One in three adolescent schoolgirls in urban northwest Ethiopia is stunted

Globally, adolescents comprise 16% (1.2 billion) of world population, more than 40% of which are adolescent girls. Of the total adolescent girls, 16 million give birth every year, off this 23% are from the sub-Saharan Africa, the region where the highest burden of maternal and child under nutrition is frequently reported [1]. Nutrition, optimal energy and micronutrient intake, plays an important role in supporting physical, mental and emotional development of adolescents [2, 3].

Poor nutritional status of adolescent girls, including stunting, has a negative effect on generation. Hence, undernourished adolescents enter pregnancy with poor nutrient reserve. Consequently they will give birth to low birth weight baby that is more vulnerable to chronic disease in later life due to early fetal programming [4, 5]. Moreover, it is associated with high risk of morbidity and mortality, delayed mental development, reduced intellectual capacity, poor educational achievement, school attendance and concentration [6, 7]. As a result, under nutrition is considered as a strong predictor of human capital and social progress [8]. However, not trivial numbers of adolescents are undernourished in developing countries [8‐10]. The high prevalence of adolescent stunting is reported in Asia and Africa. As an illustration, nearly half of (47.0–47.4%) adolescent girls are stunted in India [11, 12] and Bangladesh (32–49%) [13, 14]. On the other hand, about 12.1 and 17.4% of adolescents have stunted growth in Kenya [15] and Nigeria [16], respectively, which is lower than Asian countries report. As like other developing countries, adolescent stunting existed as public health problem in Ethiopia [17]. One-third (31.5%) of adolescent girls are affected by stunting in Amhara region, the region where the study area is located [18]. Similarly, higher prevalence (25.5%) of stunting is shown in Eastern Tigray [19]. Nevertheless, a bit lower burden of adolescent stunting is reported in City Administration of the country: 15.6% in Adama [18] and 12.2% from Adawa city [19].

Some of the former literatures identified the determinants of adolescent stunting. Attending public schools, low maternal education [16], not starting menarche [20], being in the middle age range [21], rural residence [21], use of unimproved water sources [19] and larger family size [19] were elicited as significant predictors of stunting.

Even though adolescence is identified as a part of critical window to address different nutritional problems [8], adolescent nutrition receives less attention as compared to child and maternal nutrition issues [22]. Recently the government of Ethiopia starts to pay especial emphasis to enhance adolescent’s nutritional status: the revised National Nutrition Program (NNP) and national school health and feeding programs are some of the current efforts which has been implemented in the country at large [17, 23]. The NNP baseline survey report showed that 23% of adolescent girls are stunted in Ethiopia [24] which implies the critical importance of regular monitoring and evaluation of the magnitude of stunting. Also, the observed discrepancy in the burden of adolescent stunting between urban and rural settlements [18, 19, 25, 26], necessitates further, separate, investigation of the specific determinants of stunting, though only few literature is available on the specific area. Therefore, this research intended to assess prevalence and associated factors of stunting among school adolescent girls in Gondar City Administration, northwest Ethiopia.

A total of 812 adolescent girls were included in the study with a response rate of 97.5%. The median age of the adolescents was 16 with (Inter-Quartile Range (IQR) of 14–17 years. Substantial proportion, 742 (93.3%) of participants resided in urban kebeles. More than half of the mothers had informal education 437(55%). Nearly half, 365(45.9%) of households had five and above family size and 168(21.1%) were found in the rich wealth category (Table 1).

Of the total respondents, 631(79.4%) had satisfactory media exposure. Large proportion 776(97.6%) of participants consumed grains and roots and 600(75.5%) of had adequate dietary diversity. Two-third 499(62.8%) of the households were food secured (Table 2). Availability of home gardening was reported in 131(16.5%) of the households, but 52.7% of which used the product for sale. Majority, 620(79.1%) also had home latrine and used improved drinking water 783(98.5%) (Table 3).

The study noted that the overall prevalence of stunting (HAZ < − 2) was 33.1% and about 2.4%of adolescent girls were wasted. The multivariable logistic regression analysis showed that age of the respondent, unsatisfactory media exposure and educational status of mothers were significantly associated with stunting (Fig. 1).

