Effect of Maternal Socio-demographic Factors and Child Feeding Practice on Wasting Among Under Five Years Children in Slum Area of Rupandehi District in Nepal

Introduction: Childhood wasting although well studied elsewhere, it has not been well understood about in slum area of Nepal. This study aimed to assess effect of socio-demographic factors and child feeding practice in the determination of wasting among the children under five years of age in slum area of Nepal. Methods: A community based cross-sectional study was performed among 150 children under five years of age from the slum area of Nepal between 1st January and 28th February 2013 using simple random sampling techniques. Multivariate analyses were performed to determine factors associated with wasting controlling the potential confounders. Results: In a total of 150 under five years children, the prevalence of wasting was 56 (37.33%). The current study demonstrated that children of mothers from dalit Adjusted Odds Ratio (OR) 11.5; 95% CI: 03.1 – 41.3), aadibasi/janajati (AOR 4.6; 95% CI: 1.2 – 17.0), illiterate mothers (AOR 3.6; 95% CI: 1.1 – 13.6), laborer mothers (AOR 2.1; 95% CI: 1.1-9.4), child age group 25-36 months (AOR 2.8; 95% CI: 1.5-5.3), multiple child birth order (AOR 10.0; 95% CI: 2.5-25.0), children who were not fed colostrums (AOR 15.0; 95% CI: 1.25-10.0) were more likely to develop wasting compared to their counterparts. Conclusions: As incremental childhood wasting is associated with maternal socio-demographic factors and child feeding practice, health promotion strategies should focus maternal sociodemographic factors, age of children and early initiation of breast feeding for the improved child nutrition in slum area of Nepal. _______________________________________________________________________________________


INTRODUCTION
Malnutrition is the major cause of child morbidity and mortality under the age of five years in the developing countries. 1,2It is responsible for 60% of the 10.9 million deaths of children under the age of five years and majority of deaths are due to inappropriate feeding practices. 3Prevalence of wasting in Nepal among under five years of age is 10% which is just 5% lower compared with Nepal Demographic and Health Survey (NDHS) 1996. 4fects of malnutrition in children under the age of five years are numerous: lower resistance to infection, poor mental and cognitive achievement and increased morbidity and mortality. 5,6[9] The current study aimed to assess effects of sociodemographic factors and child feeding practices in the determination of wasting among the children under five years of age.

METHODS
A community based cross-sectional study was conducted from 1 st January to 28 th February, 2013 in the urban slum areas of Butwal Municipality, Rupandehi, Nepal to assess the nutritional status of children under 5 years of age.
The research proposal was approved by the Ethics Committee for Health Research from Sanjeevani College of Medical Sciences, Rupandehi, Nepal.Mothers provided written consent for themselves and their children.Personal identifiers were removed prior to the data analysis.
Mothers with children of six months to five years of age in the selected households were considered as respondents of this study.For each family within the household, a mother and child pair (youngest child) was taken into consideration when there was more than one child.If a child of six months to five years of age was not found, a subsequent household was recruited until the eligible respondents' requirement was met.Children below six months and above five years of age were excluded from the study.
The sample size of present study was 150 including 74 male and 76 female children which were calculated by assuming the National Prevalence of Wasting (NDHS 2011) as 11% at 95% confidence interval.Households were selected using simple random sampling technique.
Data were collected by face-to-face interviews and measurement of the study subject using a structured questionnaire adapted from the Nepal Demographic and Health Survey 2011. 10 The nutritional status was assessed by using the anthropometric measurements; height and weight by trained field workers.Height of the child was measured in centimeter (cm) using a measuring tape.The child was asked to stand without footwear with the feet parallel, and height of those children below one year was measured in recumbent length by keeping the knee extended, foot plantar flexed and forehead touching the wall.Weight of child was taken in kilogram (kg) under light clothing by using a portable weighing machine.Children who were not able to stand were weighed together with their mother and the mother's weight was subtracted to calculate the exact weight of child.
The nutritional status was assessed by calculating the Height for age (Wasted) for each child and was compared with the CDC 2000 value.The z-scores between ±2 SD was considered as the cut-off values and was considered as normal.The data was collected and compiled by using Microsoft Office Excel 2010.Statistical Package for Social Sciences (SPSS 20.0) was employed to analyze the frequency distribution of socio-demographic parameters, Chi-square value was observed between different variables and P<0.05 was considered as statistically significant.Multivariate analysis was used to find the association between the socio-demographic parameters, child feeding practices and nutritional status.

