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ASSESSMENT OF NUTRITIONAL STATUS OF PRIMARY SCHOOL CHILDREN IN
ENUGU NORTH LOCAL GOVERNMENT AREA USING ANTHROPOMETRY.
THIS DISSERTATION IS SUBMITTED IN PART FULFILMENT OF THE REQUIREMENT
FOR THE AWARD OF THE FELLOWSHIP OF THE NATIONAL POSTGRADUATE
MEDICAL COLLEGE OF NIGERIA IN THE FACULTY OF PAEDIATRICS.
BY DR IGBOKWE, OBIANUJU OJINIKA
MBBS (MAY 2003)
EXAMINATION DATE: MAY 2014
2
DECLARATION
It is hereby declared that this work is original unless otherwise acknowledged. The work has
neither been presented to any other College for a Fellowship nor has it been submitted elsewhere
for publication.
------------------------------------------
IGBOKWE, OBIANUJU OJINIKA
DATE ---------------------------------
3
ATTESTATION
The study reported in this dissertation was done by the candidate under our supervision. We have
also supervised the writing of the dissertation.
PROF. G.N ADIMORA
CONSULTANT PAEDIATRICIAN
UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU
SIGNATURE___________________________________
DATE ________________________________________
DR. A.N IKEFUNA
CONSULTANT PAEDIATRICIAN
UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU
SIGNATURE___________________________________
DATE ________________________________________
DR. S.N IBEZIAKO
UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU
SIGNATURE___________________________________
DATE ________________________________________
4
TABLE OF CONTENTS Page
Title i
Declaration ii
Certification iii
Table of Contents iv
List of Tables v
List of Abbreviations vi
List of appendices vii
Dedication viii
Acknowledgements ix
Summary x
Introduction and Justification 1
Literature Review 5
Aims and Objectives 25
Subjects and Methods 26
Results 32
Discussion 43
Conclusion 50
Recommendations 51
Lines of future research 52
References 53
Appendices 70
5
LIST OF TABLES
Table Page
I. Sociodemographic characteristics of the study subjects in private and public schools 32
II. Comparism of means between children in private and public schools 33
III. Distribution of the nutritional status of the study participants 34
IV. Relationship between age and wasting among the study participants 35
V. Relationship between age and stunting among the study participants 36
VI. Relationship between age and underweight among the study participants 36
VII. Relationship between age and overweight among the study participants 37
VIII. Association between age and obesity among the study participants 37
IX. Gender differences in nutritional status of the study subjects 38
X. Effect of maternal educational status on the nutritional status of the study population 39
XI. Effect of paternal educational status on the nutritional status of the study population 40
XII. Relationship between socioeconomic class and nutritional status of the study population 41
XIII. Relationship between socioeconomic class and nutritional status of the study population 42
XIV. Differences in nutritional status between subjects in Public and Private Schools 43
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LIST OF ABBREVIATIONS
BMI Body Mass Index
ESUBEB Enugu State Universal Basic Education Board
HAZ Height-for-age z score
IQ Intelligence Quotient
LGA Local Government Area
MDG Millennium Development Goals
NCHS National Center for Health Statistics
NDHS National Demographic Health Survey
PEM Protein Energy Malnutrition
PHC Primary Health Care
SPSS Statistical Package for Social Sciences
TST Triceps Skinfold Thickness
UNICEF United Nations children Fund
UNTH University of Nigeria Teaching Hospital
WAZ Weight-for-age z score
WC Waist Circumference
WHZ Weight-for-height z score
WHO World Health Organization
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LIST OF APPENDICES
1. Proforma for the assessment of Nutritional Status of Primary school children in Enugu
North LGA
2. Approval for commencement of study from Enugu State Universal Basic Education Board
(ESUBEB)
3. Ethical clearance certificate
4. Informed consent form
5. Olusanya’s social classification
6. List of schools which participated in the study
8
DEDICATION
This dissertation is dedicated to all the primary school children in Enugu North LGA and their
teachers. You made it all worthwhile.
9
ACKNOWLEDGEMENTS
I wish to acknowledge God Almighty, who made it possible for this work to be completed
successfully. Thank you Lord.
I would like to use this opportunity to thank my supervisors Prof Adimora, Dr Ikefuna and Dr
Ibeziako, who always made out time from their busy schedules to read this work thoroughly.
Their sound advice, gentle corrections and encouragement brought much hope, even when it
seemed impossible to go on. I am eternally grateful.
I am also grateful to my wonderful family and friends who walked with me through it all. Your
unwavering love and unflinching support gave me reason to go on.
I equally acknowledge all my teachers who helped mould me into the doctor I am today. I will
continue to make you proud.
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SUMMARY
The survival and wellbeing of children is largely dependent on nutrition. Malnutrition has long
term consequences in children. Undernutrition in children can lead to impaired cognitive
functioning, decreased productivity and reproductive problems in adulthood. On the other hand,
overnutrition in childhood can progress to obesity in adolescence and adulthood, with its
attendant medical risks. There is paucity of information regarding the nutritional status of
primary school children in Enugu.
The aim of this study was to determine the nutritional status of primary school children in Enugu
North LGA, using anthropometry. This was a cross sectional descriptive study involving public
and private primary school children in Enugu North local government area. Subjects were
selected using multistage sampling technique over a 3 month period. A proforma was used to
obtain information which included age, sex, parental education and occupation. Each child’s
socioeconomic class was subsequently obtained using the classification proposed by Olusanya et
al. Weight and height of the participants were measured using a digital scale and a wooden
stadiometer. BMI, WAZ, HAZ and BMI for age z scores were then derived using the new WHO
reference standards.
Three hundred and forty eight (40.4%) children were recruited from public schools while 512
(59.6%) were recruited from private schools. The mean age of the study subjects was 9.18 years
with a male to female ratio of 1:1.7.
Normal nutritional status was observed in 691 (80.3%) subjects. Seven (0.8%) children were
found to be stunted, 26 (3.3%) wasted and 28 (3.3%) underweight. Overweight was observed in
73 (8.5%) subjects, while 35 (4.1%) were obese. Wasting, stunting and underweight were found
11
to be more prevalent in children aged 12 years (p = 0.001). Males were found to be more obese
than females (p = 0.02). Underweight and wasting were significantly more prevalent in children
of parents with secondary education and below (p < 0.05). On the other hand, overweight and
obesity were more prevalent in children of parents with tertiary education (p < 0.001). Children
of lower socioeconomic class were more stunted, underweight and wasted, while overweight and
obesity were more prevalent in the upper socioeconomic class. Children attending private
schools were more overweight and obese than those in public schools. (p < 0.001)
Majority of the children in Enugu North LGA had normal nutritional status. Factors such as age
and sex, parental education and socioeconomic class had a significant impact on nutritional
status. Overweight and obesity were more prevalent among the children from the upper
socioeconomic class, attending private schools, while stunting and wasting were more in children
attending public schools. There is need for health promotion and nutrition education programmes
for mothers and school children, which will aid in improvement of nutrition.
12
INTRODUCTION
Nutrition is the sum total of the processes involved in the intake and utilization of food
substances by which growth, repair and maintenance of the body are accomplished.1
It is a fundamental pillar of human life, health and development across the entire life span.2
The socioeconomic development of a country is largely dependent on nutrition3 as adequate food
and good nutrition are vital for survival, physical growth, and mental development.4 In addition,
nutrition is an essential component of the Millennium Development Goals (MDGs) and primary
health care (PHC),5 as eradication of extreme hunger and poverty, as well as reduction in child
mortality are largely dependent on the nutritional status of children.6 Malnutrition is a silent
emergency which has devastating effects on children, the society and the future of humankind.7
It is a major public health challenge in developing countries.7
Nutritional status has been defined as the extent to which the customary diet of any population
group has been able to meet their nutritional requirements.8 It is an important determinant of
growth and is the best indicator of the global wellbeing of children.9 The efficiency with which
the body utilizes the food consumed is a key determinant of nutritional status.10 This can be
affected by ill health and reduced significantly by specific disease conditions such as infections,
helminthiasis and diarrhoea.10 When the nutritional status of children deteriorates, it leads to a
vicious cycle of recurring sickness and growth failure.10 Therefore, an in-depth knowledge of the
nutritional status of children has far reaching implications for promoting the health of future
generations.10
Primary school age is a period of dynamic physical growth and mental development.11 Research
has shown that poor nutritional status results in low school enrolment, high absenteeism, early
13
dropout and unsatisfactory classroom performance.11 Well-nourished children perform better in
school and achieve their full physical and mental potential.12
Nutritional assessment is a detailed evaluation of objective and subjective data relating to an
individual’s food intake, lifestyle and medical history.13 The results of this assessment then leads
to either a plan of care or intervention designed to help the individual maintain the assessed
status or attain a healthier status.13 In any community, nutritional assessment is essential for
accurate planning and implementation of intervention programmes which are designed to reduce
the morbidity and mortality associated with malnutrition.14,15 The most frequently used
quantitative method for assessment of the nutritional status of individuals or population groups is
anthropometry.16
Several studies have been conducted worldwide on nutritional status of children of all ages.
14,17,18,19,20 Studies done in rural and urban areas in different parts of Nigeria have reported high
prevalence of malnutrition among children.14,17,18,19 However information based on nutritional
status and anthropometric indices in primary school children in Enugu, South-east Nigeria is
scarce.
This study evaluated the nutritional status of children attending primary schools in Enugu North
Local Government Area (LGA), which is one of the three LGAs in Enugu Metropolis. The
results will be useful to healthcare providers, school administrators and parents as it will serve as
a reliable basis for resource management and policy formulation.
