Undernutrition and associated factors

among school-age children in Wolaita

Zone, South Ethiopia: a comparative cross-
sectional study
Frontiers in Nutrition

Front. Nutr., 17 September 2024

Sec. Nutrition and Sustainable Diets
Volume 11 - 2024 | https://doi.org/10.3389/fnut.2024.1400276

Background: Nutritional deficiencies in school-age children are a public health concern, especially in
resource-limited countries. A school feeding program involves the provision of food on-site or taken
home to reduce hunger. It is implemented in several developing nations; however, little is known about
the association of school feeding programs with the nutritional status of school-age children in the study
area.

Objectives: The study aimed to determine the magnitudes and associated factors of undernutrition
among school-age children with school feeding programs (SFPs) and non-school feeding programs (N-
SFPs) in Kindo Didaye woreda, South Ethiopia.

Methods: A school-based comparative cross-sectional study was conducted in Kindo Didaye district from
May to June 2023. A total of 612 participants were included in the study. The data were collected from
each selected student's parents by using a structured interviewer-administered questionnaire. The
weight and height of the children were measured, and a household dietary diversity assessment was
conducted. The data were analyzed using SPSS version 25. A binary logistic regression analysis was
carried out. A p-value of <0.05 and 95% confidence interval (CI) were used to establish a statistically
significant association.

Results: The magnitude of undernutrition among the school-age children was 38.9%: 43.3% in the
children from the SFP schools and 34.5% in the children from the N-SFP schools. Stunting was 24.1%
among the children in the schools with SFPs and 16% among the children in the N-SFP schools, whereas
thinness was 33.8% among the children in the SFP schools and 25.6% among the children in the N-SFP
schools. The children who were in the older age group [adjusted odds ratio (AOR) = 4.4, 95%CI; 2.22–
8.85], consumed less than three meals per day at home (AOR = 6.03; 95%CI 3.9–9.3), and did not eat
breakfast at all before going to school (AOR = 3.5; 95%CI 1.15–10.76) were more likely to become
undernourished. The children whose fathers received secondary and above education (AOR = 0.52; 95%
CI (0.27–0.971) had lower odds of becoming underweight.

Conclusion: The magnitude of undernutrition was high in the current study. Existing interventions that
work to improve the nutritional status of school-age children should be strengthened. Children should
consume any type of food as breakfast at home before going to school regardless of the presence of
school feeding programs and at least three times a day.

Introduction

Undernutrition results from inadequate intake of energy, protein, and micronutrients. It can also be
caused by poor absorption or quick loss of nutrients owing to disease or excessive energy use. It is
characterized by low birth weight, stunting, wasting, underweight, and micronutrient deficiencies (1, 2).
School age is characterized by dynamic physical growth, mental development, and a high vulnerability
stage (3). For a child who is severely malnourished, attending school is less crucial than getting enough
food to eat. Children are more likely to participate in school if they are guaranteed at least one healthy
meal daily. Human development progresses quickly when nutritional needs increase and dietary habits
are established. To prepare for the body's rapid growth during adolescence, it is also the ideal time to
increase nutrient storage. Being well-nourished during school age is essential because poor nutrition
during childhood can cause malnutrition, growth impairment, decreased work ability, and poor mental
and social development (4, 5).

Nutritional deficiencies in school-age children are a public health concern, especially in resource-limited
countries. Stunting and thinness, which have severe consequences for survival and health and the
development of school-age children, most commonly affect children in low- and middle-income
countries. Approximately 52.0% of school-age children in such countries are stunted (5, 6).

According to the Global Education Monitoring Report, more than a quarter of children under the age of
15 living in Sub-Saharan Africa (SSA) were thin. The global prevalence of malnutrition among school-age
children (5–15 years old), as indicated by the prevalence of stunting, was approximately 28% (171
million children), with Eastern Africa experiencing a higher rate of 45 % (7, 8).

