Undernutrition and its determinants among adolescent girls in low land area of Southern Ethiopia

PLoS ONE, Volume 16, No. 1 January, Year 2021

Interpretation

Background Undernutrition is one of the most common causes of morbidity and mortality among adolescent girls worldwide, especially in South-East Asia and Africa. Even though adolescence is a window of opportunity to break the intergenerational cycle of undernutrition, adolescent girls are a neglected group. The objective of this study was to assess the nutritional status and associated factors among adolescent girls in the Wolaita and Hadiya zones of Southern Ethiopia. Methods A community-based cross-sectional study was conducted, and a multistage random sampling method was used to select a sample of 843 adolescent girls. Anthropometric measurements were collected from all participants and entered in the WHO Anthro plus software for Z-score analysis. The data was analyzed using EPI-data 4.4.2 and SPSS version 21.0. The odds ratios for logistic regression along with a 95% confidence interval (CI) were generated. A P-value < 0.05 was declared as the level of statistical significance. Result Thinness (27.5%) and stunting (8.8%) are found to be public health problems in the study area. Age [AOR(adjusted odds ratio) (95% CI) = 2.91 (2.03–4.173)], large family size [AOR (95% CI) = 1.63(1.105–2.396)], low monthly income [AOR (95% CI) = 2.54(1.66–3.87)], not taking deworming tablets [AOR (95% CI) = 1.56(1.11–21)], low educational status of the father [AOR (95% CI) = 2.45(1.02–5.86)], the source of food for the family only from market [AOR (95% CI) = 5.14(2.1–12.8)], not visited by health extension workers [AOR (95% CI) = 1.72(1.7–2.4)], and not washing hand with soap before eating and after using the toilet [AOR (95% CI) = 2.25(1.079–4.675)] were positively associated with poor nutritional status of adolescent girls in the Wolaita and Hadiya zones, Southern Ethiopia. Conclusion Thinness and stunting were found to be high in the study area. Age, family size, monthly household income, regularly skipping meals, fathers’ educational status, visits by health extension workers, and nutrition services decision-making are the main predictors of thinness. Hand washing practice, visits by health extension workers, and nutrition services decision-making are the main predictors of stunting among adolescent girls. Multisectoral community-based, adolescent health and nutrition programs should be implemented. The study was conducted in the Wolaita and Hadiya zones of Southern Ethiopia. These zones are predominantly dependent on agriculture, practicing mixed crop-livestock production and living in permanent settlements. Within their landholdings, community members cultivate fruits, vegetables, roots, and tuber crops. Fig 1 shows Map of the study sites (Wolaita and Hadiya zones) in southern nation nationality and peoples region (SNNPR), 2019. A community-based cross-sectional study was conducted at two zones in Southern Ethiopia from April 30, 2019 to May 30, 2019. The inclusion criteria were adolescent girls (both attending and not attending school) between the ages of 10–19 years in two Southern Ethiopian zones. Participants who met the inclusion criteria were randomly selected to be the study population. BMI-for-age Body mass index for age z-score and height-for-age z-score were the dependent variables. Age, educational status of the participant, family size, maternal and paternal educational level, access to nutritional counseling services in health facilities, deworming tablets, iron-folic acid supplementation, household monthly income, source of food, and number of meals per day were the independent variables for our study. A single population proportion formula, [n = z∝22P (1-P) /d2] was used to estimate the sample size. From the literature review, the prevalence of thinness (24.4%) and stunting (29.4%) were used for sample size calculations. Sample size calculation by using thinness (24.4%) was n = (Z α/2)2*p (1-p)/d2 = 748 and sample size calculation by using stunting (29.4%) was n = n = (Z α/2)2*p (1-p)/d2 = 843. So that for this study, stunting (29.4%) was selected to estimate the sample size as it gives a larger sample; considering a 95% confidence interval (CI) and d = 0.05%, the initial sample size was 383. By adding 10% for non-response and a design effect of 2.4, the final sample size was 843. n = (Z α/2)2*p (1-p) DE /d2. Where: Z = Standard normal distribution value at 95% CI = (1.96)2, DE = design effect, and d = 0.05 (5% margin of error). This study used multistage sampling techniques and was conducted in the Wolaita and Hadiya zones. From these two selected zones, two districts were selected based on a simple random sampling procedure, the Humbo district from Wolaita zone and the Misrak Badawacho district from the Hadiya zone. Three kebeles (villages) were selected from each district using a simple random sampling method. A listing of adolescent girls was conducted at these selected kebeles. This