Community based cross-sectional study design complemented with qualitative methods (Focus Group Discussion/FGD and Key Informant Interview/KII) was used. The study was conducted in Dilla town, Gedeo zone, Southern Ethiopia from 5, Dec.2017–18, Jan.2018. Dilla town is located 359 km from Addis Ababa (the capital city of Ethiopia, and the main road from Addiss Abeba to Nairob Kenya crosses the center of the town. Its astronomical location is 6°20′ North Latitude and 38°13′ East Longitude. It comprises nine kebeles (the lowest administrative unit in Ethiopia) The total population is 94,189 out of which 46,058 (49.9%) are males and 48,131 (50.1%) are females. Though the total number of orphans in Dilla town was not known before, according to complete enumeration carried out for the sake of this study, it is 2895.
Source and study population
The source populations were all orphans aged 6–59 month with their caregivers who were considered for the quantitative and anthropometric survey; mothers, elders, experts from town gender office and community leaders were considered for the qualitative aspect. Whereas Study population was randomly selected orphans aged 6–59 month with their caregivers in selected kebeles of Dilla town.
Inclusion criteria
Orphans aged 6–59 month in selected kebeles and which were identified to be included in sample.
Exclusion criteria
Orphans 6–59 month of age that are known severely ill because of chronic diseases, like Human immunodeficiency virus/ HIV/ Acquired Immuno Deficiency Syndrome/ AIDS.
and those with immobility precautions like fracture.
Sample size determination
The sample size of Orphans included in the study was calculated using the formula for single population proportion, just based on the prevalence rate of Wasting (45.7%) from study conducted in Gonder city, Northern Ethiopia, 2014. Considering 95% confidence interval and 5% marginal error; n = \( \frac{z^2\ast p\ast \left(1-p\right)}{d^{2.}} \)
=381 with 10% non-response rate = 381*0.1 = 420
Since the total population is < 10,000 correction was made and final sample was 367
Sampling technique and procedures
First, all kebeles in Dilla town were identified by name and complete enumeration has been conducted by preparing “complete enumeration format” for the sake of this study and all under five orphans in Dilla town have been identified; and then by using simple random sampling technique three kebeles were selected and the sample size for each kebele has been proportionally allocated. So, the sampling frame has been prepared based on complete enumeration format register and subjects for the household survey have been identified. Snow ball and judgmental sampling technique was used to involve all possible cases from mothers, elders, experts from town gender office and community leaders just purposively to obtain information through 2 FGD and key informants For qualitative aspect.
Study variables are Wasting, Demographic factors (age, sex, education, number of children in HH, marital status), Socio economic variables (wealth index, employment), Child health care (immunization, sickness), Environmental /sanitation factors (source of water, domestic waste disposal), Food insecurity, Dietary intake (child feeding and practices).
Data collection instruments and procedure
A pre-tested structured interviewer administered questionnaire was used for data collection in one of the kebele out of selected for sampling; it was adapted from different relevant studies and standards to meet the purpose (8,12,13). Initially, the questionnaire was prepared in English and translated into Amharic and Gedeaufa to obtain information on demographic characteristics, socio economic status, sanitation and hygienic conditions, feeding practices and child care, HH food security status, immunization status, exposure to diarrhea and acute febrile illness of the under 5 years orphans.
Quality assurance
The data collection was facilitated by 2 volunteer HDA guiders at each kebele who know the house with selected orphans’ well. The data was collected by 6 data collectors; who were diploma nurses/urban health extension workers and managed by 2 supervising health officers. Prior to the commencement, data collectors and supervisors were given 2 days refreshment training by PI in Haroresa health center on the objectives of the study, on the contents of the questionnaire, on the methodology of the study, inclusion and exclusion criteria, on the issues of the confidentiality of the responses, on the use of instruments, on the procedures how to take anthropometric measurement by Nurses and reduction of error: for the first day and then re-demonstration of anthropometric measurement and pretest training for the next day. All measurements were carried out using standard procedures by explaining the procedure to the mothers, fathers, or caregivers. The data collection, application of standard procedure and accuracy of test results were supervised and checked daily for its completeness and consistency through close follow up of PI. For anthropometric measurements, average result has been considered. Then after, the collected data was back translated into English to ensure quality.
