# Nutritional Status and Educational Performance of School-Aged Children in Lalibela Town Primary Schools, Northern Ethiopia

Authors: Muluken Ayalew; Alemayehu Bayray; Abate Bekele; Simegnew Handebo
Journal: International Journal of Pediatrics
 (2020)

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## Abstract

Background. Every student has the potential to do well in school. Failing to provide good nutrition puts them at risk for missing out on meeting that potential and leads to long-term irreversible damage to cognitive development. However, taking action today to provide healthier choices in schools can help set students up for a successful future full of possibilities. So, this study is aimed at assessing the effect of nutritional status on academic performance of school-aged children. Methods. A school-based cross-sectional study was conducted from Feb 05- March 30, 2017 in Lalibela town. A total of 505 primary school students were included in the study. The child anthropometric measures were calculated using AnthroPlus software version 1.0.4 WHO 2007 standards. Bivariable and multivariable ordinal logistic regression were fitted. The proportional odds ratio (POR) with a 95% CI and P value < 0.05 were considered statistically significant. Results. The overall prevalence of stunting, underweight, and thinness was 29.5%, 35.7%, and 29.5%, respectively. In this study, 14.7% of the study participants had low academic achievement in the semester. The multivariable analysis showed that rural residence (POR=0.39; 95% CI: (0.21, 0.75)), not studying regularly (POR=0.49; 95% CI: (0.29, 0.82)), severe underweight (POR=0.25; 95% CI: (0.09, 0.71)), and severe stunting (POR=0.03; 95% CI: (0.01, 0.37)) were associated with decreased odds of high average semester score achievement of school-aged children. Additionally, higher maternal educational status (POR=2.12; 95% CI: (1.10, 4.07)) and family income from 550 to 2999 ETB (POR=1.71; 95% CI: (1.04, 2.81)) were associated with increased odds of high semester average score achievement. Conclusion. Nearly one-third of school-aged children in Lalibela town were stunted, thin, and underweight. Rural place of residence, not studying regularly study, underweight, and stunting were associated with decreased academic achievement. While, family monthly income from 550 to 2999 ETB and higher maternal education status were associated with increased academic achievement.


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## Body

## 1. Background

Globally, the magnitude and severity of malnutrition are still a public health problem. Malnourishment accounts for 2.6 million of deaths per year and more than 450 million children’s failure in somatic and mental development [1]. Child undernutrition is a challenge of global health, especially in low- and middle-income countries [2]. Current evidences on children in Africa, Asia, and Latin America reported that the mortality of stunted and underweight children was greater than three times that of well-nourished children [3].Anthropometric indices are commonly used to assess nutritional status, health, and development of children as well as the whole population [4, 5]. Nutritional status depends on dietary intake of food, nutrients, diseases and overall health status, and health care practices, which indirectly affects the educational performances [6]. Academic performance, intellectual development, and school attendance of the children and adolescents were adversely affected by undernutrition. On the other hand, good nutrition was associated with progress of perceptive and behavioral talents and improved school attendance [7, 8].Empirical evidences witnessed the influence of nutritional status on academic achievement of the students. For example, in Indonesia, the cognitive development of preschool children was significantly affected by stunting, underweight, and severe wasting [9]. Additionally, low level of educational performance (marks<40%) in Tamil (a language in Nuwara Eliya Educational Zone), mathematics, and overall subject average was significantly associated with underweight [10]. On the other hand, stunting is associated with decreased school-age enrolment and reduced achievement equivalent to three years of schooling as well as productivity deficit of greater than 20% [8, 11].Though there are different issues raised for poor educational performances, 16% of the total repetition rate in primary education is highly associated with stunting in Ethiopia [12]. The participation rate of primary education is less than 22% of the relevant age cohort [13]. Similarly, realities in the country indicates that low educational performance rate of children with stunting is 15.1% and 11.2% with nonstunted children [14]. So, undernutrition was pointed to be associated with low educational achievements in primary education [15]. Higher risk of grade repetition and dropout of schools among age category of 6-18 years is still because of stunting [12].Although there are several reports of malnutrition in Ethiopia, the relationship of nutritional status and educational performance of school-aged children was not yet explored in different areas of the country. Thus, this study was aimed at assessing nutritional status and academic achievements of primary school children in Lalibela, Northern Ethiopia.


## 2. Methods

### 2.1. Study Setting and Design

A school-based cross-sectional study was carried out from February 5 to March 30, 2017 in Lalibela town. Lalibela town is located in North Wollo Administrative Zone, which is 701 km from Addis Ababa, the capital of Ethiopia. According to the town health bureau population profile, the total population of the town is estimated to be 32,668. One district hospital and a health center provide health service in the town. With regard to education, one College, one preparatory school, one high school, nine primary schools, and two kindergarten schools are available in the town. There are about 2,992 total children in primary schools in the town [16].


### 2.2. Study Population

All school-aged children in Lalibela primary schools and those who lived in the town for at least six months were recruited in the study. The sample size was computed using Epi Info version 7, by considering the following assumptions: proportion of low academic performance in unexposed 34.9% [10], power=80%, two−sidedCI=95%, ratiounexposed:exposed=1, and OR=1.667. By adding 10% nonresponse rate, the final sample size was 542. Four public schools were selected randomly from nine primary schools in Lalibela town. The sample size was distributed proportionally to the selected schools. Then, simple random sampling method was employed to select each study participant.


### 2.3. Data Collection Procedures

Structured, pretested, and interviewer-administered questionnaires were used for data collection. First, the questionnaire was prepared in English and translated into the local language, Amharic, and then translated back to English to check the consistency. Mothers or caregivers were interviewed on socioeconomic and other demographic data. Anthropometric data (height and weight) were collected from the school-aged children using standardized procedures. Weight was measured to the nearest 0.1 kg with an electronic scale. Child height was measured to the nearest 0.1 cm using a wooden stadiometer placed on a flat surface. Regarding educational performance, 2017-year first semester scores on Amharic (local language), English, Mathematics, and Science courses as well as semester average score were extracted from the roster book of students in each school. Three supervisors and five clinical nurse data collectors were recruited for data collection. Intensive training was given for the data collectors and supervisors by the primary investigator.


