An assessment of the nutritional status of internally displaced school children in the West and Littoral Regions of Cameroon

Abstract Malnutrition remains a major public health challenge among children in developing countries, especially those experiencing civil wars and political unrest. It is imperative to ascertain the level of malnutrition, particularly in displaced children, to develop and effectively implement interventions. This study was a cross‐sectional survey conducted to assess the nutritional status of 657 internally displaced school‐aged children (5–15 years) enrolled in primary schools in the West and Littoral Regions of Cameroon. The height, weight, and mid‐upper arm circumference of the children were measured using standard measurements. Clinical examinations were also made on the children. Other parameters that affect nutritional status, such as morbidity and health‐seeking practices, were assessed using pre‐tested, structured interviewer questionnaires. An analysis of the data revealed that stunting was the most prevalent form of malnutrition (27.1%), followed by wasting (23%), thinness (21.6%), and underweight (20.1%). About 44.5% of the children had low serum iron, and 35.7% of them had poor protein status. The prevalence of anemia was 30.0%. The most common signs of protein, vitamin A, and iron deficiencies observed were thin, dry, or sparse hair (5.2%), pallor (7.3%), and xerosis (3.3%), respectively. About 32% of the children had been sick within the previous month of the study, and the most common illness was the common cold (19.8%). Most of them (>60%) had good health‐seeking practices. The high prevalence of stunting, wasting, thinness, underweight, anemia, protein, and iron deficiency calls for interventions such as nutrition education and supplementation to prevent malnutrition and diet‐related diseases among children.

| 4087   EJOH et al.   is also associated with decreased resistance to infection, impairment of intellectual development and learning capacity, functional deterioration in adulthood, decreased work competence, and reduced financial output of the individual (Khan et al., 2017;WHO, 2017).
Malnutrition, "the silent emergency," is a conspirator, with at least 5.45 million child deaths recorded every year (UNICEF/WHO/World Bank Group, 2018).
Undernutrition is the most prevalent form of malnutrition, especially in developing countries (UNICEF/WHO/World Bank Group, 2018).It may be expressed in the form of protein-energy malnutrition (PEM), which includes wasting, underweight, stunting, and/or micronutrient malnutrition.PEM is the most fatal type of malnutrition globally.About one-quarter of all children worldwide are affected by PEM (UNICEF/WHO/World Bank Group, 2018).
An evaluation of trends in malnutrition in the countries of Africa reveals that the rates of undernutrition are increasing instead of dropping to attain the global target for 2025, which is to decrease the percentage of children who are stunted by 40% (WHO, 2017).
Undernutrition is highly prevalent among children in Cameroon, as the rate of stunting among children <5 years old is 31%, underweight is 16%, and 5.2% of them are wasted (Global Nutrition Report, 2018).The prevailing nutritional status of children in the two regions from which the study children were displaced (the Northwest and Southwest Regions) is worrisome, as 4.4% and 5.6% of children in the Northwest and Southwest Regions, respectively, are suffering from global acute malnutrition (GAM) (OCHA, 2022).This prevailing trend of malnutrition is nowhere near that of the Sustainable Development Goals, whose goal is to stop all types of malnutrition by 2030 by terminating hunger, attaining food security and upgraded nutrition, and fostering sustainable agriculture (United Nations, 2016).
The school-age period is nutritionally very significant, and deficiencies are of major concern because school age is a dynamic growth stage, as well as mental development (Wrottesley et al., 2022).Studies have shown that health complications due to poor nutritional status in school-age children are among the greatest widespread causes of low school turnout, nonattendance, early dropout, and poor classroom outcomes (Teo et al., 2021).In schoolaged children, thinness can result in delayed maturity, deficits in muscle potency and work competence, and decreased bone solidity later in life.Iron deficiency in school-age children is associated with delay in growth, increased vulnerability to diseases, and poor mental development, resulting in a lower intelligence quotient and behavioral anomalies that reduce the quality of life of the individuals concerned (Zerga et al., 2022).
Conflict unavoidably results in damage to lives, substantial injuries, extensive psychological anguish, an exacerbation of existing malnutrition among vulnerable persons (especially children), and outbursts of infectious diseases, particularly among persons who are internally displaced (Loewenberg, 2015).Forcible displacement of populations usually affects health systems as it lessens people's political security and restricts their food accessibility, medications, portable water, hygiene, shelter, and access to health care services, which may result in malnutrition.Internally displaced persons are among the most vulnerable of forced migrants and often suffer intensely from several types of malnutrition (Dago, 2021).
Populations affected by an emergency often live in difficult conditions.This makes them vulnerable to malnutrition.IDPs often arrive in camps in a nutrient-depleted state, and most of them are fully dependent on emergency food rations (Dago, 2021).Such populations often have little access to local markets, and even if they do, they often have little purchasing power to buy micronutrientrich foods to supplement their diet.Also, in emergencies, the general deterioration in nutritional status, loss of access to traditional foods, and lack of dietary diversity further exacerbate micronutrient deficiencies in the affected population (Dago, 2021).Additionally, growing vegetables and fruit, which are micronutrient-rich foods, is often limited by land and water availability, hence limiting access to fresh foods (Prinzo & de Benoist, 2002).While forcible displacement is the foremost cause of malnutrition, its consequences, such as inadequate supplies of food, and communicable diseases, may also contribute to the deterioration of the condition.Moreover, previous studies revealed that IDP children are more likely to suffer from diseases such as malaria, diarrhea, and measles and, consequently, mortality (Vos et al., 2020).
Nutritional status is affected by dietary intake and the occurrence of infections (Kathryn & Begum, 2011).The examination of anthropometry is a compulsory instrument to evaluate the health and nutritional status of children, who are the cornerstone of a nation (WHO, 2017).It is imperative to provide high-quality data on the nutritional and health status of children, particularly those who are forcibly displaced, as it would aid in prioritizing and formulating precautious nutrition intervention programs that are evidencebased, ensuring that the nutritional problems that are of substantial concern are targeted (Development Initiatives, 2017).
Numerous studies have shown that children who are affected by conflicts face a disproportionate problem of malnutrition and poor health (Akeh et al., 2022;Bougma et al., 2022;Chidiogo et al., 2022;Salami et al., 2020;Vos et al., 2020).Since 2016, the Northwest and Southwest Regions of Cameroon have been experiencing armed conflicts associated with insecurity and the operation "no school", which led to the displacement of approximately 679,393 people by the end of 2022, and about 43% of the displaced persons are children (OCHA, 2022).Most of the IDPs are located in the Littoral, Central, and West Regions of Cameroon (OCHA, 2022).Some of the displaced people live in rented houses, while others are staying in overcrowded houses with host families, and others live in "critical shelter" without mosquito nets, resulting in a general increase in malaria and flu syndrome.Food security, shelter, and education were expressed as the top three priority needs of the displaced pupils (OCHA, 2019).To understand the full extent of this problem of displacement among schoolchildren in Cameroon, a reliable assessment of nutritional status is required.Yet, to the best of our knowledge, data on the nutritional status of internally displaced schoolchildren in Cameroon has not been published.
The purpose of this study was therefore to determine the nutritional and health status of internally displaced schoolchildren in the West and Littoral Regions of Cameroon through a participatory baseline survey.