Anthropometric measurements
Age was collected from mothers, fathers or caregivers; and then was cross-checked with birth certificate; Sex was recorded as male or female; Weight of the child was measured to the nearest 0.1 kg using 25 kg hanging spring scale; in light cloths and without shoes; MUAC: was measured using color coded standard MUAC tape meter by calculating the midpoint of the child’s left upper arm by first locating the tip of the child’s shoulder and the tip of the elbow through right angle position and measurement was taken in the midpoint by straighten the child’s arm and read the measurement to the nearest 0.1 cm. Anthropometric measurements were taken two times and averages taken.
For qualitative aspect
The data was collected from 2 FGD, each has 8 members that comprise: mothers/caretakers, elders, town gender office experts and community leaders; and also some key relevant informants.
Operational definition and definition of terms
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Nutritional status assessment: was an assessment carried out to understand the magnitude of undernutirition in under 5 years orphans at Dilla town.
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An orphan: a child aged 6 to 59 month, living in Dilla town and whose mother, father, or both have died or can be referred as maternal, paternal or dual orphan respectively.
Standard Definition
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Wasting: is weight-for-height/length below minus two standard deviations (<−2SD) from the median of WHO reference population.
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Diversified balanced diet: Food intake that includes all of the diversified dietary needs of the organism in the correct proportion; the access would be measured based on the cutoff point during analysis: households with poor access, those scored 1 and households with good access, those scored 2.
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Food insecurity: Lack of adequate physical, social or economic access to food; the household food security status would be measured based on the cutoff point during analysis: food secured households, those who scored 1 and food insecured households, those who scored 2.
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Wealth index: Households with poor wealth index are those who scored 1; households with medium wealth index are those who scored 2 & households with rich wealth index are those who scored 3.
Data processing and analysis
Data was entered and cleaned up using EPI-info version 3.5.4 and ENA for SMART 2012 version software was used for anthropometric data management. Principal component analysis (PCA) was carried out for the reduction of variables involved in wealth index, food security status and balanced diversified diet assessment.
Principal component analysis (PCA) was carried out for the reduction of variables involved in wealth index, food security status and balanced diversified diet assessment and factor one would be considered to address extracted components:
Fifteen variables (Electricity, Watch, Radio, TV, Mobile, Refrigerator, Separate room used for kitchen, Bicycle, Any land used for agriculture, Livestock, Account in bank or credit association, Cement/ceramic floor, Corrugated iron/cement/concrete roof, Mud/wood with mud & cement wall & Pit latrine) would be entered into the pool of analysis for the assessment of wealth index and the rank would be assigned into three categories from lowest to highest values; so that 1 was given for poor households, 2 for medium households & 3 for the consideration of rich households. The variables had been entered into the pool of PCA, whereas only 4 components whose load Eigen value greater than one were taken under the first factor and categorized as wealth index status:
Nine variables (Worry about not having enough food, Not eat preferred food, Eat just a few food, Eat food preferred not to eat, Eat smaller due to food lack, Eat fewer due to food lack, No food at all, Sleep hungry & Whole day eat nothing) would be entered into the pool of analysis for the assessment of household (HH) food security status and the rank would be assigned into two categories from highest to lowest values; so that 1 was given for food secured households & 2 for the consideration of food insecure households.
12 variables (Cereals, Roots and tubers, Vegetables, Fruits, Meat, Eggs, Poultry, Pulses and nuts, Milk and milk product, Oils and fats, Sugar, honey/soft drinks, Spices, condiments, coffee, tea) would be entered into the pool of analysis, based on the seven diversified food groups for the assessment of access to balanced diversified diet and the rank would be assigned into two categories from lowest to highest values; so that 1 was given for poor access & 2 for the consideration of good access.