### 2.4. Study Variables

Academic performance was defined as low score if less than 50%, medium score if 50%-75%, and high score if ≥75% [15]. Undernutrition was assessed according to the new WHO recommendation using stunting (height-for-age score (HAZ−score<−2SD), underweight is a weight for age (WAZ−score≤−2SD), and thinness (body mass index for ageBAZ<−2SD. The four categories were defined as normal (+1 to -1SD Z-score), mild (between -1 and -2SD Z-score), moderate (between -2 and -3SD Z-score), and severe (less than -3SD Z-score) [17].


### 2.5. Data Processing and Analysis

Data were coded and entered in SPSS version 22 and exported to Stata version 14 statistical software for analysis. HAZ, WAZ, and BAZ were calculated using AnthroPlus software version 1.0.4 by the WHO 2007 growth reference standard. Descriptive statistics were used to present the findings. A bivariable analysis was done for each subject and total average score separately. Variables withP values of < 0.2 in the bivariable analysis were entered into a multivariable ordinal logistic regression analysis to identify the independent predictors associated with academic achievement. In the multivariable ordinal regression, the statistical significance of a variable was declared with a P value of < 0.05. The proportional odds assumption was checked using the Pearson chi-squared goodness-of-fit test, and data were consistent with the fitted model.


### 2.6. Ethical Consideration

The procedure of this study was approved by the Institutional Review Board of Mekelle University College of Health Sciences. Formal letters of cooperation were written to all selected public primary schools in Lalibela Town Administration. Written consent was obtained from each parent, caregivers, and directly from the school directors of all study participants. Parents and caregivers were kindly asked by formal letter to get permission before any procedure. Then, each study participant was asked for their willingness to participate in the study. Furthermore, we gave all the participants a full right to discontinue the procedures when they assumed that things were going bad with them.


## 2.1. Study Setting and Design

A school-based cross-sectional study was carried out from February 5 to March 30, 2017 in Lalibela town. Lalibela town is located in North Wollo Administrative Zone, which is 701 km from Addis Ababa, the capital of Ethiopia. According to the town health bureau population profile, the total population of the town is estimated to be 32,668. One district hospital and a health center provide health service in the town. With regard to education, one College, one preparatory school, one high school, nine primary schools, and two kindergarten schools are available in the town. There are about 2,992 total children in primary schools in the town [16].


## 2.2. Study Population

All school-aged children in Lalibela primary schools and those who lived in the town for at least six months were recruited in the study. The sample size was computed using Epi Info version 7, by considering the following assumptions: proportion of low academic performance in unexposed 34.9% [10], power=80%, two−sidedCI=95%, ratiounexposed:exposed=1, and OR=1.667. By adding 10% nonresponse rate, the final sample size was 542. Four public schools were selected randomly from nine primary schools in Lalibela town. The sample size was distributed proportionally to the selected schools. Then, simple random sampling method was employed to select each study participant.


## 2.3. Data Collection Procedures

Structured, pretested, and interviewer-administered questionnaires were used for data collection. First, the questionnaire was prepared in English and translated into the local language, Amharic, and then translated back to English to check the consistency. Mothers or caregivers were interviewed on socioeconomic and other demographic data. Anthropometric data (height and weight) were collected from the school-aged children using standardized procedures. Weight was measured to the nearest 0.1 kg with an electronic scale. Child height was measured to the nearest 0.1 cm using a wooden stadiometer placed on a flat surface. Regarding educational performance, 2017-year first semester scores on Amharic (local language), English, Mathematics, and Science courses as well as semester average score were extracted from the roster book of students in each school. Three supervisors and five clinical nurse data collectors were recruited for data collection. Intensive training was given for the data collectors and supervisors by the primary investigator.


## 2.4. Study Variables

Academic performance was defined as low score if less than 50%, medium score if 50%-75%, and high score if ≥75% [15]. Undernutrition was assessed according to the new WHO recommendation using stunting (height-for-age score (HAZ−score<−2SD), underweight is a weight for age (WAZ−score≤−2SD), and thinness (body mass index for ageBAZ<−2SD. The four categories were defined as normal (+1 to -1SD Z-score), mild (between -1 and -2SD Z-score), moderate (between -2 and -3SD Z-score), and severe (less than -3SD Z-score) [17].


## 2.5. Data Processing and Analysis

Data were coded and entered in SPSS version 22 and exported to Stata version 14 statistical software for analysis. HAZ, WAZ, and BAZ were calculated using AnthroPlus software version 1.0.4 by the WHO 2007 growth reference standard. Descriptive statistics were used to present the findings. A bivariable analysis was done for each subject and total average score separately. Variables withP values of < 0.2 in the bivariable analysis were entered into a multivariable ordinal logistic regression analysis to identify the independent predictors associated with academic achievement. In the multivariable ordinal regression, the statistical significance of a variable was declared with a P value of < 0.05. The proportional odds assumption was checked using the Pearson chi-squared goodness-of-fit test, and data were consistent with the fitted model.


## 2.6. Ethical Consideration

The procedure of this study was approved by the Institutional Review Board of Mekelle University College of Health Sciences. Formal letters of cooperation were written to all selected public primary schools in Lalibela Town Administration. Written consent was obtained from each parent, caregivers, and directly from the school directors of all study participants. Parents and caregivers were kindly asked by formal letter to get permission before any procedure. Then, each study participant was asked for their willingness to participate in the study. Furthermore, we gave all the participants a full right to discontinue the procedures when they assumed that things were going bad with them.


## 3. Results

### 3.1. Sociodemographic Characteristics

A total of 505 school-aged children were included in the study which gives the response rate of 93%. The mean age of the participant was9.45±1.97 year. About 89.7% and 78.6% of the participants were living with their mothers and live in urban setting, respectively. Majority of them (98.6%) were Orthodox Christian. With regard to maternal characteristics, 79.3% and 46.9% of the mothers were married and illiterate on educational status, see Table 1.Table 1
Sociodemographic and economic characteristics of the study participants in Lalibela primary schools (N=505), 2017.
Variables
Frequencies
Percent (%)
Gender
Male
252
49.90
Female
253
50.10
Is a child living with his mother?
Yes
453
89.70
No
52
10.30
Maternal age (year)
<20
3
0.59
20-25
44
8.71
26-29
90
17.82
30-35
140
27.72
>35
228
45.15
Residence
Urban
397
78.61
Rural
108
21.39
Maternal marital status:
Married
410
81.19
Divorced
50
9.90
Separated
33
6.53
Widowed
12
2.38
Maternal religion
Orthodox
498
98.61
Muslim
7
1.39
Family income per month (ETB)
<1000
251
49.70
1001-2500
189
37.43
2501 and above
65
12.87
Number of family living together
2
46
9.1
3-5
307
60.8
>5
152
30.1


### 3.2. Nutritional Status

The prevalence of stunting, underweight, and thinness was 29.5%, 35.7%, and 29.5%, respectively. Of all study participants, 89.3% ate breakfast and/or lunch before they went to school. Additionally, 55% of the study participant’s household did not use iodized salt. 19.6% of the families reported that they had offered special food like fish oil for their child during childhood period.


