The document discusses protein energy malnutrition (PEM) among children under five years old. It addresses several key points: 1. PEM is caused by a deficiency of protein and energy. It can cause conditions like kwashiorkor and marasmus. Young children are especially vulnerable. 2. PEM leads to long-term physical and mental retardation. It increases mortality rates and susceptibility to infection. Malnutrition is a major cause of illness and death in developing nations. 3. The document reviews literature on the causes, forms, effects and complications of PEM. Poverty, lack of education, and cultural beliefs can all contribute to malnutrition. PEM stunts growth and impacts cognitive development.

1. CHAPTER ONE
INTRODUCTION
Background of the Study
Protein Energy Malnutrition (PEM) is a range of pathological conditions arising from a
deficiency of protein and energy, and is commonly associated with infections. In children, PEM
is defined by measurements that fall below minus two standard deviations of the normal weight
for age (underweight), height for age (stunting) and weight for height (wasting).
Protein Energy Malnutrition (PEM) is possibly a fatal body depletion disorder. The term PEM is
related to a group of associated disorders that include kwashiorkor and marasmus. Severe form
of malnutrition, associated with the cognitive effect. Mostly affected are the infants and young
children because of their high protein and energy needs related to body weight and their
particular susceptibility to infection.
PEM leads to chronic short -and long-term mental, physical retardation and worse resistant to the
infection, and increased death rate among children. Nearly one in five children who are under
five years in the developing world is malnourished and it remains to be a major cause of
mortality and ill health among children.
The World Health Organization has reported hunger and related malnutrition as the only threat to
the world's health problem. Nutritional disorder is the main subsidizing factor affecting
malnourished children to infections and increased prevalence and prolongation of vomiting and
diarrhea in children.
This happened because the mucosal surfaces are mainly prone to be attacked by micro-
organisms, and decreased immunity within this age. Malnutrition is the leading cause of the
global burden for disease.

2. In globally, almost 65% of children under the age of five years are underweight and 50% of these
children die as a result of PEM. Most common causes of morbidity and mortality among children
is malnutrition in all over world.
In Southern Asia and sub-Saharan Africa, malnutrition is public health problem in developing
world. These countries are having scarcity with diet of micronutrients (vitamin, water, mineral)
and macronutrients (fat, carbohydrates, and protein etc.).
In African countries, around 9% of under five children were having muscle wasting, 27.6% were
having underweight and 32.5% were stunted. Around 70% of children are delivered by
malnourished mother. Deficiency apart from the single nutrition such as essential fatty acid can
cause muscle degeneration and osteoporosis. In developing countries, parasitic and diseases
contribute greatly to malnutrition.
In developing countries more than one quarter of children younger than 5 years of age were
malnourished. According to the United Nations Children's Fund (UNICEF. 2015), 27% of
children with more than 5 years of age in developing countries were suffering from muscle
wasting.
In Nigeria, incidence of malnourished children ranges from 3.6% to 21.6%. In middle class
families poverty is found to be a major cause of underweight. A well -nourished child has good
access to care and food supply. A child will have height and weight measurements that compare
very healthy with the standard normal distribution of weights and heights of fit children of the
same sex and age.
The prevalence of underweight in children under five still poses greater risk of death in Mayo-
Belwa Local Government Area of Adamawa State, since the prevalence cut off value for
underweight (30% or higher) is very high. Moreover, one study showed that severely

3. underweight children were found to be two to eight times more likely to die within the following
year as compared to children of normal weight for their age.
There is considerable variation in results of the studies. One neglected but important factor that
influences the problem is the role of service delivery mechanisms.
Statement of the Problem
Malnutrition in growing children is one of the major causes of child morbidity and mortality as
up to 33% of children who die in Nigeria is due to the problem of malnutrition. At least 30 –
50% of all childhood death and 10 – 40% hospital admissions in developing countries occur as a
result of malnutrition (WHO, 2015).
Among growing children, severe under nutrition increases risk of morbidity because
malnourished children are susceptible to infection and with impaired cognitive development,
poor social and emotional achievement and low economic productivity. In order to make a
sustainable impact, intervention need to address direct cause and also the contextual factor
poverty has been identified as a important determinant of severe malnutrition, the path way for
this is complex. Improved economic performance has not automatically led to improved
nutritional status, poverty increases susceptibility to poor nutritional outcome, a significant
number of children brought up in poverty thrive. Therefore, adequate food is only one factor that
is important.
The prevalence of wasting among children under five years is a severe problem. According to the
World Health Organization (WHO) expert committee, “for wasting, prevalence cut off value
14% is taken as serious and 15% or more than 15% is considered critical.” The situation is also
so serious that wasting increases dramatically in the first two years of life and the prevalence is
highest among children age 11 months.

