Bahirdar University
Bahirdar University
Bahirdar University
AUGUST, 2017
i
THE IMPACT OF MATERNAL WORK STATUS OUTSIDE THE HOME ON
NUTRITIONAL STATUS OF 6-59 MONTH-OLD CHILDREN IN BAHIRDAR
CITY, AMHARA REGIONAL STATE, ETHIOPIA 2017.
ADVISORS:
AUGUST, 2017
BAHIR DAR ETHIOPIA
ii
BAHIRDAR UNIVERSITY
SCHOOL OF GRADUATE STUDIES
By:Mesfin Tegegne
Bahirdar University College of Medicine and Health Science school of
public health
Approved by
iii
ACKNOWLEDGEMENT
First of all, I would like to express my heartfelt thanks and appreciation to my advisors
Mr. Dabere Nigatu and Mr.Dereje Birhanu for their invaluable and constructive
comments in the preparation research proposal.
i
TABLE OF CONTENT
Contents
ACKNOWLEDGEMENT ............................................................................................................................. i
TABLE OF CONTENT ............................................................................................................................... ii
LIST OF FIGURES.................................................................................................................................... iv
LIST OF TABLES ....................................................................................................................................... v
LIST OF ABBREVIATION ........................................................................................................................ vi
LIST OF ANNEXES ................................................................................................................................. vii
SUMMARY ............................................................................................................................................... viii
1. INTRODUCTION ................................................................................................................................... 1
1.1 Background ......................................................................................................................................... 1
1.2 Statement of the Problem statement. ................................................................................................ 2
1.3 Justification of the research ................................................................................................................ 3
2. LITERATURE REVIEW ........................................................................................................................ 5
OPERATIONAL DEFINITION .................................................................................................................. 9
3. OBJECTIVES: ...................................................................................................................................... 10
3.1. General objective ............................................................................................................................. 10
3.2. Specific objective: ............................................................................................................................ 10
4. METHOD AND MATERIALS.............................................................................................................. 11
4.1. Study Area: ....................................................................................................................................... 11
4.2. Study Design and period: ................................................................................................................. 11
4.3. Source population: ........................................................................................................................... 11
4.4. Study Population: ............................................................................................................................. 11
4.5. Eligibility criteria............................................................................................................................... 11
4.6. Sample size calculation: ................................................................................................................... 11
4.7. Sampling Procedure: ........................................................................................................................ 12
4.9. Tools for data collection: ................................................................................................................. 14
4.10. Data quality .................................................................................................................................... 14
4.11. Data processing and analysis ......................................................................................................... 15
4.12. Ethical clearance ............................................................................................................................ 15
6. WORK PLAN ........................................................................................................................................ 16
ii
7. BUDGET BREAK DOWN ................................................................................................................... 18
8. REFERRENCES .................................................................................................................................. 20
9. ANNEX .................................................................................................................................................. 23
iii
LIST OF FIGURES
iv
LIST OF TABLES
v
LIST OF ABBREVIATION
vi
LIST OF ANNEXES
vii
SUMMARY
Back ground: Lack of proper nutrition, caused by not having enough to eat, not eating
enough of the right things, or being unable to use the food that one does eat.
Malnutrition accounts for 11% of the global burden of disease, leading to long-term poor
health and disability and poor educational and developmental outcomes.
Objective: The objective of the study is to determine the effect of maternal work status
outside the home on nutritional status of 6-59 month-old children.
Method: community based comparative cross sectional study will be conducted to
measure the level of child malnutrition among children aged 6-59 months old age.