### 3.3. School Environmental and Academic Performance

In majority, 95.4% and 88.1% of the children like their school and have a smooth relationship with teachers and school administration. Among all study participants, 74.3% study their lesson on a regular basis and 87.7% did their homework and exercise. With regard to academic achievement, among all study participants, 17.6% in Amharic, 19.2% in English, 15.8% in Science, and 26.1% in the Mathematics course had low academic achievement. Additionally, 14.7% of them had scored below 50% on the semester average, see Table2.Table 2
Descriptive results of academic performance of primary school children in Lalibela (N=505), 2017.
Variables
Frequency
Percent
Amharic score
<50
89
17.6
50-75
215
42.6
>75
201
39.8
English score
<50
97
19.2
50-75
246
48.7
>75
162
32.1
Science score
<50
80
15.8
50-75
220
43.6
>75
205
40.6
Mathematics score
<50
132
26.1
50-75
207
41.0
>75
166
32.9
Semester average score
<50
74
14.7
50-75
257
50.9
>75
174
34.5


### 3.4. Factors Associated with Academic Performance of School-Aged Children

In this study, five ordinal regression models were fitted; one for overall semester average and four for each course. In the multivariable analysis, place of residence, maternal educational status, family income, studying regularly, underweight, and stunting were associated with semester average achievement of school-aged children. For a child who lived in the rural, the odds of high average semester score achievement was decreased by 61% compared to those who lived in urban settings given that all of the other variables in the model are held constant (POR=0.39; 95% CI: (0.21, 0.75)). Children who have mothers with secondary and above educational status had more than two times higher average semester score than children with illiterate mothers (POR=2.12; 95% CI: (1.10, 4.07)). Additionally, a child whose family’s income was from 550 to 2999 ETB had 1.71 times higher odds of achieving high average semester score (POR=1.71; 95% CI: (1.04, 2.81)) compared to that whose income was less than 550 ETB. Compared to children who study regularly, the odds of achieving high average semester score was decreased by 51% (POR=0.49; 95% CI: (0.29, 0.82) among students who will not do so. Concerning nutritional status, severely underweighted children have 75% decreased achievement on average semester score compared to normal weighted children (POR=0.25; 95% CI: (0.09, 0.71)). Similarly, severely stunted children have 97% decreased average semester score compared to normal children (POR=0.03; 95% CI: (0.01, 0.37)), see Table 3.Table 3
Factors associated with average semester score achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Semester average score achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
55
209
146
1
1
Divorced
14
23
13
0.5 (0.28,0.90)∗
0.65 (0.30, 1.4)
Separated
4
16
13
1.16 (0.59,2.29)
1.6 (0.64, 4.21)
Widowed
1
9
2
0.66 (0.23,1.84)
0.96 (0.28, 3.3)
Residence
Urban
59
183
155
1
1
Rural
15
74
19
0.54 (0.36, 0.81)∗
0.39 (0.21,0.75)∗
Maternal education status
Illiterate
38
137
62
1
1
Primary
26
71
52
1.26 (0.85, 1.88)
1.20 (0.71, 2.03)
Secondary and above
10
48
60
2.63(1.71, 4.05)∗
2.12 (1.10, 4.07)∗
Maternal occupation
Housewife
47
177
106
1
1
Employed
14
32
36
1.37 (0.85, 2.20)
0.90 (0.46, 1.76)
Private business
4
22
21
1.69 (0.94, 3.03)
0.87 (0.40, 1.86)
Other
9
26
11
0.68 (0.38, 1.23)
0.56 (0.24, 1.34)
Number of family living together
<2
15
19
12
1
1
3-5
38
156
113
2.45 (1.31, 4.56)∗
1.43 (0.62, 3.29)
>5
21
82
49
2.05 (1.07, 3.96)∗
1.62 (0.65, 4.05)
HH income
<550
48
137
66
1
1
550-2999
22
95
72
1.75 (1.21, 2.52)∗
1.71 (1.04, 2.81)∗
>3000
4
25
36
3.5 (2.04, 6.03)∗
1.32 (0.61, 2.85)
HH iodized salt use
Yes
33
97
98
1
1
No
41
160
76
0.61 (0.43, 0.85)∗
0.87 (0.54, 1.41)
Special foods took during childhood
Yes
9
39
51
1
1
No
65
218
123
0.43 (0.28, 0.66)∗
0.74 (0.41, 1.33)
Regular study
Yes
48
191
136
1
1
No
26
66
38
0.67(0.46,0.99)∗
0.49(0.29,0.82) ∗
Under weight
Normal
3
64
35
1
1
Mild
8
59
54
1.29(0.78,2.11)
0.90(0.46,1.77)
Moderate
27
39
24
0.39(0.22,0.68)∗
0.25(0.09,0.71) ∗
Severe
11
12
11
0.43(0.19,0.95)∗
0.61(0.15,2.47)
Stunting
Normal
11
108
56
1
1
Mild
17
96
69
1.12 (0.76, 1.65)
1.48 (0.84, 2.61)
Moderate
32
46
41
0.64 (0.40, 1.01)
0.89 (0.37, 2.15)
Severe
14
7
8
0.24 (0.11, 0.56)
0.03 (0.01, 0.37)
Thinness
Normal
14
115
72
1
1
Mild
24
75
56
0.83 (0.56, 1.24)
1.22 (0.64, 2.32)
Moderate
23
45
36
0.67 (0.42, 1.06)
1.49 (0.62, 3. 60)
Severe
13
22
10
0.38 (0.20, 0.71)
0.64 (0.20, 2.02)In the second ordinal regression model, the Science course score was modeled. Accordingly, the results reveal that achieving higher Science course score was decreased by 52% among children who lived in rural areas as compared to urban dwellers (POR=0.48; 95% CI: (0.26, 0.90). Additionally, a child whose family’s income was from 550 to 2999 ETB had 1.67 times higher odds of achieving a high Science course score (POR=1.67; 95% CI: (1.02, 2.75)) compared to that whose income was less than 550 ETB. With regard to nutritional status, moderate underweighted children had 68% decreased odds of achieving high science score compared to normal underweighted children (POR=0.32; 95% CI: (0.12, 0.89)). Similarly, severely stunted children had 90% decreased odds of achieving a high Science score compared to stunted children as compared to normal children (POR=0.10; 95% CI: (0.02, 0.61)), see Table 4.Table 4
Factors associated with Science course achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Science course achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
57
184
169
1
1
Divorced
16
16
18
0.55 (0.31, 0.99)
0.85 (0.39, 1.87)
Separated
4
14
15
1.18 (0.60, 2.31)
1.77 (0.70, 4.52)
Widowed
3
6
3
0.49 (0.17, 1.43)
0.67 (0.19, 2.35)
Residence
Urban
62
