Sally Fitzgibbons Foundation

Beginning the Academic Essay

DETERMINANTS OF UNDER NUTRITION AMONG CHILDREN AGED 6 TO 59 MONTHS IN GICUMBI DISTRICT NORTHERN PROVINCE, RWANDA.

KYAMUSOKE BORAUZIMA KyameMPH/50698/2016
A Research Proposal submitted in partial fulfillment of the Award Degree in Master in Public Health (Epidemiology and Disease Control Option)
September 2017
DECLARATIONThis research study is my original work and has not been presented to any other Institution. No part of this research should be reproduced without the authors’ consent or that of the Mount Kenya University.

Student’s Name: KYAMUSOKE BORAUZIMA KyameRegistration Number: MPH/50698/2016
Sign ____________________Date _____________
Declaration by the supervisor(s)
This research has been submitted with our approval as The Mount Kenya University Supervisor, and Co supervisor.

Name: RUTAYISIRE ErigeneSign ____________________Date _____________
Name: MUKARWEGO BeathaSign ____________________Date _____________
DEDICATIONI dedicate this work to my wife IDA WABONGYA Rachel, to my daughter and sons; Rany SAKINA Borauzima, Ray MUPENDA Borauzima, Raynald Kyamusoke Borauzima and to the members of my family.

May God bless you.ACKNOWLEDGEMENTGlory be to God for giving me the strength and courage to pursue this program under very trying moment.
I highlight recognized the various contributions extended to me during the preparation of this research thesis.

I express my gratitude to the administration of Mount Kenya University Rwanda (MKUR), in particular the faculty of health sciences and all lectures in the Public Health Department for the assistant they provided to me throughout my study.

I am most grateful to Mrs. MUKARWEGO Beatha; despite his tight schedule, she guided me through this entire work offering academic guidance and useful suggestions when I most needed them.

Special thanks to Dr. RUTAYISIRE Erigene for assistance and encouragement during the hard time of my work.

I would like to express my thanks to everyone who assisted me during my research.

ABSTRACTMalnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Approximately 156 million of the world’s children under the age of 5 are malnutrition, with an estimated 80% of these children concentrated in only 14 countries in 2017. Under nutrition jeopardizes child survival and development by contributing to child mortality, morbidity, and disability, including impaired or non-optimal physical growth and cognitive development. Poverty remains the major contributor to this ill. The general objective of this study is to determine the determinants of under nutrition among children aged 6 to 59 months in Gicumbi District. And the specific objectives will determine the prevalence of under nutrition, will also identify socio-demographic factors associated with malnutrition, and determine factors associated with under nutrition among children aged 6 to 59 months. A cross-sectional study will be conducted; the study will use a questionnaire as a tool for collecting data. A stratified sampling technique will be used to obtain samples. The target population will be 69369 children from 21 sectors of Gicumbi district where the sample size will be 362 participants. Data will be organized and analyzed quantitatively by using the Statistical Package for Social Sciences (SPSS) for analysis using statistics to generate frequency, tables and graphics. The Chi-square (?2) test will be conducted to test the association between the determinants and nutrition status. Authorization for data collection will be requested from Mount Kenya University Rwanda and an authorization to conduct the study will also be requested from local authorities of administration of Gicumbi District. The research ensured that participants completely understood the purpose and methods that will be used in the study. The participants will also make to understand that they had the right to withdraw from the study any time. A consent form will be availed to the participants to sign as to whether they would participate in the study or not. The assurance that all the information provided by the respondents would be treated with utmost confidentiality will also granted. The finding of this study will assist the community of Gicumbi District with developing improved nutritional health status of children under five years.

TABLE OF CONTENTS TOC o “1-3” h z u DECLARATION PAGEREF _Toc523824748 h iDEDICATION PAGEREF _Toc523824749 h iiACKNOWLEDGEMENT PAGEREF _Toc523824750 h iiiABSTRACT PAGEREF _Toc523824751 h ivTABLE OF CONTENTS PAGEREF _Toc523824752 h vLIST OF FIGURE PAGEREF _Toc523824753 h viiLIST OF TABLE PAGEREF _Toc523824754 h viiiLIST OF ACRONYMS AND ABREVIATIONS PAGEREF _Toc523824755 h ixDEFINITION OF KEY TERMS PAGEREF _Toc523824756 h xiCHAPITER ONE: INTRODUCTION PAGEREF _Toc523824757 h 11.0Introduction PAGEREF _Toc523824758 h 11.1 Background of the Study PAGEREF _Toc523824759 h 11.2 Problem Statement PAGEREF _Toc523824760 h 41.3 Objectives of study PAGEREF _Toc523824761 h 41.3.1 General objective PAGEREF _Toc523824762 h 41.3.2 Specific objectives PAGEREF _Toc523824763 h 51.4 Research questions PAGEREF _Toc523824764 h 51.5 Significance of the Study PAGEREF _Toc523824765 h 51.6 Limitation of the Study PAGEREF _Toc523824766 h 61.7 Scope of the Study PAGEREF _Toc523824767 h 61.8 Organization of the Study PAGEREF _Toc523824768 h 7CHAPITER TWO: REVIEW OF RELATED LITERATURE PAGEREF _Toc523824769 h 82.0Introduction PAGEREF _Toc523824770 h 82.1Theoretical Review PAGEREF _Toc523824771 h 82.1.1 Critical Period of Child Development PAGEREF _Toc523824772 h 102.1.2 Assessment of nutritional status PAGEREF _Toc523824773 h 122.1.3 Anthropometry PAGEREF _Toc523824774 h 122.1.4 Use of biochemical and clinical indicators PAGEREF _Toc523824775 h 132.1.5 Treatment and management of under nutrition PAGEREF _Toc523824776 h 132.1.6 Consequences of under nutrition PAGEREF _Toc523824777 h 132.2 Empirical Literature PAGEREF _Toc523824778 h 152.2The prevalence of malnutrition PAGEREF _Toc523824779 h 202.4. Critical review and research gap identification PAGEREF _Toc523824780 h 352.6Conceptual framework PAGEREF _Toc523824781 h 40CHAPITER THREE: RESEARCH METHODOLOGY PAGEREF _Toc523824782 h 413.1Introduction PAGEREF _Toc523824783 h 413.2Research design PAGEREF _Toc523824784 h 413.4 Target population PAGEREF _Toc523824785 h 413.3 Sample Design PAGEREF _Toc523824786 h 423.3.1 Sample size PAGEREF _Toc523824787 h 423.3.2 Sampling techniques PAGEREF _Toc523824788 h 443.4 Data Collection Methods PAGEREF _Toc523824789 h 443.4.1 Data Collection Instruments PAGEREF _Toc523824790 h 443.4.2 Administration of Data Collection Instruments PAGEREF _Toc523824791 h 443.4.3 Reliability and Validity PAGEREF _Toc523824792 h 453.5 Data analysis Procedure PAGEREF _Toc523824793 h 463.6. Ethical Consideration PAGEREF _Toc523824794 h 46REFERENCES PAGEREF _Toc523824795 h 47APPENDIX I: PAGEREF _Toc523824796 h 51CONSENT FORM PAGEREF _Toc523824797 h 51
LIST OF FIGURE TOC h z c “Figure” Figure 1 show that manipulating the stated independent variables would have an effect on children nutrition. PAGEREF _Toc534486530 h 40

LIST OF TABLE TOC h z c “Table 3.” Table 3. 1: Strata sample sizes PAGEREF _Toc523824724 h 43

LIST OF ACRONYMS AND ABREVIATIONSARI Acute Respiratory InfectionsARVAntiretroviral drugsBASICSBasic Support for Institutionalizing Child SurvivalBMIBody Mass IndexCHWCommunity Health WorkersCIAFComposite Index of Anthropometric FailureCOHACost of Hunger in AfricaCREDCentre for Research on Epidemiology of DisastersDrDoctorFAOFood and Agriculture OrganizationGDPGross Domestic ProductionGMPGrowth Monitoring and PromotionHAZHeight for Age Z-scoreHANCIHunger and Nutrition Commitment IndexHIVHuman Immune VirusIFAD International Fund for Agricultural DevelopmentIFPRIInternational Food Policy Research InstituteIQIntelligence QuotientIYCFInfant and Young Child NutritionMAM Moderate Acute MalnutritionMDGMillennium Development GoalMPHMaster of Public HealthMr.MisterMUACMid Upper Arm CircumferenceNISRNational Institute of Statistics of RwandaRHHSRwanda Demographic Health SurveyRWF Rwanda FrancSAM Severe Acute MalnutritionSDStandard DeviationsSSARSub-Saharan Africa regionSPSSStatistical Package for Social Sciences (Software Package)SUN Scaling up NutritionUNFPAUnited Nations Fund for PopulationUNICEFUnited Nations Children’s FundUSAUnited States of AmericaUSAIDUnited States Agency for international for DevelopmentUSD/US$United States DollarWAZWeight for Age Z-scoreWFPWorld Food ProgrammeWHZWeight for Height Z-scoreWBWorld BankWHOWorld Health Organization
DEFINITION OF KEY TERMSThe Determinant is a factor or cause that makes something happen or leads directly to a decision.

Under nutrition a condition in which the body does not have enough of the right kind of food to meet its energy, macronutrient and micronutrient requirement. Under nutrition denotes insufficient intake of energy and nutrients to meet an individual’s needs to maintain good health.
Nutrition is the intake of food, considered in relation to the body’s dietary needs.
The Child is a human being between the stages of birth and puberty.This study focused on children aged 6 to 59 months, that is to say children aged less than 5 years.

CHAPITER ONE: INTRODUCTIONIntroductionThis chapter includes eight sections, namely: background of the study, problem statement, and objectives of the study, research questions, significance of study, limitations of the study, the scope of the study, and organization of the study.

1.1 Background of the StudyAdequate nutrition is essential for children’s health and development. Globally, it is estimated that under nutrition is responsible, directly or indirectly, for at least 35% of deaths in children less than five years of age. Under nutrition is also a major cause of disability preventing children who survive from reaching their full development potential. Estimated 32%, or 186 million, children below five years of age in developing countries are stunted and about 10%, or 55 million, are wasted. Unless massive improvements in child nutrition are made, it will be difficult to achieve Millennium Development Goals 1: Eradicate extreme poverty and hunger and 4: Reduce child mortality by 2015 ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “WHO”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Conclusions of a consensus meeting held 6u20138 November 2007 in Washington, DC, USA”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2008” }, “title” : “Indicators for assessing infant and young child feeding practices”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=1ad627a8-b82e-43fb-b44e-225157f2d002” } , “mendeley” : { “formattedCitation” : “(WHO, 2008)”, “plainTextFormattedCitation” : “(WHO, 2008)”, “previouslyFormattedCitation” : “(WHO, 2008)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(WHO, 2008).

Globally 161 million of children aged 6 to 59 months were estimated to undernourish in 2013. The global trend in stunting prevalence and numbers affected is decreased .Between 2000 and 2013 stunting prevalence declined from 33% to 25 % and number declined from 199 million to 161 million. In 2013 about half of all undernourished children lived in Asia and over one third in Africa. UNICEF, WHO, World Bank global and regional child malnutrition estimates from 1990 to 2017 reveal that we are still far from a world without malnutrition. The joint estimates, published in May 2017, cover indicators of stunting, wasting, severe wasting and overweight among children under five, and reveal insufficient progress to reach the World Health Assembly targets set for 2025 and the Sustainable Development Goals (SDGs) set for 2030.Child deaths worldwide resulted from under nutrition (ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “0896291146”, “author” : { “dropping-particle” : “”, “family” : “Smith”, “given” : “Lisa C”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “East”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2000” }, “title” : “Over Com Ing Child Mal Nu Tri Tion in De Vel Op Ing Coun Tries : Past Achieve Ments and Fu Ture Choices”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=ea5e18d2-3c3c-4a32-be2c-8a71541157b9” } , “mendeley” : { “formattedCitation” : “(Smith, 2000)”, “manualFormatting” : “Smith, 2000)”, “plainTextFormattedCitation” : “(Smith, 2000)”, “previouslyFormattedCitation” : “(Smith, 2000)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }Smith, 2000). Again malnutrition contributed to 2.2 million deaths of children under five years old in 2008 ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Caulfield”, “given” : “Laura E”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “De”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Black”, “given” : “Robert E”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2004” }, “page” : “193-198”, “title” : “Undernutrition as an underlying cause of child deaths associated”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=1c667997-12e4-4a42-99a6-b0b2aa5d0bdb” } , “mendeley” : { “formattedCitation” : “(Caulfield, Onis, Blu00f6ssner, & Black, 2004)”, “plainTextFormattedCitation” : “(Caulfield, Onis, Blu00f6ssner, & Black, 2004)”, “previouslyFormattedCitation” : “(Caulfield, Onis, Blu00f6ssner, & Black, 2004)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Caulfield, Onis, Blössner, ; Black, 2004) and in 2009 more than one third of all the children’s deaths worldwide were caused by under-nutrition as well ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1371/journal.pone.0107040”, “ISBN” : “WHO Environmental Burden of Disease Series, no 12”, “ISSN” : “1932-6203”, “PMID” : “25188502”, “abstract” : “Malnutrition, defined as underweight, is a serious public-health problem that has been linked to a substantial increase in the risk of mortality and morbidity. Women and young children bear the brunt of the disease burden associated with malnutrition. In Africa and south Asia, 27u221251% of women of reproductive age are underweight (ACC/SCN, 2000), and it is predicted that about 130 million children will be underweight in 2005 (21% of all children) (de Onis et al., 2004a). Many of the 30 million low-birth-weight babies born annually (23.8% of all births) face severe short-term and long-term health consequences (de Onis, Blu00f6ssner & Villar, 1998). In this guide we outline a method for estimating the disease burden at national or local level that is associated with maternal and child malnutrition. The goal is to help policy- makers and others quantify the increased risk associated with malnutrition, in terms of attributable mortality and morbidity, at country or local levels. The estimates will allow policy-makers to compare the disease burden of malnutrition for different countries, or regions within countries, and enable resources to be deployed more effectively. Repeated assessments will also allow trends to be monitored and the impact of interventions to be evaluated. To quantify the disease burden, population attributable fractions are derived from the assessed exposure (malnutrition) and from the relative risk estimates of disease and death associated with malnutrition. The level of malnutrition in the population groups is assessed by anthropometry (i.e. measurements of body size and composition), using as indicators low birth weight in newborns, low weight-for-age in preschool children, and low body mass index in women. Relative risk estimates for diarrhoea, malaria, measles, acute respiratory infections and other infectious diseases are based on a meta-analysis that was part of a global comparative risk assessment project conducted by the World Health Organization (WHO) and its partners. Checklists for collecting and analysing data are also suggested, and a step-by-step example of how to quantify the health impact associated with malnutrition is given for Nepal, a country in the WHO SEAR D subregion. Estimates of the disease burden of malnutrition give policy-makers an indication of the burden that could be avoided if malnutrition were to be eliminated. Disaggregated estimates (e.g. by age, sex, degree of malnutrition) can also help policy-makers identu2026”, “author” : { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “De”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “WHO”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Environmental Burden Disease Series”, “id” : “ITEM-1”, “issue” : “12”, “issued” : { “date-parts” : “2005” }, “page” : “43”, “title” : “Malnutrition: quantifying the health impact at national and local levels”, “type” : “article-journal”, “volume” : “12” }, “uris” : “http://www.mendeley.com/documents/?uuid=e0184df8-f277-49b2-9ff4-69e4a60dd488” } , “mendeley” : { “formattedCitation” : “(Blu00f6ssner, Onis, & WHO, 2005)”, “plainTextFormattedCitation” : “(Blu00f6ssner, Onis, & WHO, 2005)”, “previouslyFormattedCitation” : “(Blu00f6ssner, Onis, & WHO, 2005)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Blössner, Onis, & WHO, 2005).Recently adverse malnutrition effects have remained to be the most health burden globally. 7.6 million Children aged 6 to 59 months died of under nutrition in 2010 ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tankoi”, “given” : “Ole”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Pub”, “given” : “Int J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Safe”, “given” : “Health”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sub-county”, “given” : “Trans-mara East”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “County”, “given” : “Narok”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2016” }, “page” : “1-18”, “title” : “International Journal of Public Health & Safety Determinants of Malnutrition among Children Aged 6-59 Months in”, “type” : “article-journal”, “volume” : “1” }, “uris” : “http://www.mendeley.com/documents/?uuid=91b895df-fa5d-4c2b-bd02-957a3327a73f” } , “mendeley” : { “formattedCitation” : “(Tankoi, Pub, Safe, Sub-county, & County, 2016)”, “plainTextFormattedCitation” : “(Tankoi, Pub, Safe, Sub-county, & County, 2016)”, “previouslyFormattedCitation” : “(Tankoi, Pub, Safe, Sub-county, & County, 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tankoi, Pub, Safe, Sub-county, & County, 2016) and it is estimated that malnutrition still contributes to 60% of 11 million deaths of children under five years old worldwide every year ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/1475-2891-10-92”, “ISBN” : “1475-2891 (Electronic)\r1475-2891 (Linking)”, “ISSN” : “1475-2891”, “PMID” : “21910909”, “abstract” : “INTRODUCTION: Dehydration and malnutrition commonly occur together among ill children in developing countries. Dehydration (change in total body water) is known to alter weight. Although muscle tissue has high water content, it is not known whether mid-upper arm circumference (MUAC) may be altered by changes in tissue hydration. We aimed to determine whether rehydration alters MUAC, MUAC Z score (MUACz), weight-for-length Z-score (WFLz) and classification of nutritional status among hospitalised Kenyan children admitted with signs of dehydration. STUDY PROCEDURE: We enrolled children aged from 3 months to 5 years admitted to a rural Kenyan district hospital with clinical signs compatible with dehydration, and without kwashiorkor. Anthropometric measurements were taken at admission and repeated after 48 hours of treatment, which included rehydration by WHO protocols. Changes in weight observed during this period were considered to be due to changes in hydration status.\n\nRESULTS: Among 325 children (median age 11 months) the median weight gain (rehydration) after 48 hours was 0.21 kg, (an increase of 2.9% of admission body weight). Each 1% change in weight was associated with a 0.40 mm (95% CI: 0.30 to 0.44 mm, p < 0.001) change in MUAC, 0.035z (95% CI: 0.027 to 0.043z, P < 0.001) change in MUACz score and 0.115z (95% CI: 0.114 to 0.116 z, p < 0.001) change in WFLz. Among children aged 6 months or more with signs of dehydration at admission who were classified as having severe acute malnutrition (SAM) at admission by WFLz <-3 or MUAC <115 mm, 21% and 19% of children respectively were above these cut offs after 48 hours.\n\nCONCLUSION: MUAC is less affected by dehydration than WFLz and is therefore more suitable for nutritional assessment of ill children. However, both WFLz and MUAC misclassify SAM among dehydrated children. Nutritional status should be re-evaluated following rehydration, and management adjusted accordingly.”, “author” : { “dropping-particle” : “”, “family” : “Mwangome”, “given” : “Martha K”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Fegan”, “given” : “Gregory”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Prentice”, “given” : “Andrew M”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Berkley”, “given” : “James a”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Nutrition Journal”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2011” }, “page” : “92”, “publisher” : “BioMed Central Ltd”, “title” : “Are diagnostic criteria for acute malnutrition affected by hydration status in hospitalized children? A repeated measures study”, “type” : “article-journal”, “volume” : “10” }, “uris” : “http://www.mendeley.com/documents/?uuid=94387b15-8cc8-469b-8ce8-6dd7285ec718” } , “mendeley” : { “formattedCitation” : “(Mwangome, Fegan, Prentice, & Berkley, 2011)”, “plainTextFormattedCitation” : “(Mwangome, Fegan, Prentice, & Berkley, 2011)”, “previouslyFormattedCitation” : “(Mwangome, Fegan, Prentice, & Berkley, 2011)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Mwangome, Fegan, Prentice, & Berkley, 2011).While cheap and nutritious foodstuffs are readily available in many areas of Sub-Saharan Africa region , millions of children are chronically malnourished and every year approximately 18 million people, especially children, die from mild to moderate malnutrition ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.18356/4fb40cfa-en”, “ISBN” : “9789280648386”, “abstract” : “State 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“”, “family” : “Ganesh”, “given” : “Vidhya”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Holland”, “given” : “Katherine”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kummer”, “given” : “Tamara”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Pandian”, “given” : “Dheepa”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Stewart”, “given” : “David”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Strecker”, “given” : “Morgan”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Taylor”, “given” : “Guy”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Van”, “given” : “Justin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Vojvoda”, “given” : “Rudina”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Wietzke”, “given” : “Frank Borge”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Yuster”, “given” : “Alexandra”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Zaman”, “given” : “Maniza”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2016” }, “number-of-pages” : “1-184”, “title” : “State of the world’s children 2016 A fair chance for every child”, “type” : “book” }, “uris” : “http://www.mendeley.com/documents/?uuid=6ec41eb2-898e-4fe0-8451-cac9a982b6a3” } , “mendeley” : { “formattedCitation” : “(Bocquenet et al., 2016)”, “plainTextFormattedCitation” : “(Bocquenet et al., 2016)”, “previouslyFormattedCitation” : “(Bocquenet et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Bocquenet et al., 2016). The number of under-five children suffering from malnutrition continues to increase. In sub-Saharan Africa remain the regions with highest prevalence of undernourishment. Africa is going through a rapid socio-demographic transition, with an alarming increase in incidences of obesity, diabetes mellitus, cardiovascular diseases (stroke and myocardial infarction). Despite the millennium development goals target to reduce hunger by half by 2015, major failures have been recorded mainly in AfricaADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “abstract” : “MQSUN aims to provide the Department for International Development (DFID) with technical services to improve the quality of nutrition-specific and nutrition-sensitive programmes. The project is resourced by a consortium of six leading non-state organisations working on nutrition. The consortium is led by PATH. The group is committed to: uf0b7 Expanding the evidence base on the causes of undernutrition uf0b7 Enhancing skills and capacity to support scaling up of nutrition-specific and nutrition-sensitive programmes uf0b7 Providing the best guidance available to support programme design, implementation, monitoring and evaluation uf0b7 Increasing innovation in nutrition programmes uf0b7 Knowledge-sharing to ensure lessons are learnt across DFID and beyond.”, “author” : { “dropping-particle” : “”, “family” : “Ahmed”, “given” : “Nabeela”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Barnett”, “given” : “Inka”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Longhurst”, “given” : “Richard”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “April”, “issued” : { “date-parts” : “2015” }, “page” : “30”, “title” : “Determinants of Child Undernutrition in Bangladesh Literature Review”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7d9c141f-700b-46cd-863b-1af8ec7b5d36” } , “mendeley” : { “formattedCitation” : “(Ahmed, Barnett, & Longhurst, 2015)”, “plainTextFormattedCitation” : “(Ahmed, Barnett, & Longhurst, 2015)”, “previouslyFormattedCitation” : “(Ahmed, Barnett, & Longhurst, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Ahmed, Barnett, & Longhurst, 2015).

