Lack of adequate nutritive elements present in the diet leads to malnutrition in children (Egata, Berhane & Worku, 2013). If left untreated, malnutrition may result in several physical and mental disabilities (Demissie & Worku, 2013). This can hinder the normal growth spurt of the children, especially who are aged below 5 years. According to World Health Organisation (WHO), among all the child deaths worldwide, 54% cases of mortality are due to malnutrition. In Ghana only, severe cases of malnutrition in children below the age of five have been reported to cause 40% child mortality (Black et al., 2013).
This study aimed to provide relevant strategic advice to the policymakers and the various stakeholders who are responsible for overall enhancement of health and well-being of the children (Bantamen, Belaynew & Dube, 2014).
Using data of from the Ghana Demographic and Health Survey (GDHS) of the year 2008 the researchers performed analysis on 2083 children who were aged below five years and suffered from malnutrition (Aheto et al., 2015). They have done multilevel regression analysis with the anthropometric measurements of the children to compute all the possible causes of malnutrition (Aheto et al., 2015).
The results were used to enumerate the probabilities of malnutrition as a cause for poor health among the children. It was found that out of the 2083 children 28% were moderately stunted, 13% were moderately underweight and 176 of them were considered to be moderately wasted (Aheto et al., 2015). Several risks of malnutrition have been assessed which includes multiple births, poor households and poor health of the mothers. It was also found that increased years of education and BMI of mothers lead to a marked decrease in the incidences of malnutrition (Aheto et al., 2015).
The Strengthening the Reporting of Observational studies in Epidemiology or STROBE checklist was used to critically analyse the research article. This method is used by most of the epidemiologists, methodologists, statisticians and researchers who conduct observational studies (Von Elm et al., 2014).
The title of this research paper provides clear indications regarding the addressed issue and the aimed population for this study, and the factors that have been assessed in this research. Although it failed to provide any reflection of the study design in the title, which could be helpful for the readers to easily, comprehend what the article was about. The readers are compelled to go through the entire article to know about the study design and the methods undertaken to assess the issue of malnutrition. Along with the study design and the methods, the data collection period was also not mentioned in the article title.
The abstract of the research article was easily comprehensible and provided a brief idea about the entire study. It was properly informed and a balance. It contained all the necessary components of the research conducted. It provided a brief summary of the entire process and the results as well. The study design and method was discussed in a lucid manner that has been proven to be quite useful for the readers who could comprehend the procedures followed in the study. It consisted of keywords such as childhood malnutrition, developing countries, epidemiology, malnutrition determinants, multilevel modelling, nutritional status, public health and under-five children, which covered a broad aspect of search and also gave the readers a significant idea regarding the details of the article. Although keywords like Ghana, malnutrition interventions could also be incorporated for a wider access of search.
The introduction of this article successfully reflected all the essential points as mentioned in the STROBE guidelines (Von Elm et al., 2014). The article introduction had thoroughly explained the scientific background for the study. The researchers have talked about malnutrition in a more general aspect. They have provided all the details regarding the prevalence of this severe issue worldwide and in Ghana, the country of focus for the study. Then they have highlighted the significant causes that are responsible for such a high global prevalence of this issue (Emamian et al., 2014). Along with this the several grave consequences, that can limit the physical growth and mental well-being of the children, have also been mentioned. The researchers then talked about the importance of selecting the particular population for the study (Ghazi et al., 2013). The authors have made a clear judgement that even though the child mortality cases have stabilised in Ghana, but malnutrition has still been the cause of death in most of the cases. The authors have stated the specific objectives for pursuing the study (Harttgen, Klasen & Vollmer, 2013). The introduction contains the reason for aiming to find out the determinant factors for the issue. According to the authors, analysing the major risk factors of childhood malnutrition will lead to a significant decrease in the mortality rates. The introduction lacked in only one sector, which is that it failed to provide any, previously published hypotheses to support the aim of the study. At the end of the introduction, the researchers have provided a brief concept of the data collection methods and the study design followed, in a simple and specific manner (Kavosi et al., 2014).
According to the STROBE framework the settings of the method must include details regarding the locations, relevant dates, exposure and data collection methods (Von Elm et al., 2014). This guideline was thoroughly followed in the research methodology of this article. This was a cross-sectional study. The data were collected from Ghana Statistical Service which is a reliable source. The study was conducted in both rural and urban areas of Ghana. Even though it is mentioned that the study used the data from 2008 GDHS, the study periods were not distinctly defined. A remarkable aspect of the research is its enormous sample size. The study population initially included 12,323 households that belonged to 411 different communities. This vast range of data collection procedure greatly minimized the chances of potential bias in the study (Aheto et al., 2015). For cross-sectional studies such as this one, the STROBE guidelines require the researchers to provide the eligibility criteria, source and selection procedure of the participants. All these points were highlighted in the study which acknowledged rural and urban children of Ghana below the age of five. The researchers interviewed the children and their parents as well; this helped them to gather an overall idea about the families and have an understanding of the socio-economic factors from relevant sources. A large number of children were excluded from the study due to missing data and irrelevant Z-scores. In the end, the study included 2083 children who were below 5 years of age and belonged to 1641 different households (Aheto et al., 2015).