155
180
1
1
Rural
18
65
25
0.52 (0.35, 0.77)
0.48 (0.26, 0.90)∗
Maternal education status
Illiterate
41
114
82
1
1
Primary
26
63
60
1.18 (0.80, 1.73)
1.23 (0.73, 2.08)
Secondary and above
13
43
62
1.98 (1.29, 3.03)
1.34 (0.71, 2.54)
Maternal occupation
Housewife
48
158
124
1
1
Employed
15
26
41
1.36 (0.85, 2.18)
1.09 (0.55, 2.15)
Private business
7
16
24
1.51 (0.83, 2.73)
0.91 (0.42, 1.97)
Other
10
20
16
0.79 (0.44, 1.41)
0.69 (0.29, 1.65)
Number of family living together
< 2
12
20
14
1
1
3-5
46
131
130
1.83 (1.01, 3.29)
1.04 (0.47, 2.30)
>5
22
69
61
1.73 (0.92, 3.30)
1.74 (0.73, 4.15)
HH income
<550
47
124
80
1
1
550-2999
27
76
86
1.65 (1.15, 2.37)∗
1.67 (1.02, 2.75)∗
>3000
6
20
39
2.98 (1.73, 5.13)∗
1.29 (0.59, 2.83)
HH iodized salt use
Yes
36
81
111
1
1
No
44
139
94
0.64 (0.46, 0.89)
0.71 (0.44, 1.14)
Does the child take special foods?
Yes
11
34
54
1
1
No
69
186
151
0.51 (0.33, 0.79)
0.92 (0.51, 1.66)
Sick with diarrhea
Yes
22
60
42
1
1
No
58
160
163
1.37 (0.94, 2.00)
1.40 (0.84, 2.33)
Regular study
Yes
54
164
157
1
1
No
26
56
48
0.76 (0.52, 1.12)
0.65 (0.39, 1.08)
No
42
69
52
0.49 (0.34, 0.71)∗
0.70 (0.41, 1.20)
Does the child like the school environment?
Yes
74
207
201
1
1
No
6
12
4
0.40 (0.18, 0.88)
0.46 (0.17, 1.21)
Under weight
Normal
6
55
41
1
1
Mild
8
52
61
1.37 (0.83, 2.25)
0.85 (0.44, 1.66)
Moderate
24
35
31
0.51 (0.30, 0.89)
0.32 (0.12, 0.89)∗
Severe
9
16
9
0.41 (0.19, 0.86)
0.59 (0.15, 2.33)
Stunting
Normal
15
89
71
1
1
Mild
15
81
86
1.23 (0.84, 1.82)
1.68 (0.95, 2.98)
Moderate
36
44
39
0.48 (0.30, 0.75)
0.64 (0.27, 1.53)
Severe
14
6
9
0.25 (0.11, 0.57)
0.10 (0.02, 0.61)∗
Thinness
Normal
21
101
79
1
1
Mild
25
58
72
1.11 (0.75, 1.65)
1.75 (0.92, 3.31)
Moderate
23
37
44
0.85 (0.54, 1.34)
1.95 (0.83, 4.58)
Severe
11
24
10
0.46 (0.25, 0.83)
0.60 (0.38, 1.89)With regard to Mathematics course score, a child whose family’s income was from 550 to 2999 ETB had 1.73 times higher odds of achieving a high Mathematics course score (POR=1.73; 95% CI: (1.06, 2.81)) compared to that whose income was less than 550 ETB. Additionally, a child who did not study his/her lesson regularly had 41% decreased odds of achieving higher Mathematics course compared to their counterparts (POR=0.59; 95% CI: (0.36, 0.97)). With regard to nutritional status moderate underweighted (POR=0.34; 95% CI: (0.12, 0.92)) and severely stunted (POR=0.05; 95% CI: (0.004, 0.48)) children had 64% and 95% decreased odds of scoring a high Mathematics score as compared to normal children, respectively, see Table 5.Table 5
Factors associated with Mathematics course achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Mathematics course achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
103
168
139
1
1
Divorced
17
19
14
0.70 (0.40, 1.21)
0.91 (0.43, 1.93)
Separated
7
14
12
1.16 (0.60, 2.23)
1.28 (0.52, 3.12)
Widowed
5
6
1
0.38 (0.13, 1.07)
0.41 (0.12, 1.43)
Maternal education status
Illiterate
68
103
66
1
1
Primary
45
58
46
1.04 (0.71, 1.52)
0.80 (0.48, 1.34)
Secondary and above
19
45
54
2.12 (1.10, 3.2)
1.85 (0.98, 3.49)
Maternal occupation
Housewife
85
146
99
1
1
Employed
25
22
35
1.26 (0.79, 2.00)
0.88 (0.45, 1.72)
Private business
7
21
19
1.65 (0.94, 2.88)
0.88 (0.42, 1.85)
Other
15
18
13
0.81 (0.46, 1.44)
0.77 (0.33, 1.79)
Number of family living together
<2
18
18
10
1
1
3-5
73
124
110
2.05 (1.15, 3.67)
1.60 (0.72, 3.53)
>5
41
65
46
1.66 (0.90, 3.06)
1.94 (0.81, 4.64)
Residence
Urban
104
145
148
1
1
Rural
28
62
18
0.62 (0.42, 0.91)
0.59 (0.32, 1.07)
HH income
<550
75
114
62
1
1
550-2999
48
68
73
1.58 (1.11, 2.25)
1.73 (1.06, 2.81)
>3000
9
25
31
2.60 (1.56, 4.36)
1.39 (0.65, 2.95)
HH iodized salt use
Yes
54
82
92
1
1
No
78
125
74
0.64 (0.46, 0.88)
0.96 (0.60, 1.53)
Deworming
Yes
99
166
135
1
1
No
33
41
31
0.77 (0.52, 1.15)
0.61 (0.38, 1.04)
Does the child eat breakfast/lunch before school?
Yes
113
187
151
1
1
No
19
20
15
0.68 (0.40, 1.15)
1.29 (0.60, 2.77)
Does the child take special foods?
Yes
16
38
45
1
1
No
116
169
121
0.50 (0.33, 0.76)
0.85 (0.48, 1.49)
Regular study
Yes
86
156
133
1
1
No
46
51
33
0.58 (0.40, 0.84)
0.59 (0.36, 0.97)
Does the child like the school environment?
Yes
121
201
160
1
1
No
10
6
6
0.51 (0.22, 1.16)
0.99 (0.36, 2.73)
Under weight
Normal
9
60
33
1
1
Mild
16
54
51
1.20 (0.74, 1.93)
0.93 (0.49, 1.77)
Moderate
40
21
29
0.41 (0.24, 0.71)
0.34 (0.12, 0.92)∗
Severe
15
9
10
0.39 (0.18, 0.83)
0.66 (0.17, 2.58)
Stunting
Normal
21
102
52
1
1
Mild
39
73
70
1.03 (0.71, 1.51)
1.58 (0.91, 2.75)
Moderate
55
26
38
0.45 (0.29, 0.70)
0.63 (0.27, 1.49)
Severe
17
6
6
0.23 (0.10 ,0.51)
0.05 (0.004, 0.48)∗
Thinness
Normal
34
102
65
1
1
Mild
44
55
56
0.86 (0.58, 1.26)
1.33 (0.71, 2.47)
Moderate
36
34
34
0.67 (0.43, 1.05)
1.36 (0.58, 3.18)
Severe
18
16
11
0.48 (0.26, 0.87)
0.99 (0.33, 3.04)In the multivariable analysis, ordinal logistic regression maternal education status, family size, residence, and underweight were statistically significant predictors of English and Amharic course scores. Moderate underweighted children had 66% decreased odds of achieving high English (POR=0.34; 95% CI: (0.13, 0.91)) and Amharic (POR=0.34; 95% CI: (0.13, 0.92)) courses score as compared to normal weighed children. Similarly, a child whose mother had secondary and above educational status has 2.02 and 2.78 times higher odds of achieving high English (POR=2.54; 95% CI: (1.09, 3.77) and Amharic (POR=2.78; 95% CI: (1.47, 5.26) course scores as compared to a child with an illiterate mother, respectively. A child who lives with more than five family members had 2.54 times higher odds of achieving higher English course score as compared to those who lived with less than two family members. On the other hand, a child who lived in rural areas had 65% decreased odds of achieving a high Amharic course score than those who lived in urban areas.