4. Prevalence rate of stunting is soaring making the child health situation critical. In children under
five, as highlighted by Pradhan (2016), PEM, and in particular stunting, has increased
vulnerability to disease and increased risk of mortality. Moreover, studies have shown that
stunted children frequently experience social disadvantages, which, in themselves, may
detrimentally affect their development.
From the above review highlights no study has been specifically completed in Mayobelwa Local
Government Area to ascertain the extent of Prevalence of Protein Energy Malnutrition among
children under five years in CMAM (community management of acute malnutrition) Health
Centres of Mayobelwa Local Government Area of Adamawa State hence the need for the present
study.
Purpose of the Study
The purpose of this study is to determine the Prevalence of Protein Energy Malnutrition
In children under five years in CMAM Health Centres of Mayobelwa Local Government Area of
Adamawa State. Specifically, it seeks to:
1. Determine the causes of Protein Energy Malnutrition among children under five years in
CMAM Health Centres of Mayobelwa Local Government Area of Adamawa State.
2, Identify the consequences of Protein Energy Malnutrition among children under five years in
CMAM Health Centres of Mayobelwa Local Government Area of Adamawa State.
3. Ascertain the solutions meant to reduce the problems of Protein Energy Malnutrition among
children under five years in CMAM Health Centres in the study area.

5. Significance of the Study
The findings of this study will enable the researcher understand the causes of Protein Energy
Malnutrition and ascertain the effects of malnutrition.
The study will also help mothers realize the consequences of Protein Energy malnutrition, the
knowledge of the incidence of malnutrition among growing children will enable Mayobelwa
health centres Local Government Area of Adamawa State to educate parents more on the
prevention of Protein Energy malnutrition.
The findings of this study may assist the students and other researchers to carry out such a
similar project for further study.
It may also serve as basis for health policy-makers to instill good management practices in the
healthcare delivery system, with respect to improvement of quality of care among children of
under five years.
ResearchQuestions
The following research questions were central to this study:
1. What are the causes of Protein Energy Malnutrition among children under five years in
CMAM Health Centres of Mayobelwa Local Government Area of Adamawa State?
2. What are the consequences of Protein Energy Malnutrition among children under five years
in CMAM Health Centres of Mayebelwa Local Government Area of Adamawa State?
3. What are the solutions meant to reduce the problems of Protein Energy Malnutrition among
children under five years in CMAM Health Centres in the study area?

6. Scope of the Study
The research project focuses on the Prevalence of Protein Energy Malnutrition among children
under five years in CMAM Health Centers of Mayo-Belwa Local Government Area of
Adamawa State.

7. CHAPTER TWO
REVIEW OF RELATED LITERATURE
This chapter deals with the literature review on the Prevalence of Protein Energy Malnutrition
among children under five years in CMAM Health Centers of Mayo-Belwa Local Government
Area of Adamawa State under the following sub-headings:-
 Causes of Protein Energy Malnutrition among children under five years
 Consequences of Protein Energy Malnutrition among children under five years
 Solutions meant to reduce the problems of Protein Energy Malnutrition among
Children under five years
 Summary of reviewed Literature
Causes of Malnutrition
Malnutrition is a term which refers to both under nutrition (sub nutrition) and over nutrition
(obesity). It can also be defined as the insufficient, excessive or imbalanced consumption of
nutrients. Though Nigeria has the second largest economy in Africa, it also has one of the highest
numbers of severely malnourished children in the world: approximately 24% of children under
five years old i.e. more than a million children suffer from malnutrition (Punch News, 2015). A
July 2013 report by the Federal Ministry of Health says “41%” of Nigerian children under age
five suffer stunted growth as a result of malnutrition. The survey conducted in all the states of the
federation by the ministry shows that there is acute malnutrition among children in the states of
the north. The United Nations international children education fund estimates that “1.1 million
children are threatened with severe malnutrition”. Notably, the report adds that children in states

