http://www.inosr.net/inosr-experimental-sciences/
Teko
INOSR Experimental Sciences 11(1):112-124,2023.
©INOSR PUBLICATIONS
International Network Organization for Scientific Research
ISSN:2705-1692
Factors Related to Malnutrition among Children Below Five Years in Rengen Health Center III, Kotido District.
Teko, FrancisSchool of Nursing Sciences, Kampala International University Western campus, Uganda
ABSTRACT
The study was carried in Rengen health center III located in Rengen sub-county Kotido district.Thegeneralobjectivesweretoassessfactorsrelatedtomalnutritionamongchildren under 5 years in Rengen health center III. Height/length for weight, weight for age, midupper arm circumference (MUAC) measurements and general physical examination were used. In 40 children 32 were found to be having malnutrition. Out of 32 children majority 17(53.1%)werebetween2and5yearsofagefollowedby11(34.4%)whowerebetween1and 2years while 4 werelessthan 1yearof age.In the treatmentoutcome, outof the 32children enrolled in the study 8 of them were having kwashiorkor with edema and of which 6 (75%) were found edema to have subsided during follow up time whereas 2 (25%) edema were not subsided. In addition, 19children that were marasmiclow weightfor age,by the time of the follow up 10 (52.6%) had gained weight whereas only 9 (47.4%) had not gained weight. The findings are presented in form of bar graphs, pie charts, table and figures. Therefore, from the findings of the study it was concluded that: malnutrition among children is still high, particularly among children between 2 and 5 years and higher in males than females. The recommendation is that screening of malnutrition should be performed to identify the risk group so that proper intervention can be taken in the management by following WHO regimen. Success rate of outpatient therapeutic feeding program where “ready to use therapeutic food” (RUTF) used, should be monitored regularly. A large multicenter study should be undertaken to determine the burden of malnutrition in the whole district and speculate its risk factors, which may help to provide proper measures on how malnutrition can be prevented.
Keywords:Malnutrition, Kotido district, Marasmus, physical examination
INTRODUCTION
Uganda faces many nutritional challenges, among them food insecurity, adult and child malnutrition. Uganda is among the least well-nourished countries in the world. In 2005, the United Nations world food program conducted a comprehensive food security & vulnerability analysis (CFSVA) in Uganda which showed that 6% of households were food insecure and 21% were moderately food insecure and at risk of becoming food insecure if conditions deteriorated [1]. According to [2], Uganda has a global hunger index (GHI) score of 16.7, placing it 42nd out of 81 countries ranked in 2011; its hunger situation is considered serious. Malnutrition accounts for 40% of all child deaths in Uganda [3], and most of these occur in north eastern Uganda (Karamoja Region) [4]
Uganda’s food security situation is complicated by the presence of more than 150,000 refugees from neighboring countries, many of whom lack the means to produce or access food [4], even in the absence of a specific crisis, many families in Rengen sub county struggle with chronic malnutrition, especially among children. The prevalence of stunting among children under five years of age is nearly 40% across the sub county, and is higher in karamoja as awhile, where it exceeds 50% [4; 5]. Nevertheless, the overall trend in underweight and stunting among children has been downward in recent years and the under-five child mortality rate has been falling, albeit slowly nevertheless, the millennium development goal to cut the number of
http://www.inosr.net/inosr-experimental-sciences/
underweight children in half before 2015 remains elusive.
The average prevalence of malnutrition in Rengen hides important variation related to differences in underlying household and socioeconomic characteristics. Children from rural areas face higher risk of being malnourished: 40% of rural children under five years are stunted versus 26% of their urban cohorts; 17% of children under five are underweight in rural areas, compared with 11% in urban areas. The most vulnerable regions are karamoja,anorthsub-region,where54%of children are stunted and 36% are underweight, and the southwest region, where 50% of children are stuntedand19% are underweight [6]. Prevalence of under nutrition among children under 5 years in Uganda (source: Nutrition Landscape Information System, World Health Organization)
Problem statement
According to [6], more than one- third of the deaths during the first 5years of life are attributed to malnutrition, which is mostly preventable through economic development and public health measures. Toalleviatethisproblem,itisnecessaryto determine the nature, magnitude and factors related to malnutrition among children below 5years. However, there is lack of evidence in agro-pastoralist communities like Karamojongs in Kotido district -Rengen health center III [5]. Therefore, this study will assess the magnitude and factors related to malnutrition among children below 5years in Rengen health center iii-Kotido districtkaramoja.
