Malnutrition in Children in Jalozai Refugee Camp, Pakistan

ABSTRACT

The magnitude of malnutrition among children under five years of age is high in Pakistan. Under nutrition and infections are the two most important factors that affect the growth of children. This study explains the extent of under nutrition and prevalence of wasting and stunting among preschool children.

This cross sectional study covered the age group 6-59 months in Jalozai Camp, District Nowshera. The total sample was 446. Height for age, weight for age and weight for height were measured as per WHO guidelines. Systematic random sampling sample was used for sample selection. For data collection a questionnaire was designed.

According to height for age Z-score, out of 446 children studied, 8.5% were stunted and 4.0% were severely stunted. According to weight for age Z score, 11.4% were underweight and 3.6% were severely underweight. According to weight for height Z-score, 4.0% were wasted and 2.7% were severely wasted.

The under nutrition in children is comparable to the national figures. Although our study found that lack of formal education, large family size, late and early weaning, lack of exclusive breast feeding and poverty were the factors that were associated with under nutrition in children, they can cause increase in under nutrition in future if not improved.

Key Words: Under nutrition, Nutritional assessment, under-5 children, Anthropometry, wasting, stunting, underweight

INTRODUCTION:

Under nutrition in children is a problem of developing countries. Under nutrition is considered as a key factor for illness and death, contributing to more than half the deaths of children globally. It also poses threat to their physical and mental development, which result in lower level of educational attainment. [1]

The UNICEF report found that 146 million children under five in the developing world are suffering from insufficient food intake, repeated infectious diseases, muscle wastage and vitamin deficiencies.

South Asia has by far the highest levels of underweight, affecting 46 per cent of all under-five children with 44 per cent of its children stunted and 15 per cent wasted, considerably in excess of rates in most other regions.[2]

There is a definite possibility that child nutrition would deteriorate in case of displacement of families.[3] Unfortunately due to manmade and natural disaster, many families have been displaced especially in Khyber Pakhtunkhwa from tribal agencies.

Pakistan stands second highest in the stunting rate (43.7%) since many decades, after Afghanistan. Nepal and India jointly shared the stunting rate at 43 percent.

Pakistan however made some improvement in wasting rate (15%). Pakistan and Sri Lanka had third highest wasting rates in the region.

Pakistan had lower rates of underweight as compare to other SAARC countries, but still Bhutan, Sri Lanka and Maldives had better rates of underweight. [4]^,[5]

The under-five mortality rate for Pakistan is high by international standards: 137 for 1,000 births.

Results from the latest National Nutrition Survey (NNS, 2011) show an alarming nutrition situation in Khyber Pakhtunkhwa. Under-nutrition is one of the main causes of death among infants and young children.[6]

About 48 % of the children in Khyber Pakhtunkhwa are stunted and 17% is wasted. This clearly indicates Khyber Pakhtunkhwa have faced chronic under nutrition over a number of years. However underweight children have improved from 35% in the 2001 to 24% in the 2011 survey.

Jalozai Camp, District Nowshera is entertaining thousand of IDP`s from different tribal areas. These children are especially vulnerable to under nutrition in such circumstances.

As no other study was conducted in Pakistan in internally displaced people to assess the nutritional status of children so this study would provide us with baseline assessment of under nutrition in children living in Jalozai IDP camp, District Nowshera.

OBJECTIVES:

• To determine the prevalence of under nutrition among children aged 6 to 59 months in internally displaced persons (IDPs) of jalozai camp, district Nowshera
• To determine the factors associated with under nutrition among children aged 6 to 59 months in internally displaced persons (IDPs) of jalozai camp, district Nowshera

MATERIALS AND METHODS:

A cross-sectional study was conducted at Jalozai IDP camp, District Nowshera having 11300 Under 5-year old children. The children in the IDP`s camp were selected through simple random sampling. Information was collected mainly from the head of the family, due to cultural constraints of the area. The sample size, calculated with prevalence rate of 29.7%⁽⁴⁾ & margin of error at 0.05, was 446.

Structured questionnaires were used to obtain the information about household characteristics and Anthropometric measurements.