8. such as Ebonyi, Delta, Benue and Bayelsa are at risk of acute malnutrition. This shouldn’t be,
because children need good nutrition more than adults, moreover, the quality of nutrition
available to a child in early age determines his or her development and health in life (Punch
News, 2015).
Nearly half of all deaths in children under five (5) years are attributable to under nutrition. This
translates into the unnecessary loss of about three (3) million young lives a year. Under nutrition
puts children at greater risk of dying from common infections, increase the rate and severity of
infections and attributes to delayed recovery. In addition, the interaction between under nutrition
and infection can create a potentially lethal cycle of worsening illness and deteriorating
nutritional status. Poor nutrition in the first three years of a child’s life can also lead to stunted
growth, which is irreversible, associated with impaired cognitive ability and reduced school
performance. Child malnutrition was associated with 54% of death in protein – energy
malnutrition (PEM), also observed most frequently in developing countries.
The causes of malnutrition include the following:-
- Primary factors: congenital abnormalities that impair adequate nutrition e.g.
malabsorption, cleft palate and deficiency of intrinsic factor.
- Secondary causes: this is caused by poverty.
- Social factors such as illiteracy and ignorance on how to prepare food, preserve it or use
the common food substance within own environments to promote nutrition.
- Cultural beliefs/taboos: some cultures in Nigeria believe it is a taboo to consume certain
foods e.g. the Yoruba’s from Ondo state have social norms against eating rabbits which is
a source of protein. (Akinsola, 2015).

9. Clinical Manifestations of Malnutrition
 Dehydration
 Diarrhoea
 Growth retardation
 Allergies
 Malabsorption
 Swollen face and puffy checks
 Distended abdomen (ascites)
 Enlarged liver and spleen
 Scanty hair
 Oedema of lower extremities
 Skin pigmentation
Forms of Malnutrition
They are:
 Kwashiorkor
 Marasmus
 Protein energy malnutrition (PEM)
Kwashiorkor
Kwashiorkor is a form of malnutrition caused by inadequate intake of protein. It is common in
countries with limited food supply or low level of education. Kwashiorkor is characterized by
fatigue, diarrhea, loss of muscle mass, failure to grow or gain weight, oedema, large belly that
protrudes and irritability (Cafasso, 2014).

10. Marasmus
This is a form of malnutrition which results from the inadequate intake of proteins and calories, a
person with marasmus presents with growth retardation and progressive wasting of subcutaneous
fat and muscle. Other symptoms may include diarrhea, dehydration, dry loose skin, brittle hair
and behavioral changes. Marasmus can be corrected by consumption of high-calorie protein-rich
diet. (Britannica, 2015).
PROTEIN ENERGY MALNUTRITION (Marasmus Kwashiorkor)
It is a deficiency syndrome caused by inadequate intake of macronutrients (carbohydrate,
protein, lipids and water). The body needs to ingest food in large amount in order to maintain
physiological functions during growth and development. Protein energy malnutrition is
characterized not only by a deficit in macronutrients; this syndrome is one of the examples of the
various levels of inadequate protein or energy intake which is the most important public health
need in developing countries in the world today. (Grover, 2019).
EFFECTS OF MALNUTRITION ON GROWING CHILDREN
 Retarded growth
 Poor vision
 Loss of coordination
 Rickets
 Pellagra
 Scurvy (Gover, 2009)

11. Complications of Malnutrition
 Risk for infection due to reduced immunity
 Failure to thrive in children
 Low intelligent quotient (I.Q)
 Learning difficulties
 Under development
 Brain damage
 Xerophthalmia (Gerard, 2004)
Food Classification and Functions
Foods are classified into the following nutrients: carbohydrate, protein, fats and oil, vitamins,
minerals and water.
Carbohydrate
This is a major food nutrient found in plants. Carbohydrate contains carbon, hydrogen, and
oxygen in the ratio of 1:2:1. It’s importance lies mainly in energy provision for body processes.
Sources
* Root/tubers e.g cassava, yam, cocoyam and potatoes
* Cereals e.g rice, wheat, corn, sorghum and millet
Classification of Carbohydrates
There are three classes of carbohydrates

