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Abstract
Objectives This study aimed to assess the prevalence and associated factors of stunting and thinness among primary school-age children in the Gudeya Bila district.
Methods and analysis A community-based cross-sectional study was conducted in the Gudeya Bila district which is located in the Western part of Ethiopia. Among the calculated sample size of 561 school-aged children, 551 children were randomly selected by systematic random sampling technique and participated in this study. Critical illness, physical disability and the inability of caregivers to respond were exclusion criteria. Under-nutrition was the primary outcome while factors associated were the second outcome of this study. Semi-structured interviewer-administered questionnaires were used to collect the data while interview and body measurement were used as data collection techniques. Health Extension Workers collected the data. Data were entered into Epi Data V.3.1 and transported into SPSS V.24.0 software for data cleaning and analysis. Both bivariable and multivariable logistic regressions were run to identify the associated factors of under-nutrition. Model fitness was checked by using Hosmer-Lemeshow’s test. Variables with p values <0.05 were considered statistically significant in the multivariable logistic regression.
Results and conclusion The prevalence of stunting and thinness among primary school children was 8.2% (95% CI 5.6% to 10.6%) and 7.1% (95% CI 4.5% to 8.9%), respectively. Being male caregiver (adjusted OR (AOR)=4.26;95% CI 1.256% to 14.464%), family size ≥4 (AOR=4.65; 95% CI 1.8 51% to 11.696%), separated kitchen room (AOR=0.096; 95% CI 0.019 to 0.501) and hand washing after toilet use (AOR=0.152; 95% CI 0.035% to 0.667%) were significantly associated with stunting. Moreover, drinking coffee (AOR=2.25; 95% CI 1.968% to 5.243%) and child dietary diversity score <4 (AOR=2.54; 95% CI 1.721% to 8.939%) were significantly associated with thinness. Under-nutrition in this study was high compared with the global target of eradicating under-nutrition. Community-based nutritional education programmes and implementing health extension programmes are important to reduce the problem of under-nutrition to an undetectable level and to eradicate chronic under-nutrition.
- nutritional support
- health services accessibility
- public health
- primary prevention
- nutrition
Data availability statement
Data are available upon reasonable request. The dataset used for this research is available upon reasonable request from the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
This study focused on school-aged children who are missed in many of the prior studies.
The study was a community-based study that would increase the generalisability of the study findings.
A standardised data collection questionnaire was translated and used.
Recall bias and social desirability bias might be there.
The cross-sectional nature of the study would make it difficult to ascertain causation.
Introduction
Under-nutrition refers to inadequate provision of energy and nutrients, and an inability to meet the body’s requirements to ensure growth, maintenance and physiological functions.1 Stunting and thinness are the two main anthropometric indicators to define under-nutrition. Stunting indicates chronic under-nutrition which is frequently associated with poor sanitation, poor nutrient intake and infection whereas wasting/thinness refers to acute under-nutrition which is associated with recent illness and/or food deprivation.2
Globally, about 200 million children of school-age are undernourished, which leads to around 2.2 million deaths annually.1 The prevalence of stunting among school-age children varies ranging from 9.3% to 24.0% in Latin America and the Caribbean to as high as 20.2%–48.1% in Africa.3 4 In South Africa, the prevalence of stunting is 18.0% but it is as high as 42.0% and 50.0% in mid and Eastern Africa, respectively.3–5 According to the Global Education Monitoring report, more than 25% of children under the age of 15 years living in sub-Saharan Africa were undernourished.6 A study carried out in Zambia showed that 28.9% were stunted and 3.9% were thin. In Ethiopia, the National School Health and Nutrition survey conducted in 2008 showed that nearly 23% of children were stunted and a similar percentage of them were also wasted.7 Based on research done in different regions of the country, the prevalence of stunting among school-age children varies from 9.8% to 48.1% in Ethiopia.8 9
Factors that can cause under nutrition are many, most of which are related to poor diet, severe and repeated infections, being underprivileged populations. Inadequate diet and disease are closely linked to the standard of living and environmental conditions.10 Although the risk factors of under nutrition are diverse and could potentially change in space and time, child age, child sex, meal frequency, family income, diversity of diet, parent education and place of residence were repeatedly observed as the significant risk factors for under nutrition among school-aged children.11 12
