Nutritional status and associated factors among primary school students, in Meket Wereda, Ethiopia: comparing schools with feeding and non-feeding program

Background: Though undernutrition affects academic performance signi�cant numbers of Ethiopian school children have undernutrition. To avert nutritional problems the government in collaboration with the world food program has implemented a school feeding program. However, data on the nutritional status of primary school students were scarce in the country. Therefore, this study aimed to compare the nutritional status of primary school students enrolled in schools with school feeding programs and in schools without school feeding programs and to identify associated factors in Meket Woreda. Methods: A school-based comparative cross-sectional study was conducted among 1,091 students, from April 1-27/2015. The study participants were selected using a multi-stage strati�ed sampling method. A structured questionnaire was used to collect data. Data entry and analysis were done using SPSS version 20 software. Descriptive statistics and logistic regression analyses were done. Anthropometric data were analyzed using Anthro-plus software. Results: The prevalence of thinness was 37.5% among students in non school feeding program schools compared with 27.8 % among students in School feeding program schools. Though it wasn’t signi�cant after adjusting for the potential confounders, the prevalence of stunting among students who took meals at school was higher (58.5%) compared with students who did not consume meals at school (48.3%). Students who did not take meal at school [AOR=2.6, 95% CI: (1.8, 3.8)], having uneducated mother [AOR=5.3, 95% CI: (2.2, 12.6)], being a male [AOR=1.9, 95% CI: (1.4, 2.5)], and taking meal once daily [AOR=2.7, 95% CI: (1.6, 3.9)] were positively associated with thinness. Conclusion: The prevalence of thinness was higher among students in schools did not implement school feeding programs compared to their counterparts. Thus, school meal program should be scaling up into schools in food insecure areas.

implemented in schools have no the program. Education should be given to improve the source of drinking water, frequency and diversity of food at home by giving emphasis to uneducated and housewife mothers.

Background
School feeding is the provision of meal to students in class or take-home ration to families with children who attend school regularly (1). Appropriately designed school feeding intervention improves the nutritional status of school children who suffer from nutrient gaps. It improves cognitive function, school attendance, academic performance, school enrolment and decreases school dropout rate (2)(3)(4)(5).
Thus, many developing countries have been implemented School Feeding Program (SFP) to prevent malnutrition (3,4). Because malnutrition reduces student's attentiveness, concentration, aptitude, attendance rate, school enrolment and academic performance. All these, in turn, have a significant effect on their productivity and quality of life (5)(6)(7)(8). Not only malnourished but also well-nourished children who are hungry at school encounter difficulties to concentrate and perform complex tasks in the class (9,10).
According to a study done in Bangladesh, Jamaica, and Kenya, nutritional status of students who took meal at school was higher than students who did not take meal at school (11)(12)(13)(14). However, in Ghana, nutritional status of students who took meal at school was similar with students who did not take meal at school which was inconsistent with the above study findings (15).
In Ethiopia, world food program (WFP) sponsored school feeding program was started in 1994 with an initial pilot project in war-affected zones in Tigray region. So far, the Ethiopian SFP provides school meal for students in six regions of the country (Afar, Amhara, Oromiya, Somali, Tigray and Southern Nations and Nationality Peoples Region). In the country, target areas to implement SFP were Woredas with chronic food insecurity, lower school enrolment and higher gender disparity (16).
Meket Woreda is one of the food insecure Woredas in North Wollo Zone. In the Woreda, SFP was implemented in 1995. Due to limited support by the donors, SFP was implemented in five schools with high school dropout rate and transport access. The program provides 120 gram fortified blended food with 6gram vegetable oil and 3gram iodized salts. The meal was served for the students in the form of porridge, once a day, in the school days.
Research-based information regarding the nutritional status of Ethiopian children who took meal at school was limited. Thus, this study was designed to compare the nutritional status of students who took meal at school and those who did not take meal at school.

Study area
The study was conducted in Meket Woreda. Meket Woreda is one of the thirteen Woredas in North Wallo Zone of Amhara Region, Ethiopia. According to 2007 Central Statistics Agency (CSA) report, the Woreda has a total population of 226, 644. From which, 112,246 are females. The Woreda was identified as one of the most drought-affected and food insecure Woreda in the Region.
According to the Woreda education bureau report, in the Woreda, there are 50 full cycle primary schools with the total of 51,869 (25,719 males and 26,150 females) students. The SFP was implemented in 5 schools with the total of 5,079 (2,560 male and 2519 female) students.

