PREVALENCE AND RISK FACTORS FOR STUNTING AND WASTING IN CHILDREN AGED 6 TO 59 MONTHS IN RURAL AND URBAN COMMUNITIES IN STATE, .

A DISSERTATION SUBMITTED TO

THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART

FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP

OF THE COLLEGE

IN PAEDIATRICS

BY

DR YUNUSA SANUSI (MBBS BUK 2002)

MAY, 2017

Declaration

It is hereby declared that this work is original unless otherwise acknowledged. The work has neither been presented to any other College for fellowship award nor submitted elsewhere for publication.

……………………….. …………………………..

Dr Yunusa Sanusi Date

ii ATTESTATION PAGE

We certify that this work was carried out by Dr Yunusa Sanusi of Aninu Kano Teaching

Hospital, Kano. We also supervised the writing of the dissertation.

1. Professor Mu’uta Ibrahim, FMCPaed, FWACP(Paed), PGDipMedEd(Dundee)

Consultant Paediatrician (Haematology and Oncology).

Department of Paediatrics,

Aminu Kano Teaching Hospital, Kano

Kano State.

Signature and date………………………………………..

2. Dr Garba Dayyabu , FMCPaed.

Consultant Paediatrician (Gastroenterology and Nutrition).

Department of Paediatrics,

Aminu Kano Teaching Hospital, Kano

Kano State.

Signature and date………………………………………..

iii Table of contents Page

Title------i

Declaration------ii

Attestation ------iii

Table of contents------iv

Dedication------vi

Definition of Terms in the Dissertation------vii

Acknowledgments------viii

List of figures------ix

List of tables ------x

List of abbreviation------xiii

Summary------1

Introduction------3

Literature review------6

Aim and Objectives------21

Subjects and methods------22

iv Results------38

Discussion------63

Conclusions------71

Recommendations ------72

Limitations ------73

Line of future research------74

References------75

Appendix I: proforma ------88

Appendix II: AKTH ethical approval------93

Appendix III: Warawa LGA approval ------94

Appendix IV: LGA approval------95

Appendix V: consent------96

Appendix VI: approval of the National Postgraduate Medical College of Nigeria ------100

Appendix VII: sketch map Warawa LGA ------101

Appendix VIII: map of Tarauni LGA------102

Appendix IX: World Health Organization Child Growth Standards------103

Appendix X: Oyedeji socio-economic classification scheme------105

v Dedication

This work is dedicated to all the undernourished children in Nigeria.

vi Definition of Terms in the Dissertation.

Stunting: Stunting is defined as height for age Z score below minus two standard deviations from the median of the World Health Organization Child Growth Standards (HAZ -2).1,2

Wasting: Wasting is defined as weight for height Z score below minus two standard deviations from the median of the World Health Organization Child Growth Standards (WHZ -2).1,2

Rural: - The term rural refers to area of any country with extensive land use for agriculture and forestry and containing spatially distinct settlements with non urban environment.3

Urban: - Urban area is a large settlement with high concentration of people of up to 20 000 as adopted by the National Population Commission. Constitutionally, all settlements functioning as local government headquarters are urban centers.3,4

vii Acknowledgement

I am highly grateful to my supervisors, Prof Muutassin Ibrahim and Dr Garba Dayyabu Gwarzo for dedicating their time in rendering fruitful contributions to this work; may the Almighty reward them both. I am also grateful to the and the management of

Aminu Kano Teaching Hospital for the opportunity and sponsorship given to me for this training. My sincere gratitude also goes to all the staff of the Department of Paediatrics, Aminu

Kano Teaching Hospital for the training, guidance and assistance throughout the period of my study. I am thankful to Dr Musa Bello, Dr Mukhtar Gadanya and Dr Amole OA of the

Department of Community Medicine, Aminu Kano Teaching Hospital Kano for their assistance in data analysis. My sincere appreciation also goes to my wonderful research assistants for their enormous contribution in carrying out this work. I am thankful to all the parents and their children who participated in the present study. My special thanks go to my parents for their unquantifiable contributions to the success of this research. In addition, I sincerely appreciate my wife Amina Aliyu and our beloved children Ashiru, Fatima and Mansur for their support and understanding throughout the period of my residency training. Above all, I praise God almighty for keeping me alive and healthy throughout the period of the training.

viii List of figures page

Figure 1: a study participant standing on a weighing scale 32

Figure 2: a study participant sitting on a weighing scale 33

Figure 3: the researcher measuring height of a participant 34

Figure 4: the researcher measuring height of a participant 34

Figure 5: the researcher and an assistant measuring recumbent length 35

Figure 6: the researcher and an assistant measuring recumbent length 35

Figure 7: a research assistant carrying some research tools 36

Figure 8: roc curve for stunting 61

Figure 9: roc curve for wasting 62

ix List of tables Page

Table I: the selected political wards and the selected settlements in Warawa LGA 27

Table II: the selected political wards and the selected settlements in Tarauni LGA 28

Table III: sampling in Warawa LGA in relation to percentage of under-five children, number of households, sample size allocated and nth households selected 29

Table IV: sampling in Tarauni LGA in relation to percentage of under five children, number of households, sample size allocated and nth households selected 30

Table V: comparison of ethnicity of the study participants and marriage types between rural and urban communities 38

Table VI: comparison of prevalence of stunting and wasting between rural and urban communities 39

Table VII: comparison of age distribution and gender of study participants between rural and urban communities 40

Table VIII: comparison of children’s birth orders between rural and urban communities 41

Table IX: comparison of immunization status of the subjects between rural and urban 42

Table X: comparison of educational status and occupations of mothers/care givers between rural and urban communities 43

Table XI: comparison of monthly incomes of mothers between rural and urban communities 43

x Table XII: comparison of breast feeding practices between rural and urban communities 44

Table XIII: comparison of complementary feeding practices between rural and urban 45

Table XIV: comparison of educational status and occupations of fathers between rural and urban communities 46

Table XV: comparison of incomes of the fathers between rural and urban communities 47

Table XVI: comparison of families’ social classes between rural and urban communities 47

Table XVII: association between stunting, maternal education and monthly maternal incomes in rural and urban communities 48

Table XVIII: association between stunting, families’ social classes and age groups of the children in rural and urban communities 49

Table XIX: association between stunting, children’s birth orders and types of complementary feeds in rural and urban communities 50

Table XX: association between stunting, children’s immunization status and gender in rural in rural and urban communities 51

Table XXI: association between stunting, father’s educational status and monthly incomes in rural and urban communities 52

Table XXII: association between wasting, maternal education and monthly maternal incomes in rural and urban communities 53

xi Table XXIII: association between wasting, families’ social classes and age groups of the children in rural and urban communities 54

Table XXIV: association between wasting, children’s birth orders and complementary feeds in rural and urban communities 55

Table XXV: association between wasting, children’s immunization status and gender in rural and urban communities 56

Table XXVI: association between wasting, father’s educational status and father’s monthly incomes in rural and urban communities 57

Table XXVII: binary logistic regression urban HAZ 59

Table XXVIII: binary logistic regression urban WHZ 59

Table XXIX: binary logistic regression rural HAZ 60

Table XXX: binary logistic regression rural WHZ 60

Table XXXI: area under the curve for stunting and MUAC 61

Table XXXII: area under the curve for wasting and MUAC 62

xii List of abbreviations

BCG Bacillus Calmette Guerin

CHEWS Community Health Extension Workers

CDC Centre for Disease Control

DPT Diphtheria Pertussis Tetanus

FAO Food and Agricultural Organization

GCE General Certificate of Education

HAZ Height for Age Z score

HND Higher National Diploma

IQ Intelligence Quotient

LGA Local Government Area

MDG Millennium Development Goals

NDHS Nigeria Demographic and Health Survey

NCE National Certificate of Education

NIMHANS National Institute of Mental Health and Neurosciences (Bangalore India).

OPV Oral polio vaccine

xiii PENTA Pentavalent vaccine – DPT, Hepatitis B, Haemophilus influenzae type b vaccine.

SD Standard deviation

UNICEF United Nations Children Fund

WHZ Weight for Height Z score

WHO World Health Organization

xiv

SUMMARY

Undernutrition remains a major health problem in the developing world. It has deleterious effects on children particularly during the critical phase of rapid growth, resulting in poor physical and cognitive development. Undernutrition contributes to nearly half of childhood deaths mostly in

Africa and Asia. It is estimated that as many as 182 million or 1 in 3 children under the age of 5 years in developing countries, mostly of sub-Saharan Africa, are undernourished. Previous local works on undernutrition in Kano State were prevalence studies, which did not provide clear direction for actionable programme planning and implementation towards control of undernutrition. Understanding the determinants of childhood stunting and wasting in rural and urban areas could be important in designing appropriate programme and policy responses tailored to the needs of the two population groups.

The objective of the present study was to determine the prevalence and risk factors for stunting and wasting in children aged 6 to 59 months in Kano State.

The present research was a comparative cross-sectional study of stunting and wasting among children aged 6 to 59 months in rural and urban communities in Kano State. The study was carried out in Warawa (rural) and Tarauni (urban) Local Government Areas of Kano State from

1st April to 30th September 2015. Seven hundred and fifty children were recruited from each of the two Local Government Areas. Subjects were selected using multistage sampling technique involving random and systematic samplings. Structured proforma were administered on the children’s care givers by trained research team members. Subsequently, the children’s weight and height were measured by the candidate. In the rural communities 750 subjects were studied, of whom 392 (52.3%) were males and 358

(47.7%) females, giving a male to female ratio of 1.1:1. The ages ranged from 6 to 59 months with a mean age of 27.6 (15.9) months. In these rural communities, 100% of the respondents were Hausas and Fulanis. The prevalence of stunting and severe stunting were 312 (41.6%) and

188 (25.1%) respectively; while the prevalence of wasting and severe wasting were 127(16.9%) and 48 (6.4%) respectively. For the urban communities 750 subjects were studied, of whom 414

(55.2%) were males and 336 (44.8%) were females with a male to female ratio of 1.2:1. The ages ranged from 6 to 59 months with a mean age of 28.1 (16.0) months. In the urban communities, apart from Hausas and Fulanis, other ethnic groups were also encountered. The prevalence of stunting and severe stunting were 284 (37.9%) and 107 (14.2%); while the prevalence of wasting and severe wasting were 110 (14.7%) and 21 (2.8%) respectively. Lack of maternal formal education, low fathers income, use of plain millet-based pap during child’s weaning, low socio- economic status, age group 12-23 months were the identified independent predictors of stunting and wasting in the study areas.

In conclusion, the prevalence of stunting and wasting was very high in Kano State with the rural populace more affected than the urban. Significant poverty reductions, formal education for all women and intensified health education especially for rural women on the use of fortified complementary feeds during child’s weaning are some of the recommendations for control of this childhood problem.

INTRODUCTION

Undernutrition is defined as an imbalance between nutrient requirement and intake resulting in cumulative deficits of energy, protein or micronutrients that may negatively affect growth and development.1,2 Stunting is defined statistically as height for age Z score below minus two standard deviations from the median of the World Health Organization Child Growth Standards

(HAZ -2).1,2 Stunting is caused by long term insufficient nutrient intake and/or frequent diseases.1,2 Wasting is defined as weight for height Z score below minus two standard deviations from the median of the World Health Organization Child Growth Standards (WHZ -2). Wasting is usually the result of acute significant food shortage and/or diseases.1,2, 5

Undernutrition is a problem of considerable magnitude that is common mostly in Africa and

Asia.5,6 Undernutrition has deleterious effects on children, particularly during the critical phase of rapid growth and may results in irreversible poor physical and cognitive development.7,8

Adults who survived undernutrition as children are less physically and intellectually productive.

In addition, they are more likely to become overweight and more prone to non communicable diseases.9,10 Other consequences of undernutrition include adverse affects on a country’s work force and may lead to increased burden on the health system.9,10 It is estimated that as many as

182 million or 1 in 3 children under the age of 5 years in developing countries, mostly of sub

Saharan Africa are undernourished.5 Undernutrition contributes 6.6 million of the 12.2 million under 5 deaths occurring annually in third world countries.5

In Nigeria, 11 million children under the age of five years are stunted.11,12 The Nigeria

Demographic and Health Surveys (NDHS) conducted in 200813 and 201314 reported that the north-west sub region, where Kano State is located, had the highest prevalence of stunting (53% and 55%) and wasting (22% and 27%) respectively.13,14 The Food and Agricultural Organization

(FAO) of the United Nation reported that 80% of the households in Kano State had food insecurity.15 Poverty, lack of education, poor child rearing practices and diseases were identified as major causes of wasting and stunting.16-18

The research questions in the present study were: (1) what are the anthropometric measurements of children aged 6 to 59 months in rural and urban communities in Kano State? (2) What is the prevalence of stunting and wasting in children aged 6 to 59 months in the two communities, based on the World Health Organization Child Growth Standards? (3) What are the risk factors for stunting and wasting in children aged 6 to 59 months in the two communities?

Null hypotheses tested were: (1) there is no significant difference in the prevalence of stunting and wasting between rural and urban communities in Kano State. (2) Socio-economic class does not significantly affect the prevalence of stunting and wasting in rural and urban households in

Kano State. The alternate hypotheses for the study were: (1) there is significant difference in the prevalence of stunting and wasting between rural and urban communities in Kano State. (2)

Socio-economic class significantly affects the prevalence of stunting and wasting in rural and urban households in Kano State.

The present research was a comparative study of prevalence and risk factors for stunting and wasting between rural and urban communities in Kano State. Previous local works on undernutrition in the State were prevalence studies that did not provide clear evidence for program planning and implementation towards control of stunting and wasting by policy makers.

