Hamza M. A. Abdeljawad & Jasem M. S. Humeid 
 

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Nutritional Status of Palestinian Children Under Five

(6 – 59 months) in Three Governorates of the Gaza Strip:

A Rapid Assessment Study

 

 

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ABSTRACT

This is a rapid cross sectional quantitative survey that is aimed at rapidly assessing the nutritional status of children aged 6 – 59 months in three governorates of the Gaza Strip, Gaza, North Gaza, and Khanyounis. The study involved 754 eligible children, 256 from Gaza, 253 from North Gaza and 245 from Khanyounis.

Cluster random sampling in the three designated governorates was used in order to randomly select the study subjects. The study involved using a structured interview questionnaire to interview the mothers of selected children (subjects); it included 3 main parts. The first part was relevant to demographic data and socioeconomic background, the second part involved anthropometric measurements (weight, height/ length and mid upper arm circumference); which were taken by the data collection teams and the third part was relevant to mother’s knowledge and practice as per child’s nutrition in terms of breastfeeding, complementary feeding, supplementation, and tea intake.

The study showed important findings, the average monthly income of the families that responded to this question (only 54.1% of the total sample size) was 1943.7 NIS, More than one fourth of those who provided estimates of their family monthly income, had incomes that are 1000 NIS at maximum. About two thirds (62.6%) of the families of surveyed children perceived their family monthly income as insufficient for securing food for the child and family. As per the nutritional status of children, 2.5% of the surveyed children were either moderately or severely underweight, 10.3% were either moderately or severely stunted (moderate stunting: 6.2%, and severe stunting: 4.1%), 2.4% either moderately or severely wasted, and 3.4% were either moderately or severely malnourished (based on MUAC for age).

As per mothers’ knowledge and practice regarding child’s nutrition, 85.8% of surveyed women perceived the appropriate length of time of breastfeeding to be more than 12 months up to 2 years; in this context, only 14.5% of the mothers of surveyed children exclusively breastfed their children for exactly 6 months, as per WHO recommendations.

As per tea intake, quite a large percentage (69.4%) of the surveyed children received tea; among those who received tea 32.9% did so 3 to 4 times a day, and 59.5% of them received tea with meals. As per supplementation, only 17.3% of the surveyed children received vitamin A and D supplementation on a frequent basis and 16.6% received iron supplementation on a frequent basis.

It was found that underweight is significantly linked to low birth weigh and, insufficient intake of fruits. Malnutrition was found to be significantly linked to low birth weight, insufficient intake of vegetables, being a refugee, and mother’s low educational level. Stunting was found to be significantly linked to insufficient intake of meat ,increased legume intake, decreased fruit intake, large family size, very low (illiterate or elementary) or very high (post graduate) level of mother’s education, insufficiency of family’s income, and family history of malnutrition. Wasting was found to be linked to insufficient meat intake. In conclusion, it is quite clear that the current economic crisis has resulted in severe impacts on child’s nutrition in the Gaza Strip; the situation can further deteriorate if no action is immediately taken.

 

INTRODUCTION

The latter period, witnesses more health ailments and deterioration in the nutritional status of many sectors of the Palestinian community. At present, malnutrition represents a noticeably increasing health problem in the Gaza Strip and it has become a general concern of health professionals (AEI, annual report 2007, and WHO, report 2008). WHO’s 2007 Reports, show an increase in stunting and Iron deficiency anemia rates amongst Palestinian children residing in the Gaza Strip in the year 2007, compared with 2006.  Annual report 2007 of Ard El-Insan (AEI), shows an increase in the rates of nutritional disorders during 2007 than during 2006 as follows; stunting (1.9%), wasting (8.5%) and under weight malnutrition (03.1%). (Ard El-Insan (AEI)’s 2007 - Annual Report & PCBS, 2007). It is undoubtedly believed that tight closure imposed on the Gaza Strip over the last 10 months might have resulted in the augmentation of nutritional disorders over that period.

Many underlying etiological factors could be an attribute to the increasing rate of childhood malnutrition in the Gaza Strip over the last decade.  New indicators derived from international organizations such as WHO refer to increased rates of macro and micronutrient deficiencies over the last year; which are coupled with the escalated deterioration in the socioeconomic status among the entire population of the Gaza Strip.  Unemployment, tightening of siege and closure, obscurity of political horizon, internal Palestinian conflict, and the absence of economic alternatives or options has contributed to worsening of the already existing deterioration (PCBS, 2007).  These factors are undoubtedly worsening the entire living conditions in the Gaza Strip, and could be drastically intensifying nutritional health problems; which are growing in a greater sector of vulnerable Palestinians. Other reasons studied include food security, breast feeding, complementary feeding, knowledge attitude and practices of families regarding nutrition and other socio-demographic and socioeconomic factors. Health professionals at the national and international levels are convinced that bad nutritional health consequences affecting the Palestinian children could be preventable.

This study will provide health professionals and decision makers with more precise information about malnutrition among Palestinian children in three governorates in the Gaza Strip. It could serve as a descriptive proxy of the nutritional status of the entire locations and population sectors of the Gaza Strip and it will enhance relevant evidence based interventions.

Taking into consideration AEI’s relevant experience, UNICEF took the initiative to conduct a rapid assessment study to further investigate the situation.  In this regard, UNICEF approached AEI for conducting a Rapid Assessment study about the nutritional status of Children aged between 6 and 59 months in the Gaza Strip. The study was mainly aimed at studying the nutritional status of Palestinian children aged 6-59 months. 

The study involved conducting a household survey in three governorates of the Gaza Strip; North Gaza, Gaza and Khanyounis. The study was conducted over 5 weeks and was mainly managed by AEI. Ard El Insan (AEI) is a leading local Palestinian non governmental organization (NGO) in the field of Child Health and Nutrition (CHN). It is worth mentioning that AEI implemented carried out this survey in cooperation with the Palestinian Ministry of Health (MOH) and Alazhar University in Gaza. In this context; both of which mainly contributed to the preparation for, and implementation of, the data collection phase.
 

Study Objectives

The Overall Goal of this study was to assess the nutritional status of children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.  In specific, this study was aimed at the following Specific Objectives:

1. To determine the overall prevalence of malnutrition amongst children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.
2. To determine the prevalence of underweight amongst children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.
3. To determine the prevalence of stunting amongst children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.
4. To determine the prevalence of wasting amongst children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.
5. To determine the risk factors associated with malnutrition amongst children aged more than 6 months up to 5 years of age in the governorates of Gaza, North Gaza and Khanyounis, of the Gaza Strip.

 

Study Locality

The study included children from three governorates of the Gaza Strip; which are in turn divided into localities as follows (as per PCBS reports):

a. North Gaza governorate

Located at the northern part of the Gaza Strip and it is mostly an agricultural area inhabited with 19.1% of the entire population of the Gaza Strip. People live in 45,440 families found in the following areas: Beit-Hanoun, Beit Lahia, Bedouin village (Aum-Al-Nussr), Jabalia camp and Jabalia town.

b. Gaza governorate

The biggest governorate in the Gaza Strip and it is inhabited with 516,882 persons (35.1%) who live in 83,368 families; residing in the following areas: Gaza city, Beach camp, Juhr Eldeek and Al-Mughraga area.

c. Khanyounis governorate

It is the second biggest populated area after Gaza in which 285,613 persons (19, 4%) live in 46,067 families.  Khanyounis city is the main city in this governorate and it is surrounded by Khanyounis camp, Al-Qarara, Bany Suhaila, Abassan Al-kabira, Abassan Al-Jadeida, Khuza'a, Al-Fukharry and Mwassi Khan Younis.  