14
JUSTIFICATION
Globally, malnutrition affects almost 800 million people, with most of them residing in
developing countries.21 The proportions are 70% in Asia, 26% in Africa and 4% in Latin
America and the Caribbean.22 Malnutrition is the most important risk factor for morbidity and
mortality, contributing to more than half of child deaths worldwide.23
About 45% of all deaths in children are linked to malnutrition.24
Sub-Saharan Africa is still struggling with high rates of underweight and stunting in children
under five, with the proportion of stunted children being 41%.24 These figures are only estimates,
since no direct data are actually available to assess the magnitude of these problems, identify
their causal factors, or describe the nutritional status of the poor.25
School age children constitute about 24% of the total population in developing countries and
about 15% in industrialized countries.26 In Nigeria, school age children constitute 23% of the
total population.27 As today’s children are the citizens of tomorrow’s world, their survival,
development and protection are requirements for the future development of humanity.28 People
who survive a malnourished childhood are less physically and intellectually productive, and
suffer from more chronic illness and disability.29 Until recently, overnutrition, obesity and its
attendant complications had been perceived as problems of developed countries only.30
However, overnutrition is increasing even in countries where hunger is endemic.30 Recent
reviews have reported significant increase in overweight and obesity in developing countries.30
The ultimate objective of nutritional assessment is to improve human health.31 Nutritional
assessment is recommended to map out the magnitude and geographical distribution of
malnutrition as a public health problem.32 This will aid in determining the factors which may be
15
responsible for the nutritional status of a community, and where possible, suggest appropriate
corrective interventions which can be applied, with continuing community participation.32
The Nigeria National Demographic Health Survey (NDHS) measures children’s nutritional status
by comparing height and weight measurements against an international reference standard.33
These surveys, carried out in 2003 and 200833 did not capture the important issue of malnutrition
among school aged children, as only children under 5years were surveyed.
Nutritional studies done in the past on Nigerian school children have shown that undernutrition
continues to be a major public health problem in both rural and urban areas.14,17 In Markudi
Nigeria in 2009, Amuta et al18 reported a very high prevalence rate of undernutrition of 50.6% in
children attending public schools. On the other hand, Opara and his coworkers19 in Calabar
documented prevalence of underweight, stunting and obesity to be 27.3%, 17.1%, and 11.1%
respectively in the private schools, and 39.4%, 25.3% and 0.2% respectively in the public
schools. In Enugu metropolis, there are over one hundred thousand primary school children, yet
there is paucity of anthropometric indices based information on their nutritional status.
The focus of most countries has been on child survival and welfare programmes which target the
pre-school children only. This is due to the fact that these children under five years of age are at
the highest risk for malnutrition. However, there is still need for attention to be given to the
school age children, because ensuring optimal child growth and development will accelerate
economic development.
16
LITERATURE REVIEW
Historical Perspective
Physical measurements such as body weight, height, circumferences of arm and waist, triceps
skin fold have been used extensively to define health and nutritional status of communities.34
The systematic study of the human physical stature dates back to the 18th century.35 The word
“anthropometry” was coined by Quetelet in 1832,36 when he developed the Quetelet index,
which is now known as the body mass index (BMI).36 By the 1830s Quetelet36 and Villerme37
recognized that biological outcomes were influenced by both the natural and the socioeconomic
environment. The first significant development in the use of growth for assessing nutritional
status occurred in the early nineteenth century when studies of army conscripts and English
working children revealed that poor growth was a reflection of poverty, malnutrition and
disease.38 Further developments later in the century had an explosive effect on growth and
development research and provided techniques for establishment of growth standards.38
Growth and development are important aspects of childhood and adolescence, and weight gain
with increasing body size are normal components of this process.39 Children require sufficient
nutritious food, and in particular sufficient energy, to achieve this growth.39
The physical growth of infants and children has long been recognized as an important indicator
of health and wellness.40 Growth charts have been used for over a century to assess whether a
child is receiving adequate nutrition, and to screen for potentially inadequate growth that might
be indicative of adverse health conditions.40 Traditionally, malnutrition has been understood to
describe undernutrition.41 However in the past few decades, there have been growing concerns
about excessive weight gain and growth charts have been used to screen for overweight and
obesity.42
17
The World Health Organization (WHO) defines malnutrition as the cellular imbalance between
supply of nutrients and energy, and the body’s demand for them to ensure growth, maintenance
and specific functions.23 Malnutrition is rarely regarded as an emergency because in most cases,
the affected children are not facing famine, and betray few or no obvious signs.43 Yet this largely
invisible crisis of malnutrition is implicated in more than half of all child deaths worldwide.43
It violates the rights of children in profound ways, compromising their physical and mental
development, and helping perpetuate poverty.43 It has been estimated that about 4% of all
children born in developing countries die of malnutrition before their fifth birthday.17
The most affected are usually children of parents of low socioeconomic status.17
Classification of Malnutrition
Malnutrition refers to all deviations from adequate nutrition relative to need.44 It includes under
nutrition and overnutrition resulting from inadequacy or excess of food respectively.44
Undernutrition
Undernutrition is defined as a dietary energy intake which is below the minimum required to
maintain the balance between actual intake and acceptable levels of energy expenditure.45 It is
the outcome of inadequate intake of dietary energy.45 Stunting, wasting and underweight are all
forms of malnutrition.45 The primary cause of ill health and premature mortality among children
in developing countries is attributed to undernutrition.7 This can lead to growth failure, impaired
cognitive function, reduced productivity and reproductive problems in adulthood, such as
prolonged obstructed labour as a result of cephalopelvic disproportion.46
Stunting is evidence of chronic malnutrition and may be associated with concurrent risks to the
health and development of children.47 In school age years, stunting may cause a decrease in adult
18
size, which will eventually result in reduced work capacity and adverse reproductive outcomes.48
Protein energy malnutrition (PEM) is a major nutritional and health problem worldwide.49 It is
an important cause of morbidity and mortality in children.49 PEM is mainly a consequence of
inadequate food intake, which could be a deficiency in quantity or quality.49 It can also result
from infections and infestations such as diarrheal diseases, helminthiasis, measles and respiratory
infections.49 The consequences of PEM among school age children include retarded physical and
mental development, which are associated with either non-enrolment or late enrolment in
school.50
It is also important to note that apparently well fed children who are receiving sufficient calories
for their daily activities can still suffer the ‘hidden hunger’ of micronutrient deficiency. In the
absence of these micronutrients such as Vitamin A, Iron, Zinc, Iodine, there is increased risk of
reduced intelligence quotient (IQ), stunting and even death.51
Overnutrition
Overnutrition results from excessive intake of high calorie diets with large proportions of
saturated fats.52 Overweight and obesity are forms of overnutrition.44 Overnutrition is an
emerging problem in some parts of Sub-Saharan Africa, especially where lifestyles have become
urbanized and westernized.53 Childhood obesity could progress to obesity in adolescence and
subsequently in adulthood, with its attendant risks, such as diabetes, dyslipidaemia, coronary
heart disease, atherosclerosis, hypertension, stroke, certain cancers and arthritis.53,54
Other comorbidities associated with childhood obesity include orthopaedic problems such as
Blount’s disease, skin fungal infections and acanthosis nigricans, liver diseases such as hepatic
steatosis, steato-hepatitis, and pseudotumor cerebri.55 They may also have psychological and
behavioral problems.53
19
All forms of malnutrition are associated with significant morbidity, mortality and economic
costs.56 In the developed nations, obesity has reached epidemic proportions in both children and
adults.56 However, many developing countries now face an increasing double burden of
undernutrition and overnutrition.21 This is especially so in countries undergoing epidemiological
transition from subsistence agriculture to increased urbanization and industrialization.57
Risk factors for malnutrition
Several environmental factors could affect the physical growth of school children before
puberty.58 These include parental literacy, illness, socioeconomic status, lack of adequate
sanitation and poor hygienic practices.
Parental Literacy
The welfare of children in developing countries is largely dependent on parental literacy
especially maternal literacy.59 Indeed, there is considerable evidence to show that child survival,
nutritional status and educational attainment are enhanced by having better educated mothers.
60,61,62,63,64 In addition, a mother’s level of education is an important determinant of her children’s
health.61 It has also been documented that the number of children born to a woman is inversely
related to her level of education.65 A small state in India known as Kerala has the highest rate of
female literacy in the country, which is 87% as compared to 54% for all India.58 Kerala’s birth
rate is 14 per 1,000 females while India’s is 25 per 1000 females. Kerala’s infant mortality rate is
15 per 1,000 births while India’s is 57. A high level of maternal education could lead to an
increased awareness of healthy behaviour, sanitation practices and a more equitable distribution
of household resources in favour of the children.58 Educated mothers can also influence the
health of their children by challenging existing traditional beliefs and attitudes.58 In addition,
20
these mothers tend to exhibit a greater willingness to accept developmental initiatives and utilize
modern health care.58 Female and male adult education has a large positive and statistically
significant effect on a child’s nutritional status.66 However the effect of maternal education is
almost double that of paternal education.66
Tertiary education also has a strong and positive effect additional to the effect of primary and
secondary schooling.66 Senbanjo et al67 in Southwestern Nigeria observed that underweight and
stunting were higher in the children whose mothers had secondary education and below, than in
those with tertiary education. However children of mothers with tertiary education were more
affected by wasting than those with less educated mothers.67 Possible explanation for this may be
the area of the study which was a rural community in Osun state, Southwestern Nigeria. As such,
these mothers with tertiary education may still not be able to provide for their children due to
their prevailing economic circumstances.