Understanding the relative importance of various determinants, whether they differ between rural and urban communities will become key to designing effective program tailored to the needs of different population groups. In addition, Z score in the present study was determined using the newer World Health Organization Child Growth Standards, whereas Z score in the previous local studies were determined using the National Centre for Health Statistics growth reference which might have underestimated the results obtained. The present study will also demonstrate any change over time in the prevalence of stunting and wasting in Kano State. It is expected that the findings from the present study would serve as guide to policy makers.

LITERATURE REVIEW

Prevalence of stunting and wasting

Globally, the number of underweight children in 2011 fell by 36% from an estimate of 159 million children in 1990.19 The above rate of progress was insufficient to meet the Millennium

Development Goals (MDG) target of halving the proportion of people who suffer from hunger by 2015.19 According to the 2015 MDG report, reduction in hunger was by 44.6%.20

Zhang et al21 in 2016 conducted meta-analysis of nutritional surveys in China from 1991 to

2009. Sample size included 5000 children under the age of 18years with Z score determined using Chinese Growth Reference Charts.22 The researchers reported 32.2% of the children as stunted. Hoffman and Lee23 in 2002 conducted a rural community based nutritional study among

6000 children two to seven years of age in Korea. Z score was determined using the National

Centre for Health Statistic reference.24 Hoffman and Lee23 reported 38.2% and 8.2% of the children as stunted and wasted respectively. The higher prevalence of stunting reported from the

Korean study compared to that of China may result from the use of older children in the China study with resultant lower prevalence of stunting. Besides, the Child Growth Reference

Standards used in the two studies were different.

In 2009, Bisai and Mallick25 in a community based study in two villages (Kora and Mudi) in

India among 119 children aged 2 to 5 years reported 49.6% and 22.7% as stunted and wasted respectively. The prevalence of stunting and wasting reported from this study were higher than those of the report by Hoffman and Lee23 from Korea. The difference in the results of the two studies may be attributable to the younger age groups of the study participants recruited in the

Indian study. Furthermore, the sample size used in the Indian study was rather small; the result obtained may not be the true representative of the entire population. In 2011, Sinha and Maiti26 conducted another community based cross-sectional study in Midnapore town, India among 658 children aged 2- 6years. The researchers reported that stunting had decreased to 40.6% while prevalence of wasting remained almost the same, 22.4% when compared to the report of Bisai and Mallick.25 The reduction in the prevalence of stunting compared to the report by Bisai and

Mallick25 may be due to the fact that older children were recruited by Sinha and Maiti26 and the sample sizes used in the two studies were different.

Yalew et al27 in a community based nutritional study in 2014 among 844 children aged 6 to 59 months in Northern Ethiopia reported a prevalence of 47.3% and 8.9% for stunting and wasting respectively. In 2002, an earlier National Nutritional Survey was carried out in Ethiopia by

Girma and Genebo28 among 2000 children aged 6 to 59 months. Girma and Genebo28 reported prevalence of 51.3% and 11% for stunting and wasting respectively. Additionally, 26% and 1% of the children were severely stunted and severely wasted respectively. The difference in prevalence of stunting between the two Ethiopian studies may probably be due to the difference in the studies locations, as Northern Ethiopia is a lively area with a lot of irrigation activities and is also a site of tourist attractions. Furthermore, the report by Girma and Genebo28 was a national average.

In 2007, Harvey and Witte29 in a review paper on nutritional status and its determinants in neighboring rural Southern Sudan (now the Republic of South Sudan), reported prevalence of

45%, and 22% for stunting and wasting respectively. Ibrahim and Alshiek30 in 2010 conducted a community based study among 780 under-five children in Khartoum, the capital of Sudan. The researchers reported the prevalence of 51% and 19% for stunting and wasting respectively. The prevalence of stunting reported was higher than that reported by Harvey and Witte29 from rural Southern Sudan. This was in contrast to the usual reports of lower prevalence of stunting in urban areas. The higher prevalence of stunting reported by Ibrahim and Alshiek30 from

Khartoum might have resulted from poor infant feeding practices as only 31.8% of the mothers interviewed breast fed their babies; with reported feeding frequency of less than six times a day in the mothers that breast-fed; whereas all the women interviewed in rural southern Sudan study breast-fed their babies. The researchers in the two Sudan studies did not state the reference standards used in determining Z score.

Ngare and Muttanga31 in 2009 carried out a cross-sectional rural community based study among children aged 6 to 72 months in fourteen districts of Kenya. Z score was determined using the

National Centre for Health Statistic growth reference standard.24 Six thousand four hundred and nineteen children were recruited, out of whom 36% were stunted and 6% wasted. Olack et al32 in 2007 conducted another study in Nairobi among 1310 under five children. Z score was obtained using the World Health Organization Child Growth Reference Standards.33 Olack et al32 reported prevalence of 47% and 2.6% for stunting and wasting respectively while severe stunting and severe wasting were 23.4% and 0.6% respectively. From the two Kenyan studies, stunting was more prevalent among the urban dwellers.32 This aberration may be attributable to the fact that the Nairobi study took place in the urban slums where living conditions can be worse than what is obtainable in the rural setting.17 Furthermore, Olack et al32 used the World

Health Organization Child Growth Reference Standards33 which usually give higher values.

In Nigeria, Manyike et al34 in 2014 carried out a community based study among 616 pre-school children in Abakiliki, south-eastern Nigeria. Z score was obtained using the National Center for

Health Statistic reference standards.24 Manyike et al34 reported 9.9% and 5.3% of the study participants as stunted and wasted respectively. The Nigeria Demographic and Health Survey (NDHS)13 conducted in 2008 involving 19,896 children under the age of five reported that 41% of Nigerian children were stunted with 23% severely stunted. Males were more affected (43%) than females (38%) and rural children more stunted (45%) than urban (31%). Similarly, stunting was most prevalent in the north-west sub- region (53%) and lowest in the south-east (22%). From the same survey, 14 % of children were wasted with almost equal frequency among boys and girls. At zonal level, north-east and north- west had wasting above national average with 22% and 20% respectively. Prevalence of stunting for the south-east sub-region was higher than what was reported by Manyike et al34 from

Abakiliki probably due to the use of World Health Organization Child Growth Standards33 by

NDHS which usually give higher values.

In 2008, Samuel et al35 in a community based comparative study among 370 under-five children in urban and rural Oyo State reported the following results: for the urban areas; 44.4% and 21% were stunted and wasted respectively and for the rural populace; 29.7% and 16.8% were reported stunted and wasted respectively. Sample size used in the Oyo study was rather small (370 children shared between the rural and urban Local Government Areas). Stunting and wasting were more pronounced in the urban areas. The small sample size used in the study may be responsible for the higher prevalence of stunting among the urban populace. Similar finding of higher prevalence of stunting among the urban dwellers was also reported by Olack et al 32 from

Nairobi slums.

Ekpo et al36 in 2004 conducted a rural community based nutritional survey in States of Ogun,

Oyo and Kwara among pastoral Fulani children aged 6 months to 16 years. Three hundred and thirty one children were recruited with Z score determined using the National Center for Health

Statistic reference standards.24 A prevalence of 38.7% for stunting and 13.6% for wasting was reported respectively. In 2011, Babatunde et al37 reported from rural Kwara State a prevalence of 23.6% and 14% for stunting and wasting respectively when they surveyed 127 under-five children. Z score was determined using the National Centre for Health Statistic Standards.24

Although, the study was conducted in the lean season when food was scarce, the prevalence of stunting was much lower compared to what was reported by Ekpo et al.36 However, the researchers failed to define the lean season mentioned above and the sample size used in the study was rather small. The higher prevalence of stunting and wasting among the Fulani was speculated by the researchers to be due to changing food habits and life style from nomadic to sedentary. They also reported that among the settled Fulani, there has been increase in their consumption of rice, cassava and soft drinks with reduction in the intake of milk products.36

However, this may not be the case because the above reasons are not known to cause increased prevalence of stunting and wasting just as undernutrition is not known to be prevalent among the nomadic Fulanis. The differences in the results of the two studies may result from the difference in the sample sizes. However, the researchers were silent on the child feeding practices of the mothers in the Fulani study. Use of National Center for Health Statistic reference standards24 in the two studies might have under estimated the prevalence of stunting and wasting obtained. The report by Ekpo et al36 was contrary to the widely held assumption that settlement of nomadic

Fulani in grazing reserves will result in better nutrition and health.38

Akor et al39 in 2003 carried out a cross-sectional nutritional study among 12,242 newly enrolled primary school children aged 5-12 years in Jos city, north-central Nigeria. Seven hundred and sixty four children were recruited with Z score determined using the National Center for Health

Statistic reference standards.24 Akor et al39 reported that 11.1% and 2.4% of the children were stunted and wasted respectively. Goon et al40 in 2005 conducted a cross-sectional nutritional study among 9-12 year old primary school children in Makurdi, Benue State, north-central

Nigeria. Z score was determined using the National Centre for Health Statistic reference standards.24 The researchers examined 2015 children out of whom 52.7% were stunted. The prevalence of stunting from this study was closer to that of NDHS 2008 north-central (44%)13 when compared to 11.1% reported by Akor39 from Jos. The very low prevalence of stunting from

Jos study may be related to the fact that majority of the children were selected from private schools and only children of well to do families go to private schools. Using the National Center for Health Statistics reference standards24 in the two studies might have underestimated the prevalence of stunting and wasting obtained.

Ojiako et al41 in 2009 conducted a rural community based cross-sectional study among 511 children aged 0-59 months in Kaduna and Kano States, north-western Nigeria. Z score was obtained using the National Center for Health Statistics reference standards and reported 61% and 17% of the children as stunted and wasted respectively. Earlier study was carried out in 2008 by Aliyu et al42 among 204 children aged 2-5 years in rural Kaduna. Z score was determined using the National Center for Health Statistics reference population.24 Prevalence of stunting and wasting reported were 44.9% and 3.7% respectively. Though the geographical location was similar, the prevalence of stunting and wasting reported were lower than those reported by

Ojiakor et al41 The difference between the two results may be due to the narrower age group and the smaller sample size used in the earlier study by Aliyu et al.42

Risk Factors for stunting and wasting.

Factors responsible for stunting and wasting include immediate causes such as inadequate food intake as well as childhood diseases such as measles, pertussis, recurrent diarrhea and malaria 5-7 Stunting and wasting can also result from underlying causes such as poor mother’s nutritional status during pregnancy, low maternal education, low socio-economic status, poor child care- seeking behavior, food insecurity, inappropriate infant feeding practices, poor health care services, the age of the child, higher child’s birth order, lack of immunization, closely spaced pregnancies and poor environmental management.5-7 Remote causes of stunting and wasting include drought, flooding and wars.5,6



 Smith et al43 conducted a meta-analysis of nutritional surveys in 36 developing countries in 2004. The sample analyzed included 129,351 children under the age of three and the researchers reported maternal illiteracy as a significant risk factor for stunting in all the regions studied. In 2011

Babatunde et al37 in a community based study among 127 under-five children from rural

Kwara State also reported lack of maternal education as one of the significant risk factors for stunting and wasting. Maternal illiteracy remained a significant risk factor for stunting and wasting even after conducting logistic regression analysis. Some of the speculations why maternal education protects against stunting and wasting were that: educated mothers are better aware of the nutritional requirements of their children and they also provide improved health care as a result of their awareness. Furthermore, educated mothers are likely to acquire better jobs and earn more resources that will enable them take care of the feeding needs of their children37 However, the sample size used in the study was rather small and the findings may not be the true representation of the entire communities.

Maternal income was reported as an important determinant of child’s nutritional status. Odunayo and Oyewole44 in 2006 conducted a community based cross-sectional study among 420 under five children in rural Osun State. The researchers reported low maternal income as a significant risk factor for stunting and wasting. Sandaruwan et al45 in 2014 carried out a rural community based study in Sri Lanka among 553 children aged 1 to 15 years. The researchers reported that children of gainfully employed mothers were significantly less stunted. Some of the reasons presented were that maternal employment increases household’s income with associated adequate dietary intake, use of health services, improved water source and sanitation.44

Proper infant feeding practices have positive impact on a child’s nutritional status. Save the

Children 46 in 2010 conducted a community based nutritional survey among under-five children in Daura and Zango LGAs of Katsina State. The authors46 reported 48% and 23% of the children as stunted and severely stunted respectively. None of the mothers interviewed was found to practice exclusive breast feeding and less than half of the mothers put their newborn babies to breast within one hour of birth. However, the methodology used in this research was not stated.

In 2005, Mathew et al47 in a nutritional study among 453 under-five children in three States of

Northern Nigeria reported a very high prevalence of severe stunting, 31.7%. The researchers also reported that complementary feeds were introduced by18% and 42.2% of the mothers as early as second and third months of life respectively. This early introduction of complementary feeds, might have contributed to the high prevalence of severe stunting reported in the study.

In the nutritional survey conducted in 2009 by Ojiako et al41 on 511 children under the age of five years in Kano and Kaduna States, they reported low protein intake as one of the significant risk factors for stunting and wasting. Adegbusi and Sule48 in a community based nutritional study in Katsina State also reported inadequate protein intake as a significant risk factor for stunting and wasting when they examined 400 under-five children. The report was similar to that of Ojiako et al41 from Kano and Kaduna States probably because the three States share a common geographical location, infant feeding and cultural practices.

Lawoyin et al49 in a nutritional study among 138 under-five children in Ibadan reported low paternal education as a significant risk factor for stunting and wasting. Lawoyin et al49 speculated that the more educated the father, the more likely he has a better job and higher socio- economic status. However, the sample size of 138 subjects used in the study was rather small and might have affected the authenticity of the research.