Multi-stage sampling procedure will be employed to select the required household a
total of 14628 households. Structured questionnaire will be used to obtain information
on demographic, social, economic factors and information on anthropometric indices
will be also collected using weighing scale and height measuring board. Which will be
analyzed by growth reference scale, EPI-INFO version 7.0 computer statistical
packages and multiple logistic regressions on SPSS
Expected result. The result will be expected that mother employment status outside
their home will have an impact of nutritional status of 6-59 month –old children
viii
1. INTRODUCTION
1.1 Background
Malnutrition means “badly nourished” but it is more than a measure of what we eat, or
fail to eat. Clinically, malnutrition is characterized by inadequate intake of protein,
energy, and micronutrients and by frequent infections or disease. Nutritional status is
the result of the complex interaction between the food we eat, our overall state of
health, and the environment in which we live – in short, food, health and caring, the
three “pillars of well-being.”(1)
Malnutrition is the basis of such human health at all ages. Children particularly, need
appropriate nutrition and protein to meet their needs for energy, cell growth and
development. One of the greatest threats of child survival and development in recent
years is malnutrition. Children in preschool stage requires most attention, at this is the
period of rapid growth and development, which makes them highly vulnerable to
malnutrition. Malnutrition in this stage has far reaching consequences on child’s future
by severely affecting child’s physical and mental development.(2)
It is a formidable challenge. Every country is facing a serious public health challenge
from malnutrition. One in three people is malnourished in one form or another.
Malnutrition manifests itself in many forms: as children who do not grow and develop to
their full potential, as people who are skin-and-bone or prone to infection, as people
who carry too much weight or whose blood contains too much sugar, salt, or
cholesterol. The consequences are literally devastating. An estimated 45 percent of
deaths of children under age 5 are linked to malnutrition. Malnutrition and diet are now
the largest risk factors responsible for the global burden of disease by far.(3)
In Nigeria, 37 per cent of children, or 6 million children, are stunted (chronically
malnourished or low height for age), more than half of them severely. In addition, 18
percent of children suffer from wasting (acutely malnourished or low weight for height),
half of them severely. Twenty-nine per cent of children are underweight (both acutely
and chronically mal nourished or low weight for age), almost half of them severely
affected.(4)
The 2016 EDHS estimated that 38 percent of children under 5 are considered short for
their age or stunted (below -2 SD), 10% are wasted, 24% are under weight and 18
1
percent are severely stunted (below -3 SD). after being fairly stable in the first 6-8
months of life, the prevalence of stunting increases steadily from age 9 months through
the first 4 years of life, before declining slightly in the fourth year of life. Children age 24-
35 months have the highest proportion of stunting (48 percent). Stunting is slightly
higher among male than female children (41 percent versus 35 percent).(5)
While women’s labor force participation tends to increase with economic development,
the relationship is not straightforward or consistent at the country level. There is
considerably more variation across developing countries in labor force participation by
women than by men. This variation is driven by a wide variety of economic and social
factors, which include economic growth, education, and social norms.(6)
African women, produce as much as 80% of the food, and supplement family income by
working in the formal and informal sectors as traders and producers. In Ethiopia, in the
rural area 85% of the women involved in agricultural work, while in the urban areas due
to various social crises as well as rural urban migration, about 35% of urban dwellers
are women. This huge work force was forced to engage in low skills, education and
inability to compete with their male counter parts.(7)
In this modern era, most mothers have become part of the labor force compared to
previous time. Maternal employment influence child feeding practices thus it reflects
child nutrition status. Mothers exert strong influence over child feeding practices.(8)
1.2 Statement of the Problem statement.
Stunting and other forms of under nutrition are clearly a major contributing factor to child
mortality, disease and disability. For example, a severely stunted child faces a four
times higher risk of dying, and a severely wasted child is at a nine times higher risk.
Specific nutritional deficiencies such as vitamin A, iron or zinc deficiency also increase
risk of death. Under nutrition can cause various diseases such as blindness due to
vitamin A deficiency and neural tube defects due to folic acid deficiency.(9)
Malnutrition in all its forms either directly or indirectly is responsible for approximately
half of all deaths worldwide. This applies to perinatal and infectious diseases as well as
chronic diseases. Malnutrition accounts for 11% of the global burden of disease, leading
to long-term poor health and disability and poor educational and developmental
outcomes. Worldwide, by 2010 it was found that about 104 million children under five
2
years of age were underweight and 171 million stunted. At the same time, it was found
that about 43 million children under five were overweight or obese. About 90% of
stunted children live in 36 countries and children under two years of age are most
affected by under nutrition.(10)
Trend in the proportion of children the prevalence of stunted and underweight over the
three EDHS surveys is decreased. The prevalence of wasting in Ethiopia has remained
constant over the last 11 years. Even though the prevalence was deceased; it continues
a major health problem yet.