Out of the 800 million people still suffering from hunger in the world, over 204 million come from Sub-Saharan Africa. East-Africa region is affected with under nutrition among children under 5 years, according to a different demographic, Health survey of east African countries is demonstrated that in Kenya. Nationally, 26 % of children are stunted, while in Tanzania, one in three children under five are Stunted, or too short for their age. Stunting is an indication of chronic under nutrition. Stunting is more common among children, who were very small at birth (51%) and Wasting (too thin for height), which is a sign of acute malnutrition, is far less common (5%). In addition, 14% of children are underweight are too thin for their age. ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1093/jae/ejn024”, “ISBN” : “0963-8024\r1464-3723”, “ISSN” : “09638024”, “abstract” : “This paper uses a pooled sample of the 1998 and 2003 Demographic and Health Survey data sets for Kenya to analyse the determinants of children’s nutritional status. We investigate the impact of child, parental, household and community characteristics on children’s height and on the probability of stunting. Descriptive and econometric analysis, augmented by policy simulations, is employed to achieve the objectives of the study. In estimation, we control for sample design and possible heterogeneity arising from unobserved community characteristics correlated with children’s nutritional status and its determinants. The key findings are that boys suffer more malnutrition than girls, and children of multiple births are more likely to be malnourished than singletons. The results further indicate that maternal education is a more important determinant of children’s nutritional status than paternal education. Household assets are also important determinants of children’s nutritional status but nutrition improves at a decreasing rate with assets. The use of public health services, more-so modern contraceptives, is also found to be an important determinant of child nutritional status. Policy simulations affirm the potential role of parental, household and community characteristics in reducing long-term malnutrition in Kenya and suggest that the correct policy mix would make a substantial reduction in the current high levels of malnutrition. Our findings suggest that, if Kenya is to achieve her strategic health objectives and millennium development target of reducing the prevalence of malnutrition, strategies for poverty alleviation, promotion of post secondary education for women and provision of basic preventive health care are critical concerns that need to be addressed. Copyright 2009 The author 2008. Published by Oxford University Press on behalf of the Centre for the Study of African Economies. All rights reserved. For permissions, please email: [email protected]”, “author” : { “dropping-particle” : “”, “family” : “Kabubo-Mariara”, “given” : “Jane”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ndenge”, “given” : “Godfrey K.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mwabu”, “given” : “Domisiano K.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of African Economies”, “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2009” }, “page” : “363-387”, “title” : “Determinants of children’s nutritional status in Kenya: Evidence from Demographic and Health Surveys”, “type” : “article-journal”, “volume” : “18” }, “uris” : “http://www.mendeley.com/documents/?uuid=f1622f2d-b3e6-4577-b47f-bd9b2fc487a6” } , “mendeley” : { “formattedCitation” : “(Kabubo-Mariara, Ndenge, & Mwabu, 2009)”, “plainTextFormattedCitation” : “(Kabubo-Mariara, Ndenge, & Mwabu, 2009)”, “previouslyFormattedCitation” : “(Kabubo-Mariara, Ndenge, & Mwabu, 2009)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Kabubo-Mariara, Ndenge, & Mwabu, 2009).In Rwanda, under nutrition among children aged 6 to 59 months has remained high despite improvement in other health indicators. According to Rwanda Demographic Health Survey (RDHS), (2010) 11% of children under 5 are underweight (low weight-for-age), and 2% are severely underweight. The percentage of children underweight increases steadily from 6 % among children under age 6 months to 10 % among children age 6-8 months and 15% among children age 18-23 months, decreasing slightly to 14% among children age 48-59 months. This may be due to inappropriate and/or inadequate feeding practices because the percentage of underweight children begins to increase at the age when normal complementary feeding starts. Rural children are twice as likely to be underweight as urban children (12 % versus 6 %). Three of the five provinces in Rwanda (South, West, and East) have percentages of underweight children above the national average. The prevalence of underweight children is 7 % in the City of Kigali and 10 percent in the North province. A mother’s health status and educational level are negatively associated with the likelihood that her child is underweight. Children born to mothers in the lowest wealth quintile are more than three times as likely to be underweight as children born to mothers in the highest wealth quintile (16% versus 5 %). Also, children born to undernourished mothers (BMI ;18.5 kg/m2) are twice as likely to be underweight as children whose mothers have a normal BMI (18.5-24.9 kg/m2) (24% versus 12 %) ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “9789997743152”, “author” : { “dropping-particle” : “”, “family” : “Rwanda”, “given” : “National Institute of Statitstics of”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “editor” : { “dropping-particle” : “”, “family” : “Rwanda”, “given” : “National Institute of Statitstics of”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “20014” }, “number-of-pages” : “72”, “publisher” : “2014”, “title” : “The Republic of Rwanda”, “type” : “book” }, “uris” : “http://www.mendeley.com/documents/?uuid=6ca12dc3-b8e3-485d-b684-f02eec66f164” } , “mendeley” : { “formattedCitation” : “(Rwanda, 20014)”, “plainTextFormattedCitation” : “(Rwanda, 20014)”, “previouslyFormattedCitation” : “(Rwanda, 20014)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(RDHS, 20014).

1.2 Problem StatementMalnutrition, in the world is by far a biggest contributor to child mortality, present in half of all cases. Around 62 million people, all causes of death combine die each year. According to Rwanda Demographic Health Survey, Nationally, 38 % of children under age five are stunted, and 14 % are severely stunted. Analysis by age group indicates that stunting is apparent even among children less than age 6 months (11 %). Stunting increases with the age of the child, rising from 18 percent among children age 6-8 months to a peak of 49 percent among children age 18-23 months before gradually declining to 37 % among children age 48-59 months. Since the Northern Province has the highest percentage of under nutrition 39 %. While the determinants of under nutrition among children aged 6 to 59 months were not mentioned, that is the reason why the researcher wanted to determine ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “9789997743190”, “author” : { “dropping-particle” : “”, “family” : “RDHS”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2015” }, “number-of-pages” : “72”, “title” : “The Republic of Rwanda”, “type” : “report” }, “uris” : “http://www.mendeley.com/documents/?uuid=780a4e7f-c96d-4e51-847b-b4c5e3e88603” } , “mendeley” : { “formattedCitation” : “(RDHS, 2015)”, “plainTextFormattedCitation” : “(RDHS, 2015)”, “previouslyFormattedCitation” : “(RDHS, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(RDHS, 2015).

1.3 Objectives of study1.3.1 General objectiveTo determine the determinants of under nutrition among children aged 6 to 59 months in Gicumbi District.

1.3.2 Specific objectives
To assess the prevalence of under nutrition among children aged 6 to 59 months in Gicumbi District.
To identify socio-demographic factors associated with malnutrition among children aged 6-59 months.
To determine factors associated with under nutrition among children aged 6 to 59 months.

1.4 Research questionsWhat is the prevalence of under nutrition among children aged 6 to 59 months in Gicumbi District?
What are socio-demographic factors associated with malnutrition among children aged 6 to 59 months?
What are the factors associated with under nutrition among children aged 6 to 59 months?
1.5 Significance of the StudyThe funding of this study is expected to be of great significance to various stakeholders, including the Government of Rwanda, partners such as national and international, other researchers and community of Gicumbi District.

The findings of this study will be of importance to the Government in policy development towards achieving the 17 new Sustainable Development Goals (SDGs), especially the 2ndgoal (end hunger, achieve food security and improved nutrition and promote sustainable agriculture) and the 3rd goal (ensure healthy lives and promote well-being of all of all ages).

Gicumbi district, children and entire Rwanda community are expected to benefit from reduced risk of various health condition associated from under nutrition following implementation of recommendations made in this research study.

The researchers, local, regional and internationally will find this study beneficial as it will add to the existing knowledge of the determinants of under nutrition among children aged 6 to 59 months.

1.6 Limitation of the StudyThis study will be conducted at Gicumbi District, Northern Province Rwanda. Thus the finding could not be generalized to the whole country; we will teach respondents and make them understand the tools of data collection as it is difficult for them to understand and answer correctly some questions.

1.7 Scope of the StudyThe scope of this study will be addressed in terms of concept scope, content scope, geographical and time scope. In relation to concept and content, this study focused on the determinants of under nutrition among children aged 6 to 59 months. Geographically, it will be conducted in Gicumbi district, one of five districts makes up of the Northern Province.

This research will be conducted in Gicumbi District, Northern Province, Rwanda in the months of April 2017, and September 2017.
1.8 Organization of the StudyThis research consists of three chapters. Chapter one, will devote to the introduction, background of the study, problem statement, research objectives, research questions, significance of the study, limitations of the study, and the scope of the study are discussed.

The second chapter presented the review of related literature which includes theoretical review, empirical review under nutrition, conceptual framework, critical review of the existing literature related to this study, and the summary of the literature reviewed.

In chapter three, the research methodology comprises the introduction, research methodology, target population, sample design, sample size data collection methods, data analysis procedure and ethical considerations.
CHAPITER TWO: REVIEW OF RELATED LITERATUREIntroductionThis chapter summarizes information from the available literature relating to malnutrition, under nutrition and the determinants of under nutrition. This chapter devoted to the review of related literature was divided into five sections, namely: theoretical review, empirical literature, critical review, conceptual framework and summary.

Theoretical ReviewUnder nutrition is defined variably by different people. In international health literature, the term is often used synonymously with malnutrition, traditionally in reference to a situation where an individual has insufficient intake of protein and energy (total calories) ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/S0140-6736(07)61690-0”, “ISBN” : “0140-6736”, “ISSN” : “01406736”, “PMID” : “18207566”, “abstract” : “Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden. In this paper, we present new analyses to estimate the effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on mortality and disease. We estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2??2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. Deficiencies of vitamin A and zinc were estimated to be responsible for 0??6 million and 0??4 million deaths, respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths, and combined were responsible for about 0??2% of global childhood DALYs. Iron deficiency as a risk factor for maternal mortality added 115 000 deaths and 0??4% of global total DALYs. Suboptimum breastfeeding was estimated to be responsible for 1??4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years). In an analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35% of child deaths and 11% of the total global disease burden. The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences. ?? 2008 Elsevier Ltd. All rights reserved.”, “author” : { “dropping-particle” : “”, “family” : “Black”, “given” : “Robert E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Allen”, “given” : “Lindsay H.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bhutta”, “given” : “Zulfiqar A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Caulfield”, “given” : “Laura E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “de”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ezzati”, “given” : “Majid”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mathers”, “given” : “Colin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Rivera”, “given” : “Juan”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “The Lancet”, “id” : “ITEM-1”, “issue” : “9608”, “issued” : { “date-parts” : “2008” }, “page” : “243-260”, “title” : “Maternal and child undernutrition: global and regional exposures and health consequences”, “type” : “article-journal”, “volume” : “371” }, “uris” : “http://www.mendeley.com/documents/?uuid=09f7a807-bcf8-43b0-b695-268889af11bb” } , “mendeley” : { “formattedCitation” : “(Black et al., 2008)”, “plainTextFormattedCitation” : “(Black et al., 2008)”, “previouslyFormattedCitation” : “(Black et al., 2008)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Black et al., 2008).The terms malnutrition, however, denotes both terms used include protein-energy malnutrition and protein-calorie malnutrition. The importance of micronutrients and the fact that the deficiency in total energy often co-total energy often co-exists with micronutrient deficiency, has led to a preference for a neutral term such as under nutrition. Under nutrition, defined as insufficient intake and utilization of nutriments to meet an individual’s needs to maintain good health is a very big problem in the developing world. Up to a third of the children in the developing world are under nutrition (de Onis et al. 2003).

Under nutrition puts children at increased risk of morbidity, delayed mental and motor development and mortality. In fact, it has been estimated that up to half of the childhood deaths in the developing world is attributable to being underweight (Pelletier et al., 2004).

The two main forms of under nutrition are: Protein-energy under nutrition and specific micronutrient deficiency e.g. Vitamin A deficiency.