12.  monosaccharides
 Disaccharides
 Polysaccharides
Monosaccharides
They are the simplest sugars and they contain one molecule of sugar. This carbohydrate contains
3 – 6 carbon atoms and the commonest ones have 6 carbon atoms which have the formula
C6H12O6. Examples are glucose, fructose and galactose.
Source of monosaccharides
Honey, fruits, juices, cakes and ice cream (Okoli, 2014).
Disaccharides
Disaccharides are formed by the union of two monosaccharide molecule with loss of water.
Examples of disaccharides are:
 Sucrose: gotten from vegetables, fruits, roots and cereals
 Maltose: mostly cereal products such as sorghum, malt, barley and wheat
 Lactose: this is the type of sugar present in milk (Okoli, 2009)
Polysaccharide
These are carbohydrates high in molecular weight, non-crystalline, generally insoluble in water
and tasteless. Polysaccharides contains more than 10 units of monosaccharides and are
predominantly found in plants. Examples include cereal and pulses (Okoli, 2009).
Functions of Carbohydrate

13.  Chief sources of energy in our diets
 Lenses of the eye, brain, nerve and red blood cells use only carbohydrate as source of
energy for their various functions
 Provides biological active substances like glycoprotein, glycolipids e.t.c (Okoli,
2009).
Proteins
Protein is one of the macronutrients that exists in foods. It is a complex compound that contains
nitrogen in addition to hydrogen, oxygen and carbon. Some proteins also contain sulphur, cobalt,
phosphorus and manganese. There are animal and plant proteins. (Okoli, 2009).
Source of Proteins
 Animal sources: are breast milk, skimmed milk, meat, whole milk, eggs, fish and
chicken
 Plant sources: are groundnut, bambara nuts, soyabean and all types of beans.
Functions of Proteins
 Essential for growth
 Formation of essential body compounds e.g antibodies and enzymes
 Replacement of worn out tissue (Okoli, 2009)
FATS (LIPIDS)
Like carbohydrates, fats contains carbons, oxygen and hydrogen atoms but because the fatty acid
chains have more carbon and hydrogen relative to oxygen they provide more energy per gram.

14. For example, fats provide approximately akcal per gram, while carbohydrates and proteins
provide 4kcal per gram. of the different types of fats, saturated fats rise cholesterol level causing
heart disease, alternatively mono-saturated and poly unsaturated fats helps to lower bad
cholesterol, decreasing the risk of heart diseases. All fats are very high in calories so they must
be used sparingly. The basic units are divided into three groups:
 Mono-saturated fatty acids
 Poly-unsaturated fatty acids
 Saturated fatty acids
Fatty acids containing double bonds are called mono-saturated, with two or more double bonds, a
fatty acid is poly-unsaturated. Generally, most dietary fats and oils are a mixture of all the three
types of fatty acids with one type predominately. For example soya beans, corn sun flower oils
relatively high in poly-unsaturated fatty acids. Olive, peanuts and canola oils are high in mono-
saturated fatty acids and most animal fat and tropical oils (e.g coconut oil and palm oil) are
relatively high in saturated fatty acids (Okoli, 2009).
Function of Fats
 Provide energy
 Insulates the body
 Aid fat soluble vitamin absorption and transport
 Regulates ovulation, body temperature and hormones

15. VITAMINS
These are chemical compounds required in very small quantities which are essential for normal
metabolism and health found in wide range of foods and are divided into two groups:
 Fat soluble vitamins A, D, E and K
 Water soluble vitamins such as B complex and C (Okoli, 2009)
Fat Soluble Vitamins
Vitamin Source Functions Deficiency
A (retinol and
carotene)
Egg yolk, liver,
milk, palm oil
 Helps in light sensitivity
in the retina of the eyes
 Xerophthalmia
 Night blindness
 Keratomalacia
D Sunlight, egg, fish,
oils
 Helps in calcification of
bones and teeth
 Rickets
 Osteomalacia
E (Tocopherol) Palm oil, egg, wheat
gem, cereals, milk.
 Prevents heart disease
 Prevents lipid
membrane from
oxidation
 Neurological
abnormalities
 Hemolytic
anemia
K Liver, vegetable
oils, leafy vegetable
 Aid in the production of
prothrombin
 Abnormal blood
coagulation
(Okoli, 2009)
Water Soluble Vitamin
Vitamins Source Functions Deficiency
B1 (Thiamine) Nuts, yeast, egg
yolk, liver meats
i. Proper
functioning of
the nervous
system
i. Beriberi
ii. Severe muscle
wasting
iii. Delayed growth
in children
iv. Susceptibility to
infection
B2 (Riboflavin) Green leafs, fish
oil, liver, milk
i. Helps in the
metabolism of
carbohydrates
and proteins
especially in the
i. Cracking of skin
ii. Inflammation of
the tongue

