Magnitude of Stunting and Associated Factors Among 6-59 Months Old Children in Hossana Town, Southern Ethiopia

Introduction: Stunting remains a public health problem of greater magnitude and it more accurately reflects nutritional deficiencies of the most critical periods of growth and development in early life. Therefore, the study was aimed to assess the magnitude of stunting and associated factors among 6-59 months old children in Hosanna town, Southern Ethiopia. Methods: A community based cross-sectional study was conducted using a simple random sampling technique with a sample size of 734 children, aged 6-59 months. The structured questionnaires were used to collect data. Data analysis was done by SPSS version 20 and ENA for SMART, 2011 software. Results: The study result reveals that 35.4% of 6-59 months old children were stunted, with even higher rates among male children 138 (53.1%). Children more likely to be stunted included: those between 24 and 35 months (AOR=2.29; 95%CI:1.10, 4.82), those whose mothers had no education (AOR=5.38; 95%CI:2.27, 12.77), those from a low income household (AOR=3.92; 95%CI:2.54, 6.06), those who were physically small at birth (AOR=2.10; 95%CI:1.13, 3.93), having birth order of 4 and above (AOR=2.32; 95%CI:1.28, 4.21), those who breastfed for longer than 24 months (AOR=2.49; 95%CI:1.03, 6.00), and those whose mothers did not use a cup to feed their children (AOR=2.08; 95%CI:1.05, 4.15). Conclusion: The findings of this study have proven stunting were a high prevalent problem in the study area. The child’s age, mother’s education level, household income, birth order, size at birth, duration of breastfeeding and cup feeding were found to be associated factors of stunting. All of the factors, except birth order, could be reversed through thoughtful programming. The findings of this study suggest that there is potential need for linking nutrition interventions in the study area.


Introduction
Malnutrition is an underlying cause of more than 2.6 million child deaths every year, a third of the total of child deaths. Every hour of every day, 300 children die because of malnutrition but it's not recorded on death certificates and, as a result, it's not effectively addressed [1,2].
Worldwide, an estimated 171 million children are stunted because of poor nutrition in the earliest months of life. More than a third of children in Asia are stunted, which accounts for almost 100 million of the global total. In Africa, almost two in five children are stunted that is a total of 60 million children [2,3].
Stunting is defined by a Height-for-Age (HAZ) Z-score below two SDs of the median WHO standards [4]. The first 1,000 days of life beginning with conception, through a mother's pregnancy and up until the age of two is the most critical period in a child's development [3].
Stunting is an indicator of chronic malnutrition, meaning longterm or accumulated nutritional deficiency resulting from lack of adequate dietary intake over a long period of time and/or recurrent illness. Stunting is caused by inadequate diet and by infection as immediate level. These primary causes of malnutrition are influenced by food access and availability, healthcare, water and sanitation, and the way a child is cared for such as whether the infant is breastfed and whether basic hygiene practices are used which includes hand-washing [3,5,6].
Stunting in early childhood also results in diminished cognitive and physical development, which puts children at a disadvantage for the rest of their lives. They may perform poorly in school, and as adults they may be less productive, earn less and face a higher risk of disease than adults who were not undernourished as children [6,7].
Height at two years of age is clearly associated with enhanced productivity and human capital in adulthood, so early nutrition is also an important contributor to economic development in which a 1% loss in adult height due to childhood stunting is associated with a 1.4% loss in productivity [5]. Progress in reducing childhood malnutrition in developing countries has been slow. The larger burden for Africa is stunting that is the failure to grow in stature [8].
Stunting is continued to be one of the most important public health problems in Ethiopia. In urban Ethiopia based on 2011 EDHS the prevalence of stunting in under five children was 32% which is with 2.2% increase in five years from 2005 EDHS [9,10].
Therefore, this study is aimed to assess the magnitude of stunting and associated factors among under five children in Hossana town, Southern Ethiopia. Furthermore, the findings of this study will enable policy makers, public health advocators, nutritionists and researchers used as baseline data to design appropriate and effective interventions.

Study area and period
This study was conducted in Hossana town. Hosanna is located 230 km south west from the capital city of Ethiopia being the capital city of Hadiya zone. The study period was as of March 15 to April 15, 2013.

