Malnutrition Status in Kenyan Children Living in Slums - Assignment Example

?Research question: How do food purchase frequencies and preparation methods affect malnutrition status in Kenyan children living in slums? Introduction Malnutrition is a serious medical condition depriving Africa and other developing countries of its future generation. This medical condition is characterized by inadequacies in energy, proteins, vitamins, minerals and essential fats in the body (Olack, 2011). The overall global mortality rate in children under five years stands at 10 million cases annually according to Black, Morris, and Bryce (2003). Malnutrition accounts for about 30% of this mortality and is still a major public health concern in Sub-Saharan Africa (Stephenson, Latham & Ottesen, 2000). Malnutrition is characteristically associated with stunting, wasting and underweight. According to United Nations report on the world nutrition status (2004), close to 50 % and 30% of school going children in East Africa are stunted and underweight respectively. This wide spread stunting and wasting in these children directly affect their cognitive development and hence their future productivity in life (Pelletier, Frongillo, & Habicht, 1993). Other direct effects of malnutrition include severe ill health and high mortality in children and chronically ill adults (WHO, World Health Report 2002). Cases of malnutrition in Kenya have been worsened by the high HIV prevalence as well as recent political instability in the region. HIV infection has impaired economic productivity among single parent families, which are the majority (Mittal, Singh, & Ahluwalia, 2007). Political instability, on the other hand, has resulted in insecurity and thus food insecurity due to an unstable economy. Kenya and many African countries have experienced an exponential growth in urbanization without an equivalent infrastructural development. This, rapid urbanization (caused by rural urban migration), has led to an increase in informal settlements, in cities and towns. A significant proportion of Kenyan’s urban population lives in these settlements (also called slums), which are characterized by poor living conditions (Mugisha, 2006). This massive relocation of people to town has diminished the once urban advantage of good health and admirable lifestyle. The reason being overcrowding in urban centres leading to health challenges similar to those seen in rural settlements (Olack, 2011). Extreme poverty has also been associated with slum dwellers since the majority of them cannot secure decent jobs because of poor or lack of education. Kibera is the largest city slums located on the North West suburbs of Kenyan’s capital Nairobi, and it is also the largest in Africa according to African Population and Health Research Centre (2002). Recently Kibera has become a key focus in health care intervention programmes as well as health research. One of the current active programmes includes infectious disease surveillance conducted by the Kenya Medical Research Institute in partnership with the America’s Centres for Disease Control (Olack, 2011). Despite the challenges aforementioned, Nairobi’s city slum Kibera is rich agricultural and local produce trade, and the cost of this food is fairly affordable. This study seeks to investigate the impact of frequency of food purchase, preparation habits and cultural beliefs on malnutrition. Literature review Despite the many studies and health intervention programmes, close to 195 million children under the age of five are across the globe are malnourished (Black, Allen, Bhutta, Caulfield, de Onis, & Ezzati et al 2008). Sub-Saharan Africa and South Asia account for more than 90% of this disease burden globally (Black et al, 2009). Many of these cases occur in urban informal settlements such as Kibera and other city slums across the continent. Despite poor living conditions, many of the slum dwellers are traders of local agricultural produce while others have well paying jobs in the city. Scientific studies have reported a strong correlation between malnutrition status and socioeconomic position in the community. In these studies, severe malnutrition cases are more likely to occur in poor than well-off families (Salah, Maria, & Theodore, 2006). Whilst this association is prominent, it is interesting to note that about 1 in 5 slum dwellers are food secure and afford admirable lifestyle. This category of slum dweller account for about half of the slum population (Faye, Baschieri, Falkingham, & Muindi, 2011). Many households in Kibera have access to indigenous nutritious food since they are involved in the actual trade of these commodities. Although these foods are available cases of malnutrition are still high, and contributing factors need to be investigated. According to Abuya et al. (2012) mother’s education level is a strong predictor of malnutrition in children, and uneducated mothers tend to have malnourished babies. The positive association between education level and good health could be attributed to by improved economic status of the mother as well proper adherence of healthcare requirements argues Glewwe (1999). Education level is also associated with proper dietary methods including a balanced diet and ability to seek proper healthcare (Glewwe, 1999). To date there are no studies that have investigated food purchase frequency and preparation habits (methods) in association with malnutrition. There are also no studies that have reported on the influence of cultural beliefs on foods purchase and consumption habits among malnourished children. It is this gap that this study seeks to fill and contribute to the general knowledge of understanding and fighting malnutrition in Kenyan children living in urban slums. Research question How do food purchase frequencies and preparation methods affect malnutrition status in Kenyan children living in slums? Research Aim To explore food purchase frequencies, household food preparation habits and cultural beliefs associated with certain foods in malnourished