Annually 10.6 million children under 5 years die worldwide. The mortality rates and causes of death in children under age of five are an indicator of social progress and inequalities within and between societies (Razum and Breckenkamp, 2007). The major causes of disease are malnutrition (Ezzati et al., 2002). In sub-Saharan Africa, about 2% of deaths and 3% of disability-adjusted life occurred in children under-five years (Nemer et al., 2001). It is well known that socio-economic and environmental conditions, in addition to the feeding patterns, are important determinants of malnutrition in developing countries (Nyovani and Mpoma, 1997). Thus, the relationship between socio-economic status, illness and death is observed to be inverse, with morbidity and mortality concentrated in those at the lowest end of the socio-economic scale (Zere and McIntyre, 2003). On the other hand, the nutritional status of children under-five is one of the determinants of household well-being and child survival (Thomas et al., 1990). Many factors seriously affect child growth status, specially in developing countries, such as: family size, educational status, parents job, parents socio-economic status, their knowledge about proper nutrition, prenatal care, mothers age, mothers weight, newborns sex, etc. (Majlesi et al., 2001).
Generally in Africa and particularly in Sudan, the increasing mortality rates due to malnutrition require strong governmental policy for combating such situations, more participation by international agencies and more health education and public awareness regarding immunization and nutrition, which will help to reduce the incidence and mortality of malnutrition in Sudan (John and Tigani, 2007). There is an urgent need of health education regarding nutrition and diet and various nutritional supplementation schemes need to be implemented in Africa to combat the mortality rates due to malnutrition (Kumari, 2005).
In Sudan, >60% of the population live in rural areas lacking the basic services and over-burdened by poverty particularly women and children (Yonos, 2001). The available data about nutritional status of children under 5 years in Sudan reflects the worse and miserable situation of children under 5 years, especially in the
marginalized rural areas. Due to these there is a need for research and studies to highlight the problem and draw attention to the childrens situation.
The objectives of the present report was to address some of the social and economic factors, which have a direct and/or indirect effect on feeding patterns and nutritional status of children under age of five in El Fau rural area as a representative model for the miserable situation in various rural areas in Sudan.
MATERIALS AND METHODS
Study area: This cross-sectional study was undertaken from end of March
to end of April 2003 in villages number 11, 14 and 15 in El Fau rural
area of Gadarif state. El Fau rural area is a part of the Rahad Irrigated Agricultural
Scheme, which was established in 1972, by Rahad Agricultural Corporation research
unit in order to cultivate the area between the Blue Nile and El Rahad River
by settlement of the nomadic tribes in this area.
Population and tribal composition: The total population of the three target villages is estimated to be 18,000 inhabitants (3000 households according to United Nations standards). The major tribal groups are Tama 41%, Kawahla 27%, Mussalamia 15%, Shokria 10%, Folany 3% and others. Considering the gender distribution, 48% of the population is males while females represent a round 52% of the total (NIDAA, 2001).
Sample size: The population in the study area is heterogeneous in terms of ethnic and tribal composition, thus a sample of 5% was chosen to represent the community. From the 18,000 inhabitants in the area who form 3,000 households, 150 families (50 families from each village) were selected as a representative sample and the eldest child from the children under five was chosen from each family to indicate the nutritional status of the rest of the children. These families were selected randomly.
Research team: The research was carried out with the help of four enumerators of whom 2 are nutritional technicians and the others a lab technician and a physician.
Field survey: The survey was covered by the distribution of 150 questionnaires designed to collect data about the Socio-economic factors affecting the food consumption patterns of children under the age of five. The form was composed of 44 questions to collect data about age, sex, level of education of parents, number of the family members and other questions concerning the socio-economic and socio-cultural status to assess the dietary patterns. Mothers were questioned about breast-feeding, complementary-feeding and weaning practices and the type of consumed diet was determined using dietary recall method. They were questioned about childhood diseases and vaccinations. In addition to questionnaire, open group discussions and observations were held to collect information about life style and other cultural norms related to the topic.
Anthropometric measurements: Anthropometric measurements of 150 children were done and data were transformed into height-for-age, weight-for-age and weight-for-height ratios.
Clinical assessments: The children were examined by a physician to check the clinical signs of malnutrition, nutritional aneamia and vitamin A deficiency.
Haemoglobin concentrations: Haemoglobin was measured for children using Sahli method (acid haematin) to assess the nutritional aneamia.
Analysis of the main food: Approximate analysis of food was done according to the protocols of AACC (1980) and AOAC (1975, 1984).
