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Trends, patterns and socio-economic predictors of underweight among young married women in Nigeria

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  • Save Public Health Research 2018, 8(2): 35-45 DOI: 10.5923/j.phr.20180802.02 Trends, Pattern and Socioeconomic Predictors of Underweight among Young Married Women in Nigeria Yusuf OB*, Gbadebo BM, Afolabi RF, Adebowale AS Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria Abstract We determined the prevalence, pattern and socioeconomic predictors of underweight among young married women (15-24yrs) in Nigeria. Two rounds (2008; n=1681 and 2013; n=3596) of a nationally representative data were analyzed. Descriptive statistics and logistic regression model were used. The proportion underweight was higher in 2008 (18.6%) than in 2013 (15.6%). In 2008, the proportion underweight was 24.0% and 8.4% among poor and rich women respectively. The proportion of underweight women reduces as household wealth increases. The likelihood of underweight was lower among participants who had one (OR=0.47; C.I=0.28-0.77, p<0.01) and two (OR=0.57; C.I=0.35-0.92, p<0.05) compared to those who had ≤3 children. The odds of underweight was higher among women who married at ages below 18yrs (OR= 2.49, C.I=1.65-3.75, p<0.001) compared to those who married at >18yrs. Underweight is still common among young married women; early marriage is a potential risk factor while lesser number of children is protective. Keywords Underweight, Early marriage, Poverty, Nigeria 1. Introduction World-wide, underweight among young women is becoming a problem of public health importance most especially in low income countries like Nigeria. Underweight is a measure of nutritional deficiency which has current and long term consequences on the overall well-being of individuals particularly the youths. The World Health Organization (WHO) defines the period of youth as a time which overlaps with the period of adolescence and extends from 15 to 24 years of age. The youth period characterizes a time during which specific health problems can be addressed for healthy growth and development in later part of life. [1] About 50% of adult bone mass including: muscles, skeletal system, other vital organs of the body and 20% of total height gain occur at this period [2, 3]. Studies have reported that young girls usually experience the maximum increase in weight and height in the year preceding menarche [4, 5]. Additionally, in the Nigeria context; it is a necessity that a married couple shows evidence of fertility few months after marriage irrespective of the age of the bride. Therefore, in young married women, nutritional demand is high in order to meet the physiological requirement for development and combating some health * Corresponding author: (Yusuf OB) Published online at Copyright © 2018 The Author(s). Published by Scientific & Academic Publishing This work is licensed under the Creative Commons Attribution International License (CC BY). challenges of childbearing and child rearing [6]. Due to the importance of adequate nutrition for socioeconomic advancement of a nation, the United Nations included it as one of the key components of the Millennium development goals (MDGs) which was to be accomplished by year 2015. Unfortunately, many developing countries did not meet the target at the deadline, thus it re-emerged as part of the themes of Sustainable Development Goals (SDGs) to be met by year 2030 [7, 8]. Being underweight has been reported as a risk factor for many diseases such as: osteoporosis, osteoporotic fractures in later life, low bone mineral density, anemia, reduced sex hormones, hypotension, feelings of fatigue and malaise. [9] [10]. Maternal underweight also has harmful effect on the nutritional status of the fetus which serves as a contributing factor for low birth weight, poor growth of the head circumference in the new born and infant mortality [6]. Inadequate growth resulting from undernourishment among young females has been implicated in the literature as having negative consequences that are related to: childbearing, increased risk of pregnancy complications and implications for caesarean delivery [11]. Furthermore, underweight during young adulthood has been linked with inadequate nutrition, poor Quality of life (QoL), morbidity and maternal mortality [12] Research is also consistent with the link between underweight and early marriage. [13] Consequently, achieving optimal growth among young married women in terms of adequate height and weight is crucial. Early marriage among young women is still a common practice in some cultures in Nigeria. [14, 15]. Child brides are often not physiologically or fully developed