An average number of eight adolescent girls (ranged from 8 to 10) participated in each FGD. The age of participants in the focused group discussion and in-depth interviews ranged from 14 to 19 years. School teachers from primary schools were interviewed to complement information provided by the adolescent girls (Table 1).
Table 1
Description of groups study participants per district, in rural communities of Tigrai Region, Ethiopia, 2017/18
District | Number of FGDs | Number of IDIs |
| In-school | Out of school | In-school | Out-school | School Teacher |
Ofla | 1 | 2 | 4 | 1 | 2 |
Seharti Samre | 1 | - | 1 | 1 | 2 |
Tanqua Abergele | 1 | 1 | 1 | - | 1 |
Lealay machew | 1 | - | 1 | 2 | 1 |
Medebay Zana | 1 | 1 | - | 1 | 1 |
Total | 5 | 4 | 7 | 5 | 7 |
FGDs: Focus Group Discussions, IDIs: In Depth Interviews |
Perceived nutritional problems among adolescents girls
Participants were asked to describe their perception regarding the nutrition related issues among adolescent girls in their community. Shortness, anemia and thinness were the most frequently discussed nutritional problems with varieties of opinions and reflections. As indication of presence of stunting among adolescent girls, participants frequently mentioned that there are adolescent girls who are with short stature in their locality. It is well mentioned by in-school adolescent girl:
There are adolescents their height is short as compared to their age […] [15 years _in-school_Ofla district].
Though the above opinion was predominantly reported, few adolescent girls also differently mentioned that short stature is not common in their locality. An adolescent girl from Hakfen reflected:
I have not seen stunted adolescents in this community up to date. […]. No adolescent is admitted due to malnutrition. I never encounter such case [14 years, out of school girl].
Regarding the presence of stunting, some others also reported that the possibility of finding short adolescent girl for age in the locality is becoming less nowadays as dietary habit is getting improved. This opinion is captured in the following quotes:
When we see in adolescents, though most of them are ok, there are some that are short or small-sized. Generally speaking, it is good from the earlier times in terms of nutrition and others issues in nowadays. The situation is changed nowadays. [… ] However, the presence of thin and short adolescents currently may shows that there is an incidence of the problem [17 years old, completed 8th grade].
A school teacher also forwarded similar reflection:
As compare to the previous one, the risk of exposure to malnutrition is low now. The feeding habit of the community is extremely changed now (23 years aged, Samre woreda).
Participants also specified their perception regarding the causes of shortness (stunting)as the result of; (1) Heredity/genetic factors of from parents; (2) Mother’s inadequate feeding, (3) Adolescent girls’ inadequate feeding, (4) Disease or Illness (5) carrying heavy objects in reference to their age. Extensive, strong and repeated reflections that favor and disfavor hereditary/genetic and dietary reasons were repeatedly raised as perceived reasons of stunting. Participants reflected that if either the mother or the father or both are short stature, they may give offspring with short stature. In this view, participants considered shortness of the girls as natural, hence, acceptable and normal status. Opinions that favor dietary reasons to hereditary/genetic reasons argued that diet is the foundation of health in reference to the nutrient demanding age of adolescence (see Table 2).