In public health, protein energy under nutrition is assessed using measures of physical status. The main measures used are Weight, and height or length related to age. Inadequate dietary intake and disease are the main causes of under nutrition. However, other factors such are water and sanitation, maternal and children cares practices, food security, politics, cultures, food behavior influence the immediate cause and thus, are indirect causes of under nutrition. Worldwide trends in under nutrition show a general pattern of decreasing prevalence ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1093/ije/dyh202”, “ISBN” : “0300-5771 (Print)\n0300-5771 (Linking)”, “ISSN” : “03005771”, “PMID” : “15542535”, “abstract” : “BACKGROUND: Child malnutrition is an important indicator for monitoring progress towards the Millennium Development Goals (MDG). This paper describes the methodology developed by the World Health Organization (WHO) to derive global and regional trends of child stunting and underweight, and reports trends in prevalence and numbers affected for 1990-2005. METHODS: National prevalence data from 139 countries were extracted from the WHO Global Database on Child Growth and Malnutrition. A total of 419 and 388 survey data points were available for underweight and stunting, respectively. To estimate trends we used linear mixed-effect models allowing for random effects at country level and for heterogeneous covariance structures. One model was fitted for each United Nation’s region using the logit transform of the prevalence and results back-transformed to the original scale. Best models were selected based on explicit statistical and graphical criteria. RESULTS: During 1990-2000 global stunting and underweight prevalences declined from 34% to 27% and 27% to 22%, respectively. Large declines were achieved in Eastern and South-eastern Asia, while South-central Asia continued to suffer very high levels of malnutrition. Substantial improvements were also made in Latin America and the Caribbean, whereas in Africa numbers of stunted and underweight children increased from 40 to 45, and 25 to 31 million, respectively. CONCLUSION: Linear mixed-effect models made best use of all available information. Trends are uneven across regions, with some showing a need for more concerted and efficient interventions to meet the MDG of reducing levels of child malnutrition by half between 1990 and 2015.”, “author” : { “dropping-particle” : “”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “de”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Borghi”, “given” : “Elaine”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Morris”, “given” : “Richard”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Frongillo”, “given” : “Edward A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “International Journal of Epidemiology”, “id” : “ITEM-1”, “issue” : “6”, “issued” : { “date-parts” : “2004” }, “page” : “1260-1270”, “title” : “Methodology for estimating regional and global trends of child malnutrition”, “type” : “article-journal”, “volume” : “33” }, “uris” : “http://www.mendeley.com/documents/?uuid=de0f820b-be94-463c-8031-f41b724d9cca” } , “mendeley” : { “formattedCitation” : “(de Onis, Blu00f6ssner, Borghi, Morris, ; Frongillo, 2004)”, “plainTextFormattedCitation” : “(de Onis, Blu00f6ssner, Borghi, Morris, ; Frongillo, 2004)”, “previouslyFormattedCitation” : “(de Onis, Blu00f6ssner, Borghi, Morris, ; Frongillo, 2004)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(De Onis, et al., 2004). However, the pattern has not been universal.
In developing regions, children in rural areas are more likely to be underweight than children living in cities. In parts of Asia and in Latin America the relative disparity actually increased between 1990 and 2008. In eastern Asia, there was a striking increase in the rural/urban ratio from 2.1 to 4.8, indicating that in 2008 children in rural area were almost five times as likely to be underweight as children in urban areas ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “abstract” : “MQSUN aims to provide the Department for International Development (DFID) with technical services to improve the quality of nutrition-specific and nutrition-sensitive programmes. The project is resourced by a consortium of six leading non-state organisations working on nutrition. The consortium is led by PATH. The group is committed to: uf0b7 Expanding the evidence base on the causes of undernutrition uf0b7 Enhancing skills and capacity to support scaling up of nutrition-specific and nutrition-sensitive programmes uf0b7 Providing the best guidance available to support programme design, implementation, monitoring and evaluation uf0b7 Increasing innovation in nutrition programmes uf0b7 Knowledge-sharing to ensure lessons are learnt across DFID and beyond.”, “author” : { “dropping-particle” : “”, “family” : “Ahmed”, “given” : “Nabeela”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Barnett”, “given” : “Inka”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Longhurst”, “given” : “Richard”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “April”, “issued” : { “date-parts” : “2015” }, “page” : “30”, “title” : “Determinants of Child Undernutrition in Bangladesh Literature Review”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=7d9c141f-700b-46cd-863b-1af8ec7b5d36” } , “mendeley” : { “formattedCitation” : “(Ahmed et al., 2015)”, “plainTextFormattedCitation” : “(Ahmed et al., 2015)”, “previouslyFormattedCitation” : “(Ahmed et al., 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Ahmed et al., 2015).

Across the developing world, children from the poorest household are twice as likely to be underweight as children from the richest household. The disparity is more dramatic in regions with a high prevalence of underweight children. This is the situation in southern Asia, where as many as 60 % of the children in the poorest families are underweight, compared to about 25 % in the richest households (Millennium Development Goal 2010).
All the same time, southeastern Asia, sub Saharan Africa and North Africa have succeeded in reducing child malnutrition more rapidly in rural area and in narrowing the gap with the urban population, demonstrating that more equitable progress is indeed.

Child under nutrition in all its forms is a global health concern. Underweight, stunting and wasting are reported to be serious problems affecting developing countries. Two billion people in the world suffer from various forms of malnutrition.ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s12887-016-0770-z”, “ISBN” : “1471-2431 (Electronic)\r1471-2431 (Linking)”, “ISSN” : “1471-2431”, “PMID” : “28086835”, “abstract” : “BACKGROUND: Stunting has been identified as one of the major proximal risk factors for poor physical and mental development of children under-5 years. Stunting predominantly occurs in the first 1000 days of life (0-23 months) and continues to the age of five. This study examines factors associated with stunting and severe stunting among children under-5 years in Nigeria. METHODS: The sample included 24,529 children aged 0-59 months from the 2013 Nigeria Demographic and Health Survey (NDHS). Height-for-age z-scores (HFAz), generated using the 2006 World Health Organisation (WHO) growth reference, were used to define stunting (HFAz ; -2SD) and severe stunting (HFAz ; -3SD). Multilevel logistic regression analyses that adjusted for cluster and survey weights were used to determine potential risk factors associated with stunting and severe stunting among children under-5 years in Nigeria. RESULTS: The prevalence of stunting and severe stunting were 29% 95% Confidence interval (Cl): 27.4, 30.8 and 16.4% 95%Cl: 15.1, 17.8, respectively for children aged 0-23 months, and 36.7% 95%Cl: 35.1, 38.3 and 21% 95%Cl: 19.7, 22.4, respectively for children aged 0-59 months. Multivariate analysis revealed that the most consistent significant risk factors for stunting and severe stunting among children aged 0-23 months and 0-59 months are: sex of child (male), mother’s perceived birth size (small and average), household wealth index (poor and poorest households), duration of breastfeeding (more than 12 months), geopolitical zone (North East, North West, North Central) and children who were reported to having had diarrhoea in the 2 weeks prior to the survey Adjusted odds ratio (AOR) for stunted children 0-23 months = 1.22 (95%Cl: 0.99, 1.49);AOR for stunted children 0-59 months = 1.31 (95%Cl: 1.16, 1.49), AOR for severely stunted children 0-23 months = 1.31 (95%Cl: 1.03, 1.67); AOR for severely stunted children 0-59 months = 1.58 (95%Cl: 1.38, 1.82). CONCLUSIONS: In order to meet the post-2015 sustainable development goals, policy interventions to reduce stunting in Nigeria should focus on poverty alleviation as well as improving women’s nutrition, child feeding practices and household sanitation.”, “author” : { “dropping-particle” : “”, “family” : “Akombi”, “given” : “B J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Agho”, “given” : “K E”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hall”, “given” : “J J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Merom”, “given” : “D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Astell-Burt”, “given” : “T”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Renzaho”, “given” : “A M”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC Pediatr”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2017” }, “page” : “15”, “publisher” : “BMC Pediatrics”, “title” : “Stunting and severe stunting among children under-5 years in Nigeria: A multilevel analysis”, “type” : “article-journal”, “volume” : “17” }, “uris” : “http://www.mendeley.com/documents/?uuid=067354c0-82cc-434c-acdf-0a7f71fd6f79” } , “mendeley” : { “formattedCitation” : “(B J Akombi et al., 2017)”, “plainTextFormattedCitation” : “(B J Akombi et al., 2017)”, “previouslyFormattedCitation” : “(B J Akombi et al., 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }( Akombi et al., 2017) Malnutrition is an underlying cause of death of 2.6 million children each year, a third of child deaths globally.1 in 4 of the world’s children are stunted; in developing countries this is as high as one in three.  This means their bodies fail to develop fully as a result of malnutrition.

Prevention and treatment of under nutrition typically target the causes of under nutrition either singly or in combination. The common approach is dietary supplementation. While institutional therapeutic feeding strategies have been well developed ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “WHO”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Conclusions of a consensus meeting held 6u20138 November 2007 in Washington, DC, USA”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2008” }, “title” : “Indicators for assessing infant and young child feeding practices”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=1ad627a8-b82e-43fb-b44e-225157f2d002” } , “mendeley” : { “formattedCitation” : “(WHO, 2008)”, “plainTextFormattedCitation” : “(WHO, 2008)”, “previouslyFormattedCitation” : “(WHO, 2008)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(WHO, 2008) strategies for community level treatment of moderate under nutrition are not well developed .this is despite the fact that the majority of undernourished children are of the moderate forms that require community-based management. Traditionally cereal/legume blends have been promoted for supplementary programs in Sub –Saharan Africa (Brown et al., 1998).their efficacy in controlled situations is however questionable ( Brown et al.,2008).

2.1.1 Critical Period of Child DevelopmentToday’s concerted focus on reducing children under nutrition reflect an improved understanding of the importance of under nutrition during the most critical period of development in early life and of the long term consequences extending into adulthood. Evidence from 54 low and middle income countries indicate that growth faltering on average begins during pregnancy and continues to about 24 months of age .This loss in linear growth is not recovered, and catch-up growth later in childhood is minimal (Victoria et al., 2008).

from a life cycle perspective, the most crucial time to meet a child’s nutritional requirements is in the first 1,000 days including the period of pregnancy and ending with the child’s second birthday. During this period the child has increased nutritional needs to support rapid growth and development, is more susceptible to infections, has heightened sensitivity to biological programming and is totally dependent on others for nutrition, care and social interactions ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “UNICEF., WHO.”, “given” : “World bank Group”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “UNICEF Data”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2015” }, “title” : “Levels and trends in child malnutrition”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=f72c6125-8106-4c49-a804-0b5e2025695e” } , “mendeley” : { “formattedCitation” : “(UNICEF., WHO., 2015)”, “plainTextFormattedCitation” : “(UNICEF., WHO., 2015)”, “previouslyFormattedCitation” : “(UNICEF., WHO., 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(UNICEF, WHO 2015).

Adequate maternal nutrition, health and physical status are crucial to prevent child under nutrition. Pregnancy increases nutrient need, protein, energy, vitamin and mineral deficiencies are common during pregnancy ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tankoi”, “given” : “Ole”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Pub”, “given” : “Int J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Safe”, “given” : “Health”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sub-county”, “given” : “Trans-mara East”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “County”, “given” : “Narok”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2016” }, “page” : “1-18”, “title” : “International Journal of Public Health ; Safety Determinants of Malnutrition among Children Aged 6-59 Months in”, “type” : “article-journal”, “volume” : “1” }, “uris” : “http://www.mendeley.com/documents/?uuid=91b895df-fa5d-4c2b-bd02-957a3327a73f” } , “mendeley” : { “formattedCitation” : “(Tankoi et al., 2016)”, “plainTextFormattedCitation” : “(Tankoi et al., 2016)”, “previouslyFormattedCitation” : “(Tankoi et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tankoi et al., 2016), stated that deficiencies are not solely the result of inadequate dietary intake: disease can impair absorption of nutrients and reduce appetite, and environmental and psychosocial stress affecting the mother can contribute to child under nutrition. Undernourished girls have greater likelihood of becoming undernourished mothers who in turn have a greater chance of giving birth to low birth-weight babies, perpetuating an intergenerational malnutrition cycle ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.11604/pamj.2013.15.120.2535”, “ISBN” : “1937-8688 (Electronic)”, “ISSN” : “19378688”, “PMID” : “24255726”, “abstract” : “Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001. Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation. Grooming undernourished children causes children to start life at mentally sub optimal levels. This becomes a serious developmental threat. Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Sociocultural barriers are major hindrances in some communities, with female children usually being the most affected. Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. A multisectorial approach is vital in tackling this problem. Improvement in government policy, fight against corruption, adopting a horizontal approach in implementing programmes at community level must be recognized. Genetically modified foods to increase food production and to survive adverse climatic conditions could be gateways in solving these problems. Socio cultural peculiarities of each community are an essential base line consideration for the implementation of any nutrition health promotion programs.”, “author” : { “dropping-particle” : “”, “family” : “Bain”, “given” : “Luchuo Engelbert”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Awah”, “given” : “Paschal Kum”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Geraldine”, “given” : “Ngia”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kindong”, “given” : “Njem Peter”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sigal”, “given” : “Yelena”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bernard”, “given” : “Nsah”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Tanjeko”, “given” : “Ajime Tom”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Pan African Medical Journal”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2013” }, “page” : “1-9”, “title” : “Malnutrition in Sub – Saharan Africa: Burden, causes and prospects”, “type” : “article-journal”, “volume” : “15” }, “uris” : “http://www.mendeley.com/documents/?uuid=8e9ed6f7-bad8-400f-bf8c-8f227e5d4895” } , “mendeley” : { “formattedCitation” : “(Bain et al., 2013)”, “plainTextFormattedCitation” : “(Bain et al., 2013)”, “previouslyFormattedCitation” : “(Bain et al., 2013)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Bain et al., 2013). Low birth weight is associated with increased morbidity and mortality, an estimated 60 to 80 % of neonatal deaths occurs among low birth weight babies (Lawn et al 2005).

2.1.2 Assessment of nutritional statusAssessments are used to provide information on the nutritional and health status of children and are an indirect measure of quality of life in a community or population ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.4172/2161-0509.1000147”, “ISSN” : “21610509”, “abstract” : “Background: Children are most vulnerable to malnutrition in developing countries because of low dietary intakes, lack of appropriate care, and inequitable distribution of food within the household. Malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. Malnutrition In Ethiopia, in the form of stunting, underweight and wasting were identified as 44%, 29% and 10% and Amhara National region state 52%, 33.4% and 9.9%, respectively in children under five. Objective: To determine the prevalence of malnutrition and associated factors among Children age 6-59 Months in Lalibela Town, Northern Ethiopia Methods: A-Community based cross-sectional study was conducted from August 19 to September 13, 2012 in Lalibela town, Northern Ethiopia which includes both urban and rural settings. Data were collected from 844 households with children age 6-59 months using pre tested structured questionnaires and measuring weight and height of children. Bivariate and multivariate logistic regression analyses were used using SPSS version 16 computer software to see the relevant associations. Anthropometric data were also converted into indices of nutritional status using Emergency Nutrition Assessment for SMART special software, 2012. Results: A total of 844 households were included in the study giving the response rate 100%. The prevalence of stunting, underweight and wasting were 47.3% (95%CI: 43.2-51.1), 25.6% (95%CI: 20.6-30.6) and 8.9% (95% CI: 6.9-10.2), respectively. Among the various socio-economic,demographic and child health and care practices characteristics considered, age of the child 11-23 months (AOR= 2.30; (95%CI: 1.28-4.12), Deworming status (AOR=2.19; (95% CI: 1.41-3.39), sex of the child(AOR= 0.75; (95% CI: 0.57-1.00) and breast feed the child still now(AOR= 0.40;(95% CI: 0.20-0.78) remained to be significantly associated with stunting. Middle wealth quintile to the households (AOR=0.51; (95%CI: 0.28-0.91), age of the child 23-35 months(AOR=2.29; (95%CI: 1.14-4.61), number of children aged 6-59 months in the household (AOR=1.61; (95%CI: 1.08-2.41) and giving honey to the child in the morning (AOR=1.52; (95%CI: 1.03-2.24) were remained to be significantly and independently associated with underweight. Conclusion: The prevalence rate of malnutrition in the study area was found high and this was coupled with association of many independent variables. This needs appropriate factor specific interventions.”, “author” : { “dropping-particle” : “”, “family” : “Birara Melese yalew, Amsalu Feleke”, “given” : “Bikes Destaw”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Journal of Nutrition and Metabolism”, “id” : “ITEM-1”, “issue” : “2”, “issued” : { “date-parts” : “2014” }, “title” : “Prevalence and Factors Associated with Stunting, Underweight and Wasting: A Community Based Cross Sectional Study among Children Age 6-59 Months at Lalibela Town, Northern Ethiopia”, “type” : “article-journal”, “volume” : “4” }, “uris” : “http://www.mendeley.com/documents/?uuid=49a559c9-4d2e-4b5f-8e92-4618c117a8ed” } , “mendeley” : { “formattedCitation” : “(Birara Melese yalew, Amsalu Feleke, 2014)”, “plainTextFormattedCitation” : “(Birara Melese yalew, Amsalu Feleke, 2014)”, “previouslyFormattedCitation” : “(Birara Melese yalew, Amsalu Feleke, 2014)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Birara Melese yalew, Amsalu Feleke, 2014). The most common ways to assess malnutrition in children is through the use of anthropometry, clinical and biochemical parameters.

