Study area and period
The study was conducted in the rural district of Enebsie Sarmidr, East Gojjam Zone, North West Ethiopia from March 1–30/2016. Enebsie Sarmidr district is located in East Gojjam Zone which is 364 km (km) far from Addis Ababa the capital city of Ethiopia, 182 km far from Bahir Dar the capital town of Amhara region and 194 km away from Debre Markos the capital town of East Gojjam Zone. The district has one district public hospital, seven public health centers, two medium private clinics and two urban and 31 rural health posts. Six health centers has stabilizing centers for complicated SAM cases management. The study area selection was done after review of the district’s annual report, as well there was paucity of research on SAM in this district.
A community based unmatched case control study design was employed to identify the risk factors of severe acute malnutrition among children under 5 years of age. Unmatched case control study was used because the number of the cases were small when compared to the number of controls. This study design was taken to determine the risk factors of SAM at the single point, case identification, followed by data collection.
Dyads defined as all mothers to children under 5 years of age living in rural district of Enebsie Sarmidr in a 1 month period in 2016.
Randomly selected cases and controls of Dyads who fulfill the inclusion criteria.
Dyads who lived at least 6 months in the study area.
Mothers unable to communicate due to illness or in voluntarism and controls from the same house of cases.
The sample size was calculated using Epi info 7 statcalc. The assumptions used for calculation were detecting a 3.5 times higher risk of suboptimal infant breast feeding practices among the cases and a 65.9 prevalence of suboptimal infant breast feeding practice among the controls based on the study done previously; 95% confidence interval (CI), 90% power and case to control ratio of 1:4 . The case control ratio of 1: 4 was used to increase the power and sample size. As the number of cases were small, the sample size was increased by increasing the number of the controls. This made the minimum calculated sample size 58 for cases and 231 for controls. By taking 10% non-response rate the total sample size required was 318 having 64 cases and 254 controls.
The district has 31 rural kebeles. All the 31 kebeles were included in the study. For this study, survey was conducted before the actual study and there were 13,122 under five children in the district. Of these, 115 were found with SAM. So the calculated sample size, 64 cases and 254 controls were selected in proportional allocation to the sample size of each of the 31 rural kebeles using computer generated simple random sampling technique in 1:4 case, control ratio. Totally 318 mother/care giver to child pairs were included.
Socio demographic characteristics; age of child, child sex, parental education, parental occupation, marital status of the mother, household economic status, maternal autonomy in decision making and family size
Nutrition and Child caring practices; Exclusive breast feeding (EBF), Sub optimal EBF, late initiation of breast feeding.
Infection and childhood illness: Fever, Human immune deficiency virus (HIV), diarrhea, other medical and surgical problems.
Obstetric History: Antenatal care (ANC) visits, number of ANC visit, birth order, birth interval, use of extra food during pregnancy and lactation, number of children ever born.
“Dyads defined as all mothers to children under 5 years of age with SAM treated in an outpatient or inpatient therapeutic program in rural district of Enebsie Sarmidr in a 1 month period in 2016.
“Dyads defined as all mothers to children under 5 years of age with no diagnosis of severe acute malnutrition in rural district of Enebsie Sarmidr in a 1 month period in 2016.
Unusual frequent and loose watery stool ≥3 times per day for 2 weeks or more.
Mothers/care takers thought as the child experienced unusual increase in temperature for 2 weeks or more.
Sub optimal exclusive breast feeding
Breast feeding less than eight times per day.
Household economic status
Monthly income of the family in Ethiopian Birr.
Maternal autonomy in decision making
Perceived maternal autonomy in decision making within the family.
Household monthly income less than 1000 Ethiopian Birr.
Instrument and personnel
Interviewers followed semi structured questionnaires that were created from published research on the study area [4, 6, 8, 10]. Data collectors were three clinical nurses who took training on nutrition courses. Two clinicians supervised the data collection process. Two days of training was provided by the principal investigators to the data collectors & supervisors.
Data quality control
Before data collection the questionnaire was first prepared in English and translated to the local language Amharic and finally again back to English for consistency. The questionnaire was pre tested on 5% of actual respondents in another kebele out of the study area. During the data collection time, regular monitoring and supervision of the overall activity was done by the supervisors and principal investigators to ensure the quality of data. All the collected data were checked, cleaned and coded to avoid some inconsistencies and incompleteness before analysis. Incomplete and inconsistent data were excluded from the analysis.
Data processing and analysis
The data was cleaned, coded and entered in Epi data version 3.1 and transferred to statistical package for Social science (SPSS) version 20.0 for analysis. Emergency nutrition assessment (ENA) software was used to calculate anthropometric measurements. Both bivariate and multivariate logistic regressions were used to determine the association. Variables with (P < 0.2) in the bivariate logistic regression was included in the final model/multivariable. Statistical significance was made at 95% CI and P-value < 0.05 for multivariate analysis. The strength of association between independent and dependent variables was assessed using odds ratio with 95% confidence interval.
Ethical clearance was obtained from research and publication committee of Debre Markos University, College of Health Sciences. Informed written consent was obtained from the mothers.