A clinical study of the nutritional status of children under 5 years of age, in rural Zambia.In 1987 in three regions around the Kamoto Hospital, Zambia,  the nutritional status of under-fives was studied to investigate the prevalence of malnutrition and some of its possible contributing factors, such as maternal education and the immunization status of the children. The main aim of the study was to confirm the clinical impression of a different nutritional status in the tree regions and to get more information about the contributing factors for those differences. The regions differ in socioeconomic level and distance from the hospital

Nouwen, J.L.

Voorhoeve, H.W.

Zondag, A.M.

Central African Journal of Medicine

English

IDS OpenDocs

The
Central African 
Journal 
of
Medicine
Supplementary Issue to 1992 Volume 38,
1991 University of Zimbabwe Annual Research Day
Vol. 38, No. 2, February, 1992
Immunisation and 
nutritional status of 
under-fives in rural 
Zambia
A M ZONDAG, J L NOUWEN,
H W A VOORHOEVE
INTRODUCTION
In 1987 in three regions around the Kamoto Hospital, 
the nutritional status of under-fives was studied to 
investigate the prevalence of malnutrition and some 
of its possible contributing factors, such as maternal 
education and the immunisation status of the 
children. The main aim of the study was to confirm 
the clinical impression of a different nutritional status 
in the tree regions and to get more information about 
the contributing factors for those differences.
The regions differ in socio-economic level and 
distance from the hospital:
a) Jumbe is within easy reach of the hospital on a 
distance within 5 kilometre with mainly government 
employees. This is a village with some shops. The 
standard of living in this area is, therefore, relatively 
high.
b) Masumba and Kakumbi: These are two different 
parts in one region; each with their own Rural Health 
Centre on a distance of about 50 (Masumba) and 70 
kilometres (Kakumbi) from the hospital, but with a 
good road. It is an area with an airport and there are 
many safari lodges. Here money is earned from 
tourism.
c) Chibembe is also at a distance of 70 kilometres 
from the hospital, however without a good road. In 
the rainy season, this region is mostly isolated from 
the hospital and from the rest of the area. It is situated 
between two wild parks, but tourists can only reach 
this area in the dry season (4 months a year). Also, 
elephants destroy the crops.
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Vol. 38, No. 2, Febiuaiy, 1992
METHODS
The investigation is done by looking for the 
availability o f the under-five records in all 
under-fives to get information about age, sex and 
immunisations of the under-fives.
The nutritional status of the 1-5-year-old children
is measured by the Mid Upper Arm Circumference
(MUAC), a general accepted measurement for the 
1 2  3nutritional status.
The MUAC is also a simple measurement 
practicable in rural areas where measuring height is 
a too difficult procedure in routine under-five clinics. 
Besides, the MUAC is nearly independent of age for 
1-5-year-olds.
A standard questionnaire of 22 questions is asked 
to the mothers, among others about their education, 
breast-feeding, the number of meals a day, water 
supply and sanitation (pit latrine).
The villages are visited separate from the routine 
mobile under-five clinics, but with the full consent of 
the Chiefs and the co-operation of the Community 
Health Workers. Some days before, the villages were 
informed about the arrival, the time and the place of 
the investigation.
Population: A total of 1 251 children is seen of 
which 1 222 are under five years of age and 29 are 5 
years and some months, the number of investigated 
children per sex and region is given in Table I. In each 
region, there are a little more male than female 
under-fives.
RESULTS
Table I: Sex distribution per region
Male Female Total
N pc N pc N pc
Jumbe
Masumba/
277 51,1 265 48,9 542 43,3
Kakumbi 180 50,7 175 49,3 355 28,4
Chibembe 181 51,1 173 48,9 354 28,3
Total 638 51,0 613 49,0 1 251 100,0
The age of the investigated children is given in Table 
II overleaf.
The education of the mothers of our population of 
1 251 children is presented in Table III.
Table III: Education o f the Mothers o f 1251 Children 
, ' --’pions together)
School in Yeats N pe Cum pc
No. School 1 5 i* 41,1 41,1
Primary 1 15 1,2 42,3
2 26 2.1 44,4
3 26 2,1 46,5
4 190 15,2 61.7
5 99 7,9 69,6
6 91 7.3 76,9
7 228 18,2 95,1
Secondary 1 9 0,7 95,8
2 12 1,0 96.8
3 25 2.0 98,8
4 4 0.3 99.1
5 12 1,0 100,1
1 251 100,1 100,1
No school education at all is seen in 40 pc of the 
mothers and up to 54 pc had some years of primary 