Fathers’ education is also an important determinant and has a positive impact on child health and
nutritional status.68 The father is usually the main earner and decision maker in the family.68 Alli
et al69 in 2005 studied the association between paternal literacy and malnutrition among children
in Karachi, Pakistan.69 The authors reported high rates of stunting and underweight in children of
illiterate fathers. However, other confounding variables such as the mothers’ education or
fathers’ financial abilities were not taken into consideration.
Illnesses
Child malnutrition can be a cause and a consequence of ill health.70 Globally, malnutrition is the
most important risk factor for illness and death.70 In developing countries, the high prevalence of
bacterial and parasitic diseases contributes greatly to the prevalence of malnutrition.71
21
Similarly, malnourished children are highly susceptible to severe infections which can lead to
illness and death.71,72,73 The risk of death is directly related to the degree of malnutrition.74,75
Torres et al76 carried out a prospective cohort study in Bangladesh in 2000 to examine the
association between infections and growth of school-age children. Diarrhoea was found to retard
weight gain and slow linear growth, while respiratory infections did not have the same effect.76
The results of the study suggested that school age children might benefit from control of
diarrheal diseases. However, the cross sectional analytic design of this study may not have
investigated the causal associations. Secondly, dietary intake was controlled for using year
averages of energy and protein intakes and this may not have represented dietary intake in
critical periods of growth.76 In addition, there may have been recall bias because of the one
month recall period for morbidity. This may lead to underestimation of the true incidence and
duration of disease. Furthermore, the information on socioeconomic status was limited to land
ownership, thus educational status, household possessions and other factors were not
considered.76
Poor Sanitation
Unfavourable living conditions such as inadequate water and sanitation can increase the
incidence of infectious diseases.77 This may indirectly lead to certain types of malnutrition.77
In 1998, Getaneh et al78 in Ethiopia found that unprotected water sources and non-availability of
latrines were associated with stunting. Similarly, Immink and Payongayong79 carried out a study
in an impoverished rural area of Guatemala, Central America. The authors assessed food and
non-food risk factors for poor health and growth failure in children of different age groups. Poor
sanitation, housing conditions and women’s literacy status were identified as the most important
risk factors for growth failure in children.
22
Similar risk factors were also reported by Amigo et al25 in Chile South America, who carried out
a case control study to identify the risk factors of short stature among Chilean children starting
primary education. These workers reported risk factors associated with short stature independent
of parents' heights. This suggests that genetic factors have limited impact on height at this age.25
However confounding variables such as socioeconomic status of the subjects were not taken into
consideration.
Socioeconomic Status
There is an established association between child nutrition and socioeconomic status.80
The nutritional status of children is a reflection of the socioeconomic status of the family and the
social wellbeing of the community.80 It also portrays the efficiency of the health care system and
the influence of the surrounding environment.34 The socioeconomic status of families can usually
be assessed through family income, housing conditions, parents’ education, occupation, and
family composition.80 The impact of socio-economic status and dietary intake on the nutritional
status of children was studied by Bogin and Macvean81 in Guatemala. The authors observed that
most of the girls from lower socioeconomic class consumed inadequate calories compared to
those of the upper class.81 Similarly, Qamra et al82 in 1990 in India also revealed that girls from
upper socioeconomic class had significantly higher anthropometric measurements (weight,
height and skin fold thickness) compared to their counterparts in the lower class.
Family size may also be positively correlated with nutritional status. Pelto and his colleagues83 in
1991 examined the extent to which house hold size was related to the nutritional status of
Mexican children. The survey results showed that children from larger households were
significantly shorter and consumed diets of poor quality.83 This is not surprising because the
23
larger the size of the family, the more difficult it is for the caregiver to cater for the individual
needs of the children adequately.
Prevalence of Malnutrition
In 2011, 160 million children were estimated to be affected by stunting worldwide, while 50
million children were affected by wasting, and 100 million were underweight.84 More than 90%
of these children reside in Africa or Asia. Overall there has been a gradual decline in the global
prevalence of stunting in the past twenty years.84 However, the rates are not falling quickly
enough to meet global targets set just a year ago at the world health assembly, which include
40% reduction of the global number of children less than five years who are stunted by year
2025.84 Unfortunately, Africa is the only major region where the number of stunted children has
increased in the past decade.84 Recent studies have shown that the locus of poverty and
undernutrition are gradually shifting from rural to urban areas, as the number of the poor and
undernourished increases more quickly in urban than rural areas.85,86 Furthermore, it is thought
that the urban population exhibits more variation in poverty, mortality and nutritional status
compared to the rural population.87
One of the largest studies of nutritional status of rural school children in five low income
countries (Ghana, Tanzania, Indonesia, Vietnam and India) was carried out in 1998. In all these
countries, there was a trend for height-for-age z-scores (HAZ) and weight-for-age z-scores
(WAZ) to decline with age indicating that children became progressively shorter as they grew
older, relative to the reference population.88 In addition, it was observed that growth retardation
seemed to occur throughout the school age years. This is comparable to findings reported by
several authors who also documented increasing prevalence of stunting with age.89,90,91 However,
24
it is known that age is difficult to ascertain especially in African populations. The age data in
some of these studies were obtained from the children themselves, thus the variability of the z
scores may have been inflated. In addition, the school based nature of some of these studies may
provide a biased sampling of the population.
Several authors have documented gender differences in height and weight of school children.
88,89,90,91 Parraga et al90 in Brazil studied the gender differences in growth of school-age children
with helminthiasis. These authors reported prevalence rates of 21% and 13% for stunting and
under nutrition respectively. Both indices of nutritional status worsened as the study population
got older, particularly for boys. The later onset of puberty and growth spurt in boys was
controlled for in the growth data analysis, yet the boys remained significantly more malnourished
than girls. Similarly, Prista and his colleagues39 in Mozambique also noted that boys were more
stunted and wasted, while the girls were more overweight. These gender differences in
nutritional status could be attributed to socioeconomic and cultural factors. Females from low
socioeconomic backgrounds are more likely to remain at home while the males who are wasted
or stunted remain in school. Hence there is likely to be a greater proportion of the remaining
females in school being from higher socioeconomic background.39 Secondly, females are usually
more involved in food preparation, hence they may have more access to food than the males.
Most stunting occurs in early childhood, usually by 3 years of age.92 Short stature that results
from chronic undernutrition is associated with reduced lean body mass and deficiencies in
muscular strength and working capacity.92 School-age children who are stunted are likely to have
been exposed to poor nutrition from early childhood.92 The degree of stunting tends to increase
throughout the school-age years.92 However, such children can still exhibit catch up growth if
their nutrition and environment improve.92
25
This implies that interventions in school-age children can supplement efforts in the preschool
years to reduce levels of stunting and related effects on children’s health and education.
However, this may not always be the case in developing countries. For instance, Friedman et al93
in Kenya in 2005 reported a prevalence of stunting, under nutrition and wasting to be 18.3%,
16% and 17.1% respectively. The results of the study suggested that stunting progressed through
the school years, and that in developing countries, there may be no catch up growth.93 The
longitudinal nature of this study encompassed a relatively long period of follow up making it
easier for conclusions to be drawn about progression of stunting throughout the school age
years.93 On the other hand, this was a school based cohort and some of the findings may be
subject to selection bias. Furthermore, older subjects were excluded from the study, thus the
impact of deficits accrued during middle childhood on final adult height was not determined.93
Fazili et al94 in 2012 assessed the nutritional status of school children in North India using the
WHO z score system. The authors documented low rates of 2.05%, 2.65% and 2.05% for
underweight, stunting and wasting respectively.94 The probable reason for this could be better
socioeconomic status in North India, as only 3.6% of the people in the area are living below the
poverty line, unlike other parts of India where higher rates of under nutrition were
documented.32,47,95,96
In Jos Nigeria, Akor and his coworkers97 carried out a cross sectional study on the nutritional
status of newly enrolled primary school children in 2010. These authors reported prevalence of
under nutrition, stunting and wasting of 10.3%, 11.1%, and 2.4% respectively.97 As expected,
children from public schools were found to be more underweight and stunted.97 In addition they
also had lower socioeconomic background.97 Boys were found to be more stunted than the girls,
though for underweight there was no gender difference.97
26
In Uyo Nigeria, Opara et al19 compared the prevalence of underweight, stunting and obesity in
children attending public and private schools. These authors reported underweight, stunting and
obesity of 27.3%, 17.1% and 11.1% respectively in the private schools, while in the public
schools they found prevalence of 39.4%, 25.3% and 0.2% respectively. Surprisingly, stunting
and underweight were noticeably present in children in private schools.19 These private schools
are mainly patronized by the elite, the middle class and the rich. The authors attributed this to the
tendency for the middle class to over school their children, while cutting down on food intake.19
Oninla et al14 in 2007 compared the nutritional status of urban and rural Nigerian school children
attending public schools in Ife, Southwestern Nigeria. These authors reported overall prevalence
rates of underweight, wasting and stunting of 61.2%, 16.8% and 27.6% respectively.14 The
nutritional indices were significantly lower among the rural than the urban pupils.14 Similarly,
Amuta and his coworkers18 in 2009 documented a significantly high prevalence rate of under
nutrition of 50.6% in children in Markudi Nigeria.18 The high prevalence of malnutrition can be
explained by the fact that both studies were carried out among children attending public schools,
who were of low socioeconomic status, despite the fact that they were in an urban area.18 Studies
done in other parts of the country have also shown higher prevalence of malnutrition among
children in public schools than in private schools.67,19 This could be a reflection of the
socioeconomic status of the caregivers.
