Determinants of undernutrition among young children in Ethiopia

Determinants of aggregate anthropometric failure among children under-five years in Ethiopia: Application of multilevel mixed-effects negative binomial regression modeling

Undernutrition significantly contributes to failure to thrive in children under five, with those experiencing multiple forms of malnutrition facing the highest risks of morbidity and mortality. Conventional markers such as stunting, wasting, and underweight have received much attention but are insufficient to identify multiple types of malnutrition, prompting the development of the Composite Index of Anthropometric Failure (CIAF) and the Composite Index of Severe Anthropometric Failure (CISAF) as an aggregate indicators. This study aimed to identify factors associated with CIAF and CISAF among Ethiopian children aged 0-59 months using data from the 2019 Ethiopia Mini Demographic and Health Survey. The study included a weighted sample of 5,259 children and used multilevel mixed-effects negative binomial regression modeling to identify determinants of CIAF and CISAF. The result showed higher incidence-rate ratio (IRR) of CIAF in male children (adjusted IRR = 1.27; 95% CI = 1.13-1.42), children aged 12-24 months (aIRR = 2.01, 95%CI: 1.63-2.48), and 24-59 months (aIRR = 2.36, 95%CI: 1.91-2.92), those from households with multiple under-five children (aIRR = 1.16, 95%CI: 1.01-1.33), poorer households (aIRR = 1.48; 95%CI: 1.02-2.15), and those who lived in houses with an earthen floor (aIRR = 1.37, 95%CI: 1.03-1.82). Similarly, the factors positively associated with CISAF among children aged 0-59 months were male children (aIRR = 1.47, 95% CI = 1.21-1.79), age group 6-11 months (aIRR = 2.30, 95%CI: 1.40-3.78), age group 12-24 months (aIRR = 3.76, 95%CI: 2.40-5.88), age group 25-59 months (aIRR = 4.23, 95%CI: 2.79-6.39), children from households living with two and more under-five children (aIRR = 1.27, 95%CI:1.01-1.59), and children from poorer households (aIRR = 1.93, 95% CI = 1.02-3.67). Children were more likely to suffer from multiple anthropometric failures if they were: aged 6-23 months, aged 24-59 months, male sex, living in households with multiple under-five children, and living in households with poor environments. These findings underscore the need to employ a wide range of strategies to effectively intervene in multiple anthropometric failures in under-five children.

Childhood undernutrition mediates the relationship between open defecation with anemia among Ethiopian children: a nationally representative cross-sectional study

BACKGROUND

Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia.

METHODS

We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders.

RESULTS

Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of β = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (βindirect = 0.014, p < 0.001), wasting (βindirect = 0.009, p = 0.002), and underweight (βindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of βtotal = 0.285, p < 0.001.

CONCLUSION

Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.

Environmental Predictors of Undernutrition Among Under-5 Children at Dabat District Health Facilities, Northwest Ethiopia, 2023

Background

In Ethiopia, undernutrition remains a significant public health concern throughout the year due to persistent household food insecurit. The intensifying conflict in the Dabat district, involving the Ethiopian government and the Tigray Liberation Front, has increased the threat of undernutrition among under-5 children. The cessation of humanitarian aid has worsened food insecurity, increasing the vulnerability of the children in the region. However,there was no data showing the prevalence and environmental pridictors of undernutrition in the Dabat district, northwestern Ethiopia. Therefore, the objective of this study was to determine the prevalence of undernutrition and identify environmental pridictors in this study setting.

Methods

This institutional-based cross-sectional study was conducted from January to March 2023. A total of 400 under-5 children were included in this study using systematic random sampling techniques with a 100% response rate. The study included all under-5 children who visited healthcare facilities during the data collection period. However, it excluded children under-5 who had physical deformities, were critically ill, or had congenital abnormalities or known chronic diseases such as HIV/AIDS, tuberculosis, or chronic heart diseases. Binary logistic regression was used to determine environmental predictors of undernutrition, with statistical significance at a P-value of ⩽.05.