In 2013, Bain et al50 in a meta-analysis involving 269 published articles in Sub-Saharan Africa reported father’s unemployment as a significant risk factor for undernutriton. Basit et al51 in

2012 conducted a hospital based case-control nutritional study among 162 under-five children in rural India. The researchers reported that the most significant risk factor for stunting and wasting was father’s unemployment. Basit et al51 stated that father’s employment is a key to household’s economic status which is an indicator of access to adequate food supply and improved water and sanitation.51 However, the sample size used by Basit et al51 was rather small and the results reported may not be the true representation of the entire community.

Child’s age is also a known risk factor for stunting and wasting. In a study by Yalew et al27 in rural Ethiopia among 844 children aged 6 to 59 months in 2014, it was found that stunting was more prevalent among children aged 11- 23 months. Child’s age remained a predictor of stunting after the data was subjected to logistic regression analysis. Akubugwo et al52 in 2013 conducted an urban community based cross-sectional nutritional study among 579 under-five children in

Anambra State, south-east Nigeria. The authors52 reported that stunting was significantly highest among children aged four to five years, reason being that less attention was paid to the feeding of children within the age group four to five years. However, this differs from the report of Yalew et al27 quoted above probably due to early onset of undernutrition among the Ethiopian children as Yalew et al27 reported that 28% of the children were not breast and 36% of them were weaned on left over foods, whereas Akubugwo et al52 reported that many of the children they recruited were exclusively breastfed and weaned on soya beans and peanut fortified pap. However, they failed to mention the actual number of the exclusively breastfed children.

Wamani et al53 in 2007 conducted a meta-analysis of nutritional surveys in 16 Sub-Saharan

African countries among under-five children. The researchers used data of National

Demographic and Health Surveys from 1995 to 2003. Wamani et al53 reported that boys were significantly more stunted than girls. There was almost equal male to female ratio of 1.0:0.96 among the subjects. The researchers speculated that, boys being more stunted than girls may be explained by gender based differential feeding practices because girls being closer to the mothers, there is a higher chance for them to eat any available food. In addition, boys are more active than girls; they expend more energy and are more influenced by environmental stresses. In

2007 Anderson et al54 in a hospital based study among 305 under-five children in Ghana reported that child’s gender was not among the significant risk for stunting and wasting. The report was contrary to that of Wamani et al 53 probably due to the fact that more males than females were recruited into the study by Anderson et al54 with a male to female ratio of 1.0:0.7.

Rodrigues-Lianes et al55 in 2008 conducted a community based cross-sectional nutritional study in rural India among 406 under-five children. Among other significant risk factors, the researchers reported a significant association between previous flood disaster and increased prevalence of stunting. Neurocognitive consequences of undernutrition in childhood

Early in life, undernutrition is associated with both structural and functional pathology of the brain.56 Structurally, undernutrition result in growth retardation, disorderly differentiation of cells, reduction in synapses, reduced neurotransmitters production, delayed myelination and reduced development of dendritic arborization.56 Long term alteration in brain functions have been reported which could be related to long lasting cognitive impairments associated with undernutrition.56 Bhoomika et al56 conducted a case-control cognitive study among 20 undernourished and 20 well nourished school children aged 5 to 10 years in Bangalore, India.

The two groups were tested using National Institute of Mental Health and Neurosciences

(NIMHANS) neuropsychological test for motor speed, attention, executive functions, visuospatial relationship, comprehension, learning and memory. The undernourished group was significantly deficient on tests of phonemic fluency, design fluency, selective attention, visuospacial working memory, visuospatial functions and verbal comprehension.

Odebode and Odebode57 in a community based neurologic study on 67 severely undernourished children aged six months to five years in Ile-Ife and Ilorin reported that the predominant neurologic findings in them included apathy, irritability, delayed walking skill, decreased muscle bulk, hypotonia, hypereflexia, spinal ataxia and nutritional neuropathy. Compared to the findings by Bhoomika et al56 from India, the researchers in this study tested mainly the motor functions with cognitive function not examined. Additionally, sample size used in this study was rather small.

Johnson et al58 conducted an urban community based three year longitudinal study among 459 children aged 4 to 9 years in Guatemala. The researchers reported a significantly low level of IQ in stunted children. However, Johnson et al58 did not control for other environmental factors such as maternal deprivation that can affect a child’s cognitive development. Intellectual development is an interactive process in which a growing child must both act and be acted upon by the world around him in order to mature.59

Liu and Raine60 in a review article in southern California reported that, childhood externalizing behavior (aggression, hyperactivity and conduct disorder) has been associated with macronutrient and micronutrient deficiencies. The long term effects of undernutrition on behavior could be reversible60

Prevention of stunting and wasting.

Eradicating undernutrition remains a tremendous public policy challenge. A community based preventive approach may be a better option in reducing the prevalence of this childhood problem. Smith and Haddad61 in the year 2000 conducted a meta-analysis of national nutritional surveys published from 1970 to 1996 in 63 developing countries. Over this period the prevalence of undernutrition had declined the fastest in South Asia (by 23%) and the slowest in Sub-Saharan

Africa (by 4%). Improvement in maternal education was responsible for 43% of the total reduction recorded; improvement in per capita food availability was responsible for 26%; improvement in environmental health contributed 19% of the reduction, whereas 12% of the reduction was contributed by improvement in women status. The researchers concluded that, efforts that can improve women’s education, raise food supplies, bolster women status and create healthy environments should be an integral part of strategies for reducing childhood undernutrition in the future.61 However, the researchers failed to mention whether the improvement was in stunting, wasting or underweight. United Nations Children Fund (UNICEF)62 in 2013 reported that community based approaches that will scale up child nutrition include: communication for behavioral and social change; improvement in water supply and sanitation; screening for acute undernutrition and follow up of undernourished children; delivering vitamin A and micronutrient supplements; mass deworming and access to health services.

According to Arathi63 in 2013, stunting can be reduced by 20 million in the year 2020 through the following steps: proper nutrition of mothers and children during the children’s first 1000 days of life; bringing girl child health into focus; reaching out to communities through community health workers; inter-sectoral collaboration with sectors such as ministry of water resources and agriculture; governments should devote adequate funds into nutrition programmes and sustaining global commitment towards preventing childhood undernutrition.63

In 2012 Ubesie and Ibeziakor64 conducted a review of nutritional surveys in Nigeria and other developing countries. The researchers reported that stunting and wasting can be prevented through the following strategies: micronutrient supplementation which will reduce the incidence of diarrhoeal disease, anaemia and respiratory tract infections; improvement in households’ food security through improving food storage and preservation during harvest; governments should create safety net for the less privilege in the society; setting up community level strategies that can support communal farming and community level donation of food items for the less privilege individuals. However, Ubesie and Ibeziakor failed to mention the number of articles reviewed and the duration of the review.

In conclusion, undernutrition remains a major health problem in the developing world. In

Nigeria, according to National Demographic and Health Survey 200813 and 2013,14 north-west sub region, where Kano State is located, had the highest prevalence of stunting (53% and 55%) and wasting (22% and 27%) respectively.13,14 The research questions in the present study were:

(1) what are the anthropometric measurements of children aged 6 to 59 months in rural and urban communities in Kano State? (2) What is the prevalence of stunting and wasting in children aged

6 to 59 months in the two communities, based on the World Health Organization Child Growth

Standards? (3) What are the risk factors for stunting and wasting in children aged 6 to 59 months in the two communities?

The Null hypotheses tested were: (1) there is no significant difference in the prevalence of stunting and wasting between rural and urban communities in Kano State. (2) Socio-economic class does not significantly affect the prevalence of stunting and wasting in rural and urban households in Kano State. The alternate hypotheses for the study were: (1) there is a significant difference in the prevalence of stunting and wasting between rural and urban communities in

Kano State. (2) Socio-economic class significantly affects the prevalence of stunting and wasting in rural and urban households in Kano State.

Previous local works on undernutrition in Kano State were prevalence studies that did not provide clear evidence for programme planning and implementation towards control of stunting and wasting by policy makers. This is important because understanding the relative importance of various determinants, whether they differ between rural and urban communities will become key in designing effective program tailored to the needs of the different population groups. In addition, Z score in the present study was determined using the newer World Health

Organization Child Growth Standards, whereas Z score in the previous local studies were determined using the National Centre for Health Statistics growth reference which might have underestimated the results obtained. The present study will also demonstrate any change over time in the prevalence of stunting and wasting in Kano State.

AIM AND OBJECTIVES OF THE STUDY

Aim: to determine the prevalence and risk factors for stunting and wasting among children aged

6 to 59 months in Kano State.

Specific Objectives:

1. To accurately measure and document the weights, heights or lengths of children aged 6 to

59 months in rural and urban communities in Kano State.

2. To determine the prevalence of stunting, severe stunting, wasting and severe wasting in

the rural and urban children studied, using the World Health Organization Child Growth

Standards.

3. To determine the risk factors for stunting and wasting in children studied from the two

communities.

SUBJECTS AND METHODS

Study Area: the study was conducted in rural and urban communities in Kano State. Kano State is located in the Sudan Savanna in the north-western Nigeria on latitude 12⁰05′N and longitude

8⁰51′E.65 It borders Katsina State to the north-west, Jigawa State to the north-east, Bauchi State to the south- east and Kaduna State to the south-west. Kano State has more than 18,684 square kilometers of land area with an estimated population of 9.4 million people.66 Daily temperature ranges from 26⁰C to 33⁰C. During March to May temperature can be as high as 40⁰C. During the dry cold harmattan months of September to February, it can be as low as 10⁰C at night. The typical crops grown in the State are millet, guinea corn and maize. Rice, tomatoes, pepper and vegetables are cultivated mostly in areas located along Kano River and several dams located across the State. Majority of the people of Kano State are Hausas and Fulanis, mostly engaged in farming and trading. Other ethnic groups are Yorubas, Igbos, Ebiras, Kanuri, Edo and several others. The predominant religion is Islam. Christianity is also practiced mainly by settlers from other parts of the country. There are several health facilities within the metropolis including four

State owned Specialist Hospitals and a Teaching Hospital. The State has 44 Local Government

Areas (LGAs)

Warawa Local Government Area is one of the rural Local Governments of Kano State with a land area of 360 km² and population of 128,787 people.65 Majority of the people are farmers and few engage in fishing and small scale trading. They are mainly Hausas and Fulanis.

Tarauni Local Government Area is one of Kano State’s urban local governments with the land area of 28 km² and population of 221,367 people.65 Majority of the people are traders and then civil servants, artisans among others. They are mainly Hausas and Fulanis with few settlers.65 Sample Size Determination:-

The sample size was calculated using a standard formula for cross-sectional comparative

study.67

2 2 n = (Z₁₋ α + Z₁₋ᵦ) [P₁ (1-P₁) +P₂ (1-P₂)]/ (P₁ -P₂)

Where,

n - Minimum sample size.

Z1-α = 1.96 (standard normal deviate) corresponding to probability of type 1 error at 5%.

Z1-ᵦ =0.84(standard normal deviate) corresponding to probability of type 2 error at power

80%.

P₁ – Prevalence of wasting in the rural communities = 15 %( NDHS 2008)13

P₂ – Prevalence of wasting in urban communities = 11% (NDHS 2008)13

(Prevalence of wasting was used in the calculation because it yielded a larger sample size.

Statistically a larger sample size is more representative of the population).

n= (1.96 + 0.84)² [0.15(1-0.15) + 0.11 (1-0.11)]/ (0.15 – 0.11)².

=685.9

The sample was approximated to 750 children for each of the two selected Local

Government Areas allowing for a 10% non-response rate.

Total = 1500 children aged 6 to 59 months. Training of research assistants

Two female and two male Community Health Extension Workers (two sets) were trained by the candidate to serve as research assistants. They assisted in administering the proforma and house numbering. They also assisted in measuring the length and weight of the children. The training took place over a two day period as follows:

Day 1: classroom based orientation which involved demonstrations on using the proforma, house numbering and the anthropometric measurement of the children.

Day 2: field practice; the research assistants were practically taught on the proforma administration, the anthropometric measurements and house numbering in a community.

Proforma pretest

Before the study was embarked upon, proforma (Appendix I) was pretested in communities far away from the study communities using 150 proforma. This was to test validity of questions and to ensure that responses generated agreed with the set objectives. However, few modifications were made on the proforma. The pretest was done outside the study community to avoid contamination that may lead to bias. Pilot study was also carried out on 150 households in the study communities. This was to test validity and feasibility of research methodology.68The pilot study had assessed the workability of the research methodology.

Study Design – This was a cross-sectional comparative study.

Ethical considerations.

Ethical clearance for the study was obtained from the Medical Ethics Committee of Aminu Kano

Teaching Hospital, Kano (Appendix II). Permission was also obtained from both rural (Appendix III) and urban (Appendix IV) Local Government Councils. Informed written consents were obtained from the parents/guardians of each child before enrolment in the study

(Appendix V). The proposal for the study was approved by the National Postgraduate Medical

College of Nigeria (Appendix VI). During the study, children with complicated severe acute malnutrition were referred to the hospital for treatment while others benefited from nutritional counseling by the research team. Children encountered, though not part of the study, with acute illnesses such as fever, cough and diarrhoea were attended to by the research team. Those that needed admission were appropriately referred to the hospitals.

