Food Security and Hygiene Practice among Adolescent Girls in Maiduguri Metropolitan Council, Borno State, Nigeria

Inadequate food security contributes to poor health outcome for all, including adolescent girls. The study aims at determining the level of food security and hygiene among adolescent girls. A school-based cross-sectional study was carried out among adolescent girls aged 10 to 19 years old from six schools in Maiduguri Metropolitan Council, Borno State. The instrument for data collection was a questionnaire using KoBoCollect Toolbox between June and July 2019. Multivariable logistic regression was used to identify the predictors of food security and hygiene among respondents. A majority of the respondents (73.5%) were in a very low food security level. Three factors were significantly associated with food security level, these included schools (p = 0.007), age of mother (p = 0.004), and occupation of mother (p < 0.001). School (p = 0.003), age (father p = 0.017; mother; p = 0.012), hygiene (p = 0.005), and occupation of mother (p = 0.002) were predictors of food security. About (46.6%) of respondents had poor hygiene practice, school (p = 0.016) was significantly associated with hygiene practice. School (p = 0.019; and p = 0.005) and food security (p = 0.009) were predictors of hygiene practice. This study reveals a high prevalence of low food security among adolescent girls.


Introduction
Adolescence is a period of transition from childhood to adulthood, often divided into early (10-13 years), middle (14-16 years), and late (17)(18)(19) years) adolescent stages [1]. Globally an estimated 821 million people (one in every nine people) are malnourished as a result of food insecurity [2]. In developing countries, adolescents are exposed to environmental factors such as food insecurity and hygiene that may influence their growth, development, and well-being [3]. Everyone needs food to have appropriate nutritional status and also to sustain life [4]. Food insecurity and poor hygiene has become a problem among low-income households in developing and underdeveloped countries globally [5]. People do not have economic, social, and physical access to sufficient and nutritious food that can meet their dietary needs for an active and healthy life. Food must be available, accessible, utilized adequately, and in stable condition to meet nutritional demand [6].
Food security is a common problem among low-income households in developing and underdeveloped countries [5]. Food security is a priority, as malnutrition is a contributing factor to morbidity, mortality, reduced productivity, and poor cognitive development [7]. The global growth Food security is a common problem among low-income households in developing and underdeveloped countries [5]. Food security is a priority, as malnutrition is a contributing factor to morbidity, mortality, reduced productivity, and poor cognitive development [7]. The global growth of population, the changes in climate, the rising price of food, and insurgency have a severe impact on food security [8]. In 2019 and 2020, the portion of the population facing food insecurity increased, and between 112 and 123 million people across 50 countries in the world were in crisis or in the worst form of food insecurity, with the Democratic Republic of the Congo and South Sudan reflecting acute food insecurity. The emergent severity of economic shocks and drought in countries such as Haiti, Pakistan, and Zimbabwe were found to be drivers of food insecurity. About 183 million people in 47 countries were classified in stressed food insecurity condition [9]. In 2019, the acute food insecurity level was almost 5 million (5%) of the population in 16 states analyzed with federal capital territory (FCT) inclusive in Nigeria. In Nigeria, in the three northeastern states affected by insecurity, about 3 million people from Borno (1.8 million), Yobe (945,000), and Adamawa state (297,000) were in an acute food insecurity level [9]. Food insecurity is a contributing factor to poor health outcomes and deficiency of nutrients among adolescents most likely to be due to inadequate intake of nutrients [10][11][12].
Food insecurity normally exists where there are limitations or uncertainty in the availability of adequate foods and in the ability to secure foods in an acceptable way [13,14]. About 37 million people from 11 African countries were declared food insecured in 2017 with the largest population from the north-eastern part of Nigeria, Congo, Somalia, and South Sudan. About 70% of the people of Borno were food insecured with some local governments still in the emergency phase, this has an impact on the internally displaced and host communities, especially households, that are entirely dependent on the market rather than on food production as shown in Figure 1 [6]. The provision of food continuously has remained a serious challenge, as food is one of the basic needs of humanity for optimal nutrition [15]. In the low-income household, the burden of food insecurity is more among adolescents than in younger children [16]. Food insecurity has negative consequences and also affects all age groups, including adolescents. Adolescents girls from food insecured households tend to have lower academic performance and poor health and nutritional status [17][18][19][20]. Adolescent girls are at risk of becoming malnourished due to poor dietary intake. They are likely to have a low birth weight baby, which can impact the next generation as the prevalence of low birth weight babies is more among adolescent girls, as shown in Figure 2 [10,21,22]. The provision of food continuously has remained a serious challenge, as food is one of the basic needs of humanity for optimal nutrition [15]. In the low-income household, the burden of food insecurity is more among adolescents than in younger children [16]. Food insecurity has negative consequences and also affects all age groups, including adolescents. Adolescents girls from food insecured households tend to have lower academic performance and poor health and nutritional status [17][18][19][20]. Adolescent girls are at risk of becoming malnourished due to poor dietary intake. They are likely to have a low birth weight baby, which can impact the next generation as the prevalence of low birth weight babies is more among adolescent girls, as shown in Figure 2 [10,21,22]. attributed to poor water, sanitation, and hygiene conditions contributes to impaired learning ability among children under 18 years [25].
Assessing the magnitude of food security and hygiene practice of adolescent girls in the Northeast, this study will provide baseline data and the need for intervention. This study aims at determining the level of food security and hygiene among adolescent girls in Maiduguri Metropolitan Council, Borno State, Nigeria.

