Undernutrition and Associated Factors among Under-five Children in Batu Town, Oromia Regional State, Ethiopia: A community-based cross-sectional study

Abstract

Enhancing nutrition significantly contributes to addressing sustainable development goals by reducing poverty. In Ethiopia, undernutrition is the leading cause of child illness and death. This study aimed to assess the prevalence and associated factors of undernutrition among children under-five years of age in Batu Town, Oromia, Ethiopia. A community-based cross-sectional study design with a simple random sampling technique was used to select 387 participants. ENA for SMART 2020 software was used to calculate the Z-score of Anthropometric Measurements. Binary logistic regression was employed to analyze the data and the outputs are presented using adjusted odds ratio with 95% confidence intervals (AOR, 95% CI). The magnitude of wasting, stunting, and underweight were 7.0%, 55.5%, and 27.0%, respectively. Being male [AOR = 1.86 (95% CI = 1.13–3.08)] and breastfeeding for over two years [AOR = 2.49 (95% CI = 1.22–5.12)] were the significant predictors of being underweight, whereas colostrum intake [AOR = 0.37 (95% CI = 0.15–0.94)] and good dietary diversity status [AOR = 0.45 (95% CI = 0.24–0.84)] were preventive factors. Similarly, colostrum intake [AOR = 0.09, (95% CI = 0.01–0.68])] and good dietary diversity status [AOR = 0.55 (95% CI = 0.33–0.94)] were preventive factors for stunting though children above 12 months [AOR = 2.89 (95% CI = 1.82–4.58] had increased odds of being stunted. However, in this study, family size [AOR = 3.54, 95% CI = 1.19–10.48] was the sole risk factor for wasting. Undernutrition was prevalent in Batu Town, exceeding regional and national rates. Boys are more affected. Moderate underweight and severe stunting are common. Breastfeeding, colostrum, and diversified diets help, while family size and child age increase the risk. To enhance children's nutritional status, tailored interventions such as promoting colostrum intake, and encouraging diversified diets are required.

Full text

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Undernutrition and Associated Factors among Under-ve
Children in Batu Town, Oromia Regional State, Ethiopia: A
community-based cross-sectional study
Amane Hussen
Batu General Hospital
Amsal Ferede
Madda Walabu University
Aster Yalew
Madda Walabu University
Dawit Urgi
Adama Hospital Medical College
Limenih Habte
Madda Walabu University
Daba Ejara (  dabaejara@gmail.com )
Madda Walabu University
Article
Keywords: Wasting, Stunting, Underweight, Batu Town, Under-ve children
Posted Date: January 24th, 2024
DOI: https://doi.org/10.21203/rs.3.rs-3858012/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full
License
Additional Declarations: No competing interests reported.

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Abstract
Enhancing nutrition signicantly contributes to addressing sustainable development goals by reducing poverty. In
Ethiopia, undernutrition is the leading cause of child illness and death. This study aimed to assess the prevalence
and associated factors of undernutrition among children under-ve years of age in Batu Town, Oromia, Ethiopia. A
community-based cross-sectional study design with a simple random sampling technique was used to select 387
participants. ENA for SMART 2020 software was used to calculate the Z-score of Anthropometric Measurements.
Binary logistic regression was employed to analyze the data and the outputs are presented using adjusted odds
ratio with 95% condence intervals (AOR, 95% CI). The magnitude of wasting, stunting, and underweight were 7.0%,
55.5%, and 27.0%, respectively. Being male [AOR = 1.86 (95% CI = 1.13–3.08)] and breastfeeding for over two years
[AOR = 2.49 (95% CI = 1.22–5.12)] were the signicant predictors of being underweight, whereas colostrum intake
[AOR = 0.37 (95% CI = 0.15–0.94)] and good dietary diversity status [AOR = 0.45 (95% CI = 0.24–0.84)] were
preventive factors. Similarly, colostrum intake [AOR = 0.09, (95% CI = 0.01–0.68])] and good dietary diversity status
[AOR = 0.55 (95% CI = 0.33–0.94)] were preventive factors for stunting though children above 12 months [AOR =
2.89 (95% CI = 1.82–4.58] had increased odds of being stunted. However, in this study, family size [AOR = 3.54, 95%
CI = 1.19–10.48] was the sole risk factor for wasting. Undernutrition was prevalent in Batu Town, exceeding
regional and national rates. Boys are more affected. Moderate underweight and severe stunting are common.
Breastfeeding, colostrum, and diversied diets help, while family size and child age increase the risk. To enhance
children's nutritional status, tailored interventions such as promoting colostrum intake, and encouraging diversied
diets are required.
Background
Sucient nutrition is crucial for normal growth and development throughout infantile period. Currently, nutrition
has increasingly been recognized as a basic pillar for social and economic development and more than half of
sustainable development goals are related to nutrition because one-third of the world population is malnourished.
Nutritional status is the result of complex interactions between food consumption and the overall status of health
and healthcare practices and is inuenced by three factors: food, health, and care(1–4).
More than 90% of the world’s stunted children live in Africa and Asia. Child malnutrition is associated with
approximately 60% of under-ve mortality in Sub-Saharan African countries. In 2015, developing countries reported
that malnutrition was responsible for 27% of under-ve deaths, and case fatality rates in hospitals treating severe
acute malnutrition remained at 20–30%. Undernutrition is a major problem that accounts, directly or indirectly, for
60% of the 10.9million deaths among children under the age of ve worldwide. Above two-thirds of these deaths,
which are frequently related to unsuitable feeding practices, occur throughout the rst year of life(5–8).
Child development is commonly recognized as a key measure of people's nutritional state and well-being.
Malnutrition prevents children from getting their full physical and mental capability. Health and physical
consequences of malnutrition include delays in physical growth and motor development, lower intellectual
quotient, greater behavioral problems, decient social skills, and susceptibility to higher levels risk of developing
chronic illnesses during adulthood life which may have intergenerational effects (9–12).
Ethiopian demographic health survey data revealed poor child feeding practices throughout the country, as well as
a serious condition regarding the nutritional status of children under the age of ve, particularly in rural areas. In
2019, Ethiopian National Center for Health Statistics reference showed that the prevalence of wasting, stunting,