listing was developed with the help of both the local government administration, woreda in particular, and health extension workers. During the development of the list, if there were more than one adolescent girl in a household, one adolescent girl was selected by simple random sampling (lottery method). From the selected six kebeles, 843 participants were chosen by simple random sampling method depending on the number of adolescent girls in each kebele. Participants were drawn from each kebele based on probability proportional to size (PPS) sampling techniques. The sampling techniques depended on the number of adolescent girls in each kebele. Adolescent girls with pregnancy, physical and mental disability were excluded from the study. Anthropometrics (i.e., height and weight) were measured on all sampled adolescent girls. Weight was measured to the nearest 100 g using a standard SECA digital scale while the participants wore light clothing and no shoes. The scale was calibrated after weighing each participant. Height was measured in a standing position to the nearest 0.1 cm using a vertical board with a detachable sliding headpiece. Measuring tape was attached to it. BMI-for- age z-scores and height-for-age z-scores were calculated using the height, weight, and age of the participants. WHO Anthro plus software was used to calculate Z-score. A structured interviewer-administered questionnaire was used to collect data. The questionnaire was developed based on a thorough review of the current literature [31–34]. A total of eight nurses with B.Sc. degrees; previous experience in collecting data; and knowledge of the culture, language, and norms of the community were employed to collect data using a pretested structured questionnaire. In addition to this, two supervisors with M.Sc. in public health were employed to supervise the data collection process. Data were collected on weekends for adolescent girls who attended school during the weekdays. The principal investigator controlled the daily overall study activities. First, the data were checked for completeness and consistency for data entry and cleaning. Then, data were entered into the computer using EPI-data version 4.4.2 and exported to SPSS version 21.0 for further analysis. Descriptive statistics such as frequencies, proportions, and cross-tabulation were used to present the data. In addition, bivariate logistic regression analysis was performed to assess the association between independent and dependent variables. Variables that showed an association (p-value ≤ 0.25) in the bivariate analysis were included in the final multivariate logistic regression model. Odds ratios for logistic regression along with a 95% CI were estimated. A p-value less than 0.05 was declared statistically significant. The questionnaire was prepared in English, translated to Amharic, and back translation to English to maintain consistency of the questions. Data collectors and supervisors were trained for 4 days to properly fill out the questionnaire and measure anthropometry. Data collectors were selected from each zone so they could communicate fluently in the local language and understand the socio-cultural practices of the community. The questionnaire was pre-tested on 5% adolescent girls in a similar area to the study sites to ensure reliability. Feedbacks from the pre-test were incorporated into the final questionnaire design. Principal investigator and supervisors performed checks on the spot and reviewed all the completed questionnaires to ensure completeness and consistency of the information collected. Standardization of anthropometric measurements was conducted. To standardize anthropometric measurements, during training an expert took two heights and weight measurements for ten adolescent girls and then let each data collector take the measurements for all ten girls twice. Then, the averages of the two measurements for each adolescent girl taken by the data collector were compared with the average of the expert’s measurements. The technical error of measurement (TEM) and coefficient of variance (CV) were computed for all data collectors using Emergency Nutrition Assessment (ENA) for SMART software. Data collators with unacceptable TEM and CV were asked to repeat the steps again. The study was approved by Addis Ababa University (AAU), College of Natural Sciences Research Ethics Review Committee. The official letter of cooperation was written to the Wolaita and Hadiya zones, and the district of health offices. The nature of the study was fully explained to the study participants and parents/guardians. Informed verbal and written consents were obtained from the parents/guardians for adolescent girls aged < 18 years old and assent was obtained from the participant before the interview. Participants ≥ 18 years aged were asked to provide verbal and written consent. The collected data were kept confidential. Each participant was given a code number, and the data were stored in a secure and password-protected database.

