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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 12  |  Page : 3865-3870  

Magnitude of malnutrition among underfive children in urban slums of commercial capital of India and its multifactorial causation: A community-based study


1 Department of Community Medicine, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane, Maharashtra, India
2 Department of Community Medicine, Grant Govt. Medical College and J.J. Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission26-Sep-2019
Date of Decision26-Sep-2019
Date of Acceptance11-Oct-2019
Date of Web Publication10-Dec-2019

Correspondence Address:
Dr. Kiran S Akhade
Flat No. 503, Bldg. No. 2, Amrut Aangan Phase 1, Parsik Nagar, Kharegaon, Kalwa (W), Thane, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_829_19

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  Abstract 


Context: Malnutrition in children is common globally and may result in both short- and long-term irreversible negative health outcomes. It is not a simple disease with single causative factor but it is a disease with multifactorial causation. Aims: 1) To estimate prevalence of malnutrition in underfive children using “Z” score. 2) To evaluate the role of epidemiological and maternal factors on the nutritional status of children. Settings and Design: Community-based cross-sectional study. Methods and Materials: Randomly 10 slums were selected and under five-year-old children and their mothers from urban slums were examined and interviewed. Statistical Analysis: Data was analyzed with SPSS ver 20 and appropriate tests were applied. Results: Four-hundred children were examined. According to Z score classification, 39.8%, 36.5%, and 24.8% of children are underweight, stunted, and wasted, respectively. Family size (P = 0.02, χ2 = 7.7), initiation of breastfeeding (P = 0.009, χ2 = 6.8), maternal education (P = 0.001, χ2 = 13.9), underweight mothers (P = 0.05, χ2 = 4.8), and maternal dietary intake (P = 0.03, χ2 = 6.5) are significantly associated with underweight children. Similarly, stunted children show strong association with increasing age of child (P = 0.001, χ2 = 18.1), birth weight (P = 0.006, χ2 = 7.6), and not seeking medical opinion (P = 0.03, χ2 = 7.0). Primary immunization (P = 0.05, χ2 = 3.5), maternal education (P = 0.002, χ2 = 12.4), employed mothers (P = 0.02, χ2 = 4.9), and underweight mothers (P = 0.05, χ2 = 5.3) are associated with wasting in children. Conclusions: This study reveals very high prevalence of malnutrition status among underfive children of urban slums of commercial capital of India. Various maternal and epidemiological factors affect child nutritional status.

Keywords: Malnutrition, underfive children, urban slums


How to cite this article:
Akhade KS, Sankhe LR, Akarte SV. Magnitude of malnutrition among underfive children in urban slums of commercial capital of India and its multifactorial causation: A community-based study. J Family Med Prim Care 2019;8:3865-70

How to cite this URL:
Akhade KS, Sankhe LR, Akarte SV. Magnitude of malnutrition among underfive children in urban slums of commercial capital of India and its multifactorial causation: A community-based study. J Family Med Prim Care [serial online] 2019 [cited 2020 Jan 22];8:3865-70. Available from: http://www.jfmpc.com/text.asp?2019/8/12/3865/272506




  Introduction Top


Malnutrition is more prevalent in developing countries. Malnutrition was the predominant risk factor for death in underfive children accounting for 68.2% in India in 2017.[1] The commercial capital of the country, Mumbai, has much appeal to anyone in search of work and better career prospects. Many rural-urban migrant workers cannot afford housing in the cities and eventually settle down in slums. Lack of basic facilities makes slum dwellers vulnerable to infections which adversely affect their nutritional status.[2] It is not a single problem with single solution. Multifactorial causation needs multipronged strategies to alleviate the problem of malnutrition.[3]

Inadequate intake of food along with various factors—sociodemographic, environmental, nutritional, and most important maternal factors contribute to child malnutrition. There is enough scientific evidence indicating the importance of the first 1000 days of a child's life.[4]

This special group of underfive children constituting 15% of total population is in their growing and developing period but suffer high rates of morbidity and mortality. Malnutrition affects in later life. Health of underfive children and family-health are interrelated.[5] In view of this context, the present study is intended to estimate the magnitude of the problem of malnutrition and the factors consistent with the same in underfive children in urban slums of Mumbai. The current study will be helpful to design the strategies to alleviate the problem of malnutrition.


