Abstract

Background

This study was conducted to examine the prevalence of malnutrition in Syrian immigrant children living in Turkey.

Methods

The study was carried out in the city of Mardin, which is one of the cities with a high Syrian immigrant population in Turkey. Height, body weight and BMI values were recorded to determine the malnutrition status of the children. Z-scores of children were calculated using the malnutrition assessment WHOAntro program.

Results

The data show that 30.5% of Syrian children between the ages of 0 and 6 months are male, making up 55.8% of the total, and that 55.3% do not follow a regular breakfast schedule. The percentages of body weight for height, height for age, and BMI for age of Syrian children with a score between 鈭掆��2 and +鈥�2 SD Number were (89.3%), (74.3%), and (79.3%), respectively. Girls are more likely than boys to experience stunting and low body weight in the context of Syrian children (Stunting OR: 0.855(0.761鈥�1.403), Underweight OR: 0.705(0.609-1,208)). Additionally, there is a link between levels of stunting and underweight and elements like the mother鈥檚 educational level and the family鈥檚 income. Contrary to the situation of adequate nutrition, it was discovered that the likelihood of stunting and low body weight in children increased by 0.809 and 1.039 times, respectively, when access to an adequate food supply was not available within the family (p鈥�&濒迟;鈥�0.05).

Conclusion

s According to the results of the study, gender, family income, mother鈥檚 education level and access to food affected the severity of malnutrition in children. Migration is an imporatnt factor affecting children鈥檚 health. In this study malnutrition was found high im immigrant children. Programs should be developed to monitor the growth and development of disadvantaged children and to support their nutrition.

Background

The effects of migration are particularly striking for children, who typically have little influence over their decision to migrate and are therefore thought to have done so against their will [1]. Children are thought to be the group most negatively impacted by migration because they are still growing and developing, are dependent on at least one parent, and are at risk due to their physical and intellectual deficiencies [2]. Children are denied their right to health, nutrition, shelter, and education, which are the cornerstones of their right to life, during this migration process [3]. Following migrations, hygiene and nutrition issues that arise from failing to meet the society鈥檚 needs for adequate shelter and nutrition can result in a number of diseases. Even though all refugees run the risk of having nutritional issues, babies and young children need special attention [4,5,6,7]. The majority of people with disabilities, growth retardation, and chronic diseases are children exposed to migration because malnutrition impairs physical and mental development [8]. Acute malnutrition has been linked to a number of major causes of morbidity [8] and mortality [1], with children under the age of five most frequently affected, according to studies done with refugees [9]. The study conducted in Lebanon showed that the children most affected by malnutrition were between 0 and 1 years of age [9]. Acute malnutrition was most prevalent in children under the age of five, according to a study done in 2019 among refugees living in camps [10]. According to UNICEF 2016 data, a moderate acute malnutrition was discovered in the refugee child as a result of the nutritional screening of more than 2200 Syrian refugee children [11] Children were also included in the treatment program, and special situations involving child nutrition, food safety, water quality, and sanitation were addressed with nutrition education [12]. Developmental delay brought on by malnutrition and malnutrition are the most frequent health issues in children after migration [5].

The Syrian civil war, which commenced in 2011, led to the displacement of over 10听million families who were compelled to seek refuge in neighboring nations [13]. Turkey is the nation to which Syrian migrants relocate in a quantity tenfold. Based on official documentation, an estimated population of around 5听million individuals from Syria currently resides within the borders of Turkey. Mardin, a bordering city in Turkey, is recognized as a prominent settlement for immigrants. The city of Mardin is home to an estimated population of around 10,000 Syrian refugees. The unresolved issues pertaining to language, economic, and health challenges faced by Syrian immigrants who have relocated to Turkey remain in need of a lasting resolution [14]. Numerous significant challenges exist, particularly within the realms of education, housing, nutrition, and healthcare provisions. It is imperative to conduct essential research, particularly focusing on vulnerable populations, in order to facilitate their access to these services. It is evident that the offspring of families compelled to migrate from Syria encounter significant challenges pertaining to their educational attainment and nutritional well-being. It has been observed that prolonged nutritional deficiencies, particularly, lead to the occurrence of malnutrition in children [14]. A study conducted in 2019 revealed that a significant proportion of children experience either obesity or a severe developmental delay as a result of poor dietary habits [15]. The significance of conducting research in this particular discipline in relation to the advancement of nutrition and health policies should not be disregarded.

The purpose of this study is to shed light on the prevalence of malnutrition among children aged 0 to 6 years old in Syrian families who were forcibly displaced and to highlight the ways in which these families differ from the local society.

