Download - Assessment of Nutritional status for under five years old children live in Hamar Jajab IDPs, Mogadishu - Somalia

Imam University

Faculty of Health science

Department of Nutrition

Title of the Thesis

Assessment of Nutritional status for under five

years old children live in Hamar Jajab IDPs

Supervisor Student

Dr: Omar Ahmed Ali Mr: Mohamed Abdinur

Academic year

2014-2015

Assessment of Nutritional status for Under five years old children live in Hamar Jajab IDPs Mogadishu, Somalia

Imam University Faculty of Health Science Department of Nutrition

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Work Declaration

I Mohamed Abdinur hereby declare that the work in this research is entirely my own

work, except where stated. Research was gathered using online data and printed texts and

all work referenced is included in a reference list. No help was wanted from an external

professional agency and there was no use of other students past work has not been

submitted as an exercise for assessment at this or any other University.

Signed:________________

Name: Mohamed Abdinur

Date: ____/_____/________



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Research Approval

This research was carried out under my close supervision as the university supervisor; I

therefore acknowledge it is authenticity and approved as the student's partial fulfillment

for the award of Bachelors degree in Nutrition at Imam University.

Signed: _________________

Name: Dr. Omar Ahmed Ali

Date: ____/_____/_______



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Thesis Committee Approval letter

We are Thesis Committee for Imam University; we hereby declare that this book titled

Assessment of Nutritional status for under five years old child live in Hamar Jajab

District is correct

Names: Signatures:

……………………………………………… ……………………………….

……………………………………………… ……………………………….

……………………………………………… ……………………………….

Dean Faculty of Health science

I Dean Faculty of health science, I hereby certify that Mohamed Abdinur Mohamed’s

book is accurate and conform to the law of the University of Thesis preparation

Name:…………………………………………………………………

Signature:……………………………… Date:……………………..



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Acknowledgment

Honor due to Allah who created the creation and much thanks to him for allowing me to

be one of his creations, and make this thesis possible to be completed in a time.

I would like to express my sincere gratitude and appreciation to my supervisor Dr. Omar

Ahmed Ali for his insights, guidance and encouragement during the trying times and all

Imam University Administration staff and Lecturers, also I would also like to express

thanks to my beloved mother (Addei Suleiman Moallim Hussein) and all my dear

brothers and sisters who gave me their support and precious advice and encouraged me to

complete my educational course until now.

In addition, I would like to acknowledge the help that I have received from my close

friends, Finally, I would like to express my relatives who were constantly supporting and

encouraging me to conclude my thesis.



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Abstract

In this study, I studied the Assessment of Nutritional status under five years old Children

in Hamar Jajab IDPs. The major objective of the study was to know nutritional status for

the Children IDPs who are the most Vulnerable and susceptible to became Malnourished

then others.

Using Simple random sampling technique, I selected 50 respondents from 200

Households live in IDP Camp in Hamar Jajab District Mogadishu-Somalia with the use

of questionnaire as instrument; Data was analyzed using descriptive statistics of mean

and frequency (percentage). Results: Number of screened children was 50, 4% ware

Severe Acute malnutrition (SAM), 14% were Moderate Acute Malnutrition (MAM) and

82% were Normal based on the findings, the researcher suggests that, make it sustainable

for current Nutrition programmes existing with inclusive development projects for the

IDPs such income generation activities to be self reliance.

The research also concludes that most of Mothers doesn’t well understand the necessary

need of child nutrition. So that in this study I recommended that this needs extra

researchers should launch researches on Nutritional Status as to check, intervene or

minimize the effects may result from malnutrition in community through mobilizing and

health education for community workers, and Make free from harmful.



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Table of contents

Contents Pages

Work Declaration……………………………………………………………………….....ii

Research Approval……………………………………………………………………….iii

Thesis committee Approval………………………………………………………………iv

Acknowledgment…………………...…………………………………………………….v

Abstract…………………………………………………………………………………...vi

Table of

Contents………………………………………………………………………...viiii

List of Tables…………………………………………………..………………………..,,xi

List of Figures……………………………………………………………………………xii

Appendixes……………………………………………………………………………...xiii

Abbreviations…………………………………………………………………................xiv

CHAPTER ONE

1.0 Introduction………………………………………………………………………1

1.1 Problem statement……………………………………………………………......3

1.2 Justification………………………………………………………………………3

1.3 Objectives of the study…………………………………………………………...4

1.4 Research questions……………………………………………………………….4

1.5 Scope of the study………………………………………………………………..4



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CHAPTER TWO

2.0 Literature review………………………………………………………………………5

2.1 Introduction……………………………………………………………………………5

2.1.1 Scientific definition……………………………………………………………….....5

2.2 Nutritional Status…………………………………………………………….………..6

2.3. Nutrition of under five years children………………………………………………...7

2.3.1 Macronutrients………………………………………………………………………7

2.3.2 Micronutrients…………………………………………………………………….....7

2.3.3 Water………………………………………………………………………………..8

2.4 Breastfeeding………………………………………………………………………….8

2.4.1 Breast-milk Composition……………………………………………………………9

2.4.2 Initiating breastfeeding………………………………………………………..…...10

2.4.3 Breastfeeding benefits……………………………………………………………...10

2.5 Definition of malnutrition……………………………………………………………10

2.5.1 Types of Malnutrition………………………………………………………….......10

2.5.2 Causes of malnutrition……………………………………………………………..10

2.6 Malnutrition of Under five years…………………………………………………….11

2.6.1 Under-nutrition………………………………………………………………….....13

2.7 Protein energy malnutrition………………………………………………………….13

2.7.1 Vitamins deficiencies………………………………………………………………13



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2.7.2. Vitamin A Deficiency……………………………………………………………..14

2.7.3 Vitamin B1 deficiency……………………………………………………………..14

2.7.4 Vitamin B2, B5 and B6 deficiencies……………………………………………….14

2.7.5 Vitamin C deficiency……………………………………………………………....14

2.7.6 Vitamin D deficiency……………………………………………………………....15

2.7.7 Zinc deficiency……………………………………………………………………..15

2.7.8 Iodine deficiency……………………………………………………………...……15

2.8 Risk factors increasing malnutrition…………………………………………………16

2.9 Sign and symptoms of Malnutrition…………………………………………………16

2.10 Measurement of malnutrition……………………………………………………….18

2.11 Treatment of malnutrition…………………………………………………………..20

2.11.1 Treatment of malnutrition at home……………………………………………….21

2.11.2 Treatment of malnutrition at the hospital…………………………………………21

2.11.3 Treatment of malnutrition for those who are unable to take food by mouth……..22

2.11.4 Treatment of malnutrition in pregnant women…………………………………...22

2.11.5 Treatment of malnutrition in children…………………………………………….23

2.12 Prevention of malnutrition………………………………………………………….23

CHAPTER THREE

3.0 Research methodology…………………………………………………….................25

3.1 Introduction…………………………………………………………………………..25



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3.2 Material & Methods………………………………………………………………….25

3.3 Ethical consideration…………………………………………………………………26

3.4 Study Area…………………………………………………………………………...26

3.5 Study design………………………………………………………………………….26

3.6 Methods of Data collection…………………………………………………………..26

3.7 Sampling Techniques………………………………………………………………...26

3.8 Sample Size…………………………………………………………………………..27

3.9 Data analysis and Interpretation method..…………………………………………...27

CHAPTER FOUR

4.0 Data analysis and interpretation……………………………………………………..28

4.1 Introduction…………………………………………………………………………..28

4.2 Socio-demographic Variables……………………………………………..................28

4.3 Usual Dietary intake and assess adequacy I summarized into……………………….37

4.4 Breastfeeding and Complementary feeding pattern of the mothers….........................45

4.5 Anthropometric index for children…………………………………………………..51

CHAPTER FIVE

5.0 Discussion, Conclusion and recommendations…………………………………........54

5.1 Discussion………………………………………………...……………………….....54

5.2 Conclusion …………………………………………………………………………..57

5.3 Recommendation ………………………...………………………………………….58

References………………………………………………………………………………..59



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List of tables

Tables Pages

Table 4.1 Gender of the children………………………………………………………...29

Table 4.2 Age of children in year………………………………………………………..30

Table 4.3 Age of Mother/respondent……………………………………………………31

Table 4.4 Level of Education of Mother………………………………………………...32

Table 4.5 Total number of Household member in the House………………………...…33

Table 4.6 Occupation of Household Head………………………………………………34

Table 4.7 Source of water of the Household…………………………………………….35

Table 4.8 Family income per month…………………………………………………….36

Table 4.9 Cereals grain and products……………………………………………………37

Table 4.10 Legumes and legume products………………………………….…………..38

Table 4.11 Nuts and Seeds………………………………………………….…………..39

Table 4.12 Vegetables and vegetable products……………………………….………...40

Table 4.13 Fruits……………………………………………………………….……….41

Table 4.14 Milk and Milk products…………………………………………….………42

Table 4.15 Meat Fish and Eggs product………………………………………….……..43

Table 4.16 Oils and Fats………………………………………………………….……..44

Table 4.17 Time initiating breastfeeding………………………………………….……45



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Table 4.18 Food or drink given to infants before breast Milk flow……………….……46

