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

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.

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Introduction
Adolescence is defined as the age range from 10-19 years, and it is a period of transition from childhood to adulthood.The adolescent age group comprises 20% of the global population [1].Malnutrition, particularly undernutrition, is highly prevalent among adolescents in developing countries [2,3].A study from northern Ethiopia reported high levels of stunting (26.5%) and thinness (58.3%) among adolescents [4].Nutrition status among adolescents is an important determinant of health outcomes; undernutrition affects the health status of adolescent girls.In addition to causing significant mortality, it creates long lasting effects on the growth, development, and physical fitness of survivors [5].This, in turn, affects their ability to learn and work at maximal productivity [6].Undernutrition is an indicator of poor nutrition and has major consequences on human health as well as the social and economic development of the population [7].Physical growth and development during puberty increase requirements for energy, protein, and many vitamins and minerals, and deficiencies can lead to physiological, anatomical, and functional disturbances [8] The nutritional status of adolescent girls can have intergenerational effects because adolescent girls with poor nutritional status are more likely to give birth to low birth weight infants [8,9].Focus on adolescent girls is important because their health and nutritional status before as well as during pregnancy influences fetal growth and newborn health.Adolescent girls' health and undernutrition is an important determinant of adverse fetal outcomes, including low birth weight, preterm births, stillbirths, and an increased risk of neonatal mortality [10].Therefore, adequate nutrition is key; it is associated with a better quality of life and has many intergeneration benefits [11].
Most causes of malnutrition are related to poor care, poor economic status, and food insecurity; however, malnutrition can sometimes be inherited genetically [12].Family size, presence of malaria infections, cigarette smoking, alcohol and drug use, environmental pollution, and domestic violence are predictors of undernutrition [13].
In regions of South-East Asia and Africa, a large number of adolescent girls suffer from chronic undernutrition, which adversely impacts their own health and development, as well as that of their offspring, contributing to an intergenerational cycle of malnutrition [14].
Even though the sustainable development goals (SDGs) include an adolescent nutrition service which is addressing adolescent malnutrition, the nutritional status of adolescent girls is not improving [15].The government of Ethiopia officially launched the National Nutrition Program (NNP) in 2009, which aimed to reduce malnutrition in Ethiopia by integrating adolescents' nutrition into community-based health and development programs but faced many challenges.The Ethiopian NNP II (2016-2020) incorporated initiatives to improve the nutritional status of adolescent girls, but which interventions under which circumstances are effective remains unknown [16,17].However, most of these studies have included only adolescents attending school, and thus, the results of these studies cannot be generalized to the whole adolescent community.In addition to this, there are no community based studies conducted in Southern Ethiopia among adolescent girls.Therefore, understanding nutritional status and its associated factors are critical to timely address malnutrition in this age group.

Methods and Materials
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.

Sampling procedures
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 were selected from each district using a simple random method.A census of adolescent girls was conducted at these selected kebeles.This census was developed with the help of both the local government administration, woreda in particular, and health extension workers.During the development of the census, if there was more than one adolescent girl in a household, one adolescent girl was randomly selected.From the selected six kebeles, 843 participants were chosen depending on the number of adolescent girls in each kebele.Participants were drawn from each kebele based on probability proportional to size (PPS) sampling.The sampling techniques depended on the number of adolescent girls in each kebele.Adolescent girls who were not eligible for the study were excluded.

Anthropometric measurements
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.
Body mass index for age z-scores and height for age z-scores were calculated using the height, weight, and age of the participants.

Data collection
A structured interviewer-administered questionnaire was used to collect data.The questionnaire was developed based on a thorough review of the current literature.A total of eight nurses with BSc degrees; previous experience 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 MSc's in public health were employed to supervise the data collection process.Data was collected on weekends for adolescent girls who attended school during the weekdays.The principal investigator controlled the daily overall study activities.

Statistical analysis
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.

Data quality assurance
The questionnaire was prepared in English, translated to Amharic, and rendered back 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 investigators 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 and coefficient of variance (CV) were computed for all data collectors using ENA for SMART software.Data collators with unacceptable TEM and CV could repeat the steps again.

Ethical considerations
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 age < 18 years old and assent was obtained from the participant before the interview.Participants ≥ 18 years 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.

Socio-demographic characteristics of adolescent girls in Southern Ethiopia
Eight hundred and twenty adolescent girls participated with a response rate of 97.3%.
As shown in Table 1, the average age of the study participants was 14.6 (±1.9) years, the average family size was 6.56 (±1.83) persons, while 69.3% of the households had ≥ 5 family members and 30.7% had < 5 family members.About three fourths (70%) of the study participants were in grades 5-

Health and sanitation-related factors of adolescent girls in Southern Ethiopia
Table 3 describes the health and sanitation related conditions of the study participants.Of the total 820 subjects, 47% of the adolescent girls are living on the floors of houses that are made from mud, and 58.5% of the study participants are living with domestic animals in the same house.Similarly, 48.7% of the study participants are brushing their teeth once per day, 53.3% are washing their hands sometimes before eating their food, 41.7% are usually washing their hands before eating, 3.4% are not washing their hands at all, 90.1% are washing their hands after using the toilet, and 6.8% are not washing their hands at all after using the toilet.When washing their hands, 90.1% of the study participants are using soap and 9.9% are not using soap.Out of the total participants who are using soap when washing their hands, only 42% are usually using soap and 58% are sometime using soap.