## 3.1. Sociodemographic Characteristics

A total of 505 school-aged children were included in the study which gives the response rate of 93%. The mean age of the participant was9.45±1.97 year. About 89.7% and 78.6% of the participants were living with their mothers and live in urban setting, respectively. Majority of them (98.6%) were Orthodox Christian. With regard to maternal characteristics, 79.3% and 46.9% of the mothers were married and illiterate on educational status, see Table 1.Table 1
Sociodemographic and economic characteristics of the study participants in Lalibela primary schools (N=505), 2017.
Variables
Frequencies
Percent (%)
Gender
Male
252
49.90
Female
253
50.10
Is a child living with his mother?
Yes
453
89.70
No
52
10.30
Maternal age (year)
<20
3
0.59
20-25
44
8.71
26-29
90
17.82
30-35
140
27.72
>35
228
45.15
Residence
Urban
397
78.61
Rural
108
21.39
Maternal marital status:
Married
410
81.19
Divorced
50
9.90
Separated
33
6.53
Widowed
12
2.38
Maternal religion
Orthodox
498
98.61
Muslim
7
1.39
Family income per month (ETB)
<1000
251
49.70
1001-2500
189
37.43
2501 and above
65
12.87
Number of family living together
2
46
9.1
3-5
307
60.8
>5
152
30.1


## 3.2. Nutritional Status

The prevalence of stunting, underweight, and thinness was 29.5%, 35.7%, and 29.5%, respectively. Of all study participants, 89.3% ate breakfast and/or lunch before they went to school. Additionally, 55% of the study participant’s household did not use iodized salt. 19.6% of the families reported that they had offered special food like fish oil for their child during childhood period.


## 3.3. School Environmental and Academic Performance

In majority, 95.4% and 88.1% of the children like their school and have a smooth relationship with teachers and school administration. Among all study participants, 74.3% study their lesson on a regular basis and 87.7% did their homework and exercise. With regard to academic achievement, among all study participants, 17.6% in Amharic, 19.2% in English, 15.8% in Science, and 26.1% in the Mathematics course had low academic achievement. Additionally, 14.7% of them had scored below 50% on the semester average, see Table2.Table 2
Descriptive results of academic performance of primary school children in Lalibela (N=505), 2017.
Variables
Frequency
Percent
Amharic score
<50
89
17.6
50-75
215
42.6
>75
201
39.8
English score
<50
97
19.2
50-75
246
48.7
>75
162
32.1
Science score
<50
80
15.8
50-75
220
43.6
>75
205
40.6
Mathematics score
<50
132
26.1
50-75
207
41.0
>75
166
32.9
Semester average score
<50
74
14.7
50-75
257
50.9
>75
174
34.5


