Journal of Clinical and Cellular Immunology
Open Access
ISSN: 2155-9899
ISSN: 2155-9899
Research Article - (2018) Volume 9, Issue 2
Background: Increased nutritional needs of adolescents relate to the fact that adolescents gain up much of their adult weight, height and skeletal mass during this period. Under nutrition among adolescents is a major public health problem in developing nations including Ethiopia. Moreover, adolescents have been considered a low risk group and often receive little attention. This study aims to assess the prevalence and associated factors of stunting among adolescents in Tehuledere district, Northeast Ethiopia, 2017
Methods: A school based cross sectional study was conducted among 535 secondary school adolescent age group students from 1st April to 20th April 2017 in Tehuledere district. Systematic random sampling technique was employed for selecting study subjects. A standardized, pre tested and structured self-administered questionnaire was used to collect the data. The outcome variable was measured with standardized anthropometric measurement. Data was entered using Epi info version 7 and analyzed using SPSS version 20 and WHO Anthro Plus soft wares. Crude and adjusted odds ratios with 95% level significance were used to measure the strength of association and statistical significance was declared at p-value less than 0.05.
Results: The overall prevalence of stunting among the adolescents (10-19 years) was 15.5%. After possible potential confounders were controlled; being male (AOR=2.394 95% CI=1.425, 4.022), being in the age group 13-16 (AOR=2.106 95% CI=1.261, 3.516), using unsafe drinking water supply (AOR=3.721 95% CI=1.397, 9.913) and having no latrine facility (AOR=3.311 95% CI=1.569, 6.988) were found significantly associated with stunting at P value <0.05
Conclusion: The study revealed that prevalence of stunting was still high beside the surplus of food in the study area. Therefore, improving nutritional status of adolescents is imperative through providing comprehensive and routine nutritional assessment and counseling services for adolescents at community, school and health facility levels. Further analytic studies are recommended to identify unexplored underlying causes of stunting among adolescents.
Keywords: Stunting; Adolescents; North east Ethiopia
AOR: Adjusted Odds Ratio; CI: Confidence Interval; COR: Crude Odds Ratio; Ht: Height; NGOs: Non-Governmental Organizations; SPSS: Statistical Package for Social Science; UNICEF: United Nations International Children’s Fund; WHO: World Health Organization
Malnutrition is a major public health problem in both developed and developing nations. Adolescents resided in the developing nations are more suffering from under nutrition [1-3].
World Health Organization (WHO) defined Adolescent as the period of life from 10 to 19 years which is characterized by rapid physical growth and maturation. This crucial period needs dietary pattern adjustment as it has vital impact on lifetime nutritional status and health United Nations international Children’s Fund (UNICEF) categorizes the causes of malnutrition into immediate causes, underlying causes, basic causes [4-10].
Adolescents have high nutritional needs and about 40% of death in the developing countries and 70–80% of deaths in the industrialized countries are linked to attitudes and behaviors adapted during adolescence. But different scholar’s witness that these segments of the population were received very little attention and were faced a series of serious nutritional challenges. Stunting is one of main nutritional problems affecting adolescent populations. So it is better to invest in the adolescents to improve the health of the population in general [11-16].
In developing countries, the magnitude of stunting among adolescent age groups ranges from 32% to 48% [17,18] . As evidenced by some scholars, it affects females than males and also primarily affects those rural resided adolescents than urban [19,20]. In Ethiopia, the prevalence of stunting among adolescents (10-19 years) ranges from 7.2% to 26.5% [11,21,22].
Several studies conducted across Africa indicated that sex, Age of adolescent, Urban Residence, poor socioeconomic status, lifestyle including alcohol and tobacco use, eating habits, level of physical activity, father educational status and sanitation have been found contributors of stunting [11,23-25].
Even though under nutrition is a major public health problem in developing countries including Ethiopia and different strategies have been tried in the past to alleviate stunting problem, its magnitude is not still reduced in the needed manner. On top of this, adolescents have been considered a low risk group for poor health, nutrition and often receive little attention. This results lack of information regarding the nutritional status of adolescents especially from the developing world [26-29].
