Journal of Pregnancy and Child Health
Open Access

Stunting; Height for age; First cycle; Primary school; Children and Asella

Linear growth failure in childhood is the most prevalent form of mal nutrition globally. The estimated global prevalence of malnutrition among school-aged children as indicated by the prevalence of stunting, is around 28.7% (171 million children), with a HAZ score less than two standard deviations below the population median. Stunting is acknowledged as the best indicator for child growth that indicates chronic under nutrition [1].

Hunger and malnutrition among children in developing countries including Ethiopia continue to impair health, quality of life and survival. Under nutiriton contributes to 53% of the 9.7 million deaths of children under five each year in developing countries. It is estimated that a child dies every six seconds from hunger related causes and one out of four children in developing countries are underweight. Every child whose physical and mental development is stunted by hunger and mal-nutrition stands to lose 5 to 10 percent in lifetime earnings.

Child stunting is a result of long-term chronic consumption of a low-quality diet in combination with infectious diseases and environmental problems [2].

Poor health and malnutrition are important underlying factors for low school enrollment, absenteeism, poor classroom result and early school dropout, as reflected in the world declaration on education for all. Stunted children do not get their full growth potential and become stunted adolescents and adults. The functional consequences of stunting continue in adulthood, with reduced work capacity and in women, increased risk of mortality during childbirth and adverse birth outcomes [3].

In developing countries, an estimated 99 million children of primary-school age are not enrolled and from enrolled, only 78% complete primary school. Most children who fail to complete are from sub-Saharan Africa and south Asia. Only around half of the children enroll in secondary schools [4]. Furthermore, children in some developing countries have much lower achievement levels than children in developed countries in the same grade. School-age children are particularly vulnerable to under nutrition as the priority in nutrition interventions is often to prevent malnutrition during fetal development and the first years of life; the most critical period for growth and development [5].

Stunting is widely believed to occur mainly in early childhood (mostly by three years of age) and through a cumulative process. Stunted children at school-age are most likely to have been exposed to under nutrition since early childhood and that the degree of stunting tends to increase throughout the school-age years. However, children can exhibit catch-up growth if their environment improves. This suggests that interventions in school-age children can supplement efforts in the preschool years to reduce levels of stunting and related effects on children’s health and education [6,7]. Early childhood care programs and primary schools which improve children’s health and nutrition can increase the learning and educational outcomes of school children. Education of good quality can lead to better health and nutrition outcomes for children, especially girls and thus for the next generation of children as well [8].

Assessment of growth in children not only serves as one of the best global indicators of children’s nutritional status but also provides an indirect measurement of quality of life of an entire population. Improving the nutrition of women and children will contribute to overcoming some of the big health challenges facing the world, including the burden of chronic and degenerative disease and maternal mortality [9,10].

According to the growth and assessment surveillance unit of the World Health Organization (WHO) 2010, the global prevalence of malnutrition among school-aged children, as indicated by the prevalence of stunting, is 28.7%. Asia is the most affected region for all three indicators. Based on the estimates, the risk of being mal nourished as measured by being underweight is 1.2 times higher in Asia than in Africa and 3 times higher in Africa than in Latin America [11]. Currently, over two-thirds (76%) of the world’s malnourished children live in Asia especially South-central Asia while 21% are found in Africa and 3% in Latin America. Eastern Africa suffering a higher rate of stunting which is 45%.

Stunting has continued to be one of the most important public health problems in Ethiopia. In recent years Ethiopia has only had limited success in reducing the prevalence of stunting with annual reduction of 1.3% over the past eleven years from 51% in 2005 to 44% in 2011. In the trend in the reduction of child under nutrition between 2000 and 2016, the prevalence of stunting has decreased considerably from 58% in 2000 to 38% in 2016, an average decline of more than 1 percentage per year [12].