Table 4.19 Period after birth the baby was given other food/fluid apart from breast

milk………………………………………………………………………………………47

Table 4.20 Duration of breastfeeding…..………………………………………………..48

Table 4.21 Immunization status for children………………………………………...…..49

Table 4.22 Knowledge of Mother for Nutritional status on her children………..………50

Table 4.23 Age of a child in month…………………………………..………………….51

Table 4.24 Weight of child in Kg………………………………………….………….…51

Table 4.25 Weight of child in Kg………………………………………….………….…52

Table 4.26 MUAC of child in cm………………………………………………….…....52

List of figures

Figures Pages

Figure 4.1 Gender of child………………………………………………………………29

Figure 4.2 Age of children in year………………………………………………………30

Figure 4.3 Age of Mother/respondent…………………………………………………...31

Figure 4.4 Level of Education of Mother……………………………………………….32

Figure 4.5 Total number of Household member in the House…………………………..33

Figure4.6 Occupation of Household Head……………………………………………....34

Figure 4.7 Source of water of the Household………………………………………...…35

Figure 4.8 Family incomes per month…………………………………………………..36



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Figure 4.9 Cereals grain and products…………………………………………………..37

Figure 4.10 Legumes and legume products……………………………………………38

Figure 4.11 Nuts and Seeds…………………………………………………………….39

Figure 4.12 Vegetables and vegetable products………………………………………..40

Figure 4.13 Fruits………………………………………………………………………41

Figure 4.14 Milk and Milk products…………………………………………………...42

Figure 4.15 Meat Fish and Eggs product………………………………………………43

Figure 4.16 Oils and Fats………………………………………………………………44

Figure 4.17 Time initiating breastfeeding……………………………………………...45

Figure 4.18 Food or drink given to infants before breast Milk flow…………………..46

Figure 4.19 Period after birth the baby was given other food/fluid apart from breast

milk…..............................................................................................................................47

Figure 4.20 Duration of breastfeeding…………………………………………………48

Figure 4.21 Immunization status for children………………………………………….49

Figure 4.22 Knowledge of Mother for Nutritional status on her children……………..50

Figure 4.23 Results from Anthropometrics…………………………………………….53

Appendixes

Appendix A Survey Questionnaires……………………………………………………..61

Appendix B Timelines……………………………………………………………….…..65

Appendix C: Events……………………………………………..……………………….66

Appendix D: Budget………………………………………………………………….….67



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Abbreviations and acronyms

BMI Body Mass Index

FAO Food and Agricultural Organization of the United Nations

FSANU Food Security and Nutrition Analysis unit

HH Household

MOH Ministry of Health

MSF Medicine Sans Frontier

MUAC Mid-Upper Arm circumference

OTP Outpatient Therapeutic Programme

PEM Protein Energy Malnutrition

SC Stabilization center

SFP Supplementary Feeding Program

UNICEF United Nations Children's Fund

WFP World Food Programme

WHO World Health Organization

99 Missing value



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CHAPTER ONE

1.0 Introduction

Nutritional status is defined as the evident state of nutrition of an individual. A person is

said to have a good nutritional status if he shows no evidence of malnutrition, whether

open or latent. Nutrition is the aspect of science that interprets the relationship of food to

the functioning of living organisms. It includes the uptake of food, liberation of energy,

elimination of wastes and the biochemical synthesis that are essential for maintenance of

normal growth and development (Laditan, 1983).

The nutritional status of any person is his/her health as dictated by the quality of

nutrients consumed, and the body’s ability to utilize them for its metabolic needs.

Thus, being nutritionally vulnerable, under-5 children’s nutritional status is generally

accepted as an indicator of the nutritional status of any particular community. It has been

estimated that approximately one out of every three Under-5 children is chronically

malnourished and thereby subjected to a pattern of ill health and poor development in

early life with malnutrition being associated with more than half of all deaths of children

worldwide (UNICEF, 1998).

Early childhood starts from in-uterus to new birth and then through postnatal life. In

intrauterine life, the nutritional status of the unborn fetus depends largely on the adequacy

of the dietary intake of the mother and this determines the outcome of birth of the new

born. Postnatal life is a continuum in human development. Normal growth and

development depend largely upon the nutritional status of the new born which is in turn,

related directly to the nutrition of the mother and inherited characteristics and to the

dietary intake of the infant.

In early childhood, nutritional status is of paramount importance for a child’s later

physical, mental and social development.



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The inadequate or excessive intake of nutrients may result from disease factors that affect

digestion, absorption, transport, and utilization of nutrients (UNICEF, 1990).

Malabsorption of nutrients may result from genetic cum environmental conditions or

illness. The most critically vulnerable groups are the developing fetus, preschool

children, women before and during pregnancy, and lactating women. Malnutrition affects

all levels of development physically, mentally, socially, psychologically and

physiologically. It thus multiplies the effect of prevailing disease or mortality in children

and infants (UNICEF, 1998).

Anthropometric measurements, though difficult to apply to young children, are

commonly used to determine the prevalence of Protein-Energy-Malnutrition. They

provide the most valid indicator of a population’s nutritional status and the most reliable

indices for determining nutritional status, especially in rural African settlements. This

technique is usually preferred because it is non-invasive, relatively simple and can be

easily carried out and interpreted without requiring professional expertise. It deals with

techniques highly useful on wide spread field basis, and rests on well adopted

classification. It is the readily available method of assessing nutritional status. Through

proper assessment, it can be employed to determine how well or how poor a particular

group or individual feeds. (UNICEF, 1990).

Whatever knowledge gathered from such assessment will help the group or individual to

step up or lower food intake for better health.

In this study, a combination of anthropometry, dietary assessment and socioeconomic

status were used to determine the nutritional status of Under-5 children, since they have

been known to give fairly accurate results (Tanner and Whitehouse, 1962). The study was

therefore designed to establish and provide baseline information on the health and

nutritional status of the target group, by determining the impact of parental socio-

economic status on the growth, nutritional status and the future outlook of Under-5

children in the study location.



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1.1 Problem statement

The right to adequate food is recognized in several instruments under international law

(Amos, 2009). Despite this recognition, globally, half of the almost 10 million children

under the age of five who die annually do so from a combination of malnutrition and

easily preventable disease. The world Health Organization estimates that Approximately

150 million children younger than 5 years in developing countries are underweight and

an additional 200 million children are stunted (WHO, 2007).

In Somalia malnutrition under five children contributes major current health problems

(morbidity and mortality) in several ways. Under nutrition remains a devastating problem

in many developing countries affecting over 815 million people causing more than one –

half of children death. 10,11Although WHO, UNICEF and Somali’s National

breastfeeding policy recommended that infants be exclusively breastfed from birth to 6

months and continue breastfeeding to 24 months and beyond for optimal survival, growth

development unfortunately only 9.00% of infants under six months of age are exclusively

breastfed in Somalia( World Bank, 2006) . The poor breastfeeding and inadequate

complementary feeding explained the protein energy malnutrition level in children as

they grow older.

1.2 Justification

Food insecurity has become a growing humanitarian problem in most developing

countries due to population increase, rural-urban migration, widespread poverty and

increasing cost of food. (MSF-F, 2008). In Somalia number children under five years in

hospitals are increasing so that it’s crucial to assess nutritional status among children less

than five years.



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1.3 Objectives of the study

A) General Objectives

To assess the nutritional status for under five years old children in Hamar Jajab IDPs

B) Specific objectives are as follows:

• To assess the socio economic status of subjects parent in Hamar Jajab IDPs.

• To determine the anthropometric indices of under-five children in the study area.

• To determine the usual dietary intake of the subjects and assess the adequacy.

• To assess the knowledge and practice of mother regarding to infant feeding,

breastfeeding and immunization.

1.4 Research questions

1. What are socio economic statuses of subject’s parent in Hamar Jajab IDPs?

2. What is the anthropometric index of under-five children in the study area?

3. How the usual dietary intake of the subjects and assess the adequacy?

4. What are the knowledge and practice of mother regarding to infant feeding,

breastfeeding and immunization?

1.5 Scope of the study

This study looks for assessment of nutritional status for under five years old children in

Hamar Jajab IDPs in Mogadishu by used Anthropometric index such MUAC, Weight for

Height and started at November, 2014 ended February 2015. All the data collected from

the target population were analysis thought SPSS software.



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CHAPTER TWO

2.0 Literature review

2.1 Introduction

Malnutrition: The World Health Organization (WHO) says that malnutrition is the

largest contributor to child mortality globally, currently present in 45 percent of all cases.

Underweight births and inter-uterine growth restrictions are responsible for about 2.2

million child deaths annually in the world. Deficiencies in vitamin A or zinc cause 1

million deaths each year.

WHO adds that malnutrition during childhood usually results in worse health and lower

educational achievements during adulthood.

2.1.1 Scientific definition

Nutrition is the provision of adequate energy and nutrients time to the cells for them to

perform their physiological function (of growth, reproduction, defense, repair, etc).

(WHO, 1999).