2.1.3 AnthropometryWeighing a child and measuring his or her height; involves taking a measurement of their weight and height and then comparing it against what would be the expected average height and weight for a child of that age. Some children will be below average as they are naturally smaller, but a significant drop below the expected level for an individual could indicate a risk of malnutrition (Müller et al., 2005). Measuring the circumference of the mid-upper arm; a mid-upper arm circumference (MUAC) measurement band has different colors along the strip. If the arm band lands in the orange section it means the child is suffering from moderate acute malnutrition. If it lands in the red section, the child is suffering from severe acute malnutrition (Caulfield et al., 2009). Checking for fluid retention or swelling in the lower legs or feet. Edema affects a child’s appearance, giving him or her puffy, swollen look in either lower limbs and feet or face. It can be detected by small pits or indentations remaining in the child’s lower ankles or feet, after pressing lightly with the thumbs. The presence of edema in both feet and lower legs is always considered a sign of severe acute malnutrition ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Caulfield”, “given” : “Laura E”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “De”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Black”, “given” : “Robert E”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2004” }, “page” : “193-198”, “title” : “Undernutrition as an underlying cause of child deaths associated”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=1c667997-12e4-4a42-99a6-b0b2aa5d0bdb” } , “mendeley” : { “formattedCitation” : “(Caulfield et al., 2004)”, “plainTextFormattedCitation” : “(Caulfield et al., 2004)”, “previouslyFormattedCitation” : “(Caulfield et al., 2004)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Caulfield et al., 2004).

2.1.4 Use of biochemical and clinical indicatorsBlood tests can also be used to measure levels of protein in the blood. Low levels of protein may suggest that a child is malnourished. The clinical findings and biochemical criteria are not effective to use for classification if the disease is not advanced, but can help to confirm a diagnosis ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s13690-016-0124-1”, “ISBN” : “1369001601241”, “ISSN” : “0778-7367”, “PMID” : “27047661”, “abstract” : “BACKGROUND Poor nutritional status during childhood and its long-term impact on economic growth and wellbeing is well known. This study assessed the nutritional status of children in selected communities in northern Ghana, to serve as baseline data for the Africa Research in Sustainable Intensification for the Next Generation (Africa RISING) project that sought to improve farm-household nutrition through agriculture. METHODS A cross-sectional study was conducted among children 0-59 months in selected communities in the Northern (Tibali and Cheyohi No. 2), Upper West (Goli and Zanko) and Upper East (Bonia and Sambulgu) regions of northern Ghana. A pre-tested, semi-structured questionnaire was used to obtain information on background characteristics of caregivers and children. Weight and height were measured for children following World Health Organization (WHO) procedures and transformed into z-scores using the WHO Anthro. RESULTS All the caregivers (522) were females; majority (73.4u00a0%) had no formal education, 82.7u00a0% were married and 70.5u00a0% engaged in farming. In all, 533 children were recruited: Northern region (38.6u00a0%), Upper West (33.4u00a0%) and Upper East (28.0u00a0%). Majority (52.5u00a0%) of the children were males. The mean age was 32u2009u00b1u200919u00a0months. Levels of stunting, underweight and wasting were 27.2, 17.6 and 8.2u00a0% respectively. Stunting, underweight and wasting levels increased within the first two years of life. Overall, 33.8u00a0% of the children in northern Ghana were malnourished; 20.2u00a0% were from the Northern region, 7.0 and 6.8u00a0% were from Upper East and Upper West respectively. CONCLUSION Different forms of malnutrition still exist as a public health problem in various communities in northern Ghana and need to be curtailed using effective agriculture-nutrition sensitive interventions.”, “author” : { “dropping-particle” : “”, “family” : “Glover-Amengor”, “given” : “Mary”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Agbemafle”, “given” : “Isaac”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hagan”, “given” : “Lynda Larmkie”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mboom”, “given” : “Frank Peget”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Gamor”, “given” : “Gladys”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Larbi”, “given” : “Asamoah”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hoeschle-Zeledon”, “given” : “Irmgard”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Archives of public health = Archives belges de santeu0301 publique”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2016” }, “page” : “12”, “publisher” : “Archives of Public Health”, “title” : “Nutritional status of children 0-59 months in selected intervention communities in northern Ghana from the africa RISING project in 2012.”, “type” : “article-journal”, “volume” : “74” }, “uris” : “http://www.mendeley.com/documents/?uuid=ece0f5dd-2399-44ac-b602-e2002b0aa9ee” } , “mendeley” : { “formattedCitation” : “(Glover-Amengor et al., 2016)”, “plainTextFormattedCitation” : “(Glover-Amengor et al., 2016)”, “previouslyFormattedCitation” : “(Glover-Amengor et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Glover-Amengor et al., 2016).

2.1.5 Treatment and management of under nutritionMalnutrition can be managed on five levels, namely in hospitals, in nutrition rehabilitation centers, in health centers, in the community and at home with regular follow up ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Birhanu”, “given” : “A”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mekonen”, “given” : “S”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Atenafu”, “given” : “A”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “3”, “issued” : { “date-parts” : “2017” }, “title” : “Stunting and Associated Factors among Children Aged 6-59 Months in Lasta Woreda , North East Ethiopia , 2015 : A Community Based Cross Sectional Study Design”, “type” : “article-journal”, “volume” : “4” }, “uris” : “http://www.mendeley.com/documents/?uuid=2cc50a19-dd3d-4be4-81b7-d6e54c453311” } , “mendeley” : { “formattedCitation” : “(Birhanu, Mekonen, ; Atenafu, 2017)”, “plainTextFormattedCitation” : “(Birhanu, Mekonen, ; Atenafu, 2017)”, “previouslyFormattedCitation” : “(Birhanu, Mekonen, ; Atenafu, 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Birhanu, Mekonen, & Atenafu, 2017). Rehabilitation programs should promote shorter hospital stay and the home or community based treatment, especially in areas where resources such as supplies and personnel are limited (Fuchs et al., 2004).

2.1.6 Consequences of under nutritionUnder nutrition generally affects the entire body, interfering with almost all body systems and functions and resulting in reduced functional capacity and body energy requirements. Malnutrition impairs immune functions which may lead to presence of infection or liver dysfunction resulting in loss of appetite and fever. Low food intakes on the other hand weakens muscles and this may cause pathological changes of the heart resulting in longer circulation time thus reduced heart rate, blood pressure or even stroke ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tavani”, “given” : “Alessandra”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “La”, “family” : “Vecchia”, “given” : “Carlo”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Negri”, “given” : “Eva”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bertuzzi”, “given” : “Michaela”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2001” }, “page” : “2135-2136”, “title” : “For personal use . Only reproduce with permission from The Lancet Publishing Group . For personal use . Only reproduce with permission from The Lancet Publishing Group .”, “type” : “article-journal”, “volume” : “357” }, “uris” : “http://www.mendeley.com/documents/?uuid=65bca137-d907-4a1a-b17c-77cdc308e260” } , “mendeley” : { “formattedCitation” : “(Tavani, Vecchia, Negri, ; Bertuzzi, 2001)”, “plainTextFormattedCitation” : “(Tavani, Vecchia, Negri, ; Bertuzzi, 2001)”, “previouslyFormattedCitation” : “(Tavani, Vecchia, Negri, ; Bertuzzi, 2001)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tavani, Vecchia, Negri, & Bertuzzi, 2001).

Stunting and other forms of under nutrition are clearly a major contributing factor to child mortality, disease and disability. for example, a severely stunted child faces a four times higher risk of dying and a severely wasted child is at nine times higher risk. Specific nutritional deficiencies such as vitamin A, iron or zinc deficiency also increase risk of death.

Under nutrition can cause various diseases such as blindness due to vitamin A deficiency and neural tube defects due to folic acid deficiency ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/S0140-6736(07)61690-0”, “ISBN” : “0140-6736”, “ISSN” : “01406736”, “PMID” : “18207566”, “abstract” : “Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden. In this paper, we present new analyses to estimate the effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on mortality and disease. We estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2??2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. Deficiencies of vitamin A and zinc were estimated to be responsible for 0??6 million and 0??4 million deaths, respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths, and combined were responsible for about 0??2% of global childhood DALYs. Iron deficiency as a risk factor for maternal mortality added 115 000 deaths and 0??4% of global total DALYs. Suboptimum breastfeeding was estimated to be responsible for 1??4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years). In an analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35% of child deaths and 11% of the total global disease burden. The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences. ?? 2008 Elsevier Ltd. All rights reserved.”, “author” : { “dropping-particle” : “”, “family” : “Black”, “given” : “Robert E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Allen”, “given” : “Lindsay H.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bhutta”, “given” : “Zulfiqar A.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Caulfield”, “given” : “Laura E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “de”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ezzati”, “given” : “Majid”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mathers”, “given” : “Colin”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Rivera”, “given” : “Juan”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “The Lancet”, “id” : “ITEM-1”, “issue” : “9608”, “issued” : { “date-parts” : “2008” }, “page” : “243-260”, “title” : “Maternal and child undernutrition: global and regional exposures and health consequences”, “type” : “article-journal”, “volume” : “371” }, “uris” : “http://www.mendeley.com/documents/?uuid=09f7a807-bcf8-43b0-b695-268889af11bb” } , “mendeley” : { “formattedCitation” : “(Black et al., 2008)”, “plainTextFormattedCitation” : “(Black et al., 2008)”, “previouslyFormattedCitation” : “(Black et al., 2008)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Black et al., 2008).The broader understanding of the divesting consequences of under nutrition on morbidity and mortality is based on well-established evidence. knowledge of impact of stunting and other forms of under nutrition on social and economic development and human capital formation has been reported and expended by more recent research ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “0119518112”, “ISSN” : “0042-9686”, “abstract” : “Malnutrition is frequently part of a vicious cycle that includes poverty and disease. These three factors are interlinked in such a way that each contributes to the presence and permanence of the others. Socioeconomic and political changes that improve health and nutrition can break the cycle; as can specific nutrition and health interventions. The WHO Global Database on Child Growth and Malnutrition seeks to contribute to the transformation of this cycle of poverty, malnutrition and disease into a virtuous one of wealth, growth and health.”, “author” : { “dropping-particle” : “”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “De”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “December”, “issued” : { “date-parts” : “1997” }, “page” : “1-74”, “title” : “Database on Child Growth and Malnutrition”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=df2ec6f1-b85e-46ec-b108-7bca5d2fb1e5” } , “mendeley” : { “formattedCitation” : “(De Onis ; Blu00f6ssner, 1997)”, “plainTextFormattedCitation” : “(De Onis ; Blu00f6ssner, 1997)”, “previouslyFormattedCitation” : “(De Onis ; Blu00f6ssner, 1997)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(De Onis & Blössner, 1997).The 2013 Cost of Hunger in Africa study conduct in Rwanda revealed a shocking impact on economy caused by chronic malnutrition .the study estimates that 49% of the current working age population in Rwanda suffered from stunting as children, thereby impacting on their current productivity. As a result, annually Rwanda loses $ 820million, the equivalent of 11% of her annual Gross Development Production (GDP).

Under nutrition early in life clearly have major consequences for future education, income and productivity outcomes. Stunting was associated with poor school achievement and poor school performance (Dewey et al., 2011).

Recent longitudinal studies among cohorts of children from Brazil, Guatemala, India, Philipine and South Africa confirmed the association between stunting and a reduction in schooling, and also attendance and educational outcomes result in diminished income-earning capacity in adulthood.

A 2007 study estimated an average of 22% loss of yearly income in adulthood (Granthman et al., 2007). What is now becoming clear is that the development impact of under nutrition happens early and is greater than previously thought. Brain and nervous system development begins early in pregnancy and is largely complete by time the child reaches the age of 59 months. The timing, severity and duration of nutritional deficiencies during this period affect brain development in different ways, influenced by the brain’s need for a given nutrient at a specific time (cursick et al., 2012). While the developing brain has the capacity for repair, it is also highly vulnerable, and nutrient deficiencies during critical periods have long term effects.

This new knowledge, together with evidence that the irreversible process of under nutrition happens early in life, has led to a shift in programming focus. Previously the emphasis was on children under age 5, while now it is increasingly on the 1,000-days period up to age 2, including pregnancy. A consequence that is also emerging more clearly is the impact of under nutrition and subsequent disproportionate and rapid weight gain on health later in life. These long term effects are referred to as the fetal programming concept: poor fetal growth, small size at birth and continued poor growth in early life followed by rapid weight gain later in childhood raises the risk of coronary heart disease, stroke and hypertension and type II diabetes (Uauy et al., 2011).

2.2 Empirical LiteratureAccording to Rwanda Demographic Health Survey (RDHS 2010), nationally, 44 % of children under age 5 are stunted, and 17% are severely stunted. Analysis by age group indicates that stunting is apparent even among children less than 6 months of age 17 %. Stunting increases with the age of the child, rising from 26 % among children age 9-11months to the highest level of 55 % among children age 18-23 months, with little change from 24 months to 59months. There is a difference in the level of stunting by gender 47 % among boys and 41% among girls.

Stunting is highest when the birth interval is less than 24 months 47 % are between 24 and 47 months 48 %. The disparity in stunting prevalence between rural and urban children is substantial: 47% of rural children are stunted, as compared with 27 % of urban children. Variation in nutritional status of children by province is quite evident, with stunting being highest in the North 51 % and West 50 % provinces and lowest in the City of Kigali 24 %. Mother’s level of education and wealth quintile has a clear inverse relationship with prevalence of stunting. For example, the prevalence of stunting is higher among children living in the poorest households 54% than among children in the richest households 26% and higher among children whose mothers have no education 52 % than among those whose mother has a secondary education or higher 23 %.Three percent of children under age 5 are wasted, and 1% are severely wasted. The wasting prevalence is highest among children age 9-11 months 8 %and begins to decline only after 11 months of age ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “ISBN” : “9789997743190”, “author” : { “dropping-particle” : “”, “family” : “RDHS”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2015” }, “number-of-pages” : “72”, “title” : “The Republic of Rwanda”, “type” : “report” }, “uris” : “http://www.mendeley.com/documents/?uuid=780a4e7f-c96d-4e51-847b-b4c5e3e88603” } , “mendeley” : { “formattedCitation” : “(RDHS, 2015)”, “plainTextFormattedCitation” : “(RDHS, 2015)”, “previouslyFormattedCitation” : “(RDHS, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(RDHS, 2015).

The proportions of children less than 6 months and 6-8 months who are wasted are 5% and 6 %, respectively. Wasting varies slightly by sex and by area of residence. Boys are more likely to be wasted than girls 3% and 2 %, respectively, and urban children are slightly more likely to be wasted than rural children 4% and 3%. Wasting is more than twice as frequent among children born to malnourished mothers with BMI below 18.5 kg/m2 as among children whose mothers have a normal BMI 18.5-24.9 kg/m2.
Wasting is highest in the City of Kigali and the South province 4 % and lowest in the North province 1 %. Overweight and obesity are other forms of malnutrition that may be on the rise among children in Rwanda. Overall, 7 percent of children below age 5 are overweight or obese (weight-for-height more than +2 SD). There are no substantial differences by sex or area of residence, but overweight and obesity increase with increasing BMI of the mother. Variation by province is small.

Eleven percent of children under 5 are underweight (low weight-for-age), and 2% are severely
underweight. The percentage of children underweight increases steadily from 6% among children under age 6 months to 10 percent among children age 6-8 months and 15 percent among children age 18-23 months, decreasing slightly to 14 percent among children age 48-59 months. This may be due to inappropriate and/or inadequate feeding practices because the percentage of underweight children begins to increase at the age when normal complementary feeding starts. Rural children are twice as likely to be underweight than urban children, 12% versus 6 %. Three of the five provinces in Rwanda (South, West, and East)have percentages of underweight children above the national average ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “RDHS”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2010” }, “number-of-pages” : “574”, “title” : “Rwanda”, “type” : “report” }, “uris” : “http://www.mendeley.com/documents/?uuid=b393d7f3-2797-4d3e-b125-462c778434d1” } , “mendeley” : { “formattedCitation” : “(RDHS, 2010)”, “plainTextFormattedCitation” : “(RDHS, 2010)”, “previouslyFormattedCitation” : “(RDHS, 2010)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(RDHS, 2010).
The prevalence of underweight children is 7 percent in the City of Kigali and 10 percent in the North province. A mother’s health status and educational level are negatively associated with the likelihood that her child is underweight. Children born to mothers in the lowest wealth quintile are more than three times as likely to be underweight as children born to mothers in the highest wealth quintile 16 % versus 5 %. Also, children born to undernourished mothers with BMI <18.5 kg/m2 are twice as likely to be underweight as children whose mothers have a normal BMI 18.5-24.9 kg/m2, 24 % versus 12 % ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Nivers”, “given” : “N”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2015” }, “title” : “Survey Key findings Rwanda National Institute of Statistics of Rwanda”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=bc8d42fb-6fec-4496-964a-955e62ac6090” } , “mendeley” : { “formattedCitation” : “(Nivers, 2015)”, “plainTextFormattedCitation” : “(Nivers, 2015)”, “previouslyFormattedCitation” : “(Nivers, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Nivers, 2015).

