CRITICAL APPRAISAL OF THE PAPER TITLED “Socio-economic factors predisposing
under five-year-old children to severe protein energy malnutrition at the Moi Teaching
and Referral Hospital, Eldoret, Kenya” by Ayaya et al. (2004)
A. USING CASP (Case-Control Design)
Appraisal component
1. Did the study address a
clearly focused issue?
2. Did the authors use an
appropriate method to answer
their question?
3. Is it worth continuing?
Were the cases recruited in
an acceptable way?
4. Were the controls selected
in an acceptable way
5. Was the exposure
accurately measured to
minimize bias?
6(a) What confounding factors
have the authors accounted
for?
6(b) Have the authors taken
account of the potential
confounding factors in the
design and/or in their
analysis?
7. What are the results of this
study?
Evaluation Notes
Yes The population studied in this study was very carefully stated
– children between the ages of 3 and 60 months admitted to
the paediatric wards or attending the paediatric outpatients
and MCH clinics. They studied risk factors pertaining to
demographic, economic characteristics, nutritional status, and
social circumstances of the children within the age group
assessed. The authors accessed the beneficial and harmful
effects (together) of the risk factors on the nutritional status of
children between the ages of 3 and 60 months.
Yes This method used was appropriate because under the
circumstances, because although not so rare, the outcome
(severe protein energy malnutrition) is harmful. Also, the
authors were able to address the study aim/ question.
Can’t tell The cases were very well described in the inclusion criteria.
The authors also used calculated a representative sample size
based on the assumption that 75% of the control mothers will
be educated, while 50% of the mothers of cases would be
educated. They also chose a power of 80% and a 5% level of
significance which was appropriate (Owor et al., 2000). This
representativeness was temporal, not geographical. The
system used in selecting cases was not very well described,
only that for each case, an age-matched child control child
was looked for in the wards and outpatient clinics. The study
mainly looked at prevalent cases, not incident ones. As
prevalent cases were being assessed, in my view, the time
frame of the study was not relevant to the disease/ exposure.
Yes The controls were representative of the population, and were
selected via matching according to age (temporarily). There
was nothing special about the controls. The authors did not
report a high non-response rate. A sufficient number of control
was also selected.
Yes In my view, the authors measured the exposures by clear and
objective methods. They used a standard questionnaire with
both open and close-ended questions. Medical students who
collected the data were also well-trained regarding
questionnaire administration and anthropometric
measurements. Nutritional assessment was also done
according to the Welcome classification.
None
No The authors, in my view, did not account for potential
confounding factors by regression, sensitivity analysis or
stratification to adjust for possible confounders.
The bottom line results of the study were that social risk
factors for protein-energy malnutrition were single mothers

8. How precise are the
results? How precise is the
estimate of risk?
9. Do you believe the results?
(OR = 14.93), living conditions of the children (OR=3.627),
having a young mother between the ages of 15-25 years
(OR=3.95), having a care taker who is not the spouse of the
parent (OR=0.10), and not living with both parents in the
preceding 6 months (OR=0.28606). Economic factors included
fathers non-ownership of land (OR=0.401), cattle (OR=0.24),
not growing maize (OR=0.15), not growing beans (OR=0.36),
and ownership of small piece of land by the grandfather
(OR=6.00). Other important risk factors included failure to
complete immunization (OR=3.87) and being female
(OR=0.44929). The results were not adjusted for confounding.
Among the significant social risk factors, having a single
mother p=0.00001) was the most significant one, whereas the
least significant one was living in a temporary house
(p=0.00257). Among the economic risk factors, the most
significant risk factor was not growing maize (p=0.00013)
whereas the least significant one was ownership of small
piece of land by grandfather (p=0.02274). The authors did not
evaluate the effect of subjects who refused to participate in the
study.
Partly Some of the results were so significant that they could not be
ignored, for instance, single motherhood (OR=14.93,
p=0.00001), whereas others like grandfathers ownership of
small piece of land could be attributable to chance alone,
since it was no controlled for. Also female sex was identified
as a risk factor, which is contradictory to the results of
previous studies that reported that PEM was more prevalent
among children in internally displaced person’s camps in the
northern part of Uganda (Olwedo et al., 2008). It was also
counter intuitive that breastfeeding pattern (Serventi et al.,
1995), which is a well-established determinant of nutritional
status yielded insignificant findings in our study.

10. Can the results be applied
to the local population?
11. Do the results of this
study fit with other available
evidence?
Can’t tell In my view, the subjects covered in the study would not be
significantly different from the population, and the local setting
is not likely to differ much from that of the study. It is however
difficult to quantify the local benefits and harms.
Yes Most of the risk factors identified fit in well with other available
evidence, such as lack of completing immunizations, and step-
parenting. A few were contradictory, such as breastfeeding,
which was insignificant, whiles other factors such as
ownership of lands by father and grandfather were risk factors
for PEM among rural and urban dwellers.

REFERENCES
Ayaya, S.O., Esamai, F.O., Rotich, J., Olwambula, A.R. (2004). Socio-economic factors
predisposing under five-year-old children to severe protein energy malnutrition at the Moi
Teaching and Referral Hospital, Eldoret, Kenya. East Afr Med J. 2004;81(8):415-21.
Olwedo, M. A., Mworozi, E., Bachou, H., & Orach, C. G. (2008). Factors associated with
malnutrition among children in internally displaced person’s camps, northern Uganda. African
Health Sciences, 8(4), 244–252.
Owor, M., Tumwine, J. K., Kikafunda, J. K. (2000). Socio-economic risk factors for severe
protein energy malnutrition among children in Mulago Hospital, Kampala. East Afr Med J. 2000
Sep;77(9):471-5.
Serventi, M., Dal Lago, A. M., Kimaro, D. N. (1995). Early cessation of breast feeding as a major
cause of severe malnutrition in under twos: a hospital based study--Dodoma Region, Tanzania.
East Afr Med J. 1995 Feb;72(2):132-4.