Malnutrition exactly means “bad nutrition “and technically includes both over- and

under- nutrition. In the context of developing countries, under-nutrition is generally the

main issue of concern, though industrialization and changes in eating habits have

increased the prevalence of over-nutrition. within the context of World Food Programme

(WFP) programs and assessments, malnutrition refers to under-nutrition unless otherwise

specified. WFP defines malnutrition as “a state in which the physical function of an

individual is impaired to the point where he or she can no longer maintain adequate

bodily performance process such as growth, pregnancy, lactation, physical work and

resisting and recovering from disease.” Malnutrition can result from a lack of

macronutrients (carbohydrates, protein and fat), micronutrients (vitamins and minerals),

or both. Macronutrient deficiencies occur when the body adapts to a reduction in

macronutrient intake by a corresponding decrease in activity and an increased use of

reserves of energy (muscle and fat), or decreased growth. Consequently, malnourished

individuals can be shorter(reduced growth over a prolonged period of time) and/or



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thinner than their well-nourished counterparts. 'Hidden Hunger', or micronutrient

malnutrition, is widespread in developing countries. It occurs when essential vitamins

and/or minerals are not present in adequate amounts in the diet. The most common

micronutrient deficiencies are iron, vitamin A, and iodine. Others, also can occur during

acute or prolonged emergencies when populations are dependent on a limited, unvaried

food source.

According to the World Health Organization (WHO) malnutrition has three commonly

used comprehensive types named stunting, wasting and underweight measures by height

for age, weight for height and weight for age indexes respectively (WHO, 1995).

2.2. Nutritional Status

Nutritional status is defined as the evident state of nutrition of an individual.

A person is said to have a good nutritional status if he shows no evidence of malnutrition,

whether open or latent. Nutrition is the aspect of science that interprets the relationship of

food to the functioning of living organisms. It includes the uptake of food, liberation of

energy, elimination of wastes and the biochemical synthesis that are essential for

maintenance of normal growth and development (Laditan, 1983).

The nutritional status of any person is his/her health as dictated by the quality of

nutrients consumed, and the body’s ability to utilize them for its metabolic needs.

Thus, being nutritionally vulnerable, under-5 children’s nutritional status is generally

accepted as an indicator of the nutritional status of any particular community and it has

been estimated that approximately one out of every three Under-5 children is chronically

malnourished and thereby subjected to a pattern of ill health and poor development in

early life with malnutrition being associated with more than half of all deaths of children

worldwide.

Early childhood starts from in-utero to new birth and then through postnatal life. In

intrauterine life, the nutritional status of the unborn fetus depends largely on the adequacy

of the dietary intake of the mother and this determines the outcome of birth of the new

born. Postnatal life is a variety in human development. Normal growth and development



7

depend largely upon the nutritional status of the new born which is in turn, related

directly to the nutrition of the mother and inherited characteristics and to the dietary

intake of the infant.

In early childhood, nutritional status is of paramount importance for a child’s later

physical, mental and social development.

The inadequate or excessive intake of nutrients may result from disease factors that affect

digestion, absorption, transport, and utilization of nutrients. The most critically

vulnerable groups are the developing fetus, preschool children, women before and during

pregnancy, and lactating women. Malnutrition affects all levels of development

physically, mentally, socially, psychologically and physiologically. It thus multiplies the

effect of prevailing disease or mortality in children and infants (UNICEF, 1998).

2.3. Nutrition of under five years children

People eat foods that contain the nutrients necessary for life. Nutrients may be divided

into categories:

2.3.1 Macronutrients

Protein, fat and carbohydrates are macronutrients that make up the bulk of a diet and

supply the body’s energy. In resource-poor populations, carbohydrates ( i.e. starches and

sugars) are often a large part of the diet (80%) and the main source of energy. Fats are

also important in cell formation. Proteins are required to build new tissue and derived

mostly from animal origin such as milk, meat and eggs, and from cereals and pulses.

Animal by-products contain essential amino acids that cannot be produced by the body

but must be eaten to promote growth and food health. (UNICEF, 2010)

2.3.2 Micronutrients

There are around forty different micronutrients that are essential for good health. Formal

functional point of view. Micronutrients can be divided into two classes: type I and type

II. Type I micronutrients, or functional nutrients, include nutrients that are required for

the hormonal, immunological, biochemical and other processes of the body. They include



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iodine, iron, vitamins A and C among others. Deficiencies in type I micronutrients do not

affect growth directly (i.e. the individual can have the normal growth with appropriate

weight and still be deficient in micronutrients) and thus a deficiency in type I

micronutrients cannot be identified by anthropometric measurements. Deficiencies in

type I micronutrients will cause major illness such as anaemia, scurvy and impaired

immunity.

Type II micronutrients, or growth nutrients, include magnesium, sulphur, nitrogen,

essential amino acids, phosphorus, zinc, potassium, sodium and chloride. They are

essential for growth and tissue repair. Type II micronutrients are required only in small

quantities by every cell and system, but the correct balance is essential for good health. A

deficiency in any of the type II micronutrients will lead to growth failure, measured by

stunting and /or wasting. replacement of all these nutrients, in the correct balance, is

essential for recovery from malnutrition and restoration from acute illness.

(UNICEF2010).

2.3.3 Water

Most of the body is water. Water is necessary for good nutrition as well as for

maintaining hydration. Only half of the body’s water is obtained through drinks, the rest

being absorbed from foods and produced by the body. Water often needs to accompany

in order to provide good dilution and absorption of nutrients. (UNICEF, 2010)

2.4 Breastfeeding

Breast milk is a valuable, readily available resource with extensive short- and long-term

benefits for both mother and infant. It is essential that health professionals understand the

benefits and management of breastfeeding and that this topic be included in their

education and training. Health professionals can thus insure the improved health and

development of almost all infants, children (Gartner Lm, Newton ER. 1998)



9

2.4.1 Breast-milk Composition

Human milk is radically different from cow’s milk and even from prepared infant

formula, despite attempts to modify formulas to make them similar to breast-milk.

Breast-milk is extremely low in protein ( about 0.9g/100 mL) compared with raw cow’s

milk, which has nearly four times the concentration of protein. Infant formulas are diluted

to provide a low protein concentration that is comparable to human milk, but the protein

structure( which is more difficult for young infant to absorb) remains the same as that

cow’s milk. In some formulas, the ration of whey to casein is altered to make is

comparable to breast-milk in which they is dominant. Because breast-milk’s

concentration of protein is very low, infants need to breastfeed frequently. Human milk

proteins contain antibodies known as secretory IgA that are structured specifically to

resist digestion. The infant in breast-milk are very different from those infant formulas

and are absorbed better than those from animal or vegetable sources. Breast-milk also

contains hundreds of micronutrients, including free amino acids, essential fatty acids,

minerals, growth factors, cytokines, and other chemical agents that contribute to virtually

every aspect of infant growth and development, May of bioactive agents to enhance the

infant’s development.

Breast-milk composition varies during the course of breastfeeding colostrums, the initial

milk, is higher in protein and lower in fat and lactose concentrations than mature milk.

Throughout the course of lactation, secretory IgA concentration gradually declines,

allowing the infant’s own immune system to develop and lose its dependency on the

mother’s sources. Because the mother and infant share the same environment, the mother

develops and secretes specific antibodies to the viruses and bacteria to which the infant is

exposed. This response is rapid, requiring only a few days. These dynamic changes in the

composition of breast-milk show how well it adapts to meet the needs of the infant.

Furthermore, breast-milk contains everything that the healthy, full-term infant requires

for about the first 6 months of life, including water and most vitamins and minerals.

(Lawrence RA.1999).



10

2.4.2 Initiating breastfeeding

Breastfeeding is established most successfully when it is begun during the first hour birth.

The infant and mother should remain together throughout the recovery and postpartum

period, with no interruptions in the “rooming-in” (American Academy of Pediatrics,

1997).

2.4.3 Breastfeeding benefits

Breastfeeding provides infants with significant protection against a variety of infectious

diseases, particularly in areas of the world with poor sanitation and contaminated water

and food supplies. Epidemiological studies in the United States and other developed

countries have shown that, compared with formula-fed infants, breastfed infants have

fewer and less severe bacterial and viral diseases, including meningitis, gastroenteritis,

otitis media, pneumonia, botism, urinary tract infections, (American Academy of

Pediatrics, 1997).

2.5 Definition of malnutrition

Malnutrition, dietary condition caused by a deficiency or excess of one or more essential

nutrients in the diet. Malnutrition is characterized by a wide array of health problems,

including extreme weight loss, stunted growth, weakened resistance to infection, and

impairment of intellect, Severe cases of malnutrition can lead to death (UNICEF,1998).

2.5.1 Types of Malnutrition

•Under nutrition: too little 1) Protein Energy Malnutrition (PEM) 2) Micronutrient

deficiencies.

•Over nutrition: too much 1) Obesity 2) Chronic diseases (diabetes, hypertension) (WHO

1999).

2.5 .2 Causes of malnutrition

In generally there are two main causes of malnutrition

A. Immediate causes of Malnutrition



11

B. Underlying causes of malnutrition

Immediate causes of Malnutrition

Malnutrition, is defined as an imbalance between the supply of nutrients and the body’s

demand for growth, maintenance, and specific functions ( World Health Organization ,

WHO) in other words, adequate nutrition is indispensable for physical development and

maintenance, resistance to disease and capacity to work.

Malnutrition is the effect of an unbalanced diet and/ or disease ( e.g. tuberculosis, HIV)

inadequate food intake ( in quality or quantity) leads to increased sensitivity for

infections .

