PREVALENCE AND ASSOCIATED FACTORS OF UNDERNUTRITION AMONG UNDER-FIVE CHILDREN OF BHARATPUR MUNICIPALITY OF CHITWAN DISTRICT , NEPAL

Methodology A cross sec onal study was conducted in Bharatpur municipality of Chitwan district. Anthropometric measurement of children and informa on regarding nutri on along with different exposures were taken from 402 randomly sampled mothers. WHO criteria was used to compare with the calculated Z-score using Anthro V3.2.2 so ware. Informed consent was taken from concerned authority. Descrip ve sta s cs were calculated and binary logis c regressions was used to determine the influence of selected variables for underweight.


Objec ve
The objec ve of the study was to assess the prevalence and associated factors of under-nutri on among under-five children of Bharatpur municipality of Chitwan district of central Nepal.

Methodology
A cross sec onal study was conducted in Bharatpur municipality of Chitwan district.Anthropometric measurement of children and informa on regarding nutri on along with different exposures were taken from 402 randomly sampled mothers.WHO criteria was used to compare with the calculated Z-score using Anthro V3.2.2 so ware.Informed consent was taken from concerned authority.Descrip ve sta s cs were calculated and binary logis c regressions was used to determine the influence of selected variables for underweight.

Results
Majority of the respondents were from rela vely advantaged groups and house makers.Almost 54% of the children were boys and the greatest share of children was of age group 25-36 months.Almost one in 10 children of Bharatpur had lower weight-for-height score (wasted).Likewise, more than one quarter (26.4%) were stunted and another 13.4% were under-weight.Families with less than four family members were less likely to have under-weight children and those who had more than two children had more chance of having under-weight children (P=0.002).Children having diarrheal episodes within 2 weeks period of study had higher odds of being malnourished.

Conclusion
The study shows that female children have higher risks of being malnourished.Higher prevalence of underweight was seen with the increasing age of children.The size of family also ma ers the nutri on status of children.It is recommended that Ministry of Health needs to have more a en on for the necessary interven on addressing the combined exposures factors for underweight.