Methods

The research was carried out between February and May 2021 with volunteer families with 0鈥�60 month-old children living with their families in the borders of Mardin Province. Within the scope of the study, a total of 400 mothers who have children between the ages of 0鈥�6 were interviewed. The questionnaire form was applied by face-to-face interview method. The consent form was read and signed by the legal representatives of the children before applying the questionnaire. Data collection continued until we reached 400 children for each group. During the research, 32 Syrian mothers and 45 Turkish mothers contected were not included in the study because they didn鈥檛 give informed consent. Mothers with cognitive decline were excluded from the study.

This study was accepted by the authorities of these locations, approved by the Ethics Committee of the Mardin Artuklu University Scientific Research Ethics Committee (Turkey) (14.06.2019 ) (No-1-2019), and followed the procedure established by the U.S. National Bioethics Advisory Commission and European Commission was used to obtain written parental or guardian consent, while oral consent was obtained from mothers responsible for children. The necessary work permit was obtained from the Mardin Provincial Directorate of Migrant Health to carry out the study.

Collection of study data

General information about the parents of all children aged 0鈥�60 months, nutritional status of children from birth (breast milk intake, use of nutritional support, starting complementary feeding and the foods given) are included. In addition, a data collection form including anthropometric measurements of children at birth and present, such as body weight (kg), height. Monthly incomes of individuals were recorded in Turkish lira, but as a result of the analyzes made, they were given in dollars ($).The questionnaire used in the research was developed by the researchers.

Characteristics of mothers

The mothers interviewed within the scope of the study, who had no communication problems, who could speak and understand Turkish and who declared that they participated in the study voluntarily, were included.

Characteristics of children

The children who were born full-term, were born with a single pregnancy, had no congenital anomalies, and did not have any chronic and metabolic diseases were included in the study. Children who lost their parents were not included in the study. One child from each family was included in the study.

Food consumption frequencies of children included in the study

Taking Anthropometric Measurements: The heights and body weights of all children participating in the study were measured.

Body Weight

The body weights of babies aged 0鈥�24 months were measured with a sensitive baby scale sensitive to 0.1听kg, by removing the thick clothes. Children aged between 24 and 60 months were asked to stay in the lightest clothing possible before their body weight was measured. The measurements were recorded in grams by paying attention to the conditions such as placing the scale on a horizontal, flat and hard surface and making the calibration before weighing [16, 17].

Height

The height of infants between 0 and 24 months was measured in lying position with an infantometer, and the height of children between 24 and 60 months was measured in cm with a stadiometer [17, 18].

Evaluation of anthropometric measurements

In this study we aimed to compare children from two different societies. Therefore, we prefer to use a standard evaluation method. In addition WHO stnadards were used instead of local standards to ensure that our study was compatible with the international literature. Anropometric measurements were evaluated according to WHO-MGRS 2006 and 2007 growth standards with the help of the WHOANTRO program version 3.2.2, January 2011 (The WHO Anthro Survey Analyzer). Findings are given by classifying them according to the intersection points as percentiles and Z-score values. The intersection points used in the classification are as follows (Table 1) [19,20,21].

Table 1 Z-score values. The intersection points used in the classification

Stunting (height for age), wasting (weight for height) and underweight (weight for age) were three major anthropometric indicators used to measure malnutrition association with response variables.

Food consumption frequency

In the study, in order to determine the food consumption frequency of children, the 鈥淔ood Consumption Frequency Form鈥� was applied with the information received by the mothers. Frequency of food consumption is a method often used to determine food intake. Frequency of food consumption; It is a method used to determine the daily, weekly, monthly or annual consumption frequency of food or food groups and to determine the consumption amounts. The food consumption frequency of children was defined as 鈥榚veryday鈥�, 鈥榮ometimes鈥�, 鈥榮ometimes鈥�, never using the 鈥淔ood Consumption Frequency Determination Form鈥�. Foods were examined in six groups: milk and dairy products, meat, eggs and legumes, bread and cereals, vegetables and fruits, fatty and sugary foods and beverages. Within the scope of the study, the consumption frequency of 19 foods containing the basic food groups was taken [22]. Dietary reference intakes (DRIs) recommendations were used in daily nutritional intake values.

Statistical analysis

Mean and standard deviation (SD) were calculated for continuous variables. The normality of the variables was analyzed with the Shapiro-Wilk test. Frequency distribution ratios of categorical variables were found in the study. The statistical significance level was accepted as p鈥�<鈥�0.05. SPSS 22.0 statistical package program was used in the statistical analysis of all data. To significant socioeconomic factors linked by child malnutrition used in this study were age, gender, mother education (none/pre-school, primary, middle, secondary and higher), family income (lowest, secondary, middle, higher and highest), family size, food access. Multivariate logistic regression analysis methods were used to identify factors associated with stunting and underweight to account for potential confounding factors. All models were adjusted for the covariates of child malnutrition.