Results

The overall prevalence of undernutrition was found to be 12% (95% CI: 8.72-21.5). Among those affected, 32.8% (95% CI: 21.5-39.8) were stunted, 37.9% (95% CI: 28.8-47.50) were underweight, and 29.3% (95% CI: 21.3-29.7) were wasted. The environmental predictors of undernutrition were latrine use, recent diarrhea episodes, mothers' occupation and place of residence, water treatment before consumption, water sources and storage, water extraction methods, and mothers' handwashing habits.

Conclusions and recommendations

The study found a higher prevalence of undernutrition among under-5 children compared to the 2019 Ethiopia Mini Demographic and Health Survey. This study recommended raising awareness about establishing private toilets, promoting water treatment, proper latrine use, and handwashing practices. Training on personal hygiene and economic support for households should also be provided. Healthcare providers should offer quality health services for under-5 children. Further research is needed to explore specific nutrient deficiencies using laboratory methods.

Nutritional status of infants and young children in India across three decades: Analysis of five national family health surveys

BACKGROUND

Three indicators of early childhood undernutrition and associated factors are evaluated among under-5 children in five National Family Health Surveys in India spanning 1992 to 2021.

METHODS

Data for 533,495 children under 5 years of age (U-5) were analysed in the context of three commonly used indicators of early childhood undernutrition - wasting, stunting and underweight. In addition to descriptive and inferential statistics, binary logistic regression was used to estimate the effects of specific explanatory factors on the three indicators using adjusted odds ratios.

RESULTS

Over the three-decade interval, stunting was reduced by 22.1% in boys and 20.9% in girls, followed by underweight, 19.3% in boys and 17.4% in girls; wasting, in contrast, was reduced to a considerably lesser extent, 2.8% in boys and 0.9% in girls. Demographic, maternal and socioeconomic factors were associated with the incidence of early childhood undernutrition, specifically among young mothers and those with less education in low-income families, and among children from Scheduled Tribes or Scheduled Castes. Stunting and underweight declined significantly over the past three decades while wasting changed negligibly. The disparity in the occurrence of early childhood undernutrition was apparent throughout socioeconomic categories and regions of India.

CONCLUSIONS

The results highlight the need for special programs aimed at reducing waste among children and also the need for customized initiatives focused on the improvement of maternal education and wealth in addition to other ancillary factors related to regional variation.

Co-existence of maternal overweight/obesity, child undernutrition, and anaemia among mother-child pairs in Ethiopia

Ethiopia is currently known to be the most food-insecure country in sub-Saharan Africa, where childhood undernutrition remains endemic. While attention is increasingly being paid to childhood undernutrition in Ethiopia, a current surge of "triple burden of malnutrition" (TBM) has received less attention. The purpose of this study was to determine the prevalence of TBM and identify the associated factors in Ethiopia. Data were from the Ethiopian Demographic and Health Surveys (2005-2016) and a total of 20,994 mother-child pairs were examined in this study. The TBM was our primary outcome variable, which encompasses three types of nutritional problems-when a mother may be overweight/obese, while her child is stunted, wasted, or underweight plus has anaemia under the same roof. A multilevel logistic regression explored the individual- and community-level factors associated with TBM. Our study indicated that children under-five years of age were anaemic, stunted, wasted, and underweight [49.3% (95% CI: 48.7-49.9), 43.1% (95% CI: 42.4-43.7), 10.3% (95% CI: 9.9-10.7), and 27.6% (95% CI: 27.0-28.1)] respectively. The overall prevalence of TBM was 2.6% (95% CI: 2.39-2.83). Multilevel analyses revealed that TBM was more likely to occur among children aged 12-23 months (AOR: 2.54, 95% CI: 1.68-3.83), 24-35 months (AOR: 1.54, 95% CI: 1.03-2.29), children perceived by their mothers to be smaller than normal at birth (AOR: 1.94, 95% CI: 1.48-2.56), who experienced fever in the past 2 weeks (AOR: 1.58, 95% CI: 1.24-2.01), and lived in urban settings (AOR: 1.79, 95% CI: 1.13-2.86). Lower odds of TBM were reported among female children (AOR: 0.59, 95% CI: 0.47-0.72), and those who lived in rich households (AOR: 0.69: 95% CI: 0.49-0.98). TBM was found to be present in almost three percent of households in Ethiopia. Addressing the TBM through double-duty actions will be of critical importance in achieving malnutrition in all its forms in Ethiopia.