## 3.4. Factors Associated with Academic Performance of School-Aged Children

In this study, five ordinal regression models were fitted; one for overall semester average and four for each course. In the multivariable analysis, place of residence, maternal educational status, family income, studying regularly, underweight, and stunting were associated with semester average achievement of school-aged children. For a child who lived in the rural, the odds of high average semester score achievement was decreased by 61% compared to those who lived in urban settings given that all of the other variables in the model are held constant (POR=0.39; 95% CI: (0.21, 0.75)). Children who have mothers with secondary and above educational status had more than two times higher average semester score than children with illiterate mothers (POR=2.12; 95% CI: (1.10, 4.07)). Additionally, a child whose family’s income was from 550 to 2999 ETB had 1.71 times higher odds of achieving high average semester score (POR=1.71; 95% CI: (1.04, 2.81)) compared to that whose income was less than 550 ETB. Compared to children who study regularly, the odds of achieving high average semester score was decreased by 51% (POR=0.49; 95% CI: (0.29, 0.82) among students who will not do so. Concerning nutritional status, severely underweighted children have 75% decreased achievement on average semester score compared to normal weighted children (POR=0.25; 95% CI: (0.09, 0.71)). Similarly, severely stunted children have 97% decreased average semester score compared to normal children (POR=0.03; 95% CI: (0.01, 0.37)), see Table 3.Table 3
Factors associated with average semester score achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Semester average score achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
55
209
146
1
1
Divorced
14
23
13
0.5 (0.28,0.90)∗
0.65 (0.30, 1.4)
Separated
4
16
13
1.16 (0.59,2.29)
1.6 (0.64, 4.21)
Widowed
1
9
2
0.66 (0.23,1.84)
0.96 (0.28, 3.3)
Residence
Urban
59
183
155
1
1
Rural
15
74
19
0.54 (0.36, 0.81)∗
0.39 (0.21,0.75)∗
Maternal education status
Illiterate
38
137
62
1
1
Primary
26
71
52
1.26 (0.85, 1.88)
1.20 (0.71, 2.03)
Secondary and above
10
48
60
2.63(1.71, 4.05)∗
2.12 (1.10, 4.07)∗
Maternal occupation
Housewife
47
177
106
1
1
Employed
14
32
36
1.37 (0.85, 2.20)
0.90 (0.46, 1.76)
Private business
4
22
21
1.69 (0.94, 3.03)
0.87 (0.40, 1.86)
Other
9
26
11
0.68 (0.38, 1.23)
0.56 (0.24, 1.34)
Number of family living together
<2
15
19
12
1
1
3-5
38
156
113
2.45 (1.31, 4.56)∗
1.43 (0.62, 3.29)
>5
21
82
49
2.05 (1.07, 3.96)∗
1.62 (0.65, 4.05)
HH income
<550
48
137
66
1
1
550-2999
22
95
72
1.75 (1.21, 2.52)∗
1.71 (1.04, 2.81)∗
>3000
4
25
36
3.5 (2.04, 6.03)∗
1.32 (0.61, 2.85)
HH iodized salt use
Yes
33
97
98
1
1
No
41
160
76
0.61 (0.43, 0.85)∗
0.87 (0.54, 1.41)
Special foods took during childhood
Yes
9
39
51
1
1
No
65
218
123
0.43 (0.28, 0.66)∗
0.74 (0.41, 1.33)
Regular study
Yes
48
191
136
1
1
No
26
66
38
0.67(0.46,0.99)∗
0.49(0.29,0.82) ∗
Under weight
Normal
3
64
35
1
1
Mild
8
59
54
1.29(0.78,2.11)
0.90(0.46,1.77)
Moderate
27
39
24
0.39(0.22,0.68)∗
0.25(0.09,0.71) ∗
Severe
11
12
11
0.43(0.19,0.95)∗
0.61(0.15,2.47)
Stunting
Normal
11
108
56
1
1
Mild
17
96
69
1.12 (0.76, 1.65)
1.48 (0.84, 2.61)
Moderate
32
46
41
0.64 (0.40, 1.01)
0.89 (0.37, 2.15)
Severe
14
7
8
0.24 (0.11, 0.56)
0.03 (0.01, 0.37)
Thinness
Normal
14
115
72
1
1
Mild
24
75
56
0.83 (0.56, 1.24)
1.22 (0.64, 2.32)
Moderate
23
45
36
0.67 (0.42, 1.06)
1.49 (0.62, 3. 60)
Severe
13
22
10
0.38 (0.20, 0.71)
0.64 (0.20, 2.02)In the second ordinal regression model, the Science course score was modeled. Accordingly, the results reveal that achieving higher Science course score was decreased by 52% among children who lived in rural areas as compared to urban dwellers (POR=0.48; 95% CI: (0.26, 0.90). Additionally, a child whose family’s income was from 550 to 2999 ETB had 1.67 times higher odds of achieving a high Science course score (POR=1.67; 95% CI: (1.02, 2.75)) compared to that whose income was less than 550 ETB. With regard to nutritional status, moderate underweighted children had 68% decreased odds of achieving high science score compared to normal underweighted children (POR=0.32; 95% CI: (0.12, 0.89)). Similarly, severely stunted children had 90% decreased odds of achieving a high Science score compared to stunted children as compared to normal children (POR=0.10; 95% CI: (0.02, 0.61)), see Table 4.Table 4
Factors associated with Science course achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Science course achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
57
184
169
1
1
Divorced
16
16
18
0.55 (0.31, 0.99)
0.85 (0.39, 1.87)
Separated
4
14
15
1.18 (0.60, 2.31)
1.77 (0.70, 4.52)
Widowed
3
6
3
0.49 (0.17, 1.43)
0.67 (0.19, 2.35)
Residence
Urban
62
155
180
1
1
Rural
18
65
25
0.52 (0.35, 0.77)
0.48 (0.26, 0.90)∗
Maternal education status
Illiterate
41
114
82
1
1
Primary
26
63
60
1.18 (0.80, 1.73)
1.23 (0.73, 2.08)
Secondary and above
13
43
62
1.98 (1.29, 3.03)
1.34 (0.71, 2.54)
Maternal occupation
Housewife
48
158
124
1
1
Employed
15
26
41
1.36 (0.85, 2.18)
1.09 (0.55, 2.15)
Private business
7
16
24
1.51 (0.83, 2.73)
0.91 (0.42, 1.97)
Other
10
20
16
0.79 (0.44, 1.41)
0.69 (0.29, 1.65)
Number of family living together
< 2
12
20
14
1
1
3-5
46
131
130
1.83 (1.01, 3.29)
1.04 (0.47, 2.30)
