = Yes


50 | P a g e




117. In the past 4 weeks, did you or any other

household member have to eat fewer meals in

a day because there was not enough food?





118. In the past 4 weeks, was there ever no food to

eat of any kind in your household because of

lack of resources to get food?






member go to sleep at night hungry because

there was not enough food?

0= No 1= Yes If “no” skip to Q.120





member go a whole day and night without

eating anything because there was not enough

food?

0= No

1= Yes

If “no” questionnaire

is finished




PART 3: House Hold and Environmental Condition Questionnaire

121. What is the main source of drinking water for

members of your household? 1. Piped water 2. Dug well

3. Water from spring

122. Where is that water source located? 1. In own dwelling 2. In own yard/plot

3. Elsewhere…….specify

123. Who usually goes to this source to fetch the

water for your household?

1. Adult woman 2. Female child

3. Male child 4. Adult man

5. Under 15 years old 6. Under 15 years old

7. Other

124. In the past two weeks, was the water from

this source not available for at least one full

day?

1. Yes 2. No

125. Do you do anything to the water to make it

safer to drink?

1. Yes 2. No 3. Don't know

126. What do you usually do to make the water

safer to drink? Anything else?

1. Boil 2. Add bleach/chlorine

3. Strain through a cloth

4. Use water filter (ceramic)

5. Sand/composite/etc/

6. Solar disinfection

7. Let it stand and settle 8. Other

127. What kind of toilet facility do members of

your household usually use?

1. Flush or pour flush toilet HHS

2. Pit latrine HHS 3) open field / brush

128. What type of fuel does your household

mainly use for cooking?

1. Electricity 2. Kerosene

3. Agricultural crop 4. LPG

5. Charcoal 6. Animal dung

51 | P a g e

7. Natural gas 8. Wood

9. No food cooked in household

10. Biogas 11. Straw/shrubs/grass

12. Other specify…….

129. Is the cooking usually done in the house, in a

separate building, or outdoors?

1. In the house 3. Outdoors

2. In a separate building 4. Other specify

130. Do you have a separate room which is used

as a kitchen?

1. Yes 2. No

131. How many rooms in this household are used

for sleeping?

1. One Rooms 2. Two rooms

3. More than 3

132. Does this household own any livestock,

herds, other farm animals, or poultry?

1. Yes 2. No

133. How many of the following animals does this

household own? IF NONE, RECORD '00'

1. Cows/bulls 2. Beehives

3. Horses/donkeys/mules

4. Chickens/poultry

6. Sheep 5. Camels 7. Goats

8. Other cattle

134. Does any member of this household own any

agricultural land?

1. Yes 2.No

135. How many hectares of agricultural land do

members of this household own

_______________ ximad/qimdii.

136. Does your household have? 1. Yes 2. No

136 a. Electricity

136 b. Television 1. Yes 2. No

136 g. Chair mattress lamp 1. Yes 2. No

136 i. Kerosene lamp/pressure 1. Yes 2. No

136 j. Bed with cotton 1. Yes 2. No

137. Does any member of this household have a

bank account?

1. Yes 2. No

138. Observe presence of water at the place for

handwashing. Record observation.

1. Water is available

2. Water is not available

139. Observe presence of soap, detergent, or other

cleansing agent at the place for handwashing.

Record observation

1. Soap or detergent (bar, liquid)

2. Ash, mud, sand

3. None

140. Observe main material of the floor of the

dwelling. Record observation.

1. Natural floor 2.Rudimentary floor

PART 4. Feeding practice Questionnaire

141. Age of the child. __________months.

142. Child gender 1. Female 2. Male

143. Number of parity of the child nurse ___________.

144. Modes of child birth 1. Multiple birth Twin

2.Triplet or higher 3 .Single

145. Feeding mode of the child currently 1. BF 2. Weaned 3. Never BF

4. Still has FF 5. Previously FF

6. Not yet solids 7. Never FF 8. Yes solids

146. Mealtime structure (environment) Feeding 1. Routine 2. On demand

147. Type of feeding your child. 1. Parent led feeding 2. Persuasive Feeding

148. Feeding for reasons of your child 1. Due hunger 3. Food rewards

2. Food to calm the child 4. Other reasons

149. Feeding on demand 1. I feed my baby whenever he wants

2. I feed my baby at set times

52 | P a g e

3. I decide when it is time for my baby to have a

feed

4. I let my baby decide when he would like to

have a feed

150. Using food to calm 1. I feed my baby to settle him, even if he is not

hungry

2. I offer my baby a feed when he is unsettled or

crying

3. I offer my baby a feed when he is hurt

4. When my baby gets unsettled or is crying,

feeding him is one of the first things I do.