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and underweight were 7.0%, 37%, and 21%, respectively. Concerning the prevalence of undernutrition in the Oromia
regional state, 4.7%, 35.6%, and 16.1% of the population were affected by wasting, stunting, and underweight
respectively (13–16).
Malnutrition is not a simple problem with a single and simple solution. The most immediate determinants are
inadequate dietary intake and diseases which are themselves caused by a number of underlying factors:
household food insecurity, poor maternal and child-caring practices, and lack of access to basic health services
including lack of safe water supply and unhealthy living environments such as open defecation(5, 17, 18). This
indicated that undernutrition might have public health signicance in the region as a result of multifactorial
factors. Thus, this study was conducted to assess the magnitude of undernutrition and its associated factors
among under-ve children in Batu town.
Methods and materials
Study setting
The study was conducted from August 15 to October 10, 2022, in Batu town also named as Ziway town. Batu town
is found in Oromia region, Ethiopia. The town has 249,999 total population, among which, 125,925 were male and
124,074 were females; 8042 were children under one year of age, and 41,087 were children under ve years of age.
Melkawaku, Malike Shalan, Batale, Washbula, Garbi Hidano, Abosa, and Warja Batale are its seven kebeles, with a
total of 30,097 homes.
Study design
A community-based cross-sectional study design with both descriptive and analytical components was conducted.
Study Participants
All randomly selected under-ve children with their mother/caregiver pairs from selected households residing in
Batu Town for more than 6 months and who were available during the study periods.
Sample size determination and Sampling technique
Sample size adequate for determining the magnitude of undernutrition among under-ve children was computed
using single population proportion formula with nite source population correction. In the calculation prevalence of
35.5%(19), 95% condence level, 5% margin of error, and 10% compensation for possible non-response were
assumed. Based on these assumptions, the sample size was determined to be 387. The adequacy of the sample
size for identifying selected predictors of undernutrition was evaluated using post-hoc power analysis. Regarding
the sampling technique, Batu town was purposively selected, then among seven kebeles, three kebeles were
randomly selected, Malike Shalan, Abosa, and Garbi Hidano. The sample size was allocated by their relative
number of under-ve children. Health extensions housing registration was used to identify households with under-
ve children. Finally, households with eligible children were selected using a simple random sampling technique.
For those households with more than one under-ve child, one child was selected by using the lottery method. Data
collectors visited the house on the next day when the children were not available at home and children who were
not available during the second visit were recorded as non-response, and then nearby household was considered.
We collected 8–10 sample children per day.
Data Collection procedure and tool