This study design was elaborative and explanatory with logical flow and sequencing. After going through this assignment, it was easy to understand the type of study population, methods and analysis was carried out to understand the effect of malnutrition in the population of Ghana. Further, the study also involved the WHO index of malnutrition so that by comparing the data collected from the neonatal study of Ghana to that of the WHO, the degree of malnutrition and its prevalence could be understood (Aheto et al., 2015). However, besides these strength, the study design had several weaknesses such as presence of bias in the study due to unavailability of certain data regarding weight and health condition of children. However, the study design was focused towards finding the research objective and was able to provide proper data in the aspect (Aheto et al., 2015).
The statistical analysis of the methodology was elucidated in detail. The researchers followed a random intercept multilevel regression model for evaluation of the outcomes which turned out to be useful for the authors since they possessed data of individual children below five years of age from different households (Aheto et al., 2015). The sampling strategy was analytically described and included each and every method used while conducting the research. This increased the replicating properties of the paper and made it more appreciable. All the statistical methods that were used to examine the interactions and relations between the article issue and its risk factors were described elaborately. In order to explain the relationships between probabilities of malnutrition in the children and the specific risk factors, probabilities were computed, plotted against the risk factors to obtain the results. Explanation of the procedure for addressing the missing data was also provided in the article (Aheto et al., 2015).
Result of this research article was concise, succinct and was backed by the research of the World Health Organisation. Therefore, as per the WHO classification for calculating the severity level of malnutrition by prevalence ranges among children under-five was used as a source to calculate the level of malnutrition in the subjects (Aheto et al., 2015). Therefore, from the observational and comparative study it was found that 28.2% children or 588 children were found moderately stunted, 276 children or 13.3% children was found moderately underweight and rest 8.4% or 176 children were found to be moderately wasted (Aheto et al., 2015). Further, the results also revealed that 38% children’s mothers did not have any formal education. Besides these, while assessing the rate of breastfeeding among this population it was found that within 2083 children included in the study, 1854 or 89% children were breastfed for more than 6 months and within this, 56% households belonged to poor economic state (Aheto et al., 2015). Further, it was also revealed in the study that 47% of the children were not delivered at any healthcare centre and within the 2 weeks of the survey conduction, 22 and 21% children showed symptoms of fever and diarrhoea respectively (Aheto et al., 2015). Hence, from this abovementioned discussion of the study results, it is observed that the researchers were able to present the results in a systematic manner and hence, it emerged as one of the major strengths of the study. The result section was divided between two portions, risk factors that are associated with WAZ, HAZ and other multilevel models, and the probabilities of malnutrition for different significant risk factors. Further, to properly understand the effect of each risk factors on the malnutrition related effect on children, it was seen that researchers used different probability graphs, charts and plotted probabilities of stunting, underweight, and wasting against the risk factors identified so that multilevel models can be provided to the readers to understand the level of analysis and the expected outcomes (Aheto et al., 2015). Further, to understand the risk factors and their expected outcomes, the researchers conducted statistical analysis with all the risk factors as variables and after the proper adjustment of time and residual household levels different covariant were assessed to understand the effect of risk factors. Further aspects such as, presence of proper cooking facility, presence of home hygiene, presence of toilets in each household facility, presence of clean environment and so on was also assessed to determine the effect of different risk factors in increasing or decreasing the level of malnutrition among the children of Ghana (Aheto et al., 2015). Therefore, while discussing the strength of the results section of the study it can be said that each subsection was able to describe and explain the variable properly and contributed in the strength of the analysis. Further, the use of graphs, charts and tables were appropriate and contributed in the better understanding of the analysis. Further, the most interesting part of the results analysis was its holistic approach and involvement of all the primary and secondary reasons that could have contributed in the study and hence, involved all the social determinants, which are responsible for the malnutrition condition among the children of Ghana, was assessed. Therefore, using all primary and secondary objectives in the study results analysis, this study opened the doors for future research works (Aheto et al., 2015).