and healthy children living in Kibera slum in Kenya. Aims and Objectives To determine the influence of food purchase frequencies on malnutrition outcome in young children living in Kibera. To determine the effect of household food preparation methods on nutritional status of young children living in Kibera To determine influence cultural beliefs (if any) on food purchase and consumption habits in malnourished young children living in Kibera Research design In this study, a cross-sectional design with a mixed method approach will be used, and both qualitative and quantitative data will be collected (Brannen, 1992). The mixed method approach is suitable because the quantitative data will be useful in analyzing associations and correlations between dependent and independent variable while the qualitative data will enhance the interpretation of these associations (Creswell, 2003). The qualitative analysis will include cultural beliefs and perspectives (among the different tribes) on food purchases, preparation and consumption and how they may affect nutritional status outcomes. This information will provide strong evidence that will support the findings of the quantitative analysis (Bryman, 2006) A pilot study will be conducted on one of the villages and a structured questionnaire used to collect data after piloting. One on one interview will be the main data collection tool and interviewers will record the responses from the discussions. The questionnaire set will comprise of demographics, frequencies of food purchase, food preparation methods, Anthropometry, and cultural beliefs on food. The quantitative questions will be close ended while the qualitative questions will be open-ended. All responses will be number coded for easy data entry, management and analysis. To determine a child's nutrition status, anthropometric measurements will be taken on all eligible children (less than 5years) using standardized techniques. In this study, only the common foods will be included for frequency and preparation habits analysis. These foods will be grouped into the following food categories; cereals, legumes, vegetables, meat, dairy, fruits, root and tubers. The frequency of purchase will include; daily, weekly monthly, yearly, and “other” frequencies while preparation habits will comprise; raw, boiling, roasting, and deep frying and steaming. Anthropometry measurements will include weight, height and the mid upper arm circumference (MUAC). For qualitative data collection, households with identified malnourished children will be selected for interviews to be conducted by assistant research officers. The questions will explore in-depth perceptions and social-cultural beliefs that promote or discourage consumption of certain foods. The questions will be translated into the local language and tribe of the participating households. This, aims is to increase the confidence of the participants and enhance the discussion, the data collected. Sampling Two villages in Kibera will be selected to represent the study area. These villages are Soweto and Gatwikira, and their selection is based on ongoing scientific work. The two villages are currently under infectious disease surveillance by KEMRI/CDC (Feikin, Audi, Olack, Bigogo, Polyak & Burke, et al, 2010), making study easily manageable in these areas. The Kenya Demographic and Health Survey 2008-2009 (Kenya National bureau of statistics 2011) will be used to identify households with children less than five years of age, which will then be randomly selected for the study. The sample size will be 400 households based on total Kibera population of 170,070 (APHRC; 2002) and a confidence level and interval of 95% and 5. Each household will have up to a maximum of three visits with a call back option where possible. The study participants will be children less than 5 years of age and the questions will be administered to the child’s parent or guardian. Anthropometric measurements will be done on only eligible study children; and, if, a household has more than one eligible child, then the younger one will be selected for the study. For the qualitative analysis, a target of between 80 to100 eligible households will be selected after the quantitative survey. Data collection techniques. Study questionnaire will be translated into the local language (Swahili), and a verbal mother tongue translation will be provided by the interviewer if necessary. The questionnaire will be self administered by research assistants who will record the responses using pre-coded responses. Filled in questionnaires will be edited by trained editors to detect incompleteness or missing data in the forms. The anthropometric measurements will be taken by trained and qualified nurses using standard equipment. Each value will be measured in duplicate and the average of the two measurements will be used in the analysis. Weight and height will be measured using portable weighing scales and height boards that will be calibrated on daily bases using known heights. A standard MUAC tape will be employed for the Mid Upper Arm Circumference. Data analysis The anthropometric measurements will be converted into indices using WHO standards and classified into Z-scores units. The indicators of malnutrition will include wasting (calculated as weight for height), stunting (calculated as height for age) and underweight (calculated as weight for height). The WHO (2006) cut-off values for these indices will be applied. The rest of the analysis will be done using SAS software and the chi-square test will be used to determine the level of significance of nutrition status and the other independent variables of interest. For instance, weekly purchase (consumption) of legumes and the likely hood of being underweight. Ethical issues The study will seek ethical approval from the Kenya Medical Research Institute (KEMRI) Ethical review Board. The study will also incorporate Household head informed consent (for the home visits) and study participant informed consent (for voluntary participation in the study) parents