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1. CHAPTER ONE
1.1. Introduction
1.1.1. Background
Malnutrition among children under five years of age is a common public health concern in
resource-constrained countries. Globally, among children under five, 149 million are stunted (i.e.
low height-for-age, a measure of chronic malnutrition), over 47 million are wasted (i.e. low
weight-for-height, a measure of acute malnutrition) and nearly 14.3 million are severely wasted,
a majority of whom live in low-income countries (UNICEF/WHO/WORLD BANK GROUP,
2020). According to World Health Organization 2019 estimates, 5.2 million under-five children
die every year and about 45% of these deaths are linked to malnutrition. As a result of these high
numbers, WHO recommends including adequate maternal nutrition before and during pregnancy
and lactation, optimal breastfeeding in the first two years of life, nutritious, diverse and safe
foods in early childhood, and a healthy environment, including access to basic health, water,
hygiene and sanitation services (WHO, 2019). Those public health actions will contribute to
reach Sustainable Development Goal (SDG) 3: ensuring good health and promoting healthy lives
for all by 2030 (UNICEF/WHO/WORLD BANK GROUP, 2019). Improving child nutritional
status demands sustained and effective programming and engagement (Lancet, 2019).
The Sustainable Development Goals (SDGs) states that by “2030 end preventable under-five
deaths by reducing under 5 mortality to at least as low as 25 per 1,000 live births.” However in
2015 about 480,000 under five children continue to die every month globally. A large percentage
of these deaths were caused by preventable diseases. Moreover, under nutrition remains a major
cause of disability and mortality, ranked as the top cause of global burden of disease. Besides it
is underlying causes of deaths in 53% children under-five years. Of total under five deaths
contributed by under nutrition, acute malnutrition is responsible for more than 28%
(UNICEF,2012) and around one million children under the age of five die every year from
severe acute malnutrition(UNICEF,2011).Globally, about 52 million under-five years old were
wasted and among this around 32%(16million) were severely wasted(UNICEF,2016). And One-
third of these children live in Africa Especially In Sub-Saharan Africa, Approximately 9% of

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children have moderate acute malnutrition and about 2% of children have Sever Acute
Malnutrition (UNICEF, 2015)
1.1.2. Statement of the problem
Globally under-nutrition is the major single underlying cause of death in children worldwide
(WHO.2009). This is responsible approximately for 3.1 million deaths in under five children
every year which is almost equivalent half (45%) of all deaths (Black RE et al., 2013). Moreover,
child's under-nutrition is a strong predictor for low school performance, poor mental
development as well as greater behavioral problems (Martins et al., 2013). Children of acute
malnutrition have high probability of death to the counter part from common childhood illness
such as diarrhea; pneumonia, and malaria (WHO.2019) In Ethiopia; child under-Community
based cross sectional study done among Nepal under five children showed that from the total
participants 7.0% were wasted (Chataut ,2016). Multi-analysis study conducted in Nigeria also
showed that the prevalence of acute malnutrition was 18% (Blessing et al.,2017). The prevalence
of acute malnutrition in Ethiopia is among the worst in the world and it remains greatest public
health treat. Ethiopian Demographic and Health Survey [EDHS] 2016 reported that 10% of
children were wasted at country level. Somali and Afar region registered the highest prevalence
acute malnutrition [wasting] of 23 and 18%, respectively (ICF, 2017).
A Study done In Hawassa, South Nation and Nationalities of Ethiopia showed that wasting was
28.20% (Tsedeke W, and Tefera B, 2014). In Bule Hora district of Oromia region wasting was
13.40% (Asfaw M. et al., 2015). The worst figure that showed the prevalence of wasting [42.3%]
was found in Somali region (Demissie S, and A. Worku, 2013). Although Ethiopia has come a
long way in reducing poverty and food insecurity, the prevalent of poverty and food insecurity
still present (CFSVA, 2014).
In Ethiopian’s Afar Region, high prevalence of acute malnutrition, food security crisis, Livestock
losses and excess mortality among under-five children were reported from the last years. This
indicates that acute malnutrition is common problem in Afar region. However, the prevalence of
acute malnutrition and associated factors in children aged 6-59 months has not been well
documented in the study area. Therefore, this study will designed to assess the prevalence of

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acute malnutrition and its associated factors in children aged 6-59 months in ewa district in afar
region in Ethiopia.
1.1.3. Significance of the study
The government and the heath administrators of the region will borrow from findings of the
study to formulate policies that will enhance the proper management of malnutrition in the
country.
The health organization will gain an understanding from the study on the malnutrition and the
factors associated to it in children aged 6-59 months years of age.
They will be able to device the ideal ways of improving the management of malnutrition and
putting in place a proper nutrition intervention in the region. With the new knowledge,
Management boards can make policy recommendation as well as policy implementation
possible.
It will also help the researcher to advance his knowledge on how to write research on more for
future studies, as the researcher will be going for further studies.
The findings will be important for other scholars as a point of reference, and they can take up the
recommendations of the study as a basis for their research articles