| Study area
The West Region is located in the central-western part of the Republic of Cameroon, and its headquarter is Bafoussam.It is the smallest of the ten regions of Cameroon, with a surface area of 14,000 km 2 .However, it has the greatest population density.It is divided into eight divisions.The West Region shares a boundary with the Northwest Region to the northwest, the Adamawa Region to the northeast, the Centre Region to the southeast, the Littoral Region to the southwest, and the Southwest Region to the west (Benneh & DeLancey, 2004).
The Littoral Region is located in the southwest of the country, with its capital in Douala.It has a population of 3,354,978 people and a surface area of 20,248 K.It is bordered to the north by the West Region, to the east by the Central Region, to the south by the South Region, and to the west by the South West Region.
The Littoral Region is divided into four divisions namely: Moungo, Nkam, Sanaga-Maritime, and the Wouri Divisions (Benneh & DeLancey, 2004).The Moungo and Wouri Divisions were purposely chosen for the study because these divisions host the greatest number of IDPs (45,000 and 31,880, respectively) compared to the other divisions (OCHA, 2022).

| Study design
A cross-sectional study was carried out in the West and Littoral Regions of Cameroon.A total of 10 and 12 schools, respectively, were randomly subsampled from the West and Littoral Regions for the study.The sample size was calculated using Fischer's formula for sample size calculation (Fisher et al., 1991), considering the prevalence of underweight among children between the ages of 5 and 19 years in Cameroon is 24% (Global Nutrition Report, 2018).The degree of accuracy desired was set at 5% or a 95% confidence level.
A non-response rate of 10% was considered.The calculated sample size was 264 children.It was increased to 657 in order to increase the accuracy of the results.The study participants were pairs of internally displaced schoolchildren and their caregivers.

