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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 162-168

Prevalence of malnutrition and its related factors among urban and rural primary school students, Abadan, in 2019


1 Instructor, MSc in Medical Surgical Nursing, Abadan University of Medical Sciences, Abadan, Iran
2 Assistant Professor, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
3 Student Research Committee, Abadan University of Medical Sciences, Abadan, Iran
4 MSc in Psychiatric Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
5 PhD Student in Medical Entomology and Carrier Control, Tehran University of Medical Sciences, Tehran, Iran

Date of Submission29-May-2022
Date of Decision12-Oct-2022
Date of Acceptance17-Oct-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Farshid Mohammad Mousaei
Student Research Committee, Abadan University of Medical Sciences, Abadan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/shb.shb_83_22

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  Abstract 


Introduction: Malnutrition is one of the most important public health problems worldwide and has adverse effects on the physical as well as mental capacities of individuals, especially school-age children. This descriptive-analytical study aimed to investigate the nutritional status of primary-school students in urban and rural areas of Abadan. Methods: Multi-stage stratified-cluster and simple random sampling was performed on urban and rural primary school students in Abadan with the demographic information, height, and weight of 1133 students measured. Furthermore, the indices of short stature for age (stunting), low weight for age (underweight), and low weight for height (wasting) in children were calculated and compared with the National Center for Health Statistics standard. Results: The results revealed that the average age of malnourished children was 9.56 years and the average age of normal children was 8.97 years. The malnutrition prevalence among primary school children of Abadan was 8%, and there was a poor correlation between factors such as sex (P = 0/8), place of residence (P = 0/4), plus school place (P = 0/9), and malnutrition, while there was a positive relationship between with the parents' level of education and malnutrition (P = 0/02). Thus, the most influential factor seems to be the parents' level of education and awareness. Conclusion: Steps can be taken to promote the social and cultural level of families and prevent malnutrition as well as improve the nutritional status of society through collaboration among various institutions, holding educational classes with the presence of education departments, and encouraging families. The household economic status is also one of the important factors in the implementation of these educational classes that must be considered.

Keywords: Khuzestan, malnutrition, students


How to cite this article:
Elhami S, Hatefimoadab N, Mousaei FM, Naeimi S, Azizi M, Moghadam DS, Ghassemi M. Prevalence of malnutrition and its related factors among urban and rural primary school students, Abadan, in 2019. Asian J Soc Health Behav 2022;5:162-8

How to cite this URL:
Elhami S, Hatefimoadab N, Mousaei FM, Naeimi S, Azizi M, Moghadam DS, Ghassemi M. Prevalence of malnutrition and its related factors among urban and rural primary school students, Abadan, in 2019. Asian J Soc Health Behav [serial online] 2022 [cited 2022 Dec 8];5:162-8. Available from: http://www.healthandbehavior.com/text.asp?2022/5/4/162/361713




  Introduction Top


Malnutrition is a major challenge worldwide, especially in Asia, Africa, and South America.[1] It is also regarded as one of the most important public health problems in the world.[2] In the UNICEF global nutrition report in 2016, Iran has been ranked 14th and 53rd regarding stunting and wasting among nearly 130 countries, respectively.[3] The occurrence of weather events such as droughts and floods, low level of education and income of households, and prevalence of poverty among households cause a decline in material and economic access to food as well as occurrence of malnutrition, especially in less privileged areas such as the southwest of Khuzestan. These factors will affect the rural population more than the urban population.[4]

Inadequate nutrition is a type of malnutrition. This happens when the body does not eat enough food. This can lead to stunted growth, low weight, or wasting. Furthermore, if a person does not receive the right balance of the right nutrients, they can become malnourished. Contrary to popular belief, with this type of malnutrition, there is also the possibility of obesity. When a person receives little food, an incorrect diet, or a condition where the body cannot maintain proper nutrients, their health will be heavily affected.

Malnutrition has adverse effects on the physical and mental capacities of the individual, including short stature, weak immune system, behavioral disorders, academic failure, intelligence, and learning failure,[5] which is irreversible even if nutritional conditions, better care, and better living conditions improve in later years.[6],[7] In some cases, this issue can even threaten a person's life.