Study design and population
A school-based comparative cross-sectional study was conducted among primary school students, from April 1-27/2015. All full cycle primary school students in the Woreda were the source population and students in selected schools were the study population. In the study area, school meal was given to the students starting from grade one. Students from grade four and above (students who took school meal for three or more years) were included in this study. Similarly, students from grade four and above were also included in schools had no school feeding program.
Sample size, sampling procedure, and data collection The required sample size of the study was calculated using two population proportion formulas by considering the following assumptions: a 95% confidence level, 50% proportion of under-nutrition among students who did not take meal at school and 40% proportion of under-nutrition among students who took meal at school, since there was no previous study, 80% power to detect 10% difference, the population allocation ratio is 1:2, Design effect 2 and 10% non response rate. The final sample size was 1176. Of these, 392 students were from schools had no SFP and 784 students were from schools had SFP.
The study participants were selected using multi-stage stratified sampling method. Using list of Kebeles as a sampling frame, 12 Kebeles were selected from 45 Kebeles in the Woreda by simple random sampling (SRS) technique (lottery method). Next, schools in selected Kebeles were stratified as school had SFP and had no SFP.
In selected Kebeles, there were 12 schools (8 schools without SFP and 4 schools with SFP). Two schools with SFP and four schools without SFP were selected by SRS technique using the list of schools in selected Kebeles as a sampling frame. The calculated sample size was allocated to the selected schools based on proportion to the size of the students from each school. Finally, using school registration log book as a sampling frame, students were selected by SRS technique. The interview with students' mothers was conducted in the school compound considering privacy.
Data were collected by Amharic version structured interviewer-administered questionnaire. The questionnaire was taken from similar literature (17) and it used to assess socio-demographic characteristics, environmental hygiene and feeding practice of the students. Eight diploma and two BSC nurses were recruited as a data collector and supervisor, respectively.
The anthropometric measurement was taken from students. During anthropometric measurement, the equipments which were used to measure weight were calibrated each day prior to the actual data collection by using a known weight material. Weight was measured to the nearest 0.1kg using a digital scale. The scale was adjusted before weighing every student by setting it to zero. The students were lightly dressed during having the weight taken.
Height was measured to the nearest 0.1 cm using a vertical measuring stadiometer taking all assumptions of height measurement in to consideration. During taking height, the student stood keeping normal anatomical position without shoes and heels, buttock, shoulder, and back of the head touched measuring board. Then, headpiece of the measuring board touched top of the head. For both weight and height two readings were recorded and the computed averages were used in the analysis.
The z-score values for BMI-for-age and height for age were calculated using WHO Anthro-Plus software. Calculated z-scores of BMI-for-age and height for age were used to classify thinness and stunting using the new WHO 2007 reference value, respectively.

Operational definition
School feeding program (SFP) participants-are students who took meal at school.
School feeding program (SFP) non-participants-are students who did not take meal at the school.
Stunted-is defined as low height-for-age at < -2 SD of the median value of the WHO international growth reference.
Severely stunted-is defined as very low height-for-age at < -3 SD of the median value of the WHO international growth reference.
Not stunted-is defined as normal height-for-age at > -2 SD of the median value of the WHO international growth reference.
Thinness-is defined as low BMI-for-age at < -2 SD of the median value of the WHO international growth reference Severely thin-defined as very low BMI-for-height at < -3 SD of the median value of the WHO international growth reference Normal-is defined as BMI-for-age between +2 SD and > -2 SD of the median value of the WHO international growth reference Overweight-is defined as high BMI-for-age at >+2 SD of the median value of the WHO international growth reference

Data Quality Control
Using trained data collector and supervisor, pre-testing the questionnaire and checking weighing scale for functionality were measures taken to assure the quality of data. Moreover, the collected data were reviewed and errors were returned to the data collectors for correction in a daily base.
Supervisors and investigators closely supervised the data collection procedure.

Data processing and analysis
Data were entered and analyzed using SPSS version 20 software. Nutritional status of the students was compared. Bivariate and multivariable logistic regressions were done to identify factors associated with stunting and thinness. The crude Odds ratio was done and p-value < 0.2 was taken as a cut-off point to select variables for the final model. Age was controlled during the multivariable logistic regression analysis. The adjusted Odds ratio was computed to determine the strength of association and control confounders. The p-value less than 0.05 was considered statistically significant.