| Inclusion and exclusion criteria
Those included in the study were internally displaced schoolchildren (5-15 years) enrolled in primary schools located in the West and Littoral Regions of Cameroon and their caregivers.Internally displaced schoolchildren whose caregiver did not give their consent and those who were chronically ill were excluded from the study.

| Data collection procedure
Data were collected using pre-tested structured interviewer questionnaires.The caregivers of the children answered the questions on the questionnaire, which included information on the demographic and socio-economic characteristics of the children and their caregivers, anthropometry, clinical signs of malnutrition, health-seeking practices, morbidity, and the biochemical status of the children.

| Sampling procedure
The West and Littoral Regions were selected for this study because these regions are among the first three that host the greatest number of internally displaced children compared to other regions in the country.Three divisions (Menoua, Bamboutos, and Mifi) in the West Region and two divisions (Wouri and Moungo) in the Littoral Region were purposely chosen because these are the most affected divisions in this region (OCHA, 2022).The names of schools with an English-speaking subsystem of education in the respective divisions that had large numbers of displaced pupils were given by the regional delegation of basic education.A random selection of schools was made from the list.A total of 10 schools in the West Region and 12 schools in the Littoral Region were selected for the study.
The multistage random sampling method was then used to ensure that the number of pupils taken from each division was proportional to the number of displaced pupils in the division.Random sampling was used in the selected schools to obtain the required sample for the study.

| Anthropometric measurements
Weight measurement was taken using a digital electronic weighing scale calibrated in kilograms and grams (Seca model 7501017009, China).The scale was placed on a flat, hard surface.The children were requested to remove any clothing that might alter their body weight and also remove their shoes before standing on the weighing machine.It was ensured that the indicator pointer of the scale was at zero before every child was weighed.The children stood still in the middle of the scale's platform without touching anything, with the weight equally distributed on both feet.Their feet were closed, and their hands were hanging by their sides.Weight measurements were taken in duplicates, and it was ensured that the difference between the two measurements should not be more than 0.05 kg, and the average was recorded to the nearest 0.01 kg.The accuracy of the scale was checked daily using an object of standard known weight and calibrated before weighing when necessary.
Height was measured using a portable stadiometer with a movable headpiece while subjects stood erect on bare feet.The height board was always placed on a hard, flat surface against a perpendicular wall.Height was measured to the nearest 0.1 cm barefooted with the shoulders in a relaxed position and the arms hanging freely by the sides with palms facing the thigh.The subjects' heels, buttocks, and upper back were in contact with the height board.The head was held comfortably erect.The children were measured while standing by the height board with their feet flat together on the base of the board, knees straight, and heads touching the back of the board, with the headboard firmly on the head as well as on the board.Two readings were taken for each child.The headboard was then lowered to the highest point of the head with enough pressure to compress the hair.Height measurements were done in duplicate.If differences between two measurements of height for the same child exceeded 0.5 cm, measurements were repeated.The average values of the two measurements were recorded.Height measurements were taken to the nearest 0.1 cm.MUAC was measured in millimeters using non-stretchable tape on the left arm while the arms were hanging in a relaxed position.To avoid compression of the soft tissues, the tape was firmly but gently positioned midway between the tip of the shoulder and the tip of the elbow and recorded to the nearest 1 mm.MUAC was used to assess MUAC-for-age Z-scores (MUACZ).
All measurements were taken according to standard procedures and recorded on the questionnaire.Height, weight, sex, and age were used to determine nutritional stats.

| Biochemical assessment of protein, iron, and anemia
Two higher diploma laboratory technicians were recruited for the blood sample collection.About 5 mL of blood was collected from each child's veins and used to determine pre-albumin, hemoglobin (Hb), and serum iron concentrations.
Protein status was assessed by determining serum pre-albumin concentrations by the ELISA assay method (Vatassery et al., 1991).
The anemia status of the children was also assessed by measuring their Hb concentration using the Hemostat GOLD hemoglobin meter (Hemoglobin screening meter, Apex Bio, and Taiwan) by the optical reflection technique.The following cutoffs were used to define iron deficiency anemia: Hb <11.5 g/dL in children 5-11 years, and Hb <12.0 g/dL in children 12-15 years.For children 5-11 years of age, Hb concentrations between 11.0 and 11.4 g/dL were termed mild anemia.Moderate anemia was defined as the Hb concentration between 8.0 and 10.9 g/dL and severe anemia was defined as the Hb concentration lower than 8.0 g/dL.For children 12-15 years of age, mild anemia was defined when Hb levels were 11.0-11.9g/dL, and moderate anemia was defined as 8.0-10.9g/dL.Severe anemia was defined as Hb <8.0 g/dL (WHO, 2011).All laboratory experiments were done in the laboratory of the Bafoussam Regional Hospital, Cameroon.