Pooled prevalence and its determinants of stunting among children during their critical period in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Stunting is a major public health concern, particularly in low and middle-income countries. Globally, nearly 149 million under-five children are suffering from stunting. Despite it can occur in all age groups, the impact is more severe among children age less than 24 months as this period is critical time of very rapid growth and development. Therefore, this review aimed to determine the pooled prevalence and determinants of stunting among children during this critical period in Ethiopia.

METHODS

The literature search was conducted using international electronic data bases (pumed, Google scholar, CINHAL, Hinari, open Google) and the hand search of reference lists of eligible articles. The presence of heterogeneity between studies was evaluated using Cochrane Q-test and I2 test statistics and sensitivity analysis was also checked. Small study effect was checked through graphical and statistical test. Sub-group analysis was performed to handle heterogeneity.

RESULTS

This study included 14 studies with a total sample size of 8,056 children. The overall pooled estimate of stunting was 35.01(95% CI: 24.73-45.28, I2 = 98.98%) in the country with the highest prevalence in Amhara region. Increased Child's age (OR = 3.83; 95% CI: 2.47-5.18, I2 = 97.76%), no maternal education (OR = 2.90; 95%CI: 1.59-4.20, I2 = 89.73%), no maternal postnatal follow up (OR = 1.81; 95% CI:1.51-2.10) less than four food diversity of the child (OR = 2.24;95%CI; 1.94-2.55,I2 = 21.55%), low maternal body mass index, failure to colostrum and exclusive breast feeding, two and more under five children in the household and poor wealth index of the family were significant factors of stunting.

CONCLUSION AND RECOMMENDATIONS

The pooled prevalence of stunting among children during their critical time is high. Increased Child's age, no maternal education and no maternal postnatal follow up, less than four food diversity of the child, low maternal body mass index, failure to colostrum and exclusive breast feeding, two and more under five children in the household and poor wealth index of the family were determinants of stunting. Therefore, providing continuous maternal postnatal follow up, increase awareness of mothers on importance of colostrum and exclusive breast feeding, feeding of children the recommended variety of foods and at large to improve the wealth status of the households are crucial interventions to meet national and international targets of zero stunting in children less than 2 years.

Utilization of growth monitoring and promotion services among children younger than 2 years in West Armachiho district, Northwest Ethiopia

Introduction

Inadequate physical growth and poor development of children are prevalent and significant problems worldwide, with 149 million children younger than 5 years stunted and 49 million wasted. Growth monitoring and promotion (GMP) is one of the major activities implemented with the aim of capturing growth faltering before the child reaches the status of undernutrition. In relation to this, the Amhara region, where the study area is found, is a highly burdened area for child malnutrition. Thus, it needs further investigation about the utilization of GMP services and associated factors among children younger than 2 years in the study area.

Objective

The aim of this study was to assess the utilization of growth monitoring and promotion services and associated factors among children younger than 2 years.

Methods

A community-based cross-sectional study was conducted in the West Armachiho district, including 703 mother-child pairs, with a response rate of 94.7%. A simple random sampling technique was used to select the respondents. Both bivariable and multivariable logistic regression analyzes were performed. An adjusted odds ratio (AOR) with a 95% confidence interval was used to measure the strength of the association.