Aim of the study
To determine factor related to malnutrition among children below 5years in Rengen health center III, Kotido district and preventive measures
Objectives of the study
1. To determine the client factors related to malnutrition
2. To determine the socio-economic and health factors related to malnutrition
3. To find out preventive measures to malnutrition among children below 5years
Research questions
1. What is the client factors related to malnutrition?
2. What are the socio-economic and health factors related to malnutrition?
3. What could be the preventive measures to malnutrition?
Justification
In recent years there were a lot of studies showing an increasing number of malnourished children in world, Uganda and the prevalence of stunting among children under five years of age is nearly 40% across the country, and is higher in karamoja and the southwest, where it exceeds 50% [4; 5]. In karamoja in particular, amongst the important reasons for such occurrence is coupled with global warming, semi-arid conditions in karamoja, low income per household, socio economic factors and low educational levels in karamoja. Therefore, the findings of this study may be beneficial to;
Nursing practice
To become active advocates of good nutrition campaigns through health education about malnutrition and good nutritional habits in the health facilities
Nursing education
the study findings may be incorporated with nursing curriculum to enhance teaching and learning of student’s nurses about malnutrition and factors related to its prevalence among the under 5years children
Nursing research
The study findings may be used as a referencebyotherresearcherswithsimilar interests in assessing factors related to malnutrition among children below 5years
Nursing administration/management
The study findings will help nurses to identify areas that need improvement in prevention and management of malnutrition among children under 5years
Rengen health center and surrounding community;
The study findings may help Rengen health center and the surrounding community to identify factors related to malnutrition among children below 5years, preventive and management
http://www.inosr.net/inosr-experimental-sciences/
measurestomalnutritionandthereforeact accordingly for a healthy living among under 5years.
METHODOLOGY
Study design and rationale
Thisstudywasconductedthroughacrosssectional study design quantitative in nature. This study design is selected because itaids in rapid data collection and allows a snap –short interaction with a small groupof respondents atone pointin time thus allows conclusion across a wide population to be drawn.
Study setting and rationale
ThestudywascarriedoutatRengenhealth center iii, Kotido district-Uganda. The health center was established in 2001 at the level of health center ii by the governmentofUgandatoaidtheprovision of health service delivery in the local community but later upgraded to health center III by 2010.The healthcenteroffers out patient, in-patient and maternity services. The health center has abed capacity of 45 beds. The health facility serves the parishes of Naponga, Lopuyo, Nakwakwa, Kotyang, Lokadeli, Naapong, Losilang and resettlement areas of MoruItit and Kopor all in Rengen Sub County Study population
The study population consists of patients diagnosed with malnutrition during daily OPD attendance, home visits, school visits and during EPI out-reaches.
Sample size determination
The sample size for the respondents at Rengen health center iii was calculated usingSloven(1962)formulawithprecision of +/-5% at confidence level of 95%. It is given by the expression; N= n/ 1+n(e)2
Where N=number of respondents
n =target population=45(estimated numberof malnourishedchildren-January 2017)
E=fixed error, e=0.05
Therefore, N=45/1+45(0.05)2
N=40 respondents
Therefore, 40 respondents were recruited for the study.
Sampling procedure
Purposive sampling method which is a non-probability sampling technique where participants are selected basing on their
characteristics and the objectives of the study will be used to recruit 149 respondents for the study. Purposive samplingmethodischeap,easyandallows the researcher to reach the targeted size sample quickly.
Selection criteria
Inclusion criteria
The study included all care takers of malnourished children enrolled in the program, that is; both in OTC and SFP in Rengen health center III
Exclusion criteria
Care takers of severely malnourished children admitted to the ward due to other medical conditions were excluded from study
Study variables
Dependent variables
Factors related to malnutrition among children below 5years.
Independent variables
Client factors related to malnutrition
Socio-economic and health factors related to malnutrition
Preventive measures to malnutrition
Research instruments
A structured questionnaire was used as a tool for gathering information. The structured questionnaire was divided into four sections; the first section was used to collect data about socio-demographic profile, the second section was used to asses client’s related factors to malnutrition, the thirdsection was used to asses health care related factors to malnutrition and the fourth section was used to assess the socio-economic factors related to malnutrition.