Table 2
Perceived reasons and elaborative quotes of stunting among adolescent girls, in rural communities of Tigrai Region, Ethiopia, 2017/18
Perceived reasons | Descriptions | Elaborative quotes |
Parents’ Heredity/genetic factors | One’s height has no relation with diet but with the parents genetic factor | -“[...] this is due natural process; if God creates you, you will be longer [taller] if not you will be short; this is not related to nutrition […] [FGD-School Adolescent_Keyih-Emba Kebele_Samire woreda]. -For height it is natural; itis not related with nutrition but when we come to weight the one who feeds properly will increase his weight with his age. [12 years old, in-school girl, Samre district] |
Mother’s inadequate diet | Inadequate diet before or during pregnancy yields short offspring | The stunted ones are because their mother did not eat a balanced diet while she was pregnant […] [IDI_School Teacher_Lemlem kebele_Samre woreda]. |
Adolescent’s inadequate diet | If adolescent girls do not eat adequate and balanced diet, they will get stunted | - In my view, it is caused due to the shortage of foods. If somebody doesn’t feed properly, s/he becomes thin and short.[18-year-old, 10th -grade-completed, Tankua-Abergele-district] -Feeding style is the base for our health. Therefore, the adolescents are ready for becoming adult, and then if they fail to feed appropriately, they may develop various health problems and fail to grow as needed [School-Teaher, Laelay-Maychew] |
Disease or Illness | Disease during or before adolescence causes stunting | There may be naturally short girls due to disease [19-years, Out of school, Samre district]. There are also naturally stunted adolescents due their illness[17-years, 7th grade, Samre district] |
Workloads | Adolescent girls with high workload are at high risk of short stature. | Adolescents who have high workload without getting balanced diet will be very short. A ten years-old adolescent who do not have much workload will be even longer than the twenty years-old girls who have high workload [18-years-old, Out of school Tankua-Abrgele-district]. |
Participants reported that anemia is evident in their locality being adolescent girls at higher risk next to pregnant women. Although school girls claimed for irregularity and interruption, school-based folic acid supplementation was provided as nutritional intervention to prevent anemia. The following quote captured existence anemia among adolescents,
[…] anemia is common among us (adolescents) and pregnant women […] [14 years_ in-School_Samire woreda].
Differently, an out-school girl and a school teacher in Medebay zana district reported that anemia is not a concern of adolescents girls.
I do not think there are adolescents with Anaemia. There is education and they are eating balance diet. Therefore, there is no Anaemia [16 years, out-school, Medebay Zana district].
Before pregnancy anemia is not that much so it is not a problem, but it becomes a problem during pregnancy [32 years old, School teacher, Medebay Zana district].
Participants repeatedly mentioned that poor balanced diet, high workload and food shortage are the main risk factors for anemia among adolescent girls. They specified that missing breakfast, long working hours under the sun, not eating “blood substituting” vegetables including carrot and red potato, as well as cereals yields to anemia. The following quotes elaborated participants’ perceived causes of anemia,
Anaemia is caused by not eating a balanced diet [16 years-in-School _MedebayZanaworeda].
Anemia is caused as the result of high workload and poor feeding among the communities [18 years, out-school, Tankua Abergele district].
Next to stunting and anemia, participants also specified presence of thinness among adolescent girls, while only few participants raised presence of vitamin deficiencies and overweight in their locality among girls. Unlike in the case of stunting, almost all participants except one agreed that thinness is the result of inadequate diet. According to the participants’ opinion, adolescent girls from households with food shortage are likely to be thin. An in-school girl captured it as follows.
There are adolescents who are short compared to their age. This could be due to their nature because sometimes there are short adolescents even if they are well nourished. However, those adolescents who are very thin are due to malnutrition [15 years, 8th grade, Ofla district].
Similarly, FGD discussant in Samre district also uncovered this reflection.
After good feeding,people can increase their weight but not their height [15 years, 8th grade, Samre district] [15 years, 8th grade, Samre district].
Dissimilar to the others, FGD discussant in Medebay Zana reported that heredity is responsible for thinness as is for shortness,
There are some who are thin and there are also some who are fat. There can be thin due to heredity and there are also hereditary for shortness [18 years, out-school, Medebay Zana].
Participants agreed that overweight is less common and if any it is often due to heredity. Few also mentioned that overweight is less likely among adolescent girls who reside in rural areas because they loss energy in domestic works.
Barriers to adolescent nutrition services
Food insecurity
Participants repeatedly mentioned that food insecurity in the community, where, adolescent girls live is predominate barrier to nutritional interventions for adolescent girls. The key contributing factors specified for the food insecurity were (1) Drought and lack of rainfall (2) Insufficient agricultural productivity (3)Limited diversification of the agricultural products (4) No land owned (5) Extended family size and (6) Households’ extravagance.