 

Study Time Frame

The study was conducted over a period of five weeks starting from early April till early May, 2008.  

Operational definitions 

Exclusive Breastfeeding (EBF): Giving the infant only breast milk with no other liquid, semi solid or solid foods, except for vitamin or mineral drops and medicines (WHO, 1999).

Child's Nutritional Status: Classifying nutritional status of children based on Z-score compared to standardized reference population by WHO and by using the Anthro 2005 program, children higher than -2 SD classified as normal while those less then -2 SD up to -3 SD classified as moderately malnourished, and those who are less than -3 SD classified as severely malnourished. Presence of nutritional pitting edema in both feet in a malnourished child is a characteristic of severe malnutrition regardless of the Z – score.

A stunted child: Child who has a height / length for age Z - score that is below -2 standard deviations (SD) based on the NCHS/CDC/WHO reference population.

Chronic malnutrition is the result of an inadequate intake of food over a long period of time and may be exacerbated by chronic illness (Mali DHS, 1996).

A wasted child: A child who has a weight for height/ length Z - score that is below -2 SD based on the NCHS/CDC/WHO reference population.

An underweight child: A child who has a weight for age Z - score that is below -2 SD based on the NCHS/CDC/WHO reference population. This condition can result from either chronic or acute malnutrition, or a combination of both (Mali DHS, 1996).

Complementary food: Any food, suitable as a complement to breast milk/Artificial milk when becomes insufficient to satisfy the nutritional requirements of the infant (WHO, 1999); it is recommended not be introduced to children aged less than 6 months. 

LITERATURE REVIEW 

The most widely used system is World Health Organization (WHO) classification based on Z - scores. The Road – to - Health (RTH) system is typically seen in clinic – based growth monitoring systems (IAP, 2003).

WHO system

< -1 to > -2 Z - score mild

< -2 to > -3 Z - score moderate

< -3 Z - score severe

On November 5^th, 2005, PCBS issued a Policy report on Child Nutrition in Exceptional Circumferences in which it presented the Case of Palestinian Children Aged 6-59 Months in the Palestinian Territory. The report showed the following results:

• Approximately 9.6% of infants in the Palestinian Territory (10.3% in the West Bank and 8.3% in Gaza Strip) had birth weights less than 2,500 grams.
• Stunting increased among children aged 6-59 months over the years, from 7.7% in 1996 to 8.0% in 2000 and 9.0% in 2002. In all three surveys, stunting significantly varied with the child’s age, with the lowest percentages of stunting found in the age group 6-11 months. The highest levels of stunting were found among those aged 12-23 months in 2000 and 2002. Significant differences in stunting levels between both sexes appeared in the 2000 survey only, at 8.6% for females compared to 7.5% for males.
• Wasting was at its highest in 1996, affecting 2.8% of children, declined in 2000 to 1.4%, and rose again in 2002, reaching a level of 2.5%. Wasting was found to be most prevalent among children aged 6-11 months in the three survey years (7.0% in 1996, 4.1% in 2000 and 7.3% in 2002).
• 63.4% of the surveyed households in the Palestinian Territory had faced difficulties in getting sufficient food supplies during the Intifada (62.5% in the West Bank and 65.0% in Gaza Strip).
• 95.8% of children aged 6-59 months were breast-fed, of them 96.0% in the West Bank and 95.7% in Gaza Strip. The mean duration of breast-feeding was 12.8 months in the Palestinian Territory (12.4 months in the West Bank and 13.5 months in Gaza Strip).
• 48.9% of children aged 6-59 months received vitamin A and D supplementation (63.7% in the West Bank and 25.9% in Gaza Strip).
• 36.1% of children aged 6-59 months received iron supplementation (33.9% in the West Bank and 39.5% in Gaza Strip).

In February 2005, the Community College of Applied Science and Technology conducted a household survey on maternal and child health and nutrition at the household level in the West Bank and Gaza Strip; which showed the following relevant results:

• 10.6% of the surveyed children in the WB and GS were either moderately or severely stunted. The percentage was 11.7% in the WB and 8.9% in the GS.
• 7.2% of the surveyed children in the WB and GS were either moderately or severely wasted. Noticeably, the WB incidence (9.4%) was considerably higher than that of the GS (4.1%).
• 8.8% of the surveyed children aged from six months to five years received Vitamin A supplementation (WB: 11.5% and GS: 5.2%).

Another relevant study was conducted by United Nations Children's Fund (UNICEF) in 2003. In its Donor Update with relevance to Humanitarian Action in the Palestinian Territory; issued on November 19^th, 2003, UNICEF reported that 3.5% of 6-59 month old children were underweight, and 9% suffered from stunting.

WHO’s recent studies show an increase in stunting and Iron deficiency anemia rates amongst Palestinian children residing in the Gaza Strip in the year 2007, compared with 2006 (WHO’s 2007 Annual Report). 

Similarly, Ard El-Insan (AEI)’s 2007 - annual report shows an increase in the rates of nutritional disorders during 2007 than during 2006 as follows; stunting (1.9%), wasting (8.5%) and under weight malnutrition (3.1%).
 

METHODOLOGY 

Study design

This is a rapid cross sectional quantitative survey aimed at rapidly assess the prevalence of malnutrition amongst the Palestinian children aged between 6 and 59 months in three governorates of the Gaza Strip and to determine the risk factors associated with it (malnutrition).  

Sample and Sampling

Originally, the study was aimed at including 750 Palestinian children aged 6 - 59 months, equally distributed among Gaza (250), North Gaza (250), and Khanyounis (250), as suggested per UNICEF. This sample size is considered as a representative sample for all study population within a 95% confidence interval. The subjects were randomly selected through cluster sampling approach.

WHO/WFP/UNHCR/IFRC formula was used to calculate the sample size needed to determine the prevalence of malnutrition in each of the three study areas. This formula helps determine the relevant sample size that is adequately sufficient to perform simple random selection. It was taken also into account that the three governorates incorporated in the study have similar distribution of risk factors of childhood malnutrition and the variations amongst them in terms of population density and household size are not apparently wide. The formula used is:

n = t²× (1-p) x cluster design factor (2)

            P× e²

where n is the required sample size, P is the expected prevalence of malnutrition = 50%, e is the relative precision required = 20%,  and t is the standard value of the 95% confidence interval = 1.96

      n= (1.96)² × (1- 0.5)   = 96

              0.5× (0.2)²   

The required sample size is 96× 2 = 192 children and this sample was then increased by at least 30% of children for the non response rate in order to allow for the reliability and relative strength of the study. Therefore, the sample size per each governorate was increased to 250 children with a resulting total sample size of 750 children.

Inclusion criteria:

1. Male or female child aged 6 - 59 months.

2. Residing in one of the three selected governorates, North Gaza, Gaza, or Khanyounis. This includes those who are normally residing outside the Gaza Strip, i.e. abroad, but were not able to leave the Gaza Strip due to the current closure of border crossings, provided that the period they spent in their current household is not less than 6 months. Residents of the Gaza Strip, other than the area in which data collection is carried out, were excluded.