In Ethiopia, previous studies show that there are a big regional variations in prevalence of stunting among schoolchildren which ranges from 4.5% to 57%, indicating that mal nutrition is a public health problem. In addition, maternal size is also associated with specific reproductive outcomes. Short women, are at greater risk for obstetric complications because of smaller pelvic size. There is also a strong association between maternal height and birth weight which is independent of maternal body mass [13]. In a study conducted in 10 countries in sub-Saharan Africa, male children are consistently more likely to become stunted than female children. There is also an intergenerational effect. About 200 million children under 5 years of age fail to reach their potential in cognitive development because of a combination of risk factors such as poverty, poor health and nutrition and inadequate caring practice. These conditions play an important part in the intergenerational transmission of poverty [14]. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and for survivors of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. In a study conducted in 2011, it is estimated that undernutrition in the aggregate including fetal growth restriction, stunting, wasting and deficiencies of vitamin A and zinc along with suboptimum breast feeding is a cause of 3.1 million child deaths per year [15].

Study area

The study was conducted at ten selected schools in Asella town, Tiyo Woreda, Arsi zone, Oromia regional state, South east Ethiopia. In Asella, there are 30 primary schools: 21 and 9 private and government schools respectively. There are about 15,427 students in both schools [16].

Study design and period

School based cross-sectional quantitative study design was conducted among school children in total sample size of 762 in Asella town, Oromiya regional state from Sep 13 to Sep 30 2018.

Source and study population

Source population: All schools children attending first cycle (grades 1-4) schools located in Asella town.

Study population: Selected students attending the frist cycle (grades 1-4) from ramdomly selected schools and parents or care givers of the students.

Inclusion criteria

Children of age group of grade 1-4 student. All those who were present on the day of data collection.

Exclusion criteria

School children who were unable to stand by themselves by physical deformities of limbs and spines were excluded because of difficulty in height measurement [17].

Sampling procedure

A multi stage random sampling technique was obtained to select schools and study participants. There are 30 primary schools in the Asella town. These primary schools were initially stratified into government schools and private schools. Then ten primary school were selected from both schools (three from government and seven from private schools). They were proportionally selected using lottery method. And the sample size was proportionally allocated for the ten randomly selected schools. Taking the grades attended in to consideration, 150 from Hamile, 256 from Andinet, 48 from Halela, 64 from Alem, 22 from Feleg Hiwot, 31 from Rohbot and 23 from Senaf, 89 from Ayelch Degife, 44 from Engida and 36 from Numan samples were taken [18].

The sampling frame was prepared from the student roster in each grade and students were selected from each grade by systematic sampling method proportional to the student size. The calculated sample size was 762. Therefore, sample was calculated as: By which 454 students are from government schools and 308 students are from private schools. After reaching this, students were selected by proportional allocation according to their class years and gender [19]. Then the parents accompanied their children to provide socio demographic data and parental involvememt in the children schools (Figure 1).

Figure 1: Schematic sampling procedure among first cycle schools children in Asella town, Ethiopia.

Variables of the study

Dependant variable stunting (Height for age Z score<-2).

Independent variables: Socio economic and demographic factors age of child, gender of child, birth order of the child, mother’s ethnicity, mother’s religion, marital status of the parent, mother’s education status, mother’s occupational status, father’s education status, father’s occupational status, household monthly income and house hold family size:

Environmental factors: Source of drinking water, latrine facility availability.

Dietary factors: Frequency of feeding per day, consumption of animal source, consumption of vitamin A. rich foods (fruit and vegetables) per week, breast-feeding, time for initiation of breastfeeding, duration of breastfeeding and type and duration complementary foods.

Health care factors: Child’s weight and size at birth, child’s immunization status, child morbidity, mother’s antenatal care visit, mother’s place of delivery.

Data quality assurance

Data were collected using a five percent pretest. A semi-structured questionnaire was done through face-to-face interviews translated into the local language (Afan Oromo) and (Amharic). In addition, for data collectors and supervisors, training was given for three days before data collection. During the training, the objective of the study, data collection procedures and techniques aided by video including how to conduct anthropometric measurements were discussed in detail. During the training, practical exercise of data collection was done through peer interviews and anthropometric measurement was conducted. The questionnaire was pretested for accuracy and reliability among 38 students of the same age at a nearby school that was not selected for the real study. The questionnaire was modified accordingly [20].

A supervisor were supervised the data collectors and submitted the filled questionnaire to the researcher who rechecked for the maintenance of the quality data. The researcher made a close supervision to data collectors and supervisors. In addition regular communications were conducted with data collectors to discuss challenges and give timely solutions on challenges.