Sub-Saharan Africa, with prevalence of under nutrition only surpassed by Asia, has shown the slowest decrease in prevalence in the world. In fact, the prevalence of under nutrition has been increasing in this region since the mid 1980S ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1371/journal.pone.0107040”, “ISBN” : “WHO Environmental Burden of Disease Series, no 12”, “ISSN” : “1932-6203”, “PMID” : “25188502”, “abstract” : “Malnutrition, defined as underweight, is a serious public-health problem that has been linked to a substantial increase in the risk of mortality and morbidity. Women and young children bear the brunt of the disease burden associated with malnutrition. In Africa and south Asia, 27u221251% of women of reproductive age are underweight (ACC/SCN, 2000), and it is predicted that about 130 million children will be underweight in 2005 (21% of all children) (de Onis et al., 2004a). Many of the 30 million low-birth-weight babies born annually (23.8% of all births) face severe short-term and long-term health consequences (de Onis, Blu00f6ssner ; Villar, 1998). In this guide we outline a method for estimating the disease burden at national or local level that is associated with maternal and child malnutrition. The goal is to help policy- makers and others quantify the increased risk associated with malnutrition, in terms of attributable mortality and morbidity, at country or local levels. The estimates will allow policy-makers to compare the disease burden of malnutrition for different countries, or regions within countries, and enable resources to be deployed more effectively. Repeated assessments will also allow trends to be monitored and the impact of interventions to be evaluated. To quantify the disease burden, population attributable fractions are derived from the assessed exposure (malnutrition) and from the relative risk estimates of disease and death associated with malnutrition. The level of malnutrition in the population groups is assessed by anthropometry (i.e. measurements of body size and composition), using as indicators low birth weight in newborns, low weight-for-age in preschool children, and low body mass index in women. Relative risk estimates for diarrhoea, malaria, measles, acute respiratory infections and other infectious diseases are based on a meta-analysis that was part of a global comparative risk assessment project conducted by the World Health Organization (WHO) and its partners. Checklists for collecting and analysing data are also suggested, and a step-by-step example of how to quantify the health impact associated with malnutrition is given for Nepal, a country in the WHO SEAR D subregion. Estimates of the disease burden of malnutrition give policy-makers an indication of the burden that could be avoided if malnutrition were to be eliminated. Disaggregated estimates (e.g. by age, sex, degree of malnutrition) can also help policy-makers identu2026”, “author” : { “dropping-particle” : “”, “family” : “Blu00f6ssner”, “given” : “Monika”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “De”, “family” : “Onis”, “given” : “Mercedes”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “WHO”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Environmental Burden Disease Series”, “id” : “ITEM-1”, “issue” : “12”, “issued” : { “date-parts” : “2005” }, “page” : “43”, “title” : “Malnutrition: quantifying the health impact at national and local levels”, “type” : “article-journal”, “volume” : “12” }, “uris” : “http://www.mendeley.com/documents/?uuid=e0184df8-f277-49b2-9ff4-69e4a60dd488” } , “mendeley” : { “formattedCitation” : “(Blu00f6ssner et al., 2005)”, “plainTextFormattedCitation” : “(Blu00f6ssner et al., 2005)”, “previouslyFormattedCitation” : “(Blu00f6ssner et al., 2005)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Blössner et al., 2005).The prevalence of wasting, stunting and under waiting in Sub-Saharan Africa is estimated at 7.2%, 27% and 39% respectively. There is a wealth of data on under nutrition, its determinants and prevention that has been reviewed by several authors ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1016/S0140-6736(07)61001-0”, “ISBN” : “1474-547X (Electronic)\r0140-6736 (Linking)”, “ISSN” : “01406736”, “PMID” : “17604787”, “abstract” : “Sunil Sazawal and colleagues did a large randomised controlled trial of zinc supplementation in a malaria holoendemic area of east Africa which showed no significant effect on mortality among children younger than 5 years. However in subgroup analyses Sazawal and colleagues showed a significant effect of the intervention on mortality in children older than 12 months and this effect was significant for boys (relative risk 0.71) but not for girls (0.95). We did a similar study on the effects of zinc supplementation in a malaria holoendemic area of west Africa. Here zinc supplementation had no effect on malaria morbidity but significantly reduced diarrhoea morbidity in children younger than 3 years. A subgroup analysis showed that this effect was also significant for boys (relative risk 0.67) but not for girls (1.03) a finding that needs further explanation. Finally we showed a significant association between malnutrition and mortality but not between malnutrition and malaria in this cohort. (excerpt)”, “author” : { “dropping-particle” : “”, “family” : “Mu00fcller”, “given” : “Olaf”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Garenne”, “given” : “Michel”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Becher”, “given” : “Heiko”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sie”, “given” : “Ali”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kouyatu00e9”, “given” : “Bocar”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Lancet”, “id” : “ITEM-1”, “issue” : “9580”, “issued” : { “date-parts” : “2007” }, “page” : “2155-2156”, “title” : “Malnutrition, zinc deficiency, and malaria in Africa”, “type” : “article-journal”, “volume” : “369” }, “uris” : “http://www.mendeley.com/documents/?uuid=4265073a-ff63-445b-a145-04eabe1b17bc” } , “mendeley” : { “formattedCitation” : “(Mu00fcller, Garenne, Becher, Sie, ; Kouyatu00e9, 2007)”, “plainTextFormattedCitation” : “(Mu00fcller, Garenne, Becher, Sie, ; Kouyatu00e9, 2007)”, “previouslyFormattedCitation” : “(Mu00fcller, Garenne, Becher, Sie, ; Kouyatu00e9, 2007)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Müller, Garenne, Becher, Sie, & Kouyaté, 2007).However under nutrition still remains a big problem in the developing world. part of reason is that some areas of the subjects are still unclear issues such as the timing of growth faltering in developing countries and appropriateness of comparing exclusively used breast fed infants to currently used international growth reference still attract debate ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1038/ejcn.2010.52”, “ISBN” : “0954-3007”, “ISSN” : “1476-5640”, “PMID” : “20354559”, “abstract” : “BACKGROUND/OBJECTIVES: Physical activity and exploration in infancy affect physical and cognitive development. Nutritional supplementation improves activity in severely malnourished infants, but the evidence in mild-to-moderately malnourished and nutritionally at-risk infants is equivocal. We tested the effect of multiple-micronutrient supplementation on physical activity and exploration in Mexican infants.\n\nSUBJECTS/METHODS: Using a quasi experimental design, we analyzed data from a supplementation study that lacked a placebo-control group. We compared infants between 8 and 12 months measured at baseline who had received no supplementation (comparison group, n=78), with infants 8-12 months measured after 4 months of daily supplementation (treatment group, n=109). The treatment consisted of three supplement types: micronutrient powder, syrup (each containing only micronutrients) and a milk-based, fortified-food supplement (FFS; containing micronutrients and macronutrients). We formed the micronutrient-only group (MM) by combining the micronutrient powder and syrup groups. We measured activity and exploration by direct observation and used cluster analysis to form and characterize activity and exploration clusters. We performed logistic regression with activity or exploration cluster as the outcome variable and treatment versus comparison and MM or FFS versus comparison as the predictor variables.\n\nRESULTS: Treatment versus comparison increased the odds of being in the high activity (odds ratio (OR)=2.35, P;0.05) and high exploration (OR=1.87, P;0.05) cluster. MM increased the odds of being in the high activity (OR=2.64, P;0.05) cluster and FFS increased the odds (OR=3.16, P;0.05) of being in the high exploration cluster.\n\nCONCLUSIONS: Nutritional supplementation benefited activity and exploration in this sample of Mexican infants.”, “author” : { “dropping-particle” : “”, “family” : “Aburto”, “given” : “N J”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ramirez-Zea”, “given” : “M”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Neufeld”, “given” : “L M”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Flores-Ayala”, “given” : “R”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “European journal of clinical nutrition”, “id” : “ITEM-1”, “issue” : “6”, “issued” : { “date-parts” : “2010” }, “page” : “644-51”, “publisher” : “Nature Publishing Group”, “title” : “The effect of nutritional supplementation on physical activity and exploratory behavior of Mexican infants aged 8-12 months.”, “type” : “article-journal”, “volume” : “64” }, “uris” : “http://www.mendeley.com/documents/?uuid=605e712d-1722-4574-8ba2-94ca3a15ce88” } , “mendeley” : { “formattedCitation” : “(Aburto et al., 2010)”, “plainTextFormattedCitation” : “(Aburto et al., 2010)”, “previouslyFormattedCitation” : “(Aburto et al., 2010)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Aburto et al., 2010). More than one-half of the 9.7 million child deaths worldwide are linked to under nutrition (De Onis et al., 2000). Malnutrition alone, not only kills, but also exacerbates the burden of infectious diseases. World Health Organization in 2002 estimated that more than 3.7 million deaths could be attributed to underweight. Since deaths from under nutrition occur among young children, the loss of healthy life years is even more substantial ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1111/mcn.12259”, “ISBN” : “1740-8695”, “ISSN” : “17408709”, “PMID” : “27187911”, “abstract” : “We use a representative sample of 2561 children 0-23u2009months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one-third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5-fold higher odds of being stunted odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96-3.27; children 6-23u2009months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24-2.14); and lower consumption of eggs was associated with a two-fold increased odds of stunting in children 6-23u2009months old (OR 2.07; 95% CI 1.19-3.61); children whose mother’s height was <u2009145u2009cm, had two-fold higher odds of being stunted (OR 2.04; 95% CI 1.46-2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17-3.02). Attained linear growth (height-for-age z-score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was <u2009145u2009cm, children born with a low birthweight and children 6-23u2009months old who were not fed dairy products, fruits and vegetables. In Maharashtra children’s birthweight and feeding practices, women’s nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2u2009years. Key messages One in five (22.7%) of children 0-23u2009months old in the state of Maharashtra were stunted, and one-third (7.4%) of the stunted children were severely stunted. Birthweight, child feeding, women’s nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2u2009years. Children born to mothers whose height was below 145u2009cm, had two-fold higher odds of being stunted; children born with a low birthweight had a 2.5-fold higher odds of being stunted. Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6-23 months old. Children of households without access to improved sanitation had 88% higher odds of being severely stunted.”, “author” : { “dropping-particle” : “”, “family” : “Aguayo”, “given” : “V??ctor M.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Nair”, “given” : “Rajilakshmi”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Badgaiyan”, “given” : “Nina”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Krishna”, “given” : “Vandana”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Maternal and Child Nutrition”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2016” }, “page” : “121-140”, “title” : “Determinants of stunting and poor linear growth in children under 2 years of age in India: An in-depth analysis of Maharashtra’s comprehensive nutrition survey”, “type” : “article-journal”, “volume” : “12” }, “uris” : “http://www.mendeley.com/documents/?uuid=689de1df-0718-4b63-8bc2-25ca3903071c” } , “mendeley” : { “formattedCitation” : “(Aguayo et al., 2016)”, “plainTextFormattedCitation” : “(Aguayo et al., 2016)”, “previouslyFormattedCitation” : “(Aguayo et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Aguayo et al., 2016).
Under nutrition accounts for 11% of the global burden of disease and is considered the number one risk to health worldwide. Child under nutrition has short and long term effects. The short term effects include morbidity and mortality as it is reported to magnify the progression of disease and it contributes to 53% of deaths among children ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1371/journal.pone.0177338”, “ISBN” : “1111111111”, “ISSN” : “19326203”, “abstract” : “Background”, “author” : { “dropping-particle” : “”, “family” : “Akombi”, “given” : “Blessing J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Agho”, “given” : “Kingsley E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Merom”, “given” : “Dafna”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Renzaho”, “given” : “Andre M.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hall”, “given” : “John J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “PLoS ONE”, “id” : “ITEM-1”, “issue” : “5”, “issued” : { “date-parts” : “2017” }, “page” : “1-11”, “title” : “Child malnutrition in sub-Saharan Africa: A meta-analysis of demographic and health surveys (2006-2016)”, “type” : “article-journal”, “volume” : “12” }, “uris” : “http://www.mendeley.com/documents/?uuid=12655786-1c7d-4d74-ac33-85c298e1e31b” } , “mendeley” : { “formattedCitation” : “(Blessing J. Akombi, Agho, Merom, Renzaho, & Hall, 2017)”, “plainTextFormattedCitation” : “(Blessing J. Akombi, Agho, Merom, Renzaho, & Hall, 2017)”, “previouslyFormattedCitation” : “(Blessing J. Akombi, Agho, Merom, Renzaho, & Hall, 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Blessing et al., 2017). The long-term effects include preventing children from reaching their full developmental potential and poor cognitive performance, which in turn has consequences for the country’s productivity. Global data shows that underweight caused 3.1 million deaths in 2011. In 2013, global data show that the prevalence of stunting, underweight, and wasting was 37%, 15% and 8%, respectively. Under nutrition is reported to be higher in Asia and Africa than in Europe ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s12889-015-1370-9”, “ISBN” : “1288901513709”, “ISSN” : “1471-2458”, “PMID” : “25636688”, “abstract” : “BACKGROUND: More than one-third of deaths during the first five years of life are attributed to undernutrition, which are mostly preventable through economic development and public health measures. To alleviate this problem, it is necessary to determine the nature, magnitude and determinants of undernutrition. However, there is lack of evidence in agro-pastoralist communities like Bule Hora district. Therefore, this study assessed magnitude and factors associated with undernutrition in children who are 6-59 months of age in agro-pastoral community of Bule Hora District, South Ethiopia.\n\nMETHODS: A community based cross-sectional study design was used to assess the magnitude and factors associated with undernutrition in children between 6-59 months. A structured questionnaire was used to collect data from 796 children paired with their mothers. Anthropometric measurements and determinant factors were collected. SPSS version 16.0 statistical software was used for analysis. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to nutritional status of the children Statistical association was declared significant if p-value was less than 0.05.\n\nRESULTS: Among study participants, 47.6%, 29.2% and 13.4% of them were stunted, underweight, and wasted respectively. Presence of diarrhea in the past two weeks, male sex, uneducated fathers andu2009>u20094 children ever born to a mother were significantly associated with being underweight. Presence of diarrhea in the past two weeks, male sex and pre-lacteal feeding were significantly associated with stunting. Similarly, presence of diarrhea in the past two weeks, age at complementary feed was started and not using family planning methods were associated to wasting.\n\nCONCLUSION: Undernutrition is very common in under-five children of Bule Hora district. Factors associated to nutritional status of children in agro-pastoralist are similar to the agrarian community. Diarrheal morbidity was associated with all forms of Protein energy malnutrition. Family planning utilization decreases the risk of stunting and underweight. Feeding practices (pre-lacteal feeding and complementary feeding practice) were also related to undernutrition. Thus, nutritional intervention program in Bule Hora district in Ethiopia should focus on these factors.”, “author” : { “dropping-particle” : “”, “family” : “Asfaw”, “given” : “Mandefro”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Wondaferash”, “given” : “Mekitie”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Taha”, “given” : “Mohammed”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Dube”, “given” : “Lamessa”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC public health”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2015” }, “page” : “41”, “title” : “Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia.”, “type” : “article-journal”, “volume” : “15” }, “uris” : “http://www.mendeley.com/documents/?uuid=00409b80-00bc-4828-a202-39527e2e27db” } , “mendeley” : { “formattedCitation” : “(Asfaw, Wondaferash, Taha, & Dube, 2015)”, “plainTextFormattedCitation” : “(Asfaw, Wondaferash, Taha, & Dube, 2015)”, “previouslyFormattedCitation” : “(Asfaw, Wondaferash, Taha, & Dube, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }( Taha et al., 2015).

Globally, 162 million under five year olds were stunted in 2012.the global trend in stunting prevalence and burden continues to decrease. Between 2000 and 2012 stunting prevalence declined from 33% to 25% and burden decline from 197 million to 162 million.

In 2012, 56% of all stunted children lived in Asia and 36% in Africa. globally 99 million of children aged 6 to 59 months olds where underweight in 2012.the global trend in underweight prevalence continue to decrease, but at slow pace, between 1990 and 2012 underweight prevalence decreased from 25% to 15%,which remains insufficient to meet the millennium Development Goal by 2015 ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s40795-015-0031-9”, “ISSN” : “2055-0928”, “abstract” : “Acute malnutrition is a recent and severe weight loss as a result of acute food shortage and/or illness. It is the leading causes of morbidity and mortality of children aged 6u201359 months as risk of death is nine times higher than that of children without it. In Ethiopia despite recent economic progress; nutritional status of children is among the worst in the world and it remains major public health problem. According to recently published mini demographic & health survey 2014; 9 % of children are wasted (3 % severely wasted) in the country and in Oromia region 8.8 % of children are wasted (1.7 % severely wasted). However there is no information on determinants of acute malnutrition in the study area. The aim of this study was to identify determinants of acute malnutrition among children aged 6u201359 months in the study area.”, “author” : { “dropping-particle” : “”, “family” : “Ayana”, “given” : “Amsalu Bokore”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hailemariam”, “given” : “Tsedeke Wolde”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Melke”, “given” : “Alemu Sufa”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC Nutrition”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2015” }, “page” : “34”, “publisher” : “BMC Nutrition”, “title” : “Determinants of acute malnutrition among children aged 6u201359 months in Public Hospitals, Oromia region, West Ethiopia: a caseu2013control study”, “type” : “article-journal”, “volume” : “1” }, “uris” : “http://www.mendeley.com/documents/?uuid=9ffad04c-cc93-4f13-a194-3ed39b5b72db” } , “mendeley” : { “formattedCitation” : “(Ayana, Hailemariam, & Melke, 2015)”, “plainTextFormattedCitation” : “(Ayana, Hailemariam, & Melke, 2015)”, “previouslyFormattedCitation” : “(Ayana, Hailemariam, & Melke, 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Ayana, Hailemariam, ; Melke, 2015).

In the world 51 million of children aged 6 to 59 months olds were wasted and 17 million were severely wasted in 2012. Approximately 71% of all severely wasted children lived in Asia and 28% in Africa, with similar figures for wasted children at 69% and 28 % respectively. The epidemiologists of different forms of under nutrition also suggest that there may be differences in the etiology of the various forms of under nutrition (De Onis et al., 2000).

The prevalence of malnutrition
Malnutrition remains one of the most common causes of morbidity and mortality among children under five children throughout the World. Worldwide, over 10 million children under the age of 5 years die every year from preventable and treatable illnesses despite effective health interventions. At least half of these deaths are caused by malnutrition. Malnourished children have lowered resistance to infection; therefore, they are more likely to die from common childhood ailments such as diarrheal diseases and respiratory infections. In addition, malnourished children that survive are likely to suffer from frequent illness, which adversely affects their nutritional status and locks them into a vicious cycle of recurring sickness, faltering growth and diminished learning ability. In developing countries, malnutrition is a major health problem. The burden of malnutrition is much higher in South Asia compared to that in Africa and other parts of the world. The prevalence of underweight and stunting in South Asia has been recorded as 46 and 44 percent, respectively. Chronic malnutrition has been a persistent problem for young children in Sub-Saharan Africa. A high percentage of these children fail to reach the normal international standard height for their age; that is, they are “stunted” In contrast, the percentage of children stunted in Southeast Asia dropped from 52 percent to 42 percent between 2015 and 2017. The number of undernourished (low weight for age) people of all ages in sub-Saharan Africa increased from about 90 million in 2007 to 225 million in 2013, and was projected to add another 100 million by 2015, even before the current world food price hikes.

