Study design and period
Quantitative cross sectional study was employed in December 2013.
Study area
The study was conducted at Amhara National Regional State which is located in the northwestern part of Ethiopia between 9° 20′ and 14° 20′ North latitude and 36° 20′ and 40° 20′ East longitude. Its land area is about 170,000 square kilometers [10]. The region is divided into 11 zones and 140 Weredas. There are about 3429 Kebeles (the smallest administrative units) in the region. During the study period, the community based nutrition(CBN) program was implemented in 10 Zones and 47 Woredas in Amhara region. The study was conducted in 5 major CBN implementing woredas namely Wogera, Ebnat, Wadla, Chilga and Dembecha [11].
Source and study population
All adolescent girls in all CBN sites in Amhara Region were the sources population. All adolescent girls in selected CBN sites in Amhara region were the study population. Those adolescent girls who were seriously ill at time of data collection were excluded in this study.
Sample size
The sample size of the Study was calculated using single population proportion formula by considering the following assumptions: Proportion of adolescents with stunting as 50 %, margin of error as 4 %, confidence level at 95 %, non response rate of 10 % and design effect of 2. The final sample size for this study was 1320.
Sampling procedure
Multistage cluster sampling was employed to select adolescent girls. There were 11 zones in the region and we have selected 4 zones by simple random sampling, then we have selected 5 woredas where CBN service implemented in 4 different phases. We have selected 15 kebeles by simple random sampling technique, three kebele in each woreda. All adolescents from selected kebeles have been incorporated in the study.
Variables of the study
Stunting and thinness in adolescent girls were considered as dependent variables in this study. Adolescent girls with height-for-age Z-score < −2 from the median value of WHO’s 2006 reference data were considered as stunted and those with BMI-for-age Z-score < −2 were considered as thin. Those adolescent girls with height-for-age or BMI-for-age Z-score < −3 from the median value of 2006 WHO’s reference data were considered as severely stunted or severely thin respectively [12]. Socio demographic variables, economic status, nutrition and health related characteristics were considered as independent variables.
Data collection instruments and procedure
A cross-sectional quantitative study design was employed. Structured questionnaire was used for data collection. The questionnaire was prepared in English first and then translated to Amharic and back to English by language experts to check for consistency. Twenty Nurse data collectors and 7 health officer supervisors were trained for data collection and supervision.
Weight of adolescent girls was measured using beam balance with light closing, and was measured to the nearest 0.1 kg, and height of adolescent girls was measured to the nearest 0.1 cm on standing position without shoes. Checking accuracy of the scale and frequent calibrating of the scale was done.
The categories for dietary diversity were determined by first asking if the adolescent girl had eaten a particular type of food in the previous 24 h prior to date of data collection. These were then combined in to different food groups. Dietary diversity score(DDS) of adolescents was assessed and scored as “poor” for 0–3 food group, as “medium” for 4–5 food group and as “high” for greater than 6 food group.
Food security was assessed using 6-item module and the sum of affirmative responses to the six questions in the module was taken. The food security status of households with raw score 0–1 was described as food secure and the two categories “low food security” and “very low food security” in combination were referred to as food insecure [13].
Data quality control
Data quality was controlled via conducting a pre-test on 5 % of the samples and through supervision during data collection. The completeness of the questionnaire was also checked before data entry. Anthropometric measurements of subjects were done by trained data collectors using standard procedures.
Data processing and analysis
First code was given to the completed questionnaire and then data were entered and analyzed using SPSS version 20 statistical package. Data cleaning was performed to check for accuracy, consistencies and missed values. Any error identified has been corrected. Frequencies, proportion and summary statistics was used to describe the study population in relation to relevant variables. Anthropometric measurements were converted to height-for- age z-scores and BMI-for-age z-scores using WHO Anthroplus software [14]. The levels of undernutrition (thinness and stunting) were regressed against the demographic, socio-economic, health and nutrition related factors. Binary logistic regression model was fitted to identify factors associated with thinness and stunting. The two outcome variables were coded as “1” for having thinness and stunting where as “0” for not having thinness and stunting. Bivariate analysis was performed and variables with p-value < 0.2 in the bivariate analysis were exported to multivariate logistic regression analysis in order to screen strong predictors of undernutrition. Significance was obtained at 95 % CI and p < 0.05.
Ethical considerations
Ethical approval has been obtained from the University of Gondar and permission letter was obtained from Amhara Regional Health Bureau and from zonal and woreda health offices. The questions from the questionnaire has proved not to affect the moral and personality of study subjects. Informed consent was obtained from each study subject after explanation of why they take part in research. They were also informed participation is volunteer based. Confidentiality has been ensured from all the data collectors, supervisors and investigators side using code numbers than names and keeping questionnaires locked.