Addressing Malnutrition in Children: An Appraisal of the Ondo State Nutrition Program

Background The report of the 2013 Nigeria Demographic and Health Survey (NDHS 2013) showed Ondo State had one of the worst indices for stunting and underweight in the southwestern geopolitical zone of the country, a development that was considered "unacceptable" by the state government. In the bid to reverse the ugly trend, the State Primary Health Care Development Agency put in place a comprehensive nutrition program in 2015 tagged "Nutrition Rebirth," aimed at reversing the high prevalence of malnutrition among under-five children in the State. Aims This study seeks to evaluate the Ondo State comprehensive nutrition program by comparing the children's nutritional status pre- and post-period under review in the implementation of the program. This provides a measure of assessment of the performance of the program as implemented in the period under review. Materials and methods This study covered the period between 2015 and 2017 in the implementation of the nutrition rebirth program. Data for the study were obtained from the NDHS (2013) and NDHS (2018) nutrition of children and women data. Analysis of the NDHS (2013) and NDHS (2018) data commenced simultaneously with field work and lasted for about six and eight months, respectively. Analysis of the data obtained from the NDHS for this study spanned through a period of about three weeks. An ecologic time-trend analysis was used to compare the trends in nutritional status indicators among under-five children in all 18 Local Government Areas (LGAs) in Ondo State. Results Malnutrition among children less than five years dropped in most of the LGAs in 2018. Malnutrition was not associated with children's gender and maternal age in 2013 and 2018. Prevalence of stunting growth and underweight was associated with maternal education, wealth index, residence type, place of delivery, and LGA in 2013 (p < 0.05) but was not in 2018 (p > 0.05). Conclusions The spatial analysis of the Ondo State comprehensive nutrition program showed that the program has a positive impact, reducing malnutrition among children under five years; but critical appraisal of implementation challenges in LGAs with no significant reduction in malnutrition among their children under five years is recommended. The comprehensive and wholistic approach of the program is also recommended for other states and settings with a high prevalence of under-five malnutrition to understudy the possible adaptation, as appropriate.


Introduction Background
Malnutrition, defined as deficiencies or imbalances in the intake of nutrients, is among the leading cause of death in children below age five in developing countries [1]. Two forms of this disorder, with fatal and other serious devastating effects, exist, namely, overnutrition and undernutrition [1][2][3][4][5]. Undernutrition, categorized 1 1 2 1   3  4  1  1 into stunting, wasting, and underweight, can be identified with anthropometric measurements. Stunting, otherwise known as low height-for-age or chronic undernutrition, is a growth retardation problem occurring as a result of long-term nutritional deprivation [6]. Wasting, otherwise known as low weight-for-height or acute undernutrition, on other hand, results from acute food shortage or the presence of a disease. The third indicator for measuring undernutrition in children is underweight, which is also referred to as low weight-for-age. This reflects both acute and chronic undernutrition [6].
The Nigeria Demographic Health Survey (NDHS) 2013 report showed that Ondo State had one of the worst indices for stunting and underweight in the southwestern geopolitical zone of the country [7]. As a result of these frightening statistics in Ondo State, a comprehensive nutrition program tagged "Nutrition Rebirth" was implemented between 2015 and 2017 (the period under study) by the Ondo State government to curb the menace of malnutrition in the State. The nutrition program took a wholistic approach to tackle the unacceptably high pre-intervention prevalence of undernutrition among under-five children in the State, which was estimated to be 24% for stunting, 6.6% for wasting, and 13.4% for underweight according to the 2013 NDHS data [7].

