Socio-economic, environmental , care, health and nutritional determinants in the aetiology of severe protein-energy malnutrition in Southern Ethiopia (Sidama) with emphasis on kwashiorkor : a one year prospective and retrospective follow-up study to find out predisposing factors

Abstract

The present study was carried out at Yirga Alem Hospital, Sidama, South Ethiopia. The study contributes to the debate about whether children with nutritional oedema, compared to controls and to those with marasmus, were exposed more often to noxae that generate oxidative stress (hypothesis 1), or/and to factors that compromise defence against free radicals (hypothesis 2) and whether children with nutritional oedema, compared to controls and to those with marasmus, were exposed more often to a lack of care (hypothesis 3). The case-control study was composed of 106 children, PEM-children, who were treated in hospital, and controls from the neighbourhood. After discharge of hospital, they were followed for one year by 24-hour home visits between April 1997 and March 1998. During this time all households were visited every 4 months. Information was obtained through quantitative (questionnaires) and qualitative (structured observations, discussions) methods. Anthropometric measurements, weighing of food of the index children, interviews with caregivers and heads of household as well as observations were carried out. The main objectives of the study were to examine predisposing factors for the development of kwashiorkor based on the concept of immediate, underlying and basic causal factors. The immediate factors comprise nutritional intake of the index children and the morbidity of the index children and their families. Underlying and basic predisposing factors include socio-economic and environmental factors, caring capacity, nutritional knowledge and nutritional behaviour of the caregivers. The most important determinants for the development of kwashiorkor were examined by a final logistic regression model. The determinant with the strongest impact on the occurence of nutritional oedema in this model turns out to be the behaviour of the caregivers concerning childcare, one of the factors belonging to the underlying causal determinants of kwashiorkor. The investigation of the caring environment of the malnourished child reveals severe household disorganisation and extensive family disruption. Resources available were not used in a way to ensure the health of the children. According to the classification of care done in this study, only good care protects from nutritional oedema. The better the care was, the better also was the fulfilment of the requirements of main nutrients. Another important risk factor is the occurence of diseases in the household. If one additional illness in the household occurred, the risk for the index child to become oedematous increased by the factor 1.476. In the pre-harvest season, when food availability was lower, more children became oedematous with the typical complications appearing together or before the oedema occured. Oedematous children were not exposed to a special pattern of infection, but the suffered diarrhoea significantly more often. Oedematous children were exposed significantly more often to diseases, but not to any specific one. The risk of becoming oedematous was higher if the number of diseases the child was exposed to increased. In the pre-harvest season illnesses were more frequent in all households. The results show that in the households where a child got oedema, the other household members were more often exposed to any kind of illnesses. Care seems to play an important role in these households. The frequency of infections and the nutritional intake of the studied index children means that nutritional deficits were not being appropriately corrected and the consequence was a constant morbidity. Concerning the impact of nutritional factors, the strongest item for the development of kwashiorkor was the Fat Energy Ratio (FER). The FER for the oedematous children was below 10 percent throughout all seasons, with the lowest value in the pre-coffee season (6%). The result of the model reveals the fact that the quality of protein is a more important determinant for the occurence of nutritional oedema than the quantity of protein. The determinant of food diversity in the household of the index child turns out to be another significant risk factor for the development of kwashiorkor. The results of the study show that the interaction of socio- cultural factors, especially the role of care for the child, and biological factors were strongly involved in the causation of the disease. Die vorliegende Studie wurde am Yirga Alem Krankenhaus, Sidama, Süd-Äthiopien durchgeführt. Ziel der vorliegenden Studie war es, prädisponierende Einflussfaktoren bei der Entstehung von Kwashiorkor zu untersuchen. Die Fall-Kontroll Studie setzte sich aus 106 Kindern zusammen, Kinder die wegen Protein-Energie-Malnutrition im Krankenhaus behandelt wurden und Kontrollkinder. Nach Entlassung aus dem Krankenhaus wurden für ein Jahr die Kinder und ihre Familien alle vier Monate zu Hause besucht. Das Forschungsteam hielt sich 24 Stunden bei den Familien auf. Informationen wurden durch eine Kombination von quantitativen und qualitativen Forschungsmethoden erfasst. Anthropometrische Messungen, das Wiegen der verzehrten Nahrung, Interviews mit Fürsorgeträgern und Haushaltsvorständen als auch Beobachtungen wurden durchgeführt. Die wichtigsten Determinanten bei der Entstehung von ödematöser Malnutrition wurden durch ein logistisches Regressionsmodell untersucht. Nach diesem Modell haben sich als bedeutendste Determinanten das Verhalten der Fürsorgeträger bei der Kinderfürsorge, das Vorkommen von Krankheiten im Haushalt, die niedrige Kalorienzufuhr aus Fett, die Qualität des Proteins und die Nahrungsvielfältigkeit erwiesen.