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3. CHAPTER THREE
3.1. Objectives of the study
3.1.1. The General objective
To assess the prevalence of acute malnutrition and its associated factors in children aged 6-59
months in Ewa district in afar region in Ethiopia.
3.1.2. Specific Objectives
 To determine prevalence of malnutrition among children aged 6-59 months.
 To identify associated factors of malnutrition among children aged 6-59 months.

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CHAPTER 4
4.1. Method
4.1.1 Study Area and Period
The study was carried out in HCs found in Ewa district in November 2014.
Ewa is the capital of zone 4 in Afar region. It lies in north Eastern of Semera and 251 km from
the capital city of Semera. The city is strategically positioned along trade routes in northeastern
Afar and almost surrounded by hills and has considerable water resources, the latter of which
makes it a prime destination for peoples from other parts of generally arid Afar as well as from
neighboring countries such as Djibouti and Ethiopia. The town’s altitude from the sea level is
722 meters. The Town contains of 10 villages. The city has estimated population of 41,000 also
Afar region population has estimated about 175, 000 (35). In the town there are three HCs, and
also there are eight HPs. .In the town there one health institution providing Nutrition services
three governmental MCHs (Sayid MCH, Central MCH and Farxaskule MCH). The institutions
not only provide Nutrition services but also Immunization and Breast-feeding counselling and all
reproductive health services (36).
4.1.2. Study Design
Institution based cross sectional study among MCHs children under five years will conducted.
The cross sectional study entail the collection of data on a cross-sectional of the population as a
whole or proportion (sample) of population. And also this method was inexpensive, time saving;
researcher has control over selection of the study subject and measurements used. That was why
this design was selected.
4.1.3. Population
4.1.4 Source Population
For Quantitative Study
The source population consisted of all children under five years that attendant the HCs in Ewa
district, Afar region, November/2022.

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4.1.5. Study Population
For Quantitative Study
The study population is sampled children under five years old attendant MCHs during data
collection time.
For Qualitative Study
The study participants for Qualitative study is purposively selected:-
 Heads of the HCs
 Heads of the child growth monitoring who provide Nutritional service
 Afar Region Health bureau
 Nutrition regional Focal person
4.1.6. Inclusion and exclusion criteria
4.6.1. Inclusion criteria
 Children who visit the HCs during the study period
 Children aged under 5 years
 Able and willing to respond
4.4.1. Exclusion criteria
 Anyone who will not fulfill the inclusion criteria
4.2. Sample Size Determination and sampling technique
4.2.1 Sample size determination
For quantitative study Sample size will be determined using single population proportion
formula by using the proportion of wasting malnutrition to be 36.6% (25), with 5% level of
significance and 5% margin of error a sample size of 103 computed.

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Where: P= Proportion of wasting malnutrition prevalence (taken from a study in Harar)
d = margin of error (5%)
Zα/2= standard normal variable at 95% confidence level (1.96)
n= (Z/2)2
P (1-P)/W2
n= (1.96) 2
0.37 (0.63) /0.052 = 358
We used population correction formula because the population source is less than 10,000
nf = n/1 + (n/N) nf = 358/1+ (358/145) = 103
Adding 10% non-response rate = 103 + 10 = 113
Final sample size N= 113
For Qualitative Study
Nine in-depth interviews will be conducted from key informants until the information obtained
was saturated. These included at least: -
 4 Growth monitoring from all Health institutions providing Nutritional service
 3 Heads of the MCH
 1 Regional Health bureau
 1 Regional Nutrition Focal point 16 Key CMCH = Central MCH SHMCH = Shacab MCH
SMMCH = Sayid Mohamed MCH FKMCH = Farxaskule MCH
4.2.2 Sampling technique
For the quantitative study
All four Maternal and child health institutions (MCHs) in Ewa town providing Nutrition service
will be included in the study. One MCH does not provide nutritional services and will be
excluded.
The required sample will be allocated among four MCHs by stratified sampling proportional to
the size on the total number of children attending MCHs. The Systematic random sampling