Malnutrition among school-age children in developing nations, especially in Africa, has been linked with
morbidity, hygienic practices, dietary intake, and family socioeconomic status (9–11). It is a major public
health problem (12, 13). It is evident that a significant percentage of school-age children experience
undernutrition and that there was no nutrition intervention for addressing the problem among school-
age children in Ethiopia until 1994 (9). Different strategies, programs, policies, and interventions were
adopted at international and national levels to minimize the burdens of children's nutritional status (8).

School feeding is the provision of food either on-site or to take home. In middle- and low-income
countries, school feeding programs (SFPs) have two different branches of aims. In the short term, it aims
to alleviate hunger, exists as a social safety net for households with very low income, increases
enrolment, promotes regular attendance to improve overall performance, and reduces temporary
hunger in schools (2, 14). In the long term, it aims to improve the nutritional status, attendance,
cognitive development, and retention of school children (15). School-feeding programs (SFPs) have been
continuously gaining popularity in developing countries, mainly among those that are severely affected
by childhood hunger and malnourishment. Currently, SFPs exist in 70 of the 108 low-income and middle-
income countries, and most of them have been initiated and funded by the World Food Programme.

In Ethiopia, a World Food Programme-sponsored school feeding program was started in 1994, with an
initial pilot project in the war-affected zones in the Tigray region. Presently, the Ethiopian SFP provides
school meals for students in six regions of the country (Afar, Amhara, Oromia, Somali, Tigray, and the
Southern Nations, Nationalities, and Peoples' Region). In the country, the target areas for implementing
SFPs were woreda (the third-level administrative divisions in the country), with chronic food insecurity,
lower school enrolment, and higher gender disparity (14, 16). However, there is no sufficient evidence
on the effect of school feeding programs on the nutritional status of school children and its associated
factors, especially in Ethiopia, particularly in the study area. Therefore, this study aimed to assess the
magnitudes and associated factors of undernutrition among school-age children enrolled in schools with
school feeding programs and non-school feeding programs (N-SFP) in Kindo Didaye district, South
Ethiopia.

Methods

Study area and period

Kindo Didaye district is one of the 16 districts in Wolaita Zone, South Ethiopia. The district is located 86
km from Wolaita Sodo city, the zonal administration center, and 475 km from Addis Ababa, the capital
city of Ethiopia. The district has 19 kebeles (smallest administrative unit), where 17 are rural and two are
urban kebeles, with an estimated total population of 96,120. The district has a total area of 38,045.7
hectares (17). The inhabitants of the district are primarily dependent on agriculture, and the typical
meals in the district include kocho, which is manufactured from fake bananas (Ensete ventricosum), kita
(primarily maize), cassavas, roots, and cereals. Teff, wheat, cassava, barley, and maize are popular crops
typically grown between May and July and harvested between September and November (17). The
school feeding program has been placed in 8 of the 28 primary schools in the woreda since 2020/21Gc.
The total number of primary school children is 20,074; among those, 10,541 are male students and
9,533 are female students (17). The study was conducted from 1st May to 20th June 2023.
Study design

A school-based comparative cross-sectional study design was employed.

Sample population

All school-aged children in all primary schools of the woreda were the source population, all school-age
children in the selected primary schools both with SFPs and N-SFPs of the woreda were the study
population, and the selected school-age students (5–15 years) in the selected primary schools both with
SFPs and with N-SFPs were the sample population.

Inclusion criteria and exclusion criteria

Inclusion criteria

Students aged between 5 and 15 years who attended school during the data collection in the schools
with and without school feeding programs were included in this study.

Exclusion criteria

Severely ill children who could not be involved in the data collection due to an illness were excluded
during the data collection period.

Sample size determination and sampling technique

The sample size was calculated using G-power software. The required sample size of the study was
calculated after comparing the prevalence of stunting, thinness, and the proportion of strongly
associated factors such as sex, monthly income, and having a farmland; the proportion that resulted in
the maximum sample size was selected. The proportion of stunting was 58.5% among the students who
did not take meals at school and 48.3% among the students who took meals at school from a study
conducted in the Meket district (18). In addition, the sample size was calculated by considering the
following assumptions: 95% confidence interval (CI) and 80% power, a margin of error of 5%, a
population allocation ratio of 1:2, a design effect of 1.5, and a 10% non-response rate. The final sample
size calculated was 616.

