1 Introduction
Intestinal parasitic infections are major public health problems worldwide. According to the World Health Organization (WHO), 1.5 billion people of the world population have intestinal parasirtic infections, mainly the soil-transmitted helminthes such as Ascaris lumbricoides (A. lumbricoides), Trichuris trichiura (T. trichiura), and hookworms [1]. Moreover, Giardia lamblia (G. lamblia), Entamoeba histolytica (E. histolytica), and Cryptosporidium are the most common intestinal protozoal infections in developing countries [2]. These infections significantly contribute to morbidity, particularly in children, leading to malnutrition and developmental issues [3]. Additionally, intestinal parasitic infections result in substantial economic costs, emphasizing the urgent need for effective public health interventions to control and prevent these infections [4]. In developing nations, factors such as poor sanitation, overcrowding, and climate conducive to parasite survival contribute significantly to transmission [5, 6]. School-aged children face a higher risk of infection due to frequent soil contact and less health awareness [6, 7]. Infected children often suffer from physical, nutritional, and cognitive impairments due to nutrient malabsorption and reduced dietary intake, which can lead to stunted growth, general weakness, and poor academic performance [5, 8].
Undernutrition also poses a severe problem in Africa and Asia, where stunting and thinness affect 20%–30% and 35% of school children in Africa, respectively [9]. While Millennium Goals targeted reducing undernutrition, the issue remains high in sub-Saharan Africa [10]. Therefore, undernutrition remains a major challenge for African children. In Ethiopia, pooled stunting and wasting prevalence among school children were 23.1% and 22%, respectively [11]. Potential contributing factors for malnutrition include meal frequency, family size, age, sex, and household income [11]. In developing nations, intestinal parasites and malnutrition are often coexisting [12]. Intestinal parasitic infections and malnutrition among children have a synergistic relationship. Parasitic infections can induce malnutrition by hindering nutrient absorption, while malnutrition compromises immunity, heightening vulnerability to parasites [13, 14]. This self-reinforcing cycle intensifies the severity of both issues over their individual impacts. Considering parasites and malnutrition jointly represent leading global health challenges, their synergistic interplay is thought to exacerbate poor general well-being in school-aged children [12, 15, 16]. Therefore, integrated interventions are required to break this cycle of deteriorating conditions to meaningfully improve children's well-being.
Although several studies in Ethiopia and other low-income countries have documented the burden of intestinal parasitic infections and malnutrition among school-aged children [17-20], many are limited in scope, focusing primarily on either the prevalence or associated risk factors without adequately examining the interplay between infections and nutritional status. Furthermore, most available studies are conducted in rural settings, with limited attention to semi-urban or peri-urban contexts where health determinants may differ [21, 22]. Despite Ethiopia's efforts in health education, deworming, and nutrition programs, intestinal parasites and malnutrition remain significant public health challenges, especially among vulnerable populations like elementary school children [23]. In developing countries like Ethiopia, intestinal parasitic infections and malnutrition are closely linked, often exacerbating one another and leading to severe health consequences. Previous studies have reported high rates of intestinal parasitic infections among children in various regions of Ethiopia [11, 12, 24]. However, there remains a significant knowledge gap regarding how socio-environmental factors (e.g., water source, hygiene practices, sanitation access, household size) interact to influence the co-occurrence of these health burdens in specific local contexts. To date, no published studies have assessed the dual burden of intestinal parasitic infections and malnutrition in Zenzelima town, despite its proximity to areas with reported high prevalence of IPIs and undernutrition. While prior research has identified various socioeconomic determinants of health, there is limited understanding of how these factors interact within the Zenzelima community. Moreover, disaggregated data at the town level are essential for designing context-specific interventions, as national surveys often lack the granularity needed to reflect local variations in disease burden and risk factors [25].
This study aims to fill these significant knowledge gaps by examining the prevalence and associated factors of intestinal parasitic infections in the study area. Despite existing research, comprehensive data on how specific behavioral and environmental factors contribute to infection rates remains limited. Therefore, this study aims to investigate the social and environmental determinants of both intestinal parasitic infections and malnutrition, providing a comprehensive view of the contributing factors. The findings will be critical for local health authorities and policymakers, as identifying the prevalence and associated risk factors will help design targeted health education, deworming programs, and nutritional interventions tailored to the community's needs. Additionally, this study will serve as a baseline for future research and health initiatives, enabling continuous monitoring of trends in intestinal parasitic infections and malnutrition over time. Given the pressing need to understand the prevalence and risk factors of these issues in Zenzelima town, Northwest Ethiopia, this study seeks to address the existing knowledge gap. Ultimately, it aims to contribute to improved health outcomes for children in the region and inform public health strategies that can effectively tackle these interlinked challenges.
