|Year : 2018 | Volume
| Issue : 2 | Page : 158-164
Prevalence and associated factors of thinness among adolescent girls attending governmental schools in Aksum Town, Northern Ethiopia
Aregawi Amha1, Tadele Girum2
1 Department of Public Health, College of Medicine and Health Sciences, Wolaita Soddo University, Soddo, Ethiopia
2 Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
|Date of Web Publication||18-May-2018|
Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite
Source of Support: None, Conflict of Interest: None
Introduction: Thinness among adolescent girls has not received due to attention in many developing countries including Ethiopia. However, adolescence period is the last window of opportunity to implement strategies to correct potential growth deficits thereby breaking the vicious cycle of intergenerational malnutrition. Objectives: The aim of this study is to assess the prevalence of thinness and associated factors among adolescent girls. Methods: School-based cross-sectional study design was employed from April to May 2014. Multi-stage sampling technique was used to select a total of 823 adolescent girl students. Data were collected using interviewer-administered technique using a pretested semi-structured questionnaire and anthropometric measurements. Five nurses as data collectors and three BSc nurse supervisors were included in the study. Data were entered into EPI INFO version 7 and then exported to SPSS version 20 software and WHO AnthroPlus software for analysis. Descriptive statistics was performed. Binary logistic regression was fitted, odds ratio (OR) with 95% confidence interval (CI) and P value was calculated to identify associated factors. Results: The overall prevalence of thinness in this study area was 12.6%. Age of the respondent (adjusted OR [AOR] =2.7, 95% CI: 1.4, 5.3), education status of mother (AOR = 5.4, 95% CI: 3.3, 6.5), menstruation status (AOR = 0.5, 95% CI: 0.3, 0.9), individual dietary diversity (AOR = 3.9, 95% CI: 2.3, 7.0), and wealth index (AOR = 3.8, 95% CI: 1.5, 5.6) were significantly associated with thinness of adolescent girls. Conclusion and Recommendation: Thinness was found to be a serious problem in the study area. Strategies are needed to improve the nutritional status of adolescent girls before they reach conception to break the vicious cycle of intergenerational malnutrition.
Keywords: Adolescent girls, anthropometry, growth, thinness
|How to cite this article:|
Amha A, Girum T. Prevalence and associated factors of thinness among adolescent girls attending governmental schools in Aksum Town, Northern Ethiopia. Med J DY Patil Vidyapeeth 2018;11:158-64
|How to cite this URL:|
Amha A, Girum T. Prevalence and associated factors of thinness among adolescent girls attending governmental schools in Aksum Town, Northern Ethiopia. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Sep 15];11:158-64. Available from: http://www.mjdrdypv.org/text.asp?2018/11/2/158/232642
| Background|| |
Adolescence is an intense anabolic period during which requirements for all nutrients increase due to rapid physical growth and development.,, Increased nutritional needs at this stage of life relate to the fact that adolescents gain up to 50% of their adult weight, >20% of their adult height and 50% of their adult skeletal mass during this period. As a result, adolescents may encounter series of serious nutritional challenges which would negatively affect this rapid growth spurt as well as their health as adults.,,
Adolescence is a unique intervention point in the life-cycle. It is a stage of receptivity to new ideas and a point at which lifestyle choices may determine an individual's life course. It provides a chance to acquire knowledge about optimal nutrition during young adulthood that could prevent or delay adult-onset diet-related illnesses in the later period of life.,,, This period of life is also a unique opportunity to break a range of vicious cycles of structural problems that are passed from one generation to the next generation, such as poverty, gender discrimination, violence, poor health, and nutrition.
Nutritional deficiencies in adolescent girls have far-reaching consequences. Undernourished adolescent girls are likely to give birth to undernourished children resulting in the vicious cycle of intergenerational malnutrition if great attention is not given to adolescent girls' nutritional needs. Poor nutrition status among adolescents is also an important determinant of poor health outcomes. Undernutrition has far-reaching consequences; they have a high risk of mortality associated with the direct and indirect consequences of malnutrition.,
The nutritional status of adolescents contributes significantly to the health status of the community in which they reside. One of the major global health problems faced by developing countries today is undernutrition. Thinness defined as low body mass index (BMI) for age, which graded into mild-I, moderate-II, and severe-III can be a marker of undernutrition although thin children are not necessarily undernourished.,,
The prevalence of thinness and its consequence on adolescent is not studied very well, however, since undernutrition in children is highly prevalent thinness is expected. Furthermore, some of the existing researches showed its high prevalence particularly in the northern part of Ethiopia. A national level survey on adolescent girls reported that 14% of adolescent girls were thin. Similarly, in Addis Ababa, the capital of Ethiopia, 6.2% of adolescents were found to be thin  and a study conducted among adolescent girls in rural communities of northern Ethiopia showed that the prevalence of thinness was 58.3%.