3. The caretaker provided consent to become a part of the study.

Exclusion criteria:

1. Children who were aged less than 6 months, five years, or more than 5 years.

2. Children who were not residents of the Gaza strip e.g. visitors; in consistency with what is mentioned above, under Inclusion Criteria.

3. Children suffering from psychomotor retardation, hormonal disorders, chronic debilitating diseases, congenital heart diseases, acute severe illnesses or acute severe diarrhea within the last two weeks. 

4. Children suffering from any disease that might impair the accuracy of the survey.

It is worth mentioning that caretaker of any sick child, regardless of being included or excluded in the study, were asked to show relevant medical reports in order to affirm the diagnosis if any. 

Study Tools

The study mainly involved two tools, a structured questionnaire and anthropometric measurements.

The Interview Questionnaire (included in the Annex) was the main method for data collection. It included close ended questions and it had a number of sections, the first one about biographic data and socioeconomic situation of the subject and subject’s family, the second one about the subject’s anthropometric measurements (weight, height/ length, and mid upper arm circumference); which were measured by the data collectors, and the third one about child’s nutrition/ feeding, including breastfeeding, complementary feeding and supplementation.

Mothers of eligible children were the source of information. In case the mother was not available (dead, divorced, etc) the primary care taker (grandmother, aunt, etc) was approached as the source of data. Interviewers (data collectors) asked the questions included in the questionnaire and carried out the anthropometric measurements themselves.

It is worth mentioning that anthropometric assessments included the measurements of weight, height/ length and mid upper arm circumference (MUAC).

The interviews took place in the interviewees’ homes, after getting consent to conduct the study. Contact information (telephone or mobile) was taken whenever possible to facilitate further future testing and confirmation of the collected data.  

Validity and Piloting

The content validity of the questionnaire was ensured being reviewed by the principal researchers, AEI and UNICEF technical experts. Some modifications were also introduced to it after conducting the training of data collectors. In addition, the questionnaire was piloted and correction of inconsistencies and/ or ambiguities was done. 

Data Collection

Training of 18 data collectors who was carried out the data collection over a period of 5 days. Each team consisted of two members. For each governorate three teams of data collectors carried out the task. Co researchers joined the data collectors in the field to provide support, monitor data collection and ensure adequate quality of data collection. The data collectors were post graduate students enrolled at Alazhar University’s Masters’ Program of Clinical Nutrition. As per the co researchers, one of them was the Coordinator of Alazhar University’s Clinical Nutrition Program; another was a lecturer at that program, whilst the third was the Director of Nutrition Department at the Palestinian MOH. Data was simultaneously collected at the three governorates, Gaza, North Gaza and Khanyounis. 

            Ethical approval:

Ethical approvals and consents were obtained from participated mothers following full explanation by data collectors.

            Confidentiality:

Interviewers were strictly instructed to maintain confidentiality of the collected data and to explain that to the interviewees. They took into consideration the confidentiality and privacy of the information they collected.

            Quality control:

Quality of data collection was emphasized through extensive training of data collectors, ensuring standardized method of measuring weight, height/ length and MUAC. In addition, the way of delivering the questions and the order of asking those questions were standardized. Field supervision of data collectors by co investigators and principal investigators during data collection was also done in order to monitor the quality of performance of data collectors and to guarantee adequacy of the data collection process and accuracy of data. Moreover, quality control was extended through the data entry and analysis processes, with 61 questionnaires being rechecked to make sure adequacy of the quality of the collected data.   

Data Entry and Analysis

Using SPSS software program data were entered. Data analysis was then carried out by the statistician and principal researchers during the third week of April using both SPSS (version 15) and Anthro 2005, the WHO anthropometric measurement statistical analysis software programs.

Use of descriptive and inferential statistics were applied, the statistical significance level was at P value less than 0.05. Chi square test were used to test relationships. 

RESULTS 

The study involved a total of 754 valid filled in questionnaires, with 33.5% of them being from North Gaza, 34.0% from Gaza, and 32.5% from Khanyounis. Figure (1) below showed the distribution of sample among the three governorates. 

Figure (1): Distribution of study sample by governorate

This distribution is consistent with the planned distribution of the sample size among the three Governorates. 

Child’s Sex

In terms of sex, the children surveyed were split into almost two halves. This finding is applicable to total GS results (49.9% males and 50.1% females) as well as the district levels: Distribution by sex as further classified in table (1). 

Table (1): Child’s Sex

 

Child’s Gestational Age at Time of Delivery

Gestational age at time of delivery for the majority of surveyed children (95.8%) was within the normal limits, 37 – 42 weeks. Only 4.2% of the children surveyed were delivered prematurely (before completing 37 weeks of gestational age), while none of them were post maturely (after completing 42 weeks of gestational age) delivered.

On the district level; it was noticed that the percentage of children prematurely born was least in North Gaza (2.4%), compared with Gaza (4.4%) and Khanyounis (5.7%).

For more details, please refer to the table below:  

Table (2): Child’s Gestational Age at the Time of Delivery

 

Child’s Birth Weight

The average birth weight of surveyed children was 3192.9 grams,

89.7% of surveyed children had birth weights that are within normal range (2500 – 4000 grams). In addition, 7.2% of surveyed children had birth weights less than 2500 grams, with only 0.7% of them having birth weights less than 1500 grams.

On the other hand, 3.1% had birth weights higher than 4000 grams. On the district level; no significant variations were noticed. Table (3) includes detailed comparative values. 

Table (3): Child’s Birth Weight

 
 

Child’s Age Group by Governorate

Average age of surveyed children was 29.8 months.

The majority (71.4%) of surveyed children were aged older than 1 year up to below 4 years, while less than one third of them were either younger than one year of age (13.5%) or older than 4 years (15.1%). It was noticed that the percentages of children whose ages fell in the age groups (12 - <24), (24 - <36), and (36 - <48), were relatively close one to another; with each one constituting about one fourth of the total sample size.

On the district level no statistical significant differences were found. More details are included in table (4). 

Table (4): Children Age Groups by Governorate

P – value = 0.649 ,  Chi – Square = 5.984 

Child’s Refugee Status

61.3 % of surveyed children were refugees, while the rest (38.7%) were non refugees.

On the district level; the percentage of refugee children surveyed was highest in Gaza (67.2%), as compared to 62.3% in North Gaza and 54.3% in Khanyounis (Table 5). 

Table (5): Child’s Refugee Status

 

Household Size (Number of family members)

The average number of residents at the surveyed households was 6.9.

Almost four fifths (78.1%) of surveyed households had sizes that ranged from 4 till 9. In addition, about half (48.1%) the surveyed households had sizes that are equal to, or greater than, 7. Households with sizes up to three constituted only 7.3%. 16.6% of the surveyed houses had sizes of at least 10; which is more evident and prominent in North Gaza (23.1% of the households are inhabited by ≥ 10 members). Table (6) provides more detailed information.  

Table (6): Household Size (Number of family members)

P – value: 0.002 ,  Chi – Square = 20. 687 
 

Father’s Employment/ Work Status

60.4% of the fathers of surveyed children had works or were employed. On the other hand, 39.6% did not have work.