Under-nutrition has both short-term and long-term effects. Its short-term effects include mortality and morbidity, whereas its long-term effects include that children do not reach their full developmental potential and would have poor cognitive performance, which in turn has consequences on the country’s economic productivity.13 Many studies reported the health and physical consequences of child under-nutrition and these may have intergenerational effects.9 Chronic under-nutrition in childhood is linked to slower cognitive development and serious health impairments later in life that reduces the quality of life of individuals.10 Stunting and wasting which have serious consequences on survival, health and the development of school-age children most commonly affect children in low-income and middle-income countries.6 The consequences of under-nutrition among school-age children include low school enrolment, high absenteeism, early dropout, unsatisfactory classroom performance,11 delayed cognitive development, short stature, reduced work capacity and poor reproductive performance.7 Under-nutrition continues to be a primary cause of disease susceptibility, morbidity and mortality among school-age children, particularly in resource-limited countries which globally account for half of all deaths in this cohort.8
The nutritional status often worsens during the school years and under-nutrition among school children is a widespread problem, particularly in South Asia and Africa.12 Nutritional deficiencies in school-age children are a public health concern, especially in resource-limited countries.6 Stunting has been declared a global health priority with the WHO calling for a 40% reduction in the number of children who are stunted by 2025.14 To address food security, the Ethiopian government established various multi-sectoral collaborations to coordinate and support efforts to step up rural economic development and food security. Other measures taken so far involve expanding health institutions and providing counselling on nutrition and food and malnutrition intervention. There is a school health programme in primary school that focuses on how to get adequate nutrition and a balanced diet to avoid under-nutrition. Despite these efforts, under-nutrition is still a problem. Nutritional services were given for under-five children but due attention was not given to primary school children. Most studies focus on under-nutrition in children less than 5 years of age, but less emphasis was given to school-age children.7 Therefore, this study aimed to assess the prevalence of under-nutrition and associated factors among primary school-aged children in the Gudeya Bila district.
Methods and materials
Study area and period
The study was conducted in Gudeya Bila district from 1–30 May 2022. The district is found 105 km away from the zonal centre, Nekemte, and 252 km west of Addis Ababa, the capital city of Ethiopia.
Gudeya Bila has a total of 15 kebeles of which 2 are urban and 13 are rural. There was an estimated 80 735 total population in the district with 41 175 females and 39 560 males categories. Of this population, 25 028 (31%) were school-age children who were eligible for the study. In the district, there were 4 health centres, 15 health posts and 9 primary-level private clinics. The primary health coverage of the woreda was 100% (according to the district health office annual report, 2021).
Economically, the settlers of the district were merchants and agriculture workers. Maize and Teff were mainly produced and they were the main source of food. Even though not in all parts of the district, beans and peas were also produced in specific areas. The climatic condition of the area was Weina Dega with an annual rainfall of about 1600–2000 mm and was found at about 200–2200 m above sea level (Gudeya Bila District Agricultural and Natural Resource Office Annual Report, 2021, unpublished).
Study design and study population
A community-based cross-sectional study design was conducted. All school-age children (6–14 years) and their mothers/caregivers in the district were the source population while all randomly selected school-age children (6–14 years) and their mothers/caregivers in randomly selected kebeles from the district were the study population.
Eligibility criteria
All school-age children (6–14 years) and mothers/caregivers residing in the woreda for more than 6 months were included in the study. Critically ill children, physically deformed and disabled school-age children whose condition interferes with data collection, particularly of body measurement were excluded from the study. In addition to these, those children whose homes were closed for two visits and/or whose caregivers were unable to respond during the study period were excluded.