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method will carried out to select and approach each study subjects from every selected institution
and every second children coming for MCHs will included until the allocated number of study
subjects for each institution will reached.
For Qualitative Study
 Key informants for in-depth interview will be included in the study purposively from Heads of
the child growth monitoring, Heads of the MCH, Regional Nutrition Focal point and Regional
Health bureau, because their in-depth information was given optimal insight into an issue about
the problem under study.
4.3 Measurement and variables
4.3.1 Data collection instrument
For Quantitative study A pretested structured face to face interviewer questionnaire will be used
to collect the data which will be developed after reviewing relevant literatures and similar studies
(12, 15 and 25).
The questionnaire will be initially prepared in English and then translated in to Afar language by
an individual who has good ability of both languages then again was retranslated back to English
by another person to check for any inconsistencies. Accordingly necessary modifications were
made. The questionnaire contains five parts which include: Sociodemographic, Child
characteristics, Child caring practice, Maternal characteristics and Environmental conditions.
For Qualitative study
For the in-depth interview, semi structured interview guide will be prepared and the interviews
will be conducted by the principal investigator. Mobile phone recorder will used and note will
take by the investigator and one supervisor to catch the interview points after obtaining their
consent. The interviews will held in quit and comfortable place.
4.4 Study Variables
Dependent variable
 Malnutrition

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Independent variables
Socio-demographic variables:
 Permanent address, Care giver , Marital status , Family size , Income , Educational status and
Occupational status
Child characteristics:  Child Age and Sex, Types of birth, Place of delivery, Gestational age,
Breastfeeding status and morbidly status (fever, measles, diarrhea and ARI (Acute Respiratory
Infection)).
Child caring practices:-  Feeding , Hygiene , Health care seeking and Immunization
Maternal characteristics:  Age of the Mother , Number of children ever born , Number of
ANC visits , Health status during pregnancy and use of extra food during pregnancy and
lactation
Environmental condition:-  Water supply, Sanitation and Housing condition.
4.4.1 Measurements
 The dependent variable for this study was status of status of Malnutrition
 Anthropometric data: The anthropometric data was collecting using the procedure
stipulated by the WHO (2006) for taking Anthropometric measurements (30).
 Height/length measurement: Body length of children age up to 23 months were
measured without shoes and the height was read to the nearest 0.1cm by using a
horizontal wooden length board with the infant in recumbent position. However, height
of children 24 months and above was measured using a vertical wooden height board by
placing the child on the measuring board, and child standing upright in the middle of
board. The child’s head, shoulders, buttocks, knees and heels touching the board.
 Weight measurement: Weight was measured by electronic digital weight scale with
minimum /lightly/ clothing and no shoes. Calibration was done before weighing every
child by setting it to zero. In case of children age below two years, the scale was allowed
weighing of very young children through an automatic mother-child adjustment that was
eliminated the mother’s weight while she standing on the scale with her baby. Oedema
was checked and noted on data sheet because children with oedema are severely
malnourished.

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 The magnitude of Malnutrition to children was calculated from anthropometric
measurements obtained from collected data.
 Socio demographic and economic factors were measured by asking questions on age, sex,
educational status, marital-status, occupation and monthly income and recorded as
informed by respondents.
 Maternal related variables like Health status during pregnancy, Use of extra food during
pregnancy and lactation was recorded as yes/no from response given by study subjects.
 Child caring practice related variables like Feeding, Hygiene, Health care seeking and
immunization was measured by yes/ no and available health records.
 Child related variables like Types of birth, Place of delivery, Gestational age, and
Breastfeeding status and morbidly status was measured by response given by
respondents.
 Environmental Health condition related variables like Water supply, Sanitation and
Housing condition was recorded from responses given.
 The finding from In-depth interview was translated word by word and triangulated to
support the quantitative where necessary and where appropriate.
4.6. Data Collection Method
For quantitative
The questionnaire will give to selected sampled mothers through face to face interview by data
collectors and also measuring children. Weight, height and other anthropometric measurements
was done by proper materials and measured.
For Qualitative
In-depth interviews will be conducted with study population to assess the same aspects of the
study objectives in order to improve the validity of the findings and conclusions made.
4.7. Data collectors training and pre-testing
4.7.1 Pre-test Before
The actual data collection, the quantitative questionnaire will be pre-tested on 5% of the total
sample size (11 children) outside the study site, in Ewa MCH in Ewa District. The purpose of the
pre-testing was to ensure that the respondents will able to understand the questions and to check

