Undernutrition, intestinal parasitic infection and associated risk factors among selected primary school children in Bahir Dar, Ethiopia

Undernutrition is one of the major causes of child mortality and morbidity in developing countries. Globally, 104 million and 171 million children are stunted and underweight in 2010, respectively [1]. The problem is particularly severe in Africa where 20.2–48.1% of preschool children are stunted and 14–36.5% are underweight [2]. Undernutrition is manifested by protein-energy malnutrition, iodine deficiency disorder, iron deficiency anemia, and vitamin deficiency related problems. The combined effects of these problems have an immense impact on children health, growth, development, and academic performance. Undernutrition is further aggravated by the presence of intestinal parasitic infections.

Intestinal parasitic infections are major health problems in preschool and school children in many developing countries. According to World Health Organization (WHO), more than 1.5 billion peoples are infected with soil-transmitted helminthes and 870 million children are living in areas where parasitic worm infection is endemic[3]. The majority of this burden is concentrated in developing countries mainly in Africa and Asia. For instance, more than 50% of school children in Sub-Saharan Africa are infected with soil-transmitted helminthes [4]. This high burden of helminthic infections further leads to undernutrition through reduced food intake, malabsorption, endogenous nutrient loss and anemia related nutritional problem via excessive blood cell destruction [5]. The presences of hook worm, Schistosoma mansoni, Trichuris trichura and Ascaris lumbricoides infection in particular are associated with undernutrition [6–8]. Undernutrition and helminthic infections are overlapping in many developing countries and may have a negative effect on student growth and development as well as their academic performance [9].

Ethiopia is one of the Sub-Saharan-African countries with high prevalence of intestinal parasitic infections and undernutrition. The prevalence of undernutrition and intestinal parasitic infections are varied from region to region. The overall prevalence of undernutrition in first cycle primary school children in Ethiopia ranges from 11–50% [10–13]. Likewise, the prevalence of intestinal parasitic infections in school children are ranging from 27.2–72% [12, 14, 15] as reported from several parts of the country. Co-occurrence of undernutrition and parasitic infections are not uncommon in the country. For example, about 22.4% of school children were undernourished as well as infected by parasitic organism in Adama, Ethiopia [10].

Epidemiological survey on the prevalence of undernutrition and intestinal parasitic infection is essential to develop appropriate intervention strategies. However, information on the nutritional status, intestinal parasitic infection and associated risk factors among school children in the study area is lacking. Therefore, this study aimed to assess the nutritional status, prevalence of intestinal parasitic infection, and their associated risk factors among first cycle primary school children in Bahir Dar, Ethiopia.

Monitoring of intestinal parasitic infection and nutritional status of school children are essential to improve their health conditions and academic performance through appropriate intervention strategies. The present study revealed that more than half of school children were positive for one or more intestinal parasites. This finding is in agreement with other reports from Ethiopia [12], Ruanda[21] and Tanzania [22]. The present study showed a high prevalence of intestinal parasite as compared with 27.2% [15] and 30% [23] reported from Ethiopia and Sudan, respectively. In the contrary, a high prevalence of intestinal parasitic infection including 69.1% [24] and 72% [25] from Ethiopia, 84.7% from Burkina Faso, [26] and 90% from Yemen [27] were reported from school children. These reported differences may be explained by the difference in methods used in the study, level of environmental sanitation, sources of drinking water and educational level of their family.

Potential risk factors associated with intestinal parasitic infection were determined in the present study. Multivariate logistic regression analysis demonstrated that a the presence of intestinal parasitic infections were strongly associated with undernutrition, irregular hand washing habit, unclean finger nails and being born from an illiterate mothers. The contribution of these risk factors to a high prevalence of intestinal parasites was reported from Ethiopia [28, 29] and Saudi Arabia [30]. As noted, undernutrition may lead to reduced immune responses that in turn render the students susceptible to parasitic infection[6].