Sample size determination and sampling technique
The sample size for the first objective was determined using a single population proportion formula by taking 21% prevalence from previous study,7 95% CI, 5% margin of error, 10% non-response rate and design effect.2 For the second objective, the sample size was determined after identifying the significant factors like the age of the children, dietary diversity score and water source from previous literature, while epi info was used to calculate the sample size for the factors. The sample size calculated for the age of the children by considering 67.7% proportion among exposed (P1), 32.3% proportion among non-exposed (P2), ratio of P1 to P2=2, 80% power and 95% CI was found to be 178.6 Since the sample size calculated for the first objective (561) was larger than the sample size calculated for the second objective (178), a larger sample size was used. The participants were approached by using a systematic random sampling technique.
Sampling procedure
A multistage sampling method was used to enrol the study participants from the district. In the first stage, 50% of the kebeles from the total 15 kebeles of the study area were selected using simple random sampling. From the selected kebeles, total households with school-aged children were registered to create a sampling frame. The calculated sample size (561) was proportionally allocated to each selected kebele based on the total number of households with school-age children in the kebele. Finally, the study participants were selected using a systematic random sampling technique using the sampling interval (K=22). One school-aged child was selected from each household. For households with more than one eligible child, one child was selected randomly by the lottery method (figure 1).
Sampling procedure for the assessment of prevalence of undernutrition and associated factors among primary school aged children in Gudeya Bila District, West Ethiopia, 2022.
Study variables
Dependent variable
Under-nutrition (stunting and thinness).
Independent variables
Independent variables of this study include socioeconomic and demographic factors of the study participants (family size, age of the child, maternal age, maternal education, paternal education, sex of the child, place of residence, family’s occupation, income and marital status of the family); dietary practice and child characteristics (individual dietary diversity, frequency of meals and hand washing practice); environmental factors of the study subjects (toilet facilities, housing condition, water source and waste disposal); and food security status.
Operational definitions
Individual dietary diversity score
This was the measure of the nutritional quality of an individual’s diet and was measured by summing the number of food groups consumed within 24 hours using the individual dietary diversity scale. Children who had Dietary Diversity Scores (DDS) <4 and ≥4 from the eight food groups were categorised as having low and high dietary diversity, respectively.6 15
Stunting
Refers to those that fall below −2SD from the median height-for-age based on the WHO reference standards.16
Thinness
Thinness is described as body mass index (BMI) below −2SD from the median weight-for-height standard.17
School-age
School-age is an age range from 6 to 14 years, which is characterised by a dynamic period of growth and development as children of this age group undergo rapid physical, mental and emotional development.12
Improved pit latrine
A pit latrine that has a superstructure with a door, and maintains privacy during defecation.16
Anthropometry
Anthropometry is the measurement of the size, weight, and proportions of the body, and both weight and height of the child were measured.18
Food security
Having, at all times, both physical and economic access to sufficient food to meet dietary needs for a productive and healthy life.18
Food insecurity
Refers to inaccessibility to sufficient food both physically and economically to meet dietary needs for a productive and healthy life18 and is measured by using responses to the nine food insecurity occurrence questions and their follow-up frequency of occurrence items.19
Food secure household
A household is considered food secure when assessed by using the standardised questionnaire developed by the Food and Nutritional Technical Assistance and it takes less than two of the nine food insecurity indicators.6
Food insecure household
A household is considered food insecure when it takes two or more of the nine food insecurity indicators.6
Data collection tools and procedures
In line with the objective of the study, semi-structured interviewer-administered questionnaires adapted from various literatures1 12 14 15 19–21 were used. This questionnaire contains socioeconomic and demographic factors, dietary practice and child characteristics, environmental factors, food security status, and anthropometric measurements with a total of 55 questions (see online supplemental file 1). Eight health extension workers and two supervisors from the health centre were recruited as data collectors and supervisors, respectively.
