Prevalence and Associated Factors of Thinness among Adolescent Students in Finote Selam Town, Northwest Ethiopia

Even if adolescence is a window of opportunity to break the intergenerational cycle of malnutrition, adolescents are the neglected age groups. Hence, information regarding the nutritional status of adolescents is lacking, making creating and implementing intervention programs difficult. This study aimed to assess the prevalence and determinants of thinness among school adolescents in Finote Selam Town, Northwest Ethiopia. A school-based cross-sectional study among adolescent students aged 10–19 in public primary and secondary schools was carried out in Finote Selam Town from February 05 to March 27, 2018. Stratified and simple random sampling techniques were employed to select study subjects. A total of 397 adolescent students were included in the study. Pretested structured questionnaires were used to collect the data. Data were entered using Epi Info version 7 and analyzed using SPSS version 20 and WHO AnthroPlus software. A multivariable binary logistic regression analysis was employed to identify factors associated with thinness. Crude and adjusted odds ratios with 95% level significance were used to measure the strength of association, and statistical significance was declared at p value less than 0.05. The prevalence of thinness among adolescents was 14.9%. Early adolescent stage (AOR = 4.81; 95% CI : 1.23, 18.51), being male adolescent students (AOR = 2.33; 95% CI : 1.60, 3.40), having less than 1000 birr family monthly income (AOR = 6.54; 95% CI : 3 : 82, 14.89), having 1000–2000 birr family monthly income (AOR = 3.47; 95% CI : 1.15, 7.45), and using well water (AOR = 3.82; 95% CI : 1.46, 10.04) were significantly associated with thinness at 95% confidence interval. The study revealed that prevalence of thinness was high in the study area. Sex, place of residence, and family monthly income were found to be important factors associated with thinness among the respondents.


Introduction
Both the UN and WHO define adolescence as a segment of population group age from 10 to 19 years old; it is a transition period from childhood to adulthood and has intense physical, psychosocial, and cognitive development [1]. During this period, the final growth spurt occurs; particularly, early adolescence after the first year of life is the critical period of rapid physical growth and changes in body composition, physiology, and endocrine [2]. Up to 45% of skeletal growth takes place, and 15 to 25% of adult height is achieved during adolescence; during the growth spurt of adolescence, up to 37% of total bone mass may be accumulated [3]. Regarding body composition change, girls begin to store fat around the breast, hips, and upper arm but boys start losing fat and develop muscle [4]. e adolescence period is a window of opportunity for human beings because there is possibility of little catch-up growth [5], and it is a time of changing lifestyles and food habit; changes affect both nutrient needs and intake, so it is an opportunity to shape this new behavior adoption [6]. Our world is a home to 1.8 billion (24.66%) young people between the ages of 10 and 24, and the youth population is growing fastest in the poorest nations; currently, adolescents make up roughly 20% of the global population [7]. In developing countries, adolescents have an even higher 85% demographic weight, for instance, roughly 26% in Salvador, compared to 14% in the USA [8]. Similarly, in Ethiopia, children and adolescents constitute about 48% of Ethiopian population, and about 25% of the Ethiopian populations are adolescents, but studies among this age group were insufficient [9].
Different researchers conducted a study on thinness among school adolescents in different parts of the country. e prevalence of thinness varies across different regions of Ethiopia. e prevalence of thinness among adolescent girls was 21.6%, 28%, 21.4%, and 14.8% in studies conducted in Babille District [10], Bedlle [11], Adwa [12], and Arsi Zone [13]. e overall prevalence of thinness among adolescent school girls in Lay Guyint Woreda, Northwest Ethiopia, was 29.0% [14]. e prevalence of thinness among adolescent school girls in Adwa Town, North Ethiopia, was 21.4% [12]. e overall prevalence of thinness among school-going adolescents in Mekelle City, Northern Ethiopia, was 37.8% [15]. e prevalence of thinness among adolescents in Wukro, Northern Ethiopia, was 26.1% [16]. However, there was no any study report on thinness in the study area. is study would serve as a baseline for further study and be important for designing intervention and a guide for policymakers and development planners. is study was mainly focused to assess the prevalence and explore determinants of thinness among school adolescents in Finote Selam Town, Northwest Ethiopia.

Study Design and Area.
e study design was a schoolbased, cross-sectional study among adolescent students aged 10-19 in public primary and secondary schools. e study was carried out from February 05 to March 27, 2018. is study was conducted in Finote Selam Town which is located 389 km northwest of Addis Ababa and 176 km southeast from Bahir Dar, the city of Amhara Region. Finote Selam town administration has been established to be the main town of West Gojjam Zone since 2004 E.C. e total population size of the town according to 2007 census report was 25913 (13, 035 males and 12, 878 females). e town is situated at an altitude ranging from 1500-2300 meters above sea level and has an area coverage of 116,954 ha. e area receives an average annual rainfall of 1250 mm. e minimum and maximum daily temperatures of the area are 14 and 32°C, respectively. It is bordered on the north by Sekela and Quarit, on the south by Dega Damot and Burie, on the east by Deg damot and Dembecha, and on the west by Burie.
ere are six primary schools, one high school, one preparatory school, and five colleges in Finote Selam Town. e total number of students from grade 5-12 was 12,323 [17].