| Clinical examinations
Clinical examinations were done to diagnose the children for clinical signs of PEM, vitamin A, and iron deficiency.PEM was diagnosed based on clinical signs such as depigmentation, bilateral pitting edema, thin, dry, sparse hair, distended abdomen, and moon face.
Clinical signs of vitamin A deficiency, such as the presence of Bitot's spots, xerosis, and night blindness, were assessed.Those for iron deficiency anemia that were assessed include easy fatigue, shortness of breath, dizziness, spoon-shape nails, angular cheilitis, and pallor of the conjunctiva, tongue, or nails (Esper, 2015;Pogatshnik & Hamilton, 2011).

| Data analysis
After collection, all data were compiled and analyzed using SPSS version 23, and appropriate statistical tests were applied.Descriptive statistics such as frequency, mean, and standard deviation were calculated and presented in tables and graphs.The WHO AnthroPlus software, which has the Growth Reference Standard for children and adolescents aged 5-19 years, was used to compute height-for-age Zscores (HAZ), weight-for-age Z-scores (WAZ), body mass index-forage Z-scores (BMIZ), and weight-for-height (WHZ) Z-scores based on the WHO growth reference (WHO, 2007).Severe acute malnutrition (SAM) was defined by the presence of nutritional edema on the feet or severe wasting.Moderate acute malnutrition (MAM) was defined by weight-for-height (WHZ) z-scores >−3SD and <−2SD.
Global acute malnutrition was a combination of SAM and MAM.The following cutoffs were used to interpret BMIZ: severe thinness <−3 Children whose weight-for-height z-score, height-for-age z-score, and weight-for-age z-score were below minus 3SD below the mean based on the WHO Growth Reference.Data for 5-19 years were classified as severely wasted, severely stunted, and severely underweight, respectively.The cutoffs used to define moderate stunting, moderate underweight, and moderate wasting were ≥−3 to <−2SD (WHO, 2007).Weight-for-age was used to determine the nutritional status only for children between 5 and 10 years, and it was not used to determine overweight among these children (WHO, 2007).
MUAC was used to calculate MUAZ and interpreted using cutoffs given by Mramba et al. (2017).
Results were expressed as means and standard deviations, frequencies, and percentages.Significant differences between the two groups were tested using t-tests, McNemar's Chi-square, and the Kruskal-Wallis test, where appropriate.The level of significance was set at p < .05.

| Demographic characteristics and socio-economic status of the mothers/caregivers
The mothers/caregivers of the displaced children had varying levels of education, ranging from no formal education, to university level or higher education as shown in Table 2. Regarding mothers'/ caregivers' educational status, 2.1% had no formal schooling, 33.3% had primary school as their highest level of education, more than half of the mothers (55.4%) ended with a secondary education level, and only (9.1%) attended higher education.Unemployment was high among the mothers/caregivers as almost half of them were unemployed (44.7%).Nearly 48.6% of the mothers/caregivers were selfemployed, while the least proportion (7.1%) of the mothers had paid jobs.The results also showed that matrimonial status varied greatly among the mothers/caregivers of the displaced children.The greatest proportion of the mothers (69.4%) were married, followed by those who had never been married (21.9%), then widows (5.3%), and lastly the divorced mothers/caregivers with a percentage of 3.3%.The household income of the families of these displaced children was low, as most of the families (68.9%) had a monthly income below 50.000 francs, whereas the rest (23.1%) had an income ranging from 50.000 to 150.000 francs.A few families (7%) had a family income above 300.000francs, as shown in Table 2.The households where these children lived were crowded, as 54.8% of the families had a household size between five and eight, while 32.9% of the households were overcrowded with more than eight people.Only 12.3% of the households were not crowded, as their sizes were less than five people.
Most of the displaced children (60.6%) are living with their mothers.Others (37.7%) are living with a family relative.Very few of them (1.2%) were living with family friends.The table also reveals that most of the mothers (59.8%) were in the age group of 25-50 years, whereas 3% of them were below 25 years old.Only 6.7% of the mothers or caregivers were above 50 years old.The table also reveals that 26.3% of the mothers/caregivers and their children were living with another family, 70.9% were renting, and 2.7% were living in their own houses.
Regarding the source of drinking water for the household, this study revealed that about 76.2% of the families had good sources of drinking water, such as tap water, spring water, and bottled water, while 18.7% drank water from bad sources, such as well and stream water.
The pit toilet was the most common type of toilet used by the families of these displaced children (84.9%).A small proportion (13.2%) are using modern toilets, and a few (1.8%) do not have toilets.Most of the respondents (73.8%) were Christians.