Ethical consideration
The study was approved by Ethical review Board of College of Medicine and Health Sciences, Bahir Dar University. Letter of permission was taken from zonal and Woreda health bureaus as well as the school administrators. Since it causes less than minimum risk, verbal consent was taken from parents and assent was taken from students. Privacy and confidentiality were maintained throughout the study period by excluding personal identifiers from the data collection tools.

Socio-demographic characteristics of the students and their parents
A total of 1091 primary school students were participated in the study, with a response rate of 92.8%.
Of which 65.8% (n =718) of them were from schools had SFP and 34.2 % (n = 373) of the study participants were from schools had no SFP. The mean (+SD) age of the respondents from schools had SFP and had no SFP were 12.12 (+1.36) years and 12.73 (+1.46) years, respectively (Table1).
The majority, 95.5% of respondents from schools had SFP and 98.9% of students from schools had no SFP were orthodox Christian followers. Almost all, 97.5% of the study participants from schools had SFP and 99.2% of students from schools had no SFP were Amhara in their ethnicity. In both groups, eighty one percent of students live with their both biological parents. Regarding their mothers, 88.6% of students' mothers from schools had SFP and 92.0% of students' mothers from schools without SFP had no formal education (Table 1).

Nutritional status of primary school students
The prevalence of stunting was higher (58.5%) among students who took meal at school compared with the prevalence of stunting (48.3%) among students who did not take meal at school. On the other hand, the magnitude of thinness was higher (37.5%) among students who did not take meal at school than the magnitude of thinness (27.8%) among students who took meal at school. The prevalence of severely stunted (22.3% Vs18.2%) and severely thin (9.7% Vs 8.6%) were higher among students who took meal at school compared with students who did not take meal at school (Table 2).

Factors associated with stunting in primary school children
In the bivariate logistic regression analysis students who did not take meal at school, whose mother have no formal education, being a male sex, who live in a household did not use latrine, being in Agew ethnic group, who frequently took Shero at home, drinking river or spring water and taking meal once per day at home were statistically associated with stunting (Table 3).
After age was controlled, in the multivariable logistic regression analysis, students in the Agew ethnic group were 3.9 times more likely to develop stunting than students in Amhara ethnic group times more likely to develop stunting than students who took meal more than once per day [AOR=2.6, 95% CI: (1.2, 5.9)] ( Table 3).

Factors associated with thinness in primary school children
In the bivariate logistic regression analysis having a mother and father with no formal education, being a male sex, taking Shero frequently at home, living in the household didn't have radio and television, having married and housewife mother, being a rural residence, taking meal once per day at home, students who did not take meal at school and wash their hand before eating were statistically associated with thinness (Table 4).
After age was controlled, in the multivariable logistic regression analysis students who did not take meal at school were 2.6 times at a higher risk to develop thinness than their counterparts [AOR=2.6, 95% CI: (1.8, 3.8)]. Educational status of the mother was another predictor for thinness, students whose mother have no formal education had 5.3 times higher probability to develop thinness than students whose mother have no formal education [AOR=5.3, 95% CI: (2.2, 12.6)].
The Odds of being thin was higher among males compared with females. Males had 1.9 times higher risk of thinness than females [AOR=1.9, 95% CI: (1.4, 2.5)]. Students who took meal once a day at home were more likely to be thinner than those who took more than one meal daily [AOR=3.5, 95% CI: (1.6, 7.6)]. Students who took Shero frequently at home had 2.7 times higher probability of thinness than those who took other foodstuffs in addition to Shero [AOR=2.7, 95% CI: (1.6, 3.9)].
Possession of radio was also a predictor for thinness. Students who live in a household have no radio were 1.7 times more likely to develop thinness than students whose family possessed radio [AOR=1.7, 95% CI: (1.1, 2.7)]. Students whose mother were a housewife had 3.1 times higher risk to thinness than those who had daily laborer and petty trader mother [AOR=3.1, 95% CI: (1.5, 6.4)] (Table 4).