to give birth 36 Yusuf OB et al.: Trends, Pattern and Socioeconomic Predictors of Underweight among Young Married Women in Nigeria and this has been reported in previous studies as having serious health consequences both on the mother and the baby [16-18]. Studies have shown that maternal mortality is higher among women below age 20 years than those in their 20’s or 30’s [19-21]. Young women are more likely to experience preterm delivery/ obstructed labor, obstetric Fistula, low birth weight and mortality [22, 23, 17, 24]. The health problems associated with early marriage are peculiar to most young women in Nigeria and most of these challenges can be alleviated if young married women have sufficient nutritional requirements. Regrettably, poverty ravages the nation and majority of Nigerians live below the poverty line. The health service delivery is worrisome and not affordable by the poor who constitutes majority of the Nigerian population. In Nigeria, social and gender discrimination against women at the household level puts young married women at higher risk of nutritional deficiencies. Young vulnerable females have been reported to have inadequate education and poor access to health and nutrition services [25, 26]. Preference for the male child and discrimination against the female child though starts at early ages [27] increases throughout the youth period. In addition, traditional values and some cultural roles put pressure on the girl child in some cultures in Nigeria [28, 29]. Underweight among young married women has been extensively studied in countries like Japan, Thailand and a host of others but few studies have investigated this problem among married female youths in Africa especially in Nigeria where underweight remains a major challenge. The available studies have only focused on obesity in young women and underweight among women of reproductive age. Information about underweight among young married women is needed for the development of appropriate policies and programs to improve their nutrition and overall health. Therefore, in this paper we present a trend analysis of a nationally representative data on underweight status of young married women aged 15 – 24 years in Nigeria between 2008and 2013. Specifically, we determined the prevalence and examined the pattern of underweight among young married women in Nigeria. We also identified the socioeconomic predictors of underweight among young married women in Nigeria. 2. Methods Study area The study was conducted in Nigeria, Africa’s most populous country. The population pyramid for Nigeria show that a reasonable proportion of the populations are young women aged 15-24 years. The level of teenage pregnancy and adolescent childbearing in Nigeria is 5% and 23% respectively [30]. The country is predominantly rural and a higher proportion of women of reproductive age are still illiterates. The poverty rate is 43.1% in urban areas, 63.8% in rural areas and the unemployment rate is high [31]. Maternal mortality ratio in Nigeria is 576 per 100,000. [30]. There is availability of food crops but in most situations, the foods are not affordable by majority of the populace. The health service delivery is poor and collapse in social infrastructures has been experienced in the past few decades and as such, life expectancy is low. Study design and sample selection The 2008 and 2013 Nigeria Demographic and Health Surveys used cross-sectional design approach and the data was nationally representative. During the survey, cluster sampling approach was used to select the respondents based on allocation of specific numbers of clusters to rural and urban settlements in the country. Different questionnaires were designed to obtain information related to men, women, household, couples and children. The validity and reliability of the questionnaires have been previously reported. [30]. However, the current study used the women questionnaire and data analyses were based on married women aged 15-24 years. Thus, 1681 and 3596 records of women who provided complete information on the explanatory variables included in this study and have their mass in kg and height in meters measured at the time of the survey were analyzed. Pregnant women, lactating mothers and those whose height and mass could not be measured as a result of illness were excluded from this study. Variable description The dependent variable is Body Mass Index (BMI) which was used as a measure of nutritional status of young women. The BMI was generated from two variables; mass in kilograms (kg) and height in meters (m) mathematically represented as; BMI = Mass height2 with the unit measured in ????????