| Nutritional status of schoolchildren based on
Z-score

| Wasting according to BMI-for-age Z-scores of the children
The prevalence of severe thinness among the children was 6.5% and thinness was 15.1%, meanwhile, overweight was 2.9% and obesity was 1.7% (Figure 1).The overall prevalence of thinness were stunted.There was a statistically significant difference in the prevalence of stunting between age groups (p = .010)as it was more prevalent among the younger age group (5-9 years).Also, more boys (30.4%) were stunted than girls (23.9%).The percentage of stunted children in the West Region (28.6%) was insignificantly (p = .39)higher than that of children in the Littoral Region (25.6%).

| Underweight in the displaced schoolchildren
As shown in Table 3, 20.1% of the displaced schoolchildren did not attain their expected weight-for-age Z-scores, 6.1% were severely underweight, and 14% were moderately underweight.The prevalence of underweight was highest among children who were between 7 and 8 years old (25.6%).The average weight-for-age Z-score recorded in the study was −1.03.The least and highest Z-scores were −3.04 and +2.13, respectively.Analyzing by sex shows that more boys (22.3%) were underweight than girls (18.2%).The prevalence of underweight in the West Region (21.2%) was slightly higher than the prevalence in the Littoral Region (19%).

| Clinical signs of malnutrition
As shown in more prevalent among children in the West Region, as 10.5% of children in the West Region had at least a clinical sign of malnutrition, whereas only 7.7% of children in the Littoral Region were found to have a clinical sign of malnutrition.Thin, dry, or sparse hair was the most prevalent sign of protein deficiency, as it was noticed among 5.2% of the children; this was followed by depigmentation, which was present in 3.8% of them.Other signs of protein deficiency, such as a distended abdomen and moon face, were noticed in 0.6% of the children.Bilateral pitting edema was not observed in any of the children.

Signs of vitamin A deficiency such as night blindness, and xerosis
were seen in 0.5%, and 3.3%, respectively.With regard to vitamin A deficiency, xerosis (3.3%) was its most prevalent sign, while Bitot's spots were not found on any of the children.
The most prevalent clinical sign of malnutrition was pallor in the skin, nail beds, palms, tongue, or inside of eyelids (7.3%), which depicts iron deficiency clinically.Other signs of iron deficiency anemia found among the children were angular cheilitis, easy fatigue, and dizziness in 0.9%, 1.1%, and 0.8%, respectively.
Shortness of breath was not experienced by any of the study children.

| Prevalence of protein deficiency
Figure 2 shows the prevalence of protein deficiency among the children based on serum pre-albumin levels.

| Prevalence of iron deficiency
About 44.5% of the children were iron-deficient (Figure 2).The mean serum iron concentration was 88.5 ± 13 μ/dL, which is within normal limits.About 54.1% of the children had normal serum iron levels, while 1.4% had unusually high levels of serum iron.Serum iron concentrations were also analyzed by gender.Iron deficiency was significantly more prevalent in females (48.4%) than in males (40.5%) (p = .04).The younger children (5-9 years) were more (54.3%)iron deficient than the older children 10-15 years (34.7%).The prevalence of iron deficiency was significantly (p = .03)higher among the children in the West Region (48.7%) than among those in the Littoral Region (40.3%).

| Prevalence of anemia
The prevalence of anemia among the children was 30.0%, as shown in Figure 3.The mean level of hemoglobin in the children was 12.1 g/dL.The least and highest levels of hemoglobin recorded in the study were 4.9 and 16.4 g/dL, respectively.Severe anemia had a prevalence of 2%, mild anemia was 7%, and moderate anemia was 21%.

| Health-seeking practices
From Figure 4, the hygiene status of the children revealed that about 73.1% always washed their hands after using the toilet, whereas 26.9% did not wash their hands after using the toilet.
Almost all of the children 98.5% had been completely immunized against all relevant diseases.About 64.2% of subjects brushed their teeth daily, and the remaining 35.8% brushed their teeth irregularly.About 84.9% of the mothers washed vegetables before cooking, 12.1% washed vegetables after cooking, and 3% had no specific time to wash vegetables.That is, they washed vegetables either before cooking or after cooking, depending on the vegetable.Most of the pupils 63% always washed fruits before eating, while 37% of them did not wash fruits or washed fruits only sometimes before eating.