On the district level; Gaza had the highest employment percentage among fathers of surveyed children (72.9%), as compared to 50.6% in North Gaza and 57.4% in Khanyounis. This is a logic finding, as Gaza constitutes the main center of employment in the Gaza Strip, with many employed people increasingly moving to reside in Gaza (coming from the rest of GS governorates).

For more details, please refer to the table below:  

Table (7): Father’s Employment/ Work Status

P – value: 0.000 ,  Chi – Square = 27. 294  

Family’s Monthly Income

Only 54.1% of the mothers of surveyed children provided answers to this question, 27.5% did not know the family’s monthly income and 18.4% refused to provide an answer.

The mean monthly income was found to be 1943.7 NIS, whilst the median monthly income was equal to 1800 NIS. At a rate of 1 $US = 3.5 NIS, the average monthly income is $US 555,3 and the median monthly income is $US 514,3.

More than one fourth (15.8% out of 54.1%) of those who provided estimates of their family monthly income, had incomes that are 1000 NIS at maximum. Among those, about a quarter (3.6% out of 15.8%), had monthly incomes that are less than 500 NIS.

In addition, more than three fifths (32.5% out of 54.1%) of those who provided estimates of their family monthly income, had incomes that ranged from 1001 and 3000 NIS.

Moreover, only one tenth (5.8% out of 54.1%) of those who provided estimates of their family monthly income, had incomes that were higher than 3000 NIS.

On the district level; North Gaza was somehow different from Gaza and Khanyounis. In this context, North Gaza had a higher percentage (19.8%) of households with incomes less or equal to 1000 NIS, compared to 11.4% in Gaza and 16.3% in Khanyounis. On the other hand, North Gaza had a lower percentage (1.6%) of households with incomes higher than 3000 NIS, compared to Gaza (7.4% and Khanyounis (8.5%). North Gaza’s mean and median monthly income values were 1462.5 NIS and 1300 NIS, respectively, compared with Gaza (mean: 2228,7 NIS and median: 1950 NIS) and Khanyounis (mean: 2076.7 NIS and median: 2000 NIS).

It was noticed also that the percentage of respondents who did not know the family’s monthly income was much lower in Khanyounis (4.9%) than in Gaza (39.1%) and North Gaza (37.5%). On the other hand, the percentage of respondents who refused to give estimates of their families’ monthly incomes was much higher in Khanyounis (33.9%) than in Gaza (7.8%) and North Gaza (14.2%). Table (8) includes detailed relevant information. 

Table (8): Family’s Monthly Income

* Data is not normally distributed, p value = 0.000

For those who gave estimates of monthly income: P – value: 0.001, Chi – Square = 31. 334

For all respondents (have income, refused, do not know): P – value: 0.000, Chi – Square = 151. 813  

Sufficiency of Family’s Monthly Income (to secure food for child and family)

About two thirds (62.6%) of the families of surveyed children perceived their family monthly income as insufficient for securing food for the child and family.

On the district level; Gaza had the highest percentage of sufficiency (54.5%), as compared to North Gaza (27.7%) and Khanyounis (31.5%); as shown in table (9).  

Table (9): Sufficiency of Family’s Monthly Income (to secure food for child and family)

P – value: 0.000 ,  Chi – Square = 41. 387 

Family Status as Per Receiving Aid/ Assistance

A little bit more than one third (35.1%) of the families of surveyed children received aid/ assistance, regardless of the type of aid/ assistance.

Among those who received aid/ assistance, 87.0% received it in the form of food supplementation, 7.3% in the form of financial assistance (money) and 5.7% in forms other than food or money; such assistance might include medical devices and/ or aides such as crutches and wheel chairs, medical care (treatments and medicines), diapers, etc.

As per the frequency of receiving aid/ assistance, the vast majority (94.4%) of those who receive aid, receive it once every more than one month, 5.2% receive aid on a monthly basis, while only 0.4% receive aid once a week.

On the district level; North Gaza had the highest percentage of receiving aid (48.8%), as compared to Gaza (28.1%) and Khanyounis (27.6%). In addition, Gaza’s percentage of material assistance among all types of assistance is high (19.0%) compared with North Gaza (1.7%) and Khanyounis (0.0%). More details are in included tables 10, 11 and 12.

 

Table (10): Family Status as Per Receiving Aid/ Assistance

P - value: 0.000 ,  Chi – Square = 31. 198

Table (11): Type of Aid/ Assistance Received by Family

P - value: 0.000 ,  Chi – Square = 33. 646 

Table (12): Frequency of Receiving Aid/ Assistance

 

History of Occurrence of Malnutrition among any of the Family’s Children

About one fourth (22.3%) of the families of surveyed children had histories of malnutrition among any of the family’s children.

On the district level; a higher percentage of families in Khanyounis (33.6%) had histories of malnutrition among any of the family’s children, as compared with Gaza (20.9%) and North Gaza (12.7%). Reference information is included in table (13).  

Table (13): History of Occurrence of Malnutrition among any of the Family’s Children

P - value: 0.000 ,  Chi – Square = 31. 457 
 

Underweight (Weight for Age)

2.5% of the surveyed children were found to be either moderately or severely underweight, meaning that their weights for age fell below (-2) standard deviation (SD). It is worth mentioning that only 0.1% of the surveyed children were severely underweight as shown in the figure below: 

Figure (2): Distribution of children based on weight for age status

 

The graph below also shows the distribution of children based on their weight for age compared to WHO standards that based on Z-score classification of nutritional status. 

Graph (1): Distribution of children based on their weight for age compared to WHO standards

 
 
 

On the district level, North Gaza was found to be of the highest percentage of underweight (3.6%) as compared with Khanyounis (1.6%) and Gaza (2.3%). Table (20) includes detailed relevant information. 

Table (14): Percentage of Children with Underweight

P – value = 0.556 ,  Chi – Square = 1.173 

Stunting (Height/ Length for age)

10.3% of the surveyed children were found to be either moderately or severely stunted, meaning that their heights/ lengths for age fell below (-2) standard deviation (SD). It was noticed that 6.2% of the surveyed children were moderately stunted, and 4.1% were severely so as shown in the figure below: 

Figure (3): Distribution of children based on height/ length for age status

Graph (2) also shows the distribution of children based on their length/height for age in accordance with WHO standards that based on Z-score classification of nutritional status. 
 
 
 

Graph (2): Distribution of children based on their height/ length for age compared to WHO standards

On the district level, North Gaza was found to be of the highest percentage of stunting (15.0%) as compared with Gaza (7.8%) and Khanyounis (8.2%). More details are included in the table below. 

Table (15): Percentage of Children with Stunting

P – value = 0.573 ,  Chi – Square = 1.112 

Wasting (Weight for Height/ Length)

2.4% of the surveyed children were found to be either moderately or severely wasted, meaning that their weights for height/ length fell below (-2) standard deviation (SD). It is worth mentioning that wasted children were divided into two halves, between the two degrees of wasting (1.2% for each) as shown in the figure below. 
 

Figure (4): Distribution of children based on weight for height/ length status

The graph below also shows the distribution of children based on their weight for length/height compared to WHO standards that based on Z-score classification of nutritional status. 

Graph (3): Distribution of children based on their weight for height / length compared to WHO standards

On the district level, Gaza was found to be of the highest percentage of wasting (3.1%) as compared with Khanyounis (1.6%) and North Gaza (2.4%). For more details, please refer to the table below. 
 