5. I feed my baby to make sure that he does not

get unsettled or cry

151. Persuasive feeding

1. I feed my baby extra milk, just to make sure

he gets enough.

2. If my baby indicates he is not hungry, I try to

get him to feed anyway.

3. I feed my baby extra milk so he sleeps longer.

152. Parent-led feeding

1. I carefully control how much my child eats

2. I have a rule about how much my child should

eats

3. I let my child decide how much she/he eats.

4. I decide how much my child eats.

5. When deciding how much to feed my baby I

rely on how much hunger he/she is

6. I feed my baby I set time.

153. Family Meal Environment 1. My child eats together with other family

members.

2. My child is given the same foods as the rest of

the family (pureed, mashed, and chopped).

3. Whether my child is eating or not, my child

sits with the rest of the family when they are

having a meal.

4. I eat my meals while my child eats.

154. Timely BF initiation (Within 1 hr. of birth) 1. Yes 2.No

155. How many times your child admitted with

SAM.

1. One 2. More than two times

156. By what case your child admitted with SAM. 1. Oedema 2. Non-edematous

157. What types of treatment given for the child

for the first time

____________milk___________plumpnut

158. For how long the baby received plumpnut

159. Did you shared plumpnut with other person 1. Yes 2. No

160. Did the baby transferred to supplementary

feeding after completion of SAM treatment

1. Yes 2. No

161. Did the baby finished the plumpnut

162. Did the baby the finished the plump sum 1. Yes 2. No

163. Did baby received antibiotics while on

treatment

1. Yes 2. No

164. Colostrum given for the child during the birth 1. Yes 2. No

165. Practiced prelacteal feeding. 1. Yes 2.No

166. Currently on breast feeding 1. Yes 2.No

167. Frequency of BF/day (including night) 1. 8-12 times 2. Less than 8 times

168. Prepare food separately for children from

family diet.

1. Yes 2. No

169. Trained on child food preparation. 1. Yes 2.No

53 | P a g e

Part 5. Questionnaire on Food Consumption Score (FCS) and Household dietary diversity

score (HDDS)

Code Food C.2.a Did you

consume [FOOD]

in the last 7 days?

0. No 1. Yes

If “0” next food

C.2.b How many

days in the past 7

days did you

consume [FOOD]?

____days

C.2.c Did you

consume

[FOOD]

yesterday?

0. No

1. Yes

170. Often wash hands with while preparing food

(Soap/ash).

1. Yes 2. No

171. Child feces disposal (Open field) 1. Yes 2.No

172. Duration after recovery in month (Mean ±

SD).

________________

173. De-worming tablet given in last 6 months 1. Yes 2.No

174. Vitamin A supplementation in the past 6

months.

1. Yes 2. No

175. Vaccinated for measles (one and two) 1. Yes 2. No

176. Illness history (Diarrhea, fever, cough) in last

2 weeks.

1. Yes 2. No

177. Does your child practiced GMP monthly? 1. Yes 2. No

178. Diagnosis during admission 1. Marasmus 2. Kwashiorkor

3. Marasmus-kwashiorkor

179. MUAC of children with termination of

treatment

1. <11.5cm 2. 11.5-12.3cm 3. >12.5cm

180. Is there enough plumpnet,plumpsum or

“faaffaa”

1. Yes 2. No

181. Admission with edema 1. Yes 2. No

182. Admission with MUAC 1. Yes 2. No

183. Outcome of first admission 1. Cured 2. Defaulter 3. Non-response

4. Transfer out 5. unknown status

184. Number days in treatment for the first

admission

____________________________

185. Where the treatment for first admission

186. Was your child currently on treatment of

severe acute malnutrition

1. Yes 2. No

187. If yes to Q.178, where is the treatment

facility

___________________________

188. Your child first treatment at SC or OTP ________SC____________OTP

189. Current MUAC value of the child ___________________________

190. Does your child have good appetite 1. Yes 2. No

191. How many under five children you have

within your family

___________________________

54 | P a g e

192. “In the past seven days, how often have you

eaten the father of the household?