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Data were collected by four trained health professionals who can speak both Amharic and Oromo language using
pre-tested structured questionnaire. The questionnaire was prepared in English and translated into two local
languages (Afan Oromo and Amharic) and re-translated back to English by an expert to check for its consistency.
During data collection process language preference of caregivers was maintained.
Assessment of Dietary Diversity
Data on the frequency of foods was taken and dietary diversity was assessed based on the number of foods
consumed from the seven food groups within the last 24 hours. The seven food groups considered were grains,
roots, and tubers; legumes and nuts; dairy products; esh foods (meats/sh/poultry); eggs; vitamin A-rich fruits
and vegetables; and other fruits and vegetables(20). Dietary Diversity Score (DDS) was collected and calculated as
the sum of the number of different food items consumed by the under-ve children aged between 6–59 months
before the assessment from the total study participants. The food frequency questionnaire was used to ascertain
the frequency of consumption of certain foods on the list on daily basis.
Anthropometric Assessment:
Weight of the under-ve children was measured using a battery-powered digital scale (Seca 770, Hanover
Germany) and heights were measured to the nearest 0.1 cm using a wooden height-measuring board with a sliding
head bar or microtome tape following standard anthropometric techniques based on USA anthropometric
indicators measurement guide. The weight and height of the under-ve children were taken on the same day from
each study subject using calibrated equipment and standardized techniques. The length was taken for those less
than two years old children in a recumbent position and the height for those above two years children in an erect
position. Measurement of height (length) was done in a lying position with a wooden board for children of age
under two years (below 85 cm) and children above two years stature were measured in a standing position in
centimeters to the nearest of 0.1 cm. The weight was measured using the weight scale. Those children, unable to
stand being weighed on their own, were weighed with their mothers, and the mothers' weights were subtracted. The
weight scale was checked before each measurement. Weight was measured with light clothing and no shoes to the
nearest of 0.1 kg. Only children under 110 cm (a proxy for 5 years) and over 65 cm (a proxy for 6 months) were
questioned to ascertain age using a detailed season calendar and the presence or absence of pitting edema was
checked by pressing the child’s foot bilaterally and graded based on World Health Organization (WHO) reference.
ENA-for-SMART Version 2020 was used to determine the level of nutritional status of study subjects based on
WHO standards of 2006/2007.
Data management and analysis
Data were entered in to Epi Info version 7 and analyzed using the statistical package for Social Science (SPSS)
version 21. The data were cleaned and prepared for analysis. Frequency distribution, mean, standard deviation &
tables were used to summarize the data. Anthropometric data were entered and analyzed using the ENA-for-
SMART 2020 software to determine the nutritional status of the study subjects using WHO 2006 standards.
Predictors of under nutrition were identied using bivariable and multivariable logistic regression analyses. The p-
value < 0.25 was taken as a cut-off point to select variables for the multivariate logistic regression model to control
for potential confounders. Multicollinearity was checked using the cutoff point variance ination factor (VIF) 0.05
and tolerance test greater than 0.1. The model tness of the nal logistic model was tested by using Hosmer and
Lemeshow test at a value of > 0.05 and use Omnibus test < 0.05 to check the relative effects of independent
variables on the outcome of interest. Adjusted Odds Ratio with 95% CI was used to measure association, and p-
values less than 0.05 were taken as statistically signicant.

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Ethical consideration
The study was approved by the Institutional Ethical Review Board (IERB) of Adama Hospital Medical College. A
letter of permission was taken from the Administration of Batu Town to Batu town selected kebeles. Information
regarding the study was explained to the participants, including the study title, procedure, and duration, potential
risks, and benets of the study. Consent was obtained from every relevant authority in the study area and assent
was taken from every participant. Condentiality was kept during the study period by eliminating personal identity
from the data collection. Children who were diagnosed with undernutrition during data collection were linked to
appropriate treatment unit for further evaluation and treatment.
Operational Denition
Underweight is weight for age, stunting is height for age, and wasting is weight for height, which are < SD of the
WHO Growth Standard chart (21).
Exclusive breastfeeding (EBF): feeding a child only breast milk without anything else for the rst six months of life,
with the exception of medicines for therapeutic purpose(22).
Good dietary diversity score: children were classied as having good dietary diversity scores if they had consumed
four and more from seven food groups(22).
Results
Socio-economic and demographic characteristics
A total of 371 mothers/caretakers participated in the study making a response rate of 96%. The mothers’ mean (±
standard deviation) age was 26.0(± 4.1) years. Majority, 297(80.1%) of the children’s mothers were married. Nearly
half, 183 (49.3%) of the mothers attended primary school. About three-fourth, 269(72.5%) of the mothers were
housewives in their occupation. More than half, 232(62.5%) of the children were living in households of less than
ve family. Nearly one-fth, 63(17.0%) of the children were living in food-insecure households and more than half,
2029 (56.3%) did not have livestock in their households (Table1).