Therefore; this study aimed to determine prevalence and associated factors of stunting among adolescents in Ethiopia.
Study setting and participants
Quantitative cross-sectional study was conducted among secondary school adolescents of Tehuledere District from 1st April to 20th April 2017. The district is located 430 Km away from the capital of Ethiopia, Addis Ababa. The District has three Governmental secondary schools. There is no private secondary school in the District.
The sample size of 535 was determined using Epi Info version 7.2.0.1 and single population proportion formula with the following assumptions: The 95% confidence interval (Zα/2=1.96), the type I error (d) is taken to be 4% (0.04), the prevalence (p) of under nutrition among adolescents was taken as 58.3% in Tigray, Northern Ethiopia [11] and an estimated non-response rate was 10%.
The study was conducted in all the three Secondary schools of the Tehuledere district. The sample was proportionally allocated to each school and the students in the adolescent age groups were selected by using systematic random sampling from their registration frame.
Data processing and analysis
A structured questionnaire prepared in English version and translated in to local language Amharic and used to collect data related to the objectives of the study. The questionnaire covered a range of topics including socio-demographics, economic factors, behavioral factors, dietary habits, health related factors, Anthropometrics, etc. Data was collected by three trained, committed and competent Nurses. Data collectors were supervised by two Health Officers. Data collectors and supervisors were trained on objectives, on how to approach study subjects (humans), on how to utilize and handle tools. Besides, height was measured for all adolescents using a measuring board without wearing shoes in centimeters with a precision of 0.1 cm.
The data was checked for completeness, coded and entered using Epi info version 7.2.0.1 and analyzed using SPSS version 20.0 and WHO Anthro-Plus software’s. The binary logistic regression was made to assess the imperative association between stunting and each independent variable with odds ratio and 95% confidence interval (CI). The variables with p-value less than 0.25 were entered into multivariable analysis model. Multivariable analysis was done to control the effect of possible confounders and to see the strength of association between dependent and covariates with the comparison of both crude and adjusted odds ratio with 95% confidence interval. Statistical significance was declared at p-value <0.05.
Socio-Demographic characteristics of participants
From a total of 535 secondary school adolescents who were selected as sample, with 96.26% response rate 515 subjects were involved. Among the study subjects, 238 (46.2%) were males and 277 (53.8%) were females. Of the selected subjects 231 (44.9%) were in the age group 13-16 years and the rest 284 (55.1%) were in the age group 17-19 year with mean age 16.73 years with SD ± 1.258. Majority of respondents were Muslims 395 (76.7%), single 472 (91.6%), live with parents 429 (83.3%), from family size range four to six 372 (72.2%) and from parents with occupation of farmer. Only 21 (4.1%) of participants were with the wealth index of high (Table 1).
| Variables | ||
|---|---|---|
| Socio-Demographic characteristics | Frequency | Percentage |
| Age group | ||
| 13-16 | 231 | 44.9 |
| 17-19 | 284 | 55.1 |
| Sex | ||
| Male | 238 | 46.2 |
| Female | 277 | 53.8 |
| Total | 515 | 100 |
| Grade level | ||
| Grade 9 | 217 | 42.2 |
| Grade 10 | 209 | 40.6 |
| Grade 11 | 78 | 15.1 |
| Grade 12 | 11 | 2.1 |
| Religion | ||
| Orthodox Christian | 112 | 21.7 |
| Muslim | 395 | 76.7 |
| Protestant | 4 | 0.8 |
| Catholic | 4 | 0.8 |
| Residence | ||
| Urban | 266 | 51.7 |
| Rural | 249 | 48.3 |