16. eye and skin
B3 (Niacin) Liver, cheese,
whole cereals,
eggs, fish and nuts
i. It inhibits the
production of
cholesterol and
assists in fats
breakdown
i. Pellagra
B6 (Pyridoxine) Egg yolk, peas,
beans, meat, liver
i. It helps in the
metabolism of
amino acids
ii. Helps in the
synthesis of non-
essential amino
acids
i. Rare
B12
(Cyanocobalamine)
Liver, meat, egg,
milk
i. It is essential for
DNA synthesis
ii. It is required for
the maintenance
of Schwann cells
of nerves
i. Megalobastic
anemia
C (ascorbic acid) Green vegetables
and fresh fruits
i. Repairs worn out
tissues
ii. Aids in wound
healing
i. Scurvy
Minerals
Minerals: these are essential inorganic elements needed in small amounts in the diet for
normal functions, growth and maintenance of body tissues. Minerals are used for all body
processes within the body usually in small quantities.

17. Mineral Source Function Deficiency
Sodium (Na) Common salt, milk,
fish, meat
i. Aids in
electrolyte
balance
ii. Aids in normal
muscle and nerve
function
iii. Helps to absorp
glucose and
amino acids
i. Hyponatreamia
ii. Dehydration
Potassium (K) Potatoes, meat,
beans, tomatoes,
vegetable
i. Maintains fluid
balance
ii. Transmitting
nerve impulse
i. Hypokaleamia
ii. Risk of stroke
Minerals Source Function Deficiency
Chloride (cl) Olive oil, lettuce
fruits, salt,
vegetable
i. Helps to maintain
extracellular fluid
and balance
i. Frequent bouts of
vomiting
Calcium (Ca) Milk, green
vegetable, eggs,
fish, bones
i. Maintenance and
development of
bones
ii. Muscle contraction
iii. Blood clotting
iv Transmission of
nerve impulse
i. Osteoporosis
Iron (Fe) Liver, egg yolk,
kidney, beet, green
vegetables
i. Oxidation of
carbohydrates
ii. Formation of
haemoglobin in red
blood cells
iii. Synthesis of some
hormones
i. Iron deficiency
anacinia
Zinc (Zn) Whole grain cereals,
milk, meat, eggs
i. Aids in protein
metabolism
ii. Aids in
carbondioxide
transfer
i. Growth
retardation
ii. Loss of appetite

18. Water
Water transports other nutrients to cells, carries wastes away and acids in digestion. It makes up
half the human weight.
Functions of water
 Works to keep muscles and skin toned
 Aids in weight loss
 Transports oxygen and nutrients to cells
 Eliminates toxins and wastes from the body
 Regulates body temperature
Sources of water includes:
Table water, well water, rain water, spring water. (Okoli, 2009)
Feeding Requirement for Growing Children (Birth to 5 years and benefits)
Infant: Birth to 6 months
At birth, exclusive breast feeding is recommended
Benefits of Breast Milk
 Protection against gastro intestinal infections
 Prevents diarrhoea
 Builds body immunity
 Contains right amount of water
 Provides energy

19. Toddlers: Six (6) to twelve (12) months
Solids should be introduced around six months of age (complementary feeding) to meet
increasing nutritional and developmental needs. However, breast feeding should continue until
12 months of age and beyond or as long as the mother desires to maintains body nutrients.
Initiating Complementary Feeding:-
 Give foods rich in iron and zinc such as infant formula, soyabean meals and rice
 Whole fruits is preferable to fruit juice
 Introduce foods one at a time
 Occasional exposure to sunlight is enough to provide baby’s vitamin D requirement
Early childhood (12 months to 5 years)
Once a child is eating solids, offer a wide range of foods to ensure adequate nutrition. Young
children (early childhood) are often picky with food but should be encourage to eat a wide
variety of foods to ensure adequate nutrition.
These measures should be observed:-
 Adequate weight gain and development will indicate whether food intake is
appropriate
 Avoid sugary foods and drinks
 Ensure adequate fluid intake
 Beware of foods that may cause allergic reaction e.g shellfish, cray fish and cow’s
milk. (state government of lake Victoria, 2015).

