PREVALENCE AND FACTORS ASSOCIATED WITH IODINE DEFICIENCY AMONG CHILDREN AGED 6-12 YEARS AND WOMEN OF REPRODUCTIVE AGE: A CASE STUDY OF GULU AND LIRA DISTRICTS BY MIRIAM AJAMBO 16/U/3058/MPH Supervisors 1.Assoc. Professor Duncan Ongeng 2.Dr. Akera Peter

INTRODUCTION Background Iodine is a vital micro nutrient needed in human body for supporting different physiological functions such as regulating thyroid function, metabolism, facilitating growth and development (Hailu et al., 2016). Inadequate iodine intake (Iodine deficiency) leads to many devastating outcomes but the most devastating are increased perinatal mortality and mental retardation (Benoist et al., 2008; Wong et al., 2011) .

Problem statement High prevalence of Iodine deficiency is still a big problem in developing countries (Benoist et al., 2008). Since 1994 universal salt Iodisation, prevalence on Iodine deficiency reduced (Shively & Hao, 2012; Acham et al., 2012) although continuously changing. Changing trends in Iodine deficiency is known to be determined by socio-economic factors that vary across populations (Pardede et al., 1998).

Problem statement… People’s knowledge, attitude and practices have also been shown to affect iodine intake (Charlton et al., 2010). This study sought to determine prevalence of Iodine deficiency, nutritional knowledge, attitude and practices associated with Iodine intake as well as the socio-economic factors that affect Iodine intake in Gulu and Lira districts due to inadequate information on these in the selected districts

Objectives of the study General Objective To contribute to nutrition wellbeing of children 6-12 years old and women of reproductive age through delineating the status and predictors of iodine deficiency in Gulu and Lira districts. Specific objectives i. Determine the prevalence of iodine deficiency among children aged 6-12 years and women of reproductive age in Gulu and Lira districts

Objectives of the study……. ii. Assess nutritional knowledge, attitude and practices associated with iodine intake in Gulu and Lira districts iii. Determine socio-economic predictors of iodine deficiency in Gulu and Lira districts

Study Questions Do children aged 6-12 years and women of reproductive age in Gulu and Lira Districts have sufficient Iodine intake? What is the status of knowledge, attitude and practices regarding iodine intake among households in Gulu and Lira District? What socio-economic factors predict iodine deficiency disorders in Gulu and Lira Districts?

METHODOLOGY Research design Study area A cross-sectional analytical study was conducted from march 2018 to june 2018 using interviewer administered questionnaire and laboratory analysis. Study area The study was conducted in 2 districts in northern Uganda (Lira and Gulu)

Objective 1: Status of Iodine deficiency Study participants School going children aged 6-12years and women of reproductive age in Gulu and Lira districts (Mesele et al., 2014). Sample size and sampling framework The study population was constituted by children aged 6-12 years and women of child bearing age in Gulu and Lira districts.

𝑛= 𝑧 2 𝑝(1−𝑝) 𝑒 2 …………………………………………….Equation 1 Objective 1: Status of Iodine deficiency…. The sample size was determined using standard formula for epidemiological studies as shown equation 1 (Kasiulevicius et al., 2006) 𝑛= 𝑧 2 𝑝(1−𝑝) 𝑒 2 …………………………………………….Equation 1 Where, n is the sample size, z is the standard value corresponding to 95% confidence interval, p is the prevalence of iodine deficiency among children aged 6-12 years and women of child bearing age in Gulu and Lira districts and e is the margin of error (level of precision=5%). p of 50% will be used since prevalence of ID is not known. n=385 but taking an attrition rate of 10%, the final sample size of 424 will be used (424 women and 424 children 6-12 years old).

Objective 1: Status of Iodine deficiency…. Women of reproductive age were obtained from randomly selected villages and they would gather at nearby health centers. The 31 women gathered at 5 health centers in each district making a total of 310 women Children were randomly sampled from 16 primary schools, 8 schools from each district.12 pupils were selected from each school making a total of 192 pupils. Thus a total of 502 urine samples and 310 questionnaires were obtained

Objective 1: Status of Iodine deficiency…. Sample collection The subjects (children and women) who consented to participate in the study were given urine polyethylene specimen bottles to collect on spot urine samples which were stored in coolers first, then they were transported to the laboratory where they were stored in a refrigerator at −40 0 𝑐 until analysis. Laboratory analysis The concentration of Iodine in the urine was determined using the Sandell-Kolthoff reaction (WHO, 2007).

Objective 1: Status of ID deficiency…. Data analysis: The median values of urinary iodine were computed for each respective age category using SPSS version 20. The UIC of women was stratified into three groups (15-24years, 25-34years, and 35-49years). The number of women corresponding to each iodine status based on cut offs was expressed as percentage of total women in the study to obtain prevalence of iodine deficiency in each respective age category.