| Health status of the children
As shown in Table 5, morbidity among the children was high because 32% of the children had suffered from a particular illness during the previous month of the study.The most common illness was respiratory tract infections (19.8%) such as common cold, cough, and pneumonia, while measles was not reported among any of the children at the time of the study.Other illnesses reported among the children included: skin infection (6.8%), stomach ache (6.4%), diarrhea (5.6%), vomiting, dental carries (5.3%), (5.2%), malaria (4.1%), and anemia (0.3%).

| DISCUSS ION
About 51.3% of the displaced children were females, whereas 48.7% were males.These results correspond to the report given by the Ministry of Public Health and WHO (2017), which documented that the number of females in Cameroon is higher than that of males.The households where these children lived were overcrowded, as many of the children (32.9%) lived in houses with a household size of more than eight people.These revelations entail that, due to the large household sizes coupled with lowincome levels reported among them, food intake was very likely to be negatively affected.The highest level of education of 33.3% of the mothers/caregivers is primary education, and 55.4%,A lower rate of stunting was observed in children of the same age in the Tiko Health District, Cameroon, where only 7.5% of the children were stunted (Tabi et al., 2019).Also, a study among the children of internally displaced persons in Bamenda Health District, Cameroon, revealed that 22.1% of the children were stunted (Akeh et al., 2022).Conversely, higher rates of stunting (61.0%) were reported among schoolchildren in the Democratic Republic of Congo (Kabongo et al., 2018) and among internally displaced school-aged children (74.5%) living in camps in the Plateau State, Nigeria (Chidiogo et al., 2022).Moreover, a systematic review that examined the nutritional status of internally displaced children in Africa revealed that 52% of them were stunted (Owoaje et al., 2016).
The most prevalent type of malnutrition determined in this study was stunting (27.1%), and this is consistent with the findings of several previous studies, which found stunting to be more prevalent than other types of malnutrition such as wasting and underweight among school-aged children in less developed countries, including Cameroon (Best et al., 2010;Chidiogo et al., 2022;Tabi et al., 2019).
These elevated rates of stunting are probably reflecting the low social and financial status of the inhabitants.The prevalence of stunting in the present study was 27.1%, which means that almost three in ten displaced school-aged children in the West and Littoral Regions were malnourished as a consequence of chronic undernutrition.This prevalence is below the national prevalence of 31% for young children (Institut National de la Statistique (INS) et ICF, 2020), inferring that the rate of stunting in Cameroon is higher among the younger age group.
The prevalence of wasting reported in this study at 21.6% is extremely higher than what was recorded among schoolchildren in other parts of the same country.For instance, a study among primary schoolchildren in the Mount Cameroon area revealed a prevalence of wasting of 0.3% among the children (Sumbele et al., 2015).Also, a study among school-aged children in Tiko,

F I G U R E 4
Health-seeking practices.