Study Population: The study population included apparently healthy children aged 6 to 59 months from Warawa (rural) and Tarauni (urban) communities of Kano State, whose parents have consented to participate in the study. The age group 6 to 59 months was chosen because children often face undernutrition during this age of rapid growth and development, which can have long lasting impact on health.69 The ages of the children were obtained from their birth certificates. Where birth certificates were not available, mother’s memory recall and/or calendar of major events in the community were used to determine the ages of the children. The major events used included traditional and religious celebrations dates, previous elections dates, dates of death of major figures, dates of swearing in of local leaders and so on.

Inclusion criteria

The study team recruited apparently healthy children aged 6 to 59 months in the selected rural and urban households in Kano State, whose parents or care givers have consented for the study.

Exclusion criteria

The following categories of children were excluded from participation in the study:- Children taking drugs that are known to affect weight or height such as steroids, children with obvious chronic illnesses, example, cardiac diseases, sickle cell anaemia, congenital anomalies, chronic infections such as tuberculosis and HIV.

Sampling Technique - A multistage sampling technique was used.

Before embarking on the study, preliminary visits were paid by the research team to the traditional leaders of the study communities. The population sizes and the maps of rural

(Appendix VII) and the urban (Appendix VIII) communities were obtained from the Local

Government secretariats. In the rural Local Government Area, the Local Government headquarters and any settlement with population of 20,000 people and above were excluded.

However, all the selected settlements in the selected urban Local Government Area were urban.

Sampling was carried out through the following stages:-

Stage one - The two Local Government Areas (LGAs) were selected by balloting after the entire

LGAs in the State were grouped into urban (eight LGAs) rural (thirty six LGAs). Warawa Local

Government Area was selected from the rural group and Tarauni Local Government Area was selected out of the urban group.

Stage two - The number of political wards in the two Local Government Areas was obtained from the Local Government secretariats. In each LGA 25% of the political wards were selected by balloting.70,71 Warawa Local Government Area has 15 political wards and four were selected by balloting. The selected political wards were Amarawa, Jemagu, Jigawa and Yangizo. Tarauni Local Government Area has ten political wards and three were selected by balloting. These three were Gyadi-gyadi Arewa ward 6, Unguwa uku and Tarauni ward.

Stage three - The total number of settlements in the selected political wards was determined and

25% of them were selected by balloting.70,71 All the households in the sampled settlements were determined and numbered.70,71 The selected political wards and the selected settlements are shown in table I for the rural communities and table II for the urban communities.

Table I shows the selected political wards and the selected settlements in Warawa Local

Government Area. All the households in the selected settlements were numbered.

Table I: the selected political wards and the selected settlements in Warawa Local Government Area.

Selected political wards Selected settlements

Amarawa (Total of 7 settlements) 1. Amarawa village

2. Kurna

Jemagu (Total of 9 settlements) 3. Makera - Gabas

4. Makera – Yamma

Jigawa ( Total of 13 settlements) 5. Token

6 .Laraba

7. Gadan Sarki

Yangizo ( Total of 12 settlements) 8. Buromawa

9. Yangizo village

10. Alitini

Table II shows the selected political wards and the selected settlements in Tarauni Local

Government Area. All the households in the selected settlements were numbered.

Table II: the selected political wards and the selected settlements in Tarauni Local Government Area

Selected Political Wards Selected Settlements

Gyadi-gyadi Arewa Ward 6 (Total of 6 1. Jaoji settlements) 2. Unguwar maigari

Unguwa – Uku (Total of 17 settlements) 3. Gidan Dagachi

4. Gidan Liman

5. Izala

6. Ado Gano

Tarauni ward ( Total of 23 settlements) 7. Tarauni Gandu

8. Unguwar – Yamma

9. Masallachin Juma’a

10. Gidan – Liman Tarauni

11. Farm centre 12. Sokoto Road

Stage four - The calculated sample sizes were distributed among the sampled settlements by proportionate allocation. The percentages of children under the age of five in each of the sampled settlements were calculated. Sample allocation was based on that percentage. The higher the percentage was, the higher the allocated sample. To obtain the sampling interval of a settlement, the total number of households in the settlement was divided by the sample size allocated to the settlement. If the sampling interval of a settlement was n, then every nth household in that settlement was selected until the required sample size was obtained. Starting point was determined using random number sampling table. The stage was summarized in tables III for rural settlements and table IV for urban settlements.

In Table III the selected settlements in Warawa Local Government Area, percentage of under five children in the settlement, sample sizes allocated to the settlements, the number of households and the nth households are presented. Sample size allocated to a settlement depended on the number of under-five children in the settlement. Sampling interval depended on the number of households in a settlement.

Table III: sampling in Warawa LGA in relation to percentage of under-five children, number of households, sample size allocated and nth households selected.

Settlement % of under five Sample size Number of nth household

children allocated households selected

Amarawa 5 37 135 4th kurna 11 83 228 3rd

Laraba 15 113 227 2nd

Gadan- sarki 14 105 207 2nd

Token 16.8 126 237 2nd

Yangizo 7.5 56 225 4th

Makera-gabas 12.7 95 407 4th

Alitini 6.6 50 244 5th

Makera-yamma 7.4 55 240 4th

Buromawa 4 30 118 4th

In Table IV the selected settlements in Tarauni Local Government Area, percentage of under- five children in a settlement, sample sizes allocated to the settlements, the number of households and the nth households are presented. Sample size allocated to a settlement depended on the number of under-five children in the settlement. Sampling interval depended on the number of households in a settlement.

Table IV: sampling in Tarauni LGA in relation to percentage of under-five children, number of households, sample size allocated and nth households selected.

Selected % of total Sample size Number of nth household settlement under-five allocated households selected

Jaoji 10.0 75 320 4th

Unguwar maigari 9.1 68 342 4th

Gidan Dagachi 8.0 60 320 5th

Gidan Liman 10.0 75 208 3rd

Izala 11.4 85 268 3rd

Ado Gano 10.2 78 287 3rd

Tarauni Gandu 11.0 83 274 3rd

Unguwar yamma 5.0 38 129 3rd

Masalacin Jumaa 8.6 64 118 2nd

Gidan Liman TR 7.0 52 94 2nd

Farm centre 5.7 42 87 2nd Sokoto Road 4.0 30 102 3rd

Stage five - The research team examined one eligible child in each sampled household. This was to give every eligible child an equal chance of participation in the study. Where there was more than one eligible child in a particular nth household, one was selected by balloting. When there was no eligible child in a particular nth household, an eligible child was selected from the next immediate household.70-72

Administration of proforma.

Structured proforma was administered on the mothers/caregivers by the research team (Appendix

I) before anthropometric measurements. The pertinent points in the proforma were children’s ages; gender; children’s eligibility criteria; children’s birth orders; occupations, incomes and educational status of the parents; mothers’ feeding practices and anthropometry measurements.

Anthropometric measurement

Anthropometric measurements of the selected children were done by the candidate with help of the Research Assistants in front of each selected household.

Weight

For children aged 24 to 59 months, the weights were measured using SECA®853 medical digital scale (Seca Germany, 2000 – 2008). The scale was placed on a hard flat surface. The children were bare footed, wearing light underwear before standing at the centre of the scale platform.

They stood still with the arms by the sides and facing forward. The weights were read and recorded to the nearest 0.1kg. Each child was weighed twice and the average readings were recorded on the proformas.73,74 This was as demonstrated in Figure 1.

Figure 1: a study participant standing on a weighing scale.

Children aged 6 to 23 months, were measured using Seca® 374 digital baby weighing scale with weighing tray ( Seca Germany, 1998 - 2013). Its accuracy was to 0.1 kg. The children in this age group were weighed naked and average of two measurements was taken and recorded on the proforma. 73,74 This was as demonstrated in Figure 2 below.

Figure 2: a research participant sitting on a weighing scale Height: The heights of children aged 24 to 59 months were measured using Seca® 213 mobile stadiometer (Seca Germany, 1996 - 2013). They stood erect on the non carpeted surface, against the stadiometer with heels together, arms by the side, legs straight and shoulders relaxed. Their heels, buttocks, scapulae and the back of their heads were against the stadiometer. They were facing forward and were not wearing any head gear. The moveable head board of the stadiometer was lowered to the highest point of the head with just enough pressure to compress the hair. The measurements of the height were recorded to the nearest 0.1 cm. The head board was moved away to check the child’s position and the measurement taken again. The average of two measurements that agreed within 1cm was recorded for each child.73,74 This was as demonstrated in Figures 3 and 4 below.

Figure 3: The candidate measuring height of a participant. Figure 4: The candidate measuring height of a participant Recumbent lengths were measured for children 6 to 23 months old using portable UNICEF length measuring Board. With the help of a trained assistant, the children were laid on the board, with head positioned firmly against a fixed head board and eyes looking vertically. The knees were extended by firm pressure and feet were flexed at right angle to the legs against a movable board that touched the soles. The lengths were recorded to the nearest 0.1 cm.73,74 This step was as demonstrated by figures 5 and 6 below.

Figure 5 Figure 6:

The candidate and an assistant measuring recumbent length using UNICEF portable length measuring board.

The research assistants carry the research tools as the research team moves around the communities as shown in figure 7.

Figure 7: A research assistant carrying some research tools

The World Health Organization Child Growth Standards33 were used to determine HAZ and

WHZ. (Appendix IX). Children whose height for age was below – 2 Z score were classified as stunted. Those below – 3 Z score were severely stunted. Children whose weight for height was below -2 Z score were classified as wasted. Those with below -3 Z score were classified as severely wasted.33

Social classes of the families were determined using Oyedeji socio-economic classification scheme75 (Appendix X). According to the scheme parents educational levels and occupations were assigned numbers from 1 to 5. The mean of four scores, two from both the father and the mother approximated to the nearest whole number were the social classes assigned to the children. Social classes I and II belong to high social class; social class III as the middle while social classes IV and V formed the low social class.

Data Analysis:

Data generated were entered into a personal computer excel sheet, transported and analyzed using the statistical package for social sciences (SPSS) version 22.0. Quantitative data were summarized using measures of central tendency (mean, mode and median) and measures of dispersion (range and standard deviation). It was also subjected to statistical analysis using student t-test with p-value of < 0.05 considered as statistically significant. Qualitative data were summarized using frequency distribution tables and were also cross tabulated and subjected to statistical analysis using chi – square test; p-value of < 0.05 was considered statistically significant.76 World Health Organization Child Growth Standards33 were used to determine HAZ and WHZ. (Appendix II). Children whose HAZ was less than -2 standard deviations from the median of the World Health Organization Child Growth Standards were stunted and less than -3 standard deviation were severely stunted. Children with WHZ less than -2 standard deviations were wasted and those with less than -3 standard deviations were severely wasted.

RESULTS

The present study was conducted over a period of six months from 1st April to 30th September

2015. There were 1,500 respondents consisting of 750 children from each Local Government

Area.

Comparison of ethnicity of the study participants and the household’s marriage type between rural and urban communities.

In table V there was a higher proportion of Fulanis in the rural communities than the urban communities. Other ethnic groups were only encountered in the urban communities, and the difference was statistically significant (χ² = 43.20; df = 2; p = 0.000). The proportion of polygamous type of marriage was higher among the rural than urban dwellers, whereas monogamy was higher among the urban dwellers, and the difference was statistically significant

(χ² 104.0; df = 1; p = 0.000).

Table V: comparison of ethnicity of the subjects and marriage types between rural and urban communities.

Variable Rural (n=750) Urban (n=750) χ² p value

Ethnicity Number (%) Number (%) Hausa 558 (74.0) 607 (80.9) 43.20 0.000 Fulani 192 (26.0) 119 (15.9) Others *0 24 (3.2) Marriage type Monogamy 368 (49.1) 560 (74.7) 104.0 0.000 Polygamy 382 (50.9) 190 (25.3) *E = 750x24/1500 = 12 others = Igbos, Yorubas, Edos, Kanuris, Ebiras, etc

COMPARISON OF PREVALENCE OF STUNTING AND WASTING BETWEEN RURAL AND URBAN COMMUNITIES.

In the present study, the prevalence of stunting, severe stunting and the overall stunting in the rural communities was 312 (41.6%), 188 (25.1%) and 500 (66.7%) respectively. In the urban communities, the prevalence of stunting, severe stunting and overall stunting was 284 (37.9%),

107 (14.2%) and 391 (52.1%) respectively. In the rural communities, the prevalence of wasting, severe wasting and the overall wasting was 127 (16.9%), 48 (6.4%) and 175 (23.3%) respectively. In the urban communities, the prevalence of wasting, severe wasting and the overall wasting was 110 (14.7%), 21 (2.8%) and 131 (17.5%) respectively.

In table VI the prevalence rates of stunting and severe stunting were higher in rural than urban communities, and the difference was statistically significant (χ² = 10.38; df = 1; p = 0.0013). The prevalence rates of wasting and severe wasting were higher in rural than urban communities, and difference was statistically significant (χ² = 5.573; df = 1; p = 0.0182).

Table VI: comparison of prevalence of stunting and wasting between rural and urban communities.

Variable Rural Urban Statistical test p value STUNTING Number (%) Number (%) χ² Moderate stunting 312(41.6) 284(37.9) 10.38 0.0013 Severe stunting 188 (25.1) 107 (14.2) Overall stunting 500 (66.7) 391 (52.1) WASTING Moderate wasting 127 (16.9) 110 (14.7) 5.573 0.0182 Severe wasting 48 (6.4) 21 (2.8) Overall wasting 175 (23.3) 131 (17.5)

COMPARISON OF RISK FACTORS FOR STUNTING AND WASTING BETWEEN RURAL AND URBAN COMMUNITIES.

In the present study the risk factors for stunting and wasting in rural and urban communities include: child’s age group, being a male child, child’s high birth order, lack maternal formal education, mother’s low income, poor mother’s feeding practices, lack of father’s formal education, father’s low income and low family’s social class.