  Subjects and Methods Top


Study design and setting

The present study is a community-based cross-sectional study aimed at primarily assessing malnutrition status among underfive children in urban slums and its association with a variety of maternal, sociodemographic, and economic factors. The study was accomplished in urban slums of Bandra during December 2010 to April 2012. Randomly 10 slums were selected in the area of Urban Health and Training Centre (UHTC), Bandra, under the Grant Govt. Medical College and J.J. Group of Hospitals, Mumbai. House-to-house survey was done to identify the children of underfive age.

Study population

The study was conducted among the underfive (0–59 months old) children residing in the selected slums along with their mothers. Those study participants who were not residents of the study area, children's mother who was seriously ill and had difficulty in communication, and children with physical deformities that hinder height measurements at the time of data collection were excluded from the study.

Sample size

Sample size was determined based on a single proportion population formula using z 2 × P × q/d 2 considering the following assumptions: 95% confidence level, estimated proportion (P) underweight (40%), and with absolute precision of 5%. The calculated sample size was 370. The total number of study participants was 400 children of 0–59 months of age with his/her mother was involved in the study.

Data collection

Data collection was done in the field by going house-to-house. A structured, pretested questionnaire was administered to the parents by researcher and physical examination of both child and his/her mother was done by researcher alone. Informed consent was obtained by parents and other caretakers. The questionnaire consists of the personal information, socioeconomic class, child health history, and anthropometry.

Measurements

Anthropometry is a simple valuable tool and the gold standard for evaluating the nutritional status, but it has many limitations. Adequate precautions are to be taken during measurement and the procedures utilized are to be standardized and checked frequently for accuracy. Bodyweight was measured using a spring balance scale. The shoes or chappals should always be removed and children should be weighed with as little clothing as custom permits. Below the age of two years, a horizontal measuring rod or infantometer is used. Shoes or chappals are removed and the child is placed on the back on a flat surface. For children 24–59 months of age, standing height to the nearest 0.1 cm was measured. Mid-Upper Arm Circumference (MUAC) measured with the help of Shakir's tape. All anthropometric measurements were taken twice, and the average of the two measurements was calculated and recorded. Anthropometric measurements were transformed into Z-scores with the aid of WHO Anthropometric calculator software version 3.2.2. The Z-score values for height for age, weight for age, weight for height, body mass index for age, and mid-upper arm circumference for age based on WHO standard-based results were calculated.

Ethical considerations

Institutional Ethical Committee approval was obtained before the start of the study. Informed consent was obtained by parents and other caretakers before including the child in the study. Institutional Ethical Committee approval obtained from Grant Medical College, Mumbai & J.J. Group of Hospitals.

Statistical analysis

Data entry and analysis were done using Excel and SPSS version 20.0, respectively. Anthropometric indices were calculated using the 2006 WHO Anthro 3.2.2 Software. Descriptive analysis was used to describe the percentages and frequency of sociodemographic characteristics and other relevant variables in the study.


  Results Top


In this study, total 400 underfive children with their mothers were included. [Table 1], [Table 2], [Table 3], [Table 4] depict the distribution of characteristics of underfive children, feeding practices and health status of children, sociodemographic factors, and maternal factors, respectively.
Table 1: Distribution of Characteristics of children

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Table 2: Distribution of feeding practices and health status of children

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Table 3: Distribution of sociodemographic factors

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Table 4: Distribution of maternal factors

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Out of 400 study participants, 126 children (31.5%) are <12 months of age, 56.5% and 43.5% are males and females, respectively. Most of the participants (74.7%) are Hindu by religion. Out of 400, 74% of children are born by normal delivery and 51% are born with low birth weight (<2.5 kg).

Only 24% of mothers started initiation of breastfeeding on time; 50% of mothers started weaning on time, whereas 31% weaned early their child. Out of total, 74% of children did not seek medical opinion, only 36% children consumed >90% of RDA, and 37% of children did not comple their primary immunization.

Out of total, 54% of children live in joint family. Most of the families are with 3–6 family members; 55% of families have less than 3 children and 25% are with child spacing of <2 years; 82% of families are not using any kind of family planning services; and 41% belongs to upper lower class as per modified Kuppuswamy scale.

Out of total, 17% of mothers are <18 years of at the time of marriage and 26% are <20 years of age at the time of childbearing; 14% are still illiterate or with primary education, whereas 87% are not working; and 22% of mother's dietary intake is less than 50% of Recommended Dietary Allowances (RDA), whereas 19% are underweight.