Sampling technique

In Kindo Didaye district, there are 28 primary schools. First, the schools in the woreda are stratified as
those implementing SFPs (eight in number) and those not implementing SFPs (20 in number). Then,
three from the SFP schools and six from the N-SFP schools, with a ratio of 1:2, were selected using a
simple random sampling method. The calculated sample size was proportionally allocated to the
selected schools based on the proportion to the size of the students from each school. The students who
fulfilled the inclusion criteria were screened by the school administrators before the selection for the
study. Then, the screened school-age students were coded with their grades and sections. Finally, using
the student list as a sampling frame, the students were selected by the simple random sampling
technique frStudy variables

The outcome variable was undernutrition, and the exposure variables included socio-demographic and
economic variables, health status, individual dietary intake, and sanitation and hygiene conditions.

Data collection tools and measurements

The questionnaire was adapted after reviewing related previous literature (11, 14, 18–22). The data
were collected using a structured interviewer-administered questionnaire via Kobo Collect software
2023.1.2 a. A part of the dietary diversity score (DDS) questionnaire was adapted from the Food and
Agriculture Organization of the United Nations and other related literature (11, 23, 24). The children's
dietary diversity was assessed according to their mothers' or caregivers' responses regarding whether
the children had eaten different food groups from yesterday's sunrise to today's sunrise (24-h recall
method) before the survey date. A child with a DDS of four and above was classified as having good
dietary diversity; other scores were classified as poor. Consuming food groups within the range of 1–3
suggests lowest dietary diversity, consuming food groups within the range of 4–5 suggests medium
dietary diversity, and consuming food groups within the range of 5–7 suggests high dietary diversity
(25).

The weight and height of the students were measured using a weighing scale and stadiometer,
respectively. A portable digital flat Seca scale (Seca electronic scale, 770 Hamburg) and a Seca body
meter (Seca 274 body meter) were used to measure the weight and height, respectively. During the
weight measurement, the weighing scales were calibrated each day before the actual data collection
using a known weight material. The weight was measured to the nearest 0.1 kg using a digital scale. The
scale was adjusted before weighing every student by setting it to zero. The students were lightly dressed
while having the weight taken. The height was measured to the nearest 0.1 cm. While measuring the
height, each student stood in a normal anatomical position without the shoes, heels, buttocks, shoulder,
and back of the head touching the measuring board. Then, the headpiece of the measuring board was
moved to touch the top of the head. For both weight and height, two readings were recorded. The z-
score values for body mass index (BMI)-for-age and height-for-age were calculated using the WHO
AnthroPlus software. The calculated z-scores of the BMI-for-age and height-for-age were used to classify
thinness and stunting using the new WHO 2007 reference values.

Operational definition

Undernutrition

This composite outcome or dependent variable was generated by summing up the variables stunting
and thinness. It is defined as having stunting, thinness, or both.
Stunting (Chronic malnutrition)

It refers to height-for-age z-score (HAZ) < −2 SD of the median value of the WHO AnthroPlus, 2007,
international growth reference (26).

Thinness (Acute malnutrition)

It refers to BMI-for-age z-score (BAZ) < −2 SD of the median value of the WHO AnthroPlus, 2007,
international growth reference (26).

Minimum dietary diversity score

It included the proportion of the school-aged children who received foods from four or more food
groups of the seven food groups over 24 h before the survey. Consuming food groups within the range
of 1–3 suggests lowest dietary diversity, consuming food groups within the range of 4–5 suggests
medium dietary diversity, and consuming food groups within the range of 5–7 suggests high dietary
diversity (25).

School age

The school age comprised 5–15 years (27).

Absenteeism rate

This was determined as the number of days a child was absent from school in the last 2 weeks of the
survey.