Activities
Activities carried out in the program included procurement of relevant nutrition, growth-monitoring equipment, and materials for all primary health facilities in Ondo State; routine growth monitoring; vitamin supplementation and distribution of zinc sulfate; live educational program on exclusive breastfeeding and consumption of appropriate diet on the State's radio stations (

Materials And Methods
We used an ecologic, time-trend analysis to compare the trend in nutritional status indicators among underfive children in all 18 LGAs in the Ondo State. Data for the study were obtained from the NDHS (2013) and NDHS (2018) nutritional status of children and the sociodemographic data of women. Data for a total of 523 and 177 under-five children in the NDHS (2013) and NDHS (2018), respectively, with valid and complete information on date of birth, height (in centimeters), and weight (in kilograms) were analyzed for Ondo State and were utilized for this study [7].
The 2013 and 2018 NDHS data on nutrition were collected using the NDHS household questionnaire. Measurements of height and weight were obtained for children born in the five years preceding the surveys in all of the selected households. Weight measurements (in kilograms) were made using lightweight SECA GmbH scales (with digital screens), while height and length (in centimeters) were measured using a ShorrBoard® measuring board. Children under 24 months were measured lying down on the board, and standing height was measured for all other children [7,8].
To assess the precision of measurements, one child per cluster was randomly selected to be measured a second time. A difference of one centimeter or less between the two height measurements was defined as an acceptable level of precision. Children with a Z-score of less than -3 or more than 3 for height-for-age, weight-for-height, or weight-for-age were flagged and measured a second time. Re-measurement of flagged cases was performed to ensure accurate reporting of height and weight measurements [8]. The interviewers for the NDHS were trained on the use of the data collection tool and anthropometric measurements. Cross-tabulations were done using the Chi-square test to determine if the populations used for the two datasets were similar. The mean and standard deviations of the ages of the children and their mothers for the two data sets were also compared using the student's t-test. The height-for-age Z-score, weight-forheight Z-score, and weight-for-age Z-score for each dataset were calculated using the WHO Anthro software version 3.2.2. The Z-score for each nutritional status indicator was dichotomized into below minus two standard deviations (<-2 SD) and minus two standard deviations and above (≥-2 SD). Children with height-for-age Z-score < -2 SD were considered stunted, children with weight-for-height Z-score < -2 SD were considered wasted, while children with weight-for-age Z-score < -2 SD were considered underweight. The percentage of children with Z-scores < -2 SD for each of the nutritional status indicators were compared between the Ondo State 2013 and 2018 NDHS data across the 18 LGAs in the State. Permission to use the 2013 and 2018 NDHS dataset was obtained from MEASURE DHS.