Supplemental material
During the data collection, when the selected house with eligible school-age children was closed, the interviewers revisited the home two times at different time intervals and when interviewers failed to get it, they excluded it from the survey. The functionality of digital weight scales was checked using known weight every day prior to the data collection and before every weight measurement. Data collectors ensured scale reading exactly at zero.12 All children were measured and weighed according to standard WHO procedures. For weight measurement, children were asked to remove their shoes and wear light clothes, and weight was measured to the nearest 0.1 kg on a battery-powered digital scale.7 For height measurement, children were told to stand erect with their shoulders level, hands at their sides, thighs and heels comfortably together, the buttocks, scapulae, and head were positioned in contact with the vertical backboard with a sliding head bar, and the measurement values were recorded to the nearest 0.1 cm.9 12 22 A 24-hour recall method was used to assess the dietary diversity practices of the children. This would depend on the children’s recall of foods consumed in the previous 24 hours prior to the interview date. Then, minimum dietary diversity was estimated using information collected from the 24-hour dietary recall.9
Data quality assurance
Before the actual data collection, pretesting was done on 28 (5%) school-age children and their guardians/caregivers in two non-selected kebeles (Jare and Hena Jawaja) to check the consistency of the questionnaires. After pretesting, necessary modifications to the questionnaires were made for unclear, difficult, erroneous or ambiguous questions.
The questionnaires for data collection were prepared in English and translated into Afaan Oromo. The data collectors and supervisors were trained by the principal investigator for 1 day on the process of data collection, including how to accurately measure the heights and weights of the children using a measuring scale, according to recommendations for anthropometric measurements.
Quality of the measurements was ensured by first having an expert measure 10 children, followed by the data collectors measuring the heights and weights of the same children twice with a time gap between the first and second measurements. The average difference between the measurements made by the expert and those of the trained data collectors, and between the first and second measurements of the data collectors was estimated to determine the ‘Technical Error of the Measurements’.22 To further minimise systematic error in measurements, each data collector took two repeated measurements, and an average height and weight were calculated and used for the final analyses. All collected data were checked for completeness, and consistency by the supervisor every day, and onsite close supervision and technical support were given by supervisors and the principal investigator.
Data processing and analysis
Data were entered into Epi Data V.3.1 and transported into SPSS V.24.0 software for data cleaning and analysis. Then, it was cleaned and analysed. For anthropometric data analysis, SDs (z-scores) were analysed by using WHO Anthro Plus software to determine the nutritional status of children. Children whose height for age z-score (HAZ) and BMI for age z-score (BAZ) ≥−2SD scores were considered as well-nourished and those below −2SD scores as being undernourished (stunted and thin, respectively).10 12
Descriptive statistics such as frequencies with percentages for categorical variables and mean with SD, and medians for quantitative variables were done. Bivariate analysis was carried out to assess the association of each independent variable with the study variable. All independent variables with p value <0.20 in bivariable logistic regression were passed for multivariable analysis. Multivariable analysis using logistic regression was also done to control the confounder variable and assess the association between independent variables and the outcome variable. Variables with p values <0.05 in the multivariable logistic regression were considered statistically significantly associated with under-nutrition. The strength of the association was measured using the adjusted OR (AOR) and 95% CI.6
The collinearity effect was checked using the variance inflation factor (VIF) and there was no multi-collinearity problem detected as the VIF was less than 2.5. Model fitness was checked using Hosmer and Lemeshow’s test.12 The model fitted the data because the value of the Hosmer and Lemeshow test was insignificant (p value >0.05). Missing data were excluded from the analysis.
Patient and public involvement
No patient was involved in this study.
Results
Socioeconomic and demographic characteristics of study participants
In this study, 551 school-age children participated with a response rate of 98.2%. The mean (±SD) age of children was 11.2 (±1.9) years. Among the children involved, the majority 541 (98.2%) were enrolled in school and nearly half 283 (52.3%) were found in 5–8 grades. Five hundred and twenty-four (95.1%) of interviewed caregivers were females, almost half 261 (49.8%) of them were primary level in educational status and more than three-fourths 408 (77.9%) were housewives. More than half, 293 (53.2%) of children were born in a family size of ≥4 (table 1).