Materials and Methods
The details of the study design and methodology are explained in a research article titled "Knowledge, Attitude, and Practice of Adolescent Girls towards Reducing Malnutrition in Maiduguri Metropolitan Council, Borno State, Nigeria: Cross-Sectional Study" [26]. A brief information of the study design is given below.
This was a school-based cross-sectional study carried out among adolescent girls 10-19 years old in six secondary schools. The schools include Government Girls Secondary School Yerwa (Yerwa), Government Girls College Maiduguri (GGC), Government Girls Secondary School Maiduguri (GGSS), Shehu Garbai Day Secondary School (SGDSS), Bulabulin Day Secondary School (BDSS), and Zajeri Day Secondary school (ZDSS) in Maiduguri, Borno State, Nigeria. The main occupations of the state are farming/fishing and trading. In 2017, only 8.3% of the populace consumed from their crop and animal production, the remaining relied on purchased food due to increased displacement of the people from their own homes and farmland to places with limited farms for agricultural activities [27]. The sample size was 612; two-stage random sampling was used to select the school and the individual respondent.
A questionnaire through respondent's interview using KoBoCollect Toolbox was used for data collection. KoBoCollect Toolbox is a data collection tool developed by Harvard, the application can run on any Android device either phone or tablet where data collected were stored in cloud storage together with the global positioning system (GPS) for the location of each school, and later exported Globally about 2.3 billion people do not have the essential sanitation services, nearly 892 million individuals are still practicing open defecation, and approximately 844 million people lack access to a good source of drinking water [23,24]. Lack of proper water facilities, water storage, water treatment, hand washing, and hygiene practices affects the health outcome of children under 18 years old. The long-term adverse effect of infection such as worm infestation, diarrhea, and dehydration attributed to poor water, sanitation, and hygiene conditions contributes to impaired learning ability among children under 18 years [25].
Assessing the magnitude of food security and hygiene practice of adolescent girls in the Northeast, this study will provide baseline data and the need for intervention. This study aims at determining the level of food security and hygiene among adolescent girls in Maiduguri Metropolitan Council, Borno State, Nigeria.