The prevalence of overweight and obesity have increased dramatically over the past few decades
in most industrialized countries.98 North America, Europe and parts of the western pacific have
the highest prevalence of overweight among children, in the range of 20-30%.98 Parts of south
East Asia and most of sub-Saharan Africa have the lowest prevalence, while South and Central
America, Northern Africa and Middle Eastern countries fall in between.98 Wang,99 in a cross
27
national comparism of childhood obesity, reported prevalence of 10% and 6% for overweight
and obesity respectively in Russian school children. The risk of obesity is higher in upper
socioeconomic class in Russia and China than in the lower class.98 However, in the USA,
obesity is more prevalent in the lower socioeconomic class.100 This has been attributed to the fact
that food deprivation or fear of deprivation can lead to overeating when food is available.101
Consumption of junk food is also a major contributor.101
Importantly, the prevalence of overweight among school age children in several countries
undergoing economic transition such as Brazil, China, Mexico and Egypt is on the increase.98
There has been a shift of the burden of nutritional problems from energy imbalance or deficiency
to excess among older children and adolescents in Brazil and China.98,102 The annual rates of
increase in the prevalence of overweight were 0.5% in Brazil and 0.2% in China in 2002.98
However, childhood obesity is not limited to the industrialized countries. In a review, de Onis
and Blössner103 in 2000 reported rapidly increasing prevalence of overweight and obesity among
pre-schoolchildren and school aged children in developing countries. In Tunisia, North Africa
9.1% of adolescent girls is at risk for being overweight.104
In an earlier study in Abeokuta, Southwest Nigeria by Akesode and Ajibade,105 the prevalence of
obesity among school children was found to be 3.2% for males and 5.1% for females based on
weight for age. In 2012, Omuemu et al106 studied the socioeconomic determinants of obesity in
school children attending public and private schools in a local government area of Edo state
Nigeria. The authors reported prevalence of 9.8% and 6.7% respectively.106 Obesity was found to
be higher in females who were attending private schools.106 In addition, higher prevalence of
obesity was observed in the subjects who were of higher socioeconomic class, and whose
mothers had tertiary education.106 In Markudi, North Central Nigeria, Goon et al107 documented
28
very low prevalence rates of 0.1% for overweight and obesity. This could be explained by the
fact that majority of the children who participated in this study were of lower socioeconomic
class despite the fact that they were residing in an urban area. Secondly these children may have
limited access to high calorie snacks and fast foods, and may be engaged in more physically
demanding activities, such as long treks to school.
Complications of Malnutrition
Malnutrition has long term effects on children. Undernutrition and micronutrient deficiencies
may lead to developmental delays throughout childhood and adolescence.44
Goiter, scurvy, anaemia and xerophthalmia result from various forms of malnutrition resulting
from an inadequate intake of iodine, vitamin C, iron and vitamin A respectively.44
Nutritional anaemia is also a consequence of malnutrition which is most prevalent in developing
countries.108 It affects mostly pregnant women and children under five years. Iron deficiency is
the most frequent cause of nutritional anaemia.108 Iron deficiency can be due to reduced intake or
excessive iron loss from the body.108
Other causes of anaemia include folate and vitamin B12 deficiency.109 Deficiencies in these
nutrient groups predict developmental outcome. Severe deficiency in a single critical nutrient
such as iron can result in behavioral deficit.109
There is also an established relationship between impaired growth status, poor school
performance and IQ.110 Indeed there is a positive correlation between socioeconomic status,
intelligence and academic achievement.80 Several studies have shown that poor feeding and
recurrent infections could lead to stunted growth, substantial brain impairment, low intellectual
competence and learning capacity of children.14,20,111 Malnutrition in early childhood usually
interacts with other environmental factors to cause poor cognitive and motor development.112
29
Poor nutrition not only affects the mental development of children, but is also likely to reduce
their work capacity in future.43 Grantham-McGregor et al113 demonstrated that psychosocial
stimulation improved development in children that were previously malnourished. However,
these children still lagged behind normal controls in psychomotor development. Mendez and
Adair114 in 1999 also assessed the relationship between stunting in the first 2 years of life and
later cognitive development among Filipino children. From their findings, the authors concluded
that there may be a direct effect of severe chronic under nutrition in early life on cognitive
development in later childhood.114 This effect occurred regardless of psychosocial factors such as
schooling and socioeconomic status. Ijarotimi and Ijadunola115 in 2007 assessed the nutritional
status and IQ of primary school children attending public and private schools in Akure,
southwest Nigeria. The authors documented high prevalence of malnutrition and intellectual
deficit among the studied population.115 Furthermore, there were a higher proportion of children
with intellectual deficit in the public schools compared to their counterparts in private schools.115
The explanation for this could be the higher prevalence of under nutrition among the children in
public schools.
Nutritional Assessment in a Community
There are two possible ways to assess the adequacy of food and nutrition as well as to detect the
presence of inadequacy in food intake among individuals or population groups.44
The first is to measure the nutritional intake of food and the second is to assess the nutritional
status of individuals.44
30
Nutritional Intake Assessment
These measures estimate the amount of food a person has eaten and can be used to assess
adequacy of dietary energy and protein supply.44 In simple terms, people are either well-
nourished or undernourished based on whether their food intake matches their energy needs or
nutrient requirements.44 Such information can be obtained from national sample surveys or
dietary surveys which attempt to measure the food consumption or intake levels of representative
individuals within a population.44 This method tends to provide an estimate of the population or
individuals at risk of inadequacy of food.44 However, it may not be useful in identifying those
who are deficient. Secondly, it does not help to define the degree of severity of the food
inadequacy.44
Nutritional Status Assessment
This option assesses the nutritional status of the individual or a representative sample of
individuals within a population.44 The assessment is usually done by measuring anthropometric,
biochemical or physiological characteristics to determine whether the individual is well-
nourished or undernourished.44 Nutritional status assessment uses objective, measurable criteria
which can detect changes in anthropometric, biochemical or functional characteristics of an
individual. These changes could be a consequence of inadequate food intake for long periods of
time, or seasonal fluctuations in intake of food, or poor absorption and utilization of ingested
food.44 The methods of assessing the nutritional status of children include:
Anthropometry - This includes measurement of weight, height, mid arm circumference, skin fold
thickness, head and chest circumferences, and calculation of the Z scores of appropriate
indices.116
31
Biochemical Methods - This includes assessment of haemoglobin levels, urinary iodine, iron
status, levels of different nutrients or their by-products.116
Clinical examination - This includes examination of the eyes, hair, nails and thyroid gland.116
Anthropometry in Nutritional Assessment
Anthropometry is the measurement of body parameters such as weight, height waist and hip
circumference.44 It is frequently used to assess nutritional status as well as growth and
development of school aged children and adolescents.117 As a public health tool, anthropometric
measurements have been widely used for the assessment of the nutritional status of both children
and adults.44 This has also been underscored by Jellife118 who described its use in nutritional
assessment as "measurements of the variations of the physical dimensions and the gross
composition of the human body at different age levels and degrees of nutrition ".118
At the level of the individual child, anthropometry is useful for detecting those who are at risk of
malnutrition, and for selection of affected children for nutritional intervention programmes. It is
also useful for assessing the effectiveness of such programmes.119
In the community, anthropometry is useful in the determination of the prevalence of
malnutrition. It can be used to monitor secular and seasonal changes in their nutritional status, as
well as to evaluate the impact of intervention programmes.120
Anthropometric methods are precise and accurate, provided standardized techniques are
utilized.120 The procedures are simple safe and non-invasive.120 The equipment required is
inexpensive, portable, durable, and can be made or purchased locally. In addition, relatively
unskilled personnel can perform measurement procedures. The information generated is based on
past nutritional history, and can be used to monitor and evaluate changes in nutritional status
over time.120 Anthropometry can also be used to quantify the degree of nutrition, and provide a
32
continuum of assessment from under- to over nutrition.120 It permits the stratification of survey
results according to age, sex, region, rural/urban or other sociodemographic characteristics of the
population.120 Hence, it aids in providing more information for detecting vulnerable groups and
for better understanding of the situation.