Sociodemographic and economic characteristics of study participants in Gudeya Bila District, West Ethiopia (n=551), 2022
Environmental characteristics of the study participants
Of the total households in this study, three-fourths 417 (75.5%) had latrines while 263 (47.7%) had improved pit latrines. More than half 289 (52.5%) of the households were using protected springs as a source of drinking water. Nearly one-third 190 (34.5%) of the households had waste disposal systems. Regarding the housing condition, the majority 504 (91.5%) of the study participants live in houses that roofs made of the corrugated iron sheet whereas 531 (96.4%) had separated kitchen rooms (table 2).
Environmental characteristics of study participants in Gudeya Bila District, West Ethiopia (n=551), 2022
Dietary practice and child characteristics of the study participants
The majority 528 (95.8%) of the primary school-age children studied had hand-washing habits with soap after the toilet while 533 (96.7%) wash their hands before and after eating. Three hundred and eighty-nine (70.6%) caregivers received nutrition-related information from health extension workers. About 328 (59.5%) and 470 (85.3%) of the primary school-age children reported to have the habits of coffee and tea drinking, respectively.
The day prior to the survey, 462 (83.8%) school-age children had their usual daily meal frequency. About 400 (72.6%), 435 (78.9%) and 448 (81.3%) participants consumed pulses/legumes/nuts, grains, roots or tubers and foods cooked in oil/fat in 24 hours prior to the survey, respectively. About eight of ten primary school-aged children 450 (81.7%) had a DDS of <4 groups (table 3).
Dietary practice and child habits in Gudeya Bila District, West Ethiopia (n=551), 2022
Household food insecurity status
Only 47 (8.5%) of the primary school-age children who participated in the study were unable to eat preferred foods and 54 (9.8%) ate a limited variety of foods. Respectively, a few 44 (8%) and 41 (7.4%) school-age children ate smaller and fewer meals in a day within the past 4 weeks prior to the study period. The majority 496 (90%) households were food secured and one-tenth 56 (10.2%) of households were food insecure (table 4).
Food Insecurity status of the households involved in the study of under-nutrition and associated factors among primary school-age children in Gudeya Bila District, West Ethiopia (n=551), 2022
Prevalence of stunting and thinness among the primary school-age children
The mean (±SD) of HAZ (stunting) and BAZ (thinness) of primary school-age children were −0.47 (±1.03) and −0.39 (±0.92), respectively. The prevalence of stunting and thinness was found to be 45 (8.2% (95% CI 5.6 to 10.3)) and 39 (7.1% (95% CI 4.5 to 8.9)), respectively. Moreover, the prevalence of severe stunting (HAZ<−3SD) and severe form of thinness (BMI<−3SD) among primary school-age children were 1 (0.2% (95% CI 0 to 0.6)) and 2 (0.4% (95% CI 0 to 1)), respectively. When compared in terms of biological sex, the prevalence of under-nutrition was 8.35% among men whereas 6.72% among women.
Factors associated with stunting and thinness
Factors associated with child stunting
From the bivariable logistic regression analyses, the age of the caregiver, sex of the caregiver, residence, schooling level, family size, separated kitchen room, hand washing habit after toilet use, nutrition-related information from health extension workers, nutrition-related information from health workers, drinking coffee, drinking tea and missing meal schedule were identified as the candidate variables for multivariable logistic regression models.
In multivariable logistic regression, the sex of the caregiver, family size, separated kitchen room, and hand washing habit after toilet were significantly associated with stunting. Accordingly, the school-age children whose caregiver is male had 4.26 times more likely to be stunted when compared with those whose caregiver is female (AOR=4.26; 95% CI 1.255 to 14.464). Children from households with large family sizes (≥4) were 4.65 times more likely to be stunted as compared with smaller family sizes (<4) (AOR=4.65; 95% CI 1.851 to 11.696).
Stunting was 90.4% less common among children from households with separated kitchen rooms as compared with their counterparts (AOR=0.096; 95% CI 0.019 to 0.501). Similarly, stunting was 84.8% less likely among children who wash their hands with soap after toilet visits as compared with those who had no hand-washing habits (AOR=0.152; 95% CI 0.035 to 0.667) (table 5).