Data quality management

The English version of the structured questionnaire was translated into the local language, Wolaitta
Doonaa, and back to English by a language expert for ensuring the consistency of the questions. The
pretest (5%) was conducted at Bele Awasa and Dinsa primary schools in Kindo Koysha district. To ensure
the accuracy and precision of the measurements, the data collectors were trained for 2 days on how to
administer the questionnaire, use Kobo Collector version 2023.1.2, and conduct anthropometry in a
standardized manner. The weighing scale calibration with a standard weight was performed daily during
the data collection. Each day after the data collection, the questionnaires were reviewed to ensure the
completeness of the data.

Data analysis
The data were exported to Excel from the KoboCollect tool and then to SPSS version 25 software for
analysis. Descriptive statistics such as frequency, proportion, measures of central tendency, and
measures of dispersion were computed. A logistic regression model was carried out for both bivariable
and multivariable analysis for identifying factors associated with undernutrition. A p-value ≤ 0.25 was
taken as the cut-off point for selecting variables for the final model. An adjusted odds ratio (AOR) with
its respective 95% CI was used to establish a statistically significant association at a p-value < 0.05. After
checking for multicollinearity by using a variance inflation factor, a variance inflation factor of < 10 was
considered the minimum threshold for collinearity. The model fitness was checked using the Hosmer
and Lemeshow model fitness.

Ethical considerations

Ethical clearance was obtained from the Institutional Review Committee of Wolaita Sodo University,
with an ethical review number of CHSM/ERC/01/15, and a permission letter was obtained from the
Kindo Didaye district education office for the data collection. From the participants involved, verbal
informed consent and assent were taken; the right to not participate was respected, and the obtained
information was confidential.

Results

Participants' socio-demographic and socioeconomic characteristics

A total of 612 school children were involved in the study, which made the response rate 99%. Of the 305
students from the schools with SFPs, 188 (53.1%) were male and 117 (46.9%) were female. Of 307
participants from the schools with N-SFPs, 163 (61.6%) were male and 144 (38.4%) were female. The
median age of the school children was 12, with an interquartile range of 3 years. The majority of the
school children, both male and female, were in the 10–15 age category, 248 (80.8%) and 280 (91.8%),
respectively (Table 1).

Table 1om each selected school (Figure 1).

Dietary history of the participants

All students enrolled in the schools with SFPs ate once in school, and each student got 150 g of a meal
prepared from wheat, nifro, kimchi, rice, pasta, and macaroni once a day from Monday to Friday. The
majority of the school children on the school feeding program were found to eat < 2 times at home in a
day, while those in the schools without a school feeding program were found to eat comparatively less.
The majority, 188 (61.2), of the children from the schools without a school feeding program were found
to take their breakfast at home every morning before going to school, while nearly a third, 111 (36.3%),
of the children from the schools with a school feeding program were found to go to school without
eating breakfast (Table 2).

According to the 24-h dietary recall, the number of food groups eaten within 24 h before the survey by
the majority of the students from the schools with a school feeding program was < 3, approximately 228
(74.8%), while nearly half of the children from the non-school feeding program schools ate more than
three food groups within 24 h (Figure 2). The dietary intake of the school children mainly consisted of
cereals, pulses, legumes, nuts, roots, tubers, other fruits, and vegetables compared to animal source
foods and green leafy vegetables. In the study, the students from both the schools with SFPs and the
non-school feeding program schools were less likely to consume food groups such as meats, eggs, and
vitamin A-rich fruits and vegetables.

Participants' incidence of ill health

The number of children who had fallen sick within 2 weeks before the data collection, as reported by the
caregivers, was 89 (29.2%) from the schools with school feeding programs and 70 (28.2 %) from the non-
school feeding program schools. Fifty-one (16.7%) children from the schools with SFPs and 28 (9.1%)
children from the non-SFP schools had diarrhea 2 weeks before the data collection. Following episodes
of malaria 2 weeks preceding the survey, the parents of 46 (15.1%) children in the schools with a school
feeding program and of 34 (11.1 %) children in the N-SFP schools reported that their children had fever
(Table 3). Malaria and other infections present symptoms such as fever. Malaria being endemic in these
communities could be the reason why both groups mentioned fever as the primary ailment in their
children.