>5
22
69
61
1.73 (0.92, 3.30)
1.74 (0.73, 4.15)
HH income
<550
47
124
80
1
1
550-2999
27
76
86
1.65 (1.15, 2.37)∗
1.67 (1.02, 2.75)∗
>3000
6
20
39
2.98 (1.73, 5.13)∗
1.29 (0.59, 2.83)
HH iodized salt use
Yes
36
81
111
1
1
No
44
139
94
0.64 (0.46, 0.89)
0.71 (0.44, 1.14)
Does the child take special foods?
Yes
11
34
54
1
1
No
69
186
151
0.51 (0.33, 0.79)
0.92 (0.51, 1.66)
Sick with diarrhea
Yes
22
60
42
1
1
No
58
160
163
1.37 (0.94, 2.00)
1.40 (0.84, 2.33)
Regular study
Yes
54
164
157
1
1
No
26
56
48
0.76 (0.52, 1.12)
0.65 (0.39, 1.08)
No
42
69
52
0.49 (0.34, 0.71)∗
0.70 (0.41, 1.20)
Does the child like the school environment?
Yes
74
207
201
1
1
No
6
12
4
0.40 (0.18, 0.88)
0.46 (0.17, 1.21)
Under weight
Normal
6
55
41
1
1
Mild
8
52
61
1.37 (0.83, 2.25)
0.85 (0.44, 1.66)
Moderate
24
35
31
0.51 (0.30, 0.89)
0.32 (0.12, 0.89)∗
Severe
9
16
9
0.41 (0.19, 0.86)
0.59 (0.15, 2.33)
Stunting
Normal
15
89
71
1
1
Mild
15
81
86
1.23 (0.84, 1.82)
1.68 (0.95, 2.98)
Moderate
36
44
39
0.48 (0.30, 0.75)
0.64 (0.27, 1.53)
Severe
14
6
9
0.25 (0.11, 0.57)
0.10 (0.02, 0.61)∗
Thinness
Normal
21
101
79
1
1
Mild
25
58
72
1.11 (0.75, 1.65)
1.75 (0.92, 3.31)
Moderate
23
37
44
0.85 (0.54, 1.34)
1.95 (0.83, 4.58)
Severe
11
24
10
0.46 (0.25, 0.83)
0.60 (0.38, 1.89)With regard to Mathematics course score, a child whose family’s income was from 550 to 2999 ETB had 1.73 times higher odds of achieving a high Mathematics course score (POR=1.73; 95% CI: (1.06, 2.81)) compared to that whose income was less than 550 ETB. Additionally, a child who did not study his/her lesson regularly had 41% decreased odds of achieving higher Mathematics course compared to their counterparts (POR=0.59; 95% CI: (0.36, 0.97)). With regard to nutritional status moderate underweighted (POR=0.34; 95% CI: (0.12, 0.92)) and severely stunted (POR=0.05; 95% CI: (0.004, 0.48)) children had 64% and 95% decreased odds of scoring a high Mathematics score as compared to normal children, respectively, see Table 5.Table 5
Factors associated with Mathematics course achievement among school-aged children in Lalibela town, North Ethiopia.
Variables
Category
Mathematics course achievements
Crude POR (95% CI)
Adjusted POR (95% CI)
Poor
Medium
High
Maternal marital status
Married
103
168
139
1
1
Divorced
17
19
14
0.70 (0.40, 1.21)
0.91 (0.43, 1.93)
Separated
7
14
12
1.16 (0.60, 2.23)
1.28 (0.52, 3.12)
Widowed
5
6
1
0.38 (0.13, 1.07)
0.41 (0.12, 1.43)
Maternal education status
Illiterate
68
103
66
1
1
Primary
45
58
46
1.04 (0.71, 1.52)
0.80 (0.48, 1.34)
Secondary and above
19
45
54
2.12 (1.10, 3.2)
1.85 (0.98, 3.49)
Maternal occupation
Housewife
85
146
99
1
1
Employed
25
22
35
1.26 (0.79, 2.00)
0.88 (0.45, 1.72)
Private business
7
21
19
1.65 (0.94, 2.88)
0.88 (0.42, 1.85)
Other
15
18
13
0.81 (0.46, 1.44)
0.77 (0.33, 1.79)
Number of family living together
<2
18
18
10
1
1
3-5
73
124
110
2.05 (1.15, 3.67)
1.60 (0.72, 3.53)
>5
41
65
46
1.66 (0.90, 3.06)
1.94 (0.81, 4.64)
Residence
Urban
104
145
148
1
1
Rural
28
62
18
0.62 (0.42, 0.91)
0.59 (0.32, 1.07)
HH income
<550
75
114
62
1
1
550-2999
48
68
73
1.58 (1.11, 2.25)
1.73 (1.06, 2.81)
>3000
9
25
31
2.60 (1.56, 4.36)
1.39 (0.65, 2.95)
HH iodized salt use
Yes
54
82
92
1
1
No
78
125
74
0.64 (0.46, 0.88)
0.96 (0.60, 1.53)
Deworming
Yes
99
166
135
1
1
No
33
41
31
0.77 (0.52, 1.15)
0.61 (0.38, 1.04)
Does the child eat breakfast/lunch before school?
Yes
113
187
151
1
1
No
19
20
15
0.68 (0.40, 1.15)
1.29 (0.60, 2.77)
Does the child take special foods?
Yes
16
38
45
1
1
No
116
169
121
0.50 (0.33, 0.76)
0.85 (0.48, 1.49)
Regular study
Yes
86
156
133
1
1
No
46
51
33
0.58 (0.40, 0.84)
0.59 (0.36, 0.97)
Does the child like the school environment?
Yes
121
201
160
1
1
No
10
6
6
0.51 (0.22, 1.16)
0.99 (0.36, 2.73)
Under weight
Normal
9
60
33
1
1
Mild
16
54
51
1.20 (0.74, 1.93)
0.93 (0.49, 1.77)
Moderate
40
21
29
0.41 (0.24, 0.71)
0.34 (0.12, 0.92)∗
Severe
15
9
10
0.39 (0.18, 0.83)
0.66 (0.17, 2.58)
Stunting
Normal
21
102
52
1
1
Mild
39
73
70
1.03 (0.71, 1.51)
1.58 (0.91, 2.75)
Moderate
55
26
38
0.45 (0.29, 0.70)
0.63 (0.27, 1.49)
Severe
17
6
6
0.23 (0.10 ,0.51)
0.05 (0.004, 0.48)∗
Thinness
Normal
34
102
65
1
1
Mild
44
55
56
0.86 (0.58, 1.26)
1.33 (0.71, 2.47)
Moderate
36
34
34
0.67 (0.43, 1.05)
1.36 (0.58, 3.18)
Severe
18
16
11
0.48 (0.26, 0.87)
0.99 (0.33, 3.04)In the multivariable analysis, ordinal logistic regression maternal education status, family size, residence, and underweight were statistically significant predictors of English and Amharic course scores. Moderate underweighted children had 66% decreased odds of achieving high English (POR=0.34; 95% CI: (0.13, 0.91)) and Amharic (POR=0.34; 95% CI: (0.13, 0.92)) courses score as compared to normal weighed children. Similarly, a child whose mother had secondary and above educational status has 2.02 and 2.78 times higher odds of achieving high English (POR=2.54; 95% CI: (1.09, 3.77) and Amharic (POR=2.78; 95% CI: (1.47, 5.26) course scores as compared to a child with an illiterate mother, respectively. A child who lives with more than five family members had 2.54 times higher odds of achieving higher English course score as compared to those who lived with less than two family members. On the other hand, a child who lived in rural areas had 65% decreased odds of achieving a high Amharic course score than those who lived in urban areas.