Factors associated with stunting in multivariable logistic regression among school age children in Gudeya Bila District, West Ethiopia (n=551), 2022
Factors associated with child thinness
In the bivariable logistic regression model, 11 variables; the age of a child, child’s sex, child’s birth order, grade level, availability of latrine, type of the roof of the house, drinking coffee, drinking tea, missing meal schedule, child’s DDS and food security status were independent predictors of thinness with a p value of less than 0.2.4
However, in a multivariable logistic regression model, only two variables (drinking coffee and a child’s DDS) showed a significant association with wasting. Accordingly, primary school children who drink coffee were 2.25 times more likely to be thin than their counterparts (AOR=2.25; 95% CI 1.968 to 5.243). Likewise, children who had DDS of <4 food groups were 2.539 times more likely to be thin as compared with children with DDS≥4 (AOR=2.539; 95% CI 1.721 to 8.939) (table 6).
Factors associated with thinness in multivariable logistic regression among school-age children in Gudeya Bila District, West Ethiopia (n=551), 2022
Discussion
So far conducted studies in different parts of Ethiopia found that the prevalence of stunting among school-age children was 9.8%–48.1%7–9 and thinness was 6.3%–21.4%.6 7 12 17 23–25
Furthermore, family size, age of the child, maternal age, family education, sex of the child, place of residence, family’s occupation, marital status of the family, individual dietary diversity, frequency of meals, household food insecurity, hand washing practice and other environmental factors were identified as the risk factors for under-nutrition.14 21 26 27 Although studies were conducted regarding child under-nutrition, the majority of the studies and even the interventions targeted children under the age of five while school-aged children were not well addressed. Besides, most of the studies were institution-based. To the level of authors’ knowledge, no prior study was conducted on this issue at all in the current study area. Hence, the finding of this study would contribute to the achievement of the goal set for the reduction of under-nutrition. This study benefits school-age children and communities of the Gudeya Bila District by filling the information gap regarding the nutritional status of school-age children. It also helps the district health office, health service planners and health managers to target their intervention by using this research as baseline data. Researchers might use this finding as a reference to conduct further study on this topic preferably by follow-up and qualitative methods.
In this study, the prevalence of under-nutrition and associated factors among primary school-age children in the Gudeya Bila District was assessed. Accordingly, the prevalence of stunting and thinness was found to be 8.2% and 7.1%, respectively. Male caregivers, family size ≥4, separated kitchen room and child hand-washing habit with soap after toilet use were factors significantly related to the child stunting. On the other hand, drinking coffee and DDS<4 were significantly related to thinness.
The prevalence of stunting among school-age children in this study (8.2%) is comparable with the results of other similar studies conducted in Kallin District, Kafr El-Sheikh Governorate, Egypt where 8.3% of the subjects were stunted,28 North-Central Nigeria where 10.5% were stunted20 and in Myanmar where 8.8% were stunted.29 The consistency between these studies might be due to related sample size, and similar ways of measuring and defining stunting. There is closeness between the sample size in this study and that of study in the Myanmar. However, the study showed that the prevalence of stunting was lower than the study done in Addis Ababa, Ethiopia where 17.8% of the school-age children were stunted,30 Bahir Dar city where 15.13% of the subjects were stunted,13 Northeast Ethiopia where 14.1% were stunted,16 North West Ethiopia where 25.5% of school-age children were stunted25 and urban slums in India where 18.5% of them were stunted.10 When compared with the study done in Arba Minch where 41.9% of the school-aged children were stunted,12 and Gondar town where 46.1% were stunted,6 the prevalence was much lower. This difference might be related to the difference in geographic location and residency characteristics of the study subjects. The observed difference might also be explained by the availability of surplus food production in the current district (study area) and the difference in the study period.