Weight measurements were undertaken to the nearest 100 g using a 10 kg beam balance and a 50 kg standard electronic balance. For children younger than 2 years of age, length was measured to the nearest millimetre in the recumbent position using an infant-meter. Children older than 2 years were measured in a standing position using a measuring board. Children between ages 6 to 59 months were included while Severely Diseased and mentally ill children were excluded.

Age was recorded as told by parents but confirmed by comparing with different events and local calendars; because birth certificates were not available in most cases. Children were classified by the reported age into the following groups (in months): 6-18, 18-26, 26-36, 36-46 and 46-59.

Children’s immunization coverage was obtained from vaccination cards available. The education of father and mother was noted. Family size was categorized as small size family (1-2 children), medium size family (3-4 children) and large size family (5 or more children).

Monthly household income in PKR was collected from respondents as a continuous variable and recoded into four categories: ≤5000, >5000–10000, >1000–15000 and >15000.

Information about Exclusive breast feeding for six months, total duration of breast feeding and weaning was obtained from the parents.

The outcomes of this study were three anthropometric indices, stunting (height-for-age) HAZ, underweight (weight-for-age) WAZ, and wasting (weight-for-height) WHZ. Stunting is an indicator of chronic under nutrition, whereas wasting often assesses acute nutritional stress within a population. HAZ is described as stunted, a condition that reflects chronic under nutrition. WHZ measures the current nutritional status of a child while WAZ captures aspects covered in both HAZ and WHZ.[7] The z-score are computed by using the World Health Organization recommended reference population (WHO, 2006).

The study was conducted with the approval by the Ethical Review Board of Khyber Medical University; Peshawar. An informed voluntary consent was obtained. Confidentiality of the data was ensured.

Data was analyzed using SPSS 16.0. Univariate and multivariate analysis was done for association between independent and dependent variables. Composite indices like WAz, HAz, and WHz were compared with the WHO reference data. Children with below -2 Z-scores and -3 Z-scores of the reference population were considered as malnourished and severe under nourishedrespectively. Quantitative Variables were described as Mean ± SD. Frequencies and percentages were calculated for qualitative variables.

RESULTS:

The survey collected data on the nutritional status of 446 children between 6-59 months of age. Among 446 children surveyed, (201) 45.1% were boys and (245) 54.9% were girls. The boy to girl ratio was 1: 1.25.

DISTRIBUTION OF AGE AND SEX OF SAMPLE:

It was found that out that majority of father and mother were illiterate. The main occupation of the household was recorded in detailed categories and later recorded as not working 79%, agricultural 6%, manual 10% and employed 5%. The children lived in families with incomes less than Rs.5000 were 84%, 13.0% children were from families with income between Rs.5000 and 10000, (5%) children were from families with income between Rs. 10000 and 15000.

Sixty nine (15.5%) children belonged to a small family (1-2 children/family), 219 (49.1%) belonged to a medium-sized family (3-4 children/family), and 158 (35.4%) of the children belonged to a large family (≥5 children per family).

The total number of bottle-fed children is 137 (30.7%), while 309 (69.3%) never fed through bottle. The weaning of children started before the age of six months in 232(52%), at six month 117(26.2%) and after six month it is in 97(21.7%). It was found 246 (55.2%) of the children did not receive any vaccine except polio drops, 135 (30.3%) were partially vaccinated and 65 (14.6%) were fully vaccinated.

According to WAZ-score 379(85.0%) were normal while 51(11.4%) were under weight and 16(3.6%) were severely underweight. According to HAZ-score, 390(87.4%) were normal while 38(8.5%) were stunted and 18(4.0%) were severely stunted. According to WAZ-score, out of 446, 416(93.3%) children were normal while 18(4.0%) were wasted and 12(2.7%) were severely wasted.

All the three indices shows an interesting association with age, highest at the younger age group, then declining sharply, and subsequently increasingly gradually with increasing age. Figure 1.

We found that underweight, stunting and wasting is more prevalent in the large family size i.e. 36.7%, 29.7%, 12.7% respectively. It shows that there is a positive relation of family size with WAZ (underweight) and WHZ (wasting) and HAZ (stunting). Figure-2 showing the relation of family size with the three measures of under nutrition

Figure-2

Father and mothers having no formal education show high frequency of under nutrition.

Figure-3 showing that the under nutrition is more prevalent in the children whose fathers are not working . We did not found any malnourished child whose fathers are employed.