education: 15,2 pc passed Grade Four, 7,3 pc had six 
years of primary school education and even 18,2 pc 
finished grade seven. Less than five percent of the 
mothers visited a secondary school and only one 
percent of the mothers finished the secondary school.
The maternal education for each region is given in 
Table IV. Here the years of primary education are 
taken together. The same is done for the five years of 
secondary education.
Table IV: Maternal Education per Region 
(of 1 251 children in percentages)
Regions Jumbe Masumba/
Kakumbi
Chibembe Total
N = 542 N = 355 N =354 1 251
No school 38,6 38,0 48.0
Primary 1-7 53,9 58,3 49,7
Secondary 1-5 7,6 3,7 2,3
100,1 100,0 100,0
The figures of Table IV show that maternal education 
in Chibembe is obviously less than in the other 
regions. Nearly 50 pc of the mothers have no 
education at all. Secondary school education in this 
region is lowest of all regions. In Jumbe, the 
secondary school education is the best of all regions.
Immunisation status according to region: In 
Zambia, immunisations are given according to the 
W H O /U N ICEF E xtended program m e of 
immunisations, known as E.P.I. So the total number 
of immunisations include BCG, usually given at
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CENTRAL AFRICAN
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VoL 3*. N a 2. Fefanuiy. 1992
Table II: Age distribution per region
Age Jumbe Masumba/Kakumbi Chibembe Total
(in months) N pc N pc N pc N PC
0 -6 68 13,1 47 13,4 83 23,6 198 16,2
6 -12 54 10,4 46 13,1 84 23,9 184 15.1
12-18 68 13,1 43 12,3 55 15,6 166 13,6
18-24 45 8.7 44 12,5 37 10,5 126 10,3
24-30 49 9.4 36 10,3 26 7,4 111 9.1
30-36 46 8.9 37 10,5 24 6,8 107 8.8
36-42 45 8.7 27 7.7 19 5,4 91 7.4
42-48 53 10,2 22 6.3 11 3,1 86 7,0
48-54 47 9,1 24 6.8 8 2,3 79 6,5
54-60 44 8,5 25 7,1 5 1.4 74 6,1
0 -60 519 42,5 351 28,7 352 28,8 1222 100
>60 23 4 2 20
Total 542 43,3 355 28,4 354 28,3 1251 100
Table V: Availability o f Under-Five Cards per Region (o fl  251 children in percentages)
Region Jumbe Masumba/Kakumbi Chibembe Total
N -5 4 2 N 355 N .3 5 4 1251
N PC N PC N pc N PC
No present 185 34,1 93 26,2 104 29,4 382 30,5
Card present 357 65,9 262 73,8 250 70,6 869 69,5
Table VI: Immunisation Status per Region (of 1 251 children, in percentages)
Region Jumbe Masumba/Kakumbi Chibembe Total
Unknown
N PC N PC N pc N PC
(no card) 
Incomplete
201 37,1 99 27,9 106 29,9 406 32,5
(1 -7 )
Complete
119 22,0 102 28,7 154 43,5 375 30,0
(8-11) 222 41,0 154 43,4 94 26,6 470 37,6
Total 542 100,1 355 100,0 354 100,0 1251 100,1
birth, DTP I, II, III and a booster. Oral Polio Vaccine 
(OPV) I, III, III and a booster and measles. At least 
eight immunisations: BCG, DTP III, OPV III and 
measles are considered as complete.
In each region, the immunisation status of the 
children is checked from the Under-Five Cards. If the 
card was not available, the immunisation was 
considered as unknown. However, it is recognised 
that a number of most older children are presumed 
immunised.
To in te rp re t w ell the figu res abou t the 
immunisation status of the children (Table V), we 
present first the availability of the Under-Five Cards 
per region in Table V.
The Chibembe region shows the highest number 
of incomplete immunisations. The high number of 
unknown immunisations in Jumbe is presumable 
because of the high number of older children in that 
region (see Table II). Especial in the older children, 
the Under-Five Card was no longer available.
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CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 38, No. 2, February, 1992
Table VII: Nutritional Status of Children 12-60 months (Measured by Mid-Arm Circumference [per region])
Region Jum be M asum ba/Kakum bi Chibem be Total
MUAC in cm N pc N pc N pc N pc
<12,5 35 9,1 14 5,6 20 10,8 69 8,3
12,4-13,5 54 13,7 48 18,7 39 21.1 141 16,9
13,5 305 77,4 195 75,9 126 68,1 626 74,9
394 100,2 257 100,2 185 100,0 836 100,1
Nutritional status: The nutritional situation of the 
children 12-60 months is measured by the MU AC. 
For each region, the results are presented in Table VII.
The nutritional status of the children in Chibembe 
is the lowest of all regions. There are less children 
with a really sufficient nutritional status and the most 
with an obvious insufficient nutritional status.
In Masumba/Kakumbi, the percentages of children 
with insufficient nutritional status is the lowest 
Otherwise the nutritional status seems more or less 
the same as in Jumbe.
Nutritional status according to immunisation 
status: The relationship between immunisation and 
nutritional status is given for the well-known 
immunisations in Table VIII. The inaccurate number 