Study design and populations
Community based cross sectional study design was used to assess the magnitude of stunting and associated factors among 6-59 months old children in Hossana town. All sampled respondents of the Hossana town from the randomly selected kebele who were present during study period were included.

Sample size and sampling procedures
The sample size was calculated using single population proportion formula by considering 32% of estimated proportion of under five children were stunted in Ethiopia, margin of error 5%, a 5% level of significance (two sided) i.e. 95% confidence interval of certainty. Based on the above assumptions, with an additional 10 percent contingency for non-response, the final sample size was 334. Considering the design effect of 2 and with an additional 10 percent contingency for non-response; the total sample size was 734. Simple random sampling technique was used to select study participants from each kebele. Socio economic and demographic factors: Age, ethnicity, religion, marital status of the mother, mother's education, father's education, mother's occupation, father's occupation, household monthly income, birth order, preceding birth interval. Environmental factors: Source of drinking water and latrine facility availability. Health care factors: child's weight and size at birth, child immunization status, child morbidity, mother's antenatal care visits, mother's age at pregnancy, mother's place of delivery. Dietary factors: ever breast feeding, time for initiation of breast feeding, colostrums feeding, pre-lacteal feeding, duration of breastfeeding, age for introduction of complementary food method of feeding. Stunting means children whose height-for-age Zscore is below minus two standard deviations (-2 SD) from the median of the WHO reference population are considered short for their age (stunted). Recurrent episodes of diarrhea is to mean child who have 2 or more an episode of diarrhea begins with a 24-hour period with three or more loose or watery stools and an episode of diarrhea is considered to have ended after 48 hours without three or more loose or watery stools within a 24-hour period Which Is determined as perceived by mother. Fully vaccinated is to mean children who have received vaccination against tuberculosis (BCG), three doses each of the DPT and polio vaccines, and a measles vaccination by the age of 12 months. Currently on vaccination with age mean children who have receiving a vaccination according to the schedule because of their age. Non-Fully vaccinated is to mean children who have not received three doses each of the DPT, a vaccination against tuberculosis (BCG), and polio vaccines, and a measles vaccination by the age of 12 months according to the standard immunization schedule. Size at birth means based on mothers' estimation and verbal report. Pre-lacteal feeding is to mean children given something other than breast milk during the first three days of life. Duration of breastfeeding means the number of months of breastfeeding among children. Complementary feeding means the child receives both breast milk or a breast milk substitute and solid (semi-solid or soft) foods. Low income is to mean households with monthly income below mean income of the sample 1,745ETB. High income is to mean households with monthly income 1,745ETB and above the mean income of the sampled households.

Data collection instrument and procedure
Data on stunting and demographic, socio-economic, environmental healthcare and dietary factors among children age (6-59 months) was collected using structured questionnaire. The questionnaire was adapted from different literatures of similar studies in English to increase the comparability of the finding. Anthropometry measurements mainly height for age was used. For height, length measurement for children below 24 months was taken in laying down or recumbent position and standing height was taken for children 24-59 months and the measurement was taken to the nearest 0.1 cm using UNICEF standard Height Measuring Board with the subjects shoeless [11,12], and for age, the child's age was collected from the mother and confirmed by using birth certificate or vaccination cards and also we were used a "local-events calendar" [11,12].

Data quality management, processing and analysis
Questionnaires were translated to local language and then back translated to English to maintain its consistency. Training was given for data collectors and pretest was done on 5% of the study subjects on similar population out of study area. Supervisors and principal investigator performed immediate supervision on a daily basis. The collected data were entered in SPSS 20.0 version for analysis. Anthropometric measurement data was entered and analyzed by Emergency Nutrition Assessment (ENA) for SMART 2011 software. Descriptive analysis was used to describe the percentages and number of distributions of the respondents by socio-demographic factors, environmental factors, health care factors and dietary factors. Furthermore, bivariate and multivariable logistic regression analyses were used to identify the influencing factors using backward variable selection techniques. All explanatory variables that were associated with outcome variable in bivariate analysis with p-value of 0.25 or less were included in the initial logistic models. The Crude Odds Ratio (COR) and Adjusted Odds Ratios (AOR) together with their corresponding 95% confidence intervals were computed and interpreted accordingly. A P-value<0.05 was considered to declare a result as statistically significant in this study.