⁄????2 . During data collection, mass and weight were captured with the use of weigh balance calibrated in kilogram and tape rule respectively. ∴ Nutritional status of a woman Underweight if BMI < 18.5 = �OvNeorwrmeiaglhift 18.5 ≤ if 25.0 BMI < ≤ BMI 25.0 < 30.0 Obese if BMI ≥ 30.0 However, in the course of data analysis at the level of multivariate, the nutritional status was reclassified into two categories as; underweight =1 and others =0 with underweight as a status category. The explanatory variables are; age, parity, age at 1st marriage, household wealth, work status in the 12 months prior to the survey and decision on how to spend family earnings. Others are; place of residence, education, family type and husband’s education. Data analysis The data were weighted before use by creating a new variable from the variable called ‘sampling weight’ which was included in the original data set. Weighting of the data set became necessary because cluster design approach was used during the data collection exercise for 2008 and 2013 NDHS and this will extrapolate and take into account of other areas not included in the clusters during the surveys. Data were analyzed using descriptive statistics, Chi-square Public Health Research 2018, 8(2): 35-45 37 and logistic regression model. Frequency distribution was used to present the data and Chi-square test was conducted to determine factors that are significantly associated with body mass index as a measure of nutritional status. At multivariate level of analysis, logistic regression was used due to dichotomous nature of the dependent variable to identify the predictors of underweight among the studied women. At this stage of analysis, five models were used to describe the relationship between underweight and background characteristics of the studied subjects. The variables included in each of the five models are as follows. Model 1 is the bivariate model while model 2 is a multivariate model that involves a dependent variable (underweight) and demographic variables (Age, Parity and Age at 1st Marriage). Models 3 and 4 included only the dependent variable and economic (Household wealth, Work status in the past 12 months prior to the survey and Decision on how to spend family earning) and social (Residence, Education, Family Type and Husband’s education) explanatory variables. In the last model all variables found to be statistically significant at bivariate level were included in the model in order to identify the important predictors of underweight among the studied women. All statistical tests were performed at 5.0% level of significance. The logistic regression model is of the form; ???? ???????????????? �1 − ????� = ????0 + ????1????????1 + ????2????????2 + ⋯ + ????????????????1; ???? = 1,2,3, … , ???? Where p is the proportion of women who are underweight and βi are regression parameters to be estimated with exponential of β being the odds ratio and ???????????? , are the explanatory variables. All analyses were done using IBM SPSS version 20 [32]. Ethical consideration Ethical approval was obtained from the National Ethical Review Board of the Federal Ministry of Health before conducting the survey. Informed consent was obtained from the study participants at the point of data collection and all the consented participants were assured of confidentiality and anonymity of the information they supplied. 3. Results In Table 1, the results show that the mean age of the women in 2008 and 2013 was 19.8±2.8 and 20.2±2.5yrs respectively. A higher proportion of the women are in age group 20-24 years in 2008 (59.7%) and 2013 (67.0%). Majority of the women live in rural areas, a distribution of 76.6% in 2008 and 74.9% in 2013. Slightly above 70.0% of the women have either primary or no formal education and in 2008, 27.0% are from rich households compared to 24.0% found in 2013. The Muslim women constitutes majority of the respondents, while 12.1% (in 2008) and 19.3% (in 2013) had had at least three children. As at the 2008 survey period, 28.4% of the women were from polygamous marriage, 73.8% got married at ages below 18 years and 52.0% had participated in the labor force in the last 12 months prior to the survey. The distribution pattern of the women in the survey year 2013 was similar to that of year 2008 in terms of marriage type, age at first marriage and labor force participation. About 23.1% and 19.5% of the women are involved in decision about how to spend family earnings in 2008 and 2013 respectively. Table 1. Percentage frequency distribution of young married women in Nigeria by background characteristics Background 2008 Characteristics Frequency % Total 1681 100 Age 15-19 677 40.3 20-24 1004 59.7 Residence Urban 359 21.4 Rural 1322 78.6 Education Less than secondary 1235 73.5 At least secondary 446 26.5 Household wealth