Students in disadvantaged areas of any society are at greater risk for various reasons and need special attention as they constitute a significant percentage of the population in developing countries. The results of the study by Namakin et al. in disadvantaged areas of southern Khorasan province reported that malnutrition prevalence was nearly 70% based on underweight and stunting indices.[8] The results of a review study by Mohammadi et al. showed that the overall underweight prevalence was 15.5% among Iranian 1-month to 12-year-old children with (95% confidence interval). The highest underweight prevalence was also reported among children of Birjand and Zahedan (68.6%) and the lowest underweight prevalence was also observed among children of Jahrom (1.8%).[9] Further, another review study reported that the overall malnutrition prevalence among Iranian children under 6 years of age was 13%. The prevalence of severe, moderate, and mild malnutrition was also 1%, 6%, and 25%, respectively.[10] Another study reported that the overweight and obesity prevalence among 7–18-year-old Iranian children was 12.67% and 10.47%, respectively.[11] The prevalence of overweight and obesity among Iranian children aged 6–18 years was reported to be 10.1% and 4.79% in another study in Iran, respectively.[11]

One of the cost-effective and reliable methods of malnutrition assessment is anthropometric evaluation.[12] This method is used to assess the nutritional status of individuals and communities. In addition to the growth and nutritional status of the child, this index determines the socioeconomic status and quality of life.[13] Height and weight have been regarded as two important indices in this method. Stunting, underweight, and wasting were proposed by the WHO (1986) to diagnose malnutrition based on the National Center for Health.[14]

Elementary-age students are in their rapid growth phase of development, and since the southwestern region of Khuzestan is one of the deprived and border regions of the country, the nutritional status of students in these regions has not been specifically studied so far. This study was conducted with an anthropometric method to investigate the nutritional status of 7–12-year-old students in schools in the urban and rural areas of southwest Khuzestan.


  Methods Top


Study design and participants

This is a descriptive-analytical study with the study population covering urban and rural primary school students in Abadan. Abadan county is located in the southwest of Khuzestan province, Iran. This city was considered one of the most beautiful and memorable cities in Iran before the Iraq's invasion to Iran. During Iran–Iraq War (8 years), Abadan was attacked by the enemy, which led to mass destruction.[15] The civilian population of the city dropped close to 0 during the 8 years of the Iran–Iraq War (1980–1988). The 1986 census recorded only 6 people. In 1991, 84,774 had returned to their residence in the city.[16] The population had jumped to 298,090, in 85,015 families, according to 2016 census.[17]

Inclusion criteria included 7-12-year-old students, parents' consent to participate in the study. Students or the school health teacher, who reported having certain diseases, including chronic kidney disease, heart disease, diabetes, and long-term use of certain medications or any disease that would affect weight, height, or learning in some way, were excluded from the study.

Sampling and sample size estimation

The multi-stage stratified-cluster and simple random sampling was used here. To this end, the list of urban and rural primary schools for girls and boys was first considered a cluster whereby five clusters were randomly selected from 113 schools and according to the population of Abadan. The students of the selected school were randomly investigated for malnutrition. Indeed, multi-stage stratified-cluster and simple random sampling was adopted. For the research, the researcher obtained the necessary permissions from the Department of Education, and then determined the clusters. Afterward, he referred to the schools and explained the research objective to the school officials, handed over informed consent forms to the students to be completed by their parents. They were also assured about confidentiality of their information, and the information was collected by a researcher of the same sex upon the next visit. Cochran's formula was used to determine the sample size. From 113 schools (82 urban and 31 rural), five clusters (2 rural and 3 urban clusters) were randomly selected and students were randomly selected from each level.



Procedure

Forms for obtaining informed consent and assuring the confidentiality of the information entered were delivered to the students to be completed by the parents. Then, in the next visit, the researcher of the same gender as the students collected the information. To collect data, demographic information (level of study, family history, place of residence, economic status, and parents' level of education) was recorded. Height and weight of all participants were measured using standard scales while wearing light clothing and no shoes. The stunting, underweight, and wasting indices were calculated and compared with the National Center for Health Statistics standard. Z-score was employed to compare these indicators with the WHO reference standard. This measure refers to the difference of the values of each individual from the average of a person of the same age and gender in the reference society, divided by the standard deviation of the reference society. In this study, according to the definition accepted by the majority of evaluations, the percentage of malnutrition in the society based on each index has been the percentage of Z-score <−2. For example, if a child has a weight-for-height Z-score equal to −2, he is considered short.[18] Some information was collected by asking students or extracting data from their school files.