[Figure 1] depicts nutritional status of underfive children, exhibiting 40% are underweight, 36% stunted, 25% wasted, 22% undernourished by head circumference for age, 25% undernourished by BMI for age, and 17% undernourished by MUAC for age.
Figure 1: Distribution of children as per nutritional indicators

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[Table 5] shows the mean Z scores with the 95% confidence interval for various anthropometric measurements.
Table 5: Nutritional status (mean Z scores) of children under five years of age

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The [Table 6] shows, as per composite index of anthropometric failure (CIAF), overall only 42% children are showing normal nutritional status, whereas 58% of the children were suffering from one or other form of “Anthropometric Failure.” Most common is stunting + underweight (16%) followed by wasting + underweight (15.5%) and stunting (14.8%).
Table 6: Malnutrition status: Composite index of anthropometric failure (CIAF)

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[Table 7], [Table 8], [Table 9] depicts the various factors significantly associated with underweight, stunting, and wasting in underfive children, respectively.
Table 7: Factors associated with underweight

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Table 8: Factors associated with stunting

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Table 9: Factors associated with wasting

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Family size with more than 10 family members, normal delivery, delayed initiation of breastfeeding maternal education up to primary level, poor maternal nutritional status, and <50% of RDA dietary intake are significantly associated with underweight in children.

Children in the age of 1–2 years, LBW (birth weight <2.5 kg), and those who do not seek medical opinion exhibit strong association with stunted children.

Children whose dietary intake is >90% of RDA are showing significantly normal nutritional status, while incomplete primary immunization, maternal education up to primary, employed mothers, and underweight mothers are positive predictors of wasting.


  Discussion Top


Malnutrition represents one of the main public health problems throughout the world, but most especially in developing countries. According to the World Health Organization, 52 million children under 5 years of age are wasted, 17 million are severely wasted, and 155 million are stunted. Around 45% of deaths among children under five years of age are linked to undernutrition. These mostly occur in low- and middle-income countries.[6]

The present study reveals that overall prevalence of malnutrition is 58% with the help of CIAF and 40%, 36%, and 25% of underweight, stunting, and wasting in underfive children, respectively. Family size with more than 10 family members leads to uneven distribution of food; neglect in care of child might be associated with undernutrition. Maternal and childcare in case of cesarean section is taken extensively as compared to normal delivery. Due to delayed initiation of breastfeeding, child is deprived of colostrum, which is rich in protein, immunoglobulins, and various protective antibodies; hence, child is prone for infections, which leads to malnutrition. Maternal education also plays important role in the nutritional status of the child. Maternal nutritional status and dietary intake affect the child nourishment from the day of conception. Children in the age group of 12–23 months have started weaning, inadequate nutrition, and increase activity during this growing age might be the reason of undernutrition. Low birth weight means undernourished since birth, which causes chronic undernutrition, i.e. stunting. Not seeking medical opinion due to poverty and illiteracy leads to vicious cycle of infection and malnutrition. Primary immunization also plays important role in the vicious cycle of malnutrition and infection.

Khan et al. have conducted study in Sindh, Pakistan among underfive children and found that 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.[7]

Chaudhary and Agrawal, 2019, done study in slums of Jaipur, Rajasthan revealed that prevalence of underweight, stunting, and wasting was 35.7%, 43%, and 10.5%, respectively, and also found that malnutrition was associated with sociodemographic factors such as age, caste, family type, birth weight, birth order, educational profile of parents, and economic status of family.[8]

Sarkar in West Bengal revealed stunting (51%) as the most common form of malnutrition among children aged under five, followed by underweight status (41%) and wasting (22%) and also found that age, religion, caste, and birth-order of the child as significant predictors of child's nutritional status.[9]

Tamoghna Biswas et al. assessed that improper immunization was identified as a risk factor of undernutrition (P = 0.049).[10]

Irarrázaval et al. evaluated 278 infants and children younger than 2 years old, in which 18.35% were underweight, 13.31% stunted, and 13.67% had wasting. Malnutrition was associated with male gender, older age, lower maternal education level, and greater numbers of siblings (χ2, P < 0.05).[11]

Gebre et al. conducted a study in Ethiopia and revealed that family size of five and above is associated with wasting; increasing age of child and incomplete immunization are strong predictors of stunting and maternal illiteracy with incomplete immunization constitutes underweight.[12]