Comparison of age distribution and gender of the study participants between rural and urban communities.

In table VII the age distribution was very similar in all age groups (χ² = 0.013; df = 4; p = 1.000).

The mean ages of the rural subjects was higher than that of the urban subjects, though the difference was not statistically significant (t = 0.03; df = 1498; p = 0.980). The proportion of male children was higher in urban communities than rural communities, though the difference was not statistically significant (χ² = 1.300; df = 1; p = 0.255).

Table VII: comparison of age distribution and gender of the study participants between rural and urban communities

Variable Rural (n=750) Urban (n=750) χ² p value

Age (months) Number (%) Number (%) 6-11 148 (19.7) 149 (19.9) 0.013 1.000 12-23 150 (20.0) 149 (19.9) 24-35 151 (20.1 152 (20.3) 36-47 152 (20.3) 151 (20.1) 48-59 149 (19.9) 149 (19.9) Mean ± SD 28.15 ± 15 28.13 ± 16 t = 0.03 0.980 Gender Males 392 (52.3) 414 (55.2) 1.300 0.255 Females 358 (47.7) 336 (44.8)

Comparison of children’s birth orders between rural and urban communities.

In table VIII the proportion of children of lower birth order of 1-4 was higher in rural than in urban communities and the proportion of children of higher birth order of >4 was higher in the urban areas, and the difference was statistically significant ( χ² = 60.28; df = 2; p = 0.000).

Table VIII – comparison of children’s birth orders between rural and urban communities.

Variable Rural Urban χ² p value

Birth order Number (%) Number (%) 1-4 555 (74.0) 412 (54.9) 60.28 0.000 5-8 169 (22.5) 283 (37.7) 9-12 26 (3.5) 55 (7.4) Total 750 (100) 750 (100)

Comparison of Bacillus Calmette Guerin (BCG), Diphtheria, Pertussis, Tetanus (DPT) and

Pentavalent (PENTA) vaccines coverage between rural and urban communities.

In table IX the immunization coverage for Bacillus Calmette Guerin (BCG), Diphtheria,

Pertussis, tetanus (DPT/Pentavalent vaccine (PENTA), Oral polio vaccine (OPV), yellow fever and measles were higher in urban than in rural area. The differences were statistically significant.

Table IX: comparison of immunization status of subjects between rural and urban communities

Variable Rural (n = 750) Urban (n = 750) χ² p value BCG Number (%) Number (%) Yes 289 (38.5) 586 (78.1) No 482 ( 61.5) 164 (21.9) 257.1 0.000 DPT 1/PENTA 1 Yes 268 (35.7) 565 (75.3) No 482 (64.3) 185 (24.7) 238.1 0.000 DPT 2/PENTA 2 Yes 241 (32.1) 498 (66.4) No 509 (67.9) 252 (33.6) 176.2 0.000 DPT 3/PENTA 3 Yes 241 (32.1) 500 (66.7) No 509 (67.9) 250 (33.3) 178.9 0.000 OPV 0 Yes 267 (35.6) 566 (75.5) No 483 (64.4) 184 (24.5) 241.4 0.000 OPV 1 Yes 242 (32.3) 499 (66.5) No 508 (67.7) 251 (33.5) 176.2 0.000 OPV 2 Yes 242 (32.3) 499 (66.5) No 508 (67.7) 251 (33.5) 176.2 0.000 OPV 3 Yes 242 (32.3) 499 (66.5) No 508 (67.7) 251 (33.5) 176.2 0.000 MEASLES Yes 193 (25.7) 461 (61.5) No 557 (74.3) 289 (38.5) 194.7 0.000 YELLOW FEVER Yes 188 (25.1) 459 (61.2) No 562 (74.9) 291 (38.8) 199.6 0.000

Comparison of educational status and occupations of the mothers and care givers between rural and urban communities.

In table X the proportion of women with formal education was higher in urban areas than rural areas, and the difference was statistically significant (χ² = 558.8; df = 1; p = 0.000). The proportion of skilled mothers was higher in urban than rural communities, and the difference was statistically significant (χ² = 52.84; df = 1; p = 0.000). Table X: comparison of educational status and occupations of mothers/care givers between rural and urban communities.

Variable Rural Urban χ² p value (n=750) (n=750) Mother’s education Formal 74 (9.9) 522 (69.6) 558.8 0.000 Non-formal 676 (90.1) 228 (30.4) Mother’s occupation Skilled 9 (1.2) 73 (9.7) 52.84 0.000 Unskilled 741(98.8) 677 (90.3)

Skilled - professionals, senior public servants, managers, intermediate grade public servants, professional drivers, Artisans, Large scale traders, school teachers.

Unskilled - Peasant farmers, Full time house wife, petty traders, unemployed, laborers, messengers.

Comparison of mothers’ monthly incomes between rural and urban communities

In table XI the median and the 75th percentile incomes of mothers in urban communities were higher than those of mothers in rural communities. The difference was statistically significant (p

= 0.000).

Table XI – comparison of monthly incomes of mothers between rural and urban communities.

25% 50% 75% p-value (Mann-Whitney U LGA Median (N) Percentile (N) percentile (N) percentile (N) test) Tarauni 2000 0.000 2000 5000 p = 0.000 Warawa 1000 400.0 1000 2000 LGA = Local Government Area

Comparison of breast-feeding practices between rural and urban communities.

In table XII the proportion of mothers who commenced breast feeding within the first hour of delivery was higher in urban than in rural communities. The proportion of mothers who commenced breast feeding after the first hour of delivery was higher in rural than urban communities, though the difference was not statistically significant (χ² = 0.554; df = 1; p =

0.457). The proportion of women who practiced exclusive breast feeding was higher in urban than in rural communities, though the difference was not statistically significant (χ² = 3.403; df =

3; p = 0.065). The proportions of mothers who stopped breast feeding within 10 to 16 months, 17 to 23 and 24 to 30 months were higher in rural than urban communities, though the difference was not statistically significant (χ² = 3.300; df = 2 p = 0.192). The mean duration of breast feeding was longer in rural than urban communities, and the difference was statistically significant ( t = 2.541; df = 1488; p = 0.011).

Table XII: comparison of breast feeding practices between rural and urban communities variable Rural Urban χ² p value

BF commencement Number (%) Number (%) Within first hour 640 (85.3) 650 (86.7) 0.554 0.457 After first hour 110 (14.4) 100 (12.8) Total 750 (100) 750 (100) Exclusive BF Yes 23 (3.1) 37 (4.9) No 727 (96.9) 713 (95.1) 3.403 0.065 Total 750 (100) 750 (100) Duration BF in months 10 – 16 57 (10.2) 50 (6.7) 3.300 0.192 17 – 23 354 (63.6) 345 (46.0) 24 – 30 146 (26.2) 109 (14.5) Mean ± SD 14.72±9.15 13.47±9.90 t = 2.541 0.011 BF = breast feeding

Comparison of complementary feeding practices between rural and urban communities. In table XIII the proportion of mothers who introduced complementary feeds to the children earlier than six months of life was higher in the rural than in the urban communities. The proportion of mothers who introduced complementary feeds to the children at six months of life was higher in the urban than rural communities, and difference was statistically significant (χ² =

21.63; df = 2; p = 0.000). The mean time of introducing complementary feeds was longer in rural than urban, though the difference was not statistically significant (t = 0.340; df =1497 p =

0.730). The proportion of children weaned on plain millet-based pap was higher in the rural than urban communities. The proportions of children weaned on milk fortified pap, commercially formulated feeds and triple mixture were higher in urban than rural communities, and the difference was statistically significant (χ² = 252.7; df = 4; p = 0.000).

Table XIII: comparison of complementary feeding practices between rural and urban communities

Variable Rural Urban χ² p Age at introduction of Number (%) Number (%) CF (months) 1 – 5 291 (38.8) 210 (28.0) 21.63 0.000 6 – 11 449 (59.9) 520 (69.3) 12 – 17 10 (1.3) 20 (2.6) Mean ± SD 5.97±1.63 5.95±1.63 t = 0.340 0.730 Complementary feeds Plain millet-based pap 614 (82.0) 340 (47.2) 252.7 0.000 Milk fortified pap 92 (12.2) 114 (15.8) Commercially formulated 32 (4.3) 120 (16.7) Triple mixture 6 (0.8) 137 (19.0) Othersᵠ 5 (0.7) 9 (1.3) Total 749 (100) 720 (100) ᵠ = potato, yam, mashed beans, CF = complementary feeds, SD = Standard deviation, commercially formulated = commercially formulated feeds such cerelac, friso cream etc. Triple mixture = pap made from triple mixture of millet, soya bean and ground nut.

Comparison of educational status and occupations of fathers between rural and urban communities. In table XIV the proportion of fathers with formal education was higher in the urban than rural communities, and the difference was statistically significant (χ² = 260.7; df = 1; p = 0.000). The proportion of skilled fathers was higher in urban than rural communities, whereas the proportion of unskilled fathers was higher in rural communities, and the difference was statistically significant (χ² = 385.9; df = 1; p = 0.000). In both rural and urban communities, 99% of the households in the present study were headed by men.

Table XIV – comparison of educational levels and occupations of fathers between rural and urban communities.

Variable Rural Urban χ² P value n =750 n =750 Education Number (%) Number (%) Formal 127 (16.9) 429 (57.2) 260.7 0.000 Non-formal 623 (83.1) 321 (42.8) Occupation Skilled 21 (2.8) 349 (46.5) 385.9 0.000 Unskilled 729 (97.2) 401 (53.5) Skilled - professionals, senior public servants, managers, intermediate grade public servants, professional drivers, Artisans, Large scale traders, school teachers.

Unskilled - Peasant farmers, Full time house wife, petty traders, unemployed, laborers, messengers

Comparison of fathers’ monthly income between rural and urban communities.

In table XV the median, 25th and 75th percentile monthly incomes of fathers in urban communities were higher than those of fathers in rural communities. The difference was statistically significant (p = 0.000).

Table XV comparison of father’s monthly income between rural and urban communities

Median 25% 50% percentile 75% p-value (Mann-Whitney U LGA (N) Percentile (N) (N) percentile (N) test) Tarauni 40000 20000 40000 60000 p < 0.0001 Warawa 10000 5000 10000 30000 LGA = Local Government Area

Comparison of social classes of the families between rural and urban communities.

In table XVI the proportions of children from high and middle social classes were higher in urban than rural communities and the proportions of children from low social class was higher in rural than urban communities. The difference was statistically significant (χ² = 347.9; df = 2, p =

0.000).

Table XVI: comparison of social classes of the families between rural and urban communities.

Variable Rural (n = 750) Urban (n = 750) χ² p

Social class Number (%) Number (%)

High 7 (0.9) 66 (8.8) 347.9 0.000

Middle 42 (5.6) 308 (41.0)

Low 701 (93.5) 376 (50.1)

ASSOCIATIONS BETWEEN RISK FACTORS AND STUNTING IN RURAL AND

URBAN COMMUNITIES.

Association between stunting, maternal education and maternal incomes in rural and urban communities.

In table XVII the proportions of stunted children were lower in children whose mothers had formal education in both rural and urban communities. The differences were statistically significant (χ² = 25.22; df = 1; p = 0.000. χ² = 10.25; df = 1; p = 0.000) for rural and urban communities respectively. The proportions of stunted children decreased with increase in maternal incomes in both rural and urban communities, though the differences were not statistically significant (χ² = 2.500; df = 2; p = 0.286. χ² = 5.910; df = 2; p = 0.052) for rural and urban communities respectively.

Table XVII - Association between stunting, maternal education and monthly maternal income in rural and urban communities.

RURAL URBAN Variable Stunted Non- χ² P Stunted Non- χ² P stunted stunted Maternal Number Number Number Number education (%) (%) (%) (%) Formal 30 (40.5) 44 (59.5) 25.22 0.000 252 (48.3) 270 (51.7) 10.25 0.000 Non-formal 470 (69.5) 206 (30.5) 139 (60.9) 89 (39.1) Total 500 250 391 359 Maternal income (₦) <750 140 (70.7) 58 (29.3) 2.500 0.286 243 (55.0) 199 (45.5) 5.910 0.052 750-1500 147 ( 65.9) 76 (34.1) 41 (50.0) 41 (50.0) >750 141 (63.5) 81 (36.5) 12 (34.3) 23 (65.7) Total 428 215 296 263

Association between stunting, families’ social classes and children’s age groups in rural and urban communities. In table XVIII the proportions of stunted children decreased with increase in the families’ social classes in both rural and urban communities, and the differences were statistically significant (χ²

= 6.647; df = 1; p = 0.009. χ² = 6.690; df = 2; p = 0.035) for rural and urban communities respectively. The proportions of stunting were highest in children aged 24 to 35 months in both rural and urban communities and the differences were statistically significant (χ² = 15.90; df = 4; p = 0.003. χ² = 10.86; df = 4; p = 0.028) for rural and urban areas respectively.

Table XVIII - Association between stunting, familie’s social classes and age groups in rural and urban communities.

RURAL URBAN Variable Stunted Non-stunted χ² p Stunted Non-stunted χ² p

Social Number Number (%) Number Number (%) class (%) (%) High 6.647 0.009 24 (36.9) 41 (63.1) 6.690 0.035 Middle 20 (48.8) 21 (51.2) 163 (52.9) 145(47.1) Low 479 (68.2) 223 (31.8) 204 (54.1) 173 (45.9) Total 499 244 391 359 Age (months) 6 - 11 82 (554) 66 (44.6) 15.90 0.003 76 (51.0) 73 (49.0) 10.86 0.028 12 - 23 103 (68.7) 47 (31.3) 79 (53.0) 70 (47.0) 24 - 35 116 (76.8) 35 (23.2) 91 (59.9) 61 (40.1) 36 – 47 99 (65.1) 53 (34.9) 83 (55.0) 68 (45.0) 48 – 59 100 (67.1) 49 (32.9) 62 (41.6) 87 (58.4) Total 500 250 391 359

Association between stunting, children’s birth orders and types of complementary feeds in rural and urban communities.