INTRODUCTION
Nutri onal status of children is very important as it determines their health, physical growth and development of children including academic performance and progress in life.All children have the right to acquire adequate nutri on, which is essen al for a ainment of the highest standard of health.¹Moreover, a good nutri on has been reported to be the corner stone for survival, health and development in the current and succeeding genera ons.²Unfortunately, the crucial period of life childhood is o en burdened with protein-energy and micronutrient inadequacies that lead to lagging op mal growth and development.³Deficiency of micro or macronutrients may ini ate the episode of malnutri on.Malnutri on may present in different forms ranging from acute deficiencies to grave and long las ng chronic condi ons.The most widely prevailing forms of malnutri on are protein-energy malnutri on (PEM) and micronutrient deficiencies.PEM comprise of stun ng, under-weight and was ng.The major burden of malnutri on has been concentrated in specific groups such as children and women, which pose great threat to socio-economic situa on of families and the na on.⁴Malnutri on during childhood is correlated to under development of children's intellect and causes learning impairment.The effects of malnutri on on human performance, health and survival have been the subject of extensive research for several decades and studies show that malnutri on affects physical growth, morbidity, mortality, cogni ve development, reproduc on, and physical work capacity.⁵Malnutri on is an underlying factor in many diseases in children, and it contributes greatly to the disability-adjusted life years worldwide.⁶Several indicators of Millennium Development Goals (MDGs) are directed towards nutri on directly or in an indirect path.It has been well accepted that improvement in nutri onal status 4 of children and women can help achieve many of the MDGs.
Currently, around 925 million people worldwide suffer from long term hunger i.e. they have no access to enough nutri ous food for a healthy life; the worst is being those living in under developed countries.Among children in developing countries, malnutri on is an important factor contribu ng to illness and death.Malnutri on during childhood can also affect growth poten al and the risk of morbidity and mortality in later years of life.Malnutri on among children is rampant among the South Asian Countries.About half of all children deaths are associated with malnutri on of which three quarters are liked to mild , and moderate forms.⁷⁸ In 2005, in all developing countries 32% of children under 5 years of age (178 million children) were es mated to be stunted.In that year, more than 40% of stun ng was found in regions of Africa and South-East Asia.The global es mate of was ng occurring among children less than 5 years of age based on WHO new standard is 10% (or 55 million).The highest numbers of affected children, 29 million are es mated to live in South-9 Central Asia.In 2007, an es mated 26% of children underfive years of age in developing countries were under weight, out of 112 million children.Under-weight is most common in regions of Asia (48%), followed by Sub-Saharan 7 Africa (28%).There is wide varia on in the state of malnutri on throughout Nepal.Stun ng (41%) is more common in mountain areas than in the Terai, but underweight (29%) and was ng (11%) are more common in the 3 Terai than in the mountain areas.
Malnutri on has been widely accepted as a serious threat to child survival and overall physical and mental development.The worst hit areas of the problem are the developing countries.The most common forms of malnutri on i.e.PEM and micronutrient deficiencies are widely prevalent in Nepal.PEM is considered a major public health problem in Nepal which is considered to be the outcome of several factors such as household food insecurity, poor nutri onal intake, frequent a acks of infec ous diseases and sanita on related factors.Several studies conducted in Nepal have found out different risk factors associated with child under nutri on.A great varia on is observed among children on the basis of their residence and topography.Malnutri on places the child to greater risk of dying from common childhood illness as 7 compared to those adequately nourished.Various risk factors are considered to be responsible for the nutri on status of children.Maternal factors such as educa on and occupa on have shown associa on with status of child nutri on.Service access and u liza on on the other hand are crucial determinants for child nutri on.Stun ng is a chronic condi on with mostly irreversible effects that usually occurs before the child reaches the age of two years.The effects include decreased development of mental abili es including learning problem and delayed motor development.Was ng on the other hand is an acute condi on resultant of no ceable weight loss due to an 10 infec on or inadequate dietary intake.Some factors iden fied by a very few or nominal studies have been conducted to address the real scenario of urban area undernutri on.Bharatpur municipality is in the process of rapid urbaniza on.Thus, this study aimed to assess the prevalence and different associated factors with under-nutri on among under-five children of Bharatpur municipality of Chitwan district of central Nepal.

METHODOLOGY
This is a cross-sec onal study carried out at Bharatpur municipality of Chitwan district.Bharatpur municipality, a headquarter of Chitwan district, is situated in the western 2 part of Narayani Zone, Nepal.It covers an area of 2,218 Km and consisted of a popula on of 579,984.Bharatpur municipality consists of 14 wards.The municipality is resided by heterogeneous group of people with mul ethnici es.The target popula on of the study was underfive children of the Bharatpur municipality.A sample size of 420 was derived on the basis of prevalence of stun ng under-five children being 49%, allowable error 5% of Regarding the sampling technique, each ward of the municipality was considered a stratum.List of the household with study popula on was obtained from municipality.Stra fied simple random sampling technique with equal alloca on method was applied.From each ward 30 children under-five years were selected randomly.With help of Village Health Workers (VHW), children under-five years were iden fied.Out of 420 samples, six respondents refused to take part in the study and 12 houses found closed even in second a empts.Semi structure ques onnaire was used to interview the mothers and observa ons were done to measure weight, height and MUAC (Mid Upper Arm Circumference) of children using weighing machine and measuring tape.

Data processing and analysis:
Data was entered into Microso Office Excel 2007 and analysis was done in Sta s cal Package for Social Science (17.0).Anthropometric data were transferred to "Anthro V3.2.2" program for further analysis.Socio-demographic informa on of mother and child were categorized and anthropometric variables of child were recorded.Anthropometric variables were further processed and categorized based on CDC/WHO (1978) classifica on.
Under-weight, stun ng and was ng were categorized using informa on regarding weight-for-age, height-forage, weight-for-height as per need during analysis.Severe and moderate stun ng, under-weight and was ng were mainly categorized as undernourished: if z-score was less than -2 SD and not undernourished: if z-score was more than -2 SD.Similarly, under-weight and normal were categorized with cut of value of 2 SD z-score.Chi-square test was used for bivariate analysis.Binary logis c regression analysis for under-weight was applied using enter method approach to find out adjusted significant predictors.Probability of significance was determined at 5% level.