Derivatives of Anthropometry
Anthropometry involves the use of body weight and height scales, skinfold caliper, head and arm
circumference tapes.121 Heights and weights of children are accepted measures for monitoring
their growth and nutritional status.121 They are also considered as indicators of the nutritional
statusoftheentirecommunity.121 The indicators used for classification by comparison with a
reference population include; weight for height, weight for age and height for age, BMI for
age.122
Weight for Age
Weight for age reflects body mass relative to chronological age.123 Underweight is defined as
low weight for age below 2 standard deviation (SD) of the median value of the National Center
for Health Statistics (NCHS) /WHO international growth reference.123 Underweight among
school-age children can reflect a broad range of insults such as prenatal under nutrition,
deficiencies of macro- and micro-nutrient, infection and possibly, neglect by care givers.123
Weight for age reflects current nutritional status and is primarily a composite of weight for
height and height for age.123 However, it fails to distinguish tall, thin children from short, well-
proportioned children. 123
33
Weight for Height
Low weight for height is used as an indicator of wasting, which is an acute condition of current
malnutrition.123 Wasting or thinness is defined as a low weight for height which is below 2SD of
the median value of the NCHS/WHO international weight for height reference.123
Wasting, which reflects acute malnutrition, is not as common as either stunting or underweight in
school-age children.124 Nevertheless, wasting rates can change rapidly in situations of acute food
crisis, with school-age children and adolescents, becoming severely malnourished.124
A prevalence of wasting or acute malnutrition ranging from 5% to 8% percent indicates a
disturbing nutritional situation and a prevalence of greater than 10% corresponds to a serious
nutritional situation.125 However, lack of evidence of wasting in a population does not imply the
absence of current nutritional problems, as stunting and other deficits may be present.126
Overweight is the preferred term for describing high weight for height.126 Although there is a
positive correlation between high weight for height and obesity as measured by adiposity, greater
lean body mass can also contribute to high weight-for-height.126
On a population-wide basis, high weight for height can be considered as an adequate indicator of
obesity, because most individuals with high weight for height are obese.126
Height for Age
Low height for age is used as an indicator of stunting, which is an index of chronic
malnutrition.47 Stunting refers to shortness that is a deficit or linear growth that has failed to
reach genetic potential. It is defined as low height for age which is below 2SD of the median
value of the NCHS/WHO International growth reference.122
34
BMI for Age
BMI can be used to assess the weight status of children and provides a good indicator for levels
of body fat.127 It is known that having a BMI that is either too low or too high is associated with
an increased risk of ill health during childhood as well as later in life.127 BMI is relatively quick
and easy to calculate and as a result, is useful for population surveys and when assessing
individual patients.127 BMI is a very useful approximation of what one should weigh depending
on height in children and teenagers.127 It is used to assess underweight, overweight and risk for
overweight.128 BMI is thought to be a more accurate indicator of body fat content than the CDC
height weight tables that have been in use for more than 30years.129 BMI for age charts shows
age related changes, which the weight for height chart does not reflect.129
Obesity is defined as BMI ≥ 95th percentile for age and sex, or BMI for age which is greater than
+2 z scores.130 Overweight is defined as BMI greater than 85th percentile but less than 95th
percentile for age or BMI for age between +1 and +2 z scores for age and sex.130
Skinfold Thickness
This is an alternative technique, which is simple and involves the measurement of subcutaneous
fat thickness or skinfolds at selected sites such as the triceps, subscapular area and the iliac
crest.131 Skin fold calipers are used for these measurements.131 It provides an estimate of the
thickness of subcutaneous fat.131 Skinfold thickness measurements may be used with reasonable
success to detect childhood obesity.131 It favours adequacy and simplicity in screening for
adiposity.131 However, it has many intraobserver variations and is only useful in skilled hands.131
35
Reference Values
Body parameters such as weight and height are age dependent, thus there’s a need to compare a
child’s measured values with those of children of the same age and sex in a reference
population.132 A reference standard is a fundamental requirement in anthropometry, as a basis for
determining whether a given anthropometric measurement represents a normal or malnourished
state.132 It should take into consideration the differences in growth patterns of children from
different ethnic backgrounds.132 Environmental factors such as disease, inadequate diet and
poverty appear to be far more important than genetic predisposition in producing deviations from
the reference values.133 These factors are closely linked to the overall standards of living, and
the ability of populations to meet their basic needs.133 The usefulness of these reference values is
limited especially in developing countries, where births may not be registered and correct age
data may not always be available. 133 Unfortunately only few local reference standards exist.133
However, the WHO has recommended the use of reference standards that were based on cross
sectional studies of healthy well-nourished American subjects, and these have remained the most
frequently used reference standards worldwide.
In conclusion, the health of children is largely dependent on their nutritional status. In the study
area, there is paucity of data on nutritional status of school age children, who constitute a
significant segment of the paediatric population. Previously, emphasis had been laid on
nutritional status of children less than five years. Malnutrition in childhood can impair physical
and intellectual development. Therefore, nutritional assessment is imperative for the
identification of malnutrition as a public health problem and subsequent application of
appropriate corrective interventions and policy formulation.
36
AIM AND OBJECTIVES
General Aim
To determine the nutritional status of children aged 6-12 years who are attending primary
schools in Enugu North Local Government Area (LGA) of Enugu State.
Specific Objectives
To determine:
1. the prevalence of malnutrition (under nutrition, stunting, wasting, obesity, overweight) in
primary school children in Enugu North LGA using WAZ, HAZ scores, BMI.
2. the factors which influence the nutritional status of this age group.
3. the differences in the aforementioned anthropometric indices between children in private
and public schools in Enugu North LGA.
SUBJECTS AND METHODS
37
Study Design
The study was a descriptive cross sectional study, involving primary school children in public
and private schools in Enugu North LGA.
Study Area and Population
The study was carried out from March to July 2013 in 14 randomly selected primary schools (9
private; 5 public) in Enugu North LGA, which is one of the three local government areas in
Enugu metropolis. Enugu metropolis is the state capital of Enugu State, Southeastern Nigeria.
The metropolis has a population of 722,664 (seven hundred and twenty two thousand six
hundred and sixty four) according to the 2006 national population census figures.134
There are 527 registered primary schools in Enugu Metropolis.135 In Enugu North LGA, which is
the study site, there are 139 primary schools comprising 51 public and 88 private schools with a
total school population of 82,116 pupils (13,855 public and 68,261 private).135
Most of the children in the public schools are from lower socio-economic backgrounds, while
majority of the children in the private schools are from middle and upper social classes.
The local language is Igbo. The working class population is made up of different groups of
individuals in various occupations but most of them are civil servants.135
Inclusion Criteria
1. Primary school children aged 6-12 years.
2. Children attending registered public and private primary schools in Enugu North LGA.
3. Subjects whose parents had given informed consent.
4. Subjects older than 7 years who gave assent.
Exclusion Criteria
38
1. Subjects on medications known to affect growth such as steroids.
2. Subjects with skeletal deformities.
Sample Size Determination
The sample size for the study was calculated using the formula below.136
n = Z2pq
d2
Where n = the desired sample size when the population is more than 10,000
Z = the standard variation, usually set at 1.96 (which corresponds to 95% confidence interval)
p = the proportion in the target population estimated to have a particular characteristic.
(Prevalence of undernutrition recorded in Uyo, Akwa Ibom state: 39.4%=0.394)19
q = 1.0 – p
d = degree of accuracy desired; set at 0.05
Therefore the minimum sample size n = (1.96)2(0.394) (0.606) = 367
. (0.05)2
A non-response rate of 10% was anticipated, hence the sample size was increased to 404. This
was then further multiplied by 2 to take care of the design effect.137 Thus, the final sample size
for the study was 810.
Sampling Method
A multi-stage sampling method was employed. A list of primary schools in Enugu North LGA
was obtained from the Enugu state Ministry of Education. All the primary schools were grouped
into public and private. The ratio of public to private schools in the study area is 1:1.7, therefore
5 public schools and 9 private schools were selected for the study. This selection was done by
39
simple random sampling without replacement. Thus, a total of 14 schools were selected for the
study. (Appendix 6)
In the next stage, the number of subjects to be selected from each school was determined using
the Neymann allocation formula138 for stratified sampling as follows;
For each school, = Total population of the index school X Total sample size
Sample size allocated Sum of the population of 14 schools
In each school selected, the allocated sample size proportionately divided among each section,
and the total number of students in each section constituted the sampling frame in that section.
The allotted sample was then divided according to the number of classes in each section. In each
class, the participants were selected by simple random sampling using a statistical table of
random numbers until the required number for the class was obtained.
Ethical Approval
Ethical approval was obtained from UNTH Health Research Ethics committee (Appendix 3).
Permission was also obtained from the Enugu State Universal Basic Education board (ESUBEB)
(Appendix 2) and from various head teachers of the selected schools. Written informed consent
was obtained from parents of the selected pupils (Appendix 4). Three or more visits were made
to each of the selected schools. The first was to get approval from the school authorities,
introduce the researcher, the study objectives and design. On subsequent visits the children were
given a brief lecture on nutrition and subject selection was carried out. The selected subjects
were given the consent forms and bio data forms (Appendix 1) to take home to their parents.
Data Collection
40
Proforma: A proforma (Appendix 1) designed for the study was used to record the information
obtained. The section A of the proforma was completed by the parents/guardians.
The study was carried out with the aid of a research assistant, who assisted in filling the section
B of the proforma, while all the anthropometric measurements were taken by the investigator
alone.
The weight and height measurements were carried out according to standard procedures
described by WHO.139 All measurements were taken with the children wearing light clothing and
without shoes. The age of the subjects was confirmed from school records since the birth
certificates are a requirement for admission in most of the schools used in the study.
Subjects whose age data could not be ascertained were excluded from the study.
Each child was weighed using a calibrated standardized digital weighing scale (OMRON
BF400), with the accuracy of the scale to the nearest 0.5kg. The weight was recorded twice and
the average value used in the analysis. The scale was set to zero point before each use and
checked for accuracy with standard weights after every 20 measurements or whenever the scale
was moved from place to place. Individual heights were measured with a wooden stadiometer
placed on a flat surface. Subjects stood on the basal part of the device with feet together, without
shoes. The shoulders, the buttocks and the heels were placed against the stadiometer. With the
children standing erect, their height was measured to the nearest 0.1cm. Two measurements were
taken and the average value was obtained.
BMI was calculated using the formula
BMI = Weight (Kg) 127
Height (M2)
41
Weight-for-age, Height-for-age, and BMI-for-age were derived from the new WHO standard/
reference.140 Computed Z scores for BMI for age , weight for age and height for age were then
used to assess underweight, wasting, stunting, overweight and obesity using the recently
published WHO reference standards.140
\Normal height was defined as height for age which is between -2 and +2 Z score while normal
weight was defined as weight for age between -2 and +2 Z score.140 Stunting was defined as
height for age less than -2 Z score.140 Underweight was defined as weight for age less than -2 Z
score.140 Wasting was defined as BMI for age less than -2 Z score.140 Obesity was defined as
BMI greater than +2 Z score, while overweight was defined as BMI for age between +1 and +2 Z
score.140
Determination of Social Class
For the purpose of the study, social class was determined using the classification proposed by
Olusanya et al141 (Appendix 5). Social class was stratified into five classes based on the parents’
level of education and occupation as described by Olusanya et al.141 Scores were awarded to each
child based on the father’s occupation and the mother’s educational attainment. Scores of 1 and 2
were grouped under the upper class; score of 3 the middle social class, while scores of 4 and 5
were the lowest socioeconomic class.141
Data Analysis
Data obtained was recorded and analyzed using the Statistical Package for Social Sciences
(SPSS) version 18.0. Descriptive statistics which include frequency, percentages, means and
standard deviations was used to summarize the variables. Logistic regression was used to
determine association between categorical variables, while comparism of means between
42
public/private schools was done using the Student’s t test. All tests were 2-tailed and significant
at less than 0.05.