193. YESTERDAY DURING DAY OR NIGHT

DID THE father ate Any food made from

grains—injera, teff, millet, sorghum, maize,

rice, wheat, bread, biscuits.

194. Or any other grain product—or any food

made from tubers—potatoes, sweet potatoes,

carrots, or other foods made from roots or

tubers?

195. Any pulses (beans, lentils, peas)?

196. Any nuts or seeds such as peanuts, sesame or

sunflower seeds?

197. Any vegetables?

198. Any fruits?

199. Any meat: beef, lamb, goat, fish, chicken, or

other birds?

200. Any liver, kidney, heart or other organ

meats?

Savory and

fried snacks 201. Crisps, chips, French fries, fried dough and

other fried foods

Sw

eets

an

d s

wee

ten

ed

bev

erag

es

202. Vitamin A-fortified sugar

203. Unfortified Sugar/honey (including use in

beverages)

204. Cakes/Candies/chocolates/sweet biscuits

205. Other sweets (specify)

206. Sweetened juice, soda and other sugar-

sweetened beverages

Co

nd

imen

ts a

nd

Sea

son

ing

s

207. Iodized salt (if they do not know, can check

container if available)

208. Non-iodized salt

209. Hot sauce, fish sauce, chilies, spices, herbs,

tomato paste, flavor cubes, or other

condiments

Oth

er

bev

erag

es

and

foo

ds 210. Tea, Coffee, Clear, broth, Alcohol, Any other

foods (specify)

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8.4. Afan Oromo Version of Data Collection Instrument.

Gaaffilee Afaan Oromoo Hirmaattota Waliin Godhamu

Lakk. Gaaffii __________________

Maqaa Nama Daataa Guuruu ____________________ Mallattoo__________ Guyyaa _______

Maqaa Supervazaraa: _______________________ Mallattoo________ Guyyaa_______

Table 10: Afan Oromo Version of Data Collection Instrument

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Kutaa I: Gaaffilee Hawaasummaa, Diinagdee fi Maatii waliin walqabatan

Code Variables/questions Response Skip to

192. Saalli Nama gaaffii gaafatamu maali? 1) Dhiira. 2) Dubartii

193. Umriin keessan waggaa meeqa? 1) 15-30 2.30-45 3. 45 oli

194. Sadarkaan fuudhaa fi heeruma keessanii akkami? 1) Kan hin fuune/heerumne 2) Kan fuudhe

3) Kan hiike/hiikte 4) Kan jalaa duute

195. Amantiin keessan maali? 1) Islaamaa 2) Kiristaana

3) Kan biraa (adda baasi)

196. Sadarkaan barnootaa keessanii akkami? 1) Kan hin baratin 2) sadarkaa tokkoffaa

3) kutaa 5-10 4) College and above

197. Hojiin keessan maali? 1) hojjataa mootummaa 2) Qotte bulaa

3) soorama kan bahe 4) Haadha mana

5) Daldalaa 6) Hirkataa 7) kan biraa_____

198. Galiin kee ji’aa meeqa ta’a? 1.________ETB 2. Don’t know

199. Maatii meeqa qabdu? _____________

200. Yeroo mara nyaata kophaa moo maatii waliin nyaattu? 1) Kophaa 2) maatii waliin

201. Dhugaatii alkoolii ni dhugduu? 1) Eeyye 2) lakkii

202. Tamboo ni xuuxxuu? 1) Eeyye 2) lakkii

203. Jimaa ni qamaatuu? 1)Eeyye 2) lakkii

Kutaa 2. Gaaffilee Haala Waan Nyaatamuu Mana Keessaa

204. Torbeewwan afran darban kana keessatti nyaanni nyaattan

nutti hirdhata jettanii yaaddoftanii beektuu?

