The childhood period is the most important stage for the overall development during the lifespan. Brain and biological development takes place at this stage Muller and Jahn, 2009. These developments are influenced by sufficient of stimulation and nutrition, and these development effects of physique, the immune system, cognition, as well as social and emotional growth (Handal et al. 2007). Such development supports to ensure that each child achieves his or her prospective and is a constructive member of society (Uthman, 2009). When children waste their early years with a reduced amount of motivating, or a less emotionally and physically encouraging condition of brain progress is affected and indications to cognitive, social and behavioral defers. Many factors can interrupt early child development such as malnutrition (WHO, 2009). The nutritional status of children is a significant presentation of health and development; it is not only a representation of past health but an important indicator of future health (Subramanyam et al. 2010).
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Malnutrition is one of the important health problems throughout the world, particularly in developing countries (Sarifzadeh et al. 2010; Hioui et al. 2010). Malnutrition is an important public health problem because it indication to improved risk of death from infectious diseases, more acute infections and a high cause of mortality, and creating additional psychosocial burdens (Jesmin et al. 2011).
Malnutrition is a condition causing stunted growth, underweight, and wasting (Faber et al. 2010; Subramanyam et al. 2010; Uthman, 2009; Kandala et al. 2011; Janevic et al.2010), insufficiency of protein, energy and other nutrients and imbalance between the nutrients the body needs and the nutrients it receives (Muller and Jahn, 2009). Malnutrition can be detected by anthropometric measurements were height/length with age (HAZ), weight with age (WAZ) and weight with height/length (WHZ) is measured against a set of WHO child and growth standards and NCHS/WHO reference (Hioui et al. 2010; Lesiapeto et al. 2010).
Malnutrition levels are still high in developing countries around the world (Sunil, 2009), an estimated wasting 9.8%, underweight 17.9% and stunting 29.2% (WHO, 2009), included Indonesia. According to the MoH Indonesia informed frequency of malnutrition in children under five years of age during the year 2010 in Indonesia 17.90% are underweight, 35.60% stunted, 13.30% showed wasting, and in West Nusa Tenggara Province 48.30% are stunting, 30.50% are underweight and 14.90% are wasting.
Many factors can be associated with the occurrence of malnutrition in children. For example, inadequate health services and an unhealthy environment (Schoeman et al. 2010; Hioui et al. 2010), socio-cultural environments (Mashal et al.2008; Noughani & Bagheri, 2010), socioeconomic, maternal, and child factors (Lesiapeto et al.2010; Hasselman et al.2006), and socio-demographic factors (Phengxay et al. 2007; Handal et al. 2007).
An understanding of the most important causes of malnutrition is imperative to be identified and an analysis would then indicate more speci¬cally the type of policies, health programs and where resources should be focused to redress the derivation causes of inequity in childhood malnutrition (Lesiapeto et al. 2010; Uthman, 2009).
OBJECTIVE
General Objective
The main objective in this research is to find out the major factors influencing the occurrence of malnutrition (stunting, underweight, and wasting) in children under five years of age.
Specific Objective
To describe prevalence of child’s factors that can influence of malnutrition in children under five year of age
To describe prevalence of mother’s factors that can influence of malnutrition in children under five year of age
To describe prevalence of household factor that can influence of malnutrition in children under five year of age
To know the dominant factor can influence of malnutrition in children under five year of age
LITERATURE REVIEW
Definition
Malnutrition is a condition manifested by stunting, being underweight, and wasting if his/her height/length with age (HAZ), weight with age (WAZ) and weight with height/length (WHZ) z-score was more than two standard deviations (SDs) below the reference median (Lesiapeto et al. 2010; Subramanyam et al. 2010; Uthman, 2009; Kandala et al. 2011; Janevic et al. 2010), insufficiency of protein, energy and other nutrients and imbalance between the nutrients the body needs and the nutrients it receives (Muller, 2009).
Stunting is characterized by shortness-for-age or measure of linear growth retardation, an indicator of chronic malnutrition and calculated by comparing the height/length with age of a child with a reference population of good nutrition and healthy children (Muller and Jahn, 2009; Sunil, 2009).
Wasting is a reflection of a recent and acute process that has conducted to substantial weight loss, usually associated with starvation and/or disease; calculated by comparing weight with height/length of a child with a reference population of good nutrition and healthy children; reveals the acute level of malnutrition or the current nutritional status of children and often used to consider the severity of the emergencies because it is intensely related to mortality (Muller and Jahn, 2009; Sunil, 2009).
Underweight is measured by comparing the weight with age of a child with a reference population of good nutrition, composite measure that indicates both acute and chronic malnutrition in children (Muller and Jahn, 2009; Sunil, 2009).
