Economic disparity and child nutrition in Bangladesh

Inequality in access to improved drinking water sources and childhood diarrhoea in low- and middle-income countries

In addition to the conventional wisdom of categorizing countries based on nationally-averaged coverage in access to improved drinking water sources (IDWS), this study incorporated sub-national inequality into a novel categorisation framework. The association between access to IDWS and the incidence of childhood diarrhoea (ICD) was also quantified. Information from 1.63 million households obtained through nationally representative and cross-sectional demographic and health survey (DHS) and multiple indicator cluster survey (MICS) from 81 countries were analysed. Sub-national inequalities in the access to IDWS were measured using proportional variability (PV). Most studied countries with low coverage and high inequalities in accessing IDWS were from Sub-Saharan Africa (SSA). Wealth status of households showed a higher variability in the IDWS than the variability across locations. Significant negative associations between accessing IDWS and ICD were observed for regional models, except for SSA. This study adds knowledge towards understanding the state of sustainable development goal achievements in terms of accessing IDWS. The knowledge may be helpful in designing country-specific, achievable, short- and long-term strategies. The non-decisive relation between access to IDWS and ICD indicates the adoption of additional measures in the modelling mechanism.

How sustainable household environment and knowledge of healthy practices relate to childhood morbidity in South Asia: analysis of survey data from Bangladesh, Nepal and Pakistan

OBJECTIVES

Prevalence of diarrhoea and acute respiratory infection (ARI) is considerably high among South Asian children. The objective of this study is to compare the associations of sustainable household environment and knowledge of healthy practices with episodes of these diseases among the children in the region.

DESIGN

The study analysed the latest, nationally representative and cross-sectional Demographic and Health Survey data.

SETTING

Data from three countries were analysed: Bangladesh, Nepal and Pakistan.

PARTICIPANTS

Women aged between 12 and 49 years living in selected households provided information on 23 940 of their children under the age of 5 years.

PRIMARY OUTCOMES MEASURES

The morbidity status of the children was recorded with respect to episodes of diarrhoea and/or ARI in the 2 weeks preceding data collection.

RESULTS

Consuming unhygienic drinking water increased the risks of childhood diarrhoea, and use of solid fuel for indoor cooking increased the risk of ARI, across all three countries investigated. However, far more significant were the effects of mother's education, with incomplete primary education leading to an odds of diarrhoea approaching twice that of a mother with secondary education or higher (OR 1.70 in Bangladesh, 95% CI 1.16 to 2.49).

CONCLUSIONS

Results from the current research underline the importance of developing and implementing integrated strategic plans for mothers and children in the countries investigated. Promoting hygienic water and sanitation facilities can help reduce the prevalence of childhood diarrhoea. Replacing indoor solid fuel cooking arrangements with cleaner fuel or more airy conditions can help reduce the prevalence of ARI. However, these strategies need to be integrated with education for women to raise the likelihood that reduced risks are actually realised.

Malnutrition and non-communicable diseases among Bangladeshi women: an urban-rural comparison

BACKGROUND/OBJECTIVES

This study aims at examining the urban-rural differentials in the effects of socioeconomic predictors on underweight and obesity of ever-married women in Bangladesh. The effect of malnutrition and other risk factors on non-communicable diseases is also examined.

SUBJECTS/METHODS

The information regarding nutritional status, socioeconomic and demographic background, and non-communicable diseases of ever-married women was extracted from the nationally representative, cross-sectional Bangladesh Demographic and Health Survey (BDHS 2011) data set. Both bivariate (χ2 test) and multivariate (multinomial logistic regression model) analyses were performed in determining the risk factors of malnutrition. The effect of malnutrition and associated risk factors on non-communicable diseases was determined using binary logistic regression models.

RESULTS

The overall prevalence as well as the effects of individual risk factors of malnutrition differ in urban and rural settings. Regional differentials in the prevalence of underweight were statistically significant only for rural areas. In rural and urban settings, women from households with poor economic status were 67% (odds ratio (OR) 0.33, 95% CI 0.26-0.43) and 81% (OR=0.19, 95% CI 0.13-0.29) less likely to be overweight, respectively, with respect to those from affluent households. Women from the Rangpur division were significantly more likely to suffer from anemia (OR=1.41, 95% CI 1.13-1.77) and hypertension (OR=1.67, 95% CI 1.19-2.34) than those from the Sylhet division (reference division). With respect to those considered as underweight, women who were categorized as overweight were 0.47 (OR=0.53, 95% CI 0.43-0.65) times less likely to suffer from anemia, and 1.83 (OR=2.83, 95% CI 1.99-4.02) and 1.70 (OR=2.70, 95% CI 2.09-3.50) times more likely to suffer from diabetes and hypertension, respectively.