Fosu-Brefo and Arthur studied the effect of breastfeeding on child health in Ghana and results indicate that timely initiation of breastfeeding, both immediately and hours after birth are important factors that influence the child's health. In addition to this, factors such as the wealth of the household, mother's education, age and size of the child at birth, and age of the mother are important factors that also influence the health of the child in Ghana.[13]


  Conclusions Top


This study reveals very high prevalence of malnutrition status among underfive children of urban slums of commercial capital of India. Incomplete primary immunization, maternal low level of educational status, employed mothers, and undernourished mothers are positively associated with wasting. Large family size, delayed initiation of breastfeeding, maternal illiteracy, undernourished mothers, <50% RDA dietary intake of mothers contribute strongly to underweight in children. Age of child between 12 and 23 months, low birth weight, and not seeking medical opinion are strong predictors of stunting.

Recommendations

Address the importance of complete immunization, emphasis on maternal education and nutrition, encourage use of family planning, propagandize early initiation of breastfeeding, and publicize the use of medical services. These are the indispensable measures to ameliorate the nutritional status of underfive children.

Declaration of patient consent

The written and informed consent obtained from the parents/guardian. In the form, the parents/guardian has given their consent for anthropometric measurements and related history. The parents/guardian understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflict of interest

There is no conflict of interest.



 
  References Top

1.
Swaminathan S, Hemalatha R, Pandey A, Kassebaum NJ, Laxmaiah A, Longvah T, et al. The burden of child and maternal malnutrition and trends in its indicators in the states of India: The global burden of disease study 1990–2017. Lancet Child Adolesc Health 2019. doi: 10.1016/S2352-4642 (19) 30273-1.  Back to cited text no. 1
    
2.
Yadav P, Dubey BN. Nutritional problems among children in urban slum area. Man in India 2017;97:349-62.  Back to cited text no. 2
    
3.
Bantamen G, Belaynew W, Dube J. Assessment of factors associated with malnutrition among under-five years age children at Machakel Woreda, Northwest Ethiopia: A case control study. J Nutr Food Sci 2014;4:256.  Back to cited text no. 3
    
4.
Paul VK, Singh A, Palit S. POSHAN Abhiyaan: Making nutrition a jan andolan. Proc Indian Natn Sci Acad 2018;84:835-41.  Back to cited text no. 4
    
5.
Elizabeth KE. editor, Nutrition and Child Development, 4th Ed. Hyderabad: Paras Medical Publisher; 2010.  Back to cited text no. 5
    
6.
World Health Organization. News room/Fact sheets/Malnutrition. 16 February 2018.  Back to cited text no. 6
    
7.
Khan GN, Turab A, Khan MI, Rizvi A, Shaheen F, Ullah A, et al. Prevalence and associated factors of malnutrition among children underfive years in Sindh, Pakistan: A crosssectional study. BMC Nutr 2016;2:69.  Back to cited text no. 7
    
8.
Chaudhary P, Agrawal M. Malnutrition and associated factors among children below five years of age residing in slum area of Jaipur City, Rajasthan, India. Asia J Clin Nutr 2019;11:1-8.  Back to cited text no. 8
    
9.
Sarkar S. Cross-sectional study of child malnutrition and associated risk factors among children aged under five in West Bengal, India. Int J Population Stud 2016;2:89-102.  Back to cited text no. 9
    
10.
Biswas T, Mandal PK, Biswas S. Assessment of Health, Nutrition And Immunisation status amongst Under five Children In Migratory Brick Kiln Population Of Periurban Kolkata, India. Sudanese Journal of Public Health 2011;6:7-13.  Back to cited text no. 10
    
11.
Irarrázaval B, Barja S, Bustos E, Doirsaint R, Senethmm G, Guzmán MP, et al. Influence of feeding practices on malnutrition in haitian infants and young children. Nutrients 2018;10. doi: 10.3390/nu10030382.  Back to cited text no. 11
    
12.
Gebre A, Reddy PS, Mulugeta A, Sedik Y, Kahssay M. Prevalence of malnutrition and associated factors among under-five children in pastoral communities of afar regional state, Northeast Ethiopia: A community-based cross-sectional study. J Nutr Metab 2019;2019:9187609.  Back to cited text no. 12
    
13.
Fosu-Brefo R, Arthur E. Effect of timely initiation of breastfeeding on child health in Ghana. Health Econ Rev 2015;5:8.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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