Poor 932 55.4 Middle 283 16.9 Rich 466 27.7 Religion Christian 477 28.4 Islam 1172 69.7 Others 32 1.9 Parity None 760 45.2 1 388 23.1 2 329 19.6 3+ 204 12.1 Family Type Monogamy 1204 71.6 Polygamy 477 28.4 Husband’s education None 764 45.4 Primary 288 17.2 Sec+ 629 37.4 Age at first marriage <18 1240 73.8 18+ 441 26.2 Work status in the past 12 months prior the survey No 806 48.0 Yes 875 52.0 Decision on how to spend family earning Respondent inclusive 388 23.1 Respondent not inclusive 1293 76.9 2013 Frequency % 3596 100 1186 33.0 2410 67.0 904 25.1 2692 74.9 2598 72.2 998 27.8 2046 56.9 688 19.1 861 24.0 857 23.8 2711 75.4 28 0.8 736 20.5 1264 35.1 900 25.0 695 19.3 2666 74.2 929 25.8 1695 47.2 544 15.1 1356 37.7 2666 74.2 929 25.8 1815 50.5 1780 49.5 702 19.5 2857 79.5 38 Yusuf OB et al.: Trends, Pattern and Socioeconomic Predictors of Underweight among Young Married Women in Nigeria Percentage 80 70 60 50 40 30 20 18.6 15.6 10 0 Underweight 69.8 73.5 9.4 8.8 Normal Overweight Body Mass Index 2.2 2.1 Obesity Mean_2008 =21.55±6.4, Mean_2013=21.56±5.2, Figure 1. Trend in percentage distribution of the respondents according to Body Mass Index 2008 2013 2008 NDHS 2013 NDHS Figure 2. Percentage cumulative distribution of young married women in Nigeria by Body Mass Index according to wealth index and place of residence Figure 1 depicts the percentage distribution of the women according to body mass index. Higher proportion of the underweight married women was found in the survey year 2008 (18.6%) than that of survey year 2013 (15.6%) while 2.2% and 2.1% were obese in the survey years respectively. The mean Body Mass Index was 21.5±6.4 in 2008 and 21.6±5.2 in 2013. In Figure 2, the data shows that in both survey years; 2008 and 2013, the level of underweight married women (BMI<18.5kg/m2) reduces as the household wealth level increases and there was a reflection of this pattern among both rural and urban women. The data further shows that higher level of underweight was observed in the rural than urban married young women in the survey periods. The data as presented in Table 2 shows that in 2008, higher proportion of women in age group 15-19 years (27.5%) was underweight compared to those in age group 20-24 years (12.5%). Higher proportion of women living in the rural areas (20.9%) were underweight than their counterparts who live in the urban areas (10.3%). About 23.0% of women who have at most primary education were underweight while the percentage of underweight women found among women who have at least secondary education was only 6.5%. The percentage of underweight women reduces consistently with increasing wealth index and increases with the level of spousal education. For instance, in 2008, the percentage of underweight women was 24.0% among poor women and 8.4% among rich women. A similar pattern was exhibited by the women studied in 2008 regarding association between underweight and background Public Health Research 2018, 8(2): 35-45 39 characteristics such as age, residence, education, household wealth and husband/partner’s education, although a reducing trend was observed in 2013. Underweight was mostly common among women who had no children (24.2% in 2008 and 21.3% in 2013) and closely followed by women who have had at least 3 children (21.1% in 2008 and 15.5% in 2013). The percentage of underweight women was higher among women in polygamous family than their counterparts in monogamous family and this pattern was observed in year 2008 (24.3% vs. 16.4%) and 2013 (18.3% vs. 14.6%). There was a striking difference in the percentage of underweight women between women who married at ages below 18 years (22.3% in 2008 and 18.4% in 2013) and those who married at ages 18 years and above (7.9% in 2008 and 7.6% in 2013). Higher underweight women were found among those who had not participated in labor force in the past 12 months prior to the survey year than those who have worked. The data also showed that in 2008, about 20.9% of women who were not involved in decision on how to spend family income were underweight compared to 10.9% found among those that were involved in such decision and the pattern for 2013 was 16.9% and 10.1% respectively. Table 2. Relationship between Body Mass Index (BMI) and background characteristics Background 2008 Under Total χ2-value 2013 Under Total χ2-value Characteristics weight Normal Women (p-value) weight Normal Women (p-value) Total 18.6 69.8 1681 15.6 73.5 3595 Age 90.90* 60.55* 15-19 27.5 67.2 677 (<0.001) 20.2 73.6 1186 (<0.001) 20-24 12.5 71.5 1004 13.3 73.4 2409 Residence 24.90* 71.22* Urban 10.3 74.4 360 (<0.001) 10.8 71.3 904 (<0.001) Rural 20.9 68.5 1321 17.2 74.2 2691 Education 89.57* 127.68*

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