2 Materials and Methods
2.1 Study Area
This study was conducted at Zenzelima Elementary School in Zenzelima town. Zenzelima is a small town located in the West Gojjam Zone of the Amhara Region in Ethiopia. It is situated about 430 km from the capital, Addis Ababa. With a population of around 15,000 people, it has a cool and temperate climate at an altitude of 2347 meters above sea level. Agriculture is the main economic activity, with crops like teff, barley, wheat, potatoes, and peas grown, as well as livestock rearing. Basic health and educational services are available but limited, with a health center providing outpatient care and a few primary schools. There are a few primary schools in the town as well as a junior high school that teaches up to Grade 8. Literacy levels remain low due to limited educational opportunities. Access to safe water, sanitation, and solid waste management is challenging, as many residents continue using open fields and streams. Overall, Zenzelima has a predominantly rural setting where subsistence farming and pastoralism are the main livelihoods, facing difficulties related to infrastructure, health services, and water/sanitation.
2.2 Study Design and Period
A school-based cross-sectional study was conducted from January to May 2022 to determine the prevalence of intestinal parasites, undernutrition, and associated factors among school children.
2.3 Inclusion and Exclusion Criteria
Children of school-going age in Grades 1 through 8 who were present during the study period were eligible for inclusion, provided their parents or guardians (for younger children) signed a written consent form confirming willingness to participate. However, the inabilities to properly collect a stool sample, incomplete responses on the sample collection form by students or guardians, and the use of antiparasitic drugs within the previous 3 weeks were excluded.
2.4 Variables
The dependent variables include the prevalence of intestinal parasitic infections and undernutrition, while independent variables encompass socioeconomic factors, behavioral factors (dietary habits, hygiene practices), environmental factors (living conditions, sanitation access), and demographic factors (age, gender) [7, 26].
2.5 Sample Size and Sampling Techniques
The sample size was calculated using the single population proportion formula, with the following assumptions: prevalence (p) of 50%, margin of error of 5%, and a 10% nonresponse rate. This yielded a required sample of 422 children. There were a total of 2121 students enrolled in Grades 1 through 8 during the study period, distributed across 36 classes with an average of 59 students/class. Students were stratified by grade level proportionate to enrollment. Final selection of participants was conducted through systematic random sampling using the class rosters as the sampling frame.
2.6 Data Collection and Laboratory Procedures
2.6.1 Sociodemographic Data and Risk Factors
A structured questionnaire was developed based on known risk factors, translated into Amharic, and back-translated into English. Student ages were obtained from the school registration book and confirmed with parents or guardians. Data collectors inquired about the use of protective shoes and hand washing before meals. They also assessed finger cleanliness and overall personal hygiene for each student. Additional data collected included family size, literacy rates of parents, meal frequency, and information on other independent variables. This questionnaire was used to interview participants or the parents of younger children, gathering sociodemographic data and information on behavioral and hygiene practices. Data collection was conducted by trained individuals with relevant experience under the continuous supervision of the investigator.
2.6.2 Stool Sample Collection and Processing
Approximately 2 g of stool were collected from each participant using a labeled, wide-mouthed, leak-proof container. Samples were transported immediately to the Zenzelima health center laboratory for processing. Approximately 2 mg of fresh stool was emulsified in a saline drop on a slide, covered, and examined microscopically at 10× and 40× objectives. Additionally, about 0.5 g of stool was mixed with 10 mL of saline, strained, and centrifuged. The supernatant was removed after adding 2.5 mL of 10% formaldehyde and 1 mL of ether. A drop of the sediment was then covered and examined microscopically following the formol-ether concentration technique [27].
2.6.3 Anthropometric Measurements
Anthropometric measurements were taken by a trained nurse using standard procedures. Height was measured to the nearest 0.1 cm using a stadiometer with shoes removed and feet flat on the ground. Weight was also measured to the nearest 0.1 kg using a digital scale with light clothing and no shoes. The WHO AnthroPlus software was used to classify nutritional status. This involved calculating z-scores for height-for-age (HAZ) and body mass index-for-age (BAZ) based on the WHO standards. Children with z-scores below −2 SD were classified as underweight (WHZ < −2 SD), stunted (HAZ < −2 SD), and wasted (BAZ < −2 SD). Undernutrition is defined as a condition where a child is classified as underweight, stunted, or wasted. This term encompasses various forms of nutritional deficiencies impacting growth and overall health [28].
