Socio-economic, environmental, care, health and nutritional determinants in the aetiology of severe protein-energy malnutrition in Southern Ethiopia (Sidama) with emphasis on kwashiorkor [Elektronische Ressource] : a one year prospective and retrospective follow-up study to find out predisposing factors / vorgelegt von Susanne Dreschl-Bogale
334 Pages
English
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Socio-economic, environmental, care, health and nutritional determinants in the aetiology of severe protein-energy malnutrition in Southern Ethiopia (Sidama) with emphasis on kwashiorkor [Elektronische Ressource] : a one year prospective and retrospective follow-up study to find out predisposing factors / vorgelegt von Susanne Dreschl-Bogale

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334 Pages
English

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Dissertation zur Erlangung des Doktorgrades beim Fachbereich Agrarwissenschaften, Ökotrophologie und Umweltmanagement Mit dem Thema: "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 - vorgelegt von: Dipl. oec.troph. Susanne Dreschl-Bogale Gießen, Februar 2007 Erstgutachter: Prof. Dr. med. M. Leichsenring Zweitgutachterin: Prof. Dr. I.-U. Leonhäuser Institut für Ernährungswissenschaft Justus-Liebig-Universität Gießen Disputationsdatum: 22.03.2007 Prüfungskommission Prüfungsvorsitz: Prof. Dr. Ernst-August Nuppenau 1. Gutachter: Prof. Dr. Michael Leichsenring 2. Gutachterin: Prof. Dr. Ingrid-Ute Leonhäuser 1. Prüfer: Prof. Dr. Michael Krawinkel 2. Prüfer: Prof. em. Dr. Claus Leitzmann We think sometimes that poverty is only being hun-gry, naked and homeless. The poverty of being un-wanted, unloved and un-cared for is the greatest poverty. We must start in our own homes to remedy this kind of poverty. (Mother Teresa) IACKNOWLEDGEMENTS It would be impossible to thank all individuals and institutions, who have contributed to this thesis, but the following deserve a special mention.

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Published 01 January 2008
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Dissertation zur Erlangung des Doktorgrades
beim Fachbereich
Agrarwissenschaften, Ökotrophologie und Umweltmanagement


Mit dem Thema:




"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 -




vorgelegt von:
Dipl. oec.troph. Susanne Dreschl-Bogale
Gießen, Februar 2007




Erstgutachter:
Prof. Dr. med. M. Leichsenring

Zweitgutachterin:
Prof. Dr. I.-U. Leonhäuser





Institut für Ernährungswissenschaft
Justus-Liebig-Universität Gießen
Disputationsdatum: 22.03.2007


Prüfungskommission

Prüfungsvorsitz: Prof. Dr. Ernst-August Nuppenau
1. Gutachter: Prof. Dr. Michael Leichsenring
2. Gutachterin: Prof. Dr. Ingrid-Ute Leonhäuser

1. Prüfer: Prof. Dr. Michael Krawinkel
2. Prüfer: Prof. em. Dr. Claus Leitzmann












We think sometimes that
poverty is only being hun-
gry, naked and homeless.
The poverty of being un-
wanted, unloved and un-
cared for is the greatest
poverty. We must start in
our own homes to remedy
this kind of poverty.
(Mother Teresa)
IACKNOWLEDGEMENTS

It would be impossible to thank all individuals and institutions, who have contributed
to this thesis, but the following deserve a special mention. I wish to express my
deepest and foremost gratitude to Professor Dr. M. Leichsenring for his untiring aca-
demic counselling, encouragement, invaluable suggestions and constructive criti-
cism. Beside his work in the children’s hospital in Heidelberg, he did not hesitate to
visit the project staff three times in Yirga Alem, Ethiopia to give us indispensable
guidance through the field work. I sincerely appreciate his support, especially when
decisions had to be made quickly and I was difficult to be contacted in Yirga Alem.
Without the full support of Professor Leichsenring this work would not have been
possible, indeed.

My grateful thanks go also to Professor Dr. Kassa Darge who was - together with
Professor Leichsenring - the initiator of the overall project. He also visited us during
the survey period several times and tirelessly supported the running of the studies. I
very much appreciate his diplomatic skills and encouragement for all staff members.
Without him this study would not have been carried out.