Nutritional status of the school-age children

The overall prevalence of undernutrition was observed in 238 (38.9%) children in total, 132 (43.3%)
among the children in the schools with an SFP and 106 (34.5%) among the children in N-SFP schools. The
magnitude of thinness was observed in 33.8% of the children in the schools with an SFP and in 25.6% of
the children in the N-SFP schools. In addition, the prevalence of stunting was observed in 24.1% of the
children in the schools with an SFP and in 16.0% of the children in the N-SFP schools (Figure 3).

Factors associated with undernutrition in both SFP and N-SFP schools

In the multivariable logistic regression model, the age of the child, the father's educational status, eating
breakfast before going to school, and the frequency of meals were significantly associated with
undernutrition. The children in the older age group (10–15 years) were 4.4 (AOR = 4.4, 95% CI: 2.22,
8.85) times more likely to be undernourished than the children in the younger age group. In addition,
the odds of undernutrition among the children whose fathers received secondary education and above
was 48% (AOR = 0.52, 95% CI: 0.27, 0.97), which was lower compared to the children whose fathers did
not receive formal education. In addition, the children who never ate breakfast before going to school
were 3.5 (AOR = 3.5, 95% CI: 1.15, 10.76) times more likely to be undernourished than those who always
ate breakfast before school. The odds of undernutrition were six (AOR = 6.0, 95% CI: 3.91, 9.32) times
higher among the children who consumed two or fewer meals a day than the children who consumed
more than two meals a day (Table 5).

Discussion

This study attempted to determine the prevalence of undernutrition and identify its associated factors.
The results of the current study showed that the overall prevalence of undernutrition was 38.9%, 43.3%
and 34.5% among the children in the SFP group and the N-SFP group, respectively. The study findings
also revealed that the children from the older age group (10–15 years), the children whose fathers
received secondary education and above, the children who never ate breakfast before school, and the
children who consumed two or fewer meals a day were statistically significantly associated with
undernutrition.

In this study, the overall prevalence of undernutrition was 38.9%. Undernutrition was higher (43.3%)
among the children in the SFP schools as compared to the children in the N-SFP schools (34.5%). The
magnitude was higher than the findings reported by studies conducted in Addis Ababa (31%), Durbete
town (32.1%), and Ethiopia (12, 28). This finding was lower than the prevalence reported in Northwest
Ethiopia, which was 41.6% and 71.98%, respectively (29, 30). The magnitude of thinness in the current
study was 33.8% and 25.6% in the schools with SFP and in the N-SFP schools, respectively, whereas
stunting was 24.1% and 16% in the schools with SFP and in the N-SFP schools, respectively. This result
was higher than that of a study conducted in Southern Ethiopia, which revealed that the prevalence of
thinness was 14.3% and 19.5% and that of stunting was 21.1% and 20.4% in SFP and N-SFP schools,
respectively (31). The prevalence of stunting and thinness in Ethiopia's Dubti district in the Afar region
was also lower than the results of the current study. In the abovementioned study, the prevalence of
stunting in the SFP and N-SFP schools was 13.7% and 21.6%, respectively, and the prevalence of thinness
was 4.9% in SFP schools and 13.9% in N-SFP schools (32). Similarly, a study in Kenya found that the
prevalence of thinness was 12% in SFP schools and 11% in N-SFP schools, whereas the prevalence of
stunting was 12% in SFP schools and 22% in N-SFP schools (9). In addition, the prevalence of thinness in
this study was higher than that in the study demonstrated by Mohammed et al., which was 23.2% and
22.71% in SFP and N-SFP schools, respectively. However, the prevalence of stunting was lower than that
in the same study, 31.5% and 26.3%, among the children in the SFP and N-SFP schools, respectively (11).
These differences may be due to differences in the sample size, study setting, and study purposes.