Besides this, adolescents remain a largely neglected segment of the population. Their health has been neglected for many years because they were considered to be less vulnerable to disease than others. As a result, their needs are often ignored though they are mothers of the future generation. Attention needs to be directed at the link between adolescent girls' nutrition and immediate and long-term health issues to prevent the worst consequences of malnutrition.,,, There is limited information available about the nutritional status of adolescent girls in Ethiopia. Therefore, this study will address the gap by assessing the nutritional status and associated factors among adolescent girls in Government schools of Aksum town.
| Methods|| |
Study design and settings
This school based cross-sectional study was conducted from April to May 2014 in Aksum town administration. Aksum town is located in the central zone of Tigray, 1042 km North of capital Addis Ababa; having a total population of 58,707 divided into four administrative Kebeles. In the town, there are three government secondary schools, one government preparatory and 8 government primary schools. In the year 2013/2014, a total of 16919 students have been enrolled in all primary, secondary, and preparatory government schools of which 8697 of the students are female and 8222 are male. There are a total of 6824 adolescent girls from grade 4 to grade 12 students in all the primary, secondary, and preparatory government schools.
Study population and sampling technique
The source population of this study was all adolescent girls attending government schools in Aksum town. The sample size was determined on the basis of previous studies done in Ethiopia for the prevalence of thinness among adolescents. Then using single population proportion formula; by taking prevalence of thinness as P = 58.3%; 5% margin of error; 95% confidence interval (CI); and Adding 10% for nonresponse rate and multiplying by 2 for design effect, the final sample size became 823. The sample size calculated for the second objective to answer the associated factors with double population proportion formula was only 236; therefore, the sample size obtained for the first objective was enough to answer the second objective as well.
Sampling technique and sampling procedure
Multi-stage sampling technique was used for this study. In the first stage, from the total of 12 governmental schools (8 primary, 3 secondary, and one preparatory), 3 schools (2 from primary and 1 from secondary schools) were selected by simple random sampling technique and 1 preparatory school purposively. In the second stage, taking a list of an identification number for each adolescent girl student in the randomly selected schools as a sampling frame, study participants were selected randomly by computer-generated random numbers. Through the process students who are physically impaired (kyphosis and scoliosis) and those who are seriously ill during data collection were excluded from the study.
Data collection procedure and data quality control
The source of data for the study was individual participant's interview information and anthropometric data. Data were collected by using standardized instruments. Questionnaires were first prepared in English and then translated to Tigrigna and translated back to English by two different individuals to check for consistency. Three BSc nurse supervisors, principal investigator and five data collectors (diploma nurses) were recruited for the data collection process.
Data were collected using semi-structured and pretested questionnaire adopted (except some variables) from the Food and agriculture organization Guidelines for measuring household and individual dietary diversity, 2011 and WHO steps instrument for chronic disease risk surveillance  with certain adjustment. Interviewer-administered questionnaire was used to collect data from adolescent girl students. Weight was measured to the nearest 0.1 kg using calibrated digital weight scales (prestige, New Delhi, India) in a standing position with light cloths and barefoot. Height was measured to the nearest 0.1 cm using height measuring stadiometer (prestige, New Delhi, India) in standing position. The scales were carefully handled and periodically calibrated by placing standard calibration weight of a 2 kg iron bar on the scale before use to ascertain accuracy. To avoid data variability among data collectors, specifically trained data collectors was used for anthropometric measurements.
Data quality management
Validity was maintained by using standardized questionnaire that was properly developed from review of published articles and WHO Stepwise approach for surveillance of noncommunicable diseases in developing countries, proper training of the measures on data collection procedures, proper categorization and coding of the questionnaires and 10% of the completed questionnaire was reviewed and checked for completeness and relevance every day by principal investigator. Reliability of the questionnaire was checked by pretesting of the tool on 5% the study subjects from institutes other than selected and measuring of height and weight were taken twice, and an average of the two reading was recorded.
- Adolescence - is the age group from 10 to 19 years 
- Thinness - is defined as BMI for age below<−2 Z-score of the 2007 WHO standard reference values 
- Individual dietary diversity score: is acceptable indicator for adequate intake of micronutrients in developing countries. The classification was based on the mean distribution of scores. i.e., adequate ≥6 and inadequate <6
- The wealth quintile: is an index of the economic status of households. Parents of respondents were ranked into four wealth quintiles. first quintiles = lowest, second quintiles = low, third quintiles = middle, and fourth quintiles = highest.