Data collection procedure
The researcher introduced himself to the prospective participants and read to the individual participants the consent form that details the title and purpose of the study as well as the rights of the participants. Whenever a participant agrees to be interviewed, he or she was asked to provide written consent by signing or thumb printing. After obtaining
http://www.inosr.net/inosr-experimental-sciences/
thewrittenconsent,theresearcherentered the questionnaire serial number, date of interview,andproceed fromthe firstupto the last question using a language understood by the participant. The researcher entered responses given by the participants by ticking the appropriate response and entering the same number into the coding box. This was done to ensure data quality as the response number ticked is supposed to be the same astheoneenteredintothecodingbox.The researcher reviewed the questionnaire on a daily basis to ensure they are being completed correctly and any errors corrected to avoid being repeated. The process of data collection continued until every effort to contact every participant in the sample has been exhausted. All completed questionnaires were kept safe by the researcher until the time of analysis
Data management
Completed questionnaires were checked for accuracy and completeness on a daily basis after data collection atthe endof the day.Thiswasfollowedbycodingandentry
of the data into the statistical package for the social scientists (SPSS) version 20 software for analysis.
Data analysis and presentation
Data were analyzed by descriptive statistics using SPSS version 20 software and presented in frequency tables, pie charts and bar graphs.
Quality control techniques
For reliability and validity, questionnaires were pretested with a tenth of the sample size outside the duty area. The questionnaires were then revised and content adjustments made accordingly. After data collection, questionnaires were checked daily for completeness, clarity, consistency and uniformity by the researcher.
Ethical considerations
A letter of introduction was obtained from Kampala international university western campus school of nursing sciences to permit the researcher to carry out the research. Permission was obtained from the health center in-charge Rengen health center. All participating respondents were selected on the basis of informed consent.
http://www.inosr.net/inosr-experimental-sciences/
Out of 40 correspondents interviewed, 40 questionnaires were returned completely filled thus a response rate of 100%.
Bio-demographic data
Table 1 shows bio-demographic data of the correspondents (n=40)
Majority of the correspondents (37%) were in the age range between 40-49 years of age while only 8% were in the age range of 18-28years.Mostof therespondents(89%) were females while only 11% were males. Majority of the respondents (93%) were
karamojongs while 7% comprised of other tribes. Most of the respondents (83%) were Christians while only 17% were Muslims. Most of the respondents (60%) were married while only 13% were single.
Client related factors
Table 2.showing responses whether the age of the child can predispose the child to malnutrition (n=40)
Majority of the respondents (78%) agreed that age of the child can predispose it to
malnutrition while only 2% strongly disagreed
http://www.inosr.net/inosr-experimental-sciences/
strongly agree neither agree nor disagree dis agree
Figure 1 shows responses whether the level of education of the care taker can predispose the child to malnutrition (n=40).
Most of the respondents (67%) agreed that level of education of the caretaker can predispose the child to malnutrition while only 4% strongly disagreed
Table 3: shows responses whetherthelevel ofincome of the familycan predispose the child below 5years to malnutrition (n=40)
Mostoftherespondents(69%)agreedthatlowlevelofincomeinthefamily couldpredispose the child below 5years to malnutrition while only 9% strongly disagreed
Figure 2; shows response on whether poor social support was related to the causes of malnutrition among children below 5years (n=40).
Most of the respondents (60%) agreed that poor social support was related to the causes of malnutrition while only 5% strongly disagreed.
http://www.inosr.net/inosr-experimental-sciences/
The health factors related to malnutrition
Table 4: shows responses whether the proximityof the health center to the child can lead to malnutrition (n=40).
Most of the respondents (70%) strongly agreed that the proximity of the health centerto the childbelow5years couldlead
to malnutrition while only 5% strongly disagreed
Strongly agree
Neither agree nor disagree Disagree
Strongly disagree
Figure 3: shows responses whether prolonged suffering from a disease can predispose a child to malnutrition (n=40)
Most of the respondents (69) agreed that prolonged suffering from a disease can predispose a child to malnutrition while only 3% strongly disagreed.
Table 5: shows responses whether delayed treatment of disease is one of the factors related to malnutrition among children below 5years (n=40)
Most of the respondents (73%) strongly agreed that delayed treatment of disease was one of the factors related to
malnutrition among children below 5years while only 5% strongly disagreed
http://www.inosr.net/inosr-experimental-sciences/
agree strongly agree neither agree nor disagree disagree strongly disagree
4: shows responses whetherhealthcare setting is relatedto the onsetof malnutrition
among children below 5years (n=40)
Most of the respondents (72%) disagreed thatthe healthcare setting was not related
to the onset of malnutrition while only 5% strongly agreed.