43
Results
The number of subjects recruited in this study was 925. However, 65 bio data forms were incompletely
filled. Thus, total number analysed was 860. Of this, 348 (40.4%) were from public schools while 512
(59.6%) were from private schools.
Demographic Characteristics of study subjects
A total of 396 (46%) males and 464 (54%) females were selected for this study. The male to
female ratio was 1:1.2. The mean age of the study subjects was 9.18 ± 1.79 years, while the
mode was 8 years. In the public schools, majority of the pupils (78.7%) were from the lower
socioeconomic class, while in the private schools, most pupils (54.7%) were from the upper
social class. The demographic characteristics of the study subjects are shown in Table I below.
Table I. Sociodemographic characteristics of the study subjects in private and public schools.
Variables Private schools
n (%)
Public schools
n (%)
Sex
Male 259 (50.6) 137 (39.4)
Female 253 (49.4) 211 (60.6)
Age (years)
6 55 (10.7) 28 (8.0)
7 48 (9.4) 26 (7.5)
8 115 (22.5) 56 (16.1)
9 91 (17.8) 53 (15.2)
10 99 (19.3) 57 (16.4)
11 68 (13.3) 65 (18.7)
12 36 (7.0) 63 (18.1)
Social class
Upper 280 (54.7) 26 (7.5)
Middle 69 (13.5) 48 (13.8)
Lower 163 (31.8) 274 (78.7)
44
Comparison of means between children in public and private schools
Table II below illustrates a comparism of means between children in public and private schools.
The children in private schools had higher mean weight than children in public schools and this
difference was statistically significant (p = 0.005). Average BMI for private schools was also
higher than that for public schools (p<0.001).
Table II. Comparison of means between children in private and public schools
Variables Private school
Mean ± SD
Public school
Mean ± SD
t value p value
Age (years) 8.94 ± 1.71 9.53 ± 1.86 4.819 < 0.001
Height (m) 1.39 ± 0.10 1.38 ± 0.12 1.064 0.288
Weight (kg) 32.31 ± 8.29 30.74 ± 7.78 2.799 0.005
BMI 16.52 ± 2.60 15.87 ± 1.99 3.915 < 0.001
45
Nutritional status of study subjects
Table III shows the summary of the nutritional status of the study subjects. Most of them
(80.3%) had normal nutritional status.
Table III. Distribution of the nutritional status of the study participants
Nutritional Status Frequency Percent
Normal 691 80.3
Stunting 7 0.8
Wasting 26 3.0
Underweight 28 3.3
Overweight 73 8.5
Obese 35 4.1
Total 860 100.0
46
Age related differences in nutritional status of the study subjects.
Tables IV to VIII below illustrate the age differences in nutritional status of the study population.
children aged 12 years were found to be wasted, stunted and underweight. These differences
were statistically significant (p < 0.05).
Table IV. Relationship between age and wasting among the study participants
Age
(years)
Wasted
n (%)
Not wasted
n (%)
p value OR 95% C. I for OR
Upper Lower
6 2 (7.7) 81 (97.6) 0.751 0.843 0.295 2.409
7 4 (15.4) 70 (94.6) 0.945 0.964 0.336 2.761
8 3 (11.5) 168 (98.2) 0.347 0.675 0.297 1.531
9 2 (7.7) 142 (98.6) 0.680 0.841 0.370 1.914
10 3 (11.5) 153 (98.1) 0.301 0.630 0.263 1.510
11 5 (19.3) 128 (96.2) 0.813 1.099 0.503 2.404
12 7 (26.9) 92 (92.9) 0.004 2.778 1.393 5.539
Total 26 834
47
Table V. Relationship between age and stunting among the study participants
Age
(years)
Stunted
n (%)
Not stunted
n (%)
p value OR 95% C. I for OR
Lower Upper
6 0 (0.0) 83 (100) 0.997 0.000 0.000 -
7 0 (0.0) 74 (100) 0.997 0.000 0.000 -
8 0 (0.0) 171 (100) 0.996 0.000 0.000 -
9 1 (14.3) 143 (99.3) 0.861 0.828 0.099 6.926
10 0 (0.0) 156 (100) 0.996 0.000 0.000 -
11 1 (14.3) 132 (99.2) 0.931 0.910 0.109 7.623
12 5 (71.4) 94 (94.9) 0.000 20.186 3.862 105.506
Total 7 853
Table VI. Relationship between age and underweight among the study participants
Age
(years)
Underweight
n (%)
Not underweight
n (%)
p value OR 95% C. I for OR
lower upper
6 4 (14.3) 79 (95.2) 0.402 1.589 0.538 4.695
7 0 (0.0) 74 (100) 0.997 0.000 0.000 -
8 0 (0.0) 171 (100) 0.995 0.000 0.000 -
9 2 (7.1) 142 (98.6) 0.183 0.374 0.088 1.593
10 6 (21.4) 150 (96.1) 0.647 1.240 0.494 3.111
11 7 (25.0) 126 (94.7) 0.162 1.868 0.778 4.486
12 9 (32.1) 90 (90.9) 0.001 3.905 1.715 8.891
Total 28 832
48
Table VII. Relationship between age and overweight among the study participants
Age
(years)
Overweight
n (%)
Not overweight
n (%)
p value OR 95% C. I for OR
Upper Lower
6 4 (5.5) 79 (95.1) 0.215 0.520 0.185 1.462 1.462
7 6 (8.2) 68 (91.8) 0.902 0.947 0.396 2.263 2.263
8 23 (31.5) 148 (86.5) 0.010 1.986 1.175 3.358 3.358
9 10 (13.7) 134 (93.0) 0.467 0.774 0.387 1.546 1.546
10 18 (24.7) 138 (88.5) 0.133 1.539 0.876 2.703 2.703
11 6 (8.2) 127 (95.5) 0.080 0.465 0.198 1.096 1.096
12 6 (8.2) 93 (93.9) 0.360 0.668 0.282 1.584 1.584
Total 73 787
Table VIII. Relationship between age and obesity among the study participants
Age
(years)
Obese
n (%)
Not obese
n (%)
p value OR 95% C. I for OR
Lower Upper
6 2 (5.7) 81 (97.5) 0.427 0.557 0.131 2.363
7 4 (11.4) 70 (94.5) 0.545 1.392 0.478 4.056
8 12 (34.3) 159 (93.0) 0.033 2.185 1.065 4.486
9 9 (25.7) 135 (93.8) 0.152 1.769 0.811 3.860
10 7 (20.0) 149 (95.5) 0.771 1.134 0.486 2.646
11 1 (2.9) 132 (99.2) 0.067 0.154 0.021 1.138
- 12 0 (0.0) 99 (100.0) 0.996 0.000 0.000
Total 35 825
49
Gender differences in Nutritional status
Normal nutritional status was found in 309 (78%) males and 382 (82.3%) females. Obesity was
present in 23 (5.8%) males and 12 (2.6%) females (p= 0.02).
Table IX. Gender differences in nutritional status of the study subjects
Nutritional
Status
Male
n (%)
Female
n (%)
p value OR 95% C.I
Normal 309 (78.0) 382 (82.3) 0.115 1.312 0.936 – 1.837
Stunting 2 (0.5) 5 (1.1) 0.363 0.466 0.090 – 2.415
Wasting 14 (3.5) 12 (2.6) 0.247 1.412 0.787 – 2.532
Underweight 17 (4.3) 11 (2.4) 0.119 1.847 0.855 – 3.992
Overweight 31 (7.8) 42 (9.1) 0.521 0.853 0.526 – 1.386
Obese 23 (5.8) 12 (2.6) 0.020 2.323 1.140 – 4.730
Total 396 464
50
Influence of maternal education on the Nutritional status of the study subjects.
As shown in Table X below, maternal education had significant statistical influence on the
nutritional indices tested.
Table X. Effect of maternal educational status on the nutritional status of the study population
Nutritional
Status
Tertiary
n (%)
Secondary
&below
n (%)
P value OR
95% C.I
Normal
Stunting
Wasting
Underweight
Overweight
Obesity
311 (76.0)
2 (0.5)
6 (1.5)
8 (2.0)
54 (13.2)
28 (6.8)
380 (84.3)
5 (1.1)
20 (4.4)
20 (4.4)
19 (4.2)
7 (1.6)
0.003
0.326
0.010
0.047
< 0.001
< 0.001
1.687
0.438
0.435
0.430
3.459
4.661
1.200 - 2.370
0.085 - 2.272
0.230 - 0.822
0.187 - 0.987
2.013 - 5.943
2.013 - 10.792
51
Influence of paternal education on nutritional status of the study subjects.
As illustrated in Table XI below, wasting and underweight was more prevalent among children
whose fathers had secondary education and this difference was statistically significant (p<0.05).
Overweight and obesity were significantly more prevalent among children of fathers with tertiary
education (p<0.001).
Table XI. Effect of paternal educational status on the nutritional status of the study population.