2.7 Quality Assurance
Several quality control measures were implemented. All data collectors received training, and data collection was supervised daily by the principal investigator. The questionnaire was translated into the local Amharic language and back-translated into English to ensure consistency. It also underwent pretesting. Anthropometric equipment was calibrated every five measurements to control inaccuracies. Laboratory procedures strictly followed standard operating procedures. This was to ensure high-quality data by controlling for potential errors and biases during data collection and analysis processes.
2.8 Data Processing and Analysis
The data were checked for completeness and entered into the Statistical Package for the Social Sciences (SPSS) version 23 for analysis. Descriptive statistics, including frequencies, prevalence, and means, were used to summarize the data. The WHO AnthroPlus software version 1.0.4 was utilized to convert anthropometric measurements into nutritional indices. Children's nutritional status was assessed based on weight-for-age, HAZ, and weight-for-height. Risk factors for the acquisition of intestinal parasitic infections and undernutrition were analyzed using bivariable and multivariable logistic regression to evaluate the associations between various independent variables and the dependent variables. A priori significance was set at p < 0.05, and two-sided tests were employed for this analysis. Variables with a p < 0.25 in the bivariable analysis were included in the multivariable logistic regression. Adjusted odds ratios (AOR) were calculated with a 95% CI to assess the strength of these associations while controlling for potential confounders, with a p < 0.05 considered statistically significant.
2.8.1 Ethical Approval and Consent to Participate
Ethical approval was secured from the Research and Ethical Review Committee of Bahir Dar University, College of Medicine and Health Sciences. Permission was also obtained from the Amhara Public Health Institute. The aim of the study was explained to the study participants and their parents or guardians. Students were involved in the study after receiving written informed consent from their families/guardians and the school principal. Confidentiality of the data was maintained. Children who tested positive for intestinal parasitic infections or were malnourished were referred to the Zenzelima Health Centre for treatment, counseling, and appropriate management. The study adhered to all principles of ethical research conduct as outlined in the Declaration of Helsinki.
3 Results
3.1 Sociodemographic Characteristics
A total of 405 elementary school children aged 6–19 years participated in the study. Among these participants, 208 (51.4%) were female, and 207 (51.1%) were aged between 11 and 15 years. The majority of the children's mothers, accounting for 72.1%, had no formal education. Furthermore, 253 (62.5%) of the study participants resided in rural areas (Table 1).
Table 1.
Sociodemographic characteristics of elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Variables |
Categories |
Frequency (n) |
Percentage (%) |
| Age groups (years) |
6–10 |
191 |
47.2 |
| 11–15 |
207 |
51.1 |
| 16–19 |
7 |
1.7 |
| Sex |
Male |
208 |
51.4 |
| Female |
197 |
48.6 |
| Level of grade |
1–4 |
211 |
52.1 |
| 5–8 |
194 |
47.9 |
| Residence |
Urban |
152 |
37.5 |
| Rural |
253 |
62.5 |
| Family size |
≤ 5 |
201 |
49.6 |
| > 5 |
204 |
50.4 |
| Literacy rate of mother |
Secondary school and above |
4 |
1.0 |
| Primary school |
109 |
26.9 |
| Illiterate |
292 |
72.1 |
| Mother's occupation |
Government employee |
4 |
1.0 |
| Private employee |
5 |
1.2 |
| Merchant |
51 |
12.6 |
| House wife |
313 |
77.3 |
| Casual labourer |
32 |
7.9 |
| Literacy rate of the father |
Secondary school and above |
10 |
2.5 |
| Primary school |
228 |
56.3 |
| Illiterate |
167 |
41.2 |
| Father occupation |
Government employee |
6 |
1.5 |
| Private employee |
7 |
1.7 |
| Merchant |
63 |
15.6 |
| Causal laborer |
46 |
11.4 |
| Farmer |
283 |
69.9 |
3.2 Prevalence of Intestinal Parasitic Infections and Associated Factors
The overall prevalence of intestinal parasites in this study was 49.6% (95% CI: 44.4–54.8), indicating that children were infected with at least one species of intestinal parasite. The rates of single, double, and triple infections were 139 (34.3%), 56 (13.6%), and 6 (2.0%), respectively. In total, eight different types of intestinal parasites were identified. The three most common parasites detected were hookworm (22.2%), G. lamblia (19.8%), and E. histolytica (13.6%) (Table 2).