A study conducted on influence of socioeconomic factors on nutritional status of children in a rural community of osun state, Nigeria revealed that the prevalence rates of underweight, wasting and stunting were 23.1%, 9 % and 26.7% respectively, and also prevalence and determinants of malnutrition among Under-five Children of Farming Households in Kwara State, Nigeria results indicate that 23.6%, 22.0% and 14.2% of the sample children were stunted, underweight and wasted, respectively.

Taha and Musaa (2014) conducted a study to identify the prevalence of malnutrition (underweight, stunting and wasting) among children under 5 year’s old living in Khartoum state, Sudan. The results showed that socioeconomic factor, poor nutrition, and mothers’ knowledge and feeding practices led to increase in the prevalence of malnutrition. MUAC indicator showed that 20.9% of children were badly nourished and 79.1% of the children were well nourished. In addition, to poor economic situation, the study found that about 15.4% of children were underweight, 8.8% were moderate underweight and 6.6% were severe underweight. The prevalence of wasting was 21.1% (12.3% moderate and 8.8% severe) and the prevalence of stunting was 24.9% (15.1% moderate and 9.7% severe). The World Health Organization standard showed that the prevalence of global malnutrition, moderate malnutrition and severe malnutrition was 12.8%, 8.0% and 13.6%, respectively. The National Center for Health Statistics reference showed that the prevalence of global malnutrition, moderate malnutrition and severe malnutrition was 23.1%, 10.2% and 12.9%, respectively. This study conclude that improvements in child feeding, and better maternal education are needed to maintain the children’s nutritional status ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Tavani”, “given” : “Alessandra”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “La”, “family” : “Vecchia”, “given” : “Carlo”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Negri”, “given” : “Eva”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bertuzzi”, “given” : “Michaela”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “2001” }, “page” : “2135-2136”, “title” : “For personal use . Only reproduce with permission from The Lancet Publishing Group . For personal use . Only reproduce with permission from The Lancet Publishing Group .”, “type” : “article-journal”, “volume” : “357” }, “uris” : “http://www.mendeley.com/documents/?uuid=65bca137-d907-4a1a-b17c-77cdc308e260” } , “mendeley” : { “formattedCitation” : “(Tavani et al., 2001)”, “plainTextFormattedCitation” : “(Tavani et al., 2001)”, “previouslyFormattedCitation” : “(Tavani et al., 2001)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Tavani et al., 2001).
The Survey conducted by Lidia Cantero (2015) on integrated nutrition survey of 6 to 59 month children Rathedaung Township Rakhine state, republic of the Union of Myanmar. A total of 372 children aged 6-59 months were included in the survey. The prevalence of global acute malnutrition was 10.5% (6.7 – 16.0 95% C. I) and severe acute malnutrition was 1.6% (0.7- 3.8 95% C. I). Global stunting was 37.9% (31.8-44.4 95% C. I) and severe stunting was 15.6% (11.9- 20.2 95% C. I). Global underweight was 30.4% (24.4-37.2 95% C.I.) and severe underweight was 10.5 % (6.2 – 17.3 95% C. I.). A total of 193 Pregnant and Lactating Women was included in the survey. 9.3% of the Pregnant and Lactating women had a MUAC under 210 mm. 33.7% of them were found with MUAC <230mm. Findings revealed measles vaccination coverage of 59.2% for 9-59 months old children. Vitamin A supplementation in the last six months had occurred in 39.7% of children. 65% of children were reported having some sort of acute illness. Food security information from 276 households was collected. The average household dietary diversity score was 6.4, which is above the minimum acceptable score of 4. The Food Consumption Score revealed that 96% of households had an adequate and 4% had a borderline.

Regarding mental health status, 275 mother’s caretakers were interviewed. 41.8% show a score less than the threshold for poor well-being and thus potentially affected by depressive mood and stress. The average score for all respondents was 13.6, almost equal to the threshold. As a result, the level of wellbeing is considered generally acceptable. The villages assessed shown low sanitation coverage with only 27% of the 273 households surveyed reporting the use of latrine and just about half of the schools having latrines. In terms of drinking water source, 97% of households had no access to an improved water source and only 67% reported treating the water, however, typically with ineffective methods. Analysis of hygiene practices evidenced the need for improvements in this issue as well.

Blessing Jaka Akombi et al., (2017) conducted a study on Stunting and severe stunting among children under-5 years in Nigeria. The prevalence of stunting and severe stunting was 29% 95% Confidence interval (Cl): 27.4, 30.8 and 16. 4% 95%Cl: 15.1, 17.8, respectively, for children aged 0–23 months, and 36.7% 95%Cl: 35.1, 38.3 and 21% 95%Cl: 19.7, 22.4, respectively for children aged 0–59 months. Multivariate analysis revealed that the most consistent significant risk factors for stunting and severe stunting among children aged 0–23 months and 0–59 months are: sex of child (male), mother’s perceived birth size (small and average), household wealth index (poor and poorest households), duration of breastfeeding (more than 12 months), geopolitical zone (North East, North West, North Central) and children who were reported to having had diarrhea in the 2 weeks prior to the survey Adjusted odds ratio (AOR) for stunted children 0–23 months = 1.22 (95%Cl: 0.99, 1.49);AOR for stunted children 0–59 months = 1.31 (95%Cl: 1.16, 1.49), AOR for severely stunted children 0–23 months = 1.31 (95%Cl: 1.03, 1.67); AOR for severely stunted children 0–59 months = 1.58 (95%Cl: 1.38, 1.82).In order to meet the post 2015 sustainable development goals, policy interventions to reduce stunting in Nigeria should focus on poverty alleviation as well as improving women’s nutrition, child feeding practices and household sanitationADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1371/journal.pone.0177338”, “ISBN” : “1111111111”, “ISSN” : “19326203”, “abstract” : “Background”, “author” : { “dropping-particle” : “”, “family” : “Akombi”, “given” : “Blessing J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Agho”, “given” : “Kingsley E.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Merom”, “given” : “Dafna”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Renzaho”, “given” : “Andre M.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hall”, “given” : “John J.”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “PLoS ONE”, “id” : “ITEM-1”, “issue” : “5”, “issued” : { “date-parts” : “2017” }, “page” : “1-11”, “title” : “Child malnutrition in sub-Saharan Africa: A meta-analysis of demographic and health surveys (2006-2016)”, “type” : “article-journal”, “volume” : “12” }, “uris” : “http://www.mendeley.com/documents/?uuid=12655786-1c7d-4d74-ac33-85c298e1e31b” } , “mendeley” : { “formattedCitation” : “(Blessing J. Akombi et al., 2017)”, “plainTextFormattedCitation” : “(Blessing J. Akombi et al., 2017)”, “previouslyFormattedCitation” : “(Blessing J. Akombi et al., 2017)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Blessing Akombi et al., 2017).

A study conducted by Gul Nawaz Khan et Al., (2016) on Prevalence and associated factors of malnutrition among children under-five years in Sindh, Pakistan.The prevalence of stunting, wasting and underweight were 48.2% (95% CI: 47.1–50.3), 16.2% (95% CI: 15.5–17. 9), and 39.5% (95% CI: 38.4–41.5), respectively. A similar relationship was observed between household wealth and underweight in children (43.8% in the poorest and 28.8% in wealthiest households (OR 2.18, CI 1.72–2.77, p ; 0.001). Household wealth was significantly associated with stunting, wasting and underweight. Diarrhea was associated with underweight. Factors such as mother’s education, parity and family size were not associated with malnutrition in study area. The findings of study revealed that malnutrition was widespread among the children under- five years of age. The food/nutrient based interventions together with improved hygiene practices and household wealth should be targeted to improve malnutrition situation in the study area and in the countryADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s40795-016-0112-4”, “ISSN” : “2055-0928”, “author” : { “dropping-particle” : “”, “family” : “Khan”, “given” : “Gul Nawaz”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Turab”, “given” : “Ali”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Khan”, “given” : “Mohammad Imran”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Rizvi”, “given” : “Arjumand”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Shaheen”, “given” : “Fariha”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ullah”, “given” : “Asmat”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hussain”, “given” : “Amjad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hussain”, “given” : “Imtiaz”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ahmed”, “given” : “Imran”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Yaqoob”, “given” : “Muhammad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ariff”, “given” : “Shabina”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Soofi”, “given” : “Sajid Bashir”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC Nutrition”, “id” : “ITEM-1”, “issue” : “December”, “issued” : { “date-parts” : “2016” }, “page” : “1-7”, “publisher” : “BMC Nutrition”, “title” : “Prevalence and associated factors of malnutrition among children under-five years in Sindh , Pakistan : a cross-sectional study”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=e960e309-9ea5-4090-964d-1a7a9fc4533b” } , “mendeley” : { “formattedCitation” : “(Khan et al., 2016)”, “plainTextFormattedCitation” : “(Khan et al., 2016)”, “previouslyFormattedCitation” : “(Khan et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Khan et al., 2016).

Sandra Nkurunziza et al., (2017) conducted a study on Determinants of stunting and severe stunting among Burundian children aged 6-23 months. The sample is made up of 6199 children aged 6 to 23 months with complete anthropometric measurements from the baseline survey of an impact evaluation study, found that the prevalence of stunting and severe stunting was 53% 95%CI: 51.8-54.3 and 20.9% 95%CI: 19.9-22.0 respectively. The factors associated with stunting were found to be applicable for severe stunting as well. Mother’s education level, mother’s knowledge about child nutrition status assessment and health facility delivery were predictors of child stunting. Study confirms that stunting and severe stunting is in Burundi, as elsewhere, a multi-sectorial problem. Some determinants relate to the general development of Burundi: education of girls, poverty, and food security; will be addressed by a large array of actions. Some others relate to the health sector and its performance we think in particular of the number of children under five in the household (birth spacing), the relationship with the health center and the knowledge of the mother on malnutrition. Findings confirm that the Ministry of Health and its partners should strive for better performing and holistic nutrition services: they can contribute to better nutrition outcomesADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s40795-016-0112-4”, “ISSN” : “2055-0928”, “author” : { “dropping-particle” : “”, “family” : “Khan”, “given” : “Gul Nawaz”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Turab”, “given” : “Ali”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Khan”, “given” : “Mohammad Imran”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Rizvi”, “given” : “Arjumand”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Shaheen”, “given” : “Fariha”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ullah”, “given” : “Asmat”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hussain”, “given” : “Amjad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Hussain”, “given” : “Imtiaz”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ahmed”, “given” : “Imran”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Yaqoob”, “given” : “Muhammad”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ariff”, “given” : “Shabina”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Soofi”, “given” : “Sajid Bashir”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC Nutrition”, “id” : “ITEM-1”, “issue” : “December”, “issued” : { “date-parts” : “2016” }, “page” : “1-7”, “publisher” : “BMC Nutrition”, “title” : “Prevalence and associated factors of malnutrition among children under-five years in Sindh , Pakistan : a cross-sectional study”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=e960e309-9ea5-4090-964d-1a7a9fc4533b” } , “mendeley” : { “formattedCitation” : “(Khan et al., 2016)”, “plainTextFormattedCitation” : “(Khan et al., 2016)”, “previouslyFormattedCitation” : “(Khan et al., 2016)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Khan et al., 2016).

A study conducted at Jomo Kenyatta University of Agriculture and Technology, by Maryam Ahmed Abdulrahim (2016) on Socio-cultural determinants of Malnutrition among children aged below 5 years in Garissa Sub County, Kenya found that Malnutrition is a serious condition that occurs when a person’s diet doesn’t contain the right amount of nutrients. It is a chronic public health problem among under-five children in the developing world. In Kenya it is also the single greatest contributor to child mortality, yet information on contributing socio-cultural factors has not been well documented. The main objective of this study was to investigate the socio-cultural factors that contribute to under nutrition among children below five years in Garissa sub county, Kenya. The prevalence of stunting, underweight and wasting in this study was found to be 38.1%, 31.0% and 26.0% respectively. Children aged 13-24 months and 25-36 were 2.71 times and 2.37 times more likely to be stunted than younger children (<12 months) respectively. Mothers/guardians aged 16-25 years had 4.52 fold more children with wasting than mothers/guardians who were aged above 36 years.
In thinking about universality, it is important to examine the prevalence of the malnutrition burden, where it exists and among which sub-populations within countries. Even better would be to have subnational, deeper disaggregated-level data to ensure that no one is left behind. These data gaps are discussed in the section data needs for tracking progress towards a universal outcome. The number of children affected by stunting globally has decreased drastically since 1990. But trends have varied across regions, with the rate of decline being unequal across regions and sub-regions. Africa is the only region that has seen an increase in the number of children stunted despite a decrease in the prevalence of stunting. Together, Africa and Asia account for nearly all the global burden of stunting. In 2016, two of every five of the world’s stunted children and more than half of all wasted children lived in South Asia.
Over the same period, the number of children under age 5 who are overweight has increased dramatically worldwide, with 40.6 million overweight in 2016.And more than 15% of children under age 5 in South Asian countries were wasted in 2016 (27.6 million). This represents a critical public health emergency (as prevalence more than 10% does) and reflects a serious and pressing problem. Disease and malnutrition are closely linked. Sometimes disease is the result of malnutrition, sometimes it is a contributing cause. In fact, malnutrition is the largest single contributor to disease in the world, according to the UN’s Standing Committee on Nutrition (SCN). The model characterizes the correlates of malnutrition as factors that impair access to food, maternal and child care, and health care. It is these very factors that impact the growth of children.
Each year about 13 million infants and children die in the developing countries. The majority of these deaths are due to infections and parasitic diseases, and many, if not most of the children die malnourished. According to Benson (2005), malnutrition is a physical condition or process that results from the interaction of inadequate diet and infection and is most commonly reflected in poor infant growth, reduced cognitive development, anemia, and blindness in those suffering severe micronutrient deficiencies, and excess morbidity and mortality in adults and children alike. The effects of malnutrition on human performance, health and survival have been the subject of extensive research for several decades and studies show that malnutrition affects physical growth, morbidity, mortality, cognitive development, reproduction, and physical work capacity. Malnutrition is particularly prevalent in developing countries, where it affects one out of every three preschool-age children. Factors that contribute to malnutrition are many and varied. The primary determinants of malnutrition, as conceptualized by several authors relate to unsatisfactory food intake, severe and repeated infections, or a combination of the two. The interactions of these conditions with the nutritional status and overall health of the child – and by extension – of the populations in which the child is raised have been shown in the UNICEF Conceptual framework of child survival.

Briefly, the model characterizes the correlates of malnutrition as factors that impair access to food, maternal and child care, and health care. It is these very factors that impact the growth of children. The nutritional status of women and children is particularly important, because it is through women and their offspring that the pernicious effects of malnutrition are propagated to future generations. A malnourished mother is likely to give birth to a low birth- weight (LBW) baby susceptible to disease and premature death, which only further undermines the economic development of the family and society, and continues the cycle of poverty and malnutrition. Although child malnutrition declined globally during the 1990s, with the prevalence of underweight children falling from 27% to 22%, national levels of malnutrition still vary considerably (0% in Australia; 49% in Afghanistan). In contrast, south-central Asia still has high levels of child malnutrition, even though the rate of underweight children declined from 50% to 41% during the 1990s. In Africa, the number of underweight children actually increased between 1990 and 2000 (from 26 million to 32 million), and 25% of all children under five years old are underweight, which signals that little changed from a decade earlier. The projection for 2005 is that the prevalence of child malnutrition will continue to decline in all regions, but Africa, which is dominated by the trend in sub-Saharan Africa.

Many factors can contribute to high rates of child malnutrition, ranging from those as fundamental as political instability and slow economic growth, to highly specific ones such as the frequency of infectious diseases and the lack of education. These factors can vary across countries. Important determinants of child malnutrition, such as the prevalence of intrauterine growth retardation, also differ considerably across geographical regions.
Malnutrition commonly affects all groups in a community, but infants and young children are the most vulnerable because of their high nutritional requirements for growth and development. Another group of concern is pregnant women, given that a malnourished mother is at high risk of giving birth to a LBW baby. Malnourished girls, in particular, risk becoming yet another malnourished mother, thus contributing to the intergenerational cycle of malnutrition.
In developing countries, poor perinatal conditions are responsible for approximately 23% of all deaths among children younger than five years old. These deaths are concentrated in the neonatal period (i.e. The first 28 days after birth), and most are attributable to LBW. LBW can be a consequence of IUGR, preterm birth, or both, but in developing countries most LBW births are due to IUGR (defined as below the tenth percentile of the Williams sex-specific weight-for- gestational age reference data). Growth assessment is the single measurement that best defines the health and nutritional status of a child, WHO has been recommending that a single international reference population be used worldwide, with common indicators and cutoffs, and that standard methods be used to analyze child growth data.
2.3 Determinant of malnutrition
Income poverty (due to unemployment, low wages, or lack of education) can lead to household food insecurity, inadequate care, unhealthy household environment, and lack of health services. People of low socioeconomic status are most vulnerable to food insecurity since purchasing power serves as a main determinant of the ability to-afford nutritional food sources. Households that cannot attain nutritious foods due to income poverty are most associated with the inadequate diet and disease that leads to malnutrition. Severe malnutrition can result in many disease-related consequences, and effects on morbidity, mortality, and disability all contribute to increased healthcare costs. Low-income households usually spend the majority of total household income on food. In these cases, even the lowest out-of-pocket healthcare service can severely diminish the remaining income to be used for food supply, further perpetuating the issue of food insecurity. Many adults living in low income countries cannot afford to be sick: healthcare costs are high, transportation costs of health facilities accumulate, and taking days off work means lost productivity and lost wages. Under nutrition is a major underlying cause of illness and disease, and one that contributes to additional health care spending.