Shortage to food access in the community attributed to absence of rainfall was strongly discussed. FGD discussants reported from Tankua Abergele uncovered that presence of drought for the three consecutive years preceding the study. They stated it as,
This year, there was no rainfall and all crops were remained dry in this community; the livestock production is also affected by the drought due to the shortage of water [18 years, out of school, Tankua Abergele district].
Insufficient agricultural productivity was evident. Pattern of participants response to the reasons for insufficient productivity were women’s low agricultural productivity, husband loss due to divorce or death, husband getting elder, few men in the household who able to plough, giving land to contract and crop pests. Consequently, food shortage was reported as a common phenomenon on September and October of a year while it could be sometimes extended from May to December. This time adolescent girls suffer from this shortage because they would be neglected to get attention. The following quotes captured this reflection,
Food shortage is common in September and October. And the problem may be extended up to December in the community until they collect their harvest. This time girls may face shortage of food [23 years, school teacher, Samre district].
For example if there is shortage of food during summer the mother gives priority for their children, what can she do? Nothing! Because she need to feed do not her children first […]. If there is shortage of food in the family, obviously we will be affected by malnutrition [14-years, in-school, Samre district].
As it is said, shortage of food occurred from May - September. The produced food is may be used up to May but it would be run out starting from May. Then shortage of food happened [16 years old, in-school, Tankua Abergele district].
Participants also mentioned that the limited diversification of the agricultural products hinders to food diversification to realize the intention to use diversified food, out-of-school FGD discussants in Tankua Abergele also reaches a consensus that they often eat one type of diet that is available.
Since there is a shortage of food in the community, we eat one type of food that is available in our home; for example, we eat Injera made from Sorghum for consecutive days [18 years, out-school, Tankua Abergele district].
School teacher also reflected that advice on diversified is not realized because of limited products.There are no diverse fruits and vegetables. Actually there is tomato but the other vegetable such as lettuce, Swiss chard and others are not available in the areas because the area is lowland in which diverse vegetable does not exist [23 years, school teacher, Ofla district].
Participants also raised that households’ extravagance on marriage and other ceremonies yields to food insecurity, hence aggravate nutritional problems on household members including the adolescent girls. Food insecurity was also reported in households with no man to plough themselves and those who do not own land,
It is to mean those who cannot farm their land by themselves because of death of their father are suffering from shortage of food. So that they give the land to other farmer for sharing the crop produced equally therefore the amount of crop the family gets is very minimal [...][31 year old, school teacher, Lalay Maychew].
There is shortage of foods those that do not have farm lands such as youngsters that have recently established a household [17 years, out school, Medebay Zana].
As is expected, adolescent girls from households of larger family size are at higher risk of food insecurity due to high food consumption. FGD discussants uncovered this opinion,
In rural, women or mother may give 6 to 7 children this may lead to shortage of food among our family and the mother and adolescents give priority to the young one [15 years, in-school, Samre district].
Moreover, participants revealed that adolescent girls from food insecurity households are especially vulnerable for nutritional deficiencies for reasons; (1) women and adolescent girls would be left at home with insufficient food while the husband and boys could be displaced to other areas for work, (2) Adolescent girls are given less priorities in the case of food shortage (3) high workload in domestic activities (4) women in general including adolescent girls are wrongly considered threat they could stay longer with no or limited food. The following quotes captured these opinions,
The female adolescents are more suffered from the food shortage because they have more workload at home than the male adolescent. The males can generate income by going out to the town but we can’t do so [19 Years, in-school, Samre district].
Females are always at home whether they get or not and they have no option. On the other hand, males can work outside and at least they can eat for themselves. Thus, females suffer most from nutritional problems. If they get [food] they would eat; otherwise, they sleep with empty stomach [16 years, in-school, Tankua Abergele district].