Study variables and data analysis
The dependent variables was prevalence of thinness (yes/no) while the independent variables were sociodemographic variables (age, religion, residence, wealth index, educational status of father, occupational status of father, educational status of mother, occupational status of mother), Individual variables (physical activity, age of menarche, eating habit, diet diversity, history of illness, alcohol use), environmental variables (source of drinking water, availability of home gardening and availability of latrine facilities).
After data collection, each questionnaire was checked for completeness and consistency. Data was cleaned, coded, and entered into Epi-info version 7 (CDC, Atlanta, GA, USA, 2011) and exported to SPSS version 20 (SPSS, IBM Corp, Armonk, NY) for Windows, then exploratory data analysis carried out to check the levels of missing values, the presence of influential outliers, independence of errors, multi-collinearity, and normality. Anthropometric measurements were converted to height-for-age z scores and BMI-for-age z scores using the world health organization Anthroplus software (Geneva, Switzerland, 2011) to assess the nutritional status of the study units. Binary and multiple logistic regressions with backward step-wise method were run to assess the association of various factors with thinness. The fitness of the model was checked by using Hosmer and Lemeshow test. The results were presented in the form of tables, texts, and figure. The strength of association of predictor variables with thinness was assessed using adjusted odds ratio and significance of variables were reported by using 95% confidence interval and P < 0.05.
Ethics approval and consent
Ethical clearance was obtained from the Institution Review Committee, Institute of Public Health of the University of Gondar and Official letter written from education office. A brief explanation about the purpose of the study was given to each school principals. After getting permission from each school, individual assent (<18 years)/consent (>18 years) and parent consent were obtained from each participant after a brief explanation of why they are taking part in the research before conducting the study. Confidentiality was maintained throughout the study by all data collectors and principal investigator using code numbers than names and keeping questionnaires locked. The voluntary nature of the study was told to the study participants. Anyone not willing to take part in the study was given full right not to participate. Those who found undernourished during the data collection period were advised to visit health institution for medical advice from health professionals.
| Results and Discussion|| |
A total of 823 adolescent girls were included in the study with a response rate of 100%. The mean age of respondents was 15.12 (±2.59 standard deviation) years. Nearly one-quarter (25.5%) of respondents was found to be in the first quintile range of wealth index. Majority 758 (92.1%) of the respondents were followers of orthodox Christianity, followed by Muslims (7.2%). Five hundred and forty-three (66%) of the respondents were urban dwellers. Regarding parents of the study participants 269 (32.7%) of mothers and 308 (37.4%) of fathers were educated at least at a primary school level. By occupation majority 620 (75.3%) of mothers and 349 (42.4%) of fathers were housewives and farmers, respectively [Table 1].
|Table 1: Sociodemographic characteristics of adolescent girls in governmental schools (n=823)|
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Individual characteristics related to nutritional status of the respondents
From the respondents, 455 (55.3%) and 447 (54.3%) were involved in moderate to vigorous work and moderate intensity sport activities for ≥10 min continuously per day, respectively. Regarding to eating habit of the respondents, 185 (22.5%), 179 (21.7%), and 534 (64.9%) of them ate fruits, vegetables, and snack, respectively, at least once/day. In general, only 89 (10.8%) of the respondents consumed at least three meals/day. Seven hundred and twenty-five (88.1%) of the respondents had used adequate diet diversity and the rest had used inadequate diet diversity. Of the respondents, 347 (42.2%) had begun their first menstruation in the age range of 14–16 years of age and 35 (4.3%) had begun their first menstruation above 16 years of age [Table 2].
|Table 2: Individual characteristics of adolescent girls in governmental schools, Aksum town, Northern Ethiopia, 2014|
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Environmental characteristics of the respondents
Nearly half of the respondents (51%) reported that home gardening was available in their home. Seven hundred and seventeen (87.1%) of the respondents reported that they had home latrine, and majority 771 (93.7%) of the respondents indicated that they had used a relatively safe drinking water [Table 3].
|Table 3: Environmental characteristics of adolescent girls in governmental schools, 2014|
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Prevalence of thinness among adolescent girls
The overall prevalence of thinness among adolescent girl students in Aksum town was 12.6% CI (8.81–14.12).
Factors associated with thinness
In the bivariate logistic regression analysis, thinness was significantly associated with age of the respondent, educational status of father, fruits eaten in the past 24 h, vegetables eaten in the past 24 h, drinking water treatment and age of menarche.
In the multivariate analysis, the age of the respondent, educational status of mother, menstruation status, women dietary diversity, and wealth index were significantly and independently associated with thinness.