Validity and reliability:
The weighing machine was calibrated before measuring weight of each respondent.Every anthropometric measurement of the child was measured twice and ensured the correct measurements, reading and recordings.Cross-ques ons were asked to each mother to verify the responses and enough me was provided to remember to minimize recall bias especially for the memories based informa on.Ques onnaire was translated into Nepali language and checked by an expert.The original and new versions of ques onnaire were compared for exactness and necessary modifica on was done.Pre-tes ng was done in similar community and validity of the tools in its contents and accuracy of informa on was ensured.The filled ques onnaires were checked in end of each day.The data was entered into computer and every 20 entry crosscheck was done.
Ethical clearance was obtained from concerned authority of college.Consent was taken with the par cipants before interview and objec ves of the study were clarified.Par cipants were assured that the informa on they provide would maintain privacy and confiden ally.

Opera onal defini on: Acute Respiratory Infec on (ARI):
This includes cough, cold, chest pain with and without fever.The episode was taken for the period of two weeks preceding the study.

Minimum dietary diversity:
It includes seven groups of food such as 1) grains, root, and tubers 2) legumes and nuts 3) dairy products 4) meet and meet products 5) eggs 6) vitamin A rich fruits and vegetables 7) other fruits and vegetables.The cutoff of at least four of the above seven food groups was selected.
Exclusive breast-feeding: Breast-feeding prac ce in which infant or child only received breast milk from mother without any addi onal food or drink.It allows oral rehydra on solu on, drops and syrups.It did not include children who receive pre-lacteal.
Complementary feeding: It is the introduc on of addi onal food to children other than breast milk in 180 days of childbirth.

Childhood diseases: It included diarrhoeal disease and ARI.
Immuniza on status: It was categorized as completed and not completed.Those children who received measles vaccine were considered to have completed immuniza on.
Economic status: It is based on Kuppuswamy's Socioeconomic Status scale, a composite indicator on the basis of educa on, monthly average income and occupa on.

Nutri onal status:
It is considered based on the prevalence of stun ng, under-weight and was ng by using anthropometric measurements.Grada on of malnutri on was categorized by Z-value of reference median popula on as outlined by the World Health Organiza on (WHO) using its so ware "Anthro" (V3.2.2).
Was ng: Anthropometric index weight-for-height reflects the body weight of a child rela ve to his/her height.Was ng refers to low weight-for-age at <-2 SD of the median value of the WHO reference.
Under weight: Anthropometric index for weight-for-age, which represents the body mass in rela ve to the age of the children.Under-weight refers to a deficit and is defined as low weight-for-age at <-2SD.

Stun ng:
Stun ng or shortness in height refers to low height-for-age that may reflect either normal varia on in growth or a deficit in growth.It is defined as low height-forage at <-2 SD of the median reference value.

RESULTS
The socio-demographic characteris cs of study par cipants were given in table 1.More than half of the respondents were Brahmin and Chhetri (57.2%), followed by Janaja (28%) and Dalit (14%).Majority (89.6%) of them were Hindu.Maximum (80.6%) of the children were living in the family with two or less children.More than 42% of the children were living in nuclear family.Almost two third of the under-five children were living in family size of 1-4.More than 61% of the children live in family having no land for farming.Moreover, among those who had their own land, 24% of the family had agricultural product enough for only six month.According to modified Kuppuswamy's socioeconomic status, more than half of the par cipants were at upper middle class.

