Abstract

Introduction

Undernutrition arises from inadequate nutrient intake or absorption in the body and can present as acute undernutrition (wasting), chronic undernutrition (stunting), or a combination of both (underweight), along with deficiencies in essential micronutrients¹. Undernutrition is the leading cause of mortality for nearly half of all under-five child deaths worldwide. It increases the chance of morbidity, puts children at risk of dying from common diseases, increases the severity of infections, and delays recovery².

Globally, undernutrition contributes to nearly 3 million deaths annually, accounting for approximately 45% of all deaths in children under five years of age³. Despite efforts to reduce undernutrition, in 2022, globally 148.1 million, or 22.3% of children under the age of five were stunted and 45 million children under 5 (6.8%) were affected by wasting, of which 13.6 million (2.1%) were suffering from severe wasting⁴. Over the past two decades, undernutrition has emerged as a major child health concern in low-and-middle-income countries (LMICs) due to its strong association with child mortality⁵.

Childhood undernutrition is a prevalent issue in Africa, according to the 2023 Joint Child Malnutrition Estimates (JME) report. In 2022, 43% of all children under five affected by stunting lived in Africa, meaning that two out of five affected children are from this region. Additionally, more than one-quarter of all children under five affected by wasting also reside in Africa, and 22% of all children with severe wasting live there⁴. These conditions have both short-term and long-term consequences, impacting physical, intellectual, and emotional development, as well as increasing susceptibility to communicable and chronic diseases⁶.

Ethiopia, as a country in Sub-Saharan Africa, grapples with a high burden of malnutrition despite efforts to reduce hunger and undernutrition. The ongoing challenge of malnutrition in Ethiopia underscores the need for sustained public health interventions to address this pressing issue⁷. According to the Ethiopian Demographic and Health Survey (EDHS) 2016, approximately 10%, 24%, and 38% of children under five were found to be wasted, underweight, and stunted, respectively. In the southern region of Ethiopia, acute malnutrition affects 6% of children, while chronic malnutrition or stunting affects 39%⁸. To decline the high prevalence of under-five malnutrition; World Health Organization (WHO) is implementing a global nutrition-monitoring framework with six targets to be achieved by 2025⁹.

According to previously conducted studies, various factors, including socio-demographic status, economic status, child and maternal health, feeding practices, and environmental conditions, have been identified as significant contributors to different forms of undernutrition among under-five children^10–16.

While previous studies in Ethiopia have focused on specific forms of undernutrition in various regions, there remains a knowledge gap in understanding the overall prevalence and determinants of undernutrition, particularly in densely populated areas. Moreover, no research has been conducted on undernutrition among children under five in our study area, the Gedio zone. Although there are studies from other densely populated regions, these earlier investigations did not differentiate between the three forms of undernutrition; instead, they treated them collectively. In contrast, our study successfully identifies the specific factors associated with each form—underweight, wasting, and stunting. This distinction will enable us to pinpoint the contributing factors for each type and ultimately aid in reducing overall undernutrition among children. Therefore, this study aims to assess the prevalence and factors associated with underweight, wasting, and stunting among children in the Gedio zone of southern Ethiopia. The findings of this study are crucial for developing effective interventions and guiding policymakers and health program implementers in addressing childhood undernutrition.

Methods

Sample size determination and sampling procedures

A single population proportion formula was applied in this study, assuming a 95% confidence level and a marginal error of 5%. This approach aimed to determine the prevalence of under-nutrition, which was found to be 48.5% based on data from a previous national-level study conducted in Ethiopia¹³.

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where n=least sample size needed to conduct the study, Z=standard normal distribution with (Z=1.96), the confidence level of 95% and α=0.05, P=prevalence or the population proportion from the previous study (P=48.5%), d=is the tolerable margin of error for the study (0.05).

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The minimum sample size needed for the study was 384, after adding, a 5% rate for non-respondents the sample size for the study was 403.

The sampling technique involved randomly selecting four out of the eight districts in the zone, each of which had three kebeles for administrative purposes. Population size, number of households, and total number of kebeles were obtained from each district’s administration office. Kebele and household lists were organized by house number for the selected districts. Following the rule of thumb, 30% of kebeles (1 kebele) from each district were selected. Subsequently, a fixed number of households were drawn from each kebele using a random sampling technique. After proportionally allocating the number of households in each kebele, the households were identified from the central place, particularly the kebele administrative offices. This process resulted in a total of 403 study participants, with 71, 148, 87, and 97 participants selected from Kochere district (Biloya kebele), Gedeb district (Halo hartume kebele), Dila zuria district (Tumticha kebele), and Chorso mazoria district (Kedida gubeta kebele) respectively.