Infections often cause nutrient mal-absorption and reduced food intake such appetite,

nausea what can lead to malnutrition, (MSF,2006) P 2.

Underlying causes of malnutrition

At the household and community level, the UNICEF Framework of Underlying causes of

Malnutrition and mortality identifies three underlying factors that influence nutritional

status: Household food security, health and environment, and social and care

environment. These factors are interrelated and need to be assessed; interventions should

address insufficient access to food, poor water/sanitation, inadequate health services and

inadequate care for the vulnerable. In many developing countries long-term (chronic)

malnutrition is widespread - simply because people do not have enough food to eat,

(MSF, 2006) p 2.

2.6 Malnutrition of under five years

Is the consequence of much food insecurity, which stems from poor food quality and

quantity, severe repeated infections or combinations of all three. These conditions are

linked to the standard of living and whether basic needs can be met. A lack of knowledge

on the nutritional needs of children and the benefits of breastfeeding contributes to

childhood malnutrition. The extent of hunger has also been associated with low energy

intake, low micronutrient intake and poor income levels. This affects growth patterns



12

negatively. Malnutrition can cause physical, cognitive and psychological impairment,

which over time causes permanent learning disabilities.

The global number of child deaths under the age of five, recorded in 2006 by UNICEF,

WHO, United Nations Population Division (UNPD) and United Nations 3 Statistics

Division (UNSD), was just below 10 million, which is a 60 percent decrease since the

1960s. During 2007, UNICEF recorded 9.2 million child deaths under the age of five,

globally. Child mortality and poverty are linked with one third of child deaths caused by

malnutrition. Globally, per region, 4.8 million child deaths were recorded in Sub-Saharan

Africa; 900 000 in East Asia and the Pacific; 3.1 million in South Asia; 400 000 thousand

in the Middle East and North Africa; and 300 000 in Latin America. According to the

United Nations Children’s Fund, 26 000 children die daily from preventable causes,

(UNICEF, 2007).

In South Africa, estimates of under-five mortality during 2005 ranged between 69 and 76

per thousand, approximately 60 000 per annum. Results from the National Food

Consumption Survey and Fortification Baseline concluded that children aged between

one and three years are most vulnerable to poor nutritional status. Malnutrition and lack

of access to clean water increase the risk of mortality. During 2000, child deaths caused

by malnutrition accounted for 12 percent of child deaths and unsafe water usage and

practices accounted for 9.3 percent.

Education of children may assist in reducing poverty. Globally, 101 million children of

primary school age are not attending school. Children are deprived of education because

of illness, being forced to care for siblings, or because they have been orphaned and

placed with caregivers who are unemployed and income is minimal. Over 140 million

children globally, between the ages of seven and 18, have never attended school.

Lack of proper education and illiteracy amongst caregivers, parents and children

contribute to the growing malnutrition epidemic. Children are not equipped to make

suitable food choices and are dependent on caregivers and parents to make choices. The

choices are, unfortunately, reflective of the poor income status. Although studies have

been done to assist in assessing nutritional status, very little has been done on nutrition



13

education as a strategy to improve the quality of life and address malnutrition. The main

purpose of this study was to assess the nutritional status of primary school children within

a community and promote nutrition education with the aim of improving nutrition

knowledge and food choices, to encourage a better quality of life into adulthood (WHO

and UNICEF 2009).

2.6.1 Under-nutrition

Under-nutrition is a condition caused by a lack of food of good nutritional value

combined with interaction from infections. Micronutrient deficiency is caused by

poverty, food insecurity, lack of knowledge, and lack of distribution of adequate

resources.

Body mass index (BMI) for age, is used to classify the nutritional status of a child. BMI

is calculated by dividing the weight, in kilograms (kg), by the height squared in meters

(m) (UNICEF 1998).

2.7 Protein energy malnutrition

Protein energy malnutrition (PEM) is now regarded as a dangerous form of malnutrition

basically caused by a lack of energy and protein. Kwashiorkor is a form of malnutrition

caused by inadequate protein intake, while marasmus is caused by a lack of energy and

protein within the diet.

Estimated globally, 854 million people are undernourished, with 820 million of these

living in developing countries. Poverty is associated with malnutrition and the level of

PEM is also affected by political, economic, seasonal and climatic conditions, education

and sanitation levels, food production and prevalence of disease

PEM is associated with poor weight gain, slow linear growth and behavioral changes

such as irritability, anxiety and attention deficit (FAO 2004).

2.7.1 Vitamins deficiencies

The three most prevalent micronutrient deficiencies include Iodine Deficiency Disease

(IDD), Iron Deficiency Anaemia and Vitamin A Deficiency.



14

According to the WHO, World Food Programme (WFP) and UNICEF (2007), an

estimated two billion people across the globe are deficient in key minerals and vitamins.

2.7.2 Vitamin A Deficiency

Vitamin A is fat-soluble vitamin derived from 2 sources: retinol ( from Animal products)

and carotenes ( from many vegetables). Vitamin A is required for the functioning of the

visual system, growth and development, maintenance of epithelial cellular integrity,

immune function, and reproduction. Vitamin A deficiency is associated with an increased

susceptibility to infections, ocular defects that may progress to blindness and other

problems such as retardation of growth and development.

2.7.3Vitamin B1 deficiency

Vitamin B1 (thiamine) is water-soluble Vitamin necessary for the metabolism of

carbohydrates, fat and alcohol. It is also necessary for the proper function of the central

and peripheral nervous system and the cardiac muscles. There is no body stock of

Vitamin B1. All excess is lost in urine. Thiamine deficiency results in beriberi and

usually occurs simultaneously with other Vitamin B deficiencies (MSF, 2006) p141.

2.7.4 Vitamin B2, B5 and B6 deficiencies

B-complex deficiencies incidence is under – estimated, since symptoms are non- specific

and may be masked by other deficiencies. These deficiencies are often found in

association with other B deficiencies. A population may develop signs when the diet is

composed of refined food (white bread, polished rice) ( MSF, 2006) p143.

2.7.5 Vitamin C deficiency

Vitamin C (ascorbic acid) is a water - soluble vitamin with minimal body tissue reserve

(excessive amounts are excreted in the urine). Vitamin C is essential for collagen

formation to maintain the integrity of cells, wound healing and growth, it is an important

anti-oxidant and helps the absorption of iron. Vitamin C deficiency results in scurvy.

Clinical cases are usually observed when the daily intake of vitamin C is below



15

10mg/day. Scurvy can be fetal is untreated. Vitamin C is destroyed during cooking (MSF,

2006) p 144.

2.7.6 Vitamin D deficiency

Vitamin D � is a fat soluble vitamin formed in the skin by exposure to sunlight and

found in fish liver oils and egg yolks. Synthesis in the skin is normally the main source of

vitamin d ( after sunlight exposure, even of short periods: 10 to 15 min/day). Only 10%

are obtained from the dietary sources, Vitamin D is essential for the Absorption of

calcium and bone mineralization. It can be stored in the body. inadequate exposure to

sunlight and low dietary intake lead to Vitamin D deficiency, Vitamin D deficiency

results in disease of abnormal bone: rickets in children and osteomalacia in adults (MSF,

2006) p145.

2.7.7 Zinc deficiency

Zinc status affect mutable physiological and metabolic functions such as physical growth,

immune- competence, reproductive function, and neurobehavioral development, Zinc

plays a central role in the immune system ( cellular and humoral immunity), Zinc is

important cell replication and for wound healing.

Clinical features of severe zinc deficiency include: growth retardation, hair loss, diarrhea,

delayed, eye and skin lesion, loss of appetite, impaired taste sensation, increased

susceptibility to infections mediated, and behavior changes, (MSF, 2006) p141.

2.7.8 Iodine deficiency

Iodine is a mineral necessary for the population of thyroid hormones and for normal

thyroid function. In the fetus, iodine is necessary for the development of the nervous

system during the first trimester of pregnancy. Iodine is stored in the thyroid gland;

excess is released in the urine Cassava and cabbage inhibits iodine absorption, Iodine

deficiency results in goiter and cretinism (MSF, 2006) p139.



16

2.8 Risk factors increasing malnutrition

Risk factors may increase malnutrition is one of the following Weakened immune system

HIV/AIDS, Diabetes , End-stage kidney disease, Certain cancers, Cancer treatment, such

as chemotherapy, chronic diseases, medical complications, limited access or availability

of food , inadequate household food security, inadequate social and care environment in

house and local community, (UNICEF 2010).

Poverty Currently 1.2 billion people live in absolute poverty. Seventy per cent of the

poor are located in rural areas. By 2020 the world population will increase by one-third to

7.5 billion people, with nearly 85% living in developing countries. The number of

absolute poor is not expected to decline sufficiently by 2010. Most possibly the majority

are those in South Asia and Sub-Saharan Africa (Nutrition Policy Paper # 16, Nov 1997).

2.9 Sign and symptoms of Malnutrition

Symptoms of malnutrition are easily distinguishable among both adults and children.

They may be outlined as follows.

A) Symptoms of malnutrition in children

Symptoms of malnutrition in children include:

• Growth failure. This may be manifested as failure to grow at a normal expected

rate in terms of weight, height or both.

• Irritability, sluggishness and excessive crying along with behavioral changes like

anxiety, attention deficit are common in children with malnutrition.