Discussion
The Ondo State "Nutrition Rebirth" program started in 2015 adopts a comprehensive and multidimensional approach to addressing the determinants of under-five nutritional status in the State. It incorporates community mobilization and awareness creation, behavioral change communication for caregivers, production of affordable BCF from locally available food materials that proved to be quite effective in rehabilitating acutely malnourished children, vitamin supplementation and distribution of deworming tablets, live educational program to address exclusive breastfeeding, consumption of appropriate diet, and training of health workers on infant and young child feeding. In this regard, it differs from the practice in other settings that employ a noncomprehensive approach to reducing the prevalence of malnutrition [9][10][11].
The BCF component of the "Nutrition Rebirth" program consists of locally sourced food materials (sorghum, maize, soybean, and orange-fleshed sweet potato), which provided a cheap source of additional protein, vitamin A, and energy for the treatment of MAM among children under-five in the State. Ample anecdotal evidence from field observation and routine data showed the BCF to be effective and efficient in the management of cases of MAM in the State, and this, no doubt, contributed to the significant reduction in the prevalence of stunting and underweight in the period under review. Complementary feeding programs have been implemented in several countries and have shown positive impacts on the nutritional status of children. These include growth-monitoring practices among health workers in India nutrition education and mega-dose of vitamin A supplementation in Nepal [12][13][14][15].
There was no statistically significant difference in the mean age, size at birth, gender, maternal age, and residence of sampled children in 2013 and 2018, showing a similarity between the 2013 and 2018 sample sizes used for the study. Stunting and wasting were dependent on the age of the children in 2013 (p < 0.05) but were not statistically significant across the children's age in 2018. This is an indication of improved nutrition for the different age groups of under-five children sampled for the study during the 2013-2018 period under review. A similar finding was observed in the assessment of the prevalence of malnutrition by LGAs, and this could be attributed to the gross effect of the improved nutritional care and support to children under five years in the LGAs during the implementation of the nutrition program in the State.
However, not all the LGAs recorded an improvement in the nutritional status of the children during this period. There was no change in the nutritional status of children in few LGAs in 2018 compared to 2013, while a few others recorded an increase in the prevalence of malnutrition. ( Table 2). This suggests the need for critical appraisal of the program with a view to strengthening it in those areas. Although the implementation of the comprehensive nutrition program started in Ondo State in 2015, the extent of the program utilization could differ from one LGA to the other due to some factors that are determinants of health services uptake, and that could undermine its success. Poor utilization or adoption of similar programs by mothers, e.g., growth-monitoring practices and exclusive breastfeeding, have been reported in areas of poor socioeconomic development in Africa [14].
Studies in Nigeria and other climes have implicated persistent negative attitudes regarding infant and young child feeding (IYCF) as a major cause of poor knowledge of health workers about similar programs both before and after the intervention, hence the poor practices and service uptake [16]. The deeply rooted sociocultural behaviors that persist among health workers shape their opinions despite previous medical or public health training and re-training [16]. The training of the State health workers on IYCF and other nutrition-related themes during the period under review would have contributed to the improvement in the knowledge and, expectedly, the attitude of the health workers, thereby facilitating improved delivery of nutrition care during the implementation of the State nutrition program [17,18]. Poor nutritional knowledge among health workers could contribute to low utilization of nutritional intervention services [19].
As expected, malnutrition was associated with maternal education, wealth index, residence type, and place of delivery, all of which are factors that affect health-care service uptake. However, this observation was only true for 2013 and not 2018. Although we cannot presently ascertain the lack of differences in nutritional status of the children relative to some of their mothers' sociodemographic characteristics in 2018 (e.g., maternal highest education, wealth index, residence, and place of delivery), this observation could be linked to the intensive, comprehensive, and state-wide community mobilization and awareness creation about malnutrition, exclusive breastfeeding, and IYCF during the period under review. Also, there was a notable improvement in the accessibility to quality and free maternal and child health-care services provided by the government during the period, which was a motivation for mothers across the socioeconomic and demographic strata in the State to patronize government health facilities for maternal and child health care, thus reducing the effect of the differing sociodemographic characteristics that exist among them on uptake of the nutrition care services being provided through the program [19][20][21].
A study on the free health program in the State during this period showed that while women in the urban areas of the State were twice as more likely to deliver their babies in a health facility compared to their counterparts in rural areas (NDHS 2013), the 2016 study survey noted that the rural-urban divide in maternal residency was no longer significantly associated with higher odds of health facility delivery [22]. The persistent economic downturn in the country which affects every sector of the population could as well have contributed to the significant difference observed in the association between malnutrition and maternal demographic characteristics (education, wealth index, residence type, and place of delivery) in 2013 and not in 2018. Those who should have been able to fend for their wards may be grossly affected by economic hardship, thus posing a threat to the overall impact of the government-based complementary feeding program, which is meant to complement the parents' efforts in nourishing their wards [23,24]. It is noteworthy that there was strong political will and improved funding for primary healthcare (PHC) activities during the period under reporting, a development that resulted in marked improvement in delivery at PHC facilities in the State (Table 1) [25,26].
The limitations of this study are ecologic fallacy and the effect of confounders. The temporal relationship cannot also be determined. This is a questionnaire-based study with data being driven by the populace. This could be a source of bias in the study as well.

Conclusions
In conclusion, the spatial analysis of the Ondo State comprehensive nutrition program showed that the program has an impact in reducing malnutrition among children under five years. However, the program has not been completely successful in some LGAs when the nutritional status of the children pre-intervention in 2013 was compared to that of post-intervention in 2018. The Ondo State government should leverage the progress made so far and critically review the program implementation plans in LGAs with children having poor nutritional status post-intervention in order to identify the bottlenecks undermining its success.
This program highlights the effectiveness of an integrated, multi-prong, and wholistic intervention program aimed at reducing MAM burden among children under five years. This program could be utilized by other Nigerian states for tackling malnutrition and its associated challenges among children under the age of five years.

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.