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Table 1
Socio-Demographic Characteristics of Mothers/Caretakers of under-ve children in Batu town, 2022 (n = 371)
Variables Description Frequency
(n) Percentage
(%)
Maternal/caretaker Age 15–24 years 161 43.4
25–34 years 175 47.2
≥ 35 years 35 9.4
Mean ± SD = 26.0 ± 4.1 years
Marital status Single 14 3.8
Married 297 80.1
Divorced/Separated 35 9.4
Widowed 25 6.7
Mothers Educational
Status Unable to read and write 112 30.2
Primary Education (1–8th Grade) 183 49.3
Secondary education & TVET (9 − 12th
Grade) 59 15.9
Higher Education (College / University) 17 4.6
Fathers Educational Status Unable to read and write 33 8.9
Primary education (1–8th Grade) 193 52.0
Secondary education (9–12th Grade) 89 24.0
Higher education (University/College) 56 15.1
Mothers Occupation Housewife 269 72.5
Merchant 76 20.5
Government employee 15 4.0
Others* 11 3.0
Average monthly income < 1000 ETB 117 31.5
1000–2000EBR 185 49.9
≥ 2000 EBR 69 18.6
Family Size ≤ 4 139 37.5
≥ 5 232 62.5
Household Food Security Not Secured 63 17.0
Secured 308 83.0
Other* - daily laborer, Private employee

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Variables Description Frequency
(n) Percentage
(%)
Livestock availability No 209 56.3
Yes 162 43.7
Other* - daily laborer, Private employee
Maternal Obstetric and Child Characteristics
Three hundred eleven (83.8%) mothers had a history of 2–3 times antenatal care (ANC) visit during their pregnancy
period. About two-thirds of their last children, 265 (71.4%) were born at the health facility. Almost half of the
mothers, 167 (45.0%), do not know their child's birth weight, however, 104 (28.0%) reported that their child had a
normal birth weight. One hundred fty-seven (42.3%) of the children were in age groups of 12–23 months. Nearly
half, 177(47.7%) of the mothers had two under-ve children (Table2).

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Table 2
Maternal obstetric and child characteristics in Batu town, 2022 (n = 371)
Variables Description Frequency (n) Percentage (%)
Number of ANC visit during last pregnancy Once 43 11.6
2–3 times 311 83.8
≥ 4 times 17 4.6
Place of delivery Home 106 28.6
Health center 184 49.6
Hospital 65 17.5
Private clinic 16 4.3
Birth weight of last child < 2.5kg 45 12.1
2.5–4 kg 104 28.0
> 4 kg 55 14.9
Unknown 167 45.0
Child age < 12 months 110 29.6
12–23 months 157 42.3
24–59 months 104 28.1
Sex of the child Male 163 43.9
Female 208 56.1
Number of under-ve children One 172 46.4
Two 177 47.7
Three or more 22 5.9
Birth order 1st Baby 172 46. 3
2nd – 3rd Baby 169 45.6
4th – 6th Baby 30 8.1
Birth interval between the last 2 children (n = 199) < 24 months 65 32.7
24 months or more 134 67.3
Immunization status Not immunized 58 15.6
Immunized 313 84.4
Diarrheal disease in last 3 month Yes 166 44.7
No 205 55.3
Febrile illness in last 3 month Yes 97 26.1

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Variables Description Frequency (n) Percentage (%)
No 274 73.9
Child feeding and caring practice-related factors
Most under-ve children, 350 (94.3%), received colostrum, and more than half of the children, 201(54.2%),
breastfeeding began within an hour after delivery. One hundred eleven (29.6%) of the mothers did not provide pre-
lacteal feeding for their infants. Cow milk is the most common type of pre-lacteal feed given to children by
mothers, accounting for 166 (63.6%), followed by butter (25.3%). About half, 182(49.1%) of the children practiced
exclusive breastfeeding for less than 6 months and only 145 (39.1%) of the children continued breast milk intake
for greater or equal to 24 months. Furthermore, half 188(50.7%) of the children initiated complementary feeding at
the age of 6 months. Regarding the child’s dietary diversity status, more than half, 204 (55%) of the children
received 4 or more food groups. Nearly half, 178 (48.0%) of the children had meal frequency of three or more times
in the last 24 hours (Table3).