Nutritional
Status
Tertiary
n (%)
Secondary& below
n (%)
OR p value 95% C.I
Normal 313 (76.2) 378 (84.2) 1.667 0.003 1.186 – 2.342
Stunting 2 (0.5) 5 (1.1) 0.434 0.320 0.084 - 2.250
Wasting 4 (1.0) 22 (4.9) 0.270 < 0.001 0.133 - 0.549
Underweight 7 (1.7) 21 (4.7) 0.353 0.019 0.149 - 0.840
Overweight 58 (14.1) 15 (3.3) 4.754 <0.001 2.649 - 8.532
Obese 27 (6.6) 8 (1.8) 3.876 0.001 1.740 - 8.632
52
Impact of socioeconomic class on nutritional status of the study population
Tables XII and XIII below illustrate the relationship between socioeconomic class and the
nutritional status of the study subjects. Children from the middle and lower socioeconomic
classes were more underweight and wasted than children from the upper class, and this
difference was statistically significant (p<0.05). Children from the upper class were more
overweight and obese than children from the other socioeconomic classes. (p =0.001).
Table XII. Relationship between socioeconomic class and nutritional status of the study
population (upper class vs. other classes)
Variable Upper
class
n (%)
Other
classes
n (%)
OR p value 95% C.I
Stunting 1 (0.3) 6 (85.7) 0.299 0.265 0.036 – 2.499
Underweight 4 (1.3) 24 (85.7) 0.292 0.024 0.101 – 0.851
Wasting 1 (0.3) 25 (96.1) 0.197 0.001 0.007 – 0.504
Overweight 47 (15.4) 26 (35.6) 3.685 0.001 2.232 – 6.085
Obese 24 (7.8) 11 (31.4) 4.201 0.001 2.029 – 8.700
Table XIII. Relationship between socioeconomic class and nutritional status of the study
population (lower vs. other classes)
Variable Lower
class
n (%)
Other classes OR p value 95% C.I
Stunting 5 (0.8) 2 (28.6) 2.436 0.289 0.470 – 12.627
Underweight 20 (4.6) 8 (28.6) 2.488 0.032 1.084 – 5.712
Wasting 22 (5.0) 4 (15.3) 0.289 0.001 0.145 – 0.574
Overweight 17 (3.9) 56 (76.7) 0.265 0.001 0.151 – 0.465
Obese 7 (1.6) 28 (80.0) 0.230 0.001 0.099 – 0.532
53
Differences in nutritional status between subjects in public and private schools
As illustrated in Table XIV below, overweight was significantly higher in private school children
than in public school children (p< 0.001). On the other hand, children from private schools were
more obese than children in public schools (p=0.001).
Table XIV. Differences in nutritional status between subjects in public and private schools
Nutritional status Private school
n (%)
Public school
n (%)
OR p value 95% C.I
Normal 384 (75.0) 307 (88.2) 0.401 < 0.001 0.273 – 0.587
Stunting 3 (0.6) 4 (1.1) 0.507 0.376 0.133 – 2.279
Wasting 10 (2.0) 16 (4.6) 0.725 0.281 0.405 – 1.300
Underweight 19 (3.7) 9 (2.6) 1.452 0.364 0.649 – 3.247
Overweight 64 (12.5) 9 (2.6) 5.381 <0.001 2.641 – 10.965
Obese 32 (6.3) 3 (0.9) 7.667 0.001 2.329 – 25.239
54
DISCUSSION
In the present study, majority of the children were found to have normal nutritional status, which
is comparable to similar studies conducted in Sagamu Southwestern Nigeria142 and Pakistan.143
The prevalence of stunting, wasting and underweight in this study were 0.8%, 3.0% and 3.3%
respectively. This was similar to findings by authors in North India,94 Pakistan143 and
Malaysia.144 However this was at variance with other Nigerian studies which reported higher
prevalence rates.19,18,142 The findings in the current study were also lower than the reports from
other African countries where higher rates of stunting, wasting and underweight were
documented.145,146 The lower prevalence of stunting, wasting and underweight in the present
study may be partly due to the fact that the study was conducted in an urban area, unlike the
study by Senbanjo et al67 which was carried out in a rural community. In addition, children from
public and private schools were recruited in the current study, unlike the study in Markudi107
which was carried out only in children attending public primary schools who were mostly of low
socioeconomic background, despite the fact that they were residing in an urban area. These
variations in prevalence rates may also be attributable to differences in methodology. The new
WHO reference values140 used in the present study are more widely applicable and had been
projected to diagnose various forms of undernutrition and overweight to variable extents from
what was previously known with the NCHS references.122 The NCHS reference standards used in
the aforementioned studies67, 107 were derived from more affluent populations, and thus may not
give a clear picture of the nutritional situation in the developing countries.
The prevalence of overweight and obesity in the present study was comparable to the findings by
Omuemu et al106 in Edo state Nigeria, who reported prevalence of 9.8% and 6.7% respectively.
Similarly Wang147, in a cross national comparism of childhood obesity, reported 10% and 6% for
55
overweight and obesity respectively in Russian school children. However, the prevalence of
obesity in the current study was higher than that reported by Ene-Obong et al148 in a study
conducted in four major cities (Lagos, Port Harcourt, Nsukka and Aba) in southern Nigeria. This
was also the case in other Nigerian studies where lower prevalence rates for overweight and
obesity were reported.18,142,67,149,150 In addition, Ben-Bassey and his colleagues149 in Lagos also
documented a slightly higher prevalence of overweight and obesity in urban areas than rural
areas of the same LGA. The prevalence of obesity and overweight in the present study can be
attributed to the higher socioeconomic status of the subjects. These children who are of high
socioeconomic classes are more likely to have unlimited access to high calorie snacks and fast
foods. Furthermore, their sedentary lifestyles and long hours spent watching television and video
games may contribute to the higher prevalence. Majority of the children used in the study by
Amuta et al18 were of lower socioeconomic classes despite the fact that they were residing in an
urban area. In addition, these children may be more engaged in more physically demanding
activities, such as long treks to school. Other African studies by Dabone et al151 in Burkina Faso
and Zerfu et al152 in Ethiopia reported lower prevalence rates of obesity and overweight.
Similarly, Kasmini et al153 in Malaysia and Wang147 in China also documented lower prevalence
of obesity and overweight. This differed from studies from the United States,147 Kuwait,154
Bahrain155 and Pakistan58 which reported higher values for overweight and obesity. This may be
explained by the fact that overnutrition is only recently emerging as a public health problem in
our society unlike in the developed world where there has been rapid modernization, with
changes in feeding patterns with increase in fat and sugar contents of the diet, and their sedentary
lifestyles.147
56
In the present study, stunting and underweight were found to be higher in children aged 12years.
This is comparable to other Nigerian studies which reported higher prevalence of stunting and
underweight in older children.17,18 Most studies from other countries such as Burkina Faso,151
Kenya,145,156 Mozambique,39 Ethiopia,152 Pakistan,143 and Brazil90 also documented higher
prevalence of stunting and underweight in older children. In Morocco, El- Hioui et al157 reported
higher prevalence of stunting, wasting and underweight in older males. However, Fetuga et al142
in Sagamu, Nigeria reported no significant correlation between age and stunting. The fact that
older children were more stunted may be a reflection of longer exposure to chronic
malnutrition.90 This may also depict an increasing vulnerability with age. In addition, it could be
a reflection of some improvement of food and health conditions over recent years, since most of
the growth deficit catch up occurs by the age of 2 years.158
The gender differences in nutritional status for stunting, wasting and underweight in the present
study were not statistically significant. This differed from findings by other Nigerian authors
who documented higher prevalence of malnutrition among boys than girls at all ages.18,97,142
Mwaniki and Makhoka156 observed similarly higher rates of stunting and wasting among boys
than girls. Prista et al39 in Mozambique also reported higher prevalence of wasting among males
than females. However, in the present study, obesity was found to be significantly higher in
males. This is comparable to studies from India,159 China147 and Malaysia.47 However, this is in
contrast to findings by several other authors who reported higher prevalence rates of overweight
and obesity in females.19,39,147,148,160 This could be due to the fact that males, especially those of
higher socioeconomic background usually spend long hours watching television and playing
video games, thus increasing their risk of becoming obese. On the other hand, no such
differences were noted in studies from the United States and France.102,161 These variations
57
across different ethnic and racial groups may also be related to genetic, cultural and
socioeconomic factors.
Parental education is an important determinant of children’s nutritional status. Parents without
good education may not be able to select healthy nutritious food for their children from the
arrays of available food items.162 Hamitton stated that parents with low educational attainment
may not be able to afford first class proteins like milk, eggs and meat.163 In the present study, the
prevalence of undernutrition was found to be lower in children of mothers with tertiary
education. This is comparable to findings by other authors who reported that higher maternal
education improves the nutritional status of school children.60,62,63,64 Alderman and Luc66 in
Ethiopia observed that mothers’ education above secondary level had a positively significant
effect on anthropometric scores of their children when compared with uneducated mothers.
Immink and Payongayong79 in Guatemala also identified maternal literacy status as an important
risk factor for growth failure in children. Similarly, Babar et al58 in Pakistan documented higher
rates of malnutrition among children of illiterate mothers compared to literate mothers. This can
be explained by the fact that mothers who are educated are more likely to be gainfully employed
and usually have easier access to information on healthy feeding for their children. In addition to
this, they have an opinion in terms of allocation of family income in favour of the children. They
are also better informed on safe hygienic practices, water resources and seek early treatment of
infections when they occur.142
In the present study, the prevalence of overweight and obesity in children of mothers with
tertiary education was noted to be higher than the prevalence in children whose mothers had
secondary education and below. This is similar to the findings by Babar et al58 in Pakistan. These
mothers with high purchasing power are likely to afford expensive fast foods and high calorie
58
diets which will increase the risk of overweight and obesity in their children.