 
 
 

Table (16): Percentage of Children with Wasting

P – value = 0.097 ,  Chi – Square = 4.667 

Malnutrition (Mid Upper Arm Circumference (MUAC) for Age)

3.4% of the surveyed children were found to be either moderately or severely malnourished, meaning that their mid upper arm circumferences (MUAC) for age fell below (-2) standard deviation (SD).

It is worth mentioning that those who were moderately malnourished wee six times greater than those who were severely malnourished.

On the district level, North Gaza was found to be of the highest percentage of malnourishment (6.7%) as compared with Khanyounis (1.2%) and Gaza (2.3%). Table (17) includes more details. 

Table (17): Percentage of Children with Malnutrition (based on MUAC) (Mid Upper Arm Circumference)

P – value = 0.387 ,  Chi – Square = 1.900 
 

Breastfeeding the Child

83.3% of the mothers of surveyed children said that they exclusively breastfed their children. It is quite interesting that only 23.3% of the women surveyed exclusively breastfed their children for periods up to 5 months of age; while only 14.5% did so exactly for 6 months, as per WHO’s recommendations.

The following tables (18, 19, 20 and 21) provide relevant details.  

Table (18): Mother’s Status as per Exclusively Breastfeeding the Child by Governorate

P - value: 0.000 ,  Chi – Square = 29. 285 

Table (19): Length of Time the Mother Exclusively Breastfed the Child

P - value: 0.000 ,  Chi – Square = 108.195 

Table (20): Appropriate Length of Time of Breastfeeding as Perceived by Mothers

P - value: 0.007 ,  Chi – Square = 17.787 

Table (21): Mother’s Status as per Currently Breastfeeding the Child

For the different age groups P - value: 0.000 & Chi – Square = 294.091 

Frequency of giving the Child complementary foods

Milk/ Milk Products: About three fifths (59.1%) of the surveyed children were given milk at least once a day, while 13.2% of them did not receive it at all.

Eggs: About two fifths (39.1%) of the surveyed children were given eggs two to three times a week while 10.9% of them did not receive eggs at all.

Meat (fresh, frozen, canned): About one third (32.7%) of the surveyed children were given meat twice or three times a week, while 17.1% of them did not receive it at all.

Liver (fresh, frozen): 30.3% of the surveyed children were given liver once a week, while 31.8% of them did not receive it at all.

Fish (fresh, frozen, canned): 24.8% of the surveyed children were given fish once a week, while 20.3% of them did not receive it at all.

Legumes (Lentils, beans, etc): About three fifths (59.0%) of the surveyed children were given legumes at least twice a week, while 14.4% of them did not receive legumes at all.

Vegetables (fresh/ cooked): 56.1% of the surveyed children were given vegetables at least once a day, while 4.5% of them did not receive vegetables at all.

Fruits: 37.1% of the surveyed children were given fruits (fresh or dried) at least once a day, while 6.8% of them did not receive fruits at all. In addition, 34.4%of the surveyed children were given fruit juice at least once a day, while 17.7% of them never receive it.

Bread and Cereals: 81.9% of the surveyed children were given bread and/ or cereals at least once a day, while 5.5% of them did not receive bread and/ or cereals at all.

Sweets or candy: 61.2% of the surveyed children were given sweets or candy at least once a day, while 13.1% of them did not receive sweets or candy at all.

On the district level, it was noticed that North Gaza had the lowest percentages of children who were given milk, eggs, meat, legumes, vegetables, fruits, fruit juice, and bread/ cereals, once or more daily, as compared with Gaza and Khanyounis.  

Tea

A big proportion (69.4%) of the surveyed children received/ drank tea.

For more details, please refer to the following three tables (22, 23, and 24).  
 
 

Table (22): Child’s Status as per Receiving/ Drinking Tea

 

Table (23): Frequency of Drinking Tea by Child

P - value: 0.000 & Chi – Square = 23.649 

Table (24): Child’s Status as per Receiving/ Drinking Tea with Meals

P - value: 0.030 & Chi – Square = 7.002 

Vitamins A and D Supplementation

Three fifths (60.1%) of the surveyed children never received vitamin A and D supplementation. In addition, only 17.3% of them received the supplementation on a daily basis.

On the district level, a lower percentage (27.8%) of Gaza’s surveyed children never received vitamin A and D supplementation, as compared with Khanyounis (74.6%) and North Gaza (77.7%), as shown in table (25).  

Table (25): Child’s Status as per Receiving Vitamins A and D Supplementation

P - value: 0.000 & Chi – Square = 162.897 

Iron Supplementation

Three fifths (60.3%) of the surveyed children never received iron supplementation. In addition, only 16.6% of them received the supplementation on a daily basis.

On the district level, a lower percentage (28.8%) of Gaza’s surveyed children never received iron supplementation, as compared with Khanyounis (74.3%) and North Gaza (78.1%)., as shown in table (26). 

Table (26): Child’s Status as per Receiving Iron Supplementation

P - value: 0.000 & Chi – Square = 159.686 

Underweight Versus Child’s Birth Weight

It was found that underweight (classified on the basis of weight) is significantly linked to birth weight. In this context, 20% of surveyed children whose birth weights fell below 1500 grams were moderately underweight. Similarly the percentage of moderately underweight children whose birth weights ranged from 1500 to 2499 grams was relatively high (8.2%).

For more details, please refer to the table below: 

Table (27): Relationship between child's birth weight and nutritional status (underweight vs normal) of children 

Chi-Square = 15.068, P-value = 0.020

  

Malnutrition Versus Child’s Birth Weight

Malnutrition (classified on the basis of MUAC) was found to be significantly linked to birth weight. In this context, 40% of surveyed children whose birth weights fell below 1500 grams were moderately malnourished. Similarly the percentage of moderately malnourished children whose birth weights ranged from 1500 to 2499 grams was relatively high (8.2%). Severe malnutrition was noticed to be highest among children whose birth weights fell above 4000 grams, as shown in table (28). 

Table (28): Relationship between child's birth weight and nutritional status (MUAC classification) of children 

Chi-Square = 38.554, P-value = 0.000 
 
 

Malnutrition Versus Child’s Refugee Status

3.5% of the refugee surveyed children were moderately malnourished, as opposed to only 1.4% of non refugee children. On the other hand, 1.0% of non refugee children were severely malnourished, as opposed to only 0.2% of refugee children. Table (29) displays relevant results. 

Table (29): Relationship between child's refugee status and nutritional status (MUAC classification) of children

Chi-Square = 6.161, P-value = 0.046 

Stunting Versus Child’s Household Size

21.6% of the surveyed children whose family sizes were at least 10; were either moderately (12.8%) or severely (8.8%) stunted (classified based on height/ length for age), as shown in table (30). 

Table (30): Relationship between child's household size and nutritional status (Stunting vs normal) of children   

Chi-Square = 24.024, P-value = 0.001 

Stunting Versus Mother’s Educational Status

Surprisingly, the percentages of severely stunted were highest, and identical (16.7%), among the two extreme groups of mothers, as per educational status classification; the illiterate ones and the post graduate ones. Mothers of elementary education level also had higher percentages of stunted children (17.2%), as shown in table (31). The fact that women of a post graduate education level have a high percentage of stunted children might be related to their work status; such women usually have jobs; which makes them unavailable for meeting their children’s needs.  
 