With the increasing burden of high workload for domestic activities, out-school adolescents girls were specified as the most vulnerable to nutritional deficiencies compare to in-school adolescent girls. This is strongly explained as:
The difference between the one that is out-school girl will only focus on the activities of food preparation for the family and no one considered her what she is eating and drinking [FGD- Out-of-School-adolescent-Hakfen kebele_Medebay Zana].
Limited nutrition awareness in the community
Participants also revealed that poor community’s awareness such of mono-diet practice, selling nutritious foods to markets, gender and discrimination in feeding contributes to adolescent girls’poor nutritional status. Rural residents take their animal production, high price crops and cereals to market to buy other consumptions, which makes members of the family including the adolescents at risk of under-nutrition.
All the things like the butter and other resources are available in the rural areas but due to lack of awareness, we take the products to the urban areas to get money. […]. There will be a deficiency of iron not because there is a shortage of foods but because we take the products to the urban areas to get money due to lack of awareness [16 years, out-of-School, Medebay Zana district].
Participants also reported that there is tendency to prioritize food for males over females in the household. Some of the participants reasoned out that it is because males involve in energy demanding labor work than females. FGD discussant from Samre stated this issue as,
[…] what is happening is that they have the perception to say let the girls stay and provide food to the boys. In case enough food is not ready, mothers provide the available food to their husband [31 years_ School teacher_Lalay-Maychew district].
An in-school girl opposed the feeding discrimination as:
“There should not be the practice of giving the “good” food types for boys/men and the remained for girls. We have to eat equally with our brothers. There should not be any feeding disparities like you have to eat this one, boys should to eat that one [14 years, in-school, Ofla district].
Limited access to water: Lack of access to adequate and safe water was repeatedly mentioned as a barrier for adolescent nutritional services. Many respondents witnessed that adolescent girls need to walk around three hours on foot to fetch water as FGD-discussants raised:
[…] The main problem in in our community is no water availability. It takes us three hours to fetch water. [..]. We need to spent much time to fetch water. Then, we feel tired and we miss the class [15 years_in-school _Tanqua Abergelle district].
Moreover to this, participants claimed that lack of water hindered them from practicing backyard gardening to produce nutritious foods like that of vegetables. :
The shortage of water supply is our main problem; we could be benefited from the home garden vegetables. The shortage of water is totally affected our life[18 years_out-school adolescents_Tankua-Abergele district].
High workload
Participants reported that there is high burden of energy demanding workload to adolescent girls in domestic activities including fetching water. Adolescent girls are prone for nutritional deficiency because of frequent miss of breakfast. Thus, as a consequence they are unable to concentrate in class education, miss classes, concentrate less in class, and unable to perform well in academic results. Hence, a participant recommended that there has to be present equal sharing of labor at home.
We should be equally treated at home in terms of workload. For example when I make Injera or prepare food my brother should help me in bringing water and wood. In addition we have to get equal time to study without discrimination [16 years, In-school, Samire district].
Service providers’ little attention for adolescents’ nutrition
Participants claimed that most of nutritional interventions including counseling, awareness creation activities, nutritional supplementations, food aids and supports are focused on pregnant, lactating women and children. This is captured in FGD discussion of:
[…] because the government’s attention for nutrition improvement is more skewed to the pregnant, lactating mothers and children, there is no special training in relation to nutrition improvement for adolescent girls”[18 years-out-school_Tankua Abergele district].
As a result, the participants assured that nutrition related awareness creation and life skill trainings to adolescents are very limited as supported by:
There is lack of sufficient awareness creation, and education for adolescents. There is no that much organized work to change the awareness of the adolescents. However, the education is only given by schools that may not be enough [31 years_School Teacher_Laylay-Maychew district].