I thank Professor Dr. I.-U. Leonhäuser for her supporting contribution to this thesis as
a second supervisor. Her suggestions have been very resourceful and she encour-
aged me all the time to finalise this thesis.

My grateful appreciation goes to Assistant. Professor Dr. Tadesse Alemu for his
practical assistance during the field work. Additionally, I wish to acknowledge the
good working atmosphere and co-operation with the Evangelical Lutheran Mission,
especially Dr. S. Lende, Dr. J. Olavson and Sister Marit and the Yirga Alem Hospital
staff during the study period.

I owe immeasurable dept of gratitude to the staff of the kwashiorkor project: to Dr.
Melese Abebe, Dr. Aster Bekele, Dr. Tedbabe Degife, to Tafasech, to Million Bogale
and my enumerators Fatele, Banchi and Martha. They did incredible work in the field
and made it possible to get deep contact and an insight view to the investigated
households .
III would like to thank the above for all the discussions we had about the research sub-
ject. My thanks also go to the drivers Gashew, Fasil and Ato Lema for their amasing
ability to bring us to the households who were living in very inaccessible villages.

Special thanks go to all Ethiopian families who co-operated in this study, who allowed
us to stay with them and for their boundless hospitality during the field survey. For
their children I wish all the best for the daily fight in surviving.

During data analysis in Germany a large number of people gave valuable support.
With all of them in mind, I can only name a few. Special thanks goes to Dr. J. Erhard
who assisted me in using the Nutrisurvey programme. I thank Dr. M. Hollenhorst,
from the HRZ, JLU Giessen for his endless patience, his continuous and competent
advisory support in the application and interpretation of statistical analysis.

I thank Professor Dr. M. Krawinkel and Professor Dr. C. Leitzmann for their advisory
support during the time of analysing. Sincere gratitude also to Jacqueline Köhler, and
Dr. D. Müller and especially Anna Tallant for their help to correct my English and to
Dr. M. Höher, the managing director of the ZEU, and Lora Köstler and Sabrina Bartel
who helped in editing.

I wish to express the German Academic Exchange Service (DAAD) for their financial
support throughout the study in Ethiopia without which this study would not have
been completed.

Finally I wish to express my deepest appreciation to my beloved husband Million
Bogale, who shared all the stress and strain, whose contributions to this work, in
Ethiopia as well as in Germany, unfailing support and organising ability have been far
beyond any acknowledgement and thanksgiving. Without his devoted collaboration,
timely accomplishment would have been enormously difficult, if not impossible. Fi-
nally I am grateful to our kids, Lisa, Joanne and Niclas, for their patience and toler-
ance when their Mama had to work.
IIICONTENTS

ACKNOWLEDGEMENTS............................................................................................II
TABLE OF CONTENTS............................................................................................. IV
LIST OF TABLES ...................................................................................................... IX
LIST OF FIGURES ................................................................................................... XII
ANNEX CONTENTS.................................................................................................XV
ABBREVIATIONS AND AGRONYMS ....................................................................XVII
TERMS AND ABBREVIATION ................................................................................ XIII