*Modified Kuppuswamy's socioeconomic status scale
Table 2 shows the maternal characteris cs of study par cipants.Majority (80.7%) were currently living together.Only 35.8% of the under-five children were reared by the mother with academic a ainment of higher secondary level.Majority (90.3%) of the under-five children were born when their mothers were of age 20 to 35 years while 6.7% born when their mothers were in teen age.Few mothers (4.5%) smoked during pregnancy and 4% were con nuing smoking.were weaned at the age of 7 or more than 7 months.Study revealed that majority of the children's diet of last 24 hours consist of grain roots/tubes and legumes nut (96.6% and 95.2%) respec vely (Table 4).

Table 4: Feeding prac ces of study par cipants (n=402) Table 5: factors associated with under-weight among under-five children (n=402)
Pokhrel AU et al

DISCUSSION
Nutri on is backbone of health of individual of any na on.However, nutri on problem may be with the whole popula on, children and women are the most at risk group from malnutri on.Appropriate and adequate nutri on is an important prerequisite for the normal development of a child.In this study, nutri onal status of children was assessed based on three different indicators like stun ng, was ng and under-weight.Age and anthropometric values such as height and weight of the study children were obtained and evaluated on the basis of the standard WHO Z-score.The cut off point for iden fica on of malnourished children was minus two standard devia on (-2SD).In this study, highest propor on of children were of age group 25-36 months (28.1%) followed by 13-24 months (25.6%) and 0-12 months (23.9%Bardiya more than 16% of children were wasted. The prevalence rate of was ng is more in the study area than the na onal data for urban areas (8.2%) but it is less than the ecological region (11.2%) and development region (11.6%)where the study area is located.More than 11% of boy were wasted compared to 8% of girls which is similar to na onal figure of 12% and 9.7% for boys and girls Inconsistent on was between educa onal status of mother and ng.The comparison of the same variables had a posi ve effec ve on was ng.With an increase of educa onal er of mother, the prevalence rate 3 declined.Significant associa on was observed with the age group of the children, compared to of age one year of less, the children aged 13-35 months were at 6 mes more risk of being wasted with P<0.05 which is in line with the study at Dhankuta.Other factors those were found to be significantly associated with was ng in na onal and 15 interna onal studies were not significant in this study.
More than 13% of under-five children of Bharatpur were under-weight compared to the na onal prevalence of 28.8%.The prevalence of under-weight seems to be almost similar for male and female child; the findings are consistent with na onal figure.Comparison based on geographic, ecological and poli cal area bases put the study area in 3 stronger posi on with lower prevalence of under-weight.
Finding are less than the study conducted in mid-western terai were 1 in 5, in Tanahun 27.1% and in Dhankuta 27.3% of [14][15][16] the under-five children were under-weight.
In this study families with less than 4 family members and 2 or less children were protec ve for under-weight and were sta s cally significant at 95% CI (P=0.008 and 0.002 respec vely).Children from joint or extended families had 2 mes higher odds of being under-weight.The probability of being under-weight was lowered with the increase in age which is consistent with the finding of Dhankuta.Mothers who smoked during their pregnancies had slightly higher chances of their child being under-weighted like finding of 15 the study of Dhankuta.Children who had diarrheal episode (s) within 2 weeks period preceding the study were 2 mes at more risk of being under-weight.Diarrhea was an associated characteris c as per the finding of the study from 14 Banke.Similar extents of odds were obtained in the study 15 of Dhankuta as well.
Inconsistent results were obtained for the effects of socioeconomic status and educa onal status of mother for low weight-for-age.Several studies have shown the associa on between these variables.The study has found that the labor/service or business as occupa on of mother was protec ve factor for under-weight.Occupa on of the mother dichotomized as paid and unpaid had a significant 14 associa on with under-weight of the children.
More than a quarter (26.4%) of under-five children of Bharatpur was found stunted in this study.The finding is too less than the na onal prevalence of stun ng as pre NDHS 2011 is 40.5% but it is almost same as the prevalence of the 3 problem for urban areas (26.7%).The prevalence of stun ng found by similar studies in different parts of country [14][15][16] were 18.6% at Banke, 36.7% at Dhankuta, 45.7% at Tanahu.