| Marital status | ||
| Married | 33 | 6.4 |
| Divorced/separated | 7 | 1.4 |
| Widowed | 3 | 0.6 |
| Single | 472 | 91.6 |
| Currently living with | ||
| With parent | 429 | 83.3 |
| Other than parent | 86 | 16.7 |
| Family size | ||
| Three and below | 69 | 13.4 |
| Four to six | 372 | 72.2 |
| Seven and above | 74 | 14.4 |
| Sex of head of the household | ||
| Male | 422 | 81.9 |
| Female | 93 | 18.1 |
| Educational status of father | ||
| Illiterate | 225 | 43.7 |
| Primary school | 145 | 28.2 |
| Secondary school | 75 | 14.6 |
| College and above | 70 | 13.6 |
| Educational status of mother | ||
| Illiterate | 256 | 49.7 |
| Primary school | 158 | 30.7 |
| Secondary school | 65 | 12.6 |
| College and above | 36 | 7.0 |
| Father occupation | ||
| Merchant | 78 | 15.1 |
| Employer in government | 78 | 15.1 |
| Employer in NGO | 18 | 3.5 |
| Daily laborer | 5 | 1.0 |
| Farmer | 324 | 62.9 |
| Other | 12 | 2.3 |
| Mother occupation | ||
| Merchant | 91 | 17.7 |
| Employer in government | 40 | 7.8 |
| Employer in NGO | 16 | 3.1 |
| Daily laborer | 6 | 1.2 |
| Farmer | 304 | 59.0 |
| Other | 58 | 11.3 |
| Wealth Index | ||
| Low | 286 | 55.5 |
| Medium | 208 | 40.4 |
| High | 21 | 4.1 |
Table 1: Socio-demographic characteristics of secondary school Adolescents in Tehuledere District, North- East Ethiopia, 2017.
Dietary habits of adolescents
Majority of the households 456 (88.5%) used sorghum and the sources of food for the households were own product 209 (40.6%) and purchase 164 (31.8%). Dietary Diversity Score of 295 (57.3%) adolescents were low (1&2). Regarding House Hold Food security only some of Houses 18 (3.5%) was very low food secured (Table 2).
| Dietary habit items | Frequency | Percentage |
|---|---|---|
| Staple food item for the household | ||
| Teff | 31 | 6.0 |
| Sorghum | 456 | 88.5 |
| Barley | 28 | 5.4 |
| Common source of food for the household | ||
| Own product | 209 | 40.6 |
| Purchase | 164 | 31.8 |
| Both own product and purchase | 142 | 27.6 |
| Dietary Diversity Score | ||
| Low (1 & 2) | 295 | 57.3 |
| Medium (3-5) | 220 | 42.7 |
| Food Security | ||
| very low FS (8 & 9) | 18 | 3.5 |
| Low FS (4-7) | 216 | 41.9 |
| marginal FS (0-3) | 281 | 54.6 |
Table 2: Descriptive Statistics on Dietary Habits secondary school Adolescents in Tehuledere District, North- East Ethiopia, 2017.
Health history and sanitation of respondents
The result about health history of the respondents showed that majority of the respondents 492 (95.5%) and 369 (71.7%) did not have previous history of any chronic diseases and any type of acute illness in period of last 1 month respectively. The result further indicated that the major source of water for majority of the respondents 436 (84.7%) was pipe water which is chlorinated and considered to be safe in Ethiopian context while only 3 (0.6%) were used river water. Majority of the respondents 468 (90.9%) had latrine in their house and large number of the respondents 429 (83.3%) washed their hands always after toilet use but only six (1.2%) respondents never washed their hands after toilet at all (Table 3).
| Health and sanitation related variables | Frequency | Percentage |
|---|---|---|
| Ever have had chronic diseases like TB, HIV, etc | ||
| No | 492 | 95.5 |
| Yes | 23 | 4.5 |
| Ever had fever, cough, diarrhea or any acute illness in the period of last 1 month | ||
| No | 369 | 71.7 |
| Yes | 146 | 28.3 |
| Source of drinking water | ||
| Pipe | 436 | 84.7 |
| Spring | 52 | 10.1 |
| Others | 27 | 5.2 |
| Have latrine in the house | ||
| No | 47 | 9.1 |
| Yes | 468 | 90.9 |
| Wash hands after toilet use | ||
| Always | 429 | 83.3 |
| Sometimes | 80 | 15.5 |
| Not at all | 6 | 1.2 |
Table 3: Descriptive Statistics on Health history and health status of secondary school Adolescents in Tehuledere District, North-East Ethiopia, 2017.