RESULTS
The maternal socio-demographic factors associated with wasting of children have been demonstrated in Table 1.In a total of 150 mother-child pairs, majority of them 105 (70%) were above 20 years of age, dalit and aadibasi/janajati 100 (66.7%), nuclear family 104 (69.0%), educational level secondary and above 40 (60.0%),housewives 114 (76.0%) and child birth order primi 75 (50%).Bi-variate analyses showed maternal caste/ethnicity, educational level, occupation and child birth order were significantly associated with wasting of children.Table 2 presents the child characteristics and feeding practice associated with wasting.In a total of 150 children of more than half 87 (58%) were of 6-24 months of age group, slightly more than half 76 (50.7%) were female, majority 128 (85.3%) colostrums fed, slightly more than half 78 (52.0%) had taken complementary feeding at six months, proper waste disposal 123 (82.0%).Age of children and colostrums feeding in bi-variate analyses were significantly associated with wasting of children.
The final results of the multiple logistic regression analysis are shown in Table 3.A numb er of factors related to childhood wasting, such as caste/ethnicity, education, occupation, birth order, age of children, colostrums feeding were significantly associated with childhood wasting.

DISCUSSION
The prevalence of undernutrition was found high in the district in the present study.Among the 150 under five children, slightly more than one third 56 (37.33%) were suffering from wasting.This finding of our study is consistent with an Ethiopian and Pakistani study. 11,12][15][16] Similarly, a study from eastern Nepal also reported only 5.2 percent of wasting among under five years children. 17The magnitude of wasting of our study when compared with recent nationally representative data obtained from Nepal demographic and health survey (NDHS) 2016 was more than 27 percent. 4his might be because the family residing in an urban slums are dependent on wage income, the instability of employment, and the high residential densities contribute to the onset of disease and malnutrition. 18urthermore, faulty infant feeding practices, impaired utilization of nutrients due to infections and parasites, inadequate food and health security, poor environmental conditions and lack of proper child care practices might be the potential factors leading to incremental childhood wasting in urban slums. 19This call for direct, more focused and integrated health promotion strategies to improve nutritional status of children in urban slums of Nepal.
Our study identified a number of maternal factors associated to childhood wasting, such as caste/ethnicity, education, occupation and the birth order.A previous study conducted in South Africa also revealed that wasting does not manifest gradients related to socioeconomic position. 20However; many studies reported the association between maternal socio-demographic characteristics with childhood malnutrition.For example, Hein, et al, in Vietnam reported the significant relation of the mothers education and occupation with childhood malnutrition 21 while Sapkota, et.al, reported maternal age and ethnicity were significantly associated with childhood malnutrition. 17Nutrition intervention should therefore, encompass maternal socio-demographic factors for the betterment of nutrition status of children below the age of five years in urban slums of Nepal.
Another point of interest of our study is that children's age and whether or not child is colostrums fed, were important predictors of childhood wasting.Opponent to our finding, in a Kenyan study revealed that there was no significant association between breastfeeding practices and wasting. 15However, this finding of the current study has been supported by several studies. 11,13,22,23ere are some important strengths of this research.First, to the best of researchers' knowledge, it might be first study being performed in urban slums of Nepal to assess the effect of socio-demographic factors and child feeding practice associated with childhood wasting.Second, this has explored an important area of future research; might be useful for the health administrators and planners to design evidence based health promotion strategies.However, there are some potential limitations of this study.First, this study is based on mothers' self-report of colostrums feeding of all under five years children may lead to potential recall bias. 24Second, information like parasitic infection, HIV status, mother's, the child's birth weight and the daily caloric intake, household wealth index and household food insecurity were not assessed in the study.Third, the small sample size itself does not allow us to generalize the study findings.

CONCLUSIONS
Prevalence of wasting among under five years children was higher in the urban slums.Maternal characteristics associated with incremental childhood wasting problems were: ethnicity, mother education, occupation while childhood factors like age of children, birth order and colostrums feeding were important predictors of wasting.Design and implementation of health promotion strategies should focus maternal socio-demographic factors, age of children and early initiation of breast feeding for a improved child nutrition in slum area of Nepal.Further, interventional study is recommended in this regards.

Table 2 . Distribution of child characteristics and feeding practices associated with acute malnutrition.
Gautam et al.Effect of Maternal Socio-demographic Factors and Child Feeding Practice on Wasting Among Under Five Years Children in ...