Study area and design
The study was conducted in rural primary schools in East Dembia district, northwest Ethiopia. The district is located 745 km from Addis Ababa, the capital of Ethiopia. The district has 34 Kebele, which is the smallest administrative unit (4 urban Kebele and 30 rural Kebele). According to the fiscal 2019 population projection report, the total population of the district is estimated at 202,534. Of which, the number of school-age children is estimated at 60,262 (29,529 boys and 30,733 girls).
The district had 56, 28 and 3 elementary, primary and secondary schools respectively. A total of 31,682 children in total were enrolled in the schools. Among the total number of children enrolled in primary school, 22,907 students (11,914 boys and 10,993 girls) were found in rural primary schools in kebele .
An institution-based cross-sectional study design was applied to assess the prevalence and associated factors of stunting and wasting among school-aged children in rural primary schools in East Dembia District, Regional State from Amhara, Ethiopia, from February 1 to March 5, 2020.
The source population consisted of all children in the age group between 6 and 14 years old who were enrolled in primary schools in East Dembia district.
The study population consisted of all children aged 6 to 14 from selected rural primary schools in East Dembia district. All children aged 6-14 in rural primary schools and attending school during the data collection period were included, while seriously ill children and those unable to stand on their own were excluded. of the study.
Sample size determination and sampling technique
The sample size was determined using the single population proportion formula taking the prevalence of undernutrition as 46.1% from the study in Gondar, Ethiopia. the Z statistic of 1.96, a margin of error of 5%, and a nonresponse rate of 10%, accounting for a design effect of 2. Then the calculated total sample size was 840.
A systematic random sampling procedure was employed to select a sample of school-aged children in rural primary schools. In the first stage, using a simple random sampling technique, eight primary schools were selected from 26 rural full-cycle primary schools (grades 1-8). Then, a proportional allocation was made to the selected schools based on the number of students in the respective school. Finally, using the list of students as a sampling frame, a systematic random sampling technique was employed to select every eleventh child [by dividing the total number of students in eight selected schools (i.e., 8958) to the calculated sample size (840). The random starting was seven, obtained by using the lottery method.
Under-nutrition (Stunting and Thinness).
Socio-demographic and economic factors include: sex, age of the child, marital status, educational status, employment status, religion, family size, and wealth index.
Health conditions: sickness, types of illness, presence of intestinal infectious diseases.
Dietary diversity and feeding practices: dietary diversity in the home, meal frequency per day.
Food Security: Household Food Insecurity.
Water, sanitation, and hygiene factors: availability of clean water, safe sanitation facilities, and hygienic practice.
“School-age children”: a child between the ages of 6 and 14 years old .
Undernutrition: children suffering from one of two forms of malnutrition (stunting or wasting).
Stunting: height for age
Thinness: BMI for age
Access to drinking water: “the proportion of the population using running water, the public tap, the protected source or the well” .
Improved sanitation facility: an excreta disposal facility with no faeces on the floor and properly constructed .
Socioeconomic status was measured using a tercile index derived from household asset and utility scores, and the wealth tercile was divided into rich, middle, and poor.
Household food security: A household is considered food secure when the sum is less than 2 of the 27 food insecurity indicators.
The dietary diversity model is ranked as the weakest ( 8) .
Data collection tools and procedure
Data was collected using a structured questionnaire via a face-to-face exit interview. The child’s guardian was traced at the household level for wealth index, household food insecurity, and dietary diversity pattern. The questionnaire was adapted from different publications [2, 5, 8, 18, 27] and guidelines [28, 29]. In addition, an anthropometric measurement and a laboratory survey for the stool sample were included in the data collection tools. Socio-demographic and economic characteristics; water, hygiene and sanitation characteristics; household dietary diversity using 24-hour recall methods; and the Household Food Insecurity Access Scale, which was developed by the Food and Nutrition Technical Assistance (FANTA) [30,31,32], were included in the questionnaire. Household Dietary Diversity Score (DDS) was categorized as low when the DDS was less than 4, medium when the DDS was 5–7, and high when the DDS was greater than 8. .
Age, weight, and height were used to determine height-for-age (HAZ) and BMI-for-age (BAZ) or thinness z-scores. The weight of the study subjects was measured with minimal clothing and without shoes to the nearest 0.1 kg. The weight scale was digital and calibrated by a 2 kg iron bar every day. Height was measured using a standiometer while standing to the nearest 0.1 cm. When the data collectors took the height of the study subject, the following points were checked: the heel, the buttocks, the shoulder touching the vertical support of the stadiometer and the adjustment of the head to be perpendicular to the plane from Frankfurt has been verified. Children with HAZ and BAZ
Each student was given a clean, labeled stool cup and an applicator stick to collect approximately 2 g of a fresh stool sample. The collected stool sample was emulsified with 0.9% saline solution and 10% formalin solution to maintain sample quality  and examined using combined wet mount and concentration techniques. For this purpose and for data collection, two medical laboratory technicians and a laboratory technologist have been assigned.
Data quality control
The data collection tool had been prepared in English and translated into the local Amharic language by language experts. Then switch back to the English language to check consistency. Before the start of the actual survey, a one-day training was given to data collectors and supervisors on how to approach and collect the data. A pre-test was carried out on 42 (5%) of the sample size at a primary school in Gondar, Zuria woreda, before the start of the actual data collection. The completeness, accuracy and clarity of the data collected were checked by the supervisor and the principal investigator. The quality of laboratory stool analysis was maintained using the standard operating procedure. Prior to analysis, the data was cleaned and cross-checked.
Data processing and analysis
Epi-Data version 18.104.22.168 was used to enter the data. Then it was exported and analyzed using SPSS version 20 software. Age, weight and height were exported from Epi-Data software and imported into AnthroPlus software version 1.4.1 to calculate height for Age Z scores (HAZ) and BMI for Age Z scores (BAZ) . The household wealth index was calculated by considering household assets (i.e. livestock, type of house, durable assets, productive assets and ownership of agricultural land).
Regression is used to assess the association between variables, and descriptive tests indicating prevalence, mean, percentage, and frequency are performed to express the results of this study.
A bivariate analysis was performed, and the variables that had a p-value less than 0.2 were selected for multivariate analysis. Finally, a multivariate analysis was performed and the variables with a p-value less than 0.05 were considered statistically significant. The fitness of the model was also checked using the Hosmer-Lemeshow test.
Ethical clearance was obtained from the University of Gondar Ethics Review Committee and the study was performed in accordance with the ethical standards set out in the 1964 Declaration of Helsinki and its advanced revisions. Then, a clearance letter was obtained from the East Dembia District Education Office. Written informed consent was obtained from parents or guardians prior to inclusion of study subjects, while informed consent was obtained from children to participate in the study. Details such as participant names and identification numbers that could reveal participants’ identities were not included in the data collection tool. The purpose of the study was briefly explained to the participants and tutors before the interview. The right to withdraw from the study was granted to study participants whenever they wished. During data collection, an anti-helminth drug was given to children who tested positive for an intestinal parasitic infection.