Meal patterns of adolescent girls in Southern Ethiopia
As indicated, about 39.5% of the study participants are eating ≥ four times per day.This indicates 60.5% of the study participants are skipping regular meals.When considering the meals that participants are skipping, 27.6%, 1.8%, and 42% are skipping breakfast, lunch, and snack, respectively.Similarly, 41.6% of the study participants are eating smaller meals that do not satisfy their needs.Maize is the primary staple food for 40.6% of the study participants, and 38.8% consume both teff and maize as a staple food.Participants purchase food from the market (40.4%) or grow their own food (50.0%) (Table 4).

Nutritional status of adolescent girls in Southern Ethiopia
As shown in Table 5, 69.5% of the study participants have a normal body mass index i.e. body mass index for age z-score is between -2 and +1.From the total study participants, 19.5% are moderately thin as defined by a body mass index for age z-score between -2 and -3, 8% are severely thin as defined by a body mass index for age z-score < -3.Only 3% of the study participants are overweight.When we considered the stunting status of the study participants, 91.2% are normal as defined as a height for age z-score > -2, 7.8% are moderately stunted, and 1% are severely stunted.

Association between variables and nutritional status of adolescent girls in Southern Ethiopia
The present study shows an association between some variables with nutritional status, as defined by BMI for age z-score (BAZ), of the study participants.BAZ was statistically associated with age, family size, monthly household income, receiving deworming tablet(s), educational status of the participant's fathers, decision making power for nutrition service, skipping regular meals, source of food, and receiving home visits from health extension workers (Table 6).There is also an association between some variables with nutritional status, as defined by height for 235 age z-scores (HAZ), of the study participants.HAZ of the study participants was statistically 236 associated with decision making power for nutrition service, hand washing practice before eating and 237 after using the toilet, and visiting a community health extension worker (Table 7).
The decision-making power of the family also might affect the nutritional status of adolescent girls.
Decision-making for receiving nutrition services is under the control of 66.1% of the study participants' fathers.Similarly, 45.1% of the study participants did not receive a deworming tablet.Therefore, this might further aggravate the low nutritional status of the study subjects [24].

Factors associated with the nutritional status (BAZ) of adolescent girls in Southern Ethiopia
In this study, the BAZs of the study participants was statistically associated with the age of the adolescent girls (p<0.001).Adolescent girls between the ages of 10-14 years were 2.9 times more likely to be malnourished (thin) than adolescent girls ≥ 15 years old.This finding is in line with the study conducted in the Amhara Region [18].
Family size was statistically associated with the nutritional status of adolescent girls (p<0.05).
Adolescent girls with a family size > 5 were 1.6 times more likely to be malnourished (thin) than those who came from a family with ≤ 5 people.This finding is supported by studies conducted in the city of Arar [25], Nigeria [26], and the Amhara Region [18].Large families may share food among the family members [19].
Monthly household income is statistically associated with the nutritional status of adolescent girls (p<0.001).Adolescent girls from families whose monthly income was < 1000 ETBirr were 2.5 times more likely to be malnourished (thin) than those from families who have monthly incomes > 2000 ETBirr.This finding is in line with studies conducted in Bangladesh [27,28] and Nigeria [29].This might be because the household income affects the purchasing power of the household and families with lower incomes are more likely to be malnourished [30].
Taking deworming tablets was significantly associated with the nutritional status of the study participants (p<0.05).Study participants who did not take deworming table every six months were 1.56 times more likely to be malnourished (thin) than those who took a deworming tablet every six months.According to WHO preventive deworming recommendations, a biannual single-dose of albendazole (400 mg) or mebendazole (500 mg) is recommended as a public health intervention for all non-pregnant adolescent girls and women of reproductive age in order to reduce the worm burden of soil-transmitted helminthes which can affect nutritional status of adolescent girls [31].In addition to this, a systematic review and meta-analysis indicated that taking deworming tablets improves the nutritional status of adolescent girls [32].
The educational status of the participant's fathers was significantly associated with the nutritional status of the study participants (p<0.05).Study participants whose fathers who had no formal education were 2.3 times more likely to be malnourished (thin) than those whose fathers completed college and university.This finding is in line with a study conducted in the cities of Tehran [33] and in Adama in Central Ethiopia [34].
Decision-making power for nutrition services was statistically associated with the nutritional status of the study participants (p<0.001).Adolescent girls from families whose decision-maker was the father or the mother were 1.9 and 2.02 times, respectively, more likely to be malnourished (thin) than adolescent girls who were from families in which both parents jointly make decisions for nutrition service.
Regularly skipping meals was significantly associated with the nutritional status of adolescent girls (p<0.0001).Adolescent girls who skip their regular meals were 2.8 times more likely to be malnourished than those who did not skipping their regular meals.This finding is supported by a study conducted in Nigeria [35,36] and in the Bale Zone [22].This might be because skipping regular meals is an unhealthy eating behavior which can affect the nutritional status of adolescent girls [37].
The source of food was statistically associated with the nutritional status of adolescent girls (p<0.0001).
Adolescent girls who were getting their food only from what their families produce or only purchasing it from the market were 3.28 and 5.14 times, respectively, more likely to be malnourished (thin) than those who were getting their food from both what their families produce and purchase from the market.
In addition to this, participants who were visited by a health extension worker at their home are more likely to be nutritionally normal.Visits by health extension workers were statistically associated with the nutritional status of adolescent girls (p<0.001).Adolescent girls who were not visited by health extension workers in their homes were 1.72 times more likely to be malnourished (thin) than those who were visited by health extension workers at their homes within the past three months.This might be due to nutritional counseling that can result in the improvement of nutritional knowledge and behavioral change for improved nutrition [38].