Ethical consideration
Ethical clearance was obtained from the Institute of Public Health, University of Gondar Ethical committee. Prior to data collection, a formal letter was obtained from University of Gonder and submitted to each kebele. The purposes and importance of the study was explained and written informed consent was secured from each mother of the children. Confidentiality was maintained at all levels of the study.
All study participants was informed that participation in this research project have no incentives or direct benefit. Participant's involvement in the study was on voluntary basis. Participants who are unwilling to participate in the study and those who wish to quit their participation at any stage were informed to do so without any restriction.

Demographic and socio-economic characteristics
A total of 734 children aged 6-59 months were included in analysis with response rate 100%. Of the 734 under-five children in the study, 374 (51%) were female and, 234 (31.9%) found in the age group 12-24 months. The mean age of the participants was 26.72 ± 13.07 months ( Table 1).

Variables Frequency Percent
Sex

Dietary characteristics
Breast feeding was almost universal in the study area children who breast fed were 723(98.5%). 523(71.3%) children started breast feeding within the first one hour ( Table 3).

Magnitude of stunting among 6-59 months children
In the analysis stunting was defined as having a z score below -2 SD of the WHO standards. The prevalence of stunting among children of 6-59 months in the study area was 35.4% (34.6-36.3; 95%:C.I.). The prevalence was 79(30.4%) in children age group 12-23 months. Of the total 138 (53.1%) of male children were stunted.