## 4. Discussion

This study is aimed at assessing the effect of nutritional status on academic performance of school-aged children. Accordingly, the prevalence of stunting, underweight, and thinness was 29.5%, 35.7%, and 29.5%, respectively. These study findings are lower than the findings in Sri Lanka in which 50%, 32%, and 34% of school-aged children are underweight, stunted, and thin, respectively [10]. The possible reason was the study done in Sri Lanka was done at the rural setting. The prevalence of stunting is similar with the study done in the urban settings of Fogera and Libo Kemkem districts, This need to be corrected as: However, it is different from the finding in the rural setting of Fogera and Libo Kemkem districts in which 42.7% of school-age children were stunted. The prevalence of thinness is higher than a study done at Fogera and Libo Kemkem districts, Ethiopia [18]. This difference could be due to the sociodemographic and geographic differences. The magnitude of stunting in this study is greater than the study done in a rural area of Morocco which was 22.8% [19].Study finding revealed that a child who lives in rural area had 65%, 52%, and 61% decreased odds of high achievement in the Amharic course, Science course and average semester scores, respectively. This study finding was supported by a study done in Iran, which shows that cognitive function of children was associated with the place of residence [20]. Children who have mothers with secondary and above educational status have more than two times higher English, Amharic, and average semester scores given that all of the other variables in the model are held constant. This study finding is similar with a study done in Morocco, Malaysia, Iran, and Hawa Gelan, Southwest Ethiopia [15, 19–21]. This signifies the importance of educating females in improving the child nutritional status as well as academic achievement.On the other hand, a child from a family with an income from 550 to 2999 ETB has 1.71, 1.67, and 1.73 times higher average semester, Science course, and Mathematics course score than that from a lower income family. The increase in household income may be linked to household food security and enhanced school attendance. This study finding was similar with a study done in Iran and Hawa Gelan, Southwest Ethiopia, where higher monthly house hold income was associated with student’s academic performance [15, 20]. This may be due to family income directly influencing the nutritional status of household members. With regard to academic performance, compared to a child who study their lesson regularly, those who did not study regularly have 51% and 41% decreased odds of achieving high average semester and Mathematics course score.With regard to nutritional status, severely underweighted children have 75% decreased odds of achieving high average semester score compared to normal weighted children. Furthermore, moderate underweighted children have 68%, 64%, 66%, and 66% decreased odds of achieving high Science, Mathematics, Amharic, and English course scores compared to normal weighted children, respectively. This study finding was similar with a study done in Nuwara Eliya Educational Zone and Hawa Gelan, Southeast Ethiopia [10, 15]. But the finding is different from a study done in Morocco that indicates WAZ did not have a significant association with academic achievement of primary school children [19]. This can be more supported by the report of Christian Perspectives in Education, while adequate and high-quality nutrition improves good academic performance, yet malnourishment contributes to low educational achievement where its prevalence is higher in developing countries [22]. This may be due to improved nutritional status being associated with better ability to learn, fewer absences, improved behavior, and causing fewer disruptions in the classroom which increases academic performance [23].Alternatively, severely stunted children have 97%, 90%, and 95% decreased odds of achieving high average semester score, Science course score, and Mathematics course score as compared to not stunted children. This study finding is similar with a study done in Sri Lanka in which low educational performance in Tamil (Language of Sri Lanka), Mathematics, and overall subject average was significantly higher among stunted participants than normal children [10]. However, it was different from a study done in Morocco, in which stunting was positively correlated with annual score and average score of Mathematics course score [9] and Malaysia where students educational achievement was not affected by stunting [21]. This may be due to nutritional status being able to directly affect mental capacity among school-aged children [23].This study has its own limitations. First, the students’ academic performance was evaluated by semester scores and it may also vary due to pedagogical factors which were not considered in this study. Second, due to WHO AnthroPlus 2007 GS limitations, participants whose age is greater than 10 years especially females during underweight assessment were excluded due to the fact that their weight increases in spite of nutritional status but by hormonal factors during pubertal period, and as a result, the sample size became small for only underweight assessment.


## 5. Conclusion

Greater magnitude of malnutrition (stunting, underweight, and thinness) is found among primary school children in Lalibela town. This nutritional status significantly affects the educational performances of primary school children. Place of residence, family monthly income, maternal education status, and regular lesson studying, underweight, and stunting are statistically significant predictors of educational performance in Science, Amharic, English, Mathematics, and semester average scores. So, health and education sectors as well as other concerned bodies should work together to avert this adverse effect of malnutrition.



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*Source: 5956732-2020-04-09.xml*