0) Lakkii yoo ta’ee gara gaaffii 113 darbii

2) eeyyee

Yoo” lakkii” ta’ee

gara G. 113 darbi

112 a. Yeroo hangamiif rakkinichi kun isin mudatee? 1) Yeroo muraasa (yeroo takka ykn lama

torbee afran darbe keessatti)

2) Yeroo tokko tokko (3-10 torban afran

darban keessatti

3) Yeroo heddu (si’aa 10 oli torbee afran

darban keessatti).

205. Torbeewwan afran darban kana keessatti isin ykn

miseensa maatii keessaa sababa hir’inatin nyaata fedhan

nyaachuu kan hin dandeenye turee?

1) Lakki yoo ta’ee gara gaaffii 114 darbii

2) Eeyyee


gara G. 114 darbi

113 a. Yeroo hangamiif rakkinichi Kun isin mudatee? 1) Yeroo murasaa (yeroo takka ykn lama



darban keessatti)


darban keessatti)

206. Torbeewwan afran darban kana keessatti sababa hir’ina

waan nyaatamuutin nyaatni gosa gosaa dhabamee turee?

1) Lakki yoo ta’e gara gaaffii 115 darbii

2) Eeyyee


gara G. 115 darbi




darban keessatti)


darban keessatti)

207. Torbeewwan afran darban kana keessatti sababa hir’ina

waan nyaatamuutin nyaata hin feene nyaattanii turtanii?

1) Lakkii, yoo ta’ee gara gaaffii 117 darbii

2) Eeyyee


gara G. 116 darbi




darban keessatti)

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darban keessatti)

208. Torbeewwan afran darban kana keessatti isinis ta’ee

miseensa maatii keessaa sababa wanti nyaatamu ga’aa

ta’uu dhabuutin nyaata hammaan xiqqaa isin quubsine

nyaattanii jirtuu?


2) Eeyyee


gara G. 117 darbi

116 a. Yeroo hangamiif rakkinichi Kun isin mudatee?

1) Yeroo murasaa (yeroo takka ykn lama



darban keessatti)


darban keessatti)

209. Torbeewwan darban afran kana keessatti isinis ta’ee

miseensa maatii keessaa namni sababa nyaata ga’aan

dhabamuutin nyaata hammaan xiqqaa nyaate jiraa?


2) Eeyyee


gara G. 118 darbi




darban keessatti)


darban keessatti)

210. Torbeewwan darban afran kana keessatti nyaanni

nyaatamu mana keessaa sababa jiruun nyaata ittiin

argattan dhabuutin nyaanni manaa dhabameeraa?


2) Eeyyee


gara G. 119 darbi




darban keessatti)


darban keessatti)

211. Torbeewwan darban afran kana keessatti isin ykn miseensa

maatii keessaa sababa wanti nyaatamu dhabamuutin osoo

beela’uu kan gara siree hirriibaa deeme jiraa?

1) Lakkii yoo ta’ee gara gaaffii 120 darbii

2) eeyyee


gara G. 120 darbi




darban keessatti)


darban keessatti)

212. Torbeewwan darban afran kana keessatti isin ykn

miseensa maatii keessaa sababa nyaatni ga’aan

dhabamuutin namni guyyaa fi halkan guutuu osoo nyaata

hin nyaanne ture jiraa?

1) Lakki Gaaffileen xumurame jira.

2) Eeyyee

Yoo” lakkii” ta’e

gaaffiin

xumuramee jira




darban keessatti)


darban keessatti)

Kutaa 3. Gaaffilee Haala Mana fi Naannoo Jireenyaa

213. Matiin keessan madda bishaan Dhugaatii maal irraa

fayyadamu?

1) Bishaan Boombaa 2) Boolla bishaanii

(haroo) 3) Bishaan lafa keessaa(madda

214. Maddi bishaanii eessatti argama? 1) Mana jireenyaa keessan keessa 2)Mooraa

kee keessa 3) Iddoo Biraa

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215. Matii keessan keessaa yeroo heddu eenyu bishaan isinii

waraaba?