Analysis of drinking water: Coliform bacterial test was carried out according to the presence-absence test for total coliform as described by WHO (1998).
RESULTS AND DISCUSSION
Demographic data: Considering gender distribution among the selected
children, 48.7% of the children were males, while 51.3% were females. Additionally,
36% of the children were of the age 37-48 months, 34% (25-36 months), 4% (49-60
months) and 6% were infants (6-12 months) (Fig. 1). Concerning
the family type 54.7% of the children lived with their extended families and
44.7% lived with nuclear families.
Socio-economic and socio cultural status: The educational level in the
area was comparatively low, with 76.7% of the mothers and 54.0% of the fathers
having received no formal schooling (Fig. 2). Illiteracy is
highly prevailing among El Fau community, particularly among women, this could
be attributed to factors related to the cultural norms, especially of the Arabic
tribes, where girls are not allowed to go to school or complete their education.
Only 19.3 and 39.9% of the mothers and fathers respectively have attended or
completed primary school and very few of them received intermediate schooling
or secondary education. None of the mothers and only 0.7% of the fathers obtained
university education (Fig. 2). The major source for the economic
earns of the family fathers was distributed between agricultural (39.3) and
labour (38%) activities while the rest (19.4%) involved in other minor occupations
(Fig. 3). On the other hand the majority of the mothers have
no real occupations (81.3%).
age group in El Fau rural area
educational level in the rural area of El Fau
Accordingly, most the families were depending mainly on the fathers (74.0%)
for covering all the financial responsibilities (Fig. 4).
Certainly such status wouldnt be sufficient for fulfilling all or most
of the obligations for the families due to the low income of such occupations.
Furthermore, when the mothers were inquired about the major source of income,
it was found mostly among the Arabic tribes that 20% of the childrens
family own farms, 36% have livestock and 44% own both. From all of that it was
clear that most of the community members practice subsistence farming
and only few of them had surplus production.
occupations in the rural area of El Fau
This was due to the agricultural policies adopted by Rahad Agricultural Corporation.
Moreover, the area suffers as well as all the other rural areas from seasonality,
physical weakness and sickness. The comprehensive study of Magboul and Mohamed
(2003) have revealed that most if not all of rural areas face low access to
diversified food in quality and quantity either due to seasonality, nature of
food production and availability, poor transportation from surplus areas or
low purchasing power. It was also obvious that the markets of the studied area
were very poor, lacking fresh fruits and vegetables, containing some handicrafts
and other commodities. Such terrible situation could be attributed to the low
purchasing power, since most of the families depend mainly on their own storage
stuffs, which consist of sorghum and dried okra as well as milk. Contrary to
the fact that the families income among the lands and herds owners of the Arabic
origin is better than non Arabic peasants, the purchasing power of those Arabian
was comparatively lower than the non Arabic peasants who used to provide fruits,
vegetables and other foods for their children.
Social norms: The social restrictions in these rural areas have a negative
implication for all the family members and in particular the mothers and their
expected babies. Such social restrictions impose girls early marriage
and consequently early delivery (Fig. 5). Moreover, our investigation
revealed that the biggest share of the children (93.3%) was born at home under
the hand of traditional or illegal midwives. The lack of the proper medical
care would be expected to affect negatively both the mothers and their children
in the short and/or long time frame. Such situation triggers the project of
the Sudan Village Concept II in the middle of 1990s, which has encouraged women
education and established women development centers.
of the household of the children's families in El Fau rural area
age at delivery of the children under age of five in El Fau
Feeding patterns of the children under five: Concerning the feeding
procedure which had been applied by the mothers for their children, it was noticed
that all mothers started breast-feeding immediately after the delivery. This
process takes part spontaneously, which indicated that the importance of early
and continuous breast-feeding was well understood.
Food type consumed daily by the children under age of five
in El Fau rural area
Around 68% of the children started to drink water before four months or even
after days from the birth. The main source of the drinking water for all the
family members including new born babies was the canal water (96%), while tap
water was used by 6% of them. Our investigation (coliform bacterial test) for
the samples of canal water which feeds the three villages indicated that this
water was not healthy due to the high level of contamination by E. coli and
other types of thermotolerant bacteria. A recent report by Abdel Rahman (2003)
gives strong evidences that the surface water, which originates from rivers,
tanks, lakes and man-made reservoirs is brone to contaminate by the human and
animal wastes. As such it is never safe for human consumption unless subjected
to sanitary production and purification before use. As a result, most of the
children were sick suffering from diarrhoea (41.3%), fever (54%), vomiting (9.3%),
malaria (25.3%) and respiratory tract infection (24.7%).