CONCLUSIONS

Rural-urban differentials in the effects of individual risk factors of malnutrition were observed. Wealth status of households and nutritional status of women showed significant effect on the prevalence of anemia, diabetes and hypertension.

Socio-Economic Inequality of Chronic Non-Communicable Diseases in Bangladesh

Introduction

Chronic non-communicable diseases (NCDs) are a major public health challenge, and undermine social and economic development in much of the developing world, including Bangladesh. Epidemiologic evidence on the socioeconomic status (SES)-related pattern of NCDs remains limited in Bangladesh. This study assessed the relationship between three chronic NCDs and SES among the Bangladeshi population, paying particular attention to the differences between urban and rural areas.

Materials and Method

Data from the 2011 Bangladesh Demographic and Health Survey were used for this study. Using a concentration index (CI), we measured relative inequality across pre-diabetes, diabetes, pre-hypertension, hypertension, and BMI (underweight, normal weight, and overweight/obese) in urban and rural areas in Bangladesh. A CI and its associated curve can be used to identify whether socioeconomic inequality exists for a given health variable. In addition, we estimated the health achievement index, integrating mean coverage and the distribution of coverage by rural and urban populations.

Results

Socioeconomic inequalities were observed across diseases and risk factors. Using CI, significant inequalities observed for pre-hypertension (CI = 0.09, p = 0.001), hypertension (CI = 0.10, p = 0.001), pre-diabetes (CI = -0.01, p = 0.005), diabetes (CI = 0.19, p<0.001), and overweight/obesity (CI = 0.45, p<0.001). In contrast to the high prevalence of the chronic health conditions among the urban richest, a significant difference in CI was observed for pre-hypertension (CI = -0.20, p = 0.001), hypertension (CI = -0.20, p = 0.005), pre-diabetes (CI = -0.15, p = 0.005), diabetes (CI = -0.26, p = 0.004) and overweight/obesity (CI = 0.25, p = 0.004) were observed more among the low wealth quintiles of rural population. In the same vein, the poorest rural households had more co-morbidities compared to the richest rural households (p = 0.003), and prevalence of co-morbidities was much higher for the richest urban households compared to the poorest urban households. On the other hand in rural the “disachievement” of health indicators is more noticeable than the urban ones.

Conclusion

The findings indicate the high burden of selected NCDs among the low wealth quintile populations in rural areas and wealthy populations in urban areas. Particular attentions may be necessary to address the problem of NCDs among these groups.

Socioeconomic gradients in early childhood health: evidence from Bangladesh and Nepal

Background

A large literature has developed researching the origins of socioeconomic gradients in child health in developed countries. Particularly, this research examines the age at which these gradient effects emerge and how they change across different stages of childhood. However, similar research on developing countries is limited.

Methods

This paper examines the socioeconomic gradients in early childhood health in two developing countries, Bangladesh and Nepal using the 2011 Demographic and Health Surveys. The paper separately studies two measures of household socioeconomic status: household wealth and maternal educational attainment. Two anthropometric measures of early childhood health, height-for-age and weight-for-age Z scores for 0–59 months of children, are used for our empirical exercise. The paper uses both non-parametric and multivariate ordinary least squares approaches to examine at what age socioeconomic disparities in health emerge, and investigates if these disparities increase with age in early childhood.

Results

The paper provides significant evidence of age-specific socioeconomic gradients in early childhood health in both countries. Health disparities in household wealth exist in both countries. This disparity emerges in the first 11 months of life, and is particularly severe for children from the poorest quintile. On the other hand, while the emergence of maternal education gradients during the first 11 months is sensitive to the choice of childhood health measure, the study finds the children of mothers with higher education to enjoy significantly higher health outcomes in comparison to those with lower education. However, controlling for father’s education weakens the effects of maternal education on child health in both countries. Further, the paper does not find statistically significant evidence where socioeconomic gradients in health increase with age in early childhood.

Conclusions

Our study concludes that socioeconomic disparities in health outcomes exist even in very early childhood in Bangladesh and Nepal. This has important implications for targeted policy interventions in the form of food security and nutrition supplement programs, free provision of health care, and maternal education in both countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0364-2) contains supplementary material, which is available to authorized users.