In table XIX the proportions of stunted children were highest in children of 5th to 8th birth orders in both rural and urban communities, though the association was only statistically significant in the rural areas (χ² = 6.390; df = 2; p = 0.041. χ² = 1.249; df = 2; p = 0.535) for rural and urban communities respectively. The proportions of stunting were higher in children weaned on millet- based plain pap in both rural and urban communities and the differences were statistically significant (χ² = 74.90; df = 1; p = 0.000. χ² = 61.60; df = 1; p = 0.000) for rural and urban communities respectively.

Table XIX: Association between stunting and children’s birth orders, complementary feeds in rural and urban communities.

RURAL URBAN Variable Stunted Non-stunted χ² p Stunted Non-stunted χ² p Birth Number Number (%) Number Number (%) order (%) (%) 1 - 4 357 (64.3) 198 (35.7) 6.390 0.041 211(51.2) 201 (48.8) 1.249 0.535 5 - 8 126 (74.6) 43 (25.4) 154 (54.4) 129 (45.6) 9 - 12 16 (61.5) 10 (38.5) 26 (47.3) 29 (52.7) Total 499 251 391 359 Compleme ntary feeds Plain pap 452 (73.6) 162 (26.4) 74.90 0.000 231 (68.0) 109 (32.0) 61.60 0.000 Non-plain 47 (34.8) 88 (65.2) 147 (38.7) 233 (61.3) Total 499 250 378 342

Association between stunting, children’s immunization status and gender in rural and urban communities.

In table XX the proportion of stunting was equal among immunized and non-immunized children in both rural and urban communities (χ² = 0.000; df = 1; p = 0.998 χ² = 0.000; df = 1; p = 0.997) for rural and urban communities respectively. The proportion of stunting was higher among male than female children in both rural and urban communities, and the difference was statistically significant (χ² = 3.861; df = 1; p = 0.049. χ²= 4.972; df = 1; p = 0.026) for rural and urban communities respectively.

Table XX: Association between stunting, children’s immunization status and gender in rural and urban communities.

RURAL URBAN Variable Stunted Non-stunted χ² p Stunted Non- stunted χ² p Immunizat ion Status Yes 197 (66.6) 99 (33.4) 0.000 0.998 306 (52.1) 281 (47.9) 0.000 0.997 No 303 (66.6) 151 (33.4) 85 (52.1) 78 (47.9) Total 500 250 391 359 Child’s Gender Male 274 (69.9) 118 (30.1) 3.861 0.049 231 (55.8) 183 (44.2) 4.972 0.026 Female 226 (45.2) 132 (52.8) 160 (47.6) 176 (52.4) Total 500 250 391 359

Association between stunting, father’s educational status and monthly incomes in rural and urban communities.

In table XXI the proportions of stunted children were lower in children whose fathers were formally educated in both rural and urban communities, and the differences were statistically significant (χ² = 11.85; df = 1; p = 0.001. χ² = 10.23; df = 1; p = 0.000) for rural and urban communities respectively. The proportions of stunted children decreased with increase in father’s income in both rural and urban communities, and the differences were statistically significant (χ²

= 11.01; df = 2; p = 0.004. χ² = 18.47; df = 2; p = 0.000) for rural and urban communities respectively. Table XXI: Association between stunting, father’s education and monthly incomes in rural and urban communities.

RURAL URBAN Variable Stunted Non-stunted Stunted Non-stunted Father’s Number Number (%) χ² p Number Number (%) χ² p education (%) (%) Formal 68 (53.5) 59 (46.5) 11.85 0.001 202 (47.1) 227 (52.9) 10.23 0.000 Non formal 432 (69.3) 191 (30.7) 189 (58.9) 132 (41.1) Total 500 250 391 359 Father’s income (₦) <7500 195 (72.0) 76 (28.0) 11.01 0.004 10 (83.3) 2 (16.7) 18.47 0.000 750-15000 174 (68.0) 82 (32.0) 105 (64.4) 58 (35.6) >15000 122 (57.8) 89(42.2) 276 (48.0) 299 (52.0) Total 491 247 391 359

ASSOCIATIONS BETWEEN RISK FACTORS AND WASTING IN RURAL AND URBAN COMMUNITIES.

Association between wasting, maternal educational status and monthly maternal incomes in rural and urban communities.

In table XXII the proportions of wasting was lower in children whose mothers had formal education in both rural and urban communities, and the differences were statistically significant

(χ² = 5.727; df = 1; p = 0.017; χ² = 98.64; df = 1; p = 0.000)) for rural and urban communities respectively. No statistically significant associations between prevalence of wasting and maternal incomes in both rural and urban communities (χ² = 0.310; df = 2; p = 0.857. χ² = 3.031; df = 2; p = 0.219) for rural and urban communities respectively.

Table XXII: association between wasting, maternal education and monthly maternal incomes in rural and urban communities.

RURAL URBAN Variable Wasted Non-Wasted χ² P Wasted Non-wasted χ² p Maternal Number Number (%) Number Number (%) education (% ) (%) Formal 9 (12.2) 65 (87.8) 5.727 0.017 27 (6.1) 418 (93.9) 98.64 0.000 Non-formal 166 (24.6) 510 (75.4) 104 (34.1) 201 (65.9) Total 175 575 131 619 Maternal income (₦) < 7500 34 (17.2) 164 (82.8) 0.310 0.857 58 (25.0) 174 (75.0) 3.031 0.219 7500-15000 35 (15.7) 188 (84.3) 35 (18.7) 152( 81.3) >15000 39 (17.6) 183 (82.4) 36 (25.7) 104 (74.3) Total 108 535 129 430

Association between wasting, families’ social classes and age groups of the children in rural and urban communities In table XXIII the proportion of children with wasting in the rural communities increased with the decrease in the family’s social class, and the difference was statistically significant (χ² =

4.866; df = 1; p = 0.027. In the urban communities wasting was not significantly associated with social class. (χ² = 2.180; df = 2; p = 0.336). The proportions of children with wasting were highest in age group 12 to 23 months in both rural and urban communities and the differences were statistically significant (χ² = 12.27; df = 4; p = 0.015. χ² = 12.67; df = 4; p = 0.013) for rural and urban communities respectively.

Table XXIII: association between wasting, families’ social classes and age groups in rural and urban communities

RURAL URBAN Variable Wasted Non-wasted Wasted Non-wasted χ² p Social class High 13 (19.7) 53 (80.3) 2.180 0.336 Middle 4* (9.5) 38 (90.5) 4.866 0.027 60 (19.5) 248 (80.5) Low 171 (24.4) 530 (75.6) 58 (15.4) 318 (84.6) Total 175 568 131 619 Age in months 6 - 11 36 (24.3) 112 (75.7) 12.27 0.015 25 (16.8) 124 (83.2) 12.67 0.013 12 - 23 49 (32.7) 101 (67.3) 37 (24.8) 112 (75.2) 24 - 35 35 (23.2) 116 (76.8) 32 (21.1) 120 (78.9) 36 – 47 25 (16.4) 127 (83.6) 20 (13.2) 131 (86.8) 48 – 59 30 (20.1) 119 (79.9) 17 (11.4) 132 (88.6) Total 175 575 131 619 *E = 42x175/743 = 9.9

Association between wasting, children’s birth orders and complementary feeds in rural and urban communities.

In table XXIV the proportion of wasting was higher in children of birth order 5 to 8 in rural communities and the difference was statistically significant (χ² = 13.23; df = 2; p = 0.001). In urban communities, the proportion of wasting was higher among children in the 1st to 4th birth order, but the difference was not statistically significant (χ² = 1.890; df = 2; p = 0.388). The proportions of wasting were higher among children weaned on plain millet-based pap in both rural and urban communities, and the differences were statistically significant (χ² = 5.440; df = 1; p = 0.019. χ²= 8.122; df = 1; p = 0.004) for rural and urban areas respectively.

Table XXIV: Association between wasting, children’s birth orders and complementary feeds in rural and urban communities.

RURAL URBAN Variable Wasted Non-wasted χ² p Wasted Non-wasted χ² p Birth order Number (%) Number Number (%) Number (%) (%) 1 - 4 114 (20.5) 441 (79.5) 13.23 0.001 79 (19.2) 333 (80.8) 1.890 0.388 5 - 8 57 (33.7) 112 (66.3) 43 (15.2) 240 (84.8) 9 - 12 4* (15.4) 22 (84.6) 9 (16.4) 46 (83.6) Total 175 575 131 619 Compleme ntary feeds Plain pap 153 (24.9) 461 (75.1) 5.440 0.019 74 (21.8) 266 (78.2) 8.122 0.004 Non plain 21 (15.6) 114 (84.4) 52 (13.7) 328 (86.3) Total 174 575 126 594 *E = 26x175/750 = 6

Plain pap = Millet-based plain pap; Non plain = Milk fortified pap, commercially formulated feeds, triple mixture of millet, ground nut and soya beans.

Association between wasting, children’s immunization status and gender in rural and urban communities.

In table XXV the proportion of wasting was higher among children who had not been immunized in the rural communities, though the difference was not statistically significant (χ² =

0.386; df = 1; p = 0.535). In the urban communities, there was also no statistically significant association between wasting and child’s immunization status (χ² = 0.205; df = 1; p = 0.651). In rural communities, the proportion of wasting was higher among girls than boys, but the difference was not statistically significant (χ² = 0.007; df = 1; p = 0.935). In urban communities, the proportion of wasting was higher among boys than girls, though the difference was not statistically significant (χ² = 0.270; df = 1; p = 0.603).

Table XXV: Association between wasting, children’s immunization status and gender.

RURAL URBAN Variable Wasted Not wasted χ² p wasted Not wasted χ² p Immuniz ation status Yes 134 (22.8) 453 (77.2) 0.386 0.535 54 (18.2) 242 (81.8) 0.205 0.651 No 41 (25.2) 122 (74.8) 77 (17.0) 377 (83.0) Total 175 575 131 619 Child’s gender Male 91 (23.2) 301 (76.8) 0.007 0.935 75 (18.1) 339 (81.9) 0.270 0.603 Female 84 (23.5) 274 (76.5) 56 (16.7) 280 (83.3) Total 175 575 131 619

Association between wasting, father’s educational status and incomes in rural and urban communities.

In table XXVI the proportions of wasting were lower in children whose fathers had formal education in both rural and urban communities, and the differences were statistically significant

(χ² = 14.66; df = 1; p = 0.000. χ² = 101.9; df = 1; p = 0.000) for rural and urban communities respectively. In the rural communities, the proportion of wasting decreased with increase in father’s income, though the difference was not statistically significant (χ² = 1.480; df = 2; p =

0.477). In urban communities, there was also no statistically significant association between wasting and father’s income. (χ² = 1.600; df = 2; p = 0.449).

Table XXVI: Association between wasting, father’s educational status and incomes in rural and urban communities.

RURAL URBAN Variable Wasted Non-wasted χ² p Wasted Non-wasted χ² p Father’s education Formal 13 (10.2) 114 (89.8) 14.66 0.000 23 (5.4) 406 (94.6) 101.9 0.000 Non-formal 162 26.0) 461 (74.0) 108 (33.6) 213 (66.4) Total 175 575 131 619 Father’s income (₦) <7500 7 (30.4) 16 (69.6) 1.480 0.477 28 (14.9) 160 (85.1) 1.600 0.449 7500-15000 20 (19.6) 82 (80.4) 33 (16.0) 173 (84.0) >15000 148 (23.7) 477 (76.3) 65 (18.9) 279 (81.1) Total 175 575 126 612

Logistic Regression Analysis

In table XXVII after subjecting the risk factors that were significantly associated with stunting and wasting at bivariate level to multivariate analysis (binary logistic regression), only the mother’s education was an independent predictor of stunting in the urban communities. In table

XXVIII within the same urban communities, only the child’s age was an independent predictor of wasting.

In table XXIX after conducting the binary logistic regression analysis on the statistically significant risk factors for stunting and wasting, only mother’s educational status and father’s income were the independent predictors of stunting in rural communities. In table XXX within the same rural communities, only type of complementary feeds and social classes of the families were the independent predictors of wasting.

In the urban communities, children of mothers with formal education had 2% decreased risk of being stunted (OR = 0.973; p = 0.013). In the same urban communities children within the age group 12 to 23 months had 62% increased risk of being wasted (OR = 1.623; p = 0.012).

In the rural communities, children of mothers without formal education had 91 % increased risk of being stunted (OR = 1.911; p = 0.003). Children of fathers with low income had 62% increased risk of being stunted (OR = 1.619 p = 0.014). In the same rural communities children who took plain millet-based pap during weaning had 64% increased risk of being wasted (OR =

1.635; P = 0.026). Children from higher social class families had 57% decreased risk of being wasted in the rural communities (OR = 0.434; p = 0.005).