Table 2.
Prevalence of intestinal parasitic infections among elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Variable |
Categories |
Frequency (n) |
Percent (%) |
| Types of intestinal parasites |
Hookworm |
90 |
22.2 |
| Ascaris lumbricoides |
11 |
2.7 |
| Strongyloides stercoralis |
1 |
0.2 |
| Schistosoma mansoni |
25 |
6.2 |
| Hymenolepis nana |
6 |
1.5 |
| Enterobius vermicularis |
2 |
0.5 |
| Giardia lamblia |
80 |
19.8 |
| Entamoeba histolytica/dispar |
55 |
13.6 |
| Types of infections |
Single infection |
139 |
34.3 |
| Double infection |
56 |
13.6 |
| Triple infection |
6 |
2.0 |
| Overall |
201 |
49.6 |
In this study, students who consumed raw or unwashed vegetables and fruits (AOR = 2.03; 95% CI: 1.33–3.11), had irregular use of closed shoes (AOR = 1.86; 95% CI: 1.09–3.47), and exhibited the habit of open-field defecation (AOR = 3.07; 95% CI: 2.00–4.71) were identified as independent predictors of intestinal parasitic infections (Table 3).
Table 3.
Binary logistic regression analysis of determinant factors associated with intestinal parasitic infections among elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Variables |
Categories |
IPs |
Crude OR (95% CI) p |
Adjusted OR (95% CI) p |
| Pos |
Neg |
| Age (years) |
6–10 |
94 |
97 |
0.73 (0.158–3.34) 0.68 |
|
| 11–15 |
103 |
104 |
0.98 (0.66–1.45) 0.91 |
|
| 16–19 |
4 |
3 |
1 |
|
| Sex |
Male |
95 |
113 |
0.72 (0.49–1.07) 0.10 |
|
| Female |
106 |
91 |
1 |
|
| Grade level |
1–4 |
103 |
108 |
0.93 (0.63–1.38) 0.73 |
|
| 5–8 |
98 |
96 |
1 |
|
| Residence |
Urban |
81 |
71 |
1 |
|
| Rural |
120 |
133 |
0.79 (0.53–1.18) 0.25 |
|
| Family size |
≤ 5 |
96 |
105 |
1 |
|
| > 5 |
105 |
99 |
1.16 (0.79–1.71) 0.46 |
|
| Literacy rate of mother |
≥ Secondary school |
3 |
1 |
1 |
|
| Primary school |
48 |
61 |
1.34 (0.86–2.09) 0.19 |
|
| Illiterate |
150 |
142 |
0.35 (0.04–3.43) 0.37 |
|
| Hand washing before and after eating |
Yes |
144 |
178 |
1 |
1 |
| No |
57 |
26 |
2.71 (1.62–4.527) 0.02 |
2.61 (0.99–4.51) 0.06 |
| Eating raw fruits and vegetables |
Yes |
116 |
80 |
2.12 (1.42–3.15) 0.001 |
2.03 (1.33–3.11) 0.001 |
| No |
85 |
124 |
1 |
1 |
| Source of drinking water |
Pipe |
87 |
98 |
1 |
|
| River |
8 |
3 |
0.39 (0.10–1.50) 0.17 |
|
| Well or stream |
106 |
103 |
1.16 (0.78–1.72) 0.47 |
|
| Open field defecation |
Yes |
141 |
84 |
3.36 (2.23–5.06) 0.001 |
3.07 (2.00–4.71) 0.001 |
| No |
60 |
120 |
1 |
1 |
| Hand washing after toilet/defecation |
Yes |
89 |
91 |
1 |
|
| No |
112 |
113 |
1.01 (0.69–1.50) 0.95 |
|
| Presence of toilet |
Yes |
116 |
131 |
1 |
|
| No |
85 |
73 |
1.32 (0.88–1.96) 0.18 |
0.66 (0.39–1.12) 0.12 |
| Finger nail trim |
Yes |
183 |
184 |
1 |
|
| No |
18 |
20 |
0.90 (0.46–1.77) 0.77 |
|
| Regular wearing of closed shoes |
Yes |
21 |
41 |
1 |
1 |
| No |
180 |
163 |
2.16 (1.22–3.80) 0.01 |
1.86 (1.09–3.47) 0.03 |
| Playing with soil |
Yes |
12 |
16 |
0.75 (0.34–1.62) 0.46 |
|
| No |
189 |
188 |
1 |
|
| Eating soil |
Yes |
6 |
7 |
0.87 (0.29–2.62) 0.80 |
|
| No |
195 |
197 |
1 |
|
| Swimming habit |
Yes |
97 |
102 |
0.93 (0.63–1.38) 0.73 |
|
| No |
104 |
102 |
1 |
|
| Nutritional status |
Undernourished |
133 |
103 |
1.92 (1.28–2.86) 0.001 |
0.82 (0.98–2.81) 0.09 |
| Normal |
68 |
101 |
1 |
1 |
- Note: Bold values are statistically significant.