Results

Table听2 shows the general characteristics of the mothers of the children in the study. The immigrants from Syria in the study at marriage age was 20.47鈥壜扁��3.23 years, and their mean age at 27.15鈥壜扁��5.65 years. Turks marry at 24.99鈥壜扁��4.93 years, and their mean age is 29.11鈥壜扁��4.93.

Mothers of Syrian children are 99.0% unemployed, 36.3% have only completed elementary school, 74.5% have 1鈥�3 children, 46.8% have 鈥�5鈥�6鈥� family members, 93.8% have monthly income equal to their expenses, with a monthly average income level of 175.5542.12 $, and 57.75% of them claiming to have food restrictions. Syrian immigrants reported an average length of residence in Mardin of 6.04 1.44 (Min: 2 Max: 12) years. In contrast, 79.82% of Turkish mothers of children do not work, 21% have only completed their primary education, 84.5% have 1鈥�3 children, 31.0% have 鈥�5鈥�6鈥� people in the family, and 41.3% have monthly income, which is equal to 203.2524.55 $ monthly income; 86.25% of them reported having a food restriction.

Table 2 Characteristics of the mothers of the children in the study

Table听3 presents an overview of the fundamental attributes pertaining to the children who were included in the study. According to the data, it is observed that 30.5% of Syrian children aged between 0 and 6 months, specifically, 55.8% of these children are male, while 55.3% do not adhere to a regular breakfast routine. Furthermore, it is noted that 81.0% of these children do not experience a loss of appetite, and 90.0% do not suffer from any diseases. Additionally, 36.0% of the children reported having at least one episode of diarrheal infection in the previous year, while 46.8% experienced at least one lung infection. Moreover, a significant majority of 95.3% of these children were exclusively breastfed, while 55.3% were introduced to complementary foods alongside breast milk during the first 6 months of their lives. Among the participants from Turkey, 36.5% of the children fell within the age range of 0鈥�6 months. Additionally, 54.0% of the participants were male, while 51.8% did not adhere to a consistent breakfast routine. Furthermore, 72.3% of the children did not report a loss of appetite, and 89.3% did not have any existing medical conditions. It was reported that 8.5% of the individuals experienced at least one instance of diarrhea infection within the preceding year. Additionally, 12.8% of the participants encountered at least one lung infection. Furthermore, a significant majority, specifically 98.8%, received breast milk. Moreover, a considerable proportion, amounting to 33.8%, consumed both breast milk and other foods exclusively for the initial six months.

Table 3 Characteristics of children aged 0鈥�60 months in the study

Fig. 1

Food consumption frequencies of children included in the study

The study鈥檚 findings regarding the frequencies of food consumption among the children are presented in Fig.听1. Foods suitable for child nutrition used in studies were questioned. According to the data, Syrian children鈥檚 daily consumption consists of 61.0% milk, 40.3% yogurt, and 35.8% biscuits. Furthermore, it was ascertained that the children did not partake in the consumption of foods from the meat group, as well as vegetables and fruits, on a daily basis, with a prevalence of 0%. Nevertheless, it was ascertained that the individuals in question regularly ingested food items resembling fast food, including Cake (35.3%), Chips (30.0%), Confectionery (18.8%), Turkish delight (16.8%), Wafer (17.0%), and Chocolate (17.0%), on a daily basis, albeit at different frequencies.

Z-Scores of Body Weight for Height, Height for Age, BMI for Age of individuals participating in the study showed in Table听4. Having a score between 鈭掆��2 and +鈥�2 SD Number the percentages of body weight for height, height for age, and BMI for age of Syrian children were (89.3%), (74.3%) and (79.3%) respectively. For Turkish children, these values were respectively (85.8%), (74.0%) and (79.0%). The study assessed the prevalence of stunted growth among children in Syria and Turkey, finding that 8.3% and 6.0% of Syrian and Turkish children, respectively, had a height-for-age below 鈭掆��3 SD Z score. The study revealed that the prevalence of individuals with BMI exceeding a Z score of +鈥�3 SD for their respective age groups was 4.3% for Syrian children and 4.0% for Turkish children.