Materials and Methods
The details of the study design and methodology are explained in a research article titled "Knowledge, Attitude, and Practice of Adolescent Girls towards Reducing Malnutrition in Maiduguri Metropolitan Council, Borno State, Nigeria: Cross-Sectional Study" [26]. A brief information of the study design is given below.
This was a school-based cross-sectional study carried out among adolescent girls 10-19 years old in six secondary schools. The schools include Government Girls Secondary School Yerwa (Yerwa), Government Girls College Maiduguri (GGC), Government Girls Secondary School Maiduguri (GGSS), Shehu Garbai Day Secondary School (SGDSS), Bulabulin Day Secondary School (BDSS), and Zajeri Day Secondary school (ZDSS) in Maiduguri, Borno State, Nigeria. The main occupations of the state are farming/fishing and trading. In 2017, only 8.3% of the populace consumed from their crop and animal production, the remaining relied on purchased food due to increased displacement of the people from their own homes and farmland to places with limited farms for agricultural activities [27]. The sample size was 612; two-stage random sampling was used to select the school and the individual respondent.
A questionnaire through respondent's interview using KoBoCollect Toolbox was used for data collection. KoBoCollect Toolbox is a data collection tool developed by Harvard, the application can run on any Android device either phone or tablet where data collected were stored in cloud storage together with the global positioning system (GPS) for the location of each school, and later exported to SPSS for analysis [28]. Information on sociodemographic characteristics was collected, details of sociodemographic characteristics were explained in a research article titled "Knowledge, Attitude and Practice of Adolescent Girls towards Reducing Malnutrition in Maiduguri Metropolitan Council, Borno State, Nigeria: Cross-Sectional Study" [26]. A food security questionnaire was adopted from food security for older children consisting of nine statements with options "a lot", "sometimes", and "never". Never was scored "1", sometimes "2", and a lot "3" in the last 30 days [29]. Never was recoded "0", sometimes and a lot weres recorded "1". The total food security score was 9. Respondents who scored 0-1 were considered food secured, those with 2-5 were regarded as low food secured, and those with 6-9 were considered very low food secured, respectively [30]; these questions are shown in Table 1. The hygiene section consists of five statements with options, choose one. Hygiene statements and characteristics are presented in the result section (Table 5). Frequency and percentage were used for each hygiene item. Scores <median were considered poor hygiene, while scores ≥median score were considered good hygiene.
Data analysis was done using Statistical Package for Social Sciences (SPSS) software version 25 used to solve research problems. Frequency and percentage were used for the distribution of each statement. Chi-square was used to determine the association of sociodemographic characteristics with food security and hygiene; multiple logistic regression was used to determine the predictors of hygiene, while multinomial logistic regression was used to determine the predictors of food security. Data with p < 0.25 in simple logistic regression were analyzed in multiple logistic regression. Variables with p < 0.05 were considered statistically significant in this study.
The Ethical Committee for Research involving Human Subjects of Universiti Putra Malaysia (JKEUPM) UPM/TNCPI/RMC/JKEUPM/1.4.18.2 gave ethical approval, and permission for various schools was obtained from the Ministry of Education Maiduguri, Borno State, Nigeria. Pan African Clinical Trials Registry (PACTR201905528313816).

Results
A total of 612 respondents were included in the study, the respondents were randomly selected based on the inclusion criteria of the study. About 562 respondents consented and were interviewed. The response rate for this study was 92%. The detailed sociodemographic characteristics of respondents were explained in a research article titled "Knowledge, Attitude and Practice of Adolescent Girls towards Reducing Malnutrition in Maiduguri Metropolitan Council, Borno State, Nigeria: Cross-Sectional Study" [26]. Table 1 shows the distribution of food security statements among respondents. The median, interquartile range (IQR) for food security was 8.0 (4.0). Almost three-quarters of the respondents did worry that food at home would run out before the family got money to buy more food sometimes (74.7%); in some cases, food bought ran out, and they did not have money to get more (69.9%); for others, their meals only included a few kinds of cheap foods because the family was running out of money to buy food (70.1%); some were not able to eat a balanced meal because the family did not have enough money (76.0); others ate less because the family did not have enough money to buy food (67.6); sometimes, the size of the meals was cut down because the family did not have enough money for food (62.6%); some skipped a meal because the family did not have enough money for food (63.0%); and others were hungry but did not eat because the family did not have enough food (63.0%). Table 2 reveals that a majority of respondents (73.5%) were in a very low food security level.

Association and Predictors of Food Security among Respondents
Association between Sociodemographic Characteristics and Food Security Table 3 shows the association of sociodemographic characteristics and hygiene with food security level. Three factors were significantly associated with food security level, these included schools (p = 0.007), age of mother (p = 0.004), occupation of mother (p < 0.001). Table 3. Factors associated with food security among respondents (n = 562).

Variables
Very Low Food Security n (%)/Mean ± SD Low Food Security n (%)/Mean ± SD Food Secured n (%)/Mean ± SD X 2 /t p-Value