During the period of breast-feeding, 97.3% of the children were found to take
complementary food. The main items of the food consumed by infants were a mixture
of kisra (made from fermented sorghum) and water, Aceda (porridge
cooked from sorghum), Weika (dried okra) and Roub (sour milk)
(Fig. 6). Its obvious from the results (Fig.
6) that none of infants consumed fresh fruits, vegetables and tubers. Getahun
et al. (2001) stated that in developing countries early introduction
of complementary foods is associated with an increased risk of diarrhoea due
to poor sanitary conditions and lower quality of supplements. Moreover complementary
foods afforded to children were often cereal-based and mainly deficient in protein
and the bioavailability of minerals such as iron and zinc is low. These foods
are bulky in nature and have lower nutrient density; therefore, they wouldnt
fulfill nutritional requirements of the growing infants (Fig.
consumed daily by the children under age of five during three consecutive
days in El Fau rural area
Protein energy malnutrition and nutritional anaemia among
children under age of 5 in El Fau rural area
analysis of the main types of the food of the local community in El Fau
Regarding the weaning regime of the infants, it was found that the biggest
percentage of the infants was weaned gradually (56%), while the rest either
weaned suddenly (23.3%) or still suckling (20.7%). Moreover, it was also noticed
that there was a remarkable variation regarding the weaning age of the infants.
Most of the infants were weaned between 19-24 months (60.7%), 0.7% were weaned
at 6 months or less, 3.3% were weaned at 7-12 months and 8% were weaned at more
than 24 months. Such habits have traditional origins and would have a negative
impact on the infants health. Lack of food diversification for children
after weaning age could be recognized from Table 1. In which
the food stuffs (three meals per day) for three consecutive days were obtained
from the children under question. The data survey reflected that aceda,
kisra and nasha which were made from fermented sorghum, in addition
to milk were basically taken in large quantities during the whole day. From
a nutritional point of view, such food types could be considered as energy and
protein sources for the growing children, however it does not supplement them
with the full nutritional ingredients and remains insufficient as a balanced
diet. Previous studies concerning the grain sorghum nutritional quality and
the main products manufactured from it (e.g., kisra) had revealed that
sorghum is basically deficient in lysine amino acid and therefore have a low
biological valu (Eggum et al., 1983). Moreover, it was proved that fermentation
of cereals as a food processing methodology improves the protein quality, although
the protein availability might be adversely affected (Yousif, 2000; Fageer and
El Tinay, 2004).
Table 2 describes the nutritional assessment of the protein energy malnutrition as well as the nutritional anaemia among children under age of five. While, almost half (50.7%) of the children were found normal, 40.0, 6.0 and 3.3% of them had shown mild, moderate and severe clinical signs of protein energy malnutrition respectively. The prevalence of various malnutrition degrees could be attributed partially to the high rate of illiteracy among the mothers accompanied by the insufficient food supply.
Getahun et al. (2001) stated that the highest prevalence rate of wasting was mainly observed in children, whose mothers has no education and as a result of insufficient and inappropriate supplementary foods and recurrent infectious (e.g., diarrhoea) due to unsanitary environment.
Based on the results, the present study clearly indicates the prevalence of nutritional anaemia which is mainly attributed to the absolute dependency on sorghum and dried okra based food, which has low bioavailability of iron. Additionally, Getahun et al. (2001) was found that other causes of iron deficiency anaemia include malaria and congenital hemolytic disease such as thalassaemia. Recently it has been recognized that the consumption of the alternative pulse crop (pigeon pea; Cajanus cajan) among the children of El Fau area had started to increase. The Nutritional Directorate of Gadarif State had great efforts to encourage people for the consumption of pigeon pea, which is available in lower prices and contains sufficient iron and therefore would an ideal alternative for solving the chronic nutritional anaemia among children and their mothers (H. El Mahi, personal communication). On the other hand, none of the investigated children were found suffering from the night blindness and other clinical signs of vitamin A deficiency and only 12.7% of the rest family members had such complains. The absence of these clinical signs among the children could be partially due to the continuous national campaign of vitamin A supplementations.
Conclusion: Educated, well-nutritional mothers who have control over the purchase of the dietary items would be more qualified and capable for taking care for their children properly. This will be reflected in the better nutritional status of their children and the vice versa for the illiterate mothers.
The lack of the basic needs (e.g., healthy water for drinking) leads spontaneously to the usage of the unsanitary environment resources (e.g., canal water).
Poverty and insufficient income for the family-household result in the lack of the food diversification was in principle the main cause of nutritional anaemia among the children under age of five in the study area.