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Table 3
Child Feeding and Care practice-related Characteristics of Under-ve Children in Batu town, 2022 (n = 371)
Variables Description Frequency(n) Percentage(%)
Colostrum intake No 21 5.7
Yes 350 94.3
Breastfeeding initiation time Within an hour 201 54.2
After one hour of birth 106 28.6
After a day of birth 64 17.3
Pre-lacteal feeding Yes 261 70.4
No 110 29.6
Types of pre-lacteal feed (n = 261) Cow milk 166 63.6
Bottled water 29 11.1
Others (butter) 66 25.3
Exclusive breastfeeding for 6 months No 189 50.9
Yes 182 49.1
Initiation time of complementary feeding 0–5 months 183 49.3
At 6 months 188 50.7
The maximum length of breastfeeding 12 months 61 16.4
12–23 months 165 44.5
≥ 24 months 145 39.1
The material used to feed complementary food Spoon with bowel 161 43.4
Cup 22 5.9
Hand 67 18.1
Bottle 121 32.6
Nutrition education on breastfeeding No 172 46.4
Yes 199 53.6
Nutrition education on complementary feeding No 190 51.2
Yes 181 48.8
Dietary diversity score < 4 food groups 167 45.0
≥ 4 food groups 204 55.0
Meal frequency of children < 2 times per day 193 52.0
≥ 3 times per day 178 48.0

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Environmental health characteristics of households
All the households of the study participants had access to drinking water. Pipe water was the primary source of
water for 260 (70.1%) of the houses. Furthermore, nearly half of the mothers/caretakers, 183(49.3%), washed their
hands before serving the child and 138 (37.2%) washed after toilet use, and 157(42.3%) of the study participants
had a toilet facility in their households (Table4).
Table 4
Environmental health characteristics of the households of under-ve children in Batu town,
2022 (n = 371)
Variables Description Frequency(n) Percentage(%)
Main source of water Unprotected Spring/wells 111 29.9
pipe water (private/public) 260 70.1
Time of handwashing After latrine use 138 37.2
Before preparing food 50 13.5
Before serving food to a child 183 49.3
Availability of latrine No 214 57.7
Yes 157 42.3
Waste disposal system Open eld 146 39.4
Pit 197 53.1
Burning 28 7.5
Prevalence of Undernutrition
The overall prevalence of underweight was 27.0% (95%CI = 22.7–31.7%), out of which 37 (10.0%) were severely
underweight (< -3SD), 63(17.0%) moderately underweight (<-2SD and > -3SD) and the mean (± SD) was − 0.92(±
1.52). The prevalence of underweight was higher among males than females. The overall prevalence of stunting
was 55.5% (95% CI = 50.4–60.5%), out of which 152 (41.0%) were severely stunted (< -3SD), 54 (14.6%) moderately
stunted (< -2SD and ≥ -3SD), and the mean (± SD) was − 2.16(± 2.47). The prevalence of stunting was higher
among boys 94(57.7%) as compared to girls 112(53.8%) (Fig.1).
The overall prevalence of acute malnutrition (wasting) was 7.0% (95% CI = 4.8–10.1%), out of which 8(2.2%) had
severe acute malnutrition (< -3SD), 18 (4.9%) of the children had moderate acute malnutrition (< -2SD and ≥ -3SD),
and the mean (± SD) was 0.60(± 1.66) (Fig.2).
Factors associated with undernutrition
In multivariate logistic regression analysis, sex of the child, colostrum intake, dietary diversity status, and
maximum duration of breastfeeding were the factors associated with underweight at a p-value of < 0.05. Male
children were nearly twice more likely to be affected with underweight as compared to female children [AOR = 1.86

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(95% CI = 1.13–3.08)]. Children who received colostrum in the rst days of life were 63% less likely to be
underweight later than those children who did not take colostrum [AOR = 0.37 (95% CI = 0.15–0.94)]. The other
factor associated with being underweight was dietary diversity status. Children who had good dietary diversity
status were 55% less likely to be underweight than their counterparts [AOR = 0.45 (95% CI = 0.24–0.84)]. Under-ve
children who breastfed for over two years were 2.49 times more likely to be underweight compared to those who
stopped before two years [AOR = 2.49 (95% CI = 1.22–5.12)] (Table5).
Factors associated with stunting
In multivariable logistic regression analysis, age of the child, colostrum intake, and dietary diversity status were
factors associated with stunting. Children between 12 and 59 months were nearly 3 times more likely to be stunted
compared to infants under 12 months old. [AOR = 2.89 (95% CI = 1.82–4.58]. Similarly, those under-ve children
who took colostrum during the early infancy period were 91% less likely to be stunted than those who did not take
colostrum [AOR = 0.09, (95% CI = 0.01–0.68])]. On the contrary, those children who had good dietary diversity status
were 45% less likely to be affected with stunting than their counterparts [AOR = 0.55 (95% CI = 0.33–0.94)]
(Table5).
Factors associated with acute malnutrition (wasting)
Only family size was associated with acute malnutrition in a multivariable logistic regression analysis. Under-ve
children from households with more than ve family members were 3.54 times more likely to be acutely
malnourished than children from households with ve or fewer members [AOR = 3.54, 95% CI = 1.19–10.48]
(Table5).