20. Growth Monitoring
Growth monitoring is a good and sensitive method of assessment of child’s growth and
development. The different methods used in nutritional surveillance are anthropometric
measurements, physical examination, and biochemical examination. E.g.hemoglobin level,
serum cholesterol, vitamin level etc. Anthropometric measurements are weight, height, upper
arm circumference and head circumference of persons measured and compared with existing
standards.
Weight
Weight is the simplest anthropometric measurement. A child weighs an average of 3.5kg at birth
and should continue to gain some weight each time he or she visits the clinic. Average weight
gains are as follows:
i. 30g per day for the first 3 months
ii. 500g to 1.0kg per month for the first 6 months
iii. 350g to 500g per month for the second 6 months
iv. Birth weight tripled at the end of the first year
v. 250g per month from first year to the second year
The child is malnourished if weight is very much below the standard for given age.
Height
Height is measured supine on a special board for infants under 2years and standing in children
over 2years. Average height for age are:
 Birth – 50cm
 6 months – 65cm

21.  1 year – 75cm
 2 years – 85cm
 4 years – 100cm
MID UPPER ARM CIRCUMFERENCE
It is measured around the arm, half way between the shoulder and the point of the elbow. A
Childs arm circumference increase from approximately 10cm at birth to 16cm at 12 months and
remains at 16cm from the age of 1year to 5years. The arm circumference measuring equipment is
called shaker strip.
The strip is colored red to indicate danger or gross malnutrition, when the circumference is
below 12.5cm, orange or yellow (between 12.5 and 13.5cm), moderately or mildly malnutrition
and green for good nutritional status above 13.5cm.
Head Circumference
This is the greatest circumference just above the ears, around the forehead and the back of the
head is 35cm at birth. The head increases as follow:
 One to 2cm per month for the first 4 months
 5cm between 4 months and 1 year
 Increase in size in the first one year by about 10 to 12cm
 After 1 years until the age of 20years the head circumference grows another 10cm.
(Obionu, 2010)

22. CONCEPTUAL FRAMEWORK (VIRGINIA HENDERSON’S NEED THEORY)
The need theory of Henderson is of the view that the nurses role is in assisting individuals (sick
or well) to gain independence to carry out their own health care by themselves. She outlined 14
fundamental principles which everyone needs to do without any assistance. They include:
i. Breathing
ii. Eat and drink
iii. Elimination of bad waste
iv. Moving and maintaining a desirable position
v. Sleep and rest
vi. Selecting suitable clothes
vii. Maintain body temperature within normal limits by changing clothes and maintaining
good body weight
viii. Keep body clean and well groomed
ix Prevent injuries and avoid dangers
x. Communicating with others in expressing emotions, needs, fears or opinions
xi. Worshipping according to ones faith
xii. Working in such a way that one feels a sense of accomplishment
xiii. Playing and participating in various forms of recreation
xiv. Learning, discovery or satisfying the curiosity that lead to normal development and
health using available health facility.
The second of which she identified as “eat and drink”. The desire of every parent or guardian to
a growing child is to groom them to a stage of independence psychologically, emotionally and
socially. But amidst this expectation are even greater challenges of growing up caused by growth
deformity due to improper nutrition. Because of inadequate nutrition, there is a threat to self

23. independence in later life if appropriate measures to correct malnutrition are not carried out. A
popular phrase spoken by Authelme Brillant – Savarin states thus; “tell me what you eat and I
will tell you what you are”. Adequate nourishing diet cannot be over emphasized especially
during the stage of growth and development when the body needs them the most. For the body to
grow well, gain tangible immunity and thrive better in the environment.
Assist the child with the “eat and drink” necessity and you are doing much good as preventing
malnutrition, growth deformities and associated complications.
Summary of Reviewed Literature
The integration of psychosocial stimulation (the exposure of a child to a variety of experiences
and the encouragement to explore the environment) into nutritional programs has been found to
be an important element in adequately addressing malnutrition. This involves the development of
parenting skills and promotion of change in the relationship between the parent and child. In any
nutritional intervention, therefore knowledge of the beliefs and behaviors of parents is an
important consideration.
As a first step in mobilizing resources to develop an appropriate intervention, a study was made
to find out what is the parent perceptions towards malnutrition as a health problem in growing
children, in a community like Mayo-Belwa Local Government Area of Adamawa State where
the mother is the care giver and generally the parent who accompanies a child to hospital for the
treatment of severe malnutrition, it is the parent who is the key to overcoming the consequences
of severe malnutrition. If the above suggestions and recommendations were being put in place,
the objective of this research work will be achieved.