Results

Socio-demographic and economic characteristics of study participants

Out of the intended 403 study participants, a complete response was obtained from 386 (96%) participants. More than half (59.1%) of the children fell into the 24–59 months age category, with a mean age of 27.11 months and a standard deviation of +14.7 for both sexes. Approximately 40.2% of the mothers were aged between 20 and 34 years, with a mean maternal age of 24.7 and a standard deviation of +3.3 years. The majority (94.6%) of women were married, and 96.5% of households were headed by a male. Two-thirds (62.7%) of respondents had a family size greater than five, and over one-third (37.6%) of households were classified as having a poor wealth index (see Table 1).

Table 1

Socio-demographic and economic characteristics of respondents in Gedio Zone, Southern Ethiopia, 2021 (n=386).

Variable	Category	Frequency (%)
Age of child	6–23 months	158 (40.9)
	24–59 months	228 (59.1)
Age of the mother	<20 years	166 (43.0)
	20–34 years	155 (40.2)
	>34 years	65 (16.8)
Sex of child	Male	201 (51.7
	Female	185 (48.3)
Residence	Urban	60 (15.5)
	Rural	326 (84.5)
Education status of mother	No formal education	155 (40.2)
	Primary level	167 (43.0)
	Secondary & above	65 (16.8)
Education status of Father	No formal education	95 (24.6)
	Primary level	210 (54.4
	Secondary & above	81 (21.0)
Occupation of mother	Housewife	262 (67.8)
	Employee	76 (19.8)
	Private work	48 (12.4)
Family size	<5 family	144 (37.3)
	≥5 family	242 (62.7)
No of <5 children	1-child	230 (59.6)
	≥2 children	156 (40.4)
The main source of family food	Own production	251 (65.0)
	Purchase	110 (28.5)
	Other	25 (6.5)
Household Wealth Index	Poor	145 (37.6)
	Medium	139 (36.0)
	Rich	102 (26.4)

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Child health and caring practices

Of the total participants in the study, around one-third (27.2%) of children were delivered in health facilities, and over two-thirds were not exclusively breastfed. Approximately 63.5% of children had evidence of being fully vaccinated. Diarrheal disease, followed by acute respiratory infections (ARIs), was the most frequent child health problem in the study area, affecting 17% and 15.4% of children in the past two weeks (Table 2).

Table 2

Child health and caring practices among the respondents in Gedio Zone, Southern Ethiopia, 2021 (n=386).

Variables	Category	Frequency (%)
Place of birth	Health facility	105 (27.2)
	Home	281 (72.8)
Perceived birth weight	Small	143 (37.0)
	Average	196 (50.8)
	Bigger than average	47 (12.2)
History of colostrum feeding	Yes	160 (41.5)
	No	226 (58.5)
Exclusive breastfed	Yes	125 (32.4)
	No	261 (67.6)
Duration of breastfeeding	<12 months	161 (41.7)
	≥12 months	225 (58.3)
The age of complementary feeding started	At 6 month	146 (37.8)
	<6 month	55 (14.3)
	>6 month	185 (47.9)
Diet diversity score	<5 food groups	231 (59.8)
	≥5 food groups	155 (40.2)
Meal frequency	<3 meals per day	120 (31.1)
	≥3 meals per day	266 (68.9)
Method of child feeding	Bottle	238 (61.7)
	Cup and/or spoon	67 (17.3)
	Hand	81 (21.0)
Vaccination status	Not started	53 (13.7)
	Up to date	88 (22.8)
	Completed	245 (63.5)
Vitamin-A supplemented in the last 6 months	Yes	254 (65.8)
	No	132 (34.2)
Deworming given in the last 6 months	Yes	208 (53.9)
	No	178 (46.2)
History of acute respiratory illness in the last two weeks	Yes	59 (15.3)
	No	327 (84.7)
History of diarrheal disease in the last two weeks	Yes	66 (17.1)
	No	320 (82.9)

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Dietary diversity score

Out of the total children, 155 (40.2%) had a diverse diet (consumed>5 out of the 8 food groups) in the previous 24 h, while 231 (59.8%) had a limited diet (consumed<5 out of the 8 food groups). The most commonly consumed food groups among the children were grains, roots, and tubers (92.5%), including the locally prevalent ‘Enset’, as well as dairy products (54.9%), followed by flesh foods such as meat (46%). Approximately one-third of the children (32.6%) were reported to be breastfeeding in the previous 24 h. Conversely, the least consumed food groups were Vitamin-A rich fruits and vegetables (22.6%) and other fruits and vegetables (18.9%) (Fig. 1).

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Fig. 1

Proportion of each food group consumption of children aged 6–59 months in Gedio Zone, Southern Ethiopia, 2021 (n=386).