Nonetheless, the finding of stunting in this study was higher than the study done in Nigeria where 5.6% of the subjects were stunted,21 and the study conducted in a sub-urban Region in Tanzania where 6.5% of the school-age children studied were stunted.31 This might be due to the variability of risk factors in different geographic regions, agricultural productivity and low dietary diversity of school-age children in the current study.
The prevalence of thinness among school-age children in this study was 7.1%. It is comparable with other studies conducted in Arba Minch 8.0%,12 Gondar town northwest Ethiopia 9%,6 South Gondar Zone, Ethiopia-6.3%17 and Kallin District, Kafr El-Sheikh Governorate, Egypt 6.7%.28 However, the finding of this study was lower than those of studies done in Mecha woreda, Amhara regional state, Ethiopia 10.8%,23 Fogera and Libo Kemkem districts, northwest Ethiopia 21.4%,7 Ethiopia 18.2%,24 Dembia district, North West Ethiopia 13%25 Nsukka, Nigeria 13.0%,21 Kassala State, Sudan 32.3%32 and Rural Madagascar 11.2%.33 The possible reason for this might be seasonal variation and the variability of risk factors across different geographic settings. The difference in study setting would be a possible justification as this current study was conducted in a highly producing district and even the food insecurity of households is relatively low. The relatively low thinness in this study might also be attributed to the availability of safe water supplies in the district, and the high prevalence of hand washing that might in turn reduce the risk of infection and under-nutrition.
In another way, the prevalence of thinness in this study was higher than that of study conducted in the Burayu town of Ethiopia 3.9%.34 The disparity might be due to rural-urban differences as the community in Burayu town might be more educated and knowledgeable and might have an improved standard of living than the community in our study setting.
School children whose caregiver was male had increased odds of stunting. A similar study was conducted in a Rural Southwestern District of Uganda.35 But this study finding is contrary to the current study which showed that having a male caregiver was associated with decreased odds of under-nutrition. These disparities might be because male involvement in child care supports joint decision-making with mothers and empowers them to care for the children.
Children belonging to households with large family sizes (≥4 family members) were more stunted than those belonging to households with small sizes (<4 family members). This finding was similar to the study conducted among school-age children in other parts of Ethiopia16 24 and North Central Nigeria.20 This might be because, in large family sizes, children might not get enough food and might not eat a variety of food items. Large family size could be a marker of household poverty. In large family members, child care might get less attention as compared with small family members, and also the child might not get necessary dietary care. There is also the possible risk of overcrowding which could lead to the spread of diseases such as respiratory infections and diarrhoea which are immediate causes of under-nutrition.
Separated kitchen room was significantly related to decreased odds of stunting. This study finding is in line with the study done in a slum in Dhaka, Bangladesh which showed that having a separate room for a kitchen is significantly related to decreased odds of child stunting.36 The possible reason for this might be that preparing food in a separate and safe room decreases the risk of contamination. Then a healthy diet would be eaten and promotes healthy growth. Besides, the lack of a separate kitchen might be an indicator for the families of stunted children to struggle with poor housing conditions and face a difficulty in affording food.
The school-age children who wash their hands with soap after toilet had 84.8% reduced odds of stunting than their counterparts. This finding is relevant to other studies conducted in Northeast Ethiopia16 and South Gondar Zone17 which revealed that poor hand washing practice after toilet use is significantly associated with stunting. The study in Northwest Ethiopia also showed relevant findings in this regard.25 The possible reason could be that hand washing with soap after toilet use is mandatory to prevent infection and intestinal parasites and promote health. If health is promoted, normal growth continues and the risk of stunting would be minimised. According to the studies, drinking clean water and hand washing with soap reduce the loss of nutrients by diarrhoea and then decrease the chance of stunting by 15% in children.37 38 In another way, hand washing practice both after the toilet (95.8%), and before and after a meal (96.7%) in this study seem inconsistent with the 20.3% proportion of piped water sources. However, it is not paradoxical as the majority of the rural population in Ethiopia uses groundwater such as protected wells and springs as sources of water for hand washing and other purposes in the absence of piped water.