24. CHAPTER THREE
METHODOLOGY
This chapter is concern with describing the Research Design, Area of Study, Population of the
Study, Sample and Sampling Technique, Instrument for Data Collection and Administration,
Validation of the Study, Reliability of the Study, Method of Data collection and Method of Data
Analysis.
ResearchDesign
Orodho (2015) defines research design as the scheme, outline or plan that is used to generate
answers to research problems. This study adopted the descriptive survey research design. Also
Mugenda (2013) define a survey research as an attempt to collect data from members of a
population in order to determine the current status of that population with respect to one or more
variables. This design was chosen because the study involved asking questions (in form of
questionnaires) to a large number of respondents in order to get their opinions and ideas
concerning the Prevalence of Protein Energy Malnutrition among children less than five years in
CMAM Health Centers of Mayo-Belwa Local Government Area of Adamawa State.
Descriptive survey design was also used because it provided the researcher with an opportunity
to probe the respondents for more information which involves collections of information through
structured questionnaire.

25. Area of Study
The research study will be conducted in all five CMAM Health Centers of Mayobelwa Local
Government Area of Adamawa State. These include: Jereng PHCC, Tola PHCC, Mayofarang
PHCC, Binkola PHCC and Mayobelwa Ardo Memorial PHCC.
Population of the Study
The population of five health centres that made up of CMAM Health Centers of Mayobelwa
Local Government Area of Adamawa State comprised Jereng PHCC, Tola PHCC, Mayofarang
PHCC, Binkola PHCC and Mayobelwa Ardo Memorial PHCC respectively is 22,150. The
population of this study is one hundred and fifty (150) respondents. 10 percent of the respondents
were considered necessary for this research work.
Table 3.1: List of Selectedhealth care centres
S/No Health Centres Population Sample
1. Jereng PHCC 4,100 30
2. Tola PHCC 3,807 30
3. Mayofarang PHCC 4,650 30
4. Yoffo PHCC 3,183 30
5. Mbilla PHCC 4,900 30
TOTAL 22,150 150

26. Sample and Sampling Techniques
Simple random sampling technique will be employed to draw a sample of one hundred and fifty
(150) respondents from the population. This sampling technique will be considered suitable and
appropriate because each member of the population has equal chances of being included in the
sample. The health centers include Jereng PHCC, Tola PHCC, Mayofarang PHCC, Yoffo PHCC
and Mbilla PHCC.
Instrument for Data Collection and Administration
The instrument for data collection is a structured questionnaire designed to elicit responses to
Answer the research questions that guided the study. It is made up of four Sections. Section A
addresses the Socio-Demographic data, Section B is on the causes of Protein Energy
Malnutrition among children under five years in CMAM Health Centers of Mayo-Belwa Local
Government Area of Adamawa State, Section C is on the consequences of Protein Energy
Malnutrition among children under five years in Cham Health Centers of Mayo-Belwa Local
Government Area of Adamawa State and Section D is on the solutions meant to reduce the
problems of Protein Energy Malnutrition among children under five years in CMAM Health
Centers in the study area.
The instrument is scored along the 5 – points rating scale as follows:
Strongly Agreed (SA) 4 points
Agree (A) 3 Points
Disagree (DA) 2 Points
Strongly Disagree (SD) 1 point

27. No answer ( NA) 0 point
Validation of the Instrument
The instrument will be subjected to both face and content validity by the project Supervisor from
the Department of PHC, Kaduna Polytechnic. Based on his comments, observations, criticisms
and suggestions modification and collations will be made before the final draft of the instrument
is produced.
Reliability of the Instrument
The reliability coefficient of the instrument will be established using test retest reliability test.
The instrument will be administered to the respondents and after some days the data collected
will be analysed.
Method of Data Collection
The data for the study will be personally collected by the researcher and two trained research
assistants whom will be given an hour training on the content and purpose of the instrument.
Copies of the instrument will then be administered to the respondents and will be collected back
on the spot, while those that could not be collected on the spot will be given 2 days for
collection. Out of 155 copies administered, 150 copies were collected back representing 100%.
Method of Data Analysis
In order to arrive at a proper and thorough data analysis, information collected will be analyzed
based on the research questions. The data collected will be computed and presented using mean