Maternal health and environmental factors

In terms of maternal health and environmental factors, 58.3% of the mothers had a birth interval of >24 months for the index pregnancy, and 78.2% had received antenatal care (ANC) follow-up. Additionally, 59.3% of the mothers had a normal BMI. The majority of sampled families (60.9%) used an unsafe water source, and only 32% had access to improved latrines (Table 3).

Table 3

Maternal health and environmental conditions among the respondents in Gedio Zone, Southern Ethiopia, 2021 (n=386).

Variables	Category	Frequency (%)
The birth interval of index pregnancy*	<24 months	89 (23.1)
	≥24 months	225 (58.3)
History of ANC during the index pregnancy	Yes	302 (78.2)
	No	84 (21.8)
TT-vaccination status	Unvaccinated	167 (43.3)
	TT1	77 (19.9)
	TT2 plus	142 (36.8)
Folic acid intake during index pregnancy	Yes	209 (54.1)
	No	177 (45.9)
Maternal BMI status	Normal weight	229 (59.3)
	Underweight	109 (28.2)
	Overweight	48 (12.4)
Ever used family planning	Yes	244 (63.2)
	No	142 (36.8)
Hand washing practice during food preparation	Yes	156 (40.5)
	No	230 (60.5)
Source of drinking water**	Safe	151 (39.1)
	Unsafe	235 (60.9)
Availability of Improved latrine***	Yes	114 (29.5)
	No	272 (70.5)
Ever heard of safe nutrition information	Yes	312 (80.8)
	No	74 (19.2)

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*Respondent’s with 1st birth was not included.

**Safe source includes tap water, public tap, and protected well and the unsafe source includes unprotected spring, well, and river.

***Improved latrine includes any non-shared toilet of: flush/pour flush toilets, septic tanks, and pit latrines; ventilated improved pit latrines; pit latrines with slabs.

Magnitude of undernutrition

The study participants showed a prevalence of under-nutrition, with 19.7% (95% CI 16-24%) classified as underweight, 10% (95% CI 7-13%) as wasted, and 49% (95% CI 44-54%) as stunted. Among the children, severe underweight (WAZ<−3SD), severe wasting (WHZ<−3SD), and severe stunting (HAZ<−3SD) were prevalent at rates of 9.1%, 5.7%, and 29.5%, respectively. Furthermore, 4.6% of children exhibited both wasting and stunting simultaneously (Fig. 2).

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Fig. 2

Proportion of under-nutrition among children aged 6–59 months in Gedio Zone, Southern Ethiopia, 2021 (n=386).

Discussion

This study found that underweight, wasting, and stunting were prevalent at rates of 19.7% (95% CI 16-24%), 10% (95% CI 7-13%), and 49% (95% CI 44-54%), respectively. When compared to the national rates reported in the Ethiopian DHS 2016, the study identified a slightly lower prevalence of underweight (19.7%), a similar prevalence of wasting (10%), and a higher prevalence of stunting (49%)³¹.The observed disparities could be attributed to differences in sampling methods and sample sizes.

The prevalence of stunting (49%) in the study area was notably higher than the regional average for Southern Ethiopia (39%)²⁴. However, this finding is consistent with the prevalence of wasting (47.6%) reported in the Bule Hora district of Southern Ethiopia, which may reflect similar socio-economic conditions and age groups of the study population¹⁰. The prevalence of underweight, wasting, and stunting in the current study was lower, similar, and higher, respectively, compared to sub-Saharan Africa’s average (25%, 10%, and 39%, respectively). However, the prevalence of stunting was consistent with a previous study in East Africa (48%)³², suggesting that differences in socio-economic, cultural, sampling, and methodological factors may explain the variations.

According to this study, the three common forms of under-nutrition (stunting, wasting, and underweight) were significantly associated with different factors that varied by the type of under-nutrition. Underweight was associated with birth weight, dietary feeding, and vaccine status. Wasting was associated with family size, meal frequency, and birth interval. Stunting was associated with the age of the child, diet diversity score, duration of breastfeeding, and the mother’s BMI status.

The analysis of this study revealed that low perceived birth weight was a risk factor for under-nutrition among children, as those with low birth weight were more likely to be underweight. This finding is consistent with studies conducted in Ghana¹¹ and Indonesia³³, which reported a high risk of underweight among children with low birth weight. This suggests that low birth weight children require extra nutrition and care to achieve normal weight compared to those with normal birth weight.

Additionally, the study revealed that insufficient dietary diversity is a significant risk factor for under-nutrition, specifically underweight and stunting. Children who consume less than five of the eight major food groups are more likely to develop these conditions compared to those who consume five or more food groups. This finding is consistent with previous studies conducted in Ethiopia, Tanzania, and India^12,34,35. The lack of dietary diversity can lead to macro and micro-nutrient deficiencies, resulting in under-nutrition, likely due to poor access to diverse foods and unequal food distribution within households^10,20,21.