 

Table (31): Relationship between mother's educational level and nutritional status (stunting vs normal) of children

Chi-Square = 20.937, P-value = 0.022 

Malnutrition (as per MUAC) Versus Mother’s Educational Status

As shown in table (32), higher percentages of malnourished children were born to mothers who were either illiterate (8.3%) or with elementary education level (12.7%). 

Table (32): Relationship between mother's educational level and nutritional status (MUAC classification) of children   

Chi-Square = 23.724, P-value = 0.008 

Stunting (Height/ Length for Age) Versus Family's Income

13.3% of the surveyed children whose families did not have sufficient incomes; were either moderately (7.7%) or severely stunted (5.6%), as displayed in table (33) below. 

Table (33): Relationship between family's income and nutritional status (stunting vs normal) of children   

Chi-Square = 8.179, P-value = 0.017 

Stunting (Height/ Length for Age) Versus Family History of Malnutrition

The percentage of either moderate or severe stunting among children with a family history of malnutrition was twice that among children with no such history, 17.4% versus 8.5%, respectively, as in table (34) below: 

Table (34): Relationship between history of malnutrition among previous children in the family and nutritional status (stunting vs normal) of children   

Chi-Square = 11.527,  P-value = 0.003 

Wasting (Weight for Height/ Length) versus Receiving Meat

4.8% of the children who never received meat and 4.0% of those who received meat once per week were either moderately or severely wasted. Surprisingly, 3.4% of the children who received meat at least once per day were stunted, as in table (35) below: 

Table (35): Relationship between frequency of child's eating meat and nutritional status (wasted vs normal) of children

Chi-Square = 18.604,  P-value = 0.017 

Stunting (Height/ Length for Age) versus Receiving Meat

The percentage of severely stunted children was highest (10.0%) among those who received meat once biweekly, followed by that among those who never received meat (5.5%) and those who received meat once per week (3.8%), as shown in table (36) below. 

Table (36): Relationship between frequency of child's eating to meat and nutritional status (stunting vs normal) of children   

Chi-Square = 22.433,  P-value = 0.004 

Stunting (Height/ Length for Age) versus Receiving Legumes

As displayed in table (48) below, the percentage of either moderately or severely stunted children was highest (14.9%) among those who received legumes at least once daily; the percentage of severe stunting is adversely related to the number of times of receiving legumes. Though these findings might seem bizarre; logic can be found; increasing the intake of a certain type of food, e.g. legumes, can be at the expense of other nutritious ones. 

Table (37): Relationship between frequency of child's eating legumes and nutritional status (stunting vs normal) of children   

Chi-Square = 21.204,  P-value = 0.007 

Stunting (Height/ Length for Age) versus Receiving Fruits

The percentages of either moderately or severely stunted children were highest among children who received fruits once or less weekly, as shown in table (38). 

Table (38): Relationship between frequency of child's eating fruits and nutritional status (stunting vs normal) of children   

Chi-Square = 21.363, P-value = 0.006 

Underweight (Weight for Age) versus Receiving Vegetables

The percentage of severely underweight children was highest (4.0%) among the children who received vegetables once weekly, as compared with the other groups. Table (39) displays relevant findings.

 

Table (39): Relationship between frequency of child's eating vegetables and nutritional status (underweight vs normal) of children   

Chi-Square = 32.704, P-value = 0.000 

Underweight (Weight for Age) versus Receiving Fruits

Among the children who never received fruits, 5.9% were either moderately or severely underweight; this is the highest percentage, compared with the other groups (Table 40). 

Table (40): Relationship between frequency of child's eating fruits and nutritional status (underweight vs normal) of children

Chi-Square = 17.901,  P-value = 0.022 

DISCUSSION 

Most represented age group was for children between 12 and less than 24 months (26.5%), with more than two thirds of the sample size falling within the 1-4 year old age group. This finding is a logical one as the youngest age group (6 -12 months) is the one with the shortest interval and quite a big proportion of children who fall within the oldest age group (4 – 5 years) is not expected to be available at the surveyed households, because this is the age when families start sending their children to kindergartens.    

In terms of refugee status, 61.3 % of surveyed children were refugees, a finding that is close to, but not similar to the actual distribution of the GS population that represent 69% refugees out of Gaza Strip population (MOH, 2006). On the district level; the percentage of refugee children surveyed was highest in Gaza (67.2%), as compared to 62.3% in North Gaza and 54.3% in Khanyounis. 

The average number of residents at the surveyed households was 6.9, with almost four fifths (78.1%) of surveyed households had sizes that ranged from 4 till 9; such findings are consistent with the characteristics of the Palestinian community in GS. The lower households sizes in Gaza district might be related to the characteristics of the its population where there might be a higher tendency to have less family size, as compared with North Gaza and Khanyounis.   

Among fathers of the surveyed children 39.6% did not have work/were unemployed, 

On the district level; Gaza had the highest employment percentage among fathers of surveyed children (72.9%), as compared to 50.6% in North Gaza and 57.4% in Khanyounis. This is a logic finding, as Gaza constitutes the main center of employment in the Gaza Strip, with many employed people increasingly moving to reside in Gaza (coming from the rest of GS governorates).  

The average monthly income of the families that responded to this question (only 54.1% of the total sample size) was found to be 1943.7 NIS, while the median monthly income was equal to 1800 NIS. At a rate of 1 $US = 3.5 NIS, the average monthly income is $US 555,3 and the median monthly income is $US 514,3. Taking into consideration that the average household size, as per this study, is 6.9, the average monthly income of each surveyed child is $US 80.5. Though this might appear a reasonable figure, it is considered relatively low in the light of the current sharp increase in prices in the Gaza Strip. This conclusion can be supported by the assumption that those who did not know their monthly incomes or refused to give estimates might have very limited income or they depend on small assistance by relatives or other community members. In such cases they might have obscured data in order not to expose themselves, as recipients of aid, something that many people consider a shameful act, or they did not want to appear as begging for assistance.

It is worth mentioning that more than one fourth of those who provided estimates of their family monthly income, had incomes that are 1000 NIS at maximum. Among those, about one third (3.6% out of 12.2%), had monthly incomes that are less than 500 NIS. This means that there are a considerable proportion of the families in the Gaza Strip that do not have adequate monthly incomes; which might affect their abilities to secure adequate nutrition for their families, in general, and their children, in particular. About two thirds (62.6%) of the families of surveyed children perceived their family monthly income as insufficient for securing food for the child and family. Taking into the current dramatic price increases in the GS and the relatively low family incomes, this finding is a logical one.  

35.1% of the families of surveyed children received aid/ assistance. Among those who received aid/ assistance, 87.0% received it in the form of food supplementation, 7.3% in the form of financial assistance (money) and 5.7% in forms other than food or money; such assistance might include medical devices and/ or aides such as crutches and wheel chairs, medical care (health insurance, treatment, medicines), diapers, etc. This finding is consistent with the characteristics of the surveyed population, the majority of which being refugees with UNRWA’s main assistance line being food. In addition, there is a tendency to concentrate on food assistance by the majority of relief organizations and NGO’s.

As per the frequency of receiving aid/ assistance, the vast majority (94.4%) of those who receive aid, receive it once every more than one month, something that might indicate insufficiency of such assistance.  