Binary logistic regression: stunting and wasting versus significant risk factors in urban and rural communities

URBAN HAZ

Table XXVII Variables in the Equation 95% C.I.for Odds Odds B S.E. Wald df Sig. ratio Lower Upper Step 1a Age (month) .171 .090 3.610 1 .057 1.187 .995 1.416 Mother’s -.018 .005 13.761 1 .013 .983 .973 .992 education Father’s .022 .083 .069 1 .793 1.022 .868 1.204 education Father’s income .000 .000 .005 1 .945 1.000 1.000 1.000 Complementary .026 .048 .303 1 .582 1.027 .935 1.127 feeds Social class .102 .168 .369 1 .543 1.107 .797 1.538 Gender -.295 .150 3.847 1 .050 .744 .554 1.000 Constant -.082 .567 .021 1 .885 .922 a. Variable(s) entered on step 1: Age (month), Mother’s education, Father’s education, Father’s income, complementary feeds, social class, Gender.

URBAN WHZ

Table XXVIII Variables in the Equation 95% C.I.for Odds Odds B S.E. Wald df Sig. ratio Lower Upper a Step 1 Age (month) .295 145 1 .012 1.623 1.103 2.388 3.215 Mother’s -.168 .091 3.422 1 .064 .845 .707 1.010 education Father’s .039 086 .209 1 .648 1.040 .879 1.231 education Fathers income .000 .000 .515 1 .473 1.000 1.000 1.000 Complementar .076 .054 1.942 1 .163 1.079 .970 1.200 y feeds Constant -.550 .479 1.318 1 .251 .577 a. Variable(s) entered on step 1: Age (month), Mother’s education, Father’s education, Father’s income, complementary feeds. RURAL HAZ

Table XXIX Variables in the Equation Odds 95% C.I.for Odds B S.E. Wald df Sig. ratio Lower Upper Step 1a Age (month) .002 .005 .170 1 .680 1.002 .992 1.012 Mother’s .648 .221 8.579 1 .003 1.911 1.239 2.948 education Father education -.040 .157 .066 1 .797 .960 .706 1.306 Birth order -.002 .032 .003 1 .957 .998 .937 1.064 Complementary .094 .197 .229 1 .632 1.099 .746 1.618 feeds Social class .073 .263 .077 1 .781 1.076 .642 1.801 Gender -.053 .159 .109 1 .741 .949 .695 1.296 Father’s income .482 .197 5.998 1 .014 1.619 1.101 2.382 Constant -2.455 1.062 5.342 1 .021 .086 a. Variable(s) entered on step 1: Age (month), mother’s education, Father’s education, Birth order, complementary feeds, social class, Gender, Father’s income.

RURAL WHZ

Table XXX Variables in the Equation 95% C.I.for Odds Odds B S.E. Wald df Sig. ratio Lower Upper Step Age in months .009 .006 2.227 1 .136 1.009 .997 1.021 1a Mother’s .121 .263 .212 1 .646 1.128 .674 1.888 education Fathers education .000 .000 8.635 1 .076 1.003 1.000 1.000 Birth orders .042 .038 1.205 1 .272 1.043 .968 1.123 Complementary .492 .221 4.942 1 .026 1.635 1.060 2.522 feeds Social class -.834 .296 7.953 1 .005 .434 .243 .775 Constant - 1.127 1.735 1 .188 .227 1.485 a. Variable(s) entered on step 1: Age (month), mother’s education, Father’s education, Birth order, complementary feeds, social class.

Receiver Operating Characteristics (ROC) Analysis77

This is a quantitative diagnostic test that uses a quantitative variable to separate group being tested in to those with and without the disease. Accuracy is measured by the area under the ROC curve; area of 1 represents a perfect test; area of 0.5 represents a worthless test.77

Stunting and MUAC

The area under the mid upper arm circumference (MUAC) ROC curve is 0.609. The MUAC would be considered “poor" at separating stunted and non-stunted children.

Figure 8: ROC curve for stunting.

Table XXXI: Area Under the Curve Test Result Variable(s): MUAC Asymptotic 95% Confidence Interval Area Std. Errora Asymptotic Sig.b Lower Bound Upper Bound .609 .015 .000 .580 .637 Wasting and MUAC

The area under the mid upper arm circumference (MUAC) ROC curve is 0.700. The MUAC would be considered to be "fair" at separating wasted and non-wasted children.

Figure 9: ROC curve for wasting

Table XXXII: Area Under the Curve Test Result Variable(s): MUAC Asymptotic 95% Confidence Interval

Area Std. Errora Asymptotic Sig.b Lower Bound Upper Bound .700 .017 .000 .662 .729

DISCUSSION

In the present study, the overall prevalence of stunting in the rural communities was 500 (66.7%) while that of wasting was 175 (23.3%) among children aged 6-59 months. For the urban communities, the overall prevalence of stunting was 391 (52.1%) and that of wasting was 131

(17.5%) among children 6-59 months in Kano State. These prevalence rates were higher than the

World Health Organization critical threshold for implementing feeding progamme. Prevalence rates of more than 40% and more than 15% for stunting and wasting respectively are regarded as critical levels.29,78 According to the World Food Progamme wasting prevalence rate of 15% and above is regarded as a nutritional emergency and a threshold for implementing feeding progamme.29,79 The prevalence of stunting and wasting in Kano State were above the national average of 37% and 18% respectively.14

The implication of this is that a significant number of children especially in the rural communities of Kano State do not reach their maximum growth potential. The high prevalence of stunting in the study communities may result in significant disadvantage to the population in terms of poor health with increase burden on health system, poor cognitive development, suboptimal educational achievement and ultimately the potential for poor economic development.80 According to the World Bank estimates, a 1% loss in adult height due to childhood stunting is associated with a 1.4% loss in economic productivity.81 In terms of maternal health, short women are at greater risk of obstetrics complications.82,83 There is also a strong association between maternal height and birth weight.82,83 There is thus an inter- generational effect, since low birth weight babies are likely to have anthropometric deficit at later age.82-84 For the high rate of wasting in the study communities, the consequences include increased mortality rate.85 Wasting puts children at increased frequency and severity of infections, delay in recovery and thus creates a vicious cycle of worsening illness and deteriorating nutritional status.5 Globally, wasting accounts for 4.7% of all deaths of children under the age of five years.85

Ojiako et al41 in 2009 reported from rural communities in Kano and Kaduna States the overall prevalence of stunting and wasting as 61% and 17% respectively. These figures were lower than those reported in the present study. This may probably be due to the use of the National Centre for Health Statistics reference standard24 by Ojiako et a;l41 which gives lower values compared to the World Health Organization Child Growth Standards33 used in the present study. The higher prevalence of stunting and wasting in the present study may represent an actual increase that occurred over time.

The World Health Organization Child Growth Charts33 are international standards that show how healthy children should grow. The standards describe the growth of children living in six countries; in environments believed to support optimal growth. It uses the growth of breastfed infants as norm for growth.33,86 de Onis et al87 in 2006 conducted a study in Bangladesh,

Dominican Republic, North America and Northern Europe, to compare growth pattern and estimate of malnutrition based on the World Health Organization (WHO) Child Growth

Standards and National Centre for Health Statistics growth reference (NCHS). The researchers reported that, healthy breast fed infants tracked along the WHO Standards weight for age Z-score while appearing to falter on the NCHS references. For all age groups stunting rates were higher according to the WHO Standards. Prevalence of wasting and severe wasting was 1.5 to 2.5 times higher than those of NCHS reference. Similar findings were reported by Julia88 and Kerac et al.89 Odunayo and Oyewole44 from rural communities in Osun State in 2006 reported stunting and wasting as 26.7% and 9.0% respectively. These figures were lower than those reported in the present study and may be due to differences in cultural practices, socio-economic and educational status of the populace in the two States. It was reported that 96.6% of the mother in the Osun study had secondary level of education as against only 2.3% of mothers in rural Kano.

Mothers in rural Osun were economically more empowered as 57.8% and 51.1% of fathers and mothers in Osun State earned more than ten thousand naira a month respectively, whereas in rural Kano State the median incomes of the mothers and fathers were one thousand naira and ten thousand naira per month respectively. The gaps between mothers and fathers incomes were wider in rural Kano State. Furthermore, the researchers used the National Centre for Health

Statistics reference standards40 to obtain Z scores; which give lower results compared to WHO

Reference Standards33 used in the present study. In terms of cultural practices, Yakubu et al90 reported that women in the north-western Nigeria have very low participations in market places and industrial sector. This is in contrast to what is obtainable in other parts of the country.

Anderson et al54 reported from rural Ghana a prevalence of 11.4% and 6.2% for stunting and wasting respectively. These lower figures may be related to the fact that 51.8% of the subjects were exclusively breast fed as against 3.1% of children in rural Kano.

Bisai and Mallick25 in 2009 reported from India the overall prevalence of 49.6% and 22.7% for stunting and wasting respectively. This result was lower than the prevalence obtained in the present study. This disparity may be explained by differences in child feeding practices.

Additionally, the researchers used the National Centre for Health Statistics reference standard40 to obtain Z scores; which gives lower results compared to World Health Organization Reference

Standards used in the present study.33 From the present study, the prevalence of stunting and wasting were significantly higher in rural than urban communities. This could be due to many factors, among which are the significant differences in socio-economic status, parent’s educational status, mothers’ feeding practices, types of marriage and childhood immunization coverage between rural and urban areas. Similar patterns of higher prevalence of stunting and wasting among rural dwellers were also reported by the Nigeria Demographic and Health Surveys (NDHS) 200813 and 2013,14 Abalo 91 and

Kennedy et al.92

Lack of maternal formal education was a significant risk factor for stunting and wasting in rural areas and for stunting in urban communities. It was discovered that, 90.1% and 30.4% of mothers in rural and urban communities respectively did not have formal education. This low literacy in mothers especially in the rural communities may have a negative impact on the children’s nutritional status. Maternal formal education protects against stunting and wasting probably because educated mothers are better aware of the nutritional requirements of their children and provide better health care as a result of their awareness. Moreover, educated mothers are more likely to acquire better jobs, to acquire more resources that enable them take care of their children. They also tend to be better at accessing health care facilities and to interact effectively with the health care providers. This finding was similar to what was reported by

Ojiako et al,41 Adegbusi et al48 and Babatunde et al.37 Several other studies, including the 2013

Nigerian Demographic and Health Survey (NDHS),14 Sufiyan et a,l93 Ajao et al94 and Smith et al43 all reported lack of maternal education as a significant risk factor for stunting.

Lack of father’s formal education was also a significant risk factor for stunting and wasting in both rural and urban communities. From the result of the present study, 80.1% and 42.5% of rural and urban fathers respectively were not formally educated. Lack of formal education in fathers may have a significant negative consequence on the children nutritional status. This was so probably because father’s education has impact on their incomes. The economic status of the fathers will also determine food availability in the home. Lawoyin et al49 from Ibadan made a similar observation on significant association between fathers incomes and nutritional status of their children.

Mother’s low income was not a significant risk factor for stunting and wasting in both rural and urban communities, whereas father’s low income was found to be a significant risk factor for stunting in both rural and urban communities. This was so probably because 99% of the households in both rural and urban communities were headed by men. Husbands are mostly the sole providers to the households in these communities. In addition the women’s earnings were negligible compared to earnings of the men in the present study.

Family’s low social class was identified as a significant risk factor for stunting and wasting in rural communities and for stunting in the urban communities. However, social class of the families in the present study did not have a significant relationship with wasting in the urban communities. One reason may be due to the higher use of locally produced high calorie triple mixture during weaning in urban communities. The triple mixture of soya beans, millet and ground nut is readily available and affordable to all regardless of the social class. However, use of triple mixture was not a common practice in the rural communities probably due to lack of awareness. Socio-economic status of the household may indicate the level of the household food security, ability to afford better health services and better nutritional status of the children. The

Nigerian Demographic and Health survey 2013,14 Odunayo and Oyewole, 44 Amosu et al, 95

Smith et al43 all reported low family’s socio-economic status as a significant risk factor for stunting and wasting. Age group 24 to 35 month was identified as a significant risk factor for stunting and 12 to 23 months as a significant risk factor for wasting. Complementary feeding should commence at six months of age. Wasting and stunting can result when complementary feeds are not calorie dense or feeding frequency is not adequate.14 A significant number of subjects in the present study were weaned on plain millet-based pap which was reported to be low in calorie.96 Marked growth deterioration usually starts during the first year of life and increases with age, peaking in children aged 24 to 35 months.13,14 Another possible explanation to it is, in the second to third year of life with the introduction of family diet, children become more responsible for feeding themselves which may contribute to undernutrition. Ngare and Muttanga.31 reported stunting and wasting to be significantly higher among children within the age group of 24 to 35 and 12 to

23 months respectively. Poor complementary feeding practice was a significant risk factor in the study by Ngare and Muttanga.31

In the present study high birth order (>4) was a significant risk factor for wasting in rural communities but was not so in urban areas. This disparity between rural and urban areas may probably be due to the higher socio-economic status of the urban populace. Urban families may be able to provide for the nutritional needs of their children despite their high number. This implies that higher number of children has more impact on the prevalence of wasting in rural communities; the rural communities would be a better target for family planning interventions.

A possible explanation could be that, intra household availability of food decreases with increasing number of births in the household. Madhavan and Townsend,97 Rahman,98 Shamah-

Levy et al,99 Rubalcava and Contreras100 all reported high birth order (>4) as a significant risk factor for wasting in rural communities. They reported that food availability in a household decreases with increase in the number of children.97-100 Consuming millet-based plain pap during weaning was a significant risk factor for stunting and wasting in rural and urban communities. From the result of this study, 88.7% and 44.1% of the rural and urban children respectively were weaned on millet-based plain pap. This implies that significant numbers of Kano State children especially in the rural communities are weaned on low calories complementary feeds with a significant impact on their growth. Anigo et al96 in

2009 conducted a study on the nutrient composition of the commonly used complementary foods in the northern Nigerian States of Niger, Kaduna and Kebbi. They found from the commonly used millet and Guinea corn pap very low fat (0.08 to 2.62 g/100g), lysine (1.55 to 3.11g/100g protein) and methionine (0.70 to 1.15g/100g protein) contents; providing only 0.2% to 6.8%,

36.9% to 74.0% and 31.8% to 52.3% of the recommended dietary allowances for fat, lysine and methionine respectively.96

Lack of childhood immunization was not a significant risk factor for stunting and wasting in both rural and urban communities. This may be explained by the low immunization coverage in the present study; especially in the rural areas. Similar findings were reported by Rutestin101 from

Ethiopia. Rutestin101 speculated that, since stunting sets in at an early age in Ethiopian children, many children of that study may be stunted before they receive all the recommended vaccines.101

However the researchers failed to mention how early stunting sets in among Ethiopian children.