AI Digest

Study Justification:

– Undernutrition is a significant cause of morbidity and mortality among adolescent girls globally, particularly in South-East Asia and Africa.
– Adolescent girls are often overlooked in nutrition programs, despite the potential to break the cycle of undernutrition during this critical period.
– The objective of this study was to assess the nutritional status and associated factors among adolescent girls in the Wolaita and Hadiya zones of Southern Ethiopia.

Study Highlights:

– Thinness (27.5%) and stunting (8.8%) were identified as public health problems in the study area.
– Factors associated with poor nutritional status included age, large family size, low monthly income, not taking deworming tablets, low educational status of the father, relying solely on market food, not being visited by health extension workers, and poor hand hygiene practices.
– Multisectoral community-based, adolescent health, and nutrition programs are recommended to address these issues.

Study Recommendations:

– Implement multisectoral community-based programs targeting adolescent girls in the Wolaita and Hadiya zones of Southern Ethiopia.
– Focus on improving nutrition services, including deworming, nutritional counseling, and access to nutritious food.
– Increase awareness and education on the importance of hand hygiene practices.
– Strengthen the involvement of health extension workers in reaching adolescent girls with health and nutrition services.

Key Role Players:

– Local government administration and officials
– Health extension workers
– Community leaders and influencers
– Non-governmental organizations (NGOs) working in health and nutrition
– Education authorities and schools

Cost Items for Planning Recommendations:

– Training and capacity building for health extension workers and community health workers
– Development and implementation of nutrition programs and services
– Provision of deworming tablets and other necessary medications
– Awareness campaigns and educational materials
– Monitoring and evaluation activities to assess the impact of interventions
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on various factors such as the scale of the interventions and the specific context of implementation.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because the study provides a detailed description of the methods used, including the study design, sample size calculation, data collection procedures, and statistical analysis. The study also presents the results and identifies the main predictors of undernutrition among adolescent girls in the study area. However, the abstract does not provide information on the limitations of the study or potential biases that may have influenced the results. To improve the evidence, the abstract could include a discussion of the study’s limitations and suggestions for future research to address these limitations. Additionally, providing information on the generalizability of the findings to other populations or settings would enhance the strength of the evidence.