Results

The proportion of utilization of growth monitoring and promotion services in the West Armachiho district was 13.7% (95%Cl; 11.2, 16.4). Factors such as maternal educational status (AOR = 2.17, 95%Cl; 1.05, 4.49), institutional delivery (AOR = 3.16, 95%Cl; 1.62, 6.13), family size (AOR = 2.66, 95%Cl; 1.13, 6.23), access to health facility (AOR = 3.17, 95%Cl; 1.45, 6.95), and maternal knowledge (AOR = 4.53, 95%Cl; 2.71, 7.59) were significantly associated with the utilization of growth monitoring and promotion services.

Conclusion

Utilization of growth monitoring and promotion services in children younger than 2 years in the West Armachiho district was low. Thus, giving due attention to the improvement of the knowledge of the mothers/caregivers about child GMP services and counseling them about the importance of facility delivery is vital to improving growth monitoring and promotion services in the area.

Gender-specific disaggregated analysis of childhood undernutrition in Ethiopia: evidence from 2000-2016 nationwide survey

INTRODUCTION

Childhood undernutrition has been investigated extensively in previous literature but gender inequality detailing the burden of undernutrition has not been adequately addressed in scientific papers, especially in Ethiopia, where undernutrition is known to be a public health problem of high significance, necessitating increased efforts to address it and reduce this inequality. This study was carried out to: (1) explore gender differences in the prevalence of stunting, wasting, and underweight, and (2) compare the factors associated with childhood undernutrition between boys and girls in Ethiopia.

METHODS

The study used a dataset of more than 33,564 children aged under 5 years (boys: 17,078 and girls: 16,486) who were included in the nationally representative Ethiopia Demographic and Health Survey (EDHS) from 2000 to 2016. The outcome variables were anthropometric indices: stunting (height-for-age < -2 standard deviations), wasting (weight-for-height < -2 standard deviations), and underweight (weight-for-age < -2 standard deviations). Gender-specific multilevel analyses were used to examine and compare the factors associated with child undernutrition.

RESULTS

The overall prevalence of stunting (49.1% for boys vs 45.3% for girls, p < 0.001), wasting (11.9% for boys vs 9.9% for girls, p < 0.001), and underweight (33.1% for boys vs 29.8% for girls, p < 0.001) higher among boys compared to girls. Boys significantly had higher odds of stunting (aOR: 1.31, 95%CI: 1.21-1.42), wasting (aOR: 1.35, 1.23-1.48), and underweight (aOR: 1.38, 95%CI: 1.26-1.50) than girls. The common factors associated with childhood undernutrition for male and female children were the child's age, perceived size of the child at birth, breastfeeding status, maternal stature, maternal education, toilet facility, wealth index, and place of residence. Boys who were perceived by their mothers to be average sized at birth and were born to uneducated mothers had a higher likelihood of experiencing wasting, in contrast to girls. Among boys, birth order (firstborn), household size (1-4), and place of residence (urban) were associated with lower odds of being underweight. Boys living in cities had lower odds of being stunted. While girls born to mothers with no education and worked in agriculture were at a higher odd of being stunted.

CONCLUSION

Our study revealed that boys were more likely to be malnourished than girls, regardless of their age category, and there were variations in the factors determining undernutrition among boys and girls. The differences in the burden of undernutrition were significant and alarming, positioning Ethiopia to be questioned whether it will meet the set Sustainable Development Goals (SDGs), including SDG 2 of zero hunger by 2030. These findings call for more effort to address malnutrition as a significant public health issue in Ethiopia, and to urgently recognise the need for enhanced interventions that address the gender gap in childhood undernutrition.