TA B L E 5
Morbidity status of study children.Cameroon, reported that only 1% of the children were wasted (Tabi et al., 2019).A systematic review of the nutritional status of children of school-going age and adolescents in countries with low-and middle-income revealed that Cameroon's school-aged children are the least wasted when compared to other countries of the same caliber (Wrottesley et al., 2022).Therefore, the high rates of thinness observed among the children in the study may be because the children are displaced and are, hence, affected by the adverse conditions that are associated with conflicts and forcible displacement, such as food insecurity and outbreaks of contagious diseases.Also, previous studies have shown that children who are affected by conflicts are usually burdened by manifold types of malnutrition (Chidiogo et al., 2022).This prevalence of thinness (21.6%) is comparable with what was noticed among displaced children in Iraq, which was (19.2%) (Riyadh et al., 2017).A lower prevalence of thinness was reported among Senegalese schoolaged children (Fiorentino, 2015).On the other hand, extremely higher rates (58•3%) were noticed by Mulugeta et al. (2009) among Ethiopian school-aged children and internally displaced schoolaged children (61.7%) living in the Plateau State, Nigeria (Chidiogo et al., 2022).
The prevalence of underweight (20.1%) found among the children in this study is extremely higher than the 0.7% reported by Nigeria (Chidiogo et al., 2022).A similar prevalence of underweight (20.4%) was reported among both internally displaced and nondisplaced children who were <5 years old in Burkina Faso (Bougma et al., 2022).
All types of malnutrition were more prevalent among the children in this study than among children of the same age in the Health District of Tiko (Tabi et al., 2019) and in the area of Mount Cameroon (Sumbele et al., 2015).The most feasible reason for the poorer results obtained in this study could be the lower socioeconomic status of the displaced children and their mothers/caregivers as the proportion of mothers/caregivers with very low household income (50.000FCFA) was as high as 68.9%.This reaffirms the detrimental consequences of forcible displacement on the nutritional status of children.
The World Health Organization (2017) has revealed that malnutrition in children is a consequence of manifold factors, which are usually associated with the quality of food, inadequate food intake, severe and recurring communicable diseases, or a blend of these factors.These conditions, in turn, are closely associated with the general living standards and the ability of the individual to meet his/her fundamental necessities, such as sufficient food, lodging, and health care services.Hence, nutritional status assessment not only serves as a means for evaluating the health and nutritional status of children but also provides an indirect measurement of the quality of life of the whole population (WHO, 2017).The poor nutritional status of these children therefore implies that their living standards are low and their quality of life is not satisfactory.et al., 2022).This reaffirms the high prevalence of micronutrient deficiencies among school-aged children in less developed countries (Best et al., 2010).The results of this study are in concordance with those of previous studies, which have proven that iron deficiency is more prevalent among younger children because they have elevated iron requirements for growth and other metabolic activities.
Among adolescents, it is more prevalent among girls who lose a significant amount of iron monthly during the process of menstruation  et al. (2015) in seemingly healthy primary schoolchildren in the premises of Mount Cameroon (19.8%) and primary schoolchildren in the Health District of Tiko, Cameroon (5%) (Tabi et al., 2019).This is probably because these children are displaced and hence there is a loss of access to traditional foods, and a lack of food diversity further exacerbates micronutrient deficiencies in the affected population.Additionally, the availability of land and water often limits the cultivation of vegetables and fruit, which are foods that are rich in micronutrients, among displaced populations, hence limiting their access to iron-rich foods which could have significantly improved the nutritional status of these displaced children.So, the prevalence of anemia among children can be reduced by improving the purchasing power of the mothers/ caregivers of the children and ensuring that nutritious foods are always available.
In this study, 30.0% of the children had anemia, implying that anemia is a critical challenge to public health among the displaced children in these regions.Nevertheless, low levels of hemoglobin are an indicator of anemia, which is non-specific as it is also affected by blood-diminishing parasites, prolonged infections, and other hematological disorders (Khallafallah & Mohamed, 2012).
The results of this study highlighted an overall higher prevalence of malnutrition among younger children and adolescent girls.
Therefore, the younger age group and adolescent girls should be the focal point for nutritional surveillance and interventions.
When the nutritional status of the children in this study was compared with that of non-displaced primary schoolchildren of the same age in Cameroon and beyond, it was noticed that different forms of malnutrition were more prevalent among the children in this study.This is not surprising, as numerous previous studies confirm these results among conflict-affected people (Bougma et al., 2022;Dago, 2021;Loewenberg, 2015).
The displaced children in this study were burdened with multiple health problems, such as malaria, respiratory tract infections, skin infections, stomach aches, diarrhea, vomiting, and dental caries.
These results are similar to the findings of a systematic review done by Owoaje et al. (2016), which also noticed that the prevalence of diseases such as diarrhea, respiratory tract infections, fever, and malaria among internally displaced persons in Africa is high.
The fact that no measles was reported among the study children is an indication of the success of the measles eradication program conducted by the Cameroon government throughout the entire territory.The most prevalent illnesses noticed among the children in this current study are similar to those revealed by Amruth (2012), which include infections of the respiratory tract, skin infections, and diarrhea.About 5.3% of the children had dental caries, which can result in difficulty in mastication and reduced food intake.This finding was in contrast to a study by Amruth (2012), who reported that almost half (47.2%) of school-aged children in Cambodia had dental caries.
Most of the children had good health-seeking practices, as more than 60% had the appropriate practice in all cases.Almost all of the children (98.7%) had received complete immunization against all relevant diseases.This might be the reason why some preventable infectious diseases, such as measles, were not reported among the displaced children.In the current study, most of the children and
The years 2018 and 2019 were the peaks of displacement (29.1% and 31.8%,respectively).Various clinical symptoms of malnutrition were present among 9.1% of the children.The most prevalent clinical sign of malnutrition was pallor (7.3%), which signifies iron deficiency, while bilateral pitting edema and Bitot's spots were not noticed among any of the children.The proportion of children who were wasted, underweight, and stunted was 23%, 20.1%, and 27.1%, respectively.Morbidity among the children was high since 32% of the children had suffered from a particular illness during the past month.The most common illness (19.8%) was respiratory tract infections such as common colds, coughs, and pneumonia, while measles was not reported among any of the children at the time of the study.Immunization (98.5%) was the most common health-seeking practice, meanwhile washing fruits before eating was the most neglected (63%) health-seeking practice among the children.About 44.4% of them had low serum iron content, and the prevalence of anemia was 30.0%.About 35.7% of them had poor protein status.
The prevailing scenario of the health and nutritional status of the displaced children in the West and Littoral Regions is very unsatisfactory and might be a reflection of the low nutrient intake of the children.Interventions to improve nutritional status should be intensified specifically among displaced families and their hosts as a strategy for preventing malnutrition in the short term and dietrelated diseases in the long term among the children.Supplementary feeding of the children with food that is particularly rich in protein, iron, and vitamin A is required.
Authorization to carry out the study was obtained from the College of Technology at the University of Bamenda.The study protocol complied with the Helsinki Declaration of 1975 and was approved by the University of Bamenda Institutional Review Board project identification number: 2021/006H/UBa/IRB.The Regional Delegate of Basic Education for the West Region gave authorization to conduct the study.Additional administrative approvals were obtained from the respective divisional delegates, inspectorates of basic education concerned, and headteachers at the selected schools.Signed informed consent was obtained from the parents or caregivers of the children.The willingness of the children to participate until the study was completed was ensured by explaining all the procedures and methods involved in the study to the children at the beginning of the study.