Table 4 Z-scores of body weight for height, height for age, bm谋 for age of children in the study

Table听5 presents the effects of socio-demographic factors on the prevalence of stunting and underweight among the children participating in the study. In the context of Syrian children, it has been observed that girls face a higher susceptibility to stunting and low body weight compared to boys (Stunting OR: 0.855(0.761鈥�1.403), Underweight OR: 0.705(0.609-1,208)). Furthermore, there exists a correlation between the levels of underweight and stunting and factors such as the educational attainment of the mother and the income of the family. In contrast to the condition of sufficient nutrition, the absence of access to an adequate food supply within the family was found to elevate the likelihood of stunting and low body weight in children by 0.809 and 1.039 times, respectively (p鈥�&濒迟;鈥�0.05). In Turkish children, it was observed that girls tended to have a lower average weight compared to boys. The ORs for being underweight is 0.582 (CI: 0.450鈥�1.239) with a p鈥�<鈥�0.05. It has been observed that maternal illiteracy is associated with both stunting and low body weight in children. Additionally, children born to mothers aged between 19 and 29 years have an increased risk of being underweight. Children from families with low income and limited access to food were found to have an increased risk of stunting and underweight. The ORs for stunting were 0.809 (95% CI: 0.569鈥�1.309) and 1.093 (95% CI: 0.907鈥�1.609) for low family income and insufficient access to food, respectively. Similarly, the ORs for underweight were 1.201 (95% CI: 0.909鈥�1.706) and 1.194 (95% CI: 0.706鈥�1.591) for low family income and insufficient access to food, respectively. These findings suggest a significant association between socioeconomic factors and the risk of stunting and underweight in children (p鈥�&濒迟;鈥�0.05).

Table 5 Socio-demographic parameters estimates of logistic regression model and factors affecting stunting and underweight

Discussion

This study represents the first attempt to compare the nutritional status of Syrian immigrant children in Turkey with that of local children, as previous research on the nutritional status of Syrian immigrants in Turkey has been conducted in recent years. The study encompassed a total of 800 children. The study鈥檚 data offers a comprehensive analysis of stunting and low body weight among Syrian immigrant children residing in Turkey. The practical requirements articulated by refugees themselves are effectively supplemented by this socioeconomic standpoint. Burge and Dharod have reported comparable results, suggesting that nutrition interventions targeting refugees should encompass various aspects such as the importance of maintaining a nutritious diet, effective grocery shopping practices, and efficient management of food budgets [23]. Culturally appropriate nutrition initiatives, especially those developed in collaboration with refugees, are of paramount importance [24].

It was observed that mothers of Syrian children included in the study had a lower average age at marriage than mothers of Turkish children, and this difference was statistically significant. According to a study done in Iran, women get married on average 5 years earlier than in western societies [25]. Another study found that Syrian immigrant women frequently get married before turning 18 years old. The findings of our study are consistent with those of these studies. It has been noted that there are more people living together in Syrian families than in Turkish participants鈥� families. In a study done in Pakistan, it was discovered that families typically had 6鈥�7 members or more [26]. Another study revealed that the average family size of Syrian immigrants is 2.2 times larger than that of German families [27]. This may be the case because immigrants frequently live with other family members besides their own parents and child(ren). Additionally, in developing nations, grandparents frequently reside with their married children [28].

When compared to Turkish people, it has been found that the family鈥檚 monthly income for Syrians is incredibly low. Families have a much lower level of income than the average in this country, according to studies on the income level of immigrants in 陌ranian [25], America [29], the Netherlands [4], and Germany [27]. This circumstance demonstrates that immigrants often accept lower-paying jobs. According to the study鈥檚 findings, Syrian immigrant mothers in Turkey face many difficulties in establishing and upholding a healthy diet and feeding routine for their kids and families. It was noted that the nutritional requirements were imposed on both the Syrian and Turkish participants. But it was found that Turkish participants had more dietary restrictions. Because they live in their own culture and nation and because this situation may result in food restrictions, the Turkish participants try to maintain their eating habits. All participants鈥� experiences with food restrictions are attributed to Turkey鈥檚 ongoing inflation and unequal income distribution.

The present study reported that most of mothers were age 19鈥�29 years, literate and had low month income. Better education means more knowledge and a higher probability to earn more, proper management of resources, practice better health promoting behaviors specifically better food choices, and might develop better children centered caring practices. This study findings is in line with preceding literature evidence which revealed that the level of education of the mothers was considered as major predictors of malnutrition, increasing the risk of undernutrition due to illiterate parents. An estimated average cost of food per month in Turkey for one person ranges from $50 to $100, depending on age. Increase in household sizes might lead to decrease in the availability of food in the household [30].