Data processing and analysis

The data was checked manually, coded and entered in to Epi Info 7, clean and data analysis was using SPSS for Windows software (version 21). WHO Anthroplus software was used to calculate means and standard deviations of HAZ. The resulting indices were used to determine the levels of malnutrition. Stunting was defined as HAZ less, than two of the mean Standard Deviation (SD), the mean of moderate stunting as HAZ less than -2 SD and severely stunting as HAZ less than-3 SD reference population media. After collection, all data were compiled, analyzed and appropriate statistical tests were applied, P<0.05 was considered as statistically significant. The proportions were calculated for categorical variables and the prevalence of stunting among school children was done by descriptive statics.

In addition, binary logistic regression analyses were carried out, using the Odds Ratio (OR) to determine the strength of predictors toward stunting and between various socio-demographic characteristics to identify potential risk factor stunting. A multivariable logistic regression model was employed to ascertain any significant association between independent variables and dependent variables. For statistical analysis, 95% confidence interval and adjusted odd ratio were checked and the significance variables were taken as associated factors of stunting.

From a total of 762-sample size, 715 primary school students participated in this study with an overall response rate of 93.8%.

Almost six out of ten respondents 410 (57.3%) belong to the age groups of 5-9 years, few 42 (5.9%) were among the age group 13-14 years. The mean age was 9.2336+SD 1.9089. Almost half of the participants 363 (50.8%) were females. About 396 (55.4%) of the respondents were orthodox christians. More than half, 385 (53.8%) of students belong to Oromo ethnic groups, while nine (1.3%) were Tigray.

Regarding educational status of student’s parents, 309 (43.2%) of students fathers have completed college and above, on the other hand 22 (3.2%) did not attended formal education. Nearly four out of ten of students mothers 277 (38.7%) have completed primary schools; only 56 (7.8%) did able to attend formal education. The employment status of students parents were 309 (43.2%) and 265 (37.1) governmental employees and housewives respectively. Whereas, their marital status is as follows: 633 (88.5%) were married and 25 (3.5) widowed. The average monthly income of students parents, 287 (40.1%), between 1000-3000 ETB; only 89 (12.4%) were 5000 and above ETB. The average family size in this study finding revealed that eight out of ten respondents, 578 (80.8) were 4-6 in number: While 66 (9.2%) were seven and above, the remaining (9.9%) being in 1-3 family number (Table 1).

Table 1: Socio demographic and other selected characteristics of first-cycle primary school children in Asella town Oromia, regional state Ethiopia, 2018.

Environmental factors

From respondents who participated in this study almost all 706 (98.7%) of the households use pipe water as a main source of drinking water. In this study, more than nine out of ten students families, 688 (96.2%) find functional latrine in their compound. Of this majority of household’s latrine, 501 (70.1%) are traditional pit latrines: However, only 66 (9.2%) have ventilated improved pit latrines (Table 2).

Table 2: Environmental factors of first-cycle primary school children in Asella town Oromia, regional state Ethiopia, 2018.

Maternal and child health care factors

More than half of students mothers, 434 (60.7%) did not complete antenatal care ANC4. Moreover, 242 (33.8%) of students mothers have completed ANC4, of while, 39 (5.5%) have never followed up ANC. Among all students mothers, 66 (9.2%) delivered their child at home and 463 (64.8%) did not attend postnatal care by health professionals. In this study, 452 (63.2%) of children had average birth weight (2.5 kg-4 kg). From the 715 children, 684 (95.7%) children were immunized and out of them 579 (81%) were fully immunized. Among children, 45 (6.3%) and 19 (2.7%) had diarrhea and fever respectively during two weeks of period prior to data collection (Table 3).

Table 3: Maternal and health care factors of first-cycle primary school children in Asella town Oromia, regional state Ethiopia, 2018.

Dietary factors

Breast-feeding is almost universal in the study area, children ever breast-fed were 696 (97.4%) of these, 322 (46.2%) children started breast-feeding within the first hour of birth. Nearly half of 342 (49.1%) the children were fed breast 1-2 years. Most respondents 463 (64.8%) started complementary feeding at the aged of 6 months. The finding of this study reveals that, 611 (85.5%) of parents offer Injera for their children. More than 95% of school children in this study consume animal products, 250 (35%) consume meat at least one times per week, on the other hand 116 (16.2%) never eat meat per week.