1) Haadha manaa 2) Abbaa manaa 3)

Ijjollee dubara 4) Ijoollee dhiira 5) Kan

biroo

216. Torbaan lamaan darbe keessa yeroo bishaan dhabame ni

jiraa, (Yoo xiqqaate guyyaa guutuu tokkoofi)? 1) Eeyyen 2) Lakki

217. Malli ykn tooftaan bishaan qulqulleessuuf itti fayyadamtan

ni jiraa?

1) Eeyyen 2) Lakki

218. Mala akkamitiin bishaan keessan qulqullessitan?

1) Bishaan danfisuu

2) Kiloorinii itti dabaluu 3) Huccuudhaan

Bishaan dhimbiibuu 4) Qulqullessituu

Bishaanii 5) Biyyee itti

makuu 6) Humna solaariin qulqullessuuf

7) Xiqqoo hanga qulqullaa’uu eeguu 8) Kan

biroo

219. Gosti mana fincaanii maatiin keessan yeroo baayyee itti

fayyadamu kami?

1) Kan Bishaan itti naqamuu ykn itti bifamu

3) Mana fincaanni Boola kan bishaan itti hin

naqamne

220. Nyaata bilcheessuuf maatiin keessan maali fayyadamu?

1) Humna electirikaa 2) Soolara (LPG) 3)

Gaazii umamaa 4) Biogas 5) Gaazii adii

6) Kasala 7) Muka 8) Marga 9) Oomisha

qonnaa (Agricultural crop 10) Dhoqqee loonii

11) Nyaanni mana keessatti hin bilcheeessan

12) Kan biroo

221. Manni nyaata itti bilcheefamu eessatti argama?

1) Mana jireenyaa keessa 2) Mana

jireenyattin alatti 3) Kan biroo

222. Mana nyaata itti bilcheeessan qophatti ni jira? 1) Eeyyen 2) Lakkii

223. Kutaa cisichaa meeqa qabdan? 1) Tokko 2) lama 3) Sadii oli

224. Maatiin keessan loon mana keessa ni qabaa? 1) Eeyyen 2) Lakkii

225. Maatiin keessan loon mana keessaa kami fa’a qabu? Yoo

hin Qabaanne 0.

1) Sangaa ykn sa’aa 2) Harree/Farda/Gaangee

3) Gaalaa 4) Re’ee 5) Hoolaa

6) Lukkuu 7) Gaagura Kanniisaa

226. Lafa ykn Ooyruu qonnaa ni qabdanii? 1) Eeyyen 2) Lakkii

227. Lafa qonna/Ooyruu/ hangammi qabdan? _______________ ximmaadii/qimdii.

228. Matiin keessan wantoota armaan gadii ni qaba? 1) Eeyyen 2) Lakkii

136 a. Humna ifa electirikaa

136 b. Televejinna 1) Eeyyen 2) Lakkii

136 g. Siree firaasha wajjiin 1) Eeyyen 2) Lakkii

136 i. Keroosinii ykn laamba 1) Eeyyen 2) Lakkii

136 j. Siree ansoolla wajjiin 1) Eeyyen 2) Lakkii

229. Maatiin keessan dabtara Herregaa baankii ni qabuu? 1) Eeyyen 2) Lakkii

230. Bishaan iddoo harka dhiqannaa ni jiraa? 1) Bishaan ni jira 2) Bishaan hin jiru

231. Iddoo harka dhiqannaa maaltu jira? 1) Saamuunaa 2) Daaraa 3) Hin jiru

232. Lafti mana jireenyaa keessan keessaa maali? Ilaali 1) Kan umamaa 2) Kan nam-tolchee

Kutaa 4 Gaaffilee Akkaataa soorata daa’immanii

233. Umriin daa’ima keessanii Kan hirdhina nyaataa cimaa

seenee meeqa?