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Table 5
Factor associated with undernutrition among under-ve children in Batu town, 2022 (n = 371)
a) Associated factors of Underweight
Variables Category Underweight status COR
(95%CI) AOR
(95%CI)
Underweight Not
Underweight
Child Age < 12
months 46(12.4%) 64(17.3%) 1 
12–59
months 54(14.6%) 207(55.8%) 0.36(0.22,
1.02) 
Child Sex Female 50(13.5%) 158(42.6%) 1 1
Male 50(13.5%) 113(30.5%) 1.39(0.88,
2.22) 1.86(1.13,
3.08) **
Timely initiation of breast milk within
1 hour No 41(11.1%) 129(34.8%) 1 
Yes 59(15.9%) 142(38.3%) 1.31(0.82,
2.08) 
Colostrum intake No 9(2.4%) 12(3.2%) 1 1
Yes 91(24.5%) 259(69.8%) 0.47(0.19,
1.15) 0.37(0.15,
0.94) *
Exclusive Breastfeeding for 6 months No 46(12.4%) 143(38.5%) 1 
Yes 54(14.6%) 128(34.5%) 1.31(0.82,
2.08) 
Timely initiation of Complementary
feeding at 6 months No 57(15.4%) 126(34.0%) 1 
Yes 43(11.6%) 145(39.1%) 0.66(0.41,
1.04) 
Dietary diversity status Poor 31(11.9%) 86(33.1%) 1 1
Good 20(7.7%) 123(47.3%) 0.45(0.24,
0.84) 0.45(0.24,
0.84) **
Maximum duration of Breastfeeding < 2 years 53(14.3%) 173(46.6%) 1 1
≥ 2 years 47(12.7%) 98(26.4%) 1.56(0.98,
2.49) 2.49(1.22,
5.12) **
b) Associated factors of Stunting
Variables Category Stunting status COR
(95%CI) AOR
(95%CI)
Stunted Not stunted
Household food security No 17(4.6%) 46(12.4%) 1 
Yes 83(22.4%) 225(60.6%) 0.57(0.32,
1.01) 

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a) Associated factors of Underweight
Variables Category Underweight status COR
(95%CI) AOR
(95%CI)
Underweight Not
Underweight
Child age <12
months 41(11.1%) 69(18.6%) 1 1
12–59
months 165(44.5%) 96(25.9%) 2.89(1.82,
4.59) 2.89(1.82,
4.58)***
Birth spacing < 2 years 15(7.5%) 50 (25.1%) 1 
≥ 2 years 38(19.1%) 96(48.2%) 0.55(0.30,
1.01) 
Pre-lacteal feeding Yes 68(18.3%) 193(52.0%) 1 
No 32(8.6%) 78(21.0%) 0.53(0.34,
0.83) 
Colostrum intake No 9(2.4%) 12(3.2%) 1 1
Yes 91(24.5%) 259(69.8%) 0.06(0.01,
0.43) 0.09(0.01,
0.68)*
Dietary diversity status Poor 31(11.9%) 86(33.1%) 1 1
Good 20(7.7%) 123(47.3%) 0.48(0.29,
0.82) 0.55(0.33,
0.94)*
Number of ANC Visit ≤ 3 108(41.5%) 9(3.5%) 1 
≥ 4 138(53.1%) 5(1.9%) 2.71(0.87,
8.48) 
c) Associated factors of Wasting
Variables Category Wasting Status COR
(95%CI) AOR
(95%CI)
Wasted Not Wasted
Child age <12
months 11(3.0%) 99(26.7%) 1 
12– 59
months 15(4.)%) 246(66.3%) 0.55(0.24,
1.24) 
Family Size < 5 4(1.1%) 135(36.4%) 1 1
≥ 5 22(5.9%) 210(56.6%) 3.54(1.19,
10.48) 3.54(1.19,
10.48) *
Monthly Income < 1000
EBR 9(2.4%) 108(29.1% 1 
1000–
2000 EBR 15(4.0%) 170(45.8%) 0.36(0.08,
1.71) 
≥ 2000
EBR 2(0.5%) 67(18.1%) 0.34(0.07,
1.52) 