28. statistics and or standard deviation; a five (5) point rating scale will be use, with nominal values
as explained earlier under instrument for data collected above.
A decision rule will be formulated using:
4+3+2+1
4
= 10/4 = 2.5
= 2.5 points
The above calculation or decision rule indicates that any questionnaire item that score 2.5 and
above will be consider agreed; while any questionnaire item with a mean value below 2. 5 will
be regarded as disagreed.

29. College of Vocational and Technical Education,
Department of Primary Health Care Education,
Kaduna polytechnic,
Kaduna state.
QUESTIONNAIRE
Dear Valued Respondent,
I am a student from the above mentioned institution undergoing PHC tutors programme
conducting research on the topic, “Prevalence of Protein Energy Malnutrition among children
under five years in CMAM Health Centers of Mayo-Belwa Local Government Area of
Adamawa State.”
Kindly assist me in filling this information which are purely for academic purposes, all responses
will be treated with utmost confidentiality.
Thanks
Socio – Demographic Data
Instruction: Tick the appropriate option from the box below
1. Age:
i. 18 years – 25 years ( )
ii. 26 years – 33 years ( )
iii. 34 years – 41 years ( )
iv. 42 years and above ( )
2. Sex: Male ( ) Female ( )
3. Marital status:
i. Married ( )
ii. Widow ( )

30. iii. Single ( )
iv. Divorced ( )
4. Educational Background
i. Primary level ( )
ii. Secondary level ( )
iii. Tertiary level ( )
iv. Not attended ( )
5.Occupation:
i. Civil servant ( )
ii. House wife ( )
iii. Trader ( )
iv. Farmer ( )
Items in tabular form
Instruction: Tick the appropriate box in the column as follows:
i. Strongly Agree (SA) ( )
ii. Agree (A) ( )
iii. Disagree (D) ( )
iv. Strongly Disagree (SD) ( )
SECTION B:
5. Malnutrition is a disease for the poor
i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA ( )
6. Malnutrition occur mostly in children under the age 5 years

31. i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA
7. Malnutrition can be regarded as an insufficient, excessive or imbalanced consumption of
food nutrients.
i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA ( )
8. Information on good or balanced diet could be obtained only from clinics or schools
i ii iii iv v
SA A ( ) D ( ) SD ( ) NA ( )
9. The nutrient composition of food plays great role in course of protein –Energy malnutrition
i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA ( )
10. Exclusive Breast feeding can be regarded as form of balance diet.
i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA ( )

32. 11. What are the causes of malnutrition?
(a) Ignorance or illiteracy [ ] (d) Both A and B above
(b) Poverty [ ] (e) None of the above
(c ) Family planning [ ]
12. What Problems can malnutrition cause in growing children?
(a) Growth retardation [ ] (b) Rickets [ ] (c) Scurvy [ ]
(d) Decreased coordination [ ] (e) All of the above [ ]
13. Adequate feeding help to increase body immunity and prevent diseases
i ii iii iv v
SA ( ) A ( ) D ( ) SD ( ) NA ( )
14. Malnutrition be prevented by one or more of the following strategies
(a) Through health education by mass media, health institutions on good nutrition. [ ]
(b) Food subsidy by the government to enhance accessibility [ ]
(c) Mothers should be encouraged to grow food locally in gardens [ ]
(d) Early diagnosis and treatment should be done to malnourished children [ ]
(e) All of the above [ ]
15 Advice to be given to Mothers during antenatal visit on nutrition include all except
(a) Start exclusivebreastfeedingassoonas possible afterdelivery. [ ]
(b) Administercomplementaryfeedingwhen the childisnine yearsold. [ ]
(c) Mothersshouldtake balanceddietwhenpregnantandthereafter. [ ]
(d) All childrenunderone yearshouldbe fullyimmunized [ ]
(e) (e) Weaningdietshouldbe readilyavailableandaccessiblebythe childrenunderfive [ ]