There is a general consensus today that a complex set of causes determines
malnutrition. Inadequate and/or inappropriate dietary intake and infectious diseases are
the immediate/ direct causes, while these in turn are related to a number of socio-
economic and environmental factors, such as environmental sanitation, water supplies
and primary health care, and family factors such as the presence of other family
members, type of housing, availability of water, household hygiene, mother’s education,
infant-feeding practices, decision-making power and maternal work status.(11)
1.3 Justification of the research
It is widely accepted that the work status of the mother plays an important role in
determining the health and nutrition status of her child.
Malnutrition is still a neglected area and too little has been done to address its causes
and serious social and economic implications. However, recently there has been
growing interest in nutrition with stronger political involvement at national and
international level leading to significant financial pledges and policy commitments. It is
now crucial to turn this momentum into results by ensuring the delivery of pledges and
accelerating progress on addressing the challenge of under nutrition.(12)
Economic theory suggests that families in which mothers work outside the home must
trade off the advantages of greater income against the disadvantages of less time for
home food production and supervision of children’s activities. This trade off may result
in positive, negative, or no net impacts on children’s nutritional well-being.(13)
First, the mother’s increased income, and, second, the time taken away from child
cares, when she goes to work, will be associated with her employment. While one of the
effects is direct and positive, the other is inverse and negative. Maternal employment
3
usually results in a loss of childcare time; presumably the mother is therefore less
available for breast feeding and making frequent meals, etc., however, it is possible
those non-working mothers also spend relatively little time in child care, or that
important care giving behaviors continue to be performed if there are adequate
substitute care takers.
In this study, I will contribute some to find out whether the well-being of children is
affected more by the time constraints of women who perform the dual role of mother, or
by the increased income generated by the mother’s working. Also it is helpful in
producing applicable recommendations that will show more areas of intervention
programs to both governments and non-government organizations to improve the health
and nutritional status of children. And also used as a base line data for those who are
concerned with capacity development of nutritional status and may also serve as a start
for any other large scale study.
4
2. LITERATURE REVIEW
5
Another study argued that there is no association between maternal working status
outside the home and children's nutritional status.(18)
Several studies have shown the association between women’s work and children’s
nutritional status controlling for potentially confounding variables. Earlier studies of this
type are reviewed that Dr Ritu Bhatia (2010) and Dr. Naheed Vaida (2013),these
researchers find a negative association of mother’s work and child nutrition, but for
others the correlation is positive.(19)
Results from the study at the Kindergartens in Selangor, Malaysia indicated that There
is a significant positive fair correlation (r=0.2, p=0.05) between child BMI and length of
working hours. However, the correlation of length of working hour and child’s height
(p=0.745) did not reach statistical significant which indicated.(8)
Results from in Shinille Woreda, Ethiopian Somali regional state, bivariate analysis
showed that family size, immunization status, maternal education, monthly income,
extra feeding during pregnancy/ lactation, ANC visit, continuation of breast feeding, birth
order, how long after birth did you first put the child to breast feed and availability of
latrine have significant association to wasting. Children from large family size were 2.0
times more likely to be wasted than children from small family size, children from
households having monthly income of less than 750 birr were 1.8 times more likely to
be wasted than children from households having monthly income of less than 750 birr,
non-immunized children were 7.6 times more likely to be wasted than their counter parts
and female were 1.5 times more wasted than boys.(20)
The result of study done at Babban-Dodo community Zaria city, Northwest Nigeria It
was found that there was significant difference, with regard to stunting, between the
children whose mothers were literate and had formal education and those whose
2
mothers had no formal education (x = 26.2, P < 0.05), but no significance was found
between the two groups as regards underweight and wasting.(21)
Findings from the 1992 Malawi DHS Survey ,Poor sanitation puts young children at risk
of increased illness, in particular diarrheal diseases, which adversely affect a child’s
nutritional status. Both inadequate food intake and poor environmental sanitation reflect
underlying social and economic conditions poor environmental sanitation reflect
underlying social and economic conditions.(22)
6
Studies show that as there is a strong relationship between a child’s age, family size,
birth interval and stunting. In communities with little access to and contact with health
care children are more vulnerable to malnutrition as a consequence of inadequate
treatment of common illness, low immunization rates, and poor antenatal care.