Prevalence of stunting
The overall prevalence of stunting among the study participants was 80 (15.5%). On sex basis segregation; 47 (9.1%) males and 33 (6.4%) females were stunted (Table 4).
| Variables | Category of variables | Frequency | Percentage |
|---|---|---|---|
| Stunting | Ht/age Z-score ≥ -2SD | 435 | 84.5 |
| Ht/age Z-score < -2SD | 80 | 15.5 | |
| Segregated by sex | Male | 47 | 9.1 |
| Female | 33 | 6.4 | |
| Segregated by Age | 13-16 | 45 | 8.7 |
| 17-19 | 35 | 6.8 |
Table 4: Prevalence and segregation of stunting by sex and age of participants in Tehuledere District, North-East Ethiopia, 2017.
Factors associated with stunting
In order to identify major factors that have associations with under nutrition bivariate and multivariate logistic regression analysis were executed by taking Stunting of respondents as dependent variable and some explanatory variables as independent.
The results of this study showed that students sex, students age, source of safe drinking water, having latrine facility, and hand wash after toilet were found associated with stunting in the bivariate analysis at P value <0.25. However, the result of the multivariate analysis indicated that hand wash after toilet had no significant association with stunting.
The result of the multivariate analysis showed that male students were 2.4 times more likely to be stunted compared to female students [AOR 2.394; 95% CI 1.425, 4.022]. The odds of being stunted was 2.1 times higher among students that were under age category 13-16 years than those students who were under the age category 17-19 years [AOR 2.106; 95% CI 1.261, 3.516].
Students from households that used unsafe water supply as main source of water supply were almost 3.7 times more likely to be at risk of being stunted than students from households that used safe water supply for human consumption [AOR 3.721; 95% CI 1.397, 9.913].
The likelihood of being stunted was also found to be 3.3 times higher among students who do not have latrine facility than students who have a latrine facility [AOR 3.311; 95% CI 1.569, 6.988] (Table 5).
| Nutritional status | ||||
|---|---|---|---|---|
| Explanatory Variables | Stunted | Normal | Crude (95% CI) | Adjusted (95% CI) |
| Age | ||||
| 13-16 years | 45 (8.7%) | 187 (36.3%) | 1.721 (1.064, 1.279)* | 2.106 (1.261, 3.516)** |
| 17-19 years | 35 (6.8%) | 248 (48.2%) | 1 | 1 |
| Sex | ||||
| Male | 47 (9.1%) | 191 (37.1%) | 1.819 (1.122, 2.951) | 2.394 (1.425, 4.022)** |
| Female | 33 (6.4%) | 244 (47.4%) | 1 | 1 |
| Source of drinking water | ||||
| Safe source | 75 (16.4%) | 362 (70.3%) | 1 | 1 |
| Unsafe source | 5 (1%) | 73 (14.2%) | 3.025 (1.182, 7.740)* | 3.721 (1.397, 9.913)* |
| Have latrine | ||||
| Yes | 75 (14.6%) | 400 (77.7%) | 1 | 1 |
| No | 5 (1%) | 35 (6.8%) | 2.584 (1.313, 5.086)** | 3.311 (1.569, 6.988)** |
| Hand wash after toilet | ||||
| Always | 63 (12.2%) | 370 (71.8%) | 1 | |
| Sometimes | 16 (3.1%) | 60 (11.7%) | 0.478 (0.269, 0.851)* | |
| Never at all | 1(0.2%) | 5(1%) | 0.797(0.092, 6.945) | |
| *P-value less than 0.05 **P-value less than 0.01 |
||||
Table 5: Factors associated Stunting among Secondary school adolescents in Tehuledere District, North-East Ethiopia, 2017.
This study was conducted to assess the prevalence and associated factors of Stunting among secondary school adolescents in Tehuledere District, Amhara Regional State, North-East Ethiopia.
The prevalence of stunting among the study participants was 15.5% which is similar to the result of the Study conducted in Jimma zone Adolescents, Southwest Ethiopia (16%) [22] and Mongolia (15.6%) [29]. The prevalence of stunting in this study was higher compared to the study conducted among Addis Ababa secondary school adolescents (7.2%) [21]. The possible reasons for the discrepancy might be mainly due to socioeconomic status discrepancy and small sample size in this study.