Additionally, hookworm was the most prevalent parasite identified in this study. The multivariable logistic regression analysis conducted to identify the factors influencing hookworm infection revealed that wearing shoes was the sole predictor of hookworm infection (Table 4).
Table 4.
Binary logistic regression analysis of determinant factors associated with hookworm infections among elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Variables |
Categories |
Hookworm |
Crude OR (95% CI) p |
Adjusted OR (95% CI) p |
| Pos |
Neg |
| Age (years) |
6–10 |
36 |
155 |
0.43 (0.16–1.20) 0.26 |
|
| 11–15 |
51 |
156 |
0.27 (0.04–1.77) 0.28 |
|
| 16–19 |
3 |
4 |
1 |
|
| Sex |
Male |
50 |
158 |
0.94 (0.56–1.58) 0.82 |
|
| Female |
40 |
157 |
1 |
|
| Grade level |
1–4 |
43 |
168 |
2.191 (0.79–6.05) 0.13 |
0.95 (0.570–1.58) 0.84 |
| 5–8 |
47 |
147 |
1 |
|
| Residence |
Urban |
37 |
115 |
1 |
|
| Rural |
53 |
200 |
0.73 (0.44–1.24) 0.24 |
0.77 (0.47–1.26) 0.30 |
| Family size |
≤ 5 |
42 |
159 |
1 |
|
| > 5 |
48 |
156 |
1.06 (0.64–1.75) 0.84 |
|
| Literacy rate of mother |
≥ Secondary school |
1 |
3 |
1 |
|
| Primary school |
20 |
89 |
1.23 (0.68–2.23) 0.77 |
|
| Illiterate |
69 |
223 |
0.70 (0.06–7.70) 0.49 |
|
| Hand washing before and after eating |
Yes |
65 |
257 |
1 |
|
| No |
25 |
58 |
1.91 (1.06–3.44) 0.03 |
1.723 (0.983–3.02) 0.07 |
| Open field defecation |
Yes |
60 |
165 |
1.79 (0.97–3.29) 0.06 |
1.65 (0.991–2.74) 0.06 |
| No |
30 |
150 |
1 |
|
| Hand washing after toilet/defecation |
Yes |
44 |
136 |
1 |
|
| No |
46 |
179 |
0.60 (0.33–1.09) 0.95 |
|
| Presence of toilet |
Yes |
52 |
195 |
1 |
|
| No |
38 |
120 |
1.08 (0.57–2.08) 0.81 |
|
| Regular wearing of closed shoes |
Yes |
5 |
57 |
1 |
|
| No |
85 |
258 |
3.16 (1.18–8.43) 0.02 |
3.09 (1.19–8.09) 0.02 |
| Playing with soil |
Yes |
6 |
22 |
1.04 (380–2.853) 0.94 |
|
| No |
84 |
293 |
1 |
|
| Eating soil |
Yes |
1 |
12 |
0.26 (0.03–2.19) 0.21 |
0.25 (0.03–2.04) 0.19 |
| No |
89 |
303 |
1 |
|
| Nutritional status |
Undernourished |
61 |
175 |
0.66 (0.38–1.15) 0.14 |
0.70 (0.45–1.19) 0.18 |
| Normal |
29 |
140 |
1 |
|
- Note: Bold values are statistically significant.
3.3 Nutritional Status and Associated Factors
The study also examined the nutritional status and associated factors among elementary school children. The results found that the overall prevalence of undernutrition was 58.3% (95% CI: 53.1–63.0). Specifically, the prevalence rates for wasting, stunting, and underweight were 49.1%, 25.9%, and 14.6%, respectively. Among the undernourished students, 31.4% were exhibited two or more concurrent forms of undernutrition, according to the findings presented in Table 5.
Table 5.
The prevalence of malnutrition among elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Nutritional status |
Categories |
Frequency (n) |
Percentage (%) |
|
Malnutrition |
Wasted |
199 |
49.1 |
| Stunted |
105 |
25.9 |
| Underweight |
59 |
14.6 |
| ≥ 2 forms of undernutrition |
127 |
31.4 |
| Overall |
236 |
58.3 |
| Normal |
|
169 |
41.7 |
- Note: Bold values are statistically significant.