However, the factors associated with the problems malnutrition may differ among
regions, zones and communities, as well as over time.(23)
Results from the study of Guatemala, Characteristics of mother's income earning that
might be associated with anthropometric status where her income per month, the
percent of the family's income she earned, and the total number of hours she had
worked in the previous year. The woman's income per month was correlated with both
height for age and weight for age, whereas the mother's percent of family income
earned was related.(24)
Mother’s education seemed to play a protective role against child’s malnutrition. Overall
93% of the mothers literate though up to different levels..Prevalence was highest where
mothers were illiterate (52.94%) vs. value of 38.46% where mothers had education
more than secondary school. Similarly, stunting were 17.65% where mother was
illiterate and 7.69% where education level was more than secondary school. Differences
were statistically significant for both cases. Education of mothers significantly influenced
the nutritional status of under- five as the prevalence of under nutrition was 52.94%
where mothers was illiterate and it was 38.46% where education level was more than
secondary school.(25)
7
Maternal work status and child nutritional status, Conceptual framework
Mothers’ employment status has potential implications for virtually all aspects of
children’s growth and development, and nutrition outcomes are no exception. The
quality of children’s diets and their subsequent physical health may depend significantly
on whether and how much their mothers work outside the home. On the one hand,
employed mothers may have less time available to supervise their children’s activities
and to prepare their meals. On the other hand, the additional income they bring into the
household may help to ensure a stable supply of high quality food.
.
Dietary
Time for intake (Food
Cooking availability)
Nutritional
Maternal Maternal status of the
work status income child
Health
condition
Time for
(diarrhea,
child care
ARI)
Identify the specific variables described in the literature and figure out how these are
related and then generate the conceptual framework.
Fig 1. Conceptual framework
8
OPERATIONAL DEFINITION
9
3. OBJECTIVES:
10
4. METHOD AND MATERIALS
4.1. Study Area: -The study will be conducted in Bahir Dar town, Tana
kifleketema.which contains 14,628 households and has a total population of 52,430 of
which 24,750 are males and 27,680 are females. Under-five children are estimated to
be 1681. In the kifleketema, three medium private clinic and one governmental health
center. 2% of the households use open defecation, while the remaining use shared pit
latrines and private toilet facility. (Health extension workers of Tana kifleketema)
4.2. Study Design and period: community based comparative cross sectional Study
will be conducted from October to November 2017
4.3. Source population: The source population will be all mothers lived in Bahir Dar
city
4.4. Study Population: working outside the home and non-working mothers with 6-59
month –old children living in Tana kifleketema
.Only working and non-working mothers of children from 6-59 months old age
.Working women may be working either full time or part time.
.Working women should be working from at least past 6 months.
4.5.2 Exclusion criteria
.Child and mother lived separately will be excluded from the study.
4.6. Sample size calculation: The sample size is calculated based on the prevalence
of stunting child for working mother, Statistical power, ratio of unexposed to exposed,
percent of outcome in unexposed group, percent of outcome in exposed group, odds
ratio and 95 percent confidence interval (CI).a total sample of 652 will be selected using
simple random sampling technique. Accordingly, the calculated optimal sample 652
working and non working mothers who have child of 6 to 59 months old.
Using open epi version 7.1 statistical package. Among exposure variables, maternal
education and maternal work status of mothers are chosen as main exposure since it is
considered to give the larger sample size In this regard
11
TABLE.4.1 variables which are used to take samples.
Assumptions Variable
CI 95%
Power 80
Ratio 1:1
% exposed 20.3
% unexposed 28.8
12
SCHEMATIC PRESENTATION OF SAMPLING PROCEDURE
Samples
13
4.9. Tools for data collection: Data will be collected using a structured
questionnaire for respondents (working and non-working mothers) and the sample will
be clinically assessed for visible symptoms of malnutrition, to take measurement of
children, weighing scale (Salter scale) for weight and a wooden measure for length and
height measurements will be used, after obtaining a written consent from the mothers
The questionnaire will contain different sections to obtain various types of
information.
I, General information: It includes the, age, sex and maternal history of the sample
and its variables (like age, qualification, occupation, monthly income, working hours
etc.). It also elicited information about the nutritional awareness of mothers.
II, Anthropometric measurements: It includes the weight, height, mid arm
circumference.