• The skin becomes dry and flaky and hair may turn dry, dull and straw like in

appearance. In addition, there may be hair loss as well.

• Muscle wasting and lack of strength in the muscles. Limbs may appear stick like.

• Swelling of the abdomen and legs. The abdomen is swollen because of lack of

strength of the muscles of the abdomen. This causes the contents of the abdomen



17

to bulge out making the abdomen swollen. Legs are swollen due to edema. This is

caused due to lack of vital nutrients. These two symptoms are seen in children

with severe malnutrition.

• There are classically two types of protein energy malnutrition (PEM) in children.

These are Marasmus and Kwashorkor.

• In Marasmus there may be obvious weight loss with muscle wasting. There is

little or no fat beneath the skin. The skin folds are thin and the face appears

pinched like an old man or monkey. Hair is sparse or brittle.

• In Kwashirkor the child is between 1 and 2 with hair changing color to a listless

red, grey or blonde. Face appears round with swollen abdomen and legs. Skin is

dry and dark with splits or stretch marks like streaks where stretched.

• In nutritional dwarfism the patient appears stunted in growth.

B) Symptoms of malnutrition in adults

The most common symptom is a notable weight loss. For example, those who have lost

more than 10% of their body weight in the course of three months and are not dieting

could be malnourished.

This is usually measured using the body mass index or the BMI. This is calculated by the

weight in kilograms divided by the height in meters squared. A healthy BMI for adults

usually lies between 18.5 and 24.9. Those with a BMI between 17 and 18.5 could be

mildly malnourished, those with BMIs between 16 and 18 could be moderately

malnourished and those with a BMI less than 16 could be severely malnourished.

Other symptoms include:

• Weakness of muscles and fatigue. The muscles of the body appear to waste away

and may be left without adequate strength to carry out daily activities.

• Many people complain of tiredness all day and lack of energy. This may also be

due to anemia caused by malnutrition.

• Increased susceptibility to infections.



18

• Delayed and prolonged healing of even small wounds and cuts.

• Irritability and dizziness.

• Skin and hair becomes dry. Skin may appear dry, and flaky and hair may turn dry,

lifeless, dull and appear like straw. Nails may appear brittle and break easily.

• Some patients suffer from persistent diarrhea or long term constipation.

• Menstruation may be irregular or stop completely in malnourished women.

• Depression is common in malnutrition. This could be both a cause as well as an

effect of malnutrition. (Medical.net).

2.10 Measurement of malnutrition

Classification of malnutrition

In emergency situations where acute forms of malnutrition are predominant, the weight –

for height index is the appropriate tool to quality acute malnutrition in the population (

along with the assessment of oedema and MUAC). Furthermore, these do not require the

determination of age what is often difficult in these situations, (MSF, 2006) p17.

Acute and chronic malnutrition

Acute malnutrition (Wasting) Chronic malnutrition (stunting in children)

Weight –for-height Height-for age

Weight-for-age weight-for age

Mid-upper arm circumference Body mass index

Body mass index

Two systems of classification are used when defining acute malnutrition in individuals or

in population :

• Individuals: Moderate acute or severe acute.

• Population: severe acute and global acute. Global acute malnutrition refers to the

total cases of moderate acute and severe acute malnutrition in a population.

The main anthropometric indices are used for children and adolescents W/H, bilateral

oedema and MUAC and for adults bilateral oedema, MUAC and BMI.



19

Weight –for-height

W/H does not require any specification of age; it is therefore a useful tool in crisis

situations, where age is often difficult to obtain. W/H can identify minor deterioration or

improvement in nutritional status of individual children, (MSF, 2006) p 18.

Height-for-age

H/A is an index of chronic malnutrition, when nutrition is inadequate for a long period of

time, children grow slowly. The height is reduced, compared to other children of the

same age. This is called “stunting”. H/A reflects an individual’s nutritional status over

time. H/A should not be used as a criterion for the admission of children into feeding

programmes.

Weight-for-age

W/A can be used to identify both chronic malnutrition (stunting) and acute malnutrition

(wasting). W/A is used to minor the individual growth of children; this is generally done

using” the Road to Health Chart” in clinics.

Since W/A does not differentiate between acute and chronic malnutrition, is should not

be used as a criterion for the admission of children into feeding programmes aiming at

actually malnourished children, (MSF, 2006) p 20.

Mid Upper Arm Circumference (MUAC)

MUAC is particularly sensitive to acute weight loss, as it reflects the peripheral wasting

of muscle and subcutaneous adipose tissue. MUAC findings provide a rapid indication of

the risk mortality.

Persons with MUAC below 110mm are at risk of death (only valid for older than 1 year).

MUAC remains relatively stable between the ages 1 and 60 month, so that only one cut

off point can be used. Agencies use different cut off values, the most commonly used cut

off points are given below.



20

MUAC cut-off points for children 1-5year

Acute malnutrition MUAC

Severe <110mm

Moderate ≥110-125mm

Global <125mm

At risk of malnutrition ≥125-135mm

Body Mass Index (BMI)

BMI expresses the bodyweight of an individual in relation to his/her height. BMI is used

for adolescents and adults, and varies according to genotype (ethnicity), gender and age.

Since there is a considerable inter- and ultra-population variation, there is no universal

standard reference for BMI. Therefore, it is necessary to verify whether proposal cut-off

points correspond to the clinical state of adult populations, including history of acute

malnutrition or chronic disease. BMI is not used in pregnant women, as their weight

changes throughout pregnancy and therefore the BMI the BMI does not reflect the

nutritional status of the women.

Body mass index = .

Example: an adult of 1.60 m weighting 40 kg has a BMI of 40/(1.60x1.60) = 15.6kg/m2.

(MSF 2006) p 19/20.

2.11 Treatment of malnutrition

Malnutrition is caused by lack of essential nutrients in diet. Treatment depends on several

factors. These include the severity of malnutrition; the underlying cause of the

malnutrition; ability to feed oneself; and ability to eat and digest food normally. In

addition age, mental status and place of living of the patient is also considered.



21

These factors determine the plan of therapy as well as where the patient is treated – at

home or under supervision of a nutritional expert or a dietician or other health

professionals or at the hospital.

2.11.1 Treatment of malnutrition at home

This is suitable for patients who are able to eat and digest food normally. Treatment at

home involves:

• The diet planner and advisor discuss the diet with the patient and makes

recommendations and diet plans to improve nutrient intake.

• In most patients with malnutrition the intake of protein, carbohydrates, water,

minerals and vitamins need to be gradually increased.

• Supplements of vitamins and minerals are often advised.

• Those with protein energy malnutrition may need to take protein bars or

supplements for correction of the deficiency.

• The Body Mass Index is regularly monitored to check for improvement or

responsiveness to dietary interventions.

• Occupational therapists and a team of physicians of different specialties may be

necessary for people with disability who cannot cook or shop for themselves or

those who have mental disorders, dementia or long term illnesses.

• Those who have difficulty in swallowing, chewing or eating may need to be given

very soft or food easy for eating.

2.11.2 Treatment of malnutrition at the hospital

The team of physicians and health care providers who manage malnutrition patients

includes a gastroenterologist who specializes in treating digestive conditions, a dietician,

a nutrition nurse, a psychologist and a social worker.



22

Nasogastric tube feeding and intravenous infusion or parenteral nutrition may be done in

the hospital for moderate to severely malnourished patients who are unable to take food

via the mouth.

2.11.3 Treatment of malnutrition for those who are unable to take food by mouth

Some patients are completely unable to take food by mouth. These patients may be

treated by feeding with artificial tubs that are inserted via the nose into the stomach. This

is called the nasogastric tube and special nutrient preparations in liquid form are given via

these tubes. Nasogastric tubes are designed for short-term use and may be used for up to

six weeks.

In some patients a tube may be surgically implanted directly into the stomach. It opens

outside over the abdomen. This is called a percutaneous endoscopic gastrostomy, or PEG,

tube. Nutrients in the form of liquids may be given via PEG tubes. This is useful in

patients with esophageal cancers or other pathologies that make feeding via the mouth

and esophagus difficult. These last for around two years and may be replaced thereafter.

Some individuals may need to be given nutrients in the form of injections via infusion

directly into the veins of the arms. This is known as parenteral nutrition. This can be done

at home under supervision but more often than not, hospital admission may be needed.

2.11.4 Treatment of malnutrition in pregnant women

Pregnant women require more calories and nutrients than non pregnant women as their

fetus grows. This requirement, however, does not translate into “eating for two” as this

may lead to excess calorie intake leading to maternal obesity but malnutrition alongside

as the vital nutrients may be lacking in diet. Iron, folic acid and other vitamins and

minerals need to be supplemented in women who are pregnant with or without

malnutrition as these are often required in higher amounts that normal diet can provide.



23

2.11.5 Treatment of malnutrition in children

During growth years the requirement of nutrients usually is high and such demands need

to be met adequately. Regular visits to the pediatrician for assessment of adequate growth

in height and weight is essential. Malnutrition causes more problems in children than any

other age group as they may lead to growth (both physical and mental) retardation and

susceptibility to repeated infections. Children with Protein energy malnutrition (PEM)

need to be identified. This includes children with Marasmus and Kwashiorkor. These

children require aggressive therapy.