As per household ownership, 91.7% of the families of surveyed children live in households that are owned by them; only 8.3% live in rented households. This finding is totally consistent with the GS population characteristics; where people prefer to live in houses they own, and abstain from renting apartments or houses, unless they do not have any other choice. Though this finding might indicate a good economic status, it should not be taken as a for taken fact; it might be giving a false picture because GS people tend live in extended family settings, with where everyone claims ownership of the household.  

With regard to occurrence of malnutrition among any of the family’s children, 22.3% of the families of surveyed children had histories of malnutrition among any of the family’s children, with such a high percentage; it is expected to have high percentages of malnutrition amongst this study’s population.  

Of the surveyed children 2.5% were found to be either moderately or severely underweight, meaning that their weights were not adequate for their ages. In addition, 10.3% of the surveyed children were found to be either moderately or severely stunted, meaning that their heights/ lengths were not adequate for their ages. It is worth mentioning that 6.2% of the surveyed children were moderately stunted, and 4.1% were severely so. As per wasting, 2.4% of the surveyed children were found to be either moderately or severely wasted, meaning that their weights were not adequate for their heights/ lengths.

It was also found that 3.4% of the surveyed children were either moderately or severely malnourished, meaning that their mid upper arm circumferences (MUAC) were not adequate for their ages.  

Compared with previous studies (PCBS’s 2005 Policy Report, UNICEF Donor’s 2003  Update, Community College for Applied Science and Technology’s 2005 Household study, WHO’s 2007 annual report, and AEI’s 2007 annual report), an increase in the prevalence of stunting was observed. 

On the district level, North Gaza was found to be of the highest percentages of underweight (3.6%) as compared with Khanyounis (1.6%) and Gaza (2.3%), stunting (15%) as compared with Gaza (7.8%) and Khanyounis (8.2%), and malnourishment (6.7%) as compared with Khanyounis (1.2%) and Gaza (2.3%), while Gaza was found to be of the highest percentage of wasting (3.1%) as compared with Khanyounis (1.6%) and North Gaza (2.4%). The fact that North Gaza has the highest prevalence of three main malnutrition indicators clearly indicates its poor status as per child nutrition. This might be due in the different population characteristics, as previously discussed. 

83.3% of the mothers of surveyed children said that they exclusively breastfed their surveyed children. The mean and median length of time in months during which the mothers of surveyed children exclusively breastfed their children were 10.8 and 10, respectively. It is quite interesting that only 23.3% of the women surveyed exclusively breastfed their children for periods up to 5 months of age; while 62.4% did so for periods longer than 6 months. Those who did so for a period of 6 months, as per WHO recommendations, constituted 14.5%. Though these findings might seem to indicate adequate periods of exclusive breastfeeding, they signal a need for exerting more concentrated efforts to get higher percentages of women abide by the 6 month period of exclusive breastfeeding. On one hand, premature stoppage of exclusive breastfeeding deprives the child of the immunity – related benefits of exclusive breastfeeding, and makes her/ him susceptible to health hazards, such as infections. On the other hand, continuing exclusive breastfeeding beyond 6 months of age deprives the child from getting sufficient nutrients not included in the mother’s breast milk. 

As per the appropriate length of time of breastfeeding, 85.8% of surveyed women perceived it to be more than 12 months up to 2 years. As per mother’s status with relevance to currently breastfeeding their surveyed children, the percentage of women who were still breastfeeding their children whose ages were up to one year, was almost three (2.9) times the percentage of those mothers who were not doing so. Though this is a positive finding, more efforts are needed to encourage all mothers to continue breastfeeding up to 2 years. 

The study showed a gap pertaining complementary feeding of the surveyed children, in consistency with what was mentioned in AEI’s 2006 study; which reported that three quarters of children aged 6 - 9 months were given less than the recommended requirement of complementary feeding (AEI, 2006). High proportions of the mothers of surveyed children introduced complementary foods for their children who were aged older than 6 months. As per the time of introducing complementary foods to the surveyed children, it was noticed that there was a wide range of answers.  

As per the frequency at which milk and animal foods were introduced, 59.1% of the surveyed children were given milk at least once a day, 39.1% were given eggs two to three times a week, 32.7% received meat 2 - 3 times a week, 30.3% were given liver once a week, while 31.8% of them did not receive it at all, 24.8% received fish once a week, while 20.3% of them did not receive it at all. These findings might indicate inadequate protein intake for quite a large proportion of children; which might be linked to the harsh economic currently prevailing in the GS; which has been accompanied by unprecedented price increases. 

As per the frequenct at which foods other than milk and animal foods were introduced, 59.0% of the surveyed children were given legumes at least twice a week, while 14.4% of them did not receive legumes at all. This finding is consistent with eating habits as many families have one of their three main meals including some form of legumes. About 56.1% of the surveyed children were given vegetables at least once a day, 37.1% were given fruits (fresh or dried) at least once a day, while 6.8% of them did not receive fruits at all. In addition, 34.4%of the surveyed children were given fruit juice at least once a day, while 17.7% of them did not receive it at all. These findings indicate the need to exert more efforts in this regard; children need to have vegetables and/ or fruits/ fruit juice on a daily basis. 

As per bread and cereals, 81.9% of the surveyed children were given bread and/ or cereals at least once a day, while 5.5% of them did not receive bread and/ or cereals at all. This finding is consistent with the fact that bread and cereals constitute the backbone of any meal in the GS. Finally, 61.2% of the surveyed children were given sweets or candy at least once a day; this is an area where extensive efforts need to be exerted. Of the surveyed children 69.4% received/ drank tea; 32.9% of them (those who received/ drank tea) did so 3 to 4 times a day; while 58.5% of them received it once to twice daily. As per drinking tea with meals, about three fifths (59.5%) of the surveyed children who drank tea, did that while having their meals. These findings are highly dangerous, because they can increase the risk of anemia among such children due to the fact that tea decreases the absorption of iron.   

Of the surveyed children 60.1% never received vitamin A and D supplementation; while only 17.3% of them received the supplementation on a frequent basis. Similarly, 60.3% of the surveyed children never received iron supplementation with only 16.6% of them receiving it on a frequent basis. These findings clearly indicate inadequate supplementation intake. Such an inadequacy might be due to inadequate supply, on the clinic side, or inadequate compliance associated with lack of knowledge, on the part of mother/ caretaker, these findings against the recommendations of WHO for children in communities where the prevalence of anemia more than 40 % as in Gaza strip (WHO, 1999).

 

It was found that underweight is significantly linked to birth weight. In this context, 20% of surveyed children whose birth weights fell below 1500 grams were moderately underweight. Similarly the percentage of moderately underweight children whose birth weights ranged from 1500 to 2499 grams was relatively high (8.2%). It is also linked to vegetable intake; with the percentage of severely underweight children among those who received vegetables once weekly mounting 4.0%. This is a logical finding as low birth weight children have a higher susceptibility for a low weight for age. 

In addition, malnutrition was found to be linked to birth weight. In this context, 40% of surveyed children whose birth weights fell below 1500 grams were moderately malnourished. Similarly the percentage of moderately malnourished children whose birth weights ranged from 1500 to 2499 grams was relatively high (8.2%). This is a logical finding as low birth weight children have a higher susceptibility for nutrition disorders than normal birth weight children. 