Being a male child was a significant risk factor for stunting in both rural and urban communities

Boys being more stunted than girls may be explained by gender based differential feeding practices because girls being closer to their mothers have a higher chance to eat any available food. Akor et al,39 Ngare and Muttanga,31 Olack et al32 and Wamani et al53 had similar reports.

The similarity may be related to the probable similar male to female preferential feeding habits among the populace. Some of the socio-economic policies put in place by Kano State government to address poor education and nutrition include: provision of free school meal and uniforms; provision of highly subsidized school transport system for the girl child and school improvement programme.102,103

Conclusions

1. The prevalence of stunting and wasting were significantly higher in rural communities than urban communities. Null hypothesis is rejected and alternate hypothesis is accepted.

2. The prevalence of stunting and wasting in the study communities were higher than the World

Health Organization critical levels, a threshold for implementing feeding programmes.

3. Lack of maternal formal education was an independent predictor of stunting in children in both rural and urban communities.

4. Consumption of plain millet-based pap during weaning was identified as an independent predictor of wasting in rural communities.

5. Age group 12 to 23 months was an independent predictor of wasting in urban communities.

6. Low father’s income was an independent predictor of stunting only in the rural communities.

7. Low social class was an independent predictor of wasting only in the rural communities but not in urban area. Null hypothesis is rejected and alternate hypothesis is accepted only in the rural communities.

Recommendations

1. Government should apply policies that are capable of enforcing formal education for all

girl child in Kano State; with full participations of families and the communities.

2. To reverse this high prevalence of stunting and wasting in the State, government and

non-governmental organizations must initiate measures to uplift families’ socio-economic

status in the State. This may be achieved through vocational training, provision of small

scale trading and strengthening agriculture through credit grants, among others.

3. Health care workers should intensify health education for all mothers, especially the

rural women, on the vital role of fortified complementary feeds during child’s weaning.

These feeds should be based on what is grown locally.

4. Families should provide proper and adequate nutrient for their children within the age

groups 12 to 23 months. This may be achieved by weaning the children using fortified

complementary feeds.

5. Government should introduce under-five children feeding programme.

Limitations

1. Inability to obtain the exact parents monthly incomes.

2. Use of mother’s memory recall in obtaining the child’s age when his/her birth certificate

was not available.

Line of Future Research

1. Study of intra-urban differences in the prevalence of stunting in children aged 6 to 59

months in Kano city, Nigeria.

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32: 1 – 2.

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Saharan African. African Nutrition. Calverton, MD: Macro International Inc. 1996: 27 -37.

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Children in 2012. Available at www.esspin.org/ESSPINex_Aug 11.pdf. (accessed 6th June 2017)

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Nigerian experience with girl’s education and linkages with actions on adult female literacy to impact on poverty alleviation: recent achievement and impact 2005: 1-4.

APPENDIX I

Proforma

SECTION A: BIODATA

Serial number………………………………………………………………………………………………

1. Name ………………………………………………………………………………………………………

2. Age (in month)……………………………………………………………………………………………

3. Date of birth………………………………………………………………………………………………

4. Gender male [ ] female [ ]

5. Ethnicity Hausa [ ] Fulani [ ] Yoruba [ ] Igbo [ ] others…………………

6. Address …………………………………………………………………………………………….

7. Religion of the parents: Islam [ ] Christianity [ ] Traditional [ ] others……………………

SECTION B: ELIGIBILITY

8. Any chronic ill health: sickle cell anemia [ ] tuberculosis [ ] HIV infection [ ] congenital heart disease [ ] malignancy [ ] Asthma [ ] others………………………………………………

9. Is the child on any chronic medication: steroid [ ] others …………………………………………

10. Have parent/care giver signed consent: yes [ ] No [ ]

SECTION C: SOCIO-DEMOGRAPHIC INFORMATIONS.

11. House/apartment ownership: rented [ ] owned [ ]

12. Head of the household: male [ ] female [ ]

13. Age of the household head in years ………………………………………………………………

14. Type of marriage: monogamous [ ] polygamous [ ]

15. Number of children in the household………………………………………………………………………

16. Number of under five children in the household……………………………………………………………

17. Child’s birth order………………………………………………………………………..

18. Is the child in school: yes [ ] No [ ]

19. Who is the child’s care giver: mother [ ] step mother [ ] grandmother [ ] others

(specify)……………………………………………………………

20. Mother’s position: 1st wife [ ] 2nd wife [ ] 3rd wife [ ] 4th wife [ ]

21. Age of the child’s mother…………………………………………………………………………………………

22. Mother’s educational level: none [ ] Qur’an [ ] primary [ ] secondary [ ] GCE [ ]

Tertiary - Degree [ ] HND [ ] NCE [ ] Diploma [ ]

23. Mother’s occupation: unemployed [ ] trader [ ] petty trader [ ] civil servant [ ] IF YES, type of work………………………… others (specify) ………………………….. 24. Mother’s income per month ……………………………………………………………………………

25. Father’s educational level: none [ ] Qur’an [ ] primary [ ] secondary [ ] GCE [ ]

Tertiary - Degree [ ] HND [ ] NCE [ ] Diploma [ ]

26. Father’s occupation: unemployed [ ] peasant farmer [ ] petty trader [ ] trader [ ] civil servant [ ], if yes, type of work …………………………………….Menial job [ ] others………………………

27. Father’s income per month………………………………………………………………………

28. Source of drinking water: stream [ ] well [ ] bore hole [ ] pipe borne [ ] water vendor [ ]

29. Sewage disposal system: bush [ ] pit latrine [ ] water closet system [ ]

30. Food commonly eaten by the child during breakfast: tea and bread with egg [ ] Kose and pap [ ] left over [ ] others…………………………………………………………………

31. Food commonly eaten by the child during lunch: rice [ ] rice/beans [ ] noodles [ ] tuwo [ ]

Fura [ ] others……………………………………

32. Food commonly eaten by the child during dinner: tuwo [ ] rice [ ] rice/beans [ ] noodles [ ] Fura [ ] others……………………………………………………

33. Meat consumption per day: none [ ] 1- 2 times [ ] 3-4 times [ ] 5 – 6 times [ ] > 6 times, specify…………………………………………

34. Frequency of snacks per day: 1 [ ] 2 [ ] 3 [ ] 4 [ ] >4 [ ]

35. Illness in the last one month: a. fever; yes [ ] No [ ] if yes, duration…………… treatment given…………….. b. Diarrhoea; yes [ ] No [ ] if yes, duration………………… episodes per day ……………… treatment given…………………………………………………………………………………….. c. Cough Yes [ ] No [ ] if yes, duration ………………. Treatment given………………………… d. Others (specify with duration and treatment)……………………………………………………………

36. Presence of electricity in the household: Yes [ ] No [ ]

SECTION D: REPRODUCTIVE HEALTH

37. Are you aware of child spacing: Yes [ ] No [ ]

38. If yes, which one do you use: Natural [ ] pills [ ] injection [ ] IUCD [ ] None [ ] other..

39. Average interval between pregnancies in months………………………………………………………………

40. Where was the child delivered: home [ ] hospital [ ] church [ ] others……………………

41. When was breastfeeding commenced: immediately [ ] after 1 day [ ] after 2 days [ ] after 3 days [ ]

42. Was he/she exclusively breastfed: Yes [ ] No [ ].

43. Was he /she immunized: Yes [ ] No [ ] incomplete [ ] how many doses……………………..

44. When did you introduce other foods other than milk [in months] ……………………………..

45. Weaning diet……………………………………………………………………………………………………….. 46. Are you still breastfeeding: yes [ ] No [ ]. If No, When did you stop……………………………

SECTION E: ANTHROPOMETRY

47. Weight (Kg)……………………………………………………………………………………………………………

48. Height / Length (Cm)………………………………………………………………………………………………

49. Mid Arm Circumference (cm)…………………………………………………………………………………….

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APPENDIX V CONSENT

Information sheet

I am Dr Yunusa Sanusi, a resident doctor with Department of Pediatrics, Aminu Kano Teaching Hospital, Kano. I am conducting a study on stunting and wasting in children aged 6 to 59 months in Kano state.

The purpose of the research:

The general aim of the study is to determine the prevalence and risk factors for stunting and wasting in children aged 6 to 59 months in rural and urban communities in Kano state. This is because; the two conditions are very common in this environment.

What will happen in this study?

Your child has been selected to participate because he is under the age of five. His participation is voluntary and only with your permission. If you agree to participation of your ward, you will be asked some questions about the factors associated with stunting and wasting as well as some of your family details. In addition to that, your child’s weight, height/length and mid arm circumference will be measured.

Benefit for your child and the family:

By participating in this study you will know the nutritional status of your child as you will be informed about it via the telephone. The family will also benefit from nutritional counseling.

Benefits for the community:

Information gathered can serve as basis for any form of nutritional intervention by the government or nongovernmental organizations.

Risks for your child and data privacy:

There is no risk of harm to your child in this study, only a possible discomfort in the process of body measurements and data collected will be kept confidential.

Voluntary withdrawal:

You may decline participation of your child now or later.

Consent form

- My child has been selected to take part in this study on stunting and wasting. - I have read the foregoing information or have been read to me. - I understand the information I have received. - I have had the opportunity to ask questions about it and my questions have been answered to my satisfaction. - I understand the benefits and possible discomfort of the study. - I consented voluntarily to have my child be a participant in this study.

Name of the child …………………………………………………………………………..

Name of the parent/guardian …………………………………………………………

Signature of the parent/ guardian ……………………………………………………

Phone number of the parent/guardian………………………………………………….

Date ……………………………………………………………………………………………

If not able to sign

Affix thumb impression of the parent/ guardian.

Signature of researcher with date………………………………………………

Hausa translation of the information sheet.

Suna na Dakta Yunusa Sanusi, likitan yara a asibitin koyarwa na malam Aminu Kano. Muna gunadar da bincike ne akan yaran Jihar Kano yan tsakanin wata shida zuwa wata hansin da tara a birni da karkara. Makasudi shine don mu gano adadin yaran da dauyin su da kuma tsayin ya gaza yadda ake bukata.

Yadda abun zai kasance:

Da yardarki/ka ne za’a yi maki/ka yan tambayoyi game da zamantakewar iyalin ka/ki. Sannan kuma za’a auna tsayi da kuma dauyin dan/yar ka/ki. Sannan kuma za’a auna kaurin hannu da kuma fadin kan yaron.

Alfanu ga yaron da mahaifan sa.

Iyayen za su san yadda halin lafiyar yaron ta ke.

Alfanu ga dukkan al’umar garin:

Dukkan bayan da aka tattara zai iya kasancewa tushen samar da wani taimako ga dukkan al’umar wannan yankin.

Yiwuwar wata illa ga yaro/sirri.

Babu wata illa ga yaro a game da binciken. Kuma dukkan bayanan za su kasance cikin sirri.

Yiwuwar janyewa daga wannan bincike. Kana/kina iya janye danka da ga cikin wannan bincike.

Hausa translation of the consent form

An zabi yata/dana don shiga wannan bincike.

Na karanta ko an karanta mini bayanin daya gabata.

Na fahimci dukkan bayanan da suka gabata.

An ba ni damar yin tambaya

Na fahimci alfanun da za’a iya samu game da wannan bincike.

Na bada izini dana/yata ya/ta kasance cikin wannan bincike.

Sunan yaron/yarinya………………………………………………………………….

Sunan mahaifi/mahaifiya………………………………………………………………

Sa hannun mahaifi……………………………………………………………………………

Lambar wayar mahaifi/mhaifiya…………………………………………….

Kwanan wata……………………………………………………………………………….

KO Dangwale……………………………………………………………..

Sa hannun mai bincike………………………………………………………………..

APPENDIX VI - National Postgraduate Medical College of Nigeria approval 

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45 50 55 60 65 70 7

100aa 

75 APPENDIX X: socio-economic classification scheme by Oyedeji. For Occupation Class Occupation I Senior Public Servants, Professionals, Managers, large scale traders, businessmen and contractors. II Intermediate grade public servants and senior school teachers. III Junior school teachers, professional drivers, artisans IV Petty traders, laborers, messengers V Unemployed, full-time housewife, students and Subsistence farmers. For Education Class Education I University graduates or equivalents II School certificate holders ordinary level (GCE) who also had teaching or other professional training. III School certificate or grade II teachers certificate holders or equivalents. IV Modern three and primary six certificate holders. V Those who could either just reads and write or were illiterate.

Note: The mean of four scores (two for the father and two for the mother) approximated to the nearest whole number was the social class assigned to the child. For example, if the mother was a junior school teacher, (score = 3) and the father a senior school teacher (score = 2) and the educational attainment of the mother was primary six (score = 4) and the father was a school certificate holder (score = 2), the socio-economic index score for this child was: (3+2+4+2)÷4 = 11÷4 = 2.75 (To the nearest whole number = 3).