Abstract

The study was conducted in the Wolaita and Hadiya zones of Southern Ethiopia. These zones are predominantly dependent on agriculture, practicing mixed crop-livestock production and living in permanent settlements. Within their landholdings, community members cultivate fruits, vegetables, roots, and tuber crops. Fig 1 shows Map of the study sites (Wolaita and Hadiya zones) in southern nation nationality and peoples region (SNNPR), 2019. A community-based cross-sectional study was conducted at two zones in Southern Ethiopia from April 30, 2019 to May 30, 2019. The inclusion criteria were adolescent girls (both attending and not attending school) between the ages of 10–19 years in two Southern Ethiopian zones. Participants who met the inclusion criteria were randomly selected to be the study population. BMI-for-age Body mass index for age z-score and height-for-age z-score were the dependent variables. Age, educational status of the participant, family size, maternal and paternal educational level, access to nutritional counseling services in health facilities, deworming tablets, iron-folic acid supplementation, household monthly income, source of food, and number of meals per day were the independent variables for our study. A single population proportion formula, [n = z∝22P (1-P) /d2] was used to estimate the sample size. From the literature review, the prevalence of thinness (24.4%) and stunting (29.4%) were used for sample size calculations. Sample size calculation by using thinness (24.4%) was n = (Z α/2)2*p (1-p)/d2 = 748 and sample size calculation by using stunting (29.4%) was n = n = (Z α/2)2*p (1-p)/d2 = 843. So that for this study, stunting (29.4%) was selected to estimate the sample size as it gives a larger sample; considering a 95% confidence interval (CI) and d = 0.05%, the initial sample size was 383. By adding 10% for non-response and a design effect of 2.4, the final sample size was 843. n = (Z α/2)2*p (1-p) DE /d2. Where: Z = Standard normal distribution value at 95% CI = (1.96)2, DE = design effect, and d = 0.05 (5% margin of error). This study used multistage sampling techniques and was conducted in the Wolaita and Hadiya zones. From these two selected zones, two districts were selected based on a simple random sampling procedure, the Humbo district from Wolaita zone and the Misrak Badawacho district from the Hadiya zone. Three kebeles (villages) were selected from each district using a simple random sampling method. A listing of adolescent girls was conducted at these selected kebeles. This listing was developed with the help of both the local government administration, woreda in particular, and health extension workers. During the development of the list, if there were more than one adolescent girl in a household, one adolescent girl was selected by simple random sampling (lottery method). From the selected six kebeles, 843 participants were chosen by simple random sampling method depending on the number of adolescent girls in each kebele. Participants were drawn from each kebele based on probability proportional to size (PPS) sampling techniques. The sampling techniques depended on the number of adolescent girls in each kebele. Adolescent girls with pregnancy, physical and mental disability were excluded from the study. Anthropometrics (i.e., height and weight) were measured on all sampled adolescent girls. Weight was measured to the nearest 100 g using a standard SECA digital scale while the participants wore light clothing and no shoes. The scale was calibrated after weighing each participant. Height was measured in a standing position to the nearest 0.1 cm using a vertical board with a detachable sliding headpiece. Measuring tape was attached to it. BMI-for- age z-scores and height-for-age z-scores were calculated using the height, weight, and age of the participants. WHO Anthro plus software was used to calculate Z-score. A structured interviewer-administered questionnaire was used to collect data. The questionnaire was developed based on a thorough review of the current literature [31–34]. A total of eight nurses with B.Sc. degrees; previous experience in collecting data; and knowledge of the culture, language, and norms of the community were employed to collect data using a pretested structured questionnaire. In addition to this, two supervisors with M.Sc. in public health were employed to supervise the data collection process. Data were collected on weekends for adolescent girls who attended school during the weekdays. The principal investigator controlled the daily overall study activities. First, the data were checked for completeness and consistency for data entry and cleaning. Then, data were entered into the computer using EPI-data version 4.4.2 and exported to SPSS version 21.0 for further analysis. Descriptive statistics such as frequencies, proportions, and cross-tabulation were used to present the data. In addition, bivariate logistic regression analysis was performed to assess the association between independent and dependent variables. Variables that showed an association (p-value ≤ 0.25) in the bivariate analysis were included in the final multivariate logistic regression model. Odds ratios for logistic regression along with a 95% CI were estimated. A p-value less than 0.05 was declared statistically significant. The questionnaire was prepared in English, translated to Amharic, and back translation to English to maintain consistency of the questions. Data collectors and supervisors were trained for 4 days to properly fill out the questionnaire and measure anthropometry. Data collectors were selected from each zone so they could communicate fluently in the local language and understand the socio-cultural practices of the community. The questionnaire was pre-tested on 5% adolescent girls in a similar area to the study sites to ensure reliability. Feedbacks from the pre-test were incorporated into the final questionnaire design. Principal investigator and supervisors performed checks on the spot and reviewed all the completed questionnaires to ensure completeness and consistency of the information collected. Standardization of anthropometric measurements was conducted. To standardize anthropometric measurements, during training an expert took two heights and weight measurements for ten adolescent girls and then let each data collector take the measurements for all ten girls twice. Then, the averages of the two measurements for each adolescent girl taken by the data collector were compared with the average of the expert’s measurements. The technical error of measurement (TEM) and coefficient of variance (CV) were computed for all data collectors using Emergency Nutrition Assessment (ENA) for SMART software. Data collators with unacceptable TEM and CV were asked to repeat the steps again. The study was approved by Addis Ababa University (AAU), College of Natural Sciences Research Ethics Review Committee. The official letter of cooperation was written to the Wolaita and Hadiya zones, and the district of health offices. The nature of the study was fully explained to the study participants and parents/guardians. Informed verbal and written consents were obtained from the parents/guardians for adolescent girls aged < 18 years old and assent was obtained from the participant before the interview. Participants ≥ 18 years aged were asked to provide verbal and written consent. The collected data were kept confidential. Each participant was given a code number, and the data were stored in a secure and password-protected database.

Materials

Innovations

Based on the provided information, here are some potential innovations that could be recommended to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information and resources related to maternal health, including nutrition, antenatal care, and postnatal care. These apps can be easily accessible to adolescent girls and their families, providing them with accurate and up-to-date information.

2. Community Health Workers: Train and deploy community health workers who can provide education and support to adolescent girls and their families regarding maternal health. These workers can conduct home visits, organize community health education sessions, and provide referrals to health facilities when needed.

3. School-based Health Programs: Integrate maternal health education into school curricula, ensuring that adolescent girls receive comprehensive information about nutrition, reproductive health, and the importance of seeking antenatal and postnatal care. This can help reach a large number of adolescent girls and promote healthy behaviors from an early age.

4. Nutritional Support Programs: Implement programs that provide nutritional support to adolescent girls, especially those who are undernourished or at risk of undernutrition. This can include providing nutritious meals or supplements, promoting the cultivation of fruits and vegetables, and educating families on the importance of a balanced diet.

5. Strengthening Health Facilities: Improve the availability and quality of maternal health services in health facilities within the Wolaita and Hadiya zones. This can involve training healthcare providers on maternal health care, ensuring the availability of essential supplies and equipment, and improving the overall infrastructure of health facilities.