Refugee status was also found to be a contributing factor to malnourishment as evidenced by the fact that 3.5% of the refugee surveyed children were moderately malnourished, as opposed to only 1.4% of non refugee children and that 1.0% of non refugee surveyed children was severely malnourished, as opposed to only 0.2% of refugee children. Refugees have more limited income generation options, as compared with non refugees, making them more susceptible to inability to afford adequate foods for their children

Moreover, low mother’s educational level was linked to higher percentages of malnourishment; it was 8.3% among those whose mothers were illiterate 12.7% among those whose mothers were of elementary education level; such women lack adequate information which makes their children more susceptible to malnutrition. 

Stunting was found to linked to insufficient intake of meat; 10% among those who received meat once biweekly, 5.5% among those who never received it and 3.8% among those who received it once per week. In addition, it was linked to increased legume intake and decreased fruit intake. In this context, the percentage of either moderately or severely stunted children was highest (14.9%) among those who received legumes at least once daily, and children who received fruits once or less weekly showed the highest percentages of either moderately or severely stunted children. Though the mentioned findings might seem bizarre; logic can be found; increasing the intake of a certain legumes can be at the expense of meat because it can be easily secured due to less cost. 

Large family sizes were found to be associated with stunting. In this context, 21.6% of the surveyed children whose family sizes were at least 10; were either moderately (12.8%) or severely (8.8%) stunted. Families with large sizes might find it difficult to afford food and health care for their children. In addition, the percentages of severely stunted children were highest, and identical (16.7%), among the two extreme groups of mothers, as per educational status classification; the illiterate ones and the post graduate ones. Mothers of elementary education level also had higher percentages of stunted children (total: 17.2%). The fact that women of a post graduate education level have a high percentage of stunted children might be related to their work status; such women usually have jobs; which makes them unavailable for meeting their children’s needs, while those who are illiterate or of elementary education level, usually lack necessary information.  

Moreover, a significant correlation was found between stunting and insufficiency of family’s income to secure the nutritional needs of both the child and family. In total 13.3% of the surveyed children whose family incomes were not sufficient, were found to be either moderately (7.7%) or severely stunted (5.6%). Families with insufficient income can not, of course, adequately afford food for the family.

Stunting was also found to be linked with a family history of malnutrition; with the percentage of either moderately or severely stunted children with a family history of malnutrition being twice that among children with no such history, 17.4% versus 8.5%, respectively. This finding is a logical one; families with a history of malnutrition have a higher probability for having other children with malnutrition, especially if necessary measures were not taken.  

Wasting was found to be linked to insufficient meat intake. I this context, the percentage of either moderately or severely wasted children was 4.8% among those who never received meat and 4.0% among those who received meat once per week. Inadequate intake of meat is a common factor in the occurrence of malnutrition. Thus malnutrition among children between 6 and 59 months in Gaza Strip has many risk factors associated with it, most of these factors could be prevented and or altered by simple interventions and contributions from all.

 

RECOMMENDATIONS 

Based on the findings of this study, the following recommendations may help in improving the nutritional status of children between 6-59 months in Gaza Strip: 

• Health education is very necessary and it should be conducted using different methods and with more involvement and participation of community members.
• Main areas on which to focus include breastfeeding and complementary feeding. Special emphasis should be put on the exact length of exclusive breastfeeding (6 months), timing of introducing complementary foods and adequacy of complementary foods in terms of quantity (amount) and quality (variety).
• Adequate supply of supplementation needs to be secured within health facilities so that health providers can give it to children. In line with that, health provides need to exert more efforts on encouraging mothers (caretakers) to give their children the prescribed supplementations as per instructions.
• Relevant international, regional, and local bodies need to do their best to ease the closure and siege imposed on the Gaza Strip and to secure work opportunities for its population so that the economic situation gets improved with a resulting ability to secure food for children.
• Relief efforts need to continue; it is clear that the GS population is deprived from essential goods. Relief bodies including international organizations and local governmental and non governmental bodies need to increase the frequency of distributing aid, especially food assistance. For that assistance to be effective and helpful, such bodies need to develop relevant tools that are aimed at monitoring and evaluating their ad activities to guarantee that the assistance reaches its designated recipients on hand, and that it is used for its designated purpose, on the other.
• Food assistance packages might need to be more varied, to include all food groups.
• Subsequent studies might be needed. Subsequent studies might need to focus more on critically dissecting the findings of this study. Such a study might need to be more probing involving a mixture of quantitative and qualitative methods. And not only to involve the mothers (caretakers) of the study population, but also groups of relevant influential community members such as health professionals, husbands, mothers, mothers in law, etc.

 

REFERENCES

A. References (English)

1. AEI (2003), Nutritional Assessment: Anthropometric Survey in the Gaza Strip.

2. Al-Wahaidi, A., Lec'hvien. S. (2006), Studying the knowledge and practices of mothers of children aged 6-59 months regarding child health and nutrition in five localities in the Gaza Strip. Ard El-Insan, Gaza, Palestine.

3. Beaton G. Kelly A, Kevany J. Martorell R. Mason J. eds. (1990), Appropriate uses of anthropometric indices in children. Geneva: ACC/SCN.

4. Frongillo EA Jr. Symposium (1999), Causes and Etiology of Stunting; 129 (2S Suppl):529S-530S.

5. Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. (1979), Physical growth: National Center for Health Statistics percentiles. American Journal of Clinical Nutrition; 32(3):607-29

6. Hammer LD, Kraemer HC, Wilson DM, Ritter PL, Dornbusch SM. (1991), Standardized percentile curves of body - mass index for children and adolescents. American Journal of Diseases of Children; 145(3):259-63

7. IAP Text Book of Pediatrics. Eds. Parthasarathy A, Menon PSN, Nair MKC (2003), New Delhi , Jaypee Brothers Medical Publishers Ltd.; p -124

8. Mali DHS. (1996), Nutrition of Infants and Young Children in Mali. Macro International Inc. 11785 Beltsville Drive, Calverton, Maryland, USA.

9. MOH (2006), Annual Health Report: Health Status in Palestine 2005.

10. Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. (1998), Body mass index as a measure of adiposity among children and adolescents: a validation study. J. Pediatr; 132(2):204-10

11. Pillitteri, A. (2003), Maternal and Child Health Nursing, USA, Lippincott Williams & Wilkins. (P 953-956).

12. UN. (1992), Second report on the world nutrition situation, vol. 1. Geneva, United Nations Administrative Committee on Coordination/ Subcommittee on Nutrition (ACC/SCN).

13. WHO, Basics and UNICEF (1999), Nutrition essentials, a guide for health managers.

14. WHO (2000), Management of The Child with a Serious Infection or Severe Malnutrition: guidelines for care at the first-referral level in developing countries.

15. MOH (2006), Annual health report: Health Status in Palestine 2005.

16. UNICEF (2003): Humanitarian Action/ Occupied Palestinian Territory - Donor Update.

17. PCBS (2005): Child Nutrition in Exceptional Circumstances - Policy Report, Child Nutrition in Exceptional Circumstances: The Case of Palestinian Children Aged 6-59 Months in the Palestinian Territory (Policy Report).

18. Community College of Applied Science and Technology (2005), Household Survey: Maternal and Child Health and Nutrition Indicators at the Household Level in the West Bank and Gaza Strip. 
 

B. References (Arabic)

المراجع العربية

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2. جمعية أرض الإنسان، تغذية أسرتك بين يديك، 2006.
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