The binary logistic regression model result showed that study participants who had a meal frequency of at most three times a day (AOR = 3.24, 95% CI: 1.98–5.32), and those being infected with intestinal parasites (AOR = 1.84; 95% CI: 1.19–2.83) were strongly associated with undernutrition (Table 6).
Table 6.
Binary logistic regression analysis of determinant factors associated with undernutrition among elementary school children in Zenzelima town, Northwest Ethiopia, 2024.
| Variables |
Categories |
Undernutrition |
Crude OR (95% CI) p |
Adjusted OR (95% CI) p |
| Yes |
No |
| Age (years) |
6–10 |
86 |
105 |
1.09 (0.24–5.01) 0.91 |
|
| 11–15 |
147 |
60 |
0.33 (0.22–1.51) 0.54 |
|
| 16–19 |
3 |
4 |
1 |
|
| Sex |
Male |
129 |
79 |
1.37 (0.92–2.04) 0.12 |
1.29 (0.83–2.01) 0.26 |
| Female |
107 |
90 |
1 |
1 |
| Grade level |
1–4 |
94 |
117 |
0.29 (0.19–1.45) 0.47 |
1 |
| 5–8 |
142 |
52 |
1 |
|
| Residence |
Urban |
89 |
63 |
1 |
1 |
| Rural |
147 |
106 |
0.98 (0.65–1.48) 0.93 |
|
| Family size |
≤ 5 |
109 |
92 |
1 |
1 |
| > 5 |
127 |
77 |
1.39 (0.94–2.07) 0.10 |
0.96 (0.62–1.50) 0.87 |
| Literacy rate of mother |
≥ Secondary school |
2 |
2 |
1 |
1 |
| Primary school |
54 |
55 |
1.61 (0.22–11.57) 0.64 |
1.50 (0.17–13.14) 0.72 |
| Illiterate |
180 |
112 |
1.64 (1.05–2.55) 0.03 |
1.59 (0.97–2.58) 0.06 |
| Literacy rate of father |
≥ Secondary school |
6 |
4 |
1 |
|
| Primary school |
135 |
93 |
0.91 (0.61–1.36) 0.64 |
|
| Illiterate |
95 |
72 |
0.88 (0.24–3.23) 0.85 |
|
| Meal frequency |
> 3 |
42 |
65 |
1 |
1 |
| ≤ 3 |
194 |
104 |
2.89 (1.83–4.55) 0.001 |
3.24 (1.98–5.32) 0.001 |
| Intestinal parasite |
Infected |
133 |
68 |
1.92 (1.28–2.86) 0.001 |
1.84 (1.19–2.83) 0.006 |
| Noninfected |
103 |
101 |
1 |
1 |
4 Discussion
Intestinal parasites are a significant public health issue in developing countries, with school-aged children being at particularly high risk, as supported by previous research [29]. The present study was conducted in elementary schools in the town of Zenzelima, Ethiopia, which has a warm climate and other factors conducive to intestinal parasitic infections. Past records from the Zenzelima health center laboratory indicated intestinal parasites were the main cause of morbidity among suspected cases in the study area. This study found the overall prevalence of intestinal parasites among primary school children in Zenzelima was 49.6% (95% CI: 44.2–54.6). This result was comparable to rates found in other studies in Ethiopia, such as 52.4% in Bahir-Dar town [24], 44.3% in Sekota town [30], 46.5% in Arba Minch town [31], 28.8% in Hakim District, Harari [32] and a pooled prevalence of 46.09% among primary school children across Ethiopia [7].
The current study found the prevalence of intestinal parasites to be higher than some past studies conducted in similar populations, such as 42.9% in Merawi town, Ethiopia [33], 28.9% in Dessie town, Ethiopia [34], 21.5% in Harbu town, Ethiopia [35], and 29.9% in Sebaya, Ethiopia [36]. Lower prevalences were also reported in studies from Kenya (17.3%) [37], Nepal (33%) [38], and Western Iran (9.8%) [39]. However, the prevalence in the present study was lower than others, including 61.7% in Mecha district, Ethiopia [40], 62.3% in Dera District, Ethiopia [41], 57.9% in Jawi town, Ethiopia [42], and 64.6% in Mizan-Aman city [43]. Higher rates were additionally found in Sudan (87.2%) [44], Madagascar (71.0%) [45], Argentina (78.1%) [15], and Colombia (100%) [46]. These differences may be due to variations in environmental and socioeconomic conditions between locations, as well as disparities in the implementation of primary healthcare, deworming interventions, diagnostic methods, and levels of community hygiene awareness and behaviors. The remarkably high prevalence reported in Colombia could potentially be related to the use of concentrated stool sediments examined microscopically and the Kato-Katz test.