According to findings of this study, most of the participants were food restriction that is, they were food insufficient. Food restriction increases the chances of malnutrition occurring. This is because, there is not enough food (calories and nutrients) thereby increasing the risk of unhealthy eating. The prevalence of food restriction from this study was higher when compared with the prevalence of 13% of a carried out in January 2019 by World Food Program to assess household food security in North West Region [31].

According to the dietary diversity assessment, vegetables, dairy and meat products, cereals, and legumes make up the four major food groups consumed by children. Fruits, vegetables, eggs, and meat products, however, were the least popular food categories. More than half of the children had a low dietary diversity score of less than four, and the average child鈥檚 diet consisted of 1.2 food groups. i.e., they consumed fewer types and varieties of food than the WHO-recommended food groups over the course of the previous 24听h. The most popular methodological approach involved constructing height-for-age and weight-for-height ratios using weight, height, and age, from which the prevalence of stunting and wasting was determined. The WHO鈥檚 anthropological definitions were largely used in studies to gauge the severity of wasting and/or stunting. Stunting levels ranged from 7.3 (in Drama and Kavala, Greece) to 29% (in Western Sahara, Algeria) [32, 33]. From 1.2 (in Za鈥檃tari, Jordan [34]) to 5.5% (in four refugee camps in Northern Greece [35]), wasting prevalence ranged. Children who participated in the study had their body weight for height, height for age, and BMI for age of Z scores examined. It has been demonstrated that stunting and underweight as indicated by anthropometric measurements increase the risk of infectious disease-related death in children. Similar to earlier analyses, mortality was higher in all stages of stunting and underweight, and the risk rose as Z scores dropped. In a synergistic relationship with infectious diseases, undernutrition can be considered the cause of death; if the undernutrition hadn鈥檛 existed, the deaths wouldn鈥檛 have happened [36]. Increased risks of death from diarrhea, pneumonia, and the measles were noted for all anthropometric measures of undernutrition; the association was also noted for other infectious diseases [37]. Numerous cross-sectional studies have linked stunting to delays in motor and cognitive development, making it a well-known risk factor for poor child development. Stunting before the ages of 2鈥�3 years has been linked to worse cognitive and educational outcomes in later childhood and adolescence, according to a number of longitudinal studies [38].

Inadequate dietary intake, inadequate care, infectious diseases, and unequal food distribution at the household level are the main factors that increase children鈥檚 vulnerability to malnutrition. Male children had a higher incidence of wasting, stunting, and underweight than female children in this study, which could be partially explained by the fact that males are thought to be more vulnerable due to health inequalities to early childhood illnesses and health issues than female children [39]. These findings agree with earlier research by [39,40,41]. These results are contrary to the studies of [42, 43], and it is possible that the community with lower socioeconomic status and less delivery of health services is the cause of the increased risk of malnutrition in children under the age of one year and those who are frequently stunted, wasting, and underweight at age four. Family size has a strong correlation with malnutrition status, including wasting, stunting, and underweight. This correlation is due to the fact that as families grow, resources become more scarce and children鈥檚 nutrition and care are given less attention. These results contrast with studies [44, 45] while being consistent with studies [41, 42]. Because educated mothers are more knowledgeable about child health, nutrition, and the use of health services, there is a significant relationship between mother education and reducing stunting. These results concur with those of the studies from [46,47,48,49].

There is an inverse relationship between the income status of families and the frequency of malnutrition in both Syrian and Turkish children. The most important reason for this is that access to adequate health services, adequate food and hygiene are associated with income status. These results are similar with the studies of [43, 50].

Households with food restriction were higher prevalence of malnutrition (stunting and underweight) in children rather than children adequate access of food. Adequate nutrition promotes health and resistance against diseases, while inadequate nutrition causes to increase severity of stunting and underweight. These findings are consistent with the study of [20].

Conclusion

The assessment of the prevalence of malnutrition in children from Syrian and Turkish was conducted through the evaluation of Z scores. This study aimed to investigate the various factors that contribute to the occurrence of stunting and low body weight resulting from malnutrition. According to this study, there is a significant relationship between childhood malnutrition in Syrian migrant children and gender, age, maternal education level, family income, family size, and access to adequate food. Girls are more vulnerable to malnutrition than boys are, so it is important to pay attention to the nutritional requirements of boys to lessen this risk. In order to combat malnutrition, it is necessary to increase public awareness of the nutritional value of foods, illnesses associated with nutritional deficiencies, and the significance of maternal education, particularly in terms of education and training for all people. Migration causes important public health problems. In order to protect and improve children鈥檚 health children鈥檚 growth and development should be constantly monitored. Nutrition of children living in disadvantged groups such as immigrants should be supported.