Children with long term diseases need therapy for malnutrition. This includes additional

nutrients, vitamins and mineral supplements etc. The underlying disease also needs to be

treated adequately to prevent malnutrition. Children with severe malnutrition need

therapy in the hospital. This includes parenteral nutrition and slow introduction of

nutrients by mouth. Once their condition stabilises then they can gradually be introduced

to a normal diet (Online news Medical Health).

2.12 Prevention of malnutrition

Malnutrition is a preventable and treatable cause of childhood morbidity and mortality. In

Bangladesh, about 47.5% of children under 5 years of age are moderately to severely

undernourished (NIPORT, 2004).

Although inadequate food intake as a result of household food insecurity is one of the

important contributors to child malnutrition, the UNICEF conceptual framework also

recognizes disease and poor caring practices as equally important causes of malnutrition

[UNICEF, 1990].

Caregivers might not make the best use of available resources because of lack of

knowledge of optimal feeding behaviors and inappropriate cultural beliefs and practices

regarding feeding [Allen LH, Gillespie SR]



24

Growth faltering among children aged 6 to 12 months is a global phenomenon, and this

period is the window of opportunity to reverse malnutrition among children [Moore AC,

Akhter S, 2006].

Interventions that provide counseling to caregivers on the initiation and continuation of

appropriate and adequate complementary feeding early in life, along with improved

hygiene and caring practices may effectively begin malnutrition [Health Popul Nutr

2005].

The present study aims to address an important public health question: whether and to

what extent a nutrition education program, especially one designed for parents of infants

aged 6 to 9 months, can prevent malnutrition in children from various community

settings, and if so, whether the impact of the intervention is sustained after its

discontinuation. A healthy balanced diet is recommended for prevention of malnutrition.

There are four major food groups that include:

1. Bread, rice, potatoes, and other starchy foods. This forms the largest portion of

the diet and provides calories for energy and carbohydrates that are converted to

sugars which provide energy.

2. Milk and dairy foods – Vital sources of fats and simple sugars like lactose as well

as minerals like Calcium.

3. Fruit and vegetables – Vital sources of vitamins and minerals as well as fiber and

roughage for better digestive health.

4. Meat, poultry, fish, eggs, beans and other non-dairy sources of protein – These

form the building blocks of the body and help in numerous body and enzyme

functions (Online news Medical Health).



25

CHAPTER THREE

3.0 Research methodology

3.1 Introduction

The research consist of the following sections: research Materials and methods, research

Ethical consideration, Study area, research design, data gathering procedure Sampling

technique and data analysis.

Methodology illustrates the choices undertaken in the process of carrying out an inquiry.

Silverman (2005) defined methodology as, “choices we make about the cases to study,

methods of data gathering and other forms of data analysis, etc., in planning and

executing a research study.

3.2 Material & Methods

This study was conducted at Hamar Jajab IDPs in Mogadishu. Children Under five years

living in Hamar Jajab IDPs randomly was selected, each child for the study was

underwent different anthropometric measurement such as Weight, Height and mid-arm

circumference by Bangle test.

Mid Upper Arm Circumference (MUAC): Normal MUAC for a child between 1-5 years

of age is greater than 13.5 cm. If the MUAC is 12.5-13.5, the child has mild to moderate

malnutrition and if it is less than 12.5 cm it is suggestive of severe malnutrition. This is

useful for screening a large number of children but less useful in long term growth

monitoring. The techniques to measure mid arm circumference include accurate

measurement with a tape and a simple bangle test. Bangle test using plastic bangles of an

inner diameter of 3.7 cm (Red Bangle) and 4 cm (Yellow bangle) the bangle was passed

up the forearm and the upper arm to decide if the upper mid-arm circumference was

below or above 12.6 cm.



26

3.3 Ethical consideration

The study was followed by the regulations outlined in the University’s ethical approval

process which identifies ethics procedure policies and principles. This means that ethics

approval was sought for all questionnaires.

3.4 Study Area

Hamar Jajab district is a district in the southeastern Banadir region of Somalia. Border

line with South: Indian Ocean, East: Hamar weyne, North: Waaberi and West: Wadajir.

Also a sector of the national capital Mogadishu, it contains the Port of Mogadishu.

3.5 Study design

This study was cross sectional study, and used for questionnaire design, which is

commonly in public health research. This choice is based on the fact that the researcher

seeks to answer with “5 W and H” the research strategy of this study will be used for

qualitative and quantitative approach to accomplish the objectives of the study because it

is easy to determine its trustiness and accuracy of the objectivity of quantitative studies.

3.6 Methods of Data collection

The data obtained from the questionnaires

For Appropriate analytical techniques were used depending on the variables or the

characteristics being considered. Descriptive and inferential statistical techniques were

used for quantitative data including socio-economic and demographic information,

anthropometry, food intake to generate frequencies and percentages using statistical

package for social sciences (SPSS) Version 16.0.

3.7 Sampling Techniques

The sampling techniques was used in this study is a probability sampling procedure

particularly Simple random sample were used to select the sample.

This study was conducted through simple random sample. Population of 200 HH living in

Hamar Jajab IDPs was conducted Nutritional Status Survey. To get 50 Children from the



27

above HH, interval number four were used as to get chance for every Under five year old

child live this IDP and used systematically up to end.

3.8 Sample Size

Sample size required to carry out using the Assessment of nutritional status on children in

Somali. The sample size was driven from the probability of Simple Ransom sample

calculation as follows:

My study population was 200 Households. Selected from 50 through simple random, the

interval number was 4

The sample was (50) respondent out of the study population to obtain. In this study the

sample of the study was reached through the Simple random sample technique.

3.9 Data analysis and Interpretation method

Although data analysis has multiple approaches, in this study, Statistical Package for the

Social Sciences software (SPSS) was used for test of hypothesis and Graphics were

engaged for interpreting data collection by the questionnaire.



28

CHAPTER FOUR

4.0 Data analysis and interpretation

4.1 Introduction

This chapter presents the findings, analysis and interpretation of the study and it is mainly

highlight the Socio-demographic data, Dietary intake assess and adequacy, Breastfeeding

and complementary feeding pattern of the mother and Anthropometric index for children

then findings for the study to be presented, interpretation, also analysis the results of all

above variables from this study.

4.2 Socio-demographic Variables

The socio-demographic data which have been taken includes:

1) Gender for the children, 2) Age of child 3) Age of Mother 4) Educational

status of the Mother 5)Total Number of Household members 6)

occupational level of Household head7) Source of water of Household and 8)

family income per month.



29

Table 4.1 Gender of the children

Gender of child

Frequency Percent Cumulative Percent

Boys 32 64% 64

Girls 18 36% 100

Valid

Total 50 100% 100

Source: Primary data

Figure 4.1 Respondents by Gender of the children



30

Table 4.2 Age of children in year

Age of Children in Year


0 to 1 year 10 20% 20

1 to 2 Year 22 44% 64

3 to 4 Year 11 22% 86

4 to 5 Year 7 14% 100

Valid

Total 50 100% 100


Figure 4.2 Respondents by Age of the children in year



31

Table 4.3 Age of Mother/respondent

Age of mother


15 to 30 Year 37 74% 74

31 to 40 Year 10 20% 94

41 and Above 3 6% 100

Valid

Total 50 100% 100


Figure 4.3 Age of mother/ respondents



32

Table 4.4 Level of Education of Mother

Level of education of mother


No formal education 41 82% 82

Primary Education 7 14% 96

Secondary Education 2 4% 100

Valid

Total 50 100% 100

Source: primary data

Figure 4.4 Respondents by Educational level of the mother



33

Table 4.5 Total number of Household member in the House

Total number of HH member live in the House


1 to 4 21 42% 42

5 to 8 16 32% 74

9 to 13 8 16% 90

13 and above 4 8% 98

Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.5 Total HH members in the House



34

Table 4.6 Occupation of Household Head

Occupation Level of HH Head


Self Employee 10 20% 20

Unemployed looking for work 21 42% 62

Retired 4 8% 70

Worker 11 22% 92

Student 3 6% 98

Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.6 respondents by Occupation of the HH head



35

Table 4.7 Source of water of the Household

Source of Water of HH


Pipe Water 32 64% 64

Filtered Water 6 12% 76

Borehole 8 16% 92

Well 1 2% 94

Missing 3 6% 100

Valid

Total 50 100% 100


Figure 4.7 respondents by source of water of the HH



36

Table 4.8 Family incomes per month

Family incomes per month


$0-50 3 6% 6

$51-100 27 54% 60

$101-150 7 14% 74

$151-200 5 10% 84

$201-250 4 8% 92

$251-300 4 8% 100

Valid

Total 50 100% 100

Source: primary data

Figure 4.8 Family incomes per month



37

4.3 Usual Dietary intake and assess adequacy I summarized into:

1) Cereals grain and products 2) Legumes and legume products 3) Nuts and Seeds 4)

Vegetables and vegetable products 5) Fruits 6) Milk and Milk products 7) Meat Fish and

Eggs product and 8) Oils and Fats.