Socio-economic factors related to malnutrition Table 6: shows responses whether denying children certain foods is related to the causes of malnutrition (n=40)
Most of the respondents (61%) strongly agreed that denying children certain foods was related to the causes of malnutrition
while only 3% neither agreed nor disagreed.
Figure 5: shows whether poor child spacing is related to malnutrition among children below 5years (n=40)
Most of the respondents (73%) agreed that poor child spacing was related to malnutrition among children below 5years
while only 2% neither agreed nor disagreed
http://www.inosr.net/inosr-experimental-sciences/
Table 7: shows responses whether long draught periods are related to malnutrition among children below 5years (n=40)
Most of the respondents (69%) strongly agreed that long draught periods were related to malnutrition among children
below 5yeras while only 2% strongly disagreed
Strongly agree
Neither agree nor disagree
Disagree
Strongly disagree
Figure 6: shows responses whether lack of balanced diet was related to malnutrition among children below 5years (n=40)
Most of the respondents (64%) strongly agreed that lack of balanced diet was related to malnutrition among children
below 5years while only 2% neither agreed nor disagreed
Table 8: shows responses whether the number of daily meals is related to malnutrition among children below 5years (n=40)
Most of the respondents (64%) strongly agreed that the number of daily meals was related to malnutrition among children
below 5years while only 6% strongly disagreed
http://www.inosr.net/inosr-experimental-sciences/
Most of the respondents (31%) gave suggestions that regular health education could help to prevent malnutrition, 20% suggested that completing immunization schedules could help to prevent malnutrition,19%saidfamilyplanningand
good child spacing could prevent malnutrition among children below 5years while the lowest number of respondents (7%) suggested that regular de worming was one of the measures for preventing malnutrition
DISCUSSION
Bio-demographic data
Majority of the correspondents (37%) were in the age range between 40-49 years of age while only 8% were in the age range of 18-28 years.Majority of respondents (78%) agreedthatageofthechildcanpredispose it to malnutrition. This study findings are in lined with the findings of [4; 5] who in their study found out that 40% stunting of children below 5years in Rengen sub county was due to malnutrition whereas it exceeded 50% in the entire karamoja region.Mostoftherespondents(89%)were females while only 11% were males. Sex of the caretakers of the children without involvement of the other partner may be one of the causes of malnutrition for example if the husband is not bothered and only it is the woman that toils, by the time she is exhausted, the child can become malnourished.
Majority of the respondents (93%) were karamojongs while only 7% comprised of other tribes. Tribes have cultural practices which can affect the nutritional status of children below 5years for example children being fed on only one meal a day and of same food value that may render them lack other food values necessary for normal body growth
Most of the respondents (83%) were Christians while only 17% were Muslims. Although this research has no significant
data about the impact of religion to malnutrition, it is important to note that religious teachings can help teach to promote good nutrition by encouraging hard work and food production.
Most of the respondents (60%) were married while only 13% were single. Good nutrition can be achieved by married couple compared to single individuals since they tend to share their problems and help each other for example during times of draught, those that have some harvest can share with those that do not have as well as giving advice on how to care for their children
Client related factors
Majority of the respondents (78%) agreed that age of the child can predispose it to malnutrition while only 2% strongly disagreed. Age is related malnutrition due to low immunity and self-care deficit. These study findings are in line with the findings of [7] who found out that early childhood development is majorly interfered by malnutrition before the age of 5years.
Most of the respondents (67%) agreed that level of education of the caretaker can predispose the child to malnutrition while only 4% strongly disagreed. Education influences attitude, knowledge and behavior change geared towards better health and self-care. This study findings
http://www.inosr.net/inosr-experimental-sciences/
agree with the [8], United Nations development program which stated that lower levels of education and high school dropouts was the main cause of poverty and malnutrition in the region.
Most of the respondents (69%) agreed that low level of income in the family could predispose the child below 5years to malnutrition while only 9% strongly disagreed. Lower income levels render the entire family to poverty and lack of adequate meals. These findings are in lined with [5] that stated that the state of foodinsecurityinthedevelopingworldare attributed to low-income levels and poor weather outcomes.