F
Protein and iron status of the children.F I G U R E 3 Anemia status of the children.| 4095 EJOH et al. is secondary education.These results indicate that the population may be facing difficulties in accessing relevant information, including information from sources that have been published.This may imply that the caregivers do not have adequate information on nutrition.This was confirmed by Boh et al. (2023), who noticed that the nutrition knowledge of the caregivers of the children was inadequate, and consequently, the dietary practices of their children were poor.The gaps in health-seeking practices and nutrition knowledge noticed in this study can be used to build the capacity of the caregivers through interventions to improve the nutritional status of the children, such as nutrition education and counseling in areas including health-seeking practices and appropriate feeding practices.The findings of this study indicate that the displaced schoolchildren in the West and Littoral Regions of Cameroon had various nutritional challenges (undernutrition, micronutrient malnutrition, and overweight).This is in accordance with recent reports of the Demographic and Health Survey of Cameroon (Institut National de la Statistique (INS) et ICF, 2020), which revealed that about 11% of children in Cameroon are overweight and 29% are stunted.
their caregivers had good health-seeking practices, unlike most of the mothers of under-five children in the Calabar South local area of the government, Nigeria, who had inappropriate health-seeking behavior toward their children(Jemide et al., 2016).Those who did not have good practices were exposed to diseases such as diarrhea and dental caries, and this may account for the high prevalence of these diseases among the children.The unsanitary practices noticed among the children and their caregivers might be due to ignorance or a lack of the necessary facilities, such as portable tap water to wash their hands, fruits, or vegetables at the right time.On a long-term basis, ensuring constant availability of potable water and hygienic modalities is among the fundamental interventions to promote health among displaced children.Hygiene and sanitation are well-recognized keys to the good health and nutritional status of children(United Nations, 2016).Also, executing regular nutritional monitoring of displaced schoolchildren as part of a school health program can be instrumental in bringing about a much-required improvement in the nutritional status of the children.

Table 4
, various clinical symptoms of malnutrition were present in 9.1% of the children.Clinical signs of malnutrition were F I G U R E 1 Prevalence of wasting according to BMI-for-age of the children.| 4093 EJOH et al.
Nutritional status of schoolchildren based on Z-scores.Clinical signs of malnutrition.
The concentrations of hemoglobin were analyzed by sex and age group.It was noticed that the prevalence of anemia among the displaced female children was higher (32.3%)TA B L E 3 than among the male children (27.7%).The prevalence of anemia among children between 5 and 9 years of age (35.5%) was higher than among those aged >9 years (24.5%).More children in the West Region (33.1%) were suffering from IDA than in the Littoral Region (26.9%).
Tabi et al. (2019) among school-aged children in the Health District of Tiko in Cameroon but lower than what was noticed among internally displaced school-aged children (28.1%) living in the Plateau State,