However, the prevalence of stunting was lower than the study conducted in Tigray, northern Ethiopia (26.5%) [11] and the study conducted in Bangladesh (42%) [29]. The discrepancy might be due to seasonal variation, socioeconomic variability, and geographical characteristics of study area.
In order to identify major factors that have association with stunting bivariate and multivariate logistic regression analysis were executed by taking stunting of respondents as dependent variable and some explanatory variables as independent.
Regarding associated factors of stunting, the result of the multivariate analysis indicated that students sex, students age, source of safe drinking water and having latrine facility were significantly associated with stunting at P value <0.05.
The result of this study showed that male students were 2.4 times more likely to be stunted compared to female students. Consistent with this study result, a study done in Chiro Town ,West Hararge, indicated that one factor associated with stunting were being male (AOR=3.91 CI=1.7, 8.98) [25].
Unlike to the result of this study, one study done in Bangladesh reflected as the prevalence of stunting was high in females than males. It was estimated to be 43.1% among boys and 50.3% among girls [20]. These differences may be in part due to variations in sample size as compared with present study.
Based on this study result age was also found to be strong predictor of stunting at P values <0.05. That is, students in age group 13-16 were 2.1 times more likely to be stunted compared to students in the age category 17-19 years. In other words, the risk of being stunted decreased in older adolescents than younger adolescents. In line with the present study finding of other previous study showed that age was strong predictor of stunting (r2=0.88, p<0.01) [11]. In contrast, other study showed that the prevalence of stunting is increased with adolescents age [29]. This might be due to variations related with sample size and related issues.
This study also found that source of water supply had association with stunting. Students from households that used unsafe water supply as main source of water supply were almost four times more likely to be at risk of being stunted than students from households that used safe water supply for human consumption. This finding is similar to study conducted western Kenya that showed more children who drank water that was not consistently treated in households were stunted [30]. Therefore, diarrhea and water borne diseases caused by unsafe drinking water at households’ level might increase the prevalence of malnutrition directly or indirectly.
This study further depicted that the presence of latrine facility in the household had negative association with stunting. In this study finding the likelihood of being stunted was found to be 3.3 times higher among students who do not have latrine facility than students who have a latrine facility in their house. Supporting this finding one previous study showed that lack of latrine facilities was also a predictor of stunting (r2=0.06, p=0.02) in Adolescents [11].
The study revealed that prevalence of stunting was still high beside the surplus of food in the study area. After adjustment; being female, being in the age group 13-16 years, using unsafe source of drinking water and have no latrine facility were found the significant predictors of stunting. Therefore, improving nutritional status of adolescents is imperative through providing comprehensive and routine nutritional assessment and counseling services for adolescents at community, school and health facility levels. Further analytic studies are recommended to identify unexplored underlying causes of stunting among adolescents.
Ethics approval and consent to participate
Ethical clearance was obtained from University of Gondar, institute of public health and Permission letter was obtained from Tehuledere District administration office, Education Office and schools. The School leaders, Teachers and students were informed about the objective of the study. Informed consent was obtained from adolescents in the age group 18-19 years and for those participants aged <18 years, assent was obtained from their parent/legal guardians. Finally, the data was collected from the study participants with the assurances of confidentiality, right to refuse at any time and right to ask any questions related to the study when the occasion arises. The entire information that was obtained from each participant remained anonymous and confidential.
Consent for publication
Not applicable since it is original work of the authors.
Availability of data and material
If the reviewers need more information, the reviewers can contact the corresponding author without any hesitations.
The authors declared as there is no conflict of interest.
Not applicable
All authors conceived and designed the study. YM and DT supervised the data collection.
YM and AW performed the data analysis, interpretation of data and drafted the manuscript.
AW, YM and DT had interpreted and critically reviewed the manuscript.
All authors read and approved the final manuscript.
The authors would like to thank University of Gondar, Institute of Public Health, Tehuledere District Education Office, and secondary schools for giving the required information. Also authors forward their deepest gratitude to study participants. The authors would like to acknowledge who were involved directly or indirectly in the accomplishment of this study.