6. Empowering Adolescent Girls: Promote the empowerment of adolescent girls by providing them with information, skills, and resources to make informed decisions about their health and well-being. This can include promoting education, life skills training, and creating safe spaces for girls to discuss their health concerns.

7. Collaboration and Partnerships: Foster collaboration between government agencies, non-governmental organizations, and community-based organizations to collectively address the challenges related to maternal health in the Wolaita and Hadiya zones. This can help leverage resources, expertise, and networks to implement effective interventions and sustain long-term improvements in access to maternal health services.

It is important to note that these recommendations are based on the provided information and may need to be further tailored and adapted to the specific context and needs of the Wolaita and Hadiya zones in Southern Ethiopia.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement Multisectoral Community-Based Programs: Develop and implement community-based programs that focus on adolescent health and nutrition. These programs should involve multiple sectors, including healthcare, education, and agriculture, to address the underlying determinants of undernutrition among adolescent girls. By targeting this vulnerable group, the intergenerational cycle of undernutrition can be broken, leading to improved maternal health outcomes in the future.

2. Strengthen Nutritional Counseling Services: Improve access to nutritional counseling services in health facilities. This can be done by training healthcare providers on adolescent nutrition and ensuring that these services are available and accessible to adolescent girls in the study area. Nutritional counseling can help address the specific nutritional needs of adolescent girls and provide them with the knowledge and skills to make healthy food choices.

3. Promote Deworming and Iron-Folic Acid Supplementation: Increase awareness and uptake of deworming tablets and iron-folic acid supplementation among adolescent girls. This can be achieved through community education campaigns, school-based programs, and collaboration with local health extension workers. Deworming tablets and iron-folic acid supplementation are important interventions to improve nutritional status and prevent anemia among adolescent girls, which can have long-term effects on maternal health.

4. Improve Household Income and Food Security: Address the socioeconomic determinants of undernutrition by implementing interventions that improve household income and food security. This can include promoting income-generating activities, supporting agricultural initiatives, and improving access to markets for the sale of agricultural products. By addressing poverty and food insecurity, the nutritional status of adolescent girls can be improved, leading to better maternal health outcomes.

5. Enhance Health Extension Worker Visits and Health Education: Strengthen the role of health extension workers in the community by increasing their visits to households and providing targeted health education on nutrition and hygiene practices. Health extension workers play a crucial role in delivering primary healthcare services at the community level. By increasing their presence and providing education on nutrition and hygiene, they can contribute to improving the nutritional status of adolescent girls and ultimately enhance maternal health.

Overall, the development and implementation of these recommendations as part of an innovative approach can help improve access to maternal health by addressing the underlying determinants of undernutrition among adolescent girls in the study area.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Increase access to nutritional counseling services: Implement programs that provide nutritional counseling services specifically targeted towards adolescent girls in the Wolaita and Hadiya zones. This can help educate them about proper nutrition and address undernutrition.

2. Improve availability of deworming tablets: Ensure that deworming tablets are readily available and accessible to adolescent girls in the study area. This can help prevent parasitic infections, which can contribute to undernutrition.

3. Enhance health extension worker visits: Increase the frequency of visits by health extension workers to the communities in the Wolaita and Hadiya zones. These workers can provide valuable health education and support, including guidance on maternal health and nutrition.

4. Promote handwashing practices: Implement hygiene promotion campaigns that emphasize the importance of handwashing with soap before eating and after using the toilet. This can help reduce the risk of infections and improve overall health.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the percentage of adolescent girls receiving nutritional counseling, the availability of deworming tablets in health facilities, the frequency of health extension worker visits, and the prevalence of handwashing practices.

2. Collect baseline data: Conduct a survey or data collection process to gather baseline information on the current status of these indicators in the study area. This will serve as a reference point for comparison.

3. Implement the recommendations: Roll out the recommended interventions, such as the provision of nutritional counseling services, ensuring availability of deworming tablets, increasing health extension worker visits, and promoting handwashing practices.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This can be done through surveys, interviews, or other data collection methods.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the identified indicators. Compare the post-intervention data with the baseline data to determine any changes or improvements.

6. Draw conclusions: Based on the analysis, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any challenges or areas for improvement.

7. Make adjustments and iterate: Use the findings from the analysis to make adjustments to the interventions if necessary. Iterate the process by implementing the adjusted recommendations and repeating the monitoring and evaluation steps.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health in the Wolaita and Hadiya zones of Southern Ethiopia.

Author

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1371/journal.pone.0240677

Research Areas:

Community Interventions, Disability, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female