The intestinal parasite analysis identified several organisms, with hookworm (22.2%), G. lamblia (19.8%), and E. histolytica (13.6%) being the dominant types detected. This high prevalence of hookworm was comparable with previous findings in Dera District (21.7%) [41], Jawi town (13.8%) [42], and Maksegnit, Northwest Ethiopia [47]. In contrast, a study in Dembecha town identified A. lumbricoides as the dominant parasite, followed by hookworms, T. trichiura, and Strongyloides stercoralis (S. stercoralis) [48]. Additionally, a systematic review in Ethiopia found Entamoeba spp. to be the most common intestinal parasite, followed by A. lumbricoides, hookworm, and G. lamblia [7]. The elevated levels of hookworm in the current study may be attributed to a lack of awareness regarding the importance of wearing protective shoes and the magnitude of open defecation practices. Not wearing shoes increases vulnerability to hookworm infection, as supported by other research [49]. This highlights the need for targeted health education and interventions to improve personal hygiene practices and reduce the incidence of intestinal parasitic infections in the community.
In addition to hookworm, G. lamblia and E. histolytica were found to dominate among the parasites detected in this study. These findings align with reports from studies conducted in Jawi town [42] and Sebeya, Ethiopia [36]. The high prevalence rates of G. lamblia and E. histolytica infection observed could potentially be attributed to various risk factors. These may include open defecation practices, consumption of raw or unwashed vegetables/fruits, poor hand washing habits before eating, and lack of access to safe drinking water. Transmission of these parasites primarily occurs through the ingestion of contaminated foods or water by healthy individuals. Factors impacting hygiene and water safety could promote increased infection risk.
This study identified the consumption of raw vegetables as a significant predictor of intestinal parasitic infections, demonstrating a positive association between raw vegetable intake and the presence of intestinal parasites. This finding is consistent with studies conducted in Delgi, Ethiopia [50], Bahir Dar City and Mecha District, Ethiopia [12], and Boricha District, South Ethiopia [51], as well as a systematic review in Ethiopia that highlighted foodborne transmission, including raw vegetables, as a major contributor to parasitic infections [26]. The association may be explained by the fact that raw vegetables, especially those irrigated with untreated wastewater or fertilised with fecal matter, are often contaminated with the infective stages of parasites such as A. lumbricoides and G. lamblia [52, 53]. Contamination may also occur during harvesting, transportation, or marketing if handled in unhygienic conditions [54]. Inadequate washing of vegetables and poor hand hygiene during preparation further increase the risk of ingestion of parasite eggs and cysts [53]. Enhancing food safety practices, such as thoroughly washing vegetables and maintaining proper hand hygiene, could significantly reduce transmission. Furthermore, health education initiatives that raise awareness of the risks associated with consuming raw vegetables and promote safe food preparation behaviours have been shown to decrease the incidence of intestinal parasitic infections [55, 56]. Similarly, children who wore protective shoes irregularly were found to be more frequently infected with intestinal parasites, including hookworm and S. stercoralis compared to their peers. Inconsistent shoe use increases vulnerability to soil-transmitted helminths, as these parasites commonly enter the human body through direct skin contact with contaminated soil This observation aligns with findings from studies conducted in Bahir Dar City and Mecha District, Ethiopia [12], Boricha District, South Ethiopia [51] and a systematic review done in Ethiopia [26]. Similar results have been reported from different parts of Ethiopia [12, 26, 51]. Additionally, studies from Kenya [57], Afghanistan [58], and Thailand [59] confirm that walking barefoot significantly increases the risk of acquiring hookworm and Strongyloides infections, particularly among school-aged children. The increased risk of infection among children who do not wear shoes regularly can be attributed to direct exposure to contaminated soil, where infective larvae are prevalent [60]. Protective footwear serves as a critical barrier against environmental pathogens, and a lack of consistent use can lead to higher rates of infection [58, 60]. Therefore, promoting the regular use of protective shoes among children, coupled with public health education about the risks associated with barefoot exposure, could significantly reduce the incidence of intestinal parasitic infections in vulnerable populations.