and guardians will represent their minors in consenting for the study. Appropriate language translations of both written and verbal informed consent will be provided. . Study participants will be assured of their right to withdraw from the study at any time they feel uncomfortable to continue. Privacy and confidentiality of participants will also be guarded by identifying questionnaires using unique study numbers. Potential Difficulties A potential challenge is study participant bias of giving socially desirable responses considering the area has been under intensive research. Availability of guardians at the time of the visit is another challenge especially for traders who are not readily available during the day. Administering the questionnaire in the evening hours also poses security risks for the interviewers. Recruiting locals as research assistants may partially resolve the security issue since they are familiar with the study area and are known by the natives. Anticipated outcomes and Potential Beneficiaries There is a potential positive correlation of food purchase frequencies, and preparation habits to malnutrition in children under the age of 5. Cultural beliefs may indirectly affect malnutrition by influencing food purchase frequencies and cooking habits. Evidence gathered from this study will directly benefit pre-school children and child bearing mothers, who are the most affected by malnutrition. Information from the study can also be used to enhance and promote healthy dietary practices at household level where most people get their meals. The information may also be useful to policy makers such as the ministry of health in Kenya and other stakeholders carrying out intervention programmes such as school feeding programmes. Dissemination Documented findings of this study availed to the ministry of health and the Nairobi Urban Health and Demographic Surveillance system database. The report will also be published in Africa’s open access journals where it will be accessible to researchers. Time table Time Period 2014 Activity Person January, Design of questionnaire and interview researcher February Ethical approval researcher March Recruiting and training research assistants researcher April Pilot study Researcher/ research assistants May Editing questionnaire researcher June Quantitative data collection Research assistants July Qualitative data collection Research assistants August Data analysis researcher September Report writing researcher October Dissemination Researcher Word count: 2,174 Appendix categories Demographics: age, number of people in the household, siblings, education level, sources of income, monthly income rate, and recent infections. Food purchase frequencies: The number of times a particular food commodity is purchased within a given time frame. Preparation habits: The methods used prepare food before consumption. Cultural beliefs: Perceptions or myths in considering certain foods as taboo to children References Abuya et al. 2012. Effect of mother’s education on child’s nutritional status in the slums of Nairobi. BMC Pediatrics. 12:80. African Population and Health Research Center. 2002. Population and Health Dynamics in Nairobi Informal Settlements. Nairobi: APHRC. Black R.E, Allen L.H, Bhutta Z.A, Caulfield L.E, de OnisM, Ezzati M et al. 2008. Maternal and Child Under-nutrition Study Group. Maternal and child under-nutrition: Global and Regional exposures and health consequences. Lancet. 371:243-60. Black R.E., Morris S.S, Bryce J. 2003. Where and why are 10 million children dying every year? Lancet. 361:2226-34. Brannen, J. (ed.) 1992 Mixing Methods: Qualitative and Quantitative Research, Aldershot: Ashgate Bryman, A. 2006. Integrating quantitative and qualitative research: how is it done? Qualitative Research 6: 97 Creswell, J.W. 2003 Research Design, Qualitative, Quantitative, and Mixed Methods Approaches, 2nd edition, SAGE, London. Faye, O., Baschieri, A., Falkingham, J. & Muindi, K. 2011. Hunger and Food Insecurity in Nairobi’s Slums: An Assessment Using IRT Models. Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 88, Suppl. 2 Feikin, D.R, Audi, A, Olack, B, Bigogo, G.M, Polyak C, and Burke, H et al. 2010. Evaluation of the optimal recall period for disease symptoms in home-based morbidity surveillance in rural and urban Kenya. International Journal of Epidemiology. 39:450-8. Glewwe P. 1999. Why Does Mother's Schooling Raise Child Health in Developing Countries? Evidence from Morocco. J. Human Res. 34(1):124–159. Kenya National Bureau of Statistics. 2010. Kenya Demo-graphic and Health Survey 2008-2009: Kenya National Bureau of Statistics. 141-50. Mittal, A., Singh, J., & Ahluwalia, S.K. 2007. Effect of maternal factors on nutritional status of 1-5-year-old children in urban slum population. Indian J Community Med. 32:264-7. Mugisha, F. 2006. School Enrollment among Urban Non-Slum, Slum and Rural children in Kenya: is the urban advantage eroding? International Journal of Education Development. 26:471-82. Olack, B. et al. 2011. Nutritional Status of Under-five Children Living in an Informal Urban Settlement in Nairobi, Kenya. Journal of Health Population and Nutrition. (4): 357-363). Pelletier ,D.L, Frongillo, E.A Jr, & Habicht, J.P. 1993. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality American Journal of Public Health. 83:1130 –3. Salah E.O, Maria N, & Theodore B. 2006. Factors affecting prevalence of malnutrition among children under three years of age in Botswana. African Journal of Food Agriculture Nutrition and Development. 6(1):1–5. Stephenson L.S, Latham M. C, & Ottesen E.A: 2000. Malnutrition and parasitic helminth infections. Parasitology. 121(Suppl):S23–38. United Nations: 2004. Standing Committee on Nutrition (SCN), 5th Report on the World Nutrition Situation. Geneva: United Nations.. World Health Organization: 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO. World Health Organization. 2006. Child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development, Geneva: World Health Organization. 306-7. Read More