Coexistence of Anaemia and Stunting among Children Aged 6-59 Months in Ethiopia: Findings from the Nationally Representative Cross-Sectional Study

INTRODUCTION

Stunting and anaemia, two severe public health problems, affect a significant number of children under the age of five. To date, the burden of and predictive factors for coexisting forms of stunting and anaemia in childhood have not been well documented in Ethiopia, where both the conditions are endemic. The primary aims of the present study were to: (i) determine the prevalence of co-morbid anaemia and stunting (CAS); (ii) and identify factors associated with these co-morbid conditions among children aged 6-59 months in Ethiopia.

METHODS

The study was based on data from the Ethiopian Demographic and Health Survey (EDHS 2005-2016). The EDHS was a cross-sectional study that used a two-stage stratified cluster sampling technique to select households. A total weighted sample of 21,172 children aged 6-59 months was included in the current study (EDHS-2005 (n = 3898), EDHS-2011 (n = 8943), and EDHS-2016 (n = 8332)). Children with height-for-age z-scores (HAZ) less than -2 SD were classified as stunted. Anaemia status was measured by haemoglobin level with readings below 11.0 g/deciliter (g/dL) categorized as anaemic. A multilevel mixed-effects logistic regression model was used to identify the factors associated with CAS. The findings from the models were reported as adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

Almost half of the children were males (51.1%) and the majority were from rural areas (89.2%). The prevalence of CAS was 24.4% [95% CI: (23.8-24.9)]. Multivariate analyses revealed that children aged 12-23 months, 24-35 months, and 36-59 months, and children perceived by their mothers to be smaller than normal at birth had higher odds of CAS. The odds of CAS were significantly higher among children born to anaemic mothers [AOR: 1.25, 95% CI: (1.11-1.41)], mothers with very short stature [AOR: 2.04, 95% CI: (1.44-2.91)], children from households which practiced open defecation [AOR: 1.57, 95% CI: (1.27-1.92)], children born to mothers without education [AOR: 3.66, 95% CI: (1.85-7.22)], and those who reside in rural areas [AOR: 1.41, 95% CI: (1.10, 1.82)]. Male children had 19% lower odds of having CAS compared to female children [AOR: 0.81, 95% CI: (0.73-0.91)]. Children born to mothers who had normal body mass index (BMI) [AOR: 0.82, 95%CI: (0.73-0.92)] reported lower odds of CAS.

CONCLUSIONS

One in four preschool-age children in Ethiopia had co-morbid anaemia and stunting, which is a significant public health problem. Future interventions to reduce CAS in Ethiopia should target those children perceived to be small at birth, anaemic mothers, and mothers with short stature.

The coexistence of stunting and overweight or obesity in Ethiopian children: prevalence, trends and associated factors

BACKGROUND

Double burden of childhood malnutrition is a condition where undernutrition (stunting) along with overweight and obesity coexist within individuals, households, and populations. It reflects a new layer of malnutrition and an understudied phenomenon in many low-income settings. To date, the prevalence and factors that are associated with concurrent stunting and overweight or obesity (overweight/obesity) (CSO) in the same children have not been well researched in Ethiopia. Hence, this study aimed to assess the prevalence, trends, and factors associated with the coexistence of stunting and overweight or obesity among children aged 0-59 months in Ethiopia.

METHODS

Pooled data from 2005, 2011 and 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A total of 23,756 (weighted sample) children aged 0-59 months were included in the study. Height-for-age z-scores (HAZ) less than - 2 SD and weight-for-height z-scores (WHZ) above 2 SD were calculated, and children were classified as stunted and overweight/obese, respectively. A child who is simultaneously stunted and overweight/obese was considered as having HAZ below - 2 SD and WHZ above 2 SD computed into a variable named CSO, and reported as a binary outcome (yes or no). Multilevel logistic regression analysis that adjusts for sampling weights and clustering was used to identify factors associated with CSO.