In this study, it was found that there was no statistically significant association between school feeding
programs and undernutrition. This finding was in line with other studies conducted in Southern Ethiopia
(31) and Ghana (33), which showed that school feeding programs had no association with the nutritional
status of children. Contrary to this, a study in Kenya (9) showed that school feeding programs had a
negative association with the nutritional status of children. However, the result contrasted with studies
conducted in different parts of Ethiopia (14, 18, 20, 32, 34), Kenya (35), Jamaica (36), and Ghana (21).
The possible explanation for this discrepancy could be variations in the duration of intervention,
availability of the required resources in schools, and the quality and quantity of foods served to children.
Reports showed that in developing countries, school feeding programs were facing different challenges
related to the quality and quantity of meals given to children (15, 37–39).

Furthermore, evidence from studies showed that SFPs have led to children being fed less at home. This
is because some parents use the SFP as a replacement for feeding at home, even though it is meant to
complement the child's diet along with home feeding (40). In addition, school feeding programs are
implemented in selected schools located in areas where there is food insecurity (40).
The current study revealed that being in the older age group was positively associated with
undernutrition. The odds of undernutrition were 4.4 times higher among the children aged between 10
and 15 years compared to the children aged 5 to 9 years. A similar finding was reported by a study
conducted in different parts of Ethiopia (11, 16, 29, 34, 41–43). This might be due to experiencing a
prolonged chronic food shortage. The consequence of undernutrition is a chronic nutritional problem,
which develops over a relatively long period and is difficult to reverse once developed.

According to this study, the odds of undernutrition among the school children whose fathers received
secondary education were 48% lower compared to the children whose fathers did not receive formal
education. This finding was also similar to the findings from other studies conducted in South Ethiopia
(42), Assam (44), Nepal (45), and India (6). This might be because literate parents adopt many improved
behaviors related to maternal and child healthcare, feeding, and eating practices, which ultimately affect
the nutritional status of children.

The odds of undernutrition among the children who never ate breakfast before school were 3.5 times
those of undernutrition among the children who ate breakfast regularly before school. This was similar
to previous studies in South Gondar Zone, Ethiopia (22), Kenya (3), and Nigeria (46). This could be
because eating breakfast is crucial for getting enough nutrients and energy to prevent acute and chronic
malnutrition in school-age children.

The frequency of meals that children take at home is another factor independently associated with
undernutrition. The odds of undernutrition were six times higher among the children who ate < 3 meals
a day compared to those who ate three or more meals a day. Previous studies in Meket Wereda,
Ethiopia (18) in East Demibra district, Northwest Ethiopia (47), Nairobi, Kenya (3), and in Aladinma
Owerri, Nigeria (46) showed similar results. This might be because those who eat < 3 times a day cannot
meet the nutrient requirements.

This study used cross-sectional data, and the estimates might have been better represented if
longitudinal follow-up data were used. Moreover, the school feeding intervention was not randomized;
rather, schools were selected for the intervention based on the food insecurity and socioeconomic
status of the area. Therefore, it is difficult to conclude that the school-feeding programs contributed to
the higher undernutrition level. A certain level of recall bias is expected regarding the age and dietary
intake. Interviewers who were aware of cultural issues collected the data to reduce recall bias.

Conclusion

This study showed that the overall magnitude of undernutrition in the study area is high. Existing
interventions that work to improve the nutritional status of school-age children should be strengthened.
Children should consume any type of food as breakfast at home before going to school regardless of the
presence of a school feeding program, and children should at least consume meals three times a day.
We also recommend conducting longitudinal studies to explore further the effect of school feeding
programs on the nutritional status of school-age children.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material,
further inquiries can be directed to the corresponding author.

Author contributions

DM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software,

Visualization, Writing – original draft. TA: Data curation, Methodology, Writing – original draft,
Visualization, Conceptualization, Writing – review & editing, Validation, Investigation, Supervision. TB:
Validation, Data curation, Conceptualization, Visualization, Writing – original draft. MK:
Conceptualization, Writing – review & editing, Validation, Methodology, Supervision, Software,
Visualization, Data curation. SD: Conceptualization, Writing – review & editing, Investigation,
Visualization, Supervision, Methodology, Data curation.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or
publication of this article.

Acknowledgments

We would like to forward our gratitude to the College of Health Sciences and Medicine, Wolaita Sodo
University. We also would like to thank the participants, data collectors, school principals, and data
collection supervisors.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of interest.

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