Objective 1: Status of ID deficiency…. Data analysis: Similarly, the prevalence of iodine deficiency in children 6-12 years old was be determined using UIC based on cut offs for children upon stratification based on sex (WHO, 2013). On the basis of UIC, children were classified in established categories

Objective 2:Nutritional KAP for Iodine Intake Study participants Women of reproductive age in Gulu and Lira districts were interviewed to determine the knowledge, attitude and practices associated with iodine intake. Sample size and sampling framework Same as for UIC

Objective 2:Nutritional KAP for Iodine Intake Instruments and data collection Nutrition knowledge, attitude and practices (KAP) on iodine intake was assessed using an interviewer administered KAP questionnaire. Constructs adapted with modification from previous studies were used to assess each aspect of KAP on iodine intake (Hailu et al., 2016; Umenwanne & Akinyele, 2000; Yamada et al., 1998; Macias & Glasauer, 2014).

Objective 2:Nutritional KAP for Iodine Intake…. Data analysis Analysis was conducted using SPSS version 20. Negative questions were reverse-coded. Nutritional knowledge were scored on a 2 point scale (1=correct, 0=Wrong or don’t know). The knowledge score for the 15 questions were summed up and expressed as a percentage of total score (Masuku and Lan et al., 2014). Nutritional attitude was scored on a 5 point scale ranging from most negative to most positive (0= strongly disagree, 1=disagree and 2=neither, 3=agree and 4 = strongly agree).

Objective 2:Nutritional KAP for Iodine Intake…. Data analysis The attitude score for the 15 questions was totalled and expressed as a percentage of total score (60). Practices was scored as knowledge above and expressed a percentage of total score (10). Knowledge, Attitude and Practices were categorised as poor or bad if the percentage score falls below cut-offs of 50%, ≤57% and ≤62.5%, respectively (Bas et al., 2007; Ul Haq et al., 2012).

Objective 3: Socio-economic predictors of Iodine deficiency Study participants The study participants were women of reproductive age in Gulu and Lira districts. Sample size and sampling framework Same as first objective.

Objective 3: Socio-economic predictors of Iodine deficiency…. Instruments and data collection Various socio-economic factors such as level of education, number of children, household size, distance to the market, level of income, attendance of training on nutrition, interaction with village health teams (VHTs) were assessed using a structured Questionnaire. Data Analysis The study adopted the Multinomial Regression Model to analyse the socio-economic predictors of Iodine deficiency among women.

Prevalence iodine deficiency among children aged 6- 12 years The highest proportion of children fell in the category of insufficient iodine intake (37.3%) of which 21.7% were insufficient mild,9.0% insufficient moderate and 6.6% insufficient severe.31.3% had adequate optimal iodine, 19.9 % had more than adequate and 11.4 % had excessive. The median UIC for children was 129 𝜇𝑔/𝑙, the mean was 157 𝜇𝑔/𝑙, and standard deviation was 10.6 𝜇𝑔/𝑙

Findings indicated that 30. 7% had insufficient UIC, 38 Findings indicated that 30.7% had insufficient UIC, 38.9% had adequate UIC while 30.4% of the women in the reproductive were found to have more than adequate (excess) UIC. Implying that the majority of the women of reproductive age have adequate UIC followed by insufficient UIC.

There is a weak positive relationship between nutritional knowledge and attitude, nutritional Knowledge and practices nutritional attitude and nutritional practices at 5% level of significance.

socioeconomic determinants of iodine defeciency It shows that size of land owned (p=0.083), distance to the market (p=0.073) and occupation of respondent (p=0.033), are significant socioeconomics factors that are associated with iodine concentration categories of inadequate, adequate and more than adequate

Specifically, an increase in land size owned is negatively associated with iodine concentration categories. In other words, an increase in land size increases the likelihood of subsequently low iodine concentration. On the hand, the further a respondent is from the market, the higher the likelihood of have higher concentrations of iodine. Respondents who are farmers also have a higher probability of having higher levels of iodine concentration.

Conclusion Iodine deficiency is still a big problem with a prevalence of 37.3% and 30.7% among children of school going age and women of reproductive age respectively. The prevalence was more among the age group 15-24yrs (16%) followed by those aged 25- 34yrs (9.7%) while those between 35-49 years had the least prevalence of 4.9%. The median Iodine concentration for women is 141μg/l, the mean is 158 μg/l and standard deviation is 100.5 μg/l. So on average, most of the WOA have adequate UIC

Gulu district was found to have more women with insufficient iodine (16.3%) as compared to Lira district. Lira had more WOA with adequate (21.5%) and excess (17.8%) as compared to Gulu which had only 17.4% and 12.6% with adequate and excess respectively. This could imply that Lira soils have a higher concentration of iodine than those in Gulu. There is no significant relationship between iodine KAP and iodine concentration The study found that size of land owned (p=0.083), distance to the market (p=0.073) and occupation of respondent (p=0.033), were significant socioeconomics factors that are associated with iodine concentration categories of inadequate, adequate and more than adequate.

Recommendations I recommend that there be alternatives to iodized salt since it is in use but iodine deficiency still remains a problem. These alternatives could include fortification of fertilizers with iodine. Future studies should focus on finding out the possible causes of iodine excess in some of the areas. This could be done by accessing the soils for iodine, testing the salt on market for iodine and analyzing the practices of those individuals with excess iodine. A study should be conducted to determine why WOA in Lira district have higher iodine concentrations than those in Gulu.