Early adolescent girls were 2.7 times more likely to become thin as compared to late adolescent girls (adjusted odds ratio [AOR] = 2.7, 95% CI: 1.4–5.3). Adolescent girl students whose mothers had not been taken formal education were 5.4 times more likely to be thin as compared to those whose mothers are completed college and above education (AOR = 5.4, 95% CI: 3.3–6.5). Adolescent girl students who began menstruation were 50% less likely to be thin than those who did not begin menstruation (AOR = 0.5, 95% CI: 0.3, 0.9). Adolescent girls who used inadequate diet diversify were 3.9 times more likely to be thin as compared to those who used adequate diet diversify in the past 24 h preceding the survey (AOR = 3.9, 95% CI: 2.3,7.0). Adolescent girls from a family with first wealth quintile were 3.8 times more likely to become thin as compared to those adolescent girls from a family with fourth wealth quintile (AOR = 3.8, 95% CI: 1.5, 5.6). Similarly, adolescent girls from a family with second wealth quintile were 1.7 times more likely to be thin as compared to those adolescent girls from family with fourth wealth quintile (AOR = 1.7, 95% CI: 1.2–2.9) [Table 4].
|Table 4: Logistic regression analysis of factors associated with thinness among adolescent girls in governmental schools, 2014|
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| Discussion|| |
In Ethiopia, many studies have been conducted to identify the extent and consequence of undernutrition in different population groups. However, the issues of undernutrition particularly of thinness was neglected among adolescent girls. Thus, this study was able to disclose the prevalence and associated factors of thinness and stunting among government school adolescent girl students in Aksum town.
The prevalence of thinness in this study was 12.6%. This finding is nearly the same to a cross-sectional study conducted in Haryana, India (13.73%). Moreover, the national level survey conducted on adolescent girls which reported the prevalence of 14%. This similarity might be because the study populations in both study areas were students who involved in lesser activities which require less energy expenditure. However, this prevalence is lower than the finding of the previous study done in Bangladesh (26%). This discrepancy might be due to set up the difference. This study was carried out in an urban area while the other study was conducted in the rural community.
Moreover, this prevalence was also lower than the previous study done in Kenya (15.6%) and Tigray region, Northern Ethiopia (58.3%)., This difference might be due to the time gap. These studies were conducted 16 years back in Kenya and 9 years back in Tigray, Northern Ethiopia.
As can be noted from findings of multivariate analysis of logistic regression, the likely hood of being thin was found to be significant among early adolescent and middle adolescent compared to late adolescent girls. Similar significant association between the adolescence age and thinness was indicated in the findings of other previous studies done in India. This could be because of the early growth spurt seen in girls with a sudden increase in height in early age group.
Adolescent girl students whose mothers had not been taken formal education were 5.4 times more likely to be thin as compared to those whose mothers are completed college and above education. This finding is supported by a previous study done in Bangladesh. This is because if the level of education of the mother is low, her finances and her contribution to the total family income will be low. This places the family at a lower social class and poor nutritional status as well.
Adolescent girls who began menstruation early were 50% less likely to be thin than their counterpart. This finding is in line with the finding of other previous study done in Kenya. This might be because early commencement in menstruation status is an indicator of good nutritional status.
Adolescent girls who used inadequate diet diversity were 3.9 times more likely to be thin as compared to their counterpart in the past 24 h. This might be explained by the fact that intake of diverse diet increases the likelihood of meeting the nutrient requirements of adolescent girls.
Adolescent girls from a family with first wealth quintile were 3.8 times more likely to become thin as compared to those adolescent girls from a family with fourth wealth quintile. This finding contradicts the finding found in a study done in Bangladesh., This might be because the higher household asset quintile reflects the higher economic status of the household, indicating the better long-term economic status of the household and hence, better nutritional status.
| Conclusion and Recommendation|| |
Thinness was found to be a serious problem in the study area according to the WHO cut-off values for public health significance. Age of the respondent, educational status of the mother, individual dietary diversity, wealth quintile, and menstruation status were significantly associated with the thinness of the respondent. Therefore, to overcome the problem: Parents should develop the habit of serving well-diversified foods to their adolescents, school teachers, and health workers should teach adolescent girls to eat healthy and well-diversified foods. The health-care administrator should design strategies and programs addressing the nutritional status of adolescent girls.
The authors would like to sincerely thank Head of the schools, data collectors, study participants and others who ever contributed to this work. We would also like to acknowledge the University of Gondar, College of Medicine and Health Sciences for facilitating the study and for USAID-ENGINE (Empowering New Generation to Improve Nutrition and Economic opportunities) for funding this research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]