Determinants of childhood morbidity in Bangladesh: evidence from the Demographic and Health Survey 2011

OBJECTIVES

The present study aims to estimate the incidence of preventable infectious diseases or associated symptoms among young children in Bangladesh and also determine the factors affecting these conditions. The study hypothesised that various background characteristics of children as well as their parents influence the incidence of morbidity of children aged below 5 years.

SETTING

The study used data from the most recent nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) conducted in 2011.

PARTICIPANTS

A total of 7550 children aged below 5 years during the survey from mothers aged between 12 and 49 years are the participants of the study.

RESULTS

In general, younger children were more likely to suffer from multiple health conditions than their older counterparts. Children belonging to households classified as poor (OR=1.425, 95% CI (1.130 to 1.796)) or middle (OR=1.349, 95% CI (1.113 to 1.636)) faced greater risk of illness than those from well-off households. A combination of source and treatment practices of drinking water showed a significant impact on incidence of childhood morbidity. Children from households using untreated non-piped water were 85.8% (OR=1.860, 95% CI (1.269 to 2.728)) more likely to suffer from comorbidity than those who treat their piped drinking water. However, we observed that water treatment alone has no impact unless the water itself was sourced from a pipe.

CONCLUSIONS

Accelerated programmes promoting access to safe drinking water along with water treatment practices, and better household environment may prove effective in reducing the incidence of childhood morbidity in Bangladesh.

Maternal nutritional status (as measured by height, weight and BMI) in Bangladesh: trends and socio-economic association over the period 1996 to 2007

Objective

To analyse trends in maternal nutritional status in Bangladesh over a 12-year period and to examine the associations between nutritional status and socio-economic variables.

Design

Maternal nutritional status indicators were height, weight and BMI. Socio-economic variables used were region, residency, education and occupation of the mothers and their husbands, house type, and possession score in the household.

Setting

Bangladesh Demographic and Health Surveys (1996, 2000, 2004 and 2007) were the source of data.

Subjects

A total of 16 278 mothers were included.

Results

All of the socio-economic variables showed significant associations with maternal nutritional status indicators. Regional variation was found to be present; all three indicators were found to be lowest in the Sylhet division. Upward trends in maternal height, weight and BMI were evident from no possessions to four possessions in households, and for no education to higher education of women and their husbands. Bangladeshi mothers measured in 2007 were found to be on average 0·34 cm taller and 3·36 kg heavier than mothers measured in 1996. Between 1996 and 2007 maternal underweight fell from nearly 50 % to just over 30 % while overweight and obesity increased from about 3 % to over 9 % (WHO cut-offs) or from 7 % to nearly 18 % (Asian cut-offs).

Conclusions

The study reveals that over the 12-year period in Bangladesh there has been a substantial reduction in maternal underweight accompanied by a considerable increase in obesity. It is also evident that malnutrition in Bangladesh is a multidimensional problem that warrants a proper policy mix and programme intervention.

Mother's education is the most important factor in socio-economic inequality of child stunting in Iran

OBJECTIVE

Malnutrition is one of the most important health problems, especially in developing countries. The present study aimed to describe the socio-economic inequality in stunting and its determinants in Iran for the first time.

DESIGN

Cross-sectional, population-based survey, carried out in 2009. Using randomized cluster sampling, weight and height of children were measured and anthropometric indices were calculated based on child growth standards given by the WHO. Socio-economic status of families was determined using principal component analysis on household assets and social specifications of families. The concentration index was used to calculate socio-economic inequality in stunting and its determinants were measured by decomposition of this index. Factors affecting the gap between socio-economic groups were recognized by using the Oaxaca-Blinder decomposition method.

SETTING

Shahroud District in north-eastern Iran.

SUBJECTS

Children (n 1395) aged <6 years.

RESULTS

The concentration index for socio-economic inequality in stunting was -0·1913. Mother's education contributed 70 % in decomposition of this index. Mean height-for-age Z-score was -0·544 and -0·335 for low and high socio-economic groups, respectively. Mother's education was the factor contributing most to the gap between these two groups.

CONCLUSIONS

There was a significant socio-economic inequality in the studied children. If mother's education is distributed equally in all the different groups of Iranian society, one can expect to eliminate 70 % of the socio-economic inequalities. Even in high socio-economic groups, the mean height-for-age Z-score was lower than the international standards. These issues emphasize the necessity of applying new interventions especially for the improvement of maternal education.