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the wording, logic and skip order of the questions in a sensible way to the respondents.
Amendments were made accordingly after pre-testing.
4.7.2 Data Collectors
Diploma nursing students will be used to collect data. Two supervisors will participate
throughout the data collection and analysis. For data collectors and supervisors training was
given for two days to make them familiar with the data collection tool, objective of the study,
discussing contents of the questionnaire, anthropometric measurement of the children and issues
of maintaining confidentiality. The Principal investigator and supervisors would have the
responsibility of coordinating the overall data collection process and discussing about the
purpose of the study with data collectors. Based on the willingness of study participants and after
informed consent is obtained from each respondent, data collection was started by face to face
interview of pre-tested questionnaire and anthropometric measurements. Finally completed
questionnaire were returned to the supervisors.
4.8. Data processing & analysis
For quantitative data
After data collection, each questionnaire and anthropometric measurement were checked for
completeness, clarity and consistency. And then code was given before data entry. Data were
cleaned, explored for outliers, missed values, entered and analyzed using IBM SPSS version 20.0
statistical package. Different frequency tables, graphs and descriptive summaries were used to
describe the study variables.
Bivariate analysis will perform to see the existence of association between dependent and
independent variables. Binary Logistic regression was performed to assess the strength of
association between each major independent variable and the outcome variables. For some
variables correlation was used to test for any relationship. Then those variables that show
significant association with the outcome variable was included in a single model and multiple
logistic regressions. Finally only those independent variables that maintain their association with
outcome variables were used to construct the final models in multiple regressions. Odds ratio
with its P- value and confidence interval was used or reported in each logistic regression
analysis.

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For Qualitative data
After the in-depth interview the data was transcribed word by word into the local language and
then translated into English language. Then similar responses were grouped and summarized
based the key variables of the study. Finally results of the qualitative study was presented and
triangulated with the quantitative results.
4.9. Operational Definitions
 Acute Respiratory Infection (ARI): A child with cough, fast breathing or difficulty in
breathing and fever
 Anthropometry: Measurement of the variation of physical dimensions and the gross
composition of the human body at different age levels and degrees of nutrition by weight
for-age, height-for-age and weight-for-height (30).
 Children: A human between the stage of birth and puberty.
 Complementary food: Foods which are required by the child, after six months of age, in
addition to sustained breastfeeding.
 Diarrhea: Diarrhea is defined for a child having three or more loose or watery stools per
day.
 Family size: refers total number of people living in a house during the study period.
 Feeding: - To provide food and supply somebody with nourishment.
 Fever: A child with elevated body temperature than usual.
 Gestational age: - the period of development in the uterus from conception until birth.
 Hygiene: - Is the state of being clean and practice of keeping away from dirty/gross
things in order to prevent illness and disease.
 Immunization: - is the method of stimulating resistance in the human body to specific
diseases using microorganisms’ bacteria or viruses that have been modified or killed.
 Income: It is periodical monthly earning from one’s business, lands, work, investment
etc.

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 Malnourished: A child is labeled as malnourished if any of the nutritional assessment
indices weight for height< 70% or < - 1 SD, weight for age < 60% or < - 1 SD, height for
age < 85% or < - 1 SD is abnormal (30).
 Measles: A child with more than three signs of the following is considered having
measles: fever, and skin rash, runny nose or red eyes, and/or mouth infection, or chest
infection.
 Morbidly: - Is the connection with things that have to do with disease or death.
 Sanitation : is to protect public health through proper solid waste disposal, sewage
disposal, and cleanliness during food processing and preparation
 Stunting: Defined as stunted if the height for age index is found to be < 85% of the
median of the standard curve. Severe stunting is diagnosed if it is below 85%.
 Underweight: Refers to a deficit and is defined as underweight below the < 60% from
the WHO reference of the median of the standard curve. A severely underweight is
diagnosed if it is below < 60%.
 Wasting: Nutritional deficient state of recent onset related to sudden food deprivation or
mal-absorption utilization of nutrients which results weight loss, weight-for-height < 70%
from the WHO median value. Severe wastage is diagnosed if it is < 70%.
 Z-Score: - statistical measurements of a score’s relationship to the mean in a group of
scores.
4.10. Data Quality Control
To assure the data quality, data collection tool was prepared after intensive reviewing of relevant
literatures and related studies. Initially the questionnaire will prepared in English then translated
to afar and back to English by different individuals who had good ability of both languages.
Training was given for both data collectors and supervisors. Pre-testing of the questionnaire was
carried. The collected data were checked for completeness before data entry.
4.11. Ethical Consideration
The study obtained Ethical clearance and approval from Research Unit and Ethical committee of
Nugaal University (NU). Permission obtained from Regional Health Bureau and head of the
MCHs after discussion of the purpose of the study. For all participants, the aim of the study will

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explained and reassured that their responses were used only for research purposes and remain
confidential. Similarly after clear discussion about the purpose of the study made oral consent
was obtained from each study subjects while the study subjects right to refuse is also respected.
To assure the confidentiality of study subject’s response, writing their names or any
identification in the questionnaire were not done.

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