Sample Size and Sampling Procedure.
e minimum sample size required was calculated using single proportion formula. e proportion of thinness among school-going adolescents of Mekelle City, Northern Ethiopia, was 37.8% [18] at a 95% confidence level, 5% margin of error adding 10% as contingency for nonresponse rate: where n � sample size, Z � Z score at 95% CI � 1.96, p � 37.8%, and d � marginal error � 105: � 361. (2) By adding 10% nonresponse rate, the minimum sample size required to estimate the prevalence of thinness and its associated factors among adolescent students was 361 + 10% (361 + 36) � 397.
To obtain the sample, stratified random sampling technique was used. e schools were stratified into primary schools, junior schools, high school, and preparatory school.
ree primary schools, namely, Bata, Bakel, and Efrata, and three junior schools, namely, Edgetber, Bata, and Bakel, were selected using simple random sampling from six primary schools and six junior schools, respectively, whereas a high school, namely, Finote Selam Secondary School, and a preparatory school, namely, Damot Preparatory School, were selected purposively since one high school and one preparatory school were present in Finote Selam Town. e total sample size was distributed proportionally to the schools. e sampling frame was students' identification number in their respective school. Numbers of students to be included in the study were determined by a simple random sampling method ( Figure 1).

Data Collection.
To generate the data set used in this study, pretested structured questionnaires were used to collect data by trained data collectors. Explanatory variables were selected after conducting a detailed literature review from related articles to collect data on the sociodemographic, nutritional, and health-related variables [16][17][18][19]. e questionnaires were translated into the local language (Amharic) for easy understanding by the respondents. Each student was interviewed to obtain information on sociodemographic, nutritional, and health-related characteristics of the adolescents' family.
Anthropometric data were collected by trained data collectors who were health extension workers. And the overall activity was coordinated by the investigator. e age of the adolescents was derived from the school register. Height and weight were measured using a stadiometer and Seca Digital Scale (Seca, Germany), respectively. e weight was recorded to the nearest 0.1 kg. It was calibrated against the known weight regularly. Before the real anthropometric data collection, a standardization exercise was performed during the training to capture technical error of 2 e Scientific World Journal measurement. During the procedure, the subjects wore light clothes and took off their shoes. Height was measured in cm using a portable stadiometer. All adolescents were measured against the wall without foot wear and with heels together and their heads position and eyes looking straight ahead (Frankfurt plane) so that the line of sight was perpendicular to the body. e height was recorded to the nearest 0.1 cm. e same measurer was employed for a given anthropometric measurement to avoid variability.

Data Quality Control and Management.
To ensure the reliability and validity of the study, training was given for the data collectors, the data collection was done by two health extension workers, and close follow-up was done by the investigator during data collection. e Amharic version of the questionnaire was tested on 5% of the samples at the Selamamba Primary School, who have similar characteristics with the study participant but did not participate in the study. e data collectors and investigator were participated on pretesting and standardization of the questionnaires. Problems highlighted during the preliminary study were corrected before the start of the actual survey. Each question was properly coded; continuous supervision was performed during the pretest and data collection period by the investigator. Completeness and consistency of recording on the questionnaire sheets were evaluated by the investigator at the end of each working day so that correction measures were taken for the next time.
2.6. Data Analyses. Sociodemographic, anthropometric, nutrition, and health-related data were entered into Epi Info version 7 and checked for completeness and consistency, followed by data cleaning and editing on Epi Info. en, the data were analyzed by using SPSS (Statistical Package for Social Sciences), version 20 software. WHO AnthroPlus software was used for assessing growth of the adolescents [20]. Descriptive statistics using frequencies and proportions was used to present the study results. For anthropometric data analysis, if the BMI-for-age Z-score is below minus two standard deviations (−2 SDs) from the median of the reference population, then the child is thin. Odds ratio with 95% confidence interval was used for checking the strength of associations between the outcome variable (thinness) and independent variables. Bivariate logistic regression was performed, and the variable with p value less than 0.25 was transported into multivariable binary logistic regression analysis to identify the determinant of malnutrition of under-five children. Finally, variables with p values <0.05 in the multivariable logistic regression model were taken as statistically significant [21].  Prevalence of thinness: the overall prevalence of thinness among adolescent students at Finote Selam Town was 14.9%. e mean Z-score of BMI-for-age of all adolescents was −1.13 which revealed the distribution of BAZ (Figure 2). e mean Z-scores of BMI-for-age among boys and girls were −1.29 and −0.51 that showed the distribution of BAZ, respectively ( Figure 3).