Tabel 1: Characteristic of malnutrition
Nutrition
Status classification
Z-score
Weight with age for wasting
Normal
≤ – 1SD
Slight
-1SD < Z ≤ -2SD
Medium
-2SD < Z ≤ -3SD
Acute
-3SD <
Height with age for underweight
Normal
≤ – 1SD
Slight
-1SD < Z ≤ -2SD
Medium
-2SD < Z ≤ -3SD
Acute
-3SD <
Weight with height for stunting
Normal
≤ – 1SD
Slight
-1SD < Z ≤ -2SD
Medium
-2SD < Z ≤ -3SD
Acute
-3SD <
Source: WHO (2009)
Factors influencing the occurrence of malnutrition
Child factors
The child factors are influencing the occurrence of malnutrition are, age of the child, sex of child, and breastfeeding times (Uthman, 2009). Adequate nutrition during childhood is crucial for child existence, optimal growth and development during life span. The World Health Organization (WHO) recommended of exclusive breastfeeding times (EBF) for the first six months after born (WHO, 2007). The benefit of EBF for growth, buildup the immunity and prevention of illness in young infants is unquestionable (Ulek et al. 2012). If nutrients are in short supply or unbalanced, or if the child is exposed to environmental stressors that interfere with nutrient intake or utilization, growth is impaired. The deficits incurred result in irreversible damage, with related consequences including shorter adult height, lower educational achievement, reduced adult proceeds and decreased of descendants birth weight (Sguassero, 2012).
Figure 1: Child growth standard weight with age in boy’s birth to 5 years
Source: WHO (2009)
Figure 2: Child growth standard length/height with age in boy’s birth to 5 years
Source: WHO (2009)
Figure 3: Child growth standard weight with age in girl’s birth to 5 years
Source: WHO (2009)
Figure 4: Child growth standard length/height with age in girl’s birth to 5 years
Source: WHO (2009)
Tabel 2: Age of children
No
Age groups (months)
1
0‑5
2
6‑11
3
12‑23
4
24‑35
5
36‑47
6
48‑60
Source: WHO (2009)
Tabel 3: Children’s Sex
No
Children sex
1
Male
2
Female
Source: WHO (2009)
Tabel 4: Breastfeeding times
No
Breastfeeding times (months)
1
0 – 2
2
3 – 4
3
5 – 6
Source: WHO (2009)
Mother factors
The mother factors influencing the occurrence of malnutrition are mother’s age, mother’s occupation, and mother’s education (Uthman, 2009). Mother’s education can generate different type of household effect and thereby reducing the risk of nutritional deficiency like malnutrition. The effect which will bring through mother’s education to improved health and nutrition knowledge, psychological changes and improved nutritional behavior, modification of power relations within the household in encourage of better nutrition which includes breastfeeding, weaning practice, and child feeding may lead to more effective dietary behavior on the part of mother’s who manage food resources.
Tabel 5: Mother’s age
No
Mother’s age (year)
1
15 – 19
2
20 – 24
3
25 – 29
4
30 – 34
5
40 – 44
6
45 – 49
Source: MoH Indonesia (2010)
Tabel 6: Mother’s occupation
No
Mother’s occupation
1
Housewife
2
Farmer
3
Seller
4
Civil government
Source: MoH Indonesia (2010)
Tabel 7: Mother’s education
No
Mother’s education
1
None
2
Primary school
3
Junior high school
4
Senior high school
5
Higher
Source: MoH Indonesia (2010)
Household factors
The household factors influencing the occurrence of malnutrition are single parent, two parent households, and extended family. The household performances as a context for the child as well as facilitator that offer the support associated with encouraging child health outcomes (Noughani, 2010). Single parent is family with the head of family has never been married, widowed, divorced, abandoned, or separated who take care of the children or family. Two parents household or nuclear family are the family consist of father, mother, and children living in one house. Extended family is one of family type which the family shares household agreements and expenditures with parents, siblings, or other close relatives (Friedman, 2003).
Tabel 8: Household: Parenting
No
Type of parenting
1
Single parent
2
Two parents
3
Extended family
Source: MoH Indonesia (2010)
MATERIALS AND METHODS
Conceptual Framework
Child’s factors:
Age
Sex
Breastfeeding
Mother’s Factors:
Age
Education
Occupation
Household Factor:
Parenting
Child malnutrition:
Stunting
Wasting
Underweight
Figure 5. Thesis plan conceptual framework adopted from UNICEF (1997)
Research hypothesis
Is there any relationship between child factors, mother factors, and household factor with occurrence of malnutrition in children under five years of age.
Research question
What is the most dominant factor influencing the occurrence of malnutrition in children under five years of age?