1) Baatii 6-11 2) Baatii 12-23 3)

Baatii 24-59

234. Saala Daa’imaa 1) Dhiira 2) Dubara

235. Daa’imni keessan Kun tartiiba ulfaatin ishee meeqafa? ___________.

236. Akkata dhaloota Daa’imaa 1) Lakkuu 2) Sadii fi Sanaa oli 3) Tokko

237. Akkaataa Daa’ima itti soorachiifnu 1) Harma lugsiisu 2) Harmaa lusiisu irra

dhabuu 3) Kanaan dura Kan nyaata

formula kennufi turte 4) Gonkuumma

Kan nyaata formula hin 5) Gonkumaa

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harma kennuufii dhabuu 6) Hanga

ammaatti nyaata jabaataa kennuufii dhabuu

7) Hanga ammaatti Kan nyaata formullaa

nyaachiftu nyaachifne 8) Nyaata

jabaataa kennuufi

238. Yeroo akkamii Daa’immanii nyaata kennitaaf? 1) Yeroo walfakkaata 2) Yeroo barbaaddetti

239. Gosa soorata daa’imma kennamu? 1) kan matiin durfamu 2) kan yeroo daa’imni

barbaade kennamufi

240. Sababni daa’imni nyaata nyaachifamuuf 1)Waan beelawaniif 2)Akka Daa’imman

caldhisaniif 3) Akka badhaasaatti

4) Sababa birootif

241. Soorata Yeroo isaan fedhanii nyaachisuuf 1) Yeroo Daa’imni nyaata fedhan qofa

kennufi

2) Yeroo Daa’imni nyaata matiin Kan

murteesufi

3) Yeroo dangefame qofatti nyaata kennufi

4) Yeroo Daa’imni fedhee nyaata kennufi

242. Nyaata daa’ima usisiisuuf kennuu 1) Osoo Daa’imni hin beelawin kennuufi 2)

Yeroo isheen miidhamte kennuufi

3) Yeroo isheen bootte nyaata kennuufi 4)

Yeroo isheen bootte waan hunda dhistee

nyaata kennuufi 5) Akka isheen

hin boonneef nyaata kennuufii

243. Nyaata dabalataa. 1) Aannan dabalataa Daa’imaaf kennuu akka

isheen sirritti quuftuuf

2) Osoo Daa’imni hin beelofne nyaata

kennuufi

3) Akka isheen hirriibaa dheeraa raftuuf

Aananii dabalataa kennuufi .

244. Soorata maatiin durfamu 1) Hanga isheen nyaattu anatu murteessaafi,

hanga isheen beelofte irratti hundaa’uun

2) Daa’ima yeroo murtaa’een nyaata kennaafi

3) Daa’imni koo hangami akka nyaattu sirritti

to’adha. 4) Hangami akka nyaattu seera

hordofuun kennuufi 5) Hanga barbaade akka

nyaatuufi ni eeyyamaafi 6) Daa’imni Koo

hangammi akka nyaattu anatu murteessafi

245. Haala Soorata maatii (Family Meal Environment) 1) Nyaata Daa’imaa miseensa matii biroo

wajjiin soorachisuu 2) Daa’imaa fi Maatii

birootiif Nyaata gosa tokkoo kennuufi 3)

Daa’imni osoo nyaata nyaatuu 4) Ani nyaata

kan sooradhu yeroo daa’imni koo nyaattu

246. Daa’imni yeroo dhalatu sa’aa tokko keessatti harmi

kennameefii jira?

1) Eeyyen 2) Lakki

247. . Daa’imni yeroo dhalatu sa’aa tokko keessatti harmi

kennameefii jira?

_____________________

248. Daa’imni keessan sababa kamiin hindhinna nyaata seente? 1) Dhiita miila ykn qaama 2) Huqqachuu

249. Wallaansa gosa kamittuu yeroo jalqabatti daa’imma

keessan kenname?

____________Aananii___________plumpnut

250. Yeroo hangamiif pilumpii fudhata turte?

251. Pilumpii nama birootif qoode jirta? 1) Eeyyen 2) Lakki

252. Daa’imni keessan erga dhinne booda gara faffatti darbe

jira?