of unknown immunisations of Table V are excluded 
as they should give a disturbing effect
Table VIII: Nutritional and Immunisation Status 
(Children 12-60 months [all regions together])
MUAC in cm. Number of immunisations
1-7 8-11 Total
<12,5 N 23 40 63
PC 14,6 10,2 11.5
12,5-13,5 N 35 73 108
PC 22,3 18,7 19.7
13,5 N 99 277 376
PC 63,0 71,0 68,7
Total N 157 390 547
The figures of Table VIII show clearly that the 
nutritional status of the complete immunised children 
is better than the nutritional status of the incomplete 
immunised children.
DISCUSSION
Although a lot of data were collected, as mentioned 
in the method, after all they were not all very useful. 
So only the results for m aternal education, 
availability of under-five records, immunisation 
status and nutritional status according to region are 
presented here.
It is impossible to give a clear interpretation of the 
figures of the jumbe region because of the high 
num ber of unavailable records (Table VI), 
presumably caused by the higher percentages of 
children over 36 months (Table II) of which the 
records are lost. For the two other regions, the figures 
are reliable for interpretation.
In the Chibembe region, the prevalence of 
malnutrition is the highest (10,8 pc) and the maternal 
education is lowest of the three regions just as the 
number of complete immunisations of the children.
In the Masumba/Kakumbi region, the prevalence 
of malnutrition is the lowest (5,6 pc) of the three 
regions and maternal education the highest, just as the 
percentage of complete immunisations. These 
correlations are in accordance with the literature from 
Cameroun and Lesotho.4,5
In Masumba/Kakumbi the percentage of available 
under-five records is higher than in Chibembe. In the 
last region, the percentage of unavailable records is 
higher.
For the 1-5-year-old children with well-known 
immunisations of the three regions together, there is 
a clear correlation between the immunisation status 
and the nutritional status as presented in Table VIII. 
The better the immunisation status the better the 
nutritional status.
A prevalence of malnutrition from 5,6 pc in 
Masumba/Kakumbi and 10,8 pc in Chibembe are of 
the same range as the figures we found in 1983 in 
some villages in the western province of Zambia.
CONCLUSIONS
The reverse relation between maternal education and 
malnutrition, well known from literature, is also seen 
in our study results. In the Chibembe region with the 
low est m aternal education , the com plete  
immunisations and nutritional status are also the 
lowest just as the available records.
65
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 38, No. 2, February, 1992
The Masumba/Kakumbi region with the highest 
maternal education has also the highest percentage of 
available records, completed immunisations and the 
best nutritional status.
For the 1-5-year-old children of the three regions 
together children with a complete immunisation have 
a better nutritional status than those with an 
incomplete immunisation.
Maternal education as important determinant of 
child health should be taken into account for each 
child at under-five clinics.
A socio-economic questionnaire is not useful to 
improve everyday child health.
Measurement of the mid-upper arm circumference 
(MUAC) should be routine at under-five clinics 
certainly where measurement of heights is too 
complex, time consuming and not done.
ACKNOWLEDGEMENT
We express our great appreciation to Prof H A 
Valkenburg, at the time Professor of Epidemiology. 
Erasmus University, Rotterdam, who make this 
investigation possible.
REFERENCES
1. Blankhart, F M: Experiences in Sierra Leone 
and Zambia. In: The Arm circumference as a 
Public Health Index of Protein-Caloric 
M aln u tritio n  o f early  C hildhood. 
Monography No. 8, Journal o f Tropical 
Paediatrics, 1969; 15: 205-208.
2. Shakir, A and M orley, D: M easuring 
malnutrition. The Lancet 1974; i: 758.
3. McDowell, J and King, T D: Interpretation of 
Arm C ircum ference as ind ication  o f 
nutritional status. Arch Dis Child. 1984; 57: 
292-296.
4. Peercnboom, P B G: Les Soins de Same au 
Cameroun. Academic Thesis, Amsterdam, 
1987; 91.
5. Tjon a Ten, W.: Growth of the Mosotho 
P re-schoo l ch ild . A cadem ic T hesis, 
Amsterdam 1989; 117.
6. Voorhoeve, H W A: Growth and Nutrition of 
Zambian Children. Central African Journal of 
Medicine, 1985; 31: 224-227.
Avo
Hat
6 6
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Immunisation and nutritional status of under-fives in rural Zambia

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Immunisation and nutritional status of under-fives in rural Zambia

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