Table 4.9 Cereals grain and products

Cereals grain and products


Once a day 14 28% 28

Twice a day 31 62% 90

Three times a day 3 6% 96

Above 4 times a day 1 2% 98

Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.9 Cereal grains and products



38

Table 4.10 Legumes and legume products

Legumes and legume products


Once a day 8 16% 16




None 9 18% 100

Valid

Total 50 100% 100


Figure 4.10 Legumes and legume products



39

Table 4.11 Nuts and Seeds

Nuts and Seeds






None 13 26% 100

Valid

Total 50 100% 100


Figure 4.11 Nuts and Seeds



40

Table 4.12 Vegetables and vegetable products

Vegetable and vegetable products






None 5 10% 100

Valid

Total 50 100% 100


Figure 4.12 Vegetables and vegetable products



41

Table 4.13 Fruits

Fruits






None 14 28% 100

Valid

Total 50 100% 100


Figure 4.13 Fruits



42

Figure 4.14 Milk and Milk products

Table 4.14 Milk and Milk products

Milk and Milk products


Once a day 7 14% 14



None 4 8% 100

Valid

Total 50 100% 100




43

Figure 4.15 Meat Fish and Eggs product

Table 4.15 Meat Fish and Eggs product

Meat Fish and Eggs product


Once a day 9 18% 18



None 10 20% 98

99 1 2% 100

Valid

Total 50 100% 100




44

Table 4.16 Oils and Fats

Oils and Fats





Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.16 Oils and Fats



45

4.4 Breastfeeding and Complementary feeding pattern of the mothers.

In this Part I concentrated on the following variables

1) Time initiating breastfeeding 2) Food or drink given to infants before breast Milk flow

3) Period after birth the baby was given other food/fluid apart from breast milk

4) Duration of breastfeeding 5) Immunization status for children 6) Knowledge of Mother

for Nutritional status on her children.

Figure 4.17 Time initiating breastfeeding

Table 4.17 Time initiating breastfeeding

Time initiating Breastfeeding


30 or Less 38 76.0 76.0

Between 30 and 1 hr 7 14.0 90.0

More than 1 hr 4 8.0 98.0

Missing 1 2.0 100.0

Valid

Total 50 100.0




46

Table 4.18 Food or drink given to infants before breast Milk flow

Food or drink given infant Before breast milk Flow


Water alone 31 62% 62

Sugar water 5 10% 72

Tea or Herbal water 2 4% 76

Infant formula 8 16% 92

Other milk 2 4% 96

None 1 2% 98

Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.18 Food or drink given to infants before breast Milk flow



47

Table 4.19 Period after birth the baby was given other food/fluid apart from breast milk

Period after birth the baby was given other food/fluid apart from breast milk


1-30 days 17 34% 34

1-2 month 6 12% 46

3-4 month 14 28% 74

5-6 month 11 22% 96

Above 6 months 2 4% 100

Valid

Total 50 100% 100


Figure 4.19 Periods after birth the baby was given other food/fluid apart from breast milk



48

Table 4.20 Duration of breastfeeding

Duration of Breastfeeding of the mother


0-6 months 13 26% 26

6-9 months 16 32% 58

9-11 months 13 26% 84

11-14 months 4 8% 92

14-24 months 4 8% 100

Valid

Total 50 100% 100


Figure 4.20 Duration of breastfeeding



49

Table 4.21 Immunization status for children

Immunization status for children


Complete immunized 4 8% 8

Partially immunized 44 88% 96

Never 2 4% 100

Valid

Total 50 100% 100


Figure 4.21 Immunization statuses for children



50

Table 4.22 Knowledge of Mother for Nutritional status on her children

Knowledge of mother for nutritional status on her child


Well Understand 18 36% 36

Not Understand 31 62% 98

Missing 1 2% 100

Valid

Total 50 100% 100


Figure 4.22 Knowledge of Mother for Nutritional status on her children



51

4.5 Anthropometric index for children.

this is the back bone of my study, because of the most important tool that can be identify

the Child weather Malnourished or not is the Anthropometric measurement, as to apply

those measurement I pick up the following three main important tools: 1) Age of a child

in month 2) Weight of child in Kg 3) Height of child in cm and finally Mid Upper Arm

Circumference (MUAC).

Table 4.23 Age of a child in month

Age of a child in month


6-11.99 7 14% 14

12-23.99 19 38% 52

24-35.99 7 14% 66

36-47.99 10 20% 86

48-59.99 7 14% 100

Valid

Total 50 100% 100


Table 4.24 Weight of child in Kg

Weight of child in Kg


3.5-6.6 1 2% 2

6.7-9.8 20 40% 42

9.9-12.0 13 26% 68

12.1-15.2 11 22% 90

15.3-18.4 4 8% 98

>18.5 1 2% 100

Valid

Total 50 100% 100




52

Table 4.25 Weight of child in Kg

Weight of child in Kg


3.5-6.6 1 2% 2

6.7-9.8 20 40% 42

9.9-12.0 13 26% 68

12.1-15.2 11 22% 90

15.3-18.4 4 8% 98

>18.5 1 2% 100

Valid

Total 50 100% 100


Table 4.26 MUAC of child in cm

MUAC of child in cm


<11.5 2 4% 4

11.6-12.4 7 14% 18

>12.4 41 82% 100

Valid

Total 50 100 100




53

Overall results from Anthropometric Measurements shows as follows chart

Figure 4.23 Results from the research



54

CHAPTER FIVE

5.0 Discussion, Conclusion and recommendations

5.1 Discussion

Malnutrition in early childhood is one of a serious dominated public health problem in

the developing countries.

There are an estimated 1.1 million internally displaced persons (IDPs) across Somalia of

which 635,000 live in the assessed (13) major settlements; ~60% of the assessed IDPs are

concentrated in Banadir/ Mogadishu, the Rates of acute malnutrition improved slightly or

remained stable since Gu 2013 – exception being Qardho IDPs and Berbera IDPs

(FSNAU 2013-14).

In my research shows that children in this research 82% of them had Normal 14% had

moderately acute malnutrition, 4% had Severely acute malnutrition see figure (4.23).

FSNAU(2013-2014) found that Global Acute Malnutrition (GAM, 12.0%) and median

Severe Acute Malnutrition (SAM, 1.9%) rates are lower, compared to six months ago

(14.9% and 2.6%, respectively) as well as one year ago (14.2% and 2.6%, respectively)

The finding of this study support FSNAU’s finding where Malnutrition rate was found to

be predominated form, among the 50 children included in the study 64% were males and

36% were females (table, 4.1).

This finding agrees with many other studies carried out in Somalia where it was found

that more males suffer from malnourished than females as their numbers in the

community are very.

In this study illiteracy was found to be high amongst the parents particularly mothers.

The result showed that the majority of the mothers respondents 82% were illiterate while

14% were Basic and 4% were Secondary see table (4.4).

Maternal education has been stressed as factor of great importance in etiology of

malnutrition. The same studied indicates that the prevalence of malnutrition varies



55

according to education of mother being significantly lower among children of more

educated mothers (secondary or higher) than among children of mothers with no or

primary education this is probably because more education provides the knowledge of the

rules of hygiene, feeding and weaning practices and the interpretation of symptoms and

enhances timely action childhood illness (Kirkwood, 1991; Diame, 1990). The majority

of the mother’s respondents according to their occupation 42% were Unemployed/house

wife while 22% were worker, 20% were self employee, 8% were Retired6% were student

and 2% were not responding see (table 4.6).

Family income is one of the most important determinants of the standard of the living,

economic and social welfare. The study showed that the 74% were low income less than

150 dollar per month, while 26% were moderate income 150-300 dollar so there was

significant difference between the forms of Malnutrition and family income.

Once of the main factors determining the nutritional status is food intake which in turn

depends on the family purchasing power. Probably no other single factor has such a

major effect on all components of nutritional status as income.

The relative importance of income, compared to other factors in etiology of malnutrition

seems to vary from one country to another.

In Nigeria Morly (1969) found that insufficient money was the biggest single factor in the

etiology of malnutrition, he found that there is a correlation between low income and

growth retardation, on the other hand Behar (1966) found that poor diet given to children

in central America is not primarily economic or the result of limited availability of food

but it is due to ignorance of the child nutritional needs.

Many workers have emphasized the family size as an etiological factor in the etiology of

Malnutrition. Raw (1992) in India found that when family size reached five, the

proportion of severely malnourished children increased.



56

In this study showed that the majority of the respondents according to the family size

42% were having 1-4 persons 32% were having 5-8 persons 16% were having 9-13

persons 2% were missing while 8% were more than 13 persons (table 4.5).

The majority of mother’s respondents according to the Duration of breastfeeding 42%

were breastfed their babies while 58% partially breastfed their babies. Bay waning is

meat complete stoppage of breast feeding culturally and according to Holly Koran most

of people used to prolong breastfeeding up to the second year. The study display the

weaning practice of mothers conducted where most of them 26% were starting weaning

to their children between (9-11), 8% were between (11-14), 8% were between (14-24)

while 32% were between (6-9), and 26% weaned less than 6 months, see (figure4.20).

The vaccination completed course is protect the diseases, the most of the mother’s

conducted them 8% were children completed their course of the immunization

/vaccination while 88%were partially Immunized, they was taking to vaccine because

they less than 9 months,4% were not updating to vaccination they were never taking to

vaccine. See figure (4.21).

Knowledge of mother in practice of nutritional status on her child is very important only

about 36% of mother’s have well understand , 62% were not understand while 2% not

responded.