Operational definition
Malnutrition in children is the child under five years of age who has diagnosed malnutrition by Department of Health in West Nusa Tenggara Province.
Child factors are the factor in a children related to age, sex and breast feeding times of the children.
Mother factors are the factors related to age, education, and occupation of the mothers in the family.
Household factor are the factors related to parenting (single parent, two parents, and extended family) model in the family.
Methodology
Research design
Research design in this study is descriptive statistic cross-sectional study. A cross-sectional study is one of the most common and famous of study designs. In this type of research study, moreover the entire population or a subset is selected, and from these individuals, data are collected to support answer the research questions. The information that is collected describes what is going on at only one point in time (Ollsen and George, 2004).
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Population and sample
Population in this research is families who have children under five years of age in West Nusa Tenggara Province of Indonesia. The focus samples are families who have children under five years of age in West Nusa Tenggara Province of Indonesia. Sampling technique in this research is using a purposive sample. The sample selection is based on the characteristics.
Inclusion Criteria
Children under five years old who live with their family
Children under five years old who not in hospital
Family who willing to take part in the study
Family in West Nusa Tenggara Province of Indonesia
One child in one family
Sample Size
The sample size was calculated using G*Power version 3.1.5 with α (error prob) = 0.05 and power (1-β error prob) = 0.80, and estimated the total minimum sample size are 113 children.
Setting
This research will be take place in families at West Nusa Tenggara Province of Indonesia.
Measurement
The anthropometric data of the children were assessed using the WHO Anthro software version 3.2.2., to measure the data about child’s factors, mother’s factors, and household factor will be using questioners. Because of this instrument used English language, the researcher will translate and then validate by translators who were expert in both the English and Indonesia languages to ensure equivalence the instrument in Indonesia language.
Ethical Consideration
Ethical approval should be granted by Kasetsart University first. Then, a permission to do the research at the provincial and district health offices, community health centers and volunteer are required. Participant information sheet (PIS), anonymity, confidentiality, and informed consent will be used to protect sample and the researcher.
Plan for data collection
The data about families who have children under five years of age collected from department of health in West Nusa Tenggara Province of Indonesia. The anthropometric data of the children were assessed using the WHO Anthro software version 3.2.2, and expressed as Z-scores for each of the anthropometric indices of malnutrition against both the new WHO child growth standards and the older NCHS/WHO reference.
A child was defined as stunted, underweight or wasted if his/her height/length with age (HAZ), weight with age (WAZ) or weight with height/length (WHZ) Z-score was more than two standard deviations (SDs) below the reference median. Direct interview with a set of questionnaires will be used to collect data from the families related with child’s factors, mother’s factors, and household factor.
Plan for data analysis
The data obtained through household interviews and anthropometric measurements were field-checked, entered into a microcomputer and then analyses using Eview 4.0. Eview provide sophisticated data analysis, regression, and forecasting tools on a Windows base computer.
The WHO and National Center for Health Statistics (NCHS) standard was employed as a reference population to determine Z-scores for height/length with age, weight with age and weight with height/length. The prevalence of stunting, underweight and wasting among children under five years of age the X² test. Both bivariate and multivariate analyses were undertaken to identify the significantly associated background variables (independent variables) with malnutrition (dependent variable). While the dependent variable is dichotomous, the independent variables are composed of categorical, ordinal, and interval/ratio variables. The associations between independent variables, which are categorical or ordinal variables, and malnutrition were examined using the X² test.
As the dependent variable is dichotomous, logistic regression was undertaken as the multivariate analysis. The background variables without a significant association with the dependent variable in bivariate analyses were dropped from independent variables for logistic regression.
A study budget
Table 9: Study budget
No
Items
Amount/ number
Estimation Price (in Rupiah)
1
Paper A4 70 GSM
5 ream
@ 50.000 = 250.000
2
Copy of questioner
5 @ 100
@ 100 = 50.000
3
Printer ink
4 colors
@ 40,000 = 160.000
4
Transportation fee
2.500.000
5
Small gift for participant
100
@10.000 = 1.000.000
Total
3.960.000 rupiah
Timetable
Table 10: Time table
Activity
2012
2013
aug
sep
oct
nov
dec
jan
feb
mar
apr
jun
july
aug
sep
Start writing proposal
Defense proposal
Ask for ethical issues
Collecting data
Analyzing data
Write chapter 4 and 5
Thesis defense
Prepare for publication
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Malnutrition, as well as other factors, has negative effect on the person’s quality of life. In the UK, hospitals admission rate and mortality were greatest in patients with BMI below 20 (kg/m2). Malnutrition can also cause reduced psychological wellbeing (increase anxiety, depression apathy, and loss of concentration and self-neglect)
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