1 INTRODUCTION.....................................................................................I
1.1 Subject..................................................................................................1
1.2 Facts, relevance of the research topic and hypotheses......................... 1
1.3 Objectives of the study .......................................................................... 4
2 METHODOLOGY ...................................................................................5
2.1 Causal model ........................................................................................ 5
2.2 Study design.......................................................................................... 7
2.3 Variables, indicators and methods........................................................10
2.4 Data analysis and statistics ..................................................................14
2.5 Limitation of the study...........................................................................17
2.6 Ethical consideration ............................................................................17
3 GENERAL CHARACTERISTICS OF THE STUDY AREA AND
STUDY SAMPLE..................................................................................19
3.1 Study area and population....................................................................19
3.2 Food pattern in the Sidama zone .........................................................20
3.3 Protein-energy malnutrition - a major problem in the Saidama zone....25
3.4 General nutritional structure of the sample...........................................25
3.4.1 Nutritional status of the index children..................................................26
IV3.4.1.1 Methods............................................................................................... 26
3.4.1.2 Results ................................................................................................ 27
3.4.2 Occurrence of nutritional oedema in the index children........................31
4 BASIC AND UNDERLING CAUSES OF MALNUTRITION,
ESPECIALLY OF KWASHIORKOR .....................................................31
4.1 General structure of households ..........................................................32
4.2 Educational status of primary caregivers and heads of households.....32
4.2.1 Method 33
4.2.2Results ................................................................................................ 33
4.3 Economic situation of the households ..................................................35
4.3.1 Background ......................................................................................... 35
4.3.2Method 35
4.3.3 Results 36
4.3.3.1Monetary income..................................................................................36
4.3.3.1.1 Absolute income...................................................................................37
4.3.3.1.2 Income per capita.................................................................................38
4.3.3.1.3 Gender aspect in income generating activities .....................................42
4.3.3.1.4 Sources of income................................................................................43
4.3.3.2 Expenditures ........................................................................................50
4.3.3.2.1 Total consumption expenditures...........................................................50
4.3.3.2.2 Food expenditure51
4.3.3.2.3 Absolute food expenditure....................................................................51
4.3.3.2.4 Food expenditure per capita.................................................................52
4.3.3.2.5 The budget share for food54
4.3.3.2.6 Frequency distribution of PEM occurrence within categories of
food expenditure...................................................................................55
4.3.3.3 Qualitative description of food expenditure.......................................... 56
4.4 Agricultural production and livestock ownership...................................67
4.4.1 Method ................................................................................................ 67
4.4.2Results 67
4.4.2.1 Agricultural products and usage pattern...............................................67
4.4.2.2 Livestock ownership, products of livestock and usage pattern .............73
4.5 Families self assessment of their problems in daily life ........................76
4.5.1Head of household’s self assessment of their problems...................... 76
4.5.2 Caregiver’s self assessment of their problems in daily life .................. 78
4.6 Food variety at the household level......................................................80
V4.6.1 Background and method ..................................................................... 81
4.6.2 Results ................................................................................................ 82
4.7 Care for children as a determinant for the occurrence of
nutritional oedema................................................................................86
4.7.1Background ......................................................................................... 87
4.7.2Methods............................................................................................... 88
4.7.3 Results 89
4.7.3.1Activity profile of caregiver and index child...........................................89
4.7.3.2 Care index: index creation and results .................................................93
4.7.3.3 Care and the occurrence of nutritional oedema..................................104
5 IMMEDIATE CAUSES OF MALNUTRITION, ESPECIALLY OF
KWASHIORKOR ................................................................................109
5.1 Illness background..............................................................................109
5.1.1 Methods and hypothesis.................................................................... 109
5.1.2Results .............................................................................................. 110
5.1.2.1 Period prevalence of diseases in the 14 days previous to the last
home visit ...........................................................................................111
5.1.2.2 Seasonal influences on the occurrence of diseases...........................112
5.1.2.3 Pattern of illnesses .............................................................................113
5.1.2.4 Illness frequency of household members ...........................................120
5.2 Nutritional background of the index children.......................................127
5.2.1 Breastfeeding and weaning practices and their relation to PEM ....... 127
5.2.2 Food intake........................................................................................ 130
5.2.2.1 Consumption frequency......................................................................132
5.2.2.1.1 Method ...............................................................................................132
5.2.2.1.2 Results133
5.2.2.2 Adequacy of the diet...........................................................................142
5.2.2.2.1 Method142
5.2.2.2.2 Results142
VI6 ANALYSIS OF DETERMINANTS.......................................................163
6.1 Relations between certain determinants.............................................163
6.1.1 Relation between the occurrence of illnesses and food diversity
in the household and the occurrence of nutritional oedema .............. 163
6.1.2 Relation between per capita income and food diversity..................... 163
6.1.3Relation between per capita income and illness................................ 166
6.1.4 Care and its impact on the adequacy rate of food supply.................. 166
6.2 Multivariate analysis of determinants - comprehensive logistic
regression of variables with significant impact on the occurence of
nutritional oedema -............................................................................168
7 DISCUSSION .....................................................................................179
8A TYPICAL HOUSEHOLD WITH A KWASHIORKOR CHILD IN
SIDAMA,- A REFLECTION OF OBSERVATIONS AND
DISCUSSIONS DURING HOME VISITS............................................221
9 RECOMMENDATIONS ......................................................................235
10SUMMARY .........................................................................................243
REFERENCES .......................................................................................................249
ANNEX .......................................................................................................275
PHOTODOCUMENTATION ....................................................................................307

VII


















































VIII