57

5.2 Conclusion

Somalia is a country with unacceptably high rates of acute malnutrition. One in nearly

eight children under 5 suffers from acute malnutrition at the time of the assessments. The

situation among IDPs is worse (about one in six).

51,000 children under 5 are suffering from severe acute malnutrition and are at higher

risk of death and disease, a slightly higher proportion (25 %) in Deyr 2013/4 compared to

20 % in Gu 2013 or 21% in Deyr 2012/13 (FSNAU 2013-14). Currently 203,000

children <5 yrs are estimated to be acutely malnourished (approximately the same

number as in Gu 2013). Sixty eight percent of these children are in South-central Somalia

(FSNAU 2013-14).

All types of malnutrition exist; Moderate acute malnutrition and sever acute malnutrition

has been n found. The study was showed a general tendency for early weaning. There is

no supplementary diet or special cooking for infant and young children. Income of the

most of the IDPs were found to be at low level and further reduced by rising market

prices. Infection comes as the main causes of malnutrition in many cases. Most of the

children admitted MCH were have diarrhea. IDPs from which mother’s came generally

lacking facilities for piped water supplies and suitable latrines. Female education which is

necessary for the assimilation of nutrition education stands at low percentage and in most

cases is the confirmed to illiteracy level. Improvement in nutrition cannot be achieved as

an isolated strategy it will depend on an all round socio-economic uplift of the

population. This will required the co-ordinate effort of all disciplines including

agriculture, education, community development, economic and health services.



58

5.3 Recommendation

• Mother usually expert in breast feeding, health authorities especially ministry of

health have to continue this practice, and to prolong its duration as long as

possible.

• Mass immunization program to immunize all children against preventable

diseases.

• Program control malaria and diarrheal diseases.

• To give health education at all levels including school, University, health services

and community level.

• Provide training courses in health and nutrition education targeting to: Para-

medical staff and auxiliaries and the women welfare worker of the social

development department.

• Use in Growth charts for regular weighing of children at all health services

because it helps to detect early malnutrition as well as getting the educational

messages to the mothers.



59

References

1. Allen LH, Gillespie SR. What works?: A review of the efficacy and effectiveness

of nutrition intervention. ACC/SCN Nutrition Policy Paper 2001;19:27

2. American Academy of Pediatrics, Work group on Breastfeeding. 1997.

Breastfeeding and the use of human milk (Policy statement no. Rep929)

3. FSNAU 2013-14 Post Deyr Seasonal Food Security and Nutrition Assessment in

Somalia)

4. Gartner Lm, Newton ER. 1998. Breastfeeding: Role of the obstetrician. ACOG

clinical Review 3:1-15

5. Gillespie S. Nutrition and poverty. Papers from the ACC/SCN 24th Session

Symposium Kathmandu March 1997, Geneva, ACC/ SCN Symposium Report.

Nutrition Policy Paper # 16, Nov 1997. Geneva: United Nations, 1997.

6. http://www.news-medical.net/health/Treatment-of-malnutrition.aspx and

www.savethechildren.org/.../Acute-Malnutrition-Summary-Sheet.pdf

7. Laditan, A.A., 1983. Nutrition and physical growth in children Nigeria. J. Nut.

Sci., 4: 5-10.

8. Lawrence RA.1999. Breastfeeding: a guide for medical Profession (5th ed.)

9. National Institute of Population Research and Training (NIPORT). Bangladesh

Demographic Health Survey (BDHS). Dhaka: NIPORT, 2004].

10. Nutrition guidelines L016NUTG01E MEDECINS SANS FRONTIERS (MSF),

May 2006 2nd ed.

11. Pages 30-33 FAO. 2004. International Year of Rice fact sheets (available at

www.fao.org/rice2004/en/ factsheets.htm). http://www.news-

medical.net/health/Symptoms-of-malnutrition.aspx



60

12. Somali guidelines for Management of Acute malnutrition United Nations

Children’s Fund (UNICEF, 2010)

13. The United Nations Children's Fund (UNICEF) presents this report on

malnutrition and its impact on children and families. 1998

14. UNICEF The state of the World’s children. Oxford University Press, Oxford

1998.

15. UNICEF. Strategy for improved nutrition of children and women in developing

countries. A UNICEF Policy Review. New York: UNICEF, 1990

16. United Nations System Standing Committee on Nutrition and the United Nations

Children’s Fund, 2007.

http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/

17. WHO et. Nutrition Essentials: A Guide for Health Managers, 1999 Robert

Mwadime (AED/LINKAGES), Training Materials from RQHCC 5-day ENA

course for Planners, Makerere University, Uganda

18. WHO. Physical Status: The Use and Interpretation of Anthropometry – Report of

a WHO Expert Committee. Technical Report Series 854. Geneva, World Health

Organization, 1995. http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf

19. World bank, Nutritional report, 2006

20. World Health Organization and United Nations Children’s Fund, 2009.

http://www.who.int/nutrition/publications/severemalnutrition/9789241598163/en/

index.html

21. World Health Organization, Nutritional report, 2007



61

Appendix A: Questionnaire on Assessment of Nutritional status of under five years old

Children in Hamar Jajab IDPs

Part I: Socio demographic characteristics:

Gender of child

1. Boy 2. Girl

Age of child

1. 0 -1 2. 1-2 3. 3-4 4. 4-5

Mother age

1. 15-30 2. 31-40 3. 41 above

Mother Educational status

1. No formal education 2. Primary education 3. Secondary

education 4. College 5. University

Total number of Household member

1. 1-4 2. 5-8 3. 9-13 4. 13 above

Primary occupation of household head



62

1. Self employee 2.Unemployed – looking work 3.Retired

4. Worker 5. Student 6.Other: _________

Primary Source of water of household

1. Pipe water 2. Filtered water 3. Borehole 4. Well 5. Other:_______

Family income per month in (USD)

1. 0-50 2. 51-100 3. 101-150 4. 151-200 5. 201-250 6.251-300

7. 301-350 8. 351-400 9. 401-45 10. 451-500 11. 501 above

Part II: Usual Dietary intake and assess adequacy

Intake of mother within last 24 hours

Cereals, grain and products

1. Once a day 2. Twice a day 3. Three times a day 4.Above 4 times a day

Legumes and legume products

1. Once a day 2. Twice a day 3. Three times a day 4.Above 4 times a day 5.

None

Nuts and seeds



63

1. Once a day 2. Twice a day 3. Three times a day 4. Above 4 times a day 5.

None

Vegetable and vegetable products

1. Once a day 2.Twice a day 3. Three times a day 4. Above 4 times a day 5.

None

Fruits

1. Once a day 2. Twice a day 3. Three times a day 4.Above 4 times a day 5.

None

Milk, milk products and beverages

1. Once a day 2.Twice a day 3. Three times a day 4.Above 4 times a day 5.

None

Meat, fish and eggs products

1. Once a day 2. Twice a day 3. Three times a day 4. Above 4 times a day

5. None

Meals


Oils and fats


5. None



64

Part III: Breastfeeding and Complementary feeding pattern of the mothers

Time of initiating breastfeeding

1. 30 or less 2. Between 30 and 1 hr 3. More than 1 hr

Food or drink given to infants before breastmilk flow

1. Water alone 2. Sugar water 3. Tea or herbal water 4. Infant formula

5. Other milk 6. Other 7. None

Period after birth the baby was given other food/fluid apart from breast milk

1. 1-30 days 2. 1-2 month 3. 3-4 month 4. 5-6 month 5. Above 6 months

Duration of breastfeeding of the mothers

1. 0-6 month 2. 6-9 month 3. 9-11month 4. 11-14 month 5. 14-24 month

Immunization status for children

1. Complete immunized 2. Partially immunized 3. Never

Knowledge of mother for nutritional status on her child

1. Well understand 2. Not understand



65

Part v : Anthropometric index for children

Age in month _____ Weight in kg______ Height in cm______

MUAC in cm _____

Appendix B: Timelines

Phases November, 2014 December,

2014

January, 2015 February,

2015

Weeks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Topic

Selection

X

Research

proposal

X X X

Literature

Review

X X X

Developed

Questionnaire

X X

Pilot

Survey

X

Revised

Questionnaire

X

Data

Collection

X



66

Data Entry

and analysis

X

Data Reading

and Review

X

Final

Draft

X X

Appendix C: Events

Date Activities

5 November 2014 Approved research topic

20 Nov, 2014 Submitted research Proposal

26 Nov,2014 Approved Research Proposal

30 Nov, 2014 Submitted Literature review or Chapter two

25 Dec,2014 Approved Literature review

30 Dec, 2014 Final Examination

1 Jan,2015 Rejected Research Methodology

6 Jan, 2015 Approved research Methodology

29 Jan, 2015 Approved Research Questionnaire

30 Jan - 8 Feb, 2015 Survey on data collection



67

21 Feb,2015 Submitted draft of thesis to the Supervisor

26 Feb, 2015 Submitted Final to the Imam University

15 June, 2015 Defended thesis book

Appendix D: Budget

Expenses Cost in (Dollars)

Travel cost (rent) $140.00

Phone and Internet charge $120.00

Refreshments $60.00

Stationary $70.00

Computer Software/printing/ ink cartridge $300.00

Miscellaneous $150.00

Total $840.00