Factors associated with stunting among 6-59 months children
In the study sex of child, father education, mother occupation and father occupation, ANC visits of mother, preceding birth interval and immunization status of the child, household main source of drinking water and also child received pre-lacteal feeds, child feed colostrums, age complementary food started, hand feeding and bottle feeding were significantly associated with stunting in bivariate analysis but the association disappears in the multivariate logistic regression analysis. The finding of the study indicated that, Child's age, mother's education, monthly income, and size at birth, birth order, duration of breast feeding, and cup feeding were identified as determinants of stunting among children in the study area in the multivariate logistic regression analysis.
Child's age was one of the risk factors which significantly associated with stunting in the study area. Comparing with children 6-11 months, children within age group 24-35 months were 2.29 times more likely to develop stunting (AOR=2.29; 95%CI:1.10, 4.82). and children within age group 36-47 months were 2.29 times more likely to develop stunting than children age 6-11months (AOR=2.29; 95%CI: 1.10, 4.76). The result also indicated that, children within age group 48-59 months were 3.34 times more likely to develop stunting than children age 6-11 months (AOR=3.34; 95%CI:1.58, 7.06).
From the analysis, children whose mothers had no education were 5.4 times more likely to be stunted as compared to mother with educational status of above secondary (AOR=5.38; 95%CI:2.27, 12.77). Children from household with low monthly income were 3.92 times more likely to be stunted than children from high monthly income (AOR=3.92; 95%CI: 2.54, 6.06).
Children who had born with small size were 2.10 times more likely to be stunted than children born larger (AOR=2.10; 95%CI: 1.13, 3.93). The result also showed that children who had normal birth size were 70% less likely to develop stunting as compared to children with large birth size (AOR=0.30; 95%CI:0.17, 0.53).
The result of the study indicated that, birth order of the child was associated with risk of stunting. Children of 4 and above birth order were 2.3 times more likely to be stunted than children of first birth order (AOR=2.32; 95%CI: 1.28, 4.21).
Duration of breast feeding was associated with risk of stunting in the study. Children who had been breast feed for 12-23 months long were 2.35 times more likely to be stunted than children who breast feed for than less than 12 months long (AOR=2.35; 95%CI:1.18, 4.66). In the study finding children who had breast feed for more than 24months long were 2.49 times more likely to be stunted than children who breast feed for than less than 12 months long (AOR=2.49; 95%CI: 1.03, 6.00).
Cup feeding as method of feeding was also associated with risk of stunting in the study. In the study mothers not used cup to feed their children were 2.08 times more likely to be stunted than mothers used cup to feed their children (AOR=2.08; 95%CI:1.05, 4.15) ( Table 4).
Child's age was one of the factors significantly associated with stunting in the study area. Comparing with children 6-11 months, children within age group 24-35 months, 36-47 months and 48-59 months were more likely to be stunted. The finding was in agreement with the study in Ethiopia [28] and Egypt [18]. This might be due to stunting in children age 24 months and above were resulted from poor nutritional status of mother's at pregnancy, inappropriate infant and young child feeding practices and other related factors which were needed to be undergone beginning from conception, through a mother's pregnancy and up until the age of two which was the most critical period in a child's development after child reaches above 24 months of age stunting was irreversible.
Mother's education was another variable which significantly associated with stunting. Children whose mothers had no education were more likely to be stunted as compared to mother with educational status of above secondary. This finding was consistent to the study conducted in India [20], Tanzania [25], and Nairobi Kenya [26] and also in Ethiopia [9,28,29]. This might be due to mother who had no education had shortage of knowledge which related to better child feeding and caring, low income and low living conditions. Birth order of children is one of the demographic variables explaining the risk of stunting in children. Children of 4 and above birth order were more likely to be stunted than children of first birth order. This finding was in line with the study conducted In Cambodia [22], Nairobi Kenya [26], and Egypt [18]. This might be due to family unable to satisfy child dietary and other health care related services because of more number of children and might also be due to low awareness of family planning.
Children from household with low monthly income were more likely to be stunted than children from high monthly income households. This might be children from low income households had low access to adequate dietary intake in kinds and the amounts and also it may be due to increment of food prices, decreased purchasing power of the family and also shortage of other important materials and utilities.
Children who had born with small size were more likely develop stunting than children born larger. The finding was in line with the study conducted In Kenya [26].This may be due to the mother's health and nutritional status before and during pregnancy in which determined size of the child during intra-uterine period and also those small sized children were frequently exposed to an infection which leads to mal absorption of nutrients in their body.
The result of the study also indicated that children who had normal birth size were less likely to develop stunting as compared to children with large birth size. The finding of this study might be due to children having optimal birth weight was mostly protective to most disease conditions related to proper growth and maturity of their body may help them to sustain the external environment.
Duration of breast feeding was associated with risk of stunting in the study. Children who had been breast feed for 12-23 months long and more than 24 months long were more likely to be stunted than children who breast feed for than less than 12 months long. The association between continued breast-feeding and stunting was also observed in similar studies conducted in Cambodia [18], Disha et al. in Zambia and Ethiopia [30] and also study conducted in Gojam North west Ethiopia [29]. This might be due to poor maternal nutrition status which mothers who are breastfeeding need two additional meals a day and had direct relation with breast milk quality and quantity, even if the duration of breast feeding long poorly attached and positioned breast feeding could affect the optimal breast feeding of children and mothers of children continue breast feeding without providing adequate, safe, appropriate solid, semi-solid and soft foods for the children which directly related to children growth. Cup feeding as method of feeding was also associated with risk of stunting in the study. In the study children whose mothers not used cup to feed them were more likely to be stunted than children whose mothers used cup to feed children. The studies which directly support this finding was not available at this point in time but WHO/UNICEF child feeding guideline support the use of cup as a method can prevent the contamination. This might be due to mothers low awareness about the advantages of cup feeding and mothers of children who were not used cup as method of feeding they may use bottle as alternative method which was not recommended at any age to feed the children which was high risk of infection. The possible limitation of the study is being a cross-sectional study may cause difficulty in identifying causeeffect relationship. And recall bias is the other fear of the researcher. In conclusion, the study revealed that stunting is high prevalent problem among children 6-59 months of age in Hossana town, Southern Ethiopia. Child's age, mother's education, household income, birth order, size at birth, duration of breast feeding and cup feeding were found to be associated factors of stunting among 6-59 months children in the study area.
At last, based on the above findings of the study, the following recommendations are forwarded:

For Federal Ministry of health
Need to expand programmes which links nutrition interventions and social protection to reach young children and pregnant or breastfeeding mothers in urban communities.

For Hossana town Health office
Need to plan nutrition interventions to effectively address the nutritional conditions with participation of stakeholders and community at large.

For health extension workers
Need to give nutrition education for the community about maternal and child nutrition to accelerate prevention of stunting by focusing the most critical periods of child development.
Need to actively involve and give training to the mothers and care givers of children with practical demonstration of how to prepare and give optimal foods for infant and young child.

For researchers
Need to conduct further studies to determine the predictors of stunting using different analytic and longitudinal studies.