Most of the respondents (60%) agreed that poor social support was related to the causes of malnutrition while only 5% strongly disagreed. Children with good social support are more likely to have better nutritional status as much attention can be given to them compared to those families where social support is less rendered to the children, their nutritional status too would impaired. These findings are in agreement with the report put forwardby [9]on Uganda full performance report.
The health factors related to malnutrition
Most of the respondents (70%) strongly agreed that the proximity of the health centerto the childbelow5years couldlead to malnutrition while only 5% strongly disagreed. The nearer the health center to the child’s place of residence, the lesser the transport costs and therefore more likelytohavebettermedicalattentionwith ease with early detection and management ofnutritionalproblems.Thisisinlinewith [10], which stated that clinic characteristics including proximity to the patient’shomeorplaceofworkimpacton his health and well being.
Most of the respondents (69) agreed that prolonged suffering from a disease can predispose a child to malnutrition while only3%stronglydisagreed.Long-suffering from a disease leads to severe mass wasting coupled with poor appetite. These findings are in agreement with the report put forward by [11] They stated that malnutritionisthehiddenepidemicswhen
early detection and treatment is not commenced as early as possible.
Most of the respondents (73%) strongly agreed that delayed treatment of disease was one of the factors related to malnutrition among children below 5years while only 5% strongly disagreed. These findings are in agreement with the report put forward by [11]. They stated that malnutritionisthehiddenepidemicswhen early detection and treatment is not commenced as early as possible.
Most of the respondents (72%) disagreed thatthe healthcare setting was not related to the onset of malnutrition while only 5% strongly agreed. This argument is not in line with any scholar whatsoever. Malnutrition cannot set on due to hospital settings however, poor sanitary being of the healthcenter may predispose the child if exposed to nosocomial infections that if not treated and managed early probably can in the long run lead to malnutrition. The socio-economic factors related to malnutrition
Most of the respondents (61%) strongly agreed that denying children certain foods was related to the causes of malnutrition while only 3% neither agreed nor disagreed. Malnutrition is worse when insufficient intake of various food nutrients, this may lead to stunting and poor growth. These findings are in agreement with research put forward by [12] which they stated that stunting is mainly attributed to lack of variety of foods in the diet.
Most of the respondents (73%) agreed that poor child spacing was related to malnutrition among children below 5years while only 2% neither agreed nor disagreed. Poorly spaced children are denied the chance to good immunity from mother’s breast milk, which may render them to infections and malnutrition because of their low immunity to resist. Thisisinagreementwithresearchdoneby [13]. They stated that poor child spacing and big number of children who are hard to manage in the developing world trigger malnutrition.
Most of the respondents (69%) strongly agreed that long draught periods were related to malnutrition among children
http://www.inosr.net/inosr-experimental-sciences/
below 5yeras while only 2% strongly disagreed. Long draught periods lead to poor yields and harvests which may predispose many families to resort to one meal in a day or sometimes spending it all without food to eat. This may worsen the life of children than adults. This research is in line with report put forward by [5] on the state of food insecurity in the world. They estimated that more than 200million children in the developing world are malnourished due to prolonged draughts. Most of the respondents (64%) strongly agreed that lack of balanced diet was related to malnutrition among children below 5years while only 2% neither agreed nor disagreed. Malnutrition is worse when insufficient intake of various food nutrients, this may lead to stunting and poor growth. These findings are in agreement with research put forward by [14] which they stated that stunting is mainly attributed to lack of variety of foods in the diet.
Most of the respondents (64%) strongly agreed that the number of daily meals was
related to malnutrition among children below 5years while only 6% strongly disagreed. Children who eat one meal in a day may not grow normally and attain weight for age compared to those who are regularly fed with variety of meals. These findings are in line with [14] They showed that under nutrition and its consequences are attributed to the number of meals and quality of food taken.
Preventive measures to malnutrition
Most of the respondents (31%) gave suggestions that regular health education could help to prevent malnutrition, 20% suggested that completing immunization schedules could help to prevent malnutrition,19%saidfamilyplanningand good child spacing could prevent malnutrition among children below 5years while the lowest number of respondents (7%) suggested that regular de worming was one of the measures for preventing malnutrition. These arguments are in line with [15], [16]
CONCLUSION
Therefore, from the findings of the study it was concluded that: different factors relatedtomalnutritionareprevalentwhich includes client related factors, health related factors and socio-economic factors. The study showed that prevalence of malnutrition among children is still high, in particular higher among those between 2 and 5 years and higher in males than females which require several activities from MOH, hospital, health professional and mothers and caretakers ofchildrenthemselves.Thefactorsrelated tomalnutritionwerefoundtobeageofthe children, low level of education of care takers, low level of income of the family, poor social support, denying children certain foods, poor child spacing, the proximity to the health center to the child, prolonged suffering from diseases, delayed treatment of diseases and irregular number of daily meals.