Predictors of Food Security among Respondents
Factors with p < 0.25 in simple multinomial logistic regression were tested in multiple multinomial logistic regression, including school, age of adolescent, place of residence, monthly income, head of household, age of the father, education of father, age of mother, education of mother, occupation of mother, family type, and hygiene. Table 4 identified five factors that were significant predictors of food security. Respondents in BDSS compared to ZDSS were less likely to be in a low food security level compared to a very low food security level (Adjusted Odds Ratio (AOR) = 0.306, 95% confidence interval (CI): 0.140-0.671, p = 0.003). Respondents with age of father and mother between 35 and 44 years compared to ≥45 years were more likely to be in low food security level compared to very low food security level (AOR = 2.610, 95% CI: 1.187-5.736, p = 0.017; AOR = 2.180, 95% CI: 1.191-3.993, p = 0.012). Respondents with poor hygiene compared to good hygiene were more likely to be in low food security level compared to very low food security level (AOR = 1.979, 95% CI: 1.228-3.187, p = 0.005). Respondents with the age of mother between 35 and 44 years compared to ≥45 years were less likely to be in a food secured level compared to a very low food security level (AOR = 0.414, 95% CI: 0.187-0.917, p = 0.030) Respondents whose mothers were civil servants compared to housewives were more likely to be in a food secured level compared to a very low food security level (AOR = 4.144, 95% CI: 1.665-10.312, p = 0.002).  Table 5 describes the hygiene of respondents. A high number of respondents (49.3%) reported borehole as their main source of water, (54.3%) used private latrine for defecating, (89.7%) answered correctly on hand-washing practice, (38.3%) used a clean, covered container to keep their drinking water, while (50.5%) of respondents used a clean cloth to strain their drinking water to make it safe for use at home. The median (IQR) for hygiene score was 10.0 (3.0). Poor hygiene was reported by (46.6%) of respondents.

Association and Predictors of Hygiene among Respondents
Association between Sociodemographic Characteristics and Hygiene Table 6 showed association of sociodemographic characteristics and food security with hygiene level. School (p = 0.016) was significantly associated with hygiene.

Predictors of Hygiene among Respondents
Simple logistic regression was used to assess the association of sociodemographic characteristics, food security with hygiene. Factors with p < 0.25 in simple logistic regression were tested in multiple logistic regression, including school, age of adolescents, class, monthly income, education father, occupation father, education mother, occupation mother, family type, and food security level. Table 7 showed that two factors were statistically significant in predicting hygiene. Respondents in SGDSS and ZDSS were less likely to have good hygiene compared Yerwa (AOR = 0.472, 95% CI: 0.252-0.884, p = 0.019; AOR = 0.416, 95% CI: 0.227-0.762, p = 0.005). Respondents in a low food secured level were less likely to have good hygiene compared to those in a very low food secured level (AOR = 0.537, 95% CI: 0.337-0.855, p = 0.009).