Furthermore, students who practiced open defecation faced double the risk of infection compared to those using latrines. This observation is consistent with other research conducted in Sebeya, Ethiopia [36] and a systematic review done in Ethiopia [26]. Similar associations have been observed in studies from other low-income settings, including Kenya and Bangladesh, where open defecation was linked to significantly higher prevalence of soil-transmitted helminths [56, 61]. Improper management of human waste can allow disease-causing pathogens, such as parasite eggs, larvae, and cysts, to contaminate the surrounding environment. Since these transmission stages can spread via the fecal–oral route or through direct skin penetration, exposure to such environmental contamination increases the risk of infection. Implementing proper sanitation facilities and practices could significantly help reduce transmission. Ensuring access to clean latrines, promoting hygienic disposal of human waste, and raising awareness about the health risks associated with open defecation are essential steps in mitigating the incidence of intestinal parasitic infections in the community.
Undernutrition poses a major public health challenge for school-aged children in developing countries such as Ethiopia, with the potential to impact physical and mental development. The present study found overall undernutrition prevalence among students of 58.3% (95% CI: 53.1–63.0). This rate was higher than previous research conducted on school children in Bahir Dar city (41.6%) [24], Jimma town (21.0%) [62], Mecha district (11.6%) [63], Sekota town (46.3%) [30], Wolaita Zone, South Ethiopia (38.9%) [64], the pooled prevalence of undernutrition in Ethiopia (21.3%) [20], the pooled prevalence of undernutrition in sub-Saharan African countries (41.34%) [65], and Argentina [65]. This discrepancy may be attributed to differences in the implementation of community health interventions and socioeconomic levels between surveyed family populations. Undernutrition often correlates directly with household monthly income, as lower-income families may struggle to sufficiently provide children with a balanced diet and meet other nutritional needs. Effective social programs and economic development could help reduce undernutrition rates over time by addressing its social and economic root causes.
The prevalence of wasting, stunting, and underweight was 49.1%, 25.9%, and 14.6%, respectively. The prevalence of wasting in this study was higher than in studies conducted in Gondar town (9.0%) [66], Sekota town [30], and Mecha District, Northwest Ethiopia [63]. Approximately one-fourth of the school children in the present study were stunted. This finding is lower than studies done in Gondar town, northwest Ethiopia (46.1%) [66] and Arba Minch, Southern Ethiopia (41.9%) [67]. Furthermore, the prevalence of underweight was lower than studies reported in different parts of Ethiopia [12, 24, 30]. These differences might be associated with the source populations studied, types and frequencies of foods, and the economic and social factors within the studied communities.
Meal frequency and infection with intestinal parasites were identified as predictors of undernutrition, consistent with studies in different parts of Ethiopia [12, 24, 30]. Children living in areas where there are problems of food shortages or low family income have a higher chance of being stunted and underweight. The levels of family income dictate the provision of a balanced diet as well as the frequency of meals to their children. Long-term exposure to food shortages at an early stage of childhood leads to chronic malnutrition, such as stunting. The level of meal frequency during early childhood plays a vital role in physical growth and development [68]. On the other hand, intestinal parasitic infection competes with children for nutritional intake and impairs host immune function, making children more susceptible to diseases [69]. Addressing both malnutrition risks and their underlying socioeconomic drivers could help improve child health outcomes.
4.1 Limitations
This study had some limitations. Intestinal parasite intensity quantification and opportunistic intestinal parasites analysis were not performed. Additionally, children's micronutrient intake levels were not determined. Assessing these factors may have offered greater insight into relationships with malnutrition. Future similar research could help address these limitations by measuring infection intensity, evaluating coinfections, and considering micronutrient status. Addressing methodological constraints will strengthen the ability to inform targeted public health interventions.
Author Contributions
Abera Ademasu Birhanu: conceptualization, data curation, formal analysis, visualization, methodology, project administration, supervision, investigation, software, validation, funding acquisition, resources, writing – original draft. Mulat Yimer: conceptualization, data curation, formal analysis, visualization, supervision, writing – original draft, methodology, investigation, project administration, software, validation, funding acquisition, resources. Habtu Debash: conceptualization, data curation, formal analysis, visualization, writing – original draft, project administration, writing – review and editing, supervision, investigation, methodology, software, validation, funding acquisition, resources. Megbaru Alemu Abate: conceptualization, data curation, formal analysis, visualization, writing – review and editing, project administration, investigation, supervision, methodology, software, validation, funding acquisition, resources, writing – original draft. All authors read and approved the final manuscript.