The probability of child thinness increases with drinking coffee. Children who drink coffee were 2.25 times more likely to be thin than their counterparts. In the Author’s knowledge, the association of drinking coffee with thinness was not reported by other authors, and difficult to make the comparison. But the possible reason for the observed association might be that coffee contains caffeine which can affect iron absorption and results in micronutrient deficiency.6
The child’s DDS was also found to be positively related to thinness among school-age children. Children with DDS of <4 food groups were more likely to be thin than those children with DDS of ≥4 food groups. This result is in line with the study done in Dembia district, Northwest Ethiopia25 and Northern Ghana39 although it is contrary to the study conducted among primary school-age children in Arba Minch, Southern Ethiopia.12 The positive association between low DDS and thinness might be because a diet with limited variety, poor quality and quantity does not fulfil nutritional requirements for child growth.6
The prevalence of stunting and thinness in this study seems low when compared with other studies. However, this still might be large if converted to an absolute number as the world is moving towards the eradication of under-nutrition. The lack of women caregivers is one of the factors increasing the chance of stunting in this study. Although not addressed by this study, maternal mortality could be one of the reasons which make the children fall into the hands of either father only or another person. Hence, this has an implication that strengthening interventions that tackle maternal mortality would also help to address child under-nutrition. Factors like large family size, lack of separate kitchens and hand washing are among the factors affecting the occurrence of stunting in school-aged children. This necessitates the strengthening of the availability and provision of integrated nutritional, reproductive and environmental health services for the community. Moreover, drinking coffee and inadequate dietary diversity are the factors contributing to thinness according to this study. This revitalises that the role of intersectoral collaboration is crucial in fighting against malnutrition.
This study has some strengths and limitations. The first strength of this study is that it tried to use a validated and updated data collection tool. Furthermore, being a community-based study would improve the precision of the responses and minimise healthy worker/user bias as it helps to address both healthy and undernourished children in their households. The limitation of this study is that there might be recall bias. Besides, social desirability bias could be there and participants might prefer to recall only the food they want during the use of the 24-hour recall method to assess individual DDS. The cross-sectional nature of the study would make it difficult to ascertain causation.
Conclusion
Although the prevalence of stunting and thinness found in this study was relatively low compared with the previously conducted studies in Ethiopia and international standards, it is high when compared with the goal set to eradicate under-nutrition by 2030.6 Being a male caregiver, family size ≥4, separated kitchen room and hand washing habit with soap after toilet use were significantly related to stunting among primary school-age children in the study area. On the other hand, drinking coffee and a child’s dietary diversity score of <4 food groups were risk factors for thinness.
This finding alerts the need to implement and strengthen school health and nutrition programmes to improve the nutritional status of primary school-age children. Focusing on the implementation of health extension programmes, diversified agricultural practice and community-based nutrition education programmes are essential activities to reduce the problems. Health workers should provide effective services on family planning for birth spacing to balance family size. Health extension workers are expected to create community awareness about the significance of having a separate kitchen room and educate hand washing with soap after toilet use. Demonstration of hand washing practice and balanced diet preparation should be done at the community level.
Data availability statement
Data are available upon reasonable request. The dataset used for this research is available upon reasonable request from the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by research ethics review committee of Wollega University with ref. no. WU/RD/559. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to thank Wollega University, Gudeya Bila District Health Office and Gudeya Bila District Administration for all their cooperation and for providing us with valuable baseline information. We are also grateful to the data collectors and supervisors for their unreserved effort during the data collection and supervision. Finally, we thank the study participants for their cooperation.
Footnotes
Twitter @adisu Tafari Shama
Contributors ATS, OW and SD conceptualised the study, wrote the proposal, analysed the data, drafted the result, prepared the manuscript and supervised the whole process of the study. ATS also assumed the responsibility as a guarantor for this work in conducting the study, accessing the data, and decision to publish. DRT, MCC and BB revised the proposal, finalised the result and prepared the manuscript, identified the journal for publication. ML and ET supervised the study process and prepared and revised the manuscript. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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