Ethical consideration

Note that all ethical considerations, including obtaining the code of ethics from Abadan University of Medical Sciences (ABADANUMS.REC.012.1397), obtaining informed consent from participants, confidentiality (information, the possibility of withdrawing from the study, and the publication of the study results in general), were taken into consideration.

Statistical analysis

Statistical analysis was carried out using descriptive statistics to obtain basic information such as frequency, frequency percentage, mean, minimum and maximum, number, and standard deviation. With regard to the inferential statistics, Eta, Phi, and Kendall's correlations were used.


  Results Top


The total number of participants of the present study was 1144, of whom 11 (0.9%) had kidney disease, 7 (0.6%) had heart problems, 6 (0.6%) had diabetes, and 43 (3.6%) had other causes imposing their exclusion from the study, and only the results of healthy individuals were reported.

[Table 1] reports information on demographic variables including health status, place of study, sex, academic year, place of residence, economic status, father's education, and mother's education. Furthermore, [Table 2] presents information on the mean values of age, height, weight, and body mass index (BMI) as well as their relationship with the malnutrition prevalence.
Table 1: Descriptive statistics of demographic variables

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Table 2: Descriptive statistics of distance variables and malnutrition prevalence

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The overall malnutrition prevalence in the present study was 8%. This prevalence was 6.88% and 1.15% in urban and rural schools, respectively.

To investigate the relationship between age, weight, height, weight to age, height to age, weight to height, and malnutrition in children, since age, weight, and height are interval variables and malnutrition is a nominal variable, the Eta coefficient was used [Table 3].
Table 3: Correlation between age, weight, and height with malnutrition

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Considering their nominal nature, there was no correlation between sex or place of residence and malnutrition according to Phi correlation (P > 0.05).

Considering the sequential nature of educational level of the child, father, mother, and family economic status with malnutrition, Kendall's rank correlation was employed. As observed in the table, there was a correlation between the education level of the child plus parents and malnutrition, but there was no relationship between economic status and malnutrition [Table 4].
Table 4: Correlation between education level of child, father, mother, family economic status, and malnutrition

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Considering the nominal nature of sex and place of residence, to identify the relationship between sex as well as place of residence and malnutrition, Phi correlation was used [Table 5].
Table 5: Correlation between place of study, sex, and place of residence with malnutrition

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  Discussion Top


Many studies have shown that excessive increase or decrease in the weight of children can have detrimental effects on their health.[19],[20],[21] Nutritional deficiencies have a significant impact on physical and mental development, and subsequent consequences are manifested in vulnerable groups of society, i.e., children. On the other hand, child obesity and overweight can elevate the risk of various disorders such as hypertension, hyperlipidemia, and even type 2 diabetes. Moreover, several factors affect the incidence of malnutrition in this group. Results of the present study indicated that the malnutrition prevalence among primary school children of Abadan is 8%. In the review study, Mohammadi et al. (2018) reported that the overall underweight prevalence in Iranian children aged 1 month to 12 years was 15.5%.[9] Mirmohammadi et al. also reported that the overweight prevalence among children aged 7–18 years was 9.27%.[11] Further, the malnutrition prevalence among children aged 7–12 years in Kerman based on stunting, wasting, and underweight indices was 6.06%, 5.58%, and 75.9%, respectively.[22] The malnutrition prevalence among primary school children in the North of Iran was 3.20%.[23] Furthermore, in the study of middle-school students of Ilam, Iran, Gholami Prizad et al. reported that the underweight prevalence was 21.5%.[22] In addition, studies by Manyike et al. and Sorrie et al. reported that the malnutrition prevalence was 19.4% and 13.8%, respectively.[24],[25] According to a systematic review by Mohammadi et al., the highest child underweight prevalence belonged to Birjand and Zahedan (68.6%) while the lowest prevalence rate was reported in Jahrom (1.8%).[9] According to these studies, it seems that malnutrition is less common among primary school children of Abadan than other studies. Although rural areas of Abadan also participated in the present study, compared to other deprived areas and small cities, malnutrition has still a relatively low prevalence which can be related to the development level of other studied provinces and cities. It also shows an increase in the level of facilities and access to these urban facilities, as well as rich foods such as fish and date in rural areas. Although the number of households has not been investigated in the present study, since parents attach greater importance to their children because of the smaller number of children in today's families than in the past, it seems that parents have increased awareness and access to information with the expansion of social networks as well as access to nutrition information through the Internet and media.