Adolescent girls found in the early and middle age range were found at 74% (AOR = 0.26, 95% CI: 0.00, 0.22) and 78% (AOR = 0.22, 95% CI: 0.15, 0.34) lesser odds of stunting compared to late adolescent girls. The odds of stunting were higher among adolescents who had unsatisfactory media exposure (AOR = 1.69, 95% CI: 1.01, 2.84) and whose mothers completed college and above education (AOR = 2.84, 95% CI: 1.02, 7.94) (Table 4).

This study illustrated that one of the three (33.1%(95% CI (29.9, 36.5)) adolescent girls were stunted, suggesting the issue as one of the major public health problem. The finding is consistent with the previous report in Nepal 32% [31]. However, the report is lower than the former Asian and African countries investigations, for instance.

51.9% of adolescent girls in Assum, India [11] and 47% in panangal [12], districts of India, are stunted. Similarly, the high magnitude of adolescent stunting is noted in Bangladesh 49% [14] and Nigeria 57.8%. The high prevalence of stunting in India [11] could be attributed to the nature of the study setting where only adolescents from the slum areas were included, while our study considered random selection of samples with regard to place of residence. Obviously, slum areas are well-known with insanitary living environments and lower socio-economic status, underlying causes of under nutrition, compared to non-slum settlements [32]. On the other hand, half participants in Bangladesh were pregnant compared to 95.6% of samples had no history of pregnancy in the current study. This could explain the increased magnitude of stunting Bangladesh. In fact, pregnancy demands significantly high energy and micronutrients even the requirement increases in case of adolescence pregnancy to support tremendous growth of both the adolescent and the fetus. Therefore, adolescence pregnancy amplifies the vulnerability of girls for under nutrition, including stunting [33]. In contrast, our finding is higher than the former local and abroad reports, such as Tigray Region, 26.5% [34], Adwa Town 12.2% [19], western Kenya 12.1% [15] and Nigeria 17.9%. This discrepancy could be related to socio-economic disparities between the study settings.

The result of the adjusted analysis showed that girls in the early and middle adolescence were 74% and 78% times less likely to be stunted, respectively, as compared to late adolescent girls. Similar finding was reported in urban set up of Kathmandu valley [31]. This could be due to the fact that sudden increase in height after the first menstruation in the middle age group and in the later time. Therefore, enhancing energy and micronutrient intake has special importance in the late adolescence.

Adolescent girls whose mothers did not have formal education were 2.84 times more likely to be stunted as compared to those whose mothers completed college and above education. This finding is supported by the study done in Bangladesh [14] and Nigeria. This may due to the fact that low job access and poor household decision making power are common social problems of poorly educated mothers which could affect nutritional status of children, including adolescents. Furthermore, early marriage and poor utilization of family planning are also observed among women with low education [35].

The odds of stunting were 1.69 times higher among adolescent girls who had unsatisfactory media exposure compared to those who had satisfactory media exposure. The observed association could be explained by the positive effect of media in changing unhealthy eating behaviors of the community which in turn could contribute for better nutritional outcomes through delivering reliable and clear nutrition information [25]. Moreover, adolescent girls with adequate media exposure might indirectly show their good economic status which in turn indicates resource availability at the household level to improve purchase diversified diet. One the previous scientific report also affirmed that poor feeding practice was associated with adolescents limited media exposure which in turn affect their nutrition condition [36].

Though this study tried fill the knowledge gap by showing the burden and related characteristics of adolescent stunting, some of the limitations should be taken into consideration. Firstly, water and sanitary services of the school environment is not assessed. Secondly, recall bias in measuring the dietary diversity and household food security status are also the possible limitation of the study, although different efforts, as described in the method section, were made to minimize it.

In summary, one-third of adolescent girls are stunted in Gondar District which confirmed serious public health importance of the problem. Age and media exposure of adolescents and mothers education were significantly associated with stunting. Therefore enhancing mother’s education and access to media are important to address the high burden of stunting.