Dairy products, fruits and vegetables consumed by children in the current study area reveals that, 272 (38%), 78 (10.9%) and 298 (41.7%) of the respondents consume at least one times per day respectively. Of the total 715 children nearly half 351 (49.1%) eat four times per day but the rest 68 (9.8%) respondents eat less than three times per day (Table 4).

Table 4: Dietary factors of first-cycle primary school children in Asella town Oromia, regional state Ethiopia, 2018.

Prevalence of stunting

Among 715 first cycle primary students who participated in this study, 139 (19.4%) students were stunted. Children whose height-forage Z-score is below minus two standard deviations (-2 SD) from the median of the WHO reference population, with the corresponding 95% confidence interval (16.53287, 22.34825). Of this 75 (54%) were within the age group 5-9 years, 55 (39.5%) are between 10-12 years and only nine (6.5%) are between 13-14 years. From the 139 (19.4%) stunted children, 107 (15%) are moderately stunted and 32 (4.4%) are severely stunted. Therefore, the overall prevalence of stunting in this study is 19.4%.

Factors associated with stunting

In the binary logistic regression analysis, monthly income, mother's educational status, family size, duration of breast feeding, age when complementary food started and dairy products consumption like milk per week are found to be predictors of stunting at a P value of less than 0.25. Consequently, these variables were subjected to multiple logistic regression analysis by considering all the factors. Simultaneously, four of the most contributing factors remained to be significantly and independently associated with stunting (monthly income, family size, duration of breast feeding and dairy products consumption milk per week). Monthly income has statistically significant association with outcome variable. Children living in a family whose average monthly income is between 1000 and 3000 ETB have 2.11 times the risk of being stunted than children who live in a family earning equal to or above 5000 ETB, (AOR: 2.11, 95% CI (1.04, 4.25).

In these, study children who fed breast below six months and between one up to two years of duration of breast-feeding had statistically significant association with stunting.

Children who fed breast for less than six months are 3.51 times more likely to be stunted than above six month duration of breast feeding (AOR=3.51, 95% CI (1.669, 7.382). Also children who fed their mother’s breast in average for 1-2 years of duration is 2.113 more likely to be stunted as compared to two and above two years breast fed children (AOR=2.113, 95% CI (1.028, 4.342).

Yet again, children who never consume dairy products like milk per week are 3.50 more likely to be stunted than children who consume milk daily (AOR=3.04, 95% CI (1.697, 7.237). Furthermore, children who consume milk two times per week also are 1.743 times more likely to be stunted as compared to those consuming milk and dairy products daily or three times per week (AOR=1.743, 95% CI (1.085, 2.800).

Nutritional status of children is an important indicator of their health. The previous reports showed that high prevalence of stunting among school in different parts of Ethiopia. The finding of this study revealed that, the prevalence of stunting among first cycle schoolchildren 5-14 years living in Asella town is 19.4%. This is similar to the finding in Addis Ababa, which is 19.6% but it is higher when compared with Delo-mena district, south eastern Ethiopia which was 4.5%, Kersa, Eastern Ethiopia, 8.9%, Adama 12.6% and Haik town, south Wollo zone, North-eastern Ethiopia, 11.3%.

The prevalence of stunting is lower in Sudan 7.1% and in South west Nigeria around 17.4% compared to our study area. This variation might be due to the difference in geography, traditions, costumes, agro-ecological factors, economical differences of each study area, types of agricultural product, knowledge on feeding practice. However, the prevalence of stunting was lower in comparison with Fogera district Northwest Ethiopia 30.7%, Debre Markos town and Gozamen Woreda, east Gojjam zone, Amhara regional state, Ethiopia, 48.1%, Humbo district, southern Ethiopia, 57% and the latest national survey of the health and nutrition of school children Ethiopia is 22.3%. Prevalence of stunting were higher in different countries, like Bangladesh 60%, Indonesia 38.87% and Egypt 34.2%. This difference might be due to increment of food prices, inappropriate infant and young child feeding practices, child health care, socioeconomic and cultural differences rather than differences in their genetic potential to achieve maximum height.