CONCLUSION
Female child were found more vulnerable for malnutri on as compared to their male counterparts.Higher prevalence of underweight was seen following the increasing age of children.The size of family also ma ers the nutri on status Binary logis c regression with enter strategy was used to find out associa on of under-weight with other independent variables.Few variables were merged for the convenience and applicability of the tests.Table 5 illustrates ethnicity has no significant associa on with under-weight of children.Children from joint or extended families were 2 mes more likely to be under-weight as compare to the Nuclear family (OR=2.4,95% CI=0.98-5.88).Size of family members was sta s cally significant with weight of the children (P=0.008,OR=0.3, 95% CI=0.12-0.73);families with less than 4 family members were at less risk against underweight in comparison to 5 or more family size.Similarly, families with two or less children had less chance of having under-weight children (P=0.002,OR=0.32, 95% CI= 0.16-0.66).Children from middle economic classes had be er status of weight-for-age as compared to their counter part from upper or lower economic classes.Under-weight seemed to have increased odds with the increase in educa onal status of the mother.Age of mother between 20-35 years was found protec ve against under-nutri on of their children.Mother who smoked during pregnancy had seven percent higher chance of having under-weight babies.Sex was not a significant predictor of under-weight.Birat Journal of Health Sciences of children.Children with episodes of diarrheal diseases had higher odds of having underweight.The overall findings of the study showed that there is an increased risk of under-nutri on among infants in comparison to more than one year old.This may be due to a combina on of different interac on such as feeding prac ces and trends.Targe ng mothers and educa ng them about health weaning prac ces may help to reduce the problem.

RECOMMENDATIONS
Malnutri on being an outcome of the various factors interplaying together requires a holis c for approach.such as nutri on intake, health issues, mother's nutri onal status and environmental sanita on are few among the key players.Common childhood diseases control programs par cularly CDD (Control of Diarrheal Disease) should take into account the nutri onal aspect of the children in that period.Extra a en on need to be taken to incorporate nutri on educa on in growth monitoring clinics from where mothers can get appropriate knowledge about their child's nutri onal status and approaches by the Ministry of Health.

LIMITATION OF THE STUDY
The study claims the result of nutri onal status assessed by was ng, under-weight and stun ng only on the basis of anthropometric measurements.Only selected factors in rela on to child nutri on were included in the analysis.This study presents all forms of malnutri on which are the result of interplay of different factors and these factors most o en do not occur in isola on.The occurrence of one may influence the occurrence of other.The under-weight of children is due the exposure of mul ple factors.

3
respec vely.It coincides with the trend obtained in a study carried out in a hill district of eastern Nepal.Sta s cal significant associa ons observed with sex of child 15 and risk of being (P=0.04).

Table 3 : Child characteris cs of the study par cipants (n=402)Table 2 : Maternal characteris cs of the study par cipants (n=402)
demonstrates malnutri on status of under-five children.Out of the total 402 children, almost one in ten (9.7%) were wasted i.e. weight-for-height Z-score than 2 standard devia on.Likewise, more than one quarter (26.4%) were stunted and another 13.4% were underweight.The Z-score weight-for-height in on to age of child lies below zero for the age group 36-47 months.Alike weight-for-height, the average Z-score for height-for-age is below zero expect for the age group 0-6 months.Unlike these two variables, no age group has an average Z-score value more than zero for weight-for age.
Only 6.2% of the study children were exclusively breast feed.However, ideal age of weaning is 5-6 months, 8% of children Pokhrel AU et al ISSN: 2542-2758 (Print) 2542-2804 (Online) Birat Journal of Health SciencesFigure 1 ).The mean age of children was 25.95 months with SD of 15.32.Male female ra o was 1.15:1.0.The study somehow shows varied data as compared to other na onal or small scale researches conducted.Almost 1 in 10 children in the study area were