Page 15/23
NB- *p ≤ 0.05, signicant; **p ≤ 0.01, very signicant; ***p ≤ 0.001, highly signicant
Discussion
The purpose of this study was to examine the prevalence and factors associated with undernutrition among under-
ve children in the study setting. According to the ndings of this study, 27.0% of the children were underweight,
55.5% were stunted, and 7.0% were wasted.
The prevalence of underweight in this study (27.0%) was comparable to ndings in Bule Hora district (29.2%)(23),
Northeast Ethiopia(28%)(24), Addis Ababa (25.5%)(25) and Afar (24.8%)(17). However, it was lower than the
ndings from Shashamene referral hospital (49.2%)(26), Taytay Adiyabo Woreda of Tigray Ethiopia (37.4%)(27)
and Tawila Locality in North Sudan (35.6%)(8). Conversely, was higher than in Bure Town of Northwest Ethiopia
(14.30%)(16) and Shinille Woreda, Ethiopian Somali (20.0%)(28). The possible reasons for this discrepancy might
be socioeconomic differences, variations in study periods, dietary habits, and childcare practices, cultural
differences, and the varying distribution of risk factors across different geographic settings.
The prevalence of stunting reported in this study (55.5%) was comparable to ndings from Taytay Adiyabo
Woreda, Tigray Ethiopia (57.1%)(27) and Northeast Ethiopia (50.2%)(24). However, it was higher than the study
conducted in Afar (43.1%)(17), Tawila Locality in North Sudan (48.9%)(8), Bule Hora District (47.6%)(23), Bure
town, Northwest Ethiopia (24.9%)(16), Shinille woreda, Ethiopian Somali (33.4%)(28), Meskan District Gurage Zone,
Ethiopia (24.9%)(29) and Shashamene referral hospital (38.3%)(26). The observed variation in ndings across
studies may stem from factors beyond differences in children's genetic potential for maximum height, such as
variations in maternal dietary habits during pregnancy and lactation, infant and young child feeding practices
(IYCF) in the study area, educational and cultural differences, and the impact of targeted policies.
The prevalence of wasting of this study was 7.0%, falling within the medium public health signicance range of 5%
to < 10%(30). This nding was comparable with the results from 2019 Ethiopia demographic and health survey
(EDHS) (7.1%)(13), Wukro town Tigray Ethiopia (7.2%)(31) and East Rural Ethiopia (7.4%)(32). However, it was
lower than in Bure Town, Northwest Ethiopia (11.1%)(16), Taytay Adiyabo Woreda of Tigray Ethiopia(17.8%)(27),
Afar Northeast Ethiopia (16.2%)(17), Tawila Locality in North Sudan (14.7%)(8), Bule Hora District, South Ethiopia
(13.4%)(23), Shinille Woreda, Ethiopian Somali Region (20%)(28) and Shashamene referral hospital(25.2%)(26).
These discrepancies in ndings may stem from various factors, including differences in study design,
socioeconomic status, child feeding practices, and disease incidence. Specic examples include disparities in
feeding habits, implementation of infant and child feeding policies, physiological demands related to growth
spurts, and the impact of targeted policies.
In this study, the odds of being underweight was 1.8 times higher among males than females. This nding in line
with a study conducted in Afar Northeast Ethiopia, Bule Hora district, South Omo zone, Ethiopia and Pakistan(17,
23, 33, 34). This might be due to differences in eating habits, energy expenditure that male might be engage in
more physically demanding activities, and vulnerable to health problems than female children.
We found that children who received colostrum in the rst days of life were 63% less likely to be underweight later
on than those children who did not take colostrum. This nding was supported by a study done in Afar Northeast
Ethiopia, Afambo district, Northeast Ethiopia, and developing countries (17, 35, 36). This might be because
colostrum acts as a nutritional and immunological fortress for newborns, safeguarding them from early infections