As expected, paternal education was also found to be closely associated with malnutrition.
Children of fathers with secondary education and below were more wasted and underweight
(p<0.05) than children of fathers with tertiary education. This was in keeping with findings of
some authors in Pakistan58,69 who documented higher rates of stunting and underweight in
children whose fathers had secondary education and below than children of fathers with tertiary
education. The reverse was the case for overweight and obesity which was found to be higher
among the children of fathers with tertiary education than in the children whose fathers had
secondary education and below. (p<0.001)
Socioeconomic status is also an important determinant of child nutritional status. It affects access
to culturally appropriate and affordable food, thus affecting the quality of the diet.163 Stunting,
underweight and wasting were significantly higher among children from lower socioeconomic
class than those of the upper class. This was similar to the findings of several authors worldwide.
In Onitsha, southeastern Nigeria Ndukwu et al164 found that children from lower social class
were more stunted than their upper class counterparts. Other Nigerian studies also reported
higher rates of stunting and underweight in children from lower socioeconomic class18,19,97 than
in those from the upper class. In the present study, prevalence of overweight and obesity were
found to be significantly higher among children from upper social class than their counterparts
from the lower socioeconomic class (p<0.001). This is comparable to findings by several authors
worldwide.39,58,163 However, this relationship between obesity and socioeconomic status varies
across countries. For instance, the risk of obesity is more prevalent in upper socioeconomic class
in Russia and China, while in the USA, obesity is more prevalent in the lower socioeconomic
59
class.98,100 This has been attributed to the fact that in people of low socioeconomic status, food
deprivation or fear of deprivation can lead to overeating when food is available.101
It is important to note that the findings for the middle class were not statistically significant. The
implication of this may be the fact that in Nigeria and other developing countries, clear
delineation of the middle class is difficult, with extremes of poverty and affluence, and erosion
of the middle class.
In the present study, stunting and wasting were found to be higher among children attending
public schools than those in private schools, while underweight was slightly higher in private
schools than in children attending public schools. This is similar to findings by Akor et al97 in
Jos, and Omigbodun et al165 in Ibadan. Wamani et al,166 in a meta-analysis of 16 demographic
and health surveys in Sub Saharan Africa also reported higher underweight and stunting rates in
public schools, than in private schools. This can easily be explained by the fact that these
children in the public schools were of lower socioeconomic background than their counterparts
in private schools. In addition, the types of food available and environmental factors also play a
role. The findings in the present study differed from that of Opara et al19 in Uyo who reported an
unexpectedly high rate of stunting and underweight in children in private schools. However, this
was still significantly lower than the rate for stunting and underweight in children in public
schools. The authors concluded that while underweight and stunting remained high in the public
schools, obesity existed alongside underweight and stunting in the privately owned schools,
presumably patronized by the elite and medium or high socio-economic groups.19
As expected, overweight and obesity were significantly higher in the children attending private
schools than those in the public schools. This was similar to findings of Dabone and Delisle151 in
60
Burkina Faso. The possible explanation for this could be the high socioeconomic status of
children in the private schools, with resultant increase in consumption of fat and refined sugar
diet, in addition to their sedentary lifestyles.
In conclusion, the findings in this study show that prevalence of under nutrition is low in Enugu
North LGA. However, overweight and obesity appear to be emerging as nutritional problems
especially among children in the private schools from upper socioeconomic class. It is therefore
pertinent that parents, caregivers and even the children be educated on the benefits of optimal
nutrition and balanced diet. There is also need for adequate physical activity to reduce the risk of
obesity and its complications.
61
Conclusions
1. In the present study, the prevalence of stunting, underweight and wasting were 0.8%,
3.3% and 3% respectively, while the prevalence of overweight and obesity were 8.5%
and 4.1% respectively.
2. Stunting, wasting and underweight were significantly higher in the older children aged 12
years, while overweight and obesity were more common among children aged 8years.
3. Males were more obese than females.
4. Children of parents with secondary education and below were more stunted, wasted and
underweight than those whose parents had tertiary education.
5. Prevalence of overweight and obesity were significantly higher in children of parents
with tertiary education than in children whose parents had secondary education and
below.
6. Children from lower socioeconomic classes were more stunted, wasted and underweight
while those from the upper class were more overweight and obese.
7. Undernutrition was more prevalent in the public schools than in the private schools, while
over nutrition was more in the private schools than in the public schools.
62
Recommendations
1. Establishment of school feeding programmes by government and private partners
especially in the government owned public primary schools, where under nutrition is
more prevalent.
2. Health promotion campaigns and nutrition education programmes for mothers and school
children, which would aid in improvement of nutrition.
63
Lines of future research
1. A multistate study may be required to obtain a reference value for anthropometric
measurements in school age children, which will be a true representation of the Nigerian
population.
2. Further studies which will compare anthropometric indices among different ethnic groups.
64
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81
APPENDIX 1
PROFORMA FOR THE ASSESSMENT OF NUTRITIONAL STATUS OF PRIMARY
SCHOOL CHILDREN IN ENUGU NORTH LGA
NAME OF SCHOOL: …………………………………….
PUBLIC/PRIVATE: ……………………………………..
A. BIODATA
1. Name………………………………….
2. Date of Birth ……………………….....
3. Sex………………………….
4. Class ……………………………..
5. Address …………………………….
6. Phone number (if any)………………………….
7. Is the child suffering from any chronic illness? .............................
8. Is the child on any medication? .............................
B. SOCIOECONOMIC STATUS
Mother’s highest education ………………
Father’s highest education ……………………
Mother’s occupation……………………………
Father’s occupation …………………………….
82
ANTHROPOMETRY
1. Height (M)…………………………..
2. Weight (kg) ………………………….
3. Body mass index (kg/m2)……………..
CLINICAL EXAMINATION
1. General clinical examination………
2. Skeletal deformities…………………
3. Other anomalies………………………
83
APPENDIX 2
84
APPENDIX 3
85
APPENDIX 4
INFORMED CONSENT FORM
STUDY TITLE: ASSESSMENT OF NUTRITIONAL STATUS OF PRIMARY SCHOOL
CHILDREN IN ENUGU NORTH LGA USING ANTHROPOMETRY.
INTRODUCTION: I am Dr Igbokwe Obianuju, a Senior Registrar in the Department of
Paediatrics, UNTH, Ituku Ozalla.
I kindly ask your permission for your child to participate in the study mentioned above. This
study is being done to determine the nutritional status of primary school children in Enugu
Metropolis.
VOLUNTARY NATURE OF PARTICIPATION: Participation is voluntary and you are free
to withdraw your child from the study at any point; your decision to do so will be respected
without further discussion.
STUDY PROCEDURE: Nutritional assessment will be done by taking measurements (weight
and height).The measurements will be taken by the researcher. The measurements will be taken
with the children’s uniforms on, and their shoes off.
RISKS: These procedures will cause no pain and there will be no risk to your child.
CONFIDENTIALITY: Information obtained will be treated with the utmost confidentiality,
and will be used for academic purposes only.
COST: Participation in the study is completely free.
FEEDBACK : I will answer any questions that you may have in the course of the study. For
further clarification, I can be reached on 07035169071.
Complaints about the research can also be made to Health Research and Ethics Committee of
UNTH Enugu on this number 08033324691.
Thank you for your kind co-operation.
CONSENT FORM I have read the consent form and the nature, risks and benefits were duly explained to me. I
hereby give full consent for my child/ward to be included in this study.
………………………………. ……..…..…………………….
Parents /guardians ‘signature or Witness’ signature or thumbprint/Date
Thumbprint/date
……………………………….
Researcher’s Signature
86
APPENDIX 5
OLUSANYA’S SOCIAL CLASS CLASSIFICATION
FATHER’S OCCUPATION
________________________________________________________________
Scores Occupation
_________________________________________________________________
1. Professionals, top civil servants, businessmen and politicians.
2. Middle level bureaucrats, technicians, skilled artisans and well-
to-do traders.
3. Unskilled workers and those in general whose income is at or
below the national minimum wage
B - MOTHER’S EDUCATION
Scores Level of Education
_____________________________________________________________________
1. Education up to University level
2. Secondary or tertiary level below the university (E.g.
colleges of Education, schools of Nursing)
3. No schooling or up to primary school level only.
Scores from A and B above when summed gives the social class of the subjects. The
social class is inversely related to the score, and the maximum score is 5, while the
minimum is 1.
Social class I (upper class): 1 or 2 represents the elite.
Social class II (middle class): score 3- represents the middle class.
Social class III (lower class): score 4 or 5; this occupies the lowest scale.
87
APPENDIX 6
LIST OF SCHOOLS
PUBLIC SCHOOLS SCHL
POPULATION
SAMPLE
ALLOCATED
1. EKULU PRIMARY SCHOOL 385 65
2. NEWHAVEN PRIMARY SCHOOL 444 75
3. WTC PRIMARY SCHOOL 426 72
4. ASATA PRIMARY SCHOOL 414 70
5. ST JAMES PRIMARY SCHOOL 390 66
PRIVATE SCHOOLS
1.UNIVERSITY PRIMARY SCHOOL 650 110
2.JUSTINE-THOMAS SCHOOL 431 73
3. FROEBEL PRIMARY SCHOOL 295 50
4. GRACELAND SCHOOL 260 44
5. PINECREST SCHOOL 331 56
6. ROCKLAND INTERNATIONAL SCH 254 43
7. ST. STEPHEN’S PRIMARY SCHOOL 177 30
8.GOD’S GIFT INTERNATIONAL SCH 361 61
9. CHIAZO PRIMARY SCHOOL 266 45
88
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