RESULTS

The prevalence of stunting, overweight or obesity, and CSO among under-five children was 43.12% [95% CI: (42.50, 43.75%)], 2.62% [95% CI: (2.42, 2.83%)], and 1.33% [95% CI: (1.18, 1.48%)], respectively. The percentage of CSO children was reported to have declined from 2.36% [95% CI: (1.94-2.85)] in 2005 to 0.87% [95%CI: (0.07-1.07)] in 2011, and the same appeared to have increased slightly to 1.34% [95%CI: (1.13-1.59)] in 2016. Children who were currently breastfeeding [AOR: 1.64, 95%CI: (1.01-2.72)], born to an overweight mother [AOR: 2.65, 95%CI: (1.19-5.88)], and lived in families with 1-4 household members [AOR: 1.52, 95%CI: (1.02-2.26)] were significantly associated with CSO. At the community level the odds of having CSO were higher among children included from EDHS-2005 [AOR: 4.38, 95%CI: (2.42-7.95)].

CONCLUSION

The study revealed that less than 2% of children had CSO in Ethiopia. CSO was linked to factors at both the individual (i.e. breastfeeding status, maternal overweight, and household size) and community-levels. Overall, the study findings indicated the necessity of focused interventions to simultaneously address double burden of childhood malnutrition in Ethiopia. To further combat the double burden of malnutrition, early identification of at-risk children, including those born to overweight women and children living with multiple household members, is indispensable.

Association between maternal stature and household-level double burden of malnutrition: findings from a comprehensive analysis of Ethiopian Demographic and Health Survey

BACKGROUND

Undernutrition among under-five children is one of the intractable public health problems in Ethiopia. More recently, Ethiopia faced a rising problem of the double burden of malnutrition-where a mother may be overweight/obese, and a child is stated as having undernutrition (i.e., stunting, wasting, or underweight) under the same roof. The burden of double burden of malnutrition (DBM) and its association with maternal height are not yet fully understood in low-income countries including Ethiopia. The current analysis sought: (a) to determine the prevalence of double burden of malnutrition (i.e., overweight/obese mother paired with her child having one form of undernutrition) and (b) to examine the associations between the double burden of malnutrition and maternal height among mother-child pairs in Ethiopia.

METHODS

We used population-representative cross-sectional pooled data from four rounds of the Ethiopia Demographic and Health Survey (EDHS), conducted between 2000 and 2016. In our analysis, we included children aged 0-59 months born to mothers aged 15-49 years. A total of 33,454 mother-child pairs from four waves of EDHS were included in this study. The burden of DBM was the primary outcome, while the maternal stature was the exposure of interest. Anthropometric data were collected from children and their mothers. Height-for-age (HFA), weight-for-height (WFH), and weight-for-age (WFA) z-scores < - 2 SD were calculated and classified as stunted, wasting, and underweight, respectively. The association between the double burden of malnutrition and maternal stature was examined using hierarchical multilevel modeling.

RESULTS

Overall, the prevalence of the double burden of malnutrition was 1.52% (95% CI 1.39-1.65). The prevalence of overweight/obese mothers and stunted children was 1.31% (95% CI 1.19-1.44), for overweight/obese mothers and wasted children, it was 0.23% (95% CI 0.18-0.28), and for overweight/obese mothers and underweight children, it was 0.58% (95% CI 0.51-0.66). Children whose mothers had tall stature (height ≥ 155.0 cm) were more likely to be in the double burden of malnutrition dyads than children whose mothers' height ranged from 145 to 155 cm (AOR: 1.37, 95% CI 1.04-1.80). Similarly, the odds of the double burden of malnutrition was 2.98 times higher for children whose mothers had short stature (height < 145.0 cm) (AOR: 2.98, 95% CI 1.52-5.86) compared to those whose mothers had tall stature.

CONCLUSIONS

The overall prevalence of double burden of malnutrition among mother-child pairs in Ethiopia was less than 2%. Mothers with short stature were more likely to suffer from the double burden of malnutrition. As a result, nutrition interventions targeting households' level double burden of malnutrition should focus on mothers with short stature to address the nutritional problem of mother and their children, which also has long-term and intergenerational benefits.