Page 16/23
that can undermine their journey towards healthy growth. The other predictors for underweight was dietary
diversity score. Children who had good dietary diversity status were 55% less likely to be underweight than their
counterparts. This is in line with a result from Addis Ababa, Ghana, Tanzania and Sub-Saharan Africa (25, 37–39).
The possible explanation for this is that eating a diversied foods ensures children get the essential nutrients they
need to grow. The current study also found that under-ve children who breastfed for more than two years were at
higher risk of underweight compared to those who weaned before two years. This contradicts with nding from
Northwest Ethiopia(40) which reported breastfeeding beyond 2 years was preventive for underweight and
Pakistan(41) which reported there was no association between duration of breastfeeding and underweight. Our
nding, however, should be interpreted with caution as there might be some unmeasured confounders. Further
research is necessary to elucidate this relationship while accounting for confounding variables.
The nding from this study highlighted that children above 12 months were more likely to be stunted compared to
those between 6 and 12 months. This nding was in line with the ndings from different parts of Ethiopia
including Menz Gera Midir district, pastoralist community of Northeast and Northern Tigray (24, 42–44) as well as
East African district, China, and India(45–47). The possible reason could be due to increased nutrient demands,
limited dietary diversity, and heightened exposure to infections in older children. The other factors associated with
stunting was colostrum intake in the rst days of child life. Children who received colostrum was 91% less likely to
be stunted than their counter parts. This is in line with the ndings from Wolayita and Afar region, Ethiopia(48, 49).
This could be because colostrum is high in nutrients and contains antibodies that act as a natural defense against
illnesses. Missing out on colostrum in the early stages puts children at risk of growth problems and illness, both of
which can contribute to stunting.
The current study indicated that dietary diversity of complementary feeding was also among the determinants of
child stunting. Child with good dietary diversity status was 45% less likely to be stunted that their counter parts.
This is supported by a study conducted Gedeo zone, East and West Gojjam and South Ari district in Ethiopia (50–
52). Beyond Ethiopia, the nding was in line with different studies in Yogyakarta, Tanzania, Indonesia and
Bangladesh (38, 53–55). The possible reason could be that good dietary diversity helped children grow taller
because they got the right mix of nutrients, and also kept them healthy and able to ght off infections and improve
their overall nutritional well-being.
Children in larger families (≥ 5) had a 4-fold higher risk of wasting compared to those in smaller families (less than
5). This is in line with the nding from Ethiopia (Wonago woreda, Liban District, and rural community in Southwest
Ethiopia, and West Ethiopia)(56–59). The possible explanation for this could be larger families often face resource
constraints, potentially impacting the quality and quantity of food available for each child. This, combined with
decreased provision of childcare and parental attention to hygiene practices, can increase vulnerability to
infections that exacerbate undernutrition.
Limitations of the study
Two limitations warrant consideration. First, the study lacked some information such as deworming, vitamin
supplementation status, and maternal nutritional status. Second, recall bias may be present in responses to
questions about past events.
Conclusions

Page 17/23
The prevalence of undernutrition among children under-ve poses a signicant public health challenge in Batu
town. Stunting (55.5%) and underweight (27%) rates exceed both Oromia regional and national gures (EDHS
2019). Wasting prevalence (7%) aligns with national gures but remains above the Oromia regional level.
Notably, males experience higher undernutrition across all types. Within the underweight category, most children
fall into the moderate classication, while most stunted children were found as severe. Sex, breastfeeding duration,
and family size inuence underweight, while colostrum intake, and dietary diversity were preventive effects. The
risk factor for stunting was child age, with colostrum and dietary diversity were found to be preventive factors.
Family size was the single most important factor for wasting.
Recommendations
Ethiopia's Ministry of Health, its partners, and communities need to develop age-appropriate interventions to
address stunting risks at all stages of early childhood development. They should also carry out focused
interventions to address gender differences in undernutrition and investigate the factors that contribute to higher
family size-related undernutrition risks. Healthcare workers and media need to promote early and exclusive
breastfeeding practices, emphasizing the importance of colostrum intake. They need also to promote diversied
diets, particularly for young children and pregnant/breastfeeding mothers.
Abbreviations
ANC       Antenatal Care
AOR        Adjusted Odd Ratio
CI         Condence Interval.
DDS        Dietary Diversity Score
EDHS      Ethiopia Demographic and Health Survey
IYCF       Infant and Young Child Feeding
OR         Odds Ratio
SD         Standard Deviation
SPSS       Statistical Package for Social Science
VIF         Variance Ination Factor
WHO        World Health Organization
Declarations
Acknowledgment

Page 18/23
First, we would like to express our deepest thanks and gratitude to the study participants. Our acknowledgment
also goes to data collectors and supervisors.
Authors' contributions
AH conceived and designed the study; collected, analyzed, and interpreted the data; and drafted the manuscript.
DE, AF, AY, LH and DU involved in the designing of the study supervision of the eldwork and the data analysis and
drafted the manuscript. All the authors critically reviewed the manuscript for intellectual content and approved the
nal manuscript.
Funding
Not applicable
Availability of data and material
The dataset analyzed during the current study is available from the corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical clearance was obtained from the Institutional Ethical Review Board of Adama Hospital Medical College.
Prior to data collection, informed consent was obtained from the mothers of the children. All methods were
performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable
Competing interests
The authors declare no competing interest.
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Figures
Figure 1
Height for age of under-ve children in Batu town, 2022 (n=371).

Page 23/23
Figure 2
Weight for height under-ve children in Batu town, 2022 (n=371).