1) Eeyyen 2) Lakki

253. Daa’imni keessan pilumpii hamma isaf barbaachisu

fudhate xumure jira?

1) Eeyyen 2) Lakki

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Kutaa 5.Gaffilee haala soorata gosa adda addaa fi Akkaataa soorata matii

254. Daa’imni keessan pilumpii samii fudhate xumure? 1) Eeyyen 2) Lakki

255. Daa’imni keessan qorichaa shuropii ykn liimee fudhate

jira yeroo hanqina nyaataf walansaa irraa ture san?

1) Eeyyen 2) Lakki

256. Daa’imni keessan yeroo dhalatu silgaa kennammeefii jira? 1) Eeyyen 2) Lakki

257. . Shaakala harma luugsisuu gootanii beektuu? 1) Eeyyen 2) Lakki

258. Yeroo amma harma luugsisutti jirtanii? 1) Eeyyen 2) Lakki

259. Guyyatti yeroo meeqa harma luugsiftu? 1. 8-12 2) Alii 8 gadii

260. Nyaata qophaatti Daa’imaa ni qopheessituu? 1) Eeyyen 2) Lakki

261. Leenjii nyaata Daa’imaaf qopheessu fudhattanii jirtanii? 1) Eeyyen 2) Lakki

262. Soorata daa’imma qopheessun dura harka keessan

Saamunaan ykn Daaraan dhiqattanii?

1) Eeyyen 2) Lakki

263. Sagaraan daa’immanii dirree irratti gad naqamaa? 1) Eeyyen 2) Lakki

264. Daa’imni keessan hanga fayyee bahe baatii meeqa? ________________

265. Daa’imni kee baatii jahaa asitti kiniina farra raammoo

garaa keessaa fudhatee jiraa?

1) Eeyyen 2) Lakki

266. Daa’imni Vitamin A baatii jahaa asitti fudhatee jiraa? 1) Eeyyen 2) Lakki

267. Daa’imni kee talaallii farra shiftee lammaffaa fudhatee? 1) Eeyyen 2) Lakki

268. Daa’imni keessan seenaa dhukkuba (Gaaran yaasuu,

leeyda qaamaa, fi qufaa) qabaa torbee lamaan dhumaa

kanatti?

1) Eeyyen 2) Lakki

269. Daa’imni keessan GMP ykn Guddina fi dagaaginni isaa

baatii tokko tokkoon ilaalamee jiraa?

1) Eeyyen 2) Lakki

270. Daa’imni keessan gosa hanqina nyaata kamiin seene? 1. Huqachuu 2. Dhita’uu

3. Huqachuu fi furdachuu

271. MUAC ni daa’imma yeroo walansaa xumure bahuu meeqa 1. <11.5cm 2. 11.5-12.3cm 3. >12.5cm

272. Pilaampiineetii,Pilumpii samii ykn faaffan gahani yeroo

amma ni jira

1) Eeyyen 2) Lakki

273. Daa’imni keessan Dhita’uun seene? 1) Eeyyen 2) Lakki

274. Daa’imni keessan MUAC ni seene? 1) Eeyyen 2) Lakki

275. Daa’imni keessan maaliin walansaa jalqabaa xumure

bahe?

2. Cured 2. Defaulter 3. Non-

response 4. Transfer out 5. unknown

status

276. Daa’imni keessan walansaa jalqabaa irraa guyyaa meeqafa

ture?

____________________________

277. Daa’imni keessan walansaa jalqabaa Essatti fudhata ture?

278. Daa’imni keessan wallaansa jalqabaa cisee (OTP) moo

deddebi’ee (SC) argachaa ture?

279. Daa’immni keessan yeroo amma walansaa hanqina nyaata

fudhachaa jira?

1) Eeyyen 2) Lakki

280. Daa’imni keessan walansaa jalqabaa essatti fudhate ture? ___________________________

281. Yeroo amma MUAC ni daa’imma meeqa? ___________________________

282. Daa’imni keessan yeroo amma fedhii nyaata ni qaba? 1) Eeyyen 2) Lakki

283. Daa’imni waggaa shan gadii meeqa qabdu? ___________________________

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Koodii Soorata C.2.a guyyaa

Torban darban

keessa soorata

soorachaa turtan?