Diagram-based Analysis of Causal Systems (DACS): elucidating inter-relationships between determinants of acute lower respiratory infections among children in sub-Saharan Africa

BACKGROUND

Effective interventions require evidence on how individual causal pathways jointly determine disease. Based on the concept of systems epidemiology, this paper develops Diagram-based Analysis of Causal Systems (DACS) as an approach to analyze complex systems, and applies it by examining the contributions of proximal and distal determinants of childhood acute lower respiratory infections (ALRI) in sub-Saharan Africa.

RESULTS

Diagram-based Analysis of Causal Systems combines the use of causal diagrams with multiple routinely available data sources, using a variety of statistical techniques. In a step-by-step process, the causal diagram evolves from conceptual based on a priori knowledge and assumptions, through operational informed by data availability which then undergoes empirical testing, to integrated which synthesizes information from multiple datasets. In our application, we apply different regression techniques to Demographic and Health Survey (DHS) datasets for Benin, Ethiopia, Kenya and Namibia and a pooled World Health Survey (WHS) dataset for sixteen African countries. Explicit strategies are employed to make decisions transparent about the inclusion/omission of arrows, the sign and strength of the relationships and homogeneity/heterogeneity across settings.Findings about the current state of evidence on the complex web of socio-economic, environmental, behavioral and healthcare factors influencing childhood ALRI, based on DHS and WHS data, are summarized in an integrated causal diagram. Notably, solid fuel use is structured by socio-economic factors and increases the risk of childhood ALRI mortality.

CONCLUSIONS

Diagram-based Analysis of Causal Systems is a means of organizing the current state of knowledge about a specific area of research, and a framework for integrating statistical analyses across a whole system. This partly a priori approach is explicit about causal assumptions guiding the analysis and about researcher judgment, and wrong assumptions can be reversed following empirical testing. This approach is well-suited to dealing with complex systems, in particular where data are scarce.

Predictors of the number of under-five malnourished children in Bangladesh: application of the generalized poisson regression model

Background

Malnutrition is one of the principal causes of child mortality in developing countries including Bangladesh. According to our knowledge, most of the available studies, that addressed the issue of malnutrition among under-five children, considered the categorical (dichotomous/polychotomous) outcome variables and applied logistic regression (binary/multinomial) to find their predictors. In this study malnutrition variable (i.e. outcome) is defined as the number of under-five malnourished children in a family, which is a non-negative count variable. The purposes of the study are (i) to demonstrate the applicability of the generalized Poisson regression (GPR) model as an alternative of other statistical methods and (ii) to find some predictors of this outcome variable.

Methods

The data is extracted from the Bangladesh Demographic and Health Survey (BDHS) 2007. Briefly, this survey employs a nationally representative sample which is based on a two-stage stratified sample of households. A total of 4,460 under-five children is analysed using various statistical techniques namely Chi-square test and GPR model.

Results

The GPR model (as compared to the standard Poisson regression and negative Binomial regression) is found to be justified to study the above-mentioned outcome variable because of its under-dispersion (variance < mean) property. Our study also identify several significant predictors of the outcome variable namely mother’s education, father’s education, wealth index, sanitation status, source of drinking water, and total number of children ever born to a woman.

Conclusions

Consistencies of our findings in light of many other studies suggest that the GPR model is an ideal alternative of other statistical models to analyse the number of under-five malnourished children in a family. Strategies based on significant predictors may improve the nutritional status of children in Bangladesh.

Analysis of Different Prognostic Indicators for Malnutrition and Shigella flexneri Infection Among the Children in Bangladesh

The present study investigates into some socio-economic, demographic, and nutritional features that can predispose Bangladeshi children to malnutrition and Shigella flexneri infection. Significant prognostic indicators associated with malnutrition were mother's illiteracy (unadjusted odds ratio, OR = 2.580; 95% confidence interval, CI = 1.134-5.867 and adjusted odds ratio, ORa, 3.814; 95% CI = 1.124-12.943), low birth weight (OR = 3.143; 95% CI = 1.2-8.232 and ORa = 2.404; 95% CI = 0.870-6.644) and poor socioeconomic status (OR = 2.549; 95% CI = 1.382-4.701 and ORa = 1.808; 95% CI = 0.852-3.838). Age was the strongest predictor for the acquisition of S. flexneri infection in the studied population (OR = 5.472; 95% CI = 2.583-11.592 and ORa = 5.808; 95% CI = 2.420-13.942). The severity of malnutrition was significantly (P = 0.033) related to seroprevalence of S. flexneri infection. To reduce malnutrition emphasis should be given on controlling the incidence of low birth weight, improving the literacy status especially of mothers and narrowing the gap between different socio-economic levels. Malnourished children should be examined for severity and direct intervention therapy should be given when necessary.