A study conducted by Elizabeth and Rose (2015) of Determinants of under nutrition among children aged 6 to 59 months in the rural Zambézia Province, Mozambique, found that 43% were undernourished in 2010 and 55% in 2014. The most common form of under nutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child’s age was found to have a nonlinear association with stunting. Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased the odds of being underweight in 2014. Introducing other foods after age six months was associated with a five year old increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.1186/s40795-015-0039-1”, “ISBN” : “4079501500391”, “ISSN” : “2055-0928”, “PMID” : “27182448”, “abstract” : “While many countries are transitioning from epidemics of undernutrition to overnutrition, Mozambiqueu2019s very high 44u00a0% prevalence of stunting in children under age 5u00a0years is cause for serious concern.”, “author” : { “dropping-particle” : “”, “family” : “Rose”, “given” : “Elizabeth S”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Blevins”, “given” : “Meridith”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Gonzu00e1lez-Calvo”, “given” : “Lazaro”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Ndatimana”, “given” : “Elisu00e9e”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Green”, “given” : “Ann F”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Lopez”, “given” : “Melanie”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Olupona”, “given” : “Omo”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Vermund”, “given” : “Sten H”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Moon”, “given” : “Troy D”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “BMC Nutrition”, “id” : “ITEM-1”, “issue” : “1”, “issued” : { “date-parts” : “2015” }, “page” : “1-11”, “title” : “Determinants of undernutrition among children aged 6 to 59u00a0months in rural Zambu00e9zia Province, Mozambique: results of two population-based serial cross-sectional surveys”, “type” : “article-journal”, “volume” : “1” }, “uris” : “http://www.mendeley.com/documents/?uuid=fd2074d9-eb86-4315-8976-d2f01ed11620” } , “mendeley” : { “formattedCitation” : “(Rose et al., 2015)”, “plainTextFormattedCitation” : “(Rose et al., 2015)”, “previouslyFormattedCitation” : “(Rose et al., 2015)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Rose et al., 2015).

Luchuo Engelbert Bain (2013) conducted a study on Malnutrition in Sub – Saharan Africa: burden, causes and prospects, they reported that Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001. Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation.
Grooming undernourished children causes children to start life at mentally sub optimal levels. This becomes a serious developmental threat. Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Socio cultural barriers are major hindrances in some communities, with female children usually being the most affected. Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. A multisectorial approach is vital in tackling this problem. Improvement in government policy, the fight against corruption, adopting a horizontal approach in implementing programs at community level must be recognized. Genetically modified foods to increase food production and to survive adverse climatic conditions could be gateways in solving these problems. Socio cultural peculiarities of each community are an essential base line consideration for the implementation of any nutrition health promotion programsADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.11604/pamj.2013.15.120.2535”, “ISBN” : “1937-8688 (Electronic)”, “ISSN” : “19378688”, “PMID” : “24255726”, “abstract” : “Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001. Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation. Grooming undernourished children causes children to start life at mentally sub optimal levels. This becomes a serious developmental threat. Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Sociocultural barriers are major hindrances in some communities, with female children usually being the most affected. Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. A multisectorial approach is vital in tackling this problem. Improvement in government policy, fight against corruption, adopting a horizontal approach in implementing programmes at community level must be recognized. Genetically modified foods to increase food production and to survive adverse climatic conditions could be gateways in solving these problems. Socio cultural peculiarities of each community are an essential base line consideration for the implementation of any nutrition health promotion programs.”, “author” : { “dropping-particle” : “”, “family” : “Bain”, “given” : “Luchuo Engelbert”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Awah”, “given” : “Paschal Kum”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Geraldine”, “given” : “Ngia”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Kindong”, “given” : “Njem Peter”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Sigal”, “given” : “Yelena”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Bernard”, “given” : “Nsah”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Tanjeko”, “given” : “Ajime Tom”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “container-title” : “Pan African Medical Journal”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2013” }, “page” : “1-9”, “title” : “Malnutrition in Sub – Saharan Africa: Burden, causes and prospects”, “type” : “article-journal”, “volume” : “15” }, “uris” : “http://www.mendeley.com/documents/?uuid=8e9ed6f7-bad8-400f-bf8c-8f227e5d4895” } , “mendeley” : { “formattedCitation” : “(Bain et al., 2013)”, “plainTextFormattedCitation” : “(Bain et al., 2013)”, “previouslyFormattedCitation” : “(Bain et al., 2013)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Bain et al., 2013).Stunting was slightly higher (51%) in boys than in girls (45%) (p;0.001). The proportion of wasting (p = 0.039) and underweight (p = 0.206) was not significantly different between boys and girls. Fifty percent children in the poorest households were stunted as compared to 42% in the wealthiest households. Children in the poorest households were two times more likely to be wasted (20.6%) than children in the wealthiest households (10.3%) (OR 2.33, CI 1.69–3.21, p ; 0.001).Compared to children from 6-11 months, children of 12-17 months and 18-23 months had a higher risk of stunting (AdjOR:2.1; 95% CI: 1.8-2.4 and 3.2; 95% CI: 2.8-3.7). Other predictors for stunting were small babies (AdjOR=1.5; 95% CI: 1.3-1.7 for medium-size babies at birth and AdjOR=2.9; 95% CI: 2.4-3.6 for small-size babies at birth) and male children (AdjOR=1.5, 95% CI: 1.4-1.8). In addition, having no education for mothers (AdjOR=1.6; 95% CI: 1.2-2.1), incorrect mothers’ child nutrition status assessment (AdjOR=3.3; 95% CI: 2.8-4), delivering at home (AdjOR=1.4; 95% CI: 1.2-1.6) were found to be predictors for stunting. More than to 2 under five children in the household (AdjOR=1.45; 95% CI: 1.1-1.9 for stunting and AdjOR= 1.5; 95% CI: 1.2-1.9 for severe stunting) and wealth were found to be predictors for both stunting and severe stunting. Households whose income per month was less than 5000 Ksh were 3.11 times more likely to have children with underweight than households? whose income was 15000- 20,000Ksh. Similarly, mothers/guardians who reported cost of preparing food for their child to be expensive had 2.07 fold more chances to have children with stunting than to those indicated the cost to be affordable. Children who have been recently sick were significantly 2.54 times and 1.76 times more likely to be wasted and underweight respectively, when compared to those who did not experience recent illness. Children with low birth weight (<2.5kgs) were 3.16 fold more likely to be underweight than children with birth weight of 2.5kgs and above ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Mutua”, “given” : “Ruth N”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Keriko”, “given” : “Joseph”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mutai”, “given” : “Joseph”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Mutua”, “given” : “Ruth N”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “Factors Associated With Stunting , Wasting and Underweight Among Children Aged 2-5 Years in Early Childhood Development and Education Centers in Masinga Sub County , Machakos County Factors Associated With Stunting , Wasting and Underweight Among Children”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=b7431c53-47c2-4199-a8d5-d15048bdb5e3” } , “mendeley” : { “formattedCitation” : “(Mutua, Keriko, Mutai, & Mutua, n.d.)”, “plainTextFormattedCitation” : “(Mutua, Keriko, Mutai, & Mutua, n.d.)”, “previouslyFormattedCitation” : “(Mutua, Keriko, Mutai, & Mutua, n.d.)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(Mutua et al.,2016).Children weaned within two months were found to be 3.12 times more stunted than children weaned at 6 months of age. Mothers who never attend ANC during their pregnancy had about 2 times more children with wasting than those who attended ANC. Female children were significantly about 2 fold more likely to be underweight than male children. 
A study conducted by Nabeela Ahmed on determinants of child under nutrition in Bangladesh demonstrate that; the underlying determinants of child under nutrition include income poverty which is concomitant with household food insecurity exacerbated by the Bangladeshi context of food price fluctuations (although fluctuations have been modest compared to other countries); deficiencies in care (both within the household and from external healthcare services); and an unhealthy household environment. The importance of gender in influencing these underlying factors is also recurrent in the literature and can intensify or modifies the impacts of food security and care giving. Water, sanitation and health facilities determine the infection environment which children are exposed and thus their risk of suffering under nutrition outcomes. Food insecurity has been defined as a condition that exists when people do not have adequate physical, social or economic access to food, (FAO 2010). Food security has major impacts on hunger and under nutrition. Food and its access and availability are cited as one of the most important long-term factors that could prevent under nutrition. The quantity and nutritional quality of food can determine the intake of energy, protein and vitamins, which affects growth, development and resistance to disease and infection. A lack of nutrients can lead to a vicious cycle of illness and under nutrition. Maternal health as a determinant of child under nutrition can spiral out to have intergenerational effects. Malnourished adolescent girls are likely to become malnourished mothers, and this can have impacts spanning from the intrauterine development phase through to the health and nutritional status of birth outcomes. Maternal health is a key factor in determining the nutritional status of children, particularly in the first stage of infancy (zero to five years) (Deolalikar 2005). Maternal health during pregnancy and exclusive breastfeeding and while caring for a child is a useful predictor of pregnancy outcomes and the subsequent nutritional status of a child. Malnourished mothers can contribute the likelihood of giving birth to children with anemia or low birth weight.
The research demonstrates that Water, sanitation and hygiene access to improved water sources is almost universal in Bangladesh (99% of households). Access to improved sanitation is less good with 33.7% of households reporting access to improved, not shared facilities and 18.9% to improved shared facilities. The literature conveys the sustained negative impact of repeated infections combined with poor nutrition, and how this can create a cyclical vulnerability to under nutrition and infection.

The basic factors deal with the wider socioeconomic, ecological and cultural contexts of child under nutrition in Bangladesh. As seen in this review, gender is a crosscutting issue across many of the determinants and sub-categories of child under nutrition. Household gender dynamics, the level of female empowerment and broader cultural attitudes regarding gender roles can all determine a child’s nutritional status at a basic level. Poverty and vulnerability must also be taken into account when looking at basic factors these are related to food security, Water, sanitation and hygiene and access to health care services which in turn are linked with the immediate factors of diet and illness. Finally, Bangladesh is prone to natural disasters heavy flooding in particular and lacks a robust disaster response infrastructure. The impacts of such disasters are compounded for the poor and vulnerable, who tend to live in areas served poorest or neglected by infrastructure. Under nutrition has been observed as both a short-term and long-term outcome of such disaster situations.

 
2.4. Critical review and research gap identification
The literature concentrates more on determinant of under nutrition among children aged 6 to 59 months. Most of the studies were done outside Rwanda. So there are few literatures on determinant of under nutrition among children in Rwanda, thus this study will form a basis for more information in Rwandan children with malnutrition heath problem as far as nutrition is public health concerned. In Rwanda the prevalence of under nutrition among children under five years had decreased from 51% in 2005 to 44% in 2010 but has stayed almost the same at 43% in 2012. However, as noted in different literature conducted, the impact of under nutrition is permanent for children under five years. Causes behind this high prevalence are not fully known. The rate of about 15% of children at two months likely indicates stunting at birth, which is attributable mainly to inadequate nutrition of the mother or serious illness during pregnancy.
Child characteristic of under five years is not considered by most of the literature developed on child malnutrition when this can be a major indicator for monitoring and evaluation under five year children’s nutritional status. After birth, exclusive breastfeeding rates are high and breastfeeding most often continues throughout the first 24 months of life or beyond often beyond. The period when under nutrition is found to rapidly increase, directly corresponds to the period when complementary foods are introduced and also when the infant starts to become more active and exposed to infectious disease. Information from qualitative studies and national surveys have found that many children are not fed in accordance with the requirements and recommendations in terms of the adequacy of the nutrients or the frequency needed because their stomachs are small.
Mother’s level of education contributes to the quality of care provided to under five year nutrition status, but on many research this is not taken into consideration than feeding practice. This research would like to identify maternal characteristic, in term of education level, feeding practices, hygiene and knowledge on providing quality and quantity food required to under five years children. Despite a major program to improve maternal, infant and young child nutrition mainly through activities at clinics and by in communities by community health workers, serious problems remained. While breastfeeding rates are very high throughout the country, complementary feeding was found to be inadequate for many infants over six months and children under five years in many households.
The direct conditions requiring improvement were the amounts and quality complementary foods and the frequency of feeding. Underlying these conditions are the need for more knowledge and skills on the parts of mothers and caregivers, inadequate household food security in some cases and problems such the mother not being able to stay with the child because of work.
As noted in the previous section, children need additional food to complement breastfeeding after six months. However, a 2012 national KAP study 13found that about 32% of mothers do not introduce complementary foods to children before they are one year of age. That study found that 36% of respondents provided children one to two years of age with complementary foods only once or twice a day.
These findings may be due to insufficient food or poor feeding and care practices, and likely contribute both to acute malnutrition and be a major factor of under nutrition among children of under five years.

Factors associated with under nutrition are unknown, and not well mentioned on many literatures, previous research conducted in Rwanda on determinant of under nutrition among children aged 6 to 59 months, but this can be a key element of the under nutrition become a public health concern. Problems of water, hygiene, and sanitation affect the synergy between malnutrition and infection. High priority for hygiene is justified because improved personal and domestic hygiene practices can reduce diarrhea by over 65% (e.g. Hand-washing with soap at critical times is estimated to reduce diarrhea by 47%) compared to safe water that links to a 15% reduction). Improving the nutrition of under five year children in Rwanda will require continued emphasis on promoting total access to hygienic latrines and hand washing and careful preparation of foods for the family and especially young children. Greater emphasis is needed on careful handling of young child faces. The latter may be caused by insufficient nutritious food in the household, poor eating habits or problems with intra household food distribution, the feeding attitude, practice, belief, culture of different community, food, and health seeking behavior; can be factors associated with under nutrition among children aged 6 to 59 months in the Gicumbi District Northern province Rwanda. But most of research developed and conducted on this topic in the country in general and in Gicumbi district in particular did not take into consideration these factors.

Literature review about under nutrition have not considered the feeding attitude, practice, belief, culture of the different community which can be among associates factors to this malnutrition among children under five years in Gicumbi district northern province Rwanda.
Theoretical framework
The study will be guided by The UNICEF conceptual framework on under nutrition is used to guide interventions from a multi-sectoral and multidimensional perspective, moving from macro to micro-levels of focus.
The framework includes the basic, underlying, and immediate causes of malnutrition. The basic causes address systemic-level challenges reflecting the structural and political processes in each society, which includes social, economic, environmental, and political issues that lead to the lack of or unequal distribution of capital. Capital includes financial, human, physical, social, and natural resources. The underlying causes focus on household food security, adequate care and feeding practices, access to health services, and residing in a healthy environment. The immediate causes are the impact of the basic and underlying causes at the individual level through inadequate food intake and disease. Ultimately, the framework provides an interface between these broader systemic-level issues and the community, household, and individual levels. The conceptual framework, originally designed in 1990, has been refined to be broad enough to encompass multiple sectors that impact the causes of malnutrition at each level.
The conceptual framework has been modified for specific geographical contexts or with a focus on interventions. Nutrition is directly related to food intake and infectious diseases such as diarrhea, acute respiratory infection, malaria, and measles. Both food intake and infectious diseases reflect underlying social and economic conditions in the household, community, and national levels that are supported by political, economic, and ideological structures within a country.

The following diagram is a conceptual framework for nutrition adapted from UNICEF. It reflects the relationships among factors and their influences on children’s nutritional status. Although political, socioeconomic, environmental and cultural factors (at the national and community levels) and poverty (at the household level) affect the nutritional status of women and children. The highlighted areas of the framework depict selected factors. These factors are
Immediate influences: such as food intake (micronutrient status and supplementation) and infectious diseases (diarrhea and respiratory infections).

Underlying biological and behavioral influences: such as maternal fertility, measles vaccinations, and feeding patterns of children under five years.

Underlying social and economic influences: such as maternal education, drinking water, and sanitation.

Basic influences: such as area of residence.

Conceptual frameworkA conceptual framework consists of concepts, together with their definition, and existing theories that are used for a particular study.

Figure SEQ Figure * ARABIC 1 shows that manipulates the stated independent variables would have an effect on
child nutrition.DEPENDENT VARIABLE
Under nutrition among children aged 6 to 59 months.

INDEPENDENTS VARIABLES
Inadequate dietary intake
Household food insecurity
Inadequate care and feeding practices.

Unhealthy household
Environmental factors
Inadequate health services.

Intervening Variables
Household access to adequate quantity and quality of resources: land, education, employment, income, technology
Inadequate financial, human, physical and social capital
Sociocultural, economic, and political context

Source: Researcher
2.8 SummaryWhereas the literature reviewed indicates that malnutrition among children under five years is determined by several factors, a need to find out if similar factors are responsible for malnutrition in Gicumbi District is quite important. This is part of the research gap that this study seeks to examine.CHAPITER THREE: RESEARCH METHODOLOGYIntroductionThis chapter entails the methods that were used in carrying out the study for the accomplishment of the study objectives. Included in this chapter is study design, study population, sample size and sampling procedures, data collection instruments, data collection procedures, data analysis and ethical consideration.