0. Lakki 1. Eeyyen

Yoo “0”ta’ee gara

soorata itti anu darbi

C.2.bguyyota

Torbanii

darbaniif keessa

guyyaa meeqa

sorate(foods)

________

C.2.c guyyaa

kaleessa

soorata (food)

nyaate jirta?

0. Lakki

1. Eeyyeen

192. “Guyyaa torban darban keessa yeroo meeqa

biddeena nyaattan?

193. Guyyaa kaleessa soorata sanyii miidhaan irraa

qophaa’ee kan akka biddeena xaafii,

mishingaa, boqolloo, ruuza, daabboo fi

buskutaa soorattanii jirtanii?

194. Ykn soorata gosa sanyii miidhaan kan biroo

irraa qophaa’ee kan akka dinnichaa, dinicha

mi’aawaa, karota fi kkf

195. Gosa nyaata ittoo,fkn: ataraa, bolokee, baqelaa,

misiraa?

196. Gosa loozii, saliixa, suufii kamuu?

197. Gosa kudraa kamuu?

198. Gosa fudraa kamuu?

199. Gosa foonii: Lukkuu, Re’ee, Hoolaa,

qurxummii, loon, kamuu nyaattanii jirtanii?

200. Gosa foonii kalee, tiruu, ykn foon qaamolee uf

danda’anii kamuu?

Soorata

subaata 201. Crisps, chips, French fries, fried dough and

other fried foods

Gosoota

Nyaata

mi’aawaa fi

Dhugaatii

mi’aawaa

202. soorata sukkaara qaban kan vitaamin A

badhadhan

203. Soorata dammaa ykn sukkaara qaban kan

Dhugaatii adda addaa dabalate

204. Keekii,buskuta, chokoleetii,

205. Soorata mi’aawaa kan biroo

206. Juusii fi Dhugaatii lallaaffaa kan sukkaara hin

qabne

Mi”eesituwwan 207. Sooqidda ayyoodinii qabu (yoo hin beekne

qabdu isa ilaali)

208. Sooqidda ayyoodinii hin qabne

209. Suugoo,shitnii fi Mi”eesituwwan biroo

Soorataa fi

Dhugaatii

kanneen biroo

210. Shaayii, Buna, Shoorbaa, Alkoolii fi kkf

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8.5. Principal Investigator Curriculum Vitae (CV)

1. Personal detail

Name: Hinsarmu Amano Erkiso

Sex: Male

Date of Birth: September 1992 G.C

Place of Birth: Abosara Alko kebele, Asella surrounding

Marital Status: Married

Nationality: Ethiopian

Address: Kurfa Chele

E-mail: [email protected]

Cellular Phone: +251922294861

2. Educational background

1999 -2007: GC 1-8 Abosara Alko elementary school.

2008 -2009: GC 9-10 Golja secondary school.

2010-2011: GC 11-12 Asella preparatory school.

2012-2015 GC Madda Walabu University, College of Health and Medical Sciences.

3. Language proficiency

S/N Language Hearing Writing Reading Speaking

1 Afan Oromo Excellent Excellent Excellent Excellent

2 Amharic Very good Very good Very good Very good

3 English Very good Excellent Excellent Very good

4. Training

I have trained on different topics like: public health emergency management (PHEM),

prevention of mother to child transmission of HIV, HMIS,SAM Guideline, IMCI and

EPHCG.

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5. working experience

from 20016 to 2021 G.C I have worked at Dire Guddina Health center and Kurfa

Chele Health center as a clinician on adult OPD and as PHCU Director.

6. Computer skill

Good skill in basic computer (Microsoft office Word, Excel, Power point and some

statistical softwares).

7. Reference

1. Dr.Tara Wilfong: Haramaya University College of health and medical sciences

instructor

Address: Phone No.

2. Dr. Kedir Teji: Haramaya University College of health and medical sciences

instructor

Address: Phone No.0945809317

Hinsarmu Amano.pdf - HrU-IR Home

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