Treatment outcomes of children enrolled in the nutrition unit were more of preferable ones such as improvement however, non-preferable ones such as complicationsanddeathwerenotcommon
but others like non-improvement were observed which require attention and intervention.
Recommendations
Screening of malnutrition should be routinely performed to identify the risk group, with different degree of malnutrition so that proper intervention can be taken in the management by following who regimen in order to reduce mortality due to malnutrition
Success rate of outpatient therapeutic feeding program should be monitored regularly.
Decentralization of outpatient therapeutic feeding program service from health centers to health posts should be carried out with great caution.
A large multicenter study should be undertaken to determine the burden of malnutrition in the region and speculate its risk factors will help to provide proper measures how malnutrition can be prevented.
Prospectivestudyshouldbeconductedfor better information by including other factors not included under this study such
http://www.inosr.net/inosr-experimental-sciences/
as existence of sharing of among siblings, proper provision of the treatment to the indexed child at home, household income level,perceptionofmotheronthediseases and effect of the maternal educational level.
Implications in nursing practice Malnutritionamongchildrenbelow5years is an issue of major concern, as many of
the children tend to suffer from this problem because of many factors related to it. Therefore, this study will highlight such factors and help nurses design appropriatemeasureswithintheircapacity toaddresstherootcauseoftheproblemat community level
REFERENCES
1. McKinney, F. K. (2009). BryozoanHydroid symbiosis and a new ichnogenus, Caupokeras. Ichnos, 16, 193-201.
2. Grebmer, K., Bernstein, J and Hossain, N. (2017). GLOBAL HUNGER INDEX THE INEQUALITIES OF HUNGER.
3. Bridge, J. A., Goldstein, T. R. and Brent, D. A. (2006). Adolescent Suicide and Suicidal Behavior. Journal of Child Psychology and Psychiatry, 47, 372394.
4. WorldHealthOrganizationWFP,(2007). United Nations System Standing Committee on Nutrition, The United Nations Children’s Fund. Communitybased management of severe acute malnutrition,
5. FAO (2010). Global Forest Resources Assessment 2010. Main Report, Rome: FAO.
6. Uganda demographic and health survey 2011, (2012); Uganda Bureau of Statistics and Macro International Inc. Calverton, maryland usa
7. Walker, S., Wachs, T., GranthamMcgregor, S., Black, M., Nelson, C., Huffman, S Baker-Henningham, H., Chang, S., Hamadani, J., Lozoff, B., Gardner, J., Powell, C., Rahman, A and Richter, L. (2011). Inequality in early childhood: Risk and protective factors for early child development. Lancet. 378. 1325-38.
8. Government of Uganda (2010): Health sectorstrategicplan2010/11-2014/15.
Government of Uganda Report. 2011, Kampala: Government of Uganda
9. Singh, P. and Manser, P. G. (2008). “Relationship between the Perceived Emotional Intelligence of School Principals and the Job Satisfaction of Educators in a Collegial Environment.” Southern African Review of Education 5, no. 1 (February 2008): 109–30.
10.Bruce science news Vol 183, No. 8, April 20th.2013
11.Burne, daily mail (London) & Jerome November 3, 2009
12. Dewey kg & begum (2011) on “long term consequences of stunting in early life”
13.Van de Paol, Ellen, who Vol 86, No.4 April 2008.
14.Black, R , Allen, L , Bhutta, Z , Culfied, L. and De Onis, M E. (2008). Maternal and child under nutrition. Global and regional exposures and health consequences. Lancet
15.Millennium development goals, report for Uganda September 2013.united nations development program.
16.Kyomuhangi, P., Tamare, A., Collins, G.K.A. (2022). Nutritional knowledge, attitude and practices of adolescents towards healthy eating in secondary schools in Sheema municipality, Sheemadistrict,Uganda. IAA Journal of Scientific Research 9(1), 34-51.