Factors associated with the nutritional status (HAZ) of adolescent girls in Southern Ethiopia
Decision-making power for nutrition services was statistically associated with HAZs of the study participants (p<0.05).Adolescent girls from families whose decision-maker the father or mother were 2.53 or 2.6 times, respectively, more likely to be malnourished(stunted) than adolescent girls from families which both parents jointly make decisions for nutrition services.Similarly, hand washing practices before eating and after using the toilet were statistically associated with the stunting of adolescent girls (p<0.05).Adolescent girls who did not wash their hands before eating and after using the toilet were 2.3 times more likely to be stunted than adolescent girls who were washing their hands before eating and after using the toilet.This is supported by a study conducted in Nepal [39].Visits by health extension workers in the community were statistically associated with the stunting status of adolescent girls (p<0.05).Adolescent girls who were not visited frequently by health extension workers at the community level were 2.04 times more likely to be stunted than those who were frequently visited by health extension workers at the community level.

Conclusions
Thinness and stunting are 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 power are the main predictors of thinness.Hand washing practice, visits by health extension workers, and nutrition services decision-making power are the main predictors of stunting among adolescent girls in Southern Ethiopia.

Recommendation
 At all levels, the girls' nutrition education/counseling should be given due emphasis as they are tomorrow's mothers which is very important to break the intergenerational cycle of malnutrition.
 Income-generating activities should be implemented to improve the monthly income status of the family as it affects the nutritional status of adolescent girls.
 Health extension workers should visit and give nutrition education regularly for adolescent girls at their homes and at community meetings.
 Hand washing practice should be improved before eating food and after using the toilet.
 Everything in the household should be decided jointly (both mother and father) to improve the ability to utilize resources among the household member.
 Health extension works should give counseling for adolescent girls not to skip their regular meals.
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Fig 1 :
Fig 1: Map of the study sites (Wolaita and Hadiya zones) in southern nation nationality and peoples

Fig 2 .Fig 3 .Fig 4 .Fig 5 .
Fig 2. Comparison of BMI-for-age z-scores (BAZ) of the study population (N=820) with the 2007 WHO All relevant data are within the manuscript and its supporting information filesPowered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation and contact information or URL).This text is appropriate if the data are owned by a third party and authors do not have permission to share the data.
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Table 1 . Socio-demographic characteristics of adolescent girls in Southern Ethiopia, 2019
172Nutrition

service and health-related factors of adolescent girls in Southern Ethiopia
deworming tablets and only 45.1% have received a deworming tablet.Out of the participants who have taken deworming tablets, 65.6% have taken two tablets and 34.4% have taken one tablet every six months.When considering iron and folate supplementation, only 0.4% of the study participants have supplements.Of the total study participants with access to nutrition services, only 60.4% received friendly nutrition service, but 39.5% of the study participants did not receive friendly nutrition service and they were not satisfied by the services that were provided by health experts.In 66.1% of the households, the fathers were the primary decision-makers regarding nutrition service.About 27.8% of the study participants had a cough in the two weeks before data collection.
173As indicated inTable 2, approximately 70.4 % of the study participants did not receive nutrition 174 education.Only 29.6 % of the study participants had nutrition education.Similarly, 54.9% of the study

Table 2 . Nutrition service and health-related factors of adolescent girls in Southern Ethiopia, 2019
186Source: Field survey, 2019; IFAS, = Iron-folic acid supplementation

Table 5 . Nutritional status of adolescent girls in Southern Ethiopia, 2019
Source: field survey, 2019; BAZ, BMI for age z-score; HAZ, height for age z-score