Age of adolescent girls (years)
Early

Discussion
Food security is essential in achieving good health among adolescent girls, neglecting the aspect of food security may have implications for achieving sustainable development goals: goal 1 (eradicating poverty), goal 2 (ending hunger and all forms of malnutrition; attaining food security; promoting sustainable agriculture; addressing the nutritional needs of adolescent girls, pregnant, and lactating mothers), goal 3 (guarantee healthy lives and promote well-being for all at all ages) [31,32]. Food security and nutritional status influences the growth and development of adolescents as it becomes woven in an intergenerational cycle of malnutrition. Food insecurity deters adolescents from attaining a normal nutritional status, therefore, it is important that adolescent girls become well-nourished at all stages of growth and development. The effects of malnutrition in women are borne throughout their lifecycle and through generations. Nutritional inadequacy through food insecurity during the period of adolescence can affect their present and future health and well-being, as it is intrinsically linked to the health and well-being of their offspring [33,34].
In this study, 69.9% of respondents reported running out of food and not having enough money to get more, 76% not able to eat a balanced meal because the family did not have enough money, 67.6% ate less because there was no money to buy food, 62.6% cut their meals because there was not enough money for food, 63.0% were hungry but did not eat as shown in Table 1. The result in this study was higher than the study conducted in Jordan [35,36]. This may be due to non-availability of sufficient food and financial resources as a result of the displacement of the populace caused by insecurity, which has limited crop production and food availability. More so, low awareness on coping strategies could be a contributing factor.
This study showed that more than half of respondents (73.5%) were in a very low food security level presented in Table 2, this was higher than research conducted in Canada [37], Dhaka city [7], Southeast, Nigeria [12,38], Ethiopia [39], Boston [40], Ethiopia [41][42][43], Australia [44], and the U.S. [45]. The differences in the outcome of the study may be due to the humanitarian crisis experienced by the region from 2009 to date that has led to the displacement of people from their homes and farmlands. Families in studies with lower percentages of very low food secured level might be receiving sufficient government aid and more so differences in demographic characteristics could contribute to the small number of very low food secured level.
Age of mother was statistically associated with food security as described in Table 3. This was similar to a study conducted in Iran [46], food insecurity increases with increase in age, as the age of the mother increases, the number of children also increases as well as the size of the household, these can affect the quality and quantity of food consumed by households thereby increasing their risk of becoming food insecured [46]. Occupation of mother was significantly associated with food security. This is in line with studies in Korea [47] and Ecuador [48], although food insecurity is not merely determined by financial poverty, occupation of the mother increases household income, contributes to the household purchasing power, helps in diversifying their food, and improves their socioeconomic status, thereby enabling them to become food secured [46,49]. The occupation of the mother is an important determinant of food insecurity especially in low-income families [50].
In this study, occupation of the mother was a predictor of food security, this concurs with the study conducted in the Southeast, Nigeria [12] and Ethiopia [49]. Mother's occupation was associated with food secured level compared to very low food secured level as mothers who earn a salary are better able to manage the household, thereby reducing the level of food insecurity among adolescent girls. Furthermore, this study hypothesizes that school, age of the father, age of the mother, and hygiene were significant predictors of food security among adolescent girls in Maiduguri Metropolitan Council, Borno State, as shown in Table 4.
A majority of respondents (49.3%) in Table 5 used a borehole as their main source of drinking water. The result obtained was higher than the result obtained from Oyo State, Nigeria [51], and lower than the result obtained from Dangila town, Ethiopia [52]. More than half of respondents (54.3%) used private latrine for defecating. This was lower than the study conducted in Tanzania [53]. A majority of respondents in this study (89.7%) answered correctly on hand-washing practice. The result is in line with the study conducted in Oyo State, Nigeria [51], Minch town, Ethiopia [54], Angolela, Ethiopia [55], Dangila town, Ethiopia [52], Southern Ethiopia [56], and higher than the result obtained from Ethiopia [52] and Klang valley, Malaysia [57]. These may be due to awareness on the need for good hygiene practice to mitigate bacterial infection as a result of the influx of people from the local government areas displaced by humanitarian crisis. In this study, about (6.9%) boiled their water before drinking. The findings from Ibadan were higher [51]. A majority of respondents (50.5%) used a clean cloth to strain their drinking water to make it safe at home. This was lower than the result obtained in Ibadan, Nigeria [51]. About (42.9) allow the dirt to settle at the bottom of the container. This was higher than the outcome from Ibadan [51]. Allowing water to settle down and the use of clean cloth to strain their drinking water were the common ways of treating water, with a lower rate of boiling water. This could be associated with low awareness on the effective ways of treating water before drinking.
Poor hygiene was reported by (46.6%) of respondents. This was higher than results obtained from Ethiopia [54] and India [58]. Poor hygiene practice in this study may be due to inadequate awareness about good sources of drinking water, proper disposal of waste, effective storage, and water treatment.
The study in Table 6 hypothesizes that school was significantly associated with hygiene practice, while school and food security level were significant predictors of hygiene among adolescent girls, as presented in Table 7.

Limitation
The study was a self-report of food security and hygiene statements that might lead to recall bias.

Conclusions
Drawing conclusions from this study, there is need for creating awareness on food security to prevent adolescent girls from the negative impact of growth, development, and undernutrition. There is also need for further research on food security as a protective factor in the outcome of adolescent health. The findings of this study recommend food security and hygiene intervention targeting adolescents to address food security-and hygiene-related problems in Borno State. Further studies on predictors and consequences of food security and hygiene are recommended. Poverty alleviation initiatives should be integrated with food security programmes to promote availability, accessibility, and consumption of diverse food to reduce the multitude of consequences of undernutrition. This study provides a significant contribution to the food security status and hygiene practice among adolescent girls in Maiduguri Metropolitan Council, Borno State, Nigeria.
The outcome of this study reveals a high prevalence of very low food security, with almost half of the girls having poor hygiene practice. School, age of the father and mother, occupation of mother, and hygiene were found to be significant predictors of food security, while school and food security were found to be significant predictors of hygiene among adolescent girls. There is need for further research to evaluate the prevalence of food security among adolescent girls in the remaining government schools, private schools, and also those out of school within the state capital to be able to generate enough evidence for policymakers. There should be a health education intervention study that is deeper and more practical in addressing the factors hindering adolescent girls from good hygiene practice. Schools should provide an access point to hand washing material to be monitored regularly.