Food taboo among adolescent girls
Hot foods (hot Injera with hot stew, hot porridge, tea, and milk, hot sauces and soup) were the most frequently mentioned categories of food as tabooed for adolescent girls. Besides, cooked liver, milk, animal testicles (sheep and goat), Ocholoni (peanut) were reported as taboo to be eaten by adolescents girls. The participants uncovered the reasons for the foods to be considered as tabooed for adolescent girls. The most frequently mentioned reason for hot and relatively high in energy, which is perceived to facilitate early physical maturity, arouse early sexual initiation. Meat, egg and milk are also prohibited for adolescent girls for similar reasons. An FGD discussant explained it:
It is not recommended for adolescent girls to not eat heated foods; for example if you want to eat porridge or soup, it should be refrigerated before our consumption. Hot foods arouse sexuality [15 years, out-school, Tankua Abergele district].
Some participants also reflected that consumption of hot foods is believed to be associated with early initiation of menses and increasing its volume. FGD discussant in Hatsebo Kebelle captured this concept as:
Yes, our mother don’t allow us to drink hot like tea and soup since it facilitate the initiation of menses and increases the volume of the menses. But when I think of it is not true it doesn’t has any effect [16 years, in-school, Laelay Maychew district].
Few participants also associated adolescent girls’ frequent consumption of milk with probability of having beard (facial hair) like men. Besides eating egg causes difficulties (womb narrowing) during child delivery [14 years, In-school, Tankua-Abregele district].
The pattern analysis of adherence to food taboo showed that among adolescent girls are getting less strictly with time. FGD from Hatsebo captured this opinion, the adolescent girls’ disobedience to the taboo,
Previously, foods like meat, egg and milk […] were not allowed to us and our parents informed us about this issue, but now we can eat them [19 years, in-school, Laelay-Maychew district].
Available Nutritional Interventions on Adolescent girls
Awareness creation: Few participants reported that there are interventions aimed to create awareness regarding balanced diet and food diversification, iodized salt, folic acid to prevent anemia. Participants claimed that there is no nutritional screening among adolescent girls where as it is due for children, pregnant, and lactating women. FGD discussant at Felege-Hiwot, reported,
No, the nutrition screening is occurred among pregnant and lactating mothers and children; but no in adolescent girls. Accordingly, supplementations such as plump sup and plump nut are provided for pregnant and lactating mothers. But there is no any measurement and food supply to the adolescent girls [18 years, Out-school, Tankua-Abergele dstrict].
Nutritional Supplementation: School based nutritional supplementation were the commonly reported nutritional interventions such as iron folic acid, mass drug administration for trachoma, Vitamin A supplementation, deworming, Most of the nutritional interventions provided. However, the interventions were inconsistently reported across the schools. FGD discussants from Hashenege Kebele reported that iron and folic acid supplementation is provided only to pregnant women not for adolescents while the discussants from Hatsebo kebele mentioned it that the services has been provided but currently terminated. Despite the distribution of iodized salt, FGD discussants also raised that they do have doubt regarding its appropriate use.
Preventing Disease: On the other hand, participants frequently reported awareness creation interventions on preventing communicable diseases mainly water borne diseases, malaria, menstrual hygiene contraceptive use to preventing pregnancy, and sexually transmitted diseases like HIV/AIDS). Optimizing the use Insecticide Treated bed Net to prevent mosquito bite was the most frequently reported intervention.
They give us [ITN] every year in the month of in May and sometimes in September. At least they give us three ITN for one house hold per year to prevent mosquito bite [19 years, In-school, Lalay Maychew district].
However, participants mentioned that a long way is remained to ensure effective use of the ITN as they use the net for other purposes than the intended ones like to carry straw, cover straw, and some of the women use it to fasten their waist (as a belt). Awareness creation activities aimed to prevent water borne diseases was also raised,
We get support and health workers regarding safe drinking water. They advised us to boil and drink the water or to drink from tap water (14 years, In-school Tankua Abergele).