Research question, study aim and objectives

2.1.1 Research question

Which risk factors are associated with the prevalence of severe acute malnutrition in vulnerable children under five years of age who live in Region B and surrounding referral areas of the City of Johannesburg, South Africa?

2.1.2 Aim

The aim of this study was to determine which risk factors are associated with the development of severe acute malnutrition in vulnerable children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

2.1.3 Objectives

a) To determine the risk factors and the degree to which they are associated with severe acute malnutrition in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

b) To determine the risk factors and the degree to which they are associated with moderate malnutrition and/or growth failure in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

c) To compare the risk factors associated with the following groups: (i) severe acute malnutrition, (ii) moderate malnutrition and growth failure and (iii) well- nourished, in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

2.2 Study plan

2.2.1 Study type

A descriptive, cross-sectional study with an analytical component was performed. This study design was used to describe a population and the relationship between exposures (risk factors) and patient outcome (malnutrition).

2.2.2 Study population

The study population was children under the age of five years who reside in Region B and surrounding referral areas of the City of Johannesburg. According to the 2011 National Census , there are 22 703 children under the age of five years in Region B, which consists of wards 68, 69, 82, 86, 87, 88, 90, 98, 99, 102, and 104 in the City of Johannesburg.1 The clinics in this region are Berario Clinic, Bosmont Clinic, Claremont Clinic, Crosby Clinic, Parkhurst Clinic, Randburg Clinic, Riverlea Major Clinic, Rosebank Clinic, Sophiatown Clinic, Westbury Clinic, and Windsor Clinic. The paediatric hospital in this region is Rahima Moosa Mother and Child Hospital (See

APPENDIX A – MAP OF REGION B, JOHANNESBURG for map).2

Rahima Moosa Mother and Child Hospital is the paediatric hospital for Region B of Johannesburg. However, it is also a referral hospital for surrounding areas such as Weldevreden Park, Zandspruit, Florida, Discovery, Mayfair, Honeydew and Diepsloot. Most of the hospital’s Severe Acute Malnutrition (SAM) patients come from these surrounding areas. Therefore, to get a true reflection of the risk factors of SAM in Johannesburg, children from the surrounding referral areas of Region B were included in the study population.

In 2012, there were 2 485 admissions of children under five years of age in the paediatric wards of Rahima Moosa Mother and Child Hospital, 130 of whom were diagnosed with SAM (5.3%).3 _{Within the SAM admissions, there was a mortality rate} of 4.6 deaths per 100 admissions. This is below the international standard of 5%,4 which indicates good management of SAM at a hospital level. Although this is good, the primary or secondary prevention of SAM is still the ideal, and therefore, malnutrition can be considered a public health concern in this region.3

2.2.3 Sample size

A power analysis for one-way Analysis of Variance (ANOVA) was done to compare three groups (SAM, moderate malnutrition/growth failure and well nourished) with 90% power to determine an effect size of 0.35 with a significance level of 𝛼 = 5%. This showed that a sample size of 𝑛 = 53 per group was required. Therefore, there was a total sample size of 𝑛 = 159 (SAM 𝑛 = 53, moderate malnutrition/growth failure 𝑛 = 53, and well-nourished 𝑛 = 53). No adjustments were made for attrition or a poor response rate since the study did not require follow-up and the investigator

went through the questionnaires with each participant, thereby eliminating the chance of no response.

2.2.4 Sample selection

Convenience sampling was used to include participants. Selection occurred from 26 August 2014 to 27 March 2015, on weekdays between 07:00 and 17:00. The participants were chosen from patients admitted to Rahima Moosa Mother and Child Hospital’s paediatric wards – wards one, two, three and four. Three groups of children are represented in the study: SAM, moderate malnutrition/growth failure and well-nourished. Sample selection continued until there were enough patients representing each group.

2.2.4.1 Inclusion criteria for study group

- Diagnosed as one of the following:

i. SAM

ii. moderately malnourished, including Moderate Acute Malnutrition (MAM), moderate stunting, moderate underweight, and growth failure (as discussed under section 1.4.6)

iii. well nourished

- Under the age of five years (0–60 months) at the time of the interview - Reside in region B or surrounding referral areas of Johannesburg - Human immunodeficiency virus (HIV) infected or HIV uninfected - Patients with a Road to Health Booklet (RTHB) present

- Admitted to Wards 1–4 of Rahima Moosa Mother and Child Hospital

MAM is defined as having one or more of the following parameters: <–2 but >–3 standard deviations (SD) weight for length/height, and mid-upper arm circumference (MUAC) <12.5cm but >11.5cm.5 _{However, many studies define moderate forms of} malnutrition as one of the following: <–2 SD but >–3 SD of either weight-for-age (underweight), height/length-for-age (stunting), or weight-for-height/length (wasting). Therefore, this review and study will use the term moderate malnutrition to include MAM, as well as moderate stunting and underweight, and growth failure.

2.2.4.2 Exclusion criteria for study group

- Premature birth (<37 weeks gestation) - Low Birth Weight

- Congenital diseases/disorders (such as heart defects, genetic disorders, foetal alcohol syndrome, chromosomal abnormalities)

- Diabetes mellitus - Overweight

- Surgical patients (except for orthopaedic surgeries) - Patients diagnosed with cancer

- Chronic diseases, such as chronic lung disease and chronic cardiac failure The exclusion criteria relating to premature birth, low birth weight and chronic or congenital diseases/disorders were set because it is known and expected that these factors affect the weight or growth of a child.