Stunting is an indicator of chronic malnutrition and it reflects the cumulative effect of under nutrition, socioeconomic factors and recurrent infections. For these reasons, wide variations in the prevalence of stunting have been observed in different countries. In our study area, we found that stunting were significantly associated with age (5-9 years) but not with gender.

Bivariate test results showed that stunting had a close relationship with the monthly income of households. Children whose household’s monthly income is between 1000-3000 ETB were 2.11 times more likely to be stunted compared to those household’s monthly income is 5000 and above ETB (AOR: 2.11,95% CI (1.04, 4.25). This is similar to the study done in Mieso Woreda, Somali region and Ethiopia. The results of these studies are also similar with a study done in Indonesia which showed (AOR 3.6, 95% CI. Where household income was positively associated with height for age z-score.

In addition to income, stunting is also closely related to the number of family members (p<0.005). In this study, children belonged to households with large family size (of seven and above family members) were 2.82 times more likely to be stunted than those who belonging to households with less than seven family members. This is related to the division of food among the family, the more the number of family the smaller food portion consumed by children. While most of them came from low income families. The results of this study, the prevalence of stunted children in Asella town, are in line with studies done by Oktarina that a close relationship between the number of family members and the prevalence of stunting.

Similar finding was documented in a study conducted in different regions of Ethiopia including Mieso, Woreda, Somali region, Ethiopia, Humbo district southern Ethiopia, Fogera district Northwest Ethiopia Amara regional state and Addis Ababa, Ethiopia. Study done in Bangladesh showed that family number 5-8 is strongly associated with stunting. This could be a marker of household poverty, supporting the fact that stunting is more of a social issue with roots in inequalities across the social strata in the society. A large number of household members could contribute to low levels of child care and dietary intake. There is also a risk of over crowding and its consequences like the spread of diseases, such as chronic respiratory infections and diarrhea, which are known causes of malnutrition.

This study found that, children who breastfed for less than 6 months were 3.51 times more likely to be stunted than those who breastfed for more than six months duration. Also, children who fed their mother’s breast in average for 1-2 years of duration were 2.11 times more likely to be stunted compared with those children who breastfed for 2 yrs and above years of duration. The finding is supported by a metaanalysis study conducted in Ethiopia. This could be explained by the fact that breast-feeding is the natural and perfect form of infant feeding for meeting a child’s nutritional needs during the first six months of life. This in turn implies that as the duration of exclusive breast feeding approaches to the recommended duration, there risk of chronic malnutrition.

Depending on the facts of the study, child stunting or chronic mal nutrition problem is observed in Asella town was 19.4%. There is significant relation seen between monthly income, family size, duration of breast-feeding and dairy products consumption per week with stunting. The finding of this study revealed that, children who never consumed dairy products like milk per week were 3.50 times more likely to be stunted than milk consumer children. Furthermore, children who consumed milk 2 times per week were 1.74 times more likely to be stunted as compared to those children who consumed milk and dairy products daily or three times per week. In a study conducted in Malaysian primary school, the effect of school milk programmers in 6-9-years-old children showed that there was a reduction in underweight, stunting and wasting after two years. A meta-analysis of 12 trials examining the association between dairy consummation and height showed that supplementation of approximately 245 ml on daily basis resulted in an additional 0.4 cm growth per year. Our current results also confirmed a positive association between dairy products consummation and growth.

Ethical approval and clearance was obtained from Arsi university health science collage/ethics committee. In addition, supportive letter was issued from Arsi university to Asella health bureau and for Asella educational office and was delivered to the respective responsible body for their cooperation. In addition, informed verbal consent was obtained from study participant mothers/care givers to confirm their willingness for participation after they reached agreement and understanding of the objective of the study. Informed oral and written consent was obtained from mother/care givers prior to participation in the study and data were kept confidential throughout the study by using coding instead of any personal identifiers and are meant only for the purpose of the study. The administrative staff and teachers were well informed about the scope and extent of the study.

We would like to express our deepest appreciation to Arsi university college of health sciences department of public health for giving the opportunity to conduct this research. We would also thanks data collectors and supervisor who devoted and committed by scarifying full of their time and capacity for the success of this research.

We all, the authors of this research article declared that we have no competing interest.

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