Discussion
In this study, the prevalence of stunting was higher among students who took meal at school compared with students who did not take meal at school (58.5% Vs 48.3%, P 0.001). This finding was similar to the study finding in Nkwanta South District-Volta Region of Ghana, where the prevalence of stunting was higher among the students who participated in SFP than their counterparts (17). The probable explanation might be due to the long-term effect of malnutrition. Most probably students who participated in the SFP were more likely to have poor nutrient intake at home starting from the first thousand days of life. Therefore, short-term supplementation may not reverse nutrient gaps occurred during early developmental periods. Additionally, parents might expect that a child who was already enrolled in SFP as satisfied at school and reduce the amount of food they give when the child comes to the home.
This finding was not in agreement with the study finding in Western Kenya (18) and Ghana (19) where the prevalence of stunting was higher among students who did not take meal at school than students who took meal at school. This discrepancy might be due to difference in enrolment criteria of school feeding programs in Ethiopia and other countries. The quality and quantity of school meal may also differ between countries. Furthermore, it might be due to the difference in home background, nutrition and child care related knowledge, attitude and practice of parents in Ethiopia and other countries.
In this study, a larger proportion of students who did not take meal at school were thin than students who took meal at school (37.5% Vs 27.8%, P 0.001). This finding was similar to the study finding in Western Kenya (18) and Ghana (19) where thinness was higher among students who did not take meal at school than students who took meal at school.
On the other hand, this finding was different from the study finding in Nkwanta South District-Volta Region of Ghana, where the prevalence of thinness was higher among students who participated in SFP than students who did not participate in SFP (17). This discrepancy might be due to the difference in quality and quantity of school meal. Moreover, this could be explained by the difference in income, nutrition and child care related knowledge and attitude of parents in Ethiopia and Ghana.
Taking meal at school had a positive significant association with thinness of students. This finding was consistent with different study findings in Kenya (20,21). Whereas, inconsistent with the study finding in Ghana where there was no statistically significant difference in nutritional status of students in schools had SFP and had no SFP (15). This discrepancy might be due to the difference in school meal quality and quantity as well as school meal participant selection criteria between the two countries. Educational status of the mother had a significant association with nutritional status of students.
Students whose mother had no formal education were more likely to be stunted and thin than students whose mother attained formal education. This finding was in agreement with the study finding in Ethiopia, Egypt, Kenya, Bangladesh and India where maternal education was inversely related to nutritional status of children (11,(22)(23)(24)(25). The possible justification might be due to the probability of having better knowledge feeding practice and health-seeking attitude when educational status increases.
The likelihood of both stunting and thinness was higher among boys compared to girls. Similar findings were reported from Jamaica, India and Sari Lanka (7,9,24). The reason might be due to high requirement of food to boys than girls.
The Odds of having thinness was higher among the students whose family had no radio as compared to their counterparts. This finding was supported by the previous study finding in Ethiopia (26).
Families who had radio were more likely to get nutrition and child care related information through media than those who did not have radio.
Students who frequently took only Shero at home were more likely to develop under-nutrition than students who took additional food such as kik, meat, vegetable and milk with Shero. This finding was supported by the study findings in Egypt and Kenya (23,27). Students who took a variety of foods are more likely to meet nutrient requirements than students who regularly take monotonous diet.
Occupational status of the mother showed significant association with thinness. Students who had a housewife mother were more likely to be thin than students who had daily laborer or petty trader mother. This finding was supported by the study findings in central India and Okolobiri (24,28). On the other hand, the finding was not consistent with the study findings from India, where more children who had working mother were malnourished than their counterpart (29). The possible explanation might be working mothers are more likely to have income and decision making power to purchase health service and food items.
Comparative nature of this study among students who took meal at school and who did not take meal at school could be the strength of this study. However, this study did not assess the effect of SFP on academic performance and the possibility of unavoidable social desirability bias could be taken as the limitation.

Conclusions
The prevalence of stunting was higher among students who took meal at school compared with students who did not take meal at school, while the prevalence of thinness was higher among students who did not take meal at school than students who took meal at school. Factors associated with stunting were being Agew in ethnicity, having uneducated mother, drinking river water, taking meal once a day at home, being a male, and taking Shero frequently at home. Whereas, students who did not take meal at school, have no radio, having uneducated mother, having housewife mother, taking meal once a day at home, being a male, and taking Shero frequently at home were positively associated with thinness.

Recommendation
Thus, to prevent thinness school meal program should be implemented in schools have no the program. Education needs to be given in improving the source of drinking water, frequency and diversity of food at home by giving emphasis to illiterate and housewife mothers. Health Sciences, Bahir Dar University. Letter of permission was taken from zonal and Woreda health bureaus as well as the school administrators. Since it causes less than minimum risk, verbal consent was taken from parents and assent was taken from students. Privacy and confidentiality were maintained throughout the study period by excluding personal identifiers from the data collection tools.

Consent for publication: Not applicable
Availability of data and materials: All the data related to this research are available in the text and tables Competing interests: the authors declare that they have no competing interests