The discussion portion of the study was involved as a comment section in the research study as were properly aligned to the STROBE framework. The section was able to summarize the strengths, limitations, involved biased and the way the study removed all the bias to provide an applied and concise result (Aheto et al., 2015). The study discussed its strengths such as large population based study, with coverage in a large section, and population, as well as it also mentioned that addressing different socio-economic levels and determinants helped the study by providing a good quality data to analyse and interpret the unidentified factors (Schmidt & Hunter, 2014). However, this broad aspect of the study emerged as the limitation of the study as in the context of Ghana it is not easy to identify the measure of wealth status with connection to its household status. Therefore, the researchers had to use a proxy to determine the household status of the population and to determine its wealth status, which affected the authenticity of the research assessment (Aheto et al., 2015). Further, the researchers also admitted that they were not being able to collect all the data for all the variables, as rest of the data were not present with the family. For example, while calculating the birth weight of all the 2992 children, it was found that 1163 children did not had any registered birth weight as most of them were not delivered at the healthcare facility. Therefore, in this case also, with a calculation of the size of children, the researchers used proxy for the child weight and hence, chances of biases were increased in the study design (Podsakoff, MacKenzie & Podsakoff, 2012). Therefore, mentioning the strengths and weaknesses of the study design and analysis methods increased the level of authenticity of the research and hence, the level of epidemiological evidences increased (Nardi, 2018). Further, it is also visible in the discussion section that the researchers were able to identify their steps, which contributed in the biasness of the study and also calculated the degree of it so that using statistical analysis such bias can be eliminated from the study calculations, hence made the study more reliable and authentic (Aheto et al., 2015). Further, the researchers were able to discuss factors that contributed in the study such as discussion of previous studies done on malnutrition and involved their strengths and weaknesses to increase the reliability of this research analysis (Podsakoff, MacKenzie & Podsakoff, 2012). Further, besides research findings, this analysis was able to include different international reports and surveys conducted in the context of breastfeeding and Ghana that increased the application of this research article internationally. Further, as an ideal research article, the study was able to deliver a string social message that despite of breastfeeding and other important aspect, it is important to keep the environment, food and dietary habit and hygiene conditional around the neonates clean and healthy so that they could be protected from several health conditions (Aheto et al., 2015). The strongest part of the study was involving the guidelines and measures of WHO to compare and determine the level of malnutrition of children in Ghana, which increased its reliability, and authenticity in every manner (Kraemer & Blasey, 2015). Therefore, the study, by following all the national and international ethical manners, following the STROBE guidelines and accepting its strengths and weaknesses increased the application of the study and no conflict was witnessed in the conduction of study (v).
Conclusion
While concluding this critical assessment of the study “Childhood Malnutrition and Its Determinants among Under-Five Children in Ghana” by researchers Justice Moses K. Aheto, Thomas J. Keegan, Benjamin M. Taylor, Peter J. Diggle it was observed that through the research article and analysis, it was able to draw attention of the government and law makers to create policies and intervention strategies so that the nutritional status and health condition of the children affected with malnutrition in Ghana could be improved. Further, the research clearly addressed that there are several unidentified factors, which need to be identified and addressed so that improved nutritional outcomes for the children affected with malnutrition in Ghana could be achieved. In this critical analysis of the research article every aspect was critically assessed and then the authenticity and reliability of the research and its analysis was provided using the STROBE framework.
References
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Bain, L. E., Awah, P. K., Geraldine, N., Kindong, N. P., Siga, Y., Bernard, N., & Tanjeko, A. T. (2013). Malnutrition in Sub–Saharan Africa: burden, causes and prospects. Pan African Medical Journal, 15(1).
Bantamen, G., Belaynew, W., & Dube, J. (2014). Assessment of factors associated with malnutrition among under five years age children at Machakel Woreda, Northwest Ethiopia: a case control study. Journal of Nutrition & Food Sciences, 4(1), 1.
Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., De Onis, M., … & Uauy, R. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The lancet, 382(9890), 427-451.
Demissie, S., & Worku, A. (2013). Magnitude and factors associated with malnutrition in children 6-59 months of age in pastoral community of Dollo Ado district, Somali region, Ethiopia. Sci J Public Health, 1(4), 175-83.
Egata, G., Berhane, Y., & Worku, A. (2013). Seasonal variation in the prevalence of acute undernutrition among children under five years of age in east rural Ethiopia: a longitudinal study. BMC Public Health, 13(1), 864.
Emamian, M. H., Fateh, M., Gorgani, N., & Fotouhi, A. (2014). Mother’s education is the most important factor in socio-economic inequality of child stunting in Iran. Public health nutrition, 17(9), 2010-2015.
Ghazi, H. F., Mustafa, J., Syed Aljunid, Z. M., & Isa, M. A. A. (2013). Malnutrition among 3 to 5 years old children in Baghdad city, Iraq: a cross-sectional study. Journal of health, population, and nutrition, 31(3), 350.
Harttgen, K., Klasen, S., & Vollmer, S. (2013). Economic growth and child undernutrition in sub?Saharan Africa. Population and Development Review, 39(3), 397-412.
Kavosi, E., Rostami, Z. H., Kavosi, Z., Nasihatkon, A., Moghadami, M., & Heidari, M. (2014). Prevalence and determinants of under-nutrition among children under six: a cross-sectional survey in Fars province, Iran. International journal of health policy and management, 3(2), 71.
Kraemer, H. C., & Blasey, C. (2015). How many subjects?: Statistical power analysis in research. Sage Publications.
Nardi, P. M. (2018). Doing survey research: A guide to quantitative methods. Routledge.
Podsakoff, P. M., MacKenzie, S. B., & Podsakoff, N. P. (2012). Sources of method bias in social science research and recommendations on how to control it. Annual review of psychology, 63, 539-569.
Schmidt, F. L., & Hunter, J. E. (2014). Methods of meta-analysis: Correcting error and bias in research findings. Sage publications.
Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P., & Strobe Initiative. (2014). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. International journal of surgery, 12(12), 1495-1499.
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