Research designA descriptive Crosse-sectional design will be used in this study. It is a descriptive study because the researcher will determines, observes, describes a phenomenon in terms of prevalence, characteristics and documented the aspect of the situation. The study is Crosse-sectional because, involve the data collection of one time (Mugenda and Mugenda 2003). The study will use a quantitative research approach.
3.4 Target population
Target population of this study will consist of all 6-59 months old children (paired with their mothers) both male and female.
According to Gicumbi District Health Survey a total of 69369 children under five years in Gicumbi District during the study period.3.3 Sample Design3.3.1 Sample sizeSample size refers to the number of units or people that are chosen from which the researcher wish to gather information or data (Evans et al., 2000). A sample of 362 respondents will be selected to provide quantitative information.

The desired sample size will be determined using the formula of Fisher et al (1991):
n=z2P(1-P)d2
Where:
n – The desired sample size (assuming the population is greater than 10,000)
z – The standard normal deviation, set at 1.96, which corresponds to 95% confidence level
p – The prevalence of under nutrition in Rwanda is estimated at 38% (the study will use 0.38)
d2 = the degree of accuracy desired, here set at (0.05).
n=1.962x 0.38 x (1-0.38)0.052=362From the sampling size calculation above, the total sample size of the study will be 362 children’s from 21 sectors which constitute Gicumbi district. This will constitute the sample size from the stratums calculated through proportionate stratification such that the sample size of each stratum is proportionate to the population size of the stratum. The stratum sizes were determined using the following formula:
nh = (Nh / N)*n (Bhanu,2011) .

Where,
nh: is the sample size for stratum h,
Nh: is the population size for stratum h,
N: is the total population size
n: is the total sample size
Table 3. SEQ Table_3. * ARABIC 1: Strata sample sizesStratum Population Formula Size
1. Bukure 5604 nh=(5604/69369)*362 29
2. Bwisige 1581 nh=(1581/69369)*362 8
3. Byumba 8283 nh=(8283/69369)*362 43
4.Cyumba 2210 nh=(2210/69369)*362 11
5.Giti 2715 nh=(2715/69369)*362 14
6.Kageyo 3199 nh=(3199/69369)*362 17
7.Kaniga 2965 nh=(2965/69369)*362 16
8. Manyagiro 3088 nh=(3088/69369)*362 16
9.Miyove 3802 nh=(3802/69369)*362 20
10. Mukarange 1004 nh=(1004/69369)*362 5
11. Muko 2483 nh=(2483/69369)*362 13
12. Mutete 4393 nh=(4393/69369)*362 23
13.Nyamiyaga 4058 nh=(4058/69369)*362 21
14.Nyankenke 3596 nh=(3596/69369)*362 19
15.Rubaya 1836 nh=(1836/69369)*362 10
16.Rukomo 2116 nh=(2116/69369)*362 11
17.Rushaki 2914 nh=(2914/69369)*362 15
18.Rutare 5485 nh=(5485/69369)*362 29
19.Ruvune 2596 nh=(2596/69369)*362 14
20.Rwamiko 2166 nh=(2166/69369)*362 11
21. Shangasha 3275 nh=(3275/69369)*362 17
Total 69369   362
Table 3.1. SEQ Table_3.1. * ARABIC 1: Strata sample sizes
Source: Primary data.

3.3.2 Sampling techniquesA Stratified sampling technique will be used to obtain the samples. The choice of this technique is based on the fact that it is more convenient when the population is very large and that it provides greater precision Wolfer (2007). The technique involves purposive sampling of Gicumbi District by selecting sectors basing on the number of children under nutrition registered in different site for community base growth monitoring program and applying random sampling methods on each stratum to obtain the final study sample size.

3.4 Data Collection Methods3.4.1 Data Collection InstrumentsThe study will use questionnaire as the tool for collecting primary data. This method of data collection will be preferred for this study due to its ease in collecting data from a large population, friendly cost of administration in-terms of time and money.
A questionnaire will be composed of multiple choices and closed-ended questions in three sections which include demographic data relevant to the study, the prevalence of under nutrition, identification of mothers and children’s characteristic and associated factors to under nutrition.
3.4.2 Administration of Data Collection InstrumentsA research instrument will be administered to the respondents, the tool will be self-administered, where necessary with the aid of research assistants, the researcher administered questionnaire to gather quantitative information regarding standard precaution. A pilot testing will be conducted in Rulindo District, which is a nearest district of the study area to assess the clarity of the questionnaire, the time required to complete the questionnaire and to see how the instrument will respond to the research questions. The research will select 39 mothers with under nutrition babies from Rulindo district, which represent 10% of the sample size, then consent form and questionnaire will be given to them in order to determine clarity and consistency of the study and those participants of pilot study will not be included in the main study. The change will be done after the pilot testing and adjusted accordingly.3.4.3 Reliability and ValidityValidity is the degree to which an instrument measures what is supposed to measure (Tobergte and Curtis, 2013). Reliability refers to the consistence, accuracy, stability with which an instrument measures an attribute. In this study the validity and reliability questionnaire used in Somalia by Mohamed et al. (2014) will be adapted with permission to assess determinant of under nutrition among children aged 6 to 59 months in Gicumbi District, also it will be adapted to the various studies used in the literature review. The questionnaire adapted in this study will be being tested for reliability.

Several steps will be used to ensure validity and reliability of the instrument. The instrument will construct using concept forms, literature and this will gave them content validity. Each item will be analyzed with assistance from the research supervisor’s and nutritionists working in Gicumbi District will be consulted to adjust any ambiguous term and to check if the questions are relevant to the topic, objectives and conceptual framework of the study.
Then the instrument will be translated from English into Kinyarwanda paying particular attention to consistency in meaning. All questionnaires which will be used in this study will be in the Kinyarwanda language.3.5 Data analysis ProcedureCollected data will be organized and analyzed as quantitative. The Statistical Package for Social Sciences (SPSS) software version 20.0 will be used and MS-Excel applications. Descriptive statistics of frequency, percentages in tables, graphs will be used to present data. Data collected will also be analyzed and organized under the objectives of the study. The Chi-square (?2) test will be conducted to test for association factors of under nutrition and determine maternal and child characteristics associated with malnutrition. These will merge with related responses from the questionnaire during the analysis.
3.6. Ethical ConsiderationAuthorization for data collection will be requested from the Mount Kenya University and an authorization to conduct the study will also be requested from local authorities of administration of Gicumbi District. The research ensured that participants completely understood the purpose and methods that will be used in the study. The participants will also make to understand that they had the right to withdraw from the study any time. A consent form will be availed to the participants to sign as to whether they would participate in the study or not. The assurance that all the information provided by the respondents would be treated with utmost confidentiality will also granted.REFERENCESADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY Aburto, N. J., Ramirez-Zea, M., Neufeld, L. M., ; Flores-Ayala, R. (2010). The effect of nutritional supplementation on physical activity and exploratory behavior of Mexican infants aged 8-12 months. European Journal of Clinical Nutrition.

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Ayana, A. B., Hailemariam, T. W., & Melke, A. S. (2015). Determinants of acute malnutrition among children aged 6–59 months in Public Hospitals, Oromia region, West Ethiopia: a case–control study. BMC Nutrition, 1(1), 34.
Bain, L. E., Awah, P. K., Geraldine, N., Kindong, N. P., Sigal, Y., Bernard, N., & Tanjeko, A. T. (2013). Malnutrition in Sub – Saharan Africa: Burden, causes and prospects. Pan African Medical Journal, 15, 1–9.

Birara Melese yalew, Amsalu Feleke, B. D. (2014). Prevalence and Factors Associated with Stunting, Underweight and Wasting: A Community Based Cross Sectional Study among Children Age 6-59 Months at Lalibela Town, Northern Ethiopia. Journal of Nutrition and Metabolism, 4(2).
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Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., … Rivera, J. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371(9608), 243–260.
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Glover-Amengor, M., Agbemafle, I., Hagan, L. L., Mboom, F. P., Gamor, G., Larbi, A., ; Hoeschle-Zeledon, I. (2016). Nutritional status of children 0-59 months in selected intervention communities in northern Ghana from the africa RISING project in 2012. Archives of Public Health = Archives Belges de Sante? Publique, 74, 12.
Kabubo-Mariara, J., Ndenge, G. K., ; Mwabu, D. K. (2009). Determinants of children’s nutritional status in Kenya: Evidence from Demographic and Health Surveys. Journal of African Economies, 18(3), 363–387.

Khan, G. N., Turab, A., Khan, M. I., Rizvi, A., Shaheen, F., Ullah, A., … Soofi, S. B. (2016). Prevalence and associated factors of malnutrition among children under-five years in Sindh , Pakistan?: a cross-sectional study. BMC Nutrition, (December), 1–7.
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Mutua, R. N., Keriko, J., Mutai, J., & Mutua, R. N. (n.d.). Factors Associated With Stunting , Wasting and Underweight Among Children Aged 2-5 Years in Early Childhood Development and Education Centers in Masinga Sub County , Machakos County Factors Associated With Stunting , Wasting and Underweight Among Children.

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APPENDIX I:CONSENT FORMProposal title: determinants of under nutrition among children aged 6 to 59 months in Gicumbi District Rwanda.

Background
The Principal Investigator is KYAMUSOKE BORAUZIMA Kyame, currently a student in the health sciences, department of Public Health, Mount Kenya University Rwanda. He is undertaking a research on determinants of under nutrition among children aged 6 to 59 months in Gicumbi District Rwanda. As a partial requirement for the award of Master Degree in public (epidemiology and disease control).Benefits and Risks
The aim will be, to determine the determinants of under nutrition among children aged 6 to 59 months in Gicumbi gicumbi district Rwanda. There is no known human risk attached to this study protocol.

Right to Refuse
Though, there are no known risks associated with this research, nevertheless, should you feel at any point in time to withdraw your participation in this study, you will be at liberty to do. You have selected on accounts of your eligibility and your inclusion in this study is absolutely voluntary under no obligation.
Anonymity and Confidentiality
You are assured that the information collected will be handled with strict confidentiality and will be used purely for academic purposes. Be assured that all your information will not be shared with any third parties not directly involved in the research.
Before taking Consent
Do you have any questions that you wish to ask? If yes, please state ……………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
If you have questions you wish to ask later, or if there is anything you wish to seek clarification on regarding the research, please don’t hesitate to contact the principal investigator
KYAMUSOKE BORAUZIMA KyameTel.: +250 788842945
Email: [email protected]
Consent
I……………………………………………………………. Understood this study, after having the consent form thoroughly explained to me in a dialect I thoroughly understand (English/french/swahili/kinyarwnda etc.) l do hereby agree to enroll for this study.
Signature/ Thumbprint of Respondent ……………………………………. Date…………………
Witness Signature…………………………………………………………………
Name of Witness………………………………………………………… Date…………………
Interviewer’s Statement:
I have explained the procedure to be followed in this study and the risks and benefits involved with the client in the language that he/she understands best and he/she has agreed to participate in the study.
Signature of interviewer ……………………………………………………
Date ……/…………/……..

QUESTIONNAIRE
Determinants of under nutrition among children aged 6 to 59 months in Gicumbi district northern province, Rwanda.

Basic information:
Questionnaire number: ______________________
Date of interview: __________________________
Name of interviewer________________________
Village (place) _____________________________
Section I. Sociodemographique Variables
Number Questions Responses
Q 101 Household head (M/F) _____________________ __________________ Age
Q 102 Respondent (M/F) ______________________ __________________ Age
Q 103 The relation to Child Q 104 Marital status of mother Single
Married
Divorced
Widowed
Separated
Q105 Size of the family Q 106 How many children under 5 years do you have? Q107 Education level Primary
Secondary
University
Others
Never attended school
Q108 Number of children in the household Q 109 Occupation of the mother? Housewife
Famer
Merchant/trade
Organization employee
Government employee
Other(specify)
Q110 Occupation of the Father? Jobless
Government employee
Marchant /trade
Organization employee
Other (specify)
Q 111 Estimated Monthly income of the family < 5000 Rwanda francs/month
5000-10000 Rwanda francs/month
10000-15000 Rwanda francs/month
15000-20000 Rwanda francs/ Month
Section II Child characteristics and Anthropometry information about child
Number Questions Responses
Q 201 Child’s Age ______________in Months
Q 202 Sex of the child Male
Female
Q 203 Place of Delivery Home
Health center
District Hospital
Other (specify)
Q 204 Birth weight _____________in Kg
Q 205 Current weight: _____________ in Kg
Q 205 Height of the child ______________ in CM
Q 207 MUAC, of the child ______________ in CM
Q 208 Gestational age at Birth Less than 36 weeks
At 36 weeks
Greater than 36 weeks
Do not know/not sure
Q 209 Was your child weighed at birth Yes
No
Q 210 How much was the birth weight of your baby in Gram Q 211 Type of birth Single
Multiple/twin
Q 212 Do you plan (want) to give birth more children? Yes
No
Q 213 Has your child ever been immunized? Yes
No
Q 214 Vaccine received (show card, if no card available asks them to recall) more than one answer is possible) BCG only (see scar)
Polio 0,1,2
Pentavalent (DPT) (Number of Doses)
Measles
No card found
Other (specify)
Q 215 Did the child give Vitamin A Supplementation in the past six months? Yes
No
Q 216 What do you think is the frequent health problem to the child? Q 217 Has the child had diarrhea in the last two weeks? Yes
No
Q 218 If yes, how frequently in the week? Once
Twice
3-4 times
; 5 times
Q 219 Has the child been ill with fever at any time in the last two weeks? Yes
No
Q 220 Presence of respiratory disease in the last two weeks? Yes
No
Q 221 Has the child got sick with measles in the last Year? Yes
No
Q 222 Presence of edema on the child (Observe) Yes
No
Section III Child caring practice
Number Questions Responses
Q 301 Did you ever breast fed the child? Yes
No
Q 302 If no, reason for no breastfeeding? Q 303 How long after birth did you first out the child to breastfeed? Immediately
Hours (less than 24)
Days
Q 304 Did you give the child pre-lactation food/fluid? Yes
No
Q 305 If yes, what did you give him/her? Water
Milk
Formula
Other(specify)
Q306 Did you squeeze out and throw the first milk? Yes
No
Q 307 Why didn’t you give it for your child? It is dirty
It creates abdominal pain to the baby
Others (specify)
Q 308 Are you still breastfeeding? Yes
No
Q 309 How many times in last 24 hours you breastfeed Q 310 How many times in the last 24 hours you breastfed? Q 311 Do you breastfeed during the night? Yes
No
Q 312 Did you give the child additional food or fluid other than breast milk in the past 48 hours? Yes
No
Q 313 If yes, what ingredients you gave (more than one answer is possible) Milk
Formula
Others (specify)
Q 314 How many times in 24 hours? Q 315 At what age did you start feeding other additional food? Q 316 What do you use to feed the child Bottle
Cup
Spoon
Others (specify)
Q317 How many months did you exclusively breastfeed the child? Q 318 Who is usually taking care of the baby feeding? Mother
Sister
Grand mother
baby sister
Others (specify)
Q 319 During the illness, has the child feeding practice changed? Yes
No
Q320 If yes, how could the practice changed Preventing from the breast
Preventing from giving food
Providing additional food
Others (specify)
Q 321 Bath taking of the child Daily
Weekly
Others (specify)
Q 322 How did you usually treat your child when get sick? Usually home treatment
Taking of traditional medicine
Taking to health institution
Other to (specify)
Q 323 What do you think are the cause of Malnutrition? Lack/inadequate food
Childhood sickness
Refusing to eat
Lack of time to feed the child
Others (specify)_________
Q 324 How do you know your child is Undernourished? Q 325 What actions do you take if your child is undernourished? Q 326 How do you know that your child is growing slowly? Section IV: Maternal characteristics
Number Questions Responses
Q 401 Mother’s Age _____________In Years
Q 402 Age at first birth _____________ in Years
Q 403 An age when the youngest child was born? ____________ In Years
Q 404 Total number of children ever born Q 405 Pre pregnancy weight of the last pregnancy? _____________In Kilogram
Q 406 During the pregnancy or lactation, did you consume extra food? Yes
No
Q407 Health status during the pregnancy Good
Not good
Other (specify)
Q408 Have you got any infectious disease during the pregnancy? Yes
No
If yes, have used an antibiotic during the pregnancy? 1.Yes
2.No
If yes, which type of antibiotics? Q 408 Did you visit a health facility for ANC? Yes
No
Q 409 If yes ,at what months of the pregnancy you started ANC? _________________at months
Q 410 How many times you visited health facility for ANC during the pregnancy? Q 411 What is the mode of delivery you did? Vaginal delivery
Assisted delivery
Caesarean section
Q 412 Do you know about family planning? Yes
No
Q 413 Have you ever used family planning methods? Yes
No
Q 414 If yes, which method have you ever used (more than one answers is possible Pills
Depo-provera
Norplant
Condom
Abstinence
Others (specify)
Q 415 When do you wash your hands (More than one answers is possible)
After latrine use
Before preparing food
Before serving the food
After cleaning, child feces
Others (specify)_________
Q 416 How do you wash your hand? Using water only
Using water and soap
Using water and ash
Other (specify)
Q 417 How long do you think should a child exclusively breastfed? Section VI: Associated Factors
Number Enveronmental factors Responses
Q 501 What are your many sources of drinking water? Pond
Unprotected spring
Protected spring
Private well
Public tap
Others (specify)_________
Q 502 What quantity of water used in the household daily in liters? Q 503 How long does it take you to go and come back to fetch water in minutes? Q 504 Do you treat water in any way to make it safer? Yes
No
Q 505 Do you have latrines? Yes
No
Q 506 Type of latrine use? Private pit
Shared latrine
Other (specify)
Q 507 How do you dispose garbage?Open field disposal
In a pit
Burning
Road (in the street)
Others (specify) _______

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