Polyparasitic infection is a common problem of school children in developing countries. Multiple parasitic infections were recorded in 6.3% of the students in the present study, which is comparable to other reports from Ethiopia [12, 15] and Pakistan [31]. In contrast to this finding high prevalence of multiple parasitosis was reported from school children in the Philippines [6].

In this study, we investigated undernutrition among children based on the three indicators (stunting, underweight and thinness). The overall prevalence of undernutrition among school children was found to be 41.6%, which is in agreement with other reports from Northwest Ethiopia[12]. Unlike the present study, a low prevalence of undernutrition was reported from different parts of Ethiopia [10, 13, 32], Nepal [33] and Burkina Faso [26]. Family monthly income, meal frequency, and parasitic infection were independently predicting undernutrition among school children in this study. A similar association of undernutrition with intestinal parasitic infection[26], meal frequency [13] and family monthly income[10, 34] were reported elsewhere. Parasitic infection particularly helminthes leads to undernutrition due to competition for essential nutrients as well as endogenous nutrient losses [5]. Hookworm and A. lumbricoides infections were the most prevalent helminthes infection in the study. Among the two helminthes, A. lumbricoides infection was strongly associated with undernutrition. However, the contribution of hookworm infection to undernutrition was not observed. This difference may be associated with the intensity of the worm, which was not determined in the present study.

Stunted student accounts for about one-fifth of the school children in the present study. This finding is in agreement with the report from school children in Uganda [35] and different regions of Ethiopia [10, 13, 24]. In contrast to our finding, high prevalence of stunting were reported in different parts of Ethiopia [12, 36, 37], Burkina Faso [26] and Malaysia [38]. The difference might be associated with source of the study population, food type and frequency, and economic and social factors of the study community. This study showed that stunting was strongly associated with age, meal frequency of students and educational level of the mother, which is in agreement with other studies reported from elsewhere [13, 36, 39]. Stunting is a chronic form of undernutrition, which manifested at the latter age of students. Therefore, it is expected to observe stunting at older age groups compared with younger age groups.

Thinness accounts for about one-fourth of the students participated in the study. A similar proportion of thinness was reported from Ethiopia [24] and the Philippines [6]. This finding was a little bit lower compared to 34–50% [12, 14, 37] reported from Ethiopia. In contrast to our finding, a low prevalence of thinness was reported from Burkina Faso [26], Nepal [33], Uganda [35] and eastern Ethiopia [15]. These reported variations of thinness in school children among countries suggest the differences in the level of acute malnutrition and food shortage in the target population. Intestinal parasitic infection and low family monthly income were important predictors of thinness in the present study. A similar association of thinness with low family monthly income [40] and parasitic infections [26] were reported elsewhere. Thinness is an acute form of undernutrition which is directly associated with family monthly income. This is because low-income family may not provide a balanced diet and other nutritional needs of the children. In addition, presence of intestinal parasitic infection such as A. lumbricoides compete for the existing limited nutrient that further leads to acute undernutrition such as thinness.

The proportion of underweight in the present study was comparable with 28.2% [39] and 24% [41] reported from Ethiopia. The prevalence of underweight in the present study was considerably lower than other reports from north-west Ethiopia [12] and Sri Lanka [42]. In contrast to our finding, low prevalence of underweight were reported from Ethiopia [13], Egypt [43] and Uganda [35]. These reported differences of underweight could be associated with variation in the socioeconomic level of the family of the target students. The major determinants of underweight in the present study were intestinal parasitic infection, meal frequency and sex of children. Previous studies have reported the contribution of intestinal parasitic infection [26, 35], being male sex [35] and meal frequency [39] on underweight status.

The present study revealed that undernutrition and intestinal parasitic infections were serious health problem in school children in our study areas. Family monthly income, meal frequency and intestinal parasitic infection were the major predisposing factors for undernutrition. Similarly, mother education, hand washing habit, undernutrition and finger cleanness of students were associated with parasitic infection. Therefore, concerted efforts are needed to address the risk factors of intestinal parasitic infection and undernutrition.