The present study revealed a significant correlation between age and malnutrition [Table 2]; the average age of children with malnutrition was higher than normal individuals, which is consistent with the results of other studies.[22],[25],[26],[27],[28],[29],[30],[31],[32] For example, Haji Faraji et al. reported the highest overweight rate in both sexes at 14 years old, the highest underweight rate in both sexes at 12 years old, and stunting in 14–15 years of age based on BMI and height indices for age.[33] Similarly, Gholami Prizad et al. reported that the highest risk of underweight was at the age of 12 and the highest stunting rate was at the age of 12–13.[22] Physiological changes in children at this age are directly related to malnutrition with children of this age experiencing the highest prevalence of weight changes in the form of malnutrition.

There was no significant relationship between school place or place of residence and malnutrition. However, Sheikholeslam et al. reported that the stunting and underweight prevalence in urban children was significantly lower than in rural children. Furthermore, the wasting prevalence in urban areas was significantly higher than in rural areas.[34] Consistent with the present study, Naderi Beni et al. along with Sharifzadeh et al. found a significant relationship between place of residence as well as ethnicity and malnutrition.[32],[35] Farajzadeh et al. stated that the highest child malnutrition prevalence was observed in a low socioeconomic area of the city.[36] It seems that the difference between the results of the present study and other studies is due to the fact that rural areas of Abadan have easy access to urban facilities and there is a short distance between villages to urban areas; thus, it is easier to provide facilities in rural areas and more convenient to enhance the awareness of families about their children's malnutrition through public education and cooperation of rural health networks. We can also increase the awareness of parents through the media and cyberspace about the principles of proper nutrition as well as promote their access to health care better than in the past. On the other hand, access to poor-quality food resources such as fast food and sandwiches and places such as restaurants are observed less frequently and home-cooked foods are used more frequently in rural areas.

The present study showed no significant relationship between sex and child malnutrition, which is consistent with studies by Ahmadipour and Tadesse et al.[37],[38] According to previous weight studies, UNICEF also has reported no difference between two sexes of children in 51 countries.[39] However, some studies, such as Yirga et al. and Darebo et al., reported that the obesity prevalence in girls was nearly twice as high as in boys.[26],[28] However, other studies have reported higher malnutrition prevalence in boys than in girls.[29],[40],[41],[42],[43] According to the different results of previous studies on child malnutrition, it can be stated that the child gender alone does not determine the presence or absence of malnutrition.

Meanwhile, there was a positive relationship between the malnutrition status of children and the parents' level of education, as in other studies.[22],[25],[28],[32],[42],[44],[45],[46],[47],[48],[49] For example, Montazerifar et al. reported that 97% of mothers of children with malnutrition were homemakers, with 51.9% of whom being illiterate.[46] Increasing the level of education directly increases the awareness of the entire family and indirectly affects the family income as well as more access to facilities for healthy nutrition and providing high-value food. Promoting parents' level of education makes them more aware of their child's health as well as nutrition recommendations and control the growth stages and health of their child, directing them to pay more visits to healthcare centers.


  Conclusion Top


According to our results, malnutrition among the students of southwestern Khuzestan has a favorable situation. The most influential factor on malnutrition in primary school students is the level of education of parents and their awareness. It is suggested to focus on holding nutritional training classes of children to promote and prevent malnutrition as well as improve the nutritional status of society as much as possible.

Limitations

In this study, there was impossible to identify related factors including genetics, heredity, early feeding and infancy, and the duration of breastfeeding.

Acknowledgments

The present article is the result of a research project approved by Abadan University of Medical Sciences with the number IR-ABADANUMS. REC.012.1397. The researchers would like to express their gratitude to the Vice Chancellor for Research and Technology of Abadan University of Medical Sciences and all those who cooperated with the research team.

Financial support and sponsorship

Abadan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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