III, Clinical assessment: the sample will be clinically assessed for visible symptoms of
malnutrition. It includes the signs of malnutrition and deficiency diseases.
IV, Health status assessment: the mothers will be interviewed about the general
hygiene of their children, any recent illness, immunization status, taking of oral
supplements, frequency of skipping meals and medical checkups conducted.
V, Nutritional Assessment: Mothers will be asked to give dietary recall of the food
consumed by their children on the previous day in all the meals.
4.10. Data quality
Six data collectors, (three nurses and three assistants), two supervisors and the
principal investigator will be involved in data collection process. Before data collection,
the investigator will provide training and guideline for data collectors and supervisors on
how to interview mothers and how to take anthropometric measurements. The
instruments will be pre-tested on 10% of the samples in similar circumstances in order
to assure whether the instrument is efficient enough to meet the objective of the study
or not. Based on the feedback obtained from the pre-test, the questionnaire will be
reviewed. The pre-test questionnaire will be conducted on adjacent kifleketema the
principal investigators will regularly supervise data collector as the closing of each day
of data collection so as to check consistency, completeness and accuracy the filled
questioners.
14
4.11. Data processing and analysis
15
6. WORK PLAN
Proposal Principal
1 preparation investigator
16
and
supervisor
Data entry investigator,
9 and cleaning data
collector
assistance
Data analysis Principal
investigator
10
N.B One month has three divisions each division has ten days
17
7. BUDGET BREAK DOWN
Table 2: budget for the fieldwork component will include funds for personnel,
transport and supplies.
18
Photo copy cost 0.75 birr 500 375
Printing cost 1.5 birr 60 90
Binding cost 8 10 80
Supplies total 2,260
19
8. REFERRENCES
http://www.who.int/mip2001/files/2232/NHDbrochure.pdf
2. UNICEF.Complementary foods for children between 6 and 36 months of age. September 2006,
Unilever Health Institute, ISBN-13: 978-92-806-3996-4
3. International Food Policy Research Institute. 2016. The new challenge: End all forms
of malnutrition by 2030. In Global Nutrition Report 2016: From Promise to Impact:
Ending Malnutrition by 2030. ISSN: 2380-644 Pp. 1-13.
4. Malnutrition rates in children under 5 years
https://www.unicef.org/nigeria/factsheets_NUTRITION_low.pdf
5. Central Statistical Agency. Ethiopia Demographic and Health Survey. Addis Ababa,
Ethiopia: 2016 pp 30
6. Verick, S. Female labor force participation in developing countries. IZA World of
Labor 2014: 87 doi: 10.15185/izawol.87
7. Federal ministry of health. National nutrition strategy, Addis Abeba, Ethiopia 2008
8. Dr. Naheed Vaida. Impact of Maternal Occupation on Health and Nutritional Status of
Pre schoolers. IOSR Journal Of Humanities And Social Science (IOSR-JHSS), e-ISSN:
2279-0837, p-ISSN: 2279-0845 Volume 7, Issue 1 (Jan. - Feb. 2013), PP 09-12
9.UNICEF. Improving child nutrition: The achievable imperative for global progress.
Unicef. April 2013 ISBN: 978-92-806-4686-3. P 124
http://www.who.int/nutrition/EB128_18_backgroundpaper2_A_reviewofhealthinterventio
nswithaneffectonnutrition.pdf
20
13. Michael C. Latham.Human nutrition in the developing world. Food and nutrition
series; 1997 (29): ISBN 925103818X P125-30
15.Mercedes de Onis, David Brown, MonikaBlössner and Elaine Borghi World Health
Organization. ISBN 978 92 4 150451 5.
17. United Nations Children’s Fund (UNICEF).Improving Child Nutrition. United Nations
Publications .April 2013 ISBN: 978-92-806-4686-3.