Factors Associated with inness.
Exploring determinants associated with thinness is important to take nutritional intervention action in the study area. Results of the multivariable binary logistic regression model showed that the age, sex, family monthly income, and sources of drinking water were significantly associated with thinness. e odds of thinness were 4.81 times higher among adolescent students in the early adolescent stage as compared to adolescent students in the late adolescent stage (AOR � 4.81; 95% CI : 1.23, 18.51). Male adolescent students had 2.13 times higher odds of thinness (AOR � 2.13; 95% CI : 1.60, 3.40) compared to female adolescent students. e students who came from

Discussion
In this study, the prevalence of thinness and associated factors in Finote Selam Town, Northwest Ethiopia, was assessed. e prevalence of thinness was 14.9%, and this finding was lower than the studies in Mekelle City (37.8%) [15], Ambo City (27.5%) [22], Wukro District (26.1%) [16], and Seychelles (27.7%) [23]. Another study in Ethiopia, in Jimma Zone, has reported a much higher level (80.8%) of thinness prevalence among adolescents [24]. e prevalence of thinness of this study was higher than studies done in Addis Ababa (6.2%) (13%) [25]. is divergence might be     [27], Tunisia (13%) [28], and Tamale Metropolis district, Ghana (10%) [29]. e variation might be due to socioeconomic background, geographical characteristics of study area, cultural difference in dietary habit, and care practices. e odds of thinness were 4.81 times higher among adolescent students in the early adolescent stage as compared to adolescent students in the late adolescent stage. is finding was in agreement with findings from Adwa Town, Northen Ethiopia, [17] and in Community-Based Nutrition implementing districts, Amhara Region, Ethiopia [30]. is might be due to as age increases, adolescents might access food easily by themselves; on the other hand, as age increases, adolescents become more matured. Male adolescent students had 2.13 times higher odds of thinness compared to female adolescent students. is study was in line with the studies conducted in Mekelle City, Northern Ethiopia [15], Jimma Zone, Southwest Ethiopia [24], and Wukro, Northern Ethiopia [16] which confirmed that males were more affected in thinness than girls. is might be due to variation of maturation time in boys and girls, for which girls reached maturation earlier than boys. e students who came from rural area were 2.16 times more likely to be thin compared to those who came from urban area. is finding is in agreement with other previously conducted studies [12,16]. e variation might be due to food preference, food consumption pattern, and inequalities in dietary diversity between urban and rural areas. e risk of being thin among school adolescents whose mothers did not attend education was 1.78 times more compared to school adolescents whose mother attended college and above education. is finding is consistent with the study that conducted in Adama City, Central Ethiopia [31]. e risk of being thin among school adolescents whose mothers attended primary school (1-8) and secondary school (9-12) education was 1.29 and 1.15 (AOR � 1.15; 95% CI: 0.66, 1.97) times more compared to students whose mothers attended college and above education, respectively.
is finding is in line with the study that conducted in Adama City, Central Ethiopia [32]. is is due to the fact that if the level of education of the mother is low, her decision-making and her contribution to the total family income will be low. is places the family at risk of not meeting their needs including nutritional needs. e odds of being thin were 1.90 times higher among school adolescents who lived in household members of ≥5 than school adolescents who had lived in household members <5. is finding was in line with the study that conducted in Adwa Town, North Ethiopia [12]. is might be due to sharing of the available food for the large household members, causing inadequate consumption of food, leading to be thin. e students who did not eat vegetables and fruits at least once per day were 1.30 and 1.23 times more likely to be thin compared to those who ate once per day. is finding is in agreement with the study that conducted in Adwa Town, North Ethiopia [12]. is is might be due to the fact that consuming insufficient vegetables and fruits are leading to poor nutritional status. e students from less than 1000 and 1000-2000 birr family monthly income were 6.54 and 3.47 times more likely to be thinness compared to greater than 2000 birr family monthly income, respectively. is might be due to the better income level of the family would enhance the nutrition status of the adolescents. Students from households that used well water supply as main source of water supply were 3.82 times more likely to be at risk of being thinness than students from households that used tap water supply for human consumption.
is finding was in line with findings from Adwa Town, Northen Ethiopia [17]. is   might be due to the fact that impure water is a vehicle for intestinal parasites which leads to loss of appetite, leading to poor nutritional status; this might also be due to repeated infection causing depressed immunity and making the severity and duration of disease more severe, contributing to poor nutritional status of the adolescents.

Conclusions
e prevalence of thinness was high in the study area. Consistent with this result, the mean Z-scores of BMI-forage were higher in boys than girls. Age, sex, family monthly income, and sources of drinking water were significantly associated with thinness among the respondents. Based on the finding, there should be collaboration among health sectors and education sectors of the town to address school adolescents under nutrition problems of the town.

Data Availability
All data in this study are included in the figures, tables, and statements.
Ethical Approval e study was approved by the University Ethical Committee of Faculty of Chemical and Food Engineering, Bahir Dar University (protocol no. 12/2010). Supportive letters were obtained from the Amhara Public Health Institute which wrote a letter to the West Gojjam Zone Health Office, and then the West Gojjam Zone Health Office wrote a letter to the Finote Selam Town Administration Health Office. Finally, Finote Selam Town Administration Health Office wrote a letter to target schools.

Consent
Written informed consent was obtained from the adolescents' parents or legal guardians, after clearly explaining the research objectives.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
Damitie Kebede Mengesha has designed the study and involved in data collection, supervision, and data processing. Damitie Kebede Mengesha has cleaned and analyzed the data as well as interpreted the results and drafted the