Furthermore, the study findings indicate that a child’s vaccination status is a significant predictor of being underweight. This observation is consistent with previous studies conducted in various regions, including northwest Ethiopia²⁵, Ethiopian Somalia region²⁷, and rural Bangladesh²⁹. Unvaccinated children are more susceptible to vaccine-preventable diseases such as diarrhea and respiratory tract infections, which can cause nutrient depletion in the body and eventually lead to malnutrition.

The study’s results indicate that a larger family size is associated with an increased risk of wasting. Specifically, living with five or more family members was identified as a significant predictor of wasting. This observation aligns with several prior studies conducted in different regions, including northwest Ethiopia²⁵, Ethiopian Somalia region²⁷, Sudan³⁶, and Pakistan³⁷. The reason for this association may be that as the size of a family grows, the likelihood of implementing appropriate feeding practices for children and ensuring access to a nutritious diet decreases.

Furthermore, the study found that children who consumed less than three meals per day were at a higher risk of developing wasting. This discovery is consistent with previous research conducted in west Gojam, Ethiopia²⁶. Inadequate meal consumption can hinder a child from receiving the necessary daily energy intake for proper nourishment. Additionally, the study revealed that children with birth intervals of less than 24 months were also at a higher risk of developing wasting. This finding is in line with research conducted in India³⁵, and aligns with WHO’s recommendations for child feeding⁹. This is because a child with a short birth interval may not receive the recommended dietary intake due to competition with the preceding child.

Moreover, the latest research indicates that the likelihood of stunting increases as a child grows older, which is consistent with previous studies in Ethiopia²⁴ and Kenya²¹. Children aged 12–23 months and older were found to have the highest risk of stunting. Similarly, a study conducted on trends of stunting from 1990 to 2020 in developing countries also showed similar findings³⁸.

The study found that the duration of breastfeeding played a significant role in predicting stunting, as children breastfed for less than 12 months exhibited a notable association with stunting. This finding is in line with evidence from a study conducted in Ethiopia²⁸ and aligns with WHO recommendations for child feeding⁹. Furthermore, the research indicated that children born to underweight mothers had an elevated risk of stunting. Previous studies have also demonstrated a higher likelihood of stunting among mothers with a low BMI^6,28), potentially attributed to the long-term nutritional status of mothers before pregnancy impacting the early growth and development of their children, thereby contributing to the risk of stunting.

Conclusion

The present study’s findings reveal a concerning prevalence of under-nutrition, including underweight, wasting, and stunting, within the study area. The research has identified several key factors associated with under-nutrition among children in this context. Specifically, birth weight, dietary feeding practices, and vaccine status were found to be correlated with underweight, while family size, meal frequency, and birth interval were linked to wasting. Additionally, stunting was significantly associated with the child’s age, diet diversity score, duration of breastfeeding, and maternal body mass index.

In light of these findings, it is evident that a multi-faceted approach is needed to address the issue of under-nutrition among children aged 6–59 months in the study area. The study recommends promoting healthier child feeding practices, encouraging optimal dietary diversification and meal frequency, prioritizing optimal breastfeeding, ensuring complete vaccination of children, advocating for wider birth intervals, and improving maternal nutritional status as crucial steps to mitigate under-nutrition among this vulnerable population.

By implementing these recommended measures, there is potential to make a significant impact on reducing the prevalence of under-nutrition and improving the overall health and well-being of children in the study area.

Acknowledgements

Abbreviations

Author contributions

Conceptualization: M.Y., T.Z., T.D., H.M., T.W., M.H., N.K. Data curation: T.Z., T.D., H.M., T.W. Formal Analysis: T.Z., H.M., M.H., N.K. Investigation: M.Y., T.Z., T.D., H.M., T.W. Methodology: M.Y., T.D., H.M., M.H., N.K. Project Administration: T.Z., T.D., H.M., T.W. Resources: M.Y., T.Z., T.D., H.M., T.W., M.H., N.K. Software: M.Y., T.Z., T.D., N.K. Supervision: M.Y., T.Z., T.W., M.H., N.K. Validation: T.Z., T.D., H.M., T.W., N.K. Visualization: M.Y., T.D., T.W., M.H., N.K. Writing-original draft: M.Y. Writing-review and editing: T.Z., M.Y., T.D., H.M., T.W., M.H., N.K.

Funding

Funding agencies do not have a role in the publication of the paper.

Data availability

The data used to support the findings of this study are available from the corresponding author upon request.

Declarations

Footnotes

References