18. Hetal Damania and Dr. Perpetua Machado Nutritional Assessment of Working and
Non-Working Mothers: march 2014, ISSN 2278–0211 Vol 3 Issues 3
19. Dr Ritu Bhatia. influence of maternal occupation on family food pattern & eating
habits of preschool children. South -Asian Journal of Multidisciplinary Studies (SAJMS)
ISSN:2349-7858:SJIF:2.246:Volume 3 Issue 5
20. Dr. Naheed Vaida. Impact of Maternal Occupation on Health and Nutritional Status
of Pre schoolers. IOSR Journal Of Humanities And Social Science (IOSR-JHSS), e-
ISSN: 2279-0837, p-ISSN: 2279-0845 Volume 7, Issue 1 (Jan. - Feb. 2013), PP 09-12
21. Farhanah Shuhaimi and Naleena Devi Muniandy. The Association of Maternal
Employment Status on Nutritional Status among Children in Selected Kindergartens .
Asian Journal of Clinical Nutrition, 2012,4: 53-66.ISSN 1992-1470
22. Abdibari Ma’alin, Dereje Birhanu, Samuel Melaku, Daniel Tolossa, Yusuf
Mohammed and Kiros Gebremicheal.Magnitude and factors associated with
malnutrition in children 6–59 months of age. BioMed Central .ISSN 2055-0928.2:44(20)
23. mu'awiyyah Babale Sufiyan, Sulaiman Saidu Bashir, Ahmad Ayuba Umar. Effect of
21
maternal literacy on nutritional status of children under 5 years of age Year : 2012 |
Volume : 6 | Issue : 2 | Page : 61-6(20)
24. Africa nutrition chart book, nutrition of infants and young children in Malawi, finding
from the 1992 Malawi DHS survey, February 1994.
25. Gugsa Yimer. Malnutrition among children in southern Ethiopia: levels and risk
22
9. ANNEX
Questionnaires
Kebele’s number
House number
Family size
Is mother working?
23
5. What is your ethnicity?
1.Amhara
2. Oromo
3. Tigrie
4. Gurage
5. Others
1. Owned
2. Rented
3. Dependent
4. Others
1. Piped water
2. Well water
3. Surface water (river,spring )
4. Others
9. What kind of toilet facility
Does your household have?
24
1. Flush toilet
2. Pit latrine, private
3. Pit latrine, shared
4. No facility / Bush / Field
1. Yes
2. No
1. Government employee
2. Private Sector Employee
3. NGO employee
4. Self employee
5. Daily laborer
6. Vending
7. No work
8. Others, specify
25
13. While you are at home, what do you
do in your leisure time?
14. The number of hours per day, days per week, months per year of work.
15. Distance from residence to work station in meter.
Section 3: Information on Characteristics of children aged 6-59 months
In months
1.Male
2. Female
26
1.Health professional
2.Trained Birth Attendant
3.Traditional Birth Attendant
4.Relatives/Friend/Neighbour
5.Others
.Yes
2. No
2. 4 - 6 months
3. 7 – 9 months
4. 10 – 12 months
5. More than 12 months
In months
In months
27
23.If the answer for 22 is yes, did you
seek advice or treatment for the
Fever?
1. Yes
2. No
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
28
27. If the answer for 26 is yes, did you
seek advice or treatment for the
cough?
1. Yes
2. No
28. If the answer for question
number 27 is yes, where did
you seek advice/treatment?
1. Public Sector
2.Private Medical Sector
3.Traditional Practitioner
29. Is your child vaccinated?
(See card)
1. Yes
2. No
30.If the answer for question
number 29 is yes, what type of
vaccination does he/she take?
A) From Card ()
B) Mother’s Report ()
1. BCG only
2. BCG, DPT1, Polio1
3. BCG, DPT1 – 2, Polio1 – 2
4. BCG, DPT1 – 3, Polio1 – 3
5. BCG, DPT1-3, Polio1-3,Meseales
29
Section 4: Information on Mother’s Work Characteristics
1. Yes
2. No
32. If the answer for question
number 31 is yes, how many
days do you work per week?
1. 1 day
2. 2 days
3. 3 days
4. 4 days
5. 5 days
6. The whole week
1. Per day
2. Per week
3. Per month
30
34. If “No” for question No. 31
how do you get earnings?
1. From husband
2. From relatives
3. Help from others
1. Respondent
2. Husband/partner
3. Both together
4. Others, specify
5. No response
31
decides whether the child is sick
enough to be taken for treatment?
1. Respondent
2. Husband/partner
3. Both together
4. Others, specify
5. No response
1. Respondent
2. Husband/partner
3. Both together
4. Others, specify
5. No response
32