Figure-3

In our study, 60% families had income less than Rs.10000 per month. In earlier studies, families with low socio-economic status, where monthly income was Rs.5000 or less, had 52.2% malnourished children, while the families with an income of Rs.10000 and more, had 24.7% malnourished children. Economic development also brings down under nutrition and vice versa. In our study families having income >5000 showing high prevalence of under nutrition as shown in Figure-4

Nutritional Status by Exclusive Breastfeeding, Bottle Feeding and Weaning:

We found that 76.9% children were exclusively breast fed and only 23.1% children were not exclusively breast fed. Under nutrition is highly prevalent in children who are not exclusively breast fed especially underweight and stunting.

Figure-5

Figure-6

Nutritional Status by Vaccination:

In our study we found that 55.2% children haven’t received any vaccination except polio drops and only 14.6% children were fully vaccinated. Figure-6 showing that in not vaccinated children there are 24.4% underweight 20% stunted and 9% are wasted.

Factors associated with malnutrition using univariate or multivariate analysis

DISCUSSION:

Prevalence of underweight is 15%, stunting 12.5% and wasting is 6.7% in children under the age of five years is quite low as compared to the national figures which are underweight 31.5%, stunting is 43.7% and wasting is 29.7%, which means better nutritional status of children.

It was observed that the main sources of foodstuff for the IDPs included food rations distributed

by WFP and PDMA. There was availability of fortified foods and supplementary feeding centers by these organizations.

A similar study was conducted in Gulu District, Uganda, in which underweight children were 20%, stunted 27% and wasted 32 %. [8]

The result showed that younger children are at higher risk of under nutrition than the older children. This finding is similar to the study conducted in displaced population of Ethopia in Sudan. [9]

The study found that lack of formal education[10], large family size, late and early weaning, lack of exclusive breast feeding[11] and poverty, very low coverage of immunization programs were associated with under nutrition in children.

The results highlight that although there is not high frequency of under nutrition in the camp but there are some risk factors present which can create worse situation of under nutrition at any time.

Combination of these factors and under nutrition, in turn, predisposes the children to various infections, hence can cause the high frequency of morbidity and mortality.[12]

CONCLUSION & RECOMMENDATIONS:

Under nutrition prevention efforts should target the younger age group.

There is need to improve the immunization coverage because the immunization status of children is very poor.

Supplementary feeding centers and fortified food must be available on large scale for the community.

Establish a nutrition surveillance system to monitor any progression of the nutritional situation.

REFERENCES:

1

[1] Pelletier DL, Olson CM, Frongillo Jr E. Food insecurity, hunger, and under nutrition. In: Bowman BA, Russell RM, editors. Present knowledge in nutrition. 8th ed. Washington DC: ILSI press; 2006. p. 701-13.

[2] Muller O, Krawinkel M. Mal nutrition and health in developing countries . CMAJ 2005;173:279-86.

[3] Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessment of the health and nutrition of Ethiopina refugees in emergency camps in Sudan 1985. Br Med J (Clin Res Ed). 2007; 295: 314-8.

[4] Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute mal nutrition in children. Lancet 2006;368:1992-2000.

[5] Shannon K, Mahmud Z, Asfia A, Ali M. The social and environmental factors underlying maternal under nutrition in rural Bangladesh: Implications for reproductive health and nutritional programs. Health Care Women Int 2008;29(8):826–40.

[6] National Nutrition Survey of Pakistan, 2011

[7] WFP/UNICEF. Health and nutritional assessment in internally displaced people living in camps, Gulu district, 2005a.

[8] ACF-USA. Field Report of nutritional assessment in IDPs, Gulu district northern Uganda, 2005.

[9] WFP/UNICEF. WFP/UNICEF. Health and nutritional assessment of internally displaced persons living in camps in Kitgum district, 2005b.

[10] Ali SS, Karim N, Billoo AG, Haider SS. Association of literacy of mothers with under nutrition among children under three years of age in rural area of district Malir, Karachi. J Pak Med Assoc 2005;55:550–3.

[11] David S, Lobo ML. Childhood Diarrhea and Under nutrition in Pakistan, Part II: Treatment and Management. J Pediatr Nurs 1995;10(3):204